ADHD – A Disorder of Executive Functions

Dr. Brett HowardADHD

Although ADHD is considered by many experts to be a disorder of our brain’s “executive functions,” this newer understanding of ADHD is not referenced in our own psychiatric manual of diagnosis, the DSM-5. When the American Psychiatric Association published the DSM-5 in 2013, it was met with some pretty heated controversy. I, however, do not mind the DSM controversy at all as it highlights some very true aspects of mental health diagnoses, including ADHD: they are dynamic, imperfect, hardly precise, and they are the best we have for now–given what we know.

Attention Deficit/Hyperactivity Disorder (ADHD) is a perfect example of how a mental health condition has evolved in its diagnostic criteria and conceptualization over time. Over the last 100 years ADHD has been understood as a condition affecting a variety of different brain functions, behavior patterns and nervous systems. But, according to A New Understanding of ADHD in Children and Adults, the symptom of “inattention” only became a central part of our understanding of ADHD in 1980.

As our understanding of ADHD continues to grow, so does our ability to help an even wider group of individuals who are suffering from performance, focus and attention deficits. One of the most recent contributions to the ADHD literature is research suggesting that ADHD can also be conceived as a condition that impairs our Executive Functions.

Executive Functions (EFs) are “those self-directed actions needed to choose goals and to create, enact, and sustain actions toward those goals.”

EFs are a collection of brain functions responsible for one’s self-management, including our abilities to plan, initiate & complete tasks, estimate time, shift between tasks, regulate emotion and inhibit responses. ADHD is a condition where the part of the brain responsible for these abilities may not be functioning optimally and can result in distraction, inattention, impulsivity, emotion dysregulation and hyperactivity.

Executive Functions Impaired by ADHD

People with ADHD may have impairments in all or just a few of these executive functions. The variability in which EFs are impacted may be one of the many reasons why people with ADHD can be so different from one another. Here is a list of several EFs that are thought to be impaired by ADHD:

1) memory – although many people with ADHD have fantastic long-term memory, their ability to efficiently use their working memory and recall recent information can be more difficult. “Working memory” is like our computer’s RAM and is involved in holding information we are currently using. Keeping in mind that phone number you just looked up while you dial uses working memory, and so does the recent placement of your car keys. Expressive writing draws heavily on working memory and is a skill in which many with ADHD have difficulty.

2) set-shifting – refers to the ability to move between multiple tasks, mental operations, and activities. Many of us can have difficulty, at times, with moving between different activities. This difficulty is particularly significant with those with ADHD and can look like a screeching halt in the middle of an otherwise productive day. Set-shifting impairments might be similar to a car trying to merge onto I-495 while not being able to control what gear your car is in.

3) emotion regulation – modulating one’s emotions and tolerating frustration is a major job of your brain’s EFs. Those with ADHD and an emotion regulation impairment may experience difficulty managing frustration, chronic worry, desires and have a history of temper or anger issues.

4) effort – this EF regulates alertness, sustained effort and the speed by which you process information. People with ADHD may excel at completing short-term projects or assignments with more of an immediate feedback mechanism. Sustained effort over longer periods can be quite a challenge.

Many of my clients have told me that they delayed their own evaluation for ADHD because they never considered themselves to be similar to the hyperactive kids they hear so much about from friends or relatives. What research is telling us is that the old characterization of what ADHD looks like is out of date and it doesn’t match the experience of many people suffering from ADHD.

Just as our understanding of ADHD has changed over the last century, so will our understanding of ADHD in the future be shaped by what we learn today. Until then, we now know that those with ADHD may manifest symptoms related to impairments in their ability to utilize their “Executive Functions.” Our wait now is to see what research will tell us next about this condition..and to see if more of my clients’ experiences will be represented in DSM-6.

Great Scott! I sometimes have problems with my EF’s! I must have ADHD!

Not necessarily. Most people, at times, have difficulties organizing themselves, feeling motivated, or staying cool-headed. A few instances of procrastination or disorganization do not a disorder make. Formally, ADHD is a persistent pattern of executive function deficits that cut across more than one life areas (aka, domains). If one’s EF deficits only happen at work, with one’s spouse or during your least favorite class, then ADHD is not the diagnostic metaphor that fits your situation best.

It might be that adding a few EF-related tools or techniques is all you need to get yourself back on track. To learn a few, I found an awesome workbook by Jan Johnston-Tyler called “The CEO of Self: An Executive Functioning Workbook.” This book has lots of cool tips & techniques to address several “types of management” problems including time, space, information, memory and obstacle. This book = very helpful.

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P.S. I didn’t know what picture to put with a post about Executive Functions, so I just chose one of my dog, Darwin.