Smart But Stuck: Emotions in Teens and Adults with ADHD
by Thomas E. Brown
Chapter One: ADHD and the emotional brain
Emotions, and struggles with and between various emotions, play a central role in the daily life of all children, adolescents, and adults. Emotions guide what we notice and what we ignore, what we focus on intently and what we carefully avoid. Conflicting emotions can cause us to disrupt engagement with a task we want to accomplish, or lead us repeatedly to do what we consciously intend never to do again. In many ways—sometimes recognized, sometimes not, subtly and powerfully—we are pushed and pulled by our emotions. Yet we also exercise some control over them: we try to distract ourselves from uncomfortable emotions; we choose how much we want our emotions to show in our words or actions; we talk to ourselves to try to tone down or jack up how noticeable our emotions are to others and to ourselves. We manage and are managed by the complexity of our emotions.
In my work as a clinical psychologist, I’ve seen that emotional struggles play an especially large role in the daily life of people with attention deficit disorders. The same chronic impairments that interfere with other aspects of their cognitive functioning also tend to interfere with their ability to manage and be adequately guided by their emotions. People with ADHD often suffer chronic difficulties in responding to and sustaining emotions that motivate them for important tasks.
Most people with ADHD experience the same frustrations, fears, sadness, pride, shame, excitement, and so on that spontaneously arise in everyone else in various situations. What is different is the chronic difficulty most people with this disorder experience in managing and responding to their emotions, particularly in the many situations where emotions are mixed and conflicting. As noted earlier, stories in this book illustrate the fact that being very smart does not prevent a person from struggling with these emotional problems, nor does it prevent having ADHD.
This book highlights the idea that emotions are linked to the brain. from but these are metaphors that serve simply to suggest that emotions come from the depth of the person. The actual source of emotions is the brain.
The difficulties that people with ADHD have with emotions are similar to the problems they often have in prioritizing tasks, shifting focus, and utilizing working memory. While cleaning a room, they may get interested in some photos they pick up, soon becoming completely diverted from the job they had begun. While searching for some specific information online, they may notice a web page that draws them off the search they started and into a protracted investigation of something totally unrelated, derailing their original task. They may abandon a task they find boring, overlooking the fact that adequate and timely completion of this task is essential to gaining something they really want, and that failure to complete the task will inevitably bite them with a painful payback.
In a similar way, many people with ADHD tend to get quickly flooded with frustration, enthusiasm, anger, affection, worry, boredom, discouragement, or other emotions, not keeping in mind and responding to related emotions also important to them. They may vent their momentary anger on a friend or family member with hurtful intensity that does not take into account that this is a person whom they love and do not want to hurt. People with ADHD report that momentary emotion often gobbles up all the space in their head, as a computer virus can gobble up all the space on a hard drive, crowding out other important feelings and thoughts.
Many with ADHD also report that they tend to have a lot of difficulty with attentional bias. They tend to be particularly alert and quick to notice any comments or actions that fit with the emotions that preoccupy them, often without paying much attention to the context or to other information that might provide a useful different view. Some seem to be constantly alert for signs of things to worry about; others are excessively alert for any signs of potential frustration or discouragement. They become too easily immersed in one especially salient emotion and tend to have chronic problems in shifting their focus to keep in mind other aspects of the situation that might call for a very different response. For example, someone hearing just a slight uncertainty in a coworker’s reaction to a suggestion may interpret this as stubborn disapproval and quickly start arguing for his or her idea without listening adequately to understand the coworker’s actual response. Attentional bias may fuel feelings of depression, anxiety, or argumentativeness or cause the person to lose interest in a particular goal.
WATCHING BASKETBALL THROUGH A TELESCOPE
For those with ADHD, life can be like trying to watch a basketball game through a telescope, which allows them to see only a small fragment of the action at any specific time. Sometimes that telescope stays too long on one part of the court, missing out completely on important events occurring elsewhere at the same time. At other times, the telescope may randomly flit from one bit of action to another, losing track of where the ball is and what various players are in a position to do. To follow what is going on in a basketball game, a person needs to be able to watch the whole court, noting movements of the ball and rapidly shifting positions of the players as they present multiple risks and opportunities in the game.
the unacknowledged role of emotions in ADHD Current diagnostic criteria for ADHD include no mention of problems with emotions, but those who live with this disorder and those who care for them know very well that problems with experiencing and managing emotions—interest, comfort, desire, anxiety, frustration, worry, disappointment, hurt, excitement, anger, pride, sadness, and shame, in various blends and sequences—play a critical role in their daily difficulties. Sometimes peoplewithADHDare unable to manage expression of these emotions; at other times, they have trouble experiencing and clearly recognizing emotions in themselves that can guide them in social interactions and fuel behaviors important for achieving longer-term goals. Researchers have recently been challenging the omission of problems with emotional regulation in current diagnostic criteria for ADHD. For example, a team of European researchers studied more than a thousand childrenwithADHD and found that almost 75 percent demonstrated significantly more intense and frequent problems with low frustration tolerance, irritability, hot temper, sadness, and sudden mood shifts than non-ADHD children of the same age.
Such mood problems tend to persist into adulthood for many people with ADHD. A longitudinal study of over a hundred hyperactive children and a matched comparison group followed into young adulthood showed that those whose ADHD persisted into adulthood continued to have significantly more difficulties with low frustration tolerance, impatience, irritability, hot temper, and emotional excitability than the comparison group. Another study demonstrated that deficient self-regulation of these negative feelings is found in a subgroup of adults with ADHD, and also that this type of emotional dysregulation tends to occur with greater frequency among siblings of those affected adults.
These recent studies have explored the role of emotions in ADHD, but most dealt exclusively with the combined type of ADHD, excluding those without hyperactive symptoms. Also, these studies have been focused primarily on difficulties in controlling negative emotions such as irritability and anger; they have neglected the role of emotions that are central to positive motivations, such as interest, enthusiasm, desire, pride, and pleasure. These studies also have not adequately explored anxiety, discouragement, stress, and hopelessness, which often compromise a person’s motivation to act.
In a comprehensive review article, Russell Barkley, a leading researcher, has argued that “deficient emotional self-regulation” should be included in diagnostic criteria for ADHD and considered a core component of the disorder, though only for the combined subtype. His emphasis is on insufficient control of more negative, disruptive emotions:
ADHD creates a state in which the normal emotion-generating properties of the limbic system, and particularly the anger, frustration, and aggression-generating properties of the amygdala, are inadequately regulated by higher cortical functions. (p. 10)
the problem of ignition and motivation
Thus far, researchers and clinicians have focused too much on how people with ADHD demonstrate problems in putting the brakes on expression of emotions. There hasn’t been sufficient attention given to the emotional problems with ignition—chronic difficulties with getting started on necessary tasks and staying motivated to finish what needs to be done.
An important clue to understanding these problems with ignition in ADHD can be found in the most puzzling and frustrating fact about children, adolescents, and adults with attention deficit disorders: their symptoms are not consistent. A person’s ADHD symptoms vary considerably from one situation to another, depending on the task or context in which he or she is operating and on the incentives involved. Despite their chronic problems with organizing themselves, getting started on tasks, and staying focused, all people with ADHD have a few activities in which they have no such problems. If you watch them while they engage in those activities, you would swear that they have no problem with attention at all.
Typically each person with ADHD, young or old, is able to focus very well for a few activities in which he or she has strong personal interest. This might be playing a sport or video games, drawing or painting, repairing a car, playing music, or using Facebook. Yet for virtually all other activities and tasks, people with ADHD have extreme difficulty in achieving and maintaining focus, with the possible exception of situations where they expect a very immediate unpleasant consequence if they don’t attend to the task at hand. If you ask a person with ADHD why he can focus for this and not for that, he will usually respond along the following lines:
I focus well on things that interest me, but if it’s not something that really interests me, I just can’t keep my focus. If I’m really freaked that something very unpleasant is going to happen quickly unless I take care of this right here, right now, that may help me focus for a while. But unless it feels like there is a gun to my head, I really have to be interested.
Because they can focus well on tasks that interest them, yet often focus very poorly or inconsistently on almost anything else, people with ADHD are often accused of lacking willpower. ADHD clearly looks like a problem with willpower, but it is not. One patient called his chronic difficulty with attaining and sustaining focus “erectile dysfunction of the mind.” He said,
If the task is something that really interests me, I can get “up” for it and I can perform. But if it’s not a task that “turns me on,” I can’t get up for it, and I can’t perform. Doesn’t matter how much I say to myself, “I need to, I ought to, I should.” I can’t make it happen. It’s just not a willpower kind of thing.
immediate or delayed “payoffs” in the ADHD brain
Underlying this “can focus for this, but not for that” problem is an important problem with emotion in ADHD: difficulty in mobilizing and sustaining interest for activities that don’t offer an immediate “payoff” of pleasure or relief. Most of us may not think of interest as an emotion, but it is in fact a critically important positive emotion. “Passionate interest” represents an intense level of sustained emotional engagement with a task or person, but interest occurs in varying degrees and with varying levels of persistence. Interest reflects the degree of a person’s motivation and emotional engagement with a task or relationship. Psychologists James Gross and Ross Thompson have emphasized that “emotions not only make us feel something, they make us feel like something.”
Emotions motivate action—action to engage or action to avoid. Many people with untreated or inadequately treated ADHD can readily mobilize interest only for activities offering very immediate gratification; they tend to have severe difficulty in activating and sustaining effort for tasks that offer rewards only over the longer term.
Problems of activating and sustaining motivation and effort for may have to do with how they may be less sensitive to potential rewards, as opposed to immediately available rewards, than are others of the same age.
PET imaging studies have demonstrated that chemicals which activate reward-recognizing circuits in the brain tend to bind on significantly fewer receptor sites in people with ADHD than do those in a healthy comparison group. These and other imaging studies may help explain why people with ADHD tend to be less able than their peers to anticipate pleasure or register satisfaction with tasks for which the payoff is delayed. An important effect is that often they have great difficulty in activating themselves to get started on tasks that are not especially interesting to them and in sustaining motivation to complete tasks for which the rewards are not imminently available. I discuss implications of this research in Chapter Two.
Problems in activating and sustaining interest (focus) and effort for tasks are two of the multiple cognitive functions included in the complex syndrome currently identified as ADHD. As I noted in the Introduction, this disorder is no longer seen as simply a problem of young children who misbehave. In fact, misbehavior is something of a red herring in the mystery of ADHD and has eclipsed the truly debilitating aspects of the disability as it often progresses to young adulthood and into middle age, bringing heartbreaking suffering, internal turmoil, and frustration in actualizing life goals. It is in fact now clear that many people with ADHD have never had significant behavioral problems, and even for those who did have such difficulties, problems with misbehavior usually tended to be among the least of their troubles. The primary problem for most individuals with ADHD, especially as they enter adolescence and adulthood, is a wide range of cognitive impairments in the management system of the brain. All of these impairments are linked to various problems with emotion.
ABOUT THE BOOK:
Smart but Stuck offers 15 true and compelling stories about intelligent, capable teens and adults who have gotten “stuck” at school, work, and/or in social relationships because of their ADHD. Dr. Brown highlights the often unrecognized role that emotions play in this complex disorder. He explains why even very bright people with ADHD get stuck because they can focus well on some tasks that interest them, but often can’t focus adequately on other important tasks and relationships.
“No matter where you are in your journey to success, if you have ADHD, this book will help to speed you on your way. I could not recommend it more highly.”
—Edward (Ned) Hallowell, MD, author, Driven to
Distraction and Delivered from Distraction