Emotion Dysregulation in Attention Deficit Hyperactivity Disorder

Philip Shaw, Argyris Stringaris, Joel Nigg, Ellen Leibenluft
2014 American Journal of Psychiatry  
It has long been recognized that many individuals with ADHD also have difficulties with emotion regulation but lack of consensus on how to conceptualize this clinically challenging domain renders a review timely. The authors examine the current literature using both quantitative and qualitative methods. Three key findings emerge. First, emotion dysregulation is prevalent in ADHD throughout the lifespan and is a major contributor to impairment. Second, emotion dysregulation in ADHD may arise
more » ... deficits in orienting towards, recognizing and/or allocating attention to emotional stimuli; these deficits that implicate dysfunction within a striatoamygdalo-medial prefrontal cortical network. Third, while current treatments for ADHD often also ameliorate emotion dysregulation, a focus on this combination of symptoms reframes clinical questions and could stimulate novel therapeutic approaches. Three models to explain the overlap between emotion dysregulation and ADHD are considered: emotion dysregulation and ADHD are correlated but distinct dimensions; emotion dysregulation is a core, diagnostic feature of ADHD; and the combination constitutes a nosological entity, distinct from both ADHD and emotion dysreguation alone. The differing predictions from each model can guide future research into this much-neglected population. We focus on emotion dysregulation itself, rather than on diagnoses that may include emotion dysregulation and be comorbid with ADHD. We do so because it is a simpler symptom construct that is familiar to clinicians and, consistent with the Research Domain Criteria initiative, may be more readily tied to underlying neurobiological mechanisms. Methods We conducted a literature search for relevant articles published before January 1 st 2013 (details in Supplementary Material). Studies were categorized according to topic: (1) prevalence; (2) pathophysiology; and (3) treatment. Quantitative syntheses using pooled effect sizes were possible for studies of three related literatures: aggressive behavior (9-20), emotion recognition (12, 21-36) and delay aversion (35,(37)(38)(39)(40)(41) (42) (43) (44) (45) (46) (47) (48) (49) (50) . Remaining studies were reviewed qualitatively. Section 1: Prevalence Childhood-Most epidemiological research has focused on children and finds a strong association between ADHD and emotion dysregulation (35, 51-56)( Table 1) . A population study of 5326 youth found mood lability in 38% of children with ADHD, a ten-fold increase over population rates (51). Elevated rates were found in non-comorbid ADHD children and equaled the rates seen in children with non-comorbid Oppositional Defiant Disorder. Research on the Child Behavior Checklist 'dysregulation profile' based on parent-reported problems with mood and aggression in youth who also have attention problems, shows community rates of 1-5%, compatible with high rates of emotion dysregulation among those likely to have ADHD (57). Clinic-based studies in youth with ADHD report similar prevalence estimates of emotion dysregulation of between 24% to 50%. Reactive aggression may reflect emotion dysregulation (5). Our meta-analysis found consistent elevation in aggressive behavior in ADHD versus non-ADHD populations, associated with a large effect size (1.92, CI 0.95 to 2.89) - Figure 1A . In the general population, the correlation is higher between aggression and hyperactivity-impulsivity (0.60-0.83) than between aggression and inattention (0.20-0.56) (6). In clinics emotion dysregulation is commonly associated with either symptom domain (52, 56). Importantly, behaviors reflecting emotion dysregulation can be reliably provoked among those with ADHD using paradigms that induce frustration (Supplemental Table 1 ). Children with ADHD show more negative affect and temper outbursts than comparison subjects during challenging tasks. This consistency is notable as different paradigms and behavioral measures were employed. Infancy and early childhood-Modest correlations (0.10-0.37) are reported between infantile temperamental characteristics such as being fussy, angry, or difficult to control, and ADHD arising later in childhood (58-62) (Figure 2 and Supplemental Table 2 ). A longitudinal study of 7,140 children, found that while temperamental emotionality at age 3 predicted comorbid ADHD and internalizing disorders at age 7, activity level predicted comorbid ADHD and Oppositional Defiant Disorder (63). A second longitudinal study found that infants who developed hyperactive symptoms alone did not differ Shaw et al.
doi:10.1176/appi.ajp.2013.13070966 pmid:24480998 pmcid:PMC4282137 fatcat:nfu5m55knvh5xdjfhlu4thwtf4