Executive Functioning difficulties are not well understood. We frequently hear from parents, students and educators who have questions and express confusion about this area of struggle. They see many kids diagnosed with ADHD and ADD, which are ostensibly about “attention”, but many people don’t fully understand what these diagnoses really mean, where the core deficits really lie, and what else is involved beyond a general understanding of what it means to “pay attention”.
Over the past decade, several studies have examined the prevalence of, and process for diagnosing, ADHD. These studies have revealed an increase in the number of diagnoses, as well as pediatrician variability in expertise and comfort making such a diagnosis. One such study found that there was substantial variability in the proportion of children receiving an ADHD diagnosis (1.3%–15.8%) across practices relative to other diagnoses (Mayne et al.). This is important to note. Generations of kids are being diagnosed with attentional issues, with medication as the primary treatment, yet many of those diagnosing and prescribing lack a clear understanding of the underlying processes and core deficits of ADHD. The relationship between ADHD and the ability or desire to pay attention is at the root of the misunderstanding about ADHD and attentional issues, and why at WPS teachers and leaders often avoid using the word “attention” when discussing an individual student’s learning profile, because that word can be so misleading. These difficulties are about so much more than whether or not kids are paying attention. Kids, and adults, fail to pay attention for a variety of reasons, not just because of an executive functioning or attentional problem.
At WPS, we work to isolate the learning problem and identify the core deficit leading to the child’s seeming lack of attention. Often, what we perceive as not paying attention is really about compliance: are kids doing what teachers expect and want them to do? If a child is not meeting that expectation, we erroneously jump to the reductive conclusion that they’re not paying attention. Instead, WPS educators focus on how kids process information and respond to stimuli, which is a much more complicated and nuanced way of thinking about these learning problems than solely through the lens of attentional issues.
Based on the work of many others in the field, we at WPS think of Executive Functions as describing the supervisory and self-regulatory mental processes involved in planning, organizing and responding in a flexible, strategic and appropriate way. Researchers highlight a variety of processes associated with supervisory and self-regulatory mental processes, such as “goal selection, planning, regulation of goal-directed behavior, and delay of gratification”. These, however, don’t always get fully to the core of what may be going on. We believe that these processes are more symptomatic of the problem: yes, a child with executive function struggles has difficulty with goal selection and planning, but why? That is why what teachers and leaders at WPS are really after.
What is the anatomy of the processes underlying executive functions? The process begins with some type of input or stimuli, such as something we’re asked to do, something we encounter randomly, an assignment we are given by a teacher, or even a request by a parent. This stimuli often includes expectations related to the time we have to respond, the norms of what a reasonable response is or not, or unique to a specific circumstance. Any time we receive new information, input of any kind, it has to fit into, or not fit into, our existing way that we understand the world – our existing schema. Students with executive functioning issues are particularly challenged to process input or stimuli that feels in conflict with their existing schema.
When we receive input we immediately have to engage our executive functions to engage at least four processes: reaction, organization, understanding, and evaluation. The most obvious one is to react, and this often happens at the expense of the other three. For example, someone pokes you in the eye with an umbrella on the street: it hurts, you cover your eye, and you say something in pain to them without pausing to organize or evaluate the situation. As a student, if your existing schema is that you have historically struggled with math, you might have a similar spontaneous reaction if someone gives you a difficult math problem in class. For WPS educators, this spontaneous reaction is an important tool. Frequently, we see kids with classic executive functioning difficulties react to an extreme, sometimes at the expense of the other things that executive functions should be doing simultaneously, because something they’ve been asked to do falls outside their existing schema.
At WPS, we encourage students to process information in a way that allows them to access other executive functioning processes – organization, understanding, and evaluation of stimuli – before they react. We talk about this process as a flow chart: we get input, we have to organize it to understand it, then we can evaluate and use it to plan and strategize. Only then do we produce a response. It is important teach our students – and note for ourselves – that an immediate response is not always the most strategic, or useful. We encourage students to use this process in a slow and deliberate way that ultimately allows them to be more creative and more connected with the world.
It is also important to highlight that executive functioning processes don’t exist in a vacuum. When a person receives input, they have to use language and comprehension to organize and evaluate the input they’ve received. This can be an additional challenge to students with specific learning difficulties beyond executive function. Simply put, one can think about executive, functions as an operating system that interacts with many other systems. Parents can understand their child and what they’re going through in a different and more nuanced way when they think about executive functions in this way.
Executive functions are complicated; yet, historically, all of these vastly different processes have been erroneously lumped together and labeled as ADD, and treated in mostly in one way. Helping kids with executive functioning difficulties requires adults to be agents of teaching kids how to work through the various processes involved in executive function response, including understanding their existing schema, teaching language, and teaching comprehension. Most importantly, in order for all of this to happen effectively, it needs to go slowly. The only chance we have of teaching kids to get better at organizing, understanding and evaluating the input they receive is to allow them the opportunity to slow down.
Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices.
Stephanie L. Mayne, MHS, a, b Michelle E. Ross, PhD, c Lihai Song, MS, a, b Banita McCarn, MEd, d Jennifer Steffes, MSW, d Weiwei Liu, MS, d Benyamin Margolis, PhD, MPH, e Romuladus Azuine, DrPH, f Edward Gotlieb, MD, d Robert W. Grundmeier, MD, g, h Laurel K. Leslie, MD, MPH, i Russell Localio, PhD, c Richard Wasserman, MD, MPH, d, j Alexander G. Fiks, MD, MSCEa, b, d, g, h, k
PEDIATRICS Volume 137 , number 5 , May 2016 :e 20152974