Miller-Executive Function 1

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Executive Function Dysfunction

:

The Newest “Learning Disability”

Karen J. Miller, MD

Boston, MA

[email protected]

Karen J. Miller, MD: disclosure slide

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No financial disclosures

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No conflicts of interest

Why talk about Executive Function?

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Hot topic

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Key component of many disorders

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Key component of daily life problems

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Impacts clinical care and adherence

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Your understanding drives your intervention

–(Ross Greene)

Basic Areas of Brain

Anterior Posterior

Inferior Superior

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New thinking is EFFORTFUL

Naïve

Practiced

Novel

Verb Generation task PET scans -Raichle 1994

Executive Functions “definition”

•Variety of “higher-order” mental processes and

behaviors

•Enables self-regulation, problem-solving and

execution of goal directed behavior

•Integrates with lower-level processes

•Develop gradually over time

Executive Function Dysfunction

•Universal experience

•Experience dependent (expertise)

•Increased in:

–Illness and fatiguestates

–Attention Deficit Hyperactivity Disorder –Autism Spectrum Disorders

–Learning Disability –Side effects of medications –Drugs or alcohol

–Fetal Alcohol syndrome

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 leukodystrophy, Neurofibromatosis, Wilson Disease

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Exec Function: Metacognition Exec Function: Self-Regulation

Basic Neurological 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

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Executive Functions -Closer look at some components

•Self-Regulatory functions –Inhibition –Shift/Flexibility –Emotional Regulation •Metacognitive functions –Working Memory –Problem-solving –Monitoring

BRIEF rating scale Gioia et al,2000

Basic Executive Functions-

Self-Regulation of

NOW

•Inhibition

–Behavioral –Cognitive

•Shift/Flexibility

•EmotionalRegulation

EF- Balancing between Inhibition and Initiation

STOP!

GO!

Basic EF Dysfunctions-

Inhibition

•Ability to INHIBITis the gateway to other EFs •Deficits in behavioralinhibition

–“Impulsive”, “can’t stop when asked”

•Deficits in cognitiveinhibition –“Daydreams”, “off topic”

•Deficit associated with Attention Deficit/Hyperactivity Disorder

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Stroop Task

Say the COLOR of the ink:

GREEN

YELLOW

RED

BLUE

BLACK

RED

BLUE

BLACK

YELLOW

GREEN

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”

•Associated with Autism spectrum

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”

–Inability to “pump up”, “unenthusiastic”

“METACOGNITION”- Managing

LATER

•Working Memory

•Problem-solving

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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

–Associated with Non-Verbal LD

Meta-cognition:

Verbal

Working Memory

•Holds language “on-line” while processing, manipulating or waiting

•“Self-talk”

•Rule-governed behavior/reasoning

–Forgetfulness, “careless errors”, comprehension problems, “rude” behavior

•Associated with learning disabilities, language disorders, AD/HD

Meta-cognition:

Problem-solving

•Problem-solvingcomponents

–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

Barkley 1997,2000

Meta-cognition:

Monitoring and Motivation

•Task Monitoring

–Is it done? Is it done right?

•Self-Monitoring

–Social feedback

–Introspection/self-awareness: WHYDO IT?

–Poor quality of work, poor pacing –“Egocentric”, socially “clueless” –Over- or under-estimating abilities/skills –Motivation; self-activation

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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. J of Child Neuro. 2004

Organization / Executive Function Control in ADHD and other EF dysfunctions

E

ff

e

c

ti

v

en

es

s

Productive Efficient Accurate Inconsistent Inefficient Limited output

Task Demands

Simple _Complex Typical EF Deficit

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)

Assessment of EF

•Medical •Psychiatric/Behavioral •Psychological/Educational •Neuropsychological •Cultural Context

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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)

•Attention Deficit Disorder Scales

BOTTOM LINE

:

Where is the breakdown?

•Is there a knowledge deficit?

•Is there a procedural skill deficit?

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Is it a cultural difference in expectation?

•Is it an Executive Functiondeficit? –Inhibition/Initiation –Shift/Flexibility –Emotional Regulation –Working Memory –Problem-solving/Organization –Monitoring

EF Intervention:

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

–Actions speak louder than words (Model)

–Talk aloud about:

•WHAT you want to do (Goals)

•HOW you are going do it (Process)

•WHAT IF things go wrong (Plan B)

•NEXT TIME I’ll … (Monitoring)

•WRITE IT DOWN(Externalize brain)

EF Intervention:Medical and Medication

•Medical

–Sleep, nutrition, medical problems

•Medication

–Attention problems

•Stimulants, atomoxetine, guanfacine

•Improves with self-regulation and focus in the moment; not metacognition or management of LATER

–Emotional problems

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EF Intervention: School issues

•Executive function not an special education disability category

•Special Education categories (partial list)

–LD, Autism, ADHD (under Other Health Impaired), Neurological, Communication

•Emerging understanding of executive function

•Accommodations

•Skill development

•Adult support

–Coaching

Summary: Where did I put my head?

•Executive functions are late developing, higher order

cognitive processes

•EF delays/deficits are common

•EF remediation involves –Modifying the environment –Structured practice –Sometimes medication

•Collaborative approach needed

•We all experience EF moments

Supplemental Slides

Resources

• Dawson, P, Guare R. Smart by Scattered: the

revolutionary “Executive Skills” approach to helping kids reach their potential.(2009) Guilford Press, NY

www.guilford.com; for parents

• Ziegler Dendy CA. Teaching Teens with ADD and ADHD: A Quick Reference Guide for Teachers and Parents. 2000.Bethesda: Woodbine House;

• 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, 2008,for more information on self-coaching www.thedisorganizedmind.com

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Resources-2

• http://www.aboutkidshealth.ca/ofhc/news/SREF/4144.asp

for series of parent-oriented articles on developmental perspectives on executive function.

• CH.A.D.D (Children and Adults with Attention Deficit

Disorders). Information, parent support and resource for professionals. website www.chadd.org, The federally funded National Resource Center (NRC) website, http://www.help4adhd.org, toll-free number (800-233-4050); English and Spanish.

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

• Powell KB, Voeller Kytja KS. Prefrontal Executive Functions Syndromes in Children. J of Child Neuro. 2004;19(10); 785-797