In this issue, we focus on ADHD and concomitant impairments in executive functioning (EF), measurement of EF via neuropsychological testing, the effects of stimulants in the treatment of EF deficits, and a case study about a child with ADHD and dyslexia as well as EF deficits is presented and discussed. Recent journal articles are also reviewed and discussed.

We look forward to continuing to presenting you the latest findings in ADHD and comorbid mental health disorders.  Please visit the APSARD site for more information and membership.

Cordially,

Andrew A. Nierenberg, MD
Director, Bipolar Research Program
Associate Director, Depression Clinical and Research Program
Massachusetts General Hospital, Boston, Massachusetts
Professor of Psychiatry, Harvard Medical School, Cambridge, Massachusetts

Lenard A. Adler, MD
Professor of Psychiatry and Child and Adolescent Psychiatry
Director, Adult ADHD Program
NYU School of Medicine, New York, New York

Statement of Need
Longitudinal studies following children with attention deficit hyperactivity disorder (ADHD) into adulthood reveal impairments in various major life activities, particularly in executive functioning. [1]. When children with ADHD progress to adulthood, they tend to have lower occupational status and annual salaries than control groups followed to adulthood; worse employer-rated job performance; more job dismissals; rapidly changing jobs; less adequate in fulfilling work demands, less likely to be working independently and to complete tasks, and less likely to be getting along well with supervisors as rated by employers; and with poorer performances at job interviews and certain tasks at work too difficult for them. [2]

While the literature has defined executive functioning (EF) in a variety of ways, 2 descriptions stand out. Pennington stated that EF “is defined as the ability to maintain an appropriate problem-solving set for attainment of a future goal." [3] They include the components of: "a) an intention to inhibit a response or to defer it to a later more appropriate time; b) a strategic plan of action sequences; and c) a mental representation of the task, including the relevant stimulus information encoded in memory and the desired future goal-state." A different approach was described by Lezar who said EFs “consist of those capacities that enable a person to engage successfully in independent, purposive, self-serving behavior. [4] They differ from cognitive functions in a number of ways. Questions about executive functions ask how and whether a person goes about doing something (e.g., Will you do it and if so, how?); questions about cognitive functions are generally phrased in terms of what or how much (e.g., How much do you know? What can you do?)."

On the neurobiological level, recent advances have improved our understanding of ADHD and how it related to EF. The higher-order association cortices in the temporal and parietal lobes and prefrontal cortex (PFC) interconnect to mediate aspects of attention [5]. The parietal association cortices are important for orienting attentional resources in time and space, while the temporal association cortices analyze visual features critical for identifying objects/places. These posterior cortices are engaged by the physical characteristics of a stimulus, such as movement and color. Conversely, the PFC is critical for regulating attention. The PFC is important for screening distractions, sustaining attention and shifting/dividing attention in a task-appropriate manner. The PFC is significant in regulating behavior/emotion, especially for inhibiting inappropriate emotions, impulses and habits. Significantly, the PFC is needed for allocating and planning to achieve goals and organizing behavior and thought, the regulatory abilities referred to as executive functions. The intent of this issue is to explore the interconnection between executive functioning and ADHD, and to approach their relationship more accurately from a therapeutic standpoint.

Citations

Learning Objectives
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