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:

What Is Parentification?

What Is Parentification?

Do you feel like you were pushed into taking care of your parents or siblings when you were only a child yourself? That you became an adult before you were ready for the role?

If you’re nodding, you may have been parentified. Being a “little parent” involves excessive responsibility or emotional burden that can impact a child’s development.

That said, it’s important to remember that some responsibility is a good thing. Helping out a parent on occasion and at the right level helps a child believe in themselves and their ability to one day also be an adult.

Let’s take a closer look at how and when the line into parentification is crossed.

In the typical order of things, parents give and children receive. Yes, sometimes — especially in the early morning hours when your baby is teething — the giving can seem never-ending.

But in general, parents are expected to give their children unconditional love and to take care of their physical needs (food, shelter, daily structure). Emotionally secure children whose physical needs are taken care of are then free to focus their energy on growing, learning, and maturing.

Sometimes, though, this gets reversed.

Instead of giving to their child, the parent takes from them. In this role reversal, the parent may relegate duties to the child. At other times, the child voluntarily takes them on.

Either way, the child learns that taking over the duties of the parent is the way to maintain closeness to them.

Children are pretty resilient. We’ve already said that some level of responsibility can help a child’s development — but 2020 research takes things further. The researchers suggest that sometimes, parentification can actually give a child feelings of self-efficacy, competence, and other positive benefits.

It seems that when a child feels positively about the person they’re caring for and the responsibilities that come with the role of caregiver, the child develops a positive self-image and feelings of self-worth. (Note that this isn’t a reason to pursue or justify parentification.)

Not all parents are able to take care of their children’s physical and emotional needs. In some families, the child takes over the role of caregiver in order to keep the family functioning as a whole.

Parentification can happen when a parent has a physical or emotional impairment, such as the following:

  • The parent was neglected or abused as a child.
  • The parent has a mental health condition.
  • The parent has an alcohol or substance use disorder.
  • The parent or a sibling is disabled or has a serious medical condition.

Parentification can also happen when life throws curveballs, like:

  • The parents are divorced or one parent has died.
  • The parents are immigrants and have difficulty integrating into society.
  • The family experiences financial hardship.

There are two types of parentification: instrumental and emotional.

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.

What to know about occupational therapy for ADHD

What to know about occupational therapy for ADHD

Occupational therapy may help individuals with ADHD in multiple ways. It can help a person identify barriers to success, develop strategies for tackling those areas, practice new skills or refine old ones, and brainstorm solutions when things do not go as planned.

Attention deficit hyperactivity disorder (ADHD) is a chronic mental health condition that affects a person’s ability to pay attention and manage impulses.

Experts estimate that 5–7% of school-aged children worldwide have ADHD, and around 63 million children and adolescents live with the condition worldwide. In the United States, about 6.1 million children have an ADHD diagnosis. Although ADHD symptoms evolve, it typically persists into adulthood, affecting about 366 million adults worldwide.

People living with ADHD may have challenges with time management, organization, focusing, and multitasking. Because ADHD symptoms are highly individualized, occupational therapy aims to help people plan and prioritize by using various techniques tailored to the situation.

Keep reading to learn more about occupational therapy for ADHD, including how it works, and why it may be effective.

At its core, occupational therapy involves helping people of all ages participate in whatever they want or need to do.

Occupational therapy encourages people to overcome the barriers that prevent them from doing important activities, and increases their independence and satisfaction in life.

It addresses the importance of people’s psychological and emotional well-being, and focuses on improving these by using everyday activities in a therapeutic manner. For people with ADHD, who may report low self-esteem and self-efficacy, this is also a focus for the therapy.

Overall, the main goal of occupational therapy is to adapt the environment to fit the individual. It follows the thinking that no two people are the same, so the surroundings should adapt to serve everyone best and allow them to be their most productive.

The basis of this reasoning is especially beneficial for those living with ADHD. Occupational therapy helps these individuals participate fully in social situations. For children with ADHD, it can also help them with school, work ethic, and performance.

While occupational therapy is beneficial when applied to other mental health conditions, limited evidence of its application with ADHD exists.

ADHD typically affects an individual’s educational functioning, management of interpersonal conflict, relationships, and ability to provide emotional support. The symptoms of ADHD include inattention and hyperactivity or impulsivity. These qualities can lead to difficulties in time management, emotional regulation, motivation, and executive function, which are needed for completing tasks.

In a small 2018 study, 38 children aged 9–15 either were randomly placed to work with an occupational therapist for 12 weeks or be in a control group. After this time, those in the occupational therapy group showed a significant improvement in their ability to manage their time effectively and their general awareness of time.

Another 2020 study involved 23 female participants, divided into either a 7-week occupational therapy intervention group or a control group. Researchers found that the 11 participants in the therapy group demonstrated reduced stress and ADHD symptoms, with enhanced task performance and satisfaction.

5 tips on parenting your kids without emotional baggage

5 tips on parenting your kids without emotional baggage

There’s no manual when it comes to parenting and sometimes, the road can be rocky – in particular if you have unresolved issues with your own parents or come from a home that was less than stable. Even without realising it, these experiences can cause trauma and will affect how you react to your own children.

Rany Moran, the owner of children’s indoor playground Amazonia, understands these things. Now a trained counsellor, life coach and parenting expert, she has begun a new business doing one-on-one and group life coaching and family counselling sessions.

Read the condensed version of this story, and other top stories with NewsLite.

“I want to build a safe, judgement-free space for personal and professional growth,” she says of her goal.

“Inheriting trauma can mean the cycles of trauma, where a victim of abuse of any form (physical, emotional, psychological) then reenacts and inflicts a similar concept of “pain” onto another person. This can be passed down and inherited from anyone—parents, grandparents, siblings, regardless of gender,” she explains.

“Children’s response to trauma largely mimics that of the parent, the more disorganised the parent, the more disorganised the child,” she continues.

“Children who have experienced violence have problems managing in social settings and tend to be withdrawn or bully other children. During adolescence, they tend to engage in destructive acting out against themselves and others without early intervention the children cannot outgrow these problems.”

As a parent, it can be difficult and even surprising to find yourself navigating your own trauma and how that can affect your children. Without realising it, this can manifest in things like favouritism, or comparing siblings to each other, or constantly fighting with your spouse. “Such toxic emotional stressors can disrupt brain architecture and other organs systems, increasing risk of stress-related disease and cognitive impairment,” says Moran.

And beyond that, there’s also traumatic content (the Covid pandemic, news of violent events) that can affect our children.

Says Moran, “It is our role as parents to explain what’s going on in the world to our children – don’t be afraid to discuss the news and current affairs with them, let them know your point of views on correcting discrimination and how violence, racism or corruption shouldn’t be tolerated.

Discuss instead of shelter them from the realities of life, so that they approach any potential traumatic experiences in the future with educated opinions of their own.”

Here Moran shares her five main tips for how to parent children without trauma.

Empathise with your child’s distress instead of dismissing it as a weakness

When working on a difficult subject, recognise signs of distress and allow your child to stop and take a break. A good parent is a good listener.

Listen to your child’s challenges and validate his or her issues-then explore the root of their problem and what led to it, rather than zooming on the inability of overcoming an obstacle, mistake or wrongdoing.

Recognise teachable moments in daily challenges

This will help young learners be open to lessons of character. Turn stumbling blocks into stepping stones by taking personal responsibility to clear up mistakes by being open to learning from challenges and by replacing shaming with naming values.

Brainstorm ideas to solve problems together. Always remember that humility is the goal not humiliation. When considering teachable moments there needs to be the opportunity for reflection.

Speak to them about trauma at a level they can understand

Autism and Grief: What to Do and How to Prepare

All parents dread the day they have to explain death to their kids. Grief and loss are difficult for anyone to experience, much less young children. Parents of kids with autism may be even more worried about how to help them cope. Although this conversation will never be easy, there are things you can do to help prepare your child. How do you tell an autistic child about death?

People on the autism spectrum often have a hard time grasping abstract concepts, so it’s important to be as clear as possible.

Here are some tips:

Don’t use euphemisms

Expressions like “he went to sleep,” “he passed away,” “he went to Heaven,” and “we lost him” can be confusing to a child with autism. Most autistic people tend to interpret language literally, so your child might wonder why he/she can’t visit Heaven, become scared of going to sleep, or just not understand what’s happened.

Explain what death is

Depending on how old your son or daughter is, he/she might not have any concept of death. Use simple, honest words when talking about it. Tell him/her that death is the end of life, and it happens to all living things. Make it clear that death is permanent, but that you’ll always have the memories of that person. You could use examples from nature or fictional media to make it concrete. Explain how the person died

An (age-appropriate) explanation of what causes death is essential to your child’s understanding. You might say that the person was old enough to die, that he/she became very sick, or he/she got hurt very badly and the doctors couldn’t help.

Just be sure to differentiate between a typical illness or injury and a life-threatening one. A child might be scared if he/she thinks that a cold or scraped knee is enough to cause death.

Be open to questions

Your kid with autism might have a lot of questions, like whether he/she will die, whether you will die, and what happens to someone when he/she dies. Many children ask the same questions over and over while processing information, so be patient. Be honest in your responses and don’t be afraid to admit when you’re unsure about something.

Both autistic and neurotypical children may not understand the concept right away, so think of learning about loss as a process rather than a singular moment. It could take weeks or months for your child to fully understand what’s happened. Prepare your child if you know the death is coming

Some deaths are sudden, but other times, a friend or relative has been sick for a while. Don’t wait until he/she has passed away to talk to your child. For one thing, your […]