Presented by: Jonine Biesman, Psy.D Pediatric and ...€¦ · Presented by: Jonine Biesman, Psy.D...

Presented by:yJonine Biesman, Psy.D

Pediatric and Adolescent NeuropsychologistNeuropsychologist

Fulton Psychological Group

1Dr. Jonine Biesman, 5/3/11

WHAT THE HECK ARE EXECUTIVE FUNCTIONS??????FUNCTIONS??????

Our “higher order” brain functions: AND DESPITE “INTELLIGENCE”

What separates us (to some degree) from other animal speciesWhat separates us (to some degree) from other animal species

Functions such as organization, planning, complex problem solving, abstract reasoning, inhibition, self-monitoring, self-regulation, working memory,

i i i i i i i hif i f iinitiation, sequencing, sustaining, shifting of attention

MULTIDIMENSIONAL: Some components may be spared, some impaired; Knowing and appreciating individual profiles is essential! g pp g p f

All of these functions are vital for smoothly operating in life and especially at school

Likened to the conductor of an orchestra or to a CEO

VERY, VERY closely linked with variables of Attention!


ADHDLEARNING DISABILITIES LEARNING DISABILITIES AUTISM SPECTRUM

DISORDERS ANXIETY ANXIETY SLEEP DISORDERSMOOD DISORDERS PERSONALITY COMMON PERSONALITY

DISORDERS DISRUPTIVE BEHAVIOR

DISORDERS

COMMON ASSOCIATED

CONDITIONS…DISORDERS

AND YES… EXECUTIVE FUNCTION N NWEAKNESSES CAN EXIST WITHOUT ANOTHER FORMAL DIAGNOSISDIAGNOSIS


We used to think all the answers were found in the cortex and the Frontal

Lobes. We now know we were wrong!

There is a reason CEO’s need their teams and conductors need their orchestra

members.

This is the same as the brain. Essential subcortical regions support cortical

functioning. Executive functions do not

Remember these Regions Especially:

• Cerebellumlie in an isolated portion of the brain but rather rely on complex neural networks and connectivity. Problems with these

subcortical functions and neural

• Basal Ganglia• Thalamus• Cortex

networks will ensure that that Executive Function deficits arise

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THINK OF A FEEDBACK LOOPDr. Jonine Biesman, 5/3/11

Oh, Yes! COMPLEXITY!!!!!!!


A NEURAL SYSTEM AS COMPLEX AS THISA NEURAL SYSTEM AS COMPLEX AS THISCAN HELP PARENTS UNDERSTAND THAT CAN HELP PARENTS UNDERSTAND THAT CAN HELP PARENTS UNDERSTAND THAT CAN HELP PARENTS UNDERSTAND THAT

BEHAVIORS HAVE A PURPOSE!! BEHAVIORS HAVE A PURPOSE!!

THERE MAY BE FRUSTRATED, SAD, ANGRY, THERE MAY BE FRUSTRATED, SAD, ANGRY, OPPOSITIONAL, ANXIOUS, CONFUSED, OPPOSITIONAL, ANXIOUS, CONFUSED,

CHALLENGING DISORGANIZED FATIGUED CHALLENGING DISORGANIZED FATIGUED CHALLENGING, DISORGANIZED, FATIGUED CHALLENGING, DISORGANIZED, FATIGUED STUDENTS STUDENTS ------ BUT NOT LAZY STUDENTS!!!BUT NOT LAZY STUDENTS!!!

NO CHILD WANTS TO PERFORM POORLY IT IS NO CHILD WANTS TO PERFORM POORLY IT IS NO CHILD WANTS TO PERFORM POORLY. IT IS NO CHILD WANTS TO PERFORM POORLY. IT IS NOT AN INNATE INSTINCT.NOT AN INNATE INSTINCT.

CHECK YOUR OWN EMOTIONS AND REACTIONS CHECK YOUR OWN EMOTIONS AND REACTIONS WITH YOUR CHILD’S AND UNDERSTAND THE WITH YOUR CHILD’S AND UNDERSTAND THE

VERY REAL ROLE OF NEUROBIOLOGY AND VERY REAL ROLE OF NEUROBIOLOGY AND

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VERY REAL ROLE OF NEUROBIOLOGY AND VERY REAL ROLE OF NEUROBIOLOGY AND GENETICS.GENETICS.

Dr. Jonine Biesman, 5/3/11

We now know that the Cerebellum is SO MUCH MORE than motor skills.

Early motor plans are cognitive plans!

This makes motor development and its keen assessment central For so many keen assessment central. For so many children with EF problems, early and ongoing motor challenges can be found as well.

Even though our Executive Functions are Back to the

Even though our Executive Functions are not fully developed until the teenage years, there are many ways in which their development may be supported early in life!!

Beginning…….

PLAY IS ESSENTIAL IN THIS EQUATION (PLAY THAT GOES BEYOND BOARD GAMES AND VIDEO GAMES; OLD FASHIONED CREATIVE PLAY)CREATIVE PLAY)

We were not meant to be sedentary!!!What has been spared in the brain through evolution proves this to us.p


ESSENTIAL FUNCTIONAL EMOTIONAL DEVELOPMENTAL LEVELS (FEDL’S)( )

As conceptualized by the late, brilliant, and heartfelt Dr. Stanley Greenspan

I. Joint Attention and RegulationII. Engagement; falling in loveIII. Interaction and Communication; Flow; Reciprocal, meaningful circlesIV Sh d l l bl l (f d f h h l l IV. Shared social-emotional problem solving (foundation for higher levels

of thinking)V. Symbolic thinking; meaningful use of ideasVI L i al thinkinVI. Logical thinkingVII. Multi-causal thinkingVIII.Comparative and Gray-area thinkingIX Reflective thinkingIX. Reflective thinking

We need to help our children and adolescents climb this developmental ladder.


Public School Evaluations:My Concerns:WHAT WILL AN

• Cursory• Focus on numbers

• Incompletef h ld l

EVALUATION DETERMINE?

• Best interest of child not always a consideration

• But, they’re free and sometimes necessary.

WHAT ARE THE DIFFERENCES

BETWEEN TYPES y

Private Evaluations:

OF EVALUATIONS?

What are the differences between Psychoeducational, Psychological,

and Neuropsychological Evaluations?

HOW DO I KNOW IF AN

ASSESSMENT IS Evaluations?

In what settings are they conducted?

ASSESSMENT IS IN ORDER?


PRIVATE EVALUATIONS: WHY NEUROPSYCHOLOGY?

Study of Brain-Behavior relationships A much “deeper dive”

Offers integration and putting essential pieces of the puzzle together

Focus on individualized treatment planning Understanding of a child’s functioning well beyond statistical

lanalysis Whole child approach

Understanding the process and path to a response is just as imp rtant if n t m re s than the resp nse itselfimportant, if not more so, than the response itself

Covers comprehensive domains of functioning not found in Psychoeducational or Psychological evaluations: Cognition, Academic Achievement Memory and Learning Variables of Academic Achievement, Memory and Learning, Variables of

Attention, Executive Functioning, Language, Sensorimotor skills, Visuospatial skills, Social-Emotional/Personality Functioning,

Behavior -- All in the context of rich understanding of the Brain

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g Important to observe children across settings and time!!


THERAPEUTIC INTERVENTIONS

Educational Therapy

Psychopharamacology

Psychotherapy

Group Therapy (e g social skills) Group Therapy (e.g., social skills)

Play Therapy (DIR/Floortime)

Parent Training/Support/Education

Occupational Therapy

Speech Therapy


ACADEMIC ACCOMMODATIONS

• Extra time (including standardized tests such as the SAT, ACT)• A quiet place in which to take exams• Copies of class notes Copies of class notes • Preferential seating• Writing templates• Extended deadlines

d• Extra credit• Allowing re-taking of an exam• Removing writing mechanics as part of writing grade for some assignments• Preferred exam format (e.g., multiple choice)d xam mat ( .g., m ltipl ch ic )• Use of a calculator • Use of a keyboard• Allowing of movement and frequent breaks

F ll l i i i d • For college, early registration; access to case management, tutoring and counseling services

• Allowing students to generate assignments• Open note test formatsp• Accommodating for individual sensory profiles


ACADEMIC ACCOMMODATIONS (cont.)

• Allowing time in schedules to be a “Library assistant” where students may catch up on work not completed

• Decreasing homework load and focusing on quality versus quantityDecreasing homework load and focusing on quality versus quantity• Keep the student active by calling on him/her or providing gentle taps

and re-direction when attention has waned. • Don’t send home unfinished work to complete.

E h l h di i d i i k kl • Ensure school-home coordination and communication; seek weekly updates.

• Provide assignments in advance.• Allow breaks during exams; “stop the clock.”g ; p• Offer an extra set of textbooks for home.• Some students may perform better with fast-paced instruction that is

varied and stimulating.• Consider “goodness of fit” in teacher selection• Consider “goodness of fit in teacher selection.• Create a student-teacher signaling system that allows a student to

communicate a specific need.


SOME SPECIFIC SOME SPECIFIC STRATEGIES:STRATEGIES:

The good news is we could go on and on and on. BUT, we need to see what fits well for each individual child. There is no Pre-prescribed formula

1. Externalizing the environment – checklists, charts, reminders, over-sized calendars, dicta-phones or i-phone to record reminders

2. Frequent organization of work areas; color coding and fun labels can help3. White noise??4. “Central Coherence” – thinking about what keeps students optimally

aroused and engaged (may be something as simple as a pen to click or a rubber band to play with); work with an OT sensory-regulatory strategies rubber band to play with); work with an OT sensory regulatory strategies that seem to work

5. Teaching how to think about thinking e.g., Self-talk (Metacognition)6. Multisensory, experiential, hands-on learning. Make it MEANINGFUL!7. Work on classifying and categorizing incoming information; chunking8. Teaching the “how” of task initiation9. Employ peer mentors


STRATEGIES (cont.):STRATEGIES (cont.):

H d b i i i i l i d l i ll 10. Have students be active participants in goal setting and planning – really having them think through what is involved in task completion and play around with estimating time. Compare time estimates to time actually taken to complete a step or goal. p g11. Use of visual timers can be helpful for some students; teach strategy of over-estimating time, if needed12. Breaking down tasks into manageable units and allowing frequent breaks

U i f t B ib i t b d id E h h k k d ff 13. Use reinforcement – Bribery is not a bad idea. Each check mark crossed off a list can equal points, tokens, small prizes, or small cash amounts

14. Provide opportunities to solve problems from a variety of perspectives to improve cognitive flexibility.

15. Strengthen working memory by encouraging mental flexibility (e.g., spelling words backward, engaging in brain teasers, holding increasingly longer units of information in his head while performing other tasks)

16 Have students repeat back directions16. Have students repeat back directions17. Use simple, expressive sentences – speaking slowly and clearly18. Provide choices within reason


STRATEGIES (cont.):STRATEGIES (cont.):

T h l i h diffi l i i i h f ll i b id d19. To help with difficulties writing, the following may be considered:Dictation into a recorderDrawing a picture of a thought for a paragraphEncouraging students to talk out loud as they writeg g yLearning abbreviations when having to writeUse of paper with raised lines or graph paper to help with neatness, organization, and spacingU ith th t t li idth iblUse a paper with the greatest line width possibleJournaling via the keyboard and practice in writing by composing letters and e-mails to friends.


STRATEGIES (contSTRATEGIES (cont.):.):

20. Create opportunities for big picture thinking by talking about meanings; working on summarizing and retelling of stories; highlighting main points; engaging the use of high affect in discussions; working on comparisons and g g g g ; g pdegrees of difference; developing internal communication and self-talk; working on establishing and understanding the student’s own point of view; engaging in debates and arguing from different perspectives; determining a

t f l d ki h ld h th d d h t set of rules and asking how one would change them and under what circumstances; reflecting on alternatives to settling disputes; developing perspective taking (e.g., what was the other thinking and feeling and why); understanding part versus whole thinking; helping students to express and understand their intuition; and using picture books to have them tell a story (and then tell it from another vantage point).


A FEWWORDS TO THE WISE

A good assessment will drive intervention

Performing decently on EF measures does not preclude the Performing decently on EF measures does not preclude the existence of EF problems in real-life: Consider all the variables

Honor and appreciate individual differences. No two children are alike and one size does not fit all!

Think outside of the box!!!!

Appreciate how HUGE, no GIGANTIC, the concepts of “motivation”; “effort”; “co-regulation,”; “scaffolding” and

d l i “i t l iti ” d “i iti ti f th ht” developing “internal capacities” and “initiation of thought” are.

Empathize rather than criticize, and take a lot of deep breaths when frustrated (of course easier said than done)

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when frustrated (of course easier said than done)


WORDS TO THE WISE (cont.)

Know your child’s limits; have REALISTIC EXPECTATIONS but never put a limit or cap on what to expect. Children surprise us all the time. So,

don’t be afraid to gently push upper limits and to seek guidance in how to do hithis.

Use salient cues. They need to “CAPTURE.”

It is a simple fact that some students need to work harder than others. The brain will learn what you teach it, but must consider frequency, intensity,

exposure, practice, repetition, opportunity.

Teaching the art of learning from experience is just that – an art. It remains difficult for even the most skilled and experienced. But, it remains a core

area of need to continually address.

Remove obstacles and avoid power struggles. What is the point?

Focus on strengths and help build intact egos

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Focus on strengths and help build intact egos


WORDS TO THE WISE (cont.)

F ll hild’ l d j i d d h ll h h f Follow your child’s lead; join, expand, and challenge rather than force compliance to procedures and methods that may not work. Our children will

teach us if we let them. Sometimes we just need to break their code.

Concepts of consistency and follow-through are essential in undertaking any program or strategies

S t “f d ti ” kill h t i i tt ti l ti t Support “foundation” skills such as sustaining attention, regulation, motor planning, social problem-solving, etc..

Know when to pull back and provide opportunities: put questions and challenges back on your child; “play dumb,” create gentle obstacles so that you

can work through these problems jointly. This will help to build internal resources.

“They should know this by now” is not necessarily true

Don’t underestimate the value of very frequent verbal praise


RECOMMENDED RESOURCES

Print:The Learning Tree, Stanley Greenspan, M.D.

S B S d D d GSmart But Scattered, Dawson and GuareExecutive Skills in Children and Adolescents, Dawson and Guare

Late, Lost and Unprepared: A Parent’s Guide to Helping Children With Executive , p p p gFunctioning, Joyce Cooper-Kahn, Ph.D.; Laurie Dietzel, Ph.D.

The Mislabeled Child, Brock Eide

Study Strategies Made Easy, Davis and Sirotowitz

Executive Function in Education: From Theory to Practice, Lynn Meltzery y

Overcoming Dyslexia, Sally Shawitz, M.D.

Why is Math So Hard for Some Children Berch and Mazzocco (a technical resource Why is Math So Hard for Some Children, Berch and Mazzocco (a technical resource, but nonetheless, good information and suggestions for useful teaching strategies).


Web Resources:

www.RussellBarkley.org (download his free pdf’s e.g., Fact Sheet: ADHD Topics, y g ( p g , p ,80+ Classroom Accommodations for Children or Teens with ADHD; The Important Role of Executive Functioning and Self-Regulation in ADHD)

h dd (A i i f Child d Ad l i h A i D fi i www.chadd.com (Association for Children and Adults with Attention Deficit Disorder).

www.inspiration.com (organizational software for writing)p g g

www.cogmed.com

www squidoo com (picture books)www.squidoo.com (picture books)

MindWare, brainy toys for kids of all ages, www.mindware.com (800) 999-0398

www.lumosity.com (brain games and brain training)www.fitbrains.comwww.gamesforthebrain.com


Web Resources (continued):

www.susankaisergreenland.com/inner-kids.html (Mindful Awareness Practices)

www.socialthinking.com (Michelle Garcia Winner)

www.learningtolearn.biz

www goodsensorylearning comwww.goodsensorylearning.com

www.braincogs.com

www.time-management-guide.com

www.collegeathome.com(for organizational strategies specific to college success)(for organizational strategies specific to college success)

www.careerpuppies.com for gaining information regarding specific vocational fields and the opportunity to take a career inventory


Web Resources (continued):

www.landmarkschool.org (good resources blog)

www.collegeconfidential.com (college-bound community on the web and college discussions)discussions)

www.ldonline.org (information about learning differences including executive function weaknesses)

SQ4R Reading Method

www.parentmagic.com, Dr. Phelan’s 1-2-3 Magicwww.parentmagic.com, Dr. Phelan s 1 2 3 Magic

www.helpforadhd.org

h l idwww.theplannerguide.com


Games:

SetMastermindBlokusBlokusChessDance Dance Revolution

i-Pad/i-phone: (from Caitlin Welsh, Ed Therapist)

TanZen HG Lite- tangram game for visual spacing and learning how to attach a problem and solve ita problem and solve it

Set Pro HD – teaches students how to keep organized information in their brain while creating groups for sorting information

Simon Says

Memory cardsMemory cards


Thank you for you participation.

To contact me or for a copy of the powerpoint, you can go to you can go to

www.fultonpsychologicalgroup.com818-591-3000 x8

or

Jonine Nazar-Biesman, Psy.D.15928 Ventura Blvd. suite 221, encino, California 91436

(818) 415-6435


[email protected]

Presented by: Jonine Biesman, Psy.D Pediatric and ...€¦ · Presented by: Jonine Biesman, Psy.D...

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Transcript of Presented by: Jonine Biesman, Psy.D Pediatric and ...€¦ · Presented by: Jonine Biesman, Psy.D...