Prioritizing Treatment 9.16

By Emerson Dickman

Executive Function - Prioritizing Treatment

“For every complex problem there is an answer that is clear, simple, and wrong” (H. L. Mencken).

There is no doubt that we humans are complex organisms physiologically, cognitively, socially, and emotionally.  Each of these aspects of us is complex and all are intertwined.  We are each an untangleable Gordian Knot made up of matter, chemicals, emotions, and social need.  When a child evidences a profile that threatens the fundamental integrity of our complex nature “we must ‘disentangle this huge conglomerate mass’ (Doris, 1993, p. 112) if we are to develop truly efficacious methodology and service delivery” (Dickman, 1996).  In this case “disentangle” refers to being able to determine what is important from what is insignificant.

Forcing a child, in the interests of full inclusion, to attend a class in geometry when the child can’t make change for a dollar or tell time on an analogue clock, is ridiculous.  In the medical profession, when a patient has multiple injuries there are protocols to determine what to treat.  If there is an immediate threat to life, for instance, assess the patient’s needs in the following order:

1.    Cardiorespiratory function: is the heart beating and the patient breathing?

2.    Control severe bleeding: stop bleeding restore fluids.

3.    Assess abdominal injuries: rule out internal bleeding and damage to internal organs.

4.    Assess brain and spinal cord.

The point is that the field of medicine dedicates a great deal of time and effort to determining the order of the injuries that must be treated to most effectively save the patient’s life.  Often the order is common sense (e.g., heart has stopped, worry about the broken finger later).  Other times the order is based on experience and data (e.g., check for abdominal injuries before head and spine).

As far back as 1996 educators and researchers referred to individuals with a particular profile of executive weaknesses with at least eleven (11) different names: 1) right hemisphere dysfunction, 2) nonverbal learning disability, 3) semantic pragmatic learning disability, 4) nonverbal right hemisphere learning disability, 5) social communications spectrum disorder, 6) social perception disability, 7) nonverbal perceptual organization output disability, 8) left hemisyndrome, 9) right parietal lobe classification, 10) nonverbal social learning difficulties, and 11) social-emotional learning disability.  Byron Rourke finally coined the name that seemed to stick (i.e., Nonverbal Learning Disability - NLD).  From my perspective the main focus of most of the experts involved was the social implications of such a profile.  However, the social implications that are experienced by such individuals appear merely consequential or incidental.  By that I mean that social problems are not a neurological weakness, but merely consequence of a neurological weakness.  For instance, if a child has a theory-of-mind weakness together with deficits with self-regulation the child is likely to find it difficult to find and keep friends.  Of course a recognized and respected talent (e.g., athletics, art, music) can often ameliorate the negative impact of such weaknesses.  However, the more significant point is that consequential social issues are not going to be efficiently addressed in a social skills class without addressing the underlying theory-of-mind and self-regulation deficits.

In order to effectively address the needs of the patient or the child you have to establish a protocol that focuses on what is important and doesn’t spend time, money, and expertise on splinting a finger before treating a sucking chest wound.  It is also true that a circumstance that masks the existence of a condition in need of treatment should be given proper weight in the big picture.  For instance, if the medical profession judged need based solely on appearance there would be no prevention and fewer cures.  In other words, talent that merely hides the deficit may not always have significant cachet.

Just some of the skills and abilities that are said to be influenced by a profile of deficits in executive functioning, sometimes referred to as NLD, include, but are not limited to:



·         Cognitive flexibility

·         Cognitive judgment

·         Conceptualizing

·         Use of demand language

·         Directionality

·         Emotional control

·         Figurative language

·         Generalizing

·         Gestalt

·         Hierarchies

·         Inhibiting

·         Initiating

·         Learning from experience

·         Literal

·         Paralinguistics (nonverbal cues)

·         Perspective taking

·         Planning

·         Prioritizing

·         Retaining learned information

·         Self-direction

·         Self-monitoring

·         Self-regulation

·         Sequencing

·         Shifting set

·         Temporal processing

·         Theory-of-mind

·         Time management

·         Utilizing feedback

·         Working memory


The impact is often more encompassing than one might expect:

1.    Academic (e.g., comprehension, expository writing, math).

2.    Social (e.g., literal, pragmatic communications, self-regulation).

3.    Emotional (e.g., hyper-vigilance, anxiety, cognitive dissonance, external locus of control, diminished frustration tolerance, depression).

4.    Physiological (e.g., higher than normal secretions of adrenaline and cortisol).