What Is ADHD?
Beyond inattention, hyperactivity, and impulsivity.
Posted Jun 29, 2020
Mark Twain described a classic book as one that everyone loves but no one has read. In some ways, Attention-Deficit/Hyperactivity Disorder (ADHD) has suffered a somewhat different fate of inciting a broad spectrum of opinion based on a similarly broad spectrum of notions of what ADHD “is.”
The acronym of A-D-H-D is a brand name that likely will not change any time soon. Its history is replete with clumsy stabs at naming, such as minimal brain dysfunction, before settling on the current moniker. However, the “A” and the “H” – and let’s throw in the snubbed “I” for completeness – are red herrings.
The core symptoms of developmentally inappropriate inattention, hyperactivity, and impulsivity are most certainly present in some assortment in all cases of ADHD. But they do not really capture the essence of ADHD and what makes it one of the more impairing disorders encountered, at least in outpatient psychological and psychiatric practice. As a colleague and leading authority on ADHD, Dr. Russell Barkley, has said, calling ADHD an attention disorder is like calling autism eye-gaze disorder.
What is ADHD? The contemporary, science-based view is that ADHD is a developmental syndrome of impaired self-regulation. What does this mean and what does this look like for free-range humans with ADHD? This self-regulation, which stems from a collection of capacities deemed the executive functions, provides the necessary skills with which to organize, plan, and execute actions over time towards a desired goal, but most often a delayed goal.
There are different and increasing expectations for such self-regulation throughout development, but they are there. For a 7-year-old, such skill is needed to wait in line for a chance to take some swings at a pinata at a friend’s birthday party; a 37-year-old draws on them to work on a monthly report in little chunks rather than waiting until the last minute. In both cases, the child and the adult know what is the expected and best way to handle the situation but the issue with the executive functions is their deployment. This leads to another important point about ADHD – it is not a knowledge problem but an implementation problem in real-world contexts, the point of performance.
Everyone has executive functions and they can be diminished by a depressive episode, a bout of the flu, or a several-day stretch of too little sleep, but they generally rebound to their baseline, intact levels once such issues remit. The difference with ADHD is that it is a developmental syndrome – it is a chronic delay in the acquisition and effective use of these self-regulatory skills. There is variation over time in terms of the degree of persistence as well as across situations, but most individuals with ADHD will describe a maddening sense of the “consistent inconsistency” across life domains. This frustration often manifests in school and work settings but also, and as insidiously, in social and interpersonal relationships and almost any endeavor from which one develops a sense of self.
This executive dysfunction disorder view of ADHD is not only a science-supported view but also allows us to “see” ADHD. Rather than gauging whether there is too much activity or too little attention, parents, teachers, spouses, bosses, and clinicians can be on the lookout for poor time management, excessive difficulties with initiation and follow through on tasks, disorganization, poor impulse control, and difficulties managing the typical emotional upsets of day-to-day life.
The other benefit of this view of ADHD is that it provides targets for coping and treatment. Most adults with ADHD will say, “I know what I need to do but I just don’t do it.” There are no trade secrets about the coping skills that will help with ADHD, but as mentioned, it is a performance problem. The good news is that there are effective medical and psychosocial treatments that can help improve symptoms and implementation of these skills, at least once we know what it “is.”