ADHD and Executive Function Deficits: Linkage with … and WF - Exec...“Broadly speaking,...
Transcript of ADHD and Executive Function Deficits: Linkage with … and WF - Exec...“Broadly speaking,...
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ADHDandExecutiveFunctionDeficits:LinkagewithDyslexia
21stAnnualStateDyslexiaSummerInstituteBeyondDyslexia:LookingattheWholeChild
July27,2016
MaryDurheimEducationalConsultant
Spring,[email protected]
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DoyouhaveExecutiveFunctiondeficits/skills?
• Howdidyougetheretoday?
• Didyouarriveontime?
• Yourfamilywantstoeatdinnerat6andyouarethecook…Howdoyougetthefoodonthetableintime?
• Someonecutsyouoffinatrafficlane(andofcourseyourchildisinthecar)...Whatkeepsyoufromyelling“#!#??%!!??”
• Thestudentsinthenextclassroomareplayingaloudgamewhileyouarewritingalesson,butyoudon’thearit.Why?
• Youaccidentallybumpintosomeoneandapoligize.Why?
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Questionstoconsider…
• Whatareexecutivefunctiondeficits(orskills)andhowdoselectedexecutivefunctionprocessesaffectschoolsuccesses?
• Howcaneducatorsbegintounderstandandinformallyassessstudents’executivefunctionprocesses?
• Howcanteachersaddresstheneedsofstudentswithexecutivefunctionweaknessestobothaccommodateandteachnecessarylackingskills?
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WhatisExecutiveFunctioning?• Executivefunctioningisatermpsychologistsusetodescribethemanytasksour
brainsperformthatareinvolvedwithplanning,problem-solvingandtheveryactofthinkingitself.
• ItisbelievedthattheEFofthebrainareprimarilycarriedoutinthepre-frontallobesofthecerebralcortexwhichisthepartofthebrainthatdirectsorconductsanumberofskillsrequiredindailylife,suchasplanning,decision-making,self-monitoring/regulation,working,memory,motivation,andtheentireproblem-solvingprocessalongwithselfevaluationoftheresults.
• Oftenreferredtoasthe“CEOofthebrain”,EFisasetofmentalprocessesthathelpsconnectpastexperiencewithpresentactionandasaresultcanhaveamajorimpactonstudentbehaviorandperformance.
• “Despitethefrequencywithwhichitismentionedintheneuropsychologicalliterature,theconceptofexecutivefunctionsisonethatstillawaitsaformaldefinition.”(Jurado&Rosselli,2007,page213.)
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ExecutiveFunctioning• McCloskeynotesthatitisimportanttodistinguishbetweenExecutiveSkillsandExecutiveFunctions.
• ExecutiveSkillsinvolvetheuseofneuralnetworksroutedthroughoutthebraintoperformspecifictasks(e.g.,attending,inhibiting,modulating,planning,organizing,associating).
• ExecutiveFunctionsinvolvethepartoftheexecutivenetworkthatisroutedthroughthefrontallobesandthatisusedtocue,direct,andcoordinatetheuseofexecutiveskillsandothermentalcapacities.
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ExecutiveFunctionDevelopment
• McCloskeynotesthesomeEF-basedclinicalsyndromes,suchasADHD,demonstrateclearpatternsofdelayeddevelopmentalprogression.
• McCloskeyalsonotesthatallindividualswithADHDexhibitEFdeficitsbutnotallindividualsthatexhibitEFdeficitsareADHD.
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ExecutiveFunctioningandADHD
• EFandADHDarenotsynonymousterms;ratherADHDisaconditioninvolvingEFdeficitsin:
• Focus/Select,Sustain,Inhibit,Modulate
• NearlyallpeoplewithADHDalsohavedifficulties;thenatureoftheseadditionaldifficultiesiswhatmakesADHDsovariablefromonepersontothenextandwhatcausesconfusionindiagnosis.(McCloskey)
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Characteristics of AD/HD
A disorder Characterized by a
PERSISTENT pattern of inattention and/or
hyperactivity and/or impulsivity that interferes with
functioning and development.
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CharacteristicsofADHD
Severalinattentiveorhyperactive-impulsivesymptomswerepresent
beforeage12andarepresentinatleast2areasoflife,suchas
Home,SocialSettings,SchoolorWork
Symptomshavebeenpresentforatleast6months§ Toadegreethatisinconsistentwithdevelopmentallevel§ Negativelyimpactssocialandacademic/occupational
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RussellBarkleyandExecutiveFunctioningWhatweknowaboutthebrainandEF…
Fourcircuitsinthebrainrelatetoexecutivefunctioning:
• The Circuit–goesfromthefrontallobebacktothebasalganglia,particularlyastructurecalledthestriatum.The“What”Circuitislinkedtoworkingmemory,soit’sinthiscircuitthatwhatwethinkstartstoguidewhatwedo.
• The Circuit–goesfromthesameprefrontalareabacktothecerebellum,locatedattheverybackmostpartofyourhead.The“When”Circuitisthetimingcircuitofthebrainandcoordinatesnotjusthowsmoothbehaviorwillbeandthesequenceofbehavior,butalsothetimelinessofyouractionsandwhenyoudocertainthings.
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RussellBarkleyandExecutiveFunctioningWhatweknowaboutthebrainandEF…
• The Circuit–alsooriginatesfromthefrontallobeandgoesthroughthecentralpartofthebrain–anteriorcingulate–totheamygdala–thegatewaytothelimbicsystem.This“hot”circuitislinkedtoouremotionswherewhatwethinkcontrolshowwefeel,andviceversa.Itisthefinaldecisionmakerinallourplans.
• The Circuit–goesfromthefrontallobetotheverybackofthehemisphere.Itiswhereself-awarenesstakesplace–whereweareawareofwhatwedo,howwefeel(bothinternallyandexternally),andwhatishappeningtous.
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ExecutiveFunctions&theBrain
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Mid-BrainLimbicsystem-Automaticbehaviors,Emotions,Memory
Brainstem-Survival
Cortex-Consciousthought
CerebellumCoordinatedmovements,balanceandvoluntarymovements
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RussellBarkleyandExecutiveFunctioning
• Knowingwhatpartsofthebraincontrolexecutivefunctions,BarkleydefinesExecutiveFunctioningthisway…
“Broadlyspeaking,executivefunctionreferstothecognitiveormentalabilitiesthatpeopleneedtoactivelypursuegoals.Inotherwords,it’sabouthowwebehavetowardourfuturegoalsandwhatmentalabilitiesweneedtoaccomplishthem.Thetermisverycloselyrelatedtoself-regulation.Executivefunctionsarethings
youdotoyourself,inordertochangeyourbehavior.Byemployingyourexecutivefunctionseffectively,you’rehopingtochangeyour
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7ExecutiveFunctionDeficitsTiedtoADHD1. Self-awareness:self-directedattention2. Inhibition:alsoknownasself-restraint3. Non-VerbalWorkingMemory:self-directedsensing;theabilitytoholdthingin
yourmind.Essentially,visualimagery–howwellyoucanpicturethingsmentally.
4. VerbalWorkingMemory:self-speech,orinternalspeech.Mostpeoplethinkofthisastheir“innermonologue.”
5. EmotionalSelf-Regulation:theabilitytotaketheprevious4EFsandusethemtomanipulateyourownemotionalstate.Thismeanslearningtousewords,images,andyourownself-awarenesstoprocessandalterhowwefeelaboutthings.
6. Self-Motivation:howwellyoucanmotivateyourselftocompleteataskwhenthereisnoimmediateexternalconsequence.
7. PlanningandProblem-Solving:alsoreferredtoas“self-directedplay.”Howweplaywithinformationinourmindstocomeupwithnewwaysofdoingsomething.Bytakingthingsapartandrecombiningthemindifferentways,we’replanningsolutionstoourproblems.
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ExecutiveFunctioningandADHD
“ExecutiveFunctionsarethoseactionsweperformtoourselvesanddirectatourselvessoastoaccomplishself-control,goal-directedbehavior,andthemaximizationoffutureoutcomes.”
RussellBarkley
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Utilizingworking
memoryandaccessing
recall
ExecutiveFunctions(worktogetherinvariouscombinations)
Brown,T.E.ManualforAttentionDeficitDisorderScalesforChildrenandAdolescents;2001.
Monitoringandself-
regulatingaction
Managingfrustrationandmodulatingemotion
Regulatingalertness,
sustainingeffortandprocessing
speed
Organizing,prioritizing,
andactivatingtowork
Focusing,
sustainingfocusandshiftingfocustotasks
1.Activation 2.Focus 3.Effort 4.Emotion 5.Memory 6.Action
Brown’sModelofExecutiveFunctionsImpairedinAD/HD
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SelfTalk–SelfAction
Forchronicproblemswith:• Regulatingactions• Jumpingintoconversations• Jumpingtoconclusionstooquickly• FailuretonoticeothersreactionsasastopmechanismforbehaviororactionItmaybenecessarytodevelopstrategiesto:
Respond Or
Act
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Dendy’sComponentsofExecutiveFunctionbasedontheworkofBarkley,Brown,andGioia
1. Workingmemoryandrecall–holdingfactsinmindwhilemanipulatinginformation;accessingfactsstoredinlong-termmemory;includesanimpairedsenseoftime
2. Activation,arousal,andeffort–gettingstarted;payingattention;finishingwork
3. Controllingemotions–abilitytotoleratefrustration;thinkingbeforeactingorspeaking
4. Internalizinglanguage–using“self-talk”tocontrolone’sbehavioranddirectfutureactions
5. Takinganissueapart,analyzingthepieces,reconstitutingandorganizingitintonewideas–complexproblemsolving
6. Shifting,inhibiting–changingactivities,stopping,existingactivity,stoppingandthinkingbeforeactingorspeaking
7. Organizing/planningahead–organizingtime,projects,materials,andpossessions
8. Monitoring–self-monitoringandprompting
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CommonAcademicProblemsLinkedtoADHDandExecutiveFunctionDeficits
• ManystudentwithADHDhaveimpairedworkingmemoryandsomealsohaveslowprocessingspeedbothofwhicharecriticalelementsofEF
• WrittenexpressionisthemostcommonlearningproblemamongstudentswithADHD(65%-studybyMayesandCalhoun)
• Memorizingmultiplicationtablesorworkingmathproblems
• Two-thirdsofchildrenwithADHDhaveatleastoneotherco-existingproblemssuchaslearningdisorders,depression,oranxiety
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Conduct Disorder 25% Children
45% - 50% Adol.
Anxiety Disorder 30% Children
25% - 40% Adults
Depression 10% - 30% Children
47% Adults
AD/HD alone 30%
Learning & Language Disorders Up to 50%
Tourettes Syndrome
7%
Oppositional Defiant Disorder
40%
Bipolar Disorder
Up to 20%
Co-ExistingDisorders
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NIMH,MTAStudy
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee…
Goal-directedAttention • Troublesustainingattentiondoingsomethingdoesnotlike• Distractedeasilybyotherthingsgoingoninclass• Distractedeasilybydaydreamsorstraythoughts• Needslotsofreminderstostayontaskandfocused• Complainsofdifficultystayingontask• Troublereadingconnectedtext,withoralreadingfluency
impactedbyleavingoutwordsormakingchanges,eventhoughsingle-worddecodingnotanissue*
• Mayskipwholelineoftextwhenreadingaloud,withoutnoticing*• Matherrorsseemtobe“careless”onesdoneoften• Mechanicalerrorsinwrittenworkalsoseemfrequentand
“careless”
*Mayalsoshowtroublewithworkingmemoryorself-monitoring
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
GoalSettingDecisionMakingPrioritizing
• Troublesettinglong-rangegoals• Seemstolivemomenttomoment• Respondstowhatishappeningintheimmediateenvironment,not
toinnerdirection• Needsmajorsupportanddirectionwithlong-termprojects,suchas
aresearchpaper• Requireslotsofsupportwhenmakingdecisionsintheclassroom• Inmoreunstructuredacademicsettings,suchasatthelibraryorin
artclass,notwell-focusedaboutdecisionstomakeanddirectionstotake
• Findsitdifficulttoknowwheretostartwithassignments• Runsoutoftimewhencompletingworkbecausehastrouble
prioritizingwhatshouldbedonefirstandthennext,andwithhowmuchtimetodevotetoeachsection
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
PlanningOrganizationSequencing
• Obviousandconsistentlackofplanningwithclassworkandhomework
• Writtenworkinneedofflowandorganization,asopposedtorandomunconnectedthoughts
• Considerableproblemswhenassignmentsrequireplanning• Losestrackofassignmentsequencinganddetails• Findsithardtochunklargeassignments,breakingthemdowninto
moredoableblocks• Becomesoverwhelmedbyassginmentsorjobsthatotherswould
findeasytodoiforganized• Strugglestosolvemathproblemsbecausehastroublefollowing
sequencedstepsofoperation• Readingcomprehensionproblemsbecausehastroublewithholding
ontoimportantdetailsinthecorrectsequenceofevents,andsostrugglestocomprehendthemainpoints
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
TaskInitiation • Troublestartingtasks,seenindifferentacademicsettings-Ask“Ifworseinsomesettingsthanothers,whataspectsofthesettingsinwhichthechildparticularlystrugglesseempoorlyalignedtohis/herneeds?”
• Seemsparalyzedaboutstartingatask–maysayheknowswhattodo,butcan’ttakethefirststeptowarddoingit
• Ifgivenhelpstarting,oftendoesfinewithcompletingtasksuccessfully
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
TaskPersistenceProblemSolving
• StartsOKbutrunsoutofsteambeforefinishingandstopsworking;can’tsustaineffort
• EvenwhenwrittenworkisplannedandsequencedOK,thereisnotmuchofit
• Eventhoughseemstogetenoughsleepathome,getsdrowsyinclass,especiallyintheafternoons
• Requireslotsofteacherpromptingtocontinueworking• Cannotapplyproblem-solvingskillsindependently,evenwhen
facedwithminordifficulties• Stopsworkingwithoutindividualizedorconsistenthelp
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
TimeManagement • Usuallystruggleswithfiguringouthowmuchtimewillbeneededtocompleteatask-“Ididn’trealizeitwouldtakesolong”
• Needsmoretimethanpeerstocompletethesameassignment/task• Oftensurprisedorupsettolearnsomethingisdue–“Youmeanthe
testistoday?!”• Cantelltimebutlosestrackofit
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomains WhatTeachersMightSee
Self-Monitoring • Writtenworkhasmanymechanicalerrors,includingmisspellings• Leavesoutsmallfunctionwordsinwriting[suchas“the”or“an”]• Unwillingtoeditownwriting• Whenreadingoutloud,ofteninsertswordsordeletesthem• Whenreadingoutloud,tendstoskipentirelinesoftextanddoesn’t
notice• Inmathwork,willmake“careless”errors[suchasmisreading
operationsigns]• Doesnotappearto“see”errorsinworkandissurprisedwhenthey
arepointedout
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomain WhatTeachersMightSee
WorkingMemory • Cannotrememberorfollowmulti-stepdirections• Losestrainofthoughtwhentalking• Forgetsdetailsofwhatwasreadsonafter• Afterreadingsomethingcananswerliteralquestionsbuthas
difficultyrememberingmorecomplexdetailsandwithmakingpredictions/inferences
• Losestrackofwhatwaslookingfor• Willstartwritingbutforgetwhatwantedtosay• MayspellwordsOKinisolationbutcannottransferthattowritten
work• Matherrorsshowpatternofforgettingwhollyorpartlythesteps
neededtosolveproblems
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomains WhatTeachersMightSee
ShiftingAdaptability
• Lowtoleranceforchangesinroutine• Getsstuckononetopicoractivityandresistsstoppinguntildone
withit• Haspatternsofactionsorbehaviorsinsocialsettingsanddoesnot
wanttochangethem,evenwithencouragement• Cannotcomeupwithmorethanonewaytosolveaproblem
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomains WhatTeachersMightSee
ImpulseControl(ResponseInhibition)
• Blurtsoutinclass• Impetuouslysaysordoesthings,thenexpressesregretorremorse• Oftensaysordoesthingsthatembarrassothers• Repeatedlyactsasthoughdoesnothaveanythoughtfilters• Willfrequentlydenyresponsibilityforbehavior,evenwhencaught
intheact[“Itwasn’tme,Iswear!”]• Cannotexplainbehavior[“Idon’tknowwhyItrippedhim,Ijustdid
it.”]• Whenreadingoutloud,willguessatwordsbasedonthefirstletter
ortwo,ratherthanreadingthroughtheword• Whenreadingoutloud,oftenwillinsertwordsnotinthetext• Inmath,willfrequentlygiveananswerwithoutthinkingthrough
therequiredprocessorapplyingproblem-solvingskills
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WhatEFDeficitsCanLookLikeinStudentsAdaptedfromTable4.2,“ExecutiveFunctionintheClassroom”-ChristopherKaufman
EFDomains WhatTeachersMightSee
EmotionalControl • Overreactstosmallproblemsthatwouldnotbotherpeers• Showsexcessiveresponsetosituations,oftencryingorwhiningor
actingoutofcontrol• Becomeseasilyupsetorangeredbywhatothersaredoing• Whenangry,canbecomeverballyandphysicallyaggressive• Canappearswampedbybothpositiveandnegativeemotions• Usuallyexpressesremorseaftershowingangerand/oraggression
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HelpingStudentswithEFIssues
• McCloskeystatesthatcognitivestrategies,suchasplanningandorganizing,canbetaught–“Executiveawarenessisawarenessofawareness.”
• Studentshouldbeawarethathe/shehasEFdifficultiesandshouldbetaughtstrategiestocopeandcompensateforanydeficits–ifstudentisnotawareofthishedoesnotknowhowtomodulatehimselfandkeepsgettingintotrouble.
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CollectionofFavoriteSchoolSuccessStrategiesforWorkingwithEFIssues
Makethelearningprocessasconcreteandvisualaspossible!WrittenExpression:
• Dictateinformationtoa“scribe”orparents
• Usegraphicorganizerstoprovidevisualprompts
• Use“post-it”notestobrainstormessayideas
Math:• Useapeertutor• Usepairedlearning–teacherexplainsproblem,studentsmakeuptheirown
examples,swapproblems,anddiscussanswers
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Memory:
• Usemnemonics(memorytricks),suchasacronymsoracrostics,e.g.,HOMEStoremembernamesoftheGreatLakes
• Use“visualposting”ofkeyinformationonstripsofposterboard
• Consider“TimesAlive”toassistwithmemorizingmultiplicationtables
• Modifyteachingmethods• Useanoverheadprojectortodemonstratehowtowriteanessay
• Usecolortohighlightimportantinformation
• Usegraphicorganizerstohelpstudentsorganizetheirthoughts
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CollectionofFavoriteSchoolSuccessStrategiesforWorkingwithEFIssues
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Memory–cont’d.:• Modifytestingandgrading
• Giveextendedtimeontests
• Dividelong-termprojectsintosegmentswithseparateduedatesandgrades
• Averagetwogradesonessays–oneforcontentandoneforgrammar
• Modifylevelofsupportandsupervision• Appoint“rowcaptains”tochecktoseethathomeworkassignmentsarewrittendownand
laterturnedintotheteacher
• Increasetheamountofsupervisionandmonitoringforthesestudents,iftheyarestruggling
• Usetechnology• Useacomputerasoftenaspossible
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CollectionofFavoriteSchoolSuccessStrategiesforWorkingwithEFIssues
Inclosing…
“Bycloselywatchingachild’sbehaviorandstudyingworksamples,youmaygainimportantinsightsintothescopeandseverityofthestruggles,whichmayhaveclearimplicationsforpossibleinterventionsstrategies.”
Kaufman,2010
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Resources• AssessmentandInterventionforExecutiveFunctionDifficultiesbyGeorgeMcCloskey,LisaA.Perkins,Bob
VanDiviner.2009
• EssentialsofExecutiveFunctionsAssessmentbyGeorgeMcCloskeyandLisaA.Perkins,2013.
• PromotingExecutiveFunctionintheClassroombyLynnMeltzer,2010.
• ExecutiveFunctionintheClassroombyChristopherKaufman,
• ANewUnderstandingofADHDinChildrenandAdults–ExecutiveFunctionImpairmentsbyThomasE.Brown,2013.
• TeenagerswithADDandADHD–AGuideforParentsandProfessionals,2ndEdition,byChrisZeiglerDendy,2006.(3rdeditioncurrentlyinprinting)
• 7ExecutiveFunctionDeficitsTiedtoADHDbyRussellBarkleypublishedinAttentionMag.com,2016.
• ExecutiveFunctioningandSelf-Regulation:ExtendedPhenotype,Synthesis,andClinicalImplicationsbyRussellBarkley,2010.
• ADHDExecutiveFunctionandSchoolSuccessbyChrisZeiglerDendy,publishedinADHD&Education,2012.
• AreYourStudent’sDifficultiesinSchoolaResultofExecutiveFunctionDeficits?byCynthiaNagrath,2012.
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