ADHD and Executive Functions
Perhaps ADHD should be renamed EFDD
This past week was my first back at work, and now I'm in my second. I have a modified schedule where for week 1, I work 2 days for 4 hours. Week 2 is 3 days at 5 hours. So on. It's been very beneficial, and I'm happy to be back. Probably the biggest relief is finally knowing what I'm returning to. For months, I would just have this formless boogeyman in my head, questioning who was still there and what policies had changed and how much energy I would need once I was back, but I finally have an actual target to work with. I've gotten some energy back in that respect.
The first week is also the hardest since that's the biggest shift. Catching up on emails, remembering passwords, replacing my laptop's dead hard drive, meeting new hires, learning that the CEO was promoted into the parent company. Week 1 to 2 will simply be an increase in hours, which will still be its own challenge, but it's much more gradual. I'll still have time to build up the computering-at-my-desk muscles, figure out the optimal break schedule, increase my body's tolerance to stress or being away from home.
I'm going to be working three days from the office. There's a full gym and locker room at the office, so that could both save me time and money. Because of the two-week extension in August for my short term disability, I was able to reset my sleep schedule, and I'm back to being a super early riser, sometimes waking up at 5 or 6 AM after a full night's sleep. I hope that means that I can start work early and leave early. We shall trial-and-error this aspect of my schedule.
Another fun component of the return to work phase has been the opportunity to try out all my new ADHD management skills. For this post, I'm going to focus in on a YouTube video that my friend sent me.
This video was taken from Part 2 of a larger, lengthy lecture by Russell Barkley on executive functions in relation to ADHD. It features a lot more hard facts than processing emotions as in the book "Scattered Minds." I'll cover only some of the video since it's so dense with information. At least he had a good takeaway page that makes for a simple to-do list for the ADHD mind, which loves to-do lists.
Barkeley proposes that we instead view it as a problem with executive functioning (EF). That is, rather than focusing on attention and hyperactivity, the evidence suggests that we frame the problem using the brain's frontal lobes, which house the executive functions. It's a fancy term for our ability as humans to self-regulate. How do we control our behaviour when our bodies want to react automatically to external inputs? If you see some delicious food, do you just eat it? Or do you question if it's safe, if it belongs to someone, if you have to pay for it? Executive functioning makes us different from all other species. I like the way Wikipedia stated it.
Cognitive control and stimulus control represent opposite processes that compete over the control of an individual's elicited behaviours; in particular, inhibitory control is necessary for overriding stimulus-driven behavioural responses.
Why focus on the brain? On average, ADHD brains are 3% to 10% smaller and two to three years behind in their development. The five areas of the frontal lobe are 10% to 25% less active. The brain stops developing in the mid-30's, so there are important implications for developmental milestones. The ADHD brain will hit them all but at very different times than for a neurotypical person. There's a well-known story about Phineas Gage, who survived having a rod blown through his forehead because of an accident with TNT. Afterwards, he went from being one of the most responsible people at the railroad where he worked to having problems with managing money, social life, living alone, and sexual urges. With the front part of his brain being irreversibly damaged, he couldn't use his executive functioning skills anymore.
Executive functioning is self-regulation. Self-control is anything you do to yourself to change your behaviour to alter the future. There are two broad categories: inhibition and metacognition (self-awareness). Since there are a ton of different models for executive functions and no clear concensus, we'll just go with whatever Barkley uses, which says there are 6-7 individual functions.
Inhibition includes motor, verbal, cognitive, and emotional control.
Metacognition covers verbal and non-verbal working memory, planning and problem-solving, and emotional self-regulation.
Executive functions live in the frontal lobes of the brain. There are five structures and three executive networks, and ADHD interferes with all three networks to a varying degree in each person.
"What?" Network. Frontal-striatal circuit.
Response suppression, freedom from distraction, working memory, organization, planning.
"When?" Network. Frontal-cerebellar circuit.
Motor coordination, timing, and timeliness. The cerebellum allows for the gracefulness of our movements and thoughts. Time management is worst in ADHD of any other disorder.
"Why?" Network. Frontal-limbic circuit.
Emotional control, motivation, hyperactivity and impulsivity, aggression. Without it, the emotional brain, aka the limbic system, runs free.
Since executive functions aren't well-defined and understood by the academic community, Barkley says the tests are essentially irrelevant. Impairment defines the disorder, as in the inability to function compared to most people, and the cognitive tests for EFs are fairly disconnected from humans live in their day to day lives; Barkley uses the example of sorting numbers or cards. Instead, EF rating scales, filled out by all of the people who spend significant time with the individual, have been shown to be more predictive of a person's impairment in real life. Such a rating scale might ask something like "On a scale of 1-10, rate how well Jon is able to make a plan before starting a task." Many with ADHD pass EF cognitive tests but fail EF rating scales. Paradoxically, society relies instead on EF tests and assessments, which have far-reaching effects into daily lives such as determining disability status and payments. Maybe it's a good thing I didn't spend much time to pursue an ADHD assessment.
Because there is a deficit in executive functioning, the ADHD brain is split in two, with knowledge in the back and performance at the front, and both sides don't communicate all that well. For most people, the connection between knowledge and performance is quite strong, whereas with ADHD, the person gets stuck in their thoughts and can't manipulate their bodies quite as well. It can almost feel like being locked in a prison of your mind, screaming at your hands to stop scrolling social media timelines but being powerless to control the meat machine. As such, providing training will not matter because there isn't a knowledge gap. Interventions must be applied at the point of performance, out in the real world. Have to create scaffolding around them, re-engineer the environment.
ADHD creates a diminished capacity, but that does not excuse the individual’s accountability. I wrote about "striving for ownership" of emotions last week with the three links in the chain: awareness of the events around you, your understanding of those events, and the feelings that arise therefrom. The problem with ADHD here is with time and timing, not consequences. All important social consequences are delayed, which is hard for ADHD brains to connect. You need to bring consequences around very quickly, even if they are artificial. Have a shorter leash, so to speak. Behavioural modification helps with functioning. Have to build "ramps." Stakeholders have to be involved because you can't do it alone.
Cutting to the punchline of the video, how can we compensate for executive functioning deficits, according to Barkley? We do it by reverse engineering the EF system:
Externalize important information at key points of performance
Externalize time and time periods related to tasks and important deadlines
Break up lengthy tasks into many small steps
Externalize sources of motivation
Externalize mental problem-solving
Replenish the self-regulation resource pool (willpower)
Practice incorporating the 5 strategies for emotional regulation in daily life activities. (He doesn't mention what they are, but these are what a web search brought up:) Situation selection, situation modification, attentional deployment, cognitive change, response modulation.
There is a limitation in the self-regulation/willpower fuel tank, and since it has a smaller capacity with ADHD, it needs to be recharged regularly using:
Rewards and positive emotion
Shorter spurts of work with frequent breaks
3+ minutes of relaxation or meditation
Visualizing long term rewards before and during self-regulating task
Keep blood-glucose high by sipping sports drinks
Executive functioning deficits are neurogenetic. Medications are neurogenetic therapies, so it is absolutely appropriate to use medication to treat ADHD, which are three times more effective than anxiety drugs and antidepressants. Additionally, ADHD is the most treatable psychiatric disorder. ADHD is the diabetes of psychiatry, says Barkley. The condition is underdiagnosed and the medication underprescribed. 90% of people respond, but 40% of children and 90% of adults are not recognized. We are undertreating the most treatable disorder.
Phew! Lots and lots of information. According to Barkley, ADHD should be renamed "Executive Functioning Deficit Disorder." Executive functions allow us as humans to control our behaviour to alter the future, and people with ADHD have trouble with both controlling their behaviour and caring about what happens in the future. As such, I should follow the to-do list to compensate for executive functioning deficits, and regularly recharge my willpower.