MYTH: ADD is just a lack ofwillpower. People with ADD focuswell on things that interest them,and they could focus on other tasksif they really wanted to.

FACT: ADD looks like a willpowerproblem, but it isn’t. It’s a chemicalproblem that undermines the man-agement systems of the brain.

For decades, the syndrome nowknown as ADD was seen simply as achildhood behavior disorder char-acterized by chronic restlessness,impulsivity, and an inability to sit

still. In the 1970s, it was recognized thathyperactive children also had significantproblems paying attention to tasks or listen-ing to their teachers. This discovery pavedthe way for changing the name of the dis-order in 1980 from “hyperkinetic disorder”to “attention-deficit disorder” and to recog-nizing that some children suffer fromchronic inattention problems without sig-nificant hyperactivity. That change, from anexclusive focus on hyperactivity and impul-sive behavior to a focus on inattention as theprincipal problem of the disorder, was thefirst major paradigm shift in understandingthis syndrome.

In recent years, there’s been anothermajor shift in our understanding of ADD.Increasingly, researchers are recognizing thatADD symptoms overlap with impairments inwhat neuropsychologists call “executivefunctions.” The term refers not to the activi-

ties of corporate executives, but to the brain’scognitive management functions.The term isused to refer to brain circuits that prioritize,integrate, and regulate other cognitive func-tions (see chart, “The Brain’s ExecutiveFunctions,” page 36).

Inconsistent inattentionEveryone I’ve ever evaluated for ADD hassome domains of activity where they can payattention without difficulty. Some are artistic,and they sketch intently. Others are child-hood engineers, constructing marvels withLego blocks and, in later years, repairingengines or designing computer networks.

InsidetheADD

MindIn 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.

This article is from AttentionDeficit Disorder: The UnfocusedMind in Children and Adults by

Thomas E. Brown, Ph.D., and

published by Yale University

Press. Reproduced by permis-

sion. For more information, or to

purchase a copy of this title,

please visit: www.yalebooks.com.

Dr. Brown is the associate

director of the Clinic for Attention

and Related Disorders at Yale

University School of Medicine,

in New Haven, Connecticut.

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Others are musicians who push themselvesfor hours at a time to learn a new song or tocompose a new piece of music.

How can someone who is good at pay-ing attention to some activities be unable topay attention to other tasks that they knoware important? When I pose this question topatients with ADD, most say something like:“It’s easy! If it’s something I’m really interest-ed in, I can pay attention. If it’s not interest-ing to me, I can’t, regardless of how much Imight want to.”

Most non-ADDers respond to thisanswer with skepticism. “That’s true for any-one,” they say. “Anybody’s going to pay bet-

ter attention to something they’re interestedin than to something they’re not.” But whenfaced with something boring that they knowthey have to do, non-ADDers can make them-selves focus on the task at hand. People withADD lack this ability unless they know thatthe consequences of not paying attention willbe immediate and severe.

Metaphors for executive functionsImagine a symphony orchestra in which eachmusician plays his or her instrument verywell. If there is no conductor to organize theorchestra, to signal the introduction of the

woodwinds or the fading out of the strings,or to convey an overall interpretation of themusic to all players, the orchestra will notproduce good music.

Symptoms of ADD can be compared toimpairments, not in the musicians but in theconductor. Typically, people with ADD areable to pay attention, to start and stop theiractions, to keep up their alertness and effort,and to use their short-term memory effec-tively when engaged in certain favorite activ-ities. This indicates that these people are nottotally unable to exercise attention, alertness,or effort. They can play their instrumentsvery well—but only sometimes. The prob-lem lies in their chronic inability to activateand manage these functions in the right wayat the right time.

One way to consider this broader viewof attention as executive functions is toobserve situations where tasks are not dealtwith effectively. Martha Bridge Denckla,M.D., professor of neurology, pediatrics, andpsychiatry at Johns Hopkins UniversitySchool of Medicine, in Baltimore, has writtenabout intelligent patients with no specificlearning disabilities who have chronic diffi-culties in dealing effectively with tasks. Inher 1996 book Attention, Memory, andExecutive Function, she compares these peo-ple to a disorganized cook trying to get ameal on the table.

“Imagine a cook who sets out to cook acertain dish, who has a well-equippedkitchen, including shelves stocked with allthe necessary ingredients, and who can evenread the recipe in the cookbook. Now imag-ine, however, that this individual does nottake from the shelves all the relevant ingre-dients, does not turn on the oven in a time-ly fashion so as to have it at the proper heatwhen called for in the recipe, and has notdefrosted the central ingredient. This indi-vidual can be observed dashing to theshelves, searching for the next spice men-tioned in the recipe, hurrying to defrost themeat and heat the oven out of sequence.Despite possessing all the equipment, ingre-dients, and instructions, this motivated butdisheveled cook is unlikely to get dinner onthe table at the appointed hour.”

The “motivated but disheveled cook”sounds very much like a person with severeADD who tries to accomplish a task but isunable to “get it together.” Individuals withADD often describe themselves as intenselywanting to accomplish various duties for

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which they are unable to activate, deploy, andsustain the needed executive functions.

Executive functions and awarenessA 43-year-old man came to my office withhis wife to be evaluated for attentional prob-lems. Both of the couple’s children hadrecently been diagnosed with ADD and hadbenefited from treatment. When I explainedthat most children diagnosed with ADD havea parent or other close relative with ADD,both parents laughingly responded, “Thoseapples haven’t fallen far from the tree.” Bothagreed that the father had more ADD symp-toms than either of the children. Here’s howthe wife described her husband:

“Most of the time he’s totally spacedout. Last Saturday he set out to fix a screenupstairs. He went to the basement to getsome nails. Downstairs he saw that the work-bench was a mess, so he started organizingthe workbench. Then he decided he neededsome pegboard to hang up the tools. So hejumped into the car and went to buy the peg-board. At the lumber yard he saw a sale onspray paint, so he bought a can to paint theporch railing and came home totally unawarethat he hadn’t gotten the pegboard, that hehad never finished sorting out the work-bench, and that he had started out to fix thebroken screen that we really needed fixed.What he needs is a lot more awareness ofwhat he is doing. Maybe that medicine ourkids are taking can give him that.”

From this wife’s description, one mightconclude that the central problem of ADD isessentially a lack of sufficient self-awareness.She seems to believe that if only her husbandwere more steadily aware of what he isdoing, he would not be so disorganized,jumping from one task to another withoutcompleting any single one. But most peopledo not require constant self-awareness tocomplete routine tasks. For most people,most of the time, operations of executivefunctions occur automatically, outside therealm of conscious awareness.

For example, while driving a car to thelocal supermarket, experienced drivers donot talk themselves through each step of theprocess. They do not have to say to them-selves: “Now I put the key in the ignition,now I turn on the engine, now I check mymirrors and prepare to back out of my drive-way,” and so on.

Experienced drivers move effortlesslythrough the steps involved in starting the car,negotiating traffic, navigating the route,observing traffic regulations, finding a park-ing place, and parking the car. In fact, while

doing these complex tasks, they may be tun-ing their radio, listening to the news, think-ing about what they intend to prepare forsupper, and carrying on a conversation.

Even the simpler example of keyboard-ing on a computer illustrates the point. If onecan type fluently without stopping to con-sciously select and press each individual key,one’s mind is left free to formulate ideas andto convert these into words, sentences, andparagraphs that convey ideas to a reader.Interrupting one’s writing to focus on andpress keys one at a time costs too much timeand effort; it cannot be done very often if oneis to write productively.

Many other routine tasks of daily life—for example, preparing a meal, shopping forgroceries, doing homework, or participatingin a meeting—involve similar self-manage-ment in order to plan, sequence, monitor,and execute the complex sequences of behav-ior required.Yet for most actions, most of thetime, this self-management operates withoutfull awareness or deliberate choice.

The problem of the “unaware” hus-band is not that he fails to think enough

The Brain’s Executive Functions

ACTIVATIONOrganizing,prioritizing,and getting

to work

FOCUSTuning in,sustaining

focus,and shifting

attention whenappropriate

EFFORTRegulatingalertness,sustainingeffort, andadjusting

processingspeed

EMOTIONSManagingfrustration

andmodulatingemotions

MEMORYHolding on toand workingwith informa-

tion; retrievingmemories

ACTIONMonitoring

and regulatingone’s actions

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.

ADD Is Not Like PregnancyADD is not like pregnancy, where one either does or does not have the characteristics, where there is no

“almost” or “a little bit.”

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

not qualify one for the diagnosis of depression. It is only when symptoms of depression significantly inter-

fere with an individual's activities over a longer time that he is eligible for such a diagnosis.

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about what he is doing. The problem is thatthe cognitive mechanisms that should helphim stay on task, without constantly andconsciously weighing alternatives, are notworking effectively.

The brain’s signaling systemSome might take my orchestra metaphor lit-erally and assume that there is a special con-sciousness in the brain that coordinates othercognitive functions. One might picture a littleman, a central executive somewhere behindone’s forehead, exercising conscious controlover cognition like a miniature Wizard of Oz.Thus, if there is a problem with the orches-tra’s playing, one might attempt to “speak” tothe conductor, requesting—or demanding—needed improvements in performance.

Indeed, this presumed “conductor,” orcontrolling consciousness, is often the targetof encouragement, pleas, and demands byparents, teachers, and others as they attemptto help those who suffer from ADD. “You justneed to make yourself focus and pay atten-tion to your schoolwork the way you focuson those video games!” they say. “You’ve gotto wake up and put the same effort into yourstudies that you put into playing hockey!”

Alternatively, they may impose punish-ments on people with ADD or shame themfor their failure to “make themselves” doconsistently what they ought to do. Thesecritics seem to assume that the person withADD needs only to speak emphatically to the“conductor” of his own mental operations toget the desired results.

In reality, there is no conscious conduc-tor within the human brain. There are net-works of neurons that prioritize and integrateall of our cognitive functions. If these net-works are impaired, as they are in ADD, then

that individual is likely to be impaired in themanagement of a wide range of cognitivefunctions, regardless of how much he or shemay wish otherwise.

How medication helpsThere is now considerable evidence thatexecutive functions of the brain impaired inADD depend primarily, though not exclu-sively, on two particular neurotransmitterchemicals: dopamine and norepinephrine.

The most persuasive evidence for theimportance of these two transmitter chemicalsin ADD impairments comes from medicationtreatment studies. Over 200 well-controlledstudies have demonstrated the effectiveness ofstimulant medications in alleviating symptomsof ADD.These medications work effectively toalleviate ADD symptoms for 70 to 80 percentof those diagnosed with this disorder.

The primary action of medicationsused for ADD is to facilitate release and toinhibit reuptake of dopamine and norepi-nephrine at neural synapses of cruciallyimportant executive functions.Improvement produced by stimulants gen-erally can be seen within 30 to 60 minutesafter an effective dose is administered.When the medication has worn off, ADDsymptoms generally reappear at their for-mer level.

Stimulants do not cure ADD; they onlyalleviate symptoms while each dose of med-ication is active. In this sense, taking stimu-lants is not like taking doses of an antibioticto wipe out an infection. It is more like wear-ing eyeglasses that correct one’s vision whilethe glasses are being worn.

Given the often-dramatic alleviation ofsymptoms experienced by people with ADDwhen they take stimulant medications, it isvery difficult to sustain the notion that ADDimpairments amount to a lack of willpower.

Much more remains to be learned abouthow the brain’s complicated neural networksoperate to sustain the broad range of func-tions encompassed in “attention.” Yet it isclear that impairments of executive func-tions, those brain processes that organize andactivate what we generally think of as atten-tion, are not the result of insufficientwillpower. Neural-chemical impairments ofthe brain’s executive functions cause someindividuals who are good at paying attentionto specific activities that interest them to havechronic impairment in focusing for manyother tasks, despite their wish and intentionto do otherwise.

Executive functionsand intelligenceDisorganization is independent of general intelli-

gence. It is quite possible for an individual to be

extremely bright on standard measures of intelli-

gence and still have severe impairments of exec-

utive functions, such as those often seen in ADD.

An individual’s overall level of “smarts,” as

measured by standard IQ tests, appears to have

little to do with whether he or she meets the

diagnostic criteria for ADD. Some of my ADD

patients are extremely bright, employed as uni-

versity professors, scientists, physicians, attor-

neys, and senior executives.

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