Executive Functioning: Targeting Students' Skills Through an Interdisciplinary Lens

Editor’s Note: This text is a transcript of the course Executive Functioning: Targeting Students' Skills Through an Interdisciplinary Lens, presented by Katrina Fulcher-Rood, PhD, CCC-SLP; Pamela Schuetze, PhD; and Kathy Doody, PhD. 

Learning Outcomes

After this course, participants will be able to:

• List specific requirements for eligibility under the IDEA
• Identify factors that contribute to high caseloads
• Describe consequences of inappropriate identification

Introduction

Thank you so much for joining us.  We're so excited to be here. We love presenting together, and it's always great to share how we work together as a team. We are going to start by providing a definition and framework for executive functioning and briefly focusing on how these skills develop. Then we will discuss the importance of these skills through each of our professional lenses. We have some case studies at the end of the course to point out the importance of executive function and how the three of us would work together in order to assess and treat those executive functioning concerns for each of those case studies.

Course Presenters

Who are we and what is the purpose of this course? We are professionals from three different disciplines that have the unique privilege of working with children across a wide age spectrum in various educational settings. First, we'll hear from Dr. Pamela Schuetze, who is a professor and expert in psychology and runs our Child Advocacy Program. Next, we have Dr. Kathy Doody, who works in the Exceptional Education Department. She's an expert in autism and provides family and child support and resources for families with children with autism. Finally, I am Katrina Fulcher-Rood, and I am an associate professor in the SLP department. I am a licensed, certified, and practicing SLP,  and I have certifications and America Board Certification in child language and assessment.

We got together during my first semester at Buffalo State when Kathy and Pam said they were looking for an SLP to work with them to do service learning with our students.  Kathy and Pam discussed this project, where they brought the exceptional education students and the psychology students together to train them on how to work on an interdisciplinary team to do developmental screenings. Because I teach a school-based issues class and a school-based SLP is all about collaboration, I thought this was an amazing project. For about the past seven years, Kathy, Pam, and I have brought our classes together to teach our students how to do developmental screenings with young children and various daycare centers.

By working together, we are starting to recognize different areas in which exceptional educators, child psychologists, and speech-language pathologists can enhance service delivery through this interdisciplinary lens. One of those areas that crosses and spans all three areas of our discipline is executive functioning. 

Defining Executive Functioning

One thing that we're interested in doing is finding a way that we can provide services for our students on campus in the area of executive functioning because we utilize them throughout the lifespan. Executive functions are critical for so many things that we do. They develop early and are important for functioning into adulthood. 

Executive functions are a set of mental or cognitive skills that are coordinated by our brain's frontal lobe.  Executive functions all work together. They are a coordinated set of skills that we use to help us achieve our goals. Those can be personal goals, academic goals, or career-related goals. 

We use executive functioning in so many areas of our life.  We use it when we plan our day, organize a task, and strategize how to best meet a goal. We use executive functions to help us with attention and to know what's critical to pay attention to at the moment versus what's a distractor that we can let go of. We also use executive functions to help remember details. So it really spans almost everything that we do from the moment we wake up until the moment we go to sleep.  I often describe executive functioning as the conductor of our brain. It's what helps connect all of the different skills and different areas of our brain. 

An example would be going home after work and preparing dinner while at the same time maybe helping children do their homework and also thinking about what appointments we need to schedule for the week and our goals for the evening after the kids go to bed. Those are our executive functions as we're strategizing about how to ensure that all of those different things are happening; we're focusing on our jobs when we need to, and we focus on our families when we need to. Knowing how to navigate that and shift from one task to another is part of our executive functioning.

Here is another example. Think back to when we had to remember phone numbers or addresses long enough to write them down.  What are the skills that we use to keep that in our memory long enough to write it down and to know that we need to write it down because we aren't going to remember it?  Another example of our executive functioning would be driving down the road and a car pulls right in front of you. In that situation, you're able to say to yourself, "Okay, that was very irritating."  You're able to take a deep breath and let it go rather than engage in some road rage. That's an inhibiting form of our executive functioning.

12 Executive Functions

Initiation

Initiation is the action of beginning a task. What do we need to do to get started on a task? This is particularly important if it's not a desirable task.  For a child, how do they come home and get started on their homework? How do we do that one task in our job that we have been procrastinating on, but we know that we have to do it? How do we get ourselves to actually start that task? That's initiation.

An example is a child who's been asked to clean their room. Most children can think of about a million other things that they would rather do than clean their room. So how do we get them to initiate that task? How do we, then, get to them to the point where they can initiate it on their own without us helping them to initiate that task? That's the ultimate goal.

What are some strategies for initiation? If it's a particularly large task, we can help by breaking that task up into small pieces. Again, the goal when we're working with children, adolescents, and even young adults, is to move them closer and closer to using these strategies on their own. But we may need to demonstrate them for them initially and help them work through these strategies.

How can we reinforce them for their efforts when they do get started? We can say things like, "You've done a really good job getting started on your room. Okay, what are you gonna do next?  What's the next task that you're gonna tackle as you're cleaning your room?"

We can also help to prioritize what needs to be done first if it's a huge task, such as cleaning a room or completing a huge group project that a child has for school and they don't know how to get started. How can we break it into smaller tasks and help them determine what needs to be done first?

Self-monitoring

The second executive functioning skill is self-monitoring, which is the ability to observe and evaluate your own behavior in the context of the environment. It's knowing yourself, knowing what environment you work best in, and what environments might be particularly distracting to you.  For example, I know that I work best in silence.  I've determined that over the years. Another example is that my 15-year-old has just come to realize that he does better when he's working on homework and has music in the background. But it has to be music without vocals. It takes some self-awareness to know that is what works best for him in order to attend to the task for as long as he needs to.

Also, part of self-monitoring is noticing when your focus begins to drift. And are you aware of what you need to do to bring yourself back to the task? It's also recognizing when you said something in a conversation that you shouldn't have. Can you recognize that, and are you able to self-correct?

What are some strategies for developing self-monitoring? Self-reflection is extremely important for some people. Self-reflection might be written, such as keeping a journal or drawing. Others might self-reflect in just quiet thoughts or meditation. But you can also self-reflect in groups. For example, reflecting on the day as a family.  This was a strategy I used with my own children every night at family dinner. We talked about highs and lows, and that became a part of how we started conversations. It also became a way that the children would start to reflect on their day, what was going well and what wasn't going well. Often they came prepared to talk about it with strategies about what could be done differently next time. That's ultimately what we are trying to do with self-monitoring.

Organizing

Organizing is the ability to monitor and keep track of materials and information in your head. This is when you have a million different tasks, people, and things that take up your time and attention. How do you keep track of that?  How do you make sure that nothing falls through the cracks?

An example of organizing is knowing your schedule for the day. What do you have to get done for the day? What are your priorities? What are things that must happen today? What things could happen another day if necessary? What are the appointments? What are you going to do with any free time that you have between appointments? How are you going to use that? 

When working on organizing with children and young adults, how do we do that? We can build routines by teaching them that they have a different routine for different parts of their day. We can talk about what their morning routine looks like: "You're going to get up and have breakfast. Then brush your teeth, get dressed, and pack your backpack." That is the morning routine. 

We can discuss their evening routine as well by talking about what that looks like: What do you do each day when you unpack your backpack? Do you have places for things? Do you know where everything goes so that you don't get lost? Do you pull out important papers to give to your parents? Checklists and planners are very helpful for getting and staying organized.

Inhibition

Inhibition is defined as controlling impulses. Sometimes it can take a while to develop the ability to inhibit.  It's the idea of being able to stop a behavior at the appropriate time or when you're asked to stop the behavior, even if you don't think it's the appropriate time. 

An example is if you have Halloween candy sitting out, and the kids want a piece of that candy so bad.  You tell them they can have some after dinner. Can they stop themselves from sneaking some when you're not looking and wait until it's the appropriate time? That's inhibition, and it's something that even adults struggle with, particularly when we're tired. At the end of the day, it's much more difficult sometimes to inhibit ourselves. So, put easier goals at the end of the day for children or adolescents and the more difficult tasks at the beginning of the day when they're more likely to be able to inhibit.

We also want to make sure that everybody's clear on the rules and expectations. Review them frequently, if necessary. Talk about past impulsive behavior and what happened as a consequence of that impulsive behavior. That needs to be part of the conversation, too.

Emotional Control

Emotional control is the ability to regulate and manage really strong, intense emotions. Those emotions can be positive or negative. If you get frustrated, are you able to calm yourself down? If you start laughing and can't stop - that's a really intense emotion. But, sometimes, we need to be able to reign it in.  That's emotional control. We often talk about emotional regulation, and that really means the same thing.

What strategies can we use to calm ourselves down, and these are different for everybody. Hopefully, you know what strategies work for you, but children sometimes need time and help to figure that out. They may need some suggestions about the types of things that they can do when they find themselves overly aroused. Maybe it's taking a break. Do they need to just walk to the end of the hallway and back, take a few breaths and then reengage?

How do we develop emotional control? With young children, the first thing we need to do is help them identify or recognize the emotion and how it affects their bodies. Then, we need to find a strategy that helps them calm down. For example, deep breathing works well for some children. Exercise, taking a break if they have a place where they can run, such as around a building or around a track, can be really useful. Drawing or journaling, and talking to a friend are all ways to develop emotional control. There are a number of different ways that people can self-regulate, so it's a matter of helping children and young adults figure out what works for them. Once that's identified, it's a matter of practicing it.  There will be many opportunities over the course of life to practice emotional control. Children need to know that they need to use those strategies on a regular basis so that they become second nature.

Shifting

Shifting is basically mental flexibility or cognitive flexibility. It's being able to adapt to different demands, switching tasks and attention from one thing to another. It's being able to move freely from one situation to another and think about how to respond appropriately to that situation.  Sometimes this is thought of as problem-solving. How do we switch from a basketball game to a board game? Some can shift much more easily than others. Other children might really struggle with shifting from one task to another and might benefit from reminders (e.g., In five minutes, it's going to be time to stop playing basketball, and we're going to move on to our next task. Then you give them another reminder at two minutes.)

Some children really need that support with shifting, and routines can really help with that. Taking short breaks in between tasks, "Okay, basketball's done, so we're all going to take a minute and just relax for a second before we move on to the next task." That can be really helpful. Also, reviewing rules when we change from one task to another and the use of visual timers can be useful as well. 

Planning

Planning is the ability to prioritize and build a roadmap to reach your goal. It's having a goal and knowing how to get from initiating the task to ultimately achieving that goal.  There are likely, a number of small tasks that must be achieved to get there. How do we prepare? How do we get to that goal? How do we achieve that task?

Some examples of planning might be thinking through the day and what a child needs from the moment they leave the house until they come home at the end of the day. They probably have homework and books for several classes that they have to remember to bring home.  They may need to turn in a permission slip for a field goal. They may need to return their track uniform and then have their gym bag with fresh clothes because they're starting the swimming unit and they need a towel and a swimsuit.  How do they think through each part of their day so that they are fully prepared for every piece of that? But it also is being mentally prepared to know, "Okay, when I come home, I'm going to have time to take a break and have a snack, but I have a big test coming up in two days, so I need to set aside some time to study. I also need to set aside some time to practice my instrument or to do my chores." 

This is all a part of mentally planning the day, and we can start this with really young children by giving them very simple tasks that they have to plan.  For example, we can have them be in charge of making their own peanut butter and jelly sandwich for lunch. Ask them what they need to do that.  What are all of the things they are going to need in order to do that, from the ingredients, the knife, the plate to make it on, the bag or container to put it in, and the lunch bag that it's going to go in? How do you help them think through that?

You can also help them learn the value of to-do lists.  In my house, we talk a lot about paper and pencil to-do lists or even digital lists.  We can rank order to-do lists. We can number them or make a list of priorities at the top with secondary priorities towards the bottom. There are a number of strategies that can be used to do that.

Self-advocacy

Self-advocacy is something that we sometimes neglect to teach children to do as well as we can.  Self-advocacy refers to how well we understand our own needs and how to tell other people what our needs are. Do we know when to ask for help? What decisions need to be made in order to get our needs met? Children need to learn to self-advocate for themselves. As adults, we often do the advocating for them. But one of our goals should always be to teach them as soon as possible to advocate for themselves. That can start with encouraging them to ask for help when they get stuck on an assignment and who to ask for help. Do they ask their teacher or do they ask their peers? Do they wait until they get home and ask a parent? What are their strategies going to be when they need to ask for help?

Another one we often neglect to do as much as we can with children is recognizing when they are overwhelmed, and when they're getting overwhelmed, do they recognize when they're getting to that breaking point? Can we help them to figure that out before they have a complete meltdown? Can we help them to recognize, "Wait a minute, I need a break. I just need a break. I'm getting upset."? We can give them those words so that they can self-advocate.

We should be looking for opportunities to teach them and reward them when they are self-advocating. We can say, "I'm so proud of you," or "That's great that you recognized that you just needed a minute to breathe," or "I'm really proud of you for telling me that." We can role-play and practice self-advocacy.  This is good for a child who, for example, is a bit more cautious about asking for help in a classroom setting.  How can we role-play that with them so that they know how to do it in a way that is comfortable for them? We want to give them opportunities to lead and be in charge so they start to feel empowered.

Development of Executive Functions

Since we are talking about children, adolescents, and emerging adults, it's important to discuss how executive functions develop over the first couple of decades of life. As I mentioned earlier, executive functions are controlled by our frontal lobe. It controls our attention, working memory, planning, organizing, and impulses. 

The frontal lobe is the last part of our brain to develop, which is why older children and adolescents struggle with executive functions. Their frontal lobe is still fairly immature and won't be mature until their mid-twenties or so. So, it takes a while for the frontal lobe to develop and for these executive functions to fully mature.

If we look at the first few decades of life, executive functions tend to be fairly slow to develop. Therefore, we have to be sure that we don't have too high of expectations for children in terms of their executive functions. We want to support them, we want to scaffold them, we want to help them to develop those skills, but we shouldn't expect them to have fully mature executive functions. It's not realistic to expect that of children.

Executive functions begin to slowly emerge towards the end of the first year of life. We see it, for example, in anticipatory looking, where a child might hear a sound, and they look towards it because they know that something's coming. They hear the door and they look to see that Mom is coming home from work. That's anticipatory looking.  That is the beginning of executive functions.

We see some significant changes though, during the preschool years. The three and four-year-olds are showing dramatic increases in their executive functions. They're learning rules that they will use to guide their behavior, they're thinking about their past, and they're starting to plan for the future. They're excited about a friend's birthday party, and they may start thinking about what birthday present they will get their friend and what outfit they are going to wear. That's actually thinking about the future.  But, at this age, they still have a lot of difficulty with the delay of gratification. They're going to be dipping into that Halloween candy if you're not looking. They're going to have some difficulty with impulse control.

Then we see major increases in all areas of executive functions from ages eight to 11. At this age, children are much better at controlling their attention, knowing how long they can pay attention to something, and blocking out distractors. They are starting to handle some delayed gratification. We see the beginning stages of problem-solving, planning, and shifting attention between tasks. All of that is really starting to develop pretty dramatically in middle childhood.

After age 11, there are smaller increases. They're still improving in executive functions, but it's not as dramatic of a change. It's more of a slow and steady development during adolescence until about the mid-twenties.

Importance of EF Across the Disciplines

Psychology

I want to start with how we think of executive functions from the discipline of psychology. From a psychologist's perspective, it's about providing an individual with the skills that they need to be successful in all parts of their life. When we're working with children in a school, we are thinking about how they can be effective and functional in a classroom setting with academic demands. But executive functions go way beyond that.  As a psychologist, I want to see them using executive functions to be successful in all parts of their life. Are they able to use adaptable thinking? Can they problem-solve? Can they think outside the box? If they're in a new situation and they have to come up with a solution, can they figure out a way to do that? Can they adjust themselves to that situation and figure out a strategy that will work? That type of adaptable thinking is important academically, but it's important beyond that as well. It's critical for self-control.

When thinking about emotions, can we control our emotions in order to make appropriate decisions rather than acting impulsively and getting ourselves into big trouble? Also, executive functions are important for social skills. Children who have better executive functions have better social relationships. I want to see children succeeding socially as well as academically. Executive functions are important for relationship-building, problem-solving, and, ultimately, career success. If I want to see a child develop and become an adult who can hold down a good job and have a successful family life, then they're going to need executive functioning skills. 

Speech-Language Pathology

Looking at executive functioning through the lens of speech-language pathology, when I first came into this field, I never thought that executive functioning skills were something that I would work on as an SLP.  I was thinking that this is what I would refer Pam (a psychologist) to. But it's important for us to know that from the American Speech Language and Hearing Association when looking at our scope of practice, cognition is one of our primary areas of service delivery. When we talk about the ASHA Big 9 areas, the cognitive aspects of communication are one of those primary areas. ASHA actually includes executive functioning in the definition of cognition. So these skills are in our scope of practice as areas to assess and treat.

When I think of children on my caseload who may have difficulties with executive functioning skills, I think of children with autism, children with developmental language disabilities, and children with SLI or social pragmatic communication disorder. For all of these pragmatic language skills that we teach, you have to have strong executive functioning to execute them. For example, how do you plan a conversation? How do you initiate a conversation? How do you maintain the topic of a conversation? How are you monitoring yourself during a conversation to know if you are taking up too much of the conversational floor? Is it my turn to volley back to somebody? Am I interrupting? Am I supposed to interrupt?

How do you change your tone? I know that it's acceptable to talk casually with my colleagues, Kathy and Pam when we're out to breakfast, but we're going to speak in a very different way when we're presenting a course.

There is also sequencing, planning, and narrative structure.  How do children build stories? That is a big component of ELA, reading, and literacy development. The ability to form a narrative is all about sequencing, planning, and monitoring. Receptive language is the ability to hold information in your head to carry out school directions.

Interestingly, executive functioning is coming up as a big area that could give us so many diagnostic possibilities because executive functioning skills are starting to differentiate populations of children in terms of those with typically developing language skills and those with language difficulties. The literature shows that impairments or issues in executive functioning can impact word learning. For example, issues with inhibition are starting to appear in children with DLD, so we are exploring the possibility of adding that to our assessments. We are starting to see difficulties with inhibition, even at the preschool level for these children, as well as shifting attention and working memory.  These are going to impact SLPs because these are skills that are needed to reach our language goals. 

Exceptional Education

From the special education standpoint, I wanted to discuss how special educators deal with executive functioning, how we assess it, how we treat it, and what curriculum and instruction methodologies are put in place for executive functioning. In special education, executive functioning comes up over and over in every aspect of a child's life.  For example, it's important for motor planning.  Many teachers think that motor planning is something only OTs and PTs need to address. But that's not necessarily true.  When I'm assessing a child and looking at their motor planning capabilities specifically, I often take a ball or a toy that's highly preferred and put it underneath the table or in an area that's hard to reach. I want to see if the child can go pick it up. In regards to motor planning, you can't just bend down, pick it up, straighten up, and go on your way. You have to make sure, particularly if that ball is under a table, that you don't stand up and hit your head. You have to bend over, pick up the toy, shimmy out from underneath the table, and then stand up. That's a perfect example of motor planning, which of course, falls in the OTs and PTs category, but there is also the pre-planning that special education teachers focus on as well.

Special educators also manage impulsive behaviors. We often deal with self-regulation and impulsive behaviors and inhibiting some of those impulsive behaviors. We help students determine what's socially appropriate, given the situation that the child is in (e.g., "I really want that truck that my friend has, but is it okay to hit him over the head as hard as I can and then grab it when he's crying?")

We teach students to use single and multi-step directions. These are hierarchical in that we teach following a single-step direction first. For example, "Stand up", "Come here," "Clap your hands," and "Line up at the door." Then we start adding multi-step directions, "Stand up, push in your chair, and come over to the door." We start small and build and scaffold until we get to those multi-step directions.

Attending to a task and task completion are two other important aspects of executive functioning. This is completing a task but also understanding that we have to assess what is in front of us, what we are asked to complete, and what parts of the task are the most important. Think of activities in your daily life.  You come home, and you have to juggle working on homework, starting dinner, and making a grocery list. You may think about what you need to do for work before you go to bed at night. That is all prioritizing, and most likely, your priority is getting food on the table for your family to eat. Then once that's done, you can address everything else. The point is that task completion and attending to a task go hand in hand. And one of the big components of that is learning how to prioritize what's the most important and then filtering out unnecessary stimuli.

One of my research interests is autism, and we find not just in autism but with many other disabilities or conditions, it's really hard to filter out unnecessary stimuli. For example, is somebody sitting next to you tapping their pen while you're trying to pay attention? Is there somebody playing music in the background with vocals? In a school-based situation, are two teachers talking outside the classroom door, and you can't focus on what's in front of you? Is somebody behind you kicking your chair? All of those things are very hard to filter out, but all of them can be addressed by special ed teachers.

EF Across the School Continuum

Early Intervention

How do we assess and treat executive functioning across all ages of the school continuum? Let's start with early intervention and full disclosure, I have a son with autism who's a young adult now. He received services from the time he was 14 months old on. He was diagnosed with autism at 14 months, which tells you how overt his characteristics were and how significant his impairment was. I remember an OT talking to me about executive functioning, and I kind of laughed. I was thinking, "My son's 14 months.  Executive functioning, in my mind, was a business person walking out the door with a briefcase and an overcoat.  I'm not thinking about my 14-month-old baby, who is wearing a diaper and drinking from a sippy cup.

But executive functioning, as we said earlier, begins at birth with turning to the sound of our mother's voice, hearing a door open, and realizing that somebody is going to walk through that door. It's knowing that when we cry, somebody will be attending to our needs. All of those things start in early infancy. So executive functioning has a fancy title, but it starts with basic foundational skills that infants develop. We turn toward the direction of a sound, such as a dog barking or a microwave going off. There is that startle reflex.  

We understand different patterns of speech even before we can speak. We know that as a child is acquiring receptive language, they're understanding the changes in our tone, the changes in our pitch, the pauses that we put into our sentences and our utterances, and the rhythm or the cadence of our speech. They understand when we're asking a question, when we're making a statement, when we're angry, and when we're inquisitive. All of those things are conveyed in our speech patterns. We always pair gestures that have underlying meanings, "Do you want me to pick you up?" "Are you ready for a big hug?" "Come here." We use gestures to align with everything that we say.  Children understand that they do not only attend to what we're saying, but they can visually attend to our gestures. Children with communication challenges depend on those gestures to get contextual clues about how they should respond.

Very young children can understand reciprocal games like peekaboo or patty cake, etc. All of the games we play with infants help to develop executive functioning skills.  Even young babies can follow along with finger plays, such as The Itsy Bitsy Spider, Mr. Sun, etc. Those activities help develop a child's executive functioning. But a child is also using their existing executive functioning skills to follow along with what we're asking them to do.

Executive functioning skills of preschoolers and toddlers include rote learning, things that we memorize, and things that stay the same such as numbers, patterns, letters, and shape recognition. Those are all things that we as children start to learn and absorb. They're the building blocks of everything else we're going to learn moving forward.

Young children can understand facial expressions and differences. They understand very simple action verbs, such as waving, clapping, eating, drinking, stand up, and sit down. They understand what underlying actions go along with those action verbs.

A lot is going on in early childhood. Most experts agree that the most critical foundations for executive functioning are developed between birth and five, with the biggest jumps between the ages of three and five. Early childhood is so important, and there is so much critical learning that's happening during those ages.

Elementary School

Moving on to elementary school. How does an elementary school child demonstrate that they have executive functioning while they're reading and they're writing? We all know that reading is a receptive language skill, and writing is an expressive language skill. School-age students are doing simple math (or maybe not-so-simple math) computations. They're dividing, adding, multiplying, and subtracting. They're understanding decimals and percentages and pie charts and Venn diagrams. They're following classroom rules and routines, which provide structure and framework, and they tell us what the behavioral expectation is given a particular setting, environment, or situation.

Routines are actually different. Routines are what we need to do in very specific situations for our classrooms to run smoothly. For example, what do I do when I arrive late to school?  Do I go to the nurse's office? Do I report to the attendance office? Do I go to the main office? What do I do if I have to use the restroom? Am I allowed to just go or do I have to ask for permission? Do I have to pick up a pass? Where do I put my homework folder when I arrive? Those are all classroom-based routines that are important for a school and a classroom to run smoothly. But we rely on our executive functioning to implement those school-based routines. We make connections between the knowledge that we already have and the new content knowledge that we are assimilating and try to form a connection between those two.

The best way to teach a new skill is to scaffold on an existing skill. Find out what your student can already do before you try to teach them something new that they can't do. We want elementary school students to start engaging in abstract thought, some of those "what if" type questions. We are moving beyond the literal and bringing in more abstract thinking. 

Elementary school students can also begin to think logically. They recognize that "My Aunt Patty is my aunt, but she's also my mother's sister."  Those types of relationships don't make sense to children at very young ages, but they do start making sense as children get a little bit older.

High School

Then when we move on to high school, with teenagers and young adults, there are a lot of impulse control issues that we see because the frontal lobe isn't fully developed yet. This is why we often see teenagers make very poor choices, like thinking that it's fun to jump off of a roof onto a trampoline or pull the fire alarm at school as a prank. We see executive functioning coming into play as children are starting to mature, but maybe their executive functioning skills haven't quite caught up to some of their interests or desires or even some of the peer pressure that they have around them.

We know that teenagers and young adults are starting to differentiate right from wrong and are making some ethical decisions, but we also know that it is still a struggle for them as they begin or continue to mature. Can they not only form and test a hypothesis in a science class but also in daily life? For example, what happens if I put a pot on the stove, turn it on to boil, and walk away? What happens if I'm supposed to be taking care of the garden over the summer, and I stop watering it? We kind of test the hypothesis, we have an idea in place, and then we test it to see what the actual result might be.

Do they understand the concept of being a good citizen, particularly if a student is on a team (e.g., a debate team, an athletic team, an academic team)? How are they part of a team approach?  How are you a good friend to others? How does your behavior impact the behavior of others around you, and what can you do for the greater good? At this age, we're working collaboratively for the greater good. How to make and sustain friendships during teenage years is a huge part of the developmental lifespan. And we certainly see adolescents struggle with this. Some of the hardest times that a child will go through, from a social-emotional point of view, are those middle school and high school years.

High school students may be juggling a lot. They may have to come home from school to wait for their younger brothers and sisters to get off the bus. They may be working part-time at night, and they have to plan how to get their homework done and still go to work and get to bed at a reasonable hour.

Higher Education

Then in higher education, some of our college students are struggling at the undergraduate and the graduate level, and we're trying to come up with some ideas of support we can put in place for them. The three of us presenting this course believe that executive functioning does not really solidify until the mid-twenties. So when we have an 18-year-old college student who's away from Mom and Dad for the very first time in their life, living in a dorm with very few restrictions and limitations on their life, can they exercise those impulse controls to go to class, to get their homework done, to not play video games all night long? We need to see that college student be able to juggle maybe five classes, a 15 or 12-credit hour semester. Can they prioritize their tasks? Can they manage their time? Can they see what assignments are due? This is where we often see many of our college students fall flat. Students, particularly those with ADHD or autism, can have a task or an assignment, and they stall and procrastinate and don't know how to get started. Then when it's two days away from the due date, they're paralyzed and don't know what to do. Even with an outline and a timeline, it's hard for them without some additional support.

Being able to meet those goals and due dates requires backward planning. If the assignment is due November 1st, when should I start it? When should I outline it? When should I have a good first draft?

Students need to recognize that this is a sacrifice that they're making. They're in college for four years and will have to say no to some things. But the greater good is that you will end up with a degree, and you'll be employable, hopefully. Your hard work will pay off in the end.

As I mentioned, college students may be without Mom and Dad for the first time in their life, and there's nobody checking up on them. They have to work independently, without any additional oversight. Although some of us, as instructors, may "mother" our students a bit because we want them to succeed. So, if they need additional supports and want me to send them reminders about due dates, I will certainly do so. But we want to foster and help our college students develop the ability to do that independently.

From a teaching point of view, we very often talk about task analysis. This is the idea of taking a very complex skill and breaking it down into smaller, manageable units, then teaching and reinforcing each step of that task analysis until we go to step two. Then we reinforce steps one and two and teach step three. Then we reinforce one, two, and three and teach step four. A task analysis is a very effective methodology for teaching. It's very durable, and it creates behaviors that are maintained and last. But it does take some prior planning. 

Case Studies

Moving on to case studies, the first one is a young boy that I worked with in early intervention.

Early Childhood: Cognitive

Joey is a two-and-a-half-year-old with a diagnosis of autism and some sensory processing dysfunction. He is strong, academically gifted, and talented. He's probably above his chronological years and was beyond his same-aged peers in terms of what he could do. He taught himself how to read. His memorization skills and math skills were strong, etc. But, where he struggled was that his behaviors were very routinized and very structured.

Early Childhood: Social-Emotional

Socially and emotionally, he was wonderful around adults. He gravitated towards adults. Our theory was that they were able to meet his needs, and they were very predictable in how they interacted with him. He always knew how they were going to respond, whereas his peers might interact with him in a very erratic way, and he couldn't necessarily predict how they would respond to him. So we struggled quite a bit to get him to interact socially with his peers. He would often separate himself from his peers. Even if a peer came over to join him and engage him in play, he would often remove himself or leave.

He was a people pleaser and an adult pleaser. He quickly learned teacher and adult-pleasing behaviors. So he was very easy to have around from an adult's point of view, but then we had to stop and think about how likable he is to his peers. It's great that we adore him, but we need other two-and-a-half-year-olds to seek him out. 

In play situations as well, he really didn't have any peer preferences. He would become very upset if he gave an incorrect answer or if he responded incorrectly, or if he thought he was being reprimanded. I remember reading him Hop On Pop, a Dr. Seuss book, over and over again, and there was a line in there that says, "Dad is very mad," and he would make me skip that page. He would physically turn the page so that I wasn't reading those lines because it made him very anxious to think about his father being very mad. He was very energetic, which made it hard to snuggle or cuddle with him unless he was very tired or sick. He really was on the move most of the time.

Early Childhood: Language/Communication

Joey started off with some slow language development, but it took off around age two. We saw so much expressive language development. His receptive skills were always very strong, even from a young age. But his vocabulary started increasing at an accelerated rate, which again, was atypical for his chronological peers. His language was much more advanced than other two-and-a-half-year-olds his age. His utterances were long,  complex, and involved thought and pre-planning.

His articulation was pretty clear, although he would speak quickly. It was hard for an unfamiliar listener to understand exactly what he was saying. But he had so many thoughts running around in his head that it was hard for him to get them out without them kind of spilling over each other. So his language skills were very strong.

He did struggle with social interactions and speech interactions with his peers, even though he came across as very cerebral to adults. There's that expression that some children with Asperger's come across as "little professors," and this was the case with this little boy. 

Early Childhood: Physical

Joey was very athletic and coordinated.  He could jump and run and skip and do so many things that we would never expect a two-and-a-half-year-old to do. However, during physical activity, he had difficulty following the rules of a game, which was interesting because he played football in high school.  But as a toddler, although he was physically gifted, it was hard for him to follow the rules of a competitive game because the adrenaline would take over, and it would be hard for him to regulate his impulses and not everything he wanted to do.

When he was younger, he would often sit at circle time with half of his body across a friend sitting next to him. He would stumble and trip and fall because he was moving so quickly; motor planning was really challenging for him. Again, we would very often find him sitting in a peer's lap during circle time, completely unaware of the fact that he had invaded somebody else's personal space.

He had a couple of pretty significant injuries that resulted in trips to the emergency department and stitches on both sides of his forehead. But his fine motor skills were very strong. He was very motivated by food, so he learned to use a spoon, cup, and fork at a very young age.  He also wanted to be very independent. So he was dressing, zippering, buttoning, and snapping at a very young age.

Adaptive skills were probably one of our biggest areas of struggle for him. He had a lot of adult-pleasing behaviors, so he was very compliant and always sought approval from adults. This can be a blessing and a curse because if he didn't receive that approval from adults, he would become demoralized and agitated. He had high levels of anxiety that would very often take over if he felt that he had displeased an adult or fallen short of their expectations.

Joey followed routines with rigidity and had very routinized types of behaviors. When there was a fire drill at school, and it changed his schedule, it was very unsettling for him. When there was a half day of school, it meant that the whole afternoon didn't happen, and that was very hard to cope with and adjust to. 

As a young boy, he drank very well from an open-faced cup. He was a very good eater, loved to eat healthy foods, and was motivated by food. But he would often keep eating until we cut him off.  He was very active, so there was no weight concern from a medical point of view. But often, his parents would say, "You have had enough. You can't be hungry. You've just eaten enough for a young adult and you're two and a half years old."

He slept very soundly, particularly due to his high levels of anxiety. It would often take him a bit longer to fall asleep because he had a hard time calming himself and turning his brain off. 

He had a strong visual memory and was very observant of any changes in his environment, such as when furniture was moved, when his schedule had changed, when his mother wore her hair in a ponytail instead of wearing it down, or when one of his aunts had Lasik surgery and no longer needed to wear glasses (that was very upsetting for him). He noticed every small nuance in the people around him, and some of those things could really throw him off of his game. Also, one of the reasons that he struggled so much with peer interactions was that when a peer or a friend was not doing what he thought they should be doing, he became very agitated. He was a rule follower and he wanted everybody else to be following the rules as well. In his mind, when they were breaking the rules, it was very anxiety provoking for him and invited a whole bunch of inappropriate behaviors.

Early Childhood: EF Concern

As I mentioned, Joey was very resistant to change. And the one thing we all know about school is that things change all of the time. And know that in the school setting, things change all of the time. We have snow days; we have half days; we have assemblies; we have substitute teachers; we have times that our seats have changed. We have times when the school cafeteria does not have buttered noodles. There are so many things that change in our day, and we have to be able to cope with them.

So, from an education viewpoint of view, as a special ed teacher, there is a delicate balance. I know my students need a framework and guidelines to be successful. I know that they function best with clearly articulated routines, but I also have to teach them what to do when those routines are no longer in place or when the schedule has changed. We often teach a change in a routine in a low-risk setting.  For example, I'm not going to wait for the fire alarm to go off to teach my students how to cope with that fire alarm. Instead, we're going to mock drills, role-playing, and practice drills. We're going to teach a situation when it's not very high stakes. I work with a lot of parents, and many of them say things like, "I can't bring my child to the grocery store. He's just unable to get through the aisles of a grocery store." Well, it turns out that you're grocery shopping for your entire week for a family of five, and you're in the grocery store for 45 to 50 minutes. It would be better to start by going into the store and picking up two things that you really don't need. If you have to abandon your shopping cart because your child's having a hard time, you can do that because it's a very low-stakes kind of setting.

We do the same things in schools when we're trying to teach a child how to follow a schedule, as well as what happens when that schedule changes. We know that our children are very often rule-governed and routinized. They may insist on those routinized behaviors. They may, as Joey did,  become very uncomfortable when someone else breaks the rules. 

Early Childhood: Collaborations

What do we do in special education? How would I assess Joey? We implemented the Social Skills Rating Scales (SSRS), which can be used with very young children. We had as many people reporting on those assessment rating skills as possible. We distributed them to related service providers, teachers, classroom aides, and parents, anybody that we thought would have input. The Vineland Adaptive Scales is given at various points in a child's developmental lifespan to determine how they are currently coping with the skills and the situations that are presented to them.

What treatments did we put into place for Joey? One of my main priorities for him was to get him better assimilated with his peers. It was great that he was my model student and that I loved spending time with him. But it wasn't natural for him to be spending time with a 45-year-old teacher. He needed to be spending time with other two-and-a-half-year-olds. He needed to have peer preferences, and he needed them to invite him into their play circles. We wanted his friends to enjoy playing with him.

To do that, we used a lot of peer modeling. We used some really strong peer mentors. We used social narratives, which worked really well in this particular situation. Video modeling is a wonderful evidence-based intervention. We can use self-video modeling, where we actually have the child showing up on the video themselves.  We can use point-of-view video modeling, where we never see the child, but the camera is the child's eye, and we see everything the way the child would see it.  We also have peer video modeling where we pick a child to star in our video model, and we ask him or her to show us what those appropriate behaviors look like. 

From the school psychologist's perspective, they often receive a referral when concerns have been noted either by the teacher or the parent. Then that school psychologist does some diagnostic work to see what is going on with the child. The diagnostic process typically involves talking at length with the teacher, the parents, or childcare providers if the child is in a daycare setting or some other form of childcare. 

After those discussions, we decide what specific diagnostic tools to use.  In Joey's case, in addition to the clinical interview to gather his history, we may do something like the Autism Diagnostic Observation Schedule (ADOS) because of the concerns about a possible autism spectrum diagnosis. But there are other tools that could be used depending on the information gathered from the clinical interview.

In regard to treatment, the school psychologist's role is to coordinate services with the special educator, the childcare providers, and whoever else is on the team. Services might include having the school psychologist talk with families and getting them on board with the services that will occur in the childcare setting as well as those services that should be carried over to the home setting.  The family may also need referrals for additional services outside of a school setting. All of this falls under the purview of the school psychologist.

Let's move on to what a speech-language pathologist would do. In doing that, I want to bring together some of the similarities between each specific discipline and how co-assessment or cotreatment might work.  Regarding assessment with Joey, we are not necessarily using standardized tests because there really aren't any based on chronological age that would be appropriate. Similar to special education and psychology, SLPs would be doing very similar tasks such as interviewing and observations. 

Parents with children this age could potentially see all three disciplines, as well as PT and OT.  That is five different professionals, five different evaluations, five different observations, and five different clinical interviews.  Because we have such great overlap in our disciplines, there are times, if appropriate and not too overwhelming to parents and clients, when you can do one play observation setting and only one or two professionals are in the room doing the play base assessment and the other colleagues are observing somewhere else.  Then you could have a couple of the other colleagues come in and give some of the clinical interview questions that overlap to not be so overwhelming to the parents. 

As an SLP, play-based assessment, play-based observation, and any realistic, natural setting are ideal.  If I have to do some type of pullout service delivery model, then I'm going to set that up so that I am on the floor with the caregivers and the child.  We may have some different activities that I've most likely talked to the parents about beforehand. They should be activities or toys that are highly motivating for Joey, things that he's interested in.  I would set up certain scenarios where he can get to some of those preferred items very easily. I may also put some other preferred items under the table or in a box, or I'll have the caregiver withhold the item for a bit. The idea is to set up different scenarios that bring about language paired with executive functioning.  We can look at Joey's attention. We can look at his pragmatic language abilities. We can also see in that play-based observation, especially if a caregiver is there, the type of language modeling that is being provided to him, as well as the type of language reinforcement that is being given.

There are also some criterion-referenced materials and checklists that can be used. The MacArthur Bates Inventory addresses both receptive and expressive language abilities. You could also use something like the Rosetti Infant Toddler Scale, which is more developmental and holistic in its approach, and also has sections that are appropriate for team members in psychology and exceptional ed. The Communication Matrix is great and can be completed by parents as well as other professionals. Some of the tools that Kathy and Pam mentioned, such as the Social Skills Rating Scales provide data that is also very valuable for pragmatic language and those behaviors. The clinical interview that Pam discussed is also crucial.

What about from that treatment standpoint? Kathy mentioned that Joey has really strong language skills. However, those language skills seem to be very context-dependent, meaning they seem to be stronger and more appropriate with adults. When we try to establish Joey's social relationships with peers, things start to fall apart for him. 

Interventions such as language stimulation, language modeling, and sentence recasting are well-researched tools that we use for children who are late talkers, language delayed, as well as language disordered. These are also great techniques that I would use with Joey to work on appropriate language use with peers. I can also see doing some push-in therapy with Joey, as well as co-treating with social narratives and social skills groups with Kathy while I do some language modeling to show what the language expectations are in those social skills groups. In addition, visual schedules and routines could be implemented to help with shifting, to help with initiation, and social skills training.

So, there are some great co-treating and co-assessment options. Many of us overlap in our responsibilities, but we do it through our own lens. The more we can get together, the more opportunities we create for our students to be able to practice in order to increase carryover and generalization.

Questions and Answers

(Comment) I completely agree with the importance of supporting and teaching components of executive function as an SLP (e.g., self-advocacy, self-identity).

Self-advocacy and self-monitoring are so important for language skills and we don't focus on them enough.  Sometimes we see children with disruptive behaviors because they don't have those self-advocacy and self-monitoring skills, and they get to the point of frustration that they have a breakdown. Sometimes, we see issues in our therapy rooms or transitioning from classrooms into our therapy rooms, or working on our language goals because of these executive functions.

There's a debate about whether there's truly such a thing as "divided attention" and whether it's actually alternating attention. Could you address the similarities, or is that under the umbrella of shifting?

Divided attention is what we often refer to as multitasking, which we're realizing people don't do as well as they think they do. But certainly, there are times when we have to pay attention to more than one stimulus at a time. That is different than shifting, though. Shifting is - can you move from one task to another? Divided attention falls more under a combination of attention and cognitive flexibility, or mental flexibility skill. That idea of being able to split your attention between two different stimuli and know when you need to pay attention to one more than the other. 

A second grader is receiving a daily reinforcement chart to take home to his parents, which shows how he did throughout the day with following directions, putting his best effort into his work and sitting in his seat correctly. He is inconsistent with these skills for at least four to five weeks or so. The parents have spoken with the child about the expectation and the child is motivated to earn video game time for being able to demonstrate these skills. But, it seems to not be working. Should the teacher continue with this chart? Are there other strategies that could be used, and is it reasonable to expect the child to change with this chart, or does the child just need extra time for his EF skills to mature and it's not in his control to change?

From the educator's perspective, some things jumped out at me right away. One, I think it's important for home-school communication and for teachers to convey to parents how a child is doing. However, we always want a child to start with a fresh slate. So, if a child struggles in school that day, I want him to be able to go home and start from scratch and start earning reinforcements or rewards for his behavior from that moment forward. A parent can't control how a child behaves in school and a teacher can't control how a child behaves at home. So I really like to see a child have a fair start within each one of those new settings.

The other thing that jumped out at me, and these are just my opinions as a teacher in the field after 20 years, is if this behavior chart has been inconsistent after it's been implemented for four or five weeks, then it's clearly not working. So it isn't that the child can't follow directions; it's that we haven't structured the environment for that child to be successful in following directions.

If the child is receiving reinforcement for following directions, putting his best effort into his work, sitting in his seat correctly, and after four or five weeks, he's not able to do that successfully, then we have to monitor and modify our expectations. Maybe we should have him follow a one-step direction instead of a two-step direction. Maybe we want him to sit in his seat appropriately for three to five minutes instead of 10 to 12 minutes, right? We want to catch him being good. We want to control the situation and lavish him with reinforcement so that he understands the value of following directions and the value of being a good student in school. In order for him to do that, we have to put those expectations within his reach.

It sounds like right now, the expectations set up for him are out of his reach. So, I would scale everything back and I find that point where he could be extremely successful and keep him there for a week or so with lots of verbal praise and tangible reinforcement. Then, taper off and rely more on verbal praise and less on the tangibles. But you can't do that right away. You have to systematically fade that level of reinforcement. And then, I would start to increase my demands while I am lessening my levels and frequency of reinforcement. It just sounds like perhaps we might have been asking this little guy to do too much too soon, and we want to set him up to be successful. I wouldn't ditch the reinforcement plan altogether, but it does need some revamping.

As a psychologist, I want to know a little bit more about what's going on with this child.  Is there a diagnosis that we need to know about? Are we talking about an attention deficit hyperactivity disorder diagnosis that might be really helpful for guiding treatment and appropriate expectations? Is there something going on at home, and this child is fidgety because there's just a lot going on? There are so many things that could be underlying those behaviors that I think we'd want to know more about that.

Are EF deficits common in children who have a diagnosis of ADHD?

Yes, absolutely. There are estimates that anywhere from 90 to 100% of children with ADHD have executive functioning deficits. So it's very common. If we would've had time to get to the next case study, it actually talks about a young boy who has an ADHD diagnosis and the kind of executive functioning skills that he has. I will also say that two of my three boys have diagnoses of ADHD. One, in particular, has significant executive functioning deficits. He's now 19 and continues to have significant deficits. He's certainly made improvements but absolutely we see it with that diagnosis.

We see it with other diagnoses as well that we did not mention. We can see it in childhood traumatic brain injury, for example. So certainly, it can be seen in a variety of other diagnoses, but we can also just see executive function deficits on their own. 

I have students that tend to get average grades but do not score proficiently on state tests. They miss steps when they're completing larger projects and struggle with math. Are there any assessments that help identify EF deficits or help assess that type of student? I've been fighting for some help since elementary school because I can see the challenges, but because a student is not failing, it's very difficult to get some help. I also see the impact when this student is engaging in sports. He's having trouble memorizing the different plays and positions and he gets notes from the teacher saying he's not really following directions or not completing all the requirements. So do you have any thoughts on this scenario?

If you look at the young adult case study in the handout, there are some assessments listed that the SLP can use to look at some of those areas, like following directions. Of course, the common tool to use is the Concepts and Following Directions subtests on the CELF. Also, for planning and sequencing and missing steps and higher levels you can give the Test of Narrative Language. I like to see that with children on the autism spectrum with pragmatic language difficulties, social communication, and pragmatic language disorder, and have really been able to identify planning, organizing and sequencing issues and have been able to link these to academic skills. There is also the Behavior Rating Inventory of Executive Function, which is more in the standardized testing realm. That also may be appropriate depending on the age of the students that you're talking about. Pam or Kathy, I'm not sure from your standpoint when you're hearing about this or if there's anything else you'd like to add.

I agree with everything Katrina said in terms of the struggles during standardized testing. I would also just share that perhaps if the student has accommodations listed on an IEP or a 504 plan, we want to make sure that those accommodations are being honored and implemented with fidelity during testing scenarios as well. And that's very often not the case, unfortunately, in a school-based setting. So I don't know if we didn't have enough information to go on really to know if that's a factor, but that would certainly be one area that I would want to explore and provide that student with some test-taking strategies.

There are a lot of strategies that we teach students. Some have acronyms or mnemonics that students can use to look at a problem on a test and figure out how to answer it. So, again, there are test-taking strategies that can be taught that could be very helpful.

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