Executive Function And Its Application To Occupational Therapy In School Based Treatment

Editor's note: This text-based course is a transcript of the webinar, Executive Function And Its Application To Occupational Therapy In School Based Treatment, presented by Tere Bowen-Irish, OTR/L.

Learning Outcomes

• After this course, participants will be able to:
  • analyze basic aspects of frontal lobe development from birth until adulthood.
  • evaluate what interventions can be applied to school-age children based on executive function.
  • analyze which diagnoses may present with prefrontal cortex challenges.

Commonly Seen Behaviors

• We have all seen these behaviors…a student who doesn’t meet the entrance criteria for what is expected for age and grade. Challenges with executive function (EF) can show up in many areas.
  • Forgets to do or hand in homework, gets lost in classroom work, or lacks goal-directed behavior
  • On the go, moving about, touching, personal space issues, and fidgeting
  • Seems to pay attention to what is not important, or everything else that you are not teaching
  • Seems disorganized
  • Emotionally reactive, irritable, has outbursts
  • Challenges with prioritizing and planning
  • Class clown behaviors, impulsivity, disinhibited

We have all seen these behaviors. A student who does not meet the entrance criteria for what is expected of their age and grade. They may have challenges with executive function, and it can show up in a variety of areas. The teacher may complain that they forget to hand in homework, get lost, or do not know the assignments' goals.

These kids look like they are always on the go. They are moving around, touching everything, and do not observe personal space. It seems like hyperactivity.

They often seem to pay attention to what is not important. I have been in a classroom where I am trying to get a child to initiate and sustain a task, and they may say, "Do you hear the lawnmower? The custodian must be mowing the fields today."

They appear externally disorganized, even though they have been in school for six months.

There may also be an emotional reaction with irritability or tears.

They may have trouble prioritizing and planning. They may say, "Oh, I should do this first, and then I can get to that."

Finally, they may display class clown behaviors with lots of disinhibition and impulse control challenges.

Executive Skills We Can Support

• Keep in mind the students on your workload. Do they seem not to be able to carry out tasks as their peers?
• Is the teacher reporting unfinished work, dysregulation, being overwhelmed by simple assignments, challenges getting along during group work, or inability to maintain posture/focus during classroom lectures or instructions?
• The research for certain diagnoses points to developmental delays in EF skills.
• Keeping those students in mind, it’s important to provide accommodations, modifications, and collaborative treatments to model and help this student access education.
  • All students can benefit from strategies and ideas to promote EF skills

We are going to delve into specific executive skills that we, as therapists, can support. When you hear me talk about these things, I am sure you will have students' faces and names pop up in your brain. Are you seeing kids that do not seem able to carry out tasks like their classmates? The teacher may report unfinished work, dysregulation, problems with simple assignments, difficulty in collaborative work with their peers, and problems with maintaining posture, focus, and attention, especially in reduced motor situations.

Information to Help With Diagnostics

• So often, we may be seeing kids for handwriting, visual perception, sensory processing, or motor skills
  • Perhaps executive skill dysfunction contributes to these lagging skills.
  • Examples might be…starting a writing project and not being able to launch or sustain time on task. The student hurries at end of 30 minutes to finish, and the writing is illegible.
  • The student may be distracted during independent math by the overhead lights and noises in the room, you’ve made accommodations, but the child isn’t using the "headphones" or visor. Question…lack of ability to act on strategies? Teacher dependent?

Some diagnoses point to developmental delays in executive function, and we need to keep these students in mind. ADHD diagnoses do not get as much attention or remediation as autism spectrum disorders. Not all people agree that ADHD is a developmental delay of executive functioning in the frontal lobe. So, we are going to think about accommodations and collaborative treatments, as all kids can benefit from executive function refinement. We can teach them how to manage and organize themselves.

We may already be seeing kids for handwriting, visual perception, sensory processing, or motor skills. Have we looked at the executive dysfunction that may be comorbid with this? For example, I had a child who had a writing project he needed to edit but could not launch. He was walking around the room, talking about the Red Sox score, and could not sit down. The teacher escorted him to the chair but already 10 of his 15 minutes were gone. As a result, his writing product was illegible.

You may also see kids that have sensory processing challenges where overhead lights and noises in the room are distracting. You may make accommodations, like they may wear a visor or "headphones." However, even with these accommodations, are they initiating things on their own? 

There may be disorganization and a lack of work prioritization. As such, these kids become teacher dependent. 

Frontal Lobe Development

• In babies, frontal lobe development ignites between 6 and 12 months. As a child ages, the following behaviors are products of executive functioning development:
  • Ability to think, plan, and act
  • Handling frustration, disappointment, and upset
  • Inhibition of impulsivity motorically
  • Delay of gratification
  • Displays of being polite, kind, caring
  • Sensitivity to other people
  • The frontal lobe does not fully develop until 25 years of age
• Another old but good book is Megaskills by Dorothy Rich

When we start to think about babies and their frontal lobe development, research shows that the frontal lobe begins to ignite between six and 12 months old. They start to think, plan, and handle frustration. They may be crying but can be consoled. You also see inhibition and delay of gratification.

I remember at one point around six months, my daughter was crying to be fed. The moment I would start to undo my blouse for nursing, she would stop crying. This is an example of simple impulse control at six months of age. There is also caring and empathy sensitivity to other people.

However, keep in mind, for the kids you are seeing, whether they be six or 16, the frontal lobe does not fully develop until 25 and for some up to 27 years old.

“Control Center, CEO, Adult in Your Brain”

• The developing frontal lobe manages incoming information and chooses how to act upon that information leading toward actions towards a contextual goal. Even though this is just one of its functions, it is one of the most crucial for the refinement of approach and avoidance behavior.
• As we all know, people with certain diagnoses, such as developmental disorders, inclusive of ADHD, ASD, Traumatic Brain Injury, and Fetal Alcohol Syndrome, may display challenges due to frontal lobe circuitry that governs motivated behavior.
  • A great book, called "Yardsticks" by Chip Wood, sheds light on executive skill development, focusing on the school years, through 14 years.

The frontal lobe is called many names, including the control center, the CEO, and the adult in your brain. The frontal lobe manages the incoming information and decided what to do with it. It determines what actions it needs to take to meet contextual goals. Even though this is just one of the functions, acting upon information is crucial for the refinement of an approach, like a writing or math task. If there is dysfunction in this area, avoidance means that kid may have an emotional reaction to flee.

Another great book is called "Yardsticks." It looks at executive functioning in kids from four to 14 in a school setting. I like it because it recognizes development. We often ask too much too soon of many of our kids in grades from kindergarten on up. This affirms what we, as therapists, who are trained in child development, have been saying all along in education.

When we look at diagnoses like ADHD, autism spectrum disorder, traumatic brain injury, which may cause attentional and focusing issues based on where the injury is in the brain, and fetal alcohol syndrome. These diagnoses present challenges in frontal lobe circuitry and govern motivated behavior.

The frontal lobe develops in the last three months in utero, which is important to note in fetal alcohol syndrome. Their forehead, where the frontal lobe is located, can actually be depressed.

These diagnostic categories interested me when I first started getting involved with executive functioning. I was seeing that kids were not able to put a lot of things together like their peers, especially in the first six weeks of school. If the teacher had a decent routine with prediction, visuals, and lots of support, the classroom would look like a well-oiled machine. However, the kids I was seeing were not getting into that routine. They needed to be reminded of the most basic things. If the child lacks automaticity of daily living in the context of the classroom, they are draining their brain and not able to put their energies into focusing on the curriculum.

Diagnosing Executive Dysfunction

• The frontal lobe is delayed 2 to 3 years in development. Do the math-30% younger than their chronological age
• Motor strip develops early, and that’s where the hyperactivity comes in
• 10 points off a typical IQ score
• Lacks a sense of time; Barkley calls it, “a blindness to the future.”
• Seems out of touch with social cueing, nonverbal communication, and norms
• Impulsiveness can prevail, blurting, unexpected reactions, inappropriate reactions
• It is not hyper-focusing, but a perseverative behavior
• In children, ADHD is more common in boys than girls, but by adulthood, they even out

Frontal lobe development is delayed by two to three years with a diagnosis of ADHD. When we do the math, if you have a 10-year-old with ADHD in a classroom, you are teaching a seven-year-old, and you have to adjust for that.

Dr. Russell Barkley, my guru, is on YouTube. He has tons of educational, practical videos that are worth watching. For example, if you are handing the car keys to a 16-year-old with this diagnosis, you are handing the car keys to a 12-year-old.

The next part is fascinating to me. The motor strip develops early, and that is where the hyperactivity comes in. Normally, these kids have 10 points off a typical IQ score. Barkley calls it their lack of sense of time or a "blindness to the future." You walk in and say, "Okay, let's start the session." They may reply, "Oh, you are here? What? I have to stay for a snack. I am not ready." When I was prepping today, I prioritized what I needed to do. These kids cannot do this because they are living in the moment and not in a great way. They seem a little out of touch with social cueing and reading non-verbal communication and norms.

As I alluded to earlier, impulsiveness shows up in blurting and reactivity, both inappropriately and almost aggressively.

Sometimes caregivers say that the child can play with LEGOs (or whatever) all night so they do not have a focusing problem. Barkley is the first one I have heard say that this hyper-focusing is perseverative behavior. They cannot stop it as it is a source of pleasure. This is good ammunition for a therapist who is trying to see what is getting in the way of the child accessing the curriculum.

ADHD is more common in boys than girls, but in adulthood, that evens out. It is a lifelong diagnosis, and can also be genetically connected to the child's parents, aunts, uncles, grandparents, et cetera. If you already have a student like this and are sending treatment ideas home, the parents may be unaware they have this diagnosis. Often what you will get back is a compromise. They may say, "Those are great ideas, but we did not get to them."

Inhibition May Look Like Hyperactivity

• Motor actions
• Verbal behavior, blurting, yelling, noise-making
• Intrusive and disruptive behavior
• Snap decision-making without thinking of the consequences
• Restlessness, often expressed as “on the go”
• By adolescence, hyperactivity is almost gone…by adulthood is not diagnostically significant…adult will have lots of thoughts

The first deficit you may see in preschool or kindergarten is inhibition. They are disinhibited and may look hyperactive. They zoom around and complete fine motor activities very fast. They do not have a crisp, grasp pattern.

You may also see blurting, yelling, and noise-making in younger kids. They cannot maintain personal space and are disruptive. These kids might be playing with toys in an aggressive way. They may not share, hit, bite, or do those kinds of things. They make snap decision-making without thinking of the consequences. For example, they may see a kid eating a Fruit Roll-Up and take it. The consequence then needs to be handled and scaffolded by the teacher. 

They can have psychomotor restlessness and be constantly "on the go." You can use a lap blanket or a weighted blanket, or have him do something motorically before a sit-down activity, but you may still see their feet tapping. There is some research, which I will share in a minute, that shows that physical work helps kids with ADHD learn more and do better.

By adolescence, the hyperactivity is almost gone. They are not jumping on couches or beds or doing cartwheels across the floor. However, Barkley says that an adult with this diagnosis has a myriad of thoughts always going through the brain, and they are unable to distinguish what is important to think about. This distractibility is hard on their regular work and relationships.

Developmental Disabilities=Delay at a Normal Rate

• Developmental disability equals a delay at a normal rate…normal development is not happening. There is a chronic lag in the development of these traits
  • “ADHD is inappropriate behavior for your age…it is different from normal in a quantitative way.”
  • Many trade books act as if ADHD is a diagnosis that is qualitatively different. Environmental upbringing has no impact to avoid the diagnosis, but obviously, a supportive, routine, and structured approach helps.

A developmental disability is a delay in a normal rate of development. Normal development for a person with attention deficit disorder is not happening, and there is a chronic lag in the development of those traits. "ADHD is inappropriate behavior for your age."

Trade books say that environmental upbringing has no impact, but a supportive routine and structured approach help. They not only require meds, but they also continue to need scaffolding, accommodations, and modifications.

ADHD is a Lifelong Risk

• According to Dr. Russell Barkley, 50 percent start to lose friendships, starting in 2nd grade…ADHD has a lifelong risk.
  • "Peer rejection due to emotional impulsiveness…friends won’t forgive anger and hostility. It is an inhibitory deficit. It explains job dismissals, road rage, and marital and parenting difficulties”.

Barkley says 50% of those with ADHD start to lose friendships starting in second grade. It has a lifelong risk of challenges like peer rejection and friends who do not forgive anger and hostility. If a child becomes aggressive on the playground, in the classroom, or during a sport, they will start to have the reputation of being a bully or not being able to keep their hands to themselves. As they get older, we may see job dismissals, road rage, and marital and parenting difficulties.

An example is a child that I coach on his impulsivity and reactivity. Around third grade, his peers were starting to reject him because he was the "class clown," and when they joined in, they would get in trouble. By six months into third grade, they were saying, "Do not talk to me. I do not want to have to stay after and miss recess." I went out to recess with him after our session, and these boys were playing wallball. It was like a swarm, where they moved together when the ball hit the wall. Someone would catch the ball, throw it, and they would swarm again. The goal was to keep the ball in the air, but it was based on the team working together. This kid was standing next to me and his classroom para, and he said, "This game is so stupid." I replied, "It looks like it's kind of fun, but I'm not quite sure how it goes." He said, "You just have to get the ball and stay on top of it, but they do not ask me to play." I said, "You could probably talk to them." All of a sudden, he ran over to the group. I said to the para, "Let's see how this goes." He got in the swarm, caught the ball, looked at everybody, held the ball above his head, and dropped it to the ground. Those boys were ready to attack him. They were so angry that he interrupted the game, and he just laughed in their face and walked back over to us. He said, "Guess they're not going to invite me now." Thinking about the scenario, you can see his lack of impulse control, his wanting attention, and his acting 30% younger than his chronological age. He was probably acting more like a kindergarten or first-grader.

Student Considerations

• As we look at these students…
  • We must consider the inability to perform as expected.
  • The diagnosis is a 24/7 one that often lasts a lifetime.
  • Where can therapists intervene?
    • Academic access
    • Social-emotional development

We must look at these kids' inability to perform as expected. The diagnosis is a 24/7 one that lasts a lifetime. Where can therapists intervene? Goals and treatment ideas can focus on the curriculum or on social-emotional development, like play skills, engagement in cooperative activities, communication, and working with other students.

Executive Skills and Abilities That Affect Classroom Independence

• I’d suggest that you conjure in your mind a student you work with.
• We all can relate to this list, and no one has deficits in all areas.
• The key is to pinpoint where these skills are impacting the student’s ability to access their curriculum.
• Prioritize the most important skills.
• From there, we decide where we can accommodate, modify or refine skills.

Let's dive into a little more nitty gritty (see additional handout). Feel free to copy and use this handout in your practice. Not all kids have deficits in these areas. The key is to pinpoint where certain skills are impacting a student's ability to access the curriculum. What I want you to think about as we discuss these skills is prioritizing what you think are the most important to go from point A to point B to get work done, get along with others, and perform grade-level tasks. Then, you decide how you are going to accommodate, modify, or refine.

When reviewing this handout, you can rate yourself and identify where you have the most challenges. We all have strengths and weaknesses and different ways to follow through with the demands of life (school, work, parenting, etc.). 

Let's now go through each area.

Activation

• Organizational ability
• Prioritizing
• Volition
• Task initiation
• Planning, thinking ahead

Activation is an organizational ability to prioritize and plan. It is also that sense of volition. It is, "I want to get an A," "Get all of these done," et cetera. Kids with a diagnosis of ADHD do not have natural volition. As such, Barkley talks about how they benefit from a dangled carrot or a token system. They do not want to delay gratification in order to get to a goal. It is also about task initiation with planning and thinking ahead.

One thing to be aware of is that, often, it is not an input problem. For example, I had a child come to the classroom in the morning with his backpack, coat, and lunchbox and stand there. I would say, "Daniel, what are you supposed to be doing?" "I have to hang everything up, put my lunch in the refrigerator, then I have to sit down and do my morning edit." I would say, "Daniel, you've been here five minutes, let's do it." He had a hard time launching. After a few weeks of observation, I gave him a point of performance cueing via an index card that had instructions to hang up his coat and backpack, put his lunch in the refrigerator, take the chair off the desk, et cetera. The first day I gave him the index card, I said, "I am going to time you and see how long it takes you." He looked at it and said, "Okay, I can do that." He ran over, hung up his backpack, and then came back and looked at what the next step was, which was to hang up his coat. Then, he came back and said, "Oh, I have to put my lunch away." It made me realize how poor his working memory was for those four or five tasks.

Focusing

• Sustaining focus
• Shifting focus from task to task
• Selective attention
• Sustained attention/concentration
• Shifting cognitive set

The next part is sustaining focus, shifting focus, selective attention, sustained attention and concentration, and shifting cognitive set. The child may initiate, but if the teacher says, "I want you to stop writing that paragraph and refer to this paragraph in the book to see how much yours looks like that." The child may give up because they cannot shift their focus.

You may also see challenges with the amount of writing or independent reading time they can do on their own. These are yellow flags.

Effort

• Regulation of alertness
• Sustaining effort
• Processing speed, output
• Goal-directed
• Persistent

Effort is the regulation of alertness. We work with kids that are dysregulated and may need more sensory input or movement. Kids may say, "Is it over?" You may have to put the Time Timer on so they know when the torture will end. If the red goes away, they are done.

You may also see erratic processing speed. They may quickly write down a bunch of letters, but their writing is illegible, and their output is minimal. They will also not want to go back and check their work.

Sometimes they need specific instructions, not "The goal of this activity is for you to create a poster with all the different clouds." A child may need more. "Let's find out how stratus clouds look. Here are the cotton balls, glue, and poster board."

They also have a lack of persistence. This goes hand-in-hand with volition.

Emotion

• Management of frustration
• Inhibition
• Modulating emotions
• Flexibility
• Stress tolerance

The next part is becoming clearer to me as I see more emotions in my kids. Behaviors I have seen are desks being thrown, punching, hiding, elopement, and biting. Emotions are part of executive skill challenges.

A child can be angry or anxious with challenges in inhibition, hearing "no," modulating emotions, and tolerating stress.

Of these skills, I certainly would hang my hat in this area and create some IEP goals and objectives in this area.

Working Memory

• Accessing recall
• Anticipation
• Relying on experience

Working memory is holding something in your brain as you perform a task. If they do not have a letter line on their desk, they may be hyperextending their neck to see the letter line on the board. They then have to hold that in their brain to be able to copy the letter.

They also need to have an anticipation of what is going to happen next, which is especially important for sequenced activities. Using your fingers, you can say, "We do this first (hold up your thumb), second (pointer finger), and third (middle finger).

If their working memory is poor, they do not seem to generalize from experience to experience. For example, in high school math class, the teacher may have them write assignments in their daily journal, while another teacher expects them to go online. They may not remember and not find any math homework online.

Action

• Monitoring own self
• Monitoring self-regulation resulting in correct action
• Self-awareness of what works and what doesn’t work

The next part is action. This is self-awareness and being able to monitor self-regulation. I had a client yesterday that said, "I had stomach pains last night. I didn't sleep well, and now they're yelling at me because I cannot focus on the MCATs." I said, "You can walk in and say, 'I am not myself today,' and share with them what you just shared with me." He was not able to think this through and plan ahead.

The next part of problem-solving is what works for you and what does not work for you. What process do you need to establish a routine in the classroom? In the earlier example, Daniel required an outside person to be his referee and direct him.

*Handout

• The handout is consolidated of what we just reviewed. I use this with students, teachers, and parents to pinpoint challenges.
  • The chart was compiled from a variety of resources. Here is how I use it:
  • Check off traits that stand out…you can limit to the top five where the parent, teacher, or student sees executive dysfunction.
  • This is a true conversation starter!
  • From there, choose just one you want to work on.

You can give this handout to a parent, teacher, or older student. They can check off the traits that stand out, and it can start the conversation. You fill out one as well and see where you both agree on traits and skills that are getting in the way of moving forward.

• This gets the ball rolling
  • If a student or teacher says activation is the challenge…
  • Observation is key…
  • Confirmation and agreement to establish strategies…
  • Working co-actively with the student and teacher, break down the accommodations and application…
  • Accommodations: Time Timer at a desk, teacher direct reminder, an executive place to work away from the group, frequent, teacher check-in, breakdown of tasks, one step at a time.
  • Review of strategies, refinement, and continued work towards independence.

That gets the ball rolling. The classroom is your observatory and laboratory. You watch how the student is functioning within the context of the classroom and their ability to access the curriculum. Sitting there for 30 minutes once every two months is going to validate what you are doing with them to see if it is working.

When you proactively work with the student and the teacher, you are breaking down the accommodations and applications. For example, I have one child who needed "headphones," as he was very distracted. He also needed to sit with his back to the class because he was always looking at what other people were doing. He would turn his desk during certain curriculum times. I would also have to cue him. "What two things do you need before you even start?" Next, I move to something taped on his desk, saying, "Where do you have to look to know where you have to start?" Eventually, the teacher started doing that, and that worked.

Accommodations include a Time Timer at the desk, a direct reminder from the teacher, and an executive place to work away from the group. Other things are frequent teacher check-ins, breakdown of tasks, et cetera. As we start looking at these strategies, we assess and refine them. The goal is that the kid can function adequately and reasonably without attachment to us.

Smart but Scattered for Teens by Guare and Dawson

• They believe there are two dimensions of Executive Skills…
• Cognitive: memory, planning, organization, time management, and metacognition
• Behavior: inhibition, emotional control, sustained attention, task initiation, goal-directed, and flexibility
  • Important to differentiate as to which dimension the student’s challenges lie

This is a great book, called "Smart but Scattered for Teens," and there also is a "Smart but Scattered for Elementary." by neuropsychologists, Ric Guard and Peg Dawson. They break down the executive skills in the cognitive areas and behavioral areas. I had a slide earlier that talked about social, emotional and academic areas. and this is an even further breakdown of that.

Accommodations, Modifications, Strategies

• In your handouts are some consolidated ideas based on arousal challenges with these students.

Now, we are going to move on to accommodations, modifications, and strategies. In your handouts, I added some ideas for arousal so I am not going to talk much about that today. What often can happen is these kids need alerting or need some downtime in order to be more regulated to do the work that is being asked of them.

Touchstone Principles

• Favorites of mine are “Touch More and Talk Less” 
• “Act, Don’t Yak”
• Holding information in their mind and using it isn’t always easy. Use lists and visual memory references as much as you can.
• Self-awareness cueing, as they need to improve this trait. He suggests video reviewing both the expected and unexpected behaviors, a non-verbal cueing system between him and the adult.
• Don’t call on, unless hand is raised (may have word retrieval challenges)

Barkley calls these the touchstone principles. One of my favorites is "touch more and talk less." When you are checking in with a student, decrease the verbiage, go over, look at them, give them a thumbs up, or put your hand on their forearm. When you do that, you are not becoming Charlie Brown's mother going "wah-wah, wah-wah."

Another favorite is, "Act and do not yak." He talks about the point of performance coaching. You may have a kid with his "deadphones," his desk turned around, and a worksheet in front of them. All you might need to do is point to number one on the page and say, "Do that. Raise your hand when you finish that one."

When they have to hold information in their mind, as I said earlier, we need to give them a lot of lists and visual memory references. It could be a point of performance for each subject or a room poster like what bus they are on or the steps they have to do when they turn in their homework.

The other part is self-awareness cueing. One thing Barkley talks about is that the child should be videotaped in the classroom. The idea is to have them look at what they are doing at certain points, tell you where they went sideways, or what they could have done differently.

Another cool thing is cueing. Many of these kids do not want their names being called seven times in 30 minutes. "Julie, Julie, Julie sit, Julie sit down." Julie is going to tune you out. Instead, go over to her and say, "Remember, if you need me, turn your paper over. I will be scanning the classroom and will come by if you need that help."

The other part Barkley talks a lot about is word retrieval. Do not call on kids with prefrontal cortex challenges if their hand is not raised. They are going to feel put on the spot, and some of that emotional dysregulation may show its ugly face. There is a YouTube video by a talented young woman called Doing ADHD that I highly recommend. In it, she talks about hand raising.

Other Accommodations/Strategies

• Emotional, self-regulation is weak. Can benefit from visualization, imagery, counting, and ritualistic motor movements
• Reduction of distractions in the environment
• Possible use of weighted lap pillow, deadphones, move and sit cushion
• A place to get away, quiet, chill out
• Helping the student rewind the video…Let me tell you about a student I had that wasn’t going directly to his classroom, once he arrived at school.

Other accommodations are for weak emotional- and self-regulation. I like to use visualization. If the teacher is reading a book, I will say, "Who can draw a picture of that scene on top of the hill?" You have first and second graders drawing the picture of a girl on a swing with a dog. You can talk to them about what they think the weather is like there. "Can you prove to me what the weather is? Is it snowing, or is the sun shining? What time of year is it?" This is a way to get more visualization and imagery into their system so it becomes more real to them.

We also want to reduce distractions. You can bring in weighted lap pillows, headphones, and seat cushions. I also advocate for a space for them to get away, be quiet, and chill out. Figure 1 shows an example.

Figure 1. Girl on a beanbag looking at an iPad.

It is a reboot station, not necessarily a "zen den," which takes commitment. It can be a space in the classroom where a child can go if they need some alone time. The teacher can set the Time Timer for five minutes. There can be books and fidgets. It is nothing overwhelming, just quiet.

One thing that I do is say, "Let's rewind the video," if I see an impulsive act that occurs while I am watching or working with them. "Okay, let's rewind that video. We were playing a game, and you didn't roll the dice you wanted, so what did you do?" They may reply, "Oh, I threw it across the room." I can then say, "Yeah. What do you need to do?" At that moment, you can break down what happened.

I have another great example. I walked by the school office and saw a boy sitting in the hallway. I said, "Ian, why are you sitting in the hallway?" He was diagnosed with ADHD when he was in second grade. He replied, "Oh, Mrs. Bowen-Irish, I am in trouble. I am supposed to get off the bus in the morning, go to the classroom, and read about what's going on for the day. First, I went to the kindergarten teacher and helped her take all the chairs down, helped my 1st-grade teacher Mrs. Smith put some pieces together for her craft project, and stopped in the 2nd-grade class to say hi to Mrs. Dowry and chat." I said, "So you didn't go directly to class." He said, "No, but I get there on time." And I said, "Hold on, Ian, I will be back." I went to each of these teachers, and they all said, "He has come a long way now that he's on meds. He's helpful and talkative." I then went to the principal and said, "He's doing his own IEP. He's talking to people, being appropriate, and getting to class on time." He was giving himself a movement and social break and then heading to class.

• Target productivity first, accuracy later
• Have student help with teaching
• Reinforce an “I can do it attitude.”
• Ask open-ended questions (metacognitive) to promote problem-solving e.g., “What do you think we ought to do before we leave for lunch?” “Where’s the best place to put this agenda book, so you will find it at home?”
• Breakdown e.g., 1. put away coat and backpack, 2. put homework in bin 3. gather materials needed: pencil, books, folder, etc. 5. look at classroom daily schedule on board 6. do classroom chore or wait for bell or next instruction

Here are some more accommodations. In an IEP, you want to target productivity first and accuracy later. Do not make a child do a bunch of work and then say, "Okay, now we are going to edit it." I will tell them to edit one line at a time, and then come back to it later.

You also want to use positive reinforcement. "You can do this. You're not there yet, but you are going to get there."

Ask open-ended questions. This is called metacognition. "What do you think we ought to do in this situation?" By doing this, you can get a sense of if they can problem solve or if they are stuck on one idea and cannot go beyond that. You want them to come up with at least three solutions to one problem and assess how well they did.

Obviously, breaking down tasks is also important.

• Externalizing time using timers, vibrating watches, minute hourglass, and other timekeepers
• One of the best...take a movement break
• Consider breaking down short- and long-term assignments, coactively
• Know that problem solving should occur like coaching, at the point of performance
• Despite the fact, we want them to work because it is their job, they still will need incentives and tangible rewards. These rewards need to change frequently.
• Immediate feedback on performance in a constructive way, with natural consequences and acknowledgment of triumphs

The Time Timer is wonderful, and I have mentioned it several times during this talk (Figure 2).

Figure 2. The Time Timer.

Vibrating watches can remind them, "Are you on task?"  There are also minute, hourglasses, and other types of timekeepers.

When I get to third grade and up, I will ask the teachers, "What long-term assignments are you going to do this year?" It may be a report on endangered species or an environmental green initiative. I have them give me the rubric, and I pick something to do with my student. The speech and language pathologist may also pick something else out of that. We help because many of these kids cannot get it together at home to be able to do this long-term project. They may tell their parents an assignment is due the next day.

I have talked about the point of performance. We want them to understand that schoolwork is their job. They may need incentives. I am not saying dangle a piece of candy in front of them or feed them by any stretch, but perhaps if they bring in their homework for three nights, they get the fourth night free with no homework. Other options are they can get an extra 10 minutes of recess or get to have lunch with me once a month. When we do that, they are learning that they can delay gratification. However, do not make it so long. I might start with, "You can have lunch with me once a week," but also give immediate feedback on performance. They may need someone to intervene right away and catch them doing a task, as a teaching moment.

IEP or 504 Plan Accommodations

• Daily check am and pm to help with grounding, knowing what worked, what didn’t work, and what will happen tomorrow
• Pairing students with a role model who will help, not do the task for them; Proximity to teachers with frequent check-ins is a must
• If in middle or high school, have notes available from lectures
• Daily progress reports tracking behavior co-actively
• Extra time for tests or homework assignments; Alternate ways of sharing knowledge
• Frequent breaks between assignments or tasks
• Seating balls, Hokki™ chairs, or Zuma chairs to allow for movement
• Movement and mindfulness activities sprinkled throughout the day

Whether it is an IEP or a 504 plan, here are some other accommodations that I use. I like daily check-ins and have seen them done in a variety of ways. A point of performance person can meet with them in the morning. "These are your classes today. Did you bring your sneakers for gym?" They may be 12 or 13 years old, but what would you do to scaffold a kid that was around eight? You break down what needs to happen. You can also double-check for homework completion. At the end of the day, you can meet up with them and do the same thing. I have seen this done one-to-one and in group situations where they all go to a classroom and not to homeroom. They meet with a counselor, a therapist, or an educator where they go through this. It is almost like pre-day coaching.

The other thing that is cool is to pair students with a role model that will help them. When you pair them up, you may find that the other person does a lot more teaching because they care more about being with their peers than being with adults. They are going to have respect for one another that they might not have for us.

The other thing that always makes me giggle is that the proximity of the teacher to the child who is having a problem with focus and attention can make a big difference. If the teacher is way across the room and the kid is sitting in the heckle section in the back, that kid is not going to be paying attention. However, if the kid is sitting near the teacher or the teacher is moving back there to give instruction, the student is much more likely to pay attention.

For middle and high school accommodations, I recommend that the teacher have notes from lectures available for that student. We do not want to drain their brain pool by having to do so much work. We want them to tell us what they know, so why not have notes available?

You can also provide daily progress reports and track behavior. One activity I learned from a behaviorist is to say to a child, "You completed a 45-minute class. These are the three things we worked on: starting the assignment, sticking with the assignment, and finishing what your teacher expected. Put your hands behind your back and rate yourself from one to five on starting the assignment. I am going to put my hand behind my back too. When I say one, two, three, we are going to show our hands." Let's say for starting the assignment, the child puts up three fingers, and I put up four. He may say, " I had a hard time starting." I replied, "You did, but you were done within five minutes." You then ask them to rate sustaining time. We both put up a two. He says, "I was in the bathroom a long time." You are being proactive. It is not you going, "Oh yeah, you only got one for that and a three for that." You are not the judge and jury, but instead, you are both working on it together.

They may need extra time for tests and homework assignments, alternative ways of sharing knowledge, and frequent breaks between assignments or tasks. Gardner talks about pulse learning. There is also high- and low-intensity learning. You have to figure out the frequency and duration based on their development and age.

We can also use environmental adjustments in the classroom, like Zuma chairs, Hokki™ chairs, and seating balls.

You do not hear me speak without a discussion about movement and mindful activities sprinkled throughout the day. We need to clean our slates. When a child moves from classroom to classroom, who knows what happens in that hallway? A teacher may say, "Put one hand on your heart, and one hand on your belly. We are going to have a quiet three minutes so you can land for my class." In another class, at teacher may add some movement to get the energy out. They can also stretch a TheraBand while learning vocabulary.

We want to do things to ignite learning, increase focus and attention, and, obviously, increase oxygenated blood flow.

Need to Squirm and Move Research

• Research at UCF found that movement helped with cognitive tasks. “Rapport's previous research had already shown that the excessive movement that's a trademark of hyperactive children -- previously thought to be ever-present -- is actually apparent only when they need to use the brain's executive brain functions, especially their working memory.”

  • Specific for ADHD diagnosis

Sarver et al., 2015

Here is some research about movement with cognitive tasks. Excessive movement is a trademark of hyperactive kids, but it is only apparent when they need to use their brain's executive brain functions and their working memory, so I thought this was fascinating.

• "What we've found is that when they're moving the most, the majority of them perform better," Rapport said. "They have to move to maintain alertness."
• “By contrast, the children in the study without ADHD also moved more during the cognitive tests, but it had the opposite effect: They performed worse.”

When they moved the most, they performed better. An example of balls and Hokki™ chairs is in Figure 3.

Figure 3. Hokki™ chairs and seating balls.

By contrast, kids without ADHD that move during the cognitive testing perform worse.

Other Accommodations That May Apply

• Ask for directions to be repeated
• Service duties within the classroom, passing out papers, hanging up posters or classroom work, putting up and taking down chairs on desks at the end or beginning of the day
• Ready menu of short breaks to choose from
• Other consequences versus taking away recess
• Once a student has the concept, don’t expect extra work
• Have homework done during school time or after school programs

Other accommodations include asking for the repetition of directions from the student's mouth and giving them motor breaks by passing out papers in the classroom, hanging up posters, taking down chairs, or choosing from a ready menu of short breaks. My Drive Thru Menu still works well because it is not putting on GoNoodle and hoping somebody participates.

It is important to consider other consequences instead of taking away recess. One of my schools decided to make kids walk the perimeter of the playground during recess. They were not playing but they were getting physical exercise.

Once the student has mastered the concept the teacher is trying to teach, do not make them do any more work. This reduces stress. It is also important to give them time to do homework during school time or in after-school programs.

Two-level System of Automaticity

• Dr. Russell Barkley talks about a two-level system, the automatic brain and executive brain…thinking fast and slow. Accommodations with a focus on habituation will help.
  • Habitual activities need to evolve and be put into place early in the school year.
  • Executive brain is more complex…has to stop, unlike the automatic brain…executive skills take more effort…there is only so much they can do in a day. Effort pool, a limited amount available…you will delete the fuel tank and self-reg issues will get worse. Use too much, too quickly, too often.
  • Exercise, visualize the goal, the pep talk to help the person use the pool, have rewards and the thought of rewards is important. An affirmation such as, “I can do this. I can accomplish this.”
    • Natural volition may not exist.

Barkley talks about a two-level system of automaticity. Habitual activities need to evolve and be put in place during the school year. I talked about that right at the beginning. The executive brain is more complex, and these skills take more effort.

• The amount of blood sugar fuels the system…a little sugar in your bloodstream. Sports drink, sugar drink…not a lot but just sips
• Practice more than others for habits to be performed, causes less taxing of the brain. Overlearning is important…coaching can help, and more trial runs to have habits connected to the automatic brain.
• https://www.youtube.com/watch?v=rulBxn3MXc8

And there's an effort pool he calls it in the brain. You can delete the fuel tank and self-regulation issues will get worse. If you use too much of that pool, the self-regulation will go sideways. So the idea is to have the person have more routine that comes automatically so they can accomplish. And the final thing that he talked about was having kids being able to sip a sports drink, a sugar drink because it does help fuel the system of attention.

Smart But Scattered: Learning Tips

• Timing of directions
• Encouragement of students (if developmentally appropriate) to use tech solutions to help remember
• Advance notice of what is coming next
• Maintenance of routines and rituals
• Active problem solving
• Use a Watchminder, which helps with sustained attention
• Praise
• Incentive systems

Finally, Guare and Dawson talk about the timing of directions. There may be tech solutions that can be helpful, like a Google calendar.

Summary

I hope you take away some value from this talk, including who these kids are, how you currently treat them, and ways to tweak your approach. As therapists, need to consider EF skills. If there is a developmental delay, we need to adjust our approach.

I love this quote. "He talks like a watch, which ticks away minutes but never strikes the hour" (Samuel Johnson). Let's have a mission for these kids.

Questions and Answers

Are there any gender differences in frontal lobe development?

From what I understand, males are diagnosed more than females. Barkley says that if you are diagnosed as a female, you never outgrow it, as girls tend to be diagnosed later in life than boys. Girls also tend to have prefrontal cortex maturation, earlier than boys. This is why I gave you the range of 25 to 27 years.

If a child with ADHD is medicated, does the 30% delay still exist?

That is a great question. Barkley says that the medication provides enough dopamine to focus, but they still need the scaffolding to be able to organize and plan. They still are delayed in prefrontal lobe development.

It seems like you said "deadphones" rather than headphones each time.

With little people, I would rather have nothing coming into the ears to distract them so that is why I call it a "headphone." I take the plug out. You can use headphones with older kids.

Can you give more examples of goals you would recommend for executive functioning?

I do not have time in these five minutes to do that, but I do think you guys can use the handout to determine the skills the child has to do in an amount of time that is measurable. 

How much of executive function therapy is changing the system versus changing the student?

I think it is changing the student or their reaction to the environment. Kids react well to medication if they truly have ADHD, and I have seen it myself in a week. All of a sudden, their handwriting,  focus, and attention are better. Environmental scaffolding is great, but the reality is what is going on in them.

Can you provide an example of a goal you would write for an executive function?

I may say, "Student will participate in cooperative learning with up to four students with no sign of avoidance, aggression, or compromise as evidenced by completing tasks, group tasks, and roles within the group in eight out of 10 opportunities."

Can you explain how delayed frontal lobe development and early motor strip development can cause hyperactivity?

From what I understand, the motor strip matures faster in the brain for these kids with this dysfunction. 

What other suggestions do you have for a teen who has trouble with time management but timers do not seem to work?

I would just sit down with the teen and say, "Let's figure this out. What's going on?" They can tell you what has worked for them. One of the worst things we can do as therapists is dictating the process. We have to find out the kids' processes. Spend time talking to them. It may not feel like treatment, but trust me, it is.

What handouts do you find most helpful to send home with students for parents?

I often refer them to Barkley's book on handling ADHD. He just wrote a new one on executive functioning. It is more for a clinician than a parent. "Puppy Mind" talks about how your mind is like a puppy when you have ADHD and can be helpful for kids. There are many resources available.

What would you say is the number one piece of adaptive equipment that you use for the majority of your students to help teachers implement in their classrooms?

I use the Time Timer. I also like weighted lap pillows and fidgets. I provide a lot of education and try to individualize it for each case.

Does it become worse as they age?

No, it morphs. In other words, they are not jumping up and down on the couch as they did at five, but you see changes in their ability to handle the demands of adulthood. It is being able to follow a schedule, meet deadlines, take care of yourself, pay your rent, and all that. When demands increase, this person is going to unravel if they are still doing disinhibited things. Barkley talked about someone saying, "It's going to snow tomorrow, so let's get in the car and drive to Florida." This is an example of this thinking. They are not thinking about things they need to do. So, it does not become worse, but it morphs according to their developmental age.

References

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Dawson, P., & Guare, R. (2011). Smart but scattered: The revolutionary ”executive skills" approach to helping kids reach their potential. Guilford Press.
Delman, M. (2018). Your kid’s gonna be ok: Building the executive function skills your child needs in the age of attention. Beyond BookSmart.
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Nimble Kids. (5/15/2018). The development of your child’s frontal lobe- The control center of the brain. Retrieved from https://www.nimblekids.ca/blog/the-development-of-your-childs-frontal-lobe-the-control-center-of-the-brain
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Sarver, D. E., Rapport, M. D., Kofler, M. J., Raiker, J. S., & Friedman, L. M. (2015). Hyperactivity in attention-deficit/hyperactivity disorder (ADHD): Impairing deficit or compensatory behavior? Journal of abnormal child psychology, 43(7), 1219–1232. https://doi.org/10.1007/s10802-015-0011-1
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