Miller-Executive Function 1

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1 Miller-Executive Function 1 Karen J. Miller, MD: disclosure slide Executive Function Dysfunction: The Newest Learning Disability No financial disclosures No conflicts of interest Karen J. Miller, MD Boston, MA kmiller7@tuftsmedicalcenter.org Why talk about Executive Function? Basic Areas of Brain Hot topic Superior Anterior Posterior Key component of many disorders Key component of daily life problems Impacts clinical care and adherence Your understanding drives your intervention (Ross Greene) Inferior

2 Miller-Executive Function 2 New thinking is EFFORTFUL Executive Functions definition Naïve Practiced Novel Verb Generation task PET scans -Raichle 1994 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 fatigue states 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

3 Miller-Executive Function 3 Basic Neurological Functions 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 EF metaphors 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 Conductor CEO Director Pilot Cook

4 Miller-Executive Function 4 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 BRIEF rating scale Gioia et al,2000 EF- Balancing between Inhibition and Initiation Basic EF Dysfunctions- Inhibition STOP! GO! 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

5 Miller-Executive Function 5 Stroop Task Say the COLOR of the ink: GREEN RED YELLOW BLUE RED BLUE BLACK YELLOW BLACK 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 Monitoring

6 Miller-Executive Function 6 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 Deficits result in: Forgetfulness, careless errors, comprehension problems, rude behavior Associated with learning disabilities, language disorders, AD/HD 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 longterm 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 Disorganization; incompleteness Barkley 1997,2000

7 Miller-Executive Function 7 Development of EF Organization / Executive Function Control in ADHD and other EF dysfunctions 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 Effectiveness Productive Efficient Accurate Inconsistent Inefficient Limited output Typical EF Deficit Powell KB, Voeller Kytja KS. J of Child Neuro Simple Task Demands Complex 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) Assessment of EF Medical Psychiatric/Behavioral Psychological/Educational Neuropsychological Cultural Context

8 Miller-Executive Function 8 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) Attention Deficit Disorder Scales BOTTOM LINE: Where is the breakdown? Is there a knowledge deficit? Is there a procedural skill deficit? Is it a cultural difference in expectation? Is it an Executive Function deficit? 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) 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 Anxiety, aggression, mood disorder WRITE IT DOWN (Externalize brain)

9 Miller-Executive Function 9 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 Resources Supplemental Slides Dawson, P, Guare R. Smart by Scattered: the revolutionary Executive Skills approach to helping kids reach their potential.(2009) Guilford Press, NY for parents Ziegler Dendy CA. Teaching Teens with ADD and ADHD: A Quick Reference Guide for Teachers and Parents 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

10 Miller-Executive Function 10 Resources-2 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 The federally funded National Resource Center (NRC) website, toll-free number ( ); English and Spanish. Miller KJ. Executive Functions. Pediatric Annals.2005;34(4): Powell KB, Voeller Kytja KS. Prefrontal Executive Functions Syndromes in Children. J of Child Neuro. 2004;19(10);