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David D Nowell PhDwww.DrNowell.com
Executive Function: Effective Strategies and Interventions
www.DrNowell.com
DavidNowell
DavidNowellSeminars
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
www.slideshare.net/dnowell
BRAIN OVERVIEW IN 27 SLIDES
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
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what IS…
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…what COULD BE
What’s wrong with this brain model?
What’s wrong with this brain model?
What’s wrong with this brain model?
MODELS OF EXECUTIVE DYSFUNCTION
• McCloskey’s model• Barkley’s model• BRIEF model
McCloskey’s Clusters
• Attentional cluster• Engagement cluster• Optimize cluster• Evaluation cluster• Efficiency cluster• Memory cluster
McCloskey’s Clusters
• 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
McCloskey’s Clusters
• Engagement cluster– Initiating– Putting in effort– Inhibiting– Stopping– Interrupting
Reward small units of effort
There’s no such thing as “disinhibited”
The “talking stick”
DRO
Differential Reinforcement of Other
McCloskey’s Clusters
• 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.
Sam rode her new blue bicycle down the steep hill, enjoying the crisp Autumn air and bright late-afternoon sun.
GREEN
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..”
McCloskey’s Clusters
• 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
McCloskey’s Clusters
• Efficiency cluster– Sensing time– Pacing– Sequencing– Using routines / executing
Distraction delay training
McCloskey’s Clusters
• 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
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
The Executive Functions
• Sensing to the self (HËDŸDT)• Speech to the self• Emotion to the self• Play to the self
Barkley, RA, (2012)
BRIEF
• Inhibiting (HËDŸDT)• Shifting • Controlling emotions• Initiating• Working memory• Planning• Organizing materials• Monitoring• Metacognition• Behavioral regulation
STRATEGIC BEHAVIORAL INQUIRY
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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?
…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?
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?
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 ____?”
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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)
Fujii, Kitagawa, et al 2013
(Airaksinen, Larsson, & Forsell 2005)
Appendix A
(Brosnan, Demetre, et al 2002)
Appendix B
ADHD OCD
Tourette
(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
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1. 1-step errands
2. Chores with cues
3. Basic inhibition
Age-appropriate ExpectationsPreschool
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1. 2-3 step directions
2. 20-30 minute assignments
3. Follow rules/inhibit/no grabbing
Age-appropriate ExpectationsKindergarten -2nd Grade
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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
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1. Complex chores
2. Organizing system
3. Time management
4. Self soothe
5. Manage conflict
Age-appropriate Expectations6th – 8th Grade
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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
Knock 3 years off his age
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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)
Executive Functions and Math
• 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
Executive Functions and Math
• Visual strategies
Executive Functions and Math
• Hands-on strategies
Executive Functions and Reading
EZ-C Reader
Executive Functions and Writing
Executive Functions and Writing
Executive Functions and Writing
Executive Functions and Writing
Executive Functions and Writing
Executive Functions and Study Skills
Cornell note-taking system
Cornell note-taking system
Class and date
Cornell note-taking system
Class and date
Notes
Cornell note-taking system
Class and date
Notes
Notes
Notes
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
SUMMARY
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
SUMMARY
Cornell note-taking system
Class and date
Cornell note-taking system
Class and date
Notes
Cornell note-taking system
Class and date
Notes
Notes
Notes
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
SUMMARY
Cornell note-taking system
Class and date
Notes
Notes
Notes
Key ideas
Vocab
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
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
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
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AANTECEDEN
T
BBEHAVIOR
CCONSEQUENC
ES
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AANTECEDENTS
BBEHAVIOR
CCONSEQUENC
ES
“Modified Independence”
• Chronic disability perspective• Time prosthetics• Problem-solving prosthetics (mind map)• Math prosthetics• Sequence prosthetics• Motivation prosthetics
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AANTECEDENTS
Set them up for success
Clear boundaries
Clear (see-through) storage
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AANTECEDENTS
Identify exceptions
Where do you see it the most?
Where do you see it the least?
Rules
•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
S
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AANTECEDENTS
Provide prosthetic cues at the “point-of-performance” (Barkley)
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easy hard
If It’s Harder than a “3” Find Some Way to Make It Easier
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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
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”
Balance screen time and “green time”
Supplements and Diet
• Omegas• Food additives• Food allergies• Pesticides
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AANTECEDEN
T
BBEHAVIOR
CCONSEQUENC
ES
Behavioral Support
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BBEHAVIOR
“A healthy high-functioning 26 year old”
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BBEHAVIOR
More
• 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
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AANTECEDEN
T
BBEHAVIOR
CCONSEQUENCES
Don’t reward them with stuff
Rotate rewards frequently
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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
10-Minute Morning Review
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…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
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
Key features of a great planner system
• 2 pages per day• Master to-do list• With the client at all times
What’s a To-Do list for anyway?
Key features of a great planner system
• 2 pages per day• Master to-do list• With the client at all times
Key features of a great planner system
• The “technology”• The “practice”
Key features of a great planner system
• The “technology”
• The “practice”
Weekly Overview
10-Minute Morning Review
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”
• Daily focus time / Motivational clarity• Nutrition• Movement• Sleep• Connection
The “Big Five”
• Daily focus time / Motivational clarity• Nutrition• Movement• Sleep• Connection
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
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Q & A & D
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)
ADHD
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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