ADHD and Executive Function Deﬁcits: Linkage with … and WF - Exec...“Broadly speaking, executive function refers to the cognitive or mental abilities that people need to actively

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Copyright©ERICC,2016 1

ADHDandExecutiveFunctionDeficits:LinkagewithDyslexia

21stAnnualStateDyslexiaSummerInstituteBeyondDyslexia:LookingattheWholeChild

July27,2016

MaryDurheimEducationalConsultant

Spring,[email protected]

Copyright©ERICC,7-2016 1


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DoyouhaveExecutiveFunctiondeficits/skills?

•  Howdidyougetheretoday?

•  Didyouarriveontime?

•  Yourfamilywantstoeatdinnerat6andyouarethecook…Howdoyougetthefoodonthetableintime?

•  Someonecutsyouoffinatrafficlane(andofcourseyourchildisinthecar)...Whatkeepsyoufromyelling“#!#??%!!??”

•  Thestudentsinthenextclassroomareplayingaloudgamewhileyouarewritingalesson,butyoudon’thearit.Why?

•  Youaccidentallybumpintosomeoneandapoligize.Why?


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Questionstoconsider…

• Whatareexecutivefunctiondeficits(orskills)andhowdoselectedexecutivefunctionprocessesaffectschoolsuccesses?

• Howcaneducatorsbegintounderstandandinformallyassessstudents’executivefunctionprocesses?

• Howcanteachersaddresstheneedsofstudentswithexecutivefunctionweaknessestobothaccommodateandteachnecessarylackingskills?


WhatisExecutiveFunctioning?•  Executivefunctioningisatermpsychologistsusetodescribethemanytasksour

brainsperformthatareinvolvedwithplanning,problem-solvingandtheveryactofthinkingitself.

•  ItisbelievedthattheEFofthebrainareprimarilycarriedoutinthepre-frontallobesofthecerebralcortexwhichisthepartofthebrainthatdirectsorconductsanumberofskillsrequiredindailylife,suchasplanning,decision-making,self-monitoring/regulation,working,memory,motivation,andtheentireproblem-solvingprocessalongwithselfevaluationoftheresults.

•  Oftenreferredtoasthe“CEOofthebrain”,EFisasetofmentalprocessesthathelpsconnectpastexperiencewithpresentactionandasaresultcanhaveamajorimpactonstudentbehaviorandperformance.

•  “Despitethefrequencywithwhichitismentionedintheneuropsychologicalliterature,theconceptofexecutivefunctionsisonethatstillawaitsaformaldefinition.”(Jurado&Rosselli,2007,page213.)


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ExecutiveFunctioning• McCloskeynotesthatitisimportanttodistinguishbetweenExecutiveSkillsandExecutiveFunctions.

• ExecutiveSkillsinvolvetheuseofneuralnetworksroutedthroughoutthebraintoperformspecifictasks(e.g.,attending,inhibiting,modulating,planning,organizing,associating).

• ExecutiveFunctionsinvolvethepartoftheexecutivenetworkthatisroutedthroughthefrontallobesandthatisusedtocue,direct,andcoordinatetheuseofexecutiveskillsandothermentalcapacities.


ExecutiveFunctionDevelopment

• McCloskeynotesthesomeEF-basedclinicalsyndromes,suchasADHD,demonstrateclearpatternsofdelayeddevelopmentalprogression.

• McCloskeyalsonotesthatallindividualswithADHDexhibitEFdeficitsbutnotallindividualsthatexhibitEFdeficitsareADHD.


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ExecutiveFunctioningandADHD

• EFandADHDarenotsynonymousterms;ratherADHDisaconditioninvolvingEFdeficitsin:

• Focus/Select,Sustain,Inhibit,Modulate

• NearlyallpeoplewithADHDalsohavedifficulties;thenatureoftheseadditionaldifficultiesiswhatmakesADHDsovariablefromonepersontothenextandwhatcausesconfusionindiagnosis.(McCloskey)


Characteristics of AD/HD

A disorder Characterized by a

PERSISTENT pattern of inattention and/or

hyperactivity and/or impulsivity that interferes with

functioning and development.


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CharacteristicsofADHD

Severalinattentiveorhyperactive-impulsivesymptomswerepresent

beforeage12andarepresentinatleast2areasoflife,suchas

Home,SocialSettings,SchoolorWork

Symptomshavebeenpresentforatleast6months§  Toadegreethatisinconsistentwithdevelopmentallevel§  Negativelyimpactssocialandacademic/occupational

activities.Copyright©ERICC,7-2016 11

RussellBarkleyandExecutiveFunctioningWhatweknowaboutthebrainandEF…

Fourcircuitsinthebrainrelatetoexecutivefunctioning:

• The Circuit–goesfromthefrontallobebacktothebasalganglia,particularlyastructurecalledthestriatum.The“What”Circuitislinkedtoworkingmemory,soit’sinthiscircuitthatwhatwethinkstartstoguidewhatwedo.

• The Circuit–goesfromthesameprefrontalareabacktothecerebellum,locatedattheverybackmostpartofyourhead.The“When”Circuitisthetimingcircuitofthebrainandcoordinatesnotjusthowsmoothbehaviorwillbeandthesequenceofbehavior,butalsothetimelinessofyouractionsandwhenyoudocertainthings.


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RussellBarkleyandExecutiveFunctioningWhatweknowaboutthebrainandEF…

• The Circuit–alsooriginatesfromthefrontallobeandgoesthroughthecentralpartofthebrain–anteriorcingulate–totheamygdala–thegatewaytothelimbicsystem.This“hot”circuitislinkedtoouremotionswherewhatwethinkcontrolshowwefeel,andviceversa.Itisthefinaldecisionmakerinallourplans.

• The Circuit–goesfromthefrontallobetotheverybackofthehemisphere.Itiswhereself-awarenesstakesplace–whereweareawareofwhatwedo,howwefeel(bothinternallyandexternally),andwhatishappeningtous.


ExecutiveFunctions&theBrain

Copyright©ERICC,7-2016

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Mid-BrainLimbicsystem-Automaticbehaviors,Emotions,Memory

Brainstem-Survival

Cortex-Consciousthought

CerebellumCoordinatedmovements,balanceandvoluntarymovements

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RussellBarkleyandExecutiveFunctioning

•  Knowingwhatpartsofthebraincontrolexecutivefunctions,BarkleydefinesExecutiveFunctioningthisway…

“Broadlyspeaking,executivefunctionreferstothecognitiveormentalabilitiesthatpeopleneedtoactivelypursuegoals.Inotherwords,it’sabouthowwebehavetowardourfuturegoalsandwhatmentalabilitiesweneedtoaccomplishthem.Thetermisverycloselyrelatedtoself-regulation.Executivefunctionsarethings

youdotoyourself,inordertochangeyourbehavior.Byemployingyourexecutivefunctionseffectively,you’rehopingtochangeyour

futureforthebetter.”Copyright©ERICC,7-2016

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7ExecutiveFunctionDeficitsTiedtoADHD1.   Self-awareness:self-directedattention2.   Inhibition:alsoknownasself-restraint3.   Non-VerbalWorkingMemory:self-directedsensing;theabilitytoholdthingin

yourmind.Essentially,visualimagery–howwellyoucanpicturethingsmentally.

4.   VerbalWorkingMemory:self-speech,orinternalspeech.Mostpeoplethinkofthisastheir“innermonologue.”

5.   EmotionalSelf-Regulation:theabilitytotaketheprevious4EFsandusethemtomanipulateyourownemotionalstate.Thismeanslearningtousewords,images,andyourownself-awarenesstoprocessandalterhowwefeelaboutthings.

6.   Self-Motivation:howwellyoucanmotivateyourselftocompleteataskwhenthereisnoimmediateexternalconsequence.

7.   PlanningandProblem-Solving:alsoreferredtoas“self-directedplay.”Howweplaywithinformationinourmindstocomeupwithnewwaysofdoingsomething.Bytakingthingsapartandrecombiningthemindifferentways,we’replanningsolutionstoourproblems.


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ExecutiveFunctioningandADHD

“ExecutiveFunctionsarethoseactionsweperformtoourselvesanddirectatourselvessoastoaccomplishself-control,goal-directedbehavior,andthemaximizationoffutureoutcomes.”

RussellBarkley


Utilizingworking

memoryandaccessing

recall

ExecutiveFunctions(worktogetherinvariouscombinations)

Brown,T.E.ManualforAttentionDeficitDisorderScalesforChildrenandAdolescents;2001.

Monitoringandself-

regulatingaction

Managingfrustrationandmodulatingemotion

Regulatingalertness,

sustainingeffortandprocessing

speed

Organizing,prioritizing,

andactivatingtowork

Focusing,

sustainingfocusandshiftingfocustotasks

1.Activation 2.Focus 3.Effort 4.Emotion 5.Memory 6.Action

Brown’sModelofExecutiveFunctionsImpairedinAD/HD


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SelfTalk–SelfAction

Forchronicproblemswith:•  Regulatingactions•  Jumpingintoconversations•  Jumpingtoconclusionstooquickly•  FailuretonoticeothersreactionsasastopmechanismforbehaviororactionItmaybenecessarytodevelopstrategiesto:

Respond Or

Act


Dendy’sComponentsofExecutiveFunctionbasedontheworkofBarkley,Brown,andGioia

1.   Workingmemoryandrecall–holdingfactsinmindwhilemanipulatinginformation;accessingfactsstoredinlong-termmemory;includesanimpairedsenseoftime

2.   Activation,arousal,andeffort–gettingstarted;payingattention;finishingwork

3.   Controllingemotions–abilitytotoleratefrustration;thinkingbeforeactingorspeaking

4.   Internalizinglanguage–using“self-talk”tocontrolone’sbehavioranddirectfutureactions

5.   Takinganissueapart,analyzingthepieces,reconstitutingandorganizingitintonewideas–complexproblemsolving

6.   Shifting,inhibiting–changingactivities,stopping,existingactivity,stoppingandthinkingbeforeactingorspeaking

7.   Organizing/planningahead–organizingtime,projects,materials,andpossessions

8.   Monitoring–self-monitoringandprompting


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CommonAcademicProblemsLinkedtoADHDandExecutiveFunctionDeficits

• ManystudentwithADHDhaveimpairedworkingmemoryandsomealsohaveslowprocessingspeedbothofwhicharecriticalelementsofEF

• WrittenexpressionisthemostcommonlearningproblemamongstudentswithADHD(65%-studybyMayesandCalhoun)

• Memorizingmultiplicationtablesorworkingmathproblems

•  Two-thirdsofchildrenwithADHDhaveatleastoneotherco-existingproblemssuchaslearningdisorders,depression,oranxiety


21

Conduct Disorder 25% Children

45% - 50% Adol.

Anxiety Disorder 30% Children

25% - 40% Adults

Depression 10% - 30% Children

47% Adults

AD/HD alone 30%

Learning & Language Disorders Up to 50%

Tourettes Syndrome

7%

Oppositional Defiant Disorder

40%

Bipolar Disorder

Up to 20%

Co-ExistingDisorders


NIMH,MTAStudy

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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman

EFDomain WhatTeachersMightSee…

Goal-directedAttention •  Troublesustainingattentiondoingsomethingdoesnotlike•  Distractedeasilybyotherthingsgoingoninclass•  Distractedeasilybydaydreamsorstraythoughts•  Needslotsofreminderstostayontaskandfocused•  Complainsofdifficultystayingontask•  Troublereadingconnectedtext,withoralreadingfluency

impactedbyleavingoutwordsormakingchanges,eventhoughsingle-worddecodingnotanissue*

•  Mayskipwholelineoftextwhenreadingaloud,withoutnoticing*•  Matherrorsseemtobe“careless”onesdoneoften•  Mechanicalerrorsinwrittenworkalsoseemfrequentand

“careless”

*Mayalsoshowtroublewithworkingmemoryorself-monitoring



EFDomain WhatTeachersMightSee

GoalSettingDecisionMakingPrioritizing

•  Troublesettinglong-rangegoals•  Seemstolivemomenttomoment•  Respondstowhatishappeningintheimmediateenvironment,not

toinnerdirection•  Needsmajorsupportanddirectionwithlong-termprojects,suchas

aresearchpaper•  Requireslotsofsupportwhenmakingdecisionsintheclassroom•  Inmoreunstructuredacademicsettings,suchasatthelibraryorin

artclass,notwell-focusedaboutdecisionstomakeanddirectionstotake

•  Findsitdifficulttoknowwheretostartwithassignments•  Runsoutoftimewhencompletingworkbecausehastrouble

prioritizingwhatshouldbedonefirstandthennext,andwithhowmuchtimetodevotetoeachsection


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PlanningOrganizationSequencing

•  Obviousandconsistentlackofplanningwithclassworkandhomework

•  Writtenworkinneedofflowandorganization,asopposedtorandomunconnectedthoughts

•  Considerableproblemswhenassignmentsrequireplanning•  Losestrackofassignmentsequencinganddetails•  Findsithardtochunklargeassignments,breakingthemdowninto

moredoableblocks•  Becomesoverwhelmedbyassginmentsorjobsthatotherswould

findeasytodoiforganized•  Strugglestosolvemathproblemsbecausehastroublefollowing

sequencedstepsofoperation•  Readingcomprehensionproblemsbecausehastroublewithholding

ontoimportantdetailsinthecorrectsequenceofevents,andsostrugglestocomprehendthemainpoints




TaskInitiation •  Troublestartingtasks,seenindifferentacademicsettings-Ask“Ifworseinsomesettingsthanothers,whataspectsofthesettingsinwhichthechildparticularlystrugglesseempoorlyalignedtohis/herneeds?”

•  Seemsparalyzedaboutstartingatask–maysayheknowswhattodo,butcan’ttakethefirststeptowarddoingit

•  Ifgivenhelpstarting,oftendoesfinewithcompletingtasksuccessfully


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TaskPersistenceProblemSolving

•  StartsOKbutrunsoutofsteambeforefinishingandstopsworking;can’tsustaineffort

•  EvenwhenwrittenworkisplannedandsequencedOK,thereisnotmuchofit

•  Eventhoughseemstogetenoughsleepathome,getsdrowsyinclass,especiallyintheafternoons

•  Requireslotsofteacherpromptingtocontinueworking•  Cannotapplyproblem-solvingskillsindependently,evenwhen

facedwithminordifficulties•  Stopsworkingwithoutindividualizedorconsistenthelp




TimeManagement •  Usuallystruggleswithfiguringouthowmuchtimewillbeneededtocompleteatask-“Ididn’trealizeitwouldtakesolong”

•  Needsmoretimethanpeerstocompletethesameassignment/task•  Oftensurprisedorupsettolearnsomethingisdue–“Youmeanthe

testistoday?!”•  Cantelltimebutlosestrackofit


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EFDomains WhatTeachersMightSee

Self-Monitoring •  Writtenworkhasmanymechanicalerrors,includingmisspellings•  Leavesoutsmallfunctionwordsinwriting[suchas“the”or“an”]•  Unwillingtoeditownwriting•  Whenreadingoutloud,ofteninsertswordsordeletesthem•  Whenreadingoutloud,tendstoskipentirelinesoftextanddoesn’t

notice•  Inmathwork,willmake“careless”errors[suchasmisreading

operationsigns]•  Doesnotappearto“see”errorsinworkandissurprisedwhenthey

arepointedout




WorkingMemory •  Cannotrememberorfollowmulti-stepdirections•  Losestrainofthoughtwhentalking•  Forgetsdetailsofwhatwasreadsonafter•  Afterreadingsomethingcananswerliteralquestionsbuthas

difficultyrememberingmorecomplexdetailsandwithmakingpredictions/inferences

•  Losestrackofwhatwaslookingfor•  Willstartwritingbutforgetwhatwantedtosay•  MayspellwordsOKinisolationbutcannottransferthattowritten

work•  Matherrorsshowpatternofforgettingwhollyorpartlythesteps

neededtosolveproblems


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ShiftingAdaptability

•  Lowtoleranceforchangesinroutine•  Getsstuckononetopicoractivityandresistsstoppinguntildone

withit•  Haspatternsofactionsorbehaviorsinsocialsettingsanddoesnot

wanttochangethem,evenwithencouragement•  Cannotcomeupwithmorethanonewaytosolveaproblem




ImpulseControl(ResponseInhibition)

•  Blurtsoutinclass•  Impetuouslysaysordoesthings,thenexpressesregretorremorse•  Oftensaysordoesthingsthatembarrassothers•  Repeatedlyactsasthoughdoesnothaveanythoughtfilters•  Willfrequentlydenyresponsibilityforbehavior,evenwhencaught

intheact[“Itwasn’tme,Iswear!”]•  Cannotexplainbehavior[“Idon’tknowwhyItrippedhim,Ijustdid

it.”]•  Whenreadingoutloud,willguessatwordsbasedonthefirstletter

ortwo,ratherthanreadingthroughtheword•  Whenreadingoutloud,oftenwillinsertwordsnotinthetext•  Inmath,willfrequentlygiveananswerwithoutthinkingthrough

therequiredprocessorapplyingproblem-solvingskills


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EmotionalControl •  Overreactstosmallproblemsthatwouldnotbotherpeers•  Showsexcessiveresponsetosituations,oftencryingorwhiningor

actingoutofcontrol•  Becomeseasilyupsetorangeredbywhatothersaredoing•  Whenangry,canbecomeverballyandphysicallyaggressive•  Canappearswampedbybothpositiveandnegativeemotions•  Usuallyexpressesremorseaftershowingangerand/oraggression


HelpingStudentswithEFIssues

• McCloskeystatesthatcognitivestrategies,suchasplanningandorganizing,canbetaught–“Executiveawarenessisawarenessofawareness.”

• Studentshouldbeawarethathe/shehasEFdifficultiesandshouldbetaughtstrategiestocopeandcompensateforanydeficits–ifstudentisnotawareofthishedoesnotknowhowtomodulatehimselfandkeepsgettingintotrouble.


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CollectionofFavoriteSchoolSuccessStrategiesforWorkingwithEFIssues

Makethelearningprocessasconcreteandvisualaspossible!WrittenExpression:

•  Dictateinformationtoa“scribe”orparents

•  Usegraphicorganizerstoprovidevisualprompts

•  Use“post-it”notestobrainstormessayideas

Math:•  Useapeertutor•  Usepairedlearning–teacherexplainsproblem,studentsmakeuptheirown

examples,swapproblems,anddiscussanswers


Memory:

•  Usemnemonics(memorytricks),suchasacronymsoracrostics,e.g.,HOMEStoremembernamesoftheGreatLakes

•  Use“visualposting”ofkeyinformationonstripsofposterboard

•  Consider“TimesAlive”toassistwithmemorizingmultiplicationtables

• Modifyteachingmethods•  Useanoverheadprojectortodemonstratehowtowriteanessay

•  Usecolortohighlightimportantinformation

•  Usegraphicorganizerstohelpstudentsorganizetheirthoughts



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Memory–cont’d.:•  Modifytestingandgrading

•  Giveextendedtimeontests

•  Dividelong-termprojectsintosegmentswithseparateduedatesandgrades

•  Averagetwogradesonessays–oneforcontentandoneforgrammar

•  Modifylevelofsupportandsupervision•  Appoint“rowcaptains”tochecktoseethathomeworkassignmentsarewrittendownand

laterturnedintotheteacher

•  Increasetheamountofsupervisionandmonitoringforthesestudents,iftheyarestruggling

•  Usetechnology•  Useacomputerasoftenaspossible

•  UsesoftwaretohelpteachskillsCopyright©ERICC,7-2016 37


Inclosing…

“Bycloselywatchingachild’sbehaviorandstudyingworksamples,youmaygainimportantinsightsintothescopeandseverityofthestruggles,whichmayhaveclearimplicationsforpossibleinterventionsstrategies.”

Kaufman,2010


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Resources•  AssessmentandInterventionforExecutiveFunctionDifficultiesbyGeorgeMcCloskey,LisaA.Perkins,Bob

VanDiviner.2009

•  EssentialsofExecutiveFunctionsAssessmentbyGeorgeMcCloskeyandLisaA.Perkins,2013.

•  PromotingExecutiveFunctionintheClassroombyLynnMeltzer,2010.

•  ExecutiveFunctionintheClassroombyChristopherKaufman,

•  ANewUnderstandingofADHDinChildrenandAdults–ExecutiveFunctionImpairmentsbyThomasE.Brown,2013.

•  TeenagerswithADDandADHD–AGuideforParentsandProfessionals,2ndEdition,byChrisZeiglerDendy,2006.(3rdeditioncurrentlyinprinting)

•  7ExecutiveFunctionDeficitsTiedtoADHDbyRussellBarkleypublishedinAttentionMag.com,2016.

•  ExecutiveFunctioningandSelf-Regulation:ExtendedPhenotype,Synthesis,andClinicalImplicationsbyRussellBarkley,2010.

•  ADHDExecutiveFunctionandSchoolSuccessbyChrisZeiglerDendy,publishedinADHD&Education,2012.

•  AreYourStudent’sDifficultiesinSchoolaResultofExecutiveFunctionDeficits?byCynthiaNagrath,2012.


Documents

ADHD and Executive Function Deﬁcits: Linkage with … and WF - Exec...“Broadly speaking, executive function refers to the cognitive or mental abilities that people need to actively