ADHD

PART ONE is the basic definiton of ADHD and PART TWO is the addition to Barkley’s Theory of ADHD where he focuses on the Emotional Aspects of ADHD.

This article is based on two papers by Dr. Russell A. Barkley, Ph.D. and can be found it its original format at Dr. Barkley’s official website …

ADDspeaker: Throughout the text, we have added some additional information to the original texts, as well as worked on the readability by adding headlines and short paragraphs, otherwise the text’s meaning and intent have not be altered. ADDspeaker has a “mentoring relationship” with Dr. Barkley for several years now, resulting in our high degree of insight into ADHD and our understanding of the scientific data from ADHD research. We would like to take this opportunity to thank Dr. Barkley for being forthcoming and gracious in sharing his vast knowledge with us, without any other gain than spreading the word, for us all to benefit from.

Background

On June 18, 2018, WHO released its 11th edition of the International Classification of Diseases (ICD-11), which redefines the definition of ADHD, so that it reflects our current understanding (validating Dr. Barkley’s Theory of ADHD from 1997) as well as aligning the understanding of ADHD as being a disorder that results in major impairments in several key ares of life, which in turn underscore that people with ADHD experience severe disability in their functioning, when trying to meet societal standards and unwritten norms, thereby fulfilling the requirements for being covered by the “UN Convention on the Rights of Persons with Disabilities (CRPD)“.

ICD-11

The ICD-11 definition of ADHD is now:

  • Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood.
  • The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning and significantly interferes with academic, occupational, or social functioning.
  • Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization.
  • Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control. Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.
  • The relative balance and the specific manifestations of inattentive and hyperactive-impulsive characteristics varies across individuals, and may change over the course of development.
  • In order for a diagnosis of disorder the behaviour pattern must be clearly observable in more than one setting.

At ADDspeaker we welcome this new definition and wish to promote the use of this, and likewise the knowledge of the basic concepts that underline this understanding, Dr. Barkley’s Theory of ADHD, which is referenced in this article.

PART ONE

DEFINITION

Attention-deficit hyperactivity disorder (ADHD) is the current term for a specific developmental disorder seen in both children and adults that is comprised of deficits in behavioral inhibition, sustained attention and resistance to distraction, and the regulation of one’s activity level to the demands of a situation (hyperactivity or restlessness). This disorder has had numerous different labels over the past century, including hyperactive child syndrome, hyperkinetic reaction of childhood, minimal brain dysfunction, and attention deficit disorder (with or without hyperactivity).

MAJOR CHARACTERISTICS

The predominant features of this disorder include:

Impaired response inhibition, impulse control, or the capacity to delay gratification. This is often noted in the individual’s inability to stop and think before acting; to wait one’s turn while playing games, conversing with others, or having to wait in line; to interrupt their responding quickly when it becomes evident that their actions are no longer effective; to resist distractions while concentrating or working; to work for larger, longer-term rewards rather than opting for smaller, more immediate ones; and inhibiting the dominant or immediate reaction to an event, as the situation may demand.

Excessive task-irrelevant activity or activity that is poorly regulated to the demands of a situation. Individuals with ADHD in many cases are noted to be excessively fidgety, restless, and “on the go.” They display excessive movement not required to complete a task, such as wriggling their feet and legs, tapping things, rocking while seated, or shifting their posture or position while performing relatively boring tasks.

Younger children with the disorder may show excessive running, climbing, and other gross motor activity. While this tends to decline with age, even teenagers with ADHD are more restless and fidgety than their peers.

In adults with the disorder, this restlessness may be more subjective than outwardly observable, although with some adults they remain outwardly restless as well and report a new to always be busy or doing something and being unable to sit still.

Poor sustained attention or persistence of effort to tasks. This problem often arises when the individual is assigned boring, tedious, protracted, or repetitive activities that lack intrinsic appeal to the person.

They often fail to show the same level of persistence, “stick-to-it-tiveness,” motivation, and will-power of others their age when uninteresting yet important tasks must be performed.

They often report becoming easily bored with such tasks and consequently shift from one uncompleted activity to another without completing these activities.

Loss of concentration during tedious, boring, or protracted tasks is commonplace, as is an inability to return to their task on which they were working should they be unexpectedly interrupted.

Thus, they are easily distracted during periods when concentration is important to the task at hand. They may also have problems with completing routine assignments without direct supervision, being unable to stay on task during independent work.

These are the three most common areas of difficulty associated with ADHD.

However, research is suggesting that those with ADHD, particularly the subtypes associated with impulsive behavior (see below), may also have difficulties in the following areas of psychological functioning as well.

MEMORY, HINDSIGHT AND FORETHOUGHT

Remembering to do things, or working memory. Working memory refers to the capacity to hold information in mind that will be used to guide one’s actions, either now, or at a later time. It is essential for remembering to do things in the near future.

Those with ADHD often have difficulties with working memory and so are described as forgetful around doing things, unable to keep important information in mind that they will need to guide their actions later, and disorganized in their thinking and other activities as they often lose track of the goal of their activities.

They may often be described as acting without hindsight or forethought, and being less able to anticipate and prepare for future events as well as others, all of which seem to be dependent on working memory.

TIME MANAGEMENT

Recently, research suggests that those with ADHD cannot sense or use time as adequately as others in their daily activities, such that they are often late for appointments and deadlines, ill-prepared for upcoming activities, and less able to pursue long-term goals and plans as well as others. Problems with time management and organizing themselves for upcoming events are commonplace in older children and adults with the disorder.

PRIVATIZATION OF SPEECH

Delayed development of internal language (the mind’s voice) and rule-following.

Research has lately been suggesting that children with ADHD are significantly delayed in the development of internal language, the private voice inside one’s mind that we employ to converse with ourselves, contemplate events, and direct or command our own behavior. This private speech is absolutely essential to the normal development of contemplation, reflection, and self-regulation. Its delay in those with ADHD contributes to significant problems with their ability to follow through on rules and instructions, to read and follow directions carefully, to follow through on their own plans, rules, and “do- lists,” and even to act with legal or moral principles in mind. When combined with their difficulties with working memory, this problem with self-talk or private speech often results in significant interference with reading comprehension, especially of complex, uninteresting, or extended reading assignments.

EMOTIONAL SELF-CONTROL

Difficulties with regulation of emotions, motivation, and arousal.

Children and adults with ADHD often have problems inhibiting their emotional reactions to events as well as do others of their age. It is not that the emotions they experience are inappropriate, but that those with ADHD are more likely to publicly manifest the emotions they experience than would someone else. They seem less able to “internalize” their feelings, to keep them to themselves, and even to moderate them when they do so as others might do. Consequently, they are likely to appear to others as less emotionally mature, more reactive with their feelings, and more hot-headed, quick-tempered, and easily frustrated by events.

Coupled with this problem with emotion regulation is the difficulty they have in generating intrinsic motivation for tasks that have no immediate payoff or appeal to them. This capacity to create private motivation, drive, or determination often makes them appear to lack will-power or self-discipline as they cannot stay with things that do not provide immediate reward, stimulation, or interest to them. Their motivation remains dependent on the immediate environment for how hard and how long they will work, whereas others develop a capacity for intrinsically motivating themselves in the absence of immediate rewards or other consequences.

Also related to these difficulties with regulating emotion and motivation is that of regulating their general level of arousal to meet situational demands. Those with ADHD find it difficult to activate or arouse themselves to initiate work that must be done, often complain of being unable to stay alert or even awake in boring situations, and frequently seem to be daydreamy or “in a fog” when they should be more alert, focused, and actively engaged in a task.

SELF-MOTIVATION AND PROBLEM-SOLVING

Diminished problem-solving ability, ingenuity, and flexibility in pursuing long-term goals.

Often times, when we are engaged in goal-directed activities, problems are encountered that are obstacles to the goal’s attainment. At these times, individuals must be capable of quickly generating a variety of options to themselves, considering their respective outcomes, and selecting among them those which seem most likely to surmount the obstacle so they can continue toward their goal.

Persons with ADHD find such hurdles to their goals to be more difficult to surmount; often giving up their goals in the face of obstacles and not taking the time to think through other options that could help them succeed toward their goal. Thus they may appear as less flexible in approaching problem situations, more likely to respond automatically or on impulse, and so are less creative at overcoming the road-blocks to their goals than others are likely to be.

These problems may even be evident in the speech and writing of those with the disorder, as they are less able to quickly assemble their ideas into a more organized, coherent explanation of their thoughts. And so they are less able to rapidly assemble their actions or ideas into a chain of responses that effectively accomplishes the goal given them, be it verbal or behavioral in nature.

WORK PERFORMANCE

Greater than normal variability in their task or work performance.

It is typical of those with ADHD, especially those subtypes associated with impulsive behavior, to show substantial variability across time in the performance of their work. These wide swings may be found in the quality, quantity, and even speed of their work, failing to maintain a relatively even pattern of productivity and accuracy in their work from moment to moment and day to day. Such variability is often puzzling to others who witness it as it is clear that at some times, the person with ADHD can complete their work quickly and correctly while at others times, their tasks are performed poorly, inaccurately, and quite erratically. Indeed, some researchers see this pattern of high variability in work-related activities to be as much a hallmark of the disorder as is the poor inhibition and inattention described above.

OTHER CHARACTERISTICS

Several other development characteristics are associated with this disorder.

ONSET OF THE DISORDER

Early onset of the major characteristics.

The symptoms of ADHD appear to arise, on average, between 3 and 6 years of age. This is particularly so for those subtypes of ADHD associated with hyperactive and impulsive behavior.

Others may not develop their symptoms until somewhat later in childhood. But certainly the vast majority of those with the disorder have had some symptoms since before the age of 13 years.

Those who have the Predominantly Inattentive Type of ADHD (ADHD-PI) that is not associated with impulsiveness appear to develop their attention problems somewhat later than do the other subtypes, often in middle or later childhood. And so the disorder is believed to be one of childhood onset, regardless of the subtype, suggesting that should these symptoms develop for the first time in adulthood, other mental disorders rather than ADHD should be suspected.

DOMAINS OF IMPAIRMENTS

Situational variation of symptoms.

The major symptoms of ADHD are likely to change markedly as a consequence of the nature of the situation the person happens to be in.

Research suggests that those with ADHD behave better in one-to-one situations, when doing tasks that they enjoy or find interesting, when there is some immediate payoff for behaving well, when they are supervised, in their work done earlier in the day rather than later, and, for children, when they are with their fathers compared to their mothers.

Conversely, those with ADHD may manifest more of their symptoms in group settings, when they must perform boring work, when they must work independently of supervision, when their work must be done later in the day, and when they are with their mothers.

Sometimes or in some cases, these situational factors may have little effect on the person’s level of ADHD symptoms but they have been noted often enough in research to make such situational changes in their symptoms important to appreciate.

Relatively chronic course. ADHD symptoms are often quite developmental stable. Although the absolute level of symptoms does decline with age, this is true of the inattentiveness, impulsiveness, and activity levels of normal individuals as well. And so those with ADHD may be improving in their behavior but not always catching up with their peer group in this regard.

This seems to leave them chronically behind others of their age in their capacity to inhibit behavior, sustain attention, control distractibility, and regulate their activity level.

Research suggests that among those children clinically diagnosed with the disorder in childhood, 50-80 percent will continue to meet the criteria for the diagnosis in adolescence, and 10-65 percent may continue to do so in adulthood.

Whether or not they have the full syndrome in adulthood, at least 50-70 percent may continue to manifest some symptoms that are causing them some impairment in their adult life.

ADDspeaker: According to the latest scientific evidence, children who have been medicated since early childhood (3-4 years old) and continually so into adulthood, may recover fully from ADHD as their physical brain finalises ints development at around 30 years of age. This is due, in part, to the plasticity of the brain in childhood, and partly due to the temporary connections that the medication creates, which over time are being converted from temporary to fixed synapses, which in turn mediates the symptoms of ADHD, since it is a neurodevelopmental disorder that has to do with the maturation of the physical brain structures and communication pathways. Dr. Barkley, Ph.D. have told me, that in around 15% of the cases with childhood onset and severity level: mild, they now see a full recovery and normalisation of functioning, after medicinal treatment from early childhood (Barkley, 2018). This is huge, since ADHD have always been understood as a chronic, life-long disorder without any cure …

I met up with Dr. Barkley in late November in Copenhagen, and apart from having a friendly chat on a personal level, we discussed his latest study on “ADHD and Estimated Life Expectancy” which is to be published soon in “Journal of Attention Disorders”. I was given access to the article before publication and you can read why untreated ADHD is now linked to a reduction of Estimated Life Expectancy of 12.7 years!

Peter ‘ADDspeaker’ Vang (venstre), and Dr. Russell A. Barkley, Ph.D. (højre)

ADULT OUTCOME

It has been estimated that anywhere from 15 to 50 percent of those with ADHD ultimately outgrow the disorder. However, these figures come from follow-up studies in which the current and more rigorous diagnostic criteria for the disorder were not used.

When more appropriate and modern criteria are employed, probably only 20-35 percent of children with the disorder no longer have any symptoms resulting in impairment in their adult life.

COMORBIDITY

Over the course of their lives, a significant minority of those with ADHD experience a greater risk for developing oppositional and defiant behavior (50%+), conduct problems and antisocial difficulties (25-45%), learning disabilities (25-40%), low self- esteem, and depression (25%).

Approximately 5-10 percent of those with ADHD may develop more serious mental disorders, such as manic-depression or bipolar disorder.

Between 10 and 20 percent may develop antisocial personality disorder by adulthood, most of whom will also have problems with substance abuse.

Overall, approximately 10-25 percent develop difficulties with over-use, dependence upon, or even abuse of legal (i.e., alcohol, tobacco) or illegal substances (i.e., marijuana, cocaine, illicit use of prescription drugs, etc.), with this risk being greatest among those who had conduct disorder or delinquency as adolescents.

Despite these risks, note should certainly be taken that upwards of half or more of those having ADHD do not develop these associated difficulties or disorders.

EDUCATION

However, the majority of those with ADHD certainly experienced problems with school performance, with as many as 30-50 percent having been retained in their school grade at least once, and 25-36 percent never completing high school.

As adults, those with ADHD are likely to be under-educated relative to their intellectual ability and family educational background. They are also likely to be experience difficulties with work adjustment, and may be under-employed in their occupations relative to their intelligence, and educational and family backgrounds.

WORK LIFE

They tend to change their jobs more often than others do, sometimes out of boredom or because of interpersonal problems in the workplace. They also tend to have a greater turnover of friendships and dating relationships and seem more prone to marital discord and even divorce.

DRIVING

Difficulties with speeding while driving are relatively commonplace, as are more traffic citations for this behavior, and, in some cases, more motor vehicle accidents than others are likely to experience in their driving careers. Thus, they are more likely to have had their driver’s license suspended or revoked.

SUBTYPES

Since 1980, it has become possible to place those with ADHD into several subtypes, depending upon the combinations of symptoms they experience.

There is considerably less research on the Predominantly Inattentive Type of ADHD, or what used to be referred to as attention deficit disorder without hyperactivity. What research does exist suggests some qualitative differences between the attention problems these individuals experience and those with the other types of ADHD in which hyperactive or impulsive behavior is present.

The Predominantly Inattentive Type of ADHD appears to be associated with more daydreaming, passiveness, sluggishness, difficulties with focused or selective attention (filtering important from unimportant information), slow processing of information, mental fogginess and confusion, social quietness or apprehensiveness, hypo-activity, and inconsistent retrieval of information from memory. It is also considerably less likely to be associated with impulsiveness (by definition) as well as oppositional/defiant behavior, conduct problems, or delinquency.

Should further research continue to demonstrate such differences, there would be good reason to view this subtype as actually a separate and distinct disorder from that of ADHD.

ADHD-PHI

Those who have difficulties primarily with impulsive and hyperactive behavior and not with attention or concentration are now referred to as having the Predominantly Hyperactive-Impulsive Type (ADHD-PHI).

ADHD-PI

Individuals with the opposite pattern, significant inattentiveness without being impulsive or hyperactive are called the Predominantly Inattentive Type (ADHD-PI).

ADHD-C

However, most individuals with the disorder will manifest both of these clinical features and so are referred to as the Combined Type of ADHD (ADHD-C). Research on those with the Combined Type suggests that they are likely to develop their hyperactive and/or impulsive symptoms first and usually during the preschool years.

At this age, then, they may be diagnosed as having the Predominantly Hyperactive- Impulsive Type. However, in most of these cases, they will eventually progress to developing the difficulties with attention span, persistence, and distractibility within a few years of entering school such that they will now be diagnosed as having the Combined Type.

PREVALENCE

ADHD occurs in approximately 3-7 percent of the childhood population and approximately 2-5 percent of the adult population.

Among children the gender ratio is approximately 3:1 with boys more likely to have the disorder than girls. Among adults, the gender ration falls to 2:1 or lower.

The disorder has been found to exist in virtually every country in which it has been investigated, including North America, South America, Great Britain, Scandinavia, Europe, Japan, China, Turkey and the middle East.

The disorder may not be referred to as ADHD in these countries and may not be treated in the same fashion as in North America but there is little doubt that the disorder is virtually universal among human populations.

The disorder is more likely to be found in families in which others have the disorder or where depression is more common.

It is also more likely to occur in those with conduct problems and delinquency, tic disorders or Tourette’s Syndrome, learning disabilities, or those with a history of prenatal alcohol or tobacco-smoke exposure, premature delivery or significantly low birth weight, or significant trauma to the frontal regions of the brain.

ETIOLOGIES

ADHD has very strong biological contributions to its occurrence. While precise causes have not yet been identified, there is little question that heredity/genetics makes the largest contribution to the expression of the disorder in the population.

GENETICS

The heritability of ADHD averages approximately 80 percent, meaning that genetic factors account for 80 percent of the differences among individuals in this set of behavioral traits.

For comparison, consider that this figure rivals that for the role of genetics in human height. Several genes associated with the disorder have been identified and undoubtedly more will be so given that ADHD represents a set of complex behavioral traits and so a single gene is unlikely to account for the disorder.

NEUROBIOLOGICAL CONTAMINATION

In instances where heredity does not seem to be a factor, difficulties during pregnancy, prenatal exposure to alcohol and tobacco smoke, prematurity of delivery and significantly low birth weight, excessively high body lead levels, as well as post-natal injury to the prefrontal regions of the brain have all been found to contribute to the risk for the disorder in varying degrees.

MYTHS – DISCREDITED BY SCIENCE

Research has not supported popularly held views that ADHD arises from excessive sugar intake, food additives, excessive viewing of television, or poor child management by parents.

Some drugs used to treat seizure disorders in children may increase symptoms of ADHD in those children as side effects of these drugs but these effects are reversible.

TREATMENT

No treatments have been found to cure this disorder, but many treatments exist which can effectively assist with its management.

MEDICATION

Chief among these treatments is the education of the family and school staff about the nature of the disorder and its management, in the case of children with the disorder, and the education and counseling of the adult with ADHD and their family members.

STIMULANTS

But among the treatments that results in the greatest degree of improvement in the symptoms of the disorder, research overwhelmingly supports the use of the stimulant medications for this disorder (e.g., methylphenidate or Ritalin, d-amphetamine or Dexedrine, Adderall, and, in rare cases, pemoline or Cylert).

TRICYCLIC ANTIDEPRESSANTS

Evidence also shows that the tricyclic antidepressants, in particular desipramine, may also be effective in managing symptoms of the disorder as well as co-existing symptoms of mood disorder or anxiety. However, these antidepressants do not appear to be as effective as the stimulants.

CLONIDINE

Research evidence is rather mixed on whether or not clonidine is of specific benefit for management of these symptoms apart from its well-known sedation effects.

POLY-PHARMACOLOGICAL TREATMENT

A small percentage of individuals with ADHD may require combinations of these medications, or others, for the management of their disorder, often because of the co-existence of other mental disorders with their ADHD.

PSYCHO-SOCIAL AND BEHAVIORAL TREATMENT

Psychological treatments, such as behavior modification in the classroom and parent training in child behavior management methods, have been shown to produce short-term benefits in these settings.

However, the improvements which they render are often limited to those settings in which treatment is occurring and do not generalize to other settings that are not included in the management program.

Moreover, recent studies suggest, as with the medications discussed above, that the gains obtained during treatment may not last once treatment has been terminated.

Thus, it appears that treatments for ADHD must often be combined and must be maintained over long periods of time so as to sustain the initial treatment effects. In this regard, ADHD should be viewed like and other chronic medical condition that requires ongoing treatment for its effective management but whose treatments do not rid the individual of the disorder.

EXTENDED HUMAN RIGHTS OF PERSONS WITH ADHD

Some children with ADHD may benefit from social skills training provided it is incorporated into their school program. Children with ADHD are now eligible for special educational services in the public schools under both the Individuals with Disabilities in Education Act (IDEA) and Section 504 of the Civil Rights Act.

Adults with ADHD are also eligible for accommodations in their workplace or educational settings under the Americans with Disabilities Act provided that the severity of their ADHD is such that it produces impairments in one or more major areas of life functioning and that they disclose their disorder to their employer or educational institution.

Adults with the disorder may also require counseling about their condition, vocational assessment and counseling to find the most suitable work environment, time management and organizational assistance, and other suggestions for coping with their disorder.

The medications noted above that are useful for children with ADHD have recently proven to be as effective in the management of ADHD in adults.

DISPROVEN TREATMENT

Treatments with little or no evidence for their effectiveness include dietary management, such as removal of sugar from the diet, high doses of vitamins, minerals, trace elements, or other popular health food remedies, long-term psychotherapy or psychoanalysis, biofeedback, play therapy, chiropractic treatment, or sensory-integration training, despite the widespread popularity of some of these treatment approaches.

BEST-PRACTICE TREATMENT

The treatment of ADHD requires a comprehensive behavioral, psychological, educational, and sometimes medical evaluation followed by education of the individual or their family members as to the nature of the disorder and the methods proven to assist with its management. Treatment is likely to be multidisciplinary, requiring the assistance of the mental health, educational, and medical professions at various points in its course. Treatment must be provided over long time periods to assist those with ADHD in the ongoing management of their disorder. In so doing, many with the disorder can lead satisfactory, reasonably adjusted, and productive lives.

AUTHOR’S NOTES

THIS TEXT HAVE BEEN ADAPTED FROM: R. A. Barkley & K. R. Murphy (2006) Attention deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York: Guilford Publications. Copyright 2006 by Guilford Publications.

SUGGESTED READINGS

ADHD Report, a bimonthly newsletter for clinicians edited by Dr. Barkley with contributions from leading clinicians and researchers. Call Guilford Publications at 800-365-7006 to subscribe or go to www.guilford.com.

American Academy of Child and Adolescent Psychiatry (2002). Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child and Adolescent Psychiatry, 41, (February supplement), 26S-49S.

American Psychiatric Association (2000). Diagnostic and Statistical Manual for Mental Disorders(4th Ed. – Revised).Washington, D. C.: Author.

Anastopoulos, A. & Shelton, T. (2001). Assessing attention-deficit/hyperactivity disorder. New York: Kluwer Academic/Plenum Publishing Co.

Barkley, R. A. (1997) Defiant Children: A Clinician’s Manual for Assessment and Parent Training. New York: Guilford Press (800-365-7006; info@guilford.com).

Barkley, R. A. (2006). Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (3rd edition). New York: Guilford Press, 72 Spring St., New York, NY 10012 (800-365-7006 or info@guilford.com).

Barkley, R. A., & Murphy, K. R. (2006). Attention Deficit Hyperactivity Disorder: A Clinical Workbook. New York: Guilford (800-365-7006 or info@guilford.com).

Barkley, R. A. (2005). ADHD and the nature of self-control. New York: Guilford. (see above)

Barkley, R. A., Edwards, G., & Robin, A. R. (1999). Defiant Teens: A Clincian’s Manual for Assessment and Family Intervention. New York: Guilford. (see above)

Brown, T. (2000). Attention deficit disorders and comorbidities in children, adolescents, and adults. Washington, DC: American Psychiatric Press.

Buell, J. (2004). Closing the Book on Homework. Amazon.com.

DuCharme, J., Atkinson, L., & Poulton, L. (2000). Success based, noncoercive treatment of oppositional behavior in children from violent homes. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 995-1004. Department of Human Development and Applied Psychology, University of Toronto (OISE), 252 Bloor Street West, Toronto, Ontario, Canada, M5S 1V6.

DuPaul, G. J., et al. (1998). The ADHD-IV Rating Scale. New York: Guilford.

DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools. New York: Guilford.

Gioia, G. A., Isquith, P. K., Guy, St. C., & Kenworthy, L. (2000). Behavior Rating Inventory of Executive Function (BRIEF). Odessa, FL: Psychological Assessment Resources. (www.parinc.com; 800-331-8378).

Goldstein, S. (1998). Managing atttention and learning disorders in late adolescence and adulthood. New York: Wiley. Goldstein, S., & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children. New York: Wiley.

Goldstein, S. & Teeter Ellison, A. (2002). Clinician’s Guide to Adult ADHD. New York: Academic Press.

Gordon, M., & McClure, D. (1997). The down and dirty guide to adult ADHD. DeWitt, NY: GSI Publications.

Jensen, P. S., & Cooper, J. R. (2003). Attention deficit hyperactivity disorder: State of Science – Best Practices. Kingston, NJ: Civic Research Institute.

Kralovec, E., & Buell, J. (2000). The End of Homework:How Homework Disrupts Families, Overburdens Children, and Limits Learning. Amazon.com.

Loo, S. & Barkley, R. A. (2005). Clinical utility of EEG in attention deficit hyperactivity disorder. Applied Neuropsychology, 12, 64-76.

Mash, E. J., & Barkley, R. A. (2003) Child Psychopathology. New York: Guilford.

Mash, E. J., & Barkley, R. A. (2005). Treatment of childhood disorders (3rd edition). New York: Guilford.

Milich R, Ballentine AC, & Lynam D. (2001). ADHD Combined Type and ADHD Predominantly Inattentive Type are distinct and unrelated disorders. Clinical Psychology: Science and Practice, 8, 463-488.

Pagani, L., Tremblay, R., Vitaro, F., Boulerice, B., & McDuff, P. (2001). Effects of grade retention on academic performance and behavioral development. Development and Psychopathology, 13, 297-315. L. Pagani, Ph.D., Research Unit on Children’s Psychosocial Maladjustment, University of Montreal, CP 6128, succursale Centre-ville, Montreal, Quebec, Canada H3C 3J7; email: paganikl@grip.umontreal.ca.

Phelps, L., Brown, R. T., & Power, T. J. (2001). Pediatric psychopharmacology: Combining medical and psychosocial interventions. Washington, D.C.: American Psychological Association. (www.apa.org/books; 800-374-2721)

Robin, A. R. (1998). ADHD in adolescents: Diagnosis and treatment. New York: Guilford. (info@guilford.com; 800-365-7006)

Rojas, N. L., & Chan, E. (2005). Old and new controversies in alternative treatments for attention deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews, 11, 116-130.
Email: Eugenia.chan@childrens.harvard.edu

Safren, S. A., Sprich, S., Perlman, C., & Otto, M. (2005). Mastery of your adult ADHD: A cognitive behavioral treatment program. New York: Oxford University Press. [198 Madison Avenue, New York, NY 10016-4314, 212-726-6000, http://www.oup.com]

Wakefield, J. (1999). Evolutionary and prototype analyses and the concept of disorder. Journal of Abnormal Psychology, 108, 374-399. This entire issue is a debate of Wakefield’s concept of disorder.

Wasserstein, J., Wolf, L., & Lefever, F. (2001). Adult attention deficit disorder: Brain mechanisms and life outcomes. In the Annals of the New York Academy of Sciences, Volume 931. New York: New York Academy of Sciences.

Weiss, M., Hechtman, L., & Weiss, G. (1999). ADHD in adulthood: A guide to current theory, diagnosis, and treatment. Baltimore, MD: Johns Hopkins Press

Werry, J. & Aman, M. (1999). Practitioners Guide to Psychoactive Drugs for Children and Adolescents (2nd edition). New York: Plenum (www.plenum.com).

Vargas, S., & Camilli, G. (1999). A meta-analysis of research on sensory- integration treatment. Journal of Occupational Therapy, 53, 189-198.

Books for Parents, Teachers, and Children

Barkley, R. A. (2005). Taking Charge of ADHD: The complete authoritative guide for parents. New York: Guilford. Call Guilford Publications, Phone: 800-365- 7006.

Barkley, R. A. (1998). Your Defiant Child: 8 steps to better behavior. New York: Guilford.

Bauermeister, Jose J. (2000). Hiperactivo, impulsivo, distraido, Me conoces? The best ADHD book in Spanish for parents. Obtain from Guilford Publications, 72 Spring St., New York, NY 10012 (800-365-7006 or info@guilford.com) or from Attencion, Inc., 177 Las Caobas, San Juan, Puerto Rico 00927. Phone: 787-763- 1946

Bramer, J. S. (1996). Succeeding in college with attention deficit hyperactivity disorders: Issues and strategies for students, counselors, and educators. Plantation, FL. Specialty Press, Inc. , 300 Northwest 70th Avenue, Suite 102, Plantation, FL 33317 800-233-9273

CHADD (2001). The CHADD Information and Resource Guide to AD/HD. Landover, MD: CHADD (301-306-7070; www.chadd.org)

D’Antoni-Phillips, A. (2000). The Power Organizer Success System. Myrtle Beach, SC: Alice D’Antoni-Phillips. Contact at Education Rx, 4703 HWY 17 Bypass South, Myrtle Beach, SC 29577, phone: 843-293-1411, fax: 843-293-1412, e-mail at: acdp44@aol.com; or website at: www.powerorganize.com.

Forgatch, M. & Patterson, G. R. (1989) Parents and Adolescents Living Together. Eugene, OR: Castalia Publishing Co.

Fowler, M. (1992). CHADD Educators Manual. Provides information to teachers on ADD, its educational manifestations, identification and assessment methods, intervention practices, and policy guidelines and recent federal rulings on special education for ADD. CHADD, 8181 Professional Drive, Suite 201, Landover, MD 20785. Phone: 800-233-4050.

Fowler, Mary Cahill (1998). Maybe you know my kid: A parents guide to identifying, understanding,and helping your child with Attention-deficit Hyperactivity Disorder (2nd ed.) New York: Birch Lane, 600 Madison Ave., New York, NY 10022

Fowler, Mary Cahill (2001). Maybe you know my teen: A parents guide to adolescents withAttention-deficit Hyperactivity Disorder. New York: Broadway Books.

Gordon, M (1992). I Would If I Could by Michael Gordon, Ph.D. GSI Publications, P. 0. Box 746, DeWitt, NY 13214.

Gordon, M. Dr. Gordon has four paperback books available for use with children with ADHD, and their parents, teachers, and siblings. He also has a new videotape for use in teaching children about ADHD. For information on these and other products, contact GSI Publications, www.gsi-add.com P. 0. Box 746, DeWitt, NY 13214. (315-446-4849, or via e-mail at ADDGSI@aol.com). Dr. Gordon also markets The Attention Training System.

Guyer, B. P. (2000). ADHD: Achieving success in school and in life. Boston, MA: Allyn & Bacon. Call the ADD Warehouse at 800-233-9273 to order.

Hallowell, E. H. (1996). When you worry about the child you love: Emotional and learning problems in children. New York: Simon & Schuster. Call the ADD Warehouse at 800-233-9273 to order)

Koplewicz, H. S. (1996). Its nobody’s fault: New hope and help for diffcult children and their parents. New York: Random House. Call the ADD Warehouse at 800-233-9273 to order.

Levin, J., & Shanken-Kaye, J. (1996). The self-control classroom: Understanding and managing the disruptive behavior of all students including students with ADHD. Dubuque, Iowa: Kendall/Hunt Publishing Co.(4050 Westmark Drive)

Nadeau, K., & Biggs, S. (1995). School strategies for ADD teens. VA: Chesapeake Psychological Services. Call the ADD Warehouse at 800-233-9273 to order.

Nadeau, K. (1994). Survival guide for college students with ADD or LD. Washington, D: Magination Press. Call the ADD Warehouse at 800-233-9273 to order.

Parker, H. (1992). The ADD Hyperactivity Handbook for Schools by Harvey Parker, Ph.D. Impact Publications, 300 NW 70th Ave., Plantation, FL 33317. (or Call the ADD Warehouse at 800-233-9273 to order).

Parker, H. (1999). Put yourself in their shoes. Understanding teenagers with ADHD. Impact Publications, 300 NW 70th Ave., Plantation, FL 33317. (or Call the ADD Warehouse at 800-233-9273 to order).

Parker, H. (1988). Attention Deficit Disorders: A Parent and Teacher Workbook. Plantation, FL: Specialty Press. Call the ADD Warehouse at 800-233- 9273 to order.

Reiff, M. I. (2004). ADHD: A complete authoritative guide. Elk Grove, IL: American Academy of Pediatrics. 141 Northwest Blvd., Elk Grove, IL 60007

Wilens, T. (1999). Straight talk about psychiatric medications for kids. New York: Guilford (phone: 800-365-7006).

Zentall, S. S., & Goldstein, S. (1999). Seven steps to homework success. Specialty Press, Inc., 300 NW 70th Ave., Plantation, FL 33317. (or Call the ADD Warehouse at 800-233-9273 to order)


PART TWO

The Important Role of Executive Functioning and Self-Regulation in ADHD

©Russell A. Barkley, Ph.D.

Parents and educators dealing with children (or adults) with ADHD are likely to have heard increasing references to the terms “executive functioning” (EF) and “self-regulation” over the past few years. Numerous books on this topic have appeared during that time along with hundreds of scientific papers focusing on the relationship between these constructs, or ideas, and ADHD. One often hears that ADHD is a disorder of EF or that ADHD involves poor self- regulation.

But what does this mean? How are these terms related to each other and to ADHD? Does this have some impact on the way in which one should manage the disorder? The purpose of this guest column is to give a brief overview of these terms and what their involvement in ADHD may mean for understanding its nature and also for planning interventions for those who have the disorder.

The most common form of ADHD is now known as the Combined Type. More than 2/3s to 3/4ths of people diagnosed with ADHD will be placed in this type at some time in their childhood or adulthood. This type of ADHD involves significant problems with sustained attention, persistence toward goals, resisting distractions along the way, inhibiting excessive task-irrelevant activity (hyperactivity), and inhibiting actions, words, thoughts, and emotions that are either socially inappropriate for the situation or inconsistent with one’s longer term goals and general welfare.

The term “self-regulation” in psychology has a relatively specific definition. While it is often considered the means by which an individual manages themselves in order to attain their goals, it can be thought of as having at least three components.

Self-regulation involves (1) any action an individual directs at themselves so as to (2) result in a change in their behavior (from what they might otherwise have done) in order to (3) change the likelihood of a future consequence or attainment of a goal.

When you walk into a coffee shop and see a display counter filled with pastries or confections you face a situation that may tempt you to buy these things that are likely to ruin your plans for losing weight this month. To deal with this temptation while you wait for your coffee to be prepared, you may avert your eyes from the counter, walk to a different section of the shop away from the tempting goodies, engage yourself in mental conversation about why you need to not buy those products, and even visualize an image of the new slenderer version of yourself you expect to achieve in the near future.

All of these are self-directed actions you are using to try and alter the likelihood of giving into temptation and therefore increase your chances of meeting your goal of weight loss this month. This situation calls upon a number of distinct yet interacting mental abilities to successfully negotiate the situation.

SELF-REGULATION

You have to be aware that a dilemma has arisen when you walked into the shop (self-awareness), you have to restrain your urge to order the pastry to go with the coffee you have ordered (inhibition), you re-directed your attention away from the tempting objects (executive attention or attentional management), you spoke to yourself using your mind’s voice (verbal self-instruction or working memory), and you visualized an image of your goal and what you would look like when you successfully attain it (nonverbal working memory, or visual imagery). You may also have found yourself thinking about various other ways you could have coped effectively with these temptations (problem-solving), and may have even used words of encouragement toward yourself to enhance the likelihood that you would follow your plan (self-motivation). These and other mental activities are usually included in the modern understanding of human self-regulation.

EMOTIONAL ASPECTS OF ADHD

Since the late 1970s, clinical researchers such as Virginia Douglas, Ph.D. (then working at McGill University), who were studying ADHD have asserted that the disorder likely involves a serious deficiency in the capacity for self-regulation.

Why? Because they had already begun documenting through various measures that ADHD was associated with deficits in inhibition, managing one’s attention, self-directed speech and rule-following, self-motivation, and eventually even self-awareness.

If ADHD involves difficulties in these faculties and these are the human mental abilities that are involved in our regulating our own behavior, then logically ADHD ought to be a disorder of self-regulation.

Since then, research has continued to affirm the involvement of deficits in these and other mental abilities that are essential for effective self- regulation in people with ADHD resulting in a tacit acceptance of the idea that ADHD is actually SRDD (self-regulation deficit disorder).

While the official name for the disorder will not be changed anytime soon in the official manual that grants names to mental disorders, it is important that people understand this equivalence of ADHD with self-regulation deficits.

Also over the past 30 years, clinical researchers such as myself and many others studying ADHD have increasingly documented deficits on tests and other measures of EF. How do the above ideas about self-regulation problems in ADHD link up with these findings and the term EF itself?

EXECUTIVE FUNCTIONING (EF)

To understand this relationship, one has to have a clear definition of EF. Unfortunately, there is no consensus at this time on the meaning of the term EF, despite it being used prolifically in journal articles, presentations, and books about ADHD. A commonly used definition in the field of ADHD has been to refer to EF as “those neuropsychological processes needed to sustain problem-solving toward a goal.”

Now we can begin to see a potential relationship between EF and self-regulation, because they share a similar if not identical definition. Both involve goal-directed, future-oriented actions. Both involve sustaining actions over time to achieve one’s goals. And both include problem-solving as part of those goal- directed actions.

Moreover, when we look at a list of the mental processes most often listed as being part of the notion of EF, they include:

  • inhibition,
  • resistance to distraction,
  • self-awareness,
  • working memory,
  • emotional self-control,
  • and even self-motivation.

These are the very mental abilities that were already identified as being essential to self-regulation. Initially in 1994, and later in 1997 in a book on ADHD, I argued for just this linkage or relationship between EF and self-regulation.

Indeed, I stipulated that each executive function can be considered to be a type or special form of self-regulation – a specific class to actions that people direct at themselves to change their behavior so as to alter a future consequence or likelihood of attaining a goal. In short, an EF is a specific type of action you are directing at yourself for purposes of self- regulation.

We can therefore take each EF that researchers have identified and redefine it as a type of self-direct action.

Inhibition becomes self-restraint, self-awareness is self-directed attention, verbal working memory is self-speech (talking to yourself, usually using your mind’s voice), nonverbal working memory is seeing to yourself, or using visual imagery along with other forms of self-directed sensing (rehearing previous conversations to yourself, re-perceiving odors you previously smelled or flavors you previously tasted, etc.). And problem-solving could be thought of as self-directed play (taking apart and recombining things or ideas to create novel re-arrangements).

Dr. Russell A. Barkley, Ph.D.

 ADDspeaker: To elaborate further on the importance of self-motivation and emotional self-control, I have chosen to add this description for better overall understanding. Self-motivation is the final result or outcome, of all of the above Executive Functions, and is what springs us into action. Emotional Self-control is the EF that enable us to postpone immediate gratification of needs, by using the Inhibitory System as a tool to break from normal stimuli/response behavior to “alter the future to receive a better outcome, later”. Emotional self-control also include emotional self-regulation, the ability to alter an internal emotional state, in ourselves and by ourselves, e.g. taking a bad emotion and rethink it to become less negative and sometimes even replace a bad emotion with a good emotion. Emotional self-regulation is key in social reciprocity, the key ability humans use to live in complex social societies.

By adulthood, all of these are largely invisible to others, or mental in form, such that the person engages in them privately, to themselves, in their mind (brain). Working memory and problem-solving in fact are the ways people typically mentally represent and manipulate information that is being held in our mind (using images and words).

In short, we use the various EFs for self-regulation to attain goals (alter future consequences): EF = SR. Now we can see that if ADHD is SRDD then SRDD is also EFDD. They are just interchangeable names for the same set of problems. People with ADHD have great difficulties with using their EFs for purposes of self-regulation and attaining their goals.

UNDERSTANDING WHAT ADHD REALLY IS

We can now understand that ADHD involves more than just the obvious symptoms of inattention/distractibility and impulsivity/hyperactivity, as listed in the Diagnostic and Statistical Manual for Mental Disorders, 4th Edition (DSM-IV).

It is now obvious that the underlying psychological difficulties that are giving rise to these symptoms involve deficits in all of the major EFs, and each of these EFs is a type of self-regulation – a special form of self-directed action. ADHD therefore involves deficits in self-restraint, self-awareness, self-speech, self-sensing and imagery, self-control of emotion, self-motivation, and self-directed play for problem-solving.

Because these difficulties are more likely to be delays in the development of these important mental abilities, and not absolute losses of these abilities as might occur after a severe brain injury, what distinguishes someone with ADHD from someone without it is that they appear to be less mature (are age-inappropriate) in their ability to engage in self-regulation (EF) toward specific goals and the future more generally.

If one is to help someone with ADHD, they must be helped to either overcome these delays or at least compensate for them (make accommodations to them) if they are to be more effective or successful in managing themselves, getting to their tasks and goals, and preparing for their future more generally.

Disorders of EF or self-regulation, like ADHD, pose great consternation for the mental health and educational arenas of service because they create disorders mainly of performance rather than of knowledge or skills. Mental health and education professionals are more expert at conveying knowledge – how to change; far fewer are expert in ways to engineer environments to facilitate performance – where and when to change.

At the core of such problems is the vexing issue of just how one gets people to behave in ways that they know may be good for them yet which they seem unlikely, unable, or unwilling to perform. Conveying more knowledge does not prove as helpful as altering the parameters associated with the performance of that behavior at its appropriate point of performance.

Coupled with this is the realization that such changes in behavior are likely to be maintained only so long as those environmental adjustments or accommodations are as well. To expect otherwise would seem to approach the treatment of EF deficits with outdated or misguided assumptions about the essential nature of EF and its impairments.

Some of the principles of EF deficit management that arise from this view of ADHD as a disorder of self-regulation (EF) are:

If the process of regulating behavior by internally represented forms of information (working memory or the internalization of behavior) is impaired or delayed in those with EF deficits, then they will be best assisted by “externalizing” those forms of information; the provision of physical representations of that information will be needed in the setting at the point of performance. Since covert or private information is weak as a source of stimulus control, making that information overt and public may assist with strengthening control of behavior by that information.

BEHAVIORAL ASPECTS OF ADHD

The organization of the individual’s behavior both within and across time is one of the ultimate disabilities rendered by the disorder.

TIME BLINDNESS

EF deficits create problems with time, timing, and timeliness of behavior such that they are to time what nearsightedness is to spatial vision; they create a temporal myopia in which the individual’s behavior is governed even more than normal by events close to or within the temporal now and immediate context rather than by internal information that pertains to longer term, future events.

This helps to understand why adults with EF deficits make the decisions they do, short-sighted as they seem to be to others around them. If one has little regard for future events, than much of one’s behavior will be aimed at maximizing the immediate rewards and escaping from immediate hardships or aversive circumstances without concern for the delayed consequences of those actions.

Those with deficient EF could be expected to be assisted by making time itself more externally represented, by reducing or eliminating gaps in time among the components of a behavioral contingency (event, response, outcome), and by serving to bridge such temporal gaps related to future events with the assistance of caregivers and others.

Given that the model hypothesizes a deficit in internally generated and represented forms of motivation that are needed to drive goal-directed behavior, those with EF deficits will require the provision of externalized sources of motivation.

BEHAVIORAL MODIFICATION THERAPY

For instance, the provision of artificial rewards, such as tokens, may be needed throughout the performance of a task or other goal-directed behavior when there is otherwise little or no such immediate consequences associated with that performance.

Such artificial reward programs become for the person with EF deficits what prosthetic devices such as mechanical limbs are to the physically disabled, allowing them to perform more effectively in some tasks and settings with which they otherwise would have considerable difficulty.

The motivational disability created by EF deficits makes such motivational prostheses nearly essential for most children deficient in EF and can be useful with adults having EF deficits as well.

UNDERSTANDING SELF-REGULATION (SR)

Related to this idea of motivational deficits accompanying EF disorders is the literature on self-regulatory strength and the resource pool of effort (willpower) that are associated with activities of SR.

There is an abundant literature on this topic that has been overlooked by neuropsychologists studying EF yet it has a direct bearing on EF given that EF is viewed as SR here.

Research indicates that each implementation of SR (and hence EF) across all types of SR (working memory, inhibition, planning, reasoning, problem-solving, etc.) depletes this limited resource pool temporarily such that protracted SR may greatly deplete the available pool of effort.

This results in an individual being less capable of SR in subsequent situations or immediately succeeding time periods and thus more likely to experience problems or fail outright in their efforts at SR and resistance to immediate gratification. Such temporary depletions may be further exacerbated by stress, alcohol or other drug use, illness, or even low levels of blood glucose.

THE “10 AND 3” RULE

Research also indicates what factors may serve to more rapidly replenish the resource pool such as routine physical exercise, taking 10 minute breaks periodically during SR strenuous situations, relaxing or meditating for at least 3 minutes after such SR exerting activities, visualizing the rewards or outcomes while involved in EF/SR tasks, arranging for periodic small rewards throughout the tasks or SR-demanding settings, engaging in self-affirming statements of self-efficacy prior to and during such tasks, experiencing positive emotions, and consuming glucose rich beverages during the task.

Some research further suggests that the actual capacity of the resource pool may be boosted by routine physical exercise and by routine practicing tasks involving self-regulation daily for two weeks.

From the extended phenotype view of EF as SR, these findings from the psychological literature on SR are directly pertinent to EF and its disorders.

ADHD is not a knowledge disorder, it’s a performance disorder

PERFORMANCE, NOT KNOWLEDGE

ADDspeaker: ADHD is not a disorder that disables the learning and storing of knowledge. It is, however, a disorder of using what you know! People with ADHD are not less intelligent or less able to learn things, they are however less able to use what they know. This is due to the fact that the symptoms of ADHD is largely related to Inhibition, or lack of inhibition, causing people with ADHD to act on impulse, disregarding what they know or how this will impact them in the future, they are driven by immediate needs and prone to basic stimuli/response behavior. It is crucial that you understand that this is not a behavioral trait, is is a biological caused impairment that the person suffering from ADHD have no control over, just like a blind person cannot see, no matter how much psycho-social therapy they receive or how much they train their ability to understand how to see, it is a given fact of life, and the only known mediating treatment is medication.

Given the above listed considerations, clinicians should likely reject most approaches to intervention for people with EF deficits that do not involve helping patients with an active intervention at the point of performance.

The point of performance is that place and time in the natural setting of the person’s life where they are failing to use what they know – they are failing to engage effectively in EF (self-regulation).

Once per week counseling without efforts to insert accommodations at key points of performance in natural settings is unlikely to succeed with the patient with deficient EF.

This is not to say that extensive training or retraining at the instrumental level of EF, as with working memory training, may not have some short-term benefits. Such practice has been shown to increase the likelihood of using EF/SR and of boosting the SR resource pool capacity in normal individuals.

Yet another implication for the management of EF deficits from the self-regulation perspective is that only a treatment that can result in improvement or normalization of the underlying neurological and even genetic substrates of EF is likely to result in an improvement or normalization of the deficits.

To date, the only treatment that exists that has any hope of achieving this end is medication, such as stimulants or the non-stimulants like atomoxetine or guanfacine XR, that improve or normalize the neural substrates in the prefrontal regions and related networks that likely underlie these deficits.

Evidence to date suggests that this improvement or normalization in EF may occur as a temporary consequence of active treatment with stimulant medication, yet only during the time course the medication remains within the brain. For instance, research shows that clinical improvement in behavior occurs in as many as 75–92% of those with ADHD and results in normalization of behavior in approximately 50–60% of these cases, on average.

ADDspeaker: Medication is high;y effective, safe and reduces symptoms by 80-90%, within minutes and we know from experience and scientific facts, that 90% of all people with ADHD will benefit from using ADHD medication. The last 10% seems to be misdiagnosed (probably Autism or Bipolar Disorder) and a small percentage is simply biologically unable to benefit from the current medications used. In recent years, clinicians and patients, have reported that combining multiple ADHD medications, results in a better coverage of symptoms, and that at lower individual dosages of each medication.

The model of EF developed here, then, implies that medication is not only a useful treatment approach for the management of certain EF deficits but may be a predominant treatment approach among those treatments currently available because it is the only treatment known to date to produce such improvement/normalization rates, albeit temporarily.

It also can be reasoned that if EF deficits result in the under-control of behavior by internally represented forms of information (EFs), then that information needs to get “externalized” as much as possible, whenever feasible, at critical points of performance in the natural setting.

To “externalize” information is to make it physical outside of the individual. The internal forms of information generated by the executive system, if they have been generated at all, appear to be extraordinarily weak in their ability to control and sustain the behavior of those with EF deficits that impair behavior toward the future.

Self-directed visual imagery, audition, and the other covert re-sensing activities that form nonverbal working memory as well as covert self-speech, if they are functional at all at certain times and contexts, are not yielding up information of sufficient power to control behavior in this disorder. That behavior is remaining largely under the control of the salient aspects of the immediate context.

The solution to this problem is not to nag those with EF difficulties to simply try harder or to remember what they are supposed to be working on or toward. It is instead to take charge of that immediate context and fill it with forms of physical cues comparable to their internal counterparts that are proving so ineffective.

In a sense, clinicians treating those with EF deficits must beat the environment at its own game. Sources of high-appealing distracters that may serve to subvert, pervert, or disrupt task-directed mentally represented information and the behavior it is guiding should be minimized whenever possible.

In their place should be cues, prompts, and other forms of information that are just as salient and appealing yet are directly associated with or are an inherent part of the task to be accomplished. Such externalized information serves to cue the individual to do what they know.

If the rules that are understood to be operating during educational or occupational activities, for instance, do not seem to be controlling the person’s behavior, they should be externalized. The rules can be externalized by posting signs about the school or work environment that are related to these rules and having the adult frequently refer to them.

Having the adult verbally self-state these rules aloud before and during these individual work performances may also be helpful. One can also tape-record these reminders on a digital recorder that the child or adult listens to through an earphone while working. It is not the intention of this column to articulate

the details of the many treatments that can be designed from this model. That is done in my other books. All I wish to do here is simply show the principle that underlies them – put external information around the person and within their sensory fields that may serve to better guide their behavior in more appropriate activities.

With the knowledge this model provides and a little ingenuity, many of these forms of internally represented information can be externalized for better management of the child or adult with EF deficits, as seen in ADHD for instance.

Chief among these internally represented forms of information that either need to be externalized or removed entirely from the tasks is that related to time. As stated earlier, time and the future are the enemies of people with EF difficulties when it comes to task accomplishment or performance toward a goal.

An obvious solution, then, is to reduce or eliminate these problematic elements of a task when feasible. For instance, rather than assign a behavioral contingency that has large temporal gaps among its elements to someone with and EF disorder, those temporal gaps should be reduced whenever possible.

In other words, the elements should be made more contiguous. Rather than tell them that a project must be done over the next month, assist them with doing a step a day toward that eventual goal so that when the deadline arrives, the work has been done but done in small daily work periods with immediate feedback and incentives for doing so.

Yet there is a major caveat to all these implications for externalizing forms of internally represented information. This caveat stems from the component of the model that deals with self- regulation of motivation (and arousal):

No matter how much clinicians, educators, and caregivers externalize prompts, cues, and other signals of the internalized forms of information by which they desire the person with EF deficits to be guided (stimuli, events, rules, images, sounds, etc.), it is likely to prove only partially successful. Even then it will prove only temporarily so.

Internal sources of motivation must be augmented with more powerful external forms as well. It is not simply the internally represented information that is weak in those with EF disorders. It is the internally generated sources of motivation associated with them that are weak as well. Those sources of motivation are critical to driving goal-directed behavior toward tasks, the future, and the intended outcome in the absence of external motivation in the immediate context.

Addressing one form of internalized information without addressing the other is a sure recipe for ineffectual treatment. Anyone wishing to treat those with deficits in EF has to understand that sources of motivation must also be externalized in those contexts in which tasks are to be performed, rules followed, and goals accomplished. Complaining to these individuals about their lack of motivation (laziness), drive, will power, or self-discipline will not suffice to correct the problem.

Pulling back from assisting them to let the natural consequences occur, as if this will teach them a lesson that will correct their behavior, is likewise a recipe for disaster. Instead, artificial means of creating external sources of motivation must be arranged at the point of performance in the context in which the work or behavior is desired.

The methods of behavior modification are particularly well suited to achieving these ends. Many techniques exist within this form of treatment that can be applied to those with children and adults with EF deficits.

What first needs to be recognized, as this model of ADHD stipulates, is that (1) internalized, self-generated forms of motivation are weak at initiating and sustaining goal directed behavior; (2) externalized sources of motivation, often artificial, must be arranged within the context at the point of performance; and (3) these compensatory, prosthetic forms of motivation must be sustained for long periods.

CONCLUSION

To conclude, this column has attempted to show that ADHD is a disorder of self-regulation. Self-regulation requires that a person have intact executive functions (EFs).

The EFs are specific types of self-regulation or self-directed actions that people use to manage themselves effectively in order to sustain their actions (and problem-solving) toward their goals and the future. I have tried to show that ADHD is both SRDD (self-regulation deficit disorder) and so is also EFDD.

By understanding this relationship among these terms, we can understand that people with ADHD have difficulties using the mental forms of self-directed actions we all use to manage ourselves effectively so as to attain our goals and see to our long-term welfare.

To deal with the problems ADHD creates, we will need to understand that it involves EF deficits and that such deficits can be compensated for by modifying the environment and making other accommodations so as to both buttress and facilitate the individual’s use of their own self- control.

ABOUT DR. BARKLEY, Ph.D.

Dr. Barkley is a Clinical Professor of Psychiatry at the Medical University of South Carolina in Charleston and is the recipient of various career achievement awards from the American Psychological Association and American Academy of Pediatrics. He is the author of 23 books, 280 scientific articles and book chapters, and 7 videos concerning ADHD and related disorders. His most recent books are When an Adult you Love Has ADHD (2016), ADHD: A Handbook for Diagnosis and Treatment (2015, 4th edition), and Managing ADHD in the Classroom (2016).

This column is partially based on his book, Executive Functioning and Self-Regulation (2012). His website is russellbarkley.org.

©This article is copyrighted by Russell A. Barkley, Ph.D. and may not be used or transmitted in any form without his written authorization.

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