Executive functioning has become a popular topic lately and it’s personally one of my favorite treatment areas for cognitive rehab. So what is executive functioning exactly, and why is it so important?

Executive function skills are a set of interrelated cognitive processes that are essential for decisions we make, actions we take, and how we interact with others. We use these skills countless times each day. Executive functioning encompasses skills such as decision making, complex problem solving, behavior and emotion regulation, planning, inhibition, time management, working memory, mental flexibility, self-monitoring, scheduling, metacognition, shifting attention, and organization. Think of executive functioning as the “command and control center” of the brain. Executive function skills combine current awareness, future anticipation, and past experiences to set and achieve goals. For most people, these skills are so innate, automatic, and a part of our human experience that it is difficult to imagine what life would look like if we were not able to do things such as solve problems or regulate our behaviors effectively. 

A part of the brain called the prefrontal cortex plays a significant role in executive functioning. However, current research has demonstrated that executive functioning involves “diffuse brain circuitry,” meaning many parts of the brain play a role. Due to the complexity and breadth of executive function skills, we cannot pinpoint one part of the brain that is solely responsible. 

Here are several examples of adult populations that may have executive dysfunction following a brain injury or neurological disorder: 

• TBI (traumatic brain injury)
• Concussion or post-concussion syndrome
• CVA (stroke)
• Dementia or Alzheimer’s Disease
• ALS
• Multiple Sclerosis
• Parkinson’s Disease

*Note- inattention, impulsivity, and disorganization are hallmark symptoms of ADHD which is a neurodevelopmental disorder and the reason I did not include it in the above list. However, many adult clients may have co-occurring ADHD + TBI, for example.

Let’s consider a common functional task including how executive function skills play a role and how I can help as an SLP for someone who has difficulty with executive function skills after neurological injury. I’ll use the example of calling to schedule a doctor’s appointment. 

Executive function skills involved in this task include:

• Planning/scheduling (looking at my calendar to see when I am available and ensuring I do not have any scheduling conflicts)
• Shifting attention (switching between reviewing my calendar and listening/responding to the office receptionist on the phone)
• Decision making (actually deciding on an appointment date and time)
• Self-monitoring (monitoring my own behavior and how I am communicating with the receptionist on the phone)
• Problem solving (being able to identify solutions or troubleshoot if issues arise such as difficulty finding a time that works for both my schedule and the doctor’s schedule)
• Working memory (actively paying attention and holding information- “Friday August 9th at 2:30 pm with Dr. Jones-” in my memory long enough to type it into my calendar as soon as I hang up the phone with the receptionist)

That’s a lot of cognitive processes involved in something as seemingly straightforward as calling to schedule a doctor’s appointment, right? For clients with executive dysfunction, these daily tasks can quickly become overwhelming. 

When I work with clients who have executive dysfunction, we utilize compensatory and metacognitive strategies (metacognitive means “thinking about how you’re thinking”) and target specific executive function skills where that particular client demonstrates difficulty. Often we are still targeting multiple skills however since these mental processes are so intertwined. For someone who struggles with decision making, we might pre-plan a few specific days and times that he/she is available prior to the phone call to make that decision easier. For someone who struggles with self-monitoring, we might role-play prior to the phone call or develop a communication script he/she can use when calling to schedule doctor’s appointments. For many clients, we could use a metacognitive strategy such as “SWAPS” or “Goal-Plan-Do-Review” to optimize and streamline this task. Finally, in addition to working with an SLP with expertise in treating executive dysfunction, collaborating with other professionals such as neuropsychologists, occupational therapists, and psychologists is the best practice for maximizing a client’s executive function skills. 

Sources: 

ASHA: Executive Function Deficits