Tourette Syndrome Plus - Conditions - Executive Dysfunction - Overview of Executive Dysfunction Pg. 3

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Information Section: Conditions
Condition: Executive Dysfunction
Article: Overview of Executive Dysfunction¹
Source: Leslie E. Packer, PhD, 1999
This File Last Updated: December, 2004

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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, 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.

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.

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.

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 consider behavior modification as you were before (if you were considering it), or 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

Amantadine (an antiviral that has been used in the treatment of Parkinson's disease) has also been found to be of benefit in some executive functions in adult patients with dementia. It would be misleading, however, to suggest that stimulant medications or any one medication might be of benefit in all types of executive functions. For many problems, we will need to make environmental changes and provide the individual with direct instruction of skills. A recent report using cognitive remediation for adults with ADHD and executive dysfunction reported that cognitive remediation was effective for certain aspects of executive dysfunction.

FOOTNOTES

1 The author is deeply indebted to Sheryl K. Pruitt, M.Ed., for her input and contributions to this section, but the author retains full responsibility for any errors.

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