The ADHD e-BOOK (free):  As a pediatric neurologist deeply involved with ADHD, Martin L. Kutscher, M.D.has created a complete online book for his patients that he would like to make available to others as well. The book emphasizes current executive function research as the key to understanding and treatment. It is empathically, usefully, and fairly written.

This is an excerpt from Chapter 10, This chapter can serve as a review for the reader, and can be reproduced for personal use by family members or teachers. 

.We’ve Been Missing the Point

“Johnny is very active!He never stops moving.He gets distracted by any little noise, and has the attention span of a flea. Often, he acts before he thinks. His sister, Jill, is often in a fog.Sometimes, she’s just so spaced!”

That is how we typically consider children with Attention Deficit Hyperactivity Disorder (ADHD).OK, not so bad.But that is often only the tip of the iceberg. Here is another likely description of the whole picture for a child with ADHD:

“I can’t take it any more!! We scream all morning to get out of the house. Homework takes hours. If I don’t help him with his work, he’s so disorganized that he’ll never do well. If I do help him, he screams at me. Since he never finishes anything, everyone thinks he doesn’t care. No matter how much we beg or punish, he keeps doing the same stupid things over and over again. He never considers the consequences of his actions, and doesn’t seem to care if they hurt me. It’s so easy for him to get overwhelmed. Sometimes, he just wants to ‘turn the noise off.’He is so inflexible, and then blows up over anything. It gets me so angry that I scream back, which makes everything even worse. Now that he’s getting older, the lies and the cursing is getting worse, too.I know he has trouble paying attention, but why does he have all of these other problems as well?”

It is not a coincidence that children with ADHD often manifest so much more than the classic triad of inattention, impulsivity, and hyperactivity. When we focus merely on these typically defined symptoms, we fail to deal with the whole vista of difficult problems experienced by patients and their families. This spectrum includes a wide range of “executive dysfunction” (such as poor self-control and foresight), additional co-morbid disorders (such as anxiety, depression or conduct disorders), and family stresses. 

Redefining ADHD as“Executive Dysfunction” 

ADHD needs to be redefined to include a wide range of “executive dysfunction.”As Russell Barkley explains (see Resources), this dysfunction stems from an inability to inhibit behavior so that demands for the future can be met.In other words, people with ADHD are so drawn to the present that the future does not even “show up on their radar screen.”There is no future or past; only “NOW.”

So, what are Executive Functions?

When you step on a snake, it bites.No verbal discussion occurs within the snake’s brain.No recall of whether striking back worked in the past. No thought as to where this action will lead to in the future. No inhibition. Stepped on. Bite back. Humans, fortunately, have the option to modulate their behavior.

No single part of the human brain is solely in charge of this modulation. does appear, however, that our frontal and pre-frontal lobes function largely as our “Chief Executive Officer (CEO).”Orchestrating language and memory functions from other parts of the brain, these frontal centers consider where we came from, where we want to go--and how to control ourselves in order to get there. 

Most importantly, the ability to inhibit (“putting on the brakes”) is central to effective executive function. Successful execution of a plan largely involves putting brakes on distracting activities. These brakes--courtesy of our pre-frontal inhibitory centers--allow us the luxury of time during which we can consider our options before reacting.

This lack of inhibition is a double problem for people with ADHD.First, without these brakes, they will be viewed as unable to adequately inhibit distractions, inhibit impulsive reactions, or inhibit physically acting upon these stimuli (hyperactivity).Second, patients with ADHD do not inhibit their behavior long enough for the other executive functions below to adequately develop either. Executive functions identified by Barkley include:

Self-talk refers to the ability to talk to ourselves--a mechanism by which we work through our choices using words.Toddlers can be heard using self-talk out loud.Eventually, this ability becomes internalized and automatic.However, ADHD patients have not inhibited their reactions long enough for this skill to fully develop.

Working memory refers to those ideas that we can keep active in our minds at a given moment.For example, in order to learn from mistakes, you have to be able to juggle not just the present situation, but also keep in mind past times when certain strategies did or did not work.Working memory hopefully also includes keeping future goals in mind (such as remembering that we want to get into a good college, not just do the most intriguing activity currently available). Without the ability to inhibit, people with ADHD never get to develop good function of their working memory.

Foresight (predicting and planning for the future) will be deficient when inadequate working memory teams up with a poor ability to inhibit the present distractions. People with ADHD cannot keep the future in mind.They are prisoners of the present; the future catches them off guard.In fact, surprisingly poor foresight is perhaps the greatest difficulty in their lives.

Sense of time is an executive function that is usually extremely poor in ADHD.

Shifting from Agenda A to Agenda B is a difficult task requiring good executive function.Pulling yourself out of one activity and switching to another--transitioning--is innately difficult, and requires effort and control.

Separating emotion from fact requires time to reflect. Each event has an objective reality, and an additional “emotional tag” which we attach to it. For example, a traffic jam may occur, causing us to be late for work.That is the objective fact. How we react, though, is up to the emotional tag of significance that we place on it. Do we stay calm, and make plans to finish up a little later. Or, do our emotions cause us to see the traffic as a personal, unfair attack--causing us to seethe and curse. Without the gift of time, we never get to separate emotion from fact.This leads to poor ability to judge the significance of what is happening to us.

In short, then, the ability to modulate behavior comes largely from our pre-frontal lobes, which function primarily as inhibitory centers. Without the luxury of inhibitory brakes, ADHD patients do not get to fully utilize any of their frontal lobe “executive functions.”

What are the different kinds of problems in ADHD?

Redefining ADHD as inadequate inhibition explains a wide spectrum of difficulties experienced by people with the syndrome.This expanded spectrum of symptoms can create an environment of havoc. 

1. Symptoms of Executive Dysfunction

a. Classical Symptoms of ADHD

ADHD is typically defined as a triad of inattention, impulsivity, and hyperactivity. These are the symptoms that receive the most attention from doctors, and all come from an inability to inhibit.

Distractible =Inadequate inhibition of extraneous stimuli.

Impulsive=Inadequate inhibition of internal stimuli.

Hyperactive=Physically checking out those stimuli.
 

b.Other Symptoms of Executive Dysfunction

If we do not address the following additional executive function issues, we are only dealing with a small part of the problem. These are not just “incidental” symptoms.They are hard to live with—ask either the patient or his family.
 

• Lack of foresight!!! (“Johnny, you’ll never get into a good college if you all you do is play videogames. Why do you keep shooting yourself in the foot?”) Foresight--the ability to predict the results of our behaviors--is a major adaptive ability of humans. We can run imaginary simulations of the future on our brain’s computer. Lack of use of this ability can be the most devastating part of ADHD. Mothers--often endowed with great foresight-- are crushed as they watch their child repeatedly head down counter-productive paths.
• Poor hindsight/Trouble learning from mistakes (“Johnny, how many times do you have to be punished for the same thing.”) Unable to inhibit the present, Johnny cannot stop to consider lessons from the past.
• Live at the “mercy of the moment.” (“Johnny is always swept away by whatever is happening to him right then and there.”) ADHD behaviors make sense once we realize that they are based on reactions taking only the present moment into account.It is not that Johnny doesn’t care about the future; it is that the future and the past don’t even exist. Such is the nature of the disability.By way of analogy, imagine riding down a river with a leaking canoe.  You would be so overwhelmed by the need to bail out water that you would not see the upcoming cliff.    It's not that you don't "care" about falling over a cliff--it's that you don't even get to consider it.
• Life in the next 4 seconds. If you want to make sense out of inexplicable behaviors by someone with ADHD, just ask yourself: “What behavior makes sense if you only had 4 seconds left to live?”For example, if you only had 4 seconds to live, it would make sense to lie in order to expediently get out of a problem…After all, who cares about a future reputation when there is no future?!”
• Poor organization(“Johnny, you never told me that there is a paper due tomorrow! And, why do we have to fight over getting out of the house every morning!”)
• Trouble returning to task (“Johnny, you never complete anything. You just don’t care.”)
• Poor sense of time (“Johnny, what have you been doing all afternoon? You can’t spend one hour on the first paragraph!”)
• Time moves too slowly (“Mommy, you are taking forever to go shopping!”)
• Poor ability to utilize “self-talk” to work through a problem (“Johnny, what were you thinking?! Did you ever think this through?”)
• Poor sense of self awareness (Johnny’s true answer to the above question is probably “I don’t have a clue.I guess I wasn’t actually thinking.”)
• Poor internalization and generalization of rules (“Johnny, why do I need to keep reminding you that playing videogames comes after you finish your homework.)
• Poor reading of social clues (“Johnny, you’re such a social klutz. Can’t you see that the other children think that’s weird.”)
• Inconsistent work and behavior. (“Johnny, if you could do it well yesterday, why is today so horrible.) With 100% of their energy, they may be able to control the task that most of us can do with 50% of our focus.But who can continually muster 100% effort? As the joke goes: ADHD children do something right once, and we hold it against them for the rest of their lives.
• Trouble with transitions (“Johnny, why do you curse at me when I’m just calling you for dinner?”)
• Hyper-focused at times (“When Johnnyis on the computer, I can’t get him off. And once his father gets his mind on something, off he goes!”)
• Poor frustration tolerance (“Johnny, why can’t you even let me help you get over this?”)
• Frequently overwhelmed (“Mommy, just stop. I can’t stand it. Just stop. Please!”)
• Gets angry frequently and quickly (“Johnny, you get flooded with emotion so quickly. Why are you always angry with me?Even though you usually apologize, it still hurts me.”)
• Push away those whose help they need the most (“Mommy, stop checking my assignment pad. Get out!”).
• “Hyper-responsiveness” (“Mommy, you know I hate sprinkles on my donuts! You never do anything for me!I hate you!”)Barkley uses the term hyper-responsiveness to indicate that people with ADHD have excessive emotions. Their responses, however, are appropriate to what they are actually feeling. So next time you see someone “over-reacting,” realize that they are actually “over-feeling,” and must feel really awful at that moment.
• Inflexible/explosive reactions (“Johnny, you’re stuck on this. No, I can’t just leave you aloneJohnny, now you’re incoherent.Johnny, just stay away. I can’t stand it when you break things!”)
• Feels calm only when in motion (“He always seems happiest when he is busy. Is that why he stays at work so late?”)
• Thrill seeking behavior (“He seems to crave stimulation at any cost.In fact, he feels most ‘on top of his game’ during an emergency.”)
• Trouble paying attention to others (“My husband never seems to listen when I talk to him. He just cannot tolerate sitting around with me and the kids.He doesn’t “pay attention” to his family any more than he “paid attention” in school.”)As the patient gets older, people in his life will increasingly expect more time and empathy to be directed their way. Yet, the behaviors above of ADHDers may interfere with their demonstration of these traits, despite their passions.
• Trouble with mutual exchange of favors with friends. Without establishing a reliable “bank account” of kept promises, friendships can be hard to make.
• Sense of failure to achieve goals (“Somehow, I never accomplished all that I thought I could or should have.”) This deep disappointment is commonly what brings adults with ADHD to seek help.
• Lying, cursing, stealing, and blaming others become frequent components of ADHD; especially as the child gets older.

According to some particularly depressing data by Russell Barkley, here is how ADHD children compare to typical children:

[Barkley RA, Fischer M, et al. The Adolescent outcome: An 8-year prospective follow up. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546-557.]

In short, the symptoms of ADHD become less “cute” as the children switch from elementary to secondary schools.The “good” news comes from understanding that these problems are commonly part of the syndrome we call ADHD. They are nobody’s fault--not yours, and not your child’s.This understanding points the way towards coping with these issues.

To download the rest of this wonderful, free e-book the address: http://www.pediatricneurology.com/adhd.htm

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