How to help a child with executive dysfunction issues
October 24, 2021 2:35 PM   Subscribe

Compiling pointers for a friend whose 3rd grade daughter has executive function issues. Snowflake details inside. Are there any good resources available (preferably free) for how to help their daughter?

The issues are specifically related to doing her assignments or other tasks, getting distracted while working on things, transitioning between tasks, doing multiple things at once and decision-making. Some examples: when the next item on her list is "practice violin" and her violin is not available, she will become paralyzed rather than moving on to the next thing. When she is doing something such as walking quickly, she cannot process instructions that are given to her.

Both parents work full-time and have limited resources, so "hire a nanny with expertise in executive function" or "quit your job so you can help your child full-time" are not on the list.
posted by rednikki to Health & Fitness (13 answers total) 7 users marked this as a favorite
Best answer: As far as i know executive function disorder is part of a larger diagnostic picture.

In my son's case it comes with his ASD. But it can be other reasons too.
So i think to help the child it will be important to know the bigger picture. Can you share the underlying cause?
If it is unknown, my advice is to get it diagnosed formally asap. Because this will inform how to help her.
Also, a formal diagnosis can be useful in accessing further resources (depending on your insurance).
posted by 15L06 at 3:52 PM on October 24, 2021 [5 favorites]

Best answer: If she attends public school, I would definitely encourage the parents to seek out support and resources that are legally guaranteed at school in the form of an IEP or 504. They’ll have a team helping them who can also offer suggestions for at home! I know some schools are bad at this but really try their best and do a great job!
posted by smorgasbord at 3:57 PM on October 24, 2021 [4 favorites]

What expectations do they have exactly? At 9 years old, how many kids can be given a timed task list (practice violin, do chores, do homework) and carry it out with no check-ins or encouragement? Do you know the situation well enough to be sure that the child isn't being pathologized for acting her age?

Practically, if the child is alone with a task list, can they text every hour or so to help with logistics and to give positive feedback?
posted by dum spiro spero at 4:04 PM on October 24, 2021 [19 favorites]

It’s not about hiring a nanny. Usually such issues have deeper reasons and require diagnosis by a professional. Parents need to know what they are dealing with.
posted by oberon_1 at 5:08 PM on October 24, 2021 [5 favorites]

My go-to resource for child mental health & cognitive issues is Child Mind.
posted by Winnie the Proust at 5:14 PM on October 24, 2021

Best answer: Re: pathologizing normal behavior - that is definitely something that's good to be aware of in any diagnosis. However I'd like to say as an adult with what sounds like very similar executive function issues (especially the task-switching and freezing described) and ADHD that I finally got diagnosed at age 36, your friends are absolutely doing the right thing trying to find help for their kid.

I think a childhood diagnosis would have been life-changing for me, and I think it's very hard for people without ADHD/executive dysfunction to fully understand the extent to which it can be disabling and limiting to go untreated into adulthood. As someone who now has a neuropsych-verified diagnosis, all of what you describe sounds so familiar it's almost eerie.
posted by augustimagination at 5:29 PM on October 24, 2021 [12 favorites]

Best answer: & so as not to abuse the edit window, I know you said free, but pursuing a diagnosis through medical providers is probably the best thing they can do. A lot of in-school support (both in primary/secondary school and in higher ed) is gatekept behind needing a formal diagnosis, and a lot of insurance companies (fortunately not mine currently, but I've dealt with this in the past) actually have requirements that adults must have been diagnosed at a certain age to have access to medication and/or treatment after an arbitrary age (26 is common). So not pursuing a diagnosis while their child is young can have consequences for her access to support later in life. I hope I'm not coming off as like THIS IS VERY DIRE, but it's an issue really close to me and if I can help one kid not go through what I did on the path to diagnosis & help I've got to try.
posted by augustimagination at 5:37 PM on October 24, 2021 [5 favorites]

Best answer: Seconding all above for getting a formal diagnosis so they can more easily advocate for their child in various systems. Occupational therapists are great for practical ideas. My kid has executive functioning issues related to autism (we are still on the fence about adhd as well) and it can be very frustrating as a parent to see your capable child apparently zoned out and misbehaving.

You have to reset your expectations to vary considerably by their task. Think of it as a very wriggly line. Neurotypical kids have a gentle wave of strengths and weaknesses, but with our kids, there are much wider gaps. Comparison to other kids and what the school/society expects will suuuuuuck. They need to set expectations appropriate to what their kid can do. No instructions while she walks, for this kid, you pause and say the instructions, get her to repeat them back, and then you smile patiently and repeat them a second time when you ask her ten minutes later what to do. You get her to text 'can't find violin' and gently remind her to go to the next step. It's like they're 9 on one area, 4 in others. You have to recalibrate.

We were also encouraged to do lots of strategy games where they get to practice memory and planning. I find written lists enormously helpful. Most of all to watch for her self-esteem/confidence. She's able to compare herself to other kids and if she sees this as a thing to slowly work at and improve, yay, not "I'm stupid and scatterbrained".
posted by dorothyisunderwood at 5:56 PM on October 24, 2021 [13 favorites]

Best answer: Diagnosis and professional help are a good idea, but that’s the long game. It can take like eighteen months to get a pediatric diagnostic work up in some bits of the US. Therapy might be accessed faster, but they may not have a lot of selection when it comes to credentials and relevant expertise.

Assuming their child does not already have a dx, while they wait, can they spend time practicing skills with their child? It doesn’t need to be a full time thing, a little bit every day helps. Then they will be in a better position to help the child’s teacher. Some ideas:

- There is a curriculum called Superflex that I am always recommending here — books and games themed around common childhood behavior and thinking challenges, some of which are executive function related. Not free, but cheaper than self pay therapy, fun for kids, and pretty easy to implement yourself with no special training.
- A strategy that I’ve heard recommended for kids irrespective of dx: making as much as possible visual. There are timers you can get to help kids visualize the passage of time even if they’re not great at clocks yet. One can also make a visual schedule so that the kid can see what comes next. If flexibility is a challenge, making it out of something that can be rearranged could help. Like a bunch of little dry erase cards with Velcro on the back and you write “play violin,” “math homework,” “walk dog” on the cards, and move them around on the to do list as needed.
- Make tasks as small as they need to be to have some success. When we were first starting out with a piano practicing habit we aimed for two minutes. Over a few months we were able to extend that to a reasonable amount of time. The key is we had to start from a place of feeling good and successful, not a place where everyone is frustrated.
- I think 8 is still an age where making games out of the difficult things can take the sting out of getting better at them. One game I liked from Superflex that relates to the taking-instructions-while-walking problem: the child is given an obstacle course to do and the grownup pretends to be a super scattered coach who is constantly changing the directions in the middle. Played with a light touch it can be hilarious but still teach redirecting-while-moving.
- When ours was in second grade and really struggling, explicit praise was critical. In third grade she’d grown enough that while praise still helped, access to concrete rewards was more motivating (“if you get all your virtual school work done, you get to play Zelda until dinner”).
- Some kids have a hard time ignoring sensory input, eg a room that is too loud or too quiet. If that’s possibly contributing to distraction, you might try either noise cancelling headphones or headphones with music. When ours was in second she liked a weighted blanket too to help settle her nerves while working.
- We had a bedtime routine that we used to practice remembering items on a short list, and as she got more capable we made the list longer.
- We made safe spaces for talking about how all this challenge felt, whether through stuffie play, pen and paper games, or mindfulness sorts of tasks (rose-bud-thorn is a popular one). And we used these spaces too to talk about our own challenges, to help Little eirias feel that it is normal and okay for some things to be hard.

Hope some of that is helpful — it’s a hard road sometimes but it’s a survivable one.
posted by eirias at 6:18 PM on October 24, 2021 [17 favorites]

She's what, 8 or 9? I'm a grown-ass 40-something woman with I suspect undiagnosed ADHD and I can't do a lot of that all of the time. Executive dysfunction like that screams ADHD to me, which is chronically undiagnosed in girls because it presents so differently than it does in boys. But I am in no way a professional, just summarizing my own Dr-Googling, so take that with the huge mountain of salt it requires.

First thing I would suggest is her parents talk to her doctor.
posted by cgg at 6:38 PM on October 24, 2021 [2 favorites]

+1 to all the comments saying "this sounds like ADHD/ASD and she should get a formal evaluation and diagnosis because treatment (meds/OT/etc) can help" and "leaving a 9 year old alone with a multi-item task list to get through independently? Are these expectations developmentally appropriate?"

But also, if her parents already know what specific tasks will be most difficult for her, they should start accommodating her. So instead of a task list like:

Do these in order:
-do homework
-practice violin
-clean room
-read a book

It should be

Here are some things you could do:
-do homework. If you can't, move to the next item!
-practice violin. If you can't, move to the next item!
-clean room. If you can't, move to the next item!
-read a book. You're done! + maybe add some suggestions for what she can do with her downtime, if she's so paralyzed by decisions and problem solving

If the problem is that she can't process instructions while she's walking quickly: stop her, get down on her level, face-to-face, make sure she's focused on you and not still mentally moving quickly, and only then tell her the instructions. Ask her to paraphrase what she understood back to you.

Basically, they need to find the choke points in her processing and figure out how to work around them. They need to be her executive functioning. As she gets older, and hopefully gets treatment for whatever the underlying condition is, they can experiment with fading some of these supports back to see if she still needs them.
posted by Nickel at 7:08 PM on October 24, 2021 [13 favorites]

Best answer: That "freezing" behavior sounds an awful lot like my (now-adult) child who lies somewhere at the high-functioning end of the autism spectrum. (Most of the other items do, too.)

We never received a formal diagnosis. He was mis-diagnosed as ADHD before kindergarten, pulled out of public school in mid-kindergarten. Then we homeschooled, which actually worked really well, since his next older sibling was (correctly) diagnosed as ADHD. However, as he grew through the teen and now adult years, it became very obvious to those who knew him well what the correct diagnosis should have been. Most of his challenges, we taught ourselves to solve, but there remained a few that occasionally surprise us.

The "freezing" was one of these. We learned quite a long while back that he will do EXACTLY the task that he's asked to do, no more, and no less. And he'll do it to exacting standards - the meltdowns he had as a public school kindergartner were due to his own frustration at his inability to meet his own standards of perfection.

However, if a task is for someone else - and he does not know how to do the task, or does not know how that person would want the task done - he freezes or derails. It helps very, very much for him to be told, in the instructions he's given, "Do this. It's perfectly ok to figure out the best way for you to do it." Over time, he's gotten much more used to that concept, but it's still a really good idea to ensure he knows the method doesn't matter, the results do... and also, if time is of an issue, that needs to be said. Otherwise, he'll get so stuck on making it perfect, he may not complete it. As time has gone on, we've gotten better at finding frameworks he can use to determine for himself where the priority is - and he's gotten better at asking for specifics if he needs them.

He's excellent at picking up things he's had no intuitive understanding of, but could be taught and then adapting them into his life. We've been literally doing that with social skills since he was small. The real challenge though is, I don't know what he needs to learn. And neither does he, because he doesn't know he's missed that concept until someone points it out to him.

He's really pretty good now at identifying what is going on in his head, and that allows me to suggest things that might give him an appropriate tactic for dealing with an issue. But there's no master list, as far as I know, of "Things he's likely not to know".

I wish now that we'd had better information when he was in grade school. A correct diagnosis and some information - THEN - might have been helpful. Neither he nor I has any idea whether it would be at all useful for him at this point in time. Given what you've said about your friend's time and resource availability - it would be in his daughter's best interest to take advantage of testing and resources provided through public schools.
posted by stormyteal at 11:49 PM on October 24, 2021 [10 favorites]

There's a book called "Smart But Scattered" that my family found very helpful. It was recommended by one of my sons' teachers and really was a lifesaver.
posted by selfmedicating at 5:17 PM on October 25, 2021 [1 favorite]

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