Understanding and Supporting Executive Functioning

1. Understanding and Supporting Executive Functioning Hayley Stinson, MSW, RSW Child & Family Clinician Community Education & Engagement Facilitator Integra Program

2. Child Development Institute

3. Learning Objectives To better understand executive functioning in children with LDs / ADHD To explore the challenges associated with executive functioning deficits To discuss practical strategies to support children with executive functioning deficits

4. Our Framework • Our understanding of the problem determines our solution • “Kids do well if they can” (Ross Greene) - if they can’t something is getting in the way and they need support in figuring out what it is and what will help • Not a lack of WILL, it’s a lack of SKILL

5. Learning Disabilities (LDs)

6. What are LDs? Neurodevelopmental disorders Affect one or more ways that a person • Takes in • Understands • Remembers • Expresses information Average to above average thinking and reasoning skills - Kids with LDs are smart! Lifelong and may present differently at different stages 5 to 10 % of Canadians have LDs (LDAO, 2001)

7. What are LDs? Impairments in one or more of the following psychological processes: • Language Processing • Phonological Processing • Visual-Spatial Processing • Processing Speed • Memory and Attention • Executive Functioning • Visual Motor Processing

9. Explaining Behaviour Non-compliant Withdrawal Outbursts Avoidance Externalizing Internalizing • Anxiety? Depression? • LD? ADHD? Learning Challenges? • Physical Issue – Sleep? Hunger? Sensory integration? • Environmental Issue – Change at home? Learned Behaviour? • Social Issue – Conflict with peers?

10. Behaviours as Communication • Behaviours/’symptoms’ communicate our way of coping with painful, intense, negative emotions (e.g., emotion regulation strategy) • I feel ____ and I cope with it by “behaviour/symptom” to feel better • E.g., I feel fear/shame and I cope with it by avoiding, worrying, controlling to feel better

11. Challenging Behaviours Arise When… Skills and Ability to Cope Demands of Environment “Kids do well if they can” (Ross Green)

12. LDs and Stress Experience of Repeated Failure Anxiety about meeting expectations Lower Sense of Mastery Frustration Patterns of Experiential Avoidance

13. Experiential Avoidance Miss out on opportunities that build resilience and mastery • Avoid interactions, activities, thoughts, and emotions associated with failure or distress by: • withdrawing from the stressful situation • engaging in problem behaviors that facilitate avoidance or distract (Ducharme & Harris, 2005) • pushing away unwanted thoughts • drugs and alcohol

14. Executive Functioning

15. What is Executive Functioning? • Umbrella term – includes various skills and function of the prefrontal cortex (neurologically based) • Responsible for mental control and self-regulation • Developmental – develops with maturity from infancy through early adulthood (age 25), not just a matter of teaching skills

16. Another Way to Think About EF EXECUTIVE FUNCTIONING OTHER PROCESSES

17. Executive Functioning Skills • Response inhibition: the capacity to think before you act (ability to resist the urge to say / do something) • Working memory: the ability to hold information in memory while performing complex tasks • Emotional control: the ability to manage emotions to achieve goals, complete tasks, or control and direct behaviour (Guare, Dawson & Guare, Smart but Scattered, 2012)

18. Executive Functioning Skills • Flexibility: the ability to revise plans in the face of obstacles, setbacks, new information or mistakes • Sustained attention: the capacity to maintain attention to a situation or task in spite of distractibility, fatigue or boredom • Task initiation: the ability to begin projects without undue procrastination (efficiently and timely) (Guare, Dawson & Guare, Smart but Scattered, 2012)

19. Executive Functioning Skills • Planning / prioritizing: the ability to create a road map to reach a goal or to complete a task • Organization: the ability to create and maintain systems to keep track of information and materials • Time management: the capacity to estimate how much time one has, how to allocate it, and how to stay within time limits and deadlines (Guare, Dawson & Guare, Smart but Scattered, 2012)

20. Executive Functioning Skills • Goal-directed behaviour: the capacity to have a goal, follow through to the completion of the goal and to not be put off or distracted by competing interests • Metacognition: the ability to stand back and take a birds eye view of yourself in a situation, to observe how you problem solve (Guare, Dawson & Guare, Smart but Scattered, 2012)

21. Everyday Tasks Requiring EF (Guare, Dawson & Guare, Smart but Scattered children, 2012)

22. Executive Functioning and ADHD • Kids with Attention Deficit Hyperactive Disorder (ADHD) have problems with executive functioning • But not all kids with executive functioning problems have ADHD • Three types of ADHD: • Hyperactive • Inattentive • Combined Executive Functioning Problems ADHD Inattentive Hyperactive Combined

23. EF and Learning Disabilities • EF and LDs go hand-in hand • EF – one of the psychological process which may be impaired in kids with LDs • EF problems often go with other kinds of processing problems • Each kids profile is unique LDs EF ADHD

24. EF and 22q11DS • Many children with 22q11Ds also struggle with executive functioning and attention

25. Stroop Task Stroop Task / Stoop Effect

26. Read Each Word Aloud 0:01 0:02 0:03 0:04 0:05 0:06 0:07 0:08 0:09 0:10 0:11 0:12 0:13 0:14 0:15 0:00

27. Read Each Word Aloud 0:01 0:02 0:03 0:04 0:05 0:06 0:07 0:08 0:09 0:10 0:11 0:12 0:13 0:14 0:15 0:16 0:17 0:18 0:19 0:20 0:00

28. Name the Colour Aloud 0:01 0:02 0:03 0:04 0:05 0:06 0:07 0:08 0:09 0:10 0:11 0:12 0:13 0:14 0:15 0:16 0:17 0:18 0:19 0:20 0:21 0:22 0:23 0:24 0:25 0:26 0:27 0:28 0:29 0:30 0:00

29. Executive Functioning Skills • What EF skills did you use during the Stroop Task? • Response inhibition • Working memory • Emotional control • Flexibility • Sustained attention • Task initiation • Planning / prioritization • Organization • Time management • Goal-directed persistence • Meta cognition

30. What behaviours Do you see in Children with Ld’s / ADHD related to executive functioning challenges?

31. Emotion Regulation

32. Emotion Regulation Emotion regulation is our ability to control or manage our emotional responses to arousing situations.

33. Emotion Dysregulation • Person whose responses are chronically out of control (in the redzone – severe, persistent, interferes with everyday life) • Experience symptoms more intensely and frequently • “Super feelers” (Emotion-Focused Family Therapy)

34. Bucket of Emotions

35. Under-Regulation Vs. Over-Regulation

36. Under-Regulated Emotions • Not able to control emotions enough • Stuck in “on” button, trouble putting brakes on • Externalization of emotions (directed outward) • Patterns of “fight” (behavioural challenges) • Need help from adults to regain control of emotions

37. What You May See

38. Over-Regulated Emotions • Try's to control emotions too much • Stuck in “off” button, trouble revving up • Internalization of emotions (directed inwards) • Patterns of “flight” (or “freeze) – avoidance • Need help from adults to express themselves and their emotions

39. What You May See

40. Meet Aaron • Aaron is 7 years old • Bright, creative, imaginative • He is very distracted • He is disruptive and will act silly with his peers • He has trouble fitting in socially • He gets easily frustrated when things don’t go as planned • He has trouble with transitions • He is very angry when he feels mistreated or thinks something is unfair

41. Taking a Closer Look What EF skills might be lagging behind for Aaron? Plan of Action: Set age appropriate expectations Modify the environment Teach lagging skills

42. Strategies to Support Children with EF Challenges

43. Identifying Strengths • Identify and understand both the factors contributing to the child’s successes and the factors standing in the way of their successes • Celebrate the child’s strengths • Support the child in improving their skills and developing compensative strategies (i.e., using their strengths to compensate for areas of weakness) (Guare, Dawson & Guare, Smart but Scattered, 2012)

44. Appropriate Expectations • Children with LDs/ADHD may require more support and supervision than other children their age • EF skill development is gradual – it will take time, practice, and opportunities for mastery • Children benefit from frequent check-ins: • Before beginning tasks • During tasks • Before shifting tasks (transitioning)

45. Scaffolding

46. Dependence to Independence • Job is not to “do for” • Job is to “help them do” • Sustaining attention, transitioning from task to task, managing and regulating emotions • Organizing, supporting, communicating, allocating time, scheduling • Operating as an external frontal lobe (Greene, Collaborative Problem Solving)

47. Don’t Cue to Do, Cue to Know What to Do (Sarah Ward, M.S., CCC/SLP)

48. Modifying the Environment • Changing the physical or social environment • Alarm clocks, organizing systems for study materials / room keeping, wall or desk calendars, whiteboards for schedules, colour coding • Reduce distractions • Changing the nature of the task • Break tasks into pieces, shorten tasks, reduce the amount of work, provide clear steps (Guare, Dawson & Guare, Smart but Scattered, 2012)

49. Teaching EF Skills • Directly teach EF skills • E.g., collaboratively identify an EF skills, set a goal, outline / break down the steps needed to reach the goal, supervise, fade supervision • Use everyday activities to teach EF skills • E.g., games (checkers, chess), cleaning up, etc. • Find natural teachable moments • Cue the skill the child needs to use in the moment

50. Validation