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Most of my experience with executive function comes from the classroom or daily living, so I jump at the chance to hear others’ perspectives. My friend, Shahrzad Rafiee, an emergency medicine doctor and marriage and family therapist, shared her experience with executive function’s ebbs and flows.
How does the emergency department challenge executive functioning?
Shahrzad Rafiee: In many ways, working a shift in the emergency department is like putting the brain’s executive functioning system through a stress test. If there is any environment that demands constant multi-tasking, rapid prioritization, emotional regulation, suppression of distractions, and adaptation to ever-changing conditions, it is the emergency department (ED). At times, shifts can feel like American Ninja Warrior for executive functioning.
There’s a running joke in medicine that every specialty has a personality: pediatricians are the nice ones, surgeons are the type A ones, and emergency physicians? We’re the ones with ADHD.
What does executive dysfunction look like from your perspective?
SR: Sometimes it’s hard to see what executive dysfunction looks like in our daily lives. Many people can still perform, compensate, and push through professionally while carrying an enormous cognitive burden internally. The collapse often comes later—at home, after the performance is over.
I notice this most on the days after a stretch of night shifts, especially when I have not slept well. I call it “zombie mode”: my head aches, my thinking becomes sluggish, and even routine tasks require disproportionate effort.
My energy levels are so depleted that even basic daily tasks—washing dishes, cleaning up, getting dressed, running errands—feel like an uphill battle. My willingness to engage with other people, including people I care deeply about, plummets. I become emotionally withdrawn, apathetic, and easily irritated. My patience shortens. My threshold for frustration shrinks.
When this happens, the path of least resistance is often lying in bed and doom-scrolling.
Over time, I’ve realized that executive function depletion creates resistance toward doing the very things that would help me feel better. What looks like laziness, irritability, avoidance, or lack of motivation may actually be a nervous system asking for restoration.
Besides ADHD, what are other causes of executive functioning issues?
SR: Executive dysfunction is often discussed through the lens of ADHD, but ADHD is only one pathway. Neurologic conditions such as stroke and dementia, mood disorders such as depression and anxiety, trauma-related conditions, and sleep disorders can all impair executive functioning. Even temporary states like sleep deprivation, chronic stress, and emotional overwhelm can significantly reduce our ability to plan, organize, focus, and regulate ourselves.
Are executive functions something you are born with, or can they be strengthened?
SR: We often think of executive functioning as something we either have or don’t have. In reality, it is better understood as a dynamic capacity.
Research suggests that sleep deprivation, loneliness, depression, and physical stress can all impair executive functioning. Under enough pressure—constant interruptions, competing priorities, emotional intensity, and insufficient rest—even highly capable people begin to show cracks.
The encouraging news is that executive functioning can be strengthened through practice, habit formation, and skill-building. Just as important, depleted executive functioning can often be restored.
How do we help restore our executive function capacity?
SR: Perhaps the most important question is not how executive functioning becomes impaired, but how it is restored.
If a camera crew followed me around on a day devoted to replenishing my executive functioning, they would not capture one magical intervention. Instead, they would see small actions repeated across multiple areas of life.
Physical activity plays a major role. For me, jiu-jitsu and rock climbing provide a sense of focus and reconnection to my body. More broadly, research consistently shows that exercise benefits mood, cognition, stress regulation, and executive functioning.
Sleep may be even more important. It is difficult to access higher-order thinking when the foundational pillars of sleep, movement, and nutrition are neglected.
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Beyond that, everyone’s restorative practices look different. Some people garden, bake, meditate, create art, spend time with loved ones, or simply sit in quiet solitude. The specific activity matters less than the principle behind it: executive functioning is not an infinite resource, and it requires time and rest to replenish and restore functioning.
Nature is another powerful source of restoration for me. Sunlight, fresh air, and walking near the ocean help me regain perspective. Even on difficult days, opening a window and listening to birds can feel grounding.
Many of my clients also find that safe, supportive relationships are restorative. Connection with friends, family members, partners, and even pets can provide an important buffer against cognitive and emotional overload.
What have you learned as a marriage and family therapist?
SR: One thing I consistently notice is that many of us are our own harshest critics. We push, pressure, and judge ourselves in ways we would never treat someone we care about.
I believe we get further by cultivating self-compassion and learning to “have our own backs.” On days when our capacity is genuinely depleted, lowering expectations may be wiser than pushing harder.
That might mean postponing an emotionally charged conversation, simplifying a to-do list, or allowing yourself additional recovery time. Sometimes restoration begins with acknowledging that your system is overloaded rather than demanding more from it.
Executive functioning is not simply a measure of productivity. It is a reflection of the health and capacity of the system supporting it. When that system becomes overwhelmed, the solution is not always to push harder. Sometimes the solution is to restore the person carrying the load.
Shahrzad Rafiee is an associate marriage and family therapist (AMFT) practicing therapy in Manhattan Beach, California. She also works as an Emergency Medicine Physician in Long Beach, California.
