2	“What’s Really Wrong with My Child?” POOR SELF-CONTROL

ADHD is probably among the best studied of all psychological disorders of childhood. Still, our understanding of the psychology of ADHD is far from complete. While we now know that ADHD represents a problem in the manner in which children develop control over their impulses and their capacity to regulate their own behavior, these problems are not perfectly well defined.

How do children develop self-control? What are the behavioral or psychological mechanisms and processes that underlie our ability as human beings to control our own behavior better than any other species can? And which of these processes appears to be impaired or delayed in ADHD? As mentioned in Chapter 1, scientific studies have shown that the obvious symptoms associated with ADHD can be reduced to poor attention, impulsiveness, and hyperactivity and that the last two seem to be part of the same problem—impairment of behavioral inhibition. Since we have also learned that problems with attention may be part of childhood psychological disorders besides ADHD, it is important to identify precisely what kinds of attention problems link up with ADHD more than these other disorders. To date research shows that they are persistence over time toward goals or tasks (attention to the future) and resistance to distractions, which is obviously related to persistence. These occur alongside the problem with behavioral inhibition that also seems to be relatively unique to ADHD—these are the hallmark symptoms.

Even what we call problems with attention at times seem to be problems with inhibiting behavior—inhibiting the urge to do something a child would rather be doing than the task at hand. So when we say that children with ADHD have a short attention span, we really mean they have a short interest span. Similarly, when children without ADHD mature and become better at inhibiting the urge to shift to more rewarding or interesting activities, we say they have acquired a longer attention span, but what we should say is that they have a more developed ability to restrain their impulses and to stay with a plan or an instruction and not be so distractible. Children with ADHD are like younger normal children. Their problem does not seem to be only one of paying attention but also just as much one of sustaining inhibition. So it seems that all three problems thought to be the primary symptoms of ADHD—inattention, impulsiveness, and hyperactivity—can be reduced to a delay in the development of inhibition of behavior and of persistence toward goals and the future more generally.

EVERYTHING COMES TO THOSE WHO CAN WAIT: ADHD AND THE BRAIN’S EXECUTIVE FUNCTIONS

I am not the first scientist to argue that the major problems of children with ADHD stem from a fundamental deficit in their ability to engage in self-control using the brain’s executive functions or abilities. Chief among those executive mental abilities is the capacity to inhibit behavior, an ability to contemplate one’s relevant past experiences, as well as to anticipate the future consequences that can be expected from such hindsight. This information is then used to decide how best to act at the moment and how to sustain one’s actions toward achieving goals. The English physician Dr. George Still made this point as far back as 1902. What these scientists have not done, however, is explain how these problems with inhibition, self-contemplation, and poor persistence toward goals lead to the many impairments we find in the academic, social, occupational, mental, language, and emotional domains. Doing so would surely strengthen the theory that deficits in inhibition and the other executive functions are at the root of ADHD. I believe that this can now be done.

The commonly held view of ADHD as a problem with inattention and hyperactivity has, over the years, failed to explain many of the findings about children with ADHD—what I call “orphan” findings, since they have no “parent” theory to account for them. For instance:

We know that children with ADHD do not benefit from warnings about what is going to happen later. They seem to base their behavior on what is at hand rather than on information about future events. How is this explained by the fact that they are impulsive or can’t concentrate?

Other studies have also found that the speech that children with ADHD typically use in talking to themselves while working or playing is less mature than that of other children. Why? What does that have to do with their not being able to inhibit their behavior?

Dr. Sydney Zentall and her colleagues at Purdue University more than 35 years ago observed that children with ADHD do not do mental arithmetic as fast or as well as other children, despite the fact that they have no problem understanding math. Many other studies have found such deficits in being able to hold information in mind and to manipulate it—deficits now known to be due to problems with working memory. How is this deficiency explained by their immature inhibition or inattention?

Drs. Carol Whalen and Barbara Henker at the University of California at Irvine found more than 30 years ago that when children with ADHD play or work with other children on a task, the information they communicate to others is less organized, less mature, and less helpful in getting the activity done than the information communicated by children of the same age without ADHD. Other studies have routinely confirmed these initial results.

These and many other such orphan findings are the issues that must be resolved if we are to have a more complete account of ADHD. My belief that all of these problems can stem from a problem with inhibition and the other executive functions begins with my discovery of a theory advanced more than 40 years ago by Dr. Jacob Bronowski—the late philosopher, physicist, mathematician, and author of The Ascent of Man, the critically acclaimed book and public television series from the late 1970s. In a brief yet profound essay, in 1977 Dr. Bronowski discussed how our language and thinking came to differ so dramatically from the types of social communication used by other animals, especially our relatives, the primates. In his essay I found the seeds to understanding both the brain’s executive (self-regulatory) abilities and what may be going wrong in the psychological development of those with ADHD.

Self-Directed Inhibition: The Mind’s Brakes

In 1977 Dr. Bronowski proposed that everything that makes our language unique (and us human) flowed from the evolution of the simple capacity to impose a delay between a signal, a message, or an event that we experience and our reaction or response to it. We have the ability to wait for far longer periods of time than other species can before responding. This power to wait stems from our greater ability to inhibit immediate urges to respond, and because inhibition takes effort, waiting is not a passive act. Being able to inhibit our immediate urges to respond and instead wait for a while, wrote Dr. Bronowski, enables us to (1) create a sense of ourselves in our past, and from it a sense of our likely or possible future giving us a conscious sense of ourselves over time and what may be possible for us to become or achieve; (2) talk to ourselves and use such language to control our own behavior; (3) separate emotion from information in our evaluation of events and thus be more rational; and (4) break incoming information or messages into parts and then recombine those parts into new outgoing messages or responses (analysis and synthesis) and so engage in planning, problem solving, and goal-directed innovation. To these I would add one more: (5) the ability to self-regulate internal motivation to drive our behavior toward our goals. If ADHD is a problem with a person’s ability to inhibit responses, then we might expect someone with ADHD to have problems with these five other mental abilities.

These five mental abilities are called executive functions because, like an executive running a corporation, they allow us to monitor and direct ourselves over time toward the future. They give us self-control. “Executive functioning” is a commonly used term these days in professional journals and in discussions with patients and their families. But there is no agreement as to its definition among scientists working in the field. To me, executive functioning is self-regulation, but it refers to types of self-regulation. Each type is considered to be such a function or mental ability. Recently, in my latest book on a theory of executive functioning and self-regulation, I specified that self-regulation can be thought of as involving three steps: (1) we direct some action back at ourselves, (2) in order to change our behavior from what it otherwise would have been, (3) so as to change our future in some important way (increase or decrease later consequences for ourselves).

With this definition of self-regulation in mind, I stated that there are six executive functions and each one is a type of self-regulation (an action we direct at ourselves to change ourselves in order to alter our future for the better). In other words, there are six things we do to change ourselves and our future. What are they? The first is (1) inhibition or self-restraint, as stated above. The others are (2) self-directed attention to achieve self-awareness, (3) self-directed visual imagery to achieve hindsight and foresight (awareness of ourselves across time), (4) self-directed speech to control ourselves by language, (5) self-directed emotions to manage them better and to achieve self-motivation, and (6) self-directed play, to solve problems and to invent solutions. I explain (2) through (6) below.

Self-Directed Attention (Self-Awareness): The Mind’s Mirror

Our ability to delay responses and wait is one of three fundamental executive abilities. It is associated with the ability to direct our attention not only at the environment around us but at ourselves as well. We watch and so monitor ourselves as we behave, and so we have self-awareness. This means that inhibition (stopping) and self-awareness are two of our most fundamental executive functions. We use this awareness of ourselves and what we are doing to monitor our actions and to inhibit them when it seems wise to do so, such as in a novel situation or when we have made a mistake. Think of it as our mind’s mirror on ourselves.

Self-Directed Imagery: The Mind’s Eye

By storing in our memory our awareness of ourselves and our actions in prior situations, we can have a sense of ourselves now as well as of ourselves in that past. Doing so gives us a sense of who we are and what we have done; it is our personal history. Such stored awareness of our past can then be consciously remembered (usually visualized) at a later time, held in mind, and used to guide us in understanding and responding to the events of the moment based on whatever wisdom our past can shed on the situation. Thus our past learning informs our current behavior. We have hindsight. Using it, we learn from our mistakes and our successes far more rapidly and effectively than any other species can do. These images of our past can be used like a GPS (global positioning system) mapping device in our cars. The GPS shows us an image of the terrain we are in, where we have been, and where we are headed at the moment, which we use to get to our destination. Similarly, we hold images of our past in mind to guide us through situations that are similar to those past ones so we can get to our goals and be better prepared for what lies ahead of us.

Thinking about our past and contrasting it with our present also enables us to create what Dr. Bronowski called hypothetical futures. They are “what if” futures that arise from asking questions like “What if I did this or that now? What would it lead to later in the future?” It represents our sense of the likely future that may be in store for us if we continue to behave as we are doing or if we change our behavior and do something else. We make educated guesses about what will happen next because we have thought about our past and used any evidence of patterns from it to develop ideas about the future if that pattern were to continue or if we were to change it in some fundamental way. In doing so, we can both prepare better for those predictable events if we don’t change and plan for the new events if we do change what we propose to do now. We now have foresight. Certainly our guesses about the likely future won’t always be right, but we will be better off making educated guesses from our sense of our past than simply failing to think about the past and so about the future altogether. This way we use our sense of the past to create a sense of the likely future if we don’t change course and of the possible future if we do change what we are doing. Eventually as children develop, along with that ability to recall memories of their past will develop their ability to manipulate and combine them, which forms their imagination. And also by recalling the past and using that to sense the likely future, we can share that sense of the future with others who have reasoned along with us; we can make plans with others and promises to them, using time as a benchmark for doing things as no other species can.

Referring backward (the past) and forward (the future) in time and our lives creates for us a mental window on ourselves across time as it applies to us. During our waking hours, we are almost continuously aware of this moving window of ourselves in time in our consciousness. From our sense of immediately past events, we are continuously inferring what is likely to happen in the immediate future. We use it to develop expectations, to create plans, and to anticipate likely future events. We seem to do this almost effortlessly, and so we take this foresight for granted. I consider this capacity for hindsight and foresight to be the third fundamental executive ability, alongside inhibition and self-awareness. Some researchers call it “nonverbal working memory,” but I see it more simply as the ability to recall our past and from it to imagine our future.

If ADHD represents a deficit in inhibiting behavior and waiting, as I have suggested, then this theory predicts that people with ADHD should show a more limited sense of self-awareness and self-monitoring. This will eventually lead to a problem with having and using their sense of their past (hindsight) and, as a result, a more limited sense of anticipating their likely future (foresight) if they don’t change their current behavior. They will also have less of a sense of the possible future that might occur for them if they would change the course of their current behavior. Their mental window on time and their sense of themselves across time should be much narrower. They would live in “the now” more exclusively than others who are thinking about themselves across time. Anyone who has lived with someone with ADHD knows that this is in fact the case. As parents often say, children with ADHD do not seem to learn from past mistakes, to act with a sense of their past, or to contemplate the future consequences of how they choose to behave. Rather than not learning, I think they respond too quickly, which prevents them from referring to their past experiences and so to consider what those might teach them about present events. In essence, this means that children and adults with ADHD have a “nearsightedness” to the future. They can see and deal with only those events that are very close at hand or imminent, and not those that lie further ahead. One could say that they are blind to time or the future, or have a sort of future neglect syndrome, in which they are less aware of and attentive to durations of time and the future that likely lies before them.

Those with ADHD will also be less prepared for the future. Because they do not “see” or contemplate events that are approaching from the future, they are likely to careen through life from crisis to crisis. When the inevitable catastrophe from such lack of foresight strikes, they are caught off-guard and react accordingly. They are far too much creatures of the moment.

The upside here is that they do not seem to be as limited by fear of the future as many of us are. We sometimes envy their almost child-like innocence, their happy-golucky nature, and their devil-may-care attitude about the moment. Those with ADHD may also take chances that might luckily pan out where others would hold back. Life for (and with) persons with ADHD may be more exciting as a result, both good and bad.

Lack of foresight, however, can have serious negative and even life-threatening consequences. At the least, the effects can be socially devastating. Promises broken, appointments unmet, and deadlines missed can bring down swift, negative, and unforgiving judgment by others. Reliability is, after all, one of the defining characteristics of a responsible adult in our society. Yet adults with ADHD or with a childhood history of hyperactivity report that they have problems with money management, household organization, management of children’s schedules, and working independently on the job, with a commensurately slower upward movement in their social and occupational status—all related to their diminished sense of time and the future.

Because of the neurological deficit in the abilities to inhibit behavior, be self-aware, and use their hindsight and foresight, people with ADHD not only do not see what lies ahead of them as well as others, but they cannot do so as well as others. In essence, holding them responsible for their problem with anticipating and planning for the future is like holding a deaf person responsible for not hearing us or a blind person accountable for not seeing us—it is ridiculous and serves no constructive social purpose. Yet that is exactly what our society tends to do. We respond with disbelief when told that a person with ADHD did not fully understand the consequences of his behavior, calling it a cop-out to avoid accepting responsibility. We label these people careless, heedless, unreliable, or risktakers, and view them as immature or even immoral or irrational. We hold them responsible for their seeming carelessness and punish them accordingly, sometimes severely.

No wonder so many of those with ADHD are so demoralized upon reaching adolescence or young adulthood. By then they begin to adopt society’s view of themselves, holding themselves as much to blame for their failures as do others. This sense of underachievement and of failing themselves and their families can be so serious in adults with ADHD as to require separate psychological treatment from what may be needed to deal with their ADHD symptoms alone.

The altered sense of time these deficits create in those with ADHD has several other interesting effects. First, it may make them feel as if time is passing more slowly than it actually does. This means most things seem to take longer than they expected, which is understandably frustrating. It’s not surprising, then, that people with ADHD seem very impatient under many circumstances. Second, without a sense of the future, it’s difficult to defer gratification. Studies that have followed children with ADHD into adulthood (see Chapter 4) provide clear evidence that they are not as likely to choose pathways in life that involve immediate sacrifice for longer term, much larger payoffs. Examples include sticking with higher education and saving money. Finally, there is some evidence that this diminished sense of the future causes those with ADHD to be less health-conscious than others. One price we pay for our sense of time is an accompanying sense of our own limited existence and eventual death. So the natural conclusion is that people with ADHD may not have the same sense of their own mortality that the rest of us have. Perhaps they are not part of the wave of increasing appreciation for the health-related consequences of our behavior.

Having less regard for the future consequences of any behavior, are individuals with ADHD more likely than others to engage in deleterious habits such as overeating, lack of exercise, smoking tobacco, drinking alcohol to excess, abusing illegal substances, and driving carelessly? Every indication that they may be so comes from follow-up studies that have found teenagers and young adults with ADHD to be more likely to smoke tobacco and drink alcohol, and to do so more frequently, than those who do not have ADHD. They also have a greater risk for speeding tickets and traffic accidents while driving than do others of their age group, as noted in Chapter 1. In addition, recent research suggests that teens with ADHD are likely to become sexually active somewhat earlier than normal teens, are less likely to employ birth control during sexual activities, and are more likely therefore to become pregnant or to contract sexually transmitted diseases. Young adults with ADHD may also be more overweight and less likely to exercise or engage in other forms of health maintenance and to use preventive medical and dental practices, and so be more prone to coronary heart disease. All of these risks illustrate the problems that can result from failure to give due deliberation to the future generally and the later consequences of current actions specifically.

Self-Directed Speech: The Mind’s Voice

Another ability that is related to being able to inhibit behavior, show self-awareness, and have a sense of our past and future is the ability to talk to ourselves. Dr. Bronowski pointed out that all other species use their language to communicate with others. Only humans have developed the ability to use language to communicate with themselves as well. We see this ability developing in children. They progress from talking to others as toddlers to talking out loud to themselves while playing during their later preschool years to gradually talking to themselves subvocally (so that others do not hear) during the early elementary years. Finally they wind up talking to themselves in their “mind’s voice” so that no one detects the self-speech at all. This is called internalized speech. It forms the fourth executive ability or function that allows us to control our own behavior. We can talk to ourselves.

The changes this self-speech brings about in behavior as it develops are quite remarkable. As speech goes from being directed solely at others to also being directed at ourselves and then being internalized, it also moves from just describing things to giving ourselves directions or instructions. That is, it becomes not just a way to talk about the world to ourselves, but a means of guiding and controlling our own behavior through self-directed instructions. Such self-instructions increasingly take over the guidance of our behavior, freeing it from the domineering control of immediate events around us. As a result, self-speech helps us stay on our course toward our plans and goals. It also helps us do better the next time we encounter a task because we have now formulated some instructions to follow, based on our initial experience with that task or situation. And it provides a means by which we can directly encourage ourselves to ride out the current situation, boring or unpleasant as it may be, so as to achieve the goal and the greater rewards often associated with such deferred gratification.

Psychologists have called the ability to use language to control behavior rule-governed behavior. When we develop plans for the future, set goals for ourselves, and then carry out our behavior according to those plans and goals, we are often using rule-governed behavior to facilitate it. These four executive abilities discussed so far largely underlie our sense of free will. We recognize that they free us from having our behavior controlled by the immediate and momentary circumstances that utterly control the behavior of other species. We can bring our behavior under the control of rules, instructions, plans, and goals so that our sense of the past informs our behavior in the present, but so does our sense of the future.

Current research on ADHD now gives us enough evidence to say with certainty that these four domains of executive functioning, including self-speech and rule-governed behavior, are deficient in those with ADHD. This may also help to explain why children with ADHD talk too much compared to others—their speech is less internalized or private. Certainly those of us who work clinically with these children, as well as many parents and teachers, have commented on the problems they have with using language and rules in the service of self-control.

Dr. Stephen Hayes, a psychologist who has written extensively about the human ability to use rule-governed behavior and its consequences, has identified a number of conditions that result from our ability to use self-speech and the rule-following behavior it permits. These conditions, being diminished in people with ADHD, support the theory that deficiencies in self-speech and rule-governed behavior are part of ADHD:

1. Our behavior in a given situation should be much less variable when we are following rules than when we are being influenced or controlled by the events of the moment. As mentioned earlier, inconsistent work performance and more variable behavior is a hallmark of ADHD.

2. A person who is following rules should be less susceptible to control by the immediate consequences or events in a situation and their momentary and potentially unpredictable changes. In ADHD, however, we constantly see people “going with the flow,” apparently letting events control them rather than the other way around.

3. Where rules are in conflict with the desires of the moment, the rule is more likely to control our behavior. In other words, we are able to stick to a plan (such as a diet) even though the lure (the ice cream in the freezer) is more attractive right now. The person with ADHD is constantly being controlled by the promise of whatever seems more rewarding at the moment; she is more likely than most to give in to the craving for the ice cream, even though it means deviating from the diet.

4. At times rule-governed behavior makes us too rigid; the rule we are following is inappropriate for the specific situation we are facing, but we follow it anyway. For example, we prepare a recipe by a cook we trust, and the resulting dish is mediocre. Yet we follow it to the letter a second time, because the cookbook author is widely known and must be right. It still comes out less than great—because, unknown to us, there is a typographical error in the recipe; the rules are incorrect. A person with ADHD may taste the recipe as he goes along and modify it to his liking, even though such modifications are not part of the recipe. Because he breaks the rules and lets his tasting of the dish (the immediate feedback or consequences) guide him, the dish may turn out better. So under some circumstances, those with ADHD may actually have an advantage over people who are too rule-governed.

5. When we follow rules, we should be able to persist at what we are doing and behave “properly,” even though any rewards for doing so will be long delayed. That is, we should be able to defer gratification. For instance, a child should be able to stick to the rules or plan to do homework because the more distant rewards—the consequences of turning in the work the next day or not—are more important than the current reward of avoiding the boring assignment. The child with ADHD is more likely to get off-task (to lose track of the rule) during the homework and to pursue things that are more rewarding at the moment.

6. Finally, we should see a steady increase in the ability to use rule-governed behavior over time during a child’s development into adulthood. Yet children with ADHD are consistently seen as immature precisely because they are more easily controlled by momentary events and immediate consequences than others their age, and because they lag behind in the ability to follow rules, to talk to themselves, to use rules to control their own behavior, and eventually to create their own rules when faced with problems.

Self-Directed Emotions: The Mind’s Heart

This is the fifth executive function or ability. Being able to inhibit our urges to respond and to wait gives our brain time to split incoming information into two parts: the personal meaning of the event (our feelings or emotional reactions) and the information or content of the event. We can then deal with the content objectively, without introducing as much personal bias into our reaction based on our emotions. We certainly do not do this all the time, but we have the power to do it and to realize that exercising this ability enables us to deal more rationally, less emotionally, and so more effectively with a given situation. This is why we tell our children to count to 10 before reacting to an upset: it gives them time to settle down and begin to reevaluate what has happened more rationally and objectively.

We know from personal experience that responding impulsively with emotional behavior is clearly not always in our best interest. Neither is it always bad, but waiting and better evaluating what is happening to us allows us to formulate our reactions, even our emotional ones, so that they are better suited to the situation. This capacity to delay our response permits us to evaluate events more objectively, rationally, and logically, as if from the standpoint of an outside, neutral witness. It gives us the power to study our world more objectively than any other species can. In fact, if we could not separate our personal feelings about information from the information itself, we could not pursue science—our most rational human endeavor.

This is not to say that we develop to a point where we have no emotions or are entirely objective in our reactions to events. Nothing could be further from the truth. Our emotional reactions are an essential part of our ability to evaluate the world around us and make decisions. But how we respond to events and make decisions about them can be affected very adversely if we allow them to be governed by the first emotions we feel when something happens to us. It is this initial emotional urge that often requires some restraint and a period of moderation to make it not only more socially acceptable to others around us, but also more effective in helping us make the right decisions and to achieve our goals. This theory seems to explain why children with ADHD are so emotional compared to other children. By not inhibiting their first reactions to a situation, they do not give themselves time to separate their feelings from the facts. They usually live to regret these impulsive and raw emotional reactions because their behavior drives others away, resulting in social hostility, punishment, rejection, and eventually loss of friendships. It gives them a bad reputation with teachers and coaches, strains relationships with parents and siblings, and in adults can lead to even greater conflicts at home and especially at work, including a greater likelihood of being fired.

Their failure to inhibit their feelings as well as other children of the same age makes us see children with ADHD as emotionally immature. A 7-year-old child with ADHD may throw a tantrum when denied a snack just before dinner, for example. While we might accept this reaction from a 4-year-old, we would expect most 7-year-olds to be able to inhibit the angry reaction for long enough to cool off and evaluate the information conveyed by Mom: the reasons for denying the snack.

Unfortunately, we cannot push that 7-year-old to the maturity we’d like to see simply by telling her to inhibit reactions or wait before responding. As Chapter 3 explains, the power to do so is impaired because of a problem in the brain centers responsible for inhibition and the other executive abilities. Although people with ADHD may be able to learn consciously to inhibit their behavior in certain situations, this takes a great deal of effort.

Consequently, people with ADHD will have difficulty adapting to situations that require being cool, calm, and unemotional or objective. Unfortunately, our society seems to place us in many such situations. Indeed, our society highly values the ability to remain calm and rational, and often rewards it with greater status, prestige, responsibility, and even income than those without such ability can expect.

There is an upside, however: those with ADHD will be very passionate and emotional in their actions, and thus may do what they do with far more personal conviction and certainly less hesitation than the rest of us. Those with ADHD may very well match or surpass others in the performing arts (such as music or drama) or in the humanities (such as writing poetry or fiction), where strong emotional expression is advantageous. Where passionate conviction is desirable, such as in negotiation or sales, we might find that people with ADHD shine. Combined with their talkativeness and preference for socializing over solitary work, such passion can make for very good salespeople. Remember, it is not their intellect that is impaired. Nor is their ability to separate emotions from information completely lacking. People with ADHD simply do not exercise that ability as well or as efficiently or use it to guide their behavior as much because they respond too quickly. By not controlling their impulse to act, they do not leave time for emotional restraint and for the splitting off of facts from personal feeling. I do not mean to imply here that those with ADHD are better than other people in these particular professions. I only mean that they may be at considerably less of a disadvantage than they may be in other occupations that stress emotional restraint and objectivity. They will be less distinguishable from others in these walks of life and so may have a better chance to excel because of their other positive attributes.

Linked to emotional self-control is the capacity for self-motivation. When normal children develop emotional self-control, part of what they are doing is internalizing their emotions and keeping them from public display. The emotional reaction exists, but its public display is being restrained. This ability to keep emotions covert or inside while we experience them and attempt to moderate them can lead us to modify them as needed before displaying them to others. We may even be able to greatly reduce or eliminate these initial emotional urges by trying to calm ourselves down, thinking of something more positive, or talking to ourselves about why it would not be good to express that feeling.

This internalizing of emotion is important for another reason, however. Emotions tell us whether we find something positive, negative or unpleasant, or just neutral. As such, they can encourage us to continue what we are doing or stop it and switch to something better. That is, they motivate us toward some sort of action. So children who can internalize their emotions are automatically developing the ability to internalize their motivation. This facility is the origin of what many people call intrinsic motivation and what others might call drive, persistence, ambition, determination, willpower, or stick-to-it-iveness. When we create our own internal motivation, we don’t need the encouragement, rewards, payoffs, or other incentives that younger children require as often as they do to stay the course. We can stick with our plans, follow through on our goals, and resist the things around us that may be distracting because we are using our own inner motivational state to drive our own behavior toward the goal. We can largely motivate ourselves in the absence of other incentives or inducements. Private, internalized emotions become the wellspring for our private motivations, and these can support our behavior directed toward goals and the future and help us stay the course toward them. This is a major part of the human will—willpower.

This revelation helps us see why children with ADHD have so much trouble with persistence, willpower, or what others call a short attention span. It’s not really attention that’s the problem, but self-motivation. They cannot create private, internal, or intrinsic motivation as well as others, and so they cannot persist at activities, plans, goals, or instructions as well as others can do when there is little incentive or motivation in the setting or task to help them sustain it. The more boring and unrewarding an activity is, the harder it will be for them to do what normal children do: create their own motivation to help them stick with the task. This means that they must depend on external sources of motivation, and that when external consequences are not provided they will drift away from the work or activity at hand—not because of laziness, but because of a biological problem with the functioning of this part of the brain. Obviously, then, helping a child with ADHD complete a task often means arranging additional and at times artificial sources of motivation, such as rewards.

Self-Directed Mental Play: The Source of Problem Solving and Innovation

The sixth and final executive ability is related to our internal use of speech and consists of two parts: (1) the ability to break information or messages we receive into parts or smaller units (analysis) and (2) the ability to recombine these parts into entirely new outgoing messages or instructions (synthesis). We do not treat instructions or information as indivisible wholes. While we may treat a sentence as one grammatical unit, we recognize that it can also be broken down into nouns, verbs, adverbs, and other parts of speech. Likewise, we know that the idea conveyed can be broken down into the objects in the idea, the actions taken with the objects, the physical nature of the objects (colors, shapes, etc.), and so on. With this mental ability, we can first decompose and analyze the messages and information we receive, in the same way that we can parse a sentence. Second, we can reassemble those parts in a nearly infinite number of ways and then choose the outgoing message or behavior that may be most adaptive or successful at that moment. This ability endows us with tremendous powers of problem solving, imagination, and creativity. Unless we wait and allow enough time for it to happen, this process, called reconstitution by Dr. Bronowski, is unlikely to occur.

This ability constitutes yet another executive function: problem solving and goal-directed innovation or creativity. We can invent new ideas and new rules when we have no past experience or immediately available rule to follow. When we inhibit our response and wait, we can take old ideas and rules and break them apart, combining them with those of other ideas and rules to come up with entirely new combinations. We call this process problem solving, and as humans we are masters at it. People who cannot inhibit and delay their responses to what’s happening around them will be less adept at devising solutions to problems they have encountered.

If ADHD involves a deficit in executive functioning, then those with ADHD should not be as good at this process of reconstitution or problem solving as people without ADHD. Very little research on this idea as it applies to ADHD is available, but what research does exist seems to support its being problematic for those with ADHD. The results of psychology experiments in which children with ADHD have been required to come up with as many solutions to a given problem as they can think of within a short period of time suggest that they are not able to do so as well as other children. Other studies examining the curiosity of children with ADHD during play have shown that they do not evaluate or explore objects as well as other children of the same age. The results suggest that children with ADHD do not analyze things they are doing into as many parts or dimensions as children without ADHD do. Such findings seem to hint that the process of problem solving or goal-directed innovation is not used as well in children with ADHD as in other children.

THE SOCIAL PURPOSES OF EXECUTIVE FUNCTIONING AND SELF-CONTROL

As I indicated earlier, these six executive functions are what give us our capacity for self-regulation and hence self-determination. We are the only species that possesses these mental abilities (though the first three of them may be evident in a very, very primitive form in our closest living evolutionary relatives, the chimpanzees). What is their purpose? How did they contribute to our survival and welfare in such important ways that they have evolved to their current far higher state of advancement in modern people? For more than a decade I have struggled to find answers to these questions. My search led me to not only review the existing science on what psychological and social deficits people have when they suffer injuries to their executive brain but also the major life activities in which we all engage to promote our survival and welfare and what research on human evolution might have to say on the matter. The results of my search were published in my 2012 book The Executive Functions: What They Are, How They Work, and Why They Evolved, which further develops my theory of executive functioning and self-control (and, by extension, of ADHD as well). The short answer to these questions was suggested in earlier books by clinical scientists studying the functions of the prefrontal lobes of the brain—those parts that have become the most highly evolved (and proportionally largest) in humans. These regions of the brain just behind the forehead have been called the “executive” brain because they direct the other parts of the brain and so other mental abilities for purposes of selecting, pursuing, and achieving our goals. Dr. Stuart Dimond, for instance, stated in 1980 that this part of the brain was the seat of our social intelligence. Fifteen years later, Dr. Muriel Lezak stated that they give us our sense of will and purpose and serve to meet our social responsibilities. Like other scientists before and after them, they saw the functions of this part of the brain as being crucial to our social life. I agree, and so I went on to create a model of executive functioning and self-control that identifies four important levels organized in a hierarchy that extend these mental abilities outward into the most important social and civilizing activities in which people engage in their daily life. This part of the brain, and hence these mental abilities, take 25–30 years to mature completely. I will very briefly describe these levels here so that you can understand what people with prefrontal lobe injuries or those with ADHD might be struggling with due to deficits in their executive mental faculties.

The Instrumental/Self-Directed Level

This first level of self-regulation consists of the six executive functions described above. They are called “instrumental” because they provide a means to an end—they consist of things we do to ourselves mentally to control, change, and adjust our behavior. We do that so that we not only can react well to the moment but, more importantly, so that we can improve our future. Specifically, we do so to maximize the later consequences for ourselves instead of always just focusing on the small immediate consequences, as other animals do. We generally cannot see people engaging in most of these self-directed actions because they are mental or private in nature, taking place in the head and forming the conscious mind of the individual; they are “cognitive.” We cannot directly observe people engaging in self-awareness, hindsight, foresight, self-talk, emotion regulation, self-motivation, and mental play, but we know from research that they can do these things and do so throughout their waking day. When people think, this is what they are using to do so. These six instruments give us a set of “mind tools,” like a Swiss Army knife that we can use to control our own behavior, and anticipate, prepare for, and maximize our future, and hence our longer term welfare and happiness. By themselves, they aren’t much good until we see how they promote the next stage or level of self-regulation.

The Self-Reliant Level

When children are born, they are helpless and depend on others (usually parents and family) for their survival and welfare. They continue to be dependent, though progressively less so, for much of the next 10 to 20 years of their lives. With each passing year, however, we witness growth in their ability to care for themselves. This is not only evident in their growing ability to feed, dress, bathe, and otherwise care for their own immediate needs and survival. It is also evident in their growing self-determination, separation from others on whom they previously depended, and self-defense against being used by others to their own disadvantage. The first immediate purpose of executive functioning, then, is to promote the development of daily adaptive functioning (self-care), self-reliance (independence from others), and social self-defense against any pernicious influences of others (self-determination). I think of this as the Robinson Crusoe level of executive functioning—we care for ourselves and our needs while also protecting ourselves from others who may not have our own best interests in mind. As this stage matures, we will see an increase in five interrelated types of behavior and activities in the daily life of the individual: (1) time management, (2) self-organization and problem solving, (3) self-restraint, (4) emotional self-control, and (5) self-motivation. I have recently developed rating scales that can be used to assess these five dimensions of daily executive activities in children and adults. Once this level is well under way, it can facilitate the development of the next stage of executive functioning.

The Social Reciprocity Level

Although this stage begins in relationships within the family, it extends outward to eventually include reciprocal interactions with others. “Reciprocity” here means exchanging, sharing, taking turns, and otherwise trading with other people: we do something for someone, and that person returns the favor. This is the stage at which we make commitments to others, keep promises, trade things we have with others for things they have that we want, and share some of our bounty with others with the understanding that in the future they will do the same for us. People do this every day many times each day. It forms the basis not only for friendships with others but also for economics, division of labor and trade, social etiquette, and even civil and criminal laws. Unlike most other creatures, we are turn-takers, sharers, traders, and reciprocators. Social reciprocity is one of the principal means by which people survive. It spreads the risk of living in an uncertain world by using others in the group like an insurance risk-pool in which all assist each other as needed with the expectation of receiving similar assistance. We live in groups with others, and we have developed a means to depend on each other to promote our own survival and that of others we care for and live with. For this to succeed, we have to police our group and be quick to detect the cheaters among us, withdraw from future dealings with them, and even punish them for their cheating or freeloading without reciprocating. This is one of the major social purposes of the executive brain besides that of social self-defense and independence seen at the prior level.

The Social Cooperative Level

Although reciprocity or sharing and trading can be thought of as being cooperative, here I use the word cooperative as a noun to mean a group of people who come together to accomplish a goal that none of them could reach alone or through simply trading with each other. Here people who have a common goal get together to work to achieve it and divide up the benefits of doing so. By working as a team they can attain goals that are longer term, larger, more complex, and more beneficial than they could achieve by themselves. This is evident every day in many employment settings, community events, and other social activities that require a group of people to work together to achieve a common purpose or goal. If these groups stay together to accomplish multiple goals over time, they may even develop a type of behavior called mutualism seen among family members and close friends. This is where people look out for each other’s longer term welfare and not just their own. They “have each other’s back” so to speak in that they not only work together to achieve a specific goal but also relate to each other in myriad ways that place the other person’s longer term welfare above their own immediate or near-term well-being. Neighborhoods, working groups, close friendship networks, military units, and other such groups that stay together long enough may eventually move up to this highest level of personal and social welfare.

When people experience injuries or developmental problems in their executive, prefrontal brain, these are the types of personal and social activities that are at risk of being deficient or impaired. Understanding executive functioning through this multistage model, we can see just how crucial it is to human survival, welfare, and everyday life and why disorders of executive functioning like ADHD are very serious.

THE DEVELOPMENT OF EXECUTIVE FUNCTIONING

We do not have this tremendous power to be aware of ourselves and to inhibit our behavior when we are first born or during our very early development. Studies of infants indicate that it begins to develop toward the end of the first year of life but continues for the next 20–30 years. As we mature, we can monitor our own behavior and delay it as needed in situations for increasingly longer periods of time so as to use our hindsight and foresight before we finally choose how to respond. Once these three executive abilities emerge (inhibition, self-awareness, hindsight/foresight), the other three mental abilities I have discussed here probably start to mature slowly and in a stepwise manner.

Dr. Bronowski seems to suggest that the ability to inhibit may develop alongside our emerging self-awareness. Perhaps it emerges during the first year of life. Within a few years, a sense of our past begins to mature and, along with it, a beginning sense of the future. The ability to talk to ourselves and to use self-speech likely develops next, between 3 and 5 years of age, and slowly becomes internalized so that others no longer hear us doing this. Research on early language development has indicated that the beginnings of self-directed and internal speech probably take 8–10 years to mature completely. Next to emerge, and dependent on the earlier stages, is the ability to create private emotions and from this self-motivation. The last to develop is the ability to analyze and break ideas down into units and then recombine or synthesize them into entirely new ideas. It is not clear when this ability begins to occur in child development, but it overlaps with the development of children’s play.

In my opinion, future scientific studies of children with ADHD are likely to show that they develop all of these executive abilities somewhat later than children without ADHD do. Future research is also likely to show that they are less proficient at them than children of the same age without ADHD. Fortunately for most children with ADHD, some research is beginning to show that ADHD medications produce a temporary improvement in executive abilities such that children with ADHD behave and think much like their age-mates without ADHD while they are taking medication. They are now able to show self-control, to direct their behavior toward the future, and to free themselves from being controlled purely by events of the moment.

The Neurological Connection: Rethinking Our View of Will

We know that ADHD involves a deficit in the ability of the individual to inhibit responses to situations or events. That is, it is a problem of self-control. As such, the term developmental disorder of self-control (executive functioning) may be the most accurate name for ADHD. The term ADHD, focusing as it does on attention deficit and hyperactivity, clearly falls short. We also know from years of research that this ability to inhibit our behavior and self-regulate is controlled by the very front part of our brain, in an area known as the prefrontal cortex. Therefore, it has not been surprising to learn during the past 25 years of research that this part of the brain in people with ADHD is not as large, as mature, or as active as it is in those who do not have ADHD. This is also true of several other areas that are interconnected to the prefrontal cortex (see Chapter 3 for more on this subject). It is a tremendous advance in our understanding of ADHD to have a number of different studies that document this underdevelopment and underactivity of the brain and relate it to deficits in the executive abilities.

The theory I have discussed in this chapter indicates that this prefrontal part of the brain, or other parts closely related to it, must give us our powers of self-control and the capacity to direct our behavior toward the future. As Dr. Joaquim Fuster showed in his extensive research summarized in his 1997 book The Prefrontal Cortex, our knowledge from human patients and from primates with injuries to this part of their brain strongly suggests that it is likely to be so. Finally, our understanding of the brain and how it functions can now be fitted, like a piece of a puzzle, to what we have come to understand about the nature of ADHD, another piece of the puzzle. From this I believe we can safely conclude that ADHD involves a problem in the development and functioning of the prefrontal area of the brain and its connections to related brain regions.

The developmental–neurological nature of ADHD directly contradicts our strongly held beliefs that self-control and free will are totally determined by individuals and their upbringing. I believe that this contradiction is what underlies much of society’s resistance to admitting this disorder into the class of developmental disabilities, for which we have great empathy and on behalf of which we make special allowances and rights. Society has struggled before with scientific advances that contradict the common wisdom of the time, and it has changed to accommodate them. It is my hope that society will come to do the same for ADHD.

Interestingly, while this understanding of ADHD should evoke empathy, it does not mean that we should stop holding children with ADHD accountable for their behavior. Those with ADHD are not insensitive to the consequences of their actions, but they have trouble connecting consequences with their own behavior because of the time delay between the behavior and the important delayed consequences of those actions. This means that to help those with ADHD we must make them more accountable, not less so. We must devise consequences that are more immediate, more frequent, and more salient than they would normally be in any given situation. Thus we can help them compensate for their deficit and live more normal, functional lives.

The perspective on ADHD presented here is the cornerstone of this book. The idea that ADHD is a disorder of self-control, executive functioning, willpower, and the organizing and directing of behavior toward the future more generally provides the rationale for almost every treatment recommendation that follows. It also provides a larger framework in which to understand the results of research on the developmental course of ADHD; the problems that are often associated with it; and the social, academic, and occupational problems that are caused by it over time.

This new outlook on ADHD can provide you with the fundamental rationale to accept your child’s executive disability, to adapt the social and academic demands made on your child to the child’s disability, to work to strengthen (where possible) your child’s weaknesses in the processes involved in developing self-control, and to advocate for your child’s need for and rights to services for this problem. This knowledge will empower you to act as the scientific, executive, and principle-centered parent that you will have to be to successfully raise a child with ADHD.