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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
- Veröffentlichungsjahr: 2014
Compelling stories that present a new view of ADHD
Smart but Stuck offers 15 true and compelling stories about intelligent, capable teens and adults who have gotten "stuck" at school, work, and/or in social relationships because of their ADHD. Dr. Brown highlights the often unrecognized role that emotions play in this complex disorder. He explains why even very bright people with ADHD get stuck because they can focus well on some tasks that interest them, but often can't focus adequately on other important tasks and relationships.
- The first book to explain and illustrate the crucial role of emotions in the daily functioning of those living with ADHD
- Brown, Associate Director of the Yale Clinic for Attention & Related Disorders, is an internationally known authority on ADHD
Drawing on the latest research findings, the book describes strategies and treatments for getting "unstuck" to move on to a more rewarding and productive life.
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Table of Contents
More Praise for Smart but Stuck
Title Page
Copyright
The Author
Acknowledgments
Introduction
the missing link: emotions
learning from patients and research
what you'll find in this book
notes and additional reading
Chapter 1: ADHD and the emotional brain
“attentional bias”
the unacknowledged role of emotions in ADHD
the problem of ignition and motivation
immediate or delayed “payoffs” in the ADHD brain
emotions, ADHD, and executive functions
a critically important hub in the brain
“hot” and “cool” executive function
it's all about context: situational influences
the profound importance of memory
the role of unconscious emotions
how do ADHD impairments of the brain affect processing of emotions?
structural and chemical brain impairments that underlie ADHD
additional psychiatric difficulties
common problems with emotions in people with ADHD
notes and additional reading
Chapter 2: Eric
fear of being alone
changes in context
fears of being embarrassed or rejected
inability to relax to go to sleep
inability to get up and start the day
insensitivity to fear of causing a driving accident
lack of motivation to work for longer-term goals
impatience with waiting
changing the time frames for incentives
notes and additional reading
Chapter 3: Karen
problems with reading comprehension and recall
extended time accommodations for examinations
social and performance anxiety linked with guilt
family worries and family roles
destructive avoidance and denial
inadequate modulation of anxiety
desperate efforts to cope
notes and additional reading
Chapter 4: Martin
risks of high IQ with ADHD
avoidance of social contacts
initial assessment
new start in a new context
struggles with excessive privacy and fears of dependency
burdens of perfectionism and poor planning
social insensitivities and unrecognized emotions
immobilizing emotions and avoidant behavior
renewed marijuana use and increased social interaction
recognizing missed opportunities and adopting a new attitude
notes and additional reading
Chapter 5: Sarah
ADHD-like symptoms not emergent until midlife
onset of symptoms of ADHD
a co-occurring disorder
menopause and midlife onset of ADHD-like symptoms
role of estrogen in cognitive impairments of menopause
treatment for midlife-onset cognitive impairments
notes and additional reading
Chapter 6: Mike
conflicting hopes and fears
possible selves
persistent social anxieties
illusion of transparency
anxiety, marijuana, and medications
reconsidering vocational goals
covert binding in family loyalties
notes and additional reading
Chapter 7: Lisa
triangular family conflict
stimulant “rebound” and late-afternoon irritability
unraveling family polarization and conflict
stresses of social ineptness
problems of asperger's syndrome in people with ADHD
impact of delayed pubescent development
recognizing strengths and increasing hope
a fresh start in a new school
shame, anger, and self-cutting
overcoming rejection from school administrators
determination to show her strengths
notes and additional reading
Chapter 8: Steve
impact of ADHD impairments on employment
difficulties in recognizing others' feelings
complications from compulsivity
loss of medication effectiveness
lack of empathy in a marriage
frustrations of ADHD impairments in marriage
overlap of ADHD and autism spectrum impairments
limited capacity for sustained intimacy
carrying on despite losses
notes and additional reading
Chapter 9: Sue
problems emerging in middle school
parental worry and frustration
distinguishing between person and behavior
undiscussed family stressors
disappointing response to medication
reassurance of love despite frustrations
gathering evidence of strengths and difficulties
reducing parental micromanaging of homework
accommodations in school
a shift in appearance and attitude
combining medications for ADHD
progressive improvement
benefits of identifying strengths and interacting problems
benefits of providing support without excessive confrontation
nurturing hope
notes and additional reading
Chapter 10: Matt
stresses of transition from high school to college
inadequate sleep
covert social anxiety
combined medications for ADHD, anxiety, and depression
efforts to hide shame
failure as an unwitting avoidance strategy
fragile efforts to overcome social anxiety
more and less intimidating settings
resistance to making changes in behavior
change of ineffective medication
failure repeated
structure and monitoring for behavior change
notes and additional reading
Chapter 11: Lois
persistent grief and continuing disappointment
depression co-occurring with ADHD
compulsive buying and hoarding
adding ADHD medication to the antidepressant medication
rekindling grief
exacerbation of depression by additional life stresses
shattered dreams and ending a marriage
gradual decline in functioning
intensive day treatment and efforts to rescue someone else
impulsive efforts to find stability
difficulties in sustaining treatment
notes and additional reading
Chapter 12: James
struggling to translate oral fluency into written text
impact of impaired executive functions on written expression
using a graphic organizer as preparation for writing
excessive perfectionism as an impediment to writing
“booster doses” of medication
“addiction” to playing video games
social anxiety and avoidance
conflicting feelings about continuing with intensive treatment
revising priorities in treatment
gradual progress
notes and additional reading
Chapter 13: Getting Unstuck
strategies that help now but hurt later
works in progress
variety in levels of difficulties, resources, and strengths
getting unstuck
cultivating realistic hope
notes and additional reading
Questions for Discussion
Index
End User License Agreement
More Praise for Smart but Stuck
“Smart but Stuck will help you get unstuck! Drawing upon a lifetime of clinical experience, Tom Brown once again strikes gold in this practical, authoritative, and, above all, helpful book. No matter where you are in your journey to success, if you have ADHD this book will help to speed you on your way. I could not recommend it more highly.”
— Edward (Ned) Hallowell, M.D., author, Driven to Distraction and Delivered from Distraction
“This is an exceptionally important book for those coping with ADHD and family members who care about them. It addresses a much overlooked component of the disorder— the importance of emotions. Clearly written, rich in detail, and full of helpful advice, this book will be beneficial to anyone with ADHD and to those who struggle to live with, understand, and help them.”
— Russell A. Barkley, Ph.D., clinical professor, psychiatry and pediatrics, Medical University of South Carolina; author, Taking Charge of ADHD and Taking Charge of Adult ADHD
“This book, reflecting Dr. Brown's 35 years of clinical practice combined with the latest findings from affective neuroscience, is a must-read for anyone who is interested in ADHD.”
— James J. Gross, Ph.D., professor, psychology, Stanford University; editor, Handbook of Emotion Regulation
“Dr. Brown introduces a forgotten piece in the life of those suffering from ADHD: the role of emotions. He provides an integrative and easy-to-understand view of how executive functioning impairments interact with emotional control in ADHD. He also offers thoughtful strategies to minimize the impact of these impairments.”
— Luis Augusto Rohde, M.D., Ph.D., president, World Federation of ADHD; professor, psychiatry, Federal University of Rio Grande do Sul, Brazil
“These engaging vignettes vividly bring to life emotional difficulties that, even for very intelligent teens and adults, can lead to frustration and failure in efforts to overcome their deficits in attention, organization, and motivation. Here Tom Brown combines a reader-friendly summary of relevant research with his clinical expertise in helping people with ADHD to get on track to success.”
— Mina K. Dulcan, M.D., professor of psychiatry, behavioral sciences and pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine
Cover design by Jeff Puda
Cover image © PM Images | Getty
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FIRST EDITION
the author
Thomas E. Brown, Ph.D., is a clinical psychologist, assistant clinical professor of psychiatry at Yale University School of Medicine, and associate director of the Yale Clinic for Attention and Related Disorders. His award-winning book Attention Deficit Disorder: The Unfocused Mind in Children and Adults (Yale University Press, 2005) has been published in seven languages. He developed the Brown Attention Deficit Disorder Scales (PsychCorp/Pearson) and has published numerous articles in professional journals. His past books include ADHD Comorbidities: Handbook of ADHD Complications in Children and Adults (American Psychiatric Press, 2009) and A New Understanding of ADHD in Children and Adults: Executive Function Impairments (Routledge, 2013). To learn more, go to www.drthomasebrown.com.
acknowledgments
Impetus for this book was sparked in a conversation I had several years ago with my son, Dave, while we were hiking a small mountain called Sleeping Giant. He asked what I considered to be the biggest missing piece in the current understanding of ADHD. My answer was “the importance of emotions.” After I explained what I meant, Dave insisted: “You've got to make that your next book, and you have to explain it with real-life stories of patients so people will catch on!” Dave read and offered helpful comments on my initial draft of each chapter. I am deeply grateful for his nudging encouragement and love.
My administrative assistant, Lisa Dziuba, and my research assistant, Ryan Kennedy, have both contributed by assisting with countless details of organizing, checking, and preparing the manuscript as well as by helping me remain organized throughout the process of working on this project while I was also attending each day to a full schedule of caring for patients.
I am grateful also for the continuing love and support of Bobbie, my beloved wife, the light of my life. Thanks too to Liza, Abel, Nancy, Noah, and Simone, for their love, enthusiasm, and encouragement, which enrich my life.
Strong encouragement and much helpful guidance to render this book more readable have been provided generously by Margie McAneny, my editor at Jossey-Bass/Wiley. Thanks also to Tracy Gallagher for her assistance with permissions, Pat Stacey for additional helpful edits and suggestions, Michele Jones for her very careful copyediting, and Joanne Clapp Fullagar for thoughtfully guiding the book through production.
Above all, I am deeply grateful to my patients—the children, adolescents, and adults who have trusted me with exploring their stories and have helped me learn of the subtle complexities of ADHD and the multiple intertwined and often conflicted emotions that can get any of us stuck—and can keep all of us going.
Thomas E. BrownJanuary 2014
introduction
All information processing is emotional . . . emotion is the energy level that drives, organizes, amplifies and attenuates cognitive activity.
—Kenneth Dodge, neuroscientist
Although the scientific understanding of ADHD has changed dramatically over the past decade, most people affected by this disorder—and many who diagnose and treat them—have not yet had the opportunity to gain a clear, up-to-date understanding of this complex condition. As you'll read in the chapters that follow, ADHD is not a simple problem of misbehavior, lack of willpower, or inability to focus attention. In this collection of true stories about extremely bright teenagers and adults, you'll find multiple examples of the ways that ADHD can cause even very intelligent individuals to experience chronic frustration and failure, which gets them “stuck” in their schooling or work and many other aspects of daily life. Fortunately, in most cases it's possible for a person with ADHD to get unstuck, and in these pages you'll find numerous examples showing how effective treatment has helped those suffering from ADHD to get back on track.
Clinical and neuroscience research has revealed that ADHD is essentially a complex set of dynamically interacting impairments of the brain's management system, otherwise known as its “executive functions.” These functions involve a number of critical operations of the brain, including the abilities to
Get organized and get started on tasks
Focus on tasks and shift focus from one task to another when needed
Regulate sleep and alertness, sustain effort, and process information efficiently
Manage frustration and modulate emotions
Utilize working memory and access recall
Monitor and self-regulate action
Everyone has trouble with these functions from time to time, but people with ADHD have much more difficulty with them than do their same-age peers. (I offer more detailed descriptions of these various executive functions in Chapter 1.)
the missing link: emotions
Despite progress made in ADHD research, one element has been lacking in most current descriptions of the disorder: the critical role played by emotions in every one of the executive functions. This book describes that missing piece. In 1996, neuroscientist Joseph LeDoux published The Emotional Brain, a book highlighting evidence of the central importance of emotion in the brain's cognitive functioning. He emphasized that emotions—mostly unconscious emotions—are powerful and critically important motivators of human thought and actions.1 This understanding of the essential role of emotion in all aspects of human behavior has not yet been integrated into current thinking about ADHD.
We must recognize the critical role of emotions, both positive and negative, in initiating and prioritizing tasks, sustaining or shifting interest and effort, holding thoughts in active memory, and choosing to engage in or avoid a task or situation.
To fully understand the role of emotions in ADHD, we must not only recognize that those with the disorder often have a hard time managing how they express their emotions but also acknowledge the critical role that emotions, both positive and negative, play in the executive functions: initiating and prioritizing tasks, sustaining or shifting interest and effort, holding thoughts in active memory, choosing to engage in or avoid a task or situation. As was observed by neuroscientist Kenneth Dodge, “All information processing is emotional . . . emotion is the energy level that drives, organizes, amplifies and attenuates cognitive activity.”2
Emotions—sometimes conscious, more often unconscious—serve to motivate cognitive activity that shapes a person's experience and action. For those with ADHD, chronic problems with recognizing and responding to various emotions tend to be a primary factor in their difficulties with managing daily life.
The stories in this book highlight the role that various emotions, positive and negative, played in the struggles of some of my patients with ADHD. Some readers of these stories might think, “Oh, this is a person with ADHD and several other disorders—anxiety, depression, or OCD. Their emotional struggles are just part of those additional disorders, not ADHD.” My response is that ADHD is not one silo of cognitive problems with another silo of emotional difficulties beside it. Problems with responding to and managing emotions are intimately, dynamically, and inextricably involved in ADHD.
Problems with responding to and managing emotions are intimately, dynamically, and inextricably involved in ADHD.
learning from patients and research
I am a clinical psychologist. For more than thirty-five years, I have spent most of my working hours talking with and listening to children, adolescents, and adults, most seeking help for problems related to ADHD. Many also have had additional difficulties with other problems involving emotions, learning, or behavior. My primary source of learning about ADHD has been the countless conversations with these patients—young and old alike—who shared with me ongoing stories of their struggles to recognize and overcome their attention impairments and to extricate themselves from feeling stuck in patterns of demoralizing frustration and failure. The stories in this book are based on my notes from conversations with some of these patients. All have been modified to protect the privacy of those involved, but the essential details of all are true.
Recently expanding research in neuroscience, psychology, and psychiatry has helped explain many puzzling facts reported by patients with ADHD, such as how they can focus and work energetically on a few favored activities, but simply can't get started or sustain enough effort for other activities that they know are important and want to do. In these pages, true stories of patients are intermingled with accessible explanations of research that will help you better understand each patient's struggles and the fuller nature of the relationship between ADHD and emotions.
One of my special interests over the years has been adolescents and adults who are especially bright. They have taught me that being smart is no protection from attention impairments. Not only is it possible for people with a high IQ to suffer from ADHD, but it's likely that they'll suffer longer without adequate support or treatment because the people in their lives assume, quite mistakenly, that anyone who is really smart can't suffer from ADHD.
Not only is it possible for people with a high IQ to suffer from ADHD, but it's likely that they'll suffer longer without adequate support or treatment because the people in their lives assume, quite mistakenly, that anyone who is really smart can't suffer from ADHD.
The patients I write about in this book are all extremely bright. They scored within the top 9 percent of the population on IQ tests, but they were stuck. They sought treatment because they were unable to get themselves out of chronically unproductive, self-defeating patterns of emotions, thought, and action. They felt trapped in their daily dealings with their education, their job, their relationships with others, or a combination of these. Their stories illustrate the persistent difficulties those with ADHD have in managing themselves and their emotions. Some are stories of amazing successes and impressive accomplishments; others are tales of ongoing frustration and tragic disappointment. Most are a mixed bag. Yet each story illuminates the complex role that emotions play in ADHD.
what you'll find in this book
Chapter 1 describes this new understanding of ADHD, drawing on the latest research findings by clinicians, researchers, and neuroscientists. Chapters Two through Twelve offer stories of real teenagers and adults with ADHD, highlighting their particular struggles with the disorder, with their emotions, and with related problems in their family or various other contexts. The final chapter summarizes some of the ways that emotions affect the life experiences of those with ADHD and what can be offered to appropriately support and treat those affected.
The stories that follow illustrate the limitations of diagnostic “pigeonholes.” The individuals you'll read about in these pages can't be neatly categorized under one or several diagnoses. Each person is a unique and complex combination of interacting strengths and difficulties in each of the shifting contexts in which he or she lives. There is great diversity among people with ADHD as well as in the varied settings in which they encounter daily life.
In telling stories of these adolescents and adults, I have also shared some of my own reactions and challenges as I tried to provide the help they sought from me. Many of the stories are success stories. I share the resources and strategies that contributed to these successes. Several stories also illustrate the significant obstacles and struggles that some people with ADHD may experience.
Stories in this book also illustrate what we currently know about how ADHD changes—sometimes for the better, sometimes for the worse—as a person progresses into the increasing challenges of adolescence and adulthood. Each story describes medications and other treatments provided to these individuals to help in alleviating their ADHD impairments.
In none of these cases were medications alone sufficient to resolve the complex difficulties. For each of these patients, therapeutic success also depended on a therapeutic relationship with many therapeutic conversations. These were essential for assessing and understanding the nature and emotional complexities of his or her difficulties. The therapeutic relationship also was the vehicle for close collaboration to develop effective treatments, help the patient to make necessary changes in environment and lifestyle, repair damaged self-esteem, and work through the frustrations, stresses, and puzzlement that inevitably arise in interactions among patients, their family members, and their doctors.
The emotional conflicts and struggles these patients experience aren't unique to those with ADHD—nor are they unique to those who are exceptionally intelligent. You will probably recognize emotional pressures, conflicts, and struggles that aren't so different from your own or from those of your family and friends.
Throughout this book, I've tried to illustrate not only the weaknesses and struggles of those with ADHD and their families but also their impressive strengths and diverse talents. There is much to respect and admire in each of the people described in these pages.
notes and additional reading
1 LeDoux, J. E. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York, NY: Simon & Schuster.
2 Dodge, K. A. (1991). Emotion and social information processing. In J. Garber & K. A. Dodge (Eds.), Development of emotion regulation and dysregulation (pp. 159–181). New York, NY: Cambridge University Press.
Chapter 1
ADHD and the emotional brain
Emotions, and struggles with and between various emotions, play a central role in the daily life of all children, adolescents, and adults. Emotions guide what we notice and what we ignore, what we focus on intently and what we carefully avoid. Conflicting emotions can cause us to disrupt engagement with a task we want to accomplish, or lead us repeatedly to do what we consciously intend never to do again. In many ways—sometimes recognized, sometimes not, subtly and powerfully—we are pushed and pulled by our emotions. Yet we also exercise some control over them: we try to distract ourselves from uncomfortable emotions; we choose how much we want our emotions to show in our words or actions; we talk to ourselves to try to tone down or jack up how noticeable our emotions are to others and to ourselves. We manage and are managed by the complexity of our emotions.
In my work as a clinical psychologist, I've seen that emotional struggles play an especially large role in the daily life of people with attention deficit disorders. The same chronic impairments that interfere with other aspects of their cognitive functioning also tend to interfere with their ability to manage and be adequately guided by their emotions. People with ADHD often suffer chronic difficulties in responding to and sustaining emotions that motivate them for important tasks.
Most people with ADHD experience the same frustrations, fears, sadness, pride, shame, excitement, and so on that spontaneously arise in everyone else in various situations. What is different is the chronic difficulty most people with this disorder experience in managing and responding to their emotions, particularly in the many situations where emotions are mixed and conflicting. As noted earlier, stories in this book illustrate the fact that being very smart does not prevent a person from struggling with these emotional problems, nor does it prevent having ADHD.
This book highlights the idea that emotions are linked to the brain. Often people think of emotion as distinct from the brain, as being “from the heart” or “in the gut,” but these are metaphors that serve simply to suggest that emotions come from the depth of the person. The actual source of emotions is the brain.
The difficulties that people with ADHD have with emotions are similar to the problems they often have in prioritizing tasks, shifting focus, and utilizing working memory. While cleaning a room, they may get interested in some photos they pick up, soon becoming completely diverted from the job they had begun. While searching for some specific information online, they may notice a web page that draws them off the search they started and into a protracted investigation of something totally unrelated, derailing their original task. They may abandon a task they find boring, overlooking the fact that adequate and timely completion of this task is essential to gaining something they really want, and that failure to complete the task will inevitably bite them with a painful payback.
People with ADHD report that momentary emotion often gobbles up all the space in their head, as a computer virus can gobble up all the space on a hard drive, crowding out other important feelings and thoughts.
In a similar way, many people with ADHD tend to get quickly flooded with frustration, enthusiasm, anger, affection, worry, boredom, discouragement, or other emotions, not keeping in mind and responding to related emotions also important to them. They may vent their momentary anger on a friend or family member with hurtful intensity that does not take into account that this is a person whom they love and do not want to hurt. People with ADHD report that momentary emotion often gobbles up all the space in their head, as a computer virus can gobble up all the space on a hard drive, crowding out other important feelings and thoughts.
“attentional bias”
Many with ADHD also report that they tend to have a lot of difficulty with attentional bias. They tend to be particularly alert and quick to notice any comments or actions that fit with the emotions that preoccupy them, often without paying much attention to the context or to other information that might provide a useful different view. Some seem to be constantly alert for signs of things to worry about; others are excessively alert for any signs of potential frustration or discouragement. They become too easily immersed in one especially salient emotion and tend to have chronic problems in shifting their focus to keep in mind other aspects of the situation that might call for a very different response. For example, someone hearing just a slight uncertainty in a coworker's reaction to a suggestion may interpret this as stubborn disapproval and quickly start arguing for his or her idea without listening adequately to understand the coworker's actual response. Attentional bias may fuel feelings of depression, anxiety, or argumentativeness or cause the person to lose interest in a particular goal.1
the unacknowledged role of emotions in ADHD
Current diagnostic criteria for ADHD include no mention of problems with emotions, but those who live with this disorder and those who care for them know very well that problems with experiencing and managing emotions—interest, comfort, desire, anxiety, frustration, worry, disappointment, hurt, excitement, anger, pride, sadness, and shame, in various blends and sequences—play a critical role in their daily difficulties. Sometimes people with ADHD are unable to manage expression of these emotions; at other times, they have trouble experiencing and clearly recognizing emotions in themselves that can guide them in social interactions and fuel behaviors important for achieving longer-term goals.
Researchers have recently been challenging the omission of problems with emotional regulation in current diagnostic criteria for ADHD. For example, a team of European researchers studied more than a thousand children with ADHD and found that almost 75 percent demonstrated significantly more intense and frequent problems with low frustration tolerance, irritability, hot temper, sadness, and sudden mood shifts than non-ADHD children of the same age.2
A longitudinal study of over a hundred hyperactive children and a matched comparison group followed into young adulthood showed that those whose ADHD persisted into adulthood continued to have significantly more difficulties with low frustration tolerance, impatience, irritability, hot temper, and emotional excitability than the comparison group.
Such mood problems tend to persist into adulthood for many people with ADHD. A longitudinal study of over a hundred hyperactive children and a matched comparison group followed into young adulthood showed that those whose ADHD persisted into adulthood continued to have significantly more difficulties with low frustration tolerance, impatience, irritability, hot temper, and emotional excitability than the comparison group. Another study demonstrated that deficient self-regulation of these negative feelings is found in a subgroup of adults with ADHD, and also that this type of emotional dysregulation tends to occur with greater frequency among siblings of those affected adults.3
These recent studies have explored the role of emotions in ADHD, but most dealt exclusively with the combined type of ADHD, excluding those without hyperactive symptoms. Also, these studies have been focused primarily on difficulties in controlling negative emotions such as irritability and anger; they have neglected the role of emotions that are central to positive motivations, such as interest, enthusiasm, desire, pride, and pleasure. These studies also have not adequately explored anxiety, discouragement, stress, and hopelessness, which often compromise a person's motivation to act.
In a comprehensive review article, Russell Barkley, a leading researcher, has argued that “deficient emotional self-regulation” should be included in diagnostic criteria for ADHD and considered a core component of the disorder, though only for the combined subtype. His emphasis is on insufficient control of more negative, disruptive emotions:
ADHD creates a state in which the normal emotion-generating properties of the limbic system, and particularly the anger, frustration, and aggression-generating properties of the amygdala, are inadequately regulated by higher cortical functions. (p. 10)4
the problem of ignition and motivation
Thus far, researchers and clinicians have focused too much on how people with ADHD demonstrate problems in putting the brakes on expression of emotions. There hasn't been sufficient attention given to the emotional problems with ignition—chronic difficulties with getting started on necessary tasks and staying motivated to finish what needs to be done.
An important clue to understanding these problems with ignition in ADHD can be found in the most puzzling and frustrating fact about children, adolescents, and adults with attention deficit disorders: their symptoms are not consistent. A person's ADHD symptoms vary considerably from one situation to another, depending on the task or context in which he or she is operating and on the incentives involved. Despite their chronic problems with organizing themselves, getting started on tasks, and staying focused, all people with ADHD have a few activities in which they have no such problems. If you watch them while they engage in those activities, you would swear that they have no problem with attention at all.5
Thus far, researchers and clinicians have focused too much on how people with ADHD demonstrate problems in putting the brakes on expression of emotions. There hasn't been sufficient attention given to the emotional problems with ignition—chronic difficulties with getting started on necessary tasks and staying motivated to finish what needs to be done.
Typically each person with ADHD, young or old, is able to focus very well for a few activities in which he or she has strong personal interest. This might be playing a sport or video games, drawing or painting, repairing a car, playing music, or using Facebook. Yet for virtually all other activities and tasks, people with ADHD have extreme difficulty in achieving and maintaining focus, with the possible exception of situations where they expect a very immediate unpleasant consequence if they don't attend to the task at hand. If you ask a person with ADHD why he can focus for this and not for that, he will usually respond along the following lines:
I focus well on things that interest me, but if it's not something that really interests me, I just can't keep my focus. If I'm really freaked that something very unpleasant is going to happen quickly unless I take care of this right here, right now, that may help me focus for a while. But unless it feels like there is a gun to my head, I really have to be interested.
Because they can focus well on tasks that interest them, yet often focus very poorly or inconsistently on almost anything else, people with ADHD are often accused of lacking willpower. ADHD clearly looks like a problem with willpower, but it is not. One patient called his chronic difficulty with attaining and sustaining focus “erectile dysfunction of the mind.” He said,
If the task is something that really interests me, I can get “up” for it and I can perform. But if it's not a task that “turns me on,” I can't get up for it, and I can't perform. Doesn't matter how much I say to myself, “I need to, I ought to, I should.” I can't make it happen. It's just not a willpower kind of thing.
immediate or delayed “payoffs” in the ADHD brain
Underlying this “can focus for this, but not for that” problem is an important problem with emotion in ADHD: difficulty in mobilizing and sustaining interest for activities that don't offer an immediate “payoff” of pleasure or relief. Most of us may not think of interest as an emotion, but it is in fact a critically important positive emotion. “Passionate interest” represents an intense level of sustained emotional engagement with a task or person, but interest occurs in varying degrees and with varying levels of persistence. Interest reflects the degree of a person's motivation and emotional engagement with a task or relationship. Psychologists James Gross and Ross Thompson have emphasized that “emotions not only make us feel something, they make us feel like doing something.”6
PET imaging studies have demonstrated that chemicals which activate reward-recognizing circuits in the brain tend to bind on significantly fewer receptor sites in people with ADHD than do those in a healthy comparison group.
Emotions motivate action—action to engage or action to avoid. Many people with untreated or inadequately treated ADHD can readily mobilize interest only for activities offering very immediate gratification; they tend to have severe difficulty in activating and sustaining effort for tasks that offer rewards only over the longer term.
Problems of activating and sustaining motivation and effort for necessary tasks—lack of sufficient interest—may have to do with how people with ADHD are “wired”: they may be less sensitive to potential rewards, as opposed to immediately available rewards, than are others of the same age.
PET imaging studies have demonstrated that chemicals which activate reward-recognizing circuits in the brain tend to bind on significantly fewer receptor sites in people with ADHD than do those in a healthy comparison group.7 These and other imaging studies may help explain why people with ADHD tend to be less able than their peers to anticipate pleasure or register satisfaction with tasks for which the payoff is delayed. An important effect is that often they have great difficulty in activating themselves to get started on tasks that are not especially interesting to them and in sustaining motivation to complete tasks for which the rewards are not imminently available. I discuss implications of this research in Chapter 2.
Problems in activating and sustaining interest (focus) and effort for tasks are two of the multiple cognitive functions included in the complex syndrome currently identified as ADHD. As I noted in the Introduction, this disorder is no longer seen as simply a problem of young children who misbehave. In fact, misbehavior is something of a red herring in the mystery of ADHD and has eclipsed the truly debilitating aspects of the disability as it often progresses to young adulthood and into middle age, bringing heartbreaking suffering, internal turmoil, and frustration in actualizing life goals. It is in fact now clear that many people with ADHD have never had significant behavioral problems, and even for those who did have such difficulties, problems with misbehavior usually tended to be among the least of their troubles. The primary problem for most individuals with ADHD, especially as they enter adolescence and adulthood, is a wide range of cognitive impairments in the management system of the brain. All of these impairments are linked to various problems with emotion.
emotions, ADHD, and executive functions
Neuroscience is quickly changing our understanding of the neurological underpinnings of psychological phenomena. Nowhere is this research more salient than in the study of ADHD, where we need better to understand how brain functions are intimately tied to emotional experiences, feelings, and decision-making processes. Here I offer a brief review of the model of executive functions (EFs) impaired in ADHD, as well as a model for how emotional processing has a special relationship to these brain functions.
understanding executive functions
In 2005, I published the book Attention Deficit Disorder: The Unfocused Mind in Children and Adults. Eight years later, I updated it with A New Understanding of ADHD in Children and Adults: Executive Function Impairments.8 In those books, I described six clusters of chronic difficulties experienced by most people with ADHD. I explained how these six clusters together constitute a description of problems in the brain's management system, its executive functions. Building on my own research and the work of others, I have suggested the new working definition of ADHD shown here:
In those earlier books, I also highlighted the puzzling question of why those with ADHD tend to have chronic EF problems in most areas of daily life, yet have almost no difficulty in effectively deploying these same functions in a few specific activities. This book explains how problems with emotion underlie this ability of people with ADHD to focus on some tasks very intently while also being chronically unable to focus on many other tasks that they know are important.
Among the six clusters of this model, illustrated in Figure 1.1, there is one that includes problems in managing frustration and modulating emotions. This book is not focused only on that one aspect of EF; it is not only about emotion management. It is about the multiple and subtle ways in which problems with emotion underlie chronic difficulties in all six clusters of EF: problems of emotion in prioritizing and getting started on tasks, in holding focus and shifting focus appropriately, in regulating alertness and sustaining effort, and in utilizing working memory—all this in addition to problems with managing frustration and emotional expression and experience.
Figure 1.1 Executive Functions Impaired in ADHD
Source: From Attention Deficit Disorder: The Unfocused Mind in Children and Adults (p. 22), by T. E. Brown, 2005, New Haven, CT: Yale University Press. Reprinted with permission.
building blocks of the executive functions
The model in Figure 1.1 provides a way to think about the variety of cognitive functions that make up the executive functions of each person's brain. The six boxes are not unitary variables like height, weight, or blood pressure—all one thing of which you can have more or less. Rather, each of these boxes represents a cluster of related cognitive functions. For most tasks that require self-management, several, if not all, of these six clusters of cognitive functions interact dynamically to do the task. Usually they operate so quickly that they are automatic, faster than lightning, not dependent on step-by-step conscious thought. The following list describes these six clusters in more detail:
In looking at this model, keep in mind that the capacity of any person to use these executive functions depends on a developmental process that starts in very early childhood and is not fully completed until the late teen years or early twenties. In other words, these cognitive functions mature and come online only gradually over the long course of development from early childhood to early adulthood.
The brain infrastructure needed for these executive functions is very slow to develop. The abilities to organize and start tasks on your own, sustain focus on a task, regulate your alertness and capacity to keep one thing in mind while doing something else—all these abilities and other EFs develop only in very rudimentary form during early childhood. For all humans, it takes almost two decades of gradual development for EFs to reach their mature capacity.
ADHD is essentially a developmental delay or ongoing impairment of these six clusters of EFs. Later in this chapter, I describe our current understanding of causes of ADHD; for additional information about how ADHD impairments appear in various forms at different ages, please refer to my two earlier books.
a critically important hub in the brain
The amygdala, a small region deep inside the brain, is the primary locus of the rapid initial processing of anything perceived, thought about, or imagined. This critically important hub links with almost every other region of the cerebral cortex to facilitate instantaneous emotional assessment—positive and negative—of current perceptions, thoughts, or imaginings. These assessments are then very rapidly communicated to various sections of the brain via the amygdala's output of a variety of neurotransmitter chemicals and hormones that quickly stimulate responses within the brain and throughout the body.9
Figure 1.2 illustrates the density of connections between the primate amygdala and other regions of the cerebral cortex. The amygdala, one of the emotional centers of the brain, is like a transit station through which massive amounts of processing take place.
Figure 1.2 Schematic Graph Showing the Complex and Widespread Output Connections Between the Amygdala and Most Other Areas of the Cortex
Source: Figure 9 from “Analysis of Connectivity: Neural Systems in the Cerebral Cortex,” by M. P. Young, J. W. Scannell, G.A.P.C. Burns, and C. Blakemore, 1994, Reviews in the Neurosciences, 5, p. 243. Reprinted with permission from Walter de Gruyter GmbH.
The amygdala, shown in the center of the diagram, is directly linked to sixty of sixty-eight regions of the cortex, including many involved in reasoning and high-level decision making. No other area of brain is so fully and directly connected with the rest of the cortex. Within this matrix of brain connections, emotional reactions are assigned and adjusted moment by moment. There, in an instant, initial appraisals are made of how potentially appealing or dangerous that specific perception or thought seems to be for that person in that moment. These initial assessments may or may not be reconsidered and may or may not be followed by responsive actions, depending on how other areas of brain respond to the amygdala's initial assessment.
Two primary sources shape the brain's appraisal of what we see, hear, or think: instincts, and memories derived from past experiences. Instinctual reactions include quick withdrawal from perceptions associated with danger—for example, blinking and trying to get out of the way when a large, fast-moving object moves closely toward one's face, spitting out foods that smell or taste rotten. Likewise, we feel instinctively drawn toward people or activities that seem to promise comfort or pleasure.
With amazing speed, the brain also accesses emotional centers that store and process memories, which have embedded emotions (see the later discussion of memory and emotions). It links whatever the person has seen, heard, thought, or imagined to relevant instincts or to memories that provide clues from past experiences. These memories weight the perception or thought with some degree of emotional significance, and the brain directs or redirects attention accordingly.
“hot” and “cool” executive function
Links between EF and emotions are complex. Some researchers have proposed that EF might be categorized along a dimension of emotional intensity; they differentiate between “hot” EF for dealing with tasks involving relatively strong emotional involvement, and “cool” EF for dealing with more abstract, less emotionally charged tasks.10 Others have suggested that hyperactive/impulsive ADHD symptoms involve more impairments of hot EF, whereas the inattention symptoms of ADHD involve more impairments of cool EF.11 Still others have argued that both hot and cool EF usually work in integrated ways. Stories in this book illustrate the complex and dynamic ways in which hot and cool aspects of EF interact in individuals with ADHD, regardless of subtype.
it's all about context: situational influences
What causes “hot” intense involvement or “cool” disinterested involvement in any given task is not the task itself but how the person perceives the task—which includes his or her emotions related to the task—in any particular moment. One university student may be intensely engaged in trying to complete a term paper long before the deadline set by the professor; another student in the same course may feel only weak interest or not even care about getting the paper in on time.
These emotions can change readily. The student who usually works hard to get every paper in on time may suddenly not care at all about the paper while he is upset because his girlfriend has just broken up with him and is now dating someone else. The student whose interest in completing papers on time is usually just lukewarm may quickly intensify interest and work hard to get a specific paper in before the deadline if he learns that timely submission may make the difference between passing or failing the course and possibly losing eligibility to continue playing on the school football team. Depending on changes in a person's situation and viewpoint, any given task may suddenly appear far more hot or cold, or he or she may vacillate between extremes of emotional interest.
Emotions don't exist as independent abstract entities; they are always embedded in perceptions, thoughts, sensations, images, or imaginings as assessed by a given individual in a particular context at a particular moment in time. Sometimes an emotion is attached to a category of people or perceptions—for example, a special affection or dislike for people of a specific race, ethnic background, or appearance, or a persistent interest in or discomfort with particular erotic images or behaviors. But often even these generalized emotions can be traced back to specific experiences or events. It is true that some people manifest a more limited range of emotions, seeming to specialize in expressions of irritability, guilt, longing, pride, and so on; these are their more salient emotions, the ones most readily elicited and expressed. But most often a wide variety of emotions are attached to or embedded in the details of particular thoughts, sensations, perceptions, or imaginings.
Please note, however, that EF capacities are not primary determinants of emotional experience for people with ADHD or for anyone else. Emotions arise from biological processes that emerge in the temperament in infancy; these are gradually shaped by development and modified by countless life experiences. From his research with infants followed into adolescence, developmental psychologist Jerome Kagan has described and emphasized how
each child is born with a profile of temperamental biases . . . that creates initial tendencies to be vocal or quiet, vigilant or relaxed, irritable or smiling, and energetic or lethargic with regard to particular events or situations. Parental behaviors, sibling rivalries, friendships, teacher attitudes, emotional identifications with family, ethnic class, religious or national categories, and even the size of the community during the childhood years combine with a host of chance events to sustain, or more often to alter, the relative strength and exact form of the traits the early biases produced.12
Emotional responses arising within each person, shaped by that person's inborn temperament and modified by his or her ongoing life experiences, are often referred to as the “bottom-up” aspect of emotional experience. This book presents examples of people who vary widely in the bottom-up flow of temperament into their experience. Some, by nature, tend to be much more anxious; others are more quick to give up in discouragement. However, in these stories, I will emphasize the “top-down” aspect of emotional experience for people with ADHD: their ability or lack of ability to utilize their EF capacities to recognize, modulate, and respond to the complexities of their emotional experience. These top-down processes can guide, shape, and alter the way people perceive and react to situations.13
the profound importance of memory
To understand the role of emotions in ADHD, it is essential to appreciate the intimate connection between emotions and memory. The brain's emotional reactions are guided by our personal memories linked to what we are seeing, hearing, thinking about, or imagining. Just as a search engine like Google can instantly pull up from the Internet a vast array of sites associated with a few key words, so the brain can far more quickly, in fractions of a second, select specific fragments and clusters of memories associated with any given perception, thought, or imagining, each memory carrying its own “charge” of associated emotion. Some memories derive directly from actual experiences in our remote or recent past that may seem relevant; other memories may emerge less directly from stories we've heard or movies we've seen or from recall of what happened to others whom we have observed in an apparently comparable situation. Some memories carry a “charge” of fear or shame; others are charged with desire and attraction; many are complicated by multiple layers and blends of emotion.
Without any conscious thought, in just milliseconds, the brain automatically appraises incoming perceptions, thoughts, or imaginings and generates reactions—to jump back or move forward, to pursue or to ignore. Often this initial appraisal leads to no significant reaction; the particular stimulus simply does not seem interesting or important in the moment. In some circumstances, the incoming perception primes us to generate more intensive or sustained reactions, which may arouse conscious awareness, thoughts, and associated memories.
Regardless of the source, within those milliseconds, the brain does its calculus and yields emotionally loaded reactions to signal further approach and engagement. This process of calculating weights of emotion attached to relevant memories is the amazing mechanism by which the brain assigns valence, positive or negative value, and relative importance to every passing perception and thought. These instantaneous, automated emotional reactions, strong or relatively weak, are the basis on which the brain allocates attention to specific perceptions, thoughts, actions, or situations, and ignores others.14
Some emotions are readily recognizable, intense and clear; more often they are subtle and blended, jumbled and conflicting, layered and sequential. Some are brief and transient; others are recurrent or long persisting, but they are all generated by the brain and embedded in our perceptions and thoughts.
Each trace of memory is charged with one or, more often, multiple emotions that may vary in intensity from insignificant to overwhelming. Sometimes these emotions are linked specifically to the initial content of the memory trace—for example, a pleasurable or embarrassing or frightening situation. For other memories, associated emotions may be added later—for example, delayed pride, guilt, or resentment over a past thought or experience. It is the emotional charge attached to our countless strings of associated memories that provides what the neuroscientist Dodge described as “the energy level that drives, amplifies and attenuates cognitive activity.”15 We depend on working memory to pull up the relevant information and associated emotions to help us size up situations and to guide us in coping with the countless tasks and interactions of daily life. Understanding of these processes is complicated, however, by the fact that emotions do not operate only at the level of consciousness. In fact, most emotional activity goes on outside our conscious awareness.
the role of unconscious emotions
Many people think of emotions as involving only conscious feelings, limited to sensations of sadness, anger, pleasure, worry, and so on that a person is fully aware of and generally able to identify. Neuroscience research has shown that conscious feelings are only the tip of the massive iceberg of emotion that operates within each person to motivate executive functions.
