A large percentage of children referred for therapy (about 50% in my practice) have executive functioning deficits. Executive functioning deficits are common in Asperger’s Disorder, PDD NOS, ADHD, and childhood-onset Bipolar Disorder. Executive functioning is the ability to formulate, initiate, sustain, and complete a plan or course of action. Deficits in executive functioning are manifested in a variety of ways, including getting started and finishing work, remembering homework, memorizing facts, writing essays or reports, working on math problems, being on time, controlling emotions, completing long-term projects, and planning for the future. Deficits in executive functioning are believed to be neurologically-based but can certainly be exacerbated by emotional and environmental issues. We do a great disservice to our clients if we don’t offer a multi-modal approach to their difficulties. It is clear that there are many well adjusted children with executive functioning deficits who have supportive families and schools and don’t need psychotherapy. Psychotherapy would be a waste of time for these individuals, but we must be able to offer some support and assistance to them. Other clients will need psychotherapy, but that alone will be insufficient to address their problems. Further, an exclusive focus on psychotherapy may delay getting the help and support that would greatly ameliorate emotional distress and family conflict.
In order to communicate to parents and children the intervention they need I divide it into three categories: medication/medical, education, and appropriate support and accommodations. We are not physicians so we should never be recommending medication. However, it is important to be able to talk intelligently with parents and children about medication, and refer children for a medication evaluation. Often a fear of medication is the result of hearing or reading sensationalistic comments that are not based on fact. Clinicians often have outdated ideas and information about medication. The popular press turns out to be a terrible source for quality information and often a Google search that turns up a random collection of web sites isn’t much better. It is not unusual for me to be the first person to sit and talk at length with parents and their child about medication, even when they are already taking a psychotropic medication. This discussion naturally leads into a discussion of education about the child’s disorder. It doesn’t hurt to make available a list of reading material and web sites that offer parents good quality information. Handouts about the disorder are almost always appreciated by parents.
The third category, support and accommodations, leads into the area that we are most comfortable with, psychotherapy/play therapy. However, children with executive functioning deficits also need support at school and parents often need training. As child clinicians we need to be familiar with behavior management techniques that we can teach parents or have resources that we can refer them to. We must also be familiar with Section 504 and Special Education modifications and support. Having resources to refer to and understanding how to obtain services in your local school district is very important.