The Unrecognized Role of Emotions in ADHD Implications

The Unrecognized Role of Emotions in ADHD: Implications for Social Interaction Thomas E. Brown, Ph. D Associate Director, Yale Clinic for Attention and Related Disorders Department of Psychiatry Yale Medical School

Not in DSM-IV Criteria for 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?

Outline ¨ 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 Emotions and EF

What is emotion? (varieties of pain and/or pleasure) (immediate or anticipated) Primary Emotions ¨ ¨ ¨ Fear Anger Disgust Surprise Sadness Happiness Social Emotions ¨ ¨ ¨ ¨ Sympathy Embarrassment Shame Pride Jealousy Gratitude Indignation Contempt Damasio (2003) Looking for Spinoza: Joy, Sorrow and the Feeling Brain

Emotional Control Items on ADHD Rating 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)

Barkley’s Model of ADHD Impaired Executive Functions 5 major components of Executive Function impaired in ADHD include: ¨ Self-regulation of emotion: affect/ motivation/ arousal ¨ Reconstitution: behavior analysis planning and synthesis

Regulation 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 4 Managing Frustration and Modulating 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 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 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 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 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 Functions (“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; Le. Doux, 1996, 2002, )

Executive Functions regulate emotion (“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 of Problems with Top Down Control

“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” ¨ 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” ¨ 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” ¨ 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” ¨ 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” ¨ 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” 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 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” ¨ 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? ¨ 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 Substantia nigra Prefrontal cortex DOPAMINE SYSTEM Ventral tegmental area Cerebellum

Increasing 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 Problems in ADHD and Comorbid Disorders

Dysregulation of Emotion is central in many disorders highly comorbid with ADHD ¨ 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? ¨ 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. Irritability garden hose = ADHD fire hose = bipolar

Boundaries between ADHD & 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” (Banaschewski, et al, 2005) e. g. “irritability” ADHD (+) depression (++) bipolar (+++) Mick, et al, 2005)

Spectrum of Emotional Regulation Problems Normal ADHD mild moderate Comorbidity severe Anxiety, Worry, Depression, Obsessionality, Irritability,

More 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” ¨ 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.

“Emotional Intelligence” is a form of social intelligence that involves ability to: 1. monitor feelings and emotions in self and others 2. discriminate among feelings 3. use this information to guide thinking and action (Salovey, Woolery & Mayer, 2001)

Emotional 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 Others/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.

Social Functioning Involves Monitoring & 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 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: Childhood 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 & Social 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 Spectrum characteristics ¨ 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!” ¨ 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 Victimization of 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 X 2 higher than others) (Little, 2001)

Social Intelligence: Depends on 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, pp 101, 121)

Right Hemisphere Impairment in 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”: a right hemisphere syndrome Characterized by deficiencies in: ¨ visualization ¨ perceptual organization ¨ conceptual organization ¨ ability to grasp “big picture” ¨ problems in summarizing & integrating (Denckla, 2000) info

Emotional Intelligence is 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

Impact on Family Life and What Might Help

Parental 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 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 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 Capacities 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 capacities 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? 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? 5. Recognize disappointments, hurt in patient & other family members 6. Acknowledge complexity of social interactions & options to engage/avoid 7. 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

Summary 1. ADHD = developmental impairment of Executive Functions (EF) 2. managing emotions and monitoring, selfregulating 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 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 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. Dr. Thomas. EBrown. com