Populations Often Impacted by Executive Function Deficits
Numerous conditions may include executive function (EF) deficits. This list is not exhaustive. Any of the conditions below may coexist, which may complicate the diagnosis and treatment of EF deficits.
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.
EF deficits may exist in the populations listed below.
Acquired Brain Injury (ABI)
ABI is an umbrella term that includes diagnoses such as traumatic brain injury (TBI), stroke, brain tumors, anoxic brain injury, and any other acute event that affects the brain’s functioning. Individuals with ABI may have difficulties with EF, including working memory; attention; impulsivity; and problems with cognitive flexibility, decision making, and organized recall of information.
ABI, particularly stroke, may impact language skills. The presence of a linguistic deficit may make the assessment and treatment of EF deficits more complex. Similarly, the presence of EF deficits can complicate the treatment and assessment of language deficits.
Natural neurologic development is interrupted when a child has an ABI. The frontal lobe, an area that is largely responsible for EF skills, is not fully developed in children and can often be damaged in TBI. As such, EF deficits may initially be missed. This can have a significant impact on the later development of EF in children with TBI. Children with TBI may need regular monitoring of their EF skills due to high potential for disrupted development in this area (Keenan et al., 2021).
Please see ASHA’s Practice Portal pages on Aphasia, Traumatic Brain Injury in Adults, Right Hemisphere Disorder, and Pediatric Traumatic Brain Injury for further information.
Attention-Deficit/Hyperactivity Disorder (ADHD)
ADHD is characterized by difficulty with attention and inhibition, which are foundational EF abilities; thus, ADHD typically involves various challenges with EF (Mueller & Tomblin, 2012). Challenges seen in academic settings for those with ADHD are often caused by EF deficits (Biederman et al., 2004). Clinicians may consider screening children with an ADHD diagnosis for specific EF deficits to best know what areas to address to maximize functioning.
It is important to obtain medication history for individuals with ADHD as these individuals are often prescribed medication that can impact performance on EF tasks (e.g., neurostimulants; Miklós et al., 2019). Some individuals may prefer to manage EF symptoms exclusively with environmental modifications and strategies or may use these approaches in addition to medication. Speech-language pathologists (SLPs) may communicate observations regarding EF performance to physicians, when indicated, to assist in the development of the client’s overall plan of care.
Autism Spectrum Disorder (ASD)
EF deficits and/or differences may occur along with ASD. Early intervention for EF differences may be key in maximizing function (Demetriou et al., 2018). It is important to recognize that the environment and environmental attitudes toward disability and neurodiversity impact individuals’ success in tasks that require EF skills. Environments may therefore need to be adapted for people with EF differences related to ASD.
COVID-19
EF deficits may occur alongside COVID-19 (Ariza et al., 2023; Crivelli et al., 2022). These deficits may be related to secondary diagnoses (e.g., acute respiratory distress syndrome, encephalopathy). SLPs may need to monitor and screen COVID-19 patients who have experienced acute respiratory distress syndrome or other severe complications (e.g., stroke) regarding EF.
Individuals Who Are Deaf and Hard of Hearing (DHH)
Individuals who are DHH may have EF deficits due to a delay in language development that may co-occur with hearing loss (Bigler et al., 2019; Goodwin et al., 2022; Hall et al., 2018). Delayed language development may happen because of delays in language access, whether language is spoken, signed, or both.
EF treatments may vary based upon preferred language modality and the client’s current skills in expressive and receptive language. Treatment for EF deficits in people who are DHH also differs depending on the age of the individual being treated. Ensuring early access to language for pediatric patients, whether spoken, manual/American Sign Language, or a combination, helps to stimulate and build neural pathways in the brain. In adults with hearing loss who use spoken language for communication, the clinician’s goal is to stimulate language centers to ensure there is no limit to language access or lack of input as the person ages. Treatment options may include, but are not limited to, hearing aids, osseointegrated devices, or cochlear implants. Please see the Cognition/Dementia section of ASHA’s Hearing Loss (Adults) Evidence Map and ASHA’s Practice Portal page on Language and Communication of Deaf and Hard of Hearing Children for additional details.
Dementia
Difficulty with EF skills is a core feature of some types of dementia (e.g., frontotemporal dementia) and is typically present in all forms of dementia once the disease has reached its advanced stages (Voss & Bullock, 2004). Dementia can have a profound impact on EF skills, particularly in its later stages, impacting independence and overall quality of life. EF decline is also associated with falls and gait speed decline in older adults (Kearney et al., 2013). As such, dementia and other progressive diseases require close monitoring by providers and family members. Please see ASHA’s Practice Portal page on Dementia for further information.
Diabetes Mellitus (DM)
Hyperglycemia and hypoglycemia can affect EF skills in people with type 1 and type 2 DM. Treatment of DM may include monitoring medication, exercise, and blood sugar. Proper maintenance and scheduling of these activities depends on intact EF. If there is poor adherence to personal medication regimens, people with DM may exhibit reduced EF skills; this, in turn, may result in a cycle of reduced personal management of DM as additional EF impairment is caused by unstable blood sugar (Zhao et al., 2020). SLPs do not directly treat DM; however, they may be involved in treatment and monitoring of resulting EF deficits (e.g., assisting a patient in following routines, or checklists for medication management). Additionally, SLPs may work alongside patients with DM and EF deficits resulting from another etiology (e.g., stroke) to build the EF skills necessary for the management of medication and other care regimes.
Environmental Factors
Factors that may impact the development of EF skills include parental responsiveness and sensitivity, environmental stimulation, biological mediators (e.g., stress), neural mediators (i.e., differences in brain structure and function, particularly in the development of the prefrontal, frontal, and temporal cortices; Johnson et al., 2016), poor nutrition or malnutrition (Haft & Hoeft, 2017), exposure to neurotoxins (e.g., lead-based paint; Arnold & Liu, 2020), and trauma (DePrince et al., 2009; Malarbi et al., 2017; Op den Kelder et al., 2018).
Fetal alcohol spectrum disorder is associated with a higher likelihood of ADHD compared to the general pediatric population as well as weaknesses in EFs that include planning, fluency, set-shifting, and working memory (Kingdon et al., 2016). Children with fetal alcohol spectrum disorder should be monitored for EF deficits (Mattson et al., 2011). Similarly, children with prenatal drug exposure should also be considered for monitoring for EF difficulties secondary to possible atypical neurodevelopment (Morie et al., 2019).
Please see ASHA’s resource on social determinants of health for further information.
Preterm and Low-Birth-Weight Children
Preterm children are at risk for neurocognitive deficits including EF challenges, which may persist into school age (Martínez-Nadal & Bosch, 2020; van Houdt et al., 2019). SLPs may closely monitor EFs for high-risk preterm-birth or low-birth-weight individuals (i.e., those born at less than 28 weeks’ gestation or those with birth weight lower than 1000 g; Burnett et al., 2013).
Psychological Disorders
EF deficits can co-occur with or be part of the symptom presentation for psychological disorders. Psychological disorders, such as depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, and bipolar disorder, may contribute to EF deficits (Dickinson et al., 2017; Polak et al., 2012; Rock et al., 2014; Walshaw et al., 2010). Other concerns such as alcohol and/or drug abuse (Morie et al., 2014) and sleep disorders (Bruni et al., 2020; Xanthopoulos et al., 2015) may also contribute to or cause EF deficits.
If an SLP is treating for EF deficits due to another diagnosis (e.g., TBI) and a comorbid psychological disorder is present, the SLP consults with the patient’s mental health professional treating that diagnosis.
SLPs may provide consultation where appropriate to other disciplines (e.g., special education teacher, school psychologist) regarding EF deficits. SLPs make appropriate referrals regarding evaluation and collaborate on treatment for such disorders. SLPs may help clients navigate difficult emotional experiences, such as anxiety, that may arise when engaging in treatment to address an EF or other cognitive deficit.
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