Running Head: RESPONSE INHIBITION

Quality Interventions for Response Inhibition Rhonda D. Williams University of Calgary

RESPONSE INHIBITION Quality Interventions for Response Inhibition Executive functions (EF) are generally recognized as cognitive mechanisms that guide and coordinate goal-directed behaviour in an adaptive and flexible way when no pre-established schema of action is available (Best and Miller, 2010; Packwood, Hodgetts & Tremblay, 2011; Silvana, Watson & Westby, 2003). Many studies identify response inhibition, working memory and set shifting as the main executive functions orchestrated by activities within the prefrontal and frontal cortex (Berlin, Bohlin, Nyberg & Janols, 2004; Blakemore & Choudhury, 2006; Del Missier, Mantyla & Bruine de Bruin, 2010; Romine & Reynolds, 2005; Silvana et al., 2003). Students having difficulty with impulse control, working memory and set shifting exhibit hindered school performance, directly impacting their learning and achievement (Lambek et al., 2010; Scope, Empson & McHale, 2010). Inhibition deficits impact the operation of other EF skills, highlighting the need to build response inhibition skills (Barkley, 1997). When planning interventions for students with inhibition deficits, best practices such as the twelve step quality indicators identified by Upah and Tilly (2002) should be utilized to facilitate a detailed and

thoughtful intervention that is tailored to the specific strengths and needs of each individual. This paper will focus on examining inhibition as an EF, the developmental and neurological underpinnings of response inhibition and effective response inhibition interventions. The second portion of the paper will focus on a specific inhibition intervention plan using Upah and Tillys (2002) problem-solving approach to emphasize best practice in designing, implementing and evaluating quality interventions. Although ambiguity exists within the literature around descriptions of EF, most theoretical models view inhibition as a key component to EF in addition to working memory and set shifting (Best and Miller, 2010; Packwood et al., 2011). Barkleys (1997) theoretical

RESPONSE INHIBITION perspective conceptualizes response inhibition as the primary executive function by inhibiting responses (inhibiting a dominant response and stopping an ongoing response) and controlling interference (distractibility; Barkley, 1997; Del Missier et al., 2010; Leon-Carrion, Garcia-Orza & Perez-Santamaria, 2004). Once inhibition takes place, opportunities for activity arise with secondary EF such as non-verbal working memory, internalization of speech (verbal working

memory), self-regulation and reconstitution (problem-solving; Barkley, 1997). Inhibitory control deficits, not general problems of attentional capacity, impact children and adolescents with issues of inattention, impulsivity and hyperactivity (Scope et al.,2010). The developmental perspective of EF attempts to explain the cortical growth of the prefrontal and frontal lobes that coincides with the improvement in EF skills during childhood and into early adulthood (Best and Miller, 2010; Blakemore & Choudhury, 2006; Leon-Carrion et al., 2004; Romine & Reynolds, 2005). Recently, studies have examined the development of response inhibition among children, adolescents and adults. Gains in attaining response inhibition appear rapidly in the preschool years for both simple and more complex inhibition tasks (Leon-Carrion et al., 2004). Inhibition abilities continue to develop as an individual gets older but at a more gradual rate. Although the performance on inhibition tasks may not demonstrate significant gains after the age of 8, the neural activity shifts from global regions of the prefrontal cortex (dorso-lateral extending to the anterior cingulate) to more localized activation patterns (ventral regions) of the prefrontal cortex for adults. In addition, individuals activating the orbitofrontal cortex perform best on inhibition tasks. These changes in neural activity reflect the growing efficiency of the brain and increasing functionality of the prefrontal cortex for complex response inhibition (Best and Miller, 2010; Blakemore & Choudhury, 2006; Leon-Carrion et al., 2004; Romine & Reynolds, 2005).

RESPONSE INHIBITION

When an inhibition deficit has been identified for a student, interventions should take into consideration the individual strengths and needs while providing a structured implementation plan (Silvana et al., 2003). Medication, planning and decision-making, behaviour management and environmental and task modification interventions have all attributed to increasing the performance of students with response inhibition deficits. Stimulant medication can be used to impact dopamine and norepinephrine receptors within the brain, increasing the ability to inhibit responses. This creates more opportunity to engage in active learning opportunities and positive interactions with others (Goldstein & Naglieri, 2008; Silvana et al., 2003). Decision making tasks can be challenging for individuals with limited executive control capacity (Del Missier et al., 2010).Other difficulties such as trouble formulating goals, creating plans to achieve the goals and implementation also impact planning. (Goldstein & Naglieri, 2008; Ylvisaker, Hibbard & Feeney, 2006). The use of self-regulatory routines and scripts within a natural setting helps to block impulsive decision making and behaviour. Explicitly taught skills in planning, set shifting and inhibition (e.g. Goal-Plan-Do-Review format) within the daily milieu can improve decision-making and promote on-task and self-monitoring behaviour (Goldstein & Naglieri, 2008; Ylvisaker & DeBonis, 2000). Students should also collaboratively engage with adults in identifying their goals and defining the interventions and supports that may be needed to achieve their goals (Ylvisaker & DeBonis, 2000). Effective behaviour management interventions should incorporate both antecedent and cost-response systems (Smith, Barkley & Sharpiro, 2006). Focusing on antecedent behaviour rather than reactive and delayed consequences is an effective way to shape behaviour (Smithet al., 2006; Ylvisaker et al., 2006).Impulsivity creates a breakdown between knowing and doing,

RESPONSE INHIBITION further impacting behavioural interventions.Reliance on punitive consequences is ineffective

because typically impulsivity overrides any associations with previous rewards and punishments. The part of the brain that initiates response inhibition (orbito-prefrontal cortex) is the same portion of the brain that enables humans to learn from consequences or benefit from feedback. Therefore, behaviour management programs that rely primarily on learning from consequences typically fail (Blakemore & Choudhury, 2006; Goldstein & Naglieri, 2008; Romine & Reynolds, 2005; Smith et al., 2006; Ylvisaker et al., 2006). In addition, the use of immediate, obvious and clear consequences should be used to mitigate the inability to anticipate future rewards as well as memory impairments. The use of tangible rewards is also more impactful than verbal praise alone. Finally, behavioural techniques should be implemented across situations, environments and over extended time intervals to avoid regression of behaviour back to pre-intervention baselines (Smith et al.,2006; Ylvisaker et al., 2006). There are several environmental and task modifications that can be implemented to help support students with response inhibition deficits. Well organized schedules and routines supported through visual representations create an orderly and predictable environment, helping impulsive students organize their behaviour more effectively. Reorganization of the daily routines to begin the day with high success tasks creates a positive beginning prior to the introduction of particularly challenging tasks (Ylvisaker & DeBonis, 2000). Although routines are important, it is also important to keep the environment engaging and check in with students regularly to avoid boredom and potential impulsivity (Smith et al., 2006; Ylvisaker et al., 2006). Generally, fast paced and interactive tasks help keep impulsive students on task with redirection as a way to refocus. These students have an active learning style with a need to move, talk, respond, question and debate (Goldstein & Naglieri, 2008). Providing opportunities for frequent

RESPONSE INHIBITION structured sensory breaks to expend some energy helps students get ready for the next activity. To further support the organization of specific tasks, break larger tasks into a series of smaller

steps with clear markers of completion for each step (Ylvisaker et al., 2006). Instructions should be delivered in a clear and concise manner, allowing for repetition (Silvana et al., 2003). The use of graphic organizers is also a way for students to provide visual cues and segment tasks successfully, further promoting independence (Ylvisaker & DeBonis, 2000). While there are many interventions to support inhibitory deficits, quality intervention requires a clear, detailed and thoughtful approach. According to Upah and Tilly (2002), intervention can be defined as a set of procedures and strategies designed to improve student performance with the intent of reducing the students problem (p. 483). Upah and Tilly (2002) propose a problem-solving approach consisting of a twelve point quality indicator model. This approach addresses the general areas of problem identification, problem analysis, plan implementation and problem evaluation to support best practice of quality interventions. To help illustrate this process, a twelve step intervention plan using this model will be created for a grade 6 student named Billy who struggles with response inhibition during one of his favourite subjects, writing. Problem Identification A clear and objective behavioural definition operationally describes the behaviour in specific, observable and measurable terminology. Using Billy as an example, on-task behaviour means that Billy is independently working for a specified period of time. Examples of on-task behaviour include sitting at his desk quietly, engaging in his writing task and working until his timer indicates it is time to end the activity. Non-examples of on-task behaviour include getting

RESPONSE INHIBITION

out of his desk, engaging in activities other than writing and talking with peers for the duration of the allotted time frame. Next, it is essential to establish a baseline to measure the target behaviour identified for intervention in the natural setting prior to implementation. Measuring a baseline helps evaluate the existence of the problem behaviour, effectiveness of the intervention and the degree of student progress throughout the process. To continue with Billys intervention, a duration baseline of on-task behaviour will be measured during the morning writing class. The educational assistant will observe Billy for the 20 minute writing block and record how many minutes and seconds he is engaged in on-task behaviour during the writing task using a timer that does not make sounds. The educational assistant will observe from approximately one to two metres away so Billy doesnt feel he is being watched. She will record her results on a daily chart and plot the results on a graph daily for two weeks to establish a baseline. Problem validation is the process of determining the magnitude of the problem by summarizing the difference between what is expected in a setting and the students current level of performance. For example, Billys grade 6 classmates are able to begin writing on their topic of interest once they receive their books and remain on-task for the entire 20 minutes of the class using writing prompts displayed on the board. Billy is easily distracted and impulsive, often only working on-task between two to five minutes at a time. The school psychologist and the teacher determined there was enough discrepancy between Billys performance and his classmates that intervention was warranted. Problem Analysis This critical step of the problem solving process determines what is currently known about the problem. It also establishes what important and relevant information is needed in order

RESPONSE INHIBITION to evaluate the underlying causes of why the problem is occurring. In Billys case, the school

psychologist should interview Billys teacher, educational assistant and parents to gather information about the instruction delivery and curriculum of the writing expectations. The psychologist also needs to gather information about the classroom environment, any current accommodations, modifications that have been tried in the past and success rates of those interventions. Information around Billys interests and learning style should also be collected. Billys cumulative school file should be reviewed to gather a historical perspective. Observations of Billys on -task behaviour in his writing class and assessments of his response inhibition skills and other executive functions could be conducted using the Behaviour Rating Inventory of Executive Function (BRIEF) teacher, parent and self-reporting inventories. Because Billy struggles with remaining on-task for the length of the writing class despite it being a high-interest activity for him, a hypothesis of why the behaviour occurs should be formulated. For example, Billys off-task behaviour occurs because he struggles to resist impulses and stop his own behaviour at the appropriate time while also controlling potential distractions(Barkley, 1997; Del Missier et al., 2010; Leon-Carrion et al.,2004). Because of a deficit in response inhibition, a prediction could be made regarding how the intervention will impact Billys on-task behaviour during the writing class, creating a direct and logical link between the assessment information and the intervention action. For example, if the

Goal-Plan-Do-Review decision-making format (Ylvisaker & DeBonis, 2000) was embedding within Billys daily writing routine (blocking impulsive thoughts), then on-task behaviour would be increased. The intervention will utilize the Goal-Plan-Do-Review format to provide a structured framework through the use of a graphic organizer to guide Billys behaviour during his writing task. After learning how to use the organizer, Billy will complete the decision-making format with the assistance of the teacher within the first 5 minutes of the writing class. Billy will

RESPONSE INHIBITION then use the Goal-Plan-Do-Review process throughout the remainder of the class to remain on task. Plan Implementation Setting clear, justifiable goals regarding the intended outcome helps direct teaching and intervention. This focus on student outcomes provides a structured method for assessment and evaluation. It is important the goal includes a time frame, a specific condition when the

behaviour occurs, a clear behavioural description and a criteria standard to evaluate success. The school psychologist should take into consideration the current performance level, target behaviour, realistic growth rate, reporting and follow up schedules and time frame of goal completion. In Billys case, a goal such as the following may be put into place: In 12 weeks, when completing his writing assignment in the morning, Billy will use his Goal-Plan-Do-Review graphic organizer with his teacher to plan his writing tasks within the first 5 minutes of class and refer to it throughout the class, resulting in on-task behaviour for 20 minutes. The intervention plan development should answer procedural questions, ensuring all parties involved (e.g. school psychologist, teacher, student, educational assistant) have the same understanding of the process. With Billys writing intervention, a checklist of the procedure will be easily accessible to everyone. At the beginning of the class, the educational assistant will collect and use the timer and observation chart to record the minutes and seconds Billy is engaged in on-task behaviour. Within the first 5 minutes of the writing class, the teacher will present Billy with the Goal-Plan-Do-Review graphic organizer, read the scripted instructions and support him in completion. The organizer will then be taped to a visible area on his desk so Billy can repeatedly refer to the plan throughout the twenty minutes. A decision-making plan should also be constructed to clarify how decisions will be made by describing the strategies used for data collection, summarization, and evaluation. For Billy,

RESPONSE INHIBITION data will be charted and recorded daily. If Billy demonstrates response inhibition and on-task behaviour for 20 minutes within his writing class for 5 consecutive days prior to 12 weeks, the time frame of the intervention will be reconsidered by the problem-solving team. If Billy does not demonstrate any progression in on-task behaviour after 10 days of intervention, the

10

implementation plan will be re-evaluated by the team and adjustments will be made accordingly.
Problem Evaluation

Throughout the intervention implementation, student progress is monitored and assessed on a continuous basis so modifications can be made as needed. Because Billys performance is recorded and graphed daily, this frequent monitoring provides a visual summary of the duration of on-task behaviour. This information can be used in the decision-making process regarding intervention effectiveness, performance progress and implementation of procedures. Formative evaluation also occurs throughout the implementation of the intervention. Success is determined through comparison between the baseline and the collected data by evaluating changes in mean, level, trend and latency. Following the decision-making plan, adjustments to the implementation can be made. Decisions around maintenance and generalization can also be discussed with the problem-solving team. For example, if Billy was able to remain on-task for 20 minutes for 5 consecutive days, discussions around generalization may occur to implement the Goal-Plan-Do-Review format with other subject areas. When evaluating the effectiveness of an intervention, treatment integrity must be considered. This can be measured in several different ways including interviewing the person implementing the intervention regarding procedural steps, direct observations or checklists. Monitoring provides information about the consistency and accuracy of the implementation, providing validity to student performance in relation to the intervention. For Billys intervention,

RESPONSE INHIBITION

11

a clearly written procedural checklist and instructional script are provided for the implementation team to ensure consistency and accuracy of implementation. The final step to quality intervention planning, implementation and evaluation is a summative evaluation upon completion of the intervention. Success is measured based on information gathered from the decision-making rules and the difference between the students baseline performance and the post-intervention performance. In Billys case, the implementation of the Goal-Plan-Do-Review graphic organizer format was successful in increasing his on-task behaviour from five to twenty minutes during his writing class. A plan to generalize this intervention to other academic blocks is underway.
Conclusion Executive functions are higher order processes that allow an individual to respond to the environment in a flexible manner and engage in deliberate goal-directed thoughts and actions (Barkley, 1997; Del Missier et al., 2010; Leon-Carrion et al., 2004). In research, response inhibition is identified as one of the primary EF responsible for inhibiting a dominant response, stopping an ongoing behaviour and controlling interference. Inhibition deficits (e.g. impulsivity) can negatively impact a students performance within the school setting. Understanding the neural structures and developmental approach associated with response inhibition aids in the understanding and development of effective interventions. Several interventions such as medication, planning and

decision-making strategies, behaviour management and modifications to tasks and the environment have been proven to positively support response inhibition deficits. Problem-solving
approaches to quality interventions such as the twelve point quality indicators identified by Upah and Tilly (2002) further best practice, tailoring clear and detailed interventions to individually support students and provide the best care possible.

RESPONSE INHIBITION

12

References Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing an unifying theory of ADHD. Psychological Bulletin, 121(1), 6594. doi:10.1037/0033-2909.121.1.65 Blakemore, S. & Choudhury, S. (2006). Development of the adolescent brain: Implications of executive function and social cognition. Journal of Child Psychology and Psychiatry, 47(3/4), 296-312. doi:10.111/j.1469-7610.2006.01611.x Berlin, L., Bohlin, G., Nyberg, L. & Janols, L. (2004). How well do measures of inhibition and other executive functions discriminate between children with ADHD and controls? Child Neuropsychology, 10(1), 1-13. Best, J. R. & Miller, P. H. (2010). A developmental perspective on executive function. Child Development, 81(6), 1641-1660. doi: 0009-3920/2010/8106-0002 Del Missier, F., Mantyla, T. & Bruine de Bruin (2010). Executive functions in decision making: An individual differences approach. Thinking & Reasoning, 16(2), 69-97. doi: 10.1080/13546781003630117 Goldstein, S. & Naglieri, J. A. (2008). The school neuropsychology of ADHD: Theory, assessment, and intervention. Psychology in the Schools, 45(9), 859- 875. doi: 10.1002/pits.20331

RESPONSE INHIBITION Lambek, R., Tannock, R., Dalsgaard, S., Trillingsgaard, A., Damm, D. & Thomsen, P. H. (2010). Validating neuropsychological subtypes of ADHD: How do children with and

13

without an executive function deficit differ? Journal of Child Psychology and Psychiatry, 51(8), 895-904. doi: 10.111/j.1269-7610.2010.02248.x Leon-Carrion, J., Garcia-Orza, J., & Perez-Santamaria, F. J. (2004). Development of the inhibitory component of the executive functions in children and adolescents. International Journal of Neuoscience, 114, 1291-1311. doi: 10.1080/00207450490476066 Packwood, S., Hodgetts, H. M. & Tremblay, S. (2011). A multiperspective approach to the conceptualization of executive functions. Journal of Clinical and Experimental Neuropsychology, 33(4), 456-470. doi: 10.1080/13803395.2010.533157 Scope, A., Empson, J. & McHale, S. (2010). Executive function in children with high and low attentional skills : Correspondences between behavioural and cognitive profiles. British Journal of Developmental Psychology, 28, 293-305. doi:10.1348/026151009X210371 Silvana, M.R., Westby, W., & Westby, C.E. (2003). Strategies for addressing the executive function impairments of students prenatally exposed to alcohol and other drugs. Communication Disorders Quarterly, 24(4), 194-204. Smith, B. H., Barkley, R. A. & Shapiro, C. J. (2006). Attention-deficit/hyperactivity disorder. In Mash, E. J. & Barkley, R. A. (Eds.), Treatment of Childhood , (pp. 65-136). New York, NY: The Guilford Press. Upah, K. & Tilly, D.W. (2002). Best practices in designing, implementing, and

RESPONSE INHIBITION evaluating quality interventions. In Thomas, A. & Grimes, J. (Eds.), Best practices in school psychology (pp. 483-501). Bethesda, MD: NASP Publications. Ylvisaker, M. & DeBonis, D. (2000). Executive function impairment in adolescence: TBI and ADHD. Topics in Language Disorders, 20(2), 29-57. Ylvisaker, M., Hibbard, M.& Feeney, T. (2006). Tutorial: Impulsiveness/disinhibition.

14

Retrieved from http://www.projectlearnet.org/tutorials/impulsiveness_ disinhibition.html