Interventions and Supports to Address Executive Function Problems
We have introduced the many types of skills and abilities that are part of the executive functions in areas of metacognition (thinking and problem solving) and the regulation of behavior. Typically, EF skills such as planning ability start to emerge as young as two years of age, while more mature aspects of EF are evident by ten to twelve years of age. However, children with deficits in EF may not develop the skills needed to interact appropriately with their environment, resulting in a variety of cognitive, social, and academic problems.
Targeting Goals for Intervention
Children with EF deficits may demonstrate problems in a number of areas that can affect academic and social functioning, including problems with initiating, organizing, monitoring, and evaluating task performance as well as regulating behavior and emotions. Given the range of possible difficulties, it is important to isolate which of the problems listed are part of the child's dysfunction and then effectively target those areas to help the child improve. The majority of skills can be taught by direct instruction through increasing the child's awareness and then systematically teaching the child how to develop the necessary skill set. In general, the most important aspect of intervention for EF deficits will be to introduce the child to strategies that can be used to effectively apply problem solving skills to goal-directed activities.
Teaching a child to break a task down into smaller steps will allow the child to develop a set of routines for problem solving and a repertoire of problem solving skills that are familiar and successful. Initially, the coach guides the child by asking relevant and leading questions, which the child will eventually learn to ask independently. With practice, the child will begin to internalize these steps, and ultimately, the coach should be able to step aside and cue the child to draw on his own set of questions when that is appropriate.
Did You Know
Parents, teachers, and peers can all serve as coaches for children who have difficulties with problem solving by modeling appropriate problem-solving strategies. They can also teach children to monitor the results as they attempt to apply the skills they have learned to new situations in their daily activities.
A Step-by-Step Intervention for Goal-Oriented Problem Solving
Interventions for problem solving involve four basic steps: Goal, Plan, Do, Review (Gioia, 2005). This four-word strategy provides a reminder that is easily stored in a child's memory. When asked what to do to solve the problem, the child should be able to respond, "Goal, Plan, Do, Review." As we will discuss, more steps can be added to the problem-solving formula (for example, prediction), depending on the child's age and the nature of the task (simple or complex). A model for building a step-by-step intervention plan to develop problem-solving skills is presented in Table 12.1.
The intervention program can be introduced to the child by explaining that people use problem solving every day to help them think, plan, and do what they need to get done. Next, let the child know that there is a way to problem solve that can be used for a variety of different types of problems and that these steps can help him to plan and finish activities every day. Once the child understands that problem solving can be taught the same way that other academic subjects can, the child is ready to begin.
Problem solving can be overwhelming, but by using a step-by-step procedure, the child can learn to identify parts of the process and gain confidence practicing each of the steps. The overall goal is to teach the child how to work through a problem, using a planned approach instead of acting impulsively. By learning how to identify the steps that are part of the task demands, the child can learn to identify the goal (or problem), identify the required steps for accomplishing the task, and provide questions and labels that will guide the process in a systematic way. For example, let's look at the task of completing homework. Using Table 12.1 as a guide, we begin with the Goal stage of the process. When asked to identify the goal, the child responds, "I need to do my homework." The coach assists the child by asking for the goal in more specific terms—for example, "Exactly what homework do you have due tomorrow?" In step 2, the child is asked to identify the assignments that are due (Plan stage). The coach continues to guide the child by asking more specific questions. In step 3, the child is asked to list the materials needed to do the homework (for example, school agenda, the paper on which homework assignments are recorded, any take-home sheets to be completed, papers, pencils and any other materials necessary to do the task). In the initial stages of guiding the child, it is important to have the child make actual lists of the assignments and all materials needed. This way, the child can compare the actual list with what was needed in his review (steps 6 and 7). With a list of assignments and the necessary materials to perform the tasks at hand, the child is almost ready to enter the Do phase, but before he does, let's get him to predict how he thinks he will do on the task.
The prediction stage can help children with EF deficits to improve their concept of space, time, and future-oriented activities. Asking children to predict how well they will do and even asking how long they think it will take to complete the task can provide very interesting information for future coaching sessions based on the child's responses. Later in this chapter, we will discuss how prediction can be a helpful intervention for improving self-monitoring, self-evaluation, and self-awareness.
Steps 6 and 7 represent the actual Do stage of the task—in our example, completing homework. Here the child learns to self-monitor as he or she is working on the homework and to record any problems that occur. Did he have all the required materials? If not, did he have to start hunting for them before he started his assignments, or did he find out part way through that some materials were missing? Similarly, did he complete all the homework assignments? Possible reasons for not completing homework in specific areas might include running out of time, not understanding the questions, not bringing home the right books, and not writing down the correct information (for example, not writing down correct page numbers for the assignment). Each of these errors when discovered can provide a valuable lesson for future planning—that is, what the child can do in the future to ensure that the error does not recur.
In steps 8 and 9, children should rate themselves on their success for the assignment (in this example, homework) and compare it to the coach's rating to assist the children to improve self-monitoring in the future. It is very important for children to understand how they can do better next time, if they remember the lesson learned from what they did today.
Finally, steps 10 and 11 set the stage for incorporating flexibility and the ability to shift strategies when the current strategy is not working. For example, if the reason for not finishing math homework was because the child did not copy down the text pages, how could he or she have solved that problem? Could the child have called a friend to get the correct pages? Next time, the child will want to take more care in copying down assignment information, so that he or she can do a better job. A Homework Planning and Review Sheet is available in Table 12.2 to help the child in the initial stages of organizing the problem-solving approach. This sheet can be photocopied and used to help guide the child through the process.
We have devoted significant time in this chapter to the EF skills involved in problem solving because problem solving is complex and draws on so many different EF abilities. However, it is also important to be able to help a child who is struggling with a particular type of EF function and to that end, we provide interventions in a number of different areas that can be used at home and at school, as well as suggestions for how IEP or 504 Plans can incorporate these goals into a child's educational plan (Gioia, 2005)
In the next section, we will discuss a number of intervention plans that can be used to address specific tasks, including goal setting, planning, organization, and self-oriented tasks of monitoring, self-awareness, and self-initiating. Following a discussion of intervention strategies for each of these areas, we will provide examples of potential goals and objectives from these interventions, which can become part of the child's IEP or 504 Plan.
A Word of Caution About Success Predictions
Younger children and those with a limited success record may be prone to overestimating their success and may be frustrated or discouraged when they do not achieve their goals. For this reason, it may be best to postpone this phase until the child has gained a greater sense of confidence in his problem solving skills or to replace the competence question ("How well do you think you will do?") with a time-based question (for example, "How long do you think it will take you to finish all your homework correctly?"). It is important to add the word correctly to a time-based question, to discourage a child from rushing against the clock at the expense of accuracy.