Executive Function Treatment and Intervention in Schools

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Executive Function Treatment and Intervention inSchoolsTulio M. Otero a , Lauren A. Barker b & Jack A. Naglieri ca Clinical Psy.D. and School Psychology Programs, Chicago School of Professional Psychology ,Chicago , Illinoisb School of Education , Loyola University-Chicago , Chicago , Illinoisc Virginia Devereux Center for Resilient Children , University of Virginia , Fairfax , VirginiaPublished online: 10 Jul 2014.

To cite this article: Tulio M. Otero , Lauren A. Barker & Jack A. Naglieri (2014) Executive Function Treatment andIntervention in Schools, Applied Neuropsychology: Child, 3:3, 205-214

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Executive Function Treatment and Intervention in Schools

Tulio M. Otero

Clinical Psy.D. and School Psychology Programs, Chicago School ofProfessional Psychology, Chicago, Illinois

Lauren A. Barker

School of Education, Loyola University-Chicago, Chicago, Illinois

Jack A. Naglieri

Virginia Devereux Center for Resilient Children, University of Virginia, Fairfax, Virginia

This selective review article examines treatment and intervention strategies for executivefunction (EF) deficits within the school environment. We begin by providing a broad defi-nition of EF.We then examine the scope of EF deficits within the school setting and ident-ify profiles of special populations of students who present with such deficits. A focus isplaced on the developmental trajectory that both EF and the frontal lobes follow andhow this drives the selection and effectiveness of treatments and interventions at parti-cular ‘‘critical periods’’ throughout a child’s academic career. Direct and indirectschool-based diagnostic assessment methods to identify EF deficits in students will bebriefly reviewed. Against that background, various treatment methods and interventionstrategies to remediate both cognitive and affective EF deficits within the confines ofthe school setting will be presented. Individual and group intervention strategies will bepresented as will their current acceptance within the scientific community and applica-bility to the educational arena. The importance of incorporating school-based neuropsy-chological assessment methods that aid in the differential diagnosis of academic andbehavioral difficulties directly related to EF will also be discussed, as the accurate identi-fication of these impairments is necessary to facilitate data-based decision making whenselecting the most appropriate interventions following a developmental model ineducational settings. Topics addressing EF treatment modalities and research-based inter-ventions for clinical and school-based practitioners to consider within educational settingswill also be presented as suggestions for future research with pediatric populations.

Key words: development, education, executive function, intervention, schools, treatment

INTRODUCTION

Executive function (EF) is a broad, overarching termthat refers to a variety of cognitive processes largelymediated by the prefrontal areas of the frontal lobes that

encompass both cognitive and affective constructsincluding planning, working memory, attention, inhi-bition, self-monitoring, self-regulation, and initiation(Goldstein, Naglieri, Princiotta, & Otero, 2014). Thesemultidimensional cognitive constructs are necessaryfor goal-directed and problem-solving behavior in allaspects of life, whether academic, vocational, or social.From a neuroanatomical perspective, there is a distinc-tion between cognitive and affective EFs and their

Address correspondence to Tulio M. Otero, Clinical Psy.D. and

School Psychology Programs, Chicago School of Professional

Psychology, 325 N. Wells St., Chicago, IL 60654. E-mail: totero@

thechicagoschool.edu

APPLIED NEUROPSYCHOLOGY: CHILD, 3: 205–214, 2014

Copyright # Taylor & Francis Group, LLC

ISSN: 2162-2965 print=2162-2973 online

DOI: 10.1080/21622965.2014.897903

localization within the frontal lobes of the brain. Cogni-tive aspects of EF stem from the dorsolateral areas ofthe prefrontal cortex, while affective components canbe traced to the ventral and medial areas of this brainregion (Zelazo & Muller, 2011). Diamond (2012) pro-vides a broad definition of EF that is based on theneural circuitry of the prefrontal cortex, and identifiesthree widely accepted core components of EF—inhi-bition, working memory, and cognitive flexibility—which allow for the development of higher-order, com-plex EF constructs such as reasoning, planning, andproblem solving.

Success in various aspects of life is highly dependenton having intact EF abilities, especially within the edu-cational environment (Alloway & Alloway, 2010). EFdeficits in childhood have been shown to have a negativeimpact on academic, social-emotional, and adaptivefunctioning later in life, and they are present at all stagesthroughout development in children both with and with-out neurodevelopmental disorders. This has significantimplications for educational programming and inter-vention selection for both the general and special edu-cation populations within school systems; however, theresearch base for EF interventions with childrenand adolescents is limited. Among special populations,the most empirical evidence exists for students withattention-deficit hyperactivity disorder (ADHD),although research is steadily expanding to students withautism spectrum disorders (ASD), as well as with chil-dren with numerous other disorders of childhood,whether congenital or acquired. Riccio and Gomes(2013) point out that the extensive nature of EF deficitsamong all populations of school-aged children results ina critical need to begin developing and identifyingresearch-based interventions that target both globaland narrow aspects of EF.

HOW DO CHILDREN WITH EF DEFICITSPRESENT IN THE SCHOOL ENVIRONMENT?

EF deficits in the school environment can be cognitiveor affective in nature. Cognitive deficits often manifestas academic difficulties, while affective deficits are oftenviewed as behavioral problems. As mentioned pre-viously, EF deficits are present in both the general andspecial education population in the school setting.Students with EF deficits often present as disorganized,lack initiation, and can appear forgetful. These childrenfrequently engage in off-task behavior. They requirefrequent prompts and cues and will typically do betterwith a visual reminder when expected to do more thanone thing at a time, as they may experience working-memory problems. These types of difficulties can makenote taking, mental math, and completion of large

projects a challenge. Starting assignments is difficultfor these children, and they may be described as lazyor procrastinators. They may struggle with shiftingbetween activities and may perseverate on one task untilit is completed, regardless of whether or not the class ismoving on, which results in them missing out on newinformation. They have difficulty prioritizing importanttasks, as well as with time management and meetingdeadlines. Planning for the future is difficult; they tendto only focus on the immediate.

Behaviorally, these students likely struggle withresisting temptation, are impulsive, and do not thinkbefore they act. They could be described as not havinga filter and can exhibit extreme emotional lability andan inability to regulate their feelings, thus engaging inextreme actions that may result in disciplinary measuresas well reduced instructional time. These children typi-cally do not handle change or unexpected situations welland may not know how to react when a change in atypical routine occurs, which can lead to anxiety, anger,frustration, or giving up. Examples of classroom beha-vior that may accompany affective aspects of executivedysfunction include blurting out answers without wait-ing to be called on or interrupting someone who isspeaking. These children may begin working after hear-ing only the first part of instructions, resulting in themcompleting the task incorrectly. They have a largenumber of missing assignments. Their desks=lockers=backpacks are messy due to poor organizational skills.They frequently lose things and need to borrow schoolsupplies or other materials from others. These studentsare often referred to as lazy, unmotivated, and forgetful,and their behaviors are often regarded as deliberate anddefiant. They may not appear to be paying attention andfrequently get out of their seat or ask to leave the room,usually at inappropriate times. They struggle with socia-lly appropriate behavior, push limits, and make poorchoices, often times failing to apply acquired knowledgefrom previous experiences or consider future outcomesof their actions.

IDENTIFICATION OF EF DEFICITS IN THESCHOOL SETTING

The identification and assessment of EF deficits inschool-aged children can be conducted in several waysthat include both qualitative and quantitative methods.The multidimensional nature of EF requires the use ofvarious diverse methods of assessment that take intoaccount the fact that EF constructs such as responseinhibition, working memory, planning, and responsepreparation are independent in various ways (O’Brien,Dowell, Mostofsky, Denckla, & Mahone, 2010); how-ever, they are also interrelated, as evidenced through

206 OTERO, BARKER, & NAGLIERI

factor analysis, showing that many constructs ‘‘load’’on several EF factors (Miyake, Friedman, Rettinger,Shah, & Hegarty, 2001).

Qualitatively, behavioral observations of howstudents approach and complete a task, as well asanecdotal reports from teachers and related schoolpersonnel are often a precursor to a referral for a stan-dardized assessment of EF, which typically utilizes morequantitative methods of assessment. These quantitativemeasures, which are norm-referenced, reliable, andvalid, can be either direct (individually administeredassessments such as the Cognitive Assessment System,Second Edition [CAS-2], Delis-Kaplan Executive Func-tion System, NEPSY-II, Wisconsin Card-Sorting Test)or indirect (behavior rating scales or frequency measuressuch as the Comprehensive Executive Function Inven-tory or Behavior Rating Inventory of Executive Func-tion). Identification of EF deficits has traditionallyoccurred through neuropsychological assessments, typi-cally conducted by private clinicians whom parents orguardians have contracted independently. It has onlybeen in recent years that the availability and use of EFtests and rating scales have been infused into the schoolsetting. Traditionally, schools perform psychoeducationalevaluations that tend to look only at overall intelligence(‘‘g’’) within the cognitive domain of functioning.School districts typically conduct evaluations in whichthe referral question revolves around the determinationof eligibility for special education services under theIndividuals With Disabilities Education Act of 2004(IDEA-2004) guidelines; thus, traditional psychoeduca-tional evaluations typically attempt to answer the ques-tion of whether or not a child has a particular disabilityin 1 of the 13 identified categories. The answer to thatquestion is not black and white, however, when one con-siders the neurological development that is occurringthroughout childhood and adolescence. We know thatno area of the brain works in isolation; rather, it isa functional unit that is highly interconnected and worksin tandem with various cortical and subcortical regions(Luria, 1973). Perhaps the question multidisciplinaryteams should be asking is what processing deficits areresulting in the child having academic or behavioraldifficulties. We feel that there is a disconnect betweenthe framework for identification of disabilities underfederal guidelines and the type of comprehensiveevaluation that should be conducted that assesses allpsychological processes, including attention, memory,and EF. Currently, there is no IDEA-2004 category toidentify EF deficits (or attention or memory). This posesa significant problem for school teams, as we know thatEF deficits can affect multiple domains of functioning.Typically, we see EF deficits classified under the cate-gory of other health impairment based on a Diagnosticand Statistical Manual of Mental Disorders-5 diagnosis

of ADHD. EF deficits are more cognitive in nature;however, classification of a disability in this domainconsiders only the presentation of an intellectualdisability, which includes impairment in overall intel-lectual and adaptive functioning. Furthermore, someschool districts have moved away from cognitive test-ing unless considering eligibility for special educationservices under the intellectual disability category, andthey rely instead on a response-to-intervention model.In these cases, it becomes even more difficult todiscern if there are EF deficits present, other thanrelying on anecdotal information and behavioralobservations of the child.

CONSIDERATIONS FOR THE SELECTION OFTREATMENT METHODS AND

INTERVENTIONS IN THE SCHOOL SETTING

Regardless of the type of intervention being implemen-ted, certain commonalities exist regarding EF interven-tions. First, we acknowledge that the research base islimited within the pediatric population, and furtherresearch needs to be conducted that examines specificEF constructs and the efficacy of interventions designedto target deficits in particular areas throughout thedevelopmental course. Diamond (2012) outlines sixgeneral principles regarding EF training that must beconsidered when selecting EF interventions for children:

. Thosewhomostneed improvementbenefit themost.

. Transfer effects from EF training are narrow.

. EFs should be challenged throughout training (i.e.,demands must continue to increase to see effects).

. Repeated practice is key.

. Whether EF gains are produced depends on howan activity is done.

. Outcome measures must test the limits of thechildren’s EF abilities to see a benefit fromtraining.

Several factors must be considered before an inter-vention to target EF deficits is selected within the schoolsetting. The first thing to consider is the child’s age andcurrent level of developmental functioning. As describedpreviously, EF and a child’s brain both follow adevelopmental trajectory that parallel each other,with notable critical periods from infancy to youngadulthood. Research has also supported the notion thatcertain EF interventions work better for certain agegroups. Across the developmental lifespan, a significantamount of research has focused on the early childhoodpopulation (Diamond, 2012, in press; Diamond &Lee, 2011). This makes sense, as we know that morecomplex executive skills develop later in life and are

EF TREATMENT AND INTERVENTION IN SCHOOLS 207

built upon the development of three broad EFconstructs: inhibition, working memory, and cognitiveflexibility (Diamond, in press). Furthermore, certainneurodevelopmental disorders such as ADHD andASD tend to present with a specific profile of EF impair-ments and must be taken into consideration duringintervention selection. The efficacy of specific interven-tions with special populations should also be taken intoconsideration. Second, a careful review of the diagnosticinformation available to the multidisciplinary team isnecessary and should be comprehensive in nature.Evaluations we consider to be comprehensive addressall areas of suspected impairment across all relevantdomains of functioning, including EF. If there are notassessment data available that address EF (whetherqualitative or quantitative), further assessment may benecessary to ensure that interventions are being carefullyselected based on an accurate differential diagnosis.Ideally, this should be done through the use of bothquantitative and qualitative assessment, preferably usingstandardized assessments that are reliable and valid.Tasks that measure EF should be relatively unfamiliarso that a child has to develop a way to solve the prob-lem. These tasks should also call for self-monitoringand error correction, could involve selective attentionin settings where a highly learned response has to beinhibited, and should draw upon methods of workingwith information that needs to be remembered duringa short period of time.

Based on what we know about the limited generali-zation of most EF interventions, accurate diagnosismust drive intervention selection; otherwise, the childwill not respond and critical developmental time willbe wasted, with deficits likely increasing with age andnegatively impacting the child’s ability to develophigher-order EF skills (Diamond, in press). Schoolpersonnel also need to consider demographic, cultural,and other environmental factors to determine if the childexhibits a pattern of strengths and weaknesses acrosssettings, and they should use this information whendesigning treatment plans, as interventions that focuson a child’s strengths and involve the support of thefamily are often more successful. Finally, school person-nel must answer the question of what is feasible toimplement within the confines of the educationalenvironment. Several evidence-based treatments areconsidered medical by nature and typically fall outsideof the scope of the school setting. Financial constraintsof interventions must also be considered, as schoolsare continuously faced with reduced budgets and limitedresources. Fortunately, a variety of approaches areavailable for both individual children and groupsthat we believe are capable of addressing both cognitiveand affective aspects of EF within the school environ-ment within these confines.

TREATMENT METHODS AND INTERVENTIONSTRATEGIES

Treatments Outside of the Scope of the SchoolSetting

Some intervention methods, such as psychopharmo-cology and neurofeedback treatment, are outside ofthe scope of the local education agency as they are con-sidered medical and must be initiated by a parent orphysician. We feel it is important to point out these twooptions; however, understanding their influence andpotential impact on outcome is critical when developinga comprehensive treatment plan to be implemented inthe school setting, as well as considering the effective-ness of school-based interventions. Certainly, psycho-tropic medications introduce an x-variable factor thatmust be considered when evaluating program effective-ness; it becomes impossible to discern if positive effectsare a result of an intervention or rather are madepossible by the stabilization of functioning that theindividual receives from the effects of a pharmacologicalintervention. Additionally, as practicing professionals,we have often been asked by parents, teachers, adminis-trators, and various other stakeholders what otherresources or referrals we can provide outside of theschool setting. Knowledge of the efficacy of psychophar-macological interventions and neurofeedback is essen-tial for consultation with parents and for providingadditional resources and referrals to families or otherprofessionals who desire additional information orsupport.

Computerized Training

With the ever-increasing role technology plays in societytoday, it is not surprising that computerized approachesare currently one of the prominent modalities for EFintervention. Computerized training of EF typicallytargets working memory and=or attention, althoughcertain approaches have also attempted to addressdeficits in inhibition, albeit with less success (Thorell,Lindqvist, Bergman Nutley, Bohlin, & Klingberg,2009). These types of interventions use repeated practiceand reinforcement in attempts to produce structuralchanges in the brain, thus improving workingmemory=EF (Klingberg et al., 2005). It is hypothesizedthat cognitive training results in increased or decreasedactivation in the various neuroanatomical locationsinvolved in task performance; it may also producea functional reorganization of brain activity, which isdefined as the combination of increased and decreasedlevels of activation across multiple brain areas. Redistri-bution refers to the change in patterns of brain activitywithin the same neuroanatomical locations before and

after working-memory training, which leads to increasedefficiency of specific cognitive-processing tasks whilereducing the demands on attention. Reorganizationrefers to the activation of new brain areas followingcognitive training and is assumed to lead to a qualitativechange in the processes used to solve the trained task(Kelly & Garavan, 2005).

Computerized programs have the greatest treatmentintegrity of all intervention strategies described as theyremove the chance of human error in implementationand allow for the accurate and precise measurement ofmultiple behaviors that are beyond the scope of a singleexaminer (i.e., reaction times, latency, impulsiveresponding). Computerized training approaches can beimplemented individually or through group processes;however, for our purposes, we will focus on the groupintervention approach, which is more conducive to theeducational environment. Within the school setting,computerized EF interventions implemented within agroup setting are appealing, as they reduce the needfor additional resources such as increased personnel,quickly provide rich data with minimal effort on thepart of the interventionist, and monitor and continu-ously adapt the difficulty of the task based on the child’sperformance on a given trial. Multiple research studieshave also examined the efficacy of computerized appro-aches implemented within the school setting amongstudents with various neurodevelopmental disorders,including students with ADHD (Klingberg et al., 2005;van der Donk, Hiemstra-Beernink, Tjeenk-Kalff, vander Leij, & Lindauer, 2013), fetal alcohol syndrome(Kerns,Macsween, VanderWekken, &Gruppuso, 2010),and very low birth weight (Grunewaldt, Løhaugen,Austeng, Brubakk, & Skranes, 2013).

Although computerized training approaches arebecoming more commercially available and fairly easyto implement in a school setting, research conductedon the efficacy of these interventions and the transferof skills to other cognitive-processing tasks has pre-sented with mixed results. Wong, He, and Chan (2013)found significant improvements in working memorywhen they examined the effects of high-intensity compu-terized training provided in a group modality within theschool setting among children with working-memorydifficulties in China. In a sample of 100 children,Bergman Nutley et al. (2011) found that computerizedtraining of working memory led to improvementsin working memory with 4-year-olds but that theseskills did not generalize to nonverbal reasoning tasks.Transfer effects are narrow among EF constructs;computerized training aimed at improving workingmemory may yield improvements within that specificarea of EF but not others, such as inhibition or speedand efficiency of cognitive processing (Diamond &Lee, 2011). Imaging studies of visual and auditory

working memory provide behavioral and functionaldata that provide a possible explanation for thesenarrow transfer effects in visual and auditory processingfollowing working-memory training (Schneiders, Opitz,Krick, & Mecklinger, 2011; Schneiders et al., 2012).We know that as the brain becomes more efficient, itrequires less energy to perform specific tasks. Schneidersand colleagues (2012) demonstrated how auditoryadaptive working-memory training resulted in reducedbrain activity in the right inferior frontal gyrus whenpresented with an auditory task following training, butthese results were not seen in a visual task, indicatingthat the training was effective within a specific modality(auditory) and suggesting that the brain became moreefficient as a result of the training.

Melby-Lervag and Hulme (2013) conducted a meta-analysis of computerized working-memory trainingprograms and concluded that there is no convincingevidence of the generalization of efficacy to othercognitive constructs, including nonverbal and verbalability, inhibitory processes in attention, or academicfunctioning (reading decoding or arithmetic). Resultsof this meta-analysis implied that computerizedworking-memory training programs appear to produceshort-term, specific training effects at best that do notgeneralize among the multitude of cognitive constructsthat are classified as EF. Results also indicatedthat effects are not sustained on follow-up measures.Computerized approaches also present a financialconsideration, which is an important factor that publiceducation systems must take into account when makingsystems-level decisions to select interventions andprograms designed to target global skill deficits amongmany populations of students. These approaches relyheavily on technology and typically require licenses thatare sold per student. Furthermore, the number ofsessions required to see improvement requires intensivetraining almost daily during a short period of time(approximately 5 weeks); to provide the interventionservices on a less frequent basis (such as two to threetimes per week), the length of intervention time dramati-cally increases to several months.

Strategy Instruction

Luke (2006) defined strategy instruction as a student-centered approach that supplies struggling learners withtools and techniques to understand and learn newmaterial or skills while allowing for the direct andimmediate application to practice in various areas ofschool and life. Meltzer, Pollica, and Barzillai (2007)indicated that interventions to address EF deficits withinthe classroom should include direct instruction ofmetacognitive strategies and that strategy instructionmust be linked to the curriculum and taught in

a structured, systematic way. Teachers should useinstructional methods that incorporate scaffolding andmodeling techniques and allow students ample time forpractice. Meltzer and colleagues also pointed out thatthe student’s motivation and self-understanding shouldbe considered to best ensure effective use and generali-zation of strategies. Traditionally, older children andadolescents benefit more from strategy instruction thando younger children (Young & Amarasinghe, 2010).

Strategy instruction is global by nature and targetsa constellation of cognitive-processing abilities, includ-ing EF skills that are necessary to be successful inmultiple settings. Strategy instruction is ideal for usein the schools, as we are teaching students lifelong skillsthat can be generalized to problem-solve difficultiesacross many domains of life. By teaching students effec-tive strategy use, we are also making them part of theprocess; children and adolescents need to understandtheir own cognitive strengths and weaknesses and needto become part of the solution to remediate deficits.When children understand their own learning styles,they will gain a better understanding over time of whatis easy and what is hard for them, and they will identifywhat situations require the use of strategies. There arealso implications for social-emotional development;children who continuously fail tend to internalize andeventually believe they cannot do something. When weprovide a child with a strategy, we are identifying thatalthough they may experience difficulty in a particulararea, they can take control of the situation and usea variety of tools to take control of the situation, thusresulting in the child feeling empowered, positive, andhaving a sense of control over the situation. We hypothe-size that taking such a proactive approach could result inimproved functioning not only in affective processes, butacross multiple neuropsychological domains as well.

Strategy instruction is a preferred approach overbehavioral interventions targeting EF deficits becausenot only do we help the child understand their weak-nesses, but we also give them the tools to help remediatethose deficits. Unlike behavioral approaches, strategyinstruction targets cognitive processes. Many educatorsfeel the need to ‘‘be the child’s frontal lobe’’ to assistthem with EF deficits. We propose this is not the bestsolution because in these cases, what we are actuallydoing is removing the accountability from the child bydoing for them. When we are the ones providing thestructure, engaging the student in the intervention, andreinforcing their performance, we assume control overthe intervention and the child is not part of the solution.The benefits of strategy instruction also appear to gener-alize to academic achievement. Iseman and Naglieri(2011) examined the effectiveness of brief cognitivestrategy instruction to encourage the development andapplication of effective planning for mathematical

computation based on the Planning, Attention, Simul-taneous, and Successive processing (PASS) theoreticalframework of processing with students with ADHD.Their study showed large pre–post effect sizes forstudents in the experimental group but not the com-parison group; furthermore, at 1 year postintervention,the experimental group continued to outperform thecomparison group. These results not only demonstratedfar transfer effects, but results were evident in the longterm; in this case, improvement was still present 1 yearpost-PASS-based cognitive strategy instruction. Haddadet al. (2003) found similar findings in the area of readingcomprehension with fourth-grade students with above-average overall cognitive ability.

Teaching students how to use strategies is notdifficult within the school environment as this methodcan be easily infused into instructional methods. Whenprovided with a specific structure to do this, the processbecomes much easier as well as empirically based. Oneway of doing this is through the provision of handoutsfor parents and teachers describing evidence-basedinterventions, such as those presented by Naglieri andPickering (2010). Their collection of interventions alsoprovides handouts for the child—thus making them partof the solution—and they are also available in Spanish.Educators will find the handouts for planning andattention have significant relevance for students withEF deficits; these interventions are also specific forvarious areas of academic achievement. This is impor-tant, as certain EF constructs have different presentationsdepending on the academic subject area. For example,researchers at the University of Kansas have conductedconsiderable research during the last 30 years on the useof strategy instruction and adolescent literacy. Theirmethod, the strategic instruction model (SIM), teachesstrategies and promotes strategic behavior for adolescentswith difficulties in reading and written expression, whilemaking the student an active participant in decidingwhich strategies they will learn and utilize across settings.SIM encompasses both teacher- and student-focusedinterventions, as well as assists students in becomingan advocate for themselves, developing appropriate socialskills, and setting goals for the future.

Curricula

The vast majority of the scientific literature describingthe effects of school curricula targeting EF deficits hasfocused on young children with an emphasis ondeveloping inhibitory skills. Tools of the Mind and theMontessori approach are considered standalone appro-aches, while Promoting Alternative Thinking Strategiesand the Chicago School Readiness Project are con-sidered supplementary add-ons to existing curricula.Diamond and colleagues have written substantially on

these programs, and readers are referred to their work(Diamond, 2012; Diamond, Barnett, Thomas, &Munro,2007; Diamond & Lee, 2011) for a comprehensivereview.

Only one curriculum to target EF skills across theentire K–12 spectrum currently exists to our knowledge.The Educational Services Department of the RushNeuroBehavioral Center (RNBC) has developedan EF Curriculum series (Bozeday, Gidaspow, Minton,& Smith 2010), which consists of a primary curriculum(kindergarten through 2nd grade), an intermediatecurriculum (3rd through 5th grades), a middle schoolcurriculum (6th through 8th grade) and a high schoolcurriculum (9th through 12th grade), utilizing a research-based framework combined with a classroom-basedorientation. The RNBC EF Program identifies thefollowing EF constructs as important for classroominstruction: self-regulation, self-awareness, goal-directedbehavior, self-monitoring, and flexibility to solve prob-lems and revise plans. The curriculum puts a heavyfocus on the use of a specially designed academicplanner that helps students maintain consistent time-management and planning skills. The planner includestools that children can use to develop study plans, setgoals, and develop action plans. Leon (2008) conductedan independent evaluation of the RNBC EF Programbeing implemented in four Chicago public schools.Findings from this review indicated that students whoperformed well in the EF Program had a higher rateof homework completion and earned higher grades, asmeasured in the subjects of math and reading. Further-more, the curriculum also appeared to impact studentperformance on standardized assessment; outcome datademonstrated that students using the curriculum in thefall demonstrated higher spring scores on the ReadingFirst and Illinois Standards Achievement Test (ISAT)reading exams, when controlling for grade, teacherratings of student academic achievement, and priorReading First or ISAT test scores. Finally, students,families, and school personnel appeared pleased withthe curriculum, and students exhibited strong buy-inas demonstrated by their adherence to the program,across ages and schools. Poulose (2012) investigatedthe changes in EFs in special education students whowere enrolled in an academic resource class for oneperiod per school day. Although this study did not finda significant difference in ratings of EF after programimplementation, all of the students’ mean grades werewithin the passing range for the first and second gradingperiods. It is important to note that at the time of datacollection, the entire curriculum had not been imple-mented, archival data were used to collect baseline infor-mation, and the tool used to measure EF in this studywas not standardized or norm-referenced. Nonetheless,generalization to academic performance as measured by

grades is promising. This study reinforces the need forfuture research using stricter methodology to examinethe effectiveness of this curriculum across the four agelevels for which it is designed.

Mindfulness and Physical Activities

Within the scientific community, multiple definitionsof mindfulness have emerged over time. Bishop et al.(2004) proposed a two-component operational definitionof mindfulness, which involves the self-regulation ofattention and adoption of a particular orientation towardone’s experiences in the present moment. Mindfulnessand physical activities that can positively impact EFsin children include meditation, martial arts, yoga, andaerobics, and they require repetition and continuedpractice to gain maximum benefits. Practicing mind-fulness activities can have positive impacts on both physi-cal and mental health (Davidson et al., 2003). Althoughmindfulness and physical activity have been found to beeffective with adults, there is a lack of empirical researchon the effectiveness of these approaches in pediatricpopulations. The following studies indicate the needfor future research on these practices and their abilityto generalize to improved cognition with children andadolescents, as we feel these are promising avenues thatcan be implemented at little to no cost in the school setting.

Through the use of functional magnetic resonanceimaging, Short et al. (2007) found that extensive medi-tation training heightened activation in executive atten-tion networks that correlated with improvements insustained attention as well as with error monitoring,thus promoting higher-order cognitive processing.Zeidan, Johnson, Diamond, David, and Goolkasian(2010) found that brief meditation training providedduring 4 days reduced fatigue and anxiety and increasedmindfulness in a sample of college students; participantsin the sample also demonstrated significantly improvedvisuospatial processing, working memory, and executive-functioning abilities. Their findings also suggested thatbrief training could enhance the ability to sustainattention.

Martial arts emphasizes effort and determination morethan innate physical ability. Progress is based on personalachievement, rather than comparing how childrenmeasure up to peers. Lakes and Hoyt (2004) implementeda 3-month school-based taekwondo intervention usingthe Leadership Education Through Athletic Develop-ment (LEAD) curriculum to evaluate cognitive, affective,and physical self-regulatory behaviors in students inkindergarten through Grade 5. To facilitate self-monitoring and self-regulation skills, students wereinstructed to ask themselves: (a) ‘‘Where am I?’’ (helps childto orient to context); (b) ‘‘What am I doing?’’ and (c) ‘‘Whatshould I be doing?’’ (select target behavior, compare it

to current behavior, and prepare to modify behavior).Children then had to make a decision to modify theirthoughts and behavior to be aligned with the expectedbehavior. The LEAD curriculum also uses incrementalincreases in the level of challenge and reward for achiev-ing higher levels of competence, which is a necessarycomponent of EF training (Diamond, 2012). Results ofthis study indicated that students participating in themartial arts group demonstrated greater improvementsin areas of cognitive and affective self-regulation,prosocial behavior, classroom conduct, and performanceon a mental math test. Boys demonstrated better resultsthan girls, which supports the current literature regard-ing the prevalence of attention and conduct problemsin boys (Arnold, 1997); this intervention may leadto improved school behaviors for boys who exhibitdifficulties in these areas.

Gothe, Pontifex, Hillman, and McAuley (2013) foundthat college women who participated in yoga practiceand aerobics demonstrated shorter reaction times andincreased accuracy on inhibition and working-memorytasks following the yoga activities. Although their studydid not show significant improvement of EFs followingaerobic exercise, other research has demonstrated someeffects with acute physical activity, including aerobics.Verbaugh, Konigs, Scherder, and Oosterlaan (2013)conducted a meta-analysis on the effects of physicalexercise on EFs in preadolescent children (6–12 years ofage), adolescents (13–17 years of age), and young adults(18–35 years of age) and found that acute physicalexercise, such as aerobics, enhanced EF, regardless ofage group. Davis et al. (2007) tested the effects of aerobicexercise on EF in overweight children aged 7 to 9 yearsold. They found that Planning scores on the CAS weresignificantly greater for the group of children whoparticipated in the high-dosage aerobics condition,suggesting that exercise may be a simple way to enhancechildren’s cognitive functioning. This has importantimplications for academics as well, as the PlanningScale of the CAS has been linked to achievement(Naglieri & Rojahn, 2004). Diamond (2012) suggeststhat exercise alone may be less effective in improvingchildren’s EFs than activities that combined exerciseand mindfulness, such as martial arts or yoga.

Traditional childhood games can also help improveEFs in children and are easy to implement in the schoolsetting, particularly during physical education classes orrecess. These informal EF interventions are best suitedfor preschool-aged and early elementary-aged students.Yeager and Yeager (2013) described how gamessuch as ‘‘Mother May I?,’’ ‘‘Simon Says,’’ ‘‘Red Light,Green Light.’’ ‘‘Freeze Tag,’’ and ‘‘Statues’’ help aid

in the development of working memory and responseinhibition. Some of the games listed involve bothEF constructs (‘‘Mother May I?,’’ ‘‘Simon Says,’’‘‘Statues’’), while the others tend to exercise only inhi-bitory skills. For example, in ‘‘Simon Says,’’ workingmemory is necessary to remember to only respond tocommands that are followed by the words ‘‘Simonsays,’’ as well as to keep the rules of the game in mindand then act appropriately. Children must also exertinhibitory skills to resist distractors presented by theleaders; in this particular case, these are the commandsthat are not preceded by the words ‘‘Simon says.’’ Thedevelopment of EF through shared activities with peersis an enjoyable, low-cost way for students and schoolsto aid in the development of EF.

FUTURE DIRECTIONS FOR THESCHOOL SETTING

This selective review article has discussed various treat-ment methods and intervention strategies to remediateboth cognitive and affective EF deficits within theconfines of the school setting. Within the scientificcommunity, it is clear that the empirical evidence forthe majority of approaches described herein is limitedand results in the need for future research with childrenin school settings. It is also clear that certain approachesmay prove to be more effective than others dependingon the developmental level of the child. Research aimedat determining the best EF intervention approachaligned with the child’s developmental trajectory ismuch needed to make appropriate intervention selectiondeterminations. When determining interventions, diag-nostic assessment of EF must drive treatment selection,which is somewhat problematic within the school settingat this time. Traditionally, neuropsychological assess-ment is not conducted in school-based psychologicalevaluations. Although the addition of rating scalesdesigned to measure EF has become more prominentduring the past decade, direct assessment of EF is notcommonplace. This has serious implications for school-based practitioners, as under current federal guidelines,students must be assessed in all domains of functioningto assess for learning difficulties, including EF. There isa large disconnect between the federal legislation and thedomain areas typically used to classify students withdisabilities educationally, and EF deficits do not fit‘‘neatly’’ into any of the current 13 eligibility categories.This was illustrated in the Supreme Court case, ForestGrove v. T.A., in which the Supreme Court ruledthat the multidisciplinary team had not identified T.A.’s disability in part because of a limited psycho-educational evaluation that did not assess him in ‘‘allareas of suspected disability,’’ which is a requirement

of IDEA-2004. Dixon, Eusebio, Turton, Wright, andHale (2011) provide a detailed analysis of this case,which supports the need for school-based teams toinclude psychological processes such as attention, mem-ory, and EF as part of comprehensive evaluations.

Several intervention strategies are typically outside ofthe scope of the public education system, thus limitingtheir access in the school settings. School districts maywish to consider these options in the future, as interven-tions such as psychopharmacology and neurofeedbackare on the rise and have been found to be effective, parti-cularly with special populations, such as children withADHD. In the future, schools may find it wise to con-sult with medical practitioners and perhaps consider=providing families with referrals to outside service provi-ders. Neurofeedback is an intervention that could beimplemented in the school setting, as evidenced byDarling (2007). Schools must also consider financialconstraints when selecting interventions. Strategyinstruction and mind=body approaches are both inter-ventions that can be implemented in the school settingat little to no cost. Physical activities are highly appeal-ing, especially considering the epidemic rates of obesityand other health-related issues with which today’s chil-dren are faced. Mind=body activities can also helpreduce stress in students, thus allowing for more ideallearning environments. Schools must pay attention tothese factors when making decisions about whatprograms=classes need to be cut out of a school day.In an era driven highly by ‘‘high-stakes’’ testing, it isoften these types of activities that are deemed irrelevant.We feel that a lesser focus should be placed on ‘‘output’’(i.e., grades, scores) and instead more focus should beplaced on how the child is functioning as a whole. Thistype of whole-body approach targets all areas of a child’sfunctioning, including affective domains, which areneeded for effective learning to take place. Computer-ized training and curricular approaches have also beenfound to be effective with certain groups of children withEF deficits; however, they typically require the school toadopt these approaches in one way or another. Further-more, there is also a concern with resources as bothapproaches require a significant financial or staff trainingrequirement to implement. It is clear that the researchbase for EF interventions in schools is in its infancy,and future studies should include factors that lookat generalization and optimal developmental periods toachieve maximum effectiveness.

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Executive Function Treatment and Intervention in Schools

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Transcript of Executive Function Treatment and Intervention in Schools

ZONAL INTERVENTION PROJECTS

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