hello welcome to my course on the importance of emotion in ADHD I'm Dr Russell Barkley and I'm a clinical professor of Psychiatry at the Medical University of South Carolina before I begin let me disclose to you my sources of support for the previous year so that you can evaluate whether there is any potential conflict of interest with the contents of this presentation I'm retired from the University Massachusetts medical school for which I receive a pension but I'm obviously not retired I've spoken for a number of healthc care organizations and professional associations during the previous 12 months and you can see many of them listed here I also receive royalties for various products I have created such as books videos newsletters and courses such as this one finally I do consult with and speak for many of the major pharmaceutical companies that have ADHD products in the marketplace this presentation is about the importance of emotion in ADHD there are several objectives of this course first I will briefly review the nature of emotion and emotional self-regulation then I will show the seven lines of evidence I believe that support the importance of a central Central role of emotional impulsiveness and deficient emotional self-control in ADHD I will also summarize the research on the impact of emotion regulation problems in ADHD on various domains of major life activities in children followed to adulthood and in adults with ADHD then finally I will discuss the implications of these findings for diagnos nois and treatment of ADHD the current clinical view of ADHD as reflected in the DSM criteria is that ADHD is a developmentally inappropriate expression of symptoms in at least two neuropsychological dimensions of development that is to say that ADHD is a delay in the rate of development of these two Dimensions the First Dimension is that of inattention it is here that see the individual having difficulties with sustained attention or more accurately with persistence toward goals tasks and the future more generally along with this difficulty with persistence there is also a problem with impaired resistance to responding to distractions giving rise to the distractability often seen in patients with ADHD when patients with ADHD are distracted they often have much greater difficulties with re-engaging the incompleted goal or task instead they will skip from one incompleted activity to another often forgetting what the previous task or goal was that they were working on if they have been distracted this problem with difficulties re-engaging a goal is a function of impaired working memory not of inattention working memory is an executive capacity that allows us to remember what it is that we are doing and how we propose to get there individuals with ADHD have considerable problems with this type of working memory now the second domain that is not developing an ADHD is that of inhibition this gives rise to the impulsiveness and the hyperactivity seen in ADHD the problems with inhibition are pervasive they are seen in verbal behavior in motor behavior in cognitive impulsiveness such as an impulsive decision-making and difficulties with deferred gratification in devaluing future consequences over immediate ones more than do others and this also gives rise to the excessive task irrelevant movement and the excessive verbal behavior in other words the hyperactivity seen in ADHD this hyperactivity is often manifested in the early childhood years by excessive fidgeting squirming running about or climbing on things and so forth but it declines markedly with age such that by adulthood it is not very apparent and patients with the disorder often express it as being more of an internal or subjective feeling of restlessness or a need to feel busy now where does emotion fit into this two-dimensional view of ADHD before we discuss this issue it will help to Define what we mean by emotions and by emotional self-regulation and then we can see where ADHD might be causing difficulties in these two concepts an emotion can be defined as a short-term change that is a short duration change in one's intentions to act usually emotions are provoked by situational events and these provocations alter the intentions of the organism as to how it will respond to that event these changes are reflected in alterations in Behavior cognition subjective experience degree of arousal and in motivation emotions are short-term changes as compared to moods moods are often cross- situational and of a much longer duration than our emotions and so we are speaking here specifically about emotions that is these short duration changes in one's reactions to situational events now emotions can be plotted along a three-dimensional grid that is to say emotions comprise three different elements there is the action or behavioral gradient in which the organism either approaches or withdraws from the provocative event in other words does the organism see this event as an opportunity or as a threat the second dimension along which emotions can be plotted is a motivational gradient and this reflects the reinforcement or punishment aspects of the event in other words does the individual desire this event and prefer to approach it or does it fear the event or find it frustrating and attempt to withdraw from it the third dimension is that of a biological Dimension uh often referred to as the intensity of the emotion and this is degree the degree of physiological arousal or activation provoked by the environmental event now emotions serve a variety of functions for organisms including humans one of these is that emotions apparently serve a corrective function that is when an organism is pursuing a particular goal and that goal is frustrated or the individual becomes off task or is not pursuing the goal as quickly as they should then emotions are often elicited and this helps to the individual to correct their behavior back toward the path of goal Direction so there is a feedback loop or corrective function that emotions appear to serve emotions will be provoked when goals are being frustrated or th thwarted in this case there will be negative emotions on the other hand when the goal is being pursued and the pace of that Pursuit is more rapid the individual will find themselves experiencing positive moods now besides serving a corrective function for goal directed Behavior emotions are also communicative to others they signal our intentions as to what we propose to do next and finally of course emotions are expressive or cathartic in nature helping to release the degree of physiological arousal allowing the individual to eventually habituate to the provoked emotion now we can Define what we mean by emotional self-regulation we can think of emotions and emotional control as a two-part process there is the Primary Emotion which I've just discussed that is provoked by a situational event and then there is the second stage which is the active attempt to regulate the emotion in some way this is an effortful topd down executive aspect of emotional self-control where the individ idual is attempting to come to grips with the emotion so to speak and moderate it so that it is more consistent with the individual's goals in this second stage which is emotional self-control the individual attempts to inhibit the strong emotion that has been provoked by the situation and then attempts to self soothe or calm themselves down or in other ways downregulate the physiological arousal that has been provoked by the Primary Emotion they may also attempt to refocus their attention away from the emotionally provocative event using distraction reappraisal or other methods in order to further downregulate or moderate the Primary Emotion and then the individual will attempt to organize a new emotion or a more moderate emotion and use more coordinated action in the service of their goals and for their long-term welfare in other words the individual attempts to bring the emotion in line with their goals and longer term welfare and to make it more socially acceptable so again we can see that emotion and emotional self-control comprise two stages emotions are the primary emotions provoked by situations and emotional self-control is what we do afterwards in an effort to moderate the expression of the emotion so that it is more acceptable and consistent with our goals and long-term welfare now the most commonly accepted model for emotion in the literature is that of JJ gross gross's process model of emotion says that all emotions proceed through a four-stage process you see the stages representing here on the slide and although these stages can occur within a matter of seconds or even milliseconds it is helpful to distinguish the four stages that appear to be involved in the emotion the first stage is that of the situation itself and that is to say the event that is provoking the emotion the second stage is that we attend to this provocative event following this direction of our attention networks to the event there is a brief moment of appraisal of the event for its threat or desirability that is to say for its approach avoidance nature does the individual appraise the event as positive desirable or reinforcing and therefore approach it or do they appraise the event as punitive or aversive and then seek to withdraw from the event finally there is the respon response to the event itself which may involve the emotion and the physiological arousal uh that has been initiated by the appraisal stage now as I've said these four stages can occur in Rapid succession and may not always be delineated by the individual but as gross has pointed out it is still helpful to separate the emotion into these four stages now when when we think about emotional self-control as I've said we think about it as a two-stage process there is the automatic level of emotion which we have just described using gross's model of uh emotional expression we can understand the second stage which is the emotional self-control stage by showing a diagram of an emotion and what humans are likely to do to control that emotion now here we see along the bottom axis time and along the left hand axis is going to be the intensity or veilance of the emotion and the intensity and its veilance can be positive or it can be negative as in the case of aversive or unpleasant emotions now we've just described the four stages that an emotion goes through when it is provoked by a situational event and we can call this the primary Prim AR emotion so that when an event occurs an individual has this primary emotional reaction to it this is an automatic emotion it is not not part of self-regulation but when humans experience these primary emotions they will engage in a second stage of emotional self-regulation and this stage is seen here as that of a secondary emotional self-regulation and as part of this stage the individual may attempt to downregulate the emotion as I've said through self-calming distraction reappraisal or leaving the situation or in other ways downregulate the individual on the other hand may decide to prolong or enhance the emotion this is more likely to occur if the emotion is positive rather than negative but there may be times where it is in the service of an individual's goals to enhance or prolong the Primary Emotion that has been provoked by the situation finally humans are able to create another emotion that may countermand or contradict the initial emotion and therefore help to bring the initial Primary Emotion back under control more quickly for instance when an individual is frustrated or angered as their Primary Emotion in response to an event they may elect to count to 10 visualize a very relaxing situation such as lying on a beach somewhere for instance and this visual imagery creates a second emotion and that second emotion competes with and helps to downregulate the initial emotion and so humans have a variety of means by which they may try to self-regulate the Primary Emotion now if ADHD involves a difficulty with emotional self-regulation what would we expect to see an ADHD as a consequence of this difficulty first we would expect to see impulsive emotion the individual would display their primary emotions much more quickly and find them much more difficult to inhibit them and therefore they would be expressed in a stronger uh capacity that is the nature of the emotion would be more raw and unmoderated relative to what we would see in under other individuals of the same developmental level and while we would see them having difficulties with expressing all emotions that is they would be impulsive in expressing both positive and negative emotions it is the negative emotions that we would see having the greatest difficulties for them and that is because in a group living species such as ourselves it is the negative emotions that have the greatest social costs on our social relationships more than the impulsive expression of positive emotions such as humor or affection that is to say that it is the negative emotions that in that are less forgiving in a social group than are the positive emotions so we would expect to see a greater expression of emotional excitability greater expression of arousal uh in all emotionally provocative situations but the emotions that are going to pose the greatest difficulties for people with ADHD are the negative ones which are those of frustration impatience anger and hostility because these are the most socially costly emotions to express now we will also see difficulties in the second stage of emotional self-control which is the attempt to self-regulate the Primary Emotion people with ADHD will be more deficient in this abity to engage in topdown regulation of the emotion in order to make it more consistent with the situation with their goals and with their long-term welfare so people with ADHD will find it harder to self-calm and self soothe they will find it more difficult to refocus their attention and distract themselves away from the provocative situation they will also find it more difficult to leave the situation if necessary as a tactic for downregulating the emotion and they will find it harder to reappraise the situation in order to further downregulate the emotion we would also see them having difficulties with inducing positive emotions to counterman the initial primary negative emotion and make it more acceptable to the situation and because as I've said emotions are motivational States people with ADHD will find it more difficult to self motivate and to self-regulate their arousal and activation to situations than will other individuals now we're going to examine whether or not ADHD does involve a difficulty with emotional impulsiveness and with deficient emotional self-regulation I will use the acronyms EI for emotional impulsiveness and Dees are for the second stage of deficient emotional self-regulation throughout the rest of these this presentation now why should we make these two components of deficient emotional control a central feature of ADHD and if we did so where would it fit in I'm going to present seven lines of evidence that I believe support the inclusion of emotional disregulation as a a central feature of ADHD along with its other two components that is those of inhibition problems and those of attention and executive difficulties these seven lines of evidence include the history of ADHD the neuroanatomy of ADHD neuros pychological models that have been developed on ADHD the psychological evidence of itself for impulsive emotion instead studies of children and adults with ADHD I'm also going to present evidence on why if emotion is part of ADHD it would help to better understand comorbid disorders with ADHD such as Oppositional Defiant Disorder which is the most common comorbidity seen with ADHD I'm also going to show that by including emotion back in ADHD we are better able to predict many of the impairments in major life activities that individuals with ADHD are likely to have across the lifespan and that this prediction will be in addition to what is predicted by the difficulties in attention and in inhibition I'm also going to show how including emotion in ADHD helps to clarify the diagnosis of ADHD and also what the implications of including emotion in ADHD are for for its clinical management let me begin with the evidence from the history of ADHD ADHD was first documented in the medical literature in 1798 by The Physician Alexander kryon in his medical textbook kryon includes a chapter on diseases of attention and in that chapter he describes the two major attention disorders that we currently recognize that of ADHD which is characterized by short attention span lack of persistence distractability and of course the uh impulsiveness that I've already mentioned and the second disorder still recognized is that of the more daydreamy Spacey easily confused and mentally foggy individual which researchers now refer to as sluggish cognitive Tempo and clinicians sometimes diagnose as add or attention deficit disorder or as the inattentive type of ADHD no matter it is kryon that first described ADHD though he didn't use that name for the disorder and in his description particularly of the destructible impersistent form of attention disorder he included the fact that these individuals often had difficulties with emotional frustration In 1902 George still described described a syndrome like adht which he referred to as defective moral regulation of behavior or poor moral control and in describing individuals who were quite hyperactive impulsive distractable and inattentive he included as a primary feature of this disorder emotional impulsiveness and difficulties with regulating emotion still referred to these individuals as being very pass passionate and by passionate he did not mean loving he meant that they had difficulties with uh controlling their emotions and were likely to express their emotions to a greater degree and more intensively than would other individuals after the two World Wars attention began to return back to doing studies of mental disorders and in the 1950s and 60s the disorder that we now call ADHD was being described as brain injured child syndrome or minimal brain damage or later minimal brain dysfunction finally it would be renamed as the hyperactive child syndrome or as hyperkinesis clinicians that were evaluating individuals that had MBD or hyperactivity described deficient emotional self-regulation as a central feature in these disorders in the 1970s Mark Stewart also included low frustration tolerance quickness to anger and emotional excitability as primary features in his description of the hyperactive child syndrome in 1975 Dennis canwell also included emotional disregulation as a core feature in his descript description of the hyperactive child syndrome or hyperkinesis also in the 1970s Paul wender also included difficulties with emotional self-regulation and impulsive expression of emotions as a key feature in his description of minimal brain dysfunction in children and adults in fact it is wender Who is credited with being among the first to describe the nature of adult MBD or what now would be called adult ADHD and in it emotion was considered to be a primary clinical finding in the disorder that is to say a central feature of it so why is emotion no longer included in ADHD why isn't it part of the DSM criteria we have to go back to 1968 when dsm2 was first published to understand what may have happened because it is in the publication of this manual and it's brief diagnostic criteria for the hyperkinetic reaction of childhood or what is now ADHD that we see that emotion was neglected dsm2 describes ADHD or hyperkinesis as involving three Central features inattentiveness with distractability the second feature is impulsiveness and the third is hyperactivity there is no mention made of emotion even though at the time and throughout its entire history hyperkinesis or hyperactivity has always included poor emotion self-regulation as I have said now I've attempted to research why emotion was ignored in dsm2 but I'm not able to find any compelling reason for it perhaps it is because this is the beginnings of the scientific study of child psychiatric disorders and doing observation studies of mental disorders was becoming increasingly important and it is easy to measure symptoms of distractability inattentiveness and impulsiveness not to mention hyperactivity but it is much more difficult to measure symptoms of emotional disregulation so perhaps it is this measurement issue that led to the neglect of emotion in dsm2 another reason might be that Stella chess had early earlier published a paper in which he described the hyperactive child syndrome as being comprised solely of excessive motor activity and Stella chess being a major child psychiatrist at the time a very influential one may have had some influence over the wording of the criteria for ADHD in dsm2 I'm not sure of that but it's one possibility nevertheless it is at this juncture that we see emotion being relegated to a secondary or unimportant status in our conceptualization of ADHD and once emotion was neglected in the official taxonomy of ADHD it has been neglected ever since all the way through DSM 4 now besides the history of ADHD supporting the inclusion of emotional disregulation as a central feature of the disorder emotional disregulation should also be found to be a part of ADHD because of the neuroanatomy of the disorder evidence on neuroanatomical findings for ADHD would support the role of emo emotion disregulation in the disorder let's have a look at the findings that have been found in n in a number of studies on the neuroanatomy of ADHD studies both of the structure of the brain and of the functioning of the brain in ADHD indicate that there are five domains or five regions in the brain that are not developing properly in people with this disorder these brain regions are about 3 to 10% smaller in their structure and they are about 10 to 25% less active in their functioning these regions are the orbital prefrontal cortex particularly in the right frontal lobe we know that this part of the brain is underdeveloped in ADHD and it suggests that the right side of the brain may be more involved in ADHD than the left side of the brain the second structure is the basal ganglia at the central part of the brain and principally the striatum this area is also smaller in individual with ADHD the third area is the cerebellum as you see here the cerebellum is an ancient brain structure at the back part of the brain and it is also smaller in people with ADHD particularly in the Central Area known as the vermis once again we see the right side of the brain being more underdeveloped in individuals with ADHD than the left side of the brain though findings do indicate underdevelopment of both brain hemispheres yet it is principally more on the right than the left next we see that the anterior singulate of the brain is less developed and less active this is a structure at the midline of the frontal cortex and it is involved in a number of aspects of conflict resolution finally we see that the Corpus colossum is involved in ADHD the Corpus colossum is the large Bund of fibers that connects to two hemispheres and allows the left and right hemisphere to communicate with each other the size of these structures and the networks that they create are directly correlated with the severity of ADHD symptoms particularly that of inhibition there are very few gender differences seen in ADHD studies and what little there are are not important for this particular topic or presentation longitudinal studies such as that by Philip Shaw indicate that there is about a 2 to threee lag in the development of these brain structures but that the structure of the brain may start to normalize by mid to late adolescence nevertheless despite this apparent normalizing of brain structure there appears to be uh a much greater lag in the development of brain activation that is to say differences in brain activity continue to be found in these brain structures well into adulthood even if the size of the brain May Lo no longer be a distinguishing feature of the disorder and finally contrary to accusations made by critics the underdevelopment and underfunctioning of these brain regions is not the result of giving stimulant medication for the management of ADHD these same findings have been evident in stimulant naive individuals that is to say those who have never been treated with medication now let me show you where these brain areas are located in this diagram of the human brain the frontal lobe of the human brain is this large structure we see here at the interior part of the brain and the area we are most concerned about within the prefrontal cortex is the orbital prefrontal region that you see right here this is the area directly behind the forehead and especially that brain region sitting just over the eye orbits it is principally in this right area that we see much less development of brain size and functioning now the second area of interest is that of the basal ganglia and that is located here this reddish orange structure nerve cells from the cortex project back and terminate on the Str striatum in particular and the nerve cells from the frontal lobe terminate at the interior part of the striatum which is known as the cordate nucleus now in addition to the basal ganglia being smaller in people with ADHD the cerebellum is also involved in ADHD as you see here at the back part of the brain and it is the central area here known as the vermis that is typically found to be smaller and less active in individuals with ADHD the fourth structure involved in ADHD is the anterior singulate and to find the interior singulate we have to go into this fissure between the two hemispheres and if we progress back several inches right about where you see this arrow and looked on the left or the right walls of the hemispheres we will see the interior singulate this is also smaller and less active in people with ADHD finally although not shown in this diagram the Corpus colossum which is located around in here and allows the two hemispheres of the brain to communicate with each other as I've said is also smaller particularly in the frontal part of the Corpus colossum known as the splenium now this is another way of viewing the human brain and here we've cut the brain in half and we're now looking directly at the right hemisphere of the brain and here we can see some of these same brain structures more clearly first of all we see the dorsal lateral frontal lobe and particular its orbital aspect over here this is smaller in ADHD as I've already said the anterior singulate which was difficult to visualize in the previous slide is located here at the medial or middle aspect of the frontal lobe and here we see the right interior singulate now now in addition we also see the remaining remaining part of the brain that is involved in the top down regulation of behavior and I'll have more to say about that in just a moment because the ability to regulate emotions brings into play other parts of the brain and not just the frontal lobe which we see up here now as I've said the cerebellum is involved in ADHD and that's back here and we're mainly looking at the central aspect of the cereb or the vermis which is right here now on this diagram we can see that the frontal lobe is able to regulate the limic system which is the emotional brain that you see here and it does so through the amydala projections go from the dorsal lateral aspect of the frontal lobe into the anterior singulate and from the anterior singulate to the amydala and from here the frontal lobe is able to regulate the expression of our emotions and therefore if ADHD is a disorder that involves these neuroanatomical regions then ADHD should also involve a problem with the top-down regulation of primary emotions we would also expect to see that ADHD would involve a problem with self awareness and particularly with the self-awareness of one's primary emotional states this diagram shows where self-awareness can be localized in the human brain most importantly it shows that the anterior singulate or the midline of the frontal lobe is critically involved in self-awareness and that the anterior singulate is also interconnected with other aspects of the brain that allow us to possess self-awareness and to engage in self-monitoring now as I've said the anterior singulate is underdeveloped and underfunctioning in ADHD and this would create a problem with self-awareness in ADHD and it would also create a problem therefore with the self-awareness of one's emotions as you see here so the neuroanatomy of ADHD indicates that there ought to be a problem with emotional control and self-regulation given that the same brain regions that are involved in emotional self-regulation are also the brain regions that are involved in ADHD there would have to be a problem with emotion in ADHD if this is the case now this diagram shows the interconnection between the anterior singulate located here and the amydala located here and we know that the amydala and the remaining part of the M the lyic system located back in this brain region that these structures have reciprocal networks with the anterior singulate and therefore if individuals with ADHD have an impairment in the development of the anterior singulate there will be difficulties in regulating the primary emotional brain which is the amygdala and Lim system so again this is just another way of showing that emotional disregulation has to be involved in ADHD if the frontal lobe and anterior singulate are involved in ADHD which they clearly are now another reason to include impulsive emotion and deficient emotional self-control in ADHD has to do with current neuros theories of the disorder all of these theories in include an emotional component in the disorder even if it isn't reflected in the formal diagnostic criteria for ADHD in the DSM various theorists that have reviewed the neuropsychological evidence and the neuroanatomy of ADHD have argued that there are three networks that can be formed out of the five brain structures that we have discussed as being involved in ADHD one of these networks is the connections from the dorsal lateral aspect of the frontal lobe back into the basal ganglia and specifically to the striatum as I showed you earlier this is known as the cool executive Network or the what network it is here that what an individual is holding in mind in their working memory for instance is going to regulate what they do in other words our thoughts or what we hold in mind are going to organize and enact behavior in support of our thoughts this is why it is called the what network in short what we hold in mind is going to manage what we do now the second Network that can be formed out of these brain structures are the connections from the frontal lobe back into the cerebellum this frontal cerebellar circuit has been called the when Network because this circuit is involved in the timing and timeliness of our actions as well as of our thoughts the cerebellum is not just involved in the smoothness of motor action and in coordination and Rapid sequencing of action it is also involved in the timing Of Human Action and the cerebellum is just as much involved in these aspects of behavior as they may occur in thinking as they are in the actual expression of the behavior itself in other words the cerebellum is instrumental in higher cortical or higher cognitive activity just as much as it is in behavioral expression so it is here that the timing of thoughts and actions is being regulated by the executive circuitry finally there is the emotional circuit the hot circuit or what is called the Y executive Network this is the connections from the frontal lobe through the anterior singulate to the amydala and the lyic system more generally it is through this circuit as I pointed out earlier that what we think is going to affect how we feel this creates not just an emotional circuit but an appraisal Network because it is here that one appraises the value of what one is thinking about in other words it is here that feelings are connected to thoughts and so when we hold an IDE in mind that idea comes with a certain emotional coloring and that coloring is provided by this particular frontal limic circuit and it helps us to quickly evaluate the worth of an idea that is whether or not it is worthwhile pursuing this idea or not and that is because sasio pointed out our feelings are welded to our thoughts as a function of this network and that is why it is called the hot or the Y executive circuit here you see the various papers by various theorists that have argued for these three networks being involved in ADHD and one of these networks is clearly the network that regulates emotion and so the neurosystem that occur in the cool executive Network here and with the difficulties with the timing and timeliness of behavior that would arise from the timing circuit that you see here now besides these particular theories of ADHD my own theory of ADHD and of executive functioning would also argue for the inclusion of emotion in ADHD my theory argues that there are six executive functions that develop in individuals these are self-awareness inhibition nonverbal and verbal working memory inhibition particularly of emotions and self-regulation of those emotions and planning and problem solving I have argued that each of these executive functions is a form of action directed at oneself that is a form of self-control individuals direct their attention back on themselves to create self-awareness they direct their primary inhibitory ability back on themselves to create self-restraint they also redirect their senses back at themselves particularly Vision to create visual imagery and this creates the non-verbal working memory system they also redirect their speech at themselves and develop a voice in the mind and this forms the verbal working memory system then they use these four executive functions to create emotional self-regulation in themselves that is by talking to themselves and by visualizing images individuals are able to provoke secondary emotions in order to help regulate their primary of emotions it is also here of course where emotion creates self motivation in individuals as I've said previously emotions are motivations and therefore if one is able to regulate their emotions they are also able to self-regulate their motivational States and finally in my theory of executive functioning planning and problem solving is seen as a form of play to the self in which children's play has become progressively internalized or privatized over development to facilitate mental planning and problem solving which in my model is simply the ability to manipulate what one is holding in mind and to play with the contents of working memory in order to discover novel recombinations of that information and develop novel ways of responding to the environment hence of problem solving so even in my theory of ADHD and of executive functioning emotion and emotional disregulation has to be a central feature of the disorder now besides the neuros cych theories of ADHD including emotion in the components of ADHD the psycholog iCal evidence also supports the inclusion of emotion and ADHD what do we find when we go out and observe individuals Behavior Uh that is their ADHD behavior in natural settings recently I have developed a rating scale of executive functioning in daily life activities and we have applied this to individuals with ADHD this rating scale has found that there are five dimensions of executive functioning in daily life and you see them here self-management to time self-organization and problem solving self-restraint or inhibition self motivation and most importantly as you see at the bottom of the slide the self-regulation of emotion here so when we evaluate children and adults with ADHD we see that they have great difficulty with all of these executive fun functions in daily life activities or what I call Executive behavior and among these five problems they have significant difficulties with emotional self-control so research clearly shows that the inclusion of emotional problems in ADHD is not hypothetical but real there is evidence from these rating scales and observations of daily behavior that emotion has to be a part of this disorder and certainly is now other evidence can be Marshal to show that emotional disregulation is part of ADHD other studies such as those using the child behavior checklist the behavioral assessment system for children the symptom checklist 90 with adults and other Behavior rating scales indicate significant elevations on subscales that reflect problems with emotional regulation such as with low frustration tolerance impatience anger and overall emotional excitability so that there is evidence from other reading scales besides my own to show that emotion is a problem for those with ADHD there have also been studies that have brought individuals with ADHD into the lab and have videotaped their emotional Expressions during emotionally provocative situations and what these studies show is that people with ADHD Express their emotions more impulsively that is they have poor inhibition of their primary emotions especially of impatience low frustration tolerance and anger and hostility these studies also indicate that when people with ADHD are instructed to try to control these emotions as well as they can that compared to control groups they are far less able to engage in self-regulation of these emotional states most recently research shows that even at the level of the autonomic nervous system there are differences in the capacity of individuals with ADHD to regulate this emotion related nervous system these studies indicate that people with ADHD have a more flattened or suppressed profile in the parasympathetic nervous system in response to emotional provocative events normally in individuals this system is increased in its activity during emotional expression and that it is decreased in activity when individuals attempt to self-regulate their emotions these studies indicate that there is abnormal regulation in brain regions that govern govern the parasympathetic nervous system in people with ADHD and these problems with emotional disregulation are evident even at the physiological level of emotional expression now follow-up studies such as my own in Milwaukee of ADH children followed to adulthood indicate that the majority of them have difficulties with impulsive emotion and deficient emotional self-regulation particularly as a function of whether or not their ADHD has persisted also studies I have done on adults with ADHD who are Clinic referred in adulthood indicate that these adults also have problems with emotional impulsiveness and deficient emotional self-control now here are the results from the Milwaukee study that I've just mentioned as you can see along the bottom of the graph here we have graphed the frequency with which these individuals describe themselves as often having difficulties with these emotions there were others that we recorded in the study but I'll just show you these five to make the point and also so that the graph can be interpreted more clearly now in my Milwaukee study we have taken our groups of children at adulthood and we have separated them into those whose ADHD has persisted to age 27 that's the adhdp group represented in the red bar that you see in the diagram and we have divided them into those whose ADHD did not persist at age 27 some of these individuals had recovered from their ADHD completely While others continue to show high levels of symptoms but did not meet all diagnostic criteria for the disorder they are represented by the light blue bar that you see in the diagram finally we have been following a control group of individuals from the same neighborhoods schools and social classes as the ADHD individuals and they are shown in the diagram by the yellow bar now what do we see here in this diagram we see that individuals whose ADHD has persisted to adulthood have considerably more problems with controlling these emotions than do individuals whose ADHD has not persisted and compared to those in our control group notice that the non-persistent group of ADHD also has more difficulties regulating these emotions than the control group but not to the degree seen in those whose ADHD that has persisted and other words the more an individual's ADHD is likely to have persisted to adulthood the greater is is the likelihood that they will have difficulties with regulating these emotions that is they will often report expressing these emotions more than do other individuals this study also found that the frequency with which these individuals were having these difficulties was just as often as for the symptoms of inattention impulsiveness and hyperactivity in the official DSM criteria so that the emotional problems of these individuals occur just as often as the traditional ADHD symptoms are likely to do in this population followed to adulthood now on the next slide you will see my study of Clinic referred adults with ADHD done with Kevin Murphy when we were at the University of Massachusetts Medical School here we see the very same emotions that were seen in the Milwaukee study graphed along the bottom of the diagram here and we have two groups Clinic referred adults with ADHD and a community control group and it is quite obvious here that the individuals with ADHD with the red bar here have considerably more difficulties with controlling these emotions than does our clinical control group and that is true across all of these emotions we also find that the frequency with which these individuals had these difficulties is just as great as for the traditional DSM symptoms reported in DSM 4 so here again to the extent that an individual has ADHD we will also find that they have considerable problems with the regulation of impulsive emotion and particularly with the control of these negative emotions in other words the evidence now shows that emotional self-regulation problems are ubiquitous in people with ADHD that is to say that they are just as common as are the other Central features of ADHD such as inattention distractability hyperactivity and impulsivity so the psychological evidence warrants returning emotional disregulation back into ADHD now now another reason to include emotion as a core feature of ADHD is that it can help to understand why certain disorders are highly comorbid with ADHD the disorder that is most comorbid with ADHD is Oppositional Defiant Disorder or OD OD occurs on average in at least 65% of ADHD individuals ranging from 40% in some studies to over 80% in other studies I therefore OD is the most common comorbidity seen in ADHD OD reflects a pattern of anger hostility Defiance stubbornness low frustration tolerance and particularly with resistance to Authority especially parental Authority now while the DSM represents OD as a single dimension of symptoms research has shown that OD actually is best represented as a two-dimensional disorder and indeed dsm5 will correct this representation in od when it is eventually published in 2013 it will also show Odd as a two-dimensional disorder now the two Dimensions that comprise OD are those of emotion disregulation and social conflict so at least three to four symptoms of OD reflect problems with control ing these negative emotions The Temper the hostility and so on would be part of the emotion disregulation Dimension and the arguing and Defiance and refusal and so forth would be symptoms reflecting of the social conflict dimension of OD now we know that OD is likely to develop in ADHD 11 times more than is the case in the general population as I've said OD is the most common comorbidity associated with ADHD and when OD develops it often develops within 2 years of the onset of ADHD by understanding OD as a two-dimensional disorder we can now see where ADHD contributes to OD and that is that ADHD is contributing to the emotional disregulation of OD and that is because emotional disregulation is an inherent part of ADHD so that the impulsive emotion in ADHD which arises from the hyperactive impulsive dimension of ADHD is strongly associated with the impulsive emotion seen in od this is why it is the hyperactive impulsive dimension of ADHD that predicts the development of OD in individuals it is also also the problem with the self-control of emotion in ADHD that is associated with its inattention Dimension that creates the problems that people with ADHD have in self-regulating both their emotions and their Oppositional Defiant Disorder so as I said before emotional self-control is a two-part process inhibiting the Primary Emotion which ADHD individuals have trouble doing and self-regulating the Primary Emotion when once it's been elicited both of these difficulties would contribute to the emotional disregulation component of OD let me put it another way if you have ADHD you already have a subclinical case of OD it may not arise to the level of being clinically diagnosable and yet there is still a subliminal or sub threshold component of OD that is part of adht and that is because of the emotion disregulation seen in ADHD now we know that the emotion disregulation in od arises from its association with ADHD and we know that it is biological not social on the other hand we also know that the social conflict dimension of OD arises from a different source and that is learning and learning in particular within the family Research indicates that some of the variation and the severity of OD is due to disrupted parenting this variation is seen in the social conflict symptoms of ADHD so the emotion disregulation seen in od is not learned it is biological and it is being contributed by the overlap of OD with ADHD on the other hand the variation in the social conflict symptoms of OD is learned and it is most often learned in the family environment as a function of disrupted parenting now specifically that disrupted parenting is a pattern of inconsistent indiscriminant use of consequences within the family as well as high rates of expressed emotions such as yelling and screaming and so on and indeed vacillating between the use of harsh and lacks consequences for uh the individual's inappropriate behavior so all of this is to say that parents who show disrupted parenting show a very inconsistent and indiscriminate use of consequences and of emotion now why would parenting be disrupted in this way because the parent often has adult ADHD as you probably learned if you took my course on this website on the ideologies of ADH D ADHD is a highly neurological and genetic disorder given that ADHD is highly inherited it is quite likely that if a child has ADHD that their parents are also likely to have the same disorder and it is Parental ADHD that is likely to be contributing to this pattern of indiscriminate impulsive and emotional parenting and therefore it increases the probability that the child will learn the social conflict component of OD in addition to having the emotional disregulation component of ADHD that also is part of OD now we also know that disrupted parenting arises not just as a consequence of Parental ADHD but it can also occur as a consequence of other parental mental disorders such as major depression antisocial personality disorder or as p and substance use disorders or Suds as you see represented on this slide so the emotional disregulation component of OD which is arising from ADHD predicts a different outcome by adolescence than does the social conflict component of OD the emotional component of OD predicts the development of major depression and anxiety disorders we know that both of these disorders are more likely to arise in children with ADHD over time and we know that one of the predictors of the development of these disorders is whether or not the child has gone on to develop OD and now we know why OD is the pathway onto later major depression and anxiety in cases of ADHD it is the emotional disregulation component of ADHD that is contributing to the risk for all three disorders to the risk for OD and then later the emotional disregulation is contributing to risk for major depression and anxiety so over time emotional disregulation predicts certain outcomes in od children the emotional outcomes the social conflict component of OD which is the more learned component is predicting later in development the risk for conduct disorder this is why it is helpful to think of OD as a two dimensional disorder one dimension the more biological component that is related to emotion and temperament is contributed by ADHD the second component the social conflict component is learned and it is likely to contribute to different disorders over time such as conduct disorder so I hope you can see that by including emotion in ADHD we have a much better understanding of why ADHD is often associated with the emergence of oppositional disorder and we also have a better understanding of which component of oppositional disorder ADHD is causing it's the emotion disregulation component but we can also understand that ADHD in the family may be contributing indirectly to the social conflict component of OD and that is because the parents ADHD is contributing to disrupted parenting now now here is a diagram that represents everything we've just described in a more visual form what we have just described is that OD child Defiance and social aggression is here and it arises from these two Pathways it arises from the biological pathway of disregulation disregulated emotion that is part of ADHD and more generally negative childhood temperament and personality so there is a biological component of the child that is contributing to the risk for OD but there is also a parenting component that contributes to OD and this is through disrupted parenting but the disrupted parenting can only be understood if we back up further and examine why it is disrupted and often that is due to parental Psychopathology and also to significant family stressors that are occurring both of these are going to contribute to the risk that parenting will be disrupted and the disrupted parenting then contributes to training the child in the social conflict component of odd the child's own disorders are going to contribute to the emotional disregulation component of OD so I hope this helps you to understand why OD would arise in ADHD ADHD is causing it and I also hope that it helps you to understand understand why other emotional disorders may also arise in ADHD as a consequence of this emotional disregulation component and that is the risk for major depression and anxiety now another reason to put emotion back into ADHD as a central feature of the disorder is that emotional impulsiveness and deficient emotional self-regulation will predict certain impairments in the life course of the individual beyond what would have been predicted by the traditional ADHD symptoms let me show you what I mean research has shown that the single best predictor of whether ADHD children will be rejected by other children when they enter a new peer group is not the traditional attention inhibition or hyperactive symptoms of ADHD it is the emotional component of ADHD that is most strong strongly associated with social rejection this is not only true in children we have more recently identified the same difficulty in adults so by putting emotion back into ADHD we can immediately understand the social difficulties that ADHD poses for individuals it is through emotional disregulation that these social problems are most likely to arise my colleagues and I have also shown in some of our public lications that interpersonal hostility as reflected on such scales as the symptom checklist 90 and also marital dissatisfaction and disharmony in adults with ADHD are best predicted by the emotional component of ADHD not by the attention or inhibition components of ADHD we have also shown that ADHD adults are likely to complain of parenting stress and and their parenting stress and family conflict is directly related to their own emotion disregulation but we have also shown that in parents who have ADHD children their parenting stress as well is most strongly predicted by emotion disregulation not by inattention or impulsive hyperactive Behavior I've conducted studies in which we have controlled or examine the contribution of emotion inattention and hyperactive impulsive behavior to the adverse driving outcomes associated with ADHD for more on these driving risks please take my course on the life course impairments associated with ADHD now specifically we have found that the emotional component of ADHD is predictive of road rage or the aggressive use of a motor vehicle driving under the influence of alcohol and to crash crash risks while driving now this is beyond any contribution made by the traditional symptoms of ADHD we have also shown that the likelihood of being fired from a job and the likelihood of having interpersonal problems in the workplace are both more related to the emotional dimension of ADHD than to its hyperactive and inattentive dimensions the inattention dimension of ADHD is related to to the individual's ability to perform their work properly in the workplace as reflected in work performance evaluations given by supervisors but the likelihood of being fired from a job or of having conflicts in the workplace is related to emotional disregulation in ADHD we have also found evidence that dating relationships or even cohabiting relationships and the degree of conflict and dissatisfaction in these relationships is more a function of the emotional component of OD of ADHD rather as well as of OD of course than of the traditional ADHD symptoms and there is some evidence to suggest that the emotional element of ADHD is likely to contribute to violence within these relationships more recently we have studied the financial management difficulties associated with ADHD which are numerous and among these financial difficulties those that were most predicted by the emotional component of ADHD were impulsive buying exceeding one's credit limit particularly on the use of a credit card and therefore also in one's poor credit rating lastly we found in our research that the extent to which a parent with ADHD had difficulties regulating their own emotions turned out to be predictive of the same problems in The Offspring of these adults with ADHD so that variation in the Parents emotional disregulation was directly predictive of risk for variation in impulsive emotions in the children of these parents and this also then went on to predict the likelihood that these children would develop Oppositional Defiant Disorder so what all of this means is that by putting emotion back into ADHD we are able to predict impairments linked to ADHD that are not predicted by the traditional symptom Dimensions included in ADHD those of inattention and those of hyperactive and impulsive behavior finally let's explore what it means for diagnosis and for treatment by putting emotion back into ADHD where it belongs first of all we know that the emotional adjustment of our patients over their life course is going to be in part now predicted not just by their core ADHD symptoms but by the emotional disregulation and the poor emotional self-control of our patients that is to say that over the life course the totality of an individual's emotional adjustment is in part being determined by some of the primary symptoms of ADHD those having to do with emotion but but we also know of course that our emotional adjustment is going to be affected by the secondary consequences of ADHD such as through failure in school in work and in family and peer relationships those repeated failures as they rack up are going to contribute their own emotional byproducts such as demoralization and low self-esteem to the clinical presentation of our patients now in addition as I have taught in my course on comorbidity on this website ADHD is likely to be associated with other psychiatric disorders some of which are mood and anxiety disorders such as dymia depression anxiety and bipolar disorder these disorders will contribute in their own right to the emotional adjustment of our patients beyond the other two sources of influence I've just described and then of course there is the contribution made by by the other disorders that link up with ADHD that are not necessarily mood disorders but that will have consequences across the life course as well contributing to social stigma and failure in Social relationships and difficulties in school and in the workplace and these are disorders such as learning disabilities and the other externalizing disorders oppositional disorder and conduct disorder not to mention substance use disorders that are also linked to conduct disorder and then the other comorbidities we see in ADHD as well these will make their own contribution to emotional maladjustment and finally as we've already discussed there is a contribution made by the social ecology around the child as they grow up that contributes in its own way to emotional maladjustment all of this is to say that if you want a complete picture of the emotional adjustment of an individual by adulthood that has grown up with ADHD you must evaluate all five of these vectors of influence that are contributing to emotional maladjustment but the point of this presentation is to draw your attention back to the contribution made by ADHD itself which has been ignored in analyses of emotional adjustment ADHD creates emotional disregulation and that has a primary contribution to emotional maladjustment over the life course now some further Diagnostic and treatment implications of putting emotion in ADHD are as follows first it cautions us not to mistake the emotional difficulties of ADHD as representing a different disorder a comorbidity such as with a mood disorder emotional impulsiveness and difficulties with regulating emotion are part of ADHD itself they are not due to comorbidity and so there is no need to rush to diagnose a second or third disorder in order to account for the emotional difficulties that most of our ADHD patients have it is simply a part of their ADHD itself on the other hand it also cautions us not to mistake certain mood disorders as arising from the impulsive emotion seen in ADHD people with ADHD can have primary mood disorders in their own right such as bipolar disorder depression and anxiety disorders and these may not necessarily always arise from the emotional disregulation in ADHD but may arise in their own right as separate and primary disorders in order to differentiate these primary disorders from ADHD and its emotion disregulation I think it helps helps to understand that ADHD causes a topdown disregulation in the management of primary emotions the emotions that the individual has in ADHD are rational they are the same emotions that you would have in response to an emotionally provoked situation but you would have inhibited that emotion and engaged in efforts to downregulate and moderate the emotion to make it more acceptable that is the problem that people with ADHD have so if the emotional problems are due to ADHD they're rational they're understandable other people would have felt those emotions also but what separates the person with ADHD is that they express the emotion impulsively and then they struggle to deal with the emotion in a socially acceptable way their emotions are not long-term moods they are not excessive in the sense that they are irrational extreme unprovoked and cannot be understood by reference to the provocative event in contrast a mood disorder is a bottom up disorder in the self- regulation of emotion the individual is creating moods and emotional states to an excessive degree probably through overactivity and disregulation within the Oly Olympic system itself and the amydala so that the individual is spewing excessive emotions irrational emotions emotions that are not necessarily provoked by a situation or if provoked are longer lasting and cross situational in nature so that in contrast to ADHD this is not a problem with top-down regulation of normal emotion but a problem with the bottomup expression of excessive emotions and moods across situations to help differentiate the two remember in ADHD the emotion is rational understandable and normal but it is not being inhibited appropriately and moderated for its social acceptability in a mood disorder the emotion is not rational it's extreme it's labile and capricious and excessive and it is not the result purely of an in ability to regulate normal emotion now others that is to say other disorders may be an excessive enhancement of emotion as a result of difficulties in the EXA uh the uh executive system for instance we know that rumination as part of obsessive compulsive disorder can occur as a result of OCD uh and is sometimes seen in conjunction with ADHD particularly if Tourette syndrome is also present obviously individuals who ruminate can overexpress emotions not because they have a difficulty in the emotion uh control system that is the lyic system but because they are ruminating on a mental event and that is provoking the emotion associated with that mental event so again what is the difference between ADHD and other emotional and mood disorders in ADHD the emotion is rational understandable Tim limited setting specific reasonable but it is not being regulated properly or is in a mood disorder or in a disorder in which the individual is ruminating the emotion is excessive irrational longterm like a mood and inconsistent with the situation so putting emotion back into ADHD can help us I believe with differential diagnosis of ADHD and its emotion disregulation from the emotional problems created by mood disorders understand that these comorbid mood disorders May therefore require separate management from the management of ADHD itself but if the emotional disregulation is the only problem in the ADHD individual then treating the ADHD will result automatically in improvements in the emotional disregulation so that putting emotion back into ADHD helps us to understand treatment of ADHD for instance as I've just said if the problem the person has is with emotional impulsiveness and deficient emotional self-control that is part of their ADHD then it will be improved by ADHD medications and it will be improved to the same degree that we see improvements in the inhibitory and in the inattentive OR metacognitive dimension of ADHD indeed studies show that the degree of improvement in Emotion is directly correlated with the degree of improvement in the ADHD symptoms and that these are correlated with each other quite highly as one improves the other improves now we also know that the different ADHD drugs are going to regulate the emotional problems in ADHD differently for instance research suggests that stimulant medications are likely to suppress the lyic system and therefore are suppressing the expression of primary emotions this may explain why in some patients particularly at high doses emotions are blunted and the individual appears to have a limited range of emotion and often has the appearance that people will describe as that of an automaton or being robot-like emotional expression expression is being blunted by the stimulants because they are acting directly on the lyic system now that is certainly one way to control the emotional problems in ADHD but since as I've said the emotional disregulation in ADHD is not arising from the lyic system but from the top down management of that limic system by the executive dorsal lateral cortex then it's possible that the stimulants are managing the emotion through an inappropriate pathway so to speak they're suppressing the expression of emotion rather than boosting the self-regulation of emotion nevertheless the end result is that the emotional problems in ADHD are being improved by the medication now in contrast drugs like atomoxetine or statura do not have a primary effect on the lyic system instead stratera has effects on the anterior singulate and on the dorsal lateral cortex and so it is likely that what stratera is doing is boosting the executive regulation of emotion rather than suppressing the expression of primary emotions that is why I believe that atomoxetine is not associated with blunted emotion or with a more robot-like or automaton uh limitation in emotional expression as can the stimulants in some cases finally the new drug guanosine XR called intuniv in the marketplace may be regulating emotion similar to that of stratti and that is by boosting the control of emotion through the anterior singulate and especially through the dorsal lateral cortex so all of this is to say that the different ADHD drugs may be managing the impulsive emotions in ADHD through different routes Within the brain keep this in mind as you come to understand the reactions that your ADHD patients may be having to the different medications that you're using and how they may be assisting them with control of the emotional component of their ADHD now the secondary impairments that arise from deficient emotional self-regulation on major life activities may also be improved by ADHD medications that is to say for instance that domains of impairment such as social rejection interpersonal relationship problems as in marriage dating or cohabiting relationships the emotional use of a motor vehicle that gives rise to road rage the emotional use of credit cards and money as we saw in the financial domain of ADHD all of these might be expected to improve as a result of the use of ADHD treatments such as ADHD medications because you're improving the contribution of the emotional element of ADHD to these major life activities now this also helps us to understand why ADHD treatments like ADHD medications also improve odd indeed research shows and has shown for more than 40 years that ADHD meds improve oppositional Behavior as much as they improve ADHD behavior and now we know why by going back and understanding that OD is a two-dimensional disorder and that one of those Dimensions is emotional disregulation that is the anger frustration and hostility dimension of OD we were able to understand how ADHD is causing OD well now we can also understand how ADHD meds are improving OD they're doing it by improving the emotional disregulation caused by ADHD and therefore they are lower ing the frequency of the OD symptoms themselves but what the ADHD medications will not be able to address is the social conflict dimension of OD because as I taught you earlier that dimension of OD is arising from social learning within the family and especially from disrupted parenting and therefore if you treat an individual who has OD with an ADHD medication and there is still res idual OD after you have reduced their ADHD symptoms then that residual OD is probably what has been learned and one is going to have to enact a behavioral parent training program for this social learning component of OD if one expects to improve that of course this would also mean that one would need to screen parents of OD children for their own ADHD and for other possible mental dis disorders because as I explained in the OD segment of this course there are parental disorders that contribute to disrupted parenting one of which is Parental ADHD and we would want to screen for that and treat the parents ADHD before taking them through any behavioral parent training program if you don't treat them then they are unlikely to be responsive to the behavioral parent training program and therefore their child's OD or at least the component that has been socially learned is not likely to respond to the parent training program either finally what this also shows is that there are some social ecological contributors to the development of emotional problems in individuals with ADHD that may require separate psychosocial interventions in addition to the ADHD medications and they may also require relocation of the family to different neighborhoods uh in order to help treat the comorbid disorder for instance we know that comorbid conduct disorder in individuals with ADHD is in part due to the uh affiliation of this individual with deviant peers who are also antisocial with living living within uh disrupted and disadvantaged neighborhoods where there may be greater amounts of crime taking place as well relocating the individual with conduct disorder to a different neighborhood a more pro-social neighborhood can have positive effects on the reduction in the comorbid disorder all of this is to say that treatment of ADHD may require also treatment of the social ecology depending upon the comorbid disorders that coexist with ADHD Now by putting emotion back in ADHD it also helps us to understand the individual's ability to use self-control in managing their emotional symptoms this is a diagram that shows that emotional self-regulation like all self-regulation is a limited resource pool we have only a certain amount of self-control of self-discipline of willpower if you wish to call it that of strength in our self-regulation and this pool this fuel tank of willpower represented over on the left hand side of this diagram that you see here by the yellow bars this fuel tank of willpower can be diminished by using all of the executive abilities and the longer the executive functions have to be deployed by an individual the lower this fuel tank will become that is the less self-control an individual will have and emotional self-control can deplete this fuel tank in its own right in addition to all of the other executive functions by the way stress alcohol drug use and other medical disorders can also deplete the fuel tank of willpower or self-regulation so let's understand that when people with ADHD are put in demanding situations where they must self-regulate their emotions for long periods of time it is going to deplete their will willpower their capacity for self-control ultimately they run out of this fuel or of this willpower and they can no longer manage their emotions properly which is to say that the next situation that comes along right after this depleting situation that may provoke their emotions is likely to lead to much greater difficulties in emotional self-control because they have little willpower or self-restraint left now we can increase the fuel tank of emotional self-control of willpower by helping individuals with ADHD to engage in a variety of uh activities that are known to replenish the will power fuel tank these replenishment activities are things like using greater rewards and helping individuals to engage in more positive emotions in situations that are emotionally provocative we can also help them increase the fuel tank by helping them with self-statements of self-efficacy and encouragement this is sort of like the locker room pep talk before going out and playing the big football game the pep talk that a coach might give to team players by helping individuals with ADHD engage in positive self-statements of their self-efficacy of their ability to manage their emotions you may be be able to help increase their willpower to do so in addition we know that taking frequent breaks during emotionally demanding situations can help to replenish the fuel tank I call it the 10 and three principle 10 minutes of sustained work followed by 3 minutes of break from a demanding situation can help increase one's willpower and self-regulatory strength research also shows that simply taking three minute breaks from time to time for relaxation or for meditation can further contribute to replenishing one's self-regulatory resource pool or willpower visualizing our goals talking about our goals visualizing and talking about the future rewards that we will earn when we attain those goals and doing this before and throughout a demanding situation can help to replenish the emotional fuel t tank that is the willpower fuel tank that we use for controlling emotions finally we know that routine physical exercise on a frequent if not daily basis also contributes to increasing our willpower and to expanding our capacity for self-regulation beyond that seen in individuals who do not exercise regularly finally research shows that the self-regulation resource pool that is the the fuel tank of willpower is directly related to the level of glucose in the bloodstream in the brain so that brain glucose is in fact the source of this self-regulation strength and to the extent that that glucose is depleted individuals will have difficulty with self-control generally and with emotional self-control specifically this suggests that we may want to encourage people with ADHD to use glucose containing substance is during demanding situations that place a heavy burden on their self-control and especially on their emotional self-control for instance keeping a sports drink nearby and consuming that sports drink frequently may help to keep blood glucose up and help to get more glucose into the brain and therefore help to keep one's resource pool for self-regulation topped up we can help people with ADHD manage their emotions better by also going back to gross's process model of emotion and seeing where one can intervene using cognitive behavioral therapy techniques to help diminish minimize or moderate the expression of emotion here again we see gross's model of the automatic level of emotion now on top of this we're going to impose the cognitive or the executive level of emotional self-regulation and we're going to see that there are five areas in which we could help people with emotional difficulties like ADHD better manage their emotions for instance we could help them with situation selection by helping them to understand which emot which situations are more likely to elicit strong emotions we can encourage them to avoid these situations for instance if stopping off at a local bar after work for a drink uh is a place where one is likely to encounter other individuals that one knows to be hostile to you and that this hostility is going to provoke emotional Outburst from you then one needs to Simply avoid this particular situation in the future and find a different place to have a drink after work so that avoiding situations that provoke strong emotions is one means of helping people cope with emotional difficulties another cognitive behavioral therapy technique for helping people cope with emotions is that if they're in a situation that is likely to provoke a strong emotion try to modify that situation in some way for instance sit in a different place or uh have an individual sit next to you that you're friends with that can help you manage your own emotions but alter the situation in some way so that it is less likely to provoke the strong emotion from you for instance if you're in a conference room with another individual uh and you've been called into a meeting and you know that this individual provoke strong emotion from you place yourself in a situation where you don't have to look at them and as I've said sit next to another individual that may help you to better regulate your emotions but modify the situation in some way another means of controlling your emotions is to divert your attention away from the emotionally provoc provocative situation that is to distract yourself from the provocation and in doing so you can help to quell the Primary Emotion you can do this by thinking of something else looking away from the emotionally provocative person or event or an other ways diverting your attention a fourth way of controlling emotions is to re-evaluate the situation itself this is a major cognitive behavioral therapy technique where the individual is asked to Simply question whether or not the situation is as important as they're making it out to be and by doing that they can serve to uh perhaps reappraise the situation downregulate its importance for themselves and therefore downregulate the emotion that is likely to be provoked by this situation cognitive reappraisal is a very common strategy in cognitive behavior therapy for helping people with emotional disregulation to better manage their emotions finally of course there is the very simple means of simply trying to sit on and suppress the expression of the Primary Emotion itself so that one can put their hand over their mouth sit on their hands turn away from the situation even leave the situation and try to grit their teeth and hold back the emotion as well as they can this is unlikely to be particularly useful for people with ADHD because of their difficulties with impulse control control but I mention it here because it is one of the five strategies mentioned in the gross model for managing emotion emotional Expressions so to reiterate there are five strategies for helping people with ADHD to better manage their emotions and their self-regulation of their emotions two of these strategies are proactive strategies situational avoidance and situation modification are ways of Simply avoiding provoking the emotion entirely and that's why I call them proactive strategies as you see here now I've already discussed much of what is on these slides uh and so let me move along rather quickly we've also discussed the three reactive strategies that can be used for dealing with emotional situations as we said one of them is redeploying your attention or distracting yourself another is reappraising the the situation resulting in cognitive change about the importance of the situation which then Alters one's emotions in response to that situation so talking to yourself reasoning with yourself using logic and evidence to help reappraise the situation can help to diminish its significance and therefore diminish the emotions it's provoking and as I've already said response modulation or modification can help uh to make manage the emotion but these are three reactive strategies now I'd like you to understand that the earlier in the sequence uh of emotion that the individual can intervene the greater is the likelihood one can succeed in altering the emotion that is to say that the reactive strategy as I just showed you on the previous slide will be more effective than the reactive strategies that you see here so again the earlier in the Stream of emotion one intervenes to head off the emotion the greater is the likelihood one can succeed in doing so so all of the strategies are effective in managing and controlling emotions but they are not equally as effective in conclusion I hope I've shown you that emotional impulsiveness and deficient emotional self-regulation have been core features of ADHD since its beginning in the medical literature in 1798 and that for 170 years or more emotion has been viewed as being a central aspect of ADHD we know that the emotional impulsiveness in ADHD arises from the same disinhibition symptom list as do the hyperactive and other impulsive symptoms mentioned in DSM 4 and that is where we would place the impulsive primary emotions of ADHD in other words we are not asking that we create a whole new set of symptoms for ADHD the symptoms of emotional impulsiv excuse me impulsiveness can simply be placed on the same symptom list along with the hyperactive impulsive symptoms such symptoms as impatience low frustration tolerance and quickness to anger would be good symptoms to include on the disinhibition symptom list in order to capture the emotional part of ADHD also the deficient emotional self control that arises from ADHD and its impaired executive functioning belong on the inattention symptom list which we now know to be a list really of executive deficits associated with ADHD and that is where the problem in the top down regulation of the primary emotions would belong finally I've shown you evidence as well that the neuroanatomy and the neuros pychology of ADHD indicate that emotional impulsiveness and poor self-control of emotion have to be a part of ADHD because the neural networks involved in ADHD are also the neural networks involved in the management of emotion I've also shown you that there is substantial psychological evidence available in the literature that emotion is a part of ADHD and that people with ADHD have significant problems with emotional disregulation I also hope that I've shown you that by returning emotional impulsiveness or emotional disregulation back into ADHD where it belongs we can better understand some of the comorbid disorders that arise with ADHD as to why they arise and how ADHD treatments may affect them and this is especially so for comorbidity with Oppositional Defiant Disorder order I've also shown you that putting emotion into ADHD helps to explain many of the impairments that people with ADHD experience Across the Life Course in major domains of life activities such as in their social relationships or impairment in managing their children and in parenting stress and in financial management and in driving and so on the emotional symptoms of ADHD predict specific impairments in these domains that the traditional ADHD symptom Dimensions simply do not lastly I believe that recognizing that impulsive emotion and poor self-control of emotion are involved in ADHD can better improve our Diagnostic and our treatment practices thank you for taking this course I hope you have learn something about the importance of emotion in ADHD I invite you to take other courses that I have prepared for you on this website with regard to ADHD its understanding diagnosis and management I also invite you to visit my Publishers website at guilford.edu in the ADHD Marketplace such as my three new adult rating scales for assessing ADHD evaluating deficits in executive functioning and assessing functional impairment in major life activities thank you again for taking this course