Self-Regulation in Children with ADHD, ODD, and OCD

Introduction

Self-regulation in children and adolescents who suffer from ADHD, ODD, and OCD (Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Obsessive-Compulsive Disorder) is frequently impaired due to several interconnected factors. Many of the issues related to self-regulation stem from the additional anxiety children and teenagers experience as a result of the difficulties these mental disorders produce. OCD is known to cause anxiety and isolationist behaviors, leading to decreased emotional self-regulation. ADHD can at times cause hyperfocus, making it difficult for the child or adolescent to switch tasks, thereby limiting their ability to manage their emotions and engage in activities that support self-regulation. ODD, which is closely associated with ADHD, is a disorder in which children react angrily and spitefully to people in situations that would normally elicit measured responses. The extreme emotions of children or adolescents who manifest ODD make it hard for them to respond to circumstances in a rational and balanced way.

Children who experience OCD are often compelled to repeat fixed, defined patterns in order to rid themselves of distressing thoughts. Self-regulation among children who suffer from this disorder is very difficult to attain because of the repetitions and obsessions that preoccupy their minds and, in more severe cases, dominate their lives. Children experiencing OCD often report increased sensitivity to external events, especially when they are outside their comfort zones and unable to perform their rituals. Additionally, they lack objective reasoning, which can further limit self-regulation by causing the child to focus on things that heighten or perpetuate negative thoughts and behaviors. Many theories exist about why behavioral disorders develop, but few thoroughly explain or connect actions and behaviors to these disorders — especially in young children, who are often not diagnosed until later in childhood.

Hyperfocus, exhibited by children with ADHD, is an intense form of mental concentration (Wong & Butler, 2012, p. 141). Some topics may elicit daydreaming in children who engage in hyperfocus. This heightened concentration limits what is otherwise easily achieved by children without mental disorders — such as multitasking, paying attention, and socialization. Socialization, as an aspect of self-regulation, requires the child to engage in several simultaneous activities, including observing, talking, responding, and thinking. When engaged in hyperfocus, the child can only pay attention to one thing and is easily sidetracked. Hyperfocus is one theory explaining why self-regulation appears to be particularly difficult for children who exhibit ADHD tendencies.

Self-regulation is a broad label encompassing several activities across different domains, all pertaining to controlling one's emotions, thoughts, actions, and responses. In sociology and psychology, self-control is understood as representative of self-regulation (Campbell, 1990, p. 118). In educational psychology, self-regulated learning constitutes a major component of self-regulation. Self-Regulation Theory (SRT), a system of conscious personal health management, can also apply to how a child manages their hygiene and nutrition. Self-policing — another form of self-regulation — applies to how a child may respond to external stimuli arising from society, authority figures, or peer interactions.

Social Theory and Analysis of Self-Regulation

Self-control is the ability to manage one's emotions, behavior, and desires in pursuit of a potential reward or to avoid punishment (Wong & Butler, 2012, p. 141). In psychology, it is often referred to as self-regulation. Children who suffer from OCD, ADHD, and ODD frequently lack self-control. Children with OCD become so consumed by rituals that they cannot stop even when a reward or punishment is imminent. They are controlled by their behaviors, not the other way around. The mechanism driving these behaviors reinforces the belief that failure to engage in the obsessive-compulsive tendencies will result in greater punishment.

Children with ADHD cannot focus on the punishment-and-reward aspect of self-control and instead view only whatever they find interesting in the moment as a reward. They cannot control what they attend to, and if they do focus on something, they struggle to redirect that focus elsewhere. This lack of self-control supports the theory that self-regulation is a pervasive challenge in children with ADHD.

ODD makes self-control difficult by preventing children from handling emotional situations in a typical fashion. Anger and aggression are exacerbated in children with ODD, causing them to react more harshly and with greater sensitivity than peers without the disorder. The absence of effective reasoning — that is, the inability to regulate emotions when confronted with social situations — is a strong indicator of decreased self-control and, therefore, impaired self-regulation. Aversive stimulation may increase the desire for self-control in children with ODD, ADHD, and OCD, but further research is needed.

Self-regulated learning (SRL) is learning guided by metacognition, strategic action, and motivation to learn. Metacognition refers to self-reflection — thinking about one's own thinking. Strategic action consists of monitoring, planning, and self-evaluating personal progress against a known standard. Self-regulated learning involves taking the process of learning and applying it to oneself through one's own actions (Scott, 2008, p. 63). Self-regulated learners direct, monitor, and regulate themselves toward goals of gaining knowledge, expanding expertise, and improving performance. They are aware of both their academic strengths and weaknesses, and they draw on an internal repertoire of methods and approaches to manage the daily challenges of academic tasks (Zelazo, 2013, p. 181–190).

Self-regulated learning is virtually nonexistent in children with ADHD. They are often far too distracted to develop or apply learning strategies. When they attempt to apply acquired knowledge, they frequently become stuck or confused, unable to interconnect the multiple areas of information required to absorb, evaluate, and use what they have learned. The same applies to children with ODD.

ODD keeps children focused on emotional relief and satisfaction, as they become agitated by people or situations with relative ease. Another feature of this disorder that undermines self-regulated learning is the lack of personal responsibility children with ODD take for their actions. Self-regulated learning requires constant self-evaluation and reflection. If children with ODD cannot self-evaluate and reflect on past behavior, they cannot learn from it or determine what they need to do to improve.

Children with OCD are not entirely unable to engage in self-regulated learning. They can reflect and self-evaluate, but they do so through a rigid and inflexible thought process. OCD narrows what they can consider or explore in relation to what they observe or experience. In this way, they are unable to fully apply self-regulated learning because they cannot maintain an open mind to incoming information. They may devise strategies to cope with learning tasks, but they ultimately become trapped by their compulsions and cannot execute those strategies broadly.

Emotional self-regulation — or the regulation of emotion — is the ability to respond to the ongoing demands of experience with an appropriate range of emotions in a socially acceptable and adequately flexible manner, allowing for both spontaneous reactions and the capacity to delay responses as needed. The definition also encompasses the intrinsic and extrinsic processes responsible for evaluating, monitoring, and modifying emotional responses (Zelazo, 2013, p. 181–190). Emotional self-regulation is part of a much broader set of emotion-regulation processes, which includes regulating both one's own emotions and one's responses to others.

Emotional regulation is an intricate process involving the initiation, inhibition, or modulation of one's behavior or internal state in any given situation. Because of its complexity, children with ADHD often cannot manage the various cognitive demands involved in considering their own feelings and those of another person simultaneously, let alone regulate those feelings. Children with ADHD frequently cannot see past the immediate situation and therefore struggle to develop awareness of what they are doing or feeling in the present moment. Even when they are paying attention to their surroundings, they may be easily distracted.

OCD presents a similar problem in that it monopolizes much of a child's conscious attention. Rather than focusing on how to respond to an emotional situation or to the feelings of another person, the child is preoccupied with the anxiety of not performing rituals and the tension-and-release cycle that defines compulsive behavior. Unlike ADHD, where anything and everything may serve as a distraction, in OCD the obsession itself becomes the sole distraction.

ODD narrows the range of emotions children can access and express, thereby reducing their capacity for emotional self-regulation. Children with this disorder predominantly experience and act from negative emotions — hate, anger, and spite — and as a result are unable to draw on the broader emotional vocabulary necessary for learning emotional regulation, including compassion, forgiveness, and temperance. Children whose behavior patterns are associated with ODD cannot distinguish their feelings from their hypersensitive reactions, further inhibiting their ability to self-regulate.

Literature Review

Self-policing is a process whereby a group — whether defined by industry, profession, or peer affiliation — monitors its own members to ensure adherence to accepted norms (Zelazo, 2013, p. 181–190). As applied to children, it allows them to learn, within a group setting, how to accommodate others' needs, demands, and expressions. It is an essential social skill frequently employed in organizations and institutions. When children exhibit mental disorders such as ADHD, ODD, and OCD, this skill often appears absent, as the children lack the capacity to implement techniques for evaluating their own behavior in relation to others.

These self-regulatory mechanisms collectively contribute to the social cognitive theory of self-regulation. Analysis of these mechanisms reveals the inherent difficulty in achieving self-regulation when mental disorders such as ADHD, ODD, and OCD are present. Determining whether children with these disorders can function within the constructs of self-regulation without treatment — including prescription medication — requires additional research. The literature review that follows provides a clearer picture of what is lacking in current research and what biological and psychological causes may be responsible for the emergence of these disorders.

This literature review focuses on gaps in research pertaining to ODD, ADHD, and OCD, and on how self-regulation is impaired in children and adolescents who exhibit behaviors characteristic of these disorders. The literature also reveals pertinent information about ways teachers and medical professionals address the challenges associated with each disorder in order to improve the self-regulatory mechanisms of affected children. The review is organized as follows: ADHD and related studies, OCD and self-regulation research, and ODD and its effects on children.

In an article by Blum, Chen, and Oscar-Berman (2008), the authors discuss recent advances in molecular genetic studies and their ability to identify several genes that may facilitate susceptibility to ADHD. "A consensus of the literature suggests that when there is a dysfunction in the 'brain reward cascade,' especially in the dopamine system, causing a low or hypo-dopaminergic trait, the brain may require dopamine for individuals to avoid unpleasant feelings" (Blum, Chen, & Oscar-Berman, 2008, p. 893). They offer an explanation of a high-risk genetic trait that leads to multiple drug-seeking behaviors, as the drugs in question are capable of activating the release of dopamine and thereby reducing the abnormal cravings inherent in children with this genetic disposition. Many studies associate biological factors with ADHD, but this article identifies specific genetic traits that may serve as precursors to the disorder. "Moreover, this genetic trait is due in part to a form of a gene (DRD2 A1 allele) that prevents the expression of the normal laying down of dopamine receptors in brain reward sites" (Blum, Chen, & Oscar-Berman, 2008, p. 893). This gene, along with others involved in neurophysiological processing of specific neurotransmitters, is linked to deficient functions that predispose individuals to impulsive, addictive, and compulsive behavioral inclinations. The article also proposes that certain genes are responsible for determining behaviors associated with Reward Deficiency Syndrome (RDS), which the authors hypothesize includes ADHD as a behavioral subtype (Blum, Chen, & Oscar-Berman, 2008, p. 893). This article was helpful in demonstrating a possible biological component to the formation of ADHD and other disorders involving dopamine and serotonin dysregulation.

In an article by Maher, Greene, and Holmes (2012), the authors discuss the limited investigation into symptoms of deficient emotional self-regulation (DESR) and its connection with ADHD. They conducted a study to determine causality and provide further evidence for this connection — specifically, to "examine the predictive utility of DESR in moderating the course of ADHD children into adolescence" (Greene, Maher, & Holmes, 2012, p. 267). Their methods involved 177 children with ADHD and 204 children without ADHD, followed for an average of four years (aged 6–18 years at baseline, 54% male), assessed with structured diagnostic interviews and measures of psychosocial functioning. DESR was defined by the presence or absence of a Child Behavior Checklist (CBCL)-DESR profile at the baseline assessment. The results demonstrated a persistent association of ADHD with DESR: "At follow-up, ADHD + DESR subjects had significantly more comorbidities (z = 2.55, P = 0.01), a higher prevalence of oppositional defiant disorder (z = 3.01, P = 0.003), and more impaired CBCL social problems t-score (t (227) = 2.41, P = 0.02) versus ADHD subjects" (Greene, Maher, & Holmes, 2012, p. 267). Studies such as these provide concrete support for long-hypothesized links between ADHD and emotional dysregulation.

In an article by Shiels and Hawk (2010), the authors characterize ADHD as "persistent and impairing developmentally inappropriate levels of inattention, hyperactivity, and impulsivity" (Shiels & Jr., 2010, p. 951) and propose that behavioral dysregulation may be a consequence of deficits in self-monitoring and adaptive control — both vital components of effective adaptive behavior. The article examines and integrates recent research on error-processing and adaptive control as aspects of self-regulation within widely accepted etiological theories of ADHD. Their review highlights data on error-processing as reflected in event-related potentials (ERN and Pe), suggesting that both early error detection and later error evaluation may be diminished in children with ADHD. The authors note that variability in results limits definitive conclusions and recommend further methodological refinement, ultimately arguing that continued research will yield more concrete and generalizable methods for testing self-regulation models in this population.

In a study by Strehl et al. (2007), the investigators examined the effects of self-regulation of slow cortical potentials (SCPs) in children with ADHD. Slow cortical potential shifts in the electrically negative direction reflect the depolarization of large cortical cell assemblies, reducing their excitation threshold — a process thought to be impaired in children with ADHD. Twenty-three children aged 8 to 13 received 30 sessions of SCP self-regulation training across three phases. Feedback was delivered both visually and auditorily, and transfer trials without feedback were interspersed to promote generalization to everyday situations. The study found, for the first time in this field, that children with ADHD learn to regulate only negative slow cortical potentials. Importantly, participants demonstrated significant improvements in attention, IQ scores, and behavior, and these gains persisted over six months. One limitation of the study was the absence of a control group, which made it difficult to establish a definitive causal relationship between the training and the observed improvements. "Regulation of slow cortical potentials may involve similar neurobiological pathways as medical treatment" (Strehl et al., 2007, p. e1530).

Gill, Papageorgiou, Gaskell, and Wells (2013) used the Thought Control Questionnaire (TCQ) to measure individual differences in thought suppression strategies. Because most studies using the TCQ are conducted with adult populations, this study generated an adolescent version in order to describe its development and psychometric properties. The modified questionnaire and measures of emotional disorder were administered to 589 school pupils aged 13–17 years. Analysis highlighted five factors that adolescents with behavioral disorders demonstrate: distraction, social control, worry, punishment, and reappraisal. "The TCQ-A showed good internal consistency and evidence of stability over time. Scores on the worry and punishment subscales were positively correlated with measures of emotional symptoms" (Gill, Papageorgiou, Gaskell, & Wells, 2013, p. 242). Studies such as this are useful in examining the processes of the child and adolescent brain and in identifying patterns or causes of behavioral problems more rapidly.

Sportel, Nauta, de Hullu, de Jong, and Hartman (2011) discuss behavioral inhibition (BI) and its association with the development of internalizing disorders — specifically, its interaction with attentional control (AC) in children and adolescents. The article states: "The combination of high BI and low AC may particularly lead to elevated symptomatology of internalizing behavior" (Sportel et al., 2011, p. 149). A sample of non-clinical adolescents (N = 1806, mean age = 13.6 years) completed the Behavioral Inhibition System/Behavioral Activation System Scales (BIS/BAS), the attentional control subscale of the Adult Temperament Questionnaire (ATQ), and the Revised Child Anxiety and Depression Scale (RCADS). As expected, BI was positively, and AC was negatively, related to internalizing dimensions — with stronger associations of BI than AC with anxiety symptoms, and a stronger association of AC than BI with depressive symptoms.

Studies focused on OCD tend to center on identifying symptoms and evaluating treatment. In a study by Freeman et al. (2012), the researchers employed a randomized controlled trial design to observe outcomes of family-based cognitive behavioral therapy (CBT) and family-based relaxation therapy for children aged 5–8 who exhibited OCD tendencies. The study measured symptom reduction, quality-of-life improvement, and functional impairment. A key emphasis of the study was the modification of existing methods to account for the developmental characteristics of young children — an important means of generating valuable knowledge about a complex and variable disorder.

Wilson and Hall (2012) examined an often-neglected topic: thought control strategies in younger populations. Like the studies above, they modified a thought control questionnaire and collected data on thought control strategies and metacognitive beliefs in relation to obsessive-compulsive (OC) interference scores in an adolescent sample (Wilson & Hall, 2012, p. 438). Results showed that adolescents used distraction and worry as coping mechanisms in ways similar to adults, but differed in their reduced use of social control and reappraisal. Adolescent males used punishment as a thought control strategy less frequently. The study also found that worry, punishment, positive beliefs about worry, uncontrollability and danger beliefs, and superstition, punishment, and responsibility beliefs predicted OC interference scores (Wilson & Hall, 2012, p. 438). The authors conclude that cognitive behavioral models of OCD developed in adult populations may be relevant to adolescents, provided that certain developmentally specific metacognitive beliefs are taken into account.

In an article by Simon, Kaufmann, Kniesche, Kischkel, and Kathmann (2013), the authors note that "elevated anxiety in obsessive-compulsive disorder (OCD) has been linked to cortico-limbic hyperactivation, whereas hyperarousal of the autonomic nervous system (ANS) has inconsistently been found" (Simon et al., 2013, p. 635). Their investigation observed responses to OCD triggers, neutral stimuli, and aversive controls. While the study was limited by a relatively small sample size, the findings suggested that ANS hyperactivity during symptom provocation may reflect arousal to the perceived threatening value of OCD triggers and might mediate elevated anxiety — though the results were not sufficient to support a definitive conclusion.

In an article by Pace, Thwaites, and Freeston (2011), the authors connect external criticism to various aspects of OCD, illustrating criticism as a potential catalyst for the development or continued progression of the disorder. The article also highlights a lack of supporting evidence and the failure of current research to successfully interpret this association: "The fragmented nature of the findings makes it difficult to identify how or why criticism impacts on OCD" (Pace, Thwaites, & Freeston, 2011, p. 361).

In a study by Cheng and Boggett-Carsjens (2005), the authors highlight dysregulation typically found in children with ODD. They note that clinicians diagnosing affect instability should consider the possibility of sensory processing difficulties, which can lead to problems with under- or over-arousal, thereby contributing to affect dysregulation (Cheng & Boggett-Carsjens, 2005, p. 44). Very little literature investigates ODD independently; it is most often studied in connection with ADHD, which accounts for the relative abundance of ADHD literature compared to ODD-specific research.

Conclusion

In conclusion, children need active participation from their parents, their schools, and the society they live in to help them overcome the negative behaviors brought on by OCD, ODD, and ADHD. Without early intervention — the most important method of minimizing such disorders — self-regulation will be lost to the children experiencing them. Several theories remain as to why behavioral disorders develop, but few provide succinct analysis of their origins, prevention, and treatment, particularly in young children.