The key message of his CHADD keynote address was that he would like the lack of behavioral inhibition or emotional dysregulation to be the center symptom that clinicians watch for when they diagnose and treat ADHD. He went to great length in his lecture explaining that emotional dysregulation is the ‘home and life wrecker’ of ADHD.
People with ADHD and emotional dysregulation are more like to:
- Get Divorced
- Get Fired from Jobs
- Be involved in Motor Vehicle Accidents
- Abuse Drugs and Alcohol
- Have Law Enforcement Problems
- Be in Jail
He spent a great deal of time explaining that emotional dysregulation had not been included in the definition of ADHD and that this was a key issue that needed inclusion. I do not think anyone would argue that emotional control is a problem with ADHD. All researchers agree that this is part of the Executive Control problems seen in this condition and that this lack of emotional control is not all that different from what we call impulsive behavior.
The problem with making emotional dysregulation (or impulsive behavior) the central issue of ADHD is that A LOT OF PEOPLE WITH ADHD DON’T HAVE EMOTIONAL DYSREGULATION!!! Yes, I am yelling because Russell Barkley is so sure of himself on this that it is maddening! I am not alone in disagreeing with Barkley. Dr. Thomas Brown of Yale University has researched ADHD extensively and also has concluded that Barkley's theory only applies to the combined type of ADHD and leaves the other subtypes of ADHD searching for a diagnostic 'home'.
I like to think of emotional dysregulation in ADHD as the same as being a brittle diabetic. Brittle diabetics are sometimes called unstable diabetics and they tend to have blood sugars that are either dangerously high or dangerously low and their blood sugars are impossibly difficult to control. These very high, uncontrollable sugars lead to very poor health outcomes for the patients with this type of diabetes.
Luckily for those of us in health care and for diabetics, most diabetics are not brittle diabetics. Some diabetics are well controlled on diet and others are well controlled on medicines but most of the diabetics we see have achieved some control of their blood sugar. Treating all diabetics as though they were brittle diabetics, or making the people with brittle diabetes the poster children for diabetes would make no sense just like making the people with diet control diabetes the poster children would make no sense. Diabetes is a medical condition that includes many different kinds of diabetics and no one group represents all diabetics.
ADHD is a medical condition that includes many different kinds of Adders. Some are impulsive, some are inattentive, some are sluggish and some are hyperactive but just because the impulsive type has the poorest life and health outcomes does not mean that this type should take the front and center position in defining this condition.
Most people with Inattentive ADHD (ADHD-PI) do not have emotional dysregulation. They may be more likely to be depressed but they do not have the type of ADHD that causes them to lose their tempers or be unable to control themselves emotionally. Many people with the combined type of ADHD (ADHD-C) do not have emotional dysregulation as their central problem either. The symptoms of impulsive behavior seem to decrease with age just as the symptoms of hyperactivity decrease with age. The primary symptoms that you see in adults with ADHD are problems with the other executive functions. These symptoms are the key symptoms seen in Inattentive type of ADHD (ADHD-PI) and in Sluggish Cognitive Tempo and they include:
- Organizing and Activating to Work
- Focusing for Tasks
- Regulating Alertness and Effort, and
- Utilizing Working Memory
I had a physics professor in college who said that genius in science was measured by how long the scientist stalled their field. What he meant was that when a scientist is highly respected in their field, other scientist will stop searching for answers because the genius’s theories are so convincing and compelling.
I think that Russell Barkley is correct that the emotional dysregulation of some people with ADHD is very damaging to society. I disagree that emotional dysregulation is the core problem of most people with ADHD and I would argue that society is as damaged, albeit in a subtler way, by the disorganization, lack of focus, lack of persistence and working memory problems which are present in a far larger number of people with ADHD.
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I disagree with you completely. I don't think "The symptoms of impulsive behavior seem to decrease with age just as the symptoms of hyperactivity decrease with age." I think that is wrong I think they change into more subtle harder to see things. I have 2 kids that by subset are only impulsive/hyperactive and they have little to no emotional control and have suffered greatly because of it. They were also my most challenging kids by far with the most underachievement in everything they did. I have one combination kid that has somewhat emotional control and she has problems just not as bad. She drinks too much but at least she was able to get through college. I have one kid that is only inattentive and he is fine with his regulation of emotions and was the easiest to raise. My husband is also combination ADHD and has some lack of control with his emotions it is really only anger. By far the more emotional control people have, the more successful they are in the work place and with their private life. Friends forgive you for forgetting things and being late to activities but they walk away from people who can't control their anger and have emotional outbursts about nothing or perceived wrongs. Work places are also more forgiving for mistakes from forgetfulness verses you yelling and screaming at your boss or physically letting loose. I would also argue that I highly doubt anyone is in jail for not remembering their Mom's birthday but I am sure there are a ton of people incarcerated for physical outbursts and defiance against authority. I think emotional controlled is the thing never discussed with ADHD and since my kids didn't have classic hyperactivity they were never diagnosed. If emotional control or lack there of was more widely known and talked about maybe, just maybe some kids can get the help they need while they are young instead of suffering needlessly.
ReplyDeleteThanks so much for your great comment!! I think lack of emotional regulation is a huge part of this condition for people with combined type ADHD. I just do not think that you can say that a person does or does not have ADHD because they have control of their emotions. People with Primarily Inattentive ADHD often have good control of their emotions but they still very much have ADHD. I have written a post called "Impulsive Behavior, Where the ADHD Rubber meets the Road", that speaks to everything you have said in your comment. I think lack of emotional regulation is a HUGE problem, I just don't think you can say that people that are able to control their impulses do not have ADHD. That is what I meant by saying that the disease is not defined by lack of emotional control.
Delete"Dr. Thomas Brown of Yale University has researched ADHD extensively and also has concluded that Barkley's theory only applies to the combined type of ADHD and leaves the other subtypes of ADHD searching for a diagnostic 'home'."
ReplyDeleteI disagree with this while my 2 combination type ADHDers have some emotional control the worst lack of emotional controll ones are the 2 that only have hyperactivity not the combination kind of ADHD so that is very untrue. I would also like to add that my inattentive type kid would have a very successful life even without medication it just would be harder for him, but the emotional out of control kids cannot be productive members of society without medication. So if we are triaging out in the world of ADHD I would think getting the people help, the emotionally out of control type, would be the most important thing.