DESR: “Does ADHD Emotional Dysregulation Ever Fade?”

DESR: “Does ADHD Emotional Dysregulation Ever Fade?”

Emotional dysregulation is a core facet of ADHD that is excluded from official diagnostic criteria and most symptom tests — a contradiction that is pushing researchers and clinicians to further investigate the connection. One such ADHD expert is Russell Barkley, Ph.D., who has coined the term deficient emotional self-regulation (DESR) to describe this fundamental trait.

Because DESR is a novel concept to many, questions abound. Below, I answer several posed during my recent ADDitude webinar titled “Deficient Emotional Self-Regulation: The Overlooked ADHD Symptom That Impacts Everything.”

Q: Does emotional dysregulation change over time? Does it ever improve?

Emotional dysregulation does change and it can improve, but it depends on the individual and the factors involved. For instance, emotional self-regulation is rarely elevated as an issue in toddlers. We don’t expect 4-year-olds to manage their emotions very well. Parents are typically more concerned with the impulsive aspect of emotion at this stage.

But by the time we get into late adolescence, and especially adulthood, we do expect individuals to have developed that second stage of emotional control: top-down executive management (or moderating emotional reactions to evocative events). However, DESR impairs just that —processes related to emotional self-regulation. And that leads to more disparaging moral judgment about adults with ADHD than it would in much younger individuals.

It’s almost like the two components of this emotion problem in ADHD — emotional impulsivity (EI) and DESR — trade places as individuals age. The former is more problematic in children, while the latter becomes a more compelling deficit for the adult individual.

We also know that ADHD symptoms fluctuate over time for many individuals, which may mean that issues like emotional dysregulation also change in severity or degree of impairment. And keep in mind that ADHD mostly persists to some degree from childhood to adulthood for 90% of people.

But can emotional regulation be “trained?” In children, the chances of that are quite slim because they haven’t yet developed the appropriate self-regulation skills that such training would require. Interventions like medication, parent training, and controlling for environmental triggers may be most helpful for this stage. Adults, however, may benefit from cognitive behavioral therapy (CBT) and mindfulness-based programs especially reformulated for adult ADHD in recent books, both of which help the individual deal with many aspects of emotional dysregulation.

Q: Do men and women with ADHD experience emotional dysregulation differently?

Generally, we know that males are more prone to exhibit aggression and hostility, which are associated with externalizing disorders, while females are more prone to anxiety and mood disorders. Both, however, do struggle with impatience and frustration, and the emotional dysregulation component in ADHD will only exacerbate that.

Q: When might DESR symptoms start to appear in children?

DESR usually appears between ages 3 and 5, though it may be quite obvious in a younger child who is significantly hyperactive and impulsive. Still, many families write off this behavior, believing it to be developmentally normal (i.e. the terrible twos), only realizing later on that the child is quite hot-headed and emotional compared to peers. Some of these children will go on to develop oppositional defiant disorder (ODD). If we accept DESR as a core feature of ADHD, we can see why the disorder poses such a significant risk for ODD and related disorders.

I blamed myself for my child’s disability

I blamed myself for my child’s disability

Parents have to ensure that they do not let society’s misconceptions make them feel guilty. DR RADICA MAHASE

“I blamed myself for my child’s disability. I felt that as his mother, I must have done something wrong when I was pregnant with him. Maybe I ate too much junk food? Maybe I didn’t take the right vitamins or should have taken more vitamins? Maybe I did something wrong in the first year of his life?

“I mean, he was my first child, I didn’t know anything about taking care of a child, supposed I hit his head, or didn’t breastfeed him enough?

“My son is now five years old and the guilt I felt when we found out he had developmental issues is now gone. After years of reading up on my son’s disability and sessions of counselling, I am finally in the place where I accept my son fully and I don’t blame myself anymore. Instead, I just focus on him and helping him with his daily challenges.”

Natalie, the mom above, is just one of many parents who blame themselves for their children’s disabilities. Many parents feel a deep sense of guilt when their children experience developmental delays and often it takes some time to process feelings of guilt. Many parents blame themselves for their child’s disability. Why do parents blame themselves? For many, both mothers and fathers, a child with a disability is just not what they imagine their child would be or what they imagine parenthood would be.

Added to this is the fact that society in general places emphasis on the high achievers and there is the common misconception that children with disabilities will not be high achievers. The general perception, propagated by media, the education system, etc, is that children who are not high achievers are “less,” or are a “disappointment” and not as capable as contributing to society.

Sadly, as a society we always looking to place blame on someone or something – it is a dominant part of our social behaviour. Thus, parents of children with disabilities are made to feel they have brought “a lesser child” into this world.

One parent, Nigel, said, “When my son was born, I had a hard time accepting him. I felt like it was my fault, that maybe I passed on ‘bad’ genes to him.

“My neighbour organised counselling for me at the church nearby and I went and I regretted it. The pastor told me that I didn’t pray enough and that my child is paying for my sins. He said that the only way to ‘cure my child’ was to come to church regularly, make regular monetary contributions and let the pastor pray for her. He said that I had […]

Eating fruit and veg associated with children's mental well-being

Eating fruit and veg associated with children’s mental well-being

  • Multiple factors influence mental well-being, including nutrition.
  • A recent study found that eating more fruits and vegetables was linked to better mental well-being among children.
  • On the other hand, children who skipped meals were more likely to have lower well-being scores.

Although well-being among adults and children is similar, it is not exactly the same for both groups. Children are still growing, and multiple factors need to be taken into account when evaluating children’s health.

One area of interest is the association between nutrition and children’s mental well-being. A new study, which appears in the journal BMJ Nutrition, Prevention & Health, suggests that children who eat more fruits and vegetables are more likely to have a better sense of mental well-being than those who eat less.

The Centers for Disease Control and Prevention (CDC) provide the following definition of what it means for children to be mentally healthy:

“Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities.”

Psychologist and well-being consultant Lee Chambers further explained the impact of children’s mental well-being to Medical News Today:

“Mental well-being in children plays a vital role in more than their health outcomes. Positive mental well-being is influenced by a variety of factors, and, in turn, impacts a range of outcomes, from education to health [and from] friendships to decision making.”

Chambers continues, “It also provides the platform to develop resilience, cope with stressors, and become rounded and healthy adults. It is also pivotal in their ability to be safe and for healthy relationships.”

“In an increasingly dynamic and uncertain world, mental well-being provides the foundations for children to build upon, to explore and learn, to play and have fun, and to navigate the challenges and adversity that come with being human.”

DESR: Why Deficient Emotional Self-Regulation is Central to ADHD (and Largely Overlooked)

DESR: Why Deficient Emotional Self-Regulation is Central to ADHD (and Largely Overlooked)

Deficient emotional self-regulation (DESR) is a relatively new term used to describe the problem of impulsive emotion coupled with emotional self-regulation difficulties long associated with attention deficit hyperactivity disorder (ADHD or ADD). DESR may be new to the ADHD lexicon, however I argue that it is a core and commonly overlooked component of the disorder — and one that can help predict a patient’s impairments, and even improve diagnostic and treatment practices.1

Emotional dysregulation is noticeably missing from diagnostic criteria for ADHD. However, most patients and experts recognize that it is central to the disorder2. DESR, a manifestation of emotional dysregulation, specifically refers to deficiencies with these four components of emotional self-regulation3:

  • Ability to inhibit inappropriate behavior triggered by strong emotions. I argue that this emotional impulsiveness (EI) is an aspect of poor inhibition associated with ADHD that is illustrated by low frustration tolerance, impatience, being quick to anger, aggression, greater emotional excitability, and other negative reactions, all of which are related to the impulsivity dimension of the disorder
  • Ability to self-soothe and down-regulate a strong emotion to reduce its severity
  • Ability to refocus attention from emotionally provocative events
  • Ability to organize or substitute more moderate, healthier emotional responses in the service of goals and long-term welfare

To understand the role of EI and DESR in ADHD is to acknowledge the prominent role of emotional control difficulties in the disorder’s appearance and outlook, including understanding the following:

  • Why these issues are prevalent in individuals with ADHD
  • Why major comorbid disorders often develop as a result of these challenges
  • The major life impairments not adequately explained by traditional symptoms of ADHD

A wealth of compelling evidence — from ADHD’s clinical conceptualization over time to neuroanatomical and psychological research — clearly shows that EI and DESR are key components of ADHD and should be incorporated into the disorder’s diagnostic criteria and treatment practices.

EI and DESR: Evidence of Its ADHD Ties

1. EI and DESR in Historical Concepts of ADHD

Conceptualizations of ADHD have included emotional control problems for centuries. One of the earliest references to attention disorder in western medical literature4, a textbook written by German physician Melchior Adam Weikard in 1770, characterizes those who have a “lack of attention” as “unwary,” “flighty,” “careless,” mercurial,” and “bacchanal.”

EI and DESR through history4:

Identifying the signs of depression in kids

Identifying the signs of depression in kids

There is a growing worldwide concern about depression and suicide among our youngest population, but the signs of depression in children can be different than those in teenagers and adults.

Joan Luby, MD says that depression can arise as early as age three.

Pandemic isolation, struggling with virtual schooling, and family-related stress all contributed to a rise in mental health concerns for children. According to mental health America, last year, more than 2.3 million kids suffered from severe depression.

“The thing that we have to look for are age-adjusted manifestation of those symptoms,” Luby, explained.

Symptoms of depression in youth include being persistently sad or irritable over several weeks, sleep disturbances, fatigue, no longer enjoying the things they use to enjoy, not being motivated to engage in activity, expressing negativity toward themselves or others, and discussing thoughts of death. The key to helping children fight off depression.

Luby recommends parents to be very aware of their child’s emotional state.

If you notice these signs in your child, get help immediately. Also, spend more time outside, take walks, play outdoor games, and get them involved in social activities.

Depression may be more treatable early in life during a time of rapid brain development and developmental change. Early treatment can help to avoid relapses, personality and medical disorders later in life.

Warning signs to look out for in your child:

  • Isolation or refusal to attend school;
  • Changes in eating habits;
  • Withdrawal from peers or social activities;
  • Withdrawal from extracurricular activities at school or in the community; and/or
  • Reports of bullying, harassment, or intimidation in school, the community, or on social media.
AAP: Healthy relationships can help offset toxic stress

Healthy relationships can help offset toxic stress

Toxic stress can have lifelong negative effects. A new policy statement from the American Academy of Pediatrics (AAP) examines how healthy relationships may serve as a buffer.

It isn’t enough to try and prevent traumatic events in childhood. Supporting healthy growth also means helping children identify stable and supportive relationships in their life. These relationships can buffer bad experiences and promote resiliency, according to a recent policy statement from the American Academy of Pediatrics (AAP).

The policy statement updates previous data on the lifelong effects of toxic stress in children with information on the value of a nurturing relationship with at least 1 stable adult.

“Childhood toxic stress is a public health crisis that demands an integrated public health response. With a social isolating pandemic, a widening of disparities, and a reckoning with centuries of systemic racism, the concept of toxic stress has never been more relevant,” said Andrew Garner, MD, PhD, FAAP, a pediatrician from Westlake, Ohio, and clinical professor of pediatrics at Case Western Reserve University in Cleveland.

Garner, a member of the AAP committee that developed the report, explained that toxic stress can permanently remodel a child’s brain at the cellular level, resulting in behavioral changes that become biologically embedded. Addressing these stresses is 1 step to helping children at risk, but Garner said the policy focuses on what pediatricians can do to be proactive.

“Toxic stress is a deficits-based model in that it defines the problem. Toxic stress explains how many of our society’s most intractable problems—disparities in health, education and economic stability—are rooted in our shared biology but divergent experiences and opportunities,” he explained. “Conversely, relational health is a strengths-based model in that it defines the solution. Relational health explains how the individual, family, and community capacities that support the development and maintenance of safe, stable, and nurturing relationships also buffer adversity and build resilience across the life course.”

In 2012, the AAP outlined the dangers of toxic stresses—early childhood experiences that become biologically embedded and impact life-long development—in a policy statement. The recent policy statement updates the lessons from that report, focusing on how relational health can be used to buffer and support growth and resiliency in spite of toxic stress.1

Toxic stress refers to a wide range of childhood experiences that have physical, behavioral, and even cellular impacts on a developing child. Many of these experiences are the result of relationship challenges like the lack of a nurturing support system, and things like homelessness or insecurity over food and housing. These stresses can damage the entire trajectory of a child’s life, according to the policy statement, and may be to blame for some of the most challenging disparities that develop in adulthood.

The statement outlines new research that suggests that positive childhood experiences can have a protective effect against toxic stress, even working to reverse the effects of damaging experiences.

Safe, stable, and nurturing relationships are key to promoting relational health, according to the paper, because they not only buffer toxic stresses but they also help build resiliency. The policy statement therefore advocates for a new focus on not just preventing toxic stress, but also on promoting relational health.

“Promoting relational health and preventing toxic stress are 2 sides of the same coin. Toxic stress is a deficits-based model that describes what goes wrong in the absence of nurturing relationships,” Garner wrote in a summary of the new policy statement for AAP.2 “Conversely, relational health is a strengths-based model that describes what goes right when children are afforded safe, stable, and nurturing relationships and positive early experiences.”

Building relational health is a process that can take at least 2 generations, he added, noting that it takes multiple layers of family and community effort to support a child’s emotional needs. When a child’s support system functions in “survival mode” because of their own stresses, they aren’t able to provide a positive childhood experience or a background of supportive relational health for future generations.

“Understanding that process allows us to see how many ‘adult-onset’ diseases are actually ‘adult-manifest’ diseases with their origins in childhood,” he added.

Addressing these issues, which Garner called a public health crisis, requires both vertically and horizontally integrated efforts. Vertical efforts are rooted in a public health approach that supports stable relationships throughout childhood. Horizontal efforts can include policy and societal changes designed to support families and community health.

Garner said pediatricians are uniquely positioned to universally promote relational health; identify and address potential barriers to relational health; and utilize the common factors approach and refer to evidence-based therapies when relationships are strained. Some examples of universal promotions include educating parents about development, promoting lots of developmentally appropriate play, and supporting emotional intelligence by helping kids tap into their passions when distressed or bored.

“Potential barriers to relational health that the pediatrician might identify and address include: parental adversity as a child; parental mental illness or substance abuse; or the child’s exposure to poverty, violence, or racism,” Garner added. “Attachment and Biobehavioral Catch-up, Parent Child Interaction Therapy, and Child Parent Psychotherapy are all evidence-based interventions to support relational health, and pediatricians are well placed to advocate for the local development of these services.”

According to the report, another challenge is the fact that our society as a whole is moving toward increased division and social isolation, leading to even more barriers to the formation of stable, healthy relationships that can support relational health. AAP is working to develop practices and policies that can help support healthy relationships despite these challenges. A few starting points that have been identifies include:

  • Support nurturing relationships. This is a core function of the family-centered pediatric medical home and a focus of the statement. How to promote relational health in families is a hot topic in pediatric research, and pediatric primary practices may be the perfect place to focus intervention efforts.
  • Reduce external stress on families. Addressing family stressors such as financial circumstances or ill family members—even in adult members who are not normally included in the pediatric care spectrum—can go a long way toward overcoming barriers that increase toxic stress and make it more difficult to promote relational health. Clinicians can suggest programs that could help either ameliorate or solve such stress points.
  • Strengthen core life skills. Offering support for core life skills like executive function and self-regulation is something pediatricians are used to doing for children, but not other members of their families. Including parents and caregivers in these efforts by doing things like providing education on basic child-rearing and the importance of establishing daily routines.