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1 EXECUTIVE FUNCTIONS Using Language To Think
The information that I will be sharing with you today comes primarily from a workshop I attended in November presented by Jill Fahy, a speech-language pathology professor from the Eastern Illinois University, and a book she co-authored with Gail Richard titled “The Source for Development of Executive Functions” available from LinguiSystems. You have several other good resources listed in the References handout. Fahy’s background is in cognitive rehabilitation with head injured adults. When she began working at the university and supervising students in clinic, she began to notice that many of the school-aged, language disordered clients they were seeing exhibited many of the same kinds of deficits as the head injured population she had worked with. So she took what she had learned and used in the rehab setting and began teaching it to her students as they worked with these school-age clients in their clinic. And from a developmental perspective, it worked. As she began exploring executive functions with regard to children, she found very little, if any, research within our own professional literature. She had to go into the professional literature for adult rehab, psychology, TBI, neurodevelopment, and brain science. Even given that, there is still very little evidence base to refer or compare to when working on the executive function skills of children. Executive functions are not a ‘new term’ in the scope of SLP practice, but I don’t really remember studying this as part of our neuro- or anatomy courses in school. But in mentioning my current workshop topic to other professionals in related fields, I found that most did not know what EFs were. Our excellent special educators at Outreach agreed that they did not learn about EF in college, but later when they began working with students with autism, Asperger’s, and ADD. Many of you may currently target what we call “meta” skills with your students – “thinking about” skills. Thinking about thinking. Thinking about language. Thinking about phonology. Internal speech. Self-talk. I would not say that “meta” skills and executive functions are synonymous, but language is certainly the mediator for both. And, realize that whatever language a student uses to communicate with others is likely the same language he uses to communicate with himself. SO LET’S GET STARTED! What are executive functions? Shelly Wier, MS, CCC-SLP Easter Seals Outreach Program

2 Orchestra Analogy Let me start with an analogy from the book. Given my own background and experience with music, this one struck a familiar chord with me. (yuk yuk) Think of an orchestra. Each section is composed of musicians who have mastered the art of playing their instruments and reading complex musical notation. Musicians must also be skilled at listening to the others around them, at taking direction from the conductor, and at merging the technical requirements of a piece of music with their own artistic expression. These discrete skills are prerequisite to becoming a member of the orchestra.

3 Orchestra Analogy The conductor must simultaneously divide his attention among the many musicians, instruments, and parts; a task which is demanding, requiring a sustained focus with attention to detail. The frontal lobe is our conductor. A conductor is skilled at processing multiple channels of incoming information. He must integrate previous experience with each new piece the orchestra attempts, so that he can identify and rectify any gaps or problems. The conductor needs to recognize strengths and weaknesses within the orchestra as a whole and compensate to achieve a satisfactory result. With an optimal blend of talented, well-trained musicians (discrete skills) and a dynamic, attentive, multi-tasking conductor (frontal lobe), the result can be beautiful. Now imagine that some of the musicians are unprepared for the performance.

4 Orchestra Analogy Imagine the sound of poorly-played violins, cellos, flutes, and clarinets. Imagine French horns, trumpets, and trombones sounding off at the same time in different keys and rhythms. No matter how gifted the conductor might be, the end result will not meet the anticipated expectations. Regardless of skilled performances by some, the outcome as a whole will be flawed, probably ruined. We might get the same result if the conductor is lacking in skill. Without competent leadership, the coordination and awareness of timing, balance, and integration of parts to achieve a satisfying whole are absent. Without order and organized direction, each section would be confused and not sure whether to play, be silent, wait, or simply leave. It is important for the conductor to pay attention to feedback from the audience and musicians and to learn from his mistakes. The deficit lies in the ability to organize the multiple talents available into a single, eloquent, focused entity that moves smoothly from one musical action to the next.

5 Language & Communication
Prerequisite Now let’s put that analogy into the framework of language and communication. A child may acquire normal language skills, and like the musician, be able to demonstrate skill on specific discrete, isolated tasks. [click] Establishing a language foundation is prerequisite to engaging in successful, appropriate communication. Yet, specific isolated or discrete skills might not translate into language competence in a connected environmental situation. Being able to generate antonyms in an isolated language subtest is very different from being able to employ them appropriately in connected discourse. [click] Communication demands a grasp of the subtle, unspoken message, which can change, depending on circumstance and context. [click] Competent language skills also demand flexibility, on-the-spot restructuring, and formatting-on-the-go. Children who have mastered phonetics, syntax, and semantics in context-free environments may not be able to competently blend into the orchestra of communication demands in real life. The communication profile associated with Asperger’s syndrome is a good example. These students can demonstrate normal or above average standard scores for the fundamental aspects of language, with the exception of pragmatics, but the practical management of using those language skills in a functional context is problematic. Language fundamentals are applied in a rigid, inflexible manner. Think of a student you know as I describe . . . . . . the Asperger orchestra, the musicians can play a given repertoire of notes, but the conductor is unable to reorganize these talents into other pieces of music, or integrate them into pleasing variations of the original style or selection. The piece must always be played in the exact, same manner. The audience hears a repetitive soliloquy, just as the communicative partners of children with Asperger’s do. The higher order integration of language skills with contextual demands and self-awareness is missing. The communication profile associated with Williams syndrome provides another example. These students often have fluent, highly embellished expressive skills that are far superior to their receptive language; impressive vocabulary and syntax, with poor semantics and overall comprehension. Their out-going, gregarious social skills often mask an underlying difficulty with basic concepts, big-picture reasoning, and organization. In the Williams orchestra, performances are theatric, exciting, and fast-paced. The musicians are likely to perform eloquent and inspiring renditions that are completely independent of their fellow players. However, they lack the capacity to listen to each other or take direction from the conductor, who is having difficulty maintaining order. The audience will get an impressive, but ultimately disorganized and incomplete performance that fails to satisfy. A lack of total comprehension of meaning in language, coupled with disorganized management and integration, results in ineffective functional communication, despite good expressive production skills. So – Effective functional communication must blend mastery of language fundamentals with executive functions to facilitate academic and social success. Subtle, Unspoken Flexible

6 Operational Definition
A cluster of brain functions/skills that allows us to . . . Anticipate consequences Generate novel solutions Initiate appropriate actions/responses to situations Monitor the ongoing success/failure of one’s behavior Modify performance based on unexpected changes. Over the years, many definitions have been presented. “…intentions capable of controlling subsequent conscious behaviors” (Luria, 1973) “those capacities that enable … independent, purposeful, self-serving behavior successfully” (Lezak, 1983) “enable … appropriate behaviors under novel circumstances in a developmental progression” (Marlowe, 2000) developmental progression meaning our expectations should differ by age. EFs is an umbrella term for a collective group of abilities that we use to establish new patterns of behavior to function successfully within the social boundaries of a culture. [Read slide] More simply … “how we use what we know to regulate, change, and adapt to meet the demands of the world around us.”

7 Tertiary Processing Conscious Independent Purposeful Goal-Oriented
Self-Serving Monitored Evaluated Flexible Adaptive Now, regulating, changing, and adapting means processing. But EFs are not reflected by our primary processing, or even our secondary processing capabilities. They reflect tertiary processing capabilities. Deciphering auditory signals, interpreting visual stimuli, and understanding speech represent primary processing. Making associations, attaching meaning, or associating feelings represent secondary processing. These types of processing, and their subsequent behaviors, occur almost instantaneously in the average brain. Tertiary processing, the ultimate in processing, results in behaviors which are: conscious independent purposeful goal-oriented self-serving monitored evaluated flexible adaptive

8 For example: If you were taking a walk and you came upon this . . . Your primary processors would instantly take in four legged, furry, brown, and your language would process /d-o-g/. Your secondary processors would identify “dog” and its meaning, as well as any associations, feelings, and experiences you have had with dogs. Your tertiary processors would say “Uh-oh! This dog looks mean. He’s chained. The sign reads ‘Stop! Beware of guard dog.’ I need to leave now.”

9 As opposed to coming across this dog.
Your primary and secondary processing is the same, but your tertiary processors might say “He looks friendly. He’s got a toy. Maybe he wants to play.” OR this dog [click] Your tertiary processors might say “He’s wagging his tail. He’s on a leash. It’s probably safe to pet him.” Your tertiary processors might say “That’s usually a friendly breed, but I’m not sure what she’s up to, so I’ll leave her alone.” Again . . . Executive functions reflect tertiary processing. conscious independent purposeful goal-oriented self-serving monitored evaluated flexible adaptive

10 Underlying Cognitive Functions
Attention Inhibition Working Memory There are three underlying cognitive functions that provide the basic support or foundation for our EFs. According to Fahy, these are required prerequisites. Attention: The most basic foundational process, other than being alert. Inhibition: Without inhibition, no other EF really works well. Working Memory: Which is dependent upon attention. Let’s break this down . . .

11 Five Levels of Attention
Focused Sustained Selective Alternating Divided There are five levels of attention. [Scan front row for someone you know or can name.] . . . levels of complexity, I guess. These certainly build upon each other, such that the first 2-3 are necessary for last 4-5 to develop. Focused: Briefly directing your attention to someone or something. EX: Hey, __(name)__! Sustained: Continuing to attend. Maintaining vigilance over time. EX: I continue to address __(name)__ and she continues to focus on me or attend to me. Selective: Ignoring what is irrelevant. In other words, relevant sustained attention. EX: She does not attend to other conversations, people, objects – whatever - which do not involve or concern her, or which are not relevant to the conversation. Alternating: Switching when necessary between relevant needs. EX: If she had a small child with her who was about to get into something, she could switch her attention to deal with that situation, then return to our conversation. Divided: This is what we currently call ‘multi-tasking’: managing relevant, multiple streams of attention simultaneously and flexibly. EX: If this conversation were taking place as we checked out at the grocery store, then she might be keeping an eye on her child, unloading her groceries, paying the cashier, arranging the bags back into the cart, getting her change or signing the sales receipt – all while attending to and continuing our conversation.

12 Inhibition Allows for sufficient planning and organization
Prevents disruptive, unwanted, unintentional and irrelevant impulses Delays appropriate actions until the appropriate time Basis for delayed gratification and optimal results at a later time Our inhibition capabilities delay action. [Read slide] When you think about it Adults without these skills are often considered ‘juvenile.’

13 Working Memory “Memory Chalkboard” Mental Storage Space
Immediate Comparison Used Repeatedly Reliant on Sustained Attention Working Memory or our Memory Chalkboard is . . . Mental storage space for incoming information from the environment and knowledge of current or immediate requirements. It holds and processes information long enough to execute the desired behavior. Allows for immediate comparison between current and past experiences AND between current and old memories. Working memory is a recurrent need. It is used repeatedly to rethink or develop new strategies. Working memory is reliant on sustained attention. [Get out laser pointer.] SIDE NOTE: Research has shown that part of Einstein’s brain was missing and another part was 15% larger. He also had a larger ratio of glial cells to neurons in his entire brain -- Glial cells provide support and nutrition in the brain, form myelin, and participate in signal transmission – With significantly more in the inferior parietal area, part of the association cortex, which houses regions of the brain responsible for incorporating and synthesizing information from multiple other brain regions. His brain functioned better in the area responsible for making meaning. Some thought him to have Asperger’s Syndrome.

14 Six Components of Executive Function
Self-Regulation Execution & Goal Attainment Now, also according to Fahy, there are six components of EF. Goal Selection “What to do?” Planning and Organization “How to do it?” Initiation and Persistence “Can I start?” “Can I stop?” “Can I continue?” “Can I finish?” Flexibility “Hmmmm? Should I change or adjust?” Execution and Goal Attainment “Do this? Yes, no, maybe, stop, go, now, later.” “Is this it?” “Am I finished?” Self-Regulation “How am I doing?” “How did I do?” “Good?” “Bad?” “Right?” “Wrong?” Let’s look at these more closely. Flexibility Initiation & Persistence Planning & Organization Goal Selection

15 Goal Selection Behavioral determination Predict and anticipate
Externally-controlled at first Increasingly internally-controlled Requires sophisticated language!! Goal Selection “What to do?” Now, I know we are all familiar with selecting goals for our students, but we are all, as part of life, selecting goals for ourselves daily– from “Do I want soda or tea?” to “What do I want to do with my life?” I may use the word “project” many times today, but remember that these EF components are necessary for even the simplest of tasks. Selecting goals requires behavioral determination. Do I use an old routine? Or do I need to develop a new plan? Goals are chosen based on priority, relevance, experience, and knowledge of current expectations and limitations. Goal selection also involves predicting outcomes and anticipating consequences. Do I do it now? Later? Not at all? What will happen if I do? I don’t? For children, especially young children, goal selection is externally-controlled by the rules of parents, teachers, and other adults, even older siblings. It becomes increasingly internally-controlled as the brain develops and we mature, and this is guided by our understanding of society’s rules. Goal selection, as well as all the other components of EF, requires sophisticated language to function well.

16 Planning & Organization
Recognize the need to act Determine what is necessary Seek relevant materials & information OR “Make do” with what is available Develop relevant strategies Sequence plans, information, materials Account for time, expectations, requirements Planning and Organization “How to do it?” Planning and organizing is syntactically complex! This EF component generates a plan and creates relevant strategies to meet the goal. It involves … Recognizing the need to act Determining what is necessary to complete the task or project Seeking materials & information that are relevant to the project OR “Making do” with what is available Developing strategies that are relevant to meet desired outcomes Sequencing plans, information, and materials, and Accounting for the amount of time needed for the project, and knowing the expectations of others, and the requirements of the task

17 Initiation & Persistence
Self-selected start OR Time-sensitive initiation Persist with efforts to completion Continually “re-start” efforts as needed Terminate efforts as appropriate Initiation and Persistence “Can I start?” “Can I stop?” “Can I continue?” “Can I finish?” This EF component initiates and maintains goal-directed behavior despite intrusions, distractions, or changes in the task demands. This requires us . . . To determine whether we can start when we want to OR whether beginning the project is time-sensitive To persist with our efforts until we’re finished To continually “re-start” efforts as needed depending on intrusions, distractions, and changes, and To terminate our efforts as appropriate

18 Remove graphics before printing participant handouts.
Flexibility Remove graphics before printing participant handouts. Adapt! Adapt! Adapt! Success requires change Allow for unexpected parameters React strategically Depends on divergent thinking and verbal reasoning Flexibility “Hmmmm? Should I change or adjust?” This EF component allows for adaptability in strategic thinking and problem solving as the goal or environment changes, and shifts our attention and plans accordingly. Successful attainment of any goal requires us to be able to change and adapt when necessary. To be aware of and prepared for any unexpected changes that might become necessary. And to react strategically, that is, with a strategy that will accommodate the problem or change. This depends on divergent thinking and verbal reasoning. A student with poor flexibility will persist in the same action or approach even after multiple failures. [Definition of insanity.]

19 Execution & Goal Attainment
Relies on . . . Initiation & Persistence Attention & Vigilance Adaptability & Flexibility Self-Evaluation Manage time constraints and pacing Poorly developed EF = more supervision Execution and Goal Attainment “Do this? Yes, no, maybe, stop, go, now, later.” “Is this it?” “Am I finished?” This EF component allows us to successfully execute the plan and strategies (original and revised) within the constraints of environment or time, and relies on . . . Initiation & Persistence: We must be able to begin and continue with a project. Attention & Vigilance: We must be able to attend to all details and notice when something is not working. Adaptability & Flexibility: We must be able to adjust when necessary and know how to make the adjustment. Self-Evaluation: We must be able to evaluate ourselves and our progress as we work. We must be able to manage our time and pacing, and any constraints on that time and pacing. Obviously, students with poor EF will require more supervision in order to execute their plans and achieve their goals.

20 Self-Regulation Relies on . . . Observation Judgment Monitoring
Making comparisons Drawing conclusions This EF component applies self-observation to monitor performance, self-judgment to evaluate performance, and self-reaction to change performance in order to achieve the ultimate goal. METAPHYSICALLY SPEAKING, the idea of self-reflection has been the subject of discussion for thousands of years. There are mentions of it in the Bible. Socrates, Plato, and Aristotle spoke of it in Classical Greece. The idea carried human beings through the Renaissance, and an entire movement tied to it sparked a sociopolitical movement called the Enlightenment. In more recent times, thought leaders such as Immanuel Kant, Karl Marx, and Sigmund Freud have all given opinions on the subject of our ability to look inside ourselves and act accordingly. It is, as Kant once wrote, the very thing that makes humans “rational animals.” So . . . Self-Regulation “How am I doing?” “How did I do?” “Good?” “Bad?” “Right?” “Wrong?” Self-regulation relies on two skills: making comparisons and drawing conclusions. It requires . . . Observation – “What am I doing right now?” Judgment – Self-evaluation. “How well am I doing it?” “Good, OK, Poorly?” Monitoring – Continually reassessing. “Am I still doing it OK?” Reaction – Altering efforts. “No, I’m not doing this right/well. Let me try this instead.” Recognizing when goal is met (task is done) or not. “Am I finished?” “Did I complete the task?” “Did I obtain the desired result or product?” This is possibly the most important component of EF. And many times the area that is most significantly impaired. Think of all the skills a student must employ to simply comply with the direction “Check your work.” Self-perception and judgment is often skewed. Observation Judgment Monitoring Reaction Recognizing

21 COMMENTS SUMMARY Defining EF is generally accomplished by listing the components associated with it, as I have done, although such a list can vary depending on the theory used to organize the components. Some models list the broad cognitive functions of attention, inhibition, and working memory alongside the other five, as component skills, equal in the outline of regulatory behaviors that govern action; but, as I said, Jill Fahy presented these three skills as underlying cognitive processes associated with and key to the effective development and use of EFs, rather than specific component skills. This reflects the theory that attention, inhibition, and working memory serve as a foundation upon which specific executive functions are acquired. Charts and lists also tend to divide these components into separate pieces, giving the impression that executive skills are entirely individual and work in a linear fashion. However, in reality, these components are not so easily separated. There is a sort of hierarchy of skills, but they don’t occur in a specific linear time frame during the course of solving a problem or determining an appropriate behavior. They are adaptable, flexible, and work simultaneously in layers over one another to meet the demands of the environment. In addition to being dependent on and interactive with attention, inhibition, and working memory, most EF strategies are mediated through verbal language. Self-talk is often used to support a student’s efforts in developing strategies, solutions, and monitoring actions. A student needs to internally generate reminders and direct behavior throughout the school day, and then again once he/she is at home or elsewhere after school. As tasks become more complex and expectations of performance increase, the ability to use language as a self-guiding system becomes even more crucial. The role of language is critical in mediating EFs and cognitive processes in order to maximize outcomes. (This is why I included first person questions with each component.) Either way you look at it, 5 components or 8, the overall purpose of our EFs is to drive goal-oriented and appropriate behaviors within a given time and circumstance. The delineation of these components, however, is necessary in order to identify potential areas for assessment and treatment. In particular, the generalization of treatment outcomes often depends on identifying exactly which EF skill has yet to mature.

22 Pop Quiz 1 Define “executive function.”
Give 3 behavioral adjectives to describe “tertiary processing.” Name 3 underlying cognitive functions that are prerequisite to EF development. Name 5 levels of attention. Name 3 of the 6 components of EF. Which component requires sophisticated language? Which component is syntactically complex? That’s a lot of information to process in a short time. Let’s see how well your memory is working. Turn over your ppt notes and find the Pop Quiz handout in your packet. Completing this is optional, but I have treats for those 9-10 brave souls who are willing to raise their hands and answer aloud. Define “executive function.” Anyone want to share another definition? Give 3 of the 9 adjectives used to describe “tertiary processing” behaviors. Three more? Last three? Name 3 underlying cognitive functions that are prerequisite to EF development. Name 5 levels of attention. Name 3 of the 6 components of EF. Last three? Which component requires sophisticated language? Which component is syntactically complex? GREAT! Now let’s move on.

23 Remediate Deficit Skills Teach Compensatory Strategies
Improve Awareness of Deficits Remediate Deficit Skills Our behavior is mediated at the highest level of integration – metacognition – which relies on developmentally intact cognitive and linguistic functions. Children must be able to reflect upon themselves and the environment at higher and higher levels of complexity and independence as they grow older. Assessment of EF requires careful analysis to determine which components are in deficit. Intervention requires the use of language-specific goals that promote a more complex level of self-awareness and regulation. Successfully treating deficit EF and promoting functional improvements require the ability to analyze whether a child has impairments in EF, in other cognitive processes, in linguistic functions, or a combination of all three. In general, children with impairments in EF often experience a wide array of breakdowns, which ultimately limit the degree of achievement and independence they attain in life. As adolescents and young adults, their potential for meeting educational, vocational, and community expectations often relies on how aware they are of deficits, how well they use strategies to compensate, and how consistently they regulate their actions (generalized, operational, functional skills). Awareness, I believe, is one of the best pieces to include in a “developmental” approach. [click] But, when do we need to shift from a “developmental” to a “rehab” mind-set? I mean, at what point to we need to shift our focus from working with a developing brain to a less malleable one? From one that can still learn to generalize skills to one that, well, can’t . . .? Or at least not as readily! Also remember, that maturity age > for certain syndromes. Obviously, weighting the different pieces of your “Therapy Pie” is an important consideration. I’ve provided a blank poster for you to diagram your own “pie” during break. What do you think the pieces are? How do you weight them with regard to importance? [click] Ultimately, we want our students to develop social competence, wisdom (being able to discern what is true, right, or lasting), insight, and altruism (an unselfish concern for the welfare of others). [Get out laser pointer.] Teach Compensatory Strategies Improve Awareness of Deficits Remediate Deficit Skills Improve Awareness of Deficits Remediate Deficit Skills Teach Compensatory Strategies Teach Compensatory Strategies

24 Longest Developmental Phase
Frontal lobe development is prolonged Slowest maturational phase of all the developmental progressions Not completed until mid-20’s Normal, age-related changes in mid-40’s Slow decline in synaptic density with age Any questions before we continue? INTRO TO DEV: Frontal lobe development is prolonged. It is the slowest maturational phase of all the human developmental progressions, incomplete until the mid-20’s. There are many developmental variables: nature, genetic influences, environmental enrichment and stimulation, experience, and nutrition, all play a part, as well as myelinization and synaptic development, pruning, and refinement. And, of course, language, which gives us thought and deliberation. As young children, we lack judgment and wisdom. Our parents and caregivers are our frontal lobe. In adolescence, we begin to try out our judgment, but continue to need adult guidance. In our 20’s, as young adults, we begin to make life plans. Hopefully, by our 30’s, we are beginning to see the results of some long-term goals and efforts: education, home, family, career. Normal, age-related changes begin to occur in our mid-40’s, with a slow decline in synaptic density with continued age. We must purposefully exercise our brains to maintain networks into old age. Let’s take a more specific look at how our EF skills develop. [Move quickly through this information.]

25 Emerging Foundations First Two Years
As infants, everything is reflexive. At about 6-12 months of age, inhibition and simple, focused attention begins to emerge. Simple shifting of attention begins to emerge between 1-2 years. Inhibition is still emerging, but pretty much non-functional. Reflexive at first Inhibition and simple, focused attention emerges between 6-12 months Simple shifting of attention emerges between 1-2 years

26 Two Year Olds Life is here-and-now Impulse-driven Distractible
Perseverative No flexibility No self-correction Immature, but developing attention For two-year-olds, life is in the here-and-now, impulse-driven, distractible, perseverative, no flexibility, no self-correction. They can attend, but they can’t inhibit because they don’t have enough working memory to actually be able to use it. Language and self-awareness is emerging. They have a little awareness of rules and environmental expectations.

27 Three Year Olds Attention, environmental awareness, and language continue to develop Verbal fluency and impulse control improves Attention, environmental awareness and language continue to develop. Verbal fluency and impulse control improves. Words are the tools that begins to provide impulse control. They are able to process 1 simple rule, maybe, and shift between tasks, one at a time. They begin to use basic strategies, but they are usually inefficient. They still have poor organization and conceptual reasoning. They still perseverate and can’t delay gratification. They make poor choices or are successful by chance. Able to process 1 simple rule Shift between tasks 1 at a time Use inefficient strategies

28 Four Year Olds Language is really starting to help
Follows simple rules Language is really starting to help. Four year olds can follow simple rules, generate new ideas, and make simple plans. They can shift btw simple tasks and have better task completion. They are able to delay a first choice and select a goal for a better reward later. EX: Can wait until after dinner for candy. Complex demands are still troublesome. They are still impulsive and perseverative, but not as much. Adults are still their frontal lobe most of the time. Generates new ideas and makes simple plans Shifts btw simple tasks Better task completion Delays first choice Complex demands still troublesome

29 Five Year Olds Impulsivity is declining
Language, verbal fluency, and now processing, is increasing Better balance btw internal needs & external demands Follow simple, multi-step directions Impulsivity is declining. Language, verbal fluency, and now processing, is increasing, which helps create better balance between internal needs and external demands. Follow simple, multi-step directions. Cannot switch between multiple sets of rules. Continue to delay some initial choices, if externally cued. Parents, and now teachers in some cases, are still the child’s frontal lobe.

30 Six Year Olds More self-controlled; less other-controlled
Attention much better; span is longer Language processing is of great help Begin to use silent, verbal mediation!!! Simple problem solving appears At 6, kids start to become more self-controlled and less “other”-controlled. Attention is definitely better. They can resist distractions and, in general, have a longer attention span, which helps with the capacity to learn which is fortunate because what happens at age 6? Formal education begins. They are expected to follow rules, attend for long periods of time, follow multiple directions. Language has to be pretty solid by 8-9 years of age for them to perform as expected in school. Language processing is of even greater help now. Self-talk emerges! They begin to use silent, verbal mediation!!! But, again, remember, if language skills are poor, self-talk will be poor… Simple problem solving also appears. They become more cognitively flexible – actually there is a spurt in mental flexibility at this time. The ability to generate alternate strategies emerges, as well as the ability to learn from mistakes. There is an increase in purposeful behavior and a decrease in perseverative behaviors Goal-setting and the desire for achievement is evidenced by more frequent strategic efforts and more planned choices and behaviors. This is when students begin to be expected to use their frontal lobe (EF) independently.

31 7 - 9 Year Olds Typically, language is well-developed
Attention skills more selective and deliberate Language is usually well-developed. We see continued use of silent, verbal self-talk. There is a rapid surge in planning & organization. Efficient reasoning becomes more obvious. They can manage more task parameters. Attention skills become more selective and deliberate. They are better at switching between rules and sets of conditions. Better at switching between rules and sets of conditions

32 Ten Year Olds Nearing maturity in ability to selectively attend and identify relevant information 10 year olds are nearing maturity in the ability to selectively attend and identify relevant information. There is a significant increase in complex reasoning and strategic behavior. They have much better impulse control and are able to consider task requirements over their own personal impulses. Significant increase in complex reasoning and strategic behavior Able to consider task requirements over personal impulses

33 11 – 12 Year Olds Language abstraction significantly increases:
Ability to learn from mistakes Ability to generate alternate strategies Goal-setting for complex issues Problem solving, and planning & organization complexity Attention skills are relatively mature. Students can inhibit irrelevant, perseverative behaviors. Self-monitoring is apparent. Language abstraction significantly improves [count on fingers]: Ability to learn from mistakes Ability to generate alternate strategies Goal-setting for complex issues Complexity of problem solving, planning, & organization Problems occur when average or above language skills can’t be used to reason.

34 Adolescents Significant increases in all skills and relative maturity of: Significant increases in all six component skills and relative maturity of: Attention & inhibition Working memory Language processing Cognitive flexibility Decision-making Deliberate behaviors Multi-goal oriented efforts Multi-strategy development [click] We also see a shadowing of the eyes and chin in both genders, [click] and a more prominent display of the navel, and [click] often prodigious use of “The Hand”, most often in the female of the species! Attention & inhibition Working memory Language processing Cognitive flexibility Decision-making Deliberate behaviors Multi-goal oriented efforts Multi-strategy development

35 Early 20’s Executive function skills come into full maturity!
Self-control Adaptive to change Goal-directed behaviors Avoid sabotaging efforts Ethical, moral, legal decisions Behave within parameters of society Executive function skills come into full maturity! Parents rejoice and give thanks! Have self-control Are adaptive to change Demonstrate goal-directed behaviors Avoid sabotaging efforts Make ethical, moral, legal decisions, and Behave within the parameters of society Now, mine is only 13, so I’m still hopeful that all this can happen in the next 7-8 years, seems unlikely, but I’m keeping my fingers crossed. What do you think about “maturity” in general these days? Too fast? Too slow? Too slow in some areas and too fast in others?

36 3 2 Motor 1 Sensory 2 1 1 2 Wernicke’s Broca’s
One of the key steps in identifying EF deficits in children is to better understand the specific brain structures involved in the normal acquisition and development of these skills, so let’s look at the anatomical and physiological components involved in EF. [Use laser pointer.] I promise, we won’t spend a lot of time on this, but I feel it is very important to understand where in the brain all of these skills are controlled. With regard to brain-behavior relationships, we know that different areas of the brain control certain things. We have the occipital lobe in yellow, the parietal lobe in red, the temporal lobe in green, and the frontal lobe in blue. The cerebellum is pink. In addition to these familiar structures, we are also aware of other major anatomical landmarks, such as . . . [click] The broad motor area with its [click] primary motor cortex along here and [click] the premotor (or secondary motor) area around here. The motor area controls our direct and indirect systems, sending messages to the cranial and spinal nerves and activating voluntary muscle movement. The premotor area sequences and programs complex, skilled movement plans. We are aware of [click] the broad sensory area with its [click] primary visual cortex here and [click] visual association (or secondary) area here. The primary area takes in the visual stimuli and the association area makes sense of it. The primary auditory cortex [click] is along here and the auditory association (or secondary) area [click] is around here. Again, the primary area takes in the auditory stimuli and the association area makes sense of it. And, of course, SLPs are familiar with the motor speech area, or (wait) Broca’s area, here [click], and the sensory speech area, or (wait) Wernicke’s area, here [click]. But how does it all work together? Remember earlier when I described tertiary processing? That’s here in the frontal lobe [click] within the prefrontal cortex. This is our “conductor,” the ultimate organizer, manager, or director, when it comes to making decisions, controlling behavior, and regulating performance. The frontal lobe, from an evolutionary perspective, is our most recent structure, and the prefrontal cortex is the most highly integrated part of the brain. It receives and processes input from our primary and secondary areas, as well as our internal states and drives. When the “conductor” fails, it doesn’t really matter how good the orchestra is. Wernicke’s 2 1 3 Broca’s 1 2

37 Prefrontal Cortex (PFC)
Integrates relevant prior learning and internal states Makes premotor cognitive decisions Mediates the temporal sequence of behaviors Produces context-dependent, relevant behavior The prefrontal cortex has four jobs. It … Integrates relevant prior learning and internal states with incoming environmental information. Makes premotor cognitive decisions, which allows us to consciously self-regulate behavior and modify impulses. Mediates the temporal sequence of behaviors. Produces context-dependent, relevant behavior that fits the requirements of any given group, culture, or situation. How does it do all of this? Association-processed information is sent forward to the PFC for tertiary processing, via afferent and efferent connections. Afferent=inside; Efferent=outside. These connections process the incoming information, compare it with internal states and previous experience, then plan, initiate, execute, and modify behavior accordingly. The PFC is intra-linked with the rest of the cerebral cortex, subcortical areas, limbic system, cerebellum, and on and on. It has three primary parts: the orbitofrontal PFC, the dorsolateral PFC, and the ventromedial PFC.

38 PFC Components Orbitofrontal = STOPS Ventromedial = DECIDES
Dorsolateral = ACTS Without going into much detail at all, [click] the orbitofrontal PFC controls our brakes. It blends the external with our internal to inhibit impulses and drives, and engages the other two PFC components for judgment and organization. [click] The ventromedial PFC decides. It helps the orbitofrontal balance the influence of emotion, mediates social behavior, and observes social conventions. It weighs the options, balances right and wrong, and delays immediate gratification. [click] The dorsolateral PFC acts. It organizes new information and complex behaviors, monitors timing and sequencing, makes inferences, and evaluates outcomes. These components also work closely with the limbic system, which is the seat of our oldest, most primal, internal drives, such as anger, hunger, fight/flight, heart rate, and adrenalin, to override emotional and impulsive behaviors. The limbic system also mediates motivation. Now, I would like everyone to place the back of your dominant hand against the middle of your forehead, quickly move it laterally away from the skull, and say “Whew!”

39 Let’s take a break! Please return in 10-15 minutes.

40 Dx: Executive Function Disorder?
So what happens to self-guided behaviors and mature independence when development of EF is atypical or something else goes wrong? [Read slide] . . . which could occur due to: [count on fingers] TBI at any age or any type of neurological damage to the PFC or FL. The profile of EF deficits suggest that problems don’t become evident until the student moves into the next developmental phase. Developmental disorders and delays, obviously including speech and language impairment OR A variety of medical diagnoses and syndromes, such as autism, Asperger’s, ADHD, NVLD, FAS, William’s Syndrome, Tourette’s, Fragile X, environmental deprivation, schizophrenia, or bipolar disorder. In her presentation as well as her book, Fahy described specific groupings, or profiles, of EF deficits that are characteristic of each of these diagnoses, which, after the first 2-3, began to blur together . . . [Play dream transition music.] It was as if all these component pieces slowly became the ingredients at Taco Bell, you know, attention and inhibition were meat and cheese, working memory was the tortilla in whatever formation (because it holds everything in one place), goal selection was the toppings, planning/organization was the construction sequence, initiation and persistence became the condiments you add yourself, and flexibility was whatever you might have special ordered (added/removed). Execution and goal attainment was the final product’s name (profile): taco, nachos, burrito. Self-Regulation was the notion of how well this combination represents what I know or expect about tacos, nachos, or burritos Asperger’s, ADHD, right? and is why I chose not to go into such detail, EXCEPT for SLI, which I will go through in a minute. I suggested to her and have provided for you, a chart which identifies in a very basic way, the EF deficits that are associated with each of the different disorders listed. For a full understanding of these individual EF profiles, I highly recommend you buy her book. But – to answer this question . . .

41 Poor Attention Poor Working Memory Poor Planning Poor Inhibition
What happens is a kind of cascading failure, depending on where the breakdown in skills or development occurs. Poor attention (can’t ID relevant info, minimal self-awareness or self-correction) . . . Leads to poor working memory (ineffective storage, incomplete responses/reactions) . . . Leads to poor inhibition (no monitoring, judgment, or correction, no emotional control) . . . Leads to poor goal selection (can’t apply prior experience, can’t anticipate or predict) . . . Leads to poor planning and organization (can’t accomplish tasks, no sequencing) . . . Leads to poor initiation and persistence (no action, cue-dependence, forced choices) . . . Leads to poor flexibility (perseveration, obsessive tendencies, failure to react) . . . Leads to poor execution and goal attainment (incompleteness, no awareness of time, no self-monitoring) . . . Leads to poor self-regulation (what Fahy called a “pathological” lack of awareness, can’t adapt, no generalization). Can we as SLPs, or is anyone, using the specific diagnosis of “EF Disorder?” I think for adults, probably. I found a couple of websites, support group kind of stuff, where adults use that “label” to describe themselves and their difficulties, but I don’t know if it was formally given to them, or if they’ve just chosen to use it. Also “Boss” disorder. I’m not so sure if it should be used by us as a label for children -- yet. Maybe in the absence of any thing else, it could become useful. Fahy indicated that she has begun seeing it more often from pediatric neurologists and neuropsychologists. We probably have a lot of kids in schools labeled LD who would be more appropriately considered to have an EFD. But is it a subset of ADHD or its own Dx? I guess we’ll have to wait on the DSM. Regardless, I do believe that language therapy is incomplete for many children when goals targeting EF skills are not included. For some students, as language improves in therapy, so will EF. For others it will need to be explicitly targeted. [Walk to Therapy Pie poster and draw a new pie with 4 pieces.] We may need to divide our “Deficit” piece. How many of you have students on your caseload right now (or maybe recently dismissed from therapy) who are beginning to “test out” even though you know, the teacher knows, and maybe even the student knows that they are still having difficulty? Poor Initiation Poor Goal Selection Poor Execution Poor Flexibility Poor Self-Regulation

42 Difficulties intensify as academic demands increase!
EF Deficits and SLI LEFT Crystallized Verbal? Syntax-Based Impaired attention Impaired inhibition Poor organization for sentences, narratives Poor strategy development and planning Decreased flexibility Difficulties intensify as academic demands increase! [PREP: Associated Impairments handout] Do they look like this? Syntax-Based Impaired attention which disrupts working memory Impaired inhibition, such that they can’t suppress irrelevant information Poor organization for sentences and narratives Poor strategy development & planning Decreased flexibility, such that they can’t develop alternate plans Difficulties intensify as academic demands increase! These are left hemisphere kinds of deficits.

43 Difficulties intensify as social demands increase!
EF Deficits and SLI RIGHT Fluid Performance? Semantics/Pragmatics-Based Failure to readily develop social relationships Impaired emotional perceptions Impaired social play Poor or no interpretation of facial expressions Difficulties intensify as social demands increase! Or this? Semantics/Pragmatics-Based Failure to readily develop social relationships Impaired emotional perceptions Impaired social play Poor or no interpretation of facial expressions Difficulties intensify as social demands increase! These are right hemisphere kinds of deficits. Please take out a handout, or chart really, called “Associated Impairments,” which was originally in the form of slides that came right after the summary of components and before anatomy/physiology – but it never felt like the right place or transition because all the impairments associated with EF are so communication- or language-oriented, even though only one heading is labeled Communication. When I got to this section on EF deficits and SLI, I found myself repeatedly flipping back to those slides to see if I could label the specific descriptors (bullets) as either “syntax-based” or “semantics/pragmatics-based”. And for the most part, I could. And if I couldn’t, I used “left” or “right” hemisphere, instead. So – from that exercise, came the thought “Group Activity!”, which I felt might give us all a better understanding of how EF and SLI are connected. So – Let’s engage in a group thought exercise by completing this chart together. There are no wrong answers. It’s just an activity to get us processing this information at another level. Don’t worry about the C/F and V/P columns just yet. We may come back to those. One area of impairment associated with an EF deficit (or disorder) is Communication [click]

44 Associated Impairments
Communication Disorganized discourse Tangential, wandering narratives Failure to comprehend main theme or idea Reduced ability to use self-talk to mediate Inattentive, impulsive listening Lack of initiation . . . Communication. You may see . . . Disorganized discourse, either verbose or incomplete [SYN-L-C/V] [Switch btw last 2 slides] Remember, syntax-based means and semantics/pragmatics-based means . . . Would you consider disorganized discourse to be syntax-based or sem/prag-based? OK Another EF deficit associated with the area of Communication is . . . Tangential, wandering narratives lacking in point and sequence. [SEM/PRAG-R-F/P] Is this more syntax-based or sem/prag-based? Why? [Work through handout; Switch btw last 2 slides as needed] Failure to comprehend main theme or idea despite understanding of specific words or sentences [SEM/PRAG-R-F/P] Reduced ability to use self-talk as a means of verbally mediating cognition and EFs [SEM/PRAG-R-F/P] Inattentive, impulsive listening that affects comprehension or memory [SYN-L-C/V] Lack of initiation which limits completeness of communication [SEM/PRAG-R-F/P] Get the idea of what we’re doing? No answer is wrong. I just want you processing a little more deeply about each of these.

45 Associated Impairments
Pragmatics & Social Interaction Poor ability to take others’ perspective Inability to transition Impaired recognition of nonverbal cues Poor inhibition of impulsivity Inaccurate judgment Inappropriate behavior Another area of impairment associated with an EF deficit (or disorder) is in . . . Pragmatics & Social Interaction. You may see . . . Poor ability to take others’ perspective [SEM/PRAG-R-F/P] Inability to transition [SYN-L-C/V] Impaired recognition of nonverbal or subtle cues [SEM/PRAG-R-F/P] Poor inhibition of impulsive desires or plans [SYN-L-C/V] Inaccurate judgment of situations [SEM/PRAG-R-F/P] Inappropriate, impulsive, or dangerous behavior [SYN-L-C/V]

46 Associated Impairments
Processing & Reasoning Limited abstract reasoning Difficulty recognizing relevant versus irrelevant input Difficulty drawing conclusions Difficulty making inferences Limited divergent thinking Limited ability to predict Another area of impairment associated with an EF deficit (or disorder) is in . . . Processing and Reasoning. You may see . . . Limited abstract reasoning [SEM/PRAG-R-F/P] Difficulty recognizing relevant vs. irrelevant input [SEM/PRAG-R-F/P] Difficulty drawing conclusions and making inferences [SEM/PRAG-R-F/P] Limited divergent thinking [SYN-L-C/V] Limited ability to predict consequences or outcomes [SYN-L-C/V]

47 Associated Impairments
Problem-Solving & Learning Impaired strategic thinking Limited ability to generate multiple solutions Difficulty generalizing Trouble learning from consequences Impaired ability to complete tasks Impulsive attempts Unable to recognize failure Another area of impairment associated with an EF deficit (or disorder) is in . . . Problem-solving and Learning. Can you see how I had trouble viewing these as “impairments associated with EF?” These areas are very representative of what SLPs also consider “impairments associated with SLI.” In this area, you may see . . . Impaired strategic thinking [SYN-L-C/V] Limited ability to generate multiple solutions [SYN-L-C/V] Difficulty generalizing to other contexts [SYN-L-C/V] Trouble learning from consequences [SYN-L-C/V] Impaired ability to carry out instructions or tasks to completion [SYN-L-C/V] Impulsive attempts with failed outcomes [SYN-L-C/V] Unable to recognize failure or the need to revise strategies [SYN-L-C/V]

48 Associated Impairments
Memory Difficulty retaining information Forget to execute tasks or be where necessary at a given time Recall information out of sequence Failure to integrate long-term memories Another area of impairment associated with an EF deficit (or disorder) is . . . Memory. You may see . . . Difficulty retaining information long enough to execute steps [SYN-L-C/V] Forgetting to execute tasks or to be where needed at a given time [SYN-L-C/V] Recall of information out of sequential or temporal order, including verbal directions [SYN-L-C/V] Failure to integrate long-term memories of past experiences into future decisions [SYN-L-C/V] These limitations may be seen in school, at home and in the community. Students who experience these deficits due to specific or indirect limitations in executive function often find themselves unable to effectively control or improve their performance. They may find it difficult to follow rules, leading to problems with discipline and transition. Social encounters may required excessive direction and modeling from parents. As they grow, the ability to learn self-care tasks or to solve more complex problems may be delayed or fail to develop, leading to compromised independence. Deficits in the ability to self-regulate and self-monitor will automatically mean the student needs more supervision than others. Put all of this together and you have recipe for failure in academics and, ultimately, community participation and vocational self-sufficiency.

49 Conceptual Differences
Traditional Tests: Control for every variable Provide scripted instructions Eliminate distractions Allow for very little novel thinking Eliminate opportunities for errors in planning or sequencing Examiner controls order of things and establishes goals and objectives As we move into evaluation of EF, I’d like to begin with some conceptual differences that must be acknowledged. Traditional Tests (especially standardized IQ and speech/language tests): Control every variable in the evaluation process. They provide scripted instructions. They describe the ideal setting which is designed to eliminate distractions. They allow for very little novel thinking, and . . . They eliminate opportunities for errors in planning or sequencing. The examiner controls the order of presentation, student behavior, and establishes goals and objectives. Now – given what you know so far about EF, what’s wrong with this type of evaluation process? When evaluating EF skills, you have to be able to let go of this structure and let the student do the thinking. You CANNOT build yourself into the testing process as the student’s PFC or FL. You must look for process first and outcome second. If you control the process, how can you identify deficits? We must learn how to step back and wait. We must learn how to watch the student fail. Then ask “Why are they failing?” Make notes on errors and find the pattern. But also look for solid fundamental skills to build on. By doing this, you identify where to begin to promote development (intervene/teach), OR where compensation is needed, OR where to make changes in the environment. What kind of classroom accommodations do you find yourself most often recommending? Do they address language deficits or do they really address EF deficits? Both?

50 Crystallized vs. Fluid Verbal Performance Vocabulary Verbal reasoning
Syntax, semantics Knowledge base Static demo of knowledge Detail analysis Performance Use of knowledge Use of language to develop strats Flexible, applied Nonverbal Perceptions Intuitions Gestalt analysis Another conceptual shift we must make in order to appropriately evaluate EF, is our view of intellectual processing. Most of us here are SLPs. We’re trained to focus on the “Verbal” type of intelligence. However, executive functions are best revealed within the “Performance” type of intelligence. Fahy uses the terms “crystallized” and “fluid” intelligence to represent “verbal” and “performance,” respectively. Crystallized intelligence refers to the use of acquired knowledge and learned skills in order to provide responses. It’s a stored body of acquired knowledge. When I had trouble synonomizing “verbal,” with which I associate output and interaction, and “crystallized,” with which I associate solid, unmoving, and maybe sharp . . . My Thought was to continue associating “crystallized” words keeping “verbal” in mind, and I came up with, factual, which lead me to accessible, or verifiable. So then, “crystallized” intelligence became for me that which, when demonstrated, could be verified in a book somewhere, something that could be read which is “verbal.” Most speech/language and IQ tests examine this . . . Rather than “Fluid intelligence”, which is reflected by how information is applied to perform inductive and deductive reasoning for novel, unfamiliar tasks that require integrative thinking. My Thought here, to help internalize this new term, is that “action” is necessary for it to be demonstrated or observed. There has to be some kind of movement, or “performance.” As we approach assessment, can we replace the words “intelligence” or “knowledge” with the word “language”? Should we . . .? L? Verbal or crystallized language. A stored body of acquired language? R? Performance or fluid language. Use of language to think and reason in novel situations? What do you think? Can we assume verbal = left-brain = syntax-based? And performance = right-brain = semantics/pragmatics-based? [click] It might be appropriate for us to begin thinking about assessment this way AND IF SO we’d be expanding our “therapy pie” to include not only remediation of stored language, but also remediation of the use of that language, both internally and communicatively. [click] If you haven’t already, take a moment to complete the top of the next page in your Notes handout and try to use the slide only to check your answers.

51 Assessment Options Formal Assessment Tools Informal Assessment Tools
Observations Interviews Rating Scales So – Now we have a better understanding of EF, its components, their development, and at least one or two ways they can be viewed with regard to SLI and the brain. Now – what are our assessment options? Before we review some of these formal assessment tools, remember that SLPs may be crossing into the realm of neuropsychology or your psych examiner. Before choosing any of these tools, you will need to check the examiner qualifications section of the sales catalog for required experience, qualifications, certification, etc. to make sure you are allowed to use it. In some cases, you may only be able to make suggestions to your school’s psych examiner. You definitely need to find out what tools they already use or have at their disposal. One formal assessment of EF that you might review is the BADS-C: Behavioral Assessment of Dysexecutive Function – Children. It assesses: flexibility novel problem solving sequencing efficient planning use of feedback impulse inhibition rule following It is appropriate for ages 6-18 (10+ is best) and provides age-scaled scores, percentiles, and an overall classification. It also contains a questionnaire which gives means and SDs compared to control groups and to impaired groups. However, the administration instructions are complex and students need fairly good language skills to participate. I’ve described a few others in your Behavioral Checklists and Formal Assessment Measures handout. They include: NEPSY (see below) Trailmaking Tests Porteus Mazes Rey-Osterrieth Complex Figure Test Wisconsin Card Sorting Test Mesulam Tests of Directed Attention Conners Continuous Performance Test Delis-Kaplan Executive Function System Figural Fluency Test Comprehensive Behavior Rating System for Children STROOP Task NEPSY: I couldn’t find what this acronym stands for, if anything, but it’s by Korkman, Kirk, and Kemp and available from Harcourt Assessments.

52 TREE A Quick Experiment
To understand the experience of having at least one of your EFs tested, I’d like to try a quick experiment. [click] Look at the word on the screen: TREE. If you are like most people, it is difficult for you not to quickly read the word. Most of us are so proficient at reading printed words that we cannot easily ignore them. In fact it takes considerable attentional effort to ignore them. This tendency to quickly read a word is used in the STROOP Task, which is a psychological test of attentional vitality and flexibility. The task takes advantage of our ability to read words more quickly and automatically than we can name colors. If a color word is printed or displayed in a color different from the color it actually names, for example, if the word “green” is displayed in blue ink, we will say the word “green” more readily than we can name “blue.” The cognitive mechanism, or EF skill, involved in this task is called directed attention. You have to manage your attention and inhibit one response in order to say or do something else. Directed attention - A combination of selective attention and inhibition? A paper version of this task, which I will simulate on the next slide, involves showing words that are the names of colors, with the actual words printed in a color of ink that is different from the color named. You are asked to respond with the color you see, and inhibit the word you read. It turns out that this is much harder than it sounds and research documents lower scores with increased attentional fatigue. As part of a study of the effect of high altitudes on mountain climbers, NOVA created an interactive web-based version of the STROOP Task, with three levels of difficulty, which is available at: My Thought: Attention being one of those prerequisite cognitive skills for EF, this task might be useful to us (SLPs) as a simple screener, on which you can base a recommendation for further assessment to your psych examiner.

53 STROOP Task green red brown white white brown green red
red white green brown brown green white red white brown red green green white brown red red brown green white For this experiment, we won’t time it or score it. I just want you to get an idea of how the task works and how it feels. Take a few minutes to name the color of each word displayed. If not quietly aloud, then at least move your articulators silently as if you were speaking aloud. How do you think you did?

54 Behavior Rating Inventory of EF
Best Buy: “BRIEF” Behavior Rating Inventory of EF Fahy’s #1 suggested tool, and the one she uses most often, is the BRIEF the Behavior Rating Inventory of EF (BRIEF), which assesses: Inhibition Shifting Emotional control Initiation Working memory Planning Organization Self-monitoring inhibition shifting emotional control initiation working memory planning organization self-monitoring It is available for preschool (BRIEF-P: 2-0 to 5-11), elementary age & adolescents (BRIEF: 5-0 to 18-0), and adults (BRIEF – Adult). There is also the BRIEF-SR, the self-report version. All of these, except the adult version, contain a parent form and/or teacher form. Each version is a rating scale based on 80 questions that provides T-scores (>65 significant), percentiles, and confidence intervals by age and gender. It takes about minutes to administer and minutes to score. It has good reliability and validity. Normative data is based on 1429 ratings from parents and 720 from teachers, and reflects 1999 US Census estimates for SES, ethnicity, and gender distribution. The clinical sample included children with dev disorders or acquired neurological disorders (e.g. reading disorder, ADHD, TBI, Tourette’s, MR, and high functioning autism). It’s published by PAR: Psychology Assessment and Research (qualification B). The BRIEF Intro Kit is $205, but I would recommend the BRIEF/BRIEF-SR Combo Kit FOR $325. There is also a BRIEF/BRIEF-P Combo Kit for $310. Another formal assessment option is to use the . . . Fluid Reasoning cluster, which is a stand-alone component of the Woodcock-Johnson (revised or III). It examines . . . novel, abstract reasoning nonverbal problem solving and concept formation utilization of instruction and feedback, and problem solving strategies I will be working within the Medicaid/AFMC Therapy Workgroup to have these two added to the recommended test list.

55 Informal Tools: Observations, Interviews, and Rating Scales
Observation Opportunities There are opportunities for informal observation of EF skills within problem solving tasks and social interactions. Enough of formal tests. What about observations and other informal measures? There are always opportunities for informal evaluation of EF within problem solving tasks and social interactions.

56 When Problem Solving . . . Watch for Overall independence and success
Novelty of problem Planning, organization, and reasoning used Adaptation Correction Self-monitoring When students are presented with solving a problem, observe for . . . overall independence and success novelty of problem planning, organization, and reasoning used adaptation correction self-monitoring

57 Possible Activities Tasks from and ZOOM Experiments
Cooking Building Designing Some possible activities include: Tasks from and the TV show ZOOM. Don’t let them watch the activity, but present the ultimate outcome (end product) requirements of the task. (I’ll talk more about this in a minute.) You can use . . . Experiments: Soda or salt water into fresh water, making silly putty or play dough. Go to your student’s science teacher or buy a book of simple experiments. Cooking: Pizza, bread, cookies, cupcakes. There are lots of children’s cookbooks and food “craft” books out there from which you can select activities. Building: Egg timer, milk carton boat, hurricane. Again, lots of books to choose from. Designing: Their own puppet, pillow case, box car, bulletin board, Halloween costume, stationary.

58 When Interacting Socially . . .
Watch for Types of behaviors “Normalness” of interaction Use of social conventions Awareness of . . . Rule-following Overall self-awareness When students are interacting socially, observe for . . . types of behaviors pragmatics “normalness” of interaction observance of social conventions awareness of need for adaptation and flexibility awareness of other’s perspective and reaction rule following overall self-awareness

59 Possible Activities Games Group crafts Running errands
Making purchases Ideally, you want to observe natural, unstructured opportunities that require cooperation and interaction. But, given the time constraints within the school setting, and as it was suggested to observe problem solving, you can set up games, like Jenga, or group crafts that require a joint goal where sharing and dependence on others is necessary to achieve success. You may want to deliberately sabotage, or set up “road blocks,” for some of these activities, like not bringing enough, or all needed, materials. Asking the student to run errands or make purchases are other possible activities.

60 Informal Assessment PROVIDE ultimate outcome (end product) requirements DO NOT provide plans or point out errors RESIST the urge to help ALLOW natural consequences WATCH for spontaneous use PROMPT only if . . . Only PROVIDE the ultimate outcome (or end product) requirements of a task. DO NOT provide plans. DO NOT point out errors. Let the student (or students) be in charge of the task. RESIST the urge to assist because it probably won’t help anyway, and you’ll sabotage your assessment and any result you obtain. Again, don’t become their frontal lobe. ALLOW natural consequences: failure, unexpected outcomes, inaccurate predictions, disorganized approaches, inefficient strategies. Take away the safety net! WATCH for spontaneous use of self-talk, inhibition, adaptation, and flexibility. Your observations (and possibly scores) should reflect process just as much as outcome. PROMPT only after you’ve identified a skill as absent; if . . . They perseverate with an unsuccessful action with no awareness. They cannot become relevant. They cannot generate a plan. They cannot establish a viable approach. They demonstrate no purposeful engagement in the activity or task. AND prompt just enough to see if they respond to and use it, or not. We must exit the clinical mind set. Executive function is most challenged in the real world. Test and treat in real environments as soon as possible.

61 Bottom Line for Assessment
Language Tools Where will student be in 10 years? Self-talk Reasoning Intent Making meaning Bottom line for assessment: [click] Language and executive functions are interdependent! They build on, support, and feed each other. We must be able to determine how well the student uses [click] the language tools of self-talk, reasoning, intent, and making meaning as they relate to [click] the social skills that guide success on the playground, making friends, establishing personal connections, and overall emotional development, (Is this RIGHT hemisphere stuff?) as well as how well these tools are used for [click] problem solving to achieve academic success, pre-vocational and self-help skills. (Is this LEFT hemisphere stuff?) Your job as diagnostician is to identify disorder as usual for that disorder, in our case SLI, but add an EF component to your battery, like the BRIEF! Become familiar with the EF profile of deficits for SLI. (We’ve worked on that!) When SLI is secondary to, or a component of, another diagnosis, such as ADHD, autism, Asperger’s, or TBI . . . Identify and review the EF deficits profile for that diagnosis. Identify the LEARNING profile: Is verbal > performance? OR Is performance > verbal? (This tells you RIGHT vs LEFT hemisphere.) Identify PRAGMATIC baselines. Then determine where skills begin to breakdown. Where’s the functional problem? Academics, social skills, home, community? What skills are in place? What skills are missing? Can you explain academic or behavioral failures in this context? What language skills can you begin to work with? And think about the information on our Therapy Pie poster. [click] How will you weight each piece of your intervention plan, so that you can predict “Where the student will be in 10 years?” Will you need a “developmental” approach OR a “rehabilitative” approach? EFs Problem Solving Social Skills Academic success Pre-vocational skills Self-help skills Playground success Friends, Connections Emotional development

62 How Do I Capture Behavior?
Build or borrow an observational worksheet that uses . . . Yes/No format Continuity format Context format Degree of independence format One last small section regarding informal assessment . . . [read slide title] Build or borrow an observational worksheet that uses . . . Yes/No format: Is EF skill present or not? Continuity format: If present, is it used consistently or not? Context format: If present, is it used in X situation, but not Y? and/or Degree of independence: If present, what is the level of support? In your Behavioral Checklists and Formal Assessment Measures handout, you should have a modified copy of Fahy’s worksheet, Informal Assessment of Executive Function Skills, which is contained in the Source text listed in your References handout which I probably shouldn’t be giving to you, BUT HEY, I borrowed it from Fahy, so . . . Her text also provides more examples of activities to use for informal assessment, several testing profiles, and some report examples within the chapter on assessment, which I highly recommend you read along with the rest of the book!!!!

63 Got Lunch? Please return in no more than one hour.

64 Concepts for Intervention
Educate Intervention First, let’s take a look at some general treatment concepts. Intervention for EF is multifaceted and not a simple linear plan. The SLP coordinating treatment needs to juggle a number of variables in determining the most effective treatment plan. We’ve touched on this idea already within our “Therapy Pie.” Part of the intervention approach will be to make changes to the external variables; part will be to improve language and EF skills themselves; and part will be to increase the child’s awareness and use of cues and compensatory strategies. Some of these things will be “tough,” but most are absolutely “do-able.” So, what’s tough and what’s do-able? [click] Educating parents and other professionals about EF deficits can be TOUGH. One of the most critical aspects of treating deficits in EF is conveying what the nature of the impairment is to those closest to the student. Parents have often been searching for years for some kind of explanation for the seemingly inconsistent elements of their child’s behavior. The same applies for teachers and other school professionals who work with the student. Just as we would explain the nature of phonological or semantic delays, we must assume responsibility for explaining what a deficit or delay in the development of EF skills means. They all need to understand the impact and ramifications of EF impairment on communication skills. Conversations of this nature can be delicate and demand both professional sensitivity and clarity. Parents and caregivers want answers, but sometimes such complex information can be difficult for them to internalize. The most effective discussions on this topic link specific examples of the student’s behavior to the underlying deficit in EF skill, combined with suggestions for making simple environmental modifications or using compensatory strategies that will offer immediate relief at home or in school. [click] Lowering or modifying expectations, even for the short term, is also TOUGH for parents and caregivers, and certainly teachers, to accept. The development of EF skills is an ongoing process that is constantly being updated and modified as new opportunities, expectations, and responsibilities enter the student’s life. The process of developing the critical thinking, the reasoning, and the focus needed to accomplish more functional independence evolves over time. The development of these EF skills is also dependent on a number of other prerequisite skills, which may or may not be in place. You will need to assist parents and teachers in understanding what the current realistic expectations should be for this student with regard to his/her EF skills. There might be a particular behavior or task that parents or teachers want the child to be immediately able to do, responsibly and independently, but the child may not be ready to perform that behavior or task because there are other skills that must be successfully attained first. Use your assessment hierarchy to help explain this and prevent unfairly-imposed expectations. [click] The other variables are more do-able, at least with respect to clarity of action and visibility of purpose. Teach EF Skill Expecta- tions D T EF Deficit Lang. Therapy Environ- ment D D Compen- sate Self D D

65 Did you note? Presence or absence of . . . Competing background noise
Overwhelming visual stimuli Physical constraints Other students Posted lists, reminders, organizational bins, or storage units Let’s start by modifying the environment. Hopefully, during your observations and informal assessments, you made careful notes about the surrounding environment, which describe . . . The amount of background noise that competed or interfered with processing. The amount of visually stimulating information present that was overwhelming. The presence or absence of physical constraints, like barriers or dividers that offer separate work space. The number of other students sharing the environment. The presence or absence of posted lists and reminders, as well as the types of organizational bins or units available. The structure and organization of the environment will have a huge impact on the student’s ability to function effectively. If minimal to no structural organization is externally provided, it is completely left up to the child to generate his own internal sense of how to organize the world around him. Cluttered environments make the student work much harder to identify priorities, find necessary materials, generate strategic plans, monitor and regulate the quality of work, and maintain focused attention on the task at hand. Disorganized environments also contribute to miscommunication, as distractions tend to disrupt joint interaction and conversation. Students predisposed to misreading social and/or nonverbal cues find it even more difficult to make these interpretations when trying to weed out irrelevant and competing stimuli at the same time. When the teacher or parent has provided a maximum amount of visual and physical organization, then the demand on the child is decreased, allowing for more independent success in communicating with peers, learning new tasks, and successfully completing familiar activities.

66 Modify the Environment
In the Classroom Balance white space with visual stimuli Create “quiet” areas and “loud” areas Specifically in the Classroom . . . Experiment with the amount of art on the walls, particularly in classrooms for students who are easily over-stimulated. Work to balance the amount of white space with the amount of visual stimuli. Create a flow plan for usage of space. Consider where “quiet” areas are in relation to “loud” areas. Provide all the necessary materials for tasks you expect the student to perform independently. Group similar items together, especially if they will be used together. Show and explain to the student your organizational system. (“All of these go here and all of those go over here because . . .”) Use labels, lists, and simple signs where appropriate. Make it easy for the student to access what he needs, get organized, and limit the amount of distraction that may interfere with independent completion of expected tasks. Any primary learning area should be designed so that the need for independently used EF skills does not go beyond what is developmentally expected for that setting. Remember, parents and teachers are the frontal lobe for young children in preschool and the early grades – so, too, can the environment support and guide learning, language, and EF growth. None of these are new ideas. We at Outreach have been preaching FOREVER on the importance of awareness of and modification of the environment for most students with disabilities. Our special educators currently have a training they can provide that addresses the “how to’s” for a lot of this. Provide all necessary materials Group similar items together Explain organizational system Use labels, lists, and simple signs

67 Modify the Environment
At Home Eliminate clutter, trash, unused items Maintain routine and consistency Monitor visual stimulation Provide visual schedules and chore lists Impose external barriers Specifically at home where we may have little, if any, control, it’s important to make sure parents understand the importance of . . . Eliminating clutter, trash, and unused items Maintaining routine and consistency in the environment. Don’t let things like clean laundry pile up and interfere with the organizational structure and accessibility of items in a space. Monitoring the amount of stimulation on bedroom walls. Providing visual schedules and lists for completing everyday routine chores. Imposing external barriers for things the child is not able to internally monitor for himself, such as placing child-locks on cabinets containing potentially dangerous materials, keeping the iron out of reach. In the classroom and at home, we have to de-junk the environment! This may be the quickest, easiest way to help initially. If a student cannot internally modify or control himself, change the environment until he can, or at least, is more successful. Organize visually, auditorily, and physically. Establish systems that will eliminate confusion (EX: use labels, pictures, color-coding, bins, files, shelves). Simplicity is the key. Provide external cues to remind or prompt the student. When possible, personalize these cues to narrow the student’s visual focus. (EX: white letters on a purple background) De-junking can be particularly useful for students who are hyperactive, inattentive, impulsive, or distractible. The idea is to make selective attention easier. Visual cues and prompts can be particularly useful for students who are poor planners, global thinkers, poor initiators, or easily distracted. Use cue cards with verb phrases in large print – adjust the words, colors, size, placement until they are used successfully. The idea is to make planning and task completion easier while working long-term to build the internal structure that will replace these cues. Fahy’s text provides “quick lists” of environmental modifications, as well as compensatory strategies, sample goals, and teaching tasks that are appropriate for different types of EF deficits (e.g. attention, impulsivity, self-regulation, flexibility, goal selection, etc.).

68 Good self-awareness requires attention and monitoring.
Improving Self . . . -Awareness -Monitoring Improving Self- [click] –Awareness, - Monitoring, -Evaluation, -Regulation The ability to use compensatory strategies to overcome deficits in EF skills, or to consciously apply intact EF skills to a given situation, requires self-awareness. This does not mean simply paying attention to the task, but rather, implies the metacognitive process of constant self-evaluation and assigning of value judgments to the cognitive and linguistic behaviors being executed. Paying attention to performance is only one part of self-awareness. Attention to a task without evaluating the quality of work being completed is fairly useless. A child could actually have good attention without being able to recognize the presence of errors or even failure on the task. Good self-awareness requires attention and monitoring. Another kind of “self-” skill is self-regulation, being able to act or behave in a certain manner right now in order to achieve a desired goal in the future. It is dependent on the ability to be aware of one’s actions and to apply some value judgment on the quality of work or communication put forth. Self-regulating behaviors are designed to meet long-term desired outcomes and require inhibition or initiation in order to alter words and actions accordingly. Good self-regulation requires awareness, inhibition, initiation, and evaluation. These “self-” skills can be impaired on a number of different levels. You may see a student who lacks awareness of his efforts, even when others perceive obvious disorganization, impending failure, or offensive social interaction. Or perhaps a student who can reflect on his performance, but does not have the capacity to evaluate the implications of his efforts, either for achieving an eventual outcome or to prevent disruptive interaction. Or you may see a child who is able to reflect on performance and behaviors, assign correct value judgments to these efforts, and is aware of the need to alter plans, but is unable to modify his performance or communication to fit the desired change, due to perseveration, difficulty generating alternative strategies, or the inability to initiate new efforts. The capacity of a student to be aware of and to regulate behaviors is fundamental to the generalization of other skills targeted in therapy, whether it is a specific language goal or an EF behavior. Learning any aspect of effective communication requires the eventual use of these skills. As SLPs, we already teach transition and generalization of skills. In the case of students with EF deficits, the internalization of skills and responsibility for appropriate use of metacognitive skills is likely to be even more difficult. As such, it must become a direct component of the treatment plan. -Evaluation -Regulation

69 Three Phases of “Self . . .” Intellectual Awareness Emergent Awareness
Anticipatory Awareness In the TBI literature, the redevelopment of self-awareness following an injury to the frontal lobe is broken down into three phases: Intellectual awareness refers to begin able to acknowledge that perhaps something is wrong with the ability to perform tasks that were executed independently before the injury. It often takes a tremendous amount of demonstration and convincing evidence for an individual to begin to recognize his deficits. It is often helpful, and even necessary, to set up a “planned failure” task in which you provide the individual with a task he claims he can do successfully and independently. Obviously, you should be fairly certain that the student will actually fail in his efforts. Videotaping the process may be very useful as well in providing the hard-core evidence the student may need to believe the impairment exists. Providing what may be painful information in such a direct manner is often necessary given that many of these students cannot process subtle or indirect information. Emergent awareness describes the condition of being more directly aware of specific deficits, whether they are in memory, language, reasoning, planning, etc. It is good treatment practice to repeatedly list the type of therapy they are receiving, what they are working on, and why. You must be clear, consistent, and able to communicate potentially unwelcome information in a sensitive, yet firm, manner. Students are likely to express a wide range of emotions as they begin to internalize this knowledge about themselves. Yet an increased awareness is vital if the student is to apply compensatory strategies, use environmental cues, learn specific skills, or begin to internally cue for improved performance. Old adage: You can’t fix a problem until you acknowledge that there is a problem. Anticipatory awareness reflects a level of awareness that promotes the anticipation of difficulty in applying a learned skill or compensatory strategy or in using an external cueing system to overcome a deficit. Without the ability to anticipate difficulty, there is no generalization. Skills learned in a controlled environment are only as good as how they are applied in a non-controlled environment. The unpredictability of real life demands constant self-appraisal and application of any number of skills and strategies to communicate effectively and perform life tasks. I cannot stress the importance of self-awareness enough. The ultimate outcome of a student’s goals will only be as effective as their application, based on the internal direction the student is able to provide. Ask the students on your caseload why they are in speech therapy. No matter what the goal, each one should be able to answer this question with at least some fundamental understanding of the purpose of treatment. In order for any treatment to be successful, a student needs to understand both the skill and strategy he is working to develop, as well as the implications it will have on his communication and behavior interactions. Don’t underestimate the capacity of even young children to understand what you are teaching them.

70 Compensatory Strategies
A student’s understanding of his own deficits, the knowledge that he is working on something, that he comes to speech for a reason, and that he has the capacity to affect some kind of change in his own life, can, and should, with your help, become his underlying internal motivation for improvement. The use of compensatory strategies may be an endpoint for some students, or it may be a temporary support or teaching tool to be used while the student works on developing independent skills. Unless your data suggests that the student can accomplish a given task independently, that is, without cues or prompts of any kind, then the student is still relying on externally driven help or supervision to elicit what should be a completely, internally generated process. (. . . Endpoint: May always need externally driven help to trigger some EF.) . . . Or a temporary support or teaching tool One way to assess the gap between “externally driven” and “internally generated” is to actually try teaching the student a simple strategy, then how to recognize when to use it, then how to self-cue it, and see how far you go, or how long it takes to internalize, from process to awareness to independence. I’d like to think I function independently at all times, but I’m sure I probably use a compensatory strategy here and there. Most of us talk to ourselves at least once a day, either silently or out loud. Why do we do that? To help prompt memory, organization, sequencing, and to double-check the quality of our thinking.

71 Self-Talk Externalized thought or thinking out loud
For a student to be able to provide himself internal direction, we must first teach him how to externalize his thoughts. Thinking out loud is an excellent strategy. Model! Model! Model! Provide: Verbal strategies Visual strategies Communication strategies Physical cues What am I doing right now? First I will _______, then I will _______. What am I supposed to be doing? Stop, Think, Plan, Do, Check What do I need to do? Stop, Think, Plan, Say, Check Am I working or playing? If I try X, Y might happen. Am I thinking or doing? What’s next? Plan first. Whatever works to make the child pause before acting. One of the best ways to teach self-talk is to use it yourself in a very purposeful way. You can also provide other verbal strategies. Keep them short and sweet. Make them a like a mantra. Anticipate need by saying it for them at the moment needed until they can say it themselves. Provide visual strategies and make them portable. Use key rings, checklists, small photo albums, cue cards, small white boards Use tally or check marks, color coded prompts, crossing out when finished or a finished box. Provide communication (or advocacy-type) strategies. I don’t understand. Show me again. Please wait. I need more time. I’m confused. Please say that again. I want to, but I don’t know how. I’m thinking. Help me get started. I need help. I need you to . . . Provide physical prompts. Light touch to elbow, chin, or face Force eye contact Knee to knee or face to face Firm “uncurling” of muscles Hold hand Pair physical prompts with short verb phrases

72 All these strategies are language-based.
Language for Thinking Read slide last. Infuse EF into language Tx and language into EF Tx Make language use meaningful Build metacognitive vocabulary Generate the idea that thinking is deliberate and useful Reinforce thru consequences Model “thought bubbles” and self-talk When should we expect the student to be able to apply these strategies? After . . . You’ve fixed the environment You’ve done some language therapy You’ve worked on awareness You’ve introduced the idea of strategies and solidified knowledge of some Now, you’re ready for the student to begin applying them. All these strategies are language-based. Language is the abstraction we use to express thoughts; Language is the tool we use to qualify our efforts and to represent ourselves to others in a socially recognized manner. We combine our language with our EF to achieve the most independent and successful outcomes possible. Compensatory strategies for EF are mediated and activated by language. It is typical for children with delayed or underdeveloped EF skills to also present with specific deficits in core speech and language skills. If significant processing deficits are part of a student’s S/L profile, then you must address those language skills before expecting any significant improvement in EF. Remember, language is the tool. Acquisition of specific speech and language skills is prerequisite to the ability to integrate them into a functional whole. WHY? Sensory stimulation is channeled to the appropriate lobe of the brain for processing and association. Once this stimulation becomes meaningful information, it is integrated with stimulation from the other lobes and sent to the frontal lobe and motor strip to formulate a response, simple to complex. If inaccurate or incomplete information is sent to the frontal lobe, it is a foregone conclusion that the EF response will be faulty. The Orchestra Analogy we began with this morning, highlights this idea. A student cannot adequately contribute to an orchestra if he doesn’t yet have the skills to play a musical instrument. So – [read slide] Infuse EF into language Tx and language into EF Tx in the right proportion. Make language use meaningful by addressing skills through projects and real-life contexts. Build metacognitive vocabulary, like the words “think, know, feel, want, need”; These words are so abstract, you must provide an appropriate task or context to express them. meaningfully. Generate the idea that thinking is deliberate and useful. Reinforce learning through actual consequences, rather than praise. Model “thought bubbles” and self-talk when teaching and with other adults.

73 Syntax for Prediction Cannot predict without logic
Cannot comprehend logic without an “if-then” construction Cannot refer to past or think about future without tense Cannot reverse thinking without active and passive verbs Cannot separate self from others without morphology We use different aspects of our language for different types of thinking. Syntax is needed in order to predict. [read slide]

74 Semantics for Reasoning
Need vocabulary to support concepts Need concept analysis to reason (compare, contrive, and deliberate) Need reasoning to strategize Need strategies to succeed Words, language, thought Semantics is needed in order to reason. [read slide]

75 Language and Discovery Learning
Discovery Learning allows for both the teaching and the application of syntax, semantics, and pragmatics skills. Discovery Learning is hands-on, inquiry-based learning. It requires active problem solving and engagement, demands the recall of prior experience and knowledge to deal with an immediate task or situation, and takes advantage of natural consequences to build understanding. Again, PBS and ZOOM have excellent examples activities. We learn most things best by doing. Many of us talk while doing. The reason Discovery Learning is great for developing language and EF is that is allows so much opportunity to build the vocabulary of thinking of inquiry of prediction of strategic planning. We want our students to become efficient self-talkers as much as other-talkers. Learning from natural consequences . . . . . . Prompts thought . . . Thought prompts action . . . Action prompts the vocabulary of “Oh I see.” Taking advantage of natural consequences also allows you to promote the . . . . . . Vocabulary of Plan B . . . Vocabulary of impulse control!! . . . Vocabulary of strategy-use . . . Vocabulary of awareness!!

76 Treatment Planning Before beginning a direct EF treatment plan, you should feel confident that you have identified which EF skills are in deficit and which are intact. You must also decide on what kind of hierarchy for treatment goals makes the most sense for the student. Obviously, you want to treat the source of the problem, not just the symptoms. Hopefully, these questions were answered by your assessment. You need to know . . . Are the foundation skills of attention and working memory impaired? Do the higher order self-regulation skills of monitoring and correcting efforts need to be addressed? What kind of organization skills does the child have intact? The structure I used in presenting this mornings information, the 3 underlying and 6 specific components of EF, attempted to separate all these different aspects into “discreet” skills, while also placing them in a relative hierarchical list. I say “relative” here because we know the process of applying knowledge to a given situation is fluid, with various executive functions overlapping and interacting with one another. However, determining where to begin therapy and which EF skills to target can be facilitated by asking why a particular task or interaction failed, then review where in the hierarchy that skill falls. If failure is due to poor attention and impulsiveness, for example, there’s no sense working on goal selection or planning and organization, even though those skills will also be in deficit. Maybe there is excellent attention and inhibition, and the ability to sequence ideas or break down the task into steps is available internally, but failure is due to an inability to select a goal and initiate action. Starting with initiation instead of goal selection is likely to be cause for difficulty and a drag on progress. Creating a treatment plan to address EF deficits requires a integrated approach that blends many, if not all, of the pieces delineated in that first diagram (slide 61: Concepts for Intervention). Just as the assessment must go beyond simple delineation of skills into functional evaluation of integrated communication abilities, the treatment plan must address both specific skills and their integration into functional life settings. Therapy goals need to encompass both immediate and long-term needs, with the ultimate goal being that the student is able to manage the most complex level of functional skills possible with the most independence possible. Some students can do all the discrete components well but are unable to initiate the effort or verbal interaction to reflect their internal organization and intent. Other students may demonstrate deficits that are apparent only when faced with unexpected changes or expectations, but do well when allowed to function within their own regimented routine. In the latter case, the student’s inflexibility is likely to reveal perseverative behaviors that lead to failure because he is unable to shift his attention or efforts accordingly.

77 Some students do quite well using their EF skills for thinking and problem solving but demonstrate poor self-regulation for emotional interactions and cannot process social information. Regardless of these various incarnations or deficit combinations, you need to identify the weakest or most basic component skill and integrate that piece into your treatment plan to work on it. Based on (Fahy’s) clinical experience, deficits in EF respond to different combinations of treatment approaches. Some areas respond well to increasing self-awareness and providing compensatory strategies that the student can use to overcome inefficient means of responding. Other areas respond well to changes in the way information is provided, combined with modifications within the environment. Teaching and repetitive drill of specific skill sets are the best way to address some aspects of EF, so the student learns how to respond or think in functional situations. Within a semester or school year, only target the 3-4 skills that will have the most impact. Plan to work on only one or two EF skills within any chosen activity or specific teaching opportunity. For example, a student may be able to attend to a task and initiate efforts but does so without first forming a strategic plan, without identifying or sequencing he relevant steps, and impulsively talks about off-topic information during the task. In this case, focus your treatment efforts on teaching the student to inhibit initiation of the task until he is able to state a plan, identify and sequence the steps, and redirect his language toward the plan he has devised. You would not, in this case, ask the student to work on increasing his attention to task or working memory. Nor would you focus him toward identifying process errors. You would stick to inhibition, sequencing, and task-relevant conversation skills. Goals might include use of self-talk to pause at the beginning of a task long enough to write down the plan and sequence. “Stop, think, plan, do” would be a useful approach. Before inhibition skills become internalized, however, you will be the one imposing restraint, either by withholding needed materials or by using verbal or physical cues to delay efforts until strategy can be verbalized. Efforts to teach specific EF skills may require a lengthy treatment period and a certain degree of patience from everyone involved. As students demonstrate improved quality of EF, begin to fade external supervision and cueing. Place more responsibility for the skill with the student until it has internalized for given set of circumstances. At that point, focus on generalizing the skill to a variety of environments and activities, which may mean a temporary return to external cues. There is one final consideration for designing therapy to address specific EF skills. It is difficult to say whether the repetitive practice of any particular skill, such as working on inhibiting impulsivity, actually improves the skill or whether increased awareness and deliberate use of compensatory strategies becomes internalized, thus resulting in better functional outcome.

78 Goals and Intervention
Determine WHAT, WHY, and HOW Blend easily measurable, functional outcomes Based on the bottom line for assessment, we know that language and EF are interdependent. You may have already been working on EF skills within your language therapy without knowing it or calling it that, specifically. Hopefully, you could take what you’ve learned so far today, integrate it into your current language therapy, and feel that you’ve upgraded your practices. But should you have students on your caseload who you now feel need a new proportion of direct intervention for EF in their Therapy Pie, I will review basic goal writing and specific intervention ideas for some of the various components of EF. The approach to developing treatment is dependent on our understanding of what is wrong and why; knowing whether it’s primary, secondary, or tertiary processing that requires intervention? As SLPs, we are ideally positioned to combine our knowledge of child language with EF abilities to help students achieve their potential. We cannot successfully accomplish this without first determining what we are working on, why, and how to work on it. What and Why should be answered within our evaluation process. The How of a treatment plan must reflect a consideration for the primary disorder – the diagnosis that accounts for the presence of the EF problems – and be consistent with the techniques that are successful for that disorder. The “What – Why – How” needs to converge in well-written goals. Goals that reflect only the What, without consideration for the underlying Why and How, will very likely fail to be accomplished. Just as we need to understand the features of a class of sounds for designing a valid cycles approach to phonological deficits, we must also understand the features of EF deficits in order to write goals and treatment plans that will successfully overcome current deficits, promote continued development, and maximize a student’s future potential for independence. Goals can be written to include a focus on the underlying deficit, which is useful since it emphasizes the reason (Why) the student is unable to carry out a particular activity. Imagine a student with adequate language development who is unable to follow classroom directions due to impairments in attention and working memory. This student’s goals need to reflect a combination of variables: use of focused/directed listening (skill), dependence on external cues to focus attention (condition), monitoring length and complexity of information to process (condition), graduated degrees of accuracy (criteria), and gradual increases in the length of time the student is expected to maintain attention to task (criteria). For goals to be effective, they should blend easily measurable, functional outcomes with the underlying cognitive or linguistic process upon which the desired behavior is dependent. Goals should also include the type and amount of external cueing required for the desired outcome to occur in a specified environment. Environmental variables to consider and manipulate include “structured v. unstructured” and “distracting v. nondistracting.” with the underlying process being targeted Include type/amount of cueing Condition! Skill! Criteria! Manipulate “structured vs unstructured” and “distracting vs nondistracting” environmental variables

79 Example? The student will demonstrate
attentive listening in structured environments by demonstrating adequate processing and comprehension of simple directions needed to complete academic tasks, given moderate amounts of verbal cues and prompts, with 80% accuracy. The student will demonstrate attentive listening in structured environments by demonstrating adequate processing and comprehension of simple directions needed to complete academic tasks, given moderate amounts of physical and verbal cues, with 80% accuracy. Sounds like everything is covered, right? Let’s analyze this goal a little more. DEMONSTRATE – ARGH!!! What does attentive listening look like? How do you demonstrate it? What constitutes a structured environment? What kinds of verbal cues and prompts? 80% accuracy of what? attentive listening? processing and comprehension? task completion? These specific aspects need to be defined according to the individual, his disorder, and treatment strategies have to be incorporated into the goal if implementation is going to be successful. In this case, the student presents with ADHD, impulsive responses and actions, and poor attention to auditory information, concomitant with language processing deficits. Attentive listening can be achieved by simply priming the student’s attentional system to receive information, such as “Be quiet and get ready to listen. I’m going to tell you something important. Here are the directions.” A structured environment for this student is one in which the amount and type of distractions are controlled and predictable. Cues and prompts for this student include the direct verbal prompt “Get ready to listen.” Gestural cues are useful as well to nonverbally remind the student to hold responses until the desired moment, while encouraging processing time before initiating an activity. These are the necessary foundations upon which the language processing needed for following simple directions can take place. Writing a goal without these considerations assumes the student can internally mediate attention, working memory, and impulse control. The goal may be designed to facilitate language processing so that the student’s comprehension is accurate, but it will certainly fail if we do not lay the foundations (EFs: attention, self-regulation, and planning) for the desired response.

80 Let’s take a break! Please return in 10-15 minutes.

81 Treatment for Attention Deficits
Visual scanning tasks Selective listening tasks Listening and repeating words Listening and repeating sentences Following directions Ignoring distractions Attention, impulse control, goal selection and prioritization, and initiation must all be in place for the student to develop Focused, Goal-Directed Efforts. Deficits in attention can impact the effectiveness of social interaction, problem solving, retention of new information with short- and long-term memory, and learning in general. It takes a considerable amount of self-regulation to focus one’s attention. The ability to carry out instructions or retain information accurately is also based in attention. The quality of attention to information has a significant impact on the accuracy of what is stored for later use (memory). Based on your assessment, you should already know if the student takes any meds, and may have already identified whether inattention is visually or verbally triggered, and whether there are other environmental triggers as well? I’ve already talked about appropriate environmental modifications – “de-junk.” A couple of possible goals . . . The student will follow one-step directions with 85% accuracy during functional tasks when given minimal verbal cues for focused attention. The student will recall and restate five related items in functional lists with 90% accuracy when given moderate verbal cues for attentive listening and use of compensatory strategies (repeat, rehearse, confirm). Sample tasks to increase attention and memory . . . Visual scanning tasks (rows of letters, numbers, symbols on a page. Student is given a target to cross out every time it occurs on the page. Selective listening tasks (similar to visual scanning except the information is presented verbally and the student is required to signify when the target is heard Listen and repeat lists of words. Start with 2-3 and increase to 5-7 words. Listen and repeat sentences, messages, descriptions. Start with brief single sentences and increase content and length. Present directions for the student to follow. Start with one-step related commands, increase to three-step related commands, and then to unrelated directions. Present a task in a controlled environment with minimal distractions. Gradually introduce planned distractions, like background noise, and increase complexity of the task.

82 Treatment for Impulsivity
Use negative consequences Withhold necessary materials or information Impose delays Use barriers or other games Use gestural cues and questions to delay Deficits in inhibition: There is a distinct difference between the perception that a student is a deliberate risk-taker, and understanding that a student is unable to regulate the impulse to act or speak before thinking. This is closely related to the capacity to regulate one’s behavior. Specifically, inhibition is the ability to exert deliberate control over initial reactions, emotional impulses, planning, or self-focused needs. It requires self-control, is somewhat dependent on and interactive with attention, and may also reflect an inability to determine an appropriate plan of action or interact in a flexible manner, socially. A few possible goals (social interactions) . . . The student will limit interruptions in structured conversation with peers to less than four times per topic when given moderate-to-maximum verbal and gestural cues. The student will take turns in structured play situations for 80% of opportunities when given minimal verbal reminders to use self-talk cues. The student will demonstrate preplanning for response to questions by delaying a response for 10 seconds for 80% of trials when given a visual timer. A couple of possible goals (problem solving) . . . The student will state intent and first two steps to a plan prior to initiating efforts for simple paper/pencil academic tasks 80% of the time when given moderate-to-maximum verbal cues. The student will independently delay efforts to solve novel problems for a 5-minute planning time with 75% accuracy. Treatment for impulsivity involves behavioral shaping more so than specific tasks. You must make the concept of “stop” as observable, tangible, concrete, and physical as possible. Examples include . . . Use negative consequences and withdraw rewards for impulsive behavior that exceeds rule boundaries. Withhold necessary materials or information until the desired delay-time has been achieved. Impose delays and gradually increase the length Uses barriers or other games that require a specific statement or where there is only one chance or move that is correct Use gestural cues and questions, like “What’s your plan?” or “Did you write anything down first?” to delay actions or words.

83 Treatment for Goal Selection
Compare and contrast exercises Interpretation of “if-then” statements Deductive and conclusive reasoning tasks Using hypothetical situations Inference-making exercises Using written lists of prediction outcomes to support memory and comparison Discriminating advantageous versus destructive plans With this foundation, the student may be ready to begin reasoning and self-directing. Basic self-talk and certain language requirements come into play. The student needs to be at least 8 years old, 10 is better, before predictions can be reliably expected. Deficits in goal selection and prioritization: The inability to identify a goal, whether simple or complex, immediate or long-term, may exist in combination with other deficits. The capacity to use language to prioritize and identify relevant cues may be impaired. The student may only select one aspect of the big picture to work on, without clearly identifying the global requirements of a task or interaction. A few possible goals . . . The student will identify and state the presence of a problem with 80% accuracy when experience various functional situations. The student will state the most relevant and appropriate solution to problems with 80% accuracy when given no verbal cues. The student will identify situations leading to problems with 75% accuracy when given visual context and input. Sample tasks to improve goal selection and prioritization . . . Compare and contrast exercises Interpretation of “if-then” statements Deductive and conclusive reasoning tasks Using hypothetical situations to foster predictions Promoting the ability to make inferences Using written lists of prediction outcomes to support memory and comparison Promoting the ability to select advantageous versus destructive plans

84 Treatment for Poor Initiation
Turn chores into “contests” Hang simple step-by-step lists Use music and rhythm Use simple verb phrases Give forced choices Use timers or time constraints Give first steps and subtask directions Divide tasks into smaller, more obvious steps Deficits in the ability to initiate deliberate, goal-oriented efforts can be a frustration to the student, teacher, and parent. Behaviors can include a student who shuts down physically or verbally, evidenced by prolonged silence or outbursts of frustration. Some are even unable to explain their frustration. The student may be described as lazy or unmotivated when the problem is actually very different. Use of external cues is very important. A few possible goals . . . The student will independently initiate use of compensatory strategies to request help for 70% of opportunities when help is needed. The student will generate and initiate a response 70% of the time when given two choices for the next steps. The student will demonstrate sufficient initiation and persistence to complete functional activities 80% of the time when given environmental cue cards and minimal verbal prompts. Sample tasks and modifications to promote initiation . . . Turn chores into “contests” to see how quickly or accurately they can be done Hang simple step-by-step lists for daily self-care tasks Pair physical activity with verbal expression Use music and rhythm to promote expression and movement Divide tasks into smaller, more obvious steps Use organizational systems to remind or prompt Give first steps and subtask directions Use timers or time constraints to prompt efforts Give forced choices for initial steps of a task Use simple verb phrases

85 Treatment for Planning & Organization
Plan itself is outcome, not execution Capitalize on the need for language Sorting and sequencing activities Teach and use key phrases Feature analysis Divide organization tasks into parts Planning & Organization and Shifting & Adapting skills must all be in place for the student to develop Cognitive Flexibility. Piaget’s stages of cognitive development is a good reference here. Deficits in the ability to plan and organize will prevent establishment of a strategic approach to problem solving, impede the creation of relevant strategies to meet goals, and delay the development of logical, hypothetical, and inferential thinking. Remember, planning and organization is syntactically complex. A few possible goals . . . The student will state three plans per task, with cues to generate multiple ideas and options. The student will state two viable plans per task, given maximum cues to organize thoughts before initiating. Sample tasks to promote planning and organization . . . Remember that the plan itself is the desired outcome, not the execution of the plan Capitalize on the need for language: State the plan, Write the plan. Real-life sorting and sequencing activities (junk drawer or other messes) Teach and use key phrases, like “Let’s make a list.” or “What comes first?” Feature analysis Divide organization tasks into parts (“Go get all the socks, now shirts.” or “All the things you can wear.”)

86 Treatment for Poor Flexibility
Verbal fluency tasks Design fluency tasks Simple real life activities Incorporate the unexpected Require plan shifting Structured, closed to uncontrolled, unpredictable environments Force sharing, joint effort, and common goals Deficits in flexibility (either in problem solving or socially) will prevent the generation of novel or creative solutions to problems, limit adaptability to changing demands, require significantly more supervision, and ultimately limit independence and self-sufficiency. Flexibility is dependent upon divergent thinking, abstract language, simultaneous processing, and self-evaluation. A few possible goals (problem solving) . . . The student will generate four potential strategies for simple problem-solving tasks when given maximum verbal cues to predict the outcome of each strategy. The student will identify failed strategies 80% of the time when given maximum verbal cues to compare results with intent for household chores requiring reading and listening comprehension for instructions. The student will improvise use of available materials to complete academic projects within a given time frame with moderate-to-maximum cues to generate alternative ideas. A few possible goals (social interaction) . . . The student will modify vocal intensity in structure therapy situations 80% of the time with moderate facial and gestural cues. The student will spontaneously share use of needed materials in three of five opportunities given moderate verbal prompts. Sample tasks to promote flexibility in problem solving and social interactions . . . Verbal fluency tasks (name as many items in a category as possible; require multiple meanings and verbal comparison) Design fluency tasks (nonverbal flexibility - make as many creations as possible using Legos, blocks, or oddly shaped items or objects, like on Who’s Line Is It Anyway?” Situational problem solving tasks (generate as many solutions as possible, regardless of quality, e.g. What would you do if . . .?) Simple real-life activities: science experiments, no-bake cooking tasks, simulated or real household chores Incorporate the unexpected – demands, changes, interruptions, such as limiting availability of one or more required items for a task Work from structured, closed environments to uncontrolled, unpredictable environments Force sharing, joint effort, and common goals

87 Treatment for Self-Skills
Use video- and audio-taping Chart problems and success Use a diary Role play Planned failure tasks Identify ineffective problem solving Compare predicted w/ actual accuracy Start in structured, nondistracting environments Transition less structured environments with planned distractions Generalize to unpredictable and distracting environments Self-awareness, self-monitoring, self-adaptation, and social perception of others, their emotions and nonverbal cues must all be present for the student to develop Self-Regulation and Social Competence. Deficits in self-awareness will prevent the development of a metacognitive framework. Deficits will cause inconsistent application or use of intact executive function and language skills. This results in ineffective problem solving as well as social or pragmatic breakdowns. All therapy plans, regardless of the target skills or primary disorder, should include an awareness component. A student’s ability to generalize across environments and function as independently as possible is inherently connected to the capacity to acquire self-awareness and monitoring. This may take up to two years to accomplish! A few possible goals . . . The student will state two reasons for attending speech therapy when given visual cues, discussion, or examples, as needed. The student will identify examples of conversational interruptions for 75% of instances when given visual feedback (e.g. viewing a videotape of self in conversation). The student will independently demonstrate use of three compensatory strategies to her parents in a structure clinical setting with no distractions during a functional practice situation. The student will identify 80% of all errors in completed work when given moderate-to-maximum verbal cues and use of examples in nondistracting, controlled environments. [Identification of errors (awareness) does not equal correction. Must have initiation, language, divergent thinking, memory, and use of comp strats to correct errors.] The student will use conversational repair strategies when needed during unstructured social interactions when given minimal reminders. Sample tasks to promote the self-skills . . . Video/Audio-tape undesired behaviors for objective concrete viewing. Chart inappropriate social interactions, as well as appropriate performance. Use a diary to record deficits and goal implementation. Identify ineffective problem solving by others. Compare predicted accuracy levels with actual accuracy levels Use role play and group interactions Use planned failure tasks to force ID of errors Begin work on self-correction/use of strategies in structured, nondistracting environments Transition to self-correction and self-driven adaptation in less structured environments with planned distractions. Generalize to unpredictable and distracting environments.

88 Questions? Comments? Thanks for coming.
Please complete evaluation forms prior to exiting. Thanks for coming. Presentation and accompanying handouts will posted to Shelly’s Communication Board. Shelly Wier, MS, CCC-SLP,

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