Thursday, February 21, 2019

Autism in the Educational Setting

Medical versus Educational

This is a big post for me to tackle, and I hope you will find it answers many of the questions you have concerning Autism in the educational setting. Many parents, including myself in the beginning of my journey, did not understand there is a difference between medical and educational diagnoses and therapies. There is a medical definition of autism as defined by the DSM V and the educational definition of Autism as defined by IDEA and may be further refined (though should not be more restrictive, because that could possibly be a violation of the federal supremacy clause) by your state. If you need help finding your state's information then you are welcome join the IEP/504 Assistance group on Facebook for some advice and help.

The same is true for therapy. There is medical therapy, which looks to make a child "whole" across all areas of life while educational therapy looks to make a child "functional" in the educational environment. The previous statement is one I often hear though the school has an obligation to make a child "functional" to ensure that all children with disabilities have available to them a free appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living as stated in the purpose of IDEA.

Personally, I like medical therapy better than educational therapy for a few reasons. One is that you do not need to convene an IEP meeting and then convince the team your child needs more services. For medical therapy you see your child's pediatrician and convince the doctor that your child needs more therapy. I tend to find this vastly easier than getting more services from the school. The second reason is because therapy in the educational setting is often led by therapy assistants, or the special education teacher, in group sessions. Medical therapy is normally a 1:1 session with a qualified therapist (OT, PT, and/or Speech) versus a therapy assistant. Keep in mind too that therapy assistants cannot practice without having supervision of a qualified therapist. In the educational setting it is not uncommon to find these therapy assistants are not being properly supervised so it is good to keep track of how your child is doing if they are working with a therapy assistant in the public school and to find out how often the lead therapist is supervising the therapy assistant's work. The third reason I like medical therapy versus educational therapy is that if a child qualifies for educational therapy they would have qualified for medical therapy a long time ago. The bar to reach to qualify medical therapy is "easier" to get to versus educational therapy. I am a FIRM believer in therapy as I think therapy is essential to help a child resolve some issues that are impeding learning.

Medical versus Educational Autism

For medical autism, the doctor, psychologist, or similar medical professional will use the Diagnostic and Statistical Manual, fifth edition (DSM V). This diagnosis focuses on persistent deficits in social communication and social interaction across multiple contexts, as manifested currently or by history; restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history; symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life); symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning; and these disturbances are not better explained by intellectual disability.

I hear families, often in frustration, complain the school will not give their child an Autism eligibility for special education when their child has a medical diagnosis of Autism. The medical definition is different than the educational definition of Autism. For the educational definition of Autism IDEA says:

(i)Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, that adversely affects a child's educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.

(ii) Autism does not apply if a child's educational performance is adversely affected primarily because the child has an emotional disturbance, as defined in paragraph (c)(4) of this section.

(iii) A child who manifests the characteristics of autism after age three could be identified as having autism if the criteria in paragraph (c)(1)(i) of this section are satisfied.

This is the educational eligibility for Autism under IDEA. When you have an IEP meeting to discuss eligibility you will want to bring in documentation, and make an argument, for your child meeting this definition if you are seeking Autism as the primary eligibility for your child's IEP.

Children with ASD with good grades or those with high cognition/2e

Since Autism is a spectrum, it can be hard to get children who have more Asperger-like issues qualified for educational autism, along with those who are 2e and have autism being gifted can "hide" areas of disability. Does this mean your child shouldn't qualify for services? No! Does it mean your child has to have bad grades to qualify for services? No!

Children with medical autism can need anywhere from a Section 504 plan to an IEP. It depends on your child's needs. That is ALWAYS, no matter the disability, what should be driving the consideration of placement and services. It is a matter of FAPE.

Children with Autism, even "mild" or "high-functioning" autism, will likely need an IEP versus a 504. Why? A 504 does not cover goals and it does not cover possible curriculum modifications that may be needed for the child. A child with autism often needs goals and assistance with social/emotional skills, executive functioning skills, and figurative/pragmatic/social language.

IDEA states that a child does not have to fail or be retained to be considered for special education and related services. 34 C.F.R. §300.101(c). A child who is making good grades may still need special instruction and related services.

  • Effort does not mean a child is learning. Teachers give out grades based on many different factors.
  • Some teachers allow students to improve their grades by doing extra credit work.
  • Other teachers base grades on class participation, a good attitude, or citizenship

Teachers may also give a student a better grade because the child is trying very hard to do good work. These kinds of grades do not mean a child is learning. Almost all teachers will do this. They do not want to fail a child who is trying.

Children with ASD can be twice exceptional (2e) and/or have a high IQ/good grades. A child CAN be academically gifted and STILL need an IEP. This is in the very definition of FAPE.

(c)Children advancing from grade to grade.

(1) Each State must ensure that FAPE is available to any individual child with a disability who needs special education and related services, even though the child has not failed or been retained in a course or grade, and is advancing from grade to grade.

(2) The determination that a child described in paragraph (a) of this section is eligible under this part, must be made on an individual basis by the group responsible within the child's LEA for making eligibility determinations.

The OSEP Letter to Delisle discussed the use of an IEP for children with high cognition and Specific Learning Disabilities (SLDs). In an April 2015 memorandum from OSEP "Letter to Delisle: Children with disabilities with high cognition," discusses twice exceptional children and their need for special education services as addressed under IDEA. The April 2015 memorandum expands on the original Letter to Delisle saying children with high cognition can have an IEP under any of the 13 categories recognized by IDEA. Don't let the schools deter you evaluating your child for an IEP if they are making "good grades" or your child has high cognition.

Importance of Social interaction

Goals for social needs are important for children with autism. Children with ASD have a difficult time interacting with peers due to missing the social nuances of personal relationships. Peer interactions are important because they can influence academic, social-emotional, and mental health outcomes. For neurotypical children, peer interactions contribute to refining of social skills, engage in "typical" leisure activities, and access to emotional support. It is assumed that children with ASD also benefit from successful peer interaction. Due to educational inclusion practices children with disabilities have more opportunities than ever to interact with typically developing peers. This makes social deficits important to address.

In a January 2017 study by Chiang, Ni, and Lee, discuss how 78% of students with Autism leave high school and STILL need assistance with life skills. Life skills can be grouped into five areas including: self-care and domestic living, recreation and leisure, social interaction, employment, and community participation. It is estimated that less than half of the secondary students with ASD would participate in postsecondary education after leaving high school and slightly higher than half of the high school leavers with ASD would have a paid job. About 57% of children with ASD have co-occurring intellectual disability (ID) or borderline intellectual functioning. Students with ASD who also have ID show poorer postsecondary outcomes than students with ASD who do not have ID.

Individuals with ASD tend to have poorer life skills than would be expected by their cognitive abilities. Many students with disabilities do not learn life skills on their own, thus, they need to be specifically taught these skills. Teaching life skills has been regarded as an evidence-based practice, especially for secondary transition. Lifelong adaptive functioning intervention should be offered to people with ASD (Matthews et al. 2015). This study found that students with ASD needed life skills training after high school. For the students who had received life skills training in school, the majority of them (78%) still needed life skills training after high school. For the students who had never received life skills training in school, about 29% of them were reported by their parents to need life skills training after high school. These findings indicate that individuals with ASD have an ongoing need for life skills training. Many individuals with ASD may need a significant amount of time to acquire life skills. Yet, some students may not realize they need life skills training until the needs exceed capacity. In terms of the specific life skills needs after high school, this study found that the most needed training was to deal with financial issues followed by relationship skills development.

In a September 2017 article by Hebron, young people with autism may face many educational challenges, particularly in terms of academic achievement, social inclusion, and mental health. School connectedness is linked to many positive outcomes and may be of particular salience at the primary-secondary school transition, when young people with ASD are expected to cope in new and unfamiliar settings. This study explores for the first time school connectedness across the primary to secondary school transition for young people with ASD. Students with ASD reported positive levels of school connectedness across transition, although their scores remained lower than those of their typically developing peers. The gap between the two groups narrowed significantly during the first year of secondary school, with students in the ASD group reporting improving levels of school connectedness, although there were non-significant signs of a decline for both groups in the second year. Transition can be a positive experience for students with ASD. However, their consistently lower levels of school connectedness compared to those of their peers highlight the need for ongoing monitoring and support during secondary education.

In a paper from Karal and Wolfe (2018), social stories frequently have been used to improve the social interaction of students with ASD. The study conducted a literature review and examined the effectiveness of social story interventions on the social interactions of students with ASD including with whom, where, and what formats have been implemented, as well as the methodological rigor of the research. Findings indicate preliminary evidence to suggest that social stories are a promising intervention to increase social interactions. Future research with methodological rigor is needed to reveal the most effective strategy for developing and implementing social story interventions.

In a randomized control trial of a school-based intervention, Mackay, Shochet, Orr offered resilience intervention to prevent depressive symptoms for young adolescents with ASD. Adolescents with ASD are at risk of increased depression and effective prevention approaches for this population are limited. A mixed methods pilot randomized controlled trial (N = 29) of the evidence-based Resourceful Adolescent Program-Autism Spectrum Disorder (RAP-A-ASD) designed to prevent depression was conducted in schools with adolescents with ASD in years 6 and 7. Quantitative results showed significant intervention effects on parent reports of adolescent coping self-efficacy (maintained at 6 month follow-up) but no effect on depressive symptoms or mental health. Qualitative outcomes reflected perceived improvements from the intervention for adolescents’ coping self-efficacy, self-confidence, social skills, and affect regulation. Converging results remain encouraging given this population’s difficulties coping with adversity, managing emotions and interacting socially which strongly influence developmental outcomes.

Importance of Pragmatic Language

As you can see, there are many reasons to be proactive and seek social/emotional interventions and goals. Beyond social/emotional intervention, there is often a need for figurative/pragmatic language intervention and goals.

A 2017 study by Parsons et al. discusses core characteristics of ASD is a deficiency in social communication and interaction. A wide range of verbal language abilities are reported in individuals with ASD, but a striking feature about their language profile is a universal impairment in pragmatic language. This review will focus on interventions that target the pragmatic aspect of language. Early definitions of pragmatic language refer to the use of language in context; encompassing the verbal, paralinguistic and non-verbal aspects of language. Contemporary definitions have expanded beyond just communicative functions to include behavior that includes social, emotional, and communicative aspects of language.

Some children with high-functioning autism have been medically diagnosed with Social Pragmatic Communication Disorder versus Autism. In a 2017 study by Mandy el al., evaluated Social (pragmatic) communication disorder (SPCD). It is a new diagnosis introduced by DSM-5, characterized by problems with verbal and nonverbal social communication. It is currently unclear whether SPCD is a valid diagnostic category, because little is known about the characteristics of those who meet its criteria. We sought to identify and describe cases of SPCD, to contribute to debates about its validity. Mandy el al. investigated whether the symptoms of SPCD cluster together to form a coherent syndrome that is distinct from ASD in terms of its core and associated features. We did not find evidence that SPCD is qualitatively distinct from ASD. Rather, it appears to lie on the borderlands of the autism spectrum, describing those with autistic traits that fall just below the threshold for an ASD diagnosis. SPCD may have clinical utility for identifying people with autistic traits that are insufficiently severe for ASD diagnosis, but who nevertheless require support.

Autism , Language Disorder , and Social (Pragmatic) Communication Disorder : DSM-V and Differential Diagnoses Mark D. Simms, Xing Jin Published 2015

A study by Randall et al discusses the importance of addressing Sensory Processing Disorder (SPD) in individuals with ASD. ASD is a common, lifelong condition, affecting 1 in 100 people. ASD affects how a person relates to others and the world around them. Difficulty responding to sensory information (noise, touch, movement, taste, sight) is common, and might include feeling overwhelmed or distressed by loud or constant low-level noise (e.g. in the classroom). Affected children may also show little or no response to these sensory cues. These 'sensory processing difficulties' are associated with behavior and socialization problems, and affect education, relationships, and participation in daily life. Sensory integration therapy (SIT) is a face-to-face therapy or treatment provided by trained occupational therapists who use play-based sensory-motor activities and the just-right challenge to influence the way the child responds to sensation, reducing distress, and improving motor skills, adaptive responses, concentration, and interaction with others. With limited research into SIT, this protocol describes in detail how the intervention will be defined and evaluated. This study is a two-arm pragmatic individually 1:1 randomized controlled trial with an internal pilot of SIT versus usual care for primary school aged children (aged 4 to 11 years) with ASD and sensory processing difficulties. Therapy will be delivered in clinics for SIT over 26 weeks (face-to-face sessions: two per week for 10 weeks, two per month for 2 months; telephone call: one per month for 2 months). Follow-up assessments will be completed at 6 and 12 months post-randomization. Results of this trial provide high-quality evidence on the clinical and cost effectiveness of SIT aimed at improving behavioral, functional, social, educational, and well-being outcomes for children and well-being outcomes for carers and families.

Voldent et al. discusses how impairments in the social use of language are universal in ASD, but few standardized measures evaluate communication skills above the level of individual words or sentences. This study evaluated the Expression, Reception, and Recall of Narrative Instrument (ERRNI; Bishop, 2004) to determine its contribution to assessing language and communicative impairment beyond the sentence level in children with ASD. A battery of assessments, including measures of cognition, language, pragmatics, severity of autism symptoms, and adaptive functioning, was administered to 74 8- to 9-year-old intellectually able children with ASD. Average performance on the ERRNI was significantly poorer than on the Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-4). In addition, ERRNI scores reflecting the number and quality of relevant story components included in the participants' narratives were significantly positively related to scores on measures of nonverbal cognitive skill, language, and everyday adaptive communication, and significantly negatively correlated with the severity of affective autism symptoms. Results suggest that the ERRNI reveals discourse impairments that may not be identified by measures that focus on individual words and sentences. Overall, the ERRNI provides a useful measure of communicative skill beyond the sentence level in school-aged children with ASD.

MacFarlane et al. conducted a study to examine deficits in social communication, particularly pragmatic language, are characteristic of individuals with ASD. Speech disfluencies may serve pragmatic functions such as cueing speaking problems. Previous studies have found that speakers with ASD differ from typically developing (TD) speakers in the types and patterns of disfluencies they produce, but fail to provide sufficiently detailed characterizations of the methods used to categorize and quantify disfluency, making cross-study comparison difficult. In this study we propose a simple schema for classifying major disfluency types, and use this schema in an exploratory analysis of differences in disfluency rates and patterns among children with ASD compared to TD and language impaired (SLI) groups. 115 children ages 4–8 participated in the study (ASD = 51; SLI = 20; TD = 44), completing a battery of experimental tasks and assessments. Measures of morphological and syntactic complexity, as well as word and disfluency counts, were derived from transcripts of the Autism Diagnostic Observation Schedule (ADOS). High inter-annotator agreement was obtained with the use of the proposed schema. Analyses showed ASD children produced a higher ratio of content to filler disfluencies than TD children. Relative frequencies of repetitions, revisions, and false starts did not differ significantly between groups. TD children also produced more cued disfluencies than ASD children.

Examples of Pragmatic Skills

Importance of Figurative Language

Kalandadze et al conducted a meta-analysis of studies that compare figurative language comprehension in individuals with autism spectrum disorder and in typically developing controls who were matched based on chronological age or/and language ability. A total of 41 studies and 45 independent effect sizes were included based on predetermined inclusion criteria. Overall, individuals with autism spectrum disorder showed poorer comprehension of figurative language than their typically developing peers (Hedges' g = -0.57). Metaphors were more difficult to comprehend for individuals with autism spectrum disorder compared with typically developing controls than were irony and sarcasm. Our findings highlight the critical role of core language skills in figurative language comprehension. Interventions and educational programs designed to improve social communication skills in individuals with autism spectrum disorder may beneficially target core language skills in addition to social skills.

Chahboun et al study discusses the problems with figurative language comprehension. This issue has been often reported against strengths in the domain of structural language in individuals with high‐functioning autism. Accounts, however, differ when concerned with what causes these problems and whether figurative language processing is directly proportionate to structural language competence. Furthermore, little is known about whether understanding of non‐literal expressions is still atypical in the absence of structural language problems. Metaphor processing requires, among other things, an adequate level of structural language abilities. Our findings demonstrate that despite adequate language competence otherwise, there is still a developmental delay in our group of highly verbal participants with autism seen in the parallel performance by the young adult group with autism (age range = 16–22 years) and the control children group (10–12 years). This suggests a consistent problem with non‐literal language on the higher end of the spectrum, which persists also into young adulthood. The study highlights the need for special attention to figurative language comprehension in ASD in designing assessment and treatment protocols. The current results suggest a possible improvement with age and indicate how possible targeted intervention programmes can be designed that cater better for the needs of that specific group.

Examples of Figurative Language

Van Herwegen and Rundblad discuss how previous studies have shown that comprehension of figurative language is impaired in individuals with autism spectrum disorder (ASD). However, most studies have focused on lexicalized expressions and have only examined performance at one particular point in time, without examining how performance changes over development. The current study examined the comprehension of novel metaphor and metonymy in individuals with ASDs from a large age range, using both a cross-sectional (Experiment 1) and longitudinal design (Experiment 2). Performance in the ASD group was lower compared to typically developing (TD) controls, across all ages. Importantly, the results from Experiments 1 and 2 showed that, although chronological age was not a good predictor for performance of either novel metaphor or metonymy in the cross-sectional design, performance improved when longitudinal data was considered. Correlations between vocabulary knowledge, visuo-spatial abilities and figurative language comprehension abilities were also explored.

Reynolds et al completed a study for children with ASD. The study demonstrates marked deficits in the ability to initiate, maintain and sustain meaningful social interaction. While the social-emotional deficits represent a core set of problems, persons with ASD also demonstrate significant problems in initiating, sustaining and maintaining appropriate goal directed behaviors. Emotional Intelligence (EI) is a construct that has been successfully applied to a range of skills that allow for the prediction of competent human social behavior. Executive Functions (EF) refer to constructs involving cognitive abilities necessary for initiating, sustaining and maintaining purposeful goal-oriented behavior. While both children and adults with ASD have previously shown to have atypical patterns of EF skills, little is known about EI in either children or adults with ASD. Moreover, there is no study examining the relationship between EI and EF that has been reported in individuals with ASD. The current study examined the relationship between EF and EI in children with ASD. Twenty children with ASD were compared to twenty neurotypical children on self-report and clinical assessments of EI and EF. Although the relationship between EF and EI was not statistically significant, results showed that children with ASD have deficits in interpersonal skills, intrapersonal skills and overall EI when compared to their neurotypical peers. These results suggest that EF and EI are relatively independent domains of development that show compromise in persons with ASD and each may be necessary to support typical socially directed behaviors.

The study by Zimmerman et al indicated that better concept formation and social inference skills were significantly associated with fewer anxiety symptoms for adults with high functioning ASD. Conversely, participants with better non-verbal reasoning, cognitive flexibility and social cognition reported more negative self-concept and lower self-esteem. Those with impaired Executive Functioning (EF) are more prone to anxiety, whereas those with stronger EF are more likely to experience negative self-concept. Screening for and monitoring mental-health concerns in people with ASD regardless of their level of EF are recommended.

The study by Lai et al researched the neuropsychological profiles seen in children and adolescents with High Functioning ASD. The study found most were moderately impaired in verbal working memory (g = 0.67), spatial working memory (g = 0.58), flexibility (g = 0.59), planning (g = 0.62), and generativity (g = 0.60) except for inhibition (g = 0.41). Subgroup analysis showed that impairments were still significant for flexibility (g = 0.57–0.61), generativity (g = 0.52–0.68), and working memory (g = 0.49–0.56) in a sample of autism spectrum disorder (ASD) subjects without comorbid ADHD or when the cognitive abilities of the ASD group and the control group were comparable.

Importance of Executive Functioning

Karalunas et al conducted a study on Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). ADHD and ASD are commonly comorbid, share genetic liability, and often exhibit overlapping cognitive impairments. Clarification of shared and distinct cognitive effects while considering comorbid symptoms across disorders has been lacking. In the current study, children ages 7–15 years assigned to three diagnostic groups:ADHD (n = 509), ASD (n = 97), and controls (n = 301) completed measures spanning the cognitive domains of attention/arousal, working memory, set-shifting, inhibition, and response variability. Specific processes contributing to response variability were examined using a drift diffusion model, which separately quantified drift rate (i.e., efficiency of information processing), boundary separation (i.e., speed-accuracy trade-offs), and non-decision time. Children with ADHD and ASD were impaired on attention/arousal, processing speed, working memory, and response inhibition but did not differ from controls on measures of delayed reward discounting, set-shifting, or interference control. Overall, impairments in the ASD group were not attributable to ADHD symptoms using either continuous symptom measures or latent categorical grouping approaches. Similarly, impairments in the ADHD group were not attributable to ASD symptoms. When specific RT parameters were considered, children with ADHD and ASD shared impairments in drift rate. However, children with ASD were uniquely characterized by a wider boundary separation. Findings suggest a combination of overlapping and unique patterns of cognitive impairment for children with ASD as compared to those with ADHD, particularly when the processes underlying reaction time measures are considered separately.

Demetriou et al showed that evidence of executive dysfunction in ASD across development remains mixed and establishing its role is critical for guiding diagnosis and intervention. The primary objectives of this meta-analysis is to analyse executive function (EF) performance in ASD, the fractionation across EF subdomains, the clinical utility of EF measures and the influence of multiple moderators (for example, age, gender, diagnosis, measure characteristics). The Embase, Medline and PsychINFO databases were searched to identify peer-reviewed studies published since the inclusion of Autism in DSM-III (1980) up to end of June 2016 that compared EF in ASD with neurotypical controls. A random-effects model was used and moderators were tested using subgroup analysis. The primary outcome measure was Hedges’ g effect size for EF and moderator factors. Clinical sensitivity was determined by the overlap percentage statistic (OL%). Results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 235 studies comprising 14 081 participants were included (N, ASD=6816, Control=7265). A moderate overall effect size for reduced EF (Hedges’ g=0.48, 95% confidence interval (CI) 0.43–0.53) was found with similar effect sizes across each domain. The majority of moderator comparisons were not significant although the overall effect of executive dysfunction has gradually reduced since the introduction of ASD. Only a small number of EF measures achieved clinical sensitivity. This study confirms a broad executive dysfunction in ASD that is relatively stable across development. The fractionation of executive dysfunction into individual subdomains was not supported, nor was diagnostic sensitivity. Development of feasible EF measures focussing on clinical sensitivity for diagnosis and treatment studies should be a priority.

Freeman et al discusses the lack of literature examining the relationship between executive and social functioning in children with ASD. Twenty-three school-aged children with ASD participated. Executive functioning was measured using the Developmental Neuropsychological Assessment, Second Edition and Differential Ability Scales, Second Edition, and the teacher-rated Behavior Rating of Inventory of Executive Function. Independent assessors observed children’s social functioning on the playground while children with ASD and their peers completed a survey to measure peer friendships and rejections. Overall, poorer executive functioning was associated with increased playground isolation and less engagement with peers. This suggests that metacognitive skills such as initiation, working memory, and planning and organization are associated with children’s social functioning.

Ryan and Marshall set out to understand executive functioning (EF) for learners with autism. We focus on learners with high functioning autism (HFA) and explore a common goal for an Autistic Spectrum Disordered (ASD) population is to increase independence, thus enabling access to experiences and opportunities similar to neuro-typical individuals. We suggest in a somewhat counterintuitive manner, educators may be preventing this development by being overly supportive. This can inhibit ASD learners by denying tools and opportunities to enable themselves. Executive functioning (EF) skills can be taken for granted by neuro-typical learners but are essential skills that need to be explicitly taught to those on the autism spectrum. Herein we support educators and understand the deficits that learners with high functioning ASD experience with EF skills and encourage all to set goals and design programming for students.

I hope this post has been helpful. Autism in the educational setting is a huge topic to cover. I hope I did it some justice and supplied you with information you cannot typically find elsewhere in other blog posts. Please take the time to click on the links in the post as it contains the reference material used to write this post. As always, you are welcome to join us for more discussion on Autism in the educational setting at our FB group, IEP/504 Assistance for parents of public school students from all over the United States.

AESA also runs a special needs homeschool group, Homeschooling Special (Needs) Kids, and we also have a group for all parents and caregivers of special needs children called Special Needs Parenting Advice and Support where we discuss ALL things related to special needs care and Educating Gifted Children is where we discuss topics concerning gifted children and those that are twice exceptional (2e). I hope to see you there!

Thursday, December 13, 2018

Interoception, Autism, and Food

I am sure you are asking yourself what the heck is interoception? I had not heard of it either until recently. Interoception, as we will be discussing today, did not really come about until the start of the 21st century. The overall definition has various interpretations; however, in this discussion, we will talk about inclusive interoception as an umbrella term to mean all experiences of sensation and consciousness that are the result of information to the brain by the central nervous system.

Interoception plays a role in so many systems in the body such as: pain, medically unexplained symptoms, anxiety, emotions in general, emotional regulation, decision -making, time perception, food and water intake, eating disorders, self-awareness, consciousness, addiction, sexual functioning, empathy, meditation, and hypnosis.

Children with interoception can have issues with food intake. A child may have a high desire for food to the point of eating when they are no longer hungry or the opposite problem, they do not want to eat and rarely, if ever, experience the sensation of hunger. Interestingly, I had one of each in this category.

Margaret Eating Fries
Margaret Eating Fries
Margaret had many issues when she was young, and I knew they were odd, but I did not know what to make of her quirky behaviors. One of her quirky behaviors was her LOVE of french fries! That girl did not eat much. Heck, she was on the 3rd percentile for a long time in height and weight, but when it came to french fries (or a few other preferred foods) she would eat them until she vomited.

I am not sure how many times I had to apologize to parents and staff at the McDonald's restaurant near us when Margaret ate too many fries and vomited in the Playplace. The parents would look at me and think Margaret had a stomach flu or something and the poor staff at the McDonald's were disgusted. I get it. I was too but I did not realize what was going on at the time. It would be another 6 months before I realized Margaret had MAJOR sensory processing issues and would be diagnosed with autism. Margaret's issues with overeating were due to interoception. When the pleasure center of her brain is turned on eating HIGHLY preferred foods, she would not receive internal signals saying she was full so she would keep eating until she vomited.

Joseph FINALLY eating Stage 2 baby food @ 20 months
Joseph FINALLY eating Stage 2 baby food at 18 months

Joseph was a complete opposite of Margaret. Where she would eat until she would vomit, Joseph would not eat. He was orally VERY defensive. Again, I know this now, but I had NO idea why he would not eat baby food! He would ONLY open his mouth for the nipple of a bottle. It wasn't until Joseph had OT to desensitize his mouth (again, no one explained about sensory processing disorder to me at that time) and work with a feeding therapist did Joseph get to a point where he could eat Stage 2 baby food without refusal or choking. He was 18 months before he started to eat any sort of food. I had no idea his sensory issues would be so profound.

It was, and to some extent still is a CHORE to get him to eat! He would button his lips SHUT if you came at him with a spoon. He would even do that with the nipple of a bottle until he could feel the texture of the nipple and then he would open his mouth. He NEVER seemed to have an internal sense of hunger. Even now, he is about to be 11 years old, an though he is the size of a 6 year old in height, he weights only 45 pounds. He has seen a nutritionist since he was a year old and has supplements to add to his food to increase the calorie content of the food, yet he never appears to gain weight. Internally, he is rarely hungry. He has gotten up in the morning and would not request to eat anything until dinner (I experimented one day to see if there was ANY internal drive to eat; thankfully there is, barely). Joseph struggles to eat because he body and his brain do not tell him he NEEDS to eat nor does his body seem to light up the reward center of his brain by eating. Again, this is an issue with interoception.

The concept of interoception has been around for awhile but the "new" science on interoception is taking the concept in interesting directions. New medical journal articles are coming out fairly regularly. I feel like we will be hearing more and more about our "8th sense" and how it impacts children with disabilities.

All research for this article is embedded into the article's links. You are welcome to join us for more discussion on ADHD at our FB group, IEP/504 Assistance for parents of public school students from all over the United States, or at our homeschool group, Homeschooling Special (Needs) Kids. We also have a group for all parents and caregivers of special needs children called Special Needs Parenting Advice and Support where we discuss ALL things related to special needs care.

Saturday, November 17, 2018

5 Ways Being a Preemie Impacts Learning

***Be aware, you can find more of my posts on learning disabilities and educational advocacy at my new blog on AESA*** November 17th is National Prematurity Day. The topic of preemies impact my life in a huge way! My surviving quadruplets were born at 27 weeks. Due to their prematurity, we lost our daughter, Martha, the day after she was born. The other three children survived their premature arrival into the world, but that impacted them in every facet of their lives. Of course, at the time (a decade ago), I had no idea of the challenges my children would face.

Did you know 11% of all births worldwide occur before 37 weeks and that 2.5% of births happen before 32 weeks? Between 30 and 40 weeks of gestational age, a baby experiences growth of the cerebellum. When that process is interrupted, it can cause two of the five topics we will discuss today... motor coordination and cognitive (intellectual) problems.

From top to bottom: Joseph, Margaret, and James @ 8m or 5m adjusted.

Developmental/Cognitive Issues

Cognitive issues have been cited in many studies. One recent study looks at the subtle forms of cognitive impairment that might be missed on standardized neuropsychological testing in both adults and children who were born prematurely with no brain lesions (damage). While another study looked at children with enlarged cerebral ventricles in the brain, which point to changes in the white and grey matter in the brain (which my daughter has), causing developmental delays including cognitive delays.

So what kind of developmental delays might you see? It depends, but in general, children have been diagnosed with a variety of issues including autism, cerebral palsy, intellectual delay, visual perception, visual motor integration (which often leads to dysgraphia), Executive Functioning Disorder/ADHD, along with suffering academically in math and spelling.


Language-based disorders are prevalent in premature infants. Preemies display slower rates of vocabulary growth, and by school age, children born preterm demonstrate language functioning below that of full-term peers. These weaknesses persist into later childhood and adolescence with one study showing weakness into adulthood. At the same time, at every developmental level, there are striking individual differences in language outcomes in children born preterm. Why? Experimental studies have shown that a variety of visual information processing skills in preterm infants could be linked to an increased risk of receptive language outcomes.

Executive Functioning

Executive Functioning is such a massive topic I have a couple of blog posts on the issue! The hallmark of ADHD is executive functioning disorder, but not all people who have Executive Functioning Disorder have ADHD. Having good Executive Functioning (EF) skills is critical for academic success. So what does EF do?

Executive functioning helps you:
  • Manage time 
  • Pay attention 
  • Switch focus 
  • Plan and organize 
  • Remember details 
  • Avoid saying or doing the wrong thing 
  • Do things based on your experience 
  • Multitask 
Lacking EF has been scientifically acknowledged to be essential for academic success. A child only lacking EF skills may never show behaviors in the classroom; however, a child having the combination of Sensory Processing Disorder (SPD), and a lack of EF skills, will often have behavioral events at school.


ADHD, or lack of Executive Functioning control, is incredibly common in children who were born prematurely. Often the inattention and impulsivity, along with sensory issues that are not addressed (also common in children with ADHD), will cause a child to have behavior problems at school. Many times the behavior is a cry for help due to a lack of support. If your child experiences behavior problems in school please visit us at IEP/504 Assistance and Special Needs Parenting Advice to get assistance with educational advocacy.

Motor (Gross and Fine)

Children who are born before 35 weeks run a risk of having gross motor impairments. The younger the baby, and the lower the weight of the baby at birth, increases the odds the child will have a gross motor impairment. One study showed approximately 60% of premature infants displayed scores in the average range for gross-motor functioning by the time the child reached 2 years of age. This means up to 40% of children born prematurely could suffer a gross-motor impairment.

Prematurity impacts fine motor skills too. For extremely premature infants (those born before 28 weeks; like my children) they are at high risk for reading, math, and fine motor delay. Even children born closer to term (29 weeks to 35 weeks) may still suffer some neurological effects of prematurity including fine and gross motor skills.

I hope this shines a light on why it is so important to try and stop premature birth. It can cause a life time of issues. I will end with a picture of my children. They are now 10 years old and though they have challenges we face each day with a great amount of joy!

Monday, October 15, 2018

Arizona Exceptional Students Association

I have been busy starting a new non-profit. The Arizona Exceptional Students Association (AESA) has been created and many of the posts on neurocognitive domains and other public school and homeschool related topics will be discussed there. I hope you stop by for a visit!

Monday, June 11, 2018

The Undiagnoseable Child

Nothing like having a medical mystery on your hands. Joseph, my baby D out of a set of quadruplets, was born 13 weeks early. The first 2 weeks of his life was so touch and go that my husband and I were told to wait on burying our daughter (baby c) that passed away the day after she was born. We waited and watched him though the clear plastic of the isolette hoping he would survive.

After 12 weeks in the NICU Joseph was the last of his surviving siblings to make it home.  That night he came home for the first time he stopped breathing, turned blue, and I had to resuscitate him while my husband called the ambulance.  This went on for about a month, the O2 monitor kept going off, before there was more testing.  I was told Joseph had missed SIDS by the emergency room but in the end it was determined he was having "silent" reflux.  That he was aspirating and he would need surgery to survive.  This was my first clue that he may have a neurologic problem.

Once he got home, and a few surgeries later, life slowed down so I could research what was going on with my poor baby.  Joseph, at 4 months old, was just a lump.  He rarely ever made a sound.  When you picked him up he was like a rag doll, he did not interact, I saw his eyes roll up in his head a few times, and the ONLY thing he did was twiddle his fingers in front of his eyes.  All of these things I would bring up to the multitude of specialists Joseph saw but all the doctors just metaphorically patted me on my head and said he had a rough start to life and he would catch up by the time he was two.

This mom's instinct knew better! I knew there was more than I was being told and the specialists were no help.  After researching online (Did I mention I have been called a Googlologist?) I determined Joseph had floppy baby syndrome.  I thought he might have a neurologic problem since I sometimes saw his eyes rolling up into his head, which a later found out is called sun-downing, to his neurologist and I was ignored.

I tried to explain my concerns to my husband but he trusted the doctors.  So I kept fighting, kept researching, and I was determined I would not give up looking for answers.

As Joseph started growing I noticed he was staying tiny in size.  More tests were run. It was determined he had an underactive thyroid and tested positive for thyroid antibodies. Thankfully, this was something I did know about as I suffered from the same condition, Hashimoto's Thyroiditis. I got him some thyroid medicine and we moved on.

Joseph was SUPER slow in hitting his milestones to roll over, it up, or crawl. After about 3 he was crawling but he still was not walking.  I knew he has muscle issues from being a floppy baby but I did not know what else was wrong. After more researching and talking to his occupational and physical therapist I realized he might have ataxic cerebral palsy. I requested he get an MRI to get a full brain scan to see if he had any type of brain damage.

This is part 1 of a series on the difficulties of having a child that doesn't quite fit into a medical diagnosis.  I hope I will be able to continue his story soon. 

Sunday, June 10, 2018

Executive Functioning and Co-morbid Conditions

Photo courtesy of

Executive functioning often comes up in my Facebook group where I provide free educational advocacy advice.  Many schools fail to recognize a child with executive functioning issues even though it is common for children with ADD, ADHD, and Autism along with many other conditions.   It is important a public school recognizes executive functioning problems and works with the child to put systems in place to help the child overcome their executive functioning issues.  Without help from teachers and adults, along with having positive supports in place, many children will feel overwhelmed and shut down in the educational setting.  Since the issue of executive functioning (EF) is so complex I have written another blog post to cover other areas of EF.

So what is executive functioning?

Executive function is a set of mental skills that help you get things done. These skills are controlled by an area of the brain called the frontal lobe.

Executive function helps you:
  • Manage time
  • Pay attention
  • Switch focus
  • Plan and organize
  • Remember details
  • Avoid saying or doing the wrong thing
  • Do things based on your experience
  • Multitask
When executive functioning isn’t working as it should, your behavior is less controlled. This can affect your ability to:
  • Work or go to school
  • Do things independently
  • Maintain relationships

Types of Executive Function

Executive function can be divided into two groups:
  • Organization: Gathering information and structuring it for evaluation
  • Regulation: Taking stock of your surroundings and changing behavior in response to it
For example, seeing a piece of chocolate cake on a dessert cart at a restaurant may be tempting. That's where executive functioning can step in. The organizational part reminds you that the slice is likely to have hundreds of calories. Regulation tells you that eating the cake conflicts with goals you may have, like eating less sugar or losing weight.

Problems With Executive Function

Some people are born with weak executive function. And people with ADHDdepression, or learning disabilities often have weaknesses in it.  I will discuss more on the various learning disabilities in a later section.

An injury to the front of the brain, where the frontal lobe is, can harm your ability to stay on task. Damage from Alzheimer's disease or strokes may also cause problems.

Children and Executive Function

Problems with executive function can run in families. You may notice them when your child starts going to school. They can hurt the ability to start and finish schoolwork.

Warning signs that a child may be having problems with executive function include trouble in:
  • Planning projects
  • Estimating how much time a project will take to complete
  • Telling stories (verbally or in writing)
  • Memorizing
  • Starting activities or tasks
  • Remembering

Co-morbid Conditions of Executive Function Impairment 

ADHD/ADD is the hallmark condition for executive function impairment. The condition of ADHD/ADD is so pervasive in life it deserves its own blog post that will be coming at a later date.  It is possible to distinguish someone with an executive function disorder from someone with ADHD by trying ADHD medication.  Someone with true Executive Function Disorder will not improve on ADHD medication.  My daughter, Margaret, is a great example of this.  We also happen to know she has Hypoxic Ischemic Encephalopathy (HIE).  She has a cyst, or hole, in her right frontal lobe.  The right frontal lobe controls reasoning, impulsivity, and emotional regulation. For her, ADHD medication would not improve her impulsivity and inattentiveness. She has a true executive function disorder versus ADHD but she also carries the medical diagnosis of ADHD. The ADHD label is appropriate since she has some ADHD characteristics too like always being in motion and people understand what ADHD entails versus executive function disorder.

Autism is another co-morbid condition that typically entails executive function disorder and/or ADHD. I am seeing more and more children with high-functioning autism being mislabeled as behavioral. I think much of this stems from poor executive functioning and lack of addressing sensory issues.  In a study released in 2017 showed children with Autism are often diagnosed with a host of learning and behavioral disorders including ADHD, Anxiety, Depression, and Disruptive Impulse Conduct Disorder.  I think all of these are related to executive functioning disorder and untreated sensory problems. I often hear from parents in my Facebook group (IEP Assistance and Special Needs Parenting Advice) say teachers make comments about their child saying, "Your child could have made better choices this year." Really?  I think this is an indication the teacher needs training.  Obviously, the teacher does not understand how executive functioning works.  Students NEED structure and rules in place to HELP them make good decisions.

Other conditions impacted by executive control issues include Obsessive-Compulsive Disorder, Tourettes, Traumatic Brain Injury, DepressionFetal Alcohol Syndrome, Developmental Coordination Disorder, and just being a preemie can greatly increase a child's risk of having an executive functioning disorder.

Signs of Executive Functioning Issues in Various Settings

At the preschool level you may see:

At Home                                         At School                                  The Issue
The child will respond                       Your child's answers                Kids with EF issues have
"yes" when asked to choose               are rarely on topic                   problems quickly retrieving
between two choices                                                                           information to answer questions

At home                                          At School                                 The Issues
Child is easily frustrated                 Child will get frustrated            Kids with EF struggle to keep
and quits without asking                 easily and give up when            information in working memory
for help                                            their attempt is not perfect        long enough to use the information

At Home                                         At School                                  The Issue
Child cannot remember to           Frequently raises hand but            Children with EF issues cannot
do multi-step directions               can't remember the answer            keep information in short-term
or does not start task                    when called upon                          memory long enough to use it.

At Home                                         At School                                  The Issue
When child is given several           Child can't seem to master         Children with EF can have task
tasks to complete at once they       simple classroom procedures      initiation problems and problems
freeze and stare like a deer             like packing up at the end of      problems with following multi-
in headlights                                   day                                              step directions

At the elementary school level you may see:

At Home                                         At School                                  The Issue
Child works on a project and         Child can solve a math               Children with EF deficits have
gets interrupted then loses             problem one way but when         problems with switching gears
interest in the project                     asked to solve the problem          and can have a hard time learning
                                                       another way they are not able     new skills and/or tasks

At Home                                         At School                                  The Issue
Child mixes up assignments        Child has a desk of school is        Children with EF have a hard time
and forgets to bring home            full of crumpled papers and         keeping their things organized
worksheets or books                    pencil stubs but folders and          even when given organizational
                                                     pencil box is empty                      tools

At Home                                         At School                                  The Issue
Child is insistent on eating           Kids are trying to play a game     Kids with EF can panic or feel
pizza on Friday night since           and Child argues how to play      frustration when rules or routines
that is traditionally pizza night     and then makes up new rules       are changed

At Home                                         At School                                  The Issue
Child seems to focus on the           Child cannot find the right         Children with EF issues can have
least important details of                information in a math word       a difficult time figuring out when
what you have said                         problem in order to solve           to look at the big picture versus
                                                        the equation                               the details and which details to
                                                                                                           focus on

How do you make the diagnosis of Executive Function Impairment?

Tests That Assess Attention

Example: Test of Variables of Attention (TOVA) (ages 4 and up)

Similar tests include: Integrated Visual and Auditory CPT (IVA-2) (ages 6 and up), Conners Continuous Performance Test II (CPT II) (ages 6 and up)

What it measures: A child’s ability to pay attention. (It also looks at processing speedand inhibitory control.)

Why it’s important: The ability to pay attention is a key executive function. Having trouble with attention is a hallmark of ADHD. While this test isn’t an assessment for ADHD, it might signal that a child has an attention issue. Learn more about the link between ADHD and executive functioning issues.

How it works: In the classic version, different letters flash on a computer screen. A child presses the space bar every time he sees the letter A. The test lasts for 15 to 20 minutes. (With CPT II, kids press the bar when they don’t see the letter.)

Kids who miss targets may be “zoning out” because of attention issues. But this test also looks at other skills that can impact attention. Missing targets might be the result of slow processing speed, for instance. Responding to the wrong targets might be a problem with focus or with inhibitory control. And if the child was doing well up to a certain point but then makes mistakes, he may have trouble sustaining attention.

Tests That Assess Inhibitory Control

Example: Stroop Color and Word Test (ages 5 to 14; adult version starts at 15)

Similar tests: The Color-Word Interference Test of Delis-Kaplan Executive Function System (D-KEFS) (ages 8 and up)

What it measures: A child’s ability to hold back on giving an automatic response, or the ability to think through something before acting.

Why it’s important: Inhibitory control is tied to self-control. It allows kids to think before they act. It also allows them to assess each new situation and consider the correct or most effective way to respond.

How it works: The evaluator shows a child the words for different colors written out. But the color of the ink doesn’t match the word that’s spelled out. For example, the word red might be written in green ink. As quickly as possible, the child must say the color she sees, as opposed to the word. The test is usually timed, so it also looks at processing speed.

Kids who haven’t learned to read yet may perform a similar task with shapes instead of words. In this case, the child might see a circle in red ink. She then has to say the color, not the shape.
Tests That Assess Working Memory

Example: Digit Span and Spatial Span subtests of the Wechsler Intelligence Test for Children (WISC) (ages 6 to 16)

Similar tests include: Working memory tasks in the Woodcock-Johnson (WJ-IV) Cognitive battery (ages 2 and up)

What they measure: The Digit Span test measures verbal working memory (the ability to store information that’s heard). The Spatial Span test measures visual working memory (the ability to store information that’s seen).

Why they’re important: Working memory is an executive function that allows kids to hold onto new information in order to put it to use. (It’s also affected by attention.)

How it works: With digit span, the evaluator dictates a series of numbers, and the child has to repeat them back in reverse order. If the examiner says “9, 6, 3,” the child has to repeat the sequence back as “3, 6, 9.” When working with younger kids, the evaluator might list a series of animals in size order, such as bee, dog and cow. The child repeats them back saying the biggest to the smallest animal.

With spatial span, the evaluator touches a series of blocks in a certain order. The child has to touch the blocks in the reverse order that the evaluator touched them.

If a child does poorly on the digit span version but well on the spatial span, it might mean she has working memory issues that are more language related. If it’s the other way around, it might mean she struggles with working memory just for visual-spatial tasks.
Tests That Assess Organization and Planning Skills

Example: Tower of Hanoi (ages 5 and up)

Similar tests include: The Tower Test of D-KEFS (ages 8 and up); Rey–Osterrieth Complex Figure Test (ages 6 and up); Tower of London Test (TLT or TOL)

What it measures: The ability to plan, sequence and organize information for problem-solving. It can also assess working memory and inhibitory control.

Why it’s important: Planning, sequencing and organizational skills are key to following directions and completing tasks efficiently. They’re also important when it comes to participating in complex discussion. Kids with executive functioning issues often struggle with these skills.

How it works: A child must rearrange beads or disks to match a model while following specific rules. A rule might be that the child can’t place a larger bead on top of a smaller one. The goal is to complete the task in as few moves as possible.
Tests That Assess Concept Formation

Example: Matrix Analogies Test (ages 5 to 17)

Similar tests: Naglieri Nonverbal Ability Test (ages 4 to 18), WISC-V Matrix Reasoning (ages 6 to 16)

What it measures: The ability to form classes of items based on what they have in common; the ability to figure out patterns or relationships between objects.

Why it’s important: Concept formation allows kids to see relationships between things and develop ideas based on what they already know about them. It’s important for abstract thinking.

How it works: A child sees a grid of four boxes with pictures in them. The top row might have a big house next to a big apple. The box below the big house has a little house. The box under the big apple is empty. The child has to pick what logically belongs there (a little apple) from five choices. (The analogies are more complex for older kids.)
Tests That Assess Set Shifting

Example: Wisconsin Card Sorting Test (ages 7 and up)

Similar tests include: The Sorting Test of D-KEFS (ages 8 and up); Minnesota Executive Function Scale (MEFS) (ages 2 and up; measures other executive functions as well); Trail Making Tests
What it measures: A child’s ability to shift from one task to another. It also measures concept formation.

Why it’s important: This executive function allows kids to shift their attention and move from one task or situation to another. This type of flexible thinking helps kids see new ways of doing things, or try something else when the first approach doesn’t work.

How it works: A child is shown a set of five cards. Each card has a different figure on it. The figures switch around with each problem. For example, in one problem the figures on the cards might be: three green stars, one red circle, two yellow blocks, four yellow crosses, and two red crosses.

The child sees four of the cards lined up in a row, and one by itself below. She’s told to match that card to one of the four above, but not told the rule for matching. (In other words, she doesn’t know whether to match by shape, color, number, etc.)

The child only gets feedback on whether she’s right or wrong in the match she makes. So through trial and error, she needs to figure out the rule herself. She’s scored by how many correct sorts she makes.

Tests That Assess Word and Idea Generation

Example: Controlled Oral Word Association Test (ages 5 to 16)

Similar tests: Verbal Fluency Test in the D-KEFS (ages 8 and up); Word Generation subtest in the NEPSY-II (ages 3 to 16)

What it measures: The ability to think of words and generate ideas. (It also looks at set-shifting and processing speed in some versions.)

Why it’s important: Kids rely on executive functioning to solve problems. Being able to quickly come up with words and ideas is key to problem-solving.

How it works: A child names as many words as she can, based on a certain letter. For example, she might have to come up with words that start with M. Or, on a harder version of the test, she may have to name as many kinds of fruit and furniture as she can, in pairs. She might start with apple/chair or banana/couch, and so on.

Another possible factor to consider when testing EF
The Picture Arrangement (PA) sub-test of the Wechsler Adult Intelligence Scales (WAIS) is not really known as an executive test. In the ‘bible’ of neuropsychological diagnostics, Lezak’s Neuropsychological Assessment (2004), this test is never described as an executive function test.

Remember,executive functions are really several different cognitive functions all humped together: concept formation, formulating a plan (planning), formulating a goal, sequencing the correct order of steps to take in order to reach a goal or follow a plan (logical reasoning), executing the steps and monitoring your own actions, mental flexibility to reformulate a plan and change the actions to reach your goal/plan and the ability to control your automatic, instinctive or impulsive reactions in order to follow your action plan consistently. In short, executive functions are functions that represent goal-directed actions: taking initiative, planning, executing actions, monitoring and self-correcting those actions.

The task requires several cognitive processes. First, you have to see all pictures in clear detail. Then you have to form several ideas about what is going on here. That’s what neuropsychologists call ‘concept formation’ or ‘formulating a plan’. Then you have to form a picture in your mind of a sequence of the 3 pictures. Not randomly, but guided by your plan or idea about what is going on in this story. Then you have to put these pictures in this planned order and finally, you have to check this whether it matches your plan/ideas. When the sequence is looking wrong, you will have to correct the order. Remember, in the PA test all pictures are separate pictures you can move around. I have programmed these pictures so that they are displayed on a computer screen and can be moved by the clinician. The patient has only to point at a picture and to point at where it should go. Except for planning, sequencing, and monitoring cognitive processes like visual perception, divided attention and memory all work together to do this task correctly.

Accommodation for Executive Function

To begin, there are some questions to start you off on your journey...
Questions to ask parents
  • What tasks does your child need help with at home?
  • Does your child lose things?
  • How often do you need to explain how to do a task?
  • Does your child have trouble concentrating?
  • Can your child plan ahead for activities?
  • Does your child get upset with change?
  • Does your child often interrupt others?
Questions for teachers
  • Does the student get distracted easily?
  • Does the student have an organized backpack or locker?
  • Can the child fix their own mistakes?
  • Is the child aware of the consequences of their words or actions?
  • Does the student demonstrate incomplete or careless work?
  • Can the student develop plans and strategies?
Goals for strengthening EF during Testing
  • Student will develop the ability to attend to individual tasks and will improve processing speed through the use of timers and cueing utilized with the entire class in the general classroom.
  • Student will successfully complete 12 or more weeks of a proven cognitive enhancement program that addresses deficits in processing speed, short-term working memory, attention to detail, monitoring, sequencing and organization skills, with instruction, for at least 1 hour per day every weekday, to alleviate effects of executive functioning disorder deficits.
Self-Awareness/Self Advocacy goals for an IEP
  • Given a specific routine for monitoring task success, such as Goal-Plan-Do-Check, student will accurately identify tasks that are easy/difficult for him.
  • Given a difficult task, student will indicate that it is difficult.
  • Student will explain why some tasks are easy/difficult for him, help develop management strategies.
  • If tasks are difficult, Student will request help.
  • When he is more capable than the other child, Student will offer help to others.
  • If student has negative behaviors, debriefing session held at appropriate time and place and student is able to identify his triggers and possible strategies.
Executive Functioning-Organizing goals for an IEP
  • Given support and visual cues, student will create a system for organizing personal items in his locker/desk/notebook
  • To tell an organized story, student will place photographs in order and then narrate the sequence of events. Given visual cues and fading adult support, student will select and use a system to organize his assignments and other school work
  • Given a complex task, student name will organize the task on paper, including the materials needed, the steps to accomplish the task, and a time frame
  • Using learned strategies and given fading adult support, student will prepare an organized outline before proceeding with writing projects.
  • student will improve organization skills for classroom work and homework through specific, repetitive instruction, and use of (list SDIs or supports) and measured by a frequency or %
Executive Functioning-Organizing goals for an IEP
  • Given training in a self-regulatory routine and visual cues and fading adult supports, the student will accurately predict how effectively he will accomplish a task. For example, he will accurately predict:
           ~whether or not he will be able to complete a task
           ~how many (of something) he can finish
           ~his grade on tests
           ~how many problems he will be able to complete in a specific time period; etc.
  • Given a specific work checking routine, student will identify errors in his work without teacher assistance.
  • student’s rating of his performance on a 10-point scale will be within one point of the teacher’s rating.
  • Student will self-initiate editing activities to correct spelling, punctuation, capitalization, and grammar on all typical classroom assignments in all settings
  • Student will self-edit his work to correct spelling, punctuation, capitalization, and grammar on all typical classroom assignments in all settings to eliminate all errors from his work
Problem Solving goals for an IEP-Executive Function:
  • Given training in and visual reminders of, self-regulatory scripts student will manage unexpected events and violations of routine without disrupting classroom activities
  • Student will use a structured recipe or routine for generating new ideas, or brainstorming to respond successfully to open-ended assignments
  • When faced with changes and/or transitions in activities or environments, student will initiate the new activity after {decreasing number of supports}
  • Given concrete training, visual supports and fading adult cueing, student will appropriately label flexible and stuck behaviors in himself
  • Given training and practice with the concept of compromise, and in the presence of visual supports, student will accept and generate compromise solutions to conflicts when working cooperatively with others.
IEP goals for personal goal setting/ self-correction and improvement
  • Student will participate with teachers and therapists in setting instructional and therapy goals
  • Given explicit instruction, visual reminders, and fading adult support, student will successfully distinguish target goals (doing well in school, making a friend, learning to read, graduating from school) from interfering goals (playing video games instead of doing homework)
  • Having failed to achieve a predicted grade on a test, student will create a plan for improving performance for the next test
IEP goals for keeping track of time/planning/time management:
  • Given a routine, student will indicate what steps or items are needed and the order of the events
  • Student will learn (after helping to develop) a self-regulatory plan for carrying out any multiple-step task (completing homework, writing an essay, doing a project) and given practice, visual cues and fading adult supports, will apply the plan independently to new situations
  • Given a selection of 3 activities for a therapy or instructional session, student will indicate their order, create a plan on paper and stick to the plan
  • Given a task that he correctly identifies as difficult for him, student will create a plan for accomplishing the task
Another break down of accommodations....  

Sustained Attention - ability to maintain attention despite distractibility, fatigue, or boredom
Elementary Classroom Behavior
  • Distractable
  • Inconsistent performance
  • Forgetfulness
  • Zoning out/daydreaming
  • Making careless mistakes
  • Difficulty completing assignments
  • Poor note-taking skills
  • Off task behaviors

Middle School Classroom Behaviors

  • Poor attention
  • "Zoning out"
  • Inconsistent performance
  • Difficulty with note-taking
  • Distractible
    • Pays attention to everything and not just the target activity
    • Inability to stay on task
  • Asks questions that were just answered

Elementary Classroom Accommodations
  • Provide frequent breaks
  • Establish eye contact with student
  • Break down tasks
  • Repeat information
  • Check for understanding
  • Rotate subjects
  • Check for understanding
  • Rotate students work areas
  • Use assistive technology
  • Provide preferential seating area near the teacher
  • Teacher should move around the room
  • Ask for the student to repeat back instructions/directions
  • Inject novelty into instruction
  • Use multi-sensory/hands-on materials
  • Present the questions first
  • Ask student to make predictions
  • Ask student to summarize information

Middle School Classroom Accommodations

  • Inject novelty into instruction
    • Games
    • Interesting and colorful material
  • Provide visuals
  • Allow for breaks as necessary
  • Structure tasks and activities
    • Rotate subjects
    • Complete homework in intervals
  • Provide extra review for material covered at the end of a class period
  • Engage attention
    • Through challenge (e.g. Few people know the answer to this...)
    • Active student participation
  • Preferential seating

Working Memory - Holding information in the mind while performing complex tasks
Elementary School Classroom Behavior
  • Student gets confused when too much information is presented
  • Has trouble remembering things (eg. phone numbers)
  • Student may lose track of what they are doing as they work
  • Student may forget what they need to retrieve when sent on an errand
  • May frequently switch tasks or fail to complete tasks
  • Difficulty keeping up with classroom lessons
  • Difficulty remaining attractive and focused for an appropriate length of time
  • Difficulty sequencing math word problems
  • Extreme difficulty solving problems mentally (eg. mental math)
  • Poor reading comprehension
  • Difficulty summarizing
  • Inconsistent performance
  • Difficulty following directions
  • Difficulty keeping track of a lot of information
Middle School Classroom Behavior

  • Difficulty in keeping up with information to complete tasks
    • May look like poor attention
    • Misses important pieces of information
    • Gets confused when too much information is presented at once or too quickly
    • Poor note-taking from lectures
  • Extreme difficulty with solving problems mentally (e.g. mental math)
  • Difficulty with keeping up and maintaining conversations
  • Frequently asking questions
  • Difficulty sequencing
Elementary School Classroom Accommodations
  • Teach visualizing techniques
  • Pre-teach and preview new information
  • Establish eye contact with the student
  • Give student a copy of class notes
  • Student should practice new skills in short sessions over the course of the day
  • Use graphic organizers
  • Use visuals
  • Chunk information
  • Use of mnemonics
  • Avoid extraneous comments and information
  • Color-code information and/or materials
  • Personalize the information taught
  • Have student design own tables and keys
  • Use a variety of tests that assess both recall and recognition
Middle School Classroom Accommodations

  • Provide structured outlines
  • Provide visuals
    • graphic organizers
    • pictures and charts
    • maps
  • Promote note-taking to avoid memory overload
  • Chunk information to help student with comprehension
  • Allow frequent breaks
  • Provide class notes
  • Repeat key concepts/information
  • Pre-teach information
  • Encourage the use of post-its for questions that cannot be contacted immediately
  • Model relevant comments during conversations
  • Introduce memory strategies

Inhibition - The ability to stop one's own behavior at the appropriate time (eg. stopping actions and thoughts)
Elementary School Classroom Behaviors
  • Difficulty waiting 
  • Interrupts and disrupts group activities
  • Student may call out
  • Touching things or people
  • Makes careless mistakes
  • Displays hyperactivity
  • Acting on auto-piolet without reflection
  • Perseveration
  • Many false starts
  • Dives right into problems without pausing, reflecting, developing a strategy or game plan
  • Excessive talking
  • Unlike to reflect or self-monitor
  • Misinterprets directions
Middle School Classroom Behavior
  • Calling Out
  • Touching Objects/Peers
  • Invading others personal space
  • Interrupting conversations
  • Making careless errors - written & verbal
  • Issues with directions (Not reading/misreading/misinterpreting)
  • Misinterpreting text
  • Attempting problem-solving without planning
  • Starting and stopping tasks repeatedly
  • Difficulty with perspective taking
    • Understanding someone else's point of view
    • Often unaware of own behavior or impacts on others
  • Difficulty with empathy
  • Difficulty knowing what to say and when to say it
High School Classroom Behaviors

  • Calling out
  • Not following directions
  • Inconsistent test performance
  • Touching things/other people
  • Restlessness
  • Over-active behaviors

Elementary School Classroom Accommodations
  • Give an explicit and clear set of rules and expectations
  • Preferential seating near the teacher with frequent eye contact
  • "Catch" the student being good
  • Ignore the disinhibited response
  • Positive reinforcement plan
  • Use checklists
  • Have student hold the pencil up until directions are given
  • Have student repeat the directions
  • Have student verbalize how they will solve the problem before they begin
  • Give verbal reminders
  • Model your thought process
  • Ask questions to make student stop and think
  • Use visual cues (eg. stop sign, traffic light)
  • Emphasize procedures of an assignment
  • Identify the skill being work on
Middle School Classroom Accommodations
  • Ask questions of students; when student answers question impulsivity is redirected
  • Repeat verbal information (Directions, assignments, and tasks)
  • Have student repeat back directions to ensure understanding
  • Emphasize on HOW to solve a problem - Don't just focus on the correct answer
  • Direct students to stop and think before acting/responding
  • Offer specific real-time feedback
  • Incorporate positive reinforcement/rewards as part of task/activity 
  • Provide effective feedback
    • Make eye contact with student
    • Give immediate feedback
    • Be specific
  • Praise appropriate behavior
  • Identify the problem and use social stories and role-playing to determine the solution
  • Create a self-monitoring rating scale with the student
  • Encourage verbal mediation 
High School Classroom Accommodations

  • Ask the student to take a few seconds before answering the question
  • Students should be given an explicit, extensive, and clear set of rules and expectations along with giving reminders as needed
  • Ask the students to explain their plan for the task (e.g. Goals for accuracy and timeframe)
  • Seat student close to the teacher to facilitate monitoring of behavior
  • Catch student "being good"

Organizing/Planning/Task Initiation - Organization is the ability to impose order on work, play, and storage spaces.  Planning is the ability to manage current and future-oriented task demands.  Task initiation is the ability to begin a task or activity and to independently generate ideas, responses, and or problem-solving strategies. 
Elementary School Classroom Behavior
  • Student may forget homework assignments/materials
  • Student can be unprepared and unable to find materials
  • Student has messy desk/workspace
  • May get "stuck"
  • Appears to be daydreaming
  • Difficulty completing assignments in a timely manner
  • Difficulty expressing ideas in an oral and/or written format
  • Student approaches tasks in a haphazard manner
  • Difficulty in responding to open-ended questions
  • Performs better with multiple choice questions
  • Difficulty making decisions
  • Difficulty starting an assignment independently
  • Difficulty generating ideas, responses, and problem-solving
  • Difficulty with multi-step problem-solving
Middle School Classroom Behaviors

  • Doesn't begin tasks (e.g. just sit and stares when given directions)
  • Messy desk/notebook/locker/backpacks
  • Difficulty with unstructured tasks
  • Off task (e.g. Looks lost or Daydreaming)
  • Difficulty understanding what to do
  • Difficulty with time management
  • Difficulty understanding what to do
  • Overwhelmed by large amounts of information
  • Difficulty retrieving information spontaneously or answering open-ended questions
  • Difficulty handing in assignments on time

High School Classroom Behaviors

  • Blank Page
  • Task avoidance behavior such as leaving the classroom
  • Gives excuses on a constant basis

Elementary Classroom Accommodations
  • Use a checklist for multi-step tasks
  • Demonstrate where to begin and what steps to follow
  • Use a timer to help student pace their work
  • Provide a model of completed projects
  • Have student verbalize a plan of approach before beginning an activity
  • Provide a "to-do" list
  • Use color-coded materials
  • Use schedules
  • Provide deadlines and timelines for assignments (be specific with exact times and dates)
  • Provide "how-to" templates
  • Break long-term assignments into sequential tasks
  • Use graphic organizers
  • Use brainstorming techniques
  • Place student in small groups with more organized peers to serve as a model
  • Provide access to assistive technology
  • Assign student planners and check for accuracy
  • Coordinate with the parents to generate a positive incentive homework plan
  • Provide access to assistive technology
Middle School Classroom Accommodations

  • Provide explicit directions
  • Don't assume information is "obvious" to the student
  • Check for understanding
  • Create mental framework
    • Provide template to help student organize the information as student hears it
    • Identify/Label steps and put it on an index card
    • Identify what to listen to
    • Color code
    • Categorize information
  • Use multiple choice versus open-ended questions
  • Set time limits, use timelines, and checklists
  • Provide access to assistive technology

High School Classroom Accommodations

  • Demonstrate where to begin and what steps to follow
  • Provide "to do" list on index cards to provide external cues and encourage the development of routine
  • Encourage students to keep a "cookbook," or list of steps for routines, in a binder for reference
  • Set up time limits for completing a task. Use of a timer may increase the initiation of a task and the speed in which the task was completed
  • Provide access to assistive technology
  • Allow student to verbalize the expectations of the assignment and give them a chance ask questions concerning potential problems in completing the project 

Emotional Regulation - The ability to regulate emotional responses by bringing rational thought to bear on feelings
Elementary Classroom Behaviors
  • Difficulty making or keeping friends
  • Emotional reactions are out-of-sync with the situation (small problem triggers huge emotional response)
  • May laugh hysterically, or cry easily, with little provocation
  • Temper tantrums and explosive outbursts
  • Bossiness
  • Easily upset/ overly-sensitive
  • Aggressive behavior
  • Rigid/ inflexible thinking
  • Emotional lability (rapid mood changes without cause)
  • Low frustration tolerance
  • Socially immature
  • Appears insensitive to other people's perspective and emotions
Middle School Behaviors

  • Tantrums
  • Crying
  • Laughing at inappropriate times
  • Calling out
  • Making irrational statements
    •  "Teacher hates me."
    •  "Someone's laughing at me."
  • Aggressive behavior physically and/or verbally

High School Classroom Behavior

  • Often calls out in class without consideration of others
  • Lacks emotional regulation
  • Difficulty redirecting and refocusing once the child exhibits the lack of emotional control (e.g. temper tantrums, cursing, crying, extreme laughter, and etc.)
  • Exhibits unpredictable emotional response that is out-of-sync with the situation

Elementary School Accommodations
  • Use of social stories and narratives
  • Role-playing activities
  • Try to anticipate problem situations
  • Manage stimuli and antecedents that appear to lead to emotional outbursts
  • Provide opportunities to discuss upcoming situations that may provoke emotional outbursts
  • Teach coping strategies to manage emotions
  • Introduce self-monitoring strategies
  • Provide scripts of appropriate language and behaviors
  • Model self-statements
  • Provide breaks
  • Attempt to plan the child's optimal time of day
  • Utilize a positive reinforcement plan/behavioral interventions
  • Provide positive role models/ model appropriate emotional regulation
  • Provide as many opportunities as possible for physical activity
  • Give the student to write down concerns to discuss later
Middle School Accommodations

  • Model positive thoughts and behaviors
    • Turn the negative and/or irrational thoughts/statements into positive ones
    • Identify possible positive outcomes
  • Identify problem
    • Discuss privately
    • Acknowledge frustrations
    • Use narratives and social stories
    • Offer the student the opportunity to write down their concerns for later discussion
      • Set a specific time and place to discuss concerns
    • Offer breaks from current (physical) setting

High School Classroom Accommodations

  • Maintain consistency and predictability in terms of teaching methods
  • Include aspects of social-emotional learning to create a safe and supportive environment with student-centered classroom rules
  • Provide verbal and visual reminders
  • Encourage peer monitoring
  • Foster empathy among classmates; highlight strength and weaknesses
  • Plan small group activities that encourage positive and productive interaction
  • Clarify expectations in order to reduce the student's feeling of being overwhelmed
  • Communicate effective strategies with parents and consult specialists as needed (e.g. school psychologist, speech therapist, social worker, and etc)
  • Be aware of stressful situations (e.g. calling on student unexpectedly, public speaking, etc)
  • Help students create rating scale of 1-5 to help them evaluate problems and put them in perspective
  • Help students be aware of the consequences of their emotional outbursts on the learning environment 

Self Monitoring - The ability to monitor one's own performance and to measure it against some standard of what is needed or expected
Elementary School Classroom Behavior
  • Makes careless mistakes
  • Rushes through work
  • Appears to lack pride in work
  • Disorganized
  • Difficulty check over work/proofreading
  • Work may be sloppy
  • Acts without thinking things through
  • Unaware of behavior and impact on others
  • Difficulty with time management
  • May have difficulty monitoring volume of voice
  • Difficulty with pragmatic language skills
  • Difficulty in empathizing
  • Procrastination
  • Missing deadlines
  • Difficulty in completing work
Elementary School Classroom Accommodations
  • Provide student with a checklist
  • Use a timer
  • Graphic organizer
  • Use of a picture schedule
  • Breaks tasks down into steps
  • Provide a peer buddy
  • Check on student progress during a project
  • Role play different situations
  • Provide grading rubrics to define the quality of work
  • Provide reinforcements for using a self-monitoring checklist
  • Teach student to talk through a task
  • Provide self-monitoring questions (eg. Am I a space invader?)

Shift - To move freely from one thought/activity to another and to think flexibly in order to respond to the situation 
Elementary School Classroom Behavior
  • Difficulty making transitions
  • Difficulty in starting a new task before the first task is complete
  • Difficulty switching gears (eg. addition and subtraction problems on the same page)
  • Repeats the same behaviors
  • Gives the same answers to different questions
  • Difficulty switching to a new topic or subject
  • Inflexibility
  • Difficulty with problems solving and conflict resolution
  • Failure to comply with task instructions
Middle School Classroom Behaviors

  • Stuck on a topic, idea, or activity
  • Repeating the same behavior after the task has changed
  • Driven by routine and consistency
    • Needs the same seat
    • Wears the same color
    • Eating the same foods
    • Difficulty transitioning between classes
    • Unable to tolerate changes in schedule
    • Difficulty in transitioning within conversations

High School Classroom Behaviors

  • Stuck on the previous task when working on the current task
  • Not being prepared for next activity
  • Student may sit and stare when given too much information at once
  • Non-participation

Elementary School Accommodations
  • Give sufficient warning for upcoming transitions
  • Make the day as predictable as possible
  • Provide a break between activities
  • Guide students to highlight math signs before solving
  • Pause between different chunks of information
  • Emphasize where one piece of information ends and the next begins
  • Provide a stopwatch/timer
  • Model problem-solving techniques
  • Model self-talk strategies
  • Use of visual organizers, schedules, planners, and calendars
Middle School Accommodations
  • Make the day as predictable as possible
  • Clearly separate different types of problems to help with task shifting
  • Identify new topic clearly
    • Change where teacher stands for new topic
    • Change student's seat for new topic
    • Begin new unit after break
    • When presenting information stay away from general remarks
  • Provide verbal feedback to individual students having difficulty shifting conversations and tasks
High School Classroom Accommodations
  • Give ample notice to the student so they have time to accept transitions
  • Allow a few minutes of "downtime" between activities
  • Be consistent with expectations
  • Use a timer to break down classroom period to promote time management
  • Leave time at the end of the period to answer questions the student may have from that day's lesson
  • Use visual organizers, schedules, planners, and calendar boards to help learn routines and adapt to changes

Abstract Reasoning/Concept Formation - The ability to make connections and to synthesize/categorize information 
Elementary School Classroom Behavior
  • Difficulty with social problem solving
  • Difficulty with perspective taking
  • May ask the same questions repeatedly
  • Concrete, literal learners
  • Difficulty in what they cannot see, hear, or touch
  • Difficulty sorting/organizing information
  • Difficulty with abstract concepts
  • Difficulty with reading comprehension
  • Difficulty in determining the most important points in a lesson
  • Difficulty in summarizing information
  • Focus on details and miss the "big picture"
  • Difficulty in determining what is relevant or not
  • Difficulty in making inferences
  • Performs better during structured tasks
  • Struggles in unstructured tasks (eg. writing a story)
  • Difficulty in reading between the line and "catching on"
Middle School Classroom Behaviors

  • Difficulty forming theories and solving problems
  • Difficulty in understanding what they cannot see, hear, or touch
  • Difficulty in understanding
    • Figurative language
    • Ambiguous language
    • Multiple meaning words
    • Similies and metaphors
    • Humor and sarcasm
  • Difficulty synthesizing information
  • Difficulty in determining important information
    • Relevant versus irrelevant
    • Details
    • Main ideas
    • Related concepts
  • Difficulty "reading between the lines"
  • Misses the "big picture"

Elementary School Accommodations

  • Multi-sensory lessons
  • Social Stories
  • Ask student to come up with a title of the story first
  • Give question prompts (eg. How might you best solve that?)
  • Provide explicit instruction (Don't assume it seems obvious)
  • Check for understanding
  • Ask student to repeat back information
  • Ask student to read questions first before reading a passage
  • Break down tasks into steps
  • Define the skills to be learned, list the steps for the skill, and then practice the skill in a variety of ways
  • Positive reinforcement plan for using defined skills
  • Model the thought process needed for the skills
  • Simulate social situations and role play
  • Highlight the most important details in one color and the supporting details in another color
  • Summarize and retell stories
  • Help student to sort and outline information (eg. outlines, venn diagrams, & graphic organizers)
Middle School Classroom Accommodations

  • Don't assume what is "obvious" is obvious to the student
  • Scaffold questions
  • Use effective reading strategies
    • Close reading
    • Graphic organizers
    • Teach how to summarize a story
    • Teach how to make predictions (inferencing)
  • Use sorting and categorizing games
  • Identify fact or opinion
  • Identifying key concepts and ideas

Some current research on Executive Functioning

In a 2018 paper by Angeliki Kallitsoglou, Executive Function Variation in Children With Conduct Problems: Influences of Coexisting Reading Difficulties, the author discusses the variations in executive functioning of children with reading problems, conduct problems, and children with both disabilities. 


It is unknown whether children with conduct problems (CP) and poor reading (PR) skills exhibit more profound executive function impairments than children with CP only and whether such impairments are explained by coexisting PR. Executive functions were compared in four groups of 7- to 8-year-old children: 26 CP only, 35 PR only, 27 CP-PR, and 31 comparison (COM) children with neither CP nor PR. The Conners’ Teacher Rating Scale–28 and a sentence completion reading test were used to assess CP and PR skills. The Wechsler Intelligence Scale for Children–Third Edition Backward Digit Span, the Conners’ Continuous Performance Test, and the Tower of London were used to assess three aspects of executive function: verbal working memory, response inhibition, and planning, respectively. The CP-PR group had lower verbal working memory than the CP-only and COM groups, but the difference was not significant after intellectual ability, inattention, and hyperactivity were controlled. The CP-PR group made more errors in the planning task (rule violations) than the COM and CP-only groups, but the difference was not significant after intellectual ability was controlled. No significant group differences were found in response inhibition. A specific PR group effect was found for verbal working memory. Children with CP-PR have more prominent executive function impairments that cannot be attributed to coexisting PR.

Assistive Technology for EF

There are numerous apps to help with executive functioning issues.  The following list is from

Listening to Recorded Audiobooks. Audiobooks are recordings of human narrators reading aloud.
Learning Ally Link (Mac, PC, iOS, Chrome)
Kindle Fire and Immersion Reading (see e-text highlighted while listening to narrated audiobook)
Audible app (Mac, PC, iOS, Android, Windows Phone)
Overdrive Media Console (borrow digital audiobooks and e-books from local libraries)
Simple text-to-speech, E-readers with text-to-speech and other tools
TextAloud MP3 (PC)
GhostReader (Mac)
NaturalReader (Mac & PC)
VoiceOver and Speak Selected Text (included in Mac operating system)
Speak Selection and Speak Screen (included in iOS)
Speak command for Microsoft Word (PC)
Bookshare Web Reader extension (for Chrome on Mac, PC; Safari on Mac; Chromebook)
Read2Go (iOS app for Bookshare books)
Voice Dream Reader (iOS and Android app for Bookshare books and other text)
GoRead (Android app for Bookshare books)
Darwin Reader (Android app for Bookshare books)
iBooks (Mac, iOS) - use device's built-in text-to-speech
Read, Write & Study Software Suites

Software that bundles multiple supports for reading, writing, and studying.
Kurzweil 3000 (Mac & PC)
Read&Write (formerly Read&Write Gold) (Mac & PC)
Read&Write for Google (Chrome extension) - for use in Google Drive on Mac, PC, Chromebook
ClaroRead (Mac & PC)
SOLO Literacy Suite (Mac & PC) – comprises four interrelated applications: Read:OutLoud, Draft:Builder, Write:OutLoud, and Co:Writer
Read:OutLoud-Bookshare Edition (Mac & PC)
Premier Literacy Productivity Suite (Mac & PC)
Resources for Alternatives to Printed Text - Electronic Text (E-text) and Narrated Audiobooks
Bookshare (e-text) - eligibility required
Learning Ally (formerly Recording for the Blind & Dyslexic-RFB&D) (audiobooks, some with e-text) - eligibility required
National Library Service (audio materials) - eligibility required
Amazon Kindle (e-text) - also see Immersion Reading in "Listening to Recorded Audiobooks", above
Audible (audiobooks)
Blio (primarily e-text in proprietary reader)
CourseSmart (e-text in proprietary reader)
Project Gutenburg (e-text)
NIMAC (e-text) - materials must be secured by a school; not available to individuals
check local digital libraries (e.g., Northern California Digital Library) to borrow downloadable audiobooks via Overdrive Media App or other platforms
check individual publishers for accessible online or e-text versions of textbooks
Graphic Organizer and Mind Map Software

Outlining and mapping software can help students organize ideas for writing, take notes while reading, break a large project into smaller individual tasks, understand broad concepts or complex processes -- any information that benefits from a structured framework and clarifying the relationship between the whole and its parts. Some of these programs, apps, and web tools also include ready-made templates (and allow creation of custom templates) to scaffold a student's thinking and learning.
Inspiration (Mac & PC)
Inspiration Maps (iOS)
Kidspiration (Mac & PC)
Kidspiration Maps (iOS)
Webspiration (online)
XMind (Mac & PC)
Free Mind (Mac & PC)
MindMeister (iOS, Android, Chrome, online)
Mindomo (Mac, PC, Linux, Chrome, online)
MindMup (online)
LucidChart (Chrome, online)
SimpleMind (Mac, PC, iOS, Android)
MindNode (Mac, iOS)
SmartArt Graphic organization layouts built into Microsoft Word (2007 and later)
Graphic organizer tools also included in some literacy software such as SOLO (Draft:Builder), Kurzweil 3000, and Read&Write (Fact Mapper)
Speech recognition (speech-to-text)
Dragon NaturallySpeaking (PC)
Dragon Dictate (Mac)
Windows Speech Recognition (included in Windows operating system)
Dictation and Dictation Commands (utilities built into Mac OS)
Dictate and commands (utilities built into iOS)
Dragon Anywhere (iOS, Android) - syncs custom words and macros with some Dragon desktop editions
Voice Typing (Google Docs on Chrome browser)
(also see MathTalk and SpeakQ, below, for other software that employs speech recognition)
PDF Annotation

Type on PDF version of worksheet, quiz, or other handout vs. handwriting on it.
Preview annotation toolbar - annotate PDF documents (included in Mac OS)
Skim - free PDF reader with annotation tools (Mac)
Adobe Reader version 11 - PDF reader with annotation tools and markups; discontinued 2015, replaced by Acrobat Reader (Mac, PC)
Acrobat Reader DC - PDF reader w/ annotation tools, markups; replaces Adobe Reader (Mac, PC)
PDF-XChange Viewer - annotate PDF documents (PC)
FoxIt Reader - PDF reader with annotation tools (PC)
ClaroPDF-Accessible Pro and ClaroPDF Lite - PDF reader app w/ annotation tools; Pro has text-to-speech (iOS)
PDF Expert - PDF reader with annotation tools, text-to-speech (iOS)
Kami (formerly Notable PDF) - PDF reader with annotation tools (Chrome)
SnapType for Occupational Therapy - simple app to snap photo and annotate (iOS)
PDF Reader tool in Read&Write for Google (Chrome extension) and Read&Write-WIndows (PC) - PDF reader with text-to-speech and annotation tools
Assorted Reading & Writing Supports

Supports for spelling, grammar, word choice, reading level, and visual readability.
Dyslexie and OpenDyslexic - fonts designed to ease visual aspects of reading for those with dyslexia
Visual Thesaurus - visual word map (online, Mac & PC)
Ginger - contextual spellchecker (online, PC)
Ghotit - contextual spelling/grammar checker with word prediction, other supports (Mac, PC, iOS, Chrome, Android, Linux)
Grammarian Pro2X - grammar and spelling checker (Mac)
Co:Writer - standalone word prediction with topic dictionaries (Mac, PC, iOS, Chrome)
WordQ - word prediction, word lists, abbreviation/expansion (Mac & PC)
SpeakQ - WordQ plus speech recognition (PC)
Clicker 7 - custom onscreen keyboards, talking word processor, word prediction, more (Mac & PC)
Clicker Apps: Sentences, Connect, Docs, Books - each app focuses on a key Clicker 7 feature (iOS)
DocsPlus - word banks, talking word processor, word prediction, mind mapping (online, Mac & PC)
BeeLine Reader - text color gradients aid visual tracking, improve reading speed, reduce effort
Mercury Reader - reduces webpage visual clutter for distraction-free reading (Chrome)
Reading Focus Cards - virtual index card-like reading guide to aid visual focus (Mac, PC)
Rewordify - automatically defines, or substitutes simpler words in place on webpages
Snap&Read Universal - text-to-speech, convert image to text, and text leveling (simplify difficult words) (Chrome)
Taking Notes & Organizing Notes
Microsoft OneNote - digital notebook (PC, Mac, iOS, Android, Chrome, online)
Growly Notes - digital notebook (Mac, iOS)
Evernote - digital file cabinet (online, Mac, PC, iOS, Android)
Livescribe smartpens - pens link recorded audio to handwritten notes (works with Mac, PC, iOS, Android depending on model: Echo, Sky Wifi (discontinued 2016), Livescribe 3)
IRISPen - handheld scanning pen captures print text, transfers to computer (Mac & PC)
C-Pen - handheld scanning pen reads print text aloud, defines/translates words, captures print text for transfer to computer (Mac & PC)
Notebook Layout w/ Audio Notes - link recorded audio with typed notes in Word (included with Microsoft Word for Mac 2008 & 2011 only)
Sonocent Audio Notetaker - software integrates audio recording, notes, slides, images, and annotations (Mac & PC)
Sonocent Recorder - companion app to Audio Notetaker; record and annotate audio (iOS, Android)
AudioNote - multi-functional notetaker app (iOS, Android, Mac, PC)
Notability - robust notetaker app (iOS, Mac)
Math & Science Notation, Graphing & Drawing
MathType (Mac & PC)
MathMagic (Mac & PC) and MathMagic Lite (Mac, PC, iOS, Android)
EquatIO (Chrome)
FX Equation (Mac & PC)
FX Graph (Mac & PC)
FX Draw (Mac & PC)
FX Chem (Mac & PC) - type chemical equations
FX ChemStruct (Mac & PC) - type chemical structure diagrams
GeoGebra (Mac, PC, iOS, Chrome)
Desmos Graphing Calculator (iOS, Android, Chrome, online)
Desmos Test Mode (iOS) - restricted test-safe version of Desmos
MathPad & MathPad Plus (PC - discontinued)
MathPad by Voice (PC - discontinued)
MathTalk (PC)
Panther Math Paper (iOS)
ModMath (iOS)
Math Concepts

National Library of Virtual Manipulatives (online, Mac, PC)
McGraw-Hill Virtual Manipulatives workspace (online)
Kidspiration-Math View (Mac & PC)
InspireData (Mac & PC)
Math Problem Solving and Processes

Apps and resources to help understand and practice multistep problem solving and sequencing steps.
Algebra Touch (iOS)
Long Division Touch (iOS)
Math 42 (iOS)
Esa Helttula Math Apps (iOS)
Khan Academy (online)
Assorted Aids for Managing Digital Distractions
Isolator - dims, blurs, or hides all but frontmost window to reduce visual distractions (Mac)
HazeOver - dims or hides all but frontmost window to reduce visual distractions (Mac)
Dropcloth - dims or hides all but frontmost window to reduce visual distractions (PC)
ScreenRuler - dims entire webpage except for movable horizontal reading ruler to aid visual focus and tracking (Mac, PC)
Screen Masking tool in Read&Write for Google - dims entire webpage except for movable horizontal reading ruler (Chrome)
Screen Masking tool in Read&Write - dims entire webpage except for movable horizontal reading ruler (Mac, PC)
Mercury Reader - reformat "main article" text on webpage, removes visual clutter (ads, images) (Chrome)
Simplify Page tool in Read&Write for Google - reformats "main article" text on webpage, removes visual clutter (ads, images) (Chrome)
AdBlock - browser extension prevents ads from loading to webpages (Safari, Chrome browsers)
Text Mode - replaces webpage images and videos with gray rectangles for uncluttered, text-only reading (Chrome)
SelfControl - restricts access to selected websites for preset times (Mac)
StayFocusd - restricts access to selected websites for preset times (Chrome)
Cold Turkey - restricts access to selected apps, websites for preset times (Mac, PC)
RescueTime - tracks time on apps, websites (Mac, PC)
Assorted Aids for Attention and Executive Functioning
VibraLite - watches with multiple customizable vibration alerts
WatchMinder - watch with multiple customizable vibration alerts, messages
Reminders - simple but capable to-do list with alerts included with Macs and iOS devices
Wunderlist - task manager app (online, Mac, PC, iOS, Android)
DropTask - visual task manager app (online, Mac, PC, iOS, Android)
Trello - visual taskboard for managing tasks and workflow (online, iOS, Android)
Assignment Calculator - break down large projects into manageable chunks (online)
Research Project Calculator - break down large projects into manageable chunks (online)
CoPilot - breaks assignments into sequence of tasks and schedules them on calendar according to learning style and study preferences (online)
30/30 - task timer app employs a modifed very of the Pomodoro Technique (iOS)
Brili Routines - "routine manager" with prompts to assist staying on task (Mac, Windows, iOS, Android, Pebble, online)
Octopus by Joy - icon-based task scheduler watch designed for young kids (shipping late summer 2017) (iOS, Android)


I hope you found this post helpful and full of ideas.  I like doing these posts since two of my children struggle with severe executive functioning issues.  Completing this post helps to remind me to give them grace when they are having executive functioning problems (practically every minute of every day!) and how EF issues impact their learning.