Executive Function and ADHD
Many people view ADHD as difficulty with focus, attention, and hyperactivity; however, the research demonstrates that deficits in executive function cause more impairment in people’s personal and professional lives. Executive function includes the following cognitive skills: planning, prioritizing, strategizing, motivation, initiating tasks, organizing, executing complex tasks, and attention to details. However, there is some debate about all of the functions included in the cluster of executive functions.
Executive function tends to be less responsive to medications for Adult ADHD compared to the high success rate, 70-80 percent, for other core ADHD symptoms such as focus, hyperactivity, attention, impulsivity, and distractibility. Thus, adults with ADHD continue to experience challenges on the job and in their personal lives.
Understanding and addressing the challenges with executive function are essential in helping adults with ADHD fully address this condition.
For example, take Winnie*, who is is a 28-year-old female who completed business school last year and is currently working in accounting for a real estate firm. Her manager has been very disappointed with her performance due to careless mistakes, missing deadlines, and erratic performance. She is on a two-month probation period and is panicking. Thus, she has contacted me to address her insomnia, anxiety, and the question of whether her past diagnosis of ADHD is currently affecting her career.
Winnie was diagnosed with ADHD, hyperactivity type, when she was in fourth grade and medications helped her for several years. In addition, she was fortunate to receive comprehensive tutoring in all of her subjects and performed well in school. However, when she moved to a different state, her parents decided to not to continue treatment. She continued with her tutoring.
She struggled with high school and college, challenged with focus, attention and time management. After college, she worked for several years in sales and did very well. She enjoyed entertaining clients and was very successful except with the tedious aspects of her work such as expense reports and monthly reports. She often worked for weeks on a project and then, when she would meet with her manager, she would discover that she had misunderstood the purpose and focus of the project and had to start from scratch. She was chronically anxious and felt overwhelmed and behind. Each day, she didn’t know which project or task start and would often jump from task to task or avoid doing her work altogether.
When we met, I did a comprehensive psychiatric assessment of her history and current symptoms. I explained to her that she had ADHD and that these symptoms often continue into adulthood. I also explained to her that the significant challenge with ADHD is difficult with executive functioning. From her history, it was clear that her anxiety and insomnia were secondary to her struggles at the office.
I restarted her on Adderall as well as a focused course of Cognitive Behavioral Therapy to teach her cognitive skills, behavioral strategies, and emotional regulation techniques to address her executive function challenges. Within four weeks, her performance and productivity had drastically improved. She had a follow-up meeting with her manager who had become quite impressed with her new level of performance. Within a year, she was promoted to a higher-level position.
For those struggling with executive function deficits like Winnie, here are five strategies that may improve performance and effectiveness, especially within the workplace.
Often, people with ADHD are very creative and energetic. As one of my mentors is known to say, people with ADHD are like fast race cars without functioning brakes, they leap out of the gate with enthusiasm, but not necessarily with realistic or well thought out goals. Like Winnie, many people will work for weeks but fail to arrive at the results that the team is seeking. Thus, always clarify the expectations with your client, boss, or manager. Here are some questions that you might want to ask:
What does success with this particular project look like? What is the time frame for the project? What is the scope of the project? Are we aiming for broad strokes and concepts or drilling down to granular details?
Often, people with ADHD have dealt with many failures or disappointments earlier in their lives. Thus, they are burdened with significant self-doubt and shame and avoid checking in with the team or manager or asking for feedback, fearing the exposure to potential criticism.
In addition to clarifying expectations, it is essential that you get feedback on your work throughout the project, especially early on in the process. One patient I worked with avoided asking for any feedback on a large project and after three months discovered that he had interesting ideas but these ideas were at odds with the team leader’s vision.
Winnie generally met with her manager on a monthly basis as part of the company protocol. However, I recommended that she also meet twice a week for ten minutes with her manager to make sure that her progress and quality of work is congruent with expectations. Winnie said that these biweekly meetings also helped her with accountability and improved her motivation and confidence level. Her manager also commented on Winnie’s dedication and newfound engagement.
Hand Write a Strategy
Winnie and many of my patients undertake large projects without having a written strategy. This is like sailing a ship to Europe without a compass or a map. Others may avoid taking on involved projects because they are overwhelmed by the idea.
Before you even start on any project, large or small, take out a sheet of paper or notebook and write down the specific steps for the project. And, I want to highlight the part about writing it out by hand. Often, people with ADHD are visual and kinesthetic learners. Writing out the plan by hand rather than typing it on a keyboard can dramatically improve your planning ability and creativity. It doesn’t have to be perfectly composed and it can be a dynamic and roundabout process. You may not even anticipate all of the steps at the outset. In that case, one of the steps might be to ask a trusted advisor a certain question or to do some research. Some of the steps may be too encompassing and may need to be broken down into smaller steps, especially if they are nebulous or seem overwhelming.
During one of our initial sessions, Winnie arrived at our session frantic about an upcoming presentation to a senior vice-president of the firm. Together, we developed a step-by-step, handwritten strategy for the presentation. By the end of our session, she was not only calmer but was enthusiastic about getting started. A few sessions later, she reported that the reception of her presentation was stellar.
Maintain a Coordinated Task list and Calendar
I have a saying with my patients: “If it’s not on the calendar, it doesn’t exist.” What this means is that if a task or to-do item is not entered or recorded on a specific time slot on the calendar, there is a good chance that it will be forgotten or “fall through the cracks”.
Once you have listed all the steps in the project, write each step at a specific date and time in your calendar. You may not know the specific times that an item can actually be completed or when a higher priority task may intervene. However, making an informed guess of the potential times when a task is likely to be worked on enhances the chances of your success as well as helps you to feel calmer and less overwhelmed moving forward. In addition, having a written calendar showing all of your tasks in one place helps you to prioritize and focus on the job at hand.
Other tasks, meetings, social or networking events, classes, and appointments should also be placed on your calendar. I recommend that people use a “week-at-a-glance” calendar in order to have an overview of the entire week showing how your different responsibilities and tasks interact and interconnect. I recommend an old-fashioned paper calendar, again, for the reason that people with ADHD often function better using handwriting rather than using a digital calendar on the computer.
Likewise, I recommend having a notebook, such as a hardcover Moleskin to use as your task notebook. Here you can write down all of your to-do’s in one place and avoid the problem of having items written in multiple places. Each page in the notebook represents a separate day and includes all tasks, phone calls, and notes that occur on that day. Again, each task should also be written at a specific time in the calendar.
Create Your Master Handbook
People with Adult ADHD often are oblivious to the “rules” of a company or team. These pieces of information may include the company-specific parameters of documents or presentations, file organization, and compliance regulations. It may also include passwords, protocols, and unwritten expectations.
One of my patients was required to organize a quarterly meeting including all of the upper-level managers with very specific requirements about invitations, reserving a conference room in advance, requesting guest speakers, and an enormous amount of small but important details. He would always get very nervous because he would usually forget many of the details of this process after the quarterly meeting. To help him we wrote out the specific pieces of information in his personal “Master Handbook”. Thus, each quarter, he had all of the details at his fingertips and subsequently felt calmer and in control of the situation.
Deficits in executive function are a major stumbling block and challenge of people with Adult ADHD. Using these organizational methods and strategies can greatly help improve executive functioning and achieve the success you are seeking in your personal and professional lives.
Over the ensuing months of treatment, Winnie started to improve. Initially, we met every two weeks to address strategies and skills. However, as Winnie began to incorporate the new behaviors, we didn’t need to meet as often and currently meet every month or two. During the past year, she has made tremendous progress and has been promoted a second time, to team leader. She manages a team of four and stays focused on her tasks, goals, and the progress of the entire team very effectively. Even though some tasks fall by the wayside and she doesn’t always adhere to the strategies perfectly, she has come a long way toward becoming a valued leader and integral member of the firm.
By using these strategies to improve executive function, many of my patients with ADHD have successfully improved their professional and personal effectiveness and it has been extremely rewarding to be a part of this journey. Some of these strategies might not apply to you or your work in exactly the same way. However, when people with Adult ADHD incorporate these strategies and fine-tune them to meet their individual needs, there can often be significant gains.
*Details have been altered to protect the confidentiality of all patients.