Wednesday, February 28, 2018

Reading :: Assessment and Intervention for Executive Function Difficulties

Assessment and Intervention for Executive Function Difficulties
By George McCloskey, Lisa A. Perkins, and Bob Van Divner

In school, "80 pound boys are not expected to wrestle 120 pound boys"—that is, "students the same age but at varying stages of physical development are not expected to perform comparatively in gym class" (p.70). However, in terms of mental development, it's a different story: students with brain development differences "are expected to perform comparably in terms of executive function-dependent capacities labeled as responsibility, self-organization, self-direction, self-discipline and the like, in order to earn passing grades in most academic classes" (p.70). Such capacities are typically not treated as developmental differences but as "well within the control of the child" (p.71).

And since they are treated this way, "the negative consequences applied to a child not performing up to such standards can be severe, unreasonable, and often uncompromising in nature" (p.71). We wouldn't chastise an 80-pound boy for losing three straight wrestling matches to a 120-pound boy, but parents and teachers do chastise students who don't perform at grade level due to developing executive functions. "School staff does not see the inordinate time and effort the student is placing into completing school work and the strain that this additional effort is placing on the child at home" (p.138). And for many students, "when no specific learning disabilities are identified and ADHD is ruled out ... they are frequently subjected to what amounts to character assassination" (p.138, my emphasis). Poor production is attributed to moral rather than developmental factors: "laziness, apathy, lack of willingness to take responsibility for their own actions, lack of motivation, overt hostility, or lack of respect for authority" (p.138). These attributions may ease the conscience of instructor or parents, the authors note, but they don't solve the problem—they only exacerbate it (p.139), and they become part of the story the child tells herself about herself. Rather than setting the student on the right path, they morally condemn the student for not doing what they literally cannot do.

Executive functions are "mental capacities that direct or cue the use of other mental processes and/or motor responses" and that "have some link to activation of portions of the frontal lobe regions of the cerebral cortex" (p.38). The authors identify 23 of them: perceive, initiate, modulate/effort, gauge, focus/select, sustain, stop/interrupt, inhibit, flexible/shift, hold, manipulate, organize, foresee/plan (short term), generate, associate, balance, store, retrieve, pace, time, execute, monitor, correct (pp.41-43, with definitions). As the authors note, as the cerebral cortex matures, these capacities can develop socioculturally. And when parts of the cerebral cortex mature more slowly than others in the age cohort, these capacities (such as the ability to focus, organize, or plan) do not develop as quickly, and thus "simple" school activities—such as paying attention, extracting information from a complex reading, or keeping up with one's schoolwork—are far more effortful for the student than for her peers. Yet for the casual observer, these difficulties seem to be of the student's own making: if only they would pay attention, apply themselves, or take the time to think ahead!

EFs are often associated with syndromes, even ones that are not founded on the EF deficiency:
For example, Generalized Anxiety Disorder (GAD) involves neural circuits routed through a number of subcortical structures classified as part of the limbic system, with the paths of these circuits also passing through the frontal lobes. While dysfunction of the neural circuit within the limbic system might be the root cause of the person's anxiety disorder, the disruption of the circuit within the subcortical region can impact the frontal lobes. This results in executive function difficulties while the person is in a state of anxiety. Therefore, some of the diagnostic criteria for GAD include difficulty controlling worry, difficulty concentrating, irritability, and sleep disturbance. All of these symptoms represent difficulty with the engagement of various executive function capacities, which are the outcome of experiencing anxiety. (p.77; their italics, but my bold type added)
As this passage implies, EFs such as "focus" are constructs that describe capacities emerging from the interaction of brain structures (in the case of "focus," these structures likely include the anterior cingulate and the dorsilateral prefrontal cortex) (p.83). The authors overview the likely brain structures associated with all 23 EFs (pp.83-85).

The authors discuss assessment as well, overviewing common EF measures and how they are combined to initiate measurable production decrement cascades (pp.120-122) and production increment cascades (pp.124-125). They note that EF difficulties are often not recognized unless they combine both learning difficulties and production difficulties: when the child has only learning difficulties, these are often not recognized, and when the child has only production difficulties, these are typically attributed to character flaws (i.e., the child is learning, but just doesn't want to do her homework) (p.137).

Fortunately, change is possible: "brain function can be altered through intervention" (p.179): Children can be taught how to activate neural networks to achieve positive goals (p.180). Beyond those interventions, the brain will typically mature: "for many children faced with overly aggressive expectations for brain maturation, a little time may be all that is needed to achieve the desired levels of self-direction. For others with more substantial delays, the ultimate solution to the executive difficulties being experienced may simply be much more time" (p.184). How much more? "Children with ADHD typically experience a 30% delay in the development of specific self-regulation capacities"—so if you are waiting for your child to exhibit the self-direction of a 20-year-old, you may have to wait until she is 30 (p.184). That's a long time—but it will happen.

I found this book to be fascinating. It's not uniformly well written, but I found it to be accessible. It helped me to think through some of Vygotsky's work on "self-mastery" and the ideological aspects surrounding his work, which largely focused on using semiotic tools to achieve that self-mastery. But it also helped me to think about the students who enter my classroom, some with documented disabilities, some without. Reading this book has helped me to better understand the challenges that some of these students face as they tackle our complex assignments, as well as the incorrect moral evaluations they may have received as they poured effort into schoolwork that was once beyond their capacities. For understanding both aspects, I recommend this book.

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