executive dysfunction

People who have good Cognitive Flexibility are able to kind of “go with the flow”. They handle sudden changes in situations or in the environment without a lot of freaking out.

Yes, ADHDers have a reputation for being laid-back and easy-going, and great in an emergency. Lots of us end up working in jobs like emergency medicine, after all.

So if we say that ADHDers struggle with Cognitive Flexibility, what gives?

*Pinnable image for this post of two ballet dancers in what could be considered extreme positions.*

Think back to when you actually lose your cool. It’s typically going to be when stuff goes sideways, when your plans can’t happen, when something breaks your routine. For people working in an ER or as paramedics, emergencies at work are just part of the daily grind. They don’t get flustered because they know what to do in these specific types of situations.

In regular life, difficulty with Cognitive Flexibility looks like melting down because someone else ate the thing you had planned to eat for lunch. It’s feeling completely lost because a friend popped in for a visit when you’d been intending to watch your favourite TV show. It’s feeling like nothing ever goes right and you shouldn’t make plans because obviously nobody else cares about what you want so why bother and life sucks, all because you missed correcting a typo in an e-mail you sent your boss.

Yeah.

Sometimes it’s the tiniest things that break us, because they’re harder to predict. Society expects us to have plans for evacuating in case of fire. We’re supposed to keep supplies on hand in case there’s a flood or something. We know to call 911 if there’s a break-in or if someone has a medical emergency. But our brains see disruption of plans and routines (both of which take a lot of energy to create and follow already) as being life-or-death emergencies.

Cognitive Flexibility is one of the executive functions that’s implicated in all three types of ADHD. It’s why transitioning from one activity to another is difficult. It’s why we melt down over “little blips”, and why we panic when they happen.

Cognitive Flexibility is part of Planning–or maybe Planning is part of Cognitive Flexibility? Unclear. They may well be entwined and part of each other. It is part of Attentional Control, because it is part of why it can be hard to change our attention. And it affects Self-Monitoring, because it can be so hard to know why we’re reacting to something in a particular way.

Since Cognitive Flexibility is implicated in all three types of ADHD but it mainly affects other Executive Functions that are involved in Inattentive ADHD more than in Hyperactive/Impulsive ADHD, you are more likely to struggle with it if you have Inattentive or Combined ADHD. It’s just one of those things: difficulties with one make others harder, and vice versa.

Having difficulties with Cognitive Flexibility is not a moral failing. It is not wrong to feel overwhelmed when something changes unexpectedly. It is not wrong to flail a bit when the rug is pulled out from under you and you feel like you’re about to fall off a cliff.

I want to encourage you, if you struggle with Cognitive Flexibility, to remember this. Remember that you’re “overreacting” because your brain, your body, feels like you’re going to die. If you can, close your eyes and take a deep breath. Slow down. Talk yourself through the new situation, out loud if necessary. “I was going to do X and now I can’t do that. What are my options? I could do Y or Z or B. Which one makes the most sense right now?” etc.

If you have someone in your life you can trust, who you feel okay asking to support you, show them this post and this explanation of what’s going on when something changes. Ask them to help you work through these sudden changes when they happen, with the idea that eventually you’ll be able to do it independently. If they aren’t sure how they would do that, come up with a key phrase they can say when they notice that you’re starting to spiral. Something like “Things have changed, what now?” Use that as your cue to breathe slowly and talk through the options.

Having ADHD is hard. Struggling with Cognitive Flexibility is hard. You are not worth less than someone else because of these challenges. Your brain literally works differently from that of a non-ADHD brain, and that’s okay. It’s okay to ask for help with your challenges. You matter, and you are allowed to have a good quality of life. If that means you need help dealing with sudden changes and making transitions and stuff, well, so be it.

Everyone needs help with something, and this is one of your things.

Yes, I’m still on this train. I’m absolutely certain that executive dysfunction is the main issue with ADHD. Since I first wrote about this, I’ve been exploring it all more fully, and I’m having more ideas and so on. So, let’s revisit this concept.

Pinnable image for this post with a picture of a person whose head and shoulders are pixellating and flying away. Or maybe the pixels are coming together to create the person. You decide.

If you do a search for executive dysfunction and ADHD, you’ll get a bunch of stuff about how executive dysfunction is a symptom of ADHD, but not everyone who has executive dysfunction has ADHD. I agree with this: having executive dysfunction doesn’t mean that you have ADHD. However, if you have ADHD you definitely have executive dysfunction.

The problem is that people don’t realize what processes are executive functions, so they don’t see how our executive functions relate to the diagnostic criteria for ADHD. Executive functions are higher-level processes in the brain that let us control our behaviours, our attention, our emotional displays, and so on. The frontal lobe handles this stuff, so if that’s not working the best we’re going to struggle with it. That’s why a lot of people who have a traumatic brain injury struggle with executive functioning, and why so many other brain-specific conditions involve executive functions.

To my mind, ADHD is unique in that every single diagnostic criteria can be tied to at least one executive function.

Inattentive ADHD expects children to show at least six of nine criteria, in multiple settings, for at least six months beginning before the age of 12. Hyperactive/Impulsive ADHD expects at least six of eight criteria, in multiple settings, for at least six months beginning before the age of 12. Combined ADHD expects both six of nine Inattentive criteria and six of eight Hyperactive/Impulsive criteria. For adults, the expectation is five criteria instead of six, but otherwise the same.

There are nine executive functions that I’ve sorted out as of this writing. Eight of these apply to Inattentive ADHD, and four apply to Hyperactive/Impulsive ADHD, while all of them apply to Combined ADHD.

This is why there’s overlap. This is why people who have Inattentive ADHD also have some Hyperactive/Impulsive symptoms, and vice versa.

There are three executive functions that contribute to all three types of ADHD. No matter what type of ADHD you have, you’re probably going to have issues with:

Cognitive Flexibility;
Goal-Directed Behaviour; and/or
Self-Monitoring.

What does this mean? It means that most ADHDers have trouble dealing with sudden changes in their situations or environment (Cognitive Flexibility). It means that most ADHDers struggle with working towards goals, especially if those goals are long-term and progress isn’t something they can see right away (Goal-Directed Behaviour). And it means that most ADHDers are a bit oblivious to how they come across to other people and don’t always realize when their emotions are starting to spike or when they need to eat, use the bathroom, sleep, etc. (Self-Monitoring).

One executive function is specific to Hyperactive/Impulsive ADHD, and that is Inhibitory Control. This means that Hyperactive/Impulsive ADHDers have trouble keeping themselves from doing or saying whatever pops into their head.

The rest of the executive functions are related to Inattentive ADHD. These are:

Attentional Control;
Cognitive Inhibition;
Organizational Skills;
Planning; and/or
Working Memory.

As a result, Inattentive ADHDers are going to probably struggle with knowing what to focus on and maintaining that attention long-term (Attentional Control). They will likely have trouble tuning out unrelated stimuli and follow a train of thought (Cognitive Inhibition). Their organization is going to be chaotic or non-existent (Organizational Skills). Making and following plans is also very hard (Planning). And their ability to hold information in their minds so they can make decisions and complete tasks is probably impaired (Working Memory).

(I’m not gonna bother explaining how bad it is for us Combined ADHDers. Suffice to say, it sucks.)

I think that if we were to approach ADHD from the view of executive dysfunction, it would suddenly become a lot easier to figure out solutions to the specific problems we experience. Executive functions all interact with each other, so the specific areas we struggle with are impacted based on which executive functions are impaired and just how severely they’re affected.

So consider this the first post in a series about executive dysfunction in ADHD. I’m going to go in-depth into the different executive functions and talk about different ways they interact with each other, and hopefully offer some useful suggestions for how to deal with the resulting problems. I think it’s important to know which executive functions are impaired and how they’re interacting, because that is why systems aren’t one-size-fits-all. The end result looks the same, but the underlying reasons for these problems are different, and that affects the solutions in important ways.

My next post is about Planning and its related executive functions. I have no printable this week, but if you go to the Printables page you’ll find some stuff about executive functioning to get you started.