ADHD is a complicated and interesting collection of brain based traits and qualities, some very positive and some that can be difficult to live with and manage. It is a neurobiological condition. Many consider ADHD a gift of sorts. Dr. Edward Hallowell, a psychiatrist who writes extensively about ADHD and has ADHD himself describes the brain of someone with ADHD as a “Ferrari brain with bicycle brakes”. Some of the world’s most influential and innovative people have ADHD. People with ADHD are frequently considered fun, smart, spontaneous, creative and/or energetic. They often think big and live large. At the same time, they can have difficulty accomplishing basic things like being on time, remembering appointments or keeping track of their keys. They can also have social problems like blurting out comments before they’ve thought about them or interrupting conversations at awkward times. This is because the prefrontal cortex – the control center of the brain and the area responsible for coordinating and organizing various activities in the brain – is slower and less fully developed in an ADHD brain than in a brain without ADHD. This is frequently associated with reduced amounts of the neurotransmitters dopamine and norepeniphrine. Medications used to treat ADHD work by increasing the levels and availability of these chemicals in the brain.
The prefrontal cortex is responsible for coordinating many of the skills required to be a responsible, productive person – skills commonly referred to collectively as executive functioning. In “normal” brains the prefrontal cortex is not fully developed until the average age of 25. In ADHD brains there can be a delay of 3-6 years in the development of the prefrontal cortex and associated executive function skills. Dr. Thomas Brown, author of Attention Deficit Disorder: the Unfocused Mind in Children and Adults, likes to compare the prefrontal cortex to the conductor of an orchestra and the many, varied functions of the brain to the musicians. In an ADHD brain there are often many wonderful assets and abilities (the musicians) that cannot be put to effective use (make good music together) because the frontal lobes are not working well (the conductor cannot coordinate the efforts of the musicians). As a result, despite often having many talents and gifts the person with ADHD often has difficulty performing effectively in school, work and/or relationships.
ADHD has nothing to do with intelligence or willpower and everything to do with these brain based problems with executive functioning. Many individuals with ADHD have strong intellectual abilities and the will to succeed but they have difficulty putting their abilities to effective use. Many people with ADHD have been repeatedly told that they were not living up to their potential. This is because the people around them can see that they have skills and abilities and cannot understand why those skills and abilities are not being put to good use. As a result these same people may attribute this observed lack of productivity and/or poor performance to laziness and a lack of motivation on the part of the person with ADHD. Most individuals with ADHD ARE motivated and DO want to succeed but sometimes give up in the face of constant criticism and frustration because most of their efforts are either unrecognized or unsuccessful or both. As a consequence the self esteem of individuals with ADHD is often poor, despite the presence of significant pockets of abilities and strengths.
The DSM-IV criteria for diagnosing ADHD require evidence of difficulty in some combination of four core areas: inattention, impulsivity, distractibility and, in some cases, hyperactivity. Although many people experience some of the problems associated with ADHD some of the time (for ex. most everybody has had times when they felt “spacey” and distracted), people with ADHD experience them to such a degree that their ability to function in important areas of their lives (like school, work or relationships) is negatively affected. In order to be diagnosed with ADHD there needs to be consistent evidence of this disruption in several key life areas for more than six months.
It is not uncommon for ADHD to be accompanied by other issues, which are commonly called co-existing or co-morbid conditions. These can include such things as depression, anxiety and learning disorders as well as oppositional defiant disorder, tic disorders and conduct disorders. The best, most effective, treatment for ADHD is multimodal treatment that targets a whole person, not just one part of the person. This may require seeing more than one professional. For example, many students with ADHD have an academic tutor, a coach and a therapist.
The trick to living successfully with ADHD is to find a way to “unwrap the gifts”* and manage the practical difficulties that come with the wonderful, quirky brain associated with ADHD. Another way to say this, using Dr. Brown’s orchestra analogy, is that you need to develop and work with the conductor so the orchestra can play well. Or using Dr. Hallowell’s analogy of the Ferrari brain with the bicycle brakes – once you develop your brakes you can really take advantage of all the Ferrari has to offer. The world would be a duller, less exciting place without ADHD. Learning how to manage it can make the personal toll less costly while preserving the benefits.
*Edward Hallowell, MD
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