Sharp Brains: Brain Fitness and Cognitive Health News

Neuroplasticity, Brain Fitness and Cognitive Health News

Icon

Self-Regulation and Barkley’s Theory of ADHD

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.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

Leave a Reply...

Loading Facebook Comments ...

4 Responses

  1. Nancy Poore says:

    We not­ed after 25 ses­sions of Cog Med that one evening while wait­ing in the car for his sis­ter to fin­ish choir, our son sat still and did 25–30 min­utes of pre-alge­bra prob­lems. Although it was 8PM, and his meds were undoubt­ed­ly pret­ty much worn off, he did it with­out rewards, threats, prompt­ing, or com­plaints.
    Hav­ing been in this sit­u­a­tion many times in the past, the shift in his abil­i­ty to stay on task and the absence of resis­tance to sus­tained effort were both quite strik­ing.

    The same week, his teacher sent a note and lat­er an email com­ment­ing that he had not only done “some of the most dif­fi­cult math” with few errors; he had also been able to assist oth­er stu­dents. (Some­thing we are unaware that he has ever done.) Since he has been on Vyvanse for sev­er­al months and with­out any dosage changes, we think it safe to be cau­tious­ly opti­mistic that the Cog Med exer­cis­es have had some train­ing effect. The only oth­er “change” is that he is in full puber­ty; but that has been the case for almost a year now.
    I thought this might be of inter­est.

  2. Hugo says:

    Great arti­cle! What are the bio­log­i­cal rea­sons for this per­spec­tive?
    Thank you

  3. Alvaro says:

    Nan­cy, thank you for shar­ing that sto­ry. Glad to hear it! we are hear­ing more pos­i­tive com­ments from the Cogmed pro­gram.

    Hugo, you may want to look into this recent NIMH study on how “Brain Matures a Few Years Late in ADHD, But Fol­lows Nor­mal Pat­tern”

    http://www.nimh.nih.gov/science-news/2007/brain-matures-a-few-years-late-in-adhd-but-follows-normal-pattern.shtml

Leave a Reply

Categories: Attention and ADD/ADHD, Cognitive Neuroscience

Tags: , , , , , , , , , , , , , , , , , , , , , , , , , ,

About SharpBrains

As seen in The New York Times, The Wall Street Journal, BBC News, CNN, Reuters,  SharpBrains is an independent market research firm tracking how brain science can improve our health and our lives.

Search in our archives

Follow us and Engage via…

twitter_logo_header
RSS Feed

Watch All Recordings Now (40+ Speakers, 12+ Hours)