ADHD and Executive Skills

Have you noticed your child has difficulty sitting still, doesn’t seem to be paying attention when you are talking, stares out the window or “daydreams”, gets distracted easily, or becomes frustrated when completing tasks? Does your child struggle with time management, planning ahead, organization, initiation of new tasks, emotional control, or remembering things like completing homework? If this sounds familiar, it may be that your child has Attention-Deficit/Hyperactivity Disorder (ADHD) as well as the typical executive skill difficulties associated with ADHD.

ADHD is one of the most prevalent neurodevelopmental disorders diagnosed in children. In 2016, according to a national parent survey conducted by Centers for Disease Control and Prevention (CDC) the estimated number of children ever diagnosed with ADHD is 9.4% or 6.1 million, with boys more likely being diagnosed than girls. Although ADHD has been associated with difficulties paying attention or inhibiting impulses, it is also related to less-developed executive functioning skills.

Based on my experiences working in the schools and with parents, children/adolescents with less-developed executive functioning skills have been described “lazy” or “unmotivated”. As Peg Dawson, the author of the book, “Smart, but Scattered” would say, “What is the intervention for lazy?” Also, if the child/adolescent is lazy are we suggesting that he/she can actually help it? Or, maybe it’s the parents fault? Perhaps the parents aren’t providing enough structure in the home. I would whole-heartily disagree with this line of thinking with these children/adolescents!! fMRI studies have repeatedly shown statistically significant differences in the brain functioning of those with ADHD compared to those individuals without ADHD (Kooij, S.J., Bejerot, S., Blackwell, A. et al. [2010];  Depue et. al [2010]).  In fact, brain-based research has found that the pre-frontal cortex, which is related to executive functioning, does not fully develop until someone is in their mid-20s. The pre-frontal cortex for children/adolescents with ADHD or executive functioning deficits take even longer to develop!!

So what are executive functioning skills? Although research has uncovered over 40 different executive skills, recent studies have pinpointed specific skills related to executive functioning.  Executive skills include thinking skills (cognition) and doing (behavior) skills, although they may be labeled differently depending on the researcher. The thinking skills include working memory, planning/prioritization, organization, time management, and meta-cognition. The doing skills include response inhibition, emotional control, sustained attention, task initiation, goal-directed persistence, and flexibility.

Why is ADHD and executive functioning testing important? Children/Adolescents who have executive skill difficulties are more likely to struggle in school, have low self-esteem, become depressed, and may lack future independence (i.e., securing and keeping a job, staying in a relationship). A comprehensive testing evaluation to determine how the child/adolescent is functioning across multiple settings helps to clarify specific skill deficits, which can be targeted for intervention.

What types of accommodations and interventions are research-based to help build executive functioning skills? First of all, it’s important to understand that changing behaviors takes time, practice, and patience. Executive skills are considered “habits of the mind” and take a long time to develop and change. These skills take continual practice every day until they become automatic. So, now back to answering the question. Accommodations are environmental changes or modifications that can be made (i.e., schedules, cues, prompts, computer apps, seating arrangements), whereas an intervention consists of specific, measureable, appropriate, time-sensitive (typically 8-10 weeks) strategies, which target each specific goal in a hierarchal way. Typically, these interventions need to change if they are not working or if the child/adolescent is making progress and needs a new goal.

Interventions for parents/school professionals may include:

• Identify one or more executive skills which are difficult for the child/adolescent
• Pick one executive skill to work on
• Collect data on the behavior of concern (1-2 weeks)
• Share the data with child/adolescent (discuss negative and positive outcomes which may happen because of this behavior/lack of behavior)
• Brainstorm strategies to try (make sure the child/adolescent has input and gain agreement from the child/adolescent)
• Let child/adolescent pick the strategy and talk about when and where the strategy will be used
• Work with the child/adolescent to identify a goal – make sure the goal is specific, reasonable, obtainable, and measurable
• Have child/adolescent observe other children/adolescents who use the strategy effectively
• Right before the targeted situation, remind the child/adolescent of agreed upon time/place to complete the strategy
• Provide positive specific feedback and debrief with the child/adolescent
• After a week meet with child/adolescent to see how it’s going (discuss negatives, positives, way to make it better)
• Continue until a habit is formed
• Address issues when they arise – if one strategy isn’t working try another one

Although this is a list that provides ways to help an adolescent with executive skills, specific strategies can include delayed gratification, organizational systems (e.g., checklists, computer apps for reminders/structure), helping a child/adolescent think through situations, and problem-solving to name a few. Also, behavioral contracts between parents and child/adolescent, communication strategies, and contingency management plans (e.g., child/adolescent completes ½ an hour of homework, he/she gets a 5 minute computer break) can be most effective.

Targeting these executive skills may seem daunting at times, but with practice, consistency, and support from professionals, these skills may become positive habits for the adolescent and set him/her up for future success.

References:

Center for Disease Control and Prevention. Data and Statistics about ADHD. Retrieved August 19^th, 2020 from https://www.cdc.gov/ncbddd/adhd/data.html

Dawson, Peg. (2018, February).  Executive Skills: State of the Art, Trends for the Future. Workshop presented at the annual convention of the National Association of School Psychologists (NASP), Chicago, IL. 

*Dawson, Peg & Guare, Richard First initial. (2009). Smart but Scattered: The Revolutionary “Executive Skills” Approach to Helping Adolescents Reach Their Potential. New York: Guildford Press.

Depue, B. E., Burgess, G. C., Willcutt, E. G., Ruzic, L., & Banich, M. T. (2010). Inhibitory control of memory retrieval and motor processing associated with the right lateral prefrontal cortex: evidence from deficits in individuals with ADHD. Neuropsychologia, 48(13), 3909–3917. https://doi.org/10.1016/j.neuropsychologia.2010.09.013

Jacob, R. & Parkinson, J. (2015). The potential for school-based interventions that target executive functioning to improve academic achievement: A review. Review of Educational Research, 20 (10), 1-41.

Kooij, S.J., Bejerot, S., Blackwell, A. et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 10, 67 (2010). https://doi.org/10.1186/1471-244X-10-67

Samuels, W.E, Tournaki, N., Blackman., S., & Zilinski, C. (2016). Executive skills predicts academic achievement in middle school: a four-year longitudinal study. Journal of Educational Research, 109, 478-490.