Executive Dysfunction by Design: A Cognitive Accessibility Analysis of AI Support vs. Healthcare Barriers
Meredith Moore · 2025 · ASSETS 2025: 27th International ACM SIGACCESS Conference on Computers and Accessibility · doi:10.1145/3663547.3749831
Summary
This first-person autoethnographic experience report examines the paradox of how generative AI tools have become effective assistive technology for executive dysfunction while healthcare systems designed to provide ADHD treatment actively undermine the cognitive functions they are meant to support. Author Meredith Moore, drawing on lived experience as a person with ADHD, contrasts two parallel narratives. The first describes how AI tools like ChatGPT and Claude unexpectedly emerged as cognitive accessibility aids — not through any deliberate assistive design, but because their conversational interfaces naturally support executive function needs. These tools help with task decomposition (breaking overwhelming projects into manageable steps), decision-making scaffolding (narrowing choices to reduce decision fatigue), digital body doubling (providing an interactive presence that aids task initiation and sustained focus), and reducing cognitive load during complex multi-step processes. The second narrative details the cascading barriers embedded in U.S. pharmacy systems and ADHD medication policies. Because ADHD medications are Schedule II controlled substances, they require new prescriptions monthly with no automatic refills, creating a recurring administrative burden that demands the very executive functions ADHD impairs — remembering deadlines, initiating phone calls, navigating bureaucratic processes, and managing time-sensitive tasks under pressure. The paper documents how prior authorization requirements, variable pharmacy stock, and rigid prescription transfer rules compound into what the author terms "cascading access barriers" where each failed step triggers additional executive function demands. The analysis frames these healthcare systems as "disabling by design" — not through malicious intent, but through institutional prioritization of liability management and regulatory compliance over patient cognitive accessibility.
Key findings
The paper identifies several key insights through its comparative analysis. First, generative AI tools function as effective executive function support not because they were designed as assistive technology, but because their interaction patterns — conversational scaffolding, step-by-step guidance, patient repetition, and contextual memory — align naturally with cognitive accessibility needs. Second, the healthcare system creates a cruel irony: obtaining ADHD medication requires sustained executive function performance across multiple bureaucratic touchpoints, meaning the system is least accessible to the people who most need its services. The author documents specific failure cascades — a missed pharmacy call leads to medication gaps, which worsen executive dysfunction, which makes the next month's prescription process even harder to navigate. Third, the paper argues that Schedule II medication policies treat all patients as potential abusers by default, embedding surveillance and restriction into routine healthcare in ways that disproportionately burden people with executive dysfunction. The author proposes concrete design implications: proactive pharmacy notification systems that push alerts rather than requiring patients to initiate contact, streamlined prior authorization with automatic submission and status tracking, and AI tools intentionally designed with cognitive accessibility principles rather than accidentally providing them.
Relevance
This paper makes a compelling case for expanding how accessibility practitioners think about cognitive accessibility beyond digital interfaces. The healthcare barriers documented here mirror patterns found in many institutional systems — banking, insurance, government services — where multi-step processes with strict deadlines and no error tolerance create disproportionate barriers for people with executive dysfunction. For technology designers, the finding that AI tools accidentally became effective assistive technology suggests that conversational AI interaction patterns contain important cognitive accessibility principles worth studying and intentionally incorporating into future designs. The paper also raises important questions about the boundary between assistive technology and accommodation — when AI tools compensate for systemic barriers, does that reduce pressure to fix the underlying systems? Practitioners working on healthcare accessibility, form design, or any multi-step process should consider the cascading failure patterns described here as a framework for identifying cognitive accessibility barriers in their own systems.
Tags: executive dysfunction · cognitive accessibility · ADHD · generative AI · assistive technology · healthcare barriers · autoethnography · neurodivergence · medication access
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