It has been argued that the fundamental deficit in individuals with ADHD is one of self-control, and that problems with attention are a secondary characteristic of the disorder.

During the course of development, control over a child's behavior gradually shifts from external sources to internal rules and standards. Controlling one's behavior by internal rules and standards is what is meant by the term "self-control."

For example, young children have very little ability to refrain from acting on an impulse, i.e. to "inhibit" their behavior. Instead, it is more typical for a young child to "act out" the things that pop into his mind. When a young child is able to refrain from acting on impulse, it is often because something in the immediate surroundings keeps them from doing so. For example, the child may refrain from throwing a toy when frustrated because his mother is present, and he knows he will be punished if he throws it.

This is different from an older child who may also have the impulse to smash a toy, but who does not act on this impulse because he can anticipate the multiple specific consequences, such as not having the toy to play with later on, his parents would be upset if he broke his toy, he would be upset for letting down his parents and he would be upset because he let himself down by letting his temper get out of control.   This older child has learned to "inhibit" and regulate his behavior based on internal controls and guidelines, rather than the younger child who controls himself only under the immediate threat of punishment, i.e., external controls. 

Self-Regulation as the Core Deficit in ADHD

It is thought that the critical deficit associated with ADHD is the failure to develop this capacity for "self-control," also referred to as "self-regulation."  It is hypothesized that this failure to develop self-control is biologically caused although we don’t know why or how this happens.  Because children with ADHD fail to develop self-regulation there are many other abilities that fail to develop as well, including working memory, internalization of speech, sense of time and goal directed behavior.  Failure to develop these specific skills results in frequent behavior, social, and academic problems.

Working Memory is the ability to recall past events and manipulate them in one's mind to be able to make predictions about the future. This is an important part of dealing effectively with day-to-day situations that is diminished in individuals with ADHD.  

Internalization of Speech is the ability to use internally generated speech to guide one's behavior and actions, i.e., talking to yourself to tell you what to do. This capacity develops later and less completely in individuals with ADHD.

Sense of Time is the ability to keep track of the passage of time and to change one's behavior in relation to time.  Consider how often one needs to evaluate the time required to accomplish a particular task and how the time you are devoting to a particular task compares to what is available, and what will be required for other tasks.   For individuals with ADHD the psychological sense of time is impaired, which prevents them from being able to modify their behavior in response to real world time demands.  This is seen, for example, in the adolescent who may become engrossed in a project and wind up spending far more time on it than he should have. 

Goal Directed Behavior is the ability to establish a goal in one's mind and use the internal image of that goal to shape, guide, and direct one's actions. This is an incredibly important capacity as it underlies consistent effort and persistence. Imagine how much harder it would be to persevere through difficult and frustrating times if you were not able to hold a long-term goal in your mind.   individuals with ADHD have great difficulty doing this, and thus have difficulty with making a consistent effort to achieve long-term goals. 

Implications of Considering ADHD a Disorder of Self-regulation

Conceptualizing ADHD as a disorder of self-regulation, and not a disorder of attention, has significant implications for understanding the difficulties experienced by individuals with ADHD and how to assist them in coping more effectively with those difficulties. 

Individuals with ADHD may not lack the skills and knowledge to be successful, but rather, their problems with self-regulation often prevent them from applying their knowledge and skills at the necessary times. ADHD is more a problem of doing what one knows rather than knowing what to do.

A child with ADHD may "know" that sharing and cooperating are an important part of making and keeping friends, but he may fail to apply this knowledge with peers because the immediate rewards associated with getting one's way overpowers the goal of keeping a friendship. Or, the child may know the steps to follow to do a good job on a school project, but not act on this knowledge because of problems with managing time and using a long-term goal to guide behavior.

The treatment implication that follows from this conceptualization is that treatment should focus on helping individuals apply the knowledge they already have at the appropriate times, rather than on teaching specific knowledge and skills. This will require frequent practice, cues and reminders to apply this knowledge, because their internal guides for behavior are less effective.

For example, consider the child who does not share and cooperate because the immediate payoff of getting what he wants is more important to him than the long-term consequences this behavior has for his friendships. It is not so much the “teaching” this child how to share and cooperate, but providing him with repeated opportunities to practice and correct his behavior with his peers, such as is done in social skills groups.  The ADHD child requires frequent external prompts since he cannot easily use his own internal prompts to guide his social behavior. 

In the classroom the ADHD child struggles with completing his work.  External prompts, cues and reminders can help the child perform better in class than if he is left so use his own internal cues.  Thus a teacher can post rules on the wall, remind the child every few minutes to stay on task or give frequent reminders of how much time is left for a task. 

The Limitations of External Prompts and why Rewards are Necessary

Even when external prompts are provided, however, their effectiveness remains dependent on the child's motivation to follow these rules rather than pursuing do what he finds more appealing at that moment. Because individuals with ADHD are so attuned to immediate consequences it is necessary to provide desirable rewards and privileges if the child complies with the rules. The reward must be more appealing than the inappropriate behavior the child might engage in.  Using rewards motivates the child to follow the rules and expectations. Thus external prompts, cues and reminders alone will not be sufficient.  Using both external prompts and rewards together is a powerful combination that results in frequent success for children and teens with ADHD.

This might be easier said than done, however.  Many parents struggle with properly using rewards and will set expectations too high and rewards that are delayed too long. Children with ADHD need immediacy in their rewards.  The problem with telling a child with ADHD that having a good week at school will result in a reward on the weekend is that it assumes the child can use the anticipation of this reward to guide their behavior over an entire week.  This will   be ineffective because it depends on the type of internalized control of behavior that the child lacks.  A child with ADHD cannot hold in his mind the idea of a reward that will come at the end of the week. He lacks the self-control to manage his behavior for this length of time. 

To overcome this long-term goal must be broken down into numerous shorter-term goals, each which has its own reward. For example, the special weekend treat needs to be supplemented by daily privileges that are given when the child's meets specific behavioral expectations each day. Behavioral expectations for the day may need to be broken down into numerous shorter intervals during the day. Frequent reminders to the child about what those expectations are, and what will be attained by meeting them, also need to be incorporated.  Obviously, this is very difficult to do, and is one reason why implementing an effective behavioral treatment plan for a child with ADHD can be so challenging.

It is important to emphasize, however, that this approach is not the same as rewarding the child for simply doing what he should be doing in the first place, as is sometimes argued. A child with ADHD is not "let off the hook" because of their condition. Instead, one needs to heighten the child's accountability by checking on their behavior more frequently, giving frequent feedback and giving frequent rewards and privileges when desired standards of behavior have been met. 

Even when these principles are faithfully applied, recognizing that the behaviors seen in ADHD results from an underlying deficit in self-regulation implies that gains associated with treatment will not persist after treatment is discontinued. Thus, treatment reflects an ongoing effort to manage the child's symptoms rather than "curing" the disorder.

While this may be discouraging, we must note that as children with ADHD mature, their capacity for self-regulation will mature as well. Thus, even though they may never fully catch up to their peers in this regard, their ability to guide and govern their behavior through internal means will nonetheless grow and develop. Over time, therefore, an individual's reliance on external sources of motivation will diminish, as will the required intensity and frequency with which these external source are need to be provided. Eventually, the adolescent or young adult with ADHD may learn to provide their own external prompts in the form of lists and other types of cues that prove to be effective, and to provide themselves with their own rewards for meeting their self-imposed standards.