executive function: effective strategies and interventions
DESCRIPTION
Executive Function: Effective Strategies and Interventions is a workshop I'll be offering at Assumption College in Worcester, Mass. on Friday 12/5/2014. Contact me if you think a workshop like this would be a good fit for your organization - [email protected]TRANSCRIPT
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David D Nowell PhDwww.DrNowell.com
Executive Function: Effective Strategies and Interventions
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www.DrNowell.com
DavidNowell
DavidNowellSeminars
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Overview
• Brain Overview in 27 Slides
• Models of EF
• Strategic Behavioral Inquiry (HËDŸDT?)
• Disorders Which Impact EF
• Real Life Implications of EF Deficits
• Assessment of EF
• Strategies and Case Studies
• Q&A&D
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www.slideshare.net/dnowell
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BRAIN OVERVIEW IN 27 SLIDES
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What does dopamine feeeel like?
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Ways of thinking about the brain
• Left to right
• Top to bottom
• Front to back
• Top-down and bottom-up
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what IS…
12/3/2014© 2011 David D. Nowell, Ph.D. All rights
reserved.28
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…what COULD BE
12/3/2014© 2011 David D. Nowell, Ph.D. All rights
reserved.29
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What’s wrong with this brain model?
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What’s wrong with this brain model?
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What’s wrong with this brain model?
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MODELS OF EXECUTIVE DYSFUNCTION
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• McCloskey’s model
• Barkley’s model
• BRIEF model
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McCloskey’s Clusters
• Attentional cluster
• Engagement cluster
• Optimize cluster
• Evaluation cluster
• Efficiency cluster
• Memory cluster
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McCloskey’s Clusters
• Attentional cluster
– Becoming aware
– Focusing attention
– Sustaining attention
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Sleep hygiene
• Strict bedtime
• Use bed only for sleep
• No caffeine after mid-afternoon
• No activating media after 7pm
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Establish bedtime routine
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Fidget supports
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McCloskey’s Clusters
• Engagement cluster
– Initiating
– Putting in effort
– Inhibiting
– Stopping
– Interrupting
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Reward small units of effort
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There’s no such thingas “disinhibited”
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The “talking stick”
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DRO
Differential Reinforcement of Other
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McCloskey’s Clusters
• Optimize cluster
– Modulating
– Monitoring
– Correcting
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Sam rode her new blue bicycle down the steep hill, enjoying the crisp Autumn air and bright late-afternoon sun.
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Sam rode her new blue bicycle down the
steep hill, enjoying the crisp Autumn air
and bright late-afternoon sun.
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GREEN
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Voice Modulation
• 5 – football game
• 4 – large clasroom
• 3 – small group
• 2 – talking quietly with a friend
• 1 - whisper
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• Give multi-step directions while playing catch
• Play mindfulness “freeze tag”
• Quiz do-over
• Make use of rhythm and music
(508) 579-7958
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Don’t stealth bomb inattentive students
• “Pete in about a minute I’ll ask you about..”
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McCloskey’s Clusters
• Evaluation cluster
– Sizing up
– Anticipating
– Estimating time
– Making associations
– Generating solutions
– Organizing
– Comparing
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12/3/2014
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12/3/2014
© 2011 David D. Nowell, Ph.D. All rights reserved.
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12/3/2014
© 2011 David D. Nowell, Ph.D. All rights reserved.
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1 hour 1 day 1 week 1 month 1 year
Time Horizon
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10-Minute Morning Review
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Using your phone’s navigator as a time-management tool
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McCloskey’s Clusters
• Efficiency cluster
– Sensing time
– Pacing
– Sequencing
– Using routines / executing
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Distraction delay training
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McCloskey’s Clusters
• Memory cluster
– Holding
– Manipulating
– Storing
– Retrieving
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Prospective Memory
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The Executive Functions
• Sensing to the self
• Speech to the self
• Emotion to the self
• Play to the self
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The Executive Functions
• Sensing to the self
• Speech to the self
• Emotion to the self
• Play to the self
Barkley, RA, (2012)
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BRIEF (Behavioral Rating Inventory of Executive Functioning)
• Inhibiting• Shifting • Controlling emotions• Initiating• Working memory• Planning• Organizing materials• Monitoring• Metacognition• Behavioral regulation
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Self-control
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The Executive Functions
• Sensing to the self (HËDŸDT)• Speech to the self
• Emotion to the self
• Play to the self
Barkley, RA, (2012)
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BRIEF
• Inhibiting (HËDŸDT)• Shifting • Controlling emotions• Initiating• Working memory• Planning• Organizing materials• Monitoring• Metacognition• Behavioral regulation
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STRATEGIC BEHAVIORAL INQUIRY
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12/3/2014© 2011 David D. Nowell, Ph.D. All rights
reserved.106
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Objectives of SBI
• Specific behavioral strategy
• What was the feeling-goal?
• Motivational level on a scale from 1-10
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Benefits of SBI
• Affirms the value of clients’ unique internal experience
• Emphasizes the culture of self-regulation
• Encourages metacognition
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Assumptions of SBI
• Everybody’s doing the best they can
• Behavior is not incomprehensible or random
• Behavior follows patterns which reveal themselves to the curious observer free of prejudice or blame or theory
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Personal Application
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…and How Exactly
Did You Do That?
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…and How Exactly
Did You Do That?
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Personal Application
• What bad habit persists? And How Exactly Do You Do That?
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Learn from your To-Do list
• Which things are not getting completed?
• How – exactly – are these not getting completed? How do you do that?
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Clinical Application
• Who in your clinic or classroom is demonstrating remarkable “resilience” –persistence despite significant obstacles? And how, exactly, does he/she do that?
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Clinical Application
• Who in your clinic or classroom is demonstrating remarkable “resilience” –persistence despite significant obstacles? And how, exactly, does he/she do that?
• What recurring behavioral problem is showing up in your clinic or classroom?
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Clinical Application
• Who in your clinic or classroom is demonstrating remarkable “resilience” –persistence despite significant obstacles? And how, exactly, does he/she do that?
• What recurring behavioral problem is showing up in your clinic or classroom?
• Note: we aren’t asking “why did you do that,” but rather “how exactly did you do that.”
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How to do SBI
“How exactly did you do that?”
“How did you know it was time to _____?”
“How long had you been thinking about ____?”
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DISORDERS WHICH IMPACT EXECUTIVE FUNCTIONS
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• ADHD• Schizophrenia• Bipolar Disorder• Anxiety Disorder• Autistic Spectrum Disorders• Sensory Processing Disorder• Specific Learning Disorders• Tourette’s Syndrome• Sleep Disorders
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20%–60% of the variance in functional outcome (Sabhesan & Parthasarathy 2005)
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Gur RE, Turetsky BI, Loughead J, et al. (2007)
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(Clark, Iversen & Goodwin 2001)
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(Rubinsztein, Fletcher, et al. 2001)
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Fujii, Kitagawa, et al 2013
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(Airaksinen, Larsson, & Forsell 2005)
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Appendix A
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(Brosnan, Demetre, et al 2002)
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Appendix B
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ADHD OCD
Tourette
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(Rechtschaffen & Siegel 2000)
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ADHD and Brain Development
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Sluggish Cognitive Tempo
• Daydreaming• Easily confused• Staring• Easily fatigued• Sluggish• Withdrawn• Slow to complete tasks• Lower levels of parent stress• Less situation-specific than hyperactive type
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REAL LIFE IMPACT OF EF DEFICITS
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1. 1-step errands
2. Chores with cues
3. Basic inhibition
Preschool
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1. 2-3 step directions
2. 20-30 minute assignments
3. Follow rules/inhibit/no grabbing
Kindergarten -2nd Grade
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1. Simple shopping list
2. Keep track of variable daily schedule
3. Inhibit and regulate even without teacher present
4. Simple delayed gratification (phone)
3rd-5th Grade
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1. Complex chores
2. Organizing system
3. Time management
4. Self soothe
5. Manage conflict
6th – 8th Grade
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1. Independent with assignments
2. Make adjustments based on feedback
3. Inhibit reckless behavior
4. Say “no” to fun activity if other plans already made
5. Take others’ perspective
Teenage-mid 20’s
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Knock 3 years off his age
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Lending Your Brain
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Arenas of Involvement
• Intrapersonal
• Interpersonal
• Environmental
• Academic / symbol system
(McCloskey & Perkins, 2013)
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Executive Functions and Math
• Verbal strategies
– Please excuse my dear Aunt Sallly (PEMDAS)
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Executive Functions and Math
• Verbal strategies
– Please excuse my dear aunt sally (PEMDAS)
– KNOW
• Key words, numbers, operation, work it out
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Key words
Numbers I need
Operations
Work it out
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Executive Functions and Math
• Visual strategies
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Executive Functions and Math
• Hands-on strategies
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Executive Functions and Reading
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EZ-C Reader
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Executive Functions and Writing
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Executive Functions and Writing
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Executive Functions and Writing
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Executive Functions and Writing
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Executive Functions and Writing
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Executive Functions and Study Skills
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Cornell note-taking system
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Cornell note-taking system
Class and date
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Cornell note-taking system
Class and date
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
SUMMARY
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Cornell note-taking system
Class and date
Notes
Notes
Notes
SUMMARY
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Cornell note-taking system
Class and date
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Cornell note-taking system
Class and date
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
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Cornell note-taking system
Class and date
Notes
Notes
Notes
SUMMARY
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Cornell note-taking system
Class and date
Notes
Notes
Notes
SUMMARY
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Chunk Chew and Check
• Grades K-2: about 5 minute chunks
• Grades 3-6: about 10 minute chunks
• Grades 7-12: about 15 minute chunks
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Executive Functions and Homework
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Executive Functions and Homework
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Homework Considerations for Teachers
• Target productivity first, then accuracy• Reduce homework
– Overall correlation of homework with achievement is just .15-.25 across all grades and weaker in elementary grades*
– For high school, best amount was 1.5-2.5 hrs/night; more time had no further benefits*
*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.
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Executive Functions and Social Skills
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Accommodations for EF Deficits
• Preferential seating• Extra set of textbooks at home• Quiet test environment• Time off the clock during testing (schedule breaks)• Pre- and post-class 1:1 review of content• Visual schedule• Movement breaks• Fidget/sensory interventions• Verbal cues• External time cues (Time Timers products, or kitchen timer)• Teacher check-off on homework binder• “Locker” is in guidance counselor’s office• Attention coach (10-15 minutes)
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Examples of IEP Goals for EF Deficits1. Self Awareness a. Student will identify tasks that are easy or difficult for him/her.b Student will accurately explain why some tasks are easy or difficultd.Student will offer help to another when he/she is more capable than another child
2. Goal setting a. Student will participate with teachers in setting academic goals.
3. Planning a.Given a selection of 6 activities for an instructional session, student will select 3, indicate their order, create a plan on paper and stick to the plan. c. Having failed to accurately predict his/her grade on a test, student will create a plan for improving performance on the next test.
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Examples of IEP Goals for EF Deficits4. Organizing a. To relate a story, student will place illustrations in order and then narrate the sequence of events B. Student will prepare an organized semantic map or outline before proceeding with writing projects
5. Self-initiating a. Without prompts, student will begin his/her assigned tasks
6. Self-monitoring & self evaluating a. Student will identify errors in his/her work without teacher assistance
7. Problem Solving a. When faced with obstacles to educational or social objectives, student will identify possible courses of action, identify pros and cons for each, choose a course of action, perform it and evaluate its effectiveness.
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What are our data sources?
• Record review
• Interview
• Collateral interview
• Checklists
• Mental status examination
• Test scores
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ASSESSMENT OF EXECUTIVE FUNCTIONING
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Curious Compassionate Nonjudgmental Evaluation
• Skillfully eliciting the chief complaint
• HËDŸDT?
• Forming a diagnostic impression
• Defending your diagnosis / impression
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Skillfully eliciting the chief complaint
• Too much of what? Or too little of what?
• Invoking the Pediatric Fairy (or the Psychiatric Genie)
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HËDŸDT?
• How exactly did you do that?
– Everybody’s doing the best he/she can
– Every behavior problem is either
• Skills deficit
• Contingency problem
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Forming a diagnostic impression
• Where do you see it the most? And where do you see it the least?
• Two disorders = two stories
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Forming a diagnostic impression
• Where do you see it the most? And where do you see it the least?
• Two disorders = two stories
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Documenting and communicating your conclusions
• The footprints in the butter
• Defend your diagnosis
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Approaches to Evaluation of EF
• Formal direct
• Informal direct
• Formal indirect
• Informal indirect
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Evaluation of EF
• Informal Indirect
– Review of records
– Collateral interviews (see McCloskey 2012)
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Evaluation of EF
• Formal Indirect
– BRIEF (Behavior Rating Inventory of Executive Functioning)
– BASC (Behavior Assessment for Children)
– CBCL (Achenbach Child Behavior Checklist)
– BDEFS-CA (Barkley Deficits in Executive Functioning Scale – Children and Adolescents)
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Evaluation of EF
• Informal Direct
– Review of work samples
– Process-approach to test performance
– Mental Status Examination
– Classroom observation
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Evaluation of EF
• Formal Direct– NEPSY
– CAS (Cognitive Assessment System)
– Delis-Kaplan Executive Function System
– Continuous Performance Tests (Vigil; Connors CPT; IVA)
– Wisconsin Card Sorting Test
– Trail Making Test for Children
– Rey-Osterreith
– Functional Behavior Assessment
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Avoiding the most common diagnostic error
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STRATEGIES AND CASE STUDIES
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Stimulant Treatment for ADHD
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Image: wikimedia commons
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Cortico-striatal loop
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Increase salience
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Two weeks from now, how will you know whether it’s working?
Appendix D
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Daily report card
Appendix C
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Antecedent Support for Executive Dysfunction
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AANTECEDENT
BBEHAVIOR
CCONSEQUENCES
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AANTECEDENTS
BBEHAVIOR
CCONSEQUENCES
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“Modified Independence”
• Chronic disability perspective
• Time prosthetics
• Problem-solving prosthetics (mind map)
• Math prosthetics
• Sequence prosthetics
• Motivation prosthetics
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AANTECEDENTS
Set them up for success
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Clear boundaries
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Clear (see-through) storage
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AANTECEDENTS
Identify exceptions
Where do you see it the most?
Where do you see it the least?
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Rules
•Waking up•Bedtime•Chores•Homework•TV / internet
AANTECEDENTS
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Launching Pad
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Expectations
•Specific•Behavioral•In advance
AANTECEDENTS
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Communication
•Get eye contact•Speak clearly•Provide behavioral info•Check for understanding
AANTECEDENTS
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AANTECEDENTS
Provide prosthetic cues at the “point-of-performance” (Barkley)
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easy hard
If It’s Harder than a “3” Find Some Way to Make It Easier
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Assign separate due dates for smaller parts of big projects
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Appendix H
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Increase salience
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StayOnTask app
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The “talking stick”
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Provide multiple cues for transitions
• Verbal “two minute warning”
• Visual schedule
• Changes in lighting
• Nonverbal cues
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Instant study carrel
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Time “in”
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Place the student with tactile defensiveness at the edge of the group
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Heavy work
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ADD Coaching
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Movement Techniques
• Exercise
• Yoga
• Martial arts
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Bal-A-Vis-X
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Balance screen time and “green time”
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Balance screen time and “green time”
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Supplements and Diet
• Omegas
• Food additives
• Food allergies
• Pesticides
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AANTECEDENT
BBEHAVIOR
CCONSEQUENCES
Behavioral Support
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BBEHAVIOR
“A healthy high-functioning 26 year old”
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reserved.314
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BBEHAVIOR
More
• Behavioral control• Choices and options• Self-regulation
• Arousal• Motivation• Mood• Attention
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Mindfulness
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Dr. Sara Lazar
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Metacognition
• How much effort am I giving this?
• What has worked for me before?
• When to shift from processing to maintenance
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Hypnosis
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Mnemonics Training
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AANTECEDENT
BBEHAVIOR
CCONSEQUENCES
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Don’t reward them with stuff
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Rotate rewards frequently
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Use extrinsic reward creatively
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Emphasize the sensory details of your desired outcome
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Cortico-striatal loop
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Determine what basic provisions are unconditional…
• Love
• Respect
• Safety
• 3 meals
• Essential clothing
• Temperature-controlled environment
• 30 minutes of video games
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…and which are contingent• Special foods
• Expensive or trendy clothing
• Extra video game time
• WiFi password
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Clip and share horrible articles about teens falling out of the back of pickup
trucks
• Review cause and effect
• Discuss consequences
• Emphasize behavioral agency
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The “Big Five”
• Daily focus time
• Nutrition
• Movement
• Sleep
• Connection
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10-Minute Morning Review
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…the most important 10 minutes of the day….
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The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it.
- E. Goldberg
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Key features of a great planner system
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Key features of a great planner system
• 2 pages per day
• Master to-do list
• With the client at all times
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Yoga / read
Staff meeting
Planningsession
Phone calls
billing
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Vh: jeff w/ puritan oil
Vc: kate re: brimfield
TC umass dermatology. Spoke w/ cindy 508 8564000
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Key features of a great planner system
• 2 pages per day
• Master to-do list
• With the client at all times
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What’s a To-Do list for anyway?
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Key features of a great planner system
• 2 pages per day
• Master to-do list
• With the client at all times
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Key features of a great planner system
• The “technology”• The “practice”
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Key features of a great planner system
• The “technology”
• The “practice”
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Weekly Overview
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10-Minute Morning Review
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The “Big Five”
• Daily focus time
• Nutrition
• Movement
• Sleep
• Connection
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Nutrition essentials
• Emphasize protein at every snack and meal
• Eat fewer processed foods
• Choose local
• Pay close attention to patterns between food and focus/mood
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The “Big Five”
• Daily focus time / Motivational clarity
• Nutrition
• Movement
• Sleep
• Connection
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“Exercise for focus” is different from "exercise for fitness”
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The “Big Five”
• Daily focus time / Motivational clarity
• Nutrition
• Movement
• Sleep
• Connection
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The “Big Five”
• Daily focus time / Motivational clarity
• Nutrition
• Movement
• Sleep
• Connection
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Positive characteristics of many people with attentional / executive challenges
Appendix G
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Don’t do anything for your ADHD teenager which could be managed by
a machine or an app
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“Walk Me Up” app
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www.slideshare.net/dnowell
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Let’s stay in touch!
Join my e-newsletter list:
Fill out a card today and drop it in the box.
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Visit us on the web: www.DrNowell.com
@davidnowell David Nowell Seminars
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Q & A & D
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Fail-proof desk activities
Appendix A
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Determine in Advance When You’ll Check Email and Facebook Tomorrow
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• Review expectations in advance
• Teens and college students may take more initiative with this
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Generic Issues Associated with Transition to Adolescence
• Increased physical size and neurological maturation
• Increasing maturation of sexuality
• Increasing desire to individuate from parents; decreasing influence of parents on teen behavior
• Increasing time away from home & parents
• Increasing number of domains of major life activities to which the teen must adapt– Sex, driving, peers, money & work, community activities, crime, drugs
• Greater involvement with and influence of peers
• Most of these are adversely affected by delay in self-regulation associated with ADHD
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How do symptoms change by adolescence?• Hyperactivity declines more steeply than does inattention and
related executive function (EF) deficits
• Motor restlessness becomes a more internalized subjective sense of feeling a need to be busy all the time
• Transition to middle school is associated with a transient increase (reversal of decline) in ADHD symptoms
• The inattentive/EF symptoms have a greater impact on school functioning than HI symptoms; increases with age
• Impulsivity is more related to impaired nonacademic domains:– development of ODD
– drug experimentation
– speeding while driving
– risky sexual behavior, taking on dares from peers
– impulsive verbal behavior
– reactive aggression
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Symptom Transitions (continued)
• But inattention also has adverse impacts on non-academic functioning :– Poor attention to traffic density and speed while in community auto
traffic settings
– Greater risk for pedestrian/cycling accidents in traffic settings
– Greater crash risk as drivers (in vehicle distractions are most contributory)
– Accelerated use of nicotine after experimentation• Self-medication ???
– Poor follow through on chores and other home responsibilities
– Poorer work performance in school
– Poor work performance part-time employment settings
– Inattention to others’ comments and needs in social activities
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Emerging Impact of EF Deficits• Poor working memory (remembering to do things)
– Less follow through on promises and commitments to others
– Increasing adverse impact of reading-listening-viewing comprehension deficits, especially in school & work settings
• Impaired planning, anticipation, and preparatory behavior; not ready for the future as it arrives– Reduced valuing of future rewards relative to peers
– Consequently, don’t persist toward future goals and show poor delay of gratification
• Deficient sense of time and time management– A restricted temporal window relative to peers
• Poor emotion regulation (related to poor inhibition)– Deficient control of anger & frustration most impairing
• Decreased fluency (rapid assembly of ideas into coherent verbal reports and behavior)
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Basic Considerations• Don’t retain in grade!
• Sept is to establish behavioral control
• Decrease total workload, or
• Give smaller quotas of work at a time
• Target productivity first, accuracy later • Reduce homework
– Overall correlation with achievement is just .15-.25 (just 2-6% of variance in achievement) across all grades and weaker in elementary grades*
– For high school, best amount was 1.5-2.5 hrs/night; more hours had no further benefits*
*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.
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Tips for Teens• As needed, use ADHD medications – have
parents negotiate a contract with the teen if necessary
• Find a “Coach” or “Mentor” (Just 15 min.)– The Coaches’ office is the student’s “locker”
– Schedule in three 5-minute checkups across each day
– Use behavior report card to monitor teen across classes
– Use daily assignment sheets requiring teacher initials
– Cross temporal accountability is the key to success
• Identify a parent-school ADHD liaison– Serves as an intermediary on issues between parents & school
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A Daily Behavior CardEach teacher rates each behavior at end of each class; 1=Excellent (+25), 2=Good (+15), 3=Fair (+5), 4=Poor (-15),
5=Terrible (-25)
Subjects 1 2 3 4 5 6 7ClassParticipation
Performs assignedclasswork
Follows class rules
Gets along wellwith others
Completes home-work assignments
Teacher’sInitials
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More Tips for Teens
• Use a daily school behavior card for self-evaluation after; move to weekly after 3+ good weeks
• Keep extra set of books at home
• Learn typing/keyboard skills for writing assignments
• Require continuous note-taking to pay attention to lectures or during reading assignments
• Tape record important lectures – check out the Smart Pen that digitally records lectures or other conversations at livescribe.com
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More Tips for Teens• “Bucks for Bs” system
– grades on each assignment = $ from parents• Get week-at-a glance calendar with journal or other organizing
notebook system• Schedule hard classes in AM• Alternate required with elective classes• Extra time on timed tests (???) – no evidence it helps
– Better to have distraction free test setting and intersperse breaks in testing to create shorter test periods (time off the clock)
• Permit music during homework*• Get written syllabus as handouts
*Soderlund et al. (2007). Journal of Child Psychology and Psychiatry, 48, 840-847.
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Still More Tips for Teens
• Learn SQ4R for reading comprehension– Survey material, draft questions, then: – Read, recite, write, review
• Peer tutoring in class• “Study-with-a-buddy” after school • Find “fall-back” classmates (swap phone, e-mail, & fax
numbers) for lost or missing assignment sheets• Attend after-school help-sessions• Schedule parent-teacher-teen review meetings every 6
weeks (not at 9 week grading period)
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Teaching skills is inadequate
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What and who is the “A”
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Chronic disability perspective
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Reverse Engineering the Carrot and Stick
• Rey O versus VMI
• Carrot and stick
• Break down large projects
• scaffolding
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• Present various models of EF
• Settle on 10-ish
• Introduce HEDYDT? (disappearing ink, do you comment, hedydt)
• Create more handouts (e.g. worksheet for determining contingencies)
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Overview
• Brain overview in 11 slides– Amygdala (mindfulness), hippocampi (exercise), PFC (screen time/green time, sleep), PFC regions, loops
• Models of EF– Small group: what is EF– Hot and cold EFs– 10 Efs - consider dawson guare model– Barkley’s 4– McCloskey’s 30-st
• EF as Self-Regulation– Sensing to the self, etc– Central impairment is in self-regulation
• Disorders which impact EF– ADHD– TBI– Schizophrenia– Bipolar Disorder– ASD– Anxiety Disorders– Leaning Disorders– Oppositional Defiant Disorder
• Real life implications of EF deficits– EF and reading– EF and writing– EF and math– EF and test-taking– Metacognitive Awareness Inventory (Schraw & Dennison 1994)
• Assessment of EF– Direct formal etc– Curious compassionate nonjudgmental evaluation
• Strategic Behavioral Inquiry (HEDYDT?)• Asking 2 Questions• Case Studies and EF Strategies• School Accommodations and Supports• Big 5 EF Supports
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• N-back with a deck of cards
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Accomodations
• Meltzer (kindle)
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ADHD
Inattentive
Sluggish Cognitive Tempo
Hyperactive Combined
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5-42 / (10-2)+3x6
P 5-42 / (8)+3x6
E 5-16 / (8)+3x6
MD 5-2+18
AS 21