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.

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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