10/15/2019 Dr. M Megan an Smith, C h, C. P Psych. ych. 1 What is executive functioning (EF)? Where do EF skills come from? How is EF related to ADHD? A closer look at specific EF skills: ◦ What they are ◦ What deficits look like ◦ What helps Resources 2 What is executive functioning? 3 1
10/15/2019 Grou Group of of n neurolog ogical proc processes th that allo allow u us to en to enga gage in in goal goal-directed beh behaviour Executive Functioning Self- Meta- Cognitive cognitive Regulation Inhibition Attention Planning Emotion Shifting Organization Regulation Working Self- Motivation Memory Monitoring 4 Consider t the E EF skills requi kills required by by a stud udent writ iting a g an es essay say… Plan ( (topic ic, p points, c conclu lusion on) Ignore d re distrac ractors ors In Initi itiate ( (star tart res resear arch) Monito tor ( r (time, p e, progres ress) Maintain arou Mai arousal Shift Sh ift 5 6 2
10/15/2019 Air-traffi affic c con contr troller Con Conductor 7 Where does executive functioning come from? 8 Highly genetic – 99% heritability Develop slowly, over time, through our early- to-mid twenties Directly related to the structure and functioning of specific parts of the brain, including specific pathways, networks, neurotransmitters, etc. 9 3
10/15/2019 FR FRON ONTAL LOB LOBE: Self- Self-regul ulat atio ion, a n, attentio ion, w n, work rking g memor memory, s , self lf-monit itor oring , g , in inhibi hibition, , planni pla nning… ng… LIMBIC IC SY SYST STEM: EM: Emotions, m ns, motivati vation, r on, reacti tivi vity ( ty (e.g. f . fight/ t/fl flight)… )… PAR PARIETAL LO LOBE BE: Att Attention BRA BRAIN S STEM EM: Aro Arousal, al aler ertness PAR PARIETAL LO LOBE BE FRON FR ONTAL LOB LOBE LIMBIC LIMB IC SYSTEM OCCI CCIPITAL LOBE LOB TEM TEMPORAL LO LOBE These parts of the brain have CEREBELL CER LLUM all been associated with BRAIN BRA N STEM STEM ADHD! 10 How is EF related to ADHD? 11 Both associated with a number of specific brain structures, neuropathways, etc. Many of these structures develop more slowly in people with ADHD ◦ Not coincidentally, development of EF skills is also delayed Each ADHD symptom is related to one or more executive functions! 12 4
10/15/2019 Fidgets with or taps hands or Regulation of… 1. squirms in seat Leaves seat in situations when 2. remaining seated is expected Motor Runs about or climbs in 3. situations where it is Activity inappropriate feeling restless Unable to play or engage in 4. leisure activities quietly “On the go" acting as if "driven by 5. a motor“ Speech Talks excessively 6. Blurts out answers before 7. questions have been completed (Other) Has difficulty awaiting turn (e.g., 8. Impulses while waiting in line) Interrupts or intrudes on others 9. 13 1. Fails to give close attention to Self-monitoring/ details/makes careless mistakes attention to detail 2. Has difficulty sustaining attention Sustained attention/ 3. Does not seem to listen when selective attention spoken to directly 4. Does not follow through on Sustained attention/ instructions and fails to finish motivation/ self- school work, chores, or duties monitoring 5. Has difficulty organizing tasks Organization/ planning and activities 6. Avoids or is reluctant to engage Emotion regulation/ in tasks that require sustained motivation mental effort 7. Loses things necessary for tasks Organization/ or activities attention… 8. Easily distracted by extraneous Selective attention stimuli Attention/ self- 9. Forgetful in daily activities monitoring/WM/planning 14 Like ADHD itself, EF deficits will likely be life-long ◦ Long-term scaffolding is critical for children and adolescents with ADHD ◦ With support, practice, and lots of strategies in place, people can be highly successful and independent, as adults Some adults will continue to need support Ple Please se use e e extr trem eme e cauti caution if if you you find nd you yoursel elf t f thinking ng: “ : “but t ut they’r ey’re goi e going t g to have ve to le lear arn…sooner or or later later.” 15 5
10/15/2019 Pro Problem Are Area o of EF EF: Possible O ssible Outcom tcomes: es: • Inhibitory control • Behavioral dysregulation • Emotional • Emotional dysregulation regulation • Rigidity; “stubbornness” • Shifting • Problems following rules, • Working Memory routines independently Environm vironmenta ental R Responses: sponses: Long-Term O ng-Term Outcomes: tcomes: • Punishment • Anxiety • Punishment and coercion • Depression • Failure • Anger • Punishment and constant • Poor relationships reminders (aka nagging) 16 A closer look at specific EF skills 17 We will look at each EF skill, and consider: What the skill is What deficits in the skill might look like Strategies to support deficits in that skill 18 6
10/15/2019 I. SELF-REGULATION ◦ Mental functions required to regulation actions, emotions, and drive ◦ Gateway EF skills Without these skills, difficult or impossible to access other EF skills. 19 Inhibition What is it? ◦ Ability to not act on impulse Ability to think before acting Ability to resist a conscious (i.e. recognized) impulse ◦ Test ◦ Essentially, inhibition is like having good brakes on your car! Allow you to stop or slow down, as needed 20 Inhibition… What do problems look like? ◦ Think: car with malfunctioning brakes! No matter how hard you slam on them, you can’t stop in time ◦ Inconsistent control over actions ◦ Acting without awareness/conscious intent ◦ Saying and doing the wrong thing at the wrong time ◦ Difficulty resisting impulses; associated with compulsions ◦ Difficulty following rules and social norms ◦ Difficulty adapting behaviour to context ◦ Often seen as annoying, inconsiderate, unempathetic, out- of-control, attention-seeking… 21 7
10/15/2019 Inhibition… What helps? ◦ Very challenging to address ◦ Imagine what would help if your brakes weren’t working ◦ Predict and prevent (collaboratively) ◦ Use priming: review context-specific expectations immediately prior to entering specific situations (e.g. recess) ◦ Reduce stressors ◦ Teach strategies for addressing problems that arise from impulsive actions ◦ Over-practice rules, routines, strategies Remember that many skills are non-transferrable ◦ Do not punish impulsive actions; increase supports 22 Emotion Regulation What is it? ◦ Ability to influence the intensity of emotions ◦ Prevent limbic system from hijacking EF processes Flip Your Lid by Dan Siegel What might problems look like? ◦ Quick, strong emotional reactions ◦ Difficulty using effective strategies to manage emotions ◦ Poor response to attempts to help (esp. logic) ◦ May escalate in response to attempts to control them ◦ Difficulty coping with environmental demands (e.g. transitions, requests, frustrations, challenges) ◦ Tendency to go into “freeze, flight, or fight” mode ◦ Often viewed as: sensitive, dramatic, aggressive, immature, manipulative, moody, spoiled, etc. 23 Emotion Regulation… What helps? ◦ Work with the person to identify situations that are most likely to trigger intense emotions, and generate potential ways to cope with or avoid those triggers (collaboratively) ◦ Help them practice strategies in 3 key areas: 1. Self-care 2. Distress tolerance (e.g. self-soothing) 3. Effective communication/relationships ◦ Provide co-regulation Recognize stress Provide required regulation support 24 8
10/15/2019 Motivation What is it? ◦ Our sense of drive ◦ Strongly mediated by reward pathways and neurotransmitters; can only manipulate for so long What do problems look like? ◦ Difficulty getting started and maintaining effort ◦ Difficulty attempting challenges ◦ Reduced sense of reward when goals are met ◦ Easily side-tracked by short-term desires ◦ Lack of ambition ◦ Often viewed as lazy, apathetic, unconcerned, etc. 25 Motivation… What helps? ◦ Make use of areas of interest* ◦ Make things into games, wherever possible ◦ Alter the environment to get dopamine pumping Motivating music Frequent breaks, especially for exercise (also needs to be fun) Build in physical releases (e.g. exercise bike-desk) ◦ Alter environment to reduce other stressors Think of the 5 senses (unpleasant sounds, sights, smells, etc.) ◦ Build self-awareness and goal-focussed thinking: Have person rate stress (i) thinking about task; (ii) doing task; (iii) after task is complete ◦ Make use of collaborative problem-solving to address ongoing areas of difficulty May include incentives to develop habits 26 II. COGNITIVE SKILLS ◦ Mental functions required for thinking, learning, remembering, reasoning, etc. 27 9
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