Video Transcript: Unstuck & On Target!

Watch Video: Unstuck & On Target!

- So it's a pleasure to welcome Dr. Lauren Kenworthy this afternoon to our webinar and to our autism and education partnership.
Dr. Kenworthy is a pediatric neuropsychologist and the director of the Center for Autism Disorders at Children's National Health System based in Washington, D.C.
She's also served as an associate professor of pediatrics, neurology and psychiatry at The George Washington University School of Medicine since 1995.
Dr. Kenworthy specializes in the neuropsychological assessment of children with ASD and co-authored the Behavior Rating Inventory of Executive Function, or BRIEF, which is the tool most often used to assess executive functioning in individuals who experience challenges in this area.
Dr. Kenworthy has authored a number of peer reviewed research studies into executive dysfunction in individuals with ASD.
She's authored three books and several book chapters and is the co-creator of Unstuck and On Target, an executive function curriculum with learners, for learners with ASD.
And she's gonna share some information about that with us this afternoon.
So welcome, Dr. Kenworthy.

- Thank you.
Let's see.
I think you're all seeing my screen now.
And I'm excited to be here.
I have to say I love speaking with people.
This is a little bit of a new experience for me, 'cause I don't get to see all of you.
I will look forward to hearing your questions when we take a break about midway through.
But if you have questions that you think really make sense to ask right at the moment you can flag that for Shelly, and I think she can break in as appropriate.
So I'm-

- [Shelly] Dr. Kenworthy, I'm just gonna pop in 'cause we're not seeing your screen yet.

- Uh oh, sorry.

- [Shelly] That's okay, no problem.

- Let's see.

- [Shelly] Perfect.

- [Lauren] Now? Good?

- [Shelly] We've got it, thank you.

- Okay, good.
Good, thank you.
I'm gonna talk to you today about Unstuck and On Target, which is an intervention that we developed, actually, a group of us developed, and I'll tell you more about that in a minute.
We developed it for people on the autism spectrum.
It is developed for elementary school age kids and designed for kids who have verbal abilities around six or seven or better.
I do think that some of what I can talk about today is very relevant to kids who have less language, but I want to be very clear that the bulk of the research and work I'm showing today was framed around kids whose language is relatively intact, at least their structural language, their grammar and their vocabulary.
It's important that you know that I do get royalties, both in the sale of Unstuck books and BRIEF manuals, so you can take what I say with a grain of salt.
So in terms of my goal for today, I'm hoping to increase your understanding of executive functions and how to enhance them.
And in terms of the plan, I want to first start by defining executive functions and why they are important for outcomes.
And then I want to talk about understanding specific executive function deficits that we see most often within autism spectrum disorders and how we should accommodate them, because that's the step that we have to take before we think about teaching kids to be more flexible, organized and planful, which is at the core of the Unstuck curriculum.
So again, it's sort of sad for me I can't see you (laughs).
Ordinarily I sort of ask for some feedback as this point, but I'm gonna guess that most of you are familiar with the concept of executive function, and it's certainly become much more readily kind of discussed and considered for children over the last decade or so.
But I'm gonna just pause a little bit here and give you kind of how I conceptualize it, largely just to make sure that we're on the same page as we have this webinar today.
So when I'm talking about executive function, I'm talking about a set of brain-based abilities.
They live in this pre-frontal subcortical circuitry of the brain.
And they are instrumental in our being able to efficiently carry out goal-directed behavior that would help us to process large amounts of information.
And they are really a collection of things our brain does that keep us kind of focused, planful and goal-oriented.
And in fact, when we think about what the executive functions are, there are really three sets of brain-based skills, and one is this one I have on top here, this cognitive regulation.
This is how we regulate or manage our thinking.
How we get started with thinking, how we hold information in working memory or in the blackboard of our mind, or the RAM if you're a computer person, how we plan and organize information, how we monitor, how we're completing tasks.
There's another set of skills that are really about regulating our behavior.
Do we inhibit and put the brakes on what we're doing? Can we track our behavior and how it's impacting others? And then there's emotion regulation, and what we found in our research with the BRIEF, and others have found this with other tools as well, is that flexibility or shifting is an executive skill that's very closely linked with emotional control or managing your emotions.
And that together they really drive a lot of our emotion regulation abilities.
So with that kind of triad of executive function issues in mind, I do want to just pause first and say one of the interesting things about executive function is that it is one of the most vulnerable cognitive functions of the brain.
It's the latest to develop.
And as many of you know, it develops over a very long trajectory.
So if there are any of you out there who are under 30 (laughs), you still have kind of executive function development to happen.
Biological executive function, that is, the networks that subserve executive function in your brain are gonna continue to get more efficient and effective up through those first three decades of life.
After that, for people like me, it's all downhill.
But it's a much longer trajectory of development than what you would have, say, for language or other skills.
And what's cool about that is that then the people like you and me who get up every day 'cause we want to help kids reach their potential and maximize their abilities, if we intervene on executive function skills we're intervening in an area where there's continued growth and development so we can kind of just take advantage of that and leap on forward that natural development and try to get that trajectory aimed in the right direction.
The other thing that that means is that because these skills are relatively vulnerable in the brain, most of us have had the experience of our executive functions not doing what we want them to do for us.
And I will just briefly have you think about a very basic example of this that most of us have had in our own lives.
And I'm gonna go to grocery shopping here and say that most of us have grocery shopped and at one point or another had the experience of not being as efficient or effective with that task as we know we can be.
So we're plenty smart enough to grocery shop, but we don't necessarily do the things we need to do to get through the store efficiently.
And when you think about adults like us, our executive functions suffer when we are sleep deprived, when we're hungry, when we're very anxious.
So let's say you've had a situation where you're worried about a family member or didn't get a good night's sleep or didn't get your breakfast, you have the potential for showing up at something like the grocery store and not being as effective as you know how to be.
And that's 'cause these executive function pieces are not gonna work effectively for you.
So one quick example of that is if you're at home like I am sometimes on Saturday mornings and I'm sitting on the couch (laughs), and I'm reading the paper it's very hard for me to initiate or get started on I gotta go.
Time to go to the store.
In my next executive challenge with the grocery store, it can be about how well I plan to organize my trip.
If I didn't make a list before I went, so I didn't have a plan going into the process, then I get to the store and I'm not very efficient, because I'm walking down the meat aisle and thinking oh, maybe I could make meatloaf tonight.
And then I have to stop and think do I have ketchup at home or don't I? So I haven't properly planned out what I want to make, what I have in my cupboard at home, what I need to get from the store.
Working memory can flare up in the shopping example.
If, for instance, you forget what you've already put in your cart, which has happened to me once or twice, or you forget why you're in it, what it is that you need in the vegetable aisle.
You don't have your list to support your working memory.
Now in terms of behavior regulation, when we think about the grocery store example, I'm guessing that some of you have probably at some point shopped when you are hungry, and that's where you can hear the inhibition flare up, right? There I am munching on a Milano cookie before I've even thought about why I came to the store, because my inhibition or impulse control isn't what it should be.
You can also get stuck in a store if you're not fully flexible.
You go with the intention of making a special pear dessert for people that are coming to dinner that night.
All of the pears are hard as rock.
You stand in front of the produce and you're mad, right? And until you can shift gears and decide I'm gonna get something else and make an apple pie, you're wasting your time.
Maybe this has never happened to you.
I live in Washington, D.C.
It's very expensive to buy produce here, and it's not very good.
And so, sometimes I have little moments of being stuck with being mad about what I can and can't get at the store.
So I just gave you that quick little example, because I just wanted you to start to be thinking about executive functions.
The fact that all of us rely on them for tasks that are simple, such as getting out of bed in the morning, getting our teeth brushed and getting out of the door with what we need in the morning.
Two tasks that are very complex.
Whether it's as adults planning a career or whether it's a kid planning a homework project or managing a social interaction, all of those things require executive function skills.
And for most of us we've had times when they're better or worse.
And as we start to talk about kids with autism who are for genetic developmental reasons struggling with executive functions, for me it's helpful to think back about my own times when I've had these challenges to kind of recognize what that looks like, what that feels like, and how we can best accommodate it.
So if that makes sense to people, and I'm hoping there aren't tons of emails showing up in Shelly's box saying, "What is she talking about?", let's move on and talk about what it means then to have executive dysfunction.
And here Teuber, long ago, talked about executive function as "The curious dissociation between knowing and doing." So what that means is that when you have executive dysfunction you may know what the right thing to do is.
I know that making a list will help me be better and more efficient in the grocery store, but I may have trouble actually doing it.
I'm not carrying out the habit.
And when we think about a disorder that dissociates our knowing from our doing, it's not too surprising that the research shows that when you have problems with executive function, and this is in the context with autism and other developmental disorders, that we see strong correlations with your ability to learn.
The worse your executive functions, the more difficulty you have learning in school and in other environments.
You know, "Why doesn't he ever learn from his mistakes?" is something you hear a lot about kids who have executive dysfunction, and they may just be slower at mastering basic academic skills, too.
Executive functions also relate to your adaptive daily living skills, and I'll give you some more details on this one in a minute.
They, lo an behold, relate to family stress.
And again, as a parent of a child with ADHD, I can say this is a really real phenomenon, right? It's stressful to be around somebody who has potential that they're not reaching because of their problems with organization and impulse control and working memory, et cetera.
And it puts a burden on the adults in that child's world to be their frontal lobes, we say sometimes, or to somehow reach in and try to make all those things go right.
It also has a huge impact on adult outcomes.
And again, I think that's why most of us are here and why you guys have signed in for this webinar today is 'cause we're in the business of helping kids become everything they can be.
And one component of making sure that that happens is supporting the development of executive functions.
So let's talk about that adaptive behavior.
So here I'm reporting on the work of a postdoc and now colleague of ours here at Children's National, Cara Pugliese, and there she is up in the corner.
And she looked at data that was collected here in our Center for Autism Spectrum Disorders from families.
Excuse me, I'm...
I have bit of a cold today, I apologize.
And she was interested in understanding within people who have autism, so all the folks in this study, and there's 421 of them have autism, they also have average IQ's.
Their average mean IQ for this group was 103, so that's right where we would expect it to be.
So their IQ's are up here on this y-axis around 100, and then she wanted to understand what's going on with their adaptive skills.
So when I say adaptive skills here, I'm reporting on Vineland Adaptive Scales.
There's a communication, daily living, socialization scale.
The communication scale is about your ability to communicate effectively to use words to communicate, whether it's following directions or explaining something to somebody.
It's those kinds of skills.
Daily living skills have to do with do you go through your morning routine effectively? What's your hygiene like? Can you use a microwave? Those kinds of questions.
And then socialization is about your social interaction skills.
Do you know how to share? Do you initiate contact with others, et cetera.
The Vineland is built for people from toddlerhood up through adulthood, and so she looked at it here in terms of kids of a range of ages.
These blue bars here are the youngest kids.
They're four to five, and then there's the six to seven-year-olds, eight to nine, all the way up to the orange bars, which are the adolescents, group 14 to 20.
So the first thing that you can see from her data is that there is a very big gap between the intelligence of these folks and their adaptive skills.
And what that gap says is that this is not typical development, because typically we expect the child's adaptive abilities, how they use words in the real world, to be directly related to their verbal intelligence, right? And so when you see that there is average intelligence, their knowing is what they're doing pretty well, but then a big gap in terms of how what they do with that knowledge, the question becomes why.
What's causing that gap? And for Cara, she wanted to ask whether age was a piece of it, because as you may have noticed, these bars seem to go down.
Lower numbers here are worse adaptive functioning, and it looks like for the older kids the adaptive functioning is significantly worse than it is for the younger kids.
This is cross-sectional data not longitudinal, so we're not looking at development here, but we're just asking.
She wanted to know is there an age effect for these kids who have autism without ID? Are the older ones showing worse adaptive behavior than the younger ones? And so she wanted to ask if age was affecting adaptive behavior scores.
She also asked about IQ, because, of course that's what we would expect to drive adaptive behavior.
And then she, after those two issues were considered, asked well, what about executive dysfunction? Does that play a role? And here's what she found.
When she looked at the communication skills, yes, the older kids were even in greater trouble than the younger ones.
IQ did play a role, but also after considering those two variables, initiate and working memory skills, two key executive metacognitive skills, played a role.
So the cognitive regulation skills are important to why kids of average IQ have trouble kind of showing that communication skill in the real world.
She found the same thing with working memory, excuse me, daily living skills here in the middle.
And when she looked at socialization, she found that shifting or flexibility was a key executive skill as well as initiate.
So this is to say that executive function is related to one really fundamental way that we think about outcome, which is you have to have the skills in the real world to communicate effectively with others to make it through daily routines and to interact in social interactions effectively enough to kind of get where you need to go.
So that outcome looks like it's in peril for a lot of our kids with autism, and we know that from other data as well.
And executive function is one target, one skill that we could target to improve in order to enhance that adaptive behavior over time.
So executive functions matter in the real worlds, because they affect those real world skills like adaptive behaviors and learning.
They also matter in the real world, because when you have executive function problems it is very easy to appear like a person who is choosing not to do something as opposed to a person who is, can't do something, right? So the concern here is that kids with executive dysfunction, it looks like they won't do things that in fact it may be that they can't do.
And this is a huge distinction for a number of reasons that we'll talk about in a minute, but let me just unpack it a little bit further first.
If you are working with a child who has a language disorder or a reading disability, that disability is pretty clear, right? Because you may find that they are drawing beautiful pictures or that they have incredible math skills.
They look like they're engaged and producing good work in certain contexts, and then it's only in those specific settings where you ask them to read or you start to listen to their language that you realize, oh, that's a problem for you.
If you contrast that with executive function, that creates, if you will, a learning disability that affects a child 24/7.
So executive function affects how they show everything that they know.
So it affects whether they get to school on time.
It affects whether they have their homework in their backpack when they do get there.
It affects whether they follow a routine of hanging their coat up the right way, and it affects how they learn, and it affects how they interact with other kids on the playground.
So it becomes very easy to see a kid who may be inflexible, have a brain-based constitutional inflexibility problem, as one who's stubborn or oppositional.
And here again, I wish I could see you guys, 'cause usually at this point people are sort of starting to think about even individual kids that you may be working with where somebody along the way may be misunderstanding some of their can'ts or won'ts.
But one of the things that I want to do, particularly with the next section of this talk, is really try to unpack what can look like won't but what may well be can't.
Because until we understand that distinction, we're really A, doing damage to kids in terms of their own self-view, because if we think of them as stubborn, they will think of themselves as stubborn, and B, disempowering ourselves in terms of we're limiting the kinds of tools that we have to help those kids become more effective and better developed kids overall.
So if we're thinking of a kid as stubborn who's actually brain-based stuck, it's like taking a kid with a reading disability and often we'll bring in for the stubborn kid some behavioral kinds of reinforcers, where we're trying to reinforce the kid for not being stubborn.
Maybe we're trying even to remove reinforcers when they are stubborn.
But that's not gonna work if the kid just plain out can't do the skill.
So you wouldn't think of a kid who had reading decoding disability as somebody to rely on a more strictly behavioral intervention.
You would think I've got to teach that kid those phonological skills that they're lacking.
And when we think about executive function that way, again it opens up another set of tools that we have to help kids improve.
So my goal of increasing your understanding of executive functions and how to enhance them, and my first, oops.
Sorry.
My first step of the plan was to define them and why they matter to outcomes.
Can I check that one off? I think we covered that one, and now I want to move on to understanding and accommodating specific executive deficits that we see a lot in autism.
I'm gonna talk about flexibility, organization, integration, working memory (mumbles).
And as I move into this part of the talk, I need to recognize the Unstuck team.
So I'm presenting to you a lot of information that was developed by this Unstuck team, of which I am one member.
And I want to make sure that you understand that these tools were developed by a multidisciplinary team.
Some of us from the Model Asperger Program at Ivymount, which is a special education program here in Washington, D.C., and Take2, an affiliated summer camp.
Katie Alexander's an occupational therapist, Lynn Cannon and Monica Werner are educators, and then Laura Anthony and myself are here at Children's National, psychologists and neuropsychologists.
In addition, John Strang and Cara Pugliese are developing secondary school versions of Unstuck and just trying them out right now as we speak in our local Fairfax County Public Schools.
But Unstuck is a little bit further along.
We've completed now a couple of trials of Unstuck, and I'll give you at the end of the presentation some data on its efficacy.
I will just tell you that there are two books related to Unstuck that are currently available.
This, the green book, is a large 8 x 11 book which contains a number of lessons.
These are lessons that could be given to kids in small groups.
They're designed to be given to kids in the school context.
So a lunch bunch or a social skills group kind of format.
It helps kids learn some of these executive function skills we're talking about today.
The blue book is a guide for parents or classroom teachers and classroom teachers and therapists if they just want to implement some of our Unstuck principles in their daily interactions with their kids.
So it's not a curriculum like the green book is.
So the Unstuck philosophy.
At our core, we believe that it is important to accommodate before we remediate.
And so that's why I'm gonna make you kind of work through with me a series of accommodations that have to be in place before we think you will be effective at teaching these Unstuck related skills.
Now there's a couple reasons why we have this philosophy, and the first one is that neurodiversity is really a civil right.
And I know I got a lot of chutzpah here as an American at this particular moment in time (laughs) lecturing to Canadians (laughs) who seem to have this much more clearer in your minds about the importance of civil rights generally and also neurodiversity, but I think all of us probably in this webinar can agree that every mind is a valuable mind, and just as we have become better as nations when we include all races, all religions, all ethnicities, we also become richer and more powerful as a nation and as a world when we include all different kinds of minds.
And we have plenty of examples of really stellar individuals who had developmental disabilities who have enriched our world in numerous ways.
And so maybe now more than ever I think it's very important to pause on this point and to recognize that the forward thinking among us realize that already that we can enrich our world by incorporating people with autism of all intellectual ability levels and language levels.
So Google (mumbles) want to hire one percent of their workforce as being somebody on the spectrum.
And even for folks who have less language and less intellectual abilities, there are remarkable strengths that people on the autism spectrum bring to the world.
Loyalty and reliability, and other such things that need to be recognized.
So we accommodate because it's the right thing to do.
We also need to accommodate, because if you don't then you end up with people who are very overwhelmed, and they don't turn out to learn very well.
Most of us know this from our own experience.
Most of us have had a moment where there were just too many things overwhelming us at one time.
Maybe the phone starts to ring, and you spill some coffee on the paper you're working on, or your kid starts to fuss, or you get to a point where you might as well just go take a nap 'cause you're not going to be very effective at problem solving the next steps.
Well, if you don't accommodate some of these executive functions, you often end up in a situation where they're kind of in constant overload.
And that turns out to be something that makes it really unpleasant to be with the child, unpleasant for the child, and really disables their ability to move forward and learn.
So we're gonna talk about some key accommodations in the context of those executive functions I mentioned: Flexibility, organization, working memory and planning.
And the key accommodations that we're gonna go through include that idea I just talked to you about of can't versus won't.
The most important thing that we can do for a person who's struggling with executive function is make sure that the team around that child is thinking really carefully about what behaviors represent can'ts versus what behaviors represent won'ts.
And problem solving or running little experiments with a sample size of one, or whatever we need to do as often we do, to parse out a choice the child is making versus a biological disability.
A second key accommodation that most of you I think are very familiar with and use all the time is to recognize the importance of predictability and structure for people on the autism spectrum and how that can support their learning in so many different ways.
We're gonna talk about making the big picture explicit.
We're gonna talk about talking less and writing more and avoiding overload.
And finally, that kind of universal accommodation that works for all of us.
Works with your mother-in-law, your spouse (laughs), your friend and also the children that we're all trying to help, which is keeping things positive.
Okay, let's start by going back to that model executive function and let's focus in now on flexibility skills.
These are a key set of skills that enable you to effectively shift from one task to another.
And I think as many of you well know, flexibility turns out to be a very common executive function challenge for people with autism.
Now for me to say as a neuropsychologist there's this cognitive deficit in your ability to think flexibly or shift your behavior, that's not really a surprise, right? Because we define autism as a disorder which based on there being social communication deficits and also deficits in somebody doing more repetitive thinking, repetitive behaviors.
And those repetitive stuck behaviors are then sort of naturally related to repetitive stuck thoughts.
But there has been a fair amount of research that makes very clear that people with autism, even those who function at very high levels in terms of their language or their intelligence have more trouble shifting their thinking from one idea to another.
Problem solving, coming up with a new strategy to fix something.
So if you have problems with flexibility, and you're trying then to navigate the real world, I think it's important for those of us who don't have this core inflexibility deficit to recognize how hard that is to manage.
A young student talked to us about the fact that Asperger's for him was "like a vise on his brain.
"Each unexpected event is like another turn of the vise, "and it just keeps building "until you feel like you're gonna explode.
"And sometimes when you explode, "it comes out the wrong way." And I think that's a very powerful statement, because it brings us back to the fact that when you have an inflexible brain and you're plunked down in the world which demands flexibility so many minutes of the day, it's actually a lot like the experience of what I would think of as medieval torture, right? This guy is saying it feels like I have a metal vise on my brain and it gets tighter each time something unexpected happens.
Each time you ask me to think in a different way.
And I think a lot of us have seen kids where you can watch this feeling of uneasiness rise in them over the course of the day as that vise is turning tighter.
And in another point this same student said your whole day becomes uneasy, and then, of course, you can explode.
And so I think it's important for us to pause, because what this individual is helping us to think about is there's a very big can't here, and it is driving difficulty in that person throughout the day that may end up resulting in behavior that looks like pretty nasty won't type behavior.
And again, for people who have less verbal abilities than this person did, I think they may not express all of this as clearly, but the same phenomenon may be occurring.
So this flexibility is a huge issue, and when we need to recognize that people on the autism spectrum are much more likely to be inflexible, at which point we need to kind of stop and think about well, so what would that cognitive inflexibility look like in school or home or other settings and how can I tell that can't from that won't? Because these behaviors, like difficulty of accepting feedback, poor frustration tolerance, difficulty stopping once you get upset, or starting when there's something you don't want to do, to avoid shutting down when something's challenging.
These are all signs of cognitive inflexibility.
Now they could also be signs of somebody who's just being a jerk, right? That can happen, too.
But you want to stop when you see these behaviors and consider if there's underlying cognitive inflexibility, because that's gonna give you, as I said before, a whole new way to intervene to try to teach those flexibility skills.
And first and foremost, to think about the fact that we need to accommodate the fact that this person has flexibility difficulties.
And here, with these accommodations I just want to remind you that we don't bat an eyelash when a child is in a wheelchair to assume that we're gonna put in a ramp in order for that kid to access school, in a therapy setting, or anywhere else for that matter.
That's just a given.
So I'm here talking about those wheelchair ramps that you need when you have executive dysfunction.
And for inflexibility I think a lot of you have thought about some of these key accommodations.
The importance of the schedules and routines, predicting changes.
The importance of being being very clear about what your expectations are.
Providing some downtime or breaks away from people when you are becoming overwhelmed.
And explicitly teaching skills like compromise.
So these words after the arrows are giving you some basic accommodations.
Again, I think many of you have tried them, but the bolded statements are giving you the types of behaviors that you might see in a person who has cognitive inflexibility that would merit these kind of accommodations.
And I want you to note that there's one accommodation that turns out to be helpful for every aspect of inflexibility, and that's the presence of a flexible adult.
I think that probably all of you have seen what happens when you get an inflexible child and an inflexible adult together and how difficult that is for the interaction to turn in a very negative direction.
And often when we see kids in our clinic who have really fallen apart, if you will, at school or at home where that you see increasing anxiety, you may see increasing oppositional kinds of behaviors, they may end up with more significant psychiatric diagnoses.
Often there is this problem that's evolved between a key interaction with an adult and a child, and the inflexible adult can drive that in a really negative way.
So thinking about who it is who's working with the kids and how those people can maximize their flexibility can be really important.
And before leaving the topic of inflexibility, I just want to note something that we were taught by this gentleman, Ari Ne'eman.
He is was on President Obama's learning disabilities council.
He ran the Autistic Self-Advocacy Network here in Washington.
He's a person with Asperger's who's brilliant and well-accomplished, and when we reviewed with him on the development of Unstuck and On Target, he was very positive and encouraged us with social skills for reinforcing what we were doing.
But he said, "There's one thing you're forgetting." And we said, "What?" And he said, "You have to remember that inflexibility "is adaptive because it limits "the unexpected overloading events we have to encounter." So here again, I want to come back to this idea of overload and recognize that if you have an inflexible brain it is easy for you to get overwhelmed.
An overload, as Ari explained to us, is particularly dangerous if you're a person who's already considered somewhat different or inappropriate.
So once overload sets in, a person's more likely to do impulsive, inappropriate, highly anxious things.
As they do that in the context of already being socially isolated, they're increasing their risk of being penalized by some way by the world around them.
So the analogy he used to try to help us neurotypical brains kind of understand his thinking here was of the minefield.
He said, "If you lived next to a minefield, "and you had to cross that minefield "every day to get to work, "and you learned one safe way across that minefield, "then you're probably gonna be pretty inflexible "about trying a different route the next day, "because it's too risky." And I thought that was a really powerful way for us to kind of frame the value of inflexibility.
And again, even for people who have less language and can't articulate this, I think a lot of that controlling kind of behavior can often be I need to know what's gonna happen next.
Because otherwise, I'm worried about how I'll respond.
So that brings us to respecting routines that don't interfere, and all of us have these.
I mean I betcha a lot of you have exactly the same routine you take to get out of the house in the morning.
To respect the use of any routine as long as it doesn't get in the way of learning or socialization.
To respect the development of deep datasets of that deep dive that an inflexible brain can take into a certain area of knowledge and the expertise that can come from that, as well as the persistence and reliability of the inflexible brain.
These are all strengths that come with inflexibility that we can celebrate and nurture in children.
Okay, so when we think about inflexibility there is a huge piece of accommodation around providing predictability and structure that will support the inflexible brain as it navigates learning and social environments and it will reduce overload.
Let's shift now and talk about organization and integration.
This is another area that's a big one for people on the autism spectrum.
We know that there's planning issues as well as problems seeing the main idea, seeing the forest for the trees, making priorities, and we've got a lot of neuropsychological research to support that argument.
And when we think about the can'ts or the won'ts here, we're thinking about kids who seem to get stuck on details.
This can be really irritating when they seem like irrelevant details, right? As little pieces of that figure might be.
They don't get their good ideas onto paper.
They might dominate in conversations.
They have trouble with goal setting.
These are the can'ts or the won'ts that we think about from these organization problems.
And they're very basic accommodations for people with disorganization problems that can help them, and one is to teach to their strength.
To teach with explicit rules, recipes, checklists and routines.
To put new information in familiar context.
And also to provide external guidance toward thinking big picture, emphasizing goals as we do in Unstuck, and also providing safe addresses or adults in the child's world who know and understand them and can help them perceive those big pictures.
Another piece that we do for kids who have these organization and integration problems that I'm sure a lot of you have already thought about is we break things down, and flowcharts are magic with a lot of these kids.
And if anybody's ever watched Sheldon on the Big Bang Theory you may have seen him do it.
He's got a flowchart for how to ask a girl on a date and many other things, right? It's because this kind of a visual approach enables a person to kind of go step-by-step.
So when a child has done an inappropriate behavior, you can map that out.
You could say, "Okay, well where do we start? "John had the book you wanted.
"You hit John with the book.
"Then there was this consequence.
"Was that what you wanted?" And then that helps the child see that something that happened very fast that they could actually break it down and understand how each step relates to the next.
It also helps them to go step-by-step to think about they could repair the situation.
And this kind of guidance for how to break things down is in that little blue book I showed you.
But the take home, the most important take home I can give you from today is go out and buy a white board and keep it with you when you're working with these kids, because it enables you to write down a step-by-step visual cues for those more large and complex situations.
So that's about making the big picture explicit.
I think I better stop here.
I'm running a little slower than I had hoped, and see if there are questions that we should entertain before I move on and talk about planning, which will be the next step in working memory.

- [Shelly] There is a question as to whether or not you've tried any of these particular strategies with older learners or teenagers?

- Yes, absolutely.
These accommodations are things that work.
I've tried a couple of them with my mom, you know (laughs).
You can use them with anybody, and certainly with yourself as well.
You can try some of these out.
I think that these accommodations are in some ways universal with people with executive function.

- [Shelly] Great, and another question.
Karen's wondering under repetitive behaviors and intense interests, you suggest agreeing on a sign.
Could you elaborate on that a little bit?

- Yeah, so the issue there is a lot of parents will feel compelled that the kid can never pace or twirl or talk about whatever their special interest is, and we try to help people think about the fact that they can do that.
That's soothing for them, it's supportive for them, but they just need to think about when and where.
And so, that sometimes parents develop a sign that they could share with the kid if it's not a good time for that.
Otherwise, and most effectively, you can identify kind of general periods of the day when those kinds of behaviors are fine versus when they might interfere with making friends or learning something.
So by sign it could be like a thumbs down or I'm scratching my eye or whatever kind of just visual cue for the kid to think, "Oh, maybe this isn't the right time."

- [Shelly] Great, thank you.
And a couple of other questions.
Christine's wondering if you've tried this with students who have selective mutism.

- We have not worked with a lot of kids with selective mutism.
I mean I have seen kids with selective mutism, and I think that pieces of this could work well.
Certainly these accommodations can work well.
If you try this and you get better behavior, better learning using these accommodations, then you know they're worth doing.
You don't have to have the kid say, "That's great," right? It can just simply be watching and to see if you're getting them better able to regulate their feelings and their learning.

- [Shelly] Great, thanks.
And one more question from Richard.
Richard's wondering about how to overcome the issue of not writing it down, particularly high school.
He's wondering about the possibility of a scribe, if that would be a possibility.

- Yes, so for that little guy that I was talking about who's in trouble for not writing, he was still young and so we did recommend a scribe, as well as some brainstorming and a structured approach to writing, which really helped him to produce the written language that he's actually capable of doing but was lacking those organizational motor skills for.
As kids get older, we really encourage moving away from a scribe to voice-activated technology, 'cause there's so much of that now where kids can talk to the computer or other device in order to transfer their words into written language.

- [Shelly] Great, there are a couple of other questions coming up, but I'm going to capture those and just hold those for you until the end if that's okay, and if you'd like to carry on.

- Okay, all right, so I'm gonna talk quickly about this area of working memory and planning so that then we can get into a little bit more of the meat of the intervention and how it works.
In addition to those organization problems, we have well-established planning problems for people with autism.
They're not as good at doing multiple-step tasks.
And I'm gonna argue here that this has to do also with their ability to hold language in mind and use it to guide their behavior, which is related to working memory.
This piece I think is a really important one in autism, and this is one that plays out regardless of how much expressive language you have.
And this is pretty confusing when you get to can't, not, won't, right? Because you can have kids who have poor expressive language, and we're not really expecting them to be talking inside their heads too much.
But then you also have kids who have very big vocabularies, and yet they are not really talking within their head so much either.
And if you think about the typical development of language, and this comes from Vygotsky's work in the 1930's all the way up through Luria and applying its executive function, we know there's a developmental trajectory where you learn words, right? And we all have hung around one-year-olds who know some words.
But then the next step is to take those words and use it to guide your own thinking, to regulate your own behavior in the real world.
So we've all seen that little kid who knows what stop means, but might be running towards the street, and you yell, "Stop!", and they just say, "Stop!" But they don't stop, right? So they have that word.
They might use it themselves, but they're not able to use it to regulate their behavior.
The adult has to come in and reach in and provide that hands-on behavioral control.
And what we see in autism is that process is delayed.
There's a much bigger lag.
In typical kids by preschool, they might be kind of whispering to themselves the directions the teacher just gave.
Maybe in kindergarten, but as they move into elementary school, they're really talking themselves through things inside their heads.
Whereas people with autism, even older people, these were older adolescents, are not doing that.
And when we take away the ability of typical individuals to talk their way through the task by making them talk about something else out loud, they do just as poorly as people with autism.
So under normal conditions, people with autism make extra moves on this task.
They do more poorly than the typically developing folks.
When we make everybody talk out loud while doing the task, we see we get equivalent performances here.
More extra moves is worse, so we've made typically developing folks worse.
And the point here is that it's really important to think about this cognitive skill of being able to guide yourself through something by talking inside your head as being something that's very problematic for people with autism.
I'll give you one real-world example.
I was observing in a school, at the Ivymount Model Asperger program, a small class of six kids.
They all had good language but significant autism.
The teacher had done a nice job of laying out for them a writing task they had to do.
She put it up on the Promethean board.
There were step-by-step instructions.
Five of the six kids got started on the task.
The sixth kid sat back in his desk, kind of crossed his arms, looked like this, wasn't gonna do the task, was looking like a won't, I'm not doing this.
The teacher comes up to him, says, "Sam, I need you to get going.
"You've got 15 minutes." "Nope, not doing it." So he's saying this is a won't, I'm refusing.
She says, "No, really, "we're gonna have recess in 15 minutes, "let's get this done." "Nope, not doing it." So at that point, she's in a power struggle.
She does a very smart thing, which is she turns away.
She came back a few minutes later with a white board, and she wrote on the white board exactly what she had said to him, "Sam, I need you to get started." She handed him the white board and the pen and he wrote "My pencil is broken." And that is a concrete example of a person who can't process in their mind both the social and the online working memory demand of what the teacher's saying to him, formulate the response appropriately, and do all that in this oral world.
He needs the concrete, the written down, he needs to stop the talking and do it more visually.
And that's where we come to talk less, write more.
Go get yourself white boards.
Use technology as much as you can, but recognize that simply by taking it away from that oral interaction you're gonna be reducing the stress and making a key accommodation for people who don't have internal language that functions the same way.
So talk less, write more.
Two last universal accommodations.
One is keep it positive.
And I think you all know we have a praise to correction ratio of four or five to one.
This is very hard to do.
You have to do praise that is specific and true.
I only recently tried to do this with my own son who is learning the violin (laughs), and I tell you it made a huge difference, but you have to work hard to make sure that you are making praises that are meaningful to the kid and doing a lot more telling the kid specifically what they're doing right then correcting.
I'm gonna move on from this fundamental point, because I think a lot of you probably know it.
There are examples in this blue book.
This is one of them of sort how you interact with kids in a way that provides more positive versus more negative cues.
And I'm gonna make one last point on the accommodations side which is about overload.
And this comes from Brenda Smith Myles' book Asperger Syndrome and Difficult Moments.
And it just makes this fundamental point.
She's here talking about kids who get really behaviorally dysregulated and rageful.
But other kids get overloaded by being very anxious and repetitive, and some kids get very overloaded by just shutting down and being non-responsive.
Whatever the behavior is, when people are in overload the fundamental message is they are not teachable.
People are teachable when they're out here in this much calmer state.
And in between that calm state and their totally out of control state, there is what people talk about as rumbling or on the other side, recovery.
And the key message here is when kids get into this very dysregulated state, the adults around them also get somewhat dysregulated, number one.
And number two, they are not available for learning.
So all of these accommodations are about keeping people here at this teachable moment stage.
When we see signs of beginning difficulty, we want to set those accommodations up as accurately as we can.
Downtime being a really important one to give to a kid who's starting to look like they're having problems.
Once we see that they've moved into overload, that's when we have to stop.
And we see some of the biggest behavior problems emerge when adults, well-meaning adults, try to help kids who are completely overwhelmed.
And there is no talking then.
There is no learning then.
There's just waiting until it's over.
And for people who are inflexible, that wait, that recovery time, can be very long.
It can be the afternoon, it can be the day, until they're back and available for teaching.
So the whole purpose of these accommodations is to keep kids in their sweet spot when we can have them learn new things, which is the second part of this talk.
'Cause now I want to move into teaching flexibility, organization and planning skills.
I just want to remind you that autism is such an exciting place to work, because we can change the trajectories of development.
And Debbie Fein has showed this looking back at kids who she determined have actually gotten so many gains that they've moved off the autism spectrum.
She calls them optimal outcome kids.
They are these gray line here, versus kids who have equivalent IQ's.
She's calling these high-functioning kids, but who still have autism.
And these determinations of whether they continue to have autism or are optimal outcome, she's making when they're adolescents.
And what she finds is when she wants to understand how she could predict who's gonna end up still with autism verus having an optimal outcome, the amount of ABA that they got and the age at which they got it, these are years, is key.
So kids who get more ABA in their toddler years are more likely to end up optimal outcome.
That obviously doesn't mean that you can cure every kid.
You can't.
This is a subset, maybe 10%.
It's a small number, but the point is this is an unusual disability.
This is not like intellectual disability where you can really move the needle.
You can really make a change through intervention.
So this Unstuck and On Target intervention is really like okay, we know ABA works, what's the next step? And again, we were thinking about those kids who are in elementary school and are pretty verbal but still have a lot, long way to go in order to learn those executive skills that they need to be successful in the world.
And now we have this challenge.
How are we gonna bridge that dissociation between knowing and doing? And our strategy is gonna be about embedding teaching in the real world and taking a coaching model.
And this is the four-part strategy that we lay out in Unstuck and On Target.
And a lot of this you'll see comes from many other folks.
We did not make this all up.
We're building on the shoulders of many, but many of you are very actively already using a lot of visual supports.
So you're teaching to the strengths.
You're breaking things down into checklists.
You're using white boards or other visual cues to help kids stay on target.
Another key component of the way we're teaching executive functions is something that all good teachers do, which is we all learn better when things are fun, right? So we're gonna use humor and rewards and make it fun and collaborative.
Specific to executive functioning, we're gonna teach and use key scripts and words, because we're concerned about that inflexible brain needing consistency across all the settings.
So Mom, Dad, therapist, teacher, have to use the same words.
Also we know that kids are getting overloaded by language easily, even those who have a big vocabulary, and so we want a few key vocabulary words that the kid can practice and use in multiple settings and learn how they help them.
And then we don't have to talk very much.
We can just say a couple things.
Do you need a Plan B? Are you stuck? And then because executive function is about the doing part, we're gonna teach by doing.
And that's that coaching model.
So we're gonna take a scaffold, fade support, look for a child to generalize a skill.
But we are not going to give knowledge about you need to do this, A, B, and C and walk away.
We're gonna have some fun activities.
We're gonna learn about how A, B, and C are helpful.
We're gonna practice them.
The next time there's an opportunity, a teacher or a parent will cue could you use A, B, or C, right? And provide as much support as we do when we teach a kid a sport, when we teach a musical instrument, when we teach a kid to ride a bike.
We're teaching a new habit, a new behavior, and we're doing it in that context where we expect to have to do a lot of repetition of the skill before it's mastered.
Nobody thinks it's a bad coach.
For my kids' soccer teams anyway, when they show up year after year and practice the same drill in practice, and yet they mess it up in the game.
That's the process of learning a process kind of skill, like playing soccer, likewise a musical instrument.
You know, you don't play in tune on a violin in the first year or the second year.
You keep doing those scales.
So it's somewhat of a shift in mindset that's a very heavily focused on practice.
In terms of the content for Unstuck and On Target, we're really focusing on six main areas.
We start with some foundational skills, and I'll show you the feelings target in a minute.
And then we do a cognitive behavioral approach to both flexibility and then for goals.
And in each case we start with what is flexibility or goals and why is it valuable to be flexible or to have goals, and then how am I gonna do that? And I'm gonna give you some examples for the curriculum now.
In terms of the foundation skills, in our latest trial, and this is not in the green book, but this feelings target will come out in the second edition of Unstuck which will be out next year sometime.
But you're welcome to copy it here if you like it, because we found that moving from a feelings thermometer to a feelings target was weirdly magical, and we're not quite sure why.
But these completely took off in the 21 public schools and charter schools where we ran our intervention most recently.
And it's just what you would think it is.
It's a target that helps a kid distinguish between when they are at a one or feeling just right, versus when they are at a five, and they could either be so excited or so mad or so sad, but they're not able to function well.
And for some kids they like the colors.
A lot of kids like the numbers.
"I'm at a one, I'm feeling great." "I'm at a four, could you help me get to a three?" We found kids coaching each other.
"Oh, I can help you get down to a two." And using this language universally, and so little mini index cards with feeling targets go to parents, they go to classroom teachers, and everybody now has a language for helping that autistic kid become aware of whether or not they're at a stage where they need to think about coming back down to that teachable moment, or whether they're actually already doing fine.
Linked with that we do a feelings chain that helps kids recognize that there are events.
They cause feelings.
This brings you back to the feelings target.
So the power is out and the feeling is I'm furious, I'm a four.
And then I'm gonna take an action.
I could yell and stomp my feet.
That's gonna make other people feel frustrated, and I'm gonna then lose my dessert.
So they'll be another event, and then I'll feel even worse.
And then we do the corrective feelings chain, whereby you use a coping strategy and we have the kids do experiments and practice some coping strategies and decide which one they like the best.
And then (coughs) if that works well, then they will find that they feel much better, and although they can't watch TV, they still get to have dessert and have a nice time.
So these foundational skills are fundamental.
You guys probably have lots of ways of teaching them already, and these are just a few new additional ones.
But I will tell you we were really impressed with how much people liked this feelings target notion.
Then we move into what is flexibility and why be flexible.
And we're very concrete here.
What would be the advantages of physical flexibility? The kids do an experiment.
A rubber band bends.
A dry spaghetti stick doesn't.
One breaks more easily than the other.
Oh, so there are advantages to being flexible.
If I'm tired and I have a flexible body, I can sit down in a chair and that feels better than having to stand rigid.
And the kids do relay races when they're flexible versus when they're rigid and see that they can move much more quickly.
Or you can even write your name with a rigid arm or a flexible one.
Just to introduce this idea that flexibility actually helps you to get more of what you want.
The second key concept for folks is that what I want is not always possible, so I need to know what to do when what I want is impossible.
And there's pie charts you can see in the Unstuck and On Target curriculum that show kind of how you can get part of what you want, and that's better than getting nothing at all.
And being flexible is what helps you to do that.
Once we've sort of ingrained what flexibility is and why you would want to be flexible, we go to how to be flexible.
And this is where we go back to that key vocabulary.
We focus heavily on a few scripts.
We want to talk less, just as Gary Larson's reminding us here with our animals, oops, the same is true with kids.
There's a lot of blah, blah, blah that they hear when we're talking, so we want to keep the words very brief and we want to keep them positive and something that they practice in other environments.
And the way we do that, let's see here, is with these few key flexibility words, and we have a magnet that has these words.
We've heard people that post them on their refrigerator or anywhere else.
But the kids get to practice using these words and again, playing games with them and having other kind of fun ways of learning that there's this word flexible.
And when I'm challenged with something I can think about the fact that when I'm flexible things might go better for me.
We have parents and teachers model using these words for themselves.
Again, we're trying to be collaborative and positive, and we're showing kids, "Hey, this works for me." This is akin to Brenda Smith Myles' notion of living aloud, right? I'm gonna talk out loud about how I regulate my behavior.
Well, when I'm stuck in traffic I think I need to be flexible, and I might even ask my kid could you help me be flexible right now, 'cause I'm just getting really stuck, right? But maybe we could play a game, and then that would be our Plan B, and I would feel better about that.
We introduce this notion of Plan A, Plan B, which again, is somewhat a revelation to a lot of kids who are inflexible.
When things don't go as I expect, I kind of tend to think as an inflexible brain there's something really wrong with me, or there's something really wrong with you, why did you do that to me, versus everybody's planned days don't work out well.
It's natural to have a Plan B, right? We need to have a Plan B or C or D or E.
And that's very liberating for a lot of inflexible people to recognize.
Oh, that's kind of to be expected.
Compromise is a key word that we have to focus on the adults really understanding, because compromise is actually where both people get some of what they want, not that the adult gets what we want.
Here's an example of the application of the word compromise and plan to a situation at school where a teacher has a goal, which is to get Brady onto the bus.
Brady has a goal, which is to keep playing kickball.
So they have a compromise, which is he's gonna get to play for a certain amount of time before the bus comes.
If he bus comes early, he'll get to play the next morning.
So if he finishes his checkout by three, the plan is number one, he will get his 20 minutes.
Number two, his Plan B, is if his bus gets called early, then he'll take the rest of his time in the morning.
The next day.
So that's just a very concrete example.
Here's another Plan A, Plan B example that a little kid wrote out.
This was one of the sort of activities that they did.
They have a goal.
They're playing a board game.
They're playing Sorry, and they have a goal, which is they want to play with the blue piece.
And their Plan A is he asks for it, and then he says, "It did not work." So he says, "Can I have it?" And she says, "No," so it did not work.
So they need a Plan B.
He asked if he could have it next round.
Parentheses it worked.
So they're just playing with, again, this concept of well, I can try something one way, and if that doesn't work I can try it another way.
And if I move to my Plan B, I'll at least get some of what I want.
I'll get the piece at some point, versus if I got stuck on my Plan A I would never get it.
Let's skip over to this part.
A big deal/little deal is a really important script or vocabulary concept for the inflexible brain because you introduce the idea that not that you're gonna tell a kid that something that they feel like is a big deal is a little deal.
You would never tell them that.
But you would introduce this idea that we can change big deals into little deals.
And I can help you with that.
I can offer ideas about how we could make this big deal a little deal.
And again, for the kid it gives them some information that not everything has to be a big deal all the time.
Even when I feel upset, I might have some more choices, Plan B's or C's that would come into place.
We also introduce choice/no choice for the kid that's just gonna bang their head against the wall about something that you cannot fix.
So this is not something that we use often.
It's like the praise to correction ratio.
You're gonna give many, many more choices than no choices, but there are no choices, there's fire drills.
There's going to school in the morning.
There's going to the doctors.
And kids love to hear the adults' no choices.
The teacher can say, "I'm not gonna be here tomorrow.
"I have to go to the dentist.
"I don't like the dentist, but it's a no choice." Those kinds of things.
And then we have another script for handling the unexpected.
The blue book just gives a lot of very concrete examples for how to just as an adult, whether you're a parent or a therapist or a teacher, use some of this language in your own conversations so that you're modeling why it's helpful to you, getting the kid to realize you use it so when you suggest it to them it may be helpful to them as well.
We also work on this concept of disappointment, which is one of the most fundamental flexibilities challenges for kids with autism and kids everywhere, right? So disappointment is when something you expect to happen doesn't happen, and it could be everything from a kid who's asked to draw their family and is thinking they're drawing something like this but ends up getting something like this, to the kids who's going to the amusement park that they've been waiting to go for for years, and they're imagining all the fun rides.
But they get there and there are the lines.
So this issue of disappointment is a really fundamental one when you're working with flexibility.
I'm just gonna touch really quickly on the goal and the plan component of the intervention.
We introduce this idea of goal, why, plan, do, check, that for everything you do you have a goal, and the goal could be to have fun at recess, right, 'cause it's your free time and you want to have fun.
And you can have a plan for that.
Well, my Plan A is I'm gonna ask Johnny if he wants to play soccer, but I might need a Plan B, 'cause Johnny might say, "No," and then I'll ask Melissa.
And I might even need a Plan C, which would be I'll go get on the swings.
And then I'm gonna try that plan out, and afterwards I'm gonna think about it.
Did I meet my goal? Did that work? Did it take the amount of time I thought it was gonna take? These goal, why, plan, do, checks can get much more complex as kids get older.
And there's a bunch of examples of them in the back of the blue book that just give you different ways you can play this out, whether your goal is to have a fun play date, or your goal is get through the morning routine on time so you can have free time before school, or your goal is to clean up your room, whatever it may be.
And again, we give lots of concrete examples just of how to use that language of making really salient for the kid that you have goals, that we do things because there's a big picture.
There's something we're headed for.
So when I'm playing with another kid, I might really want that blue piece in the Sorry game, but my goal is I want to have this kid be my friend.
I want him to come over to my house another time, right? And so for that big goal I might need a Plan B around the blue piece.
So that's an example of the language.
Just really quickly we have completed one NIH trial, and we've just completed a second trial of Unstuck actually with kids who have ADHD as well as autism as long as they have inflexibility problems.
And the results are positive.
This is from the first trial where we contrasted Unstuck to Jed Baker's Social Skills curriculum.
We had kids who were very well-matched going in.
They all had autism.
They were the same age and the same severity of autism, and they were all average IQ's (mumbles).
And what we saw was that Unstuck, when we looked at pre-intervention to post-intervention performance, Unstuck actually made some significant change in comparison with this other intervention of equal dose and intensity.
We did the same training for the school interventionists, the same training for the parents, the kids got the same number of sessions.
Unstuck made a significantly different greater impact on in this case visual problem solving on the block design test, on parents' and teachers' reports of flexibility on the BRIEF, and here we actually had some follow-up data.
A year later, the Unstuck kids had maintained greater flexibility as described by parents and teachers, as well as for planning and organization.
And these are blinded classroom observations, so this was watching the kids from the back of the room.
The research assistants who watched them didn't know whether they were getting the Social Skills or the Unstuck intervention.
They watched them at the beginning of the year and then at the end after they had the intervention.
And you can see these really nice gains from Unstuck in term of the percent of kids who improved in following the rules and making transitions in not getting stuck and not getting negative.
And this was impressive to us 'cause it was blinded data.
It wasn't influenced by the fact that we like Unstuck.
And it was in the real world.
It was them doing better in their mainstream settings.
So I am gonna stop there.
I see I've left two minutes for questions, but I'm happy to stay a little bit longer if Shelly consents for that, yeah.

- [Shelly] Great, thank you very much.
If anybody has any questions for Dr. Kenworthy and wants to type them in the Q&A box then I'll take a look at those.
One of the questions that was left from the first part, Dr. Kenworthy, I think you touched on it a little bit when you touched on your research, but some folks have commented that these seem like really good strategies to use with learners with a variety of challenges, and they wondered if you had used, or if there was any research on working with learners without a diagnosis of autism, but with ADHD or anxiety or trauma using these strategies.

- Yes, so, and as a neuropsychologist that really excites me, because I think what we're developing is not a diagnosis specific intervention, but really a cognitive phenotype specific intervention.
So if you have a child who has problems with flexibility, who has problems with being organized, with being on target, making a plan and following through, then I would argue that these interventions could be very helpful.
Now the only data we have so far is the fresh off the computer and so we haven't even fully analyzed it or published it yet.
But we do have data that's indicating that the Unstuck does help people with ADHD.
We would love to study it in anxiety and other disorders but haven't done that yet.
But go try it and see what you think.

- [Shelly] Great, that's excellent.
So I'm hearing that there's a building empirical base to support the use of these strategies and it's ongoing.
I have another viewer who's wondering if they purchased the resources, are they fairly self-explanatory, or is there a training component that would be recommended to go along with them?

- The Unstuck authors will come and do trainings for groups of people, but you may well not need that.
It's pretty self-explanatory, and because we wrote it with teachers we found that it can be picked up.
They're really written as lesson plans, and so I think it's worth getting the books, looking at it, and then deciding if you think you need more training.

- [Shelly] Perfect, thank you.
Everybody's really interested in your white board strategy and thinks it's really exciting.
They're wondering about children who aren't good readers or good writers.
Would visuals be just as effective, and what might that look like?

- Yes, absolutely.
And, you know, most of the people I betcha have tried it with different visuals.
So you can think about any visual tool.
Even pets, right? So we're more natural using visual tools with people who have less language, but my message is just take those same tools, even if you're hearing more language, if it's not being used functionally.
And any kind of visual tool can work for that.
And the wonderful thing is all the burgeoning technology we have.

- [Shelly] Great, where can folks find out more information about the BRIEF if they're interested in that and how that's used?

- The BRIEF is published by PAR, Inc.
And PAR offers training in the BRIEF.
All the BRIEF is is an informant report.
So it's parent, teacher, and child, their self-report as well on these executive function skills.
So it's not a laboratory test.
It's not a test where we watch the kid do something.
It's where we hear from people about their skills.
So it's easily purchased and used.
The BRIEF authors, myself included, do do trainings in the BRIEF if people want that.
But you go through PAR, Inc.

- [Shelly] Thank you so much.
And one more question if you don't mind.
As you and I talked about when we initially talked about this presentation, folks are very interested as well in the resource for older children, for teenagers.
So can you tell us a little bit about the status of the development of that tool?

- Yeah, we're super excited about that.
This work, I have to tell you, is hard (laughs).
It takes time, and it's so frustrating, 'cause people are like, "But we want that now!" So On Target for Life is being developed for middle school kids.
John Strang is taking the lead in that.
He's developed a really nice curriculum that basically just takes the principles of Unstuck and applied them upward.
So there's more around goal setting and planning.
But definitely those flexibility scripts and routines and some wonderful innovations for the older kids.
They start to monitor each other for getting stuck on a detail, for instance.
They do really well with that.
He's running a small scale trial.
This is the first time we'll be testing how On Target or Life works in Fairfax County Public Schools this year.
And so, nothing's published yet.
We don't like to publish things when we don't have any idea whether they're effective or not.
Cara Pugliese has developed Flexible Futures.
That's for high school kids, and it's really for kids who are launching to some kind of college.
It could be vocational school or two-year school, but it's kids who are gonna do somewhat more educational work as well.
And again, she's in the first year of a trial, and so nothing's published, and it won't be available for several years.
And I'm sorry, but we're working as fast as we can.

- [Shelly] That's great.
We'll look forward to that when it's available for sure.

- [Lauren] Good.

- [Shelly] So at this point, I want to thank Dr. Kenworthy very much for joining us this afternoon.
I know from the comments coming in that people are really excited about Unstuck and On Target, about the strategies that you've shared with us, so we'll very much look forward to having further discussions about that going forward as well.
Just for the folks on the webinar, as I had mentioned in the email to many of you we are recording Dr. Kenworthy's presentation today, and she's graciously allowed us to put it on our website for future reference.
So within a few weeks once we have it edited and add some accessibility features like closed captions and a written transcript, we'll have that on there for everybody who's interested in viewing it again.
And the PowerPoint presentation, the slides that Dr. Kenworthy shared today will be available there as well.
So if you're looking for any of those you'll be able to access those.
And within a few minutes this afternoon I will send out that feedback survey, so if you could let us know your feedback on today's webinar and also if you're interested in requesting a certificate of participation, that'll be available this afternoon.
So thanks so much, Dr. Kenworthy.
We really appreciate it, and hopefully we'll have a chance to talk with you again in the future.

- [Lauren] Thank you.

- [Shelly] All right, have good afternoon, everybody.
Take care.

- [Lauren] Bye-bye.