The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Dr. Warner has a private practice in Wisconsin
drcollenn@charter.net
Definition of Executive Dysfunction:
A neuropsychological concept referring to the cognitive processes required to plan and
direct activities, including task initiation and follow-through, working memory, sustained
attention, performance monitoring, inhibition of impulses, and goal-directed persistence.
(definition from Dawson, P. & Guare, R., Executive Skills in Children and Adolescents:
A Practical Guide to Assessment and Intervention, Guilford Press, New York, 2004)
10 Areas of Executive Function: (the number of functions varies according to who
categorizes them)
1. Sustaining Attention
2. Shifting Attention
3. Inhibiting Impulses
4. Initiating Activity
5. Working Memory
6. Emotional Control
7. Planning and Organizing
8. Organization of Materials
9. Self-Monitoring
10. Time Management
These functions can be summarized in 3 or 4 factors: (Anderson, P., “Assessment
and Development of Executive Function (EF) During Childhood, Child
Neuropsychology, 8 (2), 2002, pp. 71-82)
1. Attentional Control: selective attention, self-regulation, self-monitoring,
inhibition
2. Cognitive Flexibility: divided attention, working memory, conceptual transfer,
feedback utilization
3. Goal Setting: initiation, conceptual reasoning, planning, strategic organization
4. Information Processing: efficiency, fluency, speed of processing
In elementary school the teacher is often the CEO, so those with EF problems can
skate by. Middle school begins to be a real problem for those with EF difficulties. In
middle school kids the part of the brain that carries out EF is being reconstructed, so it’s
not always totally available. Most students need help to learn EF skills.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Sustaining Attention
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Ability to hold one’s focus on the task at hand long enough to complete it.
A pre-requisite to other executive function skills.
To stay with or stick to an activity, especially if it’s hard or boring.
A person can’t plan if they don’t have sustained attention.
A planner by itself won’t help those who can’t sustain their attention.
Computer games are very interesting, rewarding, and stimulating and may
enable sustained attention during those activities, but they tend to have a similar
effect to cocaine.
Accommodations
 Write start and stop times on assignments.
 Use incentive system.
 Increase excitement about tasks by making them a game, giving a reward,
letting the student make their own answer key, having them check the adult’s
work (make mistakes on purpose.)
 Use a timer/challenge to increase excitement, if the student isn’t anxious.
 Interruptible timer for timed tasks; break down as needed but give same
amount of time as everyone else.
 Do difficult tasks when most alert.
Interventions
 Model, assist, prompt, then monitor breaking assignments into manageable
tasks and developing a work plan.
 Practice focusing for short periods of time, then gradually increase the time as
a challenge. Monitor the length of time and increase as student handles it.
(this can backfire, so be careful)
Shifting Attention
 Ability to move freely from one situation, activity, or aspect of a problem to
another as the situation changes.
 Ability to shift one’s attention from one task to another.
 Ability to let go of one idea or strategy that is proving ineffective and try another.
 Ability to make transitions.
 Can a student be interrupted and then go back to what they were doing?
 Ability to solve problems flexibly. If unable to do this, may be unable to accept a
suggestion (often seen in students with Asperger’s).
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Environmental Modifications
 Visual calendars.
 Increase supervision at transitions; have locker close to an adult who can
monitor.
 Anchor changes with known situation.
 (“Remember last week when I worked late and you went to latch key?
Well, today I have to work late and dad is going to pick you up.”
 Set the student up for liking a different person.
 Prompts for stopping. Make sure they do.
 Provide preparation and warnings prior to changes in schedule or activity.
 Provide verbal structuring to aid in shifting mindset.
 E.g. “Now we are going to do something different. English is over. Math is
starting. Put away… Get out…
Interventions
 Practice shifting from one activity to another.
 Practice change, change is good, change is fun. Notice all of the changes in
30 seconds; do the regular task, but notice all of the changes (give a prize for
noticing). Start with less anxiety-producing changes first.
 Play games that require changing strategies such as UNO. This may make
some students very anxious, such as those with Asperger’s.
Inhibiting Impulses
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Ability to control impulses.
Capacity to think before acting.
To appropriately stop own behavior at the proper time.
Ability to resist the urge to say or do something long enough to evaluate the
situation and how one’s behavior might effect it.
 Students with this problem may be inconsistent from one day to the next.
Accommodations
 Use immediate reinforcers such as smiles, approval, praise. Change
reinforcers frequently.
 Do not withdraw recess! May take away free choice, but still do physical
activity. Talk to parents first.
 Provide lots of physical activity.
 Provide redirection.
 Cue: “Did I think it only or did I say it?”
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Environmental Modifications
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Provide a “wiggle” ball or other object to direct physical energy to.
Use a weighted vest.
Provide cues of what to do, instead of telling what not to do.
Use a Velcro strip on the desk for a fidget.
Set up a delivery job for the student; may help if it’s something fairly heavy,
such as having teachers trade dictionaries twice a day.
Set rules for equipment; if something is thrown then it goes in time-out.
Increase external controls—restrict access to settings or situations.
Increase supervision.
Proximics! (having locker close to an adult)
Find ways to provide cueing such as a card on the desk that’s red or green for
young students. Older students who have good energy but annoy others
could have a secret signal that’s not routine for everyone, or an adult could
put their hand on the student’s shoulder as a signal. Provide cueing in a way
that doesn’t embarrass the student.
Initiating Activity
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Ability to begin a task or activity without undue procrastination.
Ability to independently generate ideas—can a student brainstorm?
Drive, desire, or motivation to complete work.
Can the student get themselves interested in the task?
With initiation problems it’s important to rule out a mood disorder or substance
abuse. Depression interferes with initiation and so do marijuana and alcohol.
With the latter two a person tends to think they are doing better than they actually
are. If there is a change in initiation, rule out depression or chemical use.
Environmental Modifications
 Provide prompts to begin
 Work with student to complete the first portion of the task, then fade
involvement (“Do two by yourself and then I’ll do one with you.”)
 Structure routines, such as homework at the same time in the same place.
 Provide options or choices if not anxious; forced choices.
 Raise motivation. Raise anxiety slightly.
 If anxious, tell where to start.
 Use the Premack Principle or “Grandma’s Rule”—non-preferred activity
before preferred.
 Sometimes if told to do nothing, will start doing something.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
 With teenagers, especially boys, rule out drugs and depression. Find out what
they’re interested in such as sports, a driver’s license, or a girl. If they want a
girl, make a list of what she might want in a guy; don’t usually want someone
with no plans, no job, who didn’t graduate.
 Ask: “Do you want to live with your parents forever?”
 Parents can make home unpleasant; make the teenager or young adult work
for everything.
Working Memory
 Ability to hold information in your mind while you complete a task.
 Ability to keep in mind information needed to complete a task.
 Ability to hold and move between differing sets of information long enough to use
them, such as files you have open on a computer.
 Ability to draw on past learning and apply to situations in the present and future.
 Remembering oral directions and oral story problems need working memory.
 If problems with this may forget the questions that need to be answered as you
read a passage.
 Students with working memory problems often learn better with hands-on tasks,
kinesthetically.
 School makes many demands on working memory.
Accommodations
 Avoid multi-step directions, if possible. If they are necessary, write them in
bullets.
 Reduce demands; simplify schedules.
 Expect to repeat directions.
 Provide prompts for each step of an activity.
 Provide templates for step-by-step procedures. Teach student to write a
template at the beginning of tests.
 Provide written and verbal outlines for new information or priorities. “This is
really important.”
Environmental Modifications
 Provide word lists or other prompts for material needed to complete an
assignment.
 Choose recognition tests rather than recall tests.
 Use storage devices (word banks, agendas/calendars, notebooks, recorders,
palm pilots). Have large spaces to write when using calendars.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
 Cueing devices: (parent, peer, alarm watch, visual cues, Post-its). Put the
Post-it on hand as going to do something. Keep Post-its in the car. Textmessage or e-mail self.
 Picture phone: Take a picture of the assignments on the board.
 Use natural cues in the environment (medication next to toothbrush).
Teaching Skills
 Digit span practice.
 Teach use of concrete reminders.
 Provide written cues, then over time move student to writing own cues with an
adult to double check them.
 Teach memory techniques such as mnemonics, chunking, visualization,
repeating information, using rhythms. Singing information often works well.
 Ask students how they remember and use what they suggest.
 Teach to make own lists, such as what they are supposed to buy on the way
home: apples, bananas, milk, cheese.
Emotional Control
 Ability to modulate emotional responses appropriately.
 Ability to manage emotions in order to achieve goals, direct behavior, or
complete tasks.
 Ability to calm down long enough to get things done.
 Students with problems in this area may be overly anxious, obsessive, or easily
upset.
 Other areas of executive functioning will fluctuate, depending on emotions.
How to Avoid Making Emotional Meltdowns Worse:
Environmental Modifications
 Provide a quiet “calming down” place. It’s best if this is not associated with
discipline. It could be a person. Eventually teach the student to go to this
place in their mind.
 Offer choices.
 Anticipate, avoid, or prepare for situations likely to be difficult. Can often do
this in counseling or therapy.
 Avoid reasoning or power struggles.
 Give breaks when tension is rising.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
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The counselor might have “Get Out of Jail Free” cards for student to use
when they feel they are going to lose control. However, limit the number of
these.
When students are anxious they tend to freeze or withdraw. It’s important
to let them have some space.
With students who have manic-depression, stay calm yourself and back
off if you can, wait until student is calm, validate their feelings.
 Strategies for calming:
 “Tell me everything from the beginning and don’t leave anything out.”
 “Count backwards from 100.”
 Offer the student choices.
 Remember that you can’t calm someone down; they have to regain
control.
 Be aware that some students will still have meltdowns in spite of these
strategies.
Teaching the Skills
 Teach emotional vocabulary. Brainstorm words for most to a little of an
emotion such as “mad.” Write in a continuum and ask the student how they
know when they are in each state.
 Teach self-monitoring skills.
 Teach relaxation skills, distraction skills, “anger management” skills.
 Practice positive self statements.
 Practice skills, don’t just talk about them.
 Encourage the student and parents to get therapy.
Planning and Organizing
 Ability to arrange or place things according to a system.
 Ability to anticipate future events, set goals, carry out tasks in a systematic
manner.
 Ability to develop steps necessary to complete a task or action.
 Ability to prioritize and focus on priorities.
 Ability to understand and communicate main ideas or key concepts.
 A student may have lofty goals with no sense of how to accomplish them.
 Writing may be rambling and disorganized.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Environmental Modifications
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Have adult provide a plan or schedule for student to follow.
Use scoring rubrics for student assignments.
Provide separate points or grades for each step of a project.
Break long-term or long assignments into clearly defined subtasks.
Create an assignment template with the steps:
 A. Pick an historical figure (with an example)
 B. Read about the person and come up with three facts.
 C. Write each fact on a card.
 D. Write sentences that include the facts.
Teaching the Skills
 Have the student break down tasks into smaller steps. Ask, “What’s first?
What’s next?”
 Start with a preferred activity (such as planning a party).
 Have the student identify “key concepts”, such as the theme of the party.
 Have the student use a planner or organizer. Work with them to complete it.
Interventions
 Teach one planning strategy that can transfer across situations, such as goal,
plan, do, review.
 Use preferred activities to model skills.
 Have the student coach someone else on something they know well and
enjoy.
 Follow the student’s lead for what works for them.
1. Walk the student through the planning process many times with different
tasks. You do the planning and talk out loud.
2. Provide specific prompts for the student to do the planning.
3. Provide general prompts.
4. Have the student verbalize what they need to do as they plan.
5. The student plans independently and you check their plan.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Meichenbaum’s Metacognitive Behavior Management
What is my problem?
How can I do it?
Goal
Plan
Am I using my plan?
How did I do?
Do
Self-Evaluate
Organization of Materials
 Ability to keep one’s workspace, play areas, and materials in an orderly manner.
 Ability to determine what materials or resources are necessary to a task and
have them available; must plan ahead to get them, think through what’s
necessary.
 A person may know what they need to do, but not have their stuff ready.
External Modifications
 Develop rituals or routines for organization. Cue and reinforce their use. Keep
materials in the same place; have extra items ready to go when packing for a
trip.
 Teach use of a “launching pad” (things ready to go) and an “in/out box.”
 Use simple organizational schemes. For young students use one folder with
the left side for “in” and the right side for “out.” For older students use an
accordion file. Keep a laminated calendar in front. First divider: “to turn in”,
second divider: “to take home,” then each subject.
 If work doesn’t come home in folder, positively reinforce that the folder came
home. If no folder, then have student do extra work at home.
 Keep a second set of textbooks at home. Make use of assignments and
materials online. Fax or e-mail assignments in.
 Color-coding may work for some students, but colors tend to be harder to
identify with.
Interventions
 Model strategies with gradually decreased cueing.
 Note: Development of these skills takes a long time, so don’t give up.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Self-Monitoring (Metacognition)
 Ability to take a “bird’s eye view” of oneself to observe how you problem solve
 Ability to self-evaluate. Ability to ask oneself, “How am I doing? How did I do?
How could I improve?”
 Ability to talk oneself through tasks.
 In OCD and anxiety disorders there’s too much self-monitoring, although people
with these may not monitor other things.
 Self-talk is important and may be hard for those with language problems; pictures
can help with this.
Interventions
 It’s important to be able to think out loud.
 Model this by talking out loud about monitoring your own progress on a task
and a student’s progress.
 Have the student practice evaluating their performance step-by-step.
Time Management
 Ability to estimate how much time a task will take; having an internal sense of
this.
 Ability to estimate how much time one has, how to allocate it, and how to stay
within time limits and deadlines.
 Recognition that time is important.
 This ability develops as we get older.
 May spend too much time on one part.
 If there’s a problem the person is probably late most of the time.
 It may feel like the time is short if it’s fun and long if it’s not.
Environmental Modifications
 Note: Time management is not the same as telling time.
 Provide a schedule and prompts for each step.
 Extend time limits. If a time limit is given, provide prompts (oral and visual) for
much time is left.
 Use cueing devices such as clocks, bells, or alarms. Use any technology
that’s already available.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Interventions
 Practice estimating how long something will take and then actually timing it.
Discuss accuracy.
 Develop temporal reference points (length of a CD, song, favorite TV show).
 Develop schedules and routines.
 Teach concepts of “work time” and “non-work” or “silly” time. Some things are
not OK during work time.
General Interventions and Accommodations
Dr. Warner uses the “principle of the least dangerous assumption” if people are
resistant to intervention or accommodation when she feels it would be helpful. People
sometimes tell her that a student might just be lazy and that intervention will waste time
and money. If the student has EF and there are no accommodations the consequences
could be very bad. Evaluate the risk.
No Accommodations
Accommodations
Lazy
+
–
↓ed Executive Function
–
+
Medications
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May reduce some symptoms, but not all.
Stimulants help with attention and impulse control.
Anticonvulsants can help with emotional control, especially anger and irritability.
SSRIs (selective serotonin uptake inhibitors such as Paxil, Zoloft, and Prozac)
help with overfocus such as excessive rumination or being overly anxious.
General Strategies
 Keep it realistic and simple; begin with just 1-2 things.
 Repetition, repetition, repetition. Say (teach), do.
 Build habits and routines; this takes 30 days for normals and 90 days for those
with brain dysfunction. There are fewer demands for EF with this.
 Developmental progression from external (verbalize as teach) to internal. None
of us do EF completely independently.
 Visuals can help; eventually want the student to have a picture in their mind.
 Sometimes a student loses one thing as they begin something new.
The Boss is Out: Helping Students with Executive Dysfunction
Dr. Colleen Warner, Licensed Psychologist
Another General Strategy
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Provide the skill that is lacking.
Verbalize and model the skill that is lacking.
Verbalize and have the student do the skill.
Prompt the student to self-prompt, then prompt to do the skill. Ask questions to
get them to self-prompt. Then, “Now do that.”
Prompt the student to self-prompt and do the skill.
Have the student do the skill, prompting when needed. “What would happen
next?”
Fade prompting.
Occasionally check to see that the student is maintaining.
Fade checking.
If the student skips a step in the above sequence, that’s great!
General Accommodations: Altering Tasks to Enhance Success
(Dawson & Guare, pg. 37)
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Make tasks shorter.
Make steps more explicit.
Make tasks close-ended (a specific ending point).
Build in variety and choice
Provide scoring rubrics; clear expectations.