Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention in Vulnerable Populations

*Marilyn Welsh, Patricia Gorman Barry and Jared M. Greenberg*

## **Abstract**

The chapter describes inhibitory control in the context of broader and related constructs, executive function and self-regulation. We discuss the adaptive functions of inhibitory control, as well as evidence that life stress, such as poverty, maltreatment, homelessness, and mental illness, negatively impacts individuals' inhibitory control and overall self-regulation skills. Moreover, these stressors are known to disrupt the development and functioning of crucial brain systems underlying inhibitory control. Following this review, we discuss a critical thinking skills intervention, BrainWise, which is designed to teach inhibitory and self-regulation skills to children, youth and adults. We describe the implementation of the program, and review evidence for its effectiveness with various populations, including our recent study that demonstrated the success of BrainWise in teaching these skills to homeless men living in transitional housing. Finally, we describe our proposed future applications of this intervention to veterans suffering serious mental health challenges. Our overarching goals are to highlight the importance of inhibitory control and overall self-regulation, the vulnerability of these important skills to life stress, and the promise held by one neurocognitive intervention for improving inhibitory control in high-risk populations.

**Keywords:** inhibitory control, executive function, self-regulation, stress, poverty, homelessness, childhood maltreatment, mental illness, intervention, BrainWise, veterans

## **1. Introduction**

Inhibitory control, as a key component of goal-directed executive function and overall self-regulation, has implications for a range of adaptive behaviors across development. Individual differences in this self-regulatory ability have implications for accomplishing important life tasks such as educational achievement, securing employment, and establishing successful relationships. Failures to achieve these milestones has enormous personal costs, as well as economic costs to society. The contributions to these individual differences are complex covariations and interactions between biological and environmental forces [1], as is true for the wide swath

of psychological development. How we respond to these individual differences, particularly at the lower end of functioning, with an appreciation of malleable environmental factors and intervention will determine the degree to which we can optimize inhibitory control, benefiting both individuals and the larger society.

The purpose of this chapter is to describe the construct that is the topic of this volume, inhibitory control. We view inhibitory control within the larger contexts of selfregulation, emotion regulation, and executive functions, skills that are all required for adaptive functioning in our increasingly complex world. We will describe the impacts of environmental challenges and life stresses, such as poverty, maltreatment, homelessness, and mental illness on the development and expression of inhibitory control. In addition, we will discuss how the neural mechanisms underlying inhibitory control and related processes are particularly vulnerable to these stressors.

The critical role that inhibitory control plays in adaptive behavior in a wide range of contexts, and its vulnerability to both environmental and biological challenges, has stimulated a diversity of interventions for children, adolescents, and adults in recent years with varying results. We will focus our discussion on one intervention that involves teaching critical thinking skills to promote inhibitory control and overall self-regulation. The BrainWise program will be described in terms of its design and effectiveness in facilitating adaptive decision making and behavior, particularly in high-risk populations. Finally, we will describe the inhibitory control and self-regulatory deficits observed in veterans experiencing mental illness and/or homelessness and a planned application of the BrainWise intervention to this vulnerable population.

## **2. Importance of inhibitory control to adaptive behavior**

#### **2.1 Inhibitory control defined**

Inhibitory control is the ability to withhold responses to both internal and external signals when such responses would be maladaptive either for immediate functioning or in service of a future goal. The more adaptive alternative response in these situations involves flexible, reflective "top down" mechanisms that operate to control the "bottom-up" arousal, emotion, and stress responses that are often present in our highly-charged daily activities [2]. Research demonstrates that the development of inhibitory control predicts school readiness and performance in young children [2], as well as a range of academic and cognitive skills [3, 4]. In adolescents and young adults, the inability to control behavior, particularly in affectively- and motivationally-charged contexts, is predicative of maladaptive risk taking [5]. Developmental disorders that have documented difficulties with inhibitory control include: autism [6, 7], ADHD [8, 9], and disruptive behavior disorders [10]. Difficulties with inhibition represent impediments to the normal trajectory of development in social–emotional and academic domains, potentially setting up the individual for struggles in adaptation throughout their lifetime.

Difficulties with inhibitory control may be manifested as maladaptive impulsivity in behavior and is described by Nigg [11] as taking two forms. One form of impulsivity that reflects a non-reflective, immediate reactions to stimuli (either internal thoughts or external events) is often called disinhibition. This can be seen when a 3-year-old overtly expresses a reaction to someone's appearance in embarrassing fashion, or when an individual with frontal lobe damage continues to make an incorrect decision despite consciously knowing these decisions are wrong. Disinhibition may be a consequence of the life stresses that we will discuss in this chapter, such as extreme trauma or mental illness, particularly when these involve possible brain damage. The second type of impulsivity involves a motivated

**85**

**3.1 Relevant brain networks**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

preference for an immediate reward over a delayed reward, even if the latter is bigger, better, and ultimately more rewarding [12]. Individual differences in inhibitory control are found in the typically-functioning population, mediated by particular brain regions, and appear to reflect temperamental differences in effortful control [13]. However, this propensity to seek out immediate rewards, even when ultimately maladaptive, also may be impacted by the stressors of poverty, trauma, homelessness, and mental illness, either through learning from one's environment, through subtle brain changes, or through the additive or interactive effects of both pathways. Inhibitory control, therefore, is a crucial component of adaptive behavior that develops with the contributions of brain maturation and support from the environment. As will be discussed in the next section, it can be viewed as a component of executive functions, the cognitive processes dedicated to accomplishing futureoriented goals, as well as a mechanism for regulating arousal to function adaptively.

**2.2 Inhibitory control as part of executive function and overall self-regulation**

ing emotional arousal to allow cognitive control processes to be executed.

when emotional tagging of memories improves encoding [15].

a range of life stress factors to which the individual has been exposed.

**3. Brain systems underlying Self-regulation and inhibitory control**

The neurophysiological mediation of self-regulation represents the intersection of brain systems activated by bottom-up, "hot" sources of emotional and

Nigg [11] developed a hierarchical model of self-regulation that attempted to reconcile several constructs in psychology that have been easily confused and often used interchangeably. Some of these constructs are executive function, effortful control, cognitive control, and emotional regulation. Nigg's model of self-regulation is designed to explain self-regulation in a domain-general manner. This would involve self-regulation over thought, action, and emotions, which fits well with our view of the importance of inhibitory control to all facets of adaptive behavior. The top-down processes of self-regulation are those that are deliberate and under the conscious control of the individual. These include basic executive functions such as inhibition, working memory, and flexibility, as well as effortful control needed to deal with conflicting demands. These top-down processes also include more complex cognitive control processes, such planning, reasoning, and other coping strategies, particularly those directed to regulat-

In Nigg's model, bottom-up processes include nervous system arousal that may reflect emotion, motivation, or stress responses. Typically, this arousal is adaptively controlled by the top-down regulatory processes, but arousal also may serve to energize self-regulation. As Blair and Raver [2] describe in the case of young children, bottom-up arousal often disrupts goal-directed behavior and, thus, requires top-down regulation. However, they point out that arousal can also facilitate adaptive behavior, as seen when a moderate level of stress improves performance [14] or

Therefore, inhibitory control fits within a complex web of executive function, effortful control and emotion regulation processes that are reciprocally connected to support overall self-regulation in service of adaptive behavior. Depending upon the individual's biological and learning history, and the contextual demands of the environment, inhibitory control and overall self-regulation will be challenged in a variety of ways. Individuals will vary widely in their self-regulatory abilities and these differences may be mediated by neurological differences and/or influenced by

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

preference for an immediate reward over a delayed reward, even if the latter is bigger, better, and ultimately more rewarding [12]. Individual differences in inhibitory control are found in the typically-functioning population, mediated by particular brain regions, and appear to reflect temperamental differences in effortful control [13]. However, this propensity to seek out immediate rewards, even when ultimately maladaptive, also may be impacted by the stressors of poverty, trauma, homelessness, and mental illness, either through learning from one's environment, through subtle brain changes, or through the additive or interactive effects of both pathways.

Inhibitory control, therefore, is a crucial component of adaptive behavior that develops with the contributions of brain maturation and support from the environment. As will be discussed in the next section, it can be viewed as a component of executive functions, the cognitive processes dedicated to accomplishing futureoriented goals, as well as a mechanism for regulating arousal to function adaptively.

### **2.2 Inhibitory control as part of executive function and overall self-regulation**

Nigg [11] developed a hierarchical model of self-regulation that attempted to reconcile several constructs in psychology that have been easily confused and often used interchangeably. Some of these constructs are executive function, effortful control, cognitive control, and emotional regulation. Nigg's model of self-regulation is designed to explain self-regulation in a domain-general manner. This would involve self-regulation over thought, action, and emotions, which fits well with our view of the importance of inhibitory control to all facets of adaptive behavior. The top-down processes of self-regulation are those that are deliberate and under the conscious control of the individual. These include basic executive functions such as inhibition, working memory, and flexibility, as well as effortful control needed to deal with conflicting demands. These top-down processes also include more complex cognitive control processes, such planning, reasoning, and other coping strategies, particularly those directed to regulating emotional arousal to allow cognitive control processes to be executed.

In Nigg's model, bottom-up processes include nervous system arousal that may reflect emotion, motivation, or stress responses. Typically, this arousal is adaptively controlled by the top-down regulatory processes, but arousal also may serve to energize self-regulation. As Blair and Raver [2] describe in the case of young children, bottom-up arousal often disrupts goal-directed behavior and, thus, requires top-down regulation. However, they point out that arousal can also facilitate adaptive behavior, as seen when a moderate level of stress improves performance [14] or when emotional tagging of memories improves encoding [15].

Therefore, inhibitory control fits within a complex web of executive function, effortful control and emotion regulation processes that are reciprocally connected to support overall self-regulation in service of adaptive behavior. Depending upon the individual's biological and learning history, and the contextual demands of the environment, inhibitory control and overall self-regulation will be challenged in a variety of ways. Individuals will vary widely in their self-regulatory abilities and these differences may be mediated by neurological differences and/or influenced by a range of life stress factors to which the individual has been exposed.

## **3. Brain systems underlying Self-regulation and inhibitory control**

### **3.1 Relevant brain networks**

The neurophysiological mediation of self-regulation represents the intersection of brain systems activated by bottom-up, "hot" sources of emotional and

*Inhibitory Control Training - A Multidisciplinary Approach*

of psychological development. How we respond to these individual differences, particularly at the lower end of functioning, with an appreciation of malleable environmental factors and intervention will determine the degree to which we can optimize inhibitory control, benefiting both individuals and the larger society.

The purpose of this chapter is to describe the construct that is the topic of this volume, inhibitory control. We view inhibitory control within the larger contexts of selfregulation, emotion regulation, and executive functions, skills that are all required for adaptive functioning in our increasingly complex world. We will describe the impacts of environmental challenges and life stresses, such as poverty, maltreatment, homelessness, and mental illness on the development and expression of inhibitory control. In addition, we will discuss how the neural mechanisms underlying inhibitory control and related processes are particularly vulnerable to these stressors.

The critical role that inhibitory control plays in adaptive behavior in a wide range of contexts, and its vulnerability to both environmental and biological challenges, has stimulated a diversity of interventions for children, adolescents, and adults in recent years with varying results. We will focus our discussion on one intervention that involves teaching critical thinking skills to promote inhibitory control and overall self-regulation. The BrainWise program will be described in terms of its design and effectiveness in facilitating adaptive decision making and behavior, particularly in high-risk populations. Finally, we will describe the inhibitory control and self-regulatory deficits observed in veterans experiencing mental illness and/or homelessness and a planned application of the BrainWise intervention to this vulnerable population.

Inhibitory control is the ability to withhold responses to both internal and external signals when such responses would be maladaptive either for immediate functioning or in service of a future goal. The more adaptive alternative response in these situations involves flexible, reflective "top down" mechanisms that operate to control the "bottom-up" arousal, emotion, and stress responses that are often present in our highly-charged daily activities [2]. Research demonstrates that the development of inhibitory control predicts school readiness and performance in young children [2], as well as a range of academic and cognitive skills [3, 4]. In adolescents and young adults, the inability to control behavior, particularly in affectively- and motivationally-charged contexts, is predicative of maladaptive risk taking [5]. Developmental disorders that have documented difficulties with inhibitory control include: autism [6, 7], ADHD [8, 9], and disruptive behavior disorders [10]. Difficulties with inhibition represent impediments to the normal trajectory of development in social–emotional and academic domains, potentially setting up the individual for struggles in

Difficulties with inhibitory control may be manifested as maladaptive impulsivity in behavior and is described by Nigg [11] as taking two forms. One form of impulsivity that reflects a non-reflective, immediate reactions to stimuli (either internal thoughts or external events) is often called disinhibition. This can be seen when a 3-year-old overtly expresses a reaction to someone's appearance in embarrassing fashion, or when an individual with frontal lobe damage continues to make an incorrect decision despite consciously knowing these decisions are wrong. Disinhibition may be a consequence of the life stresses that we will discuss in this chapter, such as extreme trauma or mental illness, particularly when these involve possible brain damage. The second type of impulsivity involves a motivated

**2. Importance of inhibitory control to adaptive behavior**

**2.1 Inhibitory control defined**

adaptation throughout their lifetime.

**84**

motivational arousal and the brain systems involved in "cool" cognitive control over that arousal for adaptive responses and decisions [16]. Emotional arousal is processed in the limbic system, particularly the amygdala, and strong motivational stimuli activates the reward system of the brain comprised of dopamine pathways and the limbic system structure, the nucleus accumbens [17]. The ventromedial portion of the prefrontal cortex serves to modulate the activity of the limbic system under conditions of strong arousal allowing the dorsolateral region of the prefrontal cortex to carry out its "cool" executive functions of planful, organized, and adaptive decision making [18]. Moreover, the right dorsolateral prefrontal cortex appears to be specifically involved in the inhibitory control aspect of executive function [19]. The smooth coordination of these various regions to appropriately react to arousing stimuli with a "fight or flight" response, as well as to mitigate such reactions when necessary to execute adaptive decision making, develops over the childhood and adolescent years [20]. Importantly, the prefrontal cortex shows the most protracted development from birth to adulthood of all cortical areas [21]. Thus, the plastic brain's vulnerability to biological and environmental insults related to life stress has critical implications for the development of inhibitory control and downstream difficulties with adaptive behavior.

## **3.2 Impacts of life stress on these brain regions**

It is well-documented that chronic stress has deleterious effects on brain development and function, and many of the targets of stress are those networks involved in self-regulation, described above. Animal models, confirmed in human studies, have identified the dorsolateral prefrontal cortex, amygdala, and the ventromedial prefrontal cortex as consistent targets of the negative impacts of chronic stress on structure and function [22]. Stress-induced changes in the ventromedial prefrontal cortex have been specifically linked to cognitive control deficits in both animals and humans [23–25].

Prenatal and early postnatal development of the brain is the consequence of a complex unfolding of genetic and epigenetic mechanisms that can be derailed by adverse biological or environmental forces [26]. There is emerging evidence that poverty—with its many correlated stressors—is related to alterations in a variety of brain regions, including those related to self-regulation, the prefrontal cortex and amygdala [2]. Similarly, there is increasing evidence that childhood maltreatment, again correlated with poverty and other stressors, is related to alterations in the structure and function of brain networks involved in self-regulation. Research has identified the brain networks that differ in maltreated individuals as those that mediate emotional regulation, attention, inhibitory control, and social cognition, particularly in situations of threat or potential reward [27, 28].

Thus, the underlying brain mechanisms of self-regulation and inhibitory control are quite vulnerable to life adversity and stress, and this is likely to be observed in behavioral disruptions in high-risk individuals. In what follows, we discuss the evidence for impairments in inhibitory control, and related constructs of executive functions and self-regulation, that have been linked to four examples of life stress.

## **4. Life stress impacts on inhibitory control, executive function, and self-regulation**

Life stress can include the mild, normative challenges that have been found to fine-tune the stress response system at the brain and behavioral levels to overcome obstacles and build resilience. Evolutionarily, our brains and bodies are equipped

**87**

**4.2 Childhood maltreatment**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

It is important to note that where there is risk, there is also substantial evidence of resilience in the face of adverse life circumstances, and this is observed both at the brain and behavioral levels [33]. Our own research has examined young adults with a childhood maltreatment history who manage to enroll in college [34] and homeless men who seek out services such as transitional housing [35]. These groups of adults are demonstrating resilience despite exposure to difficult and sometimes traumatic circumstances. While there is evidence of inhibitory control deficits in these groups, this capacity for resilience is likely to make these groups excellent candidates for interventions to strengthen inhibitory control and a range of related

According to 2017 data, almost 40 million people lived below the poverty line in the United States, and 12.8 million of this group were children [36]. Poverty is not a monolithic factor affecting psychological development; rather, poverty is correlated with numerous risk factors [37] that combine to create a cumulative risk to healthy development. Poverty-related risk factors that have a negative impact on the development of self-regulatory abilities in children include low maternal education, elevated maternal depression, exposure to domestic and neighborhood violence, lower housing quality, exposure to environmental pollutants, and poor access to needed services [38]. A gap in self-regulatory abilities is seen as early as preschool in low-income children [39], and growth in self-regulation is slower in impoverished children with a greater number of cumulative risks [40]. In a large, nationallyrepresentative sample of children in Head Start, Son, Choi and Kwon [41] identified reciprocal associations between inhibitory control and math skills, and the researchers suggest that intervening to improve inhibitory control in low-income children will improve academic abilities, which in turn will improve self-regulation. Poverty continues to negatively impact self-regulation beyond childhood. Lambert et al. [42] found that poverty was related to cognitive control deficits, while violence exposure was related to emotional dysregulation in a sample of adolescents. In a sample of more than 5000 adults 18–30 years of age, exposure to two decades or more of sustained poverty was related to poorer executive functions, which the researchers suggest have a negative impact on health-related behaviors and ultimately on longevity [43]. Poverty is a complex multifactorial construct that is clearly associated with many other risk factors, including those discussed below, which are themselves predictive of impairments in inhibitory control and related skills.

Based on data from the Centers for Disease Control and Prevention, approximately 1 in 7 U.S. children experience child abuse and/or neglect in the past year, and this statistic likely underestimates the scope of the problem [44]. Childhood

to deal with acute, short-lived stressors without serious negative consequences [29], but chronic, long-lasting, frequent, and/or extreme stress exposure results in what has been referred to as the toxic stress response [30]. Adverse childhood experiences, such as poverty, maltreatment, and parental conflict, are included in the category of toxic stress and have been found to disrupt inhibitory control, emotional regulation, and organized, reflective thinking [31, 32]. Individuals who contend with chronic life stress as adults may have also had exposure to toxic stress in their childhoods during the period of critical brain and behavioral development. As adults, these challenging conditions are likely to continue to impair the brain

functions necessary for inhibitory control and overall self-regulation.

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

self-regulatory skills.

**4.1 Poverty**

#### *Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

to deal with acute, short-lived stressors without serious negative consequences [29], but chronic, long-lasting, frequent, and/or extreme stress exposure results in what has been referred to as the toxic stress response [30]. Adverse childhood experiences, such as poverty, maltreatment, and parental conflict, are included in the category of toxic stress and have been found to disrupt inhibitory control, emotional regulation, and organized, reflective thinking [31, 32]. Individuals who contend with chronic life stress as adults may have also had exposure to toxic stress in their childhoods during the period of critical brain and behavioral development. As adults, these challenging conditions are likely to continue to impair the brain functions necessary for inhibitory control and overall self-regulation.

It is important to note that where there is risk, there is also substantial evidence of resilience in the face of adverse life circumstances, and this is observed both at the brain and behavioral levels [33]. Our own research has examined young adults with a childhood maltreatment history who manage to enroll in college [34] and homeless men who seek out services such as transitional housing [35]. These groups of adults are demonstrating resilience despite exposure to difficult and sometimes traumatic circumstances. While there is evidence of inhibitory control deficits in these groups, this capacity for resilience is likely to make these groups excellent candidates for interventions to strengthen inhibitory control and a range of related self-regulatory skills.

### **4.1 Poverty**

*Inhibitory Control Training - A Multidisciplinary Approach*

difficulties with adaptive behavior.

humans [23–25].

**3.2 Impacts of life stress on these brain regions**

motivational arousal and the brain systems involved in "cool" cognitive control over that arousal for adaptive responses and decisions [16]. Emotional arousal is processed in the limbic system, particularly the amygdala, and strong motivational stimuli activates the reward system of the brain comprised of dopamine pathways and the limbic system structure, the nucleus accumbens [17]. The ventromedial portion of the prefrontal cortex serves to modulate the activity of the limbic system under conditions of strong arousal allowing the dorsolateral region of the prefrontal cortex to carry out its "cool" executive functions of planful, organized, and adaptive decision making [18]. Moreover, the right dorsolateral prefrontal cortex appears to be specifically involved in the inhibitory control aspect of executive function [19]. The smooth coordination of these various regions to appropriately react to arousing stimuli with a "fight or flight" response, as well as to mitigate such reactions when necessary to execute adaptive decision making, develops over the childhood and adolescent years [20]. Importantly, the prefrontal cortex shows the most protracted development from birth to adulthood of all cortical areas [21]. Thus, the plastic brain's vulnerability to biological and environmental insults related to life stress has critical implications for the development of inhibitory control and downstream

It is well-documented that chronic stress has deleterious effects on brain development and function, and many of the targets of stress are those networks involved in self-regulation, described above. Animal models, confirmed in human studies, have identified the dorsolateral prefrontal cortex, amygdala, and the ventromedial prefrontal cortex as consistent targets of the negative impacts of chronic stress on structure and function [22]. Stress-induced changes in the ventromedial prefrontal cortex have been specifically linked to cognitive control deficits in both animals and

Prenatal and early postnatal development of the brain is the consequence of a complex unfolding of genetic and epigenetic mechanisms that can be derailed by adverse biological or environmental forces [26]. There is emerging evidence that poverty—with its many correlated stressors—is related to alterations in a variety of brain regions, including those related to self-regulation, the prefrontal cortex and amygdala [2]. Similarly, there is increasing evidence that childhood maltreatment, again correlated with poverty and other stressors, is related to alterations in the structure and function of brain networks involved in self-regulation. Research has identified the brain networks that differ in maltreated individuals as those that mediate emotional regulation, attention, inhibitory control, and social cognition,

Thus, the underlying brain mechanisms of self-regulation and inhibitory control

are quite vulnerable to life adversity and stress, and this is likely to be observed in behavioral disruptions in high-risk individuals. In what follows, we discuss the evidence for impairments in inhibitory control, and related constructs of executive functions and self-regulation, that have been linked to four examples of life stress.

**4. Life stress impacts on inhibitory control, executive function, and** 

Life stress can include the mild, normative challenges that have been found to fine-tune the stress response system at the brain and behavioral levels to overcome obstacles and build resilience. Evolutionarily, our brains and bodies are equipped

particularly in situations of threat or potential reward [27, 28].

**86**

**self-regulation**

According to 2017 data, almost 40 million people lived below the poverty line in the United States, and 12.8 million of this group were children [36]. Poverty is not a monolithic factor affecting psychological development; rather, poverty is correlated with numerous risk factors [37] that combine to create a cumulative risk to healthy development. Poverty-related risk factors that have a negative impact on the development of self-regulatory abilities in children include low maternal education, elevated maternal depression, exposure to domestic and neighborhood violence, lower housing quality, exposure to environmental pollutants, and poor access to needed services [38]. A gap in self-regulatory abilities is seen as early as preschool in low-income children [39], and growth in self-regulation is slower in impoverished children with a greater number of cumulative risks [40]. In a large, nationallyrepresentative sample of children in Head Start, Son, Choi and Kwon [41] identified reciprocal associations between inhibitory control and math skills, and the researchers suggest that intervening to improve inhibitory control in low-income children will improve academic abilities, which in turn will improve self-regulation.

Poverty continues to negatively impact self-regulation beyond childhood. Lambert et al. [42] found that poverty was related to cognitive control deficits, while violence exposure was related to emotional dysregulation in a sample of adolescents. In a sample of more than 5000 adults 18–30 years of age, exposure to two decades or more of sustained poverty was related to poorer executive functions, which the researchers suggest have a negative impact on health-related behaviors and ultimately on longevity [43]. Poverty is a complex multifactorial construct that is clearly associated with many other risk factors, including those discussed below, which are themselves predictive of impairments in inhibitory control and related skills.

#### **4.2 Childhood maltreatment**

Based on data from the Centers for Disease Control and Prevention, approximately 1 in 7 U.S. children experience child abuse and/or neglect in the past year, and this statistic likely underestimates the scope of the problem [44]. Childhood maltreatment and other adverse experiences have been found to increase risks to physical health and overall adaptive functioning according to the well-known, large-scale Kaiser Foundation study [45]. Given the likely negative impacts on the developing brain and the altered learning environment of the child exposed to maltreatment, cognitive deficits and difficulties with self-regulation will potentially have life-long implications for adaptive behavior.

Evidence suggests impairments in a range of executive functions in childhood samples that have experienced maltreatment [46, 47]. Such deficits are also observed in adolescents and adults reporting a maltreatment history [48, 49]. Inhibitory control is frequently measured by the neurocognitive Go-No-Go task, which requires a response to a specific target and withholding a response (inhibition) to other targets. Adults self-reporting a history of abuse or neglect demonstrate difficulties with this task, particularly in the No-Go condition that demands inhibitory control [50, 51]. Such inhibitory control deficits may manifest as overall difficulties with self-regulation, placing adolescents and adults at risk for maladaptive behaviors and decision making [52].

### **4.3 Homelessness**

As is the case for other adverse environmental conditions already discussed, homelessness is a serious societal problem; in January of 2015, it was estimated that there were 564,708 homeless people in the United States. Executive function impairments, among other cognitive deficits, are observed in youth who have experienced homelessness, foster care, and poverty according to a recent meta-analysis. For children experiencing homelessness, deficits in effortful and emotional control predict academic difficulties [53], and effortful control has also been found to be an individual resource contributing to overall adaptive functioning and resilience among these children [54]. Schmitt et al. [55] demonstrated that difficulties with inhibitory control mediated the relationship between housing insecurity and academic functioning of preschoolers. Thus, homelessness has a deleterious effect on the development of children particularly at a critical milestone of early academic adjustment and achievement, with potential negative impacts on later adaptation.

In adults, executive function skills, including inhibitory control, suffer substantially if a person experiences psychosocial stress [24], social exclusion [56, 57], interpersonal strain [58], or disrupted sleep [59], all of which are common among those experiencing homelessness. It is therefore not surprising that several studies have reported deficits in executive functions among homeless individuals including youth [60], adults [61], and older adults [62]. The experience of homelessness not only appears to put someone at risk for disrupted self-regulatory behaviors, such as executive function and inhibitory control, but these deficits also may result in maladaptive behavior that results in homelessness. Gabrielian et al. [63] compared the problem-solving skills homeless-experienced veterans in a US federal government study who retained ("stayers") or lost ("exiters") housing for at least 1 year. Both groups had poor cognition, but there was a trend toward greater problemsolving complexity in stayers as compared to exiters [64]. Similarly, in a study of the influence of cognition on community functioning among formerly homeless persons with mental illness, better executive functions predicted improved self-care and less turbulent behavior [65].

In the United States, the prevalent problem of homelessness among military veterans merits particular attention. Veterans are at particularly high risk of homelessness for several reasons including relatively disadvantaged socioeconomic status and increased risk of mental disorders, both of which are associated with impairments in executive functions (as discussed in Sections 4.1 and 4.4, respectively) [66, 67].

**89**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

As will be discussed in Section 6, there is a need to carefully consider the role of executive functions in homeless veterans with and without mental illness, both as a potential cause and consequence of these problems, and to develop interventions

There is evidence on both brain and behavioral levels that cognitive and emotional regulation deficits may be transdiagnostic symptoms; that is, these difficulties are found across a range of mental illness diagnosis in children and adults. Maladaptive decision-making behavior is observed in youth with anxiety, depression, conduct disorder, and ADHD, though the particular manifestations of these deficits may vary [68]. A meta-analysis by Wright et al. [69] identified smallto-moderate deficits in inhibitory control on tasks such as the Go-No-Go across 11 different mental illness diagnoses in adults. In adolescents with a history of depression, specific deficits in inhibitory control were still observed even after remission of their depression, while other executive functions and cognitive abilities had

Adults with serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and posttraumatic stress disorder) frequently exhibit impairments in executive function and cognitive control [70, 71]. Notably, executive functions have been shown to be the most important cognitive domain for a variety of adaptive outcomes for individuals with serious mental illness, including occupational functioning and independent living [72]. Similarly, difficulties with executive functions and overall self-regulation predict maladaptive outcomes in these mentally ill adults, such as treatment nonadherence and violent behavior [72], poor treatment response [73], and overall psychosocial function [74]. In summary, severe life stresses such as poverty, childhood maltreatment, homelessness, and mental illness have adverse effects on the self-regulatory processes such as executive function and inhibitory control. In many cases such stresses co-occur, with cumulative negative effects. Inhibitory control is critical to adaptive functioning across a wide range of domains: academic, employment, interpersonal, and physical and mental health. Stressful life circumstances can create a cascade effect on self-regulatory capacities that may lead to maladaptive behavioral consequences such as risky or antisocial behavior. In turn, maladaptive behaviors place the individual in environments that continue to limit the development of these important skills. For example, an adolescent who engages in delinquent behaviors with peers will not have the role models or the learning experiences to shape appropriate inhibitory control or executive functions in the future. As will be described later in the chapter, US military veterans frequently experience a combination of these stresses when they return home (e.g., homelessness and mental illness) and are at great risk for difficulties with self-regulation. Thus, due to the biological and environmental risk factors that may contribute to deficits in these critical skills in a substantial minority of the population, interventions that can ameliorate these difficulties should hold promise for substantial benefits for both the individual and society.

**5. Interventions for inhibitory control and executive function**

Scientists are using increasingly advanced techniques to study the brain, behavior, and interventions for improving health [75–77]. Findings include

**5.1 Growing interest in prevention intervention**

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

**4.4 Mental illness**

improved.

tailored to the needs of this vulnerable population.

As will be discussed in Section 6, there is a need to carefully consider the role of executive functions in homeless veterans with and without mental illness, both as a potential cause and consequence of these problems, and to develop interventions tailored to the needs of this vulnerable population.

## **4.4 Mental illness**

*Inhibitory Control Training - A Multidisciplinary Approach*

have life-long implications for adaptive behavior.

tive behaviors and decision making [52].

**4.3 Homelessness**

maltreatment and other adverse experiences have been found to increase risks to physical health and overall adaptive functioning according to the well-known, large-scale Kaiser Foundation study [45]. Given the likely negative impacts on the developing brain and the altered learning environment of the child exposed to maltreatment, cognitive deficits and difficulties with self-regulation will potentially

Evidence suggests impairments in a range of executive functions in childhood samples that have experienced maltreatment [46, 47]. Such deficits are also observed in adolescents and adults reporting a maltreatment history [48, 49]. Inhibitory control is frequently measured by the neurocognitive Go-No-Go task, which requires a response to a specific target and withholding a response (inhibition) to other targets. Adults self-reporting a history of abuse or neglect demonstrate difficulties with this task, particularly in the No-Go condition that demands inhibitory control [50, 51]. Such inhibitory control deficits may manifest as overall difficulties with self-regulation, placing adolescents and adults at risk for maladap-

As is the case for other adverse environmental conditions already discussed, homelessness is a serious societal problem; in January of 2015, it was estimated that there were 564,708 homeless people in the United States. Executive function impairments, among other cognitive deficits, are observed in youth who have experienced homelessness, foster care, and poverty according to a recent meta-analysis. For children experiencing homelessness, deficits in effortful and emotional control predict academic difficulties [53], and effortful control has also been found to be an individual resource contributing to overall adaptive functioning and resilience among these children [54]. Schmitt et al. [55] demonstrated that difficulties with inhibitory control mediated the relationship between housing insecurity and academic functioning of preschoolers. Thus, homelessness has a deleterious effect on the development of children particularly at a critical milestone of early academic adjustment and achievement, with potential negative impacts on later adaptation. In adults, executive function skills, including inhibitory control, suffer substantially if a person experiences psychosocial stress [24], social exclusion [56, 57], interpersonal strain [58], or disrupted sleep [59], all of which are common among those experiencing homelessness. It is therefore not surprising that several studies have reported deficits in executive functions among homeless individuals including youth [60], adults [61], and older adults [62]. The experience of homelessness not only appears to put someone at risk for disrupted self-regulatory behaviors, such as executive function and inhibitory control, but these deficits also may result in maladaptive behavior that results in homelessness. Gabrielian et al. [63] compared the problem-solving skills homeless-experienced veterans in a US federal government study who retained ("stayers") or lost ("exiters") housing for at least 1 year. Both groups had poor cognition, but there was a trend toward greater problemsolving complexity in stayers as compared to exiters [64]. Similarly, in a study of the influence of cognition on community functioning among formerly homeless persons with mental illness, better executive functions predicted improved self-care

In the United States, the prevalent problem of homelessness among military veterans merits particular attention. Veterans are at particularly high risk of homelessness for several reasons including relatively disadvantaged socioeconomic status and increased risk of mental disorders, both of which are associated with impairments in executive functions (as discussed in Sections 4.1 and 4.4, respectively) [66, 67].

**88**

and less turbulent behavior [65].

There is evidence on both brain and behavioral levels that cognitive and emotional regulation deficits may be transdiagnostic symptoms; that is, these difficulties are found across a range of mental illness diagnosis in children and adults. Maladaptive decision-making behavior is observed in youth with anxiety, depression, conduct disorder, and ADHD, though the particular manifestations of these deficits may vary [68]. A meta-analysis by Wright et al. [69] identified smallto-moderate deficits in inhibitory control on tasks such as the Go-No-Go across 11 different mental illness diagnoses in adults. In adolescents with a history of depression, specific deficits in inhibitory control were still observed even after remission of their depression, while other executive functions and cognitive abilities had improved.

Adults with serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and posttraumatic stress disorder) frequently exhibit impairments in executive function and cognitive control [70, 71]. Notably, executive functions have been shown to be the most important cognitive domain for a variety of adaptive outcomes for individuals with serious mental illness, including occupational functioning and independent living [72]. Similarly, difficulties with executive functions and overall self-regulation predict maladaptive outcomes in these mentally ill adults, such as treatment nonadherence and violent behavior [72], poor treatment response [73], and overall psychosocial function [74].

In summary, severe life stresses such as poverty, childhood maltreatment, homelessness, and mental illness have adverse effects on the self-regulatory processes such as executive function and inhibitory control. In many cases such stresses co-occur, with cumulative negative effects. Inhibitory control is critical to adaptive functioning across a wide range of domains: academic, employment, interpersonal, and physical and mental health. Stressful life circumstances can create a cascade effect on self-regulatory capacities that may lead to maladaptive behavioral consequences such as risky or antisocial behavior. In turn, maladaptive behaviors place the individual in environments that continue to limit the development of these important skills. For example, an adolescent who engages in delinquent behaviors with peers will not have the role models or the learning experiences to shape appropriate inhibitory control or executive functions in the future. As will be described later in the chapter, US military veterans frequently experience a combination of these stresses when they return home (e.g., homelessness and mental illness) and are at great risk for difficulties with self-regulation. Thus, due to the biological and environmental risk factors that may contribute to deficits in these critical skills in a substantial minority of the population, interventions that can ameliorate these difficulties should hold promise for substantial benefits for both the individual and society.

## **5. Interventions for inhibitory control and executive function**

## **5.1 Growing interest in prevention intervention**

Scientists are using increasingly advanced techniques to study the brain, behavior, and interventions for improving health [75–77]. Findings include

Nobel-prize-winning research that demonstrates how the brain forms synapses when it learns something new [78], the identification of executive functions that are learned through practice [79–81], and research indicating the brain continues to produce neurons well into old age [82].

These and other studies support and complement research showing that thinking skills are learned behaviors and that when they are not developed, are only partially learned, or are compromised by adversity and stress, they negatively impact the physical and mental health of individuals, families, and communities [26, 75, 77, 83]. We know that most mental health disorders and problems are largely preventable. This knowledge underlies requests from health providers, educators, and concerned citizens for access to research and prevention programs [76, 84]. In the last two decades, a greater number of scientific papers has been published on prevention programs [85], biological and social behavior interventions [76], and self-control and intertemporal choice in economics [86]. They reflect the diverse and valuable advances in research on a wide range of approaches that address prevention to promote healthy life choices.

#### **5.2 BrainWise program**

The BrainWise program is a prevention curriculum that uses a multidisciplinary approach to teach 10 thinking skills that include inhibitory control and other executive functions [35]. The program focuses on neurocognitive development and integrates findings from social science, education, and neuroscience. It integrates the roles that the prefrontal cortex and limbic system play in decision making, explains them simply, and provides a template for teaching thinking skills.

Program participants are students and clients of diverse ages, backgrounds, and abilities. The program uses nonscientific terms to explain basic brain processes and provides scripted lessons, making the material easy to understand and remember by children, youth, and adults, including individuals with disabilities and mental health challenges [87, 88]. BrainWise instructors can adapt scientific terms to fit their students' and clients' level of understanding whether the individuals are learning disabled or high performers.

The curriculum uses activities that combine kinesthetic, sensory-motor, visual, auditory, cognitive, and socioemotional techniques instructors can adapt and customize as needed. Its approach includes teaching basic brain concepts using activities that engage participants of all ages, helping them understand why learning and practicing enables them to stop and think before they act. The program can be adapted to address a wide range of teaching situations and can be taught in classes, small groups, and one-on-one. This flexibility appeals to instructors and helps ensure they will teach and reinforce the lessons with fidelity [89, 90]. Instructors learn how to integrate the lessons into daily activities, providing opportunities to use examples that are specific to problems faced by their clients and students.

Reinforcement is key to retention [76, 91–94]. Instructors have access to several BrainWise teaching aids and create their own. These include problem-solving worksheets, checklists, reinforcement games, and support activities that sometimes call for older students to teach and reinforce lessons with younger students. Depending on the site and instructor, text messages, apps, telephone, emails, and other devices are additional reinforcement strategies. For example, instructors may randomly send customized text messages to remind a participant to "Exit Your Emotions Elevator" or "Use Your Wizard Brain!". Course instructors also have access to a "members-only" BrainWise network where they share teaching strategies and techniques and receive a monthly online newsletter containing research updates, teaching tips, and instructors' stories.

**91**

**Figure 1.** *The 10 Wise Ways.*

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

BrainWise is taught in schools, clinics, faith-based organizations, agencies, worksites, homeless shelters, hospitals, and households throughout the United States and in Canada, China, India, and 17 other countries [95]. U.S. Indian Health Services (IHS) has recognized BrainWise as a program that benefits Native Americans and Alaska natives, and the University of Tennessee Extension has trained its agents to teach BrainWise throughout the state [96]. The advocacy of program users underlies this growth, and a future direction for application of

BrainWise starts with four tenets: (1) everyone has problems; (2) people who have fewer problems use thinking skills; (3) the brain can help prevent problems; and (4) the 10 Wise Ways teach thinking skills. This section presents the lessons and

This statement lays the foundation for the nine lessons that follow. Participants learn how the body's five senses act as sentinels and send signals to the brain's thalamus, which is also called the relay center because it collects sensory information and

The limbic system is located beneath the relay center and contains the amygdala (where fear and any intense emotion are triggered) and the hypothalamus (which sets off the fight or flight reaction; [97]). These survival responses are also found in reptiles, leading us to call this section the Lizard Brain. Instructors use this information to discuss the history and importance of survival instincts and how the amygdala (emotion center) and hypothalamus (fight or flight reaction) contribute to impulsive

Participants receive worksheets with age-appropriate pictures of brains and label the parts as they learn about them. They see the Lizard Brain's proximity to the brain stem. They learn that the part of the brain behind the forehead contains the thinking area known as the prefrontal cortex. For simplicity, we call it the Wizard Brain and point out that all of us are born with only rudimentary connections from the relay center to the Wizard Brain. These connections develop as we learn, Sapolsky [76] discusses the neurobiological stages involved in top-down, Wizard Brain decision-making.

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

BrainWise will be to incarcerated youth and adults.

*5.3.1 Wise Way 1: use your Wizard Brain over your Lizard Brain*

research supporting each one (**Figure 1**).

sends it to the limbic system to be processed.

reactions, such as maladaptive road rage [98].

**5.3 The 10 Wise Ways**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

BrainWise is taught in schools, clinics, faith-based organizations, agencies, worksites, homeless shelters, hospitals, and households throughout the United States and in Canada, China, India, and 17 other countries [95]. U.S. Indian Health Services (IHS) has recognized BrainWise as a program that benefits Native Americans and Alaska natives, and the University of Tennessee Extension has trained its agents to teach BrainWise throughout the state [96]. The advocacy of program users underlies this growth, and a future direction for application of BrainWise will be to incarcerated youth and adults.

## **5.3 The 10 Wise Ways**

*Inhibitory Control Training - A Multidisciplinary Approach*

produce neurons well into old age [82].

prevention to promote healthy life choices.

learning disabled or high performers.

teaching tips, and instructors' stories.

**5.2 BrainWise program**

Nobel-prize-winning research that demonstrates how the brain forms synapses when it learns something new [78], the identification of executive functions that are learned through practice [79–81], and research indicating the brain continues to

These and other studies support and complement research showing that thinking skills are learned behaviors and that when they are not developed, are only partially learned, or are compromised by adversity and stress, they negatively impact the physical and mental health of individuals, families, and communities [26, 75, 77, 83]. We know that most mental health disorders and problems are largely preventable. This knowledge underlies requests from health providers, educators, and concerned citizens for access to research and prevention programs [76, 84]. In the last two decades, a greater number of scientific papers has been published on prevention programs [85], biological and social behavior interventions [76], and self-control and intertemporal choice in economics [86]. They reflect the diverse and valuable advances in research on a wide range of approaches that address

The BrainWise program is a prevention curriculum that uses a multidisciplinary

Program participants are students and clients of diverse ages, backgrounds, and abilities. The program uses nonscientific terms to explain basic brain processes and provides scripted lessons, making the material easy to understand and remember by children, youth, and adults, including individuals with disabilities and mental health challenges [87, 88]. BrainWise instructors can adapt scientific terms to fit their students' and clients' level of understanding whether the individuals are

The curriculum uses activities that combine kinesthetic, sensory-motor, visual, auditory, cognitive, and socioemotional techniques instructors can adapt and customize as needed. Its approach includes teaching basic brain concepts using activities that engage participants of all ages, helping them understand why learning and practicing enables them to stop and think before they act. The program can be adapted to address a wide range of teaching situations and can be taught in classes, small groups, and one-on-one. This flexibility appeals to instructors and helps ensure they will teach and reinforce the lessons with fidelity [89, 90]. Instructors learn how to integrate the lessons into daily activities, providing opportunities to use examples that are specific to problems faced by their clients and students.

Reinforcement is key to retention [76, 91–94]. Instructors have access to several

BrainWise teaching aids and create their own. These include problem-solving worksheets, checklists, reinforcement games, and support activities that sometimes call for older students to teach and reinforce lessons with younger students. Depending on the site and instructor, text messages, apps, telephone, emails, and other devices are additional reinforcement strategies. For example, instructors may randomly send customized text messages to remind a participant to "Exit Your Emotions Elevator" or "Use Your Wizard Brain!". Course instructors also have access to a "members-only" BrainWise network where they share teaching strategies and techniques and receive a monthly online newsletter containing research updates,

approach to teach 10 thinking skills that include inhibitory control and other executive functions [35]. The program focuses on neurocognitive development and integrates findings from social science, education, and neuroscience. It integrates the roles that the prefrontal cortex and limbic system play in decision making, explains them simply, and provides a template for teaching thinking skills.

**90**

BrainWise starts with four tenets: (1) everyone has problems; (2) people who have fewer problems use thinking skills; (3) the brain can help prevent problems; and (4) the 10 Wise Ways teach thinking skills. This section presents the lessons and research supporting each one (**Figure 1**).

#### *5.3.1 Wise Way 1: use your Wizard Brain over your Lizard Brain*

This statement lays the foundation for the nine lessons that follow. Participants learn how the body's five senses act as sentinels and send signals to the brain's thalamus, which is also called the relay center because it collects sensory information and sends it to the limbic system to be processed.

The limbic system is located beneath the relay center and contains the amygdala (where fear and any intense emotion are triggered) and the hypothalamus (which sets off the fight or flight reaction; [97]). These survival responses are also found in reptiles, leading us to call this section the Lizard Brain. Instructors use this information to discuss the history and importance of survival instincts and how the amygdala (emotion center) and hypothalamus (fight or flight reaction) contribute to impulsive reactions, such as maladaptive road rage [98].

Participants receive worksheets with age-appropriate pictures of brains and label the parts as they learn about them. They see the Lizard Brain's proximity to the brain stem. They learn that the part of the brain behind the forehead contains the thinking area known as the prefrontal cortex. For simplicity, we call it the Wizard Brain and point out that all of us are born with only rudimentary connections from the relay center to the Wizard Brain. These connections develop as we learn, Sapolsky [76] discusses the neurobiological stages involved in top-down, Wizard Brain decision-making.


**Figure 1.** *The 10 Wise Ways.*

This sets the stage for presenting a powerful piece of information. The skills participants learn in BrainWise help them build connections to their Wizard Brain so that when signals are sent to the relay center, they are diverted away from the Lizard Brain and to the Wizard Brain. This simplified explanation is easy for almost anyone to understand [35]. Each time participants learns a wise way, they draw a line from the relay center/Lizard Brain to the Wizard Brain. This process helps participants of all ages and abilities form a clear picture of how different parts of the brain respond to a stimulus.

Wise Way 1 lays the foundation for the remaining skills by helping participants learn how the brain is involved in behaviors and what they can do to prevent and manage problems. As discussed in the previous section, the hierarchical model of self-regulation developed by Nigg [11] describes these processes as "top-down" and "bottom-up." The top-down processes are Wizard Brain responses that include executive functions and the complex planning, reasoning, and other coping strategies taught throughout the remaining Wise Ways. The bottom-up processes are all Lizard Brain reactions to events that arouse strong emotions. These will be addressed in Wise Ways 2–10.

The lesson ends with participants drawing a line on the brain worksheet to show that Wise Way 1 helps them make a connection. Sapolsky [76] presents this process in a discussion about how the ventromedial prefrontal cortex forms connections with the limbic system, and the biological processes underlying such neuroplasticity are presented by Kandel [78].

### *5.3.2 Wise Way 2: build a Constellation of Support*

Research supports the importance of human connection [99–102] and identifies how support systems can be lifelines out of loneliness, helplessness, sadness, and other feelings of being isolated. Wise Way 2 helps people learn how to create and use an effective support network by teaching about resources for different types of support, as well as how to find and access dependable support sources.

Participants learn to identify a wider range of sources they can go to for help, a process that increases their awareness of the benefits of sources they previously may not have considered. This includes learning that valued help takes many forms human, animal, spiritual, and inanimate—and that we all need to identify and access different types of support for our various problems [103, 104].

The Constellation of Support shows that we connect with the "stars" in our constellation in three ways: (1) Broken Line (not helpful), (2) Single Line (not unhelpful, but not helpful either), or (3) Double Lines (helpful). This activity creates awareness that broken lines may include unthinking friends and family, members with their own set of problems who do not realize that alternative help is available or how to access it. The course instructor is always a double line for the client or student and is a resource for other support sources. This lesson and visual teaching activities are valuable tools that help participants assess the degree of help a support resource provides.

The science of social support is complex and involves many biological pathways, including neuropeptides, genes, and hormones [76, 105]. These studies are consistent with the advantages of utilizing resources and support, a concept that is taught as a key connection to the Wizard Brain. Participants learn that the Constellation of Support is complicated, and resources can be deceptive, potentially causing problems instead of preventing them if one is not careful. The lesson makes individuals aware that help is always available and the skills they are learning will help them access the most useful sources.

**93**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

Teaching about Red Flag Warnings builds on what participants learned about the Lizard Brain's bottom-up arousal. The body's five senses continuously receive sensory cues, and this lesson creates awareness of signals that warn "something is going to happen." Individuals learn about their unique sensations warning of problems and the importance of recognizing two types: External Red Flags and

External Red Flags are audio signals, such as a siren, or visual cues, such as gang colors or empty beer cans on the front porch. Participants learn to identify how they react to red flags, especially in problem situations. This recognition creates an awareness of maladaptive behaviors. For example, one client realized that he would turn his head and spit immediately before he lost his temper. When he recognized

Internal Red Flags are what a person feels inside, a key component of emotion regulation. Participants may say, "I feel mad," or name emotions such as frustration, sadness, loneliness, and unhappiness. Instructors ask them to describe what they feel inside, probing to identify physical sensations such as tight muscles, hot flashes, and upset stomach. Helping them become aware of internal red flags is as important for 5-year-olds as it is for older youth and adults. Instructors and parents find that students with ADHD and autism can learn to identify internal sensations they may

The Red Flag Warnings content includes teaching aids and activities that promote reinforcement. Participants, including adults, make personalized red flags and list their Internal Red Flags on one side and External Red Flags on the other. Young children complete Red Flag Buddy worksheets, marking areas where they feel red flags. This awareness helps prepare them for times when sensory information streams toward their brains and rapidly, powerfully, and automatically triggers

After they learn the lesson, they draw a line on the brain worksheet showing that they are building another connection to their Wizard Brain. This seemingly simple process puts into practice the neuroscience behind emotions and impulse [76] and gives instructors a segue to the next lesson on emotions and how to control them.

The Constellation of Support and Red Flag Warnings lessons prepare participants to learn about their emotions and techniques to control them using their Wizard Brain. The first part of the lesson explains emotions by using the metaphor of an elevator, but instructors can use metaphors that may be more familiar to their students; e.g., instructors in rural China and India use fires and volcanoes, so

In the context of teaching Wise Way 4, participants learn the following: (1) Emotions are cumulative and have a range of intensity [22]. BrainWise teaches that the first floor is low emotion and the higher floors are out of control. (2) Multiple emotions are experienced simultaneously, e.g., one can be enraged but also feel admiration for a worthy adversary. Additionally, participants learn that emotions can be on different floors of the Elevator—one can be scared, but also extremely curious and excited; extreme emotions, from one to many, hijack Wizard Brain thinking and replace it with Lizard Brain impulse. (3) Any emotion that is high on the elevator triggers Lizard Brain reactions, from being "crazy in love" to taking a

this as an external warning signal, he was able to control his behavior.

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

feel before an emotional or physical incident.

*5.3.4 Wise Way 4: exit the Emotions Elevator*

selfie in a dangerous location [76].

participants create individualized Emotions Elevators.

*5.3.3 Wise Way 3: Red Flag Warnings*

Internal Red Flags.

behaviors [85].

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

### *5.3.3 Wise Way 3: Red Flag Warnings*

*Inhibitory Control Training - A Multidisciplinary Approach*

to a stimulus.

addressed in Wise Ways 2–10.

city are presented by Kandel [78].

a support resource provides.

access the most useful sources.

*5.3.2 Wise Way 2: build a Constellation of Support*

This sets the stage for presenting a powerful piece of information. The skills participants learn in BrainWise help them build connections to their Wizard Brain so that when signals are sent to the relay center, they are diverted away from the Lizard Brain and to the Wizard Brain. This simplified explanation is easy for almost anyone to understand [35]. Each time participants learns a wise way, they draw a line from the relay center/Lizard Brain to the Wizard Brain. This process helps participants of all ages and abilities form a clear picture of how different parts of the brain respond

Wise Way 1 lays the foundation for the remaining skills by helping participants learn how the brain is involved in behaviors and what they can do to prevent and manage problems. As discussed in the previous section, the hierarchical model of self-regulation developed by Nigg [11] describes these processes as "top-down" and "bottom-up." The top-down processes are Wizard Brain responses that include executive functions and the complex planning, reasoning, and other coping strategies taught throughout the remaining Wise Ways. The bottom-up processes are all Lizard Brain reactions to events that arouse strong emotions. These will be

The lesson ends with participants drawing a line on the brain worksheet to show that Wise Way 1 helps them make a connection. Sapolsky [76] presents this process in a discussion about how the ventromedial prefrontal cortex forms connections with the limbic system, and the biological processes underlying such neuroplasti-

Research supports the importance of human connection [99–102] and identifies how support systems can be lifelines out of loneliness, helplessness, sadness, and other feelings of being isolated. Wise Way 2 helps people learn how to create and use an effective support network by teaching about resources for different types of

Participants learn to identify a wider range of sources they can go to for help, a process that increases their awareness of the benefits of sources they previously may not have considered. This includes learning that valued help takes many forms human, animal, spiritual, and inanimate—and that we all need to identify and

The Constellation of Support shows that we connect with the "stars" in our constellation in three ways: (1) Broken Line (not helpful), (2) Single Line (not unhelpful, but not helpful either), or (3) Double Lines (helpful). This activity creates awareness that broken lines may include unthinking friends and family, members with their own set of problems who do not realize that alternative help is available or how to access it. The course instructor is always a double line for the client or student and is a resource for other support sources. This lesson and visual teaching activities are valuable tools that help participants assess the degree of help

The science of social support is complex and involves many biological pathways, including neuropeptides, genes, and hormones [76, 105]. These studies are consistent with the advantages of utilizing resources and support, a concept that is taught as a key connection to the Wizard Brain. Participants learn that the Constellation of Support is complicated, and resources can be deceptive, potentially causing problems instead of preventing them if one is not careful. The lesson makes individuals aware that help is always available and the skills they are learning will help them

support, as well as how to find and access dependable support sources.

access different types of support for our various problems [103, 104].

**92**

Teaching about Red Flag Warnings builds on what participants learned about the Lizard Brain's bottom-up arousal. The body's five senses continuously receive sensory cues, and this lesson creates awareness of signals that warn "something is going to happen." Individuals learn about their unique sensations warning of problems and the importance of recognizing two types: External Red Flags and Internal Red Flags.

External Red Flags are audio signals, such as a siren, or visual cues, such as gang colors or empty beer cans on the front porch. Participants learn to identify how they react to red flags, especially in problem situations. This recognition creates an awareness of maladaptive behaviors. For example, one client realized that he would turn his head and spit immediately before he lost his temper. When he recognized this as an external warning signal, he was able to control his behavior.

Internal Red Flags are what a person feels inside, a key component of emotion regulation. Participants may say, "I feel mad," or name emotions such as frustration, sadness, loneliness, and unhappiness. Instructors ask them to describe what they feel inside, probing to identify physical sensations such as tight muscles, hot flashes, and upset stomach. Helping them become aware of internal red flags is as important for 5-year-olds as it is for older youth and adults. Instructors and parents find that students with ADHD and autism can learn to identify internal sensations they may feel before an emotional or physical incident.

The Red Flag Warnings content includes teaching aids and activities that promote reinforcement. Participants, including adults, make personalized red flags and list their Internal Red Flags on one side and External Red Flags on the other. Young children complete Red Flag Buddy worksheets, marking areas where they feel red flags. This awareness helps prepare them for times when sensory information streams toward their brains and rapidly, powerfully, and automatically triggers behaviors [85].

After they learn the lesson, they draw a line on the brain worksheet showing that they are building another connection to their Wizard Brain. This seemingly simple process puts into practice the neuroscience behind emotions and impulse [76] and gives instructors a segue to the next lesson on emotions and how to control them.

#### *5.3.4 Wise Way 4: exit the Emotions Elevator*

The Constellation of Support and Red Flag Warnings lessons prepare participants to learn about their emotions and techniques to control them using their Wizard Brain. The first part of the lesson explains emotions by using the metaphor of an elevator, but instructors can use metaphors that may be more familiar to their students; e.g., instructors in rural China and India use fires and volcanoes, so participants create individualized Emotions Elevators.

In the context of teaching Wise Way 4, participants learn the following: (1) Emotions are cumulative and have a range of intensity [22]. BrainWise teaches that the first floor is low emotion and the higher floors are out of control. (2) Multiple emotions are experienced simultaneously, e.g., one can be enraged but also feel admiration for a worthy adversary. Additionally, participants learn that emotions can be on different floors of the Elevator—one can be scared, but also extremely curious and excited; extreme emotions, from one to many, hijack Wizard Brain thinking and replace it with Lizard Brain impulse. (3) Any emotion that is high on the elevator triggers Lizard Brain reactions, from being "crazy in love" to taking a selfie in a dangerous location [76].

They also learn that it is difficult to impossible to stop emotions when they hit the high floors of the Emotions Elevator. Lizard Brain reactions are swift, from uttering hateful words to acting in anger. Participants learn to distinguish between helpful emotions and toxic emotions and are taught that skills help them control their emotions to decrease stress and promote healthy behaviors [24, 31].

The second part of the lesson teaches them how to stay off their Emotions Elevators or how to stay on the lower floors, so they can access the Wizard Brain. These techniques include strategies that help control emotions such as control self-talk, stop talking, leave the situation, redirect your emotions, and control relaxation. Instructors are encouraged to add any number of interventions that will help their clients and students regulate inhibition and improve self-control [85, 106, 107]. BrainWise helps participants recognize that many strategies are available and use the Wizard Brain to find what works best for them.

Skills to exit the Emotions Elevator are taught as behaviors used to promote Wizard Brain thinking and help participants build neural pathways to reroute Lizard Brain impulses. This process builds on Wise Ways 1–3 and lays a foundation for subsequent lessons.

#### *5.3.5 Wise Way 5: Fact vs. Opinion*

Fake news has existed for a long time. Parkinson [108] describes the propaganda, cooked-up stories, and hoaxes deliberately planted by Benjamin Franklin, John Adams, Nathaniel Hawthorne, and other Revolutionary leaders to instill fear in colonists against the British, Indians, and African Americans. Instructors have no shortage of examples of falsehoods and half-truths from past and present history as well as daily events in the participants' lives.

Research conducted by the Stanford History Education Group (SHEG) with 7804 middle school, high school and college students in 12 states found that students have a "dismaying" inability to tell fake news from real news [109]. SHEG is working with educators to create materials that help young people navigate the fake news they encounter online. These are the kinds of resources BrainWise instructors use to teach and reinforce Fact vs. Opinion.

These lessons promote awareness of the role emotions play in fostering Lizard Brain actions and spark discussion on how using Wise Ways 1–4 puts questionable information into perspective. At the end of the lesson, participants draw a line on the brain worksheet to show they have learned another skill to help them use their Wizard Brain to prevent and solve problems. Instructors encourage them to reinforce the lesson by applying the skill to relationships, work, and current events.

#### *5.3.6 Wise Way 6: ask questions and gather information*

Asking the right questions helps people separate facts from opinions. Participants recognize that learning to ask good questions involves using their Wizard Brain, being off (or low on) their Emotions Elevators and accessing reliable sources in their Constellation of Support. Participants may have little or no experience stopping to think about the information they need. The lesson is a primer on obtaining facts and helps individuals practice gathering them effectively. This skill strengthens the neural networks that help the Wizard Brain to regulate the emotional arousal of the Lizard Brain transition [76]. At the conclusion of the lesson, participants add another line to their brain worksheet, creating a visual reminder that the skills they are learning will help divert Lizard Brain impulses.

**95**

Brain.

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

Individuals dependent on their Lizard Brain often feel victimized. They are clueless about other choices because the limbic system's rapid-fire reactions drive their behavior and blind them to other choices they could make. The high intensity of their anger, sadness, despair, hopelessness, or other emotions they experience overcomes them, making it impossible to consider other choices [22]. Even if they

Exploring all of one's choices is a new concept for participants who rely mainly on their Lizard Brains. To bolster awareness of identifying and making choices, instructors ask participants to generate as many choices as they can, positive and negative, for problem situations. They are reminded to include "not making a choice." This activity helps change myopic perceptions that cause problems. Ericson and Laibson [107] discuss how myopic behavior creates "cognitive noise" that causes perceptual limitations. Wise Way 7 helps participants expand their thinking about choices and prepares them for the next skill—considering the consequences

For many participants, considering consequences is a missing step. Learning the skill and using it can be an "Aha!" moment for them. People who have never learned consequential thinking fall back on Lizard Brain impulses. Being aware not only that they have choices, but that they can determine the best choice by considering the consequences now and later (CNL) and the consequences affecting others

Thinking about the outcomes of choices is complicated [2, 76, 107]. This lesson teaches consequential thinking in the context of the seven preceding skills. It provides a framework that helps individuals put the lessons together as part of the Wizard Brain thinking that usurps harmful Lizard Brain reactions. Considering the impact of choices involves future thinking (i.e., executive functions) and inhibitory control, instructors may use this introduction to expand the lesson to discussions of mental health, diets, the environment, relationships, education, and finances.

One teenager referred to CNL as the "thinking skill that saved my life." She said she was considering committing suicide and did not follow through because she thought about the consequences her death would have on her mother. She wrote her teacher a testimonial about the incident. Another student at her school had recently committed suicide, and we are grateful she did not repeat the act. Her positive choice is supported by research showing that people who are suicidal or self-injure have decreased neurocognitive functions and an absence of inhibitory control [111]. Lizard Brain dominance eliminates consequential thinking as emotions hijack thinking. Sadly, we know that even strong Wizard Brain connections are not a guarantee against harmful behaviors, but they are helpful for prevention and intervention. When participants draw lines on their brain worksheets indicating they have learned another connection, they know that practice strengthens the connections. They also begin to recognize positive results they attribute to using their Wizard

Translating goals to behaviors requires using multiple Wise Ways. People who have never been taught how to apply goal setting to achieve success—graduating, losing weight, making friends, getting sober—often rely on Lizard Brain reactions

want to make good choices, they fail to follow through [110].

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

*5.3.7 Wise Way 7: Identify choices (IDC)*

of making a choice.

*5.3.8 Wise Way 8: consider consequences*

(CAO) gives them options they never knew they had.

*5.3.9 Wise Way 9: set goals and plans for action*

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

#### *5.3.7 Wise Way 7: Identify choices (IDC)*

*Inhibitory Control Training - A Multidisciplinary Approach*

for subsequent lessons.

*5.3.5 Wise Way 5: Fact vs. Opinion*

well as daily events in the participants' lives.

use to teach and reinforce Fact vs. Opinion.

*5.3.6 Wise Way 6: ask questions and gather information*

They also learn that it is difficult to impossible to stop emotions when they hit the high floors of the Emotions Elevator. Lizard Brain reactions are swift, from uttering hateful words to acting in anger. Participants learn to distinguish between helpful emotions and toxic emotions and are taught that skills help them control

their emotions to decrease stress and promote healthy behaviors [24, 31].

help their clients and students regulate inhibition and improve self-control [85, 106, 107]. BrainWise helps participants recognize that many strategies are

available and use the Wizard Brain to find what works best for them.

The second part of the lesson teaches them how to stay off their Emotions Elevators or how to stay on the lower floors, so they can access the Wizard Brain. These techniques include strategies that help control emotions such as control self-talk, stop talking, leave the situation, redirect your emotions, and control relaxation. Instructors are encouraged to add any number of interventions that will

Skills to exit the Emotions Elevator are taught as behaviors used to promote Wizard Brain thinking and help participants build neural pathways to reroute Lizard Brain impulses. This process builds on Wise Ways 1–3 and lays a foundation

Fake news has existed for a long time. Parkinson [108] describes the propaganda, cooked-up stories, and hoaxes deliberately planted by Benjamin Franklin, John Adams, Nathaniel Hawthorne, and other Revolutionary leaders to instill fear in colonists against the British, Indians, and African Americans. Instructors have no shortage of examples of falsehoods and half-truths from past and present history as

Research conducted by the Stanford History Education Group (SHEG) with 7804 middle school, high school and college students in 12 states found that students have a "dismaying" inability to tell fake news from real news [109]. SHEG is working with educators to create materials that help young people navigate the fake news they encounter online. These are the kinds of resources BrainWise instructors

These lessons promote awareness of the role emotions play in fostering Lizard Brain actions and spark discussion on how using Wise Ways 1–4 puts questionable information into perspective. At the end of the lesson, participants draw a line on the brain worksheet to show they have learned another skill to help them use their Wizard Brain to prevent and solve problems. Instructors encourage them to reinforce the lesson by applying the skill to relationships, work, and

Asking the right questions helps people separate facts from opinions. Participants recognize that learning to ask good questions involves using their Wizard Brain, being off (or low on) their Emotions Elevators and accessing reliable sources in their Constellation of Support. Participants may have little or no experience stopping to think about the information they need. The lesson is a primer on obtaining facts and helps individuals practice gathering them effectively. This skill strengthens the neural networks that help the Wizard Brain to regulate the emotional arousal of the Lizard Brain transition [76]. At the conclusion of the lesson, participants add another line to their brain worksheet, creating a visual reminder that the skills they are learning will help divert Lizard Brain

**94**

impulses.

current events.

Individuals dependent on their Lizard Brain often feel victimized. They are clueless about other choices because the limbic system's rapid-fire reactions drive their behavior and blind them to other choices they could make. The high intensity of their anger, sadness, despair, hopelessness, or other emotions they experience overcomes them, making it impossible to consider other choices [22]. Even if they want to make good choices, they fail to follow through [110].

Exploring all of one's choices is a new concept for participants who rely mainly on their Lizard Brains. To bolster awareness of identifying and making choices, instructors ask participants to generate as many choices as they can, positive and negative, for problem situations. They are reminded to include "not making a choice." This activity helps change myopic perceptions that cause problems. Ericson and Laibson [107] discuss how myopic behavior creates "cognitive noise" that causes perceptual limitations. Wise Way 7 helps participants expand their thinking about choices and prepares them for the next skill—considering the consequences of making a choice.

#### *5.3.8 Wise Way 8: consider consequences*

For many participants, considering consequences is a missing step. Learning the skill and using it can be an "Aha!" moment for them. People who have never learned consequential thinking fall back on Lizard Brain impulses. Being aware not only that they have choices, but that they can determine the best choice by considering the consequences now and later (CNL) and the consequences affecting others (CAO) gives them options they never knew they had.

Thinking about the outcomes of choices is complicated [2, 76, 107]. This lesson teaches consequential thinking in the context of the seven preceding skills. It provides a framework that helps individuals put the lessons together as part of the Wizard Brain thinking that usurps harmful Lizard Brain reactions. Considering the impact of choices involves future thinking (i.e., executive functions) and inhibitory control, instructors may use this introduction to expand the lesson to discussions of mental health, diets, the environment, relationships, education, and finances.

One teenager referred to CNL as the "thinking skill that saved my life." She said she was considering committing suicide and did not follow through because she thought about the consequences her death would have on her mother. She wrote her teacher a testimonial about the incident. Another student at her school had recently committed suicide, and we are grateful she did not repeat the act. Her positive choice is supported by research showing that people who are suicidal or self-injure have decreased neurocognitive functions and an absence of inhibitory control [111].

Lizard Brain dominance eliminates consequential thinking as emotions hijack thinking. Sadly, we know that even strong Wizard Brain connections are not a guarantee against harmful behaviors, but they are helpful for prevention and intervention. When participants draw lines on their brain worksheets indicating they have learned another connection, they know that practice strengthens the connections. They also begin to recognize positive results they attribute to using their Wizard Brain.

#### *5.3.9 Wise Way 9: set goals and plans for action*

Translating goals to behaviors requires using multiple Wise Ways. People who have never been taught how to apply goal setting to achieve success—graduating, losing weight, making friends, getting sober—often rely on Lizard Brain reactions that sabotage their good intentions and lead to failure. Their high Emotions Elevator excitement may not be directed in an adaptive manner to get sober, lose weight, exercise, or achieve whatever goal they set, and instead it fuels a greater desire to drink, eat, and give up.

Industries have been built around goal setting and ways to motivate people to change and sustain behaviors. Even people who have thinking skills are stymied by powerful emotions that destroy goals. This lesson creates awareness of the delicate balance between the Wizard Brain and Lizard Brain. Our brains can be tricky, and it helps when people understand how to obtain resources, why Lizard Brain responses can dominate, and what boosts Wizard Brain thinking. Participants learn that people who achieve their goals know how to manage the bottom-up Lizard Brain urges with top-down Wizard Brain skills. These lessons, activities, and problemsolving worksheets are additional tools that help participants use their brains to make good choices.

## *5.3.10 Wise Way 10: communicate effectively*

This skill is taught at the end of the course because its successful implementation requires knowledge and use of the preceding nine Wise Ways. It is divided into three sections: verbal communication, nonverbal communication, and assertive communication.

The teaching activities include participant role plays that demonstrate using "I" messages, sending double messages, taking other people's point of view, and discussing the simultaneous use of communication with other Wise Ways. Participants learn to differentiate between assertive communication behaviors and passive, aggressive, and passive-aggressive behaviors. The lesson includes discussions about replacing Lizard Brain reactions with Wizard Brain behaviors, using support resources, recognizing red flag warnings, understanding the role emotions play, separating fact from opinion, asking questions, identifying choices, and setting goals.

Participants draw the tenth line on their brain worksheet to show that they have learned how to build another brain connection. They know that if they do not practice and use the skills, the links to the Wizard Brain weaken and disappear and are quickly replaced by Lizard Brain reactions.

The BrainWise curriculum was developed for nonscientists—the children, youth, and adults who take the course to learn skills that will help them make healthy decisions. It presents information in an easily understood format, so that it will be practiced until the skills and behaviors are automatic and retained [112]. Retention indicates mastery of the 10 Wise Ways. Program graduates are aware of the difference between Lizard Brain and Wizard Brain behaviors and have skills that make it easier to choose healthy behaviors.

## **5.4 BrainWise efficacy with populations exposed to childhood maltreatment and poverty—research with schools and families**

Consistent, positive results have been reported on evaluations conducted across a variety of populations by different researchers. Participants in these studies include children living below the poverty line who have experienced multiple Adverse Childhood Experiences (ACEs), including maltreatment. A primary context for studying the effectiveness of BrainWise has been in schools identified as "at-risk." One study compared a group of inner-city middle school students who were taught BrainWise with a matched control group. The results found that students who took BrainWise demonstrated significant changes in decreasing physical

**97**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

aggression, reducing negative feelings, and increasing peer acceptance. They also showed improvements on a belief scale and moral order scale. The control group showed no changes. A student described the program by stating, "It doesn't change the person. It changes how the person thinks" [113]. In another study described by Barry and Welsh [95], students given the BrainWise curriculum in schools in a large metropolitan district were administered executive function tasks, Tower of London and Stroop, in a pre-post design. The findings indicated students who learned BrainWise showed improvements on the measures, and knowledge of the 10 Wise Ways also was related to self-reported executive function skills [113]. Pre- and postdata also were collected on 539 K–5 students who took BrainWise. Teachers rated the children on goal-oriented behavior, decision-making, emotional regulation, self-management, self-awareness, and relationship skills. Significant improvements

The efficacy of the BrainWise curriculum also has been demonstrated in public health contexts. Research was conducted on BrainWise by public health nurses working with at-risk families at a state agency. All the families had more than one child and presented risk behaviors and health problems: some had histories of child abuse, 75% were single parents with less than 12 years of education, and 61% were unemployed. The nurses visited the families a minimum of four times and measured outcomes using a Life Skills Progression checklist. Following each visit, the nurse used the checklist to measure parental behaviors. Data collected on 112 families found improvement on all 39 life-skill variables and significant improve-

There is a small, emerging literature on the effect of homelessness on neuropsychological impairment, including the evidence discussed in Section 4.3, but studies with comparison groups are rare [116]. We conducted a study of the BrainWise program delivered to homeless men at a transitional housing facility [35]. The homeless organization serving the men in our study presented a rare opportunity to conduct research with a comparison group. The men in both groups had progressed from the intake phase to transitional housing, indicating high motivation to change

The treatment group (N = 210) was taught BrainWise in Phase 1 of the treatment that included services such as counseling and case management, along with classes in life skills, career training, education, and spiritual development. The control group (N = 66) received all the services and classes with the exception of BrainWise. A staff counselor taught BrainWise and customized the examples using problems and situations typical of those the men faced. She consolidated the lessons and taught them during the first week of the men's placement. She reinforced the concepts outside the classroom during her daily interactions with the men. Other staff and volunteers received training in BrainWise and reinforced the lessons dur-

The men completed pretests and posttests on validated instruments that included eight scales measuring executive functions (Behavior Rating Scale for Executive Function, or BRIEF), one scale measuring coping self-efficacy (Coping Self-Efficacy Scale, or CSES), a self-report on problem solving skills (Wasik Problem Solving Rating Scale, or WPSRS), and a scale that measured participants' knowledge of the thinking and emotional skills taught in BrainWise (BrainWise Knowledge Survey, or BKS). These instruments were found to be reliable for a sample unaccustomed to taking such measures. They were administered the post-

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

were noted on all measures [114].

ment on 24 variables [115].

**5.5 BrainWise efficacy with homeless men**

the behaviors that contributed to their homelessness.

ing their interactions with the men.

test 4 months after learning the 10 Wise Ways.

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

aggression, reducing negative feelings, and increasing peer acceptance. They also showed improvements on a belief scale and moral order scale. The control group showed no changes. A student described the program by stating, "It doesn't change the person. It changes how the person thinks" [113]. In another study described by Barry and Welsh [95], students given the BrainWise curriculum in schools in a large metropolitan district were administered executive function tasks, Tower of London and Stroop, in a pre-post design. The findings indicated students who learned BrainWise showed improvements on the measures, and knowledge of the 10 Wise Ways also was related to self-reported executive function skills [113]. Pre- and postdata also were collected on 539 K–5 students who took BrainWise. Teachers rated the children on goal-oriented behavior, decision-making, emotional regulation, self-management, self-awareness, and relationship skills. Significant improvements were noted on all measures [114].

The efficacy of the BrainWise curriculum also has been demonstrated in public health contexts. Research was conducted on BrainWise by public health nurses working with at-risk families at a state agency. All the families had more than one child and presented risk behaviors and health problems: some had histories of child abuse, 75% were single parents with less than 12 years of education, and 61% were unemployed. The nurses visited the families a minimum of four times and measured outcomes using a Life Skills Progression checklist. Following each visit, the nurse used the checklist to measure parental behaviors. Data collected on 112 families found improvement on all 39 life-skill variables and significant improvement on 24 variables [115].

#### **5.5 BrainWise efficacy with homeless men**

There is a small, emerging literature on the effect of homelessness on neuropsychological impairment, including the evidence discussed in Section 4.3, but studies with comparison groups are rare [116]. We conducted a study of the BrainWise program delivered to homeless men at a transitional housing facility [35]. The homeless organization serving the men in our study presented a rare opportunity to conduct research with a comparison group. The men in both groups had progressed from the intake phase to transitional housing, indicating high motivation to change the behaviors that contributed to their homelessness.

The treatment group (N = 210) was taught BrainWise in Phase 1 of the treatment that included services such as counseling and case management, along with classes in life skills, career training, education, and spiritual development. The control group (N = 66) received all the services and classes with the exception of BrainWise. A staff counselor taught BrainWise and customized the examples using problems and situations typical of those the men faced. She consolidated the lessons and taught them during the first week of the men's placement. She reinforced the concepts outside the classroom during her daily interactions with the men. Other staff and volunteers received training in BrainWise and reinforced the lessons during their interactions with the men.

The men completed pretests and posttests on validated instruments that included eight scales measuring executive functions (Behavior Rating Scale for Executive Function, or BRIEF), one scale measuring coping self-efficacy (Coping Self-Efficacy Scale, or CSES), a self-report on problem solving skills (Wasik Problem Solving Rating Scale, or WPSRS), and a scale that measured participants' knowledge of the thinking and emotional skills taught in BrainWise (BrainWise Knowledge Survey, or BKS). These instruments were found to be reliable for a sample unaccustomed to taking such measures. They were administered the posttest 4 months after learning the 10 Wise Ways.

*Inhibitory Control Training - A Multidisciplinary Approach*

drink, eat, and give up.

make good choices.

communication.

goals.

*5.3.10 Wise Way 10: communicate effectively*

are quickly replaced by Lizard Brain reactions.

make it easier to choose healthy behaviors.

**and poverty—research with schools and families**

that sabotage their good intentions and lead to failure. Their high Emotions Elevator excitement may not be directed in an adaptive manner to get sober, lose weight, exercise, or achieve whatever goal they set, and instead it fuels a greater desire to

Industries have been built around goal setting and ways to motivate people to change and sustain behaviors. Even people who have thinking skills are stymied by powerful emotions that destroy goals. This lesson creates awareness of the delicate balance between the Wizard Brain and Lizard Brain. Our brains can be tricky, and it helps when people understand how to obtain resources, why Lizard Brain responses can dominate, and what boosts Wizard Brain thinking. Participants learn that people who achieve their goals know how to manage the bottom-up Lizard Brain urges with top-down Wizard Brain skills. These lessons, activities, and problemsolving worksheets are additional tools that help participants use their brains to

This skill is taught at the end of the course because its successful implementation requires knowledge and use of the preceding nine Wise Ways. It is divided into three sections: verbal communication, nonverbal communication, and assertive

The teaching activities include participant role plays that demonstrate using "I" messages, sending double messages, taking other people's point of view, and discussing the simultaneous use of communication with other Wise Ways. Participants learn to differentiate between assertive communication behaviors and passive, aggressive, and passive-aggressive behaviors. The lesson includes discussions about replacing Lizard Brain reactions with Wizard Brain behaviors, using support resources, recognizing red flag warnings, understanding the role emotions play, separating fact from opinion, asking questions, identifying choices, and setting

Participants draw the tenth line on their brain worksheet to show that they have learned how to build another brain connection. They know that if they do not practice and use the skills, the links to the Wizard Brain weaken and disappear and

The BrainWise curriculum was developed for nonscientists—the children, youth, and adults who take the course to learn skills that will help them make healthy decisions. It presents information in an easily understood format, so that it will be practiced until the skills and behaviors are automatic and retained [112]. Retention indicates mastery of the 10 Wise Ways. Program graduates are aware of the difference between Lizard Brain and Wizard Brain behaviors and have skills that

**5.4 BrainWise efficacy with populations exposed to childhood maltreatment** 

a variety of populations by different researchers. Participants in these studies include children living below the poverty line who have experienced multiple Adverse Childhood Experiences (ACEs), including maltreatment. A primary context for studying the effectiveness of BrainWise has been in schools identified as "at-risk." One study compared a group of inner-city middle school students who were taught BrainWise with a matched control group. The results found that students who took BrainWise demonstrated significant changes in decreasing physical

Consistent, positive results have been reported on evaluations conducted across

**96**

The results demonstrated that the men in the treatment group improved on a much wider range of executive functions (including inhibitory control), coping self-efficacy, and BrainWise knowledge than the men in the comparison group. This provided evidence that BrainWise positively influences critical skills for adaptive functioning and resilience. These improved skills and knowledge will likely help them better face the many daily challenges, such as maintaining healthy relationships, holding jobs, and becoming productive members of society [35].

## **6. Vulnerable veteran populations and the BrainWise intervention**

## **6.1 Veteran homelessness and serious mental illness**

The promising results of the preceding study have given rise to an effort to study the implementation of BrainWise within the U.S. Department of Veterans Affairs (VA). Homelessness among veterans is a sizeable and urgent problem and addressing it is a high priority for VA. According to the 2018 Annual Homeless Assessment Report (AHAR) to Congress, nearly 38,000 Veterans in the U.S. were experiencing homelessness on a single night, of whom roughly 14,500 were completely unsheltered [115]. The cornerstone of the VA's efforts to reduce veteran homelessness is the Housing and Urban Development–Veterans Affairs Supported Housing (HUD-VASH) program, which provides housing subsidies and case management services to eligible veterans. HUD-VASH has been instrumental in reducing the nation's homeless veteran population, which dropped by 52% from 2009 to 2018 [117]. However, many veterans in the program fail to obtain housing, and many who do subsequently return to homelessness [118]. Clearly, despite access to similar resources, many veterans are not succeeding. While the reasons for this are complex, individual characteristics account for some of these disparate outcomes. In particular, serious mental illnesses such as schizophrenia and bipolar disorder [119, 120] and substance use disorders [121] are major risk factors for homelessness among veterans.

## **6.2 Combat-related risk factors for executive dysfunction**

Given disproportionate rates of mental illness among Veterans, the impairments in executive functions related to a variety of psychiatric conditions discussed in Section 4.4 are especially relevant to this population [67]. In addition, veterans are at unique risk for combat-related posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). PTSD and TBI, which frequently co-occur, are considered signature conditions of the wars in Iraq and Afghanistan due to their high prevalence among this cohort [122]. PTSD is associated with impaired executive function irrespective of current symptom severity [123]. Similarly, because the frontal lobes are particularly susceptible to traumatic injury, deficits in executive function are common sequelae of TBI, even in mild cases [124]. Rabinowitz and Levin highlight the negative impact of moderate to severe TBI on judgment and everyday decision making, suggesting a possible role for the BrainWise program given its emphasis on and approach to decision making skills [125]. Specifically, TBI can disrupt the process of associating visceral emotional responses with positive and negative outcomes. TBI impacts several aspects of decision making, including impulsivity, risk adjustment, and rational choice, owing to abnormalities in the anatomic regions responsible for each of these functions [126]. Although untested in this regard, the BrainWise program's emphasis on strengthening systems of emotional control and reinforcing neural pathways involved in adaptive decision making may be well suited as a rehabilitative strategy for persons with TBI.

**99**

**Figure 2.**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

As previously discussed in Sections 4.1–4.4, homelessness itself, predisposing factors for homelessness such as poverty and childhood maltreatment, factors resulting from homelessness such as stress and social exclusion, psychiatric illness in general, and veteran-specific conditions such as combat PTSD and TBI are all associated with impairments in executive functions. Many individuals are burdened by several of these factors. In turn, there is evidence that executive functions mediate several processes may which impact a person's ability to obtain housing and remain housed, such as risk-taking behaviors, conduct problems (e.g., violent behavior), and aspects of self-care. Taken together, a conceptual model begins to emerge by which we can represent some of the relationships between executive function, factors that impact it, and its effect on housing outcomes (**Figure 2**). The symbols indicate positive (+) and negative (−) associations. As shown in the model, executive functions appear to have both direct and indirect effects on housing stability. For example, poor planning can lead directly to loss of housing (e.g., via failure to pay rent), and poor inhibitory control can lead to behaviors such as substance use and conduct problems which then lead to housing loss. Of note, a number of possible points of intervention within the model are addressed by existing VA services—treatment of mental illness, TBI, and substance use, provision of housing services, and case management to address psychosocial needs—but a focus on executive functions is not among these. The possibility of intervening to improve executive functions presents an opportunity to augment existing VA services with the aim of improving housing outcomes for homeless veterans. BrainWise was selected for this purpose because it is the only program known to have evidence for

**6.3 Conceptual model of executive functions and veteran homelessness**

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

improving executive functions in homeless individuals.

*Conceptual model of life stress, executive functions and housing stability.*

**6.4 Adaptation of BrainWise for homeless veterans with serious mental illness**

The chapter authors, working with other investigators at VA, have developed a proposal to adapt the BrainWise curriculum for use with homeless and recently homeless veterans diagnosed with serious mental illness, using input from VA staff and veterans themselves. The initial pilot study would be carried out at the Greater Los Angeles VA Medical Center, in an integrated care clinic for homeless veterans called a Homeless Patient-Aligned Care Team (HPACT). HPACT services include primary care, mental health and substance use treatment, and case management, with care tailored to the unique needs of homeless veterans. The HPACT model has resulted in a number of positive outcomes [121, 127] and presents an opportune

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

## **6.3 Conceptual model of executive functions and veteran homelessness**

As previously discussed in Sections 4.1–4.4, homelessness itself, predisposing factors for homelessness such as poverty and childhood maltreatment, factors resulting from homelessness such as stress and social exclusion, psychiatric illness in general, and veteran-specific conditions such as combat PTSD and TBI are all associated with impairments in executive functions. Many individuals are burdened by several of these factors. In turn, there is evidence that executive functions mediate several processes may which impact a person's ability to obtain housing and remain housed, such as risk-taking behaviors, conduct problems (e.g., violent behavior), and aspects of self-care. Taken together, a conceptual model begins to emerge by which we can represent some of the relationships between executive function, factors that impact it, and its effect on housing outcomes (**Figure 2**).

The symbols indicate positive (+) and negative (−) associations. As shown in the model, executive functions appear to have both direct and indirect effects on housing stability. For example, poor planning can lead directly to loss of housing (e.g., via failure to pay rent), and poor inhibitory control can lead to behaviors such as substance use and conduct problems which then lead to housing loss. Of note, a number of possible points of intervention within the model are addressed by existing VA services—treatment of mental illness, TBI, and substance use, provision of housing services, and case management to address psychosocial needs—but a focus on executive functions is not among these. The possibility of intervening to improve executive functions presents an opportunity to augment existing VA services with the aim of improving housing outcomes for homeless veterans. BrainWise was selected for this purpose because it is the only program known to have evidence for improving executive functions in homeless individuals.

## **6.4 Adaptation of BrainWise for homeless veterans with serious mental illness**

The chapter authors, working with other investigators at VA, have developed a proposal to adapt the BrainWise curriculum for use with homeless and recently homeless veterans diagnosed with serious mental illness, using input from VA staff and veterans themselves. The initial pilot study would be carried out at the Greater Los Angeles VA Medical Center, in an integrated care clinic for homeless veterans called a Homeless Patient-Aligned Care Team (HPACT). HPACT services include primary care, mental health and substance use treatment, and case management, with care tailored to the unique needs of homeless veterans. The HPACT model has resulted in a number of positive outcomes [121, 127] and presents an opportune

**Figure 2.** *Conceptual model of life stress, executive functions and housing stability.*

*Inhibitory Control Training - A Multidisciplinary Approach*

**6.1 Veteran homelessness and serious mental illness**

The results demonstrated that the men in the treatment group improved on a much wider range of executive functions (including inhibitory control), coping self-efficacy, and BrainWise knowledge than the men in the comparison group. This provided evidence that BrainWise positively influences critical skills for adaptive functioning and resilience. These improved skills and knowledge will likely help them better face the many daily challenges, such as maintaining healthy relation-

ships, holding jobs, and becoming productive members of society [35].

**6. Vulnerable veteran populations and the BrainWise intervention**

use disorders [121] are major risk factors for homelessness among veterans.

Given disproportionate rates of mental illness among Veterans, the impairments in executive functions related to a variety of psychiatric conditions discussed in Section 4.4 are especially relevant to this population [67]. In addition, veterans are at unique risk for combat-related posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). PTSD and TBI, which frequently co-occur, are considered signature conditions of the wars in Iraq and Afghanistan due to their high prevalence among this cohort [122]. PTSD is associated with impaired executive function irrespective of current symptom severity [123]. Similarly, because the frontal lobes are particularly susceptible to traumatic injury, deficits in executive function are common sequelae of TBI, even in mild cases [124]. Rabinowitz and Levin highlight the negative impact of moderate to severe TBI on judgment and everyday decision making, suggesting a possible role for the BrainWise program given its emphasis on and approach to decision making skills [125]. Specifically, TBI can disrupt the process of associating visceral emotional responses with positive and negative outcomes. TBI impacts several aspects of decision making, including impulsivity, risk adjustment, and rational choice, owing to abnormalities in the anatomic regions responsible for each of these functions [126]. Although untested in this regard, the BrainWise program's emphasis on strengthening systems of emotional control and reinforcing neural pathways involved in adaptive decision making may be well

**6.2 Combat-related risk factors for executive dysfunction**

suited as a rehabilitative strategy for persons with TBI.

The promising results of the preceding study have given rise to an effort to study the implementation of BrainWise within the U.S. Department of Veterans Affairs (VA). Homelessness among veterans is a sizeable and urgent problem and addressing it is a high priority for VA. According to the 2018 Annual Homeless Assessment Report (AHAR) to Congress, nearly 38,000 Veterans in the U.S. were experiencing homelessness on a single night, of whom roughly 14,500 were completely unsheltered [115]. The cornerstone of the VA's efforts to reduce veteran homelessness is the Housing and Urban Development–Veterans Affairs Supported Housing (HUD-VASH) program, which provides housing subsidies and case management services to eligible veterans. HUD-VASH has been instrumental in reducing the nation's homeless veteran population, which dropped by 52% from 2009 to 2018 [117]. However, many veterans in the program fail to obtain housing, and many who do subsequently return to homelessness [118]. Clearly, despite access to similar resources, many veterans are not succeeding. While the reasons for this are complex, individual characteristics account for some of these disparate outcomes. In particular, serious mental illnesses such as schizophrenia and bipolar disorder [119, 120] and substance

**98**

venue for implementation of innovations that fill service gaps. The design and procedures of this proposed pilot study are described, below.

During an initial adaptation phase, the research team interview key stakeholders consisting of clinicians and administrators in the HPACT clinic and HUD-VASH program, as well as homeless veterans from an established Veteran Engagement Group. The BrainWise program and materials are described and shown to the stakeholders, who are then asked to provide input regarding aspects of the curriculum that appear most and least relevant, barriers or problems they anticipate in delivering the intervention, situations homeless veterans face which could be used as teaching examples, and other suggestions or thoughts they may have. The interviews are recorded, transcribed, and analyzed using qualitative research methods in order to identify salient themes and extract information to be used to guide the initial adaptation of the BrainWise materials.

The adapted curriculum is taught in a series of weekly sessions to two groups of approximately 8–12 HPACT patients diagnosed with schizophrenia or other forms of psychosis, with or without a substance use disorder. Immediately following each intervention session, participants provide feedback on the session, and this information is recorded, analyzed, used to conduct further modifications of the curriculum based on input from participants. At the same time, the research team monitors the fidelity of the adapted curriculum to assure that core BrainWise elements are retained.

In addition to the development of content and format tailored to this population, the key outcomes of interest for this pilot study are the feasibility and acceptability of the intervention for the population of homeless veterans with psychotic disorders. We would also gather preliminary data on the effects of the intervention on executive functions, BrainWise content knowledge, substance use, and housing trajectory, by assessing these variables prior to and immediately following the intervention course. Although such results are not intended to be conclusive due to the lack of a control group and the small number of participants planned for the initial study, conducting these assessments would provide valuable information about the feasibility of the data collection methods in this population. It would also yield descriptive statistics that would assist in planning a larger controlled trial of the adapted BrainWise curriculum. Our hope is that this work may form the foundation for the wide-scale incorporation of BrainWise programming into homeless services throughout VA, and more importantly that the tools gained from the program can help these vulnerable veterans emerge from homelessness and more successfully navigate their everyday lives.

## **7. Conclusions**

Researchers continue to explore the diverse manifestations of inhibitory control across development, as well as its importance to the adaptive domains of executive functions and self-regulation. The brain systems critical to the normal development of these skills are guided by genetic and epigenetic phenomenon, as well as supported by an environment that provides learning opportunities and age-appropriate challenges. However, it is also clear that the brain systems underlying inhibitory control are vulnerable to a variety of stressors, which can result is differences in developmental trajectories and functioning. Research also confirms that such life stressors as poverty, childhood maltreatment, homelessness, and mental illness, are associated with impaired functioning in inhibitory control, executive functions, and overall self-regulation.

In this chapter, we introduced the BrainWise program as a universal curriculum that translates basic biological science to prevention skills taught by educators and

**101**

**Author details**

Marilyn Welsh1

2 BrainWise, Denver, CO, USA

System, Los Angeles, CA, USA

provided the original work is properly cited.

CO, USA

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

health providers. We discussed how its approach optimizes findings on effective interventions, simplifies their delivery, and integrates them with brain science. The section described the 10 skills instructors teach to students and clients and the scientific support for each one, and presented research that had been conducted

We gave examples of how the program has been successfully used with elementary, middle, and high school students as well as families on welfare and homelessexperienced men, shared research on the program's outcomes, and provided access to additional resources. The information provided a template showing how science can be scaled to develop lessons that teach thinking skills to diverse populations and reach individuals who will benefit from learning executive functions, including

Finally, we suggest an application of the BrainWise curriculum to a very vulnerable population of veterans with serious mental illness, and potential TBI, who have experienced homelessness. The simplicity and accessibility of this intervention to a wide range of circumstances, as well as it's focus on some key executive function impairments in this population make this a promising direction for inquiry. At-risk and high-risk populations of individuals incur personal and societal costs of poor decision making and impulsive behaviors which may be ameliorated by appropri-

and Jared M. Greenberg3,4

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

with children, adolescents, and adults.

inhibitory control and emotional regulation.

ate, targeted, and flexible neurocognitive interventions.

\*, Patricia Gorman Barry2

\*Address all correspondence to: marilyn.welsh@unco.edu

1 School of Psychological Sciences, University of Northern Colorado, Greeley,

3 Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of

4 VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Medicine, University of California, Los Angeles, Los Angeles, CA, USA

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

health providers. We discussed how its approach optimizes findings on effective interventions, simplifies their delivery, and integrates them with brain science. The section described the 10 skills instructors teach to students and clients and the scientific support for each one, and presented research that had been conducted with children, adolescents, and adults.

We gave examples of how the program has been successfully used with elementary, middle, and high school students as well as families on welfare and homelessexperienced men, shared research on the program's outcomes, and provided access to additional resources. The information provided a template showing how science can be scaled to develop lessons that teach thinking skills to diverse populations and reach individuals who will benefit from learning executive functions, including inhibitory control and emotional regulation.

Finally, we suggest an application of the BrainWise curriculum to a very vulnerable population of veterans with serious mental illness, and potential TBI, who have experienced homelessness. The simplicity and accessibility of this intervention to a wide range of circumstances, as well as it's focus on some key executive function impairments in this population make this a promising direction for inquiry. At-risk and high-risk populations of individuals incur personal and societal costs of poor decision making and impulsive behaviors which may be ameliorated by appropriate, targeted, and flexible neurocognitive interventions.

## **Author details**

*Inhibitory Control Training - A Multidisciplinary Approach*

initial adaptation of the BrainWise materials.

navigate their everyday lives.

and overall self-regulation.

**7. Conclusions**

procedures of this proposed pilot study are described, below.

venue for implementation of innovations that fill service gaps. The design and

During an initial adaptation phase, the research team interview key stakeholders consisting of clinicians and administrators in the HPACT clinic and HUD-VASH program, as well as homeless veterans from an established Veteran Engagement Group. The BrainWise program and materials are described and shown to the stakeholders, who are then asked to provide input regarding aspects of the curriculum that appear most and least relevant, barriers or problems they anticipate in delivering the intervention, situations homeless veterans face which could be used as teaching examples, and other suggestions or thoughts they may have. The interviews are recorded, transcribed, and analyzed using qualitative research methods in order to identify salient themes and extract information to be used to guide the

The adapted curriculum is taught in a series of weekly sessions to two groups of approximately 8–12 HPACT patients diagnosed with schizophrenia or other forms of psychosis, with or without a substance use disorder. Immediately following each intervention session, participants provide feedback on the session, and this information is recorded, analyzed, used to conduct further modifications of the curriculum based on input from participants. At the same time, the research team monitors the fidelity of

In addition to the development of content and format tailored to this population, the key outcomes of interest for this pilot study are the feasibility and acceptability of the intervention for the population of homeless veterans with psychotic disorders. We would also gather preliminary data on the effects of the intervention on executive functions, BrainWise content knowledge, substance use, and housing trajectory, by assessing these variables prior to and immediately following the intervention course. Although such results are not intended to be conclusive due to the lack of a control group and the small number of participants planned for the initial study, conducting these assessments would provide valuable information about the feasibility of the data collection methods in this population. It would also yield descriptive statistics that would assist in planning a larger controlled trial of the adapted BrainWise curriculum. Our hope is that this work may form the foundation for the wide-scale incorporation of BrainWise programming into homeless services throughout VA, and more importantly that the tools gained from the program can help these vulnerable veterans emerge from homelessness and more successfully

Researchers continue to explore the diverse manifestations of inhibitory control across development, as well as its importance to the adaptive domains of executive functions and self-regulation. The brain systems critical to the normal development of these skills are guided by genetic and epigenetic phenomenon, as well as supported by an environment that provides learning opportunities and age-appropriate challenges. However, it is also clear that the brain systems underlying inhibitory control are vulnerable to a variety of stressors, which can result is differences in developmental trajectories and functioning. Research also confirms that such life stressors as poverty, childhood maltreatment, homelessness, and mental illness, are associated with impaired functioning in inhibitory control, executive functions,

In this chapter, we introduced the BrainWise program as a universal curriculum that translates basic biological science to prevention skills taught by educators and

the adapted curriculum to assure that core BrainWise elements are retained.

**100**

Marilyn Welsh1 \*, Patricia Gorman Barry2 and Jared M. Greenberg3,4

1 School of Psychological Sciences, University of Northern Colorado, Greeley, CO, USA

2 BrainWise, Denver, CO, USA

3 Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

4 VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

\*Address all correspondence to: marilyn.welsh@unco.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Sameroff A. A unified theory of development: A dialectic integration of nature and nurture. Child Development. 2010;**81**(1):6-22. DOI: 10.1111/j.1467-8624.2009.01378.x

[2] Blair C, Raver CC. Poverty, stress, and brain development: New directions for prevention and intervention. Academic Pediatrics. 2016;**16**(3):S30- S36. DOI: 10.1016/j.acap.2016.01.010

[3] Gilmore C, Attridge N, Clayton S, et al. Individual differences in inhibitory control, not non-verbal number acuity, correlate with mathematics achievement. PLoS One. 2013;**8**(6). DOI: 10.1371/journal.pone.0067374

[4] Houde' O, Borst GG. Measuring inhibitory control in children and adults: Brain imaging and mental chronometry. Frontiers in Psychology. 2014;**5**:1-7. DOI: 10.3389/ fpsyg.2014.00616

[5] Shulman EP, Smith AR, Silva K, et al. The dual systems model: Review, reappraisal, and reaffirmation. Developmental Cognitive Neuroscience. 2016;**17**:103-117. DOI: 10.1016/j. dcn.2015.12.010

[6] Geurts HM, Van Den Bergh SFWM, Ruzzano L. Prepotent response inhibition and interference control in autism spectrum disorders: Two meta-analyses. Autism Research. 2014;**7**(4):407-420. DOI: 10.1002/aur.1369

[7] Padmanabhan A, Garver K, O'Hearn K, et al. Developmental changes in brain function underlying inhibitory control in autism spectrum disorders. Autism Research. 2014;**8**(2):123-135. DOI: 10.1002/ aur.1398

[8] Fan L-Y, Gau SS-F, Chou T-L. Neural correlates of inhibitory control and visual processing in youths

with attention deficit hyperactivity disorder: A counting Stroop functional MRI study. Psychological Medicine. 2014;**44**(12):2661-2671. DOI: 10.1017/ s0033291714000038

[9] Geurts HM, Oord SVD, Crone EA. Hot and cool aspects of cognitive control in children with ADHD: Decision-making and inhibition. Journal of Abnormal Child Psychology. 2006;**34**(6):811-822. DOI: 10.1007/s10802-006-9059-2

[10] Woltering S, Lishak V, Hodgson N, Granic I, Zelazo PD. Executive function in children with externalizing and comorbid internalizing behavior problems. Journal of Child Psychology and Psychiatry. 2015;**57**(1):30-38. DOI: 10.1111/jcpp.12428

[11] Nigg JT. Annual research review: On the relations among self-regulation, self-control, executive functioning, effortful control, cognitive control, impulsivity, risk-taking, and inhibition for developmental psychopathology. Journal of Child Psychology and Psychiatry. 2016;**58**(4):361-383. DOI: 10.1111/jcpp.12675

[12] Mischel W, Shoda Y, Rodriguez M. Delay of gratification in children. Science. 1989;**244**(4907):933-938. DOI: 10.1126/science.2658056

[13] Rothbart MK. Temperament: A developmental framework. In: Strelau J, Angleitner A, editors. Perspectives on Individual Differences. Explorations in temperament: International perspectives on theory and measurement. 1991;**16**(4):207-212. DOI: 10.1007/978-1-4899-0643-4\_5

[14] Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology. 1908;**18**(5):459-482. DOI: 10.1002/cne.920180503

**103**

hbm.23062

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

2012;**109**(Supplement\_2):17180-17185.

DOI: 10.1073/pnas.1121254109

[23] Liston C, Miller MM, Goldwater DS, et al. Stress-induced alterations in prefrontal cortical dendritic morphology predict selective

impairments in perceptual attentional set-shifting. Journal of Neuroscience. 2006;**26**(30):7870-7874. DOI: 10.1523/

[24] Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proceedings of the National Academy of Sciences of the United States of America. 2009;**106**(3):912-917. DOI: 10.1073/

[25] Dias-Ferreira E et al. Chronic stress causes frontostriatal reorganization and affects decision-making. Science.

[26] Fox SE, Levitt P, Iii CAN. How the timing and quality of early

of brain architecture. Child

[27] Heim C. Psychobiological

[28] Teicher MH, Samson JA. Annual research review: Enduring neurobiological effects of childhood abuse and neglect. Journal of Child Psychology and Psychiatry. 2016;**57**(3):241-266. DOI: 10.1111/

[29] Ursin H, Olff M. Psychobiology of coping and defence strategies. Neuropsychobiology. 1993;**28**(1-2): 66-71. DOI: 10.1159/000119002

jcpp.12507

experiences influence the development

Development. 2010;**81**(1):28-40. DOI: 10.1111/j.1467-8624.2009.01380.x

consequences of child maltreatment. In: Noll JG, Shalev I, editors. The Biology of Early Life Stress: Understanding Child Maltreatment and Trauma (15-30); Child Maltreatment Solutions Network. Switzerland: Springer International; 2018

jneurosci.1184-06.2006

pnas.0807041106

2009;**325**:621-625

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

plasticity. Molecular Brain. 2010;**3**(1):15.

Sorensen L, Fontaine A. Self-regulation

[17] Pessoa L. A network model of the emotional brain. Trends in Cognitive Sciences. 2017;**21**(5):357-371. DOI:

[18] Banich MT. Executive Function. Current Directions in Psychological Science. 2009;**18**(2):89-94. DOI: 10.1111/j.1467-8721.2009.01615.x

[19] Banich MT, Depue BE. Recent advances in understanding neural systems that support inhibitory

[20] Diekhof EK, Geier K, Falkai P, Gruber O. Fear is only as deep as the mind allows. NeuroImage. 2011;**58**(1):275-285. DOI: 10.1016/j.

[21] Wierenga LM, Heuvel MPVD, Dijk SV, Rijks Y, Reus MAD, Durston S. The development of brain network architecture. Human Brain Mapping. 2015;**37**(2):717-729. DOI: 10.1002/

[22] McEwen BS. Brain on stress: How the social environment gets under the skin. Proceedings of the National Academy of Sciences.

control. Current Opinion in Behavioral Sciences. 2015;**1**:17-22. DOI: 10.1016/j.

DOI: 10.1186/1756-6606-3-15

[16] Hamoudi A, Murray DW,

and Toxic Stress: A Review of Ecological, Biological, and Developmental Studies of Selfregulation and Stress. InOPRE Report# 2015-30. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, US Department of Health and Human

Services; 2015

10.1016/j.tics.2017.03.002

cobeha.2014.07.006

neuroimage.2011.05.073

[15] Tully K, Bolshakov VY. Emotional enhancement of memory: How norepinephrine enables synaptic

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

[15] Tully K, Bolshakov VY. Emotional enhancement of memory: How norepinephrine enables synaptic plasticity. Molecular Brain. 2010;**3**(1):15. DOI: 10.1186/1756-6606-3-15

[16] Hamoudi A, Murray DW, Sorensen L, Fontaine A. Self-regulation and Toxic Stress: A Review of Ecological, Biological, and Developmental Studies of Selfregulation and Stress. InOPRE Report# 2015-30. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, US Department of Health and Human Services; 2015

[17] Pessoa L. A network model of the emotional brain. Trends in Cognitive Sciences. 2017;**21**(5):357-371. DOI: 10.1016/j.tics.2017.03.002

[18] Banich MT. Executive Function. Current Directions in Psychological Science. 2009;**18**(2):89-94. DOI: 10.1111/j.1467-8721.2009.01615.x

[19] Banich MT, Depue BE. Recent advances in understanding neural systems that support inhibitory control. Current Opinion in Behavioral Sciences. 2015;**1**:17-22. DOI: 10.1016/j. cobeha.2014.07.006

[20] Diekhof EK, Geier K, Falkai P, Gruber O. Fear is only as deep as the mind allows. NeuroImage. 2011;**58**(1):275-285. DOI: 10.1016/j. neuroimage.2011.05.073

[21] Wierenga LM, Heuvel MPVD, Dijk SV, Rijks Y, Reus MAD, Durston S. The development of brain network architecture. Human Brain Mapping. 2015;**37**(2):717-729. DOI: 10.1002/ hbm.23062

[22] McEwen BS. Brain on stress: How the social environment gets under the skin. Proceedings of the National Academy of Sciences.

2012;**109**(Supplement\_2):17180-17185. DOI: 10.1073/pnas.1121254109

[23] Liston C, Miller MM, Goldwater DS, et al. Stress-induced alterations in prefrontal cortical dendritic morphology predict selective impairments in perceptual attentional set-shifting. Journal of Neuroscience. 2006;**26**(30):7870-7874. DOI: 10.1523/ jneurosci.1184-06.2006

[24] Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proceedings of the National Academy of Sciences of the United States of America. 2009;**106**(3):912-917. DOI: 10.1073/ pnas.0807041106

[25] Dias-Ferreira E et al. Chronic stress causes frontostriatal reorganization and affects decision-making. Science. 2009;**325**:621-625

[26] Fox SE, Levitt P, Iii CAN. How the timing and quality of early experiences influence the development of brain architecture. Child Development. 2010;**81**(1):28-40. DOI: 10.1111/j.1467-8624.2009.01380.x

[27] Heim C. Psychobiological consequences of child maltreatment. In: Noll JG, Shalev I, editors. The Biology of Early Life Stress: Understanding Child Maltreatment and Trauma (15-30); Child Maltreatment Solutions Network. Switzerland: Springer International; 2018

[28] Teicher MH, Samson JA. Annual research review: Enduring neurobiological effects of childhood abuse and neglect. Journal of Child Psychology and Psychiatry. 2016;**57**(3):241-266. DOI: 10.1111/ jcpp.12507

[29] Ursin H, Olff M. Psychobiology of coping and defence strategies. Neuropsychobiology. 1993;**28**(1-2): 66-71. DOI: 10.1159/000119002

**102**

aur.1398

*Inhibitory Control Training - A Multidisciplinary Approach*

with attention deficit hyperactivity disorder: A counting Stroop functional MRI study. Psychological Medicine. 2014;**44**(12):2661-2671. DOI: 10.1017/

[9] Geurts HM, Oord SVD, Crone EA. Hot and cool aspects of cognitive control in children with ADHD: Decision-making and inhibition. Journal of Abnormal Child Psychology. 2006;**34**(6):811-822. DOI: 10.1007/s10802-006-9059-2

[10] Woltering S, Lishak V, Hodgson N, Granic I, Zelazo PD. Executive function in children with externalizing and comorbid internalizing behavior problems. Journal of Child Psychology and Psychiatry. 2015;**57**(1):30-38. DOI:

[11] Nigg JT. Annual research review: On the relations among self-regulation, self-control, executive functioning, effortful control, cognitive control, impulsivity, risk-taking, and inhibition for developmental psychopathology. Journal of Child Psychology and Psychiatry. 2016;**58**(4):361-383. DOI:

[12] Mischel W, Shoda Y, Rodriguez M. Delay of gratification in children. Science. 1989;**244**(4907):933-938. DOI:

[13] Rothbart MK. Temperament: A developmental framework. In: Strelau J, Angleitner A, editors. Perspectives on Individual Differences. Explorations in temperament: International perspectives on theory and

measurement. 1991;**16**(4):207-212. DOI:

10.1007/978-1-4899-0643-4\_5

[14] Yerkes RM, Dodson JD. The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurology and Psychology. 1908;**18**(5):459-482. DOI:

10.1002/cne.920180503

s0033291714000038

10.1111/jcpp.12428

10.1111/jcpp.12675

10.1126/science.2658056

[1] Sameroff A. A unified theory of development: A dialectic integration

Development. 2010;**81**(1):6-22. DOI: 10.1111/j.1467-8624.2009.01378.x

[2] Blair C, Raver CC. Poverty, stress, and brain development: New directions for prevention and intervention. Academic Pediatrics. 2016;**16**(3):S30- S36. DOI: 10.1016/j.acap.2016.01.010

[3] Gilmore C, Attridge N, Clayton S, et al. Individual differences in inhibitory

control, not non-verbal number acuity, correlate with mathematics achievement. PLoS One. 2013;**8**(6). DOI: 10.1371/journal.pone.0067374

[4] Houde' O, Borst GG. Measuring inhibitory control in children and adults: Brain imaging and mental chronometry. Frontiers in Psychology. 2014;**5**:1-7. DOI: 10.3389/

[5] Shulman EP, Smith AR, Silva K, et al. The dual systems model: Review, reappraisal, and reaffirmation.

2016;**17**:103-117. DOI: 10.1016/j.

[7] Padmanabhan A, Garver K, O'Hearn K, et al. Developmental changes in brain function underlying inhibitory control in autism spectrum

disorders. Autism Research. 2014;**8**(2):123-135. DOI: 10.1002/

correlates of inhibitory control and visual processing in youths

[8] Fan L-Y, Gau SS-F, Chou T-L. Neural

Developmental Cognitive Neuroscience.

[6] Geurts HM, Van Den Bergh SFWM, Ruzzano L. Prepotent response inhibition and interference control in autism spectrum disorders: Two meta-analyses. Autism Research. 2014;**7**(4):407-420.

fpsyg.2014.00616

dcn.2015.12.010

DOI: 10.1002/aur.1369

of nature and nurture. Child

**References**

[30] Shonkoff JP, Garner AS, Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2011;**129**(1). DOI: 10.1542/peds.2011-2663

[31] Lovallo WR. Early life adversity reduces stress reactivity and enhances impulsive behavior: Implications for health behaviors. International Journal of Psychophysiology. 2013;**90**(1):8-16. DOI: 10.1016/j.ijpsycho.2012.10.006

[32] Pears KC, Fisher PA, Bruce J, Kim HK, Yoerger K. Early elementary school adjustment of maltreated children in foster care: The roles of inhibitory control and caregiver involvement. Child Development. 2010;**81**(5):1550-1564. DOI: 10.1111/j.1467-8624.2010.01491.x

[33] Cichetti D. Developmental psychopathology. In: Lamb M, Freund A, editors. The Handbook of Life-Span Development. Hoboken, NJ: Wiley; 2010. DOI: 10.1002/9780470880166.hlsd002014

[34] Welsh MC, Peterson E, Jameson MM. History of childhood maltreatment and college academic outcomes: Indirect effects of hot execution function. Frontiers in Psychology. 2017;**8**:1-13. DOI: 10.3389/fpsyg.2017.01091

[35] Welsh M, Barry PG, Jacobs AA, Beddes LA. Homeless men living in transitional housing: The BrainWise program and improvements in executive functions and coping self-efficacy. SAGE Open. 2018;**8**(2):215824401876913. DOI: 10.1177/2158244018769138

[36] Poverty Facts. Poverty Solutions. Available from: https://poverty.umich. edu/about/poverty-facts/ [Accessed: 06 June 2019]

[37] Heberle AE, Carter AS. Cognitive aspects of young children's experience of economic disadvantage. Psychological Bulletin. 2015;**141**(4):723- 746. DOI: 10.1037/bul0000010

[38] Sektnan M, McClelland MM, Acock A, Morrison FJ. Relations between early family risk, childrens behavioral regulation, and academic achievement. Early Childhood Research Quarterly. 2010;**25**(4):464-479. DOI: 10.1016/j.ecresq.2010.02.005

[39] Wanless SB, McClelland MM, Tominey SL, Acock AC. The influence of demographic risk factors on childrens behavioral regulation in prekindergarten and kindergarten. Early Education and Development. 2011;**22**(3):461-488. DOI: 10.1080/10409289.2011.536132

[40] Pacheco D, Owen M, Caughy M. Growth in inhibitory control among low-income, ethnic-minority preschoolers: A group-based modeling approach. Early Childhood Research Quarterly. 2018;**42**:247-255. DOI: 10.1016/j.ecresq.2017.10.010

[41] Son S-HC, Choi JY, Kwon K-A. Reciprocal associations between inhibitory control and early academic skills: Evidence from a nationally representative sample of head start children. Early Education and Development. 2019;**30**(4):456-477. DOI: 10.1080/10409289.2019.1572382

[42] Lambert HK, King KM, Monahan KC, McLaughlin KA. Differential associations of threat and deprivation with emotion regulation and cognitive control in adolescence. Development and Psychopathology. 2016;**29**(3):929-940. DOI: 10.1017/s0954579416000584

[43] Hazzouri AZA, Elfassy T, Sidney S, Jacobs D, Stable EJP, Yaffe K. Sustained economic hardship and cognitive function: The coronary artery risk development in young adults study. American Journal of Preventive Medicine. 2017;**52**(1):1-9. DOI: 10.1016/j.amepre.2016.08.009

**105**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

and cognitive function in college women. Journal of Neuropsychiatry. 2006;**18**(1):45-53. DOI: 10.1176/appi.

[52] Shin SH, Jiskrova GK, Wills TA. Childhood maltreatment and alcohol use in young adulthood: The role of self-regulation processes. Addictive Behaviors. 2019;**90**:241-249. DOI: 10.1016/j.addbeh.2018.11.006

[53] Lafavor T. Predictors of academic success in 9- to 11-year-old homeless children: The role of executive function, social competence, and emotional control. The Journal of Early Adolescence. 2017;**38**(9):1236-1264. DOI: 10.1177/0272431616678989

[54] Obradović J. Effortful control and adaptive functioning of homeless children: Variable-focused and person-focused analyses. Journal of Applied Developmental Psychology. 2010;**31**(2):109-117. DOI: 10.1016/j.

appdev.2009.09.004

[55] Schmitt SA, Finders JK,

1998;**280**(5370):1711-1712

2006;**1**(2):124-134

McClelland MM. Residential mobility, inhibitory control, and academic achievement in preschool. Early Education and Development. 2014;**26**(2):189-208. DOI: 10.1080/10409289.2015.975033

[56] Arnsten AF. The biology of being frazzled. Science (New York, N.Y.).

[57] Campbell WK, Krusemark EA, Dyckman KA, et al. A magnetoencephalography investigation of neural correlates for social exclusion and self-control. Social Neuroscience.

[58] Baumeister RF, Twenge JM, Nuss CK. Effects of social exclusion on cognitive processes: Anticipated aloneness reduces intelligent thought. Journal of Personality and Social Psychology. 2002;**83**(4):817-827

neuropsych.18.1.45

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

Prevention|Violence Prevention|Injury Center|CDC. Centers for Disease Control and Prevention. Available from: https:// www.cdc.gov/violenceprevention/ childabuseandneglect [Accessed: 06 June

[45] Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;**14**(4):245-258. DOI: 10.1016/s0749-3797(98)00017-8

[46] Augusti E-M, Melinder A.

[47] DePrince AP, Weinzierl KM, Combs MD. Executive function performance and trauma exposure in a community sample of children. Child Abuse and Neglect. 2009;**33**(6):353-361. DOI: 10.1016/j.chiabu.2008.08.002

Maltreatment is associated with specific impairments in executive functions: A pilot study. Journal of Traumatic Stress. 2013;**26**(6):780-783. DOI: 10.1002/

[48] Kirke-Smith M, Henry L, Messer D. Executive functioning: Developmental consequences on adolescents with histories of maltreatment. British Journal of Developmental Psychology. 2014;**32**(3):305-319. DOI: 10.1111/

[49] Vasilevski V, Tucker A. Wideranging cognitive deficits in adolescents following early life maltreatment. Neuropsychology. 2016;**30**(2):239-246.

[50] Marshall DF, Passarotti AM, Ryan KA, et al. Deficient inhibitory control as an outcome of childhood trauma. Psychiatry Research. 2016;**235**:7-12. DOI: 10.1016/j.

[51] Navalta CP. Effects of childhood sexual abuse on neuropsychological

DOI: 10.1037/neu0000215

psychres.2015.12.013

[44] Child Abuse and Neglect

2019]

jts.21860

bjdp.12041

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

[44] Child Abuse and Neglect Prevention|Violence Prevention|Injury Center|CDC. Centers for Disease Control and Prevention. Available from: https:// www.cdc.gov/violenceprevention/ childabuseandneglect [Accessed: 06 June 2019]

*Inhibitory Control Training - A Multidisciplinary Approach*

Psychological Bulletin. 2015;**141**(4):723-

746. DOI: 10.1037/bul0000010

10.1016/j.ecresq.2010.02.005

[39] Wanless SB, McClelland MM, Tominey SL, Acock AC. The influence

[40] Pacheco D, Owen M, Caughy M. Growth in inhibitory control among low-income, ethnic-minority

preschoolers: A group-based modeling approach. Early Childhood Research Quarterly. 2018;**42**:247-255. DOI: 10.1016/j.ecresq.2017.10.010

K-A. Reciprocal associations between inhibitory control and early academic skills: Evidence from a nationally representative sample of head start children. Early Education and Development. 2019;**30**(4):456-477. DOI:

[41] Son S-HC, Choi JY, Kwon

10.1080/10409289.2019.1572382

[42] Lambert HK, King KM, Monahan KC, McLaughlin KA. Differential associations of threat and deprivation with emotion regulation and cognitive control in adolescence. Development and Psychopathology. 2016;**29**(3):929-940. DOI: 10.1017/s0954579416000584

[43] Hazzouri AZA, Elfassy T, Sidney S, Jacobs D, Stable EJP, Yaffe K. Sustained economic hardship and cognitive function: The coronary artery risk development in young adults study. American Journal of Preventive Medicine. 2017;**52**(1):1-9. DOI: 10.1016/j.amepre.2016.08.009

of demographic risk factors on childrens behavioral regulation in prekindergarten and kindergarten. Early Education and Development.

2011;**22**(3):461-488. DOI: 10.1080/10409289.2011.536132

[38] Sektnan M, McClelland MM, Acock A, Morrison FJ. Relations between early family risk, childrens behavioral regulation, and academic achievement. Early Childhood Research Quarterly. 2010;**25**(4):464-479. DOI:

[30] Shonkoff JP, Garner AS,

10.1542/peds.2011-2663

Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2011;**129**(1). DOI:

[31] Lovallo WR. Early life adversity reduces stress reactivity and enhances impulsive behavior: Implications for health behaviors. International Journal of Psychophysiology. 2013;**90**(1):8-16. DOI: 10.1016/j.ijpsycho.2012.10.006

[32] Pears KC, Fisher PA, Bruce J, Kim HK, Yoerger K. Early elementary school adjustment of maltreated children in foster care: The roles of inhibitory control and caregiver involvement. Child Development. 2010;**81**(5):1550-1564. DOI: 10.1111/j.1467-8624.2010.01491.x

[33] Cichetti D. Developmental psychopathology. In: Lamb M, Freund A, editors. The Handbook of Life-Span Development. Hoboken, NJ: Wiley; 2010. DOI: 10.1002/9780470880166.hlsd002014

[34] Welsh MC, Peterson E, Jameson MM. History of childhood maltreatment and college academic outcomes: Indirect effects of hot execution function. Frontiers in Psychology. 2017;**8**:1-13. DOI: 10.3389/fpsyg.2017.01091

[35] Welsh M, Barry PG, Jacobs AA, Beddes LA. Homeless men living in transitional housing: The BrainWise program and improvements in executive functions and coping self-efficacy. SAGE Open.

2018;**8**(2):215824401876913. DOI: 10.1177/2158244018769138

[36] Poverty Facts. Poverty Solutions. Available from: https://poverty.umich. edu/about/poverty-facts/ [Accessed:

[37] Heberle AE, Carter AS. Cognitive

experience of economic disadvantage.

aspects of young children's

**104**

06 June 2019]

[45] Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;**14**(4):245-258. DOI: 10.1016/s0749-3797(98)00017-8

[46] Augusti E-M, Melinder A. Maltreatment is associated with specific impairments in executive functions: A pilot study. Journal of Traumatic Stress. 2013;**26**(6):780-783. DOI: 10.1002/ jts.21860

[47] DePrince AP, Weinzierl KM, Combs MD. Executive function performance and trauma exposure in a community sample of children. Child Abuse and Neglect. 2009;**33**(6):353-361. DOI: 10.1016/j.chiabu.2008.08.002

[48] Kirke-Smith M, Henry L, Messer D. Executive functioning: Developmental consequences on adolescents with histories of maltreatment. British Journal of Developmental Psychology. 2014;**32**(3):305-319. DOI: 10.1111/ bjdp.12041

[49] Vasilevski V, Tucker A. Wideranging cognitive deficits in adolescents following early life maltreatment. Neuropsychology. 2016;**30**(2):239-246. DOI: 10.1037/neu0000215

[50] Marshall DF, Passarotti AM, Ryan KA, et al. Deficient inhibitory control as an outcome of childhood trauma. Psychiatry Research. 2016;**235**:7-12. DOI: 10.1016/j. psychres.2015.12.013

[51] Navalta CP. Effects of childhood sexual abuse on neuropsychological

and cognitive function in college women. Journal of Neuropsychiatry. 2006;**18**(1):45-53. DOI: 10.1176/appi. neuropsych.18.1.45

[52] Shin SH, Jiskrova GK, Wills TA. Childhood maltreatment and alcohol use in young adulthood: The role of self-regulation processes. Addictive Behaviors. 2019;**90**:241-249. DOI: 10.1016/j.addbeh.2018.11.006

[53] Lafavor T. Predictors of academic success in 9- to 11-year-old homeless children: The role of executive function, social competence, and emotional control. The Journal of Early Adolescence. 2017;**38**(9):1236-1264. DOI: 10.1177/0272431616678989

[54] Obradović J. Effortful control and adaptive functioning of homeless children: Variable-focused and person-focused analyses. Journal of Applied Developmental Psychology. 2010;**31**(2):109-117. DOI: 10.1016/j. appdev.2009.09.004

[55] Schmitt SA, Finders JK, McClelland MM. Residential mobility, inhibitory control, and academic achievement in preschool. Early Education and Development. 2014;**26**(2):189-208. DOI: 10.1080/10409289.2015.975033

[56] Arnsten AF. The biology of being frazzled. Science (New York, N.Y.). 1998;**280**(5370):1711-1712

[57] Campbell WK, Krusemark EA, Dyckman KA, et al. A magnetoencephalography investigation of neural correlates for social exclusion and self-control. Social Neuroscience. 2006;**1**(2):124-134

[58] Baumeister RF, Twenge JM, Nuss CK. Effects of social exclusion on cognitive processes: Anticipated aloneness reduces intelligent thought. Journal of Personality and Social Psychology. 2002;**83**(4):817-827

[59] Barnes ME, Gozal D, Molfese DL. Attention in children with obstructive sleep apnoea: An event-related potentials study. Sleep Medicine. 2012;**13**(4):368-377

[60] Tun PA, Miller-Martinez D, Lachman ME, et al. Social strain and executive function across the lifespan: The dark (and light) sides of social engagement. Neuropsychology, Development, and Cognition Section B, Aging, Neuropsychology and Cognition. 2013;**20**(3):320-338

[61] Hurstak E, Johnson JK, Tieu L, et al. Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study. Drug and Alcohol Dependence. 2017;**178**:562-570

[62] Pluck G, Nakakarumai M, Sato Y. Homelessness and cognitive impairment: An exploratory study in Tokyo, Japan. East Asian Archives of Psychiatry. 2015;**25**(3):122-127

[63] Gabrielian S, Bromley E, Hamilton AB, Vu VT, Alexandrino A, et al. Problem solving skills and deficits among homeless veterans with serious mental illness. The American Journal of Orthopsychiatry. 2019;**89**(2):287-295. DOI: 10.1037/ort0000340

[64] Schutt RK, Seidman LJ, Caplan B, et al. The role of neurocognition and social context in predicting community functioning among formerly homeless seriously mentally ill persons. Schizophrenia Bulletin. 2007;**33**(6):1388-1396

[65] Essau C, LeBlanc S, llendick T. Emotion Regulation and Psychhopathology in Children and Adolescents. Oxford, UK: Oxford University Press; 2019

[66] MacLean A. The things they carry. American Sociological

Review. 2010;**75**(4):563-585. DOI: 10.1177/0003122410374085

[67] Weissman JD, Russell D, Harris R, Dixon L, Haghighi F, Goodman M. Sociodemographic risk factors for serious psychological distress among U.S. veterans: Findings from the 2016 National Health Interview Survey. Psychiatric Quarterly. 2019;**90**:1-14. DOI: 10.1007/s11126-019-09651-2

[68] Sonuga-Barke EJS, Cortese S, Fairchild G, Stringaris A. Annual research review: Transdiagnostic neuroscience of child and adolescent mental disorders - differentiating decision making in attention-deficit/ hyperactivity disorder, conduct disorder, depression, and anxiety. Journal of Child Psychology and Psychiatry. 2015;**57**(3):321-349. DOI: 10.1111/jcpp.12496

[69] Wright L, Lipszyc J, Dupuis A, Thayapararajah SW, Schachar R. Response inhibition and psychopathology: A meta-analysis of go/no-go task performance. Journal of Abnormal Psychology. 2014;**123**(2):429- 439. DOI: 10.1037/a0036295

[70] Braff DL, Heaton R, Kuck J, et al. The generalized pattern of neuropsychological deficits in outpatients with chronic schizophrenia with heterogeneous Wisconsin Card Sorting Test results. Archives of General Psychiatry. 1991;**48**(10):891-898

[71] Goldberg TE, Saint-Cyr JA, Weinberger DR. Assessment of procedural learning and problem solving in schizophrenic patients by Tower of Hanoi type tasks. The Journal of Neuropsychiatry and Clinical Neurosciences. 1990;**2**(2):165-173

[72] Sharma T, Antonova L. Cognitive function in schizophrenia. Deficits, functional consequences, and future treatment. Psychiatric Clinics of North America. 2003;**26**(1):25-40

**107**

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

Psychophysiology of the Frontal Lobes. 1973:3-26. DOI: 10.1016/ b978-0-12-564340-5.50006-8

[83] Kishiyama MM, Boyce WT, Jimenez AM, Perry LM, Knight RT. Sociodemographic disparities affect prefrontal function in children. Journal of Cognitive Neuroscience. 2008;**21**:1106-1115. DOI: 10.1162/

[84] Schilling EA, Aseltine RH,

[85] Durlak JA, Weissberg RP, Dymnicki AB, Taylor RD,

students' social and emotional learning: A meta-analysis of schoolbased universal interventions. Child Development. 2011;**82**(1):405-432. DOI: 10.1111/j.1467-8624.2010.01564.x

[86] McClelland M, Geldhof J,

[87] Insel T. From neurons to

[Accessed: 06 June 2019]

[89] Teaster PB, Stansbury KL, Nerenberg L, Stanis P. An adult

2014

Gore S. Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health. 2007;**7**(1):30-40. DOI: 10.1186/1471-2458-7-30

Schellinger KB. The impact of enhancing

Morrison F, Gestsdottir S, Camerson C, Bowers E, et al. Self-regulation. In: Halfon N, Forrest C, Lerner R, Faustman E, editors. Handbook of Life Course Health Development. Switzerland: Springer; 2018. p. 275-298

neighborhoods: Charting a new science of mental health. Wu Tsai Neuroscience Institute, Stanford University; October

[88] Center on the Developing Child at Harvard University. Available from: https://developingchild.harvard.edu/

10.3233/bpl-180065

jocn.2009.21101

[82] Llorens-Martín M. Exercising new neurons to vanquish Alzheimer disease. Brain Plasticity. 2018;**4**(1):111-126. DOI:

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

[74] Knight MJ, Baune BT. Executive function and spatial cognition mediate psychosocial dysfunction in major depressive disorder. Frontiers in

[75] Insel TR, Fernald RD. How the brain processes social information: Searching for the social brain. Annual Review of Neuroscience. 2004;**27**(1):697-722. DOI: 10.1146/annurev.neuro.27.070203.144148

[76] Sapolsky RM. Behave: The Biology of Humans at our Best and Worst. 5th ed. New York: Penguin; 2017. 800p

[77] Sloboda Z, Petras H, Robertson E. Prevention of substance use. In: Hingson R, editor. Switzerland:

[78] Kandel ER. Neuroscience: Breaking down scientific barriers to the study of brain and mind. Science. 2000;**290**(5494):1113-1120. DOI: 10.1126/science.290.5494.1113

[79] Pennington BF, Ozonoff S.

[80] Welsh MC, Pennington BF,

psychopathology. Journal of Child Psychology and Psychiatry. 1996;**37**(1):51-87. DOI: 10.1111/j.1469-

7610.1996.tb01380.x

1991;**7**(2):131-149. DOI: 10.1080/87565649109540483

[81] Luria A. The frontal lobes and the regulation of behavior.

Executive functions and developmental

Groisser DB. A normative-developmental study of executive function: A window on prefrontal function in children. Developmental Neuropsychology.

[73] Crocker LD, Jurick SM, Thomas KR, et al. Worse baseline executive functioning is associated with dropout and poorer response to traumafocused treatment for veterans with PTSD and comorbid traumatic brain injury. Behaviour Research and Therapy.

2018;**108**:68-77

Springer; 2019

Psychiatry. 2018;**9**:539

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

[73] Crocker LD, Jurick SM, Thomas KR, et al. Worse baseline executive functioning is associated with dropout and poorer response to traumafocused treatment for veterans with PTSD and comorbid traumatic brain injury. Behaviour Research and Therapy. 2018;**108**:68-77

*Inhibitory Control Training - A Multidisciplinary Approach*

Review. 2010;**75**(4):563-585. DOI: 10.1177/0003122410374085

[68] Sonuga-Barke EJS, Cortese S, Fairchild G, Stringaris A. Annual research review: Transdiagnostic neuroscience of child and adolescent mental disorders - differentiating decision making in attention-deficit/ hyperactivity disorder, conduct disorder, depression, and anxiety. Journal of Child Psychology and Psychiatry. 2015;**57**(3):321-349. DOI:

[69] Wright L, Lipszyc J, Dupuis A, Thayapararajah SW, Schachar R.

psychopathology: A meta-analysis of go/no-go task performance. Journal of Abnormal Psychology. 2014;**123**(2):429-

Kuck J, et al. The generalized pattern of neuropsychological deficits in outpatients with chronic schizophrenia with heterogeneous Wisconsin Card Sorting Test results. Archives of General

Psychiatry. 1991;**48**(10):891-898

[71] Goldberg TE, Saint-Cyr JA, Weinberger DR. Assessment of procedural learning and problem solving in schizophrenic patients by Tower of Hanoi type tasks. The Journal of Neuropsychiatry and Clinical Neurosciences. 1990;**2**(2):165-173

[72] Sharma T, Antonova L. Cognitive function in schizophrenia. Deficits, functional consequences, and future treatment. Psychiatric Clinics of North

America. 2003;**26**(1):25-40

10.1111/jcpp.12496

Response inhibition and

439. DOI: 10.1037/a0036295

[70] Braff DL, Heaton R,

[67] Weissman JD, Russell D, Harris R, Dixon L, Haghighi F, Goodman M. Sociodemographic risk factors for serious psychological distress among U.S. veterans: Findings from the 2016 National Health Interview Survey. Psychiatric Quarterly. 2019;**90**:1-14. DOI: 10.1007/s11126-019-09651-2

[59] Barnes ME, Gozal D, Molfese DL. Attention in children with obstructive sleep apnoea: An event-related potentials study. Sleep Medicine.

[60] Tun PA, Miller-Martinez D, Lachman ME, et al. Social strain and executive function across the lifespan: The dark (and light) sides of social engagement. Neuropsychology, Development, and Cognition Section B, Aging, Neuropsychology and Cognition. 2013;**20**(3):320-338

[61] Hurstak E, Johnson JK, Tieu L, et al. Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study. Drug and Alcohol

Dependence. 2017;**178**:562-570

[62] Pluck G, Nakakarumai M, Sato Y. Homelessness and cognitive impairment: An exploratory study in Tokyo, Japan. East Asian Archives of Psychiatry. 2015;**25**(3):122-127

[63] Gabrielian S, Bromley E,

DOI: 10.1037/ort0000340

social context in predicting community functioning among formerly homeless seriously mentally ill persons. Schizophrenia Bulletin.

2007;**33**(6):1388-1396

Emotion Regulation and

University Press; 2019

Hamilton AB, Vu VT, Alexandrino A, et al. Problem solving skills and deficits among homeless veterans with serious mental illness. The American Journal of Orthopsychiatry. 2019;**89**(2):287-295.

[64] Schutt RK, Seidman LJ, Caplan B, et al. The role of neurocognition and

[65] Essau C, LeBlanc S, llendick T.

Psychhopathology in Children and Adolescents. Oxford, UK: Oxford

[66] MacLean A. The things they carry. American Sociological

2012;**13**(4):368-377

**106**

[74] Knight MJ, Baune BT. Executive function and spatial cognition mediate psychosocial dysfunction in major depressive disorder. Frontiers in Psychiatry. 2018;**9**:539

[75] Insel TR, Fernald RD. How the brain processes social information: Searching for the social brain. Annual Review of Neuroscience. 2004;**27**(1):697-722. DOI: 10.1146/annurev.neuro.27.070203.144148

[76] Sapolsky RM. Behave: The Biology of Humans at our Best and Worst. 5th ed. New York: Penguin; 2017. 800p

[77] Sloboda Z, Petras H, Robertson E. Prevention of substance use. In: Hingson R, editor. Switzerland: Springer; 2019

[78] Kandel ER. Neuroscience: Breaking down scientific barriers to the study of brain and mind. Science. 2000;**290**(5494):1113-1120. DOI: 10.1126/science.290.5494.1113

[79] Pennington BF, Ozonoff S. Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry. 1996;**37**(1):51-87. DOI: 10.1111/j.1469- 7610.1996.tb01380.x

[80] Welsh MC, Pennington BF, Groisser DB. A normative-developmental study of executive function: A window on prefrontal function in children. Developmental Neuropsychology. 1991;**7**(2):131-149. DOI: 10.1080/87565649109540483

[81] Luria A. The frontal lobes and the regulation of behavior. Psychophysiology of the Frontal Lobes. 1973:3-26. DOI: 10.1016/ b978-0-12-564340-5.50006-8

[82] Llorens-Martín M. Exercising new neurons to vanquish Alzheimer disease. Brain Plasticity. 2018;**4**(1):111-126. DOI: 10.3233/bpl-180065

[83] Kishiyama MM, Boyce WT, Jimenez AM, Perry LM, Knight RT. Sociodemographic disparities affect prefrontal function in children. Journal of Cognitive Neuroscience. 2008;**21**:1106-1115. DOI: 10.1162/ jocn.2009.21101

[84] Schilling EA, Aseltine RH, Gore S. Adverse childhood experiences and mental health in young adults: A longitudinal survey. BMC Public Health. 2007;**7**(1):30-40. DOI: 10.1186/1471-2458-7-30

[85] Durlak JA, Weissberg RP, Dymnicki AB, Taylor RD, Schellinger KB. The impact of enhancing students' social and emotional learning: A meta-analysis of schoolbased universal interventions. Child Development. 2011;**82**(1):405-432. DOI: 10.1111/j.1467-8624.2010.01564.x

[86] McClelland M, Geldhof J, Morrison F, Gestsdottir S, Camerson C, Bowers E, et al. Self-regulation. In: Halfon N, Forrest C, Lerner R, Faustman E, editors. Handbook of Life Course Health Development. Switzerland: Springer; 2018. p. 275-298

[87] Insel T. From neurons to neighborhoods: Charting a new science of mental health. Wu Tsai Neuroscience Institute, Stanford University; October 2014

[88] Center on the Developing Child at Harvard University. Available from: https://developingchild.harvard.edu/ [Accessed: 06 June 2019]

[89] Teaster PB, Stansbury KL, Nerenberg L, Stanis P. An adult protective services' view of collaboration with mental health services. Journal of Elder Abuse & Neglect. 2009;**21**(4):289- 306. DOI: 10.1080/08946560903004821

[90] Dusenbury L. A review of research on fidelity of implementation: Implications for drug abuse prevention in school settings. Health Education Research. 2003;**18**(2):237-256. DOI: 10.1093/her/18.2.237

[91] Escoffery C, Lebow-Skelley E, Udelson H, et al. A scoping study of frameworks for adapting public health evidence-based interventions. Translational Behavioral Medicine. 2018;**9**(1):1-10. DOI: 10.1093/tbm/ ibx067

[92] Brabeck M, Jeffrey J, Fry S. Practice for knowledge acquisition (not drill and kill). https://www.apa.org/education/K12/p

[93] Connell JP. A new multidimensional measure of childrens perceptions of control. Child Development. 1985;**56**(4):1018. DOI: 10.2307/1130113

[94] Custers EJFN. Long-term retention of basic science knowledge: A review study.Advances in Health Sciences Education. 2010;**15**(1):109-128. DOI: 10.1007/s10459-008-9101-y

[95] Barry PG, Welsh M. The BrainWise curriculum: Neurocognitive development intervention Program. In: Romer D, Walker EF, editors. Adolescent psychopathology and the Developing Brain: Integrating Brain and Prevention Sciene. NY: Oxford University press. pp. 420-440. ISBN: 978-0-19-530625-5

[96] A Proven Evidence-based Approach. The BrainWise Program. Available from: https://www.brainwiseplc.org/ [Accessed: 06 June 2019]

[97] History. The BrainWise Program. Available from: https://www.brainwiseplc.org/about/history/ [Accessed: 06 June 2019]

[98] Ledoux J. Fear and the brain: Where have we been, and where are we going? Biological Psychiatry. 1998;**44**(12):1229-1238. DOI: 10.1016/ s0006-3223(98)00282-0

[99] Riggs NR, Greenberg MT, Kusché CA, Pentz MA. The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prevention Science. 2006;**7**(1):91-102. DOI: 10.1007/s11121-005-0022-1

[100] Cacioppo S, Grippo AJ, London S, Goossens L, Cacioppo JT. Loneliness. Perspectives on Psychological Science. 2015;**10**(2):238-249. DOI: 10.1177/1745691615570616

[101] Cyranowski JM, Zill N, Bode R, et al. Assessing social support, companionship, and distress: National Institute of Health (NIH) Toolbox Adult Social Relationship Scales. Health Psychology. 2013;**32**(3):293-301. DOI: 10.1037/a0028586

[102] Southwick SM, Morgan CA, Vythilingam M, Charney D. Mentors enhance resilience in at-risk children and adolescents. Psychoanalytic Inquiry. 2007;**26**(4):577-584. DOI: 10.1080/07351690701310631

[103] Holt-Lunstad J, Robles TF, Sbarra DA. Advancing social connection as a public health priority in the United States. American Psychologist. 2017;**72**(6):517- 530. DOI: 10.1037/amp0000103

[104] Donahue MJ, Benson PL. Religion and the well-being of adolescents. Journal of Social Issues. 1995;**51**(2):145- 160. DOI: 10.1111/j.1540-4560.1995. tb01328.x

[105] Southwick SM, Vythilingam M, Charney DS. The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of

**109**

2019]

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention…*

[114] Norwood S, Rosa J, Fairbanks K, Downes D, Cerbana C, Gorman Barry P.

executive functioning for children from 1st through 5th grade using BrainWise. In: Poster Presented at the Rocky Mounting Psychological Association

Promoting the development of

Conference; Boise, ID; 2015

[115] Persing R, Gorman Barry P, Welsh M, Cazzell K, Peifer, Reyes A. Improving health decisions in atrisk families: Nurse home visits, BrainWise and technology. In: Poster presented at the Colorado Public Health Association

Conference; Pueblo, CO; 2011

nmd.0b013e3181f97dff

Development; 2018

2010;**33**(4):308-319

2015;**37**:177-195

1993;**44**(12):1172-1176

Report (AHAR) to Congress. Washington, D.C.: U.S. Department of Housing and Urban Health Office of Community Planning and

[118] O'Connell M, Kasprow W,

[119] Tsai J, Rosenheck RA. Risk factors for homelessness among US veterans. Epidemiologic Reviews.

[120] Wenzel SL et al. Indicators of chronic homelessness among veterans. Hospital & Community Psychiatry.

[121] Goldfinger SM, Schutt RK, Tolomiczenko GS, Seidman L, Penk WE, Turner W, et al. Housing

Rosenheck RA. National dissemination of supported housing in the VA: Model adherence versus model modification. Psychiatric Rehabilitation Journal.

[116] Bousman CA, Twamley EW, Vella L, et al. Homelessness and neuropsychological Impairment. The Journal of Nervous and Mental Disease. 2010;**198**(11):790-794. DOI: 10.1097/

[117] Henry M, Mahathey A, Morrill T, Robinson A, Shivji A, Watt R, et al. The 2018 Annual Homeless Assessment

*DOI: http://dx.doi.org/10.5772/intechopen.88642*

Clinical Psychology. 2005;**1**(1):255-

[106] Diamond A, Lee K. Interventions shown to aid executive function development in children 4 to 12 years old. Science. 2011;**333**(6045):959-964.

Intertemporal choice. National Bureau of Economic Research (NBER) Working Paper No. 25358. December 2018. http://

291. DOI: 10.1146/annurev. clinpsy.1.102803.143948

DOI: 10.1126/science.1204529

[107] Ericson KM, Laibson D.

www.nber.org/papers/w25358

Educator. 2017;Fall:4-10

10.1111/SLTB.12307

10.1126/science.1226918

768 p

[108] Parkinson RG. The common cause: Creating race and nation in the american revolution. Chapel Hill: University of North Carolina Press;

[109] McGrew S, Ortega, T, Breaksonte J, Wineburg S. The challenge that's bigger than fake news: Civic reasoning in a social media environment. American

[110] Wineberg J, Mann S. Salford Jewish Community Health Research Report 2015. Available from: https://archive.jpr. org.uk/object-uk370 (Published January 1, 1970) [Accessed: 06 June 2019]

[111] Naifeh JA, Nock MK, Ursano RJ, Vegella PL, Aliaga PA, et al. Neurocognitive function and suicidal behavior in US Army soldiers. Suicide Life Threat Behavior. 2017;**47**(5):589-602. DOI:

[112] Marteau TM, Hollands GJ,

[113] Barry P. Research and Results. The BrainWise Program. Available from: https://www.brainwise-plc.org/ research-results/ [Accessed: 06 June

Fletcher PC. Changing human behavior to prevent disease: The importance of targeting automatic processes. Science. 2012;**337**(6101):1492-1495. DOI:

*Life Stress and Inhibitory Control Deficits: Teaching BrainWise as a Neurocognitive Intervention… DOI: http://dx.doi.org/10.5772/intechopen.88642*

Clinical Psychology. 2005;**1**(1):255- 291. DOI: 10.1146/annurev. clinpsy.1.102803.143948

*Inhibitory Control Training - A Multidisciplinary Approach*

[98] Ledoux J. Fear and the brain: Where have we been, and where are we going? Biological Psychiatry. 1998;**44**(12):1229-1238. DOI: 10.1016/

s0006-3223(98)00282-0

[99] Riggs NR, Greenberg MT,

10.1177/1745691615570616

[101] Cyranowski JM, Zill N,

10.1037/a0028586

Kusché CA, Pentz MA. The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prevention Science. 2006;**7**(1):91-102. DOI: 10.1007/s11121-005-0022-1

[100] Cacioppo S, Grippo AJ, London S, Goossens L, Cacioppo JT. Loneliness. Perspectives on Psychological Science. 2015;**10**(2):238-249. DOI:

Bode R, et al. Assessing social support, companionship, and distress: National Institute of Health (NIH) Toolbox Adult Social Relationship Scales. Health Psychology. 2013;**32**(3):293-301. DOI:

[102] Southwick SM, Morgan CA, Vythilingam M, Charney D. Mentors enhance resilience in at-risk children and adolescents. Psychoanalytic Inquiry. 2007;**26**(4):577-584. DOI: 10.1080/07351690701310631

[103] Holt-Lunstad J, Robles TF, Sbarra DA. Advancing social connection as a public health priority in the United States. American Psychologist. 2017;**72**(6):517-

[104] Donahue MJ, Benson PL. Religion and the well-being of adolescents. Journal of Social Issues. 1995;**51**(2):145- 160. DOI: 10.1111/j.1540-4560.1995.

[105] Southwick SM, Vythilingam M, Charney DS. The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of

530. DOI: 10.1037/amp0000103

tb01328.x

protective services' view of collaboration with mental health services. Journal of Elder Abuse & Neglect. 2009;**21**(4):289- 306. DOI: 10.1080/08946560903004821

research on fidelity of implementation: Implications for drug abuse prevention in school settings. Health Education Research. 2003;**18**(2):237-256. DOI:

[90] Dusenbury L. A review of

[91] Escoffery C, Lebow-Skelley E, Udelson H, et al. A scoping study of frameworks for adapting public health evidence-based interventions. Translational Behavioral Medicine. 2018;**9**(1):1-10. DOI: 10.1093/tbm/

[92] Brabeck M, Jeffrey J, Fry S. Practice for knowledge acquisition (not drill and kill). https://www.apa.org/education/K12/p

[93] Connell JP. A new multidimensional measure of childrens perceptions of control. Child Development. 1985;**56**(4):1018. DOI: 10.2307/1130113

[94] Custers EJFN. Long-term retention of basic science knowledge: A review study.Advances in Health Sciences Education. 2010;**15**(1):109-128. DOI:

BrainWise curriculum: Neurocognitive development intervention Program. In: Romer D, Walker EF, editors. Adolescent psychopathology and the Developing Brain: Integrating Brain and Prevention Sciene. NY: Oxford University press. pp. 420-440. ISBN: 978-0-19-530625-5

10.1007/s10459-008-9101-y

[95] Barry PG, Welsh M. The

[96] A Proven Evidence-based Approach. The BrainWise Program. Available from: https://www.brainwiseplc.org/ [Accessed: 06 June 2019]

[97] History. The BrainWise Program. Available from: https://www.brainwiseplc.org/about/history/ [Accessed:

10.1093/her/18.2.237

ibx067

**108**

06 June 2019]

[106] Diamond A, Lee K. Interventions shown to aid executive function development in children 4 to 12 years old. Science. 2011;**333**(6045):959-964. DOI: 10.1126/science.1204529

[107] Ericson KM, Laibson D. Intertemporal choice. National Bureau of Economic Research (NBER) Working Paper No. 25358. December 2018. http:// www.nber.org/papers/w25358

[108] Parkinson RG. The common cause: Creating race and nation in the american revolution. Chapel Hill: University of North Carolina Press; 768 p

[109] McGrew S, Ortega, T, Breaksonte J, Wineburg S. The challenge that's bigger than fake news: Civic reasoning in a social media environment. American Educator. 2017;Fall:4-10

[110] Wineberg J, Mann S. Salford Jewish Community Health Research Report 2015. Available from: https://archive.jpr. org.uk/object-uk370 (Published January 1, 1970) [Accessed: 06 June 2019]

[111] Naifeh JA, Nock MK, Ursano RJ, Vegella PL, Aliaga PA, et al. Neurocognitive function and suicidal behavior in US Army soldiers. Suicide Life Threat Behavior. 2017;**47**(5):589-602. DOI: 10.1111/SLTB.12307

[112] Marteau TM, Hollands GJ, Fletcher PC. Changing human behavior to prevent disease: The importance of targeting automatic processes. Science. 2012;**337**(6101):1492-1495. DOI: 10.1126/science.1226918

[113] Barry P. Research and Results. The BrainWise Program. Available from: https://www.brainwise-plc.org/ research-results/ [Accessed: 06 June 2019]

[114] Norwood S, Rosa J, Fairbanks K, Downes D, Cerbana C, Gorman Barry P. Promoting the development of executive functioning for children from 1st through 5th grade using BrainWise. In: Poster Presented at the Rocky Mounting Psychological Association Conference; Boise, ID; 2015

[115] Persing R, Gorman Barry P, Welsh M, Cazzell K, Peifer, Reyes A. Improving health decisions in atrisk families: Nurse home visits, BrainWise and technology. In: Poster presented at the Colorado Public Health Association Conference; Pueblo, CO; 2011

[116] Bousman CA, Twamley EW, Vella L, et al. Homelessness and neuropsychological Impairment. The Journal of Nervous and Mental Disease. 2010;**198**(11):790-794. DOI: 10.1097/ nmd.0b013e3181f97dff

[117] Henry M, Mahathey A, Morrill T, Robinson A, Shivji A, Watt R, et al. The 2018 Annual Homeless Assessment Report (AHAR) to Congress. Washington, D.C.: U.S. Department of Housing and Urban Health Office of Community Planning and Development; 2018

[118] O'Connell M, Kasprow W, Rosenheck RA. National dissemination of supported housing in the VA: Model adherence versus model modification. Psychiatric Rehabilitation Journal. 2010;**33**(4):308-319

[119] Tsai J, Rosenheck RA. Risk factors for homelessness among US veterans. Epidemiologic Reviews. 2015;**37**:177-195

[120] Wenzel SL et al. Indicators of chronic homelessness among veterans. Hospital & Community Psychiatry. 1993;**44**(12):1172-1176

[121] Goldfinger SM, Schutt RK, Tolomiczenko GS, Seidman L, Penk WE, Turner W, et al. Housing placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatric Services. 1999;**50**(5):674-679

[122] Palermo S. Crossing in the red zone: mTBI/concussion in the context of war. EC Psychology and Psychiatry. 2018;**7**:287-288

[123] Woon FL, Farrer TJ, Braman CR, Mabey JK, Hedges DW. A meta-analysis of the relationship between symptom severity of posttraumatic stress disorder and executive function. Cognitive Neuropsychiatry. 2016;**22**(1):1-16. DOI: 10.1080/13546805.2016.1255603

[124] MacDonald BC, Flashman LA, Saykin AJ. Executive dysfunction following traumatic brain injury: Neural substrates and treatment strategies. NeuroRehabilitation. 2002;**17**:333-344

[125] Rabinowitz AR, Levin HS. Cognitive sequelae of traumatic brain injury. Psychiatric Clinics of North America. 2014;**37**(1):1-11. DOI: 10.1016/j.psc.2013.11.004

[126] Newcombe VFJ, Outtrim JG, Chatfield DA, et al. Parcellating the neuroanatomical basis of impaired decision-making in traumatic brain injury. Brain. 2011;**134**(3):759-768. DOI: 10.1093/brain/awq388

[127] Simmons MM, Gabrielian S, Byrne T, McCullough MB, Smith JL, Taylor TJ, et al. A hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs. Implementation Science. 2017;**12**(1):46-55

**111**

**Chapter 6**

**Abstract**

When Aggression Is Out of

*J. Gagnon, J.E. Quansah and W.S. Kim*

person neuropsychological approach.

would like to help people with uncontrolled aggression.

implementation intentions

**1. Introduction**

Control: From One-Person to

Two-Person Neuropsychology

From a neuropsychological perspective, impulsive aggression and its treatment

are usually conceptualized in most research as a closed executive functioning system, as though the behavior was the product of the person's cerebral functioning only. However, recent studies in social cognitive neuroscience have emphasized the influence of social factors on cognitive processes and cerebral functioning for the development and maintenance of impulsive aggression. This chapter will review studies that highlight the relevance of initiating a shift of paradigm from a one-person-cerebral functioning model to a social interactive-cerebral functioning model of impulsive aggression. First, the influences of an aversive environment on a child's cognitive processes and executive functioning will be discussed with the aim of explaining the development of impulsive aggressive behaviors in early childhood. Second, we will review studies that have shown how the link between social information processes and executive/inhibitory functioning serve to maintain behaviors. Finally, strengths and weaknesses of existing inhibitory control strategies will be discussed with the intention of proposing some novel ideas that incorporate a two-

**Keywords:** impulsive aggression, executive functions, inhibitory processes, social information processing, child development, treatment, inhibitory control training,

When facing a dangerous or threatening situation, aggression is a behavioral response that is often appropriate and necessary. An individual who is unable to perceive the hostile intentions of others is also unable to protect him- or herself or their personal needs. Aggression can also be characterized as a vital energy that allows an individual to mobilize the physical and psychological resources necessary to compete with others in a healthy way. Finally, aggression is present in many positive forms of emotional expression; it gives rise to creativity and the establishment of new relationships. It is when aggression is out of control that it becomes unbeneficial, problematic, and potentially harmful. Lack of control over the intensity, form, and timing of aggressive behavior is thus an issue of interest to clinicians who

## **Chapter 6**

*Inhibitory Control Training - A Multidisciplinary Approach*

placement and subsequent days homeless among formerly homeless adults with mental illness. Psychiatric

Services. 1999;**50**(5):674-679

2018;**7**:287-288

[122] Palermo S. Crossing in the red zone: mTBI/concussion in the context of war. EC Psychology and Psychiatry.

[123] Woon FL, Farrer TJ, Braman CR, Mabey JK, Hedges DW. A meta-analysis of the relationship between symptom severity of posttraumatic stress disorder and executive function. Cognitive Neuropsychiatry. 2016;**22**(1):1-16. DOI:

10.1080/13546805.2016.1255603

[125] Rabinowitz AR, Levin HS. Cognitive sequelae of traumatic brain injury. Psychiatric Clinics of North America. 2014;**37**(1):1-11. DOI: 10.1016/j.psc.2013.11.004

[126] Newcombe VFJ, Outtrim JG, Chatfield DA, et al. Parcellating the neuroanatomical basis of impaired decision-making in traumatic brain injury. Brain. 2011;**134**(3):759-768. DOI:

[127] Simmons MM, Gabrielian S, Byrne T, McCullough MB, Smith JL, Taylor TJ, et al. A hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs. Implementation Science.

10.1093/brain/awq388

2017;**12**(1):46-55

[124] MacDonald BC, Flashman LA, Saykin AJ. Executive dysfunction following traumatic brain injury: Neural substrates and treatment strategies. NeuroRehabilitation. 2002;**17**:333-344

**110**
