Scott J. Hunter

Empirical status regarding the remediation of executive skills

As has been discussed in previous chapters, EdF is a frequent consequence of neurodevelopmental and acquired neurological conditions, and often warrants intervention. At this time, there are several approaches available for the treatment of EdF. Treatment can involve cognitive, behavioral, or pharmacologic approaches. While there is a paucity of research on the efficacy of interventions to address EdF in children, there is a solid literature describing the theoretical considerations and models for remediation of EF in children. In this chapter, the current empirical literature describing cognitive and behavioral interventions for EdF are reviewed, with a brief discussion of the efficacy of pharmacologic treatments for EdF. Examining efficacy of interventions It has been proposed that the best context for EdF intervention is through everyday functional activities, using everyday people and routines. According to this theoretical model, teaching cognitive processes in an entirely decontextualized manner is not likely to be effective. Instead, it is believed necessary to teach and support EF skills in the context of everyday routines. These skills emerge through a process of sequential mastery; slowly introducing new EF demands into daily routines (such as expecting the child to initiate each step independently) or alternating the sequence of steps to achieve a goal more efficiently is the typical approach taken to ensure successful acquisition. As such, interventions should be integrated into the childs home routine and educational program and implemented by caregivers, teachers, and therapists.

Executive Function and Dysfunction: Models of executive functioning

Scientists have approached executive functioning (EF) from a variety of perspectives, including neuroanatomical, neurochemical, evolutionary, syndrome-based, and statistical. Many have attempted to concisely define EF and executive dysfunction (EdF) by listing functions or underlying operations, while others have focused on its neuroanatomical or neurophysiological correlates. There is some degree of overlap among these descriptions, but no consensus. Perhaps the confusion regarding exactly what constitutes EF reflects the ways in which it has been examined historically. Early studies were adult-based , examining behaviors produced by brains that had already developed. These studies, while informative about adults with acquired EdF, did not take into account issues of development, such as how an insult impacts EF in a still-developing brain or how neurodevelopmental disorders impact brain and function. Early work in the field primarily examined the effects of insults to the frontal lobes , which led to a circular argument that “damage to the frontal lobes causes EdF, therefore EF must be regulated by the frontal lobes.” This was later refined and modified with attribution of EF to the prefrontal cortex (PFC), but the assumption of one-to-one correspondence between function and structure, with limited consideration of the rich network we now know is involved in EF, remained the dominant model. Yet this model failed to account for evidence of intact functioning after removal of the frontal lobe, EdF experienced after damage to other brain areas, or evidence of EdF in the absence of a known neurologic insult (as is the case with some of the neurodevelopmental disorders).