ADHD: Emotional dysregulation

Since emotional symptoms are common in ADHD patients and commonly associated with much morbidity, some consider it to be a core feature rather than an associated trait. Others argue that emotional symptoms are too nonspecific for use as diagnostic criteria. This review gives guidance to clinicians and patients on the topic.


Article summary

Dr. Russell A. Barkley, Ph.D., who wrote the unifying theory of ADHD (Barkley, R. A. (1997) back in 1997, which is today the de facto foundation of our collective knowledge of ADHD, have since then tried to get Emotional Dysregulation (ED) (back) into the symptomatology of ADHD, but to no prevail in DSM-5, in ICD-11 though, it seems to have been adopted, but time will tell in 2022.

On the historical background of ED, Dr. Barkley, Ph.D. writes: […] ADHD is currently understood to be a disorder of inattention, impulsivity, and usually hyperactivity that arises in childhood or early adolescence and is highly persistent over time in most cases. However, since the first medical papers have been published on ADHD starting in 1798, emotion has always been included in the conceptualization of the disorder up through the 1970s. But beginning with DSM-II and progressing to the present, emotional dysregulation has been excluded from the clinical conceptualization of the disorder and the diagnostic criteria and relegated to an associated problem or the result of comorbid disorders. […] (Barkley, R.A. (2015))

Plain language summary

Emotions run high in people with ADHD, that is common knowledge, but what is not completely understood, is why? Emotional Dysregulation means that the ability to manage emotions is impaired, due to Emotional Impulsivity (EI) and Deficient Emotional Self-regulation (DESR). EI refers to the lability in which people with ADHD emote (e.g. quick to anger, easily emotionally excitable), and DESR refers to the impairment to emotionally self-regulate emotions (e.g. suppressing a negative emotional state, while focusing on replacing that with a positive emotional state instead, or trying to divert attention to the stimuli that is creating that emotional state (e.g. holding your hands over your ears or eyes). Since these normal functions are impaired in people with ADHD (due to the age-inappropriate development of inhibitory control, causing the hyperactive, impulsive, inattentive, and emotional volatility).

Faraone et al., (2019) argues that Emotional Dysregulation (ED) is a core component of ADHD, and he provides evidence for why it is so. Likewise he provide guidelines on how to test for these symptoms, referring to a multitude of different tests that could be used, in diagnosing emotional symptoms in ADHD, both in children, adolescents, and adults.

The definition of what ED is, is still under scholarly debate, but Dr. Barkley, Ph.D. have provided a plausible definition already in 2010, which defines the core areas of symptomatology of Emotional Dysregulation: […] Two dimensions of age-inappropriate behavior comprise the central elements in the current conceptualization of attention-deficit/hyperactivity disorder (ADHD), these being inattention and hyperactivityimpulsivity. This conceptualization may ignore an equally compelling and central role of emotional impulsivity (EI) in the disorder. These impulsive emotions are impatience, low frustration tolerance, hot-temperedness, quickness to anger, irritability, and easily emotionally excitable. Emotional self-control may involve at least two stages: (1) the inhibition of the emotional reactions provoked by events, and (2) the subsequent self-regulation of the emotional state to be more socially appropriate and consistent with longer-term goals.[…] (Barkley et al., (2010))


Watch this lecture on Emotional Dysregulation in ADHD

Dr. Russell A. Barkley, Ph.D. explains the scientific evidence for Emotional Dysregulation.

REVIEW FROM FARAONE ET AL. ON EMOTIONAL DYSREGULATION

Practitioner Review: Emotional dysregulation in ADHD
implications for clinical recognition and intervention

Study Conclusion

Key points

  • There is a high prevalence of emotional symptoms (ES) in children, adolescents, and adults with ADHD.
  • Many terms have been used to describe emotional symptoms – including emotional lability or emotional impulsivity (EI), deficient emotional self-regulation (DESR), distress intolerance (DI) and even severe mood dysregulation (SMD); this non-standardized nomenclature could lead to clinical confusion.
  • ADHD is associated with many symptoms of emotional impulsivity (EI) and deficient emotional self-regulation (DESR), which can be considered as important presenting features and potential treatment targets.
  • Irritability should not be considered as a symptom of ADHD. Emotional impulsivity (EI) and disrupted emotional self-regulation may be more specific to the disorder.
  • DSM and ICD guidelines for defining mood disorders are sufficient for demarcating ADHD from bipolar (BD), major depressive (MDD) and disruptive mood dysregulation disorders (DMDD).

Faraone, S. V., Rostain, A. L., Blader, J., Busch, B., Childress, A. C., Connor, D. F., & Newcorn, J. H. (2019, February 1). Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. Journal of Child Psychology and Psychiatry and Allied Disciplines. Blackwell Publishing Ltd. https://doi.org/10.1111/jcpp.12899

ABSTRACT

BACKGROUND: Because emotional symptoms are common in attention-deficit/hyperactivity disorder (ADHD) patients and associate with much morbidity, some consider it to be a core feature rather than an associated trait. Others argue that emotional symptoms are too nonspecific for use as diagnostic criteria. This debate has been difficult to resolve due, in part, to the many terms used to describe emotional symptoms in ADHD and to concerns about overlap with mood disorders.

METHODS: We sought to clarify the nature of emotional symptoms in ADHD by reviewing conceptual and measurement issues and by examining the evidence base regarding specificity of such symptoms for ADHD. We reviewed the various terms used to define emotional symptoms in ADHD, clarify how these symptoms are demarcated from mood disorders, and assess the possibility that symptoms of emotional impulsivity and deficient emotional self-regulation should be considered as core symptoms. We addressed psychiatric comorbidities, the effects of ADHD treatments on associated emotional dysregulation, and the utility of current rating scales to assess emotional symptoms associated with ADHD.

RESULTS: Emotional symptoms are common and persistent in youth and adults with ADHD. Although emotional symptoms are common in other psychiatric disorders, emotional impulsivity (EI), and deficient emotional self-regulation (DESR) may be sufficiently specific for ADHD to function as diagnostic criteria.

CONCLUSION: Emotional symptoms in ADHD cause clinically significant impairments. Although there is a solid theoretical rationale for considering EI and DESR to be core symptoms of ADHD, there is no consensus about how to define these constructs sin a manner that would be specific to the disorder. An instrument to measure EI and DESR which demarcates them from irritability and other emotional symptoms could improve the accuracy of diagnostic criteria for ADHD.


INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder diagnosed by symptoms of age-inappropriate inattention, hyperactivity, and impulsivity that cause impairment in two or more domains of daily life (Faraone et al., 2015). Many iterations of the DSM since DSM-III view emotional symptoms as an associated feature supporting the diagnosis of ADHD. In contrast, in descriptions of the disorder prior to DSM-III, emotional symptoms had a prominent role in characterizing ADHD youth (Barkley, 2015) and such symptoms were core criteria of the Wender Utah Criteria for adults (Ward, Wender, & Reimherr, 1993). Despite recognition that intense, emotionally charged behavior was common in ADHD, DSM-III’s framing the disorder in terms of inattention and under inhibited behavior de-emphasized affective disturbances and excluded them from diagnostic criteria. Since then, however, research has only strengthened the association between ADHD and emotion-related problems. Forty to 50% of children with ADHD have significant impairments that stem from rages, irritability, or other manifestations of susceptibility to anger and low tolerance for distress (Anastopoulos et al., 2011; Barkley, 2015; Barkley & Fischer, 2010; Biederman et al., 2012; Karalunas et al., 2014; Liu et al., 2016; Shaw, Stringaris, Nigg, & Leibenluft, 2014; Skirrow & Asherson, 2013; Sobanski et al., 2010; Spencer et al., 2011). We will refer to these collectively as ‘emotional symptoms’. These symptoms are more prevalent in the combined subtype (now called ‘presentation’ in DSM-5) of ADHD compared with other subtypes and their severity increases with the severity of other ADHD symptoms (Sobanski et al., 2010; Vidal et al., 2014). Emotional symptoms are also common among adults with ADHD (Barkley & Fischer, 2010; Skirrow & Asherson, 2013; Surman et al., 2011, 2013). Due to the high prevalence of emotional symptoms among patients with ADHD along with prevailing models of ADHD that emphasize the inadequacy of self-regulatory functions, some consider emotional symptoms integral to ADHD, rather than an associated trait (Barkley, 2015; Barkley et al., 2000; Nigg & Casey, 2005; Sagvolden, Johansen, Aase, & Russell, 2005). On the other hand, emotional symptoms are not specific to ADHD and are present variably among patients with the disorder (Copeland, Brotman, & Costello, 2015; Stringaris, Cohen, Pine, & Leibenluft, 2009), casting uncertainty on the merits of including them as a ‘core feature’ of ADHD. Although there is substantial debate about the nature of emotional symptoms in ADHD and whether they should someday be incorporated into the diagnostic nomenclature, there is little question about their importance.

Many studies have shown that such symptoms have a serious impact on patients with the disorder. In a study of 358 children aged 5–12 years with ADHD, emotional symptoms correlated with impaired social, daily living, and adaptive skills and were associated with increased rates of treatment service utilization (Anastopoulos et al., 2011).

Children with ADHD and higher levels of emotional symptoms were rated as less likeable by unfamiliar peers in playgroups (Lee etal., 2017).

Higher levels of emotional excitability/impatience, lack of behavioral control with strong emotions and inflexibility/slow return to baseline associate with parent and self-rated social impairment in adolescents. (Bunford, Evans, & Langberg, 2018).

Children with ADHD and emotional symptoms are more likely to have hyperactive/impulsive symptoms continuing into early adulthood as well as a lower likelihood that fully syndromic ADHD will remit (Biederman et al., 2012).

People with ADHD and emotional symptoms have significantly lower quality of life, significantly worse social adjustment and reduced marital status compared to those with ADHD and no emotional symptoms (Surman et al., 2013).

Among people with ADHD, emotional symptoms associate with unemployment, poor work performance and peer relations, and being fired or quitting work out of boredom.Emotional symptoms associate with fewer years of schooling, decreases in the likelihood of graduation from high school and college, and higher rates of suspensions and expulsions from school. Patients with ADHD and emotional symptoms are more likely to have had driver license suspensions, traffic tickets and financial problems than those without emotional dysregulation (Surman et al., 2013).

Given the serious impact of emotional symptoms on people with ADHD, the present review sought to clarify the nature of these symptoms in ADHD.

We first review conceptual and measurement issues and examine the evidence base regarding specificity of such symptoms for ADHD. We then evaluate implications for both medical and psychological treatments.

For more information on this topic, read the full article here: Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention


REFERENCES

Barkley, R.A. (2015). Emotional dysregulation is a core component of ADHD. In R.A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edn). New York: Guilford Press.

Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65–94. https://doi.org/10.1037/0033-2909.121.1.65

Barkley, R. A., & Fischer, M. (2010). The Unique Contribution of Emotional Impulsiveness to Impairment in Major Life Activities in Hyperactive Children as Adults. Journal of the American Academy of Child and Adolescent Psychiatry, 49(5), 503–513. https://doi.org/10.1097/00004583-201005000-00011

Faraone, S. V., Rostain, A. L., Blader, J., Busch, B., Childress, A. C., Connor, D. F., & Newcorn, J. H. (2019, February 1). Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. Journal of Child Psychology and Psychiatry and Allied Disciplines, Vol. 60, pp. 133–150. https://doi.org/10.1111/jcpp.12899

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