A colleague recently connected me with an author wrapping up a book on adult ADHD. He shot me some questions on the topic of Executive Functioning and Dysfunction as it relates to adult ADD.
Thought I’d share my responses to his questions right here —
What is executive functioning?
Executive functioning is an umbrella term referring to all those capacities which separate humans from other animals. The capacities which separate adults from children. The capacities which separate higher functioning adults from those who struggle with time- and goal-management, procrastination, and poor impulse control.
Executive functions referred to serious (boring) adult stuff like concentration and delayed gratification, but they also include exciting and almost magical human capacities such as creativity and visualization and mental sketch pad capacity. Imagine a pink elephant, about 40 yards away from you, walking from left to right or right to left. You’ve never seen a pink elephant before in real life but you are able to create and visualize this thing which has never existed. Now visualize your ZIP Code on the elephant’s belly. Does that ZIP Code appear handwritten or typed out in font? What color is the ZIP Code, black ink or blue, for example? If the ZIP Code appears to be font, are you able to identify the font by name? Now, reverse your ZIP Code. Right there on the elephant’s belly, last number first, working way back to front, your ZIP Code on the elephant’s belly button backwards.
These are mental control capacities that as far as we know uniquely human. Now – imagine the most important relationship in your life. Right now, what relationship is most important? Your relationship with a coworker, spouse, or an adult child? Give that relationship a number on a 10 point scale. How good is it? On a scale from 1 to 10, where 10 is awesome and one is dysfunctional, quietly give that relationship a rating. Now, come up with 3 things you could do in the next 24 hours to improve their relationship by just one number. If the first thing that comes up for you is something he could do, let me ask the question again. What are 3 things that you could do in the next 24 hours to improve that relationship just a little bit? If you notice any resistance, any feeling that you don’t want to make these changes, remember this is just a thought experiment. I’m not asking you to do this thing; rather, I’m asking you to simply imaging something, or 3 things, you could do to make that relationship just a bit better.
Did you come up with something? Again, as far as we know only humans are capable this type of executive function. I could ask you a similar line of questioning around your health or your finances. What do you do to improve your income by just $5000 over the next calendar year? What are the 2 most important things you could do this week to improve your health?
Executive functions involve multiple areas of the brain, but chiefly supported by prefrontal cortex, and by networks within the brain which involve the prefrontal cortex.
What does it mean when someone has executive functioning disorder?
The term executive dysfunction is another umbrella term. It is not a specific diagnostic category, and when I hear that an adult or student has “executive dysfunction”, I will typically try to identify specific areas of weakness. The term “executive functioning disorder” refers to poorer functioning than would be expected for age in one of these areas of executive functioning described above. Difficulty with impulse control, for example, or difficulty organizing one’s material belongings, or difficulty sequencing and managing time.
How does this affect adults?
Executive dysfunction impacts adults in their close relationships – for example their ability to tolerate boredom, and the ability to tolerate anger. Once a romantic relationship is past the infatuation stage, for example, takes creativity and executive functioning maintain our interest and commitment. Working with others, or being supervised by others, whom we find irritating is a common adult experience, and the ability to tolerate that discomfort, and to manage our emotions is the mark of good executive functioning. Poor impulse control and poor emotional regulation, on the other hand, may impair these relationships. Legal history, and work and relationship history may reveal evidence of executive dysfunction.
Executive dysfunction may create problems with finances, so that our credit score might be another area of impairment. Paying bills late or failing to respond to important requests – these are examples of executive dysfunction which may impact our finances.
Arriving late for meetings, missing flights, forgetting appointments, these are potential evidence of executive dysfunction is it pertains to time management. Managing time required a bodily felt sense of time as well as an executive or thinking sense of time.
How common is this in adults with ADHD?
Examples of executive dysfunction related to acquired injury include traumatic brain injury, multiple sclerosis, and cerebrovascular accident. On the other hand, ADHD is a classic example of developmental executive dysfunction. In other words, adults and students with ADHD will give some evidence of functional impairment, and in fact diagnosis of ADHD requires evidence of significant functional impairment in several domains or areas of life functioning.
What can be done to help an adult with this? Coaching, etc…
Medical treatment for executive dysfunction associated with ADHD includes stimulant therapy. Additionally, there are several non-stimulant ADHD medications which have been approved for the condition.
Nonmedical treatment for ADHD includes closely managing sleep, taking a closer look at nutrition, and making a commitment to exercise. My recommendations in these areas include getting to bed before midnight, getting up before 7 AM, having no screens in the bedroom, and limiting exposure to activating media in the one or 2 hours prior to that time. Around nutrition, my recommendations are to emphasize protein at every snack and meal and to minimize exposure processed foods. When it comes to physical exercise, I make a distinction between exercise for focus and exercise for fitness. Exercise for fitness requires spandex, a gym membership, and an hour-long commitment. All of that is between you and your physical trainer. That’s exercise for fitness, but what I recommend is exercise for focus. Even 10 minutes of alternating intensity exercise may be enough to get the mental benefits, the focus benefits, of exercise. Alternating intensity would suggest for example 30 seconds of high-intensity alternating with 30 seconds of moderate intensity exercise, back and forth, high-intensity that is not likely sufficient exercise to lower your cholesterol or change your muscle mass, but again this exercise for focus, quite separate from exercise for fitness.
What else is important for people to understand about executive functioning?
The very definition of ADHD involves a discrepancy between ability on one hand and day-to-day performance on the other. There is a gap between that which you know you are capable of, and that which you may demonstrate on a given Wednesday or Monday.
Living in that gap requires compassion and self-compassion. One motto to consider here is “always be starting.” Didn’t exercise for 3 days in a row? Start again. Haven’t done your daily review of the list or calendar for about a week? Just start again. Realize you just spend an hour and a half on Instagram, again? Just close your browser tab and start again. Just keep starting.