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(p. 113) Emotion Regulation and Attention Deficit Hyperactivity Disorder 

(p. 113) Emotion Regulation and Attention Deficit Hyperactivity Disorder
Chapter:
(p. 113) Emotion Regulation and Attention Deficit Hyperactivity Disorder
Author(s):

Blossom Fernandes

, Roseann Tan-Mansukhani

, and Cecilia A. Essau

DOI:
10.1093/med:psych/9780198765844.003.0006
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Diagnostic criteria

Attention Deficit Hyperactivity Disorder (ADHD) is considered one of the most pervasive disorders of childhood (Castellanos & Tannock, 2002). ADHD frequently persists into adolescence and adulthood and is consistently associated with a range of negative outcomes. The term ADHD was first coined as part of the restructure and enhancement of the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association (American Psychiatric Association, 1980); prior to this, children with ADHD were diagnosed with brain dysfunction or brain damage with hyperkinesia (Barkley, 1990).

The diagnostic criteria for ADHD has undergone several changes, but most notably, the DSM-IV (American Psychiatric Association, 2000) has classified behavioural symptoms comprising three major subtypes: Inattention (I), hyperactivity-impulsivity (HI), and Combined. Children presenting with the inattentive subtype have difficulty with tasks that require sustained mental effort, are more disorganized and are easily distracted and forgetful when compared to peers of a similar age (Sergeant, Oosterlaan, & van der Meere, 1999). Children with the HI subtype were characterized as more fidgety, restless and “squirmy” when compared to typically developing children. The combined subtype is the most commonly diagnosed sub-type and involves six or more symptoms of each of the inattention and hyperactivity subtypes (APA, 2000). Research has shown children with ADHD, as compared to other children, also have difficulty inhibiting on-going behavior (Oosterlaan, Logan, & Sergeant, 1998) and difficulty inhibiting immediate gratification (Douglas & Parry, 1983). As with attention problems, these difficulties lead to serious problems in home and school functioning.

The fifth revision of the DSM (DSM-5; American Psychiatric Association, 2013) characterized ADHD as a neurodevelopmental disorder consisting of a pattern of inattention and/or hyperactivity-impulsivity that affects every day functioning. It further specifies the severity of ADHD as mild (involving minor impairments with few, if any, symptoms in excess of the six required for diagnosis), moderate (impairment between mild and severe), and severe (marked impairment and with several symptoms in excess of those necessary for a diagnosis). The DSM-5 suggests that these symptoms should have persisted for at least six months, directly impacting social and academic/occupational activities and be present before the age of 12 years. Additionally, the DSM-5 allows for diagnosis in adolescents and adults, including types of behaviour and examples of how the disorder could manifest itself in different age groups. The symptoms are expected to persist for at least five months in individual above the age of 17, unlike six months for children and adolescents; moreover, those aged 17 and older need to exhibit only five of the requisite symptoms, not the six required for younger children.

(p. 114) Prevalence

There is growing consensus that ADHD occurs in approximately 5% of school-aged children, a prevalence rate that is seen across cultures (Esser, Schmidt, & Woerner, 1990; Polanczyk et al. 2007; Polanczyk et al. 2014). However, ADHD prevalence rates diverge widely as a result of age, definition of disorder and assessment method. Distinctions based on definitions (e.g., clinical classifications of ADHD versus scores on a behavior checklist) and more rigorous assessment criteria lead to fewer cases of ADHD. For example, a review of 86 studies using the DSM-IV criteria (American Psychiatric Association, 1994) indicated the prevalence of ADHD ranged from 5.9% to 7.1% (Willcutt, 2012). ADHD diagnosis also seems to be influenced by parental practices and beliefs. As reported by Asherson and colleagues (2012), in Asian countries such as Hong Kong and Taiwan parental monitoring of child behavior is considered essential in reducing disruptive behaviors and poor habits, thereby influencing diagnosis and access to treatment. Variations in the prevalence rates of ADHD in different countries has raised a question to whether ADHD is a universal syndrome affecting children worldwide regardless of race and society (Bauermeister et al., 2010; Goetz et al., 2010; Polanczyk et al., 2007) or a cultural construct generally based on a Western conceptualization (Asherson et al., 2012; Faraone et al., 2003; Jacobsen, 2002; Timimi & Taylor, 2003).

Gender differences

ADHD is observed more often in boys than girls, with a male to female ratio approximating three to one (Skounti, Philalithis, & Galanakis, 2007). Relatedly, girls have been found to have lower levels of inattention, hyperactivity, and oppositional/defiant behaviour compared to boys. Research shows that boys under the age of 13 years tend to be overt and display severe disruptive behaviours in the classroom; whereas, girls appear to exhibit more cognitive and academic problems (Gaub & Carlson, 1997). In addition, females are less likely to be identified in samples due to the manifestation of the disorder, as they are less likely to exhibit disruptive behaviors compared to ADHD males, and are more likely to go unnoticed if they present inattentive behaviours (Gaub & Carlson, 1997). Importantly, a large number of referral for ADHD males who exhibit disruptive behaviours occur in school settings; therefore, females who similarly display disruptive behaviors, may be ignored (Gaub & Carlson, 1997; Gershon & Gershon, 2002).

Psychosocial impairment

As mentioned previously, children with ADHD often suffer from academic and social impairments. Academic deficits, school-related problems, and peer neglect tend to be most associated with elevated symptoms of inattention; whereas, peer rejection and, to a lesser extent, accidental injury are frequently linked with symptoms of hyperactivity or impulsivity (Willcutt et al., 2012). Compounding the stress for a person with ADHD, family relationships are consistently strained and lead to discord and negative interactions. In addition, attentional problems frequently have a significant impact on rates of mother–child rejection; however for fathers, rejection seems to significantly impact their children’s attention problems (Lifford, Harold, & Thapar, 2008). Moreover, peer relationships are affected by peer rejection, neglect, or teasing of the individual with ADHD. In its severe presentation, ADHD is markedly impairing, due to its deleterious impact on social, familial, and scholastic/occupational functioning (Hinshaw & Melnick, 1995; Hoza et al., 2005).

Individuals with ADHD have significant difficulty regulating their initial thoughts, behaviors, and emotions during a given task, thereby impacting their ability to successfully manage tasks and achieve their desired outcomes (Barkley, 2006). A main feature of ADHD is difficulty (p. 115) with behavioral inhibition and self-regulation, with several models supporting this (Cleary & Zimmerman, 2004). One such model primarily conceptualizes ADHD as an issue of behavioral inhibition, which in turn, leads to a flawed concept of time awareness culminating in ineffective time management (Barkley, 2006). This model closely links ADHD and its constructs to executive function—a system that underlies the capacity for self-organisation and goal-directed actions; thus, impairments in executive functioning result in behavioral disinhibition. Barkley claims that the foundation for the key symptoms of ADHD (i.e., impulsivity, inattention, and hyperactivity) is the result of the initial inability to diminish pre-potent responses to a given situation. Behavioral inhibition allows individuals to halt an on-going response or response pattern; thus, creating a delay and permitting self-directed action (Barkley, 2006). These self-directed actions are outlined by core executive function processes, such as planning and working memory (Elliott, 2003); this delay in time and executive functioning during normative functioning is what leads to effectual and appropriate actions in addition to appropriate expression of emotions in relation to a task. In contrast, for individuals with ADHD, difficulties inhibiting behavior and creating this delay indicates they are often unable to prevent immediate responses to situations, such as answering or talking out of turn, moderating emotional responses, controlling movements, or maintaining attention and focusing on tasks with little immediate reward or positive consequence (Travell & Visser, 2006).

Emotional impairments in children and adolescents with ADHD involve poor self-regulation of emotion, excessive emotional expression, problems with anger and aggression, and greater problems coping with frustration and empathy. Studies show that children with emotional and behavioral difficulties are impulsively emotional and lack the ability to regulate their behavioral responses to emotionally provoking events when compared to children without emotional and behavioral difficulties (Cross, 2011).

Comorbidity

ADHD is highly comorbid with externalising disorders such as conduct disorder and oppositional defiant disorder (ODD) (with comorbidity rates ranging from 43% to 93%) and internalising disorders (with comorbidity rates ranging from 13% to 51%) including anxiety and depression (Jarrett & Ollendick, 2008). Moreover, children with ADHD are highly likely to develop ODD, which involves difficulties with expressions of anger, hostility, frustration, and aggression toward others, especially towards authority figures such as parents, alongside problems such as disobedience. Boys with ADHD and comorbid ODD or conduct disorder in particular, have been found to suffer from the impaired regulation of negative emotions (Melnick & Hinshaw, 2000). Concordantly, approximately 45% of children with ADHD may also develop conduct disorder. Furthermore within a subset of those with ADHD and conduct disorder the likelihood of childhood psychopathy such as callousness, lack of emotion and low empathy for others is increased (Waschbusch, 2002).

Importantly, callous unemotional traits have been found to be prevalent in ADHD even after controlling for conduct disorder (Musser et al., 2013). Marsh et al. (2013) compared ten to 17 year olds with and without psychopathic traits on the subjective experiences of emotion during five recent emotionally evocative life events. Their findings revealed that fewer children with psychopathic traits reported the subjective experience of fear relative to other emotions. These results suggest that comorbid psychopathy impairs fear learning, physiological responses to threats, and the recognition of fear in others, as these children have difficulties expressing and displaying pro-social emotions and behaviors, which is characterized by lower levels of empathy, a lack of a sense of guilt or remorse, shallow or blunted affect, in conjunction with physiological under arousal (p. 116) (Kimonis et al., 2008). These callous unemotional traits are therefore, important when considering emotional arousal and regulation in ADHD. As but one example, Musser et al. (2013) tested ADHD children with age appropriate levels of pro-social behaviors and those with low levels of pro-social behaviors on affect based tasks measuring emotional suppression and arousal. The results from this study showed that children with ADHD and low pro-social behaviours displayed a reduced level of arousal and elevated emotion dysregulation, which highlights the significance of physiological responses in ADHD and emotion regulation.

ADHD also has a negative effect on the emotional wellbeing of the affected child or adolescent, including those at risk for major depression (Edbom et al., 2006). Research additionally shows that 75% of children diagnosed with ADHD are likely to have mood disorders and are therefore, at an increased risk of developing depression (Biederman et al. 2008). Furthermore youths with ADHD show greater levels of depressive symptoms, compared to those without ADHD (Lee et al., 2008). A recent study by Seymour et al. (2014) found that emotion regulation mediated symptoms of depression in ADHD youth, such that young people with ADHD and comorbid depression exhibited poor emotion regulation strategies. Seymour et al. argue that this could be as a result of executive function deficits, in particular working memory. Specifically, those with impairments in working memory and inhibition experience and express heightened emotions in response to emotionally laden stimuli when compared to individuals with intact working memory; as working memory affects the ability to effectively appraise emotional stimuli and supress negative and positive emotions.

Executive dysfunctions

Executive functions are a set of inter-related cognitive processes that allow for effective problem solving, and facilitate goal directed activities; these processes are comprized of inhibition, working memory, attention shifting, planning, initiating tasks, detecting and correcting errors (Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). Researchers indicate that self-regulatory processes underlie cognitive, behavioral and emotional regulation (Berger, Kofman, Livneh, & Henik, 2007; Posner & Rothbart, 1998). This suggests that executive functions are involved in the self-regulation of emotions in goal directed situations (Zelazo & Cunningham, 2007).

Emotion regulation has been found to be consistently linked to inhibitory processes; for example, a study of typically developing preschool children’s performance on an emotion regulation task (i.e., responses to a disappointing gift) significantly correlated with responses on tasks investigating inhibitory processes (i.e., Simon Says) and suppression or slowing of responses (e.g., not pulling a lever or drawing a line very slowly) (Carlson & Wang, 2007). Moreover, a study measuring the performance of young adults during a Stroop task revealed that this measure of inhibitory functions and conflict monitoring was linked with the ability to successfully manage negative responses to unfamiliar and visually unappetizing food (Kieras, Tobin, Graziano, & Rothbart, 2005). Additionally, when asked to divide their attention by remembering an eight-digit number during a task to challenge executive function processing capacity, individuals were increasingly found to have difficulties modulating their negative responses. This is supported by Walcott and Landau’s (2004) findings, in that emotion regulation was strongly associated with the speed of the inhibition process using tasks such as the Stop Signal Reaction Time Task (SSRT).

Hoeksma, Oosterlan, and Schipper (2004) found that in children aged between ten and 13 anger variability over a number of days was strongly associated with outcomes on SSRT, which measures the time needed to stop an inappropriate response. This is a further indication of behavioral inhibition, as studies show that deficits in SSRT also reflect impairments in attentional and cognitive processes (Alderson, Rapport, & Kofler, 2007). Rich et al. (2008) showed that children (p. 117) with severe mood disorder had problems with attentional orienting and initial attentional processing; moreover, approximately 80% of their participants had comorbid ADHD. This suggests that the underlying processes involved in ADHD are also related to attentional processes and emotion regulation, supporting the view that executive function task difficulties are closely linked to ADHD and emotion regulation (Skirrow, McLoughlin, Kuntsi, & Asherson, 2009).

As outlined earlier, children with ADHD consistently display deficits in most areas of executive functions (Barkley, 2006). Research suggests that behavioral disinhibition is an important characteristic of ADHD; Nigg (2001) suggests there are two distinct forms of impairments in inhibition that can be applied to ADHD. Firstly, motivational inhibition automatically ceases an on-going response that is usually caused by fear or anxiety as a result of a novel event. Secondly, executive inhibition involves processing of the deliberate suppression of a response for goal-directed purposes. As proposed by Barkley’s (1997) behavioral disinhibition theory, children with ADHD do not effectively respond to social circumstances, but rather display rules detached from the emotional context of the situation. These children therefore, appear more dysregulated as they fail to consider social cues and rules, thereby appearing more socially dysregulated. According to this theory, the successful regulation of emotions would therefore, depend on successful behavioral inhibition. This is supported by a study investigating behavioral disinhibition and its associations to emotion regulation using a frustration-inducing task (Walcott & Landau, 2004). In this study, boys with and without ADHD were explicitly given instruction to hide their emotional display in the presence of a peer. Results determined that boys with ADHD failed to succeed on this task, whereas, non-symptomatic boys were more effective at regulating their emotional displays in response to contextual demands. Importantly, disinhibition scores were higher for boys with ADHD than those without ADHD (Walcott & Landau, 2004).

The findings discussed above are generally supported by imaging data investigating executive processes and ADHD, whereby the frontal regions of the brain are associated with inhibitory control and emotional processing (Posner et al., 2011). Thus, children with ADHD are shown to have increased activation in prefrontal regions, relative to healthy controls on an emotional processing task; these findings were specific to emotional processing even after controlling for cognitive processes. Essentially, this indicates that normal function in the prefrontal regions are impaired in ADHD, however, they may also mediate or facilitate affective responses i.e., negatively valenced words such as “kill” drew increased attention than neutral words such as “month;” similarly positive words could induce self-reflection to a greater extent than neutral words (Posner et al., 2011).

In relation to emotion regulation, Shaw et al. (2014) proposed a top-down regulatory process and bottom-up mechanistic theory to explain the processes affecting emotion regulation in ADHD. According to a bottom-up psychological mechanism, the attention systems identify emotionally significant stimuli and exert control—an aspect that is thought to be impaired in ADHD. In contrast, in healthy individuals, affectively salient stimuli receive appropriate sensory coding and early detection, whilst this effect is significantly reduced in ADHD as a result of heightened emotions (i.e., the over perception of negative stimuli). Concordantly, the accurate identification of emotions in human faces is associated with well-regulated behavior; thus, misperception could be caused as a result of emotion dysregulation. Furthermore, aversion to delayed rewards is an indication of impulsivity; this is mediated in the limbic regions of the brain, which are also responsible for emotion processing; thus, it is probable that these brain regions may also be involved in emotion regulation (Musser et al., 2013; Shaw et al., 2014).

In relation to top-down regulatory processes, the importance of the autonomic nervous system is paramount, as it recognizes emotional valence and task demands, particularly when the stimuli are negative rather than positive. This is difficult for those with ADHD because they lack physiological indicators of regulation. Thus, the inability to focus on a goal or allocate appropriate levels (p. 118) of attention to a task means that individuals with ADHD have difficulties managing emotions or focusing on emotional stimuli. For example, when completing an emotional Stroop task, the performance of adolescents with ADHD is severely impaired when compared to healthy counterparts (Posner et al., 2011).

Neural mechanisms

ADHD is a neurodegenerative disorder with most models highlighting deficits in the frontal lobe networks. In particular the prefrontal cortex (PFC) region has been consistently found to mediate cognitive control processes, including decision-making and emotion regulation, in particular the orbitofrontal cortex, dorsomedial prefrontal cortex, anterior cingulate gyrus, dorsolateral prefrontal cortex and ventrolateral prefrontal cortex (Phillips, Ladouceur & Drevets, 2008). Shaw et al. (2014) claim that for individuals with ADHD, the prefrontal regions, including the ventrolateral, orbitofrontal and medial prefrontal cortices are impaired. Plessen and colleagues (2009) suggest that deficits in the connections between the amygdala and orbitofrontal cortex may lead to behavioral disinhibition. The orbitofrontal cortex is strongly connected with the amygdala, thalamus and multiple cortical regions, thus, it is an important region involved in emotion regulation processes. In addition, the amygdala plays a crucial role as it is involved in processing emotion and emotional behavior.

The majority of studies have shown amygdala hyperactivation in ADHD, during both the subliminal perception of fearful expressions and while subjects rated their fear of neutral faces (Malisza et al., 2011). These findings are similar to behavioral measures of delay aversion, during which amygdala hyperactivation was observed for the processing of delayed rewards (Plichta et al., 2009). The anticipation (and receipt) of rewards causes reduced ventral striatum responsiveness in ADHD, thus contributing to aversion delay. This is supported by dysfunction in a neural network composed of the amygdala, ventral striatum, and orbitofrontal cortex, which mediates emotional stimuli, and is implicated in emotion regulation. Therefore, Shaw et al. (2014) have argued that emotion dysregulation in ADHD implicates dysfunction in the amygdala, ventral striatum and orbitofrontal cortex. Relatedly, lesion studies have shown that the orbitofrontal region, in particular, is important for the generation of emotional states and emotion regulation (Ochsner & Gross, 2004). Thus, neural theory predicts (Shaw et al., 2014) deficits in these regions are strongly associated with symptoms of both ADHD and emotion dysregulation.

Emotion dysregulation

One of the earlier models for emotional dysregulation (ED) (Cicchetti, Ackerman, & Izard, 1995) posited that regulating emotion requires certain control mechanisms involving structure or a strategy that will allow for co-ordination and actions. Cicchetti and colleagues (1995) outlined four of these aspects: Firstly, control concerns the cause of felt emotion, involving cognitive and affective mechanisms. Secondly, control structures mediate the output of this emotional system, whereby earlier mechanisms of cognitive and affective processes are reflected in expression. Thirdly, control structures coordinate expression and inhibit responses based on context. Finally, this control structure deviates for those with externalising and internalising problems, as these individuals tend to suffer from weak or absent control structures. As such, individuals with ADHD are thought to have problems moderating or suppressing the emotional reactions they experience, leading to impulsive and severe emotional reactions toward events when compared to non-ADHD individuals of a similar age. Emotion dysregulation therefore, results from a lack of knowledge concerning affective behavior or difficulty in modulating emotional responses to social situations or environmental demands (Saarni, 1999).

(p. 119) Impairments in emotional control are closely associated with hyperactive and impulsive symptoms, and likely arise from the poor inhibitory capacity involved in ADHD (Barkley, Murphy, & Fisher, 2008). Observational studies show that children with ADHD display heightened emotional reaction and frustrations compared to their non-ADHD peers; this is further supported by parent reports of increased levels of sadness, anger and guilt. Importantly, these youth have difficulty self-regulating these negative emotions (Berlin, Bohlin, Nyberg, & Janols, 2004; Braaten & Rosen, 2000; Melnick & Hinshaw, 2000). Moreover, as irritability is an aspect of reactive aggression and emotional outbursts, it is considered one of the main outcomes of emotion dysregulation in ADHD (Leibenluft, 2011). In fact, a study examining ADHD children with and without irritability found increased rates of ODD and depression/dysthymia in children with irritable mood and ADHD (Ambrosini, Bennet, & Elia, 2013).

A recent meta-analysis by Shaw et al. (2014) revealed a consistent increase in aggressive behavior in ADHD compared to non-ADHD samples. Their results suggest a strong association between aggression and hyperactivity-impulsivity rather than between aggression and inattention. Emotion dysregulation was further reflected in frustration inducing situations in ADHD. In addition, children with ADHD were more likely to express negative affect and have emotional outbursts when compared with non-ADHD participants during challenging tasks. Based on their meta-analysis Shaw et al. (2014) described three distinct features of ADHD and emotion dysregulation. The first feature suggests that at its core, emotion dysregulation is a main characteristic of ADHD and its symptoms of hyperactivity, impulsivity and inattention, are reflective of deficits in executive functions. The second feature considers ADHD and emotion dysregulation as a unique entity, formed as a result of distinct neurocognitive features and the clinical outcomes for those with the combination of ADHD and emotion dysregulation. The third feature refers to the fact that symptoms of ADHD and emotion dysregulation overlap and are underlined by dissociable neurocognitive deficits such as impairments in executive function, which impacts decision-making and emotional control. This model is supported by correlations observed for deficits in emotional processes, for example in emotion recognition and frustration tolerance (Banaschewski et al., 2012); however it is important to note that not all those with ADHD display impaired levels of emotion dysregulation

Results from longitudinal studies reveal that ADHD symptoms and emotion dysregulation difficulties emerge in early childhood and continue into adulthood (Biederman et al., 2012). Skirrow, McLoughlin, Kuntsi, and Asherson (2009) argue that these symptoms of emotional dysregulation significantly differ from mood instability, as mood instability is used to describe volatile, irritable and changeable mood with a hot temper and low frustration tolerance in the absence of underlying deficits. Emotion dysregulation however, is believed to be an active modification or alteration of on-going emotional responses. These responses are associated to emotions linked with the environment and therefore, part of emotional patterns. Therefore, those with emotion dysregulation do not usually suffer from mood instability, as mood instability arises from existing processes that lead to deviant emotional responses independent of regulatory processes.

Development

Research shows a strong association between ADHD and emotion dysregulation (Sjöwall, Roth, Lindqvist, & Thorell, 2012). Stringaris and Goodman’s (2009) study examining 5,326 youth found mood lability (i.e., poorly controlled shifts in emotion) in 38% of children with ADHD. Parent reports of the Child Behaviour Checklist revealed that adolescents with mood and aggression problems also tended to suffer from attention difficulties and were more likely to suffer from (p. 120) emotion dysregulation among those likely to have ADHD (Althoff et al., 2006). Shaw et al. (2014) noted that clinic-based studies in young people with ADHD conveyed similar levels of emotion dysregulation, ranging between 24% and 50%.

Longitudinal research of children with ADHD spanning into adulthood has rarely considered emotion dysregulation, but rather has focused on outcomes from the DSM-IV disruptive and antisocial disorders (Klein et al., 2012). Stringaris, Maughan, and Goodman (2010) conducted a longitudinal study of 7,140 children and found that temperamental emotionality in three-year-olds predicted co-morbid ADHD with internalising disorders by the age of seven. Another longitudinal study by Sanson, Smart, Prior, and Oberklaid (1993) showed that infants who developed hyperactive symptoms alone did not differ in their temperament from typical infants; whereas, children who developed ADHD and aggressive traits were prominently uncooperative and irritable from infancy. Therefore, a difficult temperament with significant negative emotionality has been linked with later ADHD combined with emotion dysregulation. Nonetheless, environmental factors such as parental criticism and hostility were associated with the development of conduct problems in children with ADHD, and with the development of childhood ADHD in pre-schoolers with behavioral problems. Shaw et al. (2014) claims that poor parental emotion regulation is reflected in high levels of hostility, thereby contributing to the development of emotional dysregulation in children with ADHD.

Transition from adolescence to adulthood

Transitions during the adolescent years has been associated with numerous issues affecting social interaction and emotional outcomes. Resultantly, low self esteem may manifest due to poor relationships with peers and the inability to effectively participate in social exchanges such as sharing, cooperating, and turn taking. These issues are adversely affected for those with ADHD as a result of delayed self-regulation (Barkley, 2006). These outcomes are further linked to impairments in self-esteem and sociability (Hoy et al., 1978). Research shows that the symptoms of ADHD are continuously changing during the adolescent years and into adulthood (Wolraich et al., 2006). In particular, hyperactivity becomes less prominent during this age, compared to inattention, which tends to remain persistent during adulthood (Barkley, 2006). Unlike hyperactivity, symptoms of inattention and executive function difficulties greatly affect academic achievement more so than symptoms of hyperactivity and impulsivity. Nonetheless, deficits in certain aspects of executive functioning (e.g., working memory) may prevent adolescents from reading, listening and comprehending and therefore, planning, which results in future rewards being less valued (Barkley, 2006). Furthermore, adolescents with ADHD are more likely to display poor delay of gratification and are less likely to persevere with set goals and have poor emotion regulation competencies as a result of deficits in anger and frustration control (Barkley, 2006).

Emotional dysregulation is considered to be an important feature of adult ADHD with 34–70% of adults in clinical samples of ADHD reporting impaired emotion regulation (Able, Johnston, Adler, & Swindle, 2007). Aggressive behaviors also continue to be persistent, as indicated in a study of 950 adults diagnosed with ADHD. As reported by Able et al. (2007), those with ADHD scored themselves higher in interpersonal conflict and reported negative, conflicted social ties. Somewhat similarly, a longitudinal study investigating the outcomes of ADHD children found higher rates of emotion dysregulation in adults with persistent ADHD when compared with adults with remitted ADHD. This suggests that as symptoms of ADHD improve, so too does emotion dysregulation (Shaw et al., 2014).

(p. 121) Clinical implications

Empirical findings demonstrate physiological and observable behaviors consistent with ED in children with ADHD (Musser et al., 2011; Musser, Galloway-Long, Frick, & Nigg, 2013; Seymour et al., 2012; Walcott & Landau, 2004). These include demoralization, learned helplessness, low self-esteem, fear and anxiety, increased frustration and occupational challenges. Previous studies have found ADHD boys to be socially inflexible, emotionally intense with poor attention and concentration levels (Sanson, Smart, Prior, & Oberklaid, 1993). Using an unsolvable puzzle task to elicit aggression, boys with ADHD who were considered highly aggressive were further found to be more emotionally reactive and less effective at emotion regulation than boys with low levels of aggression and without ADHD (Hinshaw & Melnick, 1995). This suggests that aggression rather than ADHD is responsible for this level of emotional response. Additional manifestations of emotion dysregulation involve over-reactivity to positive and negative emotions (Martel & Nigg, 2006), lack of emotional control (Erhardt & Hinshaw, 1994; Saunders & Chambers, 1996); and impatience which most likely leads to peer perceptions of youth with ADHD as easily excited, disruptive, or intrusive in their social interactions (Landau & Moore, 1991). Children with inattentive presentations of ADHD show emotion dysregulation enhanced by emotional intensity and display heightened emotions (Wheeler, Maedgen & Carlson, 2000).

Negative emotionality however is also a characteristic of ODD which includes loss of temper, as the child gets easily angry and resentful (Barkley et al., 2010). Negative emotionality is similar to emotional dysregulation, however it is a risk-factor for ED (Belsky, Friedman, & Hsieh, 2001) and is considered a risk factor for developing ODD in children with ADHD (Martel & Nigg, 2006). Children and adolescents with ADHD are therefore more likely to experience impairments in social relationships, as they exhibit aggressive behaviors and consistent rule breaking unlike typically developing peers (Buhrmester, Whalen, Henker, MacDonald, & Hinshaw, 1992).

Treatment

Treatments for ADHD involve a broad range of options including behavioral therapy, psychotherapeutic approaches and pharmacotherapy; the aim of treatment is to treat the disorder as early and as effectively as possible. When considering non-pharmacological treatments, studies show that parent and family education is important, along with effective parent training in behavioral management involving teachers to improve classroom behaviors. These treatments indicate that with appropriate behavior modification training and special education placement, outcomes for children with ADHD can be greatly improved (Thompson et al., 2004). In addition, treatment programs have shown that the management of adolescents with ADHD can be effective; these include parent and teacher training in behavioral management, particularly contingency management methods applied in classrooms and similar settings, such as summer camp (Antshel & Barkley, 2008). However, Barkley (2006) argues that interventions for behavioral management in children with ADHD are most effective when inappropriate behaviors are targeted in the child’s natural environment, as it occurs. Subsequently, Barkley suggests it is important to assist the child/individual in understanding suitable behavior which is contextually expected.

Most psychosocial treatment programs involve a multimodal treatment plan part of which includes medication (Jensen et al., 2001). The Multimodal Treatment Study of Children with ADHD investigated long term outcomes of interventions, including medication and behavior modification in combination and alone. The results showed that medication alone and medication with behavior modification was superior to behavior modification alone or standard community care (MTA Cooperative Group, 1999). Apart from decreasing levels of ADHD symptoms, (p. 122) these two intervention strategies improved aggressive behavior, social skills, academic achievement, and parent-child relationships. Stimulant medications such as methylphenidate have been found to be effective in improving academic outcomes and emotional wellbeing. In addition, a study evaluating the effectiveness of multimodal psychosocial treatment of children with ADHD being treated with methylphenidate reported a consistent pattern of improvement in academic achievement and emotional status, particularly self-esteem and ratings of depression (Hechtman et al., 2004). Non-stimulant medications, such as atomoxetine have also been found to reduce core ADHD symptoms, improve social interactions and quality of life in children and adolescents with ADHD (Cheng et al., 2007; Wilens et al., 2006).

In relation to psychological intervention, Cognitive Behavioural Therapy (CBT) has been shown to benefit individuals with ADHD by helping them to understand and categorize the emotions they experience accurately. Importantly, CBT has been found to help with labeling emotions correctly and coping with intense negative reactions (Mongia & Hechtman, 2012). Moreover, these skills can be developed alongside mindfulness training (Mongia & Hechtman, 2012), which promotes present centered focused awareness of emotions (Farb et al., 2007). Additionally, interventions aiming to treat avoidance behavior and mood disturbances in ADHD may also improve emotion regulation by enhancing motivation and providing individuals with strategies to cope with daily life (Mongia & Hechtman, 2012).

Considering emotion dysregulation in ADHD treatment has been challenging, primarily this is due to the fact that studies have measured emotional changes as a secondary outcome (Shaw et al., 2014). However, one of the few studies measuring the attributes of stimulants on emotional expression found improvement in emotional dysregulation, parallel to improvements observed in hyperactivity and impulsivity (Mccracken et al., 2003). According to Manos et al.’s (2011) literature review, emotional lability and irritability reduced by 3% in ADHD as a result of medication alone. Stimulants have also been found to improve emotion recognition, whilst concurrently improving performance (Conzelmann et al., 2011). These findings are supported by neural activities, as medicated adolescents have been found to have reduced activity in the prefrontal regions, similar to healthy controls, contrasted by increased reactivity found in ADHD participants not taking medication. ADHD adolescents taking medication were found to have better performance on emotional processing tasks when compared to ADHD adolescents without medication. Shaw et al. (2014) suggest that stimulant treatment of the core symptoms of ADHD also leads towards improvement in emotion dysregulation. Additionally, behaviour modification combined with medication is effective at reducing externalising and internalising symptoms, which are linked with emotion dysregulation (Stringaris & Goodman, 2009).

Conclusions

ADHD is one of the most commonly occurring psychiatric disorders of childhood (Spencer, Biederman, & Mick, 2007). Moreover, it frequently persists into adolescence and adulthood and is associated with multiple functional impairments. Research has revealed that externalizing behavioral problems and social impairment are associated with emotion dysregulation in children with ADHD (Wheeler, Maedgen & Carlson, 2000; Melnick & Hinshaw, 2000; Parker, Majeski, & Collin, 2004). Emotion dysregulation is strongly linked to inhibitory deficit, which may manifest into socially inappropriate behavioral responses to extreme emotional expression and the inability to self-regulate (Barkley, 2006). This then suggests the individual finds it difficult to self-soothe during enhanced emotional experiences, focus on the task at hand, and to organize thoughts to achieve goal driven behavior (Lynn, Carroll, Houghton, & Cobham, 2013). The association (p. 123) between emotion dysregulation and ADHD has been mainly explored in children; therefore, generalizability across developmental stages remains largely unaddressed. Moreover, ADHD is highly comorbid with the internalising/externalizing disorders which significantly impact emotion dysregulation, yet very few studies have considered the effect of subtype or comorbidity on emotion dysregulation (Wheeler, Maedgen & Carlson, 2000; Melnick & Hinshaw, 2000).

In summary, emotion dysregulation affects approximately 25–45% of children and between 30–70% of adults with ADHD. It represents a major source of impairment and presages a poor clinical outcome (Shaw et al., 2014). Emotion dysregulation in ADHD may be caused through deficits at multiple levels, ranging from abnormal early orientation to emotional stimuli to deficits in cognitive processes, in particular working memory and response inhibition. Although these deficits may contribute to emotion dysregulation they alone do not explain its presence in ADHD, as the underlying mechanism is likely complex, and is influenced by impairments in neural networks in the prefrontal cortex and executive functioning processes.

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