I had been trying to post on the blog much more frequently than this, but I am shocked to find that it has been 2 months! The office has been very busy -- but that has been because I have taken several short vacations and I have had to "squeeze in" appointments when I have been here. The major reason for my silence has been a lack of inspiration -- I am still reading the book by Barkley to which I referred on May 31.
I finally found another issue which struck me as worth posting about. It is in the portion of his book where he is predicting the likely problems which will result from ADHD if, as he has proposed, the disorder is primarily a delayed ability to stop immediate responses to environmental stimuli. (He denies that these "predictions" have stemmed from actual observations of people with ADHD rather than coming only from his hypothesis and the evidence with which he supported it. Personally, I don't see how his years of experience in evaluating children and adults with ADHD can help but inform these predictions, but I won't argue the point any further.) After he predicts "Diminished and Disorganized Verbal Thought," he addresses "Impaired Self-Regulation of Affect/Motivation/Arousal."
I was intrigued by his mention of motivation, as some of my patients state that their lack of motivation is one of the aspects of ADHD they find most frustrating. One parent complained that her teenage son didn't seem to like doing anything and that she was hard pressed to reward good behavior, since there was so little he regarded in a positive light. This worried me and I examined him carefully for signs of depression, but he had no other symptoms suggestive of it. An older patient came in to resume treatment after being off of medication for some time. He complained that when he was unmedicated "I just didn't want to do anything!"
Barkley suggests that a lack of self-motivation results from the difficulties with remembering emotional states associated with previous similar situations. (Remember the executive functions of self-regulation and working memory.) Because a person with ADHD has trouble calling to mind previous rewards from a given activity, he or she is less likely to repeat that action unless immediate positive feedback is anticipated. The actual wording is as follows: "By being less capable of mentally representing and sustaining internal information about prior contingencies, those with ADHD are less able to reawaken their associated affective and motivational states. This should create a condition in which those with ADHD are unable to covertly emote to and motivate themselves.... and so remain dependent on external forms of immediate reinforcement in order to persist at tasks and activities and to defer gratification." (You can see why it's taking me so long to read his book. Every paragraph is like that.)
It was gratifying to be able to apply his complex prediction to my simpler model of ADHD. Essentially, the problem in ADHD brains is that they cannot always stop the automatic shift of attention that occurs for every sensory event. The message to do so is sent, but does not get through. More messages are sent (and thus one of them will be more likely to reach its goal) if positive reinforcement is anticipated for sustained attention, or if negative reinforcement will result from distraction. When a brain does not efficiently recall previously felt emotions, it cannot anticipate either good or bad results and no additional messages will be sent. A general lack of motivation then results from an inability to sustain attention to a situation long enough to predict a positive or negative outcome. Such prediction may be even less likely in a person with ADHD since they cannot easily "relive" previous similar situations.