From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Executive_dysfunction
Executive functioning
is a theoretical construct representing a domain of cognitive processes
that regulate, control, and manage other cognitive processes. Executive
functioning is not a unitary concept; it is a broad description of the
set of processes involved in certain areas of cognitive and behavioural
control. Executive processes are integral to higher brain function, particularly in the areas of goal formation, planning, goal-directed action, self-monitoring, attention, response inhibition, and coordination of complex cognition and motor control for effective performance.
Deficits of the executive functions are observed in all populations to
varying degrees, but severe executive dysfunction can have devastating
effects on cognition and behaviour in both individual and social
contexts on a day to day basis.
Executive dysfunction does occur to a minor degree in all
individuals on both short-term and long-term scales. In non-clinical
populations, the activation of executive processes appears to inhibit
further activation of the same processes, suggesting a mechanism for
normal fluctuations in executive control. Decline in executive functioning is also associated with both normal and clinical aging.
The decline of memory processes as people age appears to affect
executive functions, which also points to the general role of memory in
executive functioning.
Executive dysfunction appears to consistently involve disruptions
in task-oriented behavior, which requires executive control in the
inhibition of habitual responses and goal activation.
Such executive control is responsible for adjusting behaviour to
reconcile environmental changes with goals for effective behaviour. Impairments in set shifting
ability are a notable feature of executive dysfunction; set shifting is
the cognitive ability to dynamically change focus between points of
fixation based on changing goals and environmental stimuli. This offers a parsimonious explanation for the common occurrence of impulsive, hyperactive, disorganized, and aggressive behaviour
in clinical patients with executive dysfunction. A recent study
confirms there is a lack of self-control, greater impulsivity, and
greater disorganization with executive dysfunction, leading to greater
amounts of aggressive behavior.
Executive dysfunction, particularly in working memory capacity, may also lead to varying degrees of emotional dysregulation, which can manifest as chronic depression, anxiety, or hyperemotionality. Russell Barkley proposed a hybrid model of the role of behavioural disinhibition in the presentation of ADHD, which has served as the basis for much research of both ADHD and broader implications of the executive system.
Other common and distinctive symptoms of executive dysfunction include utilization behaviour,
which is compulsive manipulation/use of nearby objects due simply to
their presence and accessibility (rather than a functional reason); and imitation behaviour, a tendency to rely on imitation as a primary means of social interaction. Research also suggests that executive set shifting is a co-mediator with episodic memory of feeling-of-knowing (FOK) accuracy, such that executive dysfunction may reduce FOK accuracy.
There is some evidence suggesting that executive dysfunction may
produce beneficial effects as well as maladaptive ones. Abraham et al. demonstrate that creative thinking in schizophrenia is mediated by executive dysfunction, and they establish a firm etiology
for creativity in psychoticism, pinpointing a cognitive preference for
broader top-down associative thinking versus goal-oriented thinking,
which closely resembles aspects of ADHD. It is postulated that elements
of psychosis are present in both ADHD and schizophrenia/schizotypy due to dopamine overlap.
Cause
The cause of executive dysfunction is heterogeneous, as many neurocognitive
processes are involved in the executive system and each may be
compromised by a range of genetic and environmental factors. Learning
and development of long-term memory play a role in the severity of
executive dysfunction through dynamic interaction with neurological
characteristics. Studies in cognitive neuroscience suggest that
executive functions are widely distributed throughout the brain, though a
few areas have been isolated as primary contributors. Executive
dysfunction is studied extensively in clinical neuropsychology as well,
allowing correlations to be drawn between such dysexecutive symptoms and
their neurological correlates. More recent research confirms that
executive dysfunction has a positive correlation with neurodevelopmental
disorders such as autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD).
Executive processes are closely integrated with memory retrieval
capabilities for overall cognitive control; in particular,
goal/task-information is stored in both short-term and long-term memory,
and effective performance requires effective storage and retrieval of
this information.
Executive dysfunction characterizes many of the symptoms observed in numerous clinical populations. In the case of acquired brain injury and neurodegenerative diseases there is a clear neurological etiology producing dysexecutive symptoms. Conversely, syndromes and disorders are defined and diagnosed based on their symptomatology rather than etiology. Thus, while Parkinson's disease, a neurodegenerative condition, causes executive dysfunction, a disorder such as attention-deficit/hyperactivity disorder
is a classification given to a set of subjectively-determined symptoms
implicating executive dysfunction – current models indicate that such
clinical symptoms are caused by executive dysfunction.
Neurophysiology
As previously mentioned, executive functioning is not a unitary concept.
Many studies have been conducted in an attempt to pinpoint the exact
regions of the brain that lead to executive dysfunction, producing a
vast amount of often conflicting information indicating wide and
inconsistent distribution of such functions. A common assumption is that
disrupted executive control processes are associated with pathology in prefrontal brain regions.
This is supported to some extent by the primary literature, which shows
both pre-frontal activation and communication between the pre-frontal
cortex and other areas associated with executive functions such as the basal ganglia and cerebellum.
In most cases of executive dysfunction, deficits are attributed
to either frontal lobe damage or dysfunction, or to disruption in
fronto-subcortical connectivity. Neuroimaging with PET and fMRI has confirmed the relationship between executive function and functional frontal pathology. Neuroimaging studies have also suggested that some constituent functions are not discretely localized in prefrontal regions.
Functional imaging studies using different tests of executive function
have implicated the dorsolateral prefrontal cortex to be the primary
site of cortical activation during these tasks.
In addition, PET studies of patients with Parkinson's disease have
suggested that tests of executive function are associated with abnormal
function in the globus pallidus and appear to be the genuine result of basal ganglia damage.
With substantial cognitive load, fMRI signals indicate a common
network of frontal, parietal and occipital cortices, thalamus, and the
cerebellum.
This observation suggests that executive function is mediated by
dynamic and flexible networks that are characterized using functional
integration and effective connectivity analyses. The complete circuit underlying executive function includes both a direct and an indirect circuit. The neural circuit responsible for executive functioning is, in fact, located primarily in the frontal lobe. This main circuit originates in the dorsolateral prefrontal cortex/orbitofrontal cortex and then projects through the striatum and thalamus to return to the prefrontal cortex.
Not surprisingly, plaques and tangles in the frontal cortex can
cause disruption in functions as well as damage to the connections
between prefrontal cortex and the hippocampus. Another important point is in the finding that structural MRI images link the severity of white matter lesions to deficits in cognition.
The emerging view suggests that cognitive processes materialize
from networks that span multiple cortical sites with closely
collaborative and over-lapping functions.
A challenge for future research will be to map the multiple brain
regions that might combine with each other in a vast number of ways,
depending on the task requirements.
Genetics
Certain
genes have been identified with a clear correlation to executive
dysfunction and related psychopathologies. According to Friedman et al. (2008), the heritability of executive functions is among the highest of any psychological trait. The dopamine receptor D4 gene (DRD4) with 7'-repeating polymorphism
(7R) has been repeatedly shown to correlate strongly with impulsive
response style on psychological tests of executive dysfunction,
particularly in clinical ADHD. The catechol-o-methyl transferase gene (COMT)
codes for an enzyme that degrades catecholamine neurotransmitters (DA
and NE), and its Val158Met polymorphism is linked with the modulation of
task-oriented cognition and behavior (including set shifting)
and the experience of reward, which are major aspects of executive
functioning. COMT is also linked to methylphenidate (stimulant
medication) response in children with ADHD.
Both the DRD4/7R and COMT/Val158Met polymorphisms are also correlated
with executive dysfunction in schizophrenia and schizotypal behaviour.
Testing and measurement
There
are several measures that can be employed to assess the executive
functioning capabilities of an individual. Although a trained
non-professional working outside of an institutionalized setting can
legally and competently perform many of these measures, a trained
professional administering the test in a standardized setting will yield
the most accurate results.
Clock drawing test
The
Clock drawing test (CDT) is a brief cognitive task that can be used by
physicians who suspect neurological dysfunction based on history and
physical examination. It is relatively easy to train non-professional
staff to administer a CDT. Therefore, this is a test that can easily be
administered in educational and geriatric settings and can be utilized
as a precursory measure to indicate the likelihood of further/future
deficits. Also, generational, educational and cultural differences are not perceived as impacting the utility of the CDT.
The procedure of the CDT begins with the instruction to the
participant to draw a clock reading a specific time (generally 11:10).
After the task is complete, the test administrator draws a clock with
the hands set at the same specific time. Then the patient is asked to
copy the image.
Errors in clock drawing are classified according to the following
categories: omissions, perseverations, rotations, misplacements,
distortions, substitutions and additions. Memory, concentration, initiation, energy, mental clarity and indecision are all measures that are scored during this activity. Those with deficits in executive functioning will often make errors on the first clock but not the second. In other words, they will be unable to generate their own example, but will show proficiency in the copying task.
Stroop task
The cognitive mechanism involved in the Stroop task
is referred to as directed attention. The Stroop task requires the
participant to engage in and allows assessment of processes such as
attention management, speed and accuracy of reading words and colours
and of inhibition of competing stimuli.
The stimulus is a colour word that is printed in a different colour
than what the written word reads. For example, the word "red" is written
in a blue font. One must verbally classify the colour that the word is
displayed/printed in, while ignoring the information provided by the
written word. In the aforementioned example, this would require the
participant to say "blue" when presented with the stimulus. Although the
majority of people will show some slowing when given incompatible text
versus font colour, this is more severe in individuals with deficits in
inhibition. The Stroop task takes advantage of the fact that most humans
are so proficient at reading colour words that it is extremely
difficult to ignore this information, and instead acknowledge, recognize
and say the colour the word is printed in. The Stroop task is an assessment of attentional vitality and flexibility. More modern variations of the Stroop task tend to be more difficult and often try to limit the sensitivity of the test.
Wisconsin card sorting test
The Wisconsin Card Sorting Test
(WCST) is used to determine an individual's competence in abstract
reasoning, and the ability to change problem-solving strategies when
needed. These abilities are primarily determined by the frontal lobes and basal ganglia, which are crucial components of executive functioning; making the WCST a good measure for this purpose.
The WCST utilizes a deck of 128 cards that contains four stimulus cards.
The figures on the cards differ with respect to color, quantity, and
shape. The participants are then given a pile of additional cards and
are asked to match each one to one of the previous cards. Typically,
children between ages 9 and 11 are able to show the cognitive flexibility that is needed for this test.
Trail-making test
Another prominent test of executive dysfunction is known as the Trail-making test.
This test is composed of two main parts (Part A & Part B). Part B
differs from Part A specifically in that it assesses more complex
factors of motor control and perception.
Part B of the Trail-making test consists of multiple circles containing
letters (A-L) and numbers (1-12). The participant's objective for this
test is to connect the circles in order, alternating between number and
letter (e.g. 1-A-2-B) from start to finish.
The participant is required not to lift their pencil from the page. The
task is also timed as a means of assessing speed of processing.
Set-switching tasks in Part B have low motor and perceptual selection
demands, and therefore provide a clearer index of executive function.
Throughout this task, some of the executive function skills that are
being measured include impulsivity, visual attention and motor speed.
In clinical populations
The
executive system's broad range of functions relies on, and is
instrumental in, a broad range of neurocognitive processes. Clinical
presentation of severe executive dysfunction that is unrelated to a
specific disease or disorder is classified as a dysexecutive syndrome, and often appears following damage to the frontal lobes of the cerebral cortex. As a result, executive dysfunction is implicated etiologically and/or co-morbidly
in many psychiatric illnesses, which often show the same symptoms as
the dysexecutive syndrome. It has been assessed and researched
extensively in relation to cognitive developmental disorders, psychotic disorders, affective disorders, and conduct disorders, as well as neurodegenerative diseases and acquired brain injury (ABI).
Environmental dependency syndrome is a dysexecutive syndrome
marked by significant behavioural dependence on environmental cues and
is marked by excessive imitation and utilization behaviour. It has been observed in patients with a variety of etiologies including ABI, exposure to phendimetrazine tartrate, stroke, and various frontal lobe lesions.
Schizophrenia
Schizophrenia
is commonly described as a mental disorder in which a person becomes
detached from reality because of disruptions in the pattern of thinking
and perception.
Although the etiology is not completely understood, it is closely
related to dopaminergic activity and is strongly associated with both
neurocognitive and genetic elements of executive dysfunction. Individuals with schizophrenia may demonstrate amnesia for portions of their episodic memory.
Observed damage to explicit, consciously accessed, memory is generally
attributed to the fragmented thoughts that characterize the disorder.
These fragmented thoughts are suggested to produce a similarly
fragmented organization in memory during encoding and storage, making
retrieval more difficult. However, implicit memory is generally preserved in patients with schizophrenia.
Patients with schizophrenia demonstrate spared performance on
measures of visual and verbal attention and concentration, as well as on
immediate digit span recall, suggesting that observed deficits cannot
be attributed to deficits in attention or short-term memory.
However, impaired performance was measured on psychometric measures
assumed to assess higher order executive function. Working memory and
multi-tasking impairments typically characterize the disorder. Persons with schizophrenia also tend to demonstrate deficits in response inhibition and cognitive flexibility.
Patients often demonstrate noticeable deficits in the central executive component of working memory as conceptualized by Baddeley and Hitch. However, performance on tasks associated with the phonological loop and visuospatial sketchpad are typically less affected.
More specifically, patients with schizophrenia show impairment to the
central executive component of working memory, specific to tasks in
which the visuospatial system is required for central executive control. The phonological system appears to be more generally spared overall.
Attention deficit hyperactivity disorder
A triad of core symptoms – inattention, hyperactivity, and impulsivity – characterize attention deficit hyperactivity disorder
(ADHD). Individuals with ADHD often experience problems with
organization, discipline, and setting priorities, and these difficulties
often persist from childhood through adulthood.
In both children and adults with ADHD, an underlying executive
dysfunction involving the prefrontal regions and other interconnected
subcortical structures has been found.
As a result, people with ADHD commonly perform more poorly than matched
controls on interference control, mental flexibility and verbal
fluency. Also, a more central impairment in self-regulation is noted in cases of ADHD.
However, some research has suggested the possibility that the severity
of executive dysfunction in individuals with ADHD declines with age as
they learn to compensate for the aforementioned deficits.
Thus, a decrease in executive dysfunction in adults with ADHD as
compared to children with ADHD is thought reflective of compensatory
strategies employed on behalf of the adults (e.g. using schedules to
organize tasks) rather than neurological differences.
Although ADHD has typically been conceptualized in a categorical
diagnostic paradigm, it has also been proposed that this disorder should
be considered within a more dimensional behavioural model that links
executive functions to observed deficits.
Proponents argue that classic conceptions of ADHD falsely localize the
problem at perception (input) rather than focusing on the inner
processes involved in producing appropriate behaviour (output).
Moreover, others have theorized that the appropriate development of
inhibition (something that is seen to be lacking in individuals with
ADHD) is essential for the normal performance of other
neuropsychological abilities such as working memory, and emotional
self-regulation.
Thus, within this model, deficits in inhibition are conceptualized to
be developmental and the result of atypically operating executive
systems.
Autism spectrum disorder
Autism
is diagnosed based on the presence of markedly abnormal or impaired
development in social interaction and communication and a markedly
restricted or repetitive repertoire of stereotypic movements,
activities, and/or interests. It is a disorder that is defined according
to behaviour as no specific biological markers are known.
Due to the variability in severity and impairment in functioning
exhibited by autistic people, the disorder is typically conceptualized
as existing along a continuum (or spectrum) of severity.
Autistic individuals commonly show impairment in three main areas of executive functioning:
- Fluency. Fluency refers to the ability to generate novel
ideas and responses. Although adult populations are largely
underrepresented in this area of research, findings have suggested that
autistic children generate fewer novel words and ideas and produce less
complex responses than matched controls.
- Planning. Planning refers to a complex, dynamic process,
wherein a sequence of planned actions must be developed, monitored,
re-evaluated and updated. Autistic persons demonstrate impairment on
tasks requiring planning abilities relative to typically functioning
controls, with this impairment maintained over time. As might be
suspected, in the case of autism comorbid with learning disability, an
additive deficit is observed in many cases.
- Flexibility. Poor mental flexibility, as demonstrated in
autistic individuals, is characterized by perseverative, stereotyped
behaviour, and deficits in both the regulation and modulation of motor
acts. Some research has suggested that autistic individuals experience a
sort of 'stuck-in-set' perseveration that is specific to the disorder,
rather than a more global perseveration tendency. These deficits have
been exhibited in cross-cultural samples and have been shown to persist
over time. Autistic individuals have also been shown to react slower as
well as perform slower in tasks that require mental flexibility when
compared to their neurotypical peers.
Although there has been some debate, inhibition is generally no
longer considered to be an executive function deficit in autistic
people.
Autistic individuals have demonstrated differential performance on
various tests of inhibition, with results being taken to indicate a
general difficulty in the inhibition of a habitual response. However, performance on the Stroop task,
for example, has been unimpaired relative to matched controls. An
alternative explanation has suggested that executive function tests that
demonstrate a clear rationale are passed by autistic individuals.
In this light, it is the design of the measures of inhibition that have
been implicated in the observation of impaired performance rather than
inhibition being a core deficit.
In general, autistic individuals show relatively spared performance on tasks that do not require mentalization.
These include: use of desire and emotion words, sequencing behavioural
pictures, and the recognition of basic facial emotional expressions. In
contrast, autistic individuals typically demonstrated impaired
performance on tasks that do require mentalizing. These include: false beliefs, use of belief and idea words, sequencing mentalistic pictures, and recognizing complex emotions such as scheming.
Bipolar disorder
Bipolar disorder
is a mood disorder that is characterized by both highs (mania) and lows
(depression) in mood. These changes in mood sometimes alternate rapidly
(changes within days or weeks) and sometimes not so rapidly (within
weeks or months).
Current research provides strong evidence of cognitive impairments in
individuals with bipolar disorder, particularly in executive function
and verbal learning. Moreover, these cognitive deficits appear to be consistent cross-culturally,
indicating that these impairments are characteristic of the disorder
and not attributable to differences in cultural values, norms, or
practice. Functional neuroimaging studies have implicated abnormalities
in the dorsolateral prefrontal cortex and the anterior cingulate cortex
as being volumetrically different in individuals with bipolar disorder.
Individuals affected by bipolar disorder exhibit deficits in
strategic thinking, inhibitory control, working memory, attention, and
initiation that are independent of affective state.
In contrast to the more generalized cognitive impairment demonstrated
in persons with schizophrenia, for example, deficits in bipolar disorder
are typically less severe and more restricted. It has been suggested
that a "stable dys-regulation of prefrontal function or the
subcortical-frontal circuitry [of the brain] may underlie the cognitive
disturbances of bipolar disorder".
Executive dysfunction in bipolar disorder is suggested to be associated
particularly with the manic state, and is largely accounted for in
terms of the formal thought disorder that is a feature of mania. It is important to note, however, that patients with bipolar disorder with a history of psychosis
demonstrated greater impairment on measures of executive functioning
and spatial working memory compared with bipolar patients without a
history of psychosis suggesting that psychotic symptoms are correlated with executive dysfunction.
Parkinson's disease
Parkinson's disease
(PD) primarily involves damage to subcortical brain structures and is
usually associated with movement difficulties, in addition to problems
with memory and thought processes. Persons affected by PD often demonstrate difficulties in working memory,
a component of executive functioning. Cognitive deficits found in early
PD process appear to involve primarily the fronto-executive functions.
Moreover, studies of the role of dopamine in the cognition of PD
patients have suggested that PD patients with inadequate dopamine
supplementation are more impaired in their performance on measures of
executive functioning.
This suggests that dopamine may contribute to executive control
processes. Increased distractibility, problems in set formation and
maintaining and shifting attentional sets, deficits in executive
functions such as self-directed planning, problems solving, and working
memory have been reported in PD patients. In terms of working memory specifically, persons with PD show deficits in the areas of: a) spatial working memory; b) central executive aspects of working memory; c) loss of episodic memories; d) locating events in time.
- Spatial working memory
- PD patients often demonstrate difficulty in updating changes in
spatial information and often become disoriented. They do not keep track
of spatial contextual information in the same way that a typical person
would do almost automatically.
Similarly, they often have trouble remembering the locations of objects
that they have recently seen, and thus also have trouble with encoding
this information into long-term memory.
- Central executive aspects
- PD is often characterized by a difficulty in regulating and
controlling one's stream of thought, and how memories are utilized in
guiding future behaviour. Also, persons affected by PD often demonstrate
perseverative behaviours such as continuing to pursue a goal after it
is completed, or an inability to adopt a new strategy that may be more
appropriate in achieving a goal. However, some research from 2007
suggests that PD patients may actually be less persistent in pursuing
goals than typical persons and may abandon tasks sooner when they
encounter problems of a higher level of difficulty.
- Loss of episodic memories
- The loss of episodic memories in PD patients typically demonstrates a
temporal gradient wherein older memories are generally more preserved
than newer memories. Also, while forgetting event content is less
compromised in Parkinson's than in Alzheimer's, the opposite is true for event data memories.
- Locating events in time
- PD patients often demonstrate deficits in their ability to sequence
information, or date events. Part of the problems is hypothesized to be
due to a more fundamental difficulty in coordinating or planning
retrieval strategies, rather than failure at the level of encoding or
storing information in memory. This deficit is also likely to be due to
an underlying difficulty in properly retrieving script information. PD
patients often exhibit signs of irrelevant intrusions, incorrect
ordering of events, and omission of minor components in their script
retrieval, leading to disorganized and inappropriate application of
script information.
Treatment
Psychosocial treatment
Since
1997, there has been experimental and clinical practice of psychosocial
treatment for adults with executive dysfunction, and particularly
attention-deficit/hyperactivity disorder (ADHD). Psychosocial treatment
addresses the many facets of executive difficulties, and as the name
suggests, covers academic, occupational and social deficits.
Psychosocial treatment facilitates marked improvements in major symptoms
of executive dysfunction such as time management, organization and
self-esteem.
One kind of psychosocial treatment has been found to be particularly
helpful, Behavioral Parent Training (BPT). Behavioral Parent Training
(BPT) helps parents learn, through the help of a trained mental health
professional, how to help their child behave better. This outlines
proper use of reward and punishment with the child, mostly using methods
of positive and negative reinforcement rather than punishment. For
example, taking away a positive reinforcement such as praise, as opposed
to adding a punishment.
Psychosocial treatments are effective for adults with
attention-deficit/hyperactivity disorder (ADHD) as well. One study shows
that there are a number of useful psychosocial interventions that help
adults with ADHD live better lives too. These included mindfulness
training, cognitive based behavioral therapy, as well as education to
help the participants recognize problem behaviors in their lives.
Cognitive-behavioral therapy and group rehabilitation
Cognitive-behavioural therapy
(CBT) is a frequently suggested treatment for executive dysfunction,
but has shown limited effectiveness. However, a study of CBT in a group
rehabilitation setting showed a significant increase in positive
treatment outcome compared with individual therapy. Patients'
self-reported symptoms on 16 different ADHD/executive-related items were
reduced following the treatment period.
Treatment for patients with acquired brain injury
The
use of auditory stimuli has been examined in the treatment of
dysexecutive syndrome. The presentation of auditory stimuli causes an
interruption in current activity, which appears to aid in preventing
"goal neglect" by increasing the patients' ability to monitor time and
focus on goals. Given such stimuli, subjects no longer performed below
their age group average IQ.
Patients with acquired brain injury have also been exposed to
goal management training (GMT). GMT skills are associated with
paper-and-pencil tasks that are suitable for patients having difficulty
setting goals. From these studies there has been support for the
effectiveness of GMT and the treatment of executive dysfunction due to
ABI.
Developmental context
An
understanding of how executive dysfunction shapes development has
implications how we conceptualize executive functions and their role in
shaping the individual. Disorders affecting children such as ADHD, along
with oppositional defiant disorder, conduct disorder, high functioning
autism, and Tourette's syndrome have all been suggested to involve
executive functioning deficits.
The main focus of current research has been on working memory,
planning, set shifting, inhibition, and fluency. This research suggests
that differences exist between typically functioning, matched controls,
and clinical groups, on measures of executive functioning.
Some research has suggested a link between a child's abilities to
gain information about the world around them and having the ability to
override emotions in order to behave appropriately.
One study required children to perform a task from a series of
psychological tests, with their performance used as a measure of
executive function.
The tests included assessments of: executive functions
(self-regulation, monitoring, attention, flexibility in thinking),
language, sensorimotor, visuospatial, and learning, in addition to
social perception. The findings suggested that the development of theory of mind
in younger children is linked to executive control abilities with
development impaired in individuals who exhibit signs of executive
dysfunction.
Both ADHD and obesity are complicated disorders and each produces a large impact on an individual's social well-being.
This being both a physical and psychological disorder has reinforced
that obese individuals with ADHD need more treatment time (with
associated costs), and are at a higher risk of developing physical and
emotional complications.
The cognitive ability to develop a comprehensive self-construct and the
ability to demonstrate capable emotion regulation is a core deficit
observed in people with ADHD and is linked to deficits in executive
function.
Overall, low executive functioning seen in individuals with ADHD has
been correlated with tendencies to overeat, as well as with emotional
eating.
This particular interest in the relationship between ADHD and obesity
is rarely clinically assessed and may deserve more attention in future
research.
It has been made known that young children with behavioral problems show poor verbal ability and executive functions.
The exact distinction between parenting style and the importance of
family structure on child development is still somewhat unclear.
However, in infancy and early childhood, parenting is among the most
critical external influences on child reactivity.
In Mahoney's study of maternal communication, results indicated that
the way mothers interacted with their children accounted for almost 25%
of variability in children's rate of development.
Every child is unique, making parenting an emotional challenge that
should be most closely related to the child's level of emotional
self-regulation (persistence, frustration and compliance).
A promising approach that is currently being investigated amid
intellectually disabled children and their parents is responsive
teaching. Responsive teaching is an early intervention curriculum
designed to address the cognitive, language, and social needs of young
children with developmental problems. Based on the principle of "active learning",
responsive teaching is a method that is currently being applauded as
adaptable for individual caregivers, children and their combined needs
The effect of parenting styles on the development of children is an
important area of research that seems to be forever ongoing and
altering. There is no doubt that there is a prominent link between
parental interaction and child development but the best child-rearing
technique continues to vary amongst experts.
Evolutionary perspective
The
prefrontal lobe controls two related executive functioning domains. The
first is mediation of abilities involved in planning, problem solving,
and understanding information, as well as engaging in working memory
processes and controlled attention. In this sense, the prefrontal lobe
is involved with dealing with basic, everyday situations, especially
those involving metacognitive functions.
The second domain involves the ability to fulfill biological needs
through the coordination of cognition and emotions which are both
associated with the frontal and prefrontal areas.
From an evolutionary perspective, it has been hypothesized that
the executive system may have evolved to serve several adaptive
purposes.
The prefrontal lobe in humans has been associated both with
metacognitive executive functions and emotional executive functions.
Theory and evidence suggest that the frontal lobes in other primates
also mediate and regulate emotion, but do not demonstrate the
metacognitive abilities that are demonstrated in humans.
This uniqueness of the executive system to humans implies that there
was also something unique about the environment of ancestral humans,
which gave rise to the need for executive functions as adaptations to
that environment.
Some examples of possible adaptive problems that would have been solved
by the evolution of an executive system are: social exchange, imitation
and observational learning, enhanced pedagogical understanding, tool
construction and use, and effective communication.
In a similar vein, some have argued that the unique metacognitive
capabilities demonstrated by humans have arisen out of the development
of a sophisticated language (symbolization) systems and culture.
Moreover, in a developmental context, it has been proposed that each
executive function capability originated as a form of public behaviour
directed at the external environment, but then became self-directed, and
then finally, became private to the individual, over the course of the
development of self-regulation.
These shifts in function illustrate the evolutionarily salient strategy
of maximizing longer-term social consequences over near-term ones,
through the development of an internal control of behaviour.
Comorbidity
Flexibility problems are more likely to be related to anxiety, and metacognition problems are more likely to be related to depression.
Socio-cultural implications
Education
In
the classroom environment, children with executive dysfunction
typically demonstrate skill deficits that can be categorized into two
broad domains: a) self-regulatory skills; and b) goal-oriented skills. The table below is an adaptation of McDougall's
summary and provides an overview of specific executive function
deficits that are commonly observed in a classroom environment. It also
offers examples of how these deficits are likely to manifest in
behaviour.
Self-regulatory skills
Often exhibit deficits in...
|
Manifestations in the classroom
|
Perception. Awareness of something happening in the environment
|
Doesn't "see" what is happening; Doesn't "hear" instructions
|
Modulation. Awareness of the amount of effort needed to perform a task (successfully)
|
Commission of errors at easy levels and success at harder levels;
Indication that student thinks the task is "easy" then cannot do it
correctly; Performance improves once the student realized that the task
is more difficult than originally thought
|
Sustained attention. Ability to focus on a task or situation despite distractions, fatigue or boredom
|
Initiates the task, but doesn't continue to work steadily; Easily
distracted; Fatigues easily; Complains task is too long or too boring
|
Flexibility. Ability to change focus, adapt to
changing conditions or revise plans in the face of obstacles, new
information or mistakes (can also be considered as "adaptability")
|
Slow to stop one activity and begin another after being instructed
to do so; Tendency to stay with one plan or strategy even after it is
shown to be ineffective; Rigid adherence to routines; Refusal to
consider new information
|
Working memory. Ability to hold information in memory while performing complex tasks with information
|
Forgets instructions (especially if multi-step); Frequently asks for
information to be repeated; Forgets books at home or at school; Can not
do mental arithmetic; Difficulty making connections with previously learned information; Difficulty with reading comprehension
|
Response inhibition. Capacity to think before acting (deficits are often observed as "impulsivity")
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Seems to act without thinking; Frequently interrupts; Talks out in
class; Often out of seat/away from desk; Rough play gets out of control;
Doesn't consider consequences of actions
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Emotional regulation. Ability to modulate emotional responses
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Temper outbursts; Cries easily; Very easily frustrated; Very quick to anger; Acts silly
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Goal-oriented skills
Often exhibit deficits in...
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Manifestations in the classroom
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Planning. Ability to list steps needed to reach a goal or complete a task
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Doesn't know where to start when given large assignments; Easily
overwhelmed by task demands; Difficulty developing a plan for long-term
projects; Problem-solving strategies are very limited and haphazard;
Starts working before adequately considering the demands of a task;
Difficulty listing steps required to complete a task
|
Organization. Ability to arrange information or materials according to a system
|
Disorganized desk, binder, notebooks, etc.; Loses books, papers,
assignments, etc.; Doesn't write down important information; Difficulty
retrieving information when needed
|
Time management. Ability to comprehend how much time
is available, or to estimate how long it will take to complete a task,
and keep track of how much time has passed relative to the amount of the
task completed
|
Very little work accomplished during a specified period of time;
Wasting time, then rushing to complete a task at the last minute; Often
late to class/assignments are often late; Difficulty estimating how long
it takes to do a task; Limited awareness of the passage of time
|
Self-monitoring. Ability to stand back and evaluate how you are doing (can also be thought of as "metacognitive" abilities)
|
Makes "careless" errors; Does not check work before handing it in;
Does not stop to evaluate how things are going in the middle of a task
or activity; Thinks a task was well done, when in fact it was done
poorly; Thinks a task was poorly done, when in fact it was done well
|
Teachers play a crucial role in the implementation of strategies
aimed at improving academic success and classroom functioning in
individuals with executive dysfunction. In a classroom environment, the
goal of intervention
should ultimately be to apply external control, as needed (e.g. adapt
the environment to suit the child, provide adult support) in an attempt
to modify problem behaviours or supplement skill deficits.
Ultimately, executive function difficulties should not be attributed to
negative personality traits or characteristics (e.g. laziness, lack of
motivation, apathy, and stubbornness) as these attributions are neither
useful nor accurate.
Several factors should be considered in the development of
intervention strategies. These include, but are not limited to:
developmental level of the child, comorbid disabilities, environmental
changes, motivating factors, and coaching strategies.
It is also recommended that strategies should take a proactive approach
in managing behaviour or skill deficits (when possible), rather than
adopt a reactive approach.
For example, an awareness of where a student may have difficulty
throughout the course of the day can aid the teacher in planning to
avoid these situations or in planning to accommodate the needs of the
student.
People with executive dysfunction have a slower cognitive
processing speed and thus often take longer to complete tasks than
people who demonstrate typical executive function capabilities. This can
be frustrating for the individual and can serve to impede academic
progress. Disorders affecting children such as ADHD, along with
oppositional defiant disorder, conduct disorder, high functioning autism
and Tourette's syndrome have all been suggested to involve executive
functioning deficits.
The main focus of current research has been on working memory,
planning, set shifting, inhibition, and fluency. This research suggests
that differences exist between typically functioning, matched controls
and clinical groups, on measures of executive functioning.
Moreover, some people with ADHD report experiencing frequent feelings of drowsiness.
This can hinder their attention for lectures, readings, and completing
assignments. Individuals with this disorder have also been found to
require more stimuli for information processing in reading and writing.
Slow processing may manifest in behavior as signaling a lack of
motivation on behalf of the learner. However, slow processing is
reflective of an impairment of the ability to coordinate and integrate
multiple skills and information sources.
The main concern with individuals with autism regarding learning is in the imitation of skills.
This can be a barrier in many aspects such as learning about others
intentions, mental states, speech, language, and general social skills.
Individuals with autism tend to be dependent on the routines that they
have already mastered, and have difficulty with initiating new
non-routine tasks. Although an estimated 25–40% of people with autism
also have a learning disability, many will demonstrate an impressive
rote memory and memory for factual knowledge. As such, repetition is the primary and most successful method for instruction when teaching people with autism.
Being attentive and focused for people with Tourette's syndrome
is a difficult process. People affected by this disorder tend to be
easily distracted and act very impulsively.
That is why it is very important to have a quiet setting with few
distractions for the ultimate learning environment. Focusing is
particularly difficult for those who are affected by Tourette's syndrome
comorbid with other disorders such as ADHD or obsessive-compulsive disorder, it makes focusing very difficult.
Also, these individuals can be found to repeat words or phrases
consistently either immediately after they are learned or after a
delayed period of time.
Criminal behaviour
Prefrontal dysfunction has been found as a marker for persistent, criminal behavior. The prefrontal cortex is involved with mental functions including; affective range of emotions, forethought, and self-control.
Moreover, there is a scarcity of mental control displayed by
individuals with a dysfunction in this area over their behavior, reduced
flexibility and self-control and their difficulty to conceive
behavioral consequences, which may conclude in unstable (or criminal)
behavior.
In a 2008 study conducted by Barbosa & Monteiro, it was discovered
that the recurrent criminals that were considered in this study had
executive dysfunction.
In view of the fact that abnormalities in executive function can limit
how people respond to rehabilitation and re-socialization programs
these findings of the recurrent criminals are justified. Statistically
significant relations have been discerned between anti-social behavior
and executive function deficits.
These findings relate to the emotional instability that is connected
with executive function as a detrimental symptom that can also be linked
towards criminal behavior. Conversely, it is unclear as to the
specificity of anti-social behavior to executive function deficits as
opposed to other generalized neuropsychological deficits.
The uncontrollable deficiency of executive function has an increased
expectancy for aggressive behavior that can result in a criminal deed. Orbitofrontal injury also hinders the ability to be risk avoidant, make social judgments, and may cause reflexive aggression.
A common retort to these findings is that the higher incidence of
cerebral lesions among the criminal population may be due to the peril
associated with a life of crime.
Along with this reasoning, it would be assumed that some other
personality trait is responsible for the disregard of social
acceptability and reduction in social aptitude.
Furthermore, some think the dysfunction cannot be entirely to blame.
There are interacting environmental factors that also have an influence
on the likelihood of criminal action. This theory proposes that
individuals with this deficit are less able to control impulses or
foresee the consequences of actions that seem attractive at the time
(see above) and are also typically provoked by environmental factors.
One must recognize that the frustrations of life, combined with a
limited ability to control life events, can easily cause aggression
and/or other criminal activities.