By S. L. Crum, B.S., M.S., Ph.D.
One of the most important and difficult set of functions to assess through neuropsychological evaluation are executive functions. By executive functions, I refer to a set of mental processes that enable us to connect past experiences with present circumstances so we executive and monitor our actions in such a manner that they are adaptive; that is they permit us to prosper in our environment. In lay person’s having good executive functions means we have the cognitive substructure to differentiate the essential from the non essential, seek out important information, anticipate outcomes, weight alternatives, plan, organize, strategize, delay gratification, transition, or modify plans and actions based upon feedback. Executive functions are those that permit us to ‘think on our feet’.
It is possible for disorders of executive function to run in families. But, it is also possible for such a disorder to be evidenced in a lone family member who has sustained some sort of insult to the brain such as hypoxia during a difficult birth, transient ischemic attacks due to high blood pressure, or axonal sheering as a result of a head injury. Although the underlying problems are often present from birth, subtle problems are often not recognized until latency or early adolescence when we begin to expect that an individual show more self-control and judgment. It is at this point, that many children with executive dysfunction have an escalation of conflict with peers, educators and parents, and some begin to have contact with the legal system.
So how do you know if your child has executive dysfunction?
To determine if a child has problems in executive functions, neuropsychologists look at what I like to call the ORS. O=organizational skills, R=regulatory skills and S-solving skills.
- Organizational skills include attention to salient factors, basic decision making, planning, sequencing and reasoning.
- Regulatory skills include initiation of actions (not to hyper or lethargic), inhibition (not impulsive) self-control, self-evaluation, and self-regulation.
- Solving skills include higher cerebral functions that typically don’t develop until late adolescence or in what Piaget called the stage of formal operations. This involves directed exploration, ability to research, ability to anticipate obstacles and change plans before encountering the problem, ability to judge other people’s reactions, ability to consider a range of alternatives and to weigh consequences, the ability to anticipate the outcome of initial actions, the ability to scanning a situation for targeting information, the ability to engage in conservative gambling, the ability to generate a hypothesis and test it out, the ability to correct errors and to trouble shoot, the ability to override automatic responses and substitute more adaptive responses, the ability to predict and to estimate, the ability to be flexible and flow with circumstances, the ability to assume the perspective of others, the ability to engage in both inductive and deductive reasoning, the ability to systematically eliminate non-viable alternatives and the ability to combine things in novel ways.
So what in the brain permits us to do these things?
The seat of executive functions in our brain is the prefrontal cortex. The executive functions managed by the prefrontal cortex include inhibition, planning, time perception, internal ordering, working memory, self-monitoring, verbal self-regulation, motor control, regulation of emotion and motivation; all essential substrata of ORS.
What happens when executive functions are impaired?
Executive dysfunction can take many forms. But, deficits in the basic substrata mentioned above can result in an inability to apply consequences from past actions to judgments about future actions. This, in turn, can lead to socially inappropriate behavior. There may also be difficult with abstract concept formation such that an individual cannot move from a specific incident to a general rule of behavior. For example, if you tell a child not to write on the wall with blue marker. They will not necessary realize that they shouldn’t write on the wall with red marker. Additionally problems with planning and initiation may be seen. In other words, the individual may seem to procrastinate, simply unable to operationalize the steps needed to get started with a big task.
An individual with executive dysfunction may experience problems with verbal fluency that cause them to “clam up” when confronted by difficult questions. Or, they may evidence an inability to shift mental sets such that the perseverate with the current task when it is time to move onto a new one. These individuals may require constant supervision by others to monitor the appropriate of their actions as they cannot adjust them to differing demands of different environments. They may also have difficulty processing, storing or retrieving information simply because they never inhibited distracting sights, sounds or internal thoughts long enough to initially attend to the stimuli. Due to problems with inhibition they may evidence rapid changes in emotions or may become stuck in one overwhelming emotions. They may demonstrate a lack of empathy as well as a lack of remorse for their behaviors and their impact on others. The lack of self-regulation may even be observed in impaired fine motor skills. But, perhaps the most difficult behavior for those around them to accept is the fact that those with executive dysfunction are often unaware that their behavior is a problem; and even then they do develop this awareness they may be impotent to change their behavior and thus as a defense mechanism, deny that their behavior is a problem and instead direct anger at others claiming that their expectations are unrealistic.
What does this mean for the academic environment?
Often, I observe those with executive dysfunction being described by teachers as being defiant or willful, as being lazy, as choosing to misbehavior or as refusing to cooperate and conform. Consequently, teaches, assistant principals, principals and IEP teams decide to adhere to their school district disciplinary policies and to punish students with tine out, detentions, in school suspensions, out of school suspensions, and even incarceration. All of this fails to serve any constructive purposes when the individual is unable to profit from environmental feedback. It would be much more productive to instead put in place a range of behavior supports that would diminish if not eliminate the inappropriate behaviors.
For example, a child with executive dysfunction may not be able to plan. Thus, sending home an assignment to read a book and write an add poster over Christmas break is unrealistic. Instead, the teacher would need to write down: “On Monday, read pages 1-40, on Tuesday, read pages 41-80, and Wednesday, read pages 81-122. No work on Thursday, Friday, Saturday or Sunday. On the next Monday, draw a picture of something you liked in the book. On Tuesday, write something about why you liked the book, On Wednesday, put these on a poster board. On Thursday, decorate the board, and so forth.
Students with executive dysfunction have problems keeping track of time. So they may rush through an assignment in an attempt to get it done handing in something that is quite messy with apparently “careless “ errors. Or they may work slowly feeling that they have much more time than they really do with the result that their assignments are only partially completed. This issue might be simply addressed by having teachers give students parts of the assignment in small chunks and setting a timer on their desk that clearly indicates the amount of remaining time for that chunk. Once that portion is completed, the next chunk would be assigned and the timer reset.
For those whose executive dysfunction manifests itself in difficulty keeping tract of more than one thing at once, multi-subject note pads or notebooks may not be practical. Instead, they may need everything for each subject color coded and kept either in a matching colored bin in their classroom or a matching colored back pack in their locker. They may need teachers to give them only one direction or assignment and not to introduce another until the first is complete.
For those who have problems evaluating their own behaviors, students may benefit from session with the school psychologist where other students role play appropriate behavior. Then, receiving specific assistance in making the connections between what they observed and what they tend to do.
Some student with executive dysfunction may change their minds and make mid-course changes while thinking, reading or writing with the result that their productions are disjointed. This student may need the one on one assistance of an aid to redirect them to complete their thought and carry it through to its reasonable conclusions before switching to another area of interest.
Waiting turns, interrupting, failing to wait to be called upon are manifestations of executive dysfunction that may be require some sensitivity training on the part of peers, along with some classmate instruction in constructive ways to respond. For instance, if Joey interrupts a peer, the peer may be taught to say: “Hey, Joey, I know you didn’t mean it. But, you didn’t let me finish telling you what I want to share. Can I have my turn now?”
Of note, there is no research supporting the view that punishment or enforcement of school disciplinary policies is at all effective in addressing the behavioral manifestations of executive dysfunction. In contrast, both tend to build resentment and anger that the student lacks the ability to control and , thereby, escalate the problem.
In the home and community
Executive functions go with the child wherever they go. Therefore, it is natural that problems will also be apparent at home and in the community. You will note that your child has difficulty planning even something they are really interested in such as what activities to have for a sleep over. They may have difficulty comprehending how long it will take to clean their room. They may have problems telling you what happened during the day or the sequence of events that lead up to an argument with a friend. They may find it very hard to memorize math facts or spelling words or dates in history in school, and equally hard to memory their daily schedule at home , or the steps in a Karate form. They may also have problem retaining informant long enough to use it. So they may forget a phone number while dialing it, or may forget where to put their shirt while walking from the laundry room to their bedroom. Likewise, they may have problems initiating activities or generating ideas on their own, so parents may often here “I don’t know”. As in school, positive supports that help the child compensate for the problem are needed; punishment is not.
So, how do you know if your child is simply oppositional and defiant or they have executive dysfunction?
A thorough neuropsychological evaluation is the first step in assessing your child’s cognitive functions. If possible, this can be combined with a quantitative EEG. The neuropsychological evaluation identifies specific cognitive deficits associated with executive dysfunction. The Qeeg identifies whether or not the areas of the brain that control executive functions are working properly when compared to a database of normal same aged individuals.
What can be done to help?
Both neurofeedback and cognitive rehabilitation has been documented to improve executive functions, so these are two therapeutic interventions you may wish to investigate. In the interim, however, you want to put in place a range of supports to help your child compensate for their dysfunction. For instance, you can help them manage their work by providing checklists that can be referred to and you can meet with teachers on a routine basis to trouble shoot problems. Parents can help children organize their work space with color codes bins clearly labeled with both photos and words. There may even be separate work areas for different types of work with all the necessary supplies in the given work area. For example, my daughter has a desk for homework, an art table for arts and crafts and using the kitchen table for Girl Scout projects. Minimizing clutter by discarding unnecessary items is also helpful, as is helping your child clean and organize their work spaces once a week.
Time management can be facilitated by paper “to do” lists the child can check off, or by computer alarms. Tasks can be broken down into chunks. For instance, I tell my daughter to feed the cats. When that is done, I tell her to change their litter. When that is done, I tell her to feed the dog. When that is done, I tell her to walk the dog. I don’t tell her: “Take care of your animals”. Visual calendars can help children plan for upcoming transitions and special events. use of management software such as the Franklin Day Planner, Palm Pilot or Lotus Organizer can be very beneficial for children who have regular access to a computer.
In general, parents want to approach all tasks step-by-step using both visual, written and voice reminders systematically. You also want to help your child plan for transition times by discussing it ahead of time and verbally walking your child through the way the day will be. Then, post an special event schedule the child can refer to. In all cases direct instruction in executive functions, positive reinforcement and compensatory supports will be more beneficial in managing your child executive dysfunction than punishment will.
Presented as a community service by: Susan L. Crum, B.S., M.S., Ph.D.; Special Needs Coach; Able2Learn; Email: Able2learn@live.com; Voice and Fax: 863-471-0281; Website: specialeducationsupport.org