Executive dysfunction pesi 050514

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Executive dysfunction pesi 050514

  1. 1. David D Nowell PhD www.DrNowell.com
  2. 2. www.DrNowell.com DavidNowell DavidNowellSeminars
  3. 3. 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
  4. 4. www.slideshare.net/dnowell
  5. 5. BRAIN OVERVIEW IN 27 SLIDES
  6. 6. Brain overview in 27 slides • Neuron • Synapse • Neurotransmitters • Lobes • Hippocampus • Amygdala • Ventricles • Cerebrospinal fluid • CT/MRI • Functional brain imaging
  7. 7. What does dopamine feeeel like?
  8. 8. Ways of thinking about the brain • Left to right • Top to bottom • Front to back • Top-down and bottom-up
  9. 9. what IS… 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 31
  10. 10. …what COULD BE 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 32
  11. 11. What’s wrong with this brain model?
  12. 12. What’s wrong with this brain model?
  13. 13. What’s wrong with this brain model?
  14. 14. MODELS OF EXECUTIVE DYSFUNCTION
  15. 15. • McCloskey’s model • Barkley’s model • Brown’s model • BRIEF model • Dawson and Guare model
  16. 16. McCloskey’s Clusters • Attentional cluster • Engagement cluster • Optimize cluster • Evaluation cluster • Efficiency cluster • Memory cluster
  17. 17. McCloskey’s Clusters • Attentional cluster – Becoming aware – Focusing attention – Sustaining attention
  18. 18. Sleep hygiene • Strict bedtime • Use bed only for sleep • No caffeine after mid-afternoon • No activating media after 7pm
  19. 19. Establish bedtime routine
  20. 20. Fidget supports
  21. 21. McCloskey’s Clusters • Engagement cluster – Initiating – Putting in effort – Inhibiting – Stopping – Interrupting
  22. 22. Reward small units of effort
  23. 23. There’s no such thing as “disinhibited”
  24. 24. The “talking stick”
  25. 25. DRO Differential Reinforcement of Other
  26. 26. McCloskey’s Clusters • Optimize cluster – Modulating – Monitoring – Correcting
  27. 27. Sam rode her new blue bicycle down the steep hill, enjoying the crisp Autumn air and bright late-afternoon sun.
  28. 28. Sam rode her new blue bicycle down the steep hill, enjoying the crisp Autumn air and bright late-afternoon sun.
  29. 29. GREEN
  30. 30. Voice Modulation • 5 – football game • 4 – large clasroom • 3 – small group • 2 – talking quietly with a friend • 1 - whisper
  31. 31. • Give multi-step directions while playing catch • Play mindfulness “freeze tag” • Quiz do-over • Make use of rhythm and music (508) 579-7958
  32. 32. Don’t stealth bomb inattentive students • “Pete in about a minute I’ll ask you about..”
  33. 33. McCloskey’s Clusters • Evaluation cluster – Sizing up – Anticipating – Estimating time – Making associations – Generating solutions – Organizing – Comparing
  34. 34. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 72
  35. 35. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 73
  36. 36. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 74
  37. 37. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 75
  38. 38. 1 hour 1 day 1 week 1 month 1 year Time Horizon
  39. 39. 10-Minute Morning Review
  40. 40. Using your phone’s navigator as a time-management tool
  41. 41. McCloskey’s Clusters • Efficiency cluster – Sensing time – Pacing – Sequencing – Using routines / executing
  42. 42. Distraction delay training
  43. 43. McCloskey’s Clusters • Memory cluster – Holding – Manipulating – Storing – Retrieving
  44. 44. Prospective Memory
  45. 45. The Executive Functions • Sensing to the self • Speech to the self • Emotion to the self • Play to the self
  46. 46. The Executive Functions • Sensing to the self • Speech to the self • Emotion to the self • Play to the self Barkley, RA, (2012)
  47. 47. BRIEF (Behavioral Rating Inventory of Executive Functioning) • Inhibiting • Shifting • Controlling emotions • Initiating • Working memory • Planning • Organizing materials • Monitoring • Metacognition • Behavioral regulation
  48. 48. Self-control
  49. 49. “Hot” and “Cold” Executive Functions
  50. 50. The Executive Functions • Sensing to the self (HËDŸDT) • Speech to the self • Emotion to the self • Play to the self Barkley, RA, (2012)
  51. 51. BRIEF • Inhibiting (HËDŸDT) • Shifting • Controlling emotions • Initiating • Working memory • Planning • Organizing materials • Monitoring • Metacognition • Behavioral regulation
  52. 52. STRATEGIC BEHAVIORAL INQUIRY
  53. 53. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 114
  54. 54. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 115
  55. 55. Objectives of SBI • Specific behavioral strategy • What was the feeling-goal? • Motivational level on a scale from 1-10
  56. 56. Benefits of SBI • Affirms the value of clients’ unique internal experience • Emphasizes the culture of self-regulation • Encourages metacognition
  57. 57. 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
  58. 58. Personal Application
  59. 59. …and How Exactly Did You Do That?
  60. 60. …and How Exactly Did You Do That?
  61. 61. Personal Application • What bad habit persists? And How Exactly Do You Do That?
  62. 62. Learn from your To-Do list • Which things are not getting completed? • How – exactly – are these not getting completed? How do you do that?
  63. 63. Clinical Application • Who in your clinic or classroom is demonstrating remarkable “resilience” – persistence despite significant obstacles? And how, exactly, does he/she do that?
  64. 64. 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?
  65. 65. 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.”
  66. 66. 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 ____?”
  67. 67. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 131
  68. 68. DISORDERS WHICH IMPACT EXECUTIVE FUNCTIONS
  69. 69. • ADHD • Schizophrenia • Bipolar Disorder • Anxiety Disorder • Autistic Spectrum Disorders • Sensory Processing Disorder • Specific Learning Disorders • Tourette’s Syndrome • Sleep Disorders
  70. 70. 20%–60% of the variance in functional outcome (Sabhesan & Parthasarathy 2005)
  71. 71. Gur RE, Turetsky BI, Loughead J, et al. (2007)
  72. 72. (Clark, Iversen & Goodwin 2001)
  73. 73. (Rubinsztein, Fletcher, et al. 2001)
  74. 74. (Phillips, Ladouceur, & Drevets 2008)
  75. 75. Fujii, Kitagawa, et al 2013
  76. 76. (Airaksinen, Larsson, & Forsell 2005)
  77. 77. Appendix A
  78. 78. (Brosnan, Demetre, et al 2002)
  79. 79. Appendix B
  80. 80. ADHD OCD
  81. 81. (Rechtschaffen & Siegel 2000)
  82. 82. ADHD and Brain Development
  83. 83. 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
  84. 84. REAL LIFE IMPACT OF EF DEFICITS
  85. 85. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 165 1. 1-step errands 2. Chores with cues 3. Basic inhibition Preschool
  86. 86. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 166 1. 2-3 step directions 2. 20-30 minute assignments 3. Follow rules/inhibit/no grabbing Kindergarten - 2nd Grade
  87. 87. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 167 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
  88. 88. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 168 1. Complex chores 2. Organizing system 3. Time management 4. Self soothe 5. Manage conflict 6th – 8th Grade
  89. 89. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 169 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
  90. 90. Automaticity frees up resources
  91. 91. Knock 3 years off his age
  92. 92. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 172 Lending Your Brain
  93. 93. Arenas of Involvement • Intrapersonal • Interpersonal • Environmental • Academic / symbol system (McCloskey & Perkins, 2013)
  94. 94. Executive Functions and Math • Verbal strategies – Please excuse my dear Aunt Sallly (PEMDAS)
  95. 95. Executive Functions and Math • Verbal strategies – Please excuse my dear aunt sally (PEMDAS) – KNOW • Key words, numbers, operation, work it out
  96. 96. Key words Numbers I need Operations Work it out
  97. 97. Executive Functions and Math • Visual strategies
  98. 98. Executive Functions and Math • Hands-on strategies
  99. 99. Executive Functions and Reading
  100. 100. EZ-C Reader
  101. 101. Executive Functions and Writing
  102. 102. Executive Functions and Writing
  103. 103. Executive Functions and Writing
  104. 104. Executive Functions and Writing
  105. 105. Executive Functions and Writing
  106. 106. Executive Functions and Study Skills
  107. 107. Cornell note-taking system
  108. 108. Cornell note-taking system Class and date
  109. 109. Cornell note-taking system Class and date Notes
  110. 110. Cornell note-taking system Class and date Notes Notes Notes
  111. 111. Cornell note-taking system Class and date Notes Notes Notes
  112. 112. Cornell note-taking system Class and date Notes Notes Notes
  113. 113. Cornell note-taking system Class and date Notes Notes Notes SUMMARY
  114. 114. Cornell note-taking system Class and date Notes Notes Notes SUMMARY
  115. 115. Cornell note-taking system Class and date
  116. 116. Cornell note-taking system Class and date Notes
  117. 117. Cornell note-taking system Class and date Notes Notes Notes
  118. 118. Cornell note-taking system Class and date Notes Notes Notes
  119. 119. Cornell note-taking system Class and date Notes Notes Notes
  120. 120. Cornell note-taking system Class and date Notes Notes Notes SUMMARY
  121. 121. Cornell note-taking system Class and date Notes Notes Notes SUMMARY
  122. 122. 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
  123. 123. Executive Functions and Homework
  124. 124. Executive Functions and Homework
  125. 125. 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.
  126. 126. Executive Functions and Social Skills
  127. 127. 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)
  128. 128. Examples of IEP Goals for EF Deficits 1. 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 difficult d.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.
  129. 129. Examples of IEP Goals for EF Deficits 4. 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.
  130. 130. What are our data sources? • Record review • Interview • Collateral interview • Checklists • Mental status examination • Test scores
  131. 131. ASSESSMENT OF EXECUTIVE FUNCTIONING
  132. 132. Curious Compassionate Nonjudgmental Evaluation • Skillfully eliciting the chief complaint • HËDŸDT? • Forming a diagnostic impression • Defending your diagnosis / impression
  133. 133. Skillfully eliciting the chief complaint • Too much of what? Or too little of what? • Invoking the Pediatric Fairy (or the Psychiatric Genie)
  134. 134. HËDŸDT? • How exactly did you do that? – Everybody’s doing the best he/she can – Every behavior problem is either • Skills deficit • Contingency problem
  135. 135. Forming a diagnostic impression • Where do you see it the most? And where do you see it the least? • Two disorders = two stories
  136. 136. Documenting and communicating your conclusions • The footprints in the butter • Defend your diagnosis
  137. 137. Approaches to Evaluation of EF • Formal direct • Informal direct • Formal indirect • Informal indirect
  138. 138. Evaluation of EF • Informal Indirect – Review of records – Collateral interviews (see McCloskey 2012)
  139. 139. 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)
  140. 140. Evaluation of EF • Informal Direct – Review of work samples – Process-approach to test performance – Mental Status Examination – Classroom observation
  141. 141. 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
  142. 142. Avoiding the most common diagnostic error
  143. 143. STRATEGIES AND CASE STUDIES
  144. 144. Stimulant Treatment for ADHD
  145. 145. Image: wikimedia commons
  146. 146. Cortico-striatal loop
  147. 147. Increase salience
  148. 148. Two weeks from now, how will you know whether it’s working? Appendix D
  149. 149. Daily report card Appendix C
  150. 150. Antecedent Support for Executive Dysfunction
  151. 151. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 267 A ANTECEDENT B BEHAVIOR C CONSEQUENCES
  152. 152. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 268 A ANTECEDENTS B BEHAVIOR C CONSEQUENCES
  153. 153. “Modified Independence” • Chronic disability perspective • Time prosthetics • Problem-solving prosthetics (mind map) • Math prosthetics • Sequence prosthetics • Motivation prosthetics
  154. 154. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 271 A ANTECEDENTS Set them up for success
  155. 155. Clear boundaries
  156. 156. Clear (see-through) storage
  157. 157. Clear (see-through) storage
  158. 158. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 284 A ANTECEDENTS Identify exceptions Where do you see it the most? Where do you see it the least?
  159. 159. Rules •Waking up •Bedtime •Chores •Homework •TV / internet A ANTECEDENTS
  160. 160. Launching Pad
  161. 161. Expectations •Specific •Behavioral •In advance A ANTECEDENTS
  162. 162. Communication •Get eye contact •Speak clearly •Provide behavioral info •Check for understanding A ANTECEDENTS
  163. 163. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 291 A ANTECEDENTS Provide prosthetic cues at the “point- of-performance” (Barkley)
  164. 164. easy hard If It’s Harder than a “3” Find Some Way to Make It Easier 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 295
  165. 165. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 297
  166. 166. Assign separate due dates for smaller parts of big projects
  167. 167. Appendix H
  168. 168. Increase salience
  169. 169. StayOnTask app
  170. 170. The “talking stick”
  171. 171. Provide multiple cues for transitions • Verbal “two minute warning” • Visual schedule • Changes in lighting • Nonverbal cues
  172. 172. Consider your own self-stim strategies • Applying lotion • Clicking pen • Sewing machine leg • Gum • Whistling
  173. 173. Instant study carrel
  174. 174. Time “in”
  175. 175. Place the student with tactile defensiveness at the edge of the group
  176. 176. Heavy work
  177. 177. ADD Coaching
  178. 178. Movement Techniques • Exercise • Yoga • Martial arts
  179. 179. Bal-A-Vis-X
  180. 180. Balance screen time and “green time”
  181. 181. Balance screen time and “green time”
  182. 182. Supplements and Diet • Omegas • Food additives • Food allergies • Pesticides
  183. 183. Bodywork • Massage • Chiropractic • Acupuncture • Transcranial magnetic stimulation
  184. 184. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 327 A ANTECEDENT B BEHAVIOR C CONSEQUENCES Behavioral Support
  185. 185. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 329 B BEHAVIOR “A healthy high- functioning 26 year old”
  186. 186. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 330
  187. 187. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 331 B BEHAVIOR More • Behavioral control • Choices and options • Self-regulation • Arousal • Motivation • Mood • Attention
  188. 188. Mindfulness
  189. 189. Dr. Sara Lazar
  190. 190. Metacognition • How much effort am I giving this? • What has worked for me before? • When to shift from processing to maintenance
  191. 191. Hypnosis
  192. 192. Mnemonics Training
  193. 193. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 342 A ANTECEDENT B BEHAVIOR C CONSEQUENCES
  194. 194. Don’t reward them with stuff
  195. 195. Rotate rewards frequently
  196. 196. Use extrinsic reward creatively 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 349
  197. 197. Emphasize the sensory details of your desired outcome
  198. 198. Cortico-striatal loop
  199. 199. Determine what basic provisions are unconditional… • Love • Respect • Safety • 3 meals • Essential clothing • Temperature-controlled environment • 30 minutes of video games
  200. 200. …and which are contingent • Special foods • Expensive or trendy clothing • Extra video game time • WiFi password
  201. 201. Clip and share horrible articles about teens falling out of the back of pickup trucks • Review cause and effect • Discuss consequences • Emphasize behavioral agency
  202. 202. The “Big Five” • Daily focus time • Nutrition • Movement • Sleep • Connection
  203. 203. 10-Minute Morning Review
  204. 204. 5/6/2014 © 2011 David D. Nowell, Ph.D. All rights reserved. 360 …the most important 10 minutes of the day….
  205. 205. The best defense against the manipulation of our attention is to determine for ourselves – in advance - how we want to invest it. - E. Goldberg
  206. 206. Key features of a great planner system
  207. 207. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
  208. 208. Yoga / read Staff meeting Planning session Phone calls billing
  209. 209. Vh: jeff w/ puritan oil Vc: kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000
  210. 210. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
  211. 211. What’s a To-Do list for anyway?
  212. 212. Key features of a great planner system • 2 pages per day • Master to-do list • With the client at all times
  213. 213. Key features of a great planner system • The “technology” • The “practice”
  214. 214. Key features of a great planner system • The “technology” • The “practice”
  215. 215. Weekly Overview
  216. 216. 10-Minute Morning Review
  217. 217. The “Big Five” • Daily focus time • Nutrition • Movement • Sleep • Connection
  218. 218. 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
  219. 219. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
  220. 220. “Exercise for focus” is different from "exercise for fitness”
  221. 221. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
  222. 222. The “Big Five” • Daily focus time / Motivational clarity • Nutrition • Movement • Sleep • Connection
  223. 223. Marry well and get a crackerjack assistant at work
  224. 224. Positive characteristics of many people with attentional / executive challenges Appendix G
  225. 225. Don’t do anything for your ADHD teenager which could be managed by a machine or an app
  226. 226. “Walk Me Up” app
  227. 227. Q & A & D
  228. 228. www.slideshare.net/dnowell
  229. 229. Let’s stay in touch! Join my e-newsletter list:  Fill out a card today and drop it in the box.  Sign up on my web site or Facebook page Visit us on the web: www.DrNowell.com @davidnowell David Nowell Seminars
  230. 230. Fail-proof desk activities Appendix A
  231. 231. Determine in Advance When You’ll Check Email and Facebook Tomorrow
  232. 232. • Review expectations in advance • Teens and college students may take more initiative with this
  233. 233. 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
  234. 234. 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
  235. 235. 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
  236. 236. 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)
  237. 237. 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.
  238. 238. 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
  239. 239. A Daily Behavior Card Each 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 7 Class Participation Performs assigned classwork Follows class rules Gets along well with others Completes home- work assignments Teacher’s Initials
  240. 240. 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
  241. 241. 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.
  242. 242. 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)
  243. 243. Teaching skills is inadequate
  244. 244. What and who is the “A”
  245. 245. Chronic disability perspective
  246. 246. Reverse Engineering the Carrot and Stick • Rey O versus VMI • Carrot and stick • Break down large projects • scaffolding
  247. 247. • 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)
  248. 248. 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
  249. 249. • N-back with a deck of cards
  250. 250. Accomodations • Meltzer (kindle)
  251. 251. ADHD Inattentive Sluggish Cognitive Tempo Hyperactive Combined
  252. 252. 5-42 / (10-2)+3x6 P 5-42 / (8)+3x6 E 5-16 / (8)+3x6 MD 5-2+18 AS 21

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