Diamonsd 2018

2/27/18

Diamonds March 10, 2018

Unstuck and On Target: Improving Executive Function, On-Task and Flexible Behavior

Lauren Kenworthy, PhD I receive royalties for Professor, Pediatrics, GW Medical School sale of Unstuck Director, Center for Autism Spectrum Disorders Children’s National Medical Center manuals and BRIEF forms. [email protected]

Unstuck Team Ivymount Model Asperger Program/Take2 Summer Camp • Katie Alexander • Lynn Cannon • Monica Werner Children’s National Center for Autism Spectrum Disorders • Laura Anthony • Lauren Kenworthy • John Strang • Cara Pugliese Copyright 2011, 2014 Brookes

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GOAL: Increase your understanding of executive functions and how to enhance them PLAN 1. What are Executive Functions (EF)? Ø EFs are fractionated and plastic 2. Why do they matter? Ø EFs are necessary for effective everyday functioning 3. Specific components of EF & accommodations Ø Flexibility, Organization, Planning/Working Memory problems 4. How can we treat EF problems in autism? Ø In everyday settings, with self regulatory scripts

“The Unity and Diversity of Executive Functions”

Initiate Working Memory PlanningInitiate Organization/IntegrationWorking Memory Plan/OrganizeTask Monitor Task Monitor

Inhibit Flexibility Self-Monitor Emotional Control Inhibit Flexibility Self-Monitor Emotional Control

Teuber, 1972; Gioia, et al 2002; 2016; Friedman & Miyake, 2017

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Executive Dysfunction (Teuber, 1964): “The curious dissociation between knowing & doing” EF problems relate to:

• Adaptive daily living skills • Academic learning • Locus of Control • Family stress • Adult outcomes

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Adaptive Skills by Age Group (ASD n=421; Mean IQ =103)

105

100

90 4-5.99 85 6-7.99

80 8-9.99

75 10-11.99

12-13.99 70

Vineland Standard Score Standard Vineland 14-20 65

55 Communication Daily Living Skills Socialization Pugliese et al, Mean Domain Scores in Each Age Group 2015

Adaptive Skills by Age Group (ASD n=327) IQ 105

100 Age Adap9ve EF Behavior 95

90 4-5.99 85 6-7.99

80 8-9.99

75 10-11.99

12-13.99 70

Vineland Standard Score Standard Vineland 14-20 65 Age, IQ, Initiate IQ, Age, Initiate Age, Initiate and and Working and Working 60 Flexibility Memory Memory

55 Communication Daily Living Skills Socialization Pugliese et al, Mean Domain Scores in Each Age Group 2015, JADD

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EF relates to autism sx & supports social learning

• Joint attention: “early developing self-organizing facility” (Mundy, 2003) • Prolonged visual ﬁxation in infants later dx’d with ASD, coincides with emergence of ASD behaviors (Zwaigenbaum et al, 2005) • EF predicts change in ToM (independent of age, language, NVIQ) (Pellicano, 2010) • Indirect “trickle-down” eﬀect of EF training on TOM performance (Fisher and Happé 2005) and social skills (Kenworthy & Anthony et al, 2014)

Looks Like Won’t… Could be Can’t Difficulty shifting Oppositional, Stubborn Avoiding overload Difficulty shifting Can do it if he wants to Lack of salience Impaired social cogni@on Self Centered Poor self monitoring Won’t put good ideas on Poor fine motor paper Disorganization Poor self monitoring Sloppy, erratic Overloaded Overloaded Won’t control outbursts Disinhibition Doesn’t care what others Impaired social cogni@on think Poor self monitoring Greene, 1998; Bernstein, 2000

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Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Can’t vs Won’t • Predictability and structure • Make Big Picture Explicit • Talk Less, Write More

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This friends and family. Be Different will help readers “For anyone who has difficulty fitting in, this book is fantastic.” • book will help you bring out those gifts.” Avoid Overload and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put • Keep it Positive Massachusetts. John serves on is a lesson in humanity and the human condition.”

e off by his inclination to blurt out non sequiturs committees and review boards —ALVARO PASCUAL-LEONE, M.D., Ph.D., Harvard Medical School and avoid eye contact. for the Centers for Disease Control and the National and Beth Israel Deaconess Medical Center By the time he was diagnosed at age forty, John Institutes of Health. He is currently involved in au- rent had already developed a myriad of coping strategies tism research and therapy programs at Harvard’s “Anyone with Asperger’s, if not everyone else, will derive knowledge and that helped him achieve a seemingly normal, even Beth Israel Deaconess Medical Center and Massachu- pleasure from the wonderful stories told in John Elder Robison’s newest book, highly successful, life. In Be Different, Robison shares setts General Hospital. John also sits on the science a new batch of endearing stories about his child- and treatment boards of Autism Speaks. His previous Be Different. Clearly, John is one of our community’s leading voices.” hood, adolescence, and young adult years, giving book, Look Me in the Eye, was a New York Times best- —MICHAEL JOHN CARLEY, author of Asperger’s from the Inside Out Adventures of a the reader a rare window into the Aspergian mind. seller and has been translated into ten languages. He and executive director of GRASP and ASTEP In each story, he offers practical advice—for Asper- lives in Amherst, Massachusetts. gians and indeed for anyone who feels “different”— Copyright © 2011 by Crown Archetype Copyright © 2011 by Crown Free-Range Aspergian “Be Different is a fascinating and unique guide for young people on how to improve the weak communication and Visit him at www.johnrobison.com. who may be struggling with autism and feel ‘out of sync’ with the social skills that keep so many people from taking

Also available as an eBook world around them. John shares personal insights about growing up, full advantage of their often remarkable gifts. and on audio from Random House feeling apart from his peers, and learning to modify his socializing skills With his trademark honesty and unapologetic eccentricity, Robison addresses questions like: and harness his gifts to discover his path to a successful life.” • How to read others and follow their behaviors —MARK ROITHMAYR, president of Autism Speaks WITH PRACTICAL ADVICE when in uncertain social situations for Aspergians, Misfits, Families & Teachers • Why manners matter Jacket design: WHITNEY G. COOKMAN • How to harness your powers of concentration to Jacket photograph: COURTESY OF THE AUTHOR master difficult skills Author photograph: AUGUSTEN BURROUGHS JOHN • How to deal with bullies ELDER • When to make an effort to fit in, and when to U.S. $24.00 ROBISON PSYCHOLOGY—AUTISM/FAMILY & RELATIONSHIPS John Elder Robison embrace eccentricity Crown Archetype I SBN 978-0-307-88481-7 • How to identify special gifts and use them to New York 52400 3/11 author of the New York Times bestselling LOOK ME IN THE EYE your advantage www.crownpublishing.com Printed in the U.S.A. 9 780307 884817 (continued on back flap)

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Ini$ate Working Memory Planning Organiza$on Task Monitor

Inhibit Flexibility Self-Monitor Emotional Control

Asperger’s is like a vise on your brain. And each unexpected event is like another turn on the vise…it just keeps building until you feel like you’re going to explode. Sometimes when you explode, it comes out the wrong way. - A young student with ASD

(Rumsey, 1985; Hill, 2004, Kenworthy et al, 2008)

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What does cognitive inflexibility look like?

Can’t or Won’t? • Accept feedback, diﬀerent opinions, ideas • Transition • Handle frustration • Start something they don’t want to do • Stop meltdowns • Stop doing something even they have been told to stop • Avoid shutting down when something is challenging • Stop correcting people • Let other kids take the lead when playing

Inflexibility Risks and Accommodations Diﬃculty with violations of expectations Ø Schedules, Routines, Predict change, Flexible Adult Rigid interpretations of rules Ø Respect need for clear, explicit expectations, Flexible Adult Overwhelming intense feelings Ø Breaks, Downtime, Flexible Adult Problems Negotiating Ø Compromise, Explicit Etiquette Rules, Flexible Adult Repetitive Behaviors/Intense Interests Ø Decide where they can/can’t happen, agree on a sign

Schopler, Mesibov & Hearsey, 1995

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Inflexibility Strengths

§ Deep datasets § Expertise in areas of interest § Persistence § Reliability § Loyalty § Routines that don’t interfere § Inflexibility is adaptive. It limits unexpected, overloading events.

February 27, 2018

Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Predictability and structure

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This “For anyone who has difficulty fitting in, this book is fantastic.” friends and family. Be Different will help readers book will help you bring out those gifts.” and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put Massachusetts. John serves on is a lesson in humanity and the human condition.”

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Initiate Working Memory Planning Organization/Integration Task Monitor

Inhibit Flexibility Self-Monitor Emotional Control

What do organization/integration deficits look like? Can’t, or Won’t? • Disorganized language • Literal language • Asks for lots of structure in new situations • Gets stuck on details- doesn’t let go of small mistake/inconsistency • Dominates discussions without knowing it • Behaves worse in unstructured groups • Doesn’t set goals • Trouble learning from mistakes • Poor written expression, Doesn’t get good ideas onto paper • Draw meaning from a reading assignment • Know what to study for on a test

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Disorganization Risks and Accommodations

Lack of generalization Ø Put new information in familiar context Ø Explicitly review inferences, nuances Ø Teach in the setting where the behavior is expected Ø Structure Difficulty knowing what is important/Getting Stuck on details Ø Emphasis on goals Ø Break things down Ø Explicit short rules, recipes, checklists and routines Ø Structure Don’t show what they know Ø Study guides, closed format tests Ø Writing rubrics Ø Structure Lack of awareness and overwhelm Ø Safe Person Ø Structure Schopler, Mesibov & Hearsey, 1995

Detail Processor Strengths

• Patience for details • Respect, follow, use rules • Good with recipes, checklists and routines • Powerful computer related thinking • Classification strengths • Attention to detail—Sherlock Holmes • Mastery of detailed datasets • Large Vocabulary • Quick recognition of visual patterns

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Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Make Big Picture Explicit

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This “For anyone who has difficulty fitting in, this book is fantastic.” friends and family. Be Different will help readers book will help you bring out those gifts.” and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put Massachusetts. John serves on is a lesson in humanity and the human condition.”

Initiate Working Memory Planning Organization Task Monitor

Inhibit Flexibility Self-Monitor Emotional Control

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The Importance of Inner Speech

Language

Self directed speech

Self regulation

Executive control Lev Vygotsky (Luria, 1961) Thinking and Speech (1934)

Poor planning/Inner Speech/Working Memory Looks Like: Won’t follow directions, work independently

• Talk Less, Write More • White Boards • Socratic method • Hand-held technology • Computer-based curricula

Schopler, Mesibov & Hearsey, 1995

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Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Talk Less, Write More

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This “For anyone who has difficulty fitting in, this book is fantastic.” friends and family. Be Different will help readers book will help you bring out those gifts.” and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put Massachusetts. John serves on is a lesson in humanity and the human condition.”

Break it Down and Make it Visual

John has a book I want

Hit John, take book Ask John for a turn

Look at book, Time out- give it back, Miss TV time get TV time

Was this what Was this what I wanted? I wanted?

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The most important accommodations of them all: Be Flexible and Keep it Positive!!

Emotions are Contagious Reinforcement Breaks the …and Flexibility is too Cycle

to Child mad

You’re Praise mad Praise

Child Praise Correction or Madder command Praise You’re madder

Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Keep it Positive

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This “For anyone who has difficulty fitting in, this book is fantastic.” friends and family. Be Different will help readers book will help you bring out those gifts.” and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put Massachusetts. John serves on is a lesson in humanity and the human condition.”

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Overload: Looks like anxiety, impulsivity, meltdowns Brenda Smith Myles: AS and Difficult Moments

Unstuck Philosophy: Accommodate, then Remediate

Neurodiversity is a civil Overwhelmed people right people can’t learn can’t learn

• Avoid Overload

(continued from front flap) Praise for $24.00 “An essential guidebook that will help all the creative, quirky, geeky, and Every person, Aspergian or not, has something be diff unique to offer the world, and every person has the be different wonderfully different kids to become successful in life.” —TEMPLE GRANDIN “I believe those of us with Asperger’s are here capacity to create strong, loving bonds with their for a reason, and we have much to offer. This “For anyone who has difficulty fitting in, this book is fantastic.” friends and family. Be Different will help readers book will help you bring out those gifts.” and those they love find their path to success. —TEMPLE GRANDIN, author of Thinking in Pictures

Adventures of a Free-Range Aspergian Free-Range a of Adventures n his bestselling memoir, Look Me in the Eye, JOHN ELDER ROBISON is “In a love poem to his wife, Pedro Salinas, the Spanish poet, wrote, John Elder Robison described growing up an author and frequent lecturer ‘Glory to the differences / between you and me.’ John Robison teaches us to with Asperger’s syndrome at a time when the about his life with Asperger’s. I celebrate differences like Salinas did, but also offers clear insight and valuable diagnosis didn’t exist. He was intelligent but so- He blogs for Psychology Today advice on how to cope with the challenges that being different can create. cially isolated; his talents won him jobs with toy and is an adjunct faculty mem- makers and rock bands but did little to endear him ber at Elms College in Chicopee, This book transcends the speciﬁc case of Asperger’s syndrome and be different to authority ﬁgures and classmates, who were put Massachusetts. John serves on is a lesson in humanity and the human condition.”

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GOAL: Increase your understanding of executive functions and how to enhance them PLAN 1. What are Executive Functions (EF)? Ø EFs are fractionated and plastic 2. Why do they matter? Ø EFs are necessary for effective everyday functioning 3. Specific components of EF & accommodations Ø Flexibility, Organization, Planning/Working Memory 4. How can we treat EF problems in autism? Ø Teaching self regulatory scripts in everyday settings

• Consistency • Coach across settings • Make Implicit • Memorized, Explicit automatic • Scaffold-fade- language Teach and generalize use key Teach by scripts and doing words

Use visual Make it supports fun!

• Checklists • Humor • Cues • Rewards • White Boards • Collaborate with child

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Scaffold Fade Generalize

http://www.bianys.org/learnet

Feelings Target

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Feelings Chain

Teaching: Why Be Flexible

• Advantages of physical ﬂexibility • The “facts” of life • What to do when what I want is impossible • Pie charts: getting part of I want is better than getting nothing at all

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Teach How to Be Flexible: Self- Regulatory Scripts ü Avoid too much talking ü Refer to the big picture ü Build an alliance— you’re collaborating! ü Need to be practiced

How to be Flexible: Words and Scripts

Flexible • Great job being flexible

• I'm getting stuck on ___, how can I get Unstuck unstuck?

• Let's compromise so we both get some of Compromise what we want

• What is our plan? Plan A/Plan B • What is our Plan B?

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Flexibility Scripts

Big Deal/Little Deal • How can we make this big deal into a little deal?

Choice/No Choice • Is this a no choice situation?

Handling the • What will change? • What will stay the same? Unexpected • Why is the change happening?

GWPDC script (Goal, Why, Plan, Do, Check)

Goal To have fun at recess Why Recess is my free time Plan A Ask Johnny if he wants to play soccer

(If J says, no) Ask Melissa to play soccer Plan B Swing on the swings Plan C

Do Follow my plans Check Did I meet my goal?

Which plan worked?

Would I do it the same or different next time?

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Modeling Goal Use • “I need to set a goal.” • “Let’s set a goal!” • “My goal is to.....” • “You did a great job making a goal!” • “That’s a terrific goal!” • “Are we on target?” • “What is your goal?” • “A goal is something you want or need to do.” • “I can see you really want to keep X as your friend, I think your target goal is to be a good friend” • “I know you really want to be a video game programmer- if this is your target goal, what are the things you need to do to accomplish this goal?” • "Oh man, I got so off target just then.” • “Way to stay on target!”

! MISSION&POSSIBLE& GOAL What%is%my%mission%for%today?%%%%%%To%have%a%fun%play%date%with%Adam%

Plan A Plan B PLAN(S) What%is%my%plan%for%my%mission?% What%is%an%alternative%plan?% 1. Pick%up%Adam%from%his%house.% 1. If%the%park%is%too%crowded%or%Adam% 2. Go%to%the%park% does%not%want%to%go%to%the%park%we% 3. Ask%Adam%if%he%wants%to%play%on% can%go%back%to%my%house.%% the%swings%or%the%climbing%wall.%% 2. Ask%Adam%if%he%want%to%play%Legos% 4. If%I%feel%tired%or%need%a%break%I% or%soccer.%% can%tell%Adam%I%need%few% minutes%to%myself.%% 5. Have%a%snack.% 6. Drive%Adam%back%to%his%house.%

DO What%plan%did%I%use%to%complete%my%mission?% % %%%%%%%%%%%%%%%%%%%%%%%%%%%Plan A Plan B Other (explain)

CHECK Did%I%accomplish%my%goal?%%%%%%%%%%%%%%%%%%%%%%%%YES NO

How%did%it%go?%% 1 2 3 4 5 Not so good OK Great NEXT STEP Tomorrow,%I%will…% % %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%MOVE ON TRY AGAIN Why?% % % % !

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GWPDC

Trial #1: (NIMH R34)

• Unstuck (n=47) • Social Skills (n=20; Baker, 2009) • Interventions delivered at school by school staff with fidelity • Parent training, teacher training, pull out groups, fidelity monitoring, interventionist supervision

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WASI Block Design Higher Score = Better Performance

56 Unstuck 55 Score -

T 54 Social Skills 53

50 Pre Post Cohen’s d=0.65 Kenworthy & Anthony et al., 2014

Blinded Classroom Observations

60 Social Skills

50 Unstuck 40

30 Percent Improved 20

0 Reciprocity Rule Transitions Gets Stuck Negativity/ Participates Abidance Overwhelm Classroom Observa4ons Kenworthy & Anthony et al, 2014

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Project Overview (PCORI AD-1304-7379 )

• 3rd – 5th graders (with ASD or ADHD) from 22 Title 1 schools • Participants ided by school staff based on flexibility problems • Random assignment to Unstuck or Contingency Behavior Management: Both target executive function/flexibility

Proportion improved to worsened: Proportion improved to worsened: Fisher=.000** Fisher=.000**

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Fisher=.045* Fisher=.002**