Executive Function Treatment and Intervention in Schools - Otero et. al. - 2014 - Article

Introduction

Executive function (EF)  refers to a variety of cognitive processes. These are largely mediated by the prefrontal areas of the frontal lobes that encompass both cognitive and affective constructs including planning, working memory, attention, inhibition, self-monitoring, self-regulation, and initiation. Success in various aspects of life is highly dependent on having intact EF abilities, especially within the educational environment. EF deficits in childhood have been shown to have a negative impact on academic, social-emotional, and adaptive functioning later in life, and they are present at all stages throughout development in children both with and without neurodevelopmental disorders. The extensive nature of EF deficits among all populations of school-aged children results in a critical need to begin developing and identifying research-based interventions that target both global and narrow aspects of EF.

How do children with EF deficits present in the school environment?

EF deficits in the school environment can be cognitive (which often manifest in academic difficulties) or affective (which are often viewed as behavioral problems) in nature. Students with deficits in EF may struggle with shifting between activities and/or may have difficulty prioritizing important tasks, as well as with time management and meeting deadlines. Planning for the future is difficult; they tend to only focus on the immediate and may struggle with resisting temptation, are impulsive, and do not think before they act. They may not appear to be paying attention and frequently get out of their seat or ask to leave the room, usually at inappropriate times.

Identification of EF deficits in the school setting

The multidimensional nature of EF requires the use of various diverse methods of assessment that take into
account the fact that EF constructs such as response inhibition, working memory, planning, and response preparation are independent in various ways, but also interrelated. Qualitatively, behavioral observations of how students approach and complete a task, as well as anecdotal reports from teachers and related school personnel are often a precursor to a referral for a standardized assessment of EF. Quantitative methods of assessment, such as the Cognitive Assessment System, Second Edition [CAS-2], Delis-Kaplan Executive Function System, NEPSY-II, Wisconsin Card-Sorting Test or behavior rating scales or frequency measures such as the Comprehensive Executive Function Inventory or Behavior Rating Inventory of Executive Function. 

Considerations for the selection of treatment methods and interventions in the school setting

6 general principles regarding EF training that must be considered when selecting EF interventions for children:

• Those who most need improvement benefit the most.

• Transfer effects from EF training are narrow.

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

• Repeated practice is key.

• Whether EF gains are produced depends on how an activity is done.

• Outcome measures must test the limits of the children’s EF abilities to see a benefit from training.

Before an intervention, it is important to consider:

• the age of the children

• the current level of developmental functioning of the child

• certain neurodevelopmental disorders such as ADHD and ASD

• a careful review of the diagnostic information available

• demographic, cultural, and other environmental factors to determine if the child exhibits a pattern of strengths and weaknesses across settings, and they should use this information when designing treatment plans, as interventions that focus on a child’s strengths and involve the support of the family are often more successful

• school personnel must answer the question of what is feasible to implement within the confines of the educational environment

Treatment methods and intervention strategies

Treatments Outside of the Scope of the School Setting

Intervention methods, such as psychopharmocology and neurofeedback treatment, are outside of the scope of the local education agency as they are considered medical and must be initiated by a parent or physician. The potential impact on outcome is critical when developing a comprehensive treatment plan to be implemented in the school setting, as well as considering the effectiveness of school-based interventions.

Computerized Training

Computerized training of EF typically targets working memory and/or attention. Within the school setting, computerized EF interventions implemented within a group setting are appealing, as they reduce the need for additional resources such as increased personnel, quickly provide rich data with minimal effort on the part of the interventionist, and monitor and continuously adapt the difficulty of the task based on the child’s performance on a given trial. However, research conducted on the efficacy of these interventions and the transfer of skills to other cognitive-processing tasks has presented with mixed results.

Strategy Instruction

Strategy instruction can be defined as a student-centered approach that supplies struggling learners with tools and techniques to understand and learn new material or skills while allowing for the direct and immediate application to practice in various areas of school and life. Strategy instruction is global by nature and targets a constellation of cognitive-processing abilities, including EF skills that are necessary to be successful in multiple settings. Strategy instruction is a preferred approach over behavioral interventions targeting EF deficits because not only do we help the child understand their weaknesses, but we also give them the tools to help remediate those deficits.

Curricula

The Educational Services Department of the Rush NeuroBehavioral Center (RNBC) has developed an EF Curriculum series utilizing a research-based framework combined with a classroom-based orientation. The RNBC EF Program identifies the following EF constructs as important for classroom instruction: self-regulation, self-awareness, goal-directed behavior, self-monitoring, and flexibility to solve problems and revise plans. Reviewing studies about the EF curriculum, it becomes clear that there is a need for future research using stricter methodology to examine the effectiveness of this curriculum across the four age levels (primary curriculum (kindergarten through 2nd grade), intermediate curriculum (3rd through 5th grades), middle school curriculum (6th through 8th grade) and high school curriculum (9th through 12th grade)), for which it is designed.

Mindfulness and Physical Activities

Mindfulness and physical activities that can positively impact EFs in children include meditation, martial arts, yoga, and aerobics, and they require repetition and continued practice to gain maximum benefits. 

Games

Traditional childhood games can help improve EFs in children and are easy to implement in the school setting. Games may help in the development of working memory and response inhibition. The development of EF through shared activities with peers is an enjoyable, low-cost way for students and schools to aid in the development of EF.

Future directions for the school setting

As interventions, such as psychopharmacology and neurofeedback are on the rise and have been found to be effective, particularly with special populations, such as children with ADHD, schools may find it wise to consult with medical practitioners and perhaps consider/providing families with referrals to outside service providers. Neurofeedback is an intervention that could be implemented in the school setting. 

Schools must also consider financial constraints when selecting interventions. Strategy instruction and mind/body approaches are both interventions that can be implemented in the school setting at little to no cost.

However, as the research base for EF interventions in schools is in its infancy, future studies should include factors that look at generalization and optimal developmental periods to achieve maximum effectiveness.