I am distracted and unsettled this week. Many things are pulling on my attention and energy. The result is that I am not as efficient at accomplishing tasks and I am experiencing more fatigue. Also, my sleep patterns have changed slightly and I didn’t get in all the exercise I had intended. Several unscheduled events have happened, and while they were enjoyable, I certainly felt a level of irritation in how my normal routine had been disrupted. These symptoms are commonly identified as attention deficit and hyperactivity problems. If prolonged, they can cause disruption in day-to-day functioning.
The type of functioning I am describing is known as “executive functioning” (EF). According to the Harvard Center on the Developing Child, “[Executive functioning] skills are the mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. Just as an air traffic control system at a busy airport safely manages the arrivals and departures of many aircraft on multiple runways, the brain needs this skill set to filter distractions, prioritize tasks, set and achieve goals, and control impulses.”
Executive functioning is one of those pre-loaded apps that come with every human, but not all of us successfully manage the upgrades over time. The brain area associated with EF is known as the pre-frontal cortex. This area typically develops last in humans. For some young adults, it may not be fully developed until they are between 17 and 25.
Pre-frontal cortex
Much of the research on EF focuses on children with learning challenges such as attention deficit, hyper-activity disorder, or impulse control disorder. While the condition has been recognized for over 200 years, for a long time it was attributed to moral failings rather than physiologic and developmental deficits. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000907/
It has only been within the last 40 years or so that we have studied the disorder sufficiently to understand that while it starts in childhood it persists into adulthood in as many as 60% of the cases. These people may be labeled as having behavior problems or misdiagnosed with cognitive impairment. These are people who were labeled “problem children” in the classroom and typically under-performed there. Many made it through school by the skin of their teeth, and as adults found some measure of success in work that consisted of doing many different tasks for short periods of time or allowed for doing one thing with a level of hyper-focus (i.e., can’t be pulled away from the task without experiencing intense emotions).
My own experience with adult ADHD came from working with a wonderful woman whom I had the pleasure of treating while she was in a skilled nursing facility. I was consulted on the case because the patient was extremely anxious and demanding. She was 82 years old and had been admitted to the facility because she had a bad case of shingles. She made the staff pull all the shades in her room because the sun was too bright. She refused to have a roommate because they would make too much noise. She had to have her food served a certain way at a certain time. All of these demands were things she had control over in her own home, but now that she was in the nursing facility, she had to adapt to their schedule, and she was not adapting well.
I started off by gathering information on her life. She had grown up in a wonderful family, had just made it through school even though she was bright, had gotten married, had children, and then raised her family as a single mother after her husband died unexpectedly. She showed a talent for art and drawing when she was quite young.
In asking her about her school experience, she told me she didn’t do well academically, and preferred to sit in the back of the room doodling and looking out the window. She had difficulty with math and only really enjoyed doing art projects. She was made fun of by other children because she daydreamed so much.
Her life after her husband died was quite challenging. Managing raising her children and work proved difficult. She was able to get employed but ended up doing many different kinds of work in different settings. She eventually found a job where she was her own boss, where she could set her schedule and decide what needed to be done when.
Her case puzzled me. In going over her symptoms and piecing together her history, it occurred to me that if I were working with a young person, I would, without any hesitation, give her a diagnosis of ADHD. You see, I had been trained to believe that ADHD was only a disorder of childhood and that the symptoms went away as we got older.
Then I did some reading and found out just how prevalent ADHD is in adults. Some were more successful in managing their symptoms than others. As an adult, my patient had been very successful in organizing her world to meet the needs of her brain up until she got sick. Then her strategies no longer worked.
Fortunately, there are medications that work wonders with attention-deficit. I spoke with her geriatrician and we came up with a plan. My patient agreed to start on medication for the ADHD. She was discharged from the nursing home after her shingles were successfully treated and she returned to her home. I followed up with her there.
I will never forget making that home visit and seeing the exquisite art work that she had produced over the years. By then we had established a good therapeutic relationship. She shared with me how frightened she had been in the nursing facility because she didn’t have access to any of the things she used to make her life work. We talked about this and about how the medication was helping.
All her life she had struggled with thoughts that had careened around in her brain and had made paying attention difficult, if not impossible. She suspected that something was wrong with her, and assumed there was nothing that could make her better. The long-term consequences of her EF challenges were being constantly distracted and unsettled. Her attention and energy were always depleted. The result was that she was inefficient and tired all the time. Her sleep patterns were irregular and she didn’t get in all the exercise she had intended. She felt constantly irritated that her normal routine had been disrupted.
She told me that getting a diagnosis of ADHD was actually a relief! While it was evident that my patient had spent a lifetime managing her EF, always with challenges, but well enough to get by, the medication made it so much easier. The best outcome from our work together was having her say to me, “Dr. Mary – this is the first time in my life that I have been able to think clearly!”
If you know someone who is struggling with paying attention, is easily distracted, has impulse control problems, and didn’t do well in school when they were younger, have them screened for ADHD. There are ways of making life easier!
