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.
The Tip of the Iceberg: Problems and Summary
Martin L. Kutscher, M.D.
Assistant Clinical Professor
of Pediatrics and Neurology, New York Medical College, Valhalla, N.Y.Pediatric
Neurological Associates, White Plains, N.Y
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
“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
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
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:
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
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.
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.
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
1. Symptoms of Executive
a. Classical Symptoms
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.
inhibition of extraneous stimuli.
inhibition of internal stimuli.
checking out those stimuli.
b.Other Symptoms of
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.
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?!”
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
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
Time moves too slowly (“Mommy,
you are taking forever to go shopping!”)
Poor ability to utilize “self-talk”
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
you’re such a social klutz. Can’t you see that the other children think
Inconsistent work and behavior.
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
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
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
Push away those whose help
they need the most (“Mommy, stop checking my assignment pad. Get out!”).
(“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.
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
always seems happiest when he is busy. Is that why he stays at work so
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
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
others for own mistakes
touchy or easily annoyed
(not involving threats)
RA, Fischer M, et al. The Adolescent outcome: An 8-year prospective follow
up. Journal of the American Academy of Child and Adolescent Psychiatry,
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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