18 Executive Dysfunction

INTRODUCTION

Parents and teachers are often baffled when students, including those who are intellectually gifted, teeter on the brink of school failure. Recently researchers may have solved part of this challenging puzzle by identifying deficits in critical cognitive skills. Known as executive functions, the lack of these skills may interfere with a student’s ability to achieve academic and even social competence. Practically speaking, executive function deficits may cause problems for students in several important areas: starting and finishing work, remembering homework, memorizing facts, writing essays or reports, working math problems, being on time, controlling emotions, completing long-term projects, and planning for the future.

Children manifesting autistic syndrome, mental retardation and/or learning disabilities are among the groups who may lack complete executive functioning. However, it has been identified that many students who are otherwise perfectly typical may suffer from a lack of development in these cognitive skills due to a lack of mediation of their early learning. Thus children, who have in one way or another suffered a deprived early developmental context, may also display a lack of these skills.

THE PROBLEM

‘Executive function’ is an umbrella term for certain mental functions such as planning, working memory, impulse control, inhibition and mental flexibility, as well as for the initiation and monitoring of action. Executive dysfunction is considered to be a neurological defect and is often connected to the functioning of the frontal lobe. Obviously, such concerns are considered to be quite serious, and unfortunately are often couched by ‘experts’ in rather dire fashion.

A rather typical posture in regard to executive functioning in both the literature and clinical interpretation would be similar to the following discussion of executive dysfunction in regard to ADD. The paper reflects the research and thoughts of a student at the time the paper was written for a course at Bryn Mawr College. Like other materials on the Serendip website, it is not intended to be “authoritative” but rather to help others further develop their own explorations. At the same time, it gives a clear indication of what students are learning in colleges and universities across the land, and is indicative of a pertinent clinical perspective.

Treating Attention Deficit Disorder as a Executive Function Disorder Rebecca Jones

Most people with ADD are born with it. The evidence that it usually runs in families indicates it is a genetic disease. Research into the brain chemistry has found a gene that is involved in a lack of dopamine. “ADHD children differed from controls in that the 7-fold repeat form of DRD4 occurred significantly more frequently than in the control sample. This form of the receptor has previously been shown to mediate a blunted intracellular response to dopamine”. The people who are not born with ADD usually develop it due to frontal lobe damage or certain toxins, such as lead, that cause brain damage.

The portions of the brain that are used for executive functions are the same portions of the brain that show abnormalities in people born with this ADD. Magnetic resonance images were used to study brain shape. “Two anterior regions, the rostrum and the rostral body, were found to have significantly smaller areas in the ADHD group.” “Total brain volume was 5% smaller in the ADHD boys, and this was not accounted for by age, height, weight, or IQ.” In studies of executive function, it was found that during use of the executive function various portions of the cinglet were active. The testing was done using PET tests of the Stroop method. People that develop this disorder due to brain damage are found to have lesions in the frontal lobe in the same region that the executive function and ADD brain abnormalities are found.

There is no cure for ADD or any executive dysfunction; treatment must be continued for life. In people with ADD, the most common treatment is stimulants such as Ritalin. The theory is that it enhances the delivery of dopamine, which ADD sufferers produce in too small amounts. There are numerous problems with using only this treatment. One of them is the lack of a study into the effects of long-term stimulant use. There are side effects from stimulants as well. Another problem is a tendency to develop a dependence on the drugs. Often, as adults, they are taken off this medicine and encouraged to live without it. The change from having this aid to figuring out how to deal with the problem on your own is difficult. Other disorders caused by problems with executive functions including injuries are treated in a more systematic way. Rather than treating the symptoms, the person is encouraged to develop other parts of the brain. They are trained to think in ways that gets around the damaged areas. If the damage is severe, there are computer systems similar to palm pilots that can help. These computers are easily carried; they have the ability to store complex schedules, the placement of items, and remind the user when it is time to do something. These machines even have a limited ability to make decisions for the user.

Treatment of ADD as an executive function disorder would mean teaching the person how to take advantage of their brain. This would include special classes, controlled schedules and routines. This would be more work for parents and schools with ADD children but it would enable the children to function well as adults. The evidence for the drugs helping among especially among children is high. So this does not mean the end of treatment with the use of drugs it means additional treatment, which will decrease the need for help as adults.

Obviously, Ms. Jones notices the problems of how we treat the executive dysfunction of ADD when she contrasts it to how we address injury to the brain. However, the basic constructs are that executive dysfunction that Ms. Jones articulates are: a) genetic and b) incurable. We wish to challenge both of those notions. The intent of this example is not to ridicule Ms. Jones. Her paper is footnoted with citations from the ‘experts’ from whom she is gathering her information. In fact, the experts below echo the issues she raises.

Most of the research relevant to this question looks at the role of stimulant medications (such as Ritalin) on specific types of tasks or activities. Although a detailed discussion of this research is beyond the scope of this web site, it is intriguing to note that there is some evidence that stimulant medications may be of benefit for some aspects of executive dysfunction. As examples:

• Kempton et al. (1999) compared unmedicated children with ADHD to children with ADHD who were on stimulant medication. They found a significant number of executive functions impaired in the unmedicated children, but those children who were on stimulant medication displayed no such impairment (with the exception of spatial recognition memory)
• Kramer, Cepeda, and Cepeda (2001) reported that methylphenidate (Ritalin) improved task-switching ability in children with ADHD
• Aron et al. (2003) reported that similar to findings in children with ADHD, adults with ADHD also display impairment in response inhibition that is ameliorated by methylphenidate

Amantadine (an antiviral that has been used in the treatment of Parkinson’s disease) has also been found to be of benefit in some executive functions in adult patients with dementia. It would be misleading, however, to suggest that stimulant medications or any one medication might be of benefit in all types of executive functions. For many problems, we will need to make environmental changes and provide the individual with direct instruction of skills. A recent report using cognitive remediation for adults with ADHD and executive dysfunction reported that cognitive remediation was effective for certain aspects of executive dysfunction.

This is not, of course, the whole story. This protocol, is about ‘hope and rational optimism ’ regarding executive functioning. There is another perspective. Dopamine is not the new Satan, and evolution has not failed to weed out a mutation disaster. In order to respond effectively to the pessimistic clinical perspective we will need to address several issues:

• what are executive functions?
• what constitutes executive dysfunction?
• what is the role of dopamine?
• what does it mean that there is a gene involved and a lack of dopamine?
• and what is Ms. Jones alluding to when she talks about “ways to train the brain”?

Along the way, we will discuss something about the assessment process and how that process might be used more effectively.

What are executive functions?

The foundations of learning are generally considered to be: (1) attention, (2) memory, and (3) executive functions. Executive functions are identified generally as those functions that are involved in pursuing a goal. Usually they are thought to include:

• initiation of and overall control of the execution of deliberate actions
• initiation of and overall control of goal directed behavior
• attention
• planning
• decision making

In light of these importance of these functions, it may be helpful to explore how an ‘inner logic’ or theory of meaning is developed by individual children as they grow and develop. All human beings are goal driven entities. The generalized goal is a very utilitarian one: to avoid pain and find pleasure. In order to predict future events and attain some control over their lives so they can achieve this goal, the individual needs to operate from experience. They have thoughts about the experience and create mental constructs to describe and define each experience and its relationship to the next experience. Therefore, from the very first experience, they begin to build schemata or a network of ideas that will provide a context in which to determine what might happen and how is best to respond. One theory that may be helpful here is George Kelly’s Theory of Personal Constructs .

The Fundamental Postulate

A person’s processes are psychologically channeled by the ways in which s/he anticipates events: The fundamental postulate first suggests that an individual should be seen as a flowing process, rather than being composed of units of ‘mental energy’. These processes are then channeled, or directed, by constructs (those frameworks which the individual employs to predict future events). The term ‘anticipates’ refers to the primary function of the constructs – they generate predictions about the world. These predictions are then tested by the individual, and according to whether or not the reality of the experience fits the prediction the construct is reinforced or altered.

Under the theory of Personal Constructs, the basis of human behavior is this very prediction and testing. An individual’s behavior operates through a structured but flexible network by which s/he predicts future events. According to Kelly, humans apply constructs to generalize the course of events in order to predict similar events in the future. In this sense, the role of the individual is seen as being quite similar to the role of the scientist: just as an individual will use a construct to hypothesize future events and then test those hypotheses through personal experience, a scientist will work within a theory to generate hypotheses and then test those hypotheses through an experiment.

Obviously, this process includes elements of executive functioning. The person is faced with a situation; s/he takes from that experience certain memory elements that are then used to compare the next experiences. These processes are carried out to pursue a goal – control of future situations.

A person anticipates events by construing their replications: Individuals note consistencies within their experiences, recognizing repetitions and recurrent themes. On the basis of these themes, hypotheses about future events can be made and tested. This corollary simply states that constructs are the tools which humans use to anticipate and to predict the future; constructs serve as the overarching framework within which predictions are made, and it is the assumptions derived from that framework that allow for predictions concerning the outcome of life experiments.

To put it differently, constructs may be conceived as a summary of past observations from which the individual extracts generalizations and patterns about the world. These patterns, if they have been consistently demonstrated in the past, are assumed to apply to future events as well. The individual construes the replication of these patterns in order to predict future events.

Persons differ from each other in their construction of events. Kelly acknowledges that not all people construe reality in the same manner, even when placed in the same objective circumstances. That is, constructions reflect individual differences in people’s interpretations of experience, rather than any objective reality. Constructs are understood to be unique to each individual and atypical children are likely to interpret personal issues, about self and other people, in ways that are distorted by their own beliefs about themselves.

A person’s construction system is composed of a finite number of dichotomous constructs:

Elements of experience (for example, events or people) are construed as being similar to, and different from, other elements; all elements of experience are placed on a bipolar axis of opposites.

Take, for example, the construct of good-bad: within such a construct, certain people or events may be placed. For instance, person A may be construed as bad, while person B as good (and yet a third person C must be construed as either similar to A and different from B, or similar to B and different from A.

Each construct is necessarily composed of two similar, and one dissimilar, elements.

No matter how one’s experience is construed, whether it be on an axis of good/bad, honest/dishonest, mature/immature, hot/cold, it is still always within such a dichotomous framework that the experience is interpreted.

According to Kelly, there are always alternative constructions available among which to choose. This means that the constructs presently constituting the ‘inner logic’ can be altered through a mediated learning experience. A child who believes him or herself to be ‘dumb’ compared to his/her ‘bright’ companions can alternatively compare him or herself as good/bad, honest/dishonest and this may make the emotional response to being ‘dumb’ more balanced and rational.

A person’s construction system varies as s/he successively construes the replications of events:

The construction system that one places upon events is like a working hypothesis that must be put to the test of experience. If the construct fails to validly predict the outcome of future events, then it must be reformulated in light of the new experiences that invalidated it.

In other words, events and experiences must constantly be reconstrued as a person broadens and varies. The important point to acknowledge is the construction system’s constant imposition of interpretation upon events, whether they are consistent with previous interpretations, or reformulations based on new experiences. In the words of Kelly, “The person who merely stands agog at each emerging event may experience a series of interesting surprises, but if he makes no attempt to discover the recurrent themes, his experience does not amount to much. It is when man begins to see the orderliness in a sequence of events that he begins to experience them”.

And this may be the crux of the executive function problem, if the child has construed constructs that do not overcome this ‘blurred’ vision of the problem. If I have not learned how to approach the problem, I have no hope of solving it.

Experience is only meaningful when events are placed within a context; if novel events arise, in order to truly experience them (that is, make sense of them), one must reformulate one’s constructs so that the novelties are not merely foreign events, but systematically explicable under a new framework.

Such novelties must be subsumed under a new construct system in which they are useful in predicting future events.

It should be obvious that most children with executive dysfunction have been able to develop some constructs with which to predict and control the future – most are simply poor at it. We would propose that for certain children the problem is two-fold: first, they have difficulty predicting and controlling future events and, second, because of this dysfunction, they have construed thoughts about themselves and others that are distorted by their constructs of the original problem.

Any child who experiences him or herself as different from others around them must answer the question: “is this a good thing?”. If not, their thoughts about self, and ultimately others must change. The issue that arises from this is the question of whether the cognitive disability or distortion is modifiable.

A construct is convenient for the anticipation of a finite range of events only: Few constructs are applicable to all situations.

The teacher’s role [whether educational or clinical] is therefore to help the child think about thinking – what constructs does the child use and how is that construct helpful in solving the presenting problem?

So the issues with executive dysfunction are generally construed as being neurologically based and unalterable. But let us examine the functions themselves more closely.

The chart [below] was developed by Leslie E. Packer, PhD, in 1999 and provides greater detail for consideration, mainly in the sense of the ability to respond effectively to the failure of a child to be able to carry out such functions. The chart is particularly helpful since it provides definitions and specific signs of dysfunction that any reasonable layperson should be able to identify in regard to any specific child’s functioning.

The twelve functions and descriptions should give you a fairly succinct understanding of the nature of executive functioning, and at the point where memory, executive function, and attention overlap, you have ‘working memory’ – the process of holding new visual or auditory information in mind as you retrieve older knowledge or procedures to apply to the new material. For example, you may have already learned the procedure for solving a two-digit multiplication problem. When you are told the numbers to multiply, you need to hold them in your mind while you retrieve the procedural memory and apply the steps, keeping track of your calculations as you do this. Or if I ask you a question, you keep the question in mind as you mentally search through all your ‘memory files’ to pull out the information you are looking for.