Russell Barkley, Ph.D.
Clinical Professor of Psychiatry
Medical University of South Carolina
Charleston, SC
Websites:
ADHDLectures.com
Russellbarkley.org

 A disorder of developmentally inappropriate degrees of:
• Inattention
• Hyperactive and impulsive behavior
 Arises in childhood
 Persistent over time
 Results in impairment in major life activities

A Neuropsychological Dimension of Poor Inhibition
 Motor impulsiveness and hyperactivity (task irrelevant movements)
• Fidgeting, squirming, running, climbing, touching
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Verbal impulsiveness
Cognitive impulsiveness (decision making; cannot wait or defer gratification)
• Greater disregard of future (delayed) consequences
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Impaired resistance to distractions (sustained inhibition)
Emotionally impulsive; poor emotional self-regulation
 NOTE: Restlessness decreases with age, becoming more internal or subjective by adulthood

There are at least 6 types of attention:
• Arousal, alertness, selective, divided, span of apprehension, & persistence.
Not all are impaired. What is?
• Poor persistence toward goals or tasks
– The cross-temporal organization and maintenance of actions toward goals or assignments
• Impaired resistance to responding to distractions
• Less likely to re-engage tasks following disruptions
– Due to impaired working memory (remembering so as to do)

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2-5% of children (using older DSM-III or III-R)
7-8% of children in US (using DSM-IV) (~3-4 million)*
• Adding Inattentive Type doubles prevalence over III-R
5.5% of children worldwide*
4-5% of adults in US (~12 million in US)**
3-4% worldwide adult prevalence***
Varies by age, social class, & urban-rural
• More common in children; less so in adults
• Somewhat more common in middle to lower-middle classes
• More common in population dense areas
• More common in certain occupations
– For instance, 12-15% of U.S. military dependents
– More common among nonprofessional workers
• No evidence for ethnic differences to date that are independent of social class, urban-rural demographics or variable access to care

Better Here: Worse Here:
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Fun
Immediate
Frequent
Boring
Delayed Consequences
Infrequent Feedback
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High
Early
Supervised
One-to-one
Low Salience
Late in the Day
Unsupervised
Group Situations
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Novelty
Fathers
Strangers
Clinic Exam Room
Familiarity
Mothers
Parents
Waiting Room

 Sometimes called Attention Deficit Disorder
 Daydreaming/Spacey/Stares/Confused
 Slow Information Processing (CAPD?)
 Hypoactive/Lethargic/Sluggish/Sleepy
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Easily Confused, Mentally “Foggy”
 Poor Focused/Selective Attention
 Erratic Retrieval - Long-Term Memory
 Socially Reticent/Uninvolved/Isolated

(2)
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Not Impulsive; also less deficient in other executive functions (self-regulation abilities)
Rarely Aggressive or have ODD/CD
Greater risk for anxiety and depression
Equally high risk for learning disabilities (LD)
• But math disorders may be more likely than reading and language disorders with SCT (?)
Not as impaired in other domains of life outside of school compared to ADHD
Parents report far less stress in parenting SCT than ADHD children; most stress is school related
Possibly greater family history of anxiety disorders and LD
(?)

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Less Likely to Have a Clinically Impressive
Response to Stimulants?
• (65% improve but only 20% show clinical response)
Other drugs have not been tested – Strattera,
Intuniv, ProVigil, etc
 Better responders than ADHD children to social skills training
 As good or better responders to behavior modification methods
 Probably better responders to cognitive behavioral therapy (self-instruction training)

 Academic Under-performance (90%+)
 Retention in Grade (25-50%)
 Require Special Education (35-60%)
 Failure to Graduate High School (30-
40%)
 Less Likely to Attend College (20%)
 Less Likely to Graduate College (5%)

 Oppositional, defiant, hot tempered (40-65%)
 Depressed, sullen, moody, irritable (20-30%)
 Anxious, fearful (0-25%)
 Peer Relationship Problems (50%+)
 Delinquency (25-35%)
 Substance Dependence/Abuse (10-20%)
 Driving Problems (Speeding, Accidents)
 Earlier Sexual Activity; Teen Pregnancy (38%+)
 Increased Risk for Sexually Transmitted Diseases
(16%)

 Delayed motor coordination (60%+)
 Greater risk for accidents and injuries
 More likely to develop dental problems
 Small increase in risk for seizures
 Bedtime behavior problems (20%+) and disordered sleep(20-25%)

From R. Barkley, Scientific American , Sept. 1998, p. 47; Reprinted with permission of Terese Winslow and Scientific American.

Delayed brain growth in ADHD (3 yrs.)
From Shaw, P. et al. (2007). ADHD is characterized by a delay in cortical maturation.
Proceedings of the National Academy of Sciences, 104, 19649-19654.
Ns: ADHD=223; Controls = 223
Greater than 2 years’ delay
0 to 2 years delay

Early cortical maturation in ADHD children
From Shaw, P. et al. (2007). ADHD is characterized by a delay in cortical maturation.
Proceedings of the National Academy of Sciences, 104, 19649-19654.
Fig. 4. Regions where the
ADHD group had early cortical maturation, as indicated by a younger age of attaining peak cortical thickness.

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Heredity : Risk to
• Siblings: 25-35% Twin: 75-92%
• Mother: 15-20% Father: 20-30%
• Offspring of an adult with ADHD: 27-54%
Genetic Contribution (80% or more)
• No contribution of the rearing environment
 Many Risk genes found to date:
• These genes appear to regulate brain growth and some brain chemicals
• Each contributes a small risk to the disorder
• Family members have some of these genes and show some of the traits of ADHD but often not enough to have the full disorder
• The more risk genes a child has, the greater the risk for having the full disorder

 Food Additives, Allergies, Sugar, Milk in Diet
 Excessive Caffeine in Diet
 Environmental Allergens
 Poor Child Management by Parents
 Family Stress; Chaotic Home Life
 Excessive Use of TV, Video-games
 Increased Cultural Tempo
 PTSD, Depression, Anxiety, Learning Disability

 That you stop and think -BEFORE you act !
 Use your hindsight (looking backward)
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To get your foresight (see what’s next)
 To anticipate and prepare for the future
 So you can be more effective and attend to your long-term welfare and happiness
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This is “executive functioning” (EF)
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There are 6 “cognitive” or “mental” components or parts to EF

Inhibition
Sensing to the Self
Self-Speech
Emotion to the Self
Play to the Self
Motor
Control

The EFs Create Four Developmental
Transitions in What is Controlling Behavior
 External Mental (private or internal)
 Others
 Immediate
Self
 Temporal now Anticipated future
Delayed gratification

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Self-Discipline (making your self STOP)
• Cognitive, behavioral, verbal, emotional
Self-Management Across Time (making mental maps)
• Consideration of past and future consequences before acting; managing your self relative to time and deadlines
Self-Organization /Problem-Solving (making options)
• Innovating, planning possible response options, problemsolving to overcome obstacles to goals, rapid assembly and performance of novel goal-directed behavior
Self-Motivation (filling the fuel tank)
• Substituting positive goal-supporting emotions for negative goal-destructive ones
Self-Regulation of Emotions (moderating your feelings)

ADHD Impairs Self-Regulation Across Time

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ADHD disrupts the 7 mental capacities that make up EF and the 5 EF abilities we use in everyday life thereby creating a disorder of selfregulation across time
ADHD is “Time Blindness” or a “Temporal
Neglect Syndrome” (Myopia to the Future)
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It adversely affects the capacity to hierarchically organize behavior across time to anticipate the future and to pursue one’s long-term goals and self-interests (welfare and happiness)
It’s not an Attention Deficit but an Intention
Deficit (Inattention to mental events & the future)

It’s a Disorder of:
 Performance, not skill
 Doing what you know, not knowing what to do
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The when and where, not the how or what
Using your past at the “point of performance”
The point of performance is the place and time in your natural settings where you should use what you know (but may not)

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Teaching skills is inadequate
The key is to design prosthetic environments around the individual to compensate for their EF deficits
Therefore, effective treatments are always those at the
“point-of-performance”
The EF deficits are neuro-genetic in origin
Therefore, medications may be essential for most (but not all) cases – meds are neuro-genetic therapies
But some evidence suggests some EFs may also be partly responsive to direct training
While ADHD creates a diminished capacity: Does this excuse accountability?
• (No! The problem is with time and timing, not with consequences)

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Behavioral treatment is essential for restructuring natural settings to assist the EFs
• They provide artificial prosthetic cues to substitute for the working memory deficits (signs, lists, cards, charts, posters)
• They provide artificial prosthetic consequences in the large time gaps between consequences (accountability) (i.e., tokens, points, etc.)
• But their effects do not generalize or endure after removal because they primarily address the motivational deficits in ADHD
The compassion and willingness of others to make accommodations are vital to success
A chronic disability perspective is most useful

 Evaluation
 Education
 Medication
 Modification (of Behavior)
 Accommodation
• Restructuring the home
• Changes in school
• Assistance in the community

 Parent Education About ADHD
 Psychopharmacology
• Stimulants (e.g., Ritalin, Adderall, etc.)
• Noradrenergic Medications (e.g., Strattera)
• Tricyclic Anti-depressants (e.g., desipramine)
• Anti-hypertensives (e.g., Catapres, Tenex)
 Parent Training in Child Management
• Children (<11 yrs., 65-75% respond)
• Adolescents (25-30% show reliable change)

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 Teacher Education About ADHD
 Teacher Training in Classroom Behavior
Management
 Special Education Services (IDEA, 504)
 Residential Treatment (5-8%)
 Parent/Family Services (25+%)
 Parent/Client Support Groups (CHADD,
ADDA, Independents)

 Biofeedback (EMG or EEG)
 Working Memory Training
 Mindfulness Meditation Training
 Omega 3/6 Food Supplements (fish oils)

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Elimination Diets – removal of sugar, additives, etc. (Weak evidence)
Megavitamins, Anti-oxidants, Minerals
– (No compelling proof or disproved)
Sensory Integration Training (disproved)
Chiropractic Skull Manipulation (no proof)
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Play Therapy, Psycho-therapy (disproved)
Self-Control (Cognitive) Therapies (in clinic)
 Social Skills Therapies (in clinic)
• Better for Inattentive (SCT) Type and Anxious
Cases

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The Scientific Parent
• Read widely
• Experiment with management methods
• Be a skeptic
The Executive Parent
• Take charge; become an advocate
The Principle-Centered Parent
• Be proactive; Begin with the end in mind; Put first things first; Seek to understand, then to be understood; Think win/win; Synergize; Find sources of renewal

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Get into treatment as soon as possible (meds., counseling, organizing advice, treatment for co-existing disorders, etc. )
Let the non-ADHD parent handle homework and schoolrelated issues, if necessary
Alternate nights with partner as to who supervises for the
ADHD child
Let the non-ADHD parent handle time sensitive household responsibilities while the ADHD parent gets the non-time sensitive ones
Put yourself in time-out when emotions escalate toward family members
Always review major child discipline decisions with the non-
ADHD parent
The non-ADHD parent drives to children to their activities if the ADHD parent is not on medication

 ADHD is a relatively common disorder, affecting 1 in every 14-20 children
 ADHD involves deficits in self-regulation and executive functioning
 It is a highly neurological – genetic disorder, not a myth or a socially causes condition
 It is associated with numerous impairments over development if left untreated
 It is the most treatable disorder in psychiatry