by Larry B. Silver, M.D.
The concept of inattention, one of the three behaviors found with ADHD, is changing. And, with this change, the explanation of what is ADHD is expanding. The understanding of inattention has shifted from the inability to stay on task to a broader concept called Executive Function Disorder (EFD). This expansion of the concept of inattention is a positive move. However, until a fuller understanding of Executive Function and EFD is part of the thinking of the clinicians who diagnose and treat individuals with ADHD, only part of the problem might be seen, leaving other results of EFD not addressed.
Marcus, a ten-year-old fifth grader, had difficulty staying on task and completing his work. He also had problems keeping his backpack and papers organized and remembering what had to be brought home from school and what needed to be returned and turned in. Formal psycho-educational testing showed that he was bright but that he had difficulties with processing speed and with working memory. Other studies showed additional evidence of difficulties with “executive function.” The conclusion was that Marcus had ADHD, Inattentive Type. He was referred to me for possible use of medication. Marcus was started on a stimulant medication and showed significant improvement in all areas.
But, think about Ethan, a twelve-year-old seventh grader. The presenting problems were the same. The results of the psycho-educational evaluation were similar and the final diagnosis of ADHD, Inattentive Type was the same. However, he did not improve when placed on stimulant medication. A further review of his psycho-educational test results showed that he had problems with reading retention and with producing written work. Like Marcus, he had an EFD. However, these problems resulted in more than inattention. His EFD resulted in Learning Disabilities (LD) and these problems had to be addressed.
Why did each child appear to have the same problems and test results yet need different interventions? As one of the premier researchers in EFD, Dr. Martha Bridge Denckla, emphasizes, EFD can be a reflection of ADHD but might also reflect a Learning Disability and often may be both. If a professional evaluating a child or adult finds evidence of EFD, it is essential to clarify if this disorder is causing ADHD, LD, or both. Since these concepts are relatively new and not all professionals explore for both possibilities, you, as parents, must know to ask the right questions in an effort to clarify.
Dr. Denkla also explains that EFD most impacts on reading and writing skills that are developed and needed by middle school. Thus, some children are identified as having ADHD initially. Then, by middle school or high school they begin to show difficulties relating to reading fluency and writing fluency (discussed later), resulting in being identified as having LD.
Why is this expanded concept of ADHD important to you as a parent or as an adult with ADHD? The treatment for ADHD is very different from the treatment for LD. If the focus of intervention is on the difficulties with organization and with time planning only and the child or adult also has problems with organizing and processing information, essential for certain reading and writing tasks, an appropriate intervention plan cannot be developed.
What Then Is Executive Function?
Before being specific, it is important to understand that Executive Function is essential for organizing a person’s “outside world.” You must organize your thoughts and plans and carry them out in a timely way. Executive Function is also essential for organizing one’s “inside world.” Reading and reading comprehension is important. But, to retain what was read requires the ability to organize the information read and then store it into memory. Knowing how to write and having the basic skills of spelling, grammar, punctuation, capitalization, and format is also important. But, before any of these steps can be initiated, the individual has to retrieve the necessary information from memory and then organize this information before it can be written. Organization, a core part of Executive Function, is essential for both sets of task. The diagnosis of ADHD, Inattentive Type focuses on these “outside world” aspects of EFD. For some or many, however, these EFDs also impact on the “inside world,” resulting in Learning Disabilities.
Around puberty, the frontal part of the cortex of the brain matures in. With this expansion in brain function, the individual is able to perform higher level tasks. These high level tasks are referred to as executive function. The term executive function suggests the role of a Chief Executive Officer in an organization. She or he must analyze a task, develop a plan for addressing the task, identify in what order these tasks must be done, make mid-course corrections as needed, and complete the task in a timely way. There are many different definitions of executive function. Each tries to explain this process:
- Analyze a task
- Plan how to address the task
- Organize the steps needed to carry out the task
- Develop time lines for completing the task
- Adjust or shift these plans as needed
- Compete the task in a timely way
A middle schooler has to read a book and to write a book report. The assignment is made on a Friday and is due the following Friday. This student must first be sure that the book is available. Based on how long and complex the book is, how long will it take to read it? Does the teacher have a specific format for writing book reports. If so, should this student have this format in mind as the book is read, perhaps making notes on specific pages that might relate to what part of the report. When should the book be completed so that enough time is left to do a draft, to get help if needed, and then to complete the report by Thursday night. (Maybe this child has soccer practice on Tuesday evening and needs to plan on not having much time on this evening for homework.) If this student has good executive function skills, the work gets done and is turned in on time.
Executive Function Disorder:
What about the student with EFD? I don’t need to give the details. You probably live with it. Given the same homework assignment to read a book and to write a report, this student understands what needs to be done and really plans to get it done. But, somehow the report does not get finished or turned in on time. Dr. Russell Barkley, who has done much of the pioneering work in exploring the role of EFD with ADHD likes to say, “It is not that the individual does not know what to do. It is that somehow, it does not get done.”
You know these kids. Maybe you have one or you were this way and continue to be this way. They have problems with organization and with time planning. They lose or misplace papers, reports, and other school materials. They come home, leaving important things at home or they go to school, leaving their homework in their room. They might have similar problems keeping track of their personal items or keeping their bedroom organized. Somehow, they are never ready on time and they never get things done on time. Yet, they are the sweetest people. They look up at you as lost and confused as you are. They knew what had to be done. You have gone over it again and again. You put up signs and use stickers. Yet, somehow it does not get done.
If you look at the criteria needed to establish the diagnosis of ADHD, Inattentive Type, you could understand why such a child would be diagnosed as ADHD, Inattentive Type.
DSM-IV-TR Criteria for ADHD, Inattentive Type
A child must display six of nine of the behaviors listed below:
- often fails to give close attention to details, or makes careless mistakes in schoolwork, work, or other activities;
- often has difficulty sustaining attention in tasks or play activities;
- often does not seem to listen when spoken to directly;
- often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions);
- often has difficulty organizing tasks and activities;
- often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);
- often loses things necessary for tasks or activities (toys, school assignments, pencils, books, or tools);
- is often easily distracted by extraneous stimuli; and,
- is often forgetful in daily activities.
It Is Important for You to Know: EFD May Also Cause Learning Disabilities
In elementary school the child learns how to read and how to comprehend what was read.
This child learns how to write and the basic concepts of writing spelling, grammar, punctuation, capitalization and the expected format. Basic math concepts from addition and subtraction to fractions and decimals are learned. Because of the newly acquired skills associated with executive function, by middle school and definitely in high school, students must add the ability to organize and process knowledge.
Thus, when reading, it is not just can you read and do you know what you have read. As the material gets longer and more complex, can you retain what you have read. That is, using their new abilities to process, organize, and store information, the student goes beyond reading and comprehending to what is called reading fluency retaining what was read in an organized and meaningful way.
Writing demands change by middle school. It becomes increasingly necessary to pull information down from memory and to organize this information before writing can start. For example, “What was the theme of the book and give examples to illustrate this theme?” Questions on tests become more complex, requiring the student to retrieve and organize information in order to answer. This ability to retrieve and organize information in order to write a response is called writing fluency. So, too, solving math problems require retrieving learned concepts (formulas, rules) as well as known facts (e.g., the times tables) as well as the ability to organize and to utilize this information to solve the problem. The ability to do this is called math fluency.
Students with EFD might have difficulty organizing information before storing it in memory or difficulty organizing information that has been retrieved from memory. They might read a chapter but not retain what they have read; thus, they cannot answer the questions at the end of the chapter.
Yet, if you help them by going over and discussing what was read, they can answer the questions. He might misread a question or instruction or a math word problem because he did not pull all of the facts together and retain them.
This student might stare at the page, not knowing what to write. She seems to know the material but be unable to write an answer or start a paper because she cannot get her thoughts organized. If you discuss the material and help her organize the ideas, she suddenly have no difficulty knowing what to write. A student is able to write out the steps in doing a math equation. But, the steps do not flow correctly, resulting in careless errors. He knew the concepts to apply but might add wrong, skip a step, or multiply incorrectly and got the wrong answer.
The results of formal testing might show data that support the problem with EFT. But, go on to the educational part of this assessment. Often, the data show that the student has difficulties with reading, writing, or math fluency. This student has EFD that results in LD.
More often, school professionals and other professionals are all too quick to decide that the problems with organization and with staying on task are the result of ADHD. They do not take the time to explore if the child also might have difficulty with reading, writing, or math fluency.
What Do You Need to Get from This Article?
The concept of ADHD is changing. Our understanding of hyperactivity and impulsivity remains essentially the same. However, our understanding of inattention has expanded beyond the concept of an inability to stay on task. Starting with early adolescents, inattention has been seen more as a weakness or disability in Executive Function an Executive Function Disorder.
Professionals doing research in EFD understand that this disorder might result in inattention and thus fit the definition of ADHD, Inattentive Type. However, they also understand that this EFD might also result in LD. However, some, maybe many practitioners do not yet understand this possible duel outcome of an EFD. Even when the test data support the diagnosis of LD, they might diagnose the ADHD, Inattentive Type and stop there.
As parents, you might have to be the educator. Does your child or adolescent have inattention only? Or, now that you know how EFD can result in LD, do you see evidence suggesting these problems as well. ADHD, Inattentive Type might respond very well to appropriate medication. LD will not. The child or adolescent with LD will need special educational tutoring beyond just organizational tutoring. The adult may need education interventions beyond the work of the adult ADHD Coach.
Larry B. Silver, M.D., is a child psychiatrist in private practice in the Washington, DC area. He is a past president of LDA and is currently serving on the Board of Directors.