Emotion Dysregulation in Attention Deficit Hyperactivity Disorder
Abstract
Method
Results
Prevalence
Childhood.
Study | Participants | Definition of “Emotion Dysregulation” | Impairment Criterion | Findings |
---|---|---|---|---|
Children and adolescents | ||||
Stringaris and Goodman (51) | Population based; N=5326 | Parent and self-report of emotional lability | Severity ratings of symptoms occurring “a lot” | Parent rating of impairing emotional lability: ADHD alone, 38% (RRR=12 compared with unaffected); ODD alone, 42% (RRR=14.7); self-report: ADHD alone, 27% (RRR=6.9); ODD alone, 14% (RRR=3.0) |
Sobanski et al. (52) | Family based; ADHD, N=216; siblings, N=142 | Conners emotional lability index, parent and teacher ratings of unpredictable mood changes, temper tantrums; tearfulness; low frustration tolerance | 3 SD above population norms | 25% of ADHD probands had emotional lability >3 SD above population norms |
Anastopoulos et al. (53) | Family based; ADHD, N=216; siblings, N=142 | Conners emotional lability index (see above) | Above 65th percentile of population norms | Elevated levels: ADHD, 47%; unaffected, 15% |
Spencer et al. (54) | Clinic based; ADHD, N=197; controls, N=224 | Parent report of “dysregulation profile” based on Child Behavior Checklist subscales of attention problems, anxiety/depression, and aggression | Scores 1–2 SD above norms (above 2 SD, considered bipolar phenotype and excluded) | ADHD, 44% with dysregulation profile; controls, 2% |
Sjöwall et al. (35) | Clinic based; ADHD, N=102; controls, N=102 | Parent report of child’s ability to regulate specific emotions | Not given | ADHD showed significant impairment compared with controls in regulating all emotions |
Strine et al. (55) | Population based; history of ADHD, N=512; no history of ADHD, N=8,169 | Strength and Difficulties Questionnaire, parent report of emotional and conduct problems, including: often loses temper, often unhappy (also clingy, fearful, somatic complaints, and having worries) | Parent rating of each symptom’s impact | Emotional problems: history of ADHD, 23%; no history of ADHD, 6.3% |
Becker et al. (56) | Clinic based; ADHD, N=1,450 | Strength and Difficulties Questionnaire, parent report of emotional problems (see above) | Based on U.K. population norms | 40% of boys and 49% of girls had abnormally high levels of emotional problems |
Adult studies | ||||
Able et al. (57) | Population based (N=21,000); diagnosed ADHD, N=198; likely ADHD (based on self-report scale), N=752; controls, N=199 | Self-report of tendency to become angry, disagree, or be critical of others; self-report of degree to which others evoke feelings of anger | Not given | Both diagnosed and likely ADHD subjects more likely to express anger, to engage in conflict, and to have been the target of anger or intimidating behavior |
Barkley and Fischer (58) | Clinic based; ADHD, N=55; controls, N=75 | Self-report of items reflecting emotional impulsivity (taken from the Behavior Rating of Executive Functioning) | Symptom occurs “often” | Impatient: ADHD, 72%; controls, 3%; quick to anger: ADHD, 65%; controls, 6%; easily frustrated: ADHD, 85%; controls, 7%; emotionally overexcitable: ADHD, 70%; controls, 6%; easily excitable: ADHD, 73%; controls, 14% |
Reimherr et al. (59) | Clinic based; ADHD, N=536 (enrolled in treatment trials) | Self-report of items from the Wender-Reimherr Adult Attention Disorder Rating Scale: irritability and outbursts; short, unpredictable mood shifts; emotional overreactivity | 2 SD above population norms | 32% met criteria for emotion dysregulation |
Reimherr et al. (60) | Clinic based; ADHD, N=47 (enrolled in treatment trial) | Wender-Reimherr Adult Attention Disorder Rating Scale (see above) | 2 SD above population norms | 78% met criteria for emotion dysregulation |
Surman et al. (61) | Clinic based; ADHD, N=206; controls, N=123 | Barkley’s self-report scale: quick to anger, loses temper, argumentative, angry; easily frustrated, touchy; overreactive emotionally, easily excited | Above 95th percentile on population norms | Met criteria for emotion dysregulation: ADHD, 55%; controls, 3% |
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Infancy and early childhood.
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Longitudinal studies.
Adult studies.
Impairment.
Pathophysiology
Study | Participants | Task | Behavioral results | fMRI results |
---|---|---|---|---|
Emotion perception and recognition | ||||
Brotman et al. (79) | ADHD with no comorbidity, N=18; severe mood dysregulation, N=29 (24 with ADHD); bipolar affective disorder, N=43 (20 with ADHD); healthy, N=37 | Rating of fear, nose width, and passive viewing of neutral, fearful, happy, and angry faces | Rating of fear in neutral faces: severe mood dysregulation = bipolar > healthy; ADHD did not differ from any group | Left amygdala activity during fear ratings: ADHD > healthy = bipolar > severe mood dysregulation |
Marsh et al. (80) | ADHD with no comorbidity, N=12; callous-unemotional traits, N=12; healthy, N=12 | Gender judgments on fearful, neutral, and angry faces | No group differences in accuracy; ADHD had slower reaction times | Amygdala activity in ADHD during fear processing did not differ from healthy |
Posner et al. (81) | ADHD, N=15 (mix of medication naive and receiving psychostimulants; some had ODD, although the number is unclear); healthy, N=15 | Subliminal presentation of fearful face followed by supraliminal presentation of neutral expression on the same face; postscan face memory test | No group differences | Greater activity in medication-naive ADHD in amygdala and stronger functional connectivity with lateral prefrontal cortex (BA47) |
Herpertz et al. (24) | ADHD without comorbidity, N=13; conduct disorder, N=22 (16 with ADHD); healthy, N=22 | Passive viewing of negative, positive, and neutral scenes | Subjects with conduct disorder rated emotional pictures as less arousing than did other groups | Increased left amygdala activation in conduct disorder with ADHD, not ADHD alone; ADHD alone had decreased insula activation to negative faces |
Schlochtermeier et al. (82) | Adults treated in childhood for ADHD with no comorbidity, N=10; adults with childhood ADHD, medication naive, N=10; healthy, N=10 | Rating of positive and negative pictures | Adults with ADHD treated in childhood rated neutral pictures as more pleasant than medication naive and healthy subjects | Decreased ventral striatum and subgenual cingulate activation in medication-naive adults with history of ADHD; ADHD treated in childhood did not differ from healthy |
Malisza et al. (29) | ADHD, N=9; autism, N=9; healthy, N=9 | View happy and angry faces and respond to happy | Accuracy: autism < ADHD = healthy | ADHD had less fusiform, temporal poles activity than healthy; ADHD showed same amygdala activity as healthy; autism showed less amygdala activity than other two groups |
Reward processing | ||||
Ströhle et al. (83) | Adult ADHD without comorbidity, N=10; controls, N=10 | Monetary incentive delay | No group differences | Decreased ventral striatum activation in ADHD during reward anticipation, and increased orbitofrontal activation during reward receipt |
Plichta et al. (38) | Adult ADHD without comorbidity, N=14; controls, N=12 | Delayed discounting task (choose between immediate small and delayed large rewards) | No group differences | Decreased ventral striatum activation in ADHD during processing of both immediate and delayed rewards; within subjects, delayed reward in ADHD associated with increased activity of amygdala and caudate |
Scheres et al. (84) | Adolescent ADHD, N=11; controls, N=11 | Monetary incentive delay | No group differences | Decreased ventral striatal activity in ADHD during reward anticipation |
Stoy et al. (85) | Adult ADHD, N=24 (analyzed as remitted versus persistent, and as history of childhood treatment with psychostimulants versus medication naive); controls, N=12 | Monetary incentive delay | No group differences | Decreased insula activation during outcome of loss avoidance in medication-naive adults compared with other groups |
Rubia et al. (86) | Childhood ADHD on and off psychostimulants, N=13 (1 with comorbid ODD); healthy, N=13 | Rewarded continuous performance task | No difference between medicated ADHD and healthy; trend to worse performance in unmedicated ADHD | Unmedicated ADHD showed orbitofrontal hyperactivation during reward receipt, normalized by psychostimulants |
Control of attention to emotional stimuli | ||||
Passarotti et al. (87) | Adolescent ADHD without comorbidity (N=14); bipolar disorder, N=23; healthy, N=19 | Working memory task using angry, happy, and neutral faces | Accuracy: healthy > ADHD > bipolar | ADHD compared with healthy: decreased prefrontal and striatal activation to angry faces, increased to happy; ADHD compared with bipolar: similar cortical anomalies, more prominent subcortical anomalies in bipolar |
Passarotti et al. (88) | Adolescent ADHD without comorbidity (N=15); bipolar disorder, N=17; healthy, N=15 | Emotional Stroop test | Bipolar and ADHD slower than healthy; more interference from positive distractors in bipolar and from negative distractors in ADHD | For negative versus neutral words: gradient of ventrolateral prefrontal cortical activation: ADHD < healthy < bipolar; both ADHD and bipolar showed more dorsolateral prefrontal and parietal activation than healthy |
Posner et al. (89) | Adolescent ADHD, on and off psychostimulants, N=15; healthy, N=15 | Emotional Stroop test | Medication-free ADHD showed medial prefrontal hyperactivity with positive and hypoactivity with negative distractors; normalized on psychostimulants |
Bottom-up psychological mechanisms.
Top-down regulatory processes.
Neural mechanisms.
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Etiological factors.
Treatment
Study | Participants | Measures | Results |
---|---|---|---|
Children | |||
Childress et al. (117) | Lisdexamphetamine versus placebo for 4 weeks, N=283; at baseline 179 had prominent emotional lability | Conners Parent Rating Scale of emotional lability (angry/resentful, losing temper, and irritability); prominent emotional lability defined as having at least one symptom “pretty much” or “very much” | For those with prominent emotional lability, medication was associated with a significant reduction in emotional symptoms; no change in emotionality seen in those with low emotional lability |
Ahmann et al. (118) | Crossover design; treated with placebo or low-dosage (0.3 mg/kg) and higher-dosage (0.5 mg/kg) methylphenidate; N=234 | Side effect questionnaire including items on dysthymia, euphoria, irritability, and anxiety | Decreased irritability on methylphenidate (odds ratio=0.33, 95% CI=0.18–0.61) |
Gillberg et al. (119) | Amphetamine versus placebo for 6 months, N=56 | Side effect questionnaire including items on dysthymia, euphoria, irritability, and anxiety | No differences between treated and placebo groups |
Kratochvil et al. (120) | Atomoxetine versus placebo, for 8 weeks, N=179 | Emotion and Expression Scale for Children | No difference between atomoxetine and placebo |
Coghill et al. (121) | Crossover methylphenidate 0.3 mg/kg and 0.6 mg/kg versus placebo for 12 weeks, N=75 | Conners’ emotional lability subscale | Significant reduction in emotional lability for both low-dosage (parent-report effect size, 0.46; teacher-report effect size, 0.45) and high-dosage methylphenidate (parent-report effect size, 0.42; teacher-report effect size, 0.79) |
Herbert et al. (122) | Randomized to waiting list or parent training to boost child’s emotion regulation and socialization, N=31 | Emotion Regulation Checklist | Parent training linked with moderate reduction of child’s emotional lability (effect size, 0.27–0.45). |
Webster-Stratton et al. (123) | Randomized to waiting list or parenting program boosting positive and consistent parenting style, N=99 | Emotion regulation scale | Moderate effect of intervention on emotion regulation (effect size, 0.25) |
Adults | |||
Reimherr et al. (60) | Crossover trial of extended-release methylphenidate versus placebo (4 weeks each arm), N=47 | Wender-Reimherr adult ADHD scale, emotion dysregulation items | Decrease in emotion dysregulation on methylphenidate (effect size, 0.7) |
Reimherr et al. (59) | Post hoc analyses of trials comparing atomoxetine and placebo; ADHD only, N=359; ADHD and emotion dysregulation, N=170 | Wender-Reimherr adult ADHD scale, emotion dysregulation items | Decrease in emotion dysregulation on atomoxetine (effect size, 0.66) |
Marchant et al. (124) | Crossover trial of transdermal methylphenidate versus placebo (4 weeks each arm); ADHD alone, N=21; ADHD and emotion dysregulation, N=28; ADHD and oppositional defiant disorder, N=9; ADHD, oppositional defiant disorder, and emotion dysregulation, N=32 | Wender-Reimherr adult ADHD scale, emotion dysregulation items | All groups showed benefit on psychostimulants; trend for those with emotion dysregulation to improve most |
Rösler et al. (125) | Methylphenidate versus placebo with 24-week double-blind phase, N=363 | Wender-Reimherr adult ADHD scale, emotion dysregulation items | Methylphenidate reduced emotional lability (effect size, 0.28–0.4) |
Emilsson et al. (126) | Cognitive behavioral therapy and medication versus medication alone, N=54 | Self-report scale of emotional control | Combination group did not show significantly better emotional control at end of intervention but did 3 months following intervention (d=1.12) |
Conceptual Models
Phenomenology | Pathophysiology | |||||
---|---|---|---|---|---|---|
Model | Correlations Between ADHD and Emotion Dysregulation | Clinical Course | Psychological Basis | Neural Basis | Genetic | Treatment |
Emotion dysregulation is integral to ADHD | Extremely high | Yoked clinical courses for symptoms of ADHD and emotion dysregulation | Deficits in behavioral inhibition and working memory mediate both core ADHD symptoms and emotion dysregulation | Anomalies confined to fronto-striatal-cerebellar circuits | Same genetic basis for ADHD with emotion dysregulation and ADHD alone | Treatments that improve ADHD will improve emotion dysregulation |
Combined ADHD and emotion dysregulation defines a distinct entity | ADHD subgroup exists that is high on both symptom domains | Distinct clinical course for ADHD with emotion dysregulation and ADHD alone | Distinct cognitive deficits in ADHD with emotion dysregulation and ADHD alone | Distinct neural bases for ADHD with emotion dysregulation and ADHD alone | Distinct genetic bases for ADHD with emotion dysregulation and ADHD alone | Existing treatments for ADHD may be less effective for ADHD with emotion dysregulation |
Symptoms of ADHD and emotion dysregulation are correlated but distinct dimensions | Modest | Similar but dissociable clinical courses for symptoms of ADHD and emotion dysregulation | Deficits in emotion processing mediate dysregulation and correlate with deficits mediating core ADHD symptoms | Anomalies extend beyond fronto-striato-cerebellar circuits to (para)limbic regions | Some genes shared between ADHD alone and ADHD with emotion dysregulation | Treating “core” ADHD symptoms benefits emotion dysregulation, but separate treatment may also be needed |
Future Research Directions
Phenomenology and Pathophysiology
Treatment
Conclusions
Supplementary Material
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