A large proportion of children with attention-deficit/hyperactivity disorder (ADHD) exhibit notable emotion-related problems (or “emotional symptoms”)1. These emotional symptoms seem to associate with poor quality of life, impaired social adjustment and reduced marital status2,3. Furthermore, children with ADHD and emotional symptoms are more likely to have hyperactivity/impulsive symptoms that continue into early adulthood than those who do not present with these problems4. Addressing the underlying emotional mechanisms in affected patients could, therefore, have a marked impact on quality of life. Whether these emotional symptoms should be considered integral to ADHD (and thus incorporated into the diagnostic nomenclature)1 or rather as an associated trait5, however, is hotly debated.
In 2019, Stephen Faraone and colleagues compiled a Practitioner Review for the Journal of Child Psychology and Psychiatry that aimed to clarify the nature of emotional symptoms in ADHD. The researchers first identified that a large number of terms are used to describe the role of emotional symptoms observed in ADHD, which could lead to clinical confusion. Such terms include emotional lability (EL), emotional reactivity, emotional impulsivity (EI), emotional instability, emotional dysregulation, deficient emotional self-regulation (DESR), distress tolerance, frustration discomfort and irritability.
They then evaluated how the emotional symptoms in ADHD differ from those observed in other mood disorders. Here, they found that EI and DESR might be sufficiently specific for ADHD to function as diagnostic criteria, while irritability should not be considered a symptom of ADHD. Poignantly, the researchers point out that impulsive and poorly regulated cognition and behaviours are already in the diagnostic criteria for ADHD, yet corresponding impulsive and poorly regulated emotions are not. The fact that only a subset of patients with ADHD exhibit emotional dysregulation and that another subset of individuals without ADHD can also present with emotional dysregulation, however, is a challenge to address before contemplating changes to the diagnostic criteria. Faraone et al. assert that more accurate identification and description of EI and DESR would likely benefit those with ADHD as well as those with other psychiatric disorders.
The researchers reiterate that few symptoms in psychiatry are fully specific, and that this fact should be considered when deciding whether emotional symptoms should form part of the core disorder in ADHD. Going forward, they explain that improvements to available treatments to effectively manage EI and DESR are now needed. They also recommend that a new measurement tool or assessment instrument is created that can capture the multi-dimensional nature of emotional symptoms in ADHD. A useful tool would be able to identify emotional symptoms in young people with ADHD and better monitor any change in emotions with treatment.
A pdf version of this article is available to download.
Faraone, S.V., Rostain, A.L., Blader, J., Busch, B., Childress, A.C., Connor, D.F. & Newcorn, J.H. (2019), Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. J. Child Psychol. Psychiatr. 60: 133-150. doi: 10.111/jcpp.12899.
Emotional impulsivity (EI): Impulsivity is broadly defined in the DSM-V as actions that are poorly conceived, prematurely expressed, unnecessarily risky, and inappropriate to the situation. EI specifically was defined by Barkley in 20151 as difficulties with emotion generation that is highly impulsive.
Deficient emotional self-regulation: Defined by Barkley in 20151 as difficulties with the self-regulatory functions that effectively manage emotional experience to rein in behaviour from accelerating to problematic degrees.
1Barkley, R.A. et al. (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.
2Anastopoulos, et al. (2011), Self-regulation of emotion, functional impairment, and comorbidity among children with AD/HD. J. Atten. Disord. 15: 583–592. doi: 10.1177/1087054710370567.
3Surman, C.B. et al. (2013), Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: A controlled study. Atten. Defic. Hyperact. Disord. 5: 273–281. doi: 10.1007/s12402-012-0100-8.
4Biederman, J. et al. (2012), Longitudinal course of emotional self-regulation CBCL profile in youth with ADHD: Prospective controlled study. Neuropsychiatr. Dis. Treat. 8:267–276. doi: 10.2147/NDT.S29670.
5Copeland, W.E. et al. (2015), Normative irritability in youth: Developmental findings from the Great Smoky Mountains Study. J. Am. Acad. Child Adolesc. Psychiatry. 54: 635–642. doi: 10.1016/j.jaac.2015.05.008.