Kavita Murthi returns for her third and final post in this series on executive functions.
The two previous blogs in this series focused on describing executive functions, how and when they develop, their importance in human development, and common assessments used to determine executive dysfunctions. This final section of this three-part blog series outlines some interventional approaches and strategies that can be used to develop and enhance executive functions in children with autism.
Executive dysfunctions are detected and assessed by Pediatric specialists including Occupational Therapists. However, it is important to understand the depth and intensity of the challenges faced by the child before initiating interventional approaches. Also, prudence must be exercised before directly incorporating therapeutic strategies before getting a comprehensive perspective of the daily challenges faced by the child as interventions might challenge the child inadequately if they are below the child’s developmental age or might cause major stress if the activities/tasks are above the child’s developmental stage. Executive functions are best developed when everyday activities are used to challenge the child’s working memory, planning, inhibition, sequencing and organization skills. Also, it is important for parents to work with specialists and facilitate in providing repeated opportunities to practice, reflect and master these skills in the child’s natural environments.
While it is important to provide a fun, stimulating and positively challenging environment for a child with autism to develop and build the different executive functions; it is equally or more crucial to understand that even typically developing children are not born with executive functions. They are born with the potential to learn them, but this process is very slow and takes place throughout childhood and extends until adolescence. While typically developing children reflect and make meanings of their social interactions themselves, children with autism experience challenges in understanding receptive (heard) language and hence find it challenging to engage in or express their thoughts and ideas. This in turn affects their executive functions greatly. It is this reservoir of meaningful social interactions that aids in building self-regulation, inhibition, and other organizational skills in typically developing children.
Right from infancy, children participate in interactions with parents and caregivers to learn attention skills, working memory development, enhancement of imitation skills and understanding meaningful social relationships. Since social communication is challenged in children with autism, they experience difficulties in paying attention, imitating others and understanding and expressing language and ideas. Hence creative play is impacted which in turn delineates working memory, inhibition skills, planning and activity engagement skills. Furthermore, school work is impacted and management of time with respect to organization of activities is greatly challenged. During these stages children are dependent on adults to provide structure. Children with autism demonstrate these difficulties through meltdowns, aggressive behaviors, temper tantrums, anxiety and depression. Hence it is vital to understand the underlying problems faced by children with autism before trying to provide solutions or interventions. Specialists are a great resource to bounce off ideas and recognize activities or approaches that might be suitable for each child on the spectrum.
Everyday activities provide a great scope for children to engage in and enhance their executive functions. Children with autism can also be encouraged in a wide array of everyday activities to not only build these skills but also to develop their higher cognitive skills. However, prudence must be exercised when urging children to participate or perform everyday tasks that involve risks – fire risks, road crossing etc. While the activities presented in this blog are not all inclusive, they do provide scope for children to think, use their judgement, planning, organization, thinking, and inhibition skills. Activities are presented according to the typical age of development and are not comprehensive. Creativity needs to be exercised while designing and choosing activities.
6-18 month old infants start assimilating and understanding information and this results in them developing executive functions. During this stage, it is very important for parents and caregivers to understand the child’s interests and use those activities or toys to build these functions. Games played on the lap like peek-a-boo, hiding toys behind a cloth, or letting older children hide themselves are good games to improve self-control, planning, working memory, and judgement skills. Apart from these games, children at this age enjoy very easy to copy activities like imitation of actions (e.g. waving bye), imitating adult behaviors (e.g. sweeping). Both these types of activities teach children to pay attention, register the activity, hold it in their minds, and copy it appropriately when expected. Also, children learn to focus their attention on objects or people by using receptive skills while listening to parents/caretakers talk to them. The focus for children with Autism would be to teach them attention skills. This skill is cardinal to teach children language and perceptual skills.
Between 18-36 months, children expand their language skills by learning to make plans and understand others language and their ideas. Toddlers are continuously engaged in physical activities that are novel and complex like running, jumping, hopping etc. They enjoy games which involves imitation, movements and hand gestures. Furthermore, they start involving themselves in narration of events, experiences and emotions. Parents can help children learn both language and attention, regulation, planning, organization and judgement skills through physical mazes, following the command games, imaginary role playing and sorting and classifying objects to increase and build their cognitive flexibility. During this age, specialists focus on teaching naming, classification, and sorting skills to children with ASD.
Children in the age group of 3-5 years develop an array of physical and cognitive skills in a manner that is unique to each child and requires different levels of support. During this age, children learn to plan and execute imaginary situations (e.g. teacher-student roles). They make coherent plans ranging in complexity and act these plans out. Moreover, they make up imaginary stories and characters and talk about them. They start playing physical games with rules of increasing complexity. Apart from these activities, children also enjoy complex puzzles, higher level sorting games, and participating in household chores. It is important to teach children with autism language comprehension and expressive skills, working memory, planning, and self-regulation skills to facilitate them to explore creative play, imitation games and group play with peers.
When children cross 5 years of age and are between 5-7 years, they find games with rules challenging and appealing. Physical games that involve fast movement, rhythmic body movements and sport games with rules appeal to them. Furthermore, they start turn taking effectively, participate in group games better, enjoy complex puzzles, problem solving games, guessing games, and games that improve cognitive flexibility (thinking flexibly). Children with autism require adequate language repertoire to build and enhance these skills and hence the focus should be directed to improve their cognitive flexibility, problem solving, self-regulation, and language skills.
Children between the ages of 7-12 are involved in building and improving complex concepts and for that same reason like to engage themselves in games that require strategy like card games, quick decision making games, games that require planning ahead like sudoku, crossword, and games that require logical thinking and reasoning. By this age, children are involved in sports and games that require constant monitoring and improvisation like paintball. Furthermore, children at this age also learn to dance a particular dance style, playing musical instruments, and sing. Children with autism might need support to improve their quick thinking and logical reasoning skills at this age.
Teenagers and adolescents are required in various settings to act as adults and therefore must plan ahead, monitor, improvise, and regulate themselves. While their independence in performing these tasks effectively depends on their self-regulation and cognitive skills, they still need to learn to think rationally and deduce their solutions by weighing both pros and cons and making logical decisions. Learning to control money and learning to drive require continuous monitoring and self-regulation. Settings goals at this stage can really help, including writing personal journals and reflecting on various issues. For adolescents with autism, judgement, reasoning and self-regulation skills are crucial and they need to be the focus of the parent or the specialist.
Having a comprehensive understanding of executive functions facilitates parents and caregivers ability to build better situations to help children with autism function independently with the optimal quality of life.
About the Author
Kavita Murthi, OTR, FHEA, MSc (OT) is a Board certified Occupational Therapist originally from India. After completing her undergraduate studies she moved to the UK to pursue her Masters in Occupational Therapy from Scotland. She received the title of “Fellow” from the Higher Education Academy, UK for her contributions towards education. Moving back to Mumbai, India, Kavita worked worked extensively with children with developmental challenges in an outpatient community setting. Here, she worked with children with various developmental challenges and helped provide therapeutic interventions using evidence based strategies. Kavita recently moved to Boston after getting married and is enjoying her time travelling, writing and volunteering.