We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids podcast from the Association for Child and Adolescent Mental Health, known as ACAMH. Today we're talking about ADHD as we look at why so many young people with ADHD struggle, not just with attention or impulsivity, but with management of their emotions. And what does that mean for their self-esteem and mental health? I'm Mark Tebbs. I'm your host for today. Spent my whole career working in mental health, from frontline service delivery to director of mental health commissioning. I'm currently a chief executive of charity, and I'm a trustee of a mental health organisation and also a career coach. I'm really pleased to be hosting these podcasts. It gives me the opportunity to speak to some of the leading clinicians and academics in the forefront of children and young people's mental health. So if you're a clinician, if you're an educator, a parent, or just curious about mental health, I hope these discussions leave you with some fresh insights and practical tools to help. Don't forget to subscribe where you get your podcasts from. And also, on your YouTube channel, just search ACAMH, and you'll find us across all socials. I'm delighted to be speaking to Professor Aja Murray from the University of Edinburgh about the links between ADHD and emotional regulation. We'll be discussing Aja's research on the topic, exploring what emotion dysregulation can actually look like for adolescents with ADHD and how it can chip away at self-esteem over time. We'll also get into rejection sensitivity dysphoria, a concept that's generated a lot of conversation within the ADHD community right now, and how it ties back into emotional regulation difficulties. Plus, we'll look at practical implications, what young people with ADHD and the people supporting them can actually do to help, the crucial role parents and caregivers play, and why supporting them matters so much. I'm very pleased to be talking with Aja. Welcome to the podcast. Lovely to be speaking to you today. Lovely to be here. Thank you very much. Great stuff. So let's start with some introductions. It'd be great if you could introduce yourself. And maybe there's an opportunity to do a little bit of a name check for any colleagues that you worked with on the paper. Sure. So I'm a professor of developmental psychology at the University of Edinburgh. And I'm going to be talking about, actually, a whole programme of research, for which there's many different people to name, all on the topic of emotion dysregulation in ADHD and how that relates to mental health issues, particularly talking about our project funded by the Medical Research Foundation and working with colleagues, in particular Dejla Hoxha and Daria Melashenko and Amanda Russell. Great stuff. Right. Yeah. So before we dive into that research, it'd be really great if we could just define some of the terms. So when we're talking about-- what do we mean by ADHD? How do we define that term? So yeah, that's a really good place to start. So I think a key term to define here is ADHD. So ADHD stands for Attention Deficit Hyperactivity Disorder. It's characterised by difficulties with attention, so, for example, having difficulty with concentrating, tending to be quite distracted, and/or hyperactivity and impulsivity. So hyperactivity relates to feeling quite restless, having difficulties with sitting still. And impulsivity relates to, for example, engaging in behaviours without really fully thinking them through. We think that ADHD can be diagnosed in up to about 8% of children and adolescents globally. But at the same time, these traits are in a continuum, so there's likely to be many more young people who are affected at what you might call subclinical levels. And emotion regulation is really relevant for ADHD, actually, because it's really common for young people with ADHD to experience difficulties with regulating their emotions. Those difficulties are not a core symptom of ADHD, but they are a commonly-associated feature. And what emotion regulation really means is the whole set of processes that we use to keep tabs on our emotions and to change our emotions to meet some kind of goal. That could be something like engaging in socially-appropriate behaviour, getting a task done, or it could simply be to feel less bad or to feel more good. When emotion regulation goes wrong, we see emotion dysregulation. And because emotion regulation is this really multistage, multifaceted process, there's quite a lot of different parts that can potentially and go wrong. So it could be to do with having difficulties identifying what you're feeling, labelling what you're feeling, choosing strategies to deal with those emotions. Or it could be to do with how well you can implement those strategies as well. It can look things like overly-intense emotions, quite changeable emotions. That's called emotional lability. Or it could actually be where emotions are quite persistent. So after you feel upset by something, it might take a long time to then come back down to baseline. And then, finally, it might look like emotionally-driven behaviours, like lashing out. And it can manifest in different ways in different people-- as I say, a multifaceted concept. Brilliant. OK. So you've defined ADHD and emotional regulation. I think your research is really focusing on ADHD, emotional regulation, and the linkages with mental health outcomes. So could you just tell us a little bit more about your research projects? So a key aspect of the work that we do in our research group relates to understanding the linkages between emotion dysregulation associated with ADHD and mental health outcomes. We're interested more broadly in the links between ADHD and mental health, but we really focus quite a lot on emotional dysregulation because this is such an important part of that story. And so we use methods that look at, for example, the ways in which emotion regulation might manifest on a day-to-day level, capturing emotion regulation processes in the course of daily life using methods like ecological momentary assessment. And what that means is that, essentially, our participants are asked multiple times a day, at random points, what they're thinking, feeling, and what emotion regulation strategies they might be using. And from that, we can gain an understanding of how emotion regulation processes play out in daily life and how that, in turn, affects mental health. We also look at the links between emotion dysregulation and mental health at a more developmental level, using longitudinal data to understand how emotion dysregulation might sit on the pathway developmentally from ADHD symptoms to later outcomes, like anxiety and depression. And what we've found, to boil it down to some key findings, is that emotion dysregulation is a really important linkage in the pathway between ADHD symptoms and an elevated risk of mental health outcomes. And we've also managed to identify some specific facets of that that seem to be particularly important. For example, we have identified how tending to get in negative cycles of rumination and negative emotions is something that particularly characterises emotion regulation difficulties associated with ADHD. You've touched on it briefly, but in more detail, what are the impacts of emotional dysregulation for adolescents with ADHD? And how can emotional dysregulation affect the self-esteem of those with ADHD? Yeah. So work by our group and by others as well has really shown that emotion dysregulation associated with ADHD can have quite wide-ranging impacts. One of those impacts would be an increased risk of difficulties with peers. This can happen because for a young person who's experiencing emotion dysregulation, they might have difficulties with social behaviours. So if they're in a state of emotional arousal, it might be quite easy to miss social cues, for example. It might be difficult to wait your turn because you're overexcited. And as a consequence, a young person who's experiencing emotional dysregulation might be perceived by their peers as being maybe too intense, maybe disruptive, maybe overexuberant. And that can lead to them being disliked or rejected, unfortunately. Unfortunately as well, for young people who experience emotional dysregulation, they might be seen as a target for victimisation because their peers might think that they can get a more explosive reaction to winding them up. So there's a whole cluster of different peer difficulties that can be associated with emotion dysregulation. Those difficulties with peers is one way in which emotion dysregulation can impact mental health and self-esteem. But there also seems to be more direct impacts between emotion dysregulation and mental health outcomes as well due to the negative emotional consequences of being dysregulated. But looking beyond mental health as well, it's been shown to be related to difficulties with relationships, with academics, and a whole range of different areas of functioning, I think just reflecting the fact that emotional functioning underpins so many different domains of functioning in life. Yeah. The concept of sensitivity dysphoria is gaining a lot of attention within the ADHD community. So could you explain what that is and how it might link to the ADHD and emotional regulation that we've been talking about? So rejection sensitivity dysphoria refers to anxiously or angrily anticipating being rejected. And actually, ironically, this can lead to something of a self-fulfilling prophecy, where young people actually bring about the very outcome that they're worried about because of the way that they react to that anticipation by becoming angry, by seeking reassurance too much. And that can be a bit off-putting for peers and actually lead to the rejection that they're worried about. So previous work has shown that although rejection sensitivity dysphoria isn't unique to ADHD, it does seem to be elevated in ADHD. And within the ADHD community, lived experience experts really emphasise how much rejection sensitivity dysphoria is an important factor for them, something that really causes them a lot of distress. And actually, as part of our project, our lived experience advisory group advised us to include a measure of rejection sensitivity. So we did. And what we found so far is that rejection sensitivity dysphoria is related to more negative emotions in daily life, showing the negative emotional impact of experiencing rejection sensitivity dysphoria. But the good news part of that is that if you have positive peer interactions, that seems to buffer against that negative effect. So that suggests that if young people can be taught to include, accept their peers with ADHD, then that can reduce this emotional burden associated with rejection sensitivity dysphoria. So it'd be really interesting if we could talk about some of the practical implications of the findings that we've been talking about. Yeah. So I think what our research has very much shown is that emotional dysregulation is really important for not just mental health, but a range of different outcomes. And that points to emotional dysregulation as an important target for intervention. And the good news is, we do know from other work that emotion dysregulation is something that is modifiable and that emotion regulation skills are things that can be learned. And with practise, they can become a habit. So what we can do is, we can help young people with ADHD to learn about different emotion regulation strategies that are available to them to become more aware of what emotion regulation strategies they tend to use by default and to encourage them to use emotion regulation strategies that are more helpful and more productive and, on the other hand, to avoid the ones that are less helpful. To give you an example, if young people can learn to use techniques like cognitive reappraisal, which means thinking differently about a situation to have a more balanced view, rather than defaulting to a negative interpretation, that can be really helpful for mental health in the long term. On the other hand, strategies like rumination, which is just thinking repetitively in a negative way, very emotion-focused way about an emotionally-evocative situation in a way that doesn't really lead to problem solving-- it doesn't really progress you. It just gets you stuck in this negative loop. We know that that's not good for mental health. But at the same time, young people with ADHD can learn how to tackle ruminative tendencies through things like learning to identify what their triggers are, to make a plan for how they're going to redirect their attention when rumination does arise so they're able to catch it and deal with it, and to teach things like problem-solving so that any thinking that does happen in relation to an emotionally-evocative situation is much more directed towards a solution rather than just this kind of negative cycle that doesn't get you anywhere. And so actually, part of the work that we're doing is translating some of our findings into practical tips about learning these types of emotion regulation strategies and, for grown-ups, some advice on how you can support young people to develop these strategies as well. So it's clear that for young people with ADHD who might struggle with emotional dysregulation-- and that can have really serious and negative impact. So what can young people with ADHD or those around them do to help the situation? I think a really key thing is to remember that emotion regulation skills can be learned, like any other skill. And so for a young person who might be struggling with emotion dysregulation, it's not hopeless. There are skills that you can invest in to alleviate that emotion dysregulation. So I mentioned a couple of examples before. So I mentioned the example of cognitive reappraisal, which is the skill in thinking differently about an emotionally-evocative situation and different strategies for avoiding rumination. We can also think about strategies like acceptance, which is allowing yourself just to feel a feeling, not judge yourself for it, not beat yourself up for it, not feel ashamed of that feeling, which is another really important skill for emotion regulation that can improve mental health in the longer term. And likewise, we can think about strategies like learning breathing techniques, so, for example, the technique of square breathing, which is where you basically breathe in for four, hold it for four, breathe out for four, hold it for four. And then you start that cycle again. And that basically hacks your physiology in order to make you feel more relaxed and calm. Another example that I really like for ADHD is grounding. And that's because it's quite simple to remember, and it's something that you can do almost anywhere and almost any situation. And it's where you, first of all, focus on five things that you can see, four things you can feel, three things you can hear, two things that you can smell, and then one thing that you can taste. And the idea is that it just brings you back to the present moment when you're feeling in a bit of a state of emotional overarousal. The key thing, though, is really about being able to have a repertoire of different emotion regulation strategies that you can use in a way that's flexible and in a way that you can match the strategy to the particular situational demands. And, of course, practise makes perfect. So do keep trying these strategies in real-life situations so that they become more of a habit. I guess it's like acquiring the skill in a nonstressful situation, and then you can apply it when you really need it. And I'm thinking about parents and caregivers. What's the messages that you would give them? Yeah. So parents and caregivers can play a really important role in supporting their child's to develop their emotion regulation skills. So, of course, parents and caregivers can work directly with the young person to help them learn about emotion regulation and develop those skills and encourage them to practise. What they can also do is actually invest in their own emotion regulation skills as well in order to be able to model helpful ways of dealing with emotions. I also think it's really important for parents and caregivers to learn as much as they can about how the ADHD brain processes emotions, because that insight that the ADHD brain does tend to generate more intense emotions and will struggle more with implementing strategies to deal with those emotions can just help grownups to perhaps be a bit more able to accommodate and be aware of the specific needs of the ADHD brain when it comes to emotion regulation. Another way that parents and caregivers are quite important, in terms of shaping emotion regulation, is how they react to expressions of emotion in their young person. So, for example, if a young person expresses an emotion and they get a reaction that is dismissive, that is an angry reaction, or some other kind of invalidating reaction, then what that can do is it can encourage the young person to adopt emotion regulation strategies that might not be particularly helpful. So it might lead them to develop a habit of trying to suppress emotions, avoid emotions, or feel ashamed of or reject their emotions, which ultimately are not going to be very good for emotion regulation and longer-term mental health. So some great advice for our listeners that I'm sure many people will be able to put in practise. So I'm also interested in positive emotions. How does this relate to the emotional regulation of positive emotions? Yeah. So emotion regulation isn't just about feeling less bad. It can also be about regulating positive emotions as well. So one aspect of this relates to emotion regulation strategies that are not so much about decreasing negative emotions but are more about increasing positive emotions. So that could be strategies like noticing positive events or positive emotions more, savouring those, or sharing positive things that you notice. And all of those can help prolong or intensify positive emotions. And, in fact, we often see these kind of techniques as part of what are called positive effects interventions. These might be quite helpful in ADHD, actually, because what we found in our research is that declines in positive emotion actually precedes increases in difficulties with attention. So it might actually be that if there is a moment where a young person with ADHD really needs the concentration to be as good as possible, maybe doing a quick, positive emotion regulation strategy to increase their positive emotion could be quite helpful to perform, like if it's a test or something like that, where concentration is needed. But there is also another aspect to this. And it is that some research has found that mobility and positive emotions or having quite changeable positive emotions is related to social difficulties in ADHD. And this might come back to what we were talking about before about how dysregulation of positive emotions might lead to difficulties with missing social cues or getting overexcited and therefore not waiting your turn in conversation, talking too much, that kind of thing, the sorts of things that could lead to difficulties with peers. So there is also potentially an element where it could be helpful to learn how to regulate positive emotions as well, not just from the point of view of increasing positive emotions, but also keeping them a bit more even over time as well, reducing that lability. It's interesting. There's been a lot less research on positive emotion regulation, I would say, than negative emotion regulation, because I think there are-- I suppose understandably-- has been more interest in how do you reduce your negative emotions than how do you increase your positive emotions. So I would say there's still ongoing research about what strategies are effective for that. But the main ones that seem to be having shown to be effective would be noticing positive things in the first place, savouring those things, sort of like really holding on to those things, and sharing those things with another person, so using social sharing. If you experience something positive, tell someone about it. The other types of things that seem to be quite helpful is actually just engaging in things that are fun, which sounds really straightforward, but we often neglect doing fun things because we have boring or important things to do first, so actually, just scheduling time to do something that you enjoy yourself with another person, whatever configuration, is another technique that often appears in these positive-effects interventions, they're called. Yeah. That's so interesting. I'm just wondering about any sort of gender differences, whether there are any significant differences in relation to emotional regulation and emotional dysregulation and ADHD symptoms. So we know more generally that girls are more vulnerable to emotional difficulties. There's been a bit less research on this in relation to ADHD symptoms more specifically, which probably reflects the historical focus on ADHD research in boys. But we do know from our work that both boys and girls do experience emotion dysregulation. And actually, when we've compared boys and girls directly, we don't see much of a difference in terms of their negative emotions day to day. We do see that for both boys and girls, emotion dysregulation sits on the pathway between ADHD symptoms and mental health issues. So it is a mechanism which increases mental health issues for boys and girls. And so there may well be gender differences in the manifestation of emotion regulation difficulties or severity and the implications for outcomes. But I think probably the more important finding and the more important takeaway is that it is something that affects both boys and girls with ADHD. There's been next to no research on any other genders. So that's almost a completely unexplored territory of research as well. So what are the next steps for your project? So I guess we've presented a bit of an early view of some of the emerging findings from our projects, but we are still analysing the data that we've collected. So I do think there's going to be many more insights to come. So, for example, in addition to some of the findings that I mentioned, we're also looking at factors, such as relationships with significant adults and how that shapes emotion dysregulation. So we're looking, for example, about how relationships with teachers and the quality of those, how that affects emotion dysregulation in adolescents with ADHD. We're also looking at how the presence of autistic traits might affect emotion dysregulation for adolescents with ADHD as well. At the same time, we're also working on translating our findings into practical resources aimed at young people, but also those who support them, so resources and training for parents and caregivers, schools, clinicians. I think we're going to be sharing some information, some of this through ACAMH Learn as well. So I guess watch this space. And we've also developed an emotion regulation app which aims to help young people with ADHD symptoms and emotion dysregulation to learn emotion regulation skills, including some of the ones that I talked about today, through a series of interactive modules. We're doing all of this, of course, in close collaboration with young people with ADHD and those who support them to try and make sure that the resources that we produce are relevant and helpful for those who are most affected. And actually, I will say, if there is anybody who's listening who maybe is a young person with ADHD or who supports a young person with ADHD, we're always very open to collaboration and input. So I think we'll have our details in the podcast description, I'm assuming. And we can also put some links to our research and other resources in there as well. And so just before we let you go, Aja, could you just give us a one final take-home message? And so I'm going to cheat a little bit, and I'm going to give you two points. The first is that emotion regulation is really important for mental health being and broader outcomes. But it can be learned as a skill. And it's really worth investing in learning emotion regulation skills. It's been great talking to you, Aja. It's really insightful stuff. Thank you so much for your time. I guess what I've learned from today is that emotional dysregulation is really common and an important feature for many young people with ADHD. It plays a significant role in mental health, in relationships, in school experiences, and overall well-being. Aja's research shows that emotional difficulties are not simply an add-on to ADHD but a key pathway through which ADHD symptoms contribute to challenges such as anxiety, depression, peer difficulties, and low self-esteem. The encouraging message is that emotional regulation is a skill that can be learned. Strategies such as cognitive reappraisal, grounding techniques, acceptance, reducing rumination can all help young people manage emotions more effectively. For me, it's a key, how supportive relationships are, from positive peer interactions to the role of parents, caregivers, teachers, and other trusted adults in modelling those kind of healthy emotional responses. So that's the end of my series, Mind the Kids. I hope you've enjoyed it. It's been a real honour and pleasure to talk to so many people from across the globe, working to help children and young people. Next week, Dr. Jane Gilmour and Professor Umar Toseeb return. And I'll see you again in a few months. [RELAXING MUSIC]