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Executive Functioning is at the Heart of an ADHD Diagnosis

By Jane N. Hannah, Ed.D

Executive Functioning is at  the Heart of an ADHD DiagnosisOver summer break, I was in a hospital elevator carrying a new book on Attention Deficit Hyperactivity Disorder (ADHD), and a person on the elevator inquired about the book. She commented that her son was just diagnosed with ADHD, which sparked a conversation between the two of us.

This scenario is not uncommon. There is great interest among parents to learn as much as they can about ADHD, especially if their child is one of the 9% of school-age children who is diagnosed with the condition. You may also be among those who have heard comments, such as “ADHD is a made-up condition” or that “there was no such thing as ADHD when I was a child.” In reality, ADHD has been observed and diagnosed for over 100 years; however, it has been called by many different names. As early as 1940, it was referred to as Minimal Brain Syndrome, in 1957 it was called Hyperkinetic Impulse Disorder, and in 1994, it was changed to Attention Deficit Hyperactivity Disorder. Even now, professionals are considering a new model for ADHD.

Throughout most of these 100 years, the emphasis has focused primarily on the behavior problems associated with ADHD. Over the last few years, a new understanding of ADHD has gained attention.

Thomas E. Brown, Associate Clinical Professor at Yale University School of Medicine, reports that recent scientific research is pointing to the belief that ADHD is a “developmental impairment of the brain’s self-management system, its executive functions” (Brown, 2013). Dr. Brown goes on to add that this new understanding is not as much about behavior but more about chronic difficulties with the executive functions of the brain. This new model is not yet refined, but many professionals in the field believe it holds merit.

What is executive functioning?
Vohn and Baumeister (2004) report that executive functions manage the brain’s cognitive functions and provide the mechanism for self-regulation. In 2009, Brown identified the following six characteristics that are needed for the executive system to function well:

1. Organizing, prioritizing, and activating the brain to work

2. Focusing, sustaining and shifting attention to tasks

3. Regulating alertness, sustaining effort and processing speed

4. Managing frustration and modulating emotions

5. Utilizing working memory and accessing recall

6. Monitoring and self-regulating action

As is recognized, there is great variability in the strengths and talents among individuals with ADHD, but Dr. Brown suggests that the person with ADHD manifests chronic problems in a number of the characteristics listed above. Brown’s model of executive functions that are impaired in the person with ADHD is derived from clinical studies of child, adolescent and adult patients diagnosed with ADHD as defined by the DSM III/IV criteria (Brown, 2013, pg. 25).

If ADHD is a developmental impairment as described above, does this mean it will change with age?
As the diagnostic criteria for ADHD is listed in DSM-5, the symptoms of the condition must be present by the age of 12 years. With this proposed understanding, symptoms of ADHD as it relates to executive function may not emerge until challenges are encountered. For example, a young child may not demonstrate problems with organization and a number of the other characteristics listed because of the nature of school and age expectations. However, when he or she reaches middle school age, executive functions must be utilized every day; thus, ADHD may not become evident until the challenges in middle school arise.

Dr. Brown also notes that it may be developmental in another sense. He quoted the research of Shaw, Eckstrand and Sharp (2007) as they used longitudinal imaging methods to compare brain development in children who were diagnosed with ADHD. They found that the “essential infrastructure of executive functioning (in children with ADHD) reached maturity about three years after their peers” (Brown, 2013, pg. 31). An earlier study completed by Weiss and Hechtman (1993) found that many individuals who were diagnosed with the hyperactive type of ADHD functioned quite well in adulthood, and the symptoms of ADHD no longer impaired their functioning. Thus, this new understanding would find support for this being a developmental impairment.

What can parents and teachers do to assist a child with executive functioning deficits?
There are a number of strategies that support improvement. Teachers can use visual supports to remind students of events or steps that are needed to maneuver throughout the day. This may include a visual daily schedule that is posted on the board and agendas that are introduced before instruction begins. Teachers can also use pictorial representations for the steps in the editing process, such as checking punctuation, capitalization and spelling. Other strategies that may support a child include:

• Help your child organize his/her space and reduce the amount of clutter in the environment;
• Teach your child routines that allow him/her to maneuver throughout the day without reminders;
• Schedule weekly times to clean out the desk, binder and backpack;
• Role-play and practice rules and routines until they are internalized or become a habit;
• Play games that require a child to stop and start on command (e.g., FREEZE and Red Light, Green Light);
• Use color to help a student with organization (e.g., red for science, yellow for math);
• Teach a child to use self-talk to help analyze, plan, organize and regulate communication (e.g., “What do I want to say? How should I organize it?”);
• Write appointments, assignments, and other activities on Post-it notes and stick the notes on a large calendar prominently displayed in the home. To help further, the Post-it notes can be color-coded by activity, such as green for school, blue for sports (Singer, 1999).

Most teachers never receive training in executive function, yet with deficits in these complex cognitive functions, children struggle in so many areas of learning, behavior, organization and attention. As Dr. Brown describes, “this new model includes problems with modulation of emotions, motivations, sleep and alertness, and multiple aspects of working memory” (pg. 39). We know that punishments for disorganization and excuse-making for misbehavior are not the answers, but we can have significant influence on a child’s future by implementing approaches to instruction that will help a child be successful when their executive functions are impaired.

Brown, T. E. (2013). A New Understanding of ADHD in Children and Adults. New York: Routledge Taylor & Francis Group.

Singer, B.D. and Bashir, A. S. (1999). What are executive functions and self-regulation and what do they have to do with language-learning disorders? Language, Speech and Hearing Services in Schools, vol. 30, 265-273.

Vohs, K.D. & Baumeister, R.F. (2004). Handbook of Self-Regulation. New York: Guildford Press.

Weiss, G. & Hechtman, L.T. (1993). Hyperactive Children Grown up, 2nd edition. New York: Guilford Press.

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