The development of cognitive flexibility and its implications for mental health disorders

This editorial examines how cognitive flexibility (CF)—a core component of executive function involving attentional shifting, strategy updating, feedback-based learning, exploration, reversal learning, and task switching—develops across the lifespan and how its developmental trajectory relates to risk for and manifestations of mental health disorders. CF is impaired in several disorders, including autism spectrum disorder (ASD), obsessive-compulsive disorder (OCD), and schizophrenia. Given that many mental health conditions emerge in childhood and adolescence, the piece emphasizes environmental influences on CF maturation from infancy through older adulthood and considers intervention opportunities to bolster CF for improved mental health and life outcomes.

The article synthesizes evidence on CF’s neurobiological foundations and developmental course. CF emergence is linked to maturation of the prefrontal cortex (PFC) and inferior parietal cortex, with synaptic pruning and myelination beginning in the first year of life and a marked increase in prefrontal gray matter volume between 1–2 years. Environmental inputs—caregiver interaction quality, sensory deprivation, prenatal substance exposure, and adverse early experiences—shape PFC development. Neurochemical modulation implicates serotonin and dopamine in CF performance, with noradrenaline showing limited effects in some tasks (e.g., CANTAB IED). Measurement across ages includes infant tasks (sequential touching/object categorization; A-not-B), preschool tasks (DCCS), childhood to adult tasks (IED; WCST). Latent-factor work indicates EF is relatively unitary in early childhood, differentiating into correlated components (working memory, inhibitory control, CF) by young adulthood. CF impairments are observed in ASD, OCD (linked to fronto-striatal circuit disruption), and schizophrenia. In older adulthood, CF declines with PFC gray matter loss and network dynamics changes (extended dwell time in L-FPN and M-FPN co-activation), and is associated with motor perseveration and fall risk. Lifestyle and training factors are reviewed: caregiving interventions (ABC-I), stress-management via mindfulness and exercise (including mindful movement forms), and bilingualism/multilingualism debates, with mixed evidence and calls for better measurement and longitudinal designs. Game-based paradigms and training approaches show promise but require age-appropriate design and evidence of far transfer. Twin studies suggest environmental influences have larger effects on CF than genetic factors, positioning CF as a potentially trainable target.

This is an editorial and narrative review synthesizing prior empirical and theoretical work. It describes developmental trajectories, neurobiological mechanisms, task paradigms, and intervention frameworks, and references cross-sectional and longitudinal findings rather than presenting new primary data.

- CF develops along a protracted trajectory: early precursors measurable as early as 6–12 months; acceleration in preschool years; adolescent improvement toward adult-like performance around ~12 years; peak performance approximately 21–30 years; stability to ~50 years, followed by gradual decline in older adulthood. - Neurobiological bases: PFC and inferior parietal maturation underpin CF; prefrontal synaptic pruning and myelination start in year 1; pronounced growth in prefrontal gray matter volume between ages 1–2. Serotonin and dopamine modulate CF; noradrenaline shows limited effect on some CF tasks (e.g., IED). - Measurement across ages: infants show flexible categorization with social scaffolding (STOC) and make A-not-B errors until ~12 months; 3-year-olds often perseverate on DCCS, whereas 4-year-olds switch successfully; typically-developing 5-year-olds can set-shift on IED; WCST captures perseveration and set-shifting deficits in adolescents and adults. - EF structure: early childhood EF may be captured by a single latent factor up to ~8 years; by ~10 years, EF differentiates (e.g., memory and general EF); in young adults, three correlated EF components (working memory, inhibitory control, CF) best fit the data ('unity and diversity'). - Clinical associations: CF impairments are documented in ASD, OCD (including severe adult CF impairment linked to fronto-striatal circuit disruptions), and schizophrenia; adolescent OCD shows early impairments in learning, memory, CF, and goal-directed control. - Ageing: Older adults exhibit increased perseveration and reduced set-shifting (WCST), with PFC gray matter loss contributing to EF/CF declines; altered brain network dynamics (extended L-FPN/M-FPN co-activation dwell time) relate to diminished CF. Motor flexibility declines are associated with cognitive perseveration and increased fall risk. - Interventions: Early caregiving quality (e.g., ABC-I) can enhance EF/CF; mindfulness and exercise reduce stress and may improve EF, with mindful exercises (Tai Chi, Taekwondo) showing greater benefits than standard aerobic/resistance training; language learning and switching training can improve attention switching and monitoring/inhibition, though bilingual advantages are mixed and measurement issues persist. Game-based CF training is promising but requires age-appropriate adaptation and evidence for far transfer. - Environmental influence: Twin and behavioral genetics data suggest CF is more influenced by environmental factors than genetics relative to other EF domains, making CF a viable target for training. - Lifespan performance pattern (CANTAB IED): CF improves from childhood to adolescence, is optimal in early young adulthood, remains stable to ~50, and declines in older adulthood.

The synthesis underscores that CF’s extended maturation makes it both susceptible to adverse environments and amenable to targeted interventions. Early identification of CF deficits is critical in disorders that often begin in childhood or adolescence (ASD, OCD, schizophrenia), enabling opportunities for mitigation through enriched caregiving, school-based CF-oriented pedagogy, and lifestyle interventions that enhance stress resilience and EF. The reviewed neurobiological and behavioral evidence connects CF development to PFC maturation and neuromodulatory systems, and shows that CF is integral to adaptive learning, problem-solving, and goal-directed behavior. In older adulthood, recognizing the coupling between cognitive and motor perseveration highlights avenues for preventing falls and maintaining quality of life through combined cognitive and motor flexibility training. The mixed findings on bilingualism and CF training transfer emphasize the need for more rigorous, longitudinal, and ecologically valid approaches to establish causal mechanisms and real-world benefits.

CF is a multifaceted, trainable component of executive function with a prolonged developmental trajectory and substantial relevance to mental health across the lifespan. Key contributions of this editorial include integrating neurobiological, developmental, clinical, and intervention evidence, highlighting modifiable environmental influences from infancy onward, and identifying promising strategies (caregiving interventions, mindfulness/exercise, language learning, game-based training). Future research should prioritize longitudinal designs, mechanistic studies of brain plasticity, improved measurement (including age-appropriate tasks in infancy and childhood), and clinical translation to detect and remediate CF deficits early in at-risk populations. Embedding CF-oriented pedagogy in schools and leveraging gamification may enhance engagement and far transfer to everyday functioning.

As an editorial narrative review, the work does not present new empirical data and relies on heterogeneous studies with varying methodologies and measures. There is a paucity of validated, age-appropriate CF tasks for infancy and early childhood, complicating developmental inferences. Evidence for bilingual advantages and far transfer of CF training is mixed, with measurement inconsistencies (e.g., binary vs. continuum assessments of bilingualism). Longitudinal stability of CF in very early life remains unclear, and more longitudinal and intervention trials are needed to establish causality and clinical efficacy across diverse populations.