DESR, or deficient emotional self-regulation, is a core facet of ADHD that may carry significant consequences. However, it is not included the disorder’s diagnostic criteria. As new research confirms the prominent role emotional dysregulation plays in ADHD’s appearance and individual patient outcomes, that may be changing. Here, learn about DESR, its central role in ADHD, along with implications for diagnosis and treatment.
EI and DESR in Historical Concepts of ADHD
Conceptualizations of ADHD have included emotional control problems for centuries. One of the earliest references to attention disorder in western medical literature, a textbook written by German physician Melchior Adam Weikard in 1770, characterizes those who have a “lack of attention” as “unwary,” “flighty,” “careless,” mercurial,” and “bacchanal.”
The History of Deficient Emotional Self-Regulation
1798: Alexander Crichton, a Scottish-born physician, includes emotional frustration in his description of disorders of attention, especially problems with persistent attention
1902: George Still, a British physician widely considered to be the “founder” of ADHD, includes emotional impulsiveness and poor regulation of emotions in his conceptualization of “defective moral control of behavior” (the precursor to ADHD)
1960s-1970s: Major clinical researchers at the time — including Mark Stewart, Dennis Cantwell, and Paul Wender — include emotion as a core feature in their concepts of “hyperactive child syndrome (now ADHD).”
So why isn’t emotion considered in the diagnostic criteria for ADHD today?
1968: DSM-II references ADHD for the first time (as hyperkinetic impulse disorder) but fails to list EI or DESR as a feature of the disorder. It is excluded from all future DSMs, for unknown reasons, despite continuing research linking emotion to ADHD.
EI and DESR and the Neuroanatomy of ADHD
The brain structures and networks implicated in ADHD are also involved in emotion and would thus logically be expected to give rise to EI and DESR and be part of the disorder.
The frontal lobe, the anterior cingulate, the ventral striatum, and the amygdala all comprise the executive circuitry that has been repeatedly shown to be involved in causing ADHD. Some of these structures also form the brain’s emotional circuitry — the amygdala and larger limbic system to which it is connected is where emotion is generated, and the prefrontal cortex and related structures attend to these generated emotions. Thus, how we feel also influences how we think, and the dorsolateral PFC is where some thinking occurs, as well as working memory (or what we are holding in mind).
DESR in Neuropsychological Theories of ADHD
The frontal-limbic circuit — one of the four executive networks of the brain — is associated with ADHD and with symptoms of emotional dyscontrol, motivation deficits, hyperactivity-impulsivity, and aggressive tendencies. This emotional regulation network is also known as the “hot” circuit. I also refer to it as the “why” circuit, because it’s absolutely crucial in decision making.
This network is also connected to the other executive networks that we know are implicated in ADHD. ADHD, of course, would be expected to disrupt this emotional regulation network substantially.
EI and DESR in ADHD Psychological Research
Emotional self-regulation is a major dimension of executive functioning required for daily life activities. It is also one of the most impaired dimensions in children and adults with ADHD. Ample evidence from an abundance of psychological research shows that children and adults with ADHD are highly likely to manifest EI-DESR including low frustration tolerance, anger, poor inhibition of emotion, and emotional excitability.
ODD is two-dimensional, comprising aspects of social conflict and emotion dysregulation. These two dimensions significantly contribute to the risk for later disorders. The emotional dimension, for example, in children contributes to the later risk for anxiety and mood disorders in teens.
Given ADHD’s prevalence in ODD, we can assume that the emotional component of ODD arises biologically from ADHD. That is, ADHD likely creates one of the two dimensions involved in ODD. Indeed, the longer ADHD goes untreated and emotions remain dysregulated, the greater the odds that comorbid conditions, particularly anxiety disorders, will develop. This framework helps us understand why emotion and ODD are managed so well by ADHD medication, but only if ADHD is also present.
Meanwhile, the social component of ODD predicts later conduct disorder and antisocial behavior. This component of ODD, contrary to the biological aspect of emotionality, is likely learned, most often within family interactions.
EI and DESR: Treatment Considerations
Re-centering ADHD on emotions also helps us understand treatment outcomes. It’s why we often observe that ADHD medications impact core EI and DESR problems in patients with ADHD, albeit in different ways. Stimulants appear to quell and even dampen the limbic system, sometimes leading to complaints from patients about having robot-like, bland emotions. Non-stimulants like atomoxetine, on the other hand, act on a different part of the brain. They help to up-regulate the executive brain, giving patients more self-control of emotion. Prescribers sometimes utilize different drug combinations to allow patients more control over ADHD, including emotional problems.
Other treatment implications:
Secondary impairments from EI-DESR on major life activities may also be improved by ADHD medication.
Cognitive behavioral therapy (CBT) programs that target EF deficits, along with mindfulness-based approaches, might help with emotional regulation in adults with ADHD, especially if they are taking ADHD medication.
In children, emotional dysregulation is better handled through medication and then, to some extent, through behavioral parent training programs that focus on restructuring situations and interactions so as not to trigger strong impulsive emotions.
Parental ADHD could contribute to emotional dysregulation in children with ADHD, not just genetically through inheritance, but through modeling of poor emotional control and by engaging in emotionally provocative encounters with the child. Clinicians should screen parents for ADHD and treat their symptoms as well.
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Original article posted by ADDitude mag.