Executive Skills & Inattentive ADHD Treatment

Executive Skills & Inattentive ADHD Treatment 

The ADHD medical community is coming to the consensus that prescription drug treatment for ADHD will need to be based mainly on the degree to which the patient's life is being disrupted by problems with their impulse control and problems with their working memories.

These two areas are controlled by the area of the brain that manages our executive function skills.  Most researchers agree that problems with the executive function skills are at the heart of a diagnosis of ADHD and that ADHD types are best identified by the degree of  problems that they have with individual executive function skills.

I have said before that Impulse control is where the rubber meets the road in ADHD and self-regulation or impulse control is one of the important executive function skills that should determines treatment. People with self regulation problems are a danger to themselves and to others. The second important executive function skill, that should guide treatment decisions, is the patient's scores on tests of executive working memory.  These two skills are extremely important. Executive working memory and self  regulation scores have been found, around the globe, to correlate with quality of life and academic achievement.

The reason that prescription drug treatment decisions should be based on measured deficiencies in Executive function skills such as these is that studies have found that the only patients who have a robust response to stimulant therapy are those with significant deficiencies in these skills.

The dose of stimulant medication required to control impulsive behavior and working memory problems will vary and depend on the degree of deficiencies and people without a significant deficiency will need other treatments. Some people with Inattentive ADHD have significant problems with working memory but most do not have problems with self-regulation while people with the Combined type of ADHD tend to have problems with both areas.

A small research study, (there were only 66 study participants), just published in Postgraduate Medicine has confirmed that Ritalin works best when given to patients with significant problems with self regulation and working memory. The authors reported that those with moderate or significant baseline Executive working memory/Self Regulation impairment showed a robust Ritalin response, whereas response for those with lower baseline impairments was not significant.

The authors went on to say that the implications for medication use and dosing, academic achievement, and long-term treatment efficacy are extremely important.  Many patients today have no idea where they score on tests of executive skills.  Their medical providers spend twenty minutes with them (if they are lucky) discussing their symptoms and they are then given a prescription for a stimulant.

These patients may go on to do well but they are more likely to stop the medication within the next 12 months.  Studies have found that two thirds of  all ADHD will no longer be taking their prescription medication a year after it is prescribed. Some will stop because of side effects, for some, the medicine will simply not help their symptoms, and others will stop for other reasons.  Clearly the medical community must do better in identifying and treating specific executive skill problems..

Postgrad Med. 2012 Sep;124(5):33-48. doi: 10.3810/pgm.2012.09.2592.
The effects of methylphenidate on cognitive function in children with attention-deficit/hyperactivitydisorder.
Kubas HA, Backenson EM, Wilcox G, Piercy JC, Hale JB.


Psychol Rep. 2011 Apr;108(2):477-86.
Executive functioning and positive psychological characteristics: a replication and extension.
Kruger GH.

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