ADHD, Executive Functioning, ADHD, Executive Functioning, and School Interventionand School Intervention

Russell A. Barkley, Ph.D.Russell A. Barkley, Ph.D.Clinical Professor of PsychiatryClinical Professor of Psychiatry

Medical University of South CarolinaMedical University of South CarolinaCharleston, SCCharleston, SC

andandResearch Professor, Department of PsychiatryResearch Professor, Department of Psychiatry

SUNY Upstate Medical UniversitySUNY Upstate Medical UniversitySyracuse, NYSyracuse, NY

©©Copyright by Russell A. Barkley, Ph.D., 2010Copyright by Russell A. Barkley, Ph.D., 2010Sources:Sources:

Barkley, R. A. (1997/2001) Barkley, R. A. (1997/2001) ADHD and the Nature of Self-Control. ADHD and the Nature of Self-Control. New York: GuilfordNew York: Guilford Barkley, R. A. (2006) Barkley, R. A. (2006) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment

(3(3rdrd ed.) ed.). New York: Guilford.. New York: Guilford.Barkley, R. A. (2010). Barkley, R. A. (2010). Assessing executive functioning in daily life activities: The Deficits in Executive Assessing executive functioning in daily life activities: The Deficits in Executive

Functioning ScaleFunctioning Scale. New York: Guilford, in press.. New York: Guilford, in press.Email: drbarkley@russellbarkley.orgEmail: drbarkley@russellbarkley.org

Website: russellbarkley.orgWebsite: russellbarkley.org

What is ADHD?What is ADHD?The Current Clinical ViewThe Current Clinical View

A disorder of age-inappropriate behavior in two domains of neuropsychological development:

I. Hyperactivity-Impulsivity (Poor Inhibition)• Impaired verbal and motor inhibition• Impulsive decision making; cannot wait or defer gratification• Greater disregard of future (delayed) consequences• Excessive task-irrelevant movement and verbal behavior

– Fidgeting, squirming, running, climbing, touching• Emotionally impulsive; poor emotional self-regulation• NOTE: Restlessness decreases with age, becoming more

internal or subjective by adulthood

More on ADHDMore on ADHDII. Inattention• But 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– Impaired resistance to responding to distractions– Deficient task re-engagement following

disruptions– Impaired working memory (remembering so as

to do)

Getting Ready for the Future Requires:Getting Ready for the Future Requires:

• That you stop and think -BEFORE you act !• Use your hindsight (looking backward)• To get your foresight (see what’s next)• To anticipate the likely future• So you can prepare for that future• So you can be more effective in managing yourself across

time• And do so by engaging in reciprocal and cooperative social

interactions• That allow you to attend to your long-term welfare• This is “executive functioning”

How Does ADHD Fit Into EF?How Does ADHD Fit Into EF?

EF Comprises 2 Broadband Domains

Inhibition:Motor, Verbal,

Cognitive &Emotional

Meta-Cognition:Nonverbal WM

Verbal WMPlanning/Problem-solvingEmotional self-regulation

Hyperactivity-Impulsivity

Inattention

Where does ADHD fit into

them?

What is EF?What is EF?• An executive function can be defined as a major

type of action-to-the-self (a type of self-regulation)• There are 7 major types of EFs:

– Self-Awareness (meta-cognition)– Inhibition and interference Control– Nonverbal and verbal working memory– Emotional - motivational self-regulation– Planning and problem-solving

• All can be redefined as actions-to-the-self• Each likely develops by behavior being turned on

the self and then internalized (privatized, inhibited)• They likely develop in a step-wise hierarchy - Each

needs the earlier ones to function well

InhibitionInhibition

MotorMotorControlControl

Sensing toSensing tothe Selfthe Self Self-SpeechSelf-Speech Emotion toEmotion to

the Selfthe SelfPlay toPlay tothe Selfthe Self

The EFs Create Four Developmental The EFs Create Four Developmental Transitions in What is Controlling BehaviorTransitions in What is Controlling Behavior

• External Mental (private or internal)

• Others Self

• Temporal now Anticipated future

• Immediate Delayed gratification

Purposes of the Executive SystemPurposes of the Executive System

• The self-regulation and organization of behavior across time to anticipate and prepare for the likely social future and to pursue one’s goals (self-interests) often in concert with others

• The EF system most likely evolved to serve social functions in a group-living species (humans) that engages in reciprocity, trade, cooperation, coalition formation, and social competition

The 5 EFs in Major Life ActivitiesThe 5 EFs in Major Life Activities• Self-Discipline (Inhibition)

– Cognitive, behavioral, verbal, emotional

• Self-Management to Time– Consideration of past and future consequences before acting;

managing self relative to time and deadlines

• Self-Organization & Problem-Solving– Innovating, planning possible response options, problem-solving

to overcome obstacles to goals, rapid assembly and performance of novel goal-directed behavior

• Self-Motivation– Substituting positive goal-supporting emotions for negative goal-

destructive ones

• Self-Activation & Concentration

ADHD Impairs Executive Functioning and Self-Regulation Across Time

Understanding ADHDUnderstanding ADHD• ADHD disrupts the 5 levels EF but especially the

tactical and strategic levels thereby creating a disorder of self-regulation across time

• ADHD can be considered as “Time Blindness” or a “Temporal Neglect Syndrome” (Myopia to the Future)

• 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)

Understanding ADHDUnderstanding ADHD

It’s a Disorder of:• Performance, not skill• Doing what you know, not knowing what to do• 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)

Implications for TreatmentImplications for Treatment

• 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)

More Treatment ImplicationsMore Treatment Implications• 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

How do we compensate for EF deficits?How do we compensate for EF deficits?By Reverse Engineering the EFsBy Reverse Engineering the EFs

• Externalize important information at key points of performance

• Externalize time and time periods related to tasks

• Break up future tasks into many small steps

• Externalize sources of motivation • Externalize mental problem-solving

Externalizing Working MemoryExternalizing Working Memory• Use externally (outside the individual)

represented forms of information to remind the individual what is to be done at the point of performance

• This can be done by using sticky notes, cues, cards, lists, posters, signs, and other prompts of critical reminders at the point of performance

• For older kids and adults, also use personal journals, digital recording devices, Watch-Minder watches, day planners, personal organizers, computer organizers

Externalizing Time and the Future Externalizing Time and the Future

Make time physical, external, and obvious• timers, clocks, counters, and anything else that

can signal time’s passing

Break down future projects and goals into small pieces and do a piece a day (or more frequently).

Bring the Es, Rs, & Os of life close together

Make Motivation ExternalMake Motivation External

• Identify tasks and settings in which consequences are too delayed or nonexistent

• Put artificial consequences into these large gaps in time– Tokens, points, prizes, praise, privileges

• Increase accountability to others – more frequent check-ins with others to see that work is being done, goals are being met

Make Problem-Solving ManualMake Problem-Solving Manual

• When tasks normally require mental problem-solving (manipulating mental information, generating multiple ideas, etc.) make the mental information external, physical, or manual

• For math, use marbles, number lines, an abacas, etc. and calculators

• For words, use cards, paper, computer word processing programs

Generic Issues Associated with Generic Issues Associated with Transition to AdolescenceTransition to Adolescence

• Increased physical size and neurological maturation• Increasing maturation of sexuality• Increasing desire to individuate from parents; decreasing

influence of parents on teen behavior• Increasing time away from home & parents• Increasing number of domains of major life activities to

which the teen must adapt– Sex, driving, peers, money & work, community activities, crime,

drugs

• Greater involvement with and influence of peers• Most of these are adversely affected by delay in self-

regulation associated with ADHD

How do symptoms change by adolescence?How do symptoms change by adolescence?• Hyperactivity declines more steeply than does inattention and

related executive function (EF) deficits• Motor restlessness becomes a more internalized subjective

sense of feeling a need to be busy all the time• Transition to middle school is associated with a transient

increase (reversal of decline) in ADHD symptoms• The inattentive/EF symptoms have a greater impact on

school functioning than HI symptoms; increases with age• Impulsivity is more related to impaired nonacademic domains:

– development of ODD– drug experimentation– speeding while driving– risky sexual behavior, taking on dares from peers– impulsive verbal behavior– reactive aggression

Symptom Transitions Symptom Transitions (continued)(continued)

• But inattention also has adverse impacts on non-academic functioning :– Poor attention to traffic density and speed while in community

auto traffic settings– Greater risk for pedestrian/cycling accidents in traffic settings– Greater crash risk as drivers (in vehicle distractions are most

contributory)– Accelerated use of nicotine after experimentation

• Self-medication ???

– Poor follow through on chores and other home responsibilities– Poorer work performance in school– Poor work performance part-time employment settings– Inattention to others’ comments and needs in social activities

Emerging Impact of EF DeficitsEmerging Impact of EF Deficits• Poor working memory (remembering to do things)

– Less follow through on promises and commitments to others– Increasing adverse impact of reading-listening-viewing comprehension

deficits, especially in school & work settings

• Impaired planning, anticipation, and preparatory behavior; not ready for the future as it arrives– Reduced valuing of future rewards relative to peers– Consequently, don’t persist toward future goals and show poor delay

of gratification

• Deficient sense of time and time management– A restricted temporal window relative to peers

• Poor emotion regulation (related to poor inhibition)– Deficient control of anger & frustration most impairing

• Decreased fluency (rapid assembly of ideas into coherent verbal reports and behavior)

School InterventionSchool Intervention

Basic ConsiderationsBasic Considerations• Don’t retain in grade!• Sept is to establish behavioral control• Decrease total workload, or• Give smaller quotas of work at a time• Target productivity first, accuracy later • Reduce homework

– Overall correlation with achievement is just .15-.25 (just 2-6% of variance in achievement) across all grades and weaker in elementary grades*

– For high school, best amount was 1.5-2.5 hrs/night; more hours had no further benefits*

*Cooper, Robinson, & Patall (2006). Review of Educational Research, 76(1), 1-62.

Tips for TeensTips for Teens• As needed, use ADHD medications – have

parents negotiate a contract with the teen if necessary

• Find a “Coach” or “Mentor” (Just 15 min.)– The Coaches’ office is the student’s “locker”– Schedule in three 5-minute checkups across each day– Use behavior report card to monitor teen across classes– Use daily assignment sheets requiring teacher initials– Cross temporal accountability is the key to success

• Identify a parent-school ADHD liaison– Serves as an intermediary on issues between parents &

school

A Daily Behavior CardA Daily Behavior CardEach teacher rates each behavior at end of each class; 1=Excellent (+25), 2=Good (+15), Each teacher rates each behavior at end of each class; 1=Excellent (+25), 2=Good (+15),

3=Fair (+5), 4=Poor (-15), 5=Terrible (-25)3=Fair (+5), 4=Poor (-15), 5=Terrible (-25)

Subjects 1 2 3 4 5 6 7ClassParticipationPerforms assignedclasswork

Follows class rulesGets along wellwith othersCompletes home-work assignments

Teacher’sInitials

More Tips for TeensMore Tips for Teens

• Use a daily school behavior card for self-evaluation after; move to weekly after 3+ good weeks

• Keep extra set of books at home• Learn typing/keyboard skills for writing

assignments• Require continuous note-taking to pay attention

to lectures or during reading assignments• Tape record important lectures – check out the

Smart Pen that digitally records lectures or other conversations at livescribe.com

More Tips for TeensMore Tips for Teens• “Bucks for Bs” system

– grades on each assignment = $ from parents• Get week-at-a glance calendar with journal or other

organizing notebook system• Schedule hard classes in AM• Alternate required with elective classes• Extra time on timed tests (???) – no evidence it helps

– Better to have distraction free test setting and intersperse breaks in testing to create shorter test periods (time off the clock)

• Permit music during homework*• Get written syllabus as handouts

*Soderlund et al. (2007). Journal of Child Psychology and Psychiatry, 48, 840-847.

Still More Tips for TeensStill More Tips for Teens• Learn SQ4R for reading comprehension

– Survey material, draft questions, then: – Read, recite, write, review

• Peer tutoring in class• “Study-with-a-buddy” after school • Find “fall-back” classmates (swap phone, e-mail, &

fax numbers) for lost or missing assignment sheets• Attend after-school help-sessions• Schedule parent-teacher-teen review meetings

every 6 weeks (not at 9 week grading period)

ConclusionsConclusions• ADHD disrupts behavioral inhibition and the

instrumental EFs producing a cascading of deficits in higher levels of EF

• By disrupting executive functioning, ADHD affects:– Self-stop or inhibit behavior, thoughts, words, emotions– Self-manage to time; anticipate and prepare for the future– Self-organize and problem solve across time– Self-motivate across time– Self-activate and concentrate across time

ConclusionsConclusions• Behavior cannot be hierarchically organized in support of

longer term goals and welfare• Resulting in a serious and pervasive disorder of self-

regulation across time and settings and impaired social functioning (mutualism)

• Preventing them from dealing effectively with the probable future and pursuing one’s long-term goals and welfare

• Thereby requiring the design of prosthetic environments that compensate for EF deficits while using neuro-genetic medicines to temporarily improve or normalize instrumental EFs