ADHD is Not a Disorder of Attention

[David Baxter PhD]

ADHD Isn?t a Disorder of Attention
by Margarita Tartakovsky, M.S., PsychCentral
December 12, 2015

Many people think of ADHD as a disorder of attention or lack thereof. This is the traditional view of ADHD. But ADHD is much more complex. It involves issues with executive functioning, a set of cognitive skills, which has far-reaching effects. In his comprehensive and excellent book Mindful Parenting for ADHD: A Guide to Cultivating Calm, Reducing Stress & Helping Children Thrive, developmental behavioral pediatrician Mark Bertin, MD, likens ADHD to an iceberg.

Above the water, people see poor focus, impulsivity and other noticeable symptoms. However, below the surface are a slew of issues caused by impaired executive function (which Bertin calls ?an inefficient, off-task brain manager?).
Understanding the role of executive function in ADHD is critical for parents, so they can find the right tools to address their child?s ADHD. Plus, what may look like deliberate misbehaving may be an issue with ADHD, a symptom that requires a different solution.

And if you?re an adult with ADHD, learning about the underlying issues can help you better understand yourself and find strategies that actually work ? versus trying harder, which doesn?t.

It helps to think of executive function as involving six skills. In Mindful Parenting for ADHD, Dr. Bertin models this idea after an outline from ADHD expert Thomas E. Brown. The categories are:

Attention Management
ADHD isn?t an inability to pay attention. ADHD makes it harder to manage your attention. According to Bertin, ?It leads to trouble focusing when demands rise, being overly focused when intensely engaged, and difficulty shifting attention.?

For instance, in noisy settings, kids with ADHD can lose the details of a conversation, feel overwhelmed and shut down (or act out). It?s also common for kids with ADHD to be so engrossed in an activity that they won?t register anything you say to them during that time.

Action Management
This is the ?ability to monitor your own physical activity and behavior,? Bertin writes. Delays in this type of executive function can lead to fidgeting, hyperactivity and impulsiveness.

It also can take longer to learn from mistakes, which requires being aware of the details and consequences of your actions. And it can cause motor delays, poor coordination and problems with handwriting.

Task Management
This includes organizing, planning, prioritizing and managing time. As kids get older, it?s task management (and not attention) that tends to become the most problematic.

Also, ?Unlike some ADHD-related difficulties, task management doesn?t respond robustly to medication,? Bertin writes. This means that it?s important to teach your kids strategies for getting organized.

Information Management
People with ADHD can have poor working memory. ?Working memory is the capacity to manage the voluminous information we encounter in the world and integrate it with what we know,? Bertin writes. We need to be able to temporarily hold information for everything from conversations to reading to writing.

This explains why your child may not follow through when you give them a series of requests. They simply lose the details. What can help is to write a list for your child, or give them a shorter list of verbal instructions.

Emotion Management
Kids with ADHD tend to be more emotionally reactive. They get upset and frustrated faster than others. But that?s because they may not have the ability to control their emotions and instead react right away.

Effort Management
Individuals with ADHD have difficulty sustaining effort. It isn?t that they don?t value work or aren?t motivated, but they may run out of steam. Some kids with ADHD also may not work as quickly or efficiently.

Trying to push them can backfire. ?For many kids with ADHD, external pressure may decrease productivity ?Stress decreases cognitive efficiency, making it harder to solve problems and make choices,? Bertin writes. This can include tasks such as leaving the house and taking tests.

Other Issues
Bertin features a list of other signs in Mindful Parenting for ADHD because many ADHD symptoms involve several parts of executive function. For instance, kids with ADHD tend to struggle with maintaining routines, and parents might need to help them manage these routines longer than other kids.

Kids with ADHD also have inconsistent performance. This leads to a common myth: If you just try harder, you?ll do better. However, as Bertin notes, ?Their inconsistency is their ADHD. If they could succeed more often, they would.?

Managing time is another issue. For instance, individuals with ADHD may not initially see all the steps that are required for a project, thereby taking a whole lot more time. They may underestimate how long a task will take (?I?ll watch the movie tonight and write my paper before the bus tomorrow?). They may not track their time accurately or prioritize effectively (playing until it?s too late to do homework).

In addition, people with ADHD often have a hard time finishing what they start. Kids may rarely put things away, leaving cabinets open and leaving their toys and clothes all over the house.

ADHD is complex and disruptions in executive functioning affect all areas of a person?s life. But this doesn?t mean that you or your child is doomed. Rather, by learning more about how ADHD really works, you can find specific strategies to address each challenge.

And thankfully there are many tools to pick from.

 

[Retired]

Secrets of the ADHD Brain
ADDitude Magazine
by William Dodson, M.D.
Posted December 18, 2015

Understanding the ADHD Brain: ADHDers know that they are bright and clever, but they are never sure whether their abilities will show up when they need them.

Most people are neurologically equipped to determine what's important and get motivated to do it, even when it doesn't interest them. Then there are the rest of us, who have attention deficit.

ADHD is a confusing, contradictory, inconsistent, and frustrating condition. It is overwhelming to people who live with it every day. The diagnostic criteria that have been used for the last 40 years leave many people wondering whether they have the condition or not. Diagnosticians have long lists of symptoms to sort through and check off. The Diagnostic and Statistical Manual of Mental Disorders has 18 criteria, and other symptom lists cite as many as 100 traits.

Practitioners, including myself, have been trying to establish a simpler, clearer way to understand the impairments of ADHD. We have been looking for the "bright and shining line" that defines the condition, explains the source of impairments, and gives direction as to what to do about it.

My work for the last decade suggests that we have been missing something important about the fundamental nature of ADHD. I went back to the experts on the condition ? the hundreds of people and their families I worked with who were diagnosed with it ? to confirm my hypothesis. My goal was to look for the feature that everyone with ADHD has, and that neurotypical people don't have.

I found it. It is the ADHD nervous system, a unique and special creation that regulates attention and emotions in different ways than the nervous system in those without the condition.

The ADHD Zone
Almost every one of my patients and their families want to drop the term Attention Deficit Hyperactivity Disorder, because it describes the opposite of what they experience every moment of their lives. It is hard to call something a disorder when it imparts many positives. ADHD is not a damaged or defective nervous system. It is a nervous system that works well using its own set of rules. Despite ADHD's association with learning disabilities, most people with an ADHD nervous system have significantly higher-than-average IQs. They also use that higher IQ in different ways than neurotypical people. By the time most people with the condition reach high school, they are able to tackle problems that stump everyone else, and can jump to solutions that no one else saw.

The vast majority of adults with an ADHD nervous system are not overtly hyperactive. They are hyperactive internally.

Those with the condition don't have a shortage of attention. They pay too much attention to everything. Most people with unmedicated ADHD have four or five things going on in their minds at once. The hallmark of the ADHD nervous system is not attention deficit, but inconsistent attention.

Why We Are How We Are, and Do What We Do: The ADHD Mind, Demystified | Online Slideshow

Everyone with ADHD knows that they can "get in the zone" at least four or five times a day. When they are in the zone, they have no impairments, and the executive function deficits they may have had before entering the zone disappear. ADHDers know that they are bright and clever, but they are never sure whether their abilities will show up when they need them. The fact that symptoms and impairments come and go throughout the day is the defining trait of ADHD. It makes the condition mystifying and frustrating.

People with ADHD primarily get in the zone by being interested in, or intrigued by, what they are doing. I call it an interest-based nervous system. Judgmental friends and family see this as being unreliable or self-serving. When friends say, "You can do the things you like," they are describing the essence of the ADHD nervous system.

ADHD individuals also get in the zone when they are challenged or thrown into a competitive environment. Sometimes a new or novel task attracts their attention. Novelty is short-lived, though, and everything gets old after a while.

Most people with an ADHD nervous system can engage in tasks and access their abilities when the task is urgent ? a do-or-die deadline, for instance. This is why procrastination is an almost universal impairment in people with ADHD. They want to get their work done, but they can't get started until the task becomes interesting, challenging, or urgent.

How the Rest of the World Functions
The 90 percent of non-ADHD people in the world are referred to as "neurotypical." It is not that they are "normal" or better. Their neurology is accepted and endorsed by the world. For people with a neurotypical nervous system, being interested in the task, or challenged, or finding the task novel or urgent is helpful, but it is not a prerequisite for doing it.

Neurotypical people use three different factors to decide what to do, how to get started on it, and to stick with it until it is completed:

1. the concept of importance (they think they should get it done).
2. the concept of secondary importance--they are motivated by the fact that their parents, teacher, boss, or someone they respect thinks the task is important to tackle and to complete.
3. the concept of rewards for doing a task and consequences/punishments for not doing it.

A person with an ADHD nervous system has never been able to use the idea of importance or rewards to start and do a task. They know what's important, they like rewards, and they don't like punishment. But for them, the things that motivate the rest of the world are merely nags.

It's Personal: get motivated has a lifelong impact on ADHDers' lives:

How can those diagnosed with the condition choose between multiple options if they can't use the concepts of importance and financial rewards to motivate them?

How can they make major decisions if the concepts of importance and rewards are neither helpful in making a decision nor a motivation to do what they choose? This understanding explains why none of the cognitive and behavioral therapies used to manage ADHD symptoms have a lasting benefit. Researchers view ADHD as stemming from a defective or deficit-based nervous system. I see ADHD stemming from a nervous system that works perfectly well by its own set of rules. Unfortunately, it does not work by any of the rules or techniques taught and encouraged in a neurotypical world. That's why:

ADDers do not fit in the standard school system, which is built on repeating what someone else thinks is important and relevant.

ADDers do not flourish in the standard job that pays people to work on what someone else (namely, the boss) thinks is important.

ADDers are disorganized, because just about every organizational system out there is built on two things ? prioritization and time management ? that ADDers do not do well.

ADDers have a hard time choosing between alternatives, because everything has the same lack of importance. To them, all of the alternatives look the same.

People with an ADHD nervous system know that, if they get engaged with a task, they can do it. Far from being damaged goods, people with an ADHD nervous system are bright and clever. The main problem is that they were given a neurotypical owner's manual at birth. It works for everyone else, not for them.

Don't Turn ADHDers into Neurotypicals
The implications of this new understanding are vast. The first thing to do is for coaches, doctors, and professionals to stop trying to turn ADHD people into neurotypical people. The goal should be to intervene as early as possible, before the ADHD individual has been frustrated and demoralized by struggling in a neurotypical world, where the deck is stacked against him. A therapeutic approach that has a chance of working, when nothing else has, should have two pieces:

Level the neurologic playing field with medication, so that the ADHD individual has the attention span, impulse control, and ability to be calm on the inside. For most people, this requires two different medications. Stimulants improve an ADHDer's day-to-day performance, helping him get things done. They are not effective at calming the internal hyperarousal that many with ADHD have. For those symptoms, the majority of people will benefit by adding one of the alpha agonist medications (clonidine/Kapvay or guanfacine/Intuniv) to the stimulant.

Medication, though, is not enough. A person can take the right medication at the right dose, but nothing will change if he still approaches tasks with neurotypical strategies.

Inattention + Hyperactivity = ADHD?? | Online Slideshow

The second piece of ADHD symptom management is to have an individual create his own ADHD owner's manual. The generic owner's manuals that have been written have been disappointing for people with the condition. Like everyone else, those with ADHD grow and mature over time. What interests and challenges someone at seven years old will not interest and challenge him at 27.

Write Your Own Rules
The ADHD owner's manual has to be based on current successes. How do you get in the zone now? Under what circumstances do you succeed and thrive in your current life? Rather than focus on where you fall short, you need to identify how you get into the zone and function at remarkable levels.

I usually suggest that my patients carry around a notepad or a tape recorder for a month to write down or explain how they get in the zone.

Is it because they are intrigued? If so, what, specifically, in the task or situation intrigues them? Is it because they feel competitive? If so, what in the "opponent" or situation brings up the competitive juices?

At the end of the month, most people have compiled 50 or 60 different techniques that they know work for them. When called on to perform and become engaged, they now understand how their nervous system works and which techniques are helpful.

I have seen these strategies work for many ADDers, because they stepped back and figured out the triggers they need to pull. This approach does not try to change people with an ADHD nervous system into neurotypical people (as if that were possible), but gives lifelong help because it builds on their strengths.