The Truth About Attention Deficit Disorder

Published originally August 16, 2011 on the web for Psychology Today magazine in The Mysteries of ADD

(Note: In this article, the term ADD is used to refer to both ADD and ADHD)

We recently published a study of 117 high IQ children and adolescents with ADD. All of these very bright students were struggling in school and often also in social relationships because of their ADD-related problems. Results from that study uncovered a pattern of vulnerabilities in executive functions, the management system of the brain, that caused these bright students to have chronic difficulty in focusing on their work, in getting their work done adequately, in keeping in mind what they had just heard or read, and in organizing and completing assignments. Some have been mystified

Students in this study, compared to others of the same age, were impaired not by lack of smarts, but by chronic inability to deploy their smarts in effective work and in getting along with other people. One of the measures used in our study was a rating scale that inquires about impairments in various clusters that describe executive functions (EF). Everyone has problems with these various functions sometimes; people with ADD have much more difficulty with these functions than do most others of the same age.

Data from this study show that individuals can have very high IQ and still suffer significant impairments in each of these executive functions that are essential for working effectively and for getting along with other people.

How can someone be an honor student in elementary school and then struggle and fail repeatedly in high school or college?

Most of the students in this study got high grades in elementary school. Many were in special programs for talented and gifted students. Their school difficulties tended to begin when they made the move from elementary school, where they were with one teacher and the same group of classmates most of the day. Entry into middle school or junior high often brought increasing difficulties in keeping track of assignments and in completing homework. We explain that these students struggled when required to operate more independently without that one teacher who can help to keep tasks and expectations organized for all subjects throughout the day. As homework requirements escalated and parents were less able to monitor what was going on in all the various classes, many of these very bright students began to flounder.

Some of the older students in the study had managed to function well even with the demands of middle school and high school. Many of them had parents who were successful in maintaining supportive scaffolding around their sons and daughters, helping them to prioritize, plan, monitor and complete multiple assignments. Often the ADD impairments of these strongly supported high IQ students did not show up until they went away to college or university. There, lost without the strong daily support of their parents, many of these very bright students were unable to cope with their schoolwork, had plummeting grades and were required to take a semester off or transfer to another, less challenging college. Just being very smart is not enough to be successful in college, university or employment; one also needs to be able to manage oneself, to work productively and to get along reasonably well with peers, professors, supervisors, and employers.

How can someone focus very well on playing a sport, video games, drawing, or making music and not be able to focus enough on almost anything else?

The most mystifying aspect of ADD is that everyone who has this disorder is able to focus very well on a few specific types of tasks, even though they have great difficulty in focusing effectively on almost everything else. All of the students in this study reported that they had no difficulty in exercising executive functions very well for a few specific activities. For some it was participating in a sport or making art or music. For others, focus came easily for repairing car engines, cooking, using the computer, or designing websites. When asked to explain why they could focus on those few specific activities, but not on other tasks they recognized as important, the students typically responded by saying: “If it’s something that really interests me, I can focus. If it’s not really interesting to me, I just can’t focus, even when I know it’s important and I really need to do it.”

One of our patients explained this: “ADD is like having erectile dysfunction of the mind. If the task is something that really interests you, you’re up for it and can perform. If it’s not something that turns you on, you can’t get it up and you’re not able to perform.” The capacity to focus and mobilize executive functions for a task depends primarily on release of dopamine in specific areas of the brain and that release of dopamine is not under voluntary control.

Does anyone ever get over having ADD as they get older?

Back when ADD was seen as simple hyperactivity, it was believed that anyone with ADD would outgrow those problems by the time they were about 14 years old, if not before. That view made sense because for several decades ADD was seen as just hyperactive behavior, not as a problem with attention and EF. Often, though not always, hyperactive symptoms of ADD do go away as one gets older. But longer term studies have shown that for about 70-80 percent of those with ADD, their attentional symptoms tend to persist into adulthood, even if hyperactive problems have remitted. We published an earlier study of 157 high IQ adults with ADD. The design of that research was almost identical to this recent study of kids with ADD and the results were very similar. For many, the EF impairments of ADD persist into adulthood.

Despite the persistence of ADD, many of those affected experience less impairment from ADD symptoms as they get older. Three reasons may contribute to such improvement: for many with ADD, junior high, high school and the first few years of university are the most difficult. This is because these are the years when one is required to cope with the widest range of academic tasks with the least opportunity to escape from the ones you’re not that good in. When one gets further along in education or employment it is often possible to specialize in work that is more interesting and which one can do reasonably well, without carrying so much of a burden of more challenging tasks. Second, imaging studies have shown that the course of brain development in adolescents with ADD is very similar to that of their age mates, except in a few specific regions of brain that are essential for executive functions. Individuals with ADD tend to catch up in development of these delayed regions of brain crucial for EF about 3 to 5 years behind their peers. This may account for some students who do poorly in high school and early college, then return to more advanced education a few years later and are very successful.

Thomas E. Brown, Ph.D., is associate director of the Yale Clinic for Attention and Related Disorders, Department of Psychiatry, Yale University School of Medicine.

Books by Thomas E. Brown, Ph.D.

Attention Deficit Disorder: The Unfocused Mind in Children and Adults (Yale University Press)

ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults (American Psychiatric Publishing, Inc.)