[Descriptive transcript: Video opens with a title cover slide with text and images. Text: “2022 Collaborative Experience Conference November 3,4, & 5. For parents and professionals serving students who are deaf, deafblind, and hard of hearing. The MN gov logo is on bottom left An image with a magnifying glass resting on the chalkboard tray next to a pile of colored pencils. Text on bottom right: “Supporting the whole child reboot”. Slide is replaced by a presenter view showing two folks, Danelle Gouramis on the left, and Peter Isquith on the right. A small frame on bottom right shows the voice/sign language interpreter. Danelle signs while the interpreter voices.
>> DANELLE: Good morning everyone and we will have the slides come up right after your introduction. Good morning! Good morning everyone! Did everyone enjoy their first workshop? I hope everyone enjoyed the first workshop they went to this morning.
[Name and title text slide on under each individual: “Danelle Gournaris, Collaborative Plan Program Director, MN Commission” and “Dr. Peter Isquith, Licensed Psychologist, Instructor of Psychiatry, Harvard Medical School.”]
>> DANELLE: I'm really excited that everything has already started.
[Name and titles slide off.]
>> DANELLE: I'm thrilled that we are opening with a wonderful keynote presentation. We have Dr. Peter Isquith with us here today. Peter is going to talk about Executive Functioning and he works with folks all over the New England states. He is an attending neuropsychologist for the Deaf and Hard of Hearing at Boston Children's Hospital where he is an instructor of psychiatry at Harvard University. We are honored to have Dr. Peter Isquith with us here today. Welcome!
[Peter signs ‘thank you” and switches to voice while the interpreter signs. Danelle’s window is replaced by a presentation window showing a video of a street with two-story wooden houses with a backdrop of a tree-covered hill.]
>> PETER ISQUITH: Thank you, thank you. Welcome to my world in Vermont, probably looks like yourself in Minnesota if I recall. I'm approaching a small town known as Cavendish Vermont, where I'm about to see a kid in a school.
[Video continues on showing a small-town main street with a school coming into view.]
>> PETER: You will see the school on the right as we pull up.
[Video becomes a photo still showing an empty roadway leading to the trees in front of the mountain.]
>> PETER: The reason I'm showing you Cavendish is that it's famous for this guy.
[Video shows a stone marker with text on it.]
>> PETER: This is a marker next to the school for Phineas Gauge. A railroad worker back in 1850 when they were running the railroad through Cavendish
[Video shows a slide with text and an image of a bar through a skull, and an image of a long thin bar below. Text: “Phineas Gage: Cavendish, VT 1848. 3” tamping iron shot through the left cheek. Destroyed much of the left frontal lobe.”]
>> PETER: and his job was to take this three-foot metal rod that weighs 20 pounds and push dynamite into the rock for blasting through the rock. One day things went wrong and the rod shot through his cheek and out the top of his head. He lived. He apparently walked down by himself, and his friends and neighbors said something is different about you, Finneas! He was changed.
[Video shows a slide with text and a sepia-colored photograph of Phineas, seated and wearing a suit and holding up a stick as his side. Text: “Phineas Gage, a Changed Man. “He is fitful, irreverent, indulging at times in the grossest profanity, impatient of restraint or advice when it conflicts with his desires; at times pertinaciously obstinate yet capricious and vacillating. His friends and acquaintances said he was no longer Gage.” Harlow, 1868.”.]
>> PETER: His physician from Harvard medical school followed him for many years. What they noticed is that he had changed. He went from being a fine, typically functioning Vermonter, very much like a fellow from Minnesota, but he became impatient with advice when it conflicts with his desires. In other words he became impulsive. He failed to inhibit his thoughts, his behaviors. We see children who don't have this kind of accident all the time who fail to inhibit it. They have a desire, they have a want, they have a need, they go ahead and they do it. They do not inhibit. So this is pretty common to us. He also was pertinentacously object to nature. That means extremely stubborn. He was not flexible. He didn't go from one thing to the next, he got focused and stuck on one thing. We also see kids who do that all the time. Who gets stuck and can't stop talking about Pokemon, their train set, their favorite video game. Again, they don't have a hole in the head like Finneas did but they're having the same kind of difficulty. Finally he was capricious and vacillating, in other words he was emotionally a bit of a roller coaster. He was all over the place, he did not regulate his emotions. Again we see children all the time who have difficulty regulating their emotions. They get referred to me all the time. They're the ones that we see in schools and psychiatry practices where someone says do an analysis and see what's going on.
[New slide: a line of three arrows pointing to the right with text above. “Goal. Why? Plan. Do. Review.” Goal is highlighted in blue. Text on top: “Increase expertise in enhancing self-regulation.]
>> PETER: Phineas taught us a lot. He taught us that behavior has something to do with the brain. Back in 1850 that wasn't the theory. The theory was that it had something to do with the devil, demons, and your bad behavior. You deserved to have all this emotional volatility or there was a demon in you or there was something in your blood. So the treatments were exorcism, get rid of the demon or bleeding to reduce the bad things in your glad. What Finneas taught us was, ah-ha, it has something to do with the brain. I see kids all of the time, I see them at the hospital or I run around rural New England and I see kids there. Very few of them have holes in their heads. Most of them have difficulties with executive control, one way or another, the kid that I see. So our job -- so we're not looking for a hole, we're looking to understand them functionally and more so what to do about them. Today what I want to do is talk about how we come to understand executive functions and more so what we did with this stuff and what are the risks and what do we need to do with Deaf and Hard of Hearing children. On your screen you will see the goal, plan, do, review. I added a why in there because that's our model. This is an active ingredient in just about every successful intervention for executive functions. This is a coaching model where we state what we are trying to do? Why are we going to do that? What's the plan for getting there? Let's do it. And then review what worked, what didn't so we can fix it the next time. Okay? So I want to use an executive intervention with you today and we're going to follow this model.
[Slide highlights the “why” to blue, and the new text above: “Explanation for Why this is important. Children with reduced hearing are at greater risk for executive function/self-regulation difficulties. EF is one of the best predictors of school readiness and has been implicated in academic, social, psychological, and behavioral functioning.”]
>> PETER: So my goal for you is to increase your expertise in enhancing or improving self-regulation or executive function in children. The purpose of stating the goal is when you state a goal out loud you're more likely to follow through. Having said that, let's give that a try. Often when we set a goal with someone we need to know where this is important. Children with hearing loss are at greater risk for executive function or self-regulation. We can use those terms fairly interchangeably. Kids with hearing loss have other issues that go along with other self-regulatory difficulties. We will talk about that. Further, executive function or self-regulation is one of the best predictors of school readiness and is implicated as meaning is predictive of a long-term school, social, psychological and behavioral functioning. It's pretty important stuff.
[New slide with text arranged in two columns. Title: “Children with poor inhibitory control (impulsivity) are more likely to:” (column A) “As teens, drop out of school, use substances, have unplanned pregnancies'' and (column B) “As adults, earn less, have worse health, become addicted, commit more crimes, be unhappy.”
>> PETER: Children with poor inhibitory control, in other words, children who are impulsive are more likely as teens to drop out of school, to get involved with substances, to have every social ill possible and as adults they will earn less, have worse health and be less happy.
[New slide with text on the left side and a bar graph on the right side. Text: “Interest in Executive Function in Children. Peer reviewed publications: 5 articles in 1985. 14 articles in 1995. 501 articles by 2005. Around 1000 articles by 2010. More than 6,000 articles by 2014.” The bar graph corresponds to the information showing the amount of articles to the year.]
>> PETER: There are all kinds of negative things that happen for people who are impulsive. Executive functions haven't always been a thing with children. In the adult neuropsychology and cognitive psychology world executive function was studied for the last 100 years or so. Only in 1985 when Ad elle Diamond who was working at Harvard and worked with executive function with regard to baby monkeys did we discover that children have the executive function and from the time we are children to adulthood we are working on being better regulated. I am always working with my 86 year old mother to be "better regulated." At times she thinks I need to be better regulated, I think she does. But that's a different story. Every day I get ten new articles on children and executive functions that I need to review to keep pace. It is less so with deaf and Hard of Hearing children. Sometimes my clicker isn't that great. Ah-oh -- oh, we are connected again.
[New slide: text on left and a bar graph on right side. Text: “Executive Function in DHH Children. Peer-reviewed publications:'' Column underneath: “14 articles by 2000. 17 articles by 2005. 21 articles by 2010. 33 articles by 2015. 36 articles by 2020.” Bar graph corresponds to the number of articles to the year.]
>> PETER: Deaf and Hard of Hearing children, the research in that area has started growing since about 1995 but to a lesser extent. It is a smaller group, there are fewer of us who do that work but nonetheless we are talking about a handful of articles that look at executive function in deaf and Hard of Hearing children.
[New slide returns back to the three-arrow with “Plan” highlighted in blue. New text above: “Define everyday executive function / self-regulation. Discuss executive function development in children with hearing loss. Review approaches to supporting executive function in children.”.]
>> PETER: We talked about the goal, why we are doing this and the plan. My plan for you is let's talk about executive function or self-regulation. Then I want to talk about what that looks like specifically in deaf and Hard of Hearing children. Finally we need to talk about how we intervene, improve executive functions in kids because that's the big point.
[“Do” is highlighted in blue with the above text disappearing.]
>> PETER: Now we need to do the thing.
[New slide showing three circles in a row, connected by arrows in between. From left to right: green circle “Frontal”, blue circle “Executive Function”, and purple circle “Self regulation”. Text underneath: “ Underlying brain structure, underlying brain function, and observable behavior.” Three images in a row on the bottom: a brain, a sketch of response behavior, and a photo of a child sitting with an oversized teddy bear.]
>> PETER: We had a goal, we asked why, what's our plan, let's do this. People use different words for executive function. Okay? Some people talk about the frontal. Frontal refers to the brain parts that we think have something to do with executive function. That's not particularly useful unless we know something about the brain. If we know that somebody has an injury or something didn't develop appropriately in that part of the brain. It's really more of a research thing. Executive function is what we think that brain part is doing. Those frontal systems, it's really not a part, it's a connected system. They're doing something and we believe they're doing this thing called executive function. We will talk about what is in a moment. What we see is self-regulation. It is okay to talk about executive function and self-regulation as if they're the same. Most people do. When I see a child and I write a report I typically talk about self-regulation because it's easier to understand and less sciencey and less scary sometimes. Self-regulation is what we observe, executive function is what we believe is happening in someone's head, frontal systems is what is happening -- are the brain systems that underlie all that.
[New slide showing a black and white photograph of Hans-Luaks Teuber. Text to the left: “The unity and diversity of executive functions. Hans-Lukas Teuber, 1972.”]
>> PETER: Teuber in '72 gave us a model of executive function that is useful today. He talked about the unit and the diversity of executive functions. In other words the unity is there is one thing that is executive function but then the diversity is we can chop that up into little pieces, too.
[New slide: “Two levels of Executive Function: Unity: Orchestration of behavior,emotion, and condition during goal-oriented problem-solving. Diversity:'' A venn diagram around a brain in the middle with three circles around the brain: behavior, emotion, cognition. Several icons with text surround the circles: Organization of Materials, Task Monitor, Planning and Organization, Working Memory, Task completion, Initiation, Emotional Control, Flexibility, Self-Monitoring, inhibition”.]
>> PETER: That was an argument for many years. When we first went into the field there was an active argument in the 80s and 90s about executive function. Or is it a collection of things that we can separate? Where we are now is both. There is unity and diversity. The picture on your screen is showing you kind of our model that you have these executive functions around the outer circle and they're inhibitory control, flexibility, working memory, emotion regulation, and we use our executive functions to control our cognition, our thinking, and attention. Our behavior and our emotions. So executive functions are kind of overarching or around all the things we do and how we show ourselves to the world.
[New slide “Executive Function: The Conductor of the Orchestra”. Two columns with a silhouette behind each: “Conductor: Inhibit; Shift flexibly; Initiate; Working memory; Plan; Organize; Monitor. Orchestra: Attention; Language; visual/nonverbal; Learning and memory; Sensory perception; Motor; Social; Emotional; Behavioral.]
>> PETER: One of the metaphors that I like to use, my colleagues and I like to use is the conductor of the orchestra. There are other metaphors, the air traffic controller, the umbrella. We like the orchestra and the conductor. The conductor is the executive, right? If you have an orchestra, the conductor comes in and holds up their wand and they say start doing this. Start making music. They say shift, stop doing that, start doing something different. Stop playing the drum, start below blowing a horn, that's shifting. The conductor initiates, he says okay you start playing while he's inhibiting and he says you stop playing. The conductor has a plan in front of them that they hold in working memory, working memory is the ability to hold something in your head for a little bit to do something else with it, throw it away, store it, calculate with it, problem solve, the conductor is holding the music. The music is the plan and the conductor organizes the music to reach that goal. The conductor monitors how things are going to see is the music coming out okay? So the conductor says start, stop, shift from this to this, while holding a plan for the music in mind and organizing the behavior of the orchestra and monitoring to make sure it sounds good. Now the interesting thing about the conductor is he doesn't do any music by himself. The conductor does nothing. He can wave the wand but there is no music. Without the orchestra parts nothing happens. For our kids that's attention, do they pay attention to anything outside themselves? It's language, that's a big one for our kids. Do they regulate their language? Does their language work in the first place? Then does the conductor control the language? Do they do visual/spatial, visual/non verbal problem solving? Do they learn and remember gnaw information, sensory inputs, motor outputs and then there is the social, emotional and behavioral functions that we all do but we're interested in our kids today. What's interesting about the orchestra is if you allow the players, the language, the attention, the motor, the sensory, to do whatever they want without control, without regulation, you have chaos, it's a mess! So we have to have the conductor, the executive say to start paying attention, stop language. In other words, don't talk. Shift from what we are talking about here, and start talking about this. The conductor says I want you to plan what you are going to say, organize your thinking and monitor it to make sure what you said is something we're close to interested in hearing. So those two pieces work together. Where this is really important is when we have a problem, I need to know does the part work? Does the instrument work, the orchestra player? Does language work? Does motor work? Does sensory work? Then I can say all right, if language is fine how is my conductor? If my language is disorganized, I ask the child what's a cat? The child says it's a small, furry animal that purrs, okay, that's well organized. If they say well, I have some, they don't like the dog, they get outside sometimes, they will eat mice, they bring the parts back in. I feed them a bowl of food twice a day and they're furry. That's not well organized. I get that it's a cat but it wasn't planful and organized. Okay? We have to look at both parts together. I cannot see the executive function by itself. It's not a thing. It's something we believe happens in your head but we can't see it except through an orchestra player. The conductor can conduct all they want but without the players, the language, the spatial, the motor, the sensory, I can't tell what's going on. So we have to look at both when we are doing an evaluation or assessment.
[Interpreter switch.]
[New slide: “Development of Executive Functions”. Bar graph showing Executive Function Skills Build Throughout Childhood and Adolescence". Along the vertical, “ Executive Function Skills Proficiency”. Along the horizontal are ages 0 to 85, broken down into age groups. Text below graph: “A range of tests measuring different forms of executive function skills indicates that they begin to develop shortly after birth, with ages 3 5o 5 providing a window of opportunity for dramatic growth in these skills. Growth continues throughout adolescence and early adulthood; proficiency begins to decline in later life”.]
>> PETER ISQUITH: Executive functions develop over time. This is a graphic design that suggests that early on kids are working on fundamental executive functions. They're working on not being impulsive. You have to not be impulsive by the time you get to kindergarten, otherwise they're going to get sent to me, okay? So kids have to work on regulating their behavior and regulating their working memory. Baby imitates or approximates and says milk? Ba-ba? Or this? They're holding the image that you did and repeating it back to you. That's evidence of working memory. So babies start working on fundamental things. They increase rapidly throughout early school years. In the teenage years our brains develop further, there is a remarkable change with the onset of adolescence up through about 30 years in brain development. Our brains become more efficient, faster, and more connected. That allows us to make better decisions and to integrate information from multiple sources at the same time and make good decisions. Adolescence is a very special time in executive function for those of you who have adolescents you probably know this already. Not always the best decision makers. It used to be believed that executive functions did not apply to children, it happens when you are eight. When one of my colleagues said that I said "why do we give kids car keys at 16 if they don't have self-control or self-regulation at 18"? If you ask a car rental company, they don't want to rent to somebody under 25. It costs them more to do so because self-regulation isn't as good. You will notice after about 40 there is a little drop in this curve. What happens is we tend to have less capabilities, not terribly, but with working memory and our ability to keep focused over time and to plan and organize our activities. There is a lot of work going on now, not just about helping kids improve executive function but keeping older, our older -- our parents better regulated. Better focused, better organized. There is a lot of work in that area as well because successful aging is keeping those skills. So doing the puzzles we get, the crossword puzzles, Wordle, those are all good activities.
[New slide: “DHH Children Show Worse Self-Regulation in Most Studies”. Chart with two columns: “study” and “Findings”. On the first column are different publication study titles, and the right column shows their summary findings.]
>> PETER ISQUITH: Deaf and Hard of Hearing children tend to show the worst self-regulation in most studies. That he is are recent studies but studies since the 80s have said deaf children are more impulsive, more inattentive, they don't focus, they don't self-regulate. There are a lot of problems with those studies. Back in the old days we didn't separate children who have Hard of Hearing with other problems, such as infectious causes or true attention disorders from kids who are genetically Deaf who don't have other risk factors. But many studies found that kids with hearing loss have greater difficulties with executive functioning and I have listed a number of studies here, some of them more recently we have also shown that they tend to have worse working memory, tend to be worse impulse control or inhibition. This tends to be fairly free of how much hearing loss you have or what kind of communication system you have. Many studies show this. I would caution that many studies still struggle with sorting kids who have other difficulties and other risk factors from kids who do not. The few studies that have been able to clearly separate children who are at risk for having other problems from those who do not have not found executive functioning difficulties being greater in Deaf and Hard of Hearing children.
[New slide: “Perspectives on Differences in Executive Function in D/HH Children”. Snapshot of a crying infant on the right side. Text on left side: “Reduced hearing causes reduced EF(Smith et al 1998). Or Reduced EF due to other factors (Hauser et al 2008).”]
>> PETER ISQUITH: Perspectives have changed over time on children who are Deaf or Hard of Hearing and their executive functions. Until the 2000s people tended to think that reduced hearing causes executive function problems or reduced hearing -- reduced executive function is because there are other factors, it's not the hearing loss itself.
[New slide: “Reduced hearing does not explain EF differences”. Text: Academically successful DHH students reported typical executive functions. (Hauser et al., 2013). Deaf native signers with strong language skills showed typical EF development vs hearing peers (Hall et al., 2017). EF differences between hearing and DHH students are strongly related to language development (Figueras, Edwards & Langdon, 2008). Language mediates executive function; Deaf/HH children’s reduced EF is explained by language development (Botting, Jones, Marshall, Denmark, Atkinson, & Morgan, 2017).]
>> PETER ISQUITH: More recent studies said that the hearing loss does not explain the executive function differences. Academically successful Deaf and Hard of Hearing students report typical executive functions. That was a study at NTID. Native Deaf signers who have strong language skills show typical executive function development commensurate with their hearing peers, both on rating scale measures people checking off yes I have problems or no I don't and on tests where we have people remember things and problem solve. Both data suggest that academically successful, strong communicators who are deaf have typical executive functioning. Executive function differences are strongly related to language development.
[New slide: “Language and Executive Function in DHH Children Using CI/HA Over 1 Year”. A graph below, with Baseline on left, and 1 Year on the right. Under Baseline is a circle with text: “Good Executive Function”. An arrow leads to 1 Year: “Better understanding of language”. Under Baseline: “Poor Executive Function” leads with “Intervene” above, to 1 Year: “Poor Understanding of Language”.]
>> PETER ISQUITH: This is where Deaf and Hard of Hearing children are different from their hearing peers because we know that Deaf and Hard of Hearing children have a varied degree of language development, depending on lots and lots of factors. More recently, one of our colleagues noted that language mediates executive function. Deaf and Hard of Hearing children's reduced executive function is explained quite a bit by the strength of their language development. Numerous studies have shown the links between language competency, your strengths in communicating in language and self-regulation. Those are important things that go together. A recent study from one of my colleagues at Boston Children's and from David Perzoni and Bill Cronenburger's lab at Indiana looked at development of language and development of executive functioning over the course of one year in children of a younger age range. So 4-7, 8, 9, 10 years old. It looked at measures of language at one point and executive function at baseline and then a year later looked at those same measures. What they found was that at one year children who had good executive function in the beginning had a better understanding of language after a year than children who had poorer executive function did not develop the same understanding of language after a year. I'm waiting for my clicker to reconnect.
[A pause before the new slide appears.]
>> PETER ISQUITH: I'm having a hard time.
[New slide shows a circle of four squares connected by arrows. Each square has text: Orange square on top: “Social, emotional, behavioral, cognitive, attentional function. Gray square on right: “Theory of Mind”. Blue square on bottom: “Inner language”. Green square on left: “Self Regulation”. Yellow square under the blue: “Social language”. A black and white photo of a man on the bottom right corner.]
>> PETER ISQUITH: There we go. I have to keep it alive somehow. There is a model for talking about the relationship between executive function that has been around for a long time and it speaks to children and their variation in executive functioning. One of the leading researchers, Russell Barkley in 2001 I was listening to him do a talk and he said language and executive function go together. Vogotsky, this guy on your slide, was right. Vogotsky was a psychologist who said children need language in order to think and self-regulate. When I was listening TOLTSD lecture, Dr. Barkley said it's too bad we can't study that and prove it to be true because we don't have large groups of people with varied language competence. Everybody here in the U.S. speaks their language so how would we study this and I said Dr. Barkley Deaf and Hard of Hearing children have huge variability in their language development, rate, success and competence and we should be looking at them and he said you go do that. But what Vogotsky said on this schematic you see on your slide is that children hear language, that's social language, or see social language, they observe their parents first and we interact, we go back and forth. That's social language. Regardless of whether it's spoken or visual, it is language. They internalize that language. The first thing we see our children do is repeat us. They imitate us. When they go off to preschool they come home and they reenact and restate all the things they heard and internalized. They're taking language in themselves and then regurgitating it, repeating it to themselves for practice. What this allows them to do is use that now inside language to self-regulate later. Think about yourself. You are driving through the Twin Cities, traffic is bad, somebody cuts you off. I don't know about you but I have an impulse when somebody does that, okay? It might be to speed up, cut them off, it might be to make a gesture, it might be to swear at them. But instead, I know that that's not helpful. My children are in the backseat. So I talk to myself, I swear at them in my head, not aloud. I tell myself cutting them off wouldn't be a good idea. We might have an accident and my insurance will go up or someone could get hurt. So I use my inside language, in my head, to regulate my impulses and not act on them. We teach children to do this all the time. That is the goal of self-regulation. But you have to do it with internalized language. Clinical story. Long ago and far away I met a child in a psychiatric hospital, he was Deaf. He had been raced in an environment where he had no exposure to accessible language, no hearing, no sign, no speech. He was feral. He was not able to regulate himself, communicate, get along with others, did not know how to interact. I sat on the floor with him. I want him to engage with me. We did some puzzles, and I discovered that he was at least of average intelligence. But he had no communication and could not regulate himself. He could not stop acting on whatever impulse or emotion he felt. So he was heavily medicated at the time. We were able to get him to a school where he could learn an accessible language. They did an amazing job. There was a lot of control around this child until -- but he became a much better regulated child over the years through the use of language that others modeled for him, that he was eventually able to learn and internalize and use that language to self-regulate in his head. This is the important thing. Children need early language, solid language that they can internalize for themselves, use it to regulate themselves. The other direction on the slide is theory of mind. What that means is the ability to appreciate or understand that other people see things differently than you do. That's also important. Taking another's perspective. These two things then allow the child to engage in social, behavioral, cognitive and attentional functions that lead them to success, whether it is in school or at home or in the community.
[New slide: “What can we do to enhance self-regulation?” Faded photograph of a smiling child behind the text.]
>> PETER ISQUITH: So what do we do to enhance self-regulation, to improve things for any child but in particular how do we think about this with Deaf and Hard of Hearing children?
[New slide: “Review of Interventions” Text underneath:
• Diamond & Ling (2019). Review of the evidence on, and fundamental questions about, efforts to improve executive functions, including working memory. In J. Novick, M.F. Bunting, M.R. Dougherty & R. W. Engle (Eds.), Cognitive and working memory training: Perspectives from psychology, neuroscience, and human development (pp.143–431). New York: Oxford.
• ClinicalTrials.gov lists 528 completed studies with executive function outcome measures. 170 are identified as intervention trials. Fifty-three are medication trials, the remainder are educational and/or behavioral approaches.]
>> PETER ISQUITH: There isn't a difference in intervening with Deaf and Hard of Hearing children other than recognizing the importance of language and that we may need to provide greater language support. This is not just for Deaf and Hard of Hearing kids. I see children, often, who have serious behavioral and emotional regulation problems. They might be hospitalized, in a locked school, because they are not regulating themselves and they get in trouble. More often than not I find a language disorder. These are children who did not have well developed internal language, hearing children but for whatever reason did not develop good language skills, did not have internal scripts, ways of talking to themselves and therefore could not regulate. So I want to just point out this reference here. Pause, it's a very important one. There are a couple here. Adelle Diamond, I mentioned her earlier. She is the person who put a baby in the MANG can I apparatus for research and showed that young children had executive functions. She has written a review in a book chapter that is on her website, you can access it that is very dense. I would recommend to my psychology colleagues or my intervention colleagues special education teachers that this might be worth a look. There is a whole section called school-based interventions. That's a good place to start. It's a lengthy thing but she reviews information and evidence about what interventions work, what makes them work. The thing that makes them work, I will cut to the punch line here, is a coaching model. That's what we're doing. It is a model like goal, plan, do, review. That's a coaching model. That turns out to be a very active ingredient in most of our interventions. With Deaf and Hard of Hearing children of course the language supports are also essential. There is also a place if you are interested in the research behind a lot of interventions, clinicatrials.gov lists hundreds of studies of executive function interventions. Many are medications, I will talk about, give examples, behavioral, computer-based programs, there are lots of studies that you can look up and learn about studies that might be applicable.
[New slide: “Working Memory Training”. Illustration on the right side shows a screenshot of a computer game to match items and deposit in a toy box. Text: But look, you see the same arrow twice with a different thing sandwiched in between them. The second arrow goes into the red box”. Text on left side: Good narrow transfer in 23% of studies
• Limited far transfer
• Gains maintained at six months
• Gains more limited at 1 year.]
>> PETER ISQUITH: Before I jump into talking about specific areas of research on executive function intervention, I pointed out before that the literature on executive function development in children is fairly new. It's been around since the 80s, it developed slowly into the 2000s and now we know a lot. Research looked at how do executive functions develop in children, more so how do we measure them? So we focused for a long time on measuring executive functions and what tests or measures work, rating scales, et cetera. We have known the answer to that since about 2000, maybe 2010. There has been nothing new in measurement of executive function, and we know how to do it. The current focus and has been for the past ten years or so, how do we fix this problem? If we can measure the problem, what do we do about it? How do we intervene? How do we enhance executive functions in all children? We have very little about -- studies about enhancing executive functions in Deaf and Hard of Hearing children but many of the same programs apply. So with that in mind, here is what we have learned about intervening with executive function. The most studied, specific intervention is working memory training. Now, there are two ways to go about intervening with most things. One is to tackle it head on. If you have a problem with reading, we should probably work on your reading. If you have a problem with executive function, maybe we can work on executive function by practicing it. The other way is to accommodate, kind of work around it and see if we can support it in some other way. For example, if you have trouble reading, then perhaps we tackle that head on and we train reading. Another way, if that doesn't work or is also supported, is to reduce the reading load. Reduce the demands, have someone read to the child. Use easier materials. Both can be valuable. I'm going to look at specific interventions to try and fix executive function problems. The first and most common study is working memory. Working memory is just the ability to hold something in your head for a short period of time to do something else with it. So you look at the phone number, can you get to your phone and plug in the phone number and call it? Holding the phone number is working memory. Pretty easy. The next time your partner or teenager says what's the phone number for the pizza place? And you tell them the number, as they start to dial it, start saying random numbers. So you tell them the number is 603-5972. They start dialing it and you say 8, 7, 5, 6, 4, 9 -- that will interfere with their working memory. So working memory training tasks have people practice working memory, remembering numbers, remembering them and telling you them backwards so instead of 1, 2, 3 you say 3, 2, 1, remembering where pictures are on a screen and identifying that later, putting them in the different way, backwards. Short, holding things in mind. This has been studied for 25 plus years. What we see is that people get better at doing the task. People do get better at holding numbers or pictures or words or things in mind for a short period of time. What doesn't happen so well is that it changes things in the classroom. Or in your everyday life. It doesn't necessarily mean that your practiced ability to hold things in your head to do these working memory tasks means that you are more focused and can concentrate more when you are doing other things. The other thing they found was that the benefits tend to wear off within a year. So you would have to keep practicing this all the time. These interventions tend to be intensive, they tend to be 45 minutes a day, five days a week for many weeks, at least five. By itself these things help with the task, they don't help so much over the long term with everyday functioning. End back training.
[New slide: “N-Back Training”. Text on left side, chart on right side. Chart shows three rows of objects. First row “D-back target = butterfly”. Second row: “1-Back (target same as one stimulus back)”. Third row: “2-Back (target if same as two stimuli back).” Text:
• Fewer studies (13) than WM training
• Most studies with adults
• Some evidence for near transfer
• Limited evidence for far transfer.]
>> PETER ISQUITH: For fun you can go out on the web and look up end back training. There are all kinds of games out there and practices for you to experience in the end back. Let me explain what this is. Pretty straightforward. There is a zero back, a one back, and a two back. If I tell you to press the button when you see the butterfly, that's paying attention, that's not executive, that's not working memory. Now I say I'm not going to tell you what to look for, forget the butterfly. When you see a picture that's the same as the one you just saw, or one back, now you press the button. So if you see a cat it goes away, you see another cat now you press a button, that's one back. Two back is you see a picture, then a different picture, then the same as you saw two ago or two back, now you press the button. Now we're talking about holding things in working memory on an ongoing basis for several minutes while you're also taking in new information. That's a lot more working memory than just holding numbers or pictures. So there is enthusiasm about "and back" training. There are very few studies, most are not with children. There is some evidence that you get better at the task, but there is not good evidence that it helps you in your everyday layoff with functioning. So once again like computer training for working memory, this kind of training doesn't seem to help us function in everyday life. Fun to do, hop on the web, find an "and back" once you have done the regular and back, try the "double and back" it will hurt your head.
[New slide: “Inhibition Training”. Text on left side: “Limited success; no evidence of transfer beyond computer”. Chart on the right side shows the words for colors with the words themselves being the wrong color ink; ie “Blue” is colored green.]
>> PETER ISQUITH: Inhibition training. The hope is that we could teach people or children to not be impulsive by practicing on the computer. No. It does not work. People act on CAMBRILS because they can't stop and think about not acting on impulse. So if you work with kids or if you have them, you know if you child who behaves impulsively, who ceases something they want to do and goes to do it, afterwards you say should you have done that? And they will say no, so they know and you say what should you have done? And the child says I should have stopped, thought about if this was a good idea or if it was against the rules and probably not done it. But you went ahead and did it and the child should say that's because I'm impulsive and can't stop to think about what I do. Many of these tasks -- I worked in a brain injury rehab in the early 1990s and the goal at that point was to see, can we make people's attention and working memory and inhibit inhibition better by doing these tasks? The answer was no. They get better at doing the tasks but not at making dinner, being with other people, regulating their feelings. They get better at the tests.
[New slide: “Medication”. Text on left side: “Double-bind, placebo controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in college students with ADHD”. Chart on right side, “Figure 2. Self-report ratings of executive functioning across dosage conditions”.]
>> PETER ISQUITH: So training specific executive functions isn't all that helpful for everyday real world functioning. Lots of medications for those who have poor executive function. Lots of medications for ADHD. This is a study looking at if you take people, college students, who have executive function difficulties they're diagnosed with ADHD which is a disorder of disrupted impulse control and or sustained attention and concentration, executive functions, turns out if you give medications, people tend to improve, that's true. There are studies of depression medications in people who show that people who take medication for depression and feel better but are still having executive difficulties, can't get started, can't focus, that those are the people who are more likely to become depressed again so maybe we need to work on treating executive functions as well. So there are a lot of studies that show staples medications can be helpful.
[New slide: “Cognitive Behavioral Intervention”. Chart underneath, showing summary of problem-solving skills training programme.]
>> PETER ISQUITH: What about cognitive behavioral interventions? There are a number of programs that people have built that are useful. This is just an early example and my point here is not that you need to read all of it but that they talk about the function of paying attention.
[New slide: Chart continues on second page, according to age groups. ]
>> PETER ISQUITH: Of organizing information as you hear it.
[New slide: Third page of chart.]
>> PETER ISQUITH: This is just a quick study at the end. These were small groups of children with brain injuries and what they found, the word on the left that says "brief" that is a rating of the child's executive function and they showed that the children who did cognitive programming to improve executive functions, their parents said that they came from having lots of problems to being more typical, so this seems to be affected whereas the children who didn't have intervention did not change.
[New slide: “Exercise”. Faded photo of two children jumping outside on the right side. Text on left side: People who are more physically active and fit have better executive functions. Aerobic exercise alone showed little to no EF benefits across age groups. Evidence is stronger with added cognitive demand”.]
>> PETER ISQUITH: Lots of cognitive interventions that are coming up that have this kind of information. Exercise. We have all been excited for quite some time that maybe exercise helps people who -- with their executive functions and this was with older people. So if we get our parents, our older parents and families exercising more, will it help with executive function? No. It turns out people who exercise more have better executive functions or self-regulation because they're better self-regulation allows them to plan and do their exercise. It's backwards, okay?
[New slide: “Mindfulness Executive Training”. Photo of an older child on the right side. Text on left side: Martial arts training with mindfulness (coaching) associated with improved attention, emotion regulation, and behavior regulation vs regular PE. Yoga with mindfulness resulted in better EF”.]
>> PETER ISQUITH: However, if we add mindfulness, I'm going to talk about that for just a moment that seems to be useful with exercise. The first study to figure this out was martial arts. In a martial arts study, you think about what's happening. The master, the teacher says "center yourself." Now what is it you want to do? That's the goal. Here is the coaching, what is your FWOEL. I'm going to do these moves. Okay. What is your man for reaching that goal? I will do this step and this step and this step. Okay. How do you think that will go? Asking the child to monitor themselves, how well do you think you're going to do? Then you do it. Then you review what went well and what went wrong and you practice it again. This is an executive coaching model. A lot of literature talks about it as mindfulness. Fine. Mindfulness typically means being self-aware, being aware of what you're doing, being present, meaning being calm, knowing what you're doing. And the executive coaching, the task that you're going to do, setting up a goal, your plan, doing it, reviewing it. One of my good friends and colleagues, Dr. Jerry Gioia, lots of vowels, who is director of neuropsychology at Children's National in Washington, D.C. He is the guru of children's concussion in sport. One of the things that we're looking at doing is how do we implement this kind of executive training into children's everyday sports, because the early research suggests this might be helpful. What people have been looking at is how does the sport affect executive function? What we need to do is turn that backwards and there is a different coach who gathers the team together and says "What is it we're planning to do with this next period?" We're planning to score one FWOEL. Okay. What is our plan for doing so? What's the play? How are we going to do that? Do you think that will work? Let's try it. At the end of the game you review it. I know it sounds so simple it's silly, but it makes a difference. We're going to start studying what he is, actually we're going to have an international discussion with people who also believe in this here and there, around the world who want to see us bring more of an executive coaching model to children's everyday sports. We can think about it with dance, with theater, with getting your homework done. We are going to talk more about these examples and how to implement this kind of thing because this is the active ingredient.
[New slide: “Coaching”. Book cover on right side: “Tools for the Mind”. Text on left side: Pre-K curriculum based on Vygotsky’s model of language and self-regulation. Pretend play requires inhibition, flexibility, and working memory”.]
>> PETER ISQUITH: A coaching program that's been studied for children, based on Vygotsky, the doctor who said you need language in order to self-regulate. This model here, the tools of the mind, is based on that kind of system. It's based on teaching parents and -- it's not a curriculum that you have to do it's teaching people around the child to have back and forth, short turns, communicating in language that talk about the child's goals, their plans, are things going well, also talk about social and emotional development things, like I wonder how your friend feels when you did that or do you think your friend might like to play? How does the doll play in the house? When beginning a project, if you go to -- I have a somewhat impulsive daughter and I would come home from work and I would see her about to begin a project such as painting on my nice wooden table without any materials and I would say Ozzie what are you trying to do? And she would say I would like to paint this picture. What do we need? We should probably cover the table. Good plan. We should have paper and she is sitting there with the paintbrush in the paint. So we would step through what is the goal, what's her plan, how are you going to do it, did that work? Will you do that tomorrow? That's what a coaching model like this will do. By the way my daughter is a professor of theater art now, big paintings. So it worked, maybe a little too well.
[New slide: “Language and Self-Regulation”. A repeat of the circle of colorful blocks from a few slides ago.]
>> PETER ISQUITH: Again, it's following this model of taking language which for our Deaf and Hard of Hearing kids is key and it's a great place to intervene. I work in a hospital where I see kids from all over the world, many of whom come as young adults with no exposure to language. It's hard to fathom, it happens in the U.S., I seen this. There is a case of that right in front of the Supreme Court this year where students manage to go through school without access to accessible communication. And had limited language and thus limited academics and everything. It's a sad story. Too many times when I go out to see a child with hearing loss in a school or in the clinic, what I find is that they're developing some language, sure, it was late but it's okay. No, it's not! Because without secure internalized language, children's thinking is limited, their ability to regulate themselves is limited, and their success in the future is limited. It begins with language and it begins by teaching all of the people in the child's world to communicate with them in an accessible way. Whether it's sign, whether it's signed English, whether it's spoken, whether it's cuing, doesn't matter. It matters that it's accessible to the child and that they have a full language system. We see more and more children coming from communities that speak a different language or come from a different country. That's a very common thing for us now in my situation at the hospital where we see children whose family speaks one language, the school is using English and we have a deaf or Hard of Hearing child who has access to neither. That's a very challenging situation because now we have to get parents on board and culturally that may not be acceptable, and we have to get the SKAL on board and the school usually is willing to but we have to get through barriers and do a lot of catching up. Language is key.
[New slide: “Findings”. Text: “Tools” as an add-on, gains were limited and narrow. Incorporated across the school day, gains were larger. BUT children with no EF risks showed minimal gains. Children with low SES showed marked gains”.]
>> PETER ISQUITH: So just some research on the tools program, what they found was important, was that if they just did this as a curriculum, for example, okay, kids now we're going to do half an hour of the tools program. It doesn't really work. It has to be built into the way that people interact throughout the school day, TLAUT the home time. That is key to coaching.
[New slide: “A Real-World Collaborative Problem-Solving Intervention for EF in ASD”. Book cover on left side: “Unstuck & on Target!” Faded photo of a child sitting at a school desk on the right side.]
>> PETER ISQUITH: Problems This is an example of a -- this is an example of a well-developed cognitive behavioral program that uses a coaching model and teaches specific language scripts to help children be more flexible. I'm showing you this because this is one of the first manual-based treatments so here is a book, parents and teachers can follow it and it's pretty simple to learn. It changes the way that people talk to and around the child in order to help them become more flexible.
[New slide: A chart with two columns, the blue column on left shows ``Flexible, Unstuck, Compromise, Whim/on Target, Plan A/Pan B, Big Deal/Little Deal, Choice/No Choice. Gray boxes on the right side show a summary of each word.]
>> PETER ISQUITH: It teaches scripts. This is a list of scripts. A script is something you say offhand. We all have scripts, hi, how are you, that's a script. My script that I work on all the time, when somebody asks me to write a paper or do a talk, I say let me get back to you on that because then I can think about it before I commit. We all use scripts all the time. Many of our children, particularly those with vulnerable language don't have scripts, they don't know them so speech and language and teachers and parents can give them scripts. It's helpful if we're all using the same one. What my colleague developed here is a set of ready-made scripts but people can create their own about being flexible. So a script that is flexible is stronger. I am stuck on something. How do I become unstuck? Can we compromise so we both get what we want? What is our plan? What's our back-up plan? What's plan B if our plan doesn't work? This is a big deal or a little deal. That's an important one. So we know that sometimes, particularly children, adolescents, and us, something seems like a nothing, not a big deal but can be a very big deal to them and helping them to change their perspective on it. Once upon a time my mother would contact me fairly frequently, regularly, throughout the day about this issue or that issue and most of them were kind of small things. I said "you know, mom, those I was doing a lecture about this very thing and she texted me and she said "okay, it's not a big deal, it's a bunch of little deals, so that sounds!" So we're still working on these things. And then do I have a choice in the matter. These are scripts that we teach kids by using them and prompting them in training. Then when my colleague does is run it through a goal, plan, do, review. She called it "check" this is the executive coaching system that we've been talking about. Executive coaching is the most active ingredient across everything that we do to improve executive functioning in children. With our Deaf and Hard of Hearing children I would add language is essential.
[New slide: “Unstuck: Outcomes”. A faded photo of a smiling teenager on the right side. Text on left side: 67 3rd-5th grade children with ASD in; 14 schools; Randomized to Unstuck vs. social skills training; Existing school staff led interventions; Interventionists: 7 training sessions; Parents: 2 training sessions, visual supports; Mainstream Teachers: 1 training session, visual supports”.]
>> PETER ISQUITH: They did a study with autistic children, those who don't like to go from one thing to the next. They trained parents in two meetings and teachers one time and the aids who were working with the chirp had seven training sessions to make sure they knew what they were doing and were good at this.
[New slide: “Parent & Teacher BRIEF Shift”. Chart showing “Higher Score = Less Flexible” with Score along the vertical side and Pre/Post on the horizontal side.]
>> PETER ISQUITH: Not a lot of investment, no new staff, just teaching people to interact differently. What they found was the blue lines were the children who got this unstuck flexibility curriculum. The red lines are children who got a social skills curriculum so they had something else they were doing to compare with. Children who got the unstuck curriculum became more flexible. That was true when they gave them tests of flexibility and when their parents and teachers rated them.
[New slide: “General Principles of a Coaching Model”. Text underneath: “Teach goal-directed problem-solving process (Goal, Plan, Do, Review); within everyday meaningful routines; having real-world relevance and application; using key people as models & “coaches”.]
>> PETER ISQUITH: So let's talk about this coaching model just a little bit more. I didn't understand it. I read about it, this comes from the work of the fellow who is cited at the bottom. This was the work of Mark Ylvisaker and Tim Feeney. Mark was a speech and language pathologist and he and Tim developed an executive coaching model. That's the one that I use and most programs that talk about coaching for students, executive coaching, most of them follow that model. I don't know of a different model. But I read Mark and Tim's work, I watched their videos, I'm not a therapist, I'm an evaluator. Mark was in my house, he came to work on a study. And I said "Mark, I don't understand this stuff. How do I do it every day?" And the next morning I was making breakfast, as I do for my kids and my youngest, 4 years old said "daddy, can I have the ketchup" I'm sorry, I made a mistake. What she said was "ketchup" and I was about to give it to her but Mark, the executive coach master said "what is it you would like?" And my daughter who has a psychologist for a father PS that this is an intervention. And she says, "I would like the ketchup" and that's the goal. Mark says "how might you get that?" And she says "I can get up and go around and get it myself" and Mark says "what's another plan?" And she said I could say "could I please have the ketchup?" And Mark says "which one do you think will be best? And she says "could I please have the ketchup?" And he says "I think that will work, give that a try. And so she says that and I give her the ketchup and Mark says did that work? She says yes it did and he asks will you do that tomorrow? She said yes. That was it. It's a way of interacting. Now, the next day I made breakfast. I did not have Mark Y. In my kitchen I forgot to prompt my daughter so she said "ketchup" and I gave it to her. So we can't forget we have to cue children to do this and reinforce it. An executive model, you don't have to buy a model, you can learn to do this. It's straightforward. It is teaching a goal-directed process. I use the script goal plan to review. Teachers have their own, parents may have their own, different books by my colleagues talk about it differently but the essence is what did you want to do? How will you do it? Do you think it will work? Try it. Did that work? It has to be meaningful. Some of us remember the days of doing an intervention by taking a child and having them do work they don't have to do for school, like let's practice writing a paper that isn't for a class. Nobody wants to do that. It needs to be something that's meaningful to them and part of their every day routine. One of the ways that we help people become more functional as adults is we give them routines every day. The more something is raw teen, the less that we have to stop and think about it, right? You drive to work the same way every day, or we used to, a few years ago. We could listen to the radio, have a conversation, not play with our phones, but then you're driving and the road is shut down. Now you have to figure out a way around it. Now it's not routine, now we have to say what's my goal, I have to get to work, what's my plan, I'm going to go this way about do I think it will work, probably, did that work? Will I follow that route next time? That's all it is. If we want children to be more independent as adults, we need them to start learning routines. Maybe it's a routine for getting up and getting dressed in the morning, maybe it's a routine for making DREFT, doing laundry, doing household chores. I encourage parents as developmentally appropriate to have their children start doing these things. How many parents send their children off to school without them knowing how to do laundry or bank? They need routines. If it's a routine, when they confront it they have a way to solve it and ask for breakfast. They don't have to stop and think about it.
[New slide: “Goal-Plan-Do-Review worksheet”. Screenshot of a worksheet with name, grade, and date across the top. Text underneath: “Use this worksheet to create a step by step plan to meet a goal and review the outcome”. Under “Goal”, a handwritten line “Get all ready for school fast each morning so dad can cook a nice breakfast and we can eat and watch a show before school”.]
>> PETER ISQUITH: My colleagues and I created this goal plan to review the coaching worksheet. As an evaluator in a clinical setting I'm often meeting with parents who say that morning is a disaster, the kids aren't ready, they don't have their shoes on, they can't find things, they have food on their clothes, they're sitting there watching television and the cereal is everywhere and I'm late for work. And I would teach them this model, how to make things better. And then I realized that's my life. So I went home to my children who were then 5 and 7, pretty functional kids so I was lucky and girls, do you like morning time? If they are happy with it they're not going to be interested in changing. I said do you like it and they said no and I said why not? And they said because you scream in the car about losing your job every day taking us to school and we don't like that. I said okay. What would you like to be different? So we wrote down a goal. They want to get ready for school in the morning so I will cook them breakfast. They meant Nutella Crepes with strawberries and whipped cream, they did that on Fridays and maybe they could watch a show. They would like a nice morning, easy going, watch a TV show, and eat a nice breakfast. I said okay that's an anyways goal. What’s your man for doing so?
[New slide: Continuation of the worksheet slide with “plan” across the top and a step by step handwritten list of items to do in the morning. On the bottom, “What materials and support do I need to reach my goal?” with two items underneath written out.]
>> PETER ISQUITH: They readily said why don't we just list all the things we have to do, we will put them in order and then decorate it because they're both artists and that's what they like to do, because it has to be fun, okay? It has to be meaningful and in the morning you give us the list, we'll follow it, you make breakfast, we will be ready for school. I said why didn't we think of this before? Why do we have to do this but okay. We will do it.
[New slide: Continuation of the worksheet with “Prediction: how long will it take me to reach my goal?” with a handwritten response under. On the bottom, “Do the plan” with a checkmark underneath when the plan is complete.]
>> PETER ISQUITH: And then I said how long do you think this will take and then later how long did it take to pause that will help them adjust. And they said we think it will take 20 minutes and then we will watch a show for 30 minutes. I said okay.
[New slide: Continuation of worksheet with “Review” on top with questions to answer, with handwritten responses underneath each: “How long did it take for me to reach my goal? How much did I get done?Did I get it done on time? What worked? What will I try differently next time? (Plan B). ]
>> PETER ISQUITH: I go in, give them their lists in the morning, they didn't need them, they followed them, I gave them each a dollar because I want to reinforce that, they had their crepes ready to go, backpacks by the door, ready to go and reviewing this I said did it work well? They said yes, it took longer than we thought so we will remember that and we wouldn't change anything else.
[New slide returns back to the three-arrow bar with “Review” highlighted in blue.]
>> PETER ISQUITH: Goal, plan, do, review. Why we put in because sometimes it's useful to know why, depending on the child.
[New slide: “Executive Function in DHH Children Review”. Snapshot of a preschool child on bottom right corner. Text on left side: EF skills are highly predictive of near and long-term outcomes; DHH children are at risk for self-regulatory problems; EF are strongly related to language, not hearing; Accessible language is essential; Two languages are fine; Bilinguals have better EF.”]
>> PETER ISQUITH: So executive function -- this is the review part because I'm doing that goal plan to review with you. Executive function skills are very predictive of long-term outcomes of all kinds. We know this. A person who is impulsive is going to get into trouble. A person who can't focus is not going to be as successful. A person who is not able to plan and organize themselves and their work is not going to be as successful. A person who doesn't regulate their emotions is going to get in trouble. Deaf and Hard of Hearing children are at risk for executive function or self-regulation problems. It may be because they're missing language. They use that in their head to self-regulate. It might be because they have other issues, their hearing loss is associated with CMV or Rubella, we're seeing that again or why are injuries, or cancer treatment. There could be lots of problems with hearing loss also that cause executive function problems. Executive functioning is related to language not hearing and we need to make sure our children have access to language, that's the key part. It's fine to have two languages, research on bilingual people have better functions, they have an advantage because they are often inhibiting one language in order to use the other one. If you are somebody who code switches between Spanish and English you may have to want to say something in Spanish, inhibit and use your English to express it. That requires practice with inhibition.
[New slide: “Intervention Review”. Text: Executive functions need to be continually challenged; Those with problems benefit more; Training across the day and across settings has greatest benefit; Coaching is likely a key ingredient applied to most activities; o Build understanding; Provide supports and accommodations; Teach skills and intervene in the everyday setting.]
>> PETER ISQUITH: Executive functions in general have to be continuously challenged. We can't just do one thing we have to do it over time. People who have problems with executive functions get better but people who are fine with executive functions don't really show much of a change. When we want to do an intervention we need to do it at home and school over the course of the day. Coaching, the very simple act of using a coaching model in things we do is likely the most active ingredient, the good news it's the simplest, the cheapest, the easiest thing to do. It requires learning to ask different questions and things.
[New slide: “The Deaf and Hard of Hearing Program Team” Three columns of headshots accompanied by names and titles.]
>> PETER ISQUITH: All right, I just want to acknowledge my team. We have a big team at Boston Children's where we see Deaf and Hard of Hearing children and we all participate in putting together our many talks in many different ways.
[New slide: “References 1” . List of references underneath.]
[New slide: “References 2” List of references underneath.]
[New slide: “References 3” List of references underneath.]
>> PETER ISQUITH: I have included some references here if you're interested in particular studies that I've mentioned.
[New slide: “Books on Executive Function in Children”. Four book covers in a row: “Smart but Scattered”; “Coaching Students with Executive Skills Deficits”; “Late, Lost and Unprepared”; Boosting Executive Skills in the classroom”. ]
>> PETER ISQUITH: I have also included a lot of references on books that you might be interested in. I have tried to pick ones that are both useful for school and for home. The "Late, Lost, and Unprepared" book is an easy read and parents seem to find it easy to understand and practical. The coaching students book I gave that to a school that I work with fifteen years ago. They used it, everybody across the classrooms knows how to coach executive functions and when families come and say my child has executive function problems what will you do I say we've got that. It's a coaching model, everybody here uses it. It's a nice thing.
[New slide: “Online Resources” List of resources with scannable QR code on bottom. “Resources on executive functioning from the Harvard Center on the Developing Child” https://developingchild.Harvard.edu/guide/a-guide-to-executive-function/
“arent videos (English or Spanish) on executive functions from the Patient Centered Outcomes Research Institute” https://www.youtube.com/watch?v=cRfGJrhPgJk . ]
>> PETER ISQUITH: There are some online resources. The Harvard center On the Developing Child I am not associated with them but they have nice videos talking about people who deal with executive functioning, not me but that's okay and handouts, they have handouts for small children, young children, and teenagers, ways that they deal with exec if I have functioning improvement and practice in the everyday life of children. My colleague has produced a bunch of individual YOEZ in both English and Spanish for teaching parents about executive function and about how to intervene. She is a master of doing interventions. The scannable code should take you to the You Tube place.
[New slide: “Hearing loss and mental health”. Four book covers in a row: “Language Deprivation and Deaf Mental Health”; “Cognitive-Behavioral Therapy for Deaf and hearing PersonsWith Language and Learning Challenges”; “Psychotherapy with Deaf Clients from Diverse Groups”; “Deaf Mental Health Care”.]
>> PETER ISQUITH: These were funded by a study, a federal study and they're nice videos that may be helpful. There are lots of good books on hearing loss and mental health, language deprivation and mental health, this is a major interest for all of us these days.
[New slide: “Marc Marschark volumes” Four book covers in a row: “Deaf cognition”; “Diversity in Deaf Education”; “Evidence-Based Practices in Deaf Education”; “Educating Deaf Students”.]
[New slide: “More Mark Marschark volumes' '. Four book covers in a row: “Deaf Studies Language, and Education”; :Deaf Studies, Language, and Education (revised edition)”; “Raising and Educating a DEaf Child”; “Co-Enrollment in Deaf Education”.]
>> PETER ISQUITH: My colleague Mark Marshark has put together many volumes useful as an educator or as a scientist or parent that you might find useful
[New slide: Photo of a toddler on right side, with quote on left side: “We are grateful to the families and children who receive services through the DEAF AND HARD OF HEARING PROGRAM of the Boston Children’s Hospital. Their support and confidence allow us to better understand and provide effective services for Deaf and hard of hearing children now and into the future.”.]
>> PETER ISQUITH: … and I would like to thank all the people and the families that we see that have taught us so much. I've been working with Boston Children's Deaf and Hard of Hearing program over the last 30 years, my mentor has been doing it for 45. We always learn from our kids and hopefully they get something from us. Let me stop in the last five or ten minutes we have if you have questions, if I can help address further questions.
[New slide: Peter.Isquith@Childrens.Harvard.edu .]
[Slide presentation is replaced by Danelle’s window reappearing.]
>> DANELLE: Thank you so much. This is a wealth of information and you have touched on so many different topics. We do have some questions. A few questions from the audience. The first question is how do you explain the model of classroom inclusion to clearly affect the teacher support system?
>> PETER ISQUITH: So let me clarify the question. How would we incorporate an executive function curriculum or program within a regular inclusion program? Did I understand that correctly? I'm going to go with that because I think that's what you understood. There are different ways to do it. Having a coaching model in the classroom is a matter of learning how to interact with children where we're asking the questions: what did you want to accomplish? What is your goal? What are you thinking about how to do that? What is your plan? Did that work or not? That's natural language for teachers in the first place. If you tell that to teachers they will say I do that. It doesn't have to be a structured curriculum. A colleague of mine who runs a study skills program does an overarching executive model where she asks students what do you need to work on? What's your goal? How will you do that? What's your plan? Okay. How long do you think it will take you? What kind of grade do you want? And then did that work? While she is also teaching study skills, methods, note taking, abstracting, that's a sophisticated high school course. But using programs like tools of the mind as an example in a preschool setting, or the unstuck curriculum, if you're working with children who don't like change, or that teaches us how to use an executive model and then it becomes secretarized nature. It becomes natural. My oldest who had executive challenges I coached all the way through her school years. I would be at the kitchen counter writing my reports. She would be at the end, drifting, not getting work done and I would ask her, what are you trying to do? Okay, well, how will you do that? When will you take a break? How long will that be and I started adding in more and more questions about making her more sophisticated. She is a professor. She still calls me in the morning on the way to work and says, "Dad, these are my goals for the semester. There's what I'm going to do and the timeline for getting them done. Do you think that will work?” She took it to heart, I think it made her more functional, I hope. My younger one didn't need any coaching and would have nothing to do with it. She said "Dad, stop it" so I did. Other questions?
(Silence.)
>> DANELLE: Okay, thank you, thank you. We do have one more question but we're about to run out of time. So the last question from the audience, they asked what are some of the tools we can use to develop that?
>> PETER ISQUITH: It's with what tools of the mind curriculum that I showed. You can look that up. You can Google that. It is a program. It's also an organization that uses a coaching model for younger children. Preschool into very early elementary school. And what it does is teach people how to use a coaching model to say what is your goal, what is your plan? How will we make this project, but also build in social/emotional learning by talking about how people feel, I wonder how you thought about that, what did that person feel? So building in perspective about others. I think it's natural teaching. It's not a book that they have to follow, but it's a way of changing how you interact. We know from recent research that we want to build in more turn-taking in language, in communication with children. Especially young children, because studies show that parents or teachers who do a lot of one-way talking versus parents or teachers who ask shorter suggestions or comments and the child responds back and forth that way lead to enhanced language which we believe would then enhance self-regulation. I think we're out of time. And I appreciate your joining me today. It's been a long time since I've been in Minnesota. I used to drive around the minimum machine early in my career. I spent about 15 years in your winters, coming to your schools. Seeing little deaf and Hard of Hearing kids, and Minnesota did an anyways job of putting teachers of the deaf and Hard of Hearing into those schools and bringing parents and families together. I live in Vermont, same thing. Thank you for stopping because it’s a long trip out there and you guys have a lot of snow. Of course, I live in Vermont so we have snow and hills, same thing Thank you very much for having me. This was a joy.
>> DANELLE: Yes. Yes. Thank you so much, Dr. Isquith, as well as my pleasure to have you here today during our Collaborative Experiences Conference. And I hope that you do get back to Minnesota one day soon. Thank you.
[Peter’s window closes and Danelle’s window shifts to the right side while a slide presentation appears on the left side. Text:”Keynote: Executive Functioning: Enhancing Self-Regulation in Deaf & Hard of Hearing Children. Evaluation ink (link under). Presenter: Dr. Peter Isquith”. QR code with “SCAN ME” next to it.]
>> DANELLE: I will pull up the QR code again for the presentation evaluation if you are trying to earn CEU credits for this. But thank you for watching the presentation and thank you to Dr. Isquith.
[All windows close and are replaced by a slide with a photo of an apple next to a magnifying glass and colored pencils on top left corner, and another photo of a pile of stacked books on bottom next to the mn.gov logo. Text on top right corner: “2022 Collaborative Experience Conference November 3-5, Thank you for joining!.” Text on bottom right: “Supporting the whole child, reboot.”
[Video ends.]
