Zach is a 13-year old 7th grader whose parents brought him in for a psychological evaluation because of concerns about behavior and poor school performance over the last year or so. At school, his problems have included talking out in class and showing off. There are also occasional problems on the school bus. At home, Zach fails to complete chores without reminders, puts them off as long as possible, and rushes through them. Homework completion is inconsistent, and he gets detentions at school for missing homework assignments. Long-term projects are particularly challenging for Zach. On a daily basis, Zach finds it difficult to forego playing computer games and instant messaging when chores or homework call.
On the face of it, this sounds like a typical youngster with oppositional-defiant behaviors and perhaps mild attention problems who has conflicts at home and at school. But in an interview with Zach and his parents and evaluation with Zach, a more complex picture emerges. For one thing, although he and his mother, who has primary management responsibilities, often do not get along, Zach's father describes his relationship with his son as good. He notes that his son does not throw tantrums at home with him and responds well to his father's discipline. Both parents report that Zach feels bad when he knows he's done something wrong. While recent testing by the school showed Zach to be of above average intelligence, he was well below average on measures of processing speed and working memory (an ability to hold and manipulate information).
Weak working memory was also confirmed in the current evaluation, both on clinic tasks and on rating scales assessing that were completed by Zach's parents, one of his teachers, and by Zach himself. Furthermore, all three reported weaknesses in impulse control, task initiation, planning and organizational skills, and selfmonitoring. Most significant was Zach's own self-report. He indicated that he interrupted others, talked at the wrong time, had difficulty completing long-term projects, forgot to bring home from school materials to complete homework, frequently lost things and forgot instructions. It also became apparent that these problems were a source of frustration to him. On other self-report checklists he was moderately elevated on inventories assessing anxiety, depression, and disruptive behaviors, and his score on a self-concept inventory was much lower than average.
Left unattended, Zach's school performance would gradually deteriorate due to late and missing assignments and inconsistent test grades. With little question about his ability to handle the work, his teachers and his parents likely would attribute this decline to a lack of motivation or effort. Zach himself also would report "laziness" as the cause although he likely would be frustrated by his flashes of strong performance. With declining school performance, there is a possibility that his behavior could deteriorate as he becomes the "standard bearer" for some of his disaffected classmates. In middle school, youngsters would rather appear defiant in the eyes of their peers than incompetent. He gradually would settle into the role of "bright student who doesn't care enough about school to make a consistent effort." While not a major behavior problem, he would be enough of a class clown and challenger of authority to be an intermittent irritant to his teachers, school administrators, and his parents.
Zach's constellation of symptoms and skill weaknesses suggest deficits in executive functions. Broadly speaking, executive functions refer to a set of cognitive processes that allow us to meet challenges in our environment and accomplish our goals, by deciding what activities we will attend to and choose to do (Hart and Jacobs, 1993). Executive skills allow us to temptations in favor of longer-term goals. Through the use of these skills we can plan and organize activities, direct our attention, and persist to complete a task. Executive skills enable us to manage our emotions and monitor our thoughts in order to work more efficiently and effectively. Simply stated, these skills enable us to regulate our behavior.
What are executive skills
In a broad sense, executive skills help us to do this in two ways. One way involves use of certain thinking skills such as planning, time management, and working memory. These skills allow us to create a picture of a goal, plot a path to that goal and calculate the resources we will need along the way. They also help us to remember the picture even though the goal may be distant and other events intervene to occupy our attention and take space in our memory. But in order to reach the goal we also use other executive skills such as response inhibition, self-regulation of affect and flexibility to guide or modify our behavior as we move along the path. These skills allow us to think before we act, regulate our emotions to reach an objective and, when necessary, revise plans in the face of obstacles.
Researchers now generally agree that frontal brain systems (the frontal/prefrontal cortex, along with connections to adjacent areas) form the neurological substrate for executive skills. At birth these skills exist in the brain of the newborn in a dormant state, as potential, in much the same way that language does. Their development parallels the development of the brain, particularly the frontal lobes, influenced by our genes along with the biological and social environments in which we live.
Beginning at birth, parents and later teachers, provide a set of "lend-lease" frontal lobes spanning the period of infancy through adolescence to support the developing executive skills. In addition, environmental supports (in the form of institutions and rules) in the home, school and community further buttress these skills. The eventual goal is that the late adolescent will independently regulate his or her behavior within the constraints of the internal and external environments. Along the way, adults and institutions attempt to titrate the degree of frontal lobe support so that the child is neither overprotected nor abandoned.
Deficits in executive skills
We now know that children (and adults), even those well within the normal curve, show differing patterns of executive skills. We also know that the constellation of executive skills falls on a continuum. Children with traumatic or acquired brain injuries involving the frontal lobes and those with presumptive frontal lobe involvement (e.g. ADHD) are more likely to evidence broad executive skills deficits.
However, even in the absence of known neurologic or neurodevelopmental problems or diagnoses such as Asperger's Syndrome or ADHD, children and adolescents may display clinically significant deficits in executive skills. While in more severe cases these deficits will be evident fairly early in the child's development, in less severe cases deficits are likely to become most evident during pivotal developmental phases and transitions - starting school full time, the transition to middle school and onset of adolescence, and moving from high school to work or college place high demands on executive skills. Of these, adolescence creates the greatest demand due to increased parent and teacher expectations, decreased teacher monitoring and support, increased volume and rate of information students are expected to absorb, and the physical and emotional changes of puberty.
For the adolescent who has executive skills weaknesses, this developmental phase will exaggerate those weaknesses. At a time when the natural inclination of adults and institutions is to decrease support, these adolescents will require increased support. If such support is not forthcoming, a decline in performance and an increase in behavioral conflicts at home and school typically follows, as is the case in Zach's situation.
Interventions that can help
So what can clinicians do with this information? First, be aware of the role executive skills play in the problems children and adolescents encounter. And second, use this understanding to develop interventions that address the shortcomings presented by weak executive skills.
Executive skill interventions fall into two broad categories. The first category involves making modifications to the environment to reduce the impact of weak executive skills. Environmental modifications can include engineering the physical or social environment more favorably (e.g., by having a student who has difficulty attending sit near the teacher in the classroom or away from windows, doors or chatty friends), providing external cues and reminders (e.g., providing a list of chores to be completed after school or check-in phone calls), changing the nature of the tasks we expect youngsters to perform (e.g., by breaking down long-term assignments into subtasks with timelines), and by changing the way adults interact with the youngster (e.g., by providing closer supervision, giving more immediate performance feedback or higher rates of praise).
The second category involves efforts to change the behavior of youngsters with executive skill weaknesses, by teaching them to use executive skills and, if needed, by building in more powerful incentive systems to motivate them to use the executive skills they already have. In the long run, teaching youngsters to use executive skills more effectively is the best intervention, since it decreases or eliminates the need for environmental controls. Through our long experience working with executive skill problems, we have learned, however, that this approach is lengthy and can be labor-intensive on the part of parents, teachers, or therapists. Typically, we tell the people we work with, "Progress is measured in years and not months." [Detailed interventions for executive skills can be found in Dawson and Guare (2004)].
Richard Guare, Ph.D. and Peg Dawson, Ed.D., are based at the Center for Learning and Attention Disorders, Portsmouth, NH. Their new book, Executive skills in children and adolescents: A practical guide to assessment and intervention, is now available from Guilford Press. See also, Dawson, P. & Guare, R. (1998). Coaching the ADHD student. North Tonowanda, NY: Multi-Health Systems.
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