Let's Talk Executive Dysfunction

How Executive Functioning Deficits Can Manifest as Expressive Language Disorders

A Litte Back Story

A few weeks ago, I was asked to observe a student who was recently re-evaluated for his triennial by the school psychologist. She made some observations that appeared to be a potential social communication deficit and his teachers had similar concerns. When I observed him, my SLP senses weren't tingling. I didn't notice any social communication deficits. I spoke with his teachers which did raise some potential red flags, and I had them each complete a pragmatic rating scale. He received 3 scores that were in the 'well below average' range. I was shocked! Something wasn't adding up...

So, I finally sat down with him to do a full pragmatic language assessment. He scored within the average range. During unstructured tasks, he initiated and maintained conversation, asked me what I liked to do in my free time (if you're an SLP, you know how rare that is!!), shared jokes, understood sarcasm, everything -- no red flags during my social interactions with him. All of which I expected based on what I had observed previously. What I didn't expect were all the seemingly small issues he exhibited throughout the evaluation:

- frequently asked me to repeat the question (could appear to be a receptive language deficit)

- inconsistent grammar and syntax errors (could appear to be expressive language deficit)

- using vague words when explaining something (thing, stuff, etc.) (might be another expressive language issue)

- difficulty retelling stories (expressive language issue)

- huge discrepancy in expressive vocabulary (average) and sentence expression (2 standard deviations below average) scores

And that's when I realized: he has executive functioning deficits! He was not having difficulty with expressive language even though it was manifesting that way. He struggled with attention, organization, and planning, which came across as poor social skills and expressive language. I was able to collaborate with the psychologist and case manager to provide the student with the proper accommodations and modifications he needed on his IEP to be successful.

So, before I get too far in, let's zoom out for a second and talk about language.

What is Language?

Language can be broken down into 5 domains, each playing a crucial role:

1. Phonology: Phonology refers to the study of the sound patterns of a particular language. In the SLP world, understanding the phonological system is essential for assessing speech sound disorders, such as articulation and phonological disorders, which can affect a person's ability to produce speech sounds accurately.

2. Morphology: Morphology pertains to the structure of words and how they are formed. SLPs analyze the morphological aspects of language to identify any difficulties individuals may have in using or understanding word formation, including prefixes, suffixes, and root words.

3. Syntax: Syntax involves the rules governing how words are combined to form phrases, clauses, and sentences. SLPs focus on identifying any challenges individuals may face in constructing grammatically correct sentences or understanding the syntactic structure of language.

4. Semantics: Semantics relates to the meaning of words and how they are used in context. SLPs examine semantic skills to assess an individual's ability to comprehend and use vocabulary appropriately, as well as understand the subtleties of word meanings and language nuances.

5. Pragmatics: Pragmatics encompasses the social aspects of language, including the rules for using language in various social contexts and for different communicative purposes. SLPs assess pragmatic language skills to determine an individual's ability to engage in appropriate conversational exchanges, understand nonverbal cues, and follow conversational rules.

As you can see, language is a large system that builds upon one another. It is also broken down into receptive language, which is our understanding of language, and expressive language, which is our use of language. When it comes to diagnosing language disorders, it's important to note that you can have an expressive language disorder or a mixed receptive-expressive language disorder... you can't have a receptive language disorder. Why? Because you can't express what you don't understand. Hopefully, that is enough of an overview to get everyone on the same page! Now, let's get into executive functioning deficits and expressive language disorders.

Understanding Executive Functioning Deficits:

Executive functioning should be viewed as the CEO of the brain. It encompasses a set of cognitive processes responsible for planning, organizing, and regulating behavior. This intricate system allows us to manage complex tasks, prioritize activities, and adapt to changing situations. From initiating a conversation to maintaining a coherent narrative, these executive functions play a critical role in facilitating effective communication.

Expressive Language Delays:

Expressive language delays, on the other hand, present as difficulties in conveying thoughts, ideas, and emotions through spoken or written language. Children with expressive language delays may struggle to form grammatically correct sentences, use appropriate vocabulary, or articulate their thoughts coherently. At first glance, it can appear to be an expressive language disorder, but sometimes it is merely a symptom of a much bigger issue. It becomes essential to delve deeper into the underlying cognitive processes influencing their expressive language abilities.

The Overlapping Terrain:

Research has increasingly highlighted the interconnected nature of executive functioning and expressive language. It's important to recognize that deficits in executive functioning can significantly impede a child's ability to organize their thoughts, plan their verbal output, and regulate their language in real-time communication. Challenges in inhibitory control may result in impulsive speech, while poor working memory could hinder the recall and organization of vocabulary and sentence structures.

Moreover, difficulties in shifting attention and multitasking can impact a child's capacity to adapt their language to different communication contexts. Consequently, children with executive functioning deficits may struggle to engage in meaningful conversations, share personal experiences, or comprehend complex instructions.

Assessment and Intervention Strategies:

As SLPs, an integrated approach is crucial in addressing the multifaceted nature of executive functioning deficits and expressive language delays. Comprehensive assessments should not only focus on language proficiency but also explore the child's cognitive processes, including attention, memory, and problem-solving skills. In the school setting, cognitive testing usually falls under the psychologists' responsibilities, so it is important to collaborate with them. During my language evaluations, I ask the student various questions relating to attention, memory, and organization.

Tailored intervention strategies can then be implemented, emphasizing the development of executive functions alongside language skills. Incorporating structured activities that promote planning, organization, and self-regulation can effectively support the improvement of expressive language abilities. Techniques such as visual aids, task sequencing, and strategic prompting can aid in fostering communication while simultaneously bolstering executive functioning skills.

The Journey Ahead:

In our pursuit of supporting those with communication challenges, recognizing the intricate connections between executive functioning deficits and expressive language delays serves as a cornerstone for effective intervention. By addressing the underlying cognitive processes that influence expressive language, we can pave the way for improved communication, enhanced cognitive flexibility, and a brighter future for every child striving to find their voice in the world.

When we encounter an expressive language deficit, it is not good enough to just slap a label on it and write expressive language goals. It is crucial to delve deeper. By bettering our understanding of the interconnectedness of executive functioning deficits and expressive language, we can change our therapy approaches to be more supportive and successful.