“Supporting Children with Weak Executive Functioning Skills”

Lecture by Ann Helmus, Ph.D. Pediatric Neuropsychologist

Children’s Evaluation Center, Newton 11/3/04

Sponsored by the Brookline Public Schools and Brookline SEPAC

Notes on the presentation taken by SEPAC member.

Two areas of the brain involved with executive function: sub cortical area (like the core of an apple) and the frontal area. Together they run goal-directed, organized behaviors.

Sub-cortical region contains structures related to memory and emotional regulation and responsivity (i.e. the limbic system).

The frontal lobe plays important role in attention, screening incoming stimuli and responses (filters out what I’m going to let in) and planning.

Executive function (“EF”)

Defined as that what you need to engage in goal-directed behavior-- open ended, novel unfamiliar tasks. Not automatic, routine tasks.

1. Regulation of mood, attention and level of arousal.

2. Task Management “I.S.I.S.”

A. Initiate: have to initiate a task with a plan.

B. Sustain: once initiate task, can you sustain it.

C. Inhibit: once initiated, can you “block out” inappropriate responses or impulses.

D. Switch: refers to mental flexibility. Once in a project, can you step back and evaluate or reflect on performance to be able to evaluate and make it better?

Weak EF

1. Students have difficulty structuring time, space and materials

2. Students have difficulty sequencing information, needed for following instructions and making a plan for executing a multi-step task.

3. Students have difficulty organizing information -- occurs at all levels, but not much demand on this in the lower grades.

4. Students have maladaptive emotional reactions to schoolwork, such as increased anxiety, reduced motivation, feeling helpless.

How to prevent this falling into the “limbic cesspool?” that may occur when a student doesn’t know what to do?

Help students ask the questions: 1) What am I being asked to do? 2) How do I do this?

Why are so many kids having trouble with EF these days?

1. If you have any type of learning disability (with a few exceptions, like dyslexia), a developmental delay or inattention, you most likely have problems with EF. It is at the core of our function.

2. Curriculum is changing dramatically for kids. Formerly, rote assignments given, e.g. a list of math facts to complete. Now, have a math program in Brookline like TERC. This places increasing demands on EF. Now, more and more, curriculum requires kids to be able to initiate, organize and plan projects either alone or in a group, often, without sufficient amounts of external organizational supports for all students to be successful.

Executive function allows us to impose some structure on our environment. If can’t do it yourself, you are more dependent on your external environment.

QUESTIONS FROM AUDIENCE

How/when does EF develop?

First 7 years of life are key years of development of this system. Brain continues to develop these skills into one’s early 20s.

Many demands placed on today’s students are developmentally inappropriate. Helmus thinks that process (projects which require lots of task management) should be taught with easy materials, and content should be taught separately.

Schools are still on a learning curve with EF. On IEP forms, there are nine categories to select from -- neurological would be the best choice to describe EF issues.

Role of Environment in EF development

Assuming normal brain, environment plays a huge role in how EF develops. A chaotic environment is not an optimal environment for developing EF. Modeling good organization, and also the “sports commentator” approach (e.g., first we go to the store, then we buy the ingredients, then we can make our treat) can be helpful in assisting children see the steps used in planning.

If child has a weak EF system, they will have a hard time learning these tasks by simply being exposed to them.

What are the developmental trajectories for EF?

Basic regulation of emotions: no temper tantrum.

¯

Task Management skills: can the student conceptualize a plan.

How does processing speed relate to EF?

There are two issues in processing speed.

1. Everyone’s brain has a certain RPM, a certain speed. For example, given a concrete task, such as comparing items to each other, how fast one can compare them is an indication of processing speed. This is unchangeable.

2. The second type of processing speed she calls “messy file drawers.” Some students have information neatly organized in their brain. Others do not, and are slower to access information. So, with complex items, speed can slow down. Must learn to build organizational structures in their brains. Have a rundown list of items/a script: what do you need to know to complete this task.

Are there newer tests to diagnose EF?

Critical part of testing is getting good data. Difficult to assess EF in the office because an office is highly structured.

* Standard BRIEF: Behavioral Rating Inventory of Executive Function

Parents, school and students each fill out a version of the test. Standardized sloping.

*Delis-Kaplan Executive Function System

These are 8 different tests which code EF. One part of is especially looks at organization.

Can your EF weaknesses be weighted one way or another (task management v. emotional regulation)?

Yes. Depends on how your brain is put together.

If your key deficit is that your limbic system development is atypical, weighted toward emotional issues.

If your key deficit is ADD family history of ADD, weighted toward task management.

If your key deficit is due to head injury, weighted toward task management.

Connection to ADD

EF problems are part and parcel with ADD

* Individuals with ADD have reduced chemical activity in the frontal lobe

* Since frontal lobe plays key in EF, issues arise.

However, you can have EF without having ADD.

ADD seems more prevalent among boys (3 or 4 boys to 1 girl)

Connection to autism spectrum and NLD

Huge part of EF is organizing incoming information.

These students don’t naturally develop scripts which help to organize and differentiate the relative importance of information -- every piece of information is equally important as the other.

Dr. Helmus gave the example: If most students are asked to write about “What is a quetzal?” they will write that it is a bird, where it lives, what it looks like. For the NLD/autism spectrum students, since all the information is seen as being of equal importance, they may start their writing by skipping the general information (that it is a bird) and go to another piece of information.

How do you teach these students how to take notes?

Start with the event, then ask a series of questions to organize the information.

What kind of event?

Where did it take place?

Who was involved?

When did it occur?

Why did it occur?

Social Functioning/Communication deficits and EF

Socialization is one of the hardest things we ask the brain to do.

Social interaction involves unique events in time which fall into a pattern, so you must develop a script for help organize the interaction.

If can’t organize a sequence of events, you will have trouble. Students with poor EF have trouble telling the story, organizing it and often can’t pick out the salient parts.

SO, have students map out/work with student to map out what happens in an interaction.

E.g. Went to recess ® played ball® Joe stole ball® I said give it back® ….

Asperger’s and NLD kids aren’t picking up on social cues in the environment, so they engage in socially inappropriate behavior and get peer rejection. So, pull them aside, go over the interaction and reinforce specific social rules. E.g. What is our rule about space between people?

Don’t want to be punitive to kids, help them to understand.

If have poor impulse control: Medication. “Think before you talk.” Slow down.

Learning Disabilities (“LD”) and EF

If have a learning disability, will have trouble with EF because they interplay with each other. If a student has to compensate for a LD, s/he has to rely on EF more. For example, if student has a reading disability, must teach the student step by step how to read. It’s EF that’s being called upon to learn.

KEY FOR CHILD IS MOTIVATION

How do you motivate this child?

With a 2^nd grader who has a reading disability, 2^nd grader is highly motivated to be like peers.

With a 13 year old, there may be significantly less motivation to tackle an area of weakness. Help them to see the consequences:

What will happen if you do the assignment. How will you feel?

What will happen if you don’t do the assignment? How will you feel?

With a high school student?

What if EF diagnosis is at 15 or 16? How do you direct child? Really difficult. One approach is to select something they are highly motivated about, such as wanting to be a camp counselor, then work on EF issues using the application process to get this job they really want.

Have student sit down with adult-- start with positive attributes, and list up to 3 problems (or maybe just one). Student is informed, but not overwhelmed.

Link note taking and written expression to EF issues to help motivate child.

A coach (not the parent) can help deflect some of the nagging.

Demystify: “You’re smart. This is the problem, so let’s work on it. Here’s how to fix it.”

Books for teens

The 7 Habits of Highly Effective Teens, by Sean Covey.

All Kinds of Minds by Mel Levine

Do regular education teachers have the skill and/or time to help students with weak EF?

It depends (and this applies to parents as well).

MUST learn to break tasks down and do them step by step.

What about high school students?

In high school, the focus should not be so much on the level of organizing their materials.

Emphasis should be on the level of written expression. Need to teach organization, an approach to organizing the information so that student can write about it.

Also, students need to fill out a checklist to make sure they are set for each class.

What materials do I need?

What steps do I need to complete it?

Do I need help?

Who will help me?

How much time do I need?

Written Expression

Students need a framework for information before they start writing. Just giving them the outline/structure of an essay is not enough. They don’t know what goes in the topic sentence, etc. They need help in organizing the information so they can put the topic sentence together and see the details. Helmus discussed the EmPower program, developed by Dr. Bonnie Singer (www.innovativelearningpartners.com).

.

EmPower “scaffolds the internal dialogue needed for problem solving.” Evaluate (task analysis), Make a plan (what do I need to do, materials, information), Organize (use a chart, thinking map, flow chart), Work (translate thinking into product), Evaluate (use checklists, discuss with someone else), Rework.

Helmus showed various thinking maps (www.thinkingmaps.com) which can help students to organize information, such as describing qualities of characters in novels, comparing/contrasting, classifying, sequencing, seeing cause and effect and analogizing information. Once material is organized in this fashion, the task of writing is then demystified, working memory is supported, initiation is aided and anxiety is reduced. Can be used across all grades.

Audience member from Dover, MA said that all regular education teachers have received training in this approach and it is successful.

What about perfectionism/fear of failure?

Many students visualize the product they want but don’t know how to get there.

Need to learn to harness your intelligence. If have high intelligence and weak EF, it is hard, because you have lots of information to organize. Give those students systems to harness this.

Motivation always plays an important role.

What about stimulant medication?

Stimulant medication helps children to pay attention. That’s all. Gives child the attention to organize or implement compensatory strategies.

What label would you give EF issues?

Helmus does not particularly like labels. It is better to say: what is it you can do, and what gets in the way? For example, you are great at vocabulary, good at reading. Sometimes students get overloaded with information and don’t know what to do with it.

Does the brain grow “out of” EF issues, or do adults have better coping strategies?

Career options for individuals with weak EF?

There are less demands on adult brains (don’t have to switch from one subject to another so frequently) but in some ways, there can be greater demands.

At higher levels of employment, need higher EF skills. However, you can have weak EF, but hire people to work for you/with you who have strong EF skills, and be successful.

In the work world, there are lots of frameworks used to perform specific tasks. These help to organize the information for the work.

If have lower cognitive function and weak EF, select jobs with more highly routinized tasks.

Where can I get more information on EF?

Get on the SEPAC and MASSPAC email lists for announcements of seminars.

Look at research associated with ADD and Tourette’s syndrome. EF is a key issue in the study of Tourette’s and there is lots of research on EF in this context.

Next week, workshop on EF at Harvard School of Education (but it is full).

Lecture on EF at Littleton High School on Tues. Nov. 15.

Specific Strategies

Dr. Helmus distributed a handout listing specific strategies. They are as follows:

Organization of Materials

Trapper; color coding

Desk space; labeled drawers, files, cubbies

Assignment book -- have it checked.

Organization of Time

Planner

Wall Calendar

Setting timer

Time-blocking

Identifying high and low energy times

Using pockets of time wisely

Schedule on board for the day or for the class

Organization of Thoughts

Charts, diagrams, flow charts, thinking maps, “talking through”

Schemas

What is important about….

Animals (habitat, size, diet, predators)

Historical events (social, economic, and political causes/impacts)

Here is the set-up of….

Novel (setting, main characters, rising action, climax, resolution)

Algebra word problems