Ask the Expert: Executive Function and Children with Down Syndrome

Note: This article originally appeared in the July/August 2011 issue of TDSN News.
In the last Newsletter, we introduced play-behaviors and their relationship to cognitive-language development in children with Down syndrome. In this article, we want to expand this concept by introducing a related cognitive function called Executive Function. Although this may appear to be an ominous term, it really is not.
Executive Function refers to how the child inhibits, plans/organizes, attends, shifts behaviors (i.e., transitioning), and uses his/her working memory. Traditionally, Executive Function has been associated with cognitive functions in the frontal lobe of the brain, or the anterior portion of the brain. It has been found to assist in reading comprehension and sound awareness, making it an important tool for later academics. Executive Function has also been found to be a problem in many children with special needs, including children with Down syndrome. Because of this, we spend a good deal of time integrating these functions into our speech/language therapy. As early intervention helps in all aspects of later cognitive-language-academic skills, so does early-intervention work on Executive Function help with later academic, language, literacy, and social skills in children with Down syndrome. We will define each of these functions and share ideas on how to integrate them into daily lessons.
Inhibition: (Thinking before you act.) Children can be either impulsive or reflective. Impulsive behaviors, or reacting quickly, are common among children with Down syndrome. They tend to just point, speak up, grab objects, throw things, make obviously poor choices, or select items that come immediately into their view without stopping and thinking whether that is the correct choice. Instead, we would like them to be more reflective: think about their choices, view all of the alternatives, make appropriate selections the first time, and hesitate before reacting. We follow a two step program to assist in this area. It is called “Look First,” and “Quiet Hands.” Quiet Hands encourages the child to rest the hands on the table before pointing, grabbing, or selecting. Look First encourages the child to use their eyes to look at all of the choices before making a decision.
Planning: (Organizing or making road maps to a goal.) Here, the child needs to make decisions or appropriate choices. S/ he has to figure out what will happen if they do something before attempting to make a choice, such as, making a decision as to which of two containers would hold all of a set of blocks, a small size container or a large container. Another activity would be explaining what would happen if they placed heavy objects onto a thin piece of tissue. Asking the child how many objects they think they would need? A more common activity would be learning the strategies for putting puzzles together: First you look at the picture, then you find the corners (i.e., must have two smooth edges), then straight edges (i.e., smooth sides), and then finally placing the inner pieces. Being able to match pictures also falls under a planning activity; that is, matching a picture requires looking at both sets of pictures, deciding where the one should go, and then placing the correct two together.
Attention: (Time on task, focusing on appropriate items, selecting relevant from irrelevant information). There is short attention and there is lack of focused attention, both causing difficulties for the child who is attempting to learn. The fleeting short attention refers to the child getting only a brief acquisition of the concept being taught. We know that most children with Down syndrome need lots of repetitive practice to acquire most skills and the fleeting attention impedes this learning. We use lots of strategies to help children improve their attention.
First, we time how long they stay on task, in general. Is it 1 minute? If so, we try to increase it to 2 minutes by encouraging them to stick to the task at least one more time. We also teach the same strategy in several different ways, hoping to get to the same learning outcome. For example, if we are attempting to teach counting, we will begin by using a pointing stick to count simple objects; we may switch to counting Gold Fish where they can eat them after they are counted; or we may switch to using the iPad where they are able to touch objects for counting. The lack of focused attention can be more of a problem because the child can be either looking at something that is not important to the concept (i.e., a bug in a picture that has nothing to do with the theme of clouds and rain) or they may be looking at too much and not the important concept (i.e., labeling all of the items in the picture rather than the important item—the trunk on the elephant.) Helping to improve focused attention is hard and requires lots of practice. We use highlighters where the child locates items and marks them. We select items, making mistakes, so the child can correct us. We give verbal cues and alternative items with similar cues to help them.
Transition: (Moving from one activity to another, alternative solutions to same problem.) Transitioning from activity-to-activity can be a problem for some children. We recommend, for these children, a picture chart with the activities laid out on the left panel and a completion panel on the right. The child sees all of the activities they have to complete. They can decide which ones they want to do first, second, etc. When the activity is done they move the picture over to the completion side. We also teach “First this, then that.” We use sign language to show the child first and last. The child is given two choices and when they select the high interest item, we say, “Wait! First this one (signing first), then we do that one (signing last).” Sometimes the child wants to do an activity over- and-over or will refuse to stop when it is time to do something else. Applying the concepts from “1-2-3 Magic” ( can work. Here the teacher/parent says, “It is time to quit and do this!” If the child does not stop, you should say “That is 1!” Ask again, and if the child still does not stop, you should say “That is 2!” After the third time, if they still do not stop, you should say, “That is 3!” and remove the child. Do not negotiate. The child should quickly learn what “3” means.
Working Memory: (Holding important information in mind while manipulating it.) A simple explanation of working memory is when I give five numbers to you (i.e., 2-4-3-8-6) and ask you to repeat them backward, you have to hold the numbers in your mind and adjust them before saying them back. This is working memory. Several literacy activities require working memory skills: for instance, telling us the first sound you hear in a word, or the last sound you hear in a word. Another example is if I ask you to take the first sound you hear in “lock” and change it to “d” what do you have? Also, completing sentence choices is another working memory activity; for instance, “Do we say the cow says “moo” or the cow says “meow.” A bigger working memory task is reading a paragraph, holding the content in our mind, and then answering simple Wh-questions, like “Who was in the story?”, “What happened?”, “How did the story end?” and “What do you think would happen if….?”
These are all important skills that require a strong working memory but can be improved through practice.