Occupational Therapist Kavita Murthi will be writing a series sharing her knowledge on Executive Functions and supporting people on the autism spectrum! Read her first post below.
Executive Functions (EF) are a set of cognitive processes that help all of us to
- plan and organize daily things or things for the future (e.g. planning a surprise party for a friend)
- be flexible between focusing on a task and shifting our attention to perform more than a single task (e.g. multitasking between making a cup of tea while watching a program on the television)
- manage time-constrained activities (e.g. remember and finish homework for Monday submission date)
- hold and manipulate things in our mind for a short duration while performing the different steps of a task/ working memory(e.g.holding information after a class and writing it down)
- control our impulses and prioritise (e.g.waiting till we finish our work before watching television)
- monitoring ourselves/ self-awareness (e.g. to understand it is not appropriate to speak loudly in certain places and reduce our tone and pitch)
- initiation (e.g. knowing when to start an activity)
Development of executive functions:
While we are not born with EF, we definitely have inherent capabilities to develop and hone these skills and this develops steadily from birth to early adulthood. Also, it is crucial to understand that executive function skills always are used in conjunction with each other and hence they develop simultaneously.
Most children start accumulating these skills from a very young age. Typically, a 6-7 month baby uses working memory to find hidden objects, a one year old baby understands and starts to anticipate the cause-effect relationship (e.g. presses a button on toys knowingly to see lights/hear music). Toddlers start processing one/two step commands like “ give me the blue circle” or “sort circles and triangles” between 2-5 years and learn to think, plan, organize and perform steps given in an instruction like “take out your Alphabet book from your bag” effectively. Also, kids start learning to control their impulses from around 5-6 months of age when told to (e.g. being told not to touch a wire). However, it is crucial to understand that kids depend on their primary caregivers to help them control their behaviors and emotions. By the age of four years, children develop enough necessary skills to build delayed gratification (e.g. waiting till break time to eat their favorite snack).
By the time children reach six years of age, they develop logical skills which help them start focusing on issues through evaluation (e.g. understanding that two vessels can hold the same amount of liquid despite being of different shapes). Evaluation skills are important and children need these skills to help them understand differences in their and others’ perspectives. This lays the foundation for more sophisticated abstract thinking and deductive skills that start to develop from early teens (around 13 years ) to young adulthood (25 years). At the same time, teens develop the ability to avoid distracting information and learn to distill their attention to focus on things that are relevant to them (e.g. not looking at other vehicles while driving but focusing on maintaining the right speed and applying brakes at signals). It is only by the mid twenty’s that individuals develop working memory or the ability to use information flexibly and manipulate them for abstract ideas to its optimal level and are able to plan and organize, think logically and consistently control their impulses for a variety of events.
What is the relationship between EF and Autism?
Learning about executive functions is crucial to gain awareness and develop better understanding about certain challenges that children with autism face. This does not mean that all children with autism experience executive dysfunctions.
Let us try to understand some of the behaviors children with autism may demonstrate and analyse them as executive dysfunctions:
Planning, organization and task initiation:
Planning an activity requires a child to build a sequential series of steps, in a reasonable amount of time and stay on task till the goal is reached. Moreover, children also must remember the steps involved in the activity and execute them in an orderly manner till the final step/goal is reached. For example, a child with autism knows “how to wear shoes” and can perform this activity independently when they want tom but cannot carry out the same activity when requested despite being highly motivated to go out and play. Even though these behaviors might be demonstrated as lack of understanding/co-operation or even a lack of motivation, in reality they may actually be planning or organizational difficulties. This can be the case in difficulty in performing daily activities like brushing/bathing etc.
These skills typically start to develop only around 3 years of age. It is at this age that children start playing “pretend” games like “party” or “cooking.” Initially, children tend to follow a rigid but simple structure and follow the same steps over and over. However, when typically developing children turn 4-5 years, they start playing these games with a more flexible approach. Around this age, typically developing children starting planning their tasks (for example, planning to write one page of homework, paint a picture). While less planning is required when performing daily habitual activities like brushing or bathing, flexibility is needed while playing pretend games with peers depending on the situation and circumstances (e.g. new child joining the group). Many children with autism are unable to plan their games or demonstrate flexibility while playing (e.g. following the same pattern in a “birthday party” game). However, children also demonstrate the challenge where they learn an array of skills and games and even play them independently, but are not able to start playing the game despite having high motivation.
It is important to understand that planning skills are associated with other executive functions which include working memory/flexibility and shifting focus between tasks. These skills together enable children to participate in social situations with their peers or family.
The ability to remember and manipulate the different but well-defined steps of an activity is called working memory. It is a short-term memory that acts like a checklist when we are performing activities and helps us control and be aware of the steps that we have performed and the steps that are remaining (for example, while shopping grocery items for baking a cake, we buy only flour, eggs, chocolates, butter, and we do not buy rice). This memory usually is working when we are processing conversations/hearing verbal requests (for example, when a parent asks a child to pack his/her lunch, the child remembers all the lunch items and fills them in their box only once). For a child with autism, since language comprehension is imminent, performing verbal instructions can be difficult. Hence many children with autism appear to be lazy or uncooperative and do not perform verbal instructions efficiently.
Shift of focus:
Sometimes we flexibly move our thinking between two tasks or between two steps in the same activity. This flexibility to effectively perform in a situation is called shift of focus/attention (for example, cutting vegetables while watching television). Difficulty in shifting focus causes children with autism to experience inconvenience whilst transitioning from one activity to another (e.g. shifting from homework to dinner). Thus these children appear to be rigidly following patterns/rules, like when a child has a meltdown after not being able to go to the park on a Sunday morning because their parents are busy. While shifting focus is required to accommodate change in circumstances, controlling impulses to sustain attention is also crucial to obtaining goals.
The ability of a child to consider their actions and suppress their instincts is called impulse control. This skill is vital to sustain a child’s attention in an activity for them to complete it (e.g. a child completes five math problems before switching on the television). Also, impulse control is crucial to developing delayed gratification/wish fulfillment that typically developing children demonstrate by the time they reach kindergarten (e.g. waiting for their turn to speak in class). Many children with autism cannot suppress their impulses (e.g. controlling their need to get up from their table during an activity or to control their impulse to hit, spit, or kick someone). These aggressive behaviors stem out of poor impulse control demonstrated by the child and is more common in children with a dual diagnoses of autism and Attention Deficit Hyperactivity Disorder (ADHD).
How to support children with executive dysfunction?
It is crucial to support children who demonstrate executive dysfunctions by providing external scaffolds (including activity breakdowns) during activity performance. Also, it is necessary to pinpoint the source of disruptive behaviors and address them with appropriate therapeutic interventions. Most importantly, understand the comprehensive nature of the presenting challenge. Not completing school work can be either a disruptive behavior or an executive dysfunction. Obtain the right support and intervention plan. The next section will be dedicated to dissecting available intervention strategies to help manage executive function challenges!
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, Kavitha 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. Kavitha recently moved to Boston after getting married and is enjoying her time travelling, writing and volunteering.