So, go back and look at those capacities that the frontal lobe is giving you as it matures and understand that ADHD and other disorders like it, but especially ADHD, restricts that development by 30 to 40 percent So, if you want to know how far behind somebody with ADHD is in self-regulation, conservatively take 30 percent off their age.
That’s where they are. By the way, the rule of thumb applies to a 24 to 30 years of age and then that’s it. It’s over. That is where you are going to stay through the rest of your lifespan. So, this helps you to understand then where are the clients we serve in their executive capacities. On average, people with ADHD are about 30 percent behind their age, which means that if you are about 16, you have the self-control of a 12-year-old. If they’re 21, it’s that of about a 14-year-old.
Eventually, by the time you get up into your late 20s and early 30s, hopefully you’re somewhere around 18 to 22 years of age, but you’re not 30. You will always continue to make less mature choices than other people are likely to do but the point is this, the concept of an executive age allows us to adjust our expectations.
To change the environment around the affected individual in order to work with the executive age we have, not with the one we want, and that reduces conflict. So, it pays to think of the brain very simplistically as a knowledge performance device.
The back part of the brain is where you acquire information. The front part of the brain is where you use it in daily adaptive functioning and ADHD separates those two parts, so it doesn’t matter what you know, you can’t do it as effectively with ADHD.
You can’t use your learning and your information for social effectiveness over time. You can get 800s on the SATs and you will do stupid things, so it doesn’t matter what you know. What matters is do you apply it.
Knowledge by itself is useless unless it is applied in human lives for effectiveness for adaptive and social activities.
So, how then do we understand ADHD?
We can understand that ADHD disrupts the executive system causing a severe time blindness leading to a contraction in the hierarchy of the system, a contraction, and spatial and social aspects of the individual’s life.
Since the executive system is future directed, ADHD is IDD, Intention Deficit Disorder. It means that ADHD is a disorder of performance, not knowledge, a disorder of doing what you have learned, not of knowing what to do, and the only way to deal with a performance disorder is to restructure the point of performance, the place in life where the problem is occurring.
The further away in space and time you are from that point, the less effective your intervention will be. Performance disorders must be treated at points of performance. We know that to alter the executive functioning of individuals over time, we are going to have to work within these five domains, information, maturation, accommodation, medication, and modification.
What are the implications of an executive view of ADHD?
Number one, the implication for treatment is obvious. These people are not stupid and yet we bring them in and act as if they don’t know. Little children have no friends; oh, you need social skills training. ADHD adults can’t manage time; oh, you need time management training.
People with ADHD have lousy working memory; we have them practice digit span back every night for 45 minutes in the place that we have somehow altered the executive deficit. You haven’t even come close. So, the point here is this. Don’t focus on the skills so much.
Restructure the point of performance. Follow what I call the 80/20 rule; 20 percent skill review to make sure they’ve got it, 80 percent changing that point of performance so that they execute it.
The goal is to show what you know, not to sit around and teach. The teach and pray strategy failed. It’s time to give it up and move on to engineering environments around executive deficits, altering the scaffolding.
Second, we have to design prosthesis environments and keep them in place. These are part official alterations that help reduce the individual’s impairment from their executive deficit, but a prosthesis does not get rid of the disorder; it reduces impairment from disorder. A ramp into this building is a prosthesis for people in a wheelchair but it does not get you out of the wheelchair. It allows you to do something you couldn’t otherwise do in that environment.
Remember, impairments are always setting specific. So, we are trying to lessen impairment from your disorder, re-altering, re-designing environments. The third, of course, is making sure it’s at the place where the problem exists, not in an office, not in a pullout service, not in a summer camp in Michigan. Where is the problem? That is the environment that requires restructuring.
We need to understand it in the case of ADHD the origin of these deficits. It’s largely neurological and genetic, not social, not a choice, not due to video games or TV, or your diet, so we have the most genetic disorder in psychiatry in ADHD. What does that mean?
It means that if you have a biological disorder, it is completely humane and rational to use copharmacology to compensate for that disorder.
It is like insulin to a diabetic. Indeed, I tell patients, ADHD is the diabetes of psychiatry because it brings to mind the treatment model that you have to have in place in order to deal with this disorder but it also speaks to the need often for neurochemical alterations of the brain to help manage that disorder.
We can now refer to ADHD medications as neurogenetic therapies. That is no hypothetical. We have a very good idea of where they work in the brain, the alterations they make. We are even learning the genes and their polymorphisms that are building and operating these networks and how the drugs alter them. Perhaps, some day in the near future, we will simply do genetic testing in the office to tell us which drug is best for your kind of ADHD. So, this is a neurogenetic disorder.
Neurogenetic therapies are completely rational and humane to be used with these individuals. Now, one thing I do want to point out. One of the greatest discoveries of the last 5 years in ADHD research, which you will never hear in the New York Times, because it is so biased against psychopharmacology for children.
We now have 29 studies that show that the longer you stay on your medication, the more normal your brain becomes, so the children who take medication have brain development and brain functioning much closer to normal individuals than people who never take medication. By the way, this is only children.
There are no studies, and I’m not sure that it would work in adults anyway, because the brain is a lot less plastic, but notice by using these medications to keep these executive networks functioning at a higher level, you may start to see brain growth in the areas that are crucial to executive functioning.
This is known as neuroprotection and just last week, a meta-analysis of all of this studies was published arguing that we have evidence that ADHD medications may well partially normalize brain development and you won’t hear that in the media. What does that tell you about the bias of our media at this point in time? That is a major discovery. Now, we also need to understand that because ADHD affects timing, ADHD is not an excuse from this behavior. We do not excuse you from the consequences.
If the problem is timing, the solution is to tighten them up. A solution for somebody with ADHD is not no consequences, its nearer consequences; closer in time, more frequent, more salient, more accountable to others. The way you treat a temporal disorder is by adjusting the temporal parameters in the components of a contingency.
If ADHD is destroying the cross-temporal organization of behavior, then stop requiring cross-temporal organization and make it much more immediate, much more salient, much more frequent, and more accountable to others.
Behavioral interventions do this beautifully, but we need to understand that behavioral interventions aren’t training you out of anything. They are a prosthesis. They are an artificial means of sprinkling artificial consequences out there in the environment where they don’t naturally occur.
There are ways of tightening up the temporal accountability.
But just because you do this does not mean you have trained this person out of anything. Remember, there are two reasons you do behavior modification. One is instructional, which is why you do it for children with intellectual disability. Two is motivational and if you do it for its motivational properties, which is why we use it for ADHD, you cannot stop doing these things.
So, what that means then is that the compassion and willingness of others is the lynchpin to successful treatment. Are other people in the environment, the caretakers, the stakeholders, willing to modify points of performance to create that additional scaffolding, those additional accommodations to facilitate this individual’s functioning in that environment.
Now, here are just a few things you can do if you wanted to practice your executive functioning, but time doesn’t permit me to go into those; I want to focus on these.
There are several ways you would alter the point of performance to help somebody with ADHD or any other executive disorder. Number one; remember mental information is not guiding behavior. The working memory system is deficient. So, what’s the solution? Put the information back in the environment where it originated. You are more into the control of things in your sensory fields, so get the information back out there.
I need you to externalize time because the internal clock is broken, using timers, clocks, counters, and other timing mechanisms. We need to break lengthy tasks into very small quotas. Self-pacing so that the individual doesn’t have to cross temporally, organize or sustain.
We are going to break the goal into smaller chunks and have the individual do smaller chunks at a time. We must use external motivators rather than rely on internal motivation. That’s what token systems do, points, privileges, money, all of those sorts of things, external motivators.
And then we must make problem-solving manual rather than mental because they can’t hold the pieces in mind in order to manipulate them to solve the problem. Finally, we need to remember that the executive system is a limited resource system and make sure that we do not defeat the system by demanding executive functioning for too long at a time.
There are various ways of dealing with that fuel tank. I’ll just list a few as I conclude here. If you want to boost your executive functioning, these are the things that will help you with your self-control. Notice they involved breaking tasks into smaller units using external reinforcement, using statements of self-efficacy and encouragement, using brief periods of relaxation in which you give the executive system a break, visualizing your goals and your consequences, and routine physical exercise improves the executive system and expands the fuel tank.
Finally, the entire fuel tank is based on blood glucose in the frontal lobe, so if you have protracted work to do, it’s like taking a high-stakes exam or doing homework, you better be sipping on some lemonade or a sports drink, or something that creates a low infusion of blood glucose into that frontal lobe because that is the basis for all of that resource pool.
So, I hope you can see then that ADHD is an executive disorder even if the test batteries don’t pick it up, that the executive system is an extraordinarily important system comprised of at least seven mental faculties that then feed forward into human life to give us these five dimensions of human activity, and these activities are the basis of our social relationships, our cooperative activities, and our culture, and all of this is put at risk in individuals like those with ADHD who have either injuries or neurogenetic disorders of the executive system.