Transcript Executive Functions

The Hill Center
Durham, NC
November 12, 2015
Cheryl Ann Chase, PhD
Clinical Psychologist
Independence, Ohio
ChasingYourPotential.com
This presentation and handout are intended for personal use only and may not
be distributed or re-presented without author consent.
Introduction to Executive Functions
 “Executive Functions” is an umbrella term for a set of
cognitive processes that are required for mental and
behavioral self control.
 Dysfunction of the EFs is often seen in children with
ADHD, learning disorders, autistic spectrum
disorders, anxiety, and many lower-incidence
syndromes, but it can occur free standing as well.
 Become a more commonly used term in education!
Defining Executive Functioning
 Many models, but they all generally stress:
 Independent
 Private
 Self-regulation skills
 Develop over the lifespan, but particularly during
childhood and adolescence (more on development later)
Dr. Russ Barkley
Model I will follow for this
talk is Russ Barkley’s –
describes them as :
“activities that one engages
in which are self-directed,
and help the person engage
in self-regulation.”
Five Primary Executive Functions
as Proposed by Barkley
 Inhibition
 Sensing to the self
 Self-speech
 Emotions / motivation to the self
 Play (Reconstitution) to the self
Inhibition



Inhibiting a dominant response
Interrupting an ongoing behavior when appropriate
Protecting the other ef’s from interference
Said slightly differently:
The capacity to stop and think before you act, resist the
urge to say or do something, and take time to evaluate
a situation and how your behavior might impact it.
Sensing to the Self
 a.k.a. nonverbal working memory (pictures, patterns)
 Imitation of complex behavioral sequences
 Vicarious learning
 Awareness of time
 Reciprocal exchange, social cooperation
 Hindsight and forethought
Said another way:
The ability to hold nonverbal information in mind while
performing complex tasks; incorporates the ability to draw on
past learning or experience to apply to the current situation, or
project problem solving strategies into the future.
Self-Speech
 Using language and words to engage in reflective
thought (rule-governed behavior).
 Making and following rules and meta-rules (self-
instruction). Stand back and look at how you problemsolve, and evaluate how you are doing.
 Strongly impacts reading comprehension, morally-
guided behavior, grammar, math, etc.
Emotion/Motivation to the Self
 Modifying one’s internal state to create new affect
(cheering self up, calming self down)
 Intrinsic motivation to achieve a future goal
Said a different way: the ability to manage emotions in
order to achieve goals, complete tasks, or control and
direct behavior. Also includes the capacity or drive to
follow through on the completion of a goal and not be
put off by other demands or competing interest.
Reconstitution to the Self
 a.k.a. play to the self
 Generating multiple options toward a goal
 Goal-directed innovation (problem solving)
 Verbal and nonverbal fluency (generating diversity)
 Rapid assembling of complex, hierarchical, goal-directed
actions (can tell you what they read, but concrete facts, out
of sequence and poorly organized)
Said differently
Coming up with novel ideas, revising plans in the face of
obstacles or new information, adapting to changing
conditions
Five Primary Executive Functions
as Proposed by Barkley
 Inhibition
 Sensing to the self
 Self-speech
 Emotions / motivation to the self
 Play (Reconstitution) to the self
Secondary Impacts











Poor organization
Poor adaptive functioning
Poor planning
Poor time management
Emotional lability
Procrastination, don’t know how to initiate tasks
Inflexible, strong adherence to routines or patterns
Quit, easily give up, tearful or emotional outbursts
Cannot persist on tasks without help, lots of questions
Poor social skills, hard time making and keeping friends
Out of seat, climbing, fidgeting
Impacts continued
 Behavior is not guided by mental events about time – it is






always NOW
Display lots of task-irrelevant behavior
Too little purposive, future-directed action
Too little complex, hierarchically organized behavior (e.g.,
writing an essay is challenging)
Little self-improvement by vicarious learning (get in
trouble for doing what brother just did)
Problems inventing more novel, complex actions (forget
math book – now what??)
Too little goal-directed persistence (easily de-railed)
Impacts Continued
 Poor task reengagement (cannot get them back on




track)
Insensitive to feedback (make same mistakes)
Poor time management (time-blindness)
Reduced sensitivity to errors (proofreading, doublechecking)
Emotional tolls – anxiety, depression, feeling worthless
or ineffective, low self-esteem….etc
Development of EFs
From
To
External
→
Mental (private)
Others
→
Self
Temporal (now)
→
Anticipated Future
Immediate gratification
→
Delayed
Development of EFs
 Tough to give exacts because depends on what aspect





of EF being measured and huge nature/nurture issue
Not fully developed until late adolescence or early
adulthood. Peak in early adulthood.
Infants as early as 5-12 months show inhibition,
nonverbal working memory
Age 3 years, acquiring speech and able to use it on self;
becomes silent between 9-12
Reconstitution – start to see around age 6 years
In general, develop gradually throughout school years
Unwilling or unable?
 Often both!
 Very few children choose to be unsuccessful
 Children with EF weakness may appear unmotivated due to
their inconsistent, unpredictable behavior.
 Children with EF weakness often give up when they see
little connection between effort and outcome
 Ask yourself:
 Does he appear to want to do well, but is surprised when he
doesn’t?
 Does she continue to perform poorly even in the face of
negative consequences?
 Does he do better when an adult is in the room, or
monitoring progress?
So, what do we do now?
BALANCE and COMPASSION!
Children do well if they can!!
Children do well if they can!!
Children do well if they can!!
~ Ross Greene, PhD
Collaborative Problem Solving
General considerations
o Take a dual approach. Strike a balance between
TODAY and TOMORROW. Accommodate the EF
weaknesses while also helping the student develop the
skills needed.
o The compassion and willingness of others to make
accommodations is VITAL to success.
o Keep a disability perspective. The student is not
choosing this.
General considerations
o This is a DOING problem, not a learning problem.
These kids know what to do, they just do not do what
they know at the point of performance.
o Teaching skills is inadequate.
o Must intervene at the point of performance – list on
the locker, reminder while packing for home, etc.
Cannot teach in the abstract – GO THERE
General considerations
oMust “design prosthetic environments”
or serve as a “surrogate frontal lobe”
o Gains do not generalize or endure once
supports are removed so DO NOT pull
programs once the child shows success!
o No two cases are alike so be sure you know what EFs
you are targeting.
General considerations
o EFs do not exist in isolation. There are no standard,
cookie-cutter treatment plans.
 IQ
 Family support/pathology **parents with ED!!!





Language skills
Other cognitive or learning conditions
Other medical/health conditions
Other psychiatric conditions
Teacher/student fit
School
General considerations
o Be patient
o Do not blame, do not preach. “Kid gets it right once
and he pays for it for the rest of his life!”
o Set realistic expectations – these kids will need more
support for a longer period of time than their agemates. Stop “should-ing” on these kids.
o Build habits – rewards, behavior plans in the service of
building a habit
o Educate everyone! Parents, child, all teachers,
nannies, grandparents if necessary, tutors, stepparents
And Acceptance
There is a limit. Accept that.
Barkley’s Five General Elements of
any EF Treatment Plan
I. Externalize important information
•
•
•
•
•
Lists, posters, signs, cues of critical reminders
Make them bright and obvious
Might habituate to them – change them occasionally
Post them at the point of performance
Examples:
•
“Pack of school” list on the front of the hall closet
•
“Pack for home” list on school locker
•
“Get ready for bed” list on bathroom mirror
•
Picture lists may be easier to use
Barkley’s Five General Elements of
any EF Treatment Plan
II. Externalize time periods related to tasks
•
•
•
•
•
Use timers – I like the Time Timer (www.timetimer.com)
Counters, egg timers, hourglasses
Train kids to feel passage of time
Train kids to persist for various amounts
of time – 5 mins, 6 mins, 7 mins – 20 mins
Have kids time themselves doing various daily
activities (brushing teeth, shower, dressing, eating)
Barkley’s Five General Elements of
any EF Treatment Plan
III. Break-up future tasks into many small steps
•
•
•
Book report – a chapter a night, summarize in 2-4
sentences. Mom and Dad reward for each chapter
Explicitly walk child through steps of complex routines
such as washing a load of laundry – step by step – and post
steps on washing machine
Keep EROs close in time – Event, Response, Outcome
(video games do this)
“Rome wasn’t built in a day”
Barkley’s Five General Elements of
any EF Treatment Plan
IV. Externalize sources of motivation
•
•
•
•
•
•
Immediate and quick praise
Token economy
Stickers, stamps, charts
Even just a smile or a high-five
Consequences are GOOD – make them clear and
immediate if possible. Consequences ≠ Punishments!
These kids generally respond to contingencies!
WORD OF CAUTION HERE – WATCH OUT – FOR SOME
KIDS, YOU COULD INDUCE A MELTDOWN!
Barkley’s Five General Elements of
any EF Treatment Plan
V. Permit more external manipulations of task
components
•
•
•
•
•
•
Manualize problems
Not just an opportunity for multisensory processing, but
also keeps information that is being processing from
fleeting out of working memory (decaying stimulus)
Cut spelling words out and sort them manually
Assemble a periodic table
Make a 3-D model of a molecule
Dissect a frog
Executive Function in the
Classroom
©2010
Christopher Kafuman, PhD
Chapter 5
Moving the Frontal Lobe to the Front of the Class: Seven core
strategies for helping students with executive function
challenges
(there are other chapters that offer intervention approaches
for reading, writing, mathematics, planning/organization,
and social functioning, but these are the foundational
strategies)
“An essential truth about executive function is that
different profiles of executive dysfunction are not equally
problematic in all settings (Brown, 2002). In other
words, the functional impact of various executive
function weaknesses is setting dependent.”
Christopher Kaufman, PhD
Executive Function in the Classroom
2010
“…..these strategies can contribute to classrooms that are
reasonably well linked to the needs of children with a
host of executive skill weaknesses.”
Christopher Kaufman, PhD
Executive Function in the Classroom
2010
So, seven core strategies:
1) Providing “surrogate prefrontal lobe” support
2) Teaching new skills/content explicitly
3) Teaching strategies and how they should be applied
in context
4) Minimizing demands on working memory
5) Providing opportunities for guided practice
6) Keeping things predictable
7) Anticipating difficult aspects of tasks and modeling
strategies to manage these challenges.
More strategies to keep
in your toolbox
So, so, so many resources out there!
Here is just a sampling of what some
of the experts suggest.
Impulse control
o Use sound behavioral principles – associate good impulse
o
o
o
o
o
o
control with reinforcers
Use visual cues – stop signs, reminders
Develop habits that deter impulsivity – everyone walk
down the hallway with their hands on their thighs, turn
around and count to 10 before choosing someone to
answer, avoid games that require competitive responding)
When a student begins to interrupt, have him/her write
down what he/she wants to say and make time for it later
Make sure “in a minute” is really in a minute
Give child 5 popsicle sticks and they must give one up each
time they ask a question during homework time
Medications
Emotional self-control
o Teach yourself to step back from a situation before
reacting
o Learn to apologize well
o Educate others not to make too much of initial
reaction
o Seek help of psychologist or counselor
Self-monitoring
o Train kids to periodically self-monitor (How am I doing?)
o Highlight math operations or other important information
o
o
o
o
o
(directions – not, but, compare and contrast, give three reasons).
Proofread out loud
Proofread by reading backwards
10 minutes before in-class test or assignment is to be turned in,
remind/prompt students to look through the document for
blanks, etc.
Provide direct instruction and practice in self-monitoring one’s
work. E.g., re-read directions when DONE and see if you
followed them.
Allow students to review assignments (their own and each
others’) and correct errors
Prospective Memory
(remembering to remember)
o Set reminders and alarms, write notes
o Use a planner or PDA and reference it regularly
o Ask others for reminders when appropriate
Activation and Persistence
o Create intermediate deadlines
o Keep a picture or reminder of the
rewards awaiting you.
o Give rewards for finishing
something big
o BOC time!
Sense of time
o Put up a bunch of clocks
o Wear a watch that beeps regularly
o Set alarms – on PDAs, clocks, timers
o Use timers
o If doing group-work, designate a person to watch the
clock
Hindsight and Forethought
o Plan ahead, consider the options, and think about
what is required
o Map out how and when to get project done
o Have a visual schedule
o Talk through plans with others to fill in gaps
o Build in time to reflect along the way
o De-brief in the end
Planning/Time Management
o Use timers and alarms
o Use picture lists with associated times for routines
o Estimate time needed, then compare to actual
o During group projects, designate a timer
o Teach how to use agendas, planners, calendars
o MAKE TIME to check to planners
o Teach how to maintain planners
o BE FLEXIBLE! Kids and families have lives too – no
homework on curriculum night? Weekly PSR night?
Planning/Time management (continued)
o Give assignments a week in advance to allow for planning
o Give students a semester-long syllabus
o Either use correctly, or don’t use at all, on-line assignment
books/grade books
o After an absence or illness, only require the makeup of
necessary work. Let go what you can
o Consider and reconsider your homework choices –
reduction?? Let parents call it quits when child gets run
down, or give several nights to get it done.
o Help child break down large assignments, projects, tasks
into reasonable parts and set intermediate deadlines.
http://www.joeschedule.com/
Positive Everyday Routines
Goal-Plan-Do-Review
GOAL - What do I need/want to get done?
PLAN – How will I get it done?
DO – Try out my plan.
REVIEW – evaluate effectiveness
Model that was designed for patients with
brain injuries, but can be applied to
helping folks with ef weakness.
Ylvisaker & Feeney (1998)
e.g., keep forgetting math book
Organization
o
o
o
o
o
o
o
o
Family launch pad that is well maintained (HCM)
E-mail assignments to teacher and self as back-up
Have a second set of textbooks at home
Parents, advisors, tutors, coaches – check the student’s
backpack, planner, on-line grade-book, assignment book
frequently
TELL parents and student when assignment is missing as
soon as possible
Color coding, labeling
Organize in a way that works for the child – NOT 6 drawers
with 40 tabbed folders, 3 drawers – NOW, LATER, DONE
Provide a stash of supplies in each classroom. Stock-up
mid-September
Initiation
o Use software programs for writing
o Allow student to begin by dictating assignment
o For younger children, use a song to guide them
through routines (morning, bedtime, cleanup)
o Before starting a seated task, do some gross motor
activity first
Working Memory
o Reduce distractions
o Have child do it right away – go to your locker now and
get your homework
o Use reminders (post-it notes, digital voice recorder,
leave self voice mail, email self)
o Write-out complex things (What elements do I need
to keep in mind while writing this essay?
Working Memory
o Make lists! Words, pictures
o Use a voice recorder to record tasks, assignments, or
o
o
o
o
o
o
reminders (email self, leave self voice mail, digital recorder)
Secure a note taker
Use Livescribe pen
Help students develop mnemonics or songs or other
strategies to remember a series of steps or other
information (be silly)
Teach visualization strategies to enhance recall
Do NOT give instructions while handing out worksheets
Do no pass around objects during talk, lecture
www.livescribe.com
www.youtube.com/watch?v=Ag6R8v9YZ2k&feature=related
Cognitive Flexibility
o Review upcoming changes to schedule or environment (e.g.,
o
o
o
o
o
o
o
o
“remember, tomorrow you will have a substitute and she will not
do things exactly the way I do, but I have told her that is OK”).
Allow for a break including a place to calm down when the child
encounters a change.
Teach relaxation techniques (breathing, visualization,
progressive relaxation)
Provide signals prior to transitions (verbal, physical, visual,
auditory)
Social stories – get school psychologist involved
Social skills training
Positive reinforcement for managing a change
Explicitly teach about rules AND exceptions
Grey ‘em up
Where to start….
Executive Function in Education (2007) Lynn Meltzer,
PhD
Executive Function in the Classroom (2010)Christopher
Kafuman, PhD
Executive Skills in Children and Adolescents, 2nd ed
(2010) (first edition 2004)Peg Dawson, EdD and Richard
Guare, PhD
Promoting Executive Function in the Classroom (2010)
Lynn Meltzer, PhD
Coaching Students with Executive Skills Deficits (2012)
Dawson and Guare
More options…….
Smart but Scattered (2009) Peg Dawson, EdD and
Richard Guare, PhD
Smart but Scattered Teens (2012) Dawson and Guare
Organizing the Disorganized Child (2009) Martin
Kutscher and Marcella Moran
The Organized Student (2005) Donna Goldberg and
Jennifer Zwiebel
Late, Lost, and Unprepared: A Parents' Guide to
Helping Children with Executive Functioning
(2008) Joyce Cooper-Kahn, PhD and Laurie Dietzel,
PhD
Additional resources
 ADHD and the Nature of Self Control (2005) Russell Barkley.
 Building a Theory of ADHD: Inhibition, Self-Control, and the Executive




Functions (2008) Russell Barkley. Professional workshop attended in
Canton, Ohio.
Building Better Executive Skills: A Model for Teaching Parents How to
Help Their Children and Teens. (2010) Joyce Cooper-Kahn and Laurie
Dietzel. CHADD Annual Conference, Cleveland, Ohio.
Executive Functions and the Frontal Lobes (2008)Edited by: Vicki
Anderson, Rani Jacobs, and Peter Anderson.
Practical Strategies for Overcome Executive Function Weaknesses:
Understand More, Live Better (2010) Ari Tuckman. CHADD Annual
Conference in Cleveland, Ohio.
Who’s Runnign the Show? Executive Dysfunction & How to Help the
Disorganized Child (2007) Laurie Dietzel, PhD. Professional workshop
offered by PESI. Attended in Cleveland, Ohio.
Conclusions
 There are no easy answers.
 If we do nothing, the secondary problems that develop
are significant – loss of wages, productivity, emotional
toll
 Instill HOPE – parents, kids, teachers worn out
 Realistic goals and adequate support
 Humor, flexibility, acceptance
“It is what it is”