Transcript CHANGING CONCEPTS OF ADHD IN ADULTS

The Unrecognized Role
of Emotions in ADHD:
Implications for Social Interaction
Thomas E. Brown, PhD
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
Social Emotions
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Fear
Anger
Disgust
Surprise
Sadness
Happiness
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; LeDoux, 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 X2 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, pp101,
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
info
(Denckla, 2000)
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.DrThomasEBrown.com