Executive Dysfunction: Failure in the frontal lobe

What controls human behavior? While most are aware the brain plays an immense role, how does this organ determine human action? Cognition is a mental process in the brain which relies on a set of skills called executive functions. Executive functions fail to facilitate the attainment of goals, these individuals have executive dysfunction. Read to learn the causes, symptoms, and treatment of executive dysfunction.  

All About Executive Functions

Controlled by the frontal lobe, which is the area of the brain integral to cognitive skills, judgment, and personality, executive functions are a set of self-regulation processes responsible for human behavior. Executive functions are necessary for identifying a goal and then executing the tasks needed to attain that goal. They allow us to focus, follow instruction, plan, organize, and recall information.

There are 3 categories areas of executive function:

1. Cognitive Flexibility: the efficiency in which the brain shifts from one concept to another
2. Working Memory: manipulating information stored over short periods
3. Inhibitory Control: the ability to control attention, behavior, thoughts, and emotions despite environmental stimuli

Executive functions control all cognitive skills such as attention, organization, prioritizing, emotional regulation, processing speed, and reflection (Diamond, 2013).

What is Executive Dysfunction?

Executive Dysfunction, also called executive function disorder, refers to a range of deficits that result when executive functions do not function properly. The impairment occurs at all ages, and its effects can be short or long term. It presents difficulty in thinking (cognitive) skills, social behavior, and personality.

Someone with this will exhibit weaknesses in 6 key areas:

1. Focusing attention
2. Regulating emotions
3. Self-monitoring
4. Impulse control
5. Utilizing working memory
6. Planning and organization

Symptoms of Executive Dysfunction

Symptoms of this include neurocognitive deficits and behavioral effects. There is a broad spectrum in the severity. Signs and symptoms are:

• Failure to stay on task
• Difficulty regaining focus after distractions
• Procrastination
• Inefficient multi-tasking
• Loss of concentration
• Poor time management
• Misplacing items
• Difficulty organizing materials and schedules
• Short-term memory issues
• Struggling to learn new information
• Unable to control emotions
• Impulsive behavior (i.e. deviating from social norms, easily tempted, etc.)

Executive Dysfunction in Daily Life

A huge reason as to why this is so distressing is that it affects daily functioning. The symptoms interfere with work, school, their sense of self, and relationships.

In general, people with this seem “scatterbrained.” Their living spaces might appear disorganized, and they forget important details of their schedules. Because of this, they show up late to school or meetings and cannot recall the items they were supposed to purchase at the store. They are prone to impulsive behavior like making poor decisions and defying social norms. For example, talking over others in a classroom setting is a prime instance of issues with impulse control. Relationships become strained, as they do not manage their emotions effectively. This leads to frequent disagreements. Work is a challenge. Co-workers may view them as easily frustrated or blame them for not following through on assigned tasks.

Executive Dysfunction in Children

Children with this present similarly to adults. However, their symptoms are impacted by the different developmental stages in their lives.

Young people with executive dysfunction experience conflict at home and school. These children tend to be stubborn and aggressive towards their peers. They might refuse to share toys, find it difficult to express emotions and have tantrums when they do not get their way. These children procrastinate on their school work. Additionally, they lose track of time and panics if plans deviate from routine. Parents and teachers accuse them of not listening, as they do not follow directions or focus on the least important instruction. As they age, they are more likely to engage in risky behaviors like drugs and alcohol.

Causes of Executive Dysfunction

Executive dysfunction is not a primary medical diagnosis. In fact, it is not listed in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). The effects are a symptom of an underlying problem. While some are born with weaknesses in executive functions, others develop executive dysfunction secondary to a variety of physical and psychological conditions.

Executive Dysfunction and Traumatic Brain Injury

The most common cause of executive dysfunction is a traumatic brain injury. Since executive functions are controlled by the frontal lobe, any trauma to the surrounding area of the brain is enough to induce significant cognitive changes. There is potential for partial recovery, but specialist document persistent cognitive impairments despite intense rehabilitation.

Executive Dysfunction and Mental Disorders

Having a preexisting mental disorder is a risk factor for executive dysfunction. It is not rare for someone to have multiple diagnoses simultaneously, as executive dysfunction is associated with various psychological pathologies:

• Schizophrenia: Schizophrenia is a severe mental disorder in which one loses touch with reality, experiencing delusions, hallucinations, and abnormal behavior. Someone with the disorder displays executive dysfunction with specific deficits in working memory, flexibility, and multi-tasking.
• Bipolar Disorder: Bipolar disorder is a mood disorder causing alternating periods of mania and depression. While not usually severe, those with bipolar disorder do show signs of executive dysfunction like impairments in working memory, attention, and inhibitory control.
• Depression: Persistent sadness greater than 2 weeks accompanied by a loss of interest in activities and hopelessness. Executive dysfunction in depression affects planning and motivation. According to a neurologist in the Expert Review of Neurotherapeutics (2005), executive dysfunction occurring with depression has poorer treatment outcome.
• Obsessive-Compulsive Disorder: Obsessive-compulsive disorder is a mental disorder hallmarked by intrusive thoughts and repetitive, ritualistic behavior to relieve anxiety. The University of Denver found that those with OCD have broad deficits in executive dysfunction, especially in shifting and inhibition control (Snyder, 2014).
• Substance Abuse Disorder: Substance abuse disorder is a drug or alcohol addiction that interferes with work, health, social relationships, and other aspects of daily functioning. The person with substance abuse disorder is unable to control substance use. Excessive substance use inevitably impacts learning and executive function, particularly inhibitory control behaviors and memory recall.
• Conduct Disorder: Conduct disorder is a mental disorder in which children and/or adolescents engage in patterns of behavior that defy social norms. Planning and working memory are most affected.

Executive Dysfunction and Autism Spectrum Disorder

Autism spectrum disorder is a group of developmental disorders affecting communication and behavior. Executive dysfunction is unique when secondary to autism. Memory is well in-tact, but those with executive dysfunction secondary to autism demonstrate poor fluency, flexibility, and emotional control. They cannot produce complex responses or ideas, organize their thoughts, and do not readily adjust to change. Communication with others provokes impulsive behavior because they are unable to express their emotions.

Executive Dysfunction and Neurodegenerative Conditions

Executive dysfunction and neurodegenerative conditions are closely related. Neurodegenerative conditions are progressive diseases that result in the loss of the brain’s neurons—nerve cells that signal functions of the central nervous system. Alzheimer’s disease, Parkinson’s disease, Lewy-body dementia, and Huntington’s disease are all diagnoses of a neurodegenerative process. Symptoms of executive dysfunction stem from damage to the frontal lobe as a result of neurodegeneration.

Executive Dysfunction and ADHD

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that primarily manifests as inattention, hyperactivity, and impulsive behavior. The symptoms of ADHD are problems with executive function like organization, decision making, and planning. Current research points to the hypothesis that ADHD is caused by underlying executive dysfunction.

Assessing Executive Dysfunction

Executive functioning encompasses a wide range of skills. Establishing a diagnosis of executive dysfunction requires a full screening of cognitive skills. This assessment is typically performed by a neuropsychologist, which is a doctor who specializes in brain-based mental disorders. A psychologist, neurologist, or audiologist also assess patients for executive dysfunction. Teachers can facilitate the proper assessments in children with suspected weaknesses of executive function skills.

The neuropsychological assessments measure memory, attention, inhibitory control, set-shifting, word idea and generation, concept formation, and organization. Professionals select a combination of tests based on the patient’s age and history.

• Stroop Color and Word Test: Patients categorize information through competing stimuli to test flexibility in processing speed, attention, and accuracy. “Green” is written in a “red” font and the patient must classify the color the word is printed in (red), while ignoring the original word (green).  
• Clock Drawing Test: The administrator instructs the patient to draw a clock reading a specific time. Next, the patient is asked to copy an image of a clock. Those with executive dysfunction make errors on the first clock, but not the second. This measures memory, attention, concentration, and the ability to stay on task.  
• Wisconsin Card Sorting Test: The Wisconsin Card Sorting Test sorting a deck of 128 cards organized by shape, color, and quantity. It assesses problem-solving strategies.
• Barkley Deficits in Executive Functioning Scale (BDEFS): Barkley Deficits in Executive Functioning Scale (BDEFS) seeks to provide a depiction of executive dysfunction skills in daily life. It is helpful for time management, self-motivation, and emotional regulation.
• Comprehensive Executive Function Inventory (CEFI): The Comprehensive Executive Function Inventory is designed for children aged 5 to 18. It can be administered by parents, teachers, or self and measures behaviors of executive function.  
• Conners 3-Parent Rating Scale: Used in pediatric patients, the Conners 3-Parent Rating Scale provides a parent’s observation about a child’s behavior. It is designed for ages 6 to 18.

Coping with Executive Dysfunction

Managing executive dysfunction takes effort on behalf of multiple professionals and loved ones. Speech therapists, psychologists, occupational therapists, and tutors mainly manage the symptoms.

Medications

No medications currently exist for executive dysfunction. However, medications to treat other conditions are occasionally beneficial. Researchers have connected executive dysfunction to numerous psychiatric conditions. Published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry, these conditions are driven by disruption of the chemical messenger in the brain called dopamine, which furthers the symptoms of executive dysfunction. Dopamine antagonists and agonists (stimulants) are effective treatments because the drugs increase the availability of dopamine in the brain by either blocking or activating the receptors.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of talk-therapy founded on the premise that false beliefs and thoughts influence behavior. With the help of a mental health professional, cognitive behavioral therapy modifies unwanted behaviors, implementing coping strategies, and improving emotional regulation. Individuals with executive dysfunction benefit from cognitive behavioral therapy because the therapy targets emotional problems and low self-esteem that arise from living with a condition and exacerbate symptoms.

Brain training

Brain training consists of skill-building games useful in the treatment of executive dysfunction. Video games through modern technology (i.e. computer, phone, tablet) train skills such as attention, memory, focus, processing speed, and more. Current studies lend evidence that brain training games in the form of puzzles, matching, and other activities are most conducive for children and young adults with executive dysfunction (Nouchi, 2013). A positive aspect of brain training is that the individual can practice by themselves rather than requiring the presence of a professional.

Tutoring

Although executive functions are non-academic, executive function skills are vital to education. Students with executive dysfunction do not retain information due to issues with attention, following instruction, and not turning in their work because of forgetfulness. Accommodations through a 504 plan are useful in overcoming challenges in school. However, tutors in executive function reinforce any unretained information while imparting the skills to use that information.

Occupational Therapy

Occupational therapy (OT) manages executive physical, cognitive, and sensory issues through the therapeutic use of daily routines. An occupational therapist aims to increase a patient’s independence in day-to-day life by teaching coping strategies. Strategies occupational therapy develop include:

Planning, Memory, and Organization

Plan the day, week, or activity through calendars, planners, diaries, mobile phones, pagers, and electronic timers. Use as many aids as possible to record. Write reminders and strategically post them in places they are visible.

To stay accountable, tell family and friends of the plans. Prepare a routine for tasks that rarely change—household chores, self-care, and shopping. Divide harder tasks into multiple steps with scheduled breaks in between.

Emotional Regulation and Social Interactions

Mood changes are prevalent amongst those with executive dysfunction, as they do not know how to regulate their emotions. Outside of traditional psychotherapy, occupational therapists suggest rehearsing social situations with a trusted individual. The practice prepares for the appropriate emotional reactions before the social interaction actually unfolds. Journaling is also an outlet for pent up emotions. Releasing unexpressed emotions is essential for living with executive dysfunction.

References

DeBattista, C. (2005). Executive dysfunction in major depressive disorder. Expert Review of Neurotherapeutics, 5:1, 79-83, DOI: 10.1586/14737175.5.1.79

Hosenbocus, S., & Chahal, R. (2012). A review of executive function deficits and pharmacological management in children and adolescents. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent, 21(3), 223–229.

Marchetta N, Hurks P, Krabbendam L & Jolles J (2008). Interference control, working memory, concept shifting, and verbal fluency in adults with attention-deficit/hyperactivity disorder (ADHD). Neruopsychology, 22(1), 74–84

Nouchi, R., Taki, Y., Takeuchi, H., Hashizume, H., Nozawa, T., Kambara, T., … Kawashima, R. (2013). Brain training game boosts executive functions, working memory and processing speed in the young adults: a randomized controlled trial. PloS one, 8(2), e55518. doi:10.1371/journal.pone.0055518

Snyder, H., Kaiser, R., Warren, S., & Heller, W. (2014). Obsessive-Compulsive Disorder Is Associated With Broad Impairments in Executive Function: A Meta-Analysis. Clinical Psychological Science. DOI: 10.1177/2167702614534210

Cheyanne Perry

Cheyanne is currently studying psychology at North Greenville University. As an avid patient advocate living with Ehlers Danlos Syndrome, she is interested in the biological processes that connect physical illness and mental health. In her spare time, she enjoys immersing herself in a good book, creating for her Etsy shop, or writing for her own blog.