ADHD and Executive Functions
ADHD and Executive Functions
By Micah Saviet, LCSW-C, NBC-HWC, BCC, CEAP
What is ADHD?
Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychological disorder characterized by symptoms of inattention, hyperactivity, and impulsivity (NIMH, 2020). This disorder is increasingly recognized as a disorder of self-regulation–i.e., dysregulation. The estimated prevalence rate of ADHD in children or adolescents worldwide is 5% (Polanczyk et al., 2007). While the main presentation of symptoms often shifts, nearly 80% of childhood diagnoses persist into adulthood with adult prevalence rates estimated at 2-3% (CHADD, 2023, Song et al., 2020).
What does ADHD have to do with Executive Functions?
One common challenge for many people across the lifespan with ADHD is impaired executive functions (EFs). These are the “higher order processes” mental skills involved in carrying out many daily tasks that occur in the prefrontal cortex (PFC) located behind the forehead in our brain. EFs work like the “cognitive management system” of the brain and function together to help us plan, work towards tasks and goals, and make real-time adjustments based on incoming feedback. Difficulty with EFs can create functional challenges at home, school, and work in addition to making it hard to focus, modulate emotions, and following through with responsibilities.
Researchers categorize EFs in varying ways. One of my favorite models of EFs is from Dr. Thomas Brown (2023) in which he outlines broad six categories of EFs that operate together. Let’s take a look at each of those next.
What are the Executive Functions?
The first category is activation which includes organizing tasks and materials, prioritizing, and activating to begin work. One common example of difficulty with activation for those with ADHD is procrastination, especially around low-stimulating or boring tasks.
Second, focus involves paying attention and shifting attention to different tasks. Different tasks require differing amounts and types of attention. Many people with ADHD are able to “hyperfocus” at times on tasks that are highly engaging or stimulating to them.
The third category of EFs is effort. Effort shows up with the ability to regulate alertness, sustaining effort over time, and processing speed. For example, if you have ADHD and find it difficult to wake up in the morning – you are not alone as this is common!
One category of EFs that often surprises people is emotion. Despite not being a diagnostic criteria in the DSM-5, modulating emotions and managing frustration is a key challenge for many with ADHD. In fact, emotional lability can often be triggered or exacerbated by something called Rejection Sensitivity Dysphoria (RSD).
The fifth category of EFs involves memory, which includes utilizing working memory and accessing recall. Most folks with ADHD tend to have vivid memory of past events (long-term), but challenges recalling what they ate for lunch yesterday or juggling several numbers in their head at the same time.
The final category of EFs is action. Action mediates many faucets of behavior including monitoring action and regulating behavior. Many people with ADHD have a difficult time modulating their actions or reactions based on response feedback from others around them, let alone paying attention to that feedback in real-time.
What can I do to improve my Executive Functions?
There’s good news! Because of a scientific concept called “neuroplasticity” we now know that it’s possible to strengthen and cultivate EF skills with practice over time. When working with clients, I typically recommend a three phased approach for building EFs. First, completing an EF assessment, checklist, or questionnaire is a helpful way to get a snapshot picture of which EFs are a bigger struggle for you vs. which ones may be easier or come more naturally.
Next, identify several EFs that you would like to start working on cultivating. The key here is to start small and keep it manageable. No one can bolster all their EFs overnight, but through consistent, committed work EFs can be strengthened and individualized routines, strategies, habits, and systems can be established.
Third, since follow-through with tasks is often a challenge for those with ADHD, establishing forms of accountability to check back in on the strategy or tool is an important, sometimes overlooked step. Accountability could take the form of having a therapist or coach check back in with you, setting a reminder or calendar alarm, or establishing a tracking system. The process of evaluating the system or strategy to assure its working for you and make any adjustments should not be overlooked.
When working with clients having ADHD, I find my background and training as an ADHD coach provides me with an in-depth understanding of the unique challenges associated with impaired EFs as well as the approaches and skills to help guide clients towards developing strategies that work for their unique brains.
What are some additional resources about EFs?
Individuals seeking to strengthen executive functions for themselves or their kids, may benefit from utilizing any of the “Smart but Scattered” series of books by Dr. Dawson & Dr. Guare:
Several useful workbooks include:
Brown, T. (2023). The brown model of executive function impairments in ADHD. https://www.brownadhdclinic.com/the-brown-model-of-add-adhd
CHADD. (2023). General prevalence of ADHD. ttps://chadd.org/about-adhd/general-prevalence/
NIMH. (2023). Attention-Deficit/Hyperactivity Disorder. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd
Polanczyk, G., De Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry, 164(6), 942-948. https://ajp.psychiatryonline.org/doi/full/10.1176/ajp.2007.164.6.942
Song, P., Zha, M., Yang, Q., Zhang, Y., Li, X., & Rudan, I. (2021). The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. Journal of Global Health, 11. doi:10.7189/jogh.11.04009