2.
Executive Function Treatment
Why is executive function so important?
Before we get into my approach to treatment, let's look at what executive function is. Executive function is also known as cognitive control. It's the part of our brain that turns on every time we try to accomplish a goal or even think about what would be required to achieve a goal. The skills we put under the label "executive function" may seem to be an unrelated jumble, but if you think about it from the perspective of "skills your brain needs in order to accomplish a goal" or even "the boss of the brain telling the rest what to do" it makes a bit more sense. It should also underscore the importance of this critical skill, because that's involved in pretty much every aspect of living. Any time you prepare, transition, trouble shoot, control your impulses, pay attention, or any number of other skills, you're using executive function.
Executive function struggles are caused by differences in the brain
Kids with poor executive function are labeled as "non-compliant", "lazy", "careless", or "oppositional" when in fact what's happening is literal differences in their brains. Let's look at an example of how physical differences in the brain can cause executive function problems. Much of executive function is controlled by the front of the brain (the prefrontal cortex). These are some of the cognitive symptoms that we see even in adults with damage to that part of their brain: impaired judgment, inability to solve problems or organize tasks, difficulty controlling emotions, socially inappropriate behavior, loss of inhibitions, and poor attention span, among other things. [source]
These are symptoms that can occur regardless of if they were "hard working", "careful", "respectful" people before the injury. I'm not saying this because I'm trying to convince you that your child has had a stroke or traumatic brain injury. (That's not the cause of most cases of executive function struggle in children.) I'm giving it as evidence of how wrong people are when they put down children with executive function problems, or blame parents for not being "strict enough". This is not a parenting thing. This is not a decision on your child's part. This is not because they're unmotivated. Like the adults who have frontal lobe damage, for various reasons our kids' brains simply do not have the executive function skills to meet expectations for typically developing children - at least, not without significant supports.
What is the connection between executive function and other disorders?
Some disorders in children that are associated with trouble with executive function skills include (but are not limited to):
- Fetal alcohol spectrum disorders (very under-diagnosed with misleading stereotypes)
- Autism
- ADHD (attention deficit hyperactivity disorder)
- Mental health disorders (evidence is strongest for bipolar and schizophrenia, but OCD and anxiety are being studied as well)
- Damage to the brain (traumatic brain injury, stroke, cerebral palsy, potentially epilepsy, and others)
Children with executive function struggles are also often diagnosed with opposition defiance disorder (ODD), even though that disorder is almost always describing the effects of other disorders.
What are the layers of executive function skills?
There are layers of skills that fall under executive function. Some examples of top level skills are:
- Planning and anticipating
- Organizing
- Decision making and prioritizing
These skills are those that are most visible in daily life. You can clearly look at a child and see if they are having problems organizing, planning, and decision making, for instance. On those occasions that the struggles are identified as areas that need to be taught, intervention generally directly targets these top level skills. However, the source of the problem is usually a deeper level skill. Without working on the source, interventions are going to have limited success.
Let's examine those skills hiding under the surface. Top level skills are supported by secondary skills including:
- Cognitive flexibility
- Initiation
- Self-monitoring, self-correcting, and self-modulating
- Time sense and pacing.
However, these secondary skills require yet another set of skills - the foundational level skills. Foundational level skills include:
- Attention (perception, focus, sustained attention)
- Inhibition (how you control your impulses)
- Working memory (both verbal and nonverbal)
These skills are the critical building blocks on which all the other skills rest. For example, without nonverbal working memory to help you simulate a task in your head, you will struggle to determine how long you need for a task and the pace at which you need to go.
How do I treat executive dysfunction?
Treatment depends entirely on which executive function skill(s) are affected, but I can give some examples. If the problem is inhibition, for instance, we would make a plan for the situation in which impulses are hard for your child to control and practice the plan with them over and over and over again for each difficult situation. For attention we would work on understanding how attention works and practice noticing when attention has wandered and bringing our minds back to the situation at hand. For verbal working memory we might do work on phonological awareness. For nonverbal working memory we would work on holding, manipulating, and sequencing whatever is being conceptualized (through visualization or other senses).
Each and every skill listed in the tiers above has its own unique method of treatment and those are simply some examples. The main key is to check all the tiers of skills for problems and teach the most base level skills first.
Hearing that executive function struggles are caused by physical differences in the brain can make it feel impossible to achieve growth. But the key is neuroplasticity - the way that as we practice something over and over and over we can literally form new connections in our brains. You just have to know the right things to practice, the right ways in which to practice them, and be prepared to practice a lot. I'm happy to provide that practice in our sessions, as well as coaching to help you or other support team members as you work together to help your child grow.