Executive Functioning: The Mind’s Gatekeeper as a Barrier to Healthcare
Your friend Samantha is always 10 minutes late. So much so you’ve begun telling her things start ten minutes earlier than they do. You made your husband the grocery list so he would get all the stuff you needed from the store…then he left the list at home. Your son is constantly being told “pay attention” or “stop day dreaming”.
All of them, and all of us, are constantly being challenged in our day-to-day lives to put our executive functions to work. And when they don’t work, someone usually notices…and it’s not usually positive. Executive functions (EF) are those brain-based skills that we need to plan and direct activities. These involve aspects of both thinking (e.g. working memory, planning, organization, and time management) as well as doing (e.g. response inhibition, emotional control, sustaining attention, and flexibility). The difficulty with EF is that they don’t develop in a smooth, continuous slope. They may be periods of increased use, then not. In addition, EFs don’t just all come online when a child is young. For some of us, they might not come online at all. Thus, the need for intervention. For example, a 5-year-old is just learning to shift her attention, inhibit herself when needed, and perspective take. If a caregiver does not understand that these EFs are just coming online, thus having unrealistic expectations, this can result frustration for all parties.
Executive functioning difficulties are commonly associated with learning and mental health disorders. However, it is important to understand that one can have EF challenges even without a disorder. For example, I don’t have the greatest memory, so I am a list maker. Conversely, there are conditions that we know we can expect the person to then have EF challenges. These include (but are not limited to) ADHD, Autism Spectrum Disorder, Anxiety, Alzheimer’s, and those with traumatic brain injuries. We often see then a negative domino effect when EF demands are placed on those that do not have strategies to make up for their challenges. A demand is placed, the person has insufficient EF ability, there is EF overload, the person gets anxious/overwhelmed, they look as if they are not complying, an argument or behavioral reaction may ensue, and then the other person acts as if the person was being willfully lazy or disobedient. Thus, instead of teaching to a skill’s deficit, we have created a punishment.
As a health care professional, you may find struggles for those with EF deficits in in the context of health care. These can include: trying to get a patient to start and be consistent with a new medication regimen; teaching a patient the steps to care for their wound; or when directing someone to follow-up (e.g. referring to another clinic or getting them to go get labs). In such cases, you can support the EF challenges by:
Creating a visual schedule or instruction to match verbal instructions. Make sure to break down the steps. If you just say “change the dressing”, but don’t include when, with what new material, and if they have to also clean it—then steps will get missed.
Demonstrate and practice. When possible, show once, do together once, and have them practice once independently.
Doing what you can together. Have them set a reminder in their phone while still at your office for their next appointment or when they should call the lab. Have them make the call to the provider you are referring to while in your office. If it is medications they need to remember, while in your office, have them download the free Medisafe app to their phone and set the pill reminders with them.
Making it memorable. It seems silly, but if possible find a date for their next appointment that is memorable. A random Tuesday at 10am when they are in their regular work routine can easily get forgotten. But if they set a date that has other significance, it is more easily remembered. For example, that is the first day of their kids’ spring break and they are already going to the dentist, so that becomes the “day of appointments.”
Having some swag. Let’s face it, kid or adult, we all love rewards and free stuff. You get a new toothbrush at the dentist office, you are excited to open it and use it. You give out a lollipop or small sweet every time a patient leaves, they remember.
Things we can all do:
Use a success-based model. Determine what is already going well and do more of it. Incorporate those components into new learning. Make sure to think outside the box and use things the person already likes.
Directive versus reactive. Avoid questions like “Why would you do that?” or “What were you thinking?” are not helpful. Instead, provide choices. Make the environment supportive by having visual supports. Praise effort!
Prepare the environment. Have a dedicated workspace that is clear of clutter and distractions. Use a timer to set small goals and allow for breaks. Use positive reinforcers to keep you going (e.g. a coffee/snack break or some time to go outside). Turn off/go cold turkey from social media, television, and other distractions during worktime. Don’t have walls covered with distracting posters, things hanging from the ceiling, and music rocking. Instead, create clean spaces. Use visual supports (e.g. calendars, reward charts, visual directions). Even labels on bins can help better organize environments.
Practice, practice, practice. Just like our bodies, our brains need training. Making a list once won’t make your memory better. Remember to practice when you are not already stressed and overwhelmed.
No magic pill. Pharmacological treatments usually only address the problems associated with the EFs (e.g. inhibit, modulate, focus/select, sustain). Most people with EF challenges will require additional interventions to assist with the additional self-regulation difficulties that persist even when medication is being used effectively.
Use resources. Use times, lists, planners, and other tools. There are wonderful books that give great tips (Smart, but Scattered by Ped Dawson and Richard Guare; CEO of Self by Jan Johnson-Tyler; and Executive Skills in Children and Adolescents by Ped Dawson and Richard Guare).
Additional websites and organizations that can offer help include:
Center on the Developing Child (www.developingchild.harvard.edu)
Child Mind Institute (www.childmind.org)
Learning Disabilities Association of Minnesota (www.ldamn.org)
Of final note, it is important to remember that what might look like an EF deficit could actually be a behavioral or emotional block that is not related to EF. For example, a patient who recently found out they have a significant medical diagnosis and they are supposed to take next steps for follow up, but they tell you they “forgot” or are “just too busy to remember”. Instead of an EF deficit, this may be a patient who is struggling with the diagnosis and may be fearful to take next steps. Thus, while you can provide great strategies, it is also important, in your already busy schedules, to spend a few extra minutes checking in with your patients and assessing the underlying cause of the behavior. You can always use your mental health colleagues as well!
Miranda Gilmore, Psy.D., LMFT, LP is a Licensed Marriage and Family Therapist and Licensed Psychologist who currently works as the Senior Clinical Manager of Clinical Staff Development at Fraser. Her work includes clinical management, supervision, testing and evaluation, therapy and service linkage for children and families. Dr. Gilmore is one of several staff who offer Executive Functioning workshops at Fraser. For more information, visit www.fraser.org.