Despite being common, Attention-Deficit/Hyperactivity Disorder (ADHD) is misrepresented as a focus disorder. While problems with attention are a big aspect of ADHD, it is much more complex. One must understand the underlying mechanics to understand how and why the symptoms manifest.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is the most recent version of the guide that professionals use to diagnose mental disorders. In the DSM-V, there were three types of ADHD: inattentive, hyperactive-impulsive, and combined. For the inattentive and hyperactive-impulsive, there need to be six (or five, if the person is over 17) symptoms to be present in order to meet the criteria. For combined type, both need to be met. For the inattentive type, symptoms include, “often has difficulty sustaining attention in tasks” or “often fails to give close attention to details or makes careless mistakes.” The symptoms of the hyper-impulsive type are characterized by feelings and behavior such as acting as if “driven by a motor” or “often has trouble waiting his/her turn.” These symptoms must be developmentally inappropriate and not explained by other disorders or lifestyles.
While the DSM-V is a guideline for a diagnosis, it doesn’t describe the inner workings of ADHD. There is a problem of underdiagnosis, especially in women and/or people who have inattentive-type ADHD. A deeper understanding of ADHD will also benefit patients who would have it because they will understand why their brain works a certain way, rather than just the fact that it does.
Two models of executive functions (EF) from highly respected researchers and speakers, Dr. Russel Barkley and Dr. Thomas Brown, are among the most digestible and efficient frameworks. Barkley presents seven EF: “inhibition, resistance to distraction, self-awareness, working memory, emotional self-control, and even self-motivation.” And Brown (2013) lists six. First, activation: “organizing, prioritizing, and activating to work.” Focus: “focusing, sustaining, and shifting attention to tasks.” Effort: “regulating alertness, sustaining effort, and processing speed.” Emotion: “Managing frustration and modulating emotions.” Memory: “utilizing working memory and accessing recall.” Action: “monitoring and self-regulating action.” Evidently, there are many similarities. The theory is that executive function deficits (EFD) are the root cause of ADHD. For example, “deficits in working memory can result in being easily forgetful and making careless mistakes” (Silverstein et al., 2020). The real beauty of the EF model is that they explain the day-to-day struggles that exist beyond the DSM-V. For example, in Brown’s book Smart but Stuck, his patient, Karen, struggles with reading assignments (2013). She would often become overwhelmed because she would have to re-read text multiple times, causing her to spend more time doing homework than her peers. Brown said that, like Karen, many people with ADHD have the capability to understand the text, but the inability “to hold focus, to sustain processing speed, and to use working memory” prevents them from comprehending the material.
Recognizing EFD can improve diagnosis rates. There is a strong correlation between ADHD severity and EFD (Silverstein et al). The EF describes the causes behind the symptoms, making it easier to recognize different presentations of symptoms. The DSM-V was modeled after the behavior of children with ADHD. While there have been adjustments, frankly, adults present differently (Nigg et al., 2005). Brown has published his own book, Smart but Stuck, describing several examples of adult ADHD, while using the EF model to examine the effects of ADHD in his patients. As mentioned earlier, Karen was failing out of college despite being a strong student in high school. In a less structured environment, her ADHD symptoms were unmanageable until she was able to seek treatment with someone who understood the cause of her problems.
Recognizing EFD can also improve the effectiveness of treatment. There are many medications for ADHD, both stimulant and nonstimulant, however, learning skills to manage the EFD is just as important. Medication can lower the barrier to start building these skills. Without a deeper understanding, patients and parents can easily assume that stimulants are a magic fix. EFDs are less responsive to treatment, so there can only be partial improvement by solely addressing DSM-V symptoms (Silverstein et al).
The DSM-V symptoms were based on male children, which is a difficult framework to adequately represent ADHD in adults, especially women. As more and more research comes out to further support the connection between ADHD and EFD, medical professionals, their patients, and anyone who is undiagnosed will benefit from a more inclusive definition of ADHD and a treatment plan that recognizes EFD. Self-advocating is a difficult but necessary part of medical care. Understanding the EFD will help people with ADHD recognize ways they are struggling outside of hyperactivity or focus and relay that information to a primary doctor, therapist, or psychiatrist.
References:
Barkley, Russell A. “The Important Role of Executive Functioning and Self-Regulation in ADHD.”
Https://www.russellbarkley.org/, Russell A. Barkley, Ph.D., LLC., 2011,
https://www.russellbarkley.org/factsheets/ADHD_EF_and_SR.pdf.
Brown, Thomas E. Smart But Stuck: Emotions in Teens and Adults with ADHD. Wiley, 2014.
Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed., American Psychiatric
Association, 2013.
Scheres, A. P. .., and M. .. Solanto. “Do ADHD Symptoms, Executive Function, and Study
Strategies Predict Temporal Reward Discounting in College Students with Varying Levels of ADHD Symptoms? A Pilot Study.” Brain Sciences, vol. 11, no. 2, 2021, p. 181–, https://doi.org/10.3390/brainsci11020181.
Silverstein, Michael J., et al. “The Relationship Between Executive Function Deficits and
DSM-5-Defined ADHD Symptoms.” Journal of Attention Disorders, vol. 24, no. 1, 2020, pp. 41–51, https://doi.org/10.1177/1087054718804347.
Nigg, Joel T., et al. “Executive Functions and Adhd in Adults: Evidence for Selective Effects on
ADHD Symptom Domains.” Journal of Abnormal Psychology, vol. 114, no. 4, Nov. 2005, pp. 706–17. EBSCOhost, https://doi-org.proxy.wexler.hunter.cuny.edu/10.1037/0021-843X.114.3.706.