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Barkley’s Theory of ADHD . Laura M. Bimbo November 3, 2004. DSM-IV ADHD . Three core ADHD symptoms: Hyperactivity Impulsivity Inattention Three ADHD subtypes: Predominately Inattentive Predominately Hyperactive-Impulsive Combined Type

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barkley s theory of adhd

Barkley’s Theory of ADHD

Laura M. Bimbo

November 3, 2004

dsm iv adhd
DSM-IV ADHD
  • Three core ADHD symptoms:
      • Hyperactivity
      • Impulsivity
      • Inattention
  • Three ADHD subtypes:
      • Predominately Inattentive
      • Predominately Hyperactive-Impulsive
      • Combined Type
  • Attention impairments have been thought to be the central ADHD deficit
why a new theory on adhd
Why a new theory on ADHD?
  • To date, most research is atheoretical
      • Descriptive
      • Exploratory
  • DSM-IV criteria is descriptive only
    • Observable behavior deficits only
  • Current criteria for ADHD assumes that subtypes represent similar deficits
    • Individuals with ADHD do not show inattention in all situations

(Barkley, 1997)

subtypes different disorders
Subtypes = Different Disorders?
  • Hyperactive-Impulsive type is a developmental precursor to Combined type
      • Preschool children vs. School aged children (Applegate et al., 1995)
  • Combined type = sustained attention and distractibility
  • High rates of ODD/CD comorbidity and other poor outcomes (school suspensions, substance use, etc.)

(Barkley, 1997)

subtypes different disorders5
Subtypes = Different Disorders?
  • Purely Inattentive type usually appears at a later age
  • Inattentive type = deficit in speed of processing; focused & selective attention)
  • Symptoms = daydreaming, “spacing out”, “being in a fog”, hypoactive, “sluggish cognitive tempo”
  • Decreased rates of comorbidities

(Barkley, 2001)

barkley s theory of adhd6
Barkley’s Theory of ADHD
  • Core impairment = Response Inhibition
  • Due to abnormalities in the prefrontal cortex and connections to other brain regions (striatum)
  • Response Inhibition affects four intermediate executive functions
  • So, poor response inhibition + deficits in executive functions = poor control
  • Barkley also asserts that individuals with ADHD don’t develop “future orientation and sense of self across time”
slide7

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

response inhibition
Response Inhibition
  • Inhibiting the initial prepotent response to an event.
  • Interrupting an ongoing response, permitting a delay in the decision to respond or continue responding
  • Protecting this period of delay from disruption by competing events and responses (interference control)

(Barkley, 1999)

evidence for poor response inhibition in adhd
Evidence for Poor Response Inhibition in ADHD
  • Behavioral Observations :
      • Greater activity level (Luk, 1985)
      • More talkative to others and self (Barkley, et al., 1983; Copeland, 1979)
      • More difficulty restricting behavior in laboratory settings than other children (Luk, 1985)
      • Less delay of gratification, less successful at resistance-to-temptation paradigms (Campbell, et al., 1994)
response inhibition10
Response Inhibition
  • Inhibiting the initial prepotent response to an event.
  • Interrupting an ongoing response, permitting a delay in the decision to respond or continue responding
  • Protecting this period of delay from disruption by competing events and responses (interference control)

(Barkley, 1999)

measuring prepotent responses
Measuring Prepotent Responses
  • Some studies have found no differences between kids with ADHD and those without ADHD on tasks measuring response inhibition
  • Methodological problems:
    • No immediate reinforcement within the task to encourage prepotent responding
    • If immediate rewards are provided, they are weak reinforcers for this individual
    • No history of reinforcement exists, so there is no prepotent response for this individual
          • (Barkley, 1999)
evidence for poor inhibition of prepotent responses
Evidence for Poor Inhibition of Prepotent Responses
  • Go-No-Go Paradigm (Barkley, 1997)
  • Continuous Performance Test
    • Errors of Commission
  • Stop-Signal Paradigm
    • Primary task of forced-choice letter discrimination
    • When presented with a signal (tone), response is inhibited
    • Kids with ADHD show:
      • Longer reaction times to signal
      • Less inhibition of primary response
      • More variation in their inhibition of primary response
evidence for poor inhibition of prepotent responses13
Evidence for Poor Inhibition of Prepotent Responses
  • Continuous Performance Test
    • Errors of Commission
  • During a direct observation study, children with ADHD interrupted more than control children (Malone & Swanson, 1993)
response inhibition14
Response Inhibition
  • Inhibiting the initial prepotent response to an event
  • Interrupting an ongoing response, permitting a delay in the decision to respond or continue responding
  • Protecting this period of delay from disruption by competing events and responses (interference control)

(Barkley, 1999)

evidence for difficulty interrupting ongoing responses
Evidence for Difficulty Interrupting Ongoing Responses
  • Stop Signal Paradigm
  • Wisconsin Card Sorting Task (WCST)
    • Involves shifting to a more effective response pattern when feedback indicates that the ongoing response is incorrect
    • Children with ADHD often perseverate, even when feedback is given (Barkley, 1997)
    • Interestingly, first-degree relatives of individuals with ADHD are more prone to perseverations
evidence for difficulty interrupting ongoing responses16
Evidence for Difficulty Interrupting Ongoing Responses
  • On an information processing task, children with ADHD were less likely to change their response style (i.e. slow down) after corrective feedback
  • Card Playing Task
    • Children with ADHD bet on more trials than control subjects, despite increased liklihood of being incorrect
response inhibition17
Response Inhibition
  • Inhibiting the initial prepotent response to an event
  • Interrupting an ongoing response, permitting a delay in the decision to respond or continue responding
  • Protecting this period of delay from disruption by competing events and responses (interference control)

(Barkley, 1999)

evidence for poor interference control
Evidence for Poor Interference Control
  • Stroop Color-Word Test
    • Subjects with ADHD (and their siblings) perform poorly when responding to the color of words rather than reading the words (Barkley, 1997)
    • Differences are also found when comorbid conditions are controlled for
    • Neuroimaging studies have shown that the right prefrontal region is involved in the performance of this task
slide19

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

working memory
Working Memory
  • Holding information in mind,
  • manipulating or acting on the information
  • Hindsight (retrospection)
  • Foresight (prospection)
  • Empirical evidence in kids with ADHD:
    • Digit span (especially backwards)
    • Mental arithmetic
slide21

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

self regulation of affect motivation arousal
Self-Regulation of Affect-Motivation-Arousal
  • Emotional self-control
  • Social perspective taking
  • Ability to express emotions internally
  • Intrinsic motivation directed at long-term goals
  • Empirical evidence in kids with ADHD:
    • More negative and emotional peer interactions
    • Impairment in persistence of effort
slide23

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

internalization of speech
Internalization of Speech
  • Self-directed speech (“private speech”)
  • Formulating rules and plans to solve problems
  • Internal reflection, description, questioning, instructing
  • Create internal rules for governing behavior
  • Empirical evidence in kids with ADHD:
    • Less compliant with verbal commands
    • Immature self-directed speech
    • Develop internal speech at a later age
slide25

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

reconstitution
Reconstitution
  • Ability to create complex and novel behavior sequences in order to attain future goals (generativity or fluency)
  • Involves analysis and synthesis
  • Empirical evidence in kids with ADHD:
    • Ideational fluency (Barkley, 1999)
    • Verbal fluency (esp. FAS)
    • Less info and organization in stories (Tannock, 1996)
    • Less creativity during free play (Funk, et al., 1993)
slide27

Barkley’s Theory of ADHD

Response

Inhibition

Self-Regulation

Of Affect/

Motivation/Arousal

Internalization

Of Speech

Reconstitution

Working

Memory

Motor Control/

Fluency/Syntax

motor control fluency syntax
Motor Control/Fluency/Syntax
  • Deficits in response inhibition and the four executive functions lead to impairments in:
    • Control
    • Timing
    • Persistence
    • Flexibility
    • Goal-directed actions
motor control fluency syntax29
Motor Control/Fluency/Syntax
  • Barkley asserts that these deficits manifest in ADHD children through:
    • Ability to adapt to new information
    • Ability to predict what will happen
    • Ability to generate responses to future info
  • ADHD = “nearsighted when it comes to time” or “time blindness”

(Barkley, 1999)

motor control fluency syntax30
Motor Control/Fluency/Syntax
  • Problems with sustained attention result from a limited intrinsic motivation for future goals
  • Effectiveness of stimulant medications:
    • Due to enhancement of inhibitory mechanismsimproved four areas of executive functioning
barkley s theory limitations
Barkley’s Theory: Limitations
  • Are difficulties in inhibition a result of ADHD or comorbid problems such as aggression, ODD, & learning disabilities
  • How much affect does response inhibition have on the 4 executive functions in the model?
  • How much does each executive function contribute to motor control?
  • Can the 4 executive functions be further reduced?
barkley s theory limitations32
Barkley’s Theory: Limitations
  • Do stimulant medications differentially affect each of the 4 executive functions?
  • Is there some hierarchical organization to the executive functions?
  • Can this model be used to dissociate Inattentive- type ADHD from the other types?
  • Does socialization affect the development of these executive functioning?
  • What gender and ethnic differences exist in the development of these executive functions?
barkley s theory treatment implications
Barkley’s Theory: Treatment Implications
  • Basis of treatment Environmental modifications
  • No delay between response and outcomes
  • Breaking down tasks into smaller components
  • Key conceptPoint of performance
barkley s theory treatment implications34
Barkley’s Theory: Treatment Implications
  • Place key information at the point of performance:
    • Provide external rewards/motivation
    • Minimize distractions
    • Put clock on student’s desk
    • Display rules at point of performance