the unrecognized role of emotions in adhd: implications for social interaction thomas e. brown, phd...
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The Unrecognized RoleThe Unrecognized Roleof Emotions in ADHD:of Emotions in ADHD:Implications for Social InteractionImplications for Social Interaction
Thomas E. Brown, PhDAssociate Director,
Yale Clinic for Attention and Related DisordersDepartment of Psychiatry
Yale Medical School
Not in DSM-IV Criteria for Not in DSM-IV Criteria for ADHD, but….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?
OutlineOutline
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 Reciprocal Impact of Emotions and EFEmotions and EF
What is emotion?What is emotion?(varieties of (varieties of painpain and/or and/or pleasurepleasure))
(immediate or anticipated)(immediate or anticipated)
Fear Anger Disgust Surprise Sadness Happiness
Sympathy Embarrassment Shame Pride Jealousy Gratitude Indignation Contempt
Primary Emotions Social Emotions
Damasio (2003) Looking for Spinoza: Joy, Sorrow and the Feeling Brain
Emotional Control Items on ADHD Emotional Control Items on ADHD Rating ScalesRating 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)
CAARS Adult ADHD Rating Scale includes 4 emotional control items among 12 best for identifying ADHD (Conners, et al, 1999)
Barkley’s Model of ADHD Impaired Barkley’s Model of ADHD Impaired Executive FunctionsExecutive Functions
5 major components of Executive Function impaired in ADHD include:
Self-regulation of emotion:
affect/ motivation/ arousal
Reconstitution: behavior analysis
planning and synthesis (Barkley, 1997)
Regulation of EmotionRegulation 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 4Brown ADD Scale-Cluster 4Managing Frustration and Managing Frustration and
Modulating EmotionsModulating 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 FeelingsEmotions 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 Emotions Feelings / motivations 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 CurbDanger 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 CookieMixed 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 FunctionsEmotion regulates Executive Functions(“bottom up” control)(“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 emotionExecutive Functions regulate emotion(“top down” control)(“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 ofCase Examples ofProblems with Top Down ControlProblems with Top Down Control
““Easily Frustrated”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”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”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”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”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”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”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 FactorThe 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”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?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
Prefrontal cortex
Substantia nigra
CerebellumVentral tegmental area
DOPAMINESYSTEM
Increasing Dopamine can Enhance InterestIncreasing 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 Problemsin ADHD and Comorbid Disorders
Dysregulation of Emotion is centralDysregulation of Emotion is centralin many disorders highly comorbid with in many disorders highly comorbid with
ADHDADHD 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?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.
Irritabilitygarden hose = ADHD fire hose = bipolar
Boundaries between ADHD Boundaries between ADHD & other disorders?& 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”
e.g. “irritability” ADHD (+) depression (++) bipolar (+++)
(Banaschewski, et al, 2005)
Mick, et al, 2005)
Spectrum of Emotional Regulation ProblemsSpectrum of Emotional Regulation Problems
Normal ADHD Comorbidity mild moderate severe
Anxiety, Worry, Depression, Obsessionality, Irritability,
More extreme anxiety impairmentMore 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”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.
Social ineptness results from deficits
in emotional intelligence
““Emotional Intelligence”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 & IntelligenceEmotional 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 Problems in Recognizing Emotions in Others/SelfOthers/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.
Zentall, et al (2001): ADHD children more impaired than peers in attending to social data, predicting social outcomes
Social Functioning Involves Social Functioning Involves Monitoring & Self-Regulating ActionMonitoring & 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 ReactionsToo 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:Peer Relations in ADHD:Childhood to AdolescenceChildhood 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 & A Spectrum of Impairments in E-IQ & Social FunctioningSocial 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 Asperger’s Disorder SpectrumSpectrumcharacteristicscharacteristics
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!”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 VictimizationPeer Victimizationof Children With Asperger’sof 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 Social Intelligence: Depends on R-Hemisphere Functionson 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 ImpairmentRight Hemisphere Impairmentin ADHDin 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”:Non-Verbal LD”:a right hemisphere syndromea 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 IntelligenceEmotional Intelligenceis complex set of abilitiesis 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
But even if medication is helpful, significant social problems may persist
Impact on Family LifeImpact on Family Lifeand What Might Helpand What Might Help
Parental TemperParental 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 PolarizationParental 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 siblingsBurdened, 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 CapacitiesSelf-regulation Capacitiesdetermined by: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 capacitiesSelf-regulation capacitiesmay be improved by: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?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?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
SummarySummary
1. ADHD = developmental impairment of Executive Functions (EF)
2. managing emotions and monitoring, self-regulating 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 PracticeImplications 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 EmailWebsites 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
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