“Why does my child often seem disorganized? I told him the same thing five times and he still did not remember! He has trouble planning and checking his work…It is difficult for him to switch from one activity to another or one thought to another. It is even difficult for my child to get started on activities.”
Issues like these can have various causes, but one of the most common culprits is a deficit in a child’s executive functions. Executive functions are higher level cognitive skills such as working memory, cognitive flexibility, and inhibitory control. More specifically, executive functions shape the ability to control impulses, plan, organize materials, monitor (check work), quick shift (switch from one activity to another), etc. Occupational therapists can assess and address executive functions deficits as they apply to daily activities such as play, school participation, home maintenance, meal preparation, financial management, community integration, etc.
What are Executive Functions?
Executive functions are higher level cognitive skills that begin to emerge around age five in most children and develop over time. Executive functions fall into three main categories: working memory, cognitive flexibility, and inhibitory control. Working memory is the ability to keep information in one’s mind and the ability to retrieve information for use during an activity. Cognitive flexibility is the ability to think of something in a different way, including the ability to cope with change and the ability to approach a task with more than one method. Inhibitory control is the ability to resist the desire to be distracted. Inhibitory control is also a part of regulating emotions and behaviors. The executive functions within the three main categories are inhibit, shift, emotional control, initiate, plan/organize, organization of materials and monitor:
Inhibit: The ability to stop initial impulse/desire. Children who have difficulty with inhibiting may run away at an impulse, touch multiple items in a room, switch from one activity to another quickly, etc.
Shift: The ability to go from one activity to another and back to the initial activity efficiently. Children who are unable to shift may persevere on the initial activity, not be able to stop an activity until it is completed, or demonstrate significant difficulty focusing on the new activity.
Emotional Control: The ability to regulate one’s own emotions. Children with emotional control issues demonstrate an inability to express emotions in a healthy and effective manner. Keep in mind that children may have tantrums or meltdowns for reasons other than poor emotional control and it is important to assess the antecedent, frequency, history, and environment of the tantrum or meltdown to fully understand treatment required. Occupational therapists can assist with assessment of executive functions, including emotional control.
Initiate: The ability to start an activity or task by oneself. Children who have difficulty with initiation may appear as if they are ignoring an instruction or staring into space, waiting for a prompt.
Plan/Organize: The ability to gather all materials needed for an activity or task and the ability to create a step-by-step guide for the activity or task.
Organization of Materials: The ability to arrange materials in a manner that is easily retrievable during the activity or task. It may not look pretty, but it has to be efficient.
Monitor: The ability to check one’s work and self-correct as needed.
How Can Executive Functions Be Improved?
The first step in treating deficits in executive functions is to identify which executive functions are affecting daily activities. Occupational therapists can assist with the assessment of executive functions and the impact of deficits on daily life. Once the deficit areas are identified, find motivating ways for the child to practice executive functions consistently. Below are some ideas of how to incorporate executive function practice at home:
A) Have multiple desired items to choose from and only allow the child to pick one. This activity can be part of an obstacle course, during a game, etc.
(B) Set a timer for an activity, either preferred or non-preferred, and have the child engage in the activity until the timer is done. Positive reinforcement (i.e., FIRST we work on-non-preferred activity, THEN you get-a desired item/activity) is a powerful tool to use as a motivator for completing non-preferred activities for a preset period of time.
(C) Play an impulse control game with your child such as Red Light/Green Light, Mother May I, Freeze Dance (i.e. play music and when the music stops the child has to freeze), etc.
(D) Have your child write what she is going to do in an activity or situation prior to the activity or situation. You can also role play certain situations with your child so he will know what is appropriate and what is impulsive. For example, when walking into a room, practice touching only the materials on the table that belong to the child. Practice multiple times until the child only touches those items.
(E) If a child consistently engages in a particular impulse, practice engaging in something more appropriate a certain number of times as a “productive consequence”. For example, if the child stands on the table instead of sitting in the chair, practice coming into the room and sitting in the chair a certain number of times.
Shift: During an activity, give your child a short task then have him go back to the activity. You may want to let your child know that you will be doing this to help him practice shifting from activity to activity prior to the start of the activity. For example, when your child is doing the chosen activity you could say “Could you hand me a pencil?” or “I need you to check the fridge to see if we have any milk.” then have him resume the activity.
Emotional Control: Emotional control strategies are specific to your child and may be best discussed and practiced with a professional such as an occupational therapist, psychologist, or counselor. In general, though, some options include using social stories about a child experiencing certain emotions, giving a child coping strategies for self-regulation (calming), and practicing strategies while she is calm. These strategies can help during times when emotional control is most needed.
Initiate: Try not to prompt the child to begin a task. Set up a preferred task then wait – it may take her time to process that she needs to start the task. Practicing this skill and reducing prompts as much as possible can help with initiation.
Plan/Organize: Choose a preferred project to do with your child. The project can be cooking, making a craft, doing a science project, or any appropriate activity of interest to your child. After choosing the project, write the project name on a piece of paper then say “Ok, what do we need to do next?” Have the child come up with as many steps as possible and make sure that ‘gathering the materials’ is one of the steps. Practicing planning and organizing with preferred projects of interest tends to be more motivating when children are practicing this skill.
Organization of Materials: One of the first things to figure out when working on organization of materials is what organization system works best for your child. Your child is supposed to be able to look through and retrieve items quickly and efficiently, but the way you organize may be different from that of your child. For example, does your child need tasks laid out on a large surface in order, placed in folders, put into a binder, etc.? Don’t worry – this does not mean that organization of materials could be a giant mess of papers scattered all over the house. Once you figure out which system works best for your child you can take a picture of the system and set it next to the organized area; this way the child knows how to keep their things. Keep in mind that organization expectations need to be age-appropriate. For example, I would not expect a five-year-old to respond to organization of materials other than placing items in a cubby or toy chest.
Monitor: Having your child check their work may be tedious and boring for her. You could go with the traditional approach of having her check over her homework herself before you check it. If/when you check her homework try circling the wrong answers and having her figure out how to complete them correctly as much as possible prior to giving help. You could have your child correct your “mistakes” on an age appropriate worksheet for practice – some children find it fun that their parents make mistakes and they can point those out! You could also have your child complete a preferred project that involves steps such as drawing a step-by-step picture, making a Lego tower according to picture instructions, etc.
These suggestions can be discussed with your child’s occupational therapist to determine what is age appropriate and best for your child. Depending on the level of deficit you may need to consult a professional to assist with executive function skill building.
Carolyn Miller, MSOT, OTR/L
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