Diagnosing Executive Functioning and ADHD: Key Symptoms and Assessment

Understanding Executive Functioning Skills ADHD

Understanding executive functioning disorder as a symptom of ADHD requires a deep dive into how it impacts daily functioning. Brown’s Model of Executive Functions, created by Dr. Thomas E. Brown (Brown, T. E. (2005), offers a comprehensive framework for this. It breaks down executive functions into six key clusters:

1. Activation
2. Focus
3. Effort
4. Emotion
5. Memory
6. Action

These clusters highlight the specific areas of everyday life where individuals with ADHD may struggle, from organizing tasks and maintaining focus to regulating emotions and actions. This model provides a valuable assessment of the challenges faced by those with ADHD, paving the way for targeted interventions and support.

This chart helps visualize the specific areas of executive functioning that the Brown EF/A Scales assess, highlighting how each component can influence a child's overall performance in various settings. By identifying these deficits in executive functioning, the scales provide a valuable overview to support the child's needs.

The Brown EF/A Scales can be used by a medical professional or a provider to asses executive dysfunction. This executive functioning scale is used to assess executive function dysfunction and its correlation to ADHD. 

Executive Function as the Brain’s Command Center

Executive function refers to the set of high-level cognitive processes that manage and regulate other cognitive abilities and cognitive skills. These processes involve several brain regions, particularly the prefrontal cortex, which acts as the brain's central control hub. They encompass a variety of tasks, such as:

• Attention Control: Focusing on relevant information while ignoring distractions.
• Working Memory: Holding and manipulating information temporarily.
• Inhibition: Controlling impulses and delaying gratification.
• Cognitive Flexibility: Shifting between tasks or perspectives smoothly.
• Planning and Organization: Structuring tasks and anticipating future needs.

These functions work together to enable complex behaviors and decision-making, helping individuals navigate daily life efficiently and effectively.

Executive Function as the Organizer of Thoughts and Actions

Executive functions continuously connect, prioritize, and integrate various cognitive processes to manage behavior and decision-making. This involves:

• Connecting: Linking different types of information, such as linking past experiences to current situations to guide behavior.

   

• Prioritizing: Deciding which tasks or pieces of information are most important at any given moment, allowing for efficient decision-making and task management.

   

• Integrating: Combining information from different sources (e.g., sensory inputs, memories, and current goals) to produce coherent responses or plans.

This dynamic interplay ensures that cognitive resources are allocated effectively, allowing individuals to respond flexibly to changing circumstances and achieve their goals.

Executive Function as a Conductor of the Brain’s Activities

The part of the brain primarily responsible for executive functions (EF) is the part of the brain called prefrontal cortex. It is located at the front of the frontal lobes and is crucial for a variety of high-level cognitive processes and complex tasks.

Executive functions can be likened to a conductor of a symphony orchestra. Just as a conductor directs the orchestra to ensure that all musicians play in harmony and according to the music, executive functions orchestrate various cognitive processes to work together seamlessly.

A child experiencing executive dysfunction with an ADHD brain may have difficulties in:

• Coordination: Ensuring that different cognitive functions (like attention, memory, and problem-solving) work together in a synchronized manner.

   

• Timing: Managing the timing of cognitive processes, such as when to shift attention or when to initiate a response.

   

• Adaptation: Adjusting strategies and processes as needed based on feedback and changing situations. They may lack self regulation and skills and inhibition control.

The executive functions' role is crucial in maintaining cognitive harmony, just as a conductor is essential for a harmonious performance. They help in maintaining focus, managing multiple tasks, and adapting to new information, ultimately guiding behavior and decision-making in an organized and effective manner.

Key Clusters of Executive Function

1. Organize, Prioritize, and Activate

Effective organization, time management, and prioritization are essential skills for managing tasks and responsibilities. When executive functions related to organization, time estimation, and task initiation are compromised, individuals may struggle with keeping their work, personal relationships, and materials in order. This can result in deficits in executive functioning and difficulties in starting and accomplishing tasks, affecting performance both academically and at home.

Difficulty Organizing Tasks and Materials

This might look like having a cluttered workspace or struggling to keep track of school supplies and assignments. Children may have trouble creating and following a structured plan for task completion.

Difficulty Estimating Time and Prioritizing Tasks

This refers to underestimating how long tasks will take or having trouble deciding which tasks are most important. For example, a child might spend too much time on less important homework while neglecting more urgent assignments.

Trouble Getting Started on Work

Initiating tasks can be challenging, often due to procrastination or feeling overwhelmed by the size of the task. This might manifest as a reluctance to begin homework or projects.

2. Focus, Shift, and Sustain Attention

Maintaining and shifting attention and focus is crucial for task initiation and following through on plans. Challenges with paying attention can manifest in various ways, from behavioral disorders such as losing focus during conversations or becoming easily distracted by internal or external stimuli. These issues can make it hard to retain and process information, impacting a person's ability to stay on track with their activities and responsibilities.

Loses Focus When Trying to Listen or Plan

This can mean becoming easily distracted during conversations or while planning future activities. A child might zone out during instructions or meetings.

Easily Distracted by Internal/External Stimuli

External distractions (like noise) or internal distractions (like daydreaming) can interrupt a child's ability to stay focused. This often leads to missed details or incomplete tasks.

Forgets What Was Read and Needs to Re-Read

Difficulty retaining information from reading or instruction often leads to having to revisit material multiple times to understand or remember it.

3. Regulating Alertness, Effort, and Processing Speed

Regulating alertness, sustaining effort, and managing processing speed are key components of executive functioning. These are areas people with ADHD struggle with. Problems in these areas can lead to difficulties with sleep, losing interest in long-term projects, and completing tasks within deadlines. These issues can significantly affect productivity and the ability to handle tasks efficiently. These are the key areas that would hold your kid's back from proper time management and organization.

Difficulty Regulating Sleep and Alertness

Problems with sleep can lead to feeling constantly tired, impacting the ability to stay alert and engaged during your day to day life tasks. This affects overall functioning and performance.

Quickly Loses Interest in Tasks, Especially Longer Projects

Sustaining interest and effort in tasks, particularly long-term projects, can be challenging. A child might start strong but then lose motivation or interest, leading to unfinished work.

Difficulty Completing Tasks on Time

This refers to problems with working at a speed that matches deadlines. Time management is one of the key skills that they lack. For example, a child might complete writing assignments slowly, causing them to miss deadlines.

4. Manage Frustration, Modulate Emotion

Emotional regulation is an integral part of executive functioning that influences how individuals manage frustration and other strong emotions. When emotions are overwhelming or disruptive, they can interfere with thinking and actions, making it challenging to stay focused and perform effectively. Understanding how emotions impact daily functioning can help in developing strategies to manage emotional control and modulate them better.

Emotions Impact Thoughts and Actions Too Much

Strong emotions like frustration or anxiety can overpower a child’s ability to think clearly or act appropriately. This might look like outbursts or difficulty focusing when upset.

Frustration, Irritations, and Worries Experienced Like a “Computer Virus”

Emotions might feel overwhelming and intrusive, similar to how a computer virus disrupts normal functioning. This means emotions can hijack a child’s focus and performance.

“Can’t Put It to the Back of My Mind”

Difficulty managing emotions can lead to constant preoccupation with worries or frustrations, making it hard to focus on other tasks or problems.

5. Utilize Working Memory, Access Recall

Working memory and recall are essential for holding and retrieving information needed to guide current thoughts and actions. Difficulties in these areas can lead to problems with remembering instructions, appointments, or integrating new information with what is already known. These challenges can affect the individual's ability to perform tasks and solve problems efficiently.

Difficulty Holding One or Several Things “On Line”

Problems with working memory mean struggling to keep multiple pieces of information active while focusing on tasks. For example, remembering a list of instructions while doing a project can be hard. This is one of the symptoms of executive dysfunction that might hinder your kids to complete tasks or to finish a project.

Difficulty “Remembering to Remember”

This refers to issues with recalling to complete tasks or appointments. For instance, a child might forget to bring home a library book that was due.

Inadequate “Search Engine” for Activating Stored Memories

Problems retrieving and using past memories effectively. This can look like struggling to recall information learned previously when it’s needed.

6. Monitor and Self-Regulate Action

Self-monitoring and regulating actions involve adjusting behavior based on situational demands and feedback. When executive functions in this area are impaired, individuals might struggle with controlling their actions, adapting to changing circumstances, and modifying their behavior as needed. It can also affect how they regulate emotions and their self control and self restraint. These difficulties can impact their ability to perform tasks effectively and respond appropriately to various situations.

Difficulty Controlling Actions and Adjusting Speed

Problems with regulating the pace and manner of one's actions. A child might act too quickly or too slowly for a given task, affecting their performance.

Doesn’t Size Up Ongoing Situations Carefully

Struggling to assess and adapt to changing situations appropriately. For instance, a child might not notice when their behavior is inappropriate or when adjustments are needed.

Hard to Monitor and Modify Own Actions

Challenges with self-awareness and adjusting actions based on feedback. This could mean not recognizing when a strategy isn’t working and failing to change course.

Key Assessments for Evaluating Executive Functioning and ADHD

A “word test” for ADHD usually refers to assessments designed to evaluate a person's cognitive and attentional abilities, particularly in relation to language and executive functioning.

Here are some tests that are used to assess executive function in ADHD:

Continuous Performance Test (CPT)
The CPT includes word-based stimuli or tasks. It measures attention and impulse control by asking individuals to respond to specific stimuli while ignoring others (Corners et al., 2003). During the test, participants might need to react to certain words or letters and refrain from responding to others, which helps assess attention and inhibitory control.

Stroop Test
This test assesses cognitive flexibility and selective attention. Participants are asked to name the color of the ink in which a word is printed rather than reading the word itself. The words are often color names that can create interference (e.g., the word “red” written in blue ink). Difficulty with this task can indicate problems with attention and executive functioning.

Wisconsin Card Sorting Test (WCST)
While not purely a word test, the WCST involves sorting cards according to different rules that change without warning. The test measures cognitive flexibility and the ability to shift attention, which are often affected by ADHD.(Grant et al.,1948), 

Verbal Fluency Tests
Verbal working memory is a cognitive system responsible for temporarily storing and manipulating verbal information. It is a critical component of the broader working memory system, which also includes spatial and visual working memory. Verbal working memory allows individuals to hold and process spoken and written language information over short periods.

Verbal fluency tests require individuals to produce as many words as possible within a certain category (e.g., animals) or starting with a specific letter (e.g., words starting with “S”). The ability to generate words quickly can be indicative of executive functioning and attentional control.

Neuropsychological Assessments
These assessments may include various tasks involving words and language to evaluate different cognitive functions. They help in understanding how ADHD affects language processing and executive functions.

These tests help giving you an official diagnosis in evaluating aspects of attention, impulse control, self motivation, and executive functioning, providing insights into the cognitive challenges often associated with ADHD.

Key Features of a Comprehensive Executive Function Inventory

A comprehensive executive function inventory is an assessment tool designed to evaluate a wide range of executive function skills in individuals. These inventories aim to identify strengths and weaknesses across various aspects of executive functioning, which are critical for goal-directed behavior, problem-solving, and self-regulation. One well-known example of such an inventory is the Behavior Rating Inventory of Executive Function (BRIEF).

1. Multi-Domain Assessment: Evaluates multiple areas of executive function, such as working memory, cognitive flexibility, inhibitory control, planning, organization, and emotional regulation.

    

2. Behavioral Observation: Gathers information about how executive function deficits manifest in daily life through observations and ratings by parents, teachers, or the individuals themselves.

    

3. Age-Appropriate Versions: Often includes different versions tailored for various age groups, from children to adults, to ensure the assessment is developmentally appropriate.

    

4. Rating Scales: Typically involves questionnaires or rating scales where respondents rate the frequency or severity of specific behaviors or challenges related to executive functioning.

    

5. Norm-Referenced Scores: Provides scores that can be compared to normative data to determine how an individual's executive functioning compares to typical performance for their age group.

    

6. Comprehensive Reporting: Generates detailed reports that outline specific areas of strength and difficulty, offering a clear picture of the individual's executive function profile.

Benefits of Diagnosing ADHD and Executive Function Disorder

Accurate Understanding

Executive functioning and ADHD diagnosis help identify the root cause of symptoms, distinguishing between conditions that may have similar presentations (e.g., ADHD vs. anxiety). This clarification is crucial because it ensures that individuals receive the correct treatment and support rather than a one-size-fits-all approach that may not address their specific needs.

Understanding the specific disorder allows for targeted treatment plans, improving the effectiveness of interventions. By pinpointing the exact nature of the condition, healthcare providers can implement strategies most likely to yield positive outcomes, enhancing the overall quality of care.

Effective Treatment Planning

Diagnosis enables the development of tailored interventions that address the unique needs of the individual. Personalized treatment plans consider the individual's strengths, weaknesses, and specific challenges, leading to more effective and meaningful progress.

Understanding executive dysfunction ensures appropriate resources and support services are allocated, such as special education services or therapy. With a clear diagnosis, schools, and healthcare providers can allocate the necessary resources to support the individual's development and well-being, ensuring they receive the help they need. A diagnosis is the first pathway to treat executive dysfunction.

Improved Outcomes

When a parent understands executive dysfunction symptoms, proper diagnosis and subsequent interventions can enhance academic performance and job productivity. When individuals understand their condition and receive appropriate support, they are better equipped to succeed in educational and professional environments. Managing executive function disorder will also become easier with the assistance of a mental health provider.

Addressing the underlying issues can lead to better emotional regulation, improved self-esteem, and healthier relationships. Understanding one's condition can alleviate feelings of frustration or inadequacy, fostering a more positive self-image and enhancing interpersonal interactions.

Access to Services

Diagnosis can facilitate access to special education services, individualized education plans (IEPs), and 504 plans in schools. These accommodations are vital for ensuring that individuals with specific needs can thrive in an educational setting.

When diagnosed with ADHD and executive function challenges, one can have eligibility for necessary healthcare services, therapies, and interventions that may not be accessible without a formal diagnosis. Access to appropriate medical and therapeutic support is crucial for managing symptoms and improving quality of life.

Support and Validation

Family support is very important for a child with ADHD. When parents understand the nature of the condition, they are more likely to offer constructive support and encouragement, which can significantly impact the individual's well-being. Parents can also assist in creating strategies to improve executive functioning and teach specific skills in task initiation, time management and self regulation skills. With the right support, healthy lifestyle and a balanced diet, kids can thrive and feel supported.

A diagnosis will also help individuals understand their own experiences, reducing self-blame and confusion about their behavior. A diagnosis can bring a sense of relief and validation, helping individuals to better navigate their daily lives and build coping strategies. This can also encourage them to self monitor and bridge the gap in their learning differences.

Teaching Executive Functioning Skills 

Teaching executive functioning skills is possible, and if you need support in doing so—whether it’s understanding more about executive functioning or addressing attention issues—the Executive Functioning Parent Toolkit is your ultimate resource. I created this toolkit specifically for parents who want to support their children and teach regulation skills, drawing from my 30 years of experience as a psychologist and therapist. 

This toolkit provides science-based strategies to tackle attention and executive function challenges, offering practical solutions to break the cycle of frustration. By implementing these evidence-backed techniques, you can manage behaviors more effectively, improve your child's focus, and foster their independence, all while reducing stress for both of you. With the Executive Functioning Parent Toolkit, you'll see meaningful improvements in just 30 days, transforming your daily parenting challenges into a more manageable and positive experience.