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Nieman: Navigating the emotional tornadoes of ADHD


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When I was in medical school, the term “political correctness” did not exist. I remember first learning about what we now call ADHD — in the 1970s it was known as “minimal brain dysfunction.” I also remember seeing in paper charts the abbreviation ‘FLK’; it stood for “funny-looking kid.” Now we call it facial dysmorphology.

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It has been said that a rose by any other name still smells like a rose. If it were only that simple when we discuss ADHD.

The term ADHD (Attention Deficit Hyperactivity Disorder) brings to mind two main features — a deficit of attention and being very active. ADHD falls well short of what actually matters. What matters as much, if not more, are things such as executive functioning and emotional regulation.

ADHD also fails to describe that this condition has a wide spectrum of presentations. In autism, we use the word “spectrum” Not so in ADHD. In fact, some fuss over the H — probably because boys tend to be more hyperactive than girls and thus some girls may not be diagnosed early enough because they are not hyperactive.

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Even though many children with ADHD can focus for long periods on something they are interested in, we do not talk about a situational inattention deficiency.

To add to the complexity of ADHD, respected researcher Russell Barkley recently wrote a very informative article in the publication ADDitude (www.additudemag.com online or get a paper copy of the Spring 2022 edition)

Dr. Barkley correctly points out that DESR — deficient emotional self-regulation — is a core component of ADHD. However, DESR is missing from the diagnostic criteria for ADHD.

Many patients with so-called ADHD also exhibit low frustration tolerances, impatience, they may be quick to anger, experience emotional excitability, an inability to self-soothe, an inability to refocus from emotionally provocative events and constantly struggle to self-regulate.

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Emotional dysregulation has been shown to uniquely predict social rejection and interpersonal hostility in childhood. In adulthood, individuals with ADHD experience more road rage, DUI’s, job dismissals, marital discord, impulse buying, and conflict with a child who has ADHD.

Barkley points out that a parent’s ADHD could exacerbate their child’s ADHD and make emotional dysregulation worse. For example, if a child with ADHD misbehaves, a parent with ADHD may fly off the handle faster than a more neurotypical parent. Two individuals feed off each other and conflict escalates. A parent with emotional dysregulation also models these reactions to his or her child.

Barkley calls these events “emotional tornados.” Each family member triggers another to higher levels of conflict.

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In Buddhist psychology, teachers mention “an amygdala hijacking” It is simply a situation where we react to an aversion rather than respond. The whole point of mindfulness-based stress reduction is for a student to learn how to cultivate a wise response rather than an unwholesome reaction.

The amygdala is a part of the brain involved in executive functioning. This section, the frontal lobe, the anterior cingulate and the ventral striatum all comprise the executive functioning and emotional circuits of our brain.

Deficient emotional self-regulation can manifest in the preschool age. Often it is dismissed as “terrible two’s.” When the child gets older, it becomes more obvious that emotional regulation, compared to peers, may be lacking. Children who are described as being emotionally impulsive grow up and exhibit a lack of self-regulation later — the lack of executive functioning then becomes the main focus.

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One of the saddest things for me to observe is that in Canada we brag about our health-care system not being two-tiered like the American system. This smugness is delusional. We do have a two-tiered system. It is true that any child in Canada can see a pediatrician to get a diagnosis of ADHD and walk away with a prescription for medication. It is also true that not all Canadian children have parents who can pay out-of-pocket for therapies such as CBT (cognitive behavioural therapy) and mindfulness-based stress reduction. These children fall through the cracks because of a two-tiered system.

More and more doctors now are interested in mindfulness and CBT training — probably because they realize that medication alone is insufficient. In fact, some stimulant medications used in ADHD may cause emotional blunting. As the stimulants wear off, the emotional brain may experience a rebound. This is less of an issue with non-stimulant medications.

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Educating both parents and a child with ADHD is always vital. In Canada, an organization called CADDRA offers great resources (www.caddra.ca).

I am very blessed to learn so much from the parents of my patients. A father of a child with ADHD introduced me to the magazine ADDITUDE, which helped their family immensely in expanding their understanding of what ADHD is all about. Via this great resource, I discovered a video on emotional dysregulation  (www.additudemag.com/emotional-dysregulation-adhd-video/)

Dr. Nieman has worked in a pediatric clinic since 1987. For more information, visit www.drnieman.com

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