Executive Function Dysfunction: The Newest Learning Disability. Karen J. Miller, MD Floating Hospital for Children Tufts Medical Center Boston, MA

Executive Function

Dysfunction:

The Newest “Learning Disability”

Karen J. Miller, MD

Floating Hospital for Children Tufts Medical Center

Examples of possible

EF dysfunction

„ Juan, 8 y.o. referred for ADHD evaluation as

he is distractible and can’t wait his turn

„ Michael, 10 y.o. with a history of TBI is now

irritable and impulsive

„ Cathy, 11 y.o. with Asperger syndrome gets

upset with transitioning to new activities

„ Anthony, 14 y.o. who did well in elementary

school now referred for being “lazy”

„ Ken, 35 y.o. pediatrician who can’t remember

Executive Functions “definition”

„

Variety of “higher-order” mental

processes and behaviors

„

Enables self-regulation, problem-solving

and goal directed behavior

„

Integrates lower-level processes

Develop gradually over time

Exec Function: Metacognition

Exec Function: Self-Regulation

Levels of Brain Function

Basic Areas of Brain

Anterior Posterior

Inferior Superior

Brain Lateralization Oversimplified

Right side control

Right Hemisphere Visual-spatial

Simultaneous processing

Imagination

Left side control Frontal Lobe

Executive Functions

Basic Neurological

functions-WHAT happens NOW

„ Physiological functions „ Sensory functions „ Speech/Language „ Spatial „ Motor „ Memory of skills „ Memory of facts

Basic Executive

Function-Not

What

but

How

and

When

„

Round-A composition for two or more

voices in which each voice enters at a

different time with the same melody

„

Row,Row,Row Your Boat

„ Row, row, row your boat „ Gently down the stream „ Merrily, merrily, merrily „ Life is but a dream

EF metaphors

Conductor

CEO

Director

Pilot

Cook

Executive Functions

-Closer look at some components

„

Self-Regulatory functions

Inhibition

Shift/Flexibility

Emotional Regulation

Metacognitive functions

Working Memory

Problem-solving

„

Monitoring

Basic Executive

Functions-Self-Regulation of NOW

Inhibition

Behavioral

Cognitive

Shift/Flexibility

Emotional Regulation

EF- Balancing between

Inhibition and Initiation

STOP!

Basic EF

Dysfunctions-Inhibition

„ Ability to inhibit is the gateway to other EFs

„ Deficits in behavioral inhibition

„ “Impulsive”, “can’t stop when asked”

„ Deficits in cognitive inhibition

„ “Daydreams”, “off topic”

„ Deficit associated with Attention

Deficit/Hyperactivity Disorder

Stroop Task-1

Say the COLOR of the ink:

GREEN

YELLOW

RED

BLUE

BLACK

Stroop Task-2

Say the COLOR of the ink:

GREEN

YELLOW

RED

BLUE

BLACK

Anterior Cingulate activated

during Stroop task-PET Scan

EF Regulates Attention

„ EF as air traffic controller „ Vigilance

„ Scanning the radar screen „ Houselights

„ Selective attention „ Focusing on the blip „ Flashlight/Spotlight

„ Dividing Attention Adaptively

Basic EF

Dysfunctions-Shift/Flexibility Deficits

„ ADAPT as new information presents „ Shifts too quickly

„ “Distractible”, “Doesn’t finish”

„ Associated with AD/HD

„ Shifts too slowly

„ “Daydreams”, “off-topic comments”

„ Associated with ADHD Inattentive

„ “Rigid”, “Perseverative”

Basic EF

Dysfunctions-Emotional Regulation Deficits

„ Ability to inhibit allows modification of

emotional expression, selection of adaptive emotional response and activate emotion if needed.

„ Self-regulation of affect (Barkley 1997,2000) „ Deficits can present as:

„ “Over-emotional”, “over-sensitive”,

“immature”, “moody”, “easily frustrated”

Exec Function: Metacognition

Exec Function: Self-Regulation

“METACOGNITION”

Managing LATER

„

Working Memory

Problem-solving

Monitoring

Meta-cognition:

Non-Verbal Working Memory

„ “mental work space” “scratch-pad” „ Non-verbal WM enables

„ Hindsight, foresight

„ Mental representations „ Pattern recognition

„ Sense of time and events in time

„ Deficits result in:

„ Poor time management, not learning from past,

difficulty reading facial expressions, poorly sequenced behavior, social incompetence,

misplacing items, clumsiness, problems in math

Meta-cognition:

Verbal Working Memory

„ Holds language “on-line” while processing,

manipulating or waiting

„ “Self-talk”

„ Rule-governed behavior/reasoning „ Deficits result in:

„ Forgetfulness, “careless errors”, comprehension

problems, “rude” behavior

„ Associated with learning disabilities, language

Working

Memory-Hidden but critical

„ Limited capacity; “budget problem” „ Easily overwhelmed or overwritten

„ May do task components in isolation but not simultaneously “Forget to remember”

„ Timing and timeliness of access

„ Need for contingent, convergent, coordinated retrieval

„ Impact is on writing, reading comprehension and time management

„ Productivity, accuracy and behavior will vary with volume, complexity and/or level of adult

Meta-cognition:

Problem-solving

„ Problem-solving components

„ Prioritizing/goal selection

„ Analysis/synthesis (“reconstitution”) „ Strategy development and selection „ Planning/Organization

„ Deficits result in problems in:

„ Completing tasks efficiently, organizing materials,

formulating responses, sequencing activities, balancing work/leisure, coping with adversity, managing long-term tasks

Meta-cognition:

Monitoring and Motivation

„ Task Monitoring

„ Is it done? Is it done right? „ Self-Monitoring

„ Social feedback

„ Introspection/self-awareness: WHY DO IT? „ Deficits result in:

„ Poor quality of work, poor pacing „ “Egocentric”, socially “clueless”

„ Over- or under-estimating abilities/skills „ Motivation; self-activation

Organization / Executive Function Control

Developmental Progression

Development of EF

„ 7-8 months

„ Demonstrates working memory „ 3 years

„ Begins ability to inhibit disadvantageous decision „ 6 years

„ Attention becomes volitional „ Adolescence

„ Manipulate and integrate complex information

Powell KB, Voeller Kytja KS.

Gray matter development

Gogtay, Giedd et al PNAS 2004

Cortical thinning of attention and executive function networks in adults with ADHD

Makris N, Biederman J, Valera EM et al; Cerebral Cortex 2007; 17(6):1264-75

ADHD - overall cortical thinning especially in dorsolateral preforontal, anterior cingulate, posterior cingulate and inferior parietal (angular gyrus)

Organization / Executive Function Control

in ADHD and other EF dysfunctions

Effectiveness Productive Efficient Accurate Inconsistent Inefficient Limited output Task Demands Simple Complex

EF:

At the interface between brain and

environment

Hot off the presses

„ Impact of Early Behavior Disturbances on

Academic Achievement in High School; J

Breslau et al;

Pediatrics

„ Attention problems at 6 significantly predict

math and reading achievement at 17

„ “interventions that target attention problems

at school entry should be tested as avenue for improving educational achievement”

Executive Function Dysfunction

„ Universal experience

„ Experience dependent (expertise) „ Increased in:

„ Illness and fatigue states

„ Attention Deficit Hyperactivity Disorder „ Autism Spectrum Disorders

„ Learning Disability

„ Fetal Alcohol syndrome

„ Side effects of medications „ Drugs or alcohol

Executive Function

Dysfunction-2

„ Brain Injury (traumatic or acquired) „ Brain disorder (e.g. dementia, tumors) „ Partial complex epilepsy, frontal origin

„ Mental illness (e.g. schizophrenia, depression,

bipolar, OCD)

„ Tic disorders

„ Genetic disorders

„ Phenylketonuria, Turner syndrome, William’s syndrome

Velocardiofacial syndrome, Metachromatic

Assessment of EF - Real Life

„ Interviews including the child/adolescent

„ Observation especially less structured settings „ Work samples

„ List areas of strengths/weak SKILLS:

„ Starting/stopping/shifting „ Flexible or creative thinking „ Response to problem or

frustration „ Social skills

„ Learn from mistakes

ƒ Parts of tasks that need adult structure/support

ƒ Ability to plan tasks?

ƒ Homework/chore breakdowns ƒ How well organized?

ƒ Attending to the right thing? Long enough?

Assessment of EF

Medical

Psychiatric/Behavioral

Psychological/Educational

Neuropsychological

Neuroimaging if indicated

EEG if indicated

Assessment of EF

-Neuropsychological Testing

„ Wechsler Intelligence Scale for Children-4th

edition WISC IV (working memory)

„ Delis-Kaplan executive function system „ NEPSY subtests

„ Rey Complex Figure

„ Behavior Rating Inventory of Executive

Function (BRIEF)

Where is the breakdown?

„ Is there a knowledge deficit?

„ Is there a procedural skill deficit? „ Is it an executive function deficit?

„ Inhibition/Initiation „ Shift/Flexibility „ Emotional Regulation „ Working Memory „ Problem-solving/Organization „ Monitoring

EF Intervention

„ ADHD, Autism, TBI, LD literature

„ Effective programs emerging for children „ Heterogeneity confounds (Denckla 2007)

„ Specify the skills (strengths/weaknesses) „ Process oriented: Not what but how

„ Levels of Intervention „ Environment „ Task „ Child Dawson, Guare 2004 Meltzer 2007

EF Intervention: Environment-based

Procedures and Routines

„ Make life predictable „ Black/white; when-then „ Establish explicit routines

„ Home „ School „ Social „ Play „ Transitions „ Disciplinary routines „ Academic procedures

EF Intervention: Environment-based

School issues

„ Executive function not an special education

disability category

„ Special Education categories (partial list) „ LD, Autism, ADHD (under Other Health

Impaired), Neurological, Communication

„ Lack of understanding of executive function „ Accommodations

„ Skill development „ Adult support

EF Intervention: Environment-based

Adopt an EF Lifestyle

„ EF is learned in day to day

activities with real life problems

„ EF is developed by modeling

and supported practice

„ Keep an EF mindset when

engaging in tasks and externalize the process

Externalizing EF

„ Talk out loud and model

„ “Hmm. What do I need to do before I…?” „ “I will write that down here”

„ “Wow! That didn’t go as I expected! What are my

options now?”

„ “I’m too upset to think clearly. I need to take a walk.” „ “I wonder who I can ask for help about…?”

„ “We want to go on vacation in two months. I’m going

EF Intervention: Task-based

Setting them up to get it right

„ Make it part of a ROUTINE

„ Increase demand by increments

(scaffold/fade)

„ Break into smaller parts „ Make steps more explicit „ Make it visual (e.g. lists)

„ Prioritize tasks or task components „ Limited choices

EF Intervention: Child-based

Medical and Medication

„

Medical

„ Sleep, nutrition, medical problems

„

Medication

„ Attention problems

„ Stimulants, atomoxetine

„ Improves with self-regulation and focus in the

moment; not metacognition

„ Emotional problems

EF Intervention:Child-based

Building

Skills

„

Practice component skills in isolation

? Role of computerized training (e.g.

Klingberg 2005)

„

Strategy instruction

„ (Meltzer 2007,Marlowe 2000)

Summary

„ Executive functions are late developing,

higher order cognitive processes

„ EF delays/deficits are common „ EF remediation involves

„ Modifying the environment „ Structured practice

„ Strategy development „ Sometimes medication

Assorted resources

(for more references/resources write to [email protected]

„ Dawson, P, Guare R. Smart by Scattered: the revolutionary “Executive

Skills” approach to helping kids reach their potential. Guilford Press, NY

www.guilford.com; for parents (2009)

„ Meltzer, L (Ed). Executive function in education: From theory to practice

(2007). New York, NY, US: Guilford Press. (for educators)

„ The Disorganized Mind: Coaching your ADHD brain to take control of your

tasks, time, and talents, The New Self-Coaching Book for ADHD Adults by Nancy Ratey, Ed. M. St. Martin’s Press, April 2008 $24.95, 320 pages,

hardcover); also visit Nancy Ratey’s websites

www.thedisorganizedmind.com for information on self-coaching for ADHD.

„ http://www.aboutkidshealth.ca/ofhc/news/SREF/4144.asp for series of

parent-oriented articles on developmental perspectives on executive function.

„ Miller KJ. Executive Functions. Pediatric Annals.2005;34(4):310-317

„ Kochanska G, Coy KC, Murray KT development of self-regulation in the first