What Does It All Mean? ADHD, Executive Functioning, Causes and Management Russell Barkley, Ph.D. Clinical Professor of Psychiatry Medical University of.

What Does It All Mean?What Does It All Mean?ADHD, Executive Functioning, Causes ADHD, Executive Functioning, Causes and Managementand Management

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

Medical University of South CarolinaMedical University of South Carolina

Charleston, SCCharleston, SC

Websites: Websites:

ADHDLectures.comADHDLectures.com

Russellbarkley.orgRussellbarkley.org

What is ADHD?What is ADHD? A disorder of developmentally inappropriate A disorder of developmentally inappropriate

degrees of:degrees of:• InattentionInattention• Hyperactive and impulsive behaviorHyperactive and impulsive behavior

Arises in childhoodArises in childhood Persistent over timePersistent over time Results in impairment in major life activitiesResults in impairment in major life activities

Nature of the Hyperactive – Nature of the Hyperactive – Impulsive SymptomsImpulsive Symptoms

A Neuropsychological Dimension of Poor InhibitionA Neuropsychological Dimension of Poor Inhibition Motor impulsiveness and hyperactivity (task irrelevant Motor impulsiveness and hyperactivity (task irrelevant

movements)movements)• Fidgeting, squirming, running, climbing, touchingFidgeting, squirming, running, climbing, touching

Verbal impulsivenessVerbal impulsiveness Cognitive impulsiveness (decision making; cannot wait or Cognitive impulsiveness (decision making; cannot wait or

defer gratification)defer gratification)• Greater disregard of future (delayed) consequencesGreater disregard of future (delayed) consequences

Impaired resistance to distractions (sustained inhibition)Impaired resistance to distractions (sustained inhibition) Emotionally impulsive; poor emotional self-regulationEmotionally impulsive; poor emotional self-regulation

NOTE: Restlessness decreases with age, becoming more NOTE: Restlessness decreases with age, becoming more internal or subjective by adulthoodinternal or subjective by adulthood

Nature of the Inattention SymptomsNature of the Inattention Symptoms

There are at least 6 types of attention:There are at least 6 types of attention:• Arousal, alertness, selective, divided, span of Arousal, alertness, selective, divided, span of

apprehension, & persistence. apprehension, & persistence.

Not all are impairedNot all are impaired. What is?. What is?• Poor persistence toward goals or tasksPoor persistence toward goals or tasks

– The cross-temporal organization and maintenance of The cross-temporal organization and maintenance of actions toward goals or assignmentsactions toward goals or assignments

• Impaired resistance to responding to Impaired resistance to responding to distractionsdistractions

• Less likely to re-engage tasks following Less likely to re-engage tasks following disruptionsdisruptions– Due to impaired working memory (remembering so Due to impaired working memory (remembering so

as to do)as to do)

PrevalencePrevalence

2-5% of children (using older DSM-III or III-R)2-5% of children (using older DSM-III or III-R) 7-8% of children in US (using DSM-IV) (~3-4 million)*7-8% of children in US (using DSM-IV) (~3-4 million)*

• Adding Inattentive Type doubles prevalence over III-RAdding Inattentive Type doubles prevalence over III-R 5.5% of children worldwide*5.5% of children worldwide* 4-5% of adults in US (~12 million in US)**4-5% of adults in US (~12 million in US)** 3-4% worldwide adult prevalence***3-4% worldwide adult prevalence*** Varies by age, social class, & urban-ruralVaries by age, social class, & urban-rural

• More common in children; less so in adultsMore common in children; less so in adults• Somewhat more common in middle to lower-middle classesSomewhat more common in middle to lower-middle classes• More common in population dense areasMore common in population dense areas• More common in certain occupationsMore common in certain occupations

– For instance, 12-15% of U.S. military dependents For instance, 12-15% of U.S. military dependents – More common among nonprofessional workersMore common among nonprofessional workers

• No evidence for ethnic differences to date that are independent of social No evidence for ethnic differences to date that are independent of social class, urban-rural demographics or variable access to careclass, urban-rural demographics or variable access to care

ADHD Varies by Setting ADHD Varies by Setting

Better Here: Worse Here:Better Here: Worse Here: Fun Fun BoringBoring Immediate Immediate Delayed ConsequencesDelayed Consequences Frequent Frequent Infrequent FeedbackInfrequent Feedback High High Low Salience Low Salience EarlyEarly Late in the DayLate in the Day Supervised Supervised UnsupervisedUnsupervised One-to-one One-to-one Group SituationsGroup Situations Novelty Novelty Familiarity Familiarity Fathers Fathers MothersMothers StrangersStrangers ParentsParents Clinic Exam RoomClinic Exam Room Waiting RoomWaiting Room

Sluggish Cognitive TempoSluggish Cognitive TempoA New Disorder of AttentionA New Disorder of Attention

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

More on SCT More on SCT (2)(2)

Not Impulsive; also less deficient in other executive Not Impulsive; also less deficient in other executive functions (self-regulation abilities)functions (self-regulation abilities)

Rarely Aggressive or have ODD/CD Rarely Aggressive or have ODD/CD Greater risk for anxiety and depressionGreater risk for anxiety and depression Equally high risk for learning disabilities (LD)Equally high risk for learning disabilities (LD)

• But math disorders may be more likely than reading and language But math disorders may be more likely than reading and language disorders with SCT (?)disorders with SCT (?)

Not as impaired in other domains of life outside of school Not as impaired in other domains of life outside of school compared to ADHDcompared to ADHD

Parents report far less stress in parenting SCT than ADHD Parents report far less stress in parenting SCT than ADHD children; most stress is school relatedchildren; most stress is school related

Possibly greater family history of anxiety disorders and LD (?)Possibly greater family history of anxiety disorders and LD (?)

Treatment of SCTTreatment of SCT Less Likely to Have a Clinically Impressive Response to Less Likely to Have a Clinically Impressive Response to

Stimulants?Stimulants?• (65% improve but only 20% show clinical response)(65% improve but only 20% show clinical response)

Other drugs have not been tested – Strattera, Intuniv, Other drugs have not been tested – Strattera, Intuniv, ProVigil, etcProVigil, etc

Better responders than ADHD children to social skills Better responders than ADHD children to social skills trainingtraining

As good or better responders to behavior modification As good or better responders to behavior modification methodsmethods

Probably better responders to cognitive behavioral Probably better responders to cognitive behavioral therapy (self-instruction training)therapy (self-instruction training)

What Are The Academic Risks What Are The Academic Risks Linked to ADHD?Linked to ADHD?

Academic Under-performance (90%+)Academic Under-performance (90%+) Retention in Grade (25-50%)Retention in Grade (25-50%) Require Special Education (35-60%)Require Special Education (35-60%) Failure to Graduate High School (30-Failure to Graduate High School (30-

40%)40%) Less Likely to Attend College (20%)Less Likely to Attend College (20%) Less Likely to Graduate College (5%) Less Likely to Graduate College (5%)

Other Developmental RisksOther Developmental Risks

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

Health ProblemsHealth Problems

Delayed motor coordination (60%+)Delayed motor coordination (60%+) Greater risk for accidents and injuriesGreater risk for accidents and injuries More likely to develop dental problemsMore likely to develop dental problems Small increase in risk for seizuresSmall increase in risk for seizures Bedtime behavior problems (20%+) and Bedtime behavior problems (20%+) and

disordered sleep(20-25%)disordered sleep(20-25%)

What Causes ADHD?What Causes ADHD?

The Neurology of ADHDThe Neurology of ADHDFrom R. Barkley, From R. Barkley, Scientific AmericanScientific American, Sept. 1998, p. 47; Reprinted with , Sept. 1998, p. 47; Reprinted with permission of Terese Winslow and permission of Terese Winslow and Scientific American.Scientific American.

Delayed brain growth in ADHD (3 yrs.)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.

Greater than 2 years’ delay0 to 2 years delayNs: ADHD=223; Controls = 223

Early cortical maturation in ADHD childrenEarly cortical maturation in ADHD childrenFrom 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, asindicated by a younger age of attaining peak cortical thickness.

The Genetics of ADHDThe Genetics of ADHD HeredityHeredity: Risk to: Risk to

• Siblings: 25-35% Twin: 75-92%Siblings: 25-35% Twin: 75-92%• Mother: 15-20% Father: 20-30%Mother: 15-20% Father: 20-30%• Offspring of an adult with ADHD: 27-54%Offspring of an adult with ADHD: 27-54%

Genetic Contribution (80% or more)Genetic Contribution (80% or more)• No contribution of the rearing environmentNo contribution of the rearing environment

Many Risk genes found to date:Many Risk genes found to date:• These genes appear to regulate brain growth and some brain chemicalsThese genes appear to regulate brain growth and some brain chemicals• Each contributes a small risk to the disorderEach contributes a small risk to the disorder• Family members have some of these genes and show some of the traits of Family members have some of these genes and show some of the traits of

ADHD but often not enough to have the full disorderADHD but often not enough to have the full disorder• The more risk genes a child has, the greater the risk for having the full The more risk genes a child has, the greater the risk for having the full

disorderdisorder

What Doesn’t Cause ADHD? What Doesn’t Cause ADHD?

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

What is Executive Functioning? What is Executive Functioning? How is it Related to ADHD? How is it Related to ADHD?

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

That you stop and think -BEFORE you act !That you stop and think -BEFORE you act ! Use your hindsight (looking backward)Use your hindsight (looking backward) To get your foresight (see what’s next)To get your foresight (see what’s next) To anticipate and prepare for the futureTo anticipate and prepare for the future So you can be more effective and attend to So you can be more effective and attend to

your long-term welfare and happinessyour long-term welfare and happiness This is “executive functioning” (EF)This is “executive functioning” (EF) There are 6 “cognitive” or “mental” There are 6 “cognitive” or “mental”

components or parts to EFcomponents or parts to EF

Inhibition

MotorControl

Sensing tothe Self

Self-SpeechEmotion to

the SelfPlay tothe Self

Self-Awareness

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

External External Mental (private or internal)Mental (private or internal)

Others Others SelfSelf

Temporal now Temporal now Anticipated future Anticipated future

Immediate Immediate Delayed gratification Delayed gratification

The 5 EFs in Major Life ActivitiesThe 5 EFs in Major Life Activities

Self-Discipline (making your self STOP)Self-Discipline (making your self STOP)• Cognitive, behavioral, verbal, emotionalCognitive, behavioral, verbal, emotional

Self-Management Across Time (making mental maps)Self-Management Across Time (making mental maps)• Consideration of past and future consequences before acting; Consideration of past and future consequences before acting;

managing your self relative to time and deadlinesmanaging your self relative to time and deadlines

Self-Organization /Problem-Solving (making options)Self-Organization /Problem-Solving (making options)• Innovating, planning possible response options, problem-Innovating, planning possible response options, problem-

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

Self-Motivation (filling the fuel tank)Self-Motivation (filling the fuel tank)• Substituting positive goal-supporting emotions for negative Substituting positive goal-supporting emotions for negative

goal-destructive onesgoal-destructive ones

Self-Regulation of Emotions (moderating your feelings)Self-Regulation of Emotions (moderating your feelings)

ADHD Impairs Self-Regulation Across Time

Understanding ADHD as a Understanding ADHD as a Disorder of Executive FunctioningDisorder of Executive Functioning

ADHD disrupts the ADHD disrupts the 77 mental capacities that mental capacities that make up EF and the 5 EF abilities we use in make up EF and the 5 EF abilities we use in everyday life thereby creating a disorder of self-everyday life thereby creating a disorder of self-regulation across timeregulation across time

ADHD is “Time Blindness” or a “Temporal ADHD is “Time Blindness” or a “Temporal Neglect Syndrome” (Myopia to the Future)Neglect Syndrome” (Myopia to the Future)

It adversely affects the capacity to hierarchically It adversely affects the capacity to hierarchically organize behavior across time to anticipate the organize behavior across time to anticipate the future and to pursue one’s long-term goals and future and to pursue one’s long-term goals and self-interests (welfare and happiness)self-interests (welfare and happiness)

It’s not an Attention Deficit but an It’s not an Attention Deficit but an IntentionIntention Deficit (Inattention to mental events & the future)Deficit (Inattention to mental events & the future)

Understanding ADHDUnderstanding ADHDIt’s a Disorder of:It’s a Disorder of: Performance, not skillPerformance, not skill Doing what you know, not knowing what to doDoing what you know, not knowing what to do The when and where, not the how or whatThe when and where, not the how or what Using your past at the “point of performance”Using your past at the “point of performance”

The point of performance is the place and time The point of performance is the place and time in your natural settings where you should use in your natural settings where you should use what you know (but may not)what you know (but may not)

Implications for TreatmentImplications for Treatment

Teaching skills is inadequate Teaching skills is inadequate The key is to design prosthetic environments around the The key is to design prosthetic environments around the

individual to compensate for their EF deficitsindividual to compensate for their EF deficits Therefore, effective treatments are always those at the Therefore, effective treatments are always those at the

“point-of-performance”“point-of-performance” The EF deficits are neuro-genetic in originThe EF deficits are neuro-genetic in origin Therefore, medications may be essential for most (but not Therefore, medications may be essential for most (but not

all) cases – meds are neuro-genetic therapiesall) cases – meds are neuro-genetic therapies But some evidence suggests some EFs may also be But some evidence suggests some EFs may also be

partly responsive to direct trainingpartly responsive to direct training While ADHD creates a diminished capacity: Does this While ADHD creates a diminished capacity: Does this

excuse accountability? excuse accountability? • (No! The problem is with time and timing, not with consequences)(No! The problem is with time and timing, not with consequences)

More Treatment ImplicationsMore Treatment Implications

Behavioral treatment is essential for restructuring Behavioral treatment is essential for restructuring natural settings to assist the EFsnatural settings to assist the EFs• They provide artificial prosthetic cues to substitute for the working They provide artificial prosthetic cues to substitute for the working

memory deficits (signs, lists, cards, charts, posters)memory deficits (signs, lists, cards, charts, posters)• They provide artificial prosthetic consequences in the large time They provide artificial prosthetic consequences in the large time

gaps between consequences (accountability) (i.e., tokens, points, gaps between consequences (accountability) (i.e., tokens, points, etc.)etc.)

• But their effects do not generalize or endure after removal because But their effects do not generalize or endure after removal because they primarily address the motivational deficits in ADHDthey primarily address the motivational deficits in ADHD

The compassion and willingness of others to make The compassion and willingness of others to make accommodations are vital to successaccommodations are vital to success

A chronic disability perspective is most usefulA chronic disability perspective is most useful

What Are The 4 Stages of What Are The 4 Stages of Treatment?Treatment?

Evaluation Evaluation Education Education MedicationMedication Modification (of Behavior) Modification (of Behavior) AccommodationAccommodation• Restructuring the homeRestructuring the home• Changes in school Changes in school • Assistance in the communityAssistance in the community

Empirically Proven TreatmentsEmpirically Proven Treatments

Parent Education About ADHDParent Education About ADHD PsychopharmacologyPsychopharmacology• Stimulants (e.g., Ritalin, Adderall, etc.)Stimulants (e.g., Ritalin, Adderall, etc.)• Noradrenergic Medications (e.g., Strattera)Noradrenergic Medications (e.g., Strattera)• Tricyclic Anti-depressants (e.g., desipramine)Tricyclic Anti-depressants (e.g., desipramine)• Anti-hypertensives (e.g., Catapres, Tenex)Anti-hypertensives (e.g., Catapres, Tenex)

Parent Training in Child Management Parent Training in Child Management • Children (<11 yrs., 65-75% respond)Children (<11 yrs., 65-75% respond)• Adolescents (25-30% show reliable change)Adolescents (25-30% show reliable change)

Empirically Proven Treatment Empirically Proven Treatment (2)(2)

Teacher Education About ADHDTeacher Education About ADHD Teacher Training in Classroom Behavior Teacher Training in Classroom Behavior

ManagementManagement Special Education Services (IDEA, 504)Special Education Services (IDEA, 504) Residential Treatment (5-8%)Residential Treatment (5-8%) Parent/Family Services (25+%)Parent/Family Services (25+%) Parent/Client Support Groups (CHADD, Parent/Client Support Groups (CHADD,

ADDA, Independents)ADDA, Independents)

Experimental TreatmentsExperimental Treatments Biofeedback (EMG or EEG)Biofeedback (EMG or EEG) Working Memory TrainingWorking Memory Training Mindfulness Meditation TrainingMindfulness Meditation Training Omega 3/6 Food Supplements (fish oils)Omega 3/6 Food Supplements (fish oils)

Unproved/Disproved TherapiesUnproved/Disproved Therapies

Elimination Diets – removal of sugar, additives, Elimination Diets – removal of sugar, additives, etc. (Weak evidence)etc. (Weak evidence)

Megavitamins, Anti-oxidants, MineralsMegavitamins, Anti-oxidants, Minerals– (No compelling proof or disproved)(No compelling proof or disproved)

Sensory Integration Training (disproved)Sensory Integration Training (disproved) Chiropractic Skull Manipulation (no proof)Chiropractic Skull Manipulation (no proof) Play Therapy, Psycho-therapy (disproved)Play Therapy, Psycho-therapy (disproved) Self-Control (Cognitive) Therapies (in clinic)Self-Control (Cognitive) Therapies (in clinic) Social Skills Therapies (in clinic) Social Skills Therapies (in clinic)

• Better for Inattentive (SCT) Type and Anxious CasesBetter for Inattentive (SCT) Type and Anxious Cases

What Roles Can Parents Play? What Roles Can Parents Play?

The Scientific ParentThe Scientific Parent• Read widelyRead widely• Experiment with management methodsExperiment with management methods• Be a skepticBe a skeptic

The Executive ParentThe Executive Parent• Take charge; become an advocateTake charge; become an advocate

The Principle-Centered ParentThe Principle-Centered Parent• Be proactive; Begin with the end in mind; Put first things Be proactive; Begin with the end in mind; Put first things

first; Seek to understand, then to be understood; Think first; Seek to understand, then to be understood; Think win/win; Synergize; Find sources of renewalwin/win; Synergize; Find sources of renewal

If the Parent Also Has ADHDIf the Parent Also Has ADHD Get into treatment as soon as possible (meds., counseling, Get into treatment as soon as possible (meds., counseling,

organizing advice, treatment for co-existing disorders, etc. )organizing advice, treatment for co-existing disorders, etc. ) Let the non-ADHD parent handle homework and school-Let the non-ADHD parent handle homework and school-

related issues, if necessaryrelated issues, if necessary Alternate nights with partner as to who supervises for the Alternate nights with partner as to who supervises for the

ADHD childADHD child Let the non-ADHD parent handle time sensitive household Let the non-ADHD parent handle time sensitive household

responsibilities while the ADHD parent gets the non-time responsibilities while the ADHD parent gets the non-time sensitive onessensitive ones

Put yourself in time-out when emotions escalate toward Put yourself in time-out when emotions escalate toward family membersfamily members

Always review major child discipline decisions with the non-Always review major child discipline decisions with the non-ADHD parentADHD parent

The non-ADHD parent drives to children to their activities if The non-ADHD parent drives to children to their activities if the ADHD parent is not on medicationthe ADHD parent is not on medication

ConclusionConclusion

ADHD is a relatively common disorder, affecting 1 in ADHD is a relatively common disorder, affecting 1 in every 14-20 childrenevery 14-20 children

ADHD involves deficits in self-regulation and ADHD involves deficits in self-regulation and executive functioningexecutive functioning

It is a highly neurological – genetic disorder, not a It is a highly neurological – genetic disorder, not a myth or a socially causes conditionmyth or a socially causes condition

It is associated with numerous impairments over It is associated with numerous impairments over development if left untreateddevelopment if left untreated

It is the most treatable disorder in psychiatryIt is the most treatable disorder in psychiatry