Emotional Dysregulation and the Gap in Youth Mental Health
What it is, why it isn't part of routine care, and what it would take to change that.
There is a difference between why a young person thinks about suicide and why they act on it. The first has had decades of attention. The second has had far less.
One of the things that separates them is how a young person handles a feeling that arrives faster than they can manage it. It can be measured. It responds to treatment. And almost nobody is looking for it.
This is an argument for changing that - and a description of what the Cocoa Classic exists to fund.
By Chris Maher
If you or someone you know is struggling, call or text 988 for the Suicide & Crisis Lifeline. Cocoa Classic is not a treatment provider.
Suicide is the second leading cause of death among Americans ages 10 to 24, with the highest rate among those ages 20 to 24. Depression is the largest single source of suicidal thinking, but it and every other known risk factor have failed to predict who acts on those thoughts. What the field has come to accept is that the causes of the thought and the causes of the act are different, and the latter has received far less attention.
One cause of the act is how a young person handles a feeling that arrives faster than they can manage it. Every parent has seen some version of this, and almost none of them have a name for it. What varies is degree. The difference between children is large, and the ones at the far end are the ones for whom a bad night can become something worse. Neither families nor much of clinical practice recognizes this as one of the main things that separates a suicidal thought from an act. An assessment for it exists, and so does a therapy.
What emotional dysregulation is, and how it differs from depression and anxiety
Emotional dysregulation is difficulty managing an emotional response once it has started. Emotions arrive fast and hard, out of proportion to what set them off, and calming down or holding back an impulse becomes difficult while flooded. It is a question of whether a person can stay in the driver’s seat when a feeling arrives faster than it can be managed.
Depression is oriented backward, toward loss of interest, loss of pleasure, worthlessness, fatigue, and the conclusion that things are bad and will not improve. Anxiety is oriented forward, toward apprehension, worry, physical tension, and the anticipation of a threat that cannot be prevented. Dysregulation is neither. It is what happens in the moment itself: a response out of proportion to what set it off, and hard to come down from once it starts.
Depression comes and goes, and a young person can be genuinely well one month and not the next, which is part of why it is hard to catch at a scheduled visit. That matters, because depression is where the thinking usually starts.
Dysregulation is closer to a trait, and it bears on something different: what happens when the thought arrives. The episodes themselves come and go, in the way blood pressure readings fluctuate, but the underlying propensity is steadier — how readily someone floods, and how hard it is to come back. That propensity is present between episodes rather than only during them, which is what would make it findable by asking once a year. It is more stable than mood, though not fixed, since it responds to treatment and shifts with development.
“It is a question of whether a person can stay in the driver’s seat when a feeling arrives faster than it can be managed.”
They also differ in speed. The depressive route unfolds over weeks, as hopelessness accumulates and what follows comes after deliberation. The dysregulated route runs from trigger to action in minutes or hours, which is why the window for anyone to notice and intervene is so small.
Instruments for measuring dysregulation already exist. The most widely used is the Difficulties in Emotion Regulation Scale, or DERS, which has been in use for twenty years. It asks about how a person responds when upset: whether they can identify what they are feeling, whether they can hold back an impulse, whether they believe there is anything they can do to feel better. It is brief, free to use, validated across clinical and community populations, and available in versions a parent can complete about a child.
It would not return the same information as the screens already in use. The PHQ-9 asks how a young person has felt over the past two weeks, and the GAD-7 asks about worry over the same window. The DERS asks what happens when a feeling arrives, a different question, and one that can be answered accurately during a good stretch.
What the DERS lacks is a threshold validated against self-harm. Establishing one means taking a population where the measure was administered and following those young people forward to see where on the scale the risk actually rises. A clinician would then know what a score means, rather than only that it is higher than average.
What the evidence already shows
Some of the clearest evidence comes from treatment. Marsha Linehan developed dialectical behavior therapy (DBT) in the 1990s for chronically suicidal patients, after finding that standard cognitive behavioral therapy alone was not enough for them. Alec Miller and colleagues adapted it for adolescents in the early 2000s. It teaches four sets of skills: paying attention to what is happening in the moment, tolerating distress without acting on it, managing an emotion as it arrives, and handling the relationships that often set these episodes off. Randomized trials in adolescents have found that it reduces self-harm and suicide attempts. The thoughts do not reliably go away, but what changes is whether they are acted on.
Depression treatment reduces the thinking. Whether it reduces suicide is unknown, and the U.S. Preventive Services Task Force reviewed depression screening in 2022 and found no evidence that it does. The thinking and the act do not move together, which is why treating depression well is not the same as addressing the risk.
When a strong emotion takes hold, people differ in how much control they keep. That difference is what predicts self-harm, and researchers call it negative urgency. It is not the same as the everyday impulsivity that defines ADHD, where a person acts without thinking even when calm. Across studies, negative urgency shows associations with self-harm several times stronger than any other form of impulsivity.
The impulsivity that defines ADHD is present at baseline, without provocation, and stimulants address it, while negative urgency appears only under emotional load and medication does not address it. The two frequently occur together, and from the outside they look the same, a young person who acts without thinking. In a clinical note both are recorded as impulsivity, and the version that responds to medication absorbs the explanation for the one that does not.
“The thinking and the act do not move together.”
What the current system misses
Researchers at UCLA and Purdue published a retrospective analysis of 72,585 suicides in JAMA Network Open in April 2026. In roughly 90 percent of cases, the investigators who attended the scene had described signs of severe emotional distress. The diagnostic codes on those same records noted a mental health condition in 44 percent, and depression in 28 percent. What investigators described was in nearly every file, and what the codes captured was in fewer than half.
The national mortality database stores both: checkboxes filled out by a coder, and narrative accounts written by police officers, coroners, and medical examiners. Until recently the narratives could not be read at scale, so analysis relied on the checkbox data, and what the codes captured became what the field knew. Artificial intelligence changed that, and the researchers used language models to read the narratives and classify what investigators had described.
The finding is not that these people were distressed. What it establishes is that the distress was recorded and the system did not register it, not that it would have been detectable a year earlier. The people at the scene saw it and described it, but the form they were filling out had nowhere to put it, and nothing in routine care asks about it.
Screening and routing also work when a health system commits to them. Henry Ford Health built this into routine practice, and across six health centers reporting data from 2012 to 2019 in JAMA Network Open, Henry Ford had the lowest rate of monthly suicide attempts, falling from 11.3 to 0.3 per 100,000 patients. An earlier report on the same program found the suicide rate among its patients fell sharply as well.
Those programs screen for current suicidal thinking, reported at the moment of contact. A young person who is not in crisis on the day of screening will not be flagged. So the approach works. What has not been tested is the same approach aimed at a characteristic present between crises rather than during one.
Most of what exists depends on distress becoming visible. Gatekeeper training, peer support, and awareness campaigns work by helping someone notice a young person who is struggling, and the better programs go further, shifting what students think is normal to say out loud. There is evidence that this works, with peer leaders in one randomized trial substantially more likely to bring a friend to an adult.
The young person it does not reach is the one whose distress is not showing on the day someone looks. What matters is not the condition but whether it shows. Their difficult stretch has passed, they are genuinely doing well, and anyone asking would get an honest answer that nothing is wrong. A measure of emotional regulation asks a different question, and that answer does not change with the good stretch.
“Not the one who is reluctant, but the one who is doing well by every measure anyone tracks.”
Why isn't this already being done?
Emotional dysregulation is not a diagnosis. It appears in ADHD, where an estimated 25 to 45 percent of children have significant dysregulation, and also in depression, anxiety, trauma, eating disorders, and in people with no psychiatric condition at all. Since a diagnostic criterion has to distinguish one condition from another, a feature that turns up everywhere fails that test. That reasoning is disputed, and Russell Barkley, among the most cited researchers in the field, has long held that deficient emotional self-regulation is a core feature of ADHD rather than an accompaniment to it.
The dispute does not affect whether the characteristic is worth measuring, because a screen and a diagnosis are not doing the same job. A screen looks for something that predicts harm and can be treated, and for that purpose the number of conditions a feature appears in does not matter. Blood pressure was measured for decades before it became a diagnosis, and the thresholds came out of the accumulated data rather than preceding it. It is elevated across many unrelated conditions and has almost no diagnostic specificity, and it is still measured on everyone.
“The pieces are well established, and what is missing is the assembly.”
Emotional dysregulation is not a diagnosis. It appears in ADHD, where an estimated 25 to 45 percent of children have significant dysregulation, and also in depression, anxiety, trauma, eating disorders, and in people with no psychiatric condition at all. Since a diagnostic criterion has to distinguish one condition from another, a feature that turns up everywhere fails that test. That reasoning is disputed, and Russell Barkley, among the most cited researchers in the field, has long held that deficient emotional self-regulation is a core feature of ADHD rather than an accompaniment to it.
The dispute does not affect whether the characteristic is worth measuring, because a screen and a diagnosis are not doing the same job. A screen looks for something that predicts harm and can be treated, and for that purpose the number of conditions a feature appears in does not matter. Blood pressure was measured for decades before it became a diagnosis, and the thresholds came out of the accumulated data rather than preceding it. It is elevated across many unrelated conditions and has almost no diagnostic specificity, and it is still measured on everyone.
Building the skills before they are needed
Building the capacity to sit with an unbearable feeling without acting on it takes months of practice. On the night it matters, it is either present or it is not. A system that waits for a crisis reaches a young person at the point when there is no longer time to build it.
The age window also runs later than most screening does. The parts of the brain that regulate emotion continue developing into the mid-twenties, well past the age at which pediatric care ends, and the suicide rate climbs steeply across exactly that stretch. The most dangerous years arrive shortly after a young person leaves home, when they are furthest from routine care and from anyone who knows their baseline. Asking from around age ten through the early twenties would cover the years when the capacity is still forming and the risk is rising fastest.
These skills do more than prevent harm. Emotional regulation in childhood predicts school adjustment, academic achievement, and long-term employment. A young person who learns to ride out that kind of episode is better off in ordinary daily ways, and those benefits arrive whether or not a crisis ever comes.
What I am trying to do
My aim is to get emotional regulation measured as a matter of routine. There is a version of that which could start now, and a larger version that will take years and a body of evidence that does not yet exist.
A young person diagnosed with depression, anxiety, ADHD, trauma, or a substance use disorder should also be assessed for emotional regulation, because the diagnosis speaks to where the suicidal thinking comes from and not to what happens when it arrives. If regulation turns out to be a problem, it should be treated alongside the condition rather than instead of it, and DBT is the best-evidenced treatment for that part. This requires no guideline and no change in how anything is billed.
This is not a way to predict who will act. What it offers is a way to find the young people whose difficulty regulating emotion can be treated. That difficulty is one of the main things that turns a thought into an act, and it responds to treatment.
The larger version takes longer. Putting a measure of emotional regulation alongside depression screening at every annual visit would require trial evidence, and that evidence does not yet exist.
Most of what follows a positive result would be skills instruction rather than intensive treatment. DBT is closer to teaching than to talking, which is part of why it can be delivered at different intensities. Comprehensive DBT runs roughly six months and is reserved for severe and chronic presentations, and clinicians who deliver it describe that level of care as appropriate for a small minority of young people in therapy. The rest benefit from the skills themselves, which are taught in groups, online, and in family formats that are considerably easier to reach.
The awareness piece runs alongside both. Most parents recognize the behavior immediately when it is described to them, but they have never had a name for it, and without a name there is nothing to raise at an appointment. The absence is compounded when a child already carries a diagnosis, because the reactions get absorbed into it. A family with an ADHD diagnosis in hand attributes the intensity to the ADHD, or concludes the child is simply more sensitive than other children, and neither conclusion prompts anyone to ask whether it is something that can be worked on, which it usually is.
Who has to be involved
Four roles determine whether a young person is identified and treated, and none of them can do it alone.
The pediatrician has the standing to raise it, the record that follows a child for years, and the annual visit where a screening question would go. What is missing is any prompt to ask, and any room to do it in, since the well visit is already crowded. An elevated result would not mean a referral to intensive treatment. It would mean the clinician knows something about that patient they did not know before.
Therapists are the next link, and the one where the chain most often breaks. A pediatrician who recognizes something generally refers to a therapist, and the therapist decides what treatment follows. Clinicians who run DBT programs report that many general therapists are unfamiliar with it, or believe they can manage the presentation themselves. A young person can reach appropriate care and still not receive the treatment matched to what they have. A therapist who recognizes dysregulation when it presents, and knows when it calls for handing the patient on, closes that gap.
The school counselor is often the first professional a struggling student reaches, and is present in the setting where the student spends most of their day. Counselors vary enormously, though. Some are licensed psychologists who know this material and route accordingly, while others have limited clinical training and would not know to ask about emotional regulation or to name a specific therapy. A school's referral quality depends substantially on who happens to hold the job. A counselor who can recognize dysregulation and refer with enough specificity that the clinician receiving the student knows what they are looking at makes the difference. Training in DBT does that, and it also gives a counselor a few things to offer a student in the room, though the evidence for skills taught in isolation is thinner than for the full model.
Parents are the only constant. They see the child across years rather than in single appointments, and they know what ordinary looks like for this particular child in a way no instrument captures. They are also the ones who decide whether anything gets pursued, and the only ones here whose stake is not professional. What would change things is a parent who knows the term well enough to raise it at an appointment, and who understands that a child who cannot come back down from an upset is describing something with a name, not a personality.
What none of them has is a connection to the others. A teacher notices something in March and it reaches no one else. When a referral does happen, the largest single loss occurs between that referral and a first appointment, because nobody owns the interval and nobody counts how many young people arrive.
None of that requires new research. What it takes is someone treating these connections as their responsibility rather than assuming they will form on their own.
What that looks like in practice
Four things follow, roughly in the order they can happen. The first is material in pediatric offices, placed where families wait, which reaches parents at the moment the conversation is relevant. The second is training for primary care through organizations that already do it, including the REACH Institute, which has taken roughly ten thousand clinicians through child mental health curricula. The third is presentations to therapists and school counselors, who are reachable through professional associations and continuing education rather than institution by institution. The fourth is a referral map, because any of the above creates a problem if there is nowhere to send a young person.
For a school, the range of what is possible is wide. The smallest version is counselors who understand what dysregulation is and can teach a few skills, which costs a professional development day. The middle version adds a referral map and someone owning the handoff, so the school knows where its students go and whether they arrive. The broadest version teaches the skills to every student as curriculum, which several groups have adapted for classroom delivery.
The map is harder than it sounds. Many therapists list DBT among their approaches, but far fewer run the full model with a skills group, individual therapy, between-session coaching, and a consultation team, which is the version the trials tested. Cost and availability are national problems, so in many places the map would show gaps rather than options.
The clinical content has to come from a clinician. That means partnering with a psychologist or physician rather than presenting it myself. I can speak to what this looks like from a family's side.
Where this came from
My son Collin died by suicide in May 2026 at nineteen, two weeks after finishing his freshman year at Washington University in St. Louis. He was diagnosed with ADHD in first grade and later with anxiety, and had seen a psychiatrist since he was six and a therapist intermittently through his teens. Four days before he died his spring grades came in, they were terrific, and he had an internship starting that he was excited about.
Whether any of this would have changed what happened is unknowable. What can be said is that emotional dysregulation can be measured, and that it responds to treatment.
If you are a parent — ask your child's pediatrician whether emotional regulation is something they assess, particularly if your child already carries a diagnosis. The question itself is the intervention. Most families have never had the words for this.
If you work in a school — a professional development day is enough to start. Counselors who understand the construct and can teach two or three distress tolerance skills change what happens in the room.
If you are a clinician or researcher — I would welcome the conversation, and I am looking for clinical partners who can carry this material to professional audiences in a way I cannot.
If you want to support the work — run the Cocoa Classic, or donate. Every dollar goes toward closing this gap.