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Executive Function And Its Application To Occupational

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- Today's course is Executive Function and its Application to Occupational Therapy in
School Based Treatment. Our presenter today is Tere Bowen-Irish. She has been
practicing occupational therapy for over 40 years in pediatrics and psychiatry. She
provides assessment, treatment, and collaborative services and public and private
school systems. Through her business, all the possibilities incorporated. She offers
workshops for therapists, parents and educators focusing on service delivery,
classroom management, mindfulness, wellness and prevention for all school-aged
children. Tere is also the creator of the Drive Thru Menu Suite of exercises, published
by Therapro, an initiative to bring movement into today's classrooms. She is also a
certified Yoga Kids Incorporated teacher and incorporates creative movement and yoga
into her practice. She is also a certified mindful schools instructor and the author of
"Yoga and Me, Come be a Tree" and co-authored "My Mindful Music" with Mary Ann
Harman. Welcome back to Tere Bowen-Irish.

- I'm happy to be here. Here we go. So these are my disclosures for your reading
pleasure. Today, the learning outcomes, I'm hoping that you will be able to analyze
basic aspects of frontal lobe development from birth to adulthood. Where I also want
you to be able to evaluate what interventions may be applied to school-age children
based on executive function. And finally, analyze which diagnoses may present with
prefrontal cortex challenges right from the get-go. So we've all seen these behaviors. A
student who doesn't meet the entrance criteria for what's expected of their age and
grade, they may have challenges with executive function and it can show up in a
variety of areas. Teacher complains, he forgets to hand in the homework, he gets lost,
he doesn't know what the goal is of the assignment.

These kids also may look like they're on the go, they're moving about, they're touching
sort of a hyperactivity feel to it. They often seems to pay attention to not what's
important. So I've been in a classroom where I'm working with a child trying to get him
initiate and start to sustain his work and he'll say, "Hey, do you hear the lawnmower

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going this. The custodian must be mowing the fields today." They appear externally as
you watch them to be very disorganized, even though they now, like for now they're six
months into school. You also see some emotional reaction and it looks like irritability or
tears. You also may see that problem with saying, oh, I should do this first and then I
can get to that.

Or finally, class clown behaviors, lots of disinhibition, and impulse control challenges.
So we're gonna delve into specific executive skills that we as therapists, I believe, can
support. So when you hear me talk about these things, I'm sure you're going to have
faces and names pop up in your brain. Are you seeing kids, they don't seem able to
carry out the tasks as their classmates. And if the teacher's reporting unfinished work,
dysregulation, problems with simple assignments, difficulty in collaborative work with
their peers, problems with maintaining posture, focus and attention, especially in
reduced motor situations. The other part we're gonna really look at is the diagnoses
that point to developmental delays in executive function. And we're also gonna keep
those students in mind.

So often as much attention that the autism spectrum diagnosis gets, I often feel the
ADHD diagnosis doesn't get the same amount of attention and remediation, if you will.
And some of that is not all people agree that is a developmental delay of executive
functioning in the frontal lobe. So we're gonna thinking about accommodations today,
collaborative treatments. And in all honesty, all kids can benefit from executive function
refinement, teaching them how to manage and organize themselves. And when we are
thinking about the kids, we're already seeing say for handwriting, possible visual
perception, sensory processing or motor skills. Have we looked at the executive
dysfunction that may be comorbid with this? For example, I had a kiddo, he knew he
had the writing project.

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It was a morning edit, but he couldn't launch. He'd work the room. He'd talk about the
Red Sox score. And he could never sit down and really get it going. What happened?
Teacher would escort him to the chair. All right, you're gonna do this now. Well, already
10 minutes of his 15 minutes to do this was gone. So what did his product look like?
Very illegible. You also may see kids that have sensory processing challenges,
overhead lights, noises in the room. So you've made these accommodations. They
wear a visor, they have dead phones, but do they initiate that on their own? And that
also may be a disorganization, lack of sense of prioritizing for what they need to be
able to do their work.

So they become teacher dependent. So let's look right now at typical frontal lobe
development. And we're going to then lead into those diagnoses that show that
developmental delay. So one book that's really good, it's very old, it's a woman named
Dorothy Rich. It's not in your handouts. You can probably buy her for $2 on used
books, Amazon or whatever. It's called "Megaskills". And it works from age three all the
way up until about 11 or 12 years old. And it talks about very similar to executive
function. It parallels many of these challenges kids have and I often give it to parents to
give them ideas 'cause it includes a lot of activities. So that was a little sidebar. So
when we start to think about babies and the frontal lobe development, there's actual
research that shows now between six and 12 months old, the frontal lobe actually
begins to ignite.

So we start thinking about them being able to think and plan. They are handling
frustration. Yeah, they may be crying, but they're handling it. They're able to be
consoled. You see inhibition, delay of gratification. I remember at one point around six
months my daughter was crying to be fed. And the moment I'd start to undo my
blouse, she would stop crying. So there's simple impulse control at six months of age.
And then the idea of caring and empathy sensitivity to other people. But keep in mind,
these kids you're seeing today, whether they be six or 16, the frontal lobe does not fully

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develop until 25 and actually up to 27 years old. So when we start to think of the frontal
lobe development, I've heard all kinds of names for it.

The control center, the CEO, the adult in your brain. And when we think about how that
develops, it's managing the incoming information. And then the brain decides, all right,
with this information, where am I going with it? What actions do I need to take to meet
the goal? And even though this is just one of the functions, it's really crucial towards
the refinement of approach towards say, a writing or a math task or the avoidance of,
gee, I am gonna go to the bathroom now that the blue task. Excuse me, math folders
are out. Because that avoidance means that kid may have an emotional part that's
coming up to flee. Another great book, older one. But it is looking at executive function
in kids from four to 14 in a school setting.

I really like it because it brings us back to recognizing development really is where it's
at. We are often asking too much too soon of many of our kids in a variety of grades
from kindergarten on up. And this kind of settles and affirms what we as therapists who
are trained in child development really had been saying all along in education. So when
we look at those diagnosis I've alluded to earlier, we're really looking at things like
ADHD, autism spectrum disorder, traumatic brain injury which is an injury that may then
in turn cause attentional and focusing issues based on where the injury was in the brain
and fetal alcohol syndrome. And these are challenges with frontal lobe circuitry and it
governs motivated behavior.

So you think of a kid with fetal alcohol syndrome the last three months in utero, that's
when the frontal lobes really develop. You see their MO of how they look, their frontal
lobe, if you look at their forehead, is actually depressed. So these diagnostic categories
really interested me when I first started getting involved in understanding executive
function and frontal lobe work, because I was seeing that kids weren't able to put a lot
together where their peers were beginning to figure things out. And what really was

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glaring was the first six weeks of school. If the teacher had a decent routine with
prediction and visuals and lots of support to create what the classroom would look like
as a well-oiled machine.

My kids often were not getting in that routine. They didn't attend the parade. And often
I was having to do a lot of reminding or the teacher was for some of the most basic
things. So when we think about that, if the child is lacking the automaticity of daily
living in the context of the classroom, they're draining their brain and not be able to put
their energies into the focusing in the curriculum academics. So frontal lobe
development is delayed two to three years with a diagnosis of ADHD. So when we do
the math, if you have a 10-year old in a classroom you're teaching and they have this
diagnosis, you're functioning with a seven-year old, you're having to scaffold for a
seven-year old.

This comes from Dr. Russell Barkley, who is my guru. And if you go on YouTube, just
check him out. He is well worth watching. He has tons of videos and it really is so
educational. And he talks to you in such a way that it's practical. So if you are handing
the car keys to a 16-year old with this diagnosis, you're really handing the car keys to a
12-year old. The next part is fascinating to me. The motor strip develops early in the
brain and that's where the hyperactivity comes in. These kids normally with this
diagnosis has 10 points off a typical IQ score.

And Barkley calls it their lack of sense of time. You walk in and say, "Okay, we're here
for session." "Oh, you're here? What? I have to stay for snack. I'm not ready." It's a
blindness to the future. So when I knew I was prepping today, I looked at the clock, I
managed what I needed in front of me. I was prepping and prioritizing. They are not.
They're just living in the moment, not in a great way. They seem a little out of touch at
times with the social cueing. Reading on non-verbal communication and norms. They
often, as I alluded to earlier again, that impulsive part shows up in blurting, being

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reactive, both on inappropriate and almost aggressive at times. And what Barkley talks
about is when the parent says to you, oh, he can play LEGOs all night.

He doesn't have a focusing problem. Or you know, he'll be fine because you know, if
you just, you know, tell him he needs to shape up like he does on his video games.
Barkley is the first one I've ever heard say that this hyper-focusing that we see with
these kids is really perseverative behavior. They can't stop it. They just go to it and they
go to it. It's a source of pleasure. And so knowing that, that's good ammunition for a
therapist who's noticing what is getting in the way of that child accessing their
curriculum. And ADHD is more common in boys than girls. But in adulthood, that evens
out, which adds to this. We must know this is a lifelong diagnosis and it can also be
genetically connected to the child's parents, aunts, uncles, grandparents, et cetera.

And if you're finding you already have a student like this and you're sending home
ideas, if those parents are unaware they have this diagnosis, often what you're gonna
get back, it will be compromise. Because they might say, oh, those are great ideas for
having them do this or that. Oh, we just didn't get to it. We meant to do it, but we really
didn't get to do it. So the first deficits you see in kindergarten, even preschool, is
inhibition. So they're disinhibited, they might look hyperactive. So they're zooming
around with their motor. When they have fine motor activities, they're doing it so fast.
They're not getting crisp grasp pattern. You also may see in those younger kids a lot
more blurting and yelling and noise making.

They may not keep their own personal space, they may be more disruptive. These kids
might be playing with toys in more of an aggressive way. Not sharing, hitting, biting,
those kinds of things. The snap decision making without the thinking of consequences.
So you know, they see a kid eating a Fruit Roll-Up. They want that roll-up and boom,
they've taken it and then the rest has to be handled and scaffolded by the teacher. You
see this restlessness. It's a psychomotor restlessness and it's expressed as on the go.

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Sure, you can put a lap blanket on them, a weighted blanket, you can exercise and
move before they do, a sit down activity, but you'll see those feet tapping.

And there is some research, which I'm gonna show you a slide in a little bit that talks
about actually doing physical work while moving ADHD kids with that diagnosis learn
more and do better. And by adolescence, the hyperactivity is almost gone. So they're
not jumping on couches or beds, they're not doing cartwheels across the floor. But
what I thought was really interesting is that Barkley said in the lecture I attended was
the adult with this diagnosis has a myriad of thoughts always going through the brain,
just kind of like unable to distinguish what's important thought to think about. So if you
can have a window right now and you're listening to me, then all of a sudden you see a
bird fly by and then you start looking at where the bird's going and you've lost me.

And so this kind of happens where they get distracted so much, it's hard in their
regular work and relationships. So when we start to think developmental disability, it's
a delay in a normal rate of development. So normal development for a person with
attention deficit disorder is not happening and there's a chronic lag in the development
of those traits. So when we start thinking about ADHD is inappropriate behavior for
your age, it's absolutely correct. The trade books say that environmental upbringing
has no impact, but a supportive routine and structured approach help. So it's not just
meds that they need. They continue to need scaffolding, accommodations and
modifications. And Barkley says 50% start to lose friendships starting in second grade.

It has a lifelong risk of challenges. Peer rejection, friends don't forgive anger and
hostility. So if a child becomes aggressive on the playground or within the classroom
contest or at a sport, this child will start the reputation of being a bully, of not being
able to keep his hands to himself or herself. And as they get older, job dismissals, road
rage, marital and parenting difficulties show their face. I'll give you an example. I work
with this child who I would coach him a lot on his impulsivity and reactivity. And he was

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having a real problem. Right around third grade, his peers were starting to reject him.
Because what would happen is he started acting up class clown and then they would
get in trouble if they joined in.

So by the six months into third grade, they were realizing they, "Hey, don't talk to me
man. I don't wanna have to stay after and do this or I don't wanna recess." So I went
out to recess with him after our session and these boys were playing wall ball. And I
really, it's like a swarm of boys, like a swarm of bees or it was in that instance, and they
had a ball. And they moved together where the ball would hit the wall, someone would
catch it and they'd swarm again. And so the goal was to keep the ball in the air, but it
was based on the teams working together. This kid was standing next to me and his
classroom para and he said, "Ah, that game is so stupid."

And I said, "Well, you know, it looks like it's kind of fun." I said, I'm not really quite sure
how it goes. He goes, "Yeah, you just gotta get the ball and stay on top of it." But you
know, he said, "They don't ask me to play." And I said, "Well, you know, you could
probably talk to them, maybe you could play with them." And he goes, "Screw it, I'm
gonna go." And all of a sudden he just ran over to the group. So I said to the para, I
said, "Well, let's see how this goes." Well, bless his bones, he got in the swarm and
he's swarming. Well, what does he do? He reaches up the ball, gets off the wall, he
grabs it, he stops, and he looks at everybody, holds it above his head, and drops it to
the ground.

And I'm telling you, those boys were ready to attack him. They were so angry that he
interrupted the game, and he just laughed in their face and walked back over. He goes,
"Guess they're not gonna invite me now." So when you start to think of that whole
scenario, you realize his impulse control or lack thereof, his wanting attention so badly
and acting 30% younger than his chronological age, right? So he probably was acting
more like a kindergarten or first grader. So once again, when we look at these students,

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we must look at their inability to perform as expected. The diagnosis is a 24/7 one that
lasts a lifetime. And where can therapists intervene? So it's really can be broken down
in academic access.

So your goals and treatment ideas of where you're wanting them to access their
curriculum or on the other side of SEL, social emotional development. So play skills,
being able to do cooperative activities, being able to communicate, and work with
other students, and the community of their classroom. So let's dive into a little more
nitty gritty. When we start to look at the handout of executive skills and abilities that
affect classroom independence that I've handed to you or I've got on here, I have
consolidated that into one page. Why? Because I want you to be able to use this in
your practice. Feel free to copy it and use it. And know that when you look at these
skills, not all of us have deficits in that area.

The key is to pinpoint where these skills are impacting the student's ability to access
their curriculum. And we're gonna go through all of these. What I want you to think
about is prioritizing what are the most important skills to go from point A to point B to
be able to get work done, get along with others, being able to perform the task
expected of his grade level and age. And then you decide how am I gonna
accommodate, modify, or refine. So again, when you even look at this handout for
yourself, you could rate yourself, where do I have the most challenges? Because our
frontal lobe development, we all have our own process and we have strengths and
weaknesses in our ability to follow through with some of our own school demands,
home demands, parenting demands, et cetera.

So here, we're starting now on the slide that holds all that's on your piece of paper. So
activation, that's one of the first things. This is their organizational ability, be able to
prioritize and plan. It's also that sense of volition. I wanna get an A in the mad minute. I
wanna get all those done. Which often kids with a diagnosis of ADHD don't have

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natural volition and Barkley talks about they benefit more with a carrot dangled or a
token system because they don't have that sense of inertia to want to delay
gratification in order to get to a goal. It's the task initiation. It's the planning and
thinking ahead. Now one thing to be aware of, often it's not an input problem.

So in other words, if that kid's work in the room and he's coming in in the morning, still
got his backpack, still got his coat on, still has his lunchbox. And I say, "Daniel, what
are you supposed to be doing?" "Oh, I gotta hang everything up, put my lunch in the
refrigerator, then I gotta sit down and do my morning edit." And I'll go, "Daniel, you've
been here five minutes, let's do it." But he really is having a hard time launching. And
so what ended up with Daniel is I ended up handing him after two couple weeks of
observation and, excuse, what I call point of performance cueing, I realized he needed
a vigil. So I put it on an index card, hang up backpack, take off coat, lunch in
refrigerator, take chair off desk, do edit.

Well, bless his bones, the first day I gave him the index card. I said, "I'm gonna time
you and see how long it takes for you to do all five and we'll work on this." He looked
at it and he goes, "Okay, I can do that." Ran over, hung up his backpack, and do you
know what he did? He came back and looked at what the next one was, which was to
hang up his coat. Then he came back and looked. Oh, okay, gotta do my lunch. And it
made me realize how poor he was in his ability to have the working memory to keep
those four or five tasks there. The next part is sustaining focus, shifting focus on
selective attention, sustain attention and concentration, and shifting cognitive set.

So they may get started, they may initiate. But if the teacher goes, "Oh, hold up, I want
you to stop writing that paragraph and I want you to refer to this paragraph in the book
and see how much yours looks like that. Have you contained all the characters?" You'll
see kids just give up at that point because they can't shift easily. You'll also see
challenges with the amount of writing time or the amount of independent reading time

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they can do on their own. And so those are the behaviors that are your yellow flags
essentially. Here's another set. Effort, regulation of alertness. So we work with kids that
are dysregulated. It may be need for more sensory input, more movement input.

Kids that look at something and go, is it over? It's almost like you have to put the Time
Timer on because they know the torture will end. So they see, they understand if that
red goes away, okay, I'm done. You'll see erratic processing speed. So they might
quickly write down a bunch of letters, but it's illegible and their output is more minimal.
Because if you make them go back and recheck that, they're just gonna give up and
say, no thanks. Sometimes they need specific. The goal of this activity is for you to do
all five parts of the stratus and cumulus and, I can't remember the other cloud that I
was in the classroom for. You need to create the poster, label each cloud, and illustrate
what they're supposed to look like.

That kid needs much more. Okay, let's find how stratus clouds look. Here's the cotton
balls, here's the glue, here's the paper, let's do it. And then that persistence. There's a
lack. Again, that's kind of hand in hand with the volition. The next part is really coming
clearer and clearer to me where I'm starting to see more emotions. So I'm seeing desk
being thrown, punches being thrown, kids hiding, kids eloping, kids biting. And that is
part of executive skill challenges. So this is the angry anxious child and some
challenges with inhibition, taking a no, modulating emotions, and stress tolerance. So
all of these skills, I certainly could hang my hat and helping myself to do some
treatment and basing my IEP goals and objectives in these areas.

And here's the next part of working memory. This is holding something in your brain as
you perform a task. And if this is very difficult, even for a little muffin, who's learning
their letters. If they don't have a letter line on their their desk, what are they doing?
They're hyperextending their neck, looking way up at the top of the ceiling where I
don't know why teachers hang it there, but that's where they are. And they have to

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hold that in their brain to be able to copy the letter. Also, that anticipation of what's
gonna happen next. So sequenced activities, you're going to have to bring them down.
We do this first, so you hold up your thumb.

Second, pointer finger. Third, middle finger. And so the child gets the idea of first,
second, and third. And in many of them, because their working memory is so poor,
they don't seem to generalize from experience to experience. For example, in math
class in high school, the teacher expects them to put it in their daily journal. And so
they write that down. The other teacher in high school expects them to go online and
find the assignment there, but they can get stuck in these and they don't remember. So
they might go for the math teacher online and not find anything. And then finally, this
next part is action. This is the ability for self-awareness, being able to monitor your own
self, monitor your own self-regulation, being able to walk in in the morning.

I had a kiddo with me yesterday and he goes, "I had stomach pains last night. I didn't
sleep very well and now they're yelling at me 'cause I can't focus on the MCATs." And
so when I chatted with him, I said, "You can walk in and say, 'I'm not myself today,'
share with them what you just shared with me." But he's so unaware in a sense he's
not able to think. I need to share this with my teachers. He can't plan ahead. And then
again, the next part of problem solving. What works for you? What doesn't work for
you? What process do you need to establish in the routine of your classroom? So if this
is what Daniel needed to do, he still required an outside person to be his referee and
direct him.

So the handout is consolidated, as I said. Give this handout to a parent. Have them
check off the traits that stand out with their kid or give it to a teacher or even give it to
an older student, middle school and high school or even fifth or sixth grade. And then it
starts the conversation. You fill out one too and see where you both agree on traits,
skills that are getting in the way of moving forward. That gets the ball rolling. But the

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one thing to really think about is use the classroom as your observatory. It's your
laboratory, laboratory. And what you're gonna do is you're gonna observe. You look at
how the student is functioning within the context of the classroom.

Our job is to have kids access the curriculum in classroom. So sitting there for 30
minutes once every two months is going to validate of what you're doing with them to
see if it's really working. And when you work to proactively work with the student and
the teacher, you're breaking down those accommodations. So for example, I have one
kiddo who definitely needed dead phones, very distracted. He needed to sit with his
back to the class because he was always looking at what other people were doing. He
just turned his desk. He didn't keep it there the whole time. And so I would have to cue,
okay, what two things do you need before you even start? And then I move to
something taped on his desk.

I'll say, "Where do you have to look to know where you have to start?" And then
eventually, the teacher started doing that, and that work. So when we start looking at
accommodations, a Time Timer at the desk. Remind the teacher to give him a direct
reminder. Make sure the executive place to work is a little away from the group if that
helps. Frequent teacher check in, breakdown of tasks, et cetera. And so when we start
looking at these strategies, we assess them and refine them. And the goal is that the
kid can function adequately, reasonably without attachment to us. This is a great book.
It's called "Smart but Scattered for Teens". There also is a "Smart but Scattered for
Elementary".

And Ric Guard and Peg Dawson are neuropsychologists. And what they do is break
down the executive skills in a sense of where are the cognitive areas and where are the
behavioral. So I had a slide earlier that talked about social, emotional and academic.
So this is even further breakdown of that. So now we're gonna move on to
accommodations and modifications and strategies. So in your handouts, I did add and

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I'm not going to talk much about it today, are some ideas for arousal. Because often
what often can happen is these kids need alerting or they need some downtime in
order to be more regulated to do the work that's being asked of them. So Barkley calls
these the touchstone principles.

One of my favorites is touch more and talk less. So in other words, when you're
checking in with a student, decrease the verbiage, go over, look at them, give them a
thumbs up, put your hand on they're forearm. How's it going? What's going on? And
when you do that, you're not becoming Charlie Brown's mother going wah-wah,
wah-wah. You're not supposed to do this. The other part that he does that's my
favorite is he says, "Act and don't yak." So he talks about point of performance
coaching. So you may have a kid, he's gotten his headphones, he's turned his desk
around, he's got the paper in front of him, and all you might need to do is point to the
number one on the page and say, "Do that.

I'm gonna go around and help some other kids. Raise your hand when you finish that
one." Done. When they have to hold information in their mind, as I said earlier, based
on working memory, we need to give them a lot of lists and visual memory references.
And so whether it's point of performance for each subject or does the teacher have
posters in the classroom to refer to for functional activities. What bus they're on? What
are the steps they have to do when they turn in their homework? The other part is
self-awareness cueing. So one thing Barkley talks about is that the educators that work
with these kids, so it could be a school counselor, it could be a teacher, it could be
yourself, it could be a speech and language pathologist that you actually video the
child in the classroom.

And then part of the idea is to have them look at what they're doing and telling you
where they went sideways or what they think they could have done differently. And
another cool thing is cueing. So many of these kids don't want their name being called

15
seven times in 30 minutes, right? Because this is what happens. Julie, Julie, Julie sit,
Julie sit down. And so if Julie gets to a point where she's just gonna tune you out,
maybe a cueing system. So you go over to her and you say, "Remember, if you need
me, I want you to sit up, turn your paper over and I will be scanning the classroom and
I'll come by if you need that help."

And the other part Barkley talks a lot about is word retrieval. And many people with
prefrontal cortex challenges. So don't call on them if their hand isn't raised. Why?
Because they are going to feel really put on the spot. And some of that emotional
dysregulation may show its ugly face. And one thing, there's a a YouTube video by a
young woman who is just so talented and it's called Doing ADHD, and I highly
recommend that. And she talks exactly about hand raising. Other accommodations
when you think about is emotional and self-regulation week, experiment with
visualization. So I've been in a classroom where the teacher is reading a book and I'll
say, "Okay, so who can draw a picture of that scene on top of the hill?"

And so here you've got these first to second graders drawing the picture of a girl on a
swing with a dog. And then talk to them about what do you think the weather is there?
How can you prove to me what the weather is? Was it snowing? Is the sun shining?
What time of year was it? So when they get more visualization and imagery into their
system, it becomes more real to them. Reductions of distractions, which we as
therapists are always talking about. You can bring in the weighted lap pillow, the
headphones and a seat cushion. One thing I'm really pushing for in the classrooms I
work in is the ability to have a space to get away, to be quiet and to chill out.

It's a reboot station, not necessarily a zen den. I mean, that's takes a commitment. But
somewhere in the classroom where if you look at the teacher and say, "I just need a
moment." And they set the Time Timer for five minutes. There's books there, there's
fidgets. Nothing overwhelming, just quiet. And one thing that I do is talk about, let's

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rewind the video. So if I see an impulsive act that occurs while I'm watching them or
working with them, I'll say, "Hold on man. Okay, let's rewind that video. We were
playing a game and you didn't roll them out on the dice you wanted, so what did you
do?" "Oh, I threw it across the room." "Yeah, okay."

First, what do you need to do? And so you, just at that moment, break down what
happened. I had this great story of this kid. I walked by the office in the school I was
working in. And I said, "Ian, what are you sitting in the hallway for?" And he was
diagnosed with ADHD when he was about second grade. He goes, "Oh, Mrs.
Bowen-Irish, I'm in so much trouble." And I said, "What kind of trouble are you in?" He
goes, "Well, you know, I get off the bus in the morning and I read the responsive
classroom full poster when I walk in of what's going on. Then I go down to my
kindergarten teacher and I help her take all the chairs down.

Then I go my first grade teacher. You know Mrs. Smith? And I helped her the other day
put some pieces together for that craft project. You remember the pumpkin thing that
she does every year? And then I go to my second grade teacher, Mrs. Dowry, and she
and I just have a chat and she asks me about my brothers and sisters and then I get to
class." And I said, "So you didn't go directly to class obviously." He goes, "No, but I
get there on time." And I said, "Hold on Ian, I'll be back." So I went to each of these
teachers real quick and they said, "Oh my God, has he come a long way now that he's
on meds?

He's really, really helpful. He's very talkative." And I walked into this principal's office
while Ian was still sitting out there and I said, "Tom? He's doing his own IEP. He's
talking to people. He's being appropriate. And he's getting to class on time." So when
we start to think about this, that was his process. He was giving himself a movement
break, a little social break and then heading to class. So here's some more
accommodations. I might not go through them all because you have access. But begin

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to look at these as you are thinking about what you might need to write in an IEP,
targeting productivity first and accuracy later. Don't make a child do all this work and
say, "Okay, now we're gonna edit it."

Often I'll put editing, I'll say edit one line at a time, period, and then leave it and then
come back to it. Positive reinforcement, obviously. You can do this. You're not there
yet, but you are gonna get there. Asking open-ended questions. So that's called
metacognition as you know. And that's what do you think we ought to do in this
situation? And you'll really get a sense of if they can figure out or problem solve, or is it
just one idea and they can't go beyond. So what my IEP goal student would be able to
problem solve, come up with at least three solutions to one problem and assess, or so
on and so forth, how well they did.

And then obviously breakdown of tasks. The Time Timer is wonderful. Obviously, we all
use it. Also, there's vibrating washes to say, "Hey, are you on task? Minute,
hourglasses and other timekeepers." I often work when I get to third grade and up. I'll
ask the teachers, "What long-term assignments are you going to do this year?" And
then they will talk to me whether it's an endangered species or whether it's some kind
of environmental green initiative. And so when they give me the rubric, I pick something
to do with my student. If I have to do pullouts speech and language pathologist, might
pick something else out of that. And we help, because often many of these kids can't
get it together at home to be able to do this long-term project.

And obviously, you hear this the night before, they tell their parents it's due. I've talked
about point of performance. And so when we work with these kids, we want them to
understand this is their job, right? But they do need those incentives to, and I'm not
saying dangle a piece of candy in front of them or feed them by any stretch, I'm saying
maybe if you bring in your homework for three nights, you get the fourth night free, no
homework. Or you get an extra 10 minutes of recess or you get to have lunch with me

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once a month. And when we do that, they are learning, oh, I can delay my gratification
to get there but don't make it so long.

So I might start with, you can have lunch with me once a week. And then again,
immediate feedback on performance. 'Cause if they're working memories off, if
somebody doesn't intervene right away, they're gonna go, "Oh, I don't remember
doing that. No, I don't think so." And so when you catch them in the moment, use that
time as a teaching moment. So whether it's an IEP or a 504 plan, here's some other
accommodations that I use. Daily check-in. Often these kids and I've seen it done in a
variety of way. Say a point of performance person that is there and they meet with
them in the morning and they'll say, "Okay, so let's say it's a middle schooler, these are
your classes today. Did you bring your sneakers for gym?"

And get them ready. Just as if, so you know, what? They're around 12, 13 years old.
But what would you do to scaffold a kid that was around eight? So you break down
what needs to happen. Double check for homework. And then at 2:30 at the end of the
day, you meet up with them and you do the same thing. Now I've seen it done
one-to-one. I've seen a group situation where they all go not to a homeroom, it's prior
to their homeroom, but they meet with a counselor or a therapist or whoever, an
educator and they go through this. It's almost like a pre-day coaching. The other thing
that's really cool to do is to start to pair students with a role model that will help them.

And when you pair them up, you may find that the other person is going to be able to
do a lot more teaching. 'Cause as we all know developmentally from third grade all the
way up to high school, they came more about their peers than they do being with an
adult. And so when we do that, they're going to have that respect for one another that
they might not have for us. The other thing that always makes me giggle but it's true, is
that the true proximity of the body, of the teacher to this kid that's having a problem
with focus and attention can make a big difference. So if the teacher is way across the

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room and the kid is sitting in the heckle section in the back, that kid is not gonna be
paying attention.

But if the kid is sitting near or the teacher' is moving back there to give instruction is at
their desk, they're much more likely to be paying attention. Now in middle school and
high school in my accommodations, I might say please have a notes from lectures
available for that student without making them take the notes. We don't wanna drain
the pool in their brain by having to do so much work. We want them to tell us what they
know. So why not have notes available? You can have daily progress reports, tracking
behavior. One activity I really love is I learned this from a behaviorist. So you say to the
child, okay you just did a 45-minute class.

Let's say they're in science in high school. Okay, these are the three things we worked
on. Starting the assignment, sticking with the assignment, and finishing what your
teacher expected. So put your hands behind your back. You're gonna rate yourself one
to five, starting the assignment. And I'm gonna put my hand behind my back too. So
when I say one, two, three, we're gonna show our hands. So let's say starting the
assignment, go! So he puts up three fingers and I put up four. And he'll go, "Well, I
think I had a hard time starting." And I said, "Well, you know, you kind of did but you
were within five minutes." And then you do the next, sustaining time.

I put two up and he puts up two. And he goes, "Yeah, I was in the bathroom a long
time." You know? And so when you do that, what are you doing? It's proactive. It's not
you going, "Oh yeah, you only got one for that and then you get a three for that." And
it's not you being the judge and jury, you're both working on it together. Extra time for
tests and homework assignments, alternative ways of sharing knowledge, frequent
breaks between assignments or tasks. So pulse learning, like Gardner talks about. High
intensity learning, low intensity. High intensity, low intensity. And you have to figure out
the frequency and duration based on their development in their age.

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Using environmental adjustment in the classroom, zuma chairs, hookie chairs, seating
balls. And then you know, you don't hear me speak without talking about movement
and mindful activities sprinkle throughout the day. Why? Because we need to clean our
slates. If we move from classroom to classroom in a middle school or a high school,
who knows what happens in that hallway? So if a kid comes into the classroom and
the teacher says, "Okay, put one hand on your heart, one hand on your belly, we're just
gonna have a quiet three minutes." You need to land for my class. Or you might have
someone come in and say, "Okay, we're gonna gonna do some movement, let's get all
that energy out."

I use maybe a TheraBand and we stretch it, and everyone is maybe learning
vocabulary. Or if it's a younger class, they're doing their alphabet or their spelling
words. Those kinds of things can ignite learning but also increase focus and attention,
and obviously oxygenated blood flow. So here's that research. Movement help with
cognitive tasks. Excessive movement is a trademark of hyperactive kid, but it's only
apparent when they need to use their brain's executive brain functions and their
working memory. So I thought this was fascinating. And what it showed is we found
that when they're moving the most, they're performing better. And by contrast, the kids
without ADHD that move during the cognitive testing perform worse. And we'll cover
this accommodations a few more.

Ask for repetition of directions from the student's mouth, not you repeating them.
Having them get some motor breaks by passing out papers in the classroom, hanging
up posters, taking down chairs, creating a ready menu of short breaks to choose some
so the teacher doesn't have to overthink that, my Drive Thru Menu still work really well
because it's not putting on GoNoodle and hoping somebody participates. 'Cause often
some participate in others just are voyeurs, right? Other consequences versus taking
away recess. One of my schools decided, okay, we'll make them walk the perimeter of

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the recess. They can't play but they're gonna get physical exercise. And then once the
student has mastered the concept the teacher is trying to teach, don't make 'em do
any more work.

And that relieves them. That reduces the stress. And then having homework done
during school time or after school programs. And then Barkley talks about a two level
system of automaticity. Habitual activities need to evolve and be put in place in the
school year. So I talked about that right at the beginning. The executive brain is more
complex. It has to stop unlike the automatic brain. Executive skills take more effort.
And there's an effort pool he calls it in the brain. You can delete the fuel tank and
self-regulation issues will get worse. If you use too much of that pool, the
self-regulation will go sideways. So the idea is to have the person have more routine
that comes automatically so they can accomplish.

And the final thing that he talked about was having kids being able to sip a sports
drink, a sugar drink because it really does help fuel the system of attention. And finally,
Guare and Dawson talk about timing of directions. Encouraging of the student to play
around for tech solutions. So I often say have the teacher have a Google calendar,
they're attached to that. They're able to go to that Google calendar with the teacher or
the parent at home. So you can read through these. But the reality is I hope you're
taking away some value and have come to the idea of who this kid is and how you're
treating them, and maybe there's some other ways you can tweak it.

And we really do, as therapists, need to consider EF skills. And we want to facilitate
those services. Because if that diagnosis is a developmental delay, then we need to
treat and we need the ones to prove why we need to treat. And I just love this quote.
He talks like a watch, which ticks away minutes but never strikes the hour. So let's
have a mission for these kids. All right, I'm gonna go to Q&A now. Is there any gender
differentiated in frontal lobe development? From what I understand, males have have

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the diagnosis much more than females. I did understand from Barkley that if you're
diagnosed as a female, you never outgrow ADHD which is fascinating.

Girls tend to be diagnosed later in life than boys. And also girls tend to have prefrontal
cortex maturation sometimes earlier than boys. So that's why I gave you that range of
25 to 27 years. If a child with ADHD is medicated, does the 30% delay still exist?
That's a great question. From what Barkley says is that the medication takes care of
the ability to have enough dopamine to focus, but they still need the scaffolding to be
able to organize and plan. So they still are delayed in prefrontal lobe development. It
seems like you said dead phones rather than headphones each time. No, so with little
people, I'd rather have nothing coming into the ears to distract them so that's why I call
it a dead phone.

So I just take the plug out, right? Headphones you can use with older kids or even, you
know, like the earplugs so they can have one ear in to listen to music while they work.
Didn't find the YouTube video. Well, go through her Doing ADHD. You'll find it, but it's
there. May you please give more examples of goals you would recommend for
executive functioning. I don't have time in this five minutes to do that, but I do think
you guys can use the rubric of the idea of what you intend for the child to be able to do
in an amount of time that's measurable. And you can work from this piece of paper of
what skills you're doing.

I apologize that I can't solve that in five minutes. I work in teletherapy and online
schools. I have lots of students with these deficits in middle school. What
recommendations do you have to help these students adhere to self OT created
schedule when the online setting is relatively unstructured? So what I hear you saying
is, are they not, I can't tell whether they're not attending OT. I will say if you view your
session for a half hour as what I call a container, at the beginning of the session, I

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might say, okay, first, we're gonna alert you so let's do some movement and wake up.
Second, this is what we're doing. Third, this is what we're doing.

And fourth, this is what we're doing. And then we'll end with some mindfulness so you
can go to your next class. You know, when I've done on telehealth, I always know what
their next class is. I make sure I do so I can prep them to go there. I also know where
they're coming from. Do you qualify students for executive functioning therapy is
changing the system environment versus changing the student? So in general, how
much of executive function therapy is changing the system versus changing the
student? Wow, I think it's changing the student, right? In their reaction thereof. You will
see kids that react well to medication if they truly have ADHD. I've seen it myself a
week.

And all of a sudden handwriting is better, focus and attention is better. And you kind of
go, whoa. 'Cause they just aren't making the chemicals and that's what the medication
does. So I think it's about the kid. Environmental scaffolding is great but the reality is, is
what's going on in them. Can you provide an example of a goal you would write for
executive function? Again, I can't give you a bunch, but I might say this student will
participate in cooperative learning with up to four students with no sign of avoidance,
aggression, or compromise as evidenced by completing tasks, group tasks and role
within the group in eight out of 10 opportunities. So please don't criticize me, I just
pulled that out of nowhere.

Okay, can you explain the part about how the delayed frontal lobe combined with
motor strip development cause hyperactivity? From what I understand, from what I
heard Barkley say is that the motor strip actually matures faster in the brain for these
kids with this dysfunction. So in other words, a typical child, whoever they are, but a
normal development brain does not have that motor strip hyper developing. In other
words, it's not completely going faster than what an ADHD diagnosis suggest. What

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other suggestions do you have for a teen who has trouble with time management but
timers don't seem to work? Well, I would just sit down with a teen and say, "Look,
okay, let's figure out. You know, what's up?

What's going on?" And when you do that, they'll tell you what worked. One of the
worst things we can do as therapists is dictate process. I think, we have to find kids'
processes. And we have to take that time 'cause what works for us to organize is not
always gonna work for them. You guys know that. So spend time talking to them. It
may not feel like treatment, but trust me it is. What handouts do you find most helpful
to send home with students for parents? I often just refer them to Barkley's book with,
you know, handling ADHD. He just wrote a new one on executive functioning. It's more
for a clinician than a parent. And then this one is for more kids, "Puppy Mind".

And it talks about how your mind's like a puppy when you have ADHD. So I mean,
there's a lot out there. But I think just sending home that sheet I gave you and talking
to parents. What would you say your number one adaptive equipment that you use for
the majority of your students to help teachers implement in their classrooms? Well, I do
use the Time Timer. I do use weighted blankets. Not weighted blankets, lap pillows. I
do use fidgets, but I give a lot of education around it and I really try to individualize it.
Does it become worse as they age? No, it morphs. It gets a little different. So in other
words, they're not jumping up and down on the couch like they did at five, but you see
changes in their ability to handle the demands of adulthood.

You know, do you remember that diagnosis years ago? Adjustment reaction to adult
life. And I don't think it's a diagnosis anymore. But it's like being able to follow a
schedule, being able to meet deadlines, being able to take care of yourself and pay
your rent and do all that. So when you really start to think about the demands
increasing, this person is going to unravel if they're still doing really disinhibited things.
Barkley talked about someone saying, "Oh, come on, it's gonna snow tomorrow. Let's

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get in the car and drive to Florida." These are these people, right? These are these
adults. You know, and then I'm thinking, "Well, you know, I gotta work or I've gotta do
this or that." So it doesn't become worse. It morphs according to their developmental
in age.

- So Tere, I'm gonna go ahead and jump in.

- Good.

- 'Cause I want to be aware of everyone's time and we have many questions coming
in. So this point I'm going to direct everyone to your email.

- Okay.

- So that if they did not get their question answered, they can email you. And actually
that might give you time to come up with some of the things. It's hard to on the fly. I
understand that. So I just wanna thank you for such a great talk today.

- Thank you so much everyone. And again, it's a lot of information to get into a small
bit. I hope you take away value.

- Right, hope everyone has a great rest of the day. You join us again on Continued and
OccupationalTherapy.com. Thanks everyone.

- Bye.

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