“FRONTAL” or HIGHER LEVEL EXECUTIVE DISORDER:
RECOMMENDATIONS

I.  ABILITY RECOMMENDATIONS

1. Compensatory strategies for children with “frontal lobe” profiles tend to include: (a) maximization of external organization (i.e., bedroom, desk, work space, etc.), (b) maximization of temporal organization including establishment of a well-defined schedule of activities (i.e., daily planner, schedule, calendar, etc.), expected time frames and a means of determining whether the schedule was accurate and (c) provision of clear, consistent and specific feedback regarding outcomes.
   
   
2. Compensatory strategies for children with “frontal lobe” profiles tend to focus on development of organization, planning and use of feedback.  Chess and other games of skill tend to provide an excellent foundation for these fundamental skills while also fostering reciprocal relationships.

II. SKILL RECOMMENDATIONS

1. Interventions among children with “frontal lobe” profiles tend to focus on strategies of interventions designed to support higher level executive functions and include: (a) maximization of external organization (i.e., keep desk clear of extraneous stimuli, arrange materials before beginning, etc.), (b) maximization of structure by using lined or grid paper to arrange columns, (c) maximization of temporal organization including establishment of a well-defined homework schedule, expected time frames for completion of specific assignments and a means of recording whether the schedule was accurate, (d) provision of clear and specific feedback regarding outcomes including marking all incorrect items with a different colored pencil, providing a second “clean” sheet (no writing on it) to redo failed items and requiring that the child check their work product against the answer sheet and (e) use of assignment books at school . 
   
   
2. Children presenting with a “frontal lobe” profile tend to be “bottom-up” readers.  “Bottom-up” readers generally are capable of reading single words (“bottom”) and short sentences.  However, when required to utilize these single units to develop an abstract theme (“up”), performance shows deterioration.  During first through about third grades, most children function as “bottom-up” readers.  However, in about third to fourth grades, children generally show a transition to being a “top-down” reader.  “Top-down” readers generally begin with a general or abstract understanding of the materials.  Using this general theme, children subsequently are in a position to read for content and to utilize context to “guess” unfamiliar words, fill in gaps in understanding and to utilize other knowledge to facilitate comprehension.  Children with frontal profiles tend to encounter difficulties in making this transition with persistence of a “bottom-up” reading strategy.  As a result, children with this profile consistently encounter difficulties in reading comprehension and writing compositions despite intact basic (bottom level) reading skills and show poor generalization of reading/spelling skills to other areas (i.e., adequate spelling skills during specific tests, but with subsequent limited use of spelling words in compositions).  Interventions of some benefit may include: (a) provision of instruction on outlining skills (before writing), (b) provision of instruction on how to take effective notes in class, (c) provision of notes from the teacher as a model of appropriate organization of notes, (d) instruction on learning to read for content with an emphasis on reading first and last paragraphs in a chapter, looking at pictures and developing hypotheses about what might happen within the chapter before actually reading the chapter and (e) instruction on mnemonic strategies (i.e., memorizing the first letter of each word in a list that has to be memorized, use of “chunking” or organizing similar information together, etc.).
   
   
3. Children with frontal profiles commonly encounter difficulties in generalization (which relies upon understanding of a theme that may apply across situations) that may be magnified in coursework that demands comprehension (i.e., social studies, science, etc.).  Generalization may be enhanced by requiring children to respond to various types of input (i.e., written vs. auditory/oral questions) and via various outputs (i.e., written composition vs. oral responses). 

II. COPING RESOURCE RECOMMENDATIONS

1. Utilization of a cognitive-behavioral therapy approach is recommended to facilitate development of coping skills sufficient to manage existing drive/distress.  Specific cognitive-behavioral therapy components include: (a) increasing self-observer functions by labeling emotions (i.e., “it looks like you are feeling…”) (to assist in articulation of negative emotions), (b) providing cues/assistance in identification of antecedents or triggers for negative emotions (i.e., “when did you begin to feel that way?  where were you?, etc.) (to assist in identification of trigger zones or antecedents), (c) learning to identify that behaviors are choices (i.e.., “what did you choose to do with those negative emotions?”) (to enhance higher level executive contributions to behavior), (d) assistance in identification of outcomes (i.e., “how did that work out for you?”) (to facilitate self-observation and utilization of feedback) and (e) assistance in recognition of the extent to which outcomes influenced triggers (“did those outcomes change the triggers?”) (to avoid vicious cycles in which behaviors have no impact on the triggers).  The reader is referred to the works of Donald Meichenbaum for a comprehensive presentation of CBT strategies.
   
   
2. Children with similar “frontal” presentations tend to benefit from community monitoring (i.e., keep track who is standing beside the child and is acting as the temporary coach).
   
   
3. Children with similar “frontal” presentations tend to fail to use feedback to make better life choices.  However, studies have consistently shown that time-outs are of somewhat inconsistent value since the time-out itself is “nothing” (i.e., children may perceive the time-out as positive, neutral or negative).  In addition, time-outs do not have an inherent instructional value.  In contrast, recent studies have indicated that use of pro-social chores is of significant value as a consequence.  Pro-social chores may include less desirable chores (not routine chores) and are designed to make the home a better place for all the inhabitants.  Since the child’s misbehavior made the world a less nice place for the entire family, pro-social chores tend to “un-do” the problem or make the home a nicer place for the family.
   
   
4. Children with similar “frontal” presentations tend to repetitively experience negative emotions with limited “learning” or adaptation.  In response, it is recommended that every “fight or flight” episode be followed by a post-mortem review.  The post-mortem review should follow cognitive-behavioral therapy strategies.