Executive function Patel Mar 21, 2013

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EXECUTIVE FUNCTION
PART 2
DEVELOPMENT, DYSFUNCTION, APPROACH
TO EVALUATION
Puja Patel
March 21, 2013
Development

Know healthy brain development for better
understanding of functional recovery and outcome
in children with brain lesions
 PFC
is especially vulnerable to brain lesions due to its
extended developmental trajectory


Adults rely on PFC; cognitive fnc less localized in
children
Development of executive skills progresses in spurts
PFC Maturation Occurs in Growth
Spurts
Development of Foundational Executive
Skills
Selective attention
 Elements formed in first years of life
 Develops considerably between 2.5–6 years,
ceiling effects by 6 years
 Another peak from 8–10 years of age; skills
functioning reliably
 Less rapid improvement from 10 years to early
adolescence
Development of Foundational Executive
Skills
Inhibition
 Emerges as early as 7–8 months of age, but not
consistently employed reflecting skill immaturity
 By age 4, signs of successful performance on simple
and complex inhibition tasks
 Improves from age 5-8, particularly for tasks that
combine inhibition and WM
 Complete by age 10; mastery by age 12
Development of Foundational Executive
Skills
WM
 Improvement during the preschool years
 By age 6 executive components sufficient to be used
during complex tasks
 Linear increase from ages 4 to 14 and a leveling
off between ages 14 and 15 across nearly all WM
tasks examined
Development of Foundational Executive
Skills
Planning
 Simple planning in children as young as 3
 Greatest period of development between ages of
5-8
 By age 7-11, strategic behavior and reasoning
abilities leads to more organized and efficient
planning
 Reach adult levels between the ages of 9-13
 Improvements continue into early adulthood period
Development of Foundational Executive
Skills
Shifting
 Preschoolers can shift between two simple response
sets when demands on inhibition are reduced
 Inhibition and WM interrelated; prerequisites for
successful shifting
 Ability to perform on complex shifting tasks
improves from age 7-9
 By middle adolescence, reaches adult-like levels
Risky Behaviors in Adolescence

Imbalance of
development of
prefrontal
regions relative
to subcortical
regions (limbic
system; involved
in desire and
fear) maximal
during
adolescence
Executive dysfunction in the clinical
setting


EF is multi-dimensionalpresents in a variety of
ways
Lesions affecting the prefrontal-subcortical system
can have delayed manifestations in children
 TBI
in children vs adults
 EF still developing throughout childhood and
adolescents, and children have fewer well established
routines and skills to rely upon
EF in Clinical Practice
Neuropsychiatric Syndromes that involve Executive Dysfunction
Autism
Frontal brain tumors
ADHD
TBI
Disruptive Behavioral
Disorders
Tourette syndrome
Frontal Lobe Epilepsy
Bipolar Disorder
Fragile X syndrome
Schizophrenia
Williams syndrome
Wilson’s disease
PKU
Fetal Alcohol syndrome
Autism


Deficits in communication, social interactions,
presence of restricted interests and repetitive
behaviors
Related to WM and cognitive flexibility
 “stuck-in-set”
perseveration, difficulty in the inhibition of
a prepotent response and planning

BUT may be preservation vs compensatory
mechanismsresponse inhibition and WM intact
ADHD


Developmentally inappropriate symptoms of
inattention, impulsivity and motor restlessness
EF deficits:
 inhibitory
control and suppression of overlearned
responsesimpulsive
 sustained attentiondistractible
 WMforgetful, slow processors
 planning and organizing
 monitoring and regulating self-actionfail to modify
behaviors
Disruptive behavioral disorders
(CD/ODD)


Oppositional, aggressive, and antisocial behaviors
fMRI shows underactivation of R-FOC (involved in
sense of euphoria, uncontained responsiveness to
impulses, behavioral disinhibition)
 compromised


processing of reward cues
Impaired inhibition after controlling for attention
Response perseveration
Frontal Lobe Epilepsy


Impacts wide scale of cognitive domains; impaired EF
and attention most frequent
RFs unclear



Age of onset, sz frequency, localization, ↑AEDs, duration
Behavioral disturbances can be ictal, interictal, or
postictal
FL/executive dysfunction in up to 84% of children and
adolescents with TLE!
Wider anatomic and functional network connects temporal
and FL
 Hypometabolism of prefrontal regions in TLE ? protection
against epileptiform discharge propagation by FL function
inhibition

Approach to Evaluation


Accurate diagnosis is basis for effective
management plan
Challenges of diagnosis
 Delayed
manifestations
 Identifying threshold of childish behavior
 Comorbid LD or severe behavioral problems
Approach to Evaluation
Multidisciplinary approach
 Psychological
 Intelligence
testing
 Personality assessment
 Behavioral observation
 Achievement testing
Approach to Evaluation


Neuropsychological: sensory processes, motor
systems, attention and concentration, learning and
memory, language, visuospatial processing,
conceptual skills, executive functions
EF assessment challenging
 Not
easily measured in office setting
 Formal testing may not correlate to daily life
 Limitless
opportunities for dysfunction
 Parents and teachers should describe problems in real word
 Multiple
tests (Dr. Goldman)
Approach to Evaluation

Psychiatry
 Prefrontal
EF impairment important feature of many
psychiatric disorders listed in the DSM-IV
 Treat psychiatric symptoms vs EF deficits vs both

Neurologic exam to r/o focal structural lesions,
genetic/metabolic disorders
 Normal
exam DOES NOT r/o prefrontal lesion
Interventional Methods

Delayed responding
Increases time devoted to objective goal-setting, systematic
screening for appropriate responses, response selection and
enactment
 Plan-Execute-Repair (P-E-R)




Thinking maps to aid organizational strategies
Self talk to enhance skills related to inhibition,
stress/anxiety, anger management, appropriate goal
setting
Self-regulated strategy development (SRSD)
intervention model to enhance self-regulation and
increase positive self-concept
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