OTS 148: Executive Function's Role in Sensory Regulation
- Jayson Davies
- Apr 22, 2024
- 4 min read
Updated: Apr 22, 2024
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Welcome to the show notes for Episode 148 of the OT Schoolhouse Podcast.
How do children’s brains manage the interplay between self-regulation and executive functioning tasks?
In this episode, join Lindy Joffe, OTD, OTR/L as she discusses the interconnectedness between sensory and executive function. She will offer insight into the clinical observations that can unlock a better understanding of student behaviors and learn actionable strategies to empower our children as co-learners in their educational journey.
Tune in to understand the connection with executive functions and sensory regulation within school-based occupational therapy!
Listen now to learn the following objectives:
Learners will identify the relationship between child behavior, environment, and factors contributing to executive functioning
Learners will understand how to empower the children as co learners and use interventions to reflect their unique needs
Learners will identify practical assessment tools to use for executive functioning
Guest Bio
Lindy Joffe is a pediatric occupational therapist with 24 years of experience specializing in the integration of executive function and sensory regulation. She is fascinated by how the motor, sensory, perceptual, and reflex systems interact with executive functioning to propel resilience in problem-solving. Lindy received her OTD from Boston University in 2022 and MSOT from Columbia University in 1999. She is committed to translating complex concepts to people from different backgrounds and has taught CE courses locally and nationally. When not working, Lindy spends time with her partner, children, dog, and friends. She loves running, hiking, biking, and tai chi, and is learning to play the bassoon.
Quotes
“There's lots of different components that people talk about as the executive functions, but the three primary ones that everybody agrees are a part of it are working memory, inhibition…and shift, which is the ability to move from one thing to another.”
-Lindy Joffe OTD, OTR/L
“I come in as, essentially a mirror to them and as a co-regulator and as a co-learner. And so they are essentially in the driver's seat in terms of the problem solving challenges that I give them.”
-Lindy Joffe OTD, OTR/L
“Jack of all trades, master of none. And I think that kind of encompasses what our society does… As OTs, we are the master of putting all these things together and understanding what's happening in these kids' systems.”
-Lindy Joffe OTD, OTR/L
“We need to notice the errors to fix the errors to build executive function, they are the ones who really need to notice what's going on, and fix it, and reflect back on the challenges.”
-Lindy Joffe OTD, OTR/L
“The second primary construct is, the idea of them having productive struggles.”
-Lindy Joffe OTD, OTR/L
“Best analogy that I've ever heard for executive function…is that it is the air traffic controller of the brain.”
-Lindy Joffe OTD, OTR/L
“I think everyone needs to be working on executive functioning. They need to have an idea and an understanding of what it is so that we can all address it from our own angle. But I think as OTs, we can't be scared of it.”
-Jayson Davies, MA, OTR/L
Resources
Additional References
Barbas, H., Zikopoulos, B., & Timbie, C. (2011). Sensory pathways and emotional context for action in primate prefrontal cortex. Biological psychiatry, 69(12), 1133–1139. https://doi.org/10.1016/j.biopsych.2010.08.008
Funahashi, S., & Andreau, J. M. (2013). Prefrontal cortex and neural mechanisms of executive function. Journal of Physiology-Paris, 107(6), 471-482. https://doi.org/10.1016/j.jphysparis.2013.05.001
Gilbert, C., Li, W. Top-down influences on visual processing. Nat Rev Neurosci 14, 350–363 (2013). https://doi.org/10.1038/nrn3476
McCarthy, B., Datta, S., Sesa-Ashton, G., Wong, R., Henderson, L. A., Dawood, T., & Macefield, V. G. (2023). Top-down control of vestibular inputs by the dorsolateral prefrontal cortex. Experimental brain research, 241(11-12), 2845–2853. https://doi.org/10.1007/s00221-023-06722-6
Nakajima, M., Schmitt, L. I., & Halassa, M. M. (2019). Prefrontal Cortex Regulates Sensory Filtering through a Basal Ganglia-to-Thalamus Pathway. Neuron, 103(3), 445–458.e10. https://doi.org/10.1016/j.neuron.2019.05.026
Romo, R., & de Lafuente, V. (2013). Conversion of sensory signals into perceptual decisions. Progress in neurobiology, 103, 41–75. https://doi.org/10.1016/j.pneurobio.2012.03.007
Skirzewski M., Molotchnikoff S., Hernandez L.F.., Maya-Vetencourt J.F.. (2022). Multisensory integration: Is medial prefrontal cortex signaling relevant for the treatment of higher-order visual dysfunctions? . Frontiers in Molecular Neuroscience, 14https://doi.org/10.3389/fnmol.2021.806376
Takeuchi, H., Taki, Y., Sassa, Y., Hashizume, H., Sekiguchi, A., Fukushima, A., & Kawashima, R. (2013). Brain structures associated with executive functions during everyday events in a non-clinical sample. Brain structure & function, 218(4), 1017–1032. https://doi.org/10.1007/s00429-012-0444-z
Zelazo, P. D. (2015). Executive function: Reflection, iterative reprocessing, complexity, and the developing brain. Developmental Review, 38, 55-68. https://doi.org/10.1016/j.dr.2015.07.001
Episode Transcript
Expand to view the full episode transcript.
Jayson Davies
Hey there and welcome to the OT schoolhouse podcast. I'm your host Jayson Davies. And in today's enlightening episode, we're joined by experienced occupational therapist Lindy Jaffe, as we dive into the intricate world of executive function and its role in sensory regulation. Two amazingly hot topics and I cannot wait to talk about them in tandem. As therapists we are often tasked with observing behaviors and attempting to identify the why behind those behaviors. Sometimes we even try to convince ourselves that something is sensory or behavior and reject the idea that there is an interconnectedness between the two. That is why I'm excited to have this chat with Lindy. As we piece together the puzzle of dysregulation through the lens of executive function. Dr. Jaffe has 24 years of experience specializing in the integration of executive functions and sensory regulation, and is fascinated by how the motor sensory perceptual and reflex systems interact with executive functioning to propel resilience and problem solving. Likewise, Lindy is committed to sharing and translating complex concepts to people with various backgrounds and has done so through various courses on this matter across the country. And our conversation today with Lindy will examine the intricate relationship between a child's behavior, their environment and the underlying factors that contribute to their executive functioning. We'll also discuss the importance of giving children the gift of time, empowering them as CO learners and designing interventions that reflect the complexity of their needs. So stay tuned as we explore the dynamic interplay between sensory processing and executive function. discuss practical assessment tools, and consider how our role as occupational therapy practitioners equips us to bring a holistic view to the educational table.
Amazing Narrator
Hello, and welcome to the OT schoolhouse podcast, your source for school based occupational therapy, tips, interviews and professional development. Now to get the conversation started. Here's your host, Jayson Davies, class is officially in session.
Jayson Davies
Lindy, welcome to the OT, schoolhouse podcast. It is such a pleasure having you here today. How are you?
Lindy Joffe
I am good. Thank you so much for having me.
Jayson Davies
Yeah, I'm excited. I really am excited because myself I remember as as a new school based occupational therapy practitioner, I felt like I had some training and self regulation. But I didn't quite feel as confident in executive functioning. In fact, in 2012, when I really got started executive functioning really wasn't as common of a term as it is nowadays. So I'm so excited to talk to you about this. And to kind of start off just, you know, share with us a little bit about where you are in your world as an occupational therapist right now.
Lindy Joffe
Well, I have been a therapist now for 24 years. So I've seen a generation of kids come through. And I, I work with people with all ages, you know, from infancy and all the way up through adulthood at this point, predominantly with kids, but I've worked with, you know, a mom with three kids and other functioning adults, as well. And I love what I do. I've been interested in executive function and sensory regulation and the integration of those two components. Throughout my practice, I really, I feel like I came in interested in it. I've been, quote unquote, sensory integration therapist. Throughout that time that I've, in many ways, I've never really seen myself as a sensory integration therapist, because it's never felt like that is all that's happening. And my practice has been a process of kind of understanding all of the different components that integrate with sensory processing and sensory regulation, to build out our understanding of what's happening with regulation and consistence.
Jayson Davies
Absolutely, I love that. And I wanted to ask, you know, kind of where you got started with executive and executive, executive functioning and self regulation, but you kind of shared a little bit about that, you know, it's just been there kind of been ingrained in you for a long time. I like that you talked about how, and I think you kind of use air quotes, and people can't see us, but share it, right sensory integration therapist, as I kind of mentioned, you know, executive functioning, I feel like it wasn't a term that I really started to learn more about and get interested in until, you know, five or six years into my career. And I feel like right now, it's just a really big buzzword. And I know sensory has been a buzzword for a while now. But I want to ask you, this is off the cuff. But why do you feel like executive functioning has become more of that buzzword right now?
Lindy Joffe
You know, I'm not honestly sure. I think I think we're understanding I'm going to back up for a second. I think that historically, we we as a western society have really divided divided things up into component parts. In fact, I'm going to tell a little story about when I was an OT student up in San Francisco, where I live, there's, there was a commuter carpool where you could pick people up and bring people I was living in Oakland at the time, and bring people into the city, and therefore get into the carpool lanes. And so I used to bring people into the city. And one day I picked up a woman, and she asked me what I did. And I said, I was an occupational therapist, and she asked me what that was. And I explained it to her. And she said, Oh, so your master of all trades, or your your jack of all trades, master of none. And I think that kind of encompasses what our society does with, Okay, well, it's sensory, or it's executive function, or it's a motor, or it's reflex, or it's all of these different things. But as OTs, we are the master of putting all of this together and understanding what's happening in these kids systems. And at the time, I was really offended. And as I went in, went on in my practice, I really came to understand that that is the beauty of what we do here, we understand things in an integrated fashion. And I think part of what really drew me to this piece was, some of it was working with wonderful mentors early on, who really emphasized cognition and perceptual processing, and, and sensory and sensory integrative pieces, and they pushed me in the right direction. Some of it was my own personal experience, I think a lot of us come by our passions very honestly, and, and I, I'm not from this country, I came to this country, when I was six, I skipped first grade, so I wasn't able to read when I went into second grade, I was behind. And I was a dysregulated kid. And a lot of that had to do with feeling like I wasn't able to do what I was supposed to be able to do as a kid. And so I think that understanding from, you know, on a firsthand basis, that not being able to meet your occupational challenges as a kid impacts your regulation. And then seeing so much of that in the kids that I work with, you know, we can't, we can't ignore all the different components that are affecting these kids feelings of efficacy and agency in their world. And when we start working with that, in addition to their sensory challenges in their sense of overwhelm, and it makes a really big difference in how they and how they manage their worlds.
Jayson Davies
Yeah, I think you're right on like, there's a lot of compartmentalizing going on in the world, right? And specialization, and everyone's looking at one particular piece of a person. And as occupational therapy practitioners, you're right, we kind of put the puzzle together in a sore, you know, we're looking at sensory, we're looking at physical, we're looking at the brain, the executive functioning piece, and sometimes we're kind of that glue that brings it all together. And, and I see this a lot when I sit on IEP team meetings, like you have the teacher who has this specialization, you have the physical therapist with this specialization, and you kind of have I don't know, I just find like that the OT is often that person that kind of says, Okay, I hear the teacher, I hear the principal, I hear the other specialists and kind of comes up with the accommodation or comes up with something that kind of bridges that altogether. So I totally understand what you're what you're saying that resonates with me. And I think it'll resonate with a lot of people listening out there as well. So thanks for sharing that.
Lindy Joffe
One of the amazing things, I think that is happening, and perhaps this is part of going back to your original question, why is executive function becoming more and more attended to in these last years in general, not just an OT is, is that we're understanding so much more about how the brain works. And we finally have the tools to really to validate what I think clinically we've seen for so many years. And with those tools, we can really see how the prefrontal cortex, which is, you know, a major player in executive function, perhaps the major player and executive function, integrates and mediates so many different other parts of the brain. And so I think as we understand that better and better, there is more talk about if there's more emphasis. And there's also more of an attempt to really define what exactly this thing is, because historically, there hasn't been a good definition for it.
Jayson Davies
Perfect. That leads right into our next question, because I have the same question too, like executive functioning is definitely not a, a term that just like tells you what it is right off of the bat by, you know, saying what it is it doesn't define itself. And so with that in mind, I do want to ask you a little bit about that term. And when we say executive functioning, what are we actually referring to what is kind of under the umbrella of EF
Lindy Joffe
So I think the best analogy that I've ever heard for executive function, people talk about it in lots of different ways. But the best analogy that I've ever heard is that it is the air traffic controller of the brain. And so if we think about what an air traffic controller does, it manages everything that's coming in. But it also manages everything that's coming out of an airport, right. And so, if we think about what we're doing, what our brain is doing, for our bodies, the executive function component, is it's organizing all the goal directed behavior that is coming out of our bodies, everything that we're doing, goes through our executive function process for organization and regulation, but it's also taking all the information that's coming into our bodies, and using that information in order to then turn it around for goal directed behavior. And one of the things that was the the working definition that I really love for this is by a researcher named Philip Laso. And what he talks about is that executive function is the set of self regulatory skills involved in the conscious goal directed modulation of thought, emotion, action. And the reason that I love that is because it in its first sentence, talks about in his first words, it is the self regulatory behaviors, and then, of course, goal directed behaviors. And so that sits it directly in the rubric of OT, because what are what are we working on? We're working on self regulatory behaviors in order to do goal directed actions.
Jayson Davies
Yeah.
Lindy Joffe
Now there's a couple of different things, a couple of other things that I think are worth talking about within the realm of executive function, as we're kind of building up that foundation. One thing that I just think is worth knowing is that there's lots of different components that people talk about as the executive functions, but the three primary ones that everybody agrees are a part of it, are working memory, inhibition, so you can think of inhibition as managing impulsivity, and shift, which is the ability to move from one thing to another one idea to another transitions, you know, one work thing, we know a lot of those kids have difficulty with shifts. So that's a problem.
Jayson Davies
I'm raising my hand right now that that's a big problem over here, and those guys get really focused on one thing, but man shifting back and forth, that is a tough one. And that's a tough one for a lot of people, kids and adults.
Lindy Joffe
Right. So those are your three kind of primary executive functions that fall into it. The other thing that that I think is really, really huge, and that really impacts us as OTs is that we tend to think of executive function as being a later developing skill. And it is because it continues to mature into the 20s. But the greatest trajectory of growth is actually between the ages of three and four, there's a huge burst of growth and executive function between three and four, there's another one in puberty, and then it continues to mature. You know, it's maturing throughout, of course, the lifespan, but those are the two steepest growth, growth areas. And why I think that that really matters, is because what I've seen over my decades of work in this field, is that kids get referred. You know, there's a, there's a huge onslaught of kids in that three to four years, and they're getting referred for sensory regulatory challenges. They're fine, you know, as as toddlers, and then they go to preschool, and then all of a sudden, they're having problems with their impulsivity and their dysregulation. And they're not keeping up with their peers, and they can't do what everybody else is doing. And the cause is identified as sensory, regulatory. And they're coming to us as OTs, because we are the frontlines of regulation. And if we as OTs are not understanding that it is sensory, because again, if we think about that air traffic controller as managing everything coming in, well, that's the sensory, but it's also this executive function piece, then we're going to be missing the boat. And so we need to be addressing it from, you know, both of these pieces. Yeah, and that's exactly why I wanted to have you on here because I think a lot of us try to compartmentalize sensory and executive functioning, and we try to focus on one or the other, when, as we're going to talk more about today, you know, really discussing both of those. Also, before we move on. I also have to say that I love the idea of using the air traffic controller, partially because I can see that as being an intervention with students like training them about being the air traffic controller have their own body. So sorry, I had to throw that in there. But yeah, and then the last thought that I had there is you were talking about that three to four age range. And I think a lot of us especially in the schools, we start to get referrals for kids, once they're beyond that. And we often think to ourselves, like, Wait, how was the student not getting services when they were younger? And you kind of alluded to that, because you're like, you're telling us, you know, that kids might do really well as a toddler. But right around that three to four age range is when things start to get a little bit more complex. So yeah, I just wanted to say, I see that and I'm sure others are as well. So thank you for sharing. And, you know, just to add one more thing to that for for years, when I was younger OT earlier on in my practice, parents used to say, you know, they never used to have problems with their clothes, or they never used to have problems with their sound and with sound. And they, all of a sudden, around three years old, they got really hypersensitive, and I don't understand it. And I mean, I can't tell you how many times I've, I've heard that comment from parents. And I used to say, well, it's probably that they were sensitive, but they just didn't understand it. Like, developmentally, they didn't have the awareness of what was going on. So they couldn't say anything about it until they hit about the age of three. And maybe there was an element of that being true. But as I've come to understand this better over time, I actually think that it is this executive function piece. That which, of course, it correlates with the cognitive piece of they come to understand it. But I think there's also something more that the overwhelm in the world and the inability to shift and the control. And all of these other factors that are a part of this executive function is and how that interacts with the sensory is what's dis regulating them. It's not just purely the sensitivity. And I might be getting ahead of myself here, but I'm gonna give a very practical example of a girl that I used to see who was referred to me she was for extreme tactile defensiveness, this was a girl, the parents could not find her underwear that she would wear. They couldn't find her socks, they had tried everything. pants were just so discombobulating for us they just could not find this kid clothes. And yet she would come in, in the most princessy kinds of dresses with, you know, a tool, I guess you'd call them shoes that were just so by my definition, so uncomfortable. And I said to them, this is not pure to tactile defensiveness, there's something else going on here. And so we see those kids, just an example. So what's happening where kid can't tolerate the softest of all? Yeah, underwear, and yet, they're coming in with the scratchy hast dresses, and they're fine when it's under their control. And so that's just a very clear example of this kind of conflict that exists between the sensory sensitivities. And yet, if it's if there's a motivational piece, then the executive system comes in and attempts down that that tactile system, so that they can tolerate it.
Jayson Davies
Yeah. And I think we've all had similar experiences, you know, implementing a sensory diet, right, and it works for two days, and then it doesn't work the next day, or it works for five minutes. And then something else works the next five minutes. And, you know, we think to ourselves, like we did our evaluation, we tested different things, we use these, and the next day is not working. And there's gotta be something more there. And and you already mentioned, right, that part of the executive functions are that that inhibitory response or being able to weed out different responses or sensory stimuli. So absolutely, I know, you're not directly in the schools every day. And you've you've worked with kids in the schools, it sounds like, but on the IEP team, we often have people that have very specific duties. And you know, the OTs, commonly known as the sensory, the fine motor, the visual motor person, teachers, or the academic person psychologists, you know, they understand psychological processes. They don't often treat though, which is interesting to me. You have counselors, you've got adaptive physical education, teachers, you've got all the gamut. But there isn't anyone that's really defined as the executive function person. And I wanted to give you a moment to kind of talk a little bit about that, and why you feel that maybe the occupational therapist or us as OT practitioners should kind of maybe step into that role potentially.
Lindy Joffe
That's interesting. I am not, I have worked with kids, as a consultant to the schools and you know, I often do go in and observe in the schools, but I'm not I've never been a formal school district therapist, and in my impression, more the psychologists and the teachers who've taken on that role. So it's interesting to hear you say, obviously, I believe you when you say there's nobody who kind of takes on that role. I think that the reason that we as OTs need to be involved in that as a to a minimum, and to be having those conversations with people is because of this regulatory piece, because we are the people who are kind of overseeing that regulation. And I think that what we need to be doing. And it can be tricky, because if there are other people that are viewing themselves as kind of the the overseers of cognition, if you will, then sometimes there can be these little, little turf wars if the relationship is at all fragile. So that's, that's really site dependent. Some people don't have that, and some people do. But I think it's really important to have these conversations so that the whole team is on board with the interaction of the systems and how they play out in terms of the kids regulation, and attention and engagement because it is ultimately about that goal directed behavior, and the ability to learn. And that is that is our job as OTs is to oversee that called directed behavior. That's what we do.
Jayson Davies
Yeah. Yeah. And, as we kind of alluded to earlier, I think we are kind of that person that really has that holistic view and can take what we're seeing in the psychologist evaluation and see what we're seeing with academic skills from the teacher's evaluation, or testing, and also our own testing and really start to put those pieces together. I think that's a big part of it as well, we just kind of are that have that holistic side of view that, that we really see it? So? Yeah, I think we need to really step into that role. Obviously, it's a team approach. I think everyone needs to be working on executive functioning, they need to have an idea and an understanding of what it is so that we can all address it from our own angle. But I think as OTs we can't be scared of it. And we can't say, You know what, that's the speech therapists role, or that's the psychs role, we really have to embrace it a little bit.
Lindy Joffe
Absolutely.
Jayson Davies
Yeah. All right. So with that kind of a little bit of background into what executive functioning is, I want to dive into, you know, how there is this overlap between sensory processing and executive functioning. And we've touched upon it a little bit, but I kind of want to point out, you know, most of us understand as occupational therapy practitioners, that sensory processing is really embedded in that deep old brain, the midbrain and executive functioning, there's more in the prefrontal context. So how are we getting this overlap between something that's occurring in that that old brain versus something that's very much in the newer brain and the prefrontal cortex?
Lindy Joffe
So I alluded earlier to the fact that there's more and more and more research out there, that showing how the prefrontal cortex mediates these different sensory systems. And at this point, you know, I've seen research that the prefrontal cortex mediates input from the vestibular system and mediates input from the auditory system mediates input from the tactile system mediates input from the visual system. So it's, you know, there are direct connections between the prefrontal cortex and and all of these different sensory systems. I'm not going to get into too much neurology here. I think we need some visuals to do that. But if we take a step back, and we can link to some of those articles, yeah, absolutely. That's helpful, and people want to read that primary research. But I think it's, it's helpful to think about it from a functional perspective. If we take the example of the auditory system, we have the acoustic sound reflex. So when we hear a low or loud sound, there are these muscles in the middle of the ear, that will contract. And what that does is it dampens the volume on those low sounds, and those loud sounds to both protect our inner ear. But it also allows us to filter out those low sounds so that we can hear the highs so that we can preferentially hear the high sounds over the lows. So we have a mechanism built into that middle ear to help us filter sounds. So for example, if you're at a loud restaurant, and there's a lot of background noise, I'm not gonna go too much into the auditory system here, because that's not what this is about. But there's a mechanism that background noises, low sounds, the people you're talking to all the details are in the high sounds, it's going to dampen the volume of those background sounds so that you can preferentially hear the people that you're talking to. So we know that that's a built in mechanism in the auditory system. But we also know that that and that would be considered bottom up mediation filtering, to to help with focus to auditory attention, but we also know that there's a mechanism in the prefrontal cortex, so that if there's something more interesting going on at the table next to us than there is in our own conversation, say the people next to us are talking about something that they did last night and that's particularly Curious to us, all of a sudden, our auditory attention is going to go away from, you know, perhaps our partner who's just talking about what happened at work today, what wasn't so interesting. And he's going to shoot over like a like one of those old fashioned, you know, ear phone things. And it's going to pick up what's happening next to us. And that's the mediation that's happening from the prefrontal cortex. Filtering is according to interest, as well as according to these kinds of lower level mechanisms. So we have all of this and the same thing is true with visual attention, we can want to attend to something, you know, movement, or whatever it is, that draws our attention through the visual mechanism, that if there's something more interesting, according to our own personal interests, that's executive function, and that's going to draw our attention. And we see that all the time. So the brain really is a closed system, the brain doesn't know what to attend to. And it has to figure it out all the time. And there's all these different sensations that are coming in. So the sensory receptors, and the sensory processing areas have ways to kind of deal with what is important and what's not. But as we get more and more and more experience, we also learn through that experience, this is the working memory component that the prefrontal cortex has. And so the prefrontal cortex is also going to tell us no, this is what you need to pay attention to not this. And that is a part of the whole process of keeping us safe. So there's this this feedback that goes back and forth between the top down and the bottom up, and we need them both. And there's no way to separate that out.
Jayson Davies
Yeah, that's so interesting how we have those built in within our ear, we have the built in systems to damp and some things, but at the same time, our brain can just with the flip of a switch, you know, just override that basically and say, You know what, no, I want to listen to that lower pitch, that lower bass sound, and it all happens in a fraction of a second. Like, we don't even notice it. It just happens. And we have some sorry, tangent here. But we have some books for my son, he's turned to in two days from now. And it's like, baby hears baby sees it like talks about the audio, or he has baby hears. And it talks about how baby hears, and they do not go into that much detail. So so thank you for sharing that with me. Like, all right, I know what Selective Hearing really is going on here now. But anyways, yeah, no, thank you for sharing that. And it's, it really just shows how complex the brain is. And how important that prefrontal cortex is that, as you mentioned earlier, new tools are evolving. And we're allowing ourselves are able to get more information from what's going on in that brain. And I know we're learning new stuff every day. And that's why it's so important to keep up with all the research coming out. So one other question before we do move on within the sensory world, a term is very common, it's called the feedback loop, right? It's you take in information, and then you put information back into the world. And that constant loop of going back and forth, is what potentially allows us to alter our response to sensory or even adapt the to filter out things that are coming in. However, when I think about the feedback loop, or when I learned about the feedback loop in relationship to sensory integration, sensory processing, executive functioning wasn't tied into it at all. But as I am listening to you, the more I think like executive functioning has to tie into that like executive functioning, is that working memory piece to tell us whether or not to let more stimuli in or to act upon a certain way? Does that make sense?
Lindy Joffe
Yeah, I think it does. What I think about with this is the same executive function researcher that I really love to Lazo has a model that he's built out, which again, I'm not going to go into the details of, but his model is for building executive function. And the first step in building executive function is pausing. And when I think about this, you know, the brain doesn't learn anything if there's not an error. So if you think about, you're just kind of going along, and you're just doing something and there's nothing wrong, you don't actually notice anything, you're just going along. And so what happens is, when there's an error when there's a problem, that's when the brain stops, pauses, notices and tries to adjust. And that's the process of building plasticity is that process of noticing errors and fixing the errors and then making changes and so that that isn't the losses model, but if we come back to the losses model, it's that noticing that pausing and then reflecting back on you know, past experience, past rules, creative modeling, whatever it might be, and then within that, that's the whole okay, you're using your working memory or you're you know, inhibiting in action, or whatever it might be, to then build a new process. And in the process of doing that you're building your working memory, you're building your inhibition, you're building your shift. And, and so that's how we build executive function. But that pause is really key. And so when we think about so many of our kids who are dysregulated, what are we missing? What are we struggling with? It's that impulsivity. It's the difficulty with that pause. And there again, we see how do we separate out sensory regulation from executive function, and I come down on the side of you can't, you have to look at this in an in an integrated fashion. Because if we can get that pause, that's where we find the feedback loop. And that's where we find the building of skills, there are lower level sensory feedback loops, that I think just happen in the body. And they're automatic, and they're quick. They're very, very low level. But most feedback loops, I think, happen at a higher level with that, that executive function piece. And, and especially if we're going to try to, you know, kind of, quote, unquote, fix something that went wrong. That's the feedback loop that I think is more, you know, rich and complex and productive.
Jayson Davies
Yeah, again, it just speaks to the complexity of the way that the body is created and built and all the checks and balances that we have within our own brain. I mean, like you said, there's feedback loops that I think occur. I'm, I haven't taken a neuro class in a long time. But if I remember, right, like, there's neuro feedback loops that happen at the spinal level before the information ever gets up to the brain, and then you got the thalamus and the basal ganglia kind of filtering stuff there. And then, yeah, so it's quite quite amazing how the brain works. It just really is and, and reactions to right, like, you know, the knee jerk reaction that just kind of happens, right? Right at the knee. So yeah, amazing how things work. But continuing on with our conversation, talking more about assessments and interventions, I just kind of want to give you a moment to kind of go broad here and just talk about the general activities within a school day that might be impacted when a student is having these cross difficulties between self regulation and executive functioning.
Lindy Joffe
Oh, gosh, I think everything. I mean, I think there's a potential for everything, because again, you're talking about goal directed behaviors, right. And so I think we can see it everywhere. And one thing I didn't say in the definition of executive function is that as we've come to understand it better, we see that there's two primary categories of executive function, there's hot executive function, and there's called executive function. And I think that called executive function is what has traditionally been thought of that's abstract, decontextualized tasks. And so that's your more academic tasks. So these are kids, who are you am I gonna say better regulated, maybe better regulated, but have difficulty, you know, with math or with sequencing or with, you know, organizing their backpacks or following instructions, or you know, those kinds of things. But it's abstract and decontextualized. And then hot executive function is the kids who you would think of as more your classic regulatory kids. And so those are kids who the hot executive function challenges are more related to motivational, emotive kinds of things. So those are your kids who are having trouble? You know, for example, with competition on the playground, that's a highly emotive motivational challenge, right. And so they're falling apart there. Or they need to be first in line, or whatever it might be. But so they're different. They're different characterizations. But because executive function is such a broad based thing, it can really impact in different ways, all kinds of different activities during the day. Yeah. So I think I, you know, and you, you said something about going into assessment before going into assessment, I believe, or maybe ahead. I think that that school based therapists are, you know, you are at a real advantage here because you do get to observe kids in the natural context and you get to observe them in so many different places and ways throughout the day. And you can see some of this you know, when I'm seeing kids in the clinic, I'm relying on you know, parent and teacher report for so much of this information. I can also see things and I'm looking at strategies, how how they go, you know, I don't do that much standardized. Testing because I find it takes a long time and doesn't give as much information. But I'm really looking at how kids approach things, not just, you know, what their scores are, but really how they approach different activities.
Jayson Davies
Yeah, I mean, I think your very first response kind of is, says it all right, like it can affect any everything and anything. As you were talking, they're talking a little bit about the hot and cold, some terms came to my mind that we often use. And for me, it almost sounded like the cold side of the executive functioning is things that we might equate to a student who has maybe dysgraphia, dyslexia, dyspraxia, and the hot side was more of a behavioral concern, maybe sometimes associated with a student with ADHD or defiant, some sort of Defiant Disorder, something like that. But I know, I don't want to say that that is necessarily the problem in students who have dyslexia, just calculate whatever it might be. But it just kind of, I guess, what I'm trying to say is that there is inherently an executive functioning disconnect, potentially within students who have those sorts of difficulties. Now, there may be a deeper level something going on. But when we see someone, a student being labeled, unfortunately, like as dysgraphic, or something that might be something that could trigger us to Okay, let's look at some of the hot versus cold executive functions. I know that was a very much incoherent somewhat ramble right there. But does that did that give a thought to that make you?
Lindy Joffe
Yes, yeah. I mean, I think that's true. There's, you know, there's been research that has been that has shown that executive function challenges are present in dysgraphic kids, and certainly ADHD. I mean, there's even research that shows with ADHD, it is an executive function problem. And there are people who have said, who have suggested that it shouldn't be called ADHD, it shouldn't be called an executive function disorder. So you absolutely and, and certainly, if you look at, if you look at some of the research on dyspraxia, in developmental motor coordination disorder, absolutely executive function, there's a huge body of research around executive function, and developmental motor coordination disorders. And so we see it in all of these areas, because again, it's your air traffic controller. And so if there is an end, the prefrontal cortex does integrate with so many different parts of the brain, we see these, we see this mediation, the basal ganglia with the thalamus with you know, just lots and lots and lots of different areas. And so I do think as OTs, we we need to be looking at these components and addressing these components. And the first step is really understanding what we're seeing once you start to understand what it is that you're looking at, I think, I think the treatment flows a little bit more naturally and things. Yeah, things Things get much, it gets much easier, because you treat things in a different way.
Jayson Davies
Yeah.
Lindy Joffe
So.
Jayson Davies
I have I have one more quick question, hopefully quick before we dive into this session, or a little bit deeper into the assessment piece. And that is a school based OTs, we don't often get the diagnosis, like x student doesn't necessarily have to have a diagnosis for school based OT. But as a private practice, you might see these a little bit more because maybe you're getting reports from the primary physician or whoever might be. But in the DSM, is there actually a category for executive function? Disorder? Or is it all really? No, we're just talking about, you know, ADHD, you know, it? Okay.
Lindy Joffe
Yeah, I don't know of any executive function disorder and be interesting. It'll be interesting to see if it's, you know, if at some point it shows up, but as a primary, it is a component of other things. You know, I'll also add any kind of spectrum disorder. It's always there. I mean, shift, just as an example, is huge spectrum disorders. Right. So but no, I don't know it is a primary. The closest thing would be ADHD. Gotcha. Okay, cool. I had no idea. So I figured I'd ask if I if I question it. There's probably someone else out there question. Yeah, so figured I'd ask. All right. With all that in mind, let's talk a little bit about assessments. I just want to hear you know how this has really changed your process with assessments. you've alluded to a few things over time of this conversation, right, that maybe you're using less standardized assessments and that school based OTs you mentioned, you know, we're kind of fortunate that we can go into the classroom or see a student at recess time. But with this knowledge that there is such a connection between self regulation and executive functioning, how might that change the way that we look at an issue rushman? Well, again, I think that I think that the biggest thing is, is to be looking for these challenges when we're assessing the kids. And so if, for example, we're seeing this is without starting without, there's just clinical observations, if you're seeing that a kid is wiggly and dysregulated and in class, so it's a place to start, we need to ask the question, when are they wiggly? When are they dysregulated? What are the times of day? Is it happening during transitions? Is it happening during circle time? Is it happening during different kinds of learnings? When are they not wiggly? When are they focused? What are the easier easier times a day? Is it happening during recess? And we need to look at the environmental context around those challenges. Because that environmental context is going to give us a lot of information about, you know, what is easy for them. And what if you will sits well in their system, and doesn't sit well in their system. And there are kids who are dysregulated all the time. And there are other kids who are, you know, it really is pretty specific. And I'm going to give an example. Excuse me, I just did a very brief observation about an hour and a half where I was supposed to be observing about five kids in a class recently, and giving feedback on the kids. And one of the kids, I knew that he was dysregulated. ahead of time, I'd gotten some good information about him from the teachers. But I came in and whenever I come into class, none of the kids knew me. Whenever I come into a class, there's always kids are curious, they want to know what I'm doing. Or they kind of look at me, who are you. And these were, these were not quite pre K kids in there last year, five year olds. And so a lot of the kids were looking at me and kind of curious. And then I would say who I was, and then they would talk to me a little some more would talk to me more than others. And that's all kind of normal, typical behavior. Well, this kid didn't know I was there for him. But he hid behind a pole first, and then kind of peeked his head out back and forth. And so I played a little hide and seek with him to get a little bit more comfortable. And he was smiling at me. And then he hid under a couch, and I did some more kind of under the couch, hide and seek with him. And then it seemed like he got a little bit more comfortable with me. And so then I didn't pay attention to him, because that's what it looked like he needed. And then the kids were lined up in a hall. And he was at the front of the line, I was all the way at the back of the line. And he pointed at me, and he yelled, throw her in the trash. And I just kind of ignored it and it kind of got ignored. And so when I talk to the teachers, you know, from an assessment perspective, what does that tell us about the kid? And to me, what it says is that with any disruption to his environment, environment, even a minor one, like an adult, who everybody else was clearly comfortable with coming in, that was a major threat to him. Yeah. And so that says this is this is an incredibly anxious kid, this is an incredibly defensive kid. It's the first component and that is a executive function problem. It is also a sensory regulatory problem. It is both. And so I think we need to look at these kinds of things. And really think, well, this is not a behavioral problem. This is a kid who's really, really, really scared. And then kind of start to piece apart underneath the fear what might be contributing to his fear? What what is the fragility in a system, the self efficacy that he has, that is causing him to be so defensive with such a minor threat coming into his world? And how is that going to impact him? And what kind of treatment does he need? So that happens from a lot of clinical observations? How does he approach, you know, a building task? How does he approach a structured task? How does he approach an unstructured task? So when it's other directed when it's self generated? I think we need to see both of those things. Because some kids do well in one environment and not the other. And that tells us a lot about their executive function. And within those structure tasks, that can be our assessments, because I know we do need some numbers. How do they what are their strategies? The strategies they use are really, really, really important. So are they using efficient, organized strategies? Or are they disorganized? Are they having to hyper verbalize while they're using it, how effortful is something? Or is there a fluidity to how they're going about something, kids who are too effortful, and how they're carrying something out are using too much? You know, it's it's the level of challenge is too much. And then when you layer too much else on them, they're gonna break down. And so those are the kinds of questions the net the specific evaluations that are done are specific to different settings. And that isn't so important that the kinds of questions we're asking, I think are to me the really important ones. And it's the clinical observations where we get the most information. And then the last thing I would say is, I always like to do a drawing task, just to see, you know, a copying kind of test just to see how they go about that.
Jayson Davies
Oh yeah, that's one of my favorites, too. And you can use simple videos on YouTube art for kids, if you want to do something that's more of a one step one step directed activity, or you can do more of a copyright, you create something, and then the student doesn't see you created, there's so many different ways that you can do drawing that can give you so much information, you can do the same drawing three different ways, and you get a lot of information. So yeah, I do want to ask you this question, because I get this question often. And I know of the brief. But beyond the brief, are there other specific tools outside of you know, your clinical observations that you're familiar with that, that maybe you've used, maybe you like, maybe you even don't like if you want to mention it too, but tools to look at executive functioning,
Lindy Joffe
I tend to use the brief, it's kind of it's the best known. It's, it's really well established, it gives some good information. So I tend to use the brief or the brief P for younger kids. And I, you know, I like to give both the school and the parent version, the brief, p only has one. And it can be answered either by parents or by the school, I tend to choose, you know, whoever I think is going to give them more challenged origin, which is usually, usually the school, not always, but more often than not the school. There are instances where I've given to both just because I suspect that there's going to be a discrepancy. But I do tend to use that. And more often than not, it generates good information. Yeah, that I think I think it cannot be a substitute for direct observation. Yeah, and I correct me if I'm wrong, but I would assume that you really use it as a starting point, as they understanding of where to go from there a lot with your clinical observations were to look deeper. I wouldn't say use it as a starting point, I would say use it as a supplement. Okay. You know, as much as I do this, the sensory processing measure, I think it gives really good information, but it would never be my sole.
Jayson Davies
Yeah.
Lindy Joffe
Form of information.
Jayson Davies
Yeah, I don't think we should ever use any questionnaire, as a as a sole information Absolutely, we got, we definitely have to pair our, our clinical observations. And they're both, especially in the schools, right, getting into the classroom to just observe, like what you were talking about earlier, and then also pulling that student out, potentially, and working with them on drawing, as we were talking about a little bit earlier to get some more information. So very cool. All right. Now with that, that's the assessment piece, I do want to talk a little bit about that the intervention piece before we wrap up, and we don't have a ton of time, but you know, just one or two of the most important tools in our Occupational Therapy toolbox to address some of these overlapping complex sensory regulation and executive functioning difficulties.
Lindy Joffe
So I use a lot of games and activities, just from a, you know, kind of a task analysis standpoint. So, you know, I will just structurally do a lot of, you know, very specific kinds of work and give kids a lot of kinds of problem solving work. I am pairing that all the time with different kinds of sensory approaches, because we need to address both. So I use a lot of auditory programming. I do. You know, I do astronaut training I do, I will use Thera pressure, sometimes I don't use it as heavily as some of the other ones. I do reflex integration work. I do brain gym and Bala basics. And I have a lot of I have a lot of sensory based tools that I'm that I'm using at all times to to really kind of approach things from all different angles. But when I'm doing my problem solving work with kids, and I pull from all kinds of different things. And I do have a program that I've created, which I'm not going to plug here and I need to but just to say I do have a program named the quest program, we do quest obstacle courses, which I think are fantastic, where I build in, there's a motor obstacle course and I build them in a cognitive component to that motor obstacle course and I want to bring that up because it has proved to be even more fantastic than I imagined when I started because they're the your high motor kids who then have to do like a two, you know, three to four step cognitive challenge while they're going through the motor course. And that can be challenging for them. It also for our developmental motor coordination kids, it kind of takes their attention away from the motor challenge and so it keeps them interested and they don't get us freaked out about some of the motor stuff. So that's really cool. And then the other thing is, while you're doing motor, you can build in a fine motor piece, you know, we'll use tools and kids don't feel like they're just, you know, using grabbers, they feel like they're going to, you know, fix a machine out in, in outer space. And so it really, you know, you can do puzzles in there, you can do all kinds of things. So I love bringing in the motor and, and the cognitive together. So those are some of the tools that you know, that I'm using. But big picture even more, I guess, important than the tools are kind of two primary constructs that I'm using at all times. And one primary construct is that the therapist, we live in a very didactic society. And in this didactic society, we as therapists, and teachers come in as we are the Knowers, and the kids are the learners. And I think it's really essential to break that down and take it away. And the reason for that is because if we always know more than the kids, then the kids immediately are coming in at a deficit to us. And it kind of takes the wind out of their sails before we even start. And so instead of coming in, as teacher knower, I come in as, essentially a mirror to them, and as a co regulator, and as a co learner. And so they are essentially in the driver's seat in terms of the problem solving challenges that I give them. They know that I'm structuring the activity. But I essentially tell them that I don't know the answer to it. And I've had kids asked me for years, you know, don't you know the answer to this, and I will say, you know, I know it's possible, I've done it before, but honestly, it's been so long, you know, me, I don't honestly remember how to do it. And it's the one lie that I will tell to my kids, but even really obvious errors that they make, I don't figure out for them. My idea behind this is I will act as an empathic mirror to them, I will kind of guide them towards the problems that they're having if they're not seeing the problems, but I won't solve it from them. And I don't Well, what do you think, you know, do you think this piece needs to go here, I don't do any of that kind of questioning. Because again, if we come back to the idea of, we need to notice the errors to fix the errors to build executive function, they're the ones who really need to notice what's going on and fix it and reflect back on the challenges, they have to have that aha moment, or else, it's not going to stick for them as well. That's how the neuro chemistry is set up in the brain. So that's my first kind of primary construct. And the second primary construct is, is the idea of them having productive struggle. And so I will let them and this is really huge, I will let them struggle and struggle and struggle and have a really hard time fixing things. Because it is essential that we as a society, I would say, and that these kids get used to the idea that they don't have the answers immediately, and that they get comfortable with that not knowing not knowing the answer to something, there are two places that I will come in and change things, or stop a situation. And that is if the anxiety is getting too big anxiety is never our friend. So I won't let the anxiety grow too big. And the second place that I stopped things is if they're about to kind of destroy everything, they've done a lot of good work, and they're about to destroy everything, I will stop them. But there are situations where I've let kids sort of swipe their work off the table. And then I'm like, Oh man, now we just have to do it again. Oh, well, we can do that. That's okay. So my job in that situation is to just hold, hold the space and be the regulating kind of force for them to learn how to do hard things and learn how to sit in discomfort. So those are kind of my two key constructs. In here.
Jayson Davies
I almost feel bad talking right now. Like you were just I just loved and was nodding along with everything you're saying. Because I've had those same type of experiences. One of my favorite stories to share with people is kind of what you alluded to right now is you know, that kid that just swipes their, their work off the desk, and immediately oh my goodness, immediately this child was just like, a light bulb just came on. And she realized what she had just done and was so you know, sorry and picked it up and work just flowed from there. And it just took that instance of her getting to the point of frustration, but not, you know, overly anxious not to the point of destroying everything. trying to kind of understand, okay, this is what's going on right now, I can do this. I know what I did. And maybe I should not have done this, but I did it, let me correct it and then move on from there. And I really do think that that's an important moment for kids to have. So yeah, I'm gonna resonate right there.
Lindy Joffe
Right. And, you know, to come back to the theory that Zillow has this theory, that is the pause. That's the pause. That's the error. That's the oh, okay, reflection. That's the building of a new construct right there. And that's the going back and fixing it. That's exactly the process of building executive function. So that's what we're looking for. And the next time she gets to that point, she remembers that, you know, hopefully, and it happens in a slightly different way. And we've all had those experiences where we live in such in a society that is so immediate gratification for everything. And so I think that this is, you know, this is a place that all of us can use, all of us can use that kind of work to just slow down. And one of the things that we have, as OTs in this work, ideally, is the gift of time and giving these kids the gift of time, no pressure, it's okay, we can just take a picture of it, we can come back to it next time. It's fine. It's fine. Like, I'm not I'm not worried. You know, I say to kids all the time, you have a good brain, I have a good brain together, we have a great brain, I'm not worried. It's gonna be okay. We'll figure it out. We just need more time. You know, that's, that's, that's what it takes. So those are, you know, those are those are the big elements. I love that story that happened with that girl.
Jayson Davies
Yeah. And I think we've all experienced something similar, right? You know, and if we haven't, we will. So it's, it's, it's a learning moment. While I think this would be a great time to end our conversation, I do want to ask you one more question. And that is, do you just have any one final tip for school based OT practitioners that just really want to kind of maybe internally look a little bit more at executive functioning? Well, just kind of that, that tip, word of advice that you might have for them?
Lindy Joffe
I think the big piece, the big thing to me is when you are going in, and you're looking at these kids, and I kind of said this earlier, you know, those kids at circle time, who are all over the place, those kids during lectures who are slumping in their chairs, or who are wiggling around to just think to yourselves, not Oh, they're needing more vestibular input, or they're, you know, to think what are all the different components that can be contributing to this kid's dysregulation. Because for years, I've heard about, you know, heard from teachers who are frustrated, because kids get, you know, put on a ball to bounce, because they're, you know, flopping over in circle time. And OT comes in and says, the kid needs more of a singular input. And, and I think it's always fun to bounce on a ball. But sometimes what these kids need is other kinds of supports around, you know, whether it's previewing, or whether it's somebody giving, you know, the auditory structure behind them, or, you know, sometimes it's, it's a more supportive chair, obviously, we, you know, you guys know that better than I do, there's all kinds of different things that can contribute to that kind of dysregulation during circle. But, you know, I think people know, as well as I do that, you know, if you go into one kind of a class that's really interesting to you, your arousal stays, you know, solid, and you stay engaged. And if you go into something that's really boring to you, you know, it's hard to stay alert, even if you're motivated to, and so our arousal systems are really and then if we don't feel good about ourselves, then, you know, we're going to take that much more. And so just when you see these things, just to think about the complexity of these little beings and their systems and, and provide the interventions that that reflect that kind of complexity, that would be, that would be my biggest, my biggest thing I went into just as an example of something that happened recently, when I went into that preschool, the teachers were doing such an amazing job of providing physical supports for the kids that probably two thirds of the kids that were sitting in those jack back chairs, or cube chairs, or being back tears, they all had these sensory supports these little five year olds. And my thought was, that's so amazing that they're all getting the support, they need to sit up during circle time. But how are these little five year olds building their core strength to be able to sit up and it's something that I want to talk to the teachers about, you know, we need to be playing the long game here. Are these kids and giving them the supports they need but also challenging them to be able to develop the skills that over time they're going to need?
Jayson Davies
Yeah, it's always that balance of trying to figure out, you know, the support now versus build for later. And within Ida, sometimes it gets shifted within the schools to support now, just because it's about making sure a child can access their education right now, but absolutely, like if we're putting something in place to support them now, we do need to consider Okay, well, what can we also do to build them up for the future? Absolutely. So check your balance. Yep. Absolutely. And we all deal with it, right? Like, not just in our job has school, right? No matter what we do, family live, all that good stuff, trying to try to make our lives easier today. And tomorrow at the same time, doesn't always work out. But we try. So with that, Lindy, thank you so much for coming on. I really appreciate your knowledge, your experience. And for anyone interested in learning more about you, and all the things that you have to offer in this amazing OT world. Where can they find you?
Lindy Joffe
I think probably the easiest best place is LinkedIn. Perfect. I have not. I'm working on building my website. It will be out there one day, it is not yet. But you can easily find me on LinkedIn. Awesome, and for everyone. You can find the spelling of her name and the probably in the title of this podcast episode. But if you just need it right away, it's L I N D YJ O F F E. And when she does have her website, I'm sure she'll let us know. And we can link to that in the show notes as well. So if there if there if not, LinkedIn is your place. So Lindy, one more time. Thank you so much. Really appreciate it. And it's been a pleasure. All right. Thank you so much, Jason.
Jayson Davies
All right. And that is going to wrap up this episode with Dr. Lindy Jaffe, I want to say thank you one more time to Linda for coming on this podcast. I just really appreciated the interplay between sensory processing and executive function. I think that as therapists, as educators, just as general beings, it is hard sometimes to put these two concepts together. And for so long, I feel like people have been trying to say it's one or the other. And we're really starting to see the interconnectedness between the two. And we really need to complete assessments thoroughly by looking at both aspects and not just trying to rely on one versus the other. I think that is one of the key takeaways from this episode, if nothing else, and I really appreciate everyone for listening to this episode, and just kind of staying in there with us to understand that concept. It's not an easy one to understand, and it's even more difficult to put into practice. And I really think Lindy has done that in her career. She has taken the time over the years to figure out how to do that. And she really explained herself and how she does that today in this episode. So Lindy, thank you so much again, for coming on and sharing your knowledge and thank you to you for listening to this episode all the way through. I really hope that you found some key nuggets to take away and implement into your practice tomorrow, or maybe the next day of today Saturday, but I really hope this episode helps you out and we will see you next time on the OT school health podcast. Until then take care.
Amazing Narrator
Thank you for listening to the OT schoolhouse podcast. For more ways to help you and your students succeed right now. Head on over to OT schoolhouse.com Until next time, class is dismissed.
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