What Is Executive Dysfunction?

Executive function skills enable us to plan, focus attention, remember instructions, and manage multiple tasks. Up to 90 percent of kids with ADHD struggle with executive dysfunction, which impairs goal-directed behavior. 

By Janice Rodden Medically reviewed by Sharon Saline, Psy.D.

Executive dysfunction is a term used to describe the range of cognitive, behavioral, and emotional difficulties which often occur as a result of another disorder or a traumatic brain injury. Individuals with executive dysfunction struggle with planning, problem-solving, organization, and time management.

Executive Functions

Children and adults with executive functioning problems struggle to organize materials, regulate emotions, set schedules and stick with tasks. They misplace papers, reports, and other school materials. They might have similar problems keeping track of their personal items or keeping their bedroom organized.

For children, behavior modification programs like token systems and daily report cards generally work well, however kids with ADHD get bored with token systems unless they collaborate on creating them. Similarly, daily report cards, while initially helpful, may end up making them feel bad about themselves when they don’t succeed, thus creating a negative reinforcement loop. Cognitive behavioral therapy (CBT) is often helpful because it offers interventions in the moment.

What Is Executive Functioning?

Broadly speaking, executive functioning refers to the cognitive and mental abilities that help people engage in goal-directed action. They direct actions, control behavior, and motivate us to achieve our goals and prepare for future events. People with executive dysfunction struggle to organize and regulate their behavior in ways that will help them accomplish long-term goals.

Attention deficit disorder (ADHD or ADD) and executive functions are tightly linked, but far from synonymous. We all have executive functioning strengths and challenges that affect the attention, learning, work, and relationships. However, for those with ADHD, executive function (EF) challenges are more severe and more numerous than for those without it.

The seven major types of self-regulation associated with executive functioning are as follows:

  1. Self-Awareness: commanding self-directed attention
  2. Self-Restraint: inhibiting yourself
  3. Non-Verbal Working Memory: holding things in your mind to guide behavior
  4. Verbal Working Memory: retaining internal speech
  5. Emotional: using words and images along with self-awareness to alter how you feel about things
  6. Self-Motivation: motivating yourself to do things when no outside consequences exist
  7. Planning and Problem Solving: finding new approaches and solutions

How Do Executive Functions Develop?

The abilities associated with executive functioning don’t all develop at once, but rather in a sequence — one skill building atop the next. All of the executive functions interact with each other, and impact how individuals regulate their behavior to create positive future outcomes.

Executive functions begin developing by age two, and are fully developed by age 30. People with ADHD often are 30 to 40 percent delayed in development, which makes them more likely to act motivated by short-term rather than longer-term goals.

The back of the brain is where you store information that is already learned. The front part of the brain is where you use this information to be socially effective and succeed in life. This prefrontal cortex mediates executive functioning and it contains four major circuits.

  • The “what” circuit controls working memory, helping you execute plans, goals, and specific steps needed to complete a project.
  • The “when” circuit helps you organize the order in which you complete activities, and address timelines.
  • The “why” circuit controls emotions — what you think about, and how you feel.
  • The fourth “how” circuit controls self-awareness of your feelings and experiences.

People with executive functioning challenges and/or ADHD may experience impairments in one or more of these circuits and, therefore, their symptoms may touch memory, planning, emotional regulation, and/or social skills. Read on to learn more about executive functions, and what therapies and interventions can help strengthen them. Consult with a physician if you recognize the symptoms below in your or your child.

Executive Dysfunction Symptoms

People with EF difficulties may experience the following symptoms:

  • time blindness, or an inability to plan for and keep in mind future events
  • difficulty stringing together actions to meet long-term goals
  • trouble organizing materials and setting schedules
  • trouble controlling emotions or impulses
  • difficulty analyzing or processing information

Executive functions allow people to do the following:

  1. Analyze a task
  2. Plan how to address the task
  3. Organize the steps needed to carry out the task
  4. Develop timelines for completing the task
  5. Adjust or shift the steps, if needed, to complete the task
  6. Complete the task in a timely way

When a person has weak executive functions in certain areas, he or she may have trouble analyzing, planning, organizing, scheduling, and completing tasks. People with executive dysfunction and/or ADHD commonly lack the ability to handle frustration, start and finish tasks, recall and follow multi-step directions, stay on track, self- monitor, and balance tasks (like sports and academic demands). Remediating the area of deficit reduces academic or work difficulties.

Executive Function and ADHD

ADHD is a biologically based disorder and a developmental impairment of executive functions the self-management system of the brain. While most people with ADHD will experience many areas of executive function impairment, people can have executive dysfunction without ADHD.

The following six clusters of executive functions tend to be impaired in individuals with ADHD:

  1. Activation: organizing tasks and materials, estimating time, getting started
  2. Focus: finding, sustaining, and shifting attention as needed
  3. Effort: regulating alertness, sustaining motivation and processing speed
  4. Emotion: managing frustration and modulating feelings
  5. Memory: using working memory and accessing recall
  6. Action: monitoring and regulating physical activity

Russell Barkley, Ph.D., who has been at the forefront of exploring the relationship between executive dysfunction and ADHD, says, “It is not that the individual does not know what to do. It is that somehow it does not get done.”

Executive Dysfunction Causes

Executive dysfunctions can be the result of heredity, especially in ADHD but they can also result from damage to the prefrontal cortex, in vitro exposure to substance use, trauma or severe neglect. A study found that people with disorders, diseases, or injuries that damage that area of the brain are more prone to difficulties with executive functioning1.

Evaluating Executive Function Difficulties

An executive function evaluation typically begins by ruling out other conditions with similar symptoms. The most common evaluation is the Behavior Rating Inventory of Executive Function (BRIEF), a written survey that kids/young adults, parents, and teachers complete to assess executive functioning. It comprises 86 questions designed to pinpoint the biggest area of difficulty. Additional evaluations include:

  • Conners 3: a rating scale that evaluates ADHD and EF using parent, self, and teacher reports
  • Barkley Deficits in Executive Functioning Scale (BDEFS) for Adults: assesses EF using self and other reports
  • Comprehensive Executive Function Inventory (CEFI): compares a person to a norm group using parent, teacher, and self-report assessments

Executive functions are typically taxed during the transitions to 6th and 9th grade, when school structures and schedules change dramatically, and academic expectations increase. Parents and teachers often don’t understand why kids can’t work independently on an assignment, and assume they’ll “pick up” the necessary skills. It’s important to start helping kids with executive dysfunctions early, and to acknowledge the associated problems so that kids don’t feel stupid or lazy.

Treatment Options for Executive Dysfunction

Experts recommend a range of strategies to help strengthen the areas of weakness associated with executive dysfunction. The first method uses occupational or speech therapists, psychologists, or reading tutors to learn how to work around problem areas. Cognitive behavioral therapy, used in combination with medication to treat any coexisting conditions like ADHD, is very effective at treating executive functioning deficits including problems with inhibition, emotion regulation, time management, and planning.

Many experts recommend redesigning the environment to help people with executive dysfunctions to stay on task. For example, adults may compensate for working memory deficits by making information external – using cards, signs, symbols, sticky notes, lists, journals, and apps. Patients can likewise make time external by using clocks, timers, computers, counters, and other devices that track time intervals. Use external motivation, like points systems, being accountable to others at work and school, daily school report cards – anything that reinforces accomplishing goals.

High protein breakfast foods help boost focus and mood all day long. Use these recipe ideas to help your child shine from the first bell to the last. 

By Laura Stevens, M.S., Susan McQuillan

Maryanne knows that breakfast is the most important meal of the day, but getting her 8-year-old son, who has attention deficit disorder (ADHD), to eat in the morning is difficult. Getting his clothes on, teeth brushed, and backpack filled leaves Maryanne little time to prepare a serious morning meal, let alone something Steve will eat. When it comes to breakfast, 8-year-old Madeline, diagnosed with ADHD last year, knows what she likes: carbohydrates. Her meal of choice is toast with jelly or waffles topped with fruit or, as her mother puts it, “anything made with white flour.”

While there’s nothing wrong with eating carbohydrates in the morning, an all-carb breakfast, or no breakfast at all, is a recipe for inattention. Carbs won’t steady a child’s blood sugar throughout the morning, help her stay alert, or prevent the energy dips that cause her to lose focus in the classroom. High-protein breakfast foods are ideal.

Research suggests a direct correlation between breakfast and academic success. A 1998 study, published in the Archives of Pediatrics & Adolescent Medicine, showed that children who ate breakfast regularly had higher reading and math scores, lower levels of anxiety, and hyperactivity, better school attendance, improved attention spans, and fewer behavior problems.

For children with ADHD, the menu matters, too. In a 1983 study published in the Journal of Psychiatric Research, researchers at George Washington University tested three breakfast types (high-carbohydrate, high-protein, and no breakfast at all) on 39 children with ADHD and 44 kids without the condition. For the hyperactive children, performance on several tests, including a test for attention, was significantly worse after eating the high-carbohydrate breakfast, as compared with the scores of the children who ate the high-protein breakfast.

Why is this? Research out of Orebro University in Sweden shows that children with ADHD have nearly 50 percent lower levels of an amino acid called tryptophan. Tryptophan is one building block of the neurotransmitters in your brain that carry important information; it is needed for attention, learning, and self-control. It is also generated by eating high-protein foods. In other words, a diet rich in protein jump-starts better learning and behavior.

Seeking Balance at Breakfast

Like most children with ADHD, Madeline has very specific preferences and she will reject any food she’s not fond of. Her mother knows what foods to keep on hand and which to serve first thing in the morning to ensure that breakfast goes smoothly. She tries to balance these foods in ways that give her daughter as many calories and as much high-quality protein as possible, especially on school days.

“When you’re thinking about your child’s eating habits, or any other behavior, you have to recognize his unique temperament and behavioral traits, and work around them,” says Dr. Stanley Greenspan, M.D., author of The Challenging Child. A balanced breakfast — high in protein and carbohydrates from whole grains, fruits, and/or vegetables — ensures a varied supply of nutrients along with enough calories to sustain mental and physical energy until the next meal.

“If you don’t eat properly, you can become distracted, impulsive, and restless,” says Ned Hallowell, M.D., founder of the Hallowell Center for Cognitive and Emotional Health in Andover, Massachusetts, and author of Delivered from Distraction. “Skipping breakfast or self-medicating with food can sabotage the best of ADHD treatment plans. In treating the condition, you must consider a balanced, healthy diet an essential component of a proper regimen.”

Protein Power

“Protein helps keep your child’s blood sugar levels steady and prevents the mental and physical declines that inevitably come from eating an unbalanced breakfast containing too many carbs,” says Hallowell.

Combining protein with complex carbs that are high in fiber and low in sugar will help your child manage ADHD symptoms better during the day. The sugars from the carbohydrates are digested more slowly because eating protein and fat along with fiber results in a more gradual and sustained blood sugar release.

For your morning menu, try scrambled eggs with whole-grain toast; or natural peanut butter on whole-grain bread. Make sure to skip sugary cereals, which can cause spikes in blood sugar and increase hyperactivity in ADHD kids.

Children need more calories and protein per pound of body weight than adults do, to ensure normal growth and development and to maintain good health. The average daily amounts of calories and protein recommended by government health experts for normal-weight children and adolescents are as follows:

  • Ages 1-3: 1300 calories, 16 grams protein
  • Ages 4-6: 1800 calories, 24 grams protein
  • Ages 7-14: 2000 calories, 28 – 45 grams protein

A varied diet that supplies enough calories will generally supply enough protein. Children with ADHD who are strictly vegetarian and those who avoid meat or dairy can get enough protein from a diet rich in whole grains, legumes (dried beans and lentils), and the many meat and dairy substitutes made from soy protein and wheat gluten.

Protein in a Pinch

Here are some quick, easy, and tasty ways to get enough protein into your carb-lover’s diet without turning your kitchen or dining room into a battlefield. The idea behind all of them is to start with her favorite carbohydrates, such as waffles, toast, jam, or fruit. Then add in high-protein foods you know your child likes, such as eggs, meat, peanut butter, yogurt, cheese or other dairy products, or beans. Combine these foods in creative ways:

  • Top waffles with melted cheese or ham and cheese, instead of syrup or fruit.
  • Spread peanut butter on apple slices, a halved banana, or celery sticks.
  • Fill a breakfast burrito with scrambled eggs, black beans, and cheese.
  • Spread a toasted, whole-grain bagel or toast with natural peanut butter or another nut butter, such as almond or hazelnut. Adding a dab of all-fruit jam is just fine.
  • Wrap a slice of turkey bacon around a firm-ripe banana; broil or grill until the bacon is thoroughly cooked.
  • Sauté lean, breakfast sausage patties with pieces of diced apples.
  • Swirl crushed fruit or all-fruit jam into plain yogurt and top with dry, whole-grain cereal or chopped nuts.
  • Fill an omelet with chopped or sliced fresh fruit or spreadable fruit.
  • Serve tuna or chicken salad, sloppy joes, chili, or baked beans over toast.
  • Offer eggs and a smoothie. To save time, make hard-boiled or deviled eggs the night before.
  • Toast a slice of whole-grain bread and add a little whipped butter or margarine and a dab of all-fruit jam; milk.
  • Serve whole-grain cereal with low-fat milk, lean meat from last night’s dinner (pork chop, chicken), and orange sections.
  • Top plain yogurt with fresh fruit or mix in oatmeal.
  • Offer a grilled-cheese sandwich made with whole-grain bread and two-percent cheese.
  • Blend up a homemade instant breakfast shake or make sausage patties (see recipes, left sidebar).
  • Serve a veggie omelet with a bran muffin.
  • Offer mixed nuts, fresh fruit, and a glass of milk — a great breakfast for kids that graze.

What works best for Madeline, her mother says, is to eat a small breakfast at home and to have a second breakfast on the way to school. Madeline takes her medication with her first meal, so by the time she’s heading out the door, it’s beginning to take effect and she’s better able to focus on eating. To fill in the protein gaps, her mom may send along some scrambled eggs with cheese in a tightly wrapped tortilla, a high-protein cereal bar, or a bottled yogurt smoothie.

Maryanne discussed Steve’s breakfast problems with her doctor, and they developed some strategies. He suggested that Maryanne and Steve get up 15 minutes earlier, to give her more time to prepare breakfast, and advised that Steve take his medication with his meal rather than just after waking up, to delay the appetite suppression.

The doctor gave them a list of possibilities get more high-protein foods into her son’s diet. Their list included lean meats and poultry, eggs, unprocessed nuts and seeds, and milk products, as well as complex carbohydrates, such as whole-grain cereals and bread and fresh fruits.

ADHD Friendly Recipes

Instant Breakfast Shake
– 3 ounces low-fat milk
– 3 ounces plain yogurt
– 1 tablespoon ground flax seed
– 3 tablespoons soy or rice protein isolate
– 1/2 cup blueberries, strawberries, or peach slices, fresh or frozen

Process all ingredients in blender on high until smooth. Serve immediately. If your child doesn’t find the shake sweet enough, add a teaspoon of sugar or half a packet of artificial sweetener.

Homemade Sausage Patties
– 2 pounds coarsely ground lean pork, beef, or turkey
– 4 teaspoons sage
– 1/2 teaspoon thyme
– 1/2 teaspoon marjoram
– 1/2 teaspoon basil
– 1 1/2 teaspoons black pepper
– 2/3 cup water

Combine all ingredients in large mixing bowl. Shape into 8 patties. Fry in a non-stick skillet until fully cooked and slightly browned, or package for freezing and use patties as needed.

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