Executive Functioning and its Relationship to Behavioral and Emotional Functioning in Children and Adolescents with Spin

1. Executive Functioning and its Relationship to Behavioral and Emotional Functioning in Children and Adolescents with Spina Bifida Natalie C. Kelly, Ph.D. Pediatric Neuropsychology Fellow Cincinnati Children’s Hospital Medical Center

2. Outline • Discuss neuropsychological outcomes in spina bifida • Define executive functioning • Discuss the development of executive skills across childhood and adolescence • Review the research on executive functioning outcomes in spina bifida • Discuss my current research on psychosocial adjustment and executive functioning in youth with spina bifida • Provide practical executive skill recommendations for parents and schools

3. Stages of Brain Development Cell birth- at conception Migration-6 weeks until 8 weeks postnatal Differentiation-complete at birth Maturation-adulthood Synaptogenesis-pre-natal-age 2; adulthood Cell death and synaptic pruning-late childhood-puberty Myelogenesis-4th-5thdecade

4. Associated Neuropathology in Spina Bifida • Arnold-Chiari II Malformation • Hydrocephalus resulting from obstruction of CSF flow in the 4th and/or 3rd ventricles; occurs in approximately 80-90% of individuals with spina bifida • Partial agenesis of the corpus callosum • Polymicrogyria • Heterotopias

6. Neuropsychological Outcomes • Verbal/Language Skills • Basic linguistic abilities are intact, but poor language pragmatics (e.g., discourse) • Hyperverbal- exhibit “Cocktail Party Syndrome” • Word retrieval, verbal fluency deficits • Poor comprehension of complex syntax

7. Neuropsychological Outcomes • Non-Verbal/Visual-Motor Skills • Studies consistently find difficulties in this area for children with spina bifida and hydrocephalus • Pattern of poor visual-spatial skills and better verbal skills individuals with spina bifida and hydrocephalus can have what has been called a Nonverbal Learning Disability (NLD)

8. Neuropsychological Outcomes • Attention • Children with spina bifida and hydrocephalus consistently perform more poorly than comparison groups on measures of attention • In a study by Burmeister et al. (2005) they found a higher incidence of AD/HD- than in the general population (31%)

9. What is Executive Functioning? • Term refers to abilities that allow a person to successfully engage in independent, planned, strategic behavior or reach a goal • They are a set of cognitive skills that are required for individuals to execute, or carry out tasks

10. They can be thought of as a “conductor” of all of our thinking skills

11. Everyday Example • We need executive skills to carry out many tasks, for example: Getting to the conference • Decide you want to come • Plan to take the time off work • Arrange transportation and hotel details • Put aside money to pay for the conference; consider your budget • Make arrangements for child care • Organize and develop the schedule of workshops you’d like to attend

12. Executive Functioning Skills • Inhibition • Shift • Emotional Control • Initiation • Working Memory • Planning/Organization • Organization of Materials • Self-Monitoring

14. Inhibition

15. Inhibition: • The ability to think before you act • Stopping behaviors at the appropriate time, including actions and thoughts • Opposite is impulsivity-weak ability to stop behaviors, “just do” • Example: Child raising their hand instead of shouting an answer; Adolescent thinks about the consequences before participating in a senior prank

16. Shift

17. Shift: • The ability to think flexibly between ideas • Transition freely between tasks • Individuals with strong skills in this area are able to generate alternative solutions and ideas and revise plans in the face of obstacles, new information, or mistakes • Example: A child can transition from playing on a puzzle to coming to the table for dinner

18. Emotional Control

19. Emotional Control: • The ability to regulate and manage emotions by thinking rationally about the situation at hand • Example: A child is able to control his disappointment when told that he is not allowed to have a piece of candy; An older child is able to refrain from retaliating after being made fun of

20. Initiation

21. Initiation: • The ability to begin a task or activity and independently create ideas, responses, or problem-solve • To begin projects without procrastination in an efficient manner • Example: A child can begin a task right after instructions are given; An adolescent begins a household chore independently

22. Working Memory

23. Working Memory: • The ability to hold information in mind long enough to complete a task • Example: Child is able to carry out 2-3 step directions given by the teacher; An adolescent is able to recall the expectations of multiple teachers throughout the school day

24. Planning/Organization

25. Planning/Organization: • The ability to manage both current and future demands • The ability to create a plan or step-by-step process to get from A to B • Example: A child can create a plan to complete a school assignment; an adolescent is able to create a plan to complete a research project due in 2 months

26. Organization of Materials

27. Organization of Materials: • The ability to organize belongings related to work and play • Efficiently creating and maintaining systems to keep track of information and materials • Example: A child can use a system with support to organize their toys; an adolescent is able to keep track of their class materials and paperwork

28. Self-Monitoring

29. Self-Monitoring: • The ability to monitor ones own performance and measure it with a standard of what is needed or expected • Being able to take a step back and ask yourself, “How am I doing?” • Example: A child changes their response based on feedback from a parent; An adolescent compares their performance to more skilled peers and adjusts as needed

30. Vignettes • Identify the EF problem in the following vignettes: • Vignette 1 • Vignette 2

31. Development of EF Skills • 6-12 months • 12-24 months • 24 months- adolescence • Inhibition, working memory, emotional control • Shift • Task initiation, planning/organization, self-monitoring

32. Pre-frontal cortex

33. Assessment of EF • Neuropsychological evaluation • Rating scales such as the BRIEF • Neuropsychological tests that have been shown to assess various domains of EF depending on the measure; these are age-normed • Neuropsychological tests are not very predictive of EF skills in everyday life

34. EF Findings in Spina Bifida Literature • Youth with spina bifida are at risk for a range of impaired executive functioning skills: • Children with spina bifida found to exhibit poorer skills in the areas of problem-solving and mental flexibility in comparison to LD, AD/HD, and healthy controls • Children with spina bifida and shunted hydrocephalus display deficits in working memory in comparison to healthy siblings • Children with spina bifida perform more poorly on measures of planning and strategy

35. EF Findings in the Spina Bifida Literature • Parent and teacher ratings of EF have been used in previous studies – Behavior Rating Inventory of Executive Function • Studies have found impairment in children with spina bifida and hydrocephalus on the Plan/Organize scale of the BRIEF • Studies have found differences on the Metacognition Index of the BRIEF for children with spina bifida as compared to controls; don’t see differences on the Behavioral Regulation Index (Mahone et al., 2002; Maines et al., 2008).

36. EF Findings in Spina Bifida Literature, con’t • Heffelfinger and colleagues (2008) • Based their study on a model that attempts to understand adaptive or functional outcomes in adolescents with spina bifida • They found that executive functioning partially explained the relationship between neurological severity and adaptive functioning

37. Psychological Outcomes • Children and adolescents with spina bifida: • Are at increased risk for internalizing and externalizing disorders • Are at a greater risk of depressive mood and low self-worth when compared to healthy controls • Females are at increased risk for depression and higher levels of suicidal ideation • Exhibit a high rate of psychiatric symptoms on the Child Symptom Inventory

38. Research Question • What role do specific neuropsychological factors have on psychosocial outcomes in children and adolescents with spina bifida?

39. Previous Literature • Fletcher et al., (1996) proposed that cognitive functions (e.g., attention, initiation) may mediate the influence of hydrocephalus and its associated physiological abnormalities on social outcomes • Landry et al. (1993) also suggested a similar role of neuropsychological variables in the relationship between biological factors and social behaviors • Rose & Holmbeck (2007) tested a mediation model and found that executive functioning mediated the relationship between Group (spina bifida v. comparison) and social outcomes • Limitations • Exploratory • Psychological outcomes not addressed

40. Methods: Sample * p<.001

41. Measures

42. * p<.001

43. Model METACOGNITION GROUP PSYCHOSOCIAL OUTCOME

44. Study Results • Metacognition fully mediated the relationship between Group and Internalizing Problems and CDI-Mother only • This suggests that internalizing behaviors and depressive symptoms can be explained by metacognitive skills regardless of whether you have spina bifida or not • Therefore, could impaired executive functioning skills (e.g., working memory, poor planning, difficulty with organization, poor self-monitoring) contribute to emotional and mood symptoms?

45. Implications • The findings have treatment implications • Target therapeutic interventions on improving executive functioning skills

46. Future Directions-Research • Investigate whether the relationship holds for children with spina bifida who have different levels of severity • Cross-sectional design-what would these relationships look like over time? Across the course of development? • Are there different aspects of Metacognition that are responsible for the relationship?

47. EF Recommendations-Context Home School Implemented in the context of a 504 Accommodation Plan or Individualized Education Program (IEP) Children with spina bifida qualify through the “Other Health Impairment” category Use behavior management strategies with the support of a school psychologist or counselor • Takes consistent implementation • Use behavior management strategies to increase the likelihood that the child will change their behavior • REINFORCE the behaviors that you want to continue and IGNORE the ones you don’t

48. EF Recommendations at Home: Antecedents • Ways to target antecedents: • Change the physical or social environment to reduce problems (e.g., reduce distractions, organizational structure) • Change the nature of the tasks expected • Make the tasks shorter, build in frequent breaks • Make the steps explicit (e.g., clean your room) • Create a schedule

49. Schedule Example

50. EF Recommendations at Home: Behavior • Directly teaching the appropriate behavior • Modeling • Use regular family activities to teach skills (e.g., planning a meal) • Games