Executive Dysfunction Overview
The foundations for learning are attention, memory, and executive function. While most parents would immediately have some sense of what “attention” and “memory” mean, they may never have heard of executive functions. And yet without these functions, so many aspects of our functioning would be impossible or significantly impaired.
Executive functions (EF) are central processes that are most intimately involved in giving organization and order to our actions and behavior. They have been compared to the “maestro” who conducts the orchestra. You could have talented musicians, but without a conductor to tell them when to show up, what to play, and how to play it, you’d have cacophony, at best. The comparison to a maestro or conductor is somewhat misleading, however, unless you recognize that a maestro is not “higher” than or “the boss” of other functions. In that sense, the image of a conductor or CEO fails. Executive functions have a unique role that they play in influencing the use of our other functions, but they are not more important than other functions. Neurologist Martha Denckla, M.D. talks about the executive functions in terms of our ability to “get our act together.” I think that’s a great description, because without executive functions, we would not be able to plan behavior to reach a goal.
So what are the executive functions? Although there is no one agreed-upon definition and there is currently no diagnosis called “Executive Dysfunction,” there seems to be a consensus that executive functions involve (at the very least):
- Planning for the future
- The ability to inhibit or delay responding
- Initiating behavior, and
- Shifting between activities flexibly
If we break down the skills or functions into sub-functions, we might say that executive functions tap into the following abilities or skills:
- Emotional control
We will consider these skills in more detail later in this article, but for now, it should also be noted that in considering executive functions, we will also be talking about “working memory,” which is not purely an executive function but overlaps executive functions, attention, and memory. Also, although “emotional control” is included in this list, it is not a purely executive function.
Functions and signs of dysfunction
Let us take a closer look at each of the functions we identified earlier, and consider what dysfunction might look like. In looking at this chart, keep in mind that there are only a few examples of what dysfunction might look like.
|FUNCTION||DESCRIPTION||POSSIBLE SIGNS OR SYMPTOMS|
|Goal||Setting a goal||Acts as if “future-blind” (Barkley, 2002), i.e. not working towards the future.|
|Plan||Develop steps towards goal; identify materials needed, set completion date.||– May start project without necessary materials|
– May not leave enough time to complete
– May not make plans for the weekend with peers
|Sequence||Arrange (and enact) steps in proper order spatially or temporally.|| May skip steps in multi-step task|
May have difficulty relating story chronologically
May “jump the gun” socially
|Prioritize||Establish ranking of needs or tasks.|| May waste time doing small project and fail to do big project|
May have difficulty identifying what material to record in note-taking
May include the wrong amount of detail in written expression (too much detail, too little detail, irrelevant detail)
May fight every fight as if were life or death
|Organize||Obtain and maintain necessary materials and aids to completing sequence and achieving goal.|| May lose important papers or possessions|
May fail to turn in completed work
May create unrealistic schedule
|Initiate||Begin or start task.||Difficulty getting started on tasks – |
may appear as oppositional behaviour
|Inhibit||Stop oneself from responding to distractors. Delay gratification in service of more|
important, long-term goal.
| May appear distractible and/or impulsive|
May pick smaller, immediate reward over larger, delayed reward
|Pace||Establish and adjust work or production rate so that goal is met by specified completion time or date.||May run out of time|
|Shift||Move from one task to another smoothly and quickly. Respond to feedback by adjusting plan or steps.||May have difficulty making transitions and/or coping with unforeseen events|
|Self -Monitor||Assessing one’s performance and progress towards goal.|| Doesn’t check to insure that each step is completed|
Doesn’t monitor pace to determine if goal will be met on time
Doesn’t check work before submitting it
|Emotional Control||Regulating and modulating responses to situations.||May exhibit inappropriate or over-reactive response to situations|
|Complete||Reaching the self-set or other-set goal.||May start tasks but not finish them|
Working memory and EDF
As noted earlier, the foundations of learning are: (1) attention, (2) memory, and (3) executive functions. Where memory, executive function, and attention overlap, you have “working memory.” Working memory enables you to hold new information in mind while you manipulate it or apply previously learned knowledge or skills. For example, suppose I ask you to multiply 25 x 23 in your head. You would have to hold the two numbers in mind while you apply the rules for two-digit multiplication and keep track of your calculations.
Working memory has been compared to a computer’s desktop. If you have a lot of space on your desktop, you can keep many files open simultaneously, which enables to you to work at a faster and more efficient pace. If you have a small desktop, you can only look at one file at a time, and it will take you longer to accomplish the task.
Many of the disorders are associated with deficits in working memory. In some cases, the child or adult may not take in new information due to attention deficits or may become distracted during learning or performance (e.g., an obsessive thought or mental ritual may intrude or a leaf might fall off a tree two miles away and distract them). In other cases, the individual’s workspace or “filing system” is a disorganized mess. The individual may not be able to retrieve the needed information to apply to the new information in a timely fashion, or they may skip a step or lose track of where they are up to due to difficulties in retaining sequence.
Working memory is crucial to academic learning and functioning, but it is also crucial to social skills. If a child or adult cannot retain newly presented information in mind while they retrieve and consider options, they may make poor social decisions or be unable to respond flexibly or appropriately to unexpected events.
“TIME HAS COME TODAY… TIME!”
On a day-to-day level, perhaps one of the most frustrating things parents encounter is what appears to be their child’s lack of time sense. It took me a while, but eventually I learned that asking my son if he would “take out the garbage in 5 minutes” was as effective as saying, “Justin, sometime before the end of your life, would you take out the garbage?” How could he not realize that more than 5 minutes had gone by? That 30 minutes had gone by… 40… 50… Was he forgetting or distracted by what he was doing, or was he unable to estimate time accurately? Even if I offered him a huge reward for doing something on time, he might miss the deadline.
Most of us probably know a child or an adult who waits until the last minute to start a huge project. They may tell us that they work better under pressure (if they tell you that, tell them that the research doesn’t support them on that point), but when people consistently have problems starting big projects in a timely fashion or leave everything until the night before, we should be curious about what’s going on and whether there’s some impaired sense of time: do they correctly estimate how long some task will take?
Russell Barkley and other researchers have been looking at time issues in children with ADHD. Deficits in time reproduction tasks have been noted, and even offering a reward or inducement was not sufficient to bring time reproduction up to the level of controls. Difficulties with sense of time (apart from difficulties with time management) have also been reported by adults diagnosed with ADHD. On a practical level, available research suggests that we will need to provide supports or strategies to enable children and adults to keep track of time independently. Learning to set times and audible and visual reminders, and keeping an external device that shows the passage of time or time remaining in front of the person may be of benefit.
How executive dysfunction may affect your child academically
If learners have deficits in ability to plan, initiate, sequence, sustain, and pace work, what is likely to happen to them in school?
Think of an academic activity such as writing a big report — a common source of frustration for many learners. The learner who has Executive Dysfunction will have difficulty picking a topic, planning the project, sequencing the material for the paper, breaking the project down into manageable units with intermediate deadlines, getting started, determining how much detail to include, and completing the activity. And because these learners frequently underestimate how long something will take, they’ll generally leave the project until the night before it’s due.
Now consider another academic activity: conducting a laboratory experiment. In the laboratory, the learner has a list of supplies that are needed to run the lab and a set of instructions. If the learner begins the lab before lining up all the supplies, she may find herself having to run to get something at a time when timing was critical. If she cannot follow sequential steps, she may skip a step and ruin the lab.
Not surprisingly to me, Langberg and his colleagues found that the transition to middle school disrupted what otherwise appeared to be a decrease in ADHD symptoms in learners with ADHD. They hypothesize that the disruption is due to the heavy demand on executive functions associated with transition to middle school, e.g., more changing of classes, more demands for organizational skills, study skills, and planning — all of which are executive functions. Learners with ADHD on medication fared no better than their non-medicated peers in this regard (abstract).
One area, which is often significantly impaired, relates to homework. Learners with EDF may experience tremendous challenges because they forget to record all their assignments or pack up necessary materials. At home, their parents may report that the child experiences significantly difficulty getting started, or sustaining their attention so that they complete their task. And on the rare occasion that they do complete the task, they may fail to pack it up and/or turn it in to receive credit. The EDF-related homework difficulties may present an obstacle to integrating learners with emotional and behavioral disturbance (EBD) in integrated classroom settings (Epstein et al.,1993, 1995). Cancio (2004) provides some empirical data on self-management and parent participation strategies to help male learners with EBD and EDF to complete more homework and improve homework accuracy. Their pilot data not only report large increases in homework compliance, but report a 1-year gain in mathematics (as measured by the KTEA) during the 4-month homework intervention phase.
A number of studies have shed additional light on EDF and what we can do to help. Langberg et al. (2008) review organizational interventions in school and note how they are associated with significant improvements in the organization of materials, homework management, time management and planning.
Of particular significance, there is some minimal evidence to suggest that improving organizational skills is associated with reductions in ADHD symptoms and improved academic function. Their review also incorporates a review of organizational interventions for adults with ADHD. Whereas interventions for children and teens with ADHD tend to use self-awareness training and a more behavioral approach to shaping and maintaining behaviors, interventions with adults have tended to use a more cognitive-behavioral approach.
Although the studies reviewed by Langberg et al. all seem to offer hope and promise, many of them are describing interventions that involved administration by school psychologists or other parties and the programs are often not readily implemented by a regular classroom teacher who has limited support. Although parents and educators may want to learn more about these interventions for individual applications, I think that a more effective approach that would help more learners can be implemented if teachers set up certain routines and structures in their classrooms that they adhere to. As Langberg et al. observed, learners with ADHD/EDF “crash and burn” in middle school, in large part because of the executive demands. All too often, middle school teachers stop using the supports and cues that elementary teachers routinely incorporate, on the premise that the learners should no longer need the supports. By incorporating more of these elements and by starting to use direct instruction to teach executive skills to all learners as part of the curriculum, many more learners should be able to function better.
The “terminally diagnosed” child or adult
How many of us have watched a disorganized or child or adult and assumed that they were just lazy or that if they really and truly wanted to, they would be more organized? How many of us have wanted to pull our hair out over the child who never brings home their assignments and materials despite supervision from the teacher, who never starts the homework without a knockdown-drag out fight, and who when they do finally do their homework, seem to lose it before it gets handed in to the teacher?
How many of us watched these children and adults suffer day after day and never thought to get a neuropsychological assessment of their executive functions? Maybe we shook our heads and just “knew” that the school’s proposed behavior modification or incentive plan wasn’t going to work, but we couldn’t put our finger on why it wouldn’t work, other than to say, “It’s not a motivational problem — he really can’t seem to organize himself”?
As frustrated and impatient as we tend to get with children and teenagers with EDF, the situation is even worse for adults with EDF. Although some adults have learned some tricks or strategies to help them compensate, many continue to fail to meet their responsibilities on a daily basis and run into trouble with their spouses or employers. The adult who does not manage time well and doesn’t submit work projects by deadlines isn’t facing the loss of a few points on their final grade — they may find their job in jeopardy. The adult who does not have an organized system for handling their financial matters may find their credit rating affected, or that they’ve failed to file their taxes on the time. The list of possible consequences for an adult is long and unpleasant.
(Excerpted from Overview of Executive Function by Leslie E. Packer, Ph.D.)