Symptom Spotlight: Executive Dysfunction
This week’s feature looks at executive dysfunction, a common feature of a number of neuro-developmental conditions including autism, ADD/ADHD, dyspraxia and dyslexia. Executive dysfunction is, as the name suggests, a difficulty in what is known as ‘executive functioning’, which can be broadly defined as the ability to plan, sequence and complete tasks in a timely fashion. It relies largely on three areas of cognitive function:
Working memory; the ability to retain and use information in order to complete a task
Cognitive flexibility; the ability to think about things from different angles, and to see relationships between concepts
Inhibitory control; the ability to ignore distractions and resist impulses.
People who experience executive dysfunction have difficulty in one or more – and usually all – of these areas, which makes it incredibly difficult to prepare for, initiate and complete a huge variety of tasks. For example, my executive dysfunction makes something like cleaning my house a nightmare. I struggle to find a starting point, trying to work out what to do first and then what process to follow (cognitive flexibility) is incredibly difficult and overwhelming, and often just trying to plan how I’m going to tackle it leaves me exhausted. Once I start, I get flustered trying to remember all the things I need to do and in what order (working memory), and thinking about this constantly whilst trying to complete the task often leads to me getting distracted (inhibitory control) and starting the next job before I’ve finished the one before. The sense of overwhelmedness, panic and cognitive fatigue is almost unbearable, and often I end up just hiding under the duvet in a state of ‘analysis paralysis’, with my brain feeling like an old laptop that is overheating.
More broadly, executive dysfunction makes it difficult for a person to:
Pay attention to one thing at once, without getting distracted by everything else. This is particularly true for people with sensory sensitivities, as these can make even the average environment significantly more distracting.
Organise and plan their daily activities, which can lead to distressing consequences especially for those who struggle with changes to routine, for example if they have forgotten the necessary equipment for an activity.
Initiate and stay focused on tasks; picking out the best starting point and organising the steps into a logical sequence.
Regulate emotions; this is particularly difficult for those who experience emotional lability or what I call ‘gale-force emotions’ as part of their neurotype.
Self-monitor and keep track of progress; this can be especially complicated by hyperfocus as it is very easy to lose track of time
This can produce a variety of difficulties, many of which are not immediately recognised as being part of a person’s neurodiversity. For example, many people who struggle with executive dysfunction become easily frustrated – due to difficulty self-regulating, and due to the intense stress produced by trying to tackle a task – but may also struggle to initiate a solution such as asking for help. This can be further complicated by social difficulties which often go hand in hand with the conditions which feature executive dysfunction, as the person may struggle to know how to ask for help.
If they do ask for help this may cause further distress, especially if advised to try a new way of approaching the task. People with executive dysfunction have often developed their strategies over a long period of time and effort, and use methods which specifically reduce the distress associated with their executive dysfunction. Changing the way they do things can actually increase their distress rather than relieving it, particularly in the case of those who have a need for routine.
Following instructions can also be difficult. Even if the instructions are comprehensive and clear, holding them in working memory can be incredibly difficult. This is exacerbated by a difficulty in picking out the most useful information in an instruction, which is common to many people with executive functioning difficulties (EFD). This can lead to focusing on the ‘wrong’ part of an instruction or task, leading to immense frustration for both the instructor and the person with EFD when this is realised. In my experience this is often a major source of conflict, especially as this apparent inability to understand simple instructions often jars with the person’s cognitive capabilities in other areas. In the worst case scenario, this can actually lead to an assumption that the person is wilfully not following the instructions, rather than experiencing genuine difficulty.
With some background reading, you can learn to spot the kinds of situations in which a person with EFD is likely to experience difficulty. Common examples include:
Completing a task in an emotionally or sensorily intense environment. The person’s difficulty with self-regulation, inhibitory control and self-monitoring are likely to make this extremely difficult. Where possible, it is best to remove the person from this environment before asking them to complete a task.
Reflecting on their work or approach. Reflexivity can be incredibly difficult for a person with EFD as it relies on them being able to identify the issue (picking out pertinent information), pause what they are doing, put the information into the broader context (cognitive flexibility), consider the options available, and respond appropriately (self-regulation). To assist with this, it is best to ask the person to reflect when they are not working on a task. Give them as much information as possible to work with rather than asking them to think through it themselves, as this is likely to be overwhelming. A clear, direct and patient approach is best.
Processing information at speed: EFD doesn’t just cover the manner of functioning, but also the speed. On IQ tests, people with EFD will often score poorly on measures of information processing speed, as they struggle to pick up, contextualise and respond to information quickly. It’s important to pace the delivery of information to ensure that the person doesn’t become overwhelmed. It can also help to situate the information in context, and advise of the required response where possible.
I hope that this week’s feature has been useful in describing the lesser-known difficulties of executive dysfunction. Feel free to comment below with your own experiences, or to provide further perspectives!