You’ve probably heard that people with ADHD have significant difficulties with executive dysfunction, but you might be wondering what exactly that means. Most of my formative understanding of executive functions came from learning how to perform and interpret neuropsychological assessments. This type of assessment seeks to break down executive processes into small components, such as set-shifting, attention-switching, response initiation and inhibition, perseveration, and sustained and divided attention, among others.
When I worked in research and clinically with older adults for several years, I began to see the types of life tasks that became harder when cognitive impairment/dementia were present. Often, executive functions are among some of the early noticeable changes of cognitive impairment and can affect behaviours as diverse as cooking, cleaning, personal hygiene, knowing quantities of groceries to buy, managing food in the fridge and throwing it out when it goes bad, even what to put in the rubbish and recycling bins, and remembering when and which ones to put out for collection. While government-funded services are available to assist older adults with dementia with a number of daily life tasks such as cleaning and cooking, these services are not available for people with ADHD who may face some similar difficulties.
When I moved to working more with adults with ADHD I had to align my understanding of executive functions to the kinds of difficulties that a cognitively healthy adult with ADHD might experience. It was a learning curve, and I'm still learning.
Metaphors for Understanding Executive Functioning
There are a number of metaphors that exist to explain what executive functions are. Below are three that I particularly like.
The CEO or Manager: Executive functions are often compared to a CEO or manager of a company. They are responsible for making decisions, planning, setting goals, solving problems, and ensuring that everything runs smoothly.
The Orchestra Conductor: Just like a conductor guides and coordinates various instruments in an orchestra to create harmonious music, executive functions guide and coordinate various mental processes to help us accomplish tasks efficiently.
The Chef in the Kitchen: A chef has to multi-task, manage time, plan the menu, and stay focused under pressure. Executive functions are like the mental chef, ensuring that all the ingredients of thought and action come together in a well-prepared 'meal'.
Specific Executive Functions with Examples
Now getting more specific, I have put together a list of executive functions below that I think are important for the clients I see:
Working Memory is like a mental notepad where you jot down information that you need to remember for just a little while. Like when you try to remember a phone number long enough to dial it. This can apply to verbal and non-verbal (visual) information.
Cognitive Flexibility allows you to adapt to changes in your environment in a relatively efficient way. The opposite is cognitive rigidity, which can lead to performing behaviours in a rigid way, without learning and adapting to the environment.
Inhibitory Control is your brain’s ability to prevent impulsive actions and helps you to think before acting. Impulsivity can exert influence in behaviours such as over-spending or eating, or in verbal behaviours such as oversharing or saying what you think to the detriment of others (or yourself).
Emotional Self-Regulation: People with ADHD often have difficulty with impulsive negative emotion. It also means a greater likelihood of being easily excited, but the negative component is usually the most impairing.
Planning & Problem-Solving refers to being able to break bigger tasks into manageable components which are then approached in a logical and prioritised fashion.
Prospective Memory is like a mental calendar and to-do list combination. Prospective memory helps you remember to do things in the future, like taking the bin out on Tuesday or calling a friend on their birthday. It's like setting little mental alarms for future tasks and events.
Time Estimation and Monitoring is related to prospective memory, and is your brain’s internal clock and stopwatch. Time estimation helps you gauge how much time you have, how long tasks will take, and how to allocate your time wisely. Monitoring keeps track of time as it passes, so you can adjust your pace and make sure you’re not falling behind.
Hindsight and Forethought: Hindsight is like looking in the rearview mirror, it helps you learn from past experiences and understand what could have done differently. Forethought, on the other hand, is like looking through a telescope into the future. It enables you to anticipate outcomes and make plans based on potential scenarios. It's all about putting past experience into action for future behaviour.
Now, imagine several of these difficulties occurring concurrently, every day, for most of a person's life. This is what is meant by executive function impairment. It can make life really difficult. And it can't be fixed in any sustainable way by just trying harder. It's not a motivational issue - in fact, motivation itself is also affected by ADHD (I could have added it to the list above).
Executive Functioning Deficits are a Real Brain Phenomenon
Executive functioning deficits can be improved through the use of external strategies, but these are performed with effort. Executive functions don't just improve with practice to the levels that a typical neurotypical person might have. It would be like expecting a short-sighted person to regain their visual acuity after enough hours of squinting and trying really hard to see. While glasses may alleviate short-sightedness, once they come off, it's back to the same difficulties, as will happen with executive function difficulties when treatment (medication or strategies) are ceased.
A person who struggles with tasks due to executive functioning difficulties is not being lazy, difficult, or a slob. They are struggling with a real brain phenomenon, as is the person with dementia. Luckily for the person with ADHD, ADHD is not a degenerative condition as dementia is, and treatment can substantially improve symptoms across the lifespan.
Expert ADHD psychologist and researcher Dr Russell Barkley shares his understanding of executive functions: What Is Executive Function? 7 Deficits Tied to ADHD
In this brief video, Russell Barkley discusses executive functioning difficulties in ADHD, and in other mental health disorders
Clinical psychologist Dr Thomas E. Brown talks about executive functioning: The Adult ADHD Mind: Executive Function Connections
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