Executive Dysfunction

What Causes Executive Dysfunction?

Scientists have not yet determined a definitive cause of executive dysfunction. It likely occurs when there is damage to or problems in the development of the parts of the brain that control basic executive functions. This damage can arise from many different causes.

Executive dysfunction is often associated with ADHD, which may have an inherited genetic cause. However, environmental factors seem to play a role, too. Therefore, the disorder is most likely caused by a combination of genetic and environmental factors, and the precise cause probably varies from case to case.

Beyond the inherited risk, research has identified some environmental factors that increase a child’s risk of developing ADHD. These factors include:

• Tobacco, alcohol, or drug use by the mother during pregnancy
• Low birth weight
• Premature birth
• Exposure to toxins such as lead during pregnancy
• Exposure to toxins during early childhood

Other possible causes of executive dysfunction include:

• Alcoholism or substance abuse
• Degenerative brain diseases such as Alzheimer’s disease
• Frontotemporal dementia and other types of dementia
• Traumatic brain injuries or concussions
• Brain tumors
• Stroke
• Encephalitis
• Meningitis
• Epilepsy
• Huntington’s disease
• Multiple sclerosis
• Depression
• Autism
• Obsessive-compulsive disorder (OCD)
• Schizophrenia

Is Executive Dysfunction Hereditary?

Some disorders associated with executive dysfunction have a genetic component and may run in families. For example, research has shown a relationship between ADHD and family history. Children whose parents, siblings, or other close relatives have ADHD are significantly more likely to have the disorder themselves. While scientists have identified several specific genes that might be a factor in the development of ADHD, no single gene defect seems to be the primary cause. Instead, it is likely that changes in multiple genes, each of which has a small overall effect, combine to produce the disorder. It is also likely that external environmental factors work together with genetic tendencies in developing ADHD and other causes of executive dysfunction.

How Is Executive Dysfunction Detected?

Early detection of executive dysfunction can be difficult because some symptoms are not easily distinguishable from normal behavior in young children. Excitability and distractibility are all typical in preschool-age children. Impulse control and attention span normally improve as a child develops, and early limitations in these areas are not necessarily an indication of executive dysfunction.

How Is Executive Dysfunction Diagnosed?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) does not recognize executive dysfunction as a distinct disorder. Rather, it is considered to be a class of symptoms that may be associated with other disorders. However, if a doctor suspects that executive dysfunction is the cause of a patient’s symptoms after ruling out other possible causes, they may recommend a psychological or psychiatric assessment by a professional familiar with the problem. 

Diagnostic steps may include:

• A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
• Neurological exams and assessments. These exams and questionnaires will look for brain-based causes of the symptoms.
• Psychological assessments. If no physical or neurological causes can be found, the doctors may use these assessments to determine if the disorder has a psychological cause. The assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Executive Dysfunction Treated?

Executive dysfunction can often be effectively treated with behavioral therapy and/or medication to control symptoms. In many cases, symptoms improve when underlying neurological or psychological disorders can be effectively treated.

Common treatments for executive dysfunction include:

• Behavioral therapies. These therapeutic approaches aim to teach people to manage their own behaviors. Therapy can improve focus, organizational skills, and impulse control.
• Psychotherapy. Talk therapy such as cognitive-behavioral therapy (CBT) with a psychologist may help some people learn strategies to manage their symptoms
• Medications. Medications may be used to treat disorders associated with executive dysfunction; these treatments may significantly improve symptoms. Stimulants such as Adderall or Ritalin are most commonly prescribed to treat ADHD. Non-stimulant drugs such as atomoxetine or clonidine tend to act more slowly, but they may be prescribed when stimulants are ineffective or cause side effects. Antidepressants and antipsychotic medications may be used to treat other associated disorders.

How Does Executive Dysfunction Progress?

Potential long-term consequences and complications of executive dysfunction include:

• Poor performance in school
• Poor performance at work
• Low self-esteem
• Unstable relationships
• Criminal or legal trouble
• Financial problems
• Drug or alcohol abuse
• Other mental disorders such as anxiety, depression

How Is Executive Dysfunction Prevented?

There is no guaranteed way to prevent executive dysfunction, but avoiding known risk factors may reduce your child’s likelihood of developing symptoms.

• Do not smoke, drink alcohol, or use drugs during pregnancy.
• Do not expose your child to toxins such as tobacco smoke or lead.
• Limit young children’s access to electronic devices and television. Some research suggests that excessive screen time in children under age 5 increases the risk of ADHD.

Executive Dysfunction Caregiver Tips

Especially when a child is young, the intervention of parents is the most effective treatment for executive dysfunction. By building an environment for your child that minimizes the effects of the disorder and encourages appropriate behavior, you can help your child to thrive.

• Provide a supportive environment. Develop a routine for your child’s daily activities and help to plan steps for getting tasks done. Do your part to limit distractions, and always be clear about your expectations.
• Take a positive approach to discipline. Help your child set goals, and be generous with praise when they meet those goals. When discipline is necessary, concentrate on consequences that are logical responses to inappropriate behavior rather than arbitrary punishments. For example, use a time-out when the child behaves inappropriately in a particular setting.
• Be an advocate for your child. Work with teachers and other people outside the home to help them understand how they can support your child.
• Encourage a healthy lifestyle. Poor wellness choices can make the effects of executive dysfunction worse. Make sure your child is eating a healthy diet, getting plenty of exercise, and getting enough sleep.

Executive Dysfunction Brain Science

Executive functions are controlled by the brain’s frontal lobes, which have extensive connections to other parts of the brain, helping to organize the processes of the other areas into more complex functions. The frontal lobes are large areas of the brain behind the forehead. Because of their size and location, they are especially vulnerable to damage from head injuries.

Executive dysfunction can also occur when there is damage to parts of the brain that connect to the frontal lobes. Some other areas that may be involved include:

• Posterior association cortex
• Dorsomedial thalamic nucleus
• Basal ganglia

Executive Dysfunction Research

Title: Engage for Late-Life Depression and Comorbid Executive Dysfunction

Stage: Not Yet Recruiting

Principal Investigator: Brenna R. Renn, PhD

University of Nevada

Las Vegas, NV 

Although there are an increasing number of mental health treatment adaptations for older adults, there are still a number of factors to consider when making these adaptations. Cognitive decline is one factor that places a significant burden on older adults and can interfere with traditional mental health therapies. Engage is a behavioral treatment approach that has shown effective in treating late-life depression. We are testing the feasibility of Engage as a treatment method for late-life depression in older adults with cognitive decline. Our objective is to corroborate Engage as an alternative late-life depression treatment method for a sub-population of older adults with cognitive decline. Cognitive decline poses a unique mental health treatment barrier often overlooked in younger populations. With a relatively higher prevalence of cognitive decline in older adulthood, we must find a feasible mental health treatment program that can be effective in the presence of cognitive decline.

Title: Adaptation and Implementation of an ASD Executive Functioning Intervention in Children’s Mental Health Services

Stage: Not Yet Recruiting

Principal Investigator: Kelsey S Dickson, PhD

Child and Adolescent Services Research Center

San Diego, CA

This project aims to conduct a feasibility test of an ASD executive functioning intervention adapted for mental health settings, including examining the effectiveness and process of implementing this adapted intervention in community mental health programs.

This project will examine the implementation and effectiveness of an ASD executive functioning intervention, entitled Unstuck and On Target (UOT), adapted for use in community mental health clinics. Minimizing the impact of executive functioning deficits in youth has broad public health implications, including improving the effectiveness of mental health services for youth such as those with autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD). Improved executive functioning also has the potential for improvement in real-world functioning, including daily living skills, mental health, and educational outcomes. Although UOT is an established evidence-based intervention, the effectiveness of this intervention in mental health settings has not been established. Therefore, the primary aim is to collect data on implementation outcomes of the adapted intervention, including feasibility, utility, and therapist fidelity, in mental health settings. The secondary aim is to collect data on the preliminary effectiveness of UOT adapted for mental health settings. This study has the potential to make a significant impact by building local capacity to serve school-age children with executive functioning deficits in routine service settings and advancing the science on the effectiveness of an established evidence-based practice (UOT) for specific service settings. It will also produce generalizable knowledge about implementation that can be applied to this population/setting.

Title: Child and Adolescent Services Research Center

Stage: Not Yet Recruiting

Principal Investigator: Barbie Zimmerman-Bier, MD

Robert Wood Johnson Medical School

New Brunswick, NJ

Although many children diagnosed with autism spectrum disorder (ASD) make significant progress in learning and their cognitive skills improve with applied behavior analysis (ABA), there are a significant number of children who show an absence or a plateau in various skills. Deficits in executive functioning are likely to be involved in many of these cognitive and learning disabilities due to poor functioning of the prefrontal cortex. Currently, the use of biological methods for improving learning and cognition is largely unexplored in research and practice.

This study aims to use transcranial direct current stimulation (tDCS) in combination with ABA to improve the acquisition of educational programs for students with ASD. tDCS is a low-level electrical neurostimulation and is most effective when combined with active training or teaching, facilitating the neuronal circuits used for that task.

tDCS has been used for various indications over a couple of decades and has been shown to be very safe and well-tolerated by children with ASD. The mechanism of tDCS is not clear. However, animal studies show that tDCS can stimulate the flow of calcium ions through channels in the astrocytes, activating them and facilitating their role in synapse formation and therefore learning.