At the heart of Attention Deficit Hyperactivity Disorder is a collection of behavior and skill deficits that neuropsychologists call Executive Functioning problems (hereafter EF). EF problems exist in a number of neurological conditions including people with dementia, post-stroke sufferers, and closed and traumatic brain injuries. In ADHD, EF problems are often overlooked or misunderstood because impulsive and hyperactive behaviors draw so much attention and are more immediately disruptive to other people. But it is EF problems that cause the most long-term disruption – all the more so because they are not easily detected in ADHD.
The ability to organize thoughts, manage details, track time, plan, follow through on commitments, track life necessities, self evaluate behavior, learn from errors and mistakes, remember things, and make wise decisions/judgements are all grouped under the general heading of Executive Functioning by neuropsychologists and neuroscientist. When EF is impaired, a person might look and sound normal in almost every way, but they just don’t seem able to manage the complexities of modern life; of school or work. The front part of the brain, the frontal lobes, acts like the conductor of a symphony orchestra. It synchronizes all the rest of the brain to function as a whole. Like a conductor it tells some parts when to play and when to be silent, what speed to play at, what the overall piece is supposed to sound like, and when a player or section is playing out of tune. It also knows when the music is supposed to stop. For the brain, when the conductor isn’t there, nothing functions as a whole, and each part of the brain runs on its own terms. Activities requiring “orchestrated” effort become haphazard – and it is this lack of EF that is the source of frustration for parents, spouses, and teachers.
Let’s take one single EF function – the estimation and processing of time - as an example, and you will begin to understand what the ADHD sufferer is up against. Your ability to sense the flow of time is an EF function. Most of us, by the time we are adults, have developed the ability to estimate how long things take. And we have the ability estimate how much time has passed while doing a particular activity. We aren’t precise with these estimates, but we’re accurate enough to function. But the ADHD person is at a great loss in their ability to estimate time. Some tasks seem to fly by for them, when in reality they may have taken hours. Other tasks seem to go on forever, when in fact it’s only been a moment or two. This ability to estimate time is so automatic with us that we don’t even realize we do it. So the parents of an ADHD child expect their children to have developed this ability by their mid-teens when they may not have it at all.
A common complaint of such parents is that their children seem to take forever to get ready in the morning. Or they may miss important school assignments because they don’t really know what day it is. They may be able to spend hours playing a video game – because it is so immersive, but 5 minutes with a book feels like an eternity. Adults with ADHD are notorious in my practice for missing appointments and coming in late – they just don’t have that internal clock helping them through the complexities of modern life. They miss bills, deadlines, are late with permission slips, and they forget promises. They are plagued with late fees, lost opportunities, and low productivity all because that part of the brain that tracks the flow of time isn’t working for them.
The ADHD sufferer needs help with EF tasks, whether or not others in their life think “they should have gotten this down by now.” Lapses in EF behavior are not laziness, willful disobedience, being inconsiderate, or lack of effort. They are missing some basic cognitive abilities that the rest of the world takes for granted. So the first two steps in compensating for weak EF are understanding and compassion. Once these two are applied behavioral supports and environmental changes can be put in place to help the ADHD sufferer compensate for weak executive functioning.
I have two more entries in this overview of ADHD and both have to do with treatment – next up: What you need to know about ADHD medications . . .Stay tuned.
Here are some useful links to more information about Executive Functioning.