Attention-Deficit/Hyperactivity Disorder (ADHD) and Emotion Regulation Over the Life Span
- 177 Downloads
Purpose of Review
Emotional symptoms are common and persistent in youth and adults with attention-deficit/hyperactivity disorder (ADHD) and cause clinically significant impairments. We review recent neuropsychological, neurophysiological, and peripheral psychophysiological evidence for emotion and emotion regulation deficits in ADHD across youth and adults.
Central and autonomous nervous system correlates argue in favor of more general self-regulation deficits and also specific emotional deficits in ADHD. These include general performance deficits in executive functions, and structural as well as functional impairments in neuronal networks associated with top-down self-regulation. Specific deficits with bottom-up emotional activation in the amygdala and emotion evaluation associated with the orbitofrontal cortex have also been described. Furthermore, vagally mediated, high-frequency heart rate variability is associated with emotional self-regulation deficits throughout the life span. The current evidence is based on multilevel studies that assess associations of emotion regulation. However, further studies that adequately consider the processual recursive character of emotion generation and regulation may give important new insights into emotional regulation of ADHD.
Emotion regulation deficits in ADHD are associated with specific as well as general self-regulation deficits traceable on the level of neuropsychological, neurophysiological, and psychophysiological assessments. The temporal dynamics of the interplay of those different systems need further study in order to optimize and personalize treatment of emotion regulation difficulties, including emotional reactivity, in patients with ADHD.
KeywordsAttention-deficit/hyperactivity disorder (ADHD) Emotion regulation Children Adults Neuropsychology Neurophysiology (fMRI EEG) Peripheral psychophysiology (heart rate variability)
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.ICD-10: international statistical classification of diseases and related health problems: tenth revision. 2nd ed. Geneva: WHO; 2004.Google Scholar
- 6.Fayyad J, Sampson NA, Hwang I, Adamowski T, Aguilar-Gaxiola S, Al-Hamzawi A, et al. The descriptive epidemiology of DSM-IV adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord. 2017;9:47–65. https://doi.org/10.1007/s12402-016-0208-3.CrossRefPubMedGoogle Scholar
- 12.Barkley RA. Deficient emotional self-regulation is a core component of ADHD. J ADHD Relat Disord. 2010:5–37.Google Scholar
- 15.•• Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171:276–93. https://doi.org/10.1176/appi.ajp.2013.13070966 Comprehensive review on emotion regulation in ADHD from a multilevel perspective. The authors finally suggest three conceptual models to explain the overlap between emotion regulation and ADHD. CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Sobanski E, Banaschewski T, Asherson P, Buitelaar J, Chen W, Franke B, et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry. 2010;51:915–23. https://doi.org/10.1111/j.1469-7610.2010.02217.x.CrossRefPubMedGoogle Scholar
- 19.• Skirrow C, Ebner-Priemer U, Reinhard I, Malliaris Y, Kuntsi J, Asherson P. Everyday emotional experience of adults with attention deficit hyperactivity disorder: evidence for reactive and endogenous emotional lability. Psychol Med. 2014;44:3571–83. https://doi.org/10.1017/S0033291714001032 This study used real-time ambulatory assessment in a sample of individuals with ADHD without comorbidity and healthy controls. The authors showed that adults with ADHD reported heightened intensity and instability of negative emotions in daily life. CrossRefPubMedGoogle Scholar
- 21.•• Faraone SV, Rostain AL, Blader J, Busch B, Childress AC, Connor DF, et al. Practitioner review: Emotional dysregulation in attention-deficit/hyperactivity disorder—implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2018. https://doi.org/10.1111/jcpp.12899 This review addresses important issues regarding emotion regulation in ADHD (conceptual clarifications, similarities, and differences between emotion regulation deficits in ADHD and other disorders, ERD treatment responses). They provide a temporal model of emotion-processing impairments in ADHD, separating emotional reactivity from emotion regulation components.
- 25.Wender PH. Attention-deficit hyperactivity disorder in adults. New York: Oxford University Press; 1995.Google Scholar
- 26.Barkley RA. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. 4th ed. New York: Guilford; 2018.Google Scholar
- 28.Schmidt-Atzert L, Peper M, Stemmler G. Emotionspsychologie: Ein Lehrbuch. 2nd ed. Stuttgart: Kohlhammer; 2014.Google Scholar
- 30.• Waugh CE, Shing EZ, Avery BM. Temporal dynamics of emotional processing in the brain. Emot Rev. 2015;7:323–9. https://doi.org/10.1177/1754073915590615 This recent review on affective neuroscience highlights the importance of examining neural temporal dynamics of emotions to better understand emotional phenomena. CrossRefGoogle Scholar
- 31.•• Gross JJ. Emotion regulation: current status and future prospects. Psychol Inq. 2015;26:1–26. https://doi.org/10.1080/1047840X.2014.940781 This target article by Gross and its discussion in the same issue is an inspiring and valuable contribution to the theoretical and empirical challenges within the field of emotion regulation. CrossRefGoogle Scholar
- 34.Sheppes G, Suri G, Gross JJ. Emotion regulation and psychopathology. Annu Rev Clin Psychol. 2015;11:379–405. https://doi.org/10.1146/annurev-clinpsy-032814-112739.CrossRefPubMedGoogle Scholar
- 35.Overgaard KR, Aase H, Torgersen S, Reichborn-Kjennerud T, Oerbeck B, Myhre A, et al. Continuity in features of anxiety and attention deficit/hyperactivity disorder in young preschool children. Eur Child Adolesc Psychiatry. 2014;23:743–52. https://doi.org/10.1007/s00787-014-0538-7.CrossRefPubMedPubMedCentralGoogle Scholar
- 39.Biederman J, Spencer TJ, Petty C, Hyder LL, O’Connor KB, Surman CB, et al. Longitudinal course of deficient emotional self-regulation CBCL profile in youth with ADHD: prospective controlled study. Neuropsychiatr Dis Treat. 2012;8:267–76. https://doi.org/10.2147/NDT.S29670.CrossRefPubMedPubMedCentralGoogle Scholar
- 40.Sasser TR, Kalvin CB, Bierman KL. Developmental trajectories of clinically significant attention-deficit/hyperactivity disorder (ADHD) symptoms from grade 3 through 12 in a high-risk sample: predictors and outcomes. J Abnorm Psychol. 2016;125:207–19. https://doi.org/10.1037/abn0000112.CrossRefPubMedPubMedCentralGoogle Scholar
- 41.• Brocki KC, Forslund T, Frick M, Bohlin G. Do individual differences in early affective and cognitive self-regulation predict developmental change in ADHD symptoms from preschool to adolescence? J Atten Disord. 2017:1087054717693372. https://doi.org/10.1177/1087054717693372 A longitudinal study that emphasizes the importance of distinguishing between cognitive and affective self-regulation in relation to inattention and hyperactivity/impulsivity over time.
- 45.Banaschewski T, Jennen-Steinmetz C, Brandeis D, Buitelaar JK, Kuntsi J, Poustka L, et al. Neuropsychological correlates of emotional lability in children with ADHD. J Child Psychol Psychiatry. 2012;53:1139–48. https://doi.org/10.1111/j.1469-7610.2012.02596.x.CrossRefPubMedPubMedCentralGoogle Scholar
- 46.van Cauwenberge V, Sonuga-Barke EJS, Hoppenbrouwers K, van Leeuwen K, Wiersema JR. "turning down the heat": is poor performance of children with ADHD on tasks tapping "hot" emotional regulation caused by deficits in "cool" executive functions? Res Dev Disabil. 2015;47:199–207. https://doi.org/10.1016/j.ridd.2015.09.012.CrossRefPubMedGoogle Scholar
- 47.Villemonteix T, Marx I, Septier M, Berger C, Hacker T, Bahadori S, et al. Attentional control of emotional interference in children with ADHD and typically developing children: an emotional N-back study. Psychiatry Res. 2017;254:1–7. https://doi.org/10.1016/j.psychres.2017.04.027.CrossRefPubMedGoogle Scholar
- 48.Posner J, Rauh V, Gruber A, Gat I, Wang Z, Peterson BS. Dissociable attentional and affective circuits in medication-naïve children with attention-deficit/hyperactivity disorder. Psychiatry Res. 2013;213:24–30. https://doi.org/10.1016/j.pscychresns.2013.01.004.CrossRefPubMedPubMedCentralGoogle Scholar
- 50.Surman CBH, Biederman J, Spencer T, Miller CA, McDermott KM, Faraone SV. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study. Atten Defic Hyperact Disord. 2013;5:273–81. https://doi.org/10.1007/s12402-012-0100-8.CrossRefPubMedPubMedCentralGoogle Scholar
- 51.Christiansen H, Hirsch O, Philipsen A, Oades RD, Matthies S, Hebebrand J, et al. German validation of the conners adult ADHD rating scale-self-report: confirmation of factor structure in a large sample of participants with ADHD. J Atten Disord. 2013;17:690–8. https://doi.org/10.1177/1087054711435680.CrossRefPubMedGoogle Scholar
- 52.• Hirsch O, Chavanon M, Riechmann E, Christiansen H. Emotional dysregulation is a primary symptom in adult attention-deficit/hyperactivity disorder (ADHD). J Affect Disord. 2018;232:41–7. https://doi.org/10.1016/j.jad.2018.02.007 Recent study of our group that probed a model that explicitly distinguished positive and negative affect, problems with self-concept and emotion regulation skills as distinct but correlating factors with the symptom domains of inattention, hyperactivity, and impulsivity. CrossRefPubMedGoogle Scholar
- 53.Hirsch O, Chavanon ML, Christiansen H. Emotional dysregulation subgroups in patients with adult attention-deficit/hyperactivity disorder (ADHD): a cluster analytic approach. Sci Rep. under review after revision.Google Scholar
- 55.Posner J, Nagel BJ, Maia TV, Mechling A, Oh M, Wang Z, et al. Abnormal amygdalar activation and connectivity in adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2011;50:828–37.e3. https://doi.org/10.1016/j.jaac.2011.05.010.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.Yu X, Liu L, Chen W, Cao Q, Zepf FD, Ji G, et al. Integrity of amygdala subregion-based functional networks and emotional lability in drug-naïve boys with ADHD. J Atten Disord. 2016:108705471666141. https://doi.org/10.1177/1087054716661419.
- 58.Plichta MM, Vasic N, Wolf RC, Lesch K-P, Brummer D, Jacob C, et al. Neural hyporesponsiveness and hyperresponsiveness during immediate and delayed reward processing in adult attention-deficit/hyperactivity disorder. Biol Psychiatry. 2009;65:7–14. https://doi.org/10.1016/j.biopsych.2008.07.008.CrossRefPubMedGoogle Scholar
- 67.Albrecht B, Brandeis D, Uebel H, Heinrich H, Mueller UC, Hasselhorn M, et al. Action monitoring in boys with attention-deficit/hyperactivity disorder, their nonaffected siblings, and normal control subjects: evidence for an endophenotype. Biol Psychiatry. 2008;64:615–25. https://doi.org/10.1016/j.biopsych.2007.12.016.CrossRefPubMedPubMedCentralGoogle Scholar
- 68.McLoughlin G, Albrecht B, Banaschewski T, Rothenberger A, Brandeis D, Asherson P, et al. Performance monitoring is altered in adult ADHD: a familial event-related potential investigation. Neuropsychologia. 2009;47:3134–42. https://doi.org/10.1016/j.neuropsychologia.2009.07.013.CrossRefPubMedPubMedCentralGoogle Scholar
- 71.Uebel H, Albrecht B, Asherson P, Börger NA, Butler L, Chen W, et al. Performance variability, impulsivity errors and the impact of incentives as gender-independent endophenotypes for ADHD. J Child Psychol Psychiatry. 2010;51:210–8. https://doi.org/10.1111/j.1469-7610.2009.02139.x.CrossRefPubMedGoogle Scholar
- 74.• Shushakova A, Ohrmann P, Pedersen A. Exploring deficient emotion regulation in adult ADHD: electrophysiological evidence. Eur Arch Psychiatry Clin Neurosci. 2018;268:359–71. https://doi.org/10.1007/s00406-017-0826-6 This study suggests that the processing of aversive stimuli as well as emotion regulation is associated with greater cognitive effort in patients with ADHD than in healthy controls. The latter also suggests difficulties during the implementation of emotion regulation strategies. CrossRefPubMedGoogle Scholar
- 75.Shushakova A, Wiesner CD, Ohrmann P, Pedersen A. Electrophysiological evidence of an attentional bias towards appetitive and aversive words in adults with attention-deficit/hyperactivity disorder. Clin Neurophysiol. 2018;129:1937–46. https://doi.org/10.1016/j.clinph.2018.06.019.CrossRefPubMedGoogle Scholar
- 78.Musser ED, Backs RW, Schmitt CF, Ablow JC, Measelle JR, Nigg JT. Emotion regulation via the autonomic nervous system in children with attention-deficit/hyperactivity disorder (ADHD). J Abnorm Child Psychol. 2011;39:841–52. https://doi.org/10.1007/s10802-011-9499-1.CrossRefPubMedPubMedCentralGoogle Scholar
- 79.Karalunas SL, Fair D, Musser ED, Aykes K, Iyer SP, Nigg JT. Subtyping attention-deficit/hyperactivity disorder using temperament dimensions: toward biologically based nosologic criteria. JAMA Psychiatry. 2014;71:1015–24. https://doi.org/10.1001/jamapsychiatry.2014.763.CrossRefPubMedPubMedCentralGoogle Scholar
- 80.• Musser ED, Nigg JT. Emotion dysregulation across emotion systems in attention deficit/hyperactivity disorder. J Clin Child Adolesc Psychol. 2017:1–13. https://doi.org/10.1080/15374416.2016.1270828 This is the first study that examined the coherence of emotion systems in children with and without ADHD. The authors demonstrated in a large sample that in youth with ADHD, emotion systems were more poorly coordinated.
- 81.Thayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart rate variability, prefrontal neural function, and cognitive performance: the neurovisceral integration perspective on self-regulation, adaptation, and health. Ann Behav Med. 2009;37:141–53. https://doi.org/10.1007/s12160-009-9101-z.CrossRefPubMedGoogle Scholar
- 82.Thayer JF, Ahs F, Fredrikson M, Sollers JJ, Wager TD. A meta-analysis of heart rate variability and neuroimaging studies: implications for heart rate variability as a marker of stress and health. Neurosci Biobehav Rev. 2012;36:747–56. https://doi.org/10.1016/j.neubiorev.2011.11.009.CrossRefPubMedGoogle Scholar
- 94.Beauchaine TP, Katkin ES, Strassberg Z, Snarr J. Disinhibitory psychopathology in male adolescents: discriminating conduct disorder from attention-deficit/hyperactivity disorder through concurrent assessment of multiple autonomic states. J Abnorm Psychol. 2001;110:610–24. https://doi.org/10.1037/0021-843X.110.4.610.CrossRefPubMedGoogle Scholar