ADHD: Executive Function Dysfunction(I meant to behave…..but I forgot!)

Andrea Ogonosky, PhD. ESC XV June 11, 2012

www.ogonoskylearning.com6/11/12 1

Core Symptoms

• Poor sustained attention (inattention, distractibility)

• Impulsivity (behavioral inhibition)• Hyperactivity

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Co-morbid Conditions

Psychiatric Disorders• Oppositional Defiant Disorder (ODD)• Conduct Disorder • Antisocial/Delinquency • Anxiety Disorders • Major Depression • Somatization Disorder

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Associated Problems (School)

• Lagging in intellectual development over time (10-15 points)

• Underperforming in school• Excessive variability in work produced• Low average achievement• Learning disabilities (25-35%)

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Associated Problems (Emotional)• Poor rule-governed behavior• Immaturity• Irritable, hostile, excitable• Hyper-responsiveness toward others• Low frustration tolerance• Demoralization• Dysthymia

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Associated Problems (Social)• Increased parent/child conflicts• Selfish/self-centered• More interpersonal problems• Peer rejection due to intrusive behavior(s)• Little regard for social consequences• Immature play• Fewer close friendships• Shorter duration of dating

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Associated Problems (Medical)

• More allergies, colds, otitis• Enuresis (43%)• Increased minor injuries due to accidents• Motor coordination problems (affects

handwriting)• Sleep disturbances

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ADHD and Self-Control

• Behavioral Inhibition (Barkley et al.)• Behavioral control shifts from external to internal• Greater motor control • Behavior focuses on time and future

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Executive Functions

• Directive capacities of the mind• Multiple in nature, not a single capacity• Cue the use of other mental abilities• Direct and control perceptions, thoughts, actions, and to some degree emotions• Part of neural circuits that are routed through the frontal lobes

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Executive Functions

Frequently referred to as “the CEO of the Brain” or the “Conductor of the Orchestra

Better to think of Executive Functions as:A Team of Conductors and Co-Conductors of a Mental

Ability Orchestra or … The Coaching Staff of a Mental Ability Football Team

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Executive Functions

• Direct and control perceptions, thoughts, actions, and to some degree emotions

• Part of neural circuits that are routed through the frontal lobes

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Executive functionsDiverse group of cognitive processes

Acts in a coordinated way to direct perception, emotion, thought and action

Set of multiple cognitive capacities

Act in a coordinated way to engage in purposeful, organized, strategic, self-regulated, goal-directed behavior.

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Development of EF• Self-regulation executive functions are

developing from the first years of life well into adulthood, and possibly throughout a person’s entire lifetime.

• Large developmental shifts are noticeable, especially around a adolescence.• Because EFs are developmental in nature,

natural maturational delays and lags are observed.

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Development of EF• All EFs do not develop evenly. For any given

individual, one EF can be more or less developed than any other EF at any given point in time.

• There is also great variation relative to chronological age. At the same age, different individuals will naturally vary considerably in their level of development of various EFs.

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Development of EF

Some EF-based clinical syndromes, such as ADHD, demonstrate clear patterns of delayed developmental progression. Barkley (1998) estimates developmental delays of about 30% associated with various EF processes such as Inhibit, Manipulate, Shift, Sustain, Time, Monitor, Correct.

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Executive Functions are involved with cueing and directing :

• Inhibiting impulsive responding;• Stopping, or interrupting, and returning to, an

ongoing activity;• Directing and focusing attention, screening

out interference and distractions, and sustaining attention

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Executive Functions are involved with cueing and directing :

• The initiation of effort • Judging about the amount of effort required

to complete a task …. Sustaining of a sufficient amount of effort

to effectively complete the task

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Executive Functions• Shifts cognitive resources to focus on new

demands , new conditions or new information• Directs the efficient use of pattern and detail

processing :– Knowing when to focus on the “big picture”, when

to concentrate on the details, and when to switch between the two).

• Monitors and regulates speed of information processing

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Executive Functions

• Monitors and corrects task performance for accuracy and efficiency

• Oversees the selection of verbal-nonverbal and abstract-concrete processing mechanisms

• Directs motor output • Directs the ability to mentally manipulate

information (working memory) • Directs the integration of multiple abilities to

produce oral or written responses 6/11/12 19

Executive Functions• Direct the efficient placement of information

in long-term storage• Direct the retrieval of information from long-

term storage• Regulates social behavior• Regulates emotional control• Enables self-observation and self-analysis• Makes use of hindsight and foresight • Enables the capacity to “take the perspective

of the other” 6/11/12 20

Executive Functions and SchoolAcquiring Knowledge Demonstrating Knowledge

Many new learning situations are structured in ways that reduce the need for strong executive direction

Requires significant involvement of executive control processes.

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Because executive control is heavily involved in demonstrating learning, executive difficulties usually manifest as “Producing Disabilities” much more so than “Learning Disabilities.” 6/11/12

Learning Difficulties and Producing Difficulties

Learning Difficulties Only Often NOT recognizedas a Learning Disability,even when severe

Learning Difficulties AndProducing Difficulties

Recognized as aLearning Disabilitymost of the time

Producing Difficulties Only When severe, typicallyattributed to motivationor personality problems

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Impact of EF and Learning

• Although executive functions are used to guide cognitive processing involved in new learning, many new learning situations are structured in ways that reduce the need for strong executive direction.

• In direct contrast, demonstrating what has been learned usually requires significant involvement of executive control processes

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Nonverbal Working Memory– Imitation and vicarious learning– Anticipation and preparation to act– Awareness of self across time– Spatial location– Organization & reproduction of

complex designs– Less proficient at imitating sequences of simple motor

gestures – Psychological awareness of time

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Verbal Working Memory• Internalization of speech– self-description and self-reflection– rule governed behavior (self-instruction)–digit span–mental computation– the basis for verbal thought –memory tasks–hindsight, forethought, and planning

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EF and School

Test taking can be exceptionally difficult for a student with executive difficulties if the test format emphasizes executive demands over

content knowledge.

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EF and School

In the classroom, the task most frequently impacted by executive function-driven

producing difficulties is written expression.

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EF and Written Language

• Poor grapho-motor control and lack of automaticity for handwriting.

• Poor organization of written material• Poor retrieval cueing or poor generate cueing

for idea generation or idea fluency when writing.

• Inability to use multiple self-regulation• EFs at one time (e.g. hold, manipulate,

retrieve with generate and execute).

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Reading and EF• Reading Decoding – poor use of one or moreself-regulation EFs (e.g., lack of attention tospecific letters in words; saying words that“look” like the word on the page).• Rapid Automatic Naming – poor executive control

of language fluency processes.• Reading Comprehension – poor direction ofone or more self-regulation EFs (e.g., Focus,Sustain, Hold, Manipulate, Balance, Pace,Time, etc.) when reading for meaning.6/11/12 29

Math and EF• Poor cueing of Focus/Select, Monitor, and

Correct functions when doing calculation routines.

• Poor cueing of hold, organize, manipulate and retrieve when setting up calculations or problems

• Poor cueing of organize, store, retrieve, execute when learning or applying rote knowledge (e.g. storing and retrieving multiplication tables).

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Interventions

General Two-Stage Approach to Intervention:1.Attempt to Affect Internal Change2.Apply External Control As Necessary

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Important Life Changes That Work! (Hallowell, 2005)

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• Positive human contact• Reduce electronics• Sleep (increase opportunities)• Diet: balanced - eat protein at breakfast• Exercise• Prayer or meditation

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Implications for Interventions

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• Intervene at “points of performance”• Externalize all information• Externalize sources of motivation• Arrange immediate consequences for task

initiation and completion• Plan to provide interventions over the long-

term

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Tier 1: Core Foundations

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Build a Culture of Acceptance and SafetyHigh performance expectations for all studentsClearly articulated rules and consequencesStrong student teacher relationshipsHigh level of parent and student participationStudent connectedness to the school processMultiple opportunities for success with academic and social skill developmentConflict resolution strategies actively taught and modeled (school-wide)

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Building Internal Strategies

Providing students with feedback about their performance enables them to engage

executive capacities more effectively to learn from their mistakes and improve future

performance

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Build Internal Strategies

• Use IES guides to develop strategy instruction within Tiered interventions.

• Align anchor activities within instructional groups for repeated practice of strategy use within intervention.

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Classroom Instruction (TIER 1)

To assure that executive functioncapacities are used to their fullest

potential, it is important to state the goalsof the learning process. Stating goalsenables executive capacities, either

consciously or nonconsciously, to engagethe perceptions, emotions, thoughts, and

actions, needed to achieve the goals.

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Tier 1

• In many ways, teachers ARE their student ‘s frontal lobes.

• Providing prompts and cues are important to assure that children are engaged appropriately in the instructional process.

• Modeling good executive functions helps children see how they can self-regulate their own perceptions, emotions, thoughts and actions.

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Homework: 7 Skills Parents Can Help Children Learn

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• Insure assignments are copied correctly and get home with proper books/materials

• Select work place at home• Start assignments by reading directions and following

them carefully• Manages difficult or long-term assignments

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Homework: 7 Skills Parents Can Help Children Learn

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• Maintains attention to boring tasks• Checks work for accuracy and completeness• Gets homework to school when done

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Homework (Parental Responsibility)

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• Create Proper homework environment– Quiet place– Regular schedule– Necessary supplies

• Teachers instructions and requirements are understood

• Awareness of child’s difficulties-inform teacher

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Homework (Parental Responsibility)

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• Set homework goals-reinforce achievement• Motivation: praise, self-monitoring• Organize assignments

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STRIVE FOR FIVE!

• Strong Positive Behavior Supports: School-wide, classroom, individual

• Highly structured classroom

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Foster Positive Teacher Student Relationships

Pair and Share

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Classroom Strategies (Self-Discipline)

• Adopt classroom management and disciplinary practices that are proactive, instructive, and corrective

• Correct behavior fairly and consistently• Arrange physical environment to reduce

congestion and facilitate smooth and quiet movement of students

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Classroom Strategies (Self-Discipline)

• Use a variety of teaching methods to address various learning styles

• Review and discuss acceptable behavior expectations throughout the year

• Reinforce positive behaviors

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Characteristics of a Positive Classroom Environment

Create a welcome and inviting atmosphere:•Free from clutter•Highly organized•Daily routines established•Rules visible and reinforced daily

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How do you arrange a classroom to increase academic

engagement?

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Physical Arrangement of Classroom

• Divide room into logical work areas:– All students can be easily seen by teacher– Maximize student personal space by arrangement

of desks– Establish traffic patterns– Minimize areas of distractions– Maintain distance between students and

supply/storage areas

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Principles for Managing EF

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• Externalize time, reduce delays• Externalize important information• Externalize motivation• Externalize problem solving (chore cards)• Immediate feedback• Increased frequency of consequences

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Principles for Managing EF

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• Increase accountability of others• Use more salient and artificial rewards• Change rewards periodically• Touch more, talk less• Act, don’t Yak• Keep sense of humor

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Principals for Managing EF

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• Use positives before negatives• Anticipate problems; have a plan• Maintain a sense of priorities• Practice forgiveness (child, self, others)

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Command Effectiveness

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Use imperatives, not questionsBreak down complex tasks to simpler onesBridge time delays in tasks (use external cues

to bridge tasks)Use single-step commandsPraise initiation of compliance and reinforce

throughout taskGet attention before giving directions

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Tier 2 Strategic Interventions

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Conduct Functional Behavior Assessment

• Tier 2: Informal data gathered through observations, consultations, review of teacher data and student products

• Purpose:– To identify the function(s) maintaining problem

behaviors• antecedent events = triggers occurrence of behaviors • consequences = maintains behavior episodes

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Tier 2: Common Principles of Strategic Interventions

• Positive Behavior Supports are used to motivate students.

• Corrective feedback is immediate. • Students master content before moving on

to more difficult activities.• Professionals are trained to implement

intervention with high level of fidelity:– Practice with all staff to ensure consistency– Meet weekly to problem solve and share ideas

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Tier 2: Behavior Reduction Strategies to Monitor

• Responding to misbehavior– Continuum of consequences established– Consider misbehavior as a behavioral error: treat like

an academic skills error– Re-teach appropriate behavior– Respond consistently and efficiently– Observe the effects of behavior reduction strategy• Punishment??? Behavior increases??

– Respond early: avoid escalation, prolonged existence576/11/12

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RtI Team Roles in Tier 2

• Ongoing progress monitoring of data (specifically ensuring fidelity of data collection)

• Social Skills Training• Motivational Strategies

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Targeted Group Interventions ADHD

• Small group instruction within the areas of self-monitoring for problem solving, social skills, behavioral regulation

• Small group instruction for identified academic deficits.

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Tier 3 Team Role: Intervention Implementation

• Assist with intervention• Fidelity checks at least weekly• Revise when needed regarding fidelity• Monitor progress • Design and implement • Provide feedback to teacher or parent

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Tier 3 InterventionsPrevention (Make problem behaviors irrelevant):•Schedule•Curriculum (content, sequence)• Instruction• Skill Building (Teach desired behaviors)•Teaching = delivering events that change

behavior, not just delivering curriculum• Replacement behaviors (maintain same function

as problem behavior)•Adaptive skills

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Increase Behavioral Successes

Find the buried Treasures (Hallowell, 2005)1.Connect2.Play3.Practice4.Master5.Recognition

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Determining Eligibility for OHI

• Full and individual evaluation that is comprehensive•Meet three prongs▫Eligible according to disability classification criteria▫Eligible due to adverse impact of disability on

attainment of an appropriate education (using RtI data collection)

▫Eligible due to need for special education (specially designed instruction and related services)

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Questions

Thank you for staying on task and engaged to a marked degree and for a long period of time!

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