Failing to Develop on Schedule

the second dimension failing to develop on schedule will appear about two to three years after the first and this is known as the attention deficit but it isn't here again we have a misnomer there are at least six or seven kinds of attention and supporting networks in the human brain they are not all disrupted by this disorder what we want to know is which one to help us with differential diagnosis to help us tell ADHD from an anxiety disorder and from autism and all the other psychiatric disorders which all interfere with attention at some point

in life ADHD is not the only attention deficit we need to be more precise if someone comes to us and says my child or I am inattentive that is useless diagnostically what I need to know is the nature of the inattentiveness and we have now known for a decade that the inattentiveness that we see in ADHD is distinct from that produced by all other disorders because it is most I think accurately described as a failure of persistence the first attention problem is persistence toward a goal notice that this implies behavior motivation and the future that

is very important the other forms of attention do not ADHD is not a problem of perception of filtering of processing of how the posterior part of our brain functions it is a problem with the motor part of the brain this frontal lobe can you sustain action toward a goal adequately to attain it that implies a motivation deficit and that is true and it implies future directed behavior and that is true ADHD is a failure to direct behavior forward in time we cannot persist toward these delayed endpoints in life the tasks the goals the things that

need to get done so persistence is deficit one in the area of attention now to persist toward a goal you must be able to resist distractions but that too is not a perceptual issue it is a motor issue the person with ADHD does not have problems with perceiving distractors better than others it is that they respond to distractors more than others and that is an inhibitory failure not a perceptual difference you and I may all hear the noise in the kitchen the person with ADHD is compelled to react to it oh did you hear that

I guess they're washing dishes maybe I'll stop in and take a look did you know I was a dishwasher when I was back in college that's how I earn my weight do you see what's going on here you all heard the dish but it was irrelevant to what we're here to do today but to the ADHD individual the distraction is going to provoke a response and the response can't be inhibited and now they're off to the races skipping from one thing to another to another now there is a third aspect here that is impaired but

it is not one of attention most people when they are distracted re-engage the in completed goal the person with ADHD is far less likely to do so and this has nothing to do with attention this is working memory so I would want a family to understand that there's more here than in attentiveness there was a working memory disorder and I would want them to know that working memory is one of the five special executive functions of the human brain suggesting that ADHD is e F D D executive function deficit disorder because working memory is where

we remember what we're doing it is remembering so as to do it is consciously effortfully holding in mind the what the when of what we are doing it's what you lose at my age and when you hit menopause you do not lose memory you lose working memory you forget what you were doing where you were going what the goal was the steps to the goal how you were getting there it is that that allows you to re-engage the in completed goal because you are holding in mind the goal that which ADHD children and adults will

lose the goal is gone it is forgotten and now anything else compelling around them will capture their behavior hence the symptom skips from one in completed activity to another the ability to re-engage a goal is a working memory disorder and that's what they cannot do and this begins to open the door on the possibility that the other four executive functions are impaired as well more on that later so let's understand that there are three interacting attentional problems but that they are best thought of as executive deficits not attention deficits and they are the problem with

persistence toward the future resistance of distractions along the way and working memory and now you understand the nature of this attention problem from the one that's produced by anxiety and depression and autism and all the other disorders including the learning disabilities which have nothing to do with these I would want families to understand that there is more to ADHD than just the inhibition and these attention and working memory problems that at its heart in its sole it is a disorder of self-regulation not one of attention I think the biggest problem we have had as a

group in convincing the general public about the seriousness of our children's disorder versus autism or schizophrenia or the other disorders is the very name itself is trivial ADHD go to Starbucks good god have some caffeine we got more serious fish to fry here in psychiatry than the fact that you just can't pay attention right part of the reason that our disorder that the name of this disorder is so often pilloried in the media is because I think we miss named it this is the developmental disorder of self-regulation not of attention and that is a serious

disorder as serious as manic depression and in its own way as autism but it doesn't convey that to people if they understand it only as a DHD as opposed to sr DD a self-regulatory developmental disorder so I would want families to understand the seriousness of this that this isn't simply inattention there are some profoundly unique human traits that are not emerging as they should in this individual and if you'll understand that you'll understand the bigger picture the why of everything if it's just an attention problem why am I seeing impairment in virtually every domain in

which this child is asked to function that would not come from just in attentiveness but it would come from an executive function disorder a self regulatory disorder so I would want parents to understand that this is the essence of this disorder self-regulation what is that it is first of all the ability to consciously willfully choose to inhibit your behavior and then to engage in a series of self-directed actions that is after all what self control is you start to do things to yourself these are responses that are not directed at the world around you they're

directed at you right you're trying to change your behavior in some fundamental way the second part of self control that your child struggles is not just the stopping but the thinking the thinking is the self-directed activity the stuff I am doing to myself why would I do these things to myself to change my behavior from what it would otherwise be and why would I do that to change my future self regulation is not just for short-term self-improvement it's for long-term self-improvement it's to see to your own welfare over the long term should you act this

way given the sustained or delayed consequences that lie ahead for you that is what you must stop and think about and that is what they don't stop and think about the delayed winces so your child is not just inattentive they cannot stop and engage in a series of self-directed actions that they will now use to modify and moderate their behavior so as to bring it in line with their long-term welfare the future and that's what your your child is struggling so mightily with in their development it's what the other kids are acquiring and your child

is so far behind him