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.
