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

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

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

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

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

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Key take-aways:

- Schools today are not yet in a position to effectively help kids with cognitive issues deal with increasing cognitive demands.

- Working Memory is a cognitive skill fundamental to planning, sequencing, and executing school-related work.

- Working Memory can be trained, as evidenced by Dr. Lavin’s work, based on Cogmed Working Memory Training, with kids who have attention deficits.

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Context on cognitive fitness and schools

AF (Alvaro Fernandez): Dr. Lavin, thanks for being with us. It is not very common for a pediatrician to have such an active interest in brain research and cognitive fitness. Can you explain the source of your interest?

AL (Arthur Lavin): Throughout my life I have been fascinated by how the mind works. Both from the research point of view and the practical one: how can scientists’ increasing knowledge improve kids’ lives? We now live in an truly exciting era in which solid scientific progress in neuroscience is at last creating opportunities to improve people’s actual cognitive function. The progress Cogmed has achieved in creating a program that can make great differences in the lives of children with attention deficits is one of the most exciting recent developments. My colleague Ms. Susan Glaser and I recently published two books: Who’s Boss: Moving Families from Conflict to Collaboration (Collaboration Press, 2006) and Baby & Toddler Sleep Solutions for Dummies (Wiley, 2007), so I not only see myself as a pediatrician but also an educator. I see parents in real need of guidance and support. They usually are both very skeptical, since they have been promised too many things too many times by “experts”, yet open-minded to ideas with good foundations. Many professionals have only the skeptical frame, since they were educated when scientists still believed the brain was pretty rigid and “untrainable”. We need much more brain science-based professional development, and appreciate the great work SharpBrains is doing.

AF: Let’s talk about that “trainability” and schools. Most people still think of “intelligence” as fixed. Now, I recently read a report on how KIPP schools emphasize the training on some basic skills, such as shared attention, as a needed foundation for good academic performance. So, even if limited in scope, it seems some schools are starting to understand their role in cognitive development. In your experience, are schools fulfilling their roles as “brain gyms”, places where young minds get shaped and ready for life?

AL: Good question. I have been a pediatrician working with schools in the Cleveland area since 1985, seen all kinds of diseases. For example, I have witnessed the growing incidence of autism spectrum disorders, such as autism and Asperger’s. I have also observed how school work has increasingly become more cognitively demanding, starting from kindergarden. There is too much pressure today, and a growing number of problems, yet I don’t see that schools are applying the best knowledge of how minds work. Just as doctors offices are centers of applied medical science, taking the latest advances in medical research and applying them to the medical care of people, schools should be the best place for applied neuroscience, taking the latest advances in cognitive research and applying it to the job of educating minds. Yet, they aren’t, and I can’t blame them , given the wide variety of pressures they work under, and the large change in perspective becoming institutes of applied neuroscience would take.

A cognitive gap?

AF: Some readers may be skeptical of the claim that school work is more demanding today than, say, 20 years ago. They may say kids are simply becoming “lazy”. What do you say to that?

AL: I have never met a lazy kid. All people want to succeed, in life if not in school. Most children who struggle at school struggle mightily to get adequate grades. It is true that some are more resilient that others-if they fail, they will try 10 times harder. The ones that are labeled as “lazy” are typically ashamed of their lack of capacity to deal with demands, and resort to an evasive strategy, they try to avoid the whole situation, run away.

AF: You mention a “lack of capacity to deal with demands”. Is that gap growing? The equation has 2 components: capacity and demands. In terms of capacity, let me mention that recently, the French Education Ministry just introduced mental arithmetic as part of the curriculum. I remember, as a kid, spending many hours in the math class where the teacher would require us to perform a progressively complex sequence of mental calculations-which is good training for skills such as working memory. Memory trainig was important.

AL: Great point. For example, years ago we had to memorize long texts, which, no matter what the content was, was a great way to train and build our attention span, working memory, and to devise strategies to learn. Today, there are less opportunities for such training.

In terms of demands, I can see how complex homework assignments are these days even in 3-4rd grade. Kids need to plan and prepare a whole matrix of tasks that require good organizational work to complete. They need to sequence what they do today, tomorrow, the day after. The major difficulty, for which such young brains may not be fully ready, is to deal with an overwhelming amount of information and demands, and execute.

Working Memory and Attention Deficits (more about WM at www.aboutworkingmemory.org)

AF: that seems to imply a higher need for good executive functions than years ago. A kid needs to have good working memory to retain, prioritize and sequence much information into actionable plans, and then execute them, as I had the fortune to discuss with Mark Katz some months ago. From my previous interviews with Dr. Klingberg and Dr. Gibson, we know that a common problem with many kids with diagnosed attention deficits is, indeed, working memory (the ability to hold in mind and manipulate several units of information). Can you explain what you see in your work with schools?

AL: I am afraid that many schools are too quick to diagnose ADD/ ADHD and consider drugs as the only potential intervention. The label itself can be misleading and counterproductive. School psychologists have wonderful expertise in evaluating subject-related problems and describing attentional deficit symptomatology, but are not trained or asked to complete neuropsychological profiles of a child’s cognitive functions. Up to a point, many kids with attention problems would benefit from educational, not medical, interventions to improve cognitive functions such as working memory. I am seeing it first hand, having used Cogmed Working Memory Training (also called RoboMemo) with 15 pre-screened kids: 80% of them presented a substantive improvement. With 50%, the results we have seen have been dramatic.

AF: Please give us some examples, so our readers can better understand what working memory is and its role in academic performance and daily life. 

AL: Let me give you 3 vignettes, all 3 with diagnosed attention deficits, who showed clear benefit not only on cognitive functioning but also on AD/HD rating scales.

Patient 1: 11-year-old boy, very impulsive, even on medication. Doesn’t do homework, constantly forgets chores. After the 5-week program, he is able to sit down and listen instructions, engaging in fewer arguments with his parents. He can do better mental math- for the first time in his life able to do so without using his fingers. He finds that following school and doing homework is easier, grades have improved dramatically.

Patient 2: 16-year-old girl with ADD. She has trouble executing homework, often telling parents she had done it when she really hadn’t. Her parents thought she liked to lie. Yet, when I talk to her, she is clearly more ashamed than dishonest. The working memory training program helps her develop a much improved perception of time. For example, she starts to manage her shower time better, being aware of when 5 minutes have passed-instead of spending 30 minutes in the shower, as before. Much improved school work, lying at home has dropped dramatically.

Patient 3: 19-year-old boy in college, who often became paralyzed when he was faced with complex challenges. He had a tough time with the cognitive training program, but after a while he started learning new strategies and developing self-confidence, and showing marked improvement. Now, he can break complex tasks into manageable pieces . His attentional deficits appeared to threaten his opportunities in his family business. Unable to keep track of change at the cash register, lines at the business would grow and customers get angry, leaving him out of consideration for key start-up employment in the business. Now he can manage day-to-day challenges such as these, and the door to being part of the family business is now open. He can sequence tasks and execute then with a clear plan in mind, without being distracted and losing sight of that plan.

AF: Dr. Lavin, this is all very exciting news, that open the way for new interventions, new policies, a new understanding of what “education” and “learning” is and how to “educate” millions of young minds and equip them for life success. Thank you very much for your time.

AL: Thank you. I really appreciate all the work you are doing to bring the latest neuroscience research and applications to professionals like me and to parents at large.

University of Notre Dame Professor and Research Team are First in U.S. to Validate Breakthrough Study on  the Effectiveness of Working Memory Training in Improving Attention Deficits in Children (pdf)

• “Dr. Bradley Gibson, associate professor of psychology at the University of Notre Dame, and his colleagues (Gibson, Seroczynski, Gondoli, Braungart-Rieker, & Grundy, 2007)  will share new findings from the first U.S. study on the effectiveness of Cogmed Working Memory Training for improving attention abilities in children with ADHD. The study validates previous research from Sweden’s Karolinska Institute which revealed a fundamental breakthrough in the way attention problems are proactively treated. Gibson will unveil the results of the U.S. study during the Society for Research in Child Development (SRCD) bi-annual conference in Boston. Cogmed is a pioneer in neurotechnology and a developer of software-based working memory training products.”

Our interview with Notre Dame’s Bradley Gibson

• AF: Tell us about ADD/ ADHD and development trajectories.
• BG: There is a very insightful study by Walter Mischel on pre-schoolers aged 4 and 5. Some of them had a better ability to control their attention and delay gratification (measured as the capacity not to immediately eat a marshmallow but to wait for a larger posterior reward), and those kids were shown, 14 years later, to be happier, have better overall school grades, score around 200 points higher in the SAT, and, when tested, display better executive functioning overall. The study showed that there are individual differences at very young ages-and the important implications from this fact. Now, the part that I consider more exciting is that these differences are not fixed. Training is very important

You can learn more about Cogmed Working Memory Training and RoboMemo.

Other interviews in our Neuroscience Interview Series: 

You can meet the Cogmed team by attending our panel on Brain Fitness at Neurotech Industry Conference, May 17th in San Francisco.