Optimizing executive function skills in children: What healthcare professionals should know

Executive function (EF) skills in childhood predict academic success better than a child’s intelligence quotient (IQ), and are associated with better physical health, more stable careers, and higher socioeconomic status in adulthood. [Psychol Sci 2005;16:939-944; J Clin Psychiatry 2012;73:941-950; Pediatrics 2013;131:637-644] Despite this, EF is an important topic that is often overlooked. To learn more about EF, MIMS Doctor interviewed Dr Evelyn Law, a clinician scientist specialising in developmental and behavioural paediatrics. Dr Law is Assistant Professor at the National University of Singapore Yong Loo Lin School of Medicine, Singapore.

EF and its developmental trajectory
“EF refers to a set of cognitive skills that allow an individual to sustain attention, hold information in mind, exercise self-control and regulate behaviours. [Cogn Psychol 2000;41:49-100; Monogr Soc Res Child Dev 2003 68(3):vii-137; Zero to Three 2014;35(2):9-17] These skills support the process (ie, the how) of learning, and enable children to master the content (ie, the what) of learning effectively and efficiently,” explained Law.

EF skills emerge in early childhood in concert with the development of the pre-frontal cortex in the brain. [J Exp Child Psychol 2010;106:20-29; Curr Opin Behav Sci 2016;10:102-107] It develops rapidly in early childhood and continues to improve across adolescence into young adulthood (ages 20–30 years). (Figure 1)

Although infants are not born with a set of EF skills, they all have the capacity to develop them. Typically, children show exponential growth in EF during the ages 3–6 years. The preschool years become an important window of opportunity to boost EF skills with appropriate EF practice and training at home and in school settings, Law emphasized.

Factors influencing EF development
EF skills are measurable in real life using standardised measures. EF is modifiable with training. Multiple studies have examined how social, environmental, genetic, and age-related variables influence EF development. [Pediatrics 2012;129:e232-246] By and large, enriched environments characterised by high-quality and structured child rearing, positive discipline, and adult engagement, as well as adequate cognitive stimulation such as interactive play, language-rich activities, and minimal electronic screen use, are all predictive of better child EF skills. [Child Dev Perspect 2014;8:258-264; Front Psychol 2019;10:1263]

Conversely, toxic stress, poor caregiver-child interactions, and adverse childhood experiences are consistently associated with poorer EF development, Law added. In addition, prematurity, chronic liver diseases, brain tumours, and exposure to chemotherapy during childhood are among the risk factors for impaired EF development. [Pediatrics 2012;129:e232-246]

Impact of early nutritional intervention on EF
Some studies support the direct benefits of breastfeeding on EF skills, but overall, there seems to be more evidence for the benefit of breastfeeding on general intelligence of children. [Am J Clin Nutr 1999;70:525-535; J Dev Behav Pediatr 2016;37:43-52; Swiss J Psychol 2012;71:215-226]

“Notably, delineating the relations between breastfeeding, the composition of breast milk, and later EF skills in children can be difficult due to confounding effects,” Law explained. “While breast milk provides nutritional and immunological benefits, breastfeeding is a frequent bonding activity that may itself enhance subsequent EF skills,” she added.

Numerous macronutrients, micronutrients, and minerals are being studied in the context of EF outcomes. For children with low iron levels, iron supplementation has been shown to be beneficial for EF development. [Dev Med Child Neurol 2013;55:453-458; Nutr Neurosci 2010;13:54-70]

Polyunsaturated fatty acids (PUFAs) are known to be necessary for normal brain development and function. There is emerging literature to suggest the benefits of combined omega-3 and omega-6 supplementation on EF skills in children, although more studies are warranted. [Am J Clin Nutr 2013;98:403-412; Am J Clin Nutr 2013;98:659-667; J Child Psychol Psychiatry 2018;59:628-636]

Holistic approach to addressing EF dysfunction and enhancing EF in children
“It is important to use an ‘ecobiodevelopmental’ framework in understanding children with EF difficulties. If a child is exposed to a suboptimal environment on a daily basis and has poor EF, the strategy to help this child may require a transdisciplinary approach involving social services, family guidance, as well as various healthcare professionals,” Law pointed out.

Other than obtaining a good family and social history, screening for additional developmental conditions or learning disorders is necessary, as these are often associated with comorbid EF deficits. To discern the child’s full developmental profile, specialist referral may be required, she advised.

“On a population level, children with typical EF development can also enhance their skills through everyday practice. An effective strategy is to empower teachers to provide students with EF training during in-class activities. My research team has developed a teacher-led classroom-based EF training programme for kindergarteners, which is intended to build EF in all children, and not only in children with deficits,” she shared.

How healthcare professionals can support EF development
Explaining the concept of EF to parents and caregivers takes time and energy on the part of healthcare professionals (HCPs). Parents from different backgrounds have varying degrees of interest in this topic. “Increasing the awareness of parents about the importance of these early skills may be a good start,” Law said.

Since every child has different EF profiles, there is no one-size-fits-all recommendation. However, given the ubiquity of digital devices, HCPs can educate parents about the strong links between excessive screen time and poor EF skills, and advise parents to support EF development by setting reasonable limits on media use, she continued.

When parents bring up symptoms that are consistent with either attention or EF deficits, it may be wise to screen the children using tools like the Executive Skills Questionnaire by Dawson and Guare (2010) or the Vanderbilt Rating Scale by Wolraich (2003). Poor attention or EF skills deserve an early referral to a child development specialist for further assessments, Law advised.