By James Chandler, MD FRCPC
The executive in a company is the person who is in charge. She or he is the person who plans out how the resources of the company will be used. She decides what the priorities are. She decides what direction things will take in the long term. When there are conflicting reports or demands, the executive decides what to do about it. In a word, the executive is paid to think about things, look at the big picture, and keep the future in mind.
In the brain, a large part of what the frontal areas do is executive functioning. They are the parts of the brain that decide the big issues like what are we going to do next? They allocate resources to different projects. They are supposed to help a person look at multiple possibilities when a decision needs to be made.
It turns out that if you have executive functioning problems, you are going to have a much more difficult time, no matter what psychiatric problem you might also have. Executive functioning deficits are not a diagnosis, but they make any other diagnosis that much worse.
The deficits are the most severe in Autistic Spectrum Disorders. They are also severe in Fetal Alcohol Syndrome. They are less severe in ADHD and learning problems.
About 15% of children have some problems with executive functioning, but about 30% or so of children and adults with ADHD have problems. They are extremely common in autism and Fetal alcohol syndrome. If a child has brain damage from slowed growth in the womb or was very premature, they are not too uncommon. In brain injured children, infections of the brain, and those with tumors, they are common, along with a host of rarer diseases. They are not common in Tourettes, ODD or CD.
There are a lot of different ways of looking at them. Here
are is a simple description:
When you are 9 years old, you don’t have to
do much planning, as your parents, family, and school will do this for you. But
an adult must plan out each day, and so must teenagers, or nothing will get
accomplished.
Joceyln can't plan
At age 16 Joceyln
has six subjects in school and a part time job at Subway 10 hours a week. She
has no boyfriend, and after failing last year, is not involved in any other
activities. Her life is one big crisis, partly due to being unable to plan. She
has a research paper due in three weeks. Rather than work on it a little each
day or two, she leaves it until the end. Then she throws all her energy into
that so that she is late for work, overtired, and behind in school. Then, when
the paper is handed in (late), she has to work extra hard at her part time job,
because her boss has threatened to fire her. Until her best friend asks her why
she never stops by anymore. So, you guessed it, now she is getting behind
because she is trying to maintain that friendship above all else.
By the time you are 12, there are many
competing needs and desires in a day and not enough time to satisfy them all.
If you can't figure out what is most important, you will be lost.
Matt is lost.
At age 13 Matt is still quite willing to do
his homework. But it never seems to get done. He can't figure out what is
important. He needs to make a Science project which includes a title page.
Before starting on the report he checks virtually every font available on the
computer, searches innumerable sites for the perfect clip art, and then finally
messes with the sizing of each part until he has it right. He can't understand
why his parents aren't satisfied with his "two hours of working on my
project"
When you are a child, persistence helps, but
it is not absolutely necessary for most children. This changes as adulthood
nears. Being unable to "stick with" a hard job is very disabling.
Terry is finished, for now
Terry dropped out of school at age 15, and
now is working at the boat shop. He is supposed to spend most of his time
sanding today. His partner Jeff calls him, "time out". Terry sands
for about 5 minutes, then either checks the cord,
checks his watch, gets a drink, wipes his eyes, adjusts his mask, replaces the
sand paper, or complains. Their boss figures Terry works 50% of the time so he
pays him 50% of his wages the first week and explains why. Terry quits.
Early elementary teachers spend endless hours
organizing their students, but this doesn’t happen in high school or at work.
Melinda's mess
Part of the reason Melinda dropped out of
school is that she lost everything at school, on the way to school, and at
home. Many great projects never got handed in. This week is she is lucky - her
sister has found her a temporary job helping at the insurance office while two
secretaries are ill with the flu. Melinda has taken the courses, and is excited
to start. By the weeks end, six invoices totaling over 10,000 dollars are lost.
It takes about a week to undo the "work" that Melinda did.
Teachers, spouses, and employers all expect
that someone can do a few things at a time. If you only have enough working
memory to do one task, life will be very difficult.
Sarah has failed
In 11th grade history class, Mr. Surette expects the students to listen to what he is
saying, read the syllabus he has given them, and make notes in their notebooks
if something important is not in the syllabus. Sarah can easily do one or two
of these things, but not all. She prefers to listen and try to follow along,
but they are graded on their notes. When Mr. Surette
sees no notes, she gets a zero. Sarah's reply, "but I can't listen and
write at the same time" falls on deaf ears.
If you have these problems, you will not get as far occupationally or academically. Adults with ADHD who also have Executive Functioning Deficits are twice as likely to have failed grades, needed extra help, or ended up in a special classroom. They ended up with lower end jobs, less money, and more legal problems compared to those who only had ADHD. There isn’t a big effect of executive functioning on psychological health.
The advantages of this is that it can test each one of these executive functions plus everything else. The disadvantage is that it is extremely costly, takes hours to test and review.
The advantage is that these can be done in less than a half and hour and can give you a good idea of the total severity of the problem with executive functioning. The disadvantage is they are not exact or complete.
To help decide how severe the Executive Functioning problem might be in a child
To get a rough idea of how severe the problem is in high risk children: severe ADHD, Fetal Alcohol Syndrome, and some Autistic patients.
The bad news is that these deficits are much less responsive to medications. While hyperactivity and inattentiveness almost always respond to ADHD medications, the executive function deficits often do not.
Outside of ADHD, there is little research on how psychiatric medications might affect executive functioning in children and adolescents.
First, brain exercises a person can do to improve their executive functioning. So far, there is only a little research about this, and all of it is from the same organizations or companies that actually make these brain exercises. Therefore I can’t recommend them at this point.
Gioia GA,
et al: Behavior rating inventory of executive
function. Child Neuropsychol. 2000 Sep;6(3):235-8.
Jason can’t get started.
SKILL: Initiate
Definition:
Beginning a task or activity\
Dysfunction:
Has trouble getting started on homework or chores
When
Sony decided to design Playstation 3, the first thing
the executives had to do was stop talking about it and
start doing something. The same thing happens with people.
In
Jason’s family, the problem was starting homework. Once he got going, as long
as his meds hadn’t worn off, it wasn’t too bad. But to start was hard. Jason
loved rockets, and his Dad was a carpenter. So they built a model rocket that
was quite sturdy and when it was time for homework, the count down started. The
first stage of the rocket had directions for what to do first to initiate. The
second stage had more, and after the third stage instructions were completed
(pencils, paper, homework, binders, chairs, TV off, radio off) He lifted the
rocket up on to the shelf and they started.
SKILL: Inhibit
Definition:
Not acting on an impulse or appropriately stopping one’s own activity at the
proper time
Dysfunction: Has trouble “putting the brakes” on behavior; acts without
thinking
SKILL: Shift
Definition:
Freely moving from one situation, activity, or aspect of a problem to another
as the situation demands Dysfunction: Gets stuck on a topic or tends to
perseverate
Hannah versus math
Hannah’s
mom says she would rather change diapers all day than work an hour doing
homework with Hannah. Hannah seems to understand what she is doing at the time,
but she gets stuck, and even though she knows she is supposed to be doing substration now, she is still doing addition, since that
was the last task. So after a half hour of this and that, Hannah and her mother
are totally frustrated, as she just can’t shift to a new topic.
Then
one day her mom turned the stove higher rather than lower to keep the dinner
warm. So in the middle of long division, smoke came out of the kitchen, the
alarm went on, and everyone ran to throw the dinner in the sink. After a few
minutes, Hannah and her mother sat down again to work on fractions, and
amazingly, she didn’t get the long division and the fractions confused! Hannah
suggested they set something on fire after each subject in school to clear her
mind, but her mom suggested just lighting some candles for a few minutes, but
when she does get confused, her mom will say, “Hannah, do I need to go burn
some dinner?!”
SKILL: Plan
Definition:
Anticipating future events, setting goals, and developing appropriate steps
ahead of time to carry out an associated task or action
Dysfunction:
Starts assignments at the last minute; does not think ahead about possible
problems
Darren has never met the future
At
13 years old, Darren still lives completely for the moment. Everyone likes him,
as long as they don’t have to work with him. Most people worry about the
future, but Darren’s mother wishes Darren could take a pill to make him worry
more, not less. Darren has been on meds for a few years for ADHD but they only
help in the classroom with the aide nearby. Yet Darren is a great worker with
his father. He helps with preparing bait, bands lobsters, and helps fix the
traps. His father used to think that there wasn’t any problem, but just a lack
of good direction on the part of the teachers. One day, his father’s hired help
couldn’t come, so it was up to Darren to get the equipment for making lobster
pots down to their shed by the wharf by the time his father came back from
town. At first everything went fine, except there weren’t enough nails. And there
wasn’t a long enough extension cord. Darren had moved a bunch of lobster pots
to back up the four-wheeler and put them on the bag full of extra netting which
they were going to need right away. The hoses for the compressor to run the
nail gun were under another crate. Darren actually did bring everything
eventually. His Dad told his mother that night in bed that thanks to Darren
they had accomplished two hours of work in only six hours! When his Dad only
paid him for two hours of work, even though it took six hours, Darren was
devastated, especially when his Dad told him that he thought he was being
generous, not charging Darren for the extra four hours of his time it took.
The
easy solution would be that Darren would never work for his Dad again. But that
wasn’t good, either, as he was a good son and was trying. So his father took
some pictures with their new digital camera of how to set things up for fixing lobster
traps. He took some pictures of what needed to come down. Then his sister, a
school teacher, laminated these together in a loose leaf notebook. Now, as long
as Darren doesn’t lose the notebook, he gets it set up okay. If he loses the
notebook, he loses all video privileges for a week, and so far that hasn’t
happened.
SKILL: Organize
Definition:
Establishing or maintaining order in an activity or place; carrying out a task
in a systematic manner
Dysfunction: Has a scattered, disorganized approach to solving a problem; is
easily overwhelmed by large tasks or assignments
Shanna lives in a hurricane
At
age 12, Shanna is in no danger of dropping out of sixth grade. However, her
teacher and parents are in danger of giving up altogether. The reason is that
Shanna seems to be immune to any attempt to organize her life. The daily agenda
is lost. Unless her backpack is packed by her teacher, given to her little
sister, and then unpacked by her mother, things are lost. Shanna hates being
treated that way. She lost the palm pilot her uncle gave her. She lost her
backpack brief case. When all the books are finally home with the right
notebooks and papers, they are lost in the house. And if you go to help her
find them in her room, you would never find them either, as every drawer has
some clothes, some papers, some toys, and who knows what else. With 7th
grade coming soon, there did not seem to be any hope, as she couldn’t even
manage 6th grade.
So
the question really was, is there anything she never
lost all day long? No, there really wasn’t. And what if she had a cell phone,
would she lose that? Shanna had been begging for a cell phone for months, but
her parents could imagine the difficulties with that. Nevertheless, that is
what helped the most. Shanna has a great cell phone and her parents have been able
to use it to send her messages, remind her of things, and help organize her.
When she can’t find it in the house or classroom, she just calls herself. Things
aren’t perfect, her room is still a mess, but as Shanna tells you, at least I
know where the phone is!
SKILL: Self-monitor
Definition:
Checking on one’s own actions during, or shortly after finishing, the task or
activity to assure appropriate attainment of goal
Dysfunction: Does not check work for mistakes; is unaware of own behavior and
its impact on others
Ms.
Surrette,
SKILL: Emotional control
Definition:
Modulating/controlling one’s own emotional response appropriate to the
situation or stressor
Dysfunction: Is too easily upset, explosive; small events trigger big emotional
response
Dealing with
Eventually
SKILL: Working memory
Definition:
Holding information in mind for the purpose of completing a specific and
related task
Dysfunction: Has trouble remembering things, even for a few minutes; when sent
to get something, forgets what he or she is supposed to get.
Is
If
you heard
In Summary,
If you ignore Executive
Functioning Deficits, you will be missing a big cause of disability in children
with a variety of psychiatric disorders.
There are many different
kinds of Executive Functioning Deficits, and rarely will you find two people
with the same profile of deficits.
Medications will not
usually fix this.
The treatment has to fit
the person, their culture, the deficits, and their family.
References