Executive Functioning and Executive Dysfunction in children with ASD, ADHD and DCD

Introduction

 Does any of the following describe your child? Intense temper tantrums over minor change, snatching things from other children, daydreaming, flitting from one thing to next, has a messy desk or school bag, gets stuck with homework but cannot ask for help, is loud and pushy with peers, struggles to complete tasks, poor sense of time, and so on.

If any of the above sounds familiar, then keep reading this article. In this article I have explained what Executive Functioning is, how common is Executive Dysfunction in children with Neurodiverse conditions, with emphasis on what can be done to mitigate the massive impact this has on children. Executive functioning difficulties reflect differences in brain development rather than poor parenting and can be meaningfully improved through practical strategies and adjustments as mentioned below.

What is executive functioning (EF)?

Executive functioning allows us to complete multi-step instructions (working memory), like putting your shoes on and be at the door, the ability to adapt to changed circumstances (cognitive flexibility), manage impulses and emotions (emotional regulation), and enables focus and self-control (ability to ignore distractions).

Executive functioning is like a team sport and executive dysfunction is like breakdown in communication between team members. To use another analogy, executive functioning is the brain’s air traffic control tower, quietly coordinating everything so that life runs safely and smoothly.

Executive functioning is based in prefrontal cortex (PFC) located in the forefront of our brain, i.e., frontal lobes, which act as CEO (Chief Executive Officer) of our brain. As part of brain development, prefrontal cortex is the last part of human brain to mature – thus executive functions keep maturing into our 2^nd and 3^rd decade of our lives. Hence, executive functioning can be improved with time and with below-mentioned interventions since it’s most neuroplastic part of our brain.

Impairment of executive function i.e., executive dysfunction (ED) can look different at each developmental stage as the brain matures. Moreover, these executive dysfunction deficits vary from child to child.

How does Executive Dysfunction affect neurodiverse children?

Executive dysfunction is common in neurodiverse children and affects them as follows:

• In ASD (Autism Spectrum Disorder) – cognitive flexibility and planning are affected more
• In ADHD (Attention Deficit Hyperactivity Disorder), – sustaining attention, impulse inhibition, working memory and planning are affected
• In DCD (Developmental Coordination Disorder)/Dyspraxia – visuospatial processing, planning, and organisation are affected

 

Executive dysfunction is also a significant feature in children with specific learning disorders (SpLD) such as Dyslexia and Dyscalculia, and other neurodevelopmental conditions such as tic disorders and Tourette’s syndrome.

Executive dysfunction difficulties go beyond age-appropriate behaviour, i.e., in the above group of children they are more frequent, more intense and interfere much more significantly with activities of daily living.

How common is ED?

 In my clinical practice I notice that children with comorbid ASD and ADHD exhibit the most severe executive dysfunction. Similarly, in children with co-morbid neurodevelopmental conditions, the magnitude of the impact of executive dysfunction is much more when compared to a single diagnosis.

Broad clinic estimates suggest that executive dysfunction difficulties are present in approximately 80-90% of children with ADHD, 50-80% of children with ASD and 40-70% of children with DCD, with considerable overlap between conditions.

It is important to note that executive dysfunction tend to get exaggerated with emotional influences such as anxiety and stress, fatigue, busy and noisy environmental settings, and impaired cognitive abilities such as slower processing speed. They can present as inconsistent performance which can be confusing for adults around them.

What does Executive Dysfunction look like?

Executive dysfunction can present as follows in the home setting:

• Difficulty getting ready (poor sequencing).
• Forgetting instructions for belongings.
• Starting but not completing tasks.
• Emotional outbursts when overwhelmed.

 

At school they can present as:

• Poor organisation,
• Slow task initiation,
• Difficulty following multi-step instructions,
• Variable academic output despite ability and
• And socially, as impulsivity, interrupting, difficulty coping with change and reduced self-monitoring.

In children of preschool years (0-5 years), executive dysfunction can present as:

• Frequent intense tantrums over minor changes such as having a different snack than expected (emotional regulation difficulty).
• Inability to stop and think leading to impulsive actions such as snatching toys or hitting instead of asking for help (poor self-control).
• Failure to follow instructions such as put your shoes and on and be at the door (reduced working memory).

During primary school years (6-11 years), executive functioning difficulties can present as:

• Messy desk or backpack, handouts and homework frequently lost or forgotten (organisation difficulty).
• Sitting for a long time without starting a work sheet or appearing lazy (task initiation difficulty).
• Getting stuck on a maths problems or if a teacher asks to solve the problem differently (flexible thinking).

At secondary school (12-18 years), executive dysfunction can present as:

• Underestimating how long a project task might take and starting the night before it is due (time blindness, time management difficulty).
• Overwhelmed by multiple homework assignments (planning and prioritising difficulty).
• Failing to check work for mistakes (self-monitoring).
• Being too loud or pushy in social groups, reacting negatively (self-monitoring).
• Struggling to complete university applications as inability to break the long-term goal into small actionable steps (future planning).

 

 

What can be done to overcome executive dysfunction?

The key principle in supporting children with executive dysfunction is to externalise what the brain cannot yet internalise – that is adults (with fully formed CEO of the brain) assist children (who’s CEO is under construction) with scaffolding (support) with following strategies.

It is also worth remembering that these strategies work best when the child is emotionally regulated. If the child is not in an emotionally baseline state, then allow the emotional storm to pass and stay calm and only then implement the below measures:

1. Use checklists: since the child with ED struggles to hold multiple instructions, cues and checklists on the back of the front door or attached to the school bag to remind things, e.g., keys, homework, lunch, PE kit, phone etc, work best.
2. Visual timers: such as “Time Timer” app – physical red disc timers that turn abstract concept of time into visible physical volume that shrinks as time passes.
3. “Echo” technique: have the child repeat the instruction back to you once or twice, to help the information given to them from temporary audio storage into active working memory.
4. Backward mapping: start at the deadline and work backwards. For example, if the project is due by Wednesday, we need to be doing it on Tuesday, and it means finishing the draft on Monday.
5. “Rule of 3”: deciding on three “must-do” tasks. Everything else is a “could do.” This technique prevents the paralysis of choice.
6. Body doubling: a parent or teacher simply sits in the room while the child works. An adults calm presence acts as an anchor that keeps the brain “on task.”
7. The five-minute rule: tell child that they only have to work for five minutes. After that, they can stop. This helps overcome the “friction of starting” and once moving, they often continue.
8. “Eat the frog”: doing the most dreaded or difficult task first thing in the morning when the EF “battery” is at its fullest helps.
9. Gamification: roll a dice to decide which task to start first. Remove the “decision fatigue,”
10. “Now/Next/Then”: Using a simple visual board showing e.g., now reading/next lunch/ then maths, reduces “anxiety about the unknown.”
11. Transition countdown: warnings at 10 minutes, five minutes and two minutes, before the end of one activity and beginning of another is used as an “auditory signal” to signal a change in activity.
12. The “two choice” strategy: through flexibility offer two acceptable choices: do you want to do your reading at the desk or on the sofa?
13. Fidget tools: using discrete fidgets such as BluTak, spinner rings, weighted lap pads, would provide the appropriate “proprioceptive input” needed to keep the brain alert and the body still.
14. The “brain dump” journal: have a notebook nearby, so that the child can write down pop-up thoughts, thus allowing the brain to let go of the thought and return to the task.
15. “Check-your-work”: create a small “final scan” list at the corner of the desk. For example, 1. Name on the paper. 2. Capital letters. 3. Full stops and so on.
16. Trello/kanban boards: Trello is cloud-based visual project management tool that uses kanban framework – “to do,” “doing” and “done.”
17. Focus apps: such as “Forest” where you grow a digital tree by staying off your phone, thus providing dopamine rewards for sustained attention.
18. Smart home systems: think of using Alexa or Google Home for verbal reminders. For example, “it is 8.10, time to put on your shoes,” removes parents from the nagging role and puts the clock in charge.
19. Break down the tasks: breaking down the task into multiple small steps and giving one instruction at a time helps address difficulties arising from poor working memory.
20. Use designated places and colour coding: to improve organisation.
21. Using emotion wheel/emotion strip: helps the child recognise early signs of overwhelm and to use calming strategies.
22. “Plan A/Plan B” approaches: technique helps build flexibility gradually with preparing alternative approaches if Plan A fails.
23. Useful tools: these include alarms, planners, age-appropriate reminder apps, white boards and now and next boards, etc.
24. Regular physical exercise: can meaningfully support attention regulation, impulse control, and mental flexibility, with even short bouts of activity helping children focus better on tasks.
25. Mindfulness and brief guided meditation practices: can improve emotional regulation and self-control, helping children to pause, think, and respond more effectively, especially in stressful situations.
26. And finally, Medications: can significantly improve attention, impulse control, and task initiation in many children with ADHD. They work best when combined with practical strategies and environmental support as discussed above.

 

Conclusion:

Children benefit from guidance rather than criticism, structure rather than pressure. Adults can play a critical role in scaffolding these executive functioning skills as they take time to develop, and I can testify from my experience that these skills improve over time. However, it is worth noting that these skills develop more slowly and unevenly in neurodivergent children especially if there is a lack of understanding and lack of above support.

Early recognition and practical support can result in improved academic, emotional and functional outcomes. While the biological wiring of executive dysfunction can make daily life feel like an uphill climb – a profile of executive dysfunction is not a lack of potential. It is delayed arrival of the CEO/brain’s management system.

By using these above strategies and “external brains” parents are not just making life easier today but they are actually providing the scaffolding the brain needs to eventually build its own internal pathways. Our goal is not to “fix” a broken child but to support a differently-wired one, as they find their own unique way to navigate the world. With the above strategies and techniques, frustration of “why won’t they?” can be replaced by the hope of “how can we?.”

Support Organisations:

1. National Autistic Society. autism.org.uk
2. IPSEA (Independent Provider of Special Education Advice). https://www.ipsea.org.uk/pages/category/what-we-do.
3. ADHD UK. https://adhduk.co.uk/.
4. Dyspraxia UK. https://dyspraxiauk.com/.
5. Young Minds: https://www.youngminds.org.uk/.
6. Contact-a charity for families with disabled children. https://contact.org.uk/.

 

References and further reading

1. Smart but Scatteredby Peg Dawson and Richard Guare.
2. The Executive Functioning Workbook for Teensby Sharon A. Hansen. A
3. Taking Charge of ADHD, by Russell A Barkley
4. Autism and Everyday Executive Functioning by Paula Moraine.
5. Oxford Handbook of Child Neurodisability and Community Child Health, by Dr Srinivas Gada.