Executive dysfunction pesi 050514

David D Nowell PhDwww.DrNowell.com

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Overview

• Brain Overview in 27 Slides• Models of EF• Strategic Behavioral Inquiry (HËDŸDT?)• Disorders Which Impact EF• Real Life Implications of EF Deficits• Assessment of EF• Strategies and Case Studies • Q&A&D

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BRAIN OVERVIEW IN 27 SLIDES

Brain overview in 27 slides

• Neuron• Synapse• Neurotransmitters• Lobes• Hippocampus• Amygdala• Ventricles• Cerebrospinal fluid• CT/MRI• Functional brain imaging

What does dopamine feeeel like?

amygdala

Prefrontalcortex

Ways of thinking about the brain

• Left to right• Top to bottom• Front to back• Top-down and bottom-up

what IS…

…what COULD BE

What’s wrong with this brain model?

MODELS OF EXECUTIVE DYSFUNCTION

• McCloskey’s model• Barkley’s model• Brown’s model• BRIEF model• Dawson and Guare model

McCloskey’s Clusters

• Attentional cluster• Engagement cluster• Optimize cluster• Evaluation cluster• Efficiency cluster• Memory cluster

• Attentional cluster– Becoming aware– Focusing attention– Sustaining attention

Sleep hygiene

• Strict bedtime• Use bed only for sleep• No caffeine after mid-afternoon• No activating media after 7pm

Establish bedtime routine

Fidget supports

• Engagement cluster– Initiating– Putting in effort– Inhibiting– Stopping– Interrupting

Reward small units of effort

There’s no such thing as “disinhibited”

The “talking stick”

Differential Reinforcement of Other

• Optimize cluster– Modulating– Monitoring– Correcting

Sam rode her new blue bicycle down the steep hill, enjoying the crisp Autumn air and bright late-afternoon sun.

Voice Modulation

• 5 – football game• 4 – large clasroom• 3 – small group • 2 – talking quietly with a friend• 1 - whisper

• Give multi-step directions while playing catch• Play mindfulness “freeze tag”• Quiz do-over• Make use of rhythm and music

(508) 579-7958

Don’t stealth bomb inattentive students

• “Pete in about a minute I’ll ask you about..”

• Evaluation cluster– Sizing up– Anticipating– Estimating time– Making associations– Generating solutions– Organizing– Comparing

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1 hour 1 day 1 week 1 month 1 year

Time Horizon

10-Minute Morning Review

Using your phone’s navigator as a time-management tool

• Efficiency cluster– Sensing time– Pacing– Sequencing– Using routines / executing

Distraction delay training

• Memory cluster– Holding– Manipulating– Storing– Retrieving

Prospective Memory

The Executive Functions

• Sensing to the self• Speech to the self• Emotion to the self• Play to the self

Barkley, RA, (2012)

BRIEF (Behavioral Rating Inventory of Executive Functioning)

• Inhibiting• Shifting • Controlling emotions• Initiating• Working memory• Planning• Organizing materials• Monitoring• Metacognition• Behavioral regulation

Self-control

“Hot” and “Cold” Executive Functions

• Sensing to the self (HËDŸDT)• Speech to the self• Emotion to the self• Play to the self

Barkley, RA, (2012)

• Inhibiting (HËDŸDT)• Shifting • Controlling emotions• Initiating• Working memory• Planning• Organizing materials• Monitoring• Metacognition• Behavioral regulation

STRATEGIC BEHAVIORAL INQUIRY

Objectives of SBI

• Specific behavioral strategy• What was the feeling-goal?• Motivational level on a scale from 1-10

Benefits of SBI

• Affirms the value of clients’ unique internal experience

• Emphasizes the culture of self-regulation• Encourages metacognition

Assumptions of SBI

• Everybody’s doing the best they can• Behavior is not incomprehensible or random• Behavior follows patterns which reveal

themselves to the curious observer free of prejudice or blame or theory

Personal Application

…and How Exactly Did You Do That?

Personal Application

• What bad habit persists? And How Exactly Do You Do That?

Learn from your To-Do list

• Which things are not getting completed?• How – exactly – are these not getting

completed? How do you do that?

Clinical Application

• Who in your clinic or classroom is demonstrating remarkable “resilience” – persistence despite significant obstacles? And how, exactly, does he/she do that?

• What recurring behavioral problem is showing up in your clinic or classroom?

• Note: we aren’t asking “why did you do that,” but rather “how exactly did you do that.”

How to do SBI

“How exactly did you do that?”“How did you know it was time to _____?”“How long had you been thinking about ____?”

DISORDERS WHICH IMPACT EXECUTIVE FUNCTIONS

• ADHD• Schizophrenia• Bipolar Disorder• Anxiety Disorder• Autistic Spectrum Disorders• Sensory Processing Disorder• Specific Learning Disorders• Tourette’s Syndrome• Sleep Disorders

20%–60% of the variance in functional outcome (Sabhesan & Parthasarathy 2005)

Gur RE, Turetsky BI, Loughead J, et al. (2007)

(Clark, Iversen & Goodwin 2001)

(Rubinsztein, Fletcher, et al. 2001)

(Phillips, Ladouceur, & Drevets 2008)

Fujii, Kitagawa, et al 2013

(Airaksinen, Larsson, & Forsell 2005)

Appendix A

(Brosnan, Demetre, et al 2002)

Appendix B

ADHD OCD

(Rechtschaffen & Siegel 2000)

ADHD and Brain Development

Sluggish Cognitive Tempo

• Daydreaming• Easily confused• Staring• Easily fatigued• Sluggish• Withdrawn• Slow to complete tasks• Lower levels of parent stress• Less situation-specific than hyperactive type

REAL LIFE IMPACT OF EF DEFICITS

1. 1-step errands

2. Chores with cues

3. Basic inhibition

Age-appropriate ExpectationsPreschool

1. 2-3 step directions

2. 20-30 minute assignments

3. Follow rules/inhibit/no grabbing

Age-appropriate ExpectationsKindergarten -2nd Grade

1. Simple shopping list

2. Keep track of variable daily schedule

3. Inhibit and regulate even without teacher present

4. Simple delayed gratification (phone)

Age-appropriate Expectations3rd-5th Grade

1. Complex chores

2. Organizing system

3. Time management

4. Self soothe

5. Manage conflict

Age-appropriate Expectations6th – 8th Grade

1. Independent with assignments

2. Make adjustments based on feedback

3. Inhibit reckless behavior

4. Say “no” to fun activity if other plans already made

5. Take others’ perspective

Age-appropriate ExpectationsTeenage-mid 20’s

Automaticity frees up resources

Knock 3 years off his age

Age-appropriate ExpectationsLending Your Brain

Arenas of Involvement

• Intrapersonal• Interpersonal• Environmental• Academic / symbol system

(McCloskey & Perkins, 2013)

Executive Functions and Math

• Verbal strategies– Please excuse my dear Aunt Sallly (PEMDAS)

• Verbal strategies– Please excuse my dear aunt sally (PEMDAS)– KNOW• Key words, numbers, operation, work it out

Key words

Numbers I need

Operations

Work it out

• Visual strategies

• Hands-on strategies

Executive Functions and Reading

EZ-C Reader

Executive Functions and Writing

Executive Functions and Study Skills

Cornell note-taking system

Class and date

Key ideas

Class and date

Key ideas

Class and date

Key ideas

SUMMARY

Class and date

Key ideas

SUMMARY

Class and date

Key ideas

Class and date

Key ideas

Class and date

Key ideas

SUMMARY

Class and date

Key ideas

SUMMARY

Chunk Chew and Check

• Grades K-2: about 5 minute chunks• Grades 3-6: about 10 minute chunks• Grades 7-12: about 15 minute chunks

Executive Functions and Homework

Homework Considerations for Teachers

• Target productivity first, then accuracy• Reduce homework– Overall correlation of homework with

achievement is just .15-.25 across all grades and weaker in elementary grades*

– For high school, best amount was 1.5-2.5 hrs/night; more time had no further benefits*

*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.

Executive Functions and Social Skills

Accommodations for EF Deficits• Preferential seating• Extra set of textbooks at home• Quiet test environment• Time off the clock during testing (schedule breaks)• Pre- and post-class 1:1 review of content• Visual schedule• Movement breaks• Fidget/sensory interventions• Verbal cues• External time cues (Time Timers products, or kitchen timer)• Teacher check-off on homework binder• “Locker” is in guidance counselor’s office• Attention coach (10-15 minutes)

Examples of IEP Goals for EF Deficits1. Self Awareness a. Student will identify tasks that are easy or difficult for him/her.b Student will accurately explain why some tasks are easy or difficultd.Student will offer help to another when he/she is more capable than another child 2. Goal setting a. Student will participate with teachers in setting academic goals. 3. Planning a.Given a selection of 6 activities for an instructional session, student will select 3, indicate their order, create a plan on paper and stick to the plan. c. Having failed to accurately predict his/her grade on a test, student will create a plan for improving performance on the next test.

Examples of IEP Goals for EF Deficits 4. Organizing a. To relate a story, student will place illustrations in order and then narrate the sequence of events B. Student will prepare an organized semantic map or outline before proceeding with writing projects 5. Self-initiating a. Without prompts, student will begin his/her assigned tasks 6. Self-monitoring & self evaluating a. Student will identify errors in his/her work without teacher assistance 7. Problem Solving a. When faced with obstacles to educational or social objectives, student will identify possible courses of action, identify pros and cons for each, choose a course of action, perform it and evaluate its effectiveness.

What are our data sources?

• Record review• Interview• Collateral interview• Checklists• Mental status examination • Test scores

ASSESSMENT OF EXECUTIVE FUNCTIONING

Curious Compassionate Nonjudgmental Evaluation

• Skillfully eliciting the chief complaint• HËDŸDT?• Forming a diagnostic impression• Defending your diagnosis / impression

Skillfully eliciting the chief complaint

• Too much of what? Or too little of what?• Invoking the Pediatric Fairy (or the Psychiatric

Genie)

HËDŸDT?

• How exactly did you do that?– Everybody’s doing the best he/she can– Every behavior problem is either• Skills deficit• Contingency problem

Forming a diagnostic impression

• Where do you see it the most? And where do you see it the least?

• Two disorders = two stories

Documenting and communicating your conclusions

• The footprints in the butter• Defend your diagnosis

Approaches to Evaluation of EF

• Formal direct• Informal direct• Formal indirect• Informal indirect

Evaluation of EF

• Informal Indirect– Review of records– Collateral interviews (see McCloskey 2012)

Evaluation of EF

• Formal Indirect– BRIEF (Behavior Rating Inventory of Executive

Functioning)– BASC (Behavior Assessment for Children)– CBCL (Achenbach Child Behavior Checklist)– BDEFS-CA (Barkley Deficits in Executive

Functioning Scale – Children and Adolescents)

Evaluation of EF

• Informal Direct– Review of work samples– Process-approach to test performance– Mental Status Examination– Classroom observation

Evaluation of EF

• Formal Direct– NEPSY– CAS (Cognitive Assessment System)– Delis-Kaplan Executive Function System– Continuous Performance Tests (Vigil; Connors CPT;

IVA)– Wisconsin Card Sorting Test– Trail Making Test for Children– Rey-Osterreith– Functional Behavior Assessment

Avoiding the most common diagnostic error

STRATEGIES AND CASE STUDIES

Stimulant Treatment for ADHD

Image: wikimedia commons

Cortico-striatal loop

Increase salience

Two weeks from now, how will you know whether it’s working?

Appendix D

Daily report card

Appendix C

Antecedent Support for Executive Dysfunction

AANTECEDEN

BBEHAVIOR

CCONSEQUENC

AANTECEDENTS

BBEHAVIOR

CCONSEQUENC

“Modified Independence”

• Chronic disability perspective• Time prosthetics• Problem-solving prosthetics (mind map)• Math prosthetics• Sequence prosthetics• Motivation prosthetics

AANTECEDENTS

Set them up for success

Clear boundaries

Clear (see-through) storage

AANTECEDENTS

Identify exceptions

Where do you see it the most?

Where do you see it the least?

•Waking up•Bedtime•Chores•Homework•TV / internet

AANTECEDENTS

Launching Pad

Expectations

•Specific•Behavioral•In advance

AANTECEDENTS

Communication

•Get eye contact•Speak clearly•Provide behavioral info•Check for understanding

AANTECEDENT

AANTECEDENTS

Provide prosthetic cues at the “point-of-performance” (Barkley)

easy hard

If It’s Harder than a “3” Find Some Way to Make It Easier

Assign separate due dates for smaller parts of big projects

Appendix H

Increase salience

StayOnTask app

The “talking stick”

Provide multiple cues for transitions

• Verbal “two minute warning” • Visual schedule• Changes in lighting• Nonverbal cues

Consider your own self-stim strategies

• Applying lotion• Clicking pen• Sewing machine leg• Gum• Whistling

Instant study carrel

Time “in”

Place the student with tactile defensiveness at the edge of the group

Heavy work

ADD Coaching

Movement Techniques

• Exercise• Yoga• Martial arts

Bal-A-Vis-X

Balance screen time and “green time”

Supplements and Diet

• Omegas• Food additives• Food allergies• Pesticides

Bodywork

• Massage• Chiropractic • Acupuncture• Transcranial magnetic stimulation

AANTECEDEN

BBEHAVIOR

CCONSEQUENC

Behavioral Support

BBEHAVIOR

“A healthy high-functioning 26 year old”

BBEHAVIOR

• Behavioral control• Choices and options• Self-regulation• Arousal• Motivation• Mood• Attention

Mindfulness

Dr. Sara Lazar

Metacognition

• How much effort am I giving this?• What has worked for me before?• When to shift from processing to maintenance

Hypnosis

Mnemonics Training

AANTECEDEN

BBEHAVIOR

CCONSEQUENCES

Don’t reward them with stuff

Rotate rewards frequently

Use extrinsic reward creatively

Emphasize the sensory details of your desired outcome

Cortico-striatal loop

Determine what basic provisions are unconditional…

• Love• Respect• Safety• 3 meals• Essential clothing• Temperature-controlled environment• 30 minutes of video games

…and which are contingent• Special foods• Expensive or trendy clothing• Extra video game time• WiFi password

Clip and share horrible articles about teens falling out of the back of pickup trucks

• Review cause and effect• Discuss consequences• Emphasize behavioral agency

The “Big Five”

• Daily focus time• Nutrition• Movement• Sleep• Connection

…the most important 10 minutes of the day….

The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it.

- E. Goldberg

Key features of a great planner system

• 2 pages per day• Master to-do list• With the client at all times

Yoga / read

Staff meeting

Planningsession

Phone calls

billing

Vh: jeff w/ puritan oil

Vc: kate re: brimfield

TC umass dermatology. Spoke w/ cindy 508 8564000

What’s a To-Do list for anyway?

• The “technology”• The “practice”

• The “technology”

• The “practice”

Weekly Overview

The “Big Five”

• Daily focus time • Nutrition• Movement• Sleep• Connection

Nutrition essentials

• Emphasize protein at every snack and meal• Eat fewer processed foods• Choose local• Pay close attention to patterns between food

and focus/mood

The “Big Five”

• Daily focus time / Motivational clarity• Nutrition• Movement• Sleep• Connection

“Exercise for focus” is different from "exercise for fitness”

The “Big Five”

Marry well and get a crackerjack assistant at work

Positive characteristics of many people with attentional / executive challenges

Appendix G

Don’t do anything for your ADHD teenager which could be managed by a machine or an app

“Walk Me Up” app

Q & A & D

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@davidnowell David Nowell Seminars

Fail-proof desk activities

Appendix A

Determine in Advance When You’ll Check Email and Facebook Tomorrow

• Review expectations in advance

• Teens and college students may take more initiative with this

Generic Issues Associated with Transition to Adolescence

• Increased physical size and neurological maturation• Increasing maturation of sexuality• Increasing desire to individuate from parents; decreasing

influence of parents on teen behavior• Increasing time away from home & parents• Increasing number of domains of major life activities to which

the teen must adapt– Sex, driving, peers, money & work, community activities, crime, drugs

• Greater involvement with and influence of peers• Most of these are adversely affected by delay in self-

regulation associated with ADHD

How do symptoms change by adolescence?• Hyperactivity declines more steeply than does inattention and

related executive function (EF) deficits• Motor restlessness becomes a more internalized subjective

sense of feeling a need to be busy all the time• Transition to middle school is associated with a transient

increase (reversal of decline) in ADHD symptoms• The inattentive/EF symptoms have a greater impact on school

functioning than HI symptoms; increases with age• Impulsivity is more related to impaired nonacademic domains:

– development of ODD– drug experimentation– speeding while driving– risky sexual behavior, taking on dares from peers– impulsive verbal behavior– reactive aggression

Symptom Transitions (continued)

• But inattention also has adverse impacts on non-academic functioning :– Poor attention to traffic density and speed while in community auto

traffic settings– Greater risk for pedestrian/cycling accidents in traffic settings– Greater crash risk as drivers (in vehicle distractions are most

contributory)– Accelerated use of nicotine after experimentation

• Self-medication ???

– Poor follow through on chores and other home responsibilities– Poorer work performance in school– Poor work performance part-time employment settings– Inattention to others’ comments and needs in social activities

Emerging Impact of EF Deficits• Poor working memory (remembering to do things)

– Less follow through on promises and commitments to others– Increasing adverse impact of reading-listening-viewing comprehension

deficits, especially in school & work settings

• Impaired planning, anticipation, and preparatory behavior; not ready for the future as it arrives– Reduced valuing of future rewards relative to peers– Consequently, don’t persist toward future goals and show poor delay of

gratification

• Deficient sense of time and time management– A restricted temporal window relative to peers

• Poor emotion regulation (related to poor inhibition)– Deficient control of anger & frustration most impairing

• Decreased fluency (rapid assembly of ideas into coherent verbal reports and behavior)

Basic Considerations• Don’t retain in grade!• Sept is to establish behavioral control• Decrease total workload, or• Give smaller quotas of work at a time• Target productivity first, accuracy later • Reduce homework

– Overall correlation with achievement is just .15-.25 (just 2-6% of variance in achievement) across all grades and weaker in elementary grades*

– For high school, best amount was 1.5-2.5 hrs/night; more hours had no further benefits*

*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.

Tips for Teens• As needed, use ADHD medications – have

parents negotiate a contract with the teen if necessary

• Find a “Coach” or “Mentor” (Just 15 min.)– The Coaches’ office is the student’s “locker”– Schedule in three 5-minute checkups across each day– Use behavior report card to monitor teen across classes– Use daily assignment sheets requiring teacher initials– Cross temporal accountability is the key to success

• Identify a parent-school ADHD liaison– Serves as an intermediary on issues between parents & school

A Daily Behavior CardEach teacher rates each behavior at end of each class; 1=Excellent (+25), 2=Good (+15), 3=Fair (+5), 4=Poor (-

15), 5=Terrible (-25)

Subjects 1 2 3 4 5 6 7ClassParticipationPerforms assignedclasswork

Follows class rulesGets along wellwith othersCompletes home-work assignments

Teacher’sInitials

More Tips for Teens• Use a daily school behavior card for self-evaluation

after; move to weekly after 3+ good weeks• Keep extra set of books at home• Learn typing/keyboard skills for writing assignments• Require continuous note-taking to pay attention to

lectures or during reading assignments• Tape record important lectures – check out the Smart

Pen that digitally records lectures or other conversations at livescribe.com

More Tips for Teens• “Bucks for Bs” system – grades on each assignment = $ from parents

• Get week-at-a glance calendar with journal or other organizing notebook system

• Schedule hard classes in AM• Alternate required with elective classes• Extra time on timed tests (???) – no evidence it helps– Better to have distraction free test setting and intersperse

breaks in testing to create shorter test periods (time off the clock)

• Permit music during homework*• Get written syllabus as handouts

*Soderlund et al. (2007). Journal of Child Psychology and Psychiatry, 48, 840-847.

Still More Tips for Teens• Learn SQ4R for reading comprehension– Survey material, draft questions, then: – Read, recite, write, review

• Peer tutoring in class• “Study-with-a-buddy” after school • Find “fall-back” classmates (swap phone, e-mail, & fax

numbers) for lost or missing assignment sheets• Attend after-school help-sessions• Schedule parent-teacher-teen review meetings every 6

weeks (not at 9 week grading period)

Teaching skills is inadequate

What and who is the “A”

Chronic disability perspective

Reverse Engineering the Carrot and Stick

• Rey O versus VMI• Carrot and stick• Break down large projects• scaffolding

• Present various models of EF• Settle on 10-ish• Introduce HEDYDT? (disappearing ink, do you

comment, hedydt)• Create more handouts (e.g. worksheet for

determining contingencies)

Overview• Brain overview in 11 slides

– Amygdala (mindfulness), hippocampi (exercise), PFC (screen time/green time, sleep), PFC regions, loops• Models of EF

– Small group: what is EF– Hot and cold EFs– 10 Efs - consider dawson guare model– Barkley’s 4– McCloskey’s 30-st

• EF as Self-Regulation– Sensing to the self, etc– Central impairment is in self-regulation

• Disorders which impact EF– ADHD– TBI– Schizophrenia– Bipolar Disorder– ASD– Anxiety Disorders– Leaning Disorders– Oppositional Defiant Disorder

• Real life implications of EF deficits– EF and reading– EF and writing– EF and math– EF and test-taking– Metacognitive Awareness Inventory (Schraw & Dennison 1994)

• Assessment of EF– Direct formal etc– Curious compassionate nonjudgmental evaluation

• Strategic Behavioral Inquiry (HEDYDT?)• Asking 2 Questions• Case Studies and EF Strategies• School Accommodations and Supports• Big 5 EF Supports

• N-back with a deck of cards

Accomodations

• Meltzer (kindle)

Inattentive

Sluggish Cognitive Tempo

Hyperactive Combined

5-42 / (10-2)+3x6

P 5-42 / (8)+3x6

E 5-16 / (8)+3x6

MD 5-2+18AS 21

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