Hierarchy of Cognitive Functions



Fatigue that is organically based and NOT due to excessive activity or abnormal sleep patterns. It can emerge suddenly without warning, especially after engaging in a cognitively demanding task.

Signs and Symptoms of Problems
  • Lack of Energy to Engage: Difficulty engaging in activities of daily living, communicating with others, or social activities.
  • Low Arousal: Difficulty waking up and staying awake throughout the day. It may require noise and/or touch (auditory and tactile cueing) to wake from sleep. It may be hard to open the eyes.
  • Decreased Alertness: Decreased ability to maintain mental awareness of surroundings, leading to decreased response to them. 
Strategies for Survivors
  • Build awareness of the causes & effects of neurofatigue
  • Identify early signs of fatigue (yawning, slow motion, in a "fog," etc.)
  • Trust others when offering feedback about your apparent fatigue levels
  • Establish a routine for activities, bedtime & wake times
  • Break large tasks into manageable chunks-use a checklist
  • Minimize stimulation in the environment when completing tasks
  • Manage the "flood" of input
  • Adjust diet, water intake, and exercise to facilitate a healthy lifestyle and to promote healing

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Low mental energy or apparent lack of will. Not "dynamic."

Signs and Symptoms of Problems
  • Trouble Initiating: Hard to get started on things (misperceived as being lazy).
  • Difficulty Generating Thoughts/Ideas: Run out of ideas quickly. Does not give a lot of details in communication.
  • Lack of Spontaneity: Loss of "spirit." Others think you are not interested or are just "going through the motions." Face often does not show emotion. "Poker Faced." 
Strategies for Survivors
  • Use a routine to encourage increased task anticipation
  • Break large tasks into manageable chunks
  • Schedule tasks and stick to the scheduled due date
  • Prepare by using notes to help initiate conversation
  • Use to-do lists, checklists, timers, watches, alarms, and other adaptive devices to improve ability to self-initiate tasks
  • Allow others to help cue you to get started or suggest where to begin
  • Establish "accountability contracts" with supportive others to help initiate activities
  • Become aware of facial expressions, posture, & eye contact (i.e., video tape self)
  • Over exaggerate emotions & speak louder (reduces monotone)

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A syndrome marked by difficulty properly directing and controlling energy and emotions.

Signs and Symptoms of Problems
  • Impulsivity: Doing or saying things without considering the consequences. Making decisions before thinking about all of the information.
  • Feelings or behaviors come on too strong and/or too fast: Feelings come to the surface and are hard to hold back. Reacting to small things with too much emotion. Talking too loud or too fast when the topic is emotional.
  • Irritable and Easily Frustrated: Hard to forget even small irritations. Brooding. Often require others to help calm down. (Restlessness)
  • Emotional Flooding: Can become easily overwhelmed when feeling challenged socially or cognitively. Mind "goes blank." Once flooded, it is temporarily impossible to think clearly or act purposefully. 
Strategies for Survivors
  • Use the "SAVE" strategy: Stop; Ask; Verify; Evaluate
  • Rely on others cues that encourage you to put more thought in to a decision or to take a time out
  • Use self-talk strategies like “Can I go slower?” or “Did I think about this long enough?”
  • Allow others to be direct in response to inappropriate behaviors (i.e., interruptions, inappropriate remarks, tone of voice, awkward facial expressions)
  • Use learned relaxation strategies
  • Take breaks to relax, calm down, and re-attempt communication & tasks when ready

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Staying awake, alert and ready, focusing, and keeping a train of thought.

Signs and Symptoms of Problems
  • Hard to Stay Alert: Not enough mental energy to engage fully in the environment.
  • Hard to Focus Attention: Easily distracted by noises and things around you. Distracted by personal thoughts, feelings, and worries.
  • Lose "Train of Thought:" Once able to focus, a person may lose "train of thought" or concentration if distracted. It may be hard for a person to make a point without getting off track and "rambling." 
Strategies for Survivors
  • Reduce environmental distractions (i.e., close doors, reduce glares) and allow extra time
  • Use cues & alarms as needed to sustain or reset focus
  • Allow others to redirect you back to the current topic when conversation becomes unfocused
  • Focus on giving eye contact during conversation, ask questions, and use nonverbal communication
  • Use a line guide to reduce amount of information to attend to on a page
  • Scan items left to right and top to bottom while using finger to anchor eyes

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Information Processing

Taking environmental stimulation in through the five senses, interpreting it, and responding to it.

Signs and Symptoms of Problems
  • Thinking Speed and Response Times are Slower: It takes longer to understand sensory information and make sense of what is going on in a situation. There may be a long pause before the person responds with words or behavior.
  • Process only Fragments of Information: Because of the slowed processing speed, parts of information heard or seen may be missed.
  • Social Inappropriateness: Difficulty interpreting and making sense of social cues and body language of others. 
Strategies for Survivors
  • Verify written, read, and verbal information gathered
  • Focus on single task completion rather than multiple tasks
  • Concentrate on accuracy first and speed later
  • Write important information down
  • Ask others to slow down or repeat information
  • Reduce visual, auditory, and internal distractions
  • Practice, Practice, Practice
  • Impose time restraints to improve concise speech

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Taking in new information, holding on to information, and recalling information when needed.

Signs and Symptoms of Problems
  • Difficulty Retaining New Information: Hard to hold on to even brief instructions or explanations. Difficulty remembering what was said at the beginning of a conversation.
  • Difficulty Storing New Information: Information is not retained long enough to be permanently stored.
  • Difficulty Retrieving Stored Information: Hard to recall the main point of a conversation, even if it just occurred. May forget important things learned from experience, causing mistakes to be repeated. 
Strategies for Survivors
  • Use external strategies like journal, calendars, lists, planner, timers, etc.
  • Increase awareness of problems to increase use of strategies
  • Follow a daily structure/routine
  • Allow repetition of new information or tasks to assist learning and recall
  • Request information in small pieces rather than lengthy ones
  • Rely on visual as well as verbal instruction of new tasks
  • Attempt to associate old information with new
  • Place items in a common location
  • May need to rely on trusted others for memory

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Executive Function

The ability to reason, plan, problem solve, make inferences, and/or evaluate results of actions and decisions.

Signs and Symptoms of Problems
  • Poor Convergent Reasoning: Hard to narrow down the key point or main idea of something. Hard to choose the best possible solution to a problem.
  • Poor Divergent Reasoning: Hard to come up with more than one way of thinking about something. Hard to see another point of view. Difficulty with empathy. Hard to think of multiple solutions to a problem, causing one to get stuck if one solution does not work.
  • Difficulty with Goal-Oriented Behavior: Hard to set reasonable, attainable goals. Difficulty thinking of all of the steps required to reach a goal. Difficulty prioritizing what to do first. Problems evaluating how your plan is going, fixing mistakes, and changing the plan as needed.
  • Making Poor Decisions: Acting on false or incomplete information. 
Strategies for Survivors
  • Encourage use of all strategies required in hierarchy to this point
  • Request other to be concrete and to the point (i.e., write things down)
  • Make pro/con lists to help with decision making
  • Answer who, what, where, why, and how questions before making a decision 
  • Break directions down into sequential parts
  • Provide set-up for tasks to assist participation
  • Use written checklists for task steps
  • Encourage the use of a planner, filing system, etc.
  • Pre-plan activities to consider all aspects including amount of time, items needed, sequence of events, etc.
  • Ask questions

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