Executive Dysfunction: Signs, Symptoms, & Treatments

Executive dysfunction is a common co-occurring symptom of many types of mental health issues such as:

• Attention-Deficit Hyperactivity Disorder (ADHD)
• Specific Learning Disabilities (SLD)
• Mood disorders
• Traumatic brain injury
• Fetal alcohol syndrome
• Neuroinflammatory disorders (e.g. multiple sclerosis)
• Autism Spectrum Disorder (ASD)

What Are Executive Functioning Skills?

Executive functioning skills help people accomplish tasks and relate to others. If a person cannot use these skills, they may have difficulty with focusing, planning, or making decisions in their daily life.

These actions include:

• Inhibiting Actions: The capacity to think before you act. This ability allows us the time to evaluate a situation and how our behavior might impact it.
• Working Memory: The ability to hold information in memory while performing complex tasks.
• Emotional Control: The ability to manage emotions in order to complete tasks.
• Sustained Attention: The ability to maintain attention to a situation or task in spite of distractibility, fatigue, or boredom.
• Task Initiation: The ability to begin projects without procrastinating, in a timely manner.
• Planning/Prioritization: The ability to create a map in order to reach a goal.
• Organization: The ability to create and maintain systems to keep track of materials and/or information.
• Goal-Directed Persistence: The ability to follow through with the completion of a goal, without being distracted by competing demands or interests.
• Cognitive Flexibility: The ability to be adaptable and revise plans in the face of challenges, barriers, or mistakes.
• Metacognition: The ability to think about one’s own thinking (i.e. self-observation and reflection).
• Stress Tolerance: The ability to cope with uncertainty and unexpected demands.

Executive function is best described as the cognitive ability to (1) define a novel problem, (2) stop, plan, and analyze ways to solve the problem, and (3) inhibiting impulsive or reactive actions en route to successfully solving the problem.

Executive Functioning Across the Lifespan

Research suggests that executive function emerges during the first few years of life and continues to develop throughout middle childhood and adolescence.⁵ One of the foundational measures of executive function is an individual’s ability to inhibit (or delay) their behavior. The ability to inhibit simple behaviors is evident in early infancy, with the ability to delay eating a preferred food item.

More complex inhibition abilities do not emerge until several years later, with motor mimicking occurring around the ages of 3 or 4 years of age. The ability to inhibit behavior improves significantly from ages 5-8 in typical development, particularly with tasks that require children to rely on storing and manipulating information for brief periods of time without the assistance of visual aids or reminders (often referred to as working memory).

Research has demonstrated that working memory gradually develops during the preschool years, with significant improvement evident by age 6.⁶ Not surprisingly, the development of working memory depends on the complexity of the task, with easier memory skills (i.e. face recognition) being mastered by age 4 and more complex skills (i.e. spatial memory) becoming evident by age 14.

Unlike the developmental trajectory of inhibition, which shows large improvements in early childhood followed by more modest improvements as the child develops, the trajectory of working memory appears to progressively improve from the preschool years through adolescence.

Similarly, the development of the ability to shift between mental states, rule sets, or tasks (i.e. “set shifting”) improves with age.⁷ In addition, some preschoolers show some ability to shift their behavioral responses in favor of an alternative response (e.g., making subtle changes to the way they are sorting objects). Also referred to as “cognitive flexibility” the ability to shift attention between tasks improves with age, with individuals reaching their potential during adolescence.

The table below highlights the different executive skill sets at points in a person’s development:¹⁴

Executive Dysfunction in Adults

Individuals who experience typical development in childhood and adolescence often reach adulthood with capabilities to get and keep a job, as well as contribute productively to the community. However, executive functioning can become impaired through some environmental factors, including chaotic, stressful, and/or threatening situations.¹⁶ Specifically, significant and continuous adversity can overload the ability to use otherwise intact processes in the brain to solve complex problems.

Types of environmental factors that can negatively affect executive function include:

• Significant early adversity and trauma
• Chaotic or unpredictable environments
• Hyper-rewarding Stimuli, such has high sugar foods or drugs
• Poverty

The impact of these stressors can be significant – the ability to identify and solve problems, set priorities, and follow through with plans can be severely compromised. In addition, overwhelming environmental events can impair self-regulation skills, which may lead to decreased frustration tolerance and hyper-emotionality.

Executive Functioning and Neurocognitive Disorders

Mild cognitive impairment and dementias are associated with problems in everyday functioning, including activities of daily living. Research in neuropsychological performance has demonstrated a link between executive functioning and the ability to complete complex daily living tasks, such as managing finances, handling medications, and housekeeping.¹⁰

Deficits in executive functioning have the strongest associations and highest prediction of progression to cognitive decline in elderly adults. The progressive decline in functions related to working memory, behavior regulation, and abstract thinking are directly linked with impacts on ability to perform daily living tasks.

Signs of Executive Dysfunction

Although many individuals can experience intermittent difficulties with complex tasks, individuals with deficits in their executive functioning typically demonstrate challenges in the following areas:

• Tolerating frustration
• Task completion
• Following multiple step directions
• Forgetfulness
• Poor self-motivation
• Difficulty with emotion regulation

Measuring Executive Function

Executive Functioning skills are most commonly measured with neuropsychological assessments, like the Delis-Kaplan Executive Function System (D-KEFS).¹¹

It examines executive functioning through specific tasks that measure a person’s:

• Flexibility of thinking
• Inhibition
• Problem-solving
• Planning
• Impulse control
• Concept formation
• Abstract thinking
• Verbal and Spatial creativity

The D-KEFS measure contains 9 different subtests, each designed to measure different components of executive function.

They include:

1. The Trail Making Test, which measures flexibility of thinking on a visual-motor sequencing task
2. The Verbal Fluency Test, which measures letter fluency, category fluency, and category switching
3. The Design Fluency Test which measures initiation of problem-solving, fluency in generating visual patterns, creativity in drawing new designs, simultaneous processing in drawing the designs while considering the rules and restrictions of the task, and inhibiting previous motor responses
4. The Color-Word Interference Test, which measures the ability to inhibit automatic verbal responses
5. The Sorting Test, which measures concept formation skills, verbal and nonverbal problem-solving skills, and the ability to explain abstract sorting concepts
6. The Twenty Questions Test, which measures the ability to categorize and formulate abstract yes/no questions, as well as incorporate feedback to create more precise questions
7. The Word Context Test, which measures deductive reasoning, the ability to integrate different pieces of information, hypothesis testing, and flexible thinking
8. The Tower Test, which measures spatial planning, learning new rules, inhibiting impulsive behaviors, and the ability to establish and maintain instructions
9. The Proverb Test, which measures the ability to form new, verbal abstract concepts

Treatments for Executive Dysfunction

There are several cognitive-behavioral interventions to treat deficits in executive function.¹² Specifically, these interventions target problem solving abilities, emotion regulation, and attention. The goal of treatment is to maximize the capacity for learning and teach the affected individual to compensate for skills deficits.

Treatments for Executive Dysfunction include:

Problem Solving Training

Problem Solving Training is an approach that explicitly teaches the steps to solving a new problem, including orienting to the problem (i.e. recognizing that a problem exists), defining the problem, generating alternative solutions, arriving at a decision, and verifying that the solution has addressed the problem in question.

Emotion Regulation Training

Emotion Regulation Training is designed to help reduce negative emotions and impulsivity, both of which can impact the problem-solving process. Individuals are trained to observe their thoughts, feelings, and behaviors that occur in response to specific problems. By analyzing the warning signs of oncoming maladaptive emotional responding, individuals can then reframe problems to minimize hyper emotional reactivity. Strategies include thought recognition (i.e. identifying maladaptive thoughts), use of positive self-talk, and relaxation techniques (i.e. diaphragmatic breathing).

Attention Training

Attention Training uses repeated discrete exercises to target both simple and complex attention tasks in order to maximize generalizability. Simple attention tasks include focusing and/or sustaining attention, and complex attention tasks include selectively attending, alternating attention, and dividing attention.

In addition to cognitive-behavioral interventions, there has been some research on the use of drug therapy13 for executive dysfunction deficits that occur in adults with progressive cognitive impairment caused by conditions like Parkinson’s disease. Atomoxetine (brand name: Strattera), which is a selective norepinephrine reuptake inhibitor indicated for the treatment of attention deficit hyperactivity disorder (ADHD), was used to treat patients diagnosed with Parkinson’s Disease who demonstrated declines in executive function but who were not diagnosed with dementia.

The results of one exploratory study suggested that as many as 75% of participants demonstrated some clinically significant improvement in their executive function.¹³ However, it is important to note that researchers do not yet fully understand the mechanism by which atomoxetine can improve executive functioning in the brain.

Managing Symptoms of Executive Dysfunction

Although specific treatments for deficits in executive functioning are best left to professional psychologists and therapists, there are strategies that can be used to help increase everyday functioning.

Some examples of these types of strategies include:

• Set short-term, achievable objectives in the pursuit of larger goals: Part of why goal achievement can be so challenging is the perceived distance between the present and future. Longer term, lofty goals can erode motivation over time, leading to procrastination. Instead, consider breaking large tasks into their components, with objectives targeting each piece of the bigger picture. For instance, if a longer-term goal involves a house renovation, identify each step that comprises the larger effort and set deadlines for each piece individually.
• Use memory boosters: There are several different methods to improve the ability to encode (i.e. store) information for later retrieval. Some examples include 1) “chunking” information into smaller parts (e.g. grouping phone numbers into groups of smaller numbers), 2) writing down important information as quickly as possible after it is presented, 3) repeating directions aloud to ensure understanding, 4) cluster new information by meaning, which can help with remembering where to locate personal belongings and work materials (e.g. canned goods might be organized into meaningful categories such as fruits, vegetables, and soups), and 5) use mnemonic devices by creating key words to facilitate remembering crucial information (e.g., ROY G. BIV = the first letter of each color of the spectrum).
• Minimize distractions: Many individuals with attentional difficulties have the most trouble maintaining their focus on situations/events that are not personally important to them. During situations where focused attention is important, be sure to 1) minimize unnecessary distractions (i.e. cell phones/technology), 2) increase physical proximity to the source of new information to increase focus, 3) use inner speech to provide self-reminders that attention is vital (e.g., “sit up straight, eyes on the speaker,” or “I need to write this down”).
• Take breaks: As with any developing skill, sustained focus on an area that needs improvement can be effortful and draining. Don’t forget to plan breaks during high effort activities in order to increase the likelihood of engagement and retention of information. These interruptions can also be unplanned if unexpected fatigue becomes a barrier to completing a task.
• Motivation is key:Motivation is a key factor in the ability to complete difficult tasks. Whether trying to assist a family member or tackling a challenging activity yourself, don’t forget about the important role of incentivizing success. The best incentives are often external, particularly when working on longer-term projects. Consider withholding preferred activities or items until objectives have been completed.

Executive Functioning Statistics

While there is little available data on the existence of executive dysfunction alone, it is extremely common as a co-occurring problem with different types of neurodevelopmental and learning disorders.

Executive Functioning in ADHD and Autism

There is some research to suggest that ADHD and Autism are very similar, and may even have high rates of comorbidity (both being present in the same patient). In fact, some studies suggest that rates of comorbidity between ADHD and autism ranging from 14-78%.¹⁵

While individuals with both disorders demonstrate difficulties with executive functions more broadly, there is some research to suggest that these populations have challenges in different executive domains.15 Specifically, it is thought that individuals with ADHD primarily display difficulties with inhibition and sustained attention, while individuals with autism tend to have more challenges with planning and shifting attention.