Wednesday, September 21, 2011

ADHD: A Disorder of Self Control…..Not Inattention

ADHD: A Disorder of Self Control…..Not Inattention

A fundamental deficit in individuals with ADHD is one of self-control.  According to researcher, Russell Barkley, problems with attention are a secondary characteristic of the disorder.  Dr. Barkley also believes that individuals with the inattentive type of ADHD, which is characterized by attention difficulties but not problems with hyperactive impulsive behavior, have a different disorder than those who have both types of symptoms.  The theory that he lays out, and which is summarized below, applies in his view to ADHD where both inattentive and hyperactive-impulsive symptoms are prominent.

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 with himself if he let his temper get out of control

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 is diminished in individuals with ADHD.  In fact, recent research has documented 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.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.

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.  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 on his mind than the long-term consequences this behavior has for his friendships.  This child 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, 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.  This is likely to be ineffective because it depends on the type of internalized control of behavior that the child is deficient to begin with.

To overcome this, the 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.  The 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, with the addition 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 reults 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.

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