Executive Function and Executive Function Deficits

Executive functions are brain-based pathways that control conscious thought. They allow people to concentrate, pay attention, and make deliberate decisions.

Some people compare executive functions to the brain's air traffic controller, or the brain's CEO. These functions allow people to monitor thinking, feelings, and actions; make intentional choices; and reflect on the outcomes of their choices.

Executive function skills develop throughout childhood and into early adulthood. Young children generally have very limited executive functions, and they gradually acquire executive function skills as they grow up.

Deficits in executive functioning can affect people in multiple ways.

A person may have a deficit in executive functioning if they have more trouble than other people their age with skills such as:

• keeping their room, bag, or desk clean and organized

• remembering to bring things back and forth to school

• keeping track of their stuff

• starting tasks promptly, and sticking with them until they are done

• stopping an activity and switching gears when needed

• estimating how long something will take

• planning how to complete a task with multiple steps

• being on time

• making alternate plans when needed

• waiting their turn

• knowing how well they are doing at something

• managing frustrating events calmly

Flexibility is the ability to alter behavior in response to changing circumstances.

It can include:

• Switching among tasks

• Trying a different strategy to solve a problem

• Changing the rules

• Attempting something new

• Making a different plan when something

  changes

• Considering an alternate perspective

• Changing our mind

• Reacting to unexpected changes calmly

People who can act flexibly are often relaxed in the face of change, and can feel successful in many different contexts and circumstances. Flexible thinking can let people understand and appreciate alternate viewpoints and opinions.

Flexibility can also improve a person's ability to solve problems, as they are able to consider multiple solutions, and switch strategies as needed.

The opposite of flexibility is rigidity. Rigid thinkers tend to insist on sameness and routine, resist alternate approaches and behaviors, and embrace black-and-white or right-and-wrong thinking.

Emotion regulation is the ability to control emotions to:

• achieve goals

• complete tasks

• interact with others in a way that is socially appropriate

Emotions are neither good nor bad, and people need to validate and feel all their emotions. However, some emotional responses can cause problems.

Young people can learn to feel and show their emotions in ways that are safe and adaptive.

Response inhibition is the ability to wait, and not do something we have an impulse to do. When a person can inhibit, they can prevent careless mistakes and unwise behaviors.

A person who has trouble inhibiting might often do or say things that they regret, and act "without thinking."

People with poor inhibition also have trouble delaying gratification. This means that they will often choose something that feels good in the short-term rather than wait for something better in the long-term.

Organization is the ability to create and maintain systems to keep track of information or materials. People organize:

• thoughts and ideas

• objects and spaces

• tasks and time

In order to be organized, people need to be able to:

1. recognize the parts that have to be organized

2. sort the parts into categories

3. figure out a logical structure to the categories

4. put the parts into the structure

5. keep up the system once it is established

Task initiation is the ability to start a planned task without unnecessary delay or procrastination. People with good task initiation can start both preferred tasks and non-preferred tasks promptly, as needed.

In order to have good task initiation, a person must be able to:

• recognize what task is most important

• be aware of the first step of the task, and have the skills needed to achieve it

• shift their focus and redirect their attention deliberately

• inhibit the pull to do a different, more-preferred activity

• tolerate some discomfort or boredom

Goal directed persistence is the ability to establish a goal, and then follow through with the steps necessary to complete the goal.

People with good goal-directed persistence must be able to:

1. name a relevant and attainable goal

2. identify the process required to achieve the goal

3. start the process

4. continue with the process until the goal is achieved, even if they become bored or distracted, or if a short-term reward appears more appealing

Sustained attention is the ability to focus on a task, and maintain a consistent level of focus over an extended period of time.

Strong sustained attention:

• may or may not be goal-directed

• may be for a preferred or non-preferred activity

• requires a capacity to filter out distractions

Variations in sustained attention are normal, including among people with attention-deficit hyperactivity disorder (ADHD).

For everyone, sustaining attention is easier when:

• tasks are interesting and enjoyable

• tasks are neither too hard nor too easy

• a person is comfortable and rested but not restless

• there are few distractions in the environment or in a person's thoughts

• an activity offers rewards in a way explicitly designed to sustain attention (such as slot machines or video games)

Monitoring is a type of metacognition, which means that it involves thinking ABOUT thinking.

Metacognition requires an ability to:

• Think abstractly

• Have an idea of oneself as a learner

• Consider multiple possible actions/strategies

• Understand cause and effect

When a person is monitoring, they are asking themself questions such as:

• How am I doing right now?

• How is this working out for me?

• What strategies am I using? How well are they working?

• What other strategies should I use?

• Should I consider changing course? If so, how?

When people are good at monitoring, they can adjust their behavior in real-time to respond flexibly to changing circumstances. They can also learn during experiences, and take steps to correct missteps.

Reflecting is another type of metacognition. Whereas monitoring involves thinking about what you are doing while you are doing it, reflecting involves thinking about what you did after you have finished.

People who are good at reflecting ask themselves questions such as:

• How did I do?

• How well did I accomplish my goals?

• What strategies did I use, and how well did they work?

• What worked, what didn't work, and why?

• How can I apply what I learned to do better next time?

When people learn how to reflect, they are able to learn from experiences, and steadily improve their performance.

Working memory is the capacity to temporarily hold information in conscious attention.

Working memory can include:

• memory of sounds and words

• memory of images

People use the information in their working memory to:

• solve problems

• make plans

• think

• perform tasks

Working memory naturally develops and increases over the course of development. This means that adults can usually hold more information in their working memory than children, and older children can usually hold more information in their working memory than younger children.

Working memory is short-term, and information in working memory may or may not be remembered for the long term.

Since people with heart defects often have deficits in executive functions, parents, educators, and other professionals should be on the lookout for possible problems. In many cases, executive function problems appear when school becomes harder, and when most other kids are making more rapid progress in learning executive function skills.

If a child with a heart defect has trouble with organizing, structuring, and regulating, they can be referred for an evaluation through their school district or a cardiac neurodevelopmental clinic. If executive function deficits are identified, children can get help through services and accommodations, so that they can continue to be successful at school and at home.

This content was reviewed by a psychologist at Boston Children's Hospital.

Families local to Boston can seek testing or treatment for executive function deficits from the Cardiac Neurodevelopmental Program.