Executive Functioning

From BH (1 of 2): 
With EF, we often want to rule out ADHD type behaviors first (which are often highly comorbid). So I would recommend the Connors in this situation, although the BRIEF would be good if you want. The issue is that with EF deficits, it is often a symptom of either ADHD, autism, trauma, or a brain injury. Of course, there are other reasons, but those would be the main ones. Cognitive assessments are the best way to gather information on EF, but of course, DPS does not recommend this unless the child has suspected ID (yet another reason I disagree with this). You don't necessarily a formal assessment. Can you do some of this? I like these ideas from one of my textbooks. Let me know if I can help in any other way.

Observations and InterviewsUse both observations and interviews to determine the following types of information regarding a student’s executive functions and the student’s ability to perform in a variety of situations and environments. Observe in the classroom and in a less structured environment. It is imperative to observe the student in “normal” settings for any type of evaluation. Another vital piece of information comes from interviews with teachers, parents, as well as the student, to determine concerns and areas of interest.

Observe During AssessmentWatch for and ask how well the student is performing on:

• Self regulation of affect when tasks are demanding or boring
• Problem solving strategies
• Perseveration of ideas or response choices
• Persistence in a goal or in attempting to complete a task
• Flexibility in ability to switch from task to task or change ideas when solving a problem
• Attention span and ability to sustain attention
• Memory or recall of previously learned information or specific words
• Working memory or the ability to recall needed information such as directions, steps or sequence needed to solve a problem

Organization

• Time management
• Theory of mind (ability to understand the perspective of another person)
• Task initiation or how long it takes a student to start a task

Classroom Observation

Observe and interview students and teachers to determine activities that indicate the ability to organize, plan, use working memory, initiate, change tasks, sustain attention, use response inhibition, and time management or other executive functions.

To do this, find out if the student:

• Has materials ready at the beginning of a lesson
• Begins and stops working when others in the class do
• Switches from one task to another task
• Recognizes that another student’s feelings and ideas are equally important
• Is considerate of others
• Has difficulty with writing
• Motor control
• Planning how written information will fit on a page
• Writing automatically
• Difficulty with organization of content in written material
• Poor retrieval and use of ideas when writing
• Difficulty holding and manipulating thoughts, retrieving ideas and executing written material
• In math, look for the following types of difficulties: monitoring progress and self correction when doing calculation; maintaining an idea, organizing a strategy and retrieving steps accurately when calculating; organizing, storing information, retrieving information and executing steps when learning and applying memorized information such as addition facts
• In reading, look for the following types of difficulties: Ability to plan, recall and use decoding strategies; Reading words fluently; Understanding and using information read in a sentence, passage, or longer article; Ability to make inferences or use strategies for reading comprehension
• In study skills, look for: Desk, backpack organization; Homework completion; Ability to read a text and glean needed information; Ability to listen and glean needed information; Turning completed homework in on time; Interpreting assignments correctly; Use of study strategies in classroom

Informal Settings ObservationWith peers look for

• Effective interaction in social situations
• Ability to join a topic of conversation
• Ability to understand information being discussed by peers
• Speaking appropriately given a setting
• Ability to start and stop a conversation appropriately
• Appropriate comments to others indicating a regard for their feelings
• Adaptation of behavior to a situation

Home ObservationsAsk the family the following types of questions

• Does the student plan events in advance?
• Is the student able to start and stop a conversation appropriately?
• Does the student adjust voice, topic of conversation, or comments depending on the setting or environment?
• What is the student’s ability to initiate activities such as going out of the house, getting to school on time, etc?
• How well does the student appropriately express emotions?
• Does the student demonstrate a full range of emotions, few emotions, or extreme emotions only?
• What types of future plans does the student have?
• Are the student’s room and belongings organized to an age appropriate degree?

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From BH (2 of 2):
Thank you so much for the information, B--. One quick follow-up question. So if a child has ADHD, then it could look like she has executive functioning deficits, because, for instance, the child's attention problems could make it appear that she a poor working memory when in fact the working memory would be fine if the child could just sustain attention, etc.? Some children with ADHD have EF deficits but some children with ADHD appear to have EF deficits but in fact don't?

I am glad you asked! Actually, EF deficits are a central component of ADHD. So you wouldn't see this ADHD without EF deficits. That being said, EF is a really big area and there has not been one agreed upon definition. I attached a couple of resources. One is an overview of EF areas and some ways that we can intervene in the schools at all tiers. I want to be careful though, EF skills can not be "cured" or improved for the most part. These are cognitive abilities that do not change. However, we can teach kids compensatory strategies to help improve the symptoms. This is why places like Brain Balance are so awful. They "guarantee" to improve EF skills which of course, is not possible (at least yet!). I am also attaching an article about EF and math. You can see that there is all sorts of research showing the impact that EF has on other areas. Typically, we see things like ADHD, Autism, trauma, TBI and other medical disorders (e.g. Tourettes) in this group. However, there has been some interesting research looking at EF impacts on academic functioning and math is much more impacted than language-based tasks (as you could imagine).

So all of this to say that this is why its helpful to evaluate using a lot of different measures. I will say the BRIEF is not the strongest in terms of psychometrics though. There are a ton of newer EF measures out there, but I don't think DPS owns any. My other hesitation is that neuropsychologists are MUCH more trained in this area so we are really just doing surface level stuff with these EF measures. Neuropsychs have a ton of different measures to assess different EF areas, its super interesting. But for the purposes of ed id, it is fine legally. Let me know if I can help in any other way.

Two attached articles: Executive Skills: The Hidden Curriculum and Longitudinal Associations Between Executive Functioning and Academic Skills Across Content Areas

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Definition

Executive functions (EFs) are the cognitive skills which allow us to plan, organize, and complete tasks. Diamond (2012) writes that there are three core executive functions: (1) inhibitory control, the ability to control our behavior, our emotions, and our attention; (2) working memory, the ability to hold information in mind and to mentally work on it (often while performing another mental operation); and (3) cognitive flexibility, the ability to change the way you think about a problem and to adjust to new demands. These core EFs form the foundation for such higher-order EFs as reasoning, problem-solving, and planning.

Interventions

Diamond and Lin (2016) conducted a systematic review on interventions meant to improve executive functioning. They note that the field lacks high-quality research studies. "What are the best methods for improving EFs?" they ask. "What about an approach accounts for its success? That is so important and we know so little about it. Studies are also sorely needed that systematically vary dose, frequency, and duration. There are so few studies that have done that to date."

The available evidence, they write, shows that "EFs can indeed be improved and that is true at all ages from infants through elders. However we do not know how much EFs can be improved." They conclude that the intervention with the most evidentiary support is CogMed, a computer program designed to improve working memory. They note that CogMed is likely only effective if a trained individual mentors those using CogMed.

Diamond and Lin (2016) found evidence that exercise programs which contain cognitively challenging elements have been shown to improve EFs. For instance, they point to studies showing the benefits of Taekwondo and yoga, activities which require "thought, planning, concentration, problem-solving, WM, and/or inhibitory control." Sports might similarly improve EFs, but research in this area still needs to be done.

Diamond (2012) writes that there is evidence for the efficacy of two add-ons to school curricula: the Chicago School Readiness Project (CSRP) and Promoting Alternative Thinking Strategies (PATHS). Diamond (2012) also writes that there is evidence for the Tools of the Mind curriculum and Montessori education. The author notes that none of these programs "have reported EF benefits in children older than 9 years of age."

(Note: CSRP is a preschool program which involves coaching teachers to implement both behavior management strategies and stress reduction techniques. PATHS is a classroom program for students from preschool to sixth grade; it "provides children with instruction regarding the expression, understanding, and regulation of emotions." Lessons last 20-30 minutes and are taught three times every week throughout the school year. Tools of the Mind is a curriculum for students in preschool through second grade that "seeks to develop cognitive skills such as self-regulation, deliberate memory, and focused attention while developing academic skills such as symbolic thought, literacy, and mathematical understanding.")

Diamond and Lin write that mindfulness-based stress reduction (MBSR) has not been shown to improve executive functioning. James Coyne has described the flaws of school-based mindfulness programs which some researchers have touted as improving EFs.

Diamond & Lin (2016) outline some general principles that apply to all EF interventions:

1. Transfer effects are narrow. EF training appears to transfer, but the transfer appears to be narrow. For example, computerized WM training improves WM but not self-control, creativity, or flexibility.
2. Practice is key. Whether EF gains are seen depends on the amount of time spent practicing. Ericsson's conclusion about the critical importance of practice (with difficulty progressively increasing) for becoming really good at anything appears to apply to improving EF skills just as it does to every other skill Ericsson investigated... Once practice ends, benefits diminish. Studies have demonstrated that EF benefits can last for months or even years, but they almost always grow smaller as the time since training increases. 
3. Interventions must be continually challenging. EFs need to be continually challenged to see improvements -- not just used, but challenged. This is consistent with what Ericsson found in his life's work of studying what makes an expert across many different fields. The answer was always the same -- lots and lots of practice and practicing not what is easy but continually pushing to go beyond one's comfort zone or current level of competence.
4. Those with the poorest EFs consistently gain the most from any program that improves EFs.
5. Interventions should strive to enhance overall well-being. Since stress, sadness, loneliness, and poor health impair EFs, and the reverse enhances EFs, we predict that approaches that will be found most successful at improving EFs will be those that not only directly train and challenge EFs but also indirectly support EFs by working to reduce things that impair them and enhance things that support them. 

Steenebergen-Hu, Olszewski-Kubilius, & Calvert (2015) plan to conduct a meta-analysis on the following four school-based interventions: Tools of the Mind (a preschool-kindergarten curriculum), Montessori education, Head Start REDI, and PATHS.

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Jacob & Parkinson (2015):

1. Prior research has documented that students with poor executive functioning skills tend to perform poorly in school, and numerous studies have documented an association between executive function and achievement in both reading and mathematics...
2. At the same time, a careful look at the literature finds no compelling evidence that these associations are causal... The few random assignment studies which rigorously evaluate interventions designed to impact executive function provide some evidence that executive function can be influenced by intervention (most of the studies we reviewed showed some positive impacts on measures of executive function) but provide no compelling evidence that impacts on executive function lead to increases in academic achievement...
3. [M]ore rigorous research is needed to better understand the relation-ship between executive function and achievement... [M]ore random assignment studies of programs designed to improve executive function, but which do not simultaneously target achievement, are needed to test whether changes in executive function are causally related to changes in achievement.

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PATHS Curriculum

Domitrovich, Cortes, & Greenberg (2007):

• RCT, 246 Head Start students. Several measures used, including measures of inhibitory control and attention. 
• No intervention effects were found on direct measures of inhibitory control or sustained attention. Very few evaluations of preventive interventions with preschoolers have included measures of attention or executive function skills as outcomes and instead, have tended to use such measures to assess characteristics that moderate the effectiveness of interventions. The expectation for a program impact on this domain may have been unrealistic given the relatively low intensity of this component of the PATHS curriculum. More intensive interventions for young children with clinical levels of behavior problems have failed to show impact on child cognitive measures despite intervention effects on teacher ratings and observations (Barkley et al., 2000). The lack of an intervention effect in this domain may also reflect problems with the measures used to assess the constructs. Very little is known about how attention and executive function skills develop in young children and there are only a handful of measures, of varying reliability, that have been used to assess these constructs (Blair, Zelazo, & Greenberg, 2005). However, a randomized trial of PATHS with elementary aged students has shown significant impacts on measures of executive function and that these improvements in execu-tive function (inhibitory control) mediate behavioral outcomes (Riggs, Greenberg, Kusche, & Pentz, 2006).

Kam, Greenberg, & Kusche (2004). 

• RCT. 133 students with disabilities, grades 1-3. According to the classification system used by the state of Washington, 53 of these children had learning disabilities, 23 had mild mental retardation, 31 had emotional and behavioral dis-orders, 21 had physical disabilities or health impairments (many of these chil-dren had attention-deficit/hyperactivity disorder), and 5 had multiple handicaps. Self-control and general social/emotional functioning improved, but other than self-control, it doesn't look like the researchers measured executive functioning.

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Diamond, A. (2012). Activities and programs that improve children’s executive functions. Current directions in psychological science, 21(5), 335-341.

Diamond, A., & Lee, K. (2011). Interventions shown to aid executive function development in children 4 to 12 years old. Science, 333(6045), 959-964.

Diamond, A., & Ling, D. S. (2016). Conclusions about interventions, programs, and approaches for improving executive functions that appear justified and those that, despite much hype, do not. Developmental cognitive neuroscience, 18, 34-48.

Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T. (2007). Improving young children's social and emotional competence: A randomized trial of the preschool 'PATHS' curriculum. Journal of Primary Prevention, 28(2), 67-91. doi: 10.1007/s10935-007-0081-0

Jacob, R., & Parkinson, J. (2015). The potential for school-based interventions that target executive function to improve academic achievement: A review. Review of Educational Research, 85(4), 512-552.

Kam, C., Greenberg, M. T., & Kusche, C. A. (2004). Sustained effects of the PATHS curriculum on the social and psychological adjustment of children in special education. Journal of Emotional and Behavioral Disorders, 12(2), 66-78. doi: 10.1177/10634266040120020101

Van der Donk, M. L., Hiemstra-Beernink, A. C., Tjeenk-Kalff, A. C., van der Leij, A. V., & Lindauer, R. J. (2013). Interventions to improve executive functioning and working memory in school-aged children with AD (H) D: a randomised controlled trial and stepped-care approach. BMC psychiatry, 13(1), 23.

Riggs, N. R., Greenberg, M. T., Kusché, C. A., & Pentz, M. A. (2006). The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: Effects of the PATHS curriculum. Prevention Science, 7(1), 91-102.

Smith, P. J., Blumenthal, J. A., Hoffman, B. M., Cooper, H., Strauman, T. A., Welsh-Bohmer, K., ... & Sherwood, A. (2010). Aerobic exercise and neurocognitive performance: A meta-analytic review of randomized controlled trials. Psychosomatic Medicine, 72(3), 239-252.

Steenebergen-Hu, S., Olszewski-Kubilius, P. & Calvert, E. (2015). Title Registration for a Systematic Review: School-Based Executive Functioning Interventions for Improving Executive Functions, Academic, Social-Emotional, and Behavioral Outcomes in School-Age Children and Adolescents: A Systematic Review and Meta-Analysis. The Campbell Collaboration.