Is ADHD a Behavioral Disorder or an Executive Function Disorder?
What is executive function impairment or disorder, and how is it different than attention deficit hyperactivity disorder (ADHD)? Are the symptoms adults and children with ADHD experience a result of a behavioral problem, or a cognitive one, a brain issue?
As an attention deficit hyperactivity disorder (ADHD) researcher, a clinical professor of psychiatry at the Yale University School of Medicine, the author of Attention Deficit Disorder: The Unfocused Mind in Children and Adults, and as a psychologist helping patients manage their symptoms and reclaim their lives, I have seen ADHD from all sides.
My research into the brain has posited a new model for ADHD. The old model thinks of ADHD as a behavioral disorder. Many adults and children living with ADHD never have had significant behavior problems; they have difficulty focusing their attention on necessary tasks and using working memory effectively, making ADHD a cognitive disorder, a developmental impairment of executive functions (EFs) — the self-management system of the brain.
My theory of executive function impairment, or executive function disorder (EFD) has been slow to filter down to family doctors who are making diagnoses and prescribing medication. Too many doctors still think about ADHD in the old way — as a behavior problem accompanied by difficulty in paying attention. They don’t understand that “executive function” is really a broad umbrella. When patients hear the symptoms associated with EFD — finding it hard to get organized or to start tasks, to sustain effort to finish tasks, to hold off instead of jumping impulsively into things, to remember what was just read or heard, to manage emotions — they’ll say, “Yeah, yeah, yeah, that’s me.” A lot of executive function impairment goes beyond the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for ADHD.
We need to better understand the individual variants of ADHD in adults. Some adults have big problems in school, but once they get out of school, they are able to specialize in something that they’re good at, or take a job where an assistant helps them manage the day-to-day minutia, and they do fine. Other adults manage through school, but they don’t do well at jobs or managing a household. We’re beginning to identify the domains of impairment and to recognize that these difficulties with executive functions not only affect people with academic tasks but also in their ability to maintain social relationships and to manage emotions.
The following six clusters of executive functions tend to be impaired in individuals with ADHD:
Activation: organizing tasks and materials, estimating time, getting started.
Focus: focusing, sustaining focus, and shifting focus between tasks.
Effort: regulating alertness, sustaining effort and processing speed.
Emotion: managing frustration and modulating emotions.
Memory: using working memory and accessing recall.
Action: monitoring/ regulating actions.