Book Review: Outside the Box: Rethinking ADD/ADHD in Children and Adults

Put simply, there are two types of books about specific social/cognitive issues that publishers market to parents and professionals. Both categories can be described as attempts to answer very broad questions. The first category is one that I’ll call the “What’s the deal with ______?” genre. Books that fall into this category attempt to provide the reader with general information about the characteristics, causes, and impacts of specific issues. The second type can be referred to as the “What do I do about my child’s ________?” category. These entries 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. Dr. Brown is a recognized authority on ADHD. Outside the Box is his 5th book on the subject and conceptualizes ADHD as a disorder of the executive functions. In making his case for this idea, Dr. Brown cites another ADHD authority, Russell Barkley, advocating 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 putting forth that idea and also implicating ADHD as being one of the underlying factors in struggles with emotional regulation and oppositional defiant disorder as well. In the intervening years, I’ve heard a number of clinicians touch on these ideas but Outside the Box does a better job than any other source I’ve come across in really fleshing them out.

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? The sections of the book that focused on the connections between ADHD and working memory, motivation, emotional regulation, and brain development were particularly fascinating. Dr. Brown does a wonderful job in tying these threads together to form a new, comprehensive, detailed picture of this disorder.

The author paints a picture of ADHD as a disorder much more complex than the one we used to have. According to Dr. Brown,

“There are 3 major ways in which research thus far has found brain development and functioning to be different in individuals with ADHD:

• Brain structure and maturation
• Maturation of functional neural connectedness within the brain
• Dynamics of electrochemical communications in the brain.”

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 in this condition will find Outside the Box a fascinating read. In particular, the section of the book that focuses on interactions between emotional regulation and working memory to explain the perceived “selective motivation” among people with ADHD was particularly captivating. 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.

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 pharmaceutical approach 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 to write them off in such a seemingly contemptuous manner really doesn’t seem fair. Outside the Box, in its other sections, is a thoughtful, detailed book but the sections on interventions adhered strictly to the medical establishment’s tendency to respond to most of our problems by throwing pills at them. It’s the one superficial section of an otherwise very thoughtful and thought-provoking book.

Many parents I’ve spoken to about books relating to ADHD and other social/cognitive issues express a strong preference for books that answer Question 2 – What do I do about my child’s ____? At this point, some of those parents may be wondering if reading Outside the Box is worth their time. My answer is a definitive “yes.” Granted, when Dr. Brown tries to provide explicit answers to that question, the results are not the most helpful sections of the book. But of all the things a parent can do about their child’s ADHD, probably the most important is to really understand it. By gaining a sense of the functional and neurological mechanisms that underly ADHD, you can respond to a child or adult with the disorder more empathically and effectively. 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