Cambridge University Press

978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment

Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

Introduction

Elizabeth P. Sparrow and Scott J. Hunter

Executive functioning (EF) is a cognitive capacity that is difficult to define succinctly. Most
explanations of EF reflect some degree of self-regulation as applied to cognition, emotion,
behavior, adaptive functioning, and even moral reasoning and choice. In line with this,
multiple models have been proposed to account for and explain the range of capacities and
acts that represent EF, although the predominant models are adult-centric, and as a result,
less applicable to thinking about EF developmentally. It is difficult to ignore the fact that
nearly every neuropsychological evaluation in the clinical setting reveals and then attempts
to address some aspect of executive dysfunction (EdF). EF deficits have a significant impact
in multiple domains of a person’s life and the lives of others around them, including
parents, teachers, siblings, and peers. The pervasive and at times quite impairing nature
of EdF calls for attention and emphasis from researchers and clinicians alike.
With this volume, the reader will find that we promote a model that emphasizes the
plurality of executive functions, as opposed to a model that views EF as a singular (albeit still
dynamic) cognitive capacity. Clinical and empirical data provide examples of dissociability
within EF, at both the level of neural organization and skill demonstration. We also find
that EF is best represented as a spectrum, such that too much or too little of a particular EF
skill can represent EdF. For example, poorly controlled emotion and behavior are EF
deficits in the Disruptive Behavior Disorders (Chapter 5), and overly controlled emotion
and behavior are EF deficits in the Anxiety Disorders (Chapter 10). Even when none of
the EF skills assessed show a significant deficit, the cumulative effect of multiple EF deficits
can result in severe impairment (i.e., the whole is greater than the sum of the parts).1
We address this directly in Chapters 2 and 4, in particular.
With this volume, we argue that it is important to examine the differences that exist for
children and adolescents in EF and EdF, specifically between the occasional lapses into
executive weakness that all people experience and “true EdF” that is persistent, pervasive,
and severely impairing. We emphasize that it is important to recognize the range of factors
that impact and moderate EF, including stable factors such as age, gender, ethnicity,
personality, and genes, and more variable factors like self-care (fatigue, pain, stress, mood,
and exercise), socioeconomic status, abuse, neglect, trauma, and social rejection. Each of
these factors serves to influence how EF skills develop, vary in their presentation, and
remain vulnerable, both environmentally and neurobiologically. These factors are discussed
at multiple points in this volume, with particular emphasis found in the chapters compris-
ing Section II, as well as Chapters 4, 19, and 20.

Executive Function and Dysfunction, ed. Scott J. Hunter and Elizabeth P. Sparrow. Published by
Cambridge University Press. © Cambridge University Press 2012.
1

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

2 Introduction

When EdF is present, it often impacts functioning widely, and hampers adjustment
across academic, vocational/occupational, social and interpersonal, emotional and intra-
personal, behavioral, and adaptive functioning (see Chapters 4, 18, and 20 in particular).
This also creates a recurring cycle between what EdF impacts and what impacts EdF;
however, intervention has the potential to change this cycle. As a result, we place a
significant emphasis across this volume on recognition and intervention for EdF.
The primary purpose of this volume is to provide a comprehensive summary of what is
known about EF and EdF in childhood and adolescence, examine what these data mean in a
practical sense, and consider future directions for clinical and research work. Throughout
this volume, our perspective is developmental, with a focus on issues usually first seen in
children and adolescents. As a result, EdF in conditions that usually show onset in
adulthood, such as schizophrenia,2,3,4,5,6 the personality disorders,7,8 and the demen-
tias,9,10,11,12,13,14,15 are not covered in this volume. There are numerous review articles
and texts available that address EF in the adult population, including the classic references
by Stuss and Benson16 and Lezak.17 Books addressing EdF in pediatric populations tend to
present very applied materials (i.e., worksheets for use in treatment) or very academic and
theoretical perspectives, but have not integrated research and practice. This volume will fill
the gap in the literature for EF in pediatric populations, as a guide for researchers and
clinicians who work with children and adolescents on a daily basis.
This volume is organized into three sections. The first section provides an overview of
the foundations for understanding EF and EdF. Chapter 1 reviews the historical context of
EF and summarizes various efforts to define and model this complex concept. The devel-
opment of EF, from infancy through young adulthood, is examined in Chapter 2. It is
critical to have an understanding of this progression as individual differences18 are super-
imposed on the “typical” leaps and plateaus in EF development. Chapter 3 reviews what is
known about the neurobiology of EF, specifically its developmental neuroanatomical, and
neurochemical correlates. Current research in this area argues against simplistic assignment
of EF to the frontal lobes,16 instead revealing the beautiful complexity of the executive
networks that involve cortical, subcortical, and cerebellar areas, among others. Ironically,
we are once again reaching what early scientists postulated in the 1800s, that “ . . . the
frontal lobes are the seat of coordination and fusion of the incoming and outgoing products
of the several sensory and motor areas of the cortex.”19 Chapter 4 concludes the first section
with a discussion of key assessment principles and a consideration of areas to address when
examining EF and EdF.
The chapters in Section II represent current advances in pediatric neuropsychology and
EF by presenting examples of a variety of pediatric clinical conditions that are associated
with EdF. Section II is composed of 12 chapters describing EF and EdF in a number of
conditions that begin in childhood or adolescence, either acquired neurodevelopmentally or
through insult to the developing brain. Each of these chapters has a similar structure to help
the reader find material, including discussion of the clinical manifestations, neuroimaging
data, neuropsychological findings, and future directions for research pertinent to each
disorder or condition. This section includes a range of neurodevelopmental and acquired
disorders involving EdF, not only the “usual suspects” such as Attention-Deficit/Hyper-
activity Disorder (ADHD) and the autism spectrum disorders (ASDs), but also less fre-
quently discussed examples, like the pediatric movement disorders, neurodevelopmental
conditions secondary to trauma and insult, the seizure disorders, human immunodeficiency
virus (HIV), and the sequelae of the childhood cancers. It was our goal with this section to

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

Introduction 3

address the range of potential conditions seen in clinical practice, as well as to provide
guidance for those less common disorders that may occasionally be referred.
The chapters in Section III represent applications of this information. Chapter 17
reviews empirically supported interventions for EdF. Chapter 18 extends this with a
consideration of educational implications, including research on school-based programs
to improve EdF. Cautions and caveats regarding the consideration of EF and EdF in the
forensic neuropsychology and child psychiatry setting are offered in Chapter 19. This
volume concludes with Chapter 20, sharing reflections on key messages and goals for
research and practice.
The reader is encouraged to mark the Appendices for easy reference while reading.
Appendix I lists abbreviations used throughout the volume. Appendix II provides infor-
mation about tests mentioned in the volume, including names, abbreviations, and quick
references to learn more about each test. Unless specified otherwise, “child” is used in this
volume to refer to children and adolescents.
The contributors to this volume were carefully considered and selected to represent a
range of neurodevelopment professionals who work with EdF on a daily basis. The authors
represent a mix of researchers, assessors, and interventionists, across both clinical and
academic settings. With their contributions, these authors are not simply summarizing
what others have written, but also extending the available research literature with clinical
observations, new interpretations, and guidance for the future. We hope that this volume
will provide practitioners and clinical consultants with a better understanding of both EF
and EdF, and provide researchers and developers of intervention programs with an impetus
for continued progress in the area. By examining the foundations, manifestations, and
implications of EF and EdF, we hope to convincingly demonstrate the importance of
addressing these issues for the many children and adolescents who present clinically for
assessment and intervention, in order to support their effective transition to productive
adulthood. We also hope to challenge our colleagues and professional peers towards a
broader, more dynamic view of both EF and EdF, and how they unfold and alter across
development, in anticipation of more effectively coaching and guiding the families who seek
our consultation.
We anticipate that this volume will be of interest to psychologists (including neuropsy-
chologists, school psychologists, developmental psychologists, and child clinical psycholo-
gists), pediatricians, pediatric neurologists, psychiatrists, rehabilitation physicians and
pediatric physiatrists, and advanced trainees in these disciplines. Additionally, it may serve
as a valuable resource for educators and even parents, to support their understanding of the
children with whom they live and work on a daily basis.

References 3. Savla GN, Twamley EW, Delis DC, et al.

Dimensions of executive functioning in
1. Suchy Y. Executive functioning: Overview, schizophrenia and their relationship with
assessment, and research issues for non- processing speed. Schizophr Bull 2010; 16.
neuropsychologists. Ann Behav Med 2009; [Epub ahead of print]
37(2): 106–16.
4. Klemm S, Schmidt B, Knappe S, Blanz B.
2. Moritz S, Birkner C, Kloss M, et al. Impaired working speed and executive
Executive functioning in obsessive- functions as frontal lobe dysfunctions in
compulsive disorder, unipolar depression, young first-degree relatives of schizophrenic
and schizophrenia. Arch Clin Neuropsychol patients. Eur Child Adolesc Psychiatry 2006;
2002; 17: 477–83. 15(7): 400–8.

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

4 Introduction

5. Raffard S, Bayard S, Gely-Nargeot MC, Huntington’s disease. Neuropsychology

et al. Insight and executive functioning 2011; 25(6): 741–51.
in schizophrenia: a multidimensional 12. Seelaar H, Rohrer JD, Pijnenburg YA,
approach. Psychiatry Res 2009; 167(3): et al. Clinical, genetic and pathological
239–50. heterogeneity of frontotemporal dementia:
6. Keshavan MS, Kulkarni S, Bhojraj T, et al. a review. J Neurol Neurosurg Psychiatry
Premorbid cognitive deficits in young 2011; 82(5): 476–86.
relatives of schizophrenia patients. Front 13. Johns EK, Phillips NA, Belleville S, et al.
Hum Neurosci 2010; 3: 62. Executive functions in frontotemporal
7. Morgan AB, Lilienfeld SO. A meta-analytic dementia and Lewy body dementia.
review of the relation between antisocial Neuropsychology 2009; 23(6): 765–77.
behavior and neuropsychological measures 14. Woods SP, Tröster AI. Prodromal frontal/
of executive function. Clin Psychol Rev executive dysfunction predicts incident
2000; 20: 113–56. dementia in Parkinson’s disease. J Int
Neuropsychol Soc 2003; 9(1): 17–24.
8. LeGris J, van Reekum R. The
neuropsychological correlates of borderline 15. Oosterman JM, de Goede M, Wester AJ,
personality disorder and suicidal et al. Perspective taking in Korsakoff’s
behaviour. Can J Psychiatry 2006; syndrome: the role of executive functioning
51: 131–42. and task complexity. Acta
Neuropsychiatrica 2011; 23: 302–8.
9. Salmon DP, Bondi MW.
Neuropsychological assessment of 16. Stuss DT, Benson DF. The Frontal Lobes.
dementia. Annu Rev Psychol 2009; New York: Raven Press, 1986.
60: 257–82. 17. Lezak MD. Neuropsychological Assessment,
10. Stopford CL, Thompson JC, Neary D, et al. Second edition. New York: Oxford
Working memory, attention, and executive University Press, 1983.
function in Alzheimer’s disease and 18. Hughes C. Changes and challenges in 20
frontotemporal dementia. Cortex 2010; 21. years of research into the development of
[Epub ahead of print] executive functions. Infant Child Developm
11. Allain P, Havet-Thomassin V, Verny C, 2011; 20(3): 251–71.
et al. Evidence for deficits on different 19. Bianchi L. The functions of the frontal
components of theory of mind in lobes. Brain 1895; 18: 497–530.

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

Section I Foundations of Executive Function/Dysfunction

Chapter
Models of executive functioning

1 Scott J. Hunter and Elizabeth P. Sparrow

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,1,2 while others have focused on its neuroanatomical or
neurophysiological correlates.3 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,4 EdF
experienced after damage to other brain areas,5 or evidence of EdF in the absence of a
known neurologic insult (as is the case with some of the neurodevelopmental disorders).
Another key assumption in early work regarding EF was that there is a homogenous
executive construct. This oversimplification led to a substantial degree of inflexibility in
planning, executing, and interpreting studies. As Salthouse has observed, the diversity of
variables used in assessing EF reveals a lack of agreement regarding the construct; different
researchers use different tasks as the primary EF variable, and even standard EF batteries
have very little overlap in tests used.2 The lack of a “gold standard” significantly limits
evaluation of EF measures beyond face and predictive validity. Efforts to examine construct
validity generally find that performance on tests hypothesized to measure EF is moderately
correlated with many other constructs, not just EF (i.e., low discriminant validity).2
Without a unifying plan or concept, investigations of EF and EdF have gone in a
number of directions. Some researchers and clinicians continue to emphasize the simplistic
explanation they learned early in their training, that EF is most related to the frontal lobes,
and that it is primarily seen after brain injury or in Attention-Deficit/Hyperactivity
Disorder (ADHD). Lack of agreement regarding what processes are part of EF contributes

Executive Function and Dysfunction, ed. Scott J. Hunter and Elizabeth P. Sparrow. Published by
Cambridge University Press. © Cambridge University Press 2012.
5

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

6 Section I: Foundations of Executive Function/Dysfunction

to the confusion, as different definitions and classifications complicate comparisons of

research findings. For example, opinions regarding whether working memory (WM) is part
of EF impact interpretation of high correlations between EF measures and intelligence
quotient (IQ) test results that are primarily moderated by the Working Memory Index (cf.
data reported by Arffa).6 This confusion regarding the EF construct limits cohesion in the
field, and thus limits progress.
In this chapter, we present a historical context within which to understand current
models of EF and EdF. We conclude with suggestions for reaching an improved, integrated
model of EF that accounts for changes in neural networks and skills across child and
adolescent development.

Evolutionary context
For many years, an assumption has been that EF is a singular, phylogenetically higher-order
cognitive skill that identifies us as human and differentiates us both behaviorally and
dynamically from other mammalian species. Bernstein and Waber, among others, have
reminded us that this fallacious concept ignores the reality that problem solving is an
inherent aspect of mammalian development.7 Although it was initially believed that the size
of the PFC was a critical difference between humans and other species, comparative analyses
indicate that the frontal lobe to total brain volume ratio is consistent across primates,
including humans.8–10 It appears that white matter volume is a differentiating factor, with
humans having more white matter than other primates.11 However, it is difficult to know
whether this represents basic species differences, or whether modern human brains reflect
high levels of stimulation that cause greater interconnectivity.12 Ultimately, it remains
important to remember that, as highlighted by Bernstein and Waber:7
“the frontal lobes are neither new in evolutionary terms nor special to humans: they have been part
of the neural apparatus of the mammalian line for 176 million years. The goal-oriented behavior
that these neural systems support is not only common to all mammals, but also critical to their
survival and to the evolutionary success of the whole mammalian enterprise . . . [The EF-directed]
control processes are – indeed, must be – inextricably embedded in the total package of biological
systems that all animals need to obtain food, reproductive partners, and other critical resources”
(p. 40).

Historical context
The concepts referred to as EF today have been considered for centuries. The Bible seems
to mention EF in verses written in approximately 900 B.C., “A man without self-control is
like a city broken into and left without walls.”13 In 1835, deNobele described impairment
after damage to the frontal lobes,14 although the more famous case is that of Phineas Gage,
who was described by Harlow in 1848.15–18 The importance of these cases was realized
retrospectively, after prominent neuropsychologists began to draw attention to this
concept.
In 1964, Teuber published a paper entitled, “The Riddle of the Frontal Lobes”.19 Much
of his commentary could be reiterated today, nearly 50 years later. He wrote,
“Man’s frontal lobes have always presented problems that seemed to exceed those encountered
in studying other regions of his brain . . . these assorted aspects of frontal lobe dysfunction, in
infrahuman species, are dissociable, since any one of these symptoms can be shown to occur

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

Chapter 1: Models of executive functioning 7

2000 Fig. 1.1. Number of articles

Articles including EF (PubMed)

1800 indexed in PubMed that

included EF or EdF (search
1600
terms ¼”executive function “OR”
1400 executive dysfunction” OR
1200 “executive functions” OR
1000 “executive dysfunction” OR
800 “dysexecutive “OR” executive
600 deficit “OR” executive deficits”)
400
200
0
1960 1970 1980 1990 2000 2010
Year of publication

without the others . . . Despite the conspicuous efforts and ingenuity that went into behavioral
analysis of these frontal lobe symptoms, their interpretation, in terms of some basic alterations
in carnivore or simian behavior, remains elusive . . . During the first third of this century, there
developed a substantial majority opinion which ascribed to the frontal lobes all the highest
conceivable functions – from “abstract behavior,” foresight, and intellectual synthesis, to capacity
for ethical behavior, control of affect, awareness of self, and recent memory. In the early forties
and through the fifties of the century, the pendulum swung in the other direction – toward a
denial of any especial importance of human prefrontal structures” (p. 25).
A next landmark in the consideration of EF is “the frontal lobe syndrome” described by
Luria in 1969.20,21 This term was coined at a time when EF deficits were believed to occur in
conjunction with insults to the frontal lobes. Although Luria22 did not explicitly refer to EF
in writing, he did attribute deficits in the ability to solve complex problems to the frontal
lobes as the locus for the “complex process of formation and execution of a programme”
(p. 219).
The first intentional use of “executive” in the published literature was noted in Baddeley
and Hitch’s model of the “central executive,” which is discussed later in this chapter.23 This
concept gradually gained popularity, including Schaie’s description of the “executive
stage of adult cognitive development” that he postulated emerged in the 30s and 40s.24
Shallice25 used the phrase “executive functions and their disorders” in a 1982 publication
applying the Norman and Shallice supervisory attentional system concept to explain
performance of patients with brain lesions (p. 199). Although the first edition of Lezak’s
well-referenced volume26 did not include a section about EF, she addressed many of the
components we now consider as such. In the second edition,27 she included a chapter
entitled “Executive Functions and Motor Performance,” describing the problems inherent
in assessing EF.
Although the earliest publications about EdF in clinical populations focused on brain
injury, the late 1980s showed an emerging interest in the EF concept as it was exhibited
in other clinical conditions including schizophrenia,28 ADHD,29 and phenylketonuria
(PKU).30 This slow trickle of research quickly became a torrent, with the 1990s showing
an explosion of articles regarding EF in various conditions. The number of articles per year
focusing on and addressing this concept has only increased (see Fig. 1.1).
In the following sections, a handful of influential models will be examined, including
evolution of language, the central executive, the Supervisory Attentional System, Theory of

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

8 Section I: Foundations of Executive Function/Dysfunction

Mind, self-regulation, “hot” and “cold” EF, the Cognitive Complexity and Control theory,
and structural equation modeling with latent variables. These models are presented roughly
in the order of publication, although it can be difficult even for theorists to know whose
idea came first. Each of these models has influenced other models and impacted our current
views of EF and EdF.

Evolution of language
Bronowski, a physicist, mathematician, linguist, philosopher, and educator, presented his
theory in 1967 to explain why human language was different from communication in other
species.31 Elements of his model included (1) a delay between a stimulus and a response,
(2) separation of affect/emotional charge, or processing content rather than simply
responding to affective charge, or self-regulation of emotion, (3) prolongation of reference,
or the capacity to recall the past to inform future decisions while keeping in mind the
present situation (much like what we now call WM), (4) internalization of language,
referring to private self-reflection and self-exploration allowing consideration of options
before responding, and (5) reconstitution, analyzing parts of a situation and synthesizing
them to construct a new response. He summarized these steps as allowing humans to
disengage from their current context and influence their environment by understanding it,
and connected the ability to delay response to development of the frontal lobes.32 Although
Bronowski’s model focused on language, it showed consideration of what would come to be
called EF in a few years. This model was a primary influence for Barkley’s33 model of
executive functions in ADHD (see below).

Working memory (central executive)

In 1974, Baddeley and Hitch published a chapter describing their three-part model of WM23
that was developed in response to concerns about the existing model that a short-term store
held information until it could be entered into long-term memory (LTM). Their tripartite
model was controlled by a system of limited attentional capacity, the “central executive,”
which was subserved by two storage or “slave” systems, the phonological loop and visuo-
spatial sketchpad. Baddeley and Hitch were not the first to use the term “working memory,”
but they were the first to include specific mention of an executive component.34 This
model of a unitary attentional executive within a WM system was challenged by findings
of intact immediate memory in patients with severely impaired LTM, findings that sur-
passed the capacity of finite slave systems. The original central executive was not believed
to have any integrational capacity, which meant the model could not explain facilitation
of short-term memory (STM) by LTM (as occurs in chunking) nor did it allow for
crosstalk between the visuospatial and auditory slave systems. After the proposal of a
dual-process control by Norman and Shallice35 (see below), Baddeley added the “episodic
buffer” to his model, a finite system controlled by the central executive that holds infor-
mation long enough to be integrated.36 Baddeley ties the central executive in this model to
a distributed neural network, writing “[t]he central executive is likely to engage multiple
brain regions in a functionally coherent network, including dorsolateral prefrontal cortex”
(p. 836).34 The central executive model has been criticized for creating a homunculus
within the brain.37

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

Chapter 1: Models of executive functioning 9

Attentional control (supervisory attentional system)

The information processing model of attentional control was presented by Norman and
Shallice in 1980.35 Rather than a single executive, Norman and Shallice proposed two
control processes: (1) routine habits, or pre-existing “schemas,” that control a specific
overlearned action or skill, and (2) an intentional “supervisory attentional system” (SAS)
that comes online when a situation is non-routine. This grew out of the information
processing movement related to artificial intelligence solutions to problem solving. Even
in routine situations, “contention scheduling” selected a certain number of schemas to
activate, inhibiting the others until environmental demands changed. The SAS serves to bias
contention scheduling such that different schemas are activated.
In a subsequent paper, Shallice referenced Luria’s work with frontal lobe lesions, stating
that the study of executive functions and their disorders was a good area for interaction of
cognitive psychology and neuropsychology.25 He then evaluated what his model could
predict about “high-level cognitive impairment” (p. 202). Shallice hypothesized that an
inoperative SAS would leave a person reliant on the contention scheduling system; this
would produce predictable behaviors that were slow to change (i.e., perseveration). In the
presence of strong environmental triggers that activated schemas, the person would have
difficulty inhibiting (i.e., distractibility), and in the absence of strong environmental triggers
he would likely do nothing at all (i.e., apathy). He drew strong parallels between these
predictions and observations of animals and humans with frontal lobe lesions. Like the
central executive model, the SAS has been criticized for creating a homunculus within
the brain.37

Theory of mind
The concept “theory of mind” was first described by Hebb in a 1958 lecture.38 The term
appeared again in 1978 when Premack and Woodruff 39 discussed its relevance to under-
standing chimpanzees, defining theory of mind as the ability to attribute mental states not
only to self, but also to others (e.g., “I think John likes you,” or, “I guess she will be happy
with this gift.”). They postulated that this ability allowed chimpanzees to make inferences
about what others believe to be the case and thus make predictions about their probable
actions. They concluded with a discussion of preliminary data from human children
showing that they did not show evidence of inferred mental states until about 4 years old.
Alan Leslie presented on theory of mind in autism at a 1983 conference,40 later
publishing a paper with Uta Frith and her doctoral student, Simon Baron-Cohen, on the
subject.41 They described a model of “metarepresentational development . . . being able to
conceive of mental states: that is, knowing that other people know, want, feel, or believe
things” (p. 38), saying that the ability to form second-order representations was a pre-
requisite for existence of this theory of mind which subserves social skills.
Frith and colleagues examined theory of mind with a variety of clever manipulations
dealing with beliefs and false beliefs. In the well-known “Sally and Anne scenario” (an
example of a “false-belief” task), Sally puts a marble in a basket and then leaves the
room. Anne hides Sally’s marble in her box. Sally returns, and the experimenter asks,
“Where will Sally look for her marble?” If theory of mind is present, the child will
recognize that Sally expects the marble to be where she left it, and he says she will look in
the basket. In the absence of theory of mind, the child does not discriminate between
his knowledge and Sally’s knowledge, and he says Sally will look in the box. There were

© in this web service Cambridge University Press [Link]

Cambridge University Press
978-0-521-88976-6 — Executive Function and Dysfunction: Identification, Assessment and Treatment
Edited by Scott J. Hunter , Elizabeth P. Sparrow
Excerpt
More Information

10 Section I: Foundations of Executive Function/Dysfunction

four questions asked: Naming (names for each girl in the story), Belief (where does Sally
believe the marble is), Reality (where is the marble really), and Memory (where was the
marble in the beginning). All members of the clinical samples (children with autism and
children with Down Syndrome) and normal control groups replied accurately to the
Naming, Reality, and Memory questions. The Belief question was answered accurately by
85% of the normal control group, 86% of the Down Syndrome group, and 20% of the
autism group (p <0.001); the children with autism pointed to the current marble location
when asked where Sally would look for the marble. In other words, the children with autism
did not demonstrate a theory of mind.
Over 1500 articles about theory of mind have been published since that time, many
examining the construct in autism. Theory of mind has been explored in typical develop-
ment42–44 as well as in clinical groups beyond autism, including disruptive behaviors,45,46
Fetal Alcohol Spectrum Disorders (FASD),47 traumatic brain injury (TBI),48 bipolar dis-
order,49 and schizophrenia.50 Although there are differing views regarding whether theory
of mind has EF components, whether EF is a prerequisite for theory of mind, whether
theory of mind is a prerequisite for EF, or whether theory of mind is actually an example of
an EF skill, results from a number of analyses show a close relationship between theory of
mind and EF,45,46,51–56 with a meta-analysis finding a strong effect size of 1.08 for the
relationship.57

Self-regulation in ADHD
In 1997, Barkley proposed a formal model of executive dysfunction in ADHD.33
His model reflected a core deficit in “behavioral inhibition” that influenced four specified
EF skills (WM, internalized speech, self-regulation of affect/motivation/arousal, and
reconstitution); all five of these components impacted the motor control systems.33
Barkley58 proposed that “behavioral inhibition sets the occasion for the executive func-
tions to occur” (p. 193). He58 described behavioral activation as playing a support role,
writing, “I would not consider arousal or activation to be executive functions in them-
selves” (p. 194). He criticized past descriptions of the central executive, saying they
produce another black box or homunculus within the brain. Barkley58 proposed instead
that the central executive might actually be “time, or the individual’s sense of the future,”
(p. 202) in that review of the past and future-directed goals represent self-regulation
relative to time.
The influence of Bronowski’s31 model on Barkley’s33,58 work is clear, as the new model
expanded Bronowski’s five elements beyond language, adding an explicit component of the
motor control system. The element of time can be linked to Fuster’s premise that “cross-
temporal contingencies,” as subserved by temporal organization, temporal integration,
attention, “executive working memory,” and preparatory set, are critical for the timely
organization of behavior and language.59,60 Barkley also acknowledges the influence of
Douglas’ early work on self-regulation as an underlying deficit in ADHD,61 Goldman-
Rakic’s WM model,62 and Damasio’s somatic marker hypothesis.63
Barkley’s model is considered by some critics to be incomplete, and in need of broader
validation than just with a sample of individuals with ADHD. As well, it is likely that this
model serves to capture some but not all of the processes underlying what we conceptualize
as EF. However, it does facilitate and foster an empirical approach to examining how EF
interacts with and is guided by broader cognitive capacities.

© in this web service Cambridge University Press [Link]