161153842 manual-inventario-brief

PAR Psychological Assessment Resources, Inc. / 16204 North Florida Ave. / Lutz, FL 33549 / 1.800.331.8378 / www.parinc.comBRIEF™ : Interpretive Report Copyright © 1996, 1998, 2000, 2002 by Psychological Assessment Resources, Inc. All rights reserved. May notbe reproduced in whole or in part in any form or by any means without written permission of Psychological Assessment Resources, Inc.

Version: 1.00 ( 1.00.007 )

Behavior Rating Inventory of Executive Function™

BRIEF™

Interpretive Report

Developed By

Peter K. Isquith, PhD, Gerard A. Gioia, PhD, and PAR Staff

Client Information

Client Name : Sample Client

Client ID : 123

Gender : Male

Grade: 2 nd.

Age : 8

Birthdate : 01/16/1994

Test Date : 02/12/2002

Test Form : Teacher Form

Test Description : Initial Evaluation

Rater Name : Ms. Smith

Relationship to Client : Teacher

Class Taught : Homeroom

Has known student for : 7 months

Knows student : Very Well

Client: Sample Client Test Date: 02/12/2002Client ID: 123 of 39

The BRIEF was developed to provide a window into the everyday behavior associated withspecific domains of the executive functions. The BRIEF can serve as a screening tool forpossible executive dysfunction. The clinical information gathered from an in-depth profileanalysis is best understood, however, within the context of a full assessment that includes (a) adetailed history of the child and the family, (b) performance-based testing, and (c) observationsof the child’s behavior. A thorough understanding of the BRIEF, including its development andits psychometric properties, is a prerequisite to interpretation. As with any clinical method orprocedure, appropriate training and clinical supervision is necessary to ensure competent use ofthe BRIEF.

This report is confidential and intended for use by qualified professionals only. This reportshould not be released to the parents or teachers of the child being evaluated. If a summary ofthe results specifically written for parents and teachers is desired, the BRIEF Feedback Reportcan be generated and given to the interested parents and/or teachers.

T scores are used to interpret the child’s level of executive functioning as reported by parentsand/or teachers on the BRIEF rating forms. These scores are linear transformations of the rawscale scores (M = 50, SD = 10). T scores provide information about an individual’s scoresrelative to the scores of respondents in the standardization sample. Percentiles, which are alsopresented within the BRIEF-SP, represent the percentage of children in the standardizationsample who fall below a given raw score.

In the process of interpreting the BRIEF, review of individual items within each scale can yielduseful information for understanding the specific nature of the child’s elevated score on anygiven clinical scale. In addition, certain items may be particularly relevant to specific clinicalgroups. Placing too much interpretive significance on individual items, however, is notrecommended due to lower reliability of individual items relative to the scales and indexes.

OverviewSample's teacher completed the Teacher form of the Behavior Rating Inventory of ExecutiveFunction (BRIEF) on 02/12/2002. There are no missing item responses in the protocol.Responses are reasonably consistent. The respondent’s ratings of Sample do not appear overlynegative. In the context of these validity considerations, ratings of Sample's executive functionexhibited in everyday behavior reveal some areas of concern.

The overall index, the Global Executive Composite (GEC), was elevated (GEC T = 73, %ile =96). Both the Behavioral Regulation (BRI) and the Metacognition (MI) Indexes were elevated(BRI T = 71, %ile = 94 and MI T = 71, %ile = 96).

Within these summary indicators, all of the individual scales are valid. One or more of theindividual BRIEF scales were elevated, suggesting that Sample exhibits difficulty with someaspects of executive function. Concerns are noted with his ability to inhibit impulsive responses(Inhibit T = 70, %ile = 99), adjust to changes in routine or task demands (Shift T = 68, %ile =94), modulate emotions (Emotional Control T = 71, %ile = 94), initiate problem solving oractivity (Initiate T = 69, %ile = 95), sustain working memory (Working Memory T = 74, %ile =99), plan and organize problem solving approaches (Plan/Organize T = 67, %ile = 94), organizehis environment and materials (Organization of Materials T = 66, %ile = 93), and monitor hisown behavior (Monitor T = 68, %ile = 93).

Sample's scores on the Shift scale and the Emotional Control scale are significantly elevatedcompared to age- and gender-matched peers. This profile suggests significant problem-solving


rigidity combined with emotional dysregulation. Children with this profile have a tendency tolose emotional control when their routines or perspectives are challenged and/or flexibility isrequired. In order to develop a better understanding of Sample's difficulties, furtherexamination of the situational demands that result in such a loss of emotional control would behelpful.

Current models of self-regulation suggest that behavioral regulation, particularly inhibitorycontrol, underlies most other areas of executive function. Essentially, one needs to beappropriately inhibited, flexible, and under emotional control for efficient, systematic, andorganized problem solving to take place. Sample's elevated scores on the Inhibit scale, and theBehavioral Regulation and the Metacognition Indexes, suggest that Sample has poor inhibitorycontrol and/or suggest that more global behavioral dysregulation is having a negative effect onactive metacognitive problem solving. The elevated Behavioral Regulation Index score,however, does not negate the meaningfulness of the elevated Metacognition Index score.Instead, one must consider the influence of the underlying behavioral regulation issues whilesimultaneously considering the unique problems with the metacognitive problem-solving skills.

BRIEF™ Score Summary TableIndex/Scale Raw Score T Score Percentile 90% C.I.

Inhibit 30 70 ≥ 99 67 - 73

Shift 22 68 94 63 - 73

Emotional Control 23 71 94 67 - 75

Behavioral Regulation Index (BRI) 75 71 94 69 - 73

Initiate 19 69 95 64 - 74

Working Memory 30 74 ≥ 99 70 - 78

Plan/Organize 24 67 94 62 - 72

Organization of Materials 17 66 93 62 - 70

Monitor 27 68 93 63 - 73

Metacognition Index (MI) 117 71 96 69 - 73

General Executive Composite (GEC) 192 73 96 71 - 75

Scale Raw Score Cumulative Percentile Protocol ClassificationNegativity 4 ≤ 94 Acceptable

Inconsistency 3 ≤ 98 Acceptable

Note: Male,age-specific norms have been used to generate this profile.For additional normative information, refer to Appendix A - D in the BRIEF™ Professional Manual.


Profile of BRIEF™ T ScoresT Score

≤ 30

35

40

45

50

55

60

65

70

75

80

85

90

95

≥ 100T Score

≤ 30

35

40

45

50

55

60

65

70

75

80

85

90

95

≥ 100

Emotional Working Plan/ Org. ofInhibit Shift Control Initiate Memory Organize Materials Monitor BRI MI GEC

T Score 70 68 71 69 74 67 66 68 71 71 73

Percentile ≥ 99 94 94 95 ≥ 99 94 93 93 94 96 96

Raw score 30 22 23 19 30 24 17 27 75 117 192

Missing 0 0 0 0 0 0 0 0 0 0 0

Note: Male,age-specific norms have been used to generate this profile.For additional normative information, refer to Appendixes A - D in the BRIEF™ Professional Manual.


ValidityBefore examining the BRIEF profile, it is essential to carefully consider the validity of the dataprovided. The inherent nature of rating scales (i.e., relying upon a third party for ratings of achild’s behavior) brings potential bias to the scores. The first step is to examine the protocol formissing data. With a valid number of responses, the Inconsistency and Negativity scales of theBRIEF provide additional validity indexes.

Missing itemsThe respondent completed 86 of a possible 86 BRIEF items. For reference purposes, thesummary table for each scale indicates the respondent’s actual rating for each item. There areno missing responses in the protocol, providing a complete data set for interpretation.

InconsistencyScores on the Inconsistency scale indicate the extent to which the respondent answered similarBRIEF items in an inconsistent manner relative to the clinical samples. For example, a highInconsistency score might be associated with marking Never in response to the item “Gets outof control more than friends” while at the same time marking Often in response to the item“Acts too wild or out of control.” Item pairs comprising the Inconsistency scale are shown inthe summary table below. T scores are not generated for the Inconsistency scale. Instead, theraw difference scores for the 10 paired items are summed and the total difference score (i.e., theInconsistency score) is used to classify the protocol as either “Acceptable,” “Questionable,” oras “Inconsistent.” The Inconsistency score of 3 falls within the Acceptable range, suggestingthat the rater was reasonably consistent in responding to BRIEF items.

Item1

Content 1 Score1

Item2

Content 2 Score2

Diff.

27 Mood changes frequently 3 26 Has outbursts for little reason 3 0

36Leaves work incomplete

2 39 Has trouble finishing tasks (chores,homework)

3 1

42 Interrupts others 3 43 Is impulsive 3 0

45 Gets out of seat at the wrong times 3 9 Needs to be told "no" or "stop that" 3 0

46 Is unaware of own behavior when ina group

3 65 Does not realize that certain actionsbother others

3 0

47Gets out of control more than friends

3 58 Has trouble putting the brakes onhis/her actions

3 0

48 Reacts more strongly to situationsthan other children

3 66Small events trigger big reactions

1 2

55 Talks or plays too loudly 3 57 Acts too wild or "out of control" 3 0

57Acts too wild or "out of control"

3 46 Is unaware of own behavior when in agroup

3 0

69 Does not think of consequencesbefore acting

3 65 Does not realize that certain actionsbother others

3 0

NegativityThe Negativity scale measures the extent to which the respondent answered selected BRIEFitems in an unusually negative manner relative to the clinical sample. Items comprising theNegativity scale are shown in the summary table below. A higher raw score on this scaleindicates a greater degree of negativity, with less than 3% of respondents scoring above 7 in the


clinical sample. As with the Inconsistency scale, T scores are not generated for this scale. TheNegativity score of 4 falls within the acceptable range, suggesting that the respondent’s view ofSample is not overly negative and that the BRIEF protocol is likely to be valid.

Item Content Item Response13 Acts upset by a change in plans Sometimes

14 Is disturbed by change of teacher or class Sometimes

24 Resists change of routine, foods, places, etc. Often

32 When sent to get something, forgets what he/she is supposed to get Often

64 Angry or tearful outbursts are intense but end suddenly Sometimes

68 Leaves a trail of belongings wherever he/she goes Often

71 Leaves messes that others have to clean up Sometimes

82 Cannot stay on the same topic when talking Sometimes

84 Says the same things over and over Often

Composite and Summary Indexes

Global Executive CompositeThe Global Executive Composite (GEC) is an overarching summary score that incorporates allof the BRIEF clinical scales. Although review of the Metacognition Index, BehavioralRegulation Index, and individual scale scores is strongly recommended for all BRIEF profiles,the GEC can sometimes be useful as a summary measure. In this case, the two summaryindexes are not substantially different, with T scores separated by 0 points. Thus, the GEC maycapture the nature of the overall profile. With this in mind, Sample's T score of 73 (%ile = 96)on the GEC is significantly elevated as compared to the scores of his peers, suggestingsignificant difficulty in one or more areas of executive function.

Behavioral Regulation and Metacognition IndexesThe Behavioral Regulation Index (BRI) captures the rated child’s ability to shift cognitive setand modulate emotions and behavior via appropriate inhibitory control. It is comprised of theInhibit, the Shift, and the Emotional Control scales. Intact behavioral regulation is likely to be aprecursor to appropriate metacognitive problem solving. Behavioral regulation enables themetacognitive processes to successfully guide active systematic problem solving; and moregenerally, behavioral regulation supports appropriate self-regulation.

The Metacognition Index (MI) reflects the rated child’s ability to initiate, plan, organize, self-monitor, and sustain working memory. It can be interpreted as Sample's ability to cognitivelyself-manage tasks and to monitor his performance. The MI relates directly to a child’s ability toactively problem solve in a variety of contexts. It is composed of the Initiate, WorkingMemory, Plan/Organize, Organization of Materials, and Monitor scales.

Examination of the indexes reveals that both the Behavioral Regulation Index (T = 71, %ile =94) and Metacognition Index (T = 71, %ile = 96) are elevated. This suggests more globaldifficulties with self-regulation, including the fundamental ability to inhibit impulses, modulateemotions, and to flexibly problem solve. These global difficulties extend to metacognitivefunctions, including the ability to sustain working memory, initiate, plan, organize, and self-monitor.


Clinical ScalesThe BRIEF clinical scales measure the extent to which the respondent reports problems withdifferent types of behavior related to the eight domains of executive functioning. The followingsections describe the scores obtained on the clinical scales and the suggested interpretation foreach individual clinical scale.

InhibitThe Inhibit scale assesses inhibitory control and impulsivity. This can be described as theability to resist impulses and the ability to stop one’s own behavior at the appropriate time.Sample's score on this scale is highly elevated (T = 70, %ile = 99) as compared to his peers.Children with similar scores on the Inhibit scale typically have marked difficulty resistingimpulses and difficulty considering consequences before acting. They are often perceived as (a)less in control of themselves than their peers, (b) having difficulty staying in place in line or inthe classroom, (c) interrupting others or “calling out” in class frequently, and (d) requiringhigher levels of adult supervision. Often, caregivers and teachers are particularly concernedabout the verbal and social intrusiveness and the lack of personal safety observed in childrenwho do not inhibit impulses well. Such children may display high levels of physical activity,inappropriate physical responses to others, a tendency to interrupt and disrupt group activities,and a general failure to “look before leaping.”

In the contexts of the classroom and assessment settings, children with inhibitory controldifficulties often require a higher degree of external structure to limit their impulsiveresponding. They may start an activity or task before listening to instructions, beforedeveloping a plan, or before grasping the organization or gist of the situation.

Examination of the individual items that comprise the Inhibit scale may be informative and mayhelp guide interpretation and intervention.

Item Content Item Response9 Needs to be told "no" or "stop that" Often

38 Does not think before doing Often

42 Interrupts others Often

43 Is impulsive Often

45 Gets out of seat at the wrong times Often

47 Gets out of control more than friends Often

57 Acts too wild or "out of control" Often

58 Has trouble putting the brakes on his/her actions Often

59 Gets in trouble if not supervised by an adult Often

69 Does not think of consequences before acting Often

ShiftThe Shift scale assesses the ability to move freely from one situation, activity, or aspect of aproblem to another as the circumstances demand. Key aspects of shifting include the ability to(a) make transitions, (b) tolerate change, (c) problem-solve flexibly, (d) switch or alternateattention, and (e) change focus from one mindset or topic to another. Sample's score on theShift scale is moderately elevated as compared to like-aged peers (T = 68, %ile = 94). Thissuggests that Sample has some difficulties with behavioral shifting, attentional shifting, and/orcognitive shifting. Difficulties with shifting often compromise the efficiency of problem-


solving abilities. Caregivers often describe children who have this level of difficulty withshifting as somewhat rigid and/or inflexible. Such children often prefer consistent routines. Insome cases, such children are described as being unable to drop certain topics of interest orunable to move beyond a specific disappointment or unmet need. On formal assessment,children with difficulties shifting cognitively are often observed to have difficulty changingfrom one task to the next or sometimes from one question to the next. They sometimes requireadditional explanations or demonstration to grasp the demands of a novel task when firstpresented. They may also “carry over” a problem-solving approach, a response style, orinformation from a previous task that is no longer appropriate. This tendency to carry over canbe seen as perseverating on content or response style from one item to the next within a task.

Item Content Item Response4 Cannot get a disappointment, scolding, or insult off his/her mind Sometimes

5 Resists or has trouble accepting a different way to solve a problem withschoolwork, friends, chores, etc.

Sometimes

6 Becomes upset with new situations Never

13 Acts upset by a change in plans Sometimes

14 Is disturbed by change of teacher or class Sometimes

24 Resists change of routine, foods, places, etc. Often

30 Has trouble getting used to new situations (classes, groups, friends) Sometimes

40 Thinks too much about the same topic Often

53 Gets stuck on one topic or activity Sometimes

62 After having a problem, will stay disappointed for a long time Often

Emotional ControlThe Emotional Control scale measures the impact of executive function problems on emotionalexpression and assesses a child’s ability to modulate or control his or her emotional responses.Sample's score on the Emotional Control scale is significantly elevated as compared to like-aged peers (T = 71, %ile = 94). This score suggests marked concerns with regulation ormodulation of emotions. Sample likely overreacts to events and likely demonstrates suddenoutbursts, sudden and/or frequent mood changes, and excessive periods of emotional upset.Poor emotional control is often expressed as emotional lability, sudden outbursts, or emotionalexplosiveness. Children with difficulties in this domain often have overblown emotionalreactions to seemingly minor events. Caregivers and teachers of such children frequentlydescribe a child who cries easily or laughs hysterically with small provocation, or a child whohas temper tantrums of a frequency or severity that is not age appropriate.

Item Content Item Response1 Overreacts to small problems Often

7 Has explosive, angry outbursts Often

26 Has outbursts for little reason Often

27 Mood changes frequently Often

48 Reacts more strongly to situations than other children Often

51 Mood is easily influenced by the situation Sometimes

64 Angry or tearful outbursts are intense but end suddenly Sometimes

66 Small events trigger big reactions Never

72 Becomes upset too easily Often


InitiateThe Initiate scale reflects a child’s ability to begin a task or activity and to independentlygenerate ideas, responses, or problem-solving strategies. Sample's score on the Initiate scale ismoderately elevated as compared to like-aged peers (T = 69, %ile = 95). This suggests thatSample may have difficulties beginning, starting or “getting going” on tasks, activities, andproblem-solving approaches appropriately. Poor initiation typically does not reflectnoncompliance or disinterest in a specific task. Children with initiation problems typically wantto succeed at and complete a task but they have trouble getting started. Caregivers of suchchildren frequently report difficulties with getting started on homework or chores along with aneed for extensive prompts or cues in order to begin a task or activity. Children with initiationdifficulties are at risk for being viewed as “unmotivated.” In the context of psychologicalassessment, initiation difficulties are often demonstrated in the form of difficulty with word anddesign fluency tasks as well as a need for additional cues from the examiner in order to begintasks in general. Alternatively, initiation deficits may reflect depression, and this should beexamined particularly if this finding is consistent with the overall affective presentation of thechild.

Item Content Item Response3 Is not a self-starter Often

10 Needs to be told to begin a task even when willing Often

19 Does not show creativity in solving a problem Often

34 Has problems coming up with different ways of solving a problem Often

50 Has trouble getting started on homework or chores Often

63 Does not take initiative Sometimes

70 Has trouble thinking of a different way to solve a problem when stuck Sometimes

Working MemoryThe Working Memory scale measures “on-line representational memory;” that is, the capacityto hold information in mind for the purpose of completing a task, encoding information, orgenerating goals, plans, and sequential steps to achieving goals. Working memory is essentialto carry out multistep activities, complete mental manipulations such as mental arithmetic, andfollow complex instructions. Sample's score on the Working Memory scale is significantlyelevated as compared to like-aged peers (T = 74, %ile = 99). This suggests that Sample hassubstantial difficulty holding an appropriate amount of information in mind or in “activememory” for further processing, encoding, and/or mental manipulation. Further, Sample's scoresuggests difficulties sustaining working memory, which has a negative impact on his ability toremain attentive and focused for appropriate lengths of time. Caregivers describe children withfragile or limited working memory as having trouble remembering things (e.g., phone numbersor instructions) even for a few seconds, losing track of what they are doing as they work, orforgetting what they are supposed to retrieve when sent on an errand. They often missinformation that exceeds their working memory capacity such as instructions for an assignment.Clinical evaluators may observe that a child cannot remember the rules governing a specifictask (even as he or she works on that task), rehearses information repeatedly, loses track of whatresponses he or she has already given on a task that requires multiple answers, and struggleswith mental manipulation tasks (e.g., repeating digits in reverse order) or solving arithmeticproblems that are orally presented without writing down figures.

Appropriate working memory is necessary to sustain performance and attention. Parents ofchildren with difficulties in this domain report that the children cannot “stick to” an activity for


an age-appropriate amount of time and frequently switch tasks or fail to complete tasks.Although working memory and the ability to sustain it have been conceptualized as distinctentities, behavioral outcomes of these two domains are often difficult to distinguish.

Item Content Item Response2 When given three things to do, remembers only the first or last Often

8 Has a short attention span Often

18 Has trouble concentrating on chores, schoolwork, etc. Often

21 Is easily distracted by noises, activity, sights, etc. Often

25 Has trouble with chores or tasks that have more than one step Often

28 Needs help from an adult to stay on task Often

31 Forgets what he/she was doing Often

32 When sent to get something, forgets what he/she is supposed to get Often

39 Has trouble finishing tasks (chores, homework) Often

60 Has trouble remembering things, even for a few minutes Often

Plan/OrganizeThe Plan/Organize scale measures the child’s ability to manage current and future-oriented taskdemands. The scale is comprised of two components: plan and organize. The plan componentcaptures the ability to anticipate future events, to set goals, and to develop appropriatesequential steps ahead of time in order to carry out a task or activity. The organize componentrefers to the ability to bring order to information and to appreciate main ideas or key conceptswhen learning or communicating information. Sample's score on the Plan/Organize scale ismoderately elevated as compared to like-aged peers (T = 67, %ile = 94). This suggests thatSample has some difficulty with the planning and the organization of information which has anegative impact on his approach to problem solving. Planning involves developing a goal orend state and then strategically determining the most effective method or steps to attain thatgoal. Evaluators can observe planning when a child is given a problem requiring multiple steps(e.g., assembling a puzzle or completing a maze). Sample may underestimate the time requiredto complete tasks or the level of difficulty inherent in a task. He may often wait until the lastminute to begin a long-term project or assignment for school, and he may have trouble carryingout the actions needed to reach his goals.

Organization involves the ability to organize oral and written expression as well as tounderstand the main points expressed in presentations or written material. Organization alsohas a clerical component that is demonstrated, for example, in the ability to efficiently scan avisual array or to keep track of a homework assignment. Sample may approach tasks in ahaphazard fashion, getting caught up in the details and missing the “big picture.” He may havegood ideas that he fails to express on tests and written assignments. He may often feeloverwhelmed by large amounts of information and may have difficulty retrieving materialspontaneously or in response to open-ended questions. He may, however, exhibit betterperformance with recognition (multiple choice) questions.

Item Content Item Response12 Does not bring home homework, assignment sheets, materials, etc. Often

17 Has good ideas but cannot get them on paper Often

23 Forgets to hand in homework, even when completed Often

29 Gets caught up in details and misses the big picture Often

35 Has good ideas but does not get job done (lacks follow-through) Often

37 Becomes overwhelmed by large assignments Sometimes


41 Underestimates time needed to finish tasks Sometimes

49 Starts assignments or chores at the last minute Sometimes

52 Does not plan ahead for school assignments Never

56 Written work is poorly organized Sometimes

Organization of MaterialsThe Organization of Materials scale measures orderliness of work, play, and storage spaces(e.g., desks, lockers, backpacks, and bedrooms). Caregivers and teachers typically can providean abundance of examples describing a child’s ability to organize, keep track of, and/or clean uptheir belongings. Sample's score on the Organization of Materials scale is moderately elevatedrelative to like-aged children (T = 66, %ile = 93). Sample is described as having a moderatedegree of difficulty with (a) keeping his materials and his belongings reasonably well organized,(b) having his materials readily available for projects or assignments, and (c) as havingdifficulty finding his belongings when needed. Children who have difficulties in this area oftendo not function efficiently in school or at home because they do not have their belongingsreadily available for use. Pragmatically, teaching a child to organize his or her belongings canbe a useful, concrete tool for teaching greater task organization.

Item Content Item Response11 Loses lunch box, lunch money, permission slips, homework, etc. Sometimes

16 Cannot find clothes, glasses, shoes, toys, books, pencils, etc. Sometimes

20 Backpack is disorganized Often

67 Cannot find things in room or school desk Often

68 Leaves a trail of belongings wherever he/she goes Often

71 Leaves messes that others have to clean up Sometimes

73 Has a messy desk Sometimes

MonitorThe Monitor scale assesses two types of monitoring behaviors: Task-oriented monitoring orwork-checking habits and Self-monitoring or interpersonal awareness. The task monitoringportion of the scale captures whether a child assesses his or her own performance during orshortly after finishing a task to ensure accuracy or appropriate attainment of a goal. The selfmonitoring portion of the scale evaluates whether a child keeps track of the effect that his or herbehavior has on others. Sample's score on the Monitor scale is moderately elevated, suggestingsome difficulty with monitoring (T = 68, %ile = 93). Examination of the task-monitoring andself-monitoring clusters of individual items that comprise the Monitor scale reveals strongerendorsement of self-oriented monitoring items but an average level of endorsement of task-oriented items. Children with similar patterns tend to be less aware of their own behavior andthe impact this behavior has on their social interactions with others. The task-oriented itemssuggest, however, that Sample is reasonably cautious in his approach to tasks or assignmentsand that he tends to notice and/or check for mistakes.

Item Content Item Response15 Does not check work for mistakes Often

22 Makes careless errors Sometimes

33 Is unaware of how his/her behavior affects or bothers others Often

36 Leaves work incomplete Sometimes

44 Does not notice when his/her behavior causes negative reactions Sometimes


46 Is unaware of own behavior when in a group Often

54 Has poor understanding of own strengths and weaknesses Often

55 Talks or plays too loudly Often

61 Work is sloppy Often

65 Does not realize that certain actions bother others Often

Additional Clinical ItemsThe BRIEF Parent and Teacher Forms both contain additional items of clinical interest that arenot included in any of the clinical scales. Although these items are not scored and therefore donot contribute to the BRIEF scale raw scores, they were retained because of their directrelevance to functional intervention programming and their relevance to specific clinicalpopulations (e.g., Pervasive Developmental Disorders, Traumatic Brain Injury, and AttentionDeficit/Hyperactivity Disorder). Careful review of these individual items can assist theexaminer in identifying and targeting areas of concern for intervention and can further reinforceinterpretation of the findings from the clinical scales by providing additional evidence ofdifficulties in the particular domain of executive function. The item summary table belowincludes the item numbers, item content, and the rater’s item responses, as well as the BRIEFscale to which the item was originally assigned.

Item Content Item Response74 Has trouble waiting for turn (Inhibit) Often

75 Does not connect doing tonight's homework with grades (Plan/Organize) Often

76 Tests poorly even when knows correct answers (Plan/Organize) Sometimes

77 Does not finish long-term projects (Plan/Organize) Sometimes

78 Has poor handwriting (Monitor) Sometimes

79 Has to be closely supervised (Inhibit) Often

80 Has trouble moving from one activity to another (Shift) Sometimes

81 Is fidgety (Inhibit) Often

82 Cannot stay on the same topic when talking (Working Memory) Sometimes

83 Blurts things out (Inhibit) Never

84 Says the same things over and over (Shift) Often

85 Talks at the wrong time (Inhibit) Sometimes

86 Does not come prepared for class (Plan/Organize) Sometimes

Comparison of BRIEF Working Memory and Inhibit Scales toADHD Groups

The BRIEF Inhibit and Working Memory scales may be helpful in identifying children withsuspected Attention-Deficit/Hyperactivity Disorder (ADHD). Theoretically, inhibitory controlenables self-regulation, and working memory enables sustained attention. It is important at theoutset, however, to appreciate the distinction between executive functions and the diagnosis ofAttention-Deficit/Hyperactivity Disorder (ADHD): Executive functions are neuropsychologicalconstructs whereas ADHD is a neuropsychiatric diagnosis based on a cluster of observedsymptoms. Although executive functions underlie the symptoms of ADHD, executivedysfunction is not synonymous with a diagnosis of ADHD. There is general agreement thatdifferent aspects of executive dysfunction contribute to the behaviors that characterize ADHD.


The Inhibit and Working Memory scales exhibit good predictive validity and good sensitivityand specificity for detecting a likely diagnosis of Attention-Deficit/Hyperactivity Disorder(ADHD) Inattentive Type or Combined Type. In clinical samples, the Working Memory scalediscriminated between children with no ADHD diagnosis (healthy controls) and those witheither the Inattentive or Combined types of ADHD. The Inhibit scale further distinguishedbetween controls and children with the Combined Type of ADHD. Please refer to pages 76through 84 in the BRIEF Professional Manual for further detail. While the BRIEF may be ahelpful and efficient tool in assessing for ADHD, it is important that all relevant data beconsidered in the context of clinical judgment before reaching a diagnostic decision.

In this particular profile, Teacher ratings of Sample's working memory (T = 74, %ile = 99) andinhibitory control (T = 70, %ile = 99) are moderately elevated. This suggests that Sample mayhave characteristics of executive dysfunction that are often seen in children diagnosed withADHD. It is important to appreciate, however, that some children with similar elevations donot meet the criteria for ADHD.

As with any diagnostic decision, consideration of all relevant clinical assessment data isessential and clinical judgment is of paramount importance. Teacher and parent rating scales,such as the BRIEF, can add valuable information to a more comprehensive assessment forADHD.


Executive System Intervention

A General FrameworkGiven the unique nature of the executive functions in playing a “command” role in terms ofguiding and regulating thought and behavior, the approach to intervention must be consideredglobally. First, one must consider the end goal or outcome of “good” executive function for thechild. The following executive outcomes for children are proposed:

♦ Demonstrating purposeful, goal-directed activity

♦ Displaying an active problem-solving approach

♦ Exerting self-control

♦ Demonstrating maximal independence

♦ Exhibiting reliable and consistent behavior and thinking

♦ Demonstrating positive self-efficacy

♦ Exhibiting an internal locus of control

The general principles of an intervention model for the executive functions used here are basedlargely on the work of Mark Ylvisaker and colleagues (Ylvisaker, 1998; Ylvisaker & Feeney,1998; Ylvisaker, Szekeres, & Feeney, 1998) who advocate an ongoing (a) contextualized (i.e.,in the child’s real world), (b) collaborative (i.e., together with the child, parents, teachers, andpeers), and (c) hypothesis-testing (i.e., generating and implementing testable methods)assessment and treatment approach. The reader is referred to these excellent resources as wellas Marlowe (2001) and Levine et al. (2000) for further discussion of executive functionintervention issues and methods.

The ultimate goal of executive function interventions is to establish regular behavioral/cognitiveroutines to maximize independent, goal-oriented problem solving and performance. A criticalfeature of any intervention is to establish external environmental preconditions that will enablethe child to develop, and, ideally, will enable the child to make automatic behavioral/cognitiveroutines. For individuals just starting to learn executive control behaviors, for young children,or for individuals with extreme executive dysfunction, the focus of intervention may need to bemore externalized or environmental (i.e., to organize and structure the external environment andto organize and provide cuing for behavioral strategies and routines). Many such children donot have the internal resources available to initiate behaviors without significant individualizedstructuring, cuing, and reinforcement. They often need help to know when and how to applythe appropriate problem-solving behavioral routine. Direct rewards and positive incentives areoften necessary to motivate the child to attend to and practice new behavioral routines. Becauseof the nature of the child’s executive dysfunction, these organizational routines may initially beexperienced as quite stressful by many children and adolescents. Therefore, establishing suchroutines may require explicit rewards. Once these behavioral routines are established, positivecuing becomes the crucial factor; cuing can then be faded, as the child’s autonomy increases.

It is possible to have an executive system focus in any and all activities, including classroomactivities, therapy activities, social/recreational activities, and activities of daily living at home.


Furthermore, this may take little time or effort, once parents and school staff have developedappropriate habits in this area. For example, any activity can include

♦ Goal setting: An initial decision about or choice of a goal to pursue. (What do I need toaccomplish?)

♦ Self-awareness of strengths/weaknesses: Recognition of one’s stronger and weakerabilities, and a decision about how easy or how difficult it will be to accomplish thegoal. (How easy or difficult is this task/goal? Have I done this type of task before?)

♦ Organization/Planning: Development of an organized plan. (What materials do weneed? Who will do what? In what order do we need to do these things? How long will ittake?)

♦ Flexibility/Strategy use: As complications or obstacles arise while working toward thegoal, planned (e.g., staff ensure that problems arise) or unplanned coaching of theindividual in flexible problem solving/strategic thinking. (When or if a problem arises,what other ways should I think about in order to reach the goal? Should I ask forassistance?)

♦ Monitoring: A review of the goal, plan, and accomplishments at the end. (How did Ido?)

♦ Summarizing: What worked and what didn't work? What was easy and what wasdifficult, and why?

An executive function intervention model includes at the outset an appropriate assessment. Thisincludes defining the relevant profile of executive strengths and weaknesses, associated domain-specific abilities or deficits, and an analysis of the everyday person, task, and situationaldemands that increase or decrease appropriate executive functioning. Determination of thedevelopmental level of the child and the age-appropriate expectations for executive function arealso necessary.

Several basic tenets are also advocated, including

♦ Teaching a goal-directed, problem-solving process.

♦ Implementing the process within positive, meaningful everyday routines.

♦ Providing real-world relevance and application of strategies and routines.

♦ Involving everyday people (parents, teachers, and peers) as models and “coaches.”

♦ Including the child in the design of the intervention as much as possible.

Most individuals with executive dysfunction do not yet possess the age-appropriate internalizedskills needed for well-regulated problem solving. Therefore, intervention often begins from an“external support” position with active and directive modeling, coaching, and guidance byimportant everyday people, which gradually transitions into an “internal” process of fading andcuing as follows

♦ External modeling of multistep problem-solving (i.e., executive) routines.

♦ External guidance with the development and implementation of everyday executiveroutines.

♦ Practice the use of executive routines in everyday situations.


♦ Fade external support and cue internal generation and use of executive routines.

♦ Support internal control in the generation and use of specific problem-solving routine(s).

♦ With external guidance, promote generalization to new situation(s).

♦ Accumulate experience and examine conditions for the selective use of variousexecutive routines.

♦ Provide feedback (external and internal) throughout the process.

In structuring an executive function intervention program, we advocate the use of everydayexecutive routines within the context of a general approach to executive problem solving asopposed to merely teaching specific skills out of context. In addition, given the difficulties withworking memory that many individuals with executive dysfunction possess, the use of a writtencopy of the active multistep executive routine is often necessary. The child should becomeincreasingly more active in formulating and carrying out the plans and reviewing hisperformance, thus promoting “internal” executive control. The goal of executive functionintervention is maximal independence and self-sufficiency, which necessitates the activeinvolvement of the child.

Goal-Plan-Do-Review SystemThe use of a general executive problem-solving routine that promotes (a) systematic goaldefinition, (b) planning, (c) action, (d) self-monitoring/evaluating, and (e) flexible, strategicadjustment of plans and actions may serve as a central framework or vehicle within whichspecific executive function intervention methods and strategies can be incorporated. The Goal-Plan-Do-Review (GPDR) method is one such system (Ylvisaker, Szkeres, et al., 1998). Othergoal-oriented problem-solving methods can also be considered (Levine et al., 2000; Marlowe,2001). The complexity of the problem-solving routine should be adapted to the competencylevel of the child. The GPDR system is presented in Figure 1.

In developing interventions for the executive functions, it is important to appreciate what theyare not. Executive function interventions are not

♦ Specific, isolated sets of skills or information that are unidirectionally taught to thechild.

♦ Mere lists of steps that are taped to the child’s desk or bedroom door.

♦ Simple behavior modification(s) to increase motivation in the absence of criticalantecedent conditions (setting variables, problem-solving routines).

♦ Just a list of treatment/IEP goals without attention to the “how, who, where, and when”of the intervention delivery system.

To cue individuals responsible for implementing the executive function interventions (e.g.,parents, teachers, and therapists), the following intervention checklists for general executivesystem impairment (see Figure 2) and specific organizational impairment (see Figure 3) can behelpful (Ylvisaker, Szekeres, et al., 1998). These checklists provide an important set ofquestions to help guide implementation of specific interventions, supports, andaccommodations.

Within the context of a collaborative, contextualized problem-solving model utilizing theeveryday routines of the child and delivered within a method such as the Goal-Plan-Do-Review


system, some specific recommendations for interventions and accommodations are offeredaccording to the specific area of functional impairment. While the efficacy of each interventionhas not been empirically demonstrated, the majority are common interventions, and they arelikely to be familiar methods to the intervention team. These recommendations are general andare intended here as suggestions or ideas that may be tailored to suit Sample's needs. As withany intervention, clinical judgement is paramount.


GOALWhat do I want to accomplish?

PLANHow am I going to accomplish my goal?

MATERIALS/EQUIPMENT STEPS/ASSIGNMENTS1. 1.2. 2.3. 3.4. 4.5. 5.

PREDICTIONHow well will I do? How much will I get done?

Self-rating 1 2 3 4 5 6 7 8 9 10

Other Rating 1 2 3 4 5 6 7 8 9 10

DOPROBLEMS ARISE? FORMULATE SOLUTIONS!1. 1.2. 2.3. 3.

REVIEWHow did I do?

Self-rating 1 2 3 4 5 6 7 8 9 10

Other Rating 1 2 3 4 5 6 7 8 9 10

What worked? What didn’t work?1. 1.2. 2.3. 3.

What will I try differently next time?

Note: From “Cognitive Rehabilitation: Executive Functions,” by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic BrainInjury Rehabilitation: Children and Adolescents (2nd ed., p. 244), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright ©1998 by Butterworth-Heinemann. Adapted with permission.

Figure 1. Goal-Plan-Do-Review Problem-Solving System.


General Considerations

� Is intervention in the areas that fall into the category of executive functions structured around the individual’smeaningful goals?

� Is intervention infused into everyday activities? Are all everyday people oriented to how they can facilitateimproved executive functions? Are all everyday people aware of the dangers of learned helplessness?

� Are everyday people aware of the strategies that the individual is being taught or is expected to use?� Is successful performance in the areas classified as executive functions richly and naturally rewarded? Is the

individual held responsible for effective strategic performance?� Is the individual given ample opportunity to identify and solve his or her own problems (with guidance, if

necessary)?� For individuals who are young or very concrete thinkers, are executive function tasks structured around

concrete physical activities (versus abstract or purely cognitive activities)?� Do everyday people in the environment routinely model expert use of executive functions?� Is the individual given sufficient practice so that strategic behavior becomes automatic?� Are everyday people in the environment supportive of strategic or compensatory ways to accomplish tasks?� Does the individual respect a strategic or compensatory approach to everyday problems? If not, is appropriate

help or counseling provided?� Are everyday people in the individual’s environment fully aware of possible limitations in the individual’s

executive functions (especially initiation and inhibition) so that they do not misinterpret behavior?

AppropriatenessLevel of Development� Preschoolers: Are preschoolers introduced to relevant vocabulary, including difficult or easy to do; plan; do

something special; review; what works and what doesn’t work? Are they actively engaged in identifying whatis difficult and easy for them (especially physical activities)? Are they richly and naturally rewarded forclever solutions to difficult everyday problems?

� Grade-school-age children: Are grade-school-age children actively engaged in identifying what is difficultand easy for them (including cognitive and academic activities)? Are they actively engaged in identifyingclever ways to accomplish difficult tasks? Are they actively encouraged to seek help on their own when tasksare difficult? Are they richly and naturally rewarded for clever solutions to difficult everyday problems? Arethey encouraged to help one another solve problems?

� Older students and adults: See entire checklist.

Level of Recovery� People who are minimally responsive: Is the individual prompted (physically, if necessary) to engage in

familiar activities (e.g., activities of daily living), so that he or she is acting, not just being acted on? Hasevery attempt been made (e.g., remote switch control) to enable the individual to control meaningful events?Do everyday people in the environment respond to the individual as an agent?

� People who are alert but confused: Is the individual given choices whenever possible (short of increasingconfusion)? Is the individual thoroughly oriented to the purposes of intervention activities? Do staff negotiateactivities with the individual? Does the individual have opportunities to experience natural consequences ofchoices?

� People who are no longer seriously confused: See entire list.

Figure 2. A checklist for intervention for individuals with executive system impairment.


Self-Awareness of Strengths and Needs

� Is the individual maximally engaged in identifying what is easy and difficult to do and in determining whatmakes activities easy or difficult?

� Is the individual given opportunities to compare performance when an activity is completed in a usual wayversus when it is completed with special strategic procedures?

� Does the individual keep a journal in which strengths and needs are recorded?� Is the individual given opportunities to identify strengths and needs in others and strategic procedures that

others may use (e.g., peer teaching)?� Is the individual given appropriate informative feedback (e.g., peer feedback, video feedback, confrontational

feedback, if appropriate)?

Goal Setting

� Is the individual routinely asked to predict how well he or she will do on activities?� Are predictions recorded in journals and compared with actual performance?� Does the individual maximally participate in rehabilitation and special education goal setting? Is adequate

support provided if this is difficult?� Are intervention activities structured around the individual’s personal goals?

Planning

� Does the individual participate maximally in planning his or her intervention activities?� Is a planning guide available, if needed?� Does the individual begin the day by preparing a plan on a planning board or in a journal? Does the

individual begin each activity by preparing a plan?� Do therapeutic activities include attempts to plan meaningful complex events (e.g., parties, outings)?� Does the individual participate maximally in long-term future planning, rehabilitation planning, and

development of the individualized plan?

Organizing See the organization checklist in Figure 3.

Self-Initiating

� Do everyday people give the individual opportunities to initiate and then wait an appropriate length of time?Are signals available to remind the individual to initiate activities?

� Do the activities in which the individual engages make appropriate demands on the individual’s ability toinitiate? (For example, board games may require little initiation, whereas conversations may require muchinitiation.)

� Are all forms of institutional learned helplessness avoided?� Are prosthetic initiators available if needed (e.g., alarm watch, NeuroPage)?� If inhibition cues are necessary, are they as subtle as possible and provided as much as possible by peers as

opposed to staff? Is nagging avoided?

Figure 2 (continued). A checklist for intervention for individuals with executive system impairment.


Self-Inhibiting

� Do everyday people give the individual opportunities to inhibit impulsive or inappropriate behavior that arerealistic in their demands?

� Do the activities in which the individual engages make appropriate demands on the individual’s ability toinhibit? (For example, unstructured and unfamiliar activities in a distracting environment require considerableinhibition.)

� If inhibition cues are necessary, are they as subtle as possible and provided as much as possible by peers asopposed to staff? Is nagging avoided?

Self-Monitoring and Evaluating

� Do everyday people give the individual opportunities to self-monitor and evaluate performance? If cues arenecessary, are they subtle? Is nagging avoided?

� Is the individual maximally involved in charting his or her own performance, in keeping a journal whichperformance is recorded, and in graphing performance?

� Is the individual routinely asked to fill in a form regarding his or her own performance; What works and whatdoesn’t work?

Problem Solving and Strategic Thinking

� Is the individual maximally involved in solving everyday problems as they arise? Are everyday peoplethoroughly oriented to the importance of problem solving?

� Is the individual maximally engaged in selecting strategies to overcome obstacles and achieve importantgoals?

� Is there an appropriate amount of external support for strategic thinking?� Does the individual have a form that cues the appropriate kind of strategic thinking?� Do everyday people in the environment expect and cue strategic performance?� Do everyday people in the environment avoid learned helplessness: That is, do they resist solving all of the

individual’s problems?� Is there consistency among staff and family members in how problem-solving tasks are presented and in the

kinds of external problem-solving supports that are provided? Is there consistency in reducing externalsupport as the individual becomes increasingly independent in problem solving?

Note: From “Cognitive Rehabilitation: Executive Functions,” by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic BrainInjury Rehabilitation: Children and Adolescents (2nd ed., p. 260-262), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright © 1998 by Butterworth-Heinemann. Adapted with permission.

Figure 2( continued). A checklist for intervention for individuals with executive system impairment.


�� Are the individual’s life experiences adequately organized?� Is there thematic or other organization within therapeutic or instructional sessions? Is the organization of

the session obvious to the individual?� Is there thematic or other organization across therapeutic or instructional sessions? For example, are the

activities in speech therapy or occupational therapy related in a clear way to activities in academicinstruction or vocational intervention?

� Is there thematic or other organization from day to day? Is the individual involved in activities or projectsthat require integrating information over several days or weeks?

� Is the individual’s life organized around well-understood routines?

�� Is the content that is used for organizational tasks personally meaningful or directly related to social,academic, or vocational success?

�� Are organizing tasks correctly placed on the continuum of involuntary (incidental) to deliberate(strategic) learning tasks?� For the concretely thinking person, is there a concrete, meaningful goal that he or she wishes to

accomplish and that requires organizational thinking?� If appropriate, is the individual engaged in trying to understand the concept of organization and what he or

she can do to organize more effectively?

�� Is there an appropriate amount of external organizational support for individuals who have difficultyorganizing?� Are advance graphic organizers available for complex tasks? That is, is the task mapped out in a way that

makes it easy to follow (e.g., sequence of photographs or drawings, written outline, flowchart, orchecklist)?

� Does the organization of the advance organizers correctly capture the way in which the information shouldbe organized in the head of the learner?

� Is a log book, day planner, or memory book available that contains schedules, maps, photographs ofcritical people, assignments, and other important information needed to stay organized?

� Are plans illustrated in appropriately concrete ways (e.g., photographs)?� If organizational reminders must be provided by other people, are they presented in a way that is not

perceived as nagging?� If the individual is confused about his or her past life, is a visually clear life line available, representing

important events in that person’s life?

�� Is there consistency among staff and family members in how tasks and information are presented and inthe kinds of external organizational support that are provided?

�� Do all everyday people understand how to use everyday activities to facilitate improvement inorganizational functioning?

�� Is there consistency in reducing external organizational support as the individual becomes increasinglyorganized?

�� Is the individual as engaged as possible in� Determining the goal of activities?� Creating a plan to achieve the goal?� Monitoring performance during the activity?� Evaluating success of the activity?� Determining what worked and what did not work in the plan?

Note: From “Cognitive Rehabilitation: Executive Functions,” by M. Ylvisaker, S. Szekeres, and T. Feeney, Traumatic BrainInjury Rehabilitation: Children and Adolescents (2nd ed., p. 217), by M. Ylvisaker (Ed.), 1998, Boston: Butterworth-Heinemann. Copyright © 1998 by Butterworth-Heinemann. Adapted with permission.

Figure 3. A checklist for intervention for individuals with organizational impairment.


InhibitExternal Structuring and Modifications

A student with inhibitory control difficulties often requires additional structure in hisenvironment at the outset in order to maintain more appropriately controlled behavior. Samplemight need a more explicit, extensive, and/or clear set of rules and expectations, and might needthese reviewed with him regularly.

Often, it is important to limit distractions that are problematic for a student with inhibitorycontrol difficulties. This might include visual and auditory distractions as well as other studentsor activities that can pull Sample's attention away from a task.

Environmental structure can be an important consideration for children like Sample. Openclassroom settings often have too many distractions and too many opportunities for impulsivebehaviors.

A student like Sample often benefits from careful placement in the classroom. This is notnecessarily in the front and center, but might be close to the center of activity to help him feelmore involved or in a place where frequent eye contact with the teacher is likely.

Disinhibited children often require more frequent redirection and more frequent limit-settingfrom the teacher. Placement in close proximity of the teacher can facilitate greater interactionwithout disturbing other students.

Sample might benefit from sitting with or near more well-controlled and more focused peerswho can serve as models and can resist his distracting tendencies.

A lower student-to-teacher ratio may be necessary to allow for more frequent interactionbetween Sample and his instructors. The inclusion of aids, parent helpers, or otherparaprofessionals within the classroom can help provide the additional external structureSample needs to remain more appropriately controlled.

Often a child with impulse control difficulties finds typical homework loads daunting. Samplemay need his homework requirements reduced to within his capabilities at the outset, withstepwise increases in expectations as he demonstrates success.

Student-Based Interventions

Response delay techniques can be helpful for some students. Sample might be taught strategiessuch as counting to 5 or 10 before responding verbally or physically.

Several “stop and think” methods are available that teach students to inhibit their initialresponse, to consider the potential consequences of their behaviors, and to further develop aplan of approach to a situation. Some are cognitive-behavioral strategies, and others areavailable as games for guidance counseling or therapy.

If Sample demonstrates an impulsive approach to tasks, he might be asked to verbalize a plan ofapproach before starting work. This places a short time period between the impulse and theaction and can allow for better planning and a more strategic approach. Sample's teacher orparent can ask him to explain how he will approach a task, including his goals for accuracy andtime.

It is often helpful to require a student like Sample to develop and express more than one plan ofapproach to a task before starting. This helps him to focus his attention on possibleconsequences, and alerts him to alternative strategies.


A child like Sample often needs more frequent breaks, particularly with motor activity. Breakscan be a reward for work completed and only need to be one or two minutes in duration.Sample might be asked to complete some independent desk work within his capabilities beforerunning an errand, taking a bathroom break, or simply bringing his work to the teacher forreview.

It is often important to set goals for accuracy of work when a child tends to rush through hiswork. Acknowledging the speed with which Sample completes his work can help him feel goodabout his accomplishments; increasing accuracy or neatness might be suggested as additionalgoals.

Behavior programs are often a necessary component for addressing impulse control difficulties,particularly when there are behavioral problems (e.g., the child acts in a physically or sociallyimpulsive fashion). It is important to appreciate that, by definition, a child with inhibitorycontrol difficulties cannot consider potential consequences of his actions in the moment, eventhough he may demonstrate appropriate knowledge of consequences. Therefore, behavioralprograms geared toward controlling stimuli that precede or lead to impulsivity are likely to bemore successful than those that focus on the consequences following an impulsive action.

Controlling antecedents, or what occurs prior to an impulsive behavior, is often an importantmethod of reducing problematic behaviors. Parents and teachers can likely anticipate timeswhen Sample is likely to act in a disinhibited manner. Intervening at that point may be moreeffective than attempting to apply consequences during or after a problem. Limiting stimuli orsituations where Sample might be impulsive can be important, or discussing the likelihood ofimpulsive behaviors and expectations may also be helpful. For example, if Sample hasdifficulty with behavioral control on the playground, he might meet with the teacher for a fewminutes before joining his peers to discuss expectations and actions that Sample or his teachermight take to avoid problems.

Consequence based systems may be an effective support for Sample. While he may havedifficulty considering consequences at the moment, reinforcement for appropriate behaviors andresponse costs for inappropriate behaviors may be helpful and necessary.

It is usually important that any behavior program be implemented across settings forconsistency. Sample's parents, teachers, and other involved individuals should be consistent intheir use of behavioral techniques.

Ongoing behavioral consultation is often important. Behavioral interventions typically requireongoing adjustments to address new situations or challenges, to modify reinforcers andconsequences as needed, and to ensure consistency. Often counselors, a behavioral specialist,or a therapist can serve as the behavior program manager.

Social difficulties often become apparent for a child with inhibitory control difficulties. A childwho behaves impulsively with peers may say or do inappropriate things and peers will learn tokeep their distance. It is important to intervene early to avert social difficulties and the negativeeffects on Sample's self-esteem. Some suggestions include

♦ Employing cross-age tutoring or mentoring with an older student who can explain andmodel appropriate social behaviors can be an effective means of increasing socialsuccess.

♦ Sample might benefit from small group activities with more focused and well-controlledpeers. His peers can serve as role models, but may need adult guidance in ways torespond to Sample's impulsive behaviors.


♦ Guided observations of peer interactions may be helpful for Sample as a means oflearning more appropriate social skills. A teacher or parent might meet with him brieflyat the outset of an activity and discuss how other children are behaving.

♦ Sample may need more limited time in unstructured activity in order to maintainappropriate behavior. He might join an activity with a prearranged expectation that hewill take a break from the activity after a set period of time. This break time can be usedto review his successes and any areas of difficulty before returning to the activity.

ShiftExternal Structuring and Modifications

Remaining consistent is an important aspect of structured, systematic teaching, and it promoteslearning and generalization across settings and time. Consistency in teaching and managementdoes not imply rigidity, but rather a systematic form of teaching and dependable, predictableenvironments. Increased consistency is often necessary at the outset for a child with difficultiesshifting or adjusting to changes in routine, schedule, or activity. This may include the use ofteaching and behavioral strategies that remain the same across time, environments, and people.

Often a child's preference for sameness or insistence on routines and sameness reflect the degreeof anxiety and distress he experiences with change. While respecting Sample's need for thecomfort which his routines may provide, the learning and home environments can gradually andincrementally introduce minor changes, one at a time.

A child with difficulties shifting can often adjust to changes in schedule or routine with the useof visual organizers such as pictures, schedules, planners, and calendar boards. This will letSample know the order of activities for the day, and can alert him to variations in the usualsequence of events before they occur.

Adherence to routines and resistance to change may reflect Sample's need for predictability inhis environment. An essential tenet of intervention is to facilitate feelings of security bymaintaining a set of basic routines, then adjusting routines slightly in a stepwise fashion. Largersteps may provoke resistance and distress.

Displaying a daily schedule and reviewing it at the outset of the day can help a student likeSample anticipate the sequence of events and can serve as a useful reminder of any changes inhis daily routine.


For a child who benefits from routines or who rigidly adheres to routines, development ofpositive routines and a set of alternative routines can be functional. Essentially, Sample's daycan be viewed as a sequence of routines, such as a morning routine, a school routine, and anevening routine. These can be further broken down into several subroutines, such as brushingteeth, washing up, getting dressed, and packing a backpack for school. Sample may then beable to learn alternative subroutines, such as different ways to get to school, that can bepracticed and swapped in and out of the larger routines. This can build in the appearance offlexibility.

A child like Sample with difficulties shifting attention and cognitive set often needs to focus ononly one task at a time. Presenting one task at a time and limiting choices to only one or twomay be helpful.


Sample might benefit from practice with shifting attention and cognitive set. Working with twoor three familiar tasks and rotating them at regular intervals can build in the appearance ofgreater flexibility and help Sample become more accustomed to shifting.

Some children can benefit from external prompting to shift attention, behavior, or cognitive setfrom one activity or focus to the next.

One of the most effective strategies for a child with difficulty adjusting to change in routine isthe use of the “2-minute warning.” Teachers and parents can alert Sample that one activity isabout to end and another will begin. Allowing a few minutes of “down time” or leisure activitybetween the end of one activity and the beginning of the next can also facilitate transitions.

Making the change in activity another form of routine may be helpful. That is, it may be usefulto indicate a change and to complete the change of activity in a similar fashion each time. Forexample, giving a 2-minute warning that the activity is about to change, providing a signal toindicate that the activity is changing, and putting away materials for one task then bringing outthe next can make the change itself a comfortable routine.

Any changes in scheduled activities, persons, or events can be placed on Sample's schedule andcalled to his attention with as much advance notice as possible. This provides more time forhim to adjust to the change.

Some children can benefit from set time limits for each task before a shift to the next task isrequired. Sample might work on one activity or assignment for a set period then an alternativeactivity for the next period. Use of a timer can facilitate Sample's adjustment to change inactivity.

Developing a “routine for when the usual routine changes” can assist the child in adapting tounanticipated change. Anticipating possible changes in the child’s everyday routine (e.g., whenthe child’s favorite cereal is not available for breakfast) and building in a new routine (e.g.,reviewing a preestablished menu of other breakfast foods) can reduce the chances of a crisis andcan promote more adaptive response to change.

Sometimes working in small groups or pairs with peers can help a child like Sample shift hisfocus or cognitive set. Peers can model that it is time to change, cuing Sample by theirbehavior.

Emotional ControlExternal Structuring and Modifications

It may be useful to manage stimuli or antecedents that appear to produce emotional changes oroutbursts in Sample. Some situations, peers, or tasks may need to be initially avoided or limiteduntil he experiences more success in managing his emotional expression.

It may be helpful for Sample's parents and teachers to model appropriate emotional modulation.They might talk aloud through a situation that provokes feelings of anger or sadness and explainhow they will deal with their feelings.

If Sample responds with emotional outbursts to school work, it may be helpful to return tomastery or success levels and to adjust academic demands.

Clear rules and expectations for behavior, including emotional modulation, both in theclassroom and at home, may be important for Sample. Such explicit expectations can provide


predictability and a feeling of control over the situation, which in turn can facilitate betteremotional modulation.


Children with executive difficulties, particularly with fragile inhibitory control and/ordifficulties adapting to change in their home and school environments, may express theirfeelings more strongly and more directly than most children. This can make them seem moreangry, irritable, sad, or silly than their peers. Such emotional expression should promptevaluation to rule out mood or affective difficulties. When difficulties with modulation ofaffect occur in the context of other self-regulatory problems, management of the child’sexecutive difficulties may be helpful.

Difficulties with emotional control can often be viewed as one expression of disinhibition.Thus, techniques for supporting inhibitory control and reducing impulsivity may be helpful.

Sample might benefit from opportunities to discuss upcoming situations or events that mayprovoke an emotional outburst. Increasing his awareness of the potential for emotionalreactivity and the likely consequences to follow may help him modulate more effectively in themoment.

Processing situations that have led to emotional outbursts with Sample in a nonthreateningsetting and manner is important. Choose a situation where he is relaxed and therefore morereceptive to objective analysis of what happened. This can help Sample gain better controlwhile increasing his awareness of his reactions.

Peer modeling may be helpful for Sample. Placing him in activity-focused, small groups withwell-controlled peers may help him emulate their behavior.

Sample might benefit from learning response delay techniques, similar to those used to helpwith inhibitory control (e.g., practice leaving the situation, counting before responding, and/ordeveloping two or more possible responses). Also, thinking through potential ramifications ofhis responses may reduce the frequency or intensity of an immediate emotional reaction.

A child with strong emotional responses to events or situations may benefit from learning aconcrete, simple metaphor to help increase emotional monitoring and increase the likelihood ofa more appropriate response. For example, Sample might work in therapy or with a counselorto develop a “thermometer” or “speedometer” metaphor for measuring anger or distress. Hemight label each temperature or speed to reflect degrees of anger, such as “10 = normal, 20 =irritated, 30 = getting mad,…. 100 = out of control.” Each level can then be tied to a specificconcrete behavior, such as counting to delay responses, terminating the conversation, seekingadult intervention, or immediately leaving the situation.

Sample might benefit from increased awareness of the strength of his emotional reactions andthe impact this has on others. Discussing a recent situation with Sample when he is calm is oneway to help increase his awareness, while also considering other ways he might approach asimilar situation in the future. Peer group counseling can provide an opportunity for feedbackfrom peers. Methods for increasing self-monitoring of behavior may be appropriate.

Some children with difficulty modulating affect require psychotherapy to help them develop aclear, practical, affective vocabulary. Such work can help them differentiate and label complex,overwhelming feelings of “upset” into more specific feeling states (i.e., angry, nervous, sad) aswell as practice alternative ways of expressing emotions. He might benefit from learning an“emotional vocabulary” or “scripts” for dealing with situations that provoke strong emotions.


A child who experiences difficulty with emotional control often needs short breaks or a coolingoff period to consider his response to an event or situation. This is best taken before anemotional outburst occurs. Sample might be given permission to take a “time out” when neededor to leave the situation and seek an identified adult with whom he can discuss his feelings. It isimportant to avoid viewing “time out” as a punishment, and to reward Sample for removinghimself from a situation independently.

Behavioral programs that are designed to support independent use of coping skills can be animportant aid. Reinforcing Sample's ability to identifying stress-inducing situations ahead oftime, his use of relaxation methods, or his implementation of more modulated forms ofemotional expression (e.g., verbalizing feelings associated with a stress response or verbalizingthe impact of the stressor) may be helpful.

InitiateExternal Structuring and Modifications

It may be helpful to appreciate that children with initiation difficulties have trouble “gettinggoing” or starting. This can be exhibited in a number of ways: (a) behaviorally, such that theycannot get started on physical activities such as getting up; (b) socially, such that they havedifficulty calling friends or going out to be with friends; (c) academically, such that they havetrouble getting started on homework or assignments; or (d) cognitively, such that they havedifficulty coming up with ideas or generating plans. Deficits in “primary” initiation arerelatively rare and are often associated with significant neurological disorders (e.g., traumaticbrain injury, anoxia, radiation). More commonly, initiation deficits are the secondaryconsequence of other executive problems (e.g., disorganization) or emotional disorders (e.g.,depression, paralyzing anxiety). Basic tenets of intervention include providing additionalexternal structure, prompting and cuing, and helping with organization and planning.

Increased structure in the environment or in an activity can help with initiation difficulties.Building in routines for everyday activities is often important, as routine tasks and theircompletion become more automatic, reducing the need for independent initiation. For example,the morning routine can be broken down into a sequence of steps, and these steps can be writtendown on index cards or a simple list. Sample might then follow the list of steps each day withsupervision as needed until the routine becomes automatic. Sample can learn to use such listsas prompts.

External prompting may be necessary to help Sample get started. Sample's teacher might stopby his desk at the outset of each task and prompt him to start his work, or perhaps demonstratethe first problem of a worksheet. At home, his parents might need to similarly prompt him toget started on homework, to perform chores, or to go out with friends.

Peers can often help serve as models to help Sample get started on tasks. Working in pairs or insmall groups may be helpful, as Sample's peers will serve as external cues. Cooperativeprojects may be most useful as the interaction with peers will continuously prompt Sample.

Some children benefit from having time limits set for completing a task. Use of a timer mayfacilitate increased initiation and speed of task completion.

Many children with initiation difficulties are viewed as “unmotivated.” It is important toreframe the problem as an initiation difficulty rather than lack of motivation.


Problems with initiating may be exacerbated by the child’s sense of being overwhelmed with agiven task. Tasks or assignments that seem too large can interfere with Sample's ability to getstarted. Breaking tasks into smaller, more structured steps may reduce his sense of beingoverwhelmed and increase initiation.

Methods designed to increase overall level of arousal or basic “energy level” can be useful forchildren like Sample who have difficulty initiating on their own. Physical activity, groupinteraction, frequent short breaks with motor activity, and variation of pace or stimulation maybe explored as means of increasing arousal and supporting initiation.

Guidance through the first problem of a set for deskwork or homework will often supportgreater initiation. Stopping by Sample's desk and demonstrating the procedures for the firstproblem of a worksheet will help him get going on the remainder of the problems.

It is often helpful to provide examples or work samples that serve as a model of what isexpected. Sample can then follow the example to help cue what is next.

Provide Sample with realistic opportunities for initiating a task with appropriate wait time thatallows for the child to “recruit” their plan and skill for the particular activity or task.

Provide appropriate supportive signals or cues that remind the child to initiate an activity (e.g.,cues by caretaker, cues by devices such as alarm watch, personal digital assistant). Use naturalcues whenever possible, including peers in social or academic situations when appropriate.

It is important to appreciate that different tasks place varying demands on Sample's ability toinitiate. Tasks that are inherently motivating often require less internal initiation than tasks thatare less motivating. Similarly, more complex tasks may require greater initiation.

Those who work with Sample should be aware of the natural tendency to do things for him,rather than support his own participation. It is important to support independent task initiation,thus avoiding the risk of “learned helplessness.” This requires a balance, however, as constantor repeated prompting may feel like “nagging” to Sample.


Children like Sample who demonstrate difficulties thinking of ideas may benefit from learning astructured, systematic approach to idea generation. They can be taught idea generationstrategies to help develop ideas for topics, for performing activities, or for ways to approachproblems.

Providing “to do” lists on paper or index cards can be a method of developing automaticroutines and can serve as external cues to begin an activity. Some children benefit fromkeeping a binder or “cookbook” with lists of steps for each activity. They can look up a pagewith steps for completing a specific task, and use the list to guide their activity.

As with any executive difficulty, it can be helpful to increase Sample's awareness of hisdifficulty with initiation. As he becomes metacognitively aware of his own difficulties gettingstarted, he can then participate more actively in using strategies.

Learning activities that increase motivation or arousal can support better initiation. Samplemight benefit from more interactive, hands on, or laboratory learning activities rather than deskwork. Active learning methods can be interspersed with more sedentary methods to sparkhigher levels of motivation and arousal.

Topics or activities that Sample finds particularly interesting will likely lead to greater initiationability. Help Sample find topics or methods that are of interest for projects and assignments.


Computer aided instruction can be a useful means of increasing arousal and initiation. Manyeducational programs include regular or continuous prompts that will supplant Sample's need toinitiate on his own.

Difficulties with initiating are often a problem of knowing where to start. Providing Samplewith greater organization for a task and demonstrating where to begin and what steps to followmay help him overcome initiation difficulties.

Working MemoryExternal Structuring and Modifications

Preteaching the general framework of new information and guiding attention to listen forimportant points can be an essential tool for circumventing working memory difficulties whenthey interfere with the ability to capture new material. Sample might meet with a resourceteacher or aide at the outset of each day and preview the gist of what will be learned that day.

Establishing eye contact with Sample prior to giving essential instructions or new material willhelp ensure that he is ready to listen carefully. Children like Sample with working memorydifficulties often need to be alerted when essential material or instructions are being presented.

The rate of presentation for new material may need to be altered for Sample. He may needadditional processing time or time to rehearse the information.

A child like Sample with working memory difficulties often needs tasks or information brokendown into smaller steps or chunks.

Changing tasks more frequently can alleviate some of the drain on sustained working memoryfor a child like Sample. Sample's focus is likely to fade more quickly than his peers. Changingfrom one task to the next sooner can help restore his focus for a brief period of time. Tasks canbe rotated, such that he might work for 10 minutes on math problems, 10 minutes on reading,and then return to another 10 minutes of math.

A child with difficulties sustaining working memory often needs frequent short breaks. Breakstypically need only be 1 or 2 minutes in duration. Observing when Sample's ability to focusbegins to wane will help determine the optimal time for a break.

“Attentional breaks” are best taken with a motor activity or a relaxing activity. Sample mightwalk to the pencil sharpener, run a short errand, get a drink, or simply bring his work to showhis teacher or his parent.

Teacher “check-ins” can be an efficacious method of providing a break with motor activity andan opportunity for reinforcement. Sample might be asked to complete only a few problems of aset or a few lines of a paragraph before bringing his work to his teacher or his parent for review.This provides a built-in break that Sample can anticipate, forces a stepwise approach to the task,includes motor activity, and an opportunity for reinforcement for work completed.

Lengthy tasks, particularly those that Sample experiences as tedious or monotonous, should beavoided or interspersed with more frequent breaks or other, more engaging tasks. Sample mightbe rewarded with a more stimulating activity such as computer instruction time for completingthe more tedious task.

Given the negative impact of competing information on working memory, it is important toreduce distractions in the environment that can tax or disrupt sustained working memory.


Sample may need increased supervision. Preferential seating can be an importantaccommodation for children with limited ability to sustain working memory. Placing his seatnear the teacher provides greater opportunity to observe when he is adequately focused andwhen he is fatiguing, and redirection or breaks can be more easily implemented.

Placing Sample where he can feel more “in the middle” of activity may help increase his arousaland help with sustained focus.

Information may need to be preorganized for Sample to reduce demands for working memoryand to make encoding more efficient at the outset.

Often children with working memory deficits also exhibit word and information retrievaldifficulties. They frequently experience the “tip of the tongue” phenomenon, or may producethe wrong details within the correct concept. Sample may need additional time to retrievedetails when answering a question. Cues may be necessary to help him focus on the correct bitof information or word. It is often helpful to avoid open-ended questions and to rely more onrecognition testing which does not require retrieval.

If Sample answers an open-ended question incorrectly such as a “fill in the blank” or shortanswer question, it will be important to follow-up with increasing levels of questions todetermine whether Sample knows the information. Offering cues for the missed response, thenfollowing up with recognition format questions will clarify whether Sample missed the answerdue to retrieval difficulty or whether he needs to relearn the material.

Computer aided instruction can be a helpful tool for children with difficulties sustainingworking memory. Computer programs can provide rehearsal in an entertaining fashion and areoften less demanding of working memory.

It may be important to observe Sample to determine whether he has greater difficulty at certaintimes of the day. Some children with difficulties sustaining working memory do better in themorning than in the afternoon as they begin to fatigue. It may be helpful to schedule moredemanding tasks in the morning.

Children with working memory difficulties often benefit from multimodal presentation ofinformation. Verbal instruction can be accompanied by visual cues, demonstration, andguidance to increase the likelihood that new material will be learned.

New information or instructions may need to be kept brief and to the point, or repeated inconcise fashion for Sample.


Children with difficulties sustaining working memory often show problems in the ability toremain focused on a task or activity, particularly for schoolwork or homework assignments.Many demonstrate a natural tendency to use “self-talk” or verbal mediation in order to guidetheir own problem solving and to direct their attention. Such verbal mediation strategies mightbe encouraged or taught directly. Initially, Sample might verbalize aloud with supervision as hesteps through a task. Eventually, talking aloud can be minimized such that Sample relies onsubvocalization or only a whisper to direct his focus.

Individuals like Sample often demonstrate difficulties keeping track of more than one or twosteps at a time. Providing a written checklist of steps required to complete a task can serve asan external memory support and alleviate some of the burden on working memory.

It is often necessary to repeat instructions or new information for children like Sample so thatthey may increase the amount of information captured.


Children like Sample can benefit from learning compensatory skills to apply independently.

Sample can learn how to actively listen, such as stopping what he is doing at the time, focus hisattention, ask questions, restate the information or question, or take notes.

Have Sample repeat or paraphrase what he has heard or understood in order to check foraccuracy and to provide an opportunity for rehearsal. Ultimately, teaching self-initiated“comprehension checking” strategies (e.g., the child asking for repetition of instructions) helpsto promote independent management of working memory weaknesses.

Mnemonic devices (i.e., memory strategies) are important tools to help children like Samplelearn, and later recall, basic skills and facts.

Teaching Sample to “chunk” information may be useful in helping him increase the amount thathe can learn or capture at one time. It may be necessary for Sample's teachers or his parents tohelp him learn how to approach new information as sets or groups of details, rather than as asingle series, in order to facilitate chunking.

Rehearsal is often a helpful method of increasing the amount of information encoded intomemory. Sample might need to practice a series of steps for solving a problem, memorizing alist of key facts, or completing an everyday activity in order to accommodate his more limitedworking memory at the outset. Spaced practice is more effective than massed practice. That is,Sample would benefit more from practicing new skills or information in short sessions over thecourse of the day rather than in one long session. He might rehearse, for example, a set of keyfacts for a few minutes two or three times during the school day, and then again at home both atnight and in the morning.

PlanningExternal Structuring and Modifications

As with most interventions for executive function difficulties, increasing external structure tolearn what supports are necessary for success is important at the outset. The amount ofstructure needed for planning successfully can then be decreased or faded gradually as Sample'sability to manage his own planning needs increases and as he assumes greater independence andresponsibility in this domain.

It is often helpful to provide examples of how students might plan differently to complete thesame task. In this way, Sample can see options for alternative methods.

Children with difficulties planning may benefit from having a binder or “cookbook” of steps forcommon routines or assignments. They might have a section for approaches to specific types ofmath problems, writing assignments, or reading materials and can reference the plans as needed.

Parent modeling is an important means of teaching good planning skills. Sample's parents candiscuss plans for the day at the breakfast table or verbalize their thinking about how to approacha series of errands. The use of the child’s planning guide for the parent’s multistep activitiesmay serve as a good model. Developing an overall plan for the day, week, month, and yearwith a calendar can also serve as a useful exercise.


Involve Sample maximally in setting a goal for the activity or task. Encourage him to generatea prediction regarding how well he expects to do in completing the task/activity. Structureplanning and organization efforts around the stated goal.


Active, maximal involvement of the child in the development of plans is important. The use ofa planning guide may be necessary to reduce the organizational and working memory demandsof this multistep process.

Have Sample verbalize a plan of approach at the outset for any given task, whether it is aneveryday chore or routine or it is an academic activity. The plan can be broken down into aseries of steps, arranged in sequential order, and written down as a bullet list. The plan can beguided interactively with his parent or his teacher to achieve sufficient detail and to increase thelikelihood of success.

Sample might be asked to develop more than one plan for a task or activity in order to increasehis awareness of alternative approaches. For example, he might plan to approach a writingassignment by starting with the introductory paragraph, but might also plan to start with adetailed outline and to write paragraphs for the body of the text first, then write an introduction.

It may be helpful to begin learning strategic planning by practicing with only a few steps at theoutset, then increasing the number of steps and the amount of detail gradually.

Strategic planning can be practiced with familiar, everyday tasks. Sample might develop a planfor completing familiar routines such as getting ready for school in a more efficient manner.Developing plans for meaningful, complex activities (e.g., his own birthday party, baking hisfavorite treat) provides inherent motivation for the child.

Teach Sample to develop time lines for completing assignments, particularly for long-termassignments such as projects or term papers. Sample may need assistance in budgeting his timeto complete each step or phase in larger projects or tasks. Break long-term assignments intosequential steps, with time lines for completion of each step and check-ins with the teacher toensure that he is keeping pace with expectations.

OrganizationExternal Structuring and Modifications

Present information in a well-organized manner at the outset. A child with difficulties graspingnew concepts or the gist or framework of new material often does best when the material ispresented in a structured fashion. Teachers that offer a higher degree of structure in theircourses may be a better fit for Sample.

A resource or special education teacher may need to serve as the communication facilitatorbetween home and school in order to help Sample stay on track with his assignments. Oftencommunication can be accomplished via an assignment or planning notebook, but more directcommunication via e-mail or phone can be helpful on a regular basis.

Keeping an extra set of books at home can be a powerful tool for helping a child withorganizational difficulties, as it alleviates a need to remember what books to bring back andforth and provides ready access to materials both at school and at home.

Given the particular difficulty managing complex, long-term assignments, students withorganizational difficulties often benefit from working on only one task, or one step of a largertask, at a time. Tasks may need to be broken down into smaller steps in order to facilitateorganization and planning. Long-term assignments, such as term papers or projects, are ofteninsurmountable for children with organization and planning difficulties. As such tasks can feeloverwhelming, they may not begin work until the night before the assignment is due. It may benecessary to break down longer assignments into smaller, sequential steps, and to develop a


time line for completion of each step. At each step, it is important to review what has beenaccomplished and to plan for the next step.

Worksheets or deskwork may seem overwhelming for Sample and he may need additionalstructure to get started. Worksheets can be separated into smaller problem sets, or divided onthe page with a marker and prioritized for approach.

Study skills classes are often available in middle schools and high schools. Children withorganizational difficulties should avail themselves of the opportunity to approach planning andorganization as an academic subject. It is important that key concepts and methods becommunicated with parents and teachers, so that they can be practiced across all environmentsfor consistency. Although study skills classes can provide important information to studentsabout academically relevant organizational strategies, the student may need ongoing assistancewith the “executive” application of these strategies. Thus, individual application of strategies,with review, cuing, and generalization should be strongly considered.

Sample may need extra organization time at the outset or the end of the day. He might reviewhis assignment notebook or planner with his parents each morning and perhaps with adesignated teacher at the end of the school day.

A supervised study hall can be an important tool for helping Sample keep pace with his work,particularly as he enters the middle school and high school years. Organizational difficultiesoften do not become apparent or problematic until middle school, when the organizationaldemands increase and supports decrease. Many schools offer study halls with direct supervisionfor organization as well as content. Alternatively, having a study period at the end of the day ina resource room where access to a special education teacher is readily available can help Samplestay on track more successfully.

Children with organizational difficulties can benefit from working in small groups with moreorganized peers who serve as models.

Cross-age tutoring can be helpful as a means of modeling better organizational strategies forSample. It is important to choose an older peer tutor carefully, considering the tutor’s ownorganizational skills and the likelihood of he or she being a good fit with Sample.


Call to Sample's attention the structure of new information at the outset of a lesson or lecture.

Preview the organizational framework of new material to be learned in a bulleted or outlineformat to increase appreciation of the structure and enhance Sample's ability to learn associateddetails.

It may be helpful to provide an outline or list of major points prior to the lesson.

Have Sample restate the overall concept and structure of the information or task following alecture. This will provide an opportunity to ensure accurate understanding as well as anopportunity to correct any misunderstanding.

As Sample becomes more aware of his difficulties grasping organization of new information, hemay be able to learn to search for the organizational frameworks inherent in novel material. Hemight be taught to listen or look for the structure in a strategic manner.

Students with difficulties keeping track of their assignments may benefit from learning to use anorganizational system, schedule book, or daily planner. Use of such a system can help facilitate


many aspects of organization and planning, but requires effort on the part of the student,parents, and teachers.

Many teachers prefer different organizational and planning systems. This can be confusing forchildren with organizational difficulties. It is best for Sample to learn one system that issufficiently flexible to be used for all or most subjects and can be maintained or expanded asneeded over the years.

It is essential that the system or the book fit well with the student’s style and needs. Samplemight enjoy choosing a planner book with which he feels comfortable. Size and appearance areimportant first considerations. Layout of the daily pages (e.g., columns, one page per day, oneweek at a time) also needs to fit with Sample's preferences and organizational needs.

Flexibility is the key to a successful organizational notebook or planner. Ring-bound books thatallow addition of pages or features (e.g., sticky note pads, computer disk holders) and removalof unnecessary pages are often best.

Essential information can be written or typed and placed in a plastic sheet protector at the frontof the book for quick access. This might include important phone numbers, locker combination,and overall schedule.

There are many options for ways to organize material including by date, by subject, or bypriority. Deciding on one method and devising a system, such as separate color-coded tabs foreach subject, is important.

Often students with organizational difficulties are inconsistent in completing homework and/orturning in completed work. This may be a problem of remembering assignments or writingthem down accurately. It may be helpful to maintain a list of students in each subject withphone numbers that Sample can call if he forgets an assignment.

An assignment sheet or organizational notebook can serve as an essential tool in helping Samplekeep on track with his work. Before leaving each class, Sample might show his teacher what hehas written down as an assignment. The teacher can initial the assignment to indicate that it iscorrect and complete. Sample's parents can then review the assignment with Sample, help himplan an approach, and initial that each assignment has been completed. Should Sample not turnin his work, this communication device can uncover the problem more quickly.

Specific, strategic approaches for reading (e.g., SQR3) can be taught to facilitate Sample'sefficiency in learning new material. For example, Sample might learn to first examine thechapter outline or list of headings, then read the chapter summary and focus questions beforeapproaching the body of the text.

Strategic approaches to structured writing can be helpful for students like Sample who havedifficulties organizing their written output. A “cookbook” of methods for responding to basictypes of writing tasks (e.g., short answer, short essay, expository paper) can be developed withSample. He might need to learn what goes in the first sentence or paragraph, what goes in thesecond, and so on.

Outlining and notetaking skills can be taught directly in a study skills course or in a resourceroom. These are essential skills that Sample will need to practice for future academic success.


Organization of MaterialsExternal Structuring and Modifications

Children with difficulty maintaining reasonable organization of their environment and materialsmay benefit from increased external structure for organization and from the development ofgood organizational routines in general.

Having an extra set of books at home can be a simple yet effective means of ensuring thatSample has the required materials both at home and in school for completing his school andhomework assignments.

Some children can benefit from having a checklist of needed materials to review on a dailybasis before leaving home for school, and/or at the end of the school day.

Some children benefit from having external tools for organization, such as backpacks, pencilcases, color-coding systems, and organizers. It is important that the materials be to Sample'sliking so that he will be more likely to use them.

Parents and teachers can model good organizational habits or routines by explicitly calling hisattention to their organizing behavior. Sample's parents might talk aloud, describing their goaland the process, while organizing a desk or room.

Often children with difficulties organizing their environment or materials have difficultyknowing where to begin or how to structure the process. It can be helpful to approach anorganizational task with Sample and to ask him about his goal, his plan of approach, and toprovide appropriate guided support as needed.


Sample may need help from his parents and his teachers in reviewing the materials needed priorto a given task or at the beginning and/or end of the day. To facilitate development of goodorganizational habits, Sample might review his plans for the day with his parents each morning,the associated materials needed to accomplish his goals, and the organization of the materials inhis backpack or desk. Similarly, he might have some “organization time” at the end of theschool day to arrange his materials.

MonitoringExternal Structuring and Modifications

Provide Sample with opportunities for self-monitoring his task performance and socialbehavior. Provide cues, as subtly as possible, if necessary.

Often, children with difficulties monitoring their output do not recognize their own errors. Itmay be helpful to build in editing or reviewing as an integral part of every task in order toincrease error recognition and correction.

Setting goals for accuracy rather than speed can help increase attention to errors. RewardSample for accuracy to support continued focus on monitoring his work.


Ask Sample to predict how well he will do on a particular task, then compare his predictionwith the actual outcome in order to increase his awareness of his strengths and weaknesses.


Encourage Sample to chart his performance and/or behavior in order to provide a tangiblerecord of activity for ongoing monitoring.

It may be helpful to videotape an activity or situation and then review it together. This allowsSample to see himself from another’s perspective. Discussion of the videotape with an adult,such as a guidance counselor or therapist, is essential. This method should be consideredcarefully, and approached collaboratively with Sample's, his parents’, and other participants’consent. While videotaping can be a powerful tool, there is also potential for emotionalconsequences and negative effects on self-esteem.

Verbal mediation can be a useful tool for helping children like Sample direct their focus to theirown behavior or work. Sample might benefit from talking through a task, as this can increaseattention to the task and, secondarily, increase error recognition. Model, cue, and encourage theuse of the phrases “What works?” and “What doesn’t work?” as self-monitoring tools.

A social skills group may be a helpful venue to increase Sample's awareness of the impact hisbehavior has on others. This can provide not only direct skill training but also an opportunityfor helpful feedback from a counselor or peers in a safe setting.

Children with self-monitoring difficulties may not be able to consider the impact of theirbehavior in the immediate situation. It may be helpful or necessary to discuss or reviewbehavior removed from the situation and from peers.

Encourage Sample to identify his strengths and weaknesses for specific tasks or activities.Allow the comparison of preactivity prediction of performance with postactivity evaluation.Provide guided constructive feedback (teacher, parent, and peer) to increase self-awareness ofstrengths and needs for similar future activities.

Application of Executive FunctionInterventions to the IEP/504 Process

For educational purposes, the goals for promoting executive system functioning are interrelatedwith all of the academic subjects and social/communication situations if they meet the followingconditions (as most will): (a) novel learning or processing tasks, (b) necessitating goal-orientedperformance, (c) requiring a delayed response, and (d) involving multiple steps over a period oftime. Therefore, for the student with executive/organizational deficits, theexecutive/organizational strategies are important to link directly with each academic contentarea (reading, writing, math, science, etc.).

One's executive/organizational skills are increasingly in demand as the curriculum in the highergrades becomes more complex. The relationship between these two factors is direct (i.e.,greater complexity of learning necessitates greater use of efficient executive skills). Thecurriculum in the later elementary grades and into middle/high school requires the student toderive information from increasingly complex text, reproduce this information in appropriatelyorganized written form, and do so in an increasingly independent manner. Thus, tasks forwhich students may have difficulty are those that (a) are long-term (requiring planning), (b)require organization of a great many pieces of detailed information (e.g., a specific multisteptask), and (c) are to be completed in a certain time frame (requiring time management).

It is important to incorporate active educational interventions into the translation of executivefunction interventions within the context of the Individualized Education Plan or the 504 Plan.A set of sample IEP/504 Plan goals and objectives are provided below. Importantly, rather than


specific academic curriculum “content,” these goals focus on the development of a learningand/or problem-solving “process” designed to enhance the efficient learning and memory ofacademic information. Implementation of the methods to achieve these unique, nontraditional“learning process” goals will likely require additional training and guidance of schoolpersonnel. The emphasis of support should be on teaching, modeling, and cuing an approach toself-management of learning through active planning, organization, and monitoring of work.

Thus, the overarching, long-term goal for the student could be stated as follows: “The studentwill independently employ a systematic learning/problem-solving method (e.g., Goal-Plan-Do-Review [GPDR] system) for tasks that involve multiple steps and/or require long-termplanning.” Domain-specific goals and objectives can then be articulated. For students who areyounger or who have more severe executive dysfunction, the objectives might be prefaced with:“With directed assistance, Sample will . . ..”

Goal Setting(1) Sample will participate with teachers in setting instructional goals (e.g., "I want to be ableto… read this book, write this paragraph”).

(2) Sample will accurately predict how effectively he will accomplish a task. For example, hewill accurately predict whether or not he will be able to complete a task; predict his grade ontests; predict how many problems he will be able to complete in a specific time period.

Planning(1) Given a routine (e.g., complete a sheet of math problems, clean his room), the student willindicate what steps or items are needed and the order in which events will proceed.

(2) Given a selection of three actions necessary for an instructional session, Sample willindicate their order, create a plan on paper, and follow the plan.

(3) Given a task that he correctly identifies as difficult for him, Sample will create a plan foraccomplishing the task.

(4) Having failed to achieve a predicted grade on a test, Sample will create a plan for improvingperformance for the next test.

Organizing(1) The student will follow/create a system for organizing personal items in his locker.

(2) The student will select and use a system to organize his assignments and other school work.

(3) Given a complex task, Sample will organize the task on paper, including the materialsneeded, the steps to accomplish the task, and a time frame for completion.

(4) Sample will prepare an organized outline before proceeding with writing projects.

Self-Monitoring, Self-Evaluating(1) The student will keep a journal in which he records his plans and predictions for success andalso records his actual level of performance and its relation to his predictions.

(2) Sample will identify errors in his work without teacher assistance.

(3) Sample's rating of his performance on a 10-point scale will be within one point of theteacher's rating.


Self-Awareness(1) Sample will accurately identify tasks that are easy/difficult for him.

(2) Sample will accurately identify his strengths and weaknesses.

(3) Sample will explain why some tasks are easy/difficult for him.

Self-Initiating(1) When Sample does not know what to do, he will ask the teacher.

(2) With regular/minimal prompting from the teacher, assistant, or parent, Sample will begin hisassigned tasks, initiate work on his plan, and so forth.

ReferencesLevine, B., Robertson, I. H., Clare, L., Carter, G., Hong, J., Wilson, B. A., et al. (2000).Rehabilitation of executive functioning: An experimental-clinical validation of GoalManagement Training. Journal of the International Neuropsychological Society, 6, 299-312.

Marlowe, W. B. (2001). An intervention for children with disorders of executive functions.Developmental Neuropsychology, 18, 445-454.

Ylvisaker, M. (Ed.). (1998). Traumatic brain injury rehabilitation: Children and adolescents(2nd ed.). Boston: Butterworth-Heinemann.

Ylvisaker, M., & Feeney, T. (1998). Collaborative brain injury intervention: Positive everydayroutines. San Diego, CA: Singular Publishing Group.

Ylvisaker, M., Szekeres, S., & Feeney, T. (1998). Cognitive rehabilitation: Executive functions.In M. Ylvisaker (Ed.), Traumatic brain injury rehabilitation: Children and adolescents (2nded., pp. 221-269). Boston: Butterworth-Heinemann.

End of Report

161153842 manual-inventario-brief

Education

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