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Interventions with Executive Functions

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Title: BRIEF Talk - Fred Co Subject: EF Author: Gerard A. Gioia Last modified by: Darla DeCarlo Created Date: 11/17/2010 1:33:09 PM Document presentation format – PowerPoint PPT presentation

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Title: Interventions with Executive Functions


1
Interventions with Executive Functions
2
Major Treatment Approaches
  • I. Evaluation (Diagnosis)
  • II. Education (Counseling)
  • III. Medication
  • IV. Working Memory Training
  • V. Behavior Management
  • VI. Educational Management
  • VII. Environmental Management
  • Maturation (accounts for 3-4x more change)

3
Unproved/Disproved Therapies
  • Elimination Diet (e.g., removal of sugar,
    additives, etc.) (Weak evidence)
  • Megavitamins, Anti-oxidants, Minerals
  • (No compelling proof or disproved)
  • Sensory Integration Training (disproved)
  • Chiropractic Skull Manipulation (no proof)
  • Play Therapy, Psycho-therapy (disproved)
  • Biofeedback (EMG or EEG) (experimental)
  • Self-Control (Cognitive) Therapies
  • Social Skills Therapies (in clinic)

4
Implications for Treatment
  • Teaching skills is inadequate
  • Treatments must be at the points of performance
  • Behavioral treatment is essential but does not
    generalize or endure after removal
  • Reverse engineer the EFs
  • Externalize important information (make lists,
    post rules, use signs, etc.)
  • Externalize time periods related to tasks
    (timers)
  • Break up future tasks into many small ones (do 1
    daily)
  • Externalize sources of motivation (token systems)
  • Permit more external manipulation of task
    information
  • The compassion and willingness of others to make
    accommodations are vital to success
  • A chronic disability perspective is most useful

5
Empirically Proven Treatments
  • Parent Education About ADHD
  • Psychopharmacology
  • Stimulants (e.g., Concerta, Adderall, etc.)
  • Noradrenergic Medications (e.g., Strattera)
  • Working Memory Training
  • Parent Training in Child Management
  • Children (lt11 yrs., 65-75 respond)
  • Adolescents (25-30 show reliable change)
  • Family Therapy for Teens Problem-Solving,
    Communication Training

6
Empirically Proven Treatment (2)
  • Teacher Education About ADHD
  • Teacher Training in Classroom Behavior Management
  • Special Education Services (IDEA, 504)
  • Residential Treatment (5-8)
  • Parent/Family Services (25)
  • Parent/Client Support Groups (CHADD, ADDA,
    Independents)

7
What to do about it Environmental
  • classroom
  • seat placement/facilitated attention
  • individualized and untimed testing
  • adjusted workload/frequent checks
  • repetition of instructions/written instructions
  • breaking things into manageable bits
  • provide motivation (behavior modification,
    increased communication bw school and home)
  • make it hands on/interactive
  • allow for physical activity/breaks

8
What to do about it Environmental
  • Home
  • increase motivation (find the right carrot)
  • shorten instructions and have them repeated or
    written down
  • reduce environmental clutter (noise, distractions
    etc.)
  • assist with organization (reminders, planners)
  • model appropriate behavior
  • Choose battles wisely (timing, necessity)

9
Interventions General Principles
  • must fit with child, environment, teacher,
    parents
  • make rationale work for the teacher/parent
  • involve teacher/parent in planning possible
    solutions
  • measure success / failure

10
Interventions General Principles
  • define relevant EF deficit, associated domain
    specific abilities or deficits, and
    task/situational demands
  • Determine the developmental level of child and
    what are age appropriate expectations for EF.
  • Teach compensatory strategies
  • Provide external control for those EF's missing
    in the child.

11
Outcome of Good Executive Function
  • Cognitively
  • control of conscious and deliberate cognitive
    activity (e.g., rehearsal of information in
    preparation of exam, preparing outline before
    beginning to write, considering plan for any
    complex, difficult task)

12
Outcome of Good Executive Function
  • Socially
  • inhibiting inappropriate socially impulsive
    behavior
  • guide behavior in social context by learned rules
    of social appropriateness
  • consider other peoples perspectives and
    interests in making decisions
  • delay immediate gratification in the interest of
    longer-term gain

13
Outcome of Good Executive Function
  • Language
  • deliberate, effortful searches of ones word
    knowledge
  • comprehension of extended language requiring
    active organization of incoming information
  • planned organization of extended discourse, both
    interactive (conversations) and non-interactive
    (descriptions, explanations)
  • controlled flexible use of abstract, ambiguous,
    indirect language (irony, metaphor, puns).

14
Systems Required to Promote Good Executive
Function
  • Appropriate Assessment of Needs in the Everyday
    Environments of the Child
  • Establish and Support Everyday Routines to
    Support the Executive Function

15
Systems Required to Promote Good Executive
Function
  • Treatment Principles
  • Real World Relevance and Application
  • Within the context of everyday, meaningful
    routines
  • Collaborative, hypothesis testing

16
Interventions General Principles
  • External to internal process
  • External models of multi-step problem-solving
    routines
  • External guidance to develop implement everyday
    routines
  • Practice application/ use of routines
  • Fade external support to cueing internal
    generation use of routines

17
Interventions General Principles
  • External to internal process
  • Internal control to generate use specific
    problem-solving routine
  • Generalization to new situation, requiring some
    external guidance
  • Accumulate experience, examine conditions for
    selective use of various routines
  • Feedback throughout (i.e., reward)

18
Reasons for a Reduced Executive Function Focus
  • Belief (misguided) that executive functions are
    higher order and must wait on their treatment
    until lower order cognitive and social
    processes are developed/ treated
  • Desire to protect the individual, resulting in
    family or school personnel assuming
    responsibility for all executive aspects of the
    individuals behavior

19
Reasons for a Reduced Executive Function Focus
  • Paradoxical avoidance of treatment focus
    because of severe impairment in this area
  • Staff tendency to assume that their role as
    helping professionals requires assuming control
    for executive dimensions of tasks (identifying
    weaknesses, setting treatment goals, planning and
    organizing their activities, etc.)

20
Reasons for a Reduced Executive Function Focus
  • Lack of focus of executive function aspects of
    treatment within professional training programs
  • Student gives appearance of being in control
    under more familiar circumstances that rely on
    old knowledge, well-established routines

21
Result of No Focus on Executive Function
treatment
  • With luck, the child will develop some sporadic
    independent problem-solving skills
  • More likely,
  • Develop learned helplessness
  • Promote dependency
  • Opposition toward caregivers

22
Structuring an executive function intervention
program
  • Use of everyday routines with (e.g.,
    Goal-Plan-Do-Review)
  • Support working memory via hard copy of routine
  • Allowing child to become increasingly more active
    in formulating plans and reviewing their
    performance

23
Goal-Plan-Do-Review
GOAL What do I want to accomplish? PLAN How am I
going to accomplish my goal? MATERIALS/
EQUIPMENT STEPS/ASSIGNMENTS 1. 1. 2. 2. PREDI
CTION HOW WELL WILL I DO? Self rating 1 2
3 4 5 6 7 8 9
10 Other Rating 1 2 3 4 5 6
7 8 9 10 How much will I get
done? DO PROBLEMS SOLUTIONS 1. 1. 2. 2. 3.
3. REVIEW HOW DID I DO? Self rating 1 2
3 4 5 6 7 8 9
10 Other rating 1 2 3 4 5 6
7 8 9 10 WHAT WORKED? WHAT DIDN'T
WORK 1. 1. 2. 2. WHAT WILL I TRY NEXT TIME?
24
Example with academic tasks
  • Written statement of students goal for the
    academic task
  • Specific list of all the steps needed to
    accomplish the task
  • Rate the performance (Self, Other)
  • Discuss discrepancies in ratings
  • Record what worked in one column and what didnt
    work in another column
  • Retain the written Sheet in a notebook

25
What EF Intervention is Not
  • Specific set of skills/ information to teach
    student (e.g., group study skills class)
  • List of steps taped to the top of the students
    desk
  • Simple behavior modification to increase
    motivation
  • A student thing - listing IEP goals without
    attention to the how, who, where, when of the
    classroom delivery system

26
Sample IEP-Speak for the EFs
  • Macro (Long-Term) Goal The student will
    independently employ a systematic problem-solving
    method (e.g., Goal-Plan-Do-Review - GPDR) for
    tasks that involve multiple steps and/or require
    long-term planning.

27
Sample IEP-Speak for the EFs
  • Note For students who are younger or with severe
    executive dysfunction, the objectives should be
    prefaced by the following statement With
    directed assistance, Johnny/ Jenny will . . .

28
  • Goal Setting
  • (1) The Student will participate with teachers in
    setting instructional goals (e.g., "I want to be
    able to read this book, write this paragraph,
    etc.)
  • (2) The student will accurately predict how
    effectively he will accomplish a task. For
    example, he will accurately predict whether or
    not he will be able to complete a task predict
    how many (of something) he can finish predict
    his grade on tests predict how many problems he
    will be able to complete in a specific time
    period etc.

29
  • Planning
  • (1) Given a routine (e.g., complete sheet of math
    problems, clean his room), the student will
    indicate what steps or items are needed and the
    order of the events.
  • (2) Given a selection of 3 actions necessary for
    an instructional session, the student will
    indicate their order, create a plan on paper, and
    stick to the plan.
  • (3) Given a task that he correctly identifies as
    difficult for him, the student will create a plan
    for accomplishing the task.
  • (4) Having failed to achieve a predicted grade on
    a test, The Student will create a plan for
    improving performance for the next test.

30
  • Organizing
  • (1) The student will follow/ create a system for
    organizing personal items in his locker.
  • (2) The student will select and use a system to
    organize his assignments and other school work.
  • (3) Given a complex task, the student will
    organize the task on paper, including the
    materials needed, the steps to accomplish the
    task, and a time frame.
  • (4) The student will prepare an organized outline
    before proceeding with writing projects.

31
  • Self-Monitoring, Self-Evaluating
  • (1) The student will keep a journal in which he
    records his plans and predictions for success and
    also records his actual level of performance and
    its relation to his predictions.
  • (2) The student will identify errors in his work
    without teacher assistance.
  • (3) The student's rating of his performance on a
    10-point scale will be within one point of the
    teacher's rating.

32
  • Self-Awareness
  • (1) The student will accurately identify tasks
    that are easy/difficult for him.
  • (2) The student will accurately identify his/her
    strengths and weaknesses.
  • (3) The student will explain why some tasks are
    easy/difficult for him.
  • Self-Initiating
  • (1) When the student does not know what to do, he
    will ask the teacher.
  • (2) With regular/ minimal prompting from the
    teacher, assistant or parent, The student will
    begin his assigned tasks, initiate work on his
    plan, etc.

33
College Accommodations
  • -   student should be allowed to take tests and
    complete work on an untimed or extended time
    basis
  • -   Student should have access to notes and class
    outlines
  • All assignments should be included on syllabi and
    student should work with someone to develop and
    appropriate plan for completing the assignments
    in a timely manner

34
College Accommodations
  • Student might be allowed to take a reduced
    courseload, but still considered a full time
    student
  • Seat placement in courses
  • Electronic Organizer
  • Use of tape recorder
  • Training in test-taking strategies
  • Relaxation training

35
18 General Ideas for Management (Barkley)
  • Parents are Shepherds not Engineers
  • Reduce delays externalize time
  • Externalize important information
  • Externalize motivation (think win/win)
  • Externalize problem solving
  • Use immediate feedback
  • Increase frequency of consequences
  • Increase accountability to others
  • Use more salient artificial rewards

36
More of the ideas
  • Change rewards periodically
  • Touch more, talk less
  • Act, dont yak
  • Keep your sense of humor
  • Use rewards before punishment (reward early
    often!)
  • Anticipate problem settings make a plan for
    them!
  • Keep a sense of priorities
  • Maintain a disability perspective
  • Practice forgiveness (child, self, others)

37
Making commands effective
  • Heavily praise high compliance commands initially
  • Use imperatives, not questions
  • Go to child, touch, use eye contact
  • Child recites request
  • Make complex tasks simpler ones
  • Make chore cards for multi-step tasks
  • List all steps involved in task on 3X5 file card
  • Stipulate a time period on the card

38
More on effective commands
  • Reduce time delays for consequences
  • Use timers at points of performance
  • Dont assign multiple tasks at once
  • Praise the initiation of compliance
  • Reward throughout the task
  • Child evaluates performance at end
  • Create a grab bag of surprises (average out to
    every third incident of compliance)

39
Classroom Management I Tips for Teachers
  • Educate yourself about ADHD (nature, course,
    outcome, causes)
  • Keep in mind the 30 rule anticipate the
    difficulties!
  • Keep in mind that interventions within the school
    setting are most effective for improving school
    performance
  • Get in-depth training and consultation on
    behavioral principles modification
  • Pick good administrators ? those that support
    recognize your efforts!
  • Know your limits and practice good self-care

40
Classroom Management II More Tips for Teachers
  • Establish behavioral control Primary objective
    in the first two weeks of school
  • Decrease workload, or give smaller quotas of work
  • Traditional desk arrangement seat close to
    teaching area
  • Target productivity first accuracy comes later
  • Dont send home unfinished class work
  • Give weekly homework assignment sheets ahead of
    time!
  • Consider reducing/eliminating homework!?!?
  • Allow restlessness
  • Review homework at start of class this helps all
    students!
  • Help the student think aloud think ahead

41
Domain-Specific Interventions
42
Initiating
  • Increase structure of tasks
  • Establish and rely on routines
  • Determine minimal level of cue to help start and
    reduce cue over time
  • Break tasks into small, manageable steps
  • Place child with partner or group for modeling
    and cuing from peers
  • Reframe "lack of motivation" as initiation
    deficit for child, parent, teachers

43
Sustaining
  • Increase salience in task- rely on high interest
    tasks
  • Hands-on activities support sustained attention
    problems
  • Ask child to choose among topics of interest to
    increase investment
  • Use verbal mediation (self talk-aloud or to self)
    to help remain focused
  • Write down list of what to attend to for a
    specific task

44
Sustained Working Memory
  • Repeat instructions as needed, perhaps quietly to
    the child
  • Keep instructions clear and concise
  • Concrete reference
  • Use of script
  • Reduce rate of presentation/initial load (sense
    of overwhelm)
  • Frequent breaks
  • Task switching (not for everyone)

45
Inhibiting
  • Increase structure in environment to set limits
    for inhibition problems
  • Make behavior and work expectations clear and
    explicit review with student
  • Post milieu rules in view point to them when
    child breaks rule
  • Teach response delay techniques (counting to ten
    before acting)
  • Environmental modifications (reduce distractions)

46
Shifting
  • Increase routine to the day
  • Make schedule clear and public
  • Forewarn of any changes in schedule
  • Give 2 minute warnings of time to change
  • Make changes from one task to the next, or one
    topic to the next, clear and explicit
  • Shifting may be a problem of inhibiting, so apply
    strategies for inhibition problems

47
Organizing
  • Increase organization in milieu
  • Increase organization of therapy to serve as
    model and help child grasp structure of novel
    material
  • Present the framework of new information to be
    learned at the outset, and review again at the
    end of a lesson
  • Begin with tasks with only few steps and increase
    gradually
  • Implement memory book/organizational system
  • Teach child to look for organization inherent in
    novel information

48
Planning
  • Practice with tasks with only a few steps first
  • Teach simple flow charting as planning tool
  • Practice with planning tasks (e.g., mazes,
    cooking)
  • Ask child to verbalize plan before beginning work
  • Ask child to verbalize second plan if first
    doesn't work
  • Ask child to verbalize possible consequences of
    actions before beginning and contingencies for
    possible blockages
  • Review incidents of poor planning/anticipation
    with child

49
Self-monitoring
  • Anticipate performance- ask child to state how
    he/she will do on a task, then compare gently
    with actual performance
  • Videotape child's behavior and review with child
    in supportive manner
  • Increase attention to behavior- ask child to
    verbalize steps as he/she is doing them
  • Find motivation for accuracy/neatness (reward
    etc.)

50
References
  • The Study Skills Handbook by Judith Dodge
  • Overcoming Underachieving by Nancy Mather and
    Sam Goldstein
  • Why Bright Kids Get Poor Grades and What You can
    Do About It by Sylvia Rimm
  • www.tourettesyndrome.org/htm.ef

51
References
  • Survival Guide for College Students with ADD or
    LD by Kathleen G. Nadeau (1994)
  • Learning How to Learn A Guide for Getting into
    College With a Learning Disability, Staying In,
    and Staying Sane by Joyanne Cobb (2000)
  • Help Yourself Handbook for College-Bound
    Students with Learning Disabilities (Princeton
    Review) by Erica-Lee Lewis Eric Lewis (1996)
  • Succeeding in College With Attention Deficit
    Disorders Issues and Strategies for Students,
    Counselors and Educators by Jennifer S. Bramer
    (1996)

52
  • Steven C. Guy, Ph.D. Licensed
    Psychologist Pediatric Neuropsychologist 170
    North Woods Blvd. Suite 220 Columbus, OH
    43235 (614) 848-9708 Fax 888-1014 stevenguy_at_colum
    bus.rr.com
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