L6 Cognitive Skills and Executive Functions PDF

OT1029 OCCUPATIONAL THERAPY IN PEDIATRICS: EVALUATION AND INTERVENTION SHIFT 2 Cognitive Skills and Executive Functions...

OT1029 OCCUPATIONAL THERAPY IN PEDIATRICS: EVALUATION AND INTERVENTION SHIFT 2 Cognitive Skills and Executive Functions LESSON Maria Ruby P. Fariñas, MFLCD, OTRP | September 22, 2024 06.. ○ Not limited to academic related concepts when OCCUPATIONAL THERAPY PRACTICE FRAMEWORK Performance Skills we talk about cognitive skills. These are actions ○ Motor Skills and processes manifested through behaviors. Involved in moving and interacting with objects or environment JEAN PIAGET’S THEORY OF COGNITIVE DEVELOPMENT Posture, mobility, “The purpose of intelligence was to help humans adapt to coordination, strength, effort, the environment. In the process of adaptation, cognitive and energy structures changed through the process of assimilation ○ Process Skills and accommodation (Piaget, 1952).” Used in completing daily tasks ○ Individuals adjust to experiences based on what Includes energy, knowledge, they knew from previous experiences. temporal organization, ○ Assimilation and accommodation should have a organizing space and balance to allow for cognitive growth and objects development. Maintaining attention, ○ Assimilation choosing appropriate tools an individual adjusts his experiences to and materials for the tasks fit his prior concepts. ○ Communication/Interaction Skills ○ Accomodation Needed to interact with other people adjusting your concepts because they Include physicality, information do not readily fit your new experiences. exchange, and relations The stages are resulting from biologic pressure to adapt Gesturing to indicate attention, to the changing environment and organized structure of expressing affect and relating thinking in a manner that will establish rapport with others PIAGET’S STAGES OF COGNITIVE DEVELOPMENT COGNITIVE SKILLS STAGE AGE TYPE OF SKILLS TYPES OF RANGE THOUGHT LEARNED PLAY COGNITIVE DEVELOPMENT Mental processes of thinking and understanding Sensorimotor 0-2 Motor schemas Object Sensorimotor Ability to use the senses to gather information and make (has 6 Sensory permanence Functional substages) information Language Constructive sense of the world Imitation ○ Through cognitive development, you can Shortest but receive, interpret, and make use of information most crucial to function properly on a daily basis Develops Progressive building of learning new skills ability to ○ Starting from infancy organize and Evaluate, analyze, remember, compare, understand coordinate sensations with cause and effect physical ○ Apply in different areas of occupation movements and actions COGNITIVE SKILLS Preoperational 2-7 Egocentrism Centration Symbolic play Actions that one uses to plan and manage the Symbolic Irreversibility Make-believe performance of activity such as being able to initiate, representation play organize, and complete a task. Animistic thought ○ Cognitive skills manifest as behavior. Other cognitive skills: problem solving, using sound Concrete 7-11 Concrete Conservation Games with judgment, and being able to prioritize and sequence operational Logical Decentration rules activities. Reversibility Seriation Cognitive skills are not limited to concepts alone. These Transitivity concepts are embedded in the skills and the behaviors. ○ Concepts: letters, numbers, shapes, colors, Formal 12+ Abstract Hypothetico-De Social matching, sorting, etc. operational thought ductive relationships Reasoning UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 1 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions 6 SUBSTAGES OF SENSORIMOTOR DEVELOPMENT ○ Infant manipulates a stick in order to bring an attractive toy within reach. ○ Visually inspect a toy and touching it SIMPLE REFLEXES Infants behavior is dominated by reflexes such as sucking TERTIARY CIRCULAR REACTIONS, NOVELTY, AND CURIOSITY and palmar grasp. Age Child repeatedly attempts tasks and modifies behavior to ○ Birth to 1 month achieve desired consequences. Description Beginning tool use is a hallmark of this stage. ○ Coordination of sensation and action through ○ Using spoon to eat, cup to drink reflexive behaviors. Age Example ○ 12 to 18 months ○ Rooting, sucking, and grasping reflexes; Description newborns suck reflexively when their lips are ○ Infants become intrigued by the many properties touched. of objects and by the many things they can make happen to objects; they experiment with new behavior. FIRST HABITS AND PRIMARY CIRCULAR REACTIONS Example Repeats reflexive movement because of pleasure. The ○ A block can be made to fall, spin, hit another movements are focused towards the infant’s body. object, and slide across the ground. Age ○ 1 to 4 months INTERNALIZATION OF SCHEMES Description ○ Coordination of sensation and two types of Invention of new means through mental combination. schemes: habits (reflex) and primary circular ○ Mental representation of objects reactions (reproduction of an event that initially Cannot directly imitate when done in front of them but can occurred by chance). Main focus is still on the imitate actions based on recall/memories infant's body. ○ Language also emerges Example Age ○ Repeating a body sensation first experienced by ○ 18 to 24 months chance (sucking thumb, for example); then Description infants might accommodate actions by sucking ○ Infants develop the ability to use primitive their thumb differently from how they suck on a symbols and form enduring mental nipple. representations. Example ○ An infant who has never thrown a temper SECONDARY CIRCULAR REACTIONS tantrum before sees a playmate throw a tantrum; Uses voluntary movements to repeat actions the infant retains a memory of the event, then ○ The infant hit a rattle with his hands and it throws one himself the next day. produced a sound, so the infant will hit it again. Age The output of all skills can be seen through play expectations. ○ 4 to 8 months (See table of stages of Cognitive Development) Description ○ Infants become more object-oriented, moving PREOPERATIONAL STAGE beyond self-preoccupation; repeat actions that bring interesting or pleasurable results. Example 2-4 YEARS ○ An infant coos to make a person stay near; as The child starts developing symbolic thought. the person starts to leave, the infant coos again. Considering objects that are not directly in front of them but planning to use it for their tasks and actions Egocentrism COORDINATION OF SECONDARY CIRCULAR REACTIONS/ ○ Inability to realize that others have thoughts and SCHEMA feelings that may not be the same as their own. Combining previously learned skills and generalizing it. ○ Self-centered thinking Object permanence is a hallmark for this stage. An Animism object exists even if it cannot be seen. ○ Mental act of giving inanimate objects lifelike Age qualities. ○ 8 to 12 months ○ Reflected on their type of play which is symbolic Description ○ Coordination of vision and touch—-hand-eye coordination; coordination of schemes and intentionality. Example UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 2 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions 5-7 YEARS Outcome is seen through social relationships Intuitive thought ○ Make conclusions, decisions, or judgements DEVELOPMENT OF COGNITIVE SKILL without relying on explicit reasoning or Development of cognitive skills are derived from multiple conscious analytical thought. Acts based on gut resources so we have to check UT3 and OTPF-4 feeling. Use UT3 and OTPF-4 to identify imbedded skills evident Centration in each developmental stage for the specific ○ Learns centration or concentrating on a single terminologies and skills feature of an object and excluding other Ask yourself: What specific cognitive skills can be features. expected at this age based on the description? ○ Showing child 2 glasses with different shapes and height but same amount of liquid. The child 0-6 MONTHS will focus only on the height OR the shape. So Infants learn to repeat behaviors that produce desired they will say that one glass has more liquid results (sucking thumb, shaking rattle; understands because it is taller (concentrating on the height) simple cause and effect); very interested the but not realizing that the other glass is wider environ-ment, especially faces; amount of time awake, (disregarding width). alert, and attentive increases; mouths objects; Irreversibility recognizes familiar caregivers; coos, smiles, and babbles ○ If something is altered or changed, it cannot be ○ Amount of time awake, alert, and attentive restored to its previous condition. increase ○ Knocking over blocks, changing arrangement of level of arousal - UT3 toys ○ Recognition - UT3 ○ Attention - OTPF 4 CONCRETE OPERATIONAL STAGE Repeats actions for pleasurable experiences Uses hands and mouth to explore objects 7-11 YEARS Searches with eyes for sound Can manipulate concrete objects and events Bangs object on table Conservation Integrates information from multiple sensory systems ○ If nothing is added or taken away, then the amount of something stays the same. 6-12 MONTHS ○ 2 clay balls of same size and weight, when you Able to coordinate schemes applied to external objects to turn the other one into a log (making it appear accomplish a goal, e.g., uses a stick to retrieve a toy; longer), the child with conservation knows that imitates simple motor movements and sounds; it’s still the same as the other clay despite it recognizes his or her name; begins to use tools such as changing shape spoons, for intended purpose; begins to understand that Decentration objects exist even if they cannot be seen (beginning ○ Focus on two things at the same time object permanence) by searching for hidden objects; Reversibility simple problem solving through trial and error; figures out ○ Believe that objects can be revered into original simple shape sorters, pop-up toys, etc.; likes peek-a-boo; state responds to simple requests Seriation Responds to own name ○ Logical order, sequence, mathematical concepts Recognizes words and family members names Transitivity Responds with appropriate gestures ○ Property of relationships or comparisons. Listens selectively Logical conclusions based on outcome of their Imitates simple gestures play (games with rules) Looks at picture book ○ If A is greater than B and B is greater than C, Begins to generalize from past experiences then A is greater than C Acts with intention on toys Takes objects out of container FORMAL OPERATIONAL STAGE 1-2 YEARS 12+ YEARS Develops a mature concept of object permanence Adolescence has the ability to think about possibilities (searches for hidden objects even when he/she does not and realities to formulate hypothesis and they can make see the object be moved); experiments and plays with decisions based on those objects in novel ways; evidence of memory functions Moral thinking (knows where favorite toys are kept; uses words; stranger Aim is more on pleasing others and being good members anxiety with unfamiliar adults); proficient in activating of the society (conforming to standards of others and cause-effect toys; groups and stacks toys; develops the obeying the law) UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 3 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions capacity for representation or the ability to use ideas or 6-12 YEARS images to represent ob- Academic performance in reading, writing, and Acts on object using variety of schema mathematics becomes important; reading should be Imitates model proficient by the end of third grade; begins abstract Symbolic play with real props (e.g., pretends to drink with thinking, with logical reasoning; understands cup) consequences of actions Understands how objects work Abstract reasoning Understands function of objects Performs mental operations without need to physically try Uses trial-and-error in problem-solving Demonstrates flexible problem solving Recognizes names of various body parts Solves complex problems Links multiple steps together Has inanimate object perform action 12+ YEARS Begins to use non realistic objects in pretend play Ability for advanced abstract reasoning develops, and Continues to use objects according to functional purpose more advanced academics, and more responsibility for Object permanence is completely developed self-directed learning; has knowledge of major current events; understands consequences, and logical 2-4 YEARS reasoning is more advanced and can project into the Develops basic preschool skills, such as identifying future name, body parts, age, colors, shapes, and some letters and numbers; counts objects up to 10 and may rote count EVALUATION further; discovers causal mechanisms, such as winding The output of thinking is play. Thinking is observed in play up a toy; performs meaningful actions in a sequence, participation such as carrying out a pretend tea party; speaks in small Think of activities to elicit desired skills and behaviors that sentences you are looking for Combines actions into entire play scenario (e.g., feeding Grading doll, then dressing in nightwear, then putting to bed) ○ Age-appropriate (AA) Shows interest in wearing costumes; creates entire ○ Age-inappropriate (AI) scripts of imaginative play Matches pictures Different grading (for other centers) Sorts shapes and colors ○ Emerging (P) Plays house Presence of skill (not totally absent, but Uses imaginary objects in play not consistent) Makes dolls and action figures carry out roles and interact ○ Developing (F) with other toys Developing, more evident, but prompts Categorizes and sorts objects are needed sometimes. Not Shows a sense of humor generalized yet ○ Mastery (G) 4-6 YEARS Clients can be in early stages of development e.g., 2 to 7, Develops an understanding of conservation of liquid and that’s too long of a range, and you can’t say AI, so volume; understands that the same amounts can appear you score with emerging, developing or mastery different depending on the size and shape of the container; develops number concepts to allow for simple OTPF 4 addition and subtraction problems; may begin to read simple words; concepts of time develop, including telling time and knowing days of the week MENTAL FUNCTIONS Understands rules to a game Remembers rules with a few reminders Specific Mental Functions Makes up stories that involve role playing with other Higher level Judgment, concept formation, children Participates in goal-oriented, cooperative play cognitive metacognition, executive func-tions, praxis, with two or three other children cognitive flexibility, insight Participates in planning a play activity Begins abstract problem solving Attention Sustained shifting and divided attention, Reasons through simple problems concentration, distractibility Bases play more on real life than on imaginary world Participates in organized games Memory Short-term, long-term, and working memory Uses complex scripts in play Demonstrates deferred imitation Sorts objects in different ways Perception Discrimination of sensations (e.g., auditory, Copies elaborate block structures tactile, visual, olfactory, gustatory, vestibular, proprioceptive) UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 4 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions Thought Control and content of thought, awareness Initiation of Activity Starting a physical or mental of reality vs. delusions, logical and coherent activity thought Termination of Activity Stopping an activity at an Mental Mental functions that regulate the speed, appropriate time Functions of response, quality, and time of motor Sequencing production, such as restlessness, toe Memory Recalling information after brief Complex tapping, or hand wringing, in response to or long periods of time Movement inner tension Sequencing Placing information, concepts, Emotional Regulation and range of emotions; and actions in order appropriateness of emotions, including anger, love, tension, and anxiety; lability of Categorization Identifying similarities of and emotions differences among pieces of environmental information Experience of Awareness of one's identity (including self and time gender identity), body, and position in the Concept Formation Organizing a variety of reality of one's environment and of time information to form thoughts and ideas Global Mental Functions Spatial Operations Mentally manipulating the Consciousness Consciousness position of objects in various State of awareness and alertness, including the clarity and continuity of the wakeful relationships state Problem Solving Recognizing a problem, Orientation Orientation to person, place, time, self, and defining a problem, identifying others alternative plans, selecting a plan, organizing steps in a Psychosocial General mental functions, as they develop plan, implementing a plan, and over the life span, required to understand evaluating the outcome and constructively integrate the mental functions that lead to the formation of the Learning Acquiring new concepts and personal and interpersonal skills needed to behaviors establish reciprocal social interactions, in terms of both meaning and purpose Generalization Applying previously learned concepts and behaviors to a Temperament Extroversion, introversion, agreeableness, variety of new situations and personality conscientiousness, emotional stability, openness to experience, self-control, self-expression, confidence, motivation, INTERVENTION impulse control, appetite What skills can the following activities facilitate? ○ Go back to toy and activity analysis Energy Energy level, motivation, appetite, craving, impulse Board Games Sleep Physiological process, quality of sleep UNIFORM TERMINOLOGY III COGNITIVE INTEGRATION AND COGNITIVE COMPONENTS Level of Arousal Demonstrating alertness and Problem solving, emotional regulation, responsiveness to concept formation, attention, memory, environmental stimuli and more Orientation Identifying person, place, time, and situation Recognition Identifying familiar faces, objects, and other previously presented materials Attention Span Focusing on a task over time UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 5 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions Arts and Crafts Musical Activities Mindfulness and Breathing Exercises Cooking and Online Baking Activities Scavenger Role Playing, Hunt Pretend Play, and Make-believe Play Outdoor Play Sensory Play EXECUTIVE FUNCTIONS Executive functions are not separate from cognitive skills. It is under cognitive skills. ○ In OTPF-4, it is under mental functions. A neuropsychological concept referring to the cognitive processes required to plan and direct activities, including task initiation and follow-through, working memory, sustained attention, performance monitoring, Memory inhibition of impulses, and goal-directed persistence Games (Dawson and Guare, 2004). ○ For daily goals, ADLs, and academic participation Lego and TWO DIMENSIONS OF EXECUTION SKILLS Building Blocks THINKING (Cognition) DOING (Behavior) Working Memory Response Inhibition Planning/Prioritization Emotional Control Organization Sustained Attention Storytelling Time Management Task Initiation and Reading Metacognition Goal-directed persistence Flexibility THINKING ○ Allows us to select and achieve goals or to develop problems UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 6 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions DOING ○ Comprehensive Behavior Rating Scale for ○ In order for us to reach our goals to guide and Children modify behaviors Formal Assessments ○ Wisconsin Card SortingTest EXECUTIVE FUNCTIONS ○ NEPSY ○ Mesulam Tests of Directed Attention Response The capacity to think before you act. Inhibition Controlling impulses BEHAVIOR RATING INVENTORY OF EXECUTIVE FUNCTIONS The ability to hold information in memory Authors: Gioia, Isquith, et al. while performing complex tasks. Assess executive function behaviors in the school and Working Memory Manipulation of information home environments while you hold the information 86 item questionnaire for parents and teachers The ability to manage emotions to 5 – 18 years old achieve goals, complete tasks, or control BRIEF (Parent and Teacher Questionnaire for children Emotional Control and direct behavior. 5-18) Like frustration tolerance BRIEF Preschool (2 – 5.11 years old) BRIEF Self-Report (11-18 years old) The capacity to keep paying attention to a situation or task in spite of distractibility, 3-point Likert Scale Sustained ○ (1) NEVER fatigue, or boredom. Attention ○ (2) SOMETIMES Attention span: compute by multiplying age to 2 to 3 ○ (3) OFTEN The ability to begin projects without Task Initiation undue procrastination, in an efficient or timely fashion. Planning/ The ability to create a roadmap to reach prioritization a goal or to complete a task. The ability to create and maintain systems to keep track of information or Organization materials. Have systems The capacity to estimate how much time Time Management one has, how to allocate it, and how to stay within time limits and deadlines. The capacity to have a goal, follow Goal-directed through to the completion of the goal, CLINICAL SCALES (BRIEF) Persistence and not be put off by or distracted by Behavioral Regulation Index (Inhibit, Shift, Emotional competing interests. Control) The ability to revise plans in the face of Metacognition Index (Initiate, Working Memory, Flexibility obstacles, setbacks, new information, or Plan/Organize, Organization of Materials, Monitor) mistakes. Global Executive Composite – total of 8 The ability to stand back and take a bird’s eye-view of yourself in a situation, to CLINICAL SCALES (BRIEF-2) Metacognition observe how you problem solve. Behavioral Regulation Index (Inhibit, Self Monitor) Adjust yourself as needed Emotional Regulation Index (Shift, Emotional Control) Cognitive Regulation Index (Initiate, Working Memory, EVALUATION Plan/Organize, Organization of Materials, Task Monitor) Informal Assessments Global Executive Composite – total of 9 ○ Case History/Interview ○ Classroom Observations ○ Work Samples Sample output from school (worksheets, projects, exams, homework) Behavior Checklists ○ Behavior Rating Inventory of Executive Functions (BRIEF) ← most common UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 7 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions vacuuming, dusting, etc.) Perform chores that take 15-30 minutes (for example, clean up after dinner, rake leaves) Bring books, papers, assignments home and take them back to school Keep track of belongings when away from home Complete homework assignments (1-hour maximum) Plan simple school project such as book reports (select book, read book, write report) Keep track of changing daily schedule (for example, different activities after school) The difference of BRIEF and BRIEF-2 is terms and categorization only Save money for desired objects, plan how to earn money EXECUTIVE FUNCTIONS Expected developmental task for each age range Inhibit/self-regulate: behave when teacher is ○ Not explicit about specific executive function out of the classroom; refrain from rude skills. It is up to you to identify evident skill in comments, temper tantrums, bad manners each stage Grades 6-8 Help out with chores around the home, Grading for EF is G, F, P including daily responsibilities and occasional tasks (for example, emptying dishwasher, raking leaves, shoveling snow); tasks may take AGE RANGE DEVELOPMENTAL TASK 60-90 minutes to complete Preschool Run simple errands (for example, "Get your Babysit younger siblings or other kids for pay shoes from the bedroom") Use a system for organizing schoolwork, Tidy bedroom or playroom with assistance including assignment books, notebooks, etc. Perform simple chores and self-help tasks with Follow complex school schedule involving reminders (for example, clear dishes from changing teachers and changing schedules table, brush teeth, get dressed) Plan and carry out long-term projects, including Inhibit behaviors: don't touch a hot stove, run tasks to be accomplished and reasonable into the street, grab a toy from another child, timeline to follow; may require planning multiple hit, bite, push, etc. large projects simultaneously Kindergarten Run errands (two- to three-step directions) to grade 2 Plan time, including after-school activities, Tidy bedroom or playroom homework, family responsibilities; estimate how long it takes to complete individual tasks and Perform simple chores, self-help tasks; may adjust schedule to fit Inhibit rule breaking in the need reminders (for example, make bed) absence of visible authority Bring papers to and from school Complete homework assignments (20-minute maximum) Decide how to spend money (allowance) Inhibit behaviors: follow safety rules, don't swear, raise hand before speaking in class, keep hands to self Grades 3-5 Run errands (may involve time delay or greater distance, such as going to a nearby store or remembering to do something after school) Tidy bedroom or playroom (may include UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 8 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions WHAT SPECIFIC EF SKILL/S CAN BE OBSERVED? Disorganized because of a needed checklist. Not memory, because he knows what he needs REASONS TO TEACH EXECUTIVE FUNCTIONING SKILLS EXPLICITLY EF skills are shaped (not innate) ○ Essential ○ Can be learned ○ Help survive everyday lives They are life skills They build independence ○ Help improve self esteem EF skills impact social skills Strong EF skills support academics EF skills enhance problem-solving abilities They are a component of SEL (self-management) Interventions support struggling kids Research supports teaching EF skills Proactively teaching EF skills supports all learners Learning tough skills requires practice UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 9 OT1029 SHIFT #2 | LESSON #6 | Cognitive Skills and Executive Functions EF skills teach positive study habits be handed in. Devon will arrange his room according to To be efficient in how we do things categories of objects. INTERVENTION Step 2: Design Intervention What environmental supports will be provided to help reach STEPS IN EF INTERVENTION PLANNING the target goal? 1. Collect assessment information from a variety of sources. Homework folders 2. Review data. Checklist of assignments and materials a. Including work sample Monitoring by parents and teacher b. Including Evaluation Pictures of model room 3. Select one executive skill domain for initial intervention Storage bins with labels and identify a specific behavioral goal. Cleaning sequence checklist 4. Design the intervention, incorporating important elements Cueing by parents and computer (environment, specific skills and procedures, incentives for child) What specific skill will be taught, who will teach the skill, 5. Evaluate intervention effectiveness. and what procedure will be used to teach it? a. Adjust plan if needed Skill: Organizing homework and room Who will teach the skill? Teacher and parents INTERVENTIONS TO PROMOTE EF SKILLS Procedure: Teacher checks for assignments recorded, materials INTERVENE AT THE LEVEL OF THE ENVIRONMENT needed, and assignments returned in folder. Changing the physical or social environment Parents check folder for presence of homework. ○ Which the child is placed Materials in room are categorized. ○ Determine if there are impediments that can be Storage spaces are made available and labeled. removed or added Checklist for cleaning is developed and used. Changing the nature of the task Parents monitor/cue and computer cues. ○ Just right challenge Changing the way cues are provided What incentives will be used to help motivate the child to ○ Have cues such as verbal prompts or reminders, use/ practice the skill? visual cues, schedules Improved grades with on-time completion of work Changing the way adults interact with students Retention of and ready access to belongings ○ Involve the children in the decision making process Motivating for children Decide on the cueing system or incentives they will receive INTERVENE AT THE LEVEL OF THE PERSON By motivating the student to use executive skills that he/she is reluctant to employ By teaching the student different ways to develop or fine-tune executive skills he/she needs TEACHING CHILDREN EXECUTIVE SKILLS Step 1: Describe the problem behaviors. Step 2: Set a goal. Step 3: Establish a procedure or set of steps to reach the goal. Step 4: Supervise the child following the procedure. Step 5: Evaluate the process and make changes if necessary. Step 6: Fade the supervision. Step 1: Establish Behavioral Goal Target executive skill(s): Organization Specific behavioral objectives: Devon will keep track of work handed out by his teacher, materials needed, and homework to UST OT 2026 | Occupational Therapy in Pediatrics: Evaluation and Intervention 10