What we know as ADHD, attention deficit hyperactivity disorder, or some people still call it ADD, attention deficit disorder, has been recognized by some doctors since way back in 1902, but from 1902 until 1980 it was all about little boys who couldn’t sit still, couldn’t shut up, and who were driving everybody nuts. It was just behavior problems.
The name of the disorder was changed a number of times and there are different formulations, but it was all about behavior problems. Since 1980, which is when they first changed the name of the disorder to include the words attention deficit, we’ve realized that this is not so much a behavior problem, but far more a problem with the brain’s management system, it’s executive functions, and we’ve also learned that there are many people who have ADHD who never had any significant behavior problems, and, but even for those who have, that’s usually the least of it.
It’s the attention problems that tend to make more trouble for people, particularly as they get a little bit older and more is expected of them for being able to manage themselves. One thing that’s important to be clear about from the very beginning is that ADHD has nothing to do with how smart a person is. There’s some people who have this who are like super, super, super smart, others high average, middle average, low average, slow. I treat people for this who are like university professors and doctors and lawyers and big shots in business.
A lot of people who are regular folks. Some people have trouble doing the basics. You can be anything along the IQ spectrum and still have ADHD. It has nothing to do with how smart you are. The other thing to know is that this is a problem, a set of problems, that include a wide range of characteristics, and what I’d like to do today is to describe for you some of the characteristics of what we call ADHD, give some examples of them, and then talk a little bit about what we know about what’s involved in the brain in the course of ADHD.
One thing that’s important is that one of the main things that people with ADHD complain about is they **** staying tuned. That when they’re listening or reading or working on something they get part of it, but then it sort of drifts off and then they’re back and then they drift off and it drifts off again and then they’re back. They have difficulty staying tuned. It’s similar in a way to the problem you have with a cell phone where you’re in an area where you don’t have good reception. You can get part of it and then the message keeps fading in and out.
The other thing is that they often have a problem with being distracted. Like anybody else, they see and hear things that are going on around them. They have thoughts going through their head, but most people if they have something they’ve got to focus on can push that stuff out of the way and focus on what they’ve got to do. People with ADHD it’s real hard for them to do that.
They’ll be sitting in a classroom trying to listen to what’s going on or perhaps they’ll be in a meeting or sitting down trying to read something or write something and somebody drops a pencil and they have to sort of check and see where did the pencil go, then they’ll be back on task again for a couple of minutes, then they’re thinking about some TV show they saw the night before, then they’re back on task again for a minute, then they’re thinking about some conversation they had with somebody 2 hours ago, and then they’re back on task again for a few minutes, and then they’re looking out the window like anybody else will from time to time, but they’re likely to sit and watch the squirrel go up the tree a little longer than somebody else and be checking out the traffic and the cloud formation, the guy who is mowing the lawn, then they’re back on task again for a few minutes.
They’ll be thinking about what they’re going to do when this is over and how soon is this thing going to be over anyhow. I’ve got things I’ve got to do and what am I going to have for supper tonight. I wonder what’s on TV tonight. All these things are coming in all at one time.
It’s almost like you’re trying to watch TV and you’ve got four different stations all coming in at the same time on one channel and it gets kind of hard to separate the signal from the noise, but the things that’s puzzling about this that really makes it very difficult for people to understand is for people who have ADHD it’s like that almost all the time, but not always.
Everybody I’ve ever seen who has ADD, and that’s a lot of people, has a few things they can do where they have no trouble paying attention, no trouble focusing. Let me give you an example. Sixteen year old boy I saw, he was the goaltender for his school’s ice hockey team, and it just happened that the day his parents brought him in to see me was the day after his team had just won the state championship in ice hockey, so they’re bragging a little bit at the beginning about how great he was in the tournament the day before, and apparently, he was a very good goalie.
They said when he was in there playing hockey he missed nothing. He knew where the puck was every second of the fast game, totally on top of it. The kind of goalie every team wants, smart kid, tested way high up in the superior range, wanted to get good grades, was hoping to go to medical school, but he was always in trouble with his teachers, and what they said was once in a while you’ll say something that shows how smart you are. We’ll be talking about something, you’ll come in with some comment that’s really very perceptive, and it’s quite impressive, but most of the time you’re out to lunch. You’re looking out the window, you’re staring at the ceiling, you look like you’re half asleep.
Half the time you don’t even know what page we’re on and the question they kept asking him was if you can pay attention so well when you’re playing hockey, how come you can’t pay attention when you’re sitting in class. Here’s another example. A lot of times parents will bring in kids for me to see and they’ll say now, the teacher says this kid can’t pay attention for more than 5 minutes.
We know that’s not true. We have watched her play video games and she can sit and play those video games for 3 hours at a time and not move, and the teacher said she’s easily distracted. That’s nonsense. When she’s playing those games, she’s locked on that screen like a laser and the only way you’re going to get her attention is to jump in her face or turn off the TV, so if can do it here, why can’t you do it there.
Now, it’s not always sports or video games. There’s some people with AD and they’re not good at that stuff. They might be into art and they’re sketching and drawing and really getting into it. Somebody else when they’re little they’re creating engineering marvels with Lego blocks and then when they’re older they’re taking car engines apart and putting them back together or designing computer networks, but everybody I have ever seen who has ADHD has a few things they can do where they have no trouble paying attention.
So, go back and look at those capacities that the frontal lobe is giving you as it matures and understand that ADHD and other disorders like it, but especially ADHD, restricts that development by 30 to 40 percent So, if you want to know how far behind somebody with ADHD is in self-regulation, conservatively take 30 percent off their age.
That’s where they are. By the way, the rule of thumb applies to a 24 to 30 years of age and then that’s it. It’s over. That is where you are going to stay through the rest of your lifespan. So, this helps you to understand then where are the clients we serve in their executive capacities. On average, people with ADHD are about 30 percent behind their age, which means that if you are about 16, you have the self-control of a 12-year-old. If they’re 21, it’s that of about a 14-year-old. Eventually, by the time you get up into your late 20s and early 30s, hopefully you’re somewhere around 18 to 22 years of age, but you’re not 30. You will always continue to make less mature choices than other people are likely to do but the point is this, the concept of an executive age allows us to adjust our expectations.
To change the environment around the affected individual in order to work with the executive age we have, not with the one we want, and that reduces conflict. So, it pays to think of the brain very simplistically as a knowledge performance device. The back part of the brain is where you acquire information. The front part of the brain is where you use it in daily adaptive functioning and ADHD separates those two parts, so it doesn’t matter what you know, you can’t do it as effectively ****.
You can’t use your learning and your information for social effectiveness over time. You can get 800s on the SATs and you will do stupid things, so it doesn’t matter what you know. What matters is do you apply it. Knowledge by itself is useless unless it is applied in human lives for effectiveness for adaptive and social activities. So, how then do we understand ADHD?
We can understand that ADHD disrupts the executive system causing a severe time blindness leading to a contraction in the hierarchy of the system, a contraction ****, and spatial and social aspects of the individual’s life. Since the executive system is future directed, ADHD is IDD, Intention Deficit Disorder. It means that ADHD is a disorder of performance, not knowledge, a disorder of doing what you have learned, not of knowing what to do, and the only way to deal with a performance disorder is to restructure the point of performance, the place in life where the problem is occurring. The further away in space and time you are from that point, the less effective your intervention will be. Performance disorders must be treated at points of performance. We know that to alter the executive **** of individuals over time, we are going to have to work within these five domains, information, maturation, accommodation, medication, and modification. So, what are the implications of an executive view of ADHD? Number one, the implication for treatment is obvious. This is not a skill disorder **** skill training. These people are not stupid and yet we bring them in and act as if they don’t know. Little children have no friends; oh, you need social skills training. ADHD adults can’t manage time; oh, you need time management training. People with ADHD have lousy working memory; we have them practice **** span back every night for 45 minutes in the place that we have somehow altered the executive deficit. You haven’t even come close. So, the point here is this. Don’t focus on the skills so much.
Restructure the point of performance. Follow what I call the 80/20 rule; 20 percent skill review to make sure they’ve got it, 80 percent changing that point of performance so that they **** it. The goal is to show what you know, not to sit around and teach. The teach and pray strategy failed. It’s time to give it up and move on to engineering environments around executive deficits, altering the scaffolding. Second, we have to design prosthesis environments and keep them in place. These are part official alterations that help reduce the individual’s impairment from their executive deficit, but a prosthesis does not get rid of the disorder; it reduces impairment from disorder. A ramp into this building is a prosthesis for people in a wheelchair but it does not get you out of the wheelchair. It allows you to do something you couldn’t otherwise do in that environment.
Remember, impairments are always setting specific. So, we are trying to lessen impairment from your disorder, re-altering, re-designing environments. The third, of course, is making sure it’s at the place where the problem exists, not in an office, not in a pullout service, not in a summer camp in Michigan. Where is the problem? That is the environment that requires restructuring. We need to understand it in the case of ADHD the origin of these deficits. It’s largely neurological and genetic, not social, not a choice, not due to video games or TV, or your diet, so we have the most **** aero genetic disorder in psychiatry in ADHD. What does that mean? It means that if you have a biological disorder, it is completely humane and rational to use copharmacology to compensate for that disorder. It is like insulin to a diabetic. Indeed, I tell patients, ADHD is the diabetes of psychiatry because it brings to mind the treatment model that you have to have in place in order to deal with this disorder but it also speaks to the need often for neurochemical alterations of the brain to help manage that disorder.
We can now refer to ADHD medications as neurogenetic therapies. That is no hypothetical. We have a very good idea of where they work in the brain, the alterations they make. We are even learning the genes and their polymorphisms that are building and operating these networks and how the drugs alter them. Perhaps, some day in the near future, we will simply do genetic testing in the office to tell us which drug is best for your kind of ADHD. So, this is a neurogenetic disorder. Neurogenetic therapies are completely rational and humane to be used with these individuals. Now, one thing I do want to point out. One of the greatest discoveries of the last 5 years in ADHD research, which you will never hear in the New York Times, because it is so biased against psychopharmacology for children. We now have 29 studies that show that the longer you stay on your medication, the more normal your brain becomes, so the children who take medication have brain development and brain functioning much closer to normal individuals than people who never take medication. By the way, this is only children.
There are no studies, and I’m not sure that it would work in adults anyway, because the brain is a lot less plastic, but notice by using these medications to keep these executive networks functioning at a higher level, you may start to see **** sprouting and brain growths in the areas that are crucial to executive functioning. This is known as neuroprotection and just last week, a meta-analysis of all of this studies was published arguing that we have evidence that ADHD medications may well partially normalize brain development and you won’t hear that in the media. What does that tell you about the bias of our media at this point in time? That is a major discovery. Now, we also need to understand that because ADHD affects timing, ADHD is not an excuse from this behavior. We do not excuse you from the consequences.
If the problem is timing, the solution is to tighten them up. A solution for somebody with ADHD is not no consequences, its nearer consequences; closer in time, more frequent, more salient, more accountable to others. The way you treat a temporal disorder is by adjusting the temporal parameters in the components of a contingency. If ADHD is destroying the cross-temporal organization of behavior, then stop requiring cross-temporal organization and make it much more immediate, much more salient, much more frequent, and more accountable to others. Behavioral interventions do this beautifully, but we need to understand that behavioral interventions aren’t training you out of anything. They are a prosthesis. They are an artificial means of sprinkling artificial consequences out there in the environment where they don’t naturally occur. There are ways of tightening up the temporal accountability. But just because you do this does not mean you have trained this person out of anything. Remember, there are two reasons you do behavior modification. One is instructional, which is why you do it for children with intellectual disability. Two is motivational and if you do it for its motivational properties, which is why we use it for ADHD, you cannot stop doing these things.
So, what that means then is that the compassion and willingness of others is the lynchpin to successful treatment. Are other people in the environment, the caretakers, the stakeholders, willing to modify points of performance to create that additional scaffolding, those additional accommodations to facilitate this individual’s functioning in that environment. Now, here are just a few things you can do if you wanted to practice your executive functioning, but time doesn’t permit me to go into those; I want to focus on these. There are several ways you would alter the point of performance to help somebody with ADHD or any other executive disorder. Number one; remember mental information is not guiding behavior. The working memory system is deficient. So, what’s the solution? Put the information back in the environment where it originated. The word is externalize as ****. You are more into the control of things in your sensory fields, so get the information back out there.
I need you to externalize time because the internal clock is broken, using timers, clocks, counters, and other timing mechanisms. We need to break lengthy tasks into very small quotas. Self-pacing so that the individual doesn’t have to cross temporally, organize or sustain. We are going to break the goal into smaller chunks and have the individual do smaller chunks at a time. We must use external motivators rather than rely on internal motivation. That’s what token systems do, points, privileges, money, all of those sorts of things, external motivators.
And then we must make problem-solving manual rather than mental because they can’t hold the pieces in mind in order to manipulate them to solve the problem. Finally, we need to remember that the executive system is a limited resource system and make sure that we do not defeat the system by demanding executive functioning for too long at a time.
There are various ways of dealing with that fuel tank. I’ll just list a few as I conclude here. If you want to boost your executive functioning, these are the things that will help you with your self-control. Notice they involved breaking tasks into smaller units using external reinforcement, using statements of self-efficacy and encouragement, using brief periods of relaxation in which you give the executive system a break, visualizing your goals and your consequences, and routine physical exercise improves the executive system and expands the fuel tank.
Finally, the entire fuel tank is based on blood glucose in the frontal lobe, so if you have protracted work to do that it’s ****, like taking a high-stakes exam or doing homework, you better be sipping on some lemonade or a sports drink, or something that creates a low infusion of blood glucose into that frontal lobe because that is the basis for all of that resource pool.
So, I hope you can see then that ADHD is an executive disorder even if the test batteries don’t pick it up, that the executive system is an extraordinarily important system comprised of at least seven mental faculties that then feed forward into human life to give us these five dimensions of human activity, and these activities are the basis of our social relationships, our cooperative activities, and our culture, and all of this is put at risk in individuals like those with ADHD who have either injuries or neurogenetic disorders of the executive system. Thank you.