4. Overview
• Brain Overview in 27 Slides
• Models of EF
• Strategic Behavioral Inquiry (HËDŸDT?)
• Disorders Which Impact EF
• Real Life Implications of EF Deficits
• Assessment of EF
• Strategies and Case Studies
• Q&A&D
116. Objectives of SBI
• Specific behavioral strategy
• What was the feeling-goal?
• Motivational level on a scale from 1-10
117. Benefits of SBI
• Affirms the value of clients’ unique internal
experience
• Emphasizes the culture of self-regulation
• Encourages metacognition
118. Assumptions of SBI
• Everybody’s doing the best they can
• Behavior is not incomprehensible or random
• Behavior follows patterns which reveal
themselves to the curious observer free of
prejudice or blame or theory
125. Learn from your To-Do list
• Which things are not getting completed?
• How – exactly – are these not getting
completed? How do you do that?
126. Clinical Application
• Who in your clinic or classroom is
demonstrating remarkable “resilience” –
persistence despite significant obstacles? And
how, exactly, does he/she do that?
127. Clinical Application
• Who in your clinic or classroom is
demonstrating remarkable “resilience” –
persistence despite significant obstacles? And
how, exactly, does he/she do that?
• What recurring behavioral problem is showing
up in your clinic or classroom?
128. Clinical Application
• Who in your clinic or classroom is
demonstrating remarkable “resilience” –
persistence despite significant obstacles? And
how, exactly, does he/she do that?
• What recurring behavioral problem is showing
up in your clinic or classroom?
• Note: we aren’t asking “why did you do that,”
but rather “how exactly did you do that.”
129. How to do SBI
“How exactly did you do that?”
“How did you know it was time to _____?”
“How long had you been thinking about ____?”
233. Homework Considerations for Teachers
• Target productivity first, then accuracy
• Reduce homework
– Overall correlation of homework with
achievement is just .15-.25 across all grades
and weaker in elementary grades*
– For high school, best amount was 1.5-2.5
hrs/night; more time had no further benefits*
*Cooper, Robinson, & Patall (2006). Review of Educational
Research, 76(1), 1-62.
235. Accommodations for EF Deficits
• Preferential seating
• Extra set of textbooks at home
• Quiet test environment
• Time off the clock during testing (schedule breaks)
• Pre- and post-class 1:1 review of content
• Visual schedule
• Movement breaks
• Fidget/sensory interventions
• Verbal cues
• External time cues (Time Timers products, or kitchen timer)
• Teacher check-off on homework binder
• “Locker” is in guidance counselor’s office
• Attention coach (10-15 minutes)
236. Examples of IEP Goals for EF Deficits
1. Self Awareness
a. Student will identify tasks that are easy or difficult for him/her.
b Student will accurately explain why some tasks are easy or difficult
d.Student will offer help to another when he/she is more capable than
another child
2. Goal setting
a. Student will participate with teachers in setting academic goals.
3. Planning
a.Given a selection of 6 activities for an instructional session, student will
select 3, indicate
their order, create a plan on paper and stick to the plan.
c. Having failed to accurately predict his/her grade on a test, student will
create a plan for improving
performance on the next test.
237. Examples of IEP Goals for EF Deficits
4. Organizing
a. To relate a story, student will place illustrations in order and then narrate
the
sequence of events
B. Student will prepare an organized semantic map or outline before
proceeding with writing projects
5. Self-initiating
a. Without prompts, student will begin his/her assigned tasks
6. Self-monitoring & self evaluating
a. Student will identify errors in his/her work without teacher assistance
7. Problem Solving
a. When faced with obstacles to educational or social objectives, student will
identify possible courses of action, identify pros and cons for each, choose a
course of action, perform it and evaluate its effectiveness.
238.
239. What are our data sources?
• Record review
• Interview
• Collateral interview
• Checklists
• Mental status examination
• Test scores
242. Skillfully eliciting the chief complaint
• Too much of what? Or too little of what?
• Invoking the Pediatric Fairy (or the Psychiatric
Genie)
243. HËDŸDT?
• How exactly did you do that?
– Everybody’s doing the best he/she can
– Every behavior problem is either
• Skills deficit
• Contingency problem
244.
245.
246. Forming a diagnostic impression
• Where do you see it the most? And where do
you see it the least?
• Two disorders = two stories
249. Approaches to Evaluation of EF
• Formal direct
• Informal direct
• Formal indirect
• Informal indirect
250. Evaluation of EF
• Informal Indirect
– Review of records
– Collateral interviews (see McCloskey 2012)
251. Evaluation of EF
• Formal Indirect
– BRIEF (Behavior Rating Inventory of Executive
Functioning)
– BASC (Behavior Assessment for Children)
– CBCL (Achenbach Child Behavior Checklist)
– BDEFS-CA (Barkley Deficits in Executive
Functioning Scale – Children and Adolescents)
252. Evaluation of EF
• Informal Direct
– Review of work samples
– Process-approach to test performance
– Mental Status Examination
– Classroom observation
253. Evaluation of EF
• Formal Direct
– NEPSY
– CAS (Cognitive Assessment System)
– Delis-Kaplan Executive Function System
– Continuous Performance Tests (Vigil; Connors CPT;
IVA)
– Wisconsin Card Sorting Test
– Trail Making Test for Children
– Rey-Osterreith
– Functional Behavior Assessment
354. Determine what basic provisions are
unconditional…
• Love
• Respect
• Safety
• 3 meals
• Essential clothing
• Temperature-controlled environment
• 30 minutes of video games
355. …and which are contingent
• Special foods
• Expensive or trendy clothing
• Extra video game time
• WiFi password
356.
357. Clip and share horrible articles about
teens falling out of the back of pickup
trucks
• Review cause and effect
• Discuss consequences
• Emphasize behavioral agency
358. The “Big Five”
• Daily focus time
• Nutrition
• Movement
• Sleep
• Connection
384. The “Big Five”
• Daily focus time
• Nutrition
• Movement
• Sleep
• Connection
385. Nutrition essentials
• Emphasize protein at every snack and meal
• Eat fewer processed foods
• Choose local
• Pay close attention to patterns between food
and focus/mood
386. The “Big Five”
• Daily focus time / Motivational clarity
• Nutrition
• Movement
• Sleep
• Connection
405. Let’s stay in touch!
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410. • Review expectations in
advance
• Teens and college
students may take more
initiative with this
411. Generic Issues Associated with Transition to
Adolescence
• Increased physical size and neurological maturation
• Increasing maturation of sexuality
• Increasing desire to individuate from parents; decreasing
influence of parents on teen behavior
• Increasing time away from home & parents
• Increasing number of domains of major life activities to which
the teen must adapt
– Sex, driving, peers, money & work, community activities, crime, drugs
• Greater involvement with and influence of peers
• Most of these are adversely affected by delay in self-
regulation associated with ADHD
412. How do symptoms change by adolescence?
• Hyperactivity declines more steeply than does inattention and
related executive function (EF) deficits
• Motor restlessness becomes a more internalized subjective sense of
feeling a need to be busy all the time
• Transition to middle school is associated with a transient increase
(reversal of decline) in ADHD symptoms
• The inattentive/EF symptoms have a greater impact on school
functioning than HI symptoms; increases with age
• Impulsivity is more related to impaired nonacademic domains:
– development of ODD
– drug experimentation
– speeding while driving
– risky sexual behavior, taking on dares from peers
– impulsive verbal behavior
– reactive aggression
413. Symptom Transitions (continued)
• But inattention also has adverse impacts on non-
academic functioning :
– Poor attention to traffic density and speed while in community auto
traffic settings
– Greater risk for pedestrian/cycling accidents in traffic settings
– Greater crash risk as drivers (in vehicle distractions are most
contributory)
– Accelerated use of nicotine after experimentation
• Self-medication ???
– Poor follow through on chores and other home responsibilities
– Poorer work performance in school
– Poor work performance part-time employment settings
– Inattention to others’ comments and needs in social activities
414. Emerging Impact of EF Deficits
• Poor working memory (remembering to do things)
– Less follow through on promises and commitments to others
– Increasing adverse impact of reading-listening-viewing comprehension
deficits, especially in school & work settings
• Impaired planning, anticipation, and preparatory behavior; not
ready for the future as it arrives
– Reduced valuing of future rewards relative to peers
– Consequently, don’t persist toward future goals and show poor delay of
gratification
• Deficient sense of time and time management
– A restricted temporal window relative to peers
• Poor emotion regulation (related to poor inhibition)
– Deficient control of anger & frustration most impairing
• Decreased fluency (rapid assembly of ideas into coherent verbal
reports and behavior)
415. Basic Considerations
• Don’t retain in grade!
• Sept is to establish behavioral control
• Decrease total workload, or
• Give smaller quotas of work at a time
• Target productivity first, accuracy later
• Reduce homework
– Overall correlation with achievement is just .15-.25 (just 2-6% of
variance in achievement) across all grades and weaker in
elementary grades*
– For high school, best amount was 1.5-2.5 hrs/night; more hours
had no further benefits*
*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.
416. Tips for Teens
• As needed, use ADHD medications – have
parents negotiate a contract with the teen if
necessary
• Find a “Coach” or “Mentor” (Just 15 min.)
– The Coaches’ office is the student’s “locker”
– Schedule in three 5-minute checkups across each day
– Use behavior report card to monitor teen across classes
– Use daily assignment sheets requiring teacher initials
– Cross temporal accountability is the key to success
• Identify a parent-school ADHD liaison
– Serves as an intermediary on issues between parents & school
417. A Daily Behavior Card
Each teacher rates each behavior at end of each class; 1=Excellent (+25), 2=Good (+15), 3=Fair (+5), 4=Poor (-15),
5=Terrible (-25)
Subjects 1 2 3 4 5 6 7
Class
Participation
Performs assigned
classwork
Follows class rules
Gets along well
with others
Completes home-
work assignments
Teacher’s
Initials
418. More Tips for Teens
• Use a daily school behavior card for self-evaluation
after; move to weekly after 3+ good weeks
• Keep extra set of books at home
• Learn typing/keyboard skills for writing assignments
• Require continuous note-taking to pay attention to
lectures or during reading assignments
• Tape record important lectures – check out the
Smart Pen that digitally records lectures or other
conversations at livescribe.com
419. More Tips for Teens
• “Bucks for Bs” system
– grades on each assignment = $ from parents
• Get week-at-a glance calendar with journal or other organizing
notebook system
• Schedule hard classes in AM
• Alternate required with elective classes
• Extra time on timed tests (???) – no evidence it helps
– Better to have distraction free test setting and intersperse
breaks in testing to create shorter test periods (time off the
clock)
• Permit music during homework*
• Get written syllabus as handouts
*Soderlund et al. (2007). Journal of Child Psychology and Psychiatry, 48, 840-847.
420. Still More Tips for Teens
• Learn SQ4R for reading comprehension
– Survey material, draft questions, then:
– Read, recite, write, review
• Peer tutoring in class
• “Study-with-a-buddy” after school
• Find “fall-back” classmates (swap phone, e-mail, & fax
numbers) for lost or missing assignment sheets
• Attend after-school help-sessions
• Schedule parent-teacher-teen review meetings every 6
weeks (not at 9 week grading period)
424. Reverse Engineering the Carrot and
Stick
• Rey O versus VMI
• Carrot and stick
• Break down large projects
• scaffolding
425. • Present various models of EF
• Settle on 10-ish
• Introduce HEDYDT? (disappearing ink, do you
comment, hedydt)
• Create more handouts (e.g. worksheet for
determining contingencies)
426. Overview
• Brain overview in 11 slides
– Amygdala (mindfulness), hippocampi (exercise), PFC (screen time/green time, sleep), PFC regions, loops
• Models of EF
– Small group: what is EF
– Hot and cold EFs
– 10 Efs - consider dawson guare model
– Barkley’s 4
– McCloskey’s 30-st
• EF as Self-Regulation
– Sensing to the self, etc
– Central impairment is in self-regulation
• Disorders which impact EF
– ADHD
– TBI
– Schizophrenia
– Bipolar Disorder
– ASD
– Anxiety Disorders
– Leaning Disorders
– Oppositional Defiant Disorder
• Real life implications of EF deficits
– EF and reading
– EF and writing
– EF and math
– EF and test-taking
– Metacognitive Awareness Inventory (Schraw & Dennison 1994)
• Assessment of EF
– Direct formal etc
– Curious compassionate nonjudgmental evaluation
• Strategic Behavioral Inquiry (HEDYDT?)
• Asking 2 Questions
• Case Studies and EF Strategies
• School Accommodations and Supports
• Big 5 EF Supports