DESR and ADHD: The Overlooked Component of the Disorder

[David Baxter PhD]

DESR and ADHD: The Overlooked Component of the Disorder​

by Russell Barkley, Ph.D., ADDitudeMag.com
Sept 17, 2021

DESR, or deficient emotional self-regulation, is a core facet of ADHD that carries significant consequences. However, it is not included the disorder’s diagnostic criteria. As new research confirms the prominent role emotional dysregulation plays in ADHD’s appearance and individual patient outcomes , that may be changing. Here, learn about DESR, its central role in ADHD, along with implications for diagnosis and treatment.

What is DESR?​

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:

• 1798: Alexander Crichton, a Scottish-born physician, includes emotional frustration in his description of disorders of attention, especially problems with persistent attention
• 1902: George Still, a British physician widely considered to be the “founder” of ADHD, includes emotional impulsiveness and poor regulation of emotions in his conceptualization of “defective moral control of behavior” (the precursor to ADHD)
• 1960s-1970s: Major clinical researchers at the time — including Mark Stewart, Dennis Cantwell, and Paul Wender — include emotion as a core feature in their concepts of “hyperactive child syndrome (now ADHD).”

So why isn’t emotion considered in the diagnostic criteria for ADHD today?

• 1968: DSM-II references ADHD for the first time (as hyperkinetic impulse disorder) but fails to list EI or DESR as a feature of the disorder. It is excluded from all future DSMs, for unknown reasons, despite continuing research linking emotion to ADHD.

2. EI and DESR and the Neuroanatomy of ADHD​

The brain structures and networks implicated in ADHD are also involved in emotion and would thus logically be expected to give rise to EI and DESR and be part of the disorder.

The frontal lobe, the anterior cingulate, the ventral striatum, and the amygdala all comprise the executive circuitry that has been repeatedly shown to be involved in causing ADHD². Some of these structures also form the brain’s emotional circuitry — the amygdala and larger limbic system to which it is connected is where emotion is generated, and the prefrontal cortex and related structures attend to these generated emotions. Thus, how we feel also influences how we think, and the dorsolateral PFC is where some thinking occurs, as well as working memory (or what we are holding in mind).

3. EI and DESR in Neuropsychological Theories of ADHD​

The frontal-limbic circuit — one of the four executive networks of the brain — is associated with ADHD and with symptoms of emotional dyscontrol, motivation deficits, hyperactivity-impulsivity, and aggressive tendencies. This emotional regulation network is also known as the “hot” circuit. I also refer to it as the “why” circuit, because it’s absolutely crucial in decision making.

This network is also connected to the other executive networks that we know are implicated in ADHD. ADHD, of course, would be expected to disrupt this emotional regulation network substantially.

4. EI and DESR in ADHD Psychological Research​

Emotional self-regulation is a major dimension of executive functioning required for daily life activities. It is also one of the most impaired dimensions in children and adults with ADHD.^5,6 Ample evidence from an abundance of psychological research shows that children and adults with ADHD are highly likely to manifest EI-DESR² including low frustration tolerance⁷, anger, poor inhibition of emotion, and emotional excitability.^8,9

Additional research on EI-DESR and ADHD:

• Meta-analysis: Emotional dysregulation is a core feature of ADHD’s psychopathology in adults10
• Developmental studies on preschool children find that negative temperament, irritability, and poor emotional regulation are strong predictors for ADHD later in life^11,12
• Studies on family genetics and ADHD show that the genes implicated in ADHD are also responsible for associated emotional problems¹³

5. EI and DESR Underpinning ADHD Comorbidities​

Putting impulsive emotion and emotional self-regulation problems back into the realm of ADHD also helps us understand the basis for several of the comorbid conditions commonly associated with ADHD, especially that of oppositional defiant disorder (ODD).¹⁴

ODD is two-dimensional, comprising aspects of social conflict and emotion dysregulation. These two dimensions significantly contribute to the risk for later disorders. The emotional dimension, for example, in children contributes to the later risk for anxiety and mood disorders in teens.

Given ADHD’s prevalence in ODD, we can assume that the emotional component of ODD arises biologically from ADHD. That is, ADHD likely creates one of the two dimensions involved in ODD. Indeed, the longer ADHD goes untreated and emotions remain dysregulated, the greater the odds that comorbid conditions, particularly anxiety disorders, will develop.¹⁵ This framework helps us understand why emotion and ODD are managed so well by ADHD medication, but only if ADHD is also present.¹⁶

Meanwhile, the social component of ODD predicts later conduct disorder and antisocial behavior. This component of ODD, contrary to the biological aspect of emotionality, is likely learned, most often within family interactions.

6. EI and DESR and Impairment in Major Life Activities​

Centering the role of emotion in ADHD predicts a variety of impairments that are not similarly associated with the traditional symptoms of ADHD: hyperactivity, inattention, and/or impulsivity.

Emotional dysregulation has been shown to uniquely predict the following⁶

• social rejection in children with ADHD
• interpersonal hostility and marital dissatisfaction in adults with ADHD
• greater parenting stress and family conflict in parents of children with ADHD; greater stress in parents with ADHD
• road rage, DUIs, and crash risks during driving
• job dismissals and workplace interpersonal problems
• dating/cohabiting relationship conflict
• impulse buying; poor finances

EI and DESR: Diagnostic Implications​

Elevating EI-DESR’s place in ADHD would greatly assist with differential diagnosis of the disorder from mood disorders and other conditions involving emotional dysregulation. In other words, it would reduce the odds of misdiagnosis for patients who are simply experiencing what is central to ADHD itself. (Individuals with ADHD are commonly misdiagnosed with mood disorders.¹⁷)

Mood disorders, however, are common in individuals with ADHD, so comorbidity must be considered¹⁸. Duration could be a guiding diagnostic principle used to distinguish a legitimate mood disorder from the emotional dysregulation associated with ADHD. Emotions, unlike moods, are of short duration, setting-specific, provoked, and easily traced to the source. EI-DESR is a “top-down” deficit in regulating rational emotional responses to events; its impact is typically shorter in duration than that of a mood disorder.

Mood disorders are generally “bottom-up” excessive expressions of emotions likely attributed to underlying amygdala-limbic system activities. Moods are of long duration — lasting hours, days, or weeks. Moods are cross situational, and irrational in the case of mood disorders (it is often not clearly understood, for example, what triggers a patient with bipolar disorder to become manic, or the opposite).

EI and DESR: Treatment Considerations​

Re-centering ADHD on emotions also helps us understand treatment outcomes. It’s why we often observe that ADHD medications impact core EI and DESR problems in patients with ADHD, albeit in different ways19. Stimulants appear to quell and even dampen the limbic system, sometimes leading to complaints from patients about having robot-like, bland emotions. Non-stimulants like atomoxetine, on the other hand, act on a different part of the brain. They help to up-regulate the executive brain, giving patients more self-control of emotion. Prescribers sometimes utilize different drug combinations to allow patients more control over ADHD, including emotional problems.
Other treatment implications:

• Secondary impairments from EI-DESR on major life activities may also be improved by ADHD medication.
• Cognitive behavioral therapy (CBT) programs that target EF deficits, along with mindfulness-based approaches, might help with emotional regulation in adults with ADHD, especially if they are taking ADHD medication.
• In children, emotional dysregulation is better handled through medication and then, to some extent, through behavioral parent training programs that focus on restructuring situations and interactions so as not to trigger strong impulsive emotions.
• Parental ADHD could contribute to emotional dysregulation in children with ADHD, not just genetically through inheritance, but through modeling of poor emotional control and by engaging in emotionally provocative encounters with the child. Clinicians should screen parents for ADHD and treat their symptoms as well.

EI and DESR: Conclusions​

Impulsive emotion and emotional dysregulation are core facets of ADHD. Impulsive emotion is linked to the impulsivity dimension of ADHD, and difficulties with emotional control is part of the large inattentive/executive dimension of ADHD. Historical concepts of ADHD include EI-DESR, and research in the fields of neuroanatomy, neuropsychology, and psychology also link ADHD to EI and DESR. This core relationship may help to explain, at least in part, why the disorder poses high risk for ODD and mood disorders, as well as the unique impairments some patients experience.
By recognizing that EI and DESR are involved in ADHD, we can significantly improve diagnostic and treatment practices.

DESR and EI with ADHD: Next Steps​

• Essential Reading: New Insights Into Rejection Sensitive Dysphoria
• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: Why We Feel So Much — and Ways to Overcome It
• Read: Learning to Cope with Intense ADHD Feelings

Sources​

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