Understanding Executive Function Concerns in Tourette Syndrome and Related Disorders

Research has shown that low executive functioning skills hamper school performance of children and teens with Tourette Syndrome and related disorders. In this webinar, we will discuss the assessment process and treatment strategies for youth that struggle with executive function. Training methods, including computer-based games, have shown some, but limited potential for impacting day-to-day behaviors at home and at school.  In contrast, treatments in the form of training in organization, time management, and planning and motivational enhancement have demonstrated significant changes.  This presentation and discussion will discuss these treatment methods and their promise in working with children and teens with TS. 

Dr. Richard Gallagher, Ph.D, Specializes in Child & Adolescent Psychology, Child & Adolescent Psychiatry, Pediatric Neuropsychology at NYU Langone.

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0:05 Good evening, and welcome, and thank you so much for joining us tonight for the webinar, Understanding Executive Function Concerns and Tourette Syndrome and Related Disorders, presented by doctor Richard Gallagher. 0:20 My name is Katie Delaney and I am the Family and Medical Outreach co-ordinator at the New Jersey Center for Tourette Syndrome. I will be your facilitator for this evening. 0:31 Yeah. 0:35 Before I introduce doctor Gallagher, here are the housekeeping notes, all participants are muted. If you have a question, please type it in the bottom of your question box and click Send. 0:48 If you have questions after tonight’s session, you can post your questions on the Wednesday webinar blog, which is accessed from our homepage at WWW dot M J C T S dot org. Under the heading programs, the blog will be monitored for the next seven days. 1:07 Far, the next. So, sorry. The New Jersey … Syndrome and Associated Disorders, its directors and employees, assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. We do not endorse any recommendation or opinion made, by any member or a physician. Nor do we advocate any treatment. 1:36 You are responsible for your own medical decisions. 1:40 Now it is my pleasure to introduce our speaker for this evening. Doctor Richard Gallagher. 1:46 Doctor Gallagher is a clinical psychologist, and neuropsychologist that has been practicing for over 40 years. 1:56 He is the director of special projects at the Institute for attention deficit hyperactivity and behavior disorders at the Child Study Center of Hassenfeld, Children’s Hospital, at new, NYU land gown. Doctor Gallagher also supervises the graduate student experience at the NYU Land Child Study Center and hackensack New Jersey where they serve youth and families living with Tourette syndrome. We’re so happy to have you here tonight. Doctor Gallagher, the floor is yours. 2:32 Thank you. 2:33 And thank you, everyone, for having me this evening. 2:36 I’m looking forward to being able to go over information. 2:40 The topic tonight is executive function and some issues around organizational skills, challenges, and their treatment. 2:48 And my focus is often, I’m working with kids and adolescence and young adults. So much of the work that we’re talking about tonight will be emphasizing issues with regard to school and some of the challenges that persons with Tourette’s have at school and helmet. 3:05 This impact be affected by executive function issues. 3:09 So just to disclose some conflicts of interest, there are some conflicts that we get with regard to royalties, four instruments that we use for measuring organizational skills, and for books that we’ve presented. 3:24 And in addition, currently, I’m involved with grants from the National Institute of Mental Health, and also the National of the Institute for Educational Sciences of the US. Department of Education. 3:37 The agenda is that we’re going to talk briefly about the clinical features of tic disorders. 3:42 And that we wanted to then understand and address related attention and academic challenges through some aspects of organizational skills training. 3:51 And I’ll talk about executive functioning in general, but why some of the general notions of dealing with executive functions and treatment should be thought about very carefully. 4:04 So just again, for everybody to be really very clear, Tourette’s Disorder is a neurological disorder. 4:10 It is characterized by repetitive stereotyped, involuntary movements and vocalizations that have been referred to as tics. 4:18 The average onset is between ages 4 and 6. 4:23 As is true for many childhood conditions that involve the nervous system in the central nervous system, More males were affected than females. 4:33 Um, and that is true for learning disabilities. 4:35 That’s true for attention deficit hyperactivity disorder, and it’s true for other conditions, as well. 4:41 The severity is ranging from mild to moderate ticks. 4:44 Um, and they’re much more common. 4:47 And recently, Katie informed me that a recent study from the Centers for Disease Control of the United States indicates that one in fifty school aged kids, so about 2% of kids in the United States have Tourette’s Disorder or another tic disorder. 5:04 So it’s not it’s not uncommon. It does affect a good number of people. 5:11 The courses that they come and go over time they vary in type frequency location. 5:17 And there’s a kind of a fractal quality. 5:21 So in other words, it happens in bursts that may last for seconds, weeks or minutes. 5:28 Um, the pattern has been that the symptoms usually are emerging in the head and neck area and then may progress downward to the muscles of the trunk and the extremities. 5:40 Motor ticks are usually first with vocal, tics, and present. 5:47 With Simple Takes, also, presenting, before, there’s complex tics, the peak severities between the mid teen years with the improvement for the majority of people in their late teen years and early adulthood. 6:00 And unfortunately, about 10 to 15% have progressive or disabling course that last into adulthood. 6:08 And these are the Diagnostic and Statistical Manual criteria. 6:12 The very specific that are used to be able to say that someone has Tourette’s Disorder. 6:18 And this is a situation where there’s multiple motor and one or more vocal tics that are present for awhile. 6:27 The other conditions that provides some examples of ticks with regard to simple motor ticks, involve eye blinking, some eye movements, nose movements, moving down to abdominal tenzing. 6:42 Sometimes leg, or foot, or tome Ids. 6:45 Complex tics involved, eye movements that go along with mouth movements and facial movements and changes in expression, or hand gestures and movements with shoulder movements and arm movements together. 6:57 And sometimes there’s tik related compulsive behaviors. 7:01 It’s kind of touching things and tapping things and engaging in some grooming exercises or engaging evening up, sometimes even up close. Like me. 7:10 Like the sleeves and making sure that they’re even, um, there’s sometimes obscene gestures, but those are really relatively rare. 7:20 Simple vocal tics involve, some sounds, clearing of the throat, some sniffing, and then, sometimes coughing. 7:30 And complex phonic symptoms include people that say different syllables and words. 7:38 In some cases, I’ve seen words, but again, not necessarily. So frequent. 7:44 And this information is all supplied to me, by my colleagues here at the Center for Excellence. That has been established here at NYU for the treatment of two tic disorders. 7:57 There’s a lot of kids and persons that have overlapping concerns. 8:01 About 63% of persons do have issues with regard to attention and behavior control that are manifest and described as attention deficit hyperactivity disorder. 8:14 Learning disabilities are also present for a good number of persons, so that completing schoolwork effectively can be a challenge. 8:23 Obsessive compulsive disorder is present in about 30% of persons and obsessive compulsive symptoms that are not necessarily the disorder are also present in a fair number of persons. 8:36 Anxiety is present and depression is present so it’s, um, a condition that does have a lot of neurodevelopmental neurones, like neurological aspects that go along with this condition. 8:51 Um, the impact on dirt on learning is what we’re going to be focusing on tonight and understanding things with regard to challenges in the school setting. And this is true in the school setting throughout the age range. 9:06 Sometimes, these are more of an issue when it’s first noted that a person has this condition. 9:15 And in many cases, schools are adapting and working on things relatively well. 9:21 But there still is a lot of challenges for somebody that is in the school situation that does have different tics and that are repetitive. 9:31 There can be difficulty completing homework, sometimes because of attention issues, but also sometimes just because of the interference of ticks themselves. 9:41 There’s an aspect of disorganization that is present with, again, a fair number of people that have attention issues with them not being able to keep track of materials. We’ll talk about that so carefully. 9:52 His handwriting issues, and that can be perfectionism in terms of social skills difficulties, There can be a really negative treatment that is brought on by other kids in the form of bullying. 10:06 And sometimes, there’s stress and anxiety in reaction to a lot of these different patterns, of both, with having the condition, and having other people notice it. And being a little bit self concerned about that, but also because of some of the possible negative reactions that people have. 10:26 Other challenges can include executive function difficulties that do play a part, oftentimes, in carrying out tasks and play themselves out, with regard to difficulty completing homework and disorganization, and handwriting issues. 10:41 And then there’s in some cases, there’s an overlap with autism spectrum disorders where people are sometimes concerned about doing it, engaging in behaviors in a certain fashion. 10:52 That is present. Mood, and anxiety disorders can be present with regard to disorders. 10:58 And we can have some learning disabilities and obsessions and compulsions, and then ADHD, as we’ve talked about, Then there can be sleep problems, where sometimes the presence of ticks can interfere. But also, in general, most persons with tic disorders in Tourette’s do not have these problems being presented during the time of sleep. 11:23 one of the really interesting kinds of mysteries of this disorder there is being explored. 11:30 In terms of the actual educational setting, many children with ticks are in special education settings and getting supports for addressing some of these different issues. 11:40 What we do want to point out, though, is that in general, Tourette’s Disorder is not associated with differences in general intellectual functioning. 11:49 So persons with Tourette’s are similar to all other persons. There’s a range of intellectual functioning in the in the group. 11:56 And persons are often quite talented and intellectually affected. 12:03 There is this pattern where persons with two Tourette’s disorder more likely to have a specific learning disability? 12:09 Especially if ADHD is part of the picture. 12:13 And finally, a recent literature review does find that impairments in attention memory, and other executive functions in individuals are present. 12:22 And so we’ll quickly kinda talk about that. 12:25 These are some of the things I just summarized. 12:29 We want to understand, what’s the nature of the executive functioning challenges in persons with Tourette’s Disorder? 12:35 And, also, just in general, what is meant by the executive functions, um, the professionals and the experts and researchers don’t have a clear, cut definition that everybody agrees what the executive functions are. 12:54 But broadly, we can talk about them as being the behaviors of the brain that help us go ahead and organize our actions to meet a goal, and they do involve a number of different elements. 13:11 So, one element of executive functioning is being able to control and manage attention. 13:19 Taking attention, and having the brain in a kind of, quiet, unconscious way, focus on the elements of the environment that are important. 13:29 You know, focusing on something that you need to look at if you’re reading. 13:33 And having the attention that says, Yes, it is important for me to pay attention to reading right now. And the brain kind of like talking to itself, saying, take your attention, and make sure it’s focused on reading. 13:44 Or, if you’re driving, take your attention and focus on driving and looking at the road ahead of you. 13:51 The executive functions are also involved with the brain, kind of saying to you, and other parts of the brain, this behavior and this pattern of behavior, is what you should use for getting to what you want to do. 14:04 In the executive functions, you’re involved with simple tasks. 14:08 If I were interested at the end of the day in getting to the door and walking out the door, the executive functions are involved with saying to my brain, no. 14:18 Let’s work on putting together this sequence of actions of standing up, turning toward the door, turning the door handle, walking out the door, and closing the door, and then going to my next destination. 14:30 The executive functions, the process of, like, telling my behaviors in my brain to kind of put together that sequence. 14:37 The executive functions help us use our memory to say, well, as I’m getting ready to do something with mathematics, Roes, I’m getting ready to make a cake. 14:47 I do need to remember that there’s different actions that are required for doing this. There’s actions that I’m remembering a sequence of actions. If I’ve made a cake before, It helps me remember that. Oh, yes! I need to mix to dry and wet ingredients together, and then you do it in a specific order. So I’m turning to my memory as, I’m going through things, and the executive functions help us with that. 15:13 And it helps us determine what memories to bring into place. 15:16 If I’m baking a cake, I may not be involved with the process much of thinking, well, how do I solve a long division problem? 15:23 My, my executive functions are kind of tell my brain, don’t pay attention to that memory. Let’s pay attention to this other memory that’s really appropriate for this task. 15:32 And so the executive functions kind of like are the general that’s in the brain. And there’s a collection of these different activities that this brain does. 15:43 In with regard to things that do affect executive functions, we do know that persons that have issues with attention control and behavior control. 15:53 That, again, gets to be described as attention deficit hyperactivity disorder. 15:57 We do find, again, with the information I laid earlier that depending upon the study, the between eight and 90% of children with Tourette’s disorder do have attention deficit hyperactivity disorder. 16:12 And when these two conditions are present together, there is more difficulty and more challenge in getting, um, proof academic performance together. 16:23 And much more so than if a person just has Tourette’s disorder by itself, It is found, unfortunately, as well, that persons that have both conditions. 16:35 These are persons that are more likely to have the symptoms continue into adulthood moreso than persons with Tourette’s disorder alone or tourettes with out. 16:46 With other disorders, but not attention deficit hyperactivity disorder. 16:50 And what we are concerned with with regard to helping persons function effectively is we want to be able to pay attention well for thinking about what can be done to help improve the use of these executive functions. 17:03 What can be done, in addition to basic maturity, certainly, people going from childhood into into adolescence, into adulthood, do improve their executive functioning experience? He helps us with that. 17:17 And there has been, it’s been found that sometimes you can use strategies for being able to say, let’s, let’s understand the executive function plates. 17:25 Let’s give some psycho education about this to know, that these may be behaviors, that you may need to be more tuned into. 17:34 You may need to be aware and alert that you could have some difficulties with these behaviors, and we think that awareness of this is the first step. 17:46 Um, the use of different kinds of school accommodations or IEP plans, for helping kids with executive function difficulties are often put into place. 17:56 That may mean, you know, some of the support teachers being involved with reminding a child to pack up his or her backpack effectively so that they do not forget items. 18:09 And so if they don’t get home without the needed materials for completing homework, or they may be informed that, let’s see. 18:17 And let’s help you think about how much time you’re going to spend on completing your math homework. 18:24 And how to be able to use your time effectively, and when you get home. 18:30 It can be helpful for a discussion. 18:33 For a person, a student with Tourette syndrome, too, be involved with thing, development of the Tick Management Strategies at School. 18:42 And that, again, is a kind of exercising of their plans That allows them to also again improve and get some practice using their executive functions. 18:52 In general, it’s also helpful for kids to have a safe space, are releasing tix, that may sometimes reduce anxiety and stress. 19:01 Preferential seating can be helpful to provide assistance with regard to attention control. 19:08 And then sometimes multi-sensory teaching methods help get information through to a person where there’s information that’s presented both orally by talking sometimes with visual supports, and then sometimes using manipulatives to help with the memory and getting things into the memory. 19:29 Um, and then, again, because of executive function, drifting and ineffectiveness, sometimes allowing extra time to complete tests and assignments, is, is often useful, as well as allowing testing to place, take place in a separate or quieter setting. 19:50 Now, another thing that seems to be helpful altogether that can be considered is to allow some attention breaks during class. 19:57 Allowing kids to kind of get themselves back together. 20:00 Um, breaking tasks down into smaller components and helping kids learn that there’s one step to do and another step to do and another step to do. 20:11 Reducing distraction in the classroom is helpful. 20:13 Then there can be things that help attention grab. 20:18 Then there’s finally, there’s reminders that are helpful where another person, as a child learns to be able to get more effective, is providing some help with these memory reminders of what it is that you’re supposed to do at certain times of the day. 20:35 These other ideas are present with regard to one-on-one instruction time, asking for questions and opinions who maintain engagement. 20:45 Having a more structure in the environment is present, and then also having some to-do lists is useful. 20:51 And altogether, giving, written, copies of the kids who are posting directions on the board does allow kids to overcome any kind of problem with their memory for information that’s been presented about how to complete tasks. 21:05 These are things we will talk about in greater detail because we want to understand as well, some of the things that we’ve done. 21:12 Experimentally, We have having kids develop and learn to use a planner, and a calendar is really helpful. 21:22 And there can be teachers helping kids by saying that there’s a table captain or a row captain, to make sure that kids are writing down their homework assignments, and then submitting them. 21:35 If kids have a cell phone, and they’re allowed to do that, taking a picture of a posted assignments helps, again, not necessarily relying upon only their memory. 21:44 And if parents and kids together are informed about missing assignments disallows the lapses in memory from having less of a negative effect. 21:57 If kids are getting ready for transition warnings, that helps them develop their plan for what to do and how to be like, no, stop doing something and get about the next things. 22:07 And altogether, we wanted to work on fighting long term projects into segments, with separate due dates, and, again, notifying parents to be able to be familiar with not just the student being familiar. 22:19 Now, we want to understand. 22:21 And we’re going to talk about more things very practically, with regard to things that we have, worked on understanding. And we’ll get to the specifics of that. 22:29 But there’s been some investigation wondering, can different things be done through game playing primarily to train executive functions? 22:40 Can people become more effective at controlling their behaviors by engaging in different kinds of activities that improve attention? I mean, many of these things are game based activities. 22:53 Um, some efforts to be able to teach kids to get involved with slowing down their actions when they’re making decisions, I’m doing things such as, we are working on, helping you look at a picture that we’re gonna give you an exercise where you’re looking at a picture. That’s it. 23:10 A relatively complicated picture. 23:13 And below here, below the picture that you see are four choices of pictures that are very similar, but only one of them is exactly the same. 23:24 We want you to slow down in practice, looking at all your choices before you make a decision. 23:31 Um, there’s some work that I’ve done with kids also to say, I’m going to ask you to be doing something and getting involved with reading, for example. But before you start to read something, I’m going to tell you the two words. 23:49 I’m going to tell you a color, and an animal. 23:52 And then I’m going to ask you to read, And then in the middle of reading, I’m going to ask you then, tell me what is the color and the animal, they said. 23:59 So I might see a red tiger, have the child read, and then say, now, remember, let’s go back, and what did I tell you to remember? And this is practice of using working memory. 24:10 This work has been found to be helpful with kids improving their reading. 24:14 It doesn’t result in improving mathematics. 24:17 And it does seem to have help for kids that don’t have had a lot of experience at their homes or in their preschools before they get to school. 24:28 However, these things don’t seem to have a big benefit for kids that are having really significant difficulties. 24:36 And what we have been finding, however, is also that some of the games that have been talked about some commercially available games like Cog med, like a new thing called The Endeavor R X. 24:49 Or there is a game that was approved by the FDA for being safe and effective in some fashions is found to help the kids get better at similar kinds of games. But unfortunately, it doesn’t result in the kids getting better in their school setting. 25:04 With regard to attention and executive functioning, it hasn’t been found to be improving improvements in academics. 25:12 So this is the information that we knew when we started doing some work with helping kids with attention deficit hyperactivity disorder improve their organizational skills. And I’m going to be using some insights from that work into some discussion. 25:27 There are evidence based treatments for children’s teens and young adults with executive function difficulties. 25:34 These different treatments involve work with parents, and in some cases, for young kids, also their teachers. 25:41 In general, they target school and home functioning, and they do involve some psycho education and behavior management training for parents and teachers. 25:50 And in our case we’re where we did work with elementary school age kids. 25:55 We did some skills training modules. 25:57 It includes the development tools and routines for tracking assignments, manager Materials’, Time management and planning, and I’m going to talk a little bit about some of the insights that we learned. 26:07 This is a, this is a book that we have for therapists that describes this program, um, and there’s a rationale, a need for this for persons with this. 26:18 So children with components of ADHD including kids with Tourette’s often integrate evidence, really significant difficulties with organization. 26:25 And this is found in elementary school, in middle school, in high school, and oftentimes even in college. 26:32 And some adults report some of these same issues, as well, in their work setting and otherwise. 26:38 Um, there’s some problems in planning and completing assignments. 26:43 Coming up with the ideas about what steps to take, that allow us to complete assignments, such as a book report, such as studying for a science test, such as simply completing some math homework. 26:57 There’s often issues with regard to managing materials for schools and activities. 27:01 And then there’s often problems with remembering tasks and materials. 27:05 Um, and finally, then completing a scheduled to complete task is an issue. 27:10 And keeping track of time is also an issue in all of these things. 27:13 Negatively impact academic performance, and too often create a lot of parent child conflict, particularly around homework. 27:22 And these are some of the issues that, when we thought about it, we said, let’s work on organizational skills training instead of general executive function training, to see what we can do about improving these things. 27:35 If a kid who does have poor attention control. 27:39 The child may fail to pay attention to teacher prompts to write down homework, or to see items on the desktop that need to go into the backpack so that the child doesn’t have information. 27:50 Others needed about what’s the details of math homework, and then also may miss, remember to put the math workbook into the into the backpack. 28:00 If there’s some issues with poor behavior control, there’s often a preference for engaging and fast actions and avoiding activities that involve slowing down, such such as the need to write down information. 28:15 And to store and place things carefully. 28:19 If there is some issues with weak working memory, that’s spatial working memory, persons may not remember where they left the items. They don’t have a picture of where they put something, and so they end up forgetting about it. 28:31 And what’s been found with persons with attention issues is that there’s a lot of patterns of time blindness that is present throughout the age range. 28:41 And people feel to keep track of the passage of time, and they fail to often learn how long it takes to complete tasks. 28:49 And so we sometimes find that the kids are saying, even for complicated tasks, then everything is supposed to take about five minutes. 28:56 Know, if that’s from doing a math homework, but also from completing an entire book report, might take about five minutes and don’t necessarily set aside enough time to do things. 29:07 So we said for ourselves, why not go directly to the behaviors of concern? Why not go to directly teaching these organizational skills? 29:17 And we found that, again, as I said, that kids often misplace or lose materials is a kind of careless approach to storing materials. 29:26 There’s forgetting when assignments are due, when Tedsters scheduled. 29:30 There is often a failure to bring home materials of her homework, or turn in completing homework, even with parents saying, I saw my child, do the homework. 29:40 I saw my child, put the homework into a folder. 29:43 I saw my child put the folder into the backpack, I saw my child, zip up, the backpack, and take it to school, and still, you know, being confused by saying the teacher said it didn’t get turned in. 29:55 I don’t understand. 29:58 There’s issues with poor time management, time estimation and planning. 30:02 Good often results in poor follow through, on long term projects, um, little consideration for what to do with other demands, such as how to balance doing schoolwork when there’s basketball practice or soccer practice on the same night, and how to be able to fit everything in in terms of getting ready in the morning on time. 30:24 And what we’ve learned is that, in our work, children, teenagers, and other people in other groups have founding adults, very, in their development of these organizational skills, Some people are able to pick up skills by watching others, and basically, listening to it. To advice. 30:40 The persons that we’ve worked with, I’ve had difficulty developing organizational skills routines, and some people learn by some verbal instruction or demonstration. 30:50 We’ve also found that a good number of persons really require some systematic instruction with reinforced practice. 30:59 And we found that the organizational skills than these reflections of executive functions are more likely to be present in boys. 31:07 More likely to be involved with students that are getting special education help, we have learning challenges, and clearly more present in children with attention and behavior control difficulties. 31:18 We’re in the midst of managing to see about collecting some information on persons with Tourette’s, And we do believe that persons with Tourette’s may find that they have there may be more organizational skills issues with that group, as well. 31:33 And as I said before, these are the areas of concern there is, in measuring this, and looking at this, across elementary and middle school kids that lapses in memory and materials management are very one of the common problems. 31:47 There are problems with task planning, or is also a common problem. 31:52 Then, inconsistent use of organizational schools or special actions, or organizing, are also likely to be present. 31:59 And we have this kinda little situation with some parents saying, and kids say, oh, no, my, what is due when, and where is it, know, they, they’re not clear exactly what it is, They don’t know exactly when and where is it. And there’s a kind of like a panic that’s associated with this. 32:16 There can be some difficulties and I had trouble finding an actual picture and drawing of a backpack, but backpacks are often very disorganized and very, you know, messy, you know. 32:28 And that’s, that’s an issue that does result in the kids having trouble finding things, when going to actually also digital files and digital storage of materials. 32:40 Oftentimes, the persons with these difficulties have really disorganize files in their computer, and have a lot of time searching for those as well. 32:50 And we have, also, there’s a kind of notion that at times it says, relax, I have plenty of time. 32:56 Then, person don’t get started with enough time and say: oh no, I can’t get this done. What happened to all of that time? Because sometimes there’s a kind of fading of attention and daydreaming that results in prisons really losing track of time. 33:11 And in the case of what might happen to a teenager or a kid, this might be multiple ways in which some of these executive function and organizational skills deficits might play out. 33:22 A teacher says to Pat Parrish, Pat, where’s your math homework! It was due today. 33:27 Patt may say, I did the homework, but I forgot to bring it to school. 33:31 It’s been done, and unfortunately, the, it’s not turned in. 33:35 And by the time kids are in middle school, in high school, they often don’t get credit if that’s the situation even after they’ve done it. 33:42 Pat says, I know I’ll put it somewhere in my backpack, but I can’t find in high school and middle school. I know I put it somewhere in my locker, but I can’t find it and you can often see these locker’s being quite messy. 33:56 Pat’s confused. I thought this math assignment was due next Wednesday. 33:59 Didn’t have it written down accurately. 34:01 Um, and so that’s another one. 34:04 Again, or Pat says, I forgot to write the assignment in my planner, and never did it. 34:08 Didn’t have any kind of reminder that it’s present. 34:10 Or, I started to do it last night, but I ran out of time and didn’t finish it. 34:15 All these different varied ways of not being able to get the homework turned in. 34:20 And having these number of different ways of getting some problems with organization. 34:27 In our test of this, we did this with children with attention deficit disorders. 34:33 And we have been testing it and other versions. With kids are not necessarily always meeting all the, the conditions of attention deficit hyperactivity disorder. 34:43 We did test it with a 20 session program that was based in our clinic. 34:47 And we did presented twice a week for lots of practice. 34:51 Teachers were involved to get involved with reminding the kids to use the skills. 34:56 And we did test two versions. 34:59 But with organizational skills training, we aimed to have the kids get comfortable expecting the impact and attention of behavior control, can have an academic functions. We want the kids to know. This is likely to be something that you’re having trouble with. 35:15 You want the kids to get calm and comfortable with interactions, with their parents and their teachers, when carrying out the need an act, 10 academic activities. 35:27 And we wanted them to be really aware, what are the details of your academic tasks. 35:32 We wanted to increase their likelihood of having the materials and books, and then increase the likelihood that things will be completed on time. 35:40 And we did want them to demonstrate planning behaviors, that they anticipate demands, that they show preparation ahead of time, and that they work on spreading tasks over time. So it’s not done at the last minute. 35:54 And in a test of The large number of, situations, in the program, The kids improved their organization, time management planning behaviors, as rated by both parents and teachers. 36:06 The kids became more academically productive. 36:09 The kids academic performance, as rated by teachers and organizational skills, training improved. 36:15 Parents reported fewer homework problems. 36:18 Parents also reported less family conflict and what was important with regard to this work when teaching these skills. 36:25 These things lasted into the next school year, as rated by parents and teachers, so that they did have a kind of lasting effect. 36:34 The treatment course, and an overview with example, of some content, was one in which we did focus on kids in third, fourth and fifth grade, and we did select them if they had organizational skills problems. 36:45 Another version of this program, or for middle school kids, is one that’s been put together by Maggie Sibley of the University of Washington called Stand, supporting Teens’ Autonomy Daily, which has also been found in it test to be highly effective. 37:04 And we do work on finding out information, We conduct a functional analysis. 37:10 Are the kids, you know, what are they having trouble with? With ideas, such as, does the child keep work areas free of clutter and distracting items? 37:17 Does the child know how long it takes to complete time and common tasks? 37:21 And do these problems with organization, time management and planning interfere with a child’s success as well as interfere with family conflict? 37:30 And if we get answers? 37:31 Yes, to these kinds of questions, We think that this is an appropriate way of doing things with kids. 37:38 And our work is work that has been designed to have the kids get skills in tracking assignments. Managing materials, managing time, and task planning. 37:48 And we do also get involved with a psycho education to be able to make it. So the kids are thinking that there’s certain grain glitches that are the cause. That it’s not that the kids are careless. It’s not that the kids are not interested in doing well. It’s not that they’re lazy. It’s that these brain glitches kind of pop up and we sell them, that these are present for everybody. 38:15 And the glitch, an analogy is this. We say that we want to externalize the problems. 38:20 It’s not you. 38:22 It’s you’re getting tripped up by these glitches that are presenting these little messages and we drew these little figures that these is the go-ahead forget a glitch, and they present these messages that say, oh, you don’t need to write that down. You’ll remember it later on. 38:36 But this glitch is very happy. 38:38 When a kid comes home or go to the afterschool program and parent or somebody else says, um, so what are you supposed to do for math? 38:46 Well, I had, no, I have some math, but I don’t know exactly what it is, And when somebody gets frustrated with the child, the co-head forget a glitch is kinda like pointing and laughing, saying, I got you again. 38:56 So we want the kids not to pay attention to that, and kind of like, avoid getting tripped up by this glitch. Go ahead lose a glitch says, oh, this paper’s important, but I’ll stuff at anywhere, and they can’t find it later on, and the go-ahead losing glitches really happy. 39:11 The time bandits steals their free time by having them really not think very well about when to do things and how to use their time. 39:20 Go ahead, don’t plan glitches, good on vacations, but it’s not good to listen to the go-ahead plan. 39:25 Don’t plan glitch when it just says, uh, you don’t need to wait and develop a plan for that book report. You’ll figure it out. 39:32 And we have found that the kids and parents and even older adolescents really liked this analogy to think that, oh, I gotta watch out for the glitches. 39:41 This is helpful. 39:43 We have parents and teachers get involved, rewarding kids, four, following through and showing certain specific behaviors, and reward the kids with praise, and sometimes points for some prizes and some extra activities that they enjoy. 39:59 And we do talk with the kids about, Let’s talk about specific situations. 40:05 Let’s learn about what those situations are. 40:08 For example, when does your teacher tell you what you’re supposed to do for homework? 40:13 And where do you find that information? These are really good questions to ask at the beginning of the school year. 40:18 Like now, to find out, you know, what’s the routine that’s in your classroom for getting the information about your homework done? 40:27 Where are you supposed to put this information? 40:29 And, yeah, do you have way of doing this effectively? 40:37 And for writing down assignments, we’ve been recommending the kids use it, a daily assignment record. 40:42 And here’s an example of this to the right, Which is a detailed review with also a checklist. Remind kids what it is that they should take home with them. 40:53 Some kids can use a planner that the school supplies who the parents supplies, we found that some students, and again, even into high school, are better off creating something like this. It’s a simple table from a Word document. 41:08 And be able to use one page for each day, because it allows enough room to write down the information. 41:15 It allows that kind of check to say, what is it with a reminder, what you should take home with you? And it also provides information on what other assignments have been announced and whether they do. 41:28 We have kids practice, this use of this daily assignment record, we don’t just tell them, B, Give them an opportunity to practice over and over again. 41:36 And this is something that we have parents and teachers remind kids to use, and also praise kids for doing so. 41:42 And if kids do it, we recommend that the families get involved, providing some small rewards for them, for doing so. 41:50 We also have them think about a big assignment and test calendar with a reminder. 41:54 What’s coming up for the next week, or even the whole month. 41:58 So that nothing is forgotten, and the kids are learning to use this calendar to be able to say, I learned about a test. I’m going to put this on my calendar. 42:06 And every evening, when I sit down to do homework, I’m going to look at what I do the next day, but I’m going to also look at my calendar to find out what’s do down the road, so I can start to get prepared for that. 42:19 We have kids get involved with learning how to store and transfer papers’ effectively. 42:24 three ring binders are a disaster for kids that have these issues. 42:27 We do recommend the use of accordeon folders offer papers to go in and finding ones that have a flap that allow the kids to kind of make sure that the papers don’t fall out. 42:40 We teach them how to use that. 42:42 We praise them how to use that. We have parents praise them on how to use them. 42:46 We have the Kids work on packing up their Back’s effectively and one of the things that many students like is having a backpack checklist, which is something that we put into a badge holder and Ident ID folder. 43:00 We put a big safety pins and pin it into the top of the backpack With a reminder list that says, Do I have all my books? 43:07 Do I have my accordion folder? 43:10 Do I have my lunch box? 43:12 Do I have my coat in the wintertime? 43:14 Whatever kids are prone to forget, this reminder list that we asked them to use over and over again, and to use their eyes, and not their memory, to like, look to make sure you really have it. 43:26 We teach kids for at home, too, work on making their areas ready to go. 43:31 We teach them to make sure that they have all the materials they need before they sit down to do their work. But then, they also put away distractions. 43:39 You kind of have them set up the environment in a way that’s effective. 43:44 And then what we do is we work on time management and planning. 43:48 And for time management, one of the big things that we do is, it’s really important, is to have kids become aware of how long it takes to actually do things. 43:57 We increase their real knowledge of the needs for being aware. We have them do this in fun ways. 44:04 This can be done at home as well. 44:06 Um, you can have kids have a stopwatch, you can have them use the phone to be able to say, well, you know, how long does it take to make a peanut butter and jelly sandwich? Let’s find out. 44:14 How long does it take to, you know, walk around the block? 44:18 How long does it take to travel to school? 44:20 Let’s let’s time these things, and let’s determine how long these things take, so that we know when we should begin to do something, if we want to get it done by a certain time. 44:30 How long does it take to put on socks? 44:33 A big issue, sometimes, at the moments of truth. 44:37 How long does it take to turn on the home computer and to get the welcome screen and to print a page? 44:43 Again, that takes a bit of time so that kids are not saying, oh, I’ve got to print this out just as the school bus is arriving. 44:51 If there’s awareness of this, then the kids are more likely to be able to say, OK, I’m willing to begin to do this sooner. 44:59 We want kids to also gather information. 45:02 What’s their personal calendar for the week? 45:05 When is basketball practice and, how long is basketball practice? 45:10 And, if it’s on a Tuesday night, Um, and you have a test on Wednesday, and you know this ahead of time in basketball, it takes awhile. 45:22 It may be a good idea to get ready for the test on Monday, and if kids are aware of their own personal calendar, This sometimes results in a few less arguments when parents know this, and say, on Monday, you should study for your test. Also. 45:39 If the kids are aware that they have basketball the next day, it may be less involved with an argument about the idea that I don’t need to study Monday night. It’s not till Wednesday. 45:49 We want kids to work on getting involved with estimating how long it takes to do things so that there can be a discussion saying, OK, so you do a basketball, how long as your homework and intake, know, when should we begin to start to do it, and how, let’s, let’s try to figure out when we should start with the kids, and the parents are involved, a little bit more, why, a collaborative effort to go through their schedules. 46:17 For planning, we also want the kids to learn the steps needed for planning. 46:22 We think that there’s some big things, and it’s similar to what we talked about before. 46:27 With regard to planning, it’s really important to know what are the steps needed to be able to do a book report, to be able to do math homework, To be able to bake a cake, we haven’t think about lots of different things. What are the big steps needed? 46:40 And in what order do you put those steps? 46:44 And once you know the steps, what materials do you need to gather together for each step? 46:52 This part, we found to be really critically important, as we did this work with, you know, over 100 kids, over actually, 150 kids. 47:01 We ran across this same story, often, of kids saying, before Covidien, where there was a and when school is in session, and now back to being school in session kids, saying to their parents, Hey, I need posterboard, I have to do something and presented on Posterboard tomorrow. 47:21 And this is a, sometimes on a Sunday night, and we heard these issues with regard to different areas, where parents are saying, where are we going to get this on Sunday night? 47:30 And then, eventually, in frustration, asked the question, when did you know this? 47:35 The kids say, oh, like I like two weeks ago, and the parents are like, oh, my gosh, why didn’t you tell me ahead of time? 47:41 Having this idea about what the steps are new materials are helps to avoid some frustration. 47:48 We do want the kids to also say, you’ve learned how to estimate, how long it takes to do things. 47:53 How long will each step take, if you do have to draw something, if you do have to do a report, how long will it take to find the information? How long will it take to gather together the pictures? 48:06 And once you know that amount of time, when can you fit it into your schedule? 48:11 So, there’s a kind of systematic way of dealing with things, kids, see parents and teachers and other people doing this all the time. 48:20 But they don’t really know and understand this, we try to bring this out, and become having something become that’s very aware that they’re really aware of what it is that they want to do, and how to be able to complete a plan. 48:32 We have them think about plans for play dates, so that they can see about planning things that are fun, or birthday parties, But also, academic tasks, so they understand this. 48:43 And altogether, this is the kind of package that we do use for the organizational skills training. 48:52 And as we do this, we are doing this also clinically. And we’re continuing to do some research on this topic. 48:59 But we do think that this is inappropriate kind of intervention that’s effective, and that there’s other interventions effective as well. 49:09 We do want to caution people to think about, you know, if they want to be able to help their kids with executive functions, whether they’re teenagers, or, in some cases, themselves. 49:18 Please be very cautious in what you pursue. 49:21 Look to see about programs or methods that do have some scientific testing behind them, because there’s many ideas out there about changing these skills. 49:32 And many of them are untested and sometimes costly. 49:38 And if it’s costly and not an untested and not effective, it’s not a good use of resources in terms of time or money. 49:46 So, I want to thank you for your time and attention. 49:49 And I’m happy to take of some questions at this point in time. 49:55 And I think what I’ll do is I’ll stop sharing my screen for a moment to be able to, you know, make it easier to address some of the questions. 50:04 Thank you. So, so much, doctor Gallagher, that was phenomenal. So we do have a couple of questions, and just a reminder for any additional questions that you guys have. Feel free to type them in the question or chat box, and send them our way, and I will read them out for you. 50:24 So our first question, bear with me. 50:31 Our first question is, how likely is it to get these treatments and to the classroom with an aide or a teacher? 50:40 Well, with consultation, with a professional, we think it’s really feasible. 50:49 Just, you know, science takes a little while to kind of develop things. 50:53 We are in a collaboration with a group of people that, at the University of Pennsylvania, in the Children’s Hospital, Pennsylvania, that is testing this program out in applications in school. 51:05 The preliminary information suggests that it’s effective as well. 51:09 But with regard to some guidelines, especially if it’s done one step at a time, you can often collaborate with a teacher and be able to end and the aide to say, OK, what are the steps and routines needed for? 51:22 Let’s talk about one thing at a time, writing down assignments. 51:26 And can we get involved with prompting my child to do this? 51:30 And can you help some of those problems, but not do it for my child? 51:34 Every once in a while, we hear about situations where the aide or a teacher is actually writing things out for the kids, but that doesn’t lead to them learning. 51:43 So, we say, Let’s what we can do together and what we can do to kind of praise the kids for getting comfortable with doing so, after writing down assignments is taken care of. 51:52 Maybe the next step would be, Well, what’s what’s the method for gathering together the papers and the books? 51:58 Can there be something done to give my child a reminder list on the desk and the backpack that says, here’s what you need to pack up. 52:05 And can we gradually have the child practice this and give praise for practicing this? 52:12 So we do think there’s ways of putting this together. Um, again, I get royalties from this. 52:18 We have a book called The Organized Child that was written for parents, and does give some suggestions, again, for how to be able to do this, and how to be able to talk with teachers about this. 52:33 So, the next question is, how much support should parents provide for high school students as they are preparing them to be independent and go to college? 52:46 Well, again, some of the same ideas are useful. 52:49 We have, because of the work we’ve been doing over the years, we’ve been getting, uh, no recommendations, and referrals from college students, and parents, of college students. 53:00 And in some cases, these are college students have been asked to take a leave of absence after they had lots of trouble in a particular semester. 53:11 And what we found in some of those cases, is that some of the students have gone off to college with their parents, basically doing everything for them. 53:19 Know the parents, keep track of the school calendar. 53:21 The parents keep track of when assignments are due and when tests aren’t. 53:26 It’s a good idea to evaluate carefully. 53:29 two, kinda like gently work on understanding, you know, What is my high school student do with regard to keeping, you know, writing down assignments and being aware of them. 53:40 Does my high school student know how to use the school portal, and Google Classroom, or the other things, to find out what to do? 53:48 Does my high school student use a calendar to provide reminders of when things are due? 53:53 And if you find that these things are not done, I would recommend getting involved with doing it one, step at a time and providing some of the support for practicing and for using these ideas. 54:07 Um, and not letting kids, no, just flounder. 54:13 We don’t think that that’s a good way, because, again, sometimes that impression can be, these are easy things to do. Why isn’t my child doing it? They’re just being difficult. 54:23 It’s better to approach than saying, well, maybe this is a skill problem, and we need to have my child learn these skills and learn to practice. 54:33 Then, our next question is, Are there any, are there any technology tools you recommend for improving executive functioning, um, within limits? 54:47 Um, I think, um, again, so, we sometimes recommend, not necessarily as an executive function tool, but as an adjunct, a cell phone can be useful. 54:58 We’re taking pictures of assignments. 55:01 That’s, that’s many, many people find that, that’s a useful way of doing things, the teacher posted on the Blackboard. It’s like, OK, I’ll take a picture. 55:08 But, again, that’s often a situation that is different for different ages, and so that. 55:18 We, we think that that’s one thing. 55:20 But with regard to actual tools, um, they teach executive functions. 55:27 We haven’t really found too many that are useful. 55:32 There are some, kind of like reminder and project management tools that you could look into there where people kind of like set goals for themselves and get like little rewards that pop up in terms of stars and different things like that. 55:47 I think for some people that’s useful, um, but in terms of actually teaching executive functions, again, like technology like computer games, um, the the the indications are that they’re not all that useful. 56:02 Then they’re really not showing great utility right now. 56:08 OK, and as high score too late to start, can it still be effective? 56:14 We think so. 56:15 There’s some indications from this other group that has been doing things that they can find with some of this teaching and practice. 56:22 The high school kids do seem to improve. 56:26 There’s evidence from a program that’s being tested out in college students, that some of these things can be even improved in college, And there’s, there are tested and proven programs for adults that have been used, that people, that adults can actually get better at this, as well. 56:45 That is a very sharing. 56:47 It is re-assuring, but it’s also basically people, you know, learning some strategies learning, some routines, and getting involved with using them over and over again and practicing them. 56:58 It’s, again, in all those different ages. 57:00 It’s not just telling people, it’s like saying, OK. 57:03 Here’s here’s how to practice this. Here’s what you should be doing. 57:09 And then you mentioned that the results of a twice a week. 57:14 Millimeter week EF intervention produce results that lasted through the entire year. Do you think that this has more to do with the change you affected, and the students, or the change that may have been affected in the teachers? 57:30 Now, we’re not sure. We, we do think, again, since it did carry over, not just into the same school year, but the next school year, we do think it’s things that the kids learned to do. 57:41 They learned these behaviors and held onto them. 57:45 We are engaged in a study where again, persons with Tourette’s would not be able to be enrolled because of just, you know, some of the specifics, we’re actually looking to see if this intervention is associated with any change in brain activity. 58:01 And then we’re in the midst of a study that’s actually looking at that to see if this results in some, not only outside behavior change, but perhaps some inside the brain behavior change. 58:14 What advice would you give an adult who struggles with executive function and their loved ones who want to help them? 58:22 Um, what I would suggest is that I’m engaged in some exploration. 58:29 There are, there are programs, again, that have been developed for adults. 58:34 A good cognitive behavioral therapist might know these programs, and might be able to, you know, help you, learn to use them by getting enrolled in some of these kinds of treatment. 58:44 There are executive function coaches, that you can be careful in reviewing, by asking also, you know, what methods have you learned, what, no scientific basis is there for your activity, and sometimes that’s another source that can be helpful as well. 59:06 There, Um, I have, bear with me one moment, OK, OK, my son has Tourette syndrome, ADHD, anxiety, and OCD. I find that these skills are the most challenging for him to obtain. He is now 17. Do you have any advice regarding a college and how we can continue learning these skills? 59:33 Well, again, I can’t give a specific advice to specific people, but sometimes it can be helpful to consider different kinds of college programs. 59:42 There are some colleges that do have really strong support programs, and it’s worth exploring and making sure that there is something in place. 59:52 Another possibility, again, if things are rather extensive, is to consider enrolling in some summer programs. 1:00:02 Lambda Bar College has some summer programs around this that seem to be effective. 1:00:07 And landmark College itself, and enrolling in landmark college, perhaps for a year or so, does involve a lot of teaching of these issues. 1:00:15 And those are the kinds of resources to consider. 1:00:18 It’s worth talking with the high school counselor. 1:00:21 That is the college counselor to find out no more information about schools that have good learning supports, so that people can continue to learn these skills and get supports in doing so in a college setting. 1:00:36 And I know that it’s 8 31, but I just have one more question. So this person says, I have a 10 year old, I’m a bit overwhelmed with how to approach the executive function training needs, where can I find information on how to start with small steps. I think reading a book right now has been overwhelming. 1:00:56 Then the next question, she had mm, hm, nevermind, sorry, I didn’t know the answer to that one. 1:01:03 Again, the, though, again, I’m not, again, we get royalties. This is a bias to when we do have a book, that, it’s a relatively short book, it is. With regard to chapters, that talk about one step at a time. 1:01:16 It does, you know, talk to parents about how to put these ideas into place, and how to do that, again, one step at a time. 1:01:24 So, we would hope it’s not too overwhelming. 1:01:27 Again, if, if it is, you know, overwhelming, again, getting involved with some, you know, a good behavior therapist, that could guide this, this work, I think, is another resource, as well. 1:01:40 OK, well, thank you so so much, everyone, for joining our webinar on Understanding Executive Function Concerns and Tourette Syndrome and Related Disorders. There is an exit survey. Please take a moment to complete. The webinar blog is now open and available for the next seven days on the New Jersey’s Center for Tourette syndrome website for any additional questions that were not covered tonight, or any questions that you may think of during the week. 1:02:09 That website is WWW dot J CTS dot org. 1:02:16 Also, an archived recording of tonight’s webinar will be posted to the site. Our next presentation will be Obsessive Compulsive Disorder, 101, presented by doctor Rob Zambrano on October 14 at 7 30 PM. 1:02:32 This ends tonight’s webinar. And thank you. So, so much, doctor Gallagher for your presentation, and thank you everyone for attending. I hope you have a wonderful night. 1:02:42 Thank you.


  1. Marie says:

    What if a parent also has ADHD, how can they help their child with executive functioning if they themselves struggle with it?

    • Richard Gallagher says:

      The question is an important one that many families face. Resources that adults can use to help themselves include two books worth exploring:
      Taking Charge of Adult ADHD by Russell Barkley and The Adult ADHD Toolkit by J. Russell Ramsay and Anthony Rostain

      Additionally, if needed, adult therapists who provide treatment to persons with ADHD often can provide guidance in coping with the condition during parenting situations.