DEVELOPMENTAL NEUROPSYCHOLOGY

https://doi.org/10.1080/87565641.2023.2166939

The Relationship Between Executive Functions and Externalizing

and Internalizing Behaviors in Mexican Preschoolers
Judith Salvador-Cruz and Jessica Paola Becerra-Arcos
Laboratorio de Neuropsicología del Desarrollo, Facultad de Estudios Superiores Zaragoza, Universidad Nacional
Autónoma de México, Ciudad de México, México

ABSTRACT ARTICLE HISTORY

Executive functions allow the regulation of behavior and emotions. This Received 13 December 2021
study aimed to analyze the association of executive functions with externa- Revised 31 December 2022
lizing and internalizing behaviors in 30 Mexican preschoolers with typical Accepted 5 January 2023
development (age M = 53.63 months; SD = 7.83 months; 40% girls) from
homes of middle-low socioeconomic status. Behavioral and cognitive mea-
sures were used to assess executive functions and analyzed them using
robust statistical methods. We found that executive functions are related to
externalizing and internalizing behaviors at the behavioral level. Only
Forward Digit Span predicts attentional problems. Individual differences in
children's cognitive development in a Mexican context were adressed, and
they have clinical and educational implications.

Introduction
The relationship of executive functions to externalizing and internalizing behaviors is one of the
cognitive-behavioral links. Executive functions permit the regulation of behavior in challenging
situations and support the accomplishment of goals in a determined way. They are widely studied
concerning externalizing behavior because they involve problems with impulse control, which can be
persistent, causing deterioration in the quality of life. Poor executive functions have been linked to
behavioral problems arising from difficulties in coping with feelings of displeasure, such as substance
misuse in adulthood, disruptive behavior in school, or tantrums in toddlerhood (Pinsonneault et al.,
2016). Externalizing behaviors in early childhood include interrupting others, being rude, or being
easily distracted compared to peers.
Recent studies indicate that executive functions are also related to internalizing behaviors (Morea &
Calvete, 2021; Patwardhan, Nelson, McClelland, & Mason, 2021; Quistberg & Mueller, 2020; Visu-
Petra, Mărcuș, Buchwald, Moore, & Arenas-Landgrave, 2019), which appear when children direct
their negative feelings toward themselves. Flexibility, for example, is affected by anxiety-depressive
traits (Patwardhan, Nelson, McClelland, & Mason, 2021).
Assessing executive functions can help to detect preschoolers’ externalizing and internalizing
behaviors (Quistberg & Mueller, 2020; Wiebe, Espy, & Charak, 2008). Executive functions have
been proposed as a risk factor for developing mental health problems (Quistberg & Mueller, 2020).
Children from low-income families are at risk of experiencing stressful situations that directly
impact their mental health (Baker & Brooks-Gunn, 2020; Pinsonneault et al., 2016). This phenomenon
has been linked to rapid urban development, where many families have experienced insecurity and
economic adversity (Caraveo-Anduaga & Martínez-Vélez, 2020).

CONTACT Judith Salvador-Cruz judith.salvador@zaragoza.unam.mx Laboratorio de Neuropsicología del Desarrollo,

Facultad de Estudios Superiores Zaragoza, Universidad Nacional Autónoma de México, Av Guelatao 66, Ejército de Oriente Indeco II
ISSSTE, Iztapalapa, 09230, Ciudad de México, México
© 2023 Taylor & Francis Group, LLC
2 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

Executive function development linked to externalizing and internalizing behaviors

Executive functions are processes with multiple relationships, including inhibition, working memory,
and flexibility, allowing for higher-level executive functions (Diamond, 2013). Children acquire
intentional and independent behaviors during preschool, mainly through developing executive func-
tions. Even infants utilize information to achieve simple goals. There is evidence that working memory
operates in 6-month-old infants, who can retain information for up to a few seconds (Reznick,
Morrow, Goldman, & Snyder, 2004), and inhibition is evident in 1-year-olds (Diamond, 1985).
Children regulate their behavior in daily activities, including play. One study observed that children
under three could inhibit visual and auditory stimuli that distracted them from playing with toys (Ruff
& Capozzoli, 2003). Another study, which included typically-developing children aged 2 to 6, found
that executive functions include only working memory and inhibition (Wiebe, Espy, & Charak, 2008).
Inhibition becomes distinct from working memory as children grow up (Lerner & Lonigan, 2014).
A review article, however, suggests that flexibility is also part of the executive functions of preschoolers
(Garon, Bryson, & Smith, 2008); it allows them to change responses, search for alternatives, and return
to previous strategies (Anderson & Reidy, 2012). There are individual differences in executive
functions, where children of the same age show variety in the quantity and quality of executive
functions.
Executive functions and externalizing behavior have been studied more extensively than inter-
nalizing behavior, especially attentional problems. Preschoolers with low levels of executive functions
show severe attentional problems during adolescence (Rajendran et al., 2013, 2013). Externalizing
behavior in preschoolers includes attentional problems and aggressive behavior (Achenbach &
Rescorla, 2000). Inhibition has received the most attention because it consists of overcoming
a dominant response and selecting an appropriate one. It allows children to regulate their behavior
by stopping for a moment and choosing a more appropriate response. Children unable to inhibit
tempting stimuli are more impulsive, restless, and distracted.
Children with externalizing behavior have negative reactions even in non-demanding circum-
stances. When things go wrong, they become furious and behave in disinhibited ways, such as being
destructive, defiant, or rude. Inhibition and temperament influence self-regulation when children have
intense emotions (Diamond, 2013). Inhibition and the rest of the executive functions operate under
cognitive and emotional conditions (Zelazo & Carlson, 2012).
Externalizing behaviors are related to performance on cognitive tasks and questionnaires. Espy,
Sheffield, Wiebe, Clark, and Moehr (2011) propose a model of externalizing behavior based on
performance on the Delayed Alternation, Six Boxes, Digit Span, Delayed Response, Shape School,
Continuous performance, Tower of Hanoi, and NEPSI tasks. Forward Digit Span is a well-known task,
part of the Wechsler Intelligence Scales, in which children have to repeat number series; they found
that difficulties on this task are related to attentional problems and that overall, this group of tasks
predicts dimensions of externalizing behavior.
A meta-analysis of 21 studies published from 1994 to 2011 that included at least one task on
inhibition, working memory, or flexibility found a moderate correlation between executive functions
and externalizing behavior in preschoolers (Schoemaker, Mulder, Deković, & Matthys, 2013).
Inhibition was measured using Stroop, Simon, and Go/No-Go tasks and working memory with
Direct and Backward Digit Span tasks. Only five studies included tasks of flexibility measured with
card sorting, and most of them investigated externalizing behavior in children with attentional
problems and hyperactivity. The results showed moderate associations of externalizing behaviors
with inhibition and low associations with working memory and flexibility. Several cross-sectional
studies agree that inhibition and working memory are related to externalizing behavior in preschoolers
(Araujo, Jané-Ballabriga, Bonillo, & Capdevilla, 2014; Dias, Trevisan, León, Prust, & Seabra, 2017;
Espy, Sheffield, Wiebe, Clark, & Moehr, 2011; Romero-López, Quesada-Conde, Bernardo, & Justicia-
Arráez, 2017).
 DEVELOPMENTAL NEUROPSYCHOLOGY 3

Studies have developed a variety of standard tasks to assess executive functions. Gerstadt, Hong,
and Diamond (1994) studied the Stroop paradigm task to assess inhibition in preschoolers and found
that older children performed better than 3-year-olds and that they performed better with more
latency time. Another inhibition task is based on the “Simon says” paradigm, in which behavior is
regulated based on language (Reed, Pien, & Rothbart, 1984). One study analyzed five versions of the
Simon task (Marshall & Drew, 2014). In the first and second versions, only one examiner gave
instructions, and the child was asked to follow the instructions only when the examiner began with
“Simon says.” Two examiners gave the instructions in the third and fourth versions, and the examiner
acted on the instructions in the first and third versions. In the fifth version, the instructions were given
by two puppets. Preschoolers could perform all versions, but the first two were more challenging than
the others.
Working memory is assessed using the Forward and Backward Digit Span tasks. The Backward task
assesses integrated working memory, while the Forward task tests the phonological loop (Tirapu-
Ustárroz, Muñoz-Céspedes, Pelegrín-Valero, & Albéniz-Ferreras, 2005). Both tasks require children to
receive and store information for an amount of time, which is essential for understanding (Giofrè,
Stoppa, Ferioli, Pezzuti, & Cornoldi, 2016). Children can perform both tasks by age 3 (Anderson &
Reidy, 2012; Garon, Bryson, & Smith, 2008). Most studies agree that inhibition and working memory
are related to externalizing behavior (Thorell & Nyberg, 2008; Volckaert & Noël, 2018). Thorell and
Nyberg (2008) conclude that inhibition and working memory tasks represent the behavioral level of
attentional problems.
There are some inconsistencies in the relationship between externalizing behavior and executive
functions in various tasks that call for interpreting the results in detail. One study found opposite
results in two different inhibition tasks related to externalizing behavior (Livesey, Keen, Rouse, &
White, 2006). Performance on one task using the Stroop paradigm was associated with externalizing
behavior, but the Stop Signal task was not. The Stop Signal task measures direct inhibition, but the
Stroop task requires verbal instruction.
An explanatory model has shown that inhibition, working memory, and flexibility are related to
externalizing behavior (Dias, Trevisan, León, Prust, & Seabra, 2017). However, a study using the
Behavior Rating Inventory of Executive Function-Preschool (BRIEF-P) found that externalizing
behaviors were not correlated with the flexibility (Romero-López, Quesada-Conde, Bernardo, &
Justicia-Arráez, 2017). The BRIEF-P is a powerful tool for evaluating preschoolers’ executive functions
at the behavioral level. It aims to detect a deficit in executive functions, considering everyday
behaviors; it was elaborated in relation to the Child Behavior Checklist (CBCL) 1.5–5 (Gioia, Espy,
& Isquith, 2016). All scales were highly correlated except somatic complaints, which is an internalizing
behavior.
Low flexibility contributes to difficulties in changing thoughts and overthinking in internalizing
behaviors, especially those related to anxiety or depression (Visu-Petra, Mărcuș, Buchwald, Moore, &
Arenas-Landgrave, 2019). Flexibility continues to be associated with internalizing behaviors during
adolescence (Morea & Calvete, 2021). One longitudinal study found reciprocal relationships between
flexibility and internalizing behaviors in 5-to-7-year-olds (Patwardhan, Nelson, McClelland, & Mason,
2021). Another longitudinal study with 5- and 6-year-olds using the Boxes task showed that inter-
nalizing behaviors were related to working memory (Quistberg & Mueller, 2020). Inhibition, assessed
with the Preschool Continuous Control Test, was related to externalizing behavior. They emphasize
that internalizing behaviors show working memory problems because they have internal distractors,
and these relationships are not quite as robust as those with externalizing behaviors.
Four key points are related to the relationship between executive functions and externalizing and
internalizing behaviors. First, low executive functions could produce externalizing and internalizing
behaviors (Dias, Trevisan, León, Prust, & Seabra, 2017; Pinsonneault et al., 2016), and executive
function issues that can cause mental health problems to call for the creation of predictive models
(Dias, Trevisan, León, Prust, & Seabra, 2017). Second, externalizing and internalizing behaviors affect
executive functions (Diamond, 2013). Children show low levels of executive functions because they
4 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

have behavioral problems such as attention-deficit/hyperactivity disorder (ADHD) or oppositional

defiant disorder (Araujo, Jané-Ballabriga, Bonillo, & Capdevilla, 2014). Third, many studies have
drawn on these observations to describe a reciprocal interaction between variables (Patwardhan,
Nelson, McClelland, & Mason, 2021; Quistberg & Mueller, 2020). Fourth, executive functions help
to mediate mental health problems in difficult situations, such as living in areas with high levels of
crime (Brennan & Baskin-Sommers, 2018), low socioeconomic status (Baker & Brooks-Gunn, 2020),
segregation of ethnic minorities (Pacheco, Owen, & Caughy, 2018), and low-quality housing
(Lohndorf, Vermeer, Cárcamo, De la Harpe, & Mesman, 2019).

Non-consolidated executive functions and at-risk socioeconomic backgrounds

Executive functions appear in the early months of life and develop through early adulthood (Diamond,
2013), so they have begun to consolidate in preschoolers and do not represent an impairment. The
term “impairment” is used in the executive function model in adults with neurological disorders. The
concept of “non-consolidated executive functions” refers to a function deficit arising from poor
stimulation in children with no neurological disorders. The neuronal basis is not the only element
for developing executive functions: they also have a social origin (Luria, 2012). It is well known that the
frontal lobes, the social brain participate in processing executive functions. The development of
executive functions depends on appropriate brain structures and functions with social stimulation.
Thus, executive functions with poor social stimulation related to at-risk socioeconomic backgrounds
do not represent organic dysfunction. Non-consolidated executive functions have been found to
diminish unexpected functioning during the assessment but do not constitute a permanent impair-
ment, as is the case with neurological disorders. Low income and education levels are risks that
interfere with children’s executive function development (Baker & Brooks-Gunn, 2020; Kia-Keating,
Nylund-Gibson, Kia-Keating, Schock, & Grimm, 2018). Traditional behavioral science focuses on
a small number of people from Western, educated, industrialized, rich, and democratic countries, the
so-called WEIRD countries. These scientific results cannot be generalized to other countries because
most of the world’s people are left out. (Henrich, Heine, & Norenzayan, 2010). Analyzing cultural
differences can thus help to understand the development of executive functions in clinical, educa-
tional, and research settings.
Adolescents and young adults in socioeconomically at-risk areas are susceptible to externalizing
behavior, especially to the extent that their executive functions have not been consolidated. Brennan
and Baskin-Sommers (2018) have found associations between electrophysiological abnormality, low
inhibition, and externalizing behavior in a group of African-American, Hispanic, and white adoles-
cents and young adults from a high-crime area. They conclude that inhibition plays a role in substance
abuse and risky behavior, both considered externalizing behavior in adults.
Although adolescents and young adults are influenced by their families, preschoolers are even more
dependent on them. For this reason, family characteristics have been studied in children’s behavior.
One study of mother-child dyads analyzed environmental variables contributing to behavior problems
(Baker & Brooks-Gunn, 2020), including maternal characteristics such as educational level, partner
status, use of harsh discipline, low socioeconomic status, and parenting ability. This study found that
executive functions moderate externalizing behaviors in homes with low socioeconomic status.
Another study analyzed externalizing behavior of African-American and Hispanic 2-year-old
children considered ethnic minorities in the United States (Pacheco et al., 2016). Those children
with low executive functions, especially inhibition, were prone to higher rates of externalizing
behavior when they were 3 years old. However, a study of native Chilean children from low-income
homes found that executive functions were not a mediator of externalizing behavior (Lohndorf,
Vermeer, Cárcamo, De la Harpe, & Mesman, 2019). Nevertheless, there was a relationship between
quality home environments and high executive functions in a Latin American context. These findings
can be attributed to this sample’s low externalizing behavior rates. They also indicate that social
disparities, not ethnicity per se expose families to harsh environments.
 DEVELOPMENTAL NEUROPSYCHOLOGY 5

Research on at-risk communities in Latin America has been insufficient; studies of these issues
usually focus on the so-called WEIRD countries. Traditional psychology has described behavior in
only a small portion of the population, forgotten cross-cultural variations, and generalized its findings
around the globe (Henrich, Heine, & Norenzayan, 2010). Mexico City, and the metropolitan area,
including bordering municipalities in Estado de México, such as Ciudad Nezahualcóyotl, Ecatepec,
and Naucalpan, is one of the largest cities in the Americas. Statistics show that accidents, murder, and
self-injury are the leading causes of adolescent mortality, with the latter more prevalent in men
(Centro de Integración Juvenil, 2018). Accidents usually mean a low perception of risk that involves
difficulties inhibiting behaviors.
In an epidemiological study of children and adolescents in the Mexico City metropolitan area,
Caraveo-Anduaga and Martínez-Vélez (2019) found that in 4- to 5-year-old children, a prevalence of
1.6 of externalizing behavior and 5.3 of internalizing behavior in girls per 134 population, and 0.8 of
externalizing behavior and 4.5 of internalizing behavior in boys per 144 population. Children coming
from homes with low socioeconomic status showed greater frequencies of internalizing behavior, and
such behavior was less common in younger children than in older ones. The prevalence of externaliz-
ing behavior was similar in boys and girls.
Thus, examining executive function as an individual variable with precise diagnostic tools and
considering cross-cultural variations is necessary.

The present study

This study aimed to analyze the relationship of executive functions to externalizing and internalizing
behaviors in preschoolers with typical development from the Mexico City metropolitan area.
Preschoolers with non-consolidated executive functions show high rates of externalizing behavior.
Most studies agree that non-consolidated executive functions are closely involved in attentional
problems (Araujo, Jané-Ballabriga, Bonillo, & Capdevilla, 2014; Espy, Sheffield, Wiebe, Clark, &
Moehr, 2011; Thorell & Nyberg, 2008), mainly the low-order executive functions of inhibition and
working memory (Thorell & Nyberg, 2008). Executive functions are also strongly related to inhibition
related to cognitive and emotional conditions (Espy, Sheffield, Wiebe, Clark, & Moehr, 2011). The
BRIEF-P is typically administered to measure executive functions, and the CBCL is well-known in
psychopathology. These studies have found strong relationships between executive functions and
externalizing and internalizing behaviors: all specific traits were highly related except somatic com-
plaints (Gioia, Espy, & Isquith, 2016).
However, there are inconsistencies in three aspects of these findings. First, there was a lack of
relationship between some executive functions, such as flexibility, to externalizing behavior (Romero-
López, Quesada-Conde, Bernardo, & Justicia-Arráez, 2017). Second, these studies disagree on whether
using tasks to assess executive functions can relate them to externalizing behavior (Espy, Sheffield,
Wiebe, Clark, & Moehr, 2011; Visu-Petra, Jurje, & Fizeşan, 2014). Third, although some executive
function tasks use the same construct, they make their assessments slightly differently. Livesey, Keen,
Rouse, and White (2006) found different results using two inhibition tasks, one was related to
externalizing behavior, but the other was not. Our study used the BRIEF-P questionnaire and four
tasks to measure executive functions.
More recent studies have shown that internalizing behavior is related to flexibility (Morea &
Calvete, 2021; Patwardhan, Nelson, McClelland, & Mason, 2021) and working memory (Quistberg
& Mueller, 2020). We included internalizing behaviors to corroborate these findings further. Our
study thus sought to provide cultural considerations for the neuropsychological assessment and
mental health diagnosis of Spanish speakers in the Latin American context. Its hypothesis is that
preschoolers with non-consolidated executive functions show more externalizing and internalizing
behaviors than children with typical executive functions. Subscales of the BRIEF-P, the CBCL 1.5–5,
and performance on tasks were investigated in detail.
6 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

Method
Participants
The participants were 30 preschoolers with typical development (age M = 53.63 months, SD = 7.83
months; 40% girls, range: 37–69 months old). All were born at term, had no visual or hearing
impairments, and had no history of illness, including neurological or psychiatric diseases.
Participants attended two different preschools, one in a UNESCO community center and the other
in a public school administered by the Secretary of Public Education, in Ciudad Nezahualcóyotl,
Estado de México, an area of middle-low socioeconomic status bordering northeast Mexico City. All
children performed executive function tasks. We also obtained information about them from their
caregivers (24 mothers and six grandmothers, fathers, or aunts). The mothers’ average age was 27.7
years (SD = 4.45), and their average educational level was 10.21 years (SD = 3.02), equivalent to middle
school. Almost half (47%) were homemakers, 30% had formal wage employment, and 23% were
informal vendors.

Measures
Executive functions
The assessment of executive functions included a questionnaire and tasks. We employed the
Behavioral Rating Inventory of Executive Function-Preschool (BRIEF-P) as a questionnaire. This
instrument contains 63 items on five clinical scales (inhibition, working memory, flexibility, emotional
control, and plan/organize), with the caregiver responding on a Likert-like scale with replies for
“never,” “sometimes,” and “often.” The Mexican Spanish adaptation has adequate reliability of α
= 0.70–0.93 (Gioia, Espy, & Isquith, 2016), with another study showing good reliability in a Mexican
sample (García-Anacleto & Salvador-Cruz, 2017).
We also used three tasks from the Neurological Soft Signs Scale (Escala de Signos Neurológicos
Blandos, Laboratorio de Neuropsicología del Desarrollo, UNAM, 2019). These included five measures
of executive functions: two of inhibition, two of working memory, and one of flexibility. The inhibition
tasks include the Red/Green and Cop/Robber tasks. The Red/Green task is based on the Stroop
paradigm (Gerstadt, Hong, & Diamond, 1994) and is a dichotomic verbal task for young children.
When the examiner says “red,” the child must reply” green,” and when the examiner says”green,” the
child must respond”red.” The child receives two points for the correct answer, one point for correcting
the wrong answer, and zero points for the wrong answer.
The Cop/Robber task is based on the Simon Says paradigm (Reed, Pien, & Rothbart, 1984), in
which children must follow the instructions of the cop and ignore those of the robber. We used one of
the most challenging versions of this task (Marshall & Drew, 2014). The examiner gives the child the
instructions and conducts two practice trials to be sure they are understood. The child would receive
two points if there were no errors, one point for correcting an incorrect response and zero points for
an incorrect response. The Red/Green and the Cop/Robber tasks have a maximum score of 22 points
from 11 definitive trials.
The Forward Digit Span task assesses working memory based on a task from the WISC-IV
(Wechsler, 2007) that examines an aspect of short-term memory known as the phonological loop
(Giofrè, Stoppa, Ferioli, Pezzuti, & Cornoldi, 2016; Tirapu-Ustárroz, Muñoz-Céspedes,
Pelegrín-Valero, & Albéniz-Ferreras, 2005). Children are asked to repeat a number series given by
the examiner. We added trials to each series to adapt the task to preschool children because repetition
favors task performance in learning numbers (Salvador-Cruz & Salgado-Magallanes, 2012). Children
were given three opportunities to repeat a number series correctly. The task included eight items, each
with two number series with the same number of digits. The maximum score was 16 points. Children
were first given two practice trials to confirm that they understood the instructions. We also intended
to include the Backward Digit Span task, but none of the children could perform it with the standard
 DEVELOPMENTAL NEUROPSYCHOLOGY 7

instructions, and only 11 could do so with additional instructions, which were similar to those for the
Forward Digit Span task.
The Maze task was based on Porteus Mazes (Levin, Song, Ewing-Cobbs, & Roberson, 2001).
Children were asked to resolve five mazes of increasing difficulty, beginning with a practice maze to
confirm that they understood the instructions. The score was the number of errors: when children
crossed a line or chose a path without an exit. High scores indicated poor performance, and there was
no limit.
Cronbach’s coefficient showed good reliability for the Red/Green task (α = 0.95) and the Cop/
Robber task (α = 0.84). After excluding the last four items of the Forward Digit Span working memory
task, we obtained acceptable reliability (α = 0.69). However, there were many inconsistencies in the
Backward Digit Span task, even with three deleted items (α = 0.65), so we did not include this task in
our study. After excluding the last maze, we obtained acceptable reliability for the Maze task (α = 0.71).

Externalizing and internalizing behaviors

We assessed the spectrum of externalizing and internalizing behavior with the Child Behavior
Checklist (CBCL 1.5–5), translated into Latin American Spanish (Achenbach & Rescorla, 2000).
This checklist provides a multidimensional diagnosis of general and specific traits of mental health
problems. This psychopathology is classified into a spectrum of externalizing and internalizing
behaviors (Achenbach & Rescorla, 2000) to which children exposed to traumatic or stressful environ-
ments are susceptible. Internalizing behavior describes children causing damage to themselves because
of the internal processes involved in directing behaviors inward; the specific traits evaluated by the
checklist are “emotionally reactive,” “anxiety/depression,” and “withdrawn.” Externalizing behavior
refers to discomfort related to inappropriate actions that affect others or the environment, and specific
traits are attentional problems or aggressive behavior.

Procedure
We informed authorities of two preschools about this study’s procedure, materials, and aims and
obtained their approval to meet with parents and caregivers to describe the study and invite them and
their children to participate. If they agreed, the parents were asked for written informed consent, and
the children were asked for oral assent. The parents or caregivers completed the BRIEF-P and CBCL
1–1.5 questionnaires after receiving instructions from the examiners. They did so in 10–15 minutes,
with the examiners present to answer any questions. The examiners verified that they had completed
the entire questionnaire.
The children performed the trials individually in a classroom, sitting in a chair facing the
experimenter across a table. Two different examiners assessed the children, who completed the
three executive function tasks in a single session of 30 minutes. All instructions given by the examiners
to each child are described in Table 1.

Data analysis
The study design was cross-sectional and correlational. Descriptive and inferential statistical analysis
was performed with R software, version 4.0.4 (2021), and z-standardized scores were obtained using
SPSS, version 20 (IBM Corp, 2011). A Kolmogorov-Smirnov test found that the distribution of the raw
scores was not normal. We used the huber function from the MASS statistical package (Venables &
Ripley, 2002) to obtain robust means and standard deviations for the BRIEF-P, the CBCL 1.5–5, and
the Red/Green, Cop/Robber, Forward Digit Span, and Maze tasks. We created two executive function
subgroups following the conceptualization in previous studies (e.g., Thorell & Nyberg, 2008), in which
the lower-order functions of inhibition and working memory are the basis of higher executive
8 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

functions (Diamond, 2013). Thus, all inhibition and working memory tasks belonged to one group,
and the Maze task was analyzed separately.
We applied robust statistical techniques to calculate multiple linear regressions and correlations.
These statistical analyses were based on predetermined procedures following García (2008). First,
robust multiple correlations were calculated with WRS2, applying the pball function with beta = 0.2
(Mair & Wilcox, 2020). We examined correlations between age, the BRIEF-P, executive function tasks,
and the CBCL 1.5–5 using the line code cor < matrix(c(x1,x2,x3,. . .,x12),30,12). We then calculated
pball (x = cor, beta = 0.2).
Next, we estimated MM-type linear regressions, which work for non-normal distributions, manage
outliers, and allow for a 50% breakdown point (Yohai, 1987). We applied the lmrob function from
robustbase (Maechler et al., 2021). Following García (2008), we computed the following code lines:
hyperplane < -lmrob(y ~ x1 + x2 + x3 + x4); after we computed # y = a – Ax1 - Bx2 - Cx3 - Dx4, and
finally computed summary (hyperplane). Each hyperplane contained age, BRIEF-P, executive function
tasks, and the Maze task to estimate externalizing and internalizing behaviors. The executive function
task score was a mean score from the z-standardized scores of the Red/Green, Cop/Robber, and
Forward Digit Span tasks.
Finally, we examined the correlation of the BRIEF-P to the “emotionally reactive,” “anxiety/
depression,” and “withdrawn” traits and attentional problems obtained with the CBCL 1.5–5. An
explanation of variance was analyzed to support the correlations.

Results
The robust means and standard deviations for the BRIEF-P, the Red/Green, Cop/Robber, Forward
Digit Span, Maze tasks, and the CBCL 1.5–5 are shown in Table 2, along with the minimum and
maximum scores attained in this study for purposes of comparison. The children’s task performance
results show that the Red/Green task had a higher mean and minor standard deviation (M = 20.43, SD
= 1.48) than the Cop/Robber task (M = 14.90, SD = 8.90). In the Forward Digit Span task, children
could, on average, repeat the three-number series, and some could repeat the four-number series (M =
5.10, SD = 1.48). Children made an average of four mistakes (M = 3.77, SD = 2.97). A higher score on
the Maze task indicated poor performance: its mean was 3.77, with a maximum score of 18 errors in
four mazes.
Significant correlation coefficients were found (Table 3). BRIEF-P was significantly correlated with
“emotionally reactive” (r = 0.76, p < .001), “anxiety/depression” (r = 0.66, p < .001), “withdrawn” (r =
0.42, p = .05), “attentional problems” (r = 0.74, p < .001), and “aggressive behavior” (r = 0.77, p < .001).
Externalizing and internalizing behaviors were related to all of the BRIEF-P scales. Performance on the
Forward Digit Span task was related to “attentional problems” (r = 0.47, p = .05) and “aggressive
behavior” (r = −0.46, p = .05), and significantly related to externalizing behaviors (r = −0.50, p = .05).
The Cop/Robber inhibition task was related to “withdrawn” (r = −0.40, p = .01) and general inter-
nalizing behaviors (r = −0.37, p = .05). Notably, attentional problems were explained by executive
function tasks (R2 = .64, p = .05), in which the Forward Digit Span task is involved (Table 4). Although
executive function tasks were related to “withdrawn,” they were not explained (R2 = .43, p > .1), and
the Maze task was not related to or explained by any of the traits of the CBCL 1.5–5. The Red/Green
and Maze tasks were unrelated to any externalizing or internalizing behavior trait. The Cop/Robber
task was unrelated to externalizing and internalizing behaviors except “withdrawn.” The Forward
Digit Span task was unrelated to internalizing behaviors except “withdrawn.”

Discussion
This study aimed to analyze the relationships between executive functions and mental health problems
in Mexican preschoolers from low-medium socioeconomic status homes. Data was obtained from
caregivers’ responses to the BRIEF-P and CBCL 1.5–5 questionnaires, and the children performed
 DEVELOPMENTAL NEUROPSYCHOLOGY 9

Table 1. Executive function task instructions in English and the original Spanish.
Instructions in English* Original in Spanish
Red/ Let’s play a game called Red/Green. I will say one of those colors. Vamos a jugar un juego que se llama rojo y verde. Te
Green When I say “red” [examiner points at self], you say “green” voy a decir uno de los dos colores, cuándo diga
[examiner points at child], and when I say “green” [examiner “rojo,” tú vas a decir “verde.” Y cuando yo diga
points at self], you say “red” [examiner points at child]. All “verde,” tú dirás “rojo.” ¿De acuerdo? Vas a hacer lo
right? Let’s begin. opuesto a mí ¡Empecemos!”.
Cop/ Let’s make believe that sometimes I’m the cop and sometimes Lo que vamos a hacer es imaginar que algunas veces
Robber I’m the robber. You have to do only what the cop says, not seré el policía y otras veces seré el ladrón. Y tú
what the robber says. For example, if I say, “the cop says tienes que hacer únicamente lo que diga el policía.
jump,” then you jump [examiner points at the child], but if Por ejemplo, si yo digo “el policía dice que saltes”
I say, “the robber says sit down,” you should not sit down entonces tú lo vas a hacer, pero si te digo “el ladrón
[examiner points at the child]. All right? Let’s begin. dice siéntate,” entonces tú no lo harás. ¿De
acuerdo? Empecemos.”
Forward I will tell you some numbers, and I want you to repeat them after Te diré unos números y tú los vas a repetir después
Digit me. Listen carefully, and when I am finished, repeat them after de mí. Escucha con atención y cuando termine
Span me. Say them just like me, ok? Let’s begin, please. Say “five- repítelos después de mí. Dilos como yo ¿vale?
seven” [the first trial; if the child does not repeat them vamos a empezar, por favor, dí cinco-siete. Vale,
correctly, this is followed by a second trial]. Ok, let’s do it again; vamos a hacerlo de nuevo, voy a decirte los mismos
I will say the same numbers. Please repeat them: “five-seven.” números, por favor repítelos, cinco-siete, ¡buen
Good job! [If necessary, a third trial.] Let’s try again, we have intento! vamos a hacerlo de nuevo, tenemos otra
another chance. Please say “five, seven.” oportunidad, por favor dí cinco-siete.
Maze Look, this is a maze for this little dog who wants to find his food. Mira esto es un laberinto para este perrito, y él quiere
Can you help him find it without crossing the lines? Ok? encontrar su comida. ¿Podrías ayudarlo
a encontrarla? Pero no debes cruzar las líneas del
laberinto. ¿Vale?
*This translation also indicates non-verbal instructions given to the children and additional instructions given by the examiners.

Table 2. Means, standard deviations, minimum and maximum scores, and highest possible scores on the cbcl 1.5–5, brief-p, and
executive functions tasks (raw scores).
Variable M (SD)* Min Max Highest Possible Score
BRIEF-P a 27.35 (20.00) 2 82 126
Red/Green-Inhibition b 20.43 (1.48) 0 22 22
Cop/Robber-Inhibition b 14.90 (8.90) 5 22 22
Forward Digit Span-Working Memory b 5.10 (1.48) 4 8 8
Maze-Flexibility c 3.77 (2.97) 0 18 18e
CBCL 1.5–5 Emotionally reactive d 1.72 (1.48) 0 10 18
CBCL 1.5–5 Anxiety/Depression d 3.07 (2.22) 0 10 16
CBCL 1.5–5 Somatic Complaints d 2.14 (1.48) 0 3 11
CBCL 1.5–5 Withdrawn d 1.91 (1.48) 0 9 16
CBCL 1.5–5 Attentional problems d 3.4 (2.97) 0 7 10
CBCL 1.5–5 Aggressive behavior d 9.86 (5.93) 0 35 38
*M and SD were obtained using huber; ahigher scores indicate non-consolidated executive functions reflected in poor performance of
everyday activities; blower scores indicate non-consolidated executive functions due to poor performance; chigher scores indicate
non-consolidated executive functions due to poor performance; dhigher scores mean mental health problems; ethere is no limit to
the number of errors in the Maze task.

executive function tasks. Our findings support the hypothesis that non-consolidated executive func-
tions are related to externalizing and internalizing behavior. Only the BRIEF-P explained attentional
problems, consistent with previous studies results (Araujo, Jané-Ballabriga, Bonillo, & Capdevilla,
2014; Dias, Trevisan, León, Prust, & Seabra, 2017; Romero-López et al., 2016; Espy, Sheffield, Wiebe,
Clark, & Moehr, 2011).
There are two relevant considerations regarding working memory and attentional problems in
preschoolers. The working memory scale in the BRIEF-P and the attentional problems scale in the
CBCL 1.5–5 contains items such as “Cannot keep focus in board games, puzzles, and other learning
activities” and “Cannot concentrate,” which are considered to be related. However, the scale of the
attentional problem also includes hyperactive behavior, and the working memory scale includes more
than purely attentional processes. Although attention in children interacts closely with working
memory, different processes are involved in managing cognitive content as a unit (Anderson &
 10
J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS
Table 3. Correlations between executive functions at behavioral and cognitive levels and general and specific behavioral traits.
Internalizing Behavior Externalizing Behavior
c
Emotionally Anxiety/ Somatic Withdrawn Total Internalizing Attentional Aggressive Total Externalizing
reactive c Depressionc Complaintsc Behaviorc Problems c Behavior c Behavior c
BRIEF-P Inhibitiona 0.72** 0.57** 0.14 0.36* 0.68** 0.71** 0.76** 0.88**
Working 0.73** 0.61** 0.23 0.37* 0.71** 0.73** 0.73** 0.82**
Memorya
Flexibilitya 0.64** 0.58** 0.37* 0.52** 0.70** 0.57** 0.49** 0.57**
Emotional 0.74** 0.67** 0.30 0.48** 0.78** 0.58** 0.80** 0.83**
Controla
Plan/Organizea 0.56** 0.49** 0.20 0.30 0.59** 0.65** 0.65** 0.71**
Executive Function Red/Green 0.04 −0.12 0.08 −0.16 −0.02 −0.36 −0.01 −0.09
tasks Cop/Robberb −0.28 −0.35 −0.25 −0.40** −0.37* −0.17 −0.16 −0.20
Forward Digit −0.34 −0.26 −0.16 −0.51** −0.38* −0.47* −0.46* −0.50*
Spanb
Mazea 0.06 0.11 0.16 0.25 0.10 0.35 0.15 0.22
Means. *p < .05, **p < .01.aHigher scores indicate poor executive functions; blower scores indicate poor executive functions; chigher scores indicate behavior problems.
 DEVELOPMENTAL NEUROPSYCHOLOGY 11

Table 4. Correlations of age, brief-p, lower-level executive functions tasks, and externalizing and internalizing behaviors using the
cbcl 1.5–5 in Mexican preschoolers, with multiple linear regression coefficients.
CBCL 1.5-5 Age BRIEF-Pb Executive function tasksd Mazec R2 ΔR2
Emotionally reactivea −0.03 0.76*** −0.28 0.06 0.61 0.54
Anxiety/depressiona −0.23 0.66*** −0.30 0.11 0.56 0.49
Withdrawna −0.15 0.42* −0.43* 0.25 0.43 0.36
Attentional problemsa −0.33 0.74*** −0.47*** 0.35 0.64 0.58
Aggressive behaviora −0.02 0.77*** −0.30 0.16 0.65 0.6
Means. *p < .05, **p < .01, ***p < .001.a Higher scores indicate mental health problems; b higher scores indicate non-consolidated
executive functions reflected in everyday activities/poor performance; c lower scores indicate non-consolidated executive functions
due to poor performance; d mean from z-scores of all tasks (Red/Green, Cop/Robber, and Forward Digit Span). Bold numbers show
significant predictors, but only attentional problems had a significant intercept in the multiple linear regression.

Reidy, 2012; Diamond, 2013; Garon, Bryson, & Smith, 2008). Working memory allows for the
conservation of objectives when the child focuses on thoughts and actions to solve a complicated
task, and attention emphasizes selecting and focusing on certain stimuli (Diamond, 2013). Detecting
non-consolidated working memory is part of the early diagnosis of attentional problems in preschool.
Although preschoolers do not focus attention the same way as adults, there is evidence of the
emergence of attention during the first four years of life (Ruff & Capozzoli, 2003). This period
represents a quantitative and qualitative improvement in executive functions (Diamond, 1985),
where children gradually take control of their behavior. For example, preschoolers can pay attention
during a specific period in the classroom. They prefer playful activities but require management of
their behavior to follow instructions and behave in a particular way. We assessed preschoolers’
executive function tasks in games; all children could perform them, except the Backward Digit
Span, which was then eliminated. The inhibition tasks were based on the Stroop and Simon Says
paradigms; these are similar but have different difficulty levels. The Red/Green and Cop/Robber tasks
have a verbal stimulus and response, but the Cop/Robber has more extensive instructions than the
Red/Green task. Complex instructions are difficult for young children (Gerstadt, Hong, & Diamond,
1994). They require greater language skills than direct inhibition tasks such as the Stop Signal task
(Livesey, Keen, Rouse, & White, 2006). Although the Red/Green task showed no correlations, we think
better measures are needed to assess inhibition in younger children or those with lesser language
development. The Cop/Robber task is based on the Simon Says game, which was not popular in the
preschool years in Mexico; it was thus a completely new activity and consequently more challenging.
Moreover, previous studies have shown that direct inhibition tasks are more strongly related to
externalizing behavior (Espy, Sheffield, Wiebe, Clark, & Moehr, 2011; Livesey, Keen, Rouse, &
White, 2006; Visu-Petra, Jurje, & Fizeşan, 2014). Nevertheless, inhibition tasks involving language
skills could help to explain how preschoolers assimilate complex instructions.
Concerning working memory tasks, we found that children could not perform the Backward Digit
Span. However, Anderson and Reidy (2012) reported that preschoolers could perform Backward Digit
Span tasks. Our sample was able to perform the Forward Digit Span task. This task does not directly
measure working memory: it assesses short-term memory (Diamond, 2013). One study has identified
the Forward Digit Span task as an indicator of problems related to the reception and storage of
cognitive content (Giofrè, Stoppa, Ferioli, Pezzuti, & Cornoldi, 2016). Few studies have included these
tasks to analyze externalizing and internalizing behaviors. However, the current study and Espy,
Sheffield, Wiebe, Clark, and Moehr (2011) found that performance on the Forward Digit Span task is
closely related to externalizing behaviors in preschoolers.
We also found that preschoolers with non-consolidated flexibility showed a greater prevalence of
emotionally reactive, anxiety/depression, and withdrawn traits, all of which are internalizing beha-
viors. Flexibility allows for changing strategies that are not functional to achieve a goal and also
different points of view regarding the same problem (Visu-Petra, Mărcuș, Buchwald, Moore, &
Arenas-Landgrave, 2019). No study in our literature review included the Maze task. However, it is
helpful for higher-level executive functions, including flexibility and planning processes. We did not
12 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

find significant results using the Maze task. One study has found that the London Tower task was
related to oppositional defiant behavior (Espy, Sheffield, Wiebe, Clark, & Moehr, 2011). We did not
examine this dimension of externalizing behavior.
Castellanos-Ryan et al. (2014) argue that inhibition tasks explain the general trait of externalizing
behavior. A deeper analysis could also differentiate between specific externalizing behavior traits to
find more robust relationships. As inhibition is closely related to attentional problems, their study
provides a helpful integrated model and specific and general analyses that we draw upon to study
internalizing behaviors in children. Detecting internalizing behaviors is difficult; they can pass
unnoticed by caregivers. Using the BRIEF-P, we found that flexibility was strongly related to inhibi-
tion, working memory, and emotional control. Only somatic complaints were related to flexibility,
which provides a stronger relationship to the general trait of internalizing behavior. These findings
suggest that flexibility at the behavioral level is a confident indicator of internalizing behavior in
children aged 4 to 5. At the cognitive level, working memory is also related to specific traits of
internalizing behavior.
The possibility of a negative halo effect instead of a relation between variables should be acknowl-
edged. There are two considerations here. First, caregivers answered the BRIEF-P and CBCL 1.5–5
questionnaires, but the task scores were obtained from children’s performance, and we did not assess
children’s executive functions according to their scores on the CBCL 1.5–5. Second, executive
functions and externalizing and internalizing behavior are conceptualized from different disciplines.
The concept of executive functions belongs to neuropsychology while externalizing and internalizing
behaviors are described as mental health disorders. Neuropsychology provides tools to connect
cognitive-behavioral links and identify transdiagnostic characteristics in these disorders. Executive
functions do not in themselves explain mental health disorders. However, they can help us understand
how children acquire the ability to regulate their behavior.
Future research should continue to explore variations on executive function tasks based on playful
activities to obtain better results. Children have difficulty learning complex instructions and taking
tasks seriously (Gerstadt, Hong, & Diamond, 1994). They usually prefer exciting activities and are
quickly bored when they require effort. Playful executive function tasks may provide a valuable tool for
analyzing externalizing and internalizing behaviors (Marshall & Drew, 2014) and other cognitive
processes.
Our study has both clinical and educational implications. Our finding that non-consolidated
working memory and flexibility are related to mental health problems is relevant to a clinical under-
standing of those problems. Working memory manipulates and maintains information, while atten-
tion selects and focuses on relevant stimuli (Diamond, 2013). Children with attentional problems
cannot filter and maintain certain information. Non-consolidated working memory and attentional
problems are closely related, and our assessment of executive function focused on working memory in
children with a probable diagnosis of attentional problems. Non-consolidated flexibility was also
related to internalizing behaviors, in which children have difficulty changing strategies and thinking
differently. Visu-Petra, Mărcuș, Buchwald, Moore, and Arenas-Landgrave (2019) found that non-
consolidated flexibility is a risk factor for internalizing problems like anxiety.
These findings also have educational implications: they suggest that preschools should include
programs for the training of executive functions. Such programs would prevent externalizing and
internalizing behaviors and promote the acquisition of emerging reading and writing skills. Early
executive function training could help avoid risks for later mental health problems.
The findings of our study of Mexican preschoolers with low-medium socioeconomic status can
help test interpretations and obtain better transdiagnostic data for the understudied Mexican popula-
tion. Children from the Mexico City metropolitan area are exposed to the harsh environment of
a rapidly growing city. Caraveo-Anduaga and Martínez-Vélez (2019) found that children from at-risk
areas were more susceptible to internalizing behavior and included more significant numbers of girls
with externalizing behavior. There is thus a great need for further study of mental health in this area.
 DEVELOPMENTAL NEUROPSYCHOLOGY 13

The relationships between executive functions and externalizing and internalizing behaviors con-
tribute to transdiagnostic analysis in neuropsychological assessment and call for neuropsychological
training programs in both clinical and educational scenarios.

Limitations and future directions

Some of the limitations of this study relate to the other factors involved in externalizing and
internalizing behaviors. The present study has considered some factors; future research should
consider additional variables to obtain better comprehensive analyses. It is also necessary to measure
mothers’ or caregivers’ mental health and children’s characteristics, including language development,
IQ, and temperament. A larger sample and longitudinal study would be recommendable. The
executive function tasks must be carefully selected to obtain accurate results. Although each parental
measure provides different information about the child, they can be considered subjectively related
because the same individual made them. We suggest collecting information from other informants like
teachers or relatives to be unbiased. Future research should explore prevention programs based on
executive function training, examine executive functions as resilience factors, and conduct long-
itudinal studies.

Conclusion
Executive functions play an essential role in mental health, and their assessment contributes to
our understanding of cognitive-behavioral links. Our study attempts to promote communication
between different psychological disciplines and enhance the connections between theory and
practice. Executive function assessment is a tool that can detect early signs of risk in children.
Individual differences in executive functions are essential in specific and general psychopathol-
ogy. Children of the same age show variations in executive functions because of individual
differences (Diamond, 1985). Genetic factors and pre-and post-natal environments are also
involved in mental health problems (Pinsonneault et al., 2016). Such variations also help to
identify risk factors in children and promote optimal executive function development. Our
contributions can help improve clinical neuropsychological diagnosis, highlighting the necessity
of creating early childcare programs in vulnerable contexts, such as populations with psycholo-
gical or learning problems.

Acknowledgments
This work was supported by a grant from the Universidad Nacional Autónoma de México (PAPIIT IN308219, “Factores
del desarrollo neurocognitivo asociados a la adquisición del proceso de lectoescritura en niños preescolares”). We are
grateful to the training program in manuscript writing in English (CEMAI-CONACYT). We also appreciate the
assistance of Julia Beatriz Barrón-Martínez and Tomás Alberto Salmerón-Enciso.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The work was supported by the Support Program for Research and Technological Innovation Projects (PAPIIT)
[PAPIIT IN308219 Factores de Desarrollo neurocognit].
14 J. SALVADOR-CRUZ AND J. P. BECERRA-ARCOS

ORCID
Judith Salvador-Cruz http://orcid.org/0000-0003-1902-1525
Jessica Paola Becerra-Arcos http://orcid.org/0000-0002-4213-2170

Compliance with ethical standards

All parents and caregivers were informed about the study procedures, materials, and aims, of the study, in accordance
with the Código Ético del Psicólogo (2013) del Consejo Nacional para la Enseñanza e Investigación en Psicología
(Psychologists’ Code of Ethics of the Mexican National Council for Teaching and Research in Psychology, CNEIP).

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