Interventions with Executive Functions

1. Interventions with Executive Functions

2. Major Treatment Approaches • I. Evaluation (Diagnosis) • II. Education (Counseling) • III. Medication • IV. Working Memory Training • V. Behavior Management • VI. Educational Management • VII. Environmental Management • Maturation (accounts for 3-4x more change)

3. Unproved/Disproved Therapies • Elimination Diet (e.g., removal of sugar, additives, etc.) (Weak evidence) • Megavitamins, Anti-oxidants, Minerals • (No compelling proof or disproved) • Sensory Integration Training (disproved) • Chiropractic Skull Manipulation (no proof) • Play Therapy, Psycho-therapy (disproved) • Biofeedback (EMG or EEG) (experimental) • Self-Control (Cognitive) Therapies • Social Skills Therapies (in clinic)

4. Implications for Treatment • Teaching skills is inadequate • Treatments must be at the points of performance • Behavioral treatment is essential but does not generalize or endure after removal • Reverse engineer the EFs: • Externalize important information (make lists, post rules, use signs, etc.) • Externalize time periods related to tasks (timers) • Break up future tasks into many small ones (do 1 daily) • Externalize sources of motivation (token systems) • Permit more external manipulation of task information • The compassion and willingness of others to make accommodations are vital to success • A chronic disability perspective is most useful

5. Empirically Proven Treatments • Parent Education About ADHD • Psychopharmacology • Stimulants (e.g., Concerta, Adderall, etc.) • Noradrenergic Medications (e.g., Strattera) • Working Memory Training • Parent Training in Child Management • Children (<11 yrs., 65-75% respond) • Adolescents (25-30% show reliable change) • Family Therapy for Teens: Problem-Solving, Communication Training

6. Empirically Proven Treatment (2) • Teacher Education About ADHD • Teacher Training in Classroom Behavior Management • Special Education Services (IDEA, 504) • Residential Treatment (5-8%) • Parent/Family Services (25+%) • Parent/Client Support Groups (CHADD, ADDA, Independents)

7. What to do about it: Environmental • classroom • seat placement/facilitated attention • individualized and untimed testing • adjusted workload/frequent checks • repetition of instructions/written instructions • breaking things into manageable bits • provide motivation (behavior modification, increased communication bw school and home) • make it hands on/interactive • allow for physical activity/breaks

8. What to do about it: Environmental • Home • increase motivation (find the right carrot) • shorten instructions and have them repeated or written down • reduce environmental clutter (noise, distractions etc.) • assist with organization (reminders, planners) • model appropriate behavior • Choose battles wisely (timing, necessity)

9. Interventions: General Principles • must fit with child, environment, teacher, parents • make rationale work for the teacher/parent • involve teacher/parent in planning possible solutions • measure success / failure

10. Interventions: General Principles • define relevant EF deficit, associated domain specific abilities or deficits, and task/situational demands • Determine the developmental level of child and what are age appropriate expectations for EF. • Teach compensatory strategies • Provide external control for those EF's missing in the child.

11. Outcome of Good Executive Function Cognitively • control of conscious and deliberate cognitive activity (e.g., rehearsal of information in preparation of exam, preparing outline before beginning to write, considering plan for any complex, difficult task)

12. Outcome of Good Executive Function Socially • inhibiting inappropriate socially impulsive behavior • guide behavior in social context by learned rules of social appropriateness • consider other people’s perspectives and interests in making decisions • delay immediate gratification in the interest of longer-term gain

13. Outcome of Good Executive Function Language • deliberate, effortful searches of one’s word knowledge • comprehension of extended language requiring active organization of incoming information • planned organization of extended discourse, both interactive (conversations) and non-interactive (descriptions, explanations) • controlled flexible use of abstract, ambiguous, indirect language (irony, metaphor, puns).

14. Systems Required to Promote Good Executive Function • Appropriate Assessment of Needs in the Everyday Environments of the Child • Establish and Support Everyday Routines to Support the Executive Function

15. Systems Required to Promote Good Executive Function Treatment Principles • Real World Relevance and Application • Within the context of everyday, meaningful routines • Collaborative, hypothesis testing

16. Interventions: General Principles External to internal process • External models of multi-step problem-solving routines • External guidance to develop & implement everyday routines • Practice application/ use of routines • Fade external support to cueing internal generation & use of routines

17. Interventions: General Principles External to internal process • Internal control to generate & use specific problem-solving routine • Generalization to new situation, requiring some external guidance • Accumulate experience, examine conditions for selective use of various routines • Feedback throughout (i.e., reward)

18. Reasons for a Reduced Executive Function Focus • Belief (misguided) that executive functions are “higher order” and must wait on their treatment until “lower order” cognitive and social processes are developed/ treated • Desire to protect the individual, resulting in family or school personnel assuming responsibility for all executive aspects of the individual’s behavior

19. Reasons for a Reduced Executive Function Focus • Paradoxical avoidance of treatment focus because of severe impairment in this area • Staff tendency to assume that their role as helping professionals requires assuming control for executive dimensions of tasks (identifying weaknesses, setting treatment goals, planning and organizing their activities, etc.)

20. Reasons for a Reduced Executive Function Focus • Lack of focus of executive function aspects of treatment within professional training programs • Student gives appearance of being in control under more familiar circumstances that rely on old knowledge, well-established routines

21. Result of No Focus on Executive Function treatment • With luck, the child will develop some sporadic independent problem-solving skills More likely, • Develop learned helplessness • Promote dependency • Opposition toward caregivers

22. Structuring an executive function intervention program • Use of everyday routines with (e.g., Goal-Plan-Do-Review) • Support working memory via “hard copy” of routine • Allowing child to become increasingly more active in formulating plans and reviewing their performance

23. Goal-Plan-Do-Review GOAL What do I want to accomplish? PLAN How am I going to accomplish my goal? MATERIALS/ EQUIPMENTSTEPS/ASSIGNMENTS 1. 1. 2. 2. PREDICTION: HOW WELL WILL I DO? Self rating 1 2 3 4 5 6 7 8 9 10 Other Rating 1 2 3 4 5 6 7 8 9 10 How much will I get done? DO PROBLEMSSOLUTIONS 1. 1. 2. 2. 3. 3. REVIEW: HOW DID I DO? Self rating 1 2 3 4 5 6 7 8 9 10 Other rating 1 2 3 4 5 6 7 8 9 10 WHAT WORKED?WHAT DIDN'T WORK 1. 1. 2. 2. WHAT WILL I TRY NEXT TIME?

24. Example with academic tasks • Written statement of student’s goal for the academic task • Specific list of all the steps needed to accomplish the task • Rate the performance (Self, Other) • Discuss discrepancies in ratings • Record what worked in one column and what didn’t work in another column • Retain the written Sheet in a notebook

25. What EF Intervention is Not • Specific set of skills/ information to “teach” student (e.g., group study skills class) • List of steps taped to the top of the student’s desk • Simple behavior modification to increase motivation • A “student thing” - listing IEP goals without attention to the “how, who, where, when” of the classroom delivery system

26. Sample “IEP-Speak” for the EF’s • Macro (Long-Term) Goal: The student will independently employ a systematic problem-solving method (e.g., Goal-Plan-Do-Review - GPDR) for tasks that involve multiple steps and/or require long-term planning.

27. Sample “IEP-Speak” for the EF’s Note: For students who are younger or with severe executive dysfunction, the objectives should be prefaced by the following statement: “With directed assistance, Johnny/ Jenny will . . .”

28. Goal Setting: (1) The Student will participate with teachers in setting instructional goals (e.g., "I want to be able to read this book, write this paragraph, etc.”) (2) The student will accurately predict how effectively he will accomplish a task. For example, he will accurately predict whether or not he will be able to complete a task; predict how many (of something) he can finish; predict his grade on tests; predict how many problems he will be able to complete in a specific time period; etc.

29. Planning: (1) Given a routine (e.g., complete sheet of math problems, clean his room), the student will indicate what steps or items are needed and the order of the events. (2) Given a selection of 3 actions necessary for an instructional session, the student will indicate their order, create a plan on paper, and stick to the plan. (3) Given a task that he correctly identifies as difficult for him, the student will create a plan for accomplishing the task. (4) Having failed to achieve a predicted grade on a test, The Student will create a plan for improving performance for the next test.

30. Organizing: (1) The student will follow/ create a system for organizing personal items in his locker. (2) The student will select and use a system to organize his assignments and other school work. (3) Given a complex task, the student will organize the task on paper, including the materials needed, the steps to accomplish the task, and a time frame. (4) The student will prepare an organized outline before proceeding with writing projects.

31. Self-Monitoring, Self-Evaluating: (1) The student will keep a journal in which he records his plans and predictions for success and also records his actual level of performance and its relation to his predictions. (2) The student will identify errors in his work without teacher assistance. (3) The student's rating of his performance on a 10-point scale will be within one point of the teacher's rating.

32. Self-Awareness: (1) The student will accurately identify tasks that are easy/difficult for him. (2) The student will accurately identify his/her strengths and weaknesses. (3) The student will explain why some tasks are easy/difficult for him. Self-Initiating: (1) When the student does not know what to do, he will ask the teacher. (2) With regular/ minimal prompting from the teacher, assistant or parent, The student will begin his assigned tasks, initiate work on his plan, etc.

33. College Accommodations • -   student should be allowed to take tests and complete work on an untimed or extended time basis • -   Student should have access to notes and class outlines • All assignments should be included on syllabi and student should work with someone to develop and appropriate plan for completing the assignments in a timely manner

34. College Accommodations • Student might be allowed to take a reduced courseload, but still considered a full time student • Seat placement in courses • Electronic Organizer • Use of tape recorder • Training in test-taking strategies • Relaxation training

35. 18 General Ideas for Management(Barkley) Parents are Shepherds; not Engineers Reduce delays & externalize time Externalize important information Externalize motivation (think win/win) Externalize problem solving Use immediate feedback Increase frequency of consequences Increase accountability to others Use more salient & artificial rewards

36. More of the ideas… Change rewards periodically Touch more, talk less Act, don’t yak… Keep your sense of humor Use rewards before punishment (reward early & often!) Anticipate problem settings; & make a plan for them! Keep a sense of priorities Maintain a disability perspective Practice forgiveness (child, self, others)

37. Making commands effective Heavily praise high compliance commands initially Use imperatives, not questions Go to child, touch, & use eye contact Child recites request Make complex tasks simpler ones Make chore cards for multi-step tasks List all steps involved in task on 3X5 file card Stipulate a time period on the card

38. More on effective commands Reduce time delays for consequences Use timers at points of performance Don’t assign multiple tasks at once Praise the initiation of compliance Reward throughout the task Child evaluates performance at end Create a “grab bag” of surprises (average out to every third incident of compliance)

39. Classroom Management I: Tips for Teachers Educate yourself about ADHD (nature, course, outcome, & causes) Keep in mind the 30% rule; anticipate the difficulties! Keep in mind that interventions within the school setting are most effective for improving school performance Get in-depth training and consultation on behavioral principles & modification Pick good administrators ; those that support & recognize your efforts! Know your limits and practice good self-care…

40. Classroom Management II: More Tips for Teachers Establish behavioral control – Primary objective in the first two weeks of school Decrease workload, or give smaller quotas of work Traditional desk arrangement & seat close to teaching area Target productivity first; accuracy comes later Don’t send home unfinished class work Give weekly homework assignment sheets; ahead of time! Consider reducing/eliminating homework!?!? Allow restlessness… Review homework at start of class; this helps all students! Help the student “think aloud & think ahead”

41. Domain-Specific Interventions

42. Initiating: • Increase structure of tasks • Establish and rely on routines • Determine minimal level of cue to help start and reduce cue over time • Break tasks into small, manageable steps • Place child with partner or group for modeling and cuing from peers • Reframe "lack of motivation" as initiation deficit for child, parent, teachers

43. Sustaining: • Increase salience in task- rely on high interest tasks • Hands-on activities support sustained attention problems • Ask child to choose among topics of interest to increase investment • Use verbal mediation (self talk-aloud or to self) to help remain focused • Write down list of what to attend to for a specific task

44. Sustained Working Memory: • Repeat instructions as needed, perhaps quietly to the child • Keep instructions clear and concise • Concrete reference • Use of script • Reduce rate of presentation/initial load (sense of overwhelm) • Frequent breaks • Task switching (not for everyone)

45. Inhibiting: • Increase structure in environment to set limits for inhibition problems • Make behavior and work expectations clear and explicit; review with student • Post milieu rules in view; point to them when child breaks rule • Teach response delay techniques (counting to ten before acting) • Environmental modifications (reduce distractions)

46. Shifting: • Increase routine to the day • Make schedule clear and public • Forewarn of any changes in schedule • Give 2 minute warnings of time to change • Make changes from one task to the next, or one topic to the next, clear and explicit • Shifting may be a problem of inhibiting, so apply strategies for inhibition problems

47. Organizing: • Increase organization in milieu • Increase organization of therapy to serve as model and help child grasp structure of novel material • Present the framework of new information to be learned at the outset, and review again at the end of a lesson • Begin with tasks with only few steps and increase gradually • Implement memory book/organizational system • Teach child to look for organization inherent in novel information

48. Planning: • Practice with tasks with only a few steps first • Teach simple flow charting as planning tool • Practice with planning tasks (e.g., mazes, cooking) • Ask child to verbalize plan before beginning work • Ask child to verbalize second plan if first doesn't work • Ask child to verbalize possible consequences of actions before beginning and contingencies for possible blockages • Review incidents of poor planning/anticipation with child

49. Self-monitoring: • Anticipate performance- ask child to state how he/she will do on a task, then compare gently with actual performance • Videotape child's behavior and review with child in supportive manner • Increase attention to behavior- ask child to verbalize steps as he/she is doing them • Find motivation for accuracy/neatness (reward etc.)

50. References • The Study Skills Handbook by Judith Dodge • Overcoming Underachieving by Nancy Mather and Sam Goldstein • Why Bright Kids Get Poor Grades and What You can Do About It by Sylvia Rimm • www.tourettesyndrome.org/htm.ef