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ADHD and the Nature of Self-Control

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 Recensions
mensional view of psychopathol-
ogy. "Schizotypy" - the focus of
this book - can be conceptualized
as a set of traits that form the basis
of a variety of illnesses, ranging
from schizophrenia to personality
disorders, as well as of normal
variations in personality that can
produce eccentricity or creativity.
Two issues arising from this
theory are of particular interest to
psychiatrists. First, some evidence
suggests that both forms of psy-
chosis originally described by
Kraepelin (i.e., schizophrenia and
bipolar disorder) could lie on a
single dimension, and may not be
as separate as we often assume.
Second, disorders not usually
considered to reflect schizotypal
traits, such as obsessive-compul-
sive disorder and dyslexia, may
reflect the same psychopathologic
dimension - at least in part.
Several chapters in the book
raise questions of broader theoret-
ical significance. There are excel-
lent reviews of research on cogni-
tive processes and cerebral
lateralization in schizotypy. Other
chapters concern the measure-
ment of schizotypal traits. Finally,
there is a whole section entitled
"schizotypy in health subjects."
This book has strengths and
weaknesses. Since all chapters are
written by Claridge and his col-
laborating colleagues, the text is
much more coherent than many
multi-author books. On the other
hand, research conducted outside
of Great Britain is not given
enough weight. Although Clar-
idge suggests that readers also
consult a recent companion vol-
ume based on a conference on
schizotypal personality,' the con-
tributions of investigators such as
Holzman2 and Siever and Davis3
312
could have been given much
more space.
Claridge's strong editing leads
to a relatively high standard of
scientific writing throughout. In-
evitably, however, some of the
chapters are hard-going, while
those written by the editor him-
self are the best. Claridge is a nat-
ural writer and communicates in
an incisive and witty way that
quickly engages the reader.
I was particularly stimulated by
Claridge's ideas about how to con-
ceptualize psychopathology in a
dimensional system. The point of
view is refreshingly different from
the perceived wisdom in North
America. These principles are also
developed in several of the chap-
ters written by neuropsychologists.
Although I agree strongly with
the general approach of this book,
it lacks breadth. It fails to address
some of the most crucial areas for
theory, most particularly genetics
and neurobiology. I also found
myself less than sympathetic to-
ward the chapters on normal
schizotypy, some of which come
dangerously close to reviving the
Laingian romanticism of the 1960s.
A related objection concerns the
emphasis in many chapters on the
role of psychosocial factors in the
etiology of schizophrenia and re-
lated disorders. I agree with Clar-
idge that psychiatrists are often
too busy prescribing medication
to consider individual differences
in the psychology of their patients,
and that cognitive therapy may
well have a role in the treatment
of psychosis. However, his views
on the role of the environment can
be somewhat quirky, most partic-
ularly his somewhat dogmatic
idea that trauma and bad parent-
ing are the major factors that de-
Revue de peet de neuroscience
termine whether traits develop
into disorders.
With these caveats, I found this
book highly original and ex-
tremely thought-provoking. Re-
searchers studying disorders re-
lated to schizotypy will find it a
useful reference, and clinicians
and clinician-teachers will benefit
from reading the theoretical chap-
ters. The main impediment to the
wide use of this volume is the
price, which, whatever the state of
the Canadian dollar, is much
higher than for books imported
from our southern neighbour.
Joel Paris, MD
Montreal, Quebec, Canada
References
1. Raine A, Lencz T, Mednick SA, edi-
tors. Schizotypal personality. New
York: Cambridge University Press;
1995.
2. Holzman PS. On the trail of the ge-
netics and pathophysiology of schizo-
phrenia. Psychiatry 1996;59:117-27.
3. Siever LJ, Davis KL. A psychobiological
perspective on the personality disor-
ders. Am J Psychiatry 1991;148:1647-58.
ADHD and the Nature of Self-
Control. Barkley RA. New York:
The Guilford Press; 1997. 410 pp
with index. ISBN 1-57230-250-X
(cloth). US$40.
Attention deficit disorder is the
most thoroughly researched psy-
chiatric condition that affects chil-
dren. There have been thousands
of scientific reports on this condi-
tion, from the story of fidgety Phil
written by the German physician
Heinrich Hoffmann some 150
years ago to a study of 20 children
by George Still, published in the
Lancet in 1902, in which he de-
scribed what it was like to have a
deficit of "volitional inhibition" or
"defect of moral control of their
VI. 23, n05, 1998

behaviour." However, virtually
all work has been atheoretical; au-
thors describe the epidemiology,
clinical symptoms, specific behav-
ioural and cognitive deficits or
treatment approaches of these
youngsters, but offer no theory on
the underlying cause.
Dr. Barkley, a highly respected
researcher and clinician in the
area of attention deficit/hyperac-
tivity disorder (ADHD), is trying
to change this, and in this volume
lays out a thought provoking and
sophisticated theory of ADHD.
He takes the reader through the
last 50 years of work on ADHD
and ends his review by conclud-
ing that there are 2 forms of sus-
tained attention: one that is con-
text dependent, contingency
shaped or externally controlled,
and one that is goal directed and
internally guided. Barkley claims
that children with ADHD only
have difficulties with the second
type and therefore suffer from a
central deficit of behavioural inhi-
bition. This function, according to
Dr. Barkley, is necessary for the
development of 4 executive func-
tions, which in turn allow us to
modulate our experiences and be-
haviour through effective internal
controls. Brief descriptions of
these 4 executive functions follow.
Non-verbal working memory. This
function allows us to hold events
in our minds, to manipulate or act
on events mentally, to have hind-
sight and foresight, to anticipate
the future and to have a sense of
time and self-awareness.
Verbal working memory. This in-
cludes an internalization of speech
and allows for description and re-
flection, problem solving, self-
questioning and effective genera-
tion of rules and moral reasoning.
X~WVoI.23,n.S, 1998
,
Self-regulation of affect, motivation
and arousal. This allows us to prac-
tise emotional self-control and
gives us social perspective and a
sense of long-range planning.
Reconstruction. This function
supports an analysis and synthe-
sis of behaviour, verbal and be-
havioural fluency, behavioural
creativity and diversity as well as
behavioural simulation.
Dr. Barkley convincingly argues
that deficits in these executive
functions can lead to problem be-
haviour and poor motor control,
primarily because of impaired
goal-directed persistence or re-
sponses, a lack of behavioural
flexibility and insufficient inhibi-
tion of tasks to relevant responses.
He supports his arguments by
citing various studies that have
documented specific cognitive
weaknesses or deficits in children
with ADHD that could reflect
problems in specific executive
functions. However, there have
not been any studies that have
looked at a wide range of execu-
tive function tests in a good sized
population of ADHD children.
Hence Dr. Barkley's theory has not
yet been empirically proven. As
far as the difficulties are con-
cerned, Dr. Barkley sees the central
deficit of children with ADHD to
be biological and located in the
prefrontal lobe. This is based on a
number of studies that have
shown a smaller size or less blood
flow to this area in children with
ADHD. The "prefrontal lobe area
causation theory" fits with Dr.
Barkley's conceptualization of the
brain. In particular, he stresses that
the cerebral cortex is concerned
with the mental representation of
the outside world and that the
temporal, parietal and occipital re-
.wrixal of Psychiatry & Nenroscience
Boo6k Reviews
gions form and store these repre-
sentations. The prefrontal lobe, in
turn, is seen as an area that acti-
vates the other regions as needed,
or holds them in line for guiding
future responses. Specifically, he
thinks that this area of the brain
shows maturational deficits in
children with ADHD that are pri-
marily inherited and only very
rarely the result of specific trau-
matic events.
Dr. Barkley's theory has implica-
tions not only for the diagnosis of
ADHD but also for its treatment.
Specifically, stimulant medication
is advocated to improve behav-
ioural inhibition and thus allow
for a strengthening of the 4 execu-
tive functions. Furthermore, the
deficit in using internally repre-
sented forms of information to di-
rect behaviour is best dealt with by
externalizing information and
making it relevant and interesting
for the child. For example, Dr.
Barkley suggests that teachers and
parents use external prompts,
cues, or reminders (e.g., a sign at
the door saying "Have you turned
off the light?") to keep children
with ADHD focused. He even sug-
gests that rules and directions can
be tape-recorded and played while
the child works.
Another recommendation is to
move interventions out of the of-
fice to the place where the behav-
iour is likely to take place. This al-
lows immediate reinforcements
and rewards to occur where they
will be most effective.
The sense of time and its passage
also need to be externalized to help
deficits of reconstruction. This can
be done by making the concept of
time concrete with the help of
eggtimers and by disassembling
past events into smaller segments
313
%,I oX
J14.
Recensions
and recombining them into more
useful and practical modules.
It follows that ADHD is seen as
a chronic disability and that the
learning that takes place while a
child is taking methylphenidate
(Ritalin) will usually not be helpful
once the medication is discontin-
ued. While Dr. Barkley stresses the
developmental aspects of ADHD
- he underlines the fact that dif-
ferent children show different de-
grees of deficits in their executive
functions and that some aspects of
the condition improve with the
maturation of the central nervous
system - ADHD is still seen as a
lifelong condition.
Dr. Barkley's theory is intriguing
and challenges much of our tradi-
tional thinking. In fact, few clini-
cians will dispute the fact that chil-
dren with ADHD have many of
the deficits described here and that
our current treatments often do
not adequately address them. The
treatment implications of the the-
ory - the use of stimulants in
combination with psycho-educa-
tional measures that aim to exter-
nalize information and motivation
- are also important and valu-
able. However, all of these sugges-
tions assume that the patient will
be at least moderately cooperative
and willing to work with parents
or teachers in a common struggle
against the negative consequences
of ADHD. Dr. Barkley's sugges-
tions do not tell us how to win out
over the external and potentially
illegal rewards (e.g., stealing or
drug use) emanating from the be-
haviour of problematic peers. The
theory also does not sufficiently
differentiate the deficits of children
with ADHD from those with other
cerebral dysfunctions who show
similar disabilities but who re-
314
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spond more successfully to selec-
tive serotonin reuptake inhibitors.
Despite these questions, I found
Dr. Barkley's book to be both in-
formative and fascinating. It
makes us rethink an age-old ques-
tion and, helped by the precise
and clear writing of the author, al-
lows us to marvel at the complexi-
ties of our feelings and thoughts. I
recommend it highly to anyone
who deals with children with
ADHD in a professional capacity.
Klaus Minde, MD
Montreal, Quebec, Canada
Psychiatric Comorbidity in
Epilepsy: Basic Mechanisms, Di-
agnosis, and Treatment. H. Mc-
Connell, Peter J. Snyder, editors.
Washington (DC): American Psy-
chiatric Press; 1998. ISBN 0-88048-
853-0 (hardcover). US$54.00.
There is a fascinating and com-
plex interrelation between psychi-
atric pathology and epilepsy. His-
torically, epilepsy was known as
the "sacred" disease because of its
alleged association with astrology,
with the divine, and with demoni-
acal possession. Despite Hip-
pocrates' assertion that epilepsy
"is no more divine nor more sa-
cred than other diseases, but has a
natural cause like other diseases,"
these misconceptions continued
until well into the 19th century,
when the neuropathologic origins
of epilepsy were identified.
However, the association be-
tween epilepsy and psychiatric ill-
ness did not cease when it was
identified as a neurologic condi-
tion. People with epilepsy have
an increased prevalence of both
affective and schizophreniform
disorders. Personality and adjust-
Revue de psychiatre et de neuroscience
ment disorders are common and
seizures may be simulated by
conversion states. Epilepsy also
has profound socioeconomic im-
plications for the sufferer. It is
perhaps therefore the "psychoso-
matic" illness par excellence.
This book is a compendium of
the psychiatric conditions associ-
ated with epilepsy. Its 12 chapters
cover the historic, physiologic,
pathologic, clinical and social as-
pects of epilepsy. There is an ex-
cellent chapter on the changing
systems of classification of the
epilepsies; the current interna-
tional classification bears little re-
semblance to the systems used
even 50 years ago. The advent of
sophisticated investigative tech-
niques for studying neuronal ac-
tivity, such as EEG recordings
and neuroimaging, has given this
system a firm neuroanatomical
basis, and has helped to integrate
the neuroanatomical changes
with the clinical seizure pattern.
There are excellent chapters on
the neuropsychological assessment
of patients with seizures, and on
the mood disorders and psychoses
associated with epilepsy. The latter
chapter is of particular interest be-
cause recent developments have
shown that there are lesions in the
medial temporal structures of the
brain in both epilepsy and schizo-
phrenia. This etiologic overlap
may explain not only the increased
prevalence of schizophreniform
psychoses in patients with epi-
lepsy, but also suggests that there
may be a neurophysiologic over-
lap at the neurotransmitter level
between these seemingly disparate
conditions.
Perhaps the 2 most useful chap-
ters in the book are those on phar-
macology. One reviews the behav-
VOL23.* n 5t 1998