There is no shortage of information regarding ADHD. Instagram and TikTok are full of “experts” who talk about what ADHD is and how to manage it. But, after decades of scholarly research, those of us who regularly assess and treat ADHD can tell you something about the condition that you may not have heard before. ADHD is not only about attention deficit, and may not primarily be about attention at all.
Awais Aftab, in his article “A.D.H.D. Is Not Necessarily About Attention,” published in The New York Times, says that evidence supports the clinical approach I’ve taken for years. We need an expanded understanding of and approach to the root cause of ADHD: emotion dysregulation.
Emotion dysregulation means having trouble managing strong emotions in a way that fits the situation. While this expands our understanding of ADHD, it does explain commonly associated issues with attention and focus. Emotion regulation plays a key role in executive functioning. This means that when people cannot regulate their body movements, manage their emotions, or organize their thoughts, it’s extremely difficult to focus or to sustain attention for periods of time.
Identifying emotion dysregulation as the core issue also helps us understand why so many conditions co-occur with ADHD. Emotion dysregulation is responsible for increasing anxiety, problems with anger, and mood instability. When I speak with clients about assessing and treating their ADHD, I tell them that not only are we identifying ADHD as a problem affecting their functioning, we are attempting to prevent the onset of mental health conditions that could affect their behavior, their relationships, and their ability to carry out many activities of everyday life.
Treatment for emotion dysregulation remains controversial. Many psychiatrists and psychologists believe that medication is an important part of effective treatment. Aftab’s article cites research stating that children under the age of 12 who are treated with medication improve in attention and emotion regulation, and that medication early on increases frontal lobe development.
The best results seem to occur when therapy to teach coping strategies is paired with medication, and people learn and practice the strategies while the medication is active in their system. I can attest that children seen as outpatients for therapy, whom I teach “coping skills” for self regulation, are often unable to effectively use those coping skills in real life because they either cannot remember them or their emotions escalate too quickly. Even adults diagnosed later in life have trouble establishing a regular use of strategies to prevent the expression of intense emotions, such as anger, without supportive medication. However, while children benefit from medication within the structured school environment, adult clients who were diagnosed as children often state that they don’t feel the need for medication once they’re finished with school.
Aside from medication and the development of coping strategies to manage intense emotions, executive function coaching is the next best intervention to pursue. Executive function includes emotional regulation, as well as attention, working memory, organization, initiating difficult or tedious tasks, and sustaining focus until the task is completed. Coaches need to have special training to work with individuals with ADHD because strategies designed for neurotypical people are often hard to acquire, and the coach needs to know how to pivot when something isn’t working. Executive function coaching is often as effective or more effective than therapy for individuals with ADHD, unless there are accompanying mental health conditions, such as anxiety and depression. In this case, both are recommended interventions.
I hope that more people will recognize that ADHD is a condition primarily characterized by emotion dysregulation, which can present as issues with attention and focus. This approach highlights the importance of diagnosis and treatment, because emotional regulation is also an important component of mental and physical well-being in general. It is not enough for people with ADHD to be “functional,” whether academically or professionally. They should also have the tools and support they need to manage their emotions.
