Executive Functions Deficits

Executive Functioning refers to the cognitive abilities one needs in order to actively plan, direct and execute actions to achieve goals in daily life. It is an umbrella term for a collective group of abilities that we use to internally regulate behavior to obtain a desired outcome.

Executive Function disorder in children encompasses the skills that enable the child to manage home and school responsibilities by setting goals, breaking tasks into manageable steps, creating and executing a plan, following it up, multitasking as needed, evaluating the outcomes, and problem solving.

Children with executive function deficits struggle at home and in school. They have difficulty setting goals, organizing steps and carrying out assignments. They may be described as lazy, unmotivated, unable to get work done and present as extremely disorganized at school and at home.

These children need to be taught strategies to execute tasks successfully and independently. They are at a particular risk of academic failure if they do not apply learned strategies to compensate for their weak executive skills.

Our treatment approach to Executive Function will teach the child to apply compensatory strategies in order to identify a problem, recognize a cause, predict consequences, generate and carryout a solution and evaluate the success of the outcome.

Our approach to executive function disorder focuses on how the child learns, not what the child learns.

Planning and Organizing skills refer to a child’s ability to plan and organize tasks related to home responsibilities, as well as school assignments and projects. The ability to prioritize tasks is a critical feature of planning and organization. As they mature, children typically begin to plan and organize tasks and materials in a more strategic manner using higher-order reasoning skills. Children with executive dysfunction may have difficulty planning a project, including identifying the materials and steps needed to execute the project. These children are described as ‘scattered’ and are known to lose or forget important items on a regular basis.

Therapy may include helping the child establish routines and schedules at home as well as teaching organization skills to better track and organize their belongings. Techniques may include using checklists and graphic organizers to plan school assignments, after school activities and home responsibilities. A “self talk” strategy might be taught to help the child identify and obtain all items needed for a task. This technique involves having the child speak plans aloud or list steps on paper. Later, the child learns to speak the plans silently. This approach helps the child slow down and be methodical in his approach to planning.

Initiation refers to one’s ability to initiate an intended activity and persist with that activity through completion. It is the ability to initiate behavior toward achieving goals and inhibit behavior incompatible with achieving those goals. Initiation includes impulse control.

A child struggling with executive function disorder may have difficulty starting a task, he may not know how to begin and will seek excuses to delay starting the task. This child may be seen as a ‘procrastinator’ in school and at home. Poor impulse control interferes with this child’s capacity to ‘think before acting’.

The speech-language pathologist may teach the child to break down large projects or lengthy tasks into workable and obtainable steps; thus providing the child with a starting point. The child will learn to use a “self talk” strategy to identify steps to a task and prioritizes these steps in order to determine how to initiate the task. Behavior techniques may be used to increase impulse control while extinguishing interfering behaviors.

Attention is the cognitive process which enables a person to sustain and selectively attend to relevant stimuli. Attention develops and increases with age for most children. Attention is considered to be the foundation for all other cognitive domains. Sustained Attention is the ability to keep paying attention to a situation or task for its duration, despite fatigue or boredom; it includes vigilance and concentration. Selective Attention is the ability to maintain attention in the presence of competing stimuli; attending to one thing while ignoring another. Alternating Attention allows the shift of focus between tasks; to move attention from one task to another. Divided Attention is the ability to respond simultaneously to multiple tasks or to do more than one activity at a time. Children with executive dysfunction have deficits in one or more of these components of attention. Impairment in attentional skills is often a hallmark feature of an executive function disorder.

Treatment may address teaching the child, parents and teachers to modify the child’s school and home environments to reduce distractions and noise interference, to establish structure in the classroom (structure materials, structure workspace) and to establish structure in the home. The speech-language pathologist will teach the child to actively select which which stimuli to focus on, while ignoring things competing for his attention and will teach techniques to assist the child maintain focus on the task at hand through its completion. The child will be taught to recognize mental fatigue and to take timed breaks as needed.

Memory refers to the cognitive processes by which the mind stores and remembers information. Working Memory is the ability to retain information while doing something with it; it is highly dependent on sustained attention skills. Prospective Memory is remembering to do something in the future within an allotted time. It is ‘remembering to remember’ and is critically important for recalling appointments, assignment due dates, and the where and when of after school activities. Prospective Memory draws on a person’s planning, scheduling and time management skills. A child with a working memory impairment may have difficulty retaining information while performing a task; such as remembering a phone number while dialing, where it is critical to recall the information in a given order. A student without the tools to compensate for working memory deficits will struggle to manipulate information before it is forgotten. A child with a prospective memory deficit may forget when assignments are due or forget to return a book to the school library before its due date.

Therapy may include teaching the child to effectively and efficiently use planners, computer apps, filing systems and more. The speech-language pathologist will help the child learn to extract only pertinent information from written or spoken language for for efficient storage and retrieval. The child may learn to use strategies such as chunking and associations to facilitate recall.

Language Therapy addresses the comprehension and expression of spoken and written language in children with varied diagnoses and levels of ability. Children with executive dysfunction tend to have disorganized expressive discourse in both spoken and written modalities. The child may struggle to tell the details of a story or event in an organized, sequenced manner.

The speech-language pathologist may teach the child to use context to deduce meaning, identify main ideas, and make inferences. Therapy may help to improve the child’s language organization and production of complex oral and written language. For the older child, therapy may increase the child’s use of nonliteral meaning, multiple meaning, figurative speech, metaphors, similes, and ambiguous language.

Additional language therapy treatment may address convergent reasoning, divergent reasoning, inductive reasoning and deductive reasoning skills.

Mental Flexibility, or shifting set, refers to the ability to problem solve and revise plans in the face of obstacles, setbacks, new information or mistakes. Mental flexibility requires the child to generate alternate approaches during a task or at the completion of the task. Children with an executive function disorder often ‘get stuck’ on a certain problem, topic or activity and struggle to switch between these easily. This child may be viewed as stubborn and unwilling to attempt an alternate approach, even when guided by parents or teachers.

Therapy may include teaching the child to adapt his performance to changing conditions and to adapt to these changing circumstances in a timely manner. The child will be taught to generate alternate or multiple strategies.

Time Management refers to the ability to be aware of and regulate an activity according to time constraints. Children with executive dysfunction may have trouble estimating the time required to complete a task. They may dawdle each morning and ‘waste time’, only to rush at the last minute to catch the school bus. They may start homework and other tasks late, without allotting sufficient time for completion.

Therapy may focus on helping the child accurately estimate how long tasks will take and how to alter his pace to complete tasks within the allotted amount of time.

Metacognition refers to the ability to think about one’s own performance; to monitor and evaluate one’s performance in relation to the goals of a task. Metacognitive skills include monitoring, modifying, repairing and self evaluating. It is the ability to learn from past experiences and apply that knowledge in new experiences. Enhancing metalinguistic and metacognitive skills is fundamental to applying any of the learned executive dysfunction compensatory strategies. These children often have poor self-awareness of their deficits and, thus, don’t independently apply given strategies or techniques when instructed. Children with an executive function disorder do not seem to learn from their mistakes as their poor insight prevents them from analyzing their own performance.

The speech-language pathologist may help these children develop increased deficit awareness and insight. The child will learn to identify his weaknesses, utilize strategies to compensate for these weaknesses, evaluate his performance toward the intended goal and revise his approach as needed. As the child’s awareness and insight increase, inner language will help the child apply learned strategies in daily contexts.

At Suburban Speech Center, our comprehensive treatment approach is individualized to each child’s needs. Home and school carryover is an integral part of the program. Each child is provided with exercises and materials to accomplish therapy goals.

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