There are three current types of Attention-Deficient Hyperactivity Disorder (ADHD) identified by the DSM-V (the main diagnostic tool that physicians and clinicians alike use for coding disorders, providing clients “labels” for IEP or medication purposes, determining appropriate course of clinical treatment, and obtaining insurance reimbursement). These are, in no specific order: (1) Inattentive, (2) Hyperactive/Impulsive, and (3) Combined.The most common type of ADHD is Combined, with roughly 50%-75% of individuals diagnosed with ADHD falling into this category. According to ADHD expert Dr. Russell Barkley, the Combined type of ADHD includes, “…significant problems with sustained attention, persistence toward goals, resisting distraction along the way, inhibiting excessive task-irrelevant activity (hyperactivity), and inhibiting actions, words, thoughts, and emotions that are either socially inappropriate for the situation or inconsistent with one’s longer-term goals and general welfare.”
Barkley further notes in his informative piece, The Important Role of Executive Functioning and Self-Regulation, that ADHD “… involves deficits in self-restraint, self-awareness, self-speech, self- sensing and imagery, self-control of emotion, self-motivation, and self-directly play for problem-solving.”
Barkley, along with other clinical researchers, has argued that self-regulation is a key component of executive functioning skill success and that ADHD is a disorder of self-regulation, therefore concluding that these three terms are “just interchangeable names for the name set of problems.”
Thus, accordingly to Barkley’s seminal work, we can understand that ADHD, self-regulation, and Executive Functioning are all related to each other. Some suggest that medication will help treat ADHD but not Executive Functioning Disorder (EFD), noting that EFD can look like ADHD but EFD can also mean that there is a Learning Disorder (LD) at play. An LD will not be helped by introducing a stimulant medication (which would help people suffering from ADHD).
The exact relationship between how and when ADHD and Executive Functioning Disorder diverge and what genetic and environmental factors are at play are still being further studied. What we understand at this point, is that we cannot talk about or treat ADHD without talking about Executive Functioning and self-regulation skills.
This has implications for clients and clinicians alike because Executive Functioning is a basic requirement for accomplishing day-to-day activities. Most importantly these skills are teachable!
Given the complexity of this matter, researchers and clinicians are now questioning if ADHD is a cognitive disorder rather than the traditionally identified behavioral disorder. The DSM-V is limited in its definition of ADHD. A myopic understanding of this complex disorder arguably fuels misunderstanding, inaccurate diagnosing, and ultimately missed opportunities for supporting clients and helping them improve their lives and their sense of self-efficacy.
From my biased seat across from hurting couples, stressed parents, and often ashamed clients (because they know what they want to do, but struggle to execute the steps necessary to reach their goal), it appears to me that any ADHD diagnosis must invite a conceptual acceptance as well as a strategic intervention at the level of cognitive functioning.
Executive Functioning Skills
The remainder of this article will explain specific Executive Functioning skills and intervention strategies from a Christian Marriage and Family Therapist’s perspective.
Impulse Control can largely be understood as “self-regulation”, or the repeated ability to resist a temptation. When we consider that ADHD has a high concurrence rate with addictions (as well as other diagnoses such as Anxiety Disorders, Depression, Eating Disorders, and Learning Disorders like Dyslexia) it is no surprise that difficulty with impulse control is one of the executive function deficits which fuels the negative cycle of overwhelming and seeking to eliminate uncomfortable and exhausting emotions, followed by engaging in use of substances, followed in turn, by feeling poorly about one’s use of the substance to finally descending into a sense of being out-of-control or overwhelm, which brings one back to the beginning of the cycle, which continues to repeat.
Better a patient person than a warrior, one with self-control than one who takes a city. – Proverbs 16:32
Working Memory is the mind’s ability to hold information while in the middle of the particular activity for which the information needs to be actively applied. For example, an individual who struggles with working memory may have a hard time remembering all the steps in a set of verbal directions or lose track of details in an interpersonal conversation.
This Executive Functioning skill relates to processing speed and stimuli intake. The individual with ADHD often has trouble sifting through which incoming stimuli are of importance to the task at hand, and which stimuli can be disregarded as irrelevant to their lives in the moment, and in the near future.
“The true art of memory is the art of attention.” – Samuel Johnson
Organization“Organization” is a common word which represents a set of psychological processes such as grouping, coordinating, structuring, planning, and tracking information and materials. The Executive Functioning skill of organization includes both external and internal components.
For example, “organization” as an umbrella term encompasses all sorts of tasks such as keeping track of when the student loan bill is due, the week’s activities, report deadlines, paying parking tickets, keeping a steady train of thought, or tracking informational exchanges in interpersonal conversations. Common tools for enhancing organization include the following:
- Establishing a routine for each main time domain in your life (morning/evening, weekdays vs weekends, work, seasonally, around the holidays)
- Use of a planner/ calendar
- Creation of a checklist at the start of each day that includes time limits
- Use of the SMART goal technique
- Use of visual reminders
- Reduction of clutter
But all things must be done properly and in an orderly manner. – 1 Corinthians 14:40
Emotional Management relates to one’s ability to pause before communicating their immediate felt response. Individuals who struggle with this Executive Functioning skill appear overreactive, struggle with critical feedback, and have difficulty bouncing back.
These individuals will feel their emotions intensely and struggle to provide themselves the immediate regulation necessary to manage the overwhelming feelings. This does contain a beneficial aspect in that the individual lives in the moment and does not struggle to communicate how they are feeling right then and there.
Unfortunately, this can sometimes lead to inappropriate social engagements, distracting feelings from critical feedback (which keeps one from refocusing the rest of the meeting content), abrasive outbursts, rapid dysregulation, or limiting communication because the immediate feeling or response may not fully communicate the individual’s full range of thoughts (but only offers the pressing emotion or opinion).
Becoming emotionally dysregulated pushes our brain into the “fight, flee, or free” state. While this part of our brain is essential in truly dangerous situations, it can cause real problems when we operate out of it too all the time. Our decisions are then purely emotional and lack high-level critical thinking and socially approved skills.
Rejoice with those who rejoice, weep with those who weep. – Romans 12:15
Task Initiation is the ability to conceptualize a need, determine a course of reasonable action, and act. Individuals who struggle with task initiation often have a hard time getting started on something, procrastinating for long periods of time. This is especially true of tasks that the individual has little to no interest in.
This may seem inconsequential since most people have a hard time doing something that they find boring, but the difference here is that for individuals who struggle with the Executive Functioning skill of task initiation it takes a monumental effort to even getting started.
If the individual has ADHD, there is a chemical component involved; their brain is actually deficient in providing consistent and sufficient chemicals to ignite engagement. It requires something of particular interest to the individual to trigger the release of a high number of chemicals to kick-start the individual to engage.
Then, because of the high level of chemicals released, the individual experiencing hyperfocus on that task. This is one area where stimulant medication can be particularly helpful. If you find yourself struggling with task initiation it can be helpful to:
- Remember that the consequence of not doing something could be worse
- Keep a running list of tasks and timelines to have a visual reminder of the parameters
- Try to keep emotion out of it
- Use rewards (especially where the task itself does not offer a natural reward, as would a task like baking a dessert or obtaining a degree)
- Use empathy and understanding in your self-dialogue, while keeping in mind your overarching values and life goals
“I long to accomplish a great and noble task, but it is my chief duty to accomplish small tasks as if they were great and noble.” – Helen Keller
Time ManagementThis Executive Functioning skill is of particular interest when we look at the adult ADHD population. As a child with ADHD, the adults around you are often the ones imposing the time constraints, providing reminders, and moving you between responsibilities and tasks. Consider the typical school day: a caregiver would usually wake you, feed you, and help you prepare.
The bus would pick you up, the bell would signal recess, the teachers would outline homework and often provide syllabi which detailed the semester plan, and the afterschool sports coach or musical instructor would guide the flow of a practice or lesson. After that, an adult would pick you up (or you would walk, and maybe get distracted along the way), and you’d usually have an imposed bedtime and bedtime routine.
This sort of structured time management is rarely the child’s responsibility. As the child ages, they are expected to take ownership of more and more of their time management. These phases of increased ownership, especially milestones (as noted in my piece on Women and ADHD) often bring about new struggles for the individual who struggles with time management and ADHD.
You may never have realized that you struggle with time management, but as you became more responsible for many tasks (responding to emails, communicating with a partner, running a household, raising children, leading Bible study, collaborating with your team at work – the list could go on and on).
It becomes more apparent that you struggle to prioritize the steps needed to accomplish multiple tasks throughout the day, estimating and then scheduling adequate time to get tasks done or get to appointments, and tracking exactly how long something took, all in order to improve your future behavior. If you find that time management is a struggle for you, consider the following ideas:
- Set a timer to learn how long each common task usually takes you to complete.
- Wear a watch.
- Ask yourself at the initiation of a task whether you know which step you’ll take next, whether your proposed order makes sense and is properly prioritized.
- Schedule tasks throughout the day and note how much time you will devote to each one.
- Record payment due dates, birthdays, important events, work deadlines, menstrual cycles (if applicable), and personal goal timelines in your calendar, create reminders, and visually note any overlap or particularly stressful periods of time that you can anticipate in advance.
- Visually track progress (via a calendar or planner).
- Schedule in breaks (set a time for these too) to adjust to estimated attention span.
“He who every morning plans the transaction of the day and follows out that plan, carries a thread that will guide him through the maze of the most busy life. But where no plan is laid, where the disposal of time is surrender merely to the chance of incidence, chaos will soon reign.”
– Victor Hugo
“Stressed Out”, Courtesy of Kinga Cichewicz, Unsplash.com, CC0 License; “Can’t Study,” courtesy of amenclinicsphotos ac, Flickr Creative Commons, CC0 License; “Jar of Colored Pencils”, Courtesy of Debby Hudson, Unsplash.com; CC0 License; “Alarm Clock,” courtesy of obpia30, pixabay.com, CC0 License