What is Executive Functioning?
The term Executive Functioning (EF) may sound like it relates to financial management. However, neuroscientists use the term to refer to "the brain-based skills that are required for humans to execute or perform tasks" (1) . Busy parents use their EF to organize car pools and set priorities to meet their work and home schedules. Eight-year-old Alex uses executive functioning to put his toys away when his parents tell him to pick them up. His efficient EF allows him to
- Avoid distractions: to do the task even though the nieghbor's kids are out playing
- Problem-solve: to avoid mixing his muddy outdoor toys together with his books
- Make choices: ask Dad to help him move a heavy basketball stand rather than trying to do so by himself
- Sustain his attention: to stay with the job until he completes it
- Focus: to notice that his bicycle is lying in the street
- Manage his time: to leave enough time to eat dinner and do his homework
- Control his impulses: to clean up even though he'd rather play
I have worked with many children, including my son, who have not only found it very challenging to clean up, but have spent many stressful hours into the night completing school assignments. A child's EF affects every task throughout the day-whether it be remembering to close the bathroom door, finishing a spelling test before the bell rings, or deciding to get a different pair of socks when unable to find a match.
The Challenge of Getting Things Done!
Dr. Jean Ayres describes autistic children as having difficulties with the "I want to do it" function in the brain. This function works closely with the sensory system that registers sensations and controls paying attention. These children may be able to plan and perform simple movements, such as lining up cars, but more complex actions do not occur to them. Children who have difficulty generating ideas tend to engage in stereotypic actions instead of the fluent, easy, quick, and imaginative motor actions typically developing children use in play (2). The inner drive to plan and learn new actions is impaired in these children. Therefore, intervention strategies should include sensory stimulation that helps them to learn more complex motor skills that they can generalize to other situations.
Six-year-old Mary like to repeatedly squeeze and release the adapted loop scissors in the air, oblivious to her classmates'' annoyed looks. She noticed that all the other children in her first-grade class could cut out shapes, yet when she tried to control the scissors the paper ripped. She hated failure, so she refused to even touch the paper her teacher offered. During story time, Mary sprawled out over her mat, leaning her head on her hand. At other times she roamed aimlesslessy around the room, talking continuousoly about her dog, Ringo. When the teaching assistant tried to redirect her back to the mat, she began crying.
Mary waited to find her lunchbox until all the other children had taken theirs and were lined up by the door. She spent so much time in the lunchroom talking about what she was going to eat and finding someone to unzip her lunchbox for her that she seldom finished her entire lunch before the recess bell rang. Mary returned to class frustrated, hungry and emotionally fragile.
Compared with her peers, Mary did have fine motor challenges. But several other difficulties also contributed to her delayed hand skills, specifically
- Distractibility: She had difficulty maintaining attention long enough to perform a task.
- Working memory: She could not remember how to unzip the lunch-box, so had to relearn this skill every lunchtime.
- Emotional control: She became frustrated easily and would get so upset she could not focus on learning the more complex task of cutting paper.
- Sustained attention: She had difficulty persisting with tasks long enough to practice or comlete them.
- Task initiation: planning, organization, and time-management: She needed all of these high-level skills to complete tasks in a reasonable time frame.
- Flexibility and problem-solving: Mary didn't make the connection that excessive talking and wandering prevented her from finishing he lunch.
When Mary was younger she didn't open and close her fingers, pretending to snip, the way her siblings had. Although she loved placing shapes into form boards, she never generalized that skill to placing stickers inside their corresponding outlines in a sticker book.
Intervention Strategies for Mary
Mary was diagnosed with Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), sensory Processing Disorder (SPD) and a learning disability. She also had above-average intelligence. Lucy, the school OT, gave Mary small tongs to practice the open-and-close movements used for cutting with scissors.
In addition, the teacher prepared a visual schedule with pictures showing the sequence of daily activities. Mary was allowed to go to the lunchroom ahead of the class so that she had extra time to eat, and her classroom aide helped her to choose a quiet place to sit. At Lucy's suggestion, Mary's mom bought her a new lunchbox with Velcro hook-and-loop closures so that she could set up and clean up her lunch without help.
Creating a Sensory Diet
Mary wanted to move and talk almost constantly. In response, Lucy created a sensory diet containing lots of structured deep-pressure movement experiences that involved following directions. Mary had to finish an activity before she could speak. For example, Mary sat on the stationary platform swing and used tongs to pick up small dog bisuits and drop them into a box. Lucy pushed the swing slightly each time Mary dropped a biscuit into the box. After dropping in 10 biscuits, Mary's reinforcement ws extra big, fast swinging while shouting out her favorite things to eat.The movmement provided sensory stimulation while also encouraing Mary to persist at this task until completion. Mary was also rewards with biscuits to take home to her dog, Ringo.
Lucy used an ecelctic approach to address Mary's EF and SPD challenges, including a sensory diet, specific skill training (manipulating tongs), and reinforcement in the forms of movement and opportunities to shout.
Strategies for Executive Functioning Challenges
Some children talk all the time! They use talking to distract themselves and avoid challenges and possible failure. Many parents also love to talk so hesitate to tell their child to be quiet. However, children like Mary may not be able to plan and execute daily tasks if they are distracted by talking. Thus, they may not finish breakfast in time to catch the bus.
The hippotherapy client shown below is standing on a stationary horse while removing and inserting objects attached with Velcro into a container. I told him that there would be NO talking until he finished the task. This was very difficult to do but he learned that the request to stop talking and focus on completely a short task was achievable.
Parents and teachers can easily become frustrated with children who have difficulty getting things done. Sometimes they may seem to be deliberately disobedient. However, children with executive functioning challenges need adults to create external structure for them as they gradually develop self-control. Here are some ways to do this.
There are many different types of auditory or visual timers that can be used to make the passage of time concrete. Timers help children learn the expectations to complete specific tasks within reasonable time frames. For example, parents can teach their children that they must finish brushing their teeth within five minutes. If they finish sooner, there will be time to talk before the bus comes. Some children's toothbrushes have built-in timers so that vibration, music or a flashing light ends after a certain amount of time. This provides a non-verbal guide as to when the goal has been achieved!
A visual schedule is a sequence of pictures or words representing tasks the child needs to do. It can be as simple as a numbered list or set of pictures such as the following:
- eat breakfast
- put dirty dishes in sink
- brush teeth
- put on jacket
- put on backpack
If my son David is spending too long eating breafast or talking to me, I can point to or tap the picture of dirty dishes in the sink instead of discussing it. This strategy can be quite effective because visual skills are commonly a strength for children with ASD. This approach also avoids arguments!
Another type of visual schedule can be made by attaching pictures to a piece of cardboard with Velcro. Using detachable pictures enables the child to be involved in planning a schedule for a specific day- such as going to the playground followed by grocery shopping. Parents may also create a board divided into the categories of "Tasks to Do" and "Tasks Completed." Moving a picture from the first to second category creates a sense of accomplishment. The child can also see that a non-desired task (such as putting toys away) will be followed by a preferred task (such as reading a book in bed).
Preparation for Transitions
Children with EF challenges need time to prepare for changes. Timers and visual schedules are two tools that help children make transitions. Parents can also use the verbal countdown technique, like this.
- We are leaving the park in 15 minutes
- You can play another 10 minutes
- OK, only 5 more minutes until we leave....
Giving Effective Directions
Make directions concrete and brief. You can use gestures with or in place of words. For example, say "use soap" or point to the soap to indicate that the child should use it. Mime washing your hands.
Break tasks into small steps and give prompts to persist until the entire task is completed:
- Put all the plates in the dishwasher.
- Now open the top rack.
- Put the cups there.
- Add soap
- Turn on the dishwasher.
Provide the least amount of cuing required for a task to be completed. Then work toward reducing the level or amount of prompts. The following video demonstrates types of prompts and assistance.
Provide activities that demand a response. For example, its difficult to ignore a large ball being thrown toward you. I taught a client to play Zoom Ball because when the ball shot across toward him, the movement and visual sensory stimulation of the action seemed to help him to react and respond by opening his arms to shoot it back. I didn't need to use words. This was a client who had such poor initiation abilities that he only ate food when an adult pointed to the plate or cup. The following video demonstrates how to make Zoom Ball.
Parents, teachers, and therapists strive to help children with EF challenges develop the internal control they need to become more independent. For some children and adults, their goal may be to wash and dress themselves. Others need extra help and structure to complete school assignments, apply to college, or prepare for a work setting.
(1)Peg Dawson and Richard Guare, Executive Skills in Children and Adolescents, 2nd ed. (New York: Guilford Press, 2010)
(2) A. Jean Ayres, Sensory Integration and the Child (Los Angeles: Western Psychological Services, 1979).