Book Reviews 111

ADHD and The Nature of Self-Control

Russell A. Barkley. New York: The Guilford Press (www.guilford.com).
1997, 410 pp., $42.00 (hardcover).
Russell Barkley has been among the most productive and prolific scientists in
the field of Attention Deficit/Hyperactivity Disorder (ADHD). This work
represents the culmination of a five-year project during which he attempted to
develop a unifying explanatory model for ADHD. This model argues that the
disorder fundamentally reflects a disruption in self-control mechanisms rather
than attention per se. In this book, Barkley takes on the ambitious task of
reviewing and synthesizing the voluminous theoretical and descriptive literature
regarding ADHD and integrating it with related writings in philosophy, child
development, and neuropsychology. Most of the ideas presented were previ-
ously published in a review article (Barkley, 1997), but are greatly expanded
here.
Essentially, Barkley argues that ADHD reflects a core deficit in inhibitory
control, which then prevents the optimal use of "executive functions," all of the
above thought to be mediated by the prefrontal cortex. Thus, ADHD is seen as
a disruption in the developmental process of inhibition, mediated by the
prefrontal cortex, whereby behavior is internalized, regulated, and directed
toward the future. Deficits in attention are seen as secondary and not universal
characteristics. Notably, this is a conceptual shift which is being increasingly
embraced in the field.
Barkley is not the first to focus on delays in the development of inhibition and
self-regulation, nor is he the first to propose that prefrontal cortex and executive
function deficits are central to ADHD. However, he goes beyond others in his
scholarly presentation and discussion of relevant neuropsychological and
developmental literature, and in his exacting effort to:
(1) specify the nature of self-regulation, (2) show how the executive
functions are involved in it, (3) articulate the basic number and nature of
these functions, (4) demonstrate their critical dependence on behavioral
inhibition, (5) argue that the purpose of executive functioning and self-
regulation is to increase the control of behavior by time, and (6) specify that
the ultimate utility function of all this activity is the net maximization of
long-term consequences . . . (p. viii)
Barkley builds what he terms a "hybrid" model for ADHD upon
Bronowski's theory of human language, and upon Fuster's theory regarding
the neuropsychological functions subserved by the prefrontal cortex. He
ultimately posits five distinct components of impaired executive functions:
nonverbal working memory; internalization of speech; self-regulation of
affect; motivation and arousal; and reconstitution. For each, he eloquently
describes how they might be affected by impaired inhibitory control, and
how these resultant deficiencies may impact behavioral and cognitive func-
tioning.
112 Book Reviews

This is an extremely important text, full of information and ideas. The first
two chapters provide valuable in-depth reviews of existing literature regarding
the clinical presentations of ADHD and various models of the biological
etiology. He convincingly argues that it is a neurological disorder, on a
developmental continuum, with a substantial genetic component. Deriva-
tively, he argues against those who claim that ADHD is a result of poor
parenting and social ills, and argues for the essential role of stimulant medica-
tion in treatment. The next eight chapters are the core of his book and focus on
development of his major thesis. The final chapter provides very useful direct
clinical applications of his theory, as well as addresses several highly charged
scientific and political issues, such as the assumption of a central role for
inattention in the name of the entity.
There are also some problems with the book. Stylistically, some readers
will welcome the extensive elaboration of meaning, intent, and implications.
Other readers may find that such expansions clutter clarity and understand-
ing. More substantively, many might argue that Barkley' s description of both
ADHD and executive functions is too narrow. For example, while failure in
the inhibitory function is a universally recognized deficit in ADHD, failure
in activation and initiation are also often seen as central features. He omits
the latter. Finally, despite his very scholarly discussion of some.theorists'
notions of executive functions, he fails to convey the full spectrum of
component cognitive processes subserved under the construct (e.g., also
initiation, set-shifting , judgment, and self-perception). For the
neuropsychologically uninformed reader, this potentially obscures the full
breadth of possible problem areas in individuals with ADHD, and/or the
extent of intellectual debate regarding the meaning of executive functions
(e.g., Lezak, 1982; Spreen & Strauss, 1998).
Overall, this book definitely presents the first comprehensive theory of
ADHD, and will generate much discussion and research. Undoubtedly, with
time and collection of additional data, this model will become better delineated
and refined. The clinical implications are also very provocative, especially for
clinicians using cognitive or meta-cognitive techniques. Barkley is essentially
talking about derivatives of a deficit in maintaining the gap between stimulus
and response. In theory these derivaties can be addressed via ideational
interventions, limited only by the practitioners' creativity. Barkley's articula-
tion of highly salient facets within, and beyond, this gap, offers the potential
for the development of more pointed interventions. Although his position
might lead one to argue that cognitive awareness will not impact the inhibition
deficit (i.e., "it is not a problem with knowing, but rather with doing" . . .
Barkley, personal communication), outcome studies will ultimately clarify
this question. Despite its limits, this is a seminal contribution and worthwhile
reading for any serious student of ADHD.
Book Reviews 113

REFERENCES
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive
functions: Constructing a unifying theory of ADHD. Psychological Bulletin,
727(1), 65-94.
Lezak, M. D. (1982). The problem of assessing executive functions. International
Journal of Psychology, 17, 281-297.
Spreen, O., & Strauss, E. (1998). Executive functioning. In A Compendium of
Neuropsychological Tests (2nd ed.). New York: Oxford University Press.

JEANETTE WASSERSTEIN
The Mount Sinai School of Medicine and
Comprechensive Neuropsychological Services (CNS)

Psychiatric Nursing: An Integration of Theory and Practice

P. G. O'Brien (Ed.), W. Z. Kennedy, and K. A. Ballard (Ed.). New York:
McGraw Hill (www.mcgraw-hill.com). 1999, 632 pp., $39.95
(softcover).
This is an ambitious contributed book written to be a basic text for undergradu-
ate nursing students and a reference text for nurses practicing in a variety of
clinical settings. The editors, who wrote 12 of the 30 chapters, are experienced
psychiatric nurses who bring with them years of clinical, administrative, and
policy expertise. As such, they have included a wide range of clinical problems
and content areas in this text. The chapter on self-help groups makes a unique
contribution to the field, the references cited are timely, and the thinking
reflected throughout the text is consistent with current practice parameters in
psychiatry.
That being said, however, the text struggles to make a unique contribution
to the field and to claim an audience for its readership. In the preface the editors
make clear that the book was not written to be a comprehensive text, yet they
then try to cover so much content that the overall discussions are superficial
and so concise that students will struggle to master the necessary material. It
would have been better if the section on special populations had been omitted
and more space given to the unit on mental health disorders and conditions,
since these are the basics of what nurses need to know in providing psychiatric
nursing care. Specifically, issues such as suicide, violence, crisis intervention,
prevention, and community care need more attention in the text, given the
critical part they play in current psychiatric nursing practice.
In many ways, the weaknesses of the text are a result of having so many
different authors contribute chapters which present content in different styles
and from individual frames of reference. As a result, there is a certain amount
of repetition and no organizing framework for the text. Most unfortunately, the
very important mental health disorder chapters are organized in different ways.
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