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Dr. Thomas Brown Ph.D. Attention Deficit Disorder - The Unfocused Mind in Children and Adults
Dr. Thomas Brown Ph.D. Attention Deficit Disorder - The Unfocused Mind in Children and Adults
A Yale University Press Health & Wellness book is an authoritative, accessible source of information on a health-related topic. It may provide
guidance to help you lead a healthy life, examine your treatment options
for a specific condition or disease, situate a healthcare issue in the context of your life as a whole, or address questions or concerns that linger
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Thomas E. Brown, Ph.D., Attention Deficit Disorder: The Unfocused Mind
in Children and Adults
Ruth Grobstein, M.D., Ph.D., The Breast Cancer Book: What You Need to
Know to Make Informed Decisions
James Hicks, M.D., Fifty Signs of Mental Illness: A Guide to Understanding
Mental Health
Mary Jane Minkin, M.D., and Carol V. Wright, Ph.D., A Womans Guide
to Menopause and Perimenopause
Mary Jane Minkin, M.D., and Carol V. Wright, Ph.D., A Womans Guide
to Sexual Health
Catherine M. Poole, with DuPont Guerry IV, M.D.,
Melanoma: Prevention, Detection, and Treatment, 2d ed.
Attention
Deficit
Disorder
The Unfocused Mind in Children and Adults
The information and suggestions contained in this book are not intended to replace
the services of your physician or caregiver. Because each person and each medical
situation is unique, you should consult your own physician to get answers to your
personal questions, to evaluate any symptoms you may have, or to receive suggestions on appropriate medications.
The author has attempted to make this book as accurate and up-to-date as
possible, but it may nevertheless contain errors, omissions, or material that is outof-date at the time you read it. Neither the author nor the publisher has any legal
responsibility or liability for errors, omissions, out-of-date material, or the readers
application of the medical information or advice contained in this book.
Copyright 2005 by Thomas E. Brown. All rights reserved. This book may not be
reproduced, in whole or in part, including illustrations, in any form (beyond that
copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except
by reviewers for the public press), without written permission from the publishers.
Designed by Rebecca Gibb. Set in Scala type by Integrated Publishing Solutions.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Brown, Thomas E., Ph. D.
Attention deficit disorder : the unfocused mind in children and adults /
Thomas E. Brown
p. cm. (Yale University Press health & wellness)
Includes bibliographical references and index.
ISBN 0-300-10641-6 (alk. paper)
1. Attention-deficit hyperactivity disorder. 2. Attention-deficit disorder in adults.
I. Title. II. Series.
RJ506.H9B765 2005
616.8589dc22
2005040895
A catalogue record for this book is available from the British Library. The paper in
this book meets the guidelines for permanence and durability of the Committee on
Production Guidelines for Book Longevity of the Council on Library Resources.
10 9 8 7 6 5 4 3 2 1
To my wife, Bobbie, with continuing love and gratitude for all you are,
all you give, and all we share together
Contents
Preface xi
Introduction xvii
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Contents
Resources 319
References 323
Index 349
ix
Preface
xii
Preface
Preface
xiii
xiv
Preface
Preface
xv
In Chapter 9, I explain options to alleviate ADD syndrome impairments with treatment. The first step in any treatment program is to provide accurate information to the patient and family about the nature and
course of ADD impairments. Since ADD syndrome is biochemically
based, the most eective treatment is usually medication. Recently, new
medications and new delivery systems for older medications have been
developed. I outline what is now known about safety, eectiveness, side
eects, and practical aspects of these medication treatments. The usefulness and limitations of behavioral treatments, accommodations, and
other supports for ADD syndrome are also described. I emphasize that it
is important to design for each patient a personalized treatment plan.
In Chapter 10, I provide examples of how untreated ADD syndrome
tends to erode hope, and how it can cause severe suering to individuals
and families. This chapter also describes fears, prejudices, and other factors that are barriers to seeking, obtaining, and sustaining adequate treatment. I contrast strategies that oer unrealistic hope with interventions
that nurture realistic hope in the daily lives of individuals and families
suering from ADD syndrome.
Many children, adolescents, and adults whom I have treated over the past
twenty years have contributed to what is written here. Their names and
identifying data have been removed, but I remain very grateful for their
comments and stories, which have infused my understanding and these
pages with essential details of real life. I also appreciate deeply the encouragement of patients, parents, and professional colleagues as I worked
to write and publish these materials; their enthusiasm has sustained me
during the long process of turning ideas and images into sentences and
paragraphs.
For helpful comments on earlier versions of the manuscript I am indebted to Dr. Jay Giedd, Dr. Anthony Rostain, Dr. Rosemary Tannock, and
Dr. Margaret Weiss. Wendy Hill is the medical illustrator who provided
the excellent drawings that illustrate the text. Our son, Dave Brown, helpfully challenged my hesitations about trying to write for a wider audience
and our daughter, Liza Somilleda, contributed perceptive comments on
xvi
Preface
Introduction
Often people think of focus as holding a camera still and adjusting the
lens for a clear picture of an unmoving object. That is not the meaning of
focus in the title of this book. Rather, focus refers here to a complex, dynamic process of selecting and engaging what is important to notice, to
do, to remember, moment to moment. Much as a careful driver focuses
on the task of driving a car in heavy trac by actively looking ahead while
also checking mirrors, observing road signs, braking, and so on (all while
monitoring dashboard gauges, keeping in mind the speed limit and destination, and ignoring the temptation to look too long at interesting
sights), a person employs this very active, rapidly shifting, repeatedly readjusted deployment of attention and memory as the focus needed to plan
and control ongoing activity. Such focus is extremely dicult for the 7 to
10 percent of the worlds population who suer from a syndrome of cognitive impairments currently known as attention deficit disorder (ADD) or
attention-deficit hyperactivity disorder (ADHD).
Syndrome is a term that describes a cluster of symptoms that tend
to appear together. For example, nasal congestion, sore throat, headache,
fatigue, and fever often appear together as a syndrome commonly referred
to as a cold. One single cause or a variety of dierent causes might lead
to one common syndrome.
xvii
xviii
Introduction
Introduction
xix
xx
Introduction
Introduction
xxi
Chapter 1
MYTH: ADD is just a lack of willpower. Persons with ADD focus well on
things that interest them; they could focus on any other tasks if they really
wanted to.
FACT: ADD looks very much like a willpower problem, but it isnt. Its essentially a chemical problem in the management systems of the brain.
Most individuals who suer chronically from an impaired ability to pay attention are able to focus their attention very well on activities that interest
them. So why cant they pay attention during other activities that they recognize as important? To answer this riddle, we have to look more carefully
at the many aspects of attention, recognizing that processes of attention in
the human brain are more complex and subtle than we might have imagined. One way to understand the complexity of attention is to listen carefully to patients with ADHD as they describe their struggles with inattention. Meet a patient of mine, a teenaged hockey player whom Ill call Larry:
Larry, a sturdy, sandy-haired high school junior, was sitting in
my oce with his parents as we began our first session together.
While introducing the family, the parents mentioned that Larrys
hockey team had just won the state championship. Proudly they
told of how well he had played. As goalie he had successfully
blocked thirty-four shots in the championship game and led his
team to victory. Larry smiled modestly, but with obvious and
well-deserved pleasure.
Then Larrys father stated their dilemma. When he is playing hockey, Larry is amazing in how he pays attention to all the
action. He knows where that puck is every second. He protects
the goal and at the same time he watches what the other guys
are doing and helps keep his team organized and motivated. He
is always totally involved and on top of his game.
But at school, his father continued, its an entirely dierent
story. We know that Larry is very bright. His IQ test scores show
hes in the superior range, in the top 3 percent. Usually he scores
high on semester exams and he did very well on the PSAT, but
his day-to-day work and his report card grades are always up and
down, from A+ to almost failing.
We know Larry wants to get good grades. Hes always talking
about how he wants to become a doctor and how he needs to get
his grades up so hell get into a good college and then medical
school. But for years he has been totally inconsistent in his
schoolwork. Once in a while we see him burning the midnight
oil to do some reading or write a paper, but most of the time
he procrastinates and avoids his schoolwork. Were constantly
getting complaints from his teachers, the same frustrations
every year.
They say that once in a while Larry will make some comment in class that shows how smart he is, how well he understands whatever they are working on. Once in a while hell write
an excellent paper or do an amazing job on an assignment. But
most of the time, the teachers are complaining that Larry is uninvolved and out to lunch. Hes not a behavior problem, but he
is gazing out the window or staring at the ceiling. They say that
in class discussions he often doesnt even know what page they
are on. And were always getting reports that his homework is
late or just not done.
How can Larry be so amazingly good at paying attention
to his hockey, and yet be so amazingly poor at paying attention
to his schoolwork?
Larry had been staring at the carpet as his father spoke, but
then he raised his head. His eyes were moist as he quietly said
to his parents, I dont know why it keeps happening. Im just as
frustrated and even more worried about this than you are. When
I saw my last report card, I went to my room and cried.
I know what I have to do and I really want to do it because
I know how important it is for all the rest of my life. I try to get
into it like Im into hockey. Sometimes I can get into it for a
while, for this assignment or that class. But mostly I just cant
make it happen.
I really want to, and I know I should be able to do it; I just
cant. I just cant make myself pay steady attention to my work
for school anywhere near the way I pay attention when Im
playing hockey.
A very similar dilemma was experienced by Monica, a shy girl in fifth
grade who hung her head as her mother angrily described to me her problems in school.
Her teachers say she cant pay attention for more than three
minutes at a time. I know thats not true! Ive watched her play
Nintendo. She can play those video games for three hours at a
time without moving. And the teacher says shes easily distracted. Thats nonsense! When shes playing those video
games shes locked onto that screen like a laser. When shes into
those games the only way you can get her attention is to jump in
her face or just turn o the TV.
Ive done everything I can think of to get her to shape up in
school. Ive gotten daily reports from school and praised her
when she did well. Ive tried to bribe her with rewards for good
work. Ive tried punishing her, taking away her Nintendo or making her do long time-outs in her room. None of it works. I know
she can pay attention when she really wants to. I dont know
what else I can do. Shes not a dumb kid and shes not a bad kid,
but if she doesnt start paying attention to her schoolwork pretty
form. But if the task you are trying to do is not intrinsically interesting, if it doesnt turn you on, then you cant get it up. You
cant make it happen. Its just not a willpower kind of thing.
Facets of Attention
What do we mean by paying attention? Over one hundred years ago,
William James wrote:
Everyone knows what attention is. It is the taking of possession
by the mind, in clear and vivid form, of one out of what seem
several possible objects or trains of thought. Focalization, concentration of consciousness [is] its essence. It implies withdrawal from some things in order to deal eectively with others,
and it is a condition which has a real opposite in the confused,
dazed, scatter-brained state which . . . is called distraction.
(1890, vol. 1, pp. 403 404)
James held what I call the spotlight theory of attention: the notion
that attention is a solitary, powerful beam focused by the mind on some
objects or trains of thought (in Jamess words) selected from the many
other perceptions and ideas that might otherwise be attended to in that
same moment.
This spotlight theory is too simple. It describes only certain types of
attentionvisual attention, for example, in which one looks steadily at one
point rather than flitting around aimlessly to see many dierent points, or
simple auditory attention, in which one listens to one sound, or a series of
sounds, while ignoring others. But when we look carefully at the descriptions of Larry and Monica, for example, we notice that they do many things
at once. They are not only watching and listening to what is happening on
the screen or on the ice, but also engaging in complex actions that may
occur simultaneously or in rapid-fire sequence. As Monica plays her video
games, she is not simply staring at the TV, but also actively monitoring
rapid movements of many objects on the screen, deciding which ones
might enrich or destroy her icon. She responds quickly by pressing control
buttons and guiding her icon with adept movements of the controls. Mon-
ica keeps track of her score and her levels in the game, all while recalling
and engaging strategies useful in earlier games. She also contains her alternating feelings of frustration and triumph so that she can attend to the
game without overreacting to its ever-changing ups and downs.
Likewise, Larrys success on the hockey rink depends on multifaceted
and simultaneously implemented aspects of attention. He not only tracks
the puck in its quick movements around the ice, but also monitors his
teammates and opposing players, trying to anticipate moves and to alert
his defensemen to dangers and opportunities. Simultaneously, he keeps
track of the passage of timehow many minutes or seconds are left in the
period, or how soon a player will be released from the penalty box.
Larry also notices subtle cues of flagging eort in his teammates and
calls out to encourage and challenge them. He stops himself from thinking too much about a goal he just blocked or one that just got by him into
the net. He keeps in mind and tries to follow tips given by his coach in
practice last week or during the momentary time out. And he tries to ignore provocative actions and comments from opposing players or spectators. All this and much more is included in Larrys paying attention while
he is playing hockey.
Larrys father suggested even broader meanings of attention when he
spoke of how Larry exercised year round in the gym to stay in shape for
hockey and how he pushed himself hard to build strength, endurance,
and skills during team practices. He elaborated on how Larry planned his
daily schedule to be on time to every practice. And he told of how carefully
Larry managed his equipment, keeping his skates sharp and his pads and
uniform in good repair. He related how this boy attended special training
clinics and studied plays of college and professional goalies so he could
use their strategies to improve his moves on the ice. From this description
it was clear that Larry gave intense and continuing attention to hockey in
a wide variety of complex ways.
The Many Components of Inattention
If attention is more than just a simple beam of focus, we can reason
that inattention is multifaceted as well. When teachers and parents
10
11
12
13
Most of the time hes totally spaced out. Last Saturday he set out
to fix a screen upstairs. He went to the basement to get some
nails. Downstairs he saw that the workbench was a mess so he
started organizing the workbench. Then he decided he needed
some pegboard to hang up the tools. So he jumped into the car
and went to buy the pegboard. At the lumberyard he saw a sale
on spray paint, so he bought a can to paint the porch railing and
came home totally unaware that he hadnt gotten the pegboard,
that he had never finished sorting out the workbench, and that
he had started out to fix the broken screen that we really needed
fixed. What he needs is a lot more awareness of what he is doing.
Maybe that medicine our kids are taking can give him that.
From this wifes description one might conclude that the central problem of ADD is essentially a lack of sucient self-awareness. She seems to
believe that if only her husband were more steadily aware of what he is
doing, he would not be so disorganized, jumping from one task to another
without completing any single one. But most people do not require constant self-awareness to complete routine tasks. For most people, most of
the time, operations of executive functions occur automatically, outside
the realm of conscious awareness. For example, while driving a car to the
local supermarket, experienced drivers do not usually talk themselves
through each step of the process. They do not have to say to themselves:
Now I put the key in the ignition, now I put my foot on the brake, now I
turn on the engine, now I check my mirrors and prepare to back out of my
driveway, and so on. Most experienced drivers move eortlessly through
the steps involved in starting the car, negotiating trac, navigating the
route, observing trac regulations, finding a parking place, and parking
the car. In fact, while they do these complex tasks they may be tuning their
radio, listening to the news, thinking about what they intend to fix for supper, and carrying on a conversation with a passenger. Eective execution
of multiple and concurrent tasks involved in driving to the supermarket
requires extensive use of executive functions, most of which operate without any conscious eort. Many other routine tasks of daily lifefor example, preparing a meal, shopping for groceries, doing homework, or par-
14
15
if one is to write productively. Grainne Fitzsimons and John Bargh (Fitzsimmons and Bargh 2004, Bargh 2005) have summarized research showing that progress on many complex tasks rests on ones ability to carry out
most of the task using such automatic self-regulation.
Executive Functions and the Brains Signaling System
Recognition of the amazing fact that executive functions generally operate
without conscious awareness oers an important caveat to my use of the
orchestra conductor as a metaphor for executive functions. Some might
take my metaphor literally and assume that there is a special consciousness in the brain that coordinates other cognitive functions. One might
picture a little man, a homunculus, a central executive somewhere behind
ones forehead, exercising conscious control over cognition like a miniature Wizard of Oz. Thus, if there is a problem with the orchestras playing,
one might attempt to speak to the conductor, requesting or demanding
needed improvements in performance.
Indeed, this presumed conductor or controlling consciousness is
often the target of encouragement, pleas, and demands by parents, teachers, and others as they attempt to help those who suer from ADD. You
just need to make yourself focus and pay attention to your schoolwork the
way you focus on those video games you love to play! they say. Youve got
to wake up and put the same eort and energy into your studies that you
put into playing hockey!
Those who care about persons with ADD and witness their poor performance in important tasks routinely prod them to deal with their impotence in the face of those tasks by insisting: Just make yourself do it! We
can all see that you have the ability. Its just a matter of realizing what is
really important and exercising willpower! Alternatively, they may impose
punishments on the person with ADD or shame them for their failure to
make themselves do consistently what they ought to do. These critics
seem to assume that the person with ADD needs only to speak emphatically
to the conductor of their own mental operations to get the desired results.
But in reality there is no conscious conductor within the human
brain. Further, each individual can only use what is made available by his
16
or her own neural networks. If the persons neural networks for executive
functions are impaired, as they are in ADD, then that individual is likely
to be proportionally impaired in the management of a wide range of cognitive functions regardless of how much he or she may wish otherwise.
There is now considerable evidence that persons appropriately diagnosed with ADD suer from significant impairments in executive functions of the brain. These functions are not all localized in a single area of
the brain; they are decentralized, with many supported by complex networks within the prefrontal cortex. Some essential components of executive functions are supported by the amygdala and other subcortical structures, while other executive functions depend on the reticular formation
and portions of the cerebellum located in the posterior of the brain. Figure 3 in Chapter 3 shows these and other critical regions and structures of
the brain.
Complex neuronal networks link the various structures in the brain
that sustain executive functions. Rapid-fire messages of input and output
travel these networks via low-voltage electrical impulses that can traverse
the entire system in much less than a millisecond. The ecient movement of these electrical impulses along the network depends on the rapid
release and reuptake of neurotransmitter chemicals, which carry each
message across synapses, or the connections between neurons, much as
a spark jumps the gap of a sparkplug.
To do this work, each of the 100 billion neurons in the brain depends
on one of the fifty or so neurotransmitter chemicals manufactured within
the brain. Without the eective release and reuptake of the needed neurotransmitter chemical, that portion of the neural network cannot eectively
carry its messages. There is now considerable evidence that executive
functions of the brain impaired in ADD depend primarily, though not exclusively, on two particular neurotransmitter chemicals: dopamine and
norepinephrine.
The most persuasive evidence for the importance of these two transmitter chemicals in ADD impairments comes from medication treatment
studies. Over two hundred well-controlled studies have demonstrated eectiveness of stimulant medications in alleviating symptoms of ADHD. Al-
17
though these medications are not eective for all persons with ADHD, they
work eectively to alleviate ADHD symptoms for 70 to 80 percent of those
diagnosed with this disorder. And the medications used to treat ADHD
symptoms tend to alleviate many symptoms of ADHD simultaneously.
The primary action of medications used for ADD is to facilitate release and to inhibit reuptake of dopamine and norepinephrine at neural
synapses of crucially important executive functions. As Antonio Damasio
(1994) emphasized,
Without basic attention and working memory there is no prospect of coherent mental activity. . . . They are necessary for the
process of reasoning, during which possible outcomes are compared, ranking of results are established, and inferences are
made. (p. 197)
ADD medications help to release dopamine or norepinephrine across the
synaptic gap between neurons and to hold it there long enough to pass the
message along. Medications that do not act powerfully to facilitate release
and to block reuptake of dopamine and norepinephrine tend not to be
eective in alleviating ADD symptoms.
Improvement produced by stimulants generally can be seen within
thirty to sixty minutes after an eective dose is administered. When the
medication has worn o, ADD symptoms generally reappear at their former level. Stimulants thus do not cure ADD symptoms; they only alleviate them while each dose of medication is active. In this sense, taking
stimulants is not like taking doses of an antibiotic to wipe out an infection;
it is more like wearing eyeglasses that correct ones vision while the glasses
are being worn, but do nothing to fix ones impaired eyes. This eect has
been demonstrated repeatedly in over two hundred medication treatment
studies that were double-blind: that is, neither the doctors nor the patients
knew during the study who was being given real stimulant medication
and who was being treated with placebos.
Given the often dramatic alleviation of ADD symptoms experienced
by 70 to 80 percent of persons diagnosed with ADHD when they take
stimulant medications, it is very dicult to sustain the notion that ADHD
18
impairments are a matter of a lack of willpower. Prior to beginning medication treatment most ADHD patients have made heroic, though often
erratic, eorts to improve their situation with willpower alone. Usually such
eorts barely work, if at all, and cannot be sustained.
Some argue that improvement in ADD symptoms requires not only
willpower, but also intensive behavioral treatments. Results of a major
study sponsored by the National Institute of Mental Health (MTA, 1999)
challenged this assumption. In the study, 576 children diagnosed with
ADHD were randomly assigned to one of four groups, which received
either:
Comprehensive behavioral treatment with no medication,
Carefully managed medication treatment with no other treatment,
A combination of comprehensive behavioral treatment with medication management, or
Community treatment with a pediatrician or another caregiver of the
familys choice.
The results of this study were striking. Stimulant medication alone,
carefully monitored for each child, was of significantly greater help than
the best battery of behavioral supports that could be developed without
medication. More surprising, children who received the combined treatment (medication and comprehensive behavioral treatment) showed no
better improvement of their core ADHD symptoms than did children
treated only with carefully managed medications. Combined treatments
were more helpful with some related problems, but nonmedication treatments, even at their best, did not improve the core symptoms of ADHD anywhere near as much as did the carefully monitored medication treatment.
This study, described with many others in Chapter 9, stands as powerful
evidence that impairments of attention and memory associated with ADHD
result primarily from malfunctions in parts of the brains neural networks
that depend on the chemicals dopamine and norepinephrine.
Much more remains to be learned about how the brains complicated
neural networks operate to sustain the broad range of functions encompassed in attention. Yet it is clear that impairments of executive func-
19
tions, those brain processes that organize and activate what we generally
think of as attention, are not the result of insucient willpower. So in fact
there is an answer to the mystery of inattention illustrated by the experiences of Larry and Monica. Neural chemical impairments of the brains
executive functions cause some individuals who are good at paying attention to specific activities that interest them to have chronic impairment
in focusing for many other tasks, despite their wish and intention to do
otherwise.
Imagine a large carton filled with photographs taken throughout your life.
The carton is filled with snapshots of you and various family members
roller skating or riding bikes, fishing o a pier or swimming in a lake,
dressing up for Halloween or setting o for the first day of school. Some
are posed with you in your Scout or Little League uniform or in costume
for a dance recital. Others are candid shots taken around a birthday cake,
in the midst of holiday celebrations, or at other memorable moments.
Given a box of such photos all mixed together, you might want to sort
them to take a more systematic look. There are many ways you could do
the sorting. You might put together all photos of a certain kind of activity,
regardless of time or place: all of the holidays, vacation shots, or birthday
parties. Or you might sort according to age periods, for example, all elementary school snapshots together, then all high school photos, then
those taken in college, and so on. Yet whatever sorting scheme is used to
organize your photographs, and regardless of how many snapshots are in
each group, those photos can capture only fragmentary, fleeting glimpses
of actual life experiences. Descriptions of the process of attention are like
those snapshots.
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21
22
Organizing,
prioritizing,
and
activating
to work
Focusing,
sustaining,
and shifting
attention to
tasks
Regulating
alertness,
sustaining
effort, and
processing
speed
Managing
frustration
and
modulating
emotions
Utilizing
working
memory
and
accessing
recall
Monitoring
and selfregulating
action
1.
Activation
2.
Focus
3.
Effort
4.
Emotion
5.
Memory
6.
Action
nosed with ADHD report significant chronic diculties in at least some aspects of each of these six clusters. Impairments in these clusters of cognitive functions tend to show up together; they appear clinically to be related.
In addition, these clusters of cognitive functions tend to improve together. When an individual with ADD is treated with appropriate medication and shows significant improvement in one of these six clusters, some
significant improvement is usually seen in aspects of the other five clusters as well.
Since these clusters of symptoms often appear together in persons
diagnosed with ADD and often respond together to treatment, it seems
reasonable to think of these symptoms of impairment as a syndrome. Because this syndrome consists primarily, though not exclusively, of symptoms associated with the disorder currently classified as attention-deficit
hyperactivity disorder, I refer to it as ADD syndrome. Taken together, the
six clusters in this model describe my understanding of the executive
functions of the brain.
Although this description of the brains executive functions is derived
primarily from studying persons with ADHD, it should be noted that
these executive functions can become impaired in other ways as well. In
Chapter 8 I describe how impairments of executive functions similar to
ADD syndrome can result from other causes, other psychiatric disorders,
23
and even from later stages of normal aging. In this chapter I use examples
from individuals with ADHD to describe how each of the six clusters
works and, for some, doesnt work.
Cluster 1: Organizing, Prioritizing, and Activating for Tasks
Although many people associate ADD with impulsive and hyperactive behavior where aected individuals are too quick to speak or act, diculties
in getting started on tasks are a primary complaint of many individuals
with ADD syndrome. Though they may be impulsive in some domains of
activity, those with this syndrome often complain that procrastination is a
major problem, particularly when they are faced with tasks that are not intrinsically interesting. Often these individuals lament that they keep putting o important tasks until the task has become an emergency. Only
when faced with dire consequences in the very immediate future are they
able to get themselves motivated enough to begin. This persistent problem in getting started was described by a patient of mine, an attorney, who
was quite successful in many aspects of his work, but who nevertheless
sought evaluation and treatment. His chronic procrastination, together
with other ADD symptoms, had put him at serious risk of getting fired.
All my life Ive had trouble getting started on my work when I
have to work by myself. I dont have any trouble when Im talking with clients or working with other lawyers or working with
the secretaries. But when Im in my oce and Ive got paperwork to do, I just cant get myself started. A couple of times a
week I set aside several hours for paperwork that I want to get
done. I need to get it done because I dont get paid until its
done. I block out several hours to do it and Im in my oce
with all the materials I need in front of me. But I just cant get
myself to start it. Usually I end up turning on my computer and
sitting in the oce doing email, checking some news sites, and
playing video games. I have to shut it o every time the secretary
comes in so she doesnt see what Im doing.
The end of the day comes and my work isnt even started. I go
home and have a bite to eat and watch some TV. Then about
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ent, she made no eort to store the bills where she would easily remember to pay them at the appropriate time.
Many people with ADD syndrome have problems regarding money.
They tend to make purchasessometimes relatively small ones like a
new shirt, book, or CD; other times larger ones like expensive clothing,
computers, and so onon the basis of how much money they anticipate
taking in. Frequently they do not take into account how much of their incoming money is already committed to standing expenses like monthly
rent or car payments. This diculty is especially acute with plastic
money. Many are shocked to discover how much they have run up in
high-interest credit card debt. They tend to think of each purchase as a discrete event without realizing how these purchases and the associated interest fees are accumulating.
A similar tendency to ignore realistic limitations is often seen in the
to do lists kept by some persons with ADD syndrome. Though they may
be very intelligent about other things, many seem clueless about how
many tasks they can actually accomplish within a single day or week.
Many create lists with thirty or more items for a single day, some of which
are time-consuming projects that no one could actually accomplish in a
month. They seem to have great diculty figuring out how long a task will
take and then prioritizing by putting some items ahead of others, deferring some to another day, or simply recognizing some as currently not
possible.
Cluster 2: Focusing, Sustaining, and Shifting Attention to Tasks
One of the most common complaints of persons with ADD syndrome is
that they cannot focus their attention on a task and keep focusing as long
as necessary. Sometimes their problem is one of selection. They find it
very hard to focus on the particular stimulus that requires attention: the
voice on the telephone or the words printed on the page.
One high school student compared his problem to the diculty of
keeping the radio signal when driving too far away from the radio station.
In my classes I always get part of whats being talked about. But
no matter how hard I try, I keep losing track of whats happen-
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may go over each word of the passage, but after a few pages they realize
that they havent the foggiest notion of what they have just tried to read.
Although the sounds of each word may have been adequately decoded, the
message of the words has not. Comprehension of the meanings of sentences and paragraphs is an active process that requires the sustained, active engagement of the readers focused attention.
Another facet of the problem of not being able to focus on an intended
task is excessive distractibility. Even when they have focused on a task,
whether reading, listening, or trying to do some other work, persons with
ADD syndrome often feel themselves drawn away by distractions. Like
anyone else they see and hear things going on around them and they have
many thoughts continually going through their head. But unlike most others, who readily block out distractions in order to do what needs to be done,
persons with ADD syndrome have chronic and severe diculty screening
out those distracting stimuli. They cannot ignore the myriad thoughts,
background noises, and perceptions in the surrounding environment.
I really try to keep my mind on what my teacher is saying, but I
just cant stay with it for long. All this other stu keeps popping
into my head. Ill be listening to what she says and then somebody drops a pencil and I have to stretch my neck and look over
and see where it fell. Then Ill be listening to the teacher again
for a couple of minutes and pretty soon Im thinking about
some TV show I saw the night before. I still hear her, but Im
not getting what shes saying.
And then Ill stop myself and start listening to try to figure
out whats been going on. Then in a couple of seconds Ill start
wondering about what I am going to do after school today and
who I could call to go out tonight. And then Im looking at the
clock and wondering how soon this class is going to be over. All
this stu is going on in my head at one time. Its like youre
watching TV and youve got four dierent stations coming in on
one channel. Its kind of hard to keep following the one youre
trying to listen to.
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in shifting focus. The same individuals who have chronic diculty with
getting distracted and drifting o task report that they sometimes have the
opposite problem: they are unable to stop focusing on one thing and redirect their focus to another when they need to. Some call this hyperfocus.
They describe it as locking on to some task, sight, or sound they are interested in while totally ignoring or losing track of everything else, including some things they ought to attend to, like looking ahead while driving
the car or answering someone who has directly spoken to them. This is
what Monicas mother described in Chapter 1 as her daughter locking onto
video games like a laser so that one can get her attention only by getting
in her face or turning o the television. Many persons with ADD syndrome report that they get stuck in this way while using their computer.
When I log on to the Internet, I come under a hypnotic spell.
Usually it starts out with just checking my e-mail. Then I get
caught up for a while reading various Listservs I subscribe to
and writing responses to notes from my friends. After that I
usually switch over to check on the various news sites to see
what has been happening. And then I think of some other site
I like that I havent visited for a long time, so I head for that. It
always seems like just a few minutes, but then Ill look over at
the clock and see that Ive been online for three or four hours.
My wife tells me that she tries to talk to me while Im online,
but I dont even hear her. I guess I just shut the whole world out
and totally immerse myself in whatever Im doing on the computer. Even when I know I should get o to help put our kids to
bed or to do some work I need for the oce the next morning,
I just cant pull myself away from it.
Sometimes this same thing happens at work. Last week I got
so involved in researching online for a project I had been assigned that I totally lost track of time and was twenty-five minutes late for a meeting with my boss. I knew I had the meeting
and I had planned to be right on time because hes a stickler for
promptness. He wasnt too happy when he had to send his secretary to get me for the meeting.
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The problem of becoming engrossed doesnt happen only with computers. Sometimes it occurs in conversation. Friends and relatives often
report that persons with ADD syndrome frequently persevere in talking
about something in which theyre interested when the conversation has
already moved on to other topics. This problem may be especially common during arguments, when the individual with ADD syndrome is presenting a particular point of view with such intensity that he is unable to
take into account other perspectives.
Some persons with ADD syndrome report similar problems in writing. While trying to compose a letter, responses to an essay exam, a report,
or some other written project, they find themselves stuck on one phrase
or one particular sentence, working and reworking it in an eort to make
it perfect. Meanwhile, their time to complete the exam has elapsed, their
interest in completing their letter has dissipated, or their deadline for
completion of the project has passed.
Maintaining eective attention requires the ability to select the most
important of countless external and internal stimuliand screen out
those that intrude on awareness. Yet it also requires the ability to shift
ones focus of attention as needed, to attend to other words, images, sounds,
feelings, topics, and matters. People with ADD syndrome often report
chronic diculty in focusing their attention, in sustaining their focus of
attention, and in shifting their focus of attention as needed to meet the demands of learning, work, social interactions, and the countless tasks of
daily life. As in the other clusters of symptoms described here, these
diculties occur occasionally for everyone. But for persons with ADD
syndrome they seem to be more persistent, pervasive, and problematic.
Cluster 3: Regulating Alertness, Sustaining Eort,
and Processing Speed
Many with ADD syndrome report that they frequently become very
drowsyto the point where they can hardly keep their eyes openwhen
they have to sit still and be quiet. Some describe themselves as borderline
narcoleptic. Usually this is not a problem when they are physically active
or actively engaged in conversation. But it can pose serious diculties
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when they are trying to listen to a lecture or proceedings of a meeting. Getting drowsy is especially problematic when they try to read, particularly if
what they are reading is not especially interesting to them. Similar diculties occur for many when they sit down to write an essay or report. Some
report the same drowsiness when they are driving long distances on a
highway, without the stimulation of having to negotiate heavy trac or the
possibility of observing many people. As one college student described it:
Im OK if Im on my feet and moving around, or if Im talking a
lot. But if I have to sit still and be quiet, I start getting drowsy.
The worst is if I have to sit through a long lecture or in a double
period seminar or meeting where you cant talk or I just dont
have much to say. My eyelids get so heavy. I have to struggle to
keep them open. Its really embarrassing to be sitting there obviously nodding o, especially if you happen to be sitting up front
where the professor is looking right at you. Now you may think
this is just because Im up partying too late the night before, but
thats not it. A lot of other guys in my dorm stay up late, but I always go to bed early.
Last spring at the end of the semester, I had gone to bed really early the night before so I could be alert. It was the last class
of the term and the professor was going to be telling us what to
study for the final exam. So I got there early and had my notebook ready and as soon as he came in and started talking I was
taking really good notes. The next thing I knew the class was
over and I was just waking up as everybody was picking up their
stu and walking out. I had great notes on the first eight or ten
minutes of class, and then I just nodded o and fell sound
asleep.
This problem of drowsiness in ADD syndrome is not simply a matter
of being overtired; it can occur when the person is well rested. Often individuals with this diculty report that they become suddenly reinvigorated when they join in conversation at the meeting or if something especially interesting arises in what they are reading. Likewise, the drowsiness
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disappears when the lecture or meeting ends and they get up to begin
some other activity.
From these clinical descriptions, it appears that this problem of drowsiness when sitting still and being quiet is related not to being overtired, but
rather to chronic diculties in sustaining alertness. It is as though individuals with ADD syndrome cannot stay alert unless they are engaged actively in a behavior that provides steady motoric, social, or cognitive feedback. They seem to need to feel themselves in motion, hear their own
voices, or be very actively engaged in internal conversation with what they
are trying to read.
Though the problem of daytime drowsiness aicts many with ADD
syndrome even when they are not tired, heavy eyelids sometimes appear
for a dierent reason. Many with ADD syndrome report that they are often
tired during the day because they have chronic and severe diculties in settling into sleep, even when they are very tired and want to fall asleep. This
is the opposite pole of the same problem: diculty in regulating alertness.
Parents often report that their children with ADHD have chronic diculty falling asleep, even when the hour is late and the kids are obviously
exhausted. Some adults with ADHD have similar problems. Here is one
example:
My mother tells me that from my first few months she always
had a hard time getting me to settle down for sleep. I was never
much of a nap-taker and always a night owl. She always said I
didnt want to close my eyes because I was afraid I would miss
out on some interesting action. I dont know what the reason is,
but I do know that even today I still have a lot of trouble getting
myself to fall asleep. I can be dead tired, my eyes blurry and almost ready to collapse, but then I lie down on my bed and I just
cant get my head to shut o so I can get to sleep. It just keeps
going over whatever Ive been thinking about. Usually I have to
listen to music or watch TV so I can block that other stu out
and get to sleep.
Once I get to sleep, I usually sleep like a dead person. They
could drop a bomb in my bedroom and I wouldnt even notice.
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That was a big problem when I was in high school. I was always
missing my bus and late for school. It took my parents about ten
tries to get me up every day. They would make noise and pull
the covers o of me and Id just mumble or swear at them and
roll over and go back to sleep. This is even when I had especially
asked them to get me up on time so I wouldnt lose credit for my
early classes.
It was even worse when I got to college because I couldnt
wake up from any alarm clock and my roommates never wanted
to take on the job of getting me out of bed. The only thing that
worked was when I lived in the fraternity house and could make
the pledges do it. Later, when I got married, my wife took it over.
This vignette illustrates dual aspects of the problem in regulating alertness commonly reported by persons with ADD syndrome. It is as though
they get stuck in whatever level of activation they are in, unable to release
themselves from full consciousness to enter sleep, or sleeping so soundly
that eorts to awaken them resemble eorts to raise the dead.
In addition to chronic problems in regulating alertness and vigilance,
many persons with ADD syndrome also report great diculty in sustaining eort for work tasks. Though they may have a virtually inexhaustible
reservoir of energy for tasks intrinsically interesting to them, they tend
quickly to run out of steam when engaged in jobs that require sustained
eort with little immediate reward. Here is one example:
If Im doing something that I can get done quickly in one
chunk, Im usually OK. I love it when people in the oce call
me to troubleshoot some problem in dealing with a client or
even to help them fix some glitch in their computer. If I could
do that kind of quick fix stu all the time I would be a great
worker.
Its the long-term projects I have trouble with, the kind of
thing where you cant get it done in one chunk in a few minutes
or even in a few hours or a whole daythose projects where you
have to keep chipping away at it because it just cant be done
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even in one day. I fade out fast on those things. I start out saying
to myself, OK, Im really going to apply myself to this job and
keep working steadily on it, one chunk a day until its finished.
But pretty soon Im getting bored and losing interest. So I usually end up just saying to myself, Hurry up, slap-dash. Lets just
get this damn thing done without worrying about how good it
is. Or sometimes I dont even get that far. I just put it o until it
becomes more of an emergency. My mind is much more of a
sprinter. Ive never been much as a long-distance runner.
The example of this sprinter highlights an important question: how
does a person keep going to complete a task that doesnt oer an immediate reward? Another clue to the dilemma comes from a college student:
In our psychology course we just finished studying about laboratory rats and how they keep pressing this little bar in their cage
longer if they get a reward like a food pellet only once in a while.
On the results chart you could see how a rat that got a food pellet for every press of the bar would quickly quit pressing the bar
if you stopped giving the pellets. But those rats that got the pellets only once in a while, they kept up pressing for a long time
after the pellets stopped coming. I guess they figured that if they
kept up pressing a little longer, sooner or later another one of
those pellets would be coming to them.
I think Im a lot like the rat that has to be getting a pellet for
every press of the bar, otherwise I just lose interest and give it
up. I know Id be a lot better o if I could keep myself going
longer. I always stop reading a book if it doesnt seem interesting in the first chapter. I just cant keep myself at it for long if
those pellets dont come quick and often.
Even when they do expend significant eort, many persons with ADD
syndrome report that they require an extraordinarily long time to complete
certain types of tasks because of a tediously slow processing speed. They
often complain that it takes them a particularly long time to read and write.
Sometimes slow processing time in reading results from the need to re-
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too loud. Chomp, chomp, chomp with every bite. The sound
of his noisy chewing quickly got on my nerves. It was driving
me nuts. It was like I had a computer virus in my head and it
was taking up all the space. Thats all I could think aboutthe
obnoxious sound of his chomping on his sandwich.
Suddenly I realized my fists were clenched and I was seriously thinking about getting up and smacking this guy in the
mouth! I didnt do it because I didnt want to get arrested. But
if I had been at home I would have been yelling at somebody.
After a few minutes, it was all over. He was still making the
same noises, but then it didnt bother me anymore. I just went
on with my lunch and started thinking about something else.
That sort of thing happens to me a lot though. Some frustration
that most people would consider a zero, one, or two on a tenpoint scale of frustration hits me as though it were a seven,
eight, or nine.
This mans analogy to a computer virus illustrates an aspect of emotional experience described by many with ADD syndrome: a feeling that
an emotion, in this case irritation, floods ones mind, taking up all available space. This overwhelming intensity of feeling then can cause one to
lose perspective and become, for a few moments or much longer, so preoccupied with that particular feeling that other relevant thoughts and feelings are displaced, ignored, or overlooked.
The immediacy of the emotion then can have too much influence on
thought and action, causing one to speak or act in ways that dont adequately take account of other feelings, ideas, or information that may also
be important. One high school student with ADD syndrome described
this as the cause of his diculties on the school debate team:
All my friends said I should join our schools debate team because they know how much I love to argue. I get really intense
in any argument. Once I get started I have to prove my point. I
get into it so much that Im like a bulldozer, running right over
everybody elses arguments, pushing their points down and
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pushing my points so much that they just have to give in. Lots of
times I get to talking really loud and practically shouting them
down. My approach didnt work very well on the debate team.
Last week I got kicked o the team. The coach said I have good
potential, but I just dont know how to listen and tie my points
to what the other team has been saying. He said I need to learn
to debate more like somebody playing chess and not so much
like somebody playing football. Hes probably right, but even
when I try to calm myself down, I have a really hard time holding back from pushing my point. When Im into my thing I just
cant listen very much to what the other guys are saying. Its like
there just isnt enough room in my head for what they are saying because Im so much into what I feel and what I want to say.
Friends and family members often complain of this intense singlemindedness of persons with ADD syndrome, because it can be very annoying and sometimes hurtful. They report that the individual with ADD
syndrome often reacts to even minor frustrations with intense outbursts
of anger. Sometimes the tirade includes very harsh words or actions. One
wife of a man with ADD syndrome described her experience this way:
It doesnt take much for my husband to lose his temper. Usually
he is in a pretty good mood, but then all of a sudden some little
frustration will set him o. Maybe someone else has eaten the
last of his favorite breakfast cereal or one of our kids forgets to
bring the trash cans from the driveway into the garage. All of a
sudden hell be shouting at the top of his lungs and getting in
your face about how nobody in the house cares about anything
and how we are all inconsiderate and lazy and worthless, never
doing anything right regardless of how many times he reminds
us. So far he has never hit any of us, but in those moments it always seems like he just might.
Usually this lasts for just a few minutes and then later hell
always apologize. But its hard to forget those comments he
makes. Seems like when he gets mad, all he can feel or think
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about is how mad he is. He just cant remember that the people
he is yelling at are people he loves and cares about. He forgets
that we can get hurt by what his says, especially when he comes
on so strong with it. Ive tried to talk with him about this and
he always feels bad afterwards, but it keeps on happening.
I know he loves me and loves our kids, but sometimes you
wonder.
This vignette illustrates a problem described by many with ADD syndrome. It resembles the computer virus in the head dilemma in the earlier example. A computer virus can suddenly gobble up all available space
in a computers operating system, crowding out all of the workspace so
the system cannot function. In a similar way, the overly intense frustration
often experienced by many persons with ADD syndrome can flood their
mind so much that, for the moment, they forget the vulnerability of the
loved ones whom they attack. Usually, as in this case, the outburst is intense, but totally verbal. Some individuals with ADD syndrome are less restrained in their anger. They often react to frustration by lashing out
throwing objects, banging doors, punching walls, driving recklessly, or
pushing or hitting people.
Everyone has had some experiences where, in a moment of intense
anger, they have said or done things hurtful to other people who did not
deserve such treatment. What is dierent for many with ADD syndrome
is that they tend to have a very low threshold for frustration and, as a result,
they experience these intense outbursts with greater frequency and intensity than most others. Unfortunately it is the people closest to them
their parents, siblings, spouse, children, or other loved oneswho most
often bear the brunt of such unrestrained attacks.
Irritability and anger are not the only emotions that are problematic
for persons with ADD syndrome. Many individuals with ADD have equal
or greater diculty modulating other emotions, such as hurt or sadness,
worry or anxiety. The salesman who had become so irritated by the loud
chewing also told a story about his problem with a dierent emotional
response:
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Last week in the oce I was walking down the hall when I saw
this friend who works in another department. He was looking
at some papers while he was walking. I said a friendly Hi and
thought he would stop and visit for a couple of minutes because I
hadnt seen him for a long time. But he just barely looked up and
mumbled a quick Hi back to me and kept right on walking.
Most people would just blow that o right away, figuring he
was just in a hurry to get someplace or preoccupied with whatever he was reading. Not me. I got to thinking about it over and
over. I kept wondering, Why wasnt he more friendly? Have
I done something to piss him o? Did I do something that annoyed somebody else in his department and now theyre all mad
at me?
All these thoughts kept going round and round in my head.
It was like that computer virus thing again only this time it went
on for most of the afternoon. I didnt get anything done for the
rest of that day. That sort of getting too sensitive and too worried
thing happens to me way too often.
While he recognized that there was probably a reason for the other
mans behavior that had little to do with him, the salesman continued to
ruminate for several hours, wondering about possible causes for the other
mans actions. Once again, the emotional virus was taking up a disproportionate share of the workspace in his head. Many with ADD syndrome
describe themselves as overly sensitive and reacting too intensely to
even minor slights or criticism.
A dierent problem in regulating emotions was described by a fortyfive-year-old man with ADD who noticed it only when he confronted that
problem in his son and was reminded by his wife about his own similar
tendencies:
Ive never been a very patient person. When I get an idea in my
head about something I want to do, or something I want to get,
or something I want to buy, that wish takes on such intense urgency that I feel Ive got to have this NOW! It almost doesnt
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cording to her he did have a few friends and spent time with them, but the
mother reported that even with his friends he had very little to say and
didnt show much pleasure.
What was striking about this adolescent boy was the change that occurred after his ADHD was diagnosed and treated with stimulant medication. Not only did the medication help to alleviate his diculties with
sustaining attention, completing tasks, and so on; it also brought a marked
improvement in his ability to initiate and sustain conversations with
friends and family. The stimulant also seemed to facilitate more spontaneous smiling and laughter. His family described him coming out of his
shell. The boy himself reported, I dont know why, but when Im on this
medicine I dont feel so bored. I feel a lot more relaxed and more like I
want to say things and talk with other people. My friends say Im more
with it when Im on it. But when it wears o or if I dont take it, I still
have that everything sucks feeling.
Not every patient with ADD syndrome experiences such improvements in mood and social interaction when on stimulant medication, but
many do. Whether their mood problems respond to stimulant medications or not, it appears that many with ADD syndrome suer from
chronic problems in managing frustration and modulating emotions.
Some have much more diculty with one class of emotions than anotherfor example, they are very consistently irritable or tend always to
be overanxious, or they are chronically oversensitive or consistently unhappy and withdrawn. Others appear to have many more problems than
their peers with modulating virtually every emotional response.
Some with ADD syndrome also meet full criteria for another disorder
that more directly reflects problems with managing one or more emotions, for example, an anxiety, depressive, or bipolar mood disorder. I discuss this overlap, which occurs very frequently, in Chapter 8. At issue in
these various examples is simply that persons with ADD syndrome, with
or without any additional psychiatric disorder, tend to suer from chronic
problems in managing frustration and other emotions. These chronic
problems appear to be an integral aspect of ADD syndrome and not just
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from memory the meanings associated with that word and hold those in
mind while linking them to meanings of other words to get the full meaning and context of the entire sentence. This process happens automatically for fluent readers as they rapidly link up and absorb layers of meaning built on words, sentences, paragraphs, chapters, and so on. Persons
whose working memory is significantly impaired, however, may experience great diculty in understanding an entire text, even if they are quite
competent in decoding each word. Reading comprehension is built on the
eective functioning of working memory in conjunction with an active,
sustained attention to the text.
Working memory is also essential for doing math, even simple arithmetic. If one cannot keep in mind what quantities have been borrowed or
need to be carried from one column to another in calculations, ones answers are not likely to be correct. And if one cannot keep in mind the sequence of operations, then much of algebra, geometry, and higher math
becomes incomprehensible.
Written expression also places strong demands on working memory.
One college student described how working memory problems interfered
with her writing:
When I write sentences to answer exam questions or to write an
essay or a term paper, I keep getting lost. I start out with one
thing I am trying to say and then I get going on that one thing
and forget about what I was supposed to hook it up with. Usually my answer doesnt really fit very well with the question.
Its even worse in longer writing projects like an essay or a
term paper. There Ill make a point and then forget to explain it
enough. Or Ill just wander o the path. Teachers are always
writing in the margins, Elaborate this more or How did you
get from what you just said to this? One teacher said that I keep
forgetting where I am supposed to be going. Shes right. When I
have to write longer things its like Im just wandering around
in what I write. I cant stick to the topic and then explain the
dierent parts to get to wherever Im supposed to take it.
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To write a paragraph, letter, or essay, one has to consider simultaneously many elements: Who is the audience? What is the major point? How
can I connect subordinate points to the main idea? Especially with longer
or more complex writing tasks, it is necessary to hold several viewpoints
in mind while putting words and images together understandably. This
process presents a major challenge to working memory.
There has not been much research on students who have problems
with written expression, but preliminary studies indicate that persons
with ADHD demonstrate a disproportionately high incidence of impairment in this respect. For reasons explained in Chapters 4 and 8, it is likely
that working memory impairments of ADD syndrome play a significant
role in creating diculties with written expression among ADHD students.
Working memory is involved not only in academic tasks, but also in
countless aspects of everyday life, as one holds briefly in mind the continuing flow of perceptions of current external eventssounds just heard,
images just observed, impressions just formed. Akira Miyake and Priti
Shah (1999) describe how working memory plays a crucial role in momentby-moment integration of memories held internally in long-term memory stores and those transient memories currently coming in from external sources:
During the performance of many (if not all) complex everyday
cognitive tasks, the processing of external information and internal information needs to interact dynamically, going back and
forth between information distributed across the internal mind
and the external world. . . . Working memory . . . may serve as
the important interface between external representations and internal representations. (p. 466)
Problems with integrating internal and external information can have a
substantial influence on ones ability to link new information being acquired with other information already in mind. One illustration is a student who had great diculty taking his SAT, a test required for college
admission.
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adequately control their actions. Children with ADHD have often been
seen as wild, restless, and impulsive, unable suciently to control their
words and bodies and so needing much more supervision from teachers
and parents than others of the same age. One mother described her sons
behavior:
My son is six years old, but he usually acts like he is only three
or four. When he wants something he just goes for it. He just
cant wait. He almost got hit by a car last summer because he
chased a ball out into the street and didnt even stop to look. In
kindergarten last year he was always in trouble because he
grabbed toys or crayons away from other kids. When they were
supposed to sit on the circle and listen for show and tell, he was
always interrupting with his own comments; he had to tell about
something he was thinking about. He couldnt just listen to another kid or even to the teacher. When he was supposed to draw
a picture or copy some shapes, he was always in a hurry. If he
tried to do what they asked him to draw or write, he did it too
fast and it was too messy.
This year he is repeating kindergarten, but Im afraid he
wont be ready for first grade even next year. He just doesnt
seem to be able to slow down enough to listen to the directions
or to do anything carefully. Hes way behind other kids his age
in self-control.
This mothers description shows many dierent ways in which her
six-year-old son is substantially behind his peers in his ability to monitor
and control his actions. He acts impulsively and doesnt slow down enough
to listen to others, to follow directions, or to do assigned tasks carefully.
Chronic and extreme problems of this sort are typical of many young children with ADD syndrome.
Researchers have identified impaired ability to inhibit as a core
problem in these hyperactive and impulsive symptoms of ADHD. Russell
Barkley (1997) has argued that impairment of the ability to inhibit is the
primary problem of persons with ADHD, and, of all the executive func-
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tions impaired in the disorder, is the one on which the development and
eective functioning of all other executive functions depends.
For some individuals with ADD syndrome, like this six-year-old, impairment in the ability to inhibit action is the most basic problem. Until
they can develop more age-appropriate control of their actionsthat is,
the ability to slow down and hold back so they can act carefully and do the
right thing at the right timethese individuals continue to make a lot of
trouble for themselves and those around them.
Yet to overemphasize inhibition as the central problem of ADHD is to
ignore the essential connection between holding back actions and engaging in actions. It is to overlook the need to go, which is as important as the
need to hold back or stop. Certainly it is important for a person to be able
to stop at the curb rather than impulsively running across a busy street.
But it is also important for that person to be able to monitor the trac on
the street, to determine when it is safe to cross, and then to actually cross.
Indeed, most behaviors require the ability to act, to do it, as well as the
ability to inhibit, to refrain from acting. And essential to ones success in
this regard is the ability to monitor the context of action, in this case, the
trac, so that one can decide when to wait and when to cross the street.
Monitoring the context of action can be quite complex, even in the
simple act of crossing a street. It involves looking both ways to notice oncoming vehicles, estimating their speed, and allowing for road conditions
for example, rain or ice that might aect their slowing down or stopping. It
also includes consideration of factors that might aect drivers ability to see
the person attempting to cross, such as sun glaring toward the driver, fog,
or darkness, as well as exceptional circumstances such as a car swerving
as though out of control or a vehicle speeding with flashing lights and siren.
Crossing the street also requires one to take into account information
about current personal circumstances that might aect the accuracy of
ones perception or ones speed and eciency of crossing. These variables
might include ones having poor vision for judging vehicles distance or
speed; feeling tired or having an injured foot; being unfamiliar with local
trac patterns; or being constrained by carrying bulky packages or having
to push a bicycle across the street.
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tend to be too random in what they notice, attending too much to some
details and too little to others that may be equally or more important. Especially dicult for these persons are those situations where one has to
monitor and gauge the emotions and intentions of other people with
whom one is interacting. Indeed, often persons with ADD syndrome complain that they have gotten into trouble because they have failed to notice
how others were reacting to them, or have been insuciently aware of
how they themselves were coming across to others. This monitoring is
made even more dicult when one is simultaneously holding in check
ones own reactions while interacting with others.
A forty-three-year-old man with ADD syndrome described his experience:
I love getting into intense conversations with other people where
its not just small talk. I love sharing impressions and opinions
between people about things that really matter. I think thats how
people get to know each other and learn from one another. Usually it works out well, but sometimes I get too intense and turn
other people o when Im trying to find out what they think and
why they think that way. Usually I dont notice it at the time; I
just see that they drop out of the conversation or walk away.
My wife says I just dont know how to keep my eyes open and
notice when others are starting to act uptight or bored with
whats being discussed. She says that most of the time I talk too
much or ask too many questions without noticing how I am
coming across and how others are reacting to what Im saying.
She says that most of the time Im too much mouth and not
enough eyes and ears when Im in a conversation.
This mans self-description highlights his diculty in self-monitoring
and context-monitoring during conversation. He emphasizes that he wants
to learn from others and share with others, but he frustrates himself, and
probably others with whom he talks, because he is not suciently attentive to facial expressions, tone of voice, or subtle eye or body movements
that signal tension, waning interest, or impatience. Careful attention to
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MYTH: Brains of persons with ADD are overactive and need medication
to calm them down.
FACT: Underactivity of the brains management networks is typical of
persons with ADD. Eective medications increase alertness and improve
communication in the brains management system.
Intertwined
neurons
Message
zips in
Message
zips on
Releasing transmitter
Neuron
Synapse
Reloading transmitter
Figure 2 Neurons releasing and reloading neurotransmitter. The neuron in
(A) is shown emerging from its matrix of intertwined neurons. Its twiglike
branches pick up information from other neurons and relay it through the
synapse to another neuron. (B) shows the release of a transmitter chemical
that helps the electrical message jump the gap to the adjoining neuron.
(C) shows the transmitter chemical reloading back into the sending neuron.
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nected by the corpus callosum, a dense band of 200 million fibers that
runs front to back and integrates operations on the two sides of the brain.
The corpus callosum is labeled in Figure 3.
In the past, the left hemisphere of the human brain was recognized as
dealing primarily with language data, while the right hemisphere was
seen as dealing primarily with visual and spatial operations. A dierent
picture emerges from more recent studies. Robert Ornstein (1997) has reviewed research suggesting that the right hemisphere tends to deal more
with getting the big picture, the wider range of possible meanings,
whereas the left hemisphere is better suited for dealing with more detailed
and focused sequential information. In his view, these two hemispheres
work together, with the right side more suited to recognizing the contextual forest while the left deals more with details of particular trees. Information flow in the brain thus involves not only circuits that pull together
information from local and regional centers across modalities of perception, but also circuits that criss-cross the hemispheres to sort out and integrate constantly shifting details, sequences, and contexts.
Central Management Networks
Given the steady flow of complex information processed in the brain, a
managerial system is essential. All neuronal networks are not created
equal. Some networks monitor, coordinate, and manage other neural networks. Networks that manage these functions constitute the matrix that
supports executive functions of the mind. These central cognitive management networks assess incoming information to establish and modify
priorities. They start, stop, and integrate various functions, deploying from
the brains vast stores of memories the particular information needed to
address the salient perceptions and tasks of each moment. These management networks are implicated in most of the impairments of ADD
syndrome.
Circuits that support these executive functions are distributed throughout the brain. This chapter highlights three major centers in which executive functions are based. From these centers (and others), circuits controlling executive functions project widely throughout the brains dense
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Cortex
Anterior
cingulate
Corpus
callosum
Prefrontal
cortex
Amygdala
Hippocampus
Ventral tegmental area
Cerebellum
Reticular formation
Locus coeruleus
matrix. Figure 3 shows these major centers of circuits for executive functions. One important center is the frontal region, particularly the prefrontal cortex, which is located just behind the forehead. Circuits important for assessing risks and rewards are located in the limbic regions
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deeper below the cortex. Centers that regulate alertness and vigilance are
at the back of the brain, just above the spinal column.
In the Prefrontal Cortex: Working Memory Circuits
The prefrontal cortex is a relatively small component of the human brain;
it takes up slightly less than one-third of the brains total volume. This central management center is connected directly with every functional unit of
the brain, those that:
receive sensory input,
control movement,
manage memory,
deal with emotion,
make decisions,
control activation, and
maintain stability of vital bodily functions.
The prefrontal cortex is the only segment of the brain so fully connected
with other aspects of the brain and the neural pathways that link them.
Among the many specialized aspects of the prefrontal cortex are circuits managing central working memory functions. Many people think of
memory as a self-contained function that, somewhat like a video recorder,
captures pictures and sounds of each moment of personal experience,
then files all of them in some cerebral vault for playback on demand. If
that were the case, the brain would quickly be flooded with so much information that eective action would be impossible. Research suggests
that the systems of memory are more ecient.
The brain has networks of neurons that very briefly hold in an active
state the perceptions and thoughts of each moment, linking them with
stored memories that allow the individual to string together experiences
moment by moment to make sense of what is being perceived or thought
and to act accordingly. This is working memory. Without it, an individual
is perpetually locked into the present moment, unable to link what was
seen, heard, or thought a moment ago with whatever is happening now.
The importance of this function is painfully evident when one observes a
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ing new memories and holding them over the longer term is seriously disrupted, or even reduced to total amnesia. The individual with a damaged
hippocampus may retain how to do it memories of certain limited skills
newly learned, but cannot consciously remember and describe what they
have learned. A more detailed description of how longer-term memories
are formed is beyond the scope of this chapter, but Joseph LeDoux (2002)
and Daniel Schacter (1996) have provided comprehensive and accessible
descriptions of those processes.
Working Memory: Search Engine for the Brain
The processes of working memory are complicated. They involve not only
briefly holding onto current information needed for current tasks, and
transiently holding information to be encoded into longer-term memory,
but also calling up those memories in longer-term storage needed for immediate tasks and experiences. Neuroscientists Stephen Kosslyn and
Olivier Koenig (1995) described these complex functions:
Working memory . . . corresponds to the activated information
in long-term memories, the information in short-term memories, and the decision processes that manage which information
is activated in the long-term memories and retained in shortterm memories . . . an interplay between information that is
stored temporarily and a larger body of stored knowledge.
(p. 388)
This interplay between a current focus of attention, some task or idea that
an individual is attending to, and that persons store of long-term memories is essential to countless functions in daily life where one must pull
out of the files of memory information needed for answering a question
or performing a task. This may involve recalling directions for driving to
the local shopping center, remembering specific aspects of learned information to answer questions on an examination, or recalling events and
characters encountered in earlier chapters of a novel when one resumes
reading the book several days later. Joaquin Fuster (2003) emphasized the
essential linkage between working memory and longer-term memory:
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The content of working memory essentially consists of longterm memory that has been activated for the processing of actions . . . attention is inseparable from selective neural processing. (p. 155)
But not all new information activated in working memory for current
tasks is held in lasting linkage with longer-term memories. What determines which information in working memory will be held onto and which
will be allowed to fade out? And what determines which information encoded in longer-term memory will be called into conscious attention and
working memory when it is needed? In short, what drives the file manager and search engine functions of working memory? One key element of these mechanisms is emotion.
Where the Brain Recognizes Risks and Possible Rewards
Circuits in the limbic region at the center of the brain beneath the cortex
manage the critical task of assigning emotional importance and priorities
to incoming perceptions and to internally generated thoughts and plans.
These circuits instantaneously assess what may be attractive, dangerous,
or rewarding.
Many think of emotion as a quality added to a perception or thought
on the basis of conscious reflectionfor example, I smelled something
burning and began to worry about whether there was a fire in the house.
I heard that song playing and began to feel sad; it reminded me of a girlfriend who left me. In these two examples something is noticed, thought
about, and then reacted to with an emotion, in this case fear or sadness.
But the process by which the brain links perceptions or thoughts and
emotions tends to be much quicker and less reflective. Usually the brain
assigns emotion and thereby importance in ways that are instantaneous
and automatic. Antonio Damasio described this process:
Emotion is critical for the appropriate direction of attention since
it provides an automated signal about the organisms past experience with given objects and thus provides a basis for assigning or
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withholding attention relative to a given object . . . first, processing of objects can take place; second, emotion can ensue; third,
further enhancement and focusing can occur, or not occur, under
the direction of emotion. (1999, p. 273, italics added)
The brain acts most quickly on perceptions that it judges as threatening. Joseph LeDoux (1996) and Elizabeth Phelps (2005) have described
how the amygdala, a tiny structure in the midbrain (see Figure 3), screens
incoming perceptions for any sign of potential danger. This structure, not
much larger than a walnut, receives constant input from all of the brains
lobes, and rapidly screens incoming perceptions and thoughts to determine whether they present any threat. It functions something like an automatic missile-avoidance system on a military aircraft.
It is this mechanism that causes one quickly to jump aside to avoid a
car that suddenly speeds around the corner as one is crossing the street.
The unexpected cars approach, caught only in the periphery of vision, is reacted to with instantaneous movement before one is even aware of being
afraid. The brain reacts without delay to unexpected objects moving quickly
toward us, to objects touched that are too hot, to substances that taste rotten; such self-protective reactions do not wait for conscious thought.
The brains recognition of some situations as dangerous, to be avoided,
extends far wider than these simple examples of possible threats to physical safety. From earliest infancy the brain builds up a massive file of
memories that can signal possible danger, not only from speeding cars or
possibly poisonous foods, but also from situations that might elicit other
kinds of pain, for example, ridicule, disgust, anger, or rejection from others. The networks of the brain are such that the amygdala and its connections will react to these acquired warnings with instantaneous release of
chemicals that activate avoidance responses, often without awaiting reflection. It is these chemicals, quickly attached to the perception or thought,
that create the fear and mobilize appropriate action.
While some fear reactions are based on instinct, many more are based
on personal memories. Contents of these files used to identify potential
dangers are highly individualized, gradually accumulated from the earli-
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Limbic Region
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Substantia
nigra
Prefrontal
cortex
Figure 4 Main pathways of the dopamine system. Dopamine pathways for executive functions originate primarily in the ventral tegmental area. They extend
throughout the prefrontal cortex and into limbic centers to release dopamine
in response to perceived danger or reward.
mine system for executive functions, in the ventral tegmental area, and its
major projections to other areas of the brain.
Once released by the ventral tegmental circuits, dopamine is carried
through two primary pathways. One pathway feeds dopamine to the prefrontal cortex, where action plans are selected. The other carries dopamine
to other regions that map and monitor the ongoing state of the organism
to reflect comfort, displeasure, and so on (Pennington 2002; Damasio
2003). Dopamine provided through these circuits provides incentive for
the brain to act when something important is noticed. This incentive is
likely to be provided without much input of conscious thought. Selection
and intensity of arousal, based on the individuals personal history, usually occurs as an aspect of perceptionhow this individual perceives any
given stimulus or situation at a given moment.
When an individual perceives a situation that for him or her appears
potentially rewarding, the brain suddenly releases more dopamine into
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quickly to abandon working and to ignore the task, even when the task
may be essential to life (Wise and Rompre 1989).
The brains reaction to the possibility of reward and to the threat of
negative consequences like loss or punishment is subtle and complex.
John ODoherty and colleagues (2001) used imaging studies to show that
the brain registers diering intensities of reward and punishment, even
when the rewards and punishment are merely symbolic. They focused on
a region in the front of the brain because previous studies had shown that
damage there causes humans to lose normal sensitivity to rewards and
punishment, whether potential or actual. When this area is damaged,
even persons who were previously cautious tend to become reckless gamblers oblivious to negative consequences, ignoring information that would
allow them to switch to more rewarding actions.
In the ODoherty study, the brain activity of adults was imaged during
repeated trials of a gambling game. On each trial they were to bet which
of two stimuli was the correct one. If they chose the correct one, they
were given a simulated money reward; the wrong choice caused them
to lose (in simulation) a portion of their accumulated rewards. Images
showed that one specific brain section increased activation when each reward was given while a dierent section increased activation in response
to each punishment. Not only was activation observed in diering regions
under these conditions, it was found to vary in intensity, proportional to
the magnitude of each reward or punishment.
If the brain can so sensitively react to dierent levels of simulated rewards and punishment in a gambling game that participants knew in advance would yield no actual gain or loss of actual money, how much more
does it react to the multiple rewards and punishments that are a part of
daily life? This mechanism by which the brain registers subtle levels of reward and punishment is crucial in many aspects of human living. These
circuits create shifting equations for motivation that guide operation of
those executive functions that activate people to work, help them sustain
eort, and coordinate their monitoring and self-regulation.
Mary Phillips and colleagues (2003a, 2003b) have described how
working memory depends on these processes of emotional weighting not
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only to figure out what stimuli are important enough to remember and act
on, but also to facilitate activation of memories from longer-term storage.
Phillips showed that emotional significance plays an important role in
culling memories related to specific tasks and situations as the individual
moves more or less seamlessly from one situation to another. The brains
processes of assigning emotional importance are crucial elements underlying multiple executive functions.
Brain Centers That Regulate Alertness and Fine-Tune Cognition
At the back of the brain are circuits that play important roles in regulating
alertness and fine-tuning cognitive processes. Systems of the brain that
control motivation, memory, and so forth are linked to the brains alertness and to cycles of wakefulness and sleep. Aspects of the warning system for potential danger continue to operate during sleep so that, for example, a person might awaken from slumber to the smell of smoke or a
sudden, unfamiliar sound. Yet for the most part, executive functions depend on the person being awake and not overly tired. Most aspects of the
brains executive functions require the brain to be open for business.
Regulation of the stages of sleep and alertness, or vigilance, is influenced primarily by two structures in the brain (Parasuraman et al. 1998).
One is the reticular formation in the middle of the brainstem near the
back of the head. This structure (shown in Figure 3) has widespread connections to receive and dispatch messages throughout the brain and spinal
cord. Antonio Damasio has described the complex connections from this
region:
The structures of the reticular formation, traditionally linked to
the control of sleep-wakefulness cycles and attention, are also
linked to emotion and feeling, as well as to the representation of
internal milieu and visceral states and autonomic control.
(1999, p. 259)
Another structure critically important in regulation of sleep and wakefulness is the locus coeruleus, located near the reticular formation. This
tiny structure is composed of two segments, each of which has about
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twelve thousand neurons that fan out throughout the brain. Its connections are more diuse than in any other neural pathway, covering like a
hairnet not only the whole cerebral cortex, but also the cortex of the cerebellum, the mini-brain near the back of the head. These connections extend into the spinal cord and down through the rest of the body, where
they aect muscle tone.
Recordings from rats and monkeys show that neurons of the locus
coeruleus are most activated by novel stimuli in the environment and are
least active when the animals are just sitting around digesting a meal or
asleep. In multiple ways these cells are involved in regulation of attention,
arousal, and sleep-wake cycles as well as learning and memory, anxiety and
pain, and mood and brain metabolism (Bear, Connors, and Paradiso 1996).
Norepinephrine is the primary neurotransmitter chemical in the reticular system and the locus coeruleus. When the locus coeruleus fires, it distributes norepinephrine through its broad network of connections, alerting
and increasing excitability in its diuse neural networks. Lack of such firing
and reduced distribution of norepinephrine is associated with inattention,
increased drowsiness, and sleep (Marrocco and Davidson 1998). Eective
operation of the executive functions activating for tasks and regulating
alertness depends on the functioning of the reticular system and locus
coeruleus, among others. Figure 5 shows the origins of the norepinephrine
system in the locus coeruleus and its projections to other areas of the brain.
The cerebellum, another structure at the back of the brain, is connected
to the brainstem. It makes up only about 10 percent of the total brain volume, yet it contains about half of all the neurons in the central nervous system (Feldman, Meyer, and Quezner 1997). Until about twenty years ago, scientists saw the cerebellum as a mechanism involved only in fine-tuning
complex movements of the body. Its extensive loops of connection with virtually every portion of the brain allow it to make ongoing comparisons between intended actions and actions in progress, so that needed adjustments
can be made to facilitate smooth bodily execution of intended actions
(Leiner, Leiner, and Dow 1989; Feldman, Meyer, and Quenzer 1997). Without these continuing readjustments, physical movements would be uncoordinated and jerky, like those of characters in very early motion pictures.
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Thalamus
Prefrontal
cortex
Locus coeruleus
Cerebellum
Figure 5 Main pathways of the norepinephrine system. Pathways for norepinephrine originate in the locus coeruleus and extend widely throughout the
brain and down the spinal column. Norepinephrine initiates vigilance and sustains alertness; perhaps not surprisingly, sleep involves reduced levels of this
transmitter chemical.
What has been recognized only in the past decade is that portions of
the cerebellum provide similar fine-tuning for a wide variety of cognitive activities. Michael Posner and Marcus Raichle (1994) have demonstrated that the cerebellum plays an important role in selecting appropriate verbs to go with specific nouns. Antonio Damasio (2003) has reviewed
research suggesting that portions of the cerebellum may also be involved
in adjusting social behaviors, for example, laughing and crying, to specific
situations. And Birgit Gottwald, with others (2003), has demonstrated
that damage to specific areas of the cerebellum significantly impairs
specific aspects of an individuals ability to divide attention between tasks
and to utilize working memory. Apparently the cerebellum contributes to
management of complex cognitive activities in a wide variety of ways.
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In a similar manner, individuals dier in their inborn baseline levels of sensitivity to change and stress. Studies by Jerome Kagan and colleagues (1994, 2004) showed that in a sample of infants about 20 percent
are born with a very low threshold for anxiety; they tend from the earliest
months of life to respond with obvious distress and excessive behavioral
inhibition when confronted with novel or stressful situations. These individuals are likely to be seen by others as exceptionally sensitive or overly
fearful well into childhood and beyond. Work by Louis Schmidt and others (1999) indicates that these more socially reticent and anxious children
tend to be less successful than age-mates at tasks requiring use of working memory and are more often o task. This may be due to these children being flooded with anxious emotions in ways that interfere with their
attending to other stimuli and tasks.
In contrast, Nathan Fox and colleagues (2001) have reported on exuberant infants who are highly reactive and display positive emotions in response to novel situations and mild stress. These children are quicker to
interact socially with others, are more active in exploring their environment, and show less fear in new situations. These temperamental characteristics, which are present in infancy and dier considerably from one individual to another, suggest what most parents of more than one child are
quick to notice: infants seem to arrive in this world with neurochemical
wiring that lays a foundation for how they respond to people and situations. Even within the same family, individual children can dier considerably along these dimensions. These individual dierences in basic physiology, sensitivity to stress, intensity of engagement and of eort, and so
on are likely to have considerable influence on the development of what
will eventually become executive functions of the brain.
Environmental Influences on Executive Function Development
Development of the brain circuits that support executive functions is
strongly influenced by genetic factors, but environmental factors also play
an important role. Patterns of interaction between the developing infant
and its caretakers actually influence the physical development of the neural networks.
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Daniel Siegel (1999) described the pivotal role of interpersonal attachment in shaping neural networks throughout life, particularly during
infancy and early childhood when the youngster is least able to regulate
the intensity of his own emotions. When a parent or other caretaker responds to an infants distress with soothing comfort, the disorganizing
eects of the infants stress are reduced and networks for self-calming are
strengthened. In addition, when the caretaker echoes the infants pleasurable reactions to daily events with warmth and enthusiasm, these more
positive emotions are amplified and networks for pleasure are strengthened. Siegel refers to this emotional interaction of infant and caretaker as
attunement. He sees it as the foundation for the emotional attachment
of the infant to caregivers.
Siegel argues that this process of attunement between infant and caregiver has a direct eect on the physical development of the infants brain.
He notes that those neural networks used most, especially in the earliest
years, have the greatest probability of further development and subsequent use, whereas those less used are more likely to atrophy.
The brains development is an experience-dependent process,
in which experience activates certain pathways in the brain,
strengthening existing connections and creating new ones.
Lack of experience can lead to cell death, called pruning. . . .
Genes contain the information for general organization of the
brains structure, but experience determines which genes become expressed, how and when. . . . Experiencethe activation
of specific neural pathwaystherefore directly shapes gene expression and leads to the maintenance, creation and strengthening of the connections that form the neural substrate of the
mind. (p. 14)
The experience of an infant during its first years of life is powerfully
shaped by emotional exchanges with caretakers. Recurrent patterns of
these interactions mold not only the content of the individuals experience, but also the structures of the brain within which subsequent experience will be processed and understood. Unlike a television that remains
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unchanged by the visual and auditory content displayed on its screen, the
actual circuits of the infants brain are shaped by the quality of the infants
early emotional experience.
When one or several caretakers for an infant closely monitors the
childs emotional reactions, sharing in moments of pleasure and providing a buer of comfort at times of distress (such as when the baby is hungry, cold, in pain, or overstimulated), this attunement can provide a
structure of support and facilitate development of brain circuits more adequate for self-regulation. When such nurturing responses are relatively
consistent over time, the infant is likely to form an attachment to that
caretaker, who becomes a source of emotional security, a secure base
from which the growing child can gradually learn to move into the wider
world.
When caretakers do not provide a reasonably secure base for attachment, when they are excessively distant, inconsistent, rejecting, or disorganized, the growing child is likely still to become attached to the caretaker, but that childs subsequent development, especially in interpersonal
interactions, is more likely to be avoidant, highly ambivalent, or disorganized. These less-secure attachments, for better and for worse, provide not
only the foundation for mental models, crystallized sets of default assumptions about self and others, but also a complex set of neural networks less adequate for self-regulation.
Mary Ainsworth and colleagues (1978), as well as subsequent researchers, have found that dierent patterns of attachment observed at
age one year are associated with varying styles of peer relationships, emotional maturity, academic performance, and capacities for self-regulation
in adolescence. According to Siegel, these behavioral patterns develop
from those neural networks preferentially developed in the brain during
the earliest years of development. Siegel (1999) noted that an individuals
patterns for attachment are not inalterably established during the first
year; they may be improved or damaged by subsequent life experiences.
This process continues throughout childhood and into adolescence, a
time when a massive surge of brain development occurs along with rapid
changes in the maturing childs social outlook.
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that the circuits that support executive functions of the human brain are
not fully developed until after puberty. This is consistent with cultural expectations that defer until some time after puberty those important responsibilities that require mature executive functionsfor example, driving a car, managing ones own finances, making contracts, and achieving
more freedom from parental control.
The Decline of Executive Functions in Later Years
Once developed, executive functions do not remain static over the lifetime. They may be refined further during early and middle adult years,
and in later adulthood, for many, they begin to decline. Monica Fabiani
and Emily Wee (2001) have shown that impairment in frontal lobe functioning is characteristic of elderly adults on many cognitive tasks, especially those involving working memory; but they emphasize that individual dierences tend to increase with age. Lifestyle, general health, and
other factors greatly contribute to the eects of age on executive functions.
Although there is considerable variability among elderly persons in
the quality of their cognitive functioning, many manifest impairments in
working memory as they age, even without any disease processes or dementias. Some suggest that the increasing ineciency of working memory
in the elderly is due to specific impairments in memory; other researchers,
for example, Timothy Salthouse (1991), suggest that the apparent memory
problem is really a result of a more generalized slowing of information
processing functions.
In contrast, Michael Milham and others (2002) demonstrated that the
problems of working memory in the elderly result from impairments in
the brains mechanisms for controlling attention. These researchers used
imaging studies to compare attentional control in younger (21- to 27-yearold) versus older (60- to 75-year-old) people during a task requiring careful attention. Results suggested that aging compromises the brains ability to exercise attentional control, allowing excessive distractibility and
causing decreasing eciency in working memory.
This decline in working memory that often occurs in later years is not
necessarily global. Robert West and colleagues (2002) compared young
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cartoon character appeared on a screen and to avoid pushing the button each time another
Pokemon
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After administration of such medications, dramatic increases in chemical activity can be observed in images of the prefrontal cortex, specific subcortical regions, and the cerebellum, important centers for management
functions of the brain (Volkow, Wang, et al. 1997; Voeller 2001; Anderson,
Polcari, et al. 2002). And these changes last only as long as the medication is on board, thus confirming self-reports and observations of persons
with ADHD.
The results from these many medication studies clearly indicate that
ADD syndrome is essentially a chemical problem, specifically an impairment in the chemical system that supports rapid and ecient communication in the brains management system. Just as diabetes is a disease that
reflects impairments in the bodys processing of insulin, ADD syndrome
is a disorder that reflects impairments in the brains processing of dopamine and norepinephrine. I discuss implications of these findings for the
treatment of ADD syndrome in Chapter 9.
At this point, we know that the structures and physiological processes
of the brain that develop and sustain executive functions are vast, subtle,
and amazingly complex. It is also clear that these structures and functions
develop rather slowly compared to other aspects of the brain, and that in
most cases they gradually decline in eciency as individuals approach old
age. The next three chapters describe the interplay of developing executive
functions and the changing demands of development and daily life during childhood, adolescence, and adulthood.
Self-Management
MYTH: ADD is simply a label for behavior problems; children with ADD
just refuse to sit still and are unwilling to listen to teachers or parents.
FACT: Many with ADD have few behavior problems. Chronic inattention
symptoms cause more severe and longer-lasting problems for learning
and relationships for those with ADD.
Many, but not all, who suer from ADD syndrome have noticeable problems during childhood. The child with ADD syndrome often needs much
more assistance and many more directions or reminders to behave appropriately and to accomplish tasks readily managed by most children of
the same age. Parents and others become progressively puzzled and frustrated as the child lags ever further behind in learning to manage daily
routines and interactions.
More than a specific skill is involved; the child tends to have trouble
with many aspects of self-management. Because children vary widely in
their speed of development, it is sometimes not clear whether a child is just
a bit slower developmentally or significantly impaired. At first, the child
just doesnt seem able to understand and to do what is generally expected
of children that age, or may show extraordinary inconsistency in behavior.
For a time, concerned adults may assume that this particular child just
needs a little longer to mature before he or she will master these tasks.
For children with ADD syndrome, the delay is often very protracted
and the dierence from expected development becomes increasingly worrisome. But for a small percentage of children eventually diagnosed with
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Childhood
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Childhood
Fortunately, not many children with ADD syndrome are so dangerously out of control as this preschool girl. Her diculties illustrate an extreme variant of frustrations and risks encountered by parents of young
children with early onset ADD syndrome.
More common are children who are far more restless and reckless
than average. Even when most other children of the same age can generally be relied on to wait a moment for help from an adult or to heed a warning, some children with ADD syndrome are chronically too quick to grab
things that may be dangerously hot or sharp, unwilling to wait for help
in crossing a busy street, or determined to climb into dangerously high
places. They are extremely impulsive and resistant to adult control. Regardless of how many times they are cautioned and shown how to be
careful, these hyperactive and impulsive children move too fast and too
heedlessly, sometimes at considerable risk.
Far more than most others of comparable age, these children depend
on parents, older siblings, teachers, and other caregivers to protect them
with constant vigilance and quick responses. Those who care for such
children need to be on high alert, always trying to anticipate and protect
against whatever dangerous move the child might try next. Compensating
for the inability of these children to be careful is a demanding and exhausting responsibilityand one that babysitters, grandparents, and other
adults who might otherwise assist with childcare are understandably reluctant to share.
Cooperating with Adults and Peers
Injury to children from ADD syndrome is not limited to the physical.
Many who are careful enough to avoid breaking their bones or being jolted
from placing metal into an electrical socket behave chronically in ways
that can provoke frustrated and angry reactions from peers, siblings,
teachers, and parents. These childrens problematic behavior can cause
serious damage to relationships and sometimes elicits hostile or abusive
treatment. One mother described the pressures of caring for her son:
My eight-year-old, Joey, is not a bad kid; often he is charming
and funny. But he really is a handful for everyday stu! Every
Childhood
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Childhood
one or more of the children frequently becomes sidetracked and is uncooperative, frustration can become intense and tempers can flare.
For many parents like Joeys mother, these challenges are repeated at
the end of each day when the parent and children return home tired and
hungry, all with very low thresholds for frustration. From late afternoon to
bedtime the parent may often be forced to fight recurrent brushfires of
conflict among siblings while trying to monitor the activities of each child,
initiate and supervise completion of homework, prepare and clean up
after dinner, spend some quality time with the kids, and get everyone
bathed, into pajamas, and settled into bed while doing housework like
laundry.
Provocative Oppositional Behavior
Some children with ADD syndrome are not only uncooperative; they are
intensely oppositionaloften mouthy, argumentative, and extremely demanding. Many are quick to mount a protracted temper tantrum if, say,
they are not allowed to eat what they want when they want it, to watch a
particular program on television even if it is their sisters turn to choose,
or to play a video game on the family computer even though an older
brother is using it for a homework assignment.
Some of these children are also outrageously presumptuous and
brazen with parents and siblings alike, acting as though their every wish
must immediately be fulfilled. For any parent, coping every morning and
every evening with the emotional intensity of frequent, protracted temper
tantrums, as well as whining or recurrent and intense sibling battles, all
while struggling to accomplish necessary tasks and daily routines, would
be an extreme challenge; for some parents it is totally unmanageable.
Some readers, when learning about such diculties in eliciting cooperation from children, might argue that more eective parenting strategies are needed. It is true that some parents, especially those who are very
inexperienced and highly stressed in many areas of life, have never
learned how to eectively guide their children. Often their eorts to direct
and intervene unwittingly throw gasoline on the fire. But there are many
parents of children with ADD syndrome, some of whom have successfully
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raised other children, who have worked very hard with multiple strategies
to elicit cooperation from their child, only to find that even carefully executed advice from experts fails to help.
Regardless of the reasons for such problems, chronic and severe lack
of cooperation between parents and children can cause serious diculties
for the child as well as for parents and other members of the family.
George DuPaul and others (2001) studied a group of children aged three
to five years, some of whom had been diagnosed with ADHD (the others
were a comparison group of normal children). Direct observations were
made of these children in a play situation where the parent was asked to
help the child do a task, and in a situation where the parent was asked to
have the child pick up toys in a playroom.
Children with ADHD exhibited more than twice the level of noncompliance and greater than five times the level of inappropriate behavior displayed by the normal comparison children when asked by their parents to
complete the assigned tasks. When parents in both groups were queried
about the level of stress they routinely experience in dealing with their
children, parents of the ADHD children reported higher levels of chronic
stress than 83 percent of the other parents; there was a very large dierence (two standard deviations) between scores for their reports and those
of parents of non-ADHD children.
In this study observers noted that parents of children with ADHD
tended to behave in a more negative way toward their children than did
parents of children who did not have ADHD. It is dicult to know how
much of their more negative interaction was due to their daily frustration
in trying to get their children to cooperate, possibly exacerbated by the demands of being observed. Alternatively it is possible that some of these
parents tend generally to be impatient and irritable, and had been very
negative and controlling with their young children from their earliest
days. In that case, the childs lack of cooperation might be a reaction to the
parents problematic temperament or parenting style.
DuPauls study demonstrated that these preschool children with
ADHD were much less cooperative not only with their parents, but also
with their peers and teachers. When observed in a free-play situation in
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shaw (1996) studied six- to twelve-year-old boys with ADHD in comparison to age-mates without ADHD, all of whom were participating in a summer camp program. They used ratings from adult observers, self-ratings,
and friendship choice ratings by the groups of boys to assess how much
each boy was liked by the others and what behaviors were associated with
more or less group acceptance. They found that many ADHD boys were
rejected quickly by the group because of excessive aggression, pushing too
much to get attention for themselves, and not sharing their peers concerns for fairness.
In a similar summer camp study, Drew Erhardt and Stephen Hinshaw
(1994) demonstrated that boys with ADHD were rejected very quickly by
their peers. Their negative status in the peer group was quick to form; they
were rejected on the first day of camp, four times faster than comparison
boys. And this negative peer status persisted, for most, until the end of the
camp session weeks later.
These data suggest that both boys and girls with ADHD tend to have
significant problems in cooperating with peers just as they tend to have
significant impairments in cooperating with their parents and other adults.
Some might consider this simply a problem of misbehavior, but, as I discuss later, these behavioral problems may be complicated, if not caused,
by less obvious problems with language development and/or impairments of executive functions.
Communicating Eectively with Others
One important aspect of cooperating with others is learning to communicate eectively. This reciprocal process involves far more than simply
understanding the meanings of specific words that are heard and stringing words together in an appropriate way to speak to others. Careful examination of the processes involved in interpersonal communication
shows it to be a complex interaction that often places heavy demands on
the executive functions impaired in individuals with ADHD.
Our son, Phil, is now twelve years old. We have always thought
of him as a really dicult child to raise. From his preschool
years he has always been stubborn. Weve always had trouble
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mates as well as with teachers and others less familiar. And when eective
communication fails, misunderstandings often arise and conflicts between persons tend to escalate.
Learning to Read and Write
Reading and writing are additional modes of communication that become
increasingly important from early childhood on. Both of these involve considerable work to develop needed skills. One mother described problems
in motivating her son to work at learning.
Our son Wally is a very bright boy, but he just wont work in
school. When they do things that interest him, he will join in the
conversation and contribute some good ideas, but he has never
had any patience for when the teachers or assignments are boring. His father and I think the problem is that he is so bright.
Most of the teachers are not very inspiring and a lot of the work
they assign is a waste of time.
Wally is in sixth grade now and he doesnt get many good
grades on his report card. He is just not a worker. In class he
spends a lot of time daydreaming and drawing cartoon characters or racing cars. At home he spends hours every day surfing
the internet and concentrating on video games, but we just cant
get him to work in school. His teacher says he just doesnt seem
motivated. We are starting to wonder how we can get him to
work on things that he really needs to do.
This mother is beginning to realize that her twelve-year-old son will
have significant problems if he doesnt learn soon to work on school tasks,
even when they are not very interesting to him. He may be very intelligent
and she may be right that his teachers are not very inspiring and that they
give him a lot of boring work, but this boy is currently lacking a willingness to work at learning content and skills set before him by others.
In the field studies used to develop the DSM-IV diagnostic criteria for
ADHD, one survey item was Seems unmotivated to do schoolwork or
homework. This descriptor fit many children with ADHD, but it was not
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ultimately included in the published diagnostic criteria, presumably because of a concern that the cause of the motivation problem might be misunderstood as a simple obstinance. Yet motivation to work is a major
problem for many who suer from ADD syndrome.
Over three decades ago, Erik Erikson (1968) wrote about the importance of children developing the capacity to work at learning the skills they
need to get along in life.
When they reach school age, children in all cultures receive
some systematic instruction. While all children at times need
to be left alone in solitary play and . . . hours and days of makebelieve in games, they all, sooner or later become dissatisfied
and disgruntled without a sense of being able to make things
and make them well and even perfectly. It is this that I have
called the sense of industry . . .
[The child] learns to win recognition by producing things.
He develops perseverance and adjusts himself to . . . become an
eager and absorbed unit of a productive situation. The danger at
this stage is the development of an estrangement from himself
and his tasks . . . the sense of inferiority . . .
Children at this age like to be mildly but firmly coerced into
the adventure of finding out that one can learn to accomplish
things which one would never have thought of oneself, things
which owe their attractiveness to the very fact that they are not
the product of play and fantasy but the product of reality, practicality, and logic; things which thus provide a token sense of participation in the real world of adults. (pp. 123127)
Eriksons point here is that it is important for children to be helped
to develop skills and attitudes that can lead to productive work. He noted
that in literate societies, where careers are more specialized, each child
needs first to be given a basic education that will prepare him or her for a
wide range of possible careers. This education is likely to involve activities
and skills that the child would not spontaneously choose for pleasure,
though the child may find pleasure in mastering the skills at progressing
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levels of diculty. But useful skills alone are not enough. Erikson emphasizes also the importance to the child of developing a work ethic, a
sense of industry, an ability to win recognition by producing things, an
idea of the pleasure of work completion by steady attention and persevering diligence (p. 259).
Studies have shown that many persons with ADD syndrome have considerable diculty developing this pleasure of work completion by steady
attention and persevering diligence. Because of their chronic problems
with executive functions, individuals with ADD syndrome are at high risk
for chronic academic underachievement and school failure.
Stephen Faraone and others (1996) compared children aged six to
seventeen years diagnosed with ADHD to normal controls. Results indicated that at some point in their schooling, 56 percent of the ADHD children had needed academic tutoring, 30 percent had repeated a grade, and
35 percent had been placed in a special class. Comparable numbers for
normal controls were much lower: 25 percent had received academic tutoring, 13 percent had repeated a grade, and 2 percent had been placed in
a special class.
Inattention Interferes with Learning to Read and Do Math
Such high rates of academic underachievement and failure among children with ADHD may result from a number of causes, one of which is
likely to be chronic inattention. David Rabiner and colleagues (2000) reported on a large study of children monitored from kindergarten through
fifth grade. They found that children identified by their teachers in kindergarten as being more inattentive than most others in their class had
significantly lower reading achievement when they reached fifth grade.
The problems of these low-achieving children were based on their significant impairments in sustaining attention, not on behavioral diculties, IQ,
or prior reading achievement. From their six-year study the researchers
concluded:
About one third of the children who were reading in the normal
range after kindergarten, but who were highly inattentive during
first grade, had fifth grade reading outcomes more than one SD
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can be taught to read, but this usually requires alternative approaches and
more intensive instruction and practice than is required for most others.
Among individuals with ADHD there is a markedly elevated incidence of dyslexia (Tannock and Brown 2000). As was shown in the Rabiner study, attentional problems and other impairments of the ADD syndrome can severely impair an individuals ability to read.
Yet phonemic decoding is not the only element involved in reading;
gradually the child needs also to develop fluency and comprehension of
longer stretches of text. Virginia Berninger and Todd Richards (2002) described the development of two types of fluency:
The first kind is oral reading fluency in which children not only
become faster in recognizing words, but their oral reading begins to reflect the melody or intonation of the spoken language.
The second kind is silent reading fluency in which children
quickly and automatically access . . . word forms . . . thereby
freeing up limited working memory resources for reading comprehension. (pp. 162 163)
Children who suer from chronic impairments in their ability to sustain attention and eort, to utilize working memory, and to employ other
executive functions usually impaired by ADD syndrome, are likely to have
continuing diculty in these more advanced aspects of reading comprehension.
In our Yale Clinic for Attention and Related Disorders, Donald Quinlan and I administered reading tests to older adolescents and adults diagnosed with ADHD. Their ability to recognize and correctly pronounce
lists of words on the Woodcock Johnson Achievement Test was in the high
average range. But their scores for demonstrating comprehension of passages several paragraphs long on the Nelson-Denny Reading Test were
significantly (1.5 standard deviations) lower. They were also significantly
slower at reading the passages. These preliminary findings suggest that
adolescents and adults with ADHD are likely to have persisting problems
with reading fluency and comprehension that are not explained by poor
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decoding skills. These findings also indicate that reading problems associated with ADD syndrome do not disappear over time.
Children with significant attention impairments during their early
school years are likely to experience diculties not only in reading, but
also in learning mathematics. Elizabeth Benedetto-Nasho and Rosemary
Tannock (1999) studied students aged seven to eleven years, half of them
with an ADHD diagnosis, half without. The two groups of students were
matched for equal math skills and none had any learning disability. When
asked to complete sets of math problems appropriate for their ability level,
the ADHD students attempted fewer problems, were three times less
eective in solving the problems, and made six times as many errors
when doing subtraction problems. Errors in subtraction were mostly errors in borrowing; for example, 120 9. Such diculties are likely to involve not only attention to details (for example, noticing whether one is
supposed to add, subtract, multiply, or divide), but also working memory
functions (such as keeping in mind that one has borrowed from the tens
column when one subtracts from the ones column).
ADD Syndrome Impairs Written Expression
Skills of written expression, the ability to put thoughts into sentences and
paragraphs that others will be able to read and understand, are also problematic for many children with ADHD. Written expression is a more demanding task than is talking, reading, or doing basic math computations.
To write ones thoughts places much heavier demands on learned skills
and executive functions. Virginia Berninger and Todd Richards (2002) described some of these demands:
Writing, especially expository writing, is not talk written down
it requires self-generated language without social supports during the initial planning and text generation processes. Thus,
writing is not the inverse of reading or aural/oral language . . .
in the sense that division is the inverse of multiplication.
(pp. 168170)
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Put another way, writing lacks the scaoldingthe supportof having a partner in conversation. And a blank page does not oer the structure of other words to read. It therefore is much more demanding on executive functions than is reading or conversation. Berninger and Todd
noted that
both writing and reading draw on . . . memory, executive
processes, and thinking processesbut in dierent ways. Because the reading system [of the brain] can refer to written text
at any time, the memory burden is greatly reduced. In contrast,
the writing system . . . may place a greater burden on working
memory than does reading comprehension. Writing is an immense juggling act, with more jobs to do than reading. The writing jobs include planning (generating ideas and setting goals),
translating those ideas into text, transcribing that text, and reviewing and revising it. . . . Control processes for extracting
meaning from a finished text (reading) are not as taxing as the
executive processes that go into generating and repairing a text
until it is deemed a final product (writing). (pp. 172174)
Relatively few studies have assessed impairments of written expression in individuals with ADHD. Susan Mayes and colleagues (2000) studied children with ADHD in comparison to children who had other emotional or behavioral problems without ADHD; all of these children were
eight to sixteen years old and had been referred to a child psychiatric treatment clinic. Each child was given individually administered tests for IQ
and academic achievement. Of the children with ADHD, 65 percent had
a score for written expression that was significantly lower than that predicted by their IQ test score; only 27 percent of the clinic-referred children
without ADHD had such a discrepancy.
Taken together, these several studies and others not described here
show that significant percentages of students with ADHD demonstrate
substantial basic impairments in reading, math, and/or written expression, often from their earliest years in learning these skills. These academic impairments suggest that many children with ADD syndrome have
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a weak foundation of basic academic skills on which to build their education. Such impairments are also important because they tend to demoralize children early in their educational careers and deprive them of the
sense of being able to make things and make them well, which Erikson
claimed was the foundation for a sense of industry.
Many children with ADD syndrome are not able to win recognition
by producing things in their elementary school classrooms. Rather, they
tend to be recognized by teachers and peers as the ones who didnt get the
assigned task completed, missed the main point of it, or did it too hastily
or with too many errors. When a child encounters such defeats frequently,
especially in the early years of schooling, it doesnt take long to become
discouraged with academic work, and to develop a sense of inferiority that
undermines ones attempts to learn. Shortly before his evaluation for
ADHD, a six-year-old boy in kindergarten was asked to try tracing the
shape of the letter H. He told his mother, I dont even want to try doing
that. Im just going to mess it all up like everything else I do.
Faced with repeated early failures and frustration in trying to learn
basic verbal and mathematical skills, many children with ADD syndrome
give up on truly learning academic tasks. They may be forced to continue
to do their lessons, prepare their papers, and take the tests, but their motivation to invest themselves in such learning, to work at learning, is likely
to be markedly diminished. They may continue so as to avoid getting into
trouble with the teacher or parents, but they may not anticipate feeling
satisfied in having done a task well. Sometimes such discouraged children
develop alternative skills that bring other kinds of recognition: clowning
to get classmates to laugh, challenging the teacher with defiance, or bullying other children.
But academic weakness is not the only reason that many children with
ADD syndrome seem relatively unmotivated. Sometimes parents unwittingly sabotage the motivation of their children to work at learning. Sometimes parents of bright children, like the underachieving Wally described
earlier, do not adequately appreciate the importance of teaching their child
to work at a task and learn to do it well, even if it is not especially interesting or challenging.
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Much of what children are required to do in school is not very interesting to them and much of it may not even be directly useful in later years.
But the experiences of accepting an assignment and working to learn a
new skill, practicing and refining the skill, applying it to assigned tasks,
and working to get it done well can all contribute substantially to a childs
developing a sense of industry. If the child finds that recognition is given
for significant eort, and if his work or developing skill is acknowledged
by others, especially the parents, as having importance and value, then the
child is likely to develop some pride and satisfaction in doing the work.
Some parents overlook the value of nurturing the childs developing academic competence, but are quick to give such recognition to their childs
eorts in sports, art, music, mechanical tasks, or other nonacademic pursuits. Often this results in the childs becoming strongly motivated to improve those skills while neglecting academic challenges.
Sarah has never been much of a student, but she has always
been a good athlete. She says she tries hard to do her schoolwork, but she never does it very well. Her father and I are both
very athletic and we have ADHD like she does; she has to have
gotten it from us. But we noticed from when she was just a
toddler how much she loves physical activities. She was pretty
good at dribbling a soccer ball when she was just five years old.
Weve spent a lot of time coaching and practicing with her and
weve paid for her to get private lessons in ice skating and tennis
and skiing. Shes been on soccer and Little League teams since
she became old enough to sign on. And shes already earned all
of the figure skating badges.
Sarah has always worked very hard to improve her performance. Coaches all tell us that she is one of hardest working kids
they have ever seen. Her natural talents and hard work pay o.
Shes always a star! We attend all her games and competitions.
We stay in close touch with her coaches and we take her to see
the pros in her sports whenever we can. We have a display of all
her ribbons and trophies in our dining room. Our only worry
now is that her sixth-grade teacher is saying she is failing and
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may have to repeat the grade. If she cant get all passing grades,
she wont be eligible to play on the school teams next term. That
would ruin everything. Shes never been very interested in working on schoolwork, at school or at home. We are getting worried
about that.
It may be true that Sarah is naturally much more talented in athletics
than in academics, and thus more motivated to work consistently at learning to improve her athletic abilities. But it is dicult to know how much
of Sarahs lopsided motivation is due to her parents strong enthusiasm
for her eorts in sports and their years of relatively weak interest in her academic work. If her parents had invested more eort and interest in encouraging Sarahs academic learning, it is possible that she would have
learned to work productively at learning in school, just as she has learned
to do in sports. She may never have become as competent and interested
in schoolwork as she has become with sports, but she might have developed that aspect of herself well enough that she would not need to repeat
her grade. Given her ADHD diagnosis, it is unlikely that her diculties in
school are due solely to the attitudes and behavior of her parents, but these
may be contributing to the problem.
Sarah is a good example of someone with situation-specific ADD syndrome impairments. She demonstrates that she is able and willing to
work hard at learning and practicing skills that interest her, while she
complains that she is unable to sustain enough interest and eort to do
the schoolwork that may eventually determine whether she will be eligible
to play on school sports teams.
Executive Functions and the Tasks of Childhood
This chapter has described examples of four developmental tasks or challenges faced by most children during childhood:
Behaving carefully,
Cooperating with adults and peers,
Communicating eectively, and
Learning to read and write
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tions of the brain. All children with ADD syndrome do not have equal impairment in each of the four self-management tasks. Some may be quite
impaired in being careful while generally being able to communicate
rather eectively. Others may be reasonably careful and generally cooperative with others, though they tend to struggle to communicate well and
to work to learn. Despite this variability, however, relative to their peers,
most of those diagnosed with ADHD during childhood tend to demonstrate significant impairments across all of the clusters of executive function impairments that constitute ADD syndrome.
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actions with other students may stir up many unsettling thoughts and
feelings in students that may linger even after the teacher begins organized instruction.
Teacher-student interactions also vary from class to class. Each teacher
has a unique personality, a dierent style of interacting with students, and
personalized ways of managing a class. Some teachers are highly structured and demanding of students, quick to confront anyone slow to comply. Others are more casual, less willing to control the class. Some teachers are very supportive and encouraging of students, whereas others may
be condescending or hostile. In more extreme cases, students can get
caught up in power struggles with a teacher or suer verbal taunts or embarrassing criticisms from a teacher whom they cannot safely confront.
Thoughts and feelings about social interactions with classmates and
teachers may consume a large portion of a students energy and time during school. Mihaly Csikszentmihalyi and Reed Larson (1984) studied adolescents who were asked to carry beepers each day and to record in detail
what they were doing, thinking, and feeling each time the beeper alerted
them. Students in this study reported that they were thinking of schoolwork only 40 percent of all occasions in class when they were randomly
beeped. This study also reported that
compared to other contexts in their lives, time in class is associated with lower-than-average states on nearly every self-report dimension. Most notably, students report feeling sad, irritable and
bored; concentration is dicult; they feel self-conscious and
strongly wish they were doing something else. (p. 204)
From intensive study of these students, selected from the general population of a suburban high school, these researchers concluded, Even in
a very good high school such as the one studied here . . . students are probably absorbing only a fraction of the information being presented. They
found that classic academic subjects such as mathematics, foreign language and English showed the lowest levels of intrinsic motivation,
coupled with low aect and activation (p. 206). If students in the general
population commonly experience such diculties in the classroom, it is
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intruded on his ability to pay attention and take adequate notes during
most classes. Similarly, he left many homework assignments undone because he could not delay his wish to surf pornographic web sites and masturbate. His problem was not simply the time involved in these activities.
He also was unable to block the self-criticism that left him feeling messed
up after each time he masturbated. He illustrates the continuing truth of
the observation of John Gagnon and William Simon (1973) that
there is little evidence that there has been any reduction in the
anxiety associated with masturbatory practices by the young who
are beginning their sexual lives . . . it is the existence of this anxiety about masturbation that supports our experiential belief that
the sexual drive is one of extreme potency. We presume that we
are experiencing a biologically powerful experience when in fact
it is the guilt and the anxiety associated with arousal identified
as sexual which is provoking our sense of intensity. (p. 56)
Many adolescents (and adults) struggle with sexual preoccupations
and with feelings of guilt over their actual or imagined sexual activities,
but those with ADD syndrome often report much more diculty in managing these thoughts and emotions than do most of their age-mates. It
seems to be more dicult for them to compartmentalize them and to
focus on necessary tasks than it is for many others of the same age.
This boys report also highlights the social risks associated with sexual development in adolescents. Impulsively, while instant-messaging, he
had shared with a friend details of his fantasies about the girl he was attracted to in his English class. Equally impulsively, the friend, who also
had ADD syndrome, pushed a button to share this electronically transmitted confession with his girlfriend, who quickly sent it to the girl who
was the object of the boys fantasies. The resulting embarrassment and
shame caused the boy who had shared too much information to avoid attending school for a full week.
Two aspects of the revelation caused the student to feel humiliated.
First, he expected, rightly, that peers would ridicule him for confessing to
masturbating, an activity in which most adolescents engage, though few
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anyway. He just didnt come to the house. I would tell them I was
going to my girlfriends house and then I would go out with him.
At first I wasnt too comfortable with the marijuana and beers; I
hadnt done that before. But then it relaxed me and I really enjoyed partying with Mike and his friends. Then that summer I
got pregnant. I found out just before Mike was going o to college. I had been on the pill, but sometimes I forgot to take it.
At the time of this incident, this girls ADD syndrome had not been
recognized. Like many other students with ADD syndrome, she had struggled with her schoolwork and found that even when she worked hard, her
grades were disappointing to her and to her parents, who were spending
a lot of money to provide a better education. In such a competitive setting,
students who do poorly in their studies often face daily humiliation as
classmates and teachers witness their inability to keep pace with burdensome homework assignments, lively class discussions, and challenging
tests. When she got caught cheating, this girl was further humiliated by
the expulsion that resulted from her desperate but misguided eorts to
get a better grade. She was then faced with the embarrassing task of having to answer seemingly countless friends, acquaintances, relatives, and
neighbors who wanted to know why she was transferring mid-semester
from a prestigious private school to the local public school. She reported,
I feel like I have a big C for cheater or R for reject
stamped on my forehead. Kids at the new school keep asking
me why Im coming here now. I cant say I just moved to town,
because some of them already know me from elementary
school. I try to tell them I just didnt like the other school, but
they all know it has to be because I got kicked out.
Faced with many weeks of multiple daily reminders of her failure to
find success at the more prestigious school, of her inability to satisfy her
own aspirations and those of her parents who struggled to continue to pay
the high tuition that had to be forfeited when she was expelled, this girl was
exceptionally vulnerable as she tried to work her way into the established
social networks of the public high school. Being attractive, she caught the
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eye of an older boy whose attentions both helped her feel valued and
brought her recognition by classmates who liked and respected him.
When her parents, fearful of her associating with an older boy, forbade her
to see him, she resorted to deceit so she could continue the relationship.
The significance of this new relationship was complicated. Not only
did the girl gain status among peers for being chosen by this popular older
boy, she also was welcomed into his peer group and included in their frequent gatherings. Because she was bright, empathic, and articulate, she
was someone her new boyfriend could confide in as he was struggling to
cope with the recent death of his father. Repeatedly she was told by his
mother and friends that her support had lifted him out of his grief; she felt
needed and valued by her boyfriend, his mother, and many of his friends.
Their warmth and gratitude served as an antidote to her strong feelings of
failure and shame; it also intensified her resistance to her parents continuing demands that she stay at home more and study harder to succeed
at school.
As she spent more time with her older boyfriend and his friends, the
girl also joined in the beer drinking and marijuana smoking that often occurred at their weekend parties. Joseph Biederman, Timothy Wilens, and
others (1998) have shown that individuals with ADHD not only have a
twofold increased lifetime risk of substance use disorders than those without ADHD, but also tend to begin substance abuse earlier and continue it
longer. Elizabeth Disney and colleagues (1999) found that girls with
ADHD often begin substance abuse earlier than boys with ADHD, possibly because they tend to associate with older boys whose patterns of substance abuse may be more fully developed.
This girl reported that despite her initial discomfort with drinking
beer and smoking marijuana, she soon came to enjoy its relaxing properties as well as the concomitant social interaction. She said she also appreciated her boyfriends gentle sexual attentions that gradually developed
into an active sexual relationship enjoyed by both of them. Her failure to
take regularly the contraceptive pills she had obtained from a clinic was
probably due to the eects of her ADD-related working memory problems
combined with her dimly sensed hope that if she were accidentally to be-
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come pregnant he might abandon his plans to go o to college the following autumn, choosing instead to remain at home to intensify his relationship with her while attending a college in the community.
This girls early adolescent coital experience and premarital pregnancy are consistent with a pattern reported from the Milwaukee longitudinal study of hyperactive children by Russell Barkley (1998). His group
followed 158 hyperactive children and 81 matched controls for more than
fourteen years. During this period the children with ADHD started having sexual intercourse earlier than the controls (at fifteen years rather than
sixteen years), had many more sexual partners in their lives (nineteen versus seven), were less likely to employ birth control methods, were more
likely to have contracted a sexually transmitted disease, and were much
more likely to have conceived a pregnancy (38 percent versus 4 percent).
These findings related to adolescents who had been hyperactive as children; most of the hyperactive subjects met DSM-III-R criteria for ADHD.
Since this pattern of high-risk behaviors has not been reported for adolescents with ADHD who lacked a history of hyperactivity, these findings
should not be taken as applicable to all adolescents with ADHD. The pattern reported for the hyperactive subjects in Milwaukee did, however, fit
closely with the experience of this particular girl.
It would be too simplistic to argue that this girls school failure, debased self-esteem, cheating, alienation from her parents, and premarital
pregnancy and subsequent problems were all a direct result of her ADD
syndrome. Multiple influences were at work in this complex situation. Yet
it is hard to avoid the conclusion that this girls life might have been much
less painful if her ADD syndrome had been recognized and treated early
in her school career. As it was, she was not evaluated, diagnosed, and
treated until after she had aborted the pregnancy and her boyfriend had
gone o to college. She responded well to medication for ADD syndrome
and completed her high school education with very high grades. Two years
later she wondered aloud:
Seeing how much this medication helps me focus, and seeing
how good my grades are now in advanced classes with only
about 60 percent of the eort I was putting into getting those
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countless details involved in preparing and serving multiple meals simultaneously, he had great diculty organizing his academic work, attending
to details of reading-based or math problems, and recalling what he had
read. His part-time work had served for many years to compensate for the
frustration and embarrassment he chronically felt in the classroom. Yet a
few months before his scheduled graduation, his demonstrated success in
practical skills of the kitchen could not alter the fact that he would be denied a high school diploma if he did not successfully complete enough of
the reading and written work required for graduation from this technical
high school. To accomplish this he needed treatment for his longstanding
ADD syndrome.
For most adolescents, employment is not so productive as it was for
this young cook. Ellen Greenberger and Laurence Steinberg (1986) studied tenth- and eleventh-grade students who were employed part-time and
a comparison sample of adolescents who had never held a steady job. They
concluded that
adolescent work is now, for the most part, totally dierent from
the type of work youngsters will do in the future. Once motivated by the economic needs of the family and the community,
most adolescent work today represents luxury employment, of
which adolescents themselves are the chief beneficiaries. And
the workplace, once an area where the generations were united
in common tasks, is now an age-segregated adolescent stronghold . . . excessive commitment to a job may pose an impediment to development by causing adolescents to spend too much
time and energy in a role that is too constraining and involves
tasks that are too simple, unchallenging and irrelevant to their
future. (pp. 67)
The young cook was an exception to these observations in some ways.
His work did place him in an apprentice-like situation where he learned
skills of his trade by working collaboratively with an experienced chef. As
it had evolved, his part-time employment had led him to become immersed
in work that held the promise of becoming a satisfying career. Such work
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is far dierent from that of most adolescents, who serve burgers in fastfood outlets or check in videotapes and DVDs at the local rental center. Yet
the many hours spent at work did take away considerable time and energy
needed for aspects of his schoolwork that were challenging to him and
necessary for graduation.
The pickup truck that the young cook had bought with his earnings
was a source of great pride to him, but it also had a negative eect on his
schooling in several dierent ways. First, the truck cost a lot of money not
only for its initial purchase, but also for insurance, fuel, desired improvements, and unanticipated repairs. Even while he was feeling desperate to
fend o the threat of failing to graduate, this young cook initially argued
that he could not reduce his long hours at work even temporarily because
he needed to get more money to pay for new tires he had already bought
and for imminently needed repair of the trucks transmission.
Second, having his own vehicle diminished contact between him and
his parents. He was rarely home for meals, he drove himself to and from
both school and work, and he used his truck during his spare time to drive
around and look for friends with whom to socialize. His mother reported
that she saw very little of her son and had little opportunity to talk with
him about school, work, or anything else. She commented, Since hes
been getting his own paycheck and paying his own bills, and not needing
to borrow my car, he feels independent, that he should be able to do pretty
much whatever he pleases. I dont have much control over him anymore.
Even for adolescents who are not employed and do not have their own
car, parents often feel a substantial loss of control over their adolescent
sons and daughters after they get their license to drive. This is one of
many reasons that most adolescents long for the day when they are able to
obtain that little plastic-covered document that certifies them legally to
drive a car. The drivers license becomes a badge of having left behind the
constraints of childhood and of entering the privileged world of adults.
But for most parents this transition is fraught with much worry and feelings of helplessness.
Parents may continue to exercise power over whether and when the
adolescent is able to use their car, but whenever the teenager gets behind
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when one considers the great demands that driving places on executive
functions, demands outlined in the opening pages of the Introduction.
Leaving Home
While getting a license and driving a car are important steps in an adolescents journey toward independence from the parents, a far greater step
occurs when the adolescent moves away from home to live at a university
or in his own apartment. It would be hard to overstate the magnitude of
change that this transition requires from any adolescent, but for those
with ADHD, this massive separation from day-to-day contact with parents
is even more challenging. At no point in life does the average individual
face so many changes in so many aspects of life at one time with so few
precedents to provide guidance.
Like most of my friends, I really looked forward to college. All
during senior year and through graduation everyone always
talked about how we could hardly wait to get out of high school
with those boring classes and ridiculous rules; and we were
desperate to get away from our nosey parents who were always
checking up on usHave you done your homework? Were
you drinking last night at the party?and making stupid curfews even for weekend nights. For us, college meant freedom,
a place where you can take care of yourself and where there is
nobody checking up on you.
When I actually got on campus it felt good, but kind of
strange. Nobody really cared when I went to bed or when I got
up or whether I ever went to class. Most nights I went out for
beers with some guys from my dorm and smoked some weed
on our way back. Back in my room I could stay on the Internet
as late as I wanted and then I would crash about three or four
in the morning. That left me too tired to get up for morning
classes. Usually I slept until about noon. I missed a lot of classes
and never really got most of the reading done. When I got up I
would smoke a little more. Then lots of times I felt too tired to
get to my afternoon classes. After a while I just gave up on going
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Its not that they had any real power over me or would punish
me. Its more that their presence, and their knowing what I was
doing or possibly finding out pretty soon if I messed up, that
would usually push me to do what I knew I really ought to be
doing. Its like just their being around made this pressure inside
me to do the right thing. When I was away at school, I wasnt
able to make myself do what I needed to do when I had to do it.
I was completely by myself where nobody else around really
knew or cared what I was doing.
For some adolescents, their primary source of emotional and social
support is not their parents, but a dating partner, an older sibling, or a
close friend. As they approach graduation, many high school students,
with and without ADD syndrome, feel great worry and grief about the loss
of their network of high school friends and others on whom they depend
for daily commiseration, encouragement, study support, advice, and companionship. They are aware that they can stay in touch with each other via
email, telephone, and occasional visits, but departing students also know
that after high school graduation it wont be the same. While some high
school seniors clearly anticipate and talk about the diculty of leaving
home, others are eventually surprised to realize the intensity of their feelings about leaving their home in this broader sense.
One high school senior in treatment for ADD syndrome was surprised
in this way. He sought consultation soon after going by ambulance to the
emergency room because of terrifying chest pains that had made him fear
he was having a heart attack.
My girlfriend and I were with a few other seniors at this one
kids house. Wed gotten a pizza and Cokes to celebrate that all
of us had finally finished up our college applications. It was the
last day for us to hand them in to the guidance counselor for
mailing. Just after we got to the house with the pizza I got this
huge pain in my chest and couldnt catch my breath. Im a good
athlete in good condition and Ive pushed hard in tough competition, but Id never had anything like this. I felt like I was going
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performance. For several years he had spent far more waking hours with
her than with his parents or anyone else. The prospect of living away from
her, even just a couple of hours away, and having to function without her
constant support, was frightening to him in many ways that he sensed
only dimly until he began to explore the reasons for his panic attack.
Although many students with ADD syndrome face diculties in
making the transition to college because they are more dependent on their
parents, dating partners, or others for daily support than are many of their
friends, some have diculty making the transition because others are dependent on them. One high school senior had been very successful in her
academic work since junior high school when her ADD syndrome had
been first diagnosed. Since that time she had been on a regimen of medication that worked well for her. She was very bright and worked hard on
her studies, which included several honors-level classes each semester. It
was a great shock to her and to her teachers when this girls grades dropped
in all of her classes during the first semester of her senior year of high
school. She lamented,
I dont know whats wrong with me. Ever since the second quarter of this senior year I just havent been keeping up with my
work. I still read a lot, but none of it is what is assigned. Ive
fallen behind in my homework in every class, even with a couple
of big projects. Some tests I do OK on because I still listen in
class, but if the test requires any real preparation, I dont do well
because Im not prepared. All my teachers are puzzled and some
of them are really mad at me. Every night I go home intending
to get my work done and every night I end up putting it o and
doing just part of it or sometimes none of it at all. Same thing
with my college applications. They all have to be done in less
than a month and I havent even started on one. Maybe Im just
not ready for college yet.
In talking further about her dilemma, this extraordinarily bright girl
described a family situation that played an important role in her uncertainty about whether she was ready to go to college. Her fathers work re-
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quired frequent traveling, often for several nights at a time. Her mother
had a long history of depression for which she had once been hospitalized
after a suicide attempt. As an only child, this young girl felt an unspoken
responsibility to provide daily companionship and support for her mother.
Each evening the girl helped her mother to prepare dinner. Later she
spent an hour or more with her mother after supper while they watched
and then discussed the television news. Just before retiring the girl would
sit again with her mother, telling her about events at school or about the
novels she was reading. These interactions brought much pleasure to
the mother, who rarely smiled except when she was with her daughter. As
the girl began her senior year of high school and began to talk about plans
for college, the mother appeared to her daughter to be getting increasingly depressed.
Although the mother was explicitly encouraging her daughter to go
forward with plans for college, her undercurrent of depression left her
daughter fearful that going o to college might leave her mother feeling
so lonely and sad that she might again become suicidal. This girl felt enormous guilt for disappointing her parents and teachers with declining academic work, but she felt even more fear about abandoning her needy
mother. Her unwitting compromise was to fail at school and remain at
home. Although adolescents with ADD syndrome often depend on others
for support more do than many of their friends, sometimes they are also
an important source of support for others, their family or friends. These
are not mutually exclusive possibilities.
Executive Functions Involved in the Tasks of Adolescence
The developmental challenges described in this chapter are only a few of
the many that adolescents face. Yet even in these simple examples, it is
clear that adolescents are confronted with many complex tasks that require extensive use and further refinement of multiple executive functions. Moreover, the teenage years are when much of the support provided
by teachers, parents, and others is diminished or withdrawn.
Sometimes the transitions are abrupt, like the move in school from
having just one teacher in a single classroom for most of the day to hav-
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ing six or seven teachers daily (with rapidly escalated requirements for
self-management of time, materials, and eort), or the move away from
home and community to go to college. Sometimes the changes are more
gradual. Either way, adolescence usually brings an escalation in the magnitude and complexity of task demands and social relationships, at a time
when the teenagers physical and social development make peer interactions more complicated and introduce sexual overtones to social relationships. At this time the individual is required to manage not only concrete tasks, but also more complex social interactions, all while taking on
much more planning for both the immediate future of the next few days
or weeks and the longer-term future of graduation and beyond.
This longer-term future planning challenges an aspect of working
memory that has not been discussed much in the neuropsychological literature thus far. Paul Eslinger (1996) observes:
Executive functions importantly include diverse goal-directed
behaviors over a period of time that extends beyond a few minutes and even to dierent spatial settings. For example, completing a graduate degree requires constant vigilance to both shortterm and long-term goals. Development and maintenance of
important social relationships . . . also requires persistent attention to immediate, short-term, and long-term goals.
This type of prospective archival memory is not well-defined
in current models. . . . It qualifies as a type of working memory
because it implies prospective memory-guided responding rather
than sensory-guided responding. It is frequently changing yet
enduring over a long period of time. Does the influence of future goals reside in some form of longer-term working memory
that is kept alive by daily activities such as the behaviors that
alter future consequences? (p. 385)
It is during adolescence that this ability to relate the choices of the moment and of the day to longer-term aims and goals becomes increasingly
important. This aspect of working memory is often significantly impaired
in adolescents with ADD syndrome. As the scaolding of earlier years is
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gradually removed and, further, as the individual encounters the cataclysmic changes of moving out of the family home to live in a university
dormitory or ones own apartment, the eect of impaired executive functions is likely to become increasingly powerful, though it may not be recognized as causing impaired functioning. Eslinger (1996) emphasized,
Executive function impairments have a particularly insidious
eect on child, adolescent and even adult development and may
underlie diculties in many poor learners and workers as well
as poorly adjusted parents and citizens. Throughout life phases,
there is increasing demand for complexity and organization of
psychological processing as well as control of powerful emotions
and potentially destructive behaviors.
With development, most settings also provide only partial information pertinent to long-term goals and require greater inhibition of prepotent responses and longer delays before rewards
are to occur. Hence, unlike content-specific deficiencies in reading and spelling, developmental executive function impairments
are much more dicult to observe, identify and manage. (p. 387)
As described in Chapter 3, Jay Giedd and others (1999) used longitudinal imaging to study brains of teenagers to demonstrate that, contrary
to earlier assumptions, adolescence is a time of amazingly rapid and extensive brain growth followed by extensive pruning of neurons to make
the adolescents brain more ecient. Despite this growth, for many adolescents there is not a good fit between their developing capacities and the
demands of their environment. Their ability to negotiate the increasingly
complex demands of adolescence is inconsistent and sometimes wildly erratic. For most adolescents who suer from ADD syndrome, this process
of major transitions is even more dicult; for some, it is overwhelming.
Finding a Niche
MYTH: Unless you have been diagnosed with ADD as a child, you cant
have it as an adult.
FACT: Many adults have struggled all of their lives with unrecognized
ADD. They havent received help because they have assumed that their
chronic diculties were caused by character faults such as laziness or
lack of motivation.
During the adult years, especially the early adult years, most individuals
are faced with many new adjustments and important choices that will
shape their future in both the short and longer term. For those who suer
from ADD syndrome, these challenges are especially dicult. One twentysix-year-old man with ADD syndrome described his diculties with selecting options and working productively:
Ive always had a hard time making choices. I switched my
major five times in the three years I was in college. I keep trying
things out and then I get bored and feel like something else
would be better, so I switch. Finally I dropped out to try getting
a job. Figured Id go back to school after I knew better what I
want. That was four years ago and since then Ive had seven
dierent jobs. All of them seemed OK for a while. I came in on
time and worked hard to learn the job and do it right. Then I always started getting bored and coming in late and slacking o.
And sometimes Id get in trouble for being too mouthy with the
boss. Once I got fired for that. The rest of the jobs I just left because I had an idea of something else that might be better.
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they were headed or how their activities day-to-day and week-to-week were
linked to any longer-term goal like completing course requirements, earning a degree, or preparing for a career.
The young mans comment Ive always had diculty making choices
reflects a problem with omnipotentialitya fantasy-based attitude, common among adolescents, that all things are possible, all choices are open.
Usually this attitude is dispelled during mid- to late adolescence as most
individuals are forced to confront the reality that some doors are not open
to them. They discover that they cannot get into a particular college they
want to attend or enroll in a specific course that sounds interesting or be
hired for a specific job that they would like to do. Sometimes these impediments to fulfilling a particular aspiration come from lack of ability,
sometimes from not having met educational prerequisites, sometimes
simply because there are many more qualified applicants than there are
available openings.
As they experience such disappointments and frustrations, most young
adults reconcile themselves to the need to make choices and to abandon
some interests, amputating some possibilities in order to invest themselves in others. Usually they also come to recognize that choosing a career is not simply a matter of making a decision about what one wants, but
about trying to make an acceptable fit between what one wants and is able
to do with opportunities that are actually available. Many young adults
with ADD syndrome take longer to learn this lesson. With a persisting
sense of omnipotentiality, they experience themselves as being on a protracted shopping trip for life optionsinterested in multiple possibilities,
but unable to invest in any one choice enough to put up with the inevitable frustrations of getting started and becoming established.
In 1978 Daniel Levinson and colleagues published a study of adult
development reporting results of in-depth interviews with a sample of
men aged thirty-five to forty-five, some blue collar, some white collar. He
found that despite their diversity of employment and social class, these
men all experienced predictable phases in their adult development. In particular, most of the men found choosing an occupation to be a long, dicult process.
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fail to allow enough time for showering, getting dressed, eating breakfast,
and driving to work.
Many of these young adults have a long history of missing their school
bus and being tardy to school, even when parents have been very active in
trying to awaken and prompt them. It is not surprising that they continue
to experience such diculties, especially when no one living with them
will take on the frustrating task of getting them started each morning. Yet
research suggests that the problems of adults with ADD syndrome in regulating their time stem not simply from failing to learn how to manage a
morning routine. Chronic diculties in fitting actions into segments of
time appear to be an aspect of the ADD syndrome.
Russell Barkley and others (2001a) studied time perception and reproduction in adults with ADHD compared to normal controls. Each was
asked to estimate the duration of various short intervals of time, from two
to sixty seconds, presented to them by an examiner. They were also asked
to reproduce time intervals by telling the examiner when to start and stop
a stopwatch to make intervals of twelve, forty-five, and sixty seconds. Regardless of ADHD subtype or gender, the adults with ADHD were able to
estimate time duration as accurately as controls, but they reproduced the
time intervals significantly less accurately than did the control subjects, by
making them longer than they were supposed to be. Barkley commented,
The problem is not so much one of inaccurate sense of time as inadequate behavioral performance relative to it (p.357). The intervals that
these adults were being asked to stipulate were only sixty seconds or less.
This is but a miniature of the problem experienced by many adults with
ADD syndrome when they need to allocate time for longer tasks with
multiple variables, for example, driving to work in rush-hour trac. Their
diculties with such tasks cause many adults with ADD syndrome chronically to arrive late for work or for meetings with colleagues or customers.
Often these adults also have chronic diculties with deadlines. One
young salesman was shocked when his employer threatened to fire him
for failing to submit expense-account reports in a timely fashion. This occurred after he had ignored repeated requests and reminders, then submitted six months worth of expense reports totaling over seventeen thou-
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sand dollars just after the small company had closed its books on the fiscal
year. He was confident that his very successful record in sales for the company would cause his employer to overlook his delinquency in filing the
reports. He assumed that his boss would make allowances just as most of
his high school teachers had given him high grades because he wrote very
good papers, even though he usually handed his papers in late. He assumed too much.
Like the young man described at the beginning of the chapter, this
salesman got mouthy with his boss when confronted about his negligence. He did not adequately modulate his emotions. Rather than accepting the correction and promising to improve his performance, he impulsively talked back to his boss, angrily pointing out shortcomings he saw in
the boss and in other colleagues. His emotional outburst exacerbated the
conflict and got him fired from a position in which he had made a very
promising start. Further, this result aected subsequent eorts to seek another position. His reference letter from the job he lost indicated strong
sales ability, but also significant problems with record keeping, meeting
deadlines, and insubordination.
Some individuals take longer than others to recognize such problems
in themselves and to begin an eort to change. In the case of the college
dropout described earlier, what caused him to seek treatment was not his
failure to complete his university studies, nor his diculty in sustaining
a job. He came seeking help because he was close to losing a relationship
that had become important to him. His girlfriend had threatened to dump
him because he was unable to sustain a serious relationship with her.
Only then did he begin to realize that he was setting himself up for longterm frustration if he continued to switch girlfriends and jobs as rapidly
and impulsively as he switched channels on the TV.
His girlfriend had told him that she loved him, but could not continue
the relationship because she was at a point in her life where she wanted
and needed someone more ready to quit jumping around and more
ready to start investing himself in one job and one long-term relationship. He described her as very special in a dierent way than any other
woman he had ever dated and said tearfully that he didnt want to lose her.
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Yet he was very uncertain about whether he could make and sustain the
kind of commitments she was asking for.
The young mans primary motive for seeking consultation was that he
wanted to resume taking medication that had been helpful in alleviating
his ADD syndrome impairments earlier in life. He had been diagnosed as
hyperactive and was given medication for these symptoms from third
grade until the end of high school, when he had decided to stop taking it.
When I was on that stu I was still pretty hyper, but it seemed like I could
stick with things a lot better. Im wondering if something like that could
help me now so I could settle down at my job and in my relationship with
her, and maybe even go back to school.
After this consultation at age twenty-six, he resumed taking a medication for ADD syndrome, an improved version of the same medication
he had stopped taking ten years earlier. With this support he was able to
sustain the relationship with his girlfriend and stay in his job long enough
to get promoted twice.
Some adults with ADD syndrome can negotiate the frustrations of
their early adult years without too much diculty. Many successfully complete their education and find that their ADD symptoms do not impair
them so much after they get into more advanced stages of education,
where they can specialize in studies that interest them. In later years of
schooling and as they enter the world of employment, some are able to
specialize in work that turns them on, avoiding tasks that were very
dicult and burdensome when they were in school full-time. Some are
even able to find employment that for them is much like getting paid to
play an enjoyable game. This fortunate outcome would be equivalent to
Larry, the inattentive goalie of Chapter 1, successfully finishing college
and then developing a career as a professional hockey player. Many others,
however, are not so fortunate.
Managing a Household and Finances
Regardless of their work situation, most adults eventually need to manage
their own household. For many young adults, the tasks of household management are initially frustrating and somewhat dicult, but mostly mas-
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tered without serious problems. For young adults with ADD syndrome,
however, these tasks often tax their impaired executive function abilities
in ways that can become highly problematic.
One twenty-seven-year-old junior high school teacher sought treatment after studying about ADHD in a graduate course she was taking to
fulfill requirements for a masters degree. Arriving thirty minutes late for
her first appointment because she had lost the directions mailed to her,
she apologized and then explained:
I need to get evaluated for ADD because I know I have it and
its really messing me up. Maybe if I get the right medication,
things will get better. In this graduate course we just studied
about ADD and every symptom on the list is something that has
been a problem for me all my life. Im terrible about planning
and organizing. I cant stay focused when I read. I never remember what Ive read. Ive got a great memory for things from a
long time ago, but my short-term memory has never been any
good. Im the worlds biggest procrastinator, always late with
everything. I got through my undergraduate degree, just barely,
but now Im really struggling with this graduate course. I cant
keep up with the reading and the tests are really hard. I havent
even started yet on a big paper that is due in three days.
I need to pass this course because I need more graduate credits to earn more money. And I desperately need more money because my financial situation is a mess. I just got an eviction notice from my landlord because Im three months behind in my
rent. And the leasing company is threatening to repossess my
car if I dont pay up on three back payments I owe them. On top
of that, Im driving now with no insurance on my car because I
havent kept up with paying that either. Ive lost two department
store charge cards because of late payments and Im up to my
neck in credit card debt. Oh, and I havent filed income tax for
the past two years, even though I want to get it done because I
should be getting a refund.
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I hope I dont have to move because I like my apartment. Besides, my place is such a mess, I could never get it all packed up.
Im totally disorganized with piles of stu all over the floor and
the tables and the chairs. Theres barely enough clear space for
two people to sit and eat a meal or watch TV. I always take good
care of my appearance, but at home Im such a slob. My sink is
always full of dirty dishes and I never do laundry until everything I own is dirty and I have nothing left to wear. Sometimes
I just go out and buy some new clothes so I can put o doing
the laundry for just a little longer.
This intelligent, witty, vivacious teacher was well liked by her students
and respected by her colleagues, but she had great diculty meeting the
demands of her graduate-level course and in managing her household
routines and finances. Her parents had provided loans to bail her out of
several financial scrapes, but their resources were limited and she recognized that she needed to manage her own money, time, and stu in a
much better planned and more responsible way.
During our evaluation, this teacher described her repeated eorts to
plan a budget so she could meet her expenses in a systematic way. Always
she found herself sabotaging her good intentions by impulsively buying
new clothes or choosing to go with friends on expensive vacations she
could not aord. Both her apartment and her leased car had been selected
too much on the basis of how desirable they were without enough attention to the high monthly payments required. She had calculated her expenses for these items on the basis of her total monthly paycheck without
taking into account the amount needed for utilities, groceries, gas, and
other recurrent expenses.
The results of her evaluation indicated severe ADHD, which responded well to appropriate medication treatment. With that treatment
she was able to organize her household more eectively, though it took
her two years to stabilize her finances. She did this by implementing plans
she had drawn up much earlier, but hadnt been able consistently to follow. Her problem had not been a failure to understand what she needed
to do. It was that she could not consistently do it.
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done, almost no time for the self. The womens lives were usually hectic, at times chaotic and exhausting. . . . It would get
better in time, they hoped, as the children grew older and the
career stabilized. (p. 349)
The nurse described in this case example faced the same draining
pressures that Levinson found characteristic of many career women, most
of whom, presumably, did not have ADD syndrome. In her case, these
pressures were intensified by the special needs of her son who suered
from ADHD, at that time untreated. The combination of these increased
demands on her executive functions and her chronic impairments of
ADD syndrome caused her to seek treatment.
During treatment, this nurse recognized her dilemma and clarified
her priorities. She spoke most of her painful awareness that she was not
providing for her children the quality of care that she wanted to give them.
She said,
Im usually doing OK at getting them the basics, but I know that
Im just not there enough for them emotionally. Im always disorganized and frazzled and tired and too frustrated. Half the
time when I lie down beside them at night to read a story, I fall
asleep before they do and during the day, so much of the time
Im just too impatient. Im not expecting to give perfection; no
parent can do that. But I know they need me to be there to talk
with them and to listen, to explain things to them, and to be
there for them emotionally. I want to do that for them. Thats an
important part of my helping them to grow up. I dont want to
miss out on it.
After some psychotherapy and talking at length with her husband,
this woman decided that she wanted not only to resume medication treatment for her ADD syndrome, but also to resign from her managers position and return to direct nursing care. She felt this would be more satisfying for her and that it would allow her to engage more fully in caring for
her children.
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I wanted to, I just couldnt manage that stu myself. You help
me with so much, and youre not even mean about it. I just
dont know if I can change the way Ive been for so many years.
I dont know if its something that can be changed.
The complicated causes of the crisis in this marriage had been festering for many years before they erupted in the wifes threat to separate. Initially the husband claimed and believed that he had not been unhappy in
the marital relationship. Later he gradually recognized that his wifes frequent reminders and supports were frustrating and sometimes very irritating to him, even though they were also helpful protection against his
own tendencies to live too much in the moment.
As they talked further about their mutual frustrations, this couple saw
that they had become trapped in maladaptive eorts to cope with the husbands unrecognized ADD syndrome. During childhood and adolescence
his mother had provided intensive support and structure without which
this man probably never would have finished high school. Shortly after
high school he met and quickly married his wife, who gradually took over
his mothers caretaking role, supporting him through his college studies,
maintaining a household, and eventually carrying most of the responsibility for caring for their two children.
Both partners agreed that they had shared many satisfactions and
good times in their sixteen years of marriage, but they also recognized that
their relationship could not continue without major changes. The change
most urgently needed was for the husband to begin treatment for the
ADD syndrome that had plagued him since childhood; it had never been
recognized in school or at home, probably because he had never been hyperactive or disruptive. As they learned about the nature of ADD, the
couple recognized that symptoms of this syndrome had contributed substantially to the husbands serious underachievement in school, his very
marginal performance in college, and his continuing erratic performance
on the job.
When he began appropriate medication treatment, the husband experienced dramatic, rapid improvement in many of his ADD symptoms.
This did not suddenly resolve all the couples marital problems, but it cre-
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Adulthood
ated and sustained conditions under which they were able gradually to
work out a very dierent, more reciprocal style of relationship. In the process they also recognized that the increasing underachievement of their
fourteen-year-old son in high school was virtually a carbon copy of his fathers problems at that time in his own life. Both father and son benefited
from ADD treatment in ways that produced a much more satisfying life
for the entire family.
In looking at the development of this family, one might wonder how
this particular husband and wife happened to find each other. How did
this man so early in life find a partner so willing and able to provide him
the scaolding previously created and sustained by his mother? Why
would this woman choose to attach herself so early in her life to this man
with such great needs for a parent-like partner? Why did she continue so
long in this pattern? And why did she then become so frustrated with their
established patterns of interaction after sixteen years of married life together? Adequate answers to these questions are beyond the scope of this
book, but the questions highlight factors that are relevant and important
to the experience of many adults with ADD syndrome.
Most individuals do not choose a life partner or other important voluntary relationships at random. People tend to seek out and pursue relationships with others to whom they feel attracted and with whom they feel
comfortable. When discussing their choice of marriage partners, people
often describe the attractions of physical appearance, but usually far more
important are mutual attractions due to many complicated, unrecognized
features of personality and interpersonal style. Such elements can have a
powerful eect on interpersonal attraction and/or conflict, often in ways
that are noticeable only over time as the attachment develops more fully.
John Bowlby (1978), a pioneer developer of attachment theory, wrote
about the persistence of early experience in such choices throughout the
lifespan. He used the term representational models to refer to individuals persisting personal views of self and otherstheir aggregated expectations, complex and only partly conscious, of persons to whom they are
attached, which includes their image of who a person is and of what that
person wants, intends, and will do.
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Adulthood
family profoundly changes the routines and dynamics of the family. The
newborn infants very survival depends on the parents adequately arranging their schedule and activities to see that the child is carefully watched
over, fed, comforted, rested, played with, and cared for throughout each
day and night. Usually this involves not only a rearrangement of schedules, but also massive sacrifices of time, energy, and freedom by the parents, often far more from one parent than from the other. And when a new
child arrives in a family that already includes one or more children,
sacrifices are inevitably forced on the older children as well.
The entry of a new child into a family does not only mean sacrifice,
however; it also enriches the lives of parents and any siblings. Donald
Winnicott, the extraordinary British pediatrician (1965), put it this way:
The parents, in their eorts to build a family, benefit from . . .
the integrative tendencies of the individual children. It is not
simply the loveableness of the infant or child; there is something more than that, for children are not always sweet. The infant and child flatter us by expecting a degree of reliability and
availability to which we respond. . . . In this way, our own capacities are strengthened and brought out, developed, by what is expected of us from our children. In innumerable and very subtle
ways, as well as in obvious ways, infants and children produce a
family around them, perhaps by needing something, something
which we give. (p. 47)
Since the needs of children are not static, but change dramatically as
the child grows older, the eects of the childs needs and of his giving to the
parents continually evolve, causing ongoing change in the parents, both
in themselves and in their interactions with one another. In the couple described earlier, the wifes frustrations with her husband escalated as their
children entered adolescence. As the children appropriately became less
engaged at home and developed more independent adolescent lives, the
mother acutely felt the loss of the precious satisfactions of providing a
competent and caring scaolding for them. And as her children became
more private and more independent from the family, this mother felt
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163
more intensely the lopsidedness, frustrations, and loneliness in her marriage. Consequently, she began increasingly to resent the continuing lack
of mature reciprocity in her relationship with her husband.
Changes in the life situation outside of the family can also alter the
eects of ADD symptoms on adult lives. A fifty-seven-year-old man, chief
executive ocer of a multinational corporation, brought his son for consultation after the boy had failed out of university. The boy had done fairly
well in an exclusive prep school where his daily routine had been tightly
organized for classes, sports, and supervised homework. In the very competitive college that enrolled him, however, he failed miserably during his
first year. At the suggestion of a perceptive professor, the father brought
his son to be evaluated for a possible attention disorder.
The boy fully met diagnostic criteria for ADHD and responded well to
appropriate medication treatment as he took courses in a local college. He
returned to the university on probationary status and was quite successful
with the support of continuing treatment. A few months later, the boys father called me, requesting an appointment to be evaluated himself. When
we met, he explained his motivation.
Ive been very successful in my career for several reasons. First,
Im a good idea man: I can envision how things can be developed in a creative way. Im also a good troubleshooter, identifying problems and finding eective ways to fix them. But most
important, I know how to pick good lieutenants.
I have several very competent administrative assistants who
keep me organized and help me do my job. They keep my calendar and remind me of what needs to be done when. They help to
organize and prioritize my work. They track my correspondence
and edit my dictation. Without them I could never stay on top of
all I have to do. If my son had someone like that to assist him in
college, he never would have flunked out.
Not many people know this, but I never finished university.
I flunked out at the end of my third year. I lasted a little longer
than my son did in his college studies, but mine was an easier
school. We both failed for very similar problems.
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Adulthood
I want this evaluation for ADD because I know I still have the
same problems my son has. I could see that when I was here as
you asked him all those questions in his evaluation. Ive made
all the money I need and Im planning to take early retirement
next year. My goal for retirement is to return to university and
finish the degree I wasnt able to complete before. But I know
I cant take any administrative assistants into courses with me,
and there is just no way I will be able to do that work unless my
attention and memory problems are fixed. I want you to evaluate
me and see if you agree that I have ADHD too. If so, Id like to
arrange to get the same medication my son is being helped by.
I believe, noI knowthat the medication will be helpful to
me. Ive already tried it.
This very successful executive did, in fact, fully meet diagnostic criteria for the predominantly inattentive type of ADHD, and he did respond
well to treatment as well as finally complete a university degree. His story
illustrates how some fortunate individuals with untreated ADD syndrome
can achieve extraordinary success, even in very demanding and responsible positions, when they have sucient help to compensate for their executive function impairments.
In this case, the administrative assistants in the corporation supported this talented man in leading his massive corporation to international success. While rising to the top of his corporations administrative
ladder, he had also benefited from the work of many other secretaries and
subordinates who helped him to do tasks that he continued to find very
dicult. But when he anticipated his early retirement, he realized that his
persisting problems with executive functions would prevent him from
completing a degree, just as they had thirty-six years earlier, unless they
were alleviated.
Not every adult with untreated ADD syndrome is fortunate enough to
have salaried assistants to help compensate for executive function impairments. But many do have coworkers, spouses, or others from whom they
obtain needed assistance. Sometimes help comes in the form of a simple
redivision of labor, whereby an employer allows a worker with ADD syn-
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165
drome to be responsible for aspects of the job in which that worker has
strong interest and talent, while assigning other parts of the usual portfolio to another worker with complementary gifts and limitations. Sometimes a spouse without ADD syndrome takes responsibility for managing
the familys financial aairs, while the spouse with those impairments
takes on other household responsibilities.
The value of such supports often is not recognized until, for some reason, they are withdrawn. One interior decorator with untreated ADD syndrome had a flourishing business until his junior partner suddenly died
from a heart attack. The business began to collapse after the younger mans
death as the senior partner failed to monitor income and expenditures,
did not follow up promptly on inquiries from prospective clients, did not
write up and send his estimates, failed to collect on accounts receivable,
invested in excessive inventory, and mistreated his oce assistants.
For twenty years these partners had thrived in a business where the
senior partner employed his strengths in imaginative use of color, design,
and arrangement while the junior partner provided steady management
of their business finances, guided the flow of inventory, oversaw interaction with clients, and provided guidance and support for their oce assistants. After the loss of his partner, the decorator received useful advice
from his oce sta, but his problematic personality style and ADD impairments, accentuated by his grief, caused him to ignore their advice and
drove them and several successors to resign. Only after the business had
virtually collapsed did the decorator finally recognize limitations from his
ADD syndrome and seek appropriate treatment.
Executive Functions Used in Adulthood
Examples in this chapter highlight four types of developmental challenges
of adulthood in which executive functions play an important role:
Selecting options and working productively,
Managing a household and finances,
Managing work while nurturing relationships, and
Parenting and sustaining partnerships.
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Adulthood
Most people who hear about the symptoms of ADD syndrome respond by
commenting, Oh, I have those problems too. Doesnt everybody? This
reaction is understandable because symptoms in this syndrome occur
from time to time in all children, adolescents, and adults, especially when
they are overtired or stressed. The dierence between persons legitimately
diagnosed as having ADHD and those who do not warrant this diagnosis
is essentially one of degree. How severely are these problems interfering
with their lives? And are they impaired just briefly once in a while or consistently over an extended time?
There is no single measure, no blood test or brain scan, no rating scale
or computer task that can make or rule out an ADHD diagnosis. The most
eective instrument for assessing ADHD is an intensive interview conducted by a clinician who understands what ADHD looks like, and who
can dierentiate ADHD from other disorders that may cause similar
problems. In this chapter I explain some things I try to keep in mind when
doing an assessment, and I describe tools and specific questions useful in
trying to determine when a diagnosis of ADHD is appropriate.
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heard similar complaints from his wife as well as from colleagues in law
school and at a previous job.
When I inquired in detail about specific ADHD symptoms, the attorney identified very few of them as applying to his experience. He had
not been significantly impaired by ADHD symptoms during his years in
school, and he was not currently experiencing more diculties from these
symptoms than most other adults. His lack of success in his goal of becoming a partner in his law firm was not due to his having ADHD. It appeared to be due more to his chronic anxiety and some personality problems. Not all lack of success is due to ADHD; countless other variables
may be involved, including luck.
Further, some individuals attain impressively high goals while suering significant impairments in executive functions needed for many other
aspects of daily life. One example is an emergency room physician who
was almost apologetic in seeking an evaluation for himself.
Most people wouldnt ever believe it, but I think I have ADHD.
Its true that I graduated from college and from medical school
and that Im licensed to practice medicine. I can be really on top
of my game when Im in the ER and managing six or eight patients with serious trauma. I can remember current vital signs
and what we are doing for every one of them. Im good at directing multiple treatments and Im good at talking with patients.
Nurses and patients all like me. But the rest of my life is a mess!
Im in constant trouble with my supervisors for not paying attention to their directions and for not doing adequate charting.
I try to study for my board exams, but cant remember what Ive
read. Ive already failed them twice. Ive never been good at
studying and just barely graduated from a second-rate medical
school. My finances are a total mess because I spend too impulsively and cant keep track of my bills. Ive had three speeding
tickets in the past six months and my wife is threatening divorce
because she says I never listen to her, Im irresponsible, and I
procrastinate on too many things that need to be done. Ive al-
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ways been this way, but its worse now that Im out of residency
and have to do so much more on my own.
Like the high school hockey player described in the Chapter 1, this physician is able to perform well under intense, immediate pressures that are
exciting and interesting to him. But despite the talents that brought him a
college degree, a medical degree, and a license to practice medicine, he
suers from longstanding problems with executive functioning. When not
under the immediate pressures of treating critically injured patients, he
has great diculty organizing and prioritizing his work, his time, and his
money. He cant sustain focus on important tasks like keeping adequate
patient records and communicating with his supervisors and his wife. He
cant hold in mind what he has studied to prepare for an important exam.
And his impulsive style of spending and driving is currently threatening
him with bankruptcy and possible loss of his drivers license. His diculties were not due to substance abuse or any other psychiatric problem;
they were the consequence of unrecognized and untreated ADHD.
Many factors contribute to a persons success or failure in specific areas.
Presence or absence of the impairments of ADD syndrome cant be determined simply by whether a person does or does not achieve a specific goal.
Many with ADHD Are Not Hyper
For decades the primary marker used to identify individuals with ADHD
impairments was hyperactivity. Children who were very obviously hyperactive were considered candidates for evaluation for ADHD, especially if
they were being disruptive or making trouble for their teachers. ADHD
diagnosis was not even considered for those who were not hyperactive and
not disruptive in school. An elementary-school janitor described this as he
came seeking evaluation for his ten-year-old daughter:
I could always spot the kids with the hyper. They were the ones
always sent out to sit in the hall because they were making too
much trouble in class. Some of them were actually pretty funny
in their antics. Usually these were the same kids who would be
running down the hall with the teacher calling after them to
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slow down and walk quietly. They were the ones on the playground who were always getting into arguments and fights with
other kids or the last ones to come back in after lunch or recess.
It was never the kids who kept the rules who got picked as
having ADD and it was never the quiet kids or the girls. Thats
why I never thought ADD could be my daughters problem.
Shes always been kind of quiet and a little shy. Never made any
trouble in class. Teachers have always liked her and said she was
really bright. She loves to read and to learn. Shes got insatiable
curiosity and lots of good ideas, but shes not getting her work
done and her grades have been dropping more every year. Shes
losing interest in school.
Many clinicians and educators still identify ADHD as the janitor described. As a result, many with ADHD, especially girls, are overlooked.
Joseph Biederman (2002) studied the role of gender in diagnosis of
ADHD. He found that although girls and boys with ADHD have similar
patterns of severity with the problem, ten boys are referred to clinics for
treatment of ADHD for every one girl referred. Community samples show
a dierent gender ratio: three boys have ADHD for every one girl who has
the disorder.
In contrast, during adulthood the rates of referral for ADHD are more
balanced between women and men. Biederman (2004) suggested a reason: adults usually self-refer for ADHD evaluation because of problems
they recognize in themselves, whereas children and adolescents are usually referred for evaluation by parents or teachersadults who are more
likely to identify those with obvious behavior problems.
Though their problems may not be so obvious, girls with ADHD can
suer significant problems. Stephen Hinshaw (2002a, 2002b) compared
a large group of girls with ADHD to other girls of the same age and social
status. He found that girls with ADHD had much more trouble according
to several measures: cognitive tasks, academic performance, getting along
with peers, and ratings of emotional problems, social isolation, and behavior problems. Biederman (1999) studied a large group of girls six to
eighteen years old with ADHD and compared them to boys with ADHD.
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He found that the girls with ADHD had problems in home and school
that were just as serious as those of boys with the disorder. The primary
dierence between the two groups was how much trouble they made for
other people. Serious behavior problems, such as oppositional defiant
disorder and conduct disorder (explained in detail in Chapter 8), were
twice as common among boys with ADHD. This 50 percent lower rate of
disruptive behavioral problems in the girls with ADHD is probably the
most important reason that girls are less often recognized as having this
disorder.
But it is not only girls whose impairments are often overlooked. Many
boys and men have ADD symptoms that go unrecognized because they
are not boisterous troublemakers. This problem of delayed recognition or
total failure to recognize ADHD in individuals who are not disruptive continues because many clinicians, educators, and persons in the general
public still assume that attentional problems of ADHD are significant
only when linked with hyperactivity.
This continuing mistaken assumption is not surprising, given that
the very name of the disorder continues to hold the two terms together. The
ocial DSM-IV label for the disorder is attention-deficit/hyperactivity
disorder, followed by a comma and the name of the subtype. For those
whose ADHD impairments do not include significant problems with hyperactivity, this system results in a diagnostic label that says essentially
attention-deficit hyperactivity disorder, without significant hyperactivity,
a rather clumsy and confusing label that perpetuates the overemphasis on
behavioral problems.
Behavior Problems Are Not Necessarily a Part of ADHD
Some researchers continue to claim that the primary problems in ADHD
are impairments in the control of behavior. In 1997 Russell Barkley introduced a new theory of ADHD that in many ways is similar to my model of
ADD syndrome. He noted that problems in ADHD lie not simply in the
individuals ability to pay attention or in excessive hyperactivity, but rather
in the executive functions of the brain. Functions included in his model of
executive functions are virtually identical to those in the model of execu-
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tive functions described in Chapter 2, albeit with dierent labels and organization.
Yet Barkleys model diers from my model in two important ways.
First, Barkley claims that his model applies only to the combined type of
ADHD, not to the predominantly inattentive subtype. He has argued that
the predominantly inattentive subtype of ADHD may be a disorder entirely
distinct from the combined type of ADHD (Barkley 1997; Barkley 2001b).
In contrast, my model of ADD syndrome is intended to describe all subtypes of ADHD, not just the combined or predominantly inattentive.
It is dicult to see how combined and inattentive subtypes of ADHD
could be completely separate disorders. In most children with combined
subtype, hyperactivity and impulsivity symptoms gradually attenuate during later childhood while their inattention symptoms persist; their ADHD
usually develops into predominantly inattentive type by mid-adolescence.
Moreover, the two subtypes appear not to be inherited separately. In a
large genetic study of twins, Susan Smalley and colleagues (2000) found
virtually complete genetic overlap for the two sets of ADHD symptoms. A
parent with ADHD might have two children, one with ADHD who is extremely hyper and another with ADHD who is a couch potato; the strong
inheritance component of this disorder does not predict which subtype
will develop.
The second way in which Barkleys (1997) model of ADHD diers from
mine is that he elevates behavioral inhibition as the primary executive function. Barkley specifies that behavioral inhibition is critical to the proficient
performance of the executive functions. It permits them, supports their
occurrence, and protects them from interference. He describes the other
executive functions as dependent on behavioral inhibition (p. 154).
In contrast to Barkleys approach, my model includes behavioral inhibition as just one among six clusters of executive functions, here called
monitoring and self-regulating behavior, without the other executive
functions being especially dependent on that one function. I believe that
inhibition, the ability to put on the brakes, is just one aspect of executive
functions. Equally important are the brains systems for ignition, transmission, and steering. All must interact to operate the car.
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Because conventional treatments for depression, anxiety, and personality disorders are not eective in alleviating symptoms of ADHD, it is important that clinicians who treat adolescents and adults be provided adequate professional training to help them recognize and provide eective
treatment for the disorder, which aicts a large percentage of individuals
who seek help from mental health professionals. Chapter 8 describes how
ADHD often appears with one or several other disorders of learning, emotions, or behavior. Having symptoms of anxiety or depression does not
rule out the possibility of ADHD; such symptoms may instead indicate a
more complicated case in which two or more disorders are present.
Very Intelligent People with ADHD Are Often Overlooked
Sometimes persons with a higher overall IQ who suer from ADHD are
at greater risk of having their impairments overlooked. At Yale, Donald
Quinlan and I studied adults who sought evaluation for chronic attentional problems, all of whom had a tested IQ in the superior range; in
terms of intelligence, they were in the top 1 to 9 percent of the general
population. Despite their very high IQ scores, 42 percent of these men
and women had dropped out of their postsecondary schooling at least
once, not because they were not smart enough to understand the work,
but because they were not able to organize, focus, and sustain their eorts
to deal with academic requirements. Some eventually returned to complete their education and achieved success in business or professions; others experienced continuing frustration and failure.
Virtually all of the very bright adults in this Yale study reported that
they had suered chronic and often severe impairments of ADD syndrome that were essentially ignored or denied by their parents, teachers,
and themselves for many years. One thirty-eight-year-old woman described her experiences:
I started reading sentences before I was in kindergarten and
everyone in my family kept saying that I was so smart. When I
was in elementary schools the teachers told my parents that I
was almost a genius because I asked so many good questions
and knew so much about so many things. In fifth grade they
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diculty in sustaining mental eort refer only to schoolwork and homework. Examples of losing things necessary for tasks and activities refer
only to toys, school assignments, pencils, books, or tools. To find out
whether an older adolescent or adult has ADD impairments, it is necessary to inquire with examples more appropriate to adult life. A good start
on that task has been made by Lenard Adler, Ronald Kessler, and Thomas
Spencer (2004), who created new, adult-focused examples for each of the
eighteen DSM-IV criteria. The adult self-report scale they developed is available on the World Health Organization web site and at www.med.nyu.edu/
Psych/training/adhd.html.
Another reason that the DSM-IV symptom cut-o system is not sucient for adults is that even just a few ADHD symptoms may severely impair adults. For example, an adult who has significant, chronic diculty
sustaining attention while driving a car can cause very serious damage.
Adults may create significant problems for themselves and others if they
repeatedly forget to pick up their children at daycare or cannot remember
to follow through on important tasks on their job. Later in this chapter I
discuss the importance of weighting symptoms by their severity and significance, not just counting them, when assessing impairment.
The Limits of Neuropsychological Tests of Executive Functions
Some neuropsychological tests traditionally have been labeled as tests of
executive function (EF tests). These include the Wisconsin Card Sorting
Test, the Stroop Color-Word Test, the Tower of London, the Rey-Osterrieth
Complex Figure Test, the California Verbal Learning Test, and various
computerized continuous-performance tests. Most of these tests were
originally developed to assess patients with schizophrenia or those who
had suered damage to the frontal lobes of the brain. At first glance, such
tests might appear to be appropriate measures to assess ADHD. In fact,
they are not.
When given to children diagnosed with ADHD, such tests give variable results. Alysa Doyle and colleagues (2000) administered a battery of
seven EF tests to a group of children diagnosed with ADHD. They found
that no single EF test accurately dierentiated children with ADHD from
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children without the disorder. Using all seven tests combined, they found
that about 18 percent of the boys with ADHD appeared significantly impaired on at least four tests, while about 5 percent of the boys who did not
have ADHD showed similar impairment. They concluded that neuropsychological tests of attention and executive functioning underidentify
cases that meet these [DSM-IV] criteria. Stephen Hinshaw and others
(2002c) obtained comparable results from a neuropsychological evaluation of girls with ADHD.
Neuropsychological tests of executive-function impairments in adults
are no better. Aaron Hervey and colleagues (2004) reviewed thirty-three
published studies that used neuropsychological EF tests to evaluate adults
with ADHD. He found that current neuropsychological measures are not
sensitive enough to pick up ADHD symptoms.
Any who seek to identify executive function impairments of ADHD
primarily by means of scores for these EF tests are likely to be frustrated
because of the lamppost problem. Lamppost here refers to the old story
of the drunken man whose friends came along on a dark night and found
him on his hands and knees crawling around under a streetlamp. When
they asked what he was doing he explained, I lost the keys to my car and
Im looking for them so I can drive home. They asked, Where do you
think you lost them? Somewhere over there in the dark across the street
where my car is parked, he responded. Then why are you looking here?
they asked. He answered, Its easier to look here because the lights so
much better!
Executive-function tests might appear to be a convenient way to assess
impairments associated with ADHD, but they dont shed enough light on
the areas that need to be examined. Patrick Rabbitt (1997) explained why
methods traditionally used by experimental psychology cannot validly be
applied to executive functions. The usual scientific approach in research
is to isolate and try to measure one variable that reflects one specific process and not others. He argued that
this venerable strategy is entirely inappropriate for analyzing executive function because an essential property of all executive
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Nick Alderman and others (2003), who assessed adults doing tasks in a
shopping mall, and by Vivienne Lawrence and colleagues (2002), who
monitored children as they followed a series of directions during a trip to
a zoo. These contrived situations are likely to be more useful than laboratory tests of executive functions, although they lack the flexibility and
scope needed to assess adequately the wider range of executive-function
impairments in real life.
What then is the test for dierentiating ADD syndrome from normal inattention? There is no one test that can determine whether a given
individual meets DSM-IV diagnostic criteria for ADHD. It is not like a
fracture where a physician can look at an X-ray and definitively see that the
bone is or is not broken. This is a diagnosis that depends on the judgment
of a skilled clinician who knows what ADHD looks like and can dierentiate it from other possible causes of impairment.
The Clinical Interview: The Most Sensitive Assessment Tool
The most sensitive instrument for making a diagnosis of ADHD is a wellconducted interview in which a skilled clinician asks about the history and
nature of the patients current functioning and life situation as well as the
patients earlier life experiences, noting the presence or absence of patterns of impairment in school, work, family life, and social relationships.
Usually such an interview requires at least two hours, during which
time the interviewer and patient will discuss the patients (1) adaptive
strengths and weaknesses, how the person does their work, what they do
for fun, and what they struggle with daily; (2) strengths and stressors in
the family background as well as any blood relatives with related problems; (3) health history, focusing on any medical or developmental problems that may be relevant; (4) history of school achievement and struggles
with particular types of academic work; (5) relationships with peers, family, teachers, employers, and friends; (6) eating and sleeping habits;
(7) current mood patterns and any significant diculties with anxiety,
temper, or behavior; and (8) history of previous evaluations or treatment.
For adolescents and adults, I make additional inquires about their
strengths and problems in significant relationships, their history of voca-
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tional aspirations and work experiences, and their past and present use or
abuse of alcohol and other drugs. Detailed formats to help clinicians in
structuring clinical interviews for evaluation of ADHD in children and
adults have been published by Barkley and Murphy (1998) and by me
(1996a, 1996b, 1996c, 2001a, 2001b, 2001c).
Throughout an evaluation interview, I try to be alert to strengths and
problems of the patient in utilizing executive functions in an age-appropriate way. I listen carefully to information given, asking for details and examples that will help to clarify the patients abilities in a variety of relevant
life situations.
Interviewing Children
In the evaluation of children, parents play a crucial role in providing relevant information, but the childs input is also essential. Since many executive functions impaired in ADHD involve cognitive processes not noticed
by others, it is crucial that I interview the patient. Even young children can
provide important information about their experience to a clinician skilled
at asking relevant questions and listening carefully to responses.
For children whose schooling is mostly in a classroom with one teacher,
information from that teacher may be very helpful. Such teachers usually
can describe the childs responses to dierent types of tasks, and can compare the childs performance to that of many other children of the same
age. Often elementary schoolteachers can also furnish valuable information about how the child gets along with classmates and how the child interacts with teachers and other adults on the school sta. Yet teachers
alone cannot and should not make or deny a diagnosis of ADHD. In some
children symptoms of ADHD are less obvious in school than elsewhere.
Observations from teachers are usually less valuable for the evaluation of junior high or high school students, who rotate among six or seven
teachers each day. Unless the teacher is also an advisor, coach, or mentor
of some kind to the student, he or she will usually see the child only for
one period each day, perhaps less, and typically will have five dierent
groups of perhaps twenty-five to thirty-five students dailyso is often not
able to report about any one student in sucient detail.
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ent, spouse, or friend; the Conners Adult ADD Rating Scales have separate forms for self-report and for report by a collateral observer. A review
of these and other rating scales for ADHD was published by Brent Collett
and others (2003).
Interviewing Adolescents and Adults
When I assess an older adolescent or adult, I invite them to have a parent,
spouse, or close friend join in at least a portion of their clinical interview.
This is not essential, but it may provide helpful information and an additional perspective. Of course, it may not be possible or desirable to involve
a parent in the evaluation. The parent may be unavailable due to long distance, ill health, or death. For adults, a parent may have little relevant information about the patients current and recent abilities. In this situation
the patient may choose to invite a close friend or relative.
Sometimes clinicians become too cautious about making a diagnosis
of ADHD in adults because the data are essentially self-reported. They feel
that some hard evidence must be provided, such as old report cards with
some teacher comments about learning or behavior problems, or direct
testimony from a parent or childhood friend. They feel that self-reporting
is too subjective. It is certainly possible for the self-report to be biased or
deceptive, but most skilled clinicians are able to sort this out in a comprehensive clinical interview. Diagnostic decisions in many other fields of
medicine are made based primarily on self-reporting. For example, there
is no laboratory test or diagnostic instrument that can measure pain, so
self-reported information about the location, intensity, and timing of pain
may be crucial for diagnostic decision-making in medicine, especially
when there are few other clues on which to base a diagnostic or treatment
decision.
Indeed, self-reported information about mental processes and cognitive functioning should play a central role in assessment of symptoms of
ADHD, particularly for adults. Patricia Murphy and Russell Schachar
(2000) reported studies showing that adults can give a true account of
their childhood and current symptoms of ADHD. And it makes sense that
assessment for this disorder should not be an adversarial process in which
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We found that 66 percent of the adults with ADHD in our sample had
a large discrepancy (one standard deviation or more) between their verbal
IQ and their story memory; in the general public only 16 percent of adults
show such a wide dierence. Children with ADHD show a similar problem with listening and remembering. In 2001c I reported on use of a similar story-memory test administered to several age groups of children.
Among those with ADHD, 57 to 73 percent showed significant impairment on story recall, while only 25 to 33 percent of children in the general
population had such diculties.
Taken together, these results suggest that across wide age spans, these
tests of story recall oer a brief and eective way to test impairments of
verbal working memory in individuals being assessed for ADHD. These
simple tests take only about ten minutes to administer. The task allows the
clinician to check the eectiveness of a patients working memory on a
task similar to many situations in daily life where one is given information orally and is able to hear it only once. It should be noted, however, that
in each age group some persons with ADHD were not impaired on the
story-recall task, while some who did not have ADHD were impaired. For
this reason, results of such a test cannot be used alone to determine the
presence or absence of ADHD. Multiple measures are needed.
A persons level of general intelligence has nothing to do with whether
they have ADHD. Russell Barkley observed that ADHD children are likely
to represent the entire spectrum of intellectual development, with some
being gifted while others are normal, slow learners, or even mildly intellectually retarded (1998, p. 98). An individuals verbal IQ, performance
IQ, or full-scale IQ score can tell nothing about whether they do or do not
suer from ADHD. Yet some IQ tests, for example, the Wechsler Intelligence Scales for Children, fourth edition (WISC-IV), introduced in 2003,
and the Wechsler Adult Intelligence Scales, third edition (WAIS-III), available since 1997, have some subtests that are fairly sensitive to impairments
in executive functions. Comparing a persons performance on these subtests can oer information useful for the assessment of ADHD.
In 2001c I considered the performance of ADHD-diagnosed children
ages eight to twelve with the overall group of same-age test-takers on four
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index scores on the WISC-III. Two of the indexesthe Verbal Comprehension Index (VCI) and the Perceptual Organization Index (POI)
summarize subtests less sensitive to executive-function impairments;
instead these identify ones general verbal ability and general perceptual
organization abilities. Indexes more sensitive to executive-function impairments are the Freedom from Distractibility [Working Memory] Index
(WMI) and the Processing Speed Index (PSI); these characterize ones
working memory and speed on simple clerical tasks.
In my sample, over 61 percent of the children with ADHD showed a
large (at least 15 points) discrepancy between their VCI or POI (whichever
was higher) and their WMI or PSI (whichever was lower). Fewer than 25
percent of the children on which the test was standardized showed such a
discrepancy (2001c). In my earlier samples of adolescents and adults, the
dierences for this measure were equally substantial (1996c).
These data show that comparisons of an individuals WISC or WAIS
index scores may oer helpful information about the degree of weakness
of that persons executive functions. Just as with scores for the verbal memory tests discussed earlier, however, such discrepancies are not shown by
all individuals with ADHD and similar discrepancies are shown by as
many as 25 percent of individuals not diagnosed with ADHD. This means
that such index score comparisons should be only one part of an evaluation for ADHD.
Additional Disorders That May Cause or Complicate ADHD
There are many reasons that a child or adolescent may be unsuccessful at
school or in social relationships, just as there are many reasons that adults
may be unsuccessful in education, work, social relationships, or family
life. ADHD is one possible reason, but not the only one. For this reason,
any evaluation for possible ADHD should include screening for environmental problems and for other learning or psychiatric disorders that may
be causing or complicating the symptoms presented as possible ADHD.
The Brown ADD Diagnostic Form in versions for children, adolescents,
and adults all include guidelines to assist clinicians in checking for pos-
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others. Using a sample of children ages seven to twelve referred for possible ADHD, they obtained ratings from parents and a teacher for each
child. Using a sophisticated statistical analysis, they created a subset of
symptoms most important to teachers and a separate subset of symptoms
most important to parents. In addition, they found that not all DSM-IV
symptoms predicted impairment equally well. Using their revised, separate, and shorter symptom lists, they increased the agreement between
parents and teachers from very poor to extremely good.
Dierences in such judgments between parents and teachers may be
due to the childs performing very dierently in the two settings, each of
which has very dierent task demands. Or the variation could be due to
the parents having unrealistic expectations of what a child of a particular
age can dowhereas the teacher can compare each child with many others
of the same age. Alternatively, the teacher may be inexperienced in assessing shortcomings in the childs learning and behavior, perhaps blaming either herself or the child too much for any problems noticed. Sometimes, too, the teacher may be caught up in a personality conflict with the
child, or be ideologically opposed to recognizing any child as having impairments of ADHD.
In situations of conflicting reports I need to elicit examples from each
parent, interview the child directly, and seek out additional information
from teacher reports and standardized testing. Usually reviewing examples
clarifies the causes for dierences of opinion about a childs symptoms.
Are the Symptoms Truly Caused by ADHD?
In other situations, there may be little question about the presence of the
symptoms, but considerable uncertainty about their causes. The parents,
child, and the childs teachers may all agree that the child has some symptoms of ADHD, yet factors other than ADHD are likely to blame. For example, the family may be suering from severe financial hardship with
both parents unemployed. One parent may be seriously addicted to alcohol, causing disruption or abuse at home. An older sibling may be severely defiant toward the parents and intimidating to the patient. A beloved grandparent may be dying of cancer. Or a childs favorite teacher
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may have left on maternity leave for several months, replaced by a series
of ineective substitutes.
Such stressors, especially when more than one is present, may be the
primary cause of the childs apparent ADHD impairments, or they may
simply be exacerbating ADHD impairments that have been present since
birth. The incidence of unemployment, marital conflict, substance abuse,
and frequent changes of residence is elevated among individuals with
ADHD. The presence of environmental stressors, even if they are many
and severe, does not rule out a diagnosis of ADHD any more than such
stressors would rule out a diagnosis of asthma.
Impairment by What Measure?
One important factor in determining impairment is the basis for comparison. To whom should an individual be compared in order to make a
diagnosis of ADHD? The DSM-IV (2001) states that the ADHD symptoms must be maladaptive and inconsistent with developmental level
(p. 92). For children, developmental level might be taken as referring
simply to age groups. One could argue that a five-year-old is not impaired
in her ability to pay attention if she can pay attention as well as most other
five-year-olds. The DSM-IV does not, however, spell out the full range of
meanings for developmental level, which could also be taken to refer to
level of intelligence. At the lower boundary, this reinterpretation would
mean that one would not make the diagnosis of ADHD for an eight-yearold developmentally disabled child with an IQ of 60 by comparing his
ability to sustain attention with that of other eight-year-olds with normal
IQ. This is generally accepted.
What is more controversial is the assessment of impairment at the
upper boundary of abilitythat is, for the very bright individual whose
overall cognitive competence as measured by standardized tests of intelligence is in, say, the top 5 to 10 percent of the age group. Should this individual be considered impaired if he is chronically unable to organize and
sustain eort for his work, to remember what he has just read, or to perform other cognitive tasks as compared to a same-age student with cognitive abilities scored in a similar range?
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DSM-IV field study selected cuto scores that included the 7 percent who
were most impaired by ADHD symptoms, thus establishing that the remaining 93 percent of children would not be considered impaired enough
to warrant diagnosis. But why should that be the cuto for diagnosis
rather than 3 percent, 10 percent, or 15 percent?
One way to address this question is to determine the percentage of individuals in the general population who typically meet diagnostic criteria
for ADHD as defined by DSM-IV. The prevalence rate cited for ADHD in
DSM-IV-TR is 3 to 7 percent of school-aged children. But this estimate has
not been well documented in epidemiological studies. In 2001, Andrew
Rowland and colleagues reported an epidemiological study that used parent and teacher reports about a population-based sample of children in
North Carolina. This study found that 16 percent of the children in their
sample were significantly impaired by ADHD symptoms, an incidence
rate much higher than the estimate in DSM-IV. Some other studies have
reported an even higher incidence of ADHD, while other researchers have
found lower rates in the general population.
Whatever the incidence rate of DSM-IV-defined ADHD, how impaired are those who meet DSM-IV diagnostic criteria for ADHD in comparison to those who are just slightly below that cuto ? Lawrence Scahill
and others (1999) reported a study that addressed this question. The group
used a combination of parent and teacher reports to assign a large sample
of children aged six to twelve years into three groups: those who fully met
DSM-III-R diagnostic criteria for ADHD; a subthreshold ADHD group
who had many symptoms, but fewer than what is usually required for diagnosis; and a non-ADHD group.
The Scahill study found that children in their subthreshold sample
had less psychosocial stressfor example, less family dysfunction and
less poverty and a lighter load of additional psychiatric disordersthan
those who fully met diagnostic criteria for ADHD. Yet this subthreshold
ADHD group still carried a burden of ADHD symptoms and, for many,
additional psychiatric impairments relative to those in the non-ADHD
group. Scahill concluded his report by noting that the subthreshold ADHD
children, who had many ADHD symptoms but not enough to meet full di-
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father active
drug addict,
visits erratic
strong loving
single mother
working full-time
Excellent
athlete
Solidly average
"smarts"
Disorder of
written
expression
losing a
supportive
teacher
ADHD
Reading
disorder
parents
divorced
Dysthymia
Handsome
Good friend
Loving son
nervous about
starting middle school
Figure 6 Venn diagnostic diagram. The inner square shows key strengths and
impairments of an eleven-year-old boy evaluated as he was preparing for transition into middle school. Venn circles within that square identify overlapping diagnostic categories that currently apply, and the outer square highlights important supports and stressors in his immediate environment.
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ADD Syndrome
MYTH: Someone cant have ADD and also have depression, anxiety,
or other psychiatric problems.
FACT: A person with ADD is six times more likely to have another psychiatric or learning disorder than most other people. ADD usually overlaps
with other disorders.
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dren ages seven to nine years diagnosed with ADHD, 70 percent were
found to have met DSM-IV diagnostic criteria for at least one other psychiatric disorder within the preceding year. These included:
Oppositional-defiant disorder
40%
Anxiety disorder
34%
Conduct disorder
14%
Tic disorder
11%
4%
Mania, hypomania
2%
The MTA sample included only young children; 80 percent were boys
and most were in first, second, or third grade during the initial evaluation.
Only children with combined-type ADHD were assessed; no children without significant hyperactive-impulsive symptoms of ADHD were included.
The profile of psychiatric and learning problems characteristic of older
children, adolescents, and adults with ADHD, especially women and those
with predominantly inattentive-type ADHD, is likely to be dierent.
A study of somewhat older children in Puerto Rico yielded results
dierent from the MTA. Among an equal mix of boys and girls ages nine
to sixteen years from the general community, Hector Bird and colleagues
(1993) found 48 percent who suered from depressive symptoms, far
more than the 4 percent of young children similarly identified in the
MTA sample. Some disorders like depression tend to emerge later in life
than others.
Studies of adults with ADHD show an even higher incidence of additional disorders accompanying ADHD. Rachel Millstein and others (1997)
compared adults whose ADHD symptoms were predominantly inattentive (37 percent) with those who had the combined type (56 percent). Rates
for some comorbid disorders were similar between these two subtypes of
ADHD; others were dierent:
Diagnosis
Combined Type
Inattentive Type
Dependence
69%
43%
Major Depression
63%
63%
Substance Abuse/
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Oppositional Disorder
40%
16%
35%
23%
Conduct Disorder
30%
20%
Social Phobia
24%
31%
Multiple Anxiety
Disorders
adult sample
Odds ratio
45%
3.0
59%
3.2
35%
2.8
69%
5.9
88%
6.3
The numbers listed under odds ratio show how much the ADHD sample
exceeded the general population sample. An odds ratio of 1.0 means that
the ADHD sample had the same percentage as was found in the larger
population, whereas an odds ratio of 3.0 indicates that the disorder occurred three times as often in the ADHD population. These estimates do
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not include any learning or language disorders, but they do highlight the
markedly elevated incidence of psychiatric disorders reported by adults
with ADHD.
Epidemiological and clinical samples each give dierent information
about the frequency with which various psychiatric disorders occur. Epidemiological studies yield information about how many individuals in a
sample of the general population report sucient symptoms to be diagnosed with a particular disorder. Typically investigators approach individuals at random and try to solicit their cooperation in answering multiple
questions about psychiatric symptoms. Such inquiries may yield useful
estimates of how many individuals in a population experience a particular
problem, but such data have an important limitation: It is highly unlikely
that most individuals will fully disclose their personal diculties to an investigator whom they do not know and when there is no significant benefit to them that might oset the potential worry and embarrassment of such
disclosures. For this reason, epidemiological studies are likely to underestimate the prevalence of psychiatric disorders.
Yet clinical samples, groups of people who have sought out help for
themselves in psychiatric clinics, are likely to overestimate the incidence
of comorbid disorders in the larger population. Clinical evaluations are
likely to probe more fully and get more candid responses than can epidemiological studies. Patients are likely to disclose their multiple diculties
more fully to the doctor whose help they have sought. Their hope for relief from suering may oset the embarrassment and shame that otherwise would cause them to avoid discussion of their private suering. Yet
those who seek treatment in clinics or hospitals are a selected population,
likely to be characterized by more severe and complicated illness than are
those in the general population who may suer similar problems, but stay
away from clinics or hospitals. Some with mild impairments and more
financial resources may get treatment from private practitioners in the
community whose records are not generally included in clinical studies;
others may cope with a less intense form of the same problem without any
treatment at all. As a result, reports describing comorbidity rates for clinical populations are likely to yield helpful information about the dramatic
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cases that appear in clinics, but may well overlook a broader range of individuals with similar problems not suciently severe or complicated to
cause them to seek treatment in a clinic or hospital.
Whether gathered in an epidemiological study or reported from clinical samples, psychiatric diagnoses are simply a set of categories, conceptual pigeonholes, for classifying complicated aspects of impaired human
functioning. Currently the DSM-IV lists over two hundred separate diagnostic categories, each described as though it were a discrete entity. These
categories divide up impairments of human cognitive, emotional, and behavioral functioning somewhat like the boundaries of nation-states divide
up peoples of the world. Both are the product of committees subject to
complex political pressures and shaped by the historical setting in which
they were developed.
Boundaries of some nations like North and South Korea arbitrarily
separate groups with closely shared connections of culture and history,
whereas boundaries of other nations like Iraq clump together disparate
groups with conflicting history and cultures, creating an entity that is far
from unified. Similarly, current diagnostic categories for cognitive, emotional, and behavioral problems divide some clusters of functions that have
common causes and similar responses to treatment, while lumping together other clusters that might better be dealt with as separate entities.
Once established, these boundaries become very dicult to change. Proposals for changes in either diagnostic or political boundaries can ignite
earnest and intense conflicts.
Bruce Pennington (2002) has highlighted the need to reconsider existing boundaries for conceptualizing psychiatric disorders. He suggested
a new framework to integrate emerging neuroscientific understandings
of psychiatric disorders, one that includes three clusters of syndromes:
disorders of motivation, disorders of action regulation, and disorders of
language and cognitive development. In the following pages I have borrowed and adapted Penningtons categories to describe some of the complicated ways in which ADD syndrome overlaps other categories of psychiatric disorders. My model is shown in Figure 7.
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Diagnostic Clusters
Social-Emotional Regulation
Aspergers Disorder
Oppositional Defiant Disorder
Conduct Disorder
Tourettes Disorder
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Sally Shaywitz (2003) has described how most children, unlike George,
learn to break the code in order to learn to read.
The very first discovery a child makes on his way to reading is
the realization that spoken words have parts. Suddenly a child
appreciates that the word he hears comes apart into smaller
pieces of sound; he has developed phonemic awareness . . .
the ability to notice, identify and manipulate the individual
soundsphonemesin spoken words. (p. 51)
Shaywitz noted that 70 to 80 percent of American children learn how
to translate the code of written letters into spoken sounds without much
diculty. The remaining 20 to 30 percent have varying levels of persisting
diculty in learning to convert combinations of letters into spoken words.
It is this impairment in learning to process phonemes, not the tendency
to reverse letters and numbers, that is the major ingredient in dyslexia, another name for reading disorder.
There is strong evidence to suggest that dyslexia is associated with
specific impairments in brain function. Sally Shaywitz and Bennett Shaywitz (2002) used functional MRI imaging to study the brains of dyslexic
children compared to nonimpaired readers. In the brains of the dyslexic
boys and girls, they found evidence of disrupted functioning in specific
left hemisphere circuits that have been shown to be crucial for reading.
Mathematics Disorder
Twelve-year-old Lois is a sixth-grade student whose grades are all
As except in math. Since first grade she has always had great
diculty doing math problems. She is an excellent reader and
has developed an exceptional vocabulary, but despite much effort she has not yet been able to learn her multiplication tables.
She still uses her fingers to count and makes many errors when
she attempts to do simple adding and subtraction. She seems to
grasp the idea of multiplying, but is not yet able to multiply two
numbers by two numbers. She finds simple division problems
very confusing and still makes many mistakes in counting
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Yet Leo failed the first test of the semester, an essay exam requiring paragraphs to explain aspects of the Civil War that had
been covered in the textbook and discussed in class. The teacher
was annoyed by his overly terse answers and the lack of elaboration to support his responses. He felt that Leo knew the answers
better than anyone else in class. He assumed that Leo had not
taken the test seriously. Immediately after class the teacher met
with Leo and required him to respond orally to each of the questions on the test. Leos answers were all top-notch. When the
teacher asked Leo why he had written such a poor test paper when
he knew all the answers so well, Leo answered, That happens to
me all the time. I can know about something and can talk about it
with no problem, but I just cant get the ideas written out on the
page. All the teachers tell me that my answers are way too short
and that I dont elaborate enough. Im just a really poor writer.
Chapter 4 explains why written expression is much more demanding
of executive functions than are talking or reading. The point here is that,
like Leo, some children, adolescents, and adults experience extraordinary
diculty in expressing in writing, particularly expository writing, what
they think, feel, and know.
After reviewing relevant research, Rosemary Tannock and I (2000)
reported that all three of the basic learning disorders occur at rates two to
three times higher among children with ADHD than among children in
the general population. One of the few studies that looked for all three
basic learning disorders in children with ADHD was reported by Susan
Mayes and colleagues (2000). In a sample of children referred to a clinic,
they found that 27 percent met diagnostic criteria for reading disorder, 31
percent for mathematics disorder, and 65 percent met diagnostic criteria
for disorder of written expression. In sum, 70 percent of those children diagnosed with ADHD fully met the diagnostic criteria for at least one of
these three learning disorders. Why are individuals with ADHD impaired
by these learning disorders at such high rates?
For decades, ADHD and learning disabilities have been seen as completely separate disorders. ADHD was seen essentially as a disruptive be-
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prospect of being away from primary caregivers and has extreme diculty
accepting a substitute caretaker even for short intervals. When required to
stay with a babysitter, spend time in day care, or to attend school, the child
may become extremely agitated and panicked.
Specific phobias involve an individuals being very fearful when faced
with some specific situationfor example, encountering a dog, snake, or
spider; sleeping alone in a dark room; entering an elevator; or flying in an
airplanethough they may experience no extraordinary fear otherwise.
Social phobia, also known as social anxiety disorder, is an intense and
persistently exaggerated fear of embarrassing oneself in interacting with
or performing for other people. Usually this intense fear causes the individual to avoid the dreaded situations whenever possible, for example, by
staying away from restaurants, parties, or other social gatherings. When
the frightening situation cannot reasonably be avoided, such as when one
is called on by a teacher to recite in class, one painfully endures the situation, getting it over as quickly as possible. Anticipation of such events
often causes extreme stress, with nausea, tremors, stomachache, diarrhea,
and so forth.
Panic disorder is characterized by recurrent panic attacksbrief but
terrifying episodes of very intense fear that come on suddenly when there
is no real danger and no anticipation of danger. Unlike phobic responses,
the panic attack comes out of the blue. The attack often includes shortness of breath, profuse sweating, chest pain, nausea, lightheadedness,
and other sensations that may feel like one is having a heart attack and is
about to die. Although such episodes usually peak within ten minutes,
they are often followed by persistent fears of recurrence. Sometimes a
panic attack is followed by strong fears of leaving ones home unless
accompanied by a trusted companion: this is called panic disorder with
agoraphobia.
Generalized anxiety disorder is a broader and more persistent pattern
of chronic worry and fearful expectation that something bad is going to
happen. Often individuals with this disorder spend long periods each day
in uncontrollable, anxious anticipation of possible troubles or dangers.
Additional symptoms such as chronic muscle tension, restlessness, ex-
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cessive fatigue, or diculty sleeping are often present. The focus of worry
may vary considerably from one situation to another. Routine tasks and
situations of daily life may become the focus of ones ruminating in gruesome detail about how badly events could turn out.
Although these various types of anxiety disorder are described as separate entities, they overlap with some aspects of normal development and
often overlap with one another in aicted individuals. To what extent are
these various disorders perhaps variants of one larger problem?
Douglas Mennin and colleagues (2000) addressed the overlap among
anxiety disorders in children with ADHD and in normal controls. His
group found that being diagnosed with two or more specific anxiety disorders identified most children who were significantly impaired by anxiety. This does not mean that an individual diagnosed with just one anxiety
disorder does not warrant treatment. Mennins measure simply identifies
individuals for whom anxiety symptoms are especially impairing. According to this standard, 17 percent of the children with ADHD were severely
impaired by anxiety.
Most of the children in the Mennin study had begun experiencing their
anxiety disorders before the age of twelve. Several studies have shown that
most individuals impaired by depression usually have a history of excessive anxiety antecedent to their hopeless feelings. Often these two streams,
anxiety and depression, converge and continue to flow together over a persons lifetime.
The overlap and complexity of these various forms of anxiety is illustrated in the following case:
Doug, a twelve-year-old boy in seventh grade, was diagnosed as
having ADHD while he was in fourth grade, but received no
medication treatment because his parents were apprehensive
about possible adverse eects. He was brought for consultation
during seventh grade because of longstanding problems with
anxiety. Since early childhood Doug had been very fearful about
being away from his family. When he started kindergarten he
had great diculty separating from his mother each day. Since
that time he has generally been able to attend school regularly,
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house until there was virtually no room to move around. When friends
oered to help her move them out so she would have adequate living
space, she responded, I just cant bring myself to get rid of them. I keep
thinking I may need to refer to them someday, even though I know it
would be much easier to look anything up in the public library microfilms.
I know its stupid, but I just have this strong feeling that I have to store
them in my own home.
These examples of cleaning, counting, arranging, checking, and hoarding are just a few of the enormous variety of tasks that people with OCD
may feel compelled to perform every day. Usually a persons compulsions
tend rather consistently to be of one type or another, though intensity of
the symptoms may wax and wane. Some persons with OCD do not feel
compelled to perform compulsive actions, but they repeatedly get stuck
thinking about specific worries. Sometimes their worries are directly connected to compulsive behaviors that seem intended to relieve the worry.
For example, the nurse who had to wash and wax her floors daily had a
persisting worry about whether her house might be dangerously dirty.
Others have concerns that are troubling in that they seem to require persistent preoccupation, but they are not accompanied by compulsive behaviors.
Examples of obsessional worries without accompanying compulsions
include a nine-year-old girl who reported chronic preoccupation with fears
that her five-year-old sister might suddenly die and a fifteen-year-old boy
who reported daily preoccupation with worries that he had contracted
AIDS, despite his awareness that he had had no experiences that would
realistically put him at risk of such an infection. Although neither of these
individuals engaged in compulsive behaviors, each reported successive
months when such thoughts persisted in their thinking for two hours or
more each day, despite their eorts to think about other things instead.
As I have described elsewhere (2000), most children, adolescents,
and adults experience occasional preoccupations with disturbing thoughts
and many engage in compulsive behaviors that do not make rational sense.
To qualify for diagnosis as OCD, obsessions or compulsions must significantly disrupt the individuals daily functioning, usually consuming at
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least an hour each day. It is this daily impairment that distinguishes the obsessions and compulsions of OCD from the repetitive worrying or superstitious behaviors that may occur from time to time with most people.
In a group of children diagnosed with ADHD, Daniel Geller and others (2002) found that over half also had some form of OCD. Previously, in
1996, these researchers had found that one-third of children diagnosed
with OCD also met full diagnostic criteria for ADHD; usually the ADHD
occurred much earlier, more than two years before the OCD symptoms
developed. Children who had both ADHD and OCD tended to have significantly worse daily functioning than those who had either disorder without
the other.
Post-Traumatic Stress Disorder
Another anxiety disorder seen more commonly among individuals with
ADHD is post-traumatic stress disorder (PTSD). Primary symptoms of
PTSD have to do with an individuals persistent disturbing reactions to an
event or series of events in which they had reason to believe that his or her
life was in danger. This disorder was first recognized in soldiers who returned from combat, where they had been exposed to acute risk of severe
injury or imminent death, and where they had seen their comrades suer
agonizing pain after being felled by bullets or bomb fragments.
For weeks, months, and years after exposure to such trauma, some
soldiers repeatedly re-experienced the terrifying events as though a video
of the situation were suddenly being replayed in their memory. In those
moments of flashback, sometimes occasional, sometimes many times a
day, they recalled the situations in painful detail as though they had suddenly been returned to the original experience. Each time they felt the
same intensity of anxiety and other emotions that had accompanied the
initial experience, a situation that seriously disrupted their sleep and
daily life.
Study of Vietnam veterans suering from PTSD yielded evidence that
these terrifying experiences had been etched into memory in a unique way
that the brain apparently reserves for situations of acute danger. For some
veterans, PTSD symptoms diminish gradually over time; they have been
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able to heal from their trauma with some success. For others, the terror
repeats over many years, and, for some, for the rest of their lives. Research
suggests that the severity and duration of PTSD symptoms are not directly
linked to the severity or duration of war trauma experienced; instead,
some individuals are more vulnerable to such reactions than others.
Gradually clinicians recognized that some victims of trauma other
than combat show similar persistent symptoms of flashbacks, sleep disturbances, and so forth. These occur in some individuals traumatized by
rape, a severe motor vehicle accident, being trapped in a burning building,
or some similar situation where, for terrifying moments or more, it appeared to the victims that they were about to die a terrible and unexpected
death or where they witnessed such a fate in others. PTSD symptoms also
occur in some people who experience life-threatening dangers in natural
disasters such as earthquakes or floods.
Similar etching of painful events into memory occurs in some who
have been subjected to physical and/or sexual abuse as children. PTSD also
has been found in adults who have experienced relationships in which they
were repeatedly battered physically and emotionally by parents or partners. Apparently there is a broad array of situations after which an individual may experience this recurrent misfiring of the brains mechanism
for acute alarm.
Among individuals with ADHD there is an elevated incidence of certain kinds of PTSD. Sally Merry and Leah Andrews (1994) studied sexually abused children and found that while 44 percent met the diagnostic
criteria for PTSD, 25 percent also met those for ADHD; this is more than
threefold the incidence of ADHD in the general population. This finding
does not necessarily indicate that those with ADHD are more vulnerable
to all types of PTSD. It may be that those with ADHD are more likely to
be in situations where certain reactive or interactive types of acute danger
to life or safetysuch as accidents, or physical or sexual abuse may be
experienced.
Combined type ADHD may increase the risk of PTSD resulting from
child abuse. Often those toddlers and young children have chronic diculty in getting to sleep at night and are often defiant and unwilling to fol-
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ADHD, but are also characterized by a number of other seriously impairing symptoms that are not part of ADD syndrome.
Substance Use Disorders
Substance use disorders, which are characterized by abuse of or dependence on alcohol, marijuana, heroin, cocaine, methamphetamine, or a variety of other drugs, significantly disrupt ones motivation to pursue education or work, interact with others, and maintain ones self and household.
Often the long-term goals and more immediate intentions of these individuals are seriously interrupted as they crave, seek, use, and react to substances of abuse. Persons given this diagnosis often suer from excessive
arousal, being excessively hyped-up in certain phases of drug use while
being excessively slowed down or somnolent in other phases of abuse or
dependence. These disruptions of motivation and arousal appear to be
closely connected to anticipated, immediate, and delayed eects of the
abused substances on the brain.
Among individuals diagnosed with ADHD, there is a markedly elevated incidence and severity of abuse and dependence on alcohol and
other drugs over the lifetime. This dierence does not become clear in
group data until after mid-adolescence, however, when many of those with
ADHD tend to become caught up in escalating problems with substance
abuse. Joseph Biederman and Timothy Wilens (1997) published data
comparing ADHD boys and normal controls use of drugs and alcohol at
baseline and four years later. They found no dierence between the ADHD
adolescents and controls in rates of substance use disorders up to age
fifteen years. Yet an earlier study of adults indicated that 52 percent of
those diagnosed with ADHD had qualified for diagnosis of substance
abuse or dependence at some point in their lives, while only half that percentage (27 percent) of adults without ADHD met the diagnostic criteria
for substance use disorder.
According to data presented by Wilens and others (1998, 2000) having ADHD (1) heightens the risk of developing a drug use disorder, (2) accelerates twofold the transition from less severe drug or alcohol abuse to
more severe dependence, and (3) more than doubles the duration of sub-
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stance use before remission. Apparently those with ADHD tend to become more involved in seriously impairing substance abuse during late
adolescence and early adulthood when most of their peers are reducing
their abuse of such substances. This raises the question of why such a
dierence should occur at that particular point.
One indirect answer to that question might be derived from the 2003
review by Wilens and colleagues of six studies involving more than a thousand adolescents with ADHD, some of whom had been treated with stimulant medications during childhood and adolescence and some of whom
had not. Their goal was to assess the eects of stimulant treatment for
ADHD on the rate of substance abuse. Results showed an almost twofold
reduction for risk of substance use disorders in individuals with ADHD
who had been treated with stimulants, compared to individuals with
ADHD who had not. In fact, those treated consistently during childhood
and adolescence with stimulant medications had a rate of substance abuse
and dependence not significantly dierent from the baseline rate in the
population. Apparently there is something about living with untreated
ADHD that increases the likelihood of abuse or dependence on drugs or
alcohol. Multiple factors may be at work. For instance, impairments of the
brains reward system, described in Chapter 3 as an aspect of ADHD, a
system managed primarily by dopamine networks, may cause aected
persons to seek out and repeatedly use addictive substances that tend to
stimulate that section of brain. Medication treatment for ADHD may reduce that vulnerability while it alleviates symptoms of ADHD.
Untreated ADHD may also cause an individual to be more frustrated
and less successful in school. The lower-achieving student is more likely
to be placed in lower-track classes with less able and less motivated classmates, a peer group where extensive and frequent use of drugs is more
common. In such a situation the student may self-medicate with illicit
substances to alleviate frustration, worry, and shame over poor achievement. In a study of adolescents in treatment for substance abuse, twothirds reported to Beverly Horner and Karl Scheibe (1997) that they had
continued use of illicit drugs not primarily for pleasure, but to improve
their mood. A combination of interacting biochemical and psychosocial
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factors is likely to be behind the elevated rates of many disorders of motivation and arousal among those with ADHD.
Similarities among Disorders of Motivation and Arousal
Among the various disorders of motivation and arousal discussed in this
section there are obvious dierences, but also underlying similarities. Dysthymia and depression both involve a significant reduction in motivation
and arousal associated with chronic feelings of hopelessness, as though an
unsatisfying outcome to ones eorts were already determined. Anxiety
disorders are characterized by an intensification of arousal often combined
with avoidance of what is assumed to be an inevitably dangerous outcome.
Bipolar disorder, in the manic phase, is marked by intense exaggeration of
arousal and an often pathological intensity of certain motivations; the depressive aspect, whether phasic or mixed, falls to the opposite extreme.
Comparison of these comorbid disorders with the characteristics of
ADD syndrome shows considerable overlap as well as dierences. Management of arousal, ability to activate for tasks, ability to sustain eort for tasks,
management of emotions, ability to eectively utilize working memory,
ability to size up and regulate actions in social situationsthese interacting executive functions tend to be impaired in each of these comorbid disorders. Yet each of the comorbid disorders of arousal and motivation is
also characterized by more extreme intensity or absence of arousal, and/or
by motivation that is more extreme in its variability or fixity, than is usually found in ADD syndrome itself. These extremes of arousal and motivation, combined with specific related impairments of these various disorders, occur among persons with ADHD more often than in most others
without ADHD. The high rates of comorbidity between ADHD and these
various disorders of motivation and arousal may be seen as another example of concurrent impairments in the conductor of the orchestra and
in specific components of the orchestra itself.
Disorders of Social-Emotional Regulation
In my reformulation of Penningtons categories, I have grouped together
the following disorders, all of which are characterized by various types and
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ond grade, but it has gotten a lot worse now that she is in
middle school.
Sometimes she will beg another girl to come over to our
house and even oer to pay her to play with her. If the girl says
she might come over sometime, my daughter will get on the
phone and call her eight to ten times on the same day to try to
get her to come over right away. If the girl says shes busy, my
daughter keeps asking her why she cant come a little later that
day. She cant tell when someone is lying or teasing or just trying to put her o. She takes everything literally. Shes not stupid.
Her grades are mostly Cs and Bs; sometimes she gets an A.
She can understand a lot about computers and science, but she
never seems to get how other people feel or why they get mad at
her or laugh at her.
This girls impairment in understanding and managing social interactions is qualitatively dierent from that of most other children with
ADHD. Her problems aect the various executive functions that comprise ADD syndrome, but she is also impaired in more fundamental ways
that have to do with the ability to read and understand emotions communicated by others in implicit, nonverbal ways. She has Aspergers disorder
as well as ADHD.
Patients with Aspergers also tend to have a lot of trouble shifting
focus flexibly between details and context. Martha Denckla (2000) described this problem as it appears in adults with nonverbal learning disabilities aecting not only their social relationships, but also other aspects
of their thinking.
Having an overly local . . . cognitive style, such adults manifest
forest for trees diseasethat is, they miss the big picture
and get stuck on detail. Despite good verbal skills, they write
poorly because they do not summarize or relate pieces of information. Asked for the main idea, the overarching concept, or
the hierarchy (rather than the sequence) of priorities inher-
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No specific medication treatment has been found to alleviate the complex impairments of Aspergers disorder, but when patients who have it
manifest symptoms of ADD syndrome, they often benefit from treatment
with stimulant medications, as do those with pervasive developmental disorder as described by Jean Frazier and others (2000).
Oppositional Defiant Disorder
My oldest daughter has always had a mind of her own, ever
since she was a toddler. Its like she never got over the terrible
twos where they say No! to everything you ask them. Now she
is twelve and wants to think that she is all grown up and doesnt
need to listen to anybody, regardless of who they are. I know a
lot of teenagers are that way, but shes really extreme, even for a
teenager.
At school they have always told me about how shes very
smart, even though she has ADHD, but most of the teachers get
fed up with her attitude. She is always arguing with whatever
they say. They say white and shell argue, No, it cant be that
way. Its really black. They call her the lawyer because shes
always going on and on with her arguments. Sometimes she can
be funny, but she doesnt know when to stop. The principal has
suspended her three times this year for being disrespectful to
teachers. They say this isnt part of her ADHD.
She seems to get along all right with other kids. Shes one of
the ringleaders of a group of girls at school. They play sports together. Shes actually pretty good at soccer, and swimming and
lacrosse. Coaches get frustrated though because anytime she
makes a mistake, she always blames somebody else. She wont
take responsibility for what is her own fault. She does the same
thing at home. Its always somebody else who didnt do what
they were supposed to. Nothing is ever her fault.
When her father and I set limits and wont let her go someplace she wants or wont buy her something she has decided she
needs, she has a tantrum that can go on for a couple of hours,
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with lots of swearing and throwing things and repeated slamming of doors. We just dont know what to do with her! Shes
not a bad kid. She gets herself to school and practice every day
and usually gets pretty good grades, but shes got a big-time attitude problem that we havent found any way to improve much
over the past ten years.
This girls chronic negativistic and oppositional attitude extend beyond impairments usually associated with ADHD. According to her mothers report she has a long history of being defiant toward not only parents, but also teachers and other adults. She is not delinquent, but she
reportedly maintains a very oppositional and defiant attitude in her interactions with most adults. This is an example of oppositional defiant disorder (ODD).
Overlap between ODD and ADHD is usually reported as very high,
particularly when only the combined type of ADHD is considered. Usual
estimates are that about 40 percent of children with ADHD also meet diagnostic criteria for ODD. Characteristics of ODD are mostly variants of
excessively negative emotional reactions and their behavioral manifestations. These include frequent angry outbursts, arguing with or defying
adults, annoyance with or blaming of others, touchiness, resentfulness,
spitefulness, and vindictiveness. Most children who meet criteria for ODD
do not have the more severe problems of conduct disorder (CD), a chronic
pattern of more delinquent behavior that is discussed later.
I explained in Chapter 2 that problems in managing frustration and
regulating emotion are one aspect of ADD syndrome. This is consistent
with my earlier work (1996, 2001) as well as reports of other researchers
such as Russell Barkley (1997), Keith Conners (1997), Conners and colleagues (1999), and Paul Wender (1995); all of us have reported problems
in regulating emotion as an important aspect of the impairments of individuals with ADHD. But current diagnostic criteria for ADHD include no
mention of problems with regulation of emotion. The very high incidence
of the ODD cluster of negative emotional reactions among children with
ADHD raises the question of whether chronic problems in managing
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emotions, especially frustration, may be an aspect of ADHD that was mistakenly excluded from the DSM-IV description of the disorder.
Ross Greene and others (2002) reported on large samples of boys and
girls, average age about ten years, who met diagnostic criteria for ODD
alone or ODD with conduct disorder. He compared these children with
others who had other psychiatric problems, but not ODD or CD. Comparisons showed that socioeconomic status was significantly lower for families of children with ODD alone, and for ODD with conduct disorder, than
for families of children with other psychiatric disorders not including
ODD or CD. These findings suggest that children with ODD and/or CD
are more likely to come from relatively disadvantaged families.
Greene found that schoolchildren with ODD and/or CD had higher
rates of placement in special education classes, though his three groups
did not dier in rates of repeated grades or need for tutorial assistance.
This suggests that children with ODD or CD were seen as needing more
intensive supervision in school. But problems of children with ODD were
not limited to school settings. Social impairments of those with ODD, with
or without CD, cut across all domains of social functioning, including relationships with parents, siblings, and peers. Individuals with this combination of executive function impairments (from ADHD) and chronic problems in managing negative attitudes and emotions (which characterize
ODD) tend to make significant diculties for themselves and others in
virtually every social setting.
Greene and colleagues (2002), as well as others, have reported that
families of children diagnosed with ODD, with or without CD, tend to
show significantly poorer family cohesion and significantly higher levels
of family conflict. One possibility is that ADHD impairments with ODD
symptoms of the child tend to create more conflict with parents. Another
is that parents of these children may be more harsh and more likely to provoke the child, thus establishing a pattern of intensified reciprocal anger
and chronic conflict that the child carries to other situations. It is likely
that socioeconomic disadvantage also contributes substantially to chronic
stress in many of these families.
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Conduct Disorder
Mike is a sixteen-year-old boy whose ADHD diagnosis describes
only a small portion of his chronic diculties. He has been getting failing grades in most of his high school courses for the
past two years since he moved into a new foster home placement. Often he cuts classes or just doesnt show up for school.
Mike has been in foster care since he was seven years old; he is
currently in his fourth placement. Each of his previous placements has ended because of serious behavior problems, for example, bullying younger children in the household, torturing
pet cats in the neighborhood, and repeatedly stealing money
from the foster parents.
Mike was arrested and put under juvenile court supervision
when he was twelve. At that time he had started a fire in the
garage of a neighbor; the garage and its contents were destroyed.
He has been arrested three additional times for shoplifting. Mike
is usually not overtly hostile; he tends to appear apathetic and
sullen, as though he just doesnt care. Foster parents note that he
can be pleasant at times, but cant be trusted to tell the truth, to
keep his commitments, or to respect others property. He smokes
cigarettes openly and is suspected of drinking alcohol and smoking marijuana, though the evidence on this is not clear.
Mike is the youngest of five children. His father is an alcoholic who was physically abusive to his wife and children when
drunk. He served time in jail for auto theft and assaulting a police ocer. Mikes mother, also an alcoholic, had Mike placed in
foster care because she was afraid of his repeatedly playing with
matches in their home. She feared that he might set their house
on fire when she was asleep.
The DSM-IV characterizes conduct disorder (CD) as having symptoms arranged in four clusters: (1) aggression toward people or animals,
(2) destruction of propertyfor example, deliberate fire setting, (3) deceitfulness or theft, and (4) serious violations of rules, such as truancy or
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running away from home before age thirteen. Only three of the fifteen behavioral symptoms listed are required for diagnosis of CD; consequently,
there are a wide variety of subtypes, one of which is characterized by various types of overt physical aggression and another in which behavior is
more covert and nonaggressive, though still delinquent.
Stephen Hinshaw and Carolyn Anderson (1996) noted that while individuals diagnosed with CD almost always have already met the criteria
for ODD, fewer than 25 percent of individuals with ODD eventually develop the more severe problems of CD. Hinshaw and Anderson also emphasized that there are many reasons that children become delinquent,
only a small percentage of which are directly related to the CD diagnosis.
The DSM-IV recognizes this distinction by stipulating that the CD diagnosis should be made only when the symptoms appear to be due to internal dysfunction.
Bruce Pennington (2002) summarized genetic studies showing that
children with ADHD and those who have conduct disorder tend to share
very similar genetic profiles. This led him to suggest that environmental
factors may play an important role in determining the CD outcome: With
optimal parenting, a child with this genetic profile will develop ADHD
only. With harsh parenting, the same child will also develop comorbid
ODD or CD (p. 183). These observations are consistent with family studies showing that harsh, abusive, and/or extremely inconsistent parenting
practices tend to set into motion a vicious cycle of aggressive behavior
from a child, which then elicits more harsh and punitive behavior from
parents. Pennington also notes that peer-group and other neighborhood
influences may cause some adolescents to engage transiently in the antisocial behaviors that characterize conduct disorder.
Usually the CD diagnosis is applied to individuals who engage in serious and persistent antisocial behaviors, some of which may be described
as psychopathic. Donal MacCoon, John Wallace, and Joseph Newman
(2004) have described how psychopathic individuals often are severely
impaired in being able to use awareness of others emotions to restrain
themselves from taking aggressive actions. What causes most individuals
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to care about and respect other persons, to treat others with respect for
their rights and feelings, and to cope with frustrations without harming
those who appear to be causing (or not alleviating) that frustration? Why
do some individuals persistently ignore or show disdain for the pain and
suering that they may cause to others?
Daniel Siegel (1999) has described how children with disorganized
attachments to their caregivers tend to develop hostile and aggressive patterns of interactions with others. From this point of view it appears that
developing or maintaining positive emotional attachments to parents or
other caretakers may increase the likelihood that the child will perceive
others as persons to be respected. This is consistent with James Blair
(1995), who suggested that a deficit in the ability to respond to distress
cues in others (a failure of empathy), produces a failure to inhibit aggressive behavior.
This emphasis on the role of positive emotional attachments in controlling aggression toward others does not rule out the influence of biological factors. Pennington (2002) noted that low levels of serotonin correlate with antisocial behavior and excessive aggression. Low resting heart
rate also has been shown to be characteristic of many individuals who
demonstrate excessive aggression or antisocial behavior. Jame Ortiz and
Adrian Raine (2004) reviewed studies involving more than 5,800 children
or teenagers manifesting antisocial behavior. Their results strongly demonstrated that antisocial children tend to have a lower resting heart rate,
especially when stressed, in comparison to both normal and psychiatric
controls; they showed less of the usual fear response.
Direct links between biological factors and the diverse symptoms of
CD have not been adequately established. One can only suspect a reduced
biological vulnerability to fear, which might result in a relative lack of responsiveness to social cues, less fearfulness about incurring disapproval
from others, or other characteristics. In any case, it seems likely that the
destructive and self-damaging impairments of CD are shaped by some
combination of inherited biological factors and the environmental influences of family and neighborhood.
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Tourettes Syndrome
Tourettes syndrome (TS) is a disorder characterized most noticeably by
chronic vocal and motor tics that occur many times virtually every day for
at least a year. These motor tics may include repetitive eye squinting, nose
twitching, facial grimacing, mouth opening, or shoulder shrugging. Sometimes more complex movements such a lifting an elbow and rotating a
wrist may occur, but the simple tics are more common. Vocal tics may include throat clearing, sning, snorting, or other repetitive noises. Many
patients with TS report that patterns of their tics tend to shift from one
movement or noise to another over time, and that they can suppress them
under certain conditions, but usually the tics tend to reemerge after suppression, sometimes in a more intense way.
Elkhonen Goldberg (2001) described two other characteristics often
seen in patients with TS: an excessive urge to explore by touching, looking
at, or smelling incidental objects that catch their interest, and verbal incontinence, by which he means not only coprolalia, the tendency to make
obscene or profane comments in socially inappropriate situations, but also
a broader pattern of making critical or derisive comments in social settings
where they are likely to hurt others feelings or provoke anger or rejection.
This verbal incontinence includes impulsively uttering observations
or reactions to others that many non-TS individuals might think, but
never say aloud. As Goldberg explains: What is on his mind may immediately be on his lips. It may be unflattering epithets, slurs of various kinds,
obnoxious editorial commentsanything forbidden (p. 183). Many TS
patients describe themselves as having chronic diculty in suppressing
the impulse to say or do what is forbidden, once that possibility enters
their mind. Goldberg observed that in Tourettes the urge to release internal tension may be ever present and unquenchable (p. 183). He quotes
one of his TS patients who described irrepressible urges to touch or smell:
It is a heightened sensory curiosity and lack of inhibition. I become focused on a body part or an object. Once I focus on it, the urge becomes uncontrollable (p. 185).
The chronic diculty of many TS patients in resisting the impulse to
say or do the socially inappropriate, the forbidden, suggests that they
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needs of others and have a lot of trouble holding back verbal or, in some
cases, physical expressions of aggression toward others, seeming to lack
sensitivity to the others pain. In TS there is rarely the deliberate verbal aggression of ODD or criminal behavior that may be seen in CD, yet TS too
reflects significant impairment in the ability to modulate the expression
of emotion by anticipating the emotional reactions of others. Thus all disorders in this group involve problems with using empathy to regulate
ones actions.
As indicated, sizable percentages of persons with ADD syndrome tend
to meet diagnostic criteria for the disorders of social-emotional regulation,
but in each case, the impairments extend well beyond the symptoms of
ADD syndrome alone. Persons with ADD syndrome and any of these disorders of social-emotional regulation tend to suer not only from a chronically impaired conductor of the brains orchestra, but also from impairment in additional brain functionsfrom the inability of a section of
players in the orchestra to interpret and follow the conductors lead.
Why Does ADD Syndrome Often Overlap with Other Disorders?
Having described three clusters of learning and psychiatric disorders that
very often overlap with ADD syndrome, we now return to the question I
raised earlier in this chapter. Why is it that having ADD substantially increases the likelihood of having another disorder? Why is it that a child
with ADHD, if untreated, has twice the risk of developing a substance use
disorder at some time in his or her life? Why do children with ADHD have
double or triple the risk of having reading disorder, math disorder, or disorder of written expression? Why do adults with ADHD have additional
psychiatric disorders at six times the rate reported for the general U.S.
population? Many researchers and clinicians point to genetics, as though
one aicted with ADHD is just unfortunate in being much more likely to
be burdened with the inheritance of additional disorders of learning, emotions, or behavior. But there is another way to look at the high incidence
of overlap between ADD syndrome and other learning and psychiatric disorders. Rather than considering ADD as just one separate disorder among
others, this syndrome might be seen as a cluster of impairments that cuts
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managing emotions, and monitoring action, but also has more specific
disruptions in aspects of the brain that are essential for noticing and monitoring emotional communications of others.
In fact, it does not make much sense to think of such combinations of
impairments, some of which involve executive functions, as chance occurrences of separate disorders. The situation is not like having a sprained
ankle and influenza at the same time. Rather, impairments of executive
function might be compared to disruptions of the operating system of a
computer that interferes in various ways with running a wide range of
software.
Executive Functions Can Be Impaired in Ways Other Than Just ADHD
Although impairments of executive functions that I call ADD syndrome seem usually to be inherited and to occur relatively early in life,
they can also result from traumatic brain injury, the hormonal changes of
menopause, and brain changes common in later stages of old age. In
these ways, symptoms very similar to ADD syndrome may occur in some
persons who have shown no evidence of ADHD earlier in life.
Traumatic Brain Injury
Joan Gerring and colleagues (1998) studied boys and girls aged four to
nineteen years diagnosed with severe to moderate closed head injuries
(CHI). Most had been injured as pedestrians or as drivers or passengers
in a motor vehicle; many had been in a coma for about ten days. Gerring
found that 20 percent of the children with CHI had ADHD prior to their
head injury. This elevated incidence is consistent with the expectation that
children with ADHD are more likely to behave in impulsive or careless
ways that put them at risk of such injuries.
During the year following their CHI, an additional 19 percent of children and adolescents in this sample developed sucient ADHD symptoms to warrant diagnosis. This development suggests that impairments of
ADHD may be acquired by certain kinds of physical damage to the brain.
Similar results were obtained in studies by Jerey Max and others (1998).
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tive tasks. The slower cognitive-processing characteristic of older individuals can aect performance in two ways. First, it may leave an individual
with insucient time to complete all aspects of a task. Second, when working slowly there is an increased risk that one will forget earlier aspects of
a problem before the problem is solved.
But the process of cognitive decline is not the same for everyone of a
particular age. Donald Stuss and Malcolm Binns (2001) reported that
whereas frontal or executive functions of the brain tend to deteriorate earlier than many other cognitive functions, they do not all decline at the same
rate. Moreover, as Scott Johnson and John Rybash (1993) observed, age
dierences in information processing depend not only on the quantity of
information to be processed, but also on what is required for specific tasks.
Individual dierences also play a role in the persistence or decline of
executive functions as one ages. The late Fergus Craik (1987) and colleagues compared three groups of elderly persons on performance of cognitive tasks. They found that the healthier, more engaged, higher-income
adults performed most like young adults. Their group of lower income but
actively engaged adults was intermediate in their cognitive performance,
and the group of adults who had both low income and low activity levels
tended to show the worst performance of the three groups.
Multiple Routes to Impaired Executive Functions
These studies show that many impairments of executive function seen in
ADD syndrome can occur in persons who did not have ADHD in their
earlier years. For some, head injuries, the hormonal changes of menopause, or cognitive changes of old age create a cluster of impairments that
looks very much like ADD without the lifespan history of symptoms. It
seems likely that severe chronic substance abuse and a variety of other
psychiatric or medical disorders may have similar damaging eects on executive functions. It also seems likely that external challenges like these
would cause some individuals who have a lifelong history of ADD syndrome to experience a worsening of their ADD symptoms.
Moreover, now we know that the brains circuits responsible for integrating and managing its various components develop very slowly, gradu-
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essary focus and eort, or to engage their working memory and monitor
their actions enough to do what they know they need to do. But when appropriate medication is in place to correct the chronic chemical problems
that have impaired their executive functions, they generally function well.
Medication Alone May Not Be Enough
For others with ADD syndrome, medication helps, but does not suciently
improve their functioning in school, employment, social relationships,
and/or family relationships. Pills do not teach skills that some with ADD
syndrome need and have not acquired. For these individuals, an important
eect of the medication is to make them more ready to learn. Previously
teachers, parents, supervisors, and friends may have struggled to coach
them to develop important understandings and skills, only to find that, despite good intentions on both sides, the learning simply did not stick, or
carry over from one situation to another. With the help of adequately managed medications to alleviate their ADD symptoms, these individuals may
become better able to remember and use their learning in ways that were
never possible for them while their ADD symptoms were untreated.
For those whose ADD impairments are complicated by symptoms of
depression, anxiety, dyslexia, substance abuse, or other disorders, treatment with medications eective for ADD symptoms may be helpful, but
not helpful enough. Treatment in these situations often requires very
skilled diagnosis and multiple treatment interventions, possibly including
careful trials of two or more dierent medications used in combination.
Psychosocial or educational interventions may also play a crucially important role.
For reasons that often are complicated (some of these are discussed in
Chapter 10), many individuals think of medication as a treatment of last
resort for impairments of ADD syndrome. They argue that psychosocial,
behavioral treatments are preferable to medication and should always be
tried first. This approach might have made sense long ago when ADD was
seen as essentially a behavioral problem of young children; in fact, there
is research evidence supporting the idea that a structured program of consistent behavior modification can be eective in getting most young chil-
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MPH may influence global cognitive processes, such as attentional capacity or working memory, that are deficient in children
with ADHD and result in improvements in aspects of response
inhibition, as well as response execution. (p. 325)
Taken together, these various studies demonstrate that stimulant medications improve a variety of functions impaired in ADD syndrome. These
include sustaining alertness, focus, motivation, and eort for tasks that
are not intrinsically interesting; shifting attention as needed; utilizing
working memory; adjusting processing speed to the demands of the task;
sustaining processing speed for ecient performance; managing emotions to persist despite frustration and failure; and monitoring and selfregulating actions. These laboratory measures stand with a large body of
research over the past half-century that powerfully demonstrates the eectiveness of stimulant medications for alleviating a wide variety of impairments associated with ADD syndrome.
Thousands of Medication Studies
In the decades since stimulant medications were first introduced, several
thousand scientific studies have assessed the eectiveness of these medications for alleviating ADHD symptoms. C. Keith Conners (2002) published a comprehensive review of research that covered hundreds of studies involving over ten thousand individuals. He reported that evidence
from many hundreds of researchers, who assessed many thousands of
children with ADHD in a wide range of diverse settings, powerfully demonstrates that stimulant medications significantly improve symptoms of
ADHD for most of those who are treated.
Stimulant Medications for Adults with ADHD
For many decades, most of the studies of stimulant medications for ADHD
assessed only children. More recently, studies have also tested the eectiveness of medications for treating ADHD in adults. Stephen Faraone
and colleagues (2004) published a meta-analysis of the ecacy of MPH
for treatment of ADHD in adults. Across studies he found strong evidence
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initial stimulant tried does not work at any dose or produces adverse
eects that make it necessary to try an alternative. For some patients, too,
none of the stimulants works well and other, nonstimulant medications
are clearly preferable. Overall, a given individual with ADD syndrome is
80 percent likely to respond positively to treatment with one or another of
the stimulant medications. But a careful fine-tuning of the dose and timing is essential to establish the optimal regimen.
Finding the Most Eective Dose
Some medications are prescribed best according to the patients age,
weight, or severity of symptoms. But stimulant medications do not reliably follow such guidelines. Nora Volkow and James Swanson (2003) described individual dierences that aect ones response to stimulant
medications. Mark Rapport and Colin Denney (2000) demonstrated that
body mass fails to predict optimal dose for ADHD patients. Some very
young and small children need quite large and frequent doses of stimulant to get a positive eect; whereas other children, adolescents, and adults
may benefit from very small doses of stimulant and may have adverse
eects to larger doses. In short, more medication is not always better. And
since it is not possible to predict the optimal dose from age, weight, or
symptom severity, the usual approach is to begin with a very small dose of
one or another of the stimulant medications and then increase the dose
gradually, allowing about three to seven days on a dose before trying a
larger one.
For decades, stimulant medications were available only in preparations eective for just four to five hours; for some whose bodies metabolized these agents more quickly, the eectiveness was much shorter, sometimes just two to two-and-a-half hours. This meant that schoolchildren
were required to go to their teacher or a school nurse once or twice during
the day to receive additional doses, and that adults on this medication had
to remember to take three to four doses each day during their employment and daily routines. Given that persons with ADD syndrome are
often chronically forgetfuland that classmates, teachers, or coworkers
who did not understand or respect the reasons for such medications often
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had negative reactions to those who took themmany with ADD used
these shorter-acting stimulants inconsistently, if at all.
Many improved, longer-acting formulations of stimulant medications
are now produced. In countries where they are available, these extendedrelease preparations have revolutionized stimulant medication treatments
for ADHD. They make it possible for children to avoid taking medication
at school, and they reduce the number of times each day that adults must
remember to take their tablets.
The American Academy of Child and Adolescent Psychiatry (AACAP)
has published approved guidelines for use of stimulant medications in the
treatment of children, adolescents, and adults (2002). For immediate release (short-acting) methylphenidate (MPH; sold as brands Ritalin or
Methylin, or as generic methylphenidate), its recommended starting dose
is 5 mg administered twice daily, increasing as needed by 5 mg weekly up
to a usual maximum of 20 mg per dose; a third daily dose may eventually
be added at the clinicians discretion. For preschoolers the starting dose is
usually lower. Laurence Greenhill and colleagues (2004) reported that initial doses of 1.25 mg of MPH with gradual increments of 1.25 mg as
needed, up to 7.5 mg three times daily, worked well for 85 percent of threeto five-year-olds in a multisite study sponsored by the National Institute of
Mental Health.
For all ages, each weekly increase is to be made only after monitoring
the eectiveness of the drug, the patients weight and vital signs, and any
side eects. Increases are made only when the current dose is not producing an adequate response and is not causing significant adverse effects. If a given dose continues to produce significant side eects, the dose
is to be reduced or the medication stopped with the option of trying another compound. Standard dosing of short-acting MPH is three times
daily, given at times adjusted to fit the individuals schedule and activities.
Some individuals may require more frequent dosing, whereas others may
respond better to taking the medicine only twice each day.
An alternative form of short-acting methylphenidate is Focalin. This
formulation is produced by removing from methylphenidate one of its
two components that reportedly is more likely to cause adverse eects.
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Recognition of the pervasiveness of impairments from ADD syndrome has led many clinicians to prescribe stimulant medications to cover
not only school or workdays, but every day of the week. In practice, the use
of stimulant medications by persons with ADHD varies as does the use of
eyeglasses. Just as some individuals wear their eyeglasses all day, every
day, because the help they provide is needed for virtually everything they
do, so do many with ADD syndrome maintain their stimulant medication
coverage throughout virtually every day. Others, like those who need their
eyeglasses only for reading or for watching TV, will plan with their physician to use their medication only when they need it for specific types of activities like schoolwork or employment.
AACAP has advised that the usual maximum daily dose of shortacting MPH be 60 mg while the maximum daily total dose for DEX and
AMP is usually 40 mg, but their report noted that some patients may need
larger doses to provide full relief or to accommodate a longer day of activities. In such situations the clinician is advised to document that the
symptoms cannot be controlled at lower doses and that the higher doses
are not producing adverse eects such as significant weight loss, an increase in blood pressure, or agitation.
Longer-Lasting Medicines
Currently there are several longer-acting stimulant preparations, some deliver methylphenidate in two or three doses within one capsule (Concerta,
Metadate-CD [Equasym-XL in the UK] and Ritalin-LA). Focalin-XR delivers
two doses of dexmethylphenidate in a single capsule, while others provide
extended release versions of dextroamphetamine (Dexedrine Spansules) or
mixed amphetamine salts (Adderall-XR). These preparations come in various sizes and dier considerably in their speed and intensity of onset, as
well as in their duration. Just as for shorter-acting stimulant medications,
careful tailoring of dose and timing is needed to provide optimal coverage
for any given patient. One size or formulation does not fit all.
Methylphenidate is available in two formulations that provide a medium duration of coverage. Ritalin-LA, currently available in 10, 20, 30, or
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40 mg sizes, releases about 50 percent of its dose within an hour of ingestion and the other 50 percent about three to four hours later. MetadateCD (Equasym-XL) currently available in 10, 20, and 30 mg sizes, releases
about 30 percent of its full dose within the first hour after ingestion and
the remaining 70 percent in another pulse about three hours later. For
most individuals these two medium-duration preparations provide about
six to eight hours of coverage. Both Ritalin-LA and Metadate-CD are capsules containing tiny beads, some of which are designed to release their
contents quickly, while others provide delayed release to extend the duration of coverage; for both of these formulations the capsules can be
opened and sprinkled on a tablespoon of applesauce, pudding, or ice
cream for a young child who is unable to swallow a pill.
A longer-acting preparation of methylphenidate is provided in Concerta, currently available in 18, 27, 36, and 54 mg sizes. Concerta releases
about 30 percent of its dose via absorption of its coating, which activates
within about an hour. The rest of the dose is released in two subsequent
pulses over the ensuing six hours. For most individuals this provides a
fairly smooth distribution of coverage over a total of about ten to twelve
hours. Concerta capsules should be swallowed whole because cutting or
breaking them destroys the time-release system.
Focalin-XR is available in 5, 10, and 20 mg capsules that release about
50 percent of the medication within about an hour after ingestion, and the
remainder about 3 to 4 hours later. Focalin-XR capsules can be opened and
sprinkled on food as described above. Dextroamphetamine is available in
longer-acting spansules containing 5, 10, and 15 mg of medication. These
release about one-third of the dose within about one hour after ingestion
and the remaining two-thirds about three hours later. Dexedrine spansules
usually are eective for about six to eight hours. Opening of Dexedrine
capsules is not recommended. Mixed salts of amphetamine are available
in Adderall-XR, a preparation currently available in 5, 10, 15, 20, 25, and
30 mg sizes. A two-phase release is provided by the mix of tiny beads inside this capsule, which can be opened and sprinkled on foods for children who cannot swallow the capsule itself. Adderall-XR provides about
ten to twelve hours of coverage.
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"wired" or anxious
irritable
serious (lost "sparkle")
during the time med is active,
dose is probably too high.
ACTIVE
DROP-OFF
TIME
Ingestion
Figure 8 Stimulant time frames and rebound. Unpleasant reactions may occur
while the stimulant medication is at full strength or as it wears o. If the reaction is limited primarily to when the medication is active, the dose may be too
high, whereas if the reaction occurs only later, as the medication is wearing o,
the problem is more likely one of rebound, an excessively quick drop-o of
medication eect. Each of these problems requires a dierent intervention.
while the medication is most active, feel slightly hungry for dinner in early
evening, and then become quite hungry later in the evening. If they are
encouraged to eat when they feel hungry, possibly having a second dinner
shortly before bedtime, appetite diculties usually become less problematic. In fact, many patients report that their appetite returns to a more normal schedule after they have been on stimulant medications for at least a
couple of months.
Recognizing Excessively High Doses and Rebound
If an individual is receiving a dose of stimulant that is too high for him or
her, that person is likely to experience one or more of the following symptoms while the medication is active:
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ment; they are discussed later.) Approved in November 2003, ATX has already been subjected to extensive testing. In controlled scientific studies
including over 1,600 individuals, ATX has been demonstrated to be safe
and eective as a treatment for ADHD in children, adolescents, and adults.
Marketed under the brand name Strattera, ATX is not a stimulant.
Unlike stimulants it is not classified as a Schedule II medication; that is,
it has very low potential for abuse and is not subject to the strict rules enforced for stimulants, pain medications, and other compounds that, if misused, could cause addiction. This means that ATX can be obtained more
conveniently by patients. Physicians can provide samples, can phone prescriptions to the pharmacy, and can provide refills without having to write
a new prescription each time.
ATX takes a dierent approach than stimulants to alleviating the impairments of ADHD. While stimulants target primarily the dopamine system in the brain, ATX targets primarily the noradrenergic neurotransmitter
system. ATX helpfully slows the reuptake of norepinephrine at noradrenergic synapses in the brain in much the same way that stimulants helpfully slow transmitter reuptake in synapses of the dopamine system. As
described in Chapter 3 of this book, the noradrenergic and dopaminergic
systems are the two neurotransmitter systems most involved in management of executive functions impaired in ADD syndrome. The relative
influence of each of these two systems on specific aspects of ADHD impairments has not yet been determined.
Adequate head-to-head research has not yet tested whether ATX
provides the same degree of improvement for inattention symptoms of
ADHD as the stimulants usually do. But clinical trials have clearly shown
in sizable groups of children, adolescents, and adults that, for many, this
medication can significantly alleviate both inattention and hyperactive or
impulsive symptoms of ADHD. In addition, ATX has the advantage of
lasting longer than stimulants. Some parents report that while on ATX
their ADHD children are easier to get along with throughout the day and
evening, are able to fall asleep with less diculty at bedtime, and are able
to awaken the next morning with less irritability and oppositional behavior. There is also some evidence that ATX may help to alleviate the anxi-
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ety and depressive symptoms that often appear with ADHD and are less
likely to be alleviated by stimulants.
One disadvantage of ATX is that it does not provide noticeable benefits until the patient has been taking it daily for three to five weeks. By
comparison, stimulants are usually noticeably eective within an hour
after the patient has ingested a dose that is of optimal strength for them.
Common side eects of ATX may include stomachache (especially if
taken on an empty stomach) and drowsiness; usually these gradually diminish after a few days or weeks on the regimen. Another disadvantage is
that the capsules should be swallowed whole; but this is usually a problem
only for very young children who are unable or unwilling to swallow a pill.
The dopaminergic and noradrenergic systems both contribute to the
biological elements underlying ADD syndrome. And individuals with ADD
syndrome vary considerably in which aspects of the ADD syndrome are
most problematic for them. Given these factors, it is likely that some patients with ADD syndrome will respond better to ATX than to stimulants
while others will respond better to treatment with a stimulant. Unfortunately, there is not yet a sucient base of research and clinical experience
for clinicians reliably to predict which of these medications will be most
helpful to any particular patient. Clinical experience and research should
eventually yield useful guidelines for such decisions.
While it is usually preferable to treat ADD syndrome with just one
medication, there may be some circumstances where neither stimulants
nor ATX alone provide adequate alleviation of an individuals impairment
from ADD syndrome. In such cases, carefully combined use of these two
medications might be considered. In 2004, I presented case reports on
the successful use of ATX and stimulants in combination for some patients who did not respond adequately to either agent alone. Yet I cautioned that there is not yet research to guide such combined use, so very
careful clinical monitoring is essential.
While ATX is the only nonstimulant medication thus far approved by
the FDA specifically for treatment of ADHD, a number of other nonstimulant medications have been demonstrated helpful for treatment of the
disorder. Guidelines from the American Academy of Pediatrics (2001) iden-
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children or for individuals with depressive problems. Despite a substantial body of research showing the eectiveness of desipramine for treatment of ADHD, many physicians stopped prescribing it, at least for prepubescent children, after sudden deaths were reported in four children
who had been taking appropriate, not excessive, doses of desipramine for
ADHD. Joseph Biederman and others (1995a) have reported that the risk
of sudden death when taking appropriate doses of desipramine is elevated
only slightly above the normal risk for sudden, unexplained death in children. Nevertheless, caution is advised when considering this specific medication for prepubescent children. For ADHD most clinicians feel more
comfortable prescribing nortriptyline because it tends to have fewer adverse eects than most other TCAs.
Nontricyclic Antidepressants
The other nonstimulant medication recommended by the American Academy of Pediatrics (2001) as a second-line treatment for ADHD is buproprion (BUP). Marketed under the brand names Wellbutrin and Zyban,
buproprion is classified as an antidepressant, but its chemical structure is
quite dierent from that of most other medications in this class. BUP acts
on the noradrenergic system and indirectly on the dopaminergic system.
Controlled studies have found BUP to be eective for treating ADHD in
children (two trials) and adults (two trials). One open-label study found
BUP useful for treating patients with ADHD and comorbid bipolar disorder. Wilens and colleagues (2002) suggested that treatment with BUP for
ADHD patients should be initiated at 37.5 mg and increased every three
or four days up to a maximum of 300 mg daily in younger children and
450 mg daily in older children or adults. Adverse eects may include excessive activation, irritability, insomnia, and (rarely) seizures.
Antihypertensives
Clonidine and guanfacine, marketed as Catapres and Tenex, respectively,
were originally developed as medications to reduce high blood pressure.
They have been found helpful for reducing excessive hyperactivity and
impulsivity in children with ADHD, but there is currently no evidence
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that these agents improve the cognitive impairments of ADHD. The effects for clonidine usually persist for about six hours, while guanfacine
usually lasts a bit longer. Usual daily doses reported by the group led by
Wilens (2002) are 0.05 to 0.4 mg for clonidine and 0.5 mg to 3 mg for
guanfacine. Many physicians using these medications do a baseline ECG
and monitor the patients vital signs during treatment. The most common
side eect of these antihypertensives is drowsiness, although they can also
cause depression or rebound hypertension as they wear o.
The sedating properties of clonidine have been exploited to help alleviate the chronic diculties in falling asleep that are common in many
children with ADHD. Jeerson Prince and colleagues (1996) reported
that of sixty-two children and adolescents treated with clonidine about an
hour before bedtime, 85 percent had significantly less diculty falling
asleep. Many of these children (68 percent) were being treated successfully with stimulant medications during the day and were given small
doses of clonidine, typically either a half or full 0.1 mg tablet, about an
hour before bedtime.
Combined Medications
Because many patients with ADHD suer from one or more comorbid
psychiatric disorders, one medication is often not sucient to control
their symptoms. For example, as described above, many patients whose
ADHD symptoms respond well to treatment with stimulants throughout
the day continue to have great diculty falling asleep at night. A significant percentage of these patients experience much less insomnia when
taking a small dose of clonidine about an hour before bedtime. Yet for
most of these patients, clonidine is of little or no help in alleviating the
cognitive impairments of ADD syndrome and also tends to be too sedating to take during the day. For such patients the combination of stimulant
medication during the day and atomoxetine or clonidine at bedtime may
provide much better alleviation of ADHD symptoms without significant
adverse eects.
Similarly, as discussed in Chapter 8, many individuals suer from severe episodes of depression, crippling anxiety, or very burdensome obses-
270
sive compulsive disorder in addition to persistent ADHD. For these patients, concurrent treatment with a stimulant and a selective serotonin reuptake inhibitor (SSRI)for example, fluoxetine, sertraline, paroxetine,
fluvoxamine, or citaprolam (marketed, respectively, as Prozac, Zoloft, Paxil,
Luvox, and Celexa)or another such agent may alleviate both sets of symptoms in ways that no one medication alone could. Davis Gammon and I
(1993) reported a study in which fluoxetine was successfully administered
with stimulants to children who had ADHD as well as depression and
other symptoms. Recent findings about an increase in suicidal thoughts
or behavior in a small percentage of children or adolescents taking SSRIs,
however, has led the FDA to urge close monitoring of use of any antidepressant prescribed for any purpose to children and adolescents.
Treatment with combinations of medications for ADHD and various
comorbid disorders is now relatively common and apparently is becoming
more widespread. Daniel Safer, Julie Zito, and Susan dosReis (2003) reported that in the mid-1990s more than 20 percent of youths in outpatient
psychiatric treatment and 40 percent of those receiving inpatient psychiatric care were given two or more concurrent psychiatric medications.
Their findings indicate that the frequency of such combined treatment is
becoming increasingly common, especially for youths being treated with
stimulants for ADHD. This is not so dierent from other fields of medicine; combined medication treatments have been shown to be significantly more eective than single medication treatment for HIV, intractable seizures, congestive heart failure, and hypertension.
The problem of combined medication treatments in psychiatry, especially when used for the treatment of children, is that the eects of medicines given for psychiatric disorders are more dicult to measure than
those used to treat many medical problems for which critical levels of antibodies, blood pressure, seizure activity, coronary output, and other vital
readings can be easily ascertained. Another important problem is that
very little research has been done to assess the risks and benefits of treatment with these various combinations of medications.
There are a few published examples of such research, however. In addition to the studies by Prince and others (1996) and Gammon and Brown
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(1993) cited earlier, Gabrielle Carlson and colleagues (1992) have reported
on the combined use of MPH and lithium for children with bipolar disorder and ADHD. More recently Russell Scheer and others (2005) reported a controlled trial of mixed amphetamine salts in combination with
a mood-stabilizing medication in bipolar children whose ADHD was impairing even after their mood problems had been stabilized. And Biederman and colleagues (2000) reviewed the use of mood-stabilizing medications, antidepressants, and stimulants. The Tourettes Syndrome Study
Group (2002) and Hazell and Stuart (2003) reported positive results
using clonidine and stimulants in combination. And Michael Aman and
colleagues (2004) summarized two studies on the combined use of stimulants and risperidone for disruptive behavior disorders. Since some of
these were chart reviews or relatively small, open-label studies, there are
limitations to what conclusions can validly be drawn; such findings are
more suggestive than definitive.
Some are quick to criticize clinicians who employ combined medication strategies for treatment of ADHD and various comorbid disorders
since there is so little research evidence to guide such treatments. While
there is good reason to prefer treating patients with just one medication
in accordance with guidelines supported by extensive clinical trials, in
some cases combining medications may relieve substantial suering
while incurring what seems to be a relatively small risk.
Is it preferable to treat a child only with a stimulant that improves his
severe problems with inattention and impulsivity, but does not aid his
chronic, severe insomnia? Should a clinician treat an adolescent with severe bipolar mood swings only with a mood stabilizer and leave untreated
the students ADD syndrome impairments, which make it impossible for
him to do his schoolwork even minimally well? Faced with such dilemmas,
many clinicians, in consultation with the patient and family, choose to
prescribe combined medication treatments for ADHD and comorbid disorders, despite the lack of sucient research to guide the process. In such
situations the apparent risks of not providing the combined treatments
may appear to outweigh considerably the uncertain risks of providing such
treatment while monitoring carefully for possible adverse eects.
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or to follow established routines for getting up, dressed, and ready for
school in time for the bus pickup. Often parents have a long list of changes
they want to see in the behavior of their child with ADHD. A clinician may
need to assist the parents (and child) in selecting the most important and
then stating each goal in a clear and positive way. For example, Show a
positive attitude is too general. Use polite language without swearing is
more specific and less likely to lead to arguments about whether the behavior has been performed. In addition, it is usually helpful to target no
more than five behaviors for change at one time.
The next step is to monitor compliance. Some target behaviors like
Make bed each morning before leaving on time for school involve a
simple yes or no for the day. Other behaviors, like Speak politely to
other family members without swearing, might be reinforced more
eectively if the child is assessed four to five times each day. In this way,
if the desired behavior is not shown during one time period, the child still
has the opportunity to improve over the course of the day.
The third task is to identify consequences, positive and/or negative,
that the parent will impose in response to how the child performs the target behaviors. Following the more flies with honey than with vinegar
rule, a parent who wants a child to speak more politely is most likely to obtain the desired change by rewarding the child for every time period in
which the child complies. Reward here may mean any of many dierent
privileges or gifts; and it often does not need to have monetary value.
Some children will work hard for verbal praise, hugs, smiles, or nods of
approval from a parent. Other children will make the desired changes in
behavior only if it means a privilege like extra reading time with a parent
before bed or a chance to play with a special toy that is desirable, but not
always available. Other children are more likely to change their behavior
only to earn points that can eventually win them a specific amount of
money or opportunity to rent a new video game.
Often behavior change requires not only rewards, but also some
penalty for a specific misbehavior. For example, a child who hits younger
siblings might be rewarded for each time period over the day when he
keeps hands to himself. Yet the behavioral treatment plan may also spec-
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ify that each time the child does hit a sibling, he or she is required to sit
on a certain chair or go to a particular room for a time-out. The time-out
period should be brief, perhaps just five minutes for a younger child or
fifteen minutes for an older child. Its purpose is to interrupt the maladaptive behavior and then to get everyone back on the track, working toward the desired behavior.
The fourth element of behavioral treatment is monitoring the eectiveness of the intervention, evaluating what is working and what needs to
be changed. This may sound simple, but success lies in a sensitive, detailoriented implementation of the plan. For example, if a child is given a
time-out for a temper tantrum, the time-out should be timed with a
kitchen timer that will ring at the end of the set time. If the child gets up
too early or persists in screaming and shouting, the timer should be
restarted until the specified time is completed quietly in the right place. If
the parent shouts to tell the child to keep quiet or to remind the child what
the consequences will be, the system collapses; the child is then being encouraged to continue the tantrum rather than learning that compliance
ends the punishment more quickly. If a parent gets intensely involved
with a child, even to scold, in reaction to undesirable behavior, the child
may be more likely to repeat that negative behavior. Dont feed it, if you
dont want it to grow! For many children, both positive and negative attention from parents are reinforcing.
Training for Parenting Children with ADHD
Most parents need some help to learn how to design and eectively implement behavioral programs. Useful strategies for all children have been described by Thomas Phelan (2003) in his book 1-2-3 Magic. Russell Barkley
(2000), in his Taking Charge of ADHD, also oers ways for parents to deal
with many behavioral problems associated with ADHD. And systematic
training programs to help parents learn how to apply behavioral treatment
strategies to children with ADHD have been described by Arthur Anastopoulos and colleagues (1998) and Charles Cunningham (1998).
Despite such training, some parentsespecially those who themselves
have ADD syndromehave great diculty making behavioral treatment
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municate, negotiate, and compromise on an increasing range of other behaviors important for development (but not worth a major meltdown) as
the child develops the abilities needed to meet more age-appropriate expectations.
There certainly are children whose impairments with severe ADD syndrome prevent them from responding to the usual behavioral treatments
(particularly when comorbid Aspergers disorder or pervasive developmental disorders are involved), yet allow them to respond to the approach
described by Greene. Most children with disruptive behavioral disorders,
however, will respond to more conventional behavioral treatment programs at home and in school.
Behavioral Interventions at School
Behavioral strategies have also been developed to support and improve the
functioning of children with ADHD and related problems in school. Details about approaches for schools are not reviewed in this book, but are
readily available elsewhere. George DuPaul and Gary Stoner (2003), for example, have described in detail a variety of ways that children with ADHD
can be supported in school. And Sandra Rief (2005) has written a book
oering practical suggestions for teachers who want to adapt their classroom to maximize learning opportunities for their students with ADHD.
One behavioral treatment strategy that can be helpful for parents is
the daily report card. This is a simple device that allows a teacher quickly
to record each day how well a student has performed on several specific
target behaviors in the classroom. Parents can then recognize and reward
their child at home for specific good behaviors at school on the very day
they occur. Sometimes weekly report cards, too, can be very helpful and
less burdensome for a busy classroom teacher.
Behavioral strategies need to be adapted carefully to each context and
to the developmental level of each child. Some approaches that work well
at school for many younger children with ADHD do not work as eectively for older children or adolescents, who usually interact with five to
seven teachers daily. Getting accurate, up-to-date information about how
an adolescent is performing in schoolwhether their homework is being
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arise as adolescents with ADHD begin driving motor vehicles and Chris
Dendys practical guidebooks on parenting adolescents with ADHD (1995)
and teaching adolescents with ADHD (2000).
Comparisons of Medications and Behavioral Treatments:
The MTA Study
Sometimes parents and clinicians wonder which type of treatment, behavioral or medication, is more eective for treatment of ADHD. Until recently there was very little empirical data to address that question. This
situation changed with completion of the Multimodal Treatment Study of
Children with ADHD (MTA Cooperative Group 1999). This massive research project, sponsored jointly by the National Institute of Mental
Health and the U.S. Department of Education, sought to answer three
questions: (1) How do medication and behavioral treatments for ADHD
compare with each other over the long term? (2) Are there additional
benefits when the two modes of treatment are used together? and (3) What
is the eectiveness of systematic, carefully delivered treatments versus the
routine care usually delivered in most communities of the United States?
At six dierent sites in the United States and Canada, children were
recruited to participate in the study. All were aged seven to 9.9 years when
the study began, and all were found after comprehensive evaluation to
meet the DSM-IV diagnostic criteria for ADHD, combined type; no children with predominantly inattentive type were included. After evaluation
these children were randomly assigned to undergo fourteen months of
treatment in one of four dierent groups:
1. Medication monitoring only. Patients were given carefully tailored
medication treatment for ADHD, which was monitored each
month and adjusted according to prearranged formulas to optimize response. These children and their families were provided
no other treatment for ADHD.
2. Behavioral treatment only. Patient families were given a comprehensive behavioral treatment package: parent training, an intensive eight-week summer day camp for the child with trained specialist counselors; episodic expert consultations for the childs
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scores of the group that did not receive any treatment other than carefully
managed medication for ADHD. These data clearly support the notion
that the primary impairments in ADHD are chemical and can often be alleviated with appropriate medications alone.
It should be noted, however, that these results were group means, the
averages, for improvement on various symptoms that had been selected
in advance. When the data were reanalyzed to determine the percentage
of individuals who had obtained excellent improvement from treatment,
the advantages of the combined treatment were more apparent. James
Swanson and colleagues (2001) reported the percentages of children who
obtained excellent, normalized responses from their treatment:
Community Care (with or without medication)
25%
34%
56%
68%
These data show that the combined treatments yielded a 12 percent increase in the percentage of children obtaining an excellent response. They
also show that some in each group obtained an excellent response while
even the most eective treatment left fully 32 percent of children in that
condition with a less than excellent response. Keep in mind that most of
those not listed as having an excellent (that is, normalized) response to
treatment still benefited in varying degrees from their treatment experiences. Follow-up studies will continue to monitor the results of this treatment study for at least ten years, even though some participants have discontinued or switched their treatments.
In assessing the results of the MTA study, it is important to keep
in mind the age of the participants. All the subjects were young children
with combined-type ADHD; the behavioral treatments that proved eective for many of the young children in the MTA study may have much
more limited eectiveness for the ADHD impairments suered by older
children, adolescents, and adults, as well as for those who have predominantly inattentive-type ADHD.
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If an individual with ADD syndrome has developed such self-defeating assumptions about himself and others, medication treatment is unlikely to cause a lasting change. To counter the persisting eects of such
self-defeating assumptions and attitudes, the patient will need help recognizing and revising them in the context of an emotionally engaged relationship.
This process of attitude change and revising assumptions is not a
purely intellectual process that can be derived from listening to a lecture
or reading a book. Such resources may be helpful, but real change will involve subtle and powerful emotions, not just an exchange of words and
ideas. The interaction may occur in a series of intensive, closely spaced
conversations, or it may happen over many months or years.
For some, the partner in this process is a parent who persists in recognizing the strengths of this son or daughter despite recurrent setbacks
and disappointments. Some parents are amazingly adept at nurturing a
positive and hopeful attitude in their children while also providing reasonable limits and honest feedback about shortcomings in the sons or
daughters plans or behavior. They cultivate recognition of the childs
strengths and they provide generous and sustained reinforcement for
constructive eorts. They encourage their child to pursue opportunities
that can be reached with extra eort, yet they avoid supporting unrealistic
expectations likely to lead only to frustration. In countless conversations
at times when the child must make critical decisions or is responding to
the delights of success or the pain of defeat, such parents can share the
emotions of their child and nurture the childs developing strengths.
Yet despite the best eorts of their parents, some children and many
adolescents and adults need more specialized help to recognize and overhaul self-defeating assumptions and attitudes developed in reaction to
their ADD syndrome. The most fortunate encounter and connect with a
wise and empathetic teacher, professor, or work supervisor who is willing
to serve as a mentor, providing ongoing guidance and emotional support
for their eorts to revise their ways of doing business with themselves and
other people. For others it may be necessary to consult and employ a professional counselor, a psychotherapist, or an ADD coach to provide per-
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spective and support for the process of self-change that may be needed, especially in the early stages of coming to terms with an ADD diagnosis.
Getting such support is not always easy. Many counselors and psychotherapists still do not understand ADHD. And persons who present
themselves as ADD coaches vary widely in their educational background,
level of training, and competence. Some have as their main qualification
their desire to be helpful to persons with ADD and their willingness to
maintain frequent contact by phone or face-to-face meetings. Others have
professional training in social work or a related field and have specialized
training to increase their understanding of ADD syndrometraining
that has given them strategies to help patients and families clarify goals,
organize tasks, and sustain the eort required to attain reasonable objectives. Development of a system for assessing qualifications and providing
credentials for ADD coaches is still in its infancy. Patients who have worked
with coaches have had reactions ranging from grateful and enthusiastic
appreciation to frustrated disappointment.
At present, it cannot reasonably be assumed that every licensed counselor, psychotherapist, psychologist, or psychiatrist is familiar with ADD
syndrome and can competently assist those who have it. Only a small percentage of professionals in the present generation have received even a
minimal education about how to recognize and treat the various forms of
this disorder. Increasing numbers are learning about the assessment of
ADD and its treatment with medications. But relatively few, at present,
have been trained to deal with assessment, medication adjustments, and
the more subtle issues of identifying and treating the problematic assumptions and attitudes of patients with ADD syndrome. Organizations
like Children and Adults with ADHD (CHADD) and Attention Deficit
Disorder Association (ADDA), listed in the resources section of this book,
may oer some information helpful for finding trained professionals.
Cognitive-Behavioral Treatment
One promising way to address problematic attitudes and behaviors that
persist in some with ADD syndrome, along with medication, is to use cognitive behavioral therapy techniques. Steven McDermott (2000) and Rus-
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sell Ramsay with Anthony Rostain (2004) have described strategies and
case examples of this approach with adults. Arthur Anastopoulos and Lisa
Gerrard (2003) have described similar processes with children and adolescents. Typically cognitive behavior strategies seek to identify the patients self-sabotaging assumptions and strategies, undermine these with
cognitive behavioral interventions, and encourage behaviors that will facilitate development of more positive and helpful approaches.
Marital and Family Treatments
Usually untreated ADD syndrome aects the entire household of the person experiencing the symptoms. Problems may emerge in couples even
when there are no children. As I described in Chapter 6, adults with ADD
syndrome often partner with someone who provides support that compensates for some of their own weaknesses. Without consciously realizing
it, a person with untreated ADD syndrome may feel drawn to someone
who is exceptionally tolerant or amused by their chronic tardiness, inattention, and disorganization, or to someone willing to take on the tasks of
managing joint finances and scheduling medical appointments and social
events. Some opt for partners more forceful and confrontational, who take
on a parenting role toward the adult partner with ADD, perhaps even by
continuing a nagging style that had been familiar, if not comfortable, in
the family of origin.
As such relationships evolve, however, the ADD syndrome impairments of one partner may become less amusing, more annoying, and
more burdensome to the other. Or the individual with ADD syndrome
may gradually start to feel resentful about the nagging demands or condescension of the helpful partner. One or both may become chronically
irritable or react with increasing distance and eventual emotional or physical abandonment. Such pressures can be even more problematic if the
couple has a childespecially if, as often happens, the couple has a child
with ADHD.
Indeed, children with ADD syndrome present a continuing series
of worries, frustrations, and management problems to their parents. Although deeply loved, they can be very high maintenance relative to
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most other children of the same age. And they may consume a disproportionate amount of time and attention from their parents, often leaving siblings frustrated and resentful over what may constitute genuine
unfairness.
Jeanne Safer (2002) grew up with an emotionally troubled older brother.
She described the complex, painful, and often unacknowledged feelings
that can aect brothers and sisters of children with chronic problems.
No one with an abnormal sibling has a normal childhood. . . .
Family gatherings and significant events become occasions for
anxiety and suppressed shame. . . . [Healthy siblings] . . . feel
tormented by the compulsion to compensate for their parents
disappointments by having no problems and making no demands. . . . Their success is always tainted by their siblings failure, their future clouded by an untoward sense of obligation and
responsibility. . . . You are ashamed that you are related, guilty
that you have a better life, envious that nothing is expected of
him, relieved that you are not the misfit to be scorned or pitied.
Because a sibling is your closest relative, you are eternally enmeshed with each other. (pp. xviiixix)
Not every individual with a sibling who has ADHD suers such intense burdens as Safer describes. Many enjoy and benefit from most of
their interactions with their brother or sister who has ADHD. Yet there are
certainly some children impaired by untreated ADHD, especially those
with severe comorbid problems, who daily disrupt family life over many
years. These children may drain so much parental time and attention that
the remaining siblings chronically get short shrift.
But it is also true that some brothers and sisters exploit their ADHD
siblings, setting them up to be unfairly punished for misdeeds they did
not commit, or gaining more favorable treatment for themselves by directing parental attention to otherwise unnoticed shortcomings of the
ADD child. Families with members who have ADD are subject to the full
range of sibling rivalries and complex emotional alliances often found in
other families.
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cluded that most research shows no credible evidence for the eectiveness
of such diets in treating ADHD. He did note that such diets may be helpful for a small subset of children who have specific food allergies, but
there is no evidence that children with ADHD have any greater incidence
of such food allergies than children in the general population.
Diet supplementstypically herbal remedies, high-dose vitamins, or
other consumable products sold over the counter in health food stores or
supermarketsare often touted as being able to, for example, improve
focus or strengthen memory. Because the FDA regulations that control
advertising for prescription drugs do not apply to diet supplements, there
is virtually no limit to the extravagance of claims that can be made for such
products. Although a few compoundsfor example, essential fatty acids
have shown some possible benefits for ADHD patients in pilot studies,
most of these products have not been proven eective thus far. Some,
such as megadose vitamins, may carry a mild risk of damage to the liver.
Some believe that any substance advertised as natural must be safer
than a pharmaceutical product. In fact, many natural substances in the
environment are quite toxic, sometimes even in small doses. Arsenic, for
example, is a natural substance. The most widely publicized example of a
natural diet supplement causing health problems was a series of cases
in 1989 where onset of eosinophilia-myalgia was linked to use of tryptophan. Arnold (2002) noted that those cases may have been due more to
impurities in the tryptophan than to the compound itself. This explanation highlights another problem with many diet supplements: their production is not regulated by the FDA to maintain high standards of quality
and purity.
EEG Biofeedback or Neurofeedback Treatments
Practitioners of biofeedback (or neurofeedback) often claim that their
treatments can train a child, adolescent, or adult with ADHD to change
their brain wave patterns and thereby alleviate their ADHD impairments.
This treatment consists of electrodes being attached to a patient and then
hooked up to a computerized monitor that displays the frequency rates of
certain types of electrical activity that normally vary in the human brain.
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The patient is given directions about how to relax himself or herself, much
as might be done in hypnosis. On a monitor the patient is then able to see
how successfully he can modify those brain waves. As Russell Barkley
(2003) has pointed out, however, there is no active ingredient in the process that directly aects the brain waves. The equipment is simply a fancy
monitor that provides immediate feedback about how successfully the patient can relax.
Although practitioners of neurofeedback claim that evidence of the
success of their treatment techniques has been published, reviews by Sandra Loo (2003) and by Russell Barkley (2003) indicate that this published
research does not meet basic scientific standards for evidence of eectiveness. Studies published thus far are deeply flawed by failure to randomize
patients, failure to use a placebo control, failure to blind patients or evaluators, contamination of results by allowing intervening or concurrent interventions with other treatments, and various other problems. Indeed,
Loo reports that the one and only published study of neurofeedback that
came close to following accepted scientific standards provided no evidence that neurofeedback was eective. Given the understanding of ADD
syndrome proposed in this book, and the physiological processes that support executive functions, it is dicult to imagine how conscious eorts to
relax oneself, with or without an electronic monitor, could cause any lasting improvement in the complex cognitive processes that constitute executive functioning. Neurofeedback treatments appear to be rooted in a simplistic notion of ADHD as an individuals simply being too tense or revved
up and needing to learn to relax.
Exercise Treatments
A program of individualized exercises purported to improve cerebellar
developmental delay is currently being marketed as a new alternative
treatment for alleviating dyslexia and attention deficit disorder. Claims
have been made that prescribed programs of exercise done for five to ten
minutes twice dailyfor example, balancing on one foot while throwing
a beanbag from one hand to the other, can produce dramatic improvement in reading ability and fully alleviate ADD symptoms without med-
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Marital or family therapy sessions, too, may help to identify unrecognized misunderstandings and may improve maladaptive patterns of interaction between partners or other family members, but these techniques
do not, in themselves, change the chemical problems underlying ADD
syndrome. Finally, accommodations such as extended time for taking examinations or a minimally distracting workplace may provide some help
for students or workers with ADHD, but they are not needed by every patient with ADD syndrome and, in any case, do not alleviate the underlying
problems.
In each individual case, decisions must be made to determine the
specific treatment needs of the patient with ADD syndrome and, if needed,
his family or household. It is also essential to consider what treatment resources are actually available, desirable, and feasible for the patient. Peter
Jensen and Howard Abiko (2000) identified seven patient characteristics useful to guide clinicians decisions about treatments for children
with ADHD:
Age and intellectual ability of the child and family
Severity and urgency of the condition itself
Patients treatment history and eects of those treatments
Presence of comorbidity or other complicating conditions that also
must be addressed as part of a comprehensive treatment plan
Family factors, including presence of psychopathology in parents or
other family members
The parents ability and willingness to apply recommended treatments
Families wish for input and preferences about specific treatment
types. (p. 638)
In addition to these patient characteristics, Jensen and Abiko also noted
that the nature of available resources to the family (for example, medical
insurance, or school-based treatment resources in the community) are important factors in treatment planning. In many communities in the United
States and elsewhere, too, there are even more basic resource questions
such as:
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Many in the general public and some professionals in medicine, psychology, and education remain skeptical about the validity of the ADHD diagnosis and its treatment. Fears and prejudices persist despite overwhelming
evidence and recommendations derived from high-quality, peer-reviewed
research.
In the mid-1990s, the American Medical Association (AMA) received
questions about the possible overprescription of medications for ADHD; in
response, they appointed a panel of medical experts to review all relevant research. To prevent bias, the panel members were experts in medical research,
but not specialists in ADHD. The panels findings, adopted by the AMA
(Goldman et al. 1998), included some strong and definitive statements:
ADHD is one of the best-researched disorders in medicine, and
the overall data on its validity are far more compelling than for
most mental disorders and even for many medical conditions.
(p. 1105)
ADHD . . . at any age increases the risk of behavioral and emotional problems at subsequent stages of life. It is thus a chronic
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illness with persistence common into adolescence and beyond. (p. 1106)
Epidemiological studies . . . suggest that 3% to 6% of the schoolaged population may have ADHD. . . . The percentage of U.S.
youth being treated for ADHD is at . . . the lower end of the
prevalence range. (p. 1106)
Pharmacotherapy, particularly stimulants, has been extensively
studied. Medication alone generally provides significant shortterm symptomatic and academic improvement. . . . The riskbenefit ratio of stimulant treatment in ADHD must be evaluated
and monitored on an ongoing basis in each case, but in general
is highly favorable. (p. 1106)
At about the same time, the American Academy of Child and Adolescent Psychiatry (1997) published guidelines on ADHD that included the
following:
Attention-deficit/hyperactivity disorder (ADHD) is one of the
most common psychiatric disorders of childhood and adolescence. . . . In most cases a stimulant is the first-choice medication . . . from large numbers of research studies and 60 years of
clinical experience . . . more is known about stimulant use in
children than about any other drug. (pp. 85S92S)
Recent clinical experience and research document the continuation of symptoms into adulthood. . . . Because adults are expected to function far more independently than children, and
because they have less structure and supervision, the consequences of inattention and impulsivity often have serious implications for functioning. . . . The risk of abuse and the possibility
of tolerance or drug refractoriness are greater in adults than in
children, but still are rare. (pp. 105S106S)
The American Academy of Pediatrics (2000, 2001) published similar
reports documenting the wealth of scientific evidence that validates the
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atively rare in most other parts of the world. To address this questioning,
Steven Faraone and other international scientists (2003) reviewed the research literature to identify epidemiological studies of ADHD in a variety
of cultures. They found that earlier studies reporting a much lower rate of
ADHD outside the United States were based on dierent definitions of the
disorder than those currently used. When they focused on studies that used
the same DSM-IV criteria, this group found six studies of ADHD in children
in the United States and nine comparable studies done in other countries.
These studies showed rates of 9.5 to 16 percent for ADHD in children
in the United States. Studies done in cultures as diverse as Australia,
Brazil, Colombia, Germany, Iceland, Sweden, and Ukraine reported rates
of childhood incidence ranging from 3.7 to 19.8 percent; five of these studies identified a narrower range of 16 to 19.8 percent. The researchers concluded: ADHD is not purely an American disorder . . . there is no convincing dierence between the prevalence of this disorder in the U.S.A.
and most other countries or cultures (p. 111).
Despite this large body of scientific evidence about ADHD and its
treatment, public skepticism persists. Criticism of ADHD in books, magazines, radio, and TV seems to emerge in two dierent forms: (1) fiercely
ideological categorical attacks pursued with religious fervor, and (2) more
modulated questioning of the diagnosis, its etiology, and its treatment.
Radical Attacks against ADHD
The most aggressive attacks against recognition of ADHD as a legitimate
disorder have come from groups such as the Citizens Commission on
Human Rights (CCHR), which advocates against using psychiatric or psychotropic medicines in any situation. This well-funded group and certain
individuals associated with it have circulated allegations that ADHD is a
fictitious disorder. One of their publications, Psychiatry Betraying Families: The Hoax of ADD/ADHD and Other Learning Disabilities, argues,
These are made up disorders along with others including severe emotional disorder . . . and dyslexia. ADHD is a total, 100% fraud.
Often media releases and educational materials of the CCHR or comparable groups do not specify their aliation with the Church of Scien-
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gues that although there are some children who wont behave or pay attention despite appearing normal in other ways, these problems are
caused not by inherited impairments of brain function, but by a variety of
societal or family problems. Armstrong referred to ADD as a social invention, a symptom of societal breakdown, a response to boring classrooms, a bad fit between parent and child, and a dierent way of
learning. He acknowledged that stimulant medication might be appropriate for some aected children, but only briefly and for specific
situations.
As alternatives to medication for ADHD, Armstrong advises that parents provide a balanced breakfast, find out what interests your child,
enroll your child in a martial arts program, use background music to
focus and calm, provide a variety of stimulating learning activities,
provide positive role models, and employ a variety of other strategies to
give the child more attention, flexible but supportive structure, and positively toned discipline.
Most of the strategies recommended by Armstrong would be helpful
for any child, including those with ADD syndrome, but in themselves they
are not likely to alleviate the persisting problems of those children whose
impairments are sucient to warrant the diagnosis of ADHD.
Arguments from critics like Armstrong and others such as Lawrence
Dillerwho described ADD as a catch-all condition encompassing a variety of childrens behavioral problems (Diller 1998, p. 63)are useful
because they caution against overly simplistic medical understandings of
ADHD and its treatment. They remind readers of the importance of optimizing classroom environments and providing direct, consistent parental
support for each child. They also warn against inadequate evaluations and
inadequate monitoring of medications, as well as the assumption that
every problem can be fixed with medication. Most reasonable persons
would readily agree with many of their fundamental arguments.
These authors, however, seem to be working with a simplistic notion
of ADHD. They characterize the disorder as unpleasant misbehavior, excessive restlessness, or intermittent distractibility. They fail to grasp the
broad complexity of impairments associated with ADD syndrome, or
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the power of this disorder to disrupt and seriously impair the daily functioning of aected individuals and their families over months, years, and
lifetimes.
ADD Syndrome Can Cause Tragic, Sustained Suering
Throughout the United States and around the world I have spoken with
many individuals who have ADD syndrome and with their family members. Repeatedly they have shown me compelling evidence that ADD syndrome can seriously impair daily functioning, disrupt ongoing development, and, in some severe cases, threaten life itself.
One especially poignant example involves Joel, a bright, lively boy
whom I met a few years ago in Scotland. Joels mother had told me about
how her son had struggled from his earliest years. He was unable to control his chronic restlessness and hyperactivity, and despite his mothers
persistent eorts, there was no treatment available for him. Though very
bright, he had great diculty learning and was often seriously disruptive
in class. He had been repeatedly suspended from school and was finally
expelled.
When I met Joel at age fifteen, he was a handsome, well-developed,
appealing boy in a wheelchair. He was unable to walk and could move his
arms and fingers only in contorted ways. He was unable to speak, but he
could smile and was able to understand much of what was said to him.
His ADHD had not been diagnosed or treated until he was twelve years
old, and even then the treatment had been insucient. Joel had continued
to struggle with severe ADHD impairments that were extremely disruptive at school and at home.
At age fourteen, Joel had attempted to hang himself at home. According to a local newspaper:
His mother said, Since [his] earliest years he went haywire in
class. He couldnt even sit down for five minutes. At the age of
nine he had been suspended from school 11 times . . . Joel was
an intelligent boy with an IQ of 126 (superior range) . . . he
could be really aectionate and he had a wonderful sense of
humor. . . . He was eventually excluded from school and it hit
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For some like Joel and Jason, the consequences of living for years with
untreated or inadequately treated ADD syndrome and related problems
can be devastating. In many other cases, the consequences are less dramatic, but nevertheless costly in a variety of ways.
The Many Costs of ADD Syndrome
A cute little six-year-old boy sat in my oce with his parents. His big
brown eyes were downcast and he looked deeply sad. I asked him, Why
are you here to talk with me today? He kept staring down at the rug and
mumbled, Because Im bad; Im very, very bad. How does one assess the
costs in self-esteem and diminished hope for a child who persistently sees
himself in this way at the age of six? How can one anticipate the costs of
living with such a view of oneself over the longer term, especially if no
treatment is provided to interrupt the cycle of negative behaviors and the
reactions of others?
And how does one assess the costs to an individual who receives appropriate treatment, but only late in his schooling? One high school senior came into my oce for a follow-up session three months after his
ADHD had been diagnosed and treated for the first time. Throughout junior high and high school this student had been chided repeatedly by his
parents and teachers. They had reminded him about his very superior
abilities demonstrated in standardized tests. They had confronted him
about how he had been placed in classes for gifted students throughout elementary school and then removed from such classes in junior high because he was too inconsistent about studying and completing homework
assignments. They had warned him that despite his strong abilities and
high ambitions, he would be unable to gain admission to a good university unless he improved his grades.
It was the time in March when most colleges and universities let applicants know whether they will be admitted. The student said:
You know, Im grateful that my ADD has finally been diagnosed
and Im glad I have this medicine now. It helps me a lot. Every
one of my teachers has commented about how now Im doing a
lot better. They noticed within a week of my starting the medi-
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cine, and none of them knew I had started it. They just saw that
all of a sudden I was consistent in getting my homework done
and was really participating in class discussions.
What Im not grateful for is the fact that nobody recognized and
did anything about this until the middle of my last year in high
school. When I was in elementary school I was always in the gifted
classes. When I got to middle school and high school I got kicked
out of those and put in lower-level classes because I couldnt
keep up with the work and wasnt prepared enough for class.
I still hang out with those kids who were my classmates in
the gifted classes back then. We all get along. We enjoy the same
jokes and share the same interests. Now theyre all getting admitted to top-tier universities and Ill be lucky to get into a thirdrate college because my grades have been so pathetic. Im just as
smart as those friends of mine, but there is no way now that I
can go back and redo the years that got me that lousy transcript!
It pisses me o that I didnt have this treatment six or eight
years ago! If I had, my life would have been very dierent and
Id have a lot more opportunities open to me today.
Even in the large number of cases where ADD syndrome impairments are not life-threatening, the consequences of not treating this syndrome can be constricting and damaging in persistent and significant
ways. To go through school with untreated ADD syndrome is like trying
to run a marathon carrying a knapsack of bricks. One can do it, but it is
much harder to run with the bricks, and ones race timethe result of all
of that hard workwill probably be much worse than the times of others
who are running without the extra load.
For many, not all, with ADD syndrome the burden of frustration and
discouragement begins very early and gets progressively worse. Some educators refer to the Matthew eect to describe how children who get a good
start in learning to read tend to do increasingly well in their schooling as
they grow older. In contrast, children who get a weak or late start in reading
tend to get further and further behind as they go through school. The reference is biblical, from the Gospel according to Matthew, chapter 25:
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For unto everyone that hath shall be given, and he shall have
abundance; but from him that hath not shall be taken away even
that which he hath.
Keith Stanovich (2000) illustrated how this process can unfold in the development of vocabulary and reading skills:
Children who are reading well and who have good vocabulary
will read more, learn more word meanings, and hence read even
better. Children with inadequate vocabularieswho read slowly
and without enjoymentread less, and as a result have slower
development of vocabulary knowledge, which inhibits further
growth in reading ability. (p. 184)
If this line of reasoning is extended to cover not just reading, math,
and other academic skills, but also the ability to utilize executive functions
throughout each stage of development, the implications are staggering.
When a young child suers from untreated ADD syndrome, that child is
likely to encounter persisting diculties with academic and social demands in many aspects of life: school, family, and social tasks and interactions. Depending on the severity of impairment and the adequacy of
supports available, the child is likely to experience frustrations and delays
that at best will make life more dicult, and at worst, may cause life to feel
unmanageable.
It is clear that individuals with ADD syndrome often suer considerably from their inherited impairments of executive function. It is also
clear that there are safe and eective treatments available that can alleviate these impairments in 70 to 80 percent of those aicted. So why do
most individuals with ADD syndrome still not receive adequate diagnosis
or treatments?
Patients, parents, and professionals throughout the United States
and in twenty-five other countries have described to me barriers to eective treatment of ADD syndrome that seem persistent in every culture:
(1) fears due to inadequate understanding of ADD syndrome and its
treatment, (2) a lack of adequate resources for assessment and treatment,
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(3) prejudice against considering genes as a major cause of ADD syndrome, and (4) prejudice against using medications to treat apparent
lack of willpower.
Fears Due to Inadequate Understanding
When a child, adolescent, or adult repeatedly fails to do what they should
be able to do, most people have an explanation. In such situations many
quickly assume that the person is performing poorly simply because they
are lazy, stupid, stubborn, unmotivated, defiant, or some combination of
these. Sometimes such assumptions are correct. Often they are not.
In every culture in every generation there probably have been substantial numbers of individuals who failed to meet performance expectations
because they suered from ADD syndrome. In most cases, their failures
have probably been explained by their parents, teachers, bosses, coworkers, spouses, and friends as due to lack of motivation, lack of ability, or
poor attitude. Undoubtedly many chronically failing individuals explained
their shortcomings to themselves in similar ways.
Significantly, these explanations for failures are usually infused with
emotion. Parents, teachers, and others feel discouragement, worry, frustration, and anger when they are repeatedly disappointed in their eorts
to encourage a struggling individual to work harder, longer, and better to
do what should be done.
Moreover, these mistaken assumptions are deeply entrenched in the
public consciousness. Educating the public about ADHD is thus no simple
matter. In explaining ADD to most people, we are trying to counter strongly
held misunderstandings with more accurate, scientifically based information about the disorder and its treatment, but often people see no need
for a dierent explanation. Many believe that they clearly understand this
disorder when they truly do not.
Yet helping people develop a scientifically accurate understanding of
ADD syndrome is vitally important, because common misunderstandings of ADD syndrome perpetuate the suering of children, adolescents,
and adults aicted with this disorder. Parents and professionals who believe ADHD is an insignificant and transient problem of childhood or just
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a diagnostic fad are not likely to help those who are suering find adequate assessment and treatment.
Unrealistic fears of the diagnosis and treatment are also a problem for
many, and those who do not understand that ADHD is a complicated and
significantly impairing problem are not likely to learn enough about the
disorder to alleviate those fears. For example, many parents worry that if
they provide stimulant treatment for their son or daughter with ADHD,
the child might have an increased risk of drug addiction later in life. Ironically, by not seeking information about ADHD treatment, they are not
likely to find out that a child who has ADHD, if untreated or inadequately
treated, has double the risk of suering, at some point in life, from substance abuse severe enough to warrant diagnosis. Indeed, five scientific
studies involving almost a thousand children with ADHD have demonstrated that children whose ADHD is consistently treated with appropriate medications during childhood and adolescence have their elevated risk
of substance abuse reduced, essentially to that of a child without ADHD
(Wilens, Faraone, et al. 2003).
Lack of Adequate Resources for Assessment and Treatment
Not every community has adequate resources to provide assessment and
treatment of ADD syndrome for children; most do not yet have any resources for treating adolescents and adults with this disorder. For most
families in developing countries and for many even in the more developed
countries, access to medical care is extremely limited. Many do not have
access to adequately trained physicians for life-threatening medical conditions, let alone services for mental health. Even in communities where
psychologists and physicians are available, patients are often put on waiting lists for many months or even years. Moreover, even when accessible,
these caregivers may or may not be familiar with current understandings
of ADD and its appropriate treatment.
Clinicians tend to interpret each patients presenting complaints
within the framework of diagnoses they know well. If they have been
trained to recognize and treat depression and anxiety, but lack adequate
training to identify and treat ADHD, clinicians are likely to interpret pa-
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tients presenting complaints about impaired short-term memory, inattention, disorganization, underachievement, and so on as signs of anxiety
or depressive problems. They also are likely to provide treatments appropriate for those disorders without even considering the possibility that
these may be symptoms of ADHD, with or without comorbid anxiety or
depression.
Even in those communities where physicians and medications are
available, such services and medications remain inaccessible to many because of cost. If family members are struggling to pay rent and to put food
on the table each day, they are not likely to be able to aord visits to a doctor or medications, especially for a disorder that does not present any immediate, obvious threat to physical health or to life. Even if a family wants
very much to provide appropriate treatment for a member with impairments of ADD, the costs may be prohibitive and insurance often does not
cover them. Medication costs, especially for the newer, longer-acting formulations, are significant. The expense of consultations with psychologists and physicians for assessment and ongoing treatment can also be
substantial. Many families simply cannot aord to beginor to continuetreatment for ADD syndrome.
When behavioral treatments are added to medication, the costs increase substantially. Peter Jensen (2003) showed that the cost of alleviating impairments of children with ADHD to the point of normalization
using MTA behavioral treatment alone or in combination with medication
management was four times the cost of typical community care. In that
study, the most cost-eective treatment for ADHD was careful medication
management. (Combined behavioral and medication management treatments were somewhat more cost-eective for children with ADHD and
comorbid disorders.)
Many are quick to argue that every patient with ADHD should receive
all relevant treatments. Such an outlook makes sense only to those who
hold unrealistic views of what professional and financial resources are actually available to most of the worlds families. The unfortunate truth is
that in many parts of the world at this time, only the most fortunate are
likely to have access to appropriate assessment and treatments for ADD.
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about .80. By comparison, the heritability index for height is .95. At the
group level, approximately 80 percent of the variance in whether an individual has ADHD can be explained by genetic factors.
The high heritability index for ADHD does not mean that these impairments are caused by a single gene. Modern genetic research thus far
has identified several specific genes that contribute to ADHD, but no
single gene (Thapar 2002). For this disorder, as for most others, its emergence appears to be related to small eects of multiple genes interacting
rather than a large eect from one or two specific genes.
Genes are substantial risk factors for ADHD, but they do not completely explain its occurrence. Environmental factors contribute at least 20
percent to the variation in emergence of the ADD syndrome. These factors may include smoking, alcohol use, or drug use by the mother during
pregnancy (Mick, Biederman, et al. 2002); complications of pregnancy,
delivery, or early infancy such as toxemia or eclampsia; fetal distress; low
birth weight; and dicult delivery (Sprich-Buckminster, Biederman, et al.
1993; Faraone and Biederman 1998). Psychosocial adversity such as severe marital discord, paternal criminality, and poverty have also been
shown to increase vulnerability to ADHD in those genetically at risk (Biederman, Milberger, et al. 1995b; Biederman, Faraone, et al. 1996).
The main point here is that impairments of ADHD result not from a
choice made by the person with ADHD nor from parental negligence.
ADHD results primarily from genetic factors interacting with prenatal,
perinatal, and postnatal experiences that together cause significant impairment in the brain. Given these findings, it makes little sense to blame
victims of ADHD for having the disorder or to censure their parents for
causing it.
The Bias against Treating a Presumed Lack of Willpower
Many who understand this biologically based view of ADHD remain reluctant to see medication used as the primary treatment. They tend to
think of cognitive problems in ADD syndrome as a special category of impairment, very dierent from malfunctions of the pancreas, heart, eyes, or
other bodily organs. For malfunctions of virtually every other organ sys-
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tem, most educated people today see prescription medication as an appropriate and often necessary treatment. Yet when the problem relates to
workings of the brain, these same individuals may object to medication
treatments and insist that the individual ought to fix the problems by
willpower or some other variant of conscious eort.
Indeed, many believe that all cognitive processes can be brought
under conscious control, that any individual can make changes in how he
thinks, what he feels, and how he acts, if only his determination is strong
enough. This is the view that Daniel Wegner (2002) has challenged as
the illusion of free will. Although he acknowledges that this illusion has
adaptive functions, Wegner quotes approvingly Bernard Schlinks (1997)
words,
I dont mean to say that the thinking and reaching decisions
have no influence on behavior. But behavior does not merely
enact what has already been thought through and decided. It has
its own sources. (p. 342)
Opposite to the view that willpower, or conscious eort, can control all
mental processes is the view that most mental processes operate outside
the realm of consciousness. As I have explained, executive functions are
quick, subtle, and complex, usually operating without much input from
conscious thought. Executive-function processes are not usually responsive to willpower on any substantial or sustained basis. But this nonwillpower view of mental functioning is misunderstood by many and
strongly opposed by some.
Resistance to the idea that much of the work of the mind is unconscious is not new. In 1917 Sigmund Freud published a short paper as a response to the strong emotional reaction many professionals and lay
people had to his emphasis on the role of unconscious processes in mental life.
You believe that you are informed of all that goes on in your
mind if it is of any importance at all, because your consciousness gives you news of it. . . . Indeed, you go so far as to regard
the mind as coextensive with consciousness, that is, with
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Psychologists Peg Dawson and Richard Guare (2004) have contributed to the problem of unrealistic hope with their manual intended to
guide educational professionals, clinicians, and parents in providing interventions for children and adolescents who demonstrate weak executive skills. They discuss reasonably how school and home environments
might be modified to support a child with these impairments. And they
acknowledge the need for children to learn to carry out executive functions with progressively less adult support. But these authors refer to executive functions as though they are simply a set of skills to be learned and
consciously exercised, much as one might learn how to type or to speak a
foreign language. For example, they oer strategies
to change the childs capacity for using her own executive skills.
This can be done in one of two ways: 1) by motivating her to use
executive skills she has but is reluctant to employ, or 2) by teaching her ways to develop or fine-tune executive skills she
needs. . . . most youngsters who fail to use executive skills do so
not because they dont care but because they dont yet have the
executive skill. Thus, we generally recommend that parents and
teachers assume this is true and begin tackling executive skill
development by teaching the desired skills. (p. 39; italics added)
The executive functions impaired in ADD syndrome are not simply
skills that need to be learned. Trying to improve the lives of persons with
ADD syndrome simply by attempting to teach them executive skills and
then motivating them to utilize this pedagogy is somewhat like installing improved software on a computer that lacks sucient memory to
run that software. It is comparable to providing didactic instruction in
social skills to individuals with the mindblindness of autism and then
expecting them to interact empathically with others. Such eorts at intervention for ADD syndrome may be well-intentioned, but they oer fundamentally unrealistic hope.
Antimedication attitudes about ADHD are not the only way to foster
unrealistic hope. Some people burden patients by minimizing the suering that often comes with ADD syndrome. They claim that this syndrome
316
317
one can responsibly say is that there is a substantial possibility that one or
another of the available medication treatments for ADD will significantly
improve that individuals ADD impairments, during periods when the
medication is taken, if the kind and amount of medication are tailored to
the individual.
Even when medication is optimally eective, for many with ADD syndrome medication alone is not sucient treatment. Medication does not
teach individuals skills that they have not learned. Moreover, medication
treatments, when they do work, may help patients to mobilize the eort
and cognitive functions required to make the changes they need to make,
but success is never guaranteed. Realistic hope recognizes up front that
the problems of life do not always have a fully adequate solution.
Luckily for some, suering from ADD syndrome may ease as one gets
out of school. The most dicult period for many with ADD syndrome is
the time from about sixth grade through the first couple of years after high
school, whether they then are in college or are engaged in another pursuit.
It is during those years that individuals in most cultures are faced with the
widest range of task demands with the least opportunity to escape from
those tasks one finds especially dicult. If one is fortunate, it gradually
becomes possible to specializeto study or gain employment in a field
where one can utilize ones strengths and avoid some areas of weakness
by delegating tasks to others at work or at home. Some persons with
significant ADD impairments struggle mightily throughout their schooling with poor or mediocre results but are able to achieve considerable success in, for example, business or the arts.
One factor that can help to create and sustain realistic hope in persons
with ADD syndrome is ongoing emotional support provided by a parent,
mentor, friend, or therapist who understands ADD syndrome and recognizes the patients strengths. Adequate support and sucient education
about the disorder can help family members to cope with their own frustrations and may enable them to be less destructively critical and more
reasonably supportive of one another.
Yet realistic hope also is tempered by the awareness that despite such
interventions, untreated or inadequately treated ADD syndrome can take
318
Resources
The websites listed here oer a variety of free information about attention
deficit disorders. Most specialize in issues concerning children and adolescents; some focus more on adults. Many are sponsored by ADD support and advocacy organizations and provide detailed, downloadable information that has been evaluated and approved by a professional advisory
board; others are less selective and may include reports that are not adequately supported by scientific research. Some list contact information for
local support and advocacy groups concerned with attention deficit disorders. Many have links to related organizations, and all are nonprofit.
International Websites Based in the United States
chadd.org oers scientifically reliable information in English and Spanish about ADD in children, adolescents, and adults. Sponsored by Children and Adults with ADHD (CHADD), the largest ADHD support
and advocacy organization in the United States, it has downloadable
fact sheets of science-based information for parents, educators, professionals, the media, and the general public. The site also includes contact information for two hundred local chapters of CHADD throughout
the United States.
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320
Resources
Resources
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322
Resources
Italy
AIFA, http://www.aifa.it
http://www.aidai.org/
Japan
http://www.e-club.jp
Mexico
http://www.deficitdeatencion.org/
The Netherlands
http://www.balansdigitaal.nl/
http://www.adhd.nl/
New Zealand
http://www.adhd.org.nz
Norway
http://www.adhd-foreningen.no
Romania
http://www.intermeding.com/speranta/
Spain
ADANA Fundacin, http://www.f-adana.org
ANSHDA, http://www.anshda.org
APNADAH, http://www.tdah.org
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