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Children with ADHD and

Au1sm Spectrum Disorder:
Managing the Challenges of Execu1ve
Func1oning
10 T H I nte r na 1o na l C o ng re s s o n
A DH D, O c to be r 2014

Joyce Cooper-Kahn, Ph.D.

cooperkahn@gmail.com

Today we will talk about:

I. Co-occurrence of AGen/on Decit/Hyperac/vity
Disorder (ADHD) and Au/sm Spectrum Disorder (ASD)
A. Overlap of symptoms
B. Why is the diagnosis important?
II. Brief Discussion of Execu/ve Func/oning
A. Deni/ons
B. PaGerns of development in individuals with ADHD and ASD
III. What can we do to help?
A. General principles of interven/on
B. Building exibility
C. Suppor/ng organiza/on and working memory
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According to a recent study, nearly one in three children

with autism also meets criteria for a diagnosis of ADHD.

Rao, P. and Landa, R. Associa/on between severity of behavioral phenotype and

comorbid aGen/on decit hyperac/vity disorder symptoms in children with au/sm
spectrum disorders. Au/sm, 18 (3), 2014: 272-280.

Among children with ADHD, almost one in five has some

Among children with ADHD, almost one in five have
symptoms of autism. (Kotte et al, 2013)
some symptoms of autism, according to Kotte, et al (2013).

The boundaries between au/sm and ADHD

are not always clear.
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When symptoms co-occur

Execu/ve
ADHD
Au/sm
Dysfunc/on

X 2

What is execu1ve func1oning?

Execu/ve func/ons are the mental processes
that serve a supervisory role in our own
thinking and behavior.

The execu/ve func/ons work together to direct

and coordinate our eorts to achieve a goal.

From Cooper-Kahn and Foster, Boos/ng Execu/ve Skills in The Classroom, 2013.

A Good CEO
Creates a master plan
Coordinates resources
Reacts eec/vely to changes and
challenges
Monitors progress on short-term and long-term
goals
Adjusts course, as necessary, to keep
the company on mission

Execu1ve Skills
Meta-Cogni/ve Skills Emo/onal Regula/on

Planning and

Organiza/on

Working Memory

Ini/a/on
Task Monitoring

Self Monitoring
Inhibi/on
Emo/onal control
Shiiing

Adapted from Gioia, G. A., Isquith, P.K., Retzla, P.D. and Espy, K.A., 2002.

 There are predictable developmental surges in the

execu/ve func/ons; expecta/ons at home and school
are designed to keep pace with typical development.
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Developmental dierences and EF

Execu/ve func/oning dicul/es are linked
to dierences in brain structure and brain
func/on.

EF proles vary among ADHD and ASD
individuals, and any aspect of EF can be
aected.

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EF and Au1sm Spectrum

Disorders
Individuals with ASD seem to consistently show
impairments in response inhibi/on and spa/al
working memory. Importantly, there appears to be
improvement in voluntary response inhibi/on over
/me. (Luna et al, 2007)

Enduring problems: ini/a/ng a cogni/ve plan and
maintaining informa/on on line over /me (Luna et al,
2007)
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ASD + ADHD = EDF X 2

Execu/ve func/oning dicul/es in individuals
with au/s/c traits plus ADHD tend to be more
generalized and more pervasive than in
individuals with ADHD only.

Looking at func/onal behavior, the most common

areas of dicul/es are exibility (emo/onal
regula/on) and organiza/on.

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Mee1ng the
Challenge
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The role of medica1on

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General recommenda1ons for

crea1ng a suppor1ve environment
Clear, explicit and specic expecta/ons
Ac/vely prepares the child so he knows what to
expect and how to manage upcoming situa/ons
Uses guided prac/ce as long as necessary
Avoids power struggles
Uses more praise than correc/on
Builds in rou/nes and allows for harmless rituals
Sensi/ve to sensory issues
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Problem Solving Approach

1. Assess: Assess the execu/ve skills of the child, assess the
level of execu/ve func/oning demand of the task or seong,
and consider the t.
Is there a gap?
What skills does the child need to bridge that gap?
2. Plan
Can you simplify the task and/or reduce compe/ng
demands?
How can you provide extra support un/l the child can
handle the situa/on independently?
How can you help the child build the necessary skills for
the long term?
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Building exibility
Categories of Strategies

1. Interven/ons before the problem gets overwhelming

2. Strategies for self-calming and regaining self-control

rituals and re-boo/ng skills (Example: becoming a
turtle)

3. Gaining skills in self monitoring

(Example: How full is your container?)

4. Preparing students for uncomfortable situa/ons

Adapted from Silverman & Weinfeld, 2007.

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Intervene before the problem gets

overwhelming & teach self-monitoring
TEACHER/PARENT INITIATED

CHILD INITIATED

Learn the students signs that he is Teach the child how to recognize
her own signs and praise aGempts
becoming overwhelmed and
to ini/ate calming strategies.
ini/ate calming strategies.
Tie behaviors to internal feeling
states.
Predict trouble spots.

Coach the child to consider what is

driving a behavior.
Preview the day with the child and
coach him to look for trouble
spots.

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Strategies for self-calming and regaining

self-control
Create calming rituals at school and at home and use
these at transi/on points during the day (soi music, yoga
or other calming movement)

Prompt self-calming rou/nes or ini/ate techniques such as

deep breathing or moving to a low-arousal area

Teach more specic strategies to children who need more

(e.g. nger-breathing, become a turtle, go under a chair)

Allow idiosyncra/c self-soothing strategies, such as access

to a favorite toy or person (example: rubbing Moms belly)
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Preparing students for
uncomfortable situa1ons
Help the child to narrow her focus:
Change the nature of the task (eg. Oer a transi/onal jobs such as
carrying the equipment basket out to the playground)
Highlight specic features of the task (eg. Youre going to stay next to
me while we walk to the bus. We will take our seats and then you
can take out your drawing things and draw during the bus ride.)
Structure the situa/on:
Here is what will happen
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Teach the child about his

temperament
Help the child understand her own
responses.
Label the emo/onal experience.
(This is one of those /mes when you will
probably have your New Situa/on JiGers.)
What will you do when? What can you
do to help yourself?
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Addressing social decits to create

more expected behavior
Social Rules Approach (See Myles, Trautman, and Schelvan
(2004), The Hidden Curriculum)
Focuses on what is expected in specic situa/ons
Teaches by concrete rules

Social thinking approach (See Winner, M.G. resources): for

students with good language and cogni/ve ability who have
weak social intelligence.
Focuses on how the individuals social understanding and behavior
are dierent from neurotypical individuals
Teaches why is it important to behave in expected ways
Teaches skills that develop social awareness and improve ability to
behave in expected ways
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General Principles for Interven1on

to Improve Organiza1on
Create rou/nes and templates to build
habits

Highlight the planning process

Relieve the burden on working memory

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Classroom rou1nes

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 Highlight the planning process

Help kids think about how they will
reach the goal
Teach them that the rst step in any
mul/-step project is always to make a
plan

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Think aloud

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Student Planner

(Cooper-Kahn and Foster, 2013, p. 83.)

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School and home strategies

Teach challenging tasks with familiar material, and

teach challenging content using familiar formats.

Break down tasks into component parts and provide

a
rubric to guide student work.

Monitor progress. What has the child produced?

Expect the child to need hands-on guidance and

prac/ce much longer than other children
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Organizersfor the mind!

(Cooper-Kahn and Foster, 2013, p.103.)

Use visual maps for brainstorming, planning and organizing. These can be done by hand
or with computer soiware (Inspira/on, Kidspira/on, MindJet MindManager).
Expect to prompt the student to use the technology un/l it becomes habitual.
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Relieve the burden on

working memory
What is the message that you want the
child to take away?

Simplify your language

Highlight the most important points

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To compensate for weak

working memory
1. Build automa/city

2. Start the lesson (or home task) with a

warm-up

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More 1ps to reduce the

burden on working memory
1. Teach the use of concrete storage systems that create an
external scratch pad.
2. Accommodate dicul:es with note-taking. (Oer an
outline with space for bullet points; allow apps that allow
note-taking on screen. )
3. Take advantage of technology to automa/cally transfer
informa/on (Google docs, iCloud, etc.)

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One step at a 1me

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References and Resources

Baker, J. (2008). No More Meltdowns: Posi2ve strategies for managing
and preven2ng out-of-control behavior. Arlington, TX: Future Horizons,
Inc.
Cannon, L., Kenworthy, L., Alexander, K., Werner, M.A., & Anthony, L.
(2011) Unstuck and On Target. Bal/more: Brookes Publishing, Inc.
Cooper-Kahn, J. and Dietzel, L. (2008) Late, Lost and Unprepared: A
Parents Guide to Helping Children with Execu2ve Func2oning.
Bethesda, MD: Woodbine House.
Cooper-Kahn, J. and Foster, M. (2013) Boos2ng Execu2ve Skills in the
Classroom: A Prac2cal Guide for Educators. San Francisco, CA: Jossey
Bass.

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References and Resources (con1nued)

Gioia, G.A., Isquith, P.K., Retzla, P.D., and Espy, K.A. Conrmatory Factor
Analysis of the Behavior Ra/ng Inventory of Execu/ve Func/on (BRIEF) in a
Clinical Sample. Clinical Neuropsychology, 2002, 8 (4), 249-257.
Hutchins, P.F. (2012) The Clark Kent Chronicles: A Mothers Tale of Life
with her ADHD and Aspergers Son. Houston, TX: Skipjack Publishing.
KoGe, A., Joshi, G., Fried, R., Uchida, M., Spencer, K., Woodworth, Y.,
Kenworthy, T., Faraone, S. V., and Biederman, J. Au/s/c Traits in Children
With and Without ADHD. Pediatrics, 2013, 132 (3), e612-e622.
Luna, B., Doll, S.K., Hegedus, S.J., Minshew, N.J. and Sweeney, J.A.
Matura/on of Execu/ve Func/on in Au/sm. Biological Psychiatry, 2007,
61, 474-481.
Madrigal, S. and Winner, M.G. (2008) SuperexA Superhero Social
Thinking Curriculum. San Jose, CA: Think Social Publishing.
Myles, B.S., Trautman, M.L. and Schelvan, R.L. (2004) The Hidden
Curriculum: Prac2cal Solu2ons for Understanding Unstated Rules in Social
Situa2ons. Shawnee Mission, KS: Asperger Au/sm Publishing Co.

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References and Resources (con1nued)

Rao, P. and Landa, R. Associa/on between severity of behavioral
phenotype and comorbid aGen/on decit hyperac/vity disorder
symptoms in children with au/sm spectrum disorders. Au/sm, 2014,
18 (3), 272-280.
Shaw, P., Stringaris, A. Nigg, J. and Leibenlui, E. Emo/on
Dysregula/on in AGen/on Decit Hyperac/vity Disorder. American
Journal of Psychiatry, 2014, 171(3), 276-93.
Silverman, S.M. and Weinfeld, R. (2007) School Success for Kids with
Aspergers Syndrome. Waco, TX: Prufrock Press.
Winner, M.G. and Crooke, P. (2009) Socially Curious and Curiously
Social. San Jose, CA: Think Social Publishing.
Woodcock, L. and Page, A. (2010) Managing Family Meltdown: The
Low Arousal Approach and Au2sm. Philadelphia, PA: Jessica Kingsley
Publishers.

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