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Executive Functions & ADHD: Overview and Intervention Strategies for Parents and Teachers by Adam J. Cox, Ph.D.
   
  Executive Functions is a term used by psychologists and related neuroscientists to describe a unique set of mental functions. Research has demonstrated that these functions are performed by the prefrontal lobes of the cerebral cortex, in conjunction with subcortical regions of the brain (limbic system). It is only within the last decade that executive functions have come to be fully appreciated for their impact on cognitive and emotional functioning, and more specifically, cognitive inhibition and initiation, self-regulation, and motor output. In general, executive functions are a collection of related, yet distinct abilities that provide for intentional, goal-directed, problem-solving action. Executive functions are conceptualized as metacognition in the sense that they orchestrate numerous subdomains of thought and action.
   
  Operational Definitions:
  Please note that executive functions have been described by various researchers using different terms. Although the different vocabularies occasionally lead to confusion, the actual observations of researchers have generally been similar. To better understand how executive functions shape a person’s behavior, various aspects of executive function are identified below:
   
 
  • Orchestrating short-term or working memory resources
  • Directing the storage of information in long-term memory
  • Directing retrieval of information from long-term memory
  • Monitoring and regulating speed of information processing
  • Overseeing alternation between pattern and detail processing
  • Inhibition of reflexive behavioral responses
  • Directing and sustaining attention while screening out interference
  • Interrupting and returning to an ongoing activity
  • Shifting cognitive resources to focus on new demands or a new hierarchy of priorities
  • Regulating social behavior including empathy and social sensitivity
  • Enabling self-observation and self-analysis
  • Applying hindsight and foresight in processing information
  • Modifying motor output and altering performance based on feedback
   
  As the above list makes clear, executive functions have a tremendous impact on our capacity to learn new information, perform what we already know, and adapt to new environments and challenges. The development of attentional control, future-oriented intentional problem-solving, and self-regulation of emotion starts in infancy and continues through preschool and school-age years.
   
  However, the demand for executive functions is limited until the upper elementary grades and, most notably, the middle school years (Holmes, 1987). As children make the adjustment from learning specific academic skills (e.g., reading writing, calculating) to applying these skills for learning content areas (e.g., literary analysis, report writing, algebra) the demand for the executive functions increases dramatically. As children enter middle school, they must also contend with significantly less organizational support than they had in elementary school.
   
  The following table has been suggested (Gioia et.al, 2001) as a guide for understanding how executive function deficits may affect children and adolescents in school.
   
  Executive Function Domains, Definitions, and Associated Behavioral Dysfunction
   
 
Subdomain Definition Dysfunction
Initiate

Beginning a task or activity


Has trouble getting started on homework or chores
Inhibit

Not acting on an impulse or appropriately stopping one's own activity at the proper time


Has trouble "putting the breaks" on behavior; acts without thinking
Shift

Freely moving from one situation, activity, or aspect of a problem to another as the situation demands


Gets stuck on a topic or tends to perseverate  
Plan

Anticipating future events, settings goals, and developing appropriate steps ahead of time to carry out an associated task or action


Starts assignments at the last minute; does not think ahead about possible problems
Organize

Establishing or maintaining order in an activity or place; carrying out a task in a systematic manner


Has a scattered, disorganized approach to solving a problem; is easily overwhelmed by large tasks or assignments
Self-monitor

Checking on one's own actions during, or shortly after finishing, the task or activity to assure appropriate attainment of goal


Does not check work for mistakes; is unaware of own behavior and its impact on others
Emotional control

Modulating/controlling one's own emotional response appropriate to the situation or stressor


Is too easily upset, explosive; small events trigger big emotional response
Working memory

Holding information in mind for the purpose of completing a specific and related task


Has trouble remembering things, even for a few minutes; when sent to get something, forgets what he or she is supposed to get
   
   
  ADHD and Learning Disorders
  By definition, all children experiencing ADHD have executive function deficits. Of particular importance to parents and teachers is the critical link between executive functions and ADHD. Ultimately, as described by Barkley (1988), individuals with executive function deficits and ADHD are “left with a form of temporal nearsightedness or time blindness that produces substantial social, educational, and occupational” problems via its disruption of day-to-day adaptive functioning. “Those with ADHD often know what they should do or what they should have done before, but knowing provides little consolation to them, little influence over their behavior, and often much irritation to others.”
   
  Effective working memory is essential to concentration. Most individuals diagnosed with ADHD have a problem retaining information in working memory due to inattentiveness or impairment in inhibiting environmental interference. When working memory is impaired, newly learned information is not fully encoded, and is thus unavailable from memory stores when searched for later. Virtually all of the executive function deficits indicated above have been observed in people diagnosed with ADHD. Neither ADHD or disorders of executive function come in “cookie cutter” forms. Rather, the expression of these syndromes is somewhat unique in each individual. Thus the basic rule in assessing these problems is to detect patterns of dysfunction. Of particular importance in assessing attentional problems is a child’s tonic level or general state of alertness. When children are understimulated relative to their own threshold for attention, learning and performance will be impaired.
   
  Intervention
  Executive function deficits, including ADHD, are neuropsychological syndromes that will be expressed similarly across different situations. When a problem behavior is observed in one area, but absent in others, there is a good chance that the problem is more environmental than biological; (of course there are some tasks, such as academic learning skills, that are generally performed in a single environment).
   
  Intervention comes in two primary forms: environmental adaptation and psychostimulant medication. Stimulants may provide relief by correcting the underlying neuropsychological deficit in behavioral inhibition. They are likely to be ineffective with problems related to initiation.
   
  In essence, teachers and parents can assist those with executive function deficits by acting as surrogate “executive controls.” This means providing an appropriate level of stimulation while reinforcing directives, goals, and related forms of future-oriented planning, organizing, and thinking. This means helping a child to understand the meaningful links between performance and outcome; clarifying for children the consequences of not initiating an action, or not inhibiting various types of environmental interference. Parents and teachers working together can expect to measurably improve a child’s ability to employ metacognitive skills by setting the stage for repeated rehearsal, and actively using reinforcement techniques; (as always, reinforcement is most effective when applied immediately and consistently).
   
  Consistency is also an important concept regarding environment. As children with executive function deficits learn to more automatically engage executive controls, they will find it easiest to do so in familiar environments where they have been appropriately reinforced for using these skills. 
   
  Unfortunately, it is not reasonable to expect intervention benefits to carry over to new places or dramatically new tasks. Everyone involved in helping those with executive function problems should recognize that learning challenges and/or behavioral problems are not attitudinally based. This is not defiant or lazy behavior. Those attributes imply a level of intention absent in those with executive function deficits. Such individuals may become easily frustrated or even prone to angry outbursts, but these behaviors are due to neuropsychological problems with self-regulation rather than maladjustment. Ideally, the “dysexecutive” child will be placed in a learning environment where she/he will receive the type of compensatory instruction that the syndrome requires.
   
  References:
  Simeonsson, R.J., & Rosenthal, S.L. (Eds.) (2001). Psychological and developmental assessment: Children with disabilities and chronic conditions. New York: Guilford Publications Inc. (see chapter 15 by Gioia, Isquith, &Guy).
   
  Holmes, J.M. (1987). Natural histories in learning disabilities: Neuropsychological difference/environmental demand. In S. J. Ceci (Ed.) Handbook of cognitive, social and neuropsychological aspects of learning disabilities (Vol.2, pp. 303-319). Hillsdale, NJ: Erlbaum.
   
  Barkley, R.A. (1988). Attention-deficit hyperactivity disorder; A handbook for diagnosis and treatment. New York: Guilford
   
  McCloskey, G. (2001) Executive functions overview: Operational definitions, clinical classifications and assessment methods. Unpublished.
   
 
 
 


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