Therapy News
Executive Functioning
where is it controlled and
how does it develop?
T
he executive functions are a set of processes that have to
do with managing oneself and one’s resources in order to
achieve a goal. It is an umbrella term for the neurologicallybased skills involving mental control and self-regulation.
Executive functioning deficit is often used as a catch-all
diagnosis for higher-order communicative-cognitive difficulties
that are not clearly understood or diagnosable. Executive
functioning (EF), when used to describe poor functioning, is
often thrown about rather casually with minimal understanding
of the immense impact the deficits can have on a person
with said difficulties. Great strides have been made in
identification and treatment with more and more practitioners
realizing the devastating and often life-altering impact these
subtle difficulties have on interpersonal skills, return-to-work
potential, social communication and the ability to manage a
home. In order to best treat executive dysfunction, we must
understand brain anatomy as it relates to EF, definitions and
models of EF, developmental acquisition of EF, remediation
techniques, and future research directions.
This article and a follow-up article in the next edition will
explore all of these concepts.
The roll of the executive system
The role of the executive system is to handle novel situations
outside of the domain of some of our more automatic
psychological processes. Norman and Shallice (1992) outlined
five types of situations in which routine activation of behavior
would not be sufficient for optimal performance, and where
executive functions must kick in.
1. Situations that involve planning or decision making
2. Situations that involve error correction or trouble
shooting
3. Situations where responses are not well-rehearsed or
contain novel sequences of actions
4. Dangerous or technically difficult situations
5. Situations that require overcoming strong habitual
response or resisting temptation
The executive functions are often evoked when it is
necessary to override responses that might otherwise be
automatically elicited by stimuli in the external environment.
For example, when being presented with a potentially
Imagine you are on a diet and
are offered a piece of pie. You
might decline the offer. Why?
Because eating the pie conflicts
with your plans to lose weight.
Executive functions are the
mechanisms that kick in to help
us set goals, make plans and
change our behavior.
rewarding stimulus, such as a piece of pie, a person might have
the automatic response to take a bite. However, where such a
response conflicts with internal plans (having decided not to
eat pie due to being on a diet), the executive functions might
engage and inhibit the response. Working memory and executive functioning
There is also a connection between working memory and
executive functioning. Working memory is a limited capacity
system that temporarily maintains and elaborates information
and supports human thought processes (Baddley, 2003). It is
often viewed as the cornerstone or pivot point for higher order
cognitive processes.
Based on Baddley’s model, working memory has three basic
components: a central executive system and two subsidiary
storage systems, the phonological sketch pad and the visuospatial
sketch pad. The subsidiary systems are responsible for temporarily
storing verbal and nonverbal information, where the central
executive system processes information in working memory.
Serino et al.(2006) and Purdy state that in the initial stage
of problem solving and goal-directed behavior, working
memory is crucial. Working memory provides the storage
and workspace for information, whereas executive functions
perform operation on the information held in working
memory so the information may be used efficiently. During
working memory tasks that involve goal-directed behavior,
the memory system, either verbal or nonverbal, must be
strong in order to allow the executive system to determine
the most suitable strategy from a set of alternatives, mentally
checked and modified if necessary. Purdy, in the text Cognitive
Communication Disorders, summarizes the interplay between
working memory and executive functions in Figure 1.
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Executive Functioning continued
Figure 1. Conceptualization of the relationships among
attention, memory, executive functions and
working memory
(Purdy, 2011)
executive
functions
working
memory
attention
memory
central executive
system
visuospatial
sketch pad
(storage)
(active manipulation
of information pulled
from storage)
phonological
sketch pad
what AREAS of the brain
control executive functioning?
Executive functions are located primarily in the prefrontal
regions of the frontal lobe with multiple neuronal connections
to other cortical, subcortical and brainstem regions.
Neuroimaging and lesion studies from a variety of neurological
diseases and injury models have confirmed the findings.
However, it should be noted that prefrontal injury does not
directly affect specific cognitive or linguistic processes; rather
it affects their regulation and effective use, likely through
alteration of the numerous neuronal connections between the
prefrontal cortex and other brain regions.
If the distinction between a cognitive process and
executive control over the process is not clearly drawn,
assessment results may be incorrectly interpreted (e.g.,
normal scores on memory or language tests interpreted to
mean that functional memory and language are intact) and
inappropriate treatment prescribed (e.g., process-specific
retraining exercises versus functional, contextualized,
metacognitive intervention).
found to be linked to verbal and design fluency, ability to
maintain and shift set, planning, response inhibition, working
recall, organization skills, reasoning, problem solving and
abstract thinking.
The anterior cingulate cortex is involved in emotional
drives, experience and integration. Associated cognitive
functions include inhibition of inappropriate responses,
decision making and motivated behaviors. Lesions in this area
can lead to low drive states such as apathy, abulia or akinetic
mutism and may also result in low drive states for such basic
needs as food or drink and possibility decrease interest in
social or vocational activities and sex.
The orbitofrontal cortex plays a key role in impulse
control, maintenance of set, monitoring ongoing behavior
and socially appropriate behaviors. It also has a role in
representing the value of reward based on sensory stimuli
and evaluating subjective emotional experiences. Lesions can
cause disinhibition, impulsivity, aggressive outbursts, sexual
promiscuity, and antisocial behavior.
Figure 2. Frontal lobe and prefrontal cortex
DORSOLATERAL
PREFRONTAL
CORTEX
ORBITOFRONTAL
CORTEX
ANTERIOR
CINGULATE
CORTEX
The dorsolateral prefrontal cortex (fig. 2) is involved in
‘online’ processing of information such as integrating different
dimensions of cognition and behavior. The areas have been
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Executive Functioning continued
Figure 4. Functional definition of the executive system
Definition and models
The executive system is a theorized cognitive system that
controls and manages other cognitive processes. To date, there
is very little agreement on one method or construct that is
the model of how the executive system functions. However,
executive functioning involves complex cognitive processes.
Elliot (2003) described a definition posited by Funahashi
whereby executive functions involve “flexible coordination
of sub-processes to achieve a specific goal.” Changes in
framework have occurred over time and with gains in
neuroimaging, further adaptations will occur. Typical models of
executive functioning determine the skills to be either part of a
hierarchy or as part of a metacognitive system.
Metacognitive MODELS
The word “metacognitive” generally means “thinking
about one’s own thinking.” So, from that perspective,
metacognitive systems stress “one’s ability to view,
observe, and assess more basic cognitive procedures and
includes self-awareness, self-monitoring, and self-control of
cognition while preforming an activity” (Kennedy & Coelho,
2005). It is a dynamic process that views lower order
processes as automatic (outside of executive functions) and
does not contribute to the higher order skill. Two models,
the Supervisory Attentional System (SAS) and Miller and
Cohen’s model are examples of metacognitive processes.
The SAS is centered on the idea that routine or wellestablished schemas automatically respond to routine
situations while executive functions are used when we
Figure 3. Executive functioning: Hierarchical models
LURIA
(1966)
LOWER
LEVEL
COGNITIVE
PROCESSES
Initiation and drive
(starting behavior)
Anticipation
Planning
Execution
HIGHER
LEVEL
COGNITIVE
PROCESSES
SOHLBERG & MATEER
(2001)
Selfmonitoring
Response inhibition
(stopping behavior)
Task persistence
(maintaining behavior)
Organization
(organizing actions and thoughts)
Generative thinking
(creativity, fluency, cognitive
flexibility)
Awareness
(monitoring and modifying
one's own behavior)
Awareness of strengths and weaknesses
Do I have the ability to complete the task based on
what I know about my strengths?
Ability to set goals, plan and organize behavior
Can I get started toward a goal? Can I revise plans and
solve problems in the event of difficulty or failure?
Assume a non-egocentric perspective
Am I aware of, and concerned about the impact that my
behavior may have on others?
Think abstractly
Can I transfer skills from training to application?
(Ylvisaker, Szekeres and Feeney, 2001)
are faced with novel situations. Miller and Cohen (2001)
presented the theory that the prefrontal cortex directs
cognitive control and that the “control is implemented by
increasing the gain of sensory or motor neurons that are
engaged by task or goal directed elements of the external
environment.” Their theory imparts that the action of the
prefrontal cortex “is to guide the flow or neural activity
along pathways that establish the proper mappings between
inputs, internal states, and outputs needed to perform a
given task.”
Hierarchical Models
Hierarchical models are based on the premise that
executive functions receive input from lower level or more
basic processes, such as attention and language, as well as
higher level metacognitive processes. (Stuss, 1991). Figure
3 (left) provides a summary of predominant hierarchical
systems.
Functional definition of the executive system
With a variety of models to conceptualize EF, how can we
sum up executive functioning in a cohesive understandable
format? One way is to utilize a functional/operational
definition of the executive system shown in Figure 4
(above).
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Executive Functioning continued
Figure 5.
Executive Function development with age
16
Developmental Spurt
Attentional Capacity
15
Developmental Spurt
14
Working Memory
13
Developmental Spurt
Goal Setting Skills
12
11
10
9
7
6
YEARS
5
in
ase
cre
n
i
ng
goi
Gender cross over.
On
Boys have higher
levels of attentional
capacity and working
memory (to 11 and 13
respectively) but this
changes here.
Inattention,
impulsivity and
distractibility
decreases.
8
Increases in
working memory,
attention and
flexibility.
s
skill
ing
n
n
pla
Plan
nin
17
g
achin
lls re
i
k
s
g
18
r it y
matu
Ability to set goals
and plan/priorities
is at adult levels
but nature of
strategies changes.
19
20
it
nning abil
Peak pla
Cross over
in "reward
sensitivity"
Weight now
given to negative
possibilities as well
as positive.
21
22+
y
Minor
improvements
in executive
functions but
strategies
continue to
change (e.g., more
consistent use of
experience.).
More likely to give
weight to "pros"
over the "cons".
From around 15 years old
Working memory, shifting attention
and inhibitory control relatively
stable and close to adult level.
Inhibition of impulses
dominates.
Development
across the life span
Genetics and environment have an
influence on how one develops higherorder cognitive skills. Gender also plays
a role. Despite these influences, some
generalizations can be made across the
life span about executive functioning
development.
Executive functions develop across
the life span with the first signs noted in
infancy. Research has shown inhibitory
control and working memory skills
emerging in children as young as 7-12
months. This is seen through meansend development. The child is able to
hold one piece of information in mind
in order to act on another. The skill is
very fragile and highly susceptible to
distraction.
By the age of one, children begin to
display gains in selective attention with
external distraction not as predominate.
At the age of two, children become
more capable of problem solving with
the acquisition of language. They begin
to use language to regulate behavior.
At two, children are also able to follow
verbal rules, requests and directives.
They are beginning to keep verbal rules
in mind and use them to guide their
behavior. Gains in rule and language use
continue to grow and impact learning.
By three years of age, the child is no
longer impulsively responding to stimuli
in a rigid stereotyped means but rather
acting deliberately and flexibly in light of
a conscious plan.
Between the ages of three and five,
children demonstrate significant gain in
performance on tasks of inhibition and
working memory. They are beginning to
reflect on their own actions. Cognitive
flexibility, goal-directed behavior and
planning gains are noted. They are
developing complex sets of rules to
guide/regulate their behavior. They begin
to ‘think’ about the intention or the act
of doing rather than simply responding
to the environment.
As children mature and change, they
continue to gain in inhibitory control,
and attentional capabilities are noted.
During the primary school years and
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Executive Functioning continued
9
KEY EXECUTIVE FUNCTIONs
1. Awareness —Age-appropriate insight of strengths
and weaknesses.
2. Planning —Spontaneous use of planning behaviors
in novel tasks; anticipate future events; grasp main
idea;
prioritize, reduce/cluster information, re-arrange
material or information.
3. Goal setting —Set intermediate and long-term goals
appropriate to abilities.
4. Self-initiation —Independently initiate new
activities; spontaneous in conversation; begins
activity without procrastination, seek and search for
information, generate ideas, persist, complete all
parts of an activity.
5. Self-monitoring —Independently assess behaviors/
responses and make changes as needed.
6. Self-inhibiting —Behavior is appropriate to
changing situations; control impulses, think before
acting, pace actions; follow or select according to
rules or criteria; manage extraneous distractions,
irrelevant information or interference; delay
responses.
7. Ability to change set —Demonstrate appropriate
variations in behaviors; independently consider
a variety of solutions in problem solving; revise
plans, move freely from one step/activity/situation to
another; transition between tasks easily.
8. Strategic behavior —Create useful strategies for
functional use; able to describe these.
9. Working memory —Hold information in mind for
the purpose of completing a task.
into early adolescence, the main changes are made in the
ability to consider variables and act accordingly. Preschoolers
can verbalize their knowledge of what is the right thing to
do but often are not able to actually follow through on it.
The need for immediate gratification overrides planning and
reasoning capabilities. Further, their ability to successfully
implement strategies to limit impulsive responses are not yet
developed, though emerging.
External supports and modeling provide reinforcement and
help internalize strategies. Gains in planning, goal setting/
directed behaviors problem solving and cognitive flexibility
are continuing and providing the basis for social skills and
academic success during pre-adolescence and adolescence.
The role of executive function development is most clearly
demonstrated and often most acknowledged during the
teenage/adolescent years. This is in part due to high-risk
behaviors that are observed during adolescence, such as
alcohol/drug use and unprotected sex.
By the age of 15, working memory, inhibitory control and
the ability to sustain and appropriately shift attention are close
to adult levels and remain relatively stable with some small
increases noted into adulthood. Though, the teen is functioning
at or near adult levels, their self-monitoring and self-reflective
abilities are not fully mature. Further, when placed in highly
complex situations or a situation in which one is required to
integrate numerous pieces of information to make an informed
decision, the teen will show shortcomings. They tend to base
decisions on the advantage of a given situation versus the
disadvantages.
Decisions and actions are based on the specific moment and
do not consider the long-term consequences, rather making
decisions based on their view of themselves at the moment and
how they will be perceived by outsiders.
Dr. Zelazo (2010) explains the shortcoming as a
“competition between the top-down influence of executive
function and the bottom-up influence of desires, drives,
impulses and habits.”
As the executive system matures, adults are able to use
stored knowledge about themselves and draw on their past
experience in making decisions.
In adulthood, gains and decline in executive skills are
noted. Between the ages of 20-29, executive functioning
skills are at their peak. Decisions regarding marriage, career,
family and long-term goals are stable, reflective and highly
obtainable. Consideration to outside influences are weighed
with internal drives to develop the best outcomes.
As the adult ages, executive functions once again change
but this time showing a decline. Declines in higher order
cognitive skills have been clearly noted in working memory,
self-monitoring, and spatial skills. What has been thought of
as normal changes in aging may be the result of an aging in
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Executive Functioning continued
the prefrontal cortex and demyelination—a deterioration of the
myelin sheath surrounding neurons which results in a slowing
of impulses that travel along the nerve.
The adage of “use it or lose it” may very well be true
in the realm of executive skills. Continued cognitive
involvement/stimulation may promote neuronal myelination
or, at minimum, slow the course of demyelination
contributing to greater quality of life, independence and
overall functional skill. v
References
Stuss, D.T. (1991). Self, awareness, and the frontal lobes: A
neuropsychological perspective. In J. Strauss & G. R. Geothals
(Eds.),
The Self: Interdisciplinary approaches (pp. 255-278). New York:
Springer-Verlag.
Kennedy, M. R. T. & Coelho, C. (2005). Self-regulation after
traumatic brain injury: A framework for intervention of memory
and problem solving. Seminars in Speech and Language, 26, 242255.
Miller, E. K., & Cohen, J. D. (2001). An integrative theory of
prefrontal cortex function. Annual Review of Neuroscience, 24,
167-202.
Norman, D. A., & Shallice, T. (1986). Attention to action: Willed
and automatic control of behavior.
In R. J. Davidson, G. E. Schwartz, & D. Shapiro (Eds.),
Consciousness and self-regulation (Vol. 4, pp. 4-18). New York:
Plenum.
Ylvisaker, M., Szekeres, S., & Feeney, T. (2001). Communication
disorders associated with traumatic brain injury. In R. Chapey (Ed.),
Language intervention strategies in aphasia and related neurogenic
communication disorders, 4th Edition (pp. 745-808). Baltimore:
Lippincott, Williams and Wilkins
Baddeley, A. D. (2003). Working memory: Looking back and
looking forward. Nature Reviews: Neuroscience, 4, 829-839
Purdy, M. (2011) Executive functions: Theory, assessment and
treatment. In M. Kimbarow (Ed.), Cognitive communication
disorders. New York: Plural publishing.
Sohlber Mateer (2001). Cognitive rehabilitation: an integrative
neuropsychological approach. Andover: Taylor and Francis Books
Ltd.
Westfall, M. & Panizzon, D. (2011). Cognitive neuroscience:
Implications for career development strategies and interventions.
Flinders University, Adelaide, Australia. Australian Government,
Department of Education, Employment and Workplace Relations.
Retrieved from http://foi.deewr.gov.au/documents/cognitiveneuroscience-implications-career-development-strategies-andinterventions.
Zelazo, P. D. (2010, May 31). Executive functioning part two:
The development of executive functioning in infancy and early
childhood. Aboutkidshealth.ca. Retrieved July 11, 2012 from
http://www.aboutkidshealth.ca
Zelazo, P. D. (2010, June 1). Executive functioning part three:
The development of executive functioning across the lifespan.
Aboutkidshealth.ca. Retrieved July 11, 2012 from http://www.
aboutkidshealth.ca
Copyright March 2013 – Rainbow Rehabilitation Centers, Inc. All
rights reserved. Printed in the United States of America. No part
of this publication may be reproduced in any manner whatsoever
without written permission from Rainbow Rehabilitation Centers, Inc.
About the author
Angie McCalla, MS, CCC-SLP, CBIS
Speech & Language Pathologist, Clinical Team Leader
Angie has a Master of Science degree in speech & language pathology from Bowling
Green State University in Ohio. She is the lead Speech & Language Pathologist at Rainbow
with experience treating persons with a range of neurological impairments. Angie is a
Certified Brain Injury Specialist (CBIS), a member of the American Speech Language Hearing
Association (ASHA) and the Michigan Speech Language Hearing Association (MSHA)..
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