ADHD is a disorder of self-regulation and executive functioning. Executive functions are a set of cognitive processes that act as the brain’s management system. These mental functions help us “execute” any task in our daily life that is not reflexive or habitual. In school, executive functions are needed all day long for self-control, planning, and managing our behavior. Executive functions work together like a stack of blocks, to monitor and facilitate goal-directed persistence.
Many of the “behavioral” problems we see in the classroom in students with ADHD are due to delayed development in executive function. Leading researcher Dr. Russell Barkley, estimates that children with ADHD will demonstrate a developmental delay in executive functions, approximately 30% behind their neurotypical peers.
Evidence has implicated executive functions to impact occupational performance in children with ADHD. However, it is essential to note that a student can have deficits or delays in executive functions without having a diagnosis of ADHD.
Knowing what is behind common behaviors related to ADHD helps reframe the perceived harmful intent and frame practical supports and interventions. Below we unpack areas of executive functioning that commonly impact occupational performance in the classroom setting.
Response inhibition is the ability to control impulses, think before acting, pace our actions and manage extraneous distractions and irrelevant information. These skills begin to develop at 3.4 years and continue to develop into your mid-twenties.
The ability to control our impulses or inhibit our responses is a foundational executive function skill. Children with ADHD have significantly impaired ability to inhibit responses verbally, motorically, cognitively, and emotionally. They are often “ready, go” with thoughts about their actions coming moments later. Response inhibition fatigues quickly, making later in the day or extended periods of use challenging (eh..hm.. homework). If you have ever been on a diet, you can relate to how much easier it is at breakfast to resist treats than after dinner.
Difficulty with response inhibition in the classroom looks like:
- Problem with raising a hand before answering. Frequently calls out.
- Often out of seat
- Interrupting/Disrupting others
- Difficulty waiting for one’s turn
- Difficulty ignoring distractions while working
- Usually starts work without reading directions.
- Speaking without thinking
Working memory refers to the ability to temporarily hold limited pieces of information in awareness while processing them.
We rely on working memory when we do not have an external form of the information we need while performing a task. For example, we use working memory to remember a telephone number while looking for a pen to write it down. Likewise, we use it when we are introduced to someone new and need to recall their name to reintroduce them.
Working memory has a limited capacity. We can keep only a certain amount of information “in mind” at any time. Researchers debate the nature of this limit. Cowen et al. state that working memory storage capacity is limited to 3 to 5 meaningful items in young adults without using strategies. Our already limited working memory capacity is susceptible to distraction and the processing demands of a task. So that is 3-5 items on a good day as a neurotypical adult.
Children’s learning activities in the classroom impose significant burdens on working memory. For example, copying from the board requires the child to remember some information ( the sentence to copy) while doing something mentally challenging (recalling the spelling of the individual words in the sentence).
Deficits in working memory represent a core characteristic in a majority of children with attention-deficit/hyperactivity disorder (ADHD). Students with working memory difficulties can hold fewer pieces of discrete information in their minds at any moment. As the amount of information overloads their memory, they lose the crucial information needed to guide their actions. As a result, children with poor working memory often have problems following multiple-step instructions because they forget the instruction before the whole sequence is complete.
Working memory difficulties are often misinterpreted as misbehavior. When students repeatedly fail to follow directions, they can appear unmotivated and oppositional, which leads to conflict with teachers and parents and accusations of not trying hard enough. Kids with working memory deficits are criticized repeatedly for forgetting their belongings and blamed when needing multiple repeats of the same direction because they are “not listening.”
Typically, children with poor working memory may also :
- Exhibits place-keeping errors and constantly have to start over.
- Frequently lose track of their belongings.
- Have difficulty keeping track of what they have done and what still has to be completed.
- The student has difficulty following a sequence of steps, verbal instructions, or tasks (despite repeated reminders).
- Has trouble with activities that require both storage (remembering) and processing (manipulating information).They have difficulty taking notes and listening at the same time.
- They struggle with reading comprehension and must read texts repeatedly to understand.
- Struggles to understand the context of a story or a conversation.
- When called on, they forget what they were planning to say.
- Has trouble waiting for their turn, in a conversation, or in line to get help.
Cognitive flexibility allows us to adapt our thoughts and behaviors in response to a change in the task, consider other perspectives, and transition between activities. Cognitive flexibility is conceptualized by research as a later developing executive function made possible by maturity in inhibitory control and working memory.
Difficulties with cognitive flexibility impact the student’s behavior, social/emotional well-being, and academic success. A student with this challenge may seem stuck or rigid, unable to go with the flow or adapt to changing circumstances or new information. Transitions can be challenging. The student may have difficulty stopping the present activity and moving on to another, even one that is on their schedule and that they usually enjoy doing.
The student with developmental deficits in cognitive flexibility may have significant difficulty in the classroom:
- Tolerating transitions between tasks
- Handling unexpected change
- Accepting No for an answer
- Independently consider a variety of solutions in problem-solving
- Revising plans
- Move freely from one step/activity/situation to another.
Simply put, task initiation is the ability to get started on the task. Chronic difficulty with task initiation is excessive procrastination. Often the student with ADHD will put off getting started on a task, even a task they recognize as very important to them, until the very last minute. Some evidence views the excessive procrastination seen in ADHD as a difference in what is needed for motivation.
Difficulties with task initiation in the classroom :
- Difficulty beginning school work .
- Does not independently initiate new activities.
- Difficulty with excessive procrastination
- Does not seek and search for information
- Difficulty generating ideas
- Difficulty completing all aspects of an activity
ADHD has a developmental impact on the core executive functions of response inhibition, working memory, flexibility, and task initiation, which impact the student’s ability to demonstrate adequate performance in higher-level executive functions. Weakness influences performance in emotional regulation, time management skills, planning, prioritizing, and organization needed in the elementary classroom.
Ample evidence from psychological research documents that students with ADHD demonstrate emotional impulsivity and excitability and have difficulties effectively modulating the intensity of emotions. Emotional responses are often disproportionate to the context in duration, intensity and frequency. Difficulty with thought inhibition leaves children with ADHD prone to intrusive thoughts and cognitive distortions.
Children with emotional regulation difficulties may have difficulty with:
- Demonstrate a low frustration tolerance
- Appear impatient
- Difficulty with the ability to inhibit inappropriate behavior triggered by strong emotions
- Difficulty with the ability to self-soothe and down-regulate a strong feeling to reduce its severity
- Difficulty with the ability to refocus attention from emotionally provocative events
Time management is a complex executive function that involves various cognitive functions. To effectively manage time, students need to understand and interpret the passing of time an be oriented to the past, present and future. They need to be able to estimate the length of time required for activities, be able to initiate tasks on time, stop and change actions relative to time and resist distractions to remain on time.
Time processing ability develops during childhood, starting with time perception, the feeling of time passing. It is followed by time orientation, the ability to tell the time and know which day and month it is.
Children with ADHD may have deficits in BOTH time processing ability and time management skills that result in :
- Over or underestimates the length of time needed for a task
- Complains that things will take forever
- Is often tardy or late
- Is often last to line up
- Difficulties hurrying up if required.
- Difficulty adjusting work speed to fill the time available
- Difficulties with automatizing routines
- Difficulties understanding the concept of time and achieving an overview of time
- Difficulties planning and completing long-term projects
- Difficulty completing assignments in the time allotted.
The ability to create a mental roadmap to complete a task requires significant executive function . Completing tasks requires the ability to have a mental plan in place so that things get done. Student need to anticipate future events; prioritize , organize, manage time, and problem solve. The will have to manage extraneous distractions, irrelevant information, or interference; handle change and delay responses.
Children with ADHD may have deficits in planning and prioritizing that result in :
- Difficulty setting priorities
- Difficulty making decisions
- Difficulty determining what to study for on a test
- Appears inefficient in getting things done with no clear beginning and end
- Exhibit writing that doesn’t follow a logical sequence
- Become easily overwhelmed with long term projects or large assignments
- Difficulties with problem solving
Organization is the ability to create or maintain systems to keep track of information and materials. Effective organization skills require task initiation, working memory, planning, prioritizing and time management.
Children with ADHD often have difficulty with organizational skills that result in :
- Difficulty keeping belongings neat and in appraise locations
- Difficulty keeping desk tidy
- Difficulty keeping track of books, papers, pencils ect.
- Difficulty keeping backpack organized
- Not being able to find needed materials
- Frequently losing assignment or important papers
Students diagnosed with ADHD may have self-regulation and executive functioning difficulties that interfere with classroom occupational performance. With an explicit understanding of executive functioning and its implications for classroom performance, school-based occupational therapists can better delineate between challenging behavior and lagging skills . We can develop scaffolded interventions to support learning within the students’ specific context. The intersection of executive function and environmental demands is the focus of occupational therapy services in the educational setting.
School based OT can implement individualized environmental modifications and teaching strategies to scaffold EF and support occupational performance in the classroom.
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