Executive Function

Definition, symptoms, causes, impact on carers, diagnosis, support options, practice approach

Three sections follow:

1.      Background Material that provides the context for the topic

2.      Suggestions for Practice

3.      A list of Supporting Material / References

Feedback welcome!

Background Material

Definition

Executive function refers to a set of mental skills that help people plan, focus, remember, and juggle multiple tasks (Peart, 2024).  It enables people to complete tasks and interact with others (Villines & Juby, 2023).  In other words, executive function skills allow people to direct their attention to any given task or activity and to take steps towards achieving everyday goals (McLean, 2018).

Executive function skills are processed in a part of the brain called the prefrontal cortex. Other parts of the brain closely connected to the prefrontal cortex are also involved (Evans, 2022).

Working memory, cognitive flexibility and inhibition control are the foundation of executive function.

• Working memory:  how one thinks about, uses, and recalls information in day-to-day life. Without an efficient working memory, people may be forgetful, disorganized, or have trouble completing ordinary tasks

• Cognitive flexibility:  the ability to change behavior in response to things around changing. Poor cognitive flexibility leads to problems with reading, switching from one task to another, or adapting to stress and unhappy events.

• Inhibition control: managing thoughts, feelings, and behavior. People with poor inhibition control may find it hard to keep quiet when they should or find it hard to manage their thoughts and focus on a certain task or problem.  There are two main ways that inhibition control works:

  • Behavioral control, i.e., the ability to avoid doing things that one shouldn’t do.

  • Interference control, i.e., the ability to steer or manage thoughts to focus on what that needs attention and ignore whatever doesn’t (Cleveland Clinic, 2022; Goodman & Shepard, 2024).

There are also higher-level executive functions including:

• Planning. This is mentally mapping out a series of actions that help reach a goal.

• Reasoning. This is the ability to apply critical thinking. It’s a central way to build on stored knowledge to think creatively or break down something complicated into easier-to-understand pieces.

• Problem-solving. This function can involve all three main executive functions, as well as planning and reasoning. It is about overcoming obstacles or problems (Cleveland Clinic, 2022).

Therefore, executive function includes a range of skills, such as:

• planning and organization.

• concentrating and managing mental focus.

• analysing and processing information.

• managing emotions and behaviour.

• remembering details.

• managing time.

• multitasking.

• solving problems.

Executive function difficulties are commonly found in childhood “disorders” such as autism, attention deficit hyperactivity disorder (ADHD), fetal alcohol spectrum disorders (FASD), and mood and anxiety disorders, although exactly how the executive skills are compromised varies between these disorders (McLean, 2018).

Disordered executive function (or executive dysfunction) happens with conditions that disrupt the brain’s ability to control thoughts, emotions and behavior. Disordered executive function can affect many parts of life, including work, social interactions and more, e.g. having trouble doing tasks that have steps, such as cooking a meal or finishing a work or school project. Executive dysfunction has little to do with intelligence; it is a disconnect in the brain's ability to coordinate and carry out tasks (Cleveland Clinic, 2022;Goodman & Shepard, 2024).  The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) does not recognize executive function disorder as a specific mental health condition. Instead, executive function issues are symptomatic of other neurological, mental health, and behavioral disorders such as depression and Alzheimer’s disease (Villines & Juby, 2023).  

Symptoms

It may be difficult to identify exactly which areas of executive dysfunction are impaired, and often more than one skill is affected. The symptoms can also range from subtle effects, which only close friends and family members may notice, to extreme and problematic behaviour (Evans, 2022).  However, there are possible symptoms of executive function difficulties.  Villines and Juby (2023), Goodman and Shepard (2024), and Cleveland Clinic (2022) provide a list of symptoms that include the following:

1.     Trouble managing emotions or impulses

• Having problems with impulse control.

• Having trouble controlling emotions.

• Speaking without thinking first.

• Socially inappropriate behaviour.

2.     Problems with starting, organizing, planning, or completing tasks

• Trouble planning or carrying out a task.

• Starting activities or tasks.

• Motivating oneself to do something that is not of interest, such as chores.

• Estimating how much time a project will take to complete.

• Difficulty solving problems.

3.     Trouble listening or paying attention

• Daydreaming or “spacing out” rather than paying attention.

• Being easily distracted.

4.     Short-term memory issues

• Inability to learn from past consequences.

• Misplacing things.

• Forgetting things, such as appointments.

• Losing one’s train of thought.

• Difficulty learning or processing new information.

5.     Inability to multitask or balance tasks

• Focusing too much on just one thing.

• Struggling to switch between tasks.

• Shifting plans when situations change.

Evans (2022) groups symptoms into the following areas:

• Difficulties with motivation and initiation, e.g. starting, organising, planning or completing tasks that may be mistaken by others as laziness or disinterest.

• Difficulties with organisation, e.g. making and sticking to plans because of difficulty thinking through the steps to get things done.

• ·Difficulties with flexible thinking, e.g. adapting or changing behaviour, or switching between tasks, as the person may become stuck or fixed on certain information or behaviours - 'rigid thinking'.

• Difficulties with problem-solving, e.g. thinking through problems, forming solutions  and anticipating the consequences of their decisions.

• Impulsivity, e.g. acting without thinking through possible consequences.

• Difficulties with planning, e.g. thinking ahead and going through the various steps to complete an activity may be more difficult.

Problems with executive function may lead to:

• affected performance at work or school.

• difficulty forming or maintaining relationships.

• mood issues.

• low self-esteem.

• avoidance of difficult tasks.

• low motivation or loss of interest in activities.

Note that many of these behaviours are typical of many young children as healthy executive function takes time to develop.   If these behaviors persist past childhood, they may indicate that the child has difficulty with executive function (Villines & Juby, 2023).

Causes

(The following was sourced from Cleveland Clinic, 2022; Goodman & Shepard, 2024; and Villines & Juby, 2023.)

Experts don’t fully understand why disordered executive function happens, or why it can take so many different forms. However, experts have linked this issue to several conditions that affect the way the brain works, including:

• Addictions (especially alcohol use disorder and drug use disorder).

• Attention-deficit hyperactivity disorder (ADHD).

• Autism spectrum disorder.

• Depression and anxiety.

• Obsessive-compulsive disorder (OCD).

• Schizophrenia.

Disordered executive function can also happen if there’s damage to or deterioration of the areas of your brain that contribute to executive function abilities. Some common examples of conditions or circumstances that can cause damage or deterioration include:

• Alzheimer’s disease.

• Brain tumours (including cancerous and noncancerous growths).

• Cerebral hypoxia (brain damage from lack of oxygen).

• Dementia and frontotemporal dementia.

• Epilepsy and seizures.

• Head injuries such as concussions or traumatic brain injuries (TBIs).

• Huntington’s disease.

• Infections (such as those that cause encephalitis or meningitis).

• Multiple sclerosis.

• Stroke.

• Toxins, such as carbon monoxide poisoning.

• Tourette syndrome.

Impact on Carers

Caring for a person with executive deficits can be a full-time job and very distressing.  Problems that carers may experience include:

• Stress, anxiety or depression.

• Increased responsibility.

• Strained relationships.

• Reduced communication with partner.

• Restricted leisure/social life.

• Reduced sexual and emotional intimacy with a partner.

• Feeling tired and frustrated.

It is important for family members, carers and friends to access support for their practical and emotional needs. Input from a rehabilitation team can help, and some people find peer support groups for carers useful (Evans, 2022).

Assessment / Diagnosis

There is not a test that can specifically diagnose executive dysfunction disorder. But there are tests to gauge how well executive function works, such as (Goodman & Shepard, 2024):

• Barkley Deficits in Executive Functioning Scale: This tool helps screen for problems with executive function tasks such as organization, self-restraint, motivation, emotional control, and time management.

• Comprehensive Executive Function Inventory: This scale measures executive function strengths and weaknesses in young people aged 5 -18.  

• Conners 3 Parent Rating Scale: This uses feedback from parents to assess executive function in children aged 6 -18. It scores areas such as learning problems, hyperactivity/impulsivity, aggression, peer relations, and attention.

• Stroop Colour and Word Test: This is used to help find things that affect a person’s reading ability. This test has three parts: a word page, a colour page, and a word-colour page. Children and adults can take it.

Older adults who think their cognitive skills are getting worse could take these tests:

• Mini-Cog: This test takes about 3 minutes and includes drawing a clock and remembering three items.

• Montreal cognitive assessment: This takes about 15 minutes and includes remembering words from a list, copying a picture, and identifying animals by name.

• Mini-mental state exam: This takes about 10 minutes and includes knowing today’s date, counting in reverse, and naming common items.

• Verbal fluency test: This test requires the person to come up with as many words as possible in one minute in a certain category, or words starting with the same letter.

• Test of variables of attention: This test takes 21 minutes. It measures things such as response time and ability to pay attention (Goodman & Shepard, 2024).

A doctor who suspects a specific disorder, such as ADHD, may skip executive function tests and instead compare the person’s symptoms with standard diagnostic criteria for that disorder.  A doctor may also recommend additional testing (e.g. blood tests, CT scans, or brain MRIs) to rule out other causes.

The Neurohealth website (2024) has a self-assessment test for personal use to that shows whether a person has symptoms similar to an executive function disorder.  An accurate diagnosis must be obtained from a health professional.

Question	Agree	Disagree
I have trouble getting started or initiating tasks.
I start tasks with enthusiasm but lose interest quickly.
I find it hard to do things that aren't necessary or highly stimulating.
I am easily distracted by things I see or hear.
I become absorbed in things or tasks that interest me—sometimes to the point of forgetting about people around me or other obligations.
I have trouble following conversations because I am distracted or because I am trying to remember what I wanted to say.
I forget things, even when they are important to me.
At least once a day I lose or misplace items—for example, keys, wallet, purse, or cell phone.
I consistently forget appointments and, when I do remember, I often am late.
I can’t seem to get a handle on clutter. My personal space is messy and has piles of papers and miscellaneous items.
I have difficulty figuring out what is most important or what I should start with given a list of things to do.
I waste time trying to decide what to do first.
I become frustrated when things don’t go as planned and can quickly become angry. I often let go of my anger as quickly as it came.
I have trouble completing multiple-step tasks and moving from one task to another.
I say, “I will do it later” and then forget all about it.

Supporting those with executive function difficulties

Children

Lack of structure in the environment and not knowing what is going to happen present difficulties for children with executive function.  Therefore, they benefit from highly structured and predictable settings and often require help to transition from one situation to another.  It is important to provide a structured and predictable care and learning environment as well as scaffolding strategies.  Strategies can be grouped around (McLean, 2018):

• Planning and starting activities and keeping on track:  break tasks into smaller steps that are clearly stepped out, establish clear routines especially in key daily transitions—waking up, going to bed, leaving for school, coming home from school, spell out expectations step by step, use cartoons or drawings to demonstrate steps.

• Working memory:  simplify interactions with the child (e.g. use shorter sentences, repeat instructions, and use visual prompts).  Children may benefit from memory rehearsal games and commercial memory training programs such as CogMed (https://www.cogmed.com/) or the Amsterdam Memory and Attention training program (AMAT-C).

• Building cognitive flexibility (i.e. the ability to alternate between different thoughts and actions; to shift easily from task to task; to come up with alternative responses to problems when frustrated; and to anticipate and respond adaptively to new situations or changing circumstances and surroundings): provide ample pre-warning about a change or transition (e.g. use a timer or a cue or a transition object), point out the similarity between new and previous situations to minimise the child’s experience of change, teach the child self-talk when change is unavoidable or unexpected.

• Developing emotional and behavioural control: teach and rehearse “stop-think-do” strategies with the child, use physical  and visual prompts to act as a “stop gap” between impulse and action (e.g. snapping an elastic bank on the wrist), teaching and rehearse safe “cool off” strategies to use when emotions become overwhelming.

Adults

When working with adults who have executive function difficulties, understanding their level of insight and awareness is key. Some people are fully aware of their struggles, while others may have little to no insight into why they’re finding life tricky.  Two models can be used as a guide:

• Intellectual awareness: This is when a client knows they have an issue with executive function.  They understand their challenges on a cognitive level but can’ fix it on their own. Social workers can help such people better manage day-to-day tasks.

• Emergent awareness: Here, the client might not be able to articulate the problem beforehand, but they feel it when it happens, e.g. when faced with a chaotic to-do list and can’t figure out where to start. In these cases, it’s about helping them recognise the issue as it arises and developing real-time coping mechanisms (Peart, 2024).

Supporting people with disordered executive function can vary based on the condition itself and a person’s circumstances, health history and preferences.  When disordered executive function happens because of a mental health condition, the goal is usually to treat the underlying condition causing it.  With treatment, the effects of disordered executive function are often minimal or barely noticeable.  The most common treatment methods for mental health conditions that cause disordered executive function include:

• stimulant medications.

• antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

• antipsychotic medications.

• psychoeducation, i.e. the provision of systematic, relevant, broad, and up-to-date information about an illness or condition, including its diagnosis and treatment.

• occupational therapy (offering support to carry out daily activities).

• speech therapy (treatment and support for people experiencing speech disorders and communication problems).

• cognitive behavioral therapy (CBT), i.e. a therapy technique that aims to help people find new ways to behave by changing their thought patterns; CBT is a very common form of mental health therapy for conditions that cause disordered executive function (Cleveland Clinic, 2022; Villines & Judy, 2023).

The treatments for disordered executive function from brain damage or degenerative brain conditions can vary widely. For some of these conditions, direct treatment or supportive care can help. For others, the underlying condition may improve on its own without treatment. Unfortunately, some of these conditions aren’t treatable (Cleveland Clinic, 2022).

Supporting clients with executive function difficulties involves guiding them without taking over, encouraging independence without overwhelming them with details. Therefore:

• Break tasks into small, manageable steps.

• Use visual aids to get organized—calendars, reminders, sticky notes as ‘scaffolding’ to support their executive function.

• Use tools such as time organizers, computers, or watches with alarms.

• Make schedules, and look at them several times a day.

• Ask for written and oral instructions whenever possible.

• Regular check-ins can help track progress and adjust strategies as needed.

• Executive function challenges aren’t going to be solved overnight. Celebrate the little victories (Goodman & Shepard, 2024; Peart, 2024).

Both Evans (2022) and Goodman & Shepard (2024) make suggestions around specific problems that people with executive function difficulties face.

Motivation

• Try to identify the reasons why a certain task is important.

• Make a note of things that need to be done and stick it in a prominent place.  Cross items off when completed.

• Set alarms to try as a  prompt to begin an activity.

• Set times and dates for completion.

• Provide a simple reward for task completion.

Organising

• Keep a list of things to do.

• Set timers and reminders for things that need doing.

• Use a filing system.

• Plan things in advance so there is time for organisation.

• Keep things that are regularly used in one single place.

• Remember: STOP-THINK, i.e. When in the middle of a task with lots of steps, try to pause regularly and ask: 'What am I doing just now? Where am I up to in my plan? Should I still be doing this task or should I have moved onto another task?' 

Flexible thinking

• Try to break larger tasks up into different stages and take one at a time.

• If multiple activities must be completed at the same time, set a prompt as a reminder to swap between them.

• Talk through plans with others. 

Planning

• Use a step-by-step approach, dividing activities into manageable 'chunks' and make a list of each step.

• Use checklists, and tick off each part of the activity when completed.

• Allow plenty of time to plan activities.  Record plans, using things such as calendars, diaries, alarms, mobile phones, etc.

• Mentally rehearse plans.

• Discuss plans with others.

• Prepare a weekly routine for tasks like shopping, washing and tidying the house.

• Make back-up plans in advance to be better prepared for problems.

Improving time management

• Create checklists, and estimate how long each task will take.

• Break long assignments into chunks, and assign times for completing each one.

• Use calendars to keep track of long-term assignments, due dates, chores, and activities.

• Write the due date on the top of each assignment.

Better management of one’s space and keeping things from getting lost

• Organize the workspace.

• Donate things that are not needed to reduce clutter.

• Schedule a weekly time to clean and organize the workspace.

• Make a designated space for everything one owns.

Improving work habits

• Make a checklist for getting through assignments. For example, a student's checklist could include items such as: get out pencil and paper; put name on paper; put due date on paper; read directions; etc.

• Meet with a teacher or supervisor regularly to review one’s work and troubleshoot problems.

• Find an executive function coach or tutor who can help improve planning and carrying out tasks.

Suggestions for Practice

The material in the Background Material section above has a number of approaches that social workers can use if assisting someone with executive function difficulties.  The remainder of this section on ‘practice’ is a synthesis of the material in the Background Material section above.

Executive function skills are processed in the prefrontal cortex area of the brain that is closely connected to other brain areas.  As the brain has the ability to repair itself from injury, it is worthwhile encouraging people who have difficulties with executive function to persevere with efforts to overcome their difficulties.  Over time, because the brain learns from experience and can repair itself, executive function in the area of concern may well improve.

Executive dysfunction has little to do with intelligence; it is a disconnect in the brain's ability to coordinate and carry out tasks. 

Common symptoms of executive dysfunction include:

• Trouble managing emotions or impulses.

• Problems with starting, organizing, planning, or completing tasks.

• Trouble listening or paying attention.

• Short-term memory issues.

• Inability to multitask or balance tasks.

• Difficulties with flexible thinking.

• Difficulties with problem-solving.

Executive function difficulties have been linked to several ‘stand-alone’ conditions such as addictions, ADHD, Autism Spectrum Disorder, depression and anxiety, OCD, schizophrenia, Tourette syndrome.  When supporting people with these conditions, use the approaches suggested by the extensive research that exists for each area.  There are posts discussing most of these conditions on this website – use the ‘contents’ button to locate them.  Likewise, there is a post “Carers: Looking After Others” on this website that offers general advice on how social workers can support those caring for others.

There is no one test that can diagnose executive dysfunction but there are suggestions in the Background Material – Assessment / Diagnosis section above.  A doctor should make a formal diagnosis, although the strategies offered in this post will provide social workers with approaches to use for people trying to address the common symptoms mentioned in the dot points immediately above.

There are four areas where children with executive function can be assisted:

1. Planning and starting activities and keeping on track (e.g. step out tasks, clear routines in transitions)

2. Working memory (e.g. simplify interactions, rehearse)

3. Building cognitive flexibility (e.g. pre-warn about transitions, look for similarity between new and old)

4. Developing emotional and behavioural control (e.g. ‘stop-think-do’, ‘cool off’ strategies).

People with executive function difficulties may face problems in the following areas: motivation, organising, flexible thinking, planning, time management and work habits.  The Background Material section above provides strategies to assist people with difficulties in these areas.

References

Cleveland Clinic. (2022). Executive dysfunction.  https://my.clevelandclinic.org/health/symptoms/23224-executive-dysfunction

Evans, J. (2022).  Executive dysfunction after brain injury.  Headway.  https://www.headway.org.uk/about-brain-injury/individuals/effects-of-brain-injury/executive-dysfunction/

Goodman, B., &  Shepard, S. (2024). Executive function disorder.  WebMD.  https://www.webmd.com/add-adhd/executive-function

McLean, S. (2018). Developmental differences in children who have experienced adversity: Difficulty with executive functioning.  CFCA Practice Guide.  https://aifs.gov.au/resources/practice-guides/developmental-differences-children-who-have-experienced-adversity-guide-no3

Neurohealth. (2024). Take the executive function self-test.   https://nhahealth.com/take-the-executive-function-self-test/

Peart, V. (2024, October 16). How to support clients with executive functioning difficulties.  Social Work News.  https://www.mysocialworknews.com/article/how-to-support-clients-with-executive-functioning-difficulties?

Villines, Z. & Juby, B. (2023).  Disordered executive function: What to know.  Medical News Today. https://www.medicalnewstoday.com/articles/325402