Executive function in early-treated phenylketonuria: profile and underlying mechanisms

Despite early and continuous dietary intervention, individuals with early-treated phenylketonuria (PKU) experience significant neurocognitive sequelae. An area of cognitive ability that is believed to be particularly affected is executive function (EF). This paper provides a critical review of the evidence for EF impairment in early-treated PKU within the context of recent advances in neuropsychological theory and research. The most consistent findings of PKU-related EF impairment were in executive working memory and prepotent response inhibition. Surprisingly, findings on shifting ability and other more complex aspects of EF were largely equivocal. Cohort (e.g., age, phenylalanine (Phe) levels) and task (e.g., standard clinical versus experimental tasks) related differences likely contributed to the variability in findings reported by these studies. Day-to-day EF also appears to be impaired although the precise pattern of impairment remains unclear, as does the relationship between laboratory measures of EF and questionnaires assessing day-to-day EF. Similarly, whereas several studies have found a relationship between Phe levels and EF, the best predictor variable (e.g., concurrent Phe level, lifetime Phe level, Phe level variability) of current EF performance varied from study to study. Neurologic compromise related to dopamine deficiency, white matter abnormalities, and disruptions in functional connectivity likely underlies the EF impairments described in this review. In closing, this review identifies remaining unanswered questions and future avenues for research.