Enhancing Outcomes: ADHD Evaluations focused on Executive Function

Executive functioning can be defined as an overarching concept representing important cognitive processes, including planning, working memory, attention, inhibition, self-monitoring, self-regulation, and initiation. Challenges with executive functioning may not always be tied to a single diagnosis and can be observed across a large number of mental health, neurological, or behavioral disorders¹. Executive function plays a crucial role in problem-solving and reasoning, and difficulties with executive function can often make simple tasks challenging. A large body of research suggests that deficits in executive function represent a prominent feature of Attention-Deficit/Hyperactivity Disorder (ADHD) in both children and adults. Individual difficulties can range from emotional dysregulation and executive inhibition to inattention or the ability to persist over time toward a goal while resisting distractions². In fact, for children with ADHD, it’s estimated that development of their executive functioning skills may be up to 30% behind that of their same age peers³. Children with ADHD may exhibit specific problems with executive functioning according to their type of ADHD presentation, and their executive function impairments tend to reflect specific rather than global impairments.

How does measuring executive functioning inform the assessment of ADHD?

For most students, getting an evaluation for ADHD is the first step to understanding and managing ADHD symptoms and behaviors. These students may have deficits in executive function that can significantly impair their academic performance. They could have difficulty paying attention, daydream in class, or forget to turn in their homework. They could be easily distracted or have difficulty initiating or completing tasks. These challenges can extend to all parts of the individual’s life and may have substantial implications on everyday social functioning. Despite the strong association between ADHD and executive functioning, the heterogeneity of executive functioning difficulties among individuals has made it challenging to assess.Multi-informant rating scales are one effective way to gather information on behavioral and executive function challenges in individuals with ADHD,especially in the context of reported concerns and intervention goals.

The Conners 4th Edition (Conners 4^®) is an inclusive measure of ADHD that provides a comprehensive assessment of symptoms, impairments and common co-occurring problems and disorders in children and youth aged 6 to 18 years. The tool includes Content Scales that measure aspects of Inattention/Executive Dysfunction, Hyperactivity, Impulsivity, Emotional Dysregulation, Depressed Mood, and Anxious Thoughts, as well as functional impairments related to ADHD symptoms in the school, social, and family domains. The Conners 4 also addresses critical clinical concerns with Severe Conduct and Self-Harm Critical Items and a Sleep Problems Indicator.

Since ADHD and executive functioning challenges are intricately linked, adding an additional executive function evaluation to the clinical diagnostic assessment process offers an essential perspective on the actual influence of executive function in everyday life. These evaluations shed light on how individuals view their own executive function skills and how they are perceived by informants who can observe their behaviors, such as parents or educators⁴. The Comprehensive Executive Function Inventory™ (CEFI®) is a multi-informant behavior rating scale of executive function strengths and weaknesses in youth aged 5 to 18 years. The CEFI has a full-scale score that provides a convenient summary and is composed of items evaluating behaviors associated with Attention, Emotion Regulation, Flexibility, Inhibitory Control, Initiation, Organization, Planning, Self-Monitoring, and Working Memory. These narrower scales complement the Conners 4 and provide specific information regarding behaviors that may require intervention or suggest strengths of specific domains of executive function.

School-based evaluations for attention-related problems are typically conducted to determine if a student meets eligibility criteria for special education supports and services. Even if there is no ADHD diagnosis, the evaluation team can determine eligibility if the student displays limited ability to attend to educational tasks due to excessive distraction or attention problems that impact academic performance. An executive function evaluation may indicate behaviors that might be characteristics of ADHD. If the evidence supports substantial impairment in one or more activities at school, students may be eligible for a Section 504 plan and could get accommodations under the 504 plan or an IEP under the Individuals with Disabilities Education Act (IDEA). 

Here is a look at how the Conners 4 and CEFI can work together to enhance student success at school and beyond.

Data-driven determination of eligibility

Behavior rating scales, used in combination with classroom observations and interviews, provide a holistic picture of a student’s executive functioning in everyday activities and environments. These formal measures can help identify executive functioning challenges and associated behaviors interfering with a student’s ability to manage school-related tasks, home responsibilities, and social situations.

Take, for example, this scenario involving a 12-year-old male student. In this case, the school psychologist involved conducted a school-based evaluation due to concerns raised by the teacher regarding the student’s classroom performance. After all interviews were conducted, the school psychologist requested that the student, both parents and the teacher complete standardized behavior rating scales, which included a narrow-band ADHD assessment (the full-length Conners 4) and a measure of executive functioning (the CEFI) since the behaviors reported suggest challenges with attention and executive functioning.

Take, for example, this scenario involving a 12-year-old male student. In this case, the school psychologist involved conducted a school-based evaluation due to concerns raised by the teacher regarding the student’s classroom performance. After all interviews were conducted, the school psychologist requested that the student, both parents and the teacher complete standardized behavior rating scales, which included a narrow-band ADHD assessment (the full-length Conners 4) and a measure of executive functioning (the CEFI) since the behaviors reported suggest challenges with attention and executive functioning.

Greater insights through multiple informants

Employing multi-rater measures like the Conners 4 and the CEFI can provide greater insights into how behavior and executive function challenges are exhibited in day-to-day scenarios through the lens of parental and teacher observation and self-assessment. A parent or teacher may interpret a child’s symptoms and impairments differently based on their individual experiences with the child. A teacher could report a student’s planning ability in a structured school environment (involving academic tasks, deadlines, and group projects) differently from parents’ observations at home. More knowledge of executive function profiles, strengths and weaknesses, and informant discrepancies will guide educators, school psychologists, and care teams to provide tailored intervention and education plans.

Impactful IEP planning and goal setting

In addition to the Conners 4 and CEFI scale scores, education teams can look closely at the individual item-level to see which endorsed items within the various scales warrant further attention. This information can function as the baseline data for IEP planning. Once they have a well-defined baseline, education teams can craft concise and meaningful IEP goals. For instance, a student’s goals may focus on specific challenges around task planning, prioritization, and time management. In addition to these goals, accommodations such as visual aids, offering consistent reminders and follow-ups, and breaking down larger projects into smaller, more manageable tasks can be put into place to support the student in the education environment

A strength-focused approach

A crucial element of an IEP is recognizing and promoting a student’s strengths. Harnessing these strengths, identified by teachers and parents through formal assessments like the CEFI, Conners 4, and through anecdotal observations, is instrumental in guiding students toward their objectives. When crafting present levels of academic achievement and functional performance (PLAAFP) statements, it can be beneficial to start by describing the student’s strengths, capabilities, talents, and interests5. The IEP team can also effectively design and enhance learning and teaching opportunities by emphasizing these attributes. A student’s empathy, for example, can be a powerful tool in regulating emotion and fostering meaningful connections with classmates. Similarly, their ability to work hard and ask for help can be used to reach goals related to building, planning, and organizing. Focusing on these strengths can also foster stronger relationships between the education team and parents, empowering them to be effective advocates for their children even outside school.

Focused skill development

Integrating executive function skill development into a student’s intervention plan can greatly assist them in overcoming challenges and achieving academic success. It offers personalized assistance that caters to their specific requirements, resulting in better academic results, improved social and emotional competencies, and a boost in self-esteem. Interventions can be directed at both the individual and their environment6. While teaching the student executive function skills and motivating them to practice and apply them, the intervention plan can also be used to modify the task requirements and adjust the methods of support and cues provided within their environment7. For a student struggling with emotional regulation, as indicated in the Conners 4 and CEFI, behavior intervention plans can focus on providing training that enables them to identify the physical effects of emotions. Skills training in muscle relaxation techniques and deep breathing exercises may help alleviate some of the physical symptoms of negative emotions, especially anxiety.

Monitoring intervention effectiveness

The CEFI Progress Monitoring and Treatment Effectiveness Report provides information on the statistical significance of changes in scores over time for a single rater. When used in a school-based evaluation, CEFI results can be collected at the beginning of an intervention and at several points throughout the year to evaluate whether a particular plan is associated with behavioral improvement and to indicate program effectiveness.

Evaluating executive functioning plays a critical role in an ADHD assessment battery to optimize support for the student. Evaluations of executive functioning in the context of ADHD can assist school psychologists, educators, and parents in various ways to support students with executive functioning difficulties, ultimately improving outcomes for students facing ADHD-related challenges. Using the Conners 4 and CEFI together allows care teams to gain valuable insights into how ADHD symptoms and executive functioning deficits intersect, develop personalized IEP goals and intervention plans, and evaluate the effectiveness of interventions over time.

Have questions about how the Conners 4 and CEFI can provide better outcomes together? Get in touch with a member of our team!

 

References

[1]Goldstein, S., & Naglieri, J. A. (Eds.). (2014). Handbook of executive functioning. Springer Science + Business Media.

[2]Barkley, R. A. (2010). Differential diagnosis of adults with ADHD: the role of executive function and self-regulation. The Journal of Clinical Psychiatry, 71(7), 27654.

[3]Barrett, K. K. (2018). ADHD and the case for support through collegiate age: Understanding the lifecycle of developmental delays in executive function for ADHD and its impact on goal setting. Journal of Childhood and Developmental Disorders, 4(3), 11.

[4]DuPaul, G. J., & Stoner, G. (2014). ADHD in the schools: Assessment and intervention strategies. Guilford Publications.

[5]Elder, B. C., Rood, C. E., & Damiani, M. L. (2018). Writing strength-based IEPs for students with disabilities in inclusive classrooms. International Journal of Whole Schooling, 14(1), 116-155.

[6]Shuai, L., Daley, D., Wang, Y. F., Zhang, J. S., Kong, Y. T., Tan, X., & Ji, N. (2017). Executive Function Training for Children with Attention Deficit Hyperactivity Disorder. Chinese Medical Journal, 130(5), 549-558.

[7]Dawson, P., & Guare, R. (2018). Executive skills in children and adolescents: A practical guide to assessment and intervention. Guilford Publications.