The main difficulty that children with ADHD/ADHD have is that they cannot inhibit the present moment enough to consider the future.
It’s not that Juan doesn’t care about the future, it’s just that for him the past and the future don’t seem to exist.
The “iceberg” of ADHD: More problems than expected
We have been missing the point:
“Juan is very active! He never stops moving. He is distracted by the slightest noise and has the attention span of a flea. He often acts before thinking. His sister Maria often lives in the middle of the fog. Sometimes she is so lost in space that when we call her we say: “Planet Earth communicating with Mary.”
This vignette is how children with attention deficit hyperactivity disorder (ADHD) are typically viewed. But many times this is only the tip of the iceberg. This is another likely description of the complete picture of a child with ADHD:
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“We screamed all morning to be able to leave the house. To do the task takes hours and hours. If you don’t help him with his homework, he is so disorganized that he will never do it well. If you help him, he yells at me. Since he never finds anything, everyone thinks he doesn’t care about anything. No matter how much we beg or punish him, he continues to do the same stupid things over and over again. He never considers the consequences of his actions and he doesn’t seem to care if these actions hurt me. It’s so easy for him to feel overwhelmed. “He is so inflexible and then he explodes over anything.”
It is no coincidence that children with ADHD often manifest much more than the classic triad of inattention, impulsivity and hyperactivity. Many problems experienced by these children and their families fall within the spectrum of executive dysfunctions (such as poor self-control and foresight), additional illnesses (which I call the “syndrome mix”—anxiety, depression, or conduct disorders), and family stress.
I think ADHD should be redefined, including the wide range of executive dysfunctions. These dysfunctions arise from an inability to inhibit present behavior so that the demands of the future can be met.
What are executive functions?
When you inadvertently step on a snake it responds by stinging. The snake has no alternative plan. No verbal discussion occurs within the snake’s brain (“do I bite it or not?”).
There is no memory of whether chopping worked properly in the past. There are no thoughts about whether this stinging action will have consequences in the future (such as the next human being being crueler to snakes). Fortunately, human beings have the option to modulate our behaviors.
The prefrontal lobes act as our CEOs. Orchestrating the language and memory functions of other areas of the brain, the prefrontals consider where we come from, where we want to go, and how flexibly to control ourselves to execute this plan. These skills are called “executive functions”:
– Inhibition (stopping your behavior): It is the key executive function. To successfully execute a plan, it is essential that we can stop those activities that distract us. These brakes, courtesy of our inhibitory prefrontal centers, allow us the luxury of time during which we can consider our options before reacting.
Lack of inhibition is a double problem for children with ADHD. First, without these brakes, they will be seen as unable to adequately inhibit distractions (inattentive), unable to inhibit instantaneous reactions (impulsive), or unable to inhibit their physical responses to these stimuli (hyperactive).
Second, children with ADHD cannot inhibit their behavior long enough for other executive functions to develop adequately.
– Initiation: It is the ability to begin. At some point you have to stop sharpening your pencil, you have to stop going to the bathroom, and start doing your homework. Postponing something is a natural activity.
Really getting to work (and not just planning to do it) requires the ability to inhibit all other possible activities and is a difficult task for children with ADHD.
– Internal dialogue: It is the ability to speak to ourselves.
One mechanism by which we look for solutions to our problems is by using words. Children with ADHD do not inhibit their reactions long enough for this ability to develop. Without the ability to inhibit their reactions, or to use self-talk, it is no surprise that children with ADHD are impulsive (which means acting quickly and without thinking).
– Work memory: It refers to those ideas that we can keep active in our mind at a given moment. For example, to learn from mistakes, we must be able to not only “juggle” the present situation, but also keep in mind the moments in the past when certain strategies worked or not. Working memory also includes keeping future goals in mind.
Working memory allows us to take apart the pieces of a problem and keep them in mind while we reorganize them into a new solution. Without the ability to inhibit, children with ADHD cannot develop adequate working memory functioning. Because of this, planning and problem-solving abilities will be damaged.
– Forecast: Predict and plan for the future. This executive function will be deficient when poor working memory is coupled with a poor ability to inhibit distractions.
Children with ADHD cannot keep the future in their minds. They are prisoners of the present. The future catches them off guard. Surprisingly, poor foresight is probably one of the biggest difficulties in their lives.
– Retrospect: Remember past experiences. This function is very necessary if we are to gain wisdom from our past experiences. When approaching a decision, it’s helpful to remember which strategies worked and which didn’t. A lack of retrospection is one of the reasons why children with ADHD have a tendency to fail to learn from their mistakes.
– Sense of time: Executive function is extremely poor in children with ADHD. Time estimation in children with ADHD is notoriously poor, being both too short and too long.
– Organization: Children with ADHD, almost by definition, are not good at this ability. Five of the nine criteria in the ADHD inattention category are purely organizational, and according to the DSM, only six of the criteria are required to be found for the diagnosis of ADHD.
– Flexibility: It is the ability to modify plans mid-course if circumstances change. The world is an unpredictable place and plans rarely behave the way we imagine them. Things happen along the way. We require flexibility to readjust our actions in the middle of the road.
– Changing from agenda A to agenda B on someone else’s order: It is a difficult task that requires good executive function, effort and self-control. This inability to change schedules (for example, stop what you are doing and go to dinner) is a common cause of “attacks” in children with ADHD.
– Separate emotions from facts: This ability requires time to reflect. Neurologically speaking every event in our lives has an objective reality and an additional limbic emotional label that we attach to it.
For example, we can find a ticket on the windshield of our car. Our emotional reaction will be absolute indignation because they gave us a fine. However, the objective fact is that the penalty is only thirty pesos. Without the gift of time we will never be able to separate our enormous emotional feeling from what is actually a small problem. We think that something really bad has happened to us when in reality it hasn’t. This leads to a poor ability to judge the meaning of what is happening.
– Add emotion to the facts: It is an important part of motivation since it is very difficult to be motivated if there are no emotions attached to the activity we are developing.
Working memory remembers not only the objective reality of past experiences but also the emotional label that was attached to said experience.
For example, when a child with ADHD remembers a punishment he received in the past, he will have trouble remembering the unpleasant sensation that accompanied that experience. The same thing happens when he remembers the time he got a good grade in school: he will have trouble re-experiencing the nice feeling that accompanied that grade.
Thus, when children with ADHD have poor working memory they may not remember the emotions that should arise with the facts and feel frustrated, disconnected and unmotivated.
I will continue developing these concepts in a future article.
Author: Dr. Roberto Rosler Neurosurgeon Physician graduated with an Honorary Diploma – University of Buenos Aires. Speaker and tutor at, a renowned online platform dedicated to neuropsychoeducation.
Image: (Flickr)