Executive Function: Concepts, Assessment, and Intervention

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Executive FunctionConcepts, Assessment, and
Intervention
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Presented by

• Julie Alexander, PhD, NCSP
• Clinical Assessment Consultant, PAR, Inc.
• School Psychologist in the public school system
  for 10 years
• Core Faculty Advisor for Nova Southeastern
  Universitys Specialist in School Psychology
  Program
• jalexander_at_parinc.com, 813-956-9213
• www.parinc.com

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Interest in Executive Function in Children

• 5 articles in 1985
• 14 articles in 1995
• 501 articles by 2005
• Bernstein Waber
• Executive Function in Education, 2007

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Plan

• What are Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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Executive Function Definitions

• Planning and sequencing of complex behaviors
• Ability to pay attention to several components at
  once
• Capacity for grasping the gist of a complex
  situation
• Resistance to distraction and interference
• Inhibition of inappropriate response tendencies
• Ability to sustain behavioral output for
  relatively prolonged periods
• Stuss Benson, 1984

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• Orchestration of basic cognitive processes during
  goal-oriented problem-solving
• Neisser, 1967

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• Functions of the Conductor
• Inhibit
• Shift Flexibly
• Modulate Emotions
• Initiate
• Working Memory
• Plan
• Organize
• Self-monitor evaluate

• Functions of the Orchestra
• Perception
• Attention
• Language processes
• Visual-spatial processes
• Memory
• Sensory inputs
• Motor outputs
• Knowledge skills
• social
• non-social

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Plan

• What are the Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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Methods of Assessing EF
Macro
Micro
Genetics
Observations
Structural Functional Imaging
Performance Tests
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Performance Tests tapping Executive Functions

• Verbal Fluency/Figural Fluency
• Stroop Color-Word Interference Test
• Rey-Osterrieth Complex Figure
• Tower of Hanoi/London/Toronto
• Wisconsin Card Sorting Test
• Verbal Learning (intrusions, perseverations)
• Mazes
• Delis-Kaplan Executive Function System
• NEPSY subtests
• TEA-Ch

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Rey Osterrieth Complex Figure
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8 year-old boy with Aspergers
Copy
Recall
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10 year-old boy with ADHD-C
Recall
Copy
Recall
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10 year old with ADHD-I
Copy
Recall
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Tower of London Starting Position
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Wisconsin Card Sorting Test
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Stroop Task
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Measurement of Executive Functions

• Executive Functions are dynamic, fluid
• No formal, single test adequate to capture EF
• Many tests are too structured to adequately
  assess EF
• Need intra-individual approach
• Executive is often provided by the examiner

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Impetus

• Clinical need for efficient external validation
• Collect standardized observational reports of
  everyday functioning
• Ecological validity, real-world anchor
• Common parent descriptions of everyday executive
  difficulties

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Purpose provide a measure of executive function
that is

• psychometrically sound
• sensitive to developmental changes
• high in ecological validity
• sufficiently broad to serve as a screen
• comprehensive in sampling content
• theoretically coherent
• useful in targeting treatment

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A BRIEF Geneology
2000
2003
2004
2005
?
200?
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BRIEF Conspirators

• Gerard A. Gioia, Ph.D. Lauren Kenworthy,
  Ph.D. Childrens National Medical Center
• Peter K. Isquith, Ph.D. Robert M. Roth, Ph.D.
  Dartmouth Medical School
• Steven C. Guy, Ph.D.
• Independent Practice
• Kimberly Andrews Espy, Ph.D.
• Vice Provost, University of Nebraska, Lincoln

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Whats in a name

• Childrens Behavior Questionnaire
• Executive Function Questionnaire
• Developmental Executive Function Test
• Behavioral Evaluation of Executive Function
• Behavioral Assessment of Regulatory Function
• Planning and Organization Rating Questionnaire
• Parent Observation Rating Questionnaire
• Behavior Rating Inventory of Executive Function

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BRIEF Structure
Meta- Cognition
Monitor
Org of Materials
Plan/Organize
Working Memory
Initiate
Behavioral Regulation
Emotional Control
Shift
Inhibit
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Behavioral Regulation Scales Inhibit

• Control impulses appropriately stop own behavior
  at the proper time
• Behavior
• Trouble sitting still
• Problems waiting turn
• Easily distracted
• Impulsive
• Needs more supervision

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Behavioral Regulation Scales Shift

• Move freely from one situation, or aspect of a
  problem, to another as needed solve problems
  flexibly
• Behavior
• Trouble changing activities
• Trouble thinking of different ways to solve a
  problems
• Bothered by having to deal with changes
• Disturbed by change in routine
• Doesnt get over problems easily

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Behavioral Regulation Scales Emotional Control

• Modulate emotional responses appropriately
• Behavior
• Overreacts emotionally
• Has angry outbursts
• Gets upset easily over little things
• Mood changes frequently
• Too emotional

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Metacognition ScalesInitiate

• Begin a task or activity fluidly generate ideas
• Behavior
• Needs to be reminded to begin tasks
• Lies around the house a lot
• Has difficulty getting started
• Has difficulty getting excited about things
• Starts things at the last minute

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Metacognition Scales Working Memory

• Hold information in mind for the purpose of
  completing a task stay with, or stick to, an
  activity
• Behavior
• Has trouble concentrating on tasks
• Forgets what he/she is doing
• Has trouble staying on the same topic
• Forgets instructions easily
• Has trouble doing more than one thing at a time

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Metacognition Scales Plan/Organize

• Anticipate future events set goals develop
  appropriate steps to carry out an associated
  action carry out tasks in a systematic manner
  understand main ideas.
• Behavior
• Gets overwhelmed by large tasks
• Has trouble prioritizing activities
• Doesnt plan ahead
• Difficulty finishing tasks
• Has trouble organizing work

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Metacognition Scales Organization of Materials

• DescriptionKeep workspace, living areas, and
  materials in an orderly manner
• Behavior
• Is disorganized
• Has a messy closet
• Loses things
• Doesnt pick up after self

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Metacognition Scales Monitor

• DescriptionCheck work assess performance during
  or after finishing a task to ensure attainment of
  goal social monitoring
• Behavior
• Makes careless errors
• Doesnt check work for mistakes
• Misjudges how difficult tasks will be
• Has trouble finishing tasks
• Unaware of how behavior affects others
• Doesnt notice others reactions

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Standardization Population

• Normative
• 1,419 parent ratings
• 720 teacher ratings
• Rural, suburban, and urban areas
• 1999 U.S. Census estimates for SES, ethnicity,
  and gender distribution.
• Clinical
• Developmental disorders or acquired neurological
  disorders (e.g., Reading Disorder, ADHD subtypes,
  TBI, Tourette's Disorder, mental retardation,
  localized brain lesions, high functioning
  autism).

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Demographic findings

• Small but significant age sex differences
• Boys show increase in Inhibit between 7-10 years,
  but steadily decrease after
• Girls show increase in EC at 14-18 years
• Small (lt5) relationship between parent ed and
  BRIEF scores
• No differences between ethnic or racial groups on
  any BRIEF measures

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BRIEF Basics
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PFA of Parent BRIEF With BASC Parent Rating
Scale (n80)
__________________________________________________
________ Scales Factor _________
_____________________1____ 2______3______4_

• Working memory
• Plan/organize
• Monitor
• Initiate
• BASC attention problems
• Organization of Materials
• BASC hyperactivity
• BASC conduct problems

• .904
• .878
• .799
• .791
• .698
• .516
• .720
• .607

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PFA of Parent BRIEF With BASC Parent Rating
Scale (Cont....)
__________________________________________________
________ Scales Factor _________
_____________________1____ 2______3______4_

• BASC anxiety
• BASC depression
• BASC somatization
• BASC atypicality
• BASC withdrawal
• Inhibit
• Emotional control
• BASC aggression
• Shift

• .764
• .696
• .661
• .467 .531
• .521
• -.769
• -.686
• -.565 -.392

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PFA of Parent BRIEF With CBCL (n200)
__________________________________________________
________ Scales Factor _________
___________________1____ 2______3______4_

• Emotional Control
• Inhibit
• Shift
• Plan/organize
• Working memory
• Initiate
• Organization of materials
• Monitor

• .656
• .633
• .599
• -.878
• -.725
• -.718
• -.653
• (.403) -.652

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PFA of Parent BRIEF With CBCL (Contd.)
__________________________________________________
________ Scales Factor _________
_____________________1____ 2______3______4_

• CBCL withdrawn
• CBCL anxious/depressed
• CBCL social problems
• CBCL attention probs
• CBCL somatic complts
• CBCL thought problems
• CBCL delinquent behavior
• CBCL aggressive behavior

• .719
• .690
• .641
• (.409) .457
• .418
• .593
• .911
• .746

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The best tool you have is your head.

• Murray Levine

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Plan

• What are Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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Development of Executive Functions
Plan/Organize/Monitor
332 yrs
Emotional Modulation
3?? yrs
Verbal Working Memory
213 yrs
Nonverbal Working Memory
3-24 mo
Inhibit
0 - ?
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Developmental Outcome of Good Executive Function

• Purposeful, goal-directed activity
• Active problem solving
• Self-control
• Independence
• Reliability and consistency
• Positive self-efficacy
• Internal locus of control

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Plan

• What are Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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The Conductor Metaphor meets the Frontal
Metaphor
Conductor
Orchestra
Note Image shown is larger than actual size.
Actual brains may vary in color and labels
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Phineas Gage 9/13, 1848 in Ludlow, VT

• 3 tamping iron shot through left cheek and
  exited left frontally
• Destroyed much of left frontal lobe

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Phineas Gage A changed man

• He is fitful, irreverent, indulging at times in
  the grossest profanity, impatient of restraint or
  advice when it conflicts with his desires at
  times pertinaciuously obstinate yet capricious
  and vascillating. His friends and acquaintances
  said he was no longer Gage
• Harlow, 1868

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Executive dysfunction can arise from damage to
the primary frontal regions as well as to the
densely interconnected secondary posterior or
subcortical areas. The associated cognitive
partners and slave systems must be present in
order for executive regulatory functions to have
any operational purpose.
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Neurons, Connections, and Pruning
Soma
Dendrites
Myelin Sheath
Axon

• Early brain development
• overproduction of neurons and neuronal
  connections until about age 11-12, especially in
  frontal cortex
• pruned over time, especially first
• five years of life

Giedd et al. (2003)
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• A second round of neuronal overproduction
  occurs just before puberty
• This is followed by the development of new
  connections and pruning through adolescence
• Myelination continues through adolescence, but
  occurs latest in brain regions involved in
  complex cognitive processes (e.g., executive
  functions).

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• So, changes in neuronal connections include
• number
• speed
• efficiency
• The changes are affected by
• life events (e.g., stress)
• the environment (e.g., exposure to toxins)
• biological factors (e.g., genetics)

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Clinical Caveats

• Neuroscience evidence for structural brain
  changes does not translate into critical periods
  for learning and intervention
• More early experience ? more synapses in
  adulthood
• Intensive early learning ? less pruning in
  adolescence and higher IQ
• No evidence that integrated curricula is
  needed because of the brains high neural
  connectivity
• Brain-based curricula promoted largely by
  non- neuroscientists
• Relationship between structure (e.g., synaptic
  density) and function poorly understood

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Clinical Implications

• Neuroscience research does support
• A neural basis for disorders
• A multi-faceted relationship between genetics,
  brain structure, brain function, test function
  and real world function
• Modifiability of brain-based problems with
  psychological, cognitive, pharmaceutical
  interventions
• The complex nature of clinical problems,
  involving interaction between genetics, neural
  integrity, and environmental factors (past and
  current)
• The potential use of cognitive
  (performance-based and rating scales) and
  imaging measures for predicting and monitoring
  outcome

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Plan

• What are Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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Disorders of Executive Function

• No singular, core disorder
• Symptom onset delayed due to prolonged
  development environmental demand
• Performance on standardized tests often
  appropriate
• Discrepancy between ability and performance
• Fluid social domain often most challenging

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Diagnostic Frameworks

• Neuro Function Psych/Med Ed
• Frontal Cognitive ADHD-I SLD
• Posterior Executive ADHD-C OHI
• Left Language TS/OCD Ortho
• Right Visual/NV RAD SLP
• Cortical Learning ASD Deaf
• Sub-cortical Memory (NLD) Vis Imp
• Motor MR PDD
• Sensory Epilepsy LI/ID
• Social/Emot TBI TBI
• Behavior LD EBD
• Academic

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BRIEF Clinical Studies

• ADHD - Jarratt et al, 2005 Loftis, 2005
  Viechnicki, 2005 Lawrence et al., 2004
  Blake- Greenberg, 2003 Palencia, 2003 Kenealy,
  2002 Mahone et al., 2002
• Reading Disorders - Gioia et al., 2002 Pratt,
  2000.
• Autism Spectrum Disorders - Gilotty et al., 2002
  Gioia et al., 2002
• Bipolar Disorder vs ADHD - Shear et al., 2002
• Tourettes Syndrome - Mahone et al., 2002
  Cummings et al., 2002
• Traumatic Brain Injury - Landry et al., 2004
  Brookshire et al., 2004 Gioia et al., 2004
  Mangeot et al., 2002 Vriezen et al., 2002
  Jacobs, 2002
• Media Violence Exposure - Kronenberger et al.
  2005.
• Spina Bifida and Hydrocephalus - Burmeister et
  al., 2005. Brown, 2005 Mahone et al., 2002.
• Obstructive Sleep Apnea - Beebe, 2004, 2002
• Galactosemia - Antshel et al., 2004
• Childhood onset MS - McCann, et al., 2004
• Sickle Cell - Kral et al., 2004
• 22q11 Deletion - Kiley-Brabeck, 2004
• PKU - Antshel et al., 2003
• Frontal lesions, PKU Hydrocephalus - Anderson
  et al., 2002

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SPORTS   September 16, 2007 Young Players,
Serious Injuries Micah Cohen, Alain
Delaqueriere, Tom Jackson, and Alan Schwarz/The
New York Times At least 50 high school or
younger football players in more than 20 states
since 1997 have been killed or have sustained
serious head injuries on the field, according to
research by The New York Times.
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Executive Functions and Performance on
High-Stakes Testing in Children From Urban
Schools DEVELOPMENTAL NEUROPSYCHOLOGY, 29(3),
459477, 2006 Deborah P. Waber, Department of
Psychiatry, Childrens Hospital, Boston,
MA Emily B. Gerber, Institute for Prevention
Science, New York University Child Study
Center Viana Y. Turcios and Erin R. Wagner,
Department of Psychiatry, Childrens Hospital,
Boston, MA Peter W. Forbes, Clinical Research
Program, Childrens Hospital, Boston, MA
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Executive dysfunction as central component in
developmental disorders

• Attention-Deficit/ Hyperactivity Disorder
• Autism Spectrum Disorders
• Learning Disabilities
• Tourettes Syndrome

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Executive Dysfunction as central component of
acquired disorders

• Traumatic Brain Injury
• Brain Tumors/ ALL
• Sickle cell disease
• Lead/ neurotoxic disorders
• Prematurity/ VLBW
• Liver/ kidney/ cardiac disease
• MS
• CVA

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ADHD and EF

• The two are not the same stem from different
  descriptive systems
• -ADHD is a diagnosis based on a cluster of
  observed behaviors
• -EF is a neuropsychological construct
• EF underlies symptoms of ADHD but the
  relationship is still under investigation

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Clinical Implications

• Performance tests and rating scales show profile
  differences between groups BUT also common
  deficits
• EF is not a diagnosis EF is a function
• Two factors and component parts are to be
  considered in interpretation
• Behavioral Regulation, esp. Inhibit, must be
  considered first prior to Metacognition
• Treatment of Behavioral Regulation is likely a
  necessary precursor to Metacognition treatment
• Treatment of metacognition via active
  problem-solving strategies

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Plan

• What are Executive Functions?
• How do we identify them?
• What is the developmental course?
• What is the brain basis?
• How do they manifest in clinical disorders?
• How do we intervene?

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Developmental Outcome of Good Executive Function

• Purposeful, organized, goal-directed
• Active problem solver
• Self-control
• Independence
• Reliable and consistent
• Positive self-efficacy
• Internal locus of control

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Are the EFs educationally relevant?

• Initiate - problems beginning task or activity
• Working Memory - difficulties holding information
  actively in mind during learning and/or
  performance
• Inhibit - problems stopping an action, thought or
  behavior
• Shift - difficulties moving from one task or
  situation to another, perseveration, rigidity
• Plan - troubles anticipating future events,
  thinking ahead and developing steps
• Organize - problems establishing, maintaining
  order of information and/or materials
• Self-monitor - lack of attention to own behavior
  or performance
• Emotional Control difficulties controlling
  emotional response

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Application to the IEP/504 Process

• Executive system functioning is related to an
  educational purpose if it the academic or social
  task meets the following conditions
• Novel learning or processing tasks necessitating
  goal-oriented performance requiring a delayed
  response and involving multiple steps over a
  period of time

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Application to the IEP/504 Process

• Executive organizational skills are increasingly
  in demand as the curriculum in higher grades
  becomes more complex
• Increasingly complex text
• Demands to reproduce information in written form
• Increasing independence

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Application to the IEP/504 Process

• Tasks for which students may have difficulty are
  those that
• Are long term (planning)
• Require organization of a lot of detailed
  information (multi-step)
• Are to be completed in a certain time frame (time
  management)

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Application to the IEP/504 Process

• EF goals focus on the development of a learning
  and/or problem-solving process versus
  curriculum content
• Implementation may require additional staff
  training
• Emphasis of support should be on teaching,
  modeling, and cueing approaches to
  self-management of learning

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General Intervention PrinciplesSteps in
intervention planning

• Step 1 Assessment
• Step 2 Review relevant data
• Step 3 Prioritize
• Step 4 Design intervention
• Step 5 Implementation
• Step 6 Progress Monitoring
• Step 7 Evaluate Intervention Effectiveness
• Step 8 Modify interventions as necessary and/or
  implement additional interventions

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Assessment of Executive Functions

• Determine the nature of executive skill deficits
• Understand profile of strengths and weaknesses

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Assessment of Executive Functions

• Background Information
• Interviews
• Classroom Observations
• Work Samples
• BRIEFBehavior Rating Inventory of Executive
  Functions
• Additional Measures

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Principles of InterventionPromote Generalization

• Begin from an external support position, slowly
  encouraging internalization of routines
• External guidance to develop routines
• External modeling of multi-step problem-solving
  routines
• Practice application/ use of routines in everyday
  situations
• Fade support to cueing

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Principles of InterventionPromote
Generalization

• External to internal process (cont.)
• Support internal control generation use of
  specific problem-solving routine
• With external guidance, promote generalization to
  new situations
• Accumulate experience, examine conditions for
  selective use of various executive routines
• Feedback throughout (i.e., reward)

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Principles of Intervention Avoid Learned
Helplessness

• Collaborate with child
• Label difficulty (This is hard)/Have child
  label difficulty
• Give child opportunity to solve problem
• Reward effort Because of the nature of the
  childs executive dysfunction, many children and
  adolescents may initially experience these
  organizational routines as quite stressful
• Hold child responsible for outcome
• Make all interventions positive

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Principles of Intervention Environmental
Interventions

• Physical or Social Environment
• Nature of tasks
• Cues
• Interactions with others

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Principles of Intervention Environmental
Interventions

• Nature of tasks
• Make the task shorter
• Make the steps more explicit
• Make the task closed-ended
• Build in variety or choice
• Provide scoring rubrics

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Principles of Intervention Environmental
Interventions

• Cues
• Verbal prompts or reminders
• Visual cues
• Schedules
• Lists
• Audiotaped cues
• Pager systems

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Principles of Intervention Environmental
Interventions

• Interactions with others
• Anticipation of problems
• Early intervention
• Reminders
• Observation
• Enhanced intervention planning
• Generalization to other students

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Principles of Intervention Individual
Interventions

• Teaching Executive Skills
• Behavior Plans and Incentive Systems
• Focus on Behavioral Regulation first

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Goal-Plan-Do-Review
GOAL What do I want to accomplish? PLAN How am I
going to accomplish my goal? MATERIALS/
EQUIPMENT STEPS/ASSIGNMENTS 1. 1. 2. 2. PREDI
CTION HOW WELL WILL I DO? Self rating 1 2
3 4 5 6 7 8 9
10 Other Rating 1 2 3 4 5 6
7 8 9 10 How much will I get
done? DO PROBLEMS SOLUTIONS 1. 1. 2. 2. 3.
3. REVIEW HOW DID I DO? Self rating 1 2
3 4 5 6 7 8 9
10 Other rating 1 2 3 4 5 6
7 8 9 10 WHAT WORKED? WHAT DIDN'T
WORK 1. 1. 2. 2. WHAT WILL I TRY NEXT TIME?
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Principles of Intervention Individual
Interventions

• Behavior Plans and Incentive Systems
• Describe problem behavior and set a goal
• Decide on possible rewards and contingencies
• Write a behavior contract
• Evaluate and revise as necessary

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Inhibit Intervention Strategies

• Provide external structure (clear rules, breaks,
  limit distractions)
• Increase supervision
• Offer support (cues, verbal prompts)
• Antecedent planning and control
• Teach alternatives
• Behavioral principles (reinforcement,, rewards,
  fading etc.)
• Use of incentives
• Ensure safety
• Increase environmental structure
• Classroom placement
• Reduce load to success levels

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Inhibit Intervention Strategies

• Behavior programs are often a necessary component
  for addressing impulse control difficulties. It
  is important to appreciate that, by definition,
  children with inhibitory control difficulties
  cannot consider potential consequences of their
  actions in the moment. Therefore, behavioral
  programs geared toward controlling stimuli that
  precede impulsivity are likely to be more
  successful than those that focus on the
  consequences that follow an impulsive action.

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Shift Intervention Strategies

• Create a consistent, predictable
  environmentreduce novelty
• Create visual cues
• Highlight changes to routine as they create
  discomfort
• Provide additional support during transitions (2
  minute warning)
• Allow additional time to adjust to changes in
  routine
• Teach student to walk through new situations
• Model multiple ways of approaching a task or
  situation
• Teach relaxation strategies and provide a place
  for self-calming
• Provide scripts

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Shift Intervention Strategies

• Displaying a daily schedule and reviewing it at
  the outset of the day can help students like
  Maria anticipate the sequence of events and can
  serve as a useful reminder of any changes in the
  daily routine.
• two minute warning. Teachers and parent can
  alert Maria that one activity is about to end and
  another will begin. Allowing a few minutes of
  down time or leisure activity between the end
  of one activity and the next can also facilitate
  transitions.

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Emotional Control Intervention Strategies

• Antecedent management
• Teaching coping/relaxation strategies
• Scripts
• Structured environment (clear rules)
• Frequent breaks
• Modeling of positive self-statements and
  emotional regulation techniques
• Pep talks
• Anticipate outbursts with student
• Process in safe setting
• Teach affective vocabulary
• Increase self-talk

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Emotional Control Intervention Strategies

• Children with executive difficulties may express
  their feelings more strongly and more directly
  than most children. This can make them seem more
  angry, irritable, sad, or silly than their peers.
  Such emotional expression should prompt
  evaluation to rule out mood or affective
  difficulties. When difficulties with modulation
  or affect occur in the context of other
  self-regulatory problems, management of the
  childs executive difficulties may be helpful.

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Initiate Intervention Strategies

• Provide external structure (verbal/visual cues)
• Develop schedules and routines
• Use technology (timers, etc.)
• Start the task with the student to help get them
  started
• Use incentives
• Reframe motivation as initiation
• External prompting (adults, peers)
• Increase arousal
• Decrease sense of overwhelm
• Provide model

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Initiate Intervention Strategies

• Methods designed to increase overall level of
  arousal, or basic energy level can be useful for
  children like Maria who have difficulty
  initiating on their own. Physical activity,
  group interaction, frequent brief breaks with
  motor activity, and change of pace or stimulation
  may be explored as means of increasing arousal
  and supporting initiation.

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Example of domain-specific goals/objectives

• Self-Initiating when students does not know what
  to do, he or she will ask the teacher / will
  minimal prompting, student will begin assigned
  tasks

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Working Memory Intervention Strategies

• Modify presentation of informationmultisensory
  strategies
• Use of planners
• Use of electronic devices such as palm pilots,
  tape recorders, etc.
• Use of alarms, paging systems
• Teach strategies and techniques to aid recall
  (i.e. mnemonics)
• Provide templates for routines and procedures
• Pre-teach
• Ready to listen
• Break up lengthy tasks
• Breaks with motor activity

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Working Memory Intervention Strategies

• Pre-teaching the general framework of new
  information and guiding attention to important
  points to listen for can be an essential tool for
  circumventing working memory difficulties when
  they interfere with ability to capture new
  material. Maria might meet with a resource
  teacher or aide at the outset of each day and
  preview the gist of what will be learned that day.

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Plan/Organize Intervention Strategies

• Break down tasks into component parts
• Provide checklists
• Provide plans and schedules
• Offer organizational frameworks in advance
• Develop templates
• Teach technological tricks
• Use of scoring rubrics
• Walk through planning process
• Modeling/Examples
• Verbalize plans

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Plan/Organize Intervention Strategies

• It is often helpful to provide examples of how
  students might plan differently to complete the
  same task, so that Maria can see options for
  alternative methods.
• Parent modeling is an important means of teaching
  good planning skills. Marias parents can
  discuss plans for the day at the breakfast table,
  or verbalize their thinking about how to approach
  a series of errands.

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Example of domain-specific goals/objectives

• Goal Setting participate with teachers in
  setting instructional goals / accurately predict
  how effectively he or she will accomplish a task
• Planning given a routine (specify), the student
  will indicate what steps or items are needed and
  the order of events / having failed a task, the
  student will create a plan for improving
  performance

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Organization of Materials Intervention
Strategies

• Provide systems of organization
• Room-cleaning schemes
• Checklists
• Incentives/Natural consequences

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Example of domain-specific goals/objectives

• Organizing will create and follow a system for
  organizing personal items in his or her locker /
  will prepare an organized outline before
  proceeding with writing projects

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Monitor Intervention Strategies

• Provide external structure and feedback
• Embedded questions
• Proofreading checklists
• Highlight the process of self-review and analysis
  of behavior
• Rating own behavior/performance
• Scoring rubrics

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Example of domain-specific goals/objectives

• Self-Monitoring will identify errors in work
  without teacher assistance / will rate his or her
  performance and will be within one point of the
  teachers rating

115
Remember!Not all strategies are for everyone
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BRIEF-SPSoftware Portfolio
117
School-Oriented Interventions
2004
118
Parent-Oriented Interventions
Woodbine Press, 2008
119
References

• Barkley, R. (1997) ADHD and the Nature of
  Self-Control. New York Guilford Press.
• Dawson, P., Guare, R. (2003). Executive Skills
  in Children Adolescents A practical guide to
  assessment and intervention. NY Guilford Press.
  Pennington, B.F. Ozonoff, S. (1996) Executive
  functions and developmental psychopathology.
  Journal of Child Psychology and Psychiatry, 37,
  51-87.
• Gioia, G. A., Isquith, P. K., Guy, S. C.
  (2001). Assessment of Executive Function in
  Children with Neurological Impairments. In R.
  Simeonsson S. Rosenthal (Eds). Psychological
  and Developmental Assessment. NY The Guilford
  Press.
• Gioia, G.A. Isquith, P.K. (2001) New
  perspectives on educating children with ADHD
  Contributions of the executive functions
  Journal of Health Care Law Policy, 5, 124-163.
• Lyon, G.R. Krasnegor, N.A. (1996) Attention,
  Memory and Executive Function. Baltimore Paul
  H. Brookes Publishing Co.
• Goldberg, E. (2000) The Executive Brain Frontal
  Lobes and the Civilized Mind. New York Oxford.
• Ylvisaker, M. Feeney, T.J. (1998)
  Collaborative Brain Injury Intervention Positive
  Everyday Routines. San Diego Singular
  Publishing Co.

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Thank You!