Neuroscientists refer to the brain’s process for managing time, financial and goal achievements as its executive function. Those of us with good executive function take it for granted: We organize our daily activities and interactions in an efficient manner without much mental effort. That’s hardly true for adults who suffer from Attention Deficit Hyperactivity Disorder (ADHD).
Less than a decade ago, referrals to my practice for an adult ADHD evaluation were virtually nonexistent. Professionals and the public assumed it was a child’s disorder and that these troubled children had somehow outgrown their problems by adulthood. Today we know from research studies and clinical evidence that ADHD affects all age groups, but the disorder exhibits itself differently in children and adults.
Stephen Stahl, MD, Professor of Psychiatry at the University of California Medical School and Laurence Mignon, Neuroscience Education Institute discuss this issue in their book, Attention Deficit Hyperactivity Disorder (NEI Press, 2010):
It is now known that ADHD does not dissipate with age. Some patients, however, might be able to compensate for some of their symptoms. At the same time, adults who were never diagnosed as children might start to exhibit ADHD symptoms as their compensatory mechanisms break down and they are faced with additional responsibilities at work as well as in their social and home life.
The recent dramatic increase in referrals for assessments in my practice, and to other professionals, is a result of this growing knowledge about adult ADHD. One of the first symptoms adults report to me goes like this: “I was doing okay and managing my life just fine until the pressure of juggling more and more stuff really got to me.” Stress often is the trigger for the onset of awareness that something is amiss in one’s life, as the following case study shows.
James’s family doctor referred him to me for an adult ADHD evaluation. He was a tall, handsome, 28-year-old man with a MS degree in the sciences and taking courses to complete a Ph.D. James was juggling a ton of things in his life, including a part-time job to supplement his scholarship from the university. In spite of his brilliant mind, his job and school performance were marginal. During our first session, he expressed frustration over several recent, major setbacks.
“My boss says he really likes my creative mind and thinks I’m a great guy, but may have to ax me if I can’t get my projects completed on time. Dr. Jones, my major professor, complains that it’s taking me twice as long as other students to finish the Ph.D program, and he can’t imagine how I’m going to complete a dissertation, which involves a lot of solo research and, above all, the big D — discipline. My fiancé Sophie, whom I dearly love, won’t consider marrying me until I get my finances in order. The irony is that I make a decent salary, but I blow every bit of it. Sophie would tell you that I’m a pretty impulsive guy. Guess I won’t be getting hitched any time soon. Doc, it’s no wonder I’m a nervous wreck. Other than being on the verge of losing my scholarship, job and fiancé, I’m in great shape.”
James had a sad, frustrating story to tell, but a good sense of humor about his tough challenges. He had the raw materials — intelligence and motivation — to succeed at work and in his love life with Sophie. And, he was an extremely likeable, engaging guy. Like many patients, he was legitimately confused, frustrated and a bit depressed about his situation.
I conducted a structured interview with James and administered the Clinical Assessment of Attention Deficit — Adult (CAT-A), a valid inventory by Bracken and Boatwright (1994). He also received a personality test to rule out other conditions such as anxiety and bipolar disorders that can complicate the diagnosis. I questioned him about habits such as distractibility and procrastination, and James answered many of my queries emphatically, with “oh yeah, that’s me to the extreme.”
On the CAT-A, his scores on the three major features of the disorder — inattentiveness, impulsiveness and hyperactivity — were in the 99th percentile. His personality inventory was in the normal range on variables such as depression, anxiety and bipolar issues. Clearly, James’s problems stemmed from trying to conduct his life while functioning on the extreme end of the adult ADHD continuum. His executive function, shall we say, was less than fully functional.
The treatment of ADHD involves a team effort, which includes the patient’s awareness that he or she may be suffering from this disorder, and a love partner who often is acutely aware of the partner’s frustrating habits. Many patients typically go to their primary care physician with complaints of disorganized, dysfunctional lifestyles or report these symptoms during routine physical exams. The physician makes a referral to an expert in ADHD and personality assessments, often a psychologist, who performs the evaluation.
The two professionals collaborate and decide on a course of both medical and psychological treatment. After prescribing medication for his condition, James was referred back to me for relaxation and habit-changing techniques. If the case is particularly complex, that is, the doctors suspect a co-morbid diagnosis such as bipolar disorder or depression, a referral to a psychiatrist is necessary. And if there is any question of brain pathology, a neurologist is consulted. This is truly a condition where coordination by the entire medical team is a must.
How does this paradox exist in the brain? A highly intelligent, hardworking, motivated-to-do-well-individual performs poorly at work, can’t manage his finances and, in James’s case, is about to lose the love of his life. Here are some research-based answers to this brain-body mystery.
First, with the help of one of the foremost experts in the field, Dr. Thomas E. Brown and his book, Attention Deficit Disorder (Yale University Press, 2005), let’s dispel a commonly held myth: “ADD is just a lack of willpower. People with ADD focus well on things that interest them, and they could focus on other tasks if they really wanted to.”
According to Dr. Brown, this is the fact: “ADD looks like a willpower problem, but it isn’t. It’s a chemical problem that undermines the management systems of the brain.”
Most people are surprised by that fact, and James was no exception. Yet the consensus among ADHD experts is that this disorder is neurobehavioral; that is, a brain dysfunction that provokes behavioral problems. To reduce my patients’ frustrations and self-critical thinking, I often say: “It’s not you. It’s your brain. Your conductor is nodding off on the job of making beautiful music with that perfectly marvelous instrument of yours.”
Most ADHD patients are relieved to hear that they are not just lazy, impulsive yet brilliant bums. And they are especially enthused to learn that modern pharmacological and psychological treatments can help to recover executive function.
James received the right assessment and treatment for his ADHD and is now maximizing the performance of his brilliant and now focused brain.
Bracken, B. A. and Boatwright, B. S. (1994). Clinical Assessment of Attention Deficit – Adult. Psychological Assessment Resources.
Brown, T. E. (2005). Attention Deficit Disorder. Yale University Press.
Stahl, S. and Mignon, L. (2010). Attention Deficit Hyperactivity Disorder. Carlsbad, CA: NEI Press.
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