Joyce Cooper-Kahn

My name is Joyce Cooper-Kahn. I’m a clinical psychologist and I work primarily with children and teens who have problems with executive functioning.

Executive functioning is such a fuzzy term for some people.  It sometimes described as the conductor of the orchestra or the CEO of the brain.  Basically executive functioning is the term that covers all of the neurological processes associated with goal directed behavior.

The metaphor that I like to use for executive functioning is it’s like the navigator on our car.  I can plug in a destination and it will not only keep track of where I am but where I am in relation to my goal, exactly what steps I need to take to get there and it will give me a prediction based on the pace that I’m going based on the traffic, when am I likely to arrive.

It adjusts if I make a wrong turn if there’s more traffic than we expect.  So it’s this process of supervising my intention of getting to a destination and it keeps adjusting my efforts in order to reach that goal.  So that’s essentially what our executive functions do for us and the goal might be I want to finish my chores by four o’clock because then I can go to the playground or it might be I need to finish this project by April 3^rd so that I can get a good grade on it.

Or it might be I want to get all my homework done so my mom doesn’t yell at me today.  Any and all of those goals are supervised by our executive functioning system and so that’s the system that pays attention to what we intend to achieve, how we’re going to get there.

So we can break down that larger task of executive functioning in a variety of different ways.  There appears to be one neurological circuit that primarily handles behavioral and emotional functioning and another circuit that’s primarily responsible for cognitive functioning.

They overlap of course, but the beauty is that the more research we accumulate, the more it seems to mirror what we’ve known all along that those things can happen in an individual, be delayed or be a strength, and sometimes both things are in sync, sometimes they are separate pieces. 

So the core skills covered under cognitive regulation are planning and organizing, initiative and task monitoring, as well as working memory.  So working memory is fascinating to me.  Working memory is the ability to hold information in your mind long enough to use it. So you may call up information from prior knowledge, you may be listening to someone talk and hold onto that piece of information, compare it to what you already have in your mind and also think about it in relation to what you’re being asked to do.

So let’s say someone says today we’re going to talk about the Civil War, we’re going to talk about the three reasons we got into the Civil War.  So now you’re pulling up in information that you already have about the Civil War and you’re trying to take in new information about what were the reasons we got into the Civil War and at the same time you’re supposed to be holding in mind that sense of what is the goal, why is the teacher talking about this, what am I supposed to get out of this?

If you have a weak working memory you have a scratchpad essentially but that scratchpad is smaller than for other people and the words are written in disappearing ink.  They fall off the scratchpad more quickly than people expect.  So very simple tasks can be really hard. If you have weak working memory and somebody says go upstairs, get your hat, your coat your shoes and your library books so we can go to the library on your way home from school, you may forget the whole sequence, you may remember one, maybe the last thing mom said is what you remember.

But it also extends to “I’m working on this long term project where did I end up yesterday, what was I working on, oh, yeah, what is the task we’re supposed to have here and what were the steps, what was I thinking yesterday when we got to the end of this?” But by that time you’re so overwhelmed that if you don’t have concrete ways to capture the information and you have to rely on a small working memory, then you’re going to give up.

And you get so overwhelmed when you have a weak working memory that it looks often like a lack of motivation, kids aren’t trying.  So working memory is critical and interventions for working memory are critical.  The ability to initiate a task, just the ability to start it when it’s time, sort of the ignition system on your car, sometimes that’s out of whack for people.

The ability to monitor where you are, like that GPS, here’s the task I have, I need to be done by April 13^th, now where am I on this path towards getting that done, am I putting in enough effort and moving quickly enough to hit that?  How am I going to juggle that in relation to my other demands?  So that whole task monitoring piece tells you whether you are doing what’s needed and what’s expected of you, and if not helps you adjust along the way.

And then the other piece is the ability to plan and organize, which is just a huge category, right, and often when we think of problems with executive functioning the first thing we think of is a disorganized kid.  So disorganized in the sense that you give them information, you give them a task and they have no clue what that means in terms of subtasks and breaking it down.

So one of the things I noticed particularly with reading is that if you give a child text and then you ask them, gee, what was this about, some of them with good organizational skills will give you the overview and the point of the text, someone who has weak planning and organization will just recount a series of details or tell you what was most interesting or tell you, you know, what stood out for them, well, the boy had a dog and he was wearing a red shirt.

And then we have the executive skills associated with behavioral and emotion regulation.  And those are essentially the ability to control impulses. That is one of the most important things of all. And it’s like cognitive flexibility, so your ability to adjust to a change in plans or when something doesn’t go as you expect, and sometimes people include attention in that group. Attention is more of a broad construct that’s sometimes included, sometimes not.

The group that most has trouble with that cognitive flexibility is the group of kids under the broad umbrella of autism spectrum disorders, but folks with ADD and plenty of folks with no diagnosis have problems with that as well. 

Assessing for problems with executive functioning is more complex than one might think, because despite the fact that there are specific tests that look at skills for executive functioning the most important thing to understand is that in the context of testing we are sometimes artificially imposing a structure and so it may help the child who has trouble with executive functioning and they look better on testing than they do in real life.

There is good reason to do in office, one-on-one assessment, but it has to be also a process of looking at some of the observational rating scales. We want to know how the child is functioning daily at home, at school, and the observations of what the child does well, what the child doesn’t do well, you want to look at the history over time.

Someone who is anxious can have trouble with executive functioning, but sometimes once that anxiety is addressed the child returns to their previous good level of executive functioning.  We would know that if we have a good history.  Other kids from the moment they started school were just having trouble managing the demands.

All of that sort of soft data is very important. And then there are specific tests that can look at say how someone organizes an essay, how they are at remembering visual material, visual working memory, auditory working memory. We have tests for all of those things. And they’re very important.

Testing is also really important to rule out some of the lookalike disorders.  So the purpose of testing for a child with executive functioning is to determine their specific profile of weaknesses and of strengths so we know what we can use to move the development along, rule out lookalike disorders and to determine if there is a diagnostic category that helps us to understand the child better.

There are generally three different ways that kids come to me.  Often they’re referred by parents, because of what they perceive of as being primarily behavioral problems.  So they may have horrible arguments about following routines, bedtime, behavior routines, and very often because the children are having trouble getting through homework and it’s becoming very tense and stressful time for the whole family.

Sometimes it’s the teachers who notice that the child doesn’t seem to be able to meet the expectations for tracking homework and paper demands and they’re not turning things in or they’re not turning things in on time or they’re disorganized or their work is not well organized.

And then often it’s pediatricians. When they hear those complaints from parents or when a child is diagnosed with one of the conditions often associated with problems with executive functioning. So if a child is diagnosed with ADHD or is determined to be on the autism spectrum and the pediatrician hears about problems at home or at school, I often get to see them.

Generally the kids who have high functioning autism have difficulty with working memory, impulse control and organization.  And there’s a pretty good research to back that up, but in terms of daily functioning, what we tend to see is dis-organization and inflexibility.  So the kids tend to be rigid, they have trouble problem solving in the moment.  If they are disappointed or things don’t go the way they expect them to, the way they did yesterday they have trouble problem solving for what they do instead.

They have trouble problem solving about their own emotions.  So that need to step back and think about your own feelings and decide what you’re going to do in relation to what you feel is often surely out of whack for these kids. So we need to teach them better flexibility and then they’re often very disorganized and so we need to help them to learn habits and routines that foster better organization.

Early in their development, folks who are high functioning tend to have problems with impulse control. That seems to get better over time and the kids, the teens, the young adults tend to be less impulsive, better able to manage impulsiveness.

What we do about that problem with flexibility, the problems with organization, they’re not that much different than what we do for any child because the interventions are not diagnosis-specific, it’s only the combination of problems that can sometimes be diagnosis-specific. And there’s so much overlap. There is no way that we can go into brains at this point and change them, and so what we’re doing is we are teaching them how to manage these tasks in life better at the same time that we’re supporting them until they can learn those strategies and until their brain develops.

There are a lot of specific strategies that people recommend for problems with executive functioning and there’s a lot out there in books and articles about that.  The most important thing from my perspective though is that there is no one specific strategy that works for every child.  It’s always got to be targeted. And situations change. So it’s important for teachers and parents to understand the principles of how you intervene to help kids.

Let’s talk about three general categories that are really important for intervention.  Number one is we have to be sure that we have both short term and long term strategies in there.  So what the research tells us, for instance, about folks with ADHD is that their executive functioning is delayed, sometimes it’s an anomaly and it will always be weak, but for some kids it can be as much three to five years delayed.

And so those kids will be out of sync with the demands in terms of executive functioning, although they may be capable of higher level cognitive work. And so our job is to support them so they can be successful in the short term.  But that’s only half of our job and if that’s all we’re doing then we’re not really doing the whole thing.

The other piece is how do we teach them what they need to know in order to function independently over time.  So that’s principle number one, we want to do short and long term accommodations.

The cornerstone of any intervention plan is building habits and routines.  This just makes me smile every time I say it.  Once something becomes a habit or a routine it no longer lives in the parts of the brain responsible for executive functioning.

The first time I read that it was like an “aha moment”, right?  Okay, so habits and routines, the more we can build those, the better we’re going to be at moving our kids along in their development.  And then number three we have to make sure that we’re focusing on executive thinking, not just executive skills.  So we’re not just teaching a kid when you have an assignment you need to pull out your notebook and start with this, right?

What we want to do is to teach them to reflect on tasks, so that they can start to expect to create a plan for what they’re going to do.  So we can do that starting when they’re very young, when we start kids on a homework routine we teach them whatever works in your house.  You get home, you have a snack, you go outside, you play for half an hour, four o’clock is homework time.

And at four o’clock you come sit down at the kitchen table and at that point we’re going to review all of your assignments, the ones that are due tomorrow, how long will it take to get them done, what are you go to start with, what do you need to do, and then if you have any assignments, things that are due later in the week or next week, we plan those out too.

And by doing that you start teaching a routine for reflection and planning, not just fill in the gaps. So obviously as tasks and as life gets more complex we have to help kids create these at a much higher level, but those principles will come back around in everything that we do.

Kids on the spectrum who have trouble with behavioral flexibility fortunately a lot of the interventions are not unlike what we do for kids anyway in classrooms.  It’s just they have to be more explicit and more pervasive for these kids.  So we want a lot of predictability and routine in the structure.

We want the day’s schedule up on the board. If there’s a change to the schedule we want to highlight what different but we also want to highlight what’s the same thing.  So that we don’t leave the kid adrift.  We want to focus on transitions, because shifting is part of what’s hard.  So we want to help build a bridge between one activity and the next until the child works through some of those issues.

So an example. I was working with a first grader. The complaints that the teacher had was that the child was too wild when he came in from the playground after recess and that despite there being another child assigned to the put the chairs on the desks he had to go around and straighten them each time.

This is a bright child who was really at the end of his rope by the end of the day.  And my suggestion was why don’t you add a job?  How about there being another job and that job is to double check to make sure that the chairs are lined up well on the desks?

I didn’t see any reason why we couldn’t just go with that child’s need for order and sameness and not make that a struggle.  So that became his job every day and that totally settled down.  Coming in off the playground we structured an unstructured time for him. What we did was we gave him a job.  Your job every day is to help me collect all of the playground equipment before you come inside.

I’m going to bring out a big basket and at five minutes before it’s time to come inside I’m going to tell you it’s time to start collecting everything.  I’m go to hold the basket and you’re going to go get the balls, whatever other toys the kids have, put them in the basket and you and I are going to walk into the classroom together.

And it totally changed the nature of the task for him because now he had a structured job to do; he was no longer anxious, he knew exactly what the routine was going to be. 

Similarly, when routines are changing for kids who are on the spectrum they often have a lot of anxiety of confusion and so we try to structure that for them initially, field trips, you and I are going to be partners today for this field trip and here’s how it’s going to go.

You and I are going to walk outside together, we’re going to hold hands, we’re go to the bus, you’re going to get onto the bus, you’re going to sit down in the first seat behind the driver. And if you do all of that without making a fuss, there will be a sticker waiting for you as soon as I get on too.

At first we structure it for them and then the principle of backing out as soon as possible, we can say to them, you know what tomorrow is a field trip day do you remember what we did last time?

I was your partner, here’s what we did, how did that work for you?  Do you want to do that again or do you have a different sort of routine in mind that you want to do?  So the organizational strategies are generic.  The flexibility strategies take a little bit more work.

And the more trouble the kids have with flexibility, the more people they may need on their team in order to help them. So very often it’s a speech and language pathologist actually who helps with that and there’s a lot written on social thinking. And those social thinking tools often help with inflexible children. 

Now as kids get older we start teaching them to monitor those routines themselves and the kids who tend to be inflexible we have to teach them that that’s the case.  And we teach them routines for what to do when they don’t know what to do.

So this is one of those confusing times for you, what are the things you do when you’re feeling confused?  I can go to the teacher and ask what I’m supposed to be doing?  I can sit down in my desk and wait for instruction.  If it’s a time when we’re allowed to talk I could ask the child next to me what I’m supposed to be doing.

All of us who have good executive functioning skills learn over time how to structure situations that make us feel anxious. But these kids need help.   

Long term we’re doing basically three simple things.  Well, they’re not as simple in practice as they sound. But what we’re doing, number one, is we’re teaching kids about their own strengths and weaknesses because the only way to be successful as an adult is to know and to have an honest appraisal of what you’re good at and what you’re not.  It’s so that you can build a life around your strengths and so that you know you’re going to need to come up with compensatory strategies if the weak areas are going to be tapped. So we teach kids about themselves.

Number two, we want to monitor carefully what they’re able to do and to make sure that we are backing out of our involvement as soon as possible.  So we’re going to fade from adult initiated to child initiated strategies and we’re going to fade from direct involvement to indirect involvement.  So a really simple example of this is that often when kids are young we tell them over and over again what they need to do, go get your hat, go get your shoes, do your chores, clear the table, feed the dog.

And if we just take one step back and we create a checklist, for young kids we can create a picture checklist, for older kids obviously they can help us to create it, and then instead of saying go do this what we say is have you checked your list for today?  I think there may be some things you haven’t done yet, come back to me when you’ve checked everything off the list.

It takes it out of our initiation and it helps them to learn tricks for supervising their own energy.    

Let’s talk a little more about what it means to have a short term intervention.  Short term interventions are things that lighten the load on the executive system.  We can do that by changing the task. So I can say I need you to get ready for school or I can say I need you to get your coat, your hat, your backpack. Got that?  Three things, they’re written down on the checklist in your room, meet me at the garage.

Now I’ve taken some of that executive load off because I’ve already given the information about what it means to get ready for school, okay?  We can help children by lending our executive competence. When they come home and they have a task to do and the kid has no clue how to start, we think about well, what would it take to get this done and we sort of plug that destination into our own navigator and we think about what would the steps be along the way and then we can assign those steps to the child.

The other things we can do for short-term success is we can change momentarily the functioning of the brain by offering rewards.  So by increasing the motivation and releasing neurotransmitters associated with the motivation system, children will function better.

We do that short term, because the long-term rewards don’t seem to operate the same way in these kids with weak executive functioning for the most part. 

The other thing that we can do is we can prompt at the point of performance.  So until something becomes a habit or a routine we may be able to tell the child two days later you’ve lost this privilege because you didn’t get this done.  But that’s not going to help them build a habit or a routine.  The way habits are formed is by daily repetition.  And so we have to help kids to perform the task and that means somebody has to be there on the spot to say this is the time to tap kids on the shoulder gently and say homework, turn in your homework now.

But until we’ve built the habits and routines we can’t expect kids to initiate them on their own.  So short term accommodations fairly straightforward actually. And the biggest problem is that we have to repeat them far longer than people want to do them.

The question becomes, what’s short term?  And short term – and it’s not a flippant answer – but short term is different for different people. And it’s until the child initiates it on their own.  That’s how long you have to prompt them. 

And somehow we tend to punish kids for problems with executive functioning. It looks so easy and often the kids know what they should do, but they don’t do it at the point of performance. So we need to be patient. We would never, we hope yell at kids who were delayed in learning to decode text. We keep giving it to them and we figure out where things are going wrong and we teach and we teach and we practice and we practice.  And really it’s no different for executive functioning.

The very best example of good intervention for executive functioning is a good kindergarten or first grade classroom, because those teachers are teaching kids how to be students; how do you operate in a classroom, how do you operate in a school building. And most of these kids with weak executive functions start to falter at the point at which they no longer have the pretty bright yellow folders with their name on the front that the teacher checks every day. 

It’s when they have to independently organize themselves that they start having trouble. Now some kids even in that kindergarten or first grade classroom you see problems.  The kids who sit down at their desks and despite the fact that we’re now way into spring, they still don’t initiate that morning routine or the kids who have the backpacks and the cubbies that are just so disheveled.

There are some kids who approach life haphazardly and there are others who are beautifully organized.  And these kids usually declare themselves pretty early on in their development.  So I work with the haphazard ones, mostly, but teachers, many of them, particularly teachers in early education are used to those kids because developmentally that’s appropriate at that stage. 

Particularly in this day and age, the sorts of goals that we have for kids are so complex and as important as they are for pushing thinking rather than rote learning. If you take a look for instance at the common core curriculum it is so loaded with executive skills that there are kids who can’t meet those goals not because they can’t understand the text and not because they don’t want to do well, but because they can’t meet the executive demands of the tasks.

I was looking at goals for a kid the other day and I’m going to get the wording, the exact wording wrong, but it was something like students will prepare a persuasive essay using at least three sources, documenting the facts associated with their opinion and organizing the essay into a cohesive whole.

And I thought, wow, that’s writing.  That’s also executive functioning, right?  And so some of the kids if they had a template they could actually do that, but if you leave them independently to do that or they’ve only done it once and they didn’t save the template or it’s crumpled up at the bottom of their backpack somewhere, they’re not going to be able to do it.

So a lot of the kids that we see are faltering because they can’t meet the executive demands of their environment and yet they are feeling that their intellect and their reasoning ability is unappreciated. 

It’s really important that we help kids to organize and we have to understand that when we talk about someone who has poor planning and organization it’s not just their stuff that’s a mess, it is also their ability to organize information in their own heads that’s difficult.  So we have to figure out ways that they can learn to organize that information in their heads.

Some of these are very simple and some are more complex.  So we can work with these graphic organizers that are very common in classrooms. We can use them to help kids not just plan writing assignments but also to read.  So if we give kids outlines that have the main topics in the text and the subtopics and then they have to go in and fill it in, that then gives them an outline in their head so that as they’re reading the information they’re organizing it and putting things into the right file folders, right?

We can help kids plan and organize their work.  There are a ton of apps for task management for students.  But really it can be done with a paper and pencil planner and the important thing is that we work on do dates, d-o, not just due dates, d-u-e.  So what happens to most kids, a high school student say or middle school student, we assign something that’s due in three weeks and we say write this in, you know, on February 21^st you’re going to have to turn in your social studies project.

And they write it on February 21^st, but they go home and they’re only looking at this week at a time, right, that the spread sheet covers one week at a time.  And so my co-author and colleague Margaret Foster who’s a wonderful learning specialist, has this technique where she takes a paper and pencil planner, if that’s what the child is working with, and teaches them that if whatever is assigned is not due tomorrow, you write it in on the day that it’s due, but you turn your planner sideways, so when you write it in it’s actually, and then turn it back to the proper orientation, it’s written vertically.

And anything written vertically on a planner is your symbol that when you get home and start your homework you have to plan out that assignment.  Now if it’s due in four weeks you write it in on the date that it’s due, but you also write it in over today’s date.  And again that’s how you know that you have planning to do.

And sometimes for a long term assignment the most important thing that a kid can do on the first day is sit down and do that whole GPS model with this assignment.  What is it that I have to have done, a list of tasks that it’s going to take, thinking about when they’re actually going to do those tasks, how long is it going to take to do and we also always teach kids that you don’t want to be done the day it’s due, you want to be done a couple of days.

What happens if you get sick?  What happens if you … you know, whatever’s going to happen … you have a snowstorm, whatever?  So we can teach kids how to plan and even without fancy technology, many of the kids that I work with though at this point in their lives prefer the technology and there’s no reason you can’t do that and again it’s sometimes a simple calendar app can be used, build there are more involved ones and I know kids who are using things that are designed specifically for tracking homework goals.

The problem is though the very kids that need to use those often don’t initiate it.  And so you still have to have somebody who’s initiating that at the point of performance.  Long beyond when you do for kids who don’t have problems with executive functioning.  So you may still need a parent on the other end to sit down and say, gee, what do you have for homework, show me your plan, have you checked the website to make sure you don’t have any missing assignments.

It takes more hands on. So when we talk about these interventions they help kids to grow and develop, they support kids while they’re developing what they need to develop.  But they don’t make the job easy for teachers or parents.  It is not an easy job to help the kids.  I don’t know of a way to make it easy.  But understanding what needs to be done takes a lot of the worry and the confusion out of it.  And that’s why we talk about principles rather than just specific sorts of interventions.

An EF Smart Classroom that supports executive functioning for all students and you know our kids with weaknesses in executive functioning can’t get away without these.  They won’t succeed. But all kids can really use these.  So we’re talking about taking the time to plan for instruction, plan for repetition, to think carefully about the kind of instruction that we do, so looking at tasks that, for instance, are new and introducing a new task with less demanding content.

If new executive skills are required, which is true for any new routine then we don’t want to also load it up with very high level content.  On the other hand, if we’re working with really easy content that might be the time to introduce a new routine, say a lab report or a book report.

We want to make sure that we have those habits and routine well laid out and we also want to make sure that we have a culture in the classroom that is responsive to the need for practice and repetition.  So a lot of times the trajectory of development for students with weak executive functions means that we’re going to have to help them with missteps for a very long time.

And that means having a mindset where we don’t first of all treat every assignment as if it’s a test and secondly where we use mistakes to help inform ourselves and the students of what they need to learn next, right?  So one of the examples that I often give for parents and teachers is this, sometimes we have kids who have long term assignments. We’ve helped them break it down by task, we have checked to make sure they have the correct things done when through supposed to have them.

We give them a little bit of rope and they hang themselves, right?  It’s not done on the day that it’s due and then we yell at them, right?  Instead of saying wow, there were 32 steps in this project, you did really well up until 27 as near as I can tell, and I think where you went wrong was that your time estimates were probably a little off and you weren’t ready with this assignment on the day it was due.

You did a great job planning it. Next time what we’re going to work on is more accurate time assessment. Let’s see if you can get this in closer to the due date next time.  It is a shame for you to lose points because you don’t have this in on time when you’ve been doing such great work. So let’s work on that for next time.

And then we’re acknowledging all the things the child has done right, all that they’ve struggled with, all the great ways they’ve worked to meet those challenges, but we’re also being clear that we’ve got a little bit more work to do here.  So the attitude of the teacher is tremendously important and we could talk about tools and techniques from now until the cows come home and if you don’t have the relationship with the child that encourages them to look to you for help, and where they feel safe, and that it’s okay to make mistakes, then they’re still not going to progress.

So lots of understanding and compassion goes into this but it all comes back down I think to some of the basic tools that we use with any human being that’s struggling.  And that is building a relationship with them that allows them to learn with us rather than to run from us.

I first became interested in executive functioning because I was looking for how to help kids with ADHD.  And that included my own son with ADHD, but I was already a clinical psychologist working with kids and it wasn’t just him, I had a larger subject pool then that.

And what I was finding was that most of what we were doing at that point in time was trying to clean up after kids mistakes and trying to fix the problem.  I was fortunate enough to have a history of knowing lots of ADHD males. I do not have ADHD, but like typhoid Mary I seem to be a carrier of the disorder, and so I am the daughter and sister and mother of males with ADHD, all of whom had significant problems with executive functioning.

And when I started looking at how successful my brother and my father had been I started thinking how am I going to get my son and all of these other kids there. I don’t have to remake them, they’re going to have ADHD that’s okay. But how am I going to make them successful human beings with ADHD?

And so that was my mission and I was a psychologist so I went to the literature and the more I read, the more I started seeing that what we were focusing on with ADHD was just the tip of the iceberg.  We were looking at hyperactivity, we were looking at in attention, but there’s this whole other body of literature and most of it not in the hands of the people who needed it.

And it was so helpful to me, and I started seeing kids make much more significant progress once I started using this information about executive functioning.  And so it has become my thing to keep up with that information and to figure out how that applies in daily life and I find the research fascinating because it has direct implications for what we do with our kids and our students.

We are in a tremendously exciting era with more and more imaging studies available and particularly these large data sets from groups that are collaborating around the world. So I think we’re going to see great changes in our understanding and our knowledge base that will continue to inform us.  I’m looking forward to learning more as the new information comes out.