Cara: I am thankful for OccupationalTherapy.com for doing this series. I am excited to be talking about executive functioning. It is one of the things that occupational therapists think they know a lot about, but I am finding out that there is so much more to still understand.
I am a mom of two children with special needs, in particular, autism, executive function disorder, sensory issues, and some other comorbid conditions. They are 15 and 18 years old. I am also getting my doctorate. If anyone on here today is thinking about getting a doctorate, I encourage you to do so because you will learn so much. You are going to need good executive functioning if you do so. As a student again in my mid-40s, I am learning this fast. I had to draw on some skills that I have not used in a few years. It is nice to be able to relate to the students that I am working with.
What is Executive Function?
For executive function, you might think of the metaphor of an executive in a company. They are the head of a company, and a company should run smoothly when there is a good executive at the helm. If there is a change in leadership, sometimes it brings better policies and a smoother running company. This is the same way with executive function. It is the chief of the brain.
- Set of skills to manage tasks we complete every day.
- What we will pay attention to and what we choose to do.
- Manage emotions and thoughts so we can be efficient.
- Regulate behavior when difficulties arise.
- Assist in the ability to function with independence.
Executive function is a set of skills that we use to manage every single task we do every day. This is from making a sandwich to doing a homework assignment. One thing that is really critical to executive function is attention. What we choose to pay attention to is really important. If I am sitting here talking to you and I see a spider crawling on the table, I may not pay 100% attention to a task. Another example may be attending to a noise, a fire drill, or a scratchy tag. A child may then not be able to attend to the task at hand. Additionally, many children also have sensory issues and comorbid conditions.
Part of executive function is managing emotions. When I talk about managing emotions, I am talking about the things that make us cranky or in a good mood. We adapt our emotions to fit the situations we are in. If a child is at a birthday party, they may feel positive and happy thoughts. However, when they are in school, they may feel stressed. And, if they have special needs, they may have another weak area like poor fine motor coordination. For example, they may already be struggling and frustrated with a writing task, and then when you add the teacher talking and giving instructions while they are writing, it might be a lot for the student. They have to regulate their stress and behavior on a daily basis as it assists their ability to function independently.
What Makes Up Executive Function?
- Attention management
- Visual imagery
If a child cannot organize what they are doing, they are not going to be able to do the task. They also have to know who they are, what is around them, and what they are feeling. As an example, I have a new dress on today, and I have a tag in the back that is really itching me. I can feel it every so often, and it is really bothering me. If I do not inhibit it, it is going to distract me from the task at hand. Inhibition depends on that self-awareness. Another example is the grocery store may be out of your favorite food. You have to inhibit or stop your frustration so that you do not scream out loud. However, it is very difficult for children with special needs to do that, especially with executive function disorder. They may not be able to stop that impulsiveness. We will talk more about that in a bit.
Visual imagery is getting a picture of the plan and seeing the steps in your head. If a student is asked to write a paper for a language arts class or a smaller child is asked to write about what makes you happy, they may not be able to come up with a plan. "First, I am going to pick up the pencil. I am going to put it down to the paper, and then I am going to write about what makes me happy." The formation of that plan can be difficult for them, and they may have trouble problem solving from there.
Lastly, are they motivated for the task? If you are not motivated to complete a task, it is going to be very difficult for you to complete it. Non-preferred tasks require us to be somewhat motivated to do the task. Let's say the task is buttoning, zipping, or toileting in school. We have to do that because we cannot sit in our classroom and have an accident. However, a lot of our students do not take that initiation to get up and use the restroom. They may hold their bowel and bladder all day. It can really affect the day to day lives of students.
Matrix of Skills
Figure 1 shows a matrix of skills.
Figure 1. A matrix of skills.
It seems like executive function fits this pattern. If we are not managing our time effectively, and you pull that out of this grid, then you are going to have a collapse of the rest of the skills. This is the same thing with any of these components.
Let's look at flexibility. Dr. Dan Siegel and Tina Payne Bryson wrote a book about regulation and the frustration of our kids called "The Whole-Brain Child." When things get disorganized, what is their strategy? They want to become rigid because they want to try to control something.
Let's talk about the brain and some things that are complicated for our students.
- Difficulty in inhibiting emotions, anger, excitement, sadness, etc.
- Difficulty understanding others' points of view, leading to anger & frustration
- Expressive language difficulty
They may not organize or hold in those emotions such as anger, excitement, and sadness. Some of our students may struggle with simple tasks like putting blocks together. They may not be able to build blocks as high as the next student, and they become frustrated. Other students may make fun of them. They may have anxiety, emotional problems, or depression. There is something called Theory of Mind. It is one of the definitions of autism where students have trouble seeing from another person's perspective. It is putting yourself in someone else's shoes, and that is difficult for them. The rate of autism is now one in 54 currently according to the Centers for Disease Control. That is a high number, and there is a chance that you are going to be working with someone with autism. When you are dealing with that, and then put an expressive or receptive language difficulty on top of that, there can be a lot of frustration.
Breaking Down Executive Function
You can see the complexity of executive function as we go through these slides.
- Important to know both order in which skills emerge AND what each skill ‘does.’
- Begin after birth and continue to adulthood (25+ years of age)
- Frontal and Pre-frontal cortex
- Two ‘types’ of skills
- Thinking (cognition)
- Doing (behavior)
As we grade skills up and down, it is important to know when a skill emerges and what it does. For instance, if we are looking at hand grasp, we know there is a specific progression of a grasp from when the baby is just reflexively grasping to using more refined pincer and tripod grasps.
This the same with executive function. We know that executive function begins at birth and continues through adulthood up until the age of 25 years. It is interesting to then reflect on what are our laws in the United States. One law is that you cannot vote until you are about 18 years old. Another is that you cannot drink alcohol until you are at least 21. These align with decision-making skills. It takes critical time for that brain to develop. This development happens in the frontal and prefrontal cortexes. The frontal lobe of the brain is right behind the forehead.
Figure 2. Two types of skills.
There are two types of skills. The thinking is the cognition and the doing is behavior. We have to have both of these skills to have an effective plan.
One thinking skill is planning. This means that you are making a plan. That is easy and self-explanatory. You also have to be somewhat organized in order to form a plan. For you to attend this course today, you had to find out the time, organize your computer, go to a quiet place, and get a pencil and some notebook paper. There was some planning, organization, and time management that went into that. I feel like OT professionals, in general, have good executive function skills. We do a lot of adapting and grading higher-level cognitive tasks in our work.
Working memory is short-term memory where you remember information for a short time in order to use it immediately. For instance, this would be remembering a number in order to make a call. This information does not go to long-term memory. You use it, and then it is gone. This is the same thing with directions in school. When the teacher says, "Take out your math book and turn to page four," the child does not remember that forever. This is why working memory is critical to students in school.
Metacognition is thinking about thinking. You are looking down from a higher perspective at how you are doing with a task, assessing it, and then making changes. This is a very high-level skill.
We talked about response inhibition. You cannot act the way you want to all the time. This also involves emotional control and is really tough for a lot of our kids. We have kids that act out. They bite, pinch, kick and scream. I had a therapist that worked with me that was pregnant with twins. A student kicked her when he was frustrated. She was new and was afraid to enforce the rules so she did not establish her dominance over the room. We had to switch the student to a different therapist for her safety. It is important to establish a rule system immediately when you get a new student or client.
Emotional control also involves interoception. We will talk about interoception in a little bit in more depth, but you have to be aware that you are having an emotion in order to deal with it. It is amazing how many people with special needs do not understand what they are feeling. Is it a good feeling or a bad feeling? How good is it? How bad is it? Understanding this information is critical.
Task initiation is beginning a task. Again, you have to be motivated to start. Let's say you have four reports to do. You may think, "How I am not going to start? I am going to go outside and play Frisbee with the dog instead. This is what happens with our students.
Flexibility is hard for our kids because they cannot control a lot of things. Finally, they need to be goal-directed. They have to want to do a task, set a goal, and not be distracted by competing interests.
Neuroscience's Star Patient
In school, many of us learned about a guy named Phineas Gage. Phineas was a railroad worker, and he lived in the mid-1800s. He had a family, and he was described as likable and a good worker. One of his roles was to lay explosives to clear the land for the railroad tracks. During an explosion, a piece of rebar, which is a really thick piece of metal, went right into his frontal lobe. He lived, but he had severe damage to his frontal lobe. As a result, his personality shifted. He became a drunk and was impulsive making terrible decisions. I do not know how many of you have worked in a trauma. I started my career in Pittsburgh at a heart and lung transplant facility, and sometimes we covered neurotrauma. The clients with head injuries were so impulsive, especially when they had injuries to the front of their head.
How Brain Connections Form
At a child's birth, brain pathways are unconnected. By seven years of age, through play, learning, engagement with others, they have tons of synapses and connections that are beautifully built. However, we do not necessarily need every single connection so at 15 years of age, there begins to be synaptic pruning. This builds neuro-connections and integration and helps us to be efficient in our processing. We use higher-level thinking to make good decisions. This is driven by experience and practice. Structural changes underlie the functional integration of the frontal lobe (Luna & Sweeny, 2004).
- Direct attention/behavior
- Link behaviors to past experience
- Control our emotions and behavior
- Observe, assess, fine-tune so we ‘won’t do THAT again’
The frontal lobe directs our attention and behavior. It links what we are doing now to the past experience. If we cannot link something we are doing to a bad experience, we are going to have a difficult time fine-tuning our skills. I used to live in Charleston, South Carolina where there is a lot of murky water. If I put my hand in that murky water, and I see an alligator, I am going to pull my away reflexively. I am probably never going to stick my hand in the murky water again as I have learned from my experience. This can be tough for many of our kids. I find that my boys take time to learn critical things. As a parent, I am thinking, "Come on, guys. This is something we've gone over."
Higher Level Processing
- Rational thinking
- Future considerations
- Mindfulness: Manage internal environment
- Manage mood (to reduce intrusive thoughts)
- Manage fatigue (pacing, regular breaks)
- Manage physical comfort (pain, hunger, thirst)
Higher level processing is going to give us our rational thinking. We are going to think about the future considerations. My son is 18 and going to college in two days. Is he thinking about how every little choice is going to impact his future? Not really. He is very impulsive, and that is not just because of autism. That is because he is18. My 15-year-old son does the same thing. They are impulsive by nature at this age because they are not thinking about how anything is going to affect their future. These skills are not going to come automatically for your students. You should not expect it, but this does not mean you cannot work on it. Mindfulness is not necessarily doing yoga. It is being present in where you are. It is being and existing, and this is a very important skill to teach our students.