Patient Presentation
A 7-year-old male came to clinic with his mother who was an elementary school teacher for his health supervision visit. He had just gotten a cast off his right arm that was caused by being thrown off a bike he rode down a rock-covered ravine. He had broken the other arm flying off a swing set the previous year. He was doing well overall in school, with his siblings and loved playing soccer. He didn’t have attentional problems in general. His mother called him a daredevil as he seemed to have little fear and said, “He hasn’t got the executive function yet to really stop himself. He actually plans some of this thinking it would be fun like riding down the ravine. He just needs some more time to get some more common sense.”

The pertinent physical exam showed a healthy boy with growth parameters at 25% and normal vital signs. He had multiple scratches and bruises on the extensor surfaces of his arms and legs. The rest of his examination was normal.

The diagnosis of a healthy boy was made. The pediatrician discussed how important it was to use safety equipment for his activities, and to really stop and think if it is a good idea to do some things. “I’m glad you were wearing your helmet, but riding down the ravine probably wasn’t the best idea. How about if you stop and ask yourself, if you think your mother or teacher would think it would be good idea before you do it. If you think they would approve, then you’re probably okay. If you think they might get upset then ask them first,” the pediatrician offered. The mother and the pediatrician laughed together as they both realized that probably only more time would help his insight.

Discussion
Executive function (EF) is the “…cognitive processes that facilitate goal-directed action and problem solving, such as working memory, cognitive flexibility, inhibitory control, and self-monitoring. EF skills are important for the conscious, effortful control of thoughts and behaviors.”

EF allow us to inhibit ingrained behaviors that could get us into trouble, e.g. shouting out in a classroom, driving the wrong-way down a one-way street. EF also allow us to pay attention to what is meaningful for the time and situation e.g. academic testing, paying attention to traffic and not the radio while driving. Additionally, EF allows us to organize our thoughts in the face of distraction, complexity, and stress, e.g. sports games, figuring out how to drive to a new location, being aware of personal items when walking down a crowded street to avoid theft.

EF are primarily housed in the prefrontal cortex yet have numerous other brain areas that support these skills such as the cingulate cortex, parietal cortex, basal ganglia, amygdala and hippocampus.

EF is distinct from Theory of Mind (ToM) which “is the social-cognitive ability to understand human actions in terms of the psychological states that motivate behavior, such as beliefs, emotions, desires and intentions.” EF and ToM are linked as they seem to develop together and are the neurobiological basis for this shared development. However the exact linking of the two is still not truly understood. Does the motivation influence the behavior, or does the behavior and it consequences influence the motivation, or is it truly a reciprocal/meshed relationship?

Learning Point

EF milestone development includes:

• 0-2 years
  • Episodic mental representations
  • Episodic thoughts and goals – past experiences and actions are intertwined with current actions
  • Example – put blocks of same shape in a shape-sorter toy
• 2-4 years
  • Emerging realistic mental representations
  • Automatic self-based actions or instruction-based actions
  • Example – bathing a toy doll or following simple request such as “bring toy here.”
• 4-6 years
  • Integration of realistic mental representations
  • Control of attentional focus, can shift between actions depending on instructions/situation
  • Example – transitioning between activities, “It’s time to eat now, then you can play.”
• 6-8 years
  • Emerging rule-based mental representations
  • Rule-based action plans
  • Example – turn-taking in games
• 8-11 years
  • Integration of rule-based mental representations
  • Flexible shifting across conceptual systems
  • Example – apply rules to mathematical concepts (multiple or divide numbers before adding and subtracting), shift between memory and inference such as “Before, we went to the ice cream store by driving this way, if mom turns down the next road, she probably is taking us to get ice cream.”
• 11-13 years
  • Emerging principle-based mental representation
  • Automation of conceptual systems
  • Example – Complex everyday plans such as homework planning, organizing errands in local order of execution
• 14-16 years
  • Integrated principles
  • Inferential relevance of mental representations
  • Example – long-term planning such as life after high school

Questions for Further Discussion
1. What other examples of executive function can you give for the different developmental stages above?
2. What is in the differential diagnosis of attentional problems? A review can be found here
3. What are indications for referral to a psychologist or psychiatrist?

Related Cases

Disease: Executive Function | Child Development | Teen Development

Symptom/Presentation: Behavior Problems | Health Maintenance and Disease Prevention

Specialty: Psychiatry and Psychology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Teen Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Blair C. Educating executive function. Wiley Interdiscip Rev Cogn Sci. 2017;8(1-2). doi:10.1002/wcs.1403

Demetriou A, Makris N, Kazi S, Spanoudis G, Shayer M. The developmental trinity of mind: Cognizance, executive control, and reasoning. Wiley Interdiscip Rev Cogn Sci. 2018;9(4):e1461. doi:10.1002/wcs.1461

Wade M, Prime H, Jenkins JM, Yeates KO, Williams T, Lee K. On the relation between theory of mind and executive functioning: A developmental cognitive neuroscience perspective. Psychon Bull Rev. 2018;25(6):2119-2140. doi:10.3758/s13423-018-1459-0

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa