The cognitive-energetic model: an empirical approach to attention-deficit hyperactivity disorder.

Attention Deficit/Hyperactivity Disorder (ADHD) is a childhood psychiatric disorder which when carefully defined, affects around 1% of the childhood population [Swanson JM, Sergeant JA, Taylor E, Sonuga-Barke EJS, Jensen PS, Canwell DP. Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet 1998;351:429-433]. The primary symptoms: distractibility, impulsivity and overactivity vary in degree and association in such children, which led DSM IV to propose three subgroups. Only one of these subgroups, the combined subtype: deficits in all three areas, meets the ICD-10 criteria. Since the other two subtypes are used extensively in North America (but not in Europe), widely different results between centres are to be expected and have been reported. Central to the ADHD syndrome is the idea of an attention deficit. In order to investigate attention, it is necessary to define what one means by this term and to operationalize it in such a manner that others can test and replicate findings. We have advocated the use of a cognitive-energetic model [Sanders, AF. Towards a model of stress and performance. Acta Psychologica 1983;53: 61-97]. The cognitive-energetic model of ADHD approaches the ADHD deficiency at three distinct levels. First, a lower set of cognitive processes: encoding, central processing and response organisation is postulated. Study of these processes has indicated that there are no deficits of processing at encoding or central processing but are present in motor organisation [Sergeant JA, van der Meere JJ. Convergence of approaches in localizing the hyperactivity deficit. In Lahey BB, Kazdin AE, editors. Advancements in clinical child psychology, vol. 13. New York: Plenum press, 1990. p. 207-45; Sergeant, JA, van der Meere JJ. Additive factor methodology applied to psychopathology with special reference to hyperactivity. Acta Psychologica 1990;74:277-295]. A second level of the cognitive-energetic model consists of the energetic pools: arousal, activation and effort. At this level, the primary deficits of ADHD are associated with the activation pool and (to some extent) effort. The third level of the model contains a management or executive function system. Barkley [Barkley RA, Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychological Bulletin 1997;121:65-94] reviewed the literature and concluded that executive function deficiencies were primarily due to a failure of inhibition. Oosterlaan, Logan and Sergeant [Oosterlaan J, Logan GD, Sergeant JA. Response inhibition in ADHD, CD, comorbid ADHD + CD, anxious and normal children: a meta-analysis of studies with the stop task. Journal of Child Psychology and Psychiatry 1998;39:411-426] demonstrated that this explanation was not specific to ADHD but also applied to children with the associated disorders of oppositional defiant and conduct disorder. Other executive functions seem to be intact, while others, are deficient. It is argued here that the cognitive-energetic model is a useful guide for determining not only ADHD deficiencies and associated disorders but also linking human cognitive neuroscience studies with neurobiological models of ADHD using animals [Sadile AG. Multiple evidence of a segmental defect in the anterior forebrain of an animal model of hyperactivity and attention deficits. Neuroscience and Biobehavioral Reviews, in press; Sagvolden T, Sergeant JA. Attention-deficit hyperactivity disorder: from brain dysyfunctions to behaviour. Behavioural Brain Research 1998;94:1-10]. A plea for an integrated attack on this research problem is made and the suggestion that conceptual refinement between levels of analysis is essential for further fundamental work to succeed is offered here.