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Deficient Emotional Self Deficient Emotional Self--Regulation is aRegulation is a

Core Component of ADHD:Core Component of ADHD:

Evidence and Treatment ImplicationsEvidence and Treatment ImplicationsRussell A. Barkle , Ph.D.Russell A. Barkle , Ph.D.

Clinical Professor of PsychiatryClinical Professor of Psychiatry

Medical University of South CarolinaMedical University of South Carolina

Charleston, SCCharleston, SC

andand

Research Professor, Department of PsychiatryResearch Professor, Department of Psychiatry

SUNY Upstate Medical UniversitySUNY Upstate Medical University

Syracuse, NYSyracuse, NY

©Copyright by Russell A. Barkley, Ph.D., 2009©Copyright by Russell A. Barkley, Ph.D., 2009

Email: drbarkle russellbarkle .or Email: drbarkle russellbarkle .or

Website: russellbarkley.orgWebsite: russellbarkley.org

Sources:Sources:

Barkley, R. A. (2006). Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment (3rd ed.).Barkley, R. A. (2006). Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment (3rd ed.).New York: Guilford.New York: Guilford.

Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says.Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says.

New York: GuilfordNew York: Guilford

Barkley, R. A. (in press). Deficient emotional self Barkley, R. A. (in press). Deficient emotional self--regulation is a core component of ADHD.regulation is a core component of ADHD. Journal of ADHDJournal of ADHD

and Related Disorders, 1(2).and Related Disorders, 1(2).

DisclosureDisclosure Retirement Pension: State of Massachusetts

Speaking Fees: PACER Institute (Minneapolis, MN), Carolinas Medical Center (Charlotte, NC)

University of Buffalo, Syracuse University, University of Massachusetts Medical School,University of Alabama

Alberta Teachers Association, Cobb County Georgia Schools, Region IV School District(Houston, TX)

American Psychological Association (Division 40 – Neuropsychology)

United Behavioral Healthcare (internet course), Four Winds Psychiatric Hospital(Saratoga, NY), Puerto Rico Association of Pediatrics

J & K Seminars, Leading Edge Seminars

Human Services Council (Springfield, IL) , Child & Adolescent Services Center (Canton,OH), Mountain and Southeast Area Health Education Cooperatives of North Carolina

Canadian Attention Deficit Disorders Resource Alliance, ADHD Resource Alliance (TheNetherlands), Society of Child Neurology and Neuropsychology (Valencia, Spain)

Royalties: Guilford Publications (books, videos, newsletter)

Jones & Bartlett Publishers (books & products), J & K Seminars (videotapes), NewEngland Educational Institute (audiotapes)

ContinuingEdCourses,Net (internet CE courses)

Speaker/Consultant to Pharmaceutical Companies: Eli Lilly, Shire, Medice, McNeil, Janssen-Ortho, Janssen-Cilag, Novartis



What is ADHD?What is ADHD?

The Current Clinical ViewThe Current Clinical View

A disorder of age A disorder of age--inappropriate behavior:inappropriate behavior:InattentionInattention Workin Memor Workin Memor – – The “Cool”The “Cool”

Executive Functions)Executive Functions)

At least 6 types of attention At least 6 types of attention – – not all are impairednot all are impairedin ADHDin ADHD

– – Arousal, alertness, selective, divided, span of Arousal, alertness, selective, divided, span ofapprehension, & persistenceapprehension, & persistence

Impaired resistance to responding to distractionsImpaired resistance to responding to distractions

Deficient task reDeficient task re--engagement following disruptionsengagement following disruptionsImpaired working memory (remembering so as toImpaired working memory (remembering so as todo)do)

More on ADHDMore on ADHD

The Current Clinical ViewThe Current Clinical View

A disorder of age A disorder of age--inappropriate behavior:inappropriate behavior:H eractivitH eractivi t --Im ulsivitIm ulsivit InhibitionInhibition – – EFEF

Impaired verbal and motor inhibitionImpaired verbal and motor inhibition

Impulsive decision making; cannot wait or defer gratificationImpulsive decision making; cannot wait or defer gratification

Greater disregard of future (delayed) consequencesGreater disregard of future (delayed) consequences

Excessive taskExcessive task--irrelevant movement and verbal behavior irrelevant movement and verbal behavior – – Fidgeting, squirming, running, climbing, touchingFidgeting, squirming, running, climbing, touching

Restlessness decreases with age, becoming more internal,Restlessness decreases with age, becoming more internal,

su ec ve y a u oosu ec ve y a u oo

Emotional impulsiveness and deficient emotional self Emotional impulsiveness and deficient emotional self--regulation?????regulation????? – – Impatient, low frustration tolerance, hotImpatient, low frustration tolerance, hot--tempered, quick to anger,tempered, quick to anger,

touchy or easily annoyed, over touchy or easily annoyed, over--react, easily excitedreact, easily excited



ADHD is a Disorder of Executive Functioning ADHD is a Disorder of Executive Functioning

EF Consists of Two Major ComponentsEF Consists of Two Major Components

Inhibition:Cognitive,

Verbal,

Motor,

& Emotional

Self-RegulationWorking Memory,

Planning/Problem Solving

(& Emotional Self-

Regulation)

ADHDHyperactivity

Impulsivity

ADHDInattention

What is an Emotion?What is an Emotion? A relatively short A relatively short--duration change in ourduration change in our

intentional state that entrains changes inintentional state that entrains changes in

behavior, cognition, physiological arousal, andbehavior, cognition, physiological arousal, and

mo va onmo va on

Emotions usually comprise 3 dimensions:Emotions usually comprise 3 dimensions:

– – Approach Approach – – withdrawal actions & cognitionswithdrawal actions & cognitions

Opportunity vs. threat (excitement vs. apprehension)Opportunity vs. threat (excitement vs. apprehension)

– – ReinforcementReinforcement – – punishment motivationspunishment motivations

. , .. , .

– – Physiological activation (intensity of reaction)Physiological activation (intensity of reaction)

Emotions serve a communicative function notEmotions serve a communicative function not

just an expressive or cathartic one just an expressive or cathartic oneHess, H. &Hess, H. & ThibaultThibault, P. (2009). Darwin and emotion expression., P. (2009). Darwin and emotion expression. American Psychologist, 64(2) American Psychologist, 64(2), 120, 120--128128

NeeseNeese, R. & Ellsworth, P. (2009). Evolution, emotions, and emotional disorders., R. & Ellsworth, P. (2009). Evolution, emotions, and emotional disorders. American Psychologist, 64(2), American Psychologist, 64(2), 129129--

139.139.



What is Emotional Self What is Emotional Self--Regulation?Regulation?

1.1. Ability to inhibit inappropriate behavior Ability to inhibit inappropriate behaviorrelated to strong negative or positiverelated to strong negative or positive

2.2. Self Self--soothe any physiological arousalsoothe any physiological arousal

related to #1 aboverelated to #1 above

3.3. Refocus attention from the emotionallyRefocus attention from the emotionally

4.4. Organize emotions for coordinated actionOrganize emotions for coordinated action

in the service of goals and longin the service of goals and long--termterm

welfarewelfareGottmanGottman , J. & Katz, L. (1989)., J. & Katz, L. (1989). Developmental Psychology, 25Developmental Psychology, 25, 373, 373--381.381.

Deficits in Emotional Self Deficits in Emotional Self--Regulation (DESR)Regulation (DESR)Emotional impulsivenessEmotional impulsiveness – – part of the Inhibition Deficitpart of the Inhibition Deficit

– – Poor inhibition of inappropriate behavior related to strongPoor inhibition of inappropriate behavior related to strong

emotionsemotions

– – ow rustrat on to erance, mpat entow rustrat on to erance, mpat ent

– – Quick to anger, hot tempered, easily annoyedQuick to anger, hot tempered, easily annoyed

– – Greater emotional excitability and reactivityGreater emotional excitability and reactivity

Difficulties self Difficulties self--regulating (moderating) emotionalregulating (moderating) emotional

reactions to evocative eventsreactions to evocative events

– – Deficient in effortful, cognitive “topDeficient in effortful, cognitive “top--down” regulation of induceddown” regulation of induced

-- ,,

– – Difficulties inducing positive, more acceptable mood statesDifficulties inducing positive, more acceptable mood states

Impaired self Impaired self--motivation and activation (arousal) whenmotivation and activation (arousal) when

needed to support goalneeded to support goal--directed actiondirected actionBarkley, R. A. (1997/2001)Barkley, R. A. (1997/2001) ADHD and the nature of self ADHD and the nature of self--controlcontrol. New York: Guilford.. New York: Guilford.

Barkley, R. A. (2009). Deficient emotional self Barkley, R. A. (2009). Deficient emotional self--regulation is a core component of ADHD.regulation is a core component of ADHD.

Journal of ADHD and Related Disorders, 1(2), in pressJournal of ADHD and Related Disorders, 1(2), in press



Why Make DESR a CoreWhy Make DESR a Core

Feature of ADHD?Feature of ADHD?

170 Years of Historical Inclusion170 Years of Historical Inclusion

17981798 – – Alexander Crichton includes emotional frustration as part of Alexander Crichton includes emotional frustration as part of

disorders of attention persistence in first medical paper on attentiondisorders of attention persistence in first medical paper on attention

disordersdisorders

– –

regulation of emotions by “moral control” in his conceptualizations ofregulation of emotions by “moral control” in his conceptualizations of

defective moral control of behavior (historical precursor to ADHD)defective moral control of behavior (historical precursor to ADHD)

1960s1960s – – Clinical researchers repeatedly include symptoms of DESRClinical researchers repeatedly include symptoms of DESR

in their concepts of MBD and the hyperactive child syndromein their concepts of MBD and the hyperactive child syndrome

19701970 – – Mark Stewart includes low frustration tolerance, quickness toMark Stewart includes low frustration tolerance, quickness to

anger, and emotional excitability in his description of the hyperactiveanger, and emotional excitability in his description of the hyperactive

child s ndromechild s ndrome

19751975 – – Dennis Cantwell includes poor emotion regulation as a coreDennis Cantwell includes poor emotion regulation as a core

feature of the hyperactive child syndromefeature of the hyperactive child syndrome

1971 & 761971 & 76 – – PaulPaul Wender Wender makes poor emotional control a keymakes poor emotional control a key

feature of his work on MBD in children and adultsfeature of his work on MBD in children and adults

19681968 – –DSMDSM--II fails to note DESR as a feature of ADHD and it staysII fails to note DESR as a feature of ADHD and it stays

out of DSMs since that timeout of DSMs since that time



DESR is Included in CurrentDESR is Included in Current

Neuropsychological Theories ofNeuropsychological Theories of

ADHD ADHD

Emotion Regulation is A Major Component inEmotion Regulation is A Major Component in

Barkley’s EF Theory of ADHDBarkley’s EF Theory of ADHD

Start with a theory of normal development of inhibition,Start with a theory of normal development of inhibition,self self--regulation, and executive functioningregulation, and executive functioning

– – Inhibiting theInhibiting the prepotentprepotent or dominant response (emotions included)or dominant response (emotions included)

– – Interrupting ongoing behavior Interrupting ongoing behavior

– – Interference control: Protecting the EFs from distractionInterference control: Protecting the EFs from distraction

Self Self--regulation can be defined as:regulation can be defined as: – – Any action a person directs toward one’s self Any action a person directs toward one’s self

– – So as to change their own behavior So as to change their own behavior

– – In order to change the likelihood of a future consequenceIn order to change the likelihood of a future consequence An executive function can be defined as: An executive function can be defined as: – – a major type of actiona major type of action--toto--thethe--self (a type of self self (a type of self--regulation)regulation)

The major purpose of the EFs is the crossThe major purpose of the EFs is the cross--temporaltemporalorganization of behavior to attain goals and maximizeorganization of behavior to attain goals and maximizelong term gains (future welfare)long term gains (future welfare)



More on the EF TheoryMore on the EF Theory

There are 4 other EFs besides inhibition:There are 4 other EFs besides inhibition: – – Nonverbal and verbal working memoryNonverbal and verbal working memory

– – Emotional inhibition and self Emotional inhibition and self--re ulationre ulation

– – Planning and problemPlanning and problem--solvingsolving

They can be redefined as actionsThey can be redefined as actions--toto--thethe--self:self: – – Sensing to the self (visual imagery & reSensing to the self (visual imagery & re--hearing)hearing)

– – Speech to the self Speech to the self

– – Emotion and motivation to the self Emotion and motivation to the self

– – Play to the self Play to the self

Each likely develops by behavior being turned onEach likely develops by behavior being turned on

the self and then internalized (privatized)the self and then internalized (privatized)They develop in a stepThey develop in a step--wise hierarchywise hierarchy -- EachEachneeds the earlier ones to function wellneeds the earlier ones to function well

Linkage of EFs to daily life activitiesLinkage of EFs to daily life activities

Traditional EFs Barkley Theory Daily Life Activities

Inhibition

Nonverbal

Working Memory

Verbal Working

MemorySelf-Speech

Inhibition

Sensing to the Self

(Imagery)

,

Motor, Verbal, Emotional

Self-Management to

Time and the Future

Self-Organization &

Problem-Solving

Emotion

Regulation

Planning, Fluency,

Mental Manipulation

Emotion - Motivation

to the Self

Self-Play

Analysis/Synthesis

Self-Motivation

Self-Activation



Theories of the Neural Networks for ADHDTheories of the Neural Networks for ADHD

All Include Emotional All Include Emotional DysregulationDysregulation

The frontalThe frontal--striatalstriatal circuit: Associated with deficits incircuit: Associated with deficits inresponse suppression, freedom from distraction, workingresponse suppression, freedom from distraction, workingmemor , or anization, and lannin , known as the “cool”memor , or anization, and lannin , known as the “cool”or “what” EF networkor “what” EF network

The frontalThe frontal--cerebellar cerebellar circuit: Associated with motorcircuit: Associated with motorcoordination deficits, and problems with the timing andcoordination deficits, and problems with the timing andtimeliness of behavior, known as the “when” EF networktimeliness of behavior, known as the “when” EF network

The frontalThe frontal--limbic circuit: Associated with symptoms oflimbic circuit: Associated with symptoms ofemotionalemotional dyscontroldyscontrol, motivation deficits, hyperactivity, motivation deficits, hyperactivity--

, ,, ,“hot” or “why” EF network“hot” or “why” EF network

Nigg, J. T., & Casey, B. (2005). An integrative theory of attentionNigg, J. T., & Casey, B. (2005). An integrative theory of attention--deficit/hyperactivity disorder based on the cognitivedeficit/hyperactivity disorder based on the cognitiveand affective neurosciences.and affective neurosciences. Development and Psychology, 17Development and Psychology, 17, 785, 785--806.806.

CastellanosCastellanos, X.,, X., SonugaSonuga--BarkeBarke, E.,, E., MilhamMilham, M., &, M., & TannockTannock, R. (2006). Characterizing cognition in ADHD: Beyond, R. (2006). Characterizing cognition in ADHD: Beyondexecutive dysfunction.executive dysfunction. Trends in Cognitive Science, 10,Trends in Cognitive Science, 10, 117117--123.123.

SagvoldenSagvolden, T., Johansen, E. B.,, T., Johansen, E. B., Aase Aase, H., & Russell, V. A. (2005). A dynamic developmental theory of attention, H., & Russell, V. A. (2005). A dynamic developmental theory of attention--deficit/hyperactivity disorder (ADHD) predominantly hyperactivedeficit/hyperactivity disorder (ADHD) predominantly hyperactive--impulsive and combined subtypes.impulsive and combined subtypes. BehavioralBehavioraland Brain Sciences, 28and Brain Sciences, 28, 397, 397--408.408.

DESR would be anticipated fromDESR would be anticipated from

neuroneuro--imaging findingsimaging findingsSmaller, Less Active, Less Developed Brain RegionsSmaller, Less Active, Less Developed Brain Regions

33--10% reduced regional volumes in these 5 regions:10% reduced regional volumes in these 5 regions: – – OrbitalOrbital--Prefrontal Cortex (primarily right side)Prefrontal Cortex (primarily right side)

Genetics contributes to under Genetics contributes to under--development of this region while acquireddevelopment of this region while acquired ADHD may be related to smaller inferior ADHD may be related to smaller inferior dorsolateraldorsolateral frontal regionfrontal region

– – Basal Ganglia (mainly striatum &Basal Ganglia (mainly striatum & globusglobus palliduspallidus))

– – Cerebellum (centralCerebellum (central vermisvermis area, more on right side)area, more on right side)

– – Anterior Anterior cingulatecingulate cortex (mostly shows under cortex (mostly shows under--activity)activity)

– – CorpusCorpus callosumcallosum – – forward aspect orforward aspect or spleniumsplenium

ze o s ne wor s corre a e w egree oze o s ne wor s corre a e w egree osymptoms, particularly inhibitionsymptoms, particularly inhibition

No gender differencesNo gender differences

22--3 year lag in brain development but achieving typical brain3 year lag in brain development but achieving typical brainvolumes by age 16volumes by age 16

Results are not due to taking stimulant medicationResults are not due to taking stimulant medication



Human BrainHuman Brain

From R. Barkley,From R. Barkley, Scientific AmericanScientific American, Sept. 1998, p. 47;, Sept. 1998, p. 47;

Reprinted with permission of Terese Winslow andReprinted with permission of Terese Winslow and Scientific American.Scientific American.

Anterior Anterior--posterior (posterior (rostralrostral--caudal) hierarchycaudal) hierarchy

of cognitive control of behavior of cognitive control of behavior

Figure 1. Schematic of major anatomical sub-divisions in the frontal lobes. Boundaries and Brodmann areas (BA)

are only approximate. Arrows indicate anatomical directions of anterior/rostral (front) versus posterior/caudal (back)

and dorsal (up) versus ventral (down). From caudal to rostral, labeled areas include motor cortex, dorsal (PMd) and

ventral premotor cortex, dorsal (pre-PMd) and ventral aspects of anterior premotor cortex, ventro- (VLPFC) and

dorsolateral PFC (DLPFC), and lateral frontal polar cortex (FPC). Badre, D. (2008). Trends in Cognitive Sciences,

12(5), 193-200.



CognitiveCognitive vsvs Emotional functioning in the ACCEmotional functioning in the ACC

Bush, G. et al. (2000). Trends in Cognitive Science, 4(6), 215-222.

Role of the ACC in downRole of the ACC in down--regulating theregulating the amygdalaamygdala

Figure 7. Previous-Trial Incongruency Increases Negative Effective Connectivity from the Rostral Cingulate to the Amygdala

Coupling coefficients for directional intrinsic connectivity are shown as values next to the arrows between the rACC and the

amygdala, while coefficients for the modulatory (bilinear) effects are shown as values associated with additional lines intersecting

with the intrinsic paths. The only significant effect in the model was greater negative modulation of the rACC to amygdala path by

previous-trial incongruency, which triggers greater current-trial conflict resolution (p = 0.02). Etkin, A. et al. (2006). Neuron, 51,

871-882.



DESR is Evident in PsychologicalDESR is Evident in Psychological

Research on ADHDResearch on ADHDResearch on child behavior rating scales showsResearch on child behavior rating scales shows

tolerance, anger, and emotional excitabilitytolerance, anger, and emotional excitability

(BRIEF, etc.)(BRIEF, etc.)

Direct observation studies of emotional controlDirect observation studies of emotional control

during emotional eliciting events shows poorduring emotional eliciting events shows poor

tolerancetolerance

FollowFollow--up studies of ADHD children intoup studies of ADHD children into

adulthood and studies of adults with ADHD showadulthood and studies of adults with ADHD show

substantial DESR symptoms in the majoritysubstantial DESR symptoms in the majority

Emotional Impulsivity inEmotional Impulsivity in Adults with ADHD Adults with ADHD

90

30

40

50

60

70

80

ADHD

Community

0

10

20

Impat ience Quick to anger or ge tupset

Easily f rustrated Over- reactemotionally

Easily excited

From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in Adults: What the

Science Says. New York: Guilford



Emotional Impulsivity in ADHDEmotional Impulsivity in ADHD

children followed to adulthoodchildren followed to adulthood80

30

40

50

60

70

ADHD-P

ADHD-NP

Controls

ADHD-P = Persistent ADHD, ADHD-NP = Nonpersistent ADHD

From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in Adults: What the Science Says. New

York: Guilford

0

10

Impa tien t Qu ick to ang er , ge tupset

Easily f rustr ated Over-r eactemotionally

Easily excited

DESR explains the linkage ofDESR explains the linkage of

ADHD to high risk for ODD ADHD to high risk for ODD



Oppositional Defiant Disorder Oppositional Defiant Disorder

A pattern of hostility, anger, defiance, stubbornness, A pattern of hostility, anger, defiance, stubbornness,low frustration tolerance and resistance to authoritylow frustration tolerance and resistance to authorityusuall arentalusuall arental

Occurs in 30Occurs in 30--80% of ADHD cases80% of ADHD cases

ADHD cases have 11x greater risk for ODD* and ADHD cases have 11x greater risk for ODD* andmay develop it within 2 yrs of ADHD onsetmay develop it within 2 yrs of ADHD onset

All of the genetic contribution to ODD and CD is All of the genetic contribution to ODD and CD isshared with (same genes as) that of ADHD**shared with (same genes as) that of ADHD**

ODD has a twoODD has a two--dimensional structure***dimensional structure***

– – EmotionalEmotional DysregulationDysregulation – – Social Conflict (and Situational Context)Social Conflict (and Situational Context)

** Angold Angold, A. et al. (1999). Journal of Child Psychology and Psychiatry, 40, A. et al. (1999). Journal of Child Psychology and Psychiatry, 40, 57, 57--88.88.

**Wood, A. et al. (2009).**Wood, A. et al. (2009). Behavior Genetics, 39Behavior Genetics, 39, 447, 447--460.;460.; TuvbladTuvblad, C. et al. (2009)., C. et al. (2009). Journal of Abnormal Child Psychology, 37Journal of Abnormal Child Psychology, 37,,153153--167167

******Hoffenaar Hoffenaar, P. J. &, P. J. & HoeksmaHoeksma, J. B. (2002)., J. B. (2002). Journal of Child Psychology and Psychiatry, 43(3), 375Journal of Child Psychology and Psychiatry, 43(3), 375--385.385.

Linking ADHD to ODDLinking ADHD to ODDEmotional Impulsiveness is the shared initialEmotional Impulsiveness is the shared initial

connection between ADHD and ODDconnection between ADHD and ODD

Inattention

Hyperactivity

Impulsivity

Impulsive Emotions:

ImpatientEasily Frustrated

Hot-tempered

Quick to Anger

ADHD ODD

Emotional:

Easily Frustrated

Hot-tempered

Quick to Anger Easil Anno ed

Social:

Defy/Refuse

Argue Annoy Others

Blame Others

Excitable

Spiteful



More on ODDMore on ODD

ADHD causes ODD ADHD causes ODD – – This happens through the hyperactiveThis happens through the hyperactive--impulsiveimpulsivedimension of ADHD which includes emotionaldimension of ADHD which includes emotionalmpu s venessmpu s veness

– – EI creates the first component of ODDEI creates the first component of ODD

But ODD also has a learned componentBut ODD also has a learned component(social conflict) due to disrupted parenting(social conflict) due to disrupted parenting – – Inconsistent, indiscriminate, emotional, andInconsistent, indiscriminate, emotional, and

e isodicall vacillatin between harsh and ermissivee isodicall vacillatin between harsh and ermissive (lax) consequences teaches social coercion as a(lax) consequences teaches social coercion as ameans of social interactionmeans of social interaction

– – Poor parenting can partly arise from parental ADHDPoor parenting can partly arise from parental ADHDand other high risk parental disorders in ADHDand other high risk parental disorders in ADHDfamilies (e.g., depression, ASP, SUDS)families (e.g., depression, ASP, SUDS)

*Burns, G. L. & Walsh, J. A. (2002).*Burns, G. L. & Walsh, J. A. (2002). Journal of Abnormal Child Psychology, 30(3), 245Journal of Abnormal Child Psychology, 30(3), 245--256.256.

More on Link of ADHD to ODDMore on Link of ADHD to ODD

EmotionalEmotional dysregulationdysregulation componentcomponent

Social conflict component predicts laterSocial conflict component predicts laterConduct Disorder Conduct Disorder

The causal linkage of ADHD to ODD canThe causal linkage of ADHD to ODD can

account for the wellaccount for the well--established findingsestablished findings

that ADHD medications reduce ODDthat ADHD medications reduce ODDsymptoms nearly as much as they dosymptoms nearly as much as they do

ADHD symptoms ADHD symptoms



44--Factor Model of DefianceFactor Model of Defiance

Parental

Psychopathology

Disrupted Parenting

, epress on,

& SUDS

Child defiance and

social aggression

Child ADHD &

Negative

Temperament

Family Stressors

DESR Predicts VariousDESR Predicts VariousDomains of Child ImpairmentDomains of Child Impairment

DESR is best predictor of social rejectionDESR is best predictor of social rejection

in children with ADHDin children with ADHD

DESR is related to educational risksDESR is related to educational risks

– – Less educationLess education

– – Need for special education,Need for special education,

– – ruancy an suspens onsruancy an suspens onsDESR in child (& full ODD) is predictor ofDESR in child (& full ODD) is predictor of

greater parenting stress and family conflictgreater parenting stress and family conflict



DESR & Adult ImpairmentDESR & Adult Impairment

DESR predicts driving: road rage, speeding,DESR predicts driving: road rage, speeding,

,,

adults with ADHDadults with ADHD

DESR predicts number of job dismissals (beingDESR predicts number of job dismissals (being

fired), periods of unemployment, and workplacefired), periods of unemployment, and workplace

behavior problems in occupational historybehavior problems in occupational history

dating/cohabiting relationship conflictdating/cohabiting relationship conflict

DESR in adult with ADHD predicts risk forDESR in adult with ADHD predicts risk for

hyperactivityhyperactivity--impulsivity , ODD, and CDimpulsivity , ODD, and CD

symptoms in offspringsymptoms in offspring

Factors Contributing toFactors Contributing toEmotional Adjustment in ADHDEmotional Adjustment in ADHD

Emotional

Adjustment

Core ADHD

Symptoms:

•Emotional

Secondary

Effects of

ADHD-related

Failures:

Comorbid

Emotional

Disorders:•Anxiety

Secondary

Effects of

Comorbid

Disorders:

Impact of

Social Ecology:•Parenting

•Parent Disorders

Impulsivity

•Deficient

Self-Regulation

of Emotions

•School•Peers

•Family

•Work

•Other Domains

•Dysthymia•Depression

& Suicidality

•Bipolar

•LDs•ODD

•CD & SUDS

•OCD

•Tics & TS

•Sleep Problems

•Family Stressors•Traumatic Events

•Deviant Peers

•School

•Poverty



Diagnostic & Treatment ImplicationsDiagnostic & Treatment Implications

Don’t mistake emotional impulsivity (EI) and deficientDon’t mistake emotional impulsivity (EI) and deficient

emotional self emotional self--regulation (DESR) as being the result ofregulation (DESR) as being the result of

comorbiditycomorbidity or reactions to previous failure experiencesor reactions to previous failure experiences --

--

Core EICore EI--DESR symptoms are improved by ADHD medsDESR symptoms are improved by ADHD meds

– – drug types will differ in effectsdrug types will differ in effects

Secondary consequences of ADHD and DESR on majorSecondary consequences of ADHD and DESR on major

life activities may also be improved by ADHD treatmentslife activities may also be improved by ADHD treatments – – Behavior at home, in school, and in community settingsBehavior at home, in school, and in community settings

– –

– – School productivity, teacher reactions, and the likelihood of school disciplinarySchool productivity, teacher reactions, and the likelihood of school disciplinary

actionsactions

– – Peer interactions and social acceptabilityPeer interactions and social acceptability

– – improved maritalimproved marital--cohabiting relationshipscohabiting relationships

– – Sports participation, driving performanceSports participation, driving performance

– – Improved occupational functioningImproved occupational functioning

More ImplicationsMore ImplicationsDon’t mistake mood disorders as arising from EIDon’t mistake mood disorders as arising from EI--DESRDESR

– – EIEI--DESR is a “topDESR is a “top--down” deficit in regulating rational emotionaldown” deficit in regulating rational emotional

responses to events probably via the Lresponses to events probably via the L--PFC and ACC; moodPFC and ACC; mood

disorders are “bottomdisorders are “bottom--up” excessive expressions of emotionsup” excessive expressions of emotions

and probably of underlyingand probably of underlying amygdalaamygdala--limbic system activitieslimbic system activities

ComorbidComorbid mood and other disorders may requiremood and other disorders may require

separate management methods targeting them directlyseparate management methods targeting them directly

ButBut comorbidcomorbid ODD may improve with ADHD meds givenODD may improve with ADHD meds given

that 4 of its 8 symptoms are related to EIthat 4 of its 8 symptoms are related to EI--DESRDESR

– – es ua may requ re e av ora parent tra n nges ua may requ re e av ora parent tra n ngSocial ecology factors will require separate psychosocialSocial ecology factors will require separate psychosocial

interventions and possibly family relocationinterventions and possibly family relocation

– – Some factors may be secondary to parental ADHD and relatedSome factors may be secondary to parental ADHD and related

disorders making their identification and management essentialdisorders making their identification and management essential

to treating their ADHD childto treating their ADHD child



ConclusionsConclusions

ADHD contains an inherent core deficit in emotional ADHD contains an inherent core deficit in emotionalimpulsiveness and deficient emotional self impulsiveness and deficient emotional self--regulationregulation

This is consistent with the history, neuroanatomy, andThis is consistent with the history, neuroanatomy, and

This can explain the linkage of ADHD to ODD and likelyThis can explain the linkage of ADHD to ODD and likelyto otherto other comorbidcomorbid disordersdisorders

The EI/DESR component of ADHD contributes to theThe EI/DESR component of ADHD contributes to thesocial and emotional impairments seen in ADHDsocial and emotional impairments seen in ADHD

This component can contribute to emotionalThis component can contribute to emotional

– – Secondary ADHDSecondary ADHD--related failure experiencesrelated failure experiences

– – ComorbidComorbid mood and anxiety disordersmood and anxiety disorders – – Secondary effects of otherSecondary effects of other comorbidcomorbid disordersdisorders

– – Direct and indirect impact of adverse social ecological factorsDirect and indirect impact of adverse social ecological factors

ConclusionsConclusionsDESR contributes to impaired socialDESR contributes to impaired socialrelationships (family, peers, community)relationships (family, peers, community)

CD, antisocial behavior, and substanceCD, antisocial behavior, and substanceuse and abuseuse and abuse

Understanding the DESR component ofUnderstanding the DESR component of ADHD explains the reductions in ODD ADHD explains the reductions in ODD

Understanding the sources of emotionalUnderstanding the sources of emotionaland social maladjustment provides aand social maladjustment provides arationale for psychosocial interventionsrationale for psychosocial interventions



ObjectivesObjectives

Discuss the important role of emotionalDiscuss the important role of emotionalimpulsiveness and deficient emotional self impulsiveness and deficient emotional self--

Review the factors that contribute to emotionalReview the factors that contribute to emotionaladjustment in ADHD children and adolescentsadjustment in ADHD children and adolescents

Summarize the results of research on the impactSummarize the results of research on the impactof poor emotion regulation in ADHD on variousof poor emotion regulation in ADHD on variousdomains of functioning in children followed todomains of functioning in children followed toadulthoodadulthood

Discuss implications of these outcomes forDiscuss implications of these outcomes fortreatment planningtreatment planning

Documents

BarkleySlides_CCFSpeakerSeries0910