Executive Function Dysfunction

Executive Function
Dysfunction:

The Newest “Learning Disability”

Karen J. Miller, MD
Floating Hospital for Children

Tufts Medical Center
Boston, MA

Examples of possible
EF dysfunction

„ Juan, 8 y.o. referred for ADHD evaluation as
he is distractible and can’t wait his turn

„ Michael, 10 y.o. with a history of TBI is now
irritable and impulsive

„ Cathy, 11 y.o. with Asperger syndrome gets
upset with transitioning to new activities

„ Anthony, 14 y.o. who did well in elementary
school now referred for being “lazy”

„ Ken, 35 y.o. pediatrician who can’t remember
where he put his keys

What are Executive Functions?

Executive Functions “definition”

„ Variety of “higher-order” mental
processes and behaviors

„ Enables self-regulation, problem-solving
and goal directed behavior

„ Integrates lower-level processes
„ Develop gradually over time

Exec Function:
Metacognition
Exec Function:
Self-Regulation

Basic Neurological Functions

Levels of Brain Function

Neocortex-
Rational thought

Midbrain/
Limbic system-
Automatic behaviors/
Emotions

Brainstem-
Survival/aggression

Basic Areas of Brain

Anterior Posterior

Superior

Inferior

Brain Lateralization Oversimplified

Left Hemisphere Frontal Lobe

Language Executive Functions
Sequential Right Hemisphere
processing
Visual-spatial
Logic Simultaneous
processing
Imagination

Routines Novelty

Right side control Left side control

Basic Neurological functions-
WHAT happens NOW

„ Physiological functions
„ Sensory functions
„ Speech/Language
„ Spatial
„ Motor
„ Memory of skills
„ Memory of facts

Basic Executive Function-

Not What but How and When

„ Round-A composition for two or more
voices in which each voice enters at a
different time with the same melody

„ Row,Row,Row Your Boat

„ Row, row, row your boat
„ Gently down the stream
„ Merrily, merrily, merrily
„ Life is but a dream

EF metaphors

„ Conductor
„ CEO
„ Director
„ Pilot
„ Cook

Executive Functions-

Closer look at some components

„ Self-Regulatory functions BRIEF rating scale
Gioia et al,2000
„ Inhibition
„ Shift/Flexibility
„ Emotional Regulation

„ Metacognitive functions

„ Working Memory
„ Problem-solving
„ Monitoring

Basic Executive Functions-

Self-Regulation of NOW

„ Inhibition

„ Behavioral
„ Cognitive

„ Shift/Flexibility
„ Emotional Regulation

EF- Balancing between
Inhibition and Initiation

STOP!

GO!

Basic EF Dysfunctions-

Inhibition

„ Ability to inhibit is the gateway to other EFs

„ Deficits in behavioral inhibition
„ “Impulsive”, “can’t stop when asked”

„ Deficits in cognitive inhibition
„ “Daydreams”, “off topic”

„ Deficit associated with Attention
Deficit/Hyperactivity Disorder

Barkley, 2000

Stroop Task-1

Say the COLOR of the ink:

GREEN YELLOW RED BLUE BLACK
RED BLUE BLACK YELLOW GREEN

Stroop Task-2

Say the COLOR of the ink:

GREEN YELLOW RED BLUE BLACK
RED BLUE BLACK YELLOW GREEN

Anterior Cingulate activated
during Stroop task-PET Scan

Images of Mind by Posner and Raichle 1994

EF Regulates Attention

„ EF as air traffic controller
„ Vigilance

„ Scanning the radar screen
„ Houselights

„ Selective attention

„ Focusing on the blip
„ Flashlight/Spotlight

„ Dividing Attention Adaptively

„ Balancing vigilance and selectivity

Basic EF Dysfunctions-

Shift/Flexibility Deficits

„ ADAPT as new information presents
„ Shifts too quickly

„ “Distractible”, “Doesn’t finish”
„ Associated with AD/HD

„ Shifts too slowly
„ “Daydreams”, “off-topic comments”
„ Associated with ADHD Inattentive
„ “Rigid”, “Perseverative”
„ Associated with Autism spectrum

Basic EF Dysfunctions-

Emotional Regulation Deficits

„ Ability to inhibit allows modification of
emotional expression, selection of adaptive
emotional response and activate emotion if
needed.

„ Self-regulation of affect (Barkley 1997,2000)
„ Deficits can present as:

„ “Over-emotional”, “over-sensitive”,
“immature”, “moody”, “easily frustrated”

„ Inability to “pump up”, “unenthusiastic”

Exec Function:
Metacognition
Exec Function:
Self-Regulation
Basic Neurological Functions

“METACOGNITION”

Managing LATER

„ Working Memory
„ Problem-solving
„ Monitoring

Meta-cognition:
Non-Verbal Working Memory

„ “mental work space” “scratch-pad”
„ Non-verbal WM enables

„ Hindsight, foresight
„ Mental representations
„ Pattern recognition
„ Sense of time and events in time
„ Deficits result in:
„ Poor time management, not learning from past,

difficulty reading facial expressions, poorly
sequenced behavior, social incompetence,
misplacing items, clumsiness, problems in math
„ Associated with Non-Verbal LD

Meta-cognition:

Verbal Working Memory

„ Holds language “on-line” while processing,
manipulating or waiting

„ “Self-talk”
„ Rule-governed behavior/reasoning
„ Deficits result in:

„ Forgetfulness, “careless errors”, comprehension
problems, “rude” behavior

„ Associated with learning disabilities, language
disorders, AD/HD

Working Memory-
Hidden but critical

„ Limited capacity; “budget problem”
„ Easily overwhelmed or overwritten
„ May do task components in isolation but not

simultaneously “Forget to remember”
„ Timing and timeliness of access

„ Need for contingent, convergent, coordinated retrieval

„ Impact is on writing, reading comprehension and
time management

„ Productivity, accuracy and behavior will vary with
volume, complexity and/or level of adult
support/structure

Meta-cognition:

Problem-solving

„ Problem-solving components

„ Prioritizing/goal selection
„ Analysis/synthesis (“reconstitution”)
„ Strategy development and selection
„ Planning/Organization

„ Deficits result in problems in:

„ Completing tasks efficiently, organizing materials,
formulating responses, sequencing activities,
balancing work/leisure, coping with adversity,
managing long-term tasks

Barkley 1997,2000

Meta-cognition:

Monitoring and Motivation

„ Task Monitoring

„ Is it done? Is it done right?

„ Self-Monitoring

„ Social feedback
„ Introspection/self-awareness: WHY DO IT?

„ Deficits result in:

„ Poor quality of work, poor pacing
„ “Egocentric”, socially “clueless”
„ Over- or under-estimating abilities/skills
„ Motivation; self-activation
„ Disorganization; incompleteness

Organization / Executive Function Control

Developmental Progression

Productive Adult
Efficient
Accurate

Effectiveness Inconsistent

Inefficient Preschool
Limited
Complex
output

Simple

Task Demands

Development of EF

„ 7-8 months

„ Demonstrates working memory

„ 3 years

„ Begins ability to inhibit disadvantageous decision

„ 6 years

„ Attention becomes volitional

„ Adolescence

„ Manipulate and integrate complex information

Powell KB, Voeller Kytja KS.

J of Child Neuro. 2004

Gray matter development

Gogtay, Giedd et al
PNAS 2004

Cortical thinning of attention and executive function
networks in adults with ADHD

Makris N, Biederman J, Valera EM et al; Cerebral Cortex 2007;
17(6):1264-75

ADHD - overall cortical thinning especially in dorsolateral preforontal,
anterior cingulate, posterior cingulate and inferior parietal (angular gyrus)

Organization / Executive Function Control

in ADHD and other EF dysfunctions

Productive
Efficient
Accurate

Effectiveness Inconsistent

Inefficient
Limited

output

Simple Complex

Task Demands

EF:
At the interface between brain and
environment

Hot off the presses

„ Impact of Early Behavior Disturbances on
Academic Achievement in High School; J

Breslau et al; Pediatrics (2009) 123(6):1472

„ Attention problems at 6 significantly predict
math and reading achievement at 17

„ “interventions that target attention problems
at school entry should be tested as avenue
for improving educational achievement”

Executive Function Dysfunction

„ Universal experience
„ Experience dependent (expertise)
„ Increased in:

„ Illness and fatigue states
„ Attention Deficit Hyperactivity Disorder
„ Autism Spectrum Disorders
„ Learning Disability
„ Fetal Alcohol syndrome
„ Side effects of medications
„ Drugs or alcohol

Executive Function
Dysfunction-2

„ Brain Injury (traumatic or acquired)
„ Brain disorder (e.g. dementia, tumors)
„ Partial complex epilepsy, frontal origin
„ Mental illness (e.g. schizophrenia, depression,

bipolar, OCD)
„ Tic disorders
„ Genetic disorders

„ Phenylketonuria, Turner syndrome, William’s syndrome
Velocardiofacial syndrome, Metachromatic
leukodystrophy, Neurofibromatosis, Wilson Disease

Assessment of EF - Real Life

„ Interviews including the child/adolescent
„ Observation especially less structured settings
„ Work samples
„ List areas of strengths/weak SKILLS:

ƒ Parts of tasks that need adult „ Starting/stopping/shifting
„ Flexible or creative thinking
structure/support „ Response to problem or

ƒ Ability to plan tasks? frustration
„ Social skills
ƒ Homework/chore breakdowns „ Learn from mistakes

ƒ How well organized?
ƒ Attending to the right thing?

Long enough?

Assessment of EF

„ Medical
„ Psychiatric/Behavioral
„ Psychological/Educational
„ Neuropsychological
„ Neuroimaging if indicated
„ EEG if indicated
„ Laboratory studies if indicated

Assessment of EF
-Neuropsychological Testing

„ Wechsler Intelligence Scale for Children-4th
edition WISC IV (working memory)

„ Delis-Kaplan executive function system
„ NEPSY subtests
„ Rey Complex Figure
„ Behavior Rating Inventory of Executive

Function (BRIEF)
„ Brown Attention Deficit Disorder Scales

Where is the breakdown?

„ Is there a knowledge deficit?
„ Is there a procedural skill deficit?
„ Is it an executive function deficit?

„ Inhibition/Initiation
„ Shift/Flexibility
„ Emotional Regulation
„ Working Memory
„ Problem-solving/Organization
„ Monitoring

EF Intervention

„ ADHD, Autism, TBI, LD literature
„ Effective programs emerging for children
„ Heterogeneity confounds (Denckla 2007)

„ Specify the skills (strengths/weaknesses)
„ Process oriented: Not what but how
„ Levels of Intervention

„ Environment
„ Task
„ Child

Dawson, Guare 2004
Meltzer 2007

EF Intervention: Environment-based

Procedures and Routines

„ Make life predictable
„ Black/white; when-then
„ Establish explicit routines

„ Home
„ School
„ Social
„ Play

„ Transitions
„ Disciplinary routines
„ Academic procedures

EF Intervention: Environment-based

School issues

„ Executive function not an special education
disability category

„ Special Education categories (partial list)

„ LD, Autism, ADHD (under Other Health
Impaired), Neurological, Communication

„ Lack of understanding of executive function
„ Accommodations
„ Skill development
„ Adult support

„ Coaching

EF Intervention: Environment-based

Adopt an EF Lifestyle

„ EF is learned in day to day
activities with real life
problems

„ EF is developed by modeling
and supported practice

„ Keep an EF mindset when
engaging in tasks and
externalize the process

Externalizing EF

„ Talk out loud and model

„ “Hmm. What do I need to do before I…?”
„ “I will write that down here”
„ “Wow! That didn’t go as I expected! What are my

options now?”
„ “I’m too upset to think clearly. I need to take a walk.”
„ “I wonder who I can ask for help about…?”
„ “We want to go on vacation in two months. I’m going

to start planning now.”

EF Intervention: Task-based

Setting them up to get it right

„ Make it part of a ROUTINE
„ Increase demand by increments

(scaffold/fade)
„ Break into smaller parts
„ Make steps more explicit
„ Make it visual (e.g. lists)
„ Prioritize tasks or task components
„ Limited choices
„ Provide criteria for completeness (rubric)

EF Intervention: Child-based

Medical and Medication

„ Medical

„ Sleep, nutrition, medical problems

„ Medication

„ Attention problems

„ Stimulants, atomoxetine
„ Improves with self-regulation and focus in the

moment; not metacognition

„ Emotional problems

„ Anxiety, aggression, mood disorder

EF Intervention:Child-based

Building Skills

„ Practice component skills in isolation
„ ? Role of computerized training (e.g.

Klingberg 2005)

„ Strategy instruction

„ (Meltzer 2007,Marlowe 2000)

„ Practice problem-solving in context

Summary

„ Executive functions are late developing,
higher order cognitive processes

„ EF delays/deficits are common
„ EF remediation involves

„ Modifying the environment
„ Structured practice
„ Strategy development
„ Sometimes medication

„ Collaborative approach needed