Executive functions: what they are and why they matter

By: Dr Joseph Mole

January 2, 2024

Executive functions: what they are and why they matter

What are executive functions?

Executive functions are considered to be a set of complex thinking skills, generally involved in addressing new challenges or solving novel problems. For example, one could be said to be drawing upon executive functions when organising a holiday but not when brushing one’s teeth.

Importantly, executive functions are not a single ability. Rather, they are a set of skills that work together in concert. These skills include the ability to inhibit distracting information, generate new ideas and check for errors.

Executive functions play an important role in coordinating all other cognitive processes (e.g. memory, language etc.). It is because of this, that these skills are likened to the ‘CEO’ of your brain. Hence, the term ‘executive’ functions.

How are executive functions supported by the brain?

Executive functions are known to be primarily underpinned by the frontal lobes of the brain. In humans this is the largest brain structure, located at the front of the brain. However, the frontal lobes don’t work in isolation. The frontal lobes are densely interconnected with other parts of the brain and work as part of a larger ‘network’ of brain areas.

Although the frontal lobes have long been known to support executive functions, research over the last few decades has shown that the situation is more complex than this. It is now understood that different parts of the frontal lobes are involved in different aspects of executive functions. For example, people with damage to the left frontal lobe may have difficulty starting new tasks. In contrast, people with damage to the right frontal lobe may find it easier to get started on a task but may have more difficulty sustaining their attention. People with damage to the lower, middle part of the frontal lobes may have no difficulty in either situation but they may find it hard to regulate their emotions and behaviour and may frequently upset other people without understanding why. It is because of this that Clinical Neuropsychologists must have a detailed understanding of executive functions so that they can tailor assessment and treatment to the individual person affected.

How common are executive difficulties?

Executive difficulties are one of the most common consequences of neurological illness. It is estimated that as many as two thirds of people with neurological conditions experience difficulties in this cognitive domain.

Problems with executive functions are also very common in people suffering from a range of other conditions that indirectly affect the brain’s normal functioning, including a range of mental and physical health conditions.

There is also growing awareness of neurodiversity in the general population. We now know that people with diagnoses such as attention deficit hyperactivity disorder, dyslexia and autism spectrum disorder, can have challenges with some aspects of executive functioning.

It is also important to note that executive abilities generally worsen as part of the normal ageing processes, so most people may experience some difficulties with these skills later in life.

Why are executive functions important to assess?

Studies have shown that executive difficulties can have a significant impact on peoples’ quality of life. Executive difficulties have been found to be a significant predictor of increased levels of depression, loss of independence and reduced likelihood of returning to previous employment and social activities.

Because these difficulties are complex and hard for patients and families to make sense of, providing an explanation has both psychological and practical benefits. It not only validates peoples’ experiences; it can empower them to develop compensatory strategies.

Good quality assessment of executive functions is also a key determinant of successful rehabilitation. This is because the effectiveness of any treatment plan rests upon a sound understanding of the difficulties to be targeted. When tailored to the individual, simple strategies can be designed to help them to adapt to their difficulties and achieve their goals, such as living independently, returning to employment or participating in personally meaningful activities.

Executive difficulties can also significantly impact the lives of the friends and families of those affected. Frequently, those around the person affected can find it hard to understand the complex but often subtle changes that they observe. This can make it incredibly challenging to know how to provide appropriate support. Assessment can play a crucial role in helping everyone involved in a person’s life to make sense of the new challenges.

On a practical level, because executive problems are a hidden disability, assessment can play a vital role in helping patients to communicate their needs, access financial support or request that employers make reasonable adjustments.

Finally, assessment of executive difficulties can provide crucial information for medical and legal professionals. For example, professionals may wish to understand whether/to what extent executive difficulties might impact upon a person’s mental capacity to make important decisions about issues related to a legal case, medical treatment or finances.

How Clinical Neuropsychologists assess executive functions.

Due to their complexity, executive functions are remarkably difficult to assess. Clinical Neuropsychologists typically assess executive functions by undertaking a neuropsychological assessment, which may include gathering information through a clinical interview, cognitive tests, behavioural observations and structured questionnaires. Cognitive testing is undertaken one-to-one, with the person affected, but it is good practice to invite person’s friends, family or other relevant people to give their perspective.

To ensure that they select the most appropriate tests/questionnaires, Clinical Neuropsychologists must have an up-to-date understanding of the latest scientific research. If clinicians do not have a good understanding of this, there is a risk that they may fail to detect difficulties that are either subtle or difficult to quantify. Assessment of executive functions is an area of specialty of several members of the London Neurocognitive Clinic, who have published scientific papers and book chapters that can guide other Clinical Neuropsychologists when assessing this area of function.

A Clinical Neuropsychologist will use the information gathered from this assessment and any other sources of information available to create a holistic neuropsychological ‘formulation’. A good formulation should provide a clear description of the nature of the person’s specific problems but also their strengths. It should describe how the difficulties sit within the person’s wider life and the meaning that the difficulties have for them. Crucially, a good formulation should provide a solid basis for intervention.

How Clinical Neuropsychologists can help people to manage executive difficulties.

It is important to reiterate that any intervention must be based on a sound understanding of the nature of the difficulty to be addressed. For this reason, assessment and formulation are essential prerequisites for effective management of executive difficulties.

Once a neuropsychological assessment has been undertaken, a Clinical Neuropsychologist will typically set goals with the client (see our earlier post ‘What really matters when we set goals’). This is to ensure that any intervention is meaningful for the person affected.

As a next step, a Clinical Neuropsychologist may spend time helping the person affected and their friends/family to deepen their understanding of the difficulties. Because executive difficulties are complex and often hard to make sense of, it is important to create a shared understanding about the nature of the challenges.

Once a shared understanding has been developed, there are a range of interventions that have been shown to be effective for helping people to minimise the impact of these difficulties of their daily life. These often involve the use of simple strategies, such as implementing structured routines and/or learning to use structured tools to help people to plan how to approach a new task. For people with executive difficulties, external prompts have been found to be particularly effective. There is growing research into the use of assistive technology in rehabilitation, with advances in technology offering promising new avenues for intervention.

Importantly, managing executive difficulties is most effective when done holistically. This means working with a Clinical Neuropsychologist who has a good understanding of the relationship between the brain and behaviour but is also able to see the person as a whole.

Conclusion

Executive functions are a complex set of thinking skills, primarily supported by the frontal lobes of the brain. Difficulties with these abilities are remarkably common and can have a significant impact on peoples’ lives. There are a number of reason that it is important to assess and understand these challenges, in both medical and legal settings. Clinical Neuropsychologists with specialist expertise in this area are well-placed to offer comprehensive assessment and rehabilitation. This can provide the person affected, their friends and family and medical and legal professionals with advice and guidance on understanding and managing these complex cognitive difficulties.