ADHD as a Disorder of Self-Regulation

ADHD as a Disorder of Self-Regulation

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article - October 15, 1999
Copyright 1999 Dr. Sam Goldstein - All Rights Reserved

Presented at the 11th Annual Conference for CH.A.D.D.
October 7-9, 1999

CURRENT FACTS

A recent review of ADHD (Barkley, 1994) has increasingly focused on ADHD as a disorder of response inhibition and executive function leading to deficits in self-regulation, impairment in the ability to organize behavior towards present and future goals and difficulty adapting socially and behaviorally to the environment. If in fact this theory is accurate then as Goldstein and Ingersoll (1993) have hypothesized for treatments of ADHD to be effective they must take place in the natural setting, prompt the type of performance to be desired and consequence the occurred behavior as quickly and as frequently as possible. Treatments have to be extended over time since the disorder is managed not cured. Treatments that are administered in time and space removed from the point of performance (e.g., psychotherapy, social skills training, cognitive therapy, etc., are less likely to be effective than those treatments such as behavior management or medication which are in effect at the point of performance.

At this time, the best predictors of successful adult outcome for ADHD children and adolescents appears to be seeded primarily with family variables, including family socio-economic status and parental psychopathology. Variables including child's intelligence (predicts educational attainment) and child's conduct problems (predicts increased probability of adult personality disorder) have also been observed.

Empirically proven treatments for ADHD in childhood include education for parents about ADHD, parent training in regards to behavior management, problem solving communication skill training with adolescents, pharmacological therapies, teacher education and training and parent support groups.

ADHD primarily inattentive type, demonstrate greater problems with social withdrawal, sluggish cognitive processing speed, greater self-conscious reports and greater learning disabilities than ADHD primarily hyperactive, impulsive or combined types. The latter group has a history of greater comorbid conduct problems and are reported as less socially popular. Fewer neuropsychological test differences have been reported between these subtypes, however (Goodyear and Hynd, 1992).

Recent longitudinal research has suggested that it may be conduct disorder or the comorbidity of conduct disorder with ADHD that predicts increased accidents and childhood injury rather than the ADHD alone (Davidson, et. al., 1992).

A recent line of research has suggested that ADHD children experience trouble with executive function while learning impaired children experience difficult with phonological processes (Pennington, et. al., 1993).
Adopted boys have been found to demonstrate significantly greater rates of disruptive disorders, including ADHD than their non-adoptive peers. As children grow older, all other risk factors appear to decrease for both sexes (Lipman, et. al., 1993).

In regards to adult outcome, children with ADHD appear seven times more likely to develop anti-social personality and substance abuse. They enter the work force at lower occupations than others with 90% reporting employment (Mannuzza, et. al., 1993).

The majority of cocaine exposed children in utero identified at birth or later on, appear to have histories of ADHD. They have been reported as responding well to stimulants (Sumner, et. al., 1993).

Children of alcoholics have been found to demonstrate higher rates of psychopathology than other children. Their disorders primarily include oppositional and conduct disorder, not necessarily depression or ADHD. Only a weak link between alcoholism and ADHD has been found (Reich, et. al., 1993).

Recent research (Semrud-Clikeman, et. al., 1994) has yielded additional data reflecting the physiological and likely physical differences in the brains of children with ADHD. These authors found a smaller splenial area of the corpus callosum. They hypothesize that this smaller area may relate to commonly seen sustained attention deficits in children with ADHD. Further brain metabolism research (Ernst, et. al., 1994), this time in females, has tentatively found further evidence of brain metabolism differences in females and males.

Recent research suggests that when an elder sibling experiences disruptive temperamental problems, there are fewer positive interactions with younger siblings. However, when the younger sibling experiences the more difficult temperamental pattern, by far negative interactions with older siblings dominate (Brody, et. al., 1994). These researchers also found a top down model of family functioning. That is, the better parents get along with each other, the better relationship they have with their children. The better relationship they have with their children, the better relationship siblings have with each other.

Tricyclic anti-depressants are being increasingly demonstrated as beneficial for adults with ADHD. Further, there as of yet has not been found to be an association between response and rate or type of comorbidity or concurrent pharmacotherapy (T. Wilens, et. al., 1993, Annual Meeting of the American Academy of Child and Adolescent Psychiatry).

A very recent study in regards to social problems of ADHD children has confirmed what researchers have thought for quite some time. Physical attractiveness, motor competence, intelligence and academic achievement for six to twelve year old boys meeting for the first time do not appear to be predictive of their ability to develop social relations. Aggression and non-compliance, however, among the ADHD boys strongly predicted negative peer nominations. Pro-social behavior independently predicted friendship ratings during the first week but the magnitude was small. Thus, the data is clear. The greatest problems socially for ADHD children appear to result from behavioral excesses in regards to non-compliance and aggression, behaviors which are quickly visible and prove quite annoying to other children. This may explain why the children with ADHD, primarily inattentive type, do not experience as extensive problems with social relations (Erhardt and Hinshaw, 1994).

Williams, Lerner and Swanson (1994), using a published drug and diagnosis medical audit, report that the diagnosis of ADHD among physicians increased from a million cases in 1990 to approximately two million cases in 1993. There appeared to be a reduction in the male to female ratio from nearly eight-to-one to four-to-one. Concerns that minorities might be over-diagnosed, however, continue to reflect and under-referral in diagnosis for minorities, especially Afro-Americans.

A very recent comparative study of diagnostic criteria utilizing DSM-IV, DSM III-R and DSM-III in a large epidemiologic sample found the prevalence for attention disorders increased from 9.6% using DSM III criteria to nearly 18% using DSM IV criteria, primarily because of new cases identified as attention - deficit inattentive type and to a lesser degree, hyperactive impulsive type. Inattention is associated with academic problems Perceived behavior problems, interestingly, were associated with more than 80% of the cases that included the hyperactive, impulsive component (Baumgaertel, Wolraich and Dietrich, 1995).

A continued series of research studies by Schachar and colleagues (1995) evaluating the relationship between ADHD and conduct disorder recently found that those with ADHD were significantly impaired on cognitive measures involving inhibitory control and response alteration and had greater delay in reading development. The conduct disorder group had been exposed to significantly greater environmental adversity and had more severe problems in arithmetic. The group demonstrating ADHD and conduct disorder appeared to experience both sets of problems. The ADHD plus CD group appears to be a hybrid of pure ADHD and pure conduct disorder.

The antidepressant Bupropion was recently evaluated in a double blind crossover study with seven to seventeen year olds and compared with methylphenidate, both drugs produced significant improvements on parent and teacher rating scales, as well as a structured assessment battery (Barrickman, et. al., 1995).

In a recent study of a large sample of children and adolescents with major depression, Biederman (1995) and colleagues found that among this group referred to a psychiatric clinic for serious problems, the comorbidity of ADHD and major depression appeared to be 74% in those with severe depression and 77% in those with mild depression. This represented the highest comorbidity with oppositional defiant disorder following second, and problems with specific anxiety disorders third. It must be noted, however, that when the anxiety disorders were combined, the major depressed group experienced anxiety disorders at the highest comorbid rate.

A recent interesting study evaluated adults with closed head injury, history of ADHD and controls. Both the head injured and ADD group demonstrated difficulty with tasks involving sustained attention (CPT). However, the performance of the head injured group was characterized by general slowness in response time. The ADD group was characterized by impulsivity and difficulty regulating attention and response (Arcia and Gualtieri, 1994)

The ongoing debate concerning the benefits of frontal lobe neuropsychological assessment tools to evaluate ADHD continues. On these measures, performance of those with ADHD may be weaker reflecting positive predictive power but negative predictive power is very poor. That is, abnormal scores on measures of frontal lobe may be indicative of ADD but not of which subtype while normal scores are not indicative of the absence of ADHD and should go uninterpreted (Barkley and Grodzinsky, 1994).

Clinicians typically when evaluating children with developmental delays make adjustments in mental age scores as they evaluate various measures, including those related to attention (e.g., questionnaires, observation or tests). A recent study involving five to sixteen year olds, however, provided very weak support for guidelines suggesting that mental age should be considered in assessing behavioral ratings when a judgment is made about severity of ADHD symptoms in children (Pearson and Aman, 1994).

Giedd, et. al. (1994) report further data supporting the structural and biochemical differences in the brains of individuals with ADHD. In a study of boys with and without ADHD two anterior regions of the corpus callosum, the rostrum and rostral body were found to have significantly smaller areas in the ADHD group. These differences correlated in the expected direction with teacher and parent ratings of hyperactivity/impulsivity.

Martin, et. al. (1994) demonstrated that aggression, inattention, hyperactivity and impulsivity in male pre-adolescents co-varied strongly with substance abuse. These authors suggested that these four factors may be an indicator of a single super ordinate factor reflecting risk for substance abuse.

Although clinicians at times question the accuracy of maternal reports of their children's behavior, Faraone and colleagues (1995) found that for most measures mothers' reports are consistent over time and unbiased. Mothers appear more accurate at identifying externalizing than internalizing symptoms.

Adding to the literature concerning the quest for genetic markers and possible related etiological explanations for ADHD is recent work by Warren and colleagues (1995). These authors found that a blood protein important in defending against infection (C4B) was low in a group of children with ADHD and their mothers. This is preliminary, unreplicated research. It suggests that this deficiency may occur in a sub-group of ADHD subjects and may in part be a genetic marker for ADHD. It is unclear whether this deficiency is a cause contributing to ADHD or a consequence along with ADHD of some additional problem. The implication, however, is that some type of resistance to virus may contribute to ADHD behavior.

In preschoolers with hyperactivity, those who experience aggression were found to have families with more restrictive fathers, siblings who retaliated aggressively and mothers who reported more physical aggression directed to their partners and more verbal aggression received (Stormont-Spurgin, et. al., 1995).

Pervasive hyperactivity again has been found to have greater comorbidity with other psychiatric disorders than situational hyperactivity. Once again the strongest links are with conduct disorder with middle and older children (MacArdle, et. al., 1995).

Based upon the field studies for DSM-IV, comparison of subjects having an age of onset after seven years with those before seven years for ADHD found no significant differences in the nature of their comorbid disorders or in the degree of impairment as assessed by various means. The arbitrary criteria of age of onset before age seven was found to reduce the accuracy of identification of currently impaired cases of ADHD. Clinicians should be careful to not overly rely on the age of onset criterion when faced with children meeting symptom criteria for ADHD (Applegate, et. al., 1997).

In a four year follow-up bipolar disorder was diagnosed in 11% of children at baseline and in an additional 12% at four year follow-up for a total of 23% comorbidity over a four year period. The authors conclude that children with ADHD are at increased risk of developing bipolar disorder and that this group of children exhibit a syndrome of severe disabling psychopathology, mood disregulation and often hospitalization (Biederman, et. al., 1996).

Children with combined ADHD were found to significantly more likely receive diagnoses of Oppositional Defiant Disorder or Conduct Disorder than control or the ADHD inattentive type groups. This study also found that the inattentive type of ADHD may not necessarily increase the risk for depression and anxiety (Eiraldi, et. al., 1997).

Children with ADHD were not found to differ from normal controls in their ability to identify hazards. They tended, however, to anticipate less severe consequences following risky behavior and reported fewer active methods of preventing injury than did controls (Farmer and Peterson, 1995).

A meta-analysis of eighteen studies meeting inclusion criteria comparing males and females with ADHD yielded insignificant findings for impulsivity, academic performance, social functioning, fine motor skills, parental education or parent depression. However, compared to males, females with ADHD displayed greater intellectual impairment, lower levels of hyperactivity and lower rates of other externalizing behaviors. Some of the effects may have been mediated by referral source. Children with ADHD identified from non-referred populations contained females who had lower levels of inattention, internalizing behavior and peer aggression than males with ADHD while males and females with ADHD identified in clinic referred samples displayed similar levels of impairment (Gaub and Carlson, 1997).

Hyperactive-impulsive symptoms were found to decline with increasing age but inattentive symptoms did not. Subjects who still met criteria for ADHD in years three and four were significantly younger, more hyperactive-impulsive and more likely to exhibit conduct disorder in year one than subjects who no longer met criteria in years three and four (Hart, et. al., 1995).

These authors concluded that thyroid hormones may provide a physiological basis for the dichotomy between symptoms of inattention and hyperactivity in a group of individuals with resistance to thyroid hormone. This problem was significantly and positively correlated with total symptoms of ADHD as well as symptoms of inattention and hyperactivity (Hauser, et. al., 1997).

Lifetime rates of ADHD and anxiety disorder were compared for relatives in three proband groups. Female relatives of ADHD probands have significantly higher rates in anxiety disorder than female relatives of non-ill controls. However, relatives of anxious probands and non-ill controls did not differ in ADHD. ADHD and anxiety were hypothesized to share common risk factors but appear to be independently transmitted in families (Last and Perrin, 1996).

In situations of ambiguity, it is likely that children with ADHD will trade accuracy for speed. The extent that tasks and settings are well organized, cues are provided and supervision is offered, they are less likely to experience problems. It appears that once a child with ADHD is prepared to respond, long delays in responding contribute to faulty performance (Leung and Connolly, 1997).

In this study, ADHD appeared to be best viewed as the extreme of behavior varying genetically throughout the entire population rather than as a disorder with discreet determinants. The authors also concluded that there was no evidence non-additive genetic variation of her shared family environmental effects for ADHD (Levy, et. al., 1997).

Studies involving a number of laboratory measures, eye movements, neuroimaging and response to methylphenidate provide converging support for a disinhibition problem as a core deficit in ADHD (Quay, 1997).

Children with ADHD were significantly impaired on cognitive measures involving inhibitory control and response alteration and had greater delay in reading development. Those with conduct disorder had been exposed to significantly greater environmental adversity and had more severe problems in arithmetic than did the ADHD group. The group demonstrating comorbid ADHD and conduct disorder appeared to experience both sets of problems. The combined group appears to present as a hybrid of the two disorders (Schachar and Tannock, 1995).

The authors suggest that the new DSM-IV criteria are likely to increase the prevalence of ADHD in comparison with DSM III-R criteria due to the creation of two new subtypes. The inattentive subtype is characterized predominantly by academic problems with few behavioral problems. It occurs more frequently in females than other subtypes. The hyperactive-impulsive type appears to be characterized by behavior problems with few cases of academic, anxiety or depressive symptoms. The combined type appears to combine both sets of characteristics and is consistent with the original DSM III diagnosis of attention deficit disorder with hyperactivity (Wolraich, et. al., 1996).

It is critical when evaluating the incidence of ADHD to make a distinction between meeting symptom criteria and meeting symptom criteria with impairment. Wolraich, et. al. (1998) reported an overall prevalence of 16% for all types of ADHD in a school wide population of over 4,000 children. However, this incidence rate dropped to 6.8% when impairment was taken into account. 3.2% had the inattentive type, 0.6% the hyperactive-impulsive type, and 2.9% the combined type. Of interest is the fact that only a third had been identified as having ADHD and of those found to meet symptom criteria for ADHD in total, only a fourth had received stimulant medication.

Anecdotally children with ADHD have been described as experiencing myriad problems related to sleep. Corkum, et. al. (1998) reviewed the empirical research published since 1970 on sleep disturbances in ADHD. Although subjective accounts of sleep disturbance in ADHD were prevalent in the studies reviewed, objective verification of these disturbances was less robust. The only consistent objective findings were that children with ADHD displayed more movements during sleep but did not differ from normal controls and total sleep time. Stimulant medication was also reported to lead to changes in children’s sleep, including prolonged sleep latency and increased length of onset of the first rapid eye movement cycle. These changes, however, were reported to be nonpathalogical. The exact nature of sleep problems in children with ADHD remains to be determined. Studies reviewed contained poorly defined diagnostic groups, small sample size, as well as methodological and procedural limitations making it difficult to determine the relationship between ADHD and sleep problems in childhood.

These three studies represent the efforts of multiple researchers utilizing up to date technology in the quest to better understand and define anatomical differences in children with ADHD. Castellanos, et. al. (1996) report nearly a 5% smaller total cerebral volume in a population of males five to eighteen years of age with ADHD in comparison to normal controls. Aylward, et. al. (1996) report that males with ADHD had significantly smaller left globus pallidus volume and total globus pallidus volume than normal controls. This finding was particularly robust on the left side and was suggested to be associated with ADHD. Finally, Filipek, et. al. (1997) note that despite smaller hemispheric volumes overall, males with ADHD demonstrated localized hemispheric structural anomalies, including smaller volumes of the left caudate, right frontal and bilateral anterior-inferior region of the white matter. The authors suggest that these findings are concordant with theoretical models of abnormal frontal-striatal and parietal function and with possible differing morphologic subtraits of response to stimulant medication. For a thorough review of neuroimaging in ADHD, interested readers are referred to Castellanos, F. (1997), Child and Adolescent Psychiatric Clinics of North America, 6, 383-411.

When compared with studies of children in the general population, children with ADHD appear to possess deficits in their ability to accurately recognize facial expressions of emotions. Whether this is a function of lack of sufficient time to process what they are seeing or actually represents a neurological deficit is unclear. Children with ADHD have the greatest difficulty identifying fear and anger. These findings may have important implications for the remediation of social skill deficits commonly seen in children with ADHD (Singh, et al., 1998).

Children with ADHD learn poorly under conditions of inconsistent or partial reinforcement in contrast to normals. Behavior modification programs that utilize partial reinforcement may develop resistance in normal children but likely will not work well in children with ADHD. In these cases, they become easily frustrated and at least in one study failed to develop persistence (Wigal, et al., 1998).

In a group of children with primary complaints of inattention in the classroom, kindergarten retention was not found to be beneficial in improving general school functioning by second grade (Mantzicopoulous, 1997).
Nearly one fourth of very low birth weight children met clinical criteria for ADHD (Botting, et al., 1997).

PREDICTING OUTCOME: RESILIENCE

Most outcome research dealing with resilience in children has focused on children growing up under chronic poverty or suffering from care giver deficits such as child abuse. Fewer studies have been completed following children exposed to biological problems, including those with birth complications, life threatening illness, physical handicap, ADHD, learning disability or depression. There are, however, a number of long term studies that have evaluated a wide range of these risk factors in terms of predicting which children turn out as functional adults despite facing adversity (Werner and Smith, 1992). These studies find a number of consistent trends. First, the impact of reproductive (birth related) problems diminish with time, and second, the developmental outcome of almost every biological risk condition is dependent on family variables. That is, it was not so much what was going on within the child but rather what was going on within the family that determined the fate of each child. This was especially true for the more mild, biological risks (e.g., ADHD, LD, etc.). Overall, rearing conditions were powerful determinants in the outcome of children studied. Resilient children have been found to:

Dr. Werner and her colleagues discovered that two out of three vulnerable children (those born into poverty, experienced moderate to severe degree of perinatal stress, lived in a family environment troubled by chronic discord, parental alcoholism or mental illness), who encountered four or more of such risk factors by age two, developed serious learning and/or behavior problems by age ten and mental health problems, delinquency or teenage pregnancy by eighteen years of age. However, one out of three of these high risk children developed into functional, young adults. For these children it appeared that their internal locus of control, good nature, ease of parenting, capacity to integrate successfully into school and the ability to develop a good self-concept predicted their outcome.

PRACTICAL DEFINITION OF ATTENTION DISORDER

The current DSM-IV characterization of ADHD provides three types: Inattentive, Hyperactive-Impulsive, and Combined. There is a fourth, Not Otherwise Specified type in which a number of symptoms present with impairment but there are an insufficient number of symptoms for one of the first three diagnoses. Children must meet six of nine criteria to qualify for each type. Inattentive symptoms include failure to give close attention to details, difficulty sustaining attention, problems listening when being spoken to, difficulty following through with instructions, poor organization, avoiding sustained effort, being easily distracted or forgetful. Hyperactive and impulsive symptoms include fidgeting, restlessness, excessive movement, talking excessively, acting without thinking and having difficulty delaying. Symptoms must be present prior to age seven, although DSM-IV field studies suggest age twelve is likely a better cut-off. Symptoms must occur in at least two settings and cause impairment in social, academic or occupational functioning.

Goldstein and Goldstein (1998) proposed a practical five-part definition to facilitate professional’s and parent’s ability to understand this group of children and provide effective management and intervention. This practical definition contains five components with the first, impulsivity, considered to be the major contributing force in shaping the other four components. The five components briefly appear below:

1. Impulsivity. ADHD children have difficulty thinking before they act. They know what to do but don't do what they know. They have difficulty weighing the consequences of their actions before acting and do not reasonably consider the consequences of their past behavior. Their difficulty following rule governed behavior (Barkley, 1981a) appears to result directly from their inability to separate experience from response, thought from emotion, and action from reaction. Although they may be well aware of a rule and able to explain it to you, in their environment they are unable to control their actions and to think before they act. This results in impetuous, unthinking behavior and children who seemingly do not appear to learn from their experiences. In actuality, they have learned from their experiences but have difficulty acting efficiently upon that knowledge. Frequently they are repeat offenders. They appear to require more parental and teacher supervision. They frustrate parents and teachers due to their seeming inability to benefit from experience. As one parent explained years ago, twenty-nine times he asked his child not to get into his tools. The child did so a thirtieth time. The child was able to explain what had been requested but the child's immediate need for gratification was overwhelmed by his limited capacity for self-control. Frequently, parent and teacher perspective of this problem is to label the behavior as purposeful, non-caring and oppositional, which in reality does not accurately describe what is taking place and often leads to punitive, ineffective interventions.
2. Inattention. ADHD children have difficulty remaining on task and focusing attention in comparison to non-ADHD children of similar chronological age (APA, 1994). It has been suggested that as children get older they become more efficient in their ability to sustain attention with two year olds capable of sustaining attention on the average for barely a few minutes and five year olds able to sustain attention for much longer periods (Caul, 1985). From that point on, children's attention span continues to increase with age. By first grade we expect children to be able to sit and work for half hour at a time. It is increasingly recognized, however, that the capacity to attend is intrinsically tied to multiple environmental factors. Thus, the measurement of attention as a unitary phenomenon has not provided very much benefit in the conceptualization and understanding of, as well as the assessment and intervention for ADHD. At one time it was also suspected that distractibility was the core problem (Strauss and Kephart, 1955). We are now aware that distractibility represents a minimal part of the ADHD child's problem. It is the inability to invest in the task rather than distractions that is primarily responsible for off task behavior. From an attention perspective, it has been increasingly recognized that repetitive, effortful, uninteresting and unchosen tasks are the most difficult ones for children with ADHD. Not surprisingly, these characteristics define the most difficult tasks for everyone to engage in. This reinforces an important point. ADHD represents an exaggeration, on a dimensional basis, of normal problems. Unfortunately, children with ADHD demonstrate too much or not enough of what adults have described, such as too much fidgeting around at the dinner table or an inadequate investment in tasks that must be completed. On a dimensional basis these children represent the extreme of what adults expect. Increasingly, it is recognized that this child's impulsiveness results in her inability to sustain attention under these circumstances.
3. Overarousal. Children with ADHD tend to be excessively restless, overactive and easily aroused emotionally. Their difficulty in controlling bodily movements is especially noted in situations in which they are required to sit still or stay put for long periods of time. They are quicker to become aroused. Whether happy or sad, the speed and intensity with which they move to the extreme of their emotions is much greater than that of their same age peers. This problem very clearly reflects their impulsive inability to separate thought from emotion. This pattern of behavior frequently frustrates parents because fifteen minutes after becoming extremely upset, the child has forgotten the upsetting event and moves on to something else. Parents, however, continue to be agitated by these events and cannot understand why the child no longer seems to be bothered. This child is then accused of lacking guilt. As one parent has aptly put it, children with ADHD wear their emotions on their coat sleeves.
4. Difficulty with gratification. As the result of impulsivity, children with ADHD require immediate, frequent, predictable and meaningful rewards. Once again they are at excess or exaggeration in comparison to normal children in regards to these variables. They experience greater difficulty working towards a long term goal for these reasons. They frequently require brief, repeated payoffs rather than a single long-term reward. They also do no appear to respond to rewards in a manner similar to other children (Haenlein and Caul, 1987). Rewards do not appear to be effective in changing their behavior on a long-term basis. Frequently once the reward and the accompanying structure of the behavior-change program is removed, the ADHD child regresses and again exhibits behavior that was the target of change. Parents then perceive this child as manipulative, accusing him of blackmail or extortion. Increasingly it has been recognized that due to impulsiveness, children with ADHD appear to require more trials to consistently demonstrate mastery over behaviors which they possess. Thus, as noted, it is not that they don't learn what to do as quickly as others, it is that they do not exhibit those behaviors as effectively. Problems result from missing the cue necessary to self-direct the behavior. Thus, they arrive at a street corner, forget to remember that the corner is a cue to look both ways and despite the fact that they understand traffic safety, blindly walk out in to the street. Because of their impulsiveness, their behavior remains consequentially bound. However, it also appears that given a sufficient number of trials and opportunity for generalization, their behavior, that is the capacity to do what one knows consistently, is shaped in a very similar way as unaffected children. For children with ADHD in regards to consequences and behavior development, the issue is not so much behavior modification but rather behavior management. The provision of a sufficient number of supervised, structured and reinforced trials for everything from simple toothbrushing behavior to social skills development is essential.

   It also appears that this group of children receive significantly more negative reinforcement than others. That is, instead of learning to work to earn good consequences or having their mistakes shaped by punishment, the majority of their interactions with adults are shaped by the child's efforts to avoid aversive consequences. Because of their impulsivity and inconsistency, adults frequently place their hot breath on the child's neck. The child responds not to complete the task but to earn relief from the adult's aversive attention. Negative reinforcement appears to offer a plausible explanation for the diverse problems children with ADHD present, ranging from completing homework and not turning it in (homework is completed so mom will stop screaming not necessarily to earn a grade) to the lack of development of seemingly responsible behavior (e.g., if you are always acting to avoid an aversive consequence you learn to wait for the threat of an aversive consequence before doing what has to be done, whether it is chores, school work or appropriate behavior towards others). In many ways, children with ADHD are cursed with negative reinforcement. In our efforts to help them, we actually increase their helplessness. It is important to keep in mind that they like rewards and they do not like punishments. However, over time it is the avoidance of aversive consequences rather than the earning of positive consequences to which their behavior is shaped. They learn to respond to demands placed upon them by the environment, principally adults in the environment, when an aversive stimulus is removed contingent upon performance rather than for the promise of a future reward.

5. Emotions and locus of control. To the original four components of this definition, this fifth component is being added. Due to their impulsiveness and emotional overarousal, children with ADHD are often on a roller coaster ride of emotions throughout their childhood. When they are happy, they are so happy, people tell them to calm down. When they are unhappy, they are so unhappy, people tell them to calm down. They frequently learn that emotions are not to be valued. Emotions, they come to learn, often leads to trouble. The combination of these qualities, feedback when received for emotionality, lack of ability to develop the skills necessary to control emotions and the disruption in relationships these qualities cause exerts a significant impact on children's emerging sense of self, locus of control and likely subsequent personality. It has been argued children with ADHD appear more prone to develop an external locus of control, projecting blame onto others and being unwilling to recognize and accept the role they play in their behavior. They appear more vulnerable to developing certain personality problems, especially those related to anti-social difficulties likely in part because of these qualities combining with certain life experiences. They may also be more prone to depression due to the lack of balance between successful and unsuccessful experiences on a day in and day out basis. It is important for practitioners to recognize this emotional impact, not just because it holds importance for today but because it is increasingly recognized that the quality of children's emotional lives very powerfully shapes their adult outcome.

TREATMENT OVERVIEW

Although research findings have not always been powerful, there has been a consistent trend that multiple interventions applied across a variety of settings appears to be the most viable way of managing ADHD problems in childhood and in fact adulthood for that matter. Effective management presupposes understanding. Therefore, a thorough understanding of the disorder and the types of interventions that have been proven or unproven is essential. It is also critical that parents are active participants from the very beginning of the assessment through the diagnostic and treatment planning process. The section after this offers a set of guidelines to help parents understand ADHD and the interventions recommended.

Treatment programs for children and adolescents with ADHD provide strategies to more effectively manage behavior by adjusting the environment, expectations and modifying consequences. Cognitive strategies are used on a limited basis since they have not demonstrated great utility with ADHD children specifically. These types of non-medical interventions are applied across a variety of settings principally within the family and at school. Medications are used as well due to their proven efficacy for reducing the severity of ADHD symptoms.

Unproven or controversial treatments are avoided since they strain family finances, energy and resources but rarely lead to much improvements. On page 86 we review the most common controversial treatments for ADHD.

GUIDELINES FOR SUCCESSFULLY
PARENTING ADHD CHILDREN

To effectively parent a child with ADHD you must be an effective manager. Your interactions with your ADHD child must be consistent, predictable and most importantly, understanding of the chronic difficulties this child likely will experience. The following guidelines are essential:

Education. You must become an educated consumer. You must thoroughly understand this disorder, including developmental, scholastic, behavioral and emotional issues.

Incompetence vs. Non-compliance. You must develop an understanding of incompetence (non-purposeful problems that result from the child's inconsistent application of skills leading to performance and behavioral deficits) and non-compliance (purposeful problems which occur when children do not wish to do as they are asked or directed). ADHD is principally a disorder of incompetence. However, since at least 50% of children with ADHD also experience other disruptive, non-compliant problems. Parents must develop a system to differentiate between these two issues and have a set of interventions for both.

Positive Directions (telling children what to do rather than what not to do or giving them a start rather than a stop direction). The provides the most effective type of commands for the ADHD population.

Rewards. Remember that children with ADHD need more frequent, predictable and consistent rewards. Both social rewards (praise) and tangible rewards (toys, treats, privileges) must be provided at a higher rate when the ADHD child is compliant or succeeds. Remember, it is likely that the ADHD child receives less positive reinforcement than siblings. Make an effort to keep the scales balanced.

Timing. Consequences (both rewards and punishment) must be provided quickly and consistently.

Response Cost. A modified response cost program (you can lose what you earn) must be utilized with this child at home. This system can provide the child with all the reinforcers starting the day and the child must work to keep them or can start the child with a blank slate, allowing the child to earn at least three to five times the amount of rewards for good behavior versus what is lost for negative behavior (earn five chips for doing something right, lose one chip for doing something wrong).

Planning. Understanding the forces that affect your ADHD child, as well as the child's limits should be used in a proactive way. Avoid placing the child in situations in which there is an increased likelihood the child's temperamental problems will result in difficulty.

Take Care of Yourself. Families with one or more children experiencing ADHD are likely to experience a greater stress, more marital disharmony, potentially more severe emotional problems in parents and often rise and fall based upon this child's behavior. It is important to understand the impact this child may have upon a family and deal with these problems in a positive, preventative way rather than a frustrated, angry and negative way after you have reached your tolerance.

Take Care of Your Child. Remember that your relationship with this child is likely to be strained. It is important to take extra time to balance the scales and maintain a positive relationship. Find an enjoyable activity and engage in this activity with your child as often as possible, at least a number of times per week.

Copyright ©1994, Neurology, Learning and Behavior Center, 230 South 500 East, Suite 100, Salt Lake City, Utah 84102, (801) 532-1484.

AN OUTLINE FOR PSYCHOTHERAPY WITH ADHD CHILDREN

Not all ADHD children require extended psychotherapy, however, all ADHD children must develop an understanding of their behavior and the problems they are experiencing. The psychotherapy model we use can be best described as teaching ADHD children to think about their actions and thereby control their behavior. This is a model that has been well defined and described by a number of practitioners. Perhaps the best description is in the chapter by Virginia Douglas entitled, Treatment and Training Approaches to Hyperactivity: Establishing Internal or External Control. This chapter appears in a text by C. Whalen and B. Henker entitled, Hyperactive Children: Social Ecology of Identification and Treatment.

The first step in our psychotherapeutic process is to help the child understand the manner in which he copes with his environment. Following our evaluation, we can now see the world through the child's eyes. We now want the child to be more aware of the motivators of his behavior and the reasons for his environmental problems. In therapy we usually begin by providing the child with simple explanations for their attentional deficits, and how these deficits may affect all areas of their functioning. We then work extensively to motivate the child to believe that with help they can gain active control over these problems and make changes in their lives.

The second phase of therapy involves assisting the child in gaining successful experiences and making changes in specific areas of their lives. During this phase, the child is taught to stop, look and listen as well as to define problems and reasonably look at alternatives before making choices. Communication training is also included during this phase of treatment. With oppositional children, this phase also entails providing the child with an opportunity to direct and control therapy sessions in an effort to assist the child in gradually feeling more comfortable in allowing the therapist to take charge.

Gradually, a cooperative effort between the therapist and the child develops. This allows the therapist to provide additional strategies to assist the child in coping with attentional problems and to carefully review the child's successes and failures in the environment. During both phases of psychotherapy, the therapist must work diligently to assist the child in internalizing control over his behavior. This is especially important for children receiving medication. There is a tendency for parents, teachers and children themselves to externalize their behavioral improvements to the medication and therefore take no responsibility for their own behavior. It is most important for children receiving stimulant medication to truly believe that they are in control of their behavior and that the medication acts as a catalyst, allowing them to exert more efficient control.

It is our belief that the information and material we deal with in psychotherapy with ADHD children can be provided within the framework of most psychotherapeutic models. Therefore, regardless of your therapeutic orientation, it is possible to successfully treat ADHD children. It is also important to keep in mind that ADHD children often have other issues, including feelings about themselves and their families which may often be a focus of therapy as well.