Executive function skills enable us to plan, focus attention, remember instructions, and manage multiple tasks. Up to 90 percent of kids with ADHD struggle with executive dysfunction, which impairs goal-directed behavior.
Executive dysfunction is a term used to describe the range of cognitive, behavioral, and emotional difficulties which often occur as a result of another disorder or a traumatic brain injury. Individuals with executive dysfunction struggle with planning, problem-solving, organization, and time management.
Children and adults with executive functioning problems struggle to organize materials, regulate emotions, set schedules and stick with tasks. They misplace papers, reports, and other school materials. They might have similar problems keeping track of their personal items or keeping their bedroom organized.
For children, behavior modification programs like token systems and daily report cards generally work well, however kids with ADHD get bored with token systems unless they collaborate on creating them. Similarly, daily report cards, while initially helpful, may end up making them feel bad about themselves when they don’t succeed, thus creating a negative reinforcement loop. Cognitive behavioral therapy (CBT) is often helpful because it offers interventions in the moment.
What Is Executive Functioning?
Broadly speaking, executive functioning refers to the cognitive and mental abilities that help people engage in goal-directed action. They direct actions, control behavior, and motivate us to achieve our goals and prepare for future events. People with executive dysfunction struggle to organize and regulate their behavior in ways that will help them accomplish long-term goals.
Attention deficit disorder (ADHD or ADD) and executive functions are tightly linked, but far from synonymous. We all have executive functioning strengths and challenges that affect the attention, learning, work, and relationships. However, for those with ADHD, executive function (EF) challenges are more severe and more numerous than for those without it.
The seven major types of self-regulation associated with executive functioning are as follows:
- Self-Awareness: commanding self-directed attention
- Self-Restraint: inhibiting yourself
- Non-Verbal Working Memory: holding things in your mind to guide behavior
- Verbal Working Memory: retaining internal speech
- Emotional: using words and images along with self-awareness to alter how you feel about things
- Self-Motivation: motivating yourself to do things when no outside consequences exist
- Planning and Problem Solving: finding new approaches and solutions
How Do Executive Functions Develop?
The abilities associated with executive functioning don’t all develop at once, but rather in a sequence — one skill building atop the next. All of the executive functions interact with each other, and impact how individuals regulate their behavior to create positive future outcomes.
Executive functions begin developing by age two, and are fully developed by age 30. People with ADHD often are 30 to 40 percent delayed in development, which makes them more likely to act motivated by short-term rather than longer-term goals.
The back of the brain is where you store information that is already learned. The front part of the brain is where you use this information to be socially effective and succeed in life. This prefrontal cortex mediates executive functioning and it contains four major circuits.
- The “what” circuit controls working memory, helping you execute plans, goals, and specific steps needed to complete a project.
- The “when” circuit helps you organize the order in which you complete activities, and address timelines.
- The “why” circuit controls emotions — what you think about, and how you feel.
- The fourth “how” circuit controls self-awareness of your feelings and experiences.
People with executive functioning challenges and/or ADHD may experience impairments in one or more of these circuits and, therefore, their symptoms may touch memory, planning, emotional regulation, and/or social skills. Read on to learn more about executive functions, and what therapies and interventions can help strengthen them. Consult with a physician if you recognize the symptoms below in your or your child.
Executive Dysfunction Symptoms
People with EF difficulties may experience the following symptoms:
- time blindness, or an inability to plan for and keep in mind future events
- difficulty stringing together actions to meet long-term goals
- trouble organizing materials and setting schedules
- trouble controlling emotions or impulses
- difficulty analyzing or processing information
Executive functions allow people to do the following:
- Analyze a task
- Plan how to address the task
- Organize the steps needed to carry out the task
- Develop timelines for completing the task
- Adjust or shift the steps, if needed, to complete the task
- Complete the task in a timely way
When a person has weak executive functions in certain areas, he or she may have trouble analyzing, planning, organizing, scheduling, and completing tasks. People with executive dysfunction and/or ADHD commonly lack the ability to handle frustration, start and finish tasks, recall and follow multi-step directions, stay on track, self- monitor, and balance tasks (like sports and academic demands). Remediating the area of deficit reduces academic or work difficulties.
Executive Function and ADHD
ADHD is a biologically based disorder and a developmental impairment of executive functions the self-management system of the brain. While most people with ADHD will experience many areas of executive function impairment, people can have executive dysfunction without ADHD.
The following six clusters of executive functions tend to be impaired in individuals with ADHD:
- Activation: organizing tasks and materials, estimating time, getting started
- Focus: finding, sustaining, and shifting attention as needed
- Effort: regulating alertness, sustaining motivation and processing speed
- Emotion: managing frustration and modulating feelings
- Memory: using working memory and accessing recall
- Action: monitoring and regulating physical activity
Russell Barkley, Ph.D., who has been at the forefront of exploring the relationship between executive dysfunction and ADHD, says, “It is not that the individual does not know what to do. It is that somehow it does not get done.”
Executive Dysfunction Causes
Executive dysfunctions can be the result of heredity, especially in ADHD but they can also result from damage to the prefrontal cortex, in vitro exposure to substance use, trauma or severe neglect. A study found that people with disorders, diseases, or injuries that damage that area of the brain are more prone to difficulties with executive functioning1.
Evaluating Executive Function Difficulties
An executive function evaluation typically begins by ruling out other conditions with similar symptoms. The most common evaluation is the Behavior Rating Inventory of Executive Function (BRIEF), a written survey that kids/young adults, parents, and teachers complete to assess executive functioning. It comprises 86 questions designed to pinpoint the biggest area of difficulty. Additional evaluations include:
- Conners 3: a rating scale that evaluates ADHD and EF using parent, self, and teacher reports
- Barkley Deficits in Executive Functioning Scale (BDEFS) for Adults: assesses EF using self and other reports
- Comprehensive Executive Function Inventory (CEFI): compares a person to a norm group using parent, teacher, and self-report assessments
Executive functions are typically taxed during the transitions to 6th and 9th grade, when school structures and schedules change dramatically, and academic expectations increase. Parents and teachers often don’t understand why kids can’t work independently on an assignment, and assume they’ll “pick up” the necessary skills. It’s important to start helping kids with executive dysfunctions early, and to acknowledge the associated problems so that kids don’t feel stupid or lazy.
Treatment Options for Executive Dysfunction
Experts recommend a range of strategies to help strengthen the areas of weakness associated with executive dysfunction. The first method uses occupational or speech therapists, psychologists, or reading tutors to learn how to work around problem areas. Cognitive behavioral therapy, used in combination with medication to treat any coexisting conditions like ADHD, is very effective at treating executive functioning deficits including problems with inhibition, emotion regulation, time management, and planning.
Many experts recommend redesigning the environment to help people with executive dysfunctions to stay on task. For example, adults may compensate for working memory deficits by making information external – using cards, signs, symbols, sticky notes, lists, journals, and apps. Patients can likewise make time external by using clocks, timers, computers, counters, and other devices that track time intervals. Use external motivation, like points systems, being accountable to others at work and school, daily school report cards – anything that reinforces accomplishing goals.