Article 1 [W2] - Executive Function Treatment Flashcards
Define Executive Functions (EFs)
Executive function (EF) is a broad, overarching term
that refers to a variety of cognitive processes largely
mediated by the prefrontal areas of the frontal lobes. It encompasses both cognitive and affective constructs
including planning, working memory, attention, inhibition, self-monitoring, self-regulation, and initiation.
These multidimensional constructs are necessary for goal-directed and problem-solving behavior in all aspects of life, whether academic, vocational, or social.
Diamond (2012) identified three widely accepted core components of EF—inhibition, working memory, and cognitive flexibility— which allow for the development of higher-order, complex EF constructs like reasoning, planning, and problem solving.
What is the neuroanatomical distinction between cognitive and affective EFs?
The primary neuroanatomical distinction between the two is related to their localization within the frontal lobes of the brain:
- Cognitive aspects of EF stem from the dorsolateral areas of
the prefrontal cortex. - Affective components of EF stem from the ventral and medial areas of the prefrontal cortex.
What are some common classroom-based difficulties observed for cognitive versus affective EF deficits?
Cognitive deficits often manifest as academic difficulties, while affective deficits often manifest as behavioral problems.
Cognitive Examples: Students with EF deficits often appear disorganized, lacking in initiation, and forgetful.
They frequently engage in off-task behavior, and require regular prompts and cues. They may experience working memory problems (hence visual reminders can be helpful in the case of multiple simultaneous tasks).
This can make note taking, mental math, and completion of large projects a challenge.
Starting assignments is difficult, and these children may be described as lazy/procrastinators. They may struggle with shifting between activities and may hyperfocus on one task until it is completed (which may result in them being left behind if the class is moving on).
They have difficulty with prioritizing important tasks, time management, and meeting deadlines. Planning for the future is difficult; they tend to only focus on the present.
Affective Examples: These students likely struggle with resisting temptation, are impulsive, and do not think before they act. They could be described as not having
a filter and can exhibit extreme emotional lability (i.e., mood swings/an inability to regulate their feelings) - therefore engaging in extreme actions that may get them in trouble (and reduce their time in class).
These children usually don’t handle change/unexpected situations well - which can lead to anxiety, anger,
frustration, or quitting in response to a new routine.
Examples of classroom behavior include blurting out answers, or interrupting someone else. These children may start working after hearing only the first part of instructions - meaning they complete the task incorrectly. They have lots of missing assignments, their desks/lockers are messy (poor organizational skills), and they frequently lose things and need to borrow from others.
These students are often called lazy, unmotivated, and forgetful, and their behaviors are often regarded as defiant.
They struggle with socially appropriate behavior, push limits, and make poor choices, often failing to apply acquired knowledge from previous experiences or consider future outcomes of their actions.
What is the relevance of EF’s multidimensionality for assessment?
EF constructs such as response inhibition, working memory, planning, and response preparation are independent in various ways; but are also interrelated.
Hence, diverse methods of assessment should be used - both quantitative and qualitative (behavioral observations of task performance/anecdotal teacher reports) where possible.
Examples of Indirect versus Direct standardized EF quantitative measures
Direct: Individually administered
assessments such as the Cognitive Assessment System Second Edition [CAS-2], DKEFS, NEPSY-II, and the Wisconsin Card-Sorting Test.
Indirect: Behavior rating scales or frequency measures such as the Comprehensive Executive Function Inventory or Behavior Rating Inventory of Executive Function.
Challenges that face reliable EF assessment in schools
In recent years, the use of EF tests and rating scales has been infused into the school
setting. However, traditionally, schools perform psychoeducational evaluations that only look at overall intelligence (‘‘g’’) - in terms of the cognitive domain of functioning.
This is typically because the evaluation is focused on determining eligibility for special education services under the
IDEA-2004 guidelines (i.e., whether or not a child has a disability in 1 of the 13 identified categories).
The authors argue that a better evaluation focus would be what are the processing deficits causing the child to have academic or behavioral difficulties. Indeed, there is no IDEA-2004 category to identify EF deficits (or attention or memory). Such deficits are instead classified under the category of “other health impairment” in the DSM-V’s ADHD diagnosis. This focuses solely on the presentation - as opposed to the more important cognitive aspects (for EF deficits)
Diamond’s (2012) 6 Key Considerations regarding EF training (for selecting an EF intervention for children)
[Note 1: The research base is still limited with pediatric populations]
- The functions who most need improvement benefit the most.
- Transfer effects from EF training are narrow.
- EFs should be challenged throughout training (i.e., task demands must continue to increase in order to elicit effects).
- Repeated practice is key.
- Whether EF gains are produced depends heavily on HOW an activity is done.
- Outcome measures must test the limits of the children’s EF abilities; to see a benefit from training.
[Note 2: Tasks that measure EF should be relatively unfamiliar, so that a child has to develop a way to solve the problem. They should require self-monitoring and error correction, response inhibition, and methods of working with information that needs to be remembered during a short period of time]
Individual Factors to Consider when Selecting an EF Intervention
The child’s age, current level of developmental functioning, whether they have any relevant neurodevelopmental disorders with specific EF deficit profiles (ADHD/ASD), and accurate diagnosis of deficits (and strengths/weaknesses) due to limited intervention generalizability.
Age is important because deficits increase with age (negatively impacting the child’s ability to develop higher-order EF skills). Indeed, early childhood interventions are preferrable as complex executive skills developed later in life are built upon the foundation of the three broad EF constructs: inhibition, working memory, and cognitive
flexibility.
Treatments for EF Deficits Outside the Scope of the School Setting (i.e., medical)
Some intervention methods (e.g., psychopharmocology and neurofeedback treatment) are outside of
the scope of education agency as they are considered medical - and must be initiated by a parent or physician.
The authors note that these are potential treatment pathways - however, the use of psychotropic medications does introduce an x-variable factor that must be considered when evaluating the effectiveness of a separate intervention (i.e., it becomes impossible to discern if positive effects
are a result of an intervention or made
possible by the pharmacological
intervention).
Regardless, knowledge on the efficacy of psychopharmacological interventions and neurofeedback is important when guiding parents/families towards additional resources.
Computerized Training for EF Deficits
Computerized approaches are currently one of the more prominent modalities for EF intervention. Typically only working memory and/or attention are targeted - although certain approaches have attempted to target inhibition deficits (with less success).
These interventions use repeated practice and reinforcement in attempts to produce structural changes in the brain (hence improving working memory/EF).
Cognitive training is hypothesized to result in increased/decreased activation in task-related neuroanatomical locations. It may also functionally reorganize brain activity (a.k.a., the combination of increased and decreased levels of activation across multiple brain areas).
Computerized programs also remove any chance of human error - and allow for the precise measurement of things an examiner couldn’t measure (i.e., impulsive responding/reaction times).
Group computerized interventions at school are particularly appealing - they require minimal personnel, minimal effort from the interventionist, and monitor/adapt the task’s difficulty based on individual child performance. Research supports their efficacy with ADHD, fetal alcohol syndrome and VLBW children.
Note that transfer effects are narrow among EF constructs. Computerized training aimed at improving working
memory may yield improvements within that specific
area of EF but not others (i.e., inhibition or speed
and efficiency of cognitive processing).
Indeed, there is no convincing evidence of the generalization of efficacy of computerized working-memory training programs to other cognitive constructs (e.g., nonverbal and verbal ability, inhibitory processes in attention, general academic functioning etc.,). At best they produce
short-term (not sustained at follow-up), specific training effects at that do not generalize across other EF cognitive constructs. They’re also costly, and require intensive use in order to actually see improvements.
Redistribution vs. Reorganization in the Brain
Redistribution refers to the Change in Patterns of brain activity within the same neuroanatomical locations before and after working-memory training - which leads to increased efficiency of specific cognitive-processing tasks while reducing the demands on attention.
Reorganization refers to the activation of new brain areas following cognitive training and is assumed to lead to a Qualitative Change in the Processes used to solve the trained task.
Strategy Instruction as an EF intervention
Strategy instruction is defined as a student-centered approach that supplies struggling learners with
tools and techniques to understand and learn new material or skills; while allowing for the direct and
immediate application to practice in various areas of school and life.
Interventions to address EF deficits within the classroom should include direct instruction of metacognitive strategies - and this strategy instruction should be linked to the curriculum and taught in a structured/systematic way. Older children and adolescents typically benefit more from strategy instruction than younger children.
Strategy instruction targets
a constellation of cognitive-processing abilities, including EF skills. By teaching students effective strategy use, it makes them part of the process; children and adolescents need to understand
their own cognitive strengths and weaknesses to become part of the solution to their deficits. Greater self-understanding for the student leads to a greater likelihood that they will be able identify when and where they need to make use of certain strategies. The student is empowered by this approach - and feels more in control.
Strategy instruction is preferred over behavioral interventions targeting EF deficits because
not only do we help the child understand their weaknesses, but we also give them the tools to help remediate deficits. The target is the cognitive processes.
Strategy instruction has been found to generalize to improved academic performance in children with ADHD. It can also be easily integrated into the classroom through the use of parent, child, and teacher handouts on planning and attention (which is of particular relevance for children with EF deficits)
Targeting EF deficits with the School Curriculum
Research in this area has focused in particular on developing inhibitory skills in young children. Tools of the Mind and the Montessori approach are example standalone approaches, while Promoting Alternative Thinking Strategies
and the Chicago School Readiness Project are supplementary add-ons to existing curricula.
Only one curriculum targets EF skills from junior infants up to sixth year - which is the RNBC EF Program. It identifies these EF constructs as important for classroom
instruction: self-regulation, self-awareness, goal-directed
behavior, self-monitoring, and flexibility to solve problems and revise plans. It has its own academic planner that helps students with time management and planning skills.
Research has found that students using this curriculum complete more homework, get better grades, do better on standardized academic assessments, and like the program/exhibit strong adherence to it (with similarly high approval ratings given by parents and teachers).
Research with special education students is less clear cut - with no significant EF differences being observed before and after completion; but general grades did improve.
Targeting EF Deficits with Mindfulness and Physical Activities
While definitions of mindfulness vary, one common two-component definition
of mindfulness involves the self-regulation of
attention, and the adoption of a particular orientation toward
one’s experiences in the present moment.
Mindfulness
and physical activities that may be able to positively impact EFs
in children include meditation, martial arts, yoga, and
aerobics, and they require repetition and continued
practice to gain maximum benefits - with such activities having the potential to positively impact both physical and mental health. However, research on their effectiveness in practice at improving cognition is still limited for children (stronger support amongst adults)
Extensive meditation training has been linked with heightened activation in executive attention networks - which correlated with improvements in sustained attention as well as with error monitoring; promoting higher-order cognitive processing. Brief meditation training has also been found to reduce fatigue and anxiety and increase
mindfulness amongst college students - as well as improve
visuospatial processing, working memory, executive functioning abilities - and potentially the ability to sustain attention.
Martial arts emphasizes effort and determination more
than innate physical ability. Progress is based on personal
achievement. A school-based taekwondo intervention focused on facilitating self-monitoring and self-regulation skills, and incrementally increased the level of task challenge and reward for achieving higher levels of competence (which is a necessary
component of EF training). The students demonstrated improvements
in areas of cognitive and affective self-regulation,
prosocial behavior, classroom conduct, and performance
on a mental math test. Boys demonstrated better results
than girls (likely because of the greater prevalence of attention and conduct problems
in boys).
College women who participated in yoga practice
and aerobics demonstrated shorter reaction times and
increased accuracy on inhibition and working-memory
tasks following the yoga activities. This study did not show significant improvement of EFs following
aerobic exercise.
A meta-analysis on the effects of physical exercise on EFs in preadolescent children, adolescents and young adults found that acute physical
exercise enhanced EF- regardless of age group.
Aerobic exercise in overweight children improves planning scores on the CAS when in a high-dosage aerobics condition -
suggesting that exercise may be a simple way to enhance
children’s cognitive functioning. This has important implications for academics as well, as the Planning
Scale of the CAS has been linked to achievement.
Diamond (2012) suggests
that exercise alone may be LESS effective in improving
children’s EFs than activities that combine exercise
and mindfulness, such as martial arts or yoga!
Targeting EF Deficits with Games
Traditional childhood games can also help improve
EFs and are easy to implement in the school
setting. These informal interventions are best suited
for preschool-aged and early elementary-aged students.
Games like ‘‘Mother May I?,’’ ‘‘Simon Says,’’ ‘‘Red Light,
Green Light.’’ ‘‘Freeze Tag,’’ and ‘‘Statues’’ help aid in the development of working memory and response
inhibition. Some of the games listed involve both
EF constructs (‘‘Mother May I?,’’ ‘‘Simon Says,’’
‘‘Statues’’), while the others tend to exercise only inhibitory skills.
The development of EF through shared activities with peers
is an enjoyable, low-cost way for students and schools
to aid in the development of EF.
