The Importance of Emotion in ADHD - Dr Russell Barkley

this one is going to be on the role of emotional dysregulation in ADHD and what that means for understanding comorbid disorders but especially for diagnosis and management of ADHD so again more slides and I probably have time to cover but we'll do the best we can to get through this in the brief hour that we have together and I will try to leave some room at the end for question and answer as well so I want to review with you the nature of emotion itself and especially self regulation of emotion then I'm going to go through seven lines of reasoning of argument and evidence as to why emotion is as central to ADHD as are the attention problems and the other traditional dsm based symptoms then we're going to summarize some of the research on the impact that emotional dysregulation has in major life activities of these individuals I also want to talk about some of the findings with regard to diagnosis and treatment so those are our objectives we have a lot to go over so let's get started the current clinical view of ADHD as I briefly mentioned it this morning but let me go into some more detail is that it's a developmental delay in two dimensions of neuropsychological brain functioning development now that statement is rich with meaning because developmental delays are not psychopathologies a psychopathology is a gross aberration in an individual's behavior allowing us to recognize the disorder at any age bipolar disorder for instance we don't have to do age comparisons for mania to tell whether or not you have a disorder so there are these pathologies like schizophrenia and bipolar disorder where we don't do age adjusted criteria if you have it you have it but with ADHD like other developmental disorders the disorder is defined by the degree of delay in the trait it's a quantitative difference not a qualitative difference and so for language disorders learning disabilities mild mental retardation and ADHD we have to do age comparisons to see what is the magnitude of the deficit and it's that magnitude that quantity that defines the disorder and so right at the beginning with ADHD we know we're dealing with a neuro developmental disorder that originates in neurology and genetics of the individual not in the social environment now there are two traits that are not developing on schedule in the person with ADHD the first of course although it's called inattention as I mentioned to you this morning is really a metacognitive dimension an executive dimension that is filled with symptoms of working memory deficits failure of language to guide behavior activation motivation problems of the individual and so on so if we look at the attention problems or the executive deficits here we see the things I mentioned this morning the first poor persistence over time toward goals clinicians call that sustained attention but William James called it persistence because it's on the motor side of the brain not the sensory side of the brain the word attention implies some kind of processing filtering perception selection and ADHD doesn't involve those things instead ADHD is a failure to string behavior together over time to get to a goal that has to do with frontal lobe output motor functions so persistence is a far more accurate term for this than sustained attention because it clearly conveys the problem on the behavioral side of the brain you can't string together sufficient complex chains of action the way other people are able to do to get toward that future event or the task here if you will now linked to the failure of persistence is a problem with resistance to distraction this also is a motor problem not a sensory problem the person with ADHD reacts too distracting events more than others do he doesn't perceive them any better than other people do but what other people do is suppress responses to goal irrelevant events they're not part of what you were doing you simply don't respond to them so there's an inhibitory part of the distraction here that needs to be appreciated it's the failure to inhibit responding not the perception of the distraction that's at issue so that is coupled with the failure to persist if you can't persist you won't resist distractions and vice versa they are opposite sides of a common coin now once the individual is disrupted a third difference emerges here the person with ADHD is less likely to re-engage and in complete a goal you get distracted all the time but once you've dealt with the distraction if it's something urgent or important and you have to stop what you're doing shift to that you will come back and finish the goal you started and they don't do that now goal reengagement is not an attention disorder it's a working memory disorder working memory as we said this morning is the ability to hold in mind information that is guiding behavior over time remembering so as to do and therefore if you have a problem with working memory and a distraction disrupts your working memory you won't remember what you were doing you won't get back to the work that you were doing you're going to be like somebody my age after 55 years of age your working memory starts to decline actually in women even more dramatically than men particularly around perimenopause so people with ADHD are like perimenopausal women and old men they can't remember what they were doing they go outside they're supposed to go to the mailbox they see the newspaper they pick it up the read at the trash can needs to be brought back in there's a few weeds in the bed so we pull those and we wander back inside with a newspaper and your wife says did you get the mail which is what you went out to do to begin with so that's a working memory disorder because what happens is as working memory decays the strength of the environmental events takes over because mental events aren't guiding you as powerfully as external events you become more field dependent as you age while ADHD and have that problem at the start they have this problem with a very weak working memory system that doesn't guide behavior is easily distorted and wiped out by any outside distracting event and then they're skipping from one uncompleted activity to another so when you hear that symptom or that complaint about these individuals that's a working memory symptom not an attention symptom now in addition to that we know that there is the hyperactive-impulsive dimension but here too I want to emphasize that it's cross-modal the DSM represents ADHD as verbal impulsiveness it has three items that measure disinhibition and they're all verbal talks too much interrupts others blurts out but the problem with inhibition and ADHD is vastly more complex than that we tried to get five new items into the dsm-5 to capture this range but the higher level committees in dsm-5 rejected any changes that might broaden the prevalence of the disorder and so as a result there were a number of science-based changes to dsm-5 that never got in because there was this growing fear of prevalence alteration and that became almost obsessional by the committee to the point where they decided not to make too many changes the point here is this we have a problem with not just verbal impulsiveness with motor impulsive miss cognitive impulsiveness rapid decision-making failure to think about the future and of course if you have that sort of rapid impulsive decision-making you are going to have what economists would call a very high time preference which means you prefer things now and the more you have to wait for something the less important it becomes the less valuable it becomes and we all show that kind of what's called reward discounting which is where you discount a consequence because of how long the delay is but a dhcp will show a steeper discounting then the general population does that's evidence also of problems with impulsiveness with a failure to stop and think before you act then of course you have the excessive off task irrelevant activity the restlessness the hyperactivity and so on but as I said this morning declines with age and by adulthood is not symptomatic of this disorder okay so that's the current DSM for or dsm-5 based view and that's also the way science would look at ADHD currently as well what I want to show you however is where emotion fits in to that and why you have to put it back there now very quickly what is an emotion it is a short-duration change in your arousal your alertness and your motivation so emotions can be plotted along these dimensions and they all contain this sort of behavioral dimension motivational dimension you know there's an approach avoidance to this there's a reward punishment aspect to motivation excuse me to emotion and there's physiological arousal so we're not going to spend any time on that but that's how we think of emotions in psychology what people need to keep in mind is that emotions have a variety of purposes they're not just cathartic them not just for reducing arousal they're communicative emotions were one of the first forms of animal communication in nonverbal organisms and they remain forms of communication very primitive ones but they convey to others around you a change in your motivation a change in your action in your stance to the environment if you will so it's not just for catharsis okay that's what an emotion happens to be now what is emotional self-control because humans have this second aspect of emotion that other species lack and emotional self-control is the capacity to voluntarily inhibit the expression of the emotion you feel it you get the autonomic nervous system part of it changes in heart rate respiration you're flushing of your skin maybe tearfulness these are things you can't very easily regulate but you suppress the voluntary the motor aspect of the emotional display so step one in self-control is suppressing the primary emotion that's been provoked by what has happened around you step two which star it's very early in infancy and progresses in childhood is you begin to direct activities at yourself to calm down little babies who are upset reach for people reach for the silk liner on their blanket stroked themselves curl up into a ball and begin to engage in self calming self soothing activities so humans try to use self directed actions to calm down then as we get older we do this we learn to refocus attention away from the stimulus that's provoking the emotion because by breaking contact with the stimulus we give our emotional system a chance to calm down by staying engaged with an emotional stimulus you're just further activating your limbic system so there's a refocusing of attention away from the stimulus including putting your hand over your eyes turning away leaving the situation all the ways our inner of interrupting contact with the event then we get to the more complex activity that doesn't come until later in childhood we begin to create another emotion in place of the detrimental one we literally can create a new emotional state to help us calm down and even replace the primary emotion that is not in our best interest very simply it's what parents teach kids to do count to 10 go to your happy place count to 10 close your eyes visualize something positive like the beach or eating ice cream or something that's really fun and that visual imagery will bring an emotion with it that will help to lessen the level of the primary emotion that you're feeling in this case frustration or anger but only humans have a capacity to generate a new emotion in all other species emotions are provoked by external events but humans can self provoke an emotion this is what actors do the method School of Acting teaches this explicitly when you see Anthony Hopkins Meryl Streep Jeremy Irons and these people when you see them act this is the technique they're using if Meryl Streep needs to grieve in what was it Osage County this recent movie or Michael Cunningham's the hours or something what does Meryl do there's nothing on the stage on the set of a movie to grieve so how do you get a genuine grief reaction well you know what she does she calls up a visual image of a legitimate situation in which she grieved and - that will be bonded and emotion so all past events have emotion welded to them of varying degrees so she chooses an image that has a strong emotion associated with it and guess what happens she starts to get flushing of the cheeks she gets tears in her eyes and she has a legitimate grief reaction so that's what I mean by self control you can provoke emotions anytime you need them to support the goals you're pursuing in the absence of any environmental provocation for the emotions a very sophisticated level of emotional self control so those are the four steps for self control of an emotion now let's take a look at what ADHD does here to screw this up now to appreciate what ADHD is going to do let's just draw a diagram of what I just taught you okay here we have time here we have the strength of the emotion and we have positive emotions and negative emotions let's take a negative emotion something happens maybe another child comes over and he takes your toy from you all right and as a young child this provokes a primary emotion frustration anger hostility right so do you express that emotion well if you're really young three four or five years of age yes but eventually what humans acquire is that second stage they begin to enact various actions to themselves to down-regulate that emotion to terminate it more quickly so that it's not as strong it's not as powerful eventually they can even suppress the expression of the emotion and if needed if this were a positive emotion or in the case of Meryl Streep who needs to grieve you can continue the emotional state if you need to by re provoking it and that's what the yellow represents here so humans have this capacity to create alternative emotions that contradict modify and help us manage our emotional state among others so now of all the emotions we need to control the negative ones are the most important and that's because we live in groups we are a group living species that relies on each other and our social networks to survive and the negative emotions are very disruptive of reciprocity cooperation friendships and so on so it's not going to be humor that gets you in trouble with other people or affection it's going to be hostility anger and aggression so it's the regulation of the negative emotions that becomes so important more than the positive emotions you can be a class clown but if you're a class bully if you are known to be reactively aggressive that's going to come with a social price to it much more than the person who is being silly in school so if we look at a DHD and we want to predict that ADHD is going to interfere with emotion we can automatically see it's going to interfere with both kinds you're not going to be able to suppress the primary emotions like other people you're going to be immature you're going to show emotion more than other people do and secondarily you're not going to be able to down regulate it if you have to you will struggle mightily to get control over yourself and it won't be very effective so you're going to have trouble not only suppressing the emotion but then down regulating it and engaging four steps we talked about self soothing and generating alternative emotions and distraction looking away interrupting that stimulus and so on so if what I say is true this is what we would see in people with ADHD and the next question is do we all right well you almost have to for these seven reasons we're going to go through each of these the history of ADHD the neuroanatomy the neuro psychology of the disorder but especially the evidence base the psychological evidence that's out there the longitudinal studies and then we're going to look at how it explains other disorders that we see with ADHD but also what it means for impairment because I'm going to demonstrate to you that emotions carry with them certain adverse consequences that cannot be explained by traditional ADHD symptoms the inattention the hyperactivity the impulsiveness and that becomes very important I think you'd be surprised at what we're able to predict from these emotional difficulties finally we're going to end up with what does it mean for diagnosis and management now one reason emotion needs to be put back in ADHD is it's always been there for the first hundred and seventy years or more of ADHD s existence in the literature it was there everybody who wrote about ADHD back to might to a Weikart which you heard me talk about this morning - Alexander Crichton all the way up through George stills lectures even the early writers describing the condition we call ADHD today had included passion emotion the inability to regulate defuses quickness to anger and easily frustrated were part of their definition of the condition so it started out there and then when we got into the 1960s as Pat Quinn mention about MBD it was there it was one of the five major components of the disorder if we look at Marc Stuart's papers like his Scientific American article describing ADHD children it's rife with descriptions of aggression temper anger hostility easily aroused easily annoyed quick to emote or arouse Denis Cantwell said it was one of the five major features of the syndrome of hyperactive children and Paul Wender not only described it in children but was the first to describe adult MBD and he made it a central part of MBD for which he was roundly criticized at the time because people said well how can you distinguish that from bipolar disorder or from mood disorder and so on and you can but you just had to make a more sophisticated argument for it so what happened I mean all the way up through my early career emotion was always part of this condition we were now calling ADHD what happened was DSM - DSM - came out describing ADHD then as hyperkinetic reaction of childhood and if you go to DSM - which I have on my bookshelf and you read it it's only a paragraph it describes ADHD as involving inattention distractibility hyperactivity impulsivity but once the official stamp of the APA was put on those criteria emotion was abandoned and has never returned in any of the subsequent DSM s oh it's occasionally mentioned in the text as possibly an ancillary related comorbidity for some people but it's not part of the criteria it's not part of the description of the central features of the disorder so we have this official if you will abandonment of emotion after a hundred and seventy - nearly 200 years of emotion being part of the disorder I don't know why this happened at the time still a chess a very influential child psychiatrist was also part of this committee she was writing papers simply saying that hyperactivity was just that excessive motor restlessness nothing more so we don't quite know what happened back then it may be that it was the fact that emotions are hard to measure and this was the beginning of scientific child psychiatry going out and beginning to measure things rather than just taking Freud's word for it about psychodynamics let's go out and actually learn something about our disorders through assessment measurement group studies randomization and so on and emotions are much more difficult to assess than is hyperactivity I don't know why they got rid of it all I know is it's always been there up until the DSM abandon it but according to the neuroanatomy of ADHD which is our second line of evidence it has to be there and we talked about this this morning so I won't spend as much time on this but we know that there are five brain regions that are smaller in people with ADHD they're at least 3 to 10% smaller and according to the newest studies which are looking at microstructure of white matter it's even worse than that but at a minimum we're looking at much smaller regions that are much less mature in their development by about 2 to 3 years and these regions are the orbital frontal cortex the midline anterior cingulate the basal ganglia and the cerebellum now because the frontal lobes are smaller especially on the right then the bundle of fibers that connects the two hemispheres would be smaller and that's the corpus callosum so the anterior part of the corpus callosum is also smaller in these individuals but that's a byproduct and by the way ADHD although it involves an immaturity in both frontal lobes is twice as bad in the right as it is in the left and we even see that in our studies of working memory non verbal working memory is twice as impaired in this disorder as is verbal working memory they're both impaired but the nonverbal is substantially worse fitting in with the right hemisphere view that ADHD is much more lateralized into the right than it is in the left hemisphere but it affects both hemispheres it's not exclusively right hemisphere so the point is this here are the five structures and as we mentioned earlier this morning we can organize those five structures that you see here dorsal lateral cortex here's your anterior cingulate you've got your basal ganglia right in here it's hard to see it here's your cerebellum back here right we can organize these structures as we said into four networks network number one as I told you this morning is from the frontal lobe back to the posterior part of the right hemisphere and from there there's also a connection and network into the anterior cingulate which is right here and this is the network for self-monitoring for turning your attention network on yourself and it's the beginnings of self-awareness you begin to track and monitor your internal and external states yourself now you know why people with ADHD have more limited self-awareness why they don't report their symptoms being as problematic as other people do and the younger they are the worse that difference is which is why dsm-5 requires that you must corroborate what patients tell you through other sources you can't take their word for it because their reports are terrible there is no correlation between what a teenager says about their ADHD and what their parents say or what their teachers say in fact the two don't even begin to agree with each other until you're in your 30s so let that be a lesson to you you never take the reports at face validity of a young person with ADHD because they massively underreport the true state of their disorder and a main reason for underreporting is more limited self monitoring self awareness they also show what is called a positive ilusory bias that simply means that they don't see themselves as being as impaired in certain areas as they really are if you ask somebody with ADHD how do you think you drive oh pretty good not as good as everybody else probably a little better okay the problem isn't in that report we all say that we all have the Lake Wobegon better-than-average view of ourselves the problem is if you look at their driving history it's awful they're the worst drivers on the highway so it's the disparity between the self-report and the evidence that's the problem they're not manic they don't claim that they're NASCAR drivers they don't think they can swim the English Channel having never had a swim lesson that's bipolar disorder that does that what they're saying is what normal people would say but the problem is they're much worse than normal people what they fail to appreciate is the degree of the deficit that they have in their functioning alright so we know from the neuroanatomy that there has to be a problem with emotion because the anterior cingulate and the frontal lobe are involved in ADHD and we know that they are instrumental to the emotion regulation circuitry of the brain so it has to be there and as I pointed out this morning besides the network for self-awareness we have these three other networks in the brain from the frontal lobe to the basal ganglia again the what network what I think influences what I do second Network frontal lobe to the cerebellum the when network the timing network and then finally the one that's important for this lecture is from the frontal lobe through the midline cingulate into the amygdala and the limbic system and that's the emotional circuit often called the hot executive circuit I call it the Y circuit because as I said earlier it also is helping you make decisions about what you're about to do if you have a range of options this is the circuit that makes the final call which is why you often see neuroimaging studies talking about the anterior cingulate being involved in conflict and conflict resolution when there are disagreements in your mind about what to do what not to do this I can do that it will be this circuit that is evaluating their consequences their emotions their motivation how you feel about these options and then makes the final call so as I pointed out to you earlier you can see all of those networks already mapped on to this brain so we're not going to spend any time on that other than to say there has to be an emotional problem in ADHD because the very regions of the brain that give you emotional self-control are not developing on schedule we also know that various theories of ADHD including my own executive theory that you heard about this morning include emotion and poor self-regulation as one of the dimensions that ADHD interferes with of the various executive functioning dimensions so it's not just me other theories say the same thing you already saw the other papers by Joel and Beth Casey and Javier Castellanos and others that I referenced on that last slide so even neuropsychological evidence is saying there has to be a problem with emotion there so now we cut to the chase all of this so far is speculative is there evidence that emotion is linked to this disorder well if you look at every single research paper that uses a rating scale that has any mayor a motion on it routinely the emotional scales are very elevated on these scales so according to people's opinions about children and adults with ADHD there's a substantial problem with regulating emotion particularly with frustration impatience anger hostility and just general excitability and arousal direct observation studies I can go on into a classroom I can go to this university I can bring people into the lab and videotape them and I can provoke emotions and watch them their emotions are more extreme and they can't down regulate them so the evidence is there from the observational studies that there is emotional dysregulation connected to the disorder and within the past few years studies that looked at the brain itself and at the psychophysiological responses of the brain have found that even at the level of the autonomic nervous system particularly the parasympathetic nervous system there are abnormalities in the reaction of the individual to emotional events and those reactions convey a failure to regulate the emotional event now besides that we have evidence from Family Studies my own Steve Ferrone Joe Biederman and others that the emotional dimension links up with ADHD in families and is transmitted across family members so if your relatives had trouble with ADHD and emotional dysregulation so will their offspring have difficulties with it so the traits go together correlate with each other segregate with each other across family lines also studies of children followed to adulthood as well as adults with ADHD clearly show that emotions are problematic for instance this is my Milwaukee follow up study and again I mentioned it this morning when I was talking about children and their executive deficits but let me remind you we have a group of children who had ADHD in childhood 27 years ago and I have followed these children ever since and as part of their assessment when they were young adults we asked them about a range of emotional symptoms now to keep the graph from getting too busy I only put five up here but I could have put the other five and you would have seen the same result so it doesn't matter the point is this look at the red bar those are the kids whose ADHD remained fully diagnoseable at 27 years of age we're going to call it persistent ADHD by the way it was at a minimum two-thirds 65% of people with ADHD will be fully ADHD in their 30s we did find that about 14% had fully recovered and the remainder were what we call subclinical and those two groups are put together in the what we call non persistent category and then you see my community control group that we followed over the same period of time what do we see here first of all we see that if your ADHD persisted so did your emotional symptoms and in fact your emotional symptoms are occurring as frequently see the percentages as the DSM symptoms the one we use for diagnosis so it's not like these are lesser symptoms they're just as common just as prevalent just as severe as our the ADHD in attention and hyperactive-impulsive symptoms but we also see in the blue bar that if you're starting to recover from your ADHD you're starting to recover from your emotional dysregulation but you're still not normal that's the yellow bar you still have some problems but not to the degree that the diagnosed persistent group does now here's the same interview and rating scale assessing the same symptoms but with a group of adults with ADHD and look at what you see here the adults aren't massively more emotional than the control groups that we use in these clinical studies and again if you look at the frequency with which these are occurring their prevalence they are as prevalent as the DSM for symptoms so if you have ADHD you are going to have emotional dysregulation to the same extent you have ADHD they're directly in line with each other as common as problematic as your attention and inhibition and hyperactive problems but especially in attention and inhibition so when we go back over the evidence the history says it's there the neuroanatomy says it's there in the neuro psychology says it's there the evidence says it's there so what does it mean well first of all if you put a motion back into ADHD you can start to explain the comorbid disorders that link up with it right now people treat comorbidity if it's just stuff happens okay ADHD kids are 11 times more likely to have oppositional disorder so our adults by the way Oh Dee Dee is an adult diagnosis not just a childhood diagnosis and it's as highly persistent as is ADHD why would ADHD link up with oppositional disorder and then with conduct disorder and then with anxiety and then with depression by putting emotional dysregulation into ADHD you can see those pathways much more clearly let me explain them to you Oh dee dee is a pattern of hostile defiant aggressive behavior willing willfulness to refuse to obey another individual resistance to Authority as we've said it is the number one comorbidity in ADHD 65 to 84 percent of ADHD children will be d it's also the most common comorbidity and adults but clinicians tend not to diagnose it they think Oh dee dee is a kids disorder rather than an adult's disorder we need to keep in mind that Oh Dee Dee forms two dimensions even dsm-5 is finally acknowledging that Oh dee dee is not a single dimension of symptoms and the two dimensions are four of the symptoms are emotional the anger the hostility the temper and four of them are social conflict they take another person to have that symptom you're refusing you're defying you're resisting Authority now the reason that we split OD D into two dimensions and why dsm-5 had to do so is because the two dimensions arise from different sources and make different predictions over life over time so the emotional symptoms of OD d come from ADHD or a mood disorder like bipolar disorder so there's a biological basis to the emotional component it's an inherent feature of the person not of their environment something has predisposed this individual to being very emotional in this case it's ADHD it's that executive function we just talked about you can't self-regulate your normal emotions the second dimension of OD D is the social conflict dimension where does that come from learning unlike ADHD half of the variants of oppositional disorder is learned within a family environment the training is inadvertent parents don't mean to be doing it but they're doing it anyway so half of OD DS severity has to do with who is raising you and how good or how poorly their parenting is so disrupted parenting is the source of the second dimension ADHD is the source of the first dimension and you put both of those together you are going to get clinical OD D to put it another way if you're diagnosed with ADHD you are halfway down the road to OD d all it's going to take is for you to be raised in a particular environment with a parent who can't manage you very well and you are off to the races honey so it takes both the environment interacting with these genetic predispositions toward emotional dysregulation to get that so we need to understand then that there are two dimensions to OD D arising from different causes and making different predictions over time if you follow these children over 10 years the emotional dimension predicts the development of depression and anxiety by adolescence but especially depression the social conflict dimension of OD D predicts conduct disorder and our social behavior crime psychopathy drug use so these two dimensions are not coming from the same sources nor are they predicting the same risks or outcomes over time you have to understand both dimensions to know the risks that are carried forward here and now you know why 25 to 35 percent of ADHD children get conduct disorder 25 percent of them go on to have depression 25 to 35 percent get anxiety disorder and the risk of anxiety disorder increases with age by adulthood 45 percent of adults coming into clinics with ADHD have developed an anxiety disorder with their ADHD and a lot of that has to do with that emotion dysregulation dimension they can't cope with emotions as well as other people are able to do now as we've said ADHD does contribute to OD D and it is likely through that emotional dimension that it is doing it but we also know that ADHD predicts OD D through disrupted parenting and I'm going to explain that little pathway to you in just a moment but by understanding the role that ADHD plays in generating oppositional disorder we now can go back 40 years and explain one of the most common findings and drug studies if you give an ADHD medication to somebody you improve their OD D as much as their ADHD even though their ADHD drugs they treat oppositional disorder as much as effectively as they treat ADHD the two dimensions are correlated point-eight with each other now why would these drugs treat OD d because part of OD d is ADHD and if you can get control of the ADHD emotion you can get control of what's contributing to OD D but only if you intervene early enough if this child remains dysregulated long enough within a family of disrupted parenting there's a learning component that's going to take place and guess what if you intervene later at eight nine or ten with your medication you are not going to get rid of that OD d you'll only get rid of the part that was linked to the early ADHD you won't get rid of the part that was due to training no medication is going to reverse your learning history so to put it another way the longer you let Odie D go untreated the more likely that social component is going to get in there and then your medication isn't going to resolve the ADHD this is why we argue for very early intervention with ADHD children even the American Academy of Pediatrics revised their guidelines a year ago telling pediatricians to start at four or younger get in there because we're trying to prevent not just impairment but comorbidity because once it gets going late treatment isn't going to rectify the problem completely as much as it would simply put you could prevent OD d if you intervened early and often enough but we don't average age of medication is eight that's four years this kid has gone from original symptom onset to when he finally gets treated for that learning history to take place now as I've said the social component of OD d is learned it's learned from this pattern of parenting indiscriminate use of consequences high rates of expressed emotion yelling screaming at each other making threats and vacillating between lacks discipline you do nothing even though your child is obnoxious to harsh discipline you practically beat the kid to a pulp if he misbehaves but you're all over the map in your parenting you are as emotional as your child is in your parenting where does disrupted parenting come from why are these parents doing this well we found out the answer in the last 10 years the parent has ADHD too it's a genetic disorder hello right if the child has at thirty five percent of the parents carry the same disorder without treatment and adult ADHD as we now know disrupts your parenting dramatically because you're impulsive you're emotional you're inconsistent you don't persist you can't follow good rules of parenting you are as emotional as your child so now I got two ADHD people trying to get along with each other living in the same household and that sets the training in motion so notice the child's ADHD contributes to OD D through the emotion dysregulation the parents ADHD contributes to OD D by disrupting their parenting and allowing the child to learn how to use emotions to coerce people out of certain interactions with them keep in mind OD d and defiant behavior is not to get attention it's negatively reinforced behavior it is designed to get you to back off I don't want to do that I don't want to do homework I don't want to go to I want to play video games that is not attention-getting and if I can elevate my anger faster than you there's a good chance I can get you to back down and that's what you see here is parent and child reinforcing each other's behavior on a partial schedule of success and failure for using anger as a social tool to get along with each other but we know the reason the parent is doing it and that's because the parent has a psychological disorder as well and the most common is adult ADHD although there are other disorders depression drug abuse and so on that will do that - in fact depression is even worse than adult ADHD at disrupted parenting ok for you people who only have a right hemisphere let's diagram what I just said make it easier for you to understand this is our oppositional child with ADHD we're going to split his opposition allottee into its two components right now where are those components coming from this is called the four factor model of oppositional disorder it is the most tested and proven pathway for oppositional disorder factor number one the child brings to the equation an inherent dysregulation of emotion normally that's ADHD that's doing that but it could also be bipolar disorder severe mood dysregulation disorder depression all of them bring with it an inherent propensity for emotion but ADHD is number one in that hit parade that contributes the emotional part of the child that's a given that comes with the equation with the turf we also know the hyperactivity contributes a little bit to the social component now we get to factor number two as we've said the parent and the parenting behavior highly disrupted that is training the social component you put these two together you're going to have a defiant child on your hands and very quickly by the way in case you doubt this studies actually have taken normal children and parents and train the parents to act this way and literally within 30 minutes they can turn a normal child into an oppositional child so we already know from experimental manipulations that this theory is in fact correct it isn't just hypothetical then we get to factor three what is driving the inconsistent parenting the parent has a psychiatric or psychological disorder and the most common of those is adult ADHD the second most common is major depression and these lesser disorders will do it as well but those are the big two and they will massively disrupt your parenting and that is going to lead to training of your child in becoming oppositional and then there is factor 4 which you've if I gave you time to think about it you would have come up with on your own there are background ecological factors that affect both the parent and their parenting how about marital discord how about marital violence how about being married to a partner who also has a psychiatric disorder like antisocial personality or drug use disorders what about raising your child in an impoverished environment that is criminogenic adults outside the home are likely to be training this child in doing these things not just people inside the home so we have a whole social ecology that is making indirect contributions here so understand this defiance starts here these are the two direct pathways one and two are the causes but we have to step back from there and say what's causing them and we move back to the indirect causes which are these two but let me tell you once this cycle gets going it feeds back to make it worse the worse this kid gets in this opposition ality the worse that parent gets and their depression their irritability and so we have a nice little cycle going here between these two people and by the way it also feeds back into the social ecology as well you have a hurricane here this is a tornado of reciprocal influences that are cycling back and forth making each other worse over time no wonder by the time this kid is 12 years of age if he has OD d the odds of him being delinquent conduct disorder are very high and the odds of you doing anything about it or less than 25% that is your success rate with an ADHD oppositional conduct disordered youth the game is over if you think once a week family therapy is going to handle that family that is a joke in our study they were successful in 5% of the time so the lesson about Oh didi is either you get in early and you treat this or you are not going to get a handle on this the longer the learning environment gets to train the individual the less likely you are to intervene successfully with that individual so that's your four factor model now we can understand comorbidity why do people with ADHD get Oh didi get conduct disorder get anxiety get depression that's the model that helps us to understand those pathways and those risks alright we've seen five lines of evidence now to argue for emotion being put back into ADHD let me give you another one right the emotional symptoms predict risks that are not accounted for by the other symptom dimensions so my colleagues and I using all of our databases went into them and said okay let's prove to people that emotion matters we're going to control for the severity of all your ADHD symptoms and then look and see does emotion still predict anything if I'm wrong emotion adds nothing to the prediction it's already explained by ADHD if I'm right emotion makes its own predictions even controlling for inattention hyperactivity impulsivity well the number one predictor that emotion predicts despite the severity of all your other symptoms is social rejection it is the number one predictor of how many friends you are not going to have other people can tolerate your distractibility your inattentiveness your laughter your fizziness and so on what they cannot tolerate is your anger your impatience your frustration people will pull back from you in 15 to 20 minutes Chuck Cunningham did a great study and Steve Henshaw replicated it it does not take hours or weeks for other children to reject you it takes minutes you drop an ADHD child into a brand new peer group and those other kids are pulling away from that kid in 20 minutes and you're red mutation is sealed they want nothing to do with you they can't manage you they can't interact with you you're a little hothead you're this firecracker going off throughout the day nobody wants to live with that and so they avoid you and they pull away from you so you want to know why these kids have no friends it's not their inattention it's their frustration and anger and emotion we also when we followed these children up into adulthood or when we looked at our clinic referred adults found that it was the best predictor of marital dissatisfaction and inner partner hostility it's also a predictor of dating violence in adolescents and college students you want to know who is at high risk for having partner violence in an intimate relationship it's the ADHD young adult and this was now replicated in a study of 50,000 people in England were evaluated looking at predictors of crime and violence and accidental injuries and so on and even they came up with this link adult ADHD is directly related to intimate partner violence not violence against strangers not the sort of psychopathic crime of mugging or robbing stores but intimate partner hostility and violence was predicted by ADHD so our research isn't the only one that is seeing this pathway of ADHD into difficulties in intimate relationships we also found that the emotional symptoms of a child were the best predictor of how stressed that parents going to be it's not the child's hyperactivity it's not their distractibility it's that child's anger that is what drives the parents to make the referral it is what drives their ratings of how stressful they are in trying to raise this child this may surprise you we've done detailed studies of driving in adults with ADHD and in my longitudinal study of ADHD we have their driving records we have behind the road evaluations I have $100,000 driving simulator that we use to assess your driving we looked at driving from all aspects and then we ran it through the analyses I mentioned what do we find emotion predicted these comes of driving it makes sense that it would predict road rage did you know that adults with ADHD are the most common people to have road rage on the highway well that's where it's coming from it's not just their risk-taking and their love of speed and desire to you know pass you on the highways I mean it also explains their anger their hostility when they're frustrated while they're driving not to mention their use of alcohol and their crash risk we looked at the adults you functioning at work what is your employer think of you how many times have you changed jobs how many times were you fired in the history of your work your motion was the best predictor of the number of times you've been fired from a job here again ADHD symptoms predict how well you do your job emotional predicted symptoms predict if you're going to get fired because employers will not tolerate that in the workplace especially toward customers not to mention other people in the workplace again we found it was a predictor of dating difficulties especially hostility and violence we have the credit reports and complete surveys of the finances of our children that we followed to adulthood so we went back and looked at financial management how you manage money and these were related to your effect dysregulation overuse of a credit card exceeding your credit limit impulse buying and so on and then we went back and looked at your parents how emotional were your parents there was a direct correlation between the degree of impulsive emotion in the parents and in the children and as Steve Ferrone showed this is highly heritable this isn't just through learning this is because both of these people have ADHD as well so all of this is to show you that there is value added in including emotion in our conceptualization of ADHD besides it's too traditional symptom dimensions we learn things about our patients we would not have realized by understanding the emotional element of the disorder now what does this mean for diagnosis of ADHD first it means don't mistake the emotions of ADHD for another disorder you have to go searching for some other mood disorder or the new SM what is a dmdd disruptive mood dysregulation disorder now is the new one that's in there major depression and so on emotion is part of ADHD so there's no reason to add a comorbidity on the other hand some ADHD children do develop bipolar disorder major depression anxiety what's the difference what evidence can I give you the environments one for sure let me explain to you several differential diagnostic tips to help you sort out what's ADHD and what's a mood disorder number one the problems in ADHD are emotions and emotions are short duration alright so this is a short duration event in contrast moods are long duration events lasting hours days weeks right doesn't the DSM require that the mood be there two weeks or longer as the predominant mood more often than not of course it does so an emotion is short duration a mood is long duration number two the emotion is provoked something in the environment triggered this response in a mood disorder it isn't you can have people fluctuating through these mood states of mania and psychotic depression as if they're bipolar and it has nothing to do with the provocation around them so one is provoked one isn't number three the emotional reaction of the ADHD person is rational you would have had the same reaction yourself what's the difference you suppress it you've felt it but you didn't show it so the emotions we see in people with ADHD are perfectly reasonable we understand we identify with them what we don't identify it is why the hell didn't you inhibit this you are so emotionally immature or you just let this stuff fly the rest of us learn to suppress calm regulate distract down regulate you can't do that so they're rational the emotions of the person with a mood disorder are irrational you don't know why they're feeling the way they do and it may be an irrational event that's even led to this this manic episode that you're having so to reiterate the problem in ADHD is a short-duration emotion that is often provoked situation-specific reasonable rational but immature you're not inhibiting it's a top-down executive failure in the management of normal emotion to put it briefly there is nothing wrong with the limbic system in people with ADHD there is in people with bipolar disorder and depression and anxiety but not in ADHD the problem is in the executive that's trying to regulate the limbic system the top-down control is absent or delayed immature whereas in mood disorders irrational their long duration their cross situational their capricious and they vacillate so that's the kind of thing you're looking for to tell whether or not the ADHD explains the whole clinical picture including the emotion or whether I need to go searching for a second disorder to explain those moods so don't mistake a mood disorder for the emotions of ADHD as we've said their long duration cross situational and so on and you're going to have to deal with that comorbid mood disorder separate from ADHD because the ADHD treatments will not treat the mood disorder by the way you can treat the ADHD in a bipolar patient or in a depressed patient but at least with bipolar patients we ask that you treat the bipolar disorder first you always treat the more severe condition before you double back to treat the other one but you can use ADHD medications with people who have bipolar and comorbid ADHD just fine so whereas people used to say oh we can't give them stimulants because that will provoke manic episodes in these individuals and that is not true we have no evidence that stimulants provoke manic episodes in these individuals so that's what it means for diagnosis no which effect goes with ADHD and which cannot be explained by ADHD now what about treatment well number one we understand that the emotional symptoms of ADHD that's what this acronym stands for will be improved by ADHD medications as much as their ADHD symptoms will be that's the point I made earlier the ADHD drugs are controlling the emotional dysregulation that is part of the ADHD but they won't control the symptoms of oppositional disorder that are part of the social environment that was learned so let me put Israel if you medicate a child with ADHD at eight nine or ten and after medication the ADHD symptoms are under control and you still hear complaints about oppositional behavior that's learned you are going to have to come in with a behavioral parent training program or some other intervention that works on rational reasonable parenting consistent parenting on the other hand the younger the child that you medicate you may be likely to hear that the OD D resolved right along with the ADHD because most of it was driven by the ADHD and the learning component didn't have a chance to take hold so the older the child the more you're going to be doing behavioral parent training in order to deal with that disrupted parenting now I also want you to understand that the ADHD drugs don't regulate the emotion of ADHD identically they all do it effectively but they do it through different pathways and this can help you to understand the drug responses that your patients your clients may be having for instance let's take the stimulants the stimulants work in controlling emotion by suppressing the limbic system the higher the dose you give the less activity in that system okay well that's certainly one way to skin a cat isn't it I can control your effect by eliminating your effect but remember the limbic system was not impaired in ADHD it's not part of the ADHD neuroanatomy but one way to control emotion is to prevent it from occurring to begin with and that's what the stimulants do and now you know why one in five patients complains to you of emotional blunting that the patient becomes like almost an automaton they begin to lose their effect yes they're compliant yes they're productive yes they're obedient but that's all they are parents in particular very concerned about this side effect and often stop their stimulant medication because they don't like what this child has become they don't see the joie de vivre affection of the child we want this kid to be poking his sister once in awhile to be getting a little upset I don't need a bland robot that sits at a computer and that some of these kids can get that way so we have to be careful with stimulants because if you push the dose too high you can get blunting of normal emotions which really isn't the goal after all is it now let's take the non stimulant up atomoxetine for instance the new open efraín ríos a kin hibbett ER that's strattera what does that do it has no effect on the limbic system whatsoever but it activates the anterior cingulate and the frontal lobe it activates the executive that is managing the emotion so what would I predict from that that Adam occitane will be better at regulating the emotional symptoms of ADHD than the stimulants will be because it's doing it at the site where the problem is at the site of the executive system that isn't down regulating affect to the extent that it should you will also find that Adam ox a teen does not produce the side effect of emotional blunting there's never been any complaints about that in any of the literature to my knowledge now you know why we are seeing clinicians in this country combining these medications and they're doing it to get greater coverage across this range of ADHD symptoms the stimulants are really good at improving your attention and executive system your cold cognition your working memory they're not so good at necessarily handling the emotional dysregulation so by adding in a non stimulant you're able to keep both drugs at lower doses that's always a good thing and get wider coverage across the ADHD symptom complex including emotional distress halation now what about the third drug that's on the market that came on the market a couple years ago in tune of Intuniv is guanfacine XR extended-release guanfacine has been around for years as an antihypertensive drug it's used to treat high blood pressure but it also has been known to have psychiatric psychopharmacological properties and it is beneficial to people with ADHD and Tourette syndrome so Shire simply took and reformulated it so that the drug lasts longer now what does guanfacine do well guanfacine is an alpha to regulator it goes to the frontal lobe and it fine Tunes the signal in nerve cells so unlike stimulants which affect the expression of dopamine and norepinephrine but mainly dopamine and they do it usually through increasing production and blocking reuptake guanfacine has its effect by latching on to a nerve fiber and opening or closing the little ports along the nerve cell the alpha 2 ports and if you close the alpha 2 port the signal is stronger down the nerve cell if you open the little alpha 2 port the signal gets dampened and noise comes into the signal what guanfacine does is to fine-tune frontal nerve cells so that signals are stronger less confounded by noise more likely to reach their endpoint and have an effect so this would argue that like Adam oxy teen guanfacine might well be activating the executive system so that the signals from the executive system are cleaner purer stronger here again you might use guanfacine like you use atomoxetine to address the emotional component of ADHD where stimulants might not be so good at doing that and what are we seeing in the u.s. today clinicians combining Intuniv with a stimulant to do just that lower doses much more pervasive coverage of ADHD symptoms so by understanding how the drugs work in the brain we have a better understanding of how they manage the emotional aspect of ADHD by the way 70% of the brain areas activated by the ADHD drugs are shared so they have a lot in common which is why their ADHD drugs but 30% of the effect of a drug is not shared with the other drugs and it tends to be mainly in these emotion regulation centers that we see some of this non overlap of drug response but let's also understand that if ADHD has gone on long enough with oppositional disorder in emotional dysregulation there are going to be downstream impairments that are going to develop like demoralisation peer rejection school failure and you can treat this child and you can't get rid of that history that's there and that has an impact going forward on that individual some of which is irreparable you can't regain friends dates marriages that you've lost just by the fact that we can now better regulate your ADHD symptoms again another argument for earlier rather than later intervention is the prevention of downstream secondary harms that accrue to the person as a result of unregulated ADHD and then as we mentioned the social ecology is very important particularly parenting and we may need to get in with behavioral parent training classes to help these parents but if you're going to do that you have to keep in mind that you have to screen all parents for ADHD before you do behavioral parent training because they'll fail if you don't you must manage the parents ADHD symptoms to make them responsive to the training and if you don't do that they will fail the single best predictor of families going through behavioral parent training as to who will fail is that the parent has ADHD that you're trying to train and you haven't done anything about it so don't bother taking an ADHD adult through a parent training program if you're not managing their ADHD you're wasting your time and their money which is why you hear us arguing as I have for a decade now you always screen every parent that brings an ADHD youth to your clinic because you need to know whether the genetics are such the that parent shares that same disorder and that that parents disorder is going to interfere with your plan to help this child or adolescent or young adult college student with their ADHD now there are ways that you can help the ADHD individual better cope with their emotions and one way to do that is to use Gross's model of an emotion and see where we can intervene so let me wrap this up just by going very quickly through what is one of the most well established models of human emotion in the psychology literature and it is this model alright when you have an emotion you put yourself in a situation something happens in that situation and that provokes your attention you attend to that stimulus that then generates an appraisal of the event is it good or bad do I like it or not this is where the emotion comes from and then you respond this happens by the way in milliseconds this is the automatic brain this is what it does and it does it very quickly but it still helps to break the stages up because if you want to help somebody manage their emotions those are the five places you will intervene and let's talk very quickly about what you can do first of all let's see if we can predict where you are likely to keep having these emotional outbursts can we avoid those situations if you keep stopping at the same bar after college in which you keep getting in fights with the people at the bar don't go to that bar anymore go somewhere else but not there so just situation selection can be a coping tool for people with emotional difficulties if you find yourself in a situation that is emotionally provocative is there something you can do the next time in that situation to avoid that if you're sitting in a classroom if you're at a conference table and there's somebody in that room that you know you don't get along with don't sit facing them so they don't see the smirks and the sneers and the little asides that this person is doing to provoke you sit so that you can't see them modify the situation now what if it's gotten out of hand this is where you do attention redeployment cover your eyes look away stand up leave get the hell out of there but terminate the interaction with the provocative event then you get to this one cognitive behavioral therapy learning to talk to yourself to reason through the emotion to reappraise and reevaluate its importance to you this is traditional CBT as its practiced in the u.s. anyway or you could be learning mindfulness meditation either one but what are they doing they're helping you to reappraise the emotion it's not that important count to ten go to your happy place deep breathe there you go and then finally all outs fails suppress it squint your face sit on your hands but if you have to terminate the motor response now here's what we've learned in years of research on this the earlier in the sequence you intervene the more effective you are the later you intervene the less effective you are so one of the things we've learned in helping people cope with emotional dysregulation is that CBT which is very common in clinical practice is very late in the sequence and you could improve your CBT counseling by moving further ahead in the sequence and giving them coping and compensatory strategies for dealing with those situations and I've given you a few descriptions here that we don't have time to go into but the point is this by breaking emotions down into the five stages we better learn how to help our clients in dealing with that dysregulation a part of course from giving them medication so what have we learned we've learned that emotion is just as much a part of ADHD as inattention hyperactivity and impulsivity we've learned as part of the neuroanatomy it's part of neuropsychological theories the evidence base shows it's there it predicts impairments we couldn't predict without putting it in there otherwise and it helps us with our clinical differential diagnosis of ADHD from other disorders and it helps us understand our management of the disorder so what else do you want people if you were a jury would you vote too put emotion back into this disorder yes okay thank you you're welcome okay we're a few minutes past our time what's new right I'll take any questions that you might have anything today I'm never coming back here again so Oh didi right right yes it wouldn't lead so much toward ADH she's asking you about children who come out of orphanages who may have been malnourished abandoned neglected what is that contributing to well we know that the background of that child is contributing to their ADHD malnutrition is part of that not the neglect but the kids who wind up in Romanian orphanages are kids of alcoholic parents in a war-torn country that often have been malnourished and their parents have smoked and drank everything I just listed is a known cause of ADHD so that aspect of that orphan would in fact be explained that you ADHD part of that would be understandable right now what about the orphanage itself the neglect the abandonment what might that do well what you would tend to see is more of a blunting of the individuals ability to interact without very inappropriate behavior if not aloofness blandness I mean there's a point where the individual almost becomes like a feral individual in terms of their ability to interact with other people and so yeah you might get like a feral reaction you know reactive aggression and anger and so on right but part of that is simply failure to be exposed to any learning environment you can't learn normal self control if there's no environment teaching it right whereas in the ADHD typical case it's not so much that the individual hasn't learned it the individual has been trained by the parent in how to use their emotion as a social tool as a device through that four factor model that we explained okay sure yes yes can ADHD contribute to substance abuse and addiction and not just substances there's now a growing literature particularly out of Asia on the risk or Internet addiction in ADHD individuals 16 percent of ADHD youth have a severe internet gaming addiction and it is predicted first of all by the the risk-taking impulsive dimension of ADHD second by social rejection okay which we've talked about that's the emotional thing operating there third the development of social anxiety as a result of the peer rejection those are three factors that are known to predict that and then later depression what happens is the individual creates a false social group on the Internet as a substitute for real world social groups you know you can create your own persona on the Internet its fake its fault you have a whole new identity you can be whatever you want to be you can put up your own picture it doesn't have to be you you know so what we find is that these people start to develop alternate social networks sort of pseudo buddies virtual friends but these are not real friendships and what we find is that they start to become addicted to gaming so but there is a risk one in for ADHD youth will develop a substance use problem oh I'm sorry oh we were done for the day okay well I'm going to have to let you go but the quick answer is yes it does contribute to drug abuse all the way down the line which means if you work in a drug abuse clinic forty percent of the people you're seeing are adults with ADHD okay if you have any other questions send me an email thanks so much for coming out today enjoy the rest of your day thank you

Channel: ADHD Science

Views: 255,060

Rating: 4.8926172 out of 5

Keywords: Attention Deficit Hyperactivity Disorder (Disease Or Medical Condition), Emotion, ADHD, Dr Russell Barkley, Russell Barkley, Dr Barkley

Id: hzhL-FA2v10

Length: 75min 36sec (4536 seconds)

Published: Sat Aug 01 2015