ADHD IS A COMPLEX DISORDER OF THE BRAIN’S COGNITIVE MANAGEMENT SYSTEM
by Thomas E. Brown & Ryan J. Kennedy
The disorder currently identified as ADHD has long been associated with chronic difficulty in paying attention as well as impulsive and hyperactive behavior. More recent research has expanded that behavioral model to recognize that ADHD is associated with developmental impairments in the brain’s cognitive management system, its executive functions. Although current diagnostic criteria for ADHD do not explicitly refer to “executive functions”, many symptoms included in the present list of diagnostic criteria are related to executive functions.
These executive functions develop slowly starting in early childhood; they are not fully matured until the late teen years or early twenties. These cognitive functions mature and come “online” only gradually over the long course of development from early childhood to early adulthood. Assessment of impairments in EF should always be in comparison to others of comparable age.
Several models and various rating scales have been proposed to describe executive functions impaired in ADHD. Most of these include impairments related to the following cognitive functions as described by Brown:
Activation: organizing tasks and materials, estimating time, prioritizing tasks, and getting started on work tasks. Individuals with ADHD describe chronic difficulty with excessive procrastination. Often they will put off getting started on a task, even a task they recognize as very important to them, until the very last minute. It is as though they cannot get themselves started until the point where they perceive the task as an acute emergency.
Focus: focusing, sustaining focus, and shifting focus to tasks. Some people with ADHD describe their difficulty in sustaining focus as similar to trying to listen to the car radio when you drive too far away from the station and the signal begins fading in and out: you get some of it and lose some of it. They say they are distracted easily not only by things that are going on around them but also by thoughts in their own minds. In addition, focusing on reading poses difficulties for many. They may generally understand the words as they read, but often have to read the material over and over again to fully grasp and remember the meaning.
Effort: regulating alertness, sustaining effort, and working with adequate processing speed. Many with ADHD report that they can perform short-term projects well, but they have much more difficulty with sustained effort over longer periods of time. They also find it difficult to complete tasks on time, especially when required to do expository writing. Many also experience chronic difficulty regulating sleep and alertness. Often, they stay up too late because they can’t shut their head off. Once asleep, they often sleep like dead people and have a big problem getting up in the morning.
Emotion: managing frustration and modulating emotions. Although the most current version of the manual used for psychiatric diagnosis does not recognize any symptoms related to the management of emotion as an aspect of ADHD, many with this disorder describe chronic difficulties managing frustration, anger, worry, disappointment, desire, and other emotions. They speak as though these emotions, when experienced, take over their thinking the way that a computer virus invades a computer, making it impossible for them to attend to anything else. They find it very difficult to get the emotion into perspective, to put it to the back of their mind, and to get on with what they need to do.
Memory: utilizing working memory and accessing recall. Very often, people with ADHD will report that they have adequate or exceptional memory for things that happened long ago, but great difficulty in being able to remember where they just put something, what someone just said to them, or what they were about to say. They may describe difficulty holding one or several things “online” while attending to other tasks. In addition, people with ADHD often complain that they cannot retrieve from memory information they have learned when they need it, though they may recall it later.
Action: monitoring and regulating self-action. Many people with ADHD, even those without problems of hyperactive behavior, report chronic problems in regulating their actions. They often are too impulsive in what they say or do and in the way they think, jumping too quickly to inaccurate conclusions. People with ADHD also report problems in self-monitoring for the context in which they are interacting. They fail to notice when other people are puzzled, hurt, or annoyed by what they have just said or done and thus fail to modify their behavior in response to specific circumstances. Often, they also report chronic difficulty in regulating the pace of their actions, in slowing themselves down or speeding up as needed for specific tasks.