The Unrecognized RoleThe Unrecognized Roleof Emotions in ADHD:of Emotions in ADHD:Implications for Social InteractionImplications for Social Interaction

Thomas E. Brown, PhDAssociate Director,

Yale Clinic for Attention and Related DisordersDepartment of Psychiatry

Yale Medical School

Not in DSM-IV Criteria for Not in DSM-IV Criteria for ADHD, but….ADHD, but….

DSM-IV diagnostic criteria for ADHD do not include any symptoms of problems in regulating emotions

But, researchers and clinicians report chronic problems in emotional regulation are characteristic of many with ADHD

Problems in regulating emotion a core aspect of ADHD?

OutlineOutline

Reciprocal impact of EF and emotions Examples of “top-down” problems Emotions in ADHD and comorbid disorders Impact on family life and what might help to

improve?

Reciprocal Impact of Reciprocal Impact of Emotions and EFEmotions and EF

What is emotion?What is emotion?(varieties of (varieties of painpain and/or and/or pleasurepleasure))

(immediate or anticipated)(immediate or anticipated)

Fear Anger Disgust Surprise Sadness Happiness

Sympathy Embarrassment Shame Pride Jealousy Gratitude Indignation Contempt

Primary Emotions Social Emotions

Damasio (2003) Looking for Spinoza: Joy, Sorrow and the Feeling Brain

Emotional Control Items on ADHD Emotional Control Items on ADHD Rating ScalesRating Scales

Utah Criteria for ADHD in adults include affective lability, hot temper, emotional reactivity (Wender, 1995)

Conners’ Parent Rating Scale for Children ncludes “easily frustrated” as 1 of 12 items in ADHD Index, “best set of items for identifying children at risk for ADHD dx.”(Conners, 1997)

CAARS Adult ADHD Rating Scale includes 4 emotional control items among 12 best for identifying ADHD (Conners, et al, 1999)

Barkley’s Model of ADHD Impaired Barkley’s Model of ADHD Impaired Executive FunctionsExecutive Functions

5 major components of Executive Function impaired in ADHD include:

Self-regulation of emotion: affect/ motivation/ arousal Reconstitution: behavior analysis planning and synthesis (Barkley, 1997)

Regulation of EmotionRegulation of Emotion

Is a very important executive function Emotion is the signal of importance for a

perception or thought May be anticipated danger or pleasure Emotional significance is assigned very

quickly, without conscious thought

Brown ADD Scale-Cluster 4Brown ADD Scale-Cluster 4Managing Frustration and Managing Frustration and

Modulating EmotionsModulating Emotions

Emotion takes over too much of thinking or feeling…Like a computer virus in the mind. Can’t push emotion to “back of mind” and get on with what needs to be done.

Each person tends to be more vulnerable to particular emotions

(Brown, 2001, 2005)

Emotions and FeelingsEmotions and Feelings

Emotions are automatic bodily reactions to thoughts or perceived situations

Emotions signal possible pain/pleasure

-instantaneous -not conscious -noticeable?

Feelings are sensations and thoughts that register emotions occurring in body / brain

-follow emotional reactions ~conscious -private

Damasio (2003)

Emotions Emotions Feelings / motivations Feelings / motivations Turn on: interest, attraction, desire, devotion

Turn off: boredom, frustration, anger, fear

Variable in intensity and object: (how much? toward what?) Based on the individual’s - unconscious personal perceptions - of immediate situation & context - reacted to on basis of cs/ uncs memories

Danger at the CurbDanger at the Curb

Emotion is embedded in perception of: situation and or thought Beauty (danger, importance) is in the eye of

the beholder based on one’s personal, secret “files”

Mixed Emotions and a Chocolate Chip CookieMixed Emotions and a Chocolate Chip Cookie

emotions are often layered or mixed

Emotional assessments are mostly learned by experience/observation

Context is important (“food police” even asleep)

Emotion regulates Executive FunctionsEmotion regulates Executive Functions(“bottom up” control)(“bottom up” control)

“All information processing is emotional …emotion is the energy level that drives, organizes, amplifies & attenuates cognitive activity.” (K. Dodge, 1991)

Emotional value is automatically, uncsly assigned to stimuli (amygdala, medial PFC)

[how threatening, important, interesting is this?] (Damasio, 1994, 1999; LeDoux, 1996, 2002,)

Executive Functions regulate emotionExecutive Functions regulate emotion(“top down” control)(“top down” control)

Brain imaging of NC shows “gating” of emotion to reduce affective interference during more valued/complex cognitive tasks.

(Levy, et al, 2002)

Many persons with ADHD self-report chronic impairment in their ability to modulate affective interference in daily life. This is consistent with their other EF impairments

(Brown, 1996, 2001)

Case Examples ofCase Examples ofProblems with Top Down ControlProblems with Top Down Control

““Easily Frustrated”Easily Frustrated”

Minor frustrations cause substantial frustrations, e.g.

-not able to understand quickly -not able to do quickly -on 10 point scale: usual 0-2 hits 7 to 9 Often frustrations are over quickly

(Brown, 2005)

““Easily wounded”Easily wounded”

Slight indications of impatience or lack of interest or affection from others leads quickly to hurt feelings

“personalizes” May be too quick to assume that another’s actions or attitudes relate to one’s actions or self

Doesn’t allow enough for other reasons(Brown, 2005)

““Easily Irritated”Easily Irritated”

Quick to anger, even over small frustrations

May lash out in temper outbursts or may feel intense wish to lash out without actually showing it to others

May later regret show of anger and want to undo it, while others may be hurt

(Brown, 2005)

““Have to Have It NOW”Have to Have It NOW”

Wishes to get something, do something or buy something take on great urgency

Doesn’t matter how expensive or inconvenient this might be to self or others

Relentless push to get it now, lasts until have it or has hit a brick wall

Often not satisfied for long

(Brown, 2005)

““Easily Discouraged”Easily Discouraged”

Overly quick to assume that “things just won’t work out”

Often feels that if it’s not OK now, it never will be—hopeless

Reluctant to keep trying at something because it feels impossible to change

Often quits too soon(Brown, 2005)

““Excessively worried”Excessively worried”

Quick to assume that something bad will probably happen

Readily develops detailed “movies in the head” about potentially dangerous or disappointing outcomes

Overly quick to cancel the picnic at the first sign of a cloud

Often avoids new situations, fears novelty(Brown, 2005)

““Persistently Bored”Persistently Bored”

Difficult to keep up interest in task (listening, reading, working) unless it’s:

really interesting steadily rewarding

Needs continuous flow of “pellets”(Brown, 2005, p. 38)

The Common FactorThe Common Factor

Emotion causes “computer virus” in the brain Emotion takes up too much space, crowding

out other concerns (One section of orchestra of mind is playing

too loud and too long) Emotional intensity reduces sensitivity to

additional relevant information

Some neural networks do “gating”Some neural networks do “gating”

Levy- gating of anxiety

Brain imaging studies show reciprocal connections via medial PFC between emotion and cognition, anxiety / dysphoria & attention

(Mayberg, et al, 1999; Simpson, et al, 2001)

What’s lacking?What’s lacking?

How do most people regulate emotion that is different from many with ADHD?

Conductor of their orchestra can better modulate the sounds of each section

In ADHD neural networks that “gate” emotion work less effectively

Limbic region

Prefrontal cortex

Substantia nigra

CerebellumVentral tegmental area

DOPAMINESYSTEM

Increasing Dopamine can Enhance InterestIncreasing Dopamine can Enhance Interest

PET scans of NC doing boring math task with and without MPH

When doing math task with MPH, Ss reported increased interest in task

MPH during math task increased DA levels in the synapses

MPH enhanced saliency of task by increasing DA in brain.

(Volkow, et al, 2004)

Emotional Regulation Problemsin ADHD and Comorbid Disorders

Dysregulation of Emotion is centralDysregulation of Emotion is centralin many disorders highly comorbid with in many disorders highly comorbid with

ADHDADHD Not included in DSM-IV ADHD Yet many disorders (anxiety, mood) involving problems in emotional

regulation-highly comorbid (25% to 60%) with ADHD

Most persons with ADHD report significant impairments in regulating emotions

Problems with regulation of emotion:

an unrecognized aspect of ADHD!

ADHD or Comorbid Disorder?ADHD or Comorbid Disorder?

Problems in regulating emotions are one aspect of EF impairments of ADHD

When problems in regulating emotions are more extreme, may qualify as a comorbid disorder, e.g.

Irritabilitygarden hose = ADHD fire hose = bipolar

Boundaries between ADHD Boundaries between ADHD & other disorders?& other disorders?

“Many deficits of ADHD are shared with other disorders and some differences between ADHD and other disorders may be quantitative rather than qualitative”

e.g. “irritability” ADHD (+) depression (++) bipolar (+++)

(Banaschewski, et al, 2005)

Mick, et al, 2005)

Spectrum of Emotional Regulation ProblemsSpectrum of Emotional Regulation Problems

Normal ADHD Comorbidity mild moderate severe

Anxiety, Worry, Depression, Obsessionality, Irritability,

More extreme anxiety impairmentMore extreme anxiety impairment

12 yo boy – long hx of separation fears Excessive absences – vague aches, etc Severe difficulty falling asleep Fearful of being alone, even in daylight Won’t leave house without companion Refuses to visit with friends, b-day parties

(Brown, 2005)

““Social Ineptness”Social Ineptness” Many persons with ADHD experience significant, chronic problems

in social relationships. Often seen as: -too hurried -too intense -too clueless -too isolated

These problems can cause much hurt for those with ADHD and for others.

Social ineptness results from deficits in emotional intelligence

““Emotional Intelligence”Emotional Intelligence”

is a form of social intelligence that involves ability to:

1. monitor feelings and emotions in self and others2. discriminate among feelings3. use this information to guide thinking and action (Salovey, Woolery & Mayer, 2001)

Emotional IQ & IntelligenceEmotional IQ & Intelligence Emotional IQ is not the same as cognitive intelligence measured by IQ

tests. Some with very high IQ have very low Emotional IQ and vice versa

Good knowledge and high IQ alone are not sufficient for good emotional IQ

Different neural circuits are involved: (ventromedial PFC, amygdala, R somatosensory/insular cortices (Bechara, Tranel, Damasio, 2000)

Problems in Recognizing Emotions in Problems in Recognizing Emotions in Others/SelfOthers/Self

Cadesky, Mota & Schachar (2000): ADHD children & “conduct problem” children: much less accurate at interpreting emotions in others than normals.

Norvilitis, Casey, et al (2000): ADHD children less adept than normals at identifying emotion in selves/others.

Zentall, et al (2001): ADHD children more impaired than peers in attending to social data, predicting social outcomes

Social Functioning Involves Social Functioning Involves Monitoring & Self-Regulating ActionMonitoring & Self-Regulating Action

Monitoring: sizing up situations moment-by-moment to recognize what is going on, what should be done, what should be changed

Self-regulating (start, adjust, stop) actions (e.g., talking, doing) to fit aims & situation

(Brown, 2005)

Too Pushy – Ignoring ReactionsToo Pushy – Ignoring Reactions

“I get really intense in any argument” “Once started, I have to prove my point” “I don’t listen much, just to get what I

need to argue them down” Got kicked off the debate team Coach says “more chess, less football”

(Brown, 2005)

Peer Relations in ADHD:Peer Relations in ADHD:Childhood to AdolescenceChildhood to Adolescence

Adolescents 13-18 yo interviews for self-report, parent and teacher report,

Compared to 100 non-ADHD, adolescents with ADHD (n= 111):

Fewer close friendships Greater peer rejection Less self-perceived social competence (Bagwell, et al, 2001)

A Spectrum of Impairments in E-IQ & A Spectrum of Impairments in E-IQ & Social FunctioningSocial Functioning

There is wide variation among all children, adolescents and adults in emotional intelligence (normal variations to Asperger’s)

Emotional IQ and social functioning depend heavily on multiple Executive Functions

EF impairments of ADHD appear to have substantial negative impact on emotional intelligence & social functioning.

Asperger’s Disorder Asperger’s Disorder SpectrumSpectrumcharacteristicscharacteristics

Inability to empathize/interact w/ peers Unusual interests-narrow focus, exclusive Lack of social/emotional reciprocity Poor non-verbal communication Odd speech patterns; literal language Early development, verbal ability normal (Klin, Volkmar, Sparrow, 2000; Attwood, 1998)

““She just doesn’t get it!”She just doesn’t get it!” 13 yo girl ADHD + many social problems Has never been able to catch on to how kids

get along with other kids All the kids pick on her & call her weird Nobody wants to play with her She repeatedly begs kids to come over Can’t tell when someone is teasing or mad

Brown, 2005)

Peer VictimizationPeer Victimizationof Children With Asperger’sof Children With Asperger’s

Reports from 411 parents 4-17 yo with diagnosis of Asperger’s or NVLD:

11% ate alone at lunch every day 33% not invited to friend’s birthday party in past year 31% always picked last for games 75% bullied and/or hit by peers or siblings (peer assault rate X2 higher than others) (Little, 2001)

Social Intelligence: Depends Social Intelligence: Depends on R-Hemisphere Functionson R-Hemisphere Functions

“The right hemisphere decodes external information we use to compute context; it helps assemble the whole field of view

…Social intelligence, like being able to judge

tone of voice, understand facial expression, decode emotion, tell a joke from a lie, and grasp the true meaning of indirect statements, involves the…right hemisphere” (Ornstein, 1997, pp101, 121)

Right Hemisphere ImpairmentRight Hemisphere Impairmentin ADHDin ADHD

Multiple studies suggest right hemisphere impairments are common in ADHD

(Stefanatos & Wasserstein, 2001

Right hemisphere impairments underlie many impairments of EF in Non-Verbal LD that overlap with EF of ADHD

(Denckla, 2000)

““Non-Verbal LD”:Non-Verbal LD”:a right hemisphere syndromea right hemisphere syndrome

Characterized by deficiencies in: visualization perceptual organization conceptual organization ability to grasp “big picture” problems in summarizing & integrating info (Denckla, 2000)

Emotional IntelligenceEmotional Intelligenceis complex set of abilitiesis complex set of abilities

Impairments in emotional intelligence and related social problems are not easy to fix

Based upon neural circuitry and body chemistry, not just on learning

Involve executive functions often impaired in ADHD Impairments of emotional intelligence may be partially

helped with meds But even if medication is helpful, significant social

problems may persist

Impact on Family LifeImpact on Family Lifeand What Might Helpand What Might Help

Parental TemperParental Temper It doesn’t take much for my husband to lose his

temper Any little frustration can set him off When he gets mad, all he can think of is how mad he

is. He can’t remember that the people he’s yelling at are people he loves and cares about

Usually this lasts for just a few min, then he’ll apologize, but it’s hard to forget what he says. (Brown, 2005)

Parental PolarizationParental Polarization One parent: “We’ve got to crack down so he can learn

how to act!” Other parent: “We need to be patient and supportive,

he’s always being confronted with what’s wrong!” Often each parent takes an extreme, polar position to

“fight for what’s right” Hard to see that both are right and to work out from

situation to situation when to crack down and when to be supportive.

(Brown, 2005)

Burdened, resentful siblingsBurdened, resentful siblings

“No one with an abnormal sibling has a normal childhood”

“Family gatherings & significant events become occasions for anxiety & shame”

Feel need to have no problems “You’re ashamed you’re related, guilty that you

have a better life, envious that nothing is expected of him, relieved you’re not the misfit”

Safer (2002) in Brown (2005)

Self-regulation CapacitiesSelf-regulation Capacitiesdetermined by:determined by:

Inherited temperament (sensitivities, salient emotions)

Adequacy of executive functions often impaired in ADHD

Intensity of situational stressors in school, work, family

Adequacy of scaffolding and personal supports available

Self-regulation capacitiesSelf-regulation capacitiesmay be improved by:may be improved by:

Reducing situational stressors

Providing more adequate scaffolding and personal support

Carefully using medications to alleviate persistently problematic body chemistry problems

What Might Help?What Might Help?

1.Evaluate for impairments in emotional intelligence when assessing for ADHD

2.When ADHD is present, treat the EF impairments with appropriate meds

3.If significant problems with emotional intelligence persist, assess specifics

4.Provide psychosocial interventions needed by patient and family

What Might Help?What Might Help?5.Recognize disappointments, hurt in patient &

other family members6.Acknowledge complexity of social interactions

& options to engage/avoid7.Help patient take perspective on events (Is

this ant or elephant?)8. Teach patient by modeling, noticing, role

playing (not in public)9. Use notebook to collect +/- examples

SummarySummary

1. ADHD = developmental impairment of Executive Functions (EF)

2. managing emotions and monitoring, self-regulating action involve EFs

3. Multiple EFs are impacted by emotion

4. Many w/ADHD show significant impairment in regulating emotions and “emotional IQ”

5. Emotional regulation may be a core aspect of ADHD impairments.

Implications for PracticeImplications for Practice Emotional regulation impacts cognitive functioning and

vice versa

Assess for emotional regulation problems with ADHD

If usual ADHD treatments aren’t adequate for emotional regulation problems, target them for treatment

psychosocial and/or medications If mood problems are severe, treat those first; then follow

with ADHD tx if needed.

Websites and EmailWebsites and Email chadd.org (in English and Spanish)

add.org (mostly adults with ADHD)

adders.org (in Eng, Span, Ger, French with listings of support groups in 40 countries)

my Website: www.DrThomasEBrown.com