I finally finished the book I've been working on for so long and I'm pleased to say that I have gotten a lot out of it. I'm not sure it's what Dr. Barkley intended me to get, however! As I have mentioned, he is a psychologist rather than an M.D., so he doesn't prescribe medication. He very firmly believes in it, but his views on the nature of ADHD are colored by his expertise in behavior management and the descriptive nature of mental disorders up to the last few years. He recommends psychological counseling in addition to medication in every person with ADHD. Furthermore, he is in a large academic center, so he aims to make recommendations that can be supported by peer reviewed research.
As I understand them, these are his new theories about ADHD:
1. It is a disorder of behavioral inhibition, not primarily a problem of attention.
2: The disorder is a delay in the usual pattern of learning to control one's behavior.
3. The usual pattern is an internalization of the external cues/environmental feedback that initially govern children's behavior.
4. Primarily inattentive ADHD may be an entirely different disorder.
I disagree with #1, primarily because I disagree with #4, but I think that his emphasis on inhibition rather than attention is not entirely wrong. As I may have said before, I feel that the basic problem in ADHD is a failure to stop an automatic response to a distraction in order to stay attentive to what one is doing. If that response is an action, then it is a failure of behavioral inhibition. However, if that response is only a change in one's focus it is a failure of attention.
If one adds "and attention" to #2 and #3, I actually agree with them. I don't agree with Dr. Barkley's following suggestion that different behavioral analysis be performed for different age groups. I think that the current symptoms can be adapted by the diagnostician to each patient's developmental stage. #3 gives a very practical suggestion to treat ADHD, which Dr Barkley acknowledges, but does not emphasize as much as his opinions about changing diagnostic and research strategies. Essentially, the person with ADHD can "re-externalize" behavioral/attentional controls. Specifically, one can replace the internal time sense lacking in so many people with ADHD by utilizing timers and cell phone alarms. Written lists replace faulty working memories and rewarding oneself for each completed task with a tangible consequence can enhance self-motivation.
The end result of reading Dr. Barkley's book, ADHD and the Nature of Self Control was that it solidified some of my impressions about the nature of ADHD. It also gave me a lot of food for thought and some practical information for my patients.