Executive Functioning: An Overview

Like most areas of mental health, neuropsychologists seem to have experienced an uptick in the number of people seeking services in the last year. I think one of the reasons is that the pandemic and related issues have stressed our executive functions. Executive functions are higher order functions that are generally associated with the frontal lobe of the brain, an area that continues to develop well into our 20’s. Executive functioning includes planning and organizing, task initiation, task completion, working memory, and inhibiting impulses. In short, executive functioning skills underlie our ability to achieve at work and at school. There seem to be two main ways that the pandemic has affected executive functioning. First of all, the pandemic has globally increased stress and anxiety. When we feel stressed, our executive functioning breaks down. Think of a time that you felt extremely anxious and overwhelmed. I bet everyday tasks seemed daunting and overwhelming. One example I like to share with patients is my personal experience at the beginning of the pandemic. Prior to March 2020, when I left my house, I had a list of essentials items that I would repeat to myself, “Keys, wallet, phone.” This is my executive functioning skills ensuring that I did not forget these essential items. All of a sudden, this list evolved into, “Keys, wallet, phone, Clorox wipes, mask, hand sanitizer.” The very act of needing to wear a mask and having Clorox wipes in my car increased my level of anxiety. I was so focused on needing these new items that there were many times in April and May 2020 that I left my house with Clorox wipes and a mask but without my keys or phone. Secondly, without much warning, the pandemic shifted the way that we worked and attended school. The physical setting of a workplace or school adds structure that supports our executive functioning. For example, there are built in times in high schoolers’ days to go to their locker and switch out materials for class. An elementary student who spaced out when directions were given and is now unclear about what materials are needed for a science project, can look around the classroom and see what his neighbors are doing. Your workday had more structure to it, with physical meeting times, and maybe even a scheduled lunch break. Suddenly, these external structures were no longer in place. Even some of the strategies we used independently were no long relevant or helpful. Without these strategies and structure, many people who have inherent executive functioning difficulties have really struggled. In short, the pandemic has shed light on difficulties that people were previously able to manage independently. A neuropsychological evaluation can help pinpoint and quantify these difficulties, identify the etiology of these struggles (something like anxiety versus ADHD), and identify recommendations to help you or your child. This will be particularly important as we return to a modified version of in-person learning or work.

A frequently asked question that I get is to explain the difference between a private neuropsychological evaluation and a school evaluation. There are several differences, including expertise of evaluators and diagnostic considerations. Both types of evaluations can be instrumental in ensuring that your child gets the accommodations and support necessary to meet his or her individual needs.  School evaluations are conducted by the special education department of your school district and are generally completed once a parent requests a full evaluation. A school evaluation has many parts, based on the presenting issue. The parts vary by school district, but generally a school psychologist will conduct a psychological portion, a special educator will conduct the educational portion, a speech and language pathologist will conduct a speech and language evaluation (if applicable), an occupational therapist will conduct an occupational therapy evaluation (if applicable), and a physical therapist will conduct a physical therapy evaluation (if applicable). Other types of evaluations may also be completed by different specialists, such as a home evaluation or functional behavioral analysis. Each evaluator has specialized training in his or her specific field. The purpose of the school evaluation is to identify any issues that impact the student’s ability to access school curricula. “Again, this varies district to district, but most districts in Massachusetts will not provide an emotional or neuropsychological diagnosis, such as anxiety, depression, ADHD, or autism. A school evaluation may be sufficient if the presenting issue is primarily academic or specific to one of these specialized areas (speech, occupational therapy, physical therapy).” The pitfall of school evaluations One pitfall of school evaluations is that typically if a child scores in the Average range on a given measure, he/she is seen as able to access the curricula, and often does not qualify for services. A private neuropsychological evaluation will consist of one evaluator who looks at most areas a school evaluation will look at. A neuropsychologist will also be able to look more in depth at certain areas and be able to tailor the evaluation to your child’s needs. A neuropsychologist will provide a diagnosis (if relevant), which may help make a case for school accommodations. Additionally, neuropsychologists will make specific recommendations to support a child’s functioning outside of school. If you are concerned that your child may have a diagnosis, such as ADHD, autism, or an emotional disorder, a private evaluation will give you the most information.

Probably the most frequently asked question when I was doing family therapy was, “How do I make my kid STOP doing something.”  Research shows that positive reinforcement is the best way to make lasting behavior changes, not punishment. This means that you need to rethink things and concentrate on the behavior you want to increase, not the behavior that you need to stop. For example, a few weeks before quarantine started, my daughter started being mean to my son (hitting, grabbing toys, etc.). Instead of working on STOPPING that behavior, we worked on increasing the number of times that she was kind to him (although dangerous behaviors like hitting were addressed with a time out). To do this we used the positive behavior jar technique. She earned a jelly bean in a jar every time we saw her doing something kind to her brother, with the promise of a present when the jar was full. It could be sharing, giving him a hug, anything. Soon enough, she started looking for ways to earn jelly beans and their relationship shifted. Gradually, we phased out the jelly beans but she was still nice to him. “Why does this work? You are reinforcing the behavior you want to increase in two ways. First, you are giving external rewards with the jelly bean and with your praise. Eventually, most children also develop an intrinsic sense of accomplishment, first for earning the reward, and eventually for mastering something.” Once that is fully developed you can remove the external reward. It also works because it changes your mindset. Instead of looking for negative behaviors you watch for positive ones. it’s not bribery, it’s positive reinforcement. The biggest roadblock I see is the parent’s reluctance. I can’t tell you how many times I’ve heard, “I don’t want to bribe my child.” Remember, it’s not bribery, it’s positive reinforcement. Ok, it’s a little bit of bribery but we all do this all the time. Did you wait to relax after bedtime until the kitchen was clean? Or did you hold off on buying that new gadget until you completed that big project at work? You are positively reinforcing yourself! When introducing any new plan like this to your child, it is so important that you are excited about it. It’s so important that I will say it again. Be enthusiastic when you introduce it! Make them feel that this is something special that they GET to do. Better yet, create some buy in by getting the child to help by decorating the jar or chart, and identifying special rewards.

5 ultimate tips for helping your child with ADHD succeed both at school and at home. Trouble paying attention, easily distracted, acting impulsively. We, as a society, commonly think of these as negative characteristics that lead to failure at school; yet, they are also attributes of many children with ADHD. ADHD (attention deficit/hyperactivity disorder) is one of the most common neurodevelopmental disorders of childhood. In fact, around 6.1 million children in the US were diagnosed with ADHD in 2016. So, are we saying that 6.1 million children in the US are doomed to fail at school? No, of course not! Now I’m not denying that there are special challenges that children with ADHD will face at school. Research does suggest that children with ADHD are more likely to need tutoring and receive lower test marks. Therefore, as a parent or teacher of a child with ADHD, their performance at school is definitely a reasonable concern. First things first, it is most important to remember that helping children with ADHD is not about getting them to try harder. While it may be tempting, it’s actually quite counter-productive to push them to try harder to concentrate or stop getting distracted. Rather, it is about providing them with a supportive environment and appropriate accommodations for them to succeed. So, here are a few steps you (as a parent or teacher) can take to help accomplish this. 1. Get a proper diagnosis This might seem obvious to some, but it’s a step that is sometimes overlooked. Lack of treatment is a major consequence of not receiving a diagnosis. Behavior therapy provided by specialists or medication can be extremely helpful and is only possible with an ADHD diagnosis. In order to be diagnosed, one must be evaluated by a medical professional at a neuropsychological testing center, much like our very own Newton Neuropsychology Group. A medical professional will not only be able provide you with an accurate diagnosis, but also provide any medications or suggestions for cognitive-behavioral therapy . 2. Work as a team Parents, the school administration, and teachers are all essential components in creating a supportive environment for the child. Parents are vital in providing information about their child’s needs and goals to the school. This is fundamental in ensuring that all important adults in the child’s life have context and information. In turn, the school may be able to place the child with teachers that fit their learning style. Teachers can also adjust their help by minimizing distractions in the classroom. Some examples include seating them at the front of the classroom, away from windows and doors. Teachers can also observe specific behaviors in the classroom that they can communicate with the parents. "Helping children with ADHD is not about getting them to try harder...it is about providing them with a supportive environment and appropriate accommodations for them to succeed."

“Why are you feeling anxious? You’re just a kid, you have no real problems to deal with!” I, along with many of my friends, remember constantly hearing this from adults when we were teenagers. I remember feeling as if I couldn’t feel worried or scared because I hadn’t earned the right to feel that way. As if there was some magical age where it would suddenly be okay to be anxious. I’m sure I wasn’t the only teenager to feel this way. While I personally was not diagnosed with depression or anxiety, depression and anxiety are among the most common mental health disorders in children and adolescents. It’s important to remember that depression and anxiety can affect people of any age. Just like adults, it’s normal for children to have fears and worries. But when those fears and worries become prolonged or extreme, they could be due to depression or anxiety. Signs of depression Depression is more than just feeling sad or having a bad day. It's a serious condition that can affect one’s sleep, appetite, and energy levels. In children and adolescents, depression can also impact schoolwork, social life, and relationships with friends and family members. Depression in children and adolescents may not always look the same as it does in adults because they have different needs at this stage of development. For example: Some will show signs of sadness or irritability when they're depressed—but others might withdraw from friends and family members instead of expressing their feelings outwardly (like crying or yelling).  A child or adolescent with depression may have abnormal sleeping habits—either sleeping too much or not getting enough sleep. This may result in difficulty paying attention at school or being unable to complete homework. Showing signs of self-injury or conducting self-destructive behaviors. Some may cause trouble, causing others to label them as lazy or a troublemaker without recognizing it as a sign of depression. Others may withdraw from others, making it difficult to notice that they are feeling depressed. Signs of anxiety Just like with depression, the signs and symptoms of anxiety can vary depending on one’s age and stage of development. Some signs may be: Being fearful or worried about what may happen. This can include worrying about developing a serious illness or injury, being separated from parents or loved ones, performing poorly in school, disappointing others or oneself, and many other things. Excessive shyness around unfamiliar people or situations (such as a new playdate). Avoidance of specific situations that cause anxiety (for example, riding in elevators because it makes your child feel trapped). Again, just like depression, anxiety can affect one’s sleep as they could be kept awake at night. Depression in children and adolescents may not always look the same as it does in adults because they have different needs at this stage of development. Diagnosis Depression is typically diagnosed when symptoms last for 2 weeks or longer. The best way is to talk to your doctor or another qualified health professional. They can make a diagnosis and give advice about treatment options, which will be essential in learning to navigate this difficult situation. Treatment Depression and anxiety in children and adolescents can be treated with psychotherapy, medication and other interventions. Psychotherapy: Psychotherapies for depression include cognitive behavioral therapy (CBT) for younger children, family therapy for younger and older children, and play therapy with older children. Medication: SSRIs (selective serotonin reuptake inhibitors) are commonly used to treat depression and anxiety disorders Changing behaviors: While changing behaviors may not completely treat depression and anxiety, it can help manage symptoms. Practicing mindfulness, doing physical activity, and getting a healthy amount of sleep each night are all helpful behaviors. How can I help? As a parent, you can help your child by: Encouraging them to find ways to deal with their emotions. For instance, if they feel like crying, encourage them to have a good cry (if appropriate). You could also suggest some activities that might make them feel better—for example, spending time with friends or going for a walk in nature. Encouraging them to seek professional support if they need it. Learn to recognize warning signs. This is the first step to helping your child battle depression and/or anxiety. Understanding the signs and symptoms of depression and anxiety in children is the first step towards getting help. Especially since children with depression or anxiety may not show any outward symptoms, it’s important to pay attention to how your child is feeling inside. If you think that your child might be suffering from depression or anxiety, speak to a mental health professional immediately. They will be able to give you advice on how best to manage these conditions so that they don't develop into something more serious later on in life.

I can’t be the only one who procrastinates on important tasks even though I know it not only doesn’t help but also causes more stress. Procrastination is defined as the act of intentionally delaying tasks by doing less important or more enjoyable tasks in place, and was once described as “ one of the least understood human miseries ”. For example, when I have a lot of work to do, I choose to binge watch a TV show for hours, instead of actually getting the work done and eliminating my stress. The negative consequences of procrastination stretch from physical health to mental health. When we procrastinate, we are more likely to sleep less, eat poorly, drink more alcohol, have illnesses, and experience anxiety, guilt, and even more pressure. This all boils down to the question of, why? Why do we engage in procrastination despite our awareness of the consequences? Why do I choose to do literally anything else, except for the actual task that will diminish my stress? It all seems pretty counterproductive. Research has shown that the causes are a complex intertwinement of behavioral, socio-cultural, and biological issues. It can not be boiled down to one single factor as the driving force. Self-efficacy Some researchers believe that at its core, procrastination is a reflection of a person’s perception of their own self-worth and self-efficacy. Self-efficacy is our belief in our ability to complete a task, which affects our effort, persistence, resilience, and level of performance. When we are faced with a challenging task, the first thing we do is evaluate our own abilities to accomplish the task. Even if it’s subconsciously, we ask ourselves, “can I do this? Do I know how to do this?” If we have a low self-efficacy, we might abandon our tasks because of our believed “deficiencies”. As self-efficacy decreases, procrastination increases. Additionally, procrastinators tend to make a direct connection between level of performance and self-worth. What this means is that when we perform poorly on a task, we may attribute that to our own capabilities and self-worth instead of recognizing other obstacles that may have affected our level of performance. And, instead of seeing our successes as the result of our efforts, we just see it as luck. Procrastination then becomes purposeful—a method to maximize the time our pride is protected. Fear of Failure and Perfectionism Very closely related to self-efficacy, procrastination can be a result of our fear of failure. It’s easier to blame disorganization and lack of time for your failures instead of admitting your own inadequacy. An illustration of this could be receiving negative feedback on a task from a superior. If you had procrastinated, you would be able to tell yourself that the reason you performed poorly was because you didn’t spend enough time on the task, not because you were incapable. This feature of failure can sometimes come from perfectionism, even if we may not know it ourselves. Many procrastinators put unrealistic demands on themselves, feeling immense pressure. As they become overwhelmed, they will procrastinate in order to withdraw themselves from the task. Perfectionists might also believe they can achieve excellence with minimal effort. When this isn’t the case, they resort to delaying the task, avoiding the truth. Task Characteristics Finally, the nature of the task itself can also be why people choose to procrastinate. The logic behind this idea is simple: if we don’t like the task, we won’t want to do it, so we’ll choose to do something else instead. I personally hate washing the dishes. So, even when I know it will take me 5 minutes to clean the lunch I just made, I simply refuse to do it and put it off until I have to make dinner. What Can We Do? If you are someone who believes a large part of your procrastination stems from self-esteem, remind yourself that your performance on tasks is not an indicator of your self-worth. Even if you fail, that’s okay! Instead of constantly trying to protect our pride, we have to acknowledge that some tasks will just have to take more effort. It doesn't mean we're not good enough. If perfectionism is the culprit of your procrastination, try not to focus on making every little detail perfect the next time you do a task. Just get started and see where you go from there, even if it might not turn out exactly like you had envisioned. Of course, there are lots of other factors that affect procrastination as well. Anxiety, depression, lack of energy, and ADHD are all also possible causes. And, many of these factors mentioned today may not apply to you as well. But, the more we reflect on ourselves, the more we may be able to figure out why we choose to procrastinate and counteract those causes.

In the first installment of our series Clinician Spotlight, we sit down with our talented clinician Dr. Haroon Malik and find out about his journey, challenges, and values as a psychologist! 

In our ongoing series 'Clinician Spotlight', we learn more about all the amazing clinicians here at Newton Neuropsychology Group. In this installment, we sit with Dr. Kristin Schultz to learn more about her! 

There are two things I struggle with everyday: one, walking up the dreaded hill outside of my house, and two, battling cognitive distortions. Cognitive distortions, or “unhelpful thoughts”, are exaggerated patterns of thought that aren’t based on facts, which lead you to believing negative things about yourself and the world. “I did well, but I just got lucky.” “I did horrible in that interview, I’m never going to get a job.” If you’ve ever had any of these thoughts, then you have experienced cognitive distortions. It’s perfectly natural to have these thoughts, but it can have a severe impact on your mental health if it happens too often. Our thoughts are connected to our behaviors and feelings; so, let’s take a look at the different types of unhelpful thoughts so you can be better equipped to reframe them in a more positive light. 1. Overgeneralization “I’m running late and I hit a red light. Nothing ever goes my way!” Overgeneralization refers to making broad, sweeping generalizations based on a single event or experience. In the above example, hitting a red light is just a single experience. Logically, it does not predict or say anything about yourself as a person or how the rest of your day will go. But, if you overgeneralize, you may view the situation as evidence for your perceived unluckiness in life, rather than what it truly is—hitting a red light. 2. Catastrophizing “If my partner leaves me, I’ll never find anyone else and I’ll never be happy again.” Catastrophizing is when we assume the worst possible outcome will happen. It is absolutely not true that if your partner leaves you, you are doomed to be unhappy forever. It’s an unhelpful thought that causes you to view your life negatively and look down on yourself. 3. Splitting “I failed this math test, so I’m horrible at math and will never succeed.” Splitting is viewing situations or people in extreme terms. In this case, a more reasonable conclusion would be to say that you’ll study harder and do better on the next test, rather than viewing yourself in the extreme that you are horrible at math. Perhaps there were some external situations that made it more difficult to study this time. This, again, is a pattern of thought that is not based on fact. 4. Minimization “My boss just complimented me on my report, but it’s just something anyone could do.” If you’ve had this thought or something similar to it, then you have participated in minimization. Minimization refers to downplaying the importance of a positive event or personal quality. Your report just might be amazing and well-written! Don’t minimize your achievements; you are allowed to be proud of them. 5. Mind reading “My friend looks serious, they must be mad at me.” Mind reading is assuming a person’s (usually negative) thoughts based on their behavior. Before assuming that your friend is mad at you, have you stopped to think that perhaps something else happened in their day that has nothing to do with you? Or, your friend may just be concentrating on a serious task. 6. Emotional reasoning “I’m feeling inadequate, so I must be worthless.” Say it with me: My feelings are NOT facts. Emotional reasoning is when you conclude that your emotional reaction means something is true. Over the years, we’ve learned to trust and rely on our emotions. But, emotions can sometimes be based on fantasies that make us unhappy. They can be based on misunderstandings or our negative perception of a situation. 7. Fortune telling “I’m not going to get the job.” This is a very common cognitive distortion of predicting (usually negative) outcomes before they occur. Why do you think you’re not going to get the job? There may be some factors that have led you to this conclusion, but there is much more that goes into whether you will actually get the job. Perhaps you had a great personality fit with the interviewer. Maybe you were the most competitive out of all the other applicants. Perhaps your experience lined up with the job requirements the best. There are so many other factors that you are unaware of, so you are drawing this conclusion without knowing the majority of the evidence. If we are aware of these types of unhelpful thoughts, it will be much easier to know when our minds are playing tricks on us so that we can reframe our thoughts.