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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 that they have difficulty with social interactions or it's common that they have sensory processing difficulties.
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The
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the problem with these statements is that the individuals who have received diagnoses of ADD often receive this just because they've had executive function difficulty,
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but they haven't had much if any differential assessment.
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So we don't know if it's really true that individuals with a pure ADD often have these coexisting features.
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Because what makes a lot of sense is that within the ADD population,
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there's some subset of it autistic individuals who say I have ADD and I notice that I also have trouble reading social cues.
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Well,
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the difficulty reading social cues then becomes a
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"common feature" associated with ADD.
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But we don't know,
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does this person have autism?
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Have they been assessed?
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And,
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and if so,
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if we get this group of just really pure ADD diagnoses and nothing else explains those features better,
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I would love to know what ... kind of... is associated with that.
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But at this point,
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00:32:14,939 --> 00:32:21,119
we really don't know. The research using people diagnosed with ADD...
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They don't go through any differential process.
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They just look and say,
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oh you have a diagnosis,
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let's put you in the ADD group and study you.
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So you see why this is a huge problem.
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It's a very messy group,
400
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a mixed group of people who have executive function problems from childhood.
401
00:32:45,310 --> 00:33:08,609
But it hasn't really been distinguished as to whether other contributors to executive function difficulty may have actually been there rather than just a pure developmental difficulty within these four categories or subtypes/subsets within that executive function definition.
402
00:33:10,469 --> 00:33:15,219
So that was a long meandering explanation,
403
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but really important.
404
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And I'm glad you followed me through those twists and turns.
405
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What do I want you to walk away with?
406
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Let me recap.
407
00:33:23,770 --> 00:33:24,270
Again.
408
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Executive function refers to a series of skills,
409
00:33:28,209 --> 00:33:32,189
not one skill that are linked anatomically,
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they hang together in the subcortical frontal systems of the brain and they work together to help us make a cohesive and meaningful product.
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ADD was added to the diagnostic manual in 1980 to describe developmental executive function differences.
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And that was really a good advancement at the time.
413
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Executive function is not specific to ADD and many,
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many things can trigger executive function difficulty.
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00:34:05,959 --> 00:34:09,209
So we would never want to hear...
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executive function difficulty ...and translate that automatically into ADD.
417
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This is where the differential diagnostic process should come in someone presenting with executive function difficulty.
418
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Then we would say,
419
00:34:27,589 --> 00:34:27,878
well,
420
00:34:27,888 --> 00:34:35,039
what conditions that could produce this kind of difficulty may present in the specific student,
421
00:34:35,049 --> 00:34:36,269
client, or patient?
422
00:34:36,519 --> 00:34:40,648
And what would be most likely do they have a medical condition?
423
00:34:40,849 --> 00:34:43,638
Has someone looked for an intellectual disability,
424
00:34:43,648 --> 00:34:45,358
auditory processing problems,
425
00:34:45,368 --> 00:34:46,519
learning disability,
426
00:34:47,399 --> 00:34:47,739
you know,
427
00:34:47,750 --> 00:34:57,810
perhaps an older individual presents with concerns that they have ADD and yet they have some medical issues,
428
00:34:57,820 --> 00:34:58,850
normal aging,
429
00:34:58,860 --> 00:34:59,860
some trauma.
430
00:35:00,270 --> 00:35:02,590
So what has the differential been,
431
00:35:02,820 --> 00:35:04,909
has there been a differential?
432
00:35:06,429 --> 00:35:10,280
What often happens instead is that especially during childhood,
433
00:35:10,290 --> 00:35:12,189
adolescence and young adulthood,
434
00:35:12,340 --> 00:35:26,300
someone presents with executive function difficulty and they're given a diagnosis of ADD without ruling out autism or other possible contributors to the inattention and other features.
435
00:35:27,939 --> 00:35:56,770
This leads to personal stories and articles and research studies about common features in ADD that are actually describing features in this huge mix of individuals with a variety of factors impacting their executive function rather than a research study with a group of people who have features specific to our definition of ADD and do not have other diagnostic conditions like autism.
436
00:35:58,129 --> 00:35:58,739
To me,
437
00:35:58,750 --> 00:36:03,409
it rarely makes sense to describe both ADD and autism.
438
00:36:03,649 --> 00:36:13,639
Usually the ADD diagnosis is describing these four subs skills of executive function when actually there are more like 12 to 15.
439
00:36:14,030 --> 00:36:22,580
And they're describing it in autism where executive function difficulty is always present in some form.
440
00:36:24,379 --> 00:36:40,040
And the diagnostic manual says that ADD should only be diagnosed when it's the diagnosis that explains the features the best you don't diagnose it just because the criteria are met,
441
00:36:40,300 --> 00:36:46,689
you diagnose it if the criteria are met and other things are not better explanations.
442
00:36:47,669 --> 00:36:56,580
I rarely see executive function difficulties in clients that extend beyond what I would expect for the autism profile.
443
00:36:56,800 --> 00:36:59,919
I have seen it certainly and I have diagnosed it.
444
00:37:00,179 --> 00:37:01,739
But by definition,
445
00:37:01,750 --> 00:37:04,139
if it's more than you'd expect,
446
00:37:04,149 --> 00:37:04,459
it's,
447
00:37:04,469 --> 00:37:07,500
it's not going to be common. To me,
448
00:37:07,510 --> 00:37:08,979
it makes sense to talk about
449
00:37:08,989 --> 00:37:18,189
executive function as including a series of sub abilities of which we can look at patterns of strengths and weaknesses in everyone,
450
00:37:18,459 --> 00:37:20,260
including those on the spectrum.
451
00:37:20,879 --> 00:37:22,129
But for now,
452
00:37:22,250 --> 00:37:37,090
we have this tiny subset of executive function characteristics in the DSM five called ADD that I would suggest should be expanded to reflect all of the executive function characteristics with,
453
00:37:37,100 --> 00:37:39,770
with specifiers like developmental.
454
00:37:40,610 --> 00:37:42,959
Thank you for listening to the recap.
455
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Thank you for going on this pathway of information with me today about executive function,
456
00:37:48,909 --> 00:37:50,540
ADD, and autism.
457
00:37:50,800 --> 00:37:51,919
In future episodes,
458
00:37:51,929 --> 00:37:57,370
we will break down some of the subsets of executive function and talk more about those.
459
00:37:58,219 --> 00:38:07,370
My favorite book series on Executive Function is The Smart But Scattered series which I will link in the show notes.
460
00:38:07,979 --> 00:38:09,439
Now there are many,
461
00:38:09,449 --> 00:38:16,669
many good books and resources on executive function and I certainly have not read or reviewed them all.
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You are encouraged to use the resources that best meet your needs.
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00:38:20,979 --> 00:38:23,530
So look for the link for the smart but scattered.
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00:38:23,540 --> 00:38:26,449
If you don't already have a series that meets your need,
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I do want to say that I don't get any financial compensation for recommending any of the resources that I list for you in my podcast episodes.
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00:38:34,939 --> 00:38:39,370
These are just recommendations from things that have helped me in the past.
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I hope you have a great few weeks, and I look forward to you joining me for our next episode on Executive Function.
View all episodes
By Theresa M Regan, Ph.D.
4.9
9595 ratings
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:
1
00:00:07,670 --> 00:00:08,560
Hi there.
2
00:00:08,569 --> 00:00:13,960
This is Doctor Regan joining you for an episode of Autism in the Adult podcast.
3
00:00:14,850 --> 00:00:16,670
I'm a neuropsychologist,
4
00:00:16,680 --> 00:00:24,350
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.
254
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Everyone on the autism spectrum will have executive function difficulty in some form or pattern.
255
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That's because of the neurology of autism.
256
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The term executive function is not specifically used in the autism criteria,
257
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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.
258
00:20:11,849 --> 00:20:21,040
So autism has this executive function component plus many nonexecutive function elements as well.
259
00:20:22,930 --> 00:20:28,709
So ADD is a diagnosis of four or so elements of executive function.
260
00:20:29,219 --> 00:20:37,819
Autism is a diagnosis that includes elements of executive function and elements outside of executive function.
261
00:20:39,469 --> 00:20:52,160
The diagnostic manual indicates that the diagnosis of ADD cannot be made if another diagnosis better accounts for the client's whole presentation.
262
00:20:54,359 --> 00:21:15,699
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.
263
00:21:19,569 --> 00:21:21,280
So let's regroup.
264
00:21:21,969 --> 00:21:23,310
Executive function,
265
00:21:23,319 --> 00:21:28,189
difficulties occur secondary to so many developmental,
266
00:21:28,199 --> 00:21:30,339
physical and psychological states.
267
00:21:30,859 --> 00:21:39,660
And ADD and autism are two developmental diagnoses that include executive function difficulty.
268
00:21:40,829 --> 00:21:49,989
ADD includes about four elements of the 12 to 15 sub elements of executive function that we generally think of.
269
00:21:50,359 --> 00:22:02,369
And autism includes some pattern of executive function difficulty across elements and also has nonexecutive function
270
00:22:02,680 --> 00:22:04,239
parts to the criteria.
271
00:22:06,560 --> 00:22:18,890
what should happen is that an individual presenting with developmental executive function difficulty would see a clinician who develops an appropriate differential,
272
00:22:19,770 --> 00:22:24,810
that is the person has developmental executive function difficulty,
273
00:22:24,839 --> 00:22:27,569
but that's not specific to ADD.
274
00:22:27,579 --> 00:22:33,810
So let's consider other developmental conditions like autism.
275
00:22:33,819 --> 00:22:40,819
And also let's consider other relevant information like the trauma history,
276
00:22:40,829 --> 00:22:42,640
medical conditions,
277
00:22:42,670 --> 00:22:44,229
intellectual abilities,
278
00:22:44,239 --> 00:22:45,839
learning disabilities,
279
00:22:45,849 --> 00:22:47,810
language processing ability.
280
00:22:48,040 --> 00:22:53,819
And let's figure out what the basis of this executive function problem is.
281
00:22:56,089 --> 00:23:02,239
But what actually happens is that a teacher, doctor, or clinician says,
282
00:23:02,359 --> 00:23:02,979
oh,
283
00:23:02,989 --> 00:23:06,750
this person has developmental executive function difficulty.
284
00:23:07,010 --> 00:23:07,900
Therefore,
285
00:23:07,910 --> 00:23:10,280
we're going to diagnose them with ADD.
286
00:23:11,709 --> 00:23:13,319
Then years later,
287
00:23:13,569 --> 00:23:17,390
they come to see a professional who does an evaluation and says,
288
00:23:17,400 --> 00:23:18,050
well,
289
00:23:18,469 --> 00:23:21,589
this person does have executive function problems,
290
00:23:21,599 --> 00:23:32,270
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.
291
00:23:32,280 --> 00:23:33,239
And so of course,
292
00:23:33,250 --> 00:23:42,689
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.
293
00:23:44,040 --> 00:23:52,050
Some of these individuals have executive function difficulty because they've been on the autism spectrum all along.
294
00:23:52,060 --> 00:23:56,359
But autism was never included in the differential process.
295
00:23:56,890 --> 00:24:00,250
So they've never been assessed for autism.
296
00:24:01,310 --> 00:24:11,819
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.
297
00:24:12,660 --> 00:24:12,880
Now,
298
00:24:12,890 --> 00:24:18,630
not everyone with fatigue is best served by a diagnosis of chronic fatigue syndrome.
299
00:24:18,829 --> 00:24:40,849
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.
300
00:24:42,290 --> 00:24:51,180
So even if the individual meets all the criteria for difficulty in those four subs skills,
301
00:24:52,859 --> 00:25:04,869
the diagnosis is not made if this executive function difficulty is better explained by autism or intellectual disability or learning disability,
302
00:25:04,880 --> 00:25:05,550
et cetera.
303
00:25:05,630 --> 00:25:11,089
So the question in the case of ADD diagnosis shouldn't just be,
304
00:25:11,099 --> 00:25:15,319
are the criteria met ... but are the criteria met
305
00:25:15,329 --> 00:25:29,270
and is this the diagnosis that best explains the whole presentation for this student or client or patient? In autism,
306
00:25:29,280 --> 00:25:41,550
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.
307
00:25:42,910 --> 00:25:44,500
They still have autism,
308
00:25:44,619 --> 00:25:48,989
they still have executive function difficulty as we would expect.
309
00:25:49,260 --> 00:25:54,510
But perhaps they're less likely to have a pairing of an ADD diagnosis.
310
00:25:56,579 --> 00:26:06,150
Another person on the autism spectrum may have all four of those difficulties in the ADD category and maybe a couple that aren't.
311
00:26:06,500 --> 00:26:12,170
And so they get these two diagnoses autism and ADD.
312
00:26:14,069 --> 00:26:14,900
However,
313
00:26:14,910 --> 00:26:22,260
if the executive function difficulty is not excessive for what we expect to see in autism,
314
00:26:22,640 --> 00:26:24,650
they shouldn't have that diagnosis.
315
00:26:24,660 --> 00:26:25,869
That second one,
316
00:26:26,209 --> 00:26:27,239
it's redundant.
317
00:26:27,250 --> 00:26:28,500
It's repetitive.
318
00:26:29,599 --> 00:26:37,270
So then do we take away the ADD diagnosis once someone has a diagnosis of autism?
319
00:26:37,640 --> 00:26:39,449
And it's not excessive?
320
00:26:39,760 --> 00:26:40,099
Well,
321
00:26:40,109 --> 00:26:40,989
we could,
322
00:26:41,130 --> 00:26:42,829
if we wanted to be precise,
323
00:26:42,839 --> 00:26:47,369
This is really what the manual talks about as making the most sense.
324
00:26:48,699 --> 00:26:49,250
However,
325
00:26:49,260 --> 00:26:50,390
practically speaking,
326
00:26:50,400 --> 00:26:51,790
this gets difficult.
327
00:26:51,800 --> 00:27:02,290
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.
328
00:27:03,219 --> 00:27:04,930
And many times after I see a
329
00:27:04,939 --> 00:27:07,349
a client for an autism evaluation,
330
00:27:07,359 --> 00:27:11,079
I'll tell them their diagnosis is autism spectrum disorder.
331
00:27:11,239 --> 00:27:12,719
And then they will ask,
332
00:27:12,729 --> 00:27:15,910
did you also check for ADD I think I have that too.
333
00:27:16,800 --> 00:27:21,949
And so it's a difficult thing to just answer with a couple sentences as you can see.
334
00:27:22,489 --> 00:27:25,150
Do they have executive function difficulty?
335
00:27:25,160 --> 00:27:26,359
Absolutely.
336
00:27:26,719 --> 00:27:36,709
Do they have executive function difficulty that fits into that four subset category that we have as our diagnosis for ADD? Possibly
337
00:27:36,719 --> 00:27:37,790
yes or possibly no.
338
00:27:37,800 --> 00:27:48,400
Depending on the case. And does the executive function difficulty exceed what is generally seen in autism? Really infrequently.
339
00:27:48,410 --> 00:27:49,260
Honestly,
340
00:27:49,670 --> 00:27:52,079
I have made both diagnoses,
341
00:27:52,089 --> 00:28:00,579
but I don't frequently see the executive function as really standing out higher than you know...
342
00:28:00,589 --> 00:28:02,369
the group of people that I see.
343
00:28:03,780 --> 00:28:04,890
So conceptually,
344
00:28:04,900 --> 00:28:05,640
to me,
345
00:28:05,959 --> 00:28:11,540
it makes no actual sense to talk about autism with and without ADD.
346
00:28:11,979 --> 00:28:12,589
In fact,
347
00:28:12,599 --> 00:28:13,339
at this stage,
348
00:28:13,349 --> 00:28:15,630
in our understanding of the nervous system,
349
00:28:15,949 --> 00:28:27,680
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.
350
00:28:29,040 --> 00:28:36,209
I would propose that it would make more sense to just have a diagnosis that says executive function disorder.
351
00:28:37,050 --> 00:28:45,969
And then you could say comma developmental or comma acquired or perhaps you could list the pattern ... like for this person,
352
00:28:45,979 --> 00:28:48,920
these are the strengths and these are the difficulties.
353
00:28:49,760 --> 00:29:00,569
It would be nice to increase the understanding that saying the diagnosis of autism automatically communicates that there are executive function difficulties present.
354
00:29:02,079 --> 00:29:04,569
That's not really our reality right now though.
355
00:29:05,920 --> 00:29:11,339
So even though that makes the most sense to me as a neuropsychologist,
356
00:29:12,650 --> 00:29:22,829
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,
357
00:29:23,229 --> 00:29:26,390
the individual can't get their attention medication,
358
00:29:26,719 --> 00:29:32,670
even if it has helped their executive function difficulty within the autism spectrum.
359
00:29:33,890 --> 00:29:34,699
Now,
360
00:29:34,709 --> 00:29:41,439
the medication is often not as effective on the spectrum as off the spectrum.
361
00:29:41,619 --> 00:29:44,380
But if someone has been helped by it,
362
00:29:44,500 --> 00:29:47,099
there's no reason to take it away because,
363
00:29:47,390 --> 00:29:47,619
you know,
364
00:29:47,630 --> 00:29:50,670
just because that ADD doesn't entirely fit.
365
00:29:51,239 --> 00:29:54,130
So practically speaking,
366
00:29:54,569 --> 00:30:01,030
they're gonna end up keeping that diagnosis because they understand what it means
367
00:30:01,310 --> 00:30:04,770
snd they don't understand what not having it means.
368
00:30:04,979 --> 00:30:11,170
And also they need medication or benefit from medication that requires that diagnosis.
369
00:30:12,540 --> 00:30:17,469
The other thing that's really a caution that I'd like you to think about...
370
00:30:20,109 --> 00:30:33,630
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...
371
00:30:33,640 --> 00:30:34,609
You know,
372
00:30:34,619 --> 00:30:35,489
people will say,
373
00:30:35,500 --> 00:30:35,930
well,
374
00:30:35,939 --> 00:30:38,969
you know what's really common for people with ADD,
375
00:30:39,140 --> 00:30:49,670
it's common that they become hyper focussed or it's common that they have difficulty with social interactions or it's common that they have sensory processing difficulties.
376
00:30:51,680 --> 00:30:52,030
The
377
00:30:52,040 --> 00:31:07,280
the problem with these statements is that the individuals who have received diagnoses of ADD often receive this just because they've had executive function difficulty,
378
00:31:07,900 --> 00:31:11,900
but they haven't had much if any differential assessment.
379
00:31:13,010 --> 00:31:25,439
So we don't know if it's really true that individuals with a pure ADD often have these coexisting features.
380
00:31:26,739 --> 00:31:33,219
Because what makes a lot of sense is that within the ADD population,
381
00:31:33,229 --> 00:31:42,439
there's some subset of it autistic individuals who say I have ADD and I notice that I also have trouble reading social cues.
382
00:31:43,380 --> 00:31:44,109
Well,
383
00:31:44,219 --> 00:31:47,780
the difficulty reading social cues then becomes a
384
00:31:47,790 --> 00:31:51,130
"common feature" associated with ADD.
385
00:31:51,140 --> 00:31:53,239
But we don't know,
386
00:31:53,780 --> 00:31:55,880
does this person have autism?
387
00:31:55,890 --> 00:31:57,150
Have they been assessed?
388
00:31:57,160 --> 00:31:57,520
And,
389
00:31:57,869 --> 00:31:58,770
and if so,
390
00:31:58,780 --> 00:32:08,359
if we get this group of just really pure ADD diagnoses and nothing else explains those features better,
391
00:32:08,650 --> 00:32:12,369
I would love to know what ... kind of... is associated with that.
392
00:32:13,420 --> 00:32:14,670
But at this point,
393
00:32:14,939 --> 00:32:21,119
we really don't know. The research using people diagnosed with ADD...
394
00:32:21,520 --> 00:32:24,770
They don't go through any differential process.
395
00:32:24,780 --> 00:32:25,969
They just look and say,
396
00:32:25,979 --> 00:32:27,739
oh you have a diagnosis,
397
00:32:27,750 --> 00:32:30,670
let's put you in the ADD group and study you.
398
00:32:31,280 --> 00:32:33,890
So you see why this is a huge problem.
399
00:32:34,050 --> 00:32:36,270
It's a very messy group,
400
00:32:36,280 --> 00:32:43,810
a mixed group of people who have executive function problems from childhood.
401
00:32:45,310 --> 00:33:08,609
But it hasn't really been distinguished as to whether other contributors to executive function difficulty may have actually been there rather than just a pure developmental difficulty within these four categories or subtypes/subsets within that executive function definition.
402
00:33:10,469 --> 00:33:15,219
So that was a long meandering explanation,
403
00:33:15,229 --> 00:33:16,660
but really important.
404
00:33:16,670 --> 00:33:19,959
And I'm glad you followed me through those twists and turns.
405
00:33:20,719 --> 00:33:22,780
What do I want you to walk away with?
406
00:33:22,790 --> 00:33:23,760
Let me recap.
407
00:33:23,770 --> 00:33:24,270
Again.
408
00:33:24,750 --> 00:33:28,199
Executive function refers to a series of skills,
409
00:33:28,209 --> 00:33:32,189
not one skill that are linked anatomically,
410
00:33:32,199 --> 00:33:41,599
they hang together in the subcortical frontal systems of the brain and they work together to help us make a cohesive and meaningful product.
411
00:33:42,540 --> 00:33:51,050
ADD was added to the diagnostic manual in 1980 to describe developmental executive function differences.
412
00:33:51,060 --> 00:33:54,630
And that was really a good advancement at the time.
413
00:33:56,219 --> 00:34:01,199
Executive function is not specific to ADD and many,
414
00:34:01,209 --> 00:34:05,250
many things can trigger executive function difficulty.
415
00:34:05,959 --> 00:34:09,209
So we would never want to hear...
416
00:34:09,219 --> 00:34:15,669
executive function difficulty ...and translate that automatically into ADD.
417
00:34:17,688 --> 00:34:25,579
This is where the differential diagnostic process should come in someone presenting with executive function difficulty.
418
00:34:26,089 --> 00:34:27,579
Then we would say,
419
00:34:27,589 --> 00:34:27,878
well,
420
00:34:27,888 --> 00:34:35,039
what conditions that could produce this kind of difficulty may present in the specific student,
421
00:34:35,049 --> 00:34:36,269
client, or patient?
422
00:34:36,519 --> 00:34:40,648
And what would be most likely do they have a medical condition?
423
00:34:40,849 --> 00:34:43,638
Has someone looked for an intellectual disability,
424
00:34:43,648 --> 00:34:45,358
auditory processing problems,
425
00:34:45,368 --> 00:34:46,519
learning disability,
426
00:34:47,399 --> 00:34:47,739
you know,
427
00:34:47,750 --> 00:34:57,810
perhaps an older individual presents with concerns that they have ADD and yet they have some medical issues,
428
00:34:57,820 --> 00:34:58,850
normal aging,
429
00:34:58,860 --> 00:34:59,860
some trauma.
430
00:35:00,270 --> 00:35:02,590
So what has the differential been,
431
00:35:02,820 --> 00:35:04,909
has there been a differential?
432
00:35:06,429 --> 00:35:10,280
What often happens instead is that especially during childhood,
433
00:35:10,290 --> 00:35:12,189
adolescence and young adulthood,
434
00:35:12,340 --> 00:35:26,300
someone presents with executive function difficulty and they're given a diagnosis of ADD without ruling out autism or other possible contributors to the inattention and other features.
435
00:35:27,939 --> 00:35:56,770
This leads to personal stories and articles and research studies about common features in ADD that are actually describing features in this huge mix of individuals with a variety of factors impacting their executive function rather than a research study with a group of people who have features specific to our definition of ADD and do not have other diagnostic conditions like autism.
436
00:35:58,129 --> 00:35:58,739
To me,
437
00:35:58,750 --> 00:36:03,409
it rarely makes sense to describe both ADD and autism.
438
00:36:03,649 --> 00:36:13,639
Usually the ADD diagnosis is describing these four subs skills of executive function when actually there are more like 12 to 15.
439
00:36:14,030 --> 00:36:22,580
And they're describing it in autism where executive function difficulty is always present in some form.
440
00:36:24,379 --> 00:36:40,040
And the diagnostic manual says that ADD should only be diagnosed when it's the diagnosis that explains the features the best you don't diagnose it just because the criteria are met,
441
00:36:40,300 --> 00:36:46,689
you diagnose it if the criteria are met and other things are not better explanations.
442
00:36:47,669 --> 00:36:56,580
I rarely see executive function difficulties in clients that extend beyond what I would expect for the autism profile.
443
00:36:56,800 --> 00:36:59,919
I have seen it certainly and I have diagnosed it.
444
00:37:00,179 --> 00:37:01,739
But by definition,
445
00:37:01,750 --> 00:37:04,139
if it's more than you'd expect,
446
00:37:04,149 --> 00:37:04,459
it's,
447
00:37:04,469 --> 00:37:07,500
it's not going to be common. To me,
448
00:37:07,510 --> 00:37:08,979
it makes sense to talk about
449
00:37:08,989 --> 00:37:18,189
executive function as including a series of sub abilities of which we can look at patterns of strengths and weaknesses in everyone,
450
00:37:18,459 --> 00:37:20,260
including those on the spectrum.
451
00:37:20,879 --> 00:37:22,129
But for now,
452
00:37:22,250 --> 00:37:37,090
we have this tiny subset of executive function characteristics in the DSM five called ADD that I would suggest should be expanded to reflect all of the executive function characteristics with,
453
00:37:37,100 --> 00:37:39,770
with specifiers like developmental.
454
00:37:40,610 --> 00:37:42,959
Thank you for listening to the recap.
455
00:37:42,969 --> 00:37:48,899
Thank you for going on this pathway of information with me today about executive function,
456
00:37:48,909 --> 00:37:50,540
ADD, and autism.
457
00:37:50,800 --> 00:37:51,919
In future episodes,
458
00:37:51,929 --> 00:37:57,370
we will break down some of the subsets of executive function and talk more about those.
459
00:37:58,219 --> 00:38:07,370
My favorite book series on Executive Function is The Smart But Scattered series which I will link in the show notes.
460
00:38:07,979 --> 00:38:09,439
Now there are many,
461
00:38:09,449 --> 00:38:16,669
many good books and resources on executive function and I certainly have not read or reviewed them all.
462
00:38:16,909 --> 00:38:20,729
You are encouraged to use the resources that best meet your needs.
463
00:38:20,979 --> 00:38:23,530
So look for the link for the smart but scattered.
464
00:38:23,540 --> 00:38:26,449
If you don't already have a series that meets your need,
465
00:38:26,889 --> 00:38:34,830
I do want to say that I don't get any financial compensation for recommending any of the resources that I list for you in my podcast episodes.
466
00:38:34,939 --> 00:38:39,370
These are just recommendations from things that have helped me in the past.
467
00:38:39,379 --> 00:38:47,659
I hope you have a great few weeks, and I look forward to you joining me for our next episode on Executive Function.
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