A CDC report esti­mated that, in 2003, 4.4 mil­lion youth ages 4–17 lived with diag­nosed ADHD, and 2.5 mil­lion of them were receiv­ing med­ica­tion treat­ment. Now, which is the core deficit under­ly­ing ADHD-so that treat­ments really address it? and how are ADHD and brain devel­op­ment related? Keep reading…

ADHD & the Nature of Self-Control — Revis­it­ing Barkley’s The­ory of ADHD

— By David Rabiner, Ph.D

As implied in the title of his book, ADHD and the Nature of Self-Control, Dr. Barkley argues that the fun­da­men­tal deficit in indi­vid­u­als with ADHD is one of self-control, and that prob­lems with atten­tion are a sec­ondary char­ac­ter­is­tic of the disorder.

Dr. Barkley empha­sizes that dur­ing the course of devel­op­ment, con­trol over a child’s behav­ior grad­u­ally shifts from exter­nal sources to being increas­ingly gov­erned by inter­nal rules and stan­dards. Con­trol­ling one’s behav­ior by inter­nal rules and stan­dards is what is meant by the term “self-control”.

For exam­ple, young chil­dren have very lit­tle abil­ity to refrain from act­ing on an impulse — i.e. to “inhibit” their behav­ior. Instead, it is more typ­i­cal for a young child to “act out” the things that pop into his or her mind. In addi­tion, when a young child is able to refrain from act­ing on impulse, it is often because some­thing in the imme­di­ate sur­round­ings keeps them from doing so. For exam­ple, the child may refrain from throw­ing a toy when frus­trated because his mother is present, and he knows he will be pun­ished if he throws it.

This is dif­fer­ent from an older child who may also have the impulse to smash a toy, but who does not act on this impulse because he/she can antic­i­pate the fol­low­ing consequences:

1. He won’t have the toy to play with later on;

2. His par­ents would be upset if he broke his new toy;

3. He would be upset for let­ting down his parents;

4. He would be upset because he let his tem­per get out of con­trol — he let him­self down;

In this exam­ple, the child has learned to “inhibit” and reg­u­late their behav­ior based on inter­nal con­trols and guide­lines, rather than requir­ing the imme­di­ate threat of exter­nal consequences.

- Self-Regulation as the Core Deficit in ADHD -

Dr. Barkley argues that the crit­i­cal deficit asso­ci­ated with ADHD is the fail­ure to develop this capac­ity for “self-control”, also referred to as “self-regulation”. He sug­gests that this results pri­mar­ily for bio­log­i­cal rea­sons, and not because of parenting.

As a result of this core deficit in self-regulation, spe­cific and impor­tant psy­cho­log­i­cal processes and func­tions sub­se­quently fail to develop in an opti­mal way. These include the following:

* Work­ing Mem­ory, which refers to the abil­ity to recall past events and manip­u­late them in one’s mind so as to be able to make pre­dic­tions about the future. This is an impor­tant part of deal­ing effec­tively with day-to-day sit­u­a­tions that Barkley feels is dimin­ished in indi­vid­u­als with ADHD. In fact, recent research has doc­u­ment a deficit in work­ing mem­ory in indi­vid­u­als with ADHD.

* Inter­nal­iza­tion of Speech, which refers to the abil­ity to use inter­nally gen­er­ated speech to guide one’s behav­ior and actions. Think about how often you use inter­nal speech — i.e., talk­ing to your­self, to help reg­u­late and guide your behav­ior and to solve prob­lems you may be con­fronting. Dr Barkley argues that this capac­ity devel­ops later and less com­pletely in indi­vid­u­als with ADHD.

* Sense of Time, which refers to the abil­ity to keep track of the pas­sage of time and to change/alter one’s behav­ior in rela­tion to time. Con­sider how often one needs to eval­u­ate the time required to accom­plish a par­tic­u­lar task and how the time you are devot­ing to a par­tic­u­lar task com­pares to what is avail­able, and what will be required for other tasks. Dr. Barkley sug­gests that for indi­vid­u­als with ADHD, the psy­cho­log­i­cal sense of time is impaired, which pre­vents them from being able to modify/alter their behav­ior in response to real world time demands. This is seen, for exam­ple, in the ado­les­cent who may become engrossed in a project and wind up spend­ing far more time on it than should have been allo­cated, given other demands that need to be met.

* Goal Directed Behav­ior, which refers to the abil­ity to estab­lish a goal in one’s mind and use the inter­nal image of that goal to shape, guide, and direct one’s actions. This is an incred­i­bly impor­tant capac­ity as it under­lies con­sis­tent effort and per­sis­tence. Imag­ine how much harder it would be to per­se­vere through dif­fi­cult and frus­trat­ing times if you were not able to hold a long-term goal in your mind. Dr. Barkley argues that indi­vid­u­als with ADHD have great dif­fi­culty doing this, and thus have dif­fi­culty with mak­ing a con­sis­tent effort to achieve long-term goals.

- Impli­ca­tions of Con­sid­er­ing ADHD a Dis­or­der of Self-regulation —

Con­cep­tu­al­iz­ing ADHD as a dis­or­der of self-regulation, and not a dis­or­der of atten­tion, has sig­nif­i­cant impli­ca­tions for under­stand­ing the dif­fi­cul­ties expe­ri­enced by indi­vid­u­als with ADHD and how to assist them in cop­ing more effec­tively with those dif­fi­cul­ties. Below is a brief sum­mary of Dr. Barkley’s views on this.

First, he argues that indi­vid­u­als with ADHD may not lack the skills and knowl­edge to be suc­cess­ful, but rather, their prob­lems with self-regulation often pre­vent them from apply­ing their knowl­edge and skills at the nec­es­sary times. As Dr. Barkley puts it, “ADHD is more a prob­lem of doing what one knows rather than know­ing what to do.”

For exam­ple, although a child with ADHD may “know” that shar­ing and coop­er­at­ing are an impor­tant part of mak­ing and keep­ing friends, he may fail to apply this knowl­edge with peers because the imme­di­ate rewards asso­ci­ated with get­ting one’s way over­pow­ers the less salient goal of keep­ing a friend­ship. Or, the child may know the steps to fol­low to do a good job on a school project, but not act on this knowl­edge because of prob­lems with man­ag­ing time and using a long-term goal to guide behavior.

The treat­ment impli­ca­tion that fol­lows from this con­cep­tu­al­iza­tion is that treat­ment should focus on help­ing indi­vid­u­als apply the knowl­edge they already have at the appro­pri­ate times, rather than on teach­ing spe­cific knowl­edge and skills. This will require fre­quent exter­nal cues and reminders to apply this knowl­edge, because their inter­nal guides for behav­ior are less effective.

For exam­ple, con­sider the child who does not share and coop­er­ate because the imme­di­ate pay­off of get­ting what he wants is more salient than the long-term con­se­quences this behav­ior has for his friend­ships. Dr. Barkley would argue that this child may not need to be taught “social skills”, as he already knows the right thing to do. Instead, he needs to be pro­vided with fre­quent reminders about how to behave dur­ing actual peer inter­ac­tions. This could take the form of hav­ing the child review a short set of “social rules” imme­di­ately before a play­time with peers, as well as remind­ing the child of these rules at reg­u­lar inter­vals dur­ing the playtime.

In regards to fol­low­ing class­room rules and get­ting work done, Dr. Barkley also empha­sizes the need to pro­vide exter­nal prompts. Writ­ing rules down on signs around the class­room is one way to do this. Post­ing class rules on an index card taped to the child’s desk is another. Dur­ing work times, one pos­si­bil­ity is to have the child wear head­phones and lis­ten to a tape that pro­vides fre­quent reminders to stay on task, to write neatly, and to check one’s work. In all of these exam­ples, the prin­ci­ple is to com­pen­sate for the child’s inabil­ity to con­trol his or her behav­ior through inter­nal means by pro­vid­ing as many exter­nal prompts and reminders as possible.

- The Lim­i­ta­tions of Exter­nal Prompts and why Rewards are Necessary —

Even when exter­nal prompts are pro­vided, how­ever, an impor­tant lim­i­ta­tion is that their effec­tive­ness remains depen­dent on the child’s moti­va­tion to fol­low these rules rather than pur­su­ing alter­na­tives that may be more imme­di­ately appeal­ing. Because indi­vid­u­als with ADHD are so attuned to imme­di­ate con­se­quences, how­ever, attrac­tive short-term alter­na­tives will often be pur­sued. To enhance the child’s moti­va­tion to meet the behav­ioral expec­ta­tions that have been set, there­fore, he feels it is nec­es­sary to pro­vide rewards and priv­i­leges for meet­ing those expec­ta­tions that are more attrac­tive and appeal­ing than those asso­ci­ated with alter­na­tive behav­iors the child could engage in.

What can make this dif­fi­cult to do with chil­dren who have ADHD is the imme­di­acy with which rewards may need to be pro­vided. For exam­ple, the prob­lem with telling a child with ADHD that hav­ing a good week at school will result in a reward on the week­end is that it assumes the child can use the antic­i­pa­tion of this reward to guide their behav­ior over an entire week. Accord­ing to Dr. Barkley, how­ever, this is likely to be inef­fec­tive because it depends on the type of inter­nal­ized con­trol of behav­ior that he believes is defi­cient to begin with.

To over­come this, he argues that long-term objec­tive must be bro­ken down into numer­ous shorter-term goals, each of which has its own asso­ci­ated reward. For exam­ple, the spe­cial week­end treat may need to be sup­ple­mented by daily priv­i­leges that are con­tin­gent on the child’s meet­ing spe­cific behav­ioral expec­ta­tions each day. Behav­ioral expec­ta­tions for the day may need to be bro­ken down into numer­ous shorter inter­vals dur­ing the day. Fre­quent reminders to the child about what those expec­ta­tions are, and what will be attained by meet­ing them, may also need to be incor­po­rated. Obvi­ously, this is very dif­fi­cult to do, and is one rea­son why imple­ment­ing an effec­tive behav­ioral treat­ment plan for a child with ADHD can be so challenging.

It is impor­tant to empha­size, how­ever, that this approach is not equiv­a­lent to reward­ing the child for sim­ply doing what he should be doing in the first place, as is some­times argued. As Dr. Barkley notes, “…the required response of oth­ers to the poor self-control shown by those with ADHD is not to elim­i­nate the out­comes of their actions and to excuse them from per­sonal account­abil­ity. It is to tem­po­rally tighten up those con­se­quences, empha­siz­ing more imme­di­ate accountability.”

In other words, a child with ADHD is not “let off the hook” because of their con­di­tion. Instead, one needs to heighten the child’s account­abil­ity in the form of more fre­quent checks and feed­back on their behav­ior, sup­ple­mented by the pro­vi­sion of appro­pri­ate rewards and priv­i­leges when desired stan­dards of behav­ior have been met.

- Why Treat­ment Needs to be Ongo­ing and Long-term —

Even when these prin­ci­ples are faith­fully applied, rec­og­niz­ing that the behav­iors seen in ADHD results from an under­ly­ing deficit in self-regulation implies that gains asso­ci­ated with treat­ment will not per­sist after treat­ment is dis­con­tin­ued. Thus, treat­ment reflects an ongo­ing effort to man­age the child’s symp­toms rather than “cur­ing” the disorder.

While this may be dis­cour­ag­ing, Dr. Barkley also notes that as chil­dren with ADHD mature, their dimin­ished capac­ity for self-regulation will mature as well. Thus, even though they may never fully catch up to their peers in this regard, their abil­ity to guide and gov­ern their behav­ior via inter­nal means will nonethe­less grow and develop. Over time, there­fore, an individual’s reliance on exter­nal sources of moti­va­tion will dimin­ish, as will the required inten­sity and fre­quency with which these exter­nal source are need to be pro­vided. Even­tu­ally, the ado­les­cent or young adult with ADHD may learn to pro­vide their own exter­nal prompts in the form of lists and other types of cues that prove to be effec­tive, and to pro­vide them­selves with their own rewards for meet­ing their self-imposed standards.

Another treat­ment impli­ca­tion that fol­lows from Dr. Barkley’s model is that med­ica­tion treat­ment may be effec­tive because it nor­mal­izes, or at least improves, the under­ly­ing deficit in behav­ioral inhi­bi­tion that he regards as the core fea­ture of ADHD. Dr. Barkley reviews evi­dence for this con­tention in his book, and argues that med­ica­tion is the only cur­rently avail­able treat­ment that has been demon­strated to pro­duce such results. As such, he believes that it should be the pre­dom­i­nant treat­ment approach for indi­vid­u­als with ADHD.

- Sum­mary and Conclusions —

Barkley’s the­ory has been widely rec­og­nized as a sig­nif­i­cant advance in our think­ing about ADHD that helps to orga­nize a vast body of lit­er­a­ture and clin­i­cal obser­va­tions about the dis­or­der. As with any the­ory, it’s ulti­mate value will depend on the amount of new research that it stim­u­lates, and the infor­ma­tion that is obtained from those studies.

One impor­tant point to note is that even if one agrees with Barkley’s notion that ADHD is fun­da­men­tally a deficit of self-regulation, it does not nec­es­sar­ily fol­low that the inter­ven­tions he advo­cates — basi­cally, behav­ior ther­apy and med­ica­tion treat­ment — are the only approaches to be pur­sued. Clearly, these are the inter­ven­tions that cur­rently enjoy the strongest empir­i­cal sup­port. They are lim­ited, how­ever, in that nei­ther is con­cep­tu­al­ized as result­ing in any endur­ing change in the child. Exter­nal prompts and the pro­vi­sion of rewards are intended to com­pen­sate for the child’s deficits rather than cor­rect them and med­ica­tion pro­vides a short-term improve­ment in those deficits that van­ishes when it has cleared the child’s system.

What about the pos­si­bil­ity of inter­ven­tions that may result in more endur­ing changes in the child? The capac­ity for self-regulation and the other exec­u­tive func­tions (e.g., work­ing mem­ory) that Barkley describes are ulti­mately the out­comes of aspects of brain func­tion­ing. Given what we know about the plas­tic­ity of the ner­vous sys­tem, espe­cially at younger ages, is it pos­si­ble that chil­dren with ADHD could be pro­vided with spe­cific cog­ni­tive train­ing exer­cises and expe­ri­ence that might result in more endur­ing changes in their functioning?

In the field of ADHD, this is the prover­bial $64,000 ques­tion. There are, in fact, intrigu­ing hints that this may be pos­si­ble. For exam­ple, recent research has demon­strated that com­put­er­ized train­ing of work­ing mem­ory skills is asso­ci­ated with a decrease in ADHD symp­toms and that this ben­e­fit per­sists beyond the dura­tion of the train­ing itself. (Dis­clo­sure — Work­ing Mem­ory Train­ing is the pro­gram mar­keted by Cogmed, a spon­sor of Atten­tion Research Update). There have also been a num­ber of stud­ies of neu­ro­feed­back — a treat­ment approach that attempts to teach indi­vid­u­als to alter and con­trol basic aspects of brain func­tion­ing — in which more endur­ing changes in the child have been reported. Many researchers, how­ever, con­tinue to raise ques­tions about the ade­quacy of these stud­ies and point to the need for well-controlled trials.

In this regard, it is encour­ag­ing to note that the pace of research on new inter­ven­tions for ADHD has picked up con­sid­er­ably in recent years and that a num­ber of addi­tional stud­ies of work­ing mem­ory train­ing, neu­ro­feed­back, and other atten­tion train­ing approaches are cur­rently under­way. I look for­ward to updat­ing you on the results of these impor­tant stud­ies as they are published.

— Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing. He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

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