The ADHD Brain

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.

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Deficient emotional self-regulation (DESR) is a new term describing an age-old problem of impulsive emotion and emotional self-regulation difficulties among people with attention deficit hyperactivity disorder (ADHD or ADD). Specifically, DESR refers to deficiencies in these four aspects of emotional regulation:

  • The ability to inhibit inappropriate responses triggered by strong emotions
  • The ability to self-soothe to reduce the severity of an intense emotion
  • The ability to refocus attention from emotionally provocative events
  • The ability to substitute healthier responses in the interest of long-term welfare

Though it’s not included in the condition’s DSM-5 criteria, DESR and emotional impulsivity are fundamental components of ADHD that shape an individual’s experiences and challenges throughout their lifetime.

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.

[Get This Free Download: 5 Emotional Control Strategies for Kids with ADHD]

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.

[Read: Why Is My Child So Angry and Defiant? An Overview of Oppositional Defiant Disorder]

Q: Can parents manage DESR in children with ADHD without medication?

It will be very, very difficult to do so. With ADHD in children, we’re looking at a dysregulated brain with a highly variable, immature executive circuitry — part of which includes this problem with emotional expression and regulation. To expect to try to find some other social or psychological intervention that can change that underlying neural network problem is asking for too much of psychotherapy. It may be best to work with the aforementioned interventions as parents await the greater maturity of these neurological systems that comes with further development.

Q: Is there residual emotional difficulty in children and adults even after taking ADHD medication?

Yes — sometimes medications can create their own problems. Stimulants, for example, may create emotional blunting, which is the absence of natural emotion in some children or adults. As stimulants wear off, it’s not uncommon for the emotional brain to go through a rebound. In some cases, that may look like irritability, a proneness to weepiness or crying, and sadness.

These experiences with stimulants are not universal, but remember that you’ve been suppressing an emotional brain and, as medication wears off, that could come to the fore. We don’t see this issue with non-stimulants so much because they’re not suppressing the emotional circuitry of the brain. Ultimately, each drug works on the brain a little differently, and therefore works on emotion a little differently. It’s why some clinicians sometimes opt to combine these medications to get much broader coverage over patient symptoms than any single drug could do alone.

Q: You noted that a parent’s own ADHD symptoms could exacerbate their child’s symptoms and thus make emotional dysregulation worse. Can you give some examples?

Let’s say a child is engaging in some defiant, oppositional behavior. A parent with ADHD may experience a much stronger reaction to that compared to a typical parent. They might exhibit a more impulsive reaction of anger or hostility toward the child, or they may arrive at that level of emotional upset faster than would a parent without ADHD.

When a parent exhibits these behaviors, they are, in effect, modeling these reactions to their child. They are also provoking the child, who has their own emotional regulation problems. What you have, I think, is an emotional tornado in the family — each person is triggering the other to higher levels of conflict.

Q: Does trauma exacerbate DESR? What about PTSD?

It’s bi-directional. Research suggests that ADHD, because of the emotional dysregulation factor, especially, puts children at a higher risk for exposure to trauma. And once trauma has occurred in a child with ADHD, it’s more likely to progress to a PTSD reaction. This is why ADHD is one of the strongest predictors of who will develop PTSD if exposed to trauma. Once PTSD develops, it will only worsen existing emotional regulation problems.

Q: Is it ever too late to get help for emotional dysregulation?

Absolutely not. It is never too late to get help for ADHD and its symptoms, even if emotional dysregulation has been an impairing factor for a long time. Multiple studies show that a diagnosis in late life and subsequent treatment only benefits the individual.

DESR and Emotional Dysregulation: Next Steps

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