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June 23, 2016

By Mendy Hecht, Hamaspik Gazette

All about… executive function disorder (EFD)

So let’s say someone has a problem in life.

Conventional wisdom, and common sense, both say that the person uses willpower to do something about it. 

The person decides to solve the problem.  The person asks or reads about solutions.  The person then uses his or her new skills to solve the problem.  The problem is solved and the person moves on.

But where the power of will and skill ends, and where a problem not solvable by will or skill begins, is no small debate in modern mental health.

Take a bright, talented but chronically-disorganized young man: he’s a poor planner, he’s frequently late, and his desk and room are pretty much always a mess.

One school of thought—we might call it the old-fashioned way—would say that our young man simply needs discipline.  A full regimen of life skills training, from daily scheduling to personal long-term goals, is often all he’ll need. 

That discipline may come from the resolve, determination and focus we know as willpower—from the inside.  And many people have positively and permanently changed their lives that way. 

It may also come from being subjected to the rigorous, consistent and inflexible rules of serving in the military—from the outside.  And many people have also positively and permanently changed their lives that way.

But the other, newer, school of thought says that there is simply something wrong with the young man’s brain—that no matter how much discipline he wills upon himself from the inside, or gets imposed upon himself by military training from the outside, he just doesn’t change.

This school of thought says that biochemical problems in the physical brain are the cause of the young man’s chronic disorganization—and that he needs medication.  This school of thought is also the driving force between much of modern mental health prescribing drugs for other things.

And each school of thought has its own way of treating our young man’s diagnosis of executive function disorder (EFD)—the subject of our article.  (Often, though, they may be combined.)

But because each approach warrants an article in its own right, we’ll stick for now—at least for treatment—to the strictly old-fashioned way of approaching EFD.

Definition

So what exactly is executive function disorder?  It almost sounds contrived, or like some joke about business executives being unable to function.

But executive function refers to the cognitive skills, the set of mental skills that help people get things done.  If the brain is an airport, then executive function is the control tower of the airport.

Executive function supervises and controls the brain’s cognitive skills—the basics of normal daily life.  These skills include:

  • Managing time

  • Paying attention

  • Planning and organizing

  • Switching focus as necessary

  • Remembering details

  • Doing or saying the right thing based on experience

  • Not doing or saying the wrong thing based on experience

According to another definition, executive function consists of six specific steps:

  1. Analyzing a task

  2. Planning how to address the task

  3. Organizing the steps needed to carry out the task

  4. Developing timelines for completing the task

  5. Adjusting or shifting the steps, if needed, to complete the task

  6. Completing the task in a timely way

Symptoms

When executive function isn’t working as it should, for whatever reason, personal behavior is less controlled.  This can affect the ability to work or go to school, do things independently, and/or maintain relationships.

For children, EFD is typically noticed regarding school—particularly with completing homework, paying attention in class, keeping the backpack organized and the like.

Problems with executive function can run in families. You may notice them when your child starts going to school.  They can hurt the ability to start and finish schoolwork.

Warning signs that a child may have EFD include trouble with planning projects, estimating how much time a project will take to complete, telling stories (verbally or in writing), memorizing, starting activities or tasks, and remembering.

Here’s a real-life example of EFD and school:

A 6th Grade teacher assigns the class a book to read.  She writes the due date for the book report on the board.  Now, each student must be able to do the following:

  1. Figure out where to get the book.

  2. Figure out how long it will take read it.

  3. If the teacher has a specific book-report format, the student will have to keep it in mind as he reads the book and takes notes. He needs enough time to write a rough draft, get help from teachers or parents, if needed, and write a final draft by the due date.

If a student has typical executive function skills, the work will get done on time.  If he or she has EFD, it won’t.

Children and adults with EFD have problems organizing materials and setting schedules.  They misplace papers, reports, and other school materials. They might have similar problems keeping track of their personal items or keeping their bedroom organized. No matter how hard they try, they fall short.

Cause

People with ADHD, depression, or learning disabilities often have weaknesses in executive function, while some people are just born with weak executive function. 

In other cases, brain injuries—particularly to the frontal lobe in the front of the brain, can harm the ability to stay on task or otherwise result in EFD.  Brain damage from Alzheimer’s disease or strokes may also cause EFD.

Current brain research suggests that executive functions are widely distributed across the brain, not concentrated in one area, though a few areas have been isolated as primary contributors.  But it remains unclear which of several brain areas are directly related to EFD.

Because goal and task information is stored in both short-term and long-term memory, executive processes are closely integrated with memory retrieval capabilities for overall cognitive control. Healthy executive function requires effective storage and retrieval of this information.

As it turns out, though, executive function disorder is something many people are born with—but, thanks to healthy parenting and/or schooling, are sufficiently “soaked” in the skills needed for healthy executive functioning that the condition ceases to exist by the time they reach adulthood.

In other words, EFD is like the inability to walk or talk at birth: it’s just something that healthy people grow out of with years of healthy development, care and education.

Diagnosis

There’s no single test to identify problems associated with EFD.  Instead, experts rely on different tests to measure specific skills.

Problems seen on these tests can’t predict how well adults or children will do in real life.  Sometimes, watching them and trying different things are better ways to improve weak executive function.  Some of these tests include:

Attention and Immediate Memory (Auditory)

This test presents short passages with three follow-up questions to determine a student’s ability to pay attention to details and remember what she hears.

Attention and Immediate Memory (Auditory and Visual)

This test presents illustrations and short vignettes.  Students answer questions about what they’ve heard and seen in the illustrations and vignettes.  There are three questions for each vignette; two require attention to detail and one presents a problem to be solved.

Working Memory and Flexible Thinking

These two executive functions are tested by asking the student to listen to a short passage and answer two “thinking” questions.

Shifting

Being able to shift one’s thinking quickly and accurately is an important executive function as it allows one to be adaptive to life’s changing demands.  The items in this subtest have two parts; first, the examiner names four items in a category and identifies the category.  The student is then asked to name a member of a similar but different category.

Treatment

The key to treating EFD is to understand that it is a treatable condition—and that with consistent long-term treatment, it can be effectively eliminated.

Treatment for EFD consists primarily of games and other activities that work the brain like a muscle—building up strength in areas of weakness.  These activities vary by patient age group.

Activities for infants (6 to 18 months)

These activities encourage infants to focus attention, use working memory, and practice basic self-control skills—and supportive, responsive interactions with adults are the foundation for the healthy development of these skills:

  • Lap games like Peek-a-Boo help working memory and self-control.

  • Rhyming games with expected surprise endings like Pat-a-Cake help manage stimulation.

  • Hiding games like covering a toy, or toys, challenge working memory.

  • Mimicking games that have adults copying kids (or vice versa) help with working memory, attention, and self-control.

  • Simple roleplaying games like kids helping adults with sweeping or collecting toys help with working memory, self-control, and selective attention.

  • Simply talking to an infant is a great way to build attention, working memory, and self-control.  Conversations in any language besides English are also helpful—bilingual kids are known to have better executive function skills.

Activities for toddlers (18 to 36 months)

  • Physically active games involving throwing, catching, walking, singing (i.e. “The Hokey Pokey”) balancing, repetition/mimicking, and so on help with attention, learning new skills, working memory, and self-control. 

  • Conversation and storytelling games like “narrating” a child’s play (“I see David holding a ball!”), especially narrating a child’s feelings (“I see David feels happy!”) helps with working language/action association, working memory, and emotional regulation.

  • Matching/sorting games like simple puzzles and shape-sorting boxes help with understanding rules, self-control, selective attention, and working memory.

  • Imaginary play (like “cooking” and then “eating” “food”) helps with self-control.

Activities for toddlers (3 to 5 years old)

  • Higher-level imaginary role play for older toddlers primarily helps with self-regulation and inhibition, as well as selective attention, working memory, planning, social problem-solving and oral language.  Example: “Going to the doctor”—playing the “sick” patient (sad and scared), the doctor (calm and reassuring) and the parent (worried and caring)—helps kids inhibit impulses or actions that don’t fit the role.

  • Storytelling—making up their own stories, drawing story books and/or acting out their stories, especially bilingually—helps kids’ working memory, organization, selective attention, and self-control.

  • Helping cook in the kitchen helps with self-control (waiting for instructions) working memory (keeping complex directions in mind), and selective attention (measuring and counting).

  • Movement songs and games, especially ones that get harder and more complex, help with inhibition and self-control, selective attention and working memory.  These include Musical Chairs, or songs that feature orders or lists of words or letters.

  • Increasingly complicated puzzles help with visual working memory and planning skills.

  • “Opposite matching” games (like marking or picking the opposite of the called item—tall man for “short man!”; day for “night!”) help with inhibition and self-control.

Activities for 5- to 7-year-olds

  • Card and board games which require kids to remember locations of specific cards are great for working memory.  Such games include Uno, Memory, Go Fish or Old Maid, which involve matching pairs and locations of images.

  • Strategy board games like Battleship, checkers, Chinese checkers, Parcheesi, Sorry! and others help with working memory, self-control, selective attention and flexibility.

  • Word/song games, especially alphabetized ones, that repeat and add on to earlier sections (either through words or motions) help with working memory.

  • Puzzles and brain teasers like mazes, and simple word finds and crosswords, help with selective attention, working memory and cognitive flexibility.

  • Logic and reasoning games like the classic Mastermind help with working memory and cognitive flexibility.

  • Guessing games like 20 Questions help with working memory and flexible thinking.

  • Rhythm games, like clapping or stepping/dancing in specific (and progressively harder) patterns, help with working memory, self-control and cognitive flexibility.

  • Physical activities and games like Simon Says, Freeze Tag, Red Light, Green Light or Duck, Duck, Goose, or more intense athletic games like dodgeball or tetherball help with cognitive flexibility, selective attention, self-control and working memory.

  • Physical activities that combine mindfulness and movement, like various exercise or martial-arts disciplines, also help children develop their ability to focus attention and control actions.

Activities for 7- to 12-year-olds

  • Card and board games that require players to track specific cards or pieces, especially at high speeds, are great for working memory, cognitive flexibility and selective attention, like chess.

  • Physical activities, games and sports help develop kids’ ability to keep complicated rules and strategies in mind, make quick decisions and respond flexibly to play.  The many variations of jump rope help with selective attention and working memory, and soccer is especially beneficial to all areas of executive function.

  • Learning to play a musical instrument, or just following rhythm patterns with clapping or drumming, helps with selective attention, self-control, cognitive flexibility and working memory, and there is some evidence that the increased two-handed coordination of musical performance supports better executive function.

  • All of the above is also true for singing and dancing, whether in groups or solo.

  • Brain teasers, crosswords, Sudoku and other puzzles, as well as three-dimensional puzzle toys like Rubik’s Cube, help with working memory, cognitive flexibility and selective attention

Activities for teens

For teens and their increasingly complex young lives, self-regulation—in terms of goal-finding and goal-setting, planning, multitasking and self-monitoring—is the most important of the executive functions.  Here are several increasingly challenging activities that foster continual improvement of executive function skills:

  • Sports, which help with selective attention, self-monitoring and quick decision-making.

  • Musical instruments/singing, which challenges working memory, selective attention, cognitive flexibility, and self-control—and the more complex, the better.

  • Strategy games like chess, and logic puzzles, build working memory and selective attention.

  • Stage performance, which draws heavily on selective attention and working memory.

Teens are also expected to have good study skills—to be increasingly independent and organized in their school work, both in and out of the classroom.  Here are some things that can help teens who have EFD with their school study skills:

  • Break projects down to manageable pieces.

  • Identify reasonable plans (with timelines) for completing each piece.  Explicitly identify each step.  Recognize and celebrate the completion of each step.

  • Use memory supports for organizing tasks.  Acronyms can be powerful tools for remembering information.  Develop the habit of writing things down.

  • Self-monitor while studying or doing homework.  Use a timer to beep every 20/30 minutes as a reminder to check if you’re paying attention and understanding the material—and to specify the problem (e.g. certain words or directions not understood) and its solution.

  • Be aware of critical times for focused attention.

  • Find ways to reduce distractions (e.g., turn off electronics, find a quiet room).

  • Keep a calendar of project deadlines and steps along the way.

  • Isolate the specific problem (missing info, sub-par skills, poor time management) behind assignments that were not completed well—and use their specific solution next time.

Activities for adults