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.