new perspectives on adhd handout

New Perspectives on Educating Children with ADHD: Contributions of the Executive Functions

Gerard A. Gioia & Peter K. Isquith

Article re-printed with permission of the Journal of Healthcare Law and Policy published by theUniversity of Maryland School of Law.

Reference: Gerard A. Gioia & Peter K. Isquith, New Perspectives on Educating Children with ADHD:Contributions of the Executive Functions, 5 J. Health Care L. & Pol'y 124 (2002).

IntroductionMany children with the diagnosis of

Attention-Deficit/Hyperactivity Disorder(ADHD) experience significant adverse effectsin their learning and educational performance.Several intervention mechanisms currently existfor assisting students with these needs includinginformal classroom accommodations, behaviormanagement programming, development andmore explicit implementation of classroomaccommodations via a 504 plan, andidentification of an educational handicappingcondition (typically Other Health Impaired) toreceive special education services. Effectiveinterventions require full and explicitidentification of the child's educationallyrelevant strengths and weaknesses. With theincreasing appreciation and definition of theexecutive functions as the underyling functionalbasis of the ADHD symptom clusters,appropriate educational programming forstudents with ADHD necessitates considerationof the inherent executive dysfunction. Thepresent paper is structured into four sections indeveloping an argument for explicit recognitionand inclusion of executive dysfunction in theeducational programming of students diagnosedwith ADHD. First, we define the clinicalsyndrome of ADHD including a brief review ofits evolutionary history. Definition of thedisorder, subtypes of the syndrome, severity ofits symptoms, and epidemiology are discussed.We next define the construct of executivefunction, including its behavioral manifestation,neurological underpinnings, and developmentalissues. This area of functioning has gained

significantly greater definition and recognitionin terms of its impact within a host ofdevelopmental and acquired neurologicaldisorders including ADHD. Third, therelationship between executive dysfunction andADHD is explored in terms of currenttheoretical models and recent work conductedby the authors. The traditional triad ofsymptoms that comprise the diagnosis of ADHD(i.e., inattention, impulsivity, hyperactivity) isnot sufficient to fully describe the treatablesymptoms. We demonstrate how executivefunction adds significantly to the functionaldescription of the disorder. Finally, with thegroundwork laid regarding executive functionand ADHD, we turn our attention to a model ofeducational programming including specificstrategies and recommendations for addressingvarious types of executive dysfunction. Thisintervention model acknowledges the uniqueaspects of executive function and proposes anapproach that necessarily takes the child and hisenvironment into account.

The disorder of ADHD is not a unitaryphenomenon. Although a set of commoncharacteristics may exist within the diagnosis,significant variability also exists betweenindividuals. In addition to differing levels ofseverity and subtypes, a variety ofenvironmental factors may affect themanifestation of disability in the child andeducational impact. Differing teacher andclassroom characteristics may ameliorate orexacerbate functional problems. Differentdevelopmental stages, e.g., the needs of theelementary student as compared to the high

ADHD New Perspectives 2

school student, call for different interventionapproaches. Thus, in designing an educationalintervention plan, one must consider both thegeneral and the unique characteristics of ADHDfor the specific student at hand.An Overview of ADHDDefinition of ADHD

Attention-Deficit/Hyperactivity Disorder(ADHD) is the most common psychiatricdisorder of childhood and is one of the mostprevalent chronic health conditions affectingschool-aged children1. The characteristicsymptoms include developmentallyinappropriate levels of inattention and mayinclude impulsivity and/or hyperactivity.Current diagnostic criteria require that thesesymptoms begin in childhood (by the age of 7years), occur across settings such as home andschool, cause functional impairment, and cannotbe attributed primarily to another disorder suchas depression or anxiety2. Typically, functionaldifficulties present in school in the form of pooracademic performance3. ADHD also isimplicated in problematic family and peerrelationships4.

Three subtypes of ADHD are defined bythe Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition5: Predominantlyinattentive type (ADHD-I), predominantlyhyperactive/impulsive type (ADHD-HI), andcombined type (ADHD-C). Each subtype isidentified by the number of criteria met withinits category: A child who exhibits 6 of 9

1 American Academy of Pediatrics (2000). Clinicalpractice guideline: diagnosis and evaluation of the childwith attention-deficit/hyperactivity disorder. Pediatrics,105.2 American Psychiatric Association (1994). Diagnosticand Statistical Manual of Mental Disorders, FourthEdition.3Zentall SS. Research on the educational implications ofattention deficit hyperactivity disorder. Exceptional Child.1993;60:143-1534 Schachar R, Taylor E, Wieselberg MB, Ghorley G,Rutter M. Changes in family functioning and relationshipsin children who respond to methylphenidate . J Am AcadChild Adolesc Psychiatry. 1987;26:728-7325 same APA as #2

possible symptoms of inattention but not 6 of 9symptoms of hyperactivity and impulsivitywould by diagnosed with ADHD-I, a child whoexhibits 6 of 9 hyperactive/ impulsive symptomsbut not inattentive symptoms would bediagnosed with ADHD-HI, and a child whoexhibits 6 of each symptom category wouldmeet criteria for the combined type of ADHD.The current DSM-IV diagnostic criteria forADHD and its subtypes are as follows6:A. Either (1) or (2)

(1) 6 (or more) of the following symptomsof inattention have persisted for at least6 months to a degree that is maladaptiveand inconsistent with developmentallevelInattention(a)Often fails to give close attention to

details or makes careless mistakes inschoolwork, work, or other activities

(b) Often has difficulty sustainingattention in tasks or play activities

(c) Often does not seem to listen whenspoken to directly

(d) Often does not follow through oninstructions and fails to finishschoolwork, chores, or duties in theworkplace (not due to oppositionalbehavior or failure to understandinstructions)

(e) Often has difficulty organizing tasksand activities

(f) Often avoids, dislikes, or is reluctantto engage in tasks that requiresustained mental effort (such asschoolwork or homework)

(g) Often loses things necessary for tasksor activities (e.g., toys, schoolassignments, pencils, books, or tools)

(h) Is often easily distracted byextraneous stimuli

6 same as #2 and #6 ( American Psychiatric Association:Diagnostic and Statistical Manual of Mental Disorders,4th ed. Washington, DC, American PsychiatricAssociation, 1994.)


(i) Is often forgetful in daily activities(2) 6 (or more) of the following symptoms

of hyperactivity-impulsivity havepersisted for at least 6 months to adegree that is maladaptive andinconsistent with developmental levelHyperactivity(a) Often fidgets with hands or feet or

squirms in seat(b) Often leaves seat in classroom or in

other situations in which remainingseated is expected

(c) Often runs about or climbsexcessively in situations in which it isinappropriate (in adolescents oradults, may be limited to subjectivefeelings of restlessness)

(d) Often has difficulty playing orengaging in leisure activities quietly

(e) Is often on the go or often acts as ifdriven by a motor

(f) Often talks excessivelyImpulsivity(g) Often blurts out answers before

questions have been completed(h) Often has difficulty awaiting turn(i) Often interrupts or intrudes on others

(e.g., butts into conversations orgames)

B. Some hyperactive-impulsive or inattentivesymptoms that caused impairment werepresent before age 7 years

C. Some impairment from the symptoms ispresent > 2 settings (e.g., at school or workand at home)

D. There must be clear evidence of clinicallysignificant impairment in social, academic, oroccupational functioning

E. The symptoms do not occur exclusivelyduring the course of a pervasivedevelopmental disorder, schizophrenia, orother psychotic disorder and are not betteraccounted for by another mental disorder(e.g., mood disorder, anxiety disorder,dissociative disorder, or a personalitydisorder)

Code based on type:314.01 Attention-Deficit/Hyperactivity

Disorder, Combined type: If bothcriteria A1 and A2 are met for the past 6months

314.00 Attention-Deficit/HyperactivityDisorder, Predominantly InattentiveType: If criterion A1 is met but criterionA2 is not met for the past 6 months

314.01 Attention-Deficit/HyperactivityDisorder, Predominantly Hyperactive-Impulse Type: If criterion A2 is met butcriterion A1 is not met for the past 6months

EpidemiologyAlthough estimates vary from a low of

2% to a high of some 10 to 12% of thepopulation, the generally accepted incidencerate is 3 to 5%7. Differences in estimates arethought to reflect different methodologies acrossstudies, the changing diagnostic criteria forADHD, and various sampling methods (e.g.,clinically referred samples versus non-referredsamples)8. More boys than girls are identifiedas meeting the diagnostic criteria for ADHD,with an approximate 6 to 1 ratio in clinicallyreferred samples and an approximate 3 to 1 ratioin non-referred samples9. ADHD is frequentlyseen along with other disorders, includingOppositional Defiant Disorder (ODD), ConductDisorder (CD), anxiety disorders, depression,learning disabilities (LD), and speech andlanguage disorders10. Among childrendiagnosed with ADHD, 40 to 70 percent are

7 same as #2,6 APA, 19948 Szatmari P: The epidemiology of attention-deficithyperactivity disorders. Child Adolesc Psychiatr ClinNorth Am 1992; 1:361-371; Bauermeister JJ, Canino G,Bird H: Epidemiology of disruptive behavior disorders.Child and Adolescent Psychiatric Clinics of NorthAmerican, 1994; 3:177-194.9 Schweitzer, J. B., Cummins, T.K., & Kant, C.A. (2001)Advances in the pathophysiology and treatment ofpsychiatric disorders: Implications for internal medicine.Attention-Deficit/Hyperactivity Disorder. Medical Clinicsof North America, 85.10 See Tasman 1997: Psychiatry, 1st ed., W. B. SaundersCompany for a review


also diagnosed with either ODD or CD, 15 to 20percent with mood disorders (e.g., BipolarAffective Disorder, depressive disorders), 20 to25 percent with anxiety disorders, and 6 to 20percent with LD. ADHD is also seen frequentlyin the context of Tourette’s disorder and majordevelopmental disabilities, such as MentalRetardation and Autism.An Historical Perspective

The clinical picture currently labeledADHD has been described for a century, withthe earliest systematic study in 190211. Stilldescribed a group of children that, today, wouldlikely meet criteria for ADHD as having a“defect in moral control” and a “deficit involitional inhibition” referring to an inhibitorycontrol deficit resulting in an inability toregulate behavior12. Later, a behavioralsimilarity to children with brain injury resultedin the diagnostic label “minimal braindamage”13. The label was changed in the1950’s and 1960’s to “minimal braindysfunction,” reflecting the presumption of aneurologically-based deficit in the face oflimited or no evidence of brain damage in mostcases. The increasing recognition ofhyperactivity as a symptom of “minimal braindysfunction” in the 1960’s again altered thediagnostic label to “hyperkinetic reaction ofchildhood”14 which included the first diagnosticconsideration of inattention, hyperactivity anddistractibility. With the publication of DSM-III15, the label “Attention Deficit Disorder” wascoined and subtyping became possible:Clinicians could indicate a diagnosis of ADDwith or without hyperactivity. With the firstrevision of DSM-III, the subtyping distinctionwas eliminated and the diagnostic label changedto the current Attention-Deficit/Hyperactivity

11 Still, GF(1902) Some abnormal psychical conditions inchildren. Lancet 1:1008.12 Mercugliano, M., 1999, What is Attention-Deficit/Hyperactivity Disorder. Pediatric Clinics of NorthAmerica, 46, 831 – 843.13 Strauss & Lehtinen, 194714 American Psychiatric Association, 19?? DSM-II15 APA 198 DSM-III

Disorder16. Finally, in 1994 with thepublication of DSM-IV17, the label remained thesame but subtypes were again included in thediagnostic scheme to reflect the broad variationin children with attentional disorders.A Current Perspective

A recent National Institutes of HealthConsensus Development Conference18 reviewedthe extant literature on ADHD and offeredseveral impressions: 1) ADHD is a commonlydiagnosed behavioral disorder of childhood thatrepresents a major public health problem withfar reaching and profound effects; 2) Despiteprogress in the assessment, diagnosis, andtreatment of ADHD, the disorder and itstreatment have remained controversial in manypublic and private sectors; 3) The validity ofADHD as a disorder is supported, althoughthere is no “test” of ADHD; 4) Cost barriers,inadequate diagnosis and treatment of ADHD,and the lack of integration of medical andeducational services represent considerablelong-term costs for society. Finally, theconsensus conference participants lamented thatthe causes of ADHD remain speculative andthat no strategies for prevention existDefining the Executive functions

Although the construct of executivefunction has gained a central position inneuropsychology over the past 15-20 years19, itsunderstanding and inclusion within the field ofeducation has lagged behind. In a recentsurvey20, psychologists in school and clinicalsettings were asked about their knowledge of

16 APA DSM-III-R17 APA DSM IV18 National Institutes of Health Consensus DevelopmentConference Statement: Diagnosis and Treatment ofAttention-Deficit/Hyperactivity Disorder (ADHD) (2000),Journal of the American Academy of Child andAdolescent Psychiatry, 39.19 G.R. Lyon & N.A. Krasnegor (Eds.) (1996) Attention,Memory and Executive Function. Baltimore: Paul H.Brookes Publishing Co.20 Gioia, G.A., Isquith, P.K., Guy, S.C. & Pratt, B. (2001)Survey of Knowledge and Practice of Executive Functionwith Children. Pediatric Neuropsychology Interest GroupNewsletter, 5, 6-10.


executive function and associated practicemethods. School psychologists reported beingless familiar with the concept of executivefunction than those in clinical settings and lessready to define executive function.Furthermore, they tend to assess and treatexecutive function to a lesser degree than theirclinical psychologist colleagues. Both groups,however, overwhelmingly cite a need for moretraining in the concepts, assessment andtreatment of executive functions, as well as theneed for additional normative measures ofexecutive function. Debonis and colleaguesfurther report school psychologists’ infrequentuse of intervention methods to address executivedysfunction in students with ADHD21. Theyalso found few references to the executivefunctions in common educational curriculummaterials for students with ADHD. Thus,educational personnel are in need of furthertraining in the concepts and methods to addressthe needs of students with executivedysfunction.

The executive functions play afundamental role in the child’s cognitive,behavioral, and social-emotional developmentwith substantial implications for everydayacademic and social functioning. It is crucial thatthe educational system fully understand theconcepts of the executive functions as well asdevelop skills for assessing and intervening whenthe student demonstrates deficiencies. Differentprofiles of executive dysfunction are found in avariety of clinical conditions associated withvulnerable brain development and/or brain injury.Although the syndrome of Attention-Deficit/Hyperactivity Disorder is the focus of thispaper, the executive functions are equallyapplicable to children with other neurologicimpairments including those with developmentalorigins (e.g., learning disabilities, autism/pervasive developmental disorder, mental

21 DeBonis, D.A., Ylvisaker, M. & Kundert, D.K. (2000)The relationship between ADHD theory and practice: Apreliminary investigation. Journal of Attention Disorders,4, 161-173.

retardation) and acquired etiologies (e.g.,traumatic, infectious, toxic, metabolic, neoplasticencephalopathies).

The term “executive control” has beenattributed to the cognitive psychologist, Neisser22,who described the “orchestration of basiccognitive processes during goal-orientedproblem-solving.”23 This early definition isimportant because it articulates the differentiationof “basic” cognitive functions from the“executive” or “orchestrative” cognitive controlfunctions. The executive functions are viewed asa collection of related yet distinct abilities thatprovide for intentional, goal-directed, problem-solving action. Welsh and Penningtoncharacterized the early development of theexecutive functions in terms of “the ability tomaintain an appropriate problem-solving set forattainment of a future goal”24. Denckla25 definedthe critical features of the executive functions foractive problem-solving as follows: providing fordelayed responding, future-oriented, strategicaction selection, intentionality, anticipatory set,freedom from interference, and the ability tosequence behavioral outputs. Although differentaspects of the executive functions have beendiscussed by various authors, most would agreethat the term is an umbrella construct for acollection of interrelated functions that areresponsible for purposeful, goal-directed,problem-solving behavior. An acceptedmetaphor conceptualizes the executive functionsas the conductor of an orchestra where thecomponent “instruments” of the orchestra are the

22 Neisser, U. (1967) Cognitive Psychology. New York:Appleton-Century-Crofts.23 Welsh, M.C. and Pennington, B.F. (1988) Assessingfrontal lobe functioning in children:Views from developmental psychology. DevelopmentalNeuropsychology, 4, 199-230. (p.202)24 Welsh, M. and Pennington, B. (1988) same as #21 (p.201)25 Denckla, M.B. (1994) Measurement of executivefunction. In G.R. Lyon (Ed.) Frames of reference for theassessment of learning disabilities: New views onmeasurement issues (pp.117-142). Baltimore: PaulBrookes Publishing Co.


“basic” domain-specific functions (e.g., language,visuospatial functions, memory, motor skills).The conductor directs – making intentionaldecisions regarding the final output of the musicand recruiting the necessary components inreaching the intended goal. The executivefunctions are defined as the control or self-regulatory functions that organize and direct allcognitive activity, emotional response, and overtbehavior. In cognitive and educationalpsychology, the executive functions are alsodescribed in terms of metacognition, the domain-general functions that serve an oversight role.Subdomains of executive function

Although not fully inclusive, we presentspecific behaviorally-referenced subdomains thatmake up this collection of regulatory ormanagement functions including the ability to:initiate behavior, inhibit competing actions orstimuli, select relevant task goals, plan andorganize a means to solve complex problems,shift problem-solving strategies flexibly whennecessary, and monitor and evaluate behavior.The working memory capacity to holdinformation actively “on-line” in the service ofproblem-solving is also described within thisdomain of functioning. Finally, the executivefunctions are not exclusive to cognition;emotional control is also relevant to effectiveproblem-solving activity. More specificdefinitions of these subdomains of executivefunction follow.

The ability to initiate is described asbeginning a task or activity, or the process ofgenerating responses or problem-solvingstrategies. Caregivers often report that childrenwith initiation difficulties have trouble gettingstarted on homework or chores, and requireprompts or cues in order to begin. It is importantto emphasize that problems with initiation are notthe result of non-compliance or disinterest in thetask. The child typically has an interest in thetask or activity and wants to succeed but cannotget started.

The ability to inhibit is a critical trait forsuccess in school and home. Measures to assess

this subdomain examine the ability to not act on(inhibit or resist) an impulse and to appropriatelystop one’s own activity at the proper time. Theability to inhibit is also readily observed in dailyactivities with common examples of disinhibitionincluding: acting without thinking, being easilydistracted, and being unable to sit still. Parentsand teachers typically possess a wealth ofinformation about a child’s ability to inhibit theirresponses and rating scales are effective meansof gathering information about this subdomain.

The ability to shift one’s problem solvingstrategy during complex tasks is a key aspect ofexecutive function. Thinking flexibly and beingable to switch or alternate attention are essentialcomponents of novel problem solving. In theirday-to-day lives, children who are rigid orinflexible may exhibit problems transitioningfrom one situation, activity, or aspect of aproblem to another as the situation demands.Caregivers often describe these children as“getting stuck” on a topic or as being highlyperseverative.

The ability to plan involves anticipatingfuture events, setting goals, and developingappropriate steps ahead of time to carry out anassociated task or action. Planning involvesimagining or developing a goal, and thenstrategically determining the most effectivemethod or steps to attain that goal. Planningoften involves the sequencing and stringingtogether of steps in order to most efficientlyachieve an end state. The ability to plan hadpreviously been considered as a skill of laterdevelopment, but research has illustrated itsactive use in preschool children. Parents andteachers may complain about the child’s lack ofplanning ability, tendency to start assignments atthe last minute, or failure to anticipate possibleproblems.

The ability to organize complex amountsof information is a subdomain that becomesincreasingly important as demands forindependent functioning increase. Organizationinvolves establishing and maintaining orderwithin an activity or carrying out a task in a


systematic manner. The way in whichinformation is strategically organized can play acritical role in how it is learned, remembered andretrieved26. Common reports from caregiverswhich suggest disorganization describe the childas “scattered,”, easily overwhelmed by largetasks or assignments, or having difficultiesorganizing personal belongings.

The ability to self monitor is typically notassessed via a discrete performance measure butrather by direct examiner observation andcaregiver reports. The ability to self monitorincludes checking on one’s own actions during orshortly after finishing a task to assure appropriateattainment of a goal. Children who do not selfmonitor often rush through assignments withoutchecking their work for mistakes. Additionally,such children may be unaware of how theiractions affect others in a social context.

Emotional Control is anothermanifestation of the executive functions. It isclosely associated with the ability to inhibit andmodulate responses. Emotional control is readilyobserved at home, school, and during assessment.The inability to modulate one’s own emotionalresponse may manifest as overblown emotionalreactions or a general affective reactivity. Suchchildren are often described as “explosive.”

Working memory is the process ofholding information in mind for the purpose ofcompleting a specific and related task. Workingmemory is essential in order to follow complexinstructions, complete mental arithmetic, orperform tasks with more than one step. Acommon observation made by parents is that theirchild often has trouble remembering things foreven a few minutes, or when sent to getsomething, forgets what s/he was supposed to get.Brain Basis for the Executive Functions

The developmental course of theexecutive functions parallels the protracted courseof neurological development, particularly with

26 Schneider, W. and Pressley, M. (1989) Memorydevelopment between 2 and 20. New York: Springer-Verlag.

respect to the prefrontal regions of the brain. Acommonly held view of the neuroanatomicorganization of the executive functions, however,is that they are seated solely in the prefrontalregion of the brain (i.e., the part of the brain thatis furthest forward). This position is anoversimplification of the complex organization ofthe brain. Although damage to the frontal lobescan result in significant dysfunction of variousexecutive subdomains27, the executive functionsdo not simply reside in the frontal lobes.Nevertheless, an understanding of thisphylogenetically unique neuroanatomic region isimportant in any discussion of the executivefunctions. The neuroanatomical essence of thefrontal lobes is their dense connectivity with othercortical and subcortical regions of the brain. Theprefrontal system is highly and reciprocallyinterconnected through bi-directional connectionswith the limbic (motivational) system, reticularactivating (arousal) system, posterior associationcortex (perceptual/ cognitive processes andknowledge base), and the motor (action) regionsof the frontal lobes28. This central neuroanatomicposition underlies the regulatory control that thefrontal systems exert over the perceptual coding/conceptual processes of the posterior cortex,

27 Anderson, V. (1998) Assessing executive functions inchildren: Biological, psychological and developmentalconsiderations. Neuropsychological Rehabilitation, 8,319-349; Fletcher, J.M. Ewing-Cobbs, L., Miner, M.E.,Levin, H.S. and Eisenberg, H. (1990) Behavioral changesafter closed head injury in children. Journal of Consultingand Clinical Psychology, 58, 93-98; Eslinger, P.J. andGrattan L.M. (1991) Perspectives on the developmentalconsequences of early frontal lobe damage: Introduction.Developmental Neuropsychology, 7, 257-260.28 Johnson, T.N., Rosvold, H.E. and Mishkin, M. (1968)Projections from behaviorally defined sectors of theprefrontal cortex to the basal ganglia, septum, anddiencephalon of the monkey. Experimental Neurology,21, 20; Porrino, L. and Goldman-Rakic, P.S. (1982)Brainstem innervation of prefrontal and anterior cingulatecortex in the rhesus monkey revealed by retrogradetransport of HRP. Journal of Comparative Neurology, 205,63-76.


attentional, and emotional functions subserved bythe subcortical systems29.Developmental Issues

The developmental course of theexecutive functions across childhood30 reveals aprotracted ontogenetic course in comparison withother cognitive functions - paralleling theprolonged pattern of neurodevelopment of theprefrontal regions of the brain. Although earlierviews of the executive functions argued for theiremergence in early adolescence31, studies indevelopmental psychology suggest a much earliertrajectory. The development of attentionalcontrol, future-oriented intentional problem-solving, and self-regulation of emotion andbehavior can be observed beginning in infancyand continuing through the preschool and school-age years32. Examples of this work includestudies of the development of goal-directed,planful problem-solving behaviors in 12-month-old infants using an object permanence and objectretrieval paradigm33. Eighteen-month-oldchildren exhibit the self-control abilities tomaintain an intentional behavior and inhibit

29Welsh and Pennington, 1988 Welsh, M.C. andPennington, B.F. (1988) Assessing frontal lobefunctioning in children: Views from developmentalpsychology. Developmental Neuropsychology, 4, 199-230.30 Passler, M.A., Isaac, W., and Hynd, G.W. (1985)Neuropsychological development of behavior attributedto frontal lobe functioning in children. DevelopmentalNeuropsychology, 1, 349-370. ; Welsh and Pennington,1988 (same as #28); Levin, H.S., Culhane, K.A., Hartmann,J., Evankovich, K., Mattson, A.J., Harward, H., Ringholz,G., Ewing-Cobbs, L., and Fletcher, J.M. (1991)Developmental changes in performance on tests ofpurported frontal lobe functioning. DevelopmentalNeuropsychology, 7, 377-395.31 Golden, C.J. (1981) The Luria-Nebraska Children’sBattery: Theory and formulation. In G.W. Hynd and J.E.Obrzut (Eds.) Neuropsychological Assessment and theSchool-Age Child. New York: Grune and Stratton.32 Welsh & Pennington, 198833 Diamond, A. and Goldman-Rakic, P.S. (1989)Comparison of human infants and rhesus monkeys onPiaget’s AB task: Evidence for dependence ondorsolateral prefrontal cortex. Experimental BrainResearch, 74, 24-40.

behavior incompatible with attaining a goal34.These examples demonstrate the utilization ofearly intentional self-control behaviors by infantsand toddlers for the purpose of goal-directedproblem-solving. The executive self-control atthese early ages is, however, variable, fragile, andbound to the external stimulus situation, whereasincreasing stability is gained between 18-30months of age. Developmental studies ofchildren through adolescence demonstrate a time-related course of development for specificsubdomains of executive function, includinginhibitory control35, flexible problem-solving36,and planning37. As is the case with mostdimensions of psychological andneuropsychological development, the emergenceof executive control functions duringdevelopment can vary across individuals in termsof when specific subdomains emerge and to whatultimate degree.

Regarding the clinical manifestation ofexecutive dysfunction, it is important toacknowledge and emphasize that there is nosingular, core disorder of executive function.Pennington and colleagues38 point out thatdisorders with different neuroanatomical basescan present with similar broad manifestations ofexecutive function deficits (for example, treatedPKU, ADHD, Autism, and Fragile X in women).On the other hand, a single clinical syndromesuch as ADHD may reflect different executivefunction deficits, such as disinhibition and

34 Vaughn, B.E., Kopp, C.B., & Krakow, J.B. (1984).The emergence and consolidation of self-control fromeighteen to thirty months of age: Normative trends andindividual differences. Child Development, 55, 990-1004.35 Passler et al. 198536Chelune, G.J. & Baer, R.L. (1986) Developmentalnorms for the Wisconsin Card Sorting Test. Journal ofClinical and Experimental Neuropsychology, 8, 210-228.37 Klahr & Robinson, 1981 Klahr, D. & Robinson, M.(1981) Formal assessment of problem-solving andplanning processes in preschool children. CognitivePsychology, 13, 113-148.38 Pennington, B.F. & Ozonoff, S. (1996) Executivefunctions and developmental psychopathology. Journalof Child Psychology and Psychiatry, 37, 51-87.


impaired working memory. Unlike a domain-specific function such as language where acommonality of deficits is seen in a clinicalsyndrome, executive function deficits can presentdifferently within a syndrome or similarly acrosssyndromes.Defining the Child’s Profile of ExecutiveFunction.

Before intervening with the executivefunctions, it is necessary to define the student’sprofile of executive function strengths andweaknesses. This can be conducted by a numberof skilled professionals given proper training.Depending on the complexity of the student’sissues, the assessment of their executive functioncan be conducted by a school psychologist,neuropsychologist, or clinical psychologist.Teaching staff must play an active role in theprocess as well. Given the directive, dynamic,fluid, and multi-form nature of the executivefunctions, assessing them with standard tests ischallenging39. Any assumption that the executivefunctions are a static set of abilities simplyamenable to traditional testing is false. The fluidstrategic, goal-oriented problem-solving involvedin the executive functions is not as amenable topaper-and-pencil assessment as are the moredomain-specific functions such as language,memory, motor, and visual/nonverbal abilities40.Furthermore, the structured nature of the typicaltesting situation often does not place a highdemand on the executive functions, reducing theopportunity for observing this importantdomain41. In considering whether or not a childhas difficulty in the executive domain, theexaminer must appreciate the structure,

39 (Anderson, 1998 – same as # 2740 Gioia, G.A., Isquith, P.K. & Guy, S.C. (2001)Assessment of executive functions in children withneurological impairment. In R.S. Simeonsson & S.Rosenthal (Eds.) Psychological and DevelopmentalAssessment. New York: Guilford Press.41 Bernstein, J.H. and Waber, D.P. (1990) Developmentalneuropsychological assessment: The systemic approach.In A.A. Boulton, G.B. Baker & M. Hiscock (Eds.)Neuromethods: Vol. 17 Neuropsychology. Clifton, N.J.:Humana.

organization, guidance, and planning, as well asthe cueing and monitoring they provide topromote optimal performance by the child. Theexaminer serves, in essence, as the child’sexternal executive control42. A child withsignificant executive dysfunction can performappropriately on well-structured tasks ofknowledge where the examiner is allowed to cueand probe for more information, thus relieving thechild of the need to be strategic and goal-directed.A full definition of the child’s profile of executivefunction should include information gatheredfrom testing, focused observations, standardizedbehavioral ratings, and clinical interview.

A paradox exists in the assessment of theexecutive functions. Some individuals withsignificant deficits in specific executive functionsubdomains may, in fact, perform appropriatelyon general intelligence tests and on manypurported "tests of executive function" yet havesignificant problems making simple real-lifedecisions43. All tests are multi-factorial, withgreater or lesser degrees of domain-specificcontent knowledge and thereby demanding ofvarying degrees of organization, planning,inhibitory control, or flexibility. For example, achild may be able to perform appropriately on theWisconsin Card Sorting Test44, which requiresflexibility in problem-solving, yet fail miserablyin strategically modifying his/her approach tocompleting a set of math problems in theclassroom or solving social problems. Thebehavioral observations and formal test findings

42 Stuss, D.T. & Benson, D.F. (1986) The frontal lobes.New York: Raven; Kaplan, E. (1988) A processapproach to neuropsychological assessment. In T. Bolland B.K. Bryant (Eds.) Clinical Neuropsychology andBrain Function: Research, Measurement and Practice(pp. 125-167). Washington, D.C.: AmericanPsychological Association.43 Stuss, D.T. and Buckle, L. (1992) Traumatic braininjury: Neuropsychological deficits and evaluation atdifferent stages of recovery and in different pathologicsubtypes. Journal of Head Trauma Rehabilitation, 7, 40-49.44 Heaton, R., Chelune, G., Talley, J., Kay, G., andCurtiss, G. (1993). Wisconsin Card Sorting Test Manual.Lutz, FL: Psychological Assessment Resources.


obtained in a formal testing situation may notcomprise a complete data set documentingstrengths and weaknesses in the array ofexecutive functions.

Assessment of the executive functionsrequires a multi-modal approach to characterizefully the child’s profile. The examiner must (1)obtain systematic observations of ways the childmanages task demands within the context of theassessment situation, (2) recruit reliable reports ofcritical problem-solving behaviors in the child’s“real world”, and (3) provide psychometricallyand developmentally appropriate tests for directobservation of executive problem-solvingperformance.

Recognizing the different stimulusconditions which are provided within the comfortof the controlled setting of testing (which may bevery necessary to identify the child’s knowledgeand abilities) versus those existing within thechild’s “real” day-to-day world is criticallyimportant. Frequently, the more novel and/orcomplex the task, the greater the demand for theexecutive functions. The more familiar,automatic, and simple the task, the less the childneeds to recruit their executive functions. Whatmay be a complex, novel task for one child maybe relatively familiar and automatic for another;thus, children recruit vastly different degrees ofexecutive control functions toward solving aparticular problem. The ultimate application ofassessment data to formulating credible, practicalrecommendations and intervention strategiesdemands a clear understanding of this issue.Assessing the child’s behavior and responsesunder greater and lesser degrees of examiner-determined control and structure can help clarifythe child’s executive competence. This pointstresses the importance of an intra-individualapproach to assessment, as opposed to a simple)normative model. Teasing apart executivefunctions from domain-specific functions is partof the challenge of their assessment anddefinition: Returning to the orchestral metaphor,the conductor (executive function) must have

players (cognitive processes) to direct in order tomake “cognitive” music.

The Role of Executive Function inADHD

The syndrome of Attention-Deficit/Hyperactivity Disorder (ADHD) hastraditionally been defined by three aspects ofdisordered functioning including sustainedattention, impulsivity, and high activity level 45.The definition of ADHD has been evolving overthe last thirty years46. More recently, the nature ofthe disorder has been re-examined and isundergoing further redefinition in terms of adisorder of the executive functions47. Variousauthors have argued that the syndrome of ADHDmight better be viewed in terms of the constructof executive function than the traditional triad ofsymptoms reflected in current diagnostic criteria.Many agree that ADHD is not a unitary disorder,and that difficulties with sustained attention,impulsivity and hyperactivity are not the solecharacteristics or areas of difficulty. A model ofAttention-Deficit/Hyperactivity Disorder definedby executive function may be both more specificand more inclusive in identifying problematicareas of functioning. Further, viewing thebehavioral symptoms of ADHD as ramificationsof deficits in executive function provides a usefulneuropsychological model, as executive functionsare one step closer to neural substrate than the

45 DSM-IV, American Psychiatric Association, 199446Barkley, R.A. (1997) ADHD and the Nature of Self-Control. New York: Guilford Press; Barkley, R.A.(2000) Genetics of Childhood Disorders: XVII. ADHD,Part 1: The executive functions and ADHD. Journal ofAmerican Academy of Child and Adolescent Psychiatry,39, 1064-1068; Brown, T.E. (1999) Does ADHDDiagnosis require impulsivity-hyperactivity?: A response toGordon & Barkley. ADHD Report, 7, 1-7; Denckla, M.B.(1996) A theory and model of executive function: Aneuropsychological perspective. In G.R. Lyon & N.A.Krasnegor (Eds.) Attention, memory and executive function(pp. 263-278). Baltimore, Md: Paul H. Brookes PublishingCo.; Pennington, B.F. & Ozonoff, S. (1996) Executivefunctions and developmental psychopathology. Journal ofChild Psychology and Psychiatry, 37, 51-87.47 Barkley, R.A. (1997) ADHD and the Nature of Self-Control. New York: Guilford Press.


ADHD diagnosis and provide a more functionalframework for research48. As can be presumedfrom the nature of executive function, there is aclose link with attentional functioning49.Theoretically, working memory deficitscontribute substantially to the PredominantlyInattentive subtype of ADHD, while inhibitorycontrol deficits account for the cluster ofsymptoms comprising the hyperactive/impulsivesubtype50.

Clinically, beyond the symptoms ofinattention (“doesn’t pay attention to lectures…”),impulsivity (“doesn’t think before he/ she acts..”),and hyperactivity (“is constantly on themove…”), parents and teachers are alsofrequently reporting significant problems withdisorganization (“can’t organize thoughts orbelongings…”), poor planning (“always startsprojects at the last minute and without the correctmaterials…”), deficient working memory (“can’tremember or follow a 3-step direction…”), poorself-monitoring (“never checks work..”),inflexible problem-solving (“gets stuck on onlyone way to solve a problem…”), and anoveremotional response (“has frequent outburststhat are out of proportion…”). We would arguethat these additional symptoms are themanifestation of the executive dysfunction that isinherent in the syndrome of ADHD. Althoughthe traditional triad of symptoms clearly must be

48 Barkley, R.A. (2000) Genetics of Childhood Disorders:XVII. ADHD, Part 1: The executive functions andADHD. Journal of American Academy of Child andAdolescent Psychiatry, 39, 1064-106849 Barkley, R.A. (1997) ADHD and the Nature of Self-Control. New York: Guilford Press; Mirsky, A.F. (1989)The neuropsychology of attention: Elements of a complexbehavior. In E. Perecman (Ed.) Integrating Theory andPractice in Clinical Neuropsychology (pp. 75-91).Hillsdale, NJ: Lawrence Erlbaum Associates.50

Barkley, R.A. (1996). Linkages between attention andexecutive functions. In G. R. Lyon & N. A. Krasnegor(Eds.), Attention, memory and executive function (pp. 307-326). Baltimore: Paul H. Brookes.; Pennington, B.F. &Ozonoff, S. (1996) Executive functions anddevelopmental psychopathology. Journal of ChildPsychology and Psychiatry, 37, 51-87.

a focus of treatment and educational support,intervention strategies to address the executivedysfunction must also be included. That is,bringing the impulsive behavior and hyperactivityunder control is a critical and fundamental aspectof treatment, but does not directly address thepoor organizational skills, monitoring ofperformance and behavior, or inflexible problem-solving approach. In fact, treatment of the poorinhibitory control is likely an important precursorto metacognitive (e.g., organizational)intervention51, but is not sufficient in developingthe necessary organizational and monitoring skillsfor managing complex tasks.Models of Executive Function in ADHD

A comprehensive understanding ofADHD requires explicit inclusion of theexecutive functions in clinical assessment andintervention, as well as in research. Severalauthors have examined ADHD in terms ofvarious executive functions. Pennington &Ozonoff52 describe the “frontal metaphor” whendefining ADHD, with specific reference to thedeficits in the executive function domains ofinhibition and working memory. Bayliss andRoodenrys53 also discuss an underlying executivefunction deficit in ADHD in terms of asupervisory attentional system54, which reflectslargely the inhibitory capacity of the child. Themost comprehensive examination of ADHD interms of a model of executive function has been

51 Gioia, G.A., Isquith, P.K., Retzlaff, P.D. & Pratt, B.M.(in press) Modeling executive functions with everydaybehaviors: A unitary or fractionated system? Brain andCognition.52 Pennington, B.F. & Ozonoff, S. (1996) Executivefunctions and developmental psychopathology. Journalof Child Psychology and Psychiatry, 37, 51-87.53 Bayliss, D.M. & Roodenrys, S. (2000) Executiveprocessing and attention deficit hyperactivity disorder:An application of the supervisory attentional system.Developmental Neuropsychology, 17, 161-180.54 Norman,D.A. & Shallice, T. (1986) Attention to action:Willed and automatic control of behavior. In R.J.Davidson, G.E. Schwartz & D. Shapiro (Eds.),Consciousness and self-regulation (Vol. 4; pp. 1-18).New York: Plenum.


well articulated by Russell Barkley55. UsingBronowski’s56 conceptualization of language andthe executive functions as the basis of his model,Barkley views inhibition as the fundamental, coreexecutive function in his model. Several otherdimensions play crucial roles in the child’s abilityto exhibit appropriate self-control, includingnonverbal working memory (visual imagery andprivate audition and internalized resensing),verbal working memory (covert language thatcontrols self; rule-governed behavior),internalized emotion/ motivation (covert affectivestates, source of intrinsic motivation that drivesfuture behavior), and reconstitution (analysiscombining with synthesis, allowing manipulationto synthesize new responses; allows flexible,fluent, inventive goal-directed behaviors).Children with ADHD have fundamental deficitsin behavioral inhibition, which result in a varietyof other executive function deficits, includingpoor verbal and nonverbal working memory;difficulties regulating their affect, motivation andarousal; and poor goal-directed analytic andsynthetic problem-solving abilities. The outcomefor the child with ADHD is disinhibited and task-irrelevant responses, impaired execution of goal-directed responses, insensitivity to feedbackregarding their behavior, inflexible problem-solving behavior, and behavior that is poorlycontrolled by internal cognitive states.

To further empirically examine the role ofthe executive functions in children with ADHD,we conducted two studies of the relationshipbetween the multiple domains of executivefunction and critical aspects of Attention-Deficit/Hyperactivity Disorder57. Specifically,we showed (1) how two key aspects of executive

55 Barkley, R. A. (1997) ADHD and the nature of self-control. New York: The Guilford Press.56 Bronowski, J. (1977) Human and animal languages. InA sense of the future. (pp.104-131). Cambridge, MA:MIT Press. (Reprinted from 1967, To Honor RomanJakobson, Vol. 1. The Hague, Netherlands: Mouton.57 Gioia, G.A. & Isquith, P.K. (in press) Executivefunction and ADHD: Exploration through children’severyday behaviors. Clinical NeuropsychologicalAssessment.

function, working memory and inhibition, canpredict ADHD subtypes, and (2) the intimateoverall relationship between a larger set ofexecutive function domains and the traditionalsymptomatology of Attention-Deficit/Hyperactivity Disorder.Study I: Working Memory and Inhibition asPredictors of ADHD Subtypes

We asked parents and teachers ofchildren who met DSM-IV criteria for eitherADHD, Predominantly Inattentive Type(ADHD-I) or ADHD Combined Type (ADHD-C) but not other comorbid diagnoses (e.g.,Conduct Disorder, Oppositional DefiantDisorder, Reading Disorder) to completeobservational measures of executive function.Parents and teachers of children withoutidentified attentional, learning, or behavioralconcerns and matched for age, gender, ethnicityand parental education to the children withADHD also completed the measure to serve ascontrols. The Parent and Teacher Forms of theBehavior Rating Inventory of ExecutiveFunction (BRIEF)58, an 86-item questionnairedesigned to assess executive functions viaratings of children’s everyday behaviors, servedas the measure of executive function. Inparticular, we were interested in two of the eightnon-overlapping BRIEF scales, - WorkingMemory and Inhibit.

Children with either Inattentive orCombined types of ADHD were rated byparents and teachers significantly, indeedsubstantially, higher than children without anADHD diagnosis on the BRIEF WorkingMemory scale. Parents and teachers also ratedchildren with the combined type of ADHDsignificantly higher on the Inhibit scale thanchildren with the inattentive type of ADHD,who were in turn rated higher on the same scalethan children with no diagnosis. Logistic

58 Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy,L. (2000). Behavior Rating Inventory of ExecutiveFunction. Lutz, FL: Psychological AssessmentResources, Inc.


regression analyses revealed that, for bothteacher and parent ratings, the BRIEF WorkingMemory scale predicted ADHD-I diagnosis in81% (parent) to 83% (teacher) of the cases. TheInhibit scale predicted ADHD-C diagnosis in85% (parent) and 79% (teacher) of the cases.Although the Working Memory scale did notdistinguish between subtypes of ADHD (i.e.,this was a significant problem in both subtypes),the Inhibit scale distinguished 65% to 68% ofcases (i.e., it was a more prominent problem inADHD-C).

This study supports the notion thatdeficits in domains of executive functionunderlie the behavioral symptom clusters thatcharacterize the diagnosis of ADHD.Specifically, working memory deficits arecharacteristic of attention problems in bothsubtypes of ADHD, while failure of inhibitorycontrol was a stronger contributor to thehyperactive/impulsive symptoms of ADHD,Combined Type.Study II: Relationship between ADHD andExecutive Function

Next, we examined the relationshipbetween the broader neuropsychologicalconstruct of executive function and aspects of theclinical syndrome of ADHD by comparing alleight BRIEF scales with a published measure ofADHD symptoms based on the DSM-IVdiagnostic criteria, the ADHD Rating Scale-IV59.We predicted that difficulties with sustainedattention and performance would be associatedwith difficulties initiating problem-solvingactivity, organization, planning, and workingmemory. These metacognitive functions would,therefore, associate more with the “cognitive”/inattention symptoms than the impulsive andhyperactive symptoms of ADHD. In contrast, wepredicted that hyperactive/ impulsive behaviorswould be associated with greater difficultiesregulating behavior including inhibiting and

59 DuPaul, G.J., Power, T.J., Anastopolous, A.D., & Reid,R. (1998). ADHD Rating Scale IV: Checklist, norms andclinical interpretation. New York, Guilford Press.

shifting behavior, as well as emotional controland self-monitoring.

For this study, parents of 81 (51 boys, 30girls) clinically referred children with diagnosesof ADHD completed the BRIEF along with theADHD Rating Scale –IV. Fifty children metcriteria for ADHD-I and 31 met criteria forADHD-C. Correlations among the eight BRIEFscales and the two scales of the ADHD RatingScale IV (Inattentive symptoms,Hyperactive/Impulsive symptoms) weresubmitted to exploratory principal factoranalysis (PFA) with oblique rotation, a methodthat allows for exploration of complexrelationships among the variables while seekinggroups of variables, or factors, that summarizethe data. A two-factor solution was the mostparsimonious. Factor 1 was defined by the fiveBRIEF Metacognition scales (Initiate,Plan/Organize, Working Memory, Organizationof Materials, and Monitor) along with theADHD Rating Scale-IV Inattention scale. Factor2 was defined by the three BRIEF BehavioralRegulation scales (Emotional Control, Inhibit,and Shift) loading with the ADHD RatingScale-IV Hyperactive/Impulsivity scale.

These findings highlight the relationshipbetween eight subdomains of executive functionand the symptom clusters of the ADHDsyndrome. The inattentive characteristics ofADHD were highly related to the metacognitivedomains of task initiation, organization andplanning, working memory, monitoring, andorganizing one’s materials. The hyperactive/impulsive characteristics of ADHD were morehighly related to the behavioral regulationaspects of executive function includinginhibitory control, emotional control, andproblem-solving flexibility. These findingsextend the viewpoint of executive function asthe underlying neuropsychological functionsthat characterize ADHD symptoms. Further, theunderlying functional elements of theInattention subtype of ADHD include notsimply inattention n the narrow sense but alsothe executive ability to initiate, organize, plan,


and monitor an action sequence and to maintainthis problem-solving set in active workingmemory. Similarly, the behaviors within theADHD Combined subtype would include theexecutive function subdomain of inhibit,consistent with Barkley’s model 60, as well asthe ability to flexibly shift problem-solving set,and maintain appropriate emotional control.

Taken together, these two studiesprovide evidence for the strong relationshipbetween the neuropsychological construct ofexecutive function and the clinical diagnosis ofAttention-Deficit/Hyperactivity Disorder,consistent with the viewpoints expressed by anumber of authors61. We concur that executivefunction is a more useful framework forunderstanding the behavioral characteristicscaptured as the triad of ADHD symptoms. Themulti-dimensional construct of executivefunction is both more specific in highlightingthe multiple functional components within thesubtypes of ADHD and more comprehensive inexpanding the critical behavioral symptomsbeyond the traditional triad.

The first study highlights the relevanceand utility of the specific executive functionbehaviors of inhibitory control and workingmemory in the diagnosis of the subtypes ofADHD. These two executive function domainsdemonstrate good ability to detect the ADHDsubtypes of Predominantly Inattentive Type andCombined Type. The second study supports the“redefinition” of the ADHD diagnosticcomponents within an executive function

60 Barkley, R.A. (1997) ADHD and the nature of self-control. New York: The Guilford Press.61 Barkley, R.A. (2000) Genetics of Childhood Disorders:XVII. ADHD, Part 1: The executive functions andADHD. Journal of American Academy of Child andAdolescent Psychiatry, 39, 1064-1068; Brown, T.E.(1999) Does ADHD Diagnosis require impulsivity-hyperactivity?: A response to Gordon & Barkley. ADHDReport, 7, 1-7; Denckla, M.B. (1996) A theory and model ofexecutive function: A neuropsychological perspective. InG.R. Lyon & N.A. Krasnegor (Eds.) Attention, memory andexecutive function (pp. 263-278). Baltimore, Md: Paul H.Brookes Publishing Co.

framework. Barkley and others62 have long heldinhibitory self-control as the fundamentalsymptom of ADHD. Redefining the criticaldiagnostic behaviors in terms of theneuropsychological construct of inhibition issupported. The construct of working memoryhas also been proposed as a possible underlyingelement of ADHD63. In fact, the “attention” inADHD has been questioned as a discriminatingaspect of ADHD64, and instead is suggested asthe secondary consequence of other moreprimary underlying functions (e.g., inhibition).Thus, the present redefinition of attention in theADHD symptom complex in terms of executivefunction has prior support.

Not only do specific components ofexecutive function serve to redefine thediagnosis of ADHD but the broadermetacognitive and behavioral/ emotionalregulatory aspects of executive function must beconsidered as well. We believe this inclusiveapplication of the executive function constructto ADHD has clinical support when oneconsiders the types of everyday problems thatare often reported by parents and teachers.Although “not paying attention” and “notthinking before he acts” are frequent concerns,reports of “disorganized thinking andperformance”, “poor planning”, “not checkinghis work”, and “difficulty accepting otherstrategies” are also expressed quite frequently.The formal assessment of these critical aspectsof executive function is necessary in functional

62 Barkley, R.A. (1994) Impaired delayed responding: Aunified theory of attention deficit hyperactivity disorder.In D.K. Routh (Ed.) Disruptive behavior disorders inchildhood: Essays honoring Herbert C. Quay (pp.11-57).New York: Plenum; Conners, C.K., & Wells, K.C.(1986). Hyperkinetic children: A neuropsychologicalapproach. Beverly Hills: Sage Publications; Douglas,V.I. (1999) Cognitive control processes in attention-deficit/hyperactivity disorder. In H.C. Quay and A. Horgan(Eds.), Handbook of Disruptive Behavior Disorders (pp.105-138). New York: Plenum Press.63 Barkley, R.A. (1997) ADHD and the nature of self-control. New York: The Guilford Press.64 Gordon, M. (1995) How to operate an ADHD clinic orsubspecialty practice. Syracuse, NY: GSI Publications.


diagnosis and treatment planning for childrenwith ADHD symptoms. Articulating theparticular behavioral subdomains of executivefunction allows for a more specific targeting ofbehavioral and cognitive/ academic treatmentmethods toward those deficient areas.Following an executive function rubric, theclinician would not only ask questions about thechild’s inattention but would also formallyinquire about the child’s ability to initiate, plan,organize, and monitor task and social behavior,as well as to hold information actively inworking memory. Furthermore, rather thanpursuing information primarily in terms ofoveractive or impulsive behavior, assessmentquestions regarding the broader aspects ofinhibitory control (including cognitiveinhibition), as well as problem-solvingflexibility and control of emotional responseswould be addressed. Finally, the redefinitionand refinement of our understanding of ADHDmay promote better clinical treatment ofindividuals with this disorder. A more specificexecutive function model of ADHD would beuseful for targeting appropriate cognitive,academic, social, and behavioral treatments.

Executive System InterventionsGiven the general theoretical discussion

regarding the integral role of executive functionwithin the diagnosis of Attention-Deficit/Hyperactivity Disorder together with theempirical evidence of executive function as bothinterwoven with ADHD symptomatology andpredictive of clinical subtypes, we believeadequate support exists for consideration ofexecutive function behaviors within aneducational intervention model. Furthermore,the reports of clinical and educational problemsby teachers and parents also implicate thecentral role of executive dysfunction. Forexample, teachers and parents frequentlybemoan the significant disorganization in thestudent’s general approach to tasks as well astheir maintenance their materials. Difficultiesfollowing multi-step directions or completion oflong-term projects are also common complaints.

Following an appropriate assessment anddefinition of the student’s specific executivedysfunction, educational intervention planningcan begin. Given the unique nature of theexecutive functions in playing a “command”role in terms of guiding and regulating thoughtand behavior, the approach to intervention mustbe considered globally. First, one must considerthe end-goal or outcome of “good” executivefunction for the child. We propose thefollowing educational executive outcomes forchildren:

Purposeful, goal-directed task andsocial activity

Active educational problem solvingapproach

Self-control within social andacademic tasks

Maximal independence in taskcompletion

Reliable and consistent behavior andthinking

Positive self-efficacy as a learner Internal locus of control Accurate awareness of one’s own

strengths and weaknessesThe general principles of an educational

executive function intervention model are basedlargely on the work of Mark Ylvisaker andcolleagues65 who advocate an ongoing,contextualized (i.e., in the child’s real world),collaborative (i.e., together with the child,parents, teachers, peers), hypothesis-testing (i.e.,generating and implementing testable methods)assessment and treatment approach. Theultimate goal of executive function intervention inthe school setting is to establish regular

65 Ylvisaker, M. (Ed.) (1998). Traumatic Brain InjuryRehabilitation: Children and Adolescents (2nd Edition)Boston: Butterworth-Heinemann; Ylvisaker, M. &Feeney, T.J. (1998) Collaborative Brain InjuryIntervention: Positive Everyday Routines. San Diego:Singular Publishing Group, Inc.; Ylvisaker, M. &DeBonis, D. (2000) Executive Function Impairment inAdolescence: TBI and ADHD. Topics in LanguageDisorders, 20, 29-57.


behavioral/cognitive routines to maximizeindependent, goal-oriented educational problem-solving and performance. A critical feature ofany educational intervention is to establishexternal environmental pre-conditions that willenable the child to learn maximally, and, ideally,establish automatic educational problem-solvingroutines. Bernstein and Waber66 further articulatethis “Brain-World” interactional model ofneuropsychological function whereby the child’sadaptation is an ongoing fluid process of theirown resources in the context of the environmentaldemands at the time. Both aspects of thisinteraction must therefore be explicitly consideredin the intervention system.

For individuals just starting to learnexecutive control behaviors, young children, orindividuals with extreme executive dysfunction,the focus of intervention may need to be moreexternalized or environmental (i.e., to organizeand structure the external environment and toorganize and cue strategies and behavioralroutines). Many such individuals do not have theinternal resources available to initiate behaviorswithout significant individualized structuring,cueing, and reinforcement. They often need helpto know when and how to apply the appropriateproblem-solving behavioral routine. Directrewards and positive incentives are oftennecessary to motivate the child to attend to andpractice new behavioral routines. Because of thenature of the child’s executive dysfunction, theseorganizational routines may initially beexperienced as quite stressful by many childrenand adolescents. Establishing such routines mayrequire, therefore, explicit rewards. Oncebehavioral routines have become established,positive cueing becomes the crucial factor; cueingcan then be faded, as a function of the child’sincreasing autonomy.

66 Bernstein, J.H. and Waber, D.P. (1990) Developmentalneuropsychological assessment: The systemic approach.In A.A. Boulton, G.B. Baker & M. Hiscock (Eds.)Neuromethods: Vol. 17 Neuropsychology. Clifton, N.J.:Humana Press.

An executive system intervention focusis possibly in most daily activities involvingmore than one step for completion, includingclassroom, therapy, social/recreational, andactivities of daily living at home67. Forexample, any of these activities can include:a. Goal-setting: an initial decision about or

choice of a goal to pursue (What do Ineed to accomplish?)

b. Self-Awareness of strengths/ weaknesses:recognition of one’s stronger and weakerabilities, and a decision about how easy ordifficult it will be to accomplish the goal(How easy or difficult is this task/ goal?Have I done this type of task before?)

c. Organization/ Planning: development ofan organized plan (what materials do weneed? who will do what? in what order dowe need to do these things? how long willit take?)

d. Flexibility/ strategy use: Ascomplications or obstructions arise,planned (e.g., staff ensure that problemsarise) or unplanned coaching of thestudents in flexible problem solving/strategic thinking (When/ if a problemarises, what other ways should I thinkabout to reach the goal? Should I ask forassistance?)

e. Monitoring: a review of the goal, plan,and accomplishments at the end (Howdid I do?

f. Summarizing: what worked and whatdidn't work; what was easy and what wasdifficult --- and whyAn executive function intervention

model includes at the outset an appropriateassessment. This includes defining the relevantprofile of executive strengths and weaknesses,associated domain-specific abilities or deficits,and an analysis of the everyday person, task,and situational demands that increase ordecrease appropriate executive functioning.

67 Ylvisaker, M. & Feeney, T.J. (1998) CollaborativeBrain Injury Intervention: Positive Everyday Routines.San Diego: Singular Publishing Group, Inc.


Determination of the developmental level ofchild and the age- appropriate expectations forexecutive function are also necessary.

Several basic tenets are also advocated,including:1. Teaching a goal-directed problem-solving

process2. Implementing the process within positive,

meaningful everyday academic routines3. Real-world relevance and application of

strategies and routines4. Involving everyday people (parents,

teachers, peers) as models and “coaches”5. Including the child in the design of the

intervention as much as possible6. Most individuals with executive dysfunction

do not yet possess the age-appropriateinternalized skills for well-regulatedproblem-solving. Therefore, interventionoften begins from an “external support”position with active and directive modeling,coaching and guidance by importanteveryday people, which proceeds over timeto an “internal” process of fading and cueingas follows:a. External modeling of multi-step

problem-solving (i.e., executive)routines

b. External guidance to develop &implement everyday executive routines

c. Practice application/ use of executiveroutines in everyday situations

d. Fade external support and cue internalgeneration & use of executive routines

e. Support internal control in generation &use of specific problem-solvingroutine(s)

f. With external guidance, promotegeneralization to new situation(s)

g. Accumulate experience, examineconditions for selective use of variousexecutive routines

h. Provide feedback (external and internal)throughout the processIn structuring an executive function

intervention program, we advocate the use

of everyday executive routines within thecontext of a general approach to executiveproblem-solving as opposed to merelyteaching specific skills out of context. Inaddition, given the difficulties that manyindividuals with executive dysfunctionpossess with working memory, the use of a“hard copy” of the active multi-stepexecutive routine is often necessary. Thechild should become increasingly moreactive in formulating and carrying out theplans and reviewing his/ her performance(thus promoting “internal” executivecontrol). The goal of executive functionintervention is maximal independence andself-sufficiency, which necessitates activeinvolvement of the child. The challenge inconducting an effective executive functionintervention is in the “delivery system”, thatis, the means by which the teacherimplements the collaborative program. Afine balance exists between too little and toomuch teacher support for the student. Thiscan be a challenge because too little supportfor the student can be overwhelming ashe/she does not yet have the competence tomanage the critical executive routines toself-manage their learning. Too muchsupport, on the other hand, can createcontinued dependence and a lack of growthin the critical executive, self-managementfunctions. Thus, the challenge is to notshift responsibility for the executive routinestoo suddenly onto the student but instead ina gradual manner with mentoring, modeling,and guided practice68. This gradual transferof responsibility for the executive functionroutines occurs with increasing competencyof the student. This approach also requiresthe teacher/ mentor to know the student wellenough to deliver the intervention in asensitive, yet empirical (i.e., based on thestudent’s actual performance) manner. This

68 Ylvisaker, M. & DeBonis, D. (2000) ExecutiveFunction Impairment in Adolescence: TBI and ADHD.Topics in Language Disorders, 20, 29-57.


approach is akin to a mentoring or coachingprocess.

In developing interventions for theexecutive functions, it is important toappreciate what they are not. They are not: Specific, isolated sets of skills or

information that are unidirectionallytaught to the child.

A mere list of steps that is taped to thechild’s desk or bedroom door.

Simple behavior modification to increasemotivation in the absence of criticalantecedent conditions (setting variables,problem-solving routines)

A “student thing” - listing treatment/ IEPgoals without attention to the “how,who, where, when” of the interventiondelivery systemWithin the context of a collaborative,

contextualized problem-solving model utilizingthe everyday routines of the child and deliveredwithin a method such as the Goal-Plan-Do-Review system69, examples of specificrecommendations for interventions andaccommodations are offered in Appendix Aaccording to area of functioning. We hope themajority of these interventions are somewhatfamiliar to the intervention team. We haveclassified them in terms of the relevantexecutive functions to which they apply. Theserecommendations are general and are intendedhere as suggestions or ideas that may be tailoredto suit the student’s individual needs. As withany intervention, clinical judgment isparamount. In following with the model ofcombined external and internal foci tointervention, the recommendations areorganized in terms of these two categories withthe expectation that a combination of both istypically necessary to promote the fullimplementation of an executive problem-solvingroutine.

69 Ylvisaker, M. & Feeney, T.J. (1998) CollaborativeBrain Injury Intervention: Positive Everyday Routines.San Diego: Singular Publishing Co.

Goal-Plan-Do-Review (GPDR) RoutineThe use of a general executive problem-

solving routine that promotes systematic goaldefinition, planning, action, self-monitoring/evaluating, and flexible, strategicadjustment of plans and actions may serve as acentral framework or vehicle within whichspecific executive function intervention methodsand strategies can be incorporated. The Goal-Plan-Do-Review method is one such systemThe complexity of the problem-solving routineshould be adapted to the competency level ofthe child. The executive problem-solvingroutine is structured such that these questionsare asked (ultimately by the student althoughinitial modeling and guidance by the teacher isnecessary):1. GOAL: What do I want to accomplish?2. PLAN: How am I going to accomplish mygoal? What materials and/or equipment will Ineed? What steps and/or assignments do I needto plan out to accomplish my goal.3. PREDICTION: How well will I do? Howmuch will I get done?4. DO: Act on the plan. Am I encounteringany problems? If so, I will generate possiblesolutions to those problems and try them.5. REVIEW: How did I do? How does myperformance compare with my prediction?What worked? What didn’t work? What will Itry differently next time?Application of Executive Function Interventionsto the IEP/504 Process

For educational purposes, the goals forpromoting executive system functioning areinterrelated with all of the academic subjects andsocial/communication situations if they meet thefollowing conditions (as most will) of: novellearning or processing tasks necessitating goal-oriented performance requiring a delayedresponse and involving multiple steps over aperiod of time. Therefore, for the student withexecutive/ organizational deficits, the executive/organizational strategies are important to linkdirectly with each academic content area(reading, writing, math, science, etc.).


One's executive/ organizational skills areincreasingly in demand as the curriculum in thehigher grades becomes more complex. Therelationship between these two factors is quitedirect, i.e., greater complexity of learningnecessitates greater use of efficient executiveskills. The curriculum in the later elementaryand into middle/ high school requires thestudent to derive information from increasinglycomplex text, reproduce this information inappropriately organized written form, and do soin an increasingly independent manner. Thus,tasks for which students may have difficulty arethose that: (1) are long-term (requiringplanning); (2) require organization of lots ofdetailed information (e.g., a specific multi-steptask), and; (3) that are to be completed in acertain time frame (requiring timemanagement).

In addition to recommendationsprovided in Appendix A, translation ofexecutive function interventions into thelanguage and context of the IndividualizedEducation Plan or the 504 Plan is necessary. Aset of sample IEP/ 504 Plan goals and objectivesare provided below70. Importantly, rather thanspecific academic curriculum “content”, thesegoals focus on the development of a learningand/or problem-solving “process” designed toenhance the efficient learning and memory ofacademic information. Implementation of themethods to achieve these unique, non-traditional“learning process” goals will likely requireadditional training and guidance of schoolpersonnel. The emphasis of support should be onteaching, modeling, and cueing an approach toself-management of learning through activeplanning, organization, and monitoring of work.

In the IEP, we recommend theoverarching, long-term goal for the student withexecutive dysfunction be stated as follows:“The student will independently employ asystematic learning/ problem-solving method(e.g., Goal-Plan-Do-Review - GPDR) for all

70 Ylvisaker (1996) Executive System IEP Goals, personalcommunication.

academic tasks and activities that involvemultiple steps and/or require long-termplanning.” Domain-specific goals andobjectives can then be articulated. For studentswho are younger or with more severe executivedysfunction, the objectives might be prefacedwith: “With directed assistance, The studentwill . . .”1. Goal Setting:

a. The student will participate withteachers in setting instructional goals(e.g., "I want to be able to read thisbook, write this paragraph, etc.”)

b. The student will accurately predict howeffectively he/ she will accomplish atask. For example, he/ she willaccurately predict whether or not he/ shewill be able to complete a task; predicthow many (of something) he/ she canfinish; predict his/ her grade on tests; etc.

2. Self-Initiating:a. When The student does not know what

to do, he/ she will ask the teacher.b. With regular/ minimal prompting from

the teacher, assistant or parent, Thestudent will begin his/ her assignedtasks, initiate work on his/ her plan, etc.

3. Planning:a. Given a routine (e.g., complete sheet of

math problems, write a paragraph), thestudent will indicate what steps or itemsare needed and the order of the events.

b. Given a selection of 3 actions necessaryfor an instructional session, The studentwill indicate their order, create a plan onpaper, and follow the plan.

c. Having failed to achieve a predictedgrade on a test, The student will create aplan for improving performance for thenext test.

4. Organizing:a. The student will follow/ create a system

for organizing personal items in his/ herlocker.


b. The student will select and use a systemto organize his/ her assignments andother school work.

c. The student will prepare an organizedoutline before proceeding with writingprojects.

5. Self-Monitoring, Self-Evaluating:a. The student will keep a journal in which

he/ she records his/ her plans andpredictions for success and also recordshis/ her actual level of performance andits relation to his/ her predictions.

b. The student will identify errors in his/her work without teacher assistance.

6. Self-Awareness:a. The student will accurately identify tasks

that are easy/difficult for him/ her.b. The student will accurately identify his/

her strengths and weaknesses.Conclusion

Given the incidence of Attention-Deficit/Hyperactivity Disorder and its potentialfor adverse impact on the student’s educationalprogress and success, one must consider anactive plan of intervention. When organizing acomprehensive set of educationally-relevantinterventions, in addition to the traditionalbehavior modification programs andpsychopharmacologic approaches, we argue thatthe understanding of ADHD is entering the eraof the executive functions, with greaterreference to the underlying brain bases of thisdisorder. Several theoretical models have beenproposed for the inclusion of the executivefunctions within the description of ADHD. Ourown work supports these theoretical models bydemonstrating the integral role of the executivefunctions within the diagnosis and functionaldescription of ADHD. The traditional triad ofsymptoms, inattention, impulsivity, andhyperactivity, are not the only significantfunctional issues associated with ADHD. Webelieve the various domains of executivefunction are highly relevant for considerationand inclusion in an appropriate educationalintervention. These problems are the very

essence of what parents and teachers describe intheir list of concerns.

We further advocate for educationalintervention teams to become familiar with theconcepts and methods for proper comprehensiveassessment of the student’s profile of executivedysfunction, thus enabling intervention planningand implementation of the relevantinterventions. Several surveys of schoolpersonnel, particularly school psychologists,indicates a need for more training in theconcepts, assessment and intervention methodswith respect to the executive functions. Wereview the unique aspects that executivefunction brings to learning as well as thedistinctive ways that the interventions must beconceptualized. Returning to our metaphorinvolving the conductor of the orchestra, webelieve one would approach the interventionprocess differently if a poor musical productwas the result of deficient orchestra playersversus a faulty leader/ conductor. The sameprinciple applies to educational interventionswhen executive dysfunction plays a primary rolein the student’s learning or social-behavioraldifficulties. Simple, skill-based treatments thatare taught to the student and are to be carriedout solely by the student, without regard to theprocess of his/her learning and theenvironmental conditions that support thatperformance, are often doomed to fail. Theseintervention methods are complex as they aremeant to provide the student with meaningful,functional routines that are geared towardeffective “online” problem-solving. Yvisakerand colleagues71 skillfully illustrate thiscollaborative process between the student andhis/her educational “caretakers.”

In addition to a conceptualbackground to the executive functions, weprovide a model and sample illustrations ofintervention plans that can assist professionalsin developing appropriate process-oriented,

71 Ylvisaker, M. & DeBonis, D. (2000) ExecutiveFunction Impairment in Adolescence: TBI and ADHD.Topics in Language Disorders, 20, 29-57.


collaborative educational problem-solvingroutines within meaningful everyday contexts.We fully understand that the language of theIndividualized Education Plan (IEP) is not fullyoriented to goals and objectives that aredeveloped to address the student’s cognitiveproblem-solving process, but we also believethat these “process routines” are, in fact,appropriate educational outcomes amenable toobjective definition and monitoring. Creativeschool teams are challenged to articulate thesegoals in meaningful ways.


Appendix AExamples of domain-specific external andstudent-focusedexecutive function interventionsInhibitStudents with inhibitory control difficulties oftenrequire additional structure in the environment atthe outset in order to maintain more appropriatelycontrolled behavior. It is important to appreciatethat, by definition, children with inhibitorycontrol problems do not anticipate consequencesof their actions. Thus, controlling antecedents totheir behavior, or environmental stimuli that maylead to impulsive behavior, is essential.Distractions need to be limited, and tasks oftenneed to be kept more focused and time limited.Social difficulties often become apparent forchildren with inhibitory control difficulties.Children who behave impulsively with peers maysay or do inappropriate things and peers will learnto keep their distance. It is important to interveneearly to avert social difficulties and the negativeeffects on the student’s self-esteem.

External Structure. (1) Provide moreexplicit, extensive and/or clear set of rules andexpectations, and reviewed with studentregularly. (2) Limit distractions, includingvisual and auditory distractors, as well as otherstudents or activities that can pull attentionaway from a task (3) Reduced homeworkrequirements to within the student’s capabilities,with stepwise increases as he/she demonstratessuccess.

Student-based interventions. (1) Teachresponse delay techniques, such as countingbefore responding. (2) “Stop and think”methods teach students to inhibit their initialresponse, to consider potential consequences,and to further develop a plan of approach to asituation. (3) Frequent, brief breaks with motoractivity can be a reward for work completed.The student might complete a small amount ofwork before bringing it to the teacher forreview. (4) Use cross-age tutoring or mentoringwith an older student who can modelappropriate social behaviors. (5) More focused

and well-controlled peers can serve as rolemodels in small group activities with adultguidance. (6) Guided observations of peerinteractions may help the student learn moreappropriate social skills. (7) Limit time inunstructured activities. The student might joinan activity with a pre-arranged expectation thathe/ she will take a break after a set period oftime and review successes and any areas ofdifficulty.ShiftRemaining consistent is an important aspect ofstructured, systematic teaching, and promoteslearning and generalization across settings andtime. Consistency in teaching and managementdoes not imply rigidity, but rather a systematicform of teaching and dependable, predictableenvironments. Increased consistency is oftennecessary at the outset for children withdifficulties shifting or adjusting to changes inroutine, schedule, or activity. This may includethe use of teaching and behavioral strategies thatremain the same across time, environments, andpeople. Often a child's preference for samenessor insistence on routines and sameness reflectthe degree of anxiety and distress he/ sheexperiences with change. While respecting thestudent’s need for the comfort which his/ herroutines may provide, the learning and homeenvironments can gradually and incrementallyintroduce minor changes, one at a time.

External Structure. (1) Develop a set ofpositive routines and a set of alternativeroutines. The day can be viewed as a sequenceof routines, such as a morning routine, schoolroutine, and evening routine. These can befurther broken down into several sub-routines,such as brushing teeth, washing up, gettingdressed, and packing a backpack for school.The student may then be able to learn alternativesub-routines, such as different ways to get toschool, that can be practiced and swapped inand out of the larger routines. This can build inthe appearance of flexibility. (2) Use externalprompting to shift attention, behavior, or


cognitive set from one activity or focus to thenext.

Student-based interventions. (1) One ofthe most effective strategies is the “two minutewarning.” Teachers and parents can alert thestudent that one activity is about to end andanother will begin. (2) Allowing a fewminutes of “down time” or leisure activitybetween the end of one activity and the next canfacilitate transitions. (3) Make the change inactivity another form of routine. (4) Changes inscheduled activities, persons, or events can beplaced on a schedule and called to attention withadvance notice. This provides more time toadjust to the change. (5) Set time limits foreach task before a shift to the next task isrequired. Use of a timer can facilitateadjustment to change in activity.Emotional ControlChildren with executive difficulties, particularlywith fragile inhibitory control and/or difficultiesadapting to change in their home and schoolenvironments, may express their feelings morestrongly and more directly than most children.This can make them seem more angry, irritable,sad, or silly than their peers. Such emotionalexpression should prompt evaluation to rule outmood or affective difficulties. When difficultieswith modulation of affect occur in the context ofother self-regulatory problems, management ofthe child’s executive difficulties may be helpful.

External Structure. (1) Manage stimulior antecedents that appear to produce emotionalchanges or outbursts. Some situations, peers, ortasks may need to be initially avoided or limiteduntil the student experiences more success inmanaging emotional expression. (2) Thestudent’s parents and teachers can modelappropriate emotional modulation. They mighttalk aloud through a situation that provokesfeelings of anger or sadness, and explain howthey will deal with their feelings. (3) If thestudent responds with emotional outbursts toschool work, it may be helpful to return tomastery or success levels and to adjustacademic demands.

Student-based interventions. (1 )Difficulties with emotional control can often beviewed as one expression of disinhibition.Techniques for supporting inhibitory controland reducing impulsivity may be helpful. (2)Provide opportunities to discuss upcomingsituations or events that may provoke anemotional outburst. (3) Teach a concrete,simple metaphor to help increase emotionalmonitoring and increase the likelihood of amore appropriate response. For example, thestudent might work in therapy to develop a“thermometer” or “speedometer” metaphor formeasuring anger or distress. He/ She mightlabel each temperature or speed to reflectdegrees of anger, such as “10 = normal, 20 =irritated, 30 = getting mad….100 = out ofcontrol.” Each level can then be tied to aspecific concrete behavior, such as counting todelay responses, terminating the conversation,seeking adult intervention, or immediatelyleaving the situation. (4) Increase the student’sawareness of potential for emotional reactivityand likely consequences.InitiateIt may be helpful to appreciate that childrenwith initiation difficulties have trouble “gettinggoing” or starting. This can be exhibitedbehaviorally, such that they cannot get startedon physical activities such as getting up, sociallysuch that they have difficulty calling friends orgoing out to be with friends, academically suchthat they have trouble getting started onhomework or assignments, or cognitively, suchthat they have difficulty coming up with ideas orgenerating plans. Deficits in “primary”initiation are relatively rare and are oftenassociated with significant neurologicaldisorders (e.g., traumatic brain injury, anoxia,radiation). More commonly, initiation deficitsare the secondary consequence of otherexecutive problems (e.g., disorganization) oremotional disorders (e.g., depression, paralyzinganxiety). Basic tenets of intervention includeproviding additional external structure,


prompting and cueing, and helping organize andplan.

External Structure. (1) Increasedstructure in the environment or in an activity canhelp with initiation difficulties. Building inroutines for everyday activities is oftenimportant, as routine tasks and their completionbecome more automatic, reducing the need forindependent initiation. For example, themorning routine can be broken down into asequence of steps, and these steps can be writtendown on index cards or a simple list. Thestudent might then follow the list of steps eachday with supervision as needed until the routinebecomes automatic. The student can learn touse such lists as prompts. (2) Externalprompting may be necessary to help the studentget started. The student’s teacher might stop byhis/ her desk at the outset of each task andprompt him/ her to start his/ her work, orperhaps demonstrate the first problem of aworksheet. At home, his/ her parents mightneed to similarly prompt him/ her to get startedon homework, chores, or to go out with friends.

Student-based interventions. (1)Children who demonstrate difficulties thinkingof ideas may benefit from learning a structured,systematic approach to idea generation. Theycan be taught idea generation strategies to helpdevelop ideas for topics, activities, or ways toapproach a problem. (2) Providing “to do”lists on paper or index cards can be a method ofdeveloping automatic routines and can serve asexternal cues to begin an activity. Somechildren benefit from keeping a binder or“cookbook” with lists of steps for each activity.They can look up a page with steps forcompleting a specific task, and use the list toguide their activity. (3) As with any executivedifficulty, it can be helpful to increase thestudent’s awareness of his/ her difficultyinitiating. As he/ she becomes metacognitivelyaware of his/ her own difficulties getting started,he/ she can participate actively in usingstrategies.Working Memory

External Structure. (1) Pre-teaching thegeneral framework of new information andguiding attention to important points to listenfor can be an essential tool for circumventingworking memory difficulties when theyinterfere with ability to capture new material.The student might meet with a resource teacheror aide at the outset of each day and preview thegist of what will be learned that day. (2) Therate of presentation for new material may needto be altered for the student. He/ She may needadditional processing time or time to rehearsethe information. (3) Children with workingmemory difficulties often need tasks orinformation broken down into smaller steps orchunks. (4) Children with working memorydifficulties can benefit from learningcompensatory skills to apply independently.

Student-based interventions. (1) Manychildren demonstrate a natural tendency to use“self-talk,” or verbal mediation in order to guidetheir own problem solving and to direct theirattention. Such verbal medication strategiesmight be encouraged or taught directly. (2)Providing a written checklist of steps required tocomplete a task can serve as an externalmemory support and alleviate some of theburden on working memory. (3) The studentcan learn how to actively listen, such asstopping what he/ she is doing at the time, focushis/ her attention, ask questions, restate theinformation or question, or take notes. (4)Mnemonic devices (i.e., memory strategies) areimportant tools to help children with workingmemory difficulties learn, and later recall, basicskills and facts. (5) Teach the student to“chunk” information to help increase theamount that he/ she can learn or capture at onetime. (6) Use rehearsal to increase the amountof information encoded into memory. Thestudent might need to practice a series of stepsfor solving a problem, memorizing a list of keyfacts, or completing an everyday activity inorder to accommodate his/ her more limitedworking memory at the outset. (7) Have thestudent repeat or paraphrase what he/ she has


heard or understood in order to check foraccuracy and to provide an opportunity forrehearsal. Ultimately, teaching self-initiated“comprehension checking” strategies (e.g., thechild asking for repetition of instructions) helpsto promote independent management ofworking memory weaknesses.Planning

External Structure. (1) It is often helpfulto provide examples of how students might plandifferently to complete the same task, so that thestudent can see options for alternative methods.(2) Children with difficulties planning maybenefit from having a binder or “cookbook” ofsteps for common routines or assignments.They might have a section for approaches tospecific types of math problems, writingassignments, or reading materials and canreference the plans as needed. (3) Childrenwith difficulties planning may benefit fromhaving a binder or “cookbook” of steps forcommon routines or assignments. They mighthave a section for approaches to specific typesof math problems, writing assignments, orreading materials and can reference the plans asneeded. (4) Teacher/ Parent modeling is animportant means of teaching good planningskills. The student’s parents can discuss plansfor the day at the breakfast table, or verbalizetheir thinking about how to approach a series oferrands. The use of the child’s planning guidefor the parent’s multi-step activities may serveas a good model. Developing an overall planfor the day, week, month and year with acalendar can also serve as a useful exercise.

Student-based interventions. (1) Involvethe student maximally in setting a goal for theactivity or task. Encourage him/ her to generatea prediction regarding how well he/ she expectsto do in completing the task/ activity. Structureplanning and organization efforts around thestated goal. (2) Active, maximal involvementof the child in the development of plans isimportant. The use of a planning guide may benecessary to reduce the organizational andworking memory demands of this multi-step

process. (3) Have the student verbalize a planof approach at the outset for any given task,whether everyday chore or routine or academicactivity. The plan can be broken down into aseries of steps, arranged in sequential order, andwritten down as a bullet list. The plan can beguided interactively with his/ her parent orteacher to achieve sufficient detail and increaselikelihood of success.Organization

External Structure. (1) Presentinformation in well-organized manner at theoutset. Children with difficulties grasping newconcepts or the gist or framework of newmaterial often do best when the material ispresented in a structured fashion. Teachers thatoffer a higher degree of structure in theircourses may be a better fit for the student. (2)Keeping an extra set at books at home can be apowerful tool for helping children withorganizational difficulties, as it alleviates a needto remember what books to bring back and forthand provides ready access to materials at schooland at home. (3) Given the particular difficultymanaging complex, long-term assignments,students with organizational difficulties oftenbenefit from working on only one task, or onestep of a larger task, at a time. Tasks may needto be broken down into smaller steps in order tofacilitate organization and planning. Long-termassignments, such as term papers or projects, areoften insurmountable for children withorganization and planning difficulties.

Student-based interventions. (1) Call tothe student’s attention the structure of newinformation at the outset of a lesson or lecture.(2) Previewing the organizational framework ofnew material to be learned in bulleted or outlineform may increase appreciation of the structureand enhance the student’s ability to learnassociated details. (3) It may be helpful toprovide an outline or list of major points prior tothe lesson. (4) Having the student restate theoverall concept and structure of the informationor task following a lecture will provide anopportunity to ensure accurate understanding as


well as an opportunity to correct anymisunderstanding. (5) As the student becomesmore aware of difficulties grasping organizationof new information, he/ she may be able to learnto search for the organizational frameworksinherent in novel material. (6) Students withdifficulties keeping track of their assignmentsmay benefit from learning to use anorganizational system, schedule book or dailyplanner. Use of such as system is a useful toolfor many aspects of organization and planning,but requires effort on the part of the student,parents, and teachers. (7) Specific, strategicapproaches for reading (e.g., SQR3) can betaught to facilitate the student’s efficiency inlearning new material. For example, the studentmight learn to first examine the chapter outlineor list of heading, then read the chaptersummary and focus questions beforeapproaching the body of the text.Organization of Materials

External Structure. (1) Children withdifficulty maintaining reasonable organizationof their environment and materials may benefitfrom increased external structure fororganization and from developing goodorganizational routines in general. (2) Havingan extra set of books at home can be a simpleyet effective means of ensuring that The studenthas the required materials at home and in schoolfor completing his/ her school and homework.(3) Some children can benefit from having achecklist of needed materials to review on adaily basis before leaving home for school,and/or at the end of the school day.

Student-based interventions. (1) Thestudent may need help from his/ her parents andhis/ her teachers in reviewing materials neededprior to a given task or at the beginning and/orend of the day. To facilitate development ofgood organizational habits, the student mightreview with his/ her parents each morning his/her plans for the day, the associated materials toaccomplish his/ her goals, and the organizationof the materials in his/ her backpack or desk.Similarly, he/ she might have some

“organization time” at the end of the school dayto arrange his/ her materials.Self-Monitoring

External Structure. (1) Provide thestudent with opportunities for self-monitoringhis/ her task performance and social behavior.Provide cues, as subtly as possible, if necessary.(2) Often, children with difficulties monitoringtheir output do not recognize their own errors.It may be helpful to build in editing orreviewing as an integral part of every task inorder to increase error recognition andcorrection. (3) Setting goals for accuracy ratherthan speed can help increase attention to errors.Rewarding the student for accuracy may supportcontinued focus on monitoring his/ her work.

Student-based interventions. (1) Askthe student to predict how well he/ she will doon a particular task, then compare predictionwith outcome in order to increase his/ herawareness of his/ her strengths and weaknesses.Encourage charting of performance and/orbehavior in order to provide a tangible record ofactivity for ongoing monitoring. (2) It may behelpful to videotape an activity or situation thenreview together. This allows the student to seehimself from others’ perspective. Discussion ofthe videotape with an adult, such as a guidancecounselor or therapist, is essential. This methodshould be considered carefully, and approachedcollaboratively with the student’s, parents’, andother participants’ consent. While videotapingcan be a powerful tool, there is also potential foremotional consequences and negative effects onself-esteem. (3) Verbal mediation can be auseful tool for helping children direct focus totheir own behavior or work. The student mightbenefit from talking through a task, as this canincrease attention to the task and, secondarily,increase error recognition. Model, cue, andencourage the use of the phrases “What works?”and “What doesn’t work?” as self-monitoringtools.

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