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Nº - 203 - Brown - 2006 - Ok PDF
Nº - 203 - Brown - 2006 - Ok PDF
Inside
theADD
Mind
In his provocative new book, psychologist
Thomas E. Brown, Ph.D., suggests a novel way of
looking at attention-deficit disorder and explains
the neurological underpinnings of its symptoms.
Adapted from Attention-Deficit Disorder: The Unfocused Mind in Children and Adults, by Thomas E. Brown, Ph.D.
ACTIVATION FOCUS EFFORT EMOTIONS MEMORY ACTION
Organizing, Tuning in, Regulating Managing Holding on to Monitoring
prioritizing, sustaining alertness, frustration and working and regulating
and getting focus, sustaining and with informa- one’s actions
to work and shifting effort, and modulating tion; retrieving
attention when adjusting emotions memories
appropriate processing
speed
ADD symptoms reflect kinks in the brain’s “executive functions,” which manage learning, perception, judgment, and so
on. Dr. Brown organizes executive functions into six clusters (above). Impairments in these clusters tend to show up
together in persons with ADD, and to respond together to ADD medication.
which they are unable to activate, deploy, and From this wife’s description, one might doing these complex tasks, they may be tun-
sustain the needed executive functions. conclude that the central problem of ADD is ing their radio, listening to the news, think-
essentially a lack of sufficient self-awareness. ing about what they intend to prepare for
Executive functions She seems to believe that if only her husband supper, and carrying on a conversation.
and awareness were more steadily aware of what he is Even the simpler example of keyboard-
A 43-year-old man came to my office with doing, he would not be so disorganized, ing on a computer illustrates the point. If one
his wife to be evaluated for attentional prob- jumping from one task to another without can type fluently without stopping to con-
lems. Both of the couple’s children had completing any single one. But most people sciously select and press each individual key,
recently been diagnosed with ADD and had do not require constant self-awareness to one’s mind is left free to formulate ideas and
benefited from treatment. When I explained complete routine tasks. For most people, to convert these into words, sentences, and
that most children diagnosed with ADD have most of the time, operations of executive paragraphs that convey ideas to a reader.
a parent or other close relative with ADD, functions occur automatically, outside the Interrupting one’s writing to focus on and
both parents laughingly responded, “Those realm of conscious awareness. press keys one at a time costs too much time
apples haven’t fallen far from the tree.” Both For example, while driving a car to the and effort; it cannot be done very often if one
agreed that the father had more ADD symp- local supermarket, experienced drivers do is to write productively.
toms than either of the children. Here’s how not talk themselves through each step of the Many other routine tasks of daily life—
the wife described her husband: process. They do not have to say to them- for example, preparing a meal, shopping for
“Most of the time he’s totally spaced selves: “Now I put the key in the ignition, groceries, doing homework, or participating
out. Last Saturday he set out to fix a screen now I turn on the engine, now I check my in a meeting—involve similar self-manage-
upstairs. He went to the basement to get mirrors and prepare to back out of my drive- ment in order to plan, sequence, monitor,
some nails. Downstairs he saw that the work- way,” and so on. and execute the complex sequences of behav-
bench was a mess, so he started organizing Experienced drivers move effortlessly ior required.Yet for most actions, most of the
the workbench. Then he decided he needed through the steps involved in starting the car, time, this self-management operates without
some pegboard to hang up the tools. So he negotiating traffic, navigating the route, full awareness or deliberate choice.
jumped into the car and went to buy the peg- observing traffic regulations, finding a park- The problem of the “unaware” hus-
board. At the lumber yard he saw a sale on ing place, and parking the car. In fact, while band is not that he fails to think enough
spray paint, so he bought a can to paint the
porch railing and came home totally unaware
that he hadn’t gotten the pegboard, that he ADD Is Not Like Pregnancy
had never finished sorting out the work- ADD is not like pregnancy, where one either does or does not have the characteristics, where there is no
bench, and that he had started out to fix the “almost” or “a little bit.”
broken screen that we really needed fixed. ADD is more like depression, which occurs along a continuum of severity.
Everyone occasionally has symptoms of a depressed mood. But being unhappy for a few days does
What he needs is a lot more awareness of not qualify one for the diagnosis of depression. It is only when symptoms of depression significantly inter-
what he is doing. Maybe that medicine our fere with an individual's activities over a longer time that he is eligible for such a diagnosis.
kids are taking can give him that.”
To subscribe, visit www.additudemag.com or call toll-free 888-762-8475.
REPRINTED FROM THE APRIL/MAY 2006 ISSUE OF ADDITUDE MAGAZINE
about what he is doing. The problem is that that individual is likely to be impaired in the
the cognitive mechanisms that should help management of a wide range of cognitive
him stay on task, without constantly and functions, regardless of how much he or she
consciously weighing alternatives, are not may wish otherwise.
working effectively.
How medication helps
The brain’s There is now considerable evidence that
signaling system executive functions of the brain impaired in
Some might take my orchestra metaphor lit- ADD depend primarily, though not exclu-
erally and assume that there is a special con- sively, on two particular neurotransmitter
sciousness in the brain that coordinates other chemicals: dopamine and norepinephrine.
cognitive functions. One might picture a little The most persuasive evidence for the
man, a central executive somewhere behind importance of these two transmitter chemicals
one’s forehead, exercising conscious control in ADD impairments comes from medication
over cognition like a miniature Wizard of Oz. treatment studies. Over 200 well-controlled
Thus, if there is a problem with the orches- studies have demonstrated the effectiveness of
tra’s playing, one might attempt to “speak” to stimulant medications in alleviating symptoms
the conductor, requesting—or demanding— of ADD. These medications work effectively to
needed improvements in performance. alleviate ADD symptoms for 70 to 80 percent
Indeed, this presumed “conductor,” or of those diagnosed with this disorder.
controlling consciousness, is often the target The primary action of medications
of encouragement, pleas, and demands by used for ADD is to facilitate release and to
parents, teachers, and others as they attempt inhibit reuptake of dopamine and norepi-
to help those who suffer from ADD. “You just nephrine at neural synapses of crucially
need to make yourself focus and pay atten- important executive functions.
tion to your schoolwork the way you focus Improvement produced by stimulants gen-
on those video games!” they say. “You’ve got erally can be seen within 30 to 60 minutes
to wake up and put the same effort into your after an effective dose is administered.
studies that you put into playing hockey!” When the medication has worn off, ADD
Alternatively, they may impose punish- symptoms generally reappear at their for-
ments on people with ADD or shame them mer level.
for their failure to “make themselves” do Stimulants do not cure ADD; they only
consistently what they ought to do. These alleviate symptoms while each dose of med-
critics seem to assume that the person with ication is active. In this sense, taking stimu-
ADD needs only to speak emphatically to the lants is not like taking doses of an antibiotic
“conductor” of his own mental operations to to wipe out an infection. It is more like wear-
get the desired results. ing eyeglasses that correct one’s vision while
In reality, there is no conscious conduc- the glasses are being worn.
tor within the human brain. There are net- Given the often-dramatic alleviation of
works of neurons that prioritize and integrate symptoms experienced by people with ADD
all of our cognitive functions. If these net- when they take stimulant medications, it is
works are impaired, as they are in ADD, then very difficult to sustain the notion that ADD
impairments amount to a lack of willpower.
Much more remains to be learned about
how the brain’s complicated neural networks
Executive functions operate to sustain the broad range of func-
and intelligence tions encompassed in “attention.” Yet it is
Disorganization is independent of general intelli- clear that impairments of executive func-
gence. It is quite possible for an individual to be tions, those brain processes that organize and
extremely bright on standard measures of intelli-
activate what we generally think of as atten-
gence and still have severe impairments of exec-
utive functions, such as those often seen in ADD. tion, are not the result of insufficient
An individual’s overall level of “smarts,” as willpower. Neural-chemical impairments of
measured by standard IQ tests, appears to have the brain’s executive functions cause some
little to do with whether he or she meets the individuals who are good at paying attention
diagnostic criteria for ADD. Some of my ADD
patients are extremely bright, employed as uni-
to specific activities that interest them to have
versity professors, scientists, physicians, attor- chronic impairment in focusing for many
neys, and senior executives. other tasks, despite their wish and intention
to do otherwise.
To subscribe, visit www.additudemag.com or call toll-free 888-762-8475.