Saturday, March 9, 2013

What I Love Lucy can teach us about Executive Function

As a Neuropsychologist, I am often asked to explain executive function to patients, families, physicians and other staff.  Executive functioning is the most complex cognitive domain and the one that is the most sensitive to decline or dysfunction. It is also very difficult to explain and includes many abilities such as multi-tasking, complex attention, speed, attention to detail and mental organization.  It also includes what we call sequencing.

Sequencing in the physical domain includes things like putting one foot in front of the other in a pattern that produces normal walking movements.  In the domain of thinking skills, sequencing involves being able to take in multiple sources of information in sequence, sort out the information, know what information to pay attention to and what to ignore, and to be able to use the information to produce a behavior in the correct sequence.  

In English please!  Of course.  Imagine a conveyor belt sending items toward you at a certain speed.  If your executive function is working well, you can see and attend to each item and use it appropriately.  However, if your mental sequencing is impaired, you will have trouble attending and responding to the items appropriately. 

Remember this I Love Lucy episode?

Watch this video clip:  I Love Lucy Video Clip

If there is executive dysfunction, an individual may have trouble keeping up with information that comes at them, sequencing what to do with the information, and producing a useful outcome. 

So for example, if you are talking to someone with executive dysfunction, and they have sequencing trouble, they may miss large chunks or details of what you are saying.  If this individual is older in age, you might wonder if they have memory problems ("I already told you that?") or if in school, you might say ("Pay attention.  Why aren't you focusing").  

Another example is with driving.  If an individual is driving, visual information comes toward them at great speed.  They have to sequence all this incoming information and quickly figure out if "all is well" or if they need to adjust what they are doing with the car.  If they need to adjust, they need to sequence a response (e.g., first I need to take my foot of the gas, then I need to put my foot on the breaks, and I also need to see if I can turn into another lane, etc).  The incoming information is sequenced, and the outgoing response is sequenced. 

Some people who develop executive dysfunction may say "things that used to be automatic, now feel like I have to think about each little step."  Executive dysfunction is common after traumatic brain injury, is the main difficulty in attention deficit disorder, and is often a part of subcortical dementias (where the center of the brain is impacted like in Parkinson's Disease, small strokes, Multiple Sclerosis), and autistic spectrum disorders.

Approaches to helping someone with sequencing problems may include:
1. Providing information in smaller chunks and repeating the information over time.  Individuals with executive function problems probably won't forget much of the information, but they may need repetition to store the information and may need cues to "get it out."  
2. Executive function deficits may become severe enough to create safety problems while driving.  A driving check-up or driving simulation exam may be helpful in these cases.
3. Break down tasks into smaller bits.  The person with executive dysfunction may be able to do small parts of a task independently, even though they can't independently sequence through the whole task.  They may only need verbal cues to keep moving on through the task (e.g, ok, now you finished this part, now move onto this next part). 
4. A significant dysfunction in the executive domain may mean that someone will benefit from cooking assistance and supervision with medications.  Cooking and sorting through medications each involves sequencing and there may be significant safety concerns if mistakes are made.