EF deficit is a common sequela across various neurologic, psychologic, and behavioral diagnoses. However, research pertaining to the incidence rates (i.e., the number of new cases identified in a specified time) and prevalence rates (i.e., the number of people who are living with EF deficits in a given time) varies across research studies due to differences in participant characteristics (e.g., age, severity), methodology (e.g., different outcomes measured), and diagnostic classification criteria used. Estimates of EF deficit in some populations, listed alphabetically, are as follows:

Amyotrophic lateral sclerosis (ALS)—22% to 70% (Crockford et al., 2018; Kasper et al., 2015)

Attention-deficit/hyperactivity disorder—50% to 83% of children (Lambek et al., 2011)

Autism spectrum disorder—41% to 78% (Lynch et al., 2017)

Dementia and Alzheimer’s disease—84% of patients with Alzheimer’s disease and 77% of individuals with vascular dementia (D’Onofrio et al., 2018)

Huntington’s disease—71% (Julayanont et al., 2020)

Parkinson’s disease—10% to 65% (Aarsland et al., 2010; Kalbe et al., 2016)

Preterm infants—6% to 18% of adolescents born very prematurely (i.e., with an average gestational age of 28 weeks or birth weight lower than 1,250 g; Luu et al., 2011)

Stroke—19% to 47% (Hayes et al., 2016; Pohjasvaara et al., 2002; Tang et al., 2019)

Traumatic brain injury (TBI)—18% to 38% of children and adolescents with mild-to-severe TBI (Sesma et al., 2008; Williams et al., 2022), 48% of adults with moderate-to-severe TBI in the subacute phase (Tsai et al., 2021), 38% of adults with moderate-to-severe TBI in the chronic phase (Tsai et al., 2021), and 55% of individuals with severe TBI in the chronic phase (Azouvi et al., 2016)

Preschool and School-Age Children

EF deficits can have a significant impact on the well-being and academic progress of preschool and school-age children. Preschoolers with EF deficits may have trouble with home and class routines, including completing steps for grooming and dressing. Children may become easily frustrated or behave impulsively due to difficulties with emotional regulation and inhibition. They may lack the ability to organize their thoughts to communicate what they are struggling with, especially in the case of a comorbid communication disorder (e.g., speech sound disorder, language disorder).

As academic, developmental, and social demands increase, children may begin to display EF deficits that were not apparent when academic demands were less complex. Older children may have difficulty developing social skills, completing school assignments, engaging with peers, staying organized, keeping up to date with homework and testing schedules, navigating the school environment, and following class schedules. EF skills can be affected by environmental factors, including adverse childhood experiences (e.g., trauma and malnutrition), family structure, and availability of educational opportunities. For further information regarding EF development in young children, see McCormack and Atance (2011).

Adolescents and Young Adults

Adolescents with EF deficits may have similar difficulties to preschool and school-age children. EF skills develop over the course of adolescence, with the prolonged development of the prefrontal cortex. Therefore, higher expectations regarding EF skills occur with increasing age during this stage of development. It should not be expected that full EF development is complete until a person is in their 20’s.

For instance, there is a significant increase in the difficulty of schoolwork as a child moves into middle school, and this becomes more challenging in higher education. A child with EF deficits who was able to do well in elementary school may begin to experience difficulty as the demands of schoolwork and complex social interactions increase. Successful transition of young adults into adulthood depends on functional EF skills. Young adults with EF deficits may struggle as decision making and responsibilities of adulthood become increasingly complex as they age (e.g., paying bills, saving money, reading contracts) and as they transition to higher education and/or the workforce.

EF deficits may potentially be associated with youth incarceration. Young males with a history of being involved with the juvenile justice system and those with a history of committing violent crimes may demonstrate reduced EF skills when compared to the general population (Syngelaki et al., 2009; Zou et al., 2013).

Adults

The experiences of adults with EF deficits are impacted by the severity of other diagnoses, the nature of their EF deficits, the cognitive demands of their environment (e.g., home or work), and environmental supports available to them. For example, some adults with EF deficits who have jobs with fewer EF demands may be able to easily complete work tasks but may have trouble managing complex life skills, such as paying bills, managing medications, or engaging appropriately in social situations. Such challenges may place these individuals at risk of losing financial security (e.g., losing consistent employment). A person with even mild EF challenges who works a cognitively complex job may have significant difficulty completing work tasks but may be able to function independently in basic home tasks/activities. Additionally, adults with EF deficits may experience reduced quality of life and increased risk of marital discord, social problems, and physical health disparities (e.g., obesity, overeating, and substance abuse; Diamond, 2013). This may be, at least in part, due to associations between EF deficits and impulsivity and risky behaviors (Reynolds et al., 2019). EF deficits and incarceration in adults may be related (Meijers et al., 2015). Adults with a history of incarceration and EF deficits may also be at greater risk for recidivism (Hancock et al., 2010).

Older Adults

As they age, older adults’ EF skills may decline due to age-related atrophy of the cerebral cortex. Older adults may have difficulty completing tasks such as problem solving through home repairs and managing finances. EF deficits in older adults may contribute to higher risk of falls in older adults—particularly those with balance and gait impairments who may rely on cognitive skills to compensate for physical problems (Kearney et al., 2013; Springer et al., 2006).

EF deficits occur in both children and adults and may present differently depending on the age group they impact, the particular EF skill(s) impacted, and the cause of the deficits (i.e., acquired or developmental). EF deficits in children (e.g., difficulties with task planning or completion due to attention-deficit/hyperactivity disorder) are likely to continue into adulthood. Please see ASHA’s Practice Portal resource on Populations Often Impacted by Executive Function Deficits. Any of the conditions listed on this resource may coexist, which may complicate the identification and treatment of EF deficits.

SLPs play a central role in the screening, assessment, and treatment of persons with EF deficits and are uniquely qualified to identify EF deficits among other related comorbidities. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

SLPs with competency in the identification of EF deficits can look to their state licensure scope of practice and legislation related to diagnosis. Reimbursement entities may limit reimbursement of services to individuals with this diagnosis.

Appropriate roles for SLPs include, but are not limited to, the following:

• Identifying risk factors for EF deficits and understanding a variety of medical diagnoses and their potential impact on EFs.
• Identifying signs and symptoms of EF deficits.
• Being aware of typical development and age-related changes regarding cognition and EF skills.
• Screening and assessment for EF deficits, including the use of both informal and formal tools.
• Providing treatment for EF deficits, documenting progress, adapting and adjusting treatment plans based on patient performance, and determining appropriate discharge criteria.
• Identifying and using appropriate functional outcome measures while determining the impact of EF deficits on the overall quality of life.
• Including patients and caregivers in the development of a treatment plan.
• Providing education and counseling to individuals and caregivers.
• Practicing interprofessional collaboration, including educating and consulting with other professionals. See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).
• Advocating for services for individuals with EF deficits.
• Performing research to advance the clinical knowledge base.

EF deficits can be clinically assessed using formal or informal approaches. Dynamic assessment is critical, as EF deficits are complex and the extent of EF deficits may not be clear at the time of the initial evaluation. Assessment can also be complicated by co-occurring issues or diagnoses. For example, assessment and treatment of EF skills in an adult with intellectual disability and a recent traumatic brain injury may be complex, as dynamic recovery from traumatic brain injury may make understanding baseline EF challenges difficult. Such comorbidities may also make it difficult for an SLP to provide an accurate prognosis. The individual’s care partner should be educated on assessment challenges related to comorbidities. Careful monitoring of individuals’ progress as well as ongoing communication with the patient and their care partner may clarify the extent of any new EF deficits and prognosis during treatment.

Although many assessment materials are based in language, nonverbal assessments are also considered. Nonverbal assessments are especially useful in the case of an accompanying language deficit.

Individuals rarely present with a chief complaint of EF deficits and may use general terms such as “memory loss,” “brain fog,” or “being scattered” to describe cognitive deficits. SLPs may ask specific questions about the individual’s EF during tasks (e.g., difficulties in planning, organization, multitasking attention; Rabinovici et al., 2015) to better understand the patient’s functional EF performance. Patient/caregiver/family/teacher interviews and discussion may help to further describe the nature of these deficits and clarify if, and how, they differ from the individual’s baseline. In many cases, a neuropsychologist may perform a comprehensive evaluation to determine the extent and the likely etiology of cognitive symptoms.

The interconnectivity of EF skills makes it challenging to assess different EF skills separately. It is difficult to isolate specific EFs and assess them in a way that does not involve a different EF skill (e.g., multifactorial problem solving cannot be assessed without considering the influence of attention). Therefore, when assessing the subcomponents of EF (e.g., attention), SLPs should be mindful of how these interconnect with other skills in the EF framework.

Additionally, the cognitive tasks that individuals face may change from day to day, and it is challenging to replicate functional situations in an assessment setting or a therapy room. Assessment in relevant contexts is therefore suggested when possible. Contextually relevant evaluations allow the SLP to dynamically assess the individual’s EF in real-life activities (e.g., classroom, noisy waiting room, workplace). There is also natural variation in any individual’s EF capacity due to factors such as fatigue, stress, sleep, nutrition, and interest in the activity. Ongoing assessment throughout the course of treatment is important for these reasons, although SLPs should also be aware of the likelihood of practice effects for the various measures they use to reassess. 

Screening

Screening tools are used to determine the need for further assessment if EF deficits are suspected. Many factors may impact performance on screening measures, and poor performance may not indicate true impairment. Some screening tools designed to assess foundational cognitive skills (e.g., attention, processing speed, memory) may assist in identifying individuals with EF deficits, whereas other screening tools may directly measure EF skills. They may include written or verbally presented tasks, rating scales to be completed by the patient and/or caregiver, parent and teacher checklists, and informal observations.

Many cognitive screenings are administrated verbally and depend on language skills, but some individuals with EF deficits may also have language deficits. Nonverbal screening tools are considered and used when appropriate.

Comprehensive Assessment

Assessment may also include the administration of formal tests (please see ASHA’s Executive Function Evidence Map for further information). SLPs collaborate with other professionals (e.g., neuropsychologists, occupational therapists, psychologists) when possible. EF skills assessed may include inhibition, flexibility, working memory, and planning, among others (Follmer, 2018). If the individual is also working with a psychologist or neuropsychologist, they may already have been administered a battery of tests. SLPs can gain valuable information about EF skills from the neuropsychological/psychoeducational evaluation and ensure that assessment materials that SLPs use are not duplicates of those already completed. The SLP can also provide valuable insights into how EF deficits identified on standardized batteries might impact a person in everyday activities. Additionally, they can explain how an individual’s functional complaints might not be observed on standardized testing. For example, when testing occurs without time pressures and in a quiet, one-on-one setting, a person may not exhibit breakdowns in selective attention or working memory.

Informal assessment tools, such as observations in real-life situations, patient/client interviews, care partner interviews, checklists, informal rating scales, and questionnaires, can help gather information about the subjective functional impact of EF deficits on a person’s day-to-day activities. Results may differ between informal, report-based assessment and formal, performance-based assessment due to differences in measure sensitivity or construct measured (i.e., behavioral observations vs. accuracy and time performance; Ten Eycke & Dewey, 2016; Toplak et al., 2008; Vriezen & Pigott, 2002). As such, informal assessment tools are often used in conjunction with standardized or formal assessments to gain a more complete understanding of the functional impact of each individual’s EF deficits at home, at school, and in the community.

Environmental assessment may be useful in determining the presence and extent of EF deficits, because the environment can serve as a barrier to or facilitator of the demonstration of EF skills, and standardized tests may have limited ecological validity. For example, in the school setting, an environmental assessment may include observation of a student’s navigation of their daily schedule, interactions with peers, and participation in their classroom. Environmental assessment for adults may be more challenging, as it may require an SLP to accompany an individual to their worksite or home, which may not be possible. In a clinical setting, environmental and/or task modifications may be made when informally assessing EF skills to better replicate an individual’s typical environment (e.g., introducing two tasks simultaneously, adding of interruptions, or presenting auditory and/or visual distractors).

The advent of telemedicine may make these sorts of observations more feasible for SLPs, although environmental assessment may occur more in the context of vocational rehabilitation than in SLP services for adult populations.

School-Based Assessment and Eligibility

Assessment and treatment of EF deficits in children is important, because EFs are foundational for school readiness and success. Children with developed EF skills make larger gains on tests of math, language, and literacy development than peers with EF deficits during their preschool years (Center on the Developing Child at Harvard University, 2011). There is an association between EF skills and academic achievement, although SLPs should remain aware that the causality of this relationship is yet to be determined (Jacob & Parkinson, 2015).

School-based assessment follows the same tenets of comprehensive assessment. However, the wide array of available tools for assessing EF in adolescence may make selection of the appropriate measurement tool(s) complicated for clinicians. See Nyongesa et al. (2019) for further discussion.

Eligibility for school-based services in public schools falls under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA, 2004). IDEA (2004) requires that a student have the presence of a disability falling under seven educational categories that adversely affect academic achievement and functional performance, requiring specialized instruction. The student is determined to be eligible based on educational, functional, and/or social impact. Definitions for eligibility vary between different states and different districts (please see ASHA’s resource on eligibility and dismissal in schools for further information). IDEA (2004) also requires that an evaluation be comprehensive and assess all areas of suspected disability. Please see ASHA’s Practice Portal page on Documentation in Schools for further information.

Students may be determined to be eligible for an individualized education program (IEP) and/or a 504 plan. An IEP is a legal document used to ensure that a student eligible for special education has measurable and achievable goals and objectives. When attending a public school, a student with EF deficits may qualify for SLP services as part of an IEP.

504 plans outline accommodations a student may need to access the general education curriculum. 504 plans require a physical or mental impairment limiting one or more life activities. Some examples of accommodations for EF difficulties may include preferential seating close to the front of the class, frequent breaks, or written transcripts of lectures.

For more information on IEPs and 504 plans, see Individualized Education Programs (IEPs), Individualized Family Service Plans (IFSPs), and Section 504 Plans.

See the Assessment section of the Executive Function Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

There are many approaches for treating EF deficits, some of which are more appropriate for children whereas others are better suited for adults. As always, the most evidence-based treatments available, focusing on the specific areas of difficulty an individual experiences, and preferences should be used. Treatment approaches include, but are not limited to, the following:

• Dual-task training
• Environmental modifications
• Explicit verbal reasoning training
• External aids (used along with compensatory strategies)
  • High-tech aids (e.g., smartphones, computers, smart pens, recording devices)
  • Low-tech aids (e.g., written notes, pictorial checklists/schedules, reminders, calendars, alarms)
• Metacognitive interventions: group of interventions that incorporate elements of self-awareness training, feedback, self-prediction, and self-evaluation in functional activities
  • Cognitive orientation to occupational performance intervention (Missiuna et al., 2001)
  • Goal management training
  • Goal-oriented attentional self-regulation (GOALS; Novakovic-Agopian et al., 2011)
  • Goal–plan–do–review (GPDR; Ylvisaker et al., 1998)
  • Metacognitive strategy instruction
  • Metacognitive contextual approach
  • Short-Term Executive Plus (STEP; Cantor et al., 2014)
  • Strategic Memory and Reasoning Training (SMART; Chapman & Gamino, 2008)
  • Time pressure management (TPM; Winkens et al., 2009)
  • Video and verbal feedback
• Verbal self-instruction

Client/patient input is important when determining treatment needs. Additionally, parents/care partners/teachers may provide a clinician with a deeper understanding of the issues that individuals with EF deficits experience in day-to-day life, particularly given that people with EF deficits may inherently lack awareness of their deficits. It is essential to work with family or other related persons (e.g., parents, care partners, teachers) to promote the generalization of EF strategies or interventions into real-life activities.

Treatment may be provided in a variety of settings, including one-on-one and group treatment. Both school and work atmospheres often include some element of teamwork. Therefore, group therapy may help some students/patients address functional goals. “Life skills” outings in the community give a practical way for individuals to use strategies and improve skills. See the Service Delivery section of the Executive Function Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Telepractice is also an option for treatment. However, as with any therapy, clinicians may need to make modifications to how they deliver services (e.g., access to resources). Please see ASHA’s Practice Portal page on Telepractice for further information.

Functional goals for both pediatric and adult populations are tailored to the individual’s unique needs. However, some potential examples of items for goal consideration may include

• maintaining a schedule to arrive on time to therapy/work/class,
• using a clock or timer to increase the awareness of the passage of time and appropriate time allotment for task completion (this is particularly useful when working with children),
• taking notes during therapy and following through on expectations,
• using computer programs related to job function or school-based activities,
• evaluating an attempt to solve a problem and recommending changes to try next time to improve success,
• prioritizing and completing multiple tasks given a time frame, or
• completing tasks with the assistance of a trained care partner or peer.

The SMART goal (Specific, Measurable, Actionable, Reasonable, and Time bound) framework can assist in appropriate EF treatment goal setting.

SLPs working on an individualized education program (IEP) team in the schools may prioritize collaborative goal writing when addressing EF deficits. Please see ASHA’s resource, How To: Writing Collaborative Goals for IEPs.

School-Based Intervention

Many of the treatment techniques described below are applicable to multiple age groups.

Developing Skills

• developing EF skills through direct treatment/instruction
• training/supporting teachers in the use of classroom management strategies
• training teachers to assist in the development of social–emotional skills by modeling and coaching pro-social behavior, social problem-solving skills, comprehension and expression of emotions, impulse control, and organizational skills
• learning chunking strategies to break up and better organize tasks
• advocating for themselves by
  • requesting repetition of complex verbal material and/or
  • requesting additional time to complete tasks
• learning to review work for errors before submission

Using Classroom Strategies

• recording classroom lectures and discussions for further review
• using visual schedules, using clocks, estimating elapsed time, and estimating expected time to complete a task
• completing prewriting tasks (e.g., flowcharts, web charts, storyboarding)
• listening for key words in class/lectures
• assistance in developing organizational tools such as
  • using a calendar app to track assignments,
  • setting an alarm as a reminder for tasks, or
  • organizing school binders to hold materials in an easy-to-navigate fashion

Environmental Accommodations and Modifications

• a dedicated note-taker
• removing clutter and visual distractions
• additional time to complete tests or homework
• reduced amount of work (i.e., grading quality, not quantity)
• the option to work or test in a distraction-free environment, separate from peers
• additional assistance with complex assignments (e.g., providing steps for breaking down assignments into manageable components)

For additional strategies and information regarding EF interventions for children aged 4–12 years, see Diamond and Lee (2011).

Treatment may vary across settings. For instance, an SLP in private practice or in a clinical setting may not have the opportunity to observe the student in a classroom setting. The ability to interact with and observe a student in functional settings can be key to therapy provision. SLPs treating in either private practice or clinical settings may consider contacting (with appropriate consent) the client’s school-based SLP or teacher, to determine if strategies taught in the clinic are effective in the classroom. If a child is being seen by both a school and an outpatient SLP, both parties may collaborate to ensure that they are targeting similar and appropriate goals.

Adults

SLPs may consider the use of restorative therapy, compensatory strategies, or a combination of the two when treating adults with EF deficits. Any course of treatment is tailored to the specific individual being treated and the specific areas of deficits observed. A combination of approaches allows SLPs to directly treat EF dysfunction and provide strategies and approaches that will be useful to the individual in each environment (i.e., home, workplace, or the community).

Therapy incorporating internal strategies for improving EF skills may include

• visualization exercises;
• self-talk exercises;
• determining the steps/sequence as part of breaking down a task;
• prioritizing tasks for completion within a specific time frame;
• estimating elapsed time and expected time to complete a task;
• self-evaluating performance;
• identifying and monitoring for the driving factors behind breakdowns in EF skills, with the generation of potential solutions to remediate them;
• proactively selecting strategies for improved performance and judging the success of selected strategies;
• identifying barriers to safety awareness secondary to EF deficit (e.g., fall prevention) and potential strategies for increased safety; and
• identifying and reducing the impact of internal (e.g., hunger, fatigue, anxiety) and external (e.g., auditory, visual, temperature) distractions when completing complex tasks.

SLPs may work with adults on developing external strategies to assist them in functional tasks, including

• prewriting when engaged in a writing activity (e.g., work e-mails);
• setting alarms to remind the patient to take their medication or complete tasks;
• developing routines and structure;
• using a planner, a calendar, or other organizational tools; and
• engaging care partners, when appropriate, to provide external structure and cueing and promote generalization of EF strategies into everyday routines.

Treatment goals, activities, and compensatory strategies differ across settings. In an outpatient setting, treatment may involve a lot of patient/caregiver report on the effectiveness of different strategies, as well as what new situations may be challenging for the patient. Therapists who visit patients in their homes/workplace can observe and assess the patient in their typical setting and may be able to develop treatment plans and goals that are specific to the individual’s environment.

Please see Brown et al. (2022) and Jeffay et al. (2023) for further information.

Audiology Treatment

Children and adults who have both EF deficits and hearing loss may benefit from additional considerations regarding hearing loss treatment and management. Patients may differ in age of onset of hearing loss, age of identification of hearing loss and intervention, degree of hearing loss, mode(s) of communication (i.e., oral/aural, manual, total communication), and severity of EF deficits.

People with hearing loss may benefit from the use of an assistive listening device (e.g., FM system, remote microphone). People who use hearing aids, bone-conduction devices, or cochlear implants may also use assistive listening devices to increase the effectiveness of their technology. The use of an assistive listening device improves the ratio between the signal of importance (often a person who is speaking) and noise. These technologies support auditory access in the classroom, in the workplace, and in other challenging listening environments. These systems may be useful for people with EF deficits (e.g., attentional difficulties) even when they have normal hearing thresholds. For more information on the evaluation and treatment considerations of children who are deaf or hard of hearing in schools, refer to Students Who are Deaf or Hard of Hearing in the School Setting and ASHA’s Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children. Assistive listening devices can be used in isolation, in addition to another hearing technology, and/or in conjunction with another accommodation.

Cognitive decline, increased likelihood of dementia, and resulting deficits in EF skills are related to age-related hearing loss. However, it is unclear if hearing loss causes cognitive decline (Slade et al., 2020). Audiologists may help identify patients who are exhibiting signs of mild cognitive impairment or EF deficits and make appropriate referrals to a physician for assessment. Some early signs an audiologist may notice are reduced electrophysiological responses, poor auditory processing, memory impairment, receptive/expressive language difficulties, and confusion (Lister et al., 2019). Some adults with hearing loss may have improved functional cognition with hearing aid use (Sanders et al., 2021). Hearing loss management and treatment is considered one of the greatest modifiable risk factors for age-related cognitive decline (Livingston et al., 2020). Audiologists may counsel patients on the consequences of untreated hearing loss when hearing loss is identified. See Untreated Hearing Loss in Adults.

Augmentative and Alternative Communication (AAC) Users

EF skills may impact decisions about the format (e.g., digital vs. analog) and complexity of a chosen AAC system. Generally, less complex systems require less advanced EF skills. More complex (e.g., digital) devices that include menu navigation may require more advanced EF skills. Regardless of the complexity of the AAC system, modifications to the AAC device (i.e., symbol type and color, organization, array size, background color, and layout) can be made to decrease EF demands on users (Thistle & Wilkinson, 2012).

Special considerations may need to be made for individuals with acquired brain injury (ABI) who use an AAC device, especially those who had reading challenges before injury and those with severe language and/or cognitive deficits. Individuals with ABI may also need separate devices for different stages of recovery (e.g., a low-tech “yes/no” selection in the acute stage of recovery and use of a dynamic display as the patient’s recovery stabilizes into the chronic stage of injury; Wallace, 2010). Please see ASHA’s Practice Portal page on Augmentative and Alternative Communication and ASHA’s Augmentative and Alternative Communication (AAC) Evidence Map for further information.

Other Effects on Treatment

There may be factors that impact the EF abilities of an individual that fall outside of the SLP’s scope of practice, such as

• nutrition,
• fatigue,
• pharmacological status,
• physical health status (e.g., pain), and
• psychological status.

Although SLPs do not directly target these factors, they may consider working with an individual on metacognitive skills to help them recognize the effects of these factors on overall EF. Clinicians may consider providing tracking sheets to assist the patient in monitoring such factors. Clinicians consult with and/or refer individuals to other providers, as appropriate.

Patient-Centered Care

Viewpoints on cognitive differences such as EF deficits vary among cultures. SLPs collaborate with patients, students, and their families to treat EF deficits in a culturally sensitive manner. Cultural considerations are a key component of assessment and ongoing treatment. Cultural background may influence performance on EF tasks (Kelkar et al., 2013; Lan et al., 2011).

Perceptions of appropriate EF behaviors vary across cultures (e.g., judgments about which behaviors are considered impulsive, what is an appropriate solution to a problem, how to best organize and prioritize information). These expectations vary not only between different cultures but also within a culture across settings, languages, and communicative exchanges (e.g., at school vs. at home, when speaking with peers vs. adults). Clinicians use collaborative goal setting—considering the needs of the individual across contexts and languages spoken—when working with individuals and their care partners.

Lack of familiarity with formal assessment methods may decrease an individual’s participation or performance in assessment. The clinician considers EF in the context of each person’s experience and background, rather than judging everyone according to the standards of the clinician’s cultural background. Gathering information using a variety of sources and techniques can help provide a more complete picture of the functional impact of EF deficits.

During assessment, documentation should include a description of any modifications and/or accommodations made to the testing process to reconcile cultural and linguistic variations, hearing and/or visual deficits, or other factors that may impact screening or comprehensive assessment. Any modifications and/or accommodations should also be considered when reporting assessment results. It is not appropriate to report standardized scores if the individual is not represented in the norming sample or if modifications are made that are not included in the standardized procedures.

Cultural stigmas related to disability may prevent individuals from advocating for themselves, requesting supports or accommodations, or using external aids. Different cultures may prioritize the value of independence to differing degrees, which can impact treatment goals. A desire for some reliance on others may be culturally appropriate, and patient and care partner preferences should be considered within the goal-setting process.

People who are neurodivergent may have differences in EF skills (Shogren et al., 2021), and variability across different EFs is common. Clinicians are mindful of neurodiversity and work with the individual and their care partners to understand their priorities and to choose functional goals consistent with their values.

Please see ASHA’s Practice Portal page on Cultural Responsiveness for more information.

Counseling and Education

Counseling is an important part of treatment for EF deficits for both the affected individual and the family/caregivers. Both individuals and families may not be aware of the extent of EF deficits. This may be particularly true of a patient with an acquired diagnosis (e.g., ABI, dementia) that has changed the person’s EF abilities from prior to this event/diagnosis. In such cases, an individual may not be able to return to their typical home, school, and/or work environment. Family members and caregivers may be counseled on such items as

• changing expectations or activities due to EF deficits,
• providing supervision or monitoring for unsafe tasks (e.g., cooking, driving) and new responsibilities for the caregiver (e.g., assisting the individual with maintaining and following a schedule),
• strategies to support the individual with EF deficits by modifying the environment, and
• recognizing the importance of practicing strategies in everyday life to increase the generalization of therapy activities.

Conversely, clients and/or family members may underestimate a client’s abilities, including EFs. In this case, providing encouragement to gradually engage in increasingly complex activities, while using the strategies taught, can help increase confidence and participation in activities that clients value.

Treatment includes patient and family education about current deficits and their potential impact on the client’s safety, ability to complete school/job functions, and quality of life. Education for the patient and their care partner may also include providing information about support groups. Education for the client may focus on metacognition, when appropriate, which may help the patient gain a better understanding of their strengths and limitations.

Please see ASHA’s Practice Portal page on Counseling For Professional Service Delivery for further information. Mental health issues (e.g., anxiety, depression) can impact performance on EF tasks. SLPs refer individuals to a mental health practitioner (e.g., psychologist) when appropriate.

Collaboration and Teaming

EF deficits may be related to or co-occur with disorders or diagnoses treated by other providers. Neuropsychologists are key members of teams that collaborate on assessment and treatment of EF deficits. Neuropsychologists and school psychologists may provide extensive assessment of cognition, psychological status, and other factors. Neuropsychological evaluation encompasses many cognitive, behavioral, and emotional facets of EF and may assist in making determinations regarding cognitive capacity; selection of recommended treatments; and readiness for return to driving, school, and/or work. They also may make recommendations for appropriate psychological supports for work and school and detail biopsychosocial factors that may negatively impact cognition if left untreated. Communicating with a patient’s neuropsychologist and any other health providers may provide further insight into that patient’s deficits. In addition to the individual’s family and/or care partner, SLPs may also collaborate with

• the individual’s primary care provider,
• a physical medicine and rehabilitation physician,
• a neurologist,
• physical and occupational therapists,
• vocational rehabilitation specialists/job coaches,
• psychologists/psychiatrists/counselors/social workers, and/or
• school-based teams.

Multidisciplinary evaluation and communication among the team members is particularly important as deficits in one area may impact those in another. For instance, if physical or occupational therapists are working with a student on motoric deficits, the attention that students must allocate to compensating for those deficits may impact their ability to complete higher level cognitive tasks. SLPs review other team members’ documentation and discuss an individual’s progress when appropriate. Please see ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).

ASHA Resources

• Assessment of Executive Functions in School-Aged Children: Challenges and Solutions for the SLP
• Coding and Payment of Cognitive Evaluation and Treatment Services
• Counseling For Professional Service Delivery 
• Dynamic Assessment
• Eligibility and Dismissal in Schools
• Executive Function Evidence Map
• How To: Writing Collaborative Goals for IEPs
• Individualized Education Programs (IEPs), Individualized Family Service Plans (IFSPs), and Section 504 plans
• Integrating Mild Cognitive Impairment Screening Tools in Audiologic Care: A Review
• Interprofessional Education / Interprofessional Practice (IPE/IPP)
• Populations Often Impacted by Executive Function Deficits
• Students Who are Deaf or Hard of Hearing in the School Setting  
• Tackling the Toll of Hearing Loss on Executive Function
• Untreated Hearing Loss in Adults 

Other Resources

• Activities Guide: Enhancing and Practicing Executive Function Skills with Children from Infancy to Adolescence
• Center on the Developing Child
• Fast Facts: Preventing Adverse Childhood Experiences
• Goal Attainment Scale
• Organizing Executive Function, Part One: Identifying and Assessing for SLPs
• RCSLT: New Long COVID Guidance and Patient Handbook
• Self-Regulation/Executive Function Issues [PDF]
• Training the Brain: Executive Function for Children with Hearing Loss

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Acknowledgements

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Executive Function Deficits page:

• Sneha Bharadwaj, PhD, CCC-SLP
• Angela Ciccia, PhD, CCC-SLP
• Leah Kapa, PhD
• Jennifer Lundine, PhD, CCC-CLP
• George McCloskey, PhD
• Michael McLeod, MA, CCC-SLP
• Kelly Ann Peña, MA, CCC-SLP, CBIST
• Katharine Seagly, PhD
• Bridgid Waldron-Perrine, PhD
• Sarah Ward, MS, CCC-SLP
• Laura Wilson, PhD, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Executive Function Deficits (Practice Portal). Retrieved month, day, year, from https://www.asha.org/practice-portal/clinical-topics/executive-function-deficits/.