Exploring ADHD, Autism, and Executive Function Subcategories

In this second episode of the executive function series, Dr. Regan breaks down how speed, working memory, and sequencing impact daily life. 

I Love Lucy chocolate factory TV clip

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 (Sept, Oct, Nov, Dec 2023)

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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Hello,

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everyone.

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This is Doctor Regan.

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I'm joining you for an episode of Autism in the adult podcast.

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For those of you.

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New to the podcast.

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I'm a neuropsychologist,

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a certified autism specialist,

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and the founder and director of an autism diagnostic clinic for adolescents,

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adults and aging adults in Central Illinois.

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And today you are listening to the second episode in a series on executive function.

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And this is a topic we're covering because many of the strengths and challenges that go along with the autistic neurology fall within the realm of executive function.

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Before we dive into that topic for today,

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I'd like to thank Amanda who pointed out that my diagnostic terms in the first episode were imprecise.

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I use terms that are common in my day to day interactions with patients,

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families and physicians,

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which are the terms ADD and ADHD.

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However,

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the most precise and current terminology is ADHD predominantly inattentive presentation.

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ADHD predominantly hyperactive - 

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impulsive presentation, or ADHD combined presentation.

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And I guess in reviewing that in my mind,

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I think it's similar with the term dementia,

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which is often still used in day to day language in clinical settings,

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even though the most recent and precise term is major neurocognitive disorder.

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So,

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thanks Amanda,

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I'll stick to being precise and specific in podcasts about the topic of ADHD

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And instead of using each of the subtypes,

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I will just use the term ADHD unless I'm speaking about specific features of one subtype. As we discussed in the first episode,

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executive function is really a broad term and it's includes multiple subfunctions or subcategories.

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And this is a series that I really encourage you to listen to the first episode before listening to subsequent episodes because it really went through a lot of layers of explaining executive function, ADHD, and autism ...

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how those relate or don't relate to each other.

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So the subcategories of executive function include things like attention,

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goal directed persistence,

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organization, response

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inhibition and several more.

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In fact,

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depending on what source you're using,

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there can be about 12 or so sub functions identified,

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even though there's really no complete agreement on how to list out the sub functions within executive function.

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There are two main developmental diagnoses with large executive function components and these include ADHD and autism,

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the ADHD criteria, as we talked about in the previous episode,

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only describe symptoms falling within about four of the subcategories.

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I would label these subcategories in the ADHD as organization,

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attention, response inhibition, and goal directed persistence. For example,

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"fails to give close attention to details or makes careless mistakes" is one of the criteria that can be met in ADHD.

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And I would say that, as a symptom, that falls within the subcategory of attention. "Blurts out answers before questions have been completed" is an ADHD symptom that falls within the executive function

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subcategory of response inhibition.

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So is somebody able to inhibit or stop a response until they think it through?

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So autism will present with core executive function features in some combination as well across the totality of the 12 categories.

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And these features are some of the strengths and gifts within the autism presentation.

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and also some of the challenges. In this episode,

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we're going to focus on the executive function 

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sub features of working memory, speed, and sequencing.

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And I've chosen these abilities to highlight together because we often use them together to accomplish daily tasks.

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And I'm hoping that in explaining them and presenting them together,

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you'll be able to watch yourself or watch other people in your life to see how these executive function abilities work for them.

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Similar to the last episode,

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I'm going to walk you through various levels of information.

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So stick with me.

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First, I want to make a comparison between the center of the brain, which is called the subcortical areas, and a conveyor belt.

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You'll,

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you've probably heard that the brain has both gray matter and white matter.

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The outside of the brain and 

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certain areas in the center are gray and these gray matter sections are connected by white matter tracts.

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The color white comes from the fact that there's a fatty substance called myelin covering these neuron tracks.

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And the presence of the fatty covering allows the nerve signals to travel faster than without that covering.

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So the center of the brain impacts speed of thinking and processing.

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So in conditions like multiple sclerosis,

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for example,

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where you have demyelinating,

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that is the white matter starts to degrade,

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one of the features can be a slowing of processing.

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So the first point is that speed is a function of the subcortical pathways that impact executive function and several autistic characteristics.

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So we do want to focus on this subcategory of speed.

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Another subcategory is working memory.

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What is this part of executive function?

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Well,

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even though we call it working memory,

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a neuropsychologist or a cognitive scientist might say it's actually really more attention than memory

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in that it has to do with the amount of information a person can hold within their attention without storing it by really memorizing it for later.

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So it usually doesn't end up in permanent memory.

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But we're able to hold information our in our attention.

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And some people have a really strong working memory and others really struggle with this. And you'll see different estimates probably about how large working memory generally is.

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But most times a person can hold about five plus or minus two bits of information in their attention.

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This makes sense because if you were

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using phones in the old days where we didn't have cell phones and

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phone numbers in our phone ...

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a lot of times someone would tell us their phone number or we'd look at it in a phone book and we'd have to

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kind of rehearse it in our working memory while we dialed.

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So we held seven digits ... in those days...

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in our mind while we pushed in the information to the phone.

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So let me give another illustration.

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Working memory is what we use,

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for example,

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if we hear an instruction with ...

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let's say three parts to it and we go to carry it out.

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Our boss may ask us to print the schedule for the day,

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put a copy on her desk, and check the phone messages from overnight.

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So we have to keep these tasks in mind while doing them.

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We have to hold them in our mind.

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And although we may recall the sequence of requests later in the day,

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we're unlikely to remember them in a month or a year because we haven't memorized them.

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But while we're carrying them out.

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We may be able to keep them in mind because they're in our working memory.

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So the term working means that we keep things in mind while we're using them.

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I'm using this information of what the three tasks are while I'm accomplishing the tasks.

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Working memory is what we use when we walk into a room for something.

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And then sometimes if the information has left our working memory,

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we feel frustrated that oh,

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I walked into a room to get something and now it's gone.

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That's something that has slipped through our working memory.

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Similarly,

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we may say,

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oh,

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shoot,

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I was going to say something or ask something,

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but I forgot what it was.

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We were keeping it in our mind while the other person finished their sentence.

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But then by the time they were finished,

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our thought had slipped through our working memory.

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It wasn't held the way that we wanted it to be.

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And so we were unable to bring it back when the person,

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signaled that it was our turn.

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So to summarize our abilities within executive function stem anatomically from the center and the front part of the brain pathways,

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the subcortical pathways that connect with the frontal lobes.

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And these pathways include white matter which impacts how quickly someone can think,

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process and respond.

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And this part of the brain also impacts working memory,

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which is our ability to hold information in mind while we work with and use it.

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So let's tie these concepts speed and working memory with the conveyor belt image that I mentioned earlier in the talk about the third piece for today,

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which is sequencing. A sequence of something is the order in which the things occur or they're arranged.

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And when we listened to our boss ask us to do three things,

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she presented them in a certain sequence.

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And when we listen to someone,

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the words and their meanings and concepts,

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these come toward our ears and into our brains as sequences of data. Picture that conveyor belt.

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Now,

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a conveyor belt is a surface that moves and it brings items to you.

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A person in a factory may work with items coming toward them on a moving surface.

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Perhaps they're employed to sort the items.

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For example,

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here come green and red candies.

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And I'm employed to take the green candies coming toward me and put them in the green box and to take the red candies and put them in the red box. Or maybe someone's employed to assemble something. As the item comes toward you,

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you add this piece,

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then you place it back on the moving belt and the next person will add the next piece and so forth.

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So items come to you in a sequence,

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one item after another,

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after another,

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the items also come with a particular speed on this moving surface and it can be increased .. like wow,

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the items are really coming quickly now... or slowed down.

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You can see that if the speed is set for a pace that most people can keep up with,

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there will be success in completing the task.

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But maybe there would even be a pace that would be too slow for the workers.

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For example,

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a worker might get bored.

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If the items aren't coming fast enough.

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a bored worker might have distraction and restlessness.

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Oh,

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my gosh.

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This is so slow.

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If the pace were too fast,

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the worker wouldn't be able to use all the items coming toward them.

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Things would get past them,

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things would get missed and only a portion of the items could be manipulated and used for that task.

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So the speed and the number of items coming at us needs to be at a just right spot.

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My favorite image for this is a classic,

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I love Lucy clip from the Chocolate Factory television episode. This episode aired in 1952 and it's considered one of the funniest of the whole comedy series.

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I've linked a clip of the Chocolate Factory scene with the conveyor belt in the show notes for those of you who would like to view it or who haven't seen it.

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It's a great demonstration of what can go wrong if the speed of the moving belt is too slow or too fast or if too many items are being sequenced on the conveyor belt at once.

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Now let's get back to the conveyor belt in our minds.

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So if my boss is giving me instructions with multiple details or steps,

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it is as if the words or chunks of information are coming toward me from her voice into my mind ... just like the little pieces of chocolate on the conveyor belt

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in the comedy clip.

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The speed of the conveyor belt is how quickly she's speaking.

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And my perception of the speed is impacted by how quickly my brain can process and keep up.

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If my brain's conveyor belt is slower.

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If I have slower information

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processing, the speed that she's giving me information for the conveyor belt may be overwhelming to me.

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Or if I have really fast processing,

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I may get really bored and distracted while she's talking because there's just not enough that's new coming toward me.

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Let's take another example,

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this one involving a student in a class.

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So a teacher is presenting information to the class.

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The student is required to receive the bits of information at the speed they're presenting as if in the conveyor belt analogy.

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And here comes new information.

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Then the student must hold the information in mind while deciding what parts to write in their notebook or to type in their laptop.

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All of this must be done while the teacher is still speaking.

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And this is all executive function.

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So we'll touch on this in a different episode,

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but the student must use another piece of executive function in this task as well ...

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prioritization.

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So I'm receiving a lot of information on this conveyor belt from the teacher.

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But what information is important for my notes and what is not important. To what do I give priority when there's a lot on the conveyor belt.

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For example,

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it's not necessary to write down every word

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the teacher is saying. What the efficient,

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just-right thing to do would be to pick out these most important things,

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these themes,

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these categories, definitions,

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dates,

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these are the things we need to jot down in our notes.

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And our executive function is what helps us with this whole process.

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Now,

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if it's working well,

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the student just does this automatically.

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If things are hard in that area of executive function,

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the person may feel like,

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gosh,

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I,

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I cannot,

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you know...

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note taking is very difficult for me.

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I just can't keep up.

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I can't keep the things in my mind while I'm writing because I either lose them because the teacher is still speaking or I lose what the teacher is now saying.

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So it either is something that happens smoothly and automatically or it really becomes a very difficult thing.

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Let me give you a social example.

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Imagine a person at a social event where a group of people are speaking about a funny experience.

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An individual in the group will need to be taking in what multiple people are saying...

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So there are multiple conveyor belts and speeds all while holding parts of the conversation in mind.

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And this person also then has to think about what they might say or contribute to the conversation and how to time what they're going to contribute and still keep up with the speed of the exchange.

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This example also involves those executive function abilities of working memory and speed and sequencing.

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Let me give you a life activity example,

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driving is a good example of a life activity that requires a person to take in multiple streams of information.

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In this case

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visual ... at varying speeds.

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Oh, this visual information is coming at me as I'm driving through the visual space.

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So the individual must first notice incoming visual details, adapt to unpredictable changes in the visual field (like, oh now I have less space in this lane than I did because the car is coming over toward me), and make quick safe decisions about how to respond.

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So one individual may feel like this all comes very automatically and at a speed that really works for them,

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another individual may feel overwhelmed by the amount of visual information coming at them in such a quick time...

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particularly because it's unpredictable and it involves safety issues.

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So if I can't keep on top of this visual information,

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I really might get in a situation that's really pretty dangerous.

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Other people while they're driving may feel concerned because they get bored.

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There's just not enough new information in the visual field to keep their mind on the road and they may find their mind wandering in a way that kind of makes them nervous and and leads them feeling like...

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they just can't focus very well while they're driving.

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What is often the case is that for many on the autism spectrum,

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they'll take longer to adjust to driving than their non autistic peers ... most often because they feel like things are really happening quickly and they can feel overwhelmed by the amount the speed and the unpredictability of information on that conveyor belt.

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So going back to our episode,

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topics of speed, working memory, and sequencing,

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we've reviewed that an individual must adapt to the speed of incoming information,

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then sequence through the items coming toward them.

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Hold enough of the information in mind that is important while then doing something with or responding to the information.

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And this is all part of the subcortical frontal pathways of the brain and the ability that globally we call executive function.

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So far,

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we've emphasized information coming toward us on the conveyor belt.

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But we can also think of executive function abilities for the information that we send out on conveyor belts to other people or to the environment.

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For example,

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how quickly do we produce a product or a response to questions from others?

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One person may be quick and efficient with tasks,

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but maybe they make a few errors on the way. Another person may finish the task more slowly, 

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but to them,

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accuracy is really important and they notice a lot of detail.

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Neither of these executive function styles is inherently better than the other

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all the time.

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But the person whose executive function is more methodical and detail oriented in producing output may struggle in a job where the boss says,

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hey,

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the priority on this project is speed.

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I need this quickly. And vice versa.

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The individual who works quickly and decisively may really struggle at jobs where the smallest detail can make or break a project.

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Individuals who make decisions more slowly may show resistance when pressed for an answer or an action.

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Other people may almost feel this psychological opposition when they try to encourage the person to decide or to move on.

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Let's take an action.

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Let's stop thinking about it.

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One example could be adult children trying to press their dad to get his roof fixed. If he has executive function

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that's significant for being very slow,

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methodical...

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He may forever be saying things like "I'll think about that" or "I'll know when the time is right,"

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but there's never any real movement toward action.

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There's this stickiness,

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the conveyor belt toward decisiveness kind of gets stuck. Again, 

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this approach to action is not right or wrong,

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but it's about whether it works for him in certain instances and against him and others.

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And when the roof is falling in,

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it's really likely working against him.

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Another factor that impacts whether something helps a situation or not is how extreme or inflexible the executive function reaction is in that situation.

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So for example,

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 if we have this situation with the dad and his roof...

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a really extreme slow and resistant response to the need for action in that circumstance...

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well,

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that's creating safety,

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health,

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financial issues ... that it really could hurt the person.

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Ideally,

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our brain is supposed to help us have the just right amount of speed,

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(you know,

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not too quickly,

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not too slowly) and sequencing.

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I see details that are important but I can let other things go so that I can get to the best outcome.

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And when it's important to, you

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can adjust to the situation itself.

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Wow,

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I didn't expect this situation but I can adjust to that.

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But sometimes the struggle that a person is having is really that it's hard to get to that just right spot for ... for anything,

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whether it's speed or executive function or,

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or anything else in life ... rather than sometimes swinging to that too much extreme.

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One more example of the sequencing of output could be seen when multiple smaller actions are needed to complete a larger task.

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So a classic example of this would be the parental request that their child clean his room.

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So the child has to think through all of the pieces of action that will need to be engaged with in order to get this finished product.

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It's almost like saying what are all the pieces I need to put on this conveyor belt,

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all the pieces that I need to to bring together for the whole action of having a clean room or the whole outcome.

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There's a first step,

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a second step,

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a third step ... all on the conveyor belt until a finished product is reached. Some ways in which this executive function task can get stuck would include...

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"Wow,

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there are so many actions or pieces to the task.

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 I just don't know where to start.

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I'm stuck.

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I'm overwhelmed by the amount of possibility.

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I can't get my direction to navigate the task even though I could do all of these little pieces,

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where should I start?"

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And this is often the situation.

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And the parent may say,

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"Hey,

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start wherever you want,

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it doesn't matter."

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But that's not likely to help the child who actually needs someone to sequence the task with them.

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Tell me where to start.

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How can I get going with this task?

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And then after I do the task,

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... the first task,

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what's the second task I should do?

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How should I string things along without getting overwhelmed or stuck or lost?

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The child knows how to do each little part of the task but doesn't have the sequencing ability to navigate this larger task without assistance.

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And so the parent who realizes this might take a picture representing each smaller task ... like a photo of clothes in the laundry basket,

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a photo of books on the bookshelf,

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a photo of the bed made ... whatever the five or seven steps to having a clean room might be.

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You can put these photos up in a place where the child can see them.

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The child then can look at the photos independently and see...

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Oh the first photo is clothes in the the clothes hamper.

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So I'm gonna do that first...  and sometimes the child likes to take the photo down when the task is done.

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And so "I know that's done."

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That's just one way to help teach an executive function skill for someone who is overwhelmed and trying to do that independently.

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Knowing that the full anatomical maturity of executive function isn't complete until the age of 20 or 21 or so.

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The parent realizes that part of their role is to help the child learn strategies for approaching tasks

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requiring executive function ... and to assist in areas where the child is still really developing that ability.

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Additionally,

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as we noted in the previous episode,

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everyone will have individual strengths and struggles in executive function.

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If this is a child who grows up and continues to have a weakness

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organizing a sequence to complete a task,

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they can really benefit from a strategy approach to give their brain some assistance.

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So their strategy might be...

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What if I think about this task as seven smaller tasks?

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What would those be?

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I would invite you to notice tasks in your everyday life that are easy or difficult for you and consider if they have executive function components like speed,

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working memory, or sequencing.

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Notice what's easy for you,

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what's difficult for you in these situations.

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This increased self-awareness can be a first step toward getting the best outcome in a variety of situations.

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You may realize "my nervous system default is to process information slowly.

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But this new job that I have requires speed in these areas.

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And how can I get a better outcome?"

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Well,

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the basic neurology of speed that your nervous system is set toward,

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you know,

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you may not be able to adjust that piece.

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But perhaps you could focus on strategies to reduce anything that would take away from the speed you're capable of neurologically.

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So perhaps you want to reduce distractions,

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maybe ask someone for input about what the most important thing to focus on is and really make sure that you're accountable to someone who can see the big picture a little better.

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As I noted in the previous episode,

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I like the book series Smart but Scattered when it comes to strategies for executive function,

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but you can choose whatever resources best fit your needs.

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And if you want to dive into more about executive function,

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learn about more strategies for success in areas that are causing you difficulty... by all means,

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reach out and find things that work well for you.

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I wanna thank you for joining me to learn about the executive function

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sub features of speed, sequencing, and working memory.

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And I hope it increases your understanding of what makes you tick. We'll be continuing our series on executive function next time.

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So I invite you to join me for that third episode.