Ari Tuckman, PsyD, MBA, is a psychologist who specializes in the diagnosis and treatment of ADHD. He is the vice president of the Attention Deficit Disorder Association. His previous books include Integrative Treatment for Adult ADHD: A Practical, Easy-to-Use Guide for Clinicians and More Attention, Less Deficit: Success Strategies for Adults with ADHD. He lives in West Chester, Pennsylvania.

Understand Your Brain, Get More Done

The ADHD Executive Functions Workbook

Specialty Press, Inc.

Contents

A BRIEF OVERVIEW OF THE EXECUTIVE FUNCTIONS

Different researchers have created somewhat different lists of executive functions. I've found that Russell Barkley's response inhibition theory is the most thorough and useful of these, so the executive functions theory that I talk about in this workbook is an outgrowth of his work. His theory is incredibly detailed and impressive but contains far more information than you need to know to manage your day to day life. So I've pulled out the aspects that are most useful for your daily life — the parts that not only explain why some things are so hard for you but also set the stage for the effective strategies that we will discuss.

The Executive Functions Develop Over Time

The development of the executive functions is part of the normal process of brain maturation. As the neurons grow and make connections through our brains we develop all sorts of abilities, from crawling to speaking to thinking about abstract concepts. Generally speaking, adults have more developed abilities than children do because our brains continue to mature into our thirties.

As with most of development, this process is guided by a combination of genetics and environmental exposure. Our genes give us a range of possibilities, and then experience shapes that genetic expression. In the case of ADHD, there is a lot of genetics going on. It is one of the most heritable of all the mental health conditions. Just as there are other abilities that run in families (like being a good athlete or having an ear for music), so too are there genes that affect the neurons involved in the executive functions and ADHD.

So your ADHD isn't the result of your parents not doing a good enough job — and there isn't much that your parents could have done differently to reduce your ADHD symptoms. When it comes to your ADHD, you can only blame your parents for your genes, but you may want to avoid that line of argument if you have kids of your own.

Summaries of the Executive Functions

I have provided brief summaries of each of the executive functions that we will cover in this workbook. Hopefully this makes these sometimes amorphous concepts feel more tangible and more easily relatable to your day to day life. We're going to get very practical in the exercises, but it helps to start with a solid understanding of the theory.

Working Memory: The Brain's RAM (Chapter 6) We use working memory constantly to hold information in mind as we remember what just happened, relate it to long-term memories, and think ahead into the future. Working memory and attention work very closely together, as working memory holds what we are attending to. People with ADHD tend to have blinky working memories, which leads to a variety of problems in their daily lives.

Sense of Time: It Can't Be 5:00 Already! (Chapter 7) People with ADHD have difficulty monitoring the passage of time and planning accordingly, a skill that's really important in today's busy world. As a result, they tend to spend too long on some activities and not plan enough time for others. This contributes to their well-known problems with time-management and getting places on time.

Remembering to Remember: It's All About Timing (Chapter 8) In our busy lives we all have dozens of little (and not so little) things to remember to do over the course of a day, such as phone calls and appointments or returning to something after an interruption. People with ADHD have great difficulty reminding themselves of these tasks at the right time, often forgetting completely or remembering only when it's too late.

Emotional Self-Control: Having Feelings Without Acting on Them (Chapter 9) People with ADHD tend to feel and express their feelings more strongly than others do and are more influenced by their feelings than other people are. This then affects their ability to see beyond their emotions in the moment and to take others' perspectives into account.

Self-Activation: Starting Then Finishing (Chapter 10) Everybody has to use a certain amount of force of will to get going on boring tasks, but people with ADHD have a much steeper hill to climb. As a result, they tend to procrastinate until the pressure of a looming deadline forces them into action.

Hindsight and Forethought: Using the Past and Future to Guide the Present (Chapter 11) We use the lessons from past experiences to make better choices the next time around. We also think ahead about the likely outcomes of various actions in order to choose the plan with the best odds of success. People with ADHD tend to react too quickly in the moment and therefore don't make the time to remember the past or think about the future, so they're more likely to make less optimal choices.

Although we can intentionally choose to approach situations in certain ways, many of the executive functions operate without conscious awareness, like breathing. If you watch little kids talking themselves through a difficult task, they are sort of verbalizing their executive functions — for example, softly repeating to themselves what they are supposed to do or giving themselves pointers along the way. Eventually it becomes automatic and we don't have to think about it as much, but we may still find that we sometimes become very intentional about using our executive functions in challenging situations.

Even though I talk about specific executive functions, keep in mind that they interact constantly and that the lines between them can be pretty blurry. Don't get hung up on exactly which executive function is at work in any specific situation. The goal in this workbook is to make it understandable and applicable in your daily life, which sometimes means simplifying a little.

Response Inhibition: It Starts with Stopping

The funny thing about executive functions is that people with ADHD use them really well — except when they don't. In fact, this inconsistency is a hallmark of ADHD (if someone has consistent struggles, then the culprit is probably something other than ADHD). So how do we explain that people with ADHD sometimes perform really well, yet at other times make really simple mistakes?

This is where Barkley's response inhibition theory comes in. Unlike simpler life forms that respond automatically to stimuli from the environment, humans are able to hold back an automatic response to the world around them (as well as their internal world of thoughts and feelings). This crucial ability to stop creates a pause that allows them to think through the various response options and then choose the best one. This usually happens in a split second. An example is almost subconsciously deciding to ignore the sound of someone dropping a pen while you're working at your computer (i.e., not getting distracted) or holding your thought to what someone is saying until she finishes talking (i.e., not impulsively interrupting).

The key to successful decision making is that tiny little pause, because it gives the executive functions time to do their thing. The executive functions live in that little space between stimulus and response. People with ADHD have difficulty stopping long enough to create this pause, so they don't use their executive functions as reliably or effectively as others do. As a result, they get distracted, forget things, leap without looking, etc. — the symptoms of ADHD you know so well.

This explains why people with ADHD don't always do what they know they should. Because they have trouble creating that pause that gives them time to make a well-considered decision, they're more vulnerable to being influenced by whatever is going on around them. They have trouble filtering out external and internal stimuli, so they react to the "wrong" thing. An example is answering the phone and getting into a lengthy conversation rather than getting ready to leave the house on time. This can look like bad judgment, but what really happens is that these other stimuli have too big an impact on the ADHD person's decision making, so a less-than-optimal choice is made. It isn't bad judgment because, in these knee-jerk reactions, they didn't stop long enough to actually judge. This is why those dreaded questions of "why did/didn't you ... lead to such unconvincing answers along the lines of "I don't know. I just didn't think of it," which is actually pretty accurate. Their brains didn't stop long enough to get a chance to think about it.

Because people with ADHD's difficulties with response inhibition tend to make them so vulnerable to being overly influenced by external and internal stimuli, many of the strategies to help them be more effective focus on increasing the strength of the desired stimuli or decreasing the strength of less desired stimuli so that they do the right thing in that moment. For example, a beeping alarm that tells the person to leave for a meeting overrides the focus on what else she was doing.

Medications (as well as Cogmed Working Memory Training and possibly neurofeedback) work directly by increasing the brain's ability to create that delay, thereby reversing the fallout that comes from an insufficient delay. This is also why admonitions to "just try harder" don't work — they ignore the fundamental problem that people with ADHD have trouble creating that moment of pause to try harder in. It's like telling someone who needs glasses that she just needs to try harder to see. It's a problem of ability, not desire. The confusing part is that people with ADHD usually have the ability to do the actual task (like pay the bills) but aren't as strong at the fundamental ability of creating that pause, so they don't get to the actual task.

As we talk at length about the executive functions and run through the exercises in Section II remember this delay, because this is the tripping point for many executive-functioning malfunctions. Therefore, the strategies that work well are the ones that take this into account.

Neurology and Psychology

I tend to make a somewhat artificial distinction between behaviors that are neurologically driven and those that are psychologically driven. We can't fully separate them out, but there are times when it's useful to think about these two separate contributions. Much of ADHD is neurological, but a lifetime of living with ADHD creates a whole lot of psychology.

When it comes to the executive functions, I tend to think of working memory, sense of time, and prospective memory as more purely neurological, with less of a psychological influence. Our psychological state may have some effect on how we use these executive functions, but they mostly operate without our conscious awareness.

However, emotional self-control, self-activation, and hindsight and forethought have more psychology interwoven into the neurological functioning. For example, if you feel like you always get the short end of the stick from your family, you're less likely to exhibit good emotional control when something comes up with them.

So things get more complicated with those executive functions. If you feel like you're doing pretty well on the first three executive functions but struggling a lot more with the next three, you may want to spend some extra time on Chapter 3: Reality-Based Motivation and/or Chapter 4: Work as a Team. This is especially the case if your struggles tend to show up more with some people than others or more in some situations than others.

If you feel like you have some pretty good strategies in place but things just aren't rolling for you, it may even be worth meeting with a therapist to figure out some things. I'm definitely not suggesting that therapy will cure the core features of ADHD, but it can be good for the fallout. Just make sure that you find someone who is pretty knowledgeable about ADHD in adults. I know, it can take some real looking to find someone who knows this stuff, but it's worth it if you do.

PEAK MENTAL PERFORMANCE: MAKE THE MOST OF WHAT YOU'VE GOT

There are certain things you can do to get the best performance out of your brain and its executive functions. Some of these aren't treatments for ADHD, but are just good advice for everyone. Some of them are treatments specifically targeted for ADHD.

Your Best Brain

Your brain is an incredibly complex machine that can do phenomenal things. Like any machine, its performance depends on how you treat it. The choices you make will affect whether your brain performs at its best. As of this moment in time, there is no cure for ADHD (and nothing promising on the horizon), so it's more a matter of making the most of what you have so that you can bring your best abilities to life's challenges. This means not only the brain functions that might be affected by ADHD, but also everything else that your brain does.

You can get the most out of your brain by treating it well. This includes:

• Good mental health. Anxiety and depression sap our ability to solve problems efficiently, as well as our enjoyment of life, so it's important to treat any mental health concerns.

• Good physical health. Our brain's performance is affected by our general health. So take care of yourself, get those aches and pains checked out, and see your doctor regularly.

• Sleep. Our brains need sleep to recharge. They function best when we consistently get enough sleep.

• Manage stress. Although a little stress can bring out our best performance, too much stress hurts our performance because we lose our ability to do complex problem solving.

• Good nutrition. Our brains rely on quality fuel to do their work. They do best with a balanced diet that is neither lacking some nutrients nor getting overloaded by others.

• Moderate alcohol use and minimal drug use. Casual drinking has tolerable effects on your brain's performance and is therefore an acceptable vice. Other recreational drug use, especially if frequent, probably crosses that line where the costs outweigh the gains.

• Regular exercise. In addition to the well-known benefits on physical health, there is research supporting the benefits of regular exercise on mood, attention, memory, and learning.

I doubt you were terribly surprised by any of the items in this bullet list. Of course, the real trick is to actually follow all this good advice. (I call these items the New Year's resolutions stuff because so many people vow to work on them every January.) Just to make matters worse, the inconsistency that is inherent in ADHD makes it all the harder to follow these good habits. So I'm not going to give you the obvious (but pointless) advice to just try harder to do all of the above, because you've already heard it. At this point, this list is merely something to keep in mind and to work towards as you move through the workbook. In fact, we can measure your success in managing your ADHD by how well you're doing with the items on this list.

Just to get some perspective on this, let's look at how you've managed these items over time. In the table below, mark down the time in your life when you handled them the best, the worst, and how you're doing now. Mark from 1-10 (1 = poorly, 10 = excellent) how well you were managing the various items in the table and then how effectively you were handling your life overall. What I expect is that your overall effectiveness will be pretty similar to how well you were managing these lifestyle matters.

I've also included a column to mark down your goal of where you would like to get this. It would be great if you could get to a point where you're consistently rating yourself a 9 or 10 on each of these, but nobody's life is that idyllic. Also, some people are more sensitive to less than ideal conditions, whereas others are less affected. For example, some people are really affected by not getting enough sleep, whereas others do pretty well even with little sleep. Our goal here is to get you to a point where overall you're doing pretty well (or at least better than before), so don't feel like you're falling short if you rate yourself less than a 9.

Finally, I've also given you a couple columns to use in the future to track your progress over time.