Challenges and Considerations With Clinical Evaluation of Associated Features

Explore practical approaches to evaluating executive dysfunction and emotional dysregulation in ADHD and considerations for addressing persistent functional impairment beyond core symptoms.

Welcome to “Evaluating Executive Dysfunction and Emotional Dysregulation in Clinical ADHD Practice.” Today, we're going to dive into the world of emotional dysregulation and executive dysfunction and how it shows up in your clinic. What we all know is most of our patients with ADHD do not present with ADHD alone. They come in with complicated, muddy, messy ADHD that includes a lot of other things. The real world of ADHD is 80, 90% of our patients will have difficulties with emotional dysregulation or executive dysfunction. Those can be terms that in some ways mean a lot, but in some ways mean nothing.

Having done this for 35 years, I've never had a patient walk into my clinic and say, "Dr Mattingly, I think I'm suffering with ADHD due to executive dysfunction." I've never had a patient walk in and say, "You know, I think my emotions are dysregulated." What patients do come in and say is, "Listen, I'm forgetting things. I forgot to pay my bills. My utilities got turned off. I just ran late for another appointment. I'm about to get fired at work because I didn't do my expense report. My wife's always frustrated because she feels like I don't care about her because I show up late to things that we're supposed to be doing together. Matter of fact, last week I forgot to pick up the kids one day from school." So when we think about executive dysfunction, I want to give you some tips or questions to ask with your patients. The first mistake we make is, as clinicians doing ADHD evaluations, there's only 2 questions that get asked of every patient. That would be, "How are you doing at work?" or "How are you doing at school?"

We want to dig deeper than that. "How are you doing outside of work or outside of school? How are you doing in the morning, getting ready for work, getting ready for school? How are you doing with organizing your day? How are you doing with planning for the future? Have you paid your bills? Have you paid your expenses? Are you running on time? Did you forget anything important this week?" As we go through the day, "How are you doing with the relationship with your friends? How are you doing at home with your wife? How are you doing with the kids? How are you doing with organizing things around the house? How are you doing with meeting your obligations?" That's where we'll start to see the true impact of executive dysfunction. "Oh my gosh, last week I blew up. I didn't mean to, but I got frustrated because I forgot to pay a bill. My wife got mad because I showed up late to dinner. My kids get mad because I get frustrated with them when I'm trying to help them with the homework."

So, when you talk about that holistic nature about how does executive dysfunction? Executive dysfunction can be working memory. Can I plan, prioritize, retrieve memories, use them when I need to use them? It's running on time, being able to organize things from a time commitment nature. It is being able to complete a task, starting a task, and being able to wrap it up. Meaning I have patients with ADHD, they'll say, "Dr Mattingly, I'm one of those creative types." I'm like, "Okay. But how many times did you actually complete the project you created?" That's where they tend to run in trouble. Our patients with ADHD have a hard time inhibiting behavioral responses. Another part of executive dysfunction is being able to inhibit a behavior. Maybe I'm talking too much. Maybe I'm frustrating people around me. Maybe I'm getting a little too amped up. Maybe I need to tone things down.

The ability to shift. Shifting is another aspect of executive dysfunction. Shifting from a preferred task: playing video games, watching sports, watching my favorite social media channel, to shifting to something that I find less stimulating: paying the bills, doing my homework, planning for work tomorrow, organizing myself. So, when we think about those questions of the executive dysfunction, I want you to dive into people's lives outside of school and work. What's happening at home? What's happening in relationships? What's happening with organization, prioritizing? The real meaning of life. Emotional dysregulation, it can get messy here because it's easy to confuse the emotional dysregulation of an ADHD brain with someone who has a more formal complex mood disorder or other mental health condition. So, the emotional dysregulation we see with ADHD is a heat of the moment. In the heat of the moment, I got frustrated, I lost it. When I was told no, God, I just got upset. When I asked my kid to come in from the playground, they melted down and lost it. How were they a few minutes later? Oh, they were fine. I was still frustrated. I was still mad, but they were doing great.

So, that emotional dysregulation in the heat of the moment, where my prefrontal cortex can't modulate impulsivity, frustration from other parts of the brain. Sometimes, that emotional dysregulation presents as an outward sense of anxiety, a sense of worry. That can lead to a misdiagnosis, where someone gets diagnosed with an anxiety condition instead of the ADHD causing the emotional dysregulation. Sometimes, that emotional dysregulation can look like mood lability, a bipolar spectrum condition, instead of the emotional dysregulation of, "How are you when things are good?" "Oh, I'm great." "When do your emotions become frustrating?" "In response to stress, in response to being told no. In response to having to shift to an activity that I don't enjoy, I get frustrated and I can't modulate emotional dysregulation. So, a sense of irritability, emotional frustration, feeling overwhelmed. Sometimes, I take those overwhelmed feelings to sleep with me at night, where I can't settle my mind as I'm trying to fall asleep." Very common in our ADHD patients.

When we think about treatments, the importance here is sometimes our traditional core ADHD treatments have been very successful for ADHD, but sometimes they don't treat aspects of executive dysfunction or emotional dysregulation. So, we want to individualize treatment. We know we have a lot of options with new options on the way. We want to talk about how [are] your ADHD symptoms, but how are those symptoms impairing you in life? How are they impairing you with aspects of executive dysfunction, planning, prioritizing, inhibiting frustration? How are they affecting you when it comes to emotional dysregulation? Anxiety, a sense of worry, emotional frustration, not being able to shut my brain off, overreacting to things that I find frustrating. How are your medicines doing for those aspects?

The good news is, with new treatments on the horizon and new treatments who have recently been developed, we now have treatments that approach not just ADHD symptoms but have also been shown to be highly successful for improving executive function and for improving ADHD dysregulation, emotional dysregulation, in the context of how they both relate to patients struggling with ADHD.

Thank you for joining me on this deep dive about the clinical importance of executive function, emotional dysregulation, the importance of probing with the right questions in your patients, and then individualizing treatment to make sure that these symptoms have been addressed.

Greg Mattingly, MD 

Dr Greg Mattingly is a physician and principal investigator in clinical trials for Midwest Research Group. He is also a founding partner of St Charles Psychiatric Associates and an associate clinical professor at Washington University. A St Louis native, he earned his medical degree and received a Fulbright scholarship while attending Washington University. Dr Mattingly is board certified in adult and adolescent psychiatry, and he is a diplomate of the National Board of Medical Examiners. He has been a principal investigator in over 400 clinical trials focusing on ADHD, anxiety disorders, major depression, bipolar disorder, and schizophrenia. Having served on numerous national and international advisory panels, he has received recognition for clinical leadership and neuroscience research. Dr Mattingly is also the president of the American Professional Society of ADHD and Related Disorders and a member of the Scientific Advisory Board for the World Federation of ADHD.