The prefrontal lobe plays an important role in planning and organizing behavioral schemes. The language cortex and associated areas (temporal lobe, Wernicke’s and Broca’s areas) help the person communicate thoughts through verbal and gestural language. Likewise, the parietal lobe, basal ganglia, and cerebellum engage in planning and execution of motor actions. It is a complex neurological process for the individual that can be derailed if basic homeostasis is not accomplished at the prior stage of development.

As the child develops the capacity to plan and organize thoughts and behaviors, he learns to adapt to changing interpersonal and learning expectations and to plan for future actions. We see this in the individual who can control his body and mind for a specific purpose or goal without becoming distracted. Individuals who have learned to meditate, slowing their active minds and bodies down to concentrate on a precise, single stimulus is one example of how this is accomplished.

This level of self-regulation requires the development of intentionality, reciprocal interactions, organized affects, and an awareness of situational meanings. This stage is critical for the child to learn how to modify actions, thoughts, or feelings in relation to events in his life. It is accomplished through the child learning to initiate, stop, modify, or change responses as situations occur, thus allowing them to engage in more adaptive behavior (Zimmermann, 2005). The child may need to inhibit the desire to leave the dinner table before finishing the meal or the urge to grab a toy when waiting is required. This ability to inhibit actions may prevent the child from fleeing from a stressful situation when staying and coping is required. It can also help a growing child to stop himself from yelling at his parent for doing something upsetting like grounding them for doing something they shouldn’t have done. Or it can help the child inhibit doing or saying things that pop into their mind while playing with peers. For instance, when Terry would get agitated in a group situation, she would poke the other children or do things like throw the game dice around the room, disrupting the fun of the other children.

At this stage of self-regulation, the person learns to initiate, maintain, and inhibit physical actions or impulses. This is the basis for problem solving, intentionality, and awareness that actions lead to a goal. On a neurophysiological level, higher cortical control (e.g., prefrontal lobe) overrides lower brain centers (e.g., reticular activating system and hypothalamus) that control basic bodily functions. Feedback loops between the reticular activating system, deep limbic structures to the cortex, and the prefrontal lobe help the child to develop intentionality, purpose, and motivation. The prefrontal lobe plays an especially important role in self-stopping, in generating ideas and maintaining motivation for adaptive behavior. It is this dynamic feedback loop that helps the child evaluate his internal bodily state, to self-observe readiness to respond, to read external situational demands, and to integrate past learning and responses to apply to the current situation. There are three main components that go into the ability to plan and organize thoughts and actions. These will be described in the sequence in which they occur in behavior.

Another common problem when a child cannot develop a clear idea and goal-directed focus is cognitive indecisiveness. This is common among children with high anxiety or obsessive–compulsive disorder. They may ruminate over and over again about when to start, what to do, will it be right, how to do it, etc. Often they have multiple ideas in their mind, but cannot focus on one or prioritize them in proper sequence. Isabella was a 7-year-old child who would compulsively clean my doll house, setting up the furniture, and placing dolls in the beds. The process was repeated exactly 3 times. Isabella was unable to make anything happen in the story and was stuck in a state of constant set-up. This spilled over to her needing to eat food in multiples of three, washing her hands three times after using the bathroom, and repeating things under her breathe three times. She was in a constant state of frustration, stuck in time.

As the person develops self-control, he learns to internalize routines and requests made by others. These routines are established early in life—a set bedtime, meals at certain times or doing certain activities, such as exercise at specific times. There are considerable individual and cultural differences that influence these schedules and routines, but what is important is that there is an established rhythm and pattern to the person’s daily activities that allows them to function well in life. Many children with severe ADHD live moment-to-moment with no capacity to plan for a regular schedule. Jason was a 9-year-old boy who went to bed at different times each night, often awakening in the wee hours because he wanted to play video games or read. His parents tried to establish bedtime rituals for Jason, but sometimes let him do whatever he wished to avoid a huge tantrum that followed their limit setting. Jason was in a constant state of sleep deprivation and irritability as a result.

In the process of planning and organizing actions, the child needs to attend to relevant details, gather important information for the task at hand, then engage in proper actions for task achievement. The child needs to be mindful of their actions and self-monitor as they engage in the task. Allocating attentional resources is critical for self-monitoring. Many children think they can multitask efficiently, but often they allocate only part of their attentional resources for each task (i.e., doing homework, surfing internet, and watching TV at the same time). Often they don’t complete any of the tasks optimally unless the activities are rote or habitual in nature (i.e., reading a book while eating). Self-monitoring requires that the child resist urges to respond to off-task or impulsive wishes. They need to delay gratification and stay focused and intent on their goal. Children who struggle with self-monitoring have poor self-control, poor self-awareness, restlessness, and usually cannot delay gratification. This is often seen in children who are chronically stressed and have poor mood modulation. Living with them is overwhelming to parents and siblings because they blow up easily. A child may have poor self-awareness and not read that they are about to lose it before it is too late (i.e., the child who insists on jumping wildly near the edge of a trampoline, then injures himself seriously).

An important aspect of this phase of development is the learning to delay one’s own actions and to comply with social expectations without needing external cues. Self-control relies upon the person’s development of forethought, planfulness, volitional control, and self-reflection (Zimmermann, 2005). In forethought, the person analyses the task before him, sets goals, and plans a strategy to accomplish his goal. If the idea is not well formed in his mind which is often the case with children with attention deficit disorder or executive functioning problems, they may struggle to get started. The child needs to be able to attend to relevant information about the task and feel motivated to do it. Self-control depends on being able to sustain effort, manage time, remain focused on the goal, and resist distractions that might divert them from their goal. Common problems at the ideation or forethought stage might be aimlessness, disorganized or risky behaviors, procrastination, or conflicting or ambivalent goals (Baumeister, 1991a,b). The child is apt to feel indecisive, emotional distress, or confused about his own identity because he lacks purposefulness.

Breakdowns in self-control are commonly observed in clinical practice. Hostility, aggression, irritability, high frustration, and violence may be manifested in persons with poor self-control. The ability to resist temptation, to resist the urge to respond when it is inappropriate, and to delay gratification are central to self-control. To develop better self-control, the child needs to be able to evaluate himself while in the process of doing a task or engaging in an interaction, all things that require mindfulness of self and others. Lev was a child adopted at age 4 years from an institution in an Eastern block country. Despite nurturing and good parenting, he never learned to control his impulses and from the age of 4 through adolescence, he would demand that his parents buy him toys or video games every day. If they did not give in to his demands, he would become very violent, ripping out a banister or a bathroom sink, smashing holes in the walls and even the car windshield with his feet, or punching his parents on the head and arms. He was completely unable to delay gratification and the only thing that eventually worked for him was to place him in a residential school where he had to earn the simplest of rewards like getting dessert for doing learning activities and chores and showing respectful behavior. After several years at the residential school, Lev developed much better self-control and was able to return and live with his family.

Finally, the capacity to self-stop or self-limit is important to self-control. It involves both mental and physical exertion and control to override the impulse to act when the task or situation requires them to inhibit or stop. Some persons cannot resist temptation as in the case of overeating, video gaming for long hours, or other addictive behaviors. There may be extreme peer pressure or external forces that urge a person to act when he shouldn’t. In addition, internal states of fatigue or high stress may break a person down and cause poor self-control.

Emotional dysregulation can cause a child to lose the capacity to plan and organize the daily tasks of life from home to school activities. However, there are also instances of short-acting emotional dysregulation, such as when a child has a frustrating event, such as a toy breaks on him, a limit is placed on him by his parents that he feels is unfair, or he’s working on the computer and the power shuts off from a thunderstorm, thus losing what project or game he was working on. The child may tantrum, take a break to regain composure by moving or other activity, then return to begin the task all over again. In contrast, a child can have long-standing, chronic stress, such as a mother who is very depressed, abusive, or who makes nasty comments to them all the time. The rage that is elicited is apt to persist for quite some time and become part of the person’s behavioral repertoire. Distinguishing the source of the dysregulation is important in understanding the problem as well as guiding next steps for treatment.

In clinical practice we often hear examples of how poor inhibition and problems with self-initiation impact the entire family. In one family, the mother complained that when she would walk in the door after a long day at work, she would find her 2-year-old child hungry and crying for attention. Her husband, Curt, was unemployed and depressed by his plight at staying at home with the toddler. As soon as Stacey would see her husband lying on the sofa reading a magazine, still in his pajamas and oblivious to their child’s distress, she was instantly triggered. Within moments, Stacey would begin shrieking at her husband for not starting the dinner for their child, raving that the house was a complete mess, and that he was clueless to her work exhaustion. Curt’s lack of intentionality and awareness of the situation not only led him to being dysregulated in a withdrawn—shut down state, but the whole family was pitched into a state of dysregulation. The child spent long hours parked in front of the TV with no purposeful activities or outings. She had started engaging in masturbation as a means of self-soothing and looked tuned-out, almost autistic in her presentation. Stacey’s dysregulation went to rage and was in opposite action to Curt’s withdrawal, but both felt distress, frustration, and irritability at their terrible situation. Support was provided for the parents and child, and in particular the little girl was placed in a nurturing and stimulating day care that helped her develop skills, motivation, and socialization. The self-stimulatory behaviors that the little girl had been engaging in stopped shortly after the parents learned better ways of providing structure, routines, and nurturing activities for the child. An important aspect of the treatment was helping the parents learn to engage in interactive play with their toddler during a range of routines and activities and providing ongoing support for both parents—father’s depression and mother’s level of stress.