Attention Deficit Hyperactivity Disorder (ADHD) has been studied perhaps more intensively than any other childhood psychiatric disorder. (2) ADHD is characterized by enduring and early problems with sustained attention, higher motor activity, and impairments in social inhibition & planning. It appears to run a chronic course, well into adulthood for many people.
More recently ADHD children have been thought to have deficiencies in the Executive Functions (3) of (a) behavior inhibition, (b) language incorporation and retrieval, (c) using language to make and share plans, (d) rule generation and application, (e) matching past memories with current situations and imagining alternative future outcomes, and (f) imagining and implementing alternative behavior sequences to solve a problem. These impairments have been suggested to comprise a deficiency in Free Will, summarized as an inability to make a plan on Monday for Friday evening and stick to it.
ADHD children have also been described as much as 30% less mature than nonaffected age-mates. Thus, the ADHD child and adult are felt to be at elevated risk as they face developmental challenges associated with school and family roles such as baby sitting, driving, dating, employment, and marriage.
Like many models, this one has some flaws. The first hint of inadequacy was that impulsive kids sometimes pay magnificent sustained attention, such as when they play Nintendo. These exceptions were explained by "he can do it when he's interested." The circularity is profoundly troubling and has been repeated for a dozen years. (The other explanation, that Nintendo has immediate, dramatic feedback and simple rules, is equally unsatisfactory.)
A second, related flaw, in this model was evident 3 years ago and I missed the significance at the time. My 12 yo female client met criteria for an ADHD diagnosis, including the immaturity aspects of the label. I related current thinking about subtracting as much as 30% from her age before granting varied responsibilities such as baby sitting. Mom emphatically, accurately, contradicted me, that her daughter was a superior sitter and excelled as well in handling children at the church day care. Oops.
Since then, I've met many more troubling exceptions to the rule about sustained attention, including the following people who meet research criteria for a diagnosis of ADHD. They are all physically active, somewhat immature socially, have difficulties with impulse control, and are underachieving yet:
(a) Sean Seamus4 (10 yo) secretly listens to hockey games at 10:30 P.M., knows the stats, reads & remembers the morning sports page. He also blissfully wets his bed, is tyrannical with his sisters, has sloppy table manners, and poor hygiene. He is mildly oppositional at home, restless and inattentive in school without his methylphenidate.
(b) Lemme Atem (12 yo) has a very poor set of numbers on his teacher ratings for ADHD, his parent ratings, and his CPT; he qualifies for a diagnosis of ADHD, possibly severe, yet is the best wide receiver in his neighborhood, especially when playing on an icy field. He needs to hear directions only once to steer his bike to a new store or to visit a friend.
(c) SheilaE (13 yo) with the mandatory red hair (diagnostic for ADHD per Dennis Cantwell!) excels with cooking and geographic directions but not academic ones (she really wants to but just can't (5) ). She, too, is superior at watching children and even saved a life at her pool when she, not the guards, noticed there was a child missing from the group. She found him on the pool bottom. She excels also at the boring tasks of sewing, laundry, and cleaning even though she's hyperactive, oppositional, and has a reputation with peers for doing unpredictable things.
These are not the only four exceptions; indeed, every ADHD client is an exception. They are all alike according to the DSM 4 list, but sticking to the list means that you miss a lot of their strengths, strengths that will direct much of their life and may bring them success despite ADHD traits. In their highly specific, individually characteristic areas of strengths these children and adults rarely have a problem with sustained attention, hyperactivity, or impulsiveness.
The inconsistencies in performance may be handled better with the concept of Adaptive Systems (AS). AS (Barkow, et al. 1992) are phylogenetically old and consist of several receptor-integrator-effector mechanisms working efficiently and cooperatively for a common goal that enhances survival. The AS include anatomical, physiological, and behavioral elements working together. It is as if our cerebellum has multiple, semiautonomous circuits for accomplishing highly specific tasks when elicited by highly specific stimuli.
AS have been described for scores of human behavior domains related to mating, child care, property management, kin recognition, and even environmental esthetics. AS for hunting may account not only for sports performance but also for varying performance on Nintendo and on continuous performance tests that require a child to respond or not to respond to specified letters of the alphabet flashed on the screen. (It's like shooting skeet but without the noise and fragmented clay disks.) Some 35% of impulsive children do well on a CPT despite pervasive difficulties with behavior inhibition in other settings.
The concept of Adaptive Systems, by some definitions, excludes the notion of variability across individuals. However, not all of us are talented in caring for children, not all of us are good building things, not all of us are good with mate selection, yet we are still human. Despite avowals in the Adapted Mind that AS are universal in humans, there is convincing evidence of great variability in their individual expression.
There remains the problem of why behavior routines associated with dominance, getting money, property acquisition, child care, winning at Nintendo, and building things are comparatively intact in many ADHD children. Given (a) intense competition through eons to reproduce, (b) that only the most domineering, competitive children reproduce, and (c) those who care for their own children are more likely to be represented in the next generation, then those same traits will have more redundancy and resistance to disruption.
Pennington (1991) has suggested that more recently evolved CNS functions are more sensitive to disruption; older systems have greater amounts of resilience. The Executive Functions of planning, memory retrieval, problem analysis and solving appear comparatively new, most elaborate in humans, and most easily disrupted. These Executive Functions may also have an impact on newer, subtle abilities to inhibit personal behavior in response to other people's emotional cues and stated wishes. If mechanisms for dominating others, amassing property and wealth, tool use, and mating are evolutionarily older, it becomes less surprising that so many complex behaviors could be intact while newer, subtle behavior routines that are highly valued in modern culture are impaired in ADHD.
As EP scientists define extensive hierarchies of AS, then assessment of not only ADHD but other childhood and adult disorders will have to be modified. We need to move quickly from our present, unsatisfactory generalities about "sustained attention" into highly specific inventories of talents that help us guide the child into settings where he can thrive. (6,7) The present system, wherein the child "selects out" of environments where he fails, is expensive, degrading, and unsatisfactory.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Washington, DC.
Barkow, J., Cosmides, L., Tooby, J. (Eds.) (1992) The adapted mind: Evolutionary psychology and the generation of culture. Oxford: New York.
Barkley, R. (1993) A new theory of ADHD. ADHD Report, 1, (5), 1-4.
Connors, K. (1994) Connors continuous performance test. North Tonawanda, NY: MHS.
Pennington, B. (1991) Diagnosing learning disorders. New York: Guilford.
(1) Drafted 1/11/97, finished 2/22/97
(2) One of the best and most reasonably priced surveys is Russ Barkley's "Taking charge of ADHD," Guilford Press, 1995.
(3) An Executive Function is a piece of behavior that manages other sequences of behavior.
(4) Names, of course, changed.
(5) The whole "directions" item on DSM 4 requires specification for geographic, cooking, or chore lists and school directions. The answer can vary wildly from client to client as a function of content. Likewise for the other attention and impulse items.
(6) Howard Gardner in "Multiple Intelligences" opts for a 7 factor model of learning strengths. He uses the word "talent" for music, art, and dance.
(7) Brian Goodwin's quote again fits: "... it's simply about finding a place where you can be yourself."