Executive Dysfunction Therapy

     The term “executive functioning” refers to mental processes involved in goal-directed activity. The work on this has been primarily done in Neuropsychology but the implications for educators are important. Executive functioning has been rather under-discussed in the school context as yet (stay tuned for my dissertation J) where these issues have been attributed to failures in discipline rather than brain function. Executive functions most directly related to academic performance include:

• setting a goal, (understanding what the assignment or question is asking one to achieve)
• planning a course to achieve it, (remembering the procedure appropriate to the task)
• holding the plan in working memory while executing it,
• sequencing the steps in the plan,
• initiating taking those steps and shifting between them,
• monitoring progress for both pace and quality,
• regulating attention and emotional responses to challenges that arise,
• making flexible changes in the plan as needed, and
• evaluating the outcome for use of the plan in a subsequent similar activity.

      For most of us these processes occur without much explicit thought on our part, and we get better at executive functioning as we mature.  For some of us, though, these functions are disordered.† Almost all people who have frontal lobe anomalies, like Attention Deficit Hyperactivity Disorder, have difficulty with executive functioning.  The medication they take (stimulant) helps with focus and impulsivity control but it only helps, it does not solve the problem entirely.What comes to most of us fairly unconsciously must be explicitly taught to folks with Executive Dysfunction. A combination of cognitive training and appropriate accommodation can make an important difference to those who suffer from these anomalies.

     But there is another element of the problem. People who have Executive Dysfunction tend to develop pretty negative beliefs about their ability in the areas where their problems are most visible. Despite more than adequate intelligence they just can’t seem to do well in those activities.  Since diagnosis of the problem has only been available in the last 7-10 years as advanced technologies allowed new observations of brain function, many kids (to say nothing of parents and teachers) do not get the understanding of what’s going on for them until they have already developed defeatist beliefs and feelings about their potential in the areas where their dysfunction shows up the most. For some this is in language based activities, and others find it in visual/spatial reasoning and math, although it does impact† functioning across most of the areas of their lives in one way or another areas as well.

      So, all that said, how does this play out in terms of school and work for the individual?  First, s/he goes in with the feeling that s/he can’t do it. With that ideation and anxiety, s/he attempts the work in front of her/him and effort is inconsistent.  You have to believe in the possibility of success to pursue it with even and sustained effort.  S/he reads the assignment or the question and either gets what it is saying/asking or not.  If not s/he either gives up or applies a fairly random set of fragmented understanding of the appropriate procedures to the problem.  For example as s/he is reading an article assigned for tomorrow’s discussion s/he gives up several times only willing to give it another shot with encouragement and partnership.† Hitting an obstacle like missing pages, or something that doesn’t make sense s/he loses the thread of the story and gives up entirely. When it comes to written assignments s/he is focused on getting the answer right, rather than on the processes needed to do that.  Often the process seems like magic to someone with Executive Dysfunction. S/he may know the answer to the math problem but have no idea how s/he came to know it.  S/he often get the critique that s/he need to “show your work!” But S/he doesn’t, because s/he has not been clearly aware of how s/he did it.

     Even if s/he has learned the formulae for the genre and has done assignments like the one s/he is currently attempting, s/he has trouble holding them in working memory while she enacts the pieces of the process this time.  S/he may apply the elements of the procedure out of sequence, or skip steps without awareness of having done so. S/he has the sense that something is going wrong but is not clear on what, and s/he has trouble monitoring her progress.  Folks tend to cope with this uncertainty and anxiety by going faster and adopting a blasé devil-take-the-details demeanor, using a sense of† humor in the circumvention of the trouble.  S/he is truly shocked when the paper comes back with a grade that s/he knows is not the sort people as bright as s/he is should be getting.  All the adults around urge her/him to make a better effort and apply incentives and consequences to help him/her achieve.†

     Now, I have no trouble imagining most kids in this situation providing their teachers and parents with “opportunities for guidance,” but treating this set of misfirings of their noggins as discipline issues will be unlikely to result in improvement because it misses the real root of the trouble. Instead we need to consistently

• encourage her/him to suspend† disbelief in his/her own potential to do well in the area of concern for a moment; We need to provide scaffolding for his/her confidence as s/he builds it.
• provide the tools and strategies that work around areas of executive dysfunction (that’s where I come in), and provide support for him/her to use them (that’s where teachers, therapists, and the family come in);
• praise efforts even if the outcome is not optimal, inviting her/him to tweak the strategy or tool use in a way that looks promising; the more s/he owns the methods and tools and fits their use to her/himself the more likely they are to become an automatized part of his/her day-to-day practice.
• maintain firm, honest, and encouragingly constructive critique of her/his efforts. Sugar-coated critique tells a kid that s/he is handicapped and a lost cause.  Harsh, or overly meticulous criticism has much the same effect.  S/he has issues to work on just like the rest of us, and like the rest of us, s/he will do better with the clear demonstration that she is respected and believed in.

The accommodations, tools and strategies we work out are for a person with Executive Dysfunction analogous to wearing glasses for a person with an astigmatism.† The difference is that over time the person with Executive Dysfunction’s making of these plans and using them will improve her/his executive functioning in problem solving, whereas the astigmatism is not much changed by the wearing of glasses.

Here is a list of the kinds of issues I work with people to resolve or work around.

People with Executive Function Disorders

• Have difficulty with goal setting, often not grasping the point of setting them
• Have the sense that things either happen or don’t, little awareness of process
• Have difficulty getting started on tasks, and shifting between them
• Tend to live in the current moment “I know that now, but when I get to school it feels different”
• Are unable to effectively reflect on past experience to plan for the future, thus common discipline measures, like incentives and consequences, produce little change in behavior
• May continue to use the same strategy to solve a life problem, even when it has already proven ineffective
• May vacillate from impulsivity to rigidity, often with rising anxiety over things not turning out right
• Have difficulty adapting to change
• Rarely matches a strategy to a problem before trying to solve it
• Have low self-esteem and tend to be both unrealistic about their abilities, and very sensitive to critique
• Have difficulty overriding an emotion in order to behave appropriately or positively in a situation
• Have very low tolerance for failure or frustration. Will quit rather than try another approach, even when one is suggested.
• Tend to believe that accepting suggestions or help indicates weakness.
• Tend to locate the source of their troubles outside their control.
• Will skip steps in a procedure and be baffled about the reason an expected outcome was not reached.
• Have difficulty putting a sequence of steps in order, or even realizing that there are sub-goals to be accomplished on the way to the finish.
• Believe they either know something or don’t, have little faith in effort.
• Have difficulty shifting perspectives
• Need prompting to consider the feelings or views of others
• Fail to see the big picture, or the connections between details† “Just when I get good at what my teachers ask me to do, they give me something new that I am no good at doing”
• See only the big picture, missing the trees for the forest.

These issues interfere with the person’s success in life across all their areas of activity, but are most noticeable in traditional school, and work settings. The good news is that through cognitive training and designing both tools and strategies to suit the individual, most of the impact of these issues can be reduced or resolved.

copyright © 1998-2015 Kristin S. Kight, all rights reserved