Jul 30 2023
Executive Function Series: EF, ADHD, and Autism (E 55)
Do you understand what Executive Function (EF) refers to and why it is important? If you have EF difficulties, have you been diagnosed with ADHD? Do you wonder if you have a diagnosis of autism or if you should have a dual diagnosis of autism and ADHD? Dr. Regan breaks down the concepts and shares about the relationship between EF, ADHD, and autism.
Executive Function Book Series by Dawson and Guare:
Smart But Scattered (children's version)
Smart But Scattered (Teen version)
Smart But Scattered (adult version)
Dr. Regan's Master Class for Clinicians:
Zur Institute: Master Class
Dr. Regan's Resources
Book: Understanding Autism in Adults and Aging Adults, 2nd ed
Audiobook
Book: Understanding Autistic Behaviors
Autism in the Adult website homepage
Website Resources for Clinicians
Read the transcript:
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Hi there.
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This is Doctor Regan joining you for an episode of Autism in the Adult podcast.
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I'm a neuropsychologist,
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the founder and director of an autism diagnostic clinic in Central Illinois and the parent of a teen on the spectrum.
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Today,
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you are joining me for the first episode in a new series about executive function.
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And I'm really excited for the series since announcing the topic.
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At the end of our last episode,
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I've received lots of emails from interested listeners before we dive into today's episode.
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Though,
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I wanna give a shout out to the clinicians and professionals who may be listening.
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I'm currently developing a master class with the continuing education platform called Zur Institute.
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This offering is unique for several reasons.
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One is the format,
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there will be four 2-hour webinars,
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one in each of September,
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October,
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November and December of 2023.
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And the first hour will be education while the second full hour will be reserved for discussion,
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question and answer and interaction with you about clinical questions and practice issues related to the topic for that day.
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Another unique feature of this offering will be the focus on advanced topics. So click on the link in the show notes to read more about the topics and how to sign up.
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If you are a clinician wanting beginner or intermediate courses,
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check out my other offerings on Zur or at my website,
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which is also linked through the show notes.
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All right,
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let's talk about executive function.
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I'll warn you that today's episode will require some executive function to get through.
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And I've spent a lot of time trying to make sure that I'm linking all of the themes together.
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So with that in mind,
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I want to start off with just a general definition of executive function.
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Later in our talks,
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we will cover a more precise and descriptive definition including sub elements and what we might call those.
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So executive function refers to a set of brain based abilities related to the functioning of the pathways connecting the center and the front of the brain.
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And the reason for the name,
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executive functioning is that executive is defined as having the power to put plans and actions into effect.
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So a CEO for example,
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is the chief executive officer of a business company and is in charge of directing the tiers of the company,
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the regional officers,
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managers,
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direct workers,
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directing all the pieces to work together toward the same goal.
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So these pathways of the brain help the parts of the brain work together to achieve a goal.
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Another image that I like is the symphony conductor,
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directing all the instruments in the orchestra,
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even if all the instruments are performing perfectly,
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if there's no conductor,
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there's no unified sound with melody and movement and this synchrony of sound.
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So the sounds don't come together to create a moving and meaningful piece of music without the conductor.
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So executive function is like the symphony conductor,
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it should bring all of the working parts of the brain together to perform.
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So that something meaningful happens.
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As I said,
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executive function is a set of brain skills,
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it's not one skill.
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And as we understand what the center of the brain,
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the subcortical areas of the brain and the connections through the center with the front of the brain,
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the frontal lobes.
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When we understand what these areas are in charge of,
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we refer to those set of abilities as executive function.
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So these executive function abilities hang together anatomically in the brain.
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So through that subcortical frontal system,
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so the number one point is that executive function refers to a series of skills,
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not one skill.
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And these skills are linked with anatomy,
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with the subcortical frontal systems of the brain.
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And the skills help the brain produce a meaningful synchronous um behavior or,
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or product.
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Now,
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let's talk about the diagnosis of AD D and A DH D and just for simplicity's sake,
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from now on,
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I'll really just refer to these as AD D but I'm referring to both diagnoses.
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This diagnosis was introduced in the diagnostic manual,
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the DSM - III in 1980 it was important because it described a developmental neurologic condition of executive function.
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So executive function was not a new concept,
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but the diagnosis of ADD was the one that captured this developmental piece.
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So here we have a diagnosis then that we can use to describe a difficulty that an individual has based on their developmental wiring.
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The way that the brain system has developed,
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the way they're wired in the executive function areas of the brain don't finish their anatomic development until about the age of 20 or 21.
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So,
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anatomically,
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executive function is still developing until about that age.
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So the number two point is that ADD was a notable addition to the diagnostic manual in 1980 because it represents a diagnosis for executive function difficulties that are developmental in nature.
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Now,
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I want to talk about the relationship between executive function and AD D executive function is not specific to ADD or ADHD.
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So the difficulties in that domain,
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they're not specific to this diagnosis.
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We're discussing executive function is one of the most sensitive brain functions to any kind of stress,
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whether that is physical or psychological.
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One of the first things to show difficulty is going to be executive function.
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It's often the first thing to become difficult and the last thing to resolve or heal after some type of challenge.
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For example,
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if an 80 year old has a bladder infection.
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What's probably the most sensitive cognitive function that's going to be disrupted first ... executive function.
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And if someone is recovering from a traumatic brain injury and they've gone through rehab and it's two or three months after ... what's probably the residual problem that's still kind of healing up.
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Well,
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that would be executive function as well.
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So there may be developmental differences in executive function and that's what we discuss
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when we talk about the diagnosis of ADD,
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there can also be acquired differences in executive function.
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This would include differences after,
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as we said,
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a traumatic brain injury,
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a stroke, within the context of a dementia... acquired
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meaning that this is not developmental.
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It's something that has occurred in the course of the life span.
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Executive function,
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difficulties can occur with acute or chronic medical problems.
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So an acute medical issue would be like an infection.
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For example,
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this is something that comes and then it goes,
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it's acute,
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it's new,
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it kind of can hit kind of hard and then heal up and go. Or executive function can be disrupted due to chronic medical problems.
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So someone with kidney failure,
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for example,
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who's on dialysis,
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what's the most likely thing they're going to have some difficulties with in the cognitive domain.
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Well,
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that would be executive function,
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someone with sugar fluctuations in the context of diabetes,
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someone with metabolic differences like their sodium is too low.
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These can also cause a disruption in someone's executive function system,
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even differences in the load that the person is carrying with regard to stress,
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emotional pain,
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trauma,
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lack of sleep,
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and even just having too much on our schedule.
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These examples of things don't change the anatomy of the brain and how the parts of the brain are working.
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But it really does interfere with our access to using our full capacity,
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our full anatomic, biologic capacity for executive function.
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So,
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if we've had trauma,
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you know,
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our brain may just go offline if we dissociate.
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And even though our anatomy is working well to produce this executive function,
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we may experience a psychological process that takes us offline.
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In addition,
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even with normal aging,
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what's the first thing to start to show difficulty?
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Yes,
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it's executive function.
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And if you are aging really well,
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you're,
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you're really aging nicely.
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You don't have any additional medical issues,
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you haven't had an injury.
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The first thing you're gonna start to notice is some problem in the area of executive function.
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That's just the aging process and how it impacts that subcortical frontal system.
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So you may walk into a room and you can't remember why, or you have this tip of the tongue phenomenon where you know what you wanna say
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but you can't get it out.
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That's executive function.
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You may have to think more slowly or take in less information at a time.
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So all individuals are likely to experience executive function difficulty in these contexts.
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So consider this comparison,
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executive function is similar to fatigue,
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for example,
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in that it's a nonspecific feature of many different kinds of conditions.
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So if someone has fatigue,
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there would be hundreds... thousands of conditions that could produce fatigue,
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anything from lack of sleep to infection,
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autoimmune conditions.
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And so many more things.
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Similarly,
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executive function difficulty can be caused by so so many conditions and situations,
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trauma,
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aging,
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ADD,
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autoimmune conditions,
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delirium, autism, and many,
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many more.
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So the third point we've really focused on here so far is that executive function is not specific to ADD.
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So many many things can trigger this executive function problem.
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Therefore,
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if someone presents with executive function difficulty --
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so I'm having a hard time paying attention,
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I just can't take in information very well.
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I can't organize myself well --
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the clinician should consider differentials in the diagnostic process because so many things can present with those features.
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There should be this process of taking into account.
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What is this person's age?
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What is their recent life experience?
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What are their medical issues?
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When did the executive function issue start?
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But executive function difficulty does not automatically mean ADD.
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It does not equal ADD,
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it's not equivalent to ADD.
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So we would consider a handful of things that could cause executive function problems in this person, and then would perform an evaluation to see what the most likely contributors are in this case.
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So let's go over our first three points.
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Executive function refers to a series of skills,
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not one skill and these skills are linked anatomically within the same pathways --
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these subcortical frontal system pathways -- and they also work together to provide some meaningful and organized output from the brain.
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The second point is that ADD was added to the diagnostic manual in 1980 to describe developmental executive function differences, and that was really helpful to have a diagnosis for developmental differences in executive function.
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The third point is that executive function is not specific to ADD -- many many things can trigger executive function difficulty.
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And so we would never want to hear executive function difficulty and then translate that automatically into ADD.
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So we talked about how executive function refers to a series of skills.
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There's not a unanimous consensus about what constitutes all these subparts,
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how to number them and what to call them.
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But many conceptualizations may refer to about 12 to 15 components.
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Give or take.
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These often include things like organization, sequencing,
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processing speed,
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prioritizing, planning,
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task initiation,
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sustained attention, goal
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directed persistence,
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impulse control,
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time management,
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generation of ideas,
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working memory,
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flexibility and emotional regulation.
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So it's not important for you to know what those mean.
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But I want you to get the sense that there are these multiple components and we'll look at each of these later in our series.
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But for now,
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wow,
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executive function is a broad category.
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ADD, which as we said describes a condition of developmental
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executive function difficulty, includes four areas as I would describe them.
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So someone may say,
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oh,
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I think it's more like five.
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so it doesn't matter,
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but it's a small subset.
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We've got attention,
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organization,
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goal directed
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persistence, and impulse control.
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The diagnostic criteria for ADD only describe four areas of executive function even though our current understanding is that there are probably more like 12 to 15 components.
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So you can see that someone could have significant difficulty with executive function developmentally and not meet the criteria for ADD because these four specific areas included may not be the ones that are causing this problem.
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This person's individual difficulty...
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I also want you to know that every single person,
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regardless of developmental neurology,
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health background,
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all humans will have a pattern of executive function,
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strengths and weaknesses.
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That's the normal way of our neurology.
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So out of those 12 to 15 subsets of skills,
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you can kind of imagine this graph across the all of these different points and sometimes we'll have ups and downs there that can help inform us what we struggle with and what we're really finding easy.
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So a person who's really good in the areas of generating ideas and flexibility,
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this person might be called creative.
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All these ideas,
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they're very flexible,
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they go from here to there,
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but they may struggle with other areas of executive function,
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they may be impulsive,
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have difficulty with time management, organization...
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So everybody has their own pattern with an executive function.
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So let's go back here.
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We are setting up a discussion of the relationship between executive function and ADD.
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And one of the difficulties we currently have is that our understanding of executive function has evolved since 1980.
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But we have a diagnosis that covers only a small subset of how we currently conceptualize executive function.
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This creates difficulty in that someone may clearly have developmental executive function problems but not fit into the box of the ADD diagnostic criteria.
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Now,
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let's compare ADD and autism.
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Everyone on the autism spectrum will have executive function difficulty in some form or pattern.
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That's because of the neurology of autism.
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The term executive function is not specifically used in the autism criteria,
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but many of the criteria describe behavioral patterns that tap into that neurology and that reflect difficulty in executive function and that subcortical frontal system.
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So autism has this executive function component plus many nonexecutive function elements as well.
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So ADD is a diagnosis of four or so elements of executive function.
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Autism is a diagnosis that includes elements of executive function and elements outside of executive function.
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The diagnostic manual indicates that the diagnosis of ADD cannot be made if another diagnosis better accounts for the client's whole presentation.
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The diagnostic manual says about autism that ADD can also be in diagnosed along with autism when attentional difficulties or hyperactivity exceeds that typically seen in autism.
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So let's regroup.
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Executive function,
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difficulties occur secondary to so many developmental,
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physical and psychological states.
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And ADD and autism are two developmental diagnoses that include executive function difficulty.
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ADD includes about four elements of the 12 to 15 sub elements of executive function that we generally think of.
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And autism includes some pattern of executive function difficulty across elements and also has nonexecutive function
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parts to the criteria.
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what should happen is that an individual presenting with developmental executive function difficulty would see a clinician who develops an appropriate differential,
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that is the person has developmental executive function difficulty,
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but that's not specific to ADD.
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So let's consider other developmental conditions like autism.
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And also let's consider other relevant information like the trauma history,
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medical conditions,
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intellectual abilities,
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learning disabilities,
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language processing ability.
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And let's figure out what the basis of this executive function problem is.
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But what actually happens is that a teacher, doctor, or clinician says,
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oh,
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this person has developmental executive function difficulty.
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Therefore,
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we're going to diagnose them with ADD.
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Then years later,
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they come to see a professional who does an evaluation and says,
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well,
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this person does have executive function problems,
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but the root of their attention problem is that they have an intellectual disability and nobody's ever checked or they can't process language well.
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And so of course,
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they can't attend in the classroom... or they have a learning disability so they can't attend if they can't understand what they're learning.
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Some of these individuals have executive function difficulty because they've been on the autism spectrum all along.
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But autism was never included in the differential process.
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So they've never been assessed for autism.
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It's kind of like hearing that someone has difficulty with fatigue and then assigning a diagnosis of chronic fatigue syndrome without thinking through any differential.
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Now,
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not everyone with fatigue is best served by a diagnosis of chronic fatigue syndrome.
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And not everyone with executive function difficulty is best described by a diagnosis of ADD. ADD should be given if another diagnosis or condition does not more fully explain the full constellation of characteristics.
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So even if the individual meets all the criteria for difficulty in those four subs skills,
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the diagnosis is not made if this executive function difficulty is better explained by autism or intellectual disability or learning disability,
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et cetera.
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So the question in the case of ADD diagnosis shouldn't just be,
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are the criteria met ... but are the criteria met
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and is this the diagnosis that best explains the whole presentation for this student or client or patient? In autism,
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executive function difficulties for one individual may include maybe two of those four subs skills that are in our definition of ADD and maybe three other executive function skills.
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They still have autism,
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they still have executive function difficulty as we would expect.
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But perhaps they're less likely to have a pairing of an ADD diagnosis.
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Another person on the autism spectrum may have all four of those difficulties in the ADD category and maybe a couple that aren't.
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And so they get these two diagnoses autism and ADD.
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However,
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if the executive function difficulty is not excessive for what we expect to see in autism,
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they shouldn't have that diagnosis.
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That second one,
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it's redundant.
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It's repetitive.
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So then do we take away the ADD diagnosis once someone has a diagnosis of autism?
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And it's not excessive?
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Well,
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we could,
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if we wanted to be precise,
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This is really what the manual talks about as making the most sense.
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However,
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practically speaking,
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this gets difficult.
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So one reason is that people don't understand the context of this ADD diagnosis and what it means and what it doesn't mean.
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And many times after I see a
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a client for an autism evaluation,
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I'll tell them their diagnosis is autism spectrum disorder.
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And then they will ask,
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did you also check for ADD I think I have that too.
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And so it's a difficult thing to just answer with a couple sentences as you can see.
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Do they have executive function difficulty?
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Absolutely.
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Do they have executive function difficulty that fits into that four subset category that we have as our diagnosis for ADD? Possibly
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yes or possibly no.
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Depending on the case. And does the executive function difficulty exceed what is generally seen in autism? Really infrequently.
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Honestly,
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I have made both diagnoses,
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but I don't frequently see the executive function as really standing out higher than you know...
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the group of people that I see.
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So conceptually,
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to me,
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it makes no actual sense to talk about autism with and without ADD.
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In fact,
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at this stage,
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in our understanding of the nervous system,
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it doesn't make sense to talk about a diagnosis that is ADD that only includes four or so subsets of the executive function skills.
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I would propose that it would make more sense to just have a diagnosis that says executive function disorder.
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And then you could say comma developmental or comma acquired or perhaps you could list the pattern ... like for this person,
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these are the strengths and these are the difficulties.
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It would be nice to increase the understanding that saying the diagnosis of autism automatically communicates that there are executive function difficulties present.
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That's not really our reality right now though.
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So even though that makes the most sense to me as a neuropsychologist,
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one of the practical difficulties (aside from people not understanding the terms) is that if we take away the ADD diagnosis for an autistic client,
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the individual can't get their attention medication,
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even if it has helped their executive function difficulty within the autism spectrum.
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Now,
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the medication is often not as effective on the spectrum as off the spectrum.
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But if someone has been helped by it,
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there's no reason to take it away because,
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you know,
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just because that ADD doesn't entirely fit.
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So practically speaking,
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they're gonna end up keeping that diagnosis because they understand what it means
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snd they don't understand what not having it means.
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And also they need medication or benefit from medication that requires that diagnosis.
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The other thing that's really a caution that I'd like you to think about...
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I really advise a lot of caution when reading things and listening to people speak about ADD and ADHD because we'll start to hear things...
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You know,
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people will say,
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well,
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you know what's really common for people with ADD,
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it's common that they become hyper focussed or it's common
