EXECUTIVE DYSFUNCTION IN ADHD

Dr Devashish Konar MD Consultant PsychiatristMental Health Care Centre, Burdwan

Presented in IPS State Annual Conference, Kolkata, WBMob: +91 9434009113

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SYMPTOMS OF ADHD

There are three major categories of symptoms associated with attention deficit hyperactivity disorder (ADHD): Inattention HyperactivityImpulsivity Inattention itself can be divided into difficulty with selective attention and difficulty with sustained attention and problem solving.

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Inattentive symptoms

Selectiveattention

Sustained attention problem solving

Impulsive symptomsHyperactive symptoms

ADHD: DECONSTRUCT THE SYNDROME INTO DIAGNOSTIC SYMPTOMS

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MATCHING ADHD SYMPTOMS TO CIRCUITS

• Problems with selective attention are believed to be linked to inefficient information processing in the dorsal anterior cingulate cortex (DACC). • Problems with sustained attention are linked to inefficient

information processing in the dorsolateral prefrontal cortex (DLPFC). • Hyperactivity may be modulated by the prefrontal motor cortex

(PMC) • Impulsivity by the orbitofrontal cortex (OFC).

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Selectiveattention

Susta

ined att

ention

problem so

lving

Hyperactive symptoms

Impulsive symptoms

Dorsal ACC DLPFC

Orbitofrontal

cortex

Prefrontal motor cortex

MAIN CIRCUITRY INVOLVED IN ADHD

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IMPACT OF DEVELOPMENT ON ADHD

• The evolution of symptoms across the ages shows that although hyperactivity and impulsivity are key symptoms in childhood, inattention becomes prevalent as the patient ages. • Additionally the rates of recognized comorbidities increase over time.• This could be due to the fact that the comorbidities were overlooked in

children with ADHD, or because ADHD was never diagnosed in some patients presenting with anxiety or learning disabilities.

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CHANGING PROFILE OF ADHD: IMPACT OF DEVELOPMENT

ADHD CORE SYMPTOMS

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ADHD: OUT-OF-TUNE PREFRONTAL CORTEX

• Different brain areas are hypothetically important in the symptoms of ADHD. • Alteration within the orbitofrontal cortex (OFC) are hypothesized

to lead to problems with impulsivity of hyperactivity.• Inadequate tuning of the DLPFC or the dACC can respectively lead

to sustained or selective attentive symptoms.

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HISTORICAL BACKGROUND• The disorder currently identified as Attention Deficit Disorder (ADD) or Attention Deficit

Hyperactivity Disorder (ADHD) has been described in the medical literature with a variety of different labels for over 100 years.

• ADHD today is used to refer to Attention Deficit Disorder with and without hyperactivity. • Throughout most of those years, the emphasis has been on behavior problems of young

children who were seen as being overly active and not listening to others. • The term “attention” as a central aspect of the syndrome was not introduced into

diagnostic criteria until 1980 (American Psychiatric Association, 1980). • Until recently, this syndrome was classified in the diagnostic manual as a “disruptive

behavior disorder.” • Rapidly old model of ADHD is being replaced by a new understanding as a developmental

impairment of the brain’s self-management system, its executive functions. 11

RECONCEPTUALIZING ADHD• There is still widespread misunderstanding as to the disorder’s

nature. • Many clinicians mistakenly continue to think of this as a behavior

disorder characterized by hyperactivity in children and excessive restlessness or impulsivity in adults. • We need to re conceptualize ADD/ADHD as essentially a cognitive

disorder, a developmental impairment of executive functions (EFs), the self management system of the brain. • Impaired EF involves a pattern of chronic difficulties in executing a

wide variety of daily tasks. • Once recognized, this disorder can be effectively treated in most

cases. 12

WHAT IS EXECUTIVE FUNCTION?

• Executive function is a set of mental processes that

helps us connect past experience with present action.

• People use it to perform activities such as planning,

organizing, strategizing, paying attention to and

remembering details and managing time and space.

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THESE ARE SKILLS AND PROCESSES EACH OF US USE EVERY DAY TO:• Make plans• Keep track of time and finish work on time• Keep track of more than one thing at once• Meaningfully include past knowledge in discussions• Evaluate ideas and reflect on our work• Ask for help or seek more information when we need it• Engage in group dynamics• Wait to speak until we’re called on• Make mid-course corrections while thinking, reading and writing 14

IN TODAY’S PARLANCE• ADHD is not like having a problem with one software program that interferes

with only one type of functioning of a computer. • It presents ADHD as more like a problem with the operating system of the

computer, a broader, more foundational impairment that impacts a wide range of cognitive functioning.• Many other learning and psychiatric disorders could be compared to

problems with specific computer software packages which, when not working well, interfere just with write text, making slides, or doing bookkeeping. • ADHD might be compared instead to a problem in the operating system of the

computer which is likely to interfere with effective operation of a wide variety of different programs and functions. 15

CLUSTERS OF COGNITIVE FUNCTIONS THAT TEND TO BE IMPAIRED IN INDIVIDUALS WITH

ADHD.

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THE SIX EXECUTIVE FUNCTIONS

• Activation: organizing, prioritizing, and activating for work.• Focus: focusing, sustaining, and shifting attention to tasks.• Efforts: regulating alertness and sustaining effort and processing

speed.• Emotion: managing frustration and modulating emotions.• Memory: using working memory and accessing recall.• Action: monitoring and self regulating action.

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ACTIVATION

• Organizing tasks and materials, estimating time, prioritizing tasks, and getting started on work tasks. • Patients with ADHD describe chronic difficulty with excessive

procrastination. • They often put off getting started on a task—even a task they

recognize as very important to them—until the last minute. • It is as if they cannot get themselves started until the point at which

they perceive the task to be an acute emergency.

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FOCUS

• Focusing, sustaining focus, and shifting focus to tasks. • They say they are distracted easily not only by things that are going on

around them but also by their own thoughts. • In addition, focus on reading poses difficulties for many. • Words are generally understood as they are read but often have to be

read over and over for the meaning to be fully grasped and remembered.

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EFFORT• Regulating alertness, sustaining effort, and processing speed. • Many with ADHD report they can perform short-term projects well but

have much more difficulty with sustained effort over longer periods of time. • They also find it difficult to complete tasks on time, especially when

required to do expository writing. • Many also experience chronic difficulty regulating sleep and alertness.

They often stay up too late because they cannot shut their head off. • Once asleep, they often sleep like dead people and have a big problem

getting up in the morning. 20

EMOTION

• Managing frustration and modulating emotions. • Many with this disorder describe chronic difficulties managing frustration, anger,

worry, disappointment, desire, and other emotions. • They speak as if these emotions, when experienced, take over their thinking as a

computer virus invades a computer, making it impossible for them to give attention to anything else. • They find it very difficult to get the emotion into perspective, to put it to the back

of their mind, and to get on with what they need to do.

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MEMORY• Using working memory and accessing recall. • People with ADHD very often report that they have adequate or exceptional

memory for things that happened long ago but great difficulty remembering where they just put something, what someone just said to them, what they have just read, or what they were about to say. • They may describe difficulty holding one or several things “on line” while

attending to other tasks. • In addition, individuals with ADHD often complain that they cannot pull

information they have learned out of memory when they need it.

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ACTION• Monitoring and regulating self-action. Many individuals with ADHD, even those

without problems of hyperactive behavior, report chronic problems in regulating their actions. • They often are too impulsive in what they say or do and in the way they think,

jumping too quickly to inaccurate conclusions. • People with ADHD also report problems in monitoring the context in which they

are interacting. • They fail to notice when other people are puzzled, hurt, or annoyed by what they

have just said or done and thus fail to modify their behavior in response to specific circumstances. • They also often report chronic difficulty in regulating the pace of their actions, in

slowing self and/or speeding up as needed for specific tasks.23

EXECUTIVE FUNCTION IMPAIRMENTS: NOT LOCALIZED ONLY IN PFC

• Executive functions are complex and involve not only the prefrontal cortex, but also many other components of the brain. • Those with ADHD have been shown to differ in the rate of maturation of specific

areas of the cortex, in the thickness of cortical tissue, in characteristics of the parietal and cerebellar regions, as well as in the basal ganglia, and in the white matter tracts that connect and provide critically important communication between various regions of the brain. • Recent research has also shown that those with ADHD tend to have different

patterns in functional connectivity, patterns of oscillations that allow different regions of the brain to exchange information.

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ADHD AS FOUNDATIONAL DISORDERS FOR COMORBIDITIES• Several epidemiological studies have demonstrated that children and adults with ADHD have a much

greater likelihood of having one or more additional psychiatric and/or learning disorders at some time in their life than do those without ADHD.

• A meta-analysis of 21 studies showed that the likelihood of anxiety disorders, depressive disorders, or conduct/oppositional disorders among children with ADHD was respectively about 3 times, 5.5 times or 10.7 times in prevalence of those disorders among children with ADHD.

• Among adults with ADHD, the likelihood of their having one or more additional psychiatric disorders by age 44 years was more than six times greater than the likelihood for adults without ADHD.

• These elevated rates of comorbid disorders among persons with ADHD may be due partially to genetic factors.

• However, since executive function impairments of ADHD occur in many other learning and psychiatric disorders, it has been proposed that ADHD may be not just one additional psychiatric disorder.

• It may be a foundational disorder that underlies most other disorders.25

A Word About Medications• Evidence now shows that ADD is a highly heritable disorder, with

impairments related to problems in the release and reloading of two crucial neurotransmitter chemicals made in the brain: dopamine and norepinephrine. • These chemicals play a crucial role in facilitating communication within

neural networks that orchestrate cognition. • A massive body of evidence indicates that 8 of 10 individuals with the

disorder experience significant improvement in their functioning when treated with appropriately fine-tuned medications. • These treatments can compensate for inefficient release and reloading of

essential neurotransmitters at countless synaptic connections in the brain.26

EVIDENCES IN FAVOUR OF MEDICATIONThere are three different types of evidence that demonstrate the effectiveness of specific medications for ADHD improving impaired executive functions.

1. Imaging studies2. Performance3. Symptom relief

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MEDICATION ALSO HELPS THE PERSON IN LONG RUN• Despite the fact that the direct effects of medication do not last beyond

the duration of the medication’s action each day, the improved functioning made possible by the medication has been shown to result in better school classroom and test performance, reduced rates of school dropout, increased rates of graduation and other achievements which can have lasting effects. • Medications may also help to support a person’s adaptive performance

while they await further brain development, enter into employment for which they are better suited, and/or improve their learning of concepts and skills they would otherwise be unlikely to master without the support of medication. 28

GUESSING THE FUTURE

• Last two decades have taught us to challenge the old way of thinking.• Future is expected to be more revealing. • It demands from us to be more open to new ideas.• Any scientific advancement needs to modify our clinics.• Stay abreast and translate the knowledge into work.• Deconstruction and reorganization is on anvil.• Psychiatry is expected to see revival of phenomenology based on new understanding

of brain.• We also may like to get rid of checklist based diagnostic systems to make it more user

friendly for UG students and fellow professionals of other medical specialty. 29

THANKS