Executive Functions and Conceptual Models: A First Look at a Complex Topic: Commentary

1.1. Conceptual Models

During the 20th century, executive functions were studied starting from their neuroanatomical bases, particularly the frontal lobe, and they were referred to as “frontal lobe functions” [4, 5]. Only later did the term “executive functions” appear, and a more articulated conceptualization of executive functions was developed.

The well-known clinical case of Phineas Gage can be considered an important starting point for the study of executive functions [6]. In 1848, Phineas Gage had a serious workplace accident in which an iron rod penetrated his skull; the iron rod destroyed a large portion of his medial frontal lobe (bilaterally). He survived but, as his physician claimed, Gage “was no longer Gage”: his basic cognitive abilities remained intact, but his personality and his capacity for planning and self-control were profoundly compromised [6].

Some years later, other clinical reports were proposed. Damasio [6] described the experience of Elliott, a man who, after the surgical removal of a meningioma in the frontal region, showed preserved general cognitive abilities but a severe inability to make appropriate decisions, regulate his emotions, and organize daily life.

In the 1980s, Stuss and Benson [4] provided a detailed description of frontal functions, defining them as a set of cognitive and behavioral abilities; they also described the domains regulated by frontal mechanisms. The authors highlighted the role of frontal lobe integrity in the coordination of those cognitive and mental functions. According to these authors, the frontal lobe and the EF act as a kind of “conductor of the orchestra,” which integrates information from different cognitive systems and directs behavior toward complex goals.

In the same years, Norman and Shallice [5] developed a cognitive model of executive control, the so-called Supervisory Attentional System (SAS). They used the SAS to describe how individuals manage novel, complex, or even conflicting situations that cannot be handled through automatic behavioral routines.

Since the 1980s, Lezak has addressed executive functions and proposed an approach to be used both in clinical and rehabilitative contexts [7]. According to Lezak, executive functions comprise four fundamental processes: goal formulation, planning strategies, execution of goal-directed actions, and monitoring of results with possible correction [7].

Some years later, Miyake and colleagues [8] proposed a model of executive functions based on three core components: updating, shifting, and inhibition. Updating refers to the ability to refresh and replace information held in working memory according to task demands. Shifting concerns the capacity for cognitive flexibility, that is, the ability to switch between tasks or strategies. Inhibition refers to the suppression of automatic or dominant responses that are inappropriate to the current situation. This model has had a major impact because it enabled the study of executive functions using rigorous experimental methods, demonstrating that these components are interrelated yet separable. The authors described this mixed structure of EF, and they referred to it as the “unity and diversity model” [8, 13-16].

In the same years, similarly to Miyake and colleagues’model [8], Diamond [9, 10] developed a developmental model of executive functions; she highlighted the role of the three core executive functions (inhibition, working memory, and cognitive flexibility) during the various phases of life; moreover, she described environmental and relational/social factors that may influence EF (quality of educational experiences, social relationships, stress levels, and physical activity) [9, 10].

In the same years, Philip Zelazo [11, 12, 17, 18] described executive functions as processes that are constructed and transformed across the lifespan, in close connection with and influenced by relational experiences and educational practices. According to his framework, executive functions are deeply tied to reflective and metacognitive capacities, and he highlighted the role of emotions and social interactions in their development. He was the first to introduce the distinction between cognitive and socio-emotional dimensions, proposing the distinction between “hot” and “cool” executive functions [17]. In Zelazo’s model, “cool” executive functions refer to abstract, decontextualized cognitive processes (cognitive flexibility, working memory, and planning) that are typically activated in emotionally neutral contexts. In contrast, “hot” executive functions operate in situations with a high emotional or motivational load, involving impulse regulation, delayed gratification, and modulation of affective responses. Zelazo points out that these dimensions, while interacting, may develop at different rates, thereby influencing self-regulation, learning, and behavioral adaptation [17, 19].

Recently, Diamond defined EFs as a “family of top-down mental processes that make it possible for us to pay attention and stay focused; reason and problem solve; exercise choice, discipline, and the self-control to avoid being impulsive, rash, or reacting without thinking; see things from different perspectives; mentally consider alternatives, see how different ideas or facts relate to one another, and reflect on the past or consider an imagined future; and flexibly adjust to change or new information” [20, p. 225].

The models described thus far highlight two main theoretical perspectives, and they can be divided into two main groups, with some overlaps. The first group proposed a unitary view of EFs: for example, Lezak’s model [7]described executive functions as an integrated cycle of self-regulation. The second group proposed a multicomponent view, as seen in the models of Miyake and colleagues [8], Diamond [9, 10], and Zelazo [17], which interpret executive functions as a set of distinct yet interconnected components. Moreover, together, all those models also reveal a distinction between process-oriented models [5]; Lezak [7]) and modular models (e.g., Miyake and colleagues [8], Diamond [10], Zelazo [17]. Each of these theoretical frameworks contributes to our understanding of different facets of executive functioning: Stuss and Benson [4] emphasized the neuroanatomical dimension; Norman and Shallice [5] introduced a cognitive framework for voluntary control; Lezak [7] focused on clinical implications of executive functions; Miyake and colleagues [8] provided an experimental and empirical structure; Diamond (2013) [10] focused on development, education and intervention; and Zelazo (2012) [6] highlighted the role of emotional dimensions.

1.2. The Clinical Role of Executive Functions in Neurodevelopmental Disorders and Major Neurocognitive Disorders

The clinical significance of executive functions is evident not only in cases of frontal lobe lesions, but also across various psychological/mental disorders. Their clinical role is broad and multifactorial, as executive functions play a crucial role in ensuring adaptive functioning in everyday life. Their impairment may manifest as difficulties in attentional control, inhibition of automatic responses, working memory, strategic planning, and cognitive flexibility, with significant repercussions for an individual’s functioning and adaptation in learning, social, and occupational settings. In the following sections, we specifically address the role of EFs in some neurodevelopmental disorders and some major and minor neurocognitive disorders.

Some previous and recent research has shown that children with specific learning disorders (SLD) often present EFs’ impairments, primarily in working memory but also in processing speed, long-term memory, and narrative abilities [21-23]. Working memory is essential for maintaining and manipulating temporary information; it is often impaired in children with SLD, making it difficult to integrate information during reading, writing, or mathematical problem-solving [21, 22]. Similarly, reduced processing speed may limit the ability to complete complex tasks efficiently, leading to cognitive overload and frustration [21, 22]. These deficits may interfere with activities in school activities and other activities of daily living. In adolescents and adults with specific learning disorders, EF difficulties may appear in different but equally significant forms. Prospective memory, the ability to remember to perform intended actions in the future, is often impaired, with practical consequences such as forgetting appointments, deadlines, or planned activities [24, 25]. Time management, closely linked to planning and goal prioritization, may also be inefficient, leading to reduced productivity and increased stress. Working memory continues to play a critical role in adulthood, influencing the ability to retain relevant information while solving complex problems or managing multiple tasks simultaneously [24, 25]. These deficits may interfere with occupational functioning and other activities of daily living.

In older adults with major and minor neurocognitive disorders, EFs are central to maintaining autonomy and quality of life, and their decline is frequently observed in both major and minor neurocognitive disorders [26, 27]. These disorders represent a heterogeneous group of syndromes characterized by progressive cognitive decline in various domains of functioning that interferes with daily functioning and personal independence. Among the various cognitive domains affected, EFs are particularly affected, exhibiting patterns of deficit that vary depending on the specific type of neurocognitive disorder [26, 27].

In major neurocognitive disorder due to Alzheimer’s disease, initial impairment primarily affects episodic memory, yet EF difficulties - particularly in planning complex actions, cognitive flexibility, and behavioral monitoring and correction - often emerge in the early stages. These deficits interfere with everyday activities such as meal preparation, financial management, and scheduling tasks [27-32].

Frontotemporal major and minor neurocognitive disorders display a distinct cognitive profile. In these conditions, executive dysfunction represents the predominant symptom from the earliest phases of the disease. People with frontotemporal major neurocognitive disorders may exhibit impulsivity, deficient inhibitory control, rigid thinking, and an inability to adapt behavior to environmental demands [33, 34]. Such alterations reflect the involvement of prefrontal regions, which are responsible for the regulation of executive processes, and profoundly affect an individual’s social and relational functioning.

In major neurocognitive disorder due to Lewy Body disease (LBD), EFs may be affected early in the onset of the disorder [27]. Individuals with LBD may show difficulties with planning, problem solving, and cognitive flexibility, which influence their ability to adapt to changes or manage complex tasks. In individuals with LBD, attention and alertness tend to fluctuate, with periods of confusion alternating with clearer moments [35]. Impulsive responses or repetitive behaviors are common due to poor inhibitory control. Working memory is also impaired, affecting the capacity to store and manipulate information. These problems are linked to dysfunction in fronto-striatal circuits and prefrontal regions. Compared with Alzheimer’s disease, LBD typically shows greater executive dysfunction but relatively better episodic memory [27]. Executive difficulties have an important impact on the patient’s independence and daily functioning [27, 36].

The executive difficulties observed in neurodevelopmental disorders and major neurocognitive disorders described thus far highlight two main patterns: while EFs are impaired in all the described disorders, some EFs could mya be more severely affected that other depending on the specific disorders, with different effects during different phases of life within the same disorder. Looking at these clinical conditions, both unitary and multi-component perspectives on EFs are supported.