Journal of Community & Public Health Nursing
Open Access

Executive Functioning Skills refers to the interactions in our brains required to perform tasks and get things done [1-4]. Executive Functions (EF) are central processes that give organization and order to our actions and behaviors [2]. Sometimes these abilities are called mental skills [3]. These cognitive skills include: planning, organizing, prioritizing, remembering things, regulating behavior and using strategies from the past to solve present issues [1,3]. Children who have weak EF may have difficulty: (a) keeping track of time, (b) making plans, (c) multitasking, (d) analyzing ideas, (e) time planning and, (f) learning from past experiences [1,3]. When children have weak EF they will have greater difficulty in analyzing tasks and breaking them down into smaller steps.

Children need EF skills to develop into independent members of their community. EF skills promote positive behavior and allow us to make healthy choices [1,4]. Deficient EF skills can be taught and current EF skills can be improved. While this may require patience and work on the part of parents, schools and health care professionals, the outcome is a better-prepared, more independent young adult.

Children are not born with Executive Functioning skills; they must be learned [4]. Children are, however, born with the ability to acquire EF skills. The manner of developing EF skills is a slow, progressive process, beginning in infancy and continuing to young adulthood. Children build EF skills through activities and social interactions. Over time EF competencies may be practiced and developed.

EF dysfunction may be found in all children. It is also commonly found in persons with the following DD: (a) attention deficit hyperactivity disorder (ADHD), (b) autism spectrum disorder (ASD), (c) fetal alcohol syndrome (FAS), (d) cancer patients on chemotherapeutic agents, (e) learning disabilities (LD) and, (e) mood disorders [1,3]. In children with DD weak EF has greater negative impact on their learning and socialization, than children without DD. Early recognition of EF weakness in all students enables comprehensive school services such as Individual Education Plans (IEPs) or Behavior Intervention Plans (BIPs) to be developed and needed services provided.

Lisa is a 14 year old in 8th grade. She is an average student who likes school and doesn’t mind doing her homework. Unfortunately, she forgets to turn it in, so she is failing several classes.

Leroy, 11 years old, in 6^th grade, never starts projects on time. He will begin working the day before a project is due. He fails to obtain all the needed materials and does not complete the work. While he enjoys the projects, his grades suffer from his poor planning.

Juan, 12 years old, receives instructions from his mother regarding the chores he needs to complete before he goes outside to play. A few minutes after being told what needs to be done, he returns to ask for the information again, as he cannot remember the list of tasks.

Iryna, 9 years old, is late to school almost every day. While she is awakened and prodded to get ready for school, she cannot get out on time. This creates great friction between her and her parents.

Hania, 10 years old has difficulty doing his math homework. Many nights he has difficulty completing the work and often tells his parents that he has finished his work, when in reality he gave up.

Kyeung, 6 years old, has difficulty moving from one activity to another. She has the greatest stress when a planned activity is cancelled or changed. At times she has even experienced mild panic attacks.

Each of the above case presentations demonstrates a child/ adolescent with a weakness in EF. In Table 1, you will see a list of EF skills and examples of weaknesses in each area. Using the scenarios from the case presentations above, you may be able to identify which EF weakness (es) each child may have.

Table 1: Executive functioning skills and examples of weaknesses in these areas [1,2].

By reviewing Table 1 above and the case presentations, the following EF weaknesses can be identified:

Lisa, who forgets to turn in her homework, has difficulty with organizational skills. She will need help in arranging her backpack to place homework in a consistent place when finished, so she can find it when it is time to turn it in.

Leroy needs help with time management where he will need to learn how to get a project completed by a certain due date. He also needs help in the EF skill of planning and prioritizing.

Juan has difficulty with working memory. He needs help learning to perform routine chores and duties without constantly being reminded of the list of tasks.

Iryna likely has a combination of difficulties such as task initiation, moving from one type of activity to another (flexibility) and time management.

Hania, needs help in reaching his goal without developing frustration. This is termed as goal-attainment persistence.

Kyeung has issues with flexibility and will need help adjusting to change.

Assessing EF difficulties

From the above case presentations, each child/adolescent has difficulty meeting their age-appropriate expectations. Teachers, primary care providers and healthcare professionals, should have a basic understanding of what age-appropriate behaviors and expectations include. This will help professionals to assist families with recognizing when their children may need some extra support. Questions families may ask are included in Table 2.

Table 2: Sample questions families may ask providers [1,5].

Teachers, paediatricians and other health care professionals are familiar with growth and development in children [5]. Below you will find a list of what is considered age-appropriate activities for this population (Table 3). While there is some variation in all children, the list below can assist in identifying if your child/adolescent is achieving certain behaviors by the age expected. For children with DD, age appropriate behaviors are based on several factors. However, most children with DD can also benefit from the strategies that will be discussed in this paper.

Table 3: Sample list of age-appropriate behaviors [5].

Development of EF skills

Children have an innate ability to want to learn and master skills to become adults. Children begin to build their EF skills by participating in meaningful social interactions and enjoyable activities [1,4]. Through games, play and school, children begin to work on EF skills and behavior regulation. Adults need to support children while they learn and slowly reduce support so that the child can become more independent.

Several activities have been identified as age-appropriate events, which may enhance the learning of EF skills. While they are not all research-based, many experts have agreed that certain events will allow children to practice and perfect their EF skills [1,4]. Many of these activities parents routinely perform. Listed below, Tables 4a-4c is a sample of undertakings that will enhance the development of EF skills in children/adolescents. For professionals and community members working with children/adolescents, programs for children should include these types of activities. When working with individual families, professionals should encourage these activities for their clients.

Table 4a: Executive functioning skill development for 3-5 year olds.

Table 4b: Executive functioning skill development for 5-7 year olds.

Table 4c: Executive functioning skill development for 7-12 year olds

Families and schools generally engage in many of the above activities. The listed information is helpful in understanding the progression of activities and how to provide more challenging pursuits for participants. Schools can use this information when creating afterschool programming allowing for a variety of recreational events, providing opportunities to focus on different EF skills.

Early recognition of EF dysfunction and timely interventions, improve the child’s/adolescent’s outcomes [6,7]. When families and/or professionals recognize the difficulties students’ experience, comprehensive assessments need to be performed. These assessments will provide the basis for services required.

Scientists, researchers and clinicians do not know exactly what causes EF weakness [3]. Experts postulate that there is a combination of influences that create the environment in which EF dysfunction is likely to occur: (a) genetics, (b) differences in brain function (in the pre-frontal cortex, (c) effects of neurological conditions, (d), mood disorders and, (d) other DD [3]. Specific signs and symptoms of EF dysfunction may vary based on each child’s/adolescents area of weakness and the severity in that area. Table 5 lists symptoms commonly found in persons with EF weakness.

Table 5: Symptoms that may indicate an EF weakness [1,3].

When parents seek professional help in regards to their child’s difficulties it is important to ask them to keep a journal of the child’s issues and monitor academic and social progress. Professionals should ask families to obtain information from the schools and other community programs in which their child is participating (church, sports, clubs, etc.). This information may be used to determine patterns and consistency of behaviors, which, is invaluable for assessing and evaluating a child’s area(s) of need. As children mature, behavioral expectations for completing complex tasks and skills increase. EF weakness may not be as noticeable in younger children, but may become paramount later in childhood/adolescence.

Interventions to improve EF functioning can begin at any age [3]. EF weakness is diagnosed through a comprehensive process (Table 6). Parents/guardians may need encouragement to request a complete evaluation for their child. This can usually be accomplished through the school (ages 4-17) and through early intervention programs (ages 0-3).

Table 6: Process for evaluation EF dysfunction [1].

Research on executive functioning weakness

Kroesbergen et al. [8] investigated the effects of Executive Functioning weakness on mathematical ability. A tool that measured inhibition ability, shifting (flexibility), planning and working memory was used to evaluate EF weaknesses. The weaknesses of the students’ EF skills were compared with their mathematical ability. The sample included 240 Kindergarten children.

The researchers noted that there was a correlation between mathematical scores and EF weaknesses; EF skills were highly related to children’s math competence. Children with weaker EF functioning had poorer math skills. Students with higher math scores had higher EF scores [8]. The authors were also able to determine through other data on the children regarding their intelligence quotients (IQ) scores, that EF skills may be more important than IQ [8].

Cantin et al. [6] investigated the following EF skills: working memory, flexibility and inhibition. They compared these skills to math, reading and theory of mind (social skills) scores. Their sample included 87 students between the ages of 7-10. They concluded that EF skills affect a student’s abilities in math, reading and social skills [6]. The authors recommend screening for EF functions along with traditional instruments early in a student’s academic life. Cantin et al. [6] postulate that EF testing should begin in elementary school, to allow for early intervention and support [6].

A study performed by Romer et al. [7] investigated the effects of working memory, cognitive control and reward processing by assessing risk-taking ability and impulsivity among 387 preadolescents. The participants were between the ages of 10-12 years of age. Adolescents with poorer impulse control and lower EF skills were found to be at higher risk for anti-social behaviors.

The researchers determined through their study that children with impulse tendencies (poor impulse control) related to low EF skills should be provided with early interventions [7]. According to the investigators, early involvement with these selected preadolescents may be reducing the development of high-risk behaviors, which, may occur later in adolescence (smoking, alcohol) [7]. Dekker et al. [9] conducted a retrospective quantitative research study examining the relationship among math difficulties, EF weakness and intelligence

quotients (IQ), in students with mild to borderline intellectual disabilities. Participants included 120 children who met the Dutch criteria for placement in schools for special education and had an IQ below 85. The students chosen were in fifth and sixth grade (ages 10-13) and their IQ ranged from 53-84. Parents self-selected to have their child participate in the study. 63 of the 120 students who entered the project had all the available data required for the investigation. Standardized Dutch mathematics tests were used to assess mathematical ability.

Intelligence scores were measured by the Dutch version of the Wechsler Intelligence Scale for Children-3rd Edition, in 89% of the students; the remaining 11% had IQ measured by other acceptable standardized tests. The investigators defined Mild Intellectual Disability (MID) as having an IQ between 50 and 70; Borderline Intellectual Disability (BID) as an IQ between 70 and 85 [9]. Executive Functioning was measured by the teachers, using their version of the BRIEF-T rating scale [9,10]. Specific areas of EF reviewed for this study included: (a) inhibition (ability to stay seated in class), (b) shifting (flexibility) and (c) working memory.

Quantitative statistical analyses were used to evaluate the data. Results from the EF problems scales (evaluating shifting, working memory, inhibition) determined that all three named scales were interrelated. Children with MID and BID demonstrated difficulties in all three areas; students with MID had more problems with shifting than did the students with BID. No significant score differences noted with student gender. IQ was highly related to math scores and the Shift EF scale. Children with higher IQ levels had better math scores and less difficulty with shifting [9]. Higher math scores were also correlated with higher Working Memory and Shift scales.

Through the examination of the data it was noted that children with less problems with working memory, flexibility and higher IQ scores had better math skills. Those with inhibitory problems did not do as well on the math tests. According to the investigators EF problems and IQ are independent of each other. However, mathematical abilities are dependent on both EF skills and IQ [9].

EF weakness in adults and children

Several commercially available books address EF issues and offer assessment tools to identify EF weaknesses. These tools may be helpful. However, they are not considered diagnostic. The most commonly used diagnostic tool is the Behavior Rating Inventory of Executive Function (BRIEF), a tool that is considered both valid and reliable [10]. Other assessment tools may be available through professional practices, or the school.

Professionals may recognize that many adults/parents have EF weaknesses, too [2]. Parents must be made to feel comfortable to discuss that they may have weaknesses in certain EF areas. Teachers and health care providers can offer support in that many of the strategies that will be discussed are helpful for adults in addition to their children. Parents may also be able to participate in Cognitive Behavioral Therapy (CBT) or use self-help books to assist them to improve their EF [2].

When both parents and children have EF weaknesses, there are several issues that can arise: (a) if a parent is strong in one EF area and the child is weak in that same area; parents may have a hard time understanding their child’s difficulty. Parent’s, however, are in an excellent position to help their child with those EF weaknesses, (b) when children and parents have different areas of strengths and weaknesses, they can learn to support/assist each other, (c) when parents and children have the same EF weaknesses they can have empathy for each other [2]. Families can try to find humor in shared weaknesses and then brainstorm with each other on how to improve them. Professionals should be familiar with community resources that can provide support for adults, in addition to the schools, which, are positioned to help the children/adolescents/students.

Strategies to assist children/adolescents to develop/enhance EF skills

Several different strategies can be used to improve the EF functions in both adults and children. Most professionals are instrumental in helping families with many of the less complex strategies. Experts will need to be consulted for more multifaceted strategies and for children who may have several EF weaknesses and cognitive impairments. Table 7 lists general recommendations for both adults and children who have EF dysfunction.

Table 7: General strategies to assist child(ren) with EF dysfunction [1].

For many students the above may be enough for them to internalize routines and expectations. Other students may require more explicit instructions. If more support is required, families can incorporate checklists, Action Plans and evaluation tools. The goal of these tools is to aid the student to internalize routines and processes that are taught through external methods.

Specific principles to keep in mind when developing more complex plans include: (a) consider the student’s developmental level, (b) create routines and schedules, (c) break down complex skills into smaller tasks, (d) use incentives, (e) provide enough support so the student is successful, (f) keep supports in place until student has mastered the skill, (g) do not allow student to become frustrated, (h) decrease support gradually, (i) help student to decrease stress, anxiety and anger and, (j) have student participate in the process as much as possible; use negotiation [1,2]. In Table 8, review the EF skills and examples of EF weaknesses. In the column furthest on the right, note specific strategies that are listed for different types of EF dysfunction.

Table 8: EF skills and examples of strategies to improve their function [1,2].

Use of checklists, instructions and other basic strategies.

One of the least complex tools to help children/adolescents enhance EF is the use of checklists. They can be written simply with few instructions (and/or pictures) for young children or complex for older children/adolescents. Please see below checklist as a sample. You can add or subtract as needed. For younger children, it is recommended that the checklist be in simple words (and pictures), with few activities on the list (Table 9).

Table 9: Checklist-activities for young children.

This next checklist carries with it instructions for parents to help their child/teen organize their backpack. Lisa, in middle school, has difficulty with organizational skills and will need support in managing this task. Organizing and reviewing Lisa’s backpack on a regular schedule, will enable her to easily find her homework, complete it and locate the paper when it needs to be handed in to her teacher. An additional suggestion is to ask if Lisa can scan her homework when completed at home, email it to her teacher and submit a hard copy the next day (Tables 10 and 11).

Table 10: Instructions for helping your child organize his/her backpack.

Table 11: Checklist for backpacks.

Children/adolescents with time management issues, along with planning and learning to prioritize, such as Leroy, a checklist is helpful. A checklist will provide the learning on how to plan for projects. Work with your child/student to plan the steps required for the projects (Table 12).

Table 12: Sample assignment/project checklist [11].

Many children/adolescents need help in learning how to study, especially in preparation for exams. In elementary schools, most of the information is taught in class and reinforced through homework. Older children may need to research or study new information on their own. A checklist may be helpful for those students who have difficulty in organizing study time for tests, or just need to “see” the steps required. The following checklist, Table 13 may be helpful.

Table 13: Study habits/test taking skills checklist [11].

Checklists can be very helpful in breaking down complicated processes into smaller steps. Encourage families to choose only one or two areas of concern at a time, so that students do not get tired or begin to ignore the checklists. Once the student has internalized a process you can discontinue the checklist. Have families/teachers reward their child/ student for sticking to the checklist and working towards improving their skills. After a short break, families can introduce another list.

Action plans

A more complex type of checklist is the Action Plan (AP) [12]. The AP is viewed more like a contract. It is most helpful when creating an Action Plan that the child/student is engaged in the process. For this type of behavior modification, we are going to look first at some helpful hints on how to develop this contract. These guidelines (Table 14) will help to develop this tool.

Table 14: Guidelines for developing an action plan [12].

An Action Plan (AP) has several sections: (a) title of plan, or behavior in need of modification, (b) goal of AP, or desired endpoint, (c) objectives, steps to meet the goal, (d) rewards, benefits of reaching goal, (e) consequences, what happens if goal is not met and, (f) other, any additional information or resources needed to complete the AP. For adolescents like Juan, who has issues with working memory, an AP with his list of chores may be helpful. He can be more independent in completing his weekly tasks and the frustration that may develop between himself and his parent/guardian will likely be reduced, as repeated instructions are no longer required. APs and checklists should be placed in a consistent area, so that they are easily found. Below is a sample of a blank Action Plan followed by a completed sample (Tables 15 and 16).

Table 15: Suggested format for action plan [12].

Table 16: Example of completed action plan/weekly chores for adolescent [12].

Below is another sample of an Action Plan. If we think back to Iryna, the 9 year old child who has difficulty getting ready for school in the morning (task initiation, time management and flexibility), we can design an Action Plan to assist her with what is expected. This will help reduce the morning friction between her and her mother/father/ guardian. It will also outline rewards/consequences for the behaviors. Please note how specific the plan is with time schedules. For children who cannot yet tell time, adjustments will need to be made. Use of alarms and digital clocks may help children who cannot yet tell time (Table 17).

Table 17: Action plan for morning routine [12].

The last example of an AP will address the issue of goal-directed persistence. Hania, who has difficulty with his math homework can use some support to manage the stress and frustration that accompanies his difficulty in maintaining his attention to complete his work (Table 18).

Table 18: Example of AP for goal-directed persistence in completing math homework [12].

Successful APs and checklists should be reviewed at regular time intervals. To start with, once a week might be helpful. As behaviors improve, checking can be done less frequently. There is no specified amount of time that improvement will occur. Some students may progress slowly and only accomplish a few steps in their plans. The goal is learning, so any amount of learning is a success. Children/Adolescents needed to be rewarded for even small steps gained in their plans.

Professionals need to keep in mind that there may be differences in beliefs between them and the families they work with, especially when it comes to rewards and consequences [1]. Professionals must adapt their plans to what works for the families (except if family decision is harmful). While professionals may introduce preferred options for implementing plans, allowing families to maintain their beliefs will ensure greater adherence to the use of plans, enhancing greater success for the child/adolescent.

For some families, keeping track of behavior improvement is helpful and modifications, if needed, can be implemented. In addition, as one behavior improves, another checklist/AP can be designed. It is recommended that no more than two behavior contracts exist at one time. Below is a sample of a progress chart that may be used to show a child/adolescent how they are improving over time (Table 19).

Table 19: Progress chart [12].

There are many different types of progress charts and means to monitor a child’s progress. The above sample is one type of chart. Depending on the age of the learner, a parent/guardian or teacher can develop charts with stickers, points, or any other system in which the adult and child/adolescent can create together.

Once a student/child/adolescent is used to the above formats, another way to increase their independence is to create a calendar of daily or weekly activities with their family Designing a schedule enables the learner to envision what his/her day is about and plan accordingly. Once a timetable is planned look/discuss ways to help children/ adolescents become empowered and take control of their own schedule. Allowing a child/adolescent to view their day can empower them to take control of what supplies are needed and what time they need to be prepared for the activity. If health care appointments are added, the child/adolescent will know how their free time will be effected.

Written schedules will reduce the questions, such as, “What do I do now?” As the child/adolescent matures s/he will be able to predict what needs to be done during an activity or in preparation of an activity. Based on the child’s/adolescents cognitive ability, they can eventually begin to create their own schedule, based on their interests and needs (Table 20).

Table 20: Daily schedule/ time management (week or a day; modified by age and cognitive level) [12].

Self-management tools/good day plans

The Good Day Plan (GDP) [13] allows children/adolescents to determine how they can have a good day and then take responsibility for achieving that goal. Created by a state directed project in Virginia, it was funded from their Department of Education (2016). The GDP strategy has been used successfully with children as young as six years old. It has been used in children/adolescents both with and without disabilities. Children with severe disabilities may need some assistance. Adding pictures to the plan may be of help for that population (Table 21).

Table 21: My good day plan (GDP) [13].

By assisting our children to learn self-management, we encourage the natural ability of our kids to want to become competent with the skills required to become independent adults. Some basic strategies to encourage self-management in our kids are to encourage the following:

1. Self-monitoring—by recording whether a behavior occurred or not.

2. Goal setting—can be used in conjunction with an Action Plan.

3. Self-evaluation—Determine actual performance with planned.

4. Self-instruction [13].

As with all strategies that we discussed, adults need to support their kids in beginning new skills. As the children/teen’s confidence and skill progress, the parent(s)/guardian should fade out the support. Do not remove support abruptly; make sure your child is ready for the decreased assistance.

Use of technological devices

One last strategy is the use of technological devices. They may be very helpful in getting your adolescent more organized (unless of course, s/ he loses the device). They can be helpful for organizational skills (use of calendars and reminders), setting of alarms and of course, the occasional text from a parent/teacher. In some states Medicaid will pay for devices. If the child’s/adolescent are IEP states a need for a device the school system should cover the cost. For a child/adolescent who may lose their device they can take pictures of assignments, email themselves the information and leave the device at the school. Technological devices help students to organize their work and the ability to take pictures decreases the stress of writing assignments in a planner.

Executive Functioning Skills refers to the interactions in our brains required to perform tasks and get things done. EF’s are central processes that assist us with organization and bring order to our actions and behaviors. These cognitive skills are required to help us achieve academic and social success and become independent members of our community. Children are not born with EF skills; they must be learned. The process of learning EF skills is slow and arduous, some children/adolescents having more difficulty in some areas than others. EF weakness commonly is found in children with DD and this may increase their learning difficulties.

Community professionals are in an optimum position when working with families to discuss EF issues. They can guide families in learning how to assist their children in improving their EF skills and/or refer them to appropriate resources. Strategies described in this paper can assist families to learn how to improve EF skills in children/adolescents and adults. Early recognition of EF weakness and commencement of plans as described in this paper, may improve academic and social success for the student.