A Holistic Approach to Executive Functioning

Executive functioning (EF) is a set of mental processes that allow us to set goals, complete tasks and adapt to new situations. The dominant theories and assessment tools of EF focus on cognitive aspects such as working memory and abstract reasoning. While these are certainly pieces of the puzzle, they don’t account for the psychological, social, emotional, and cultural factors that also impact a client’s functioning. A client’s ability to focus and think clearly will be impacted by issues such as anxiety, depression, chronic stress and trauma. It is up to the clinician to make the connection between the presenting problem, the assessment data, and the whole person sitting across from them. 

A 4th grader is having trouble sitting still and completing her assignments. She is obviously having difficulty with her executive functioning in the classroom, but what is the cause and how do we help her? Do her challenges arise from her brain, mind, body, relationships, community, or some combination of all five? Is it because she has ADHD or sustained a head trauma last month while on the playground? Her symptoms could be the result of abuse or neglect, being bullied, or the stress caused by a parent’s illness. Perhaps she feels that her teacher doesn’t like her, is disturbed by some violent content she came across on the internet, or her mother’s unexplained absence from the home? All of these experiences can result in the same problems with attention, focus, and task perseverance as brain-based ADHD. 

When it comes to EF, mental health and educational professionals over-index on cognitive assessment and pharmacological interventions. Stimulant medications often help a child focus better during class, whether or not they have ADHD. However, this “solution” runs the risk of masking or ignoring other, more fundamental life challenges. There certainly are children with brain-based difficulties that are helped by medication. However, this has become the “go to” solution instead of utilizing a more complex and in-depth exploration of the whole child and the world they are attempting to navigate. Parents are also vulnerable to this misdirection out of desperation to help their child, a need to avoid being blamed for their child’s difficulties, or because the trauma of their own childhoods is being triggered. ADHD may run in families, but so does anxiety, depression, and trauma. ADHD as a grab-bag diagnosis and cultural cliché has likely done more damage than good. 

The reality is that the majority of EF challenges are caused by difficulties with emotional dysregulation and anxiety. This is because heightened emotions, stress and physiological arousal from anxiety create disruptions to the prefrontal cortex as the brain diverts attention away from abstract thinking and toward immediate survival needs. When a client is in survival mode, their brain functions in altered ways that can mimic the symptoms of ADHD. The way that we treat these types of EF issues are the same as any client who is struggling with dysregulation. We begin by understanding the whole client in the context of their relationships, life circumstances and coping skills. From there, we can help them process their emotions and learn skills to downregulate anxiety, allowing their EF skills to come back online.