Why They Don’t Show What They Know: Understanding and Helping the Child with Executive/Regulatory Difficulties Steven C. Guy, Ph.D. Columbus, Ohio

Goal ê Develop conceptual foundations in executive functions ê Increase awareness of how executive functions impact assessment and treatment ê Develop skills to screen and assess aspects of executive control functions ê Develop intervention strategies

Plan 1. Introduce definitions and concepts 2. Review neurodevelopmental underpinnings 3. Critically review assessment methods 4. Learn to use a new rating scale of executive function 5. Present illustrative cases

“So, what are these executive function things? Are they real? Are they a fad? Tell me what we need to know.” S. Leviton circa 2/2001

IN THE HUNT FOR EXECUTIVE FUNCTIONS

What are the Executive Functions? u “An “umbrella” term, encompassing… those interrelated skills necessary for purposeful, goal-directed activity” ( Anderson, 1998) u “Capacities that enable a person to engage successfully in independent, purposeful, self-serving behaviors” (Lezak, 1993)

Executive Function Definitions u Orchestration of basic cognitive processes during goal- oriented problem-solving (Neisser, 1967) u Ability to maintain appropriate problem-solving set for attainment of future goal (Welsh & Pennington 1988). Involves one or more of the following: 3 intention to inhibit/defer response 3 strategic plan of action sequences 3 mental representation of the task including relevant stimulus information and desired future goal state.

Executive Function Definitions u "The planning and sequencing of complex behaviors, the ability to pay attention to several components at once, the capacity for grasping the gist of a complex situation, the resistance to distraction and interference, the inhibition of inappropriate response tendencies and the ability to sustain behavioral output for relatively prolonged periods” ( Stuss & Benson, 1984 ).

Components of Executive Function u Stuss & Benson (1986): 3 Anticipation 3 Goal Selection 3 Planning 3 Monitoring 3 Use of Feedback u Fuster (1985): 3 "Mediation of cross-temporal contingencies" 3 Temporally retrospective function of working memory 3 Temporally prospective function of anticipatory set 3 Interference control to suppress goal-incompatible behavior

Critical features of Executive Control Functions (Denckla 1995) 4 Provide for delayed responding 4 Future-oriented 4 Strategic action selection 4 Intentionality 4 Anticipatory Set 4 Freedom from interference 4 Ability to sequence behavioral outputs

Components of the Executive System Awareness of one’s strengths/weaknesses Awareness of one’s strengths/weaknesses Ô Set realistic goals for oneself Ô Plan and organize behavior to achieve goals Ô Initiate behavior in pursuit of goals Ô Inhibit behavior incompatible with goals Ô Monitor performance in relation to goals Ô Flexibly and strategically, shift behavior with obstacles that interfere with goal pursuit

Functional Domains of The Executive 3 Inhibit - stop an action or not react to impulse 3 Shift - move from one task or situation to another 3 Emotional Control - regulate emotional response 3 Working Memory - hold information actively in mind 3 Initiate - begin task, activity, attention 3 Plan - anticipate future events and develop steps 3 Organize - establish, maintain order 3 Self-monitor - attend to behavior/output; revise

Behavioral Descriptors u Initiate: 3 trouble starting chores 3 "couch potato" 3 relies on others to structure time, tasks u Sustain: 3 starts strong but fades across tasks 3 attention/concentration wanes u Inhibit: 3 blurts out 3 acts quickly without regard to consequences 3 distracted, sidetracked u Shift: 3 stuck on a topic or activity 3 poor flexibility 3 resists change in routine

u Self-monitor: 3 unaware of impact of own behavior 3 makes careless errors 3 doesn't check work u Plan: 3 does assignments at last minute 3 underestimates time needed Behavioral Descriptors: u Organize: 3 worse in chaos 3 not a leader with peers 3 messy 3 homework poorly organized Working Memory: 3 Cannot remember multi- step instructions

Relationship to Other Functions u " conductor of the orchestra" u “CEO of the corporation” u “general of the army” u "domain general processes” u "supramodal" u "central processes

Executive Functions as the “Conductor of the Orchestra”

Functions of the “Conductor” 1. Initiate goal-oriented action 2. Working Memory 3. Plan & Organize 4. Self-monitor & evaluate 5. Inhibit 6. Flexibility 7. Emotional regulation 8. Self-awareness

Functions of the “Orchestra” 1. Perception 2. Conceptual thinking 3. Language processes 3. Visual-spatial processes 4. Memory 5. Sensory inputs 6. Motor outputs 7. Emotion 8. Knowledge & skills social non-social

The Conductor in Charge

Functions of the “Conductor” 1. Initiate goal-oriented action 2. Working Memory 3. Plan & Organize 4. Self-monitor & evaluate 5. Inhibit 6. Flexibility 7. Emotional regulation 8. Self-awareness Functions of the “Orchestra” 1. Perception 2. Conceptual thinking 3. Language processes 3. Visual-spatial processes 4. Memory 5. Sensory inputs 6. Motor outputs 7. Emotion 8. Knowledge & skills social non-social

Demand Situations for Executive Functions u Novelty vs Automaticity (lack of experience base) u High vs low stress u Future vs present orientation u Intentional action selection u Multi-step tasks/ learning

Dysfunctional Domains of The Executive 3 Initiate - deficits beginning task, activity 3 Working Memory - difficulties holding information actively in mind 3 Inhibit - problems stopping an action 3 Shift - difficulties moving from one task or situation to another, perseveration, rigidity 3 Plan - deficits anticipating future events and developing steps/contingencies 3 Organize - problems establishing, maintaining order 3 Self-monitor - lack of attention to own behavior or performance 3 Emotional Control - deficits regulating emotional response

Outcome of “Good” Executive Function u Purposeful, goal-directed activity u Active problem solving u Self-control u Independence u Reliability and consistency u Positive self-efficacy u Internal locus of control

Developmental Tasks è Infancy: stimulus driven; early cause effect relationships, initiates and maintains attention and intention, inhibits incompatible behavior with goal è Preschool: Inhibitory abilities actively developing, initiation established è Elementary: Inhibitory functions established, planning, organization, self-monitoring developing but situational è Adolescence: Final stages of planning, organizing, self- monitoring, flexibility.

Disorders of Executive Function u No singular, core disorder u Symptom onset delayed due to environmental demand u Performance on standardized tests often appropriate u Discrepancy between ability and performance u Social domain most challenging

Contribution of EF to Other Disorders u Language-based Learning Disability 3 Reading (comprehension, monitoring) 3 Writing & Organization (basic mechanics, coherency) u Visual/Nonverbal LD 3 Visual problem solving 3 Visual organization 3 Mathematics difficulties u The "Social Executive“/PDD u Psychiatric symptoms (depression, anxiety, impulse control disorders)

The Social Executive Eslinger (1996) u The social disability in EF is frequently distinctive u Uses "frontal lobe" patients to define problems as: 3demanding and self centered 3lack of social tact and restraint 3impulsive speech and actions 3disinhibition 3apathy and indifference 3lack of empathy 3(add poor insight/awareness)

Etiologies of Executive Deficits u No one basis, no single cause u In utero exposure to ETOH, cocaine, opiates u Toxic exposures (lead) u Low birth weight u Birth trauma u Traumatic brain injury u Genetics u Emotional Trauma