A New Understanding of ADHD in Children and Adults

The full title is A New Understanding of ADHD in Children and Adults: Executive Function Impairments. It was published by Routledge in 2013. About two hundred pages.

Thomas E. Brown is a clinical psychologist with a doctorate from Yale. At the time the book was written he was a clinical faculty member at the Yale School of Medicine and served as associate director of the Yale Clinic for Attention and Related Disorders. Today he runs his own clinic in California.

The book says it addresses both specialists and patients, families and educators. When I read it, I felt the weight was on the specialist side.

I could not find a verified Turkish edition. Brown has two books translated into Turkish by ODTÜ Geliştirme Vakfı Yayıncılık (the METU Development Foundation Publishing), but I did not see any record showing that this title is among them; I am writing it under its English name.

From a behavior disorder to a management system

The book has a single big claim, and this is the "new understanding" in the title.

For many years ADHD was seen essentially as a behavior disorder: the child who cannot stay in their seat, cannot wait their turn, interrupts. According to Brown, research has changed this picture. ADHD is a developmental disorder of the brain's cognitive management system, that is, of the executive functions.

Brown explains this with a computer analogy. Executive functions are like an operating system; when something goes wrong in that system, many programs running on it are affected at once. Reading, writing, getting work done, building relationships, managing time. This analogy explains very well why ADHD leaks into so many different areas of life.

The book emphasizes that most of these functions normally work automatically and outside awareness. A person with ADHD, on the other hand, has to turn things most people do without thinking into tasks that demand conscious effort. Reading this, I made sense of my tiredness.

Why the structure of the book is so plain

There is an introduction and six chapters. Each chapter title is built like a question or a claim: the false beliefs, the new model, what research says about causes, how the model changes assessment, how treatments affect the brain, why co-occurring conditions are so common.

This plainness is deliberate. The book proceeds like a piece of advocacy. First it shows what is wrong with the old frame, then it builds the new one, then it explains how the new frame is to be applied to diagnosis, treatment and co-occurring conditions.

Thirty-five misconceptions

The first chapter is the most useful part of the book: it lists thirty-five common misconceptions about ADHD and puts next to each one, briefly, what research says.

The belief Brown dwells on most in this book is the idea that ADHD is a problem of willpower. Right beside it comes the second: that someone who can focus for hours on a task that interests them cannot have ADHD. Brown's entire model is built to explain why these two are wrong.

I will not list the whole thing here, but this chapter is a reference text on its own. It would be useful to have at hand at a family gathering, in a meeting with a teacher, or when arguing with someone who says "everybody is a bit like that." While reading this list I noticed that I still carry a few of the misconceptions inside me.

I had collected the same subject in a shorter form, in Turkish, in the article ADHD myths and misconceptions.

Six clusters

The second chapter presents Brown's model. Executive functions are grouped into six clusters: activation, focus, effort, emotion, memory and action.

The model matters in two ways.

First, these clusters do not work independently of one another. They operate together, quickly and mostly outside awareness. A person with ADHD is expected to have difficulties in at least some of each of these six clusters.

Second, the model explains the situational variability in ADHD. The same person may show no difficulty at all while playing sports or games. Brown reads this not as an indicator of willpower but as the management system being switched on differently by interest and emotional importance.

The article what are executive functions, which describes executive functions in more general language, can be a good introduction to this chapter.

Causes and development

The third chapter compiles what research says about the causes of ADHD and how it unfolds across a lifetime.

Brown links ADHD to differences in brain development, to the connections between brain regions and to changes in chemical transmission. He also accepts the strong role of heredity.

This chapter is still largely valid today. The 2019 review by Faraone and Larsson gives the heritability as about 74 percent, in line with the general picture the book draws.

Brown treats ADHD as a developmental process and looks at how difficulties change across life stages. This view explains very well the experience of adults diagnosed late: as environmental support decreases and responsibilities increase, executive function difficulties that were managed for years become visible.

Assessment: how the model changes diagnosis

The fourth chapter discusses how this new model should change assessment in children and adults.

The book came out in the very year DSM-5 was published. DSM-5 raised the age of onset from seven to twelve, lowered the number of symptoms required above age seventeen from six to five, and added examples of how symptoms may look in adults. Brown's emphasis on adult diagnosis points in the same direction as these changes.

But Brown's model is broader than the DSM. It puts regulating emotion and effort close to the center of the diagnosis. The DSM-5 criteria, on the other hand, do not include these areas directly. This difference can lead, for example, to a clinician who has read Brown taking seriously, in terms of executive function difficulty, someone who does not fully meet the DSM criteria.

The executive function and attention rating scales that carry Brown's name are the clinical extension of this model. They rely on reports from the person and their surroundings about functioning in daily life.

Treatment and the brain

The fifth chapter describes how treatments affect the brain and the executive functions.

The account is balanced and informative. Instead of praising or frightening people about medication, it tries to understand the mechanism. The decision about medication is always made with a doctor; this chapter helps you go to that conversation with better questions.

Since the book was written, medication options and ways of using them have changed. The general logic of this chapter holds, but the details need updating.

Co-occurring conditions

The sixth and last chapter discusses why learning difficulties and psychiatric disorders are so often seen together with ADHD.

Brown's claim is a bold one: executive function difficulties may be a common ground beneath many co-occurring conditions. The operating system analogy is at work here as well.

This idea is interesting but disputed. Co-occurring conditions have other explanations too, such as shared genetic predispositions, shared risk factors, or secondary difficulties caused by ADHD.

Side by side with Barkley

On this site I had also reviewed Barkley's Taking Charge of Adult ADHD. The two models are close but not the same.

In Barkley's model behavioral inhibition, the ability to stop a response, stands at the center, and the other executive functions are built on it. Brown does not propose a single center; he treats the six clusters as a system that works together, and he gives more weight than Barkley to emotion and motivation.

There is also a general limit to the executive function approach. The 2005 meta-analysis by Willcutt and colleagues showed that groups with ADHD perform on average worse on executive function tests, but that this weakness is not found in every individual with ADHD. So executive function difficulty appears to be neither necessary nor sufficient on its own to explain ADHD.

Brown's approach leans on everyday functioning and rating scales more than on laboratory tests. Behind this choice is the view that laboratory tasks capture the real demands of life only to a limited extent. This defense is reasonable but does not close the debate.

The density problem

The book is short but cannot be called light. Every page refers to a study or a concept. One review had said that, despite its small size, the book is densely packed with current research; I agree.

As a reader with ADHD, this wore me out. It was hard to sit down and finish a chapter. In the end I read the book chapter by chapter, leaving time in between.

It is ironic that a book on ADHD should be this tiring for a reader with ADHD. But the aim of this book is less to ease the reader than to give everyone who talks about ADHD a common language.

The method that worked for me was this: before starting each chapter, read only its title and write myself in one sentence which question the chapter answers. When I finished the chapter, add my own answer to the same question. That way, instead of getting lost in a dense text, I was left with a trail. The small number of short chapters in the book suits this method very well.

Together with Smart but Stuck

A year later Brown published Smart but Stuck. The two books explain the same model through two different doors.

This book builds the model systematically, ties it to research, and applies it to diagnosis and treatment. Smart but Stuck tells the same model through cases, putting emotion at the center.

My recommendation is Smart but Stuck first, then this book. When you recognize something in the cases, this book tells you why it is that way.

One page I was left with when I finished the book

Because of this book's density, when I finished I reduced what stayed in my mind to a single page. Maybe it will be useful to someone else:

• Seeing ADHD only as a picture of behavior does not explain most of the difficulties in daily life. The management system frame explains far more.
• Things most people do automatically demand conscious effort in ADHD. Part of the tiredness comes from here.
• Being able to focus on something that interests you does not rule out ADHD. The same system works differently with interest and emotional importance.
• The diagnostic criteria and this model are not equally broad. Regulating emotion and effort is near the center in the model and absent from the criteria.
• Executive function difficulty is marked on average in the group with ADHD, but it does not show up in tests in every individual.

Even writing these five points on a piece of paper and taking them to a diagnostic appointment can make that appointment more productive.

For whom

For an adult who wants to understand ADHD through its scientific frame and is used to somewhat academic language. For someone who works with people with ADHD, such as a psychologist, psychiatrist, teacher or school counselor. For a parent looking for a serious source to understand their child's diagnosis.

I would not recommend it as a first book to someone who has just been diagnosed and is going through an emotionally hard period; before this, Brown's own Smart but Stuck is a much warmer introduction.

How to read it: read the first chapter from start to finish and keep it at hand. Read the second chapter to understand the model. From the later chapters, choose according to your need: the fourth if you are in the diagnostic process, the fifth if you are about to decide on medication, the sixth if there is a co-occurring condition.