unstuck and on target: improving executive function, …€¦ · unstuck and on target: improving...

Unstuck and On Target: Improving Executive Function, On-Task and Flexible Behavior

Lauren Kenworthy, PhD [email protected] Pediatric Neuropsychologist; Director, Center for Autism Spectrum Disorders Associate Professor, The George Washington University School of Medicine

Overview

n Does Executive Function matter in the real world?

n What is Executive Function and how does it develop?

n How can we help? n  An Ounce of Prevention = Accommodations

or Supports n  Teaching Executive Function Skills

Global Problem of Executive Dysfunction:

“The curious dissociation between knowing and doing” (Teuber, 1964)

WISC FSIQ vs. VABS Composite

VABS Composite

WISC FSIQ

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Asperger

Kenworthy et al, 2005

• EF abilities are linked to adaptive play, social and communication problems (Gilotty et al., 2002)

Executive Function and Adaptive Behavior

Executive Function and Learning: Teacher EF ratings @ 4 years predict Math Fluency @ 6yrs

Clark, CA, Pritchard, VE & Woodward, LJ. (2010). Preschool executive functioning abilities predict early mathematics achievement. Developmental Psychology, 46, 1176-91.

EF problems in ASD & ADHD relate to: •  Adaptive daily living skills (Lopata et al, 2012,

Ware et al, 2012, Wahlstedt et al, 2008)

•  Learning (Akshoomoff, 2005; Blair & Razza, 2007; Raver et al, 2011)

•  Family stress (Graziano et al , 2011; Lounds, 2007)

•  Adult outcomes (Hume et al, 2009)

Executive Function Matters in Real Life

“Won’t” versus “Can’t” ? “Oppositional, Stubborn” Cognitive inflexibility

Protective effort to avoid being overwhelmed “Can do it if he wants to” Difficulty shifting “Doesn’t try” Poor initiation

Impaired planning & generativity “Won’t put good ideas on paper”

Poor fine motor Disorganization

“Sloppy, erratic” “Careless errors”

Poor self monitoring Impulsive Overloaded

“No self control” Overload Disinhibition

“Not listening” Poor attention or working memory

“Pushy, interrupts constantly” Impulsive disinhibited

Executive Function and Moral Turpitude

Overview





What is EF?

Metacognitive Problem-Solving

–  Initiate - begin task, activity, attention

–  Working Memory - hold information actively in mind

–  Plan - anticipate future events and develop steps

–  Organize - establish, maintain order

–  Self-monitor - attend to behavior/ performance; revise

What is EF?

Behavioral/ Emotional Regulation –  Inhibit - stop an action or not react to impulse

– Shift - move from one task or situation to another

– Emotional Control - regulate emotional response

Romine & Reynolds, 2005; Applied Neuropsychology; see also Best & Miller, 2010

How does Executive Function develop?

How does Executive Function develop? …in typical children…

•  Significant age effects on the Working Memory subscale of the parent completed Behavior Rating Inventory of Executive Function (BRIEF); driven by worse ratings among 14-18 year olds compared to 5-7 year olds

How does Executive Function develop? …in children with Executive Dysfunction…

Rosenthal et al. 2013; Neuropsychology

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5 to 7 8 to 10 ��11 to 13 ��14 to 18

T-Sc

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Age group

------------------------------------------------------------------ Clinical Elevation Cut-off

ASD cross-sectional sample: n=185

Working Memory Problems in Children/Adolescents with ASD

Inflexibility Risk: Getting Stuck •  Difficulty with violations of expectations •  Trouble “going with the flow” •  Rigid interpretations of rules •  Getting stuck on an idea or a perception •  Overwhelming intense feelings •  Trouble taking direction from others •  Difficulty negotiating, accepting differing

viewpoints •  Repetitive Behaviors/Intense Interests

What about Vygotsky?

Language

Self directed speech

Self regulation

Executive control (Luria, 1961)

Articulatory Suppression and Planning

•  Articulatory suppression significantly reduced planning performance in the typically developing group (p<.05), not in the ASD group.

•  Performance in the typically developing group under articulatory suppression closely resembled ASD performance under normal conditions.

Wallace et al. (2009) Journal of Autism and Developmental Disorders

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Autism Spectrum Disorder Typically Developing

Articulatory Suppression

Normal

Overview

§ Does Executive Function matter in the real world?

§ What is Executive Function and how does it develop?

§ How can we help? § An Ounce of Prevention = Accommodations

or Supports §  Teaching Executive Function Skills

Unstuck Team

The Ivymount School Model Asperger Program

Take2 Summer Camp n  Katie Alexander n  Lynn Cannon n  Monica Werner

Children’s National Center for Autism Spectrum Disorders n  Laura Anthony n  Lauren Kenworthy n  Caroline Luong Tran n  John Strang n  Jenni Sokoloff n  Meagan Wills

Unstuck Philosophy: Accommodate, then Remediate

•  Predictability and structure •  Make Big Picture Explicit •  Talk Less, Write More

•  Avoid Overload •  Can’t vs Won’t •  Keep it Positive

Praise for

be different“For anyone who has difficulty fitting in, this book is fantastic.”

—TEMPLE GRANDIN, author of Thinking in Pictures

“In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, ‘Glory to the differences / between you and me.’ John Robison teaches us to

celebrate differences like Salinas did, but also offers clear insight and valuable advice on how to cope with the challenges that being different can create.

This book transcends the specific case of Asperger’s syndrome and is a lesson in humanity and the human condition.”

—ALVARO PASCUAL-LEONE, M.D., Ph.D., Harvard Medical School and Beth Israel Deaconess Medical Center

“Anyone with Asperger’s, if not everyone else, will derive knowledge and pleasure from the wonderful stories told in John Elder Robison’s newest book,

Be Different. Clearly, John is one of our community’s leading voices.”—MICHAEL JOHN CARLEY, author of Asperger’s from the Inside Out

and executive director of GRASP and ASTEP

“Be Different is a fascinating and unique guide for young people who may be struggling with autism and feel ‘out of sync’ with the

world around them. John shares personal insights about growing up, feeling apart from his peers, and learning to modify his socializing skills

and harness his gifts to discover his path to a successful life.” —MARK ROITHMAYR, president of Autism Speaks

(continued on back flap)

(continued from front flap) $24.00

Jacket design: WHITNEY G. COOKMAN

Jacket photograph: COURTESY OF THE AUTHOR

Author photograph: AUGUSTEN BURROUGHS

Crown ArchetypeNew York

3/11www.crownpublishing.com

Printed in the U.S.A.

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“I believe those of us with Asperger’s are here for a reason, and we have much to offer. This book will help you bring out those gifts.”

In his bestselling memoir, Look Me in the Eye, John Elder Robison described growing up with Asperger’s syndrome at a time when the

diagnosis didn’t exist. He was intelligent but so-cially isolated; his talents won him jobs with toy makers and rock bands but did little to endear him to authority figures and classmates, who were put off by his inclination to blurt out non sequiturs and avoid eye contact.

By the time he was diagnosed at age forty, John had already developed a myriad of coping strategies that helped him achieve a seemingly normal, even highly successful, life. In Be Different, Robison shares a new batch of endearing stories about his child-hood, adolescence, and young adult years, giving the reader a rare window into the Aspergian mind. In each story, he offers practical advice—for Asper-gians and indeed for anyone who feels “different”—on how to improve the weak communication and social skills that keep so many people from taking full advantage of their often remarkable gifts.

With his trademark honesty and unapologetic eccentricity, Robison addresses questions like:

• How to read others and follow their behaviors when in uncertain social situations

• Why manners matter• How to harness your powers of concentration to

master difficult skills• How to deal with bullies• When to make an effort to fit in, and when to

embrace eccentricity• How to identify special gifts and use them to

your advantage

Every person, Aspergian or not, has something unique to offer the world, and every person has the capacity to create strong, loving bonds with their friends and family. Be Different will help readers and those they love find their path to success.

JOHN ELDER ROBISON is an author and frequent lecturer about his life with Asperger’s. He blogs for Psychology Today and is an adjunct faculty mem-ber at Elms College in Chicopee, Massachusetts. John serves on committees and review boards

for the Centers for Disease Control and the National Institutes of Health. He is currently involved in au-tism research and therapy programs at Harvard’s Beth Israel Deaconess Medical Center and Massachu-setts General Hospital. John also sits on the science and treatment boards of Autism Speaks. His previous book, Look Me in the Eye, was a New York Times best-seller and has been translated into ten languages. He lives in Amherst, Massachusetts.

Visit him at www.johnrobison.com.

Also available as an eBook and on audio from Random House

I S B N 978-0-307-88481-7

9 780307 884817

5 2 4 0 0

U.S. $24.00PSYCHOLOGY—AUTISM/FAMILY & RELATIONSHIPS

be d i f f e ren t

Adventures of a Free-Range Aspergian

WITH PRACTICAL ADVICE

for Aspergians , Misf i ts , Famil ies & Teachers

John Elder Robisonauthor o f the New York T imes bestse l l ing L O O K M E I N T H E E Y E

JOHNELDER

ROBISON

be d

ifferent

Ad

ventu

res of a Free-Ran

ge Aspergian

“An essential guidebook that will help all the creative, quirky, geeky, and wonderfully different kids to become successful in life.” —TEMPLE GRANDIN

Neural Diversity is a civil right…

Overwhelmed people can’t learn

Accommodations: Inflexibility §  Inflexibility is adaptive: limits unexpected,

overloading events §  Overload is dangerous: It leads to anxiety, impulsivity,

inappropriate behavior §  Overload creates profound risk in context of: Social

isolation, teasing and bullying §  In a mine field it is wise to use caution

§  Respect §  Routines that don’t interfere §  Deep datasets §  Expertise in areas of interest

Accommodations: Organization/Planning n Emphasis on goals

n Safe Address n Teach to strength: explicit short rules,

recipes, checklists and routines. n Put new information in familiar context. n Explicitly review inferences, nuances. n Predict decline in abilities as size of

group increases.

Copyright 2014, Brookes Publishing Co., Inc

Break it Down

John has a book I want

Hit John, take book Ask John for a turn

Time out- Miss TV time

Was this what I wanted?

Look at book, give it back, get TV time

Was this what I wanted?

Accommodations: Working Memory Talk Less, Write More

• Time: Google calendar, iCal, Pure Calendar App, Outlook • Tasks: Workflowy, ToodleDo, GoogleTasks, Checklists, recipes • Writing: Noodle Tools, Inspiration.com, Diigo, MyStudyBar, Readwritethink.org • Communication: e-mail, texting, white board • Behavior: Routines, rules Source: The Lab School

Make it Fun: Keep it Positive

Emotions are Contagious

Child mad

You’re mad

Child Madder

You’re madder

Reinforcement Breaks the Cycle

Praise

Praise

Praise

Praise

Correction or command

Copyright 2014, Brookes Publishing Co., Inc.

to

Overview





Global Problem of Executive Dysfunction:

n “The curious dissociation between knowing and doing” (Teuber, 1964)

n  Hard to generalize EF skills (Ylvisaker et al., 2003)

n  A college student with EF deficits: “My biggest problem in college has been executive functioning. I’m not organized, I’m late with everything and I don’t know how to get started. My school did a great job of including me in school, but why didn’t anyone teach me this EF stuff?”

•  Humor, rewards •  Collaborate with

your child

•  Checklists •  Cues •  White Boards

•  Coach •  Make Implicit

Explicit •  Support-fade-

generalize

•  Consistency across settings

Teach and use key

scripts and words

Teach by doing

Make it fun! Use visual supports


Active Coaching


Scaffold Fade Generalize

http://www.bianys.org/learnet

Flexibility Words


•  Great job being flexible Flexible

•  I'm getting stuck on ___, how can I get unstuck? Unstuck

•  Let's compromise so we both get some of what we want Compromise

•  What is our plan? •  What is our Plan B? Plan A/Plan B

Flexibility Scripts

•  How can we make this big deal into a little deal?

Big Deal/Little Deal

•  Is this a no choice situation? Choice/No

Choice

•  What will change? •  What will stay the same? •  Why is the change happening?

Handling the Unexpected


Target Goals/Whim Goals

To get to school on time

Target Goal Want to

watch TV

Possible Whim Record show

to watch later

Plan


When you have gotten derailed by a whim goal while making dinner. “Ooops. My target goal was to make dinner, but here I am checking my e-mail. I guess that is a whim goal that I should only do after I finish making dinner, what do you think?

When you get distracted while shopping. “Wait a minute, what did we come to the mall for, what was our target goal?” “So eating this ice cream cone right now is a whim isn’t it?” Before a play date. “What is your target goal for this play date?”… If no answer or a whim goal is offered: “What about making sure Elias has a good time so he will want to play with you again? Or what about having Elias become your friend?” … “What are whims that could get in the way of your target goal”? If no answer or an inappropriate whim is offered: “What about wanting to go first in every game you play?”

Target key times of day when your child often gets derailed. Before going to bed you could say, “What do you think the target goal is for the morning before school?” [Or: “My target goal for the morning before school is getting you to school on time and me to work on time.] Write the goal down on a post-it note. Then say, “What whims could get in our way?”


Goal, Plan, Do, Check


Goal What do we want

to do?

Plan

How will we do it?

Do Let's try our plan

Check

How did it work?

Running errands: My goal was to finish all my errands today, so I could just relax tomorrow, and my plan was to do the grocery shopping, get the car fixed, get your prescription filed and get home in time to run before dinner, but now it is 5pm and I have only done the first two steps on my plan, can you help me come up with a plan B? Your spouse wants to go out with old friends: If your goal is for me to let you go out on Saturday night, you need a plan that includes giving me a foot rub during the day! Your child is resisting homework: You had a goal of getting an A in math right? Wasn’t part of the plan for achieving that goal doing your homework?


Goal: What do you want to do? Keep my room clean Plan A: How do you want to do it? Put clothes away:

Clean clothes in the closet Dirty Clothes in the hamper

Put toys in toy box Put books on bookshelf When I finish cleaning my room, I get to play a game with Mom. Do: When do you want to try out your plan? I will create a checklist of my plan and do the plan everyday after snack, checking off my checklist as I go. Every time that I do my plan, I get to play a game with mom. Check: How did it go? Do I need to add any steps to the checklist?


Unstuck Trial: Participant Demographics

Kenworthy & Anthony et al., 2014

Unstuck (n=47) Social Skills (n=20)

Male 87% 90% White 70% 55% On Psychotropic Medication 55% 60% Mean (SD) Mean (SD) Age 9.49(1.00) 9.58(1.10) Mother’s education 1.91(0.88) 1.95(0.76)

Father’s education 2.04(1.12) 1.95(0.91)

WASI FSIQ 108.80(18.52) 107.63(17.20)

ADOS Social+Comm 11.64(3.76) 12.00(4.39)

ADOS Stereotyped Beh 1.98(1.71) 1.90(1.33)

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WASI Block Design Higher Score = Better Performance

Kenworthy & Anthony et al., 2014 Cohen’s d=0.65

Mean Challenge Task Flexibility Higher score = Less flexible

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Cohen’s d=-‐0.72 Kenworthy & Anthony et al., submitted

Kenworthy & Anthony et al, submitted

Proportion of Individuals Who Improved by Blinded Classroom Observation

Parent & Teacher BRIEF Shift Higher score = Less flexible

Kenworthy & Anthony et al, submitted

Parent Cohens d=-0.64; Teacher Cohen’s d=-0.89

Anecdotal evidence

Ø  Parent: “This has been a life changing experience for my daughter”

Ø  Teacher: “One student had three meltdowns per day, and UOT reduced her outbursts to two occurrences in one quarter”

Ø  Parent: “UOT was a lifesaver for us this year!”

Conclusions

Ø Unstuck = SS for social skills

Ø Unstuck > SS for flexibility, problem solving, and transitioning, negativity and following rules in class

Ø Unstuck > SS real world planning/organization

Ø Many Unstuck gains maintained 1 year after intervention

Books on Supporting and Teaching Executive Function

n  Solving Executive Function Challenges: Simple Ways to Get Kids with Autism Unstuck and on Target Kenworthy et al (2014)

n  Unstuck and On Target: Teaching Flexibility and Goal Directed Behavior to Children with ASD Cannon et al (2011)

n  Smart by Scattered Dawson & Guare (2009) n  Late Lost and Unprepared Cooper-Kahn & Dietzel (2008) n  Executive Skills in Children and Adolescents: A Practical Guide

to Assessment and Intervention Dawson & Guare (2010) n  School Success for Kids With Asperger’s Syndrome Silverman et

al (2014) n  School Success for Kids With ADHD Silverman et al (2009)

unstuck and on target: improving executive function, …€¦ · unstuck and on target: improving...

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