Executive function disorders: rehabilitation challenges and strategies

Individuals with frontal lobe impairments often demonstrate a variety of disorders of executive function that pose significant challenges to rehabilitation. Impairments in initiation, sequencing, impulse control, attention, prospective memory, and self-awareness frequently manifest in disorganized and maladaptive behaviors that severely impact many aspects of adaptive functioning. A greater awareness of the nature of these deficits, improved tools for evaluation, and an increased interest in rehabilitation have led to the development of both specific strategies and general schemas for treating and managing executive function deficits. Studies supporting the use of environmental manipulations, compensatory strategy training, and techniques to improve underlying skills, including attention and prospective memory, are described. An overarching strategy for working with individuals with impaired executive functions is proposed, based on the individual's level of awareness and context dependency. Rehabilitation is conceptualized as a set of activities, which assist the individual in moving from a more dependent, externally supported state to a more independent, internally supported and self-regulated state through the systematic shift in external to internal regulation of behavior. Successful movement along this continuum is variable across cases, but the literature suggests that significant gains in function and behavior are possible.