Attention Magazine April 2022

ARE THEY MORE LIKE TWINS OR COUSINS?

Jack is a twenty-eight-year-old man who has chronic issues with running late that date back to childhood. He also has difficulty keeping track of his schedule and tends to finish tasks at the last minute. Jack remembers having the same issues as far back as elementary school.

Margaret is a forty-two-year-old woman whose struggles to manage her time and keep things organized began when she moved out into the world on her own as an adult. Her difficulties have fluctuated over time, based on her comfort level with the job that she has at any given time.

Are Jack’s and Margaret’s challenges related to ADHD, executive function issues, or both? How can we understand the difference between the two, and why is it important?

As the awareness of executive functions has migrated from the scientific arena into popular discussion, so has confusion about what the term means. Often, people talk about executive functioning weaknesses and ADHD as if they are one and the same thing. A fuller understanding of executive functions, ADHD, and the relationship between the two can help you to identify what’s causing the problems that are vexing you and can lead you to treatment that improves your ability to perform at your best.

It’s important to know that there are many reasons that problems with executive functioning can occur other than ADHD. Executive functioning issues are best understood as a generic cluster of performance challenges. Sometimes they occur alone and sometimes they are part of a broader problem, such as ADHD, a learning disability, autism spectrum disorder, depression, or anxiety. Some medical disorders are associated with executive functioning problems, such as dementia or Huntington’s disease. Further, sometimes the issues with EF are chronic, or lifelong; however, EF difficulties can also emerge when someone is experiencing temporary stress.

The bottom line: ADHD and executive functioning issues are close cousins, not twins. While individuals with ADHD make up a large percentage of those with executive functioning difficulties, they are not the same conditions.

Definitions and characteristics
To understand EF and ADHD, let’s look at each of them separately first.

The term executive functioning has gained popularity in the past ten years, though it is often used without a clear understanding of what these skills truly are as well as what causes issues with them. Here is a brief definition: EF refers to a set of complex mental processes that support your efforts to achieve a goal. These processes allow you to operate with intention, to supervise your own thinking and behavior so that you can meet demands. EF is an umbrella term that covers a variety of core skills, including attention, working memory, task initiation (i.e., getting started on something), planning, organizing, emotional control, and impulse control/self-regulation.

When a person has poor EF skills, they may have difficulty staying focused, holding information in their mind, getting started on tasks, and having trouble breaking down steps into parts and following them. They may also struggle with physical organization, including keeping track of items and maintaining an orderly space.

Additionally, issues with emotional self-regulation can occur, leading to problems with impulse control and managing the appropriate expression of emotions.

EF issues themselves are not considered a medical diagnosis recognized by any formal entity such as APA or WHO. If you hear terms like executive function disorder or executive dysfunction, these are a shorthand way to convey EF issues, rather than a diagnosis. Since EF issues have many causes, referring to them as a disorder can be confusing and misleading.

On the other hand, ADHD is classified in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) as a neurodevelopmental disorder, and there are specific criteria that define the diagnosis. The diagnosis is characterized by deficits in self-regulation of attention and behavior. The diagnosis is based on symptoms of inattention and/or hyperactivity-impulsivity. Issues with inattention (i.e., easily distracted, “spaciness,” problems with detail-oriented work), hyperactivity (i.e., excessive fidgeting or other uncontrolled movements), impulsivity (i.e., blurting out answers before hearing the full question, making decisions without thinking about the consequences) define the syndrome.

Do EF issues sound a lot like ADHD?
There is a great deal of overlap, and most individuals with ADHD have some limitations in EF skills, though the severity of impairment varies widely. However, it’s important to remember that it is possible to have EF issues without having ADHD.

Let’s consider anxiety and depression as examples. If you are nervous or sad, your focus may be impaired. You may have difficulty getting started on a task because you are worried that you’re going to get it wrong. Or you may lack the physical and emotional energy to persist on a task, despite your wish to succeed.

To summarize, EF issues are strongly connected to ADHD and can occur together. However, they can also be present on their own or with numerous other disorders. This is why an accurate diagnosis is essential. To understand and help, you need to understand the various factors that may be contributing to or coexisting with EF impairment. The onset time often provides good clues on likely possible causes of EF-related issues.

Treatment options for EF issues
It is vital to understand the cause of the EF issues to choose the most appropriate treatment options. While each individual’s needs may be different, there are a few guiding principles that may be helpful to use.

If EF issues seem to exist without any underlying cause (other than already treated ADHD), then seeking support to bolster EF is a good approach. Jack, the first of our examples above, fits into this category. Possible interventions may involve working with an executive function or ADHD coach or working with a tutor who helps teach EF skills for school-related EF issues. Some mental health professionals can also help with practical skills.

If you know that you have ADHD, but have not sought treatment, then you may well find that starting with treatment of the ADHD leads to diminished problems with EF. So, starting with ADHD and following up with services specifically designed to help with EF makes good sense.

When EF issues are accompanied by mood issues, such as anxiety or depression, or they occur with other mental health concerns, such as OCD, then the priority is to address mental health first. Progress here will often lead to improved EF skills. Once treatment is well established, speak with your provider to determine whether additional EF support would make sense. You may already have recognized that Margaret, the second of our examples, probably has anxiety that interferes with her daily success.

Improving executive functioning can make a big difference in life satisfaction, and there are many resources available to help you. However, it’s not always as simple as picking a few strategies from a book or finding the right calendar app. If you are not making the progress you expect, it may be time to speak with your current providers to reassess how best to approach your goals.

Carey A. Heller, PsyD, is a licensed psychologist based in Maryland. He specializes in the evaluation and treatment of ADHD and executive function issues. Learn more at hellerpsychologygroup.com. The coordinator for the Montgomery County chapter of CHADD, Dr. Heller also serves as co-chair of the editorial advisory board for Attention magazine.

Joyce Cooper-Kahn, PhD, is a clinical child psychologist and coauthor of two books on executive functioning: Late, Lost, and Unprepared:  A Parent’s Guide to Helping Children with Executive Functioning (Woodbine, 2008) and Boosting Executive Skills in the Classroom: A Practical Guide for Educators (Wiley, 2013). She is co-chair of Attention’s editorial advisory board.