Pediatric Therapeutic Services

Executive –Function

They are the buzzwords right now: Executive Function.  But what is it?


Formally stated:  Executive function is a broad term that encompasses the tasks involved in self-regulation of thoughts, emotions and behaviors. Strong executive function is critical to successfully navigating the complex adult world. Although executive function peaks in the 20s and 30s, researchers at Harvard found that the sharpest rate of growth occurs from birth through age 10, with a dramatic spike between the ages of 3 and 5.  (

Executive Functioning skills include: response inhibition; working memory, emotional control, sustained attention, task initiation, planning/prioritization, organization, time management, goal directed persistence, flexibility and metacognition.

The area of the brain that provides executive functioning skills include the pre-frontal and frontal cortex, which is the last part of the brain to become myelinated (nerves develop their protective sheath), which is why it’s one of the latest skills to be developed fully later in young adulthood.  Why do you think we cringe when our teens “don’t get it” or don’t seem to grasp skills we have demonstrated over and over again?  They can’t!!!!!!!!  Their executive functioning hasn’t quite kicked in.  This is perhaps a big reason for the recent spike in reports of teenage drug addiction.

What we as a Child Study Team have noticed in the school setting is that there is a common appearance of kids who are “distracted, impulsive, not looking where he/she should be, unable to handle/organize supplies, unaware of routine, etc.”  What we have decided is to look at helping this age group by providing strategies to help with development of executive functioning skills since many are developing at this time.  We are finding that many of these needs are popping up in first grade, about 6 years of age.

As the OT on the Child Study Team, I am providing support and strategies to address these issues/concerns.  Suggested strategies are presented to staff, trialed, and monitored/modeled by OT staff as well.  And revisited after a few weeks. Some suggestions have included the following:

  • Time Timer (with red disappearing area)
  • Tap a number on desk before raising hand
  • Practice freeze play to encourage stopping actions
  • Play “stop” game and then ask child random questions: “what color is your shirt, who is standing next to you? What were you doing?”
  • Calming breathing techniques (OT has some)
  • Yoga and mindfulness scripts (OT has some)
  • Isometric muscle exercises (tense and sustain muscle contractions
  • Heavy work (carry heavy items; put chairs on desks or off desks, push/carry lunch baskets)
  • Wall pushups and chair pushups (OT can instruct)
  • Adaptations to chair to provide sensory input (sit disk, chair band)
  • Videos of desired behaviors
  • Therapy putty at daily five stations
  • Stretching exercises and weight bearing before writing tasks
  • Activities that encourage visual attention prior to intense work (seek and find sheets, removing things from playdoh, stringing beads, movement or dance games wherein child is following movements with body)
  • Calming smells (lavender, vanilla)
  • White noise
  • Sit near competent peer
  • Goal creation
  • Ask to repeat back directions
  • Ask student “what materials do you need?”
  • STOP – THINK – COUNT: (Before leaving, stop, think “are you ready to go?,” count your things before you leave)
  • First then; countdowns
  • Use a time timer
  • Have student sit in designated space such as a circle      taped to floor, hoola hoop
  • Deskadoo or plastic container down the middle of desk
  • Sticker system for sides of desk (blue/red)
  • Colored tape to outline desk to designate area
  • Tape on floor where chair must remain
  • Ring special bell; flick the lights, sing song, clap hands in rhythmic pattern
  • Videos of desired behaviors
  • Checklist for morning work and pack up at the end of day
  • Goal  creation
  • Ask to repeat back directions
  • Ask student “what tools do you need?”
Nervous;  confused;
  • Transition object to carry (heavy helps) with a drop box area at next location so it’s not a distraction
  • Ring special bell; flick the lights, sing song, clap hands in rhythmic pattern
  • Brain break (see OT for strategies)
  • Sticker strategies (see OT for these)
  • Matching Size of problem to reaction (OT has more info)
  • Checklist for morning work and pack up at the end of day
  • Yoga
  • Breathing techniques (figure 8 etc)
  • Mindfulness scripts
  • Beginning or end of line for transitions
  • Goal creation
  • Ask to repeat back directions
  • Visuals that say such things as “look at speaker” “pencil down when spoken to” “look at board” “how to sit in chair”
  • Chunking
  • Decrease things on wall
  • Provide corral or folder during writing work or other work
  • Yoga exercises
  • Breathing exercises
  • Mindfulness scripts
  • Mantra
  • Transition objects to travel with
  • Beginning or end of line for transitions
  • Sit near competent peer
  • Goal creation
  • Time timer
Low Sensory; slow engine
  • Alerting such as movement breaks or movement videos
  • Dancing
  • Brain breaks
  • Smells (citrus, mint)
  • Exercises (jumping jacks, windmills, etc.)
  • Sit disk/therapy ball to sit on
  • Time timer
  • No distractors on desktop
  • Fidget
  • Velcro inside desk
  • Goal creation
  • Ask to repeat back directions

For instance for a disorganized or unfocused student, a visual time timer (image pictured above) slowly shows how much time is left with a disappearing red wedge……this is used to help a child visually see how much time they have to complete a task and encourage a child to get his/her work done in that time period.  This has helped some students get morning done work.  It provides ownership, responsibility and a visual representation of time management.  The directions, “do your morning work and get done in 20 minutes” is abstract and with environmental distractions, is difficult. The time timer provides a visual and a point of focus for the student and give that ownership to the child, instilling an internal ability to manage time.

There are many strategies/techniques in the above chart, and it is still growing. Remember, each child is different, and see what your OT feels is a right fit/suggestion for your student.

This post is just barely scraping executive functioning skills.  It could be pages.  I will revisit.  Until then, be happy your frontal lobe has fully developed (if you are over 20).


Mary L. Adolf, M.S., OTR/L

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