Recognizing and Supporting Executive Functioning Deficits in Teens
“The usual parenting techniques and behavior management that work for regular children, including rewards or consequences, have not had much success with children suffering from EF disorders.”
Children with executive functioning (EF) deficiencies are often judged and misunderstood, characterized as lazy, stubborn, unmotivated and oppositional. They are likely accustomed to being “blamed” in one form or another for “underperforming.” Keeping in mind that EF deficiencies are independent of IQ, the child may be highly intelligent and still severely impacted, prompting his environment--including parents and teachers--to assume that his challenges are volitional and even disrespectful and defiant. In fact, parents and teachers may have been employing traditional strategies of positive and negative consequences for years, to no avail.
If your child struggles to organize, plan, or get things done in a timely manner and, instead, resorts to avoidance, procrastination and delay no matter the consequences, it’s possible their executive functioning may be at play.
The term executive functioning (EF) refers to a host of complex cognitive functions that allow us to prepare for the future, exert meaningful self-control and successfully complete goal-directed activities. The significance of EFs cannot be overstated. There is evidence suggesting that EFs may be a more reliable predictor of achievement, employment, health, wealth and general quality of life than IQ or socioeconomic status.
It is now firmly established that EF dysfunction plays a meaningful role in a host of mental health conditions, including attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), fetal alcohol spectrum disorder (FASD), depression, schizophrenia, bipolar disorder and obsessive-compulsive disorder (OCD). And yet, the Diagnostic and Statistical Manual for Mental Disorders (DSM) does not include an independent diagnostic designation for executive function deficiency. As a result, children and adolescents suffering from EF deficits, who do not fit neatly within any recognized DSM diagnostic criteria, are often mislabeled and can spend years feeling judged or overlooked, without getting the support they need to address these challenges.
Despite emerging insights into neural and genetic basis of EF, it seems clear that there’s currently no medication that directly improves executive function. Rather, it appears that when the “primary” DSM disorder is medicated, EF deficits may also improve. Most notably, for children and teens diagnosed with ADHD, there is evidence that both stimulant (e.g. Adderall, Ritalin) and non-stimulant medication for ADHD (Strattera) significantly improve EFs. Studies of ASD consistently reflect a strong correlation with diminished EF capacities, although it is unclear whether medication used to treat ASD symptoms also improve EF performance. The effects of bipolar medication on EF are unknown at this time and the effects of SSRI’s on EF--used to treat mood disorders and OCD--appear limited. Relying on medication alone in the treatment of EF deficiencies is plainly unrealistic.
A great deal of research is underway exploring behavioral interventions for EF. It appears that EFs can be improved at any age to some degree, although the transfer of skills from one EF measure to another has not been demonstrated and the duration of benefits is limited to the duration EF skills are practiced. There is some evidence that physical exercise that also requires cognitive skills (like team sports) may help improve EFs. In short, there appears to be no “cure” for EF deficiency. Nevertheless, the effects of EFs can be ameliorated with understanding and support that scaffolds a client’s cognitive challenges.
Under these circumstances, therapeutic attunement is critical in establishing a foundation for success. A treatment plan must follow a detailed understanding of the specific EF challenging affecting the individual client, as well as the client’s defenses and coping strategies. It is critical to support the client as they become more aware of their challenges, understand the medical realities at the core of their challenges, and convert blame and shame to acceptance and action. The therapist can then work with the family to develop coping strategies that will positively support the client’s needs and goals. The therapist can be instrumental in aligning support around the client’s needs. Success for clients struggling with EF deficiencies cannot be attained in isolation and it is imperative that the therapist communicate effectively with the client’s parents and school, and refer the client for a formal neuropsychiatric assessment and a medical consultation.
In addition to working with a therapist, the client would likely benefit from working with a learning disabilities tutor, specializing in EF. Moreover, the therapist might recommend that parents obtain appropriate parenting psycho-education to recognize and support their unique parenting challenges. Further recommendations and accommodations (which the school is legally required to implement) will be included in any thorough neuropsychological evaluation. Finally, the therapist has an obligation to make the client aware of their medical options and help process any fears or resistance as well as any overblown hopes that may be associated with seeking medical intervention.