Understanding ADHD and Executive Functioning

I set foot on this campus as a psychology major, having just left the United States Air Force at Seymour Johnson Air Force Base, and having just returned from Vietnam. So it was a real privilege for me to be able to come to this campus and receive all of its education and wisdom and support, because this truly is where my career in this profession began. I had wonderful mentors, not only in psychology, but I also did research at the medical school, particularly the Child Development Center. I also took courses not only in the sciences but also in statistics and so on here as well. So this was the formative stage of my career and I have a fondness for this place you would not believe. I also have a nephew who attends here who I'm hoping will have a chance to show up. Hi Jake, good to see you. Thanks so much. I told you he was here. Thanks Jake. I knew he would make it. What a guy. So it's good to be back home. I love this town, I love this campus, and it means a great deal to me to be back speaking again. Now, I do want to just mention that this is going to be a, hopefully, a very informative workshop or seminar. I am going to be covering theories, to some extent philosophy, in addition to that, clinical management and the implications of this view for ADHD. So this is a wide-ranging topic going anywhere from Covering faculty, the students, staff, patients, families, and so on. And hopefully there's enough in here that everyone will be able to get something out of this presentation that is meaningful for them. I want to first of all, of course, thank the Burnetts, myself, for sponsoring this program today. Thanks to their generosity, I would not be here otherwise. And certainly the various deans that you have heard about today as well. I won't recant all the names. but will or recount them, but thank Teresa for doing that. But most importantly, I want to thank Teresa Matlin for doing this program. She is the one who really contacted me, has been organizing this, and working with the staff at the Learning Center as well, has really pulled this off. It takes months to do something like this and to bring it together. And so our thanks to everyone that had a hand involved in that, my personal thanks as well. I have three missions today. The first is to teach you about ADHD. The second is to teach you about executive functioning, a term that is being used extensively today. Also about self-regulation and why these three ideas are related to each other and why ADHD really is EFDD, masquerading under the wrong name. And then most importantly, after the break, I will be talking about so what. What does it mean if we link all of these up into our view of ADHD? What is the take-home message? that you can take to the bank and use tomorrow in your practice or with your loved ones or with your students or in your classrooms? What does all of this mean for the evaluation and especially for the management of this disorder? And I hope to show you that there is great value added to our clinical care of these individuals by shifting to the executive and self-regulatory perspective about ADHD rather than continuing to view it as... an attention disorder. As Teresa and I have sometimes mentioned, ADHD suffers from a name that suggests it is insignificant. It doesn't rival autism and bipolar disorder and schizophrenia. It doesn't have the social cash that all of those have. I mean, after all, it's just an attention disorder. Just go to Starbucks and have a coffee and you'll get over it. And it turns out that ADHD actually, as I will show you, interferes with A human's principal means by which we survive on this planet. And that makes it an extraordinarily important disorder, as much or more so than the other disorders that I've mentioned. And that's my job, is to convince you of that today as well. So I have big fish to fry, many things on my plate. Hope to be able to get to all of them. When I last gave this lecture last week in Canada, someone said it's like sitting in front of a fire hydrant with the valve open. There is just so much information that is coming at you. Fortunately, this is going to be posted on the internet in due time for those of you who want to refresh your memory or send other people to it. And of course, you're able to download the slides. Just a word about the slides. Like any professor, I've been adjusting some of the content even up to this morning. And so they may not be exactly as you're downloading them off the internet, but they'll be pretty close, about 95% correct. I've got about three or four more slides. to this presentation as well. Now, because some of you will be asking for CME and CEU and educational credits, I am required to show you my sources of support for the prior year so that you can evaluate whether I have any conflict of interest with the content of this program. And you can see that I'm retired from the University of Massachusetts, but I'm not retired. I also have spoken a number of places in the previous year, and I do receive fees for that. I have a number of books. and online courses and videos and newsletters for which I receive royalties. And I do speak for the pharmaceutical industry from time to time and work with them as a consultant on their products in the ADHD marketplace. So there is my financial disclosure. I'm a busy guy, and at the end of the day, what it comes down to is if you want to know about this disorder, I will teach you. I will teach anyone, anywhere, anytime who asks, who wants to know about ADHD. And that is why I am here, thanks to Teresa and her colleagues. So let's begin, first of all, with just a very quick overview of what is ADHD, because I can't teach you about why it might be a disorder of executive abilities unless we start at the beginning with what is it? How do we view it right now? And then how does this begin to fit into this new way of thinking about ADHD that I've been arguing about now for well over a decade or more? If you're not familiar with ADHD, it's a developmental disorder of two psychological traits that are not emerging on time in the individual. That's important because ADHD is not a psychopathology. It is not a gross aberration in behavior like bipolar disorder where you can recognize it at any age by a set of symptoms. What separates ADHD from other individuals is a quantitative difference. There is a lag in the emergence of these very important... neuropsychological traits and so what distinguishes the disorder from other people is the degree of the lag the quantitative difference not the qualitative difference people with ADHD will hit the same milestones that other people meet for the most part they will not hit them at the same time at the same rate and when the parts of the brain that are responsible for these abilities eventually reaches its maturity which is in your early 30s that is where they will level off in their abilities. So that is not to say that they will outgrow the problem, some do, most do not. But it is to say that there is this developmental lag, a chronic delay in the rate at which these traits are emerging within these individuals. Now, these problems fall into two domains. The domain of inattention, after which the disorder is named, and the domain of inhibition, which gives rise to both the hyperactivity and the impulsive behavior. We know that these arise early. On average, at least half or more people have their symptoms by age seven, many in the preschool years. A few of them were recognized in utero by mothers who said that this was an unusually active little fetus. But on average, 98% by 16 years of age. That is to say that there is a small percentage of cases that do come on in adulthood, but it's very, very few. This is a childhood onset disorder for the most part. As you can see here, the disorder occurs across many places, not just one, but it can fluctuate dramatically based upon the context. So people with ADHD are not equally severe in all domains, on all tasks, everywhere, with all people. And that really causes a lot of consternation because if they can play video games for hours but spend only five minutes on their homework, it makes it sound like it's a willful form of disobedience, as if this person has the ability, has the talent, and is just choosing to play video games. not to behave that way. But that distinction between video games and work, especially work for which there is no immediate consequence, tells someone like myself that there is a profound disturbance within the brain's executive system. Because that is what explains the difference across these situations. Whereas if you didn't know that, you would start to blame the child for willfully disobeying you, or just not caring, or having some sort of a moral failure, or just being lazy, and so on. Many of the pejorative terms that have been used. for these individuals. So it occurs across many places but not everywhere. And most importantly, to be a disorderer, and this is what separates normal from abnormal, from non-disordered to disordered, what separates them is there must be impairment in major life activities. It has to be interfering with adaptive behavior, self-care, family functioning, peer relationships, educational functioning, and then as we grow up, our relationships within the community. Our ability to manage money, to drive, to raise our children, to enter into long-term relationships with other people, our occupational functioning. All of these are major life activities and ADHD needs to lead to impairment in one or more of these before it's a disorder. So having a high number of symptoms alone just makes you a sparkling personality. What turns that into a disorder is that your sparklingness is a little too much so and it is leading to impairment in areas where other people are not impaired. And that's the line when something becomes a disorder, the line of impairment. And now, as you will see here, we also try to rule out other disorders because many other disorders produce deficits in attention. If someone comes into our clinic and says, I can't concentrate, we don't know what they have. Every disorder at one time or another, in one way or another, interferes with the six different circuits in the brain that gives rise to the six different kinds of attention that we possess. So ADHD is not the only disorder of attention. But it is a relatively unique disorder in the kind of inattention that it produces. So let me explain. First of all, ADHD starts out in early childhood as a problem in the area of inhibition. The attention problems don't show up for two to four more years. But the problem with impulsiveness starts out very early. This is where the hyperactivity and the restlessness are coming from. There is a problem with inhibiting the motor part of the brain. And therefore it is just on go all the time. That leads to the fidgeting, the hyperactivity, the restless, the squirming. It also leads to the verbal impulsiveness, the talkativeness, the interrupting others and so on. In addition to that there is a cognitive impulsiveness. They don't stop to think about things before they act. They don't stop to consider what will happen later if I behave this way now. So there's a cognitive and a decision-making impulsiveness. associated with the disorder. And that leads to a steep discounting of future consequences. What that means is that they don't value the future to the extent that other people of their age would do so. They live in the moment, the now that all that matters, it's all that drives them, it's all that counts, and what comes next is of far less value to them in their decision making. And so we look at them as individuals who basically are stuck in the now. in terms of what matters to them, what is controlling them, and how they're making their decisions. Now, they are also very prone to distraction, but the distractibility is not a perceptual problem. It's not like the hear and see distracting events more than others. The difference is they react to them when other people ignore them. It's a problem of inhibition, so that when they hear the noise or the sound or see the bird fly by the classroom window, the difference between them and us is they get up and talk about it. And the rest of us ignore it and go on with our work. So there was a problem with distraction, but it is an inhibitory problem, not a perceptual problem. And then there was a set of symptoms that nobody talks about until the past couple of years, but was always associated with ADHD, back to the first paper on ADHD in a medical textbook in 1775 in Germany. Believe it or not, Melchior Weichert is the first person to describe this disorder. It's been around for well over 200 years in the medical literature. This is not some Johnny-come-lately disorder. And we have over 10,000 research papers on this disorder as well. But one of the things that we haven't spoken about since the 1960s, but now that we are coming back to, is that ADHD is just as much a disorder of emotion as it is of hyperactivity, inhibition, distraction, and concentration. People with ADHD are very impulsive in displaying their emotions so that their emotions come up too quickly, too raw, too unmoderated. And as a result of that, they are often accused of being socially and emotionally immature. Now, this is not a mood disorder. Their moods are not irrational. It's simply a disorder in which they can't regulate the emotions like other people can. The top-down executive control over normal emotion just isn't there to the degree that it should be. be. Now the reason that we are so convinced that emotion needs to be put back into ADHD is because this set of symptoms accounts for many of the impairments that can't be explained by the more traditional symptoms of the disorder. Not the least of which is it's the single best predictor of why you have no friends. Other people can forgive you your restless behavior, your fidgeting, your distractibility, your fizziness, you're disrupting them. But what they don't forgive is anger and frustration and hostility and reactive aggression. So that when things provoke you and upset you, if you have ADHD, your emotions are up and out and the damage is done before you've had a chance to get any traction. over-moderating this and bringing your emotions to be more consistent with the situation and with your long-term welfare. So we are now realizing, and many papers have been written this year making this case, that ADHD is just as much a problem with impulsive emotion as it is with impulsive behavior, impulsive cognition, and impulsive speech. And it explains a lot about these individuals, not the least of which is, of course, their social difficulties. But it's also one of the best predictors. of their driving problems, their financial problems, their marital problems, their child-rearing problems. And it's one of the main reasons why they will be fired from a job four times more often than other people are likely to do. You don't get fired because you're distractible, but you will get fired if you are angry with the customers and if you will blow up and are impatient and are easily frustrated. So this is a domain of ADHD that is underappreciated but is now being put back into our models and theories and explanations. of the disorder. Now one final caveat before moving on. The hyperactivity declines so steeply with age that by late adolescence and certainly by adulthood, it is of no diagnostic value whatsoever. Adults with ADHD are not hyperactive. They feel internally like they are. They feel a need to be busy and restless and doing multiple projects. They often say that they're good at multitasking. Well, you are if you finish the things you start, but they don't finish anything. And so this is not... Multitasking. You know, this is distractibility, but they are not climbing on furniture, sliding down banisters, and doing all of the other gross motor hyperactivity that we see in the young children. So please pay attention to that. Adults with ADHD are not hyperactive. Now, the inattention domain is much, much more than inattention. But let's start with the inattentiveness. First of all, you need to understand that there are six different kinds of attention in your brain. And ADHD does not cut a wide swath through all of them. It is particularly salient in one area that other disorders are much less likely to have their impact on. And that is persistence toward the future. There is a very special kind of attention, you call it sustained attention, but it is persistence toward the future, toward goals, toward tasks, toward what is coming up or what I need to be doing. It is attention to the later. in your life, not the now. People with ADHD attend to the now just fine, but as you get older, you spend more and more of your time looking ahead and preparing for what is coming next and setting your own goals or following up on the tasks and goals and assignments given to you by other important people in your life. And so what ADHD disrupts is persistence over time toward that future. It is the only future directed form of inattention that we see. And that is how we can diagnose it from schizophrenia and anxiety disorders and panic attacks and depression. All of which interfere with attention but not in this way. So this is a problem with sustaining action over time toward your goals and the future more generally. Now the ability to persist is coupled with the ability to resist reacting to irrelevant events. I've already spoken about that. It's an inhibitory problem. That's the source of the distractibility. So that they are very prone to being easily distracted by irrelevant events that have nothing to do with the goal, the task, or the future at hand. And this is what captures their behavior and leads them off task and gets them skipping from one uncompleted activity to another, is this problem with impulsive responding to irrelevant events. Now, there is an interesting problem coupled with that, and it has nothing to do with attention. All of us occasionally get distracted by things we didn't plan on. And we have to stop what we're doing and attend to those things. There are important interruptions that take place in your day. But what you do is once you've dealt with the interruption, you return to the task at hand, the incompleted goal. The future that lies before you recaptures your behavior. That doesn't happen with people with ADHD. Once distracted, they do not re-engage the incompleted goal. They are off on a tangent. from one to another to another. So that that is where the now, so to speak, is pulling them along by the nose when you and I get back to the work we had planned to do. The goals, the assignments, the instructions, and so on. Now this problem with task re-engagement has nothing to do with attention. It is the most important feature of what is called working memory. Working memory is one of the big seven executive functions. Working memory is consciously holding in mind What your goal is, how you plan to get there, and what progress you are making toward that goal. Memory put to work, or as I explain it to patients, remembering to do. This is not memory. This is not storage and retrieval of facts and knowledge. This is remembering what you're doing. What was the goal? What was the plan? How far along that road am I to accomplishing that goal? And that governs your behavior. That's what takes over from the now, is what you should be doing. It's what you start to lose in your 50s. At my age, I'm 63 or will be shortly, it's what women lose even more when they hit perimenopause. So what you are losing is your working memory. You don't forget information. You forget what you were doing. You walk into a room, something distracts you, and now you can't remember why you entered the room. So having ADHD is like aging times 100, or being little menopausal women, however you want to think about it. So what they are impaired in is memory put to work, remembering to do. So if they are forgetful during the day, it's not knowledge they're forgetting. It's what they're supposed to be doing, where they're supposed to be going, what calls to them by way of their goals and their tasks and so on. So that's your disorder, but you can see that it's much more than a disorder of attention. The fact that working memory is involved in this and that inhibition is involved in this, Those are two of the seven big executive functions given to you by this massive frontal lobe in your brain. And that opens the door to the possibility that ADHD is EFDD. And the question then is, are the other five also impaired? Is this a very focal disorder of executive ability, hitting only working memory, or working memory and inhibition, as some people have argued? Or does it hit... All of them. Is it a pervasive disorder? Now to answer that question, we're going to have to take a detour into executive functioning. And we're going to have to talk about what that happens to be. Now before I do that, I did want to give you a slide in your handout that does talk about the prevalence of the disorder, how common it is, and so forth. But my time is so precious today that I don't wish to waste it with well-known facts and figures that are out there and easily available to you. But just in passing, you should know this is a very prevalent disorder. that it's about 7.5% of children and nearly 5.5% of adults have this disorder. It is universal. It is worldwide. It is seen in all countries ever studied. It's not just a U.S. disorder, as some critics have argued, but it is not evenly spread across the populations. Three times more common in boys than girls, but that sex difference disappears by adulthood when it is equally common in men and women. We don't know why the gender difference dissipates, but it does. We also know that it's more common in lower middle class families. It's more common in population dense than rural areas. It's also more common in children in the military and the children of other professions like the performing arts and music and door-to-door sales and athletes. The reason for all of those differences is this is where adults with ADHD tend to go as they grow up. And because ADHD is the most genetically influenced psychiatric disorder we know of, rivaled only by autism and bipolar disorder, and far more prevalent than either of those disorders. If you have ADHD and you're an adult and you start self-selecting into certain careers because that's where you tend to function a little better, like the military, well, guess what? More of your children are going to have the same disorder that you had by virtue of the genetics alone. So there's nothing unique to athletics or the military. It has to do with where people with ADHD are likely to find themselves functioning with less impairment than they would had they chosen some other occupation like law or science or medicine or technology. It doesn't mean they can't go into those professions. It just means that they are far less likely to be in them than are other people in the general population. Now, back to the question I was raising. Is ADHD EFDD? To answer that, we have to talk about EF, what it is. But I can assure you that ADHD has to be. EFDD. We could stop the lecture right here. The neuroanatomy of ADHD is the neuroanatomy of the executive brain. The executive brain, as Karl Pribram first coined the term, is what the frontal lobes do. And although he didn't go on to particularly define what he meant by executive functioning, he gets credit as the first person to coin the term. But what he was trying to do is describe why primates, and especially humans, have this massive frontal lobe to their brain. And the history of that goes back another hundred years or more. to the middle 1800s, efforts to study what do parts of the brain do, what does the frontal lobe do. The term executive functioning just sneaks in as one possible description for these activities of this executive brain. We know that there are at least five structures involved in the executive brain. We know that they form three executive networks, and we know that ADHD interferes with all three. to varying degrees. So clinicians and parents, one of the reasons you see such heterogeneity in ADHD is it depends on which of these circuits has been hit the most. They're all affected, but not all to the same degree in each person who possesses the disorder. Now the first circuit, and I'm not going to spend much time on this, and I do have a diagram for you, so you know we'll get there, okay? I don't want to make it sound too complicated here, but the first network is the what. network of the brain and that is from the outside of the frontal lobe the dorsolateral surface back into a structure deep in the brain called the basal ganglia let me just bring it up here for a moment excuse me this slide usually takes a little encouragement to move on deep inside the brain is the basal ganglia right so we're talking about the outside surface of the frontal lobe which is over here looks like my Laser pointer is gone. Over here, the outside surface, back through the center of the brain to that structure. That is called the what network because that is where what you hold in mind, working memory, is going to guide what you do, your motor system. So this part of the brain is now suppressing that structure so that other signals in the brain don't get out and don't distract you. And then it is going to use your thoughts, your mental representations, to guide that motor behavior toward what your goals are. The future is taking over your brain in that sense. What I think controls what I do. By the way, that's a miraculous process. How can this ephemeral mental event actually come into the real world and guide your behavior around through it? It's kind of like a Garmin GPS. It's exactly how it works. So that is our what network. Now let me just back up if I can. Oh, don't tell me this thing is great. Well, I may need you to replace these batteries if you would please. Do you have any double A's or triple A's? Okay, great. Oh, there it is. It's back again. All right, if you'll get those batteries, let's see if I'm going to need them. The second network to continue is the WEN network, the timing network. This one surprises people because it's not often talked about in relationship to ADHD unless you read some of my books or you happen to be familiar with the frontal lobes. This is the WEN network. It goes from the same outside surface of the frontal lobe back through that basal ganglia and now to the cerebellum, the old ancient brain at the back part of the brain. We often think of the cerebellum as... important for the grace and the movement and the timeliness of our actions, like in gymnastics or dance, or just the general fluidity of our behavior. But the cerebellum is also just as important for the grace and the timing of our thoughts, not just our actions. It's as much involved in higher cognitive activity as is the frontal lobe. Indeed, an injury to the cerebellum can sometimes mimic a frontal lobe injury. causing neurologists difficulty in finding out where is the problem. This is the timing circuit of the brain. We call it the when network. And it explains why ADHD is the worst disorder when it comes to time management. There is no disorder as bad as this one, four to five times worse than any other disorder we have seen in terms of its interference with the timing and the timeliness of one's actions. Indeed, it eviscerates your sense of time itself, which is why people with the disorder are adrift in time and can't deal, as well as others, with this invisible dimension of our lives that becomes increasingly important as we grow older. Three-year-olds don't have to be timely. Thirty-year-olds do, or they get fired. So of all of the deficits, this will be the most devastating, and it is also the most impaired. Now, the third... circuit of the brain is the hot circuit known as the Y circuit. Again, we go from the frontal lobe to the midline of the frontal lobe and then to the amygdala right here. This is the emotion regulating circuit. That's why it's called the hot circuit. This is where the problems with emotional self-regulation are coming from. The executive that sits over top of your emotional brain, which is your limbic system, is out to lunch, checked out, gone, leaving your emotional brain to just spew normal emotions. But they're not normal because people of your age would have been moderating them and suppressing them and doing things to make them more consistent with the moment, other people, the goal that I have at hand, my general long-term welfare. So this is where you get the impulsive emotions from, the impatience, the frustration, the quickness to anger, the easily aroused, the easily excitable, the overreacting to events, and indeed in a subset of people, the reactive aggression. People with ADHD aren't predatory. They're not psychopathic. They're not out there raping and pillaging our community with a plan. But if you provoke them, they will respond very quickly, more than other people, with these negative, frustrative, hostile forms of emotion. Thank you so much. I appreciate that. Thanks, Tristan. So, we have three circuits made up of five brain areas, which we know are not functioning well in these individuals. And that creates a range of symptoms and differences among people and how much these circuits are impaired. So the heterogeneity is part of that. But all five of these form the executive brain. We know that they are 3 to 10% smaller in people with this disorder. That is so small that you would not recognize it on an individual MRI, which is why you will not see neuroimaging be useful for diagnosis, not yet. Because you couldn't visually tell an ADHD from a normal brain looking at one person's scan. But if I take 100 of those scans and I average them together and compare them to 100 scans of typical people, now the difference has become apparent. More importantly, these parts of the brain are at least two to three years behind in their development. So there is a developmental lag. And if you want to see a beautiful video diagram of this maturational lag, You can go to the NIMH website and you can search for Philip Shaw's longitudinal study of ADHD. And they have up there a short video showing the development of the ADHD brain. Why? Because they studied it. They neuro-image ADHD children every year to two years for ten years. And that allows them to compute and demonstrate the degree of this lag. It's very impressive. It's an excellent teaching tool, by the way, as well. Now, so we know it's smaller. We know it's two to three years behind in its development, but most importantly, it's underactive. These five areas of the brain are between 10 and 25% less active than they should be for someone of your age. So it's the activity in the area more than the size of the area that is the most telling about ADHD as a frontal lobe disorder. So we could stop there. We know ADHD is in the brain. We know it's in the executive brain. We know the five structures it implicates. We know what's happening within them and why they're not doing the job they're supposed to do. So, case closed. ADHD has to be EFDD. And then you pick up a journal, a review paper, a textbook, and it says it isn't. Only a subset of people with ADHD have executive deficits. And it's the minority. And therefore, ADHD can't be EFDD. And you get yourself into a real logical quandary here, because according to the neuroanatomy, it has to be. But according to the neuropsychology evidence, it isn't. And we have a disparity. And that's where the fight is going on right now in the literature. I know I am in the thick of it. But as we get started, I'm going to sort of give away some of my thunder for the end of the presentation, just to kind of set the stage here. How would ADHD fit into the neuropsychology of executive functioning, if I'm going to convince you that it does? Where does all of that fit in? Well, that's very easy. Because you see, it turns out that executive functioning is one thing. When we do statistical procedures called factor analysis, we take all of these various measures of executive functioning, we toss them into a computer, and the computer looks for underlying dimensions in these multiple tests, we get one factor, one dimension. Just like when we analyze intelligence tests. We get one factor called G for general intelligence. And we get one factor here. But just as in intelligence, we can break it down into two narrower bands, highly correlated with each other, all coming under the mothership here of this overlying executive dimension, but worth separating into two dimensions to get a little value added to our understanding. Just as we can separate intelligence into verbal, and nonverbal, known as visual-spatial, we can separate executive functioning into inhibition and metacognition. Now, as with intelligence tests, we can take these broad bands and subdivide them into narrower bands, all of which are highly correlated, all of which are part of the mothership up here, but some value in distinguishing among them for our purposes. Inhibition, as I've said, is four things. Problems with impulsiveness affect all of those domains. But metacognition, which most people don't understand, refers to these abilities, including, most importantly, something not on here, which is my mistake, self-awareness. So, we have two broad bands of executive abilities. And now you're going to start to see where ADHD fits in. Because the hyperactive impulsive symptoms of ADHD are just a subset of these. You're just calling it by a different name. And the inattention is not inattention. It's metacognition. You've labeled it with the wrong label. The list of symptoms in the DSM and that you read about in parents'books is not inattention. That is a minor part of what this does. It is those metacognitive abilities. Self-awareness, nonverbal working memory, verbal working memory, planning, problem solving, and emotional self-regulation. So ADHD is going to map right into these two broad bands. We have just given them, by mistake, the wrong name. So at the end of this lecture, that is where I hope to show you. I'm not inventing a new way of structuring ADHD. I'm inventing a new way to describe what you already know. You're just using the wrong term to describe the deficit. But in relabeling these terms to their more appropriate labels, you can see that ADHD is a much wider swath of impairments in brain functioning than the term attention can capture. ADHD is the Rodney Dangerfield of psychiatry. It gets no respect. And part of that is it's got this silly name, right? Nobody thinks attention is all that important, not like mood or depression or mania for God's sake, not to mention hallucinations and delusions. Oh my God, lions and tigers and bears, oh my. So it's just this little poor stepchild over here in attention. Just get some sleep, have some coffee, and you'll be fine. Well, we're telling you that it is two of the most important domains of human mental activity are the areas that ADHD eviscerates. And that makes it an extraordinarily important disorder. And it also explains why in 2008, when my colleagues and I reviewed everything we know about ADHD in adults and outcome studies of children followed to adulthood, my book Outside, where we concluded in the last chapter, this is the most impairing disorder you see on an outpatient basis. You would have to go to an inpatient unit to find disorders that are more impairing than this one. Schizophrenia, of course. But compared to anxiety, depression, LD, language problems, mild mental retardation, high functioning, autism or Asperger's, they don't hold a candle to this one. This is the bad guy because it undercuts every major life activity. There is no domain of life that we have studied in adults with ADHD that this disorder does not adversely affect. None. So that is why we can say this is a serious disorder. And the public needs to take it seriously. And it needs to take it more seriously that we take anxiety and depression, for which we are giving away antidepressants and anxiolytics like they were candy. I mean, half the women I know are on anxiety drugs, and a lot of the guys I know are taking antidepressants, sometimes just to improve their personalities. Prozac Nation, you remember that? Viagra is not the only drug people are using who don't need it. We are also using psychiatric drugs for that reason. Performance enhancement. I have drifted away. My medication is growing thin. Okay, so now let's come in and take a look at how could these reviews of the literature reach such conclusions that are so far afield from what we know clinically and what we know about the neuroanatomy of the disorder. And to explain that, we've got to go into executive functioning. So hold onto your seats, ladies and gentlemen. Here we go. This is going to be a theoretical romp through the literature, of which there are thousands of articles. I can tell you, EF is one of the most commonly used. Indeed, it's become a fashion trend. We have books for teachers on executive functioning, books for parents on executive functioning, and so on, as if we really know what this is. The problem is, we don't. Wink, wink, we don't know what this is. There are more than 30 definitions of executive functioning. So to find out what you mean, I've got to read your paper very closely to the point where you tell me what you think it is. But it's not the same as what somebody else said it was, and it's not the same as other people as well. So we're all just sort of pointing at each other. Well, he said it was this, and she said it was that, and they said it was that. So that's what it is. Well, that's not science, right? If it is, it's science by vote, not by evidence. So we do not have a definition, a specific operational definition of this very popular term. And that's going to hold back our science. The second problem that we have is that people have said that this term is really an umbrella, a tent. a mothership under which we can put these very specific components of executive functioning. And people have labeled up to 33 of these different components in this tent. That's impossible. The minute you start getting up to this number, you can explain anything. I can ask you by rights, what mental faculty is not executive in nature? I mean, by God, you got most of them up here already. So what is it? Well, if you don't have a definition, then anything goes. And that's what's going on right here. Just about anything you wish to declare as an executive ability, nobody can challenge you. It's in the tent. The third problem, which is related to the other two, is we have no theory. There is absolutely no accepted theory explaining what is an executive function, how many are there, and what do they do. You see, See, theories aren't just descriptions. They explain how something works. They're the mechanism. They show us how these parts are related to each other, why they go together, how they sequence each other, what they do, what's important about them. Theories are very, very important because they give us that deep insight into our disorder. And when you have that, you can start to treat it better. If you don't have a theory, then treatment is just chance, just luck. So we don't have a theory of ADHD. And the most important thing is a theory tells you, why do you have this? And that's where we start to get into evolutionary biology. And why has this part of the brain become so unique in humans? Because you don't need this part of the brain to live on this planet. Virtually all other species have done just fine. Alligators on my golf course in Charleston have been around millions of years longer than you and I have been on this planet. They're doing just fine. Thank you. They don't have a frontal lobe, they don't need one. So there's nothing about the physical world that requires a frontal lobe. And that is why you don't see it very often. So we have to look at humans and say, what is it that humans do that is so special, so unique, that they require this massive expansion in the front part of the brain? And the answer to that is that we live in groups. with other people with whom we are not related. And that is a rarity. So rare, in fact, there are probably fewer than five other species that do that. In all other species that live in groups, they're genetic relatives. Indeed, like wasps or ants or termites, they're virtual clones of each other. So it's easy for cooperation to arise genetically when you're genetically related to people. It's not easy to explain reciprocity. cooperation and group living when you're doing it with people with whom you share no genes. That is so rare in biology that it requires a special explanation, and it is so rare in psychology that it requires a special brain. And as Diamond pointed out in 1980, this is the seat of social intelligence. And that's what makes it so important. But now we have to prove that. So, we need a theory of the why of executive functioning. And if we get that... We can then go back and have a definition and have a look at the pieces that should be there, what components should belong and what shouldn't. Now, these three problems have led to a fourth one. And it's the one I think that most directly impacts clinicians and families and patients. Because if you don't have a theory, then you don't know what to assess. And if you don't know what to assess, then anything goes in assessment. Any tool, any device, any preferred little set of methods. can be declared as executive in nature, and you get away with it. And most importantly, what's happened over the past 20 years, is we've seen a battery of cognitive tests developed and marketed as executive function measures. Well, that would be fine if we knew what executive functioning was, then we would know what we're measuring. But because we don't have a definition, we don't know what we're measuring, and I can invent any damn test I want to, and you can't challenge it. I've done it, by the way. Now, here's the most important point. Over the past 10 years, 15 perhaps, but 10 certainly, we have learned something startling, surprising, and devastating about these tests that are ubiquitous in our life. Every day, thousands of people in the U.S. have their lives determined by these test batteries. Whether they get Social Security, whether they get ADA accommodations in college, or under the Americans with Disabilities Act in their workplace, whether children get special education. whether you are going to have your sentence commuted or amended because of a crime, whether you're going to get an insurance settlement because of a car accident, whether or not you're going to get veterans disability benefits from a traumatic brain injury in the Veterans Administration. They're all, every one of them, decided by these test batteries. And here is the most shocking thing of all. These tests cannot do what they say they do. And we now know that for a fact. These tests are not reliable. They have very poor norms in the population, and the most important thing, they don't correlate with anything important in modern life. Nothing. If executive functioning is crucial to human survival, if it underlies every major life activity in which we must engage, then executive function tests should be correlated with all of that. Education, workplace, child rearing, driving, money management, and so on. It's not correlated with any of them. We can go out and have people directly observe your executive behavior in daily life and record them. Or we can have your relatives fill out rating scales of executive functioning about you. And guess what? The tests don't predict them either. There is no correlation between a battery of tests and a rating scale that is supposed to measure the same construct. Zero. We have a problem, ladies and gentlemen. We have a construct being assessed by a battery of tests. that can't assess the construct. That is reprehensible. It means we are making decisions, important decisions, about the lives of people, what they can and can't get, what entitlements, what protections, on the basis of batteries of tests that have been oversold, over-marketed, and can't do what they are supposed to do. And this explains... the fight that's going on in the literature. Because 99% of all research on executive functioning uses these tests. And if you give these tests, the vast majority of people with ADHD pass them. What would that lead you to say? No executive deficits here. ADHD can't be EFDD because our gold standard, gold-plated tests say so. And no one stopped. to question the premise. Can the tests measure what they're supposed to measure? And the answer seems to be, no. So here's the paradox. ADHD is a disorder of the frontal lobe. Hands down, fact in the bag, know it's there, know where it is, what it is, how delayed it is, what structures it is, right down to the single nerve cells. What is going on? It's got to be EFDD. But we give these test batteries, and on average, 35% of the children and adults fail them. Two-thirds of them pass the test. They don't have EFDD. Oh, but hold on a second. Then we have your parents and teachers and your loved ones and your husbands and your wives and other people who know you well fill out rating scales that measure executive functioning as you use it out there in daily life. And all of you have a disorder. Every person with ADHD fails these rating scales. What the heck is going on here? You pass the test, you fail the scale. And so people started blaming the rating scales right away. Oh, that's subjective. Oh, that's your mother. Oh, your teacher doesn't know what the heck she's saying. Oh, that's your self-report, and we know what you have. Oh, you're malingering. You're like one in four college students who's coming in for our disability services evaluation. By the way, malingering is at its highest on college campuses. Feigning ADHD. People want those accommodations. They want those drugs, even if they have no disorder. So if you're working on a college campus, you're going to see more malingering than anybody else anywhere in clinical practice. Doesn't mean that people with ADHD aren't there. Just means that probably one in five of them doesn't really have that disorder. But that's not the point. The point is here. It's a universal disorder of executive functioning on the rating scales. It isn't on the tests. And if you buy the tests, which nearly all of my colleagues have, you reach the wrong conclusion. If you buy the observations and the rating scales, you reach the right conclusion. This is EFDD, because the tests, as I've said, predict nothing. No correlation with the ratings, no correlation with the observations, no correlation with many areas of domains of impairment. So the tests and the ratings are not measuring the same thing. So how do we know which one we should use? Which? one predicts your life, which one tells me how well or how poorly you are likely to do in school, in work, in relationships, driving a car, managing your money. It's all the rating scales. The rating scales predict impairment five times more, in some cases ten times more, than any test or test battery. Cheap, easy, flimsy little rating scale data turns out to be the best. And this hurts, because my neuropsychological colleagues were all trained in test batteries. That's how they make their living. $1,000 to $2,000 per shot. Come on in, I'll test your executive functioning, I'll make conclusions about your life. No wonder they're so upset. No wonder my name is being pilloried on the list serves for these major professions. It can't be true. What Russ is saying, no, no, it can't be. Well, I get some value out of these tests. Well, okay, big shot, prove it. Show me the articles. Show me the publications. Every single publication on this topic reaches the same conclusion that I just did. But they won't let go of the tests. Not yet. They still think there's something about the tests that's good. I don't know. We'll see. But we have a problem on your hands. This is just a study. I'll show it to you very quickly. This is my study of adults with ADHD. This is the rating scale of executive functioning. Virtually all of them are impaired. This is the test battery we gave. None of them are impaired. You see the disparity? It's not even close. It's not just this study. Here's another one. This is my 30-year longitudinal study in Milwaukee. I've actually been following children since 1978 in southeastern Wisconsin. Same rating scale. Everybody who's ADHD persisted to age 27. And there's the test battery. Same thing. On the test, virtually nobody's impaired. On the rating scales, virtually everybody who's ADHD lasted to adulthood is impaired. And the level of impairment is as bad as it is in their ADHD symptoms. Something's got to give here, people. These two areas of literature just do not talk to each other, do not agree with each other. So what's the best method? Well, as I've told you, and I'll skip over these data, but the scientists in the audience are going to want to have it. In virtually every study that we have looked at, the rating scales outpredict the tests, massively outpredict the tests. If I was going to evaluate somebody's executive functioning, I'd give them a 10-minute rating scale. Done. And then I'd have somebody who knows them well fill out another copy. And it's not because they're necessarily going to exaggerate. People with ADHD actually do the opposite. They tend to under-report their symptoms compared to other people who know them well, on average, at least until they're 30. So what's the problem here? Why this disparity? Why don't the tests do what they're supposed to do? And to answer that, I'm going to go back to the first and classic case of a frontal lobe injury in the literature, good old Phineas Gage. You've heard of this guy, I imagine? If not, you should have. If you're in psychology, you damn well better have. Phineas was a railroad foreman who had drilled a hole in a boulder, stuffed it with powdered TNT, dynamite, and then what you do is you take this metal rod and you tap on it gently to compact the powder. But you've got to be careful. because the rod is metal, and if it sparks, it blows up. And that's what it did. It drove that rod right up through his frontal lobe, and there is a beautiful description by Harlow, the physician who treated him. of what he was like before and after this massive frontal lobe injury. I'll get rid of it so as not to gross the ladies out anymore. By the way, that photo was discovered about 60 years later in someone's attic. It's the one and only photo of Phineas after the event, which explains why he's holding the rod. Nobody could figure out who the heck that was. It took a neurologist at Harvard to say, you know who I think that is. There's only one guy with a damping rod that I know of. That's him. Before the accident, Phineas was one of the most responsible people ever hired by this railroad. And they say so when they were interviewed. After the injury, he became one of the most impulsive individuals prone to his animal propensities, as Harlow so well described it. And you can read through here all of the various problems that he had. Suffice to say that what Phineas had was a problem in many areas of life. A problem with his social relationships, a problem with his inhibition and self-restraint, with his emotions and his drive, particularly his sexual misconduct, difficulties with ethical and moral behavior, and, of course, difficulties managing money, holding a job, being responsible, caring for himself. He had to move in with his sister, actually, for a while. Wound up at the end of his life driving a stagecoach in Brazil. I want you to look at these deficits. That's what Phineas suffered from. Then he comes into a clinic in modern life, and these are the tests we give him, right? So he loses these, we give him these, right? He loses some very important domains of human life, and we make him do digit span backwards. Over the past 20 years, neuropsychology has drifted ever more. toward the assessment of cold cognition, intellectual information. None of these tests, not a one of them, assesses any of these. But this is what he lost. And now you know why the tests don't pick up frontal lobe injuries or executive deficits. They are pure, cold, academic, intellectual, short-term, asocial, unemotional cognition. Who the heck cares whether you can sort cards into categories? Is that a major function of daily life? Do I really care whether you can spot an X from an O and push a button on a computer? Or whether you can do digit span backwards? Oh, that's a really important domain of adult functioning. But that's the test that you drag out to assess people like Phineas. It is no wonder that you have missed the boat entirely. Now rating scales, on the other hand, assess five major dimensions of adult functioning. So this is what we get off the rating scales, that is what we get off the tests. So what you can see here then is why the rating scales are so much better at picking up the deficits than the tests are. They are at least making an effort to pick up many of these domains of functioning. Emotion, social functioning, self-restraint. organization, planning, anticipation, problem solving, time management. Those are very important mental faculties, but not digits spanned backward. So what's wrong with the tests? They cannot capture executive functioning the way it plays out in modern life. They don't have emotion, they don't have social purposes, they're very short term. I mean the purpose of the frontal lobe is to anticipate the future. You've got to plan a wedding. I'm only going to give you a 15 minute test. How on earth does a test that takes only 15 minutes assess your ability to plan out over hours and days and weeks and months of your life? It can't. Hence, that's another drawback among the many drawbacks. So, you can now see why the rating scales beat the tests. So, when you come back from your coffee break, we're going to talk about how do we resolve this disparity. Can we save the tests at all? Should we just throw them in the trash bin and walk away from them? Or is there a way of thinking about executive functioning where they might continue to have a role, albeit a very narrow, limited role? I'll answer that question after your coffee break. Thank you. Thank you. Started a little late, so...

I also took courses not only in the sciences but also in statistics and so on here as well. So this was the formative stage of my career and I have a fondness for this place you would not believe. I also have a nephew who attends here who I'm hoping will have a chance to show up. Hi Jake, good to see you.

Thanks so much. I told you he was here. Thanks Jake. I knew he would make it.

What a guy. So it's good to be back home. I love this town, I love this campus, and it means a great deal to me to be back speaking again. Now, I do want to just mention that this is going to be a, hopefully, a very informative workshop or seminar.

I am going to be covering theories, to some extent philosophy, in addition to that, clinical management and the implications of this view for ADHD. So this is a wide-ranging topic going anywhere from Covering faculty, the students, staff, patients, families, and so on. And hopefully there's enough in here that everyone will be able to get something out of this presentation that is meaningful for them. I want to first of all, of course, thank the Burnetts, myself, for sponsoring this program today. Thanks to their generosity, I would not be here otherwise.

And certainly the various deans that you have heard about today as well. I won't recant all the names. but will or recount them, but thank Teresa for doing that. But most importantly, I want to thank Teresa Matlin for doing this program. She is the one who really contacted me, has been organizing this, and working with the staff at the Learning Center as well, has really pulled this off.

It takes months to do something like this and to bring it together. And so our thanks to everyone that had a hand involved in that, my personal thanks as well. I have three missions today. The first is to teach you about ADHD. The second is to teach you about executive functioning, a term that is being used extensively today.

Also about self-regulation and why these three ideas are related to each other and why ADHD really is EFDD, masquerading under the wrong name. And then most importantly, after the break, I will be talking about so what. What does it mean if we link all of these up into our view of ADHD? What is the take-home message?

that you can take to the bank and use tomorrow in your practice or with your loved ones or with your students or in your classrooms? What does all of this mean for the evaluation and especially for the management of this disorder? And I hope to show you that there is great value added to our clinical care of these individuals by shifting to the executive and self-regulatory perspective about ADHD rather than continuing to view it as...

an attention disorder. As Teresa and I have sometimes mentioned, ADHD suffers from a name that suggests it is insignificant. It doesn't rival autism and bipolar disorder and schizophrenia. It doesn't have the social cash that all of those have.

I mean, after all, it's just an attention disorder. Just go to Starbucks and have a coffee and you'll get over it. And it turns out that ADHD actually, as I will show you, interferes with A human's principal means by which we survive on this planet.

And that makes it an extraordinarily important disorder, as much or more so than the other disorders that I've mentioned. And that's my job, is to convince you of that today as well. So I have big fish to fry, many things on my plate.

Hope to be able to get to all of them. When I last gave this lecture last week in Canada, someone said it's like sitting in front of a fire hydrant with the valve open. There is just so much information that is coming at you.

Fortunately, this is going to be posted on the internet in due time for those of you who want to refresh your memory or send other people to it. And of course, you're able to download the slides. Just a word about the slides. Like any professor, I've been adjusting some of the content even up to this morning.

And so they may not be exactly as you're downloading them off the internet, but they'll be pretty close, about 95% correct. I've got about three or four more slides. to this presentation as well. Now, because some of you will be asking for CME and CEU and educational credits, I am required to show you my sources of support for the prior year so that you can evaluate whether I have any conflict of interest with the content of this program.

And you can see that I'm retired from the University of Massachusetts, but I'm not retired. I also have spoken a number of places in the previous year, and I do receive fees for that. I have a number of books.

and online courses and videos and newsletters for which I receive royalties. And I do speak for the pharmaceutical industry from time to time and work with them as a consultant on their products in the ADHD marketplace. So there is my financial disclosure.

I'm a busy guy, and at the end of the day, what it comes down to is if you want to know about this disorder, I will teach you. I will teach anyone, anywhere, anytime who asks, who wants to know about ADHD. And that is why I am here, thanks to Teresa and her colleagues. So let's begin, first of all, with just a very quick overview of what is ADHD, because I can't teach you about why it might be a disorder of executive abilities unless we start at the beginning with what is it? How do we view it right now?

And then how does this begin to fit into this new way of thinking about ADHD that I've been arguing about now for well over a decade or more? If you're not familiar with ADHD, it's a developmental disorder of two psychological traits that are not emerging on time in the individual. That's important because ADHD is not a psychopathology. It is not a gross aberration in behavior like bipolar disorder where you can recognize it at any age by a set of symptoms. What separates ADHD from other individuals is a quantitative difference.

There is a lag in the emergence of these very important... neuropsychological traits and so what distinguishes the disorder from other people is the degree of the lag the quantitative difference not the qualitative difference people with ADHD will hit the same milestones that other people meet for the most part they will not hit them at the same time at the same rate and when the parts of the brain that are responsible for these abilities eventually reaches its maturity which is in your early 30s that is where they will level off in their abilities. So that is not to say that they will outgrow the problem, some do, most do not.

But it is to say that there is this developmental lag, a chronic delay in the rate at which these traits are emerging within these individuals. Now, these problems fall into two domains. The domain of inattention, after which the disorder is named, and the domain of inhibition, which gives rise to both the hyperactivity and the impulsive behavior. We know that these arise early. On average, at least half or more people have their symptoms by age seven, many in the preschool years.

A few of them were recognized in utero by mothers who said that this was an unusually active little fetus. But on average, 98% by 16 years of age. That is to say that there is a small percentage of cases that do come on in adulthood, but it's very, very few. This is a childhood onset disorder for the most part.

As you can see here, the disorder occurs across many places, not just one, but it can fluctuate dramatically based upon the context. So people with ADHD are not equally severe in all domains, on all tasks, everywhere, with all people. And that really causes a lot of consternation because if they can play video games for hours but spend only five minutes on their homework, it makes it sound like it's a willful form of disobedience, as if this person has the ability, has the talent, and is just choosing to play video games.

not to behave that way. But that distinction between video games and work, especially work for which there is no immediate consequence, tells someone like myself that there is a profound disturbance within the brain's executive system. Because that is what explains the difference across these situations.

Whereas if you didn't know that, you would start to blame the child for willfully disobeying you, or just not caring, or having some sort of a moral failure, or just being lazy, and so on. Many of the pejorative terms that have been used. for these individuals.

So it occurs across many places but not everywhere. And most importantly, to be a disorderer, and this is what separates normal from abnormal, from non-disordered to disordered, what separates them is there must be impairment in major life activities. It has to be interfering with adaptive behavior, self-care, family functioning, peer relationships, educational functioning, and then as we grow up, our relationships within the community. Our ability to manage money, to drive, to raise our children, to enter into long-term relationships with other people, our occupational functioning. All of these are major life activities and ADHD needs to lead to impairment in one or more of these before it's a disorder.

So having a high number of symptoms alone just makes you a sparkling personality. What turns that into a disorder is that your sparklingness is a little too much so and it is leading to impairment in areas where other people are not impaired. And that's the line when something becomes a disorder, the line of impairment.

And now, as you will see here, we also try to rule out other disorders because many other disorders produce deficits in attention. If someone comes into our clinic and says, I can't concentrate, we don't know what they have. Every disorder at one time or another, in one way or another, interferes with the six different circuits in the brain that gives rise to the six different kinds of attention that we possess.

So ADHD is not the only disorder of attention. But it is a relatively unique disorder in the kind of inattention that it produces. So let me explain.

First of all, ADHD starts out in early childhood as a problem in the area of inhibition. The attention problems don't show up for two to four more years. But the problem with impulsiveness starts out very early.

This is where the hyperactivity and the restlessness are coming from. There is a problem with inhibiting the motor part of the brain. And therefore it is just on go all the time.

That leads to the fidgeting, the hyperactivity, the restless, the squirming. It also leads to the verbal impulsiveness, the talkativeness, the interrupting others and so on. In addition to that there is a cognitive impulsiveness. They don't stop to think about things before they act.

They don't stop to consider what will happen later if I behave this way now. So there's a cognitive and a decision-making impulsiveness. associated with the disorder.

And that leads to a steep discounting of future consequences. What that means is that they don't value the future to the extent that other people of their age would do so. They live in the moment, the now that all that matters, it's all that drives them, it's all that counts, and what comes next is of far less value to them in their decision making. And so we look at them as individuals who basically are stuck in the now. in terms of what matters to them, what is controlling them, and how they're making their decisions.

Now, they are also very prone to distraction, but the distractibility is not a perceptual problem. It's not like the hear and see distracting events more than others. The difference is they react to them when other people ignore them. It's a problem of inhibition, so that when they hear the noise or the sound or see the bird fly by the classroom window, the difference between them and us is they get up and talk about it.

And the rest of us ignore it and go on with our work. So there was a problem with distraction, but it is an inhibitory problem, not a perceptual problem. And then there was a set of symptoms that nobody talks about until the past couple of years, but was always associated with ADHD, back to the first paper on ADHD in a medical textbook in 1775 in Germany.

Believe it or not, Melchior Weichert is the first person to describe this disorder. It's been around for well over 200 years in the medical literature. This is not some Johnny-come-lately disorder. And we have over 10,000 research papers on this disorder as well. But one of the things that we haven't spoken about since the 1960s, but now that we are coming back to, is that ADHD is just as much a disorder of emotion as it is of hyperactivity, inhibition, distraction, and concentration.

People with ADHD are very impulsive in displaying their emotions so that their emotions come up too quickly, too raw, too unmoderated. And as a result of that, they are often accused of being socially and emotionally immature. Now, this is not a mood disorder. Their moods are not irrational. It's simply a disorder in which they can't regulate the emotions like other people can.

The top-down executive control over normal emotion just isn't there to the degree that it should be. be. Now the reason that we are so convinced that emotion needs to be put back into ADHD is because this set of symptoms accounts for many of the impairments that can't be explained by the more traditional symptoms of the disorder.

Not the least of which is it's the single best predictor of why you have no friends. Other people can forgive you your restless behavior, your fidgeting, your distractibility, your fizziness, you're disrupting them. But what they don't forgive is anger and frustration and hostility and reactive aggression.

So that when things provoke you and upset you, if you have ADHD, your emotions are up and out and the damage is done before you've had a chance to get any traction. over-moderating this and bringing your emotions to be more consistent with the situation and with your long-term welfare. So we are now realizing, and many papers have been written this year making this case, that ADHD is just as much a problem with impulsive emotion as it is with impulsive behavior, impulsive cognition, and impulsive speech.

And it explains a lot about these individuals, not the least of which is, of course, their social difficulties. But it's also one of the best predictors. of their driving problems, their financial problems, their marital problems, their child-rearing problems.

And it's one of the main reasons why they will be fired from a job four times more often than other people are likely to do. You don't get fired because you're distractible, but you will get fired if you are angry with the customers and if you will blow up and are impatient and are easily frustrated. So this is a domain of ADHD that is underappreciated but is now being put back into our models and theories and explanations. of the disorder.

Now one final caveat before moving on. The hyperactivity declines so steeply with age that by late adolescence and certainly by adulthood, it is of no diagnostic value whatsoever. Adults with ADHD are not hyperactive.

They feel internally like they are. They feel a need to be busy and restless and doing multiple projects. They often say that they're good at multitasking.

Well, you are if you finish the things you start, but they don't finish anything. And so this is not... Multitasking.

You know, this is distractibility, but they are not climbing on furniture, sliding down banisters, and doing all of the other gross motor hyperactivity that we see in the young children. So please pay attention to that. Adults with ADHD are not hyperactive. Now, the inattention domain is much, much more than inattention.

But let's start with the inattentiveness. First of all, you need to understand that there are six different kinds of attention in your brain. And ADHD does not cut a wide swath through all of them. It is particularly salient in one area that other disorders are much less likely to have their impact on.

And that is persistence toward the future. There is a very special kind of attention, you call it sustained attention, but it is persistence toward the future, toward goals, toward tasks, toward what is coming up or what I need to be doing. It is attention to the later. in your life, not the now. People with ADHD attend to the now just fine, but as you get older, you spend more and more of your time looking ahead and preparing for what is coming next and setting your own goals or following up on the tasks and goals and assignments given to you by other important people in your life.

And so what ADHD disrupts is persistence over time toward that future. It is the only future directed form of inattention that we see. And that is how we can diagnose it from schizophrenia and anxiety disorders and panic attacks and depression.

All of which interfere with attention but not in this way. So this is a problem with sustaining action over time toward your goals and the future more generally. Now the ability to persist is coupled with the ability to resist reacting to irrelevant events. I've already spoken about that. It's an inhibitory problem.

That's the source of the distractibility. So that they are very prone to being easily distracted by irrelevant events that have nothing to do with the goal, the task, or the future at hand. And this is what captures their behavior and leads them off task and gets them skipping from one uncompleted activity to another, is this problem with impulsive responding to irrelevant events. Now, there is an interesting problem coupled with that, and it has nothing to do with attention. All of us occasionally get distracted by things we didn't plan on.

And we have to stop what we're doing and attend to those things. There are important interruptions that take place in your day. But what you do is once you've dealt with the interruption, you return to the task at hand, the incompleted goal. The future that lies before you recaptures your behavior. That doesn't happen with people with ADHD.

Once distracted, they do not re-engage the incompleted goal. They are off on a tangent. from one to another to another.

So that that is where the now, so to speak, is pulling them along by the nose when you and I get back to the work we had planned to do. The goals, the assignments, the instructions, and so on. Now this problem with task re-engagement has nothing to do with attention. It is the most important feature of what is called working memory.

Working memory is one of the big seven executive functions. Working memory is consciously holding in mind What your goal is, how you plan to get there, and what progress you are making toward that goal. Memory put to work, or as I explain it to patients, remembering to do. This is not memory.

This is not storage and retrieval of facts and knowledge. This is remembering what you're doing. What was the goal?

What was the plan? How far along that road am I to accomplishing that goal? And that governs your behavior.

That's what takes over from the now, is what you should be doing. It's what you start to lose in your 50s. At my age, I'm 63 or will be shortly, it's what women lose even more when they hit perimenopause. So what you are losing is your working memory. You don't forget information.

You forget what you were doing. You walk into a room, something distracts you, and now you can't remember why you entered the room. So having ADHD is like aging times 100, or being little menopausal women, however you want to think about it. So what they are impaired in is memory put to work, remembering to do. So if they are forgetful during the day, it's not knowledge they're forgetting.

It's what they're supposed to be doing, where they're supposed to be going, what calls to them by way of their goals and their tasks and so on. So that's your disorder, but you can see that it's much more than a disorder of attention. The fact that working memory is involved in this and that inhibition is involved in this, Those are two of the seven big executive functions given to you by this massive frontal lobe in your brain.

And that opens the door to the possibility that ADHD is EFDD. And the question then is, are the other five also impaired? Is this a very focal disorder of executive ability, hitting only working memory, or working memory and inhibition, as some people have argued?

Or does it hit... All of them. Is it a pervasive disorder?

Now to answer that question, we're going to have to take a detour into executive functioning. And we're going to have to talk about what that happens to be. Now before I do that, I did want to give you a slide in your handout that does talk about the prevalence of the disorder, how common it is, and so forth. But my time is so precious today that I don't wish to waste it with well-known facts and figures that are out there and easily available to you.

But just in passing, you should know this is a very prevalent disorder. that it's about 7.5% of children and nearly 5.5% of adults have this disorder. It is universal. It is worldwide. It is seen in all countries ever studied.

It's not just a U.S. disorder, as some critics have argued, but it is not evenly spread across the populations. Three times more common in boys than girls, but that sex difference disappears by adulthood when it is equally common in men and women. We don't know why the gender difference dissipates, but it does. We also know that it's more common in lower middle class families.

It's more common in population dense than rural areas. It's also more common in children in the military and the children of other professions like the performing arts and music and door-to-door sales and athletes. The reason for all of those differences is this is where adults with ADHD tend to go as they grow up.

And because ADHD is the most genetically influenced psychiatric disorder we know of, rivaled only by autism and bipolar disorder, and far more prevalent than either of those disorders. If you have ADHD and you're an adult and you start self-selecting into certain careers because that's where you tend to function a little better, like the military, well, guess what? More of your children are going to have the same disorder that you had by virtue of the genetics alone. So there's nothing unique to athletics or the military.

It has to do with where people with ADHD are likely to find themselves functioning with less impairment than they would had they chosen some other occupation like law or science or medicine or technology. It doesn't mean they can't go into those professions. It just means that they are far less likely to be in them than are other people in the general population. Now, back to the question I was raising. Is ADHD EFDD?

To answer that, we have to talk about EF, what it is. But I can assure you that ADHD has to be. EFDD.

We could stop the lecture right here. The neuroanatomy of ADHD is the neuroanatomy of the executive brain. The executive brain, as Karl Pribram first coined the term, is what the frontal lobes do. And although he didn't go on to particularly define what he meant by executive functioning, he gets credit as the first person to coin the term. But what he was trying to do is describe why primates, and especially humans, have this massive frontal lobe to their brain.

And the history of that goes back another hundred years or more. to the middle 1800s, efforts to study what do parts of the brain do, what does the frontal lobe do. The term executive functioning just sneaks in as one possible description for these activities of this executive brain.

We know that there are at least five structures involved in the executive brain. We know that they form three executive networks, and we know that ADHD interferes with all three. to varying degrees.

So clinicians and parents, one of the reasons you see such heterogeneity in ADHD is it depends on which of these circuits has been hit the most. They're all affected, but not all to the same degree in each person who possesses the disorder. Now the first circuit, and I'm not going to spend much time on this, and I do have a diagram for you, so you know we'll get there, okay?

I don't want to make it sound too complicated here, but the first network is the what. network of the brain and that is from the outside of the frontal lobe the dorsolateral surface back into a structure deep in the brain called the basal ganglia let me just bring it up here for a moment excuse me this slide usually takes a little encouragement to move on deep inside the brain is the basal ganglia right so we're talking about the outside surface of the frontal lobe which is over here looks like my Laser pointer is gone. Over here, the outside surface, back through the center of the brain to that structure. That is called the what network because that is where what you hold in mind, working memory, is going to guide what you do, your motor system.

So this part of the brain is now suppressing that structure so that other signals in the brain don't get out and don't distract you. And then it is going to use your thoughts, your mental representations, to guide that motor behavior toward what your goals are. The future is taking over your brain in that sense.

What I think controls what I do. By the way, that's a miraculous process. How can this ephemeral mental event actually come into the real world and guide your behavior around through it? It's kind of like a Garmin GPS.

It's exactly how it works. So that is our what network. Now let me just back up if I can.

Oh, don't tell me this thing is great. Well, I may need you to replace these batteries if you would please. Do you have any double A's or triple A's?

Okay, great. Oh, there it is. It's back again. All right, if you'll get those batteries, let's see if I'm going to need them. The second network to continue is the WEN network, the timing network.

This one surprises people because it's not often talked about in relationship to ADHD unless you read some of my books or you happen to be familiar with the frontal lobes. This is the WEN network. It goes from the same outside surface of the frontal lobe back through that basal ganglia and now to the cerebellum, the old ancient brain at the back part of the brain. We often think of the cerebellum as... important for the grace and the movement and the timeliness of our actions, like in gymnastics or dance, or just the general fluidity of our behavior.

But the cerebellum is also just as important for the grace and the timing of our thoughts, not just our actions. It's as much involved in higher cognitive activity as is the frontal lobe. Indeed, an injury to the cerebellum can sometimes mimic a frontal lobe injury. causing neurologists difficulty in finding out where is the problem. This is the timing circuit of the brain.

We call it the when network. And it explains why ADHD is the worst disorder when it comes to time management. There is no disorder as bad as this one, four to five times worse than any other disorder we have seen in terms of its interference with the timing and the timeliness of one's actions.

Indeed, it eviscerates your sense of time itself, which is why people with the disorder are adrift in time and can't deal, as well as others, with this invisible dimension of our lives that becomes increasingly important as we grow older. Three-year-olds don't have to be timely. Thirty-year-olds do, or they get fired.

So of all of the deficits, this will be the most devastating, and it is also the most impaired. Now, the third... circuit of the brain is the hot circuit known as the Y circuit. Again, we go from the frontal lobe to the midline of the frontal lobe and then to the amygdala right here.

This is the emotion regulating circuit. That's why it's called the hot circuit. This is where the problems with emotional self-regulation are coming from. The executive that sits over top of your emotional brain, which is your limbic system, is out to lunch, checked out, gone, leaving your emotional brain to just spew normal emotions. But they're not normal because people of your age would have been moderating them and suppressing them and doing things to make them more consistent with the moment, other people, the goal that I have at hand, my general long-term welfare.

So this is where you get the impulsive emotions from, the impatience, the frustration, the quickness to anger, the easily aroused, the easily excitable, the overreacting to events, and indeed in a subset of people, the reactive aggression. People with ADHD aren't predatory. They're not psychopathic.

They're not out there raping and pillaging our community with a plan. But if you provoke them, they will respond very quickly, more than other people, with these negative, frustrative, hostile forms of emotion. Thank you so much. I appreciate that. Thanks, Tristan.

So, we have three circuits made up of five brain areas, which we know are not functioning well in these individuals. And that creates a range of symptoms and differences among people and how much these circuits are impaired. So the heterogeneity is part of that. But all five of these form the executive brain.

We know that they are 3 to 10% smaller in people with this disorder. That is so small that you would not recognize it on an individual MRI, which is why you will not see neuroimaging be useful for diagnosis, not yet. Because you couldn't visually tell an ADHD from a normal brain looking at one person's scan.

But if I take 100 of those scans and I average them together and compare them to 100 scans of typical people, now the difference has become apparent. More importantly, these parts of the brain are at least two to three years behind in their development. So there is a developmental lag. And if you want to see a beautiful video diagram of this maturational lag, You can go to the NIMH website and you can search for Philip Shaw's longitudinal study of ADHD.

And they have up there a short video showing the development of the ADHD brain. Why? Because they studied it. They neuro-image ADHD children every year to two years for ten years. And that allows them to compute and demonstrate the degree of this lag.

It's very impressive. It's an excellent teaching tool, by the way, as well. Now, so we know it's smaller.

We know it's two to three years behind in its development, but most importantly, it's underactive. These five areas of the brain are between 10 and 25% less active than they should be for someone of your age. So it's the activity in the area more than the size of the area that is the most telling about ADHD as a frontal lobe disorder. So we could stop there.

We know ADHD is in the brain. We know it's in the executive brain. We know the five structures it implicates. We know what's happening within them and why they're not doing the job they're supposed to do.

So, case closed. ADHD has to be EFDD. And then you pick up a journal, a review paper, a textbook, and it says it isn't. Only a subset of people with ADHD have executive deficits. And it's the minority.

And therefore, ADHD can't be EFDD. And you get yourself into a real logical quandary here, because according to the neuroanatomy, it has to be. But according to the neuropsychology evidence, it isn't.

And we have a disparity. And that's where the fight is going on right now in the literature. I know I am in the thick of it.

But as we get started, I'm going to sort of give away some of my thunder for the end of the presentation, just to kind of set the stage here. How would ADHD fit into the neuropsychology of executive functioning, if I'm going to convince you that it does? Where does all of that fit in? Well, that's very easy.

Because you see, it turns out that executive functioning is one thing. When we do statistical procedures called factor analysis, we take all of these various measures of executive functioning, we toss them into a computer, and the computer looks for underlying dimensions in these multiple tests, we get one factor, one dimension. Just like when we analyze intelligence tests.

We get one factor called G for general intelligence. And we get one factor here. But just as in intelligence, we can break it down into two narrower bands, highly correlated with each other, all coming under the mothership here of this overlying executive dimension, but worth separating into two dimensions to get a little value added to our understanding. Just as we can separate intelligence into verbal, and nonverbal, known as visual-spatial, we can separate executive functioning into inhibition and metacognition. Now, as with intelligence tests, we can take these broad bands and subdivide them into narrower bands, all of which are highly correlated, all of which are part of the mothership up here, but some value in distinguishing among them for our purposes.

Inhibition, as I've said, is four things. Problems with impulsiveness affect all of those domains. But metacognition, which most people don't understand, refers to these abilities, including, most importantly, something not on here, which is my mistake, self-awareness. So, we have two broad bands of executive abilities. And now you're going to start to see where ADHD fits in.

Because the hyperactive impulsive symptoms of ADHD are just a subset of these. You're just calling it by a different name. And the inattention is not inattention.

It's metacognition. You've labeled it with the wrong label. The list of symptoms in the DSM and that you read about in parents'books is not inattention.

That is a minor part of what this does. It is those metacognitive abilities. Self-awareness, nonverbal working memory, verbal working memory, planning, problem solving, and emotional self-regulation.

So ADHD is going to map right into these two broad bands. We have just given them, by mistake, the wrong name. So at the end of this lecture, that is where I hope to show you.

I'm not inventing a new way of structuring ADHD. I'm inventing a new way to describe what you already know. You're just using the wrong term to describe the deficit.

But in relabeling these terms to their more appropriate labels, you can see that ADHD is a much wider swath of impairments in brain functioning than the term attention can capture. ADHD is the Rodney Dangerfield of psychiatry. It gets no respect.

And part of that is it's got this silly name, right? Nobody thinks attention is all that important, not like mood or depression or mania for God's sake, not to mention hallucinations and delusions. Oh my God, lions and tigers and bears, oh my. So it's just this little poor stepchild over here in attention. Just get some sleep, have some coffee, and you'll be fine.

Well, we're telling you that it is two of the most important domains of human mental activity are the areas that ADHD eviscerates. And that makes it an extraordinarily important disorder. And it also explains why in 2008, when my colleagues and I reviewed everything we know about ADHD in adults and outcome studies of children followed to adulthood, my book Outside, where we concluded in the last chapter, this is the most impairing disorder you see on an outpatient basis.

You would have to go to an inpatient unit to find disorders that are more impairing than this one. Schizophrenia, of course. But compared to anxiety, depression, LD, language problems, mild mental retardation, high functioning, autism or Asperger's, they don't hold a candle to this one.

This is the bad guy because it undercuts every major life activity. There is no domain of life that we have studied in adults with ADHD that this disorder does not adversely affect. None.

So that is why we can say this is a serious disorder. And the public needs to take it seriously. And it needs to take it more seriously that we take anxiety and depression, for which we are giving away antidepressants and anxiolytics like they were candy. I mean, half the women I know are on anxiety drugs, and a lot of the guys I know are taking antidepressants, sometimes just to improve their personalities. Prozac Nation, you remember that?

Viagra is not the only drug people are using who don't need it. We are also using psychiatric drugs for that reason. Performance enhancement.

I have drifted away. My medication is growing thin. Okay, so now let's come in and take a look at how could these reviews of the literature reach such conclusions that are so far afield from what we know clinically and what we know about the neuroanatomy of the disorder.

And to explain that, we've got to go into executive functioning. So hold onto your seats, ladies and gentlemen. Here we go. This is going to be a theoretical romp through the literature, of which there are thousands of articles.

I can tell you, EF is one of the most commonly used. Indeed, it's become a fashion trend. We have books for teachers on executive functioning, books for parents on executive functioning, and so on, as if we really know what this is. The problem is, we don't. Wink, wink, we don't know what this is.

There are more than 30 definitions of executive functioning. So to find out what you mean, I've got to read your paper very closely to the point where you tell me what you think it is. But it's not the same as what somebody else said it was, and it's not the same as other people as well. So we're all just sort of pointing at each other. Well, he said it was this, and she said it was that, and they said it was that.

So that's what it is. Well, that's not science, right? If it is, it's science by vote, not by evidence. So we do not have a definition, a specific operational definition of this very popular term. And that's going to hold back our science.

The second problem that we have is that people have said that this term is really an umbrella, a tent. a mothership under which we can put these very specific components of executive functioning. And people have labeled up to 33 of these different components in this tent. That's impossible.

The minute you start getting up to this number, you can explain anything. I can ask you by rights, what mental faculty is not executive in nature? I mean, by God, you got most of them up here already. So what is it?

Well, if you don't have a definition, then anything goes. And that's what's going on right here. Just about anything you wish to declare as an executive ability, nobody can challenge you.

It's in the tent. The third problem, which is related to the other two, is we have no theory. There is absolutely no accepted theory explaining what is an executive function, how many are there, and what do they do. You see, See, theories aren't just descriptions.

They explain how something works. They're the mechanism. They show us how these parts are related to each other, why they go together, how they sequence each other, what they do, what's important about them.

Theories are very, very important because they give us that deep insight into our disorder. And when you have that, you can start to treat it better. If you don't have a theory, then treatment is just chance, just luck.

So we don't have a theory of ADHD. And the most important thing is a theory tells you, why do you have this? And that's where we start to get into evolutionary biology.

And why has this part of the brain become so unique in humans? Because you don't need this part of the brain to live on this planet. Virtually all other species have done just fine. Alligators on my golf course in Charleston have been around millions of years longer than you and I have been on this planet. They're doing just fine.

Thank you. They don't have a frontal lobe, they don't need one. So there's nothing about the physical world that requires a frontal lobe. And that is why you don't see it very often. So we have to look at humans and say, what is it that humans do that is so special, so unique, that they require this massive expansion in the front part of the brain?

And the answer to that is that we live in groups. with other people with whom we are not related. And that is a rarity. So rare, in fact, there are probably fewer than five other species that do that.

In all other species that live in groups, they're genetic relatives. Indeed, like wasps or ants or termites, they're virtual clones of each other. So it's easy for cooperation to arise genetically when you're genetically related to people.

It's not easy to explain reciprocity. cooperation and group living when you're doing it with people with whom you share no genes. That is so rare in biology that it requires a special explanation, and it is so rare in psychology that it requires a special brain.

And as Diamond pointed out in 1980, this is the seat of social intelligence. And that's what makes it so important. But now we have to prove that. So, we need a theory of the why of executive functioning.

And if we get that... We can then go back and have a definition and have a look at the pieces that should be there, what components should belong and what shouldn't. Now, these three problems have led to a fourth one. And it's the one I think that most directly impacts clinicians and families and patients.

Because if you don't have a theory, then you don't know what to assess. And if you don't know what to assess, then anything goes in assessment. Any tool, any device, any preferred little set of methods. can be declared as executive in nature, and you get away with it. And most importantly, what's happened over the past 20 years, is we've seen a battery of cognitive tests developed and marketed as executive function measures.

Well, that would be fine if we knew what executive functioning was, then we would know what we're measuring. But because we don't have a definition, we don't know what we're measuring, and I can invent any damn test I want to, and you can't challenge it. I've done it, by the way. Now, here's the most important point.

Over the past 10 years, 15 perhaps, but 10 certainly, we have learned something startling, surprising, and devastating about these tests that are ubiquitous in our life. Every day, thousands of people in the U.S. have their lives determined by these test batteries. Whether they get Social Security, whether they get ADA accommodations in college, or under the Americans with Disabilities Act in their workplace, whether children get special education. whether you are going to have your sentence commuted or amended because of a crime, whether you're going to get an insurance settlement because of a car accident, whether or not you're going to get veterans disability benefits from a traumatic brain injury in the Veterans Administration. They're all, every one of them, decided by these test batteries.

And here is the most shocking thing of all. These tests cannot do what they say they do. And we now know that for a fact. These tests are not reliable.

They have very poor norms in the population, and the most important thing, they don't correlate with anything important in modern life. Nothing. If executive functioning is crucial to human survival, if it underlies every major life activity in which we must engage, then executive function tests should be correlated with all of that. Education, workplace, child rearing, driving, money management, and so on. It's not correlated with any of them.

We can go out and have people directly observe your executive behavior in daily life and record them. Or we can have your relatives fill out rating scales of executive functioning about you. And guess what? The tests don't predict them either. There is no correlation between a battery of tests and a rating scale that is supposed to measure the same construct.

Zero. We have a problem, ladies and gentlemen. We have a construct being assessed by a battery of tests. that can't assess the construct.

That is reprehensible. It means we are making decisions, important decisions, about the lives of people, what they can and can't get, what entitlements, what protections, on the basis of batteries of tests that have been oversold, over-marketed, and can't do what they are supposed to do. And this explains... the fight that's going on in the literature.

Because 99% of all research on executive functioning uses these tests. And if you give these tests, the vast majority of people with ADHD pass them. What would that lead you to say?

No executive deficits here. ADHD can't be EFDD because our gold standard, gold-plated tests say so. And no one stopped.

to question the premise. Can the tests measure what they're supposed to measure? And the answer seems to be, no.

So here's the paradox. ADHD is a disorder of the frontal lobe. Hands down, fact in the bag, know it's there, know where it is, what it is, how delayed it is, what structures it is, right down to the single nerve cells. What is going on?

It's got to be EFDD. But we give these test batteries, and on average, 35% of the children and adults fail them. Two-thirds of them pass the test.

They don't have EFDD. Oh, but hold on a second. Then we have your parents and teachers and your loved ones and your husbands and your wives and other people who know you well fill out rating scales that measure executive functioning as you use it out there in daily life. And all of you have a disorder. Every person with ADHD fails these rating scales.

What the heck is going on here? You pass the test, you fail the scale. And so people started blaming the rating scales right away. Oh, that's subjective.

Oh, that's your mother. Oh, your teacher doesn't know what the heck she's saying. Oh, that's your self-report, and we know what you have.

Oh, you're malingering. You're like one in four college students who's coming in for our disability services evaluation. By the way, malingering is at its highest on college campuses.

Feigning ADHD. People want those accommodations. They want those drugs, even if they have no disorder.

So if you're working on a college campus, you're going to see more malingering than anybody else anywhere in clinical practice. Doesn't mean that people with ADHD aren't there. Just means that probably one in five of them doesn't really have that disorder.

But that's not the point. The point is here. It's a universal disorder of executive functioning on the rating scales.

It isn't on the tests. And if you buy the tests, which nearly all of my colleagues have, you reach the wrong conclusion. If you buy the observations and the rating scales, you reach the right conclusion.

This is EFDD, because the tests, as I've said, predict nothing. No correlation with the ratings, no correlation with the observations, no correlation with many areas of domains of impairment. So the tests and the ratings are not measuring the same thing.

So how do we know which one we should use? Which? one predicts your life, which one tells me how well or how poorly you are likely to do in school, in work, in relationships, driving a car, managing your money.

It's all the rating scales. The rating scales predict impairment five times more, in some cases ten times more, than any test or test battery. Cheap, easy, flimsy little rating scale data turns out to be the best. And this hurts, because my neuropsychological colleagues were all trained in test batteries.

That's how they make their living. $1,000 to $2,000 per shot. Come on in, I'll test your executive functioning, I'll make conclusions about your life. No wonder they're so upset. No wonder my name is being pilloried on the list serves for these major professions.

It can't be true. What Russ is saying, no, no, it can't be. Well, I get some value out of these tests.

Well, okay, big shot, prove it. Show me the articles. Show me the publications.

Every single publication on this topic reaches the same conclusion that I just did. But they won't let go of the tests. Not yet. They still think there's something about the tests that's good. I don't know.

We'll see. But we have a problem on your hands. This is just a study. I'll show it to you very quickly.

This is my study of adults with ADHD. This is the rating scale of executive functioning. Virtually all of them are impaired. This is the test battery we gave. None of them are impaired.

You see the disparity? It's not even close. It's not just this study. Here's another one.

This is my 30-year longitudinal study in Milwaukee. I've actually been following children since 1978 in southeastern Wisconsin. Same rating scale.

Everybody who's ADHD persisted to age 27. And there's the test battery. Same thing. On the test, virtually nobody's impaired.

On the rating scales, virtually everybody who's ADHD lasted to adulthood is impaired. And the level of impairment is as bad as it is in their ADHD symptoms. Something's got to give here, people. These two areas of literature just do not talk to each other, do not agree with each other. So what's the best method?

Well, as I've told you, and I'll skip over these data, but the scientists in the audience are going to want to have it. In virtually every study that we have looked at, the rating scales outpredict the tests, massively outpredict the tests. If I was going to evaluate somebody's executive functioning, I'd give them a 10-minute rating scale. Done. And then I'd have somebody who knows them well fill out another copy.

And it's not because they're necessarily going to exaggerate. People with ADHD actually do the opposite. They tend to under-report their symptoms compared to other people who know them well, on average, at least until they're 30. So what's the problem here?

Why this disparity? Why don't the tests do what they're supposed to do? And to answer that, I'm going to go back to the first and classic case of a frontal lobe injury in the literature, good old Phineas Gage. You've heard of this guy, I imagine?

If not, you should have. If you're in psychology, you damn well better have. Phineas was a railroad foreman who had drilled a hole in a boulder, stuffed it with powdered TNT, dynamite, and then what you do is you take this metal rod and you tap on it gently to compact the powder. But you've got to be careful. because the rod is metal, and if it sparks, it blows up.

And that's what it did. It drove that rod right up through his frontal lobe, and there is a beautiful description by Harlow, the physician who treated him. of what he was like before and after this massive frontal lobe injury.

I'll get rid of it so as not to gross the ladies out anymore. By the way, that photo was discovered about 60 years later in someone's attic. It's the one and only photo of Phineas after the event, which explains why he's holding the rod.

Nobody could figure out who the heck that was. It took a neurologist at Harvard to say, you know who I think that is. There's only one guy with a damping rod that I know of.

That's him. Before the accident, Phineas was one of the most responsible people ever hired by this railroad. And they say so when they were interviewed. After the injury, he became one of the most impulsive individuals prone to his animal propensities, as Harlow so well described it. And you can read through here all of the various problems that he had.

Suffice to say that what Phineas had was a problem in many areas of life. A problem with his social relationships, a problem with his inhibition and self-restraint, with his emotions and his drive, particularly his sexual misconduct, difficulties with ethical and moral behavior, and, of course, difficulties managing money, holding a job, being responsible, caring for himself. He had to move in with his sister, actually, for a while. Wound up at the end of his life driving a stagecoach in Brazil.

I want you to look at these deficits. That's what Phineas suffered from. Then he comes into a clinic in modern life, and these are the tests we give him, right?

So he loses these, we give him these, right? He loses some very important domains of human life, and we make him do digit span backwards. Over the past 20 years, neuropsychology has drifted ever more. toward the assessment of cold cognition, intellectual information.

None of these tests, not a one of them, assesses any of these. But this is what he lost. And now you know why the tests don't pick up frontal lobe injuries or executive deficits.

They are pure, cold, academic, intellectual, short-term, asocial, unemotional cognition. Who the heck cares whether you can sort cards into categories? Is that a major function of daily life? Do I really care whether you can spot an X from an O and push a button on a computer? Or whether you can do digit span backwards?

Oh, that's a really important domain of adult functioning. But that's the test that you drag out to assess people like Phineas. It is no wonder that you have missed the boat entirely. Now rating scales, on the other hand, assess five major dimensions of adult functioning. So this is what we get off the rating scales, that is what we get off the tests.

So what you can see here then is why the rating scales are so much better at picking up the deficits than the tests are. They are at least making an effort to pick up many of these domains of functioning. Emotion, social functioning, self-restraint. organization, planning, anticipation, problem solving, time management.

Those are very important mental faculties, but not digits spanned backward. So what's wrong with the tests? They cannot capture executive functioning the way it plays out in modern life.

They don't have emotion, they don't have social purposes, they're very short term. I mean the purpose of the frontal lobe is to anticipate the future. You've got to plan a wedding. I'm only going to give you a 15 minute test.

How on earth does a test that takes only 15 minutes assess your ability to plan out over hours and days and weeks and months of your life? It can't. Hence, that's another drawback among the many drawbacks.

So, you can now see why the rating scales beat the tests. So, when you come back from your coffee break, we're going to talk about how do we resolve this disparity. Can we save the tests at all? Should we just throw them in the trash bin and walk away from them?

Or is there a way of thinking about executive functioning where they might continue to have a role, albeit a very narrow, limited role? I'll answer that question after your coffee break. Thank you. Thank you. Started a little late, so...

Transcript for:Understanding ADHD and Executive Functioning

Transcript for:
Understanding ADHD and Executive Functioning