Executive Function Disorder, Explained!
“What is Executive Function Disorder, and how is it different from ADHD?”
by Larry Silver, M.D.
Is It ADHD? Or Executive Functions?
A child or an adult with attention deficit disorder (ADHD or ADD) might be hyperactive, inattentive, and/or impulsive. Clinicians have always understood hyperactivity and impulsivity. The understanding of inattention, though, has shifted from primarily “the inability to stay on task” to a broader concept called executive function disorder(EFD), which involves a pattern of chronic difficulties in executing daily tasks. This is sometimes called executive dysfunction.
What Is Executive Function?
Think of executive function as what the chief executive officer of a company must do — analyze, organize, decide, and execute. Around the time of puberty, the frontal part of the cortex of the brain matures, allowing individuals to perform higher-level tasks like these:
- Analyze a task
- Plan how to address the task
- Organize the steps needed to carry out the task
- Develop timelines for completing the task
- Adjust or shift the steps, if needed, to complete the task
- Complete the task in a timely way
What Is Executive Dysfunction?
What is executive function disorder (EFD)?
It follows naturally that someone with issues with executive functioning may have problems with analyzing, planning, organizing, scheduling, and completing tasks at all — or on deadline.
A child without problems with executive function may appear like this: A middle-schooler’s teacher assigns the class a book to read, and writes the due date for the book report on the board. A student must be able to determine where to get the book and how long he thinks it will take to finish reading it. If the teacher has a specific book-report format, the student will have to keep it in mind as he reads the book and takes notes. He needs enough time to write a rough draft, get help from teachers or parents, if needed, and write a final draft by the due date. If the student has good executive function skills, the work will get done on time. If he has EFD, it won’t.
Recognize the signs and symptoms of executive function disorder (EFD).
Children and adults with EFD have problems organizing materials and setting schedules. They misplace papers, reports, and other school materials. They might have similar problems keeping track of their personal items or keeping their bedroom organized. No matter how hard they try, they fall short.
A Tale of Two Children: One Diagnosed With ADHD and EFD, One Diagnosed With EFD and LD
Marcus, a fifth-grader, had difficulty staying on task and completing his schoolwork. He also had problems keeping his backpack and papers organized and remembering what to bring home from or take to school. Psycho-educational testing showed that he was bright, but that he had difficulties with processing speed and working memory. These findings, plus other studies, showed evidence of difficulties with executive function. The psychologist concluded that Marcus had ADHD, inattentive type, and started him on a stimulant medication. He showed significant improvement in all areas.
Ethan, a sixth-grader, received the same diagnosis but had a different result. The presenting problems, and the psycho-educational test results, were the same as Marcus’. Ethan was given a stimulant, but his symptoms didn’t improve. A closer review of his psycho-educational test results showed that he had problems retaining what he read and with written work. Ethan had EFD, but his problems resulted in Learning Disabilities (LD). He needed tutoring, plus accommodations, to overcome his challenges.
Signs and Symptoms of EFD and LD
If you look at the criteria used to diagnose ADHD, inattentive type, you could understand why a child with EFD might be diagnosed as having ADHD. But it’s important to know that EFD can cause learning disabilities (LD).
Martha Bridge Denckla, M.D., an expert on executive function disorder, says, “EFD can be a reflection of ADHD, but it might also indicate an LD.” When a professional evaluating a child or adult finds evidence of EFD, it is essential for her to clarify whether the disorder results in ADHD, LD, or both. Only then can the child or adult receive the appropriate treatment for his specific problem.
In elementary school, a child learns to read, to write, and the basics of spelling, grammar, punctuation, and capitalization. She learns basic math concepts — addition, subtraction, fractions, and decimals. In middle and high school, with expanded executive function abilities, the student has a greater ability to organize and process information.
When reading, the student must organize the content before it can be stored. This is reading fluency. When writing, a student must be able to pull information from memory and to organize this information before he can start. A teacher might ask, “Can you tell me the theme of the book, and give examples to illustrate it?” The ability to retrieve and organize information in order to write a response is called writing fluency. Solving math problems requires retrieving learned concepts (formulas, rules) as well as known facts (multiplication tables) — and to use this information to find the answer.
A student with EFD might have difficulty organizing information before storing it in memory, or difficulty organizing information that is retrieved from memory. He might read a chapter but not retain what he has read. He might know the material but be unable to write an answer or start a paper because he cannot organize his thoughts. He might be able to write out math equations, but makes careless errors along the way.
When such students are tested, the results might show that their problems stem from EFD, but professionals are too quick to decide that the problem is ADHD. Professionals must look closely at the educational part of the assessment. If the results show that the student has difficulties with reading, writing, or math fluency, the EFD is also a reflection of an LD. It is vital to make the correct diagnosis — for the child’s sake.
Not all practitioners understand that executive function disorder can bring a diagnosis of ADHD, LD, or both. Even when psycho-educational test results support a diagnosis of LD, some conclude that the child has ADHD, inattentive type.
Signs and Symptoms of ADHD and EFD
Russell Barkley, Ph.D., who has been at the forefront of exploring the relationship between ADHD and EFD, says, “It is not that the individual does not know what to do. It is that somehow it does not get done.”
The symptoms of ADHD, inattentive type, often improve with a stimulant. The symptoms of LD don’t improve with medication. The best way to manage LD is through specialized accommodations and one-on-one work with a learning specialist.
Observe your child closely at home. Now that you understand how EFD affects learning, look for signs of LD and ADHD. If the only focus is on ADHD, talk with your family doctor and school professionals about your concerns.
If necessary, share this article with the school administrators and other professionals to educate them about the relationship between EFD, LD, and attention deficit.
A child or adult with attention deficit hyperactivity disorder may be diagnosed with one of three types of ADHD:
- ADHD – Combined Type means that the individual is hyperactive, inattentive, and impulsive
- ADHD – Hyperactive-Impulsive Type means that the individual is hyperactive and impulsive
- ADHD – Inattentive Type means that the individual is only inattentive.
It is not difficult to understand what behaviors go with being hyperactive or impulsive. But what does inattentive mean?
ADHD Inattentive Type: What Does It Look Like?
The guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders-V — used to establish whether a child or adult has inattentive ADHD — requires the clinician to identify at least six behaviors out of nine.
One of the nine behaviors listed refers to being distracted by external stimuli (sounds or visual stimuli). Another refers to difficulty sustaining attention. The remaining seven describe difficulties related to the concept of executive function — the ability to conceptualize a task, plan how to carry it out, and complete it in a timely way. (These problems can also be thought of as difficulties with organization and planning your time.) Thus, a child or adult who had difficulties with executive function alone could meet the criteria to be identified as having inattention.
When ADHD Medication Doesn’t Work
Sometimes difficulties with inattention significantly improve when an ADHD stimulant is used.
Often, though, medication does not fully address these organization and time-management problems, and additional help is needed: special-education tutoring for the child or, for an adult, working with an ADHD coach who specializes in organization.
These difficulties with organization and time planning may be due to ADHD — or they may result from learning disabilities (LD). Sometimes those difficulties are due to both ADHD and LD.
It is important for the parent of a child with inattention, as well as for an adult who is experiencing the same problem, to understand the potential causes and how they dictate the most effective treatment.
Parents must understand the ways that symptoms of inattentive ADHD may impact their child. For instance, organization and time-planning problems might also cause academic difficulties — in retaining what is read and organizing one’s thoughts to write a paper.
Inattentive ADHD: Case Studies
When I asked Jane, a mother of three children, who suspected she had ADHD, to talk about her symptoms, she told me the following story. “I go upstairs to collect the laundry,” she said. “At the top of the steps, I look into a bedroom and see something that needs to be done. I do it. Then, I remember the laundry, but I notice something else and stop to do that. The laundry never gets collected.”
After further questioning, Jane described a history of inattention. She was distracted by anything she saw or heard. She couldn’t manage household chores and her three children. She was never on time, and she often forgot what needed to be done each day.
I confirmed a diagnosis of inattentive-type ADHD, and I placed Jane on a stimulant. Her life changed. On medication, she could complete tasks without being distracted by other activities. Her life was organized.
Jessica, a tenth grader, was a more complicated case. She had struggled in school since eighth grade, and she was now in serious academic trouble. After a psycho-educational evaluation at school, it was found that she had above-average intellectual ability, but her processing-speed and working-memory scores were below average.
The school suspected she had inattentive-type ADHD. Jessica saw her pediatrician, and was started on a stimulant. Her focus improved, but her academic performance did not. That is when Jessica’s parents asked me to evaluate her.
I discovered that Jessica had been a good student until seventh grade. She had more difficulty keeping up with assignments and completing her work each year. While she comprehended the material, she didn’t retain what she read. She appeared to understand lectures, but she couldn’t organize her thoughts well enough to write them down in a paper.
“I just stare at the page and nothing comes out,” she said. Adding to these difficulties was the fact that she often forgot to write assignments down.
I re-read Jessica’s psycho-educational evaluation. Her educational difficulties were not addressed at the school conference. Instead, most professionals concluded that she had ADHD. Yet educational testing showed her trouble with retaining what she read and organizing her thoughts. It was not clear to me that she had ADHD. It was clear that she had learning disabilities. I suggested special-education tutoring, and encouraged the school to provide accommodations. The medication was stopped. Her grades slowly and steadily improved.
What do these two stories show? Both women had organization and time-planning problems. Jane’s problems were secondary to inattentive-type ADHD. She responded beautifully to a stimulant medication. Jessica, on the other hand, had organizational problems that resulted from learning disabilities. She needed special-education interventions. Some children or adults have both problems, and require medication and coaching or special education services.
The Right Help for ADHD or LD
Some school professionals are too quick to interpret symptoms of inattention and problems with executive function (specifically, organization and time planning) as ADHD.
In fact, many school evaluation teams focus on the findings that support an ADHD diagnosis. Your family physician might use these results as evidence for prescribing medication. This is well and good if the medication significantly improves the child’s inattentive symptoms. But what if it doesn’t? Be aware that symptoms might stem from learning disabilities, which require a different treatment plan.
What about adults? Say, you’ve been diagnosed with inattentive-type ADHD, take a stimulant, and work with an organizational coach. If these don’t help, chances are, you have a learning disability. Think back to your school days: Did you struggle with academics? Do certain “academic” tasks — math on an expense report, say — complicate your career and life? If so, you may benefit from a special education-focused intervention. It is never too late to get help.
What Are the Symptoms of Inattentive ADHD?
- Often fails to give close attention to details, or makes careless mistakes in school or at work
- Often has difficulty sustaining attention in tasks or play activities
- Often does not seem to listen when spoken to directly
- Often does not follow through on instructions and fails to finish school work or chores
- Often has difficulty organizing tasks and activities
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (homework or filing paperwork)
- Often loses things necessary for tasks or activities
- Often easily distracted by extraneous stimuli
- Often forgetful in daily activities
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