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

Transcription

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

2 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 where he put his keys

3 What are Executive Functions?

4 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

5 Exec Function: Metacognition Exec Function: Self-Regulation Basic Neurological Functions

6 Levels of Brain Function Neocortex- Rational thought Midbrain/ Limbic system- Automatic behaviors/ Emotions Brainstem- Survival/aggression

7 Basic Areas of Brain Anterior Posterior Superior Inferior

8 Brain Lateralization Oversimplified Frontal Lobe Left Hemisphere Language Sequential processing Logic Executive Functions Right Hemisphere Visual-spatial Simultaneous processing Imagination Routines Right side control Novelty Left side control

9 Basic Neurological functions- WHAT happens NOW Physiological functions Sensory functions Speech/Language Spatial Motor Memory of skills Memory of facts

10 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

11 EF metaphors Conductor CEO Director Pilot Cook

12 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

13 Basic Executive Functions- Self-Regulation of NOW Inhibition Behavioral Cognitive Shift/Flexibility Emotional Regulation

14 EF- Balancing between Inhibition and Initiation STOP! GO!

15 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 Barkley, 2000

16 Stroop Task-1 Say the COLOR of the ink: GREEN YELLOW RED BLUE BLACK RED BLUE BLACK YELLOW GREEN

17 Stroop Task-2 Say the COLOR of the ink: GREEN YELLOW RED BLUE BLACK RED BLUE BLACK YELLOW GREEN

18 Anterior Cingulate activated during Stroop task-pet Scan Images of Mind by Posner and Raichle 1994

19 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 Balancing vigilance and selectivity

20 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

21 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

22 Exec Function: Metacognition Exec Function: Self-Regulation Basic Neurological Functions

23 METACOGNITION Managing LATER Working Memory Problem-solving Monitoring

24 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

25 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 disorders, AD/HD

26 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 support/structure

27 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 Barkley 1997,2000

28 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 Disorganization; incompleteness

29 Organization / Executive Function Control Developmental Progression Productive Efficient Accurate Adult Effectiveness Inconsistent Inefficient Limited output Simple Task Demands Preschool Complex

30 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

31 Gray matter development Gogtay, Giedd et al PNAS 2004

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

33 Organization / Executive Function Control in ADHD and other EF dysfunctions Productive Efficient Accurate Effectiveness Inconsistent Inefficient Limited output Simple Complex Task Demands

34 EF: At the interface between brain and environment

35 Hot off the presses Impact of Early Behavior Disturbances on Academic Achievement in High School; J Breslau et al; Pediatrics (2009) 123(6):1472 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

36 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

37 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

38 Assessment of EF - Real Life Interviews including the child/adolescent Observation especially less structured settings Work samples List areas of strengths/weak SKILLS: Parts of tasks that need adult structure/support Ability to plan tasks? Homework/chore breakdowns How well organized? Attending to the right thing? Long enough? Starting/stopping/shifting Flexible or creative thinking Response to problem or frustration Social skills Learn from mistakes

39 Assessment of EF Medical Psychiatric/Behavioral Psychological/Educational Neuropsychological Neuroimaging if indicated EEG if indicated Laboratory studies if indicated

40 Assessment of EF -Neuropsychological Testing Wechsler Intelligence Scale for Children-4 th edition WISC IV (working memory) Delis-Kaplan executive function system NEPSY subtests Rey Complex Figure Behavior Rating Inventory of Executive Function (BRIEF) Brown Attention Deficit Disorder Scales

41 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

42 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

43 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

44 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 Coaching

45 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

46 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 to start planning now.

47 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 Provide criteria for completeness (rubric)

48 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 Anxiety, aggression, mood disorder

49 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) Practice problem-solving in context

50 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 Collaborative approach needed

51 Assorted resources (for more references/resources write to Dawson, P, Guare R. Smart by Scattered: the revolutionary Executive Skills approach to helping kids reach their potential. Guilford Press, NY 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 for information on self-coaching for ADHD. for series of parent-oriented articles on developmental perspectives on executive function. Miller KJ. Executive Functions. Pediatric Annals.2005;34(4): Kochanska G, Coy KC, Murray KT development of self-regulation in the first four years of life 2001 Child Devel 72: