ADHD and Executive Function
I watched this 2012 YouTube video from Russell A. Barkley What Science Tells Us About ADHD, which is an excerpt from the longer Self Regulation and Executive Function Theory (missing the slides, though), and extracted the interesting bits. The Executive Function elements are in a book called Executive Functions: What They Are, How They Work, and Why They Evolved
He say people with ADHD have a split between "knowing" and "doing". It is a "performance disorder"; you can know something, but you can't do it. It is not an "attention disorder", but an intention disorder; an inattentiveness to mental event with respect to the future.
ADHD Executive Function Deficits
He has a definition of executive function based on his own detailed model, created to fill in the gaps he perceived in pre-existing literature. He defined ADHD in these executive terms:
- Having Time Blindness, also called "temporal neglect syndrome" or a "myopia to the future"
- Lacking capacity to "hierarchically organize behavior across time to anticipate the future in the pursuit of one's long-term goals and self-interest" that leads to "wellfare and happiness"
Information has to be externalized and put into one's visual field. People have to create the scaffolding for the individual with ADHD, and it is a chronic condition that does not go away or is cured. It however has very effective medications available and is highly treatable. Stakeholders must be involved!
Some takeaways for treatment dos and don'ts of ADHD treatment with my own embellishments:
- It is useless to try to teach skills, because this information has no "controlling value" and does not leave the classroom. It is not willfull, it is just the way it is.
- It is not a motivational problem. The environment itself has to be engineered to help maintain motivation.
- It is a neuro-genetic condition that responds to neuro-genetic therapies (medication for example). A therapy is not a cure.
- It is not known whether "working memory practice" helps. It might.
- Accountability and social consequence have be be put into the now. It has to be more frequent and very closely coupled with the time spent doing the goal-based activity.
- behavior modification is effective because it creates "artificial prosthetic cues" to substitute for working memory deficits (signs, lists, cards, charts) and "artificial prosthetic consequences" that address accountability (tokens, points)
- these do not create skills or strengths that will endure with practice and can be stopped. They are required to overcome the motivation deficit. It is a "chronic disability" and requires accomodation from people.
Timestamp here is where he talks about this stuff.
- make mental information physical: cues, signs, charts, reminders in the visual field (working memory is shot)
- make time physical and real through timers, watch minders, to be able to judge performance, in visual (no clock in head).
- break up lengthy tasks into small steps, get rid of the "delay" of finishing a book report, into baby steps every day.
- motivation externalized: dependent on environment for motivation, consequences in the now otherwise. video games provide continuous external motivation. wha'ts the sex/drugs/money consequence of doing something
- Make the problem solving "manual". Can't hold thing in mind and move them around as well as other people, use physical in the visual field with manual pieces to it. The principle is the point.
- Limited fuel take of executive fuel tank. The tank empties quickly, and then self-control disappears. Need to refuel the tank...pep talks, breaks often, tasks in smaller units, relaxation and meditation, don't use the executive system all the time. "10 minutes, 3 break" rule. Visualizing and talking about the future work, and routine aerobic exercise. More exercise increases the size of the tank. The fuel in the tank is sugar in the blood glucose in the frontal lobe. Sipping on lemonade. Not gulping. Sipping. Sugar in fluid form drip helps.
- He says it's an Executive Function / Self-Regulation issue
- Effective programs mentioned (these are from 2012, 10 years ago!)
- J. Ramsay, Anthony Rostain Cognitive Behavior Therapy for Adult ADHD: An Integrative Psycosocial and Medical Approach
- Steve Saffren Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program, Therapist Guide
- Mary Solanto et al Stimulant Drugs and ADHD
Executive Function Theory, Self-Regulation
The entire video has the background on what he means by "EF/SR" (executive function/self-regulation) as being the deficit, which is a complicated and multi-level thing. The video is Self Regulation and Executive Function Theory
He describes his model of self control as 7 things that are based on Vogotsky's Theory on Inner Speech from 1934. This is a "swiss army knife" in the frontal lobe that allows humans to change the future so it's better, and its development through childhood (the first 15 years of life) can be observed. There is a "switch" in the brain that keeps what we're thinking from being expressed as motion or vocalizations or other actions.
Barkley's theory is based on the same pattern identified by vygotsky. There are three precedeeding the voice and three after. These guide our ability to revisit the past, resensing our past, using it as a map and guide. These are things that humans can do, but not animals.
- redirect attention system on self: self-awareness (sense of self over time, 10 years or so)
- executive inhibition: self restraint and inhibit the motor system (very early)
- non-verbal working memory / "what are you doing to yourself": theater of the mind, can replay images of the relevant path and proceed to goals. Develops simultaneouslyl with 1 and 2, peak in 15 years.
- private speech at age 5-7 the voice is internalized and three changes are observed: (1) switches from describing the world to giving himself commands (2) what he says to himself starts to govern behavior (3) starts to suppress face instead of saying things out loud (face still moves though, almost undetectably)
- use 1-4 to manipulate emotions and create their own emotions now. Like method school of acting. Calling up an image of the past with a legimate emotion. Images have emotions welded onto them. The very utterance of the image brings the emotion with it, and c an modify one's emotional taste. To build networks of people, need to manage emotions, and emotions are motivational states.
- You can create your own motivation and stay the course. Can use the emotions as a delaying strategy, tasting and imagining
- planning and problem solving - adult play. Children playing is "let's see what happens". Internalized play is solving problems. Analysis, synthesis. Can imagine, manipulate in the head.
Another way to look at it is as a two-part system:
- The automatic brain makes a distinction between stimulus/appraise/response (mentions a book by Daniel Kahnmean Thinking Fast and Slow that talks about this)
- Self-Awareness is the application of EF to monitor the automatic level, which takes them over. Most of the time you're using the automatic brain, and the EF does the thinking part.
Executive Function depends on 4 levels:
- basic mental functions: vision, motor, reaction time
- opereration: where are the brakes, mirrors, how does it drive,
- tactical: on the road with other people, learn the rules of the road and constraining behavior to adjust to theirs
- strategic: answer the question why driving the car, what goals, where going, what best sequence, did you listen to traffic or whether reports, altered plan as they play out (the executive level)
He notes that EF tests tend to only check the 4th one, but not the prior three levels.
The executive functions that related to ADHD are these Eight Developmental Capacities (from his book chapter "Eight emerging development capacities arising from EF"), and it's number 4 where he says the ADHD difficulties lay.
- Spatial Capacity - distance over which one can contemplate a goal and the means to attain it
- Temporal Capacity - How far into the future individual can contemplate a goal ("time horizon")
- Motivational Capacity - the "hot" of the future shown by 1 and 2 (which are "cold" information), what I might call "visceral"
- Inhibatory Capacity - duration one can inhibit responses, restrain, subordinate immediate interests for the sake of the goal. It's highly dependent on the prior 3.
- Conceptual/Abstract Capacity - rules to follow to meet the goal, from self-directed simple "stop" to complex "do unto others what you would have them do to you"
- Behavioral-Structural Capacity - capcity to structure actions needed to bridge time and distance between NOW and the contemplated goal. Represented in the label of EF levels: instrumental, methodical, tactical, strategic, and even-principled.
- Social Capacity - Number of other individuals with which individual interacts, reciprocates, cooperates with to reach the goal. Social networks
- Cultural Capacity - the degree of cultural information and devices (methods, products, etc) or scaffolding that the individual is adopting to attain the goal. Culture is "shared information" inherited from prior generations, shared withing the current one.