ADHD: A Subset of Executive Functioning Disorders

By Julie Steck, Ph.D., HSPP

The term “executive functioning disorders” has been used increasingly in educational settings and is often used as another term for the characteristics associated with Attention Deficit/Hyperactivity Disorder (ADHD), particularly the inattentive form of ADHD. However, Executive Functioning Disorders (EFD) are not unique to ADHD. The causes of EFD are heterogeneous and are linked to a number of neurocognitive and behavioral issues. Some EFD’s, such as ADHD, are present in early childhood and often continue well into adulthood. Other EFD’s are acquired as the result of accidents and illnesses or as part of a progressive neurodegenerative disorder, such as Parkinson’s disease. Individuals who are suffering depression or who are overwhelmed by anxiety and stress may also demonstrate executive functioning difficulties, but these are typically transient and improve as the anxiety, depression or stress is alleviated.

Attention Deficit/Hyperactivity Disorder (ADHD) can present in a number of ways. The most commonly known and easily recognized form is ADHD-Combined Type. Individuals with this type of ADHD are typically diagnosed during childhood due to their poor impulse control and hyperactivity. Their difficulty with self-regulation and behavioral control is noted by teachers, coaches and parents. However, their deficits in executive functioning are often not as apparent at a young age. ADHD-Predominantly Inattentive Type (at times referred to as ADD) is not as easily recognized. These individuals are often perceived as being poorly organized and inconsistent in their performance and are often referred to as “lazy.” Their deficits in executive functioning become more apparent as the demands for organization across time and space become more apparent. For reasons that are not well understood yet, females are more likely to be diagnosed with the Inattentive subtype of ADHD although males certainly receive this diagnosis, too.

As a psychologist, I am often asked if ADHD is over-diagnosed and over-treated. The reality is that ADHD is more often under-diagnosed and under-treated. And it is often misdiagnosed or is only part of the diagnostic picture for an individual. I am also frequently asked what causes ADHD. Approximately 80% of individuals with ADHD have inherited the disorder and there is a genetic basis to their condition. The remaining 20% of individuals with ADHD can attribute their diagnosis to environmental factors such as maternal smoking during pregnancy, prematurity, and traumatic brain injury. Current estimates are that ADHD is present in approximately 9% of the school-age population. ADHD frequently co-exists with other learning disorders, developmental disorders and psychiatric conditions.

So how does a psychologist assist individuals and families in addressing and treating ADHD? First and foremost, treatment of ADHD begins with a good assessment. Prior to treating symptoms of ADHD, it is important to be sure that the disorder is present and to also know what other conditions may co-exist with ADHD. The observable symptoms of ADHD –hyperactivity, impulsivity and inattention – are often just the “tip of the iceberg.” Assessment should include interview with family members, review of available records, information and rating scales from others knowledgeable of the individual, and interview of the individual. Following the interviews and review of records, further evaluation may be needed to clarify the diagnosis of ADHD and/or other co-existing conditions. There is a wide range of tests available to assist in the diagnosis of ADHD but there is no one test that can be used to make a definitive diagnosis. The diagnosis of ADHD is a clinical diagnosis based on all available information.

The second part of treatment of ADHD is parent/family/patient education about the condition. Understanding the nature of ADHD is critical to treating the disorder. A very important part of this education includes awareness of the deficits in inhibition, self-regulation and executive functioning associated with ADHD. While awareness of how ADHD impacts an individual will not “cure” the condition, it will help the individual and others better understand the behaviors associated with ADHD and, thus, assist in finding ways to minimize the deficits. One of the pieces of information I share with families of children, adolescents and young adults is the fact that individuals with ADHD have approximately a 30% delay in their ability to self-regulate, plan, organize and follow-through. This fact alone helps families recognize that they need to have realistic expectations for their family member and to assist with areas of deficit. ADHD is not an excuse but an explanation that can provide direction for intervention and support.

The third part of treatment is consideration of medication. Dr. Rowland addresses this topic in his article, “The Use of Stimulant Medications in Treating Executive Functioning Disorders.” While many families want to pursue other interventions, such as diet changes, it is important to at least discuss and explore the option of medication as part of an overall intervention plan.

The fourth part of treatment is the provision of external supports through accommodations and changes in the environment. The knowledge of how to provide supports is often gleaned through therapy with a psychologist or therapist knowledgeable regarding ADHD. When dealing with children and adolescents, the therapy includes the parents/caregivers as well as the child or adolescent. The younger the child, the more the focus is on assisting the parents in knowing how to optimize the child’s behavior, learning and development. Most individuals with ADHD are not ready to embrace their diagnosis and try to build their own supports until late high school. Even then, the parents will need to be involved in therapy to some extent. In dealing with college students and adults, supportive family members or significant others are often involved in the therapy and treatment. At this stage, it may be helpful to begin working with an ADD coach who can form a co-active partnership with the student/individual with ADD. Coaches help late adolescents/adults with ADHD create and implement their own approaches to improved organization, time management, and goal attainment. They ask “powerful questions” and use other techniques designed to strengthen the individual’s executive functioning skills. See the article in this issue by Dr. David Parker for more information about ADD coaching.

ADHD needs to be viewed as a developmental disorder in which the symptoms and behaviors may change over time but the underlying deficits in inhibition, self-regulation and executive functioning persist. In closing, let me synthesize many of the above points with a list I have discussed with countless individuals, families, and audiences over the years. I refer to it as the “Top 10 Things to Keep in Mind” when you have ADHD:

1. For individuals with ADHD, time is the enemy. If they are doing something they enjoy, there is not enough time. If they are to do something they don’t enjoy, they will procrastinate or just not do it.
2. Individuals with ADHD have difficulty sustaining mental effort.
3. They also have trouble remembering to do what they need to do when they need to do it.
4. ADHD causes a 30% delay in acquisition of skills requiring self-regulation.
5. The greater the requirement for self-organization across time and space, the greater the likelihood for failure.
6. An individual with ADHD performs well once and we hold it against them forever.
7. Those with ADHD live in the moment – they don’t reflect on the past to remember what happened last time or look to the future to think of consequences of their behavior.
8. ADHD causes individuals to have trouble stopping a behavior in the middle of a behavior.
9. Most of what we know about ADHD is based on research on males, but females with ADHD are just as much at risk for problems in all areas of functioning.
10. Hope starts with diagnosis. Without diagnosis, much time, energy, and money is spent on ineffective treatment. When treatments don’t work, the blame begins.