ADHD: Look before you leap

January 12, 2008

—Nina Pierpont, MD, PhD

I already talked about mental energy (alertness, effort, consistency, and sleep) and the input controls (deciding what is most important, things glancing off the surface of the mind, making connections, and how exciting things need to be to hold attention).  The third part of attention is the output controls.  These are the parts we use to regulate what we do or say—deciding when, where, or how much, or whether to skip doing something altogether.

The output controls have a lot of overlap with what psychologists call executive functions.  These seem to be housed mostly in the front of the brain, behind the forehead, though everything the brain does works via circuits of interconnection involving many parts.

The output controls all involve thinking about multiple things at once.  They involve holding contrasts in mind—yes vs. no, now vs. later, my needs and your needs, past experience and likely futures.  The mind needs a “space” where the different possibilities can be held in place as they are turned over.  This space is called working memory.  It’s like the RAM of a computer, where programs being used right now are held, awake.  Or it’s like the top of a table, holding the things you’ve gotten out to work on a project.

A good working memory can keep everything it needs on the table, even when it walks over to a shelf (long-term memory) to get something else, or brings in more information from the outside.  When it comes back to the table, the other parts are still there, and it hasn’t forgotten what the project is.  There isn’t a lot of extra clutter on the table, either—unimportant stuff is put away.  When work is in full swing (meaning, active thinking going on), needed information or parts don’t fall off the table or out of memory.

It’s easy to see how frustrating it could be to have a working memory not working well.  Or a big unsolved problem sitting in the middle of the table, taking up the space the mind needs for solving all the other problems coming along, in a steady stream, over the course of a day.

I’ll describe some of the types of thinking which go on in this executive function/frontal lobe/working memory space.  Some people are innately good or bad at this stuff, but a lot of it can also be learned and self-trained.

1) Previewing, or playing out likely scenarios resulting from an action.  To make a decision, one plays an internal movie or story of what might happen if one does A vs. B, using past experience (or stories about other people).  Some people do a lot of this.  They anticipate problems and prepare in advance.  Others do very little, responding impulsively and getting surprised.  Still others may not be realistic in the scenarios they create, believing in fearful stories (there are people outside waiting to crawl in my windows) or happy but unlikely ones (if I buy one more ticket I’ll win the lottery).  The ability to play out realistic future scenarios is an important skill, and incorporates the ability to remember the past and judge it accurately in the first place.

2) Holding back on choosing an option until the thinking process is complete.  Some people rush, and would do better if they took a minute.  On the other hand, fast responding is required in many situations, including talking, social relationships of all sorts, and physical skills.  Fast, good processing is different from rushing and making mistakes.  The issue is telling the difference, which brings us to…

3) Self-monitoring, or figuring out if one is doing well.  I don’t think there are many people who don’t care how they seem to others, but I think there are a lot who can’t tell very well, or who find it so painful or difficult to think in this way that they pretend they don’t care or limit their caring to a small group of people.

4) Pacing.  People think at different speeds, and have different thresholds for getting impatient or slowing down to be more careful.  Memory itself moves at different speeds.  For some people words pop into mind instantly, while others struggle to find words for what they want to say.  Some people can shift easily and quickly from one set of expectations and rules to another (e.g., recess to social studies), and others need time for this process.

In a future column I’ll talk about teaching kids to do better in these areas, by practice at flexibility and problem-solving.