Overview of Executive Dysfunction


by Leslie E. Packer, PhD
This article last updated July 2010

Article Table of Contents

Preface
What are the Executive Functions?
How Are They Assessed?
Functions and Signs of Dysfunction
Working Memory and EDF
“Time Has Come Today… Time!”
Students with Executive Dysfunction
The “Terminally Disorganized” Child or Adult
Recognize Anyone You Know (Relationship between EDF and ADHD)?
“If it is EDF. Would Medication Help?”
Now what?
Executive Function in Adults
Comment

PREFACE

It is now over a decade since I first created this section of the web site and over 16 years since I first started trying to educate educators and parents about the importance of this topic in children’s development and functioning. We have made a lot of progress in that time, but we still have a long way to go to increase awareness and understanding, and we need much more research on effective interventions and treatments. Executive Dysfunction (EDF) continues to be one of the most overlooked contributors to academic, behavioral, and social problems for both youth and adults.

WHAT ARE THE EXECUTIVE FUNCTIONS?

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 subfunctions, we might say that executive functions tap into the following abilities or skills:

  • Goal
  • Plan
  • Sequence
  • Prioritize
  • Organize
  • Initiate
  • Inhibit
  • Pace
  • Shift
  • Self-monitor
  • Emotional control
  • Completing

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.

HOW ARE EXECUTIVE FUNCTIONS ASSESSED?

Because there is no uniform agreement on what the executive functions are, there has been no agreement on how to assess them. If we talk about particular subfunctions, however, it is possible to answer the question.

Executive functions are generally assessed via neuropsychological tests and assessments. For any one function or subfunction, there may be a variety of tasks or tests that tap into components. There are also several batteries of tests that can be used.

If you suspect that you, your child, your spouse, or your student has executive dysfunction (EDF), the appropriate referral would be to a board-certified neuropsychologist. Neuropsychologists are psychologists who specialize in the relationship between brain and behavior. In school settings, school psychologists may wish to use B.R.I.E.F. if they have been trained to use it. Although it has limitations, it frequently provides parents and school personnel with a better understanding of the child’s functioning and need for accommodations or services.

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 of Dysfunction
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 behavior
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

In other articles in this section of the web site, you can find helpful tips and strategies for addressing some of the deficits identified in the chart above.

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 described on this web site are associated with deficits in working memory. In some cases, the child or adult may not take in new information due to attentional 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!”1

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 students 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 students. The student 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 students 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 student has a list of supplies that are needed to run the lab and a set of instructions. If the student 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 students 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. Students with ADHD on medication fared no better than their nonmedicated peers in this regard (abstract).

One area which is often significantly impaired relates to homework. Students 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 students 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 students 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 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 involve 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 students can be implemented if teachers set up certain routines and structures in their classrooms that they adhere to. As Langberg et al. observed, students 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 students 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 students as part of the curriculum, many more students should be able to function better.

THE “TERMINALLY DISORGANIZED” 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.

Since the last update, there has been an upsurge in a new “industry” – coaching. Adults with EDF can arrange for a coach to help them manage their time and belongings. For information on coaches, see IAAC’s web site. It is important to find a coach who has been trained and certified by the ICF. Additional helpful information can be found on the Edge Foundation‘s site; they also provide coaches for children with ADHD. The ADHD Coaches Organization and Peer Resources in Canada also provide helpful information and resources.

RECOGNIZE ANYONE YOU KNOW?

The deficits associated with EDF can be in the form of difficulty in organizing time, difficulty in organizing materials and belongings, difficulty in organizing thoughts, difficulty in initiating tasks, difficulty in switching flexibly between tasks, difficulty in sustaining focus on the relevant aspects of a stimulus or task, or any combination of these skills. If you know someone who suffers from disorganization — books that inexplicably disappear from desks, lockers, and home, papers that never seem to make it from work to home or back to work or school, school, home, or work projects that seemingly have no known due date, the mysterious disappearance of all writing instruments into some great Black Hole, you may know someone with executive dysfunction.

By now, many site visitors will be thinking, “Oh good grief, that’s my [son/husband/student/self] she’s describing!”

Others may be wondering, “Wait a minute. I thought all those things were Attention Deficit Hyperactivity Disorder. What’s going on? Are Executive Dysfunction and ADHD the same thing?”

As you will discover if you start to read the research, ADHD and EDF are intimately connected, and many individuals with Asperger’s Disorder will also have aspects of executive dysfunction. EDF has also been found in adults with OCD and it also associated with Bipolar Disorder, to name but some of the conditions.

But look at the difference in your own reaction when you thought more broadly about “impulsivity” or “hyperactivity,” and compare that to your reaction when you saw an ability or function represented as a higher-order brain function. When viewed as executive functions, are you as likely to write the problems off as a motivational problem? And are you now curious about what kinds of skills-training, accommodations, or interventions might be appropriate to help a child or adult who has a neurologically based problem with executive dysfunction?

IF IT IS EDF, WOULD MEDICATION HELP?

Most of the research relevant to this question looks at the role of stimulant medications (such as Ritalin) on specific types of tasks or activities. Although a detailed discussion of this research is beyond the scope of this web site, it is intriguing to note that there is some evidence that stimulant medications may be of benefit for some aspects of executive dysfunction. As examples:

  • Kempton et al. (1999) compared unmedicated children with ADHD to children with ADHD who were on stimulant medication . They found a significant number of executive functions impaired in the unmedicated children, but those children who were on stimulant medication displayed no such impairment (with the exception of of spatial recognition memory)
  • Kramer, Cepeda, and Cepeda (2001) reported that methylphenidate (Ritalin) improved task-switching ability in children with ADHD
  • Aron et al. (2003) reported that similar to findings in children with ADHD, adults with ADHD also display impairment in response inhibition that it ameliorated by methylphenidate

There is no evidence, however, that any medication ameliorates deficits in all executive functions. For example, Biederman et al. (2008) found that stimulants improved measures of sustained attention, but did not have any effect on other measures of executive functioning (a href=”http://www.ncbi.nlm.nih.gov/pubmed/18517288″ target=”_blank”>abstract). Similarly, and as noted earlier, Langberger et al. (2008) found no evidence that medicated students with ADHD fared any better than nonmedicated students on middle school transition when it came to transition to middle school.

NOW WHAT?

What happens when we recognize that someone has serious problems with organization and that the source of the problem isn’t laziness or lack of motivation?

In the author’s experiences with schools, she has often observed that the 504 Plan or IEP makes all kinds of provisions for the teachers and parents to somehow compensate for the student’s problem: the teacher is to record the assignments or check off that the student has recorded and packed them; the parent is to initial a notebook showing what came home and what got done, etc. The parents and the teachers, who are already more organized than the child, just engage in more organizing behavior without ever really teaching the child how to organize himself or constructively engaging him in solving his problem. Seldom do I see an IEP where there are specific goals and objectives listed that address teaching the child the organizational skills that he will need to function independently.

Unless you want to be following that child around when he’s 30, you’d better start figuring out a way to teach him how to organize himself and meet his responsibilities.

There are two ways to view this problem. One is to say that the child needs our support, and that by supporting the child by providing the back-up copies, etc., we are reducing the child’s vulnerability and doing A Good Thing. And maybe, along the way, the child will begin to do what he sees us doing and will develop the organizational skills. But if the child is feeling vulnerable and our taking care of all the organizational problems reduces that vulnerability, why will the child risk “blowing that” by attempting to organize himself? Even a child who is motivated to organize himself is likely to assess the situation and recognize that the adults are going to do a much better and more consistent job than he could ever do, so why even try?

Now consider another approach — one in which we work with the child as their consultant or supporter to help them organize themselves. We let the child recognize and appreciate where their problems are and ask how we can be of help to them, assuming the best — that they want to be responsible and organized. Often, the ideas or strategies that they come up with may be better than anything we could come up with and since they are now vested in the strategy, they are more likely to comply with it.

So we determine if they’re motivated to organize themselves and offer our support. We can also offer some positive inducement in the way of positive behavior contingencies (yes, old-fashioned bribery helps!). Within that context, there are a number of tricks or strategies that can be used. Hopefully, they will be used within in a context in which we are trying to support the child’s efforts to organize themselves. We do so recognizing that there will be many ‘failures’ along the way, and that if we want the child to succeed, we have to make it emotionally safe for them to try and even to fail. We need to reduce their vulnerability and we do by reducing our own. As parents, teachers, or spouses, we are not responsible for doing our child’s work. We are not responsible for ‘nagging’ them to do their work. If they tell us that they would find it helpful to have a reminder at a particular time so that they can start their work, we can provide that reminder. But we probably should stop at the point when our efforts are not experienced as support and become ‘nagging’ or confrontation — particularly if they have mood lability or are otherwise prone to explosive outbursts.

One final note: students and adults both may benefit from computers or electronic organizers that incorporate calendars with repeating functions. How much better to teach someone that although he may not remember things easily, he can teach himself to rely on a computer as a memory prosthesis. We can teach most children and adults to program their own reminders on computers. Alarms can be set (by them) so that they stay in control of taking responsibility. Such devices become lifelong tools that enable independent functioning and can rightfully be considered assistive technology and/or a reasonable accommodation. A device by itself, however, is not likely to be sufficient for students with EDF when it comes to homework or studying, as remembering to record assignments or tests is not the sole source of problems.

EXECUTIVE FUNCTION IN ADULTS

Although this site focuses on children and adolescents, adults with EDF have the same needs for strategies, training, and support. In the last decade, there has been a growing field of “coaches” to help adults organize themselves. There are also self-help books to provide tips and strategies, and there’s even a show on cable TV oriented to how to organize one’s space and belongings.

Executive dysfunction is not the kind of problem that you ‘outgrow,’ although many children and adolescents do learn strategies to manage themselves. But how many “terminally disorganized” adults never realized that they had a neurocognitive problem — or knew what to do about it?

Some of the same kinds of strategies that work for students may also be of benefit to adults who suffer from executive dysfunction. Learning to use a day planner or PalmPilot, learning to allow more time for activities or to get to a business appointment, learning how to successfully cope with the multi-tasking demands of the employment setting are all essential skills, and adults with EDF (or their spouses) may find it helpful to look at the tips or strategies articles on this site and adapt the strategies to their needs.

Adults who are really struggling may wish to hire a coach who can help with learning employment-related skills or routines; other coaches serve to help individuals organize their personal lives.

And if you’re really disheartened — or if you’re a spouse who is frustrated beyond belief by all the time spent looking for misplaced car keys, the wallet, important documents, etc., here’s a true story that may inspire you:

Years ago, my husband decided that he was going to learn to organize himself (yes, I am married to one of those “terminally disorganized” ADDults). Off he went to the library to get a book to teach him how to organize himself. It was one of those books with an overly optimistic title like “How to Organize Your Life in 7 Days and Prevent Your Spouse From Killing You Out of Frustration” (if there’s no book by that title, there probably should be). He came home with the book, read the preface, and then happily explained to me how he was to read one chapter a day, and at the end of the week, he’d be organized.

Six weeks later, the first overdue notice arrived from the library. My husband had put the book done after reading the preface, and had forgotten about it. Because the book was not where he’d see it as he went about his daily routine, he’d forgotten all about it and never gotten past the preface.

Did I mention that you should expect a bumpy road? It took a while and a lot of experimentation, but one night, when my husband was watching an old “Columbo” re-run, Peter Falk’s character took out an old steno notebook and explained to another character how he wrote himself work reminders starting from the front of the pad, and would flip the pad over and start at the back to enter home reminders. That way he kept his work and home reminders in the same notebook but separate. My husband thought that was a terrific idea, and he’s been using it ever since. Of course, if he doesn’t remember to write something down, it doesn’t get taken care of, but he has gotten better at writing things down and I’ve learned to give him reminders when he has his book handy to write it down.

COMMENT

If you’re feeling a bit “stunned” by what you’re reading, that’s fine. I get a slew of emails from parents and teachers who just went “wow” when they read this section of the site and realized that I was describing their child or student.

If you’re a parent and you’re feeling guilty that you didn’t know, then think about this:

If the professionals you talked to or took your child to didn’t think to consider assessment, then why should you have known?

FOOTNOTES

1 From the song, “Time Has Come Today,” recorded by the Chambers Brothers in 1968. If you don’t know the song I’m talking about, you’re too young and should go away. 🙂

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