Cluster 6 Monitoring and Self Regulating Action

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Treating Social Phobias and Social Anxiety

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Most descriptions of the disorder now known as ADHD emphasize problems with hyperactive and impulsive behavior. Many persons identified with this disorder tend to act without sufficient forethought, or are chronically restless and hyperactive, finding it very difficult to slow down and adequately control their actions. Children with ADHD have often been seen as wild, restless, and impulsive, unable sufficiently to control their words and bodies and so needing much more supervision from teachers and parents than others of the same age. One mother described her son's behavior:

My son is six years old, but he usually acts like he is only three or four. When he wants something he just goes for it. He just can't wait. He almost got hit by a car last summer because he chased a ball out into the street and didn't even stop to look. In kindergarten last year he was always in trouble because he grabbed toys or crayons away from other kids. When they were supposed to sit on the circle and listen for show and tell, he was always interrupting with his own comments; he had to tell about something he was thinking about. He couldn't just listen to another kid or even to the teacher. When he was supposed to draw a picture or copy some shapes, he was always in a hurry. If he tried to do what they asked him to draw or write, he did it too fast and it was too messy.

This year he is repeating kindergarten, but I'm afraid he won't be ready for first grade even next year. He just doesn't seem to be able to slow down enough to listen to the directions or to do anything carefully. He's way behind other kids his age in self-control.

This mother's description shows many different ways in which her six-year-old son is substantially behind his peers in his ability to monitor and control his actions. He acts impulsively and doesn't slow down enough to listen to others, to follow directions, or to do assigned tasks carefully. Chronic and extreme problems of this sort are typical of many young children with ADD syndrome.

Researchers have identified "impaired ability to inhibit" as a core problem in these hyperactive and impulsive symptoms of ADHD. Russell Barkley (1997) has argued that impairment of the ability to inhibit is the primary problem of persons with ADHD, and, of all the executive func tions impaired in the disorder, is the one on which the development and effective functioning of all other executive functions depends.

For some individuals with ADD syndrome, like this six-year-old, impairment in the ability to inhibit action is the most basic problem. Until they can develop more age-appropriate control of their actions—that is, the ability to slow down and hold back so they can act carefully and do the right thing at the right time—these individuals continue to make a lot of trouble for themselves and those around them.

Yet to overemphasize inhibition as the central problem of ADHD is to ignore the essential connection between holding back actions and engaging in actions. It is to overlook the need to "go," which is as important as the need to hold back or stop. Certainly it is important for a person to be able to stop at the curb rather than impulsively running across a busy street. But it is also important for that person to be able to monitor the traffic on the street, to determine when it is safe to cross, and then to actually cross. Indeed, most behaviors require the ability to act, to "do it," as well as the ability to inhibit, to refrain from acting. And essential to one's success in this regard is the ability to monitor the context of action, in this case, the traffic, so that one can decide when to wait and when to cross the street.

Monitoring the context of action can be quite complex, even in the simple act of crossing a street. It involves looking both ways to notice oncoming vehicles, estimating their speed, and allowing for road conditions— for example, rain or ice that might affect their slowing down or stopping. It also includes consideration of factors that might affect drivers' ability to see the person attempting to cross, such as sun glaring toward the driver, fog, or darkness, as well as exceptional circumstances such as a car swerving as though out of control or a vehicle speeding with flashing lights and siren.

Crossing the street also requires one to take into account information about current personal circumstances that might affect the accuracy of one's perception or one's speed and efficiency of crossing. These variables might include one's having poor vision for judging vehicles' distance or speed; feeling tired or having an injured foot; being unfamiliar with local traffic patterns; or being constrained by carrying bulky packages or having to push a bicycle across the street.

To cross a street safely, or to do almost anything carefully, requires four coordinated functions: (1) inhibiting the action until the right moment, (2) monitoring one's self and the specific circumstances of the situation to decide how and when to act, (3) executing the appropriate actions when needed, and (4) monitoring one's self and the current situation while acting. Effective self-regulation of behavior involves simultaneous, often instantaneous, coordination of all these key functions.

Countless actions of daily life involve carrying out these components in an integrated way: interacting in a business meeting, participating in a classroom discussion, shopping in a supermarket, playing a game, attending a party, or driving a car.

For me driving my car is a constant struggle. It really scares me because there are so many things to notice and think about, all at the same time you are propelling this huge, powerful machine along the highway or in the midst of heavy traffic and pedestrians. I've seen some car accidents where people got seriously hurt. I don't want that to happen to me. But it could.

When I'm driving I have to be constantly watching what I am doing, what other drivers are doing, and what the pedestrians are doing. At the same time I have to monitor my speedometer so I don't go too fast and I have to keep watching the stop signs and traffic lights and lane changes. And I have to keep checking my rearview mirror and the side mirrors. If I'm trying to get to someplace I'm not familiar with I have to watch street signs and check addresses, all at the same time.

Driving is a complex task, but social situations are often among the most challenging for those with difficulties monitoring and self-regulating their actions. In those circumstances, one must quickly assess the expectations and perceptions of other persons in order to behave appropriately. When is it okay to tell this joke, or to complain about an injustice, or to confront one's boss, teacher, coworker, customer, parent, spouse, child, or friend? Because persons with ADD syndrome find it hard to monitor effectively the context in which they are operating, they report that they tend to be too random in what they notice, attending too much to some details and too little to others that may be equally or more important. Especially difficult for these persons are those situations where one has to monitor and gauge the emotions and intentions of other people with whom one is interacting. Indeed, often persons with ADD syndrome complain that they have gotten into trouble because they have failed to notice how others were reacting to them, or have been insufficiently aware of how they themselves were coming across to others. This monitoring is made even more difficult when one is simultaneously holding in check one's own reactions while interacting with others.

A forty-three-year-old man with ADD syndrome described his experience:

I love getting into intense conversations with other people where it's not just small talk. I love sharing impressions and opinions between people about things that really matter. I think that's how people get to know each other and learn from one another. Usually it works out well, but sometimes I get too intense and turn other people off when I'm trying to find out what they think and why they think that way. Usually I don't notice it at the time; I just see that they drop out of the conversation or walk away.

My wife says I just don't know how to keep my eyes open and notice when others are starting to act uptight or bored with what's being discussed. She says that most of the time I talk too much or ask too many questions without noticing how I am coming across and how others are reacting to what I'm saying. She says that most of the time I'm too much mouth and not enough eyes and ears when I'm in a conversation.

This man's self-description highlights his difficulty in self-monitoring and context-monitoring during conversation. He emphasizes that he wants to learn from others and share with others, but he frustrates himself, and probably others with whom he talks, because he is not sufficiently attentive to facial expressions, tone of voice, or subtle eye or body movements that signal tension, waning interest, or impatience. Careful attention to such cues is important for developing understanding and reciprocity in social interaction. Often people with ADD syndrome report chronic difficulty with this sort of social monitoring and self-control. They don't notice enough about themselves and others, and they have chronic problems in holding back or in keeping still, even for just a few moments.

Some other persons with ADD syndrome have a different problem with self-monitoring, contextual monitoring, and controlling their actions in social situations. They tend to be excessively focused on how others are reacting and are excessively self-conscious. They tend to be too constricted, too shy, too inhibited in their social actions. One thirty-five-year-old woman with ADD syndrome described her wish to be more sociable:

I really wish I had more friends. Often I complain that nobody ever wants to talk with me, but I know that the problem is more with me than it is them. I'm not shy in my family or with a few people I know really well. But with everybody else I always feel like it is never the right time for me to say something or I just can't think of anything to say that would fit into the conversation. I'm always holding back, waiting until the right moment or until I can think of something to say.

Though these more cautious individuals with ADD syndrome may long for more reciprocity with others and may have many interesting ideas and feelings to share, they often get so caught up with intently monitoring that they are unable to engage themselves in social interactions. While they have no difficulty inhibiting their own actions and being very attentive in monitoring the social context, these persons often cannot bring themselves to act effectively in a group.

Although there are a variety of ways in which individuals experience difficulty in monitoring and regulating their actions, most with ADD syndrome report chronic difficulties in one of more aspects of inhibiting action, monitoring one's self, monitoring one's context, and taking action in an appropriate way. This cluster of ADD-related impairments extends far beyond simple excesses of hyperactive or impulsive behavior: these problems hamper one's ability to perform well in a wide variety of everyday tasks.

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