The Multiple Components of Executive Function

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.

5
00:00:25,180 --> 00:00:25,899
Today,

6
00:00:25,909 --> 00:00:31,610
you are joining me for the first episode in a new series about executive function.

7
00:00:31,989 --> 00:00:36,509
And I'm really excited for the series since announcing the topic.

8
00:00:36,520 --> 00:00:38,509
At the end of our last episode,

9
00:00:38,520 --> 00:00:45,709
I've received lots of emails from interested listeners before we dive into today's episode.

10
00:00:45,720 --> 00:00:45,990
Though,

11
00:00:46,000 --> 00:00:50,490
I wanna give a shout out to the clinicians and professionals who may be listening.

12
00:00:50,799 --> 00:01:00,610
I'm currently developing a master class with the continuing education platform called Zur Institute.

13
00:01:01,020 --> 00:01:04,010
This offering is unique for several reasons.

14
00:01:04,019 --> 00:01:05,449
One is the format,

15
00:01:06,050 --> 00:01:09,550
there will be four 2-hour webinars,

16
00:01:09,559 --> 00:01:11,949
one in each of September,

17
00:01:12,209 --> 00:01:13,099
October,

18
00:01:13,110 --> 00:01:16,180
November and December of 2023.

19
00:01:16,809 --> 00:01:23,629
And the first hour will be education while the second full hour will be reserved for discussion,

20
00:01:23,639 --> 00:01:32,519
question and answer and interaction with you about clinical questions and practice issues related to the topic for that day.

21
00:01:32,889 --> 00:01:44,419
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.

22
00:01:45,330 --> 00:01:49,569
If you are a clinician wanting beginner or intermediate courses,

23
00:01:49,599 --> 00:01:54,440
check out my other offerings on Zur or at my website,

24
00:01:54,449 --> 00:01:57,819
which is also linked through the show notes.

25
00:01:58,440 --> 00:01:59,040
All right,

26
00:01:59,050 --> 00:02:01,580
let's talk about executive function.

27
00:02:02,449 --> 00:02:07,800
I'll warn you that today's episode will require some executive function to get through.

28
00:02:08,350 --> 00:02:14,740
And I've spent a lot of time trying to make sure that I'm linking all of the themes together.

29
00:02:15,179 --> 00:02:16,649
So with that in mind,

30
00:02:16,800 --> 00:02:22,440
I want to start off with just a general definition of executive function.

31
00:02:24,440 --> 00:02:26,500
Later in our talks,

32
00:02:26,509 --> 00:02:34,229
we will cover a more precise and descriptive definition including sub elements and what we might call those.

33
00:02:35,020 --> 00:02:45,990
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.

34
00:02:46,679 --> 00:02:48,710
And the reason for the name,

35
00:02:48,720 --> 00:02:59,850
executive functioning is that executive is defined as having the power to put plans and actions into effect.

36
00:03:00,860 --> 00:03:04,710
So a CEO for example,

37
00:03:05,240 --> 00:03:14,669
is the chief executive officer of a business company and is in charge of directing the tiers of the company,

38
00:03:14,679 --> 00:03:16,250
the regional officers,

39
00:03:16,259 --> 00:03:17,059
managers,

40
00:03:17,070 --> 00:03:18,270
direct workers,

41
00:03:18,490 --> 00:03:24,440
directing all the pieces to work together toward the same goal.

42
00:03:24,970 --> 00:03:33,339
So these pathways of the brain help the parts of the brain work together to achieve a goal.

43
00:03:34,259 --> 00:03:38,360
Another image that I like is the symphony conductor,

44
00:03:38,899 --> 00:03:42,190
directing all the instruments in the orchestra,

45
00:03:42,199 --> 00:03:46,130
even if all the instruments are performing perfectly,

46
00:03:46,240 --> 00:03:48,300
if there's no conductor,

47
00:03:48,679 --> 00:03:56,179
there's no unified sound with melody and movement and this synchrony of sound.

48
00:03:56,399 --> 00:04:04,309
So the sounds don't come together to create a moving and meaningful piece of music without the conductor.

49
00:04:05,039 --> 00:04:09,100
So executive function is like the symphony conductor,

50
00:04:09,490 --> 00:04:14,199
it should bring all of the working parts of the brain together to perform.

51
00:04:14,210 --> 00:04:17,049
So that something meaningful happens.

52
00:04:18,998 --> 00:04:19,688
As I said,

53
00:04:19,699 --> 00:04:22,848
executive function is a set of brain skills,

54
00:04:22,859 --> 00:04:24,408
it's not one skill.

55
00:04:25,160 --> 00:04:29,929
And as we understand what the center of the brain,

56
00:04:30,109 --> 00:04:37,130
the subcortical areas of the brain and the connections through the center with the front of the brain,

57
00:04:37,140 --> 00:04:38,350
the frontal lobes.

58
00:04:38,809 --> 00:04:42,209
When we understand what these areas are in charge of,

59
00:04:42,220 --> 00:04:46,820
we refer to those set of abilities as executive function.

60
00:04:46,829 --> 00:04:53,149
So these executive function abilities hang together anatomically in the brain.

61
00:04:53,540 --> 00:04:56,640
So through that subcortical frontal system,

62
00:04:57,339 --> 00:05:04,059
so the number one point is that executive function refers to a series of skills,

63
00:05:04,070 --> 00:05:05,519
not one skill.

64
00:05:05,850 --> 00:05:10,190
And these skills are linked with anatomy,

65
00:05:10,200 --> 00:05:13,290
with the subcortical frontal systems of the brain.

66
00:05:13,609 --> 00:05:21,279
And the skills help the brain produce a meaningful synchronous um behavior or,

67
00:05:21,290 --> 00:05:22,489
or product.

68
00:05:24,070 --> 00:05:24,470
Now,

69
00:05:24,480 --> 00:05:32,950
let's talk about the diagnosis of AD D and A DH D and just for simplicity's sake,

70
00:05:32,959 --> 00:05:33,920
from now on,

71
00:05:33,929 --> 00:05:39,920
I'll really just refer to these as AD D but I'm referring to both diagnoses.

72
00:05:41,269 --> 00:05:45,839
This diagnosis was introduced in the diagnostic manual,

73
00:05:45,850 --> 00:05:57,970
the DSM - III in 1980 it was important because it described a developmental neurologic condition of executive function.

74
00:05:58,950 --> 00:06:02,820
So executive function was not a new concept,

75
00:06:02,989 --> 00:06:10,739
but the diagnosis of ADD was the one that captured this developmental piece.

76
00:06:11,190 --> 00:06:22,299
So here we have a diagnosis then that we can use to describe a difficulty that an individual has based on their developmental wiring.

77
00:06:22,309 --> 00:06:26,200
The way that the brain system has developed,

78
00:06:26,239 --> 00:06:38,600
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.

79
00:06:38,980 --> 00:06:39,440
So,

80
00:06:39,450 --> 00:06:40,799
anatomically,

81
00:06:40,989 --> 00:06:45,730
executive function is still developing until about that age.

82
00:06:47,119 --> 00:07:02,500
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.

83
00:07:04,059 --> 00:07:05,190
Now,

84
00:07:05,399 --> 00:07:19,910
I want to talk about the relationship between executive function and AD D executive function is not specific to ADD or ADHD.

85
00:07:20,690 --> 00:07:23,239
So the difficulties in that domain,

86
00:07:23,540 --> 00:07:26,559
they're not specific to this diagnosis.

87
00:07:26,570 --> 00:07:36,290
We're discussing executive function is one of the most sensitive brain functions to any kind of stress,

88
00:07:36,299 --> 00:07:39,619
whether that is physical or psychological.

89
00:07:40,049 --> 00:07:45,429
One of the first things to show difficulty is going to be executive function.

90
00:07:47,630 --> 00:07:56,119
It's often the first thing to become difficult and the last thing to resolve or heal after some type of challenge.

91
00:07:57,390 --> 00:07:58,829
For example,

92
00:07:59,089 --> 00:08:02,600
if an 80 year old has a bladder infection.

93
00:08:02,609 --> 00:08:11,040
What's probably the most sensitive cognitive function that's going to be disrupted first ... executive function.

94
00:08:11,739 --> 00:08:25,959
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.

95
00:08:25,970 --> 00:08:26,299
Well,

96
00:08:26,309 --> 00:08:28,679
that would be executive function as well.

97
00:08:31,179 --> 00:08:39,059
So there may be developmental differences in executive function and that's what we discuss

98
00:08:39,070 --> 00:08:41,969
when we talk about the diagnosis of ADD,

99
00:08:43,000 --> 00:08:47,960
there can also be acquired differences in executive function.

100
00:08:48,409 --> 00:08:51,690
This would include differences after,

101
00:08:51,700 --> 00:08:52,450
as we said,

102
00:08:52,460 --> 00:08:53,869
a traumatic brain injury,

103
00:08:53,880 --> 00:08:58,830
a stroke, within the context of a dementia... acquired

104
00:08:58,840 --> 00:09:02,070
meaning that this is not developmental.

105
00:09:02,080 --> 00:09:06,469
It's something that has occurred in the course of the life span.

106
00:09:08,809 --> 00:09:10,039
Executive function,

107
00:09:10,049 --> 00:09:15,609
difficulties can occur with acute or chronic medical problems.

108
00:09:15,619 --> 00:09:19,820
So an acute medical issue would be like an infection.

109
00:09:19,830 --> 00:09:20,599
For example,

110
00:09:20,609 --> 00:09:23,340
this is something that comes and then it goes,

111
00:09:23,609 --> 00:09:24,500
it's acute,

112
00:09:24,510 --> 00:09:25,460
it's new,

113
00:09:25,619 --> 00:09:35,299
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.

114
00:09:35,330 --> 00:09:37,510
So someone with kidney failure,

115
00:09:37,520 --> 00:09:38,469
for example,

116
00:09:38,479 --> 00:09:40,090
who's on dialysis,

117
00:09:40,289 --> 00:09:45,484
what's the most likely thing they're going to have some difficulties with in the cognitive domain.

118
00:09:45,585 --> 00:09:45,955
Well,

119
00:09:45,965 --> 00:09:47,765
that would be executive function,

120
00:09:47,914 --> 00:09:52,255
someone with sugar fluctuations in the context of diabetes,

121
00:09:52,284 --> 00:09:56,525
someone with metabolic differences like their sodium is too low.

122
00:09:56,554 --> 00:10:02,385
These can also cause a disruption in someone's executive function system,

123
00:10:04,080 --> 00:10:10,169
even differences in the load that the person is carrying with regard to stress,

124
00:10:10,179 --> 00:10:11,530
emotional pain,

125
00:10:11,539 --> 00:10:12,330
trauma,

126
00:10:12,340 --> 00:10:13,679
lack of sleep,

127
00:10:13,710 --> 00:10:17,429
and even just having too much on our schedule.

128
00:10:17,780 --> 00:10:25,729
These examples of things don't change the anatomy of the brain and how the parts of the brain are working.

129
00:10:25,739 --> 00:10:32,450
But it really does interfere with our access to using our full capacity,

130
00:10:32,460 --> 00:10:37,109
our full anatomic, biologic capacity for executive function.

131
00:10:37,530 --> 00:10:37,880
So,

132
00:10:37,890 --> 00:10:39,359
if we've had trauma,

133
00:10:39,479 --> 00:10:39,830
you know,

134
00:10:39,840 --> 00:10:43,409
our brain may just go offline if we dissociate.

135
00:10:43,659 --> 00:10:50,400
And even though our anatomy is working well to produce this executive function,

136
00:10:50,750 --> 00:10:55,419
we may experience a psychological process that takes us offline.

137
00:10:56,520 --> 00:10:57,299
In addition,

138
00:10:57,309 --> 00:10:59,390
even with normal aging,

139
00:10:59,469 --> 00:11:02,750
what's the first thing to start to show difficulty?

140
00:11:02,830 --> 00:11:03,270
Yes,

141
00:11:03,280 --> 00:11:04,830
it's executive function.

142
00:11:05,200 --> 00:11:08,419
And if you are aging really well,

143
00:11:08,440 --> 00:11:08,900
you're,

144
00:11:08,909 --> 00:11:10,820
you're really aging nicely.

145
00:11:10,900 --> 00:11:13,380
You don't have any additional medical issues,

146
00:11:13,390 --> 00:11:14,719
you haven't had an injury.

147
00:11:15,059 --> 00:11:20,659
The first thing you're gonna start to notice is some problem in the area of executive function.

148
00:11:20,849 --> 00:11:26,770
That's just the aging process and how it impacts that subcortical frontal system.

149
00:11:27,210 --> 00:11:37,190
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

150
00:11:37,200 --> 00:11:38,549
but you can't get it out.

151
00:11:38,570 --> 00:11:40,049
That's executive function.

152
00:11:40,619 --> 00:11:45,500
You may have to think more slowly or take in less information at a time.

153
00:11:47,140 --> 00:11:53,719
So all individuals are likely to experience executive function difficulty in these contexts.

154
00:11:54,270 --> 00:11:56,609
So consider this comparison,

155
00:11:57,869 --> 00:12:01,799
executive function is similar to fatigue,

156
00:12:01,809 --> 00:12:02,739
for example,

157
00:12:02,750 --> 00:12:10,200
in that it's a nonspecific feature of many different kinds of conditions.

158
00:12:10,849 --> 00:12:12,820
So if someone has fatigue,

159
00:12:13,409 --> 00:12:18,700
there would be hundreds... thousands of conditions that could produce fatigue,

160
00:12:19,020 --> 00:12:22,039
anything from lack of sleep to infection,

161
00:12:22,109 --> 00:12:23,799
autoimmune conditions.

162
00:12:23,809 --> 00:12:25,440
And so many more things.

163
00:12:26,419 --> 00:12:27,340
Similarly,

164
00:12:27,349 --> 00:12:34,140
executive function difficulty can be caused by so so many conditions and situations,

165
00:12:34,150 --> 00:12:34,880
trauma,

166
00:12:34,890 --> 00:12:35,520
aging,

167
00:12:35,530 --> 00:12:36,320
ADD,

168
00:12:36,330 --> 00:12:37,780
autoimmune conditions,

169
00:12:37,789 --> 00:12:39,669
delirium, autism, and many,

170
00:12:39,679 --> 00:12:40,429
many more.

171
00:12:40,799 --> 00:12:49,750
So the third point we've really focused on here so far is that executive function is not specific to ADD.

172
00:12:50,080 --> 00:12:55,119
So many many things can trigger this executive function problem.

173
00:12:57,539 --> 00:12:58,150
Therefore,

174
00:12:58,159 --> 00:13:01,859
if someone presents with executive function difficulty --

175
00:13:02,200 --> 00:13:05,030
so I'm having a hard time paying attention,

176
00:13:05,039 --> 00:13:07,700
I just can't take in information very well.

177
00:13:07,729 --> 00:13:10,349
I can't organize myself well --

178
00:13:10,359 --> 00:13:20,570
the clinician should consider differentials in the diagnostic process because so many things can present with those features.

179
00:13:20,840 --> 00:13:24,369
There should be this process of taking into account.

180
00:13:24,630 --> 00:13:26,590
What is this person's age?

181
00:13:26,599 --> 00:13:28,750
What is their recent life experience?

182
00:13:28,760 --> 00:13:30,679
What are their medical issues?

183
00:13:30,690 --> 00:13:33,390
When did the executive function issue start?

184
00:13:34,210 --> 00:13:39,469
But executive function difficulty does not automatically mean ADD.

185
00:13:39,479 --> 00:13:41,549
It does not equal ADD,

186
00:13:41,559 --> 00:13:43,739
it's not equivalent to ADD.

187
00:13:45,469 --> 00:14:00,440
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.

188
00:14:01,289 --> 00:14:04,830
So let's go over our first three points.

189
00:14:05,109 --> 00:14:09,489
Executive function refers to a series of skills,

190
00:14:09,500 --> 00:14:16,190
not one skill and these skills are linked anatomically within the same pathways --

191
00:14:16,200 --> 00:14:27,729
these subcortical frontal system pathways -- and they also work together to provide some meaningful and organized output from the brain.

192
00:14:29,229 --> 00:14:47,950
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.

193
00:14:49,669 --> 00:15:00,539
The third point is that executive function is not specific to ADD -- many many things can trigger executive function difficulty.

194
00:15:01,239 --> 00:15:10,909
And so we would never want to hear executive function difficulty and then translate that automatically into ADD.

195
00:15:15,289 --> 00:15:20,659
So we talked about how executive function refers to a series of skills.

196
00:15:21,270 --> 00:15:28,479
There's not a unanimous consensus about what constitutes all these subparts,

197
00:15:28,489 --> 00:15:30,979
how to number them and what to call them.

198
00:15:31,090 --> 00:15:37,080
But many conceptualizations may refer to about 12 to 15 components.

199
00:15:37,090 --> 00:15:38,039
Give or take.

200
00:15:39,330 --> 00:15:44,460
These often include things like organization, sequencing,

201
00:15:44,469 --> 00:15:46,020
processing speed,

202
00:15:46,030 --> 00:15:48,260
prioritizing, planning,

203
00:15:48,270 --> 00:15:49,960
task initiation,

204
00:15:50,070 --> 00:15:52,130
sustained attention, goal

205
00:15:52,140 --> 00:15:53,510
directed persistence,

206
00:15:53,520 --> 00:15:54,859
impulse control,

207
00:15:54,869 --> 00:15:56,099
time management,

208
00:15:56,109 --> 00:15:57,640
generation of ideas,

209
00:15:57,650 --> 00:15:58,739
working memory,

210
00:15:58,750 --> 00:16:01,880
flexibility and emotional regulation.

211
00:16:03,119 --> 00:16:06,030
So it's not important for you to know what those mean.

212
00:16:06,250 --> 00:16:14,309
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.

213
00:16:14,320 --> 00:16:15,559
But for now,

214
00:16:15,570 --> 00:16:16,150
wow,

215
00:16:16,159 --> 00:16:19,669
executive function is a broad category.

216
00:16:22,250 --> 00:16:28,020
ADD, which as we said describes a condition of developmental

217
00:16:28,030 --> 00:16:36,700
executive function difficulty, includes four areas as I would describe them.

218
00:16:36,710 --> 00:16:38,880
So someone may say,

219
00:16:38,890 --> 00:16:38,909
oh,

220
00:16:38,919 --> 00:16:40,869
I think it's more like five.

221
00:16:40,940 --> 00:16:42,520
so it doesn't matter,

222
00:16:42,530 --> 00:16:44,270
but it's a small subset.

223
00:16:44,280 --> 00:16:45,679
We've got attention,

224
00:16:45,909 --> 00:16:47,119
organization,

225
00:16:47,130 --> 00:16:47,940
goal directed

226
00:16:47,950 --> 00:16:50,109
persistence, and impulse control.

227
00:16:51,869 --> 00:17:09,130
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.

228
00:17:10,900 --> 00:17:28,949
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.

229
00:17:29,290 --> 00:17:31,949
This person's individual difficulty...

230
00:17:33,109 --> 00:17:36,160
I also want you to know that every single person,

231
00:17:37,189 --> 00:17:40,119
regardless of developmental neurology,

232
00:17:40,130 --> 00:17:41,920
health background,

233
00:17:42,130 --> 00:17:46,449
all humans will have a pattern of executive function,

234
00:17:46,630 --> 00:17:48,839
strengths and weaknesses.

235
00:17:49,040 --> 00:17:51,599
That's the normal way of our neurology.

236
00:17:52,329 --> 00:17:56,780
So out of those 12 to 15 subsets of skills,

237
00:17:56,959 --> 00:18:11,640
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.

238
00:18:12,449 --> 00:18:18,640
So a person who's really good in the areas of generating ideas and flexibility,

239
00:18:18,650 --> 00:18:21,339
this person might be called creative.

240
00:18:21,349 --> 00:18:22,920
All these ideas,

241
00:18:22,930 --> 00:18:24,140
they're very flexible,

242
00:18:24,150 --> 00:18:25,579
they go from here to there,

243
00:18:25,839 --> 00:18:29,609
but they may struggle with other areas of executive function,

244
00:18:30,040 --> 00:18:31,959
they may be impulsive,

245
00:18:32,000 --> 00:18:35,979
have difficulty with time management, organization...

246
00:18:36,180 --> 00:18:41,780
So everybody has their own pattern with an executive function.

247
00:18:43,069 --> 00:18:45,640
So let's go back here.

248
00:18:45,650 --> 00:18:52,219
We are setting up a discussion of the relationship between executive function and ADD.

249
00:18:52,819 --> 00:19:01,339
And one of the difficulties we currently have is that our understanding of executive function has evolved since 1980.

250
00:19:01,780 --> 00:19:12,500
But we have a diagnosis that covers only a small subset of how we currently conceptualize executive function.

251
00:19:13,349 --> 00:19:25,880
This creates difficulty in that someone may clearly have developmental executive function problems but not fit into the box of the ADD diagnostic criteria.

252
00:19:28,280 --> 00:19:29,010
Now,

253
00:19:29,849 --> 00:19:33,420
let's compare ADD and autism.

254
00:19:35,489 --> 00:19:43,300
Everyone on the autism spectrum will have executive function difficulty in some form or pattern.

255
00:19:45,040 --> 00:19:48,290
That's because of the neurology of autism.

256
00:19:50,880 --> 00:19:57,329
The term executive function is not specifically used in the autism criteria,

257
00:19:57,359 --> 00:20:09,849
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.