ADHD and "Executive Function"

Discussion in 'General Parenting Archives' started by Fran, Sep 4, 2006.

  1. Fran

    Fran Former Site Owner

    ADHD and "Executive Function"
    Dr. Martin L. Kutscher

    ADHD needs to be redefined to include a wide range of "executive dysfunction." As Russell Barkley explains, this dysfunction stems from an inability to inhibit present behavior so that demands for the future can be met.
    So, What are Executive Functions?

    When you step on a snake, it bites. No verbal discussion occurs within the snake's brain. No recall of whether striking back worked in the past. No thought as to where this action will lead in the future. No inhibition. Stepped on. Bite back. Humans, fortunately, have the option to modulate their behavior.

    No single part of the human brain is solely in charge of this modulation. It does appear, however, that our frontal and pre-frontal lobes function largely as our "Chief Executive Officer (CEO)." Orchestrating language and memory functions from other parts of the brain, these frontal centers consider where we came from, where we want to go - and how to control ourselves in order to get there.

    Most importantly, the ability to inhibit ("putting on the brakes") is central to effective executive function. Successful execution of a plan largely involves putting brakes on distracting activities. These brakes - courtesy of our pre-frontal inhibitory centers - allow us the luxury of time during which we can consider our options before reacting.

    This lack of inhibition is a double problem for people with ADHD. First, without these brakes, they will be viewed as unable to adequately inhibit distractions, inhibit impulsive reactions, or inhibit physically acting upon these stimuli (hyperactivity). Second, patients with ADHD do not inhibit their behavior long enough for the other executive functions below to adequately develop either. Executive functions identified by Barkley include:

    Self-talk refers to the ability to talk to ourselves - a mechanism by which we work through our choices using words. Toddlers can be heard using self-talk out loud. Eventually, this ability becomes internalized and automatic. However, ADHD patients have not inhibited their reactions long enough for this skill to fully develop.

    Working memory refers to those ideas that we can keep active in our minds at a given moment. For example, in order to learn from mistakes, you have to be able to juggle not just the present situation, but also keep in mind past times when certain strategies did or did not work. Working memory hopefully also includes keeping future goals in mind (such as remembering that we want to get into a good college, not just do the most intriguing activity currently available). Without the ability to inhibit, people with ADHD never get to develop good function of their working memory.

    Foresight (predicting and planning for the future) will be deficient when inadequate working memory teams up with a poor ability to inhibit the present distractions. People with ADHD cannot keep the future in mind. They are prisoners of the present; the future catches them off guard. In fact, surprisingly poor foresight is perhaps the greatest difficulty in their lives.

    Sense of time is an executive function that is usually extremely poor in ADHD.

    Shifting from Agenda A to Agenda B is a difficult task requiring good executive function. Pulling yourself out of one activity and switching to another - transitioning - is innately difficult, and requires effort and control.

    Separating emotion from fact requires time to reflect. Each event has an objective reality, and an additional "emotional tag" which we attach to it. For example, a traffic jam may occur, causing us to be late for work. That is the objective fact. How we react, though, is up to the emotional tag of significance that we place on it. Do we stay calm, and make plans to finish up a little later? Or, do our emotions cause us to see the traffic as a personal, unfair attack - causing us to seethe and curse? Without the gift of time, we never get to separate emotion from fact. This leads to poor ability to judge the significance of what is happening to us.

    In short, then, the ability to modulate behavior comes largely from our pre-frontal lobes, which function primarily as inhibitory centers. Without the luxury of inhibitory brakes, ADHD patients do not get to fully utilize any of their frontal lobe "executive functions."



    For further info from Dr. Kutchner go to Pediatric Neurology

    Martin L.Kutscher, M.D. graduated from Columbia University's College of Physicians and Surgeons. He is board certified in Pediatrics and in Neurology, with Special Competancy in Child Neurology. Dr. Kutscher is currently an Assistant Clinical Professor of Pediatrics and of Neurology at the New York Medical College.
     
  2. Wiped Out

    Wiped Out Well-Known Member Staff Member

    Fran,
    Thanks for a very interesting article. This really describes difficult child. difficult child's Reactive Attachment Disorder (RAD) therapist seemed to think that his birthmother using crack probably did some damage to that part of his brain.
     
  3. jamrobmic

    jamrobmic New Member

    I think this is true of my son. It's so frustrating, because it seems so simple to me, but no matter how much talking I do, he still doesn't get it. It's a little better the older he gets...but not much. Great article, thanks for posting it.
     
  4. SunnyFlorida

    SunnyFlorida Active Member

    So...........how do we treat executive function deficits?

    Congnitive counseling?
     
  5. Fran

    Fran Former Site Owner

    Maybe someone can find some articles and books to help us improve how we can help our kids, Sunny.
    It's a tough one, that's for sure.
     
  6. kmt

    kmt New Member

    It explains a lot. I've read a little about executive function before (was it in Explosive Child?) but this explanation is much clearer. Thanks for sharing, Fran.

    Karen
     
  7. Sheila

    Sheila Moderator

    New members may need to know that Executive Dysfunction isn't confined to ADHD.

    http://www.tourettesyndrome.net/disorders/executive-dysfunction/
    Table of Contents
    Preface
    What are the Executive Functions?
    How Are They Assessed?
    Functions and Signs of Dysfunction
    Working Memory and EDF
    "Time Has Come Today... Time!"
    Students with Executive Dysfunction
    The "Terminally Disorganized" Child or Adult
    Recognize Anyone You Know (Relationship between EDF and ADHD)?
    "If it is EDF. Would Medication Help?"
    Now what?
    Executive Function in Adults
    Comment

    ADHD and Executive Control:
    Intervention Strategies For Parents And Teachers
    http://addadhdadvances.com/executivecontrol.html

    Lazy Kid or Executive Dysfunction?
    http://www.ldonline.org/article/6311

    Executive Functioning and Executive Dysfunction
    http://www.learningabledkids.com/learning_disability_LD/executive_functioning.htm
     
  8. StepMomLMP

    StepMomLMP New Member

    Nail on the head Fran. Thanks for the info.
     
  9. LisaNicole

    LisaNicole New Member

    How very true!!!

    Thanks Fran!
     
  10. Fran

    Fran Former Site Owner

    Lazy Kid or Executive Dysfunction?

    By: Tracy Landon and Linda Oggel (2002)

    Do you have a student who seems incredibly lazy? Intentionally forgetful? Absolutely unmotivated? Deliberately late? Do you feel like a broken record? Constantly asking where his homework is? Constantly asking him to clean out his desk? Constantly asking her to pick up stuff around her desk? Do you have a student who is chronically distracted? Are you repeating directions to get the student back on task when he gets distracted? Do you have a student who knows the information but can’t seem to communicate it to you in a logical sequence? Do you ask a question and get an answer that’s related but not quite connected to the question? If so, it might be that the student is not using these behaviors intentionally.

    One of the least studied and most frequently overlooked contributors to academic and behavioral problems is a problem in the frontal lobes of the brain known as executive dysfunction (Parker, 2001). Students with executive dysfunction have problems of a neurobiological nature that particularly affect “planning, flexibility, organization, and self-monitoring (Ozonoff, 1998, p.282). These students may have “difficulty picking a topic, planning the project, sequencing the materials for a paper, breaking the project down into manageable units with intermediate deadlines, getting started, and completing the activity. And because these students frequently underestimate how long something will take, they’ll generally leave the project until the night before it is due” (Packer, 2001, p. 2). Just imagine how difficult it would be if you had trouble organizing your time, materials, belongings, thoughts or any combination of these!

    If you believe your student has executive dysfunction (also called executive function deficits—called “executive” because the tasks are often the responsibilities of a company executive), consider helping the student to organize himself. Begin by developing a relationship with the student that is emotionally supportive. Emphasize that you want the student to succeed. Help the student to understand his problems and that there are strategies he can use to organize him/ herself. For example, you could say, “Kids with executive function problems have difficulty in certain areas. There are many ways you can help yourself. Let’s talk about the areas and supports. Then you can choose which ways to help yourself.” Then describe the following potentially troublesome areas and potential supports that are identified in the shaded area. (Linda Parker, 2001):
    Managing time

    * Use time management techniques such as the use of checklists, prioritized “To Do” lists, and prioritizing assignments.
    * Estimate how long a task will take and then check on the accuracy of your estimate.
    * Plan for more time to do a project that you think you will need.
    * Break long assignments into chunks with time frames for completing each chunk.
    * Establish intermediate deadlines for big projects with your teacher and show her the project at these deadlines.
    * Use a word processor and time management software such as the Franklin Day Planner, Palm Pilot, Lotus Organizer.
    * Write the due date on the top of each assignment in a brightly colored marker.

    Managing space

    * Ask the student to identify ways he would like to organize himself.
    * Have separate work areas with complete sets of supplies for different activities.
    * Schedule a weekly time to clean out your desk and book bag (in school).

    Managing materials

    * Leave a large supply of pencils/pens in the class-room with the teacher.
    * (For younger students) Have one notebook in which all assignments are recorded. Ask your teacher to check the assignments at the end of each day to insure that the assignments are recorded properly and that the necessary materials to complete the assignments are packed in your book bag. Also ask her to make sure the due date for each assignment is written at the top of each page.
    * (For older students) Use a three-ring binder with organized sections enclosed by a zipper. Headings could include “Assignments Due/Date,” “To Do Tonight,” “Ongoing Work.” Use dividers in the notebook that are color-coded (e.g., Red for assignments that must be done right away, yellow for those due at the end of the week, etc.).
    * Color code materials. Cover the textbook for one course in the same color as the notebook for that course. Use the same color coding to prioritize assignments.
    * Establish a daily routine for school organization and include a written version of it in the notebook (e.g., turn in homework at the beginning of classes, get out paper/text/pen and check blackboard for assignment, prepare to leave class three minutes before it ends—pack books, papers, etc., turn in assignment book for checking and initialing at the end of each day, etc.). Use this same approach at home (e.g., do homework at a certain time, have parent initial homework, clean out book bag, check for necessary supplies for school).
    * Obtain two copies of each textbook. Mark one “To be left in school” and the other “To be left at home.”

    Managing work

    * Use a checklist to guide you through an independent assignment. Include items such as: get out pencil and paper, put name on paper, put due date on paper, read directions, ask teacher to further explain if needed, do work, put work away in note-book in appropriate section (e.g., to do tonight, to do this week), write assignment on assignment sheet, get teacher to sign, take home and complete work.
    * Finally, have the student identify which strategies she would like to try using and get started. Consider meeting with the student after a week to evaluate her use of the strategies. Be sure to praise the student’s progress rather than focusing on areas of continued disorganization. In addition, suggest that student’s family be included so that they can help him or her continue the strategies at home.

    As the educator you can support the student (and others) by making some changes in the classroom. Some suggestions (Stokes, 2001, pg. 6) you can implement include:

    * Maintaining a highly structured classroom.
    * Using a written (visual) schedule to keep the student focused and “on task” so that he or she can complete tasks as independently as possible.
    * Giving written directions whenever possible (dry erase boards, index cards, etc.) rather than auditory prompting.
    * Giving fewer problems/questions on worksheets and/or creating boxes next to each question so the student can check it off as it is answered.
    * Making the classroom as distraction free as possible (away from windows, doors or favorite activity areas).
    * Keeping assignment folders in specific and consistent places.
    * Using a visual calendar for both school and home to help the student anticipate events.
    * Using a visual timer to help the student understand time constraints.

    Also, if you suspect a student has executive dysfunction, consult with your school psychologist. While executive function deficits are most commonly associated with Autism Spectrum Disorder, they also are known to occur in students with ADHD, Fragile X Syndrome, conduct disorder, obsessive-compulsive disorder, traumatic brain injury, and schizophrenia (Ozonoff, p. 277). Although there are currently no agreed-upon protocols that constitute a battery of tests for executive dysfunction, several tests have been used in research that seem to tap into aspects of the disorder. These include the Matching Familiar Figures Test (Waterhouse & Fein, 1982), Wisconsin Card Sorting Test, and various computerized tests. For more information on tests and their purposes, see the resources at the end of this article.

    Teach your student with executive dysfunction to organize himself. In addition, provide support by making some adaptations in your classroom and in your interaction style. Remember that students with executive dysfunction are not unmotivated or willfully engaging in problematic behavior. They really cannot organize and flexibly solve problems themselves without appropriate supports.
    Resources

    Ozonoff, S. (1998) Treatment of executive dysfunction. In E. Schopler, G. B. Mesibov, & L. Kunce (Eds.), Asperger syndrome or high-functioning autism (pp 263-289). New York: Plenum Press.

    Pennington, B.F., Rogers, S.J., Bennetto, L., Griffith, E.M., Reed, D.T., & Shyu, V. (1997). Validity tests of the executive dysfunction hypothesis of autism. In J. Russell (Ed.), Autism as an executive disorder (pp. 142-178). New York: Oxford University Press.
    References
    References

    Click the "References" link above to hide these references.

    Parker, L. (2001). Executive Functions. Tourette syndrome “plus”. http://www.tourettesyndrome.net/disorders/executive-dysfunction/

    Stokes, S. (2001) Children with Asperger’s syndrome: characteristics/ learning styles and intervention strategies. www.cesa7.k12.wi.us/sped/autism/asper/asper11.html

    Tracy Landon, Ed.D. Linda Oggel, M.A., CCC-Speech Language Pathologist (SLP) Innovations & Perspectives March 2002, Volume 5, Number 2, pp.1-2


    This is from the link Sheila posted.
    http://www.ldonline.org/article/6311
     
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