Milton J. Dehn, Ed.D. NYASP Conference Fall 2017 Identifying Specific Executive Function Deficits That Guide Intervention Milton J. Dehn, Ed.D. NYASP Conference Fall 2017

Notice of Copyright 2017 These PowerPoint slides are copyrighted by Milton J. Dehn and Schoolhouse Educational Services, LLC. They are not to be reprinted, copied, or electronically disseminated without written permission. To obtain permission, email milt@psychprocesses.com.

Workshop Topics An In-Depth EF Assessment EFs and Academics How the MEFS Depth Guides Interventions Case study Interventions for the Classroom

New Directions for EF Assessment More than just an ADHD assessment component Should be part of all youth psychological evaluations, including SLD and Autism Depth of assessment should match the depth of executive functions Differentiate between academic and social-emotional EFs Identify EF production deficits Link more directly to specific EF interventions

Executive Functions A complex construct There are many different EFs Different theories Different from intelligence (correlate .2 - .3) Cues and controls cognition, emotion, social functioning, and behavior Have a neurological basis Conscious and unconscious Important for academic learning and production

EF Definitions Directive capacities Supervisory system with multiple parts Cue the use of other mental capacities such as cognitive abilities but are not those capacities themselves “Purposeful, organized, strategic, self-regulated, goal-directed processing of emotions, thoughts, and actions”

Executive vs Cognitive Executive includes both abilities and skills EF’s are measured in cognitive scales Directly: Working Memory, Planning, and Attention Indirectly during any cognitive testing task From a neuropsych perspective, these are prefrontal cortex abilities

WM: Both Executive and Cognitive The executive dimension of WM supervises short-term memory (a cognitive process) The executive aspect of WM inhibits, shifts, and updates The executive aspect of WM supports cognitive processes such as fluid reasoning The executive aspect of WM cues the use of an executive skill/strategy, such as rehearsal

Is There a “g” of EF? Factor analysis does not prove that EF is one “thing” in the brain or one function Rather, “Co-conductors” that collaborate Thus, the development of EF’s can vary; can be specific strengths and weaknesses Domain’s have their own EFs; e.g. language Efs also differ by environment or “arena” Saying that EF in general is weak is not especially helpful in understanding the problem, child, or developing an intervention

EF Self-Awareness How self/mind functions Self-analysis Appraisal of self is accurate How one is perceived by others Self-monitoring Knowing one’s strengths and weaknesses Setting goals: short- and long-term Strategic knowledge

Awareness of Others & Environment Is attentive to others and environment Perceives cues from others Perceives cues from the environment Interprets cues correctly When cues are perceived, higher level executive functions select and directs EF skills, such as planning

Self-Regulation EFs These are what are typically considered EFs Cue and direct how we feel, think, and act Can self-regulate without being consciously aware McCloskey theory and McCloskey Executive Functions Scale (MEFS) has 31 specific self-regulation EFs (see image)

McCloskey (MEFS) Self-Regulation EFs Perceiving Focusing Sustaining Initiating Energizing Inhibiting Stopping Pausing Being Flexible Shifting Monitoring Modulating Correcting Balancing Sensing Time Pacing Using Routines Sequencing Holding/Working Storing/Retrieving Gauging Anticipating Estimating Time Analyzing Evaluating Generating Associating Organizing Planning Prioritizing Deciding Link to Item Examples

McCloskey (MEFS) Self-Regulation Clusters Attention Engagement (initiating, inhibiting, flexible) Optimization (monitoring, correcting) Efficiency (pacing, using routines) Memory (holding/working, storing/retrieving) Inquiry (anticipating, analyzing) Solution (organizing, planning, deciding)

Higher Level EFs (McCloskey) These develop later, adolescence typically Have low correlations with self-regulation Self-Realization is a sense of self and others Theory of mind Self-awareness Sense of personal strengths and weaknesses Can enhance self-regulation, but not always Self-Determination Goal setting and long-term planning

Arenas of Involvement (McCloskey) EF’s vary greatly by situation, environment, and domain of functioning Intrapersonal (internal processes) and Interpersonal (social) (these two combined on MEFS) Autism has deficits in this arena Academic (symbol system) Language and academic learning LD often deficient in this arena

Neurological Basis of EF Control center in prefrontal cortex (PFC) Each EF has its own pathway through the frontal lobes and with other parts of brain Connectivity is important for EFs functioning Executive working memory, attentional control, and fluid reasoning also located in PFC Inhibition is a fundamental function of the PFC; it underlies attention and WM

Prefrontal Cortex Image

Development of EFs Begin to develop in early infancy E.g., choosing where to look Control of actions The different EFs are on different developmental tracks and rates Major developmental advances in adolescence Development is not under the child’s control

Development of EFs Initially cued by external demand Then become more internally driven Complying with external EF demands requires more mental effort and greater control capacity than internal (ADHD) Females more advanced than males in most EFs at all ages except elementary years (MEFS study)

EFs and Misattributions Misattributions: Laziness, apathy, irresponsible, lack of motivation, lack of respect for authority Poor study skills Low intelligence

EFs and Other Disorders Executive deficits are evident in every neuropsychiatric disorder (does not mean they are the cause) Examples: ADHD, Anxiety, ODD, CD, SLD autism Can have executive deficits without having a disorder

EF and Academic Learning EFs are good predictors of achievement EF deficits more evident in production problems (homework) than acquiring academic skills Production deficit: has the academic skills, but does not demonstrate/apply them May be that teacher provides more executive controls during skill learning Influence skill development in math and wr. language EF demands increase in middle & high school In middle school, there is a mismatch between demands and students’ EFs developmental level

EF and Reading Comprehension Important EFs: Focusing, Sustaining, Organizing, Planning, Shifting, Inhibiting, Monitoring, Holding/Working, Generating, Associating, Storing/Retrieving, Balancing

EF and Math EFs needed for math computation include: Focusing, inhibiting, storing/retrieving, monitoring, and correcting For math reasoning/problem solving, planning is important

EFs and Written Expression Of all academic skills, is the most impacted by EF difficulties EFs needed to integrate the various processes, abilities, and skills when writing. Such EFs include: Sustaining, gauging, holding/working, organizing, planning, balancing, monitoring, correcting, generating, associating

EF and SLD Identification A deficit in executive functioning (general or specific) is a “processing” deficit that can be used to document a processing deficit for SLD In Pattern of Strengths and Weaknesses (PSW) approach EF scores are compared with scores of other processes The Psychological Processing Analyzer (PPA; Dehn) includes EF scores and statistically determines PSW

Assessment of EF Should be a component of every psychological/educational evaluation It determines success/failure; influences all aspects of functioning Provides insights into what underlies, behavior, social functioning, learning, etc. May be more informative than an FBA Kids with EF deficits are the ones who get referred first for every type of disability

EF Assessment Challenges Assessments focus primarily on EF with symbolic material (academic learning arena) Direct assessments provide much EF support Each scale structures the EFs differently Scales don’t assess for different arenas Rating items are mostly general, not specific E.g., the BRIEF Working Memory subscale has other EFs: Focus, Select, Modulate, Organize, Monitor, Execute, Direct

Problem with Direct Standardized Testing of EFs Standardized tests provide structure, focus, short intervals; reduce need for EF functions May lack validity for the individual. Typically, overestimate the EF abilities and skills Multiple EFs are required by each task The tasks also require cognitive processes that are difficult to separate out The assessment task is not a real world task

Rating Scales vs Standardized Tests Some studies have found rating scales to be more valid assessment of EFs than direct testing for reasons on previous slide Rater is observing many aspects of EF; tests only sampling a few Rating scales can be just as valid and reliable if they pass validity scale criteria, e.g., consistency and negativity

MEFS Standardization and Norming 254 Teacher raters, 167 cities, 29 states Ages 5-19; N = 1,000; 5 age groups Matches U.S. demographics well 17% of norming sample: disability/disorder Online data collection 110 Items <15 minutes to complete

MEFS Structure 7 Self-Regulation Clusters 31 Self-Regulation EFs Also, Self-Realization and Self-Determination Two arenas: Academic and Self/Social Identifies strengths and deficits across self-regulation EFs by arena Individual item analysis

Directive EFs vs EF Skills Directive EFs: Becoming aware of the need to cue and then cuing and directing its executive skill counterpart, such as planning Equivalent to construct of metacognitive awareness Expressive Executive Skills: The actual expression of the EF skill, such as planning Having the EF skill, but not expressing it because it has not been cued is an “EF production deficit”

Working Memory (WM) Example WM Directive Cues Noticing you just forgot something Recognizing it will be difficult to remember EF Skills Review your previous thoughts Write it down Rehearsal Chunking Visualizing

Unique Rating Structure Identifies Different Types of EF Deficits Rating Description Strengths or Deficits 5 – Almost always does on own without prompting 4 – Frequently does on own without prompting 3 – Seldom does it on own without prompting 2 – Does it, but only after prompting 1 – Only does it with direct assistance 0 – Unable to do even with assistance 5 and 4 – Executive Function Strength (has both directive function and expressive skill) 3 and 2 – Executive Function Deficit (directive EF lacking but has expressive skill) 1 and 0 Executive Skill Deficit (the executive skill is lacking; can’t do even when cued)

Gender Differences on MEFS At all age levels, females significantly better EFs on Engagement and Optimization clusters Ages 5-6, females better on all self-regulation clusters except Memory Ages 7-8, females better only on Engagement and Optimization Ages 9-10, females better on all except Efficiency and Memory Ages 11-18, females better on all clusters

EF Correlation with Academic Skills Teachers rated student’s overall academic skill level Below average students had the lowest EF scores, and above average the highest Significant differences by academic skill level for all MEFS clusters, regardless of disability status

MEFS SLD Profile (n = 48) Percentages of SLD students rated as having EF deficits in Academic EFs ranged from 8% (Engagement) to 42% (Solution) Percentages of SLD students rated as having Academic EF strengths ranged from 33% (Attention) to 3% (Memory) Compared with non-SLD were significantly weaker on all 7 MEFS clusters, both academic and Self/Social (about a standard deviation weaker on most clusters)

MEFS ADHD Profile (n = 47) ADHD sample had significantly lower scores on MEFS clusters in both academic and self/social arenas, except for the Memory cluster The majority of the differences were around one half of a standard deviation Those on medication did not have significant differences on Memory, Efficiency, and Self-Realization and self/social under Solution Better on EF clusters than SLD sample

MEFS Autism Profile (n = 38) Autism sample had significantly lower scores on all MEFS clusters in both academic and self/social arenas The majority of the differences were around one standard deviation

Case Study 12 year old, 6th grade female WJ IV GIA of 71; ST WM a strength (95) Academic skills 2nd to 4th grade level She is in unstructured charter school project-based regular ed. class; performance is poor No interest in learning Can shut down and become noncompliant Can be socially appropriate when she chooses to

Case Study MEFS Results MEFS completed by classroom teacher All cluster scores 1st percentile except Memory No EF strengths EF Deficits and Executive Skills Deficits are fairly even, meaning she can perform some self-regulation EFs when prompted and thus has the capacity/skill for these EFs Has more EF deficits under academic than self/social, consistent with underachievement indicators on the WJ IV NEPSY-II EF scaled scores are 7-12, majority around 9 Why? See Report

EF Assessment to Intervention Identify MEFS strengths and weaknesses At the cluster level At the cluster level by arena: Academic vs Self-Social At the specific self-regulation executive function level At the item level within each specific self-regulation Report The items suggest specific skills to teach or to teach self-cueing of

MEFS Autism Case Study The items identify specific skills that need teaching or available skills that need to be self-cued Quick Gains: develop more self-cueing for skills that are already there Talk about situations, stimuli that mean it’s time to engage the skill, e.g., someone says, “Hello” means it time to focus on what the other person is saying and respond Practice responding to cues

Autism Case Continued Some Executive Skills that are deficient may also be prioritized These skills need to be taught Assess whether they are being cued; if not, also train the self-cueing Sometimes the child is aware of the need (is being cued) and has the directive capacity but does not have the skill; does not know how to do it Review examples in MEFS report

Autism Case Continued Review number of responses under Strengths, EF Deficits, and Exec Skills Deficit columns while contrasting Academic and Self/Social arenas Engagement stronger socially than academically Inquiry and Solution stronger socially than academically What is the priority arena: Academic or Self/Social

Autism Case Continued Decide to focus on Solution in the Academic arena Thus, needs skills training in Generating (ideas), Associating (seeing connections between ideas), Organizing (thoughts), Planning, Prioritizing, and Deciding Then look at item responses under these self-regulation EFs

Autism Case Continued Examples of specific items that identify the specific executive skills that need to taught Examples of specific items the identify the type of self-cuing and self-directing that needs to be taught

Self-Realization & Self-Determination Different rating system than self-reg. items Frequency only Begin to emerge at age 10 Fairly well developed at age 14 Strengths below age 14 are advanced development

Case Study Self-Realization and Self-Determination Awareness and goal setting is emerging Percentiles are higher than for self-regulation skills Not a priority at this time

EF Assessment to Intervention Prioritize; select EF’s to work on first based such considerations as: Safety of self and others Ability to function independently Social vs Academic Parent goals Self goals Environmental modifications necessary when EFs are very deficient

EF Intervention Considerations Don’t assume the child has conscious control over the EFs in question Directive EF deficits: Skill is present; needs to be taught how to recognize cues If EF skills are lacking, then they need to be taught before cuing is taught When skills taught, metacognitive (awareness) component needs to be embedded

Metacognitive (Awareness) Emphasis “Thinking about thinking” Applies to all EF Deficits and EF Interventions Teach child how EF works Inform child of strengths and weaknesses Teach how to control, apply, use the EF skills Emphasize personal efficacy of intervention Includes strategy knowledge and application Teach conditional strategy knowledge: how, when, where, why

General EF Intervention Guidelines Model effective EF use (think aloud) Focus on making child aware of the EF’s needed to accomplish a task Begin with external control when there are directive EF deficits Gains may be minimal and progress slow Have reasonable expectations Teach specific executive functions as skills routines The end goal is the internalization of directive capacities and skills that can be accessed

Environmental Modifications for Poor Inhibition Increase external controls Restrict access to things that cause problems Increase supervision Create ways to cue child to control impulses “What should you do when this happens?” Teach child to ask himself specific questions in problem situations “Did I get too close?”

Executive Functioning: Planning Developing planning improves math performance (Naglieri’s study; ATI) Discuss benefits of plans Learn how to plan step-by-step Develop plans Verbalize them Implement them and evaluate Practicing planning steps with a variety of materials and situations

Problem-Solving Steps Define the problem Brainstorm solutions Pick a solution Implement the solution Review the results

Questions to Ask Self When Planning and Problem Solving What prior knowledge do I have than can help with this task? What strategies should I use? What should I do first? How am I doing? What adjustments to I need to make? How did I do? What could I have done differently?

Attention Self-Monitoring Research documents efficacy of this method Works because it increases the EF Directive (self-cuing) aspect Increasing self-monitoring increases on-task behavior, extends sustaining attention Assumes the EF skill is adequate

Attention: Self-Monitoring Teacher, or device carried by student, cues student at variable intervals, 1 - 5 minutes When cued, student marks monitoring sheet regarding behavior when cue occurred or behavior since last cue When teacher is cueing, she also provides her rating alongside student’s; student receives bonus point when ratings match Set a points goal that student is working for, easy at first, then keep adjusting upward Link Reinforcement system is helpful

EF Strategies for the Whole Class (Meltzer): Metacognitive Instruction Recognize the purpose of a strategy (basically an EF Skill) Recognize the benefits of a strategy Teach conditional strategy knowledge: how, when, where, why to use the strategy When students understand the above, they personalize and generalize strategies and persist at using them

EF Strategies for the Whole Class (Meltzer): Goal Setting Short-Term and Long-Term goals Makes students more motivated when they set goals themselves Identify the steps involved Visual the steps Breaking tasks into manageable parts Identify the strategies needed Includes planning and time management Example of a college class

EF Strategies for the Whole Class (Meltzer): Flexibility and Shifting Shifting examples: from one approach to another, from one process to another, from the main ideas to the details, from writing to editing, from reading to computing Flexibility examples: interpreting information in different ways, solving math problem in different ways, studying differently for different kinds of tests

EF Strategies for the Whole Class (Meltzer): Organizing and Prioritizing Prioritize based on level of importance Allocate time based on priority Teach them to impose their own structure on the task Organize concepts, such as semantically Organize materials and work space Graphic organizers Following a rubric for writing

EF Strategies for the Whole Class (Meltzer): Working Memory Learn how to manage cognitive load What is cognitive load? Using rehearsal Chunking and visualizing Using long-term memory mnemonics, such as keyword

EF Strategies for the Whole Class (Meltzer): Self-Monitoring & Checking Review progress towards goals Reflect on strategy use Develop and use personalized checklists Use self-cuing

Increasing Homework Completion Organizing materials Using an assignment notebook Time Management Getting started on homework Don’t provide too much help; guide student through the processes needed Routinely preview and review upcoming tasks

EF Strategies Working Memory Learn how to self-manage cognitive load Using rehearsal Visualizing

Free Recorded Webinar on the MEFS An hour in length Can be accessed at: https://attendee.gotowebinar.com/recording/8207945938457043202 NOTE: An internet search for the MEFS will bring up the Minnesota Executive Functions Scale. This is NOT McCloskey’s Executive Functions Scale (the real MEFS)