Book Review: Outside the Box: Rethinking ADD/ADHD in Children and Adults
Simply put, there are two types of books about specific social/cognitive issues that publishers market to parents and professionals. Entries from both categories attempt to answer a couple of very broad questions. The first category is one that I’ll call the “What’s the deal with ______?” genre. These books try to provide the reader with information about the characteristics, underlying causes, and impacts of that specific issue. The second category can be referred to as the “What do I do about my child’s ________?” category. Books like this strive to provide a basic roadmap for parents and other professionals as they try to craft interventions aimed at mitigating those issues. Outside the Box: Rethinking ADD/ADHD in Children and Adults, by Thomas Brown, can be placed solidly within the former category as it attempts to answer the question “What’s the deal with ADHD?”
By and large, Outside the Box answers that question very well. Outside the Box is Dr. Brown’s 5th book on the subject of ADHD and conceptualizes it as a disorder of the executive functions. In making his case for this idea, Dr. Brown cites another ADHD authority, Russell Barkley, taking up the idea “…that ADHD eventually will be renamed executive function deficit disorder (EFDD) to reduce confusion and to recognize the full scope of what science has discovered about this complex disorder.” About 10 years ago, I attended one of Dr. Barkley’s lectures and remember him advocating that idea as well as implicating ADHD as one of the underlying factors in struggles with emotional regulation and oppositional defiant disorder. In the intervening years, I’ve been waiting for Dr. Barkley to write a book elaborating on these ideas but as far as I know, he hasn’t done so yet. Outside the Box fills that void and fleshes those ideas out very nicely.
Of all the things a parent can do about their child’s ADHD, probably the most important is to really understand it…If you’re looking for that greater understanding of ADHD, Outside the Box can be a valuable resource and I recommend it highly.
While Outside the Box does offer some suggestions about intervention and treatment, these sections come across as afterthoughts. This book is at its best when it focuses on presenting up-to-date information, gleaned from cutting edge research and thinking, and fully sinks its teeth into that big question – What is the Deal with ADHD?
In Outside the Box, Dr. Brown presents ADHD as a disorder that is considerably more complex than the one we may have previously imagined. While readers looking for a more basic understanding of ADHD might be well advised to begin their reading with Driven to Distraction, by Ned Hallowell, those who seek a more detailed, comprehensive, understanding of the neurology involved will find Outside the Box to be a fascinating and accessible read. In particular, the section on interactions between emotional regulation and working memory as factors in the perceived “selective motivation” among people with ADHD was particularly captivating and left me ruminating on the topic for hours after putting the book down. Dr. Brown draws extensively from current research to support his ideas but in addition, from my own perspective as a clinician, the ideas he presents make great, intuitive sense. They fit.
Additionally, from where I sit, as director of a counseling program aimed at helping children, many of whom have ADHD, address self-image and social skills, I appreciated Dr. Brown’s attention to the significant impediments to social connection, self-confidence, and resilience that ADHD can create for people who struggle with it. Dr. Brown writes “Young children with ADHD, especially if it is not effectively treated, often complain that their parents, teachers, and other adults are constantly yelling at them…Many teachers and parents of children with ADHD report that they need to give reminders or corrections to these children as many as 5-10 times more often than to most of their classmates or siblings…When this pattern goes on with much daily frequency for many years, as it does for some children with ADHD, the result is often a combination of feeling picked on, unappreciated, and incompetent, relative to others of similar age.” While that idea has informed the goals and techniques I employ in my work, it’s gratifying to see it expressed in print with such clarity and concision.
The sections of the book that attempt to answer “Question 2 (What do I do about my child’s ________?),” are much less satisfying. Shockingly (not really), just about all of his suggestions involve medicine. I am, by no means, opposed to the use of a well-considered regimen of medication as a treatment for ADHD, but I was struck by how dismissive Dr. Brown seemed to be of any alternative approaches or of any voices that might be more skeptical of a pharmacologically-focused response to the disorder. While there is an entire chapter of the book devoted to medical treatment of ADHD, he only manages to fit in 2 pages about alternative treatments and he doesn’t really have anything positive to say about any of them. Additionally, he refers to an article in The New York Times, which was critical of big pharma’s role in “The Selling of ADHD,” as being just “another sensationalized article.” That article was the basis for Alan Schwarz’ book, ADHD Nation, which I reviewed here in 2016. I didn’t agree with all of Mr. Schwarz’ premises but he made some serious, considered arguments and to write them off in such a contemptuous manner really doesn’t seem fair. Outside the Box, in its other sections, is a thoughtful, detailed discussion but the sections on interventions adhered pretty strictly to the psychiatric establishment’s instinct to respond to all our problems by throwing pills at them. It’s the one superficial section of an otherwise thoughtful and thought-provoking book.
Many parents express a strong preference for books that answer Question 2 – What do I do about my child’s ____? Some of them may be wondering if reading Outside the Box is worth their time. My answer is a definitive “yes.” Of all the things a parent can do about their child’s ADHD, probably the most important is to really try to understand it. By gaining a sense of the functional and neurological mechanisms that underly ADHD, you can learn to respond empathically and effectively. The feedback and support you provide to your children will be better matched to what their needs are as you begin to understand more about the way their brains work. If you’re looking for that greater understanding of ADHD, Outside the Box can be a valuable resource and I recommend it highly.
Dr. Thomas Brown