Feb 23, 2008
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.