AG Bell Symposium 2009: Saturday Sessions

Bright and early Saturday morning, we braved the rain to make it to Day Two of the Symposium… and it was well worth it!  Here is what I learned…


GENERAL SESSION: Speech and Language Outcomes in Deaf Children Following Cochlear Implantation (Dr. David B. Pisoni, Chancellors’ Professor of Psychology and Cognitive Science, and Director, Speech Research Laboratory, Indiana University)


Dr. Pisoni discussed his research on factors that may contribute to differences in reading ability among children with cochlear implants.  He posed the question, “What contributes to differences in benefits and outcomes experienced by children who receive cochlear implants?” and discussed efficacy (CIs work and provide benefit) vs. effectiveness (CIs do not produce the same results in all recipients). Dr. Pisoni highly recommended Biological Foundations of Language by eric H. Lenneberg and The Working Brain by A.R. Luria, and reminded us of his own personal philosophy, “The ear is connected to the brain!”


He summarized six key findings on CIs:

  1. There are large differences in speech and language outcomes.

  2. Age of implantation (“sensitive periods”)

  3. Effects of early experience (listening and spoken language vs. TC/ASL)

  4. Cross-modal neural plasticity (i.e. “use it or lose it” auditory cortex neurons will be “stolen” by visual and other parts of the brain if they are not actively used)

  5. Hard to predict speech and language outcomes before implant (we know the factors that contribute to success, though!)

  6. New abilities emerge after implantation (children learn and grow once given access to sound, they can develop new neural connections and new skills)


Dr. Pisoni also showed some preliminary findings from an experiment he is conducting to examine the effects of using a computer game-type program to improve children’s executive skills.



PANEL DISCUSSION (David B. Pisoni, Ph.D., Ann Geers, Ph.D., Lisa Davidson, Ph.D., CCC-A, Gitry Heydebrand, Ph.D., and Joyce Cooper-Kahn, Ph.D.)


In the panel discussion, various audience members asked questions about Dr. Pisoni’s proposed EF training system and discussed how it could relate to children on their caseloads.  The researchers all cautioned that more work is needed to see if EF training programs, which are currently being developed/marketed to help children with ADHD, have any clinical efficacy for children with cochlear implants.  More research needs to be done in this area, and the current methods are just experimental, not yet proven!



WORKSHOP: Relating Measures of Executive Function to Language and Reading Skills in Children with Cochlear Implants (Ann Geers, Ph.D., Psychologist and Adjunct Professor of Communication Disorders, Callier Advanced Hearing Research Center and Southwestern Medical Center, University of Texas at Dallas)


The “Digit Span” is a subtest on the WISC (Wechsler Intelligence Scale for Children, a common “IQ test”).  The examiner gives the child a list of digits, starting with just one and working up until the child cannot do the task anymore, and the child must repeat the numbers back to the examiner.  The child does the task once repeating the numbers forward, and again doing it backward.  The normed score for children of any age compared to their age-peers is 10 +/- 3, which means a child who scores between 7 and 13 is considered “within normal limits” for his age.  When tested, 50% of the children in oral education programs in Geers’ sample tested within normal limits on the Digit Span.  Only 30% of children in total communication/signing programs were within normal limits.  This suggests that the auditory memory skills emphasized in listening and spoken language programs lead to better Digit Span performance, which has been shown to be a strong predictor of reading ability, even better than overall IQ!


Geers also discussed the BRIEF (Behavior Rating Inventory of Executive Function), and EF assessment that is based on parent/teacher/observer reports and ratings of children’s behavior and executive function skills.  The BRIEF consists of to subsets of skills.


The first is the BRI (Behavior Regulation Index), which includes:

  • INHIBITION: ability to stop behavior at the appropriate time (Does the child blurt things out?)

  • SHIFT: ability to move from one aspect of an activity to another when appropriate (Does the child resist a change in plans?  New people or new situations, new foods?)

  • EMOTIONAL CONTROL: ability to modulate emotional responses (Does the child have explosive, unprompted anger?)


The second is the measure of Metacognition, which includes:

  • INITIATION: ability to begin a task, independently generate ideas and responses (Is the child a “couch potato”?  Does the child have trouble starting his homework?)

  • WORKING MEMORY: ability to hold information in mind for purpose of completing a task, functional memory (Does the child need help to stay on task or seem to have no short-term memory?)

  • PLAN/ORGANIZE: ability to anticipate events, set goals, develop appropriate steps (Does the child forget to hand in homework?  Does the child underestimate the time needed to complete a task?)

  • ORGANIZE MATERIALS: ability to maintain an orderly space (Does the child have a messy room or closet?)

  • MONITOR: ability to track the effect your behavior has on others (Does the child have illegible handwriting, forget to check her work?  Does the child fail to see that his behavior bothers others?)



WORKSHOP: Late, Lost, and Unprepared: Helping Children and Teens Build Better Executive Skills (Joyce Cooper-Kahn, Ph.D., Clinical Child Psychologist, Psychological Resource Associates)


How does change happen in children who need remediation for EF deficits?  Brain maturation, incidental learning, learning from direct instruction, and scaffolding (building new skills from underlying support of skills already acquired).  For children who have EF deficits, they may need more direct instruction than just picking up these skills from incidental learning in everyday life.  The challenges to developing EF skills in children/teens include:


  • EF is not one discrete entity, children tend to have problems across a variety of domains (He’s not just late, he’s late, lost, and unprepared!)


  • We don’t know the “upper limit” of how well a person should perform executive functions, and the ceiling of ability varies between individuals — where do you draw the line between intervention vs. accommodation?


  • Brain maturation takes a long time!


  • Children/teens have an emotional need for independence that conflicts with need for direct instruction and EF skill practice.  The benefits of EF skill practice are not immediate and may not seem “worth it” to the child/teen.


Factors that can help children develop EF skills include: higher IQ, skills in other areas (encourage good self-esteem by praising success in other domains that are easier for the child, sports, music, art, etc.), and a well-adjusted caretaker/parent/teacher with good EF skills to help the child develop good habits of their own.


EF develops into the 20s, and there is even some evidence that it peaks around 40 years old!  Major “growth spurts” in EF occur around 6y.o. (about 1st grade), 8-9y.o. (about 3rd grade), and 18-19y.o. (HS graduation, beginning college/work).  Though there are some times of more growth (the “growth spurts”), the brain is continually growing and changing, so these skills should be practiced throughout the lifespan.


In her clinical practice, and in the lecture she shared with us, Dr. Cooper-Kahn advocates a “Two-Pronged Approach” to EF remediation, including both short-term and long-term components.


SHORT TERM: support growth of EF skills, provide accommodations if necessary

  • Allow child to be successful in daily demands


  • Provide opportunities for children to continue to take part in activities and experiences to further practice EF skills (for example, scouting — it’s fun, but it also requires planning, memory, and organization to complete the requirements needed to earn badges!)


  • Use small daily successes to decrease anxiety, resistance, and other negative behaviors that may cause the child to “shut down” and refuse to participate in EF skill activities.


  • Adapt the environment, adapt the task, “lend” your EF skills to the child as a “short term loan” — don’t do everything for her, but give her some of your skills as a model to help.


  • “Short term” accommodations may need to be in place for a long time (months or years) because of long frontal lobe developmental trajectory.


LONG TERM: facilitate independent skills

  • Strengthen executive system and build repertoire of effective self-management skills.


  • Allow child to be independently confident to manage life on their own.


  • Focus on developing habits and routines (making it automatic and “over-learning” takes it out of executive control and reduces cognitive load).


  • Encourage self-knowledge of strengths and weaknesses in EF skills (and other skills) and appropriate self-advocacy.


Cooper-Kahn suggests involving the child in the development of interventions as much as possible.  Allow the child to help design the plan and to choose what rewards they would like to “earn” for successful behavior.  Cooper-Kahn encourages use of natural consequences/awards if the child is within reasonable reaching distance of a goal, and when the cost of failure is not too high.  For example, if the skill is incredibly difficult for the child, and he may not reach the natural consequence of straight As or making the Honor Roll, providing a non-material reward, like 10 minutes later on bedtime, may be motivating to a child for whom the task of completing nightly homework seems monumental.  As another example, allowing a child to fail out of school may be a natural consequence, but that price is much too high, so you may have to help your child out more than you’d like as a short-term “band-aid” while teaching long-term independent EF skills.



  • Accommodation/Intervention means that you do everything for the child.  (No!  You do what they can’t and work to wean them off of dependence to the greatest of their abilities.)


  • Poor EF skills are an excuse for poor behavior or lack of effort.  (The child is “just lazy” or “bad”)


  • You should praise or reward ALL behavior.  (Reward desired behavior.  Contrary to popular wisdom, praising everything a child does, good or bad, does NOT lead to improved behavior or self-esteem.)


How can you get EF skill remediation into a child’s IEP?  IDEA 2004 states that children should be, “[…] prepared to lead productive and independent adult lives[,]” and that education should, “[…] prepare them for further education, employment, and independent living[.]”  While various districts differ in how they interpret these “requisite learning” skills for independent living, you may use this language to cite the need for EF development as part of your child’s overall education plan.  It is also important for professionals involved in EF skill development to monitor the balance between parents’/teachers’ tendency to do either too much or too little for the child.  We want to provide just the right amount of accommodation for success and just the right amount of challenge for growth.



  • Clearly and specifically define the problem (Mary fails to write down her homework assignments.)


  • Reframe the problem in terms of the executive skills needed (Mary needs to organize her materials and use her working memory to hear, remember, and write down the assignments.)


  • Address the problem using systematic principles of what works (Give Mary an assignment notebook, have the teacher write assignments on the board and check that Mary has them all written down before leaving school each day.)


  • Build in both short-term and long-term interventions (Have teacher check that Mary has all assignments written down until she is consistently achieving this goal.  Next year, see if she can get all of the assignments without having someone checking over her.)



  • Break tasks into component parts — create a checklist.


  • Offer organizational frameworks in advance to provide a way to organize new material (ex: teach scripts like, “When the teacher says a date that something is due, I know I should get out my assignment notebook and write it down.  Then, I should make a list of what I need to do to complete the project on time.  I can ask X, Y, and Z for help if I’m confused.  I will tell my Mom about my plans so she can help me achieve my goal.”).


  • Use tricks and technology to help compensate (taping classes, using an electronic planner or timer).


  • Develop templates for repetitive procedures (If the child has to do a book report each quarter, create a “Book Report Checklist” with the steps needed to complete the assignment and replicate it each time.  Make a list of “Things I Need to Have in My Soccer Bag Each Tuesday,” laminate it, and put it in the duffel bag so the child can prepare each week).


  • Walk through the planning process with the child, then slowly decrease the level of guidance and support you provide and increase the child’s independence.


  • Use accommodations at school and home to “lighten the cognitive load” and increase success.  Success is a cycle that builds on itself, so help the child meet progressively more difficult challenges with increasing independence!

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