6.11 Executive Function – Central Bedfordshire APPP Hub

This chapter was added in April 2025.

1. What is Executive Function and Impaired Executive Function?
2. Executive Functioning and Mental Capacity
3. Signs of Impaired Executive Functioning
4. Key Areas to Consider when Assessing Mental Capacity with an Adult who has or may have Impaired Executive Functioning
5. Further Reading

1. What is Executive Function and Impaired Executive Function?

Executive function is a term used to describe a set of cognitive skills that are controlled by the frontal lobes of the brain, and which help us function in day-to-day life. This includes normally automatic abilities such as decision making, emotional control, flexibility in thinking, being able to multi-task, motivation, inhibition, self-control, planning and organisation. When executive function is impaired (also known as executive dysfunction or executive impairment), it can impact on these areas. This, in turn, can mean adults find it more difficult to make appropriate decisions and solve problems, and may struggle with aspects of their lives if they do not receive support. Often people with impaired executive functioning may say one thing but then find it difficult to put it into practice.

2. Executive Functioning and Mental Capacity

Carrying out mental capacity assessments can be challenging when an adult has impaired executive functioning, as their actions will often be different to what they are saying. If the presence of impaired executive functioning is overlooked it can lead to inaccurate conclusions and leave adults at risk of harm, with no services, or the wrong services, in place to support them. However, it must be emphasised that impaired executive functioning is not, by itself, evidence of a lack of mental capacity (see Mental Capacity chapter, Section 3 Assessing Capacity).

Adults with impaired executive function can often present well in a mental capacity assessment, as they may be able to mask their shortcomings. They may often be unaware they are doing this or, having undergone previous assessments, may know what answers to give. Despite this, there will often be signs that they struggle in their day-to-day lives. This is known as the ‘frontal lobe paradox’, which is when they can ‘talk the talk’ but ‘not walk the walk’ (Executive Functioning and the Mental Capacity Act, Community Care).

Case example

During an assessment of capacity in relation to managing finances, Lesley explains how they manage their money, where they bank and can give an overview of their income and outgoings. They clearly recognise bank notes and coins, can add them up and describe will happen if they do not pay their bills. On the basis of this information, they appear to have mental capacity. However, care staff in their supported accommodation then explain that Lesley does not pay their bills, spends all their money on computer games, is building up large debts and not purchasing essential items, such as food or personal care items. This highlights the importance of gathering evidence to confirm whether an adult can implement in practice what they say they can do.

Similar situations have been highlighted in court judgments, including AW (A Local Authority v AW [2020] EWCOP 24. In this case, AW had a learning disability and autism. Concerns had been raised regarding his mental capacity in relation to sexual relationships, contact with others, social media, accommodation and care and support needs. Mental capacity assessments had been completed and AW was found to have mental capacity in relation to his accommodation and support needs. But further concerns were raised regarding this outcome as it was believed that AW did not understand the risks to himself as a result, as what he said did not reflect his later actions. The judge found AW lacked mental capacity and noted:

“Although the written material may have suggested otherwise, having heard the oral evidence and submissions I have reached the conclusion that this is not a case in which AW fluctuates in his capacity to decide on the issues under consideration. I accept that there is a basic and profound lack of understanding, and that, by reason of the deficits in his executive functioning, he has a pervasive inability to use or weigh the information.” The judge also raised that “the ability to think, act, and solve problems, including the functions of the brain which help us learn new information, remember and retrieve the information we’ve learned in the past, and use this information to solve problems of everyday life”.

The Second National Analysis of Safeguarding Adult Reviews, Final report: Stage 2 Analysis (LGA) also highlighted the implications of not recognising impaired executive function, which can mean practitioners do not carry out thorough mental capacity assessments. This appears to be a particular issue in cases of drug or alcohol dependency, when practitioners may conclude that the adult is making decisions because of a ‘lifestyle choice’ and therefore does not require a mental capacity assessment. This can expose the adult to substantial risk, because the practitioner has not taken a holistic view of their life and considered whether they are actually able to make their own decisions.

3. Signs of Impaired Executive Functioning

Impaired executive functioning is more common in certain situations including self-neglect and hoarding (see Self-Neglect and Hoarding chapter) and among adults who are autistic, (see Working with Autistic Adults chapter), have an acquired brain injury, eating disorder, learning disability or who misuse drugs or alcohol.

Some of the key signs that an adult has impaired executive function include:

being able to say but not do – they tell practitioners the ‘right thing’, but there is no evidence they are putting this into practice;
making lots of promises and being very plausible in their reasonings;
acting as if there is no reason for practitioners to be concerned, even when provided with evidence to the contrary;
struggling to initiate, plan and order their activities;
struggling with new situations, new places and / or changes in routine;
behaviour which is aimless, impulsive and fragmented;
being unable to see the impact of their actions or able to reflect on these;
being unable to think flexibly or see any nuances;
thinking which is quite black and white in style;
lacking a filter in social situations – they may say what they think or see and not be concerned or think about any potential impact of this;
acting impulsively.

Where an adult may have impaired executive functioning, a full mental capacity assessment will be required to explore if they can make the decision in question and, if not, if they have an impairment of their mind or brain. Once this is established, it is important to check there is a connection (also called the ‘causative nexus’) between any impairment and their decision-making difficulties. The adult should also be provided with support so they can develop skills to help them overcome these difficulties and make as many of their own decisions as possible.

4. Key Areas to Consider when Assessing Mental Capacity with an Adult who has or may have Impaired Executive Functioning

Mental capacity assessments can be challenging for practitioners where there are concerns about an adult’s executive functioning. Key points for practice include the following.

4.1 Material time

The Mental Capacity Act (2005) Code of Practice Mental Capacity Act Code of Practice – GOV.UK states:

“For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.”

Cameron and Codling have highlighted that practitioners often misinterpret the meaning of ‘material time’ (which generally refers to a person’s ability to make a specific decision at the time it needs to be made) and only consider evidence that is presented to them on the day of the mental capacity assessment. With adults who have impaired executive functioning, this can mean that the incorrect outcome is reached, with them either being deemed to have mental capacity or that they are solely making an ‘unwise decision’. When it comes to executive functioning, it is particularly important to remember that the material time may not be the time when the person was assessed, and that ‘real world’ evidence from other practitioners, family, friends and carers should also be taken into account to ensure that a fuller picture of their capacity to make decisions is gained.

4.2 Problem-solving skills

Problem solving can be difficult for an adult with impaired executive functioning as they can struggle to weigh up different situations and manage the unexpected. It is important to explore how the adult came to the conclusion they have reached. They should be asked questions around their ability to problem-solve, for example – Can you tell me why it’s a good thing that…? Can you tell me the bad things about ……? What would happen without…..?

4.3 Impulsiveness

Being impulsive can affect an adult’s decision making and is often observed in those with impaired executive function. Deciding when an impulsive decision indicates a lack of mental capacity can pose a challenge to the assessor (as all adults can be impulsive to a degree). It is important to look for a link (or causative nexus) between the impulsive decision making and any underlying impairment of the adult’s mind or brain.

People with executive functioning difficulties may find it hard to explain why they changed their mind in the moment.

4.4 Unwise decision

Distinguishing between unwise decision making (which, on its own, does not indicate that a person lacks mental capacity) and decisions affected by impaired executive functioning can be a challenge.

What may appear to be ‘unwise decision’ in line with principle 3 of the Mental Capacity Act could, if there are repeated examples, be evidence of impaired executive functioning. When assessing ‘unwise decisions’, the functional test of mental capacity is important as this involves looking at the process of how the adult reached their decision. In unwise decision making, the adult is fully aware of the facts / risks involved but consciously chooses to ignore or give less weight to certain facts relevant to the decision. When an adult has impaired executive functioning, they cannot pull together the correct pieces of information and use or weigh them in a meaningful way to make the decision.

For more information see, see Assessing Capacity, Mental Capacity chapter.

Scaling questions (where adults are asked to rate their observations, impressions or predictions on a scale from 0 to 10), can be useful in these situations, to see where the adult benchmarks themselves in risk-taking, and if they have any awareness of their impulsive decision making.

4.5 Professional curiosity

4.6 Holistic approach

It is essential to gather information from those involved in the adult’s life, to ensure you have a sound evidence base to support decision-making. An adult with impaired executive functioning can say the right thing, but will often struggle to put this into practice, so assessments must also seek evidence from other sources. This means it is particularly important to speak to family, carers and other practitioners to ensure that what the adult is telling you matches with their actions. It can be helpful to see the adult in different settings at different times, as it is only by understanding how difficulties with executive function are impacting on the adult and their life, that support can be put in place to help them to do what they want to do.

It is good practice to regularly re-assess the adult’s mental capacity in as, with support and practical strategies in place, they may be able to make decisions. It can also assist with gathering further evidence, as any repeated mismatch between the adult’s words and actions should be documented.