Understanding the Associated Features of ADHD

Learn about executive dysfunction and emotional dysregulation as common and clinically meaningful features of ADHD that extend beyond core symptoms and contribute to functional impairment across multiple areas of daily life.

Welcome to “Beneath the Surface: The Importance of Assessing Executive Dysfunction and Emotional Dysregulation.” I'm Dr Greg Mattingly, an associate clinical professor at the Washington University School of Medicine and the immediate past president for the American Professional Society of ADHD and Related Disorders. Today, we're going to talk about executive dysfunction and emotional dysregulation in ADHD clinical settings. We're going to talk about 2 very important but very related topics in the field of ADHD, and that is digging beneath the core symptoms, those 18 symptoms that we all memorized in medical school or nursing school. Those symptoms of inattention, impulsivity, hyperactivity, the symptoms that make the diagnosis. Beyond those 18 symptoms, though, we have to have levels of impairment. Quite often, what we find is the impairment comes from executive dysfunction and emotional dysregulation.

Let's dive into a little bit of a discussion about executive function. Quite often, clinicians will think that executive function purely means memory, retrieval of memory, maybe planning for the future, but executive dysfunction goes far deeper than that. Executive dysfunction includes things such as working memory. Can I recall what I'm having to work with, what I'm doing next week, the memories that I just stored? Can I retrieve those and use those? Some people will think about it as planning for a strategy, thinking about tomorrow, thinking about the future, anticipating events that are coming up. Beyond working memory, we talk about shifting. My ability to stay engaged with an activity that I need to stay engaged with, but then shift to another activity, perhaps a non-preferred activity, an activity that has less stimulation, it's less rewarding, but I know it's something that I must get done. Many of our patients with ADHD will have difficulties with shifting. In common man's words, it's called procrastination. "I'm very good at the things I find interesting, but it's very difficult. I tend to put off the things I don't find interesting. My brain just won't stick with those, Dr Mattingly."

Beyond that, we see that there's a group of people that have difficulties with planning in a different sense, and this is planning with regards to timelines, a term we call time blindness. So, that ability to store the time that I'm at, be able to plan for the future, to get my tasks done on time, to anticipate the amount of time that I may have, versus I tend to run late, I tend to forget things, I tend to get overwhelmed by this, and I tend to have difficulties with time management. In addition, we talk about something called inhibitory control. Inhibitory control is the ability to stop doing things that I shouldn't be doing or inhibit myself from responding to things that I find frustrating or want to partake in. So, inhibitory control could be getting frustrated at work and being able to say, "Listen, don't react. It's time to stay calm." Inhibitory control could be staying with something that you find monotonous or slightly boring, but it's a task that I need to complete. Organizing my apartment, paying my bills, sticking with something that I know I need to complete without shifting over to something else.

Quite often, we think about these areas, about executive dysfunction. Another term we talk about is the signal-to-noise ratio. Being able to stick with a signal and not get distracted by the noise around me. Another way we think about this is top-down control. Top-down control from the prefrontal cortex going down to deeper cognitive structures such as the anterior cingulate on down to the amygdala. Thoughts become emotions, become actions. So, when executive function is working well, a thought can modulate my emotions, can modulate my actions. It's time to go ahead and get my homework done. I should stop playing video games. I should not get frustrated by it. It's time to sit down and pay my bills. I need to avoid the distractions around me. I need to stay on time. I need to make this appointment. I need to show up when I'm supposed to be with someone else. That ability to manage time and time commitments.

When we think about executive dysfunction, we know that it can be linked with ADHD symptoms, but quite often it runs over and above those symptoms. In another section, we're going to talk about treatments and how treatments can sometimes help with core ADHD symptoms but may leave those executive dysfunction symptoms still wanting. Tightly linked with executive dysfunction is an area we talk a lot about in mental health. That is, our patients quite often don't come in with just ADHD, they come in with emotional frustration. The term we talk about is emotional dysregulation in response to stress, in response to frustration, in response to being told no or having to shift from one action to another, I become frustrated. This can manifest as emotional lability. Someone who blows up in the heat of the moment. After that moment, the blowup's gone, but everyone around them is less than awake.

It can look like outer irritability. I become irritable. I become aggressive. I become hyper-aroused. I have a heightened irritability. It can be emotional reactivity, reactivity in response to stressors, frustrations, but also emotional reactivity in response to social situations. A breakup, a friendship, where our patients with ADHD will quite often have this emotional over-reactivity that's part of their brain's ability trying to harness executive function. Finally, we talk about the ability to go back to your baseline. So, resilience is being able to encounter a stress, deal with a stress, but then return to a baseline in a resilient status. Many of our patients with ADHD are left with a sense of emotional distress, emotional frustration, emotional dysregulation, heightened irritability. This can lead to misdiagnosis, over-diagnosis, or sometimes a clouding of the diagnosis of ADHD, where other symptoms associated with emotional dysregulation may have been picked up on instead of the underlying ADHD.

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.