Executive Dysfunction: Late, Lost and Unprepared

There are two things that parents are asked to accept about Executive Dysfunction:  

1) Their child will likely need more support than their peers.  They will have a longer developmental process to maturity, than their peers.  Not everyone will be independent at age 18 or 21.  Children need supportive parents while they are still developing these skills without enabling them.

2) Parents are also asked to accept that these kids are more variable in their performance from day to day than their peers.

What is common sense to us may be novel to a parent. Often times, the child’s brain is fine, IQ is high, however school and/or parental expectations are too high.

1)  Why don’t kids remember to turn in their homework? Stop asking this question, Kids just simply don’t know why.

  • The intervention is to have the teacher politely prompt the child to turn it in.

2)  Difficulty transitioning: affect cognitive flexibility, planning and organization.

  • The intervention is routine, prompting for change, such as a visual timer (countdown).
  • Many kids can’t organize themselves at their locker in time, and therefore carry all of their
    materials with them, rather than using their lockers.
  • Have a full set of text books at each classroom, with consumables so the child doesn’t have to
    try to manage getting everything to each class. If the family can afford it, get online
    and order used text books.

3) One of the goals for executive functioning is to move from external support to internal

4) Difficulty catching “careless” error: cognitive areas affected are inhibition and impulse control (definition is not doing or saying the first thing that you want to do or say), and self-monitoring.

  • There is a difference between behavioral impulsivity, and cognitive impulsivity.  Cognitive impulsivity leads to careless errors.
  • Lecturing does not help, giving verbal instructions to “slow down” does not help.  Use behavioral techniques such as working for shorter periods of time followed with a reward.  Medications may be needed.  Exercise and diet may help. Parent training is necessary.  Often one-on-one assistance may be needed.

5) Difficulty keeping track of directions: affects language and memory.

  • If a child can’t follow 3-step verbal directions, give 1-step, use pictures, write directions down.
  • Can’t keep track of stuff.  Develop a habit or routine for where we keep the “stuff”.

6) What is executive functioning (EF)

  • It is made up of a profile of one or a combination of many of all cognitive skills.

7) Executive functions include the ability to:

  • Set goals independently
  • Plan, organize, initiate, sequence, and monitor one’s behavior (get started with Non-Preferred tasks); Intervention is to initiate the task with the child and then let them progress on their own, as they can – similar to helping them balance on a bike until they  can take off on their own
  • Good time management;  Individuals with EFD have trouble tracking the passage of time.  Teach time in terms of “Dougs”
  • Keep track of information in working memory
  • Think in a flexible manner (cognitive flexibility)

8) EF is the Cognitive Conductor, Master Control, It is the CEO of the brain

  •  creates a master plan, reacts effectively to changes and challenges.

9) As a therapist, we must be aware that there are huge cultural differences in values related to EF and development.

10) Play is a child’s job.  That is how they develop cognition, social skills, EF, etc.

  • Decades ago, toys did not come with directions for play.  Children acted upon them, made them work, used creativity, structure and imagination. Technology is great, however the level of stimulation  and lack of structure and imagination is a huge change.
  • Kids are spending more and more time, in an adult supervised, structured world.  Kids have much less solitary and peer-play time than they used to.  Over time, this may have an effect on a child’s ability to plan, organize and structure their time independently. These activities actually help children develop executive skills.
  • There are actually some programs out there that are designed to teach children how to play.

11) Nature and Nurture – Yes, it is both.

  • There are no markers or predictors, that determine which children will progress the most, or the best through EF dysfunction.

12) Assessment

    • There are no norms, or standardizations for cognitive flexibility, or impulse control, etc.
    • One-on-one testing may not capture all of the difficulties.  One child may do just fine in this type of set of setting.
    • Some children perform very well on standardized testing, but are still impaired, and may have significant deficits with real-life performance.
    • See testing instruments and/or rating scales on page 4 and 5 of the handout.
    • Useful questions to ask:
      1. Does what you hear make sense?
      2. How long can you sit and read?
      3. How often do you need to cue this child?
      4. Is the child aware of their difficulty?
      5. How much time each night does he/she spend doing homework to just “keep up”?
      6. Has he/she had to give up extracurricular activities to just “keep up”?
      7. Is he/she an “oops” child?
  • Observation in different settings and at different times of day are critical, and very often overlooked.
  • Feedback to the student that was tested:
    1. Emphasize genuine strengths
    2. Keep it short. Check in with the child at least every 5 min.
    3. Use visuals
    4. Discuss weaknesses as hypotheses (it seems that you lose track of your ideas when you are writing…is that true?)
    5. Instill hope as you describe interventions.

Learn more about the Circles in the Box.

13) EF weaknesses at school are often not identified until demand increases and structure decreases.  Typically around 5th-6th grade when demand exceeds coping skills, transition to Jr. High, High School, College.

  • Teachers can email parents on a mass email listing
  • Print homework assignments on a label that children can peel off and stick somewhere
  • Powerschool
  • Study hall or at least something at the end of the day (15 min) when a staff member can review what homework assignments are due, make sure all materials are taken home to complete the assignments and make a plan for what will be done in the evening.
  • E-mail assignments home.
  • Turn all  homework into one person at the beginning of the day, who is responsible to deliver it to each teacher.
  • Involve the child in the process so they learn, not so they are enabled.
  • E-mail assignments from home to school. Use OCR apps to send homework to teachers.

14) EF weaknesses at home

  • Chores are a wonderful way of working on these skills, growth and development, but kids with EF need to be hand-held through the process.

15) How to help less efficient readers

  • learningalli.org

16)  EF and math

  • Highlight the computation signs.
  • Have them read it aloud.

17)  EF and writing

  • Inspiration software (kidspiration)
  • Dragon software.

18) EF and PDD

  • Are almost always concomitant
  • Most often always have cognitive rigidity.  Change = stress, which is bad for autistic kids. Cognitive rigidity is one of the definitions of EFD

19) Nonverbal Learning Disability

  • Shared with autism
  • Difficulty w/ idioms, social cues.  Miss prosody and intonation of the conversation.  Desire social contact, but don’t know how to handle it.

20) Tourette’s disorder

  • Inhibition problems
  • Sensory Integration Dysfunction
  • Self-regulation
  • Some sensory problems are under-stimulation and some are over-stimulation.

21) Setting expectations

  • Sometimes the messy room is not the biggest issue.  Concentrate on the big issues.
  • Do not set expectations too high, or too low.  Must be an adequate balance.  What is the natural consequence of our expectations?  What will someone suffer if they fail?
  • It is difficult to know where to draw the line, because the line changes from day to day, sometimes hour to hour.  Life is not always fair, some kids need more accommodations than others.  We don’t need to treat all kids the same.

22) Dopamine deficits (Dopamine is a reward chemical)

  • Kids without ADHD, can be conditioned to receive a small dopamine burst without getting the reward, which is an explanation for intrinsic motivation.  Kids with ADHD do not get this
  • Conditioned burst of dopamine, therefore, they need the reward each time to receive this chemical.  This explains why children with ADHD choose small rewards, rather than delayed larger rewards
  •  Lack of dopamine requires movement, which is why there is so much hyperactivity.
    • use a sitting ball, exercise ball, standing desk.  This may work for some, but not for others.  It may call unwanted attention, increase anxiety, sensory issues.

23) It takes 30 days to establish a habit/behavior.

  • School age kids are 5 days on, 2 days off
  • Therapy is one day per week
  • Work on one behavior at a time if possible.
  • Don’t try to teach these skills in the abstract.

24) Ongoing evaluation.

  • Not only fade the accommodations, but adjust, eliminate or add new goals as needed.

25) Use a fidget ball, or object to “give the hands something to do”.

  • When you work with a child, experiment with a fidget ball.  See if they can focus with one or if  it makes it worse.  Also see if they can focus and pay attention, participate while walking, rolling round the room, playing, etc.

26) Organization

  • Launching and landing pad, a basket, plate, crate, etc. where everything for the child goes.  Less things get lost, organization takes less cognitive effort.
  • Second set of textbooks at home.
  • Weekly or even daily time to help organize.
  • Frequent check of backpacks, desks, lockers, etc.

LINKS:

John Ratey Spark – The science of physical activity as it relates to cognitive activity.
ADHD coaches federation