In this article:
EXECUTIVE FUNCTIONS/EXECUTIVE DYSFUNCTION
In my last article I addressed Attention-Deficit/Hyperactivity Disorder (ADHD). While people with ADHD are typically inattentive, hyperactive, and impulsive, these symptoms do not fully account for the range of academic, social, emotional, and behavioral problems present. All people with ADHD exhibit some degree of executive dysfunction which is central to many of their problems. So what is executive dysfunction, and what are executive functions?
So often we see adolescents who do well on IQ tests, and seem bright in any number of ways, but they never seem to perform well in school. Work is not completed, deadlines are missed, and important opportunities for learning are wasted. Similarly, social situations with family and friends may have a high degree of drama, misunderstanding, and disruption. What is going on? General intelligence and social intelligence may be present to an adequate extent. In order to make good use of these abilities, the brain must be able to organize which skills to select, inhibit, coordinate, and apply to a given task or set of circumstances. A frequently used analogy is that the executive functions are the conductor of the orchestra, with each musician (virtuosos they may be) needing organizational direction in order to play as a unit. Executive function include emotional regulation, concentration, self-regulation, planning, initiation, purposeful action, volition, pacing (of self, time, projects) behavior inhibition/initiation, mental alertness, coordination of cognitive tasks, and cognitive flexibility (list offered by psychologist Laura Ehlert, Psy.D). Executive dysfunction is always present to some extent in teens with ADHD, and usually present in other conditions including Learning Disabilities, Developmental Disorders, Disruptive Behavior Disorders, and Traumatic Brain Injury.
No two individuals with executive dysfunction appear the same, but there are frequently occurring characteristics. Emotional expression may be heightened and changeable or conversely flattened and deadened. The teen may be described as irritable, excitable, impulsive, erratic, careless, and rigid. There is a reduced ability to self control, so spontaneous, inappropriate expression is exhibited. Reduced self-direction leads to aimless activity, with little planning. Rapid shifts in attention and poor cognitive flexibility are particularly difficult, leading the teen to seeing much of the world in black and white terms. This deficit complicates academics (multi-step math problems, shades of meaning in literature), and social interaction as the teen takes things literally, missing nuance and subtlety. This leads to misunderstanding and often argument. Teens with executive dysfunction often have impairments in motivation and cannot will themselves to initiate a project. The tools of goal directed behavior; planning, organizing, recognizing time requirements, and following a sequence of steps, may all be lacking. Finally, Working Memory, the ability to hold two or more mental images in mind simultaneously while performing some operation on one of those images, is frequently impaired. Thus the teen cannot listen to the teacher, and take notes simultaneously, or focus on writing a sentence and remember the overall point being made in the essay he is writing.
Executive functions are generally performed in the prefrontal cortex of the brain. The prefrontal cortex goes through significant growth and development during adolescence, and thus adolescence is viewed as a "window of sensitivity" for the development of executive functions. There is much opportunity to create positive change during adolescence, but if the opportunity is lost, dysfunctional characteristics may endure, perhaps for a lifetime. The emotional and memory areas of the brain (hippocampus, amygdale) are also under development during adolescence. These areas as well as the prefrontal cortex are sensitive to the effects of alcohol and drug use. Chronic use during the adolescent period can confound the "window of sensitivity", causing no growth in executive functions.
Treatments exist to deal with executive dysfunction. There are three main areas of treatment; external (changing the environment), internal (changing the person), and medication. Ideally, use of all three areas over an extended period of time is most helpful. There are other lesser used programs including neurofeedback, working memory training, and Cerebellar Stimulation Training. Evidence suggests that therapies are successful, and make a significant difference in the life of the executive dysfunctioning teen. With treatment, there is good reason for optimism.