Fact Add is a complex disorder that involves impairments in focus organization motivation emotional modulation memory and other functions of the brains management system

Imagine a large carton filled with photographs taken throughout your life. The carton is filled with snapshots of you and various family members roller skating or riding bikes, fishing off a pier or swimming in a lake, dressing up for Halloween or setting off for the first day of school. Some are posed with you in your Scout or Little League uniform or in costume for a dance recital. Others are candid shots taken around a birthday cake, in the midst of holiday celebrations, or at other memorable moments.

Given a box of such photos all mixed together, you might want to sort them to take a more systematic look. There are many ways you could do the sorting. You might put together all photos of a certain kind of activity, regardless of time or place: all of the holidays, vacation shots, or birthday parties. Or you might sort according to age periods, for example, all elementary school snapshots together, then all high school photos, then those taken in college, and so on. Yet whatever sorting scheme is used to organize your photographs, and regardless of how many snapshots are in each group, those photos can capture only fragmentary, fleeting glimpses of actual life experiences. Descriptions of the process of attention are like those snapshots.

Attention is an incredibly complex, multifaceted function of the mind. It plays a crucial role in what we perceive, remember, think, feel, and do. And it is not just one isolated activity of the brain. The continuous process of attention involves organizing and setting priorities, focusing and shifting focus, regulating alertness, sustaining effort, and regulating the mind's processing speed and output. It also involves managing frustration and other emotions, recalling facts, using short-term memory, and monitoring and self-regulating action.

This understanding of the wide-ranging facets of attention has emerged from my study of children, adolescents, and adults diagnosed with attention deficit disorder. Observing the problems that result when attention fails has allowed me to notice the effects of attentional processes on multiple aspects of daily life. Documenting the interconnected improvements that occur when attentional impairments are effectively treated has shown me the subtle but powerful linkages between attention and multiple aspects of the brain's management system. All of these observations have led me to conclude that attention is essentially a name for the integrated operation of the executive functions of the brain.

In this chapter I have gathered vignettes from many patients who have described problems resulting from failures of attention. These snapshots are organized under six clusters shown in Figure 1. Each cluster encompasses one important aspect of the brain's executive functions. Although each has a one-word label (for example, activation, focus, effort, and so on), these clusters are not single qualities like height, weight, or temperature. Each cluster is more like a basket encompassing related cognitive functions that depend on and interact continuously with the others, in ever-shifting ways. Together these clusters describe executive functions, the management system of the brain.

The arrangement used in this chapter is just one of many possible ways to describe executive functions and to clump symptoms of inattention reported by most persons with ADD. Until we know much more about underlying neural processes, any descriptive model is likely to be a bit arbitrary. But regardless of how the clusters are arranged, these executive functions tend to operate in an integrated way. Most persons diag-

Executive Functions Impaired in ADD Syndrome

Executive Functions Impaired in ADD Syndrome

Impaired Executive Functioning
Figure 1 Executive functions impaired in ADD syndrome. Source: Brown 2001c.

nosed with ADHD report significant chronic difficulties in at least some aspects of each of these six clusters. Impairments in these clusters of cognitive functions tend to show up together; they appear clinically to be related.

In addition, these clusters of cognitive functions tend to improve together. When an individual with ADD is treated with appropriate medication and shows significant improvement in one of these six clusters, some significant improvement is usually seen in aspects of the other five clusters as well.

Since these clusters of symptoms often appear together in persons diagnosed with ADD and often respond together to treatment, it seems reasonable to think of these symptoms of impairment as a "syndrome." Because this syndrome consists primarily, though not exclusively, of symptoms associated with the disorder currently classified as attention-deficit hyperactivity disorder, I refer to it as "ADD syndrome." Taken together, the six clusters in this model describe my understanding of the executive functions of the brain.

Although this description of the brain's executive functions is derived primarily from studying persons with ADHD, it should be noted that these executive functions can become impaired in other ways as well. In Chapter 8 I describe how impairments of executive functions similar to ADD syndrome can result from other causes, other psychiatric disorders, and even from later stages of normal aging. In this chapter I use examples from individuals with ADHD to describe how each of the six clusters works and, for some, doesn't work.

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