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OM: I hadn’t realized that all the pieces were part of one picture. Sara has so much potential — I want her to have a normal fulfilling life!

TEACHER: Sara is smart. It’s just that her disorganization and lack of executive functioning skills interfere with her ability to get any learning done.

SARA: I just want to be like all the other girls in my class.

Sara and I are sitting at a table covered with paper dolls clothes and accessories. On my side I’ve arranged little piles by category: tops here skirts there then accessories. Sara’s side looks like a hurricane has hit.

I hold up my doll. “This is Hindy.”

“This is Mindy!” Sara returns. “Twins! Let’s dress them alike!” Clearly she’s bright and creative.

“Can you make your side look like mine?”

Sara looks blank. I look meaningfully from my piles to her side but she doesn’t get the cue.

Sara displays no joint attention (shared attention between two people usually using a nonverbal cue). She cannot follow what I am doing.

Taking the lead I select clothes from my piles: A dark blue skirt white blouse Mary Janes. I hold up my doll. “All ready! Can you dress your doll to match mine?”

She can… with help. And it takes far too long.

When Sara knows what the end result should look like she can copy it but her disorganization slows her down.

When the evaluation is over I send Sara out ahead of her mother. “Sara suffers from poor executive function skills” I tell her frankly.

Mrs. Gelbwirth looks puzzled. “Executive what?”

“‘Executive function’ is the mental skills that enable you to get things done: to plan what you want to do figure out what you’ll need to do it and actually follow the steps to accomplish it. This skill set includes the ability to regulate your emotions as well as the ability to keep information in your head long enough to make use of it called ‘working memory.’ Without these skills you can’t function properly in life.”

The silence hangs for a moment. Mrs. Gelbwirth stares across the hall to where Sara sits.

“Sara can’t think outside the present moment” I continue. “When you tell a child to clean their room they have to be able to picture what a clean room will look like and work backward from there. Sara can’t plan tasks. She can’t figure out right arm first then left or put this here for a minute until I’m ready for it. That’s why she’s always ‘flying ’ with her stuff all over the place.” $$$$(3)$$$$

We look at Sara and see a kid who’s a mess. But Sara experiences the world as chaotic and unpredictable. No wonder she has meltdowns!

Mrs. Gelbwirth nods.

“She doesn’t ‘get’ what’s going on around her so of course she can’t respond to it appropriately and even when she knows what to do she doesn’t know how to get it done. All this causes tremendous frustration but emotional regulation is a weak point for her too. You’re CEO of your business; you have a handle on every part of the company. Sara doesn’t have a handle on anything.”

“What can we do?”

“We can teach her the skills she’s missing: futuristic thinking time management situational awareness how to break a task down into its parts. She’ll go from being a helpless kid to the CEO — in control of every part of her life.”

D. Himy M.S. CCC-SLP is a speech-language pathologist in private practice for over 15 years.