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Andrea Ogonosky, PhD. ESC XV June 11, 2012

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1 Andrea Ogonosky, PhD. ESC XV June 11, 2012
ADHD: Executive Function Dysfunction (I meant to behave…..but I forgot!) Andrea Ogonosky, PhD. ESC XV June 11, 2012 6/11/12

2 Core Symptoms Poor sustained attention (inattention, distractibility)
ADHD Strategies Core Symptoms Poor sustained attention (inattention, distractibility) Impulsivity (behavioral inhibition) Hyperactivity Attention is a multidimensional construct that can refer to alertness, arousal, selectivity, sustained attention, distractibility, orspan of apprehension (Barkley, 1988). The problem appears consistently to be one of the diminished persistence of effort or sustained responding to tasks that have little intrinsic appeal or minimal immediate consequences for completion. Impulsiveness or behavioral disinhibition in response to situational demands is frequently associated with ADHD. Like attention, impulsivity can be viewed as multidimensional in nature. Evidence of behavioral disinhibition is the hallmark of this disorder. Hyperactivity can be defined as the excessive or developmentally inappropriate levels of activity, whether motor or vocal. Restlessness, fidgeting, and generally unnecessary gross bodily movements are common. 6/11/12 Andrea Ogonosky, Ph.D. May 2002

3 Co-morbid Conditions Psychiatric Disorders
ADHD Strategies Co-morbid Conditions Psychiatric Disorders Oppositional Defiant Disorder (ODD) Conduct Disorder Antisocial/Delinquency Anxiety Disorders Major Depression Somatization Disorder 6/11/12 Andrea Ogonosky, Ph.D. May 2002

4 Associated Problems (School)
ADHD Strategies Associated Problems (School) Lagging in intellectual development over time (10-15 points) Underperforming in school Excessive variability in work produced Low average achievement Learning disabilities (25-35%) 56% of ADHD children may require academic tutoring, approximately 30% may repeat a grade in school, and 30-40% may be placed in one or more special education programs. 6/11/12 Andrea Ogonosky, Ph.D. May 2002

5 Associated Problems (Emotional)
ADHD Strategies Associated Problems (Emotional) Poor rule-governed behavior Immaturity Irritable, hostile, excitable Hyper-responsiveness toward others Low frustration tolerance Demoralization Dysthymia ADHD children have difficulties with adherence to rules and instructions. ADHD children has been observed to be less compliant with directions and commands given by their mothers than are normal children. 6/11/12 Andrea Ogonosky, Ph.D. May 2002

6 Associated Problems (Social)
ADHD Strategies Associated Problems (Social) Increased parent/child conflicts Selfish/self-centered More interpersonal problems Peer rejection due to intrusive behavior(s) Little regard for social consequences Immature play Fewer close friendships Shorter duration of dating 6/11/12 Andrea Ogonosky, Ph.D. May 2002

7 Associated Problems (Medical)
ADHD Strategies Associated Problems (Medical) More allergies, colds, otitis Enuresis (43%) Increased minor injuries due to accidents Motor coordination problems (affects handwriting) Sleep disturbances 6/11/12 Andrea Ogonosky, Ph.D. May 2002

8 ADHD and Self-Control Behavioral Inhibition (Barkley et al.)
ADHD Strategies ADHD and Self-Control Behavioral Inhibition (Barkley et al.) Behavioral control shifts from external to internal Greater motor control Behavior focuses on time and future Need to understand normal development of self-regulation. First year of life--develop ability to wait; to inhibit initial reactions to environment Executive system gives us self-control--requires self-regulation 4 executive functions--each started out as observable, public behavior; then gets turned on to control selves and make our self-directed behavior cover (disappears from public view as observable) As the functions mature, behaviors become private, internalized, covert Humans act to maximize the future over the moment--very effective way of dealing with environment. We delay consequences. 6/11/12 Andrea Ogonosky, Ph.D. May 2002

9 Executive Functions Directive capacities of the mind
Multiple in nature, not a single capacity Cue the use of other mental abilities Direct and control perceptions, thoughts, actions, and to some degree emotions Part of neural circuits that are routed through the frontal lobes 6/11/12

10 Executive Functions Frequently referred to as “the CEO of the
Brain” or the “Conductor of the Orchestra Better to think of Executive Functions as: A Team of Conductors and Co-Conductors of a Mental Ability Orchestra or … The Coaching Staff of a Mental Ability Football Team 6/11/12

11 Executive Functions Direct and control perceptions, thoughts,
actions, and to some degree emotions Part of neural circuits that are routed through the frontal lobes 6/11/12

12 Executive functions Diverse group of cognitive processes
Acts in a coordinated way to direct perception, emotion, thought and action Set of multiple cognitive capacities Act in a coordinated way to engage in purposeful, organized, strategic, self-regulated, goal-directed behavior. 6/11/12

13 Development of EF Self-regulation executive functions are developing from the first years of life well into adulthood, and possibly throughout a person’s entire lifetime. Large developmental shifts are noticeable, especially around a adolescence. Because EFs are developmental in nature, natural maturational delays and lags are observed. 6/11/12

14 Development of EF All EFs do not develop evenly. For any given individual, one EF can be more or less developed than any other EF at any given point in time. There is also great variation relative to chronological age. At the same age, different individuals will naturally vary considerably in their level of development of various EFs. 6/11/12

15 Development of EF Some EF-based clinical syndromes, such as ADHD, demonstrate clear patterns of delayed developmental progression. Barkley (1998) estimates developmental delays of about 30% associated with various EF processes such as Inhibit, Manipulate, Shift, Sustain, Time, Monitor, Correct. 6/11/12

16 Executive Functions are involved with cueing and directing :
Inhibiting impulsive responding; Stopping, or interrupting, and returning to, an ongoing activity; Directing and focusing attention, screening out interference and distractions, and sustaining attention 6/11/12

17 Executive Functions are involved with cueing and directing :
The initiation of effort Judging about the amount of effort required to complete a task …. Sustaining of a sufficient amount of effort to effectively complete the task 6/11/12

18 Executive Functions Shifts cognitive resources to focus on new demands , new conditions or new information Directs the efficient use of pattern and detail processing : Knowing when to focus on the “big picture”, when to concentrate on the details, and when to switch between the two). Monitors and regulates speed of information processing 6/11/12

19 Executive Functions Monitors and corrects task performance for accuracy and efficiency Oversees the selection of verbal-nonverbal and abstract-concrete processing mechanisms Directs motor output Directs the ability to mentally manipulate information (working memory) Directs the integration of multiple abilities to produce oral or written responses 6/11/12

20 Executive Functions Direct the efficient placement of information in long-term storage Direct the retrieval of information from long-term storage Regulates social behavior Regulates emotional control Enables self-observation and self-analysis Makes use of hindsight and foresight Enables the capacity to “take the perspective of the other” 6/11/12

21 Executive Functions and School
Acquiring Knowledge Demonstrating Knowledge Many new learning situations are structured in ways that reduce the need for strong executive direction Requires significant involvement of executive control processes. Because executive control is heavily involved in demonstrating learning, executive difficulties usually manifest as “Producing Disabilities” much more so than “Learning Disabilities.” 6/11/12

22 Learning Difficulties and Producing Difficulties
Learning Difficulties Only Often NOT recognized as a Learning Disability, even when severe Learning Difficulties And Producing Difficulties Recognized as a Learning Disability most of the time Producing Difficulties Only When severe, typically attributed to motivation or personality problems 6/11/12

23 Impact of EF and Learning
Although executive functions are used to guide cognitive processing involved in new learning, many new learning situations are structured in ways that reduce the need for strong executive direction. In direct contrast, demonstrating what has been learned usually requires significant involvement of executive control processes 6/11/12

24 Nonverbal Working Memory
ADHD Strategies Nonverbal Working Memory Imitation and vicarious learning Anticipation and preparation to act Awareness of self across time Spatial location Organization & reproduction of complex designs Less proficient at imitating sequences of simple motor gestures Psychological awareness of time 6/11/12 Andrea Ogonosky, Ph.D. May 2002

25 Verbal Working Memory Internalization of speech
ADHD Strategies Verbal Working Memory Internalization of speech self-description and self-reflection rule governed behavior (self-instruction) digit span mental computation the basis for verbal thought memory tasks hindsight, forethought, and planning In combination with NVM systems it gives us: reading comprehension and moral reasoning and guidance of behavior 6/11/12 Andrea Ogonosky, Ph.D. May 2002

26 EF and School Test taking can be exceptionally difficult for a student with executive difficulties if the test format emphasizes executive demands over content knowledge. 6/11/12

27 EF and School In the classroom, the task most frequently impacted by executive function-driven producing difficulties is written expression. 6/11/12

28 EF and Written Language
Poor grapho-motor control and lack of automaticity for handwriting. Poor organization of written material Poor retrieval cueing or poor generate cueing for idea generation or idea fluency when writing. Inability to use multiple self-regulation EFs at one time (e.g. hold, manipulate, retrieve with generate and execute). 6/11/12

29 Reading and EF Reading Decoding – poor use of one or more
self-regulation EFs (e.g., lack of attention to specific letters in words; saying words that “look” like the word on the page). Rapid Automatic Naming – poor executive control of language fluency processes. Reading Comprehension – poor direction of one or more self-regulation EFs (e.g., Focus, Sustain, Hold, Manipulate, Balance, Pace, Time, etc.) when reading for meaning. 6/11/12

30 Math and EF Poor cueing of Focus/Select, Monitor, and Correct functions when doing calculation routines. Poor cueing of hold, organize, manipulate and retrieve when setting up calculations or problems Poor cueing of organize, store, retrieve, execute when learning or applying rote knowledge (e.g. storing and retrieving multiplication tables). 6/11/12

31 Interventions General Two-Stage Approach to Intervention:
Attempt to Affect Internal Change Apply External Control As Necessary 6/11/12

32 Important Life Changes That Work! (Hallowell, 2005)
Positive human contact Reduce electronics Sleep (increase opportunities) Diet: balanced - eat protein at breakfast Exercise Prayer or meditation 6/11/12

33 Implications for Interventions
Intervene at “points of performance” Externalize all information Externalize sources of motivation Arrange immediate consequences for task initiation and completion Plan to provide interventions over the long-term Take over the now! Physically represent time--they have no sense of time! Externalize--post it, print it, put it in front of them. Externalize motivation--bring them into the now and keep it in place. If you don’t externalize motivation, then externalizing information will fail! Will probably always need something like token system. 6/11/12

34 Tier 1: Core Foundations
Build a Culture of Acceptance and Safety High performance expectations for all students Clearly articulated rules and consequences Strong student teacher relationships High level of parent and student participation Student connectedness to the school process Multiple opportunities for success with academic and social skill development Conflict resolution strategies actively taught and modeled (school-wide) 6/11/12

35 Building Internal Strategies
Providing students with feedback about their performance enables them to engage executive capacities more effectively to learn from their mistakes and improve future performance 6/11/12

36 Build Internal Strategies
Use IES guides to develop strategy instruction within Tiered interventions. Align anchor activities within instructional groups for repeated practice of strategy use within intervention. 6/11/12

37 Classroom Instruction (TIER 1)
To assure that executive function capacities are used to their fullest potential, it is important to state the goals of the learning process. Stating goals enables executive capacities, either consciously or nonconsciously, to engage the perceptions, emotions, thoughts, and actions, needed to achieve the goals. 6/11/12

38 Tier 1 In many ways, teachers ARE their student ‘s frontal lobes.
Providing prompts and cues are important to assure that children are engaged appropriately in the instructional process. Modeling good executive functions helps children see how they can self-regulate their own perceptions, emotions, thoughts and actions. 6/11/12

39 Homework: 7 Skills Parents Can Help Children Learn
Insure assignments are copied correctly and get home with proper books/materials Select work place at home Start assignments by reading directions and following them carefully Manages difficult or long-term assignments 6/11/12

40 Homework: 7 Skills Parents Can Help Children Learn
Maintains attention to boring tasks Checks work for accuracy and completeness Gets homework to school when done 6/11/12

41 Homework (Parental Responsibility)
Create Proper homework environment Quiet place Regular schedule Necessary supplies Teachers instructions and requirements are understood Awareness of child’s difficulties-inform teacher 6/11/12

42 Homework (Parental Responsibility)
Set homework goals-reinforce achievement Motivation: praise, self-monitoring Organize assignments 6/11/12

43 STRIVE FOR FIVE! Strong Positive Behavior Supports: School-wide, classroom, individual Highly structured classroom 6/11/12

44 Foster Positive Teacher Student Relationships
Pair and Share 6/11/12

45 Classroom Strategies (Self-Discipline)
Adopt classroom management and disciplinary practices that are proactive, instructive, and corrective Correct behavior fairly and consistently Arrange physical environment to reduce congestion and facilitate smooth and quiet movement of students 6/11/12

46 Classroom Strategies (Self-Discipline)
Use a variety of teaching methods to address various learning styles Review and discuss acceptable behavior expectations throughout the year Reinforce positive behaviors 6/11/12

47 Characteristics of a Positive Classroom Environment
Create a welcome and inviting atmosphere: Free from clutter Highly organized Daily routines established Rules visible and reinforced daily 6/11/12

48 How do you arrange a classroom to increase academic engagement?

49 Physical Arrangement of Classroom
Divide room into logical work areas: All students can be easily seen by teacher Maximize student personal space by arrangement of desks Establish traffic patterns Minimize areas of distractions Maintain distance between students and supply/storage areas 6/11/12

50 Principles for Managing EF
Externalize time, reduce delays Externalize important information Externalize motivation Externalize problem solving (chore cards) Immediate feedback Increased frequency of consequences Externalize time--bridging time Example of book report--Read book (externalize event), write 2 sentences, get 10 tokens. Break into small daily doses. Consequences as immediate as you can. Another example; page of math problems. Cut into strips (rows). Hand one row to child to complete. Child gets reinforced when completes row plus gets exercise and attention. Act don’t yak--manage consequences and shut up--it’s not an “information-deficit disorder!” 6/11/12

51 Principles for Managing EF
Increase accountability of others Use more salient and artificial rewards Change rewards periodically Touch more, talk less Act, don’t Yak Keep sense of humor Use positives before negatives--kids being punished enough! Anticipate--kids have no sense of time/no forethought--we have to break it down for them and anticipate. Keep perspective--”invisible but real” Priorities--keep in mind developmental priorities Forgiveness--formally teach forgiveness 6/11/12

52 Principals for Managing EF
Use positives before negatives Anticipate problems; have a plan Maintain a sense of priorities Practice forgiveness (child, self, others) 6/11/12

53 Command Effectiveness
Use imperatives, not questions Break down complex tasks to simpler ones Bridge time delays in tasks (use external cues to bridge tasks) Use single-step commands Praise initiation of compliance and reinforce throughout task Get attention before giving directions 6/11/12

54 Tier 2 Strategic Interventions

55 Conduct Functional Behavior Assessment
Tier 2: Informal data gathered through observations, consultations, review of teacher data and student products Purpose: To identify the function(s) maintaining problem behaviors antecedent events = triggers occurrence of behaviors consequences = maintains behavior episodes 6/11/12

56 Tier 2: Common Principles of Strategic Interventions
Positive Behavior Supports are used to motivate students. Corrective feedback is immediate. Students master content before moving on to more difficult activities. Professionals are trained to implement intervention with high level of fidelity: Practice with all staff to ensure consistency Meet weekly to problem solve and share ideas These are some of the important aspects of any tutoring program. The tutoring program should include a point system for motivation and provide students with immediate corrective feedback. Students should master content before moving on to more difficult tutoring activities. Students work with their tutor to set goals and learn how to self-monitor their learning. Training the tutors to implement the tutoring intervention effectively is a very important aspect of secondary prevention. When learning to implement the tutoring, tutors should be presented with demonstrations of each tutoring activity and have time to practice the tutoring strategies. Tutors should schedule practice time with one another before tutoring students in the schools. Tutors could also practice with age-appropriate students who are not the actual students to be tutored. Weekly meetings for the tutors should be arranged so tutors can share ideas, plan for upcoming tutoring sessions, and problem solve. 6/11/12

57 Tier 2: Behavior Reduction Strategies to Monitor
Responding to misbehavior Continuum of consequences established Consider misbehavior as a behavioral error: treat like an academic skills error Re-teach appropriate behavior Respond consistently and efficiently Observe the effects of behavior reduction strategy Punishment??? Behavior increases?? Respond early: avoid escalation, prolonged existence 6/11/12

58 RtI Team Roles in Tier 2 Ongoing progress monitoring of data (specifically ensuring fidelity of data collection) Social Skills Training Motivational Strategies 6/11/12

59 Targeted Group Interventions ADHD
Small group instruction within the areas of self-monitoring for problem solving, social skills, behavioral regulation Small group instruction for identified academic deficits. 6/11/12

60 Tier 3 Team Role: Intervention Implementation
Assist with intervention Fidelity checks at least weekly Revise when needed regarding fidelity Monitor progress Design and implement Provide feedback to teacher or parent 6/11/12

61 Tier 3 Interventions Prevention (Make problem behaviors irrelevant):
Schedule Curriculum (content, sequence) Instruction Skill Building (Teach desired behaviors) Teaching = delivering events that change behavior, not just delivering curriculum Replacement behaviors (maintain same function as problem behavior) Adaptive skills 6/11/12

62 Increase Behavioral Successes
Find the buried Treasures (Hallowell, 2005) Connect Play Practice Master Recognition 6/11/12

63 Determining Eligibility for OHI
Full and individual evaluation that is comprehensive Meet three prongs Eligible according to disability classification criteria Eligible due to adverse impact of disability on attainment of an appropriate education (using RtI data collection) Eligible due to need for special education (specially designed instruction and related services) 6/11/12

64 Questions Thank you for staying on task and engaged to a marked degree and for a long period of time! 6/11/12

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