Unstuck and On Target: Improving Executive Function, On-Task and Flexible Behavior

Improving Executive Function,
On-Task and Flexible Behavior
Lauren Kenworthy, Ph.D.
Professor, Pediatrics, GW Medical School
Director, Center for Autism Spectrum Disorders
Children’s National Medical Center
Lynn Cannon, M.Ed.
Social Learning Coordinator
The Ivymount School, The Maddux School

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Lynn Cannon, M.Ed., is a social learning specialist at The Ivymount School and The Maddux School. She
received her M.Ed. in special education from the University of Virginia. For over 15 years, she has worked as an
educator, administrator and program director, serving students with neurodevelopmental disabilities. Lynn is also
a co-author of Solving Executive Challenges, a resource guide for teachers and parents; The Conversation
Club, an instructional manual for teaching conversation skills to students with neurodevelopmental disabilities;
and the Ivymount Social Cognition Instructional Package (IvySCIP). The IvySCIP offers a comprehensive, online
system for assessing and supporting social and emotional learning in K–8 students with high-functioning autism
spectrum disorders. Her research and teaching interests are in developing interventions and support materials
for students with neurodevelopmental disabilities, therapists, educators and their families. She has co-authored
more than five peer-reviewed publications and has received federal funding for two research grants.
Lauren Kenworthy, Ph.D., is Professor of Neurology, Pediatrics, and Psychiatry at the George Washington
University School of Medicine, and Director of the Center for Autism Spectrum Disorders at Children’s National
Health System. Dr. Kenworthy received her B.A. from Yale University and Ph.D. from the University of Maryland.
Her research interests are in describing and treating the neuropsychological phenotype of autism. She is an
author of more than 60 peer-reviewed publications; a co-author of the Behavior Rating Inventory of Executive
Function (BRIEF); and a co-author of Solving Executive Challenges, a resource guide for teachers and parents.
She is currently completing a trial of Unstuck and On-Target in low-income schools for children with ADHD or
ASD.

Unstuck Team
Ivymount Model Asperger Program/Take2 Summer Camp
• Katie Alexander
• Lynn Cannon
• Monica Werner
Children’s National Center for Autism Spectrum Disorders
• Laura Anthony
• Lauren Kenworthy
Copyright 2011, 2014, 2018 Brookes

GOAL: Increase your understanding of
executive functions and how to enhance them
PLAN
1. What are Executive Function (EF)?
oEFs are fractioned and plastic
2. Why do they matter?
oEFs are necessary for effective everyday functioning
3. Specific components of EF & accommodations
oFlexibility, Organization, Planning/Working Memory problems
4. How can we treat EF problems in autism?
oIn everyday settings, with self regulatory scripts

“The Unity & Diversity of
Executive Function”
Teuber, 1972; Gioia, et al 2002; 2016; Friedman & Miyake, 2017
Initiate
Working
Memory
Plan/Organize
Task Monitor
Inhibit
Self-
Monitor
Flexibility
Emotional
Control
Initiate
Working Memory
Planning
Organization/Integration
Task Monitor
Inhibit
Self-Monitor
Flexibility
Emotional Control

PLAN


Executive Dysfunction (Teuber, 1964):
“The curious dissociation between knowing & doing”
EF problems relate to:
• Adaptive daily living skills
• Academic learning
• Locus of Control
• Family stress
• Adult outcomes
• Understanding our social world

Looks Like Won’t… Could be Can’t
Oppositional, Stubborn
Difficulty shifting
Avoiding overload
Can do it if he wants to
Difficulty shifting
Lack of salience
Self Centered
Impaired social cognition
Poor self monitoring
Won’t put good ideas on
paper
Poor fine motor
Disorganization
Sloppy, erratic
Overloaded
Won’t control outbursts
Overloaded
Disinhibition
Doesn’t care what others
think
Impaired social cognition
Greene, 1998; Bernstein, 2000

This video is from online “e-Unstuck” course made in partnership with 3C Institute
Video 1

PLAN



Unstuck Philosophy: Accommodate, then Remediate
Neurodiversity is a civil right
• Can’t vs Won’t
• Predictability and Structure
• Make Big Picture Explicit
• Talk Less, Write More
• Avoid Overload
• Keep it Positive
Overwhelmed people can’t learn

Initiate
Working Memory
Plan/Organize
Task Monitor
Inhibit
Self-Monitor
Flexibility
Emotional Control
Initiate
Working Memory
Planning
Organization/Integration
Task Monitor
Inhibit
Self-Monitor
Flexibility
Emotional Control
*

“Asperger’s is like a vise on your brain. And
each unexpected event is like another turn on
the vise…it just keeps building until you feel like
you’re going to explode. Sometimes when you
explode, it comes out the wrong way.”
- A young student with ASD
(Rumsey, 1985; Hill, 2004, Kenworthy et al, 2008)

What does cognitive inflexibility look like?
Can’t or Won’t?
• Accept feedback, different opinions, ideas
• Transition
• Handle frustration
• Start something they don’t want to do
• Stop meltdowns
• Stop doing something even if they have been told to stop
• Avoid shutting down when something is challenging
• Stop correcting people
• Let other kids take the lead when playing

Inflexibility Risks and Accomodations
Difficulty with violations of expectations
• Schedules, Routines, Predict Change, Flexible Adult
Rigid interpretations of rules
• Respect need for clear, explicit expectations, Flexible Adult
Overwhelming intense feelings
• Breaks, Downtime, Flexible Adult
Problems Negotiating
• Compromise, Explicit Etiquette Rules, Flexible Adult
Repetitive Behaviors/Intense Interests
• Decide where they can/can’t happen, agree on a sign
Schopler, Mesibov & Hearsey, 1995

Inflexibility Strengths
• Deep datasets
• Expertise in areas of interest
• Persistence
• Reliability
• Loyalty
• Routines that don’t interfere
• Inflexibility is adaptive. It limits unexpected,
overloading events.
September 20, 2018

• Predictability and Structure

What do organization/integration deficits look like?
Can’t or Won’t?
• Disorganized language
• Literal language
• Asks for lots of structure in new situations
• Gets stuck on details- doesn’t let go of small mistake/inconsistency
• Dominates discussions without knowing it
• Behaves worse in unstructured groups
• Doesn’t set goals
• Trouble learning from mistakes
• Poor written expression, Doesn’t get good ideas onto paper
• Draw meaning from a reading assignment
• Know what to study for on a test

Disorganization Risks and Accommodations
Lack of generalization
• Put new information in familiar context
• Explicitly review inferences, nuances
• Teach in the setting where the behavior is expected
• Structure
Difficulty knowing what is important/Getting Stuck on details
• Emphasis on goals
• Break things down
• Explicit short rules, recipes, checklists and routines
• Structure

Disorganization Risks and Accommodations Con’t
Don’t show what they know
• Study guides, closed format tests
• Writing rubrics
• Structure
Lack of awareness and overwhelm
• Safe Person
• Structure

Detail Processor Strengths
• Patience for details
• Respect, follow, use rules
• Good with recipes, checklists, and routines
• Powerful computer related thinking
• Classification strengths
• Attention to detail—Sherlock Holmes
• Mastery of detailed datasets
• Large vocabulary

• Make Big Picture Explicit

Poor Planning/Inner Speech/Working Memory Looks Like:
Won’t Follow Directions, Work Independently
• White Boards
• Socratic method
• Hand-held technology
• Computer-based curricula

Break it Down & Make it Visual
John has a
book I want
Hit John, take book Ask John for a turn
Time out-
Miss TV time
Was this what
I wanted?
Look at book,
give it back,
get TV time
Was this what
I wanted?

• Keep it Positive

Overload: Looks like anxiety, impulsivity, meltdowns
Brenda Smith Myles: AS and Difficult Moments

PLAN
4. How can we treat EF problems in autism?
oIn everyday settings, with self regulatory scripts




Teaching: Why Be Flexible
• Advantages of physical flexibility
• The “facts” of life
• What to do when what I want is impossible
• Pie charts: getting part of I want is better than
getting nothing at all

The Story of Silly Putty (Why, Plan A/Plan B)
Photo credits to Maurice Tome
http://schoolwithinschool.org/look-forward-to-succeeding/

Teach How to Be Flexible: Self-Regulatory Scripts
•Avoid too much talking
•Refer to the big picture
•Build an alliance—you’re
collaborating!
•Need to be practiced

Video: Modeling Plan A/ Plan B & Little Deal
Video 2

GWPDC Script (Goal, Why, Plan, Do, Check)
Goal To have fun at recess
Why Recess is my free time
Plan A
Plan B
Plan C
Ask Johnny if he wants to play soccer
(If J says, “no”) Ask Melissa to play soccer
Swing on the swings
Do Follow my plans
Check Did I meet my goal?
Which plan worked?
Would I do it the same or different next time?

Modeling Goal Use
• “I need to set a goal.”
• “Let’s set a goal!”
• “My goal is to.....”
• “You did a great job making a goal!”
• “That’s a terrific goal!”
• “Are we on target?”
• “What is your goal?”
• “A goal is something you want or need to do.”
• “I can see you really want to keep X as your friend, I think your target goal is to be a good
friend”
• “I know you really want to be a video game programmer- if this is your target goal, what are
the things you need to do to accomplish this goal?”
• "Oh man, I got so off target just then.”
• “Way to stay on target!”

MISSION POSSIBLE
GOAL What is my mission for today? To have a fun play date with Adam
PLAN(S)
Plan A
What is my plan for my mission?
1. Pick up Adam from his house.
2. Go to the park
3. Ask Adam if he wants to play on
the swings or the climbing wall.
4. If I feel tired or need a break I
can tell Adam I need few
minutes to myself.
5. Have a snack.
6. Drive Adam back to his house.
Plan B
What is an alternative plan?
1. If the park is too crowded or Adam
does not want to go to the park we
can go back to my house.
2. Ask Adam if he want to play Legos
or soccer.
DO What plan did I use to complete my mission?
Plan A Plan B Other (explain)
CHECK Did I accomplish my goal? YES NO
How did it go?
1 2 3 4 5
Not so good OK Grea t
NEXTSTEP Tomorrow, I will…
MOVEON TRY AGAIN
Why?

Video: GWPDC
This video is from online “e-Unstuck” course made in partnership with 3C Institute
Video 3

Trial #1 (NIMHR34):
• Unstuck (n=47)
• Social Skills (n=20; Baker, 2009)
• Interventions delivered at school by school staff with fidelity
• Parent training, teacher training, pull out groups, fidelity monitoring,
interventionist supervision

WASI Block Design
Higher Score = Better Performance
50
51
52
53
54
55
56
57
58
59
Pre Post
T-Score
Unstuck
Social Skills

Blinded Classroom Observations
0
10
20
30
40
50
60
70
80
Reciprocity Rule
Abidance
Transitions Gets Stuck Negativity/
Overwhelm
Participates
PercentImproved
Classroom Observations
Social Skills
Unstuck
Kenworthy & Anthony et al, 2014

Project Overview (PCORI AD-1304-7379)
• 3rd – 5th graders (with ASD or ADHD) from 22 Title 1 schools
• Participants ided by school staff based on flexibility problems
• Random assignment to Unstuck or Contingency Behavior Management: Both
target executive function/flexibility

Unstuck Authors: (photo, L to R):
Laura Anthony (lanthony@UCDenver.edu),
Monica Adler Werner (mwerner@ivymount.org),
Lauren Kenworthy (lkenwort@unmc.org),
Katie Alexander (kt.calexander@gmail.com),
Lynn Cannon (lcannon@ivymount.org)
New for Parents & Teachers Summer 2018
e-Unstuck online training modules
Developed with The 3C Institute
Deb Childress childress@3cisd.com
New for Interventionists

Q&A Session
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*Not to be combined with any other discounts or offers. Consumer orders only, please. Excludes BOL training, pre-
discounted bundles, and online products such as ASQ Online and AEPSinteractive™.
Save 20%
at brookespublishing.com*
Use code: EDWEBLC
Expires 10/31/18

Thank you to our presenters!
Learn more about Brookes Publishing at www.brookespublishing.com
Give us your feedback on this edWebinar! Click on this link in the chat:
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Lynn Cannon, M.Ed.
The Ivymount School and The Maddux School
Email: lcannon@ivymount.org
Lauren Kenworthy, Ph.D.
George Washington University School of Medicine & Center for Autism Spectrum
Disorders at Children’s National Health System
Email: lkenwort@unmc.org

Unstuck and On Target: Improving Executive Function, On-Task and Flexible Behavior

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