Types of problems with executive functions

The term executive functions describes a range of abilities. A typical list of these includes initiation, sustained attention, planning, organization, set-shifting, conceptual functioning, awareness, and insight. Let's review the behavior relevant to each of these abilities:

Patients with deficits in initiation have problems getting started with their behavior. Often they cannot come up with a plan of what to do with themselves. They do not talk very often. They do not do very much without prompting from others. Accordingly, they might appear to be apathetic or lacking in drive. This may be true in some cases, but other patients do experience motivation internally. They have a specific problem with putting it into action.

Neurologists commonly use the term "abulia" (ah-BOO-lee-uh) to describe a state in which one is lacking in initiative and speaks very little. On first glance, patients behaving this way might appear to be depressed, but they do not express any sadness or bad feelings about themselves. The problem is a neurologically based inability to initiate action.

We need to persist in paying attention to get through daily activities such as reading, working, or conversing with a friend. All of these actions require a consistent and undisturbed pattern of brain activity. Patients with problems sustaining attention might have a brain disorder that keeps them from generating this kind of consistent flow of activity. More commonly, sustained attention is disrupted by distraction. While performing an activity, the person thinks or sees something that gets them off the track. People who do not have this kind of problem generally can avoid responding to an inappropriate stimulus (for instance, they can read in a public library without looking at people walking past). This ability is called response inhibition. Individuals lacking in this skill are often considered "distractible" or "impulsive."

Being able to plan a behavior or activity before it occurs is one of the major achievements of the human mind. The plan may vary in complexity from something like complete arrangements for a two-week vacation to a plan to go to the water fountain for a drink. In making a plan, we transcend time and think about how we will behave in the future. Starting to develop a plan is similar to the function of initiation, as just described.

After developing the plan, organization is needed to carry it out in an effective and systematic manner. Patients who have problems with organization may look as if they are doing things in a confused or haphazard way. They are essentially unable to execute the plan that was set out for the activity. They have problems in following the required sequence of events. A simple difficulty in sequencing can seriously disturb even the best-made plans. (Have you ever missed an important step in following a recipe or instructions for assembling a bicycle?) People who have problems with organization function best in conditions of minimal complexity, with less room for error.

Some people have problems in quickly moving from one activity to another, changing their behavioral "set." This is known as a problem in set-shifting. They have difficulty responding to changes in their environment. Doctors commonly use the term perseveration to describe this tendency to inappropriately continue a previous behavior. People who perseverate tend to persist with a behavior even when it is no longer needed. They may seem "stuck" on acting a certain way. They may repeat the same question or tell the same story over and over again unless the people around them make an effort to get them shifted to another topic. It's easy to become angry at this kind of person, who appears too persistent, but in truth this behavior is the result of a neurological problem that is interfering with the ability to shift behavioral programs.

The ability to form concepts is basic to our thinking and to our ability to communicate with others. Using concepts allows us to refer to classes of objects or observations rather than specific examples. If we tell a friend that we have a dog named Sparky, using the concept of "dog" tells our friend certain things about our pet.

Some people have specific problems in forming and using concepts. They might have trouble seeing what things have in common, a difficulty that can significantly disrupt learning. They also might have trouble seeing how specific features of an object may relate to more abstract concepts. The term "concrete" is used to describe behavior that focuses on specific attributes at the expense of more general concepts. For example, it would be common to think of a table and chair as both being types of furniture. A person who thinks concretely, however, might describe them as both being made of wood. Individuals with concrete thinking may also have problems interpreting common proverbs or metaphors. For example, they may be unable to figure out that "A stitch in time saves nine" is not just about sewing. Asking about proverbs is one way that doctors test for problems with concrete thinking.

Human beings have a special and unique ability to reflect upon their behavior. In many ways, awareness and insight are linked to many of the other functions we have just discussed. Most complex behaviors begin with the formation of a specific plan and proceed with its execution. Awareness involves the process of determining whether our behavior has correctly met the conditions set out in our plan. Many consider insight to be the end result of this process, the ability to reflect upon the consequences of our behavior.

People with poor awareness or insight may be unable to perceive whether their intentions match their behavior. Often these people can form an intention and state what it is, but they cannot pull it off. They also might behave in a manner that is totally out of line with their intentions and not be aware of it because they have difficulty in receiving feedback on their performance. Some of them can benefit from receiving input from other people, but others are oblivious to advice or criticism.