Metaphor for Executive Functions

Imagine a symphony orchestra in which each musician plays his or her instrument very well. If there is no conductor to organize the orchestra and start the players together, to signal the introduction of the woodwinds or the fading out of the strings, or to convey an overall interpretation of the music to all players, the orchestra will not produce good music.

Symptoms of ADD can be compared to impairments not in the individual musicians, but in the orchestra's conductor. As is clear in the cases of Larry and Monica, persons diagnosed with ADD usually are able to pay attention, to start and stop their actions, to keep up their alertness and effort, and to utilize their short-term memory effectively when engaged in certain favorite activities. This successful functioning of persons with ADD in preferred activities indicates that these people are not totally unable to exercise attention, alertness, or effort. They can play their instru ments very well—sometimes. The problem of persons with ADD lies in their chronic inability to activate and manage these functions in the right way at the right time. Impairment lies not at the level of the individual musicians (those functions work perfectly well under certain circumstances), but at the level of the conductor, who has to start and guide all of the individual players.

This notion that the core attentional problems in ADD are impairments of executive functions is quite different from William James's "spotlight" concept of attention. The new paradigm describes the complex and rapidly shifting integration of multiple aspects of attention to achieve multiple tasks. Yet this notion does resonate with James's description of attention as "withdrawal from some things in order to deal effectively with others." The concept of executive functions is a way of describing how the brain's various cognitive functions are managed—by being continually shifted and reconfigured—to "deal effectively" with the moment-by-moment demands of life.

One way to consider this broader view of attention as executive functions is to observe situations where tasks are not dealt with effectively. Martha Bridge Denckla (1996) has written about patients with high intelligence and no specific learning disabilities who have chronic difficulties in dealing effectively with tasks. She compares these persons to a disorganized cook trying to get a meal on the table.

Imagine a cook who sets out to cook a certain dish, who has a well-equipped kitchen, including shelves stocked with all the necessary ingredients, and who can even read the recipe in the cookbook. Now imagine, however, that this individual does not take from the shelves all the ingredients relevant to the recipe, does not turn on the oven in a timely fashion so as to have it at the proper heat when called for in the recipe, and has not defrosted the central ingredient. This individual can be observed dashing to the shelves, searching for the spice next mentioned in the recipe, hurrying to defrost the meat and heat the oven out of sequence. Despite possession of all equipment, ingredients and recipe, this motivated but disheveled cook is unlikely to get dinner on the table at the appointed hour. (p. 264)

The "motivated but disheveled cook" sounds very much like a person with severe ADD who tries to accomplish a task, but is unable to "get it together." Individuals with ADD often describe themselves as intensely wanting to accomplish various duties for which they are unable to activate, deploy, and sustain the needed executive functions.

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