“What exactly is executive functioning, and what can be done to improve it?” – with Dr. Marla Baum PsyD

In this episode, Dr. Nathan Fox speaks with Dr. Marla Baum, a child psychologist, about executive functioning, which is a label that’s used to characterize and quantify all of the skills that you need in order to go about your day successfully. They also discuss how this may tie into issues such as ADHD or OCD in kids.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and Maternal Fetal Medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right. Dr. Marla Baum, welcome back to the podcast.

Dr. Baum: Thank you.

Dr. Fox: We just spoke to each other like a minute ago. And we’re doing podcast number two back to back. Because you know what? You’re busy. You’re seeing people. You’re helping. You’re saving the world one kid at a time.

Dr. Baum: Oh, yeah. Right. That’s the goal.

Dr. Fox: That’s the goal. And we mentioned this on the prior podcast on ADHD that there’s this concept called executive functioning. And one of the things you do is executive functioning, I guess coaching, or improvement, or skills. And I thought it’d be a really interesting follow up and an interesting topic also itself. What the hell is executive functioning? What are we talking about here? Because it’s a big thing. It’s a big buzzword, hot topic, important stuff. So, who better to break it down than Marla Baum?

Dr. Baum: Okay. I’m happy to be here, Natey. Thank you so much for having me. [Inaudible 00:01:16] so much fun.

Dr. Fox: Let’s do it. What is executive functioning? What are we talking about here?

Dr. Baum: Okay. Executive functioning is a label that’s used to characterize and quantify all of the skills that you need in order to go about your day successfully. Now, obviously, that’s a very big term because there’s a lot of skills that we need in order to negotiate the daily demands of our lives. Executive functioning, it comes from the word executive. If you think about an executive assistant, it’s that part of your brain that helps you stay organized and on track and focused. There’s a lot of overlap between difficulties with attention and difficulties with executive function. It’s not a total overlap. I’ve had many patients that have one or the other. But very often, kids have both attentional issues and executive functioning issues.

So, executive functioning can basically be broken down into two main subsets of behaviors. One set is about your behavior regulation skills and the other set is about what I call work-based executive function. Some people will call it metacognition, your ability to get organized and get your work done. So, first, let’s talk about the behavior regulation.

Behavior regulation is your ability to inhibit your impulses, control your feelings, particularly when you’re feeling upset. Although, you know, happy emotional regulation can also be a problem for these kids. Being able to transition between activities, a lot of parents will say, “Well, my teacher says my son can’t transition, or my kid can’t get through the morning routine on time.” You know, to be able to move through those times of transition where you’re between activities. And the other type of behavior regulations skill that gets looked at is your ability to sort of see the impact of your behavior on those around you. Like, if you are not really self-regulated, and you’re screaming, are you able to pick up on the fact that you’re irritating the people around you because you’re too loud, for example?

So, those four main behaviors comprise what we call the behavior regulation aspects of executive function. The other type of executive functions are the work-based ones. That is your ability to see a task and figure out how to get started, staying focused while you’re on task, which is why this overlaps often with attention, being able to sequence out a set of steps in order to plan out how to complete a novel task, monitoring what you’re doing while you’re doing it to make sure you’re following task directions, answering the question correctly, monitoring your writing for punctuation and spelling and grammar while you’re actually doing the writing.

And the other one that goes under this domain is your ability to what we call maintain order amongst your belongings, which basically means, is your stuff a mess or is it relatively organized? Is your room a mess, your backpack, your locker, anything where you have to keep track of papers and books and things like that? You know, what people often call planning and prioritizing your assignments, seeing big tasks through to completion by breaking them down into smaller chunks. Those are all what we call work-based executive function. So, when I’m assessing a child, I look at both because they’re both equally important.

Dr. Fox: You know, for full disclosure, when we spoke about ADHD, I knew a fair amount about it, you know, nothing at a sort of a master level. I know nothing about executive functioning and what it is. So, I’m asking you like basic questions here. And pardon me if they’re not really good ones.

Dr. Baum: Sure. No.

Dr. Fox: So, what you’re saying is obviously the things you’re describing, it would make sense that someone who has ADHD may have difficulty with some or all of those potentially. And treatment of ADHD with medication or therapy, this would obviously, hopefully improve many of these things. But you’re saying that there are people who have these things or troubles with these things or difficulty with these things who would not have the diagnosis of ADHD. I mean, you do testing, and you’re like, “They don’t have ADHD. They’re just really bad at emotional regulation or behavior regulation.”

Dr. Baum: Correct. Correct.

Dr. Fox: And is that something that would get teased out in your neuropsych evaluation? Meaning you do a full evaluation, you say, “Hey, good news. Your daughter does not have ADHD, but I found that she has certain aspects of work-based cognition issues, and here’s what they are. And she has certain behavior regulations, and here’s what they are. And we’re gonna sort of go there. But she’s not gonna be helped by Ritalin because she doesn’t have ADHD.”

Dr. Baum: That’s interesting. It’s interesting you bring this up. So, yeah. So, the main thing is that ADHD medication, which often gets looped into this because the attention executive functions, it’s all the same area of the brain. It’s all the frontal lobe. Medication will not teach you how to be organized. Medications doesn’t teach you how to be able to break down a 10-page paper, and organize it, and get your research, and figure out what you’re gonna say when, and what to quote, and what not to quote. Medication doesn’t help with that. Medication will help with, if you have a difficulty focusing, it will allow you to have the stamina to get through these executive functioning tasks. But if you have a deficit in executive functioning per se, then you need to what we call be taught how to be more organized.

And so, usually, when I’m assessing and I see that a kid is having trouble with this, really the main recommendation is to work with an executive functioning coach, someone who has a lot of experience teaching these skills. Sometimes, it’s a really well-seasoned teacher. Sometimes, it’s a learning specialist. Sometimes, it’s psychologists like me. So, there’s a lot of people that can do this executive functioning work because it’s really not amenable to medication.

Dr. Fox: Right. Or if there was an attention issue, you could fix that. But then, you still have to work on the… you know, it’ll help them be present for the coaching essentially.

Dr. Baum: Correct.

Dr. Fox: Got it.

Dr. Baum: Exactly. Very well put.

Dr. Fox: Oh, thank you. Now, when you were describing the work-based or the metacognition part, what struck me is you are almost describing the exact opposite of OCD in a sense, or what people think of as OCD. Are those two things just the polar opposites of the same spectrum? Are they totally unrelated to one another?

Dr. Baum: They’re very different psychological experiences. So, someone with executive functioning issues, they just can’t figure it out. Like, they have a list of assignments, and they can’t figure out what should they do first, second, third. And then, what am I gonna need in order to do steps one and two? Is that different from what I need for step three? You know, that’s a very different experience in someone with OCD who’s having all these intrusive thoughts.

Dr. Fox: Right. I guess what I was saying, like, if you take someone with the messy backpack, is it messy because unlike someone with OCD, they just don’t care that their backpack’s messy, where someone with OCD, it would like drive ’em nuts, like, they could not deal with their backpack being not messy, or is it the person who has a messy backpack might want it to be neat, but has no clue how to do that?

Dr. Baum: Correct. That’s exactly right. And that’s when it goes to, like, you know, there’s this concept in the field, is the behavior ego-syntonic or ego-dystonic. Yeah. I’m really dazzling you now. If the behavior is ego-syntonic, that means the person doesn’t care. It’s not bothering them. You know, I deal with this with kids with OCD symptoms, actually. Yeah, I have two patients I’m thinking of in particular. And it’s like, “Well I’m not bothering anybody by, you know, making sure I tap my foot before I’ll feel safe to leave the house. So, if I’m not bothering anybody and it’s not bothering me, then like, why am I seeing you, Dr. Baum,” you know?

Dr. Fox: And what do you say?

Dr. Baum: I say because, you know… I mean, a lot of times, I’ll end up saying, “You know, because eventually, it’s gonna be a problem. So, it’s nice to get started with these things early.”

Dr. Fox: “Because you’re still under the rule of your parents, bub, sorry. They want you here.” Yeah.

Dr. Baum: But when the issue is ego-dystonic, meaning like awry or going against, when you don’t want the behavior, like, the kid that wants a neat backpack, but has no idea how to do it, that’s more of an executive functioning issue, you know, that can be worked on and, you know, through executive functioning means as opposed to, you know, if it was like an OCD sort of situation. But it speaks a lot to the fact that when you’re doing executive functioning work, the kid really has to wanna do it. It’s very difficult to do the work with a kid that doesn’t really care, you know, if they have this issue or not. It has to be bothering them in some way. Otherwise, why are they coming in?

Dr. Fox: Yeah. I mean, you mentioned the coaching for the work-based. Is it also coaching for the behavior regulation or is that a little bit different?

Dr. Baum: It’s different sorts of skills. So, when it comes to the behavior regulation piece, sometimes, that gets treated through medication. Sometimes, that gets treated through the behaviorist, like training the child how to stay focused during transition. And a lot of times, there’s a lot of, you know, cognitive behavioral and dialectical behavioral strategies that you can use to help kids with their emotional regulation. Sometimes, those same strategies can help with executive function. It really depends on how it’s manifesting for the child.

So, if it’s a matter of not being able to keep track of their assignments, that would lead down the path of, “Well how are you writing down your assignments? Do you need to have a planner? Do you wanna use your computer?” You know, figuring out what works for the child versus if the issue really only comes up in their writing because a lot of kids with executive functioning issues have a lot of trouble with writing, then they really might need a writing tutor that can help them with the organization of their ideas when they’re doing writing. So, I’m making it sound murkier than it is. But there’s a lot of different things that you can do based on how the executive functioning issues are manifesting.

Dr. Fox: Well, yeah. It makes sense they’re sort of targeted. Like, what is the thing they’re struggling with? And you target towards that because, again, unless it’s ADHD, it’s not a global issue per se. Like, you can’t go to the peak of the pyramid and it’ll fix everything downstream from it. It’s really just what’s going on. You said with the behavior, you mentioned medications. Did you mean the same medication you would get for ADHD or are there more, since this is like emotional mood stuff? Would it be like a different type or class of medication?

Dr. Baum: Excellent question. So, when you’re working with a child that has the emotional regulation issue, that’s where it’s very important to get a sense from the child and the people in their lives. What are the triggers? Does it seem more like they just get overly silly when they’re with their friends because they’re so excited but they have trouble modulating their excitement, or is there more of a mood component? Is there an anxiety that might be brewing, or are there depressive symptoms that might be present? So, when it comes to the medication, sometimes it will be the ADHD medication that will help because that’s the child’s experience that they’re just really revved up and they can’t calm down. Or if there’s more of an anxiety or sadness to it, that would then lead maybe down the road to a different kind of medication.

Dr. Fox: Interesting. And I would think that the behavior regulation portion would probably present younger than the work-based one. Is that correct?

Dr. Baum: Yes. And this issomewhat regional in terms of the country’s geography. So, yes. The younger children, it’s more of the behavior regulation piece. But I will tell you, living in New York and New Jersey, the demands that we put on our kids in kindergarten…

Dr. Fox: Oh, I hear you. Yeah. My three-year-old’s poetry is a little bit disorganized.

Dr. Baum: You know, there are just some kids that, you know, if you give them a bucket of blocks, and you say, “Go build,” they will go build. And other kids will be like, “I have no idea how to start. I don’t know what to do.” You know, so, you can see the beginnings of some of the work-based executive functioning issue during pre-K and kindergarten. But yes, I mean, mostly the work-based executive functions come up more in like third grade.

Dr. Fox: Interesting.

Dr. Baum: Because executive functions can hit you in your reading comprehension. It can hit you in your written expression and things like that. So, you can see brewings of it in the early elementary grades, but it’s really by about, you know, second half of second grade into third grade. They don’t see the work-based stuff come up.

Dr. Fox: Is this something where if it’s left undiagnosed or untreated, it’s gonna really lead to like bad grades in school, you know, sort of difficulty achieving? Or is it just more frustrating or both?

Dr. Baum: Well, it’s both. It’s both because what ends up happening, these are the kids that the teachers will say, “You know, I know they know it, but they can’t apply themselves. They can’t apply what they’ve learned.” That to me is a huge red flag because the ability to sort of take the information and figure out how to apply it to a new problem, that’s an important executive function. So, it comes up in your ability to sort of argue a thesis when you’re writing, your ability to see the main ideas in detail in reading comprehension. Those are executive functions also. So, what happens is a lot of times the kids know it, but they can’t show it. And those are the kids that end up getting frustrated because their grades don’t match what the teachers say and parents say is the child’s potential.

Dr. Fox: Yeah. It seems like that’d be really hard to sort of recognize. I mean, the behavior part, I guess, it’s pretty straightforward. Like, this is the kid who we can’t get to go from playtime to sitting time or from when they’re sad, they’re sad all day, and when they’re happy, they’re happy all day. You know, all right. That seems like it would manifest pretty obvious whether it’s a problem or not a problem, whatever. But everyone’s gonna recognize it. But how would someone know, like, my kid is having a hard time with math? And they’re like, “All right. Let’s, you know, put them in an easier class or let’s not challenge them, or let’s hold them back a grade,” or something like that. How would a parent know or a teacher know whether it’s just, all right, you know, they don’t have the chops for this, versus no, they do, but they don’t have executive functioning skills? Like, because who’s heard of this?

Dr. Baum: So, the main way it comes up in math, to use your example, is the child will learn how to solve the problem when it’s in one format, but then they can’t then shift and apply that structure to another problem. So, like, if they learn how to solve for an algebraic variable and that algebraic variable was on the left side of the equation, if the teacher then flips it and puts the algebraic variable on the right side of the equation, can the kids shift and be able to do that if they recognize? So, that’s a basic level with math. Another way is in word problems. The child will learn a certain type of word problem with like one set of numbers and then the teacher gives a new problem that’s almost the same structure, but there’s different numbers that have to be calculated. It’s your ability to sort of apply the structure of what you’ve learned to a novel path. That’s math.

In reading comprehension, it’s the ability to see the main ideas versus the details. And then, in writing it is your ability to organize a thesis statement and organize your supporting evidence and, you know, all those graphic organizers that the kids are now using to learn how to structure these five-paragraph essays. That’s where in the writing, the executive function issue can come up.

Another way it can come up that’s not necessarily so subject-based is if you have eight assignments that you get assigned on Monday, and they’re all due Friday, what do you do? Do you start with the easier ones to get them checked off? Do you start with the harder ones? How do you know which one is hard? Does one need a lot more prep in order to be able to get done? Do you have to go do research? Or how long will each one of these take? You know, your ability to sort of get done what you have to get done within a week, managing your schedule and things like that.

Dr. Fox: What I’m trying to get is, like, I get how you would be able to tell the difference between the two. But how would a student know, or a parent know, or a teacher know if the student’s not able to do this, that they need to get assessed for executive function? I’m just thinking like a listener’s out there, and they’re like, “Hey, my kid’s in fourth grade and struggles in math.” And everyone’s just said, “Well, you know, he’s not great at math. He’s really good at music.” But is he really not great at math or does he just have executive functioning that’s undiagnosed? Is this something that all the teachers know about?

Dr. Baum: I hear what you’re saying. Teachers do know about this. I’ve definitely done a lot of workshops educating teachers about this. A really good teacher will know if the child knows the material and if they’re able to show it on a test, or they are so articulate when they’re discussing the concepts in class, but their written work doesn’t reflect what they say. You know, so, what you’ll end up hearing as a parent or the pediatrician is something along the lines of, “Well, they’re not showing me what they know. I know they know it, but then, they can’t apply what they know. Or there is such a discrepancy between what they know and how they’re doing on the test.” So, that’s a lot of what you’ll hear.

And then, a lot of times, the parents will say, “You know, get my kid to sit down and get his homework done. It’s like pulling teeth. He can’t do anything himself. He needs constant supervision. He can’t figure out what to get done first.” And then, it comes Thursday night, and he got all of his easy assignments done, but he left the hardest one to the last minute. And he’s not prepared, and I have to go get all these arts and crafts, you know, because the kid didn’t think it through in terms of managing all of their assignments. So, those are the types of things that you hear that you’ll start to think yourself, “Is this an executive functioning problem?”

Dr. Fox: And so, if they’re sent to you with a diagnosis or you diagnose them and you’re gonna start to do executive functioning work with them, what does that even entail?

Dr. Baum: Again, I always say it sort of depends. If the issues are more about time management and planning and prioritizing your assignments, that sort of treatment, really it’s just a very frank conversation where you go through a set of steps. What do you need to do? How long is each one going to take? What materials do you need in order to do all of these assignments? If you don’t have some of the materials, what do you need to do to get them? And I really just talk it out so explicitly with them so they start to see the process of getting yourself organized.

For example, if they have to do like one of these, you know, like crazy arts and crafts projects where they have to go to one of the stores and get all these materials, if they wait till Thursday night and it’s due Friday and they don’t realize till about 8:00 they’ve gotta do it, if the store’s closed, what are you gonna do, right? Then your work is gonna be late.

So, I always start my executive functioning sessions with kids by taking out their planner and opening up either what they’ve written down on the planner or most of the times nowadays, I have kids log on to their online school portal, whatever it might be, Schoology, Haiku, any of these portals that schools use. And I have the kids write down all their assignments. And I have them think through all the aspects of planning and prioritizing so that they know what they need to do when, and I have them write that down. That’s one aspect of the executive function.

The other main aspect that I personally have a lot of experience with is helping kids with their writing. So, I’m actually trained on the Windward Schools Methodology. It’s called the Hoffman Method. It’s really just how to teach writing in a very explicit step by step way. How do you develop your thesis? How do you develop your body paragraphs where you have to give supporting evidence? And all those aspects of writing that a lot of it does get taught in the context of the classroom, but some kids need it more explicitly taught, especially the kids with executive function and organization issues.

So, in that way, I will have them bring in their papers. And we’ll go through the process over the number of weeks that I see them for that particular assignment. We go through, you know, what do you need to have done by when? And, you know, what research do you have to do? And where are you gonna go find those articles? And, you know, it’s a very long, big process that takes a lot of management, which is why it has to be broken down step by step for these kids because they’re not able to do that on their own.

Dr. Fox: I mean, it sounds like this type of work would be helpful for everybody. Who wouldn’t benefit from this? That sounds awesome, you know?

Dr. Baum: Yeah. You’re exactly right. And there’s a lot of schools that have sent their teachers for training on writing organization or executive functions in general because the teachers are in a unique position to really help with the development of this. I’ve worked with so many schools. Some teachers are really game who work on all of this explicitly with their kids, with their students. You know, some teachers are less wanting to do that, you know? A lot of times, schools have learning centers where you can get executive functioning support. And sometimes, the situation warrants where you have to have someone privately help the child.

Dr. Fox: Right. How would they find someone who specializes in this? Is it a certain degree? Is it just experience? Is it, you know, “My kid needs executive functioning.”

Dr. Baum: That’s where it gets tricky because there are a lot of different people that can do this. A really fantastic teacher that really understands executive functioning and sees how important they are, they can do it. A learning specialist can do it. I’ve met some guidance counselors that are able to do it. And then, sometimes, you know, I end up doing it, you know, for different reasons or whatever.

So, you wanna look for someone who’s a learning specialist or a lot of times people will advertise these companies that do like executive function support, you know? And then, most clinicians in our world have a list of people that they refer to that they know are good. Unfortunately, sometimes, you just have to see how a person works, and then, you can feel more confident making recommendations. So, you know, I have a whole list of people who I know are very good no matter what their background might be originally, and I refer to them.

Dr. Fox: Right. Now, there must be families out there where one or both of the parents has very high executive functioning and one of their kids or all their kids or some of their kids don’t. Is this something that parents can themselves coach their kids on? Like, you know, some of the things you’re mentioning, like, okay, let’s develop a schedule. Let’s look what you have to do. Let’s map it out, let’s do this. I mean, parents do that with kids with certain things a lot. I mean, maybe not so much like writing, coaching and tutoring, but some of the other stuff. Is this something that parents can be good at or do you advise like, “Don’t bother. You’re just gonna all be fighting all day?”

Dr. Baum: You know, you just said it. If there’s a lot of fighting, then I tell parents to not get involved anymore because there’s always this notion of shame on the child’s part that they’re not meeting their parents’ expectations. And my experience is that parents with good executive functions really just don’t get how the kid doesn’t have good executive functions. It’s hard for people that are so organized to then like break it down into one thing at a time. So, most of the time, there’s fighting going on and so I want the parents out of it. You know, let the parents just be the parent. Sometimes, if it’s a really nice, good working relationship between parent and child and the parent has the patience and the wherewithal to do some of this, sure they can. But you’re right in what you said that when it comes to like writing papers and things like that, then you really need someone specialized in it.

Dr. Fox: That’s interesting. Now, when you’re working with these kids, this is something obviously that’s gonna continue through middle school, high school, college, adulthood, whatever, is it something where the things that you’re doing are quite effective sort of right away, or is this like a lifelong thing? I mean, do you ever like graduate kids and say, “You’re functioning. Your executive functioning is tiptop now. Like, off you go to the world.”

Dr. Baum: That’s an excellent question. So, I had mentioned this before in the talk we did on ADHD. So, these kids are on the two to three-year developmental lag in their executive functions. It follows a lot of the same timing as the attentional issues. So, these kids need to be explicitly taught. The research shows that after two or three years of being explicitly taught, they’re usually good to go so that they can manage their time and prioritize their assignments. They know what they need to do and when to do it. A lot of times, they have mastered the ability to write effectively or see the main ideas and details when they’re doing reading. And then, they might just want the support when they need it for something big.

So, like, I’ll have a lot of kids that will go to college, and they’re generally fine. But they still wanna go to the learning center at school just to go over their papers just to make sure it’s organized enough and, you know, they’re saying what they wanna say and things like that. So, some kids do graduate. Some kids end up needing more support, and it’s really a case by case basis as are most of these things in this field.

Dr. Fox: That’s really interesting. If someone’s just curious, you know, reading more about it or learning more about it to see if it sort of fits what their kid is like or just…

Dr. Baum: About executive functions?

Dr. Fox: Yeah. Is there other good books out there or websites or anything?

Dr. Baum: Yes. One of the gurus in the field who I’ve had the good fortune of hearing speak, her name is Peg Dawson, D-A-W-S-O-N. She writes a book. It’s actually a series now called “Smart but Scattered.” And she has really, really, really effective interventions in there for every aspect of executive functioning that I spoke about earlier. She lays it out very clearly. It’s very easy for the parents to understand, and she gives a lot of good information and advice for parents how to help their kids manage and develop their executive functions. I give her books out regularly. I reference them regularly. She’s very good. That would be the main thing I would recommend.

Dr. Fox: You’re very good, too.

Dr. Baum: Oh, thanks. Oh, thanks.

Dr. Fox: Marla, thank you so much for doing this. I really appreciate it. This is such helpful stuff, you know, for parents.

Dr. Baum: You’re welcome.

Dr. Fox: You know, listen, being a parent is a disaster. It’s terrifying. We have no idea what the hell we’re doing, all of us. And we’re just like hoping we don’t ruin these kids forever.

Dr. Baum: That’s true.

Dr. Fox: And this is stuff that it’s just, you know, who knows? Like we don’t know what we’re doing. And it’s really helpful to have people who can really dissect what’s going on with the kids and what they have, what they don’t have, what’s gonna help, what’s not gonna help, and to educate us a little bit about that. And I really appreciate it.

Dr. Baum: Oh, anytime, Natey.

Dr. Fox: Thank you for listening to the “Healthful Woman Podcast”. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.