good morning viewers and especially greetings to my subscribers in this short commentary I'd like to speak about a very important concept that pertains to ADHD and that is that ADHD is a disorder of performance not a disorder of knowledge now this concept is covered over in my longer lecture on my theory of ADHD as a disorder of executive functioning but I thought it might be useful to pull it out and dedicate a short video just to this concept in case you wanted to use it to share with others uh to help explain to them a key Concept in understanding ADHD so let's get started with the PowerPoint presentation here and you can see from this diagram that we can simplify the brain see it here as a two-part system I know that's a gross oversimplification but for our purposes it works the ADHD brain or the typical brain both can be thought of as a knowledge performance device now at the back part of the brain here is where we acquire and store information about the environment about how we interact with with the environment so this is where our information knowledge skills and other things are largely located the front part of the brain which as you now know is the frontal loes or the executive function brain is a performance brain it's a motor brain it's a doer it gets things done so there's the knowledge brain at the back and the performance brain at the front now we know that ADHD separates the executive function networks from the rest of the brain it's not a complete separation it's more of a dysfunction deficiency and highly variable activity within the executive networks but for for this concept it'll suffice to say that there's a disconnection between what we know at the back part of the brain and what we do with it at the front part of the brain the performance brain an ADHD is therefore leading people to have a disorder of performance it's not a problem with knowing what to do it's a problem with doing what you know with guiding our Behavior through these mental represent M ation that we activate at the back part of the brain and then bring them forward to the front part of the brain in order to guide our ongoing performance in a situation so it's a disorder of performance not skill or knowledge it's doing what you know that's the problem not knowing what to do it is a problem with the when and the where that we use the knowledge we have not the how or the what that needs to be done or how to do it what this means is that people with ADHD know pretty much about as much as other people of their age are likely to know they've been exposed to the same television schooling education Concepts Media news and so on so they have the information available the problem is putting it into practice where it would be important to do so and that's where things break down in people with ADHD is this guidance of our performance by our knowledge now important to understand in a performance disorder is this concept that Sam Goldstein and later I came up with about the point of performance and the point of performance is the place in our life where that knowledge should have been applied and probably wasn't it's where the problems are taking place it's where and when we are engaging the environment and how effectively we are doing so so it's that place and time in the natural setting where we should use what we know and maybe we didn't hence the problems that ADHD poses because of these executive deficits is one of getting things done doing things as we should do them given the experience history and knowledge that we have and that's very hard for them to do the knowledge at the back part of the brain is not very con consistent in guiding our behavior that is being created and monitored and executed at the front part of the brain performance at the front knowledge at the back so what would that mean for treatment it means that teaching skills to someone with ADHD just won't cut it you're simply conveying more knowledge and they're not necessarily in need of that knowledge but even if you teach it to them they're not going to use it out there in their typical lives and natural environments because ADHD precludes that from happening consistently and effectively so teach all the skills you want to but it's not going to help you can put kids in social skills camps it's not going to work you can teach them self-regulation you can teach them time management that's not going to work because just spewing more knowledge at them what they need help with is using that knowledge at the point of performance and to deal with that we have to design artificial what I call prosthetic environments around the person at that point of performance to help compensate for these executive deficits so treating ADHD is treatment at the point of performance any treatments that take place outside of that point of performance in a therapist office or elsewhere isn't going to generalize to that natural setting where it should be used we would be better off thinking of ourselves not as therapists but as Engineers how do I design environments that are problematic for people with with ADHD so they can perform more effectively do what they know use the knowledge they have in that situation to be more successful how do we do that so that's a key concept here treatment must be at the point of performance medications work because they're in the brain and altering brain functioning at those points of performance and when the medication goes away the control they provide over executive functioning dissipates as well but while they are in the brain in the bloodstream ADHD medications do help to guide Behavior by knowledge and so they are point of performance treatments but so are Behavior therapies so are cognitive behavior therapies and other things that we can apply at key points of performance to help overcome these executive deficits now these executive deficits are neurological and largely genetic in origin and therefore using medications biological agents is justifiable in overcoming a biological problem there's nothing wrong with applying medication for physical medical neurological genetic difficulties that we may be suffering makes perfect sense so the idea that there's something reprehensible going on here when we recommend medication for this behavioral condition we're not papering over the problem often thought to be Parenting by the way we're not giving excuses we're not subduing the individual with a chemical straight jacket right the ADHD medications are forms of neuro genetic therapies that temporarily compensate for this disconnection between the knowledge brain and the performance brain but there are other things that we can do as well to help with that deficiency in knowledge guiding performance this performance disorder now some people raise their hand at this point and say but but but can't we directly train these executive functions well no so far the training that's been done through games apps EEG biof feedback and other cognitive means of trying to practice executive functioning don't generalize to the environment and my theory of ADHD and this concept of a performance problem helps to understand why when you train you teach you teach knowledge and skill it doesn't automatically translate from that over into using that information where it would have been important to do so everybody assumes that it does that if I teach you this stuff now you know it now you will use it my job is done well no it's not because you missed the point this is not a teaching disorder a knowledge disorder a skill Disorder so probably no we're not going to be able to directly train these executive functions at least not yet maybe someone will come up with a clever means of doing so as this slide shows there's actually a couple of studies by Kya rubia on doing functional MRI feedback to these executive parts of the brain to see if we can improve them so far she's having some degree of success but a small study lot of work needs to be done here before we would recommend that so essentially we're talking here about altering restructuring ing points of performance scaffolding if you want to call that what do I need to add into the environment to compensate for the problems the person is having there to help them show what they know behavior therapy is useful for ADHD for precisely this reason not because it's training in something new that you know a new skill or knowledge but that it is providing structure in order to prompt you to show what you know and continue to use it so behavior therapy provides artificial stimuli in the environment sticky notes cards reminders cues signs to substitute for the deficit in working memory and mental representations but behavior therapy also provides artificial consequences where we are sprinkling in consequences that don't ordin narly occur in these environments things such as points tokens Privileges Rewards or in the case of of the adult social accountability where we make ourselves accountable to others around us for what we are doing but those are artificial means of correcting for this performance problem as long as we put them there and keep them there they may be helpful but as you know the minute you start to remove them things go back to the way they were before and that requires that we understand something very important ADHD as I've said is not an informational disorder now there are certain disorders that are intellectual disability probably autism spectrum disorder and others learning disorders there those are skill and knowledge disorders so it makes sense that we would use behavior modification or behavior therapy in order to teach new skills with the Assumption then that when the person tries out the new skill in their natural setting the contingencies the rewards in that natural setting will provide the incentive to perform and sustain the behavior but that's not what's happening in ADHD as my other video on the topic says adhd's motivation deficit disorder in that case behavior therapy is providing artificial motivators in the environment to compensate for this problem with motivating ourselves when there aren't other rewards and consequences in the environment to do that instead so it is a way of compensating for the motivation deficit by sprinkling in these artificial consequences in the environment when they don't ordinarily belong there so behavior therapy is effective for ADHD because it addresses the motivational difficulties not because it teaches anything new maybe it does maybe the person could use that too but that's not the problem that their ADHD is creating instead ADHD creates the motivational and the performance problem what does that mean these behavioral techniques these accommodations the scaffolding and structure can be very helpful at improving performance but it also means that we can't get rid of them too quickly maybe we can thin them out a bit so that there's not as much needed particularly as children and teens get older but even in adulthood we can't remove them completely because they're compensatory devices they're not corrective devices that change the underlying problem cure it and then we can remove it and it's done it's not like an antibiotic where we cure the disease instead it's more like a ramp coming into a building for someone in a wheelchair we've provided an accommodation that allows them access so they can function more effectively and more typically and that's what these artificial means are doing for people with ADHD they are providing compensatory ways workarounds if you will for getting the job done done for using what we know for performing effectively in various situations in our lives so I hope that this concept of ADHD as a performance disorder was of value to you and that you can take it out and use it with your family with your children with teens with yourself if you have adult ADHD and understand that ADHD people know pretty much what other people know they are as intelligent as other people are are where the breakdown occurs is in translating that knowledge and intelligence into performance in everyday life thank you so much