Willpower and ADHD

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CONFERENCE REPORTER

“Why is it that people with ADHD can do some specific things that they happen to be really interested in, or where they feel like, if they don’t take care of this right here, right now, something they do not want to see happen is going to happen fast?”

Thomas E. Brown, PhD, of the Brown Clinic for ADHD and Related Disorders and the University of California-Riverside School of Medicine shared with 2022 American Psychiatric Association (APA) Annual Meeting attendees that attention-deficit/hyperactivity disorder (ADHD) may appear to be a problem of motivation, or “willpower,” but it is not.

“The central mystery about ADHD is the situational variability of the symptoms…” Brown said. “Every patient I’ve ever seen with ADHD has a few activities in which they have no difficulty utilizing their executive functions, but has a lot of difficulty with doing almost everything else. It comes down to that one phrase: if I’m interested.”

Brown compared the problem to “erectile dysfunction of the mind”: “If a task you’re trying to do is something that turns you on or that you’re really interested in, you can perform. But if the task you’re trying to do is not something that’s intrinsically interesting, it doesn’t turn you on and you can’t perform. And if you can’t perform in that situation, it doesn’t matter how much you may say to yourself, ‘I need to do this’ or ‘I should make this happen’—it is simply not possible.”

This can be a challenge for individuals with ADHD at all ages. Although the most difficult times for these individuals tend to be middle school, high school, the first 2 years of college, and when moving away from home, these individuals may also have difficulty as adults with parenting or administrative tasks at work. At any stage, these individuals often have difficulty with the executive functions of activation, focus, effort, emotion, memory, and action.

Understanding that ADHD is not a problem of motivation is important for effective assessment and treatment, according to Brown, who recommended a variety of tools for assessing youth for ADHD, including semi-structured clinical interviews with the patient and a parent; teacher reports; normed ADHD rating scales such as the Behavior Assessment System for Children (BASC) and the Behavior Rating Inventory of Executive Function (BRIEF); and others that can give clinicians considerable data on the patient’s daily functioning.

Pharmacologic treatment may also be effective, according to fellow presenter Ryan Kennedy, DNP, NP-C, of the Brown Clinic for ADHD and Related Disorders, who noted that, when selecting and fine-tuning medications, it is important to consider many factors such as previous medical trials, growth and appetite, polypharmacy, metabolism, comorbidity, cost/insurance, sensitive body chemistry, and how to monitor effects in other settings.

“Effective treatment of ADHD can and should improve both academic and social learning,” Brown concluded.