63: Russell Barkley on the Meaning of ADHD


with Dr. Russell Barkley, professor, researcher, educator

Renowned professor, educator, and author of numerous ADHD books and clinical manuals, Dr. Russell Barkley talks about the mechanics and ideas behind many core ADHD concepts. Ranging from executive functions, to neuroimaging, to public perception and more, Dr. Barkley shares knowledge from his extensive research and informed perspective on ADHD, breaking down its basic concepts in an understandable and approachable way.

Russell Barkley:

  • Clinical professor of psychiatry and pediatrics at the Medical University of South Carolina in Charleston

  • Clinical scientist, educator, and practitioner who has authored, co-authored, and co-edited over twenty books and clinical manuals.

  • Has published over 200 scientific articles and books related to the nature, assessment, and treatment of ADHD and related disorders.

Studies on Executive Function:

  • Russell, trained as a neuropsychologist, found years of research signaling that the symptoms of ADHD were very similar to the symptoms of those with frontal lobe disorders, albeit milder.

  • Many have continued to study the overlap between ADHD and frontal lobe functions and, in particular, executive functions.

  • In surveying available research, Russell came across over twenty-five different definitions for “executive functioning”, which in turn creates problems assessing disorders if different people are working off of different definitions.

  • In order to tackle this issue, Russell decided to focus on creating a concrete operational definition and began at a point where virtually all of the existing research agreed: self-regulation. Thus, executive functioning has to do with what one does to oneself.

  • Self-regulation, or self-control, is any action one directs at oneself to change their behavior from what it automatically would have been, with the intent being to then affect change in their future.

  • The most common executive functions that almost all researchers agree on are:

    • Self-awareness

    • Inhibition

    • Non-verbal working memory

    • Verbal working memory

    • Emotion regulation

    • Self-motivation

    • Planning and problem-solving

  • Eric: When I read that self-awareness was an executive function, it made a lot of other aspects of ADHD more understandable; if you’re not aware of what you’re doing and why you’re doing it, you can’t modify your behavior.

  • With those seven functions as a framework, Barkley then turned toward what people are doing to themselves and used that to rephrase the ideas.

  • According to Barkley’s model, and consistent with others’, people don’t attain their executive functions all at once – they’re developed in stages as they grow up.

  • The first three that tend to develop together are self-awareness, self-restraint, and visual imagery (seeing to yourself). Within about five years, self-speech will then develop.

  • The remaining functions, self-directed emotion, self-motivation, and planning and problem-solving, are forms of self-play. In other words, they’re derivatives of when people take apart new information and restructure it in their minds in order to invent new ideas, overcome obstacles, and create multiple options for themselves.

  • If the executive functions developed early are impaired, as is the case with ADHD, the later ones are at risk of being as well.

Executive Functions as a Developmental Model:

  • In, for instance, those with reading disorders, there is a certain level of executive functioning one needs to have by adulthood in order to be considered to be on a functional level – in the case of reading, that is usually somewhere around a sixth or seventh grade level.

  • If people are able to attain a functional level of proficiency with their executive functions, they will at least function okay in normal life.

  • Unfortunately, many with ADHD either don’t reach a functional level, only reach that level marginally, or do so erratically, which leads to problems.

Neuroimaging:

  • When compared to neuro-typical people, when neuroimaging studies are conducted across large groups of people, we can see numerous differences, particularly in five different areas. Within these regions, there has been observed anywhere from a five percent to a thirty-five percent difference in size.

  •  However, the overlap between the brains of those with ADHD and those without is sufficient enough to prevent the use of brain scans in diagnosis.

  • The functional differences between the brains of those with ADHD and those without are so subtle that they’re not reliably visible on an individual basis – they can only be viewed through averaging results from testing large groups of people.

  • It is for this reason that attempting to individually diagnose people via these brain scan methods will fail or provide false negatives approximately thirty-five to fifty percent of the time; thus, the devices cannot be used for clinical practice.

Question: If ADHD is a developmental delay of the cortex, why do people not outgrow ADHD once their brains catch up developmentally?

Answer: When the word “delay” is used here, it’s not to mean that the delay is temporary. Delays can be permanent, and can indicate development at a rate that is below the rate of typical people. Similar milestones may be met, but they will be met later, and one’s “ceiling” once development has ended, will be lower than that of a typical person.

Time and Planning:

  • Executive functions become harder to spot individually as a person grows older.

  • The seven core executive functions are used together to form the five dimensions of executive functioning in everyday life:

    • Self-restraint (Inhibition)

    • Time management

    • Self-organization (verbal and non-verbal working memory systems) and problem solving

    • Emotional self-control

    • Self-motivation

  • These five qualities are the parts of people’s daily lives that the executive functions contribute to and, thus what are disrupted by ADHD.

  • As a typical person grows older, the scope of their time management ability grows with them:

    • Young children think about only the present

    • Early elementary school-age children think about twelve hours ahead

    • Later in elementary school, the time extends to about one or two days

    • Teenagers: between three and seven days ahead

    • College students: one to three weeks ahead

    • People in their thirties: two to three months ahead

  • Those with ADHD incur about a 30–40% delay in their time management and planning ability.

  • “Adult ADHD is the worst disorder you can have with regard to time management. There is no psychiatric disorder as impairing of time as adult ADHD.”

  • “As Ned Hallowell says, people start to view this aspect of ADHD as a moral failing, as a choice. ‘You just don’t care. Because, if you cared you’d get these things done.’ Whereas we know it’s a neural–biological deficit. It has nothing to do with choice and moral turpitude.”

Externalizing and Scaffolding:

  • In order to cope with it, those with ADHD have to focus on “scaffolding”: building structures around them to handle the timing, inhibitory, problem-solving, emotional, and motivational deficits.

  • Those with ADHD have to create structures outside of themselves to manage what other people’s internal structures manage.

  • Barkley: “You can’t rely on mental information to guide you, to help you remember. You need to be using journals and sticky notes and cards and reminders on your computer and all this other technology.” “You have to offload your working memory on to other devices.”

  • Eric: “In my office, there’s no spot where I will be looking where I do not have a clock in my field of vision.”

  • There are six recommendations for handling deficits in executive functioning:

    • Externalize information

    • Externalize time

    • Externalize your motivation (e.g. creating extra sources of reward, making oneself accountable, and creating consequences where they didn’t exist)

    • Externalize your emotional control (e.g. asking others to cue you in when you drift into overly emotional states – being too silly, talking too loud, becoming frustrated, etc.)

    • Externalize problem-solving (e.g. writing down pieces of a problem, then playing with them outside of your mind)

  • Eric: “My internal clock never came with batteries, so I make sure all my timers have fresh batteries in them.”

Misinformation, Media, and Emotion:

  • Barkley: Part of the misinformation published to the public comes from fringe political and religious groups attacking psychiatry, mental health, diagnoses, and medication.

  • On the other hand, part of the problem also stems from the public at large not having a great understanding of mental disorders.

  • Some assume others misbehaving as a result of mental disorders are instead acting that way because of their upbringings, poor parenting, lacking schooling or education, and that the core reasons for that misbehavior lie outside of the person.

  • People will then use that assumption as a foundation for thinking that these disorders either don’t really exist, or that solutions for their treatment can be found in parenting and education.

  • In reality, ADHD has neuro-biological causes: genetics and neurologic foundations; upbringing plays no part in ADHD.

  • After more than twenty-thousand studies, it’s evident we are dealing with a genetic and biological disorder.

  • Eric: Having struggled with managing emotions as part of ADHD, I can see how much of a factor emotions might play into this scenario, despite the clear-cut data existing. Perhaps there are ways we can discuss this data that will make others respond to it more on an emotional level.

  • Other disorders, like intellectual development disorders, autism, learning disorders, were also initially blamed on similar socially based causes before they were studied enough and found their way into the public consciousness.

  • It took anywhere from ten to thirty years for many other disorders to attain public recognition and respect as biological disorders.

  • However many of these other disorders had champions in the celebrity communities, spokespeople in the main-stream media, actors, athletes, and even TV shows where the disorders were woven into plotlines. Over time, they became normalized as neurobiological.

  • Although ADHD has its spokespeople and celebrities, it’s ultimately going to take some time for it to fall into general acceptance.

  • Barkley: We need to start calling out people out who are holding these misguided views.

Sluggish Cognitive Tempo, Concentration Deficient Disorder:

  • Barkley: There is a subset of people with attention problems that don’t appear to be in line with ADHD at all, but they’re still being categorized under the umbrella of ADHD.

  • A term was coined in 1986 by Ben Lahey to describe this dimension of inattention: Sluggish Cognitive Tempo (SCT).

  • SCT consists of staring, daydreaming, pensiveness, a sleepy sluggish appearance, being very inwardly preoccupied, etc.

  • SCT is distinct from ADHD in many ways:

    • While ADHD is sometimes linked with conduct problems, substance abuse, anger, hostility, and aggression, SCT is more linked with depression and anxiety.

    • Those with ADHD are usually very outspoken, talkative, and engaging. Those with SCT tend to be reticent, shy, reserved, and quiet.

  • In the past five years, Dr. Barkley and others have conducted national surveys that document SCT being as prevalent as ADHD.

  • Also, they realized both ADHD and SCT can exist at the same time in the same person.

  • When combined, they are far more impairing than either one is by itself.

  • The name, however, is not liked by many – it is pejorative. Barkley has proposed it be named Concentration Deficient Disorder (CDD).

Russell’s Brother:

  • ADHD is a spectrum disorder, in that it can be mildly or severely impairing.

  • Often, ADHD will be paired alongside other disorders.

  • Dr. Barkley had a twin brother, Ron, who had severe ADHD alongside other learning disabilities.

  • Even at a young age, Ron had encountered multiple life-threatening accidental injuries

  • Though he was a very engaging, funny, talkative person, he was a poor student. At age sixteen he left school to pursue a career as a talented rock musician.

  • Despite being tremendously creative and having relative success as a musician, he struggled with impulsiveness, risk-taking, poor organization, and emotions, which then lead to poor relationships with others.

  • He would regularly speed, drive without a seatbelt, drink too much, and engage with drugs.

  • In and out of treatment, Ron would sometimes willingly be treated and other times deny there were any problems before stopping treatment.

  • Unfortunately, Ron died following a car accident during which he was speeding with no seatbelt.

  • Barkley: This just illustrates the life-threatening nature that this disorder can have. This is a disorder that needs to be taken seriously.

  • ADHD is a spectrum disorder, in that it can be mildly or severely impairing.

  • Often, ADHD will be paired alongside other disorders.

  • Dr. Barkley had a twin brother, Ron, who had severe ADHD alongside other learning disabilities.

  • Even at a young age, Ron had encountered multiple life-threatening accidental injuries

  • Though he was a very engaging, funny, talkative person, he was a poor student. At age sixteen he left school to pursue a career as a talented rock musician.

  • Despite being tremendously creative and having relative success as a musician, he struggled with impulsiveness, risk-taking, poor organization, and emotions, which then lead to poor relationships with others.

  • He would regularly speed, drive without a seatbelt, drink too much, and engage with drugs.

  • In and out of treatment, Ron would sometimes willingly be treated and other times deny there were any problems before stopping treatment.

  • Unfortunately, Ron died following a car accident during which he was speeding with no seatbelt.

  • Barkley: This just illustrates the life-threatening nature that this disorder can have. This is a disorder that needs to be taken seriously.

Random Question Round:

  • If you could either create a new invention or improve upon an existing one, what would it be?

  • If you were to enter a talent show, what would your talent be?

  • What animal freaks you out the most?

  • If every meal you ate from now on had to be the same, what would you eat?

Links:

Find and Contact Russell Barkley:

Other information:

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  • Help CHADD, an ADHD organization dedicated to improving the lives of those with ADHD through useful research and support, by donating to their fundraising campaign here: gofundme.com/oneof15m.

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