Executive Functions: Big Ideas in Addressing EF in ADHD
Let's get more specific
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Executive function deficits in ADHD drive the symptoms seen in classrooms of difficulties with sustained attention, inhibition, and regulation of activity levels.
So what can be done to help address these deficits? |
It's important to understand that these EF deficits are considered "developmental," i.e., they are developing and their development will progress in a particular order. Remember when your kids were little and you wanted them to walk up the stairs one foot on each step? If you really helped them -holding their hand, pulling up as they moved, telling them what to do step-by-step, stopping them when they wanted to put that foot on the step with their other foot- they were able to "do" it. Of course, without those accommodations you were making, they would have climbed stairs just like other kids their age. But eventually, they became good stair-climbers! Even if you hadn't helped them, they would still have learned to climb stairs when their brain had matured. EF skills are like that - developmental. When the brain is ready, the skill will come online. Until the brain is ready, though, accommodations are crucial. |
There is a classic study of twins which was done by Arnold Gesell, PhD, MD. He studied a pair of toddler twins, who were not yet able to climb stairs. For the study, one of the twins was given daily practice and encouragement to climb stairs, and the other twin had no stairs to practice on. After six weeks of practice, the “trained” twin could climb the stairs, and the “untrained” twin could not. However, within one week of being given the opportunity to climb stairs, the untrained twin completely caught up with the trained twin’s stair-climbing ability.
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Kids take developmental steps when their brain is ready.
This is an important thing to remember.
There are other really important ideas as we begin to address EF deficits in students with ADHD:
This is an important thing to remember.
There are other really important ideas as we begin to address EF deficits in students with ADHD:
Environmental supports are supports that are "external" to the child. The key is to develop environments that compensate for EF deficits. If you go back to Barkley's theory that these kids are 30% delayed (or 3 to 5 years if that's easier) in executive functions, you can see that it will take some time to "catch-up" with typical children's EF skills. So these supports are likely to be in place for awhile.
Externalizing supports include externalizing time (Time Timers, bridging time by breaking tasks up), highlighting the important information (writing rules down and keeping them at hand), the source of motivation (when you are done, then you can...), and externalizing problem-solving strategies (writing down ideas and then moving them around as you think about solving the problem). We'll talk about specific supports when we get to the individual executive functions! |
Let's go back to little kids again for another example: potty training. Most kids are ready to learn to use the potty by 24 months - some are earlier and some are later, of course! To be ready to learn to use the potty, he must be physically and mentally ready and he must be motivated to learn. Now we've all heard of those kids who were "potty-trained" by 9 months. What this really means is that their caregivers were trained to take them and hold them over the potty at the appropriate times. They were given environmental supports to accomplish the task but didn't really have the brain maturation to use the skills without those supports.
So, for some children with ADHD who have been provided with effective and intensive environmental supports, their ADHD symptoms can seem "fixed." But just like the 9 month old who is potty-regulated (not potty-trained), the child continues to need intensive supports.
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While environmental modifications and supports can reduce the impact of weak EF skills, they require a lot of effort on the part of the teachers and parents to be successful. Thus, there is a place for teaching EF skills directly. Be aware, however, that there is not a lot of evidence that this type of direct instruction in EF skills transfers (and again, if the child is not ready developmentally, there is even less chance that direct instruction will pay off).
However, there are some reasons to consider some direct instruction, particularly in areas where the child's EF skills seem to be emerging. First, practicing the skills gives the child (and you) shared vocabulary so that as he matures and develops, you create another way to "cue" him. Second, children don't just develop the "whole" executive function all at one time. Practicing the skill may allow the child to begin to internalize some of the steps. Finally, you will have to teach the child how to use some of the environmental supports that you have identified he needs. For example, if you want the child to enter the classroom, put his bookbag and coat in the cupboard and start the "do-now" lesson, you might create a list in which he has to check off as he does each step. You'll have to teach him to use the list and monitor his use of the list for a period of time until he learns to be independent with the list. You may also have to continue to use some form of external motivation to ensure that he continues to use the list system over a longer period of time.
However, there are some reasons to consider some direct instruction, particularly in areas where the child's EF skills seem to be emerging. First, practicing the skills gives the child (and you) shared vocabulary so that as he matures and develops, you create another way to "cue" him. Second, children don't just develop the "whole" executive function all at one time. Practicing the skill may allow the child to begin to internalize some of the steps. Finally, you will have to teach the child how to use some of the environmental supports that you have identified he needs. For example, if you want the child to enter the classroom, put his bookbag and coat in the cupboard and start the "do-now" lesson, you might create a list in which he has to check off as he does each step. You'll have to teach him to use the list and monitor his use of the list for a period of time until he learns to be independent with the list. You may also have to continue to use some form of external motivation to ensure that he continues to use the list system over a longer period of time.
So don't hold his one successful moment against him for the rest of his life! One of the hallmarks of ADHD is inconsistency. In some circumstances (usually those that are novel, urgent, or interesting to the person), children with ADHD can "get in the zone" and their EF deficiencies appear to be lessened or even non-existent. If they lose those conditions, however, their situation deteriorates.
Additionally, skill weakness can be compounded by difficulty staying motivated. Motivation is an area in which students with ADHD often have struggles. A recent study has found a disruption in the brain's reward/motivation pathway related to dopamine. This disruption in the pathway appears to be directly related to the severity of the inattentiveness. The more inattentive the child seems, the more the pathway is disrupted. Additionally, this study suggests that children with ADHD don't respond to rewards in the same way as children without ADHD. The implication of this study finding is that ADHD might begin with a disruption in motivation which, then, leads to inattention and hyperactivity.
Additionally, skill weakness can be compounded by difficulty staying motivated. Motivation is an area in which students with ADHD often have struggles. A recent study has found a disruption in the brain's reward/motivation pathway related to dopamine. This disruption in the pathway appears to be directly related to the severity of the inattentiveness. The more inattentive the child seems, the more the pathway is disrupted. Additionally, this study suggests that children with ADHD don't respond to rewards in the same way as children without ADHD. The implication of this study finding is that ADHD might begin with a disruption in motivation which, then, leads to inattention and hyperactivity.
When children with ADHD are confronted by a job that they find tedious, boring, or unrewarding, they feel the urge to do something else....now! This is because boredom (a chemical state in the brain) is truly aversive to them. If you want them to stay at the task, you'll have to arrange for positive feedback frequently enough to combat the tediousness, boring-ness and unrewarding-ness of the task at hand. You can also arrange consequences (positive ones!) to help them stay motivated.
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Kids with ADHD often have difficulty delaying or inhibiting their responses. They see something more interesting and they pay attention to that, even if the task at hand is important. They tend to live in the moment, reacting immediately to that moment without thought (i.e., response inhibition). In order for a child to make a connection between a specific action and consequence (the cause and effect), he needs to be able to stop himself, think through and weigh the consequences of the behavior, and then allow these thoughts to guide his decision making about the behavior. For many children with ADHD, there is often a disconnect between thinking and reacting. It all just seems to happen at once! So they respond impulsively without using information about past experiences to guide their behavior. This is why kids with ADHD do not seem to learn from past mistakes as easily as their peers.
Impairments in working memory can also result in problems being able to "see what lies ahead". In other words, the child may have trouble keeping relevant information in his thoughts in order to make decisions about future behavior. In addition, kids with ADHD may experience a delay in the development of internal language -- the voice inside our head that helps us to "talk" to ourselves, contemplate what we should do, and then regulate our behavior. |
When you have a child who thinks and reacts impulsively, it is helpful if you can intervene and provide cues, reminders, incentives and guidance at the point of performance (the moment in time when your son must inhibit behavior to meet the demands of the situation). Your immediate feedback about his behavior -- pointing out, reinforcing, and rewarding him when he is displaying the behavior you want to see, and providing mild reprimands and redirection to help get him back on track when he is beginning to engage in inappropriate behavior -- will help him to "stop and think" or "put on the brakes" before responding. Your teaching and training in this area will also help him develop greater self-awareness. And as he becomes more aware and in-tune to situations, the more likely he will be to connect cause and effect and use it to guide his behavior.