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12/6/12 Literature Review Paper

Current Interventions to Improve Executive Function in Students With Disabilities

Executive functions (EF) can be described as a group of control functions that

direct and regulate cognitive (e.g. paying attention, remembering information) and

social behavior (e.g., being polite around people you do not like) (Watson and Westby,

2003).. These behaviors can include inhibiting actions, restraining and delaying

responses, attention selectively, goal setting, planning, and organizing (Singer and

Bashir, 1999). EF also governs the formulation of future plans and the sequence in

which those plans are enacted (Penington and Ozonoff, 1996). A broad range of

behaviors have been observed in students with EF deficits. “Students who have

problems in these areas often are not aware of their behavior, emotions, and thought

processes.” (Watson and Westby, 2003) Because of these inabilities, students with EF

deficits fail to see cause and effect relationships, shot and long-term goals, and display

appropriate behavior.

Additionally, students with EF impairments are hindered in their ability to learn

and encode new material, adjust or change learning and behavior strategies while

problem solving, and determine when to adhere to established to rules and social

constructs. Students with EF deficits can be disruptive in class and their performance

levels can be detrimentally affected. Behavioral disorders including ADHD, reading

comprehension disorders, LLD, and those that accompany prenatal exposure to illicit

drugs and alcohol have been documented to display a measurably higher incidence of

EF deficits in the afflicted individuals. In this paper, I will review intervention techniques

designed to improve EF skills in students diagnosed with these behavioral disorders.

The first article I will discuss, What are Executive Functions as Self-Regulation

and What Do They Have to Do With Language-Learning Disorders? (Singer and Bashir,

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1999), outlines the relationship between EF and language learning behaviors. In this

article, the authors examine the connection between metacognitive processes and EF

abilities. Metacognition is vitally important to student success, even in typically

achieving and learning disabled students. Strategies and routines facilitated by

metacognitive processes are dependent on understanding and use of language. As

both Vygotsky have argued, speech is an integral component to social interaction, self-

control, self-direction, problem-solving and task performance. In order for students to

effectively plan and regulate behavior, there must be some sort of coherent “internal

language” students use to talk to “talk to themselves about what they are doing and

how they are doing it.” (Singer and Bashir, 1999) Without the capacity to functionally

utilize speech in a social context, students will be inhibited in the regulation of their

“participation in the various learning and communication demands of school” (Singer

and Bashir, 1999).

The authors argue that EFs and language production are interrelated. Students

diagnosed with LLD “do not naturally bring to the learning process a sense of self-

awareness, reflection, and task analysis” (Singer and Bashir, 1999). Without these

metacognitive abilities, students may not be able to sufficiently engage in the regulatory

behaviors that are necessary for success in academic contexts. For the purposes of their

study, the authors document the intervention of a student named George, a 16 year-old

high school student with a history of LLD, to illustrate techniques to improve EF in

students with LLD. The general intervention approach was structured around

“metacognitive and speech-language instructional strategies” (Singer and Bashir, 1999).

Using George as an example, the authors offer general principles of intervention

to increase EF in LLD students. When initiating intervention, the authors suggest that

teachers first use standardized testing techniques to determine the strengths and

deficits present in the student. Next, a student interview should be conducted in order

to determine any specific communication problems the student may be having and how

they may affect academic performance. Information gained through the use of these

formal and informal assessments will help make the student aware of the influence of

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“different settings, contexts, and content demands on performance.” (Singer and Bashir,

1999). The student’s strengths and needs should be openly discussed as evidenced by

the assessment data. Finally, the student should be able to recognize how such

proposed intervention will improve performance so a more meaningful commitment to

improvement can be made.

The framework of intervention should work toward promoting independence

through the use of both academic and communicative strategies. Dialogue and

interactive teaching approaches meant to aid student understanding and problem-

solving skills should be designed. These activities should “develop active problem-

solving through self-reflection.” (Singer and Bashir, 1999) To account for the necessary

connection between language use and metacognitive function, language deficits should

be addressed and therapeutically corrected. Also, self-efficacy and motivation skills

should be addressed so the EF can be developed, thus enabling the student to “ “control

their performance and their learning environment.” (Singer and Bashir, 1999).

Components of EF intervention in LLD students should be designed around goals

that address “linguistic, executive, self-regulatory, and strategic learning needs” (Singer

and Bashir, 1999). The authors warn that these interventions should not be

contextualized, so that day-to-day use of the skills outside the classroom is possible.

Teaching the student to ask themselves “where”, “when”, “why”, and “how” questions

also aid in the development of situation-specific strategies that can be applied to both

social and academic paradigms as well as written and spoken language systems. (Singer

and Bashir, 1999) Also, encouraging risk-taking behavior within the arena of learning

and communication should be encouraged because students with these EF deficiencies

will often refrain from participating in assigned classroom tasks. In so doing, students

are forced to apply and adapt the intervention strategies they have learned.

The final and arguably most important component of intervention is the use of

“frequent and systematic” (Singer and Bashir, 1999) communication with the student.

Regularly conferencing with students helps them set realistic goals and appraise growth

and progress in both personal and academic realms. Once progress has been

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determined, new goals can be set and appropriately worked toward. Through personal

communication with the student, teachers and counselors can best monitor the

effectiveness of the prescribed EF interventions.

The next type of intervention I will discuss involves students who have been

exposed to alcohol and other drugs before birth. In an article titled Strategies for

Addressing the Executive Function Impairments of student Prenatally Exposed to Alcohol

and other Drugs (Watson and Westby, 2003), interventions designed to increase EF in

such student are specifically detailed. These interventions are very similar in nature to

those outlined in the previous article, however there are some disability-specific

differences. To complicate matters, students with prenatal exposure to drugs and

alcohol present a perplexing and very hard to diagnose set of symptoms that may not

even be evident until late childhood.

Surprisingly little research has been conducted on the long-term effects of

prenatal exposure to drugs and alcohol, meaning detection of symptoms and

formulation of an effective EF intervention system can be challenging. The symptoms

of such exposure may be quite difficult to diagnose for several reasons (Watson and

Westby, 2003). “Not all students who have been exposed prenatally have low

intellectual ability, “ report the authors (Watson and Westby, 2003). In addition, many

other environmental factors may also contribute to the symptoms observed in these

students. “Deficient parenting skills, maltreatment, poor nutrition, poverty, an

unpredictable and unstable home environment, and low educational achievement of

the parents” (Watson and Westby, 2003) may also contribute to the decelerated

achievement of students with such exposure. Because of the environment many

exposed students originate from, there may be external stressors that contribute to the

symptoms that are observed. Their effects are likely to be very subtle, making detection

difficult or unlikely. Educators can also be grossly uninformed of student backgrounds

because oftentimes little or no personal information is known of the affected students.

Relevant communication about students’ domestic situations and academic

background may be unavailable to teachers or simply unknown. If counselors had

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access to this information, external stressors and their resulting symptoms could be

much more easily detected and treated. In addition, teachers may lack training in how

to intervene and modify instruction effectively, even if sufficient background knowledge

is available. The authors reported that 88% of the respondents to an educator survey

“acknowledged that more information was needed about educating children exposed

prenatally to alcohol and other drugs.” (Watson and Westby, 2003) Even though the

treatments and interventions to increase EF in these students are very similar to other

conditions, nothing can be done at all until educators are properly trained.

When interventions can be implemented, there are some specific approaches

that focus educators should focus on. Students who have been exposed prenatally to

drugs and alcohol display specific deficits in EF. Such individuals tend to have “particular

difficulty in learning new material (i.e. encoding information), shifting or changing

strategies (i.e. being flexible in problem solving), and knowing when to apply certain

rules in daily situations,” (Watson and Westby, 2003). In this article, Watson and

Westby utilize a model that focuses on understanding the components of EF in order to

structure interventions for these students. This model was originally designed by

Barkley (1997) for use on individuals with behavioral or response inhibition deficits

aligned with ADHD, who display an inability to inhibit impulsive responding, stop

inappropriate or ineffective behavior, and avoid distractions (Watson and Westby,

2003). The intervention strategy is designed to focus treatments for each of the four

components of EF; nonverbal working memory, verbal working memory, self-regulation

of mood and motivation, and problem solving. These four components build on one-

another and are highly interactive. In addition to designing an intervention plan that

encompasses treating each of these four components, the authors also stress adjusting

treatment to account for uniqueness of each student. In so doing, teachers should

assess the distinctive set of strengths and weakness displayed by each student before

designing a system of intervention.

In order to address nonverbal working memory intervention, the authors

recommend visualization training such as immediate corrective feedback and video

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taping students in class (Watson and Westby, 2003). These processes help the student

internalize the feedback through heightened self-awareness. Off-task behaviors can

thus be recognized and curtailed, while corrective behaviors can also be practiced and

reviewed. Visual cues are also a very important component to nonverbal intervention.

Displaying visual instructional cues and daily schedules also assist the student in staying

on task and engaging in long-range planning (Watson and Westby, 2003). Providing the

structure of checklists and consistent and structured environments also help the student

make connections between their behaviors and their goals.

Verbal working memory interventions involve building and modeling cognition

and language understanding behaviors. Developing semantic, syntactic, and pragmatic

verbal skills is integral to this type of EF training (Watson and Westby, 2003). By making

similar use of the metacognitive “self-talk” discussed in the Singer and Bashir paper,

students can develop self-governing strategies through language use and practice

(Watson and Westby, 2003). These strategies generally involve the teacher modeling

self-instruction that involves verbalizing the steps of an assigned task. Use of

mnemonics and visual cues are also recommended in this type of intervention (Watson

and Westby, 2003). Modeling cognitive processes verbally and requiring students to

utilize verbal mediation, in which the student uses language to mediate behavior, are

also recommended (Watson and Westby, 2003). The authors indicate that these types

of interventions, whenever possible, should be used in a scaffolded fashion that

promotes student independence.

Self-regulation of mood and motivation can be achieved through the use of

vocabulary and social skills instruction. These students may not have a strong

mechanism to control behaviors and outward emotions. They act impulsively in social

environments and can cause undue disruptions in class. By teaching students to

verbalize their emotions, students become “more fully aware of their feelings or the

feelings of others” (Watson and Westby, 2003). Augmenting these behaviors by

teaching the student to actively verbalize or assign visual cues, such as a color, to these

emotions also helps students control outbursts and remain on task (Watson and

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Westby, 2003). Role-playing is another often-used strategy to train the student to

respond to social situations more appropriately. Teacher modeling and student self-

evaluation of performance during and after these activities can also be beneficial to the

student’s future EF.

Finally, problem-solving ability can be affected by any of the aforementioned

components of EF. Increasing the quality of these skills aids students in becoming self-

determined, thus enabling them to be causal agents in determining their own future

goals (Watson and Westby, 2003). As in the other components, cognitive modeling and

role-play techniques can be used to model the consequences of behaviors and aid the

development of alternative responses to situations. Teachers can also assist the

student in setting goals to develop compensatory skills that offset their EF deficits

(Watson and Westby, 2003). By utilizing intervention techniques used in the other

three EF components, teachers can guide these students to assess possible outcomes

and formulate courses of action that are in line with proposed goals and outcomes.

In a paper titled, The contribution of Executive Skills to Reading Comprehension

(Sesma, Mahone, et. al., 2009), children with word reading deficits (WRD) and reading

comprehension deficits (RCD) were determined to have EF deficits that affect their

reading comprehension. The authors explain that studies show that WRD can lead to

RCD because contextual meanings are affected by an inability to sound out individual

words properly (Sesma, Mahone, et. al., 2009). EF is implicated in these deficits because

adequate reading comprehension depends on other cognitive skills beyond word

decoding such as working memory, planning, organizing and self-monitoring. Deficits in

these skills may lead to impartments such as poor inference making and ineffective

comprehension monitoring (Sesma, Mahone, et. al., 2009).

Working memory skill deficits are the component of EF most focused on by these

authors. They contend that working memory, which has significant influence on EF, may

be impaired in students with conditions such as dyslexia (Sesma, Mahone, et. al., 2009).

Planning skills, another component of EF, contribute to reading comprehension skills.

Students struggling with RCD tend to perform worse than typical students on “measures

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that require planning an organized response,” (Sesma, Mahone, et. al., 2009). Single

word accuracy may be retained in these students, however reading comprehension

skills are still insufficient. The authors contend that insufficient EF may contribute to

these types of reading comprehension difficulties.

After a comprehensive study of children whose single word reading skills were

intact “may require interventions that focus on applying more ‘executive skills’ to the

task of reading,” (Sesma, Mahone, et. al., 2009). They suggest that these students may

benefit from interventions that promote EF, such as comprehension monitoring or

training on the meaning of linguistic context. Another interesting implication in the data

was the early identification of students with such difficulties. In their findings, they

noted those students with known EF dysfunction or a diagnosis of ADHD “may not be

considered at risk for difficulties with reading comprehension until their deficits become

frankly apparent,” (Sesma, Mahone, et. al., 2009). These RCD issues may not become

outwardly noticeable in students until the elementary years of instruction, or perhaps

even later. The authors recommend students with EF deficits and ADHD be monitored

and sufficiently trained in the use of reading strategies that develop and/or remediate

reading comprehension skills (Sesma, Mahone, et. al., 2009). They also contend that

these remediations should be structured around the development and accentuation of

EF skill sets in ways quite similar to those outlined in the previous two articles.

In order to further address EF interventions for students diagnosed with ADHD,

another study titled Effect of Acute Exercise on Executive Function in Children with

Attention Deficit Hyperactivity Disorder, (Chang, Liu, et. al., 2012) a Chinese group of

researchers tested how a single bout of aerobic exercise may increase EF in students

diagnosed with ADHD. The authors based their experiments on the role of the

prefrontal cortex on EF according to what is known as the “prefrontal hypothesis”. The

authors explain that the “prefrontal related cortices have a potential role linked to

executive function and are abnormal in ADHD,” (Chang, Liu, et. al., 2012). ADHD has

also been shown to affect attention circuits that are regulated by the presence of

neurotransmitters such as dopamine and norepinephrine (Chang, Liu, et. al., 2012).

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Stimulants that are prescribed to patients diagnosed with ADHD are

hypothesized to affect reuptake of these neurotransmitters in the prefrontal cortex,

thus up-regulating that structure’s influence on EF. Use of these stimulants is also

linked to an increase EF in adults without ADHD, implicating that simulation of the

prefrontal cortex, though increased levels of these neurotransmitters, increases EF

regulation universally. Since such exogenous control of EF can be influenced medically,

then why not simply medicate students with ADHD as a means of intervention? The

answer to that question proves to be quite simple: there are noticeable negative side

effects associated with these medications such as decreased appetite, sleep loss, and

personality changes. The students and their parents can be deeply affected by these

side effects, and alternative interventions are being rigorously sought.

In an effort to produce the same up-regulation of the prefrontal cortex that is

observed in patients taking said stimulants, the authors were searching for a more

humane intervention to increase EF in young students. Recent studies suggest that

intense exercise increases some aspects of EF such as inhibition, planning, working

memory, and processing speed in children with ADHD (Chang, Liu, et. al., 2012).

Aerobic exercise has also been shown to have a positive effect on cognitive abilities in

children, especially exercise that is acute in nature (Chang, Liu, et. al., 2012). Since

cognitive function and EF are closely related, the researchers tested whether acute

aerobic exercise could, in fact, increase EF in students with ADHD. In order to test

these parameters, the team assessed cognitive function in children after a single bout of

aerobic exercise lasting for 30 minutes. Children used for the study were between 8 and

15 that had been previously diagnosed with ADHD (Chang, Liu, et. al., 2012).

What the group found was that acute exercise did in fact increase cognitive

ability in both the Stroop Color-Word Test and the Wisconsin Card Scoring Test (WCST),

both of which assess EF. The results of the Stroop test indicated that students

“particularly benefitted from inhibition-related EF,” (Chang, Liu, et. al., 2012). The

results of the WCST, which has been shown to measure EF that are handled by the

prefrontal cortices, also showed increases in performance after acute exercise. (Chang,

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Liu, et. al., 2012). Additionally, numerous other animal and human studies indicate a

correlation between increased dopamine levels and exercise. As mentioned earlier,

increased dopamine levels will increase the influence of the prefrontal cortex on EF. If

these findings are accurate, there is a positive correlation between acute aerobic

exercise, dopamine level increases, and prefrontal cortex influence on EF. The authors

are confident the results indicate that acute aerobic exercise may be used as a means of

intervention in individuals suffering from EF dysfunctions such as ADHD (Chang, Liu, et.

al., 2012), although warn that future testing may be needed to strengthen these claims.

In conclusion, EF disorders that affect the cognitive process and self-regulatory

behaviors in afflicted individuals are numerous in nature. Equally numerous are the

interventions teachers can utilize to assist the development of EF in students with such

deficits. Students with LLD and reading comprehension disorders can be treated with a

similar regiment cognitive modeling interventions and visual cues to increase their EF.

Although much more difficult to diagnose and treat, students who have been prenatally

exposed to drugs and alcohol can be treated with interventions that pertain to each of

the four components of EF; nonverbal working memory, verbal working memory, self-

regulation of mood and motivation, and problem solving. There are a few condition-

specific interventions for these individuals, however this intervention construct closely

mirrors the treatment prescribed for students with ADHD. Additionally, it has been

found that acute aerobic exercise may be a viable intervention technique, as it has been

shown to increase EF in children with ADHD.

The interventions meant to increase EF in students are numerous in nature and

can include a combination of focus on increasing cognitive function, modeling proper

behaviors, increasing language understanding and use, and perhaps even a little

exercise. After compiling the research articles discussed in this paper, I am left

wondering how to recognize and correct such EF disorders in the students I will have in

class. Moreover, I feel that all of my students would benefit in some way from the

interventions discussed in this paper. Perhaps teachers should include these strategies

even in the classroom activities meant for the general population of students. The

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faster students learn how to utilize the power of EF and how those skills can affect their

long-term goals, the more successful they will be outside the classroom and in their

future life pursuits.

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Literature Cited:

1. Barkley, R. A. 1997. Behavioral Inhibition, Sustained Attention, and Executive Functions: Constructing a Unifying Theory of ADHD. Psychological Bulletin. 121; 65-94.

2. Chang, Yui-Kai, Liu, Suyen, Yu, Hui-Hsiang, and Lee, Yuan-Hung. 2012. Effect of

Acute Exercise on Executive Function in Children with Attention Deficit Hyperactivity Disorder. Archives of Clinical Neuropsychology. 27: 225-237 .

3. Ormond, Jeanne Ellis. Sociocultural Theory And Other Contextual Perspectives.

In: Human Learning. Pearson, Boston, MA, pp 313-350.

4. Pennington, B. F and Ozonoff, S. 1996. Executive Functions and Developmental Psychopathology. Journal of Child Psychology and Psychiatry. 37; 51-87.

5. Sesma, Heather Whitney, Manhone, E. Mark, Levine, Terry, Eason, Sarah H., and

Cutting, Laure E. 2009. The Contribution of Executive Skills to Reading Comprehension. Child Neuropsychology. 2009. 15(3); 232-246.

6. Singer, Bonnie D. and Bashir, Anthony S. 1999. What are Executive Function and

Self-Regulation and What do They Have to do With Language-Learning Disorders?. Language, Speech & Hearing Services in Schools. 30,3; 265-273.

7. Watson, Silvana M. R. and Westby, Carol E. 2003. Strategies for Addressing the

Executive Function Impairments of Students Prenatally Exposed to Alcohol and Other Drugs. Communication Disorders Quarterly. 24:4; 194-204.