Understanding ADD and ADHD: is it really an attention deficit?
Reading time: 10 minutes
A look at terminology: is there a difference between ADD and ADHD?
ADD (Attention Deficit Disorder) and ADHD (Attention Deficit/Hyperactivity Disorder) are two names for the same thing – one new, one old.
Historically, ADD was used to describe what is now known as the primarily inattentive type of ADHD.
The terms have been used to describe a wide range of pathologies in both children and adults.
Constantly fidgeting or feeling like you need to do something? ADHD.
Can’t focus on the task you’re doing although you really want to? ADHD.
In reality, the terms refer to very complex sets of behaviors which can be broken down into three main types:
Predominantly hyperactive-impulsive ADHD marked by restlessness and impulsivity.
Predominantly inattentive ADHD, characterized by inattention, forgetfulness, and difficulty completing tasks.
Combined ADHD (most common): showing both symptoms of inattention, and hyperactivity/impulsivity.
Debunking myths: what ADHD is not
Contrary to popular belief, ADHD is not an attention deficit. People with ADHD don’t lack attention. If anything, they have an abundance of attention. What they lack is the ability to control what to focus their attention on.
…And not for lack of trying.
The ADHD mind: A Closer Look
Imagine your mind is like a TV with many different channels. You’ve got channels for each sense, bodily functions, emotions, memories… You get the gist.
Most people can switch between those channels seamlessly, whenever they want. For people with ADHD… it’s not as easy. It’s like someone else holds the remote and does one of two things:
Get stuck on a single channel (blocking out hunger, or sleep, or… Ooops… it’s 7 pm, I should let my friend know I won’t make it to our 5 pm meeting…)
Switch randomly between channels (much like Lorelai’s thought process in this video)
The neuroscience behind ADHD
Brain development
The brains of children with ADHD develop differently than the brains of their neurotypical peers¹.
While the motor cortex (the area responsible for muscle contractions and movement) shows slightly earlier maturation, other areas show a developmental delay.
On average, the delay observed was 30%. The area with the highest delay is the prefrontal cortex, the area responsible for executive functions.
This means that an 18-year-old with ADHD might have, in certain aspects, the maturity of a 12-year-old. And the growing consensus among scientists is that the ADHD brain will continue to be wired differently even after full maturation.
Wait, does this mean an 18-year-old is only as smart as a 12-year-old?
NO! This delay has nothing to do with intelligence.
So, while your 18-year-old will be able to read and understand the same things as their peers, some of their executive functions (like the ability to not say out loud everything that pops up in their mind, or the ability to plan their finances, etc.) will likely be underdeveloped.
And although people with ADHD feel this delay, they might not have the language or the knowledge to explain it.
Executive functions explained
Well, researchers have not yet settled on one definition, but there is a common thread throughout several researchers’ usage of the term. For instance:
Dr. Barkley (one of the most respected researchers in the field of ADHD) explains Executive Function as the ability to manage current behavior so that future needs can be met.
Michelle Garcia Winner (founder of socialthinking.com) explains executive functions as having a goal, thinking about how to achieve the goal, creating an action plan to get to the goal, and self-regulating behaviors and emotions to carry out the goal.
I love the metaphor Dr. Thomas Brown (another very respected researcher in the field of ADHD) uses to explain Executive Function:
Regardless of how well the musicians in a symphony orchestra may play their instruments, they are not likely to produce very good symphonic music if they do not have a conductor to select what piece is to be played, to start their playing together, to keep them on time, to modulate the pace and volume of each section, and to introduce or fade out various instruments at appropriate times. Although each musician may play their instrument skillfully, the subtle, dynamic, integrated functioning of the orchestra depends crucially upon the coordinating and managing functions of the conductor².
Real-life implications of ADHD – Andy’s example
Andy is in school and wants to pay attention to what his teacher is saying. At the same time, his classmate, Steve (whom he fought with this morning) tells him to look out the window. At some point, Andy remembers Tina’s birthday is today.
How does this play out for neurotypical people?
If you’re a neurotypical person, your inner conductor (to continue with Dr. Brown’s metaphor) helps you prioritize and regulate your reactions.
If Andy were neurotypical, things would usually look something like this:
Andy has a long-term goal: finishing school. This goal is always somewhere in the back of his mind. He has a plan to achieve the goal: he will pay attention in class, do his homework, and learn, all of which will allow him to pass the final exams.
Right now, he knows his priority: focusing in class. So he signals to Steve that they can talk after class. When Andy realizes he’s hungry, he tells himself he’ll eat in the next break. Then he decides to focus on what his teacher is saying.
How does this play out for people with ADHD?
If you have ADHD, your inner conductor might be…sleeping on the job.
For ADHD Andy, the situation can play out in a few ways:
He might hyperfocus on the class subject if it is interesting for him. Or his brain might decide it’s more interesting to hyperfocus on the fight he had earlier, and start ruminating.
If none of the topics above are interesting enough to get his brain engaged, this is what happens:
While listening to the lesson, Andy hears Tina asking a question. He remembers it’s Tina’s birthday today, and starts looking through his backpack to make sure he brought her present. As he reaches into his backpack, his fingers find his lunch. Oh, I’m so hungry! I wonder what mom packed for lunch…
5 minutes later he wakes up from that thought: Oh no, the teacher just erased the blackboard, and I did not copy down the homework! I’ll ask Steve for the notes. If he is willing to give them to me after the fight this morning. Oh, yes, he was pointing out the window…
While looking out the window to see what Steve was showing, Andy realized his hands were still in his backpack: What was I looking for? And why is the bell ringing already, the class can’t have ended, we just got started like…oh my, where did 50 minutes go?
That must be exhausting, right?
Why is the ADHD experience so different? A deep dive into Andy’s example
A thinking trap that all people experience is called temporal discounting. The more distant in time a reward is (like finishing school), the less value it has. For most ADHD-ers, research has proven that the temporal discounting is much steeper³. Because of the temporal discounting, Andy’s long-term goal of finishing school is not as valuable as short-term ones (like checking to see if he remembered to bring Tina’s present).
Moreover, even though Andy knows that he wants to finish school (it’s the whole reason he came to school today, right?), he rarely has his goal in the back of his mind.
And even for his short-term goals, Andy is unable to self-regulate. He impulsively chases each thought that comes into his mind, acting on each of them, getting distracted, and…not finalizing any.
He is also struggling with focus: he only realizes he is hungry when he touches the sandwich. Most of the time, his thoughts are so stimulating, that he does not know what his body needs or feels in the present.
And lastly, Andy is faced with time blindness: he was so lost in his thoughts and actions, that he did not even realize when the time flew by, and now he finds himself having to get the notes from Steve (if he even remembers asking!).
In closing
…But everyone struggles with these things every once in a while, right?
Yes, everyone struggles with some of these issues sometimes. But for people with ADHD, this happens very often. This means that they must constantly look for strategies to compensate or readjust to overcome setbacks - an exhausting daily struggle.
Carmen Mitroescu, in this previous article: link
These are all executive functions that people with ADHD struggle with. Andy did not choose if he wanted to be distracted or not. If you ask him, he will tell you that his goal of finishing school is much more important than whatever Steve was showing out the window. Andy does not have a say in how his brain perceives time. And he also wishes he was more aware of what is going on in his body.
But wishing things were different, or trying harder does not help. Accepting this is the first step to a more fulfilling life for Andy. Because only when he accepts this, will he start looking for solutions. For strategies that work for him to mitigate all his executive function struggles. And with the right strategies… Life can become so much easier and more fulfilling.
Next week, we will talk about Andy and why he can sometimes focus perfectly fine, and sometimes he can’t focus no matter how much he tries to. Stay tuned!
Until then… What insights did you gain from today's discussion? Do you have any of the challenges Andy has? Share your thoughts in the comments below!
References:
[1] Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J. D., Lerch, J. P., Greenstein, D., … & Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences, 104(49), 19649-19654. https://doi.org/10.1073/pnas.0707741104
[2] The Adult ADHD Mind: Executive Function Connections Thomas E. Brown, Ph.D.: https://www.additudemag.com/inside-the-add-mind/
[3] Scheres A, Tontsch C, Thoeny AL, Kaczkurkin A. Temporal reward discounting in attention-deficit/hyperactivity disorder: the contribution of symptom domains, reward magnitude, and session length. https://pubmed.ncbi.nlm.nih.gov/20034616/