IMPROVING SELF SUFFICIENCY: EXECUTIVE FUNCTIONS STRATEGIES

FOR CHILDREN WITH ASD

Jannel M. Phillips, Ph.D. Pediatric Neuropsychologist Henry Ford HospitalAnnette Richard, M.S. Neuropsychology Intern Eastern Michigan University

AGENDA

o What are executive functions?

o Common executive functioning difficulties in children with ASD

o How can we help?

o Additional resources

“BEN” Ben is an 8-year-old boy who was recently diagnosed with high-functioning Autism Spectrum Disorder. At home and at school, he often has trouble transitioning from one activity to another. He becomes upset and sometimes has temper tantrums when his parents ask him to put away his favorite video game to work on his homework or eat dinner with the family. At school, he becomes frustrated when asked to move to a new task before he is ready. Completing in-class assignments and homework is often a struggle because he is easily sidetracked and takes much longer than other students to complete the same amount of work. He becomes upset when his routine changes, such as when he has a substitute teacher or when taking a family trip to an unfamiliar place. His classmates sometimes become upset when he blurts out inappropriate or hurtful comments. He says that he knows that he shouldn’t say things that hurt others’ feelings, but he seems to have a hard time knowing when to keep his thoughts to himself.

WHAT ARE EXECUTIVE FUNCTIONS?o Higher-order reasoning

o Initiation

o Judgment

o Inhibition

o Planning

o Shifting

o Self-monitoring

COMMON DIFFICULTIES RELATED TO EXECUTIVE FUNCTIONS

o Distractibility

o Impulsivity

o Disorganization

o Difficulty with problem-solving

o Inflexibility (in activities, routines, etc.)

o Difficulty planning

o Difficulty getting started on tasks

WHAT ARE EXECUTIVE FUNCTIONS?o Skills that allow us to coordinate and integrate more fundamental knowledge and skills to pursue particular goals and adapt to changes in the environment

o Self-Regulation: a set of control capacities that cue and direct functioning across domains of sensation/perception, emotion, cognition, and action

o Metacognitive Skills: higher level thinking, attending, and problem-solving that is goal directed. “Thinking about thinking”

WHAT ARE EXECUTIVE FUNCTIONS?

o Executive functions depend on the activity of large networks of brain cells. Within these networks, the frontal lobes are particularly important

o The frontal lobes are one of the last areas of the brain to fully develop, and continue to make new connections and become more efficient into the early- to mid-20’s

WHAT ARE EXECUTIVE FUNCTIONS? Difficulties with executive function are seen in children and adults with many different diagnoses, including:o ASD o ADHDo Behavioral disorders including Oppositional Defiant Disordero Intellectual Developmental Disordero Anxietyo Depressiono Traumatic Brain Injury

HOW CAN WE HELP?

o Medications can help improve attention and impulsivity. However, currently available medications cannot help with other executive functioning abilities such as organization, problem solving, shifting, and planning

o Parents, teachers, and therapists can help with these difficulties with a combination of skill-building and compensation strategies

HOW CAN WE HELP?o Skill buildingo Resisting impulseso Recognizing strengths and weaknesseso Sustaining attentiono Active listeningo Independent problem-solvingo Organizationo Time managemento Using feedback and learning from mistakes

HOW CAN WE HELP?o Accommodations and supportso Develop appropriate, achievable goals and expectations based on the child’s individual needs and abilitieso Use positive reinforcement of the child’s new skills o Problem-solve how to manage challenging behaviorso Encourage use of technology and other external supports when appropriate

HOW CAN WE HELP?oUse “behavioral experiments”o There are lots of strategies that can be helpful for kids with executive functioning difficultieso Every child is different: parents and teachers may need to try different strategies for each childo Try a strategy and see if it works. If it does, keep it up! If not, try another one.

IDEAS FOR INATTENTION: AT HOMEo Make your instructions brief and to the point. Break things down into component steps, then give only one or two steps at a time. Praise completion of each step

o Accompany oral directions with written ones

o Check for comprehension by asking the child to summarize what was said

o Provide a private work space for homework. Clear the space of unnecessary distractions

o Make use of “to do” lists, checklists, and routines

o Schedule brief breaks from homework and chores

o Make rewards and negative consequences brief, concrete, visible, and active

o Praise on-task behaviors whenever possible: “catch” the child at work and reward that behavior. Focus on being on-task, not necessarily on the child’s skill at whatever he or she is doing

o Increase one-on-one interaction time

IDEAS FOR INATTENTION: AT SCHOOLo Create a private signal to use with the child when his or her attention is waning

o Accompany oral directions with written ones

o Encourage active participation

o Decrease the length of assignments, focusing on quality rather than quantity

oStop frequently for short "fun breaks" that allow the child to do something enjoyable

o Incorporate demonstrations and hands-on presentations into your teaching whenever possible

o Use study guides/sheets that are partial outlines, and have students fill in the missing words based on what you are saying and/or writing on the board or overhead

o Use visuals. Write key words or pictures on the board or overhead projector while presenting. Use pictures, diagrams, gestures, manipulatives, and high-interest material

o Block out material by covering or removing from the visual field that which you visually don't want students to focus on

IDEAS FOR INFLEXIBILITY/DIFFICULTY SHIFTINGo Teach the child relaxation strategies and self-talk to help them through transitions

o Allow choices, but do not allow for too many alternatives

o Allow children to carry over some element of one activity into the next (e.g., allowing a child to carry a toy they are playing with when they have to go to the car)

o Use kitchen timers or other visible timing device to signal the beginning and end of activities

o Give advance warning that a change is going to take place and the expectation for the transition

oWhen reasonable, avoid transitions, physical relocation, changes in schedule, and disruptions

IDEAS FOR INFLEXIBILITY/DIFFICULTY SHIFTINGo Watch for signs of an impending “melt-down” and attempt to diffuse the stress level at that point

o Prioritize your goals and decide which ones are really important. Activities and rules that are of utmost importance (e.g., safety) are those for which the adults are willing to endure a melt-down. Those that are less important may have room for negotiation. Those that are not important should not be rules, and should be set aside for the time being

o Have a plan for melt-downs: diffuse the situation by having the child go to an area of safety and reduced stimulation

o If there are problems shifting to or from certain activities, consider whether the order of activities can be changed, or eliminate some altogether for the time being

o If the child is susceptible to rigidity at certain times of day, look into what is happening at those times, and consider changing the routine to help the “flow.”

IDEAS FOR IMPULSIVITY/POOR IMPULSE CONTROL: AT HOMEo Make rules of behavior for the family that are simple, clear and short. Rules should be explained clearly. Write down the rules and results of not following them

o Respond quickly and often, especially in response to appropriate/positive behaviors

o Be positive. Tell your child what you want rather than what you don't want. Reward your child regularly for any good behavior, even little things, as children with poor impulse control often spend most of their day being told what they are doing wrong

o Have the child repeat a question before answering

o Reinforce careful work and, to a lesser degree, accuracy. Don’t reinforce work speed

o Do what you say you are going to do. Repeating directions and requests many times doesn't work well. When your child breaks the rules, warn only once in a quiet voice. If the warning does not work, follow through with the consequence that you promised

IDEAS FOR IMPULSIVITY/POOR IMPULSE CONTROL: AT SCHOOLo Have the child repeat a question before answering

o Remove unnecessary stimulation from the study environment, and have the child work away from distractions (e.g., away from doorways, windows, etc.)

o Keep assignments short and/or break them down in a clear step-by-step fashion

o Seat students near the teacher's desk, but include them as part of the regular class seating.

o Produce a stimulus-reduced study area. Let all students have access to this area so the target student will not feel different.

o When rules are broken, act quickly. Remain calm, state infraction of the rule, and avoid debating or arguing with the student

o Have pre-established consequences for misbehavior. Administer consequences immediately, and monitor proper behavior frequently. Enforce classroom rules consistently. Make sure the discipline fits the "crime," without harshness

IDEAS FOR POOR INITIATION/TROUBLE GETTING STARTED o Use kitchen timers to signal the beginning and end of activities, or develop other simple cues

o Reinforce based on effort and rapid initiation of the activity

o Save mentally demanding activities for times when the child has the best energy and attention

o Encourage the use of brainstorming to begin the work process, providing guidance on how to later pare down the “brainstorm” to a workable project

o Make sure that pleasurable activities are contingent upon satisfactory completion of work (e.g., homework before television)

o Offer to help the child start a project, then back off once he or she has gotten moving

o Develop a strong routine, such that one activity follows naturally from the previous one. Explain any changes in routine in advance

IDEAS FOR DISORGANIZATION: AT HOMETime Organization

o Organize your schedule at home. Write the schedule on a backboard or a piece of paper and hang it where your child will always see it. If your child can't read yet, use drawings or symbols to show the activities of each day. Explain any changes in routine in advance

o Emphasize structure and predictability in routines. Stick with the routines consistently

o Establish a "homework-comes-first" policy

o Set limits on your child's television watching and (especially for teens) phone use

o Have your child do the harder assignments earlier in the evening when he is most alert

o Mark on the family calendar tests, projects, and important school activities

IDEAS FOR DISORGANIZATION: AT HOMEMaterial Organization

o Ask your child daily for notes from school, or look in the part of his binder or backpack reserved for parent information

o Put up a checklist in a prominent place to remind your child of materials to be brought to school daily

o Have your child put all school materials inside his backpack before going to bed

o If possible, have an extra set of books at home

o Encourage your child to put his school materials in the same place every day

o Buy and consistently use and label storage containers. The see-through plastic variety is particularly useful

o Build room/house/desk cleaning time into the family schedule

IDEAS FOR DISORGANIZATION: AT SCHOOLTime Organization

oProvide structure and routine. Spell out the rules of your classroom clearly and simply, and tell your students what materials they must bring to class daily

o Have students with complex schedules write them out and tape them on their desks or inside their binders

o Have an assignment log or calendar in which to enter the date and description of an assignment, due date, homework, parent’s and teacher’s signatures, and date turned in

o Develop and hand out to your students monthly an assignment and events calendar

o Write the assignment on the board in the same place every day, and keep it posted there. If you hand out papers to be completed, include the due date on them Require your students to write assignments down

IDEAS FOR DISORGANIZATION: AT SCHOOLMaterials Organization

o Require students to use a three-ring binder with subject dividers and blank notebook paper

o Punch holes in the handouts you give to students so they can easily put them in their binders

o Color code subjects and/or assignments that need to be done immediately

o Have students use a container for small items, such as pencils, pens, erasers, and scissors

o To lessen the chance that students will lose papers, tell them to turn in classwork as soon as it is completed to a designated spot in the classroom

oUse paper of different colors for different tasks so students can locate the papers easily

o Require disorganized students to check with you before they go home, to make sure they have the proper materials and have correctly recorded assignments

IDEAS FOR DISORGANIZATION: AT SCHOOLOther Organizational Issues

o Have a study-skills or organizational tutor to help the student identify the main idea and to draw inferences when doing classwork or homework

o Encourage the student to organize material into categories or chunks

o Teach the use of work organizational tools such as flow-charts, diagrams, tables, and outlines

o Encourage the use of a word-processor, which can allow for restructuring and reorganization of written assignments based upon intermediate feedback, without the frustration of having to rewrite the whole assignment

oEncourage the use of checklists. You can have a younger student draw pictures rather than use words as reminders

o If the child is repeatedly “bailed out” by adults, allow him or her to experience the consequences of his forgetfulness and disorganization

IDEAS FOR PLANNING: AT HOMEo Get ready the night before--lay out school clothes and get the book bag ready. Allow enough time for your child to get dressed and eat a good breakfast. If your child is slow in the mornings, it is important to make enough time to dress and eat

o Emphasize structure and predictability in routines. Stick with the routines consistently

o Use explicit written contracts; never rely on verbal contracts and avoid oral bargaining. Contracts are especially useful with adolescents. Children tend to be more compliant when they have helped to develop the contract. Contracts also serve an important organizational purpose by:o Setting a clear goal or objectiveo Prioritizing that particular goal or objective above many competing oneso Focusing attention on one distinct areao Outlining what steps need to be taken to secure the goalo Having an evaluation component that encourages the individual to monitor his own performance.

IDEAS FOR PLANNING: AT SCHOOLo Use direct instructional techniques that highlight:o Setting goals

o Subdividing assignments into component parts

o Developing a list of needed materials for each part

o Setting time deadlines for intermediate parts

oModel the way to approach a project or assignmento Monitor progress frequentlyo Encourage the use of a word-processor, which can allow for restructuring and reorganization of written assignments based upon intermediate feedback, without the frustration of having to rewrite the whole assignmento Encourage planning by frequently using lists, calendars, charts, pictures, and finished products in the classroom

ADDITIONAL RESOURCESo Thinking Organized for Parents and Children by Rhona M. Gordon

o Executive Skills in Children and Adolescents by Dawson and Guare

o No Mind Left Behind by Adam Cox

o Organizing the Disorganized Child by Kutscher and Moran

o Late, Lost and Unprepared by Cooper-Kahn & Dietzel

o Smart but Scattered by Dawson and Guare

o Taking Charge of ADHD by Barkley

o The Explosive Child by Greene