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“We Are Negligent When We Overlook Emotional Dysregulation in ADHD”

“Emotional dysregulation is not new — to my daughter or to any other person with ADHD. But it was an aspect of ADHD that took me a long time to fully appreciate.”

By Gilly Kahn, Ph.D. Updated on August 22, 2024
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I can still vividly recall my daughter’s meltdown during a trip to the Georgia Aquarium. As I sensed she was on the verge of losing it, it felt like someone scooped out every organ in my body. Still, I was fresh out of parent coaching training, and here — right in front of the otters’ exhibit smack in the middle of a giant aquarium — was an opportunity to show off the skills I learned. But, boy, did my daughter put on a show. She screamed and screamed, her tiny body thrashing against the aquarium floor, until her face turned red and her hair clung to her sweaty forehead.

Parent training didn’t prepare me for this. My husband and I stood there, quietly whispering to each other for an excruciating 20 minutes until our daughter finally calmed down. In that time, I was desperate for the screaming, the stares, and others’ well-intentioned, albeit unhelpful, suggestions (to give her a snack or a drink) to stop. This was not the highlight of my mothering career.

Eventually, all those things did (thankfully) come to a halt. My baby stood up quietly after her meltdown, looking disoriented. Then, she stumbled in my direction and finally held my hand instead of running ahead of us like we asked her to, which is what led to the whole fiasco in the first place.

Emotional Dysregulation: A Core But Overlooked Part of ADHD

Emotional dysregulation is not new — to my daughter or to any other person with ADHD. But it was an aspect of ADHD that took me a long time to fully appreciate.

The problem is that the diagnostic criteria for ADHD intentionally exclude emotion dysregulation, despite it being historically conceptualized as a crucial characteristic of the condition. Emotional dysregulation was written about as an issue related to ADHD symptoms as early as the 1700s up until 1968, when the diagnosis of hyperkinetic reaction of childhood was first introduced in the DSM-II. Around this time, emotion dysregulation started to become a forgotten part of the equation for ADHD, and public discussion of ADHD-fueled tantrums and angry outbursts all but halted.

[Get This Free Download: 9 Truths About ADHD and Intense Emotions]

This is why, despite my psychology graduate coursework and training in ADHD, my daughter’s behavior was still confounding. On the one hand, I knew that she struggled with ADHD from an early age because her symptoms were consistent with current diagnostic criteria. On the other, her obvious emotional challenges compared to other girls and children her age, were not reflected in the DSM.

Could My Daughter’s Intense Emotions Be a Sign of DMDD?

Adding to my confusion was the fact that emotion dysregulation isn’t exclusive to ADHD. For example, children with disruptive mood dysregulation disorder (DMDD) display irritable mood and emotional outbursts that could be verbal or physical and that occur at least three times per week. It is a condition that goes beyond temper tantrums.

DMDD was added to the DSM-5 because mental health professionals were over-diagnosing bipolar disorder, a condition that causes extreme changes in mood in children. DMDD was meant to account for children who didn’t quite meet criteria for bipolar disorder, and who presented with more general irritability.

Without much mention of emotion dysregulation’s connection to ADHD in my training and in what doctors told me, my daughter’s intense emotional responses made me wonder — could this be a case of DMDD, too?

[Self Test: Does My Child Have Disruptive Mood Dysregulation Disorder?]

The Truth About ADHD and Intense Emotions

William French, M.D., explains that the key to differentiating between DMDD and emotion dysregulation as a part of ADHD is the child’s mood between temper outbursts. Children with ADHD (and adults, too, for that matter) experience emotions intensely, but these emotions are not all negative.

Individuals with ADHD can also be incredibly excited or calm between emotional outbursts. Russell Barkley, Ph.D., says the reason the negative emotions get so much attention is because they lead to obvious social and functional challenges. While someone with ADHD experiences various emotions between periods of intense negative emotional outbursts, a person with DMDD has more persistent irritable mood between episodes.

Without a shred of doubt, I understand today – though it took lots of time and headaches to get here – that my daughter’s intense emotions are part of her ADHD.

But in my own practice, where I see neurodivergent youth, I increasingly see patients come in with an ill-fitting DMDD diagnosis. As I’ve become more and more self-educated about ADHD and emotion dysregulation, I’m convinced that many clinicians, misled by current diagnostic criteria, may be readily misattributing this central feature of ADHD to DMDD.

This is a problem, for one, because inaccurate diagnoses delay access to life-changing treatment and can cause further health complications. In addition. whether we’d like to admit it or not, certain labels carry heavier stigma than do others. Before they see me, many children with the DMDD diagnosis are turned away from other private practices, deemed too “severe” to treat. Children can also be inappropriately judged by schools when they are given labels reflecting severely dysregulated mood.

It’s important to remember that the DSM, in general, aims to simplify. But, far from simple, human beings are nuanced, and so is the way ADHD presents.

If diagnosticians took a step back and actually looked at the ADHD brain and listened to the lived experiences of individuals, maybe then they could start to understand those who are so unnecessarily misjudged, like my daughter could have been.

ADHD and Intense Emotions: Next Steps

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