Difference between ADHD and Executive Functioning Dr. Josette Abdalla
DSM-5 Definition of ADHD The DSM-5 diagnoses 3 types of ADHD: ADHD Predominantly Inattentive type ADHD Predominantly Hyperactive-Impulsive type ADHD Combined type
Assessment of ADHD There are numerous assessment tools that may be used to determine whether a child/individual has ADHD. Among the more commonly used assessment tools are: The BASC (Behavior Assessment System for Children) The Conners 3
The Conners 3 This tool is used to indicate whether or not a child/individual meets the DSM 5 symptom count requirements for the diagnosis of: oadhd Predominantly Inattentive type oadhd Predominantly Hyperactive-Impulsive type oadhd Combined type oconduct Disorder ooppositional Defiant Disorder
What is Attention Deficit Hyperactivity Disorder (ADHD)? ADHD is one of the most frequently-occurring disorders that most often manifests itself in childhood and continues to pose challenges throughout adolescence and into adulthood. Causes are, as yet, undetermined. It is a genetically-oriented disorder that may run in families. Its symptoms include difficulty getting and staying focused, modulating attention, and/or restlessness and constant need for movement and controlling impulsivity (verbal, mental or physical) and inability to anticipate consequences to actions. ADHD is sometimes accompanied by Conduct Disorder or Oppositional Defiant Disorder. Medication is often useful to control the symptoms, but does not cure the ADHD.
What are Executive Functions? The frontal part of the brain s cortex is in charge of enabling individuals to perform higher-level tasks such as those required in executive function the easiest way to think about this is to imagine what the chief executive officer of a company is tasked with doing, including: plan, organize, anticipate, link or analyze, etc.. All executive functions are activated, orchestrated and monitored by the frontal lobes. Any damage or lack of appropriate functioning of part or parts of these lobes (or their connections with other parts of the brain) may result in malfunctioning of the basic role involved.
Executive Function Core Cognitive Capacities Eight core cognitive capacities which form the building blocks for all learning include: Sustained Attention Working Memory Speed of Information Processing Response Inhibition Cognitive Flexibility Category Formation Pattern Recognition Multiple Simultaneous Attention
Assessment of Executive Functions There are numerous assessment tools that may be used to assess a child or individual s executive functions. Among the commonly used assessment tools are: The BRIEF (Behavior Rating Inventory of Executive Function) The CEFI (Comprehensive Executive Function Inventory) The TOVA (Test of Variables of Attention)
The CEFI The CEFI measures the following 9 executive functions: Attention Emotion regulation Flexibility Inhibitory control Initiation Organization Planning Self-monitoring Working memory
What is Executive Function Disorder (EFD)? When the Executive in the frontal lobes of the brain fails, the result may be EFD. Children and adults with EFD may exhibit issues with any of the previously mentioned executive functions. Among the more common ones that teachers, in particular, often comment about are: the child cannot concentrate or pay attention for long, is easily distracted, has difficulty organizing materials or following instructions, looses or misplaces belongings, does not hand in homework (even if done), is disorganized, cannot prioritize, plan, follow a program, etc. No matter how hard the child tries, the failure rate remains.
ADHD & EFD Compared Both include difficulties with attention. While they share some of their respective symptoms, the definitions of ADHD and EFD aren t quite the same, and there is a definite difference between ADHD and Executive Function Disorder. ADHD is a common misdiagnosis for EFD. One view suggests that some not all who meet a certain criteria for ADHD suffer from significant impairments of (executive) function. An alternative viewpoint holds that all individuals with ADHD suffer from significant impairment of executive function, and that ADHD is, essentially, a developmental impairment of executive function.
Diagnosis The CEFI and Conners should NEVER be the sole diagnostic criteria. Observations from other assessments and measures must be included before a diagnosis is issued. It is imperative to determine whether the symptoms in both are primary or secondary to other problems. Among the numerous primary causes for symptoms that are similar to EFD or ADHD are: Cognitive impairment or discrepancies between related abilities, Academic or Learning Difficulties, Speech or Language Delay, Sensory-motor or Occupational Therapy problems, Social or Emotional or Psychological variables.
Assessment of ADHD
Intervention
Intervention Intervention at the level of the SENCO Tier 1 involves: Objectively observing the child s problematic behaviors. Describing each of them in pragmatic or operationally defined terms. Noting their frequency, intensity and duration throughout the day. Handling the symptoms themselves by preparing a plan that is suitable for the child s unique or individual issues and needs.
Intervention (cont.) Close collaboration with other teachers and with the parents of the child is imperative. Teaching the child in smaller groups, support classes or one-on-one settings is sometimes needed. Referral to a more specialized assessment/intervention center may be necessary when available measures are unsuccessful. Use of medication may also be considered in specific cases, and based on the above.
General Guidelines for Teachers of Students with ADHD and/or EFD Regardless of whether the cause of the behavioral shortcomings is due to ADHD or to EFD, teachers are to address the problematic behaviors per se. All teachers are urged, after the previous issues have been considered, to understand the nature of the child with the problematic behaviors and its possible triggers, and to know as much as possible about home circumstances and personal strengths. The focus should be on enhancing strengths, and adopt a generally more positive (in comparison to negative) approach. Anticipating in advance, and being well-prepared with intervention before the misbehavior is exhibited, is considered a must. Ignoring misbehavior (whenever possible) is to be encouraged.
Points to Keep in Mind The child with ADHD or ADHD is not lazy or unmotivated. The teacher has to have a list of preplanned activities for the child when the problematic behavior is about to be triggered, or is actually being exhibited. Accommodations to suit the child s particular needs without drawing negative attention to the child may sometimes be necessary. It is important to have a pragmatic, cheerful and fast-paced approach, in general. Teachers should be lavish with praise and rewards, but only when deserved and not as general comments. Close cooperation with the family is highly recommended. When all these approaches fail, refer to a specialist.
Sample of Some Recommendations for Specific Issues of Concern
Attention: Average Concentration Span
Attention Seating arrangements away from distractors, and close to cooperative and competent peers Shorten tasks so that they can be accomplished successfully Have specific charts or contracts with clarification of specific requirements in a step-by-step manner Follow a predictable and well-known routine Allow the child to have gadgets/activities to occupy him while doing work. Stand next to child while performing work.
Attention (cont.) Use timers or cues to keep the child on track. Abstain from repeating instructions. Make sure the child has understood requirements. Develop strategies to ensure child has completed work and/or handed in homework. Maintain eye contact when addressing the child. Encourage child to attend to time parameters.
Hyperactivity Allow for physical breaks before hyperactivity becomes excessive. Fasten pace of instruction and engaging approach. Seat the student next to supportive peers or in a place where his level of activity will not distract other. Ignore movement whenever possible. Allow for use of particular gadgets (e.g. squeeze ball, elastic band, etc) to preoccupy self with. Never deprive from breaks. Give the child some responsibility that includes physical movement.
Impulsivity Provide the child with cue cards to present before talking out Ignore comments that are out of turn Make sure that the child knows consequences to different impulsive comments/actions Encourage the child to monitor his ability to control impulsivity in class Have him define how he can control himself, and relevant rewards/consequences Breathing techniques Engage in turn-taking activities
Aggressive/Defiant Behavior
Aggressive/Defiant Behavior (cont.) Ignore and divert, whenever possible. Never ignore inappropriate aggressions and do not get drawn into a power struggle. Attempt to identify possible triggers and intervene. Have the child operationally define what is meant by aggressive or defiant behavior/attitude. Help the child express emotions/frustrations and needs verbally or through a written format (e.g. diary) or by drawing. The thinking or cooling-down room is to be controlled by a counselor who is in charge of understanding the reason(s) for anger or defiant behavior, and help the child learn how to cope accordingly through discussions, relevant worksheets, and identifying alternative approaches to cope with the problem.
Aggressive/Defiant Behavior (cont.) Give the child a responsibility he can, and is willing to, handle. Also provide him with activities that bring forth leadership in a positive way. Acknowledge efforts done to control temper. Deal one-to-one with aggressive/defiant child, and devise a plan for him/her to take control of behavior. For example, behavior contracts or charts. Provide the child with opportunities to act appropriately and get some badly needed attention.
Self-Monitoring Make sure the child understands what is required of him. Encourage him to use a self-monitoring form. Have him identify and write down the important points needed to monitor the work or task. Initially supervise the child, then gradually wean him off your supervision. Increase motivation with verbal praise or extra incentives. Have the child identify alternatives, if the initial points are unsuccessful, and how to deal with lack of success.
Memory Use organizers, colored binders, memory cards, etc. as different means to enhance memory and remember information, books/material needed for class or homework, instructions, etc. Use multisensory approaches whenever possible. Try not to rely on only visual or auditory cues. Use mnemonics, whenever feasible. Use a step-by-step approach when giving instructions or information, and encourage the child to repeat what has been grasped. Increase number of instructions/rules when mastery of fewer ones is accomplished. Simplify language and shorten repetitive words and sentences. Repeat, only if necessary.
Making and Maintaining Friends Seat next to specific peers and away from particular others. Engage in cooperative activities with peer(s). Engage child with particular others during recess. Prepare the child for social functions at school by assigning him a specific role or responsibility. Encourage the student to take a leadership role in some activities, but also follow well or turn take appropriately in others. Inform the parent of particular children to encourage socialization with outside of school.
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