Full PreFrontal

Ep. 99: Thomas Brown, Ph.D. - Ready. Fire. Aim!

December 20, 2019 Sucheta Kamath Season 1 Episode 99
Full PreFrontal
Ep. 99: Thomas Brown, Ph.D. - Ready. Fire. Aim!
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Full PreFrontal
Ep. 99: Thomas Brown, Ph.D. - Ready. Fire. Aim!
Dec 20, 2019 Season 1 Episode 99
Sucheta Kamath

When you shoot before you aim you get bad results. But that’s what everyday impulsiveness looks like for someone with ADHD. Pencil tapping, restless legs, inability to sit too long, distracted mind, interrupting others, and getting bored too quickly are some additional commonplace behaviors that highlight the habits and symptoms of those with ADHD. But beneath the surface the mismanagement of the goals, missing the forest for the trees, shooting from the hip, or regretting bad decisions is invisible to the naked eye.

On today’s podcast, clinical psychologist, celebrated author, and director of the Brown ADHD Clinic for ADHD, Thomas Brown, Ph.D. discusses the complex syndrome of ADHD and its developmental impairments which often are situationally specific and its chronic and ongoing interference with life can be exhausting.

About Thomas E. Brown, Ph.D.
Dr. Brown is a clinical psychologist who received his Ph.D. from Yale University and is Director of the Brown Clinic for Attention & Related Disorders in Manhattan Beach, CA. He specializes in assessment and treatment of high-IQ children, adolescents and adults with ADD/ADHD and related problems.

After serving on the clinical faculty of the Yale Medical School for 20 years, Dr. Brown resigned to relocate to Manhattan Beach, California where he directs the Brown ADHD Clinic for ADHD and Related Problems in children and adults. He holds an appointment as Adjunct Clinical Associate Professor of Psychiatry and Behavioral Sciences at the Keck School of Medicine of the University of Southern California.  He is also an elected Fellow of the American Psychological Assn.

Dr. Brown has presented papers, workshops, courses and symposia at national meetings of the American Academy of Pediatrics, American Psychological Association, American Psychiatric Association,  American Academy of Child & Adolescent Psychiatry, National Association of School Psychologists, International Neuropsychological Society, the National Attention Deficit Disorder Association and CHADD. He has also lectured at universities and international meetings of professionals in more than 40 countries.

He is author of 5 books on ADHD; his work has been published in six different languages. His most recent books are: Smart but Stuck: Emotions in Teens and Adults with ADHD (2014) and Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide (2017).

Websites:

Books

Show Notes Transcript

When you shoot before you aim you get bad results. But that’s what everyday impulsiveness looks like for someone with ADHD. Pencil tapping, restless legs, inability to sit too long, distracted mind, interrupting others, and getting bored too quickly are some additional commonplace behaviors that highlight the habits and symptoms of those with ADHD. But beneath the surface the mismanagement of the goals, missing the forest for the trees, shooting from the hip, or regretting bad decisions is invisible to the naked eye.

On today’s podcast, clinical psychologist, celebrated author, and director of the Brown ADHD Clinic for ADHD, Thomas Brown, Ph.D. discusses the complex syndrome of ADHD and its developmental impairments which often are situationally specific and its chronic and ongoing interference with life can be exhausting.

About Thomas E. Brown, Ph.D.
Dr. Brown is a clinical psychologist who received his Ph.D. from Yale University and is Director of the Brown Clinic for Attention & Related Disorders in Manhattan Beach, CA. He specializes in assessment and treatment of high-IQ children, adolescents and adults with ADD/ADHD and related problems.

After serving on the clinical faculty of the Yale Medical School for 20 years, Dr. Brown resigned to relocate to Manhattan Beach, California where he directs the Brown ADHD Clinic for ADHD and Related Problems in children and adults. He holds an appointment as Adjunct Clinical Associate Professor of Psychiatry and Behavioral Sciences at the Keck School of Medicine of the University of Southern California.  He is also an elected Fellow of the American Psychological Assn.

Dr. Brown has presented papers, workshops, courses and symposia at national meetings of the American Academy of Pediatrics, American Psychological Association, American Psychiatric Association,  American Academy of Child & Adolescent Psychiatry, National Association of School Psychologists, International Neuropsychological Society, the National Attention Deficit Disorder Association and CHADD. He has also lectured at universities and international meetings of professionals in more than 40 countries.

He is author of 5 books on ADHD; his work has been published in six different languages. His most recent books are: Smart but Stuck: Emotions in Teens and Adults with ADHD (2014) and Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide (2017).

Websites:

Books

Support the show (https://mailchi.mp/7c848462e96f/full-prefrontal-sign-up)

Producer: Welcome back to Full PreFrontal where we are exposing the mysteries of executive function. I am here as always with our host, Sucheta Kamath. Good morning, my dear friend, very much looking forward to today’s conversation.

Sucheta Kamath: Yes, great to be with you, Todd, and this is going to be another fantastic discussion. This is a hero of mine and I have known and seen his work and read it for several, several years, 20 years-plus, and now I get to talk to him, so I’m very excited, but before we get into that, I was going to say this just happened to me yesterday. I have a pre-teenager, I guess, a 13-year-old, and she is working with me, she has ADHD and executive dysfunction and we have some work that we have decided to focus on, is to give her the tools and strategies that she needs to manage her own attention and focus, and she goes home and complains to her mom that the work that I’m giving is really hard and she doesn’t want to do it. It gets her frustrated, it makes her angry, and so I get an email from the mom that “I don’t want to see my child uncomfortable and I’m not sure if this is the right thing for us to do,” so what we are going to talk about is so relevant because one of the things that often happens is that people who are struggling need help and redirection, and they seek help but then when they look at the work and the work often invokes challenge and pressures which leads to emotional instability and that dysregulated self often is the first one to complain.

So, with that in mind, today, it’s my honor and privilege to welcome Dr. Thomas Brown who is a clinical psychologist and he received his PhD from Yale University and is a director of the Brown Clinic of Attention and Related Disorders in Manhattan Beach, California. He specializes in assessment and treatment of high IQ children, adolescents, and adults with ADHD or ADD and related problems. After serving on the clinical faculty at Yale Medical School for 20 years, Dr. Brown resigned to relocate to Manhattan Beach. Of course, much better, I suppose. Gorgeous weather there, and he now is treating children and adolescents, and adults there. He holds an appointment as adjunct clinical associate professor of psychiatry and behavioral sciences at the Keck School of Medicine of the University of Southern California. He is also an elected fellow of the American Psychological Association. He is a prolific author, a prolific speaker, and just to give you a brief overview of that, he has published six different books that have been translated into six different languages. As I mentioned to him earlier, what my favorite book that I’m obsessed right now is called Smart but Stuck: Emotions in Teens and Adults with ADHD which was published in 2014. He also has given tons of courses and written an incredible amount of papers, is well respected and I am delighted to welcome him to the podcast.

Welcome, Tom, to the podcast.

Dr. Thomas Brown: Well, thanks very much, Sucheta, I’m very happy to be here.

Sucheta: So happy to have you. So, I ask this question of all my guests. Since our talk is about executive function, self-regulation, guiding one’s self to take better decisions and manage one’s own learning and thinking, may I start with you? How are you as a young child and a learner, and a thinker and when did you discover your own understanding of self and how does that shape you to take the course that you took in your career?

Dr. Brown: Oh, actually, I went all the way through college without being quite sure what I wanted to do. I was a history major.

Sucheta: Oh, really?

Dr. Brown: Yeah, I was a history major and because I knew that we had some very good faculty in history there, I was quite interested in it, and I was thinking, well, I might go into teaching history on the university level or I had some interest in psychology as well, and then I also was thinking about the possibility of going into medicine.

Sucheta: Really?

Dr. Brown: So, it was a while in becoming and finally, after starting it out a bit, I decided that I would take the route of psychology and went on to do my graduate work at Yale but that didn’t happen until nearly the last semester of my studying in college.

Sucheta: Gotcha, but you were aware as a learner, you were pretty organized and you had great focus, you would say?

Dr. Brown: Well, I had to be somewhat organized because I grew up in a family with no money and so I had to work half and three quarters’ time throughout the years I was in my undergraduate work, and so I was working as a lifeguard and a swimming instructor at the YMCA and I helped to manage some other group programs there, and so having to be off-campus for about 20 to 25 hours a week, I had to be organized in order to stay on top of what I had to do in school.

Sucheta: Wow, and you were willing to put a lot of effort, it sounds like, so definitely dedicated and focused. That’s great.

Dr. Brown: I was fortunate, I liked also what I was doing, so that helps.

Sucheta: So, let’s start with ADHD. Why don’t you help us with the definition of ADHD as a neuropsychological disorder and do you agree that at its core, ADHD is an executive function disorder? What would you say to that?

Dr. Brown: I’ve been really thinking about this quite a bit over recent years and most of the things I’ve published are related to it. My feeling is that you can write an equation that says ADHD equals developmental impairment of executive function. Now, [6:11] the word ‘developmental’ in there is to say that there are many ways in which executive functions can be impaired. For example, if a person is in a motor vehicle accident and they smashed their head too hard against the dashboard or the window, depending on where the trauma is affecting the brain, they may have impaired executive function or if somebody has a cardiovascular accident, a stroke, because the blood flow gets messed up in their brain, depending on where that happens, that can cause impairment of executive function. There are things like Alzheimer’s dementia which is impairment of executive function as one of its core symptoms, but in each of those three cases, you’d usually assume that the person has had fairly adequate executive function to begin with and it gets messed up simply because of the tissue damage to the brain, but in the case of ADHD, what we are talking about is that the development of those executive functions isn’t unfolding. It’s not opening up. It’s not maturing in the way that you normally would expect for a person of that particular age, so in that situation, we are looking at executive functions – I think you could say that’s the management system of the brain, just a shorthand way of talking about the brain’s self-management system.

Sucheta: So, is it fair to think that I like to always describe to parents and teachers that there are two criteria one can think of, so if you have a child who is expected to perform certain tasks and actions, and take decisions and manage emotions but is not, and second is the peers are able to do it but this child is not, so it is not absent, it is not just not present at the right time, is that a fair way to think about it?

Dr. Brown: Yeah, I think it’s a developmental thing, it’s not showing up the way you do except it to for somebody of that age.

Sucheta: Exactly, yeah, yeah.

Dr. Brown: And that’s quite understandable because it is the self-management functions, the executive functions are dependent upon structures and circuits in the brain which are not fully developed in most people until they are 18, 20, 22 years old. These are among the last components of the brain to really mature.

Sucheta: You know, and that’s kind of a sad thing, yet we are expecting our children to drive, we are expecting them to manage multiple subjects, and we are expecting them to navigate the technology pressure, so there’s a great amount of executive function proficiency we are expecting but maturationally, they may or may not be able to do but it may appear as a dysfunction.

Dr. Brown: Yeah, I think the process of development of executive functions goes on for a long time. You can see its very beginning as you gradually teach a child to be able to dress himself or herself and be able to manage tasks that we routinely asked kids of different ages, but as we get older, the demands and executive function increase. For example, yeah, we expect different things out of 12-year-olds than we do 10-year-olds and we certainly expect different things out of 15, 16-year-olds than we do of the 12-year-olds, and the maturation of the circuits that are most important – for example, the reason most states will not allow someone under 16 to drive a motor vehicle is not that their legs are too short to be able to reach the pedals, that could easily be fixed by design. The problem is they don’t have the maturation of the complexities of the brain that are needed to safely drive a car.

Sucheta: Yeah, and I love the way you described ADHD with a metaphor. You say it’s watching basketball through a telescope. Do you mind telling us what that means?

Dr. Brown: Yeah, I used that example to talk about the way in which people sometimes find themselves, people with ADHD – [10:12] by saying all the things that I’m going to talk about as part of ADD are things all of us have trouble with sometimes. It’s just that people with ADD have a lot more trouble with it, so in essence, this is not something that’s an all or nothing thing, like pregnancy – you are pregnant or you’re not pregnant, there’s nothing in between. It’s more like depression, and everybody gets bummed out once in a while. Just because somebody’s unhappy for a couple of days, does not mean we will diagnose it as clinically depressed; it is only when these depressive symptoms are persistent and making a lot of trouble for him, we say yeah, that’s depression, we should do something about it.

Sucheta: And I love the way you always specify with ADHD that these impairments are situationally specific, chronic, and significantly interfere with functioning of many aspects of a person’s daily life. This is your quote from Smart but Stuck. You see why I love that book.

Dr. Brown: Yeah, and the reason that I like to focus on that is a lot of people get puzzled by the fact that what I call situational specificity of the ADD or ADHD symptoms, and so I use ADD/ADHD interchangeably, but here’s what I’m talking about. My favorite example of it is a 16-year-old boy I saw sometime back who was the goaltender for his school’s ice hockey team and it just happened that the parents were bringing him in to see me for initial evaluation the day after he had just been playing with his team and they had won the state championship in ice hockey, and so at the beginning of the conversation, the parents were bragging a little bit about how great he had been on the tournament the day before and apparently, he was an extraordinarily good goalie. [11:45] playing hockey, he missed nothing; he knew where that puck was every second of that game, totally on top of it, he’s the goalie every team wants. Smart kid, tested way high up in the superior range, wanted to get good grades, he’s open to go to medical school and he was always in trouble with his teachers, and what they say to him is, “You know, once in a while, you’ll say something that shows how smart you are. When we are talking about something [12:06] some comment is really very perceptive and suppressive but most of the time, you’re out to lunch or looking out the window and you’re staring at the ceiling, you look like you’re half asleep. Half the time, you don’t even know what page we are on,” and so the question they kept asking him was, “If you could pay attention so well when you’re playing hockey, how come you can’t pay attention to sit in class?” [12:23]

Sucheta: What did he say?

Dr. Brown: Well, he said, “I want to but I can’t.” Another example would be parents who would bring in kids and they will say, “The teacher says this kid can’t pay attention for more than five minutes. We know that’s not true. We’ve watched him play video games. He can sit and play those video games for three hours at a time and not move. Teachers say he’s easily distracted, that’s nonsense. When he’s playing those games, he’s locked on that screen like a laser. The only way you’re going to get his attention is to jump in his face or turn off the TV.” So again, if you do it here, why can’t you do it there? Now, it’s not always sports or video games. There’s some people with ADD, they are not good at that stuff. They might be into art, they are sketching and drawing for hours at a time. Somebody else, when they’re little, they are creating engineering marvels with Lego blocks, and then when they are older, they are taking car engines apart and putting them back together or designing a computer that works, but everybody I’ve ever seen with ADD has a few things they can do where they have no trouble paying attention, even on almost anything else, they got a lot of trouble paying attention. If you ask them, “Hey, what’s with this? How come you can do it here but you can’t do it there?” Usually, what they’ll say is, “It’s easy. If it’s something I am interested, I can pay attention. If not, I can’t,” and most people who hear that, they say, “Yeah, right, congratulations. That’s true for anybody. Anybody’s going to pay attention better for something they’re interested in than for something they’re not,” which is true, but here’s the difference: people who don’t have ADD, they’ve got something they’ve got to do and they know they got to do it, it’s important, they can usually make themselves pay attention even when it’s pretty boring just because they know they need to do it. With ADD, it’s incredibly difficult for them to be able to make themselves pay attention. Unless a task is something that’s really interesting to them, not because somebody said, “Hey, you should be interested. This is going to improve your grade average,” but just because it is interesting to them, for whatever reasons.

Sucheta: Exactly.

Dr. Brown: Or if they feel they have a gun to their head and it’s something they think of as very unpleasant, it’s going to be happening very fast if they don’t take care of it right here right now. Those two conditions, no problem. Anything else, they do have a problem, so it makes it appear that it’s a problem with willpower, and I had a college kid one time who came in and gave me a good illustration for that. He said, “You know, having ADD is like having erectile dysfunction of the mind. The task you’re trying to do is something that turns you on, you’re up for it, you can perform but if the task you’re trying to do is not something that’s intrinsically interesting and doesn’t turn you on, you can’t get it up, and if you can’t get it up, you’re not going to be able to perform and in that situation, it doesn’t matter how much people – they may say , I want to, I need to, I should do.” You can’t make it happen. It simply not a willpower kind of thing.

Sucheta: I just love that. It’s giving me a bad visual imagery but yes, it is so true that it is that will – it almost looks like a kind of battle of bulges, when a young mind is refusing to engage, it looks like they can but they will not and that can lead to lots of punishments, so tell us a little bit more about you write a lot about this common misunderstandings of ADHD. In what ways people get it wrong because of these inconsistencies and these erratic presentations of symptoms?

Dr. Brown: Yeah, the most common problem is that parents and teachers, and other family members often assume that if you can focus so well on a few things, you ought to be able to focus equally well on other things just because you know you need to do it, and the fact is that this thing, understanding of the way their brains motivation operates, because it’s fundamentally a chemical problem and it’s based on how we see situations, and it’s not just how you consciously think about it. There’s a lot of unconscious aspects of how we feel about any task that we are presented with.

Sucheta: So, how would you say it is a chemical problem. Can you help people understand that a little bit?

Dr. Brown: Well, yeah, it’s a chemical problem because if you have something that you are saying you want to do and you feel you want to do, in order for that to happen, there are messages that have to be carried in the brain from one neuron to another. If you picture the brain as having 100 billion neurons, those are the cells that make up most of the brain tissue, it’s hard for most people to imagine a number as big as 100 billion but here’s a way you can do it: think about a good-sized TV screen or a computer screen. For example, the one I’m looking at right now is not one of these huge TV screens – it’s just my computer screen and on there, I know there are over 200,000 pixels, then imagine a skyscraper 110 stories tall and you’re going to take these screens of the size of a good-sized computer screen and cover the entire building top to bottom all the way around with these screens. If we then have each one of the screens and all the pixels on every one of those screens, it would tally up to a number which would be roughly equivalent to how many neurons one person has in their brain.

Sucheta: Yes, great imagery.

Dr. Brown: So, we are talking big, big numbers here and the thing is, these things are small, you need a powerful microscope to be able to see them and they are about 1/5 the thickness of a human hair. So, if you imagine, they are all wedged together in the skull but the fact is, the signaling functions go on through the connections around the synapse. These things do not directly touch each other. There is a gap thinner than a piece of tissue paper between them and the only way the brain can operate is with low-voltage electrical signals that zip through these networks that are formed by neurons to do specific tasks, and every time they get to one of these gaps which mean synapses, they’ve got to jump the gap like a spark plug, [18:12] the spark, and so you’ve got this low-voltage charge coming through, it’s carrying some information that needs to get to another part of the brain in order to make something happen and in order to make that happen, the brain manufactures a total of more than 50 different types of chemicals and every neuron works on one of them and the ones that are most important in ADHD are dopamine and norepinephrine, and those chemicals are manufactured in little tiny bubbles right at the end of where the one neurons is meeting another, the synapse, and so the electrical impulse comes in when it arrives at the point of the synapse, there is a release of a microdot of the chemical and that’s what facilitates the crossing of the electrical charge across that open gap over to the next neuron.

Sucheta: Absolutely.

Dr. Brown: And this is fast, in one thousands of a second, you get 12 messages across and it’s all done with these chemicals, and then the brain also has, it’s built in amazing ways, on the sending side, there are also little protein cells that are called transporters and they work like little vacuum cleaners, so that fraction of a second after the message has gone across, it sucks it right back in, it sucks back in the chemical that was involved which is the way the system reloads because otherwise, when you locked open, you’ll never get anything else through it, and so the chemicals which facilitate the communication between these neurons are the mechanism by which the brain carries messages from one part of the brain to the other, and the messages of what we see, what we hear, what we are remembering, all that stuff depends on circuits that are set up and they keep shifting all the time depending on what we are doing, and within one thousands of a second, you can get 12 messages across. It’s fast.

Sucheta: It’s very, very fast, and what’s so amazing about this system as you described this is this transmission of information that happens through low-voltage electric signals, if it doesn’t transmit, if the gap between two neurons which is that floating space, if this doesn’t get activated, then the impulse ends, that electric energy dissipates right there and that’s when –

Dr. Brown: Yeah, the messages just doesn’t get any places.

Sucheta: It doesn’t go, yeah.

Dr. Brown: Nothing is going to happen.

Sucheta: And mostly as you know, in terms of executive function means taking action, it’s a motor system, it’s producing some sort of action or stopping some action from happening, requires a lot of these activations which if they don’t happen, then you are seeing a kid going bonkers who’s acting on everything that he sees, wants to touch it, he wants to comment on it and also [21:10].

Dr. Brown: And also, [21:10] a lot of other things that people might want them to be doing instead.

Sucheta: Yes. So, now that we know that in so many ways as you described this, the common misunderstanding is that it is not a failure of will or antagonistic behavior to challenge authority. It is a genuine dysregulation of not knowing how to pay respect and attention to all the things that are relevant for personal progress, correct?

Dr. Brown: Yeah, and it’s not a matter of not being willing to pay attention, it’s a matter of that’s just not where the person’s, that is, and that something which depends on a whole lot of things in the brain.

Sucheta: So, let’s talk about then diagnosing ADHD. How does a neuropsychologist diagnose this disorder and how do we, because of the symptoms, not all need to be present in order to be called ADHD, right?

Dr. Brown: True. Well, first of all, I’m a clinical psychologist, I’m not a neuropsychologist and in fact, I annoy neuropsychologist quite frequently because I –

Sucheta: Can you differentiate for our listeners? I don’t think they know that.

Dr. Brown: Yeah. Well, the clinical psychologists deal with – we usually spend – a lot of things we do, the different kinds of clinical psychologists, but the main thing we do is talk with people, listen to people, and try and learn about them from the things that they are struggling with, and then try to help them sort it out, and there are various ways of doing that. However, the neuropsychologist is a psychologist who specialize in administering neuropsychological tests and those include things like IQ tests, but those are done also by clinical psychologists and by school psychologists, but they have a whole set of tests, like the Rey-Osterrieth test and well, Wisconsin card sorting test, and a number of the things whereas like you sit down with a neuropsychologist and arrange things with blocks and you look at puzzles and try sequencing various tasks, and then they try from that to describe for you in which ways your brain is working similar to what you’d expect for a person of this age and which way it’s not. However, Russell Barkley and we have both written on this topic, both argue that those tests may be helpful for identifying problems with tumors and problems with paralysis, and a variety of cognitive and motor system problems, but they don’t work for being able to identify the symptoms of ADHD and to make a diagnosis, and so you do have still a lot of school systems who are saying, well, in order to get diagnosed with ADHD, you need a battery of neuropsychological tests, and I would argue you don’t because those neuropsychological tests are quite good for finding out certain things about how the brain works, but they are not good at seeing how you function across situations in different activities. They’re not good at being able to – you can’t generalize from them to know what things a person is going to be able to do and what things they’re not going to be able to do that are influenced by a whole lot of other things, and so –

Sucheta: So, can I ask you a question about this?

Dr. Brown: Yeah, go ahead.

Sucheta: Here’s a dilemma. You’re right, if the teacher is observing something, often which means they are suggesting to parents to do something. The child is not cooperating, the child is not paying attention and the child is not optimally learning, then the parents have their own set of preconceived notions about what it means to have a diagnosis of ADHD or medication, blah, blah, blah, but when they see a psychologist, whether it’s a neuropsychologist or a clinical psychologist, one of my pet peeves is, like you said, a robust history taking and contextualizing symptoms and seeing a common thread is really what this clinical discernment you are talking about needs, but I find that when you – often, a lot of children in schools go to educational psychologists, they get measures of reading and math and academic skills, but the executive processes did not get addressed because no executive function tool is used, so whoever is most equipped, don’t you see or do you recommend the value of using some certain executive tests that tap into executive processes, whether it’s Wisconsin card sorting, whether it’s a Rey-Osterreith, but by itself, it’s of no use but that should be contextualized in the places where the child lives, right?

Dr. Brown: Very much fit. I think a neuropsychological test battery generally costs thousands of dollars and it’s very intensive and you can [25:57] reports off but the fact is, it doesn’t tell you a whole lot about ADHD.

Sucheta: Yes, or what to do or –

Dr. Brown: And yeah, much less work to do. So, I think that there are certain – I do some from time to time administer IQ tests and academic achievement tests, those things can be useful for helping to understand sort of how well a person is doing in school and what kind of difficulties they are running into but they are not required for making a diagnosis of ADHD. The main thing I do in evaluating for ADHD is to talk with the patient and family members or whoever else is available to help me understand about what it’s like for them day by day in their school or in their job , and ADHD –

Sucheta: So, do you use measures like certain type of case history forms or some symptom checklists?

Dr. Brown: Yeah, I’ve published some diagnostic forms.

Sucheta: Can you share with us what you would recommend? Yeah.

Dr. Brown: But the other thing – and they are published by Pearson company, the company that makes the WISC and WAIS IQ test, but the main thing I have is I’ve got a rating scale – in fact, I published my rating scales for teenagers and adults back in 1996 and then in 2001 published a version for children from three all the way to adolescence, and then just last December, we did completely overhaul those measures, so we now have what’s called the Brown Executive Function/Attention Rating Scales and –

Sucheta: And I saw you present on that and I’m so excited, I haven’t had the chance to use that but that sounds absolutely amazing. Can you tell us in what way you have set it up?

Dr. Brown: Yeah. It’s set up so that it depends at what age you are talking about, but there are roughly about 50, give or take 10 questions, about how the person deals with a variety of situations and it’s talking about six clusters of problems and those clusters are the model that I work with and basically I developed my model by just talking with lots and lots of patients over the years, and the parts of the model are first, being able to get organized and get started – activation, and then another is being able to focus, and then shift focus when you need to. The third cluster is being able to regulate alertness which involves being able to be awake when you need to be awake and asleep when you need to be asleep, and being able to sustain effort, keep up the effort to finish things, and then be able to adjust processing speed so you’re not going to slow or too fast for what you got to do.

Sucheta: I really like that you addressed that effort piece because a lot of times, people are only focused on attention and they don’t understand attention sustained over time is really the key, not just am I focused or not focused?

Dr. Brown: Yeah, exactly.

Sucheta: That’s great.

Dr. Brown: And then, there’s another piece of this, the fourth cluster in this six-factor model is managing frustration and modulating emotions and you should know, the official diagnostic criteria for ADD don’t include anything about emotions [29:05].

Sucheta: It makes no sense.

Dr. Brown: But most of us that do research on this and who treat patients, and anybody who knows people with ADD can usually tell you, oh, yeah, that’s a pretty big part of what people struggle with and it’s different emotions for different people, we can talk more about that later if you want but the fact is, managing – the rating scale I published has one whole section that deals with managing frustration and modulating emotions, and then the fifth group is memory. That is not remembering things from a long time ago. It’s short-term working memory, it’s your memory, what you just heard from somebody when you’re talking with them, something you were about to say to somebody or the sort of thing that’s involved when you don’t remember when you in thr other room to get something and you’re standing there scratching your head wondering what the hell you came in there for, or it’s being able to follow a conversation and then be able then to pull out of memory what you need when you need it, but that’s the working memory. It’s not remembering things from a long time ago, and then finally, monitoring and self-regulating action, and that’s just being aware of sort of what you need to be doing and being able to stop when you need to stop and being able to modulate your action, so that you are not going way too fast or way too slow in terms of how you are talking with people or how you are moving. Often, adults with ADHD tease each other about how when they use the image that you do when [30:30] to use when you’re getting ready to shoot a weapon, it’s ready, aim, fire, and what they tease about is often for people with ADD, there’s a lot of impulsiveness to it, and so they actually are doing ready, fire, aim, so they’re not sort of able to check out what they are doing before they say it or before they do it, and so those are the six clusters that these rating scales ask about with very practical questions about how you do it and they are all or as phrased in terms of the particular age group that that scale is designed for, and then we got them for kids from three years old up to adults in old age, and then we’ve got [31:11] having administered these tests to large numbers of people in each age group and to both males and females, and then you can plug in the scores into a computer and it prints out a report that describes which of these six clusters a person’s functioning pretty well at, which things they’re having a little trouble in, which things they’re having a lot of trouble in, but that’s a good rating scale, and there are a number of other scales out there. Barkley’s got rating scales, Connor’s got rating scales, there are a number of others as well that you can use to get – ask people a lot about what happened in the last 10 minutes or in the two hours you’re spending with me, but what it’s like for you day to day and the various things you need to do?

Sucheta: Live this life.

Dr. Brown: Yeah, how you live your life, and so that’s –

Sucheta: I really like that.

Dr. Brown: So, a matter of the rating scales, yes, but also a lot of clinical interviews, conversation, gathering information about what’s easy for the person, what’s difficult, what are their strengths, what are their difficulties? And then thinking about that in the context of the diagnostic criteria for ADHD.

Sucheta: So, I have a question about this.

Dr. Brown: [32:17]

Sucheta: Sorry, sorry, I don’t mean to interrupt you. I did have a question about a couple of components of executive processes and what do you think of or where do you structure them in this context of six clusters? So when I do the intervention, I often see one of the prominent areas of their need is prospective memory, the ability to remind themselves to remember to remember by formulating memory trays and creating a plan, rehearsing the plan and executing at the time of by reminding self without any help, or setting the help in advance, so how do you see that the set of skills in the context of the six clusters?

Dr. Brown: Oh, that’s very much a part of working memory.

Sucheta: Okay, okay. So, you see that and know –

Dr. Brown: It’s being able to remember to remember.

Sucheta: Got it, got it, so that’s what I thought when you said short-term memory, you are saying that not just the limited aspect of envisioning of working memory as holding onto information while you are using it to process it.

Dr. Brown: Yes, exactly.

Sucheta: You’re going beyond that, and second thought I had was where do self-awareness and self-efficacy skills fit into that? Because those with ADHD, as you know, are least self-aware as well as they don’t have the accurate self-appraisal, so they are not able to strategize or discard strategies flexibly when they are not working, that’s why you see a lot of preservation, getting hung up or stuck, so where do you see this ability to recognize itself as a thinking entity?

Dr. Brown: Oh, I think part of that depends on all of – for all of us, it just depends on how we grow up and what kind of education we’ve got through thinking about ourselves, but the things that I would come back to here is that these cognitive functions or most people with ADD, young or old, are exercised pretty well for certain kinds of things even though they have a lot of trouble with other things. For example, I will go back to the issue about the hockey player, his ability to be aware of himself and his strengths and his difficulties and to be aware of his environment, where the other players are and where the puck is, and what’s going on in the game could be varied a bit. In that particular case, he was extraordinarily good with it even though he remained clueless about where he stood on some of the things he needed to do in his history class.

Sucheta: So true. So, let’s talk about emotions, one of my favorite topics, and you say that emotions guide what we notice and what we ignore, what we focus intently, and what we carefully avoid, so I feel that emotions – I mean, neuroscience and cognitive psychology are just coming out with better and better understanding of the role of emotions, but we almost have busted this myth that learning has nothing to do with emotions, but I think with respect to ADHD, that is one of the elements that is really out of whack, isn’t it? So, what is the role of emotions in ADHD and how does this fit with the overall dysregulation a child with ADHD often experiences?

Dr. Brown: You see, the way I think about it is that emotions play a huge role in everything that all of us do, and the issue is not that people with ADD have any different emotions. We have differences certainly among us in terms of which emotions get triggered under what circumstances, but I think the issue is mainly how do you manage them? How do you respond to them, emotions in yourself and emotions [35:51]? And that’s where the executive function comes in. It’s not that the emotions are different. It’s that the ability to sort of recognize emotions relative to what you’d expect from somebody of similar age and learning and to be able to manage them, to be able to learn, for example, when you might be angry about something, when to be able to speak up about it, so you might have a chance of getting the problem corrected, and when to shut up because if you deal with it right now in this particular situation, you’re going to make things way worse.

Sucheta: You know, that’s a really great distinction, that it is not the amount of emotions that ADHD children or adults differ, it is the way they don’t manage or don’t have tools to manage them effectively, and just going back to this metaphor that you used, the ready, fire, aim, if you keep doing ready, fire, aim, that you are definitely going to also be doing the same thing to your emotions. You are nodding off when you shouldn’t, you read about that in the newspaper all day long. They may or may not have ADHD but we do take poor decisions when we are running high and not regulated, right?

Dr. Brown: Yeah, we do, and we need to take emotions into account and to take into account other people’s emotions because that’s the sort of thing. That’s something I think most of us continue to learn about over the course of a lifespan, it’s being able to sort of read the signals from other people, being able to get a sense of how strongly they feel about something. Some people spell it out very clearly for you with tone of voice and the facial expression, and the words they choose, and then there are other people where they may not be as explicit about it but you can damn well bet that they got some feelings about various things, good feelings and cautious feelings, and angry feelings, and discouraged feelings.

Sucheta: And we could, as you said, see it very clearly. They don’t mince words. So, let’s talk about this, if that’s the case with respect to ADHD, does that mean we need to always have a special approach or a different approach in managing helping those with ADHD manage their own emotions, and what does that plan look like?

Dr. Brown: Oh, I think the plan needs to be shaped by what the difficulties are that a particular person is bringing in.

Sucheta: Tell us more.

Dr. Brown: Well, I think that there are some people with ADHD who have trouble because they are too aggressive in the way they deal with – whether it’s other little kids or other adults, that they tend to be pushed a lot by their anger and by their frustration, and they need to be able to modulate that in order to be able to interact with other people in ways that you are not constantly going to be pissing people off or hurting their feelings needlessly, but there are other people where their difficulties are much more with different emotions where they’ve got a propensity to be so timid and fearful that they’re living constantly with fear that others are going to just want to ignore them or hurt them, criticize them, give them a hard time, and there are other people who struggle more with their jealousy and the intensity with which they feel they have to go after some things they want that are things that other people seem to have a better advantage on. I’m just naming a variety of emotions and I think different people, in different situations – this is where the situational variability comes in, that there are some things that people are far more sensitive about than others, sensitive in a good way and that they’ll pick it up and work with it and sensitive in a bad way that it scares them off or annoys them excessively, and so I think that if that self-management of emotions, as they emerge in our interacting with life.

Sucheta: Yeah, and I think what I’m getting from you is that there is a quickness with which they get flooded by these emotions and once they get flooded, they are drowning in it and once you are drowning, you are never – you may be a good swimmer but if you are drowning, you start panicking and that panic, you are never guiding yourself well and the consequences are too far out, and people don’t change their mind about you if they see you lose it all the time, right? So, the social impact is far worse than the actual emotional dysregulation in the moment – at least that’s what I see in my practice. Reputation management.

Dr. Brown: Yeah, it has impact, how we deal with other people is going to affect how they’re going to deal with us.

Sucheta: So, that brings me to, as we are coming to the end of our discussion, do you mind talking with us the co-occurring disorders – ADHD, rarely do these things exist in isolation, right? These are complex disorders that have comorbidity and situational complexities that make coping with them much more harder, so what are some of the considerations and what should we think about when we think about ADHD?

Dr. Brown: Okay, well, I think it’s important to do – you pointed out exactly what you were just talking about and that is that most people with ADHD are having trouble with something more than just ADHD. Sometimes, that’s because of genetic vulnerability and sometimes there are just other things that come along with it, but I can tell you, I remember one of the first books I published was on attention deficit disorders and comorbidities in ADHD [41:29] in children and adults. The first book came out in 2000 and I put out a new version of it in 2009, but comorbidities is just medical jargon for having more than one problem at the same time, and that got started – I was having a conversation with a couple of my colleagues one time about how they’re having trouble getting people into the research of ADHD because they couldn’t find people that had just pure ADHD. Everybody seem to be coming in with an anxiety disorder with depression or with impulsive problems in their behavior and other co-occurring disorders, and at that time, we weren’t thinking or talking too much about that, and so I eventually got together with some of my colleagues who I published that first book back in 2000. It’s quite a few years back, but the issue here is being able to recognize that – well, for example, what you know from Kessler’s work that if you look at adults around 40-ish who have ADHD, you can say that that person has six times the likelihood of having at least one other psychiatric disorder in their life relative to people who do not have ADHD.

Sucheta: Yeah, isn’t that crazy? Yes.

Dr. Brown: And sometimes, it’s depression. Sometimes, it’s excessive moodiness, sometimes, it’s anxiety, sometimes, it’s a specific learning disability in reading or in math, or in writing. For example, with young kids, the incidence of anxiety disorders in young children is about 5%, anxiety that goes to the level where you make a diagnosis for it, and among kids with ADHD, it’s 35%. It’s markedly increased. Take something like substance use disorders. Show me a kid who is 10 years old and I can tell you [43:14] diagnosed for ADHD, I can tell you that kid has doubled the risk of having a drug or alcohol problem at some point in his or her life if they are not treated with medication.

Sucheta: Yeah, isn’t that crazy? Yes, and people don’t take this seriously. Yeah.

Dr. Brown: It’s understandable. Some parents are just very worried about putting their kids on medicine for ADHD because they are afraid that if they are taking pills for the ADHD, this may make them more likely to take alcohol or drugs of other kinds [43:43].

Sucheta: So, how do you answer that question, actually? That’s a great question. How do you answer that?

Dr. Brown: Well, what I say it’s look, I can tell you that this kid who has [43:53] diagnosis having ADHD has double the risk of having a drug or alcohol problem at some point in his/her life and that is if he is not treated with medicine, but if we treat with medicine, it doesn’t guarantee that the kid is not going to have a substance-abuse problem at some point in his life, but it does reduce the chances of him having such a problem back to where they’d be for a kid who didn’t have ADHD. So, it’s not that it’s protective in some magical way. It just reduces the risk that you have as a result of having untreated ADHD.

Sucheta: I think the fact untreated means you’re not acknowledging these difficulties having a real life impact, so to me, when you actually go to a clinical psychologist, when you come to a person like me, when somebody actually sits down with you and explains that the way your brain works is a little bit different but it has no barriers in living a rich and meaningful life, that is very healing, you know what I mean? So a lot of times, I feel that that opportunity is so lost when you don’t address it because you have all kinds of fears that medication means it’s a stamp, it’s a label, it’s a permanent ailment. That’s what I always say and I always remind people, tell me if this is right where to do it or not but I say, you do not contest with a person who has diabetes that “Hey, get rid of your diabetes, overcome it.” You’re open to treatment because you consider that as an ailment that your body is not producing.

Dr. Brown: Yeah, and you know it’s not a problem of the person choosing to have it.

Sucheta: Yes, yes! And it’s not also a sign of having less intelligence because now you have diabetes.

Dr. Brown: Certainly not. We’ve got very good evidence that yeah, IQ, people of my specialty is dealing with kids and adults who have a high IQ and ADHD, and the reason I got into that particular interest is not like everybody I see has to have a high IQ, but I have a special interest in it simply because I find that those people who are particularly bright are often delayed in getting recognition of their ADHD. People think, oh, you’re so smart, you should be able to fix all this stuff. It’s all just laziness, it’s all that’s all it is for you, and in fact, those people often wait a lot longer to get diagnosed and get help for ADHD.

Sucheta: And I like to point out this strength-weakness gap, I think particularly gifted children with ADHD tend to get undiagnosed and then they tend to, their families, because they recognize the talent, feed the talent and  ignore the weaknesses, and strengths-weaknesses gap really becomes very costly because then, you are left to reconcile with this gap thinking that wait a minute, what’s wrong with me? I’m never getting any proper attention.

Well, Tom, this has been just a spectacular discussion and I have so thoroughly enjoyed everything you had to say and particularly really helping people see the larger picture of direct and meaningful relationship between ADHD and executive function, so I’m very grateful for your time.

Dr. Brown: Thanks very much, I enjoyed talking with you.

Sucheta: Same here, thank you.

Producer: Alright, well, that’s all the time we have for today. If you know of someone who might benefit from listening to today’s podcast, we would be most grateful if you would kindly forward it to them. So, on behalf of our host Sucheta Kamath, today’s guest, Dr. Thomas Brown and all of us at Cerebral Matters, thanks for listening today and we look forward to seeing you again right here next week on Full PreFrontal.