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    Adhd

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    EEE aoe Coppi 197 by Amen opel Behavioral Inhibition, Sustained Attention, and Executive Functions: Constructing a Unifying Theory of ADHD Russell A. Barkley ‘University of Massachusetts Medicel Center Attention deficit hyperectiity digordet (ADHD) comprises a dei in behaves inhibition. A Ateoretical model is constructed that links inhibition to 4 executive neuropeychologicalfusesions that appear to depend on it for thelr effective execution: (a) werking mersry, (8) self-regulation ‘of afeet-mosvation~ arousal (c)intemalizaion of speech and (4 reconsttion (behavioral anal sis and synthesis). Extended fo ADHD. the model redicis that ADHD should be associated with secondary impairments in these 4 executive sles andthe motor contol they afford. The authoe Feviews evidence for each of these domains of Functioning apd fins it to be strongest fr deficits in behavior inhibition, working emor, regulation O mkiaticn, aad motor ccato i thee with ADHD. Although the model is promising at a potential theory of self-sonuol and ADHD, far more esearch Is required to evaluat its merits. nd the many predictions it makes about ADHD. For over 20 years, atemtion deficit hyperactivity disorder (ADHD) has been viewed as comprising thee primary symp: toms, these being poor sustained attention, impulsiveness, and hhyperactivity (American Psychiatric Association [APA], 1980, 1987; Barkley, 1981; Douglas, 1972, 1983). These behavioral deficits arise relatively early in childhood, typically before the age of 7, and are fairy persistent over development (Barkley, 1990; Hinshaw, 1994; Weiss & Hechtman, 1993). The three ‘majo impairments now have been reduced to two, with hyperac- tivity and impulsivity constituting a single impairment. As a ‘esul, three subiypes ofthe disorder have been propased in the ‘current clinical view of ADHD offered in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA. 1994): predominantly inatientive, predomi- nantly byperactive-impulsive, and combined types ADEDD occurs in approximately 3~79 ofthe childhood popu- {ation (Barkley, 1990; Szatmari, 1992), with boys being over- represented, on average, approximately 3:1. The disorder per- sists into adolescence in 50-80% of eases clinically diagnosed in childhood and into adulthood in 30-30% or more of these same cases (Barkley, Fischer. Edelbrock, & Smallish, 1990: ‘Rossel A, Barkley: Deparentsf Pychisry and Neurology, Univer sity of Massacheset Medical Celer “This article was supported by Grants MHAS7I4, MH2181, ant (MHEISES fiom doe Nacional Insite of Mental Heald and Grane HD26I71. from és National Istints of Child Healt and Homan Development 1 thank Charles Cunningham, Eric Mash, and Stewe Hayes fr their enlightening discussions ofthis theoretical model and their suggestions ‘or ts improvement Correspondence conceming this article should be addressed w Ruwell A. Barkley, Department of Psychiatr. Uiversity of Masiacho- sens Medical Cente, 55 Lake Averue North. Worceste, Massachu: seus 01685, Elecronie mt! may be sent vis Intemet to rhakley@ Dangatelsurmed edt Klein & Manmzza, 1991; Weiss & Hechtman, 1993). Over development, ADHD is associated with greater risks for low academic achievement, poor schoo! performance, retention in ‘grade, school suspensions and expulsions, poor peer and family relations, anxiety and depression, aggression, conduct problems and delinquency, early substance experimentation and abuse, diving accidents and speeding violations, as well as dificulties in adult social relaionships, marriage, and employment (Bark- ley, 1990; Barkley, Fischer, et a, 1990; Barkley, Guevremont, Anastopoutos. DuPaul. & Shelton, 1993; Barkley. Murphy, & Kwasnik, 1996, in press; Biederman, Fartone, & Lapey. Hinshaw, 1994; Murphy & Barkley. in press: Nadeau, 1995; Weiss & Hechiman, 1993). Most of these developmental risks may be exacerbated by the presence of comorbid aggression— ‘conduct problems (Barkley, Fischer, etal, 1990; Barkley etal. 1993; Hinshaw, 1987, 1992, 1994), Treatments for ADHD ofter include parent, family, and teacher 1 tO disr- der; parent and teacher training in behavior management tech- nigues; special education resources; and psychoactive medica tions (Barkley, 1990). ‘The history of ADHD has been reviewed elsewhere (Berkley, 1990; Schachar, 1986; Werry, 1992), so only briefly consider ithere. Initially, the symptoms were thought to arise out of poor volitional inhibition snd defective moral regulation of bedavior Sti], 1902). Later, problems with hyperactivity were thought to be the major feature of the disorder (Chess, 1960; Laufer & Denhoff, 1957). Eventually, Douglas (1972; Douglas & Peters, 1979) stressed an equal if not greater Tole for poor sustained altention and impulse contro! in the disorder. She subsequently “amended her view to include four major deficits: (a) poor invest. ment and maintenance of effort, (b) deficient modulation of arousal to meet situational demands, (ca strong inclination to seek immediate reinforcement, along. with (d) the originally Proposed difficulties with impulse controt (Douglas. 1980, 1983). Douglas (1988) later concluded that these four defi- cioncies arise from # more eontal impairment in self-regulation in ADHD, 66 Others have argued thatthe cognitive deficits in ADHD may best be understood ax a motivational deficit (Glow & Glow, 1979) of as arising from poor stimulus control, a diminished sensitivity to reinforcement, or deficient rule-governed behavior ‘Barkley, 1981, 1989; Haeelein & Caul, 1987). Such views, however, were not widely adopted, nor did they serve as an impetus to much new research, Zentall (1985) set forth an ‘optimal stimulation theory of ADHD, arguing that the hyperac- ‘ivity arises from low levels of arousal and serves to maintain ‘an optims| arousal level: the hyperactivity in a sense isa form of selfstimulation. More recently researchers theorizing on ADHD. ‘have emphasized poor behavioral inhibition as the central im- pairment of the disorder (Barkley, 1990, 1994; Quay, 19884: Schachar, Tannock, & Logan, 1993; Schachar, Tannock, Marr ‘ott, & Logan, 1995), Jn keeping with this trend, inthis article T attempt to provide 1 unifying model of ADHD that is founded on prior theories of ‘the neurapsychological functions ofthe brain's prefrontal lobes. ie ‘behavioral inhibition is specified as the central deficiency jn ADHD. The model then sets forth a linkage between response ‘inhibition and four executive funetions that depend on such Inhibition for their own effective performance. These four func tions serve to bring behavior under the contre} of internally represented information and self-directed actions. By doing s0, the four functions permit greater goal-directed action and task persistence. The model provides a more comprehensive account ‘of research findings on the cognitive deficits associated with ADHD than does the current clinical view, which sees ADHD as primacily an attention deficit. The model also predicts many ‘ditional deficits likely to be associated with ADHD that have _zceived litle or no testing in research, Such predictions provide avenues for attempts at falsification of the model and point to ‘new areas for scientific investigation, ‘The goal here is admittedly ambitious, perhaps overly 0, ‘because the model I propose may be potentially misconstrued as a “theory of everything” Yet its boundaries are generally ‘circumscribed to the domain of self-regulation in developmental psychology or executive functions in neuropsychology. Albeit a broad domain, itis not unlimited. It can be readily distinguished from other major domains of neuropsychological functioning such a8 sensation end perception, memory, language, and the spatial, sequential, emotional, and motivational domains, among others. The model may overlap with these other domains, how- fever, tothe extent that self-regulation may affect them. Before I proceed to discuss the origins of the model. its components, and its extension to ADHD, the ambitiousness ofthis undertak- ing demands a justification for why a new model of ADHD is ‘even necessary at this time, ‘The Need for a New Model of ADHD ‘A new theory of ADHD is needed for « numberof reasons. First, current research on ADHD is neatly aheoretical st least in regards tots basic nature. That research is mainly exploratory and descriptive, with two exceptions. One is Quay's (1988a, 1988p, 1996) use of Gray's (1982) neuropsychological model ‘of anxiety to explain the origin of the poor inhibition seen in ADHD. This Quay—Gray model sates that the impulsiveness woot BARKLEY.) ie eae pe ‘arises from an underfunctioning of the brain’s behavioral inbibi- tion system, That system is suid 10 be sensitive to signals of ‘conditioned punishment, and the model predicts that those with "ADHD should prove less sensitive to such signals, particularly [in passive avoidance paradigms (Milich, Hartung, Mastin, & Haigles, 1994; Quay, 1988). The second exception isthe work lof Sergeant and van der Meere (1988; Sergeant, 1995a, 1995b. 1996, van der Meere, in press; van der Meete, van Baal, & Sergeant, 1989), who successfully used information processing. theory and its associated energetic mode! (arousal, acuivation, and effort) for isolating the central deficit(s) in ADHD within ‘hat paradigm (Sergeant, 1995b), However, this approach does ‘not set forth s theory of ADHD; like the Quay—Gray theory, it ‘makes no effort at large-scale theory construction 50 as 10 pro- Vide a unifying account of the various cognitive deficits associ- ted with ADD. Apart from these exceptions the curreatclini- cal view of ADHD (i. that of the DSM-IV) and the vast majority of current research being conducted on its nature are not theory driven (Taylor, 1996). One sign of advancement in 4 sclemtific field is that its research becomes so driven, This synthesis is an attempt to move research on ADHD fercher along in that direction Douglas's (1980) earlier model of ADHD is not actually 2 theory: itis mainly descriptive and was arrived at inductively from a teview ofthe extant research findings on ADHD in which Douglas (1980, 1983; Douglas & Peters, 1979) discemed a pattern among the findings consistenly noted in this field. That pattems comprised the four deficiencies noted earlie. Although twas tremendously helpful at the time, such pater discernment remains at a descriptive level, albeit one more synthetic than prior effort at conceptualizing ADHD. But itis neither explans- tory nor, more important, predictive of new hypotheses that are testable. Tt still begs the question of just how the pattem itself is to be explained, Appealing to the construct of self-regulation (Douglas, 1988) is a step in the right direetion but is of only modest help untess self-regulation itself is defined and dhe mau- rer in which it leads to the four impairments is expluined, Both the patter and the later use of self-regulation as an explanatory construct by Douglas fit well within the model developed below. This thory, however, goes much further by providing the needed definition of self-regulation, articulating the cognitive compo- rents that contribute to it, specifying the primacy of behevioral inhibition within the theory, and seting forth motor contr ‘component to ADHD. Most important, the model reveal a diver- ‘ity of new, untested, yet testzble predictions about cognitive and behavioral deficits deserving of study. ‘A second reason why a theory of ADHD is sorely needed is thatthe current clinical view of ADHD (ie. that of the DSA— 1), being purely descriptive of two behavioral deficits (inatten- tion and hyperactivity impulsivity). also cannot readily account or the many cognitive and behavioral deficits associated with ADHD that are reviewed later in this article, To account for ‘such findings, any model rms full at least five key require ‘ments: (a) Itmmast explain why an actual deficit in attention in regulation of affect and in the internalization of speech, and S0 requite brief clarification here. Behavioral Inhibition ‘As previously defined, behavioral inhibition ia Figure 1 refers 10 chree inhibitory functions. These exert a direct controlling influence over the motor system, fence the direct downward areow in Figure 1 between behavioral inhibition and motor con- trol fluencysymtax, Behavicral inhibition, however, does not directly cause the four inlermesiate executive functions to occur tbat merely sets the occasion for their performance. Visily rep- resenting this crucial point, the lines connecting inhibition to those four executive functions are blunted. But because those ‘executive functions produce direct and causal effects on motor control, arrows connect each executive fonction with motor contro Self- Regulation of Affect—Motivation~Arousal ‘This component includes Bronowski's (1977) concept ofthe separation and self-regulation of affect. Unlike Bronowski, how- Behavioral inhibition Inhibit prepotent response ‘Stop an ongoing reeponso Interference controt ‘Working memory ‘Reconstitution Hong eves inn ‘mctivallen/arowsa) ‘aly ad yes of behavior Mangaaing or sting on tbe events Vettel Aueneyebavoed ery dation of tomplk abv segues ‘soning Goaltreet babel reaty Revowpetve ecto igi) Debeveralemclton ‘Preparave aseton ereough) Synnof tena ‘Anita st ‘Sem ot tne _Cowemporalxpnizaiog of ever aHaY OXY NOLEN: Motor control/fluency/syntax _ Inhibiting ask-irrelevant responses Executing goal-directed responses Execution of noveV/complex motor sequences ‘Goal-directed persistence ‘Sensitivity to response feedback ‘Task re-engagement following disruption Control of behavior by internally represented information Figure 1. schematic coniguation of conceptual model that links behavior inhibition with te performance of the four executive functions that being motor coneo) fueney. and Symi under the conta of intmally represented information ee aaa miele oot San ety 4 ‘ever I beliewe that affect may not be completely separable from ‘the decision to respond or even from the response itslf (see Dimasio, 1994). Instead, a mote self-regulatory role of the ‘executive system is stressed here in that emotions, once elicited, ‘come to he moderated or regulated by self-directed, executive actions. Included in this component is also the self-generation ‘of drive or motivational and arousal states that support the exe- cation of goal-directed actions and persistence toward the goal “This combination into a single component makes some sence. ‘Lang (1995) cogently argued thatthe array of human emotions catirednta oa wocinentona mel of whch ine ‘mension is motivation (evAForeement and punishment) and the other, level OT arousal. So the ability o selfregulate and even induce Emotional sales as needed in the service of goal-directed behavior also may involse the ability to regulate and induce ‘motivation, driv, and arousal states in support of such behavior ‘Thus, children! may learn to create mote positive emotional and ‘motivational stats in themselves when angered, frastrated, di appointed, saddened, anxious, or bored by learning to manipu- late the variables of which such negative states and their positive altematives are a function (Cole, Zahn-Waxler, & Smith, 1994; Eisenberg et al,, 1993; Kopp, 1989). Such self-directed actions may involve efforts at self comforting, self directed speech, ‘sual imagery, and self-zeinforcement, anoag olber means (Kopp, 1989). This process of self-regulating affect may begi as early as $~ 10 months of age (Stifter & Braungar, 1995). I also conceivable that children may learn to selfceguiate arousal levels forthe purposes of goal accomplishment. This component of the model, therefor, includes se following subfunctions, all ‘of which are performed in the service of goal-directed actions: (a) the self-regulation of emotion, (b) a capacity for objectivity ‘and social perspective, (c) the self-regulation of drive and moti vational states, and (d) the self-regulation of arousal ‘Among the variety of human erosions, it may be the negative jones that are most in need of such self-control (Kopp. 1989). ‘This is because negative affect may prove more socially unac- ‘ceptable and thereby produce more salient, Tong-term negative focial consequences for te individual relative to the postive ‘emotions, such as laughter or affection. In the immediate com text, such negative displays may achieve postive reinforcement ‘of more likely, escape from or avoidance of aversive events ‘Patterson, 1982, 1986), Internalization of Speech Fuste’s (1989) model had litle to say about the internaliza- tion of speech as « function of the prefrontal cortex. Bronowski (1977), however, stressed the uniqueness and importance of the selfditection and ineemnalization of speech and the profound ‘contr it may exert on te individual's behavior. Developmental psychologists (Berk & Potts, 1991; Kepp, 1982) and develop- menial neuropsychologists (Vygotsky, 1978. 1987) have like- ‘wise emphasized the importance ofthis process forthe develop- ‘ment of self-control, So Ihave included it here. Berk and Potts argued that the influence of private speech on self-control cer- tainly may be reciprocal—inhibitory control contributes to the internalization of speech, which contributes to even greater self: restraint and self-guidance. Despite this reciprocity, initial pri= BARKLEY macy within this bidirectional process is given here to behavioral (motor) inhibition, Self-drected speech also is believed to pro- vide & means for reflection, description, and self-questioning through language, creating an important source of problem. solving ability as well as a means of formulating rules and plans. ‘Eventually, rules about rules (metarsies) can be generated into «hierarchically arranged system that resembles the concept of ‘metacognition in developmental psychology (Flavell, Mile, & Miller, 1993). The combination of internal speoch with the pro- spective function of working memory (forethought) may well Contribute to moral reasoning (ibe internalization of community norms, mores, or morals). And so I have listed these various functions releted to internal speech under this component of ure 1 “Although the progressive shift from public to private speech {is fascinating in its own right, a more important aspect of this privatization may be the increasing control language comes to have over motor behavior with development (Berk & Potts, 1991; Vygotsky, 1978). This control has been referred to within behavioral anslysi as rule-governed behavior (Ceruti, 1989; ‘Hayes, 1989; Skinner, 1953). Rules are defined as behavior. specifying stimuli. Language constituies a large class of such stim, Skinner hypothesized that this influence of language ‘over behavior oceurs in tree stages: (a) the control of behavior by the language of others; (1b) the progressive control of behav ior by self-directed and eventually private speech, as discussed ‘above; and (c) the creation of new rules by the individual, which came about through the use of self-directed questions (second ‘order rules). Both Bronowski (1977) and Skinner stressed two important aspects of internalized speech. One was informa- tional—the power of self-directed speech for description, e- ‘lection, and the creation of new rules by which 1o guide behav- for (problem solving). The other was insiructive—the power ‘of these messages to actually control motor responses. Rule- governed behavior appears 10 provide a means of sustaining Dbohavior across large gaps in time among the units of a behav ioral contingency (event~response—comsequence). By formic lating rules, the individual can construct novel. complex (hierar- chically organized), and protonged behavioral chains. These rales can then provide the template for reading off the appro- ‘sequences of behavioral chains and can guide behavior ‘toward the attainment of a future goal (Cerut, 1989). By this process, the individual's behavior is no longer under the total ‘contro ofthe immediate surrounding contest. Control of behay= Joris now shifted to internally represented information (rules). ‘The control of behavior by the sense of past and future, as well as by the more general rules or metarules formulated from thers or acquired through socialization, most likely makes some con- tribution to the development of conscience and moral reasoning (Hoffman, 1970; Kochanska, DeVe, Goldman, Murray, & Put nam, 1994). Hayes (1989) and Cerutti (1989) stipulated a number of specific effects on behavior that rule governance produces. ‘These become important later a8 predictions from the model (ers er variability of responses to-a task is much tes 5 when rule-governed behavior is in effect than when behav jor ig contingency shaped (developed and maintained by the ‘environmental contingencies alone); (b) behavior that is rule 1ed may be less affected or entirely unaffected by the tation, the rule is more likely to gain control over the individu- al’s behavior. and this will be progressively more the case asthe individual matures; (d) rule-governed responding under some conditions may be rigid or inflexible, even if the rule being followed is incorrect, and (e) self-directed rules permit individ- uals to persist in responding under conditions of very low levels of immediate reinforcement, oF even in the absence of reward, as well as during extreme delays in the consequences for responding. In short, self-directed rules assist with bridging temporal gaps in behavioral contingencies and thus contribute to the ctoss- ‘temporal ongunization of behavior. The motor execution of such verbal rules appears to be partially dependent on the capacity to retain them in working memory and to inhibit prepotent of inmelevant responses tha: compete with tbe rule (Zelazo, Rez- nick, & Pinon, 1995). Motor Control—Fluency—Syntax ‘The self-directed and frequently private actions constituting these four executive components serve to create a sifin dhe Somtol of behavior rom contol exelusively by the-exezpl exist to congo By 7 cated information user THB. TOSS Cott & Bayon 1008 Goldner Tox, 1995; Goldmen-Rakic, 1995), Bosh seasory input ax well as motor behavior that is unrelated to the goal and its internally represented behavioral structares become minimized ‘oreven suppressed. This occurs not only during the performance of these four executive Retions but also during the execution of the complex, goal-directed motor responses they generate. Throughout the execution of goal-direcied behaviors, Working merry permits the feedback from the lst response(s) to be held in mind (rewospective function) and fed forward (prospee= tive function) to modify subsequent responding: thus sensi ity to eros is created. Just as important when interruptions in this chain of goal-directed behaviors acu the individual is able to disengage, respond to the interruption, and then re-engage the original goal-directed sequence because tha plan hasbeen eld ‘in minal despie the interruption. Ths, inhibition sets the ocea- sion forthe engagement of the four executive functions, which ten provide considerably greater control of behavior by the internally represented information they generate Extension of the Model to ADHD. ‘Tremendous progress has been made in the [ast 2 decades in Understanding the ncuropsychological functions subserved by the prefrontat cortex. This progress has led to the development ‘of treories for organizing and explaining these functions (Fuster, 1989, 1995). Increasing evidence suggests that ADHD appears ‘o arise ftom abnormalities inthe structure and furction of the prefrontal cortex and its networks with other brain regions, ‘especially the striatum (Castellanos etal. 1994; Heilman er al. 1991; Low et al, 1984, 1989; Rapoport, 1996; Seig et al. 1995; INHIBITION AND ADHD 78 Zametkin et al, 1990). A model of prefrontal executive fune- tions therefore, should fer some promise a a model for uader- staading ADHD as well “The hybrid model developed in Figure 1 pedics that the ‘efciency in behavioral inhibition that charactetzes ADHD diminishes the effective deployment ofthe four execuive abi ties tht subserve self-control aud goal-directed behavier, This inhibitory deficit thereby indireety disrupts the contol of goal- ‘directed moter behavior by its influence on these exeeutive func fons. A the behavior of those with ADI is controll? tore iat content and is com than isthe behavior of omer. The Behavior of ther, im contrat, if mor controled By ialernally represented infoxmation, such a hindsigh, forethought ime plans rues, and seli:motivating ‘inal tha ukimately provide for the maximization of future net outcomes ‘What follows is brief review of dhe evidence that supports the view of ADHD as a deficit in behavioral inhibition, Ths is followed by a selective review of evidence linking behavioral inhibition each ofthe components ofthe present mde. Fuster (1989, 1998) and bers (Goldberg & Poll, 1995; Goldman Rakic, 1995; Knights ea, 1995: Milner, 1995; Suss & Beason, 1986) have reviewed a far more exteusive body of evidence from both animal and human vewopsychoogical research that also supports the existence of these prefrontal functions and thai link to inhibitory processes. More important co te purpose here, findings are reviewed that implicate the impairment of ‘hese functions among thse with ADHD. ADHD and Deficient inhibition The evidence supporting deficiency in behavioral inhibition in ADHD comes from a number of sources, Many studies using Parent and teacher raings of hyperactive and impulsive behav fon in chikiren find these behaviors to cluster into a single dimegsion, often called impulsive byperacive_or undeion- ‘colleLbehavior (Achenbach & Edelfeock, 1983, 1985; Goyette, omnes, & Ulrich, 1978: Hinshaw, 1987; Lahey eta, 1988, 1994), Ici his dimension of behavior hat, vitally by defni- tion, distinguishes those with ADHD from others without ic (Hinshaw, 1987, 1994). This argument, however 1s circular, ‘ating of byperactve impulsive Behavior are sel wo erate & diagnostic category of ADHD, and ten those with ADHD ate foun to differ oa such ratings. The circularity i dealt with by evidence of extemal validation from sources ote than prent= teacher ratings. Many sudies that have sed objective measbres have shown that children rated ax being mee hyperactive impulsive or who were clinically diagnosed as ADHD. infact, displayed a higher activity lve than oer children not so raed ‘or ciagmosed (Gomez & Sanson, 1994: Porrno cal, 1983: see Luk, 1985, fora review), ADHD childen aso talk roce Ua other children, whether to others (Barkley, Cunningham, & Kasson, 1983; Cunningham & Siegel, 1987) or outloud 1 themeeles (Betk & otis, 1991; Copeland, 1979), and make ‘more vocal noises than do other chitren (Copeland & Weiss- trod, 1978). All of this may be taken ax evidence of poor behavioral inhibition. ‘Children with ADHD, compared with controls, ako have F wr et® 6 BARKLEY more difficulties restricting their behavior in conformance with : instructions 10 do so (Barkley & Ullman, 1975: Milich, Landau, Kilby, & Whitten, 1982; Routh & Schroeder, 1976: Ullman, Barkley, é& Brown, 1978), deferring gratification (Carapbell, Pierce, March, Ewing, & Szumowski, 1994; Rapport, Tocker, DuPaul, Metlo, & Stoner, 1986), and resisting mptation (Campbell et al, 1994: Campbell, Szumowski, Ewing, Ghick, & Breaux, 1982; Hinshaw, Helles, & McHale, 1992; Hinshav Simmel, & Heller, 1995). Again, a significant deficit in inhibi tion, especially in situations where rewards are imunediately ble for emitting impulsive responses, might be inferred P fern dese resis Further evidence of poor inhibition in ADHD comes from = studies that used motor inhibition tasks, such as go-no-go para. @ digms (laboni, Douglas, & Baker. 1995; Milich et al., 1994; “4, Shoe & Douglas, 1989; Tiommer, Hoeppnet, Lorber, & Arm 4 é strong, 1988; Voeller & Heilman, 1988), the stop-sigeal task (osterlaan & Sergesnt, 1995; Schachar & Logan, 1990; Scha- char et al., 1993), the change paradigm (related to the stop- signal paradigm: Schachar etal, 1995), and. delayed response tasks (Gordon, 1979; Schweitzer & SulzerAzaroff, 1995; So- ‘uge-Barke, Taylor, & Hepinstall, 1992; Sonuga-Barke, Taylor, ‘Sembi, & Smith, 1992), Blurting out incorrect verbal responses fami disrupting tbe conversations of others with such intrusive responses are considered primary symptoms of impulsiveness in those with ADHD (APA, 1994) and have been objectively i Idocumented (Malone & Swanson, 1993). : ‘Numerous studies also demonstrate that children with hyper- activity or ADHD produce greater eqors_of commission on continuous performance tasks, whether computerized (Barkley, 1991; Barkley, DuPaul, etal, 1990; Barkley et al. 1992; Grod- insky & Diamond, 1992; Robins, 1992; see Corkum & Siegel, 1993, fora review) or given by paper and pencil such as leter cancellation tasks (Aman & Turbott, 1986: Brown & Wynne, 1982; Carte, Nigg, & Hinshaw, in press: Keogh & Margolis. 1976). However, results for the ater tasks, particularly when self-paced, have proven contradictory (Gomez & Sanson, 1994; vvan der Meere, Wekking, d& Sergeant, 1991). Problems with response inhibition in children with ADHD have even been noted on tasks that assess mone molecular motor movements, such as occular gaze shifts on delayed response tasks (Ross, Homsver, Breiger. Varley, & Radant, 1994), ‘Poor behavioral inhibition ikewise should be evident in deR- ‘cient performances in learning under passive versus active avoid- ance paradigms. Here passivity or the inhibiting of a response is required to terminate, escape, or avoid punishment. In such tasks, those with ADHD have been found to show more such punished trials than is normal (Freeman & Kinsbourne, 1990; Milich etal. 1994), Poor behavioral inhibition also should be evident when a task requires stepping an ongoing response when, signalled to do so or when feedback suggests that the response is ineffective or maladaptive. Many studies of those with ADHD hhave noted them to have such difficulties (Oostertaan & Ser- ‘geant, 1995; Schachar & Logan, 1990; Schachar et al, 1993, 1995), ‘The stopping of an ongoing response pattern is required in the performance of the Wisconsin Card Sorting Test (WCST).. Patients with frontal lobe damage often have difficulties on this test, and its performance has been associated with action of the dorsolateral prefrontal cortex (Berman eta 1995), Chil dren with ADHD seom to have difficulties. performing. te WOST as well Barkley et al. (1992) reviewed 13 studies that used the WCST, 8 of which found significant differences be tween ADHD and contol participants Methadolopieal prob- tems such as low statistical power duc to smal samples and verse age groups, my well have limited some ofthe studi, that yielded nonsignificant findings. Performance on this tit has been shown to improve with age in both childen with ADHD and controls (Seidman eal, 1996). Family history of ‘ADHD may also determine the severity of results (Seidman et 41, 1996), Even so, of 6 ational suds of ADHD that used thy WCST. 4 (Kreaer, Carter, Chadenjan, Wolfe, & Northet, 1993; MeBuret et al, 1993; Seidman el, 1995, 1996) also found differences beteen ADHD and control. groups on this test, the remaining 2 did not (Nari & Ahonen, 1998: Pen ington et al, 1993). Althoush the evidence is not ently Consistent, the weight of the evidence show the with ADHD {have e problem with response perseveration, despite feedback about ero. Tn Keeping with this interpretation, Sergent and van dor ‘Meere (1988) found Uist children with ADHD performing an inforation-procesing ask wee less likely ale their subse quem responding wien they mada SOY Wan were chien Bee er one Respontepeteraton tn tose th ADHD also ha ben Enna Tseatch with he ca playing task (Milich et al., 1994). Similarly, patients with pre- froma lobe ijores have boen noted to show persistence in & previously rcinforeed respons pattern, even though the enti fences changed and they could verbally report that such Changes occurred (Dimasio. 19%; Rolls, Horak, Wade, & MeGrath, 1994), to ster (1989), the allure tas motor perfor- mance given feedback concerning its ineffectiveness may act lly reece an intcaction between behavioral nbition and he revospective-prospecive functions of working memory. The Trlivdol fails t holdin mind information on the success Ot bis wrTeresponing onthe mmodiely preceding als rto- SPT SRN Tew feos loreal Gaon or een stp fed fee ap eso neg ie fi rt gests that the cessation, shifting. and ‘erengagemen of ongoing Tesponies according t ask fcdback belongs under the moor cool component of tie mode as a effect of working memory on this componcat. Regardless, this. Seperation of motor shifting and re-engageroent rom behavioral inhibition has recently been demonstrated im chldren with 'ADHD, who were inferior ro comrols in both processes (Scha- char eta, 1995). A distinction between the two processes also Supgets thatthe peseveratve responding seen on fhe WCST ty those with ADHD may he less reflstve of poor inhibition and move elective of deficient working memory an interpre tation more consistent with neuroimaging research involving this test (Berman eta, 1985). Evidence of Poor Interference Control Evidence for poor interference control in those with ADHD ‘comes from several sources. Studies that used the Stroop Color oe Word Interference Test with children having ADHD nearly al- ways found them to perform poorly on this test. In a previous review (Barkley et al, 1992), six such studies were located, five of which found chikdren with ADHD to take moce time and. ‘make more errors than contol children daring the interference portion of the task. Four more studies produced siailar results (Krener et al, 1993; Leung & Connolly, 1996; Pennington et al, 1993; Seidman et a, 1996). The consistency of such find- ings across studies is striking despite differences in cultures, group selection procedures, and sample sizes. It suggests that a deficiency in the control of interference from prepotent re- sponses is reliably associated with ADHD. Group differences could not be arributed to comorbid learning or conduct disor. ders (Leung & Connolly, 1996: Pennington eta, 1993; Seidman et a, 1996), which argues for the specificity of these differ- ences to ADHD. Neuroimaging research with this task has iden- tified the orbital~prefrontal regions, particularly te eight pax Frontal region, as being involved in its performance (Bench et al, T993; Venirell et al, 1995). ‘The capacity to maintain performance toward a task despite distraction might also serve as an indicator of poor interference ‘control. Whether or not distrators disrupted task performance, ‘however, would depend on the prepotency of the response likely (o be elicited by the distracting event as well as the extent to which any executive functions tking place during the task performance required protection from such interference, Those task-related factors calling for such executive control might be Temporal delays, temporally related conflicts in consequences, and problem-solving tasks requiring the formation of novel, ‘complex responses. Research on ADHD suggests that distrac- ions outside of the immediate task materials are unlikely to differentially affect the performances of children with and with- ‘out ADHD; distractions embedded within the tsk seem more likely to do so (Leung & Connelly, 1996), The more salient Ge ype of distraction, the more it occurs within the tsk: oF the more that time and delays occur within the task parameters, the greater the likelihood that distractors wil interfere with the task performance by ADHD children (Barkley, Koplowicn, & Anderson, 1996; Bremer & Stern, 1976; Cohen, Weiss. & Minde, 1972; Landau, Lorch, & Milich, 1992; Rosenthal & Allen, 1980; Steinkamp, 1980), Other evidence of poor imerfer- ‘ence control in ADHD might have been found in 2 study of college students with ADHD who hud more task-irrelevant thoughts during performance of a continuous performance test than did the control group (Shaw & Giambra, 1993). Althoug (2 might imply poor interference control over internal sources of disrastion, other imerprettions coud account for findings ce “Te studies reviewed above idicate that children with ADHD have difficulties with behavioral iaibition on various ass (see also Pennington & Ozonof, 1996). Is there evidence forthe inverse relationship as well? That i, do young children with ‘oor behaviors! inhibition have a higher Hklibood of having Symptoms of ADHD? Some studies suggest thr this may be the ease. Young chilérenidentited as more impulsive and less INHIBITION AND ADHD n ‘Able to delay responses, particularly in resistance-to-temptation tasks, have been rated by others as displaying higher levels of ADHD symptoms both concurrently and later in development (Campbell & Ewing, 1990: Mischel, Shoda, & Peake, 1988; Mischel, Shoda, & Rodriguez, 1989; Shoda, Mischel.& Peake, 1990; Silverman & Ragusa, 1991). Likewise, children with igher levels of activity at Age 2 displayed less self-control at ‘Age 7 (Halverson & Waldrop, 1976). "To summarize, the evidence that ADHD involves impaired behavioral inhibition seems compelling, arising as it does from multiple studies, methods, and sources. Suggestive evidence from developmentat psychology also points to the inverse rela jonship as well, chat early deficits in behavioral inhibition may bbe prodictve of risks for later ADHD symptoms. Working Memory ‘The hybrid model in Figure 1 predicts that poor behavioral inhibition, as in ADHD, should lead to secondary deficiencies in working memory and its subfunctions. (a) Children with ADHD should be more influenced by context and less controlled bby intermally represented information than same-age peers with- ‘out ADHD. ¢b) Children with ADHD should be more influenced bby immediste events and their consequences than by those more distant in time. (c) Those with ADHD should be less likely to recall and bold in mind information about tbe past (hindsight) for the formulation of a plan in the furure (forethought and planning), (d) Anticipatory or preparatory behaviors founded ‘on such planning should be less evident in those with ADHD, 80 motor presetting in anticipation of the arrival of future events shold likewise be less proficient. (e) A form of temporal myo- pia should exist in children with ADHD, in that Behavior is ‘more controlled by the temporal “now” than by internally rep- resented information pertaining to the pas, the future, and the sense of time. (f) Children with ADHD ‘should exhibit less control of behavior by time and more deficient organization of behavior relative to time. (g) Performance under cross-temporal Cif-then) contingencies should be less effective im those with "ADHD because they cannot bridge the delays in the contingen- ies, using internally represented information, And (h) the larger the delays in time that separate the components of a behavioral contingency (events, responses, and their consequences), the less successful those with ADHD should be in effectively man- aging those tasks. There should also he less ability (0 success fully persist in goal-directed belwvior in those with ADHD. And ‘even when those with ADHD undertake goal-directed belavior, it should be subject to greater interference by sources of disrup- tion in both the external and infernal environments and result in less success at goal attainment. ‘The mode! in Figure { predicts six additional delicits in asso- ciation with ADHD: (a) There should be an inability to imitate lengthy sequences of goal-directed behavior demonstrated by ‘others, given that such sequences cannot be held in mind as well fot the orchestration of their execution. (b) Toe sense of time should be impaired. (¢) Information recalled from memory (ret= rospective function) should be temporally disorganized —that is, the very syntax of recall should be deficient. (d) Conse- ‘quently, the syntax of moter planning and execution should like- oo we — ‘wise be disorganized. (e) Discourse with others should eeflect to rule out these potential confounding factors in their study of fewer references to time, the pas, and especially the future. And mental computation in children with ADHD, thus giving greater () significant deficiencies should exist in the performance of weight to deficient working memory in ADHD. | those social skills (ie. sharing, cooperation, ete.) as well as The Tower of Hanoi and Tawer of London tasks require that ‘other adaptive behaviors (i.e., concem for safety, health con- individuals be able to mentally represent and test out various sciousness, etc,) that are predicated on the valuation of future ways of removing and replacing disks on a set of pegs or spin- pessonal and social consequences over immediate ones. The des before undertaking the actual motor execution of the re- knowledge of those social and adaptive skills or behaviors is arrangement, Patients with injuries tothe prefrontal cortex often ‘not a issue here; that kowledge should not be deficient in those have difficulty performing these vests (Goel & Grafman, 1995; i with ADHD. [tis the application of that knowledge in daysto- Levinetal, 1994), and neuroimaging research has found activa- day functioning that should be impaired. The problem, then, for tion ofthe prefrontal cortex tobe involved in their performance those with ADHD is not one of knowing what to do but one of (Morris. Ahmed, Syed, & Toone, 1993). Studies of ADHD that doing what you know when it would be most adaptive todo $0, used these tasks found children with ADHD to perform both ‘This same problem is typical of patients with injuries to the tasks more poly than children without ADHD (Brady & Den- Prefrontal cortex (Delis, Squire, Bihrle, & Massman, 1992, chia, 1994, Pennington et al., 1993; Weyandt & Wills, 1994), Stuss & Benson, 1986), “The tasks have been interpreted (Pennington et al., 1993) as Js there evidence for hese predicted defcincis in impulsive taxing three ofthe processes sepresened in the model: working & individuals or in those with ADHD? There is limited evidence, memory, problem solving, and planing. Other, however, be- {mainly because lite research has specifically set out to test lieve the Tower of London task at least reflects difficulties in © these predicvions. Research om young children suggests that inhibiting prepotent responses (Goel & Grafman, 1995). € measures of response inhhition (resistance to temptation) ap- (~The slorage ad recall of simple information in memory test H | Spear be significantly and positively associated with measures _ | as nt been fund to be impaired in those with ADHD (Barkley fot memory for spacial location or working memory (Lee, | DuPaul, etal, PETE 1995; Douglas, 1983. Vaughan, a& Kopp, 1983). "The performance of delayed response | 1988). Instead, it seems that when more, and more complex, Tasks also requires waiting for a reward while keeping in mind information must be held in mind, especially over a lengthy its hidden location, Children as young 25 18-30 months of age delay period, deficits become evident (Douglas, 1983, 1988; demonstrate both the presence of such working memory and its Seidman et al., 1995, 1996). Also, when strategies are apparent dependence on response inhibition (Diamond, Cratten- for organizing material 50 as to remember it more elfectively. den, & Neiderman, 1994). those ih ADHD priors es well than contols (Angest ‘Working memory has often been assessed in neuropsychologi- 1987! Benezra & Douglas. 198: Borcherding et al, 1988; cal esearch with the following tasks: retention and oral repeti-. Douglas, 1983: Douglas & Benezra, 1990: Felton.” Wood, sion of digit spans {especially in reverse onder); mental arithine- Brown, Cempbell, & Harter, 1987; Frost, Moffit, & McGee, ic, such as seria ation; locating stiral within spatial arrays 1989; Shapino, Hughes. August, & Bloomquist, 1993) of information that must be held ia memory: and holding se- The use of strategies by children with ADHD 10 organize quences of information in memory to properly execute a task, complex material has primarily been studied with verbal infor asin self-odered pointing tasks (see Becker, 19%; and Milner, mation. Some studies, however, have used the Rey—Osterieth 1995). Consistent with the model, children with ADHD appear (‘Complex Figure Drawing Test. A amber of stdies of ADHD to be less proficient in mental arithmetic (Ackerman, Anhalt, & | have identified organizational deficits (Douglas é& Benezra, %4£ Dykman, 1986; Barkley, DuPaul, tal. 1990; Mariani & Bark- §8 1990; Grodzinsky & Diamond, 1992: Seidman et al, 1996), ley, in press; Zentall & Smith, 1993). Both children and adults "] but a few others have not (Moffit & Silva, 1988) or have D rraitN ADHD have als shown more fclies wih epton | found debits ely in cien with ADHD and ting diodes % {of digit spans (pancicularty. backwards; Barkley, Murphy, & (McGee, Williams, Moff, & Anderson, 1989). The rwo stud- Kovasnik, 1996; Mariani & Barkley. in press: Milich & Loney, is that found nonsignificant results used samples drawn from 1979), memory for spatial location (Mariani & Barkley, in comramity screenings of children, whereas those staies that ress), and memory for finger-pointing or hand-movernentse- found differences used clinic-referted samples, which perhaps ‘quences than have control group participants (Barkley, Mur- may explain these discrepant results hy, & Kwasnik, 1996: Breen, 1989: Grodzinsky & Diemond. As noted earlier. the incapacity to hold information in mind 1992: Mariani & Barkley, in press) in those with ADHD creates a disability in imitating complex ‘The Freedom From Distractibility factor ofthe Wechsler ln- and lengthy behavioral sequences performed by olhers that may telligence Scale for Children-Revised comprises tests of digit be novel to the indviduel. T found no studies of ADHD that span, mental arithmetic, and coding, These tests ental the use expressly tested this prediction. However, several stuics have of working memory. among other mental functions. Children found that children with ADHD are less proficient a imitating With ADHD score more poorly on this factor than do those increasingly lengthy and novel sequences of simple motor ges ‘without ADHD (Anastoponlos, Spisto, & Maher, 1994; Luf, tres than are children without ADHD (Breen, 1989; Grodzin Cohen, & Patish Pass, 1990; Mich & Loney, 1979). By therm sky & Diamond, 1992: Mariani & Barkley. in press), Adults selves, uch findings might sbggest a variety of problems besides with ADHD have also been shown to be less ble to replicate ‘working memory (i. deiciont arithmetic knowledge, slow mo- increasingly longer sequences involving pointing co locations tor speed, et.). However, Zentall and Smith (1993) wore able than are adults without ADHD (Barkley etal, in press). Though INHIBITION AND ADHD Dardly definitive, such findings suggest that this prediction is ‘worth testing in future studies of ADHD. Figure 1 also links poor inhibition with an impaired sense of ‘ime (working memory). Gerbing, Ahadi, and Patton (1987) also argued that the performance of time estimation—prodiction tasks say be related to impulsiveness, and White & al, (1994) found some evidence supporting that argument. Bat more direct ‘evidence for an impairment in the sense of time in children with ADETD has been found in two separate studies by Cappella, Genile, and Juliano (1977) and in three studies of mine, in which both rating scales assessing the seuse of time and its regulation of child behavior and a ime reproduction tak similar to that used by Zakay (1992) were used (Barkley, Koplowicr, a Koplowicr & Barkley, 1995), Ina fourth study, « Gai hp on ra esr (Chby young aduls with ADHD despite the liraitedsatsical power ‘of that study. All of these studies had a aumber of significant methodological flaws, which makes artempts at replication im- erative, but their general consistency supports the hypothesis about an impaired senso of time in ADHD. The model in Figure 1 also predicts that temporal delays should more adversely affect the performance of those with ‘ADHD than that of controls. Numerous studies of ADHD have found that both delays interposed in tasks and temporal uncer- taintics produce poorer performances (Chee, Logan, Schschat. Lindsey. & Wachemnth, 1989; Gordon, 1979; Somuge-Barke, Taylor & Hepinstall, 1992; Sonuga-Barke, Tayler. Sembi, & ‘Smith, 1992; van der Meere, Shalev, Borger & Gross-Teur, 1995; van der Mecre, Vreeling, & Sergeant, 1992: Zahn, Keusei, & Rapoport, 1991). Although supportive ofa deficit in time, tin- ing, and the cross-emporal organization of behavior in those with ADHD, such dela create and may delays may simply create boredom increase off-tak Sehavior m cer with ADAD ‘homamal tei petomance a sect Zonas (1985 Y optial staan Theory. Hindsight nd forethought have 201 been well tied in hose wif ADHD. But iin its most elementary form hindsight ean be taken to mean the ability to aller subsequent responses on the bass of immediately past mistakes, then the research fnd- ings imply a deficit in insight in hose with ADHD, Children With ADHD, like adus with prefrontal fbe injuries (Miner, 1998), are fess likely toads responses on ‘the basis of an immedis ‘incorrect response in an infor ‘mor foSnng est SUR ova de MoO AE) Te Amtngs oF petseaion on the WCST, as noted eat, ase sige suc a problem. esearch al ied complex ection ime aks with Warning stil and preparation nervals ny be relevant the const Of fretbough In sch eberhy chide wit ADD) fon filed to ae the warning stl fo preps for Ue wpcomag Tesponse trial (Douglas, 1983), and longer preparatory intervals. ttre mca with poorer perfomance Te eilren With [ADHD than in contol chen (Chee eal 1985 van det Meee etal, 1992, Zan et aly 1991) The capacity fo reat tnd mini niciptery st fr an impening set tao hat ‘been shown to be impaired by ADHD (vam der Meere et al.. 192), Mave perfomance may refect planing silty or fore- thought. Some studies have found children with ADHD to per- form poy on maze tase: ers ba hve. Bale tal, 1992: Grodzinsky & Diamond, 1992; Mariani & Barkley. in press: McG etal. 1989; Milich & Kramer, 1985; Moffit & va, 1988). The young, age ofthe participants may bea factor in some of the negative findings (Mariani & Barkley, in press). a5 may be the low power associated with the use of small samples (n < 20 per group: Barkley tal, 1992; McGee et al. 1989; Moffit & Silva, 1988). As noted earlier, the Tower of Hanoi and Tower of London tasks may reflect the capacity 10 plan or “look ahead" (Pennington etal. 1993), and children ‘with ADHD performed pool on these tasks. Although they are hardly definitive, the findings reviewed here are at least sugges- live OF deficiencies in hindsight, forethought, and. planning ability [No researchers of ADHD have examines verbal references ‘to time, plans for the future, the future more generally and other aspects of hindsight and forethought in discourse with others ‘Also, just how well those with ADHD are abe to temporally tag for organize thei recall and internal representation of sequential events has not been studied. Such deficits are common in. pat tients with prefrontal Jobe injures (Gershbere & Shimamura, 1995; Godbout & Doyon, 1995), however, which argues for thei Weely impairment in those with ADHD as well. Recent research on the verbal discourse of children with ADHD (Tan- rock, 1996) found deficits in the children’s organization of sequential material inthe retelling of stories, which might imply such a difficulty. Prior studies of narrative ability (Tannock, Purvis, & Schachar, 1992) and elicited language (Zenall, 1988) have also noted organizational deficits in children with ADHD. ‘Although organizational deficits in discourse are suggested by ‘these results, they may also reflect the presence of comorbid language problems known to exist in a substantial minority of| children with ADHD (Cantwell, & Baker, 1992). Possibly rl ing against such an interpretation is that Tannock (1996) used ‘2 control group of children with reading disorders who were [known to have language problems, and she still found greater ‘organizational deficits in the ADHD group. ‘The present model suggests that those with ADHD are less well contolled by internally represented information than are ‘others. Like patiems with prefrontal lobe injuries (Stuss & Ben- son, 1986), those with ADHD may be more controlled by exter ‘al stil. For instance, patients with prefrontal injuries are ‘more likely than nonpatients to have objects in the surrounding context elicit responses that may be appropriate as far as the objects’ use is concemed but that are not appropriate in that particular context (¢.8. opening an umbrella found inside an examination room; Goldberg & Podell, 1995); such phenomena are referred (0 as “utilization behavior” The model predicts that utilization behavior should be more evideat i children with ADHD, yet no research has been conducted on the issue. Such research might profit {rom borrowing the methodologies used to study this issue in patients with brain injury (see Goldberg é Podelt, 1995), ‘As noted cartier, those with ADHD have more trouble doing what hey know dian knowing what to do, Suggestive of this are past studies that have found hyperactive—impulsve chikien to be more prone to accidents than children who are not so 80 BARKLEY iagnosed (Bijur, Golding, Hastum, & Kurzon, 1988: Cayton, Bailey, Wagner & Hardesty. 1986: Methany & Fiske, 1984; “Taylor, Sanbere, Thorley. & Giles, 1991). yet hyperactive {impulsive children are not deficient i their knowledge of safety ‘or accident prevention (Mori & Peterson, 1995). Barkley etal. {in pres) also found that teens aad young aduls with ADHD have sigificandy more motor vehicle ascidems ard exhibit ‘ther driving risks (speeding) but demonstrate no deficiencies in their knowledge of driving, safety, and accident prevention. ‘Self-Regulation of Affect~Morivation—Arousal Inhibition is important in the development of emotional sef- regulation (Kopp. 1989), Figure 1 makes the following preic- tions about those who have deficiencices in inhibition, as in ADHD. They should show (1) greater errotional reactivity to ‘emotionally charged immediate events: (b) fewer anticipatory ‘emotional reactions to future emotionally charged events (in view ofthe decreased capacity for forethought): (c) decreased ability to act with the impact of their emotions on otbers in mind: (4) less capacity to induce and regulate emotional, drive ‘or motivational, and arousal stats in the service of goal-directed ‘behavior (the further away in time the goal, the greater the incapacity to sustain the arousal and drive toward the goal): and, the corrollary of d, (e) a greater dependence on extemal sources affecting drive, motivation, and arousal that are within the immediate contett in determining the degree of persisteace ‘of effort in goal-directed actions. Only a few of these predictions have been examined in ce- search, The development of inhibition has been shown to be important for developing self-regulation of emotion aod mative tion (sce Garber & Dodge, 1991; Kopp, 1989; and Misctel eta, 1989, for reviews), Preschool children's emotional responses to disappointment also have been shown to be related to sel regulation and disruptive behavior pattems (Cole etal, 1994) ‘Similarly, children’s erosional intensity and negative emotion have also been relate to teachar ratings of interference contol (Eisenberg et al, 1993). And Shoda et al, (1990) also found significant associations between inhibition in a resistance-0- {emptation ask in children’s preschool years and parent ratings ‘of the same children’s emotional control and frustration toler- ance at adolescence. ‘More evidence of a link between inhibition and emotional seiFeglation comes from research on neurologically injured pations. Disorders of emotion are common in individuals with injury sustained to the prefrontal corex. which suggests that this region is eriécal not onty for inhibition but for the self control of ematicn (Fuster, 1989; Rolls et al, 1994; Smss é Benson, 1986). The emotional changes secondary to frontal lobe injury can be grouped into three types of disturbance: (3) disorders of drive or motivation, (b) subjective emotional experience (mood), and (c) emotional expression (affect ‘Stuss, Gow, d Hetherington, 1992). Emotional hyperreactivity. itrtabilty, low frustration tolerance, loss of emotional seif- control, and lack of concem for athers (Rolls eta, 1994) are commonly noted in such patients. Akbough these findings are suggestive of link between behavioral inhibition and emotional self-tegulation, they do not confirm i Ueiabitey, hostility, excitability, and a general emotional hy- perresponsiveness toward others Rave been frequently described i the clinical lierature on ADHD (sce Barkley, 1990; Stil, 1902). Douglas (1983, 1988) anecdotally observed and later objectively documented the tendency of children with ADHD to become overaoused and excitable in response to rewarts and to be more visibly frusrazed when past rats of reinforcement declined (Douglas & Parry, 1994; Wigal etal, 1993, cited in Douglas & Parry. 1994). Rosenbaum and Baker (1984) also reported finding grester negative affect expressed by children ‘with ADHD during a concept learning ask involving noncontin. gent negative feedback. Ard Coe tal. (1984) found that levels Of negative affect were signfcanly and positively corclated ‘wih symptoms of and risk for ADHD bat only in boys. The opposite proved tue for gts. ‘The foregoing. stais intimate that emotional self-control say be problematic for children with ADHD. However children with ADHD may experience a greater number of failures on such tasks because of their other cognitive deficits (working tmemory) or comorbid learing disabilities that could lead 10 seater frusoation and oher negative emotional actions. Future researchers must therefore take cae to equate the levels of suc- cess berween children with and without ADHD before conclud- ing that children with ADHD ate more emotional during their performance om leasing tks. ‘Greater emotional reactivity has been reported as wel inthe social interactions of ehilzen with ADHD. FJ. Mash (persona communication, February 1993) found. that chitden wis ADHD displayed greater emotional intonation in theie verbal interactions wath their mothers than children without ADHD. Studies of peer imeracions have also found children with ADHD, compared with ose without ADHD, o be mose nepa- tive and emtaional in their social communications with peers (Petharn & Bender, 1982). The commonly noted association of ADHD with defiant and hostile behavior (for reviews, see Bark ley, 1990; and Hinshaw, 1987) may, at least in part, ster from 4 deficiency in emotional selfregulation in thse with ADHD. ‘Again however these findings are merely suggestive rather han eonfimatory of such a fink ‘The mode! also predicts that the peception of others” emo- tions will not be affected by ADHD because such perception is nonesecutive in nature The only stody of this issue of which 1 am aware support this view (Shapiro etal, 1993), but aution tat be exeised gen the many possible explanations for 8 failure wo reject the null bypotbess. ‘As for ADHD being associted with less drive, motivation, of fort inthe performance of goal-directed behaviors, researchers Ihave frequently commented on the appearance of such difficult {es when those with ADHD perform repetitive tasks that involve Tite or no reinforcement (Barber, Milch & Welsh 1996; Bark- ley, 1990; Douglas, 1972, 1983, 1988). Writen productivity in anihmesic sks, mn particlay, may be taken as a measure of persistence: se with ADHD are often found wo be ess produc- tive on such asks than contol children (Beskley, DuPal tal, 1990). Mukple studies also have documented an impairment in paristence of effort in laboratory tasks with chilrem with ‘ADHD (August, 1987; Barber et al, 1996; Borcherding eta. 1988; Douglas & Bevezra, 1990; Milich, in press; van det INHIBITION AND ADHD 81 Meere, Hughes, ef al, 1995; Wilkison, Kircher, MeMabon, & Sloane, 1995). Thus, the evidence for difficulties in the self regulation of motivation (effort) in those with ADHD is fairly impressive. Is possible thet his component ofthe model (self-regulation ‘of motivation) provides an explanation for the apparent insensi= tivity wo reinforcement reported in some studies of children with ADHD (see Barkley. 1989; Douglas, 1988; Haenlein & Caul, 1987; and Saguolden, Waltz, Moser. Moser, & Morkrid, 1989, for reviews). Studies that used varying schedules of reinforce. ‘ment typically found that children with and without ADHD did not citfer in their task performances under immediate and ccontinaous reward (Barber etal. 1996; Cunningham & Knights, 1978; Douglas & Parry, 1983, 1994; Parry & Douglas, 1983). {In contrast, in some studies when partial reinforcement was introduced, the performance of children with ADHD declined telative to that of children without ADHD (Parry & Dougiss. 1983; Freibergs & Douglas, 1969). Just as many studies, how. fever did not find this decline (Barber et al., 1996; Pelham, Milich, & Walker, 1986) or found thatthe difficulty of the task moderated the effect (Barber & Milich, 1989). In a similar vein, the performance of children with ADHD during relatively tedious tasks involving little oF no reward was often enhanced by the addition of reinforcement, yet so was the performance ‘of children without ADHD (Carlson & Alexander, 1993; Iabont et al. 1995: Kupierz, Camp, & Weissman, 1976; Pelham et al., 1986; Solanto, 1990; van der Mere, Hughes, Borger & Salloe, 1995), These findings have been interpreted as suggesting that children with ADHD have areduced sensitivity to reinforcement (Haenlein & Caul, 1987) or are dominated by immediate rein- forcement (Douglas, 1983; Sagvolden ef al, 1989). Bout the similar enhencement of the performance of children without ADHD by reward in some studies hs challenged this imerpreta- tion (Pelham et al, 1986; Solanto, 1990). Douglas (aboni et al, 1995) also did not find the predicted reward dominance ellect in those with ADHD. ‘The model in Figure 1 suggests a more plausible explanation ‘or these results. It focuses on the observations that he perfor= ‘mance of children without ADHD is superior to that of those with ADHD under conditions of little or no reward and may be less affected by reductions in schedules of reinforcement depending on the task duration and its difficulty level. Tis may result from children without ADHD developing the capacity (0 bridge temporal delays between the elements of behavioral Contingencies through the executive functions in the model. Combined with working memory as well as setf-directed speech and the rule-govemed behavior it permits the self-regulation of ‘motivation may allow children without ADHD not only to retain the goal of their performance in mind and subvocally encourage themse!ves in their persistence but also to create the drive neces- ‘ary for such persistence. This line of reasoning suggests that, across development, the behavior of those with ADHD remains ‘more contingency shaped, or more undet the control of the immediate and external soorces of reward, than does the behav- lor of children without ADHD. Children without ADHD are becoming increasingly rule governed and internally controlled. Therefore, itis not that children with ADHD are les sensitive 19 reinforcement or are dominated by a tendency to seek immediate rewards, Rather they have a diminished capacity for self-regula- tion of motivation {effort) as well as poorer worki and internalized self-speech, all of which assist wit Gelays im reinforcement and permit the persistence of goal rected acts despite dearth of immediate reinforcement for doing so. CConceming the self-regulation of arousal, some evidence does xis for possible problems jn those with ADED in the regula- tion of central and autonomic nervous stem arousal fr meet- ing ask demands. Multiple reviews ofthe psychophysiological (Brand & van der Viuge, 1989: Hastings & Barkley. 1978: Klor- rman etal, 1988; Rosenthal & Allen, 1978; Rothenberg, 1995) and cognitive (Douglas, 1983, 1988) literatures have concluded that childen with ADHD show greater variailty in cena! and autonomic arousel patterns and seem underreatve 10 simul tion in evoked response paradigms, particularly in te later P300 feaures of the evoked response. These P30) characteristics have been shown to be assocsled with frontal lobe activation (lor rman, 1992; Klorman ta, 1988: Knights etal, 1995), Children with ADHD, relative to contol groups. have also been shown to display less antiipatory activation on electromneephalogras in response to impending events within tasks, knovn as the ‘contingent negative variation (CNV) ar “expectancy” wave ‘(Hastings & Barkley. 1978), and to have less reoruiting of paychophysiological activity over the frontal regions when nec= ‘scary for appropriate task performance (Brand & van. der Viugt. 1989: Rothenberger, 1995). Suadies that used positron emission tomography (PET) to measure brain activity also found diminished brain activation in adults as well as in adoles- cent gets with ADHD (Emst et at, 1998; Zametkin et al, 1990). Results obtained with adolescent boys were more equiv- cal (Zametkin et al, 1993). Similarly. studies that wed cere- ‘ral blood flow to measure brain activity found decreased perf- sion of the frontal regions and striatum in those with ADHD (Lou et al, 1984, 1989: Seig et al, 1995). The evidence avi able to date is certainly suggestive of problems inthe regulation ‘of arousal or aetivation in those with ADHD. wich much of this evidence implicating frontal lobe underactvity. Internalization of Speech “The association of uninhibited behavior with less mature self

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