Cited by 698Neural and Behavioral Psychology StudiesCognitive Functions and MemoryNeurotransmitter Receptor Influence on Behavior

The DOI matches its Crossref record; 148 of the 150 references it cites were found in a registry or an index; 2 of the 107 sources its claims cite were checked for support.

Cognitive and behavioural flexibility: neural mechanisms and clinical considerations

Open access
Uddin, Lucina Q.·2021·Nature Reviews Neuroscience

Abstract

Cognitive and behavioural flexibility permit the appropriate adjustment of thoughts and behaviours in response to changing environmental demands. Brain mechanisms enabling flexibility have been examined using non-invasive neuroimaging and behavioural approaches in humans alongside pharmacological and lesion studies in animals. This work has identified large-scale functional brain networks encompassing lateral and orbital frontoparietal, midcingulo-insular and frontostriatal regions that support flexibility across the lifespan. Flexibility can be compromised in early-life neurodevelopmental disorders, clinical conditions that emerge during adolescence and late-life dementias. We critically evaluate evidence for the enhancement of flexibility through cognitive training, physical activity and bilingual experience. Flexibility is critical for the optimal adaptation of thoughts and actions under changing circumstances. In this Review, Uddin summarizes research that has identified cognitive processes and neural systems supporting flexibility and discusses ways to improve flexibility across the lifespan.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This review synthesizes human neuroimaging and animal work on cognitive and behavioural flexibility, emphasizing distributed frontoparietal, midcingulo-insular, and frontostriatal systems across the lifespan. It argues that flexibility deficits cut across neurodevelopmental, adolescent-onset, and late-life disorders, while evidence for enhancing flexibility through training, exercise, and bilingualism remains mixed.

Key findings

  • Flexibility is supported by large-scale functional networks: a lateral frontoparietal network (including dorsolateral prefrontal cortex, inferior frontal junction, and inferior parietal lobule), a midcingulo-insular network (including anterior insula and anterior midcingulate cortex), and frontostriatal circuits. The inferior frontal junction is engaged during updating of task representations and flexible item selection, with connectivity strength related to individual task performance.
  • Flexibility follows an inverted U-shaped lifespan trajectory, peaking between the second and third decades and declining in later life. Brain signal variability generally decreases from ages 6 to 85 across most regions, except the anterior insula, which increases; higher variability has been linked to better performance in some older adults.
  • Flexibility deficits appear transdiagnostically in autism spectrum disorder, ADHD, mood and anxiety disorders, obsessive–compulsive disorder, schizophrenia, Alzheimer disease, and Parkinson disease. The review’s table links manifestations such as restricted/repetitive behaviours, repetitive negative thinking, cognitive rigidity, and compulsions to putative substrates including frontostriatal, orbitofrontal, midcingulo-insular, and frontoparietal systems.
  • Intervention evidence is mixed: cognitive training often produces narrow short-term transfer; a game-based flexibility training study reported reading comprehension gains only at 6-week follow-up; a randomized controlled trial of working memory and cognitive flexibility training in autism did not show differential improvement; “Unstuck and On Target” improved classroom behaviour, flexibility, and problem-solving in autism; exercise alone showed little or no executive function benefit; bilingual advantages were inconsistent but observed in lower socio-economic status children and as possible cognitive reserve.

Methods

  • Narrative critical review, not a primary empirical study. It synthesizes non-invasive human neuroimaging and behavioural paradigms (including task-switching, set-shifting, Wisconsin Card Sorting Test, and reversal learning) alongside animal lesion, pharmacological, and behavioural studies.
  • The review spans typical development, adulthood, ageing, and clinical conditions, and evaluates cognitive training, physical activity, and bilingualism as potential flexibility interventions.
  • Main analysis is qualitative synthesis and critical evaluation; no systematic search strategy, meta-analysis, or primary sample is described.

Limitations

  • The paper states measurement problems: laboratory/performance-based measures and self- or informant-report measures are only weakly correlated, and construct validity versus ecological validity remains a challenge. It calls for standardized, transdiagnostic, age-normed assessments.
  • The paper states that intervention evidence is mixed, bilingualism findings lack consensus, and no interventional studies have yet shown that training changes brain network dynamics supporting flexibility. Cholinergic contributions are complicated by co-release of other neurotransmitters.
  • Evident from the text: as a narrative review, it does not report a systematic search, formal effect sizes, or risk-of-bias assessment, and conclusions draw on heterogeneous paradigms, populations, and study designs.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1038/s41583-021-00428-w

Cites

148 of 148 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

94 Not checked yet · 10 No basis given · 6 Own interpretation · 2 Partly supported · accuracy not yet measured

Verify all 105 references — free account
  • It may state two separate claims as one. 42
  • Probably not a substantial claim. 6
47 of 47
  • The paper relies on this without support.

    Cognitive and behavioural flexibility are impaired in autism spectrum disorder, attention-deficit/hyperactivity disorder, schizophrenia, mood disorders, and dementias.

    “Cognitive and behavioural flexibility are compromised in clinical conditions affecting early life such as autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD); those that emerge in adolescence, including schizophrenia and mood disorders; and dementias with later-life onset.”
  • The paper relies on this without support.

    Many of these clinical conditions share flexibility deficits.

    “While many of these conditions share flexibility deficits, the heterogeneous nature, severity and patterns of co-morbid symptoms complicate efforts to develop treatment strategies for enhancing flexibility.”
  • The paper relies on this without support.

    The heterogeneity, severity, and co-morbidity of these conditions make it difficult to develop treatments to enhance flexibility.

    “While many of these conditions share flexibility deficits, the heterogeneous nature, severity and patterns of co-morbid symptoms complicate efforts to develop treatment strategies for enhancing flexibility.”
  • The paper relies on this without support.

    All DSM-V categories, possibly except sleep-wake disorders, include clinical conditions with compromised executive function domains.

    “All of the DSM-V categories (with the possible exception of sleep–wake disorders) include clinical conditions in which domains of executive function are compromised; this raises the question of the extent to which the construct of flexibility has discriminative value.”
  • The paper relies on this without support.

    In several disorders with documented flexibility deficits, these impairments can be observed while basic perceptual and motor performance remains unchanged.

    “In several of the disorders in which flexibility deficits have been documented, these impairments can be observed even while performance on basic perceptual and motor tasks remains unaltered.”
  • The authors state this as an assumption.

    The common behavioural manifestations of cognitive inflexibility across ASD and ADHD should be reflected in shared neural substrates.

    “Although it is hypothesized that the common behavioural manifestations of cognitive inflexibility across ASD and ADHD should be reflected in shared neural substrates, few assessments of brain circuitry supporting flexibility across these disorders have been conducted.”
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Citations

Cites

Show all 150 references

Research works printed but not linked: 2

  1. Cambridge Cognition. Intra-Extra Dimensional Set Shift (IED). https://www.cambridgecognition.com/cantab/cognitive-tests/executive-function/intra-extra-dimensional-set-shift-ied/ (2021).
  2. Casey, B. J., Jones, R. & Hare, T. The adolescent brain. The year in cognitive neuroscience. Ann. NY Acad. Sci. 11, 84–94 (2008).

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Metadata

Authors
Uddin, L. Q.
Affiliations
University of Miami (US)
Corresponding author
Uddin, Lucina Q.
Venue
Nature Reviews Neuroscience
Published
2021-02-03
Volume
22
Issue
3
Pages
167-179
ISSN
  • 1471-003X (ISSN-L)
  • 1471-0048
OpenAlex
W3128518091
Cited by
698
References
150
Citations by year
2026: 151 · 2025: 175 · 2024: 146 · 2023: 111 · 2022: 79 · 2021: 36
FWCI
13.66
Type
journal article
Language
en
Open access
Locations
  • Nature reviews. Neuroscience (publishedVersion, cc-by)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • University of Miami
  • Canadian Institute for Advanced Research
  • National Institute of Mental Health (R01MH107549)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Cognitive Functions and Memory
  • Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Neurotransmitter Receptor Influence on Behavior
Keywords
cognitive flexibility, behavioral flexibility, neural mechanisms, frontoparietal network, frontostriatal circuits, neurodevelopmental disorders, dementia, cognitive training, physical activity, bilingualism
MeSH terms
Animals, Behavior, Behavioral Symptoms, Cognition, Cognition Disorders, Humans, Nerve Net, Nervous System Physiological Phenomena, Neural Pathways

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