The key message of his CHADD keynote address was that he would like the lack of behavioral inhibition or emotional dysregulation to be the center symptom that clinicians watch for when they diagnose and treat ADHD. He went to great length in his lecture explaining that emotional dysregulation is the ‘home and life wrecker’ of ADHD.
People with ADHD and emotional dysregulation are more like to:
- Get Divorced
- Get Fired from Jobs
- Be involved in Motor Vehicle Accidents
- Abuse Drugs and Alcohol
- Have Law Enforcement Problems
- Be in Jail
He spent a great deal of time explaining that emotional dysregulation had not been included in the definition of ADHD and that this was a key issue that needed inclusion. I do not think anyone would argue that emotional control is a problem with ADHD. All researchers agree that this is part of the Executive Control problems seen in this condition and that this lack of emotional control is not all that different from what we call impulsive behavior.
The problem with making emotional dysregulation (or impulsive behavior) the central issue of ADHD is that A LOT OF PEOPLE WITH ADHD DON’T HAVE EMOTIONAL DYSREGULATION!!! Yes, I am yelling because Russell Barkley is so sure of himself on this that it is maddening! I am not alone in disagreeing with Barkley. Dr. Thomas Brown of Yale University has researched ADHD extensively and also has concluded that Barkley's theory only applies to the combined type of ADHD and leaves the other subtypes of ADHD searching for a diagnostic 'home'.
I like to think of emotional dysregulation in ADHD as the same as being a brittle diabetic. Brittle diabetics are sometimes called unstable diabetics and they tend to have blood sugars that are either dangerously high or dangerously low and their blood sugars are impossibly difficult to control. These very high, uncontrollable sugars lead to very poor health outcomes for the patients with this type of diabetes.
Luckily for those of us in health care and for diabetics, most diabetics are not brittle diabetics. Some diabetics are well controlled on diet and others are well controlled on medicines but most of the diabetics we see have achieved some control of their blood sugar. Treating all diabetics as though they were brittle diabetics, or making the people with brittle diabetes the poster children for diabetes would make no sense just like making the people with diet control diabetes the poster children would make no sense. Diabetes is a medical condition that includes many different kinds of diabetics and no one group represents all diabetics.
ADHD is a medical condition that includes many different kinds of Adders. Some are impulsive, some are inattentive, some are sluggish and some are hyperactive but just because the impulsive type has the poorest life and health outcomes does not mean that this type should take the front and center position in defining this condition.
Most people with Inattentive ADHD (ADHD-PI) do not have emotional dysregulation. They may be more likely to be depressed but they do not have the type of ADHD that causes them to lose their tempers or be unable to control themselves emotionally. Many people with the combined type of ADHD (ADHD-C) do not have emotional dysregulation as their central problem either. The symptoms of impulsive behavior seem to decrease with age just as the symptoms of hyperactivity decrease with age. The primary symptoms that you see in adults with ADHD are problems with the other executive functions. These symptoms are the key symptoms seen in Inattentive type of ADHD (ADHD-PI) and in Sluggish Cognitive Tempo and they include:
- Organizing and Activating to Work
- Focusing for Tasks
- Regulating Alertness and Effort, and
- Utilizing Working Memory
I had a physics professor in college who said that genius in science was measured by how long the scientist stalled their field. What he meant was that when a scientist is highly respected in their field, other scientist will stop searching for answers because the genius’s theories are so convincing and compelling.
I think that Russell Barkley is correct that the emotional dysregulation of some people with ADHD is very damaging to society. I disagree that emotional dysregulation is the core problem of most people with ADHD and I would argue that society is as damaged, albeit in a subtler way, by the disorganization, lack of focus, lack of persistence and working memory problems which are present in a far larger number of people with ADHD.
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