What’s in a label……
As humans we love a good label. They allow us to quickly make a determination about something and move on. We can conserve precious time and energy with an effective label. A proper label helps us to understand and, in some cases, even helps to keep us safe. But what happens when there is a poorly named diagnosis for an already misunderstood condition? A label, in the case of ADHD (attention-deficit hyperactivity disorder) leads to what we see and experience every day – perpetuating a stereotype. The cliché of a hyperactive 8-year-old boy or (maybe) the “flighty” middle school girl allows for misunderstanding and minimizes ADHD to a set of challenges that interfere with attention at school. It preserves lack of knowledge.
Dr. William W. Dodson, M.D., LF-APA, an expert in ADHD, has written several articles asserting that ADHD is not a disorder, but a condition with its own set of unique benefits and impairments including a nervous system that is “interest-based.” It isn’t a lack of attention, but difficulty managing or directing attention with the biggest challenge being that interest-based nervous systems result in performance inconsistency. If we still needed to label ADHD as a disorder then, it is a disorder of performance (not attention) that is suffered by internalizing messages that we should: be motivated differently, process information differently, and behave differently, with a clear message that ADHD is not only different, but also sub-par.
With ADHD we have a very keen awareness of the gap between what we are capable of and how we are performing. Most times nobody is more surprised by our outcomes than us because we are never certain about what we are going to get on any given day. Inconsistency makes life unpredictable. Most infuriating is that when we are delighted with our result, we are hard pressed to replicate it because it’s in the design, the building, the process, that we so often get lost.
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Overlooking the abject naming convention to really see the parts that make up its whole allows us to truly understand ADHD. It is essentially an interest-based nervous system that is impaired by a disorder of executive skills, which are a set of skills that we use every day to learn, work, interact, and manage daily life. It is often called the “management system of the brain.”
Executive Functioning Skills
I often use the sandwich metaphor with my clients. We see the sandwich that we want to eat. Everything is set out in front of us so that we can build the delectable handheld meal. We have all the tools and ingredients, and we are staring at other people who look just like us whipping those sandwiches together with ease. Most of them are already eating! But we are staring at their sandwiches, and staring at our ingredients, and staring at our tools. Mouths watering. We have everything we “need”, but we just cannot put that damn sandwich together. ADHD is not a problem of knowing what to do, but in doing what we know – executing the way we visualize. It’s in the meat.
Allow me to take you on a guided tour.
I would like you to imagine yourself at work, where we will assume you are required to have a decent amount of emotional control, or what we often refer to as “emotion regulation.” This is the ability to manage emotions in order to achieve goals, complete tasks, or control and manage behavior. Struggling in this area might look like you losing your temper, crying, or becoming overwhelmed or anxious when the stakes are high – like, say, trying to make a delicious sandwich on your lunchbreak.
Now imagine that you are on your lunchbreak, trying to make that delicious sandwich, when you are informed that you only have 7 minutes for your lunch break. This means you need to make that beautiful sandwich and eat it within 7 minutes. It requires you to have mental flexibility which means you must have the ability to revise plans in the face of obstacles, setbacks, new information or mistakes. It demands an ability to adapt to changing conditions. When you receive news of your shortened lunch break, you become overwhelmed due to this unforeseen obstacle that requires you to quickly adapt. Henceforth emotional control deficits (see above) partner up with mental flexibility deficits to journey together down this montage of rapid decompensation.
While you rigidly deny reality by vehemently stating how unfair these circumstances are, you unknowingly lose 2 minutes of your already abbreviated lunch break. You are shocked at how time is slipping away because of your challenges with time management which requires the capacity to estimate how much time one has, how to allocate it, and how to stay within time limits and deadlines. It also involves a sense of importance (determining what is important and when, i.e.: is it important to argue fairness or make my sandwich right now).
You desperately want to make your sandwich, but task initiation requires the ability to begin projects or responsibilities without undue procrastination or in a timely manner. You have delayed making your sandwich for another minute and a half due to the continued emotional turbulence that the lack of time management has caused.
You suddenly have the thought “I need to remember to go outside and close the moonroof on my car after I eat lunch, but I have to go to the bathroom first.” Planning / Prioritization is the ability to create a roadmap to reach a goal or complete a task. Includes the ability to determine what is important now versus what is not important right now. Your discomfort with the overwhelm, pressure, frustration and anger have caused you to procrastinate which also causes further emotional discomfort, so you are distracted by a thought that is a diversion to that discomfort. You are also in a heightened state, and very aware of every feeling in your body, resulting in the sensation of even a slightly full bladder completely derailing your attention to the matter at hand: making the sandwich.
Now you have lost track of the ingredients and forgotten to add your favorite part of the sandwich – the cheese – but forget it because you have also lost track of the last 3 minutes. At this point, you are struggling with any sort of organization, the ability to create and maintain systems in order to keep track of information or materials. You are now late and you haven’t even started eating yet. You refocus, reaching for the knife when you have the thought “I have to remember to run out to my car.” Which leads you to think about the podcast you started listening to in your car on the way to work because you wanted to finish listening to it on your lunchbreak, which leads you to think about how much time was left on the podcast, “I bet I can at least get a few minutes in….” which leads you to start to do mental math “I think there are 23 minutes left” which leads you to think “I HAVE GOT TO REMEMBER to return Jane’s call, it’s been two days…..how much did she say I owed, $23? Or was it $32…….wait…. maybe it was $223….do I have that much in my account right now……I need to remember to do the bills tomorrow morning, I better just put that reminder in my phone quick right now….UGH” You look at your phone and see that another 3 minutes has lapsed in your 6 degrees of ADHD word association.
Sustained Attention is the capacity to maintain attention to any given situation or task despite distractions, boredom or fatigue competing for attention. Now you are not even sure if you are hungry anymore because – emotion regulation – you feel stressed and late, and you are trying to hurry and where the hell is that knife- you just saw it! But the sensations of your semi-full bladder, the stressful emotions, the sound of your coworkers chewing, the loud tv and the busy-ness of your own thoughts have all made it impossible for you to sustain your attention on any one of these distractions, let alone being able to focus on making the sandwich.
You refocus your attention to the sandwich when your coworker starts talking to you about your day and asking you questions that require you to access information and respond to her. Working Memory is the ability to hold information in memory while performing other tasks. It Requires the ability to draw on past learning or experience to apply to the situation at hand. You have to stop making the sandwich in order to speak to her to answer her, or, you need to ignore her so that you can focus on the sandwich but you cannot do both. You don’t want to appear rude so you attempt to respond to her without pausing on the sandwich building. You feel a sting and realize that you have cut your finger.
Despite your feelings of overwhelm compounded by your now throbbing finger and an acute awareness of the time slipping away, you still try to throw together something to eat. Goal-directed Persistence is the capacity to have a goal and follow through to the completion despite distractions by competing interests. “I’m doing this – I’ve got it – it’s just a sandwich, it won’t be great, but it will be edible, I’m already late…..what’s one more minute” You can feel sweat on your brow as you reach for the — “wait did the meteorologist just say it’s raining? Damn – my moonroof is open!”
This is when you really need Response Inhibition, which is the capacity to think before you act. Resisting the urge to say or do something and pausing to consider what effect your response will have. But your finger hurts, and your bladder is full and your stomach is empty and you feel all the emotions like a volcano erupting out of your chest, “F!@K IT” you scream at the top of your lungs and you throw your unfinished sandwich on the ground. You look and see that your boss, mother and grandmother (where did they come from!?) are all standing there and witnessed your outburst because (say it with me – emotion regulation and response inhibition).
You stomp off leaving your sandwich on the floor, hangry and full of shame for the past 8 minutes events. You are given a verbal warning for being late again and you are written up for creating a hostile work environment with your unpredictable and chaotic behavior. You don’t understand how you didn’t see this coming…..”why can’t I just stay calm and get things done just like everyone else?” Metacognition is The ability to observe how you problem-solve. It Includes self-monitoring and self-evaluative skills (“How am I doing?”). If you had this skill, you would have been able to (at several points in the past 7 minutes) noticed how you were doing mentally and physically.
You are mentally exhausted from trying to make it all work, but it never does, depleted physically from lack of sustenance, irritable from the emotional roller coaster, humiliated from your lack of impulse control and feeling like a failure yet again.
This is ADHD. And this is just the tip of the iceberg. Executive functioning deficits impact every facet of life. And this doesn’t even begin to address the rejection sensitivity, sensory overload, dopamine deficiency, internalized shame messages, and the price of late or misdiagnoses. But sure – let’s just continue to say that “lack of attention” is the meat in this shit-sandwich.
Labels matter. They can lead to understanding which can lead to empathy, and we can all agree we need more of that.
What took me years to understand, implement, and refine, you can begin today.
This workbook contains exercises to reflect on symptoms, gain awareness to your stories, explore your strengths and consider new possibilities. Plus, some grounding exercises to help along the way!