Thursday, September 13, 2012

No Mind Left Behind, a book review

Recently, I got a book called No Mind Left Behind: Understanding and Fostering Executive Control - The Eight Essential Brain Skills Every Child Needs to Thrive, by Adam J Cox. The title makes it pretty clear what the book is about - it's a book explaining executive dysfunction in layman's terms to parents, and giving them advice on how to help a child build better executive functions.

For the most part, it's a pretty good book. There are some things it got wrong, however. I think how I'll organize this is to first discuss the introduction, and then discuss the meat of the book, and finally the conclusion.

Firstly, personally I find his renaming executive functions as 'Factor Ex' a little annoying. To me, it comes across as condescending. But this could be just me, and it's really not that big a deal, so we'll move on.

This is another of those books saying 'IQ isn't what determines success, this is'. Those books tend to make me feel discouraged, because I have a high IQ but usually lack whatever they think really determines success, but that doesn't mean they don't have a point. And when it comes to executive functions, much as I hate to admit it, executive dysfunction is a big impediment to success. I'm just as smart as my father, who mostly got straight As in college. However, I have yet to earn an A - I usually get Cs, and I'm excited if I get a B. The difference is clearly a matter of executive dysfunction. Specifically, I rarely study my material, and when I do it's far less intensely and efficiently than most people. This means I get less practice at it, and it takes more for me to learn it. I usually compensate by picking classes where I've had, or currently have, a fascination with the topic, and the few classes I've taken that weren't major interests of mine I barely passed. I'm gradually learning how to study, but it's not just a matter of being told a good strategy and trying it out. I need to find something I'm capable of doing and not burning out, and my weak executive functions mean I burn out quickly if I use them too much.

He also discusses the relationship between ADHD and executive dysfunction, explaining it by saying that all kids with ADHD have executive dysfunction (attention is an executive function, and so is inhibition), but not all kids with executive dysfunction have ADHD. Which is certainly true of me. Although I identify with a lot of what ADHD people say, and have found many of the non-medical interventions for ADHD helpful for me as well, I've had numerous experts tell my parents quite clearly that I do not have ADHD. (None of them considered autism as a possibility, however.) I do think it's possible to be autistic and not have executive dysfunction, although it's uncommon. My Dad, although he's undiagnosed, he himself, our family, and several people knowledgable about autism have all suggested that he's probably on the spectrum. But as I said before, he shows no sign of executive dysfunction.

One error I can see is in his use of the word epigenesis. This is a fairly new concept in genetics, and not very well understood outside of that field. It does not refer to how the brain rewires itself in response to the environment, which is how he uses the term. Instead, it refers to how genes are turned on and off in reaction to environmental stimuli, and is a process that goes on throughout the entire body. Epigenetics also allows for a form of Lamarckian inheritance, because the activation patterns of an embryo/fetus' cells can be affected by the mother's biochemistry. The way the brain rewires itself is referred to as neuroplasticity. It may be powered by epigenesis (I'm not sure on the details), but it's not the same thing.

And now we get to his checklist. (Personally, I find filling out checklists about myself exciting, so I was happy to get to this point.) Each section has six questions, each of which can be rated as 'about average' or 'lags behind' in comparison to others of the same age. I can tell by the wording that it's intended for school-age children, but I think it's valid for me as well, as long as we keep in mind that my peers are most people in their early twenties. With each section, if at least three options are checked 'lags behind', the child is considered impaired in that section. If the child shows impairment in two or more areas, they recommend seeking an in-depth evaluation and team intervention (code for: your child probably has a clinically significant disability affecting executive function).

I answered it with my Dad's help, because he knows more about what 20 year olds usually can do. We weren't certain how to answer three options, because they referred to things I can do sometimes but not consistently. If you count the uncertain ones as 'about average', I'm impaired in six of the eight areas of executive function - if you count the uncertain ones as 'lags behind', that jumps to seven, with the only area of executive function that is unimpaired being 'sustaining attention'.

So now I will discuss each area of executive function separately, because he has separate chapters for them.

Initiating Action is the area where I go from unimpaired to impaired depending on how we interpret the uncertain ones. It includes these items (my response after each one):
  • Begins homework/jobs with little or no prompting - lags behind
  • Knows how to set goals for personal accomplishment and follow through - variable
  • Devises solutions to solvable problems; doesn't just "hope they'll go away" - variable
  • Sets a specific time to act (says "I'll do it after dinner" and does so) - lags behind
  • Rarely makes excuses to avoid action - about average
  • Independently pursues hobbies and activities of personal interest - about average (actually, I'd say I'm ahead in this)
This is about getting started. He starts by distinguishing between difficulty initiating and procrastination. He says that procrastination is motivated, consciously or unconsciously, by expecting a negative outcome of doing the task (eg 'I don't want to get my driver's license because then I need to get a job to pay for the insurance'). In contrast, a person with difficulty initiating wants to do the action, but gets overwhelmed at all the actions involved in actually doing it (eg 'I want to be a lifeguard, but all the things you have to do are so overwhelming, I just give up'). In other words, they get lost in the procedure, which is a common indication of executive dysfunction. By that definition, I've shown both procrastination and difficulty initiating, although I'm learning to replace procrastination with direct refusal and an honest explanation (eg 'I can't take the garbage out because I have OCD tendencies and the thought of touching that dirty garbage makes me feel panicky' instead of agreeing to do it and then avoiding thinking about it until my Dad gets fed up and does it himself).

Unfortunately, after that gem, he goes into a long talk about metacognition. While difficulty with metacognition can be a significant issue for a kid, it's a different issue from difficulty initiating. When I'm having trouble initiating, I know exactly what's going on. I can analyze it in detail. But that doesn't necessarily mean I can get over the hump and get started doing the thing. I can talk about all the steps involved in writing a good cover letter to send off to a publisher to get your manuscript published, and I can talk about exactly what I find difficult in that process. But I still have only sent off about five or so cover letters, which isn't enough given how many manuscripts get rejected. Admittedly, metacognition is a very useful skill for someone with executive dysfunction of any form, because it allows you to find workarounds - for example, I'm often deliberately impulsive because otherwise I can't get started. But I'm not sure what a discussion of metacognition is doing in the initiation chapter.

Then he talks about prioritizing, which I think is more relevant. They say there are two kinds of difficulty prioritizing, poor organization and poor work-play balance. Poor organization is just getting so overwhelmed by the option that you can't pick which one to do first. In contrast, poor work-play balance is emotionally motivated - you'd rather do the things you enjoy first, even if other things are more important. (Not to say that this isn't also an executive dysfunction, because emotional control is one of the executive functions.) Oh, and he has another checklist! (Two or more 'yes'es in a section indicates an issue.)

Organizational challenges:
  • Doesn't see a logical sequence; starts in the middle or at the end first - no (here I think my excellent conceptual reasoning helps; the sequence itself doesn't stick in my mind, but I can reason it out by understanding cause and effect)
  • Tries to do a little bit of everything at once - no
  • Doesn't allot enough time fir the most important steps of the task - yes (because I have no time sense and therefore no clue how long things take)
  • Has trouble seeing how things are accomplished in steps - yes
  • Makes the same kind of procedural mistakes over and over again - yes
Work-play balance (note: this is answered counting things involving my special interests as play, even if they're what most people would consider work, because they feel like play to me):
  • Always feels inclined to play before work - yes
  • Demonstrates very different energy levels when doing work vs. play - yes
  • Thinks there will be enough time for work after play, even when there isn't - yes (this is because when I'm playing, hours can go by without me noticing)
  • Can be remarkably persuasive in convincing you that he or she will get to it after play - no (my parents know me better than this!)
  • Unless you are literally standing there to supervise, often leaves chore or project to go play - yes (often I don't even realize it, such as when I shift from cleaning my room to reading the long-lost book I just found)
  • "Forgets" to let you know about situations likely to result in work. ("Matt didn't tell me he spilled the paint, because he knew I'd make him clean it," or "Cicely didn't tell me about the book report because she was invited to a party that weekend") - no (I really, honestly forget, and if I do remember, I'll tell my parents)
So, I have 3 yeses in organization and 4 in work-play balance. Incidentally, I noted that I answered for special interests as play - this is one reason why making use of special interests is so important with autistic students. To the autistic person, pursuing their special interest is just as exciting as typical play is for neurotypicals. But many special interests can easily be turned towards completing schoolwork, or even paying work. Imagine if you could get a kid just as excited about doing their homework as most kids are about playing ball with friends. Well, with an autistic kid, this is a distinct possibility, if you frame the homework the right way. My plan is to make a career out of my fascination with psychology, and essentially spend my lifetime getting paid to play all day.

As for his recommendations, they recommend: a) explaining why tasks are a priority, b) making the task enjoyable (he doesn't outright state this, but gives an example where they turned cleaning a room into pretend play), and c) breaking things down into small steps and working on each step one at a time.

He also makes the important note that when a child is having trouble initiating an activity, you shouldn't start blaming or lecturing them. (This applies to procrastination as well, especially since it can be motivated by anxiety.) Instead, they recommend helping to break the task down and guide them through it. When a child is having trouble making a decision, they suggest writing down (or drawing for younger children) their options and going through the pros and cons of each.

And then he gets to time sense. Although on the face of it, this seems distinct from poor initiation, there is actually a very close link - if you plan to do something at any time other than right now, you need some way of knowing when that time has come. They describe how children often have trouble imagining the 'space' of time, lose track of time when they're having fun, and don't keep in mind how many things they need to get done in a given amount of time.

Flexible Thinking is an area where I scored as lagging behind in three out of six aspects:
  • Can analyze a situation from multiple perspectives - about average (actually, probably better than average)
  • Is able to have fun with available toys/diversions - about average (actually better than average because I daydream so much; this used to cause conflict while babysitting my brother when he was younger, because I forgot to make sure he had something amusing-to-kids to do, assuming he would be as proficient at daydreaming as I was at his age)
  • Can adjust to atypical behavior in a friend ("Justin's grumpy because he's sick") - lags behind (I'm perpetually mistaking my Dad's arthritis acting up for him being mad at me)
  • Transition times rarely incite tantrums/excessive anxiety - lags behind (this used to be a major issue, now it's much less but I still have more struggle with transitions than most young adults)
  • Can adapt to changes in meal or bedtime routine - about average
  • Adapts to impact of new peer on social group - lags behind (some good friendships were ruined because I didn't know how to handle the way things changed when we added a third friend)
One of the big reasons I don't meet criteria for ADHD is because my attention is different in the opposite direction - while an ADHD kid tends to move on very quickly to thinking about something new, I keep on thinking about one thing longer than most. When I was a kid, I struggled with changing periods, and would seem inattentive because I was still on last period's topic instead of shifting to this period. Now, in university, I usually have free time right after a university class, and I spend this time thinking/talking/reading about the topic discussed in class. Most people can do this and find it beneficial to their learning, I have to do this because I don't transition well.

Incidentally, he discusses some scientific tests for flexible thinking. I've found a test online that tests shifting attention, along with verbal memory (it's intended to screen for dementia, but can be indicative of many conditions). I took it awhile ago, but since I couldn't find where I saved the results, I retook it just now, and the results were similar to what I remembered - normal in verbal memory (immediate and delayed) and poor (though better than last time) in shifting attention. (I scored 79, and this test is normed just like an IQ test, so that's in the borderline range. Before, I scored in the 60s.) They also mention the Stroop Test - while everyone shows slower responding when asked to name the text color of color words written in the wrong color of text for the word, this effect is magnified in people with difficulty shifting. However, I haven't been able to find an online version of the Stroop Test that tells you how your results compare with the norm, so I don't know if this is true of me.

Then he discusses the relationship between flexible thinking and creativity. Personally, as an inflexible but highly creative person, I'd say this relationship isn't as strong as many people believe. Whether you can think up many different things when you're not stuck on a single idea is a different skill from how easily you get stuck and unstuck. A lot of people with difficulty shifting attention may not test well on tests intended to assess creative thinking because they got stuck on one thing and couldn't move off of it. But on their own time, under the right conditions, they may come up with many different ideas spontaneously - I know it's true for me. I raise the question of whether you can actually test creativity, given that creativity often doesn't take place on demand. Personally, I'd think a better test is to analyze what the child has created spontaneously, rather than asking them to create on demand. (Or, if you want to ask them to create on demand, give a lot of lag time - hours or even days - between each production.) And if you tested it that way, my guess is that there would be a lot less of a link between creativity and shifting attention.

Next, he talks about how social skills are affected by poor shifting, and says that kids who are poor at shifting are very often self-absorbed. He explains the distinction between self-absorbed and self-centered by saying that a self-centered person doesn't care about others and may be described as egotistical, while someone who is self-absorbed is so caught up in their own thoughts and feelings that they can't perceive what others are experiencing.

He then lists how poor flexibility can affect social interaction. To me, it seems like he's practically equating inflexibility and autism here, when I personally think they're distinct but related. (There are highly inflexible kids who are not autistic, and occasionally you find autistics who are reasonably flexible.) He says that inflexibility can cause a) difficulty with conversational pace, b) poor eye contact (too much or too little), and c) difficulty stopping talking long enough to listen.

Personally, I think the conversational skills he mentions do have a lot to do shifting attention, but eye contact doesn't. To me, poor eye contact can result from several things:
  1. Visual hypersensitivity - This causes eye contact to be experienced as painful or overwhelming, making it uncomfortable for the person to make eye contact. Therefore, they avoid eye contact for much the same reason most people avoid touching a hot stove.
  2. Decreased interest in faces - Research shows that neurotypicals, right from birth, have a fascination with faces, and newborns can even recognize individual faces of family members. There is a region of the brain known as the fusiform gyrus, which is associated with 'expert' visual recognition (for example, birdwatchers use this region to recognize bird species, and car aficionados use it to recognize cars). In most people, this region also recognizes faces (essentially, most people are 'face experts'). In many autistic people, this region works fine, but it doesn't recognize faces, because the autistic person's brain doesn't single out faces as being particularly important. This also results in reduced eye contact, because their eyes aren't drawn to faces the way NTs' eyes are.
  3. Not understanding the meaning of eye contact - This has to do with not knowing the nonverbal 'language' that most people know. This isn't because of difficulty shifting attention, because it'll affect both shifting-related behavior and non-shifting behavior such as 'held' facial expressions (as opposed to microexpressions, which do shift).
Then he discusses processing speed, commenting that slower processing can contribute to difficulty shifting. Processing speed correlates with IQ, but not perfectly - there are highly intelligent kids who process things slowly. (I agree, though, that in my experience, most people with cognitive disabilities are slow processors. It's recommended, when talking to a person with a cognitive disability, to give them extra time to respond because it may take them longer.) A person with slower processing will have trouble transitioning because it'll take them longer to realize what they need to be doing. They also note that both faster and slower processing can cause conflict with others who process at a different speed than you.

And then he makes one of the single best recommendations for dealing with someone who has trouble shifting attention - give advance warning of transitions. I can't emphasize this enough. This makes a huge difference. For me, it can mean the difference between having a meltdown or being ready without any fuss at all. If you don't warn me, sometimes even a transition I want can be stressful ('your turn on the computer' 'no, I'm not ready!'). If you do, even unpleasant transitions can often be handled fairly well.

He also points out that tone makes a big difference - whether you're nice about it, or whether you announce the transition forcefully and abruptly. He points out that no one likes when someone 'pulls rank' and tries to force you to do something without concern for your own interests. When you're already struggling to do something you find difficult (shifting focus), it makes it a lot harder if someone adds the stress of dealing with a conflict over your failure to shift quickly. (In general, in my experience, stress makes all executive functions work less efficiently.)

He then brings up the concept of surrogate executive control, which he says is a great way to coach executive control. (To me, this is reminiscent of the 'external brain' concept in the FASD community.) By prompting, reminding, checklists, preparation, review, rehearsal, thinking out loud and prioritizing, a parent can help a child with executive dysfunction remain organized. Often, with help of this kind, the kid will grow until they can start managing those things on their own. If they don't, they may need ongoing help in adulthood, which is often overlooked because executive dysfunction is so poorly understood. He also describes a number of games that can teach flexibility in children. For example, you can try a 'double game challenge' where the two of you play two games at once (eg tic-tac-toe and hangman), shifting whenever a timer goes off. (I can tell you that I'd do a lot poorer under those conditions.)

Then he discusses the relationship between flexibility and anxiety - specifically, many kids become inflexible when they're anxious. (I know I do!) Fear of change can be due to not knowing what to expect and whether you can handle it. Personally, I'd add another comment - this can be a bigger issue for many people with neurodevelopmental disabilities, not only as a direct effect on their disability, but also because of having an invisible disability that requires accommodation from others.

When I go into a new situation, I never know if the person will be a) do what I need without needing to be told about autism, b) not understand intuitively but be willing to listen when I explain what I need, c) refuse to change their ways and expect me to rewire my brain to suit them, or d) overreact to hearing that I'm autistic and start treating me like I'm helpless. The more I experience c) and d), the more leery of new people I become. Even the b) type of people can be a problem, because I don't always predict what needs to be explained before a crisis occurs.

Then he discusses deliberate rigidity. He says this can come out of a strong-willed temperament, a kid who doesn't like others asserting power over him or her. For these kids, it works best to explain and coach changes in ways that make it clear that you're not just being bossy and controlling, and to build an alliance with the child. Remember, to the child, this is of vital importance, and they're willing to sink in all they've got into a power struggle with a parent.

Furthermore, he points out that uncontrollable stress can make a child seek control in whatever place they can find it. He cites the case of a 12 year old boy whose parents were going through a contentious divorce, and the kid reacted by becoming almost completely inflexible with what either parent wanted him to do. He says when inflexibility comes out of uncontrollable stress, psychotherapy is usually the best solution.

Sustaining Attention - the one area I don't have issues with. I checked off only two of the six, and those could be related to other areas of executive dysfunction.
  • Able to track and follow directions involving three or more steps - lags behind (I have trouble with sequencing)
  • Can adequately block distractions when needed - about average (actually, I'm too good at this, and miss needed background cues when I'm concentrating)
  • Can tolerate boring or repetitive activities - lags behind (pretty much the only time I act distractible is when I'm trying to focus on an activity I hate)
  • Remains quiet enough to optimize ability to comprehend - about average (talking a lot can aid my comprehension, so I tend to be more talkative when learning than most people, but never to the point where it interferes with my understanding)
  • Can read a book or listen to one being read - about average (I used to read pretty much nonstop when I was 10-12 years old)
  • Doesn't make you feel rushed to finish a conversation before s/he "spaces out" - about average (interrupts, yes, but if I space out it's more at the start of a conversation because of difficulty shifting attention)
This is the classic issue of ADHD. But he points out that ADHD is often used as a catch-all for kids with executive dysfunction, even those who don't struggle with attention. (My teachers certainly confirm that impression.) He also points out that more is needed to succeed at a task than simply paying attention.

Then, once again, he goes into the difference between deliberate behavior and executive dysfunction - this time talking about the difference between disinhibition and purposeful inattention. He comments that kids who can't block out distractions aren't tuning you out - they're paying attention simultaneously to you and everything else around, and they can't process it all. My impression is that highly distractible kids may in fact be less capable of deliberately tuning out an adult's commands, just like they're less capable of tuning out their classmates' conversation and the bird flying outside the window.

He says there are two big benefits to paying attention - learning and social interaction. Regarding learning, you can't retain what you didn't absorb in the first place. Secondly, people judge how much you care about partly by how well you pay attention to them. Empathy involves paying attention to how other people feel. (Incidentally, distractibility can also make you more empathetic, in situations where the stimulus provoking empathy is irrelevant to the task at hand. This study's finding that aggressive/destructive toddlers were more empathetic than well-behaved toddlers could be explained by this phenomenon, given the overlap between ADHD and externalizing behavior problems.)

He goes on to describe attention in three dimensions - length, width and depth. Length is how long you can remain focused on one thing. He says the longer you can focus on one thing, the more you can learn about it. Most of his examples feature kids struggling against distractions, however, which I'd put more under too wide of attention. I'd say length of attention has more to do with how much energy it takes to sustain attention on one topic - when you run out of energy, you have to shift focus to restore your energy.

Width is whether you're focusing on one thing, or several. For example, a kid with a narrow focus may be searching for a lost puzzle piece on the table, but not think to check the floor as well. A kid with a broad focus may be unable to narrow things down enough to act, or unable to tune out other things.

Depth, he says, is the ability to maintain consistency in their focus. He comments, for example, that on a continuous performance task, variability in performance predicts ADHD better than the average reaction time, number of missed targets or number of inappropriately selected targets.

He also mentions how anxiety interferes with attention. This study on the association between PTSD and ADHD confirms this observation of his. He notes that very often kids can easily recognize how much the elimination of stress could impact on their ability to focus, but parents may be pleasantly surprised by this. In a child with both anxiety and attention issues, addressing the anxiety is the first thing to do - the attention issues might disappear altogether once the kid is less anxious.

Thrill-seeking, too, can impair attention. These kids have a battle between their emotional desire for a thrill and their attempts to pay attention, and very often, the thrill-seeking wins. In some cases, this can be driven by a desire not to think about something upsetting, such as a traumatic experience. (I'd add that in other cases, it can be due to a reduced sensitivity to stimulation which means that only the most intense stimulation brings any excitement to the child.)

He discusses several ways to help attention. Visual cues, firstly, can be helpful, since many people take in a lot more visually than they do auditorally. Proximity is another thing - simply moving an inattentive kid to the front of class and away from windows can make a big difference to their attention. More generally, distraction-free spaces can help in a lot of situations. He also points out that many homes are designed in a way that bombards with stimulation, with the TV constantly on, kids running, people yelling to be noticed and clutter everywhere. Lastly, he points out the importance of physical activity. (I've noticed myself that many fidgety kids focus better after they've had an opportunity to be active.)

The next chapter combines analysis of two related areas, both of which I struggle with.

Organization is one of the areas I have the most difficulty with - 5 out of the 6 items were marked as 'lags behind'.
  • Consistently brings all homework/school notices home - lags behind
  • Keeps personal belongings organized and accessible - lags behind
  • Can pull together elements of personal wardrode - lags behind
  • Bedroom basically neat; messes confined, not "chaotic" - lags behind (I had to move out of my first bedroom and sleep in the living room because it had gotten so dirty as to be uninhabitable)
  • Could follow the directions to make a simple recipe, such as pancakes - about average
  • Uses school book bag/locker effectively - lags behind
Planning is not as badly off as organization, but I still lag behind in three areas.
  • Is rarely short of time to complete projects - lags behind
  • Can think beyond "today," saving money for tomorrow or next week - lags behind (I can only save money by forgetting I have it)
  • Is able to coordinate multistep projects in order, e.g., draw, cut, paste - about average
  • Considers consequences of actions - about average
  • Understands what a priority is and why they are useful - about average
  • Notices factors that could impact plans, e.g., checks weather before dressing - lags behind
He refers to organization as managing space, and planning as managing time. He also makes the note that you need a balance - you can be too organized, and some degree of disorganization is important for creativity.

And he says that effective planning has three elements - thinking ahead, sequencing steps and time awareness.

Thinking ahead doesn't just mean having goals, but having clearly articulated goals and thinking through the details. In my case, I often have goals but no clue how I'd actually put them into action. He recommends asking kids to articulate their goals, think through the details and make time for planning, as well as praising them when they spontaneously think ahead.

Sequencing, he says, is the most important part of planning. He recommends parents teach by example, describing the sequences they follow. When the child gets frustrated, talk them through it. He also recommends reading 'The Little Red Hen' to kids, which irks me because I hate that selfish little hen (I wrote a version of the story once in which I explained why each of the other animals didn't help), but I do see the lesson in sequencing to that story.

Time awareness is the aspect I find most difficult. Here I think he doesn't get the real issue. He talks about time awareness as something that grows with age, but there are some people who literally don't have a mental clock. I've had it happen that I ask someone the time, and they reply before looking at their watch, and are correct. If you asked me to answer the time without looking at a watch, unless I'd recently gotten a time cue such as eating lunch, I'd pretty much only know if it was morning or afternoon. (And if I've missed lunch, not even that.)

Looking at his recommendations, the ones for preschoolers seem to be at about my level of time awareness. He recommends using analogies ('as long as it takes to sing the ABC song') - well, one of the best ways I keep track of time is by watching TV shows. ('Two more Pokemon episodes until lunchtime.') He recommends talking about how time feels longer or shorter at different times and to different people, and suggests using a timer. All of these are helpful for me as an adult. (The only one in his preschooler recommendations that wouldn't help me is avoiding confusing statements like 'I'll be there in a minute' when you mean fifteen minutes. 'A minute' doesn't really mean anything to me, I won't notice if you take longer than a minute to do something.)

Elementary school aged kids, he suggests, should be asked to participate in decisions about time ('should we spend more time at the zoo and skip ice cream, or leave now and get a cone?') and to have a regular schedule. I can participate in decisions about time if they're phrased in terms I can understand, but a regular schedule doesn't help much. We've had pretty much the same 'getting ready in the morning' schedule for ten years at least, but I still need prompting to complete all the steps of getting ready. (Schedules consisting of 'be there at X time', such as my class schedule, are easier, because all I need to do is figure out a trick to tell when X time is.)

With teens and preteens, he recommends a bunch of stuff that's way over my head. Getting the child to write out their own schedule. Estimating the time a project will take and testing how accurate your estimation was. (In my case, no matter how much I train, it's pretty much random.)

Then he discusses how planning affects social interaction, telling the story of a kid who failed to produce his assigned portion of a project he was passionate about, and how this made the other kids think he didn't care about it. This bit made me feel really down, and I ended up having a lengthy talk with my Dad as he tried to reassure me. It horrifies me to think of people assuming I don't care when I fall down in my planning skills. As I write this now, tears are coming to my eyes. So many times I tried and failed - now thinking that people thought I didn't care... (And why would they think that? It makes no sense to me. It's obvious that wanting to do it isn't the same as being able to do it.)

Poor planning has another impact socially. I have a good friend at my old university who understand about my poor planning skills and doesn't read in things that aren't there. But when my family goes on a trip to our old home, often I don't realize they're headed there and contact my friend in time for us to arrange to meet while I'm in town. I miss out on chances to hang out. It's actually worse when I live in the same town as someone but don't have a regular event that we share (such as classes), because I lack the cue to when I should try to arrange to get together with them. Many good friendships within classes ended as soon as the class did because I couldn't get organized enough to keep in touch.

Then he discusses how emotional barriers can affect planning/organization. Anxiety, of course, features here. Sometimes kids can get so paralyzed by worry that they can't make a plan. Or fear of failure can make them toss out a plan already-made. Perfectionism can mean setting unrealistic goals and getting bogged down.

Also, sometimes kids don't want to acknowledge the real reason for avoiding a task. This is one of the most frustrating things about my brother - many times he'll suddenly start acting extremely selfish, refusing to do something and giving a ridiculous, self-centered reason. Then, when he finally admits the real reason, it's something that makes sense, that we could've easily worked with.

For example, one time we bought hot lunches and drinks, and were going to carry them across the street to my Dad's office. I took the hot lunches and told him to carry the drinks - he refused. Why? Supposedly he thought it was my job to carry everything, for some reason. I went into arguing mode, dug in my heels and had a full-on fight with him, to no avail. Finally, he admitted that in reality, he didn't want to carry the drinks because the cold hurt his skin. Had he told me this from the start, I'd have taken the drinks and had him carry the hot lunches.

Lastly, he points out that many kids find planning boring. He suggests with these kids that you a) build excitement by talking about what those plans could bring them, b) give them an ultimatum, or c) reward hard work.

Then he discusses kids who overplan - such as kids who can't tolerate a change in routine, or kids who try to plan out everyone's actions as a control strategy, or kids who try to plan things out to make sure nothing happens that they don't want. Personally, I'd disagree with his implication that these kids are too good at planning, because very often this kind of behavior is a compensation for poor executive functions. A kid who insists on routine may do so because they can't easily think up new plans and find not having any plan terrifying. And kids who try to control others might be unable to adjust to the wildcards that other people's plans can throw in. You do have to have a minimal level of planning ability to show this kind of behavior, but the kids who are best at planning typically don't need to control everything to have their plans work out.

Then he talks about messes. He first questions why we treat neatness as such a desirable trait, and give approval to kids for being neat. This never made sense to me. Sure, being neat means you can make better use of your things, and reduces the risk of pests or rotting forgotten food. But 'cleanliness is next to Godliness'? How on earth did it get such overblown importance in many people's minds? What kind of silly God would care more about how clean your room is than how kind you are to others? Seriously, if God has any sense, he'd prefer a kind but messy person to someone who shames that messy person for being messy.

He points out that it's far better to teach kids how to be neat than to try to instill neatness as a value. Don't personalize it, set clear expectations and limits, and be ready to tolerate a mess now and then.

He also discusses the difference between someone who is disorganized and someone with an unconventional organization. Unconventional organization may look chaotic, but if you look closer there is a pattern to the scattered objects, and the kid him/herself knows where everything is. Sometimes this can represent a preference for associative thinking - some people think more creatively when they have lots of things around to cue their ideas.

Working Memory is another area I struggle with - 4 out of six areas are lagging behind.
  • Is able to retain information long enough to apply it to new learning challenges - about average
  • Can remember and talk about what was learned in school that day - about average
  • Remembers significant dates, phone numbers, etc - lags behind
  • Recalls procedural steps, doesn't "stare blankly" when asked what was said - lags behind (when asking directions, I've learnt to listen for the first step and ignore the rest, then go do that step and find someone else to ask for the next step)
  • Rarely loses belongings - lags behind (my Dad has recommended I get a PDA to help me get organized, but I pointed out that I'd just lose it and PDAs aren't cheap)
  • Is comfortable accepting "memory responsibilities" (e.g., feed the dog, pay dues each month, set the alarm) - lags behind (I know my limits, and refuse such responsibilities unless I have a pretty good idea how to help myself remember to do them)
Working memory is related to, but distinct from, short term memory. He cites a study showing that working memory correlates strongly with executive functions, not with IQ. Working memory is essentially the ability to regulate your use of memory for complex tasks. He compares working memory to a computer's RAM, while long term memory is more like the computer's hard drive. As a computer runs a program, it pulls stuff from the hard drive and puts it into RAM. When you save something, it gets written in the hard drive again. (Incidentally, apparently girls tend to have better working memory, and this difference seems to be related to effects of one's estrogen levels.)

Like all the other functions so far, he talks about the impact of working memory on social interaction. When interacting with others, you keep in mind a wealth of information about them, which helps you to interact effectively - things like their names, who are friends with who, what they've just said, what you are doing as a group right now, and so forth. Poor working memory makes it hard to process all of that information at once.

Also, working memory issues impede learning, making kids prone to making the same mistakes over and over. (Incidentally, this is reminiscent of the issues in learning among people with anterograde amnesia - typically they can learn new skills implicitly but have no explicit memory of their learning. One side effect of this is that they tend to repeat the same mistakes, because they implicitly 'learn' their mistakes as well.) And difficulty retrieving memories can make it harder to relate new information to old.

Unfortunately, he fails to distinguish between working memory and prospective memory. Both are intersections between executive function and memory, but working memory is more about keeping information in mind in order to perform a task right now, while prospective memory is 'remembering to remember' - in other words, filing away a memory that is supposed to come to mind at a pre-determined time in the future. His questions are a mix of working memory and procedural memory questions (1, 2 and possibly 5 are working memory, while 3, 4 and 6 are prospective memory).

Myself, my working memory is fine. One example of working memory is the ability to solve math problems without showing your work, something I'm just fine at. Overall, my guess is that my working memory is roughly normal.

Prospective memory, on the other hand, is a tremendous area of difficulty for me. I have no clue how most people manage it - the very idea seems foreign to me. I tend to recall things best based on location, which means I often have the frustrating experience of remembering I should do something only when I'm in a particular situation where I can't do it. (Such as only remembering at university that I wanted to take a certain item from home, for several days in a row!) Anything that requires remembering to do something in the future takes a great deal of mental effort on my part, essentially me obsessing over it for the intervening time if I can't set up an external reminder.

For the most part, this chapter only discusses working memory, not prospective memory.

And next we get to the horribly misnamed category he calls Self-Awareness (the one area in which I lag behind on every option).
  • Picks up on important social cues such as taking turns during play with peers - lags behind
  • Uses appropriate vocal volume in conversation - lags behind
  • Intuitively senses how to "fit in." - lags behind
  • Is able to make and sustain friendships - lags behind
  • Rarely "crosses over the line" of acceptable behavior - lags behind
  • Accurately attributes the reactions of others to his/her own behavior - lags behind
Notice something? These questions aren't actually about self-awareness! Only the last two would even be affected by a person's level of self-awareness, and that skill still isn't the primary determinant of those behaviors. This section is not self-awareness. It's social skills. If I wanted to assess a child's self-awareness, I'd have questions like:
  • Can accurately predict whether a task will be easy, doable but hard, or impossible given the child's skill level.
  • When he or she describes his or her own personality, this description matches what people who know the child would say.
  • If asked 'why did you do that?' the child can give a reasonably accurate explanation.
  • When he or she hears descriptions of other people, the child can recognize if his or her own behavior is similar to theirs.
  • Can ask for help on problems the child cannot do alone, and does not ask for help if the child can do it alone.
  • Has strategies for learning that match his or her own learning style.
(Incidentally, my own self-awareness is quite good.)

There are people with good social skills and poor self-awareness. People with borderline personality disorder are a key example. Although these individuals have subtle issues with facial recognition, particularly oversensitivity to negative emotion cues, their recognition of emotions is generally mostly normal. In contrast, they can show marked difficulty in understanding themselves and their own identity, with their personality shifting dramatically depending on situation.

In contrast, I'm a person with good self-awareness and poor social skills. I find it very hard to understand and predict other people's reactions and behavior, and I'm often oblivious to many social cues. But from a young age I've been able to analyze my own thoughts and feelings in great detail, and describe exactly what is going on inside my head. I self-identified as 'probably autistic' about a year before my official diagnosis - and this was while being unaware that, several years earlier, one of my school principals had suggested the diagnosis of Asperger Syndrome to my parents. I can readily recognize when others are acting similarly to how I would act (which usually means they're on the autistic spectrum) and I know exactly how to handle a kid who misbehaves for the same reasons I used to misbehave. (I met a girl like that at one of volunteering programs. She was considered a difficult child by the other volunteers, but I got along very well with her.)

Of course, there are many who struggle with both. Autistic people with alexithymia are a good example of people who are poor at both self-awareness and social skills. In addition, young NT children develop the two skills mostly in tandem, because they use self-awareness to predict others and apply what they learn about others to themselves. (This only really works because they're the cognitive majority.) But this does not mean the two skills are equivalent.

This problem, unfortunately, pretty much ruins the entire chapter. The whole chapter is about building self-awareness, with the assumption that this will help their social skills. Well, I can tell you from personal experience that being very self-aware does not automatically mean you'll have a clue how to relate to other people. For a person on the autistic spectrum, if you assume others think like you, this leads you down the wrong path more often than not. And if you don't assume that, then your self-awareness will have no influence on your social skills.

Managing Emotions is the last category. This is the other one with an item we were uncertain about, as well as four items where I lag behind.
  • Able to shrug off or quickly recover from minor disappointments - lags behind
  • Seldom overreacts to words or behavior of peers - variable
  • Is able to use imagination, reason, or logic to cope with adversity - lags behind
  • Can control emotional impulses to make considered decisions - about average
  • Does not allow emotions to overwhelm reasoning skills or impair problem-solving - lags behind
  • Expresses constructive emotions that elicit positive attention from peers - lags behind
This is another relatively poor chapter. The big problem is that he fails to distinguish between intensity and control of emotions. Differences in both of these look similar, but need to be handled differently. And research can distinguish between the two dimensions by measures aspects of emotional expression that no one (apart from a few highly-trained monks, I suppose) can control, such as heart rate. It used to be thought, for example, that psychopaths were good at repressing their emotions - now we know they actually don't feel certain emotions, or not as intensely. (Incidentally, with those emotions that psychopaths do feel quite strongly, they're pretty poor at controlling them.) For another example, people with PTSD do, indeed, have stronger emotional reactions to stress. So if someone expresses emotions more or less intensely, it doesn't necessarily mean better or poorer control. It could mean they are actually feeling a different intensity of emotion. (Given that I have PTSD, and that during my worst meltdowns my parents have noticed my pupils visibly dilating and other physiological signs of utter terror, I'd say my problems have more to do with intense emotions than poor control.)

Most of what this chapter is about, therefore, has a lot more to do with emotional control than with intensity of emotion. Which makes it not applicable to many of the kids he's discussed so far, such as kids with reactive attachment disorder. But there are some kids who do, indeed, have poor emotional control as a result of executive dysfunction, such as many kids with ADHD (others do have problems with more intense emotions as well). He does acknowledge that some syndromes have issues with emotions that go beyond executive problems, but says difficulty with executive control is part of the picture as well. I disagree. It is possible to have both poor emotional regulation skills and overly intense emotions, but many people who struggle with problems related to intense emotions are just fine or in fact better than average at emotional regulation - it's just that those skills aren't enough to avoid falling apart.

He mentions the concept of Emotional Intelligence, another of those areas that people claim is more relevant to success than IQ. I'll discuss this more as I go on, because somewhere, lost in my mounds of stuff, I have a book on raising an emotionally intelligent child, which I think has a far better take on how to handle kids' emotions than this chapter.

He gets into how all the other executive functions interact with emotions. He's discussed this in other chapters, but here he explains how emotional control can help regulate other executive functions. Thinking of how your father will feel if you fail to do your chores, suppressing the hurt of being criticized to instead use the criticism to get better, setting aside your emotions to focus on a task, restraining the impulse to buy items not on the shopping list, or practicing social scripts to reduce anxiety about a social situation.

It's important to note that you can't tell, just by looking at a person's outward behavior, if they are failing to regulate a normal-intensity emotion or actually experiencing more intense emotion. If a kid 'overreacts' to a minor problem, sometimes it really isn't minor to the child. (For example, sensory processing issues can mean sensations that most people find annoying are extremely uncomfortable to the child. It's not an overreaction if a child covers his ears to a sound that he finds physically painful.)

He provides several examples of overreacting children, many of which could instead be a child for whom the situation is a bigger deal than it seems for the adult. For example, one girl, Faith, grumps about how no one ever calls her on her cell phone. This could be a girl with no friends, who feels rejected and lonely and is beginning to seriously suffer emotionally as a result. In that case, her 'minor' complaint about no one calling her sounds a lot more serious. I've found very often, if you probe the reasons why a child is reacting the way they are, apparent 'overreactions' seem more reasonable.

He then discusses kids who are 'underreactive'. When discussing the neurological underpinnings of underreactivity (which he claims comes from problems in the right hemisphere - nonverbal learning disability), it becomes clear (to someone who actually knows the subject) that he's not talking about kids who generally fail to express emotions, but to kids who fail to react to the emotions of others (because they don't know what others are feeling!). This distinction is not even hinted at in his discussion of the issue.

He also mentions kids who deliberately hide their emotions. This would actually be a case of too much emotional control, but anyway. He also mentions kids who don't express emotion until they finally explode. In my case, this pattern developed in me as a reaction to the ill-advised advice to 'just ignore' the bullies. They were too persistent for me to ignore, despite my best efforts, and when I finally hit my limit I'd explode. (Ignoring only works on very casual, 'testing' attempts at bullying. Once a bullying pattern has become established, ignoring only makes the bullies escalate until the kid snaps.)

Another issue, which he doesn't get into here, are kids with atypical expressive nonverbal communication, who are hard for others to read. I once read a journal article from the 1960s about children with schizophrenia (who'd now be considered autistic) which noted that these kids, rather than not feeling emotion as strongly like many people thought back then, do feel emotion but don't give off the same nonverbal cues. I've met an autistic kid who never changed facial expression, but showed emotions by his body posture and his stims. It's important to remember that, just as autistics can have trouble reading neurotypical nonverbal cues, many autistics are just as difficult for neurotypicals to read.

And then he gives a bit of really bad advice. He has an example of a girl freaking out over not getting to go to a certain movie, and two possible parent responses. One parent acts sympathetic and comforting, and tries to find her another movie to watch. The other tells her that she's overreacting and says that once she's calmed down, they can discuss her choices. He says the second parent is likely to support development of executive functions.

I come down on the exact opposite side. That book I read on emotional intelligence cited evidence that showing sympathy for your child's feelings (without giving in) helps develop their ability to manage their own emotions, and I agree. The second parent gives off the impression that he/she doesn't care about the daughter's feelings, which, if it's a general pattern, tends to make kids feel insecure. About the only time that acting unsympathetic helps is if the child's faking an emotion to manipulate you, and it's generally safer to assume they aren't. (A manipulative ploy will still be discouraged by not giving in when they pitch a fit, whether you act sympathetic or not.)

With his three suggestions about how to coach emotional control, two are good and some aren't. Here are the good ones - creating a subtle gesture to signal to your child when their emotions are running too high, and giving support in advance for situations you know will be tough. But his suggestion to talk about emotional reactions as a choice is terrible. You can't chose your emotions. The idea that you can places the blame on unhappy people for their own unhappiness. If my brother could chose how he felt, he would not be depressed. No one would be.

And then he gives a very good point - children learn about emotional expression and regulation from their parents. They do what parents do, not what they say. And they will notice when parents are being hypocritical. As a parent, it's important to remember to model behavior yourself if you want your children to imitate it.

2 Comments:

Blogger alice said...

I read this a few weeks ago and wanted to come back to say thank you for such a useful review- I'd always heard 'weak central coherence' used as a very vague (and unhelpful!) term, and this is just the opposite.
In fact, I didn't even realise that some things I have difficulty with that come up here were a part of being autistic- I thought I was just the world's worst procrastinator ;) It's been really helpful to me to know what to focus on. So thank you!

9:44 AM  
Blogger Bhavna Prakash said...

Very informative and eloquently written post. Helps a lot in understanding my son's behaviour. The difference in ADHD and exec function disorder is very lucidly explained. You mentioned that you have written your version of the story 'The Little Red Hen'. Is is possible for you to send me a link to that version?
Thank you.

12:15 AM  

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