Executive Functions: From Assessment to Intervention

Executive Functions: From Assessment to Intervention Presenters: Erin K. Avirett Jordana E. Mortimer Contributors: Denise E. Maricle, Ph.D. Daniel C. Miller, Ph.D. 1

OVERVIEW OF EXECUTIVE FUNCTIONING 2

What is Executive Functioning (EF)? Globally, EF refers to the array of cognitive abilities that contribute to make the brain a unique, organized, sophisticated structure. The set of processes needed for engaging in independent, purposeful, goal-directed behaviors. (Lezak, Howieson, & Loring, 2004) However, there is no mutually agreed upon definition or list of EFs, due to much debate regarding their roles and structure. 3

Popular Viewpoints Some equate EF to the intelligence s g. Conductor of an orchestra, Executive of a Company, or Football Coach view. EF = Cognitive Skill 4

Popular Viewpoints, cont. Some view EF as a set of supervisory skills, - Co-conductor and Coaching Staff view. EF EF EF EF EF EF 5

Popular Viewpoints, cont Others view EF as an umbrella term for a set complex cognitive skills. EF 6

Commonly accepted components response inhibition cognitive flexibility setting and achieving goals task initiation planning, organization, and time management abstract reasoning/ concept formation working memory attentional control controlling emotions and social behaviors self-monitoring and regulation/ metacognition 7

Executive Dysfunction (EDF) EDF may materialize from congenital abnormalities/ disorders, traumatic/acquired brain injury, brain lesions, developmental delays, or unknown etiology. Much of what science has learned about executive functions is through what is known of executive dysfunction. EDF can manifest in a multitude of different ways, typically associated with deficits in EF components. 8

EF Component Response Inhibition Cognitive Flexibility Setting and Achieving Goals Task Initiation Planning, Organization, and Time Management Abstract Reasoning/ Concept Formation Working Memory Attentional Control Controlling Emotions and Social Behaviors Self-Monitoring and Regulation/ Metacognition Associated EDF Area of Weakness Difficulty inhibiting responses; May blurt out answers; May seem to act without thinking Perseveration on thoughts, concepts, or tasks; Difficulty shifting tasks; Difficulty multitasking Difficulty setting appropriate goals and maintaining course; Difficulty generating individuals strategies for problem solving Reduction in self-generated behaviors; Procrastination Poor planning/ organizational skills; Inefficient use of time Use of concrete thinking; Difficulty understanding consequences and cause-effect relationships Difficulties accessing knowledge; Forgetfulness Poor attention; Distractibility Emotional lability; Poor frustration tolerance; A tendency to blame others Poor self-control; Reduced insight; Difficulty learning from past experiences 9

Neurophysiology Associated with the prefrontal cortex (PFC). One of the most well-connected parts of the brain. Three primary cortices/circuits responsible for EF: dorsolateral prefrontal cortex anterior cingulate cortex orbitofrontal cortex 10

Dorsolateral Prefrontal Cortex The last area (45 th ) to fully develop and myelinate. Typically thought to be responsible for classic EF functions. response inhibition setting and achieving goals organizational and planning strategies sustained/ shifting / divided attention short-term and working memory self-monitoring/ regulation verbal and design fluency 11

Anterior Cingulate Cortex controls behavioral processes related to the initiation and motivation for tasks/ behaviors responsible for: motivation and task initiation behavioral inhibition creativity selective/ divided attention working memory self-monitoring language responding to novelty 12

Orbitofrontal Cortex Involved with social and cognitive aspects of behavior that determine the emotional significance and social appropriateness of behavior. Some of the processes that are controlled by the orbitofrontal cortex include: tactfulness sensitivity emotional inhibition attention activity level 13

Stages of Development Development of PFC and EF begins in infancy and continues through late adolescence/ early adulthood. Development of EF skills generally moves from external skills (i.e. goal directed behavior) to internal skills (i.e. metacognition). Development occurs in age dependent growth spurts: Birth to 2 years 6 to 9 years Adolescence to early 20s 14

Development Birth through 2 years Basic EF processes, such as simple memory and attention, are apparent in early infancy. Infants rapidly learn new strategies and motor planning skills that aid in getting crucial needs fulfilled. The following associated EF processes are used: Organized search Goal directed behavior Response inhibition More advanced memory and attentional skills Social skills/ nonverbal signals 15

Development - Early and Middle Childhood Most significant period of EF development. Many EF processes related to the control of goaldirected behavior develop during this time, these include: basic inhibitory skills planning organizational strategies concept formation creative problem solving working memory Adult level maturation of these skills might not fully develop until adolescence or adulthood. 16

Development - Late Childhood, Adolescence, and Early Adulthood Maturation of the prefrontal cortex should be reached during this time. Some processes that may develop during this time include: the advanced coordination of working memory and inhibition complex planning and foresight visual working memory verbal fluency processing speed motor sequencing Self-monitoring regulation & metacognition 17

Disorders that Commonly Manifest EF Dysfunction EDF is strongly associated with components of the following childhood disorders: ADHD (attention and inhibition) SLD (self-regulation and monitoring, cognitive flexibility, and organizing and prioritizing tasks, problem solving) NVLD (cognitive flexibility, fluently shifting tasks/environments, adapting to novel situations, working memory, self-regulation, attentional control ) AU/ ASD (cognitive flexibility, fluently shifting attention to novel tasks, planning, appropriately responding to social cues, regulating social interactions, and nonverbal behaviors ) Tourette s Syndrome (inhibition) Sleep Disorders/ sleep deprivation Neurological impairments (i.e. TBI, epilepsy, tumors) 18

When is an EF Assessment Appropriate? Children with: Known or Suspected Neurological Disorder Past or Recent Head Injury w/ Academic of Behavioral Difficulties Acquired or Congenital Brain Damage Neuromuscular Diseases Brain Tumors Central Nervous System Infection or Compromise Hydrocephalus Neurodevelopmental Risk Factors Prenatal Exposure to Drugs and/or Alcohol ADHD SLD/ NVLD AU/ASD An unexplainable cognitive profile 19

Assessment of Executive Functions 20

Tests and Abbreviations Behavior Rating Inventory of Executive Function (BRIEF) Continuous Performance Test (CPT) Das-Naglieri Cognitive Assessment System (DN: CAS) D-KEFS (Delis Kaplan Executive Function System) Kaufman Assessment Battery for Children Second Edition (KABC-II) NEPSY-II A Developmental Neuropsychological Assessment (NEPSY-II) Neuroprocessing Concerns Checklist (NPCC; Miller, 2007) Test of Everyday Attention for Children (TEA-Ch) Test of Memory and Learning (TOMAL) Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) Wide Range Assessment of Memory and Learning Second Edition (WRAML-2) Wisconsin Card Sorting Test (WCST) Woodcock Johnson III: Tests of Cognitive Abilities (WJIII: COG) 21

History of EF Assessment Traditional roles in clinical neuropsychology. Tend to be used in adults rather than children. Tests often do not address the application of executive capacities directly to academic skill development. 22

Principles of EF Assessment All EF tasks also measure other information processing capacities. All measures of information processing and/or academic skills are also indirect measures of EF functions. No measure purely assesses the use of only one self-regulation executive function capacity. The amount and nature of executive functions that are involved in a task will vary greatly. 23

Principles of EF Assessment cont d EF embodies a wide array of processes that are seen only when brought into play by multiple measures. No single measure will provide an accurate estimate of an entire person s executive function capacities. Behavioral checklists, when used singularly, tend to overestimate executive impairments. Keep in mind that these are opinions of an individual s EF. EF assessments should be assessed in tandem with other abilities and skills. A multifaceted, comprehensive assessment is required to obtain the best understanding of an individual s functioning. 24

Approaches to Assessment No two EF tasks exactly measure the same EF construct. Examples: Inhibition CPT vs. Tower tasks Motor Programming Fingertip tapping vs. Hand Movements (KABC-II) Completing a task analysis is imperative. 1 25

Conducting an EF Assessment: How is it different? Semi-structured interview Generate hypotheses from information and how to collect data What additional questions should be asked that are related to EF functioning Parent, Teacher, Self Report Inventories Global behavioral rating scales EF inventories (BRIEF, Neuropsychological Processing Concerns Checklist) How can these supplement your EF assessment? Standardized Measures To be reviewed in the following slides 26

EF Component Response Inhibition Cognitive Flexibility Setting and Achieving Goals Task Initiation Planning, Organization, and Time Management Abstract Reasoning/ Concept Formation Working Memory Attentional Control Controlling Emotions and Social Behaviors Self-Monitoring and Regulation/ Metacognition Associated EDF Area of Weakness Difficulty inhibiting responses; May blurt out answers; May seem to act without thinking Perseveration on thoughts, concepts, or tasks; Difficulty shifting tasks; Difficulty multitasking Difficulty setting appropriate goals and maintaining course; Difficulty generating individuals strategies for problem solving Reduction in self-generated behaviors; Procrastination Poor planning/ organizational skills; Inefficient use of time Use of concrete thinking; Difficulty understanding consequences and cause-effect relationships Difficulties accessing knowledge; Forgetfulness Poor attention; Distractibility Emotional lability; Poor frustration tolerance; A tendency to blame others Poor self-control; Reduced insight; Difficulty learning from past experiences 27

EF Assessment Areas Concept Generation Inhibition Motor Programming Planning, Reasoning, Problem Solving Set Shifting Retrieval Fluency Attention Working Memory 28

Measures of Concept Generation D-KEFS: Card Sorting Test WCST WJCOG III: Concept Formation D-KEFS Test Materials 29

Measures of Inhibition Go-No-Go Tasks NEPSY-II Auditory Attention and Response Set Inhibition Statue Stroop Color-Word Test Similar tasks in D-KEFS and DN: CAS 30

Measures of Motor Programming Dean-Woodcock Sensory-Motor Battery Fingertip Tapping NEPSY-II Manual Motor Movements KABC Fingertip Tapping 31

Measures of Planning, Reasoning, and Problem Solving Traditional EF tests Category Tests Tower Tests Trail-Making Tests D-KEFS 20 Questions Tower Proverbs Word Context NEPSY-II Block Construction Tests of Cognitive Abilities KABC-II Conceptual Thinking Pattern Reasoning Rover Triangles WJIII-COG Concept Formation Planning Pair Cancellation Analysis-Synthesis WISC-IV Block Design Matrix Reasoning Picture Completion Picture Concepts WISC-IV Integrated Elithorn Mazes 32

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Measures of Set Shifting Category Tests D-KEFS Color-Word Interference Test (Condition 4) Design Fluency (Condition 3) Trail Making (Condition 4) Verbal Fluency (Condition 3) NEPSY-II Auditory Attention & Response Set (Response Set portion) Inhibition (Condition 3 Switching) Animal Sorting Stroop Tests Trail-Making Tests Wisconsin Card Sorting Test 34

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NEPSY-II Animal Sorting 36

Trail Making Test Condition 4 Number/Letter Sequencing Assesses complex mental processes of cognitive flexibility, multi-tasking, simultaneous processing, and divided attention. 5 4 C 3 B Start 1 E End D A 2 This time I want you to switch between connecting the numbers and letters. 37

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Measures of Retrieval Fluency Non-verbal D-KEFS Design Fluency (Conditions 1 & 2) NEPSY-II Design Fluency Verbal D-KEFS Verbal Fluency (Conditions 1 & 2) NEPSY-II Verbal Fluency WJIII-COG Retrieval Fluency 39

Design Fluency Test Condition 1 Filled Dots Assesses aspects of non-verbal productivity/creativity and visual-perceptual speed. Connect empty dots only. Use a different design in each square. Use only 4 straight lines to connect dots. Each line touches at least one other line at a dot. 40

EF Assessment of Attention Selective D-KEFS Color Word Interference Test NEPSY II Auditory Attention & Response Set WISC-IV Coding & Symbol Search WJIII-COG Auditory Attention TEA-Ch Sustained Continuous Performance Tests NEPSY II Auditory Attention & Response Set TEA-Ch: Score!; Score DT; Walk Don t Walk WISC-IV Cancellation Shifting -D-KEFS: Trail Making (C-4); Verbal Fluency (C-3); Color- Word Interference Test (C-4); Design Fluency (C-3) - NEPSY-II Response Set (Auditory Attention) -Wisconsin Card Sort Test -TEA-Ch 41

Measures of Working Memory WISC-IV Digit Span Letter-Number Sequencing WISC-IV Integrated Digit Span: Backward Letter-Number Sequencing Process Approach Spatial Span: Backward WJIII:COG Numbers Reversed Auditory Working Memory TOMAL Digits Backward Letters Backward WRAML-2 Symbolic Working Memory Verbal Working Memory 42

Linking EF to Academics 43

Examples of EF Problems in Reading Skills Reading Decoding poor use of one or more self-regulation EF s (lack of attention to specific letters in words). Rapid Automatic Naming poor executive control of language fluency processes. Reading Comprehension poor direction of EF processes when reading for meaning. 44

Examples of EF Problems in Writing Skills Poor graphomotor control and lack of automaticity for handwriting. Poor organization of written material. Poor retrieval cueing or poor generation cueing (idea generation or idea fluency when writing). Inability to use multiple self-regulation EF s at one time (hold, manipulate, retrieve, generate, execute). 45

Examples of EF Problems in Mathematics Poor cueing and monitoring when doing calculation routines. Poor ability to organize, manipulate, and retrieve when setting up calculations or problems. Poor ability to execute when learning or applying rote knowledge. 1 16 +17? 46

Interventions 47

Important Considerations for EF Interventions Typical EF development should be taken into account when designing interventions for EF. Since developmental progression of EF skills moves from the external to the internal, interventions should match. A lot of external support (i.e. preferential seating, reinforcements) may be needed at first, but should gradually fade out. EF skills can be intervened in one of two ways at the level of the environment, or at the level of the individual 48

Environmental Interventions Environmental supports Increased supervision Preferential seating/ placement Daily rules & routines Visual & verbal cues Incentive systems Task Modification Breaking tasks into pieces, with breaks Using close-ended tasks Building in variety and choice in tasks 49

Person-Centered Interventions Generally speaking, EF difficulties are associated with suboptimal brain function. Interventions may be: Compensatory strategies that are used for dealing with EF deficits Teaching EF skills that have not yet developed Rehabilitating damaged EF skills Brain function can be altered through intervention. Interventions can activate the use of intact brain function. 50

Compensatory Strategies Strategies that an individual with neurological deficits uses to improve performance and behavioral skills. Self-talking through steps of an assignment; Thinking out loud Using planners/ schedules/ checklists/ lists Rehearsal strategies for memory Learning cool down procedures 51

Teaching EF skills Some children require more than incidental learning to master EF skills Directly teaching EF skills involves several broad steps: 1. Describe the problem behaviors to child 2. Describe what target behavior/ skill looks like 3. Set a goal 4. Set a procedure for reaching the goal 5. Supervise the child following the procedure 6. Evaluate process and make changes as necessary 7. Gradually fade supervision 52

Rehabilitating EF skills Attempting to alter brain function by specifically targeting suboptimal functioning Game-based approaches Play-based approaches Book therapy Art therapy Social skills groups 53

How does RtI fit in? Which intervention is used at what tier depends on the specific needs of the classroom, small group, and individual child. Interventions should be based on very specific goals and interim goals. Data/ progress monitoring This also gives the student a very concrete image of how they are progressing towards their goals. Initiating Tasks 54

References Anderson, V., Levin, H.S., & Jacobs., R. (2002). Executive functioning after frontal lobe injury: A developmental perspective. In Stuss, D.T. & Knight, R.T. (eds.) Principles of Frontal Lobe Function (pp. 504-527). New York: Oxford University Press. Avirett, E. & Maricle, D. (in press). Executive Function. In S. Goldstein & J. Naglieri (Eds.) Encyclopedia of Children Behavior and Development. New York, NY: Springer. Avirett, E. & Maricle, D. (in press). Executive Dysfunction. In S. Goldstein & J. Naglieri (Eds.) Encyclopedia of Children Behavior and Development. New York, NY: Springer. Bradshaw, J.L. (2001). Developmental disorders of the frontostriatal system: Neuropsychological, neuropsychiatric, and evolutionary perspectives. East Sussex: Psychology Press, LTD Cooper-Kahn, J., & Dietzel, L. (2008). Late, lost, and unprepared: A parents guide to helping children with executive functioning. Woodbine House, Inc.: Bethesda, MD. Dawson, P. & Guare, R. (2004). Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention. Guilford Press: New York. Dawson, P., & Guare, R. (2009). Smart but Scattered. Guilford Press: New York. Goldberg, E. (2002). The executive brain: Frontal lobes and the civilized mind. New York: Oxford University Press. 55

References, cont. Hale, J. B. & Fiorello, C. A. (2004). School Neuropsychology: A Practitioner s Handbook. Guilford Press: New York. Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004). Neuropsychological assessment (4 th ed). New York: Oxford University Press. Maricle, D., Bauman, W., & E. Avirett. (2010). Best practices in the assessment of executive functioning in children. In D. Miller (Ed.). Best practices in school neuropsychology: Guidelines for effective practice, assessment, and evidencedbased intervention. New York: John Wiley & Sons, pp. 599-640. McCloskey, G., Perkins, A., & Divner, B.V. (2009). Assessment and Intervention for Executive Function Difficulties. Routledge: New York. Meltzer, L. (ed.). (2007). Executive function in education: From theory to practice. The Guilford Press: New York. Miller, D. C. (2007). Essentials of School Neuropsychological Assessment. John Wiley & Sons: New Jersey. (Can get NPCC from book) Stuss, D.T., & Alexander, M.P. (2000). Executive functions and the frontal lobes: A conceptual view. Psychological Research, 63, 289-298. Welsh, M.C., Pennington, B.F., & Groisser, D.B. (1991). A normative-developmental study of executive function: A window of prefrontal function in children. Developmental neuropsychology, 7(2), 131-149. 56