Tag Archives: executive functioning

Explore tools, strategies, and assessments that support the development of executive functioning skills including organization, planning, attention, self-monitoring, and emotional regulation across age groups and settings.

picture of a boy in a wheelchair completing an art project using the functionalhand to help hold his tools.

Executive Function – Making Strategies Inclusive

Daily Living, Therapist Resources, ,

Linda Merry, OTR/L, NDT/C

What is Executive Function?

The phrase “executive function” as described in the Harvard Journal, Developing Child, refers to a set of skills.  These skills underlie the capacity to plan ahead and meet goals, display self-control, follow multiple-step directions even when interrupted and stay focused despite distractions, among others.  

No one is born with executive function skills but nearly everyone can learn them.  Adults set up the framework for children to learn and practice these skills over time by establishing routines, breaking big tasks into smaller chunks, and encouraging activities involving rules, directions and planning skills.  

As our child becomes more competent and these areas of the brain develop, it enables them to plan for themselves.  It also allows them to focus and stay engaged with information to complete tasks.  Research has shown by 12 months of age, a child’s experiences are helping to lay the foundation for the ongoing development of executive function skills. 

Get Ready, Do, Done

Sara Ward and Kristen Jacobsen’s  framework, “get ready, do, done”, to support skill development provides a process to develop the executive functioning abilities.   This system is easily incorporated into all activities.  

Implementation

The first step is to help your child or student visualize what the project will look like when it is done i.e., what does the end look like.  Children need the opportunity to visualize the end before they plan their steps. This is especially true for a child who lacks the motor control to move their body or communication skills to verbalize their intent.  A child may have the ability to plan a task but lack the opportunity when others bring materials to them, place them on their surface and physically help with each step.

Next, you want the child to visualize the steps they need to take.  It may involve cutting a circle, drawing a picture, gluing, etc.  You want your child to think through the process. Let the child tell you what steps they want to take before beginning.

Last, to “get ready” the child should tell you what materials they need.  Is it markers, paper, ruler, glue stick, etc.?

Accessibility For The Child With Special Needs.

When a child can visualize what their completed project looks like, they can talk through the process and collect needed materials as independent as possible.  What if a child is unable to communicate verbally or walk over to get what they need?  Here are strategies that provide inclusive opportunities to use this framework.  It allows the child with neuromotor difficulties to participate in opportunities that lay the foundation for executive functioning.  The goal is to support their abilities and not allow their impairments to limit their learning.

Get Ready, Do, Done provides a visual or template to clearly demonstrate the thinking process.

Strategies To Support Inclusive Learning

  • Positioning Needs of the Child: When completing activities that require attention, concentration and upper extremity control, optimal positioning is important.  A child seated upright so they can view what their project looks like when completed.  Positioning  the child at 90:90:90 for the hips:knees:ankles  with feet supported is usually preferred.  
  • Tray Surface: Supporting the upper arm on a table surface provides a base of support for upper extremity control.  By increasing the contact surface of the forearm and hand, it provides stability and increased sensory awareness of movement in space. We have found a tray surface that supports the elbows, by curving around the body, makes a significant difference. The work surface should be large enough to fit materials and support the upper body.  Common errors are elbows falling off the table or not enough room for materials. 
  • Organization of Work Surface:  For the individual with motor coordination, it can be helpful to have a container where materials are placed avoiding knocking them off the tray.  This can be a small bowl or box that serves as a “waiting area” for items such as scissors and glue.
  • Vision Considerations: The size, colors and position of the project are important.  Placing the project that is “done” and showing what the end looks like should be of a size, position and contrast that supports vision needs.  Placing it on an easel, on the wall or at an angle that allows for easy viewing is helpful and allows the child to visually reference the project that they are completing.  Adjusting the size by enlarging pictures or having a black contrasting background may help the individual with vision impairments.
  • Activity Selection/Material Considerations:  Using templates and/or pre-made cut outs may help the individual with motor impairments.  If the end is a picture of a farm, using a template that supports coloring inside can be helpful.  Using stickers that allow the individual to place or glue them reduces the motor demands.  Forming Wikki Stix into shapes that allow the child to color inside simple shapes is another option.
  • Tool Use: Using adaptive crayons or adapted markers, glue sticks and other materials may allow the child to do the task without hand over hand assistance.  You want to reduce the motor demands when you increase the cognitive requirements.  There are many options to help children hold their own tools.  The Functionalhand allows children to hold objects in either the  horizontal or vertical orientation.  Any size crayon, marker, glue stick, dry erase markers or school tools can fit into the flexible cord system.  For children who are unable to sustain a grasp on the Functionalhand independently, the Eazyhold strap is the ideal complimentary product.  
Finished project displayed on a slant board as a visual reference for "Done"
Finished project displayed on a slant board as a visual reference for “Done”
Alistair references done while he uses the Functionalhand to paint his cow.  
Alistair references done while he uses the Functionalhand to paint his cow.  

Do 

Keeping the activity initially simple and building on the concept once the child is familiar is important. Initial activities may be to color pictures and glue them in position.   Having two sets of icons, one showing the action and the other showing the tool helps them to understand the difference.

Visual of a girl cutting- an example of an inclusive executive function strategy
Use a picture of the action for “Do”
Scissor Visual- - an example of an inclusive executive function strategy
Use a picture of the item for “Get Ready”

You may start by showing  the pictures and asking, “do we cut first or color first”.  Using “first” and “then” concepts allows your child to know there is a progression to activities and reflect on the order.  The child can point, answer or place the icons in order. 

Get Ready

Several strategies will assist the individual to be actively engaged in the “ Do” and “Get Ready” process.

  • Use picture icons that allow the child to point to or grasp to put in the “Get Ready” column. Using Velcro to keep the pictures in position may be helpful.
  • Use an augmentative communication device with a page that lists options and allowing the child to point to or use a stylus to access their selections individually. The child can then grasp the item to put into their “waiting area” bowl or box or you place them upon making their selection.

Summary

How does a child with neuromotor impairment that may lack the postural control to move, reach and communicate get the same opportunities to develop executive functioning skills as other children?  Structuring the learning opportunity and providing activities in a manner that supports their thought processes to plan and participate in the execution of tasks is important. Incorporating alternative strategies to minimize hand over hand assistance is the start.  The key is to  let the child do as much for themselves as possible both in terms of thought process and motor participation.  Learn more about Executive Functioning by listening to Therapro’s Lecture series on this and other topics.

References

Ward, S., & Jacobsen, K. (2014). A clinical model for developing executive function skills. Perspectives on Language Learning and Education, 21(2), 72-84.

What Is Executive Function? And How Does It Relate to Child Development? (N.D.) Center for the Developing Child Harvard University. https://developingchild.harvard.edu/resources/what-is-executive-function-and-how-does-it-relate-to-child-development/

Trunks

Adapting Trunks®: Inclusive Strategies for Play and Therapy

Games, Motor & Movement, , , ,

Trunks® is an engaging, interactive game developed by Diane Long, EdD, MOTR/L  and published by Therapro. Adapting Trunks® is easy to do and allows for gameplay for all abilities!

How Do You Play Trunks®?

In this game, players move their bodies, make sounds, and perform actions from memory! Gameplay involves picking an Action Memory Card and performing the action depicted. Six categories of actions are involved:

  • Musical You: Encourages creativity with motor actions that produce sounds.
  • Animal Sounds: Players mimic animal sounds.
  • Animal Motions: Players move their bodies and demonstrate how animals move.
  • Sound Like: Players recall and reproduce commonly heard sounds.
  • Pretend To: Encourages imagination as players pretend to be like someone else.
  • Show How: Involves a step-by-step demonstration of an action requiring the player to create an original sequence.

Trunks involves remembering and performing motor sequences. Players draw a card, look at the given action from the six categories previously mentioned, turn the card over and perform the action from memory. There are visual pictures as well as words on each card. On their next turn they would draw an additional card and perform both actions in their memory sequence, without looking at the cards. When an action is performed correctly, the player gets to keep their card and continue to work toward building a “trunk” (a series of 4 cards that, when combined, create an elephant’s trunk). 

The ability to perform individual actions may differ from child to child. Furthermore, the ability to memorize subsequent actions or sequences may vary as well. For this reason the game was created with many variations that afford enjoyable game play for all ability levels.

What Skill Area Does Trunks® Target?

Working Memory! Working Memory is a necessity for engaging in a variety of everyday occupations, including learning, socializing, and task completion. Sequencing naturally falls under the broader category of working memory.  Inherent to the game is the pairing of multi-modal forms of input (visual cues, reading cues, motor engagement, etc.). Read on to learn how to adapt and modify this game to target other skill areas! 

How Can Trunks® Be Adapted?

Preschool. Adapting Trunks® for this age group is easy to do! Trunks® can be used to target motor planning development for kids in preschool. Choose a card from the deck and ask the kids to complete the action. Things like pretending to lift weights, leap like a frog, and pretend to lick a drippy ice cream cone are good activities to choose. You can also use the Sounds Like cards for the kids to use their voices to participate. This is also a great option when working on oral motor and language skill. What does a train sound like?, snort like a pig, and hoot like an owl are sounds that preschool kids should be able to perform. Having their peers guess the sounds and or actions turns it into a whole group game everyone can participate in. Pro Tip: Pre-picking cards targeting the specific skill or development level of the group is always a good idea! 

Early Elementary Age. Working memory develops as kids age. Building a trunk of 2-3 trunk cards can make the game achievable for the younger crowd. The pictures on the trunk cards are helpful for the non-readers at this age (which many of them are)! Again preselecting cards can be key. If you are working with students who are nonverbal, take the sound cards out. If you are working with children who have limits in mobility, take the jumping and balance cards out. Pro Tip: For students struggling with motor planning, pre-teach and practice the actions on the cards prior to the whole group activity to help bolster confidence!

Later Elementary and Beyond. Target teamwork, this can be a difficult skill for some! Have the kids build the entire trunk, working in teams or as a whole group. Pro Tip: If you need an additional challenge, have the players remember the sequence both forwards and then backwards!

Other Helpful Tips

  • Use as many trunk pieces or make as many trunks as you have time for! For a 10 min group use 2-3 pieces or just complete one trunk. If you have a longer amount of  time, make multiple trunks!
  • Use the extra action cards or don’t! You know the players best. Is the extra challenge needed or will it be too much?
  • Playing the game Trunks is a great opportunity for co-treatments! Physical therapists, speech language pathologists, occupational therapists, and teachers all have skills that can be worked on during this game!

Trunks is a great option for targeting many key skill areas. It’s versatility makes it a great choice for a wide range of ages and ability levels. Check out Therapro’s handy guide, Gear Up for Games, for more great game adaptations and modifications. 

Sarah Glovasky, M.S., OTR/L

Modifying Games to Address Therapeutic Goals

Games, , , , , ,

Games are a useful therapeutic tool; they are versatile, engaging, and so much fun! WIth a few simple modifications games can address a wide range of therapeutic needs.  A few simple modifications can be used for almost every game:

  1. Add Visuals.  Visuals can be anything from simplified directions to communication aids, like “your turn” and “my turn”. Visuals can help those who struggle with sequencing, memory, or communication participate more independently in game play.  
  2. Change the playing position. Playing games on the floor, at a countertop, or with alternative seating helps to increase participation and access.  Playing a game on the floor allows players to play in alternative positions, like laying on their bellies. This position is great for those with postural instability, and helps increase their focus and endurance.  Another option is to use a therapy ball (add a base for stability), Alert Seat, Ball Chair, or air filled cushion instead of a traditional chair.  These types of alternative seating provides movement input which may allow those with shortened attention spans to participate longer and with more focus.  Some games like, Left Center Right, have few manipulatives making these great games to use on scooter boards or swings.  
  3. Modify the Manipulatives.  Some game pieces are just too small, too big, or too difficult for students to access.  One quick fix is to swap out the game tokens for something more manageable like a jumbo dice.  Another option, insert game pieces into putty for a bigger gripping surface.  Other modifications include using a card holder or book holder.  
  4. Manipulating the manipulatives to target hand skills. To encourage a pincer grasp, place smaller game pieces into an egg carton (or similar small container); the smaller space allows for only a few fingers to access the piece, encouraging a two or three finger grasp pattern every time the player picks up the game pieces.  To incorporate hand strengthening and bilateral coordination, use a tennis ball with a small slit cut into it.  Players must squeeze the tennis ball with one hand while using the other hand to insert or remove their pieces.  To target fine motor manipulation with insertion, use plastic containers (your recycling bin is a great resource); cut a slit in the lid and work on inserting game manipulatives into the containers.
  5. Change the game rules to address specific therapeutic goals. If your focus is social interactions, team building, or cooperative problem solving, change game play so players play as a group instead of competing against each other. If you are doing individual treatment sessions instead of group sessions, change gameplay to make it a single-person game.  When time is limited or you have participants who struggle with extended attention and focus, add a time rule where gameplay ends after a set amount of minutes.  When the game is too hard or too easy for players, add more complexity or decrease the complexity.   
Example of modifying a game; tube with cover
Example of modifying a game; coins in a clear tube
A tennis ball with a slit and a coin inserted
coins in an egg carton

With a little bit of creativity, most games can be changed, adapted, or modified in order to use them as a therapeutic tool.  Check out Therapro’s handy games guide to see these modifications applied to some of our great games!