Read an Excerpt
More Attention, Less Deficit
Success Strategies for Adults with ADHD
By Ari Tuckman Specialty Press, Inc.
Copyright © 2009 Ari Tuckman, Psy.D., MBA
All rights reserved.
ISBN: 978-1-886941-81-6
CHAPTER 1
EXECUTIVE FUNCTIONS: IT ALL FLOWS FROM HERE
ADHD involves far more than merely not enough attention or too much hyperactivity. It affects many aspects of how you process information and manage the demands in your life. This chapter covers executive functions, our highest-level brain processes that enable us to make good decisions in a complex world. Research is increasingly finding that people with ADHD display specific weaknesses in certain executive functions. This explains why people with ADHD tend to have the particular struggles that they do — and also why they don't have other struggles.
This is why I chose to start the book with a chapter on executive functions, rather than the obvious choice of beginning with getting diagnosed (that comes second). If you understand how executive functions operate, everything else in this book and about ADHD makes perfect sense. It explains
• all the difficulties that people with ADHD face in various parts of their lives, as well as the areas where they don't have trouble;
• why certain time-management and organizational strategies tend to work well for people with ADHD, whereas others don't; and
• why some treatments are effective for ADHD, whereas others aren't.
This unifying framework not only explains why your past looks the way it does but also offers some promise for making the future look better. This foundation means that you don't need to reinvent the wheel every time you're faced with a new challenge, since you already know how your brain tends to operate. This makes life much easier.
This chapter includes a series of related articles on the topic of executive functions. Since most adults with ADHD struggle with reading books cover to cover, I've included summaries here so that you can choose the articles that are most helpful to you or most relevant right now.
Executive Functioning: Who's Calling the Shots Around Here, Anyway? (p. 7) The executive functions are our highest-level brain processes. They enable us to make good decisions in a complex world. Research is increasingly explaining ADHD struggles as deriving from executive-functioning weaknesses.
Response Inhibition: It Starts with Stopping (p. 8) The key to successful decision making is that tiny little pause where we think through our options and make a good choice. People with ADHD have difficulty creating this pause and therefore get distracted, forget things, and leap without looking.
Working Memory: The Brain's RAM (p. 9) We use working memory constantly to hold information in mind as we remember what just happened, relate it to long-term memories, and think ahead into the future. People with ADHD tend to have blinky working memories, which leads to a variety of problems in their daily lives.
Sense of Time: It Can't Be 5:00 Already! (p. 11) People with ADHD have difficulty monitoring the passage of time and planning accordingly, a skill that's really important in today's busy world. As a result, they tend to spend too long on some activities and not plan enough time for others. This contributes to their well-known time-management problems.
Remembering to Remember: It's All About Timing (p. 12) In our busy lives, we all have dozens of little (and not so little) things to remember to do over the course of a day, such as phone calls and appointments. People with ADHD have great difficulty reminding themselves of these tasks at the right time, often forgetting completely or remembering only when it's too late.
Emotional Self-Control: Having Feelings Without Acting on Them (p. 13) People with ADHD tend to express their feelings more strongly than others do and are more influenced by their feelings than other people are. This also affects their ability to see beyond their emotions and to take others' perspectives into account.
Self-Activation: Getting That Heavy Ball Rolling (p. 14) Everybody has to use a certain amount of force of will to get going on boring tasks, but people with ADHD have a much steeper hill to climb. As a result, they tend to procrastinate until the pressure of a looming deadline pushes them into action.
Persistence of Effort: The Little Engine That Sometimes Could (p. 16) Once someone with ADHD gets going on something, there's the second challenge of sticking with it all the way through. Unfortunately, most of our daily obligations don't give partial credit for tasks that are mostly done.
Hindsight and Forethought: Using the Past and Future to Guide the Present (p. 17) We use the lessons from past experiences to make better choices the next time around. People with ADHD have a hard time stopping long enough to remember those lessons and apply them forward, so they're more likely to make the same mistakes.
Executive Functioning: Who's Calling the Shots Around Here, Anyway?
There is growing consensus among researchers that ADHD involves weaknesses in executive functions, a broad range of high-level information-processing functions that are crucial to success in life, especially as an adult. Rather than respond automatically and thoughtlessly to whatever the environment throws at us (like amoebas do), we use executive functions to modify our behavior for a better outcome, to maximize future gains, even at the price of losing out in the short term. This can mean forgoing something enjoyable in the moment (like a fat piece of chocolate cake) or pushing ourselves to endure something boring but important (like studying for a test). We could almost say that the executive functions enable us to see beyond the current moment by bringing back the lessons from the past and bringing forward the goals of the future to better guide our behavior. Executive functions enable us to resist distractions and temptations to go for the greater gain.
Although we can intentionally choose to approach situations in certain ways, many of the executive functions operate without conscious awareness, like breathing. If you watch little kids talking themselves through a difficult task, they are sort of verbalizing their executive functions — for example, "one step at a time," "slow down," "don't look over there." Eventually it becomes automatic and we don't have to think about it as much, but we may still find that we talk ourselves through challenges sometimes.
Different researchers have created somewhat different lists of executive functions. I've found that Russell Barkley's response inhibition theory is the most thorough and useful of these, so most of what I talk about in this chapter is an outgrowth of his work. His theory is incredibly detailed and impressive but contains far more information than most nonclinicians need to know. So I've pulled out the aspects that are most useful for your daily life — the parts that not only explain why some things are so hard for you but also set the stage for the rest of the book to offer helpful strategies. Even though I talk about specific executive functions, keep in mind that they interact constantly and the lines between them can be pretty blurry.
In case you're interested in the details, Barkley breaks the executive functions into four connected types: nonverbal working memory; verbal working memory; self-regulation of affect, motivation, and arousal; and reconstitution (planning). There's a lot to the executive functions, but the details are less important in terms of your day-to-day life.
As you will see in the rest of this chapter, the executive functions give rise to all sorts of important abilities, some of which I'll talk about in detail. And as you probably know far too well, a significant price is paid by people who are weak in these various skills. Life as an adult in this society is complicated, so those who have weak executive functions will struggle and stand out. They will have trouble managing all the details of life and making "responsible" choices (i.e., ones that benefit the future more than the present). As a result, many adults with untreated ADHD are seen as irresponsible or immature because they tend to react too much in the moment and lose sight of the bigger picture. Society expects and forgives this of children, but not of adults. As a result of these difficulties with managing the thousand and one details of daily life, people with ADHD spend a lot of time scrambling to hold it all together and prevent disaster. It takes a lot more energy to put out fires than to prevent them. This reactive lifestyle is much more stressful than the one led by adults without ADHD.
We expect adults to be able to show self-control and not need as much direction from others. Because people with ADHD struggle with making themselves do the right thing at the right time, parents and romantic partners often step in to provide these executive functions to keep their loved one from going too far off the rails — for example, by reminding her about upcoming appointments, organizing her stuff, or stopping impulsive purchases. Alternatively, she may find tools that can do the job for her — for example, setting up automatic debits to eliminate having to remember to send out the bills or using a PDA to remind her of upcoming meetings.
Spend some time on this chapter and maybe even come back to it later. I think you will find that it explains a lot.
Response Inhibition: It Starts with Stopping
What makes ADHD ADHD rather than Asperger's syndrome or whatever? Russell Barkley, Ph.D., indisputably the top ADHD expert in the world, has created the response inhibition theory to explain why ADHD people have certain typical weaknesses, yet don't have other weaknesses. This sophisticated theory places primary emphasis on response inhibition — that is, the ability to hold back a response.
Barkley proposes that our executive functions can work only when they have a space to work in. Unlike simpler life forms that respond automatically to stimuli from the environment, humans are able to pause and think through the various response options and then choose the best one. This may ultimately lead to choosing a larger payoff in the future instead of a smaller payoff in the moment (also known as delay of gratification). But what we're talking about here is much more fundamental than consciously deciding to resist impulse buys. It's an almost invisible information processing that happens in a split second. An example is almost subconsciously deciding to ignore the sound of someone dropping a pen while you're working at your computer (i.e., not getting distracted), or holding your thought to what someone is saying until she finishes talking (i.e., not impulsively interrupting).
This explains why people with ADHD don't always do what they know they should — they have trouble filtering out external and internal stimuli, so they react to the "wrong" thing. An example is getting lost in a magazine rather than paying the bills sitting next to it. This can look like bad judgment, but what really happens is that these other stimuli have too big an impact on the ADHD person's decision making, so a less-than-optimal choice is made. It isn't bad judgment because he didn't stop long enough to judge. This is why those dreaded questions of "why did/didn't you ..." lead to such unconvincing answers along the lines of "I don't know. I just didn't think of it," which is actually pretty accurate. Their brains didn't stop long enough to get a chance to think about it.
Because people with ADHD tend to be so vulnerable to external and internal stimuli, many of the strategies to help them be more effective focus on increasing the strength of the desired stimuli or decreasing the strength of less desired stimuli so that they do the right thing in that moment. For example, a beeping PDA that tells the person to leave for a meeting overrides the focus on what else he was doing. Medications (and possibly neurofeedback) work directly by increasing the brain's ability to create that delay, thereby reversing the fallout that comes from an insufficient delay. This is also why admonitions to "just try harder" don't work — they ignore the fundamental problem that people with ADHD have trouble creating that moment of pause to try harder in. It's like telling someone who needs glasses that she just needs to try harder to see.
As you read about the rest of the executive functions in this chapter, remember this delay, because this is the tripping point for many executive functioning malfunctions.
Working Memory: The Brain's RAM
Even though we often talk of memory as if there were only one kind, we actually have many kinds of memory. People with ADHD sometimes complain that they don't remember well. (And their family members probably complain more!) This is somewhat true, but not completely. Their long-term memory is fine — for example, Columbus discovered America in 1492 or my third-grade teacher was Mrs. Phillips. Although ADHD folks may get distracted at times when trying to remember this information, their memories actually work well. (For more on long-term memory, see The Fundamentals of Memory on p. 237.)
Where they run into trouble is in getting information into that long-term memory — if something never gets into long-term memory, then there is nothing there to remember, so it isn't really a memory problem at that point. Where things break down is in the working memory, which is the part of memory that holds information in the moment as it is being processed. We use working memory whenever we do anything that involves integrating two or more pieces of information. Here are examples:
• Integrating two or more things that happen close together in time, such as tracking the things that are said in a conversation or following events in an article or book
• Connecting a new piece of information with something from long-term memory, such as considering how a new task will fit into an existing schedule
• Holding some pieces of information while simultaneously paying attention to others, like keeping in mind that you need to change the laundry while you stop to answer a child's question
We use working memory constantly and in almost every aspect of daily life. If a person's working memory tends to blink and drop pieces of information, all sorts of problems occur, as you may know far too well. So, even if the rest of your brain works great and you are absolutely brilliant, a weak working memory will limit your ability to perform to your potential (something else you may know too well).
To use a computer analogy, long-term memory is like the hard drive and working memory is like the RAM. So ADHD folks' hard drives work well, but their RAM is kind of glitchy. Just as when you try to do too many things at once on your computer and a program crashes, ADHD people are prone to working-memory dumps where something important gets pushed out by something new. For example, while walking back to your desk to get some information for your boss, your cell phone rings and your attention goes to that, so your boss's request gets pushed out the back. If you're lucky, some bits and pieces got recorded into your long-term memory, so you may remember it later, especially if reminded by something else. So you get back to your desk and see the paperwork that your boss wanted and suddenly remember her request. Other times the memory is completely gone, so even a lie detector wouldn't pick anything up when your boss asks why you didn't get her the information. (What information? You didn't ask for any information.) It's easy to get the feeling that other people enjoy making things up if you have no memory of things that others swear happened. This also makes for all sorts of fun arguments.
Another example of a working-memory blank is forgetting where you put your keys down the instant that they leave your fingers, making it impossible to remember when looking for them the next day.
(Continues...)
Excerpted from More Attention, Less Deficit by Ari Tuckman. Copyright © 2009 Ari Tuckman, Psy.D., MBA. Excerpted by permission of Specialty Press, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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