Using stimulants to treat ADHD-related emotional lability

Are all ADHD medications created equal? Exploring the differences that enable evening dosing

With more than 30 available stimulant medications, choosing among therapeutic options for attention-deficit/hyperactivity disorder (ADHD) has become increasingly complex and patient specific. All ADHD stimulants owe their action to variants of either amphetamine or methylphenidate, yet formulation and delivery system differences create unique pharmacokinetic and clinical profiles for each medication. A benefit of the diversity within ADHD pharmacotherapy is that it facilitates tailoring treatment to meet patient needs. Historically, there has been a constant among long-acting stimulant options, regardless of formulation, which was morning dosing. The introduction of delayed-release and extended-release methylphenidate (DR/ER-MPH) is the first long-acting stimulant that patients take in the evening, with the clinical effect delayed until awakening in the morning. This paradigm shift has generated questions among clinicians and continued interest in real-world experience and data. This review used available clinical data, real-world evidence, emerging analyses, and clinical experience to evaluate the characteristics of DR/ER-MPH and its clinical utility within the greater context of ADHD medications and to provide clinicians with practical guidance on the use of DR/ER-MPH in children, adolescents, and adults with ADHD.

A Post-Hoc Analysis of Emotional Lability With Delayed-Release/Extended-Release Methylphenidate in Children Aged 6 to 12 Years of Age Participating in Two Phase 3 Clinical Trials

OBJECTIVE

DR/ER-MPH (formerly HLD200) is an evening-dosed delayed-release and extended-release methylphenidate approved for the treatment of ADHD in patients ≥6 years. Post hoc analyses of two pivotal Phase 3 trials: HLD200-107 (NCT02493777) and HLD200-108 (NCT02520388) evaluated emotional lability (EL) with DR/ER-MPH treatment.

METHODS

Differences in Conners Global Index-Parent (CGI-P) EL subscale scores and age- and gender-adjusted T-scores over an open-label titration phase (HLD200-107) and between treatment and placebo groups at endpoint (HLD200-108) were evaluated.

RESULTS

In HLD200-107 (N = 117) mean CGI-P EL subscale scores improved from 5.3 to 1.3 (p < .0001) after 6 weeks; in HLD200-108 significant improvements were observed in the treatment group (n = 81) versus placebo (n = 80; 3.11 vs. 4.08; p = .0053). T-scores showed an improvement with DR/ER-MPH treatment in both trials. Few emotional adverse events (AEs) were reported.

CONCLUSION

DR/ER-MPH treatment resulted in statistically significant improvements in EL to the level of non-ADHD peers as contextualized by T-scores.

Indirect effect of ADHD on parenting stress through increased child anxiety and decreased emotional regulatory coping

Parents of children with ADHD experience significantly more parenting stress in comparison to parents of typically developing children due to the emotional and behavioral difficulties related to ADHD. Additionally, approximately 30% of children with ADHD experience co-occurring anxiety. Parents of children with co-occurring anxiety and ADHD report increased stress due to role restriction and isolation compared to parents of children with ADHD alone. Poor emotional regulatory coping in children with ADHD has been linked to elevated negative affect and irritability, which also contributes to increased stress among parents. The present study examined the direct and indirect associations of child anxiety symptoms and emotional regulatory coping on elevated ADHD symptoms and parenting stress. Participants were 203 children aged 7-12-years-old and their parents. Parents completed a self-report measure of parenting stress and measures of their child's ADHD symptoms, anxiety, and emotional regulatory coping. Additionally, children completed self-report measures of emotional regulatory coping. Model testing indicated that the overall model demonstrated excellent fit to the data. Parameter testing supported an indirect effect of child ADHD symptoms on parenting stress through child anxiety symptoms and an indirect effect of child ADHD symptoms on parenting stress through child emotional regulatory coping. These results suggest that child anxiety and emotion dysregulation in children with ADHD have a negative impact on parental stress. The current study adds to the understanding of the important roles emotional regulatory coping and anxiety play in children with ADHD to contribute to increased parenting stress.

Longitudinal associations between anxiety sensitivity and substance use in adolescents: Mediation by depressive affect

Though anxiety sensitivity (AS)-fear of anxiety-related experiences-is primarily tied to anxiety vulnerability, AS has also been prospectively associated with general negative affect and depression. Furthermore, depression has been longitudinally associated with different forms of substance use, and some AS subfactors (e.g., cognitive concerns) have been associated more consistently with depression and substance use than others. However, no previous study has investigated if longitudinal associations of AS with substance use may be mediated by depression or whether aspects of AS may be prospectively associated with substance use among adolescents. Hence, the present study tested depressive affect (the negative affective aspect of depression) as a prospective mediator of AS associations with substance use and examined longitudinal AS subfactor associations with substance use and problems. High school 9th graders (N = 2,877; Mage = 14.1 years; 55.3% female) completed self-report measures at baseline and at 6 months and 1 year later. Depressive affect mediated AS associations with subsequent alcohol, cigarette, electronic cigarette, cannabis, benzodiazepine, and opioid use. Also, AS cognitive and social concerns (vs. physical concerns) were more consistently associated with later depressive affect and substance use and problems. Current findings suggest that adolescents high in anxiety sensitivity tend to prospectively experience greater depressive affect, which in turn is related to a higher likelihood of engaging in several different forms of substance use. Thus, it is possible that interventions which target AS (particularly AS cognitive concerns) may help to treat or prevent depression and substance use among adolescents. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of emotional dysregulation and comorbid depressive symptoms on clinical features, brain arousal, and treatment response in adults with ADHD

Introduction

The role of emotional dysregulation (ED) in attention-deficit/hyperactivity disorder (ADHD) has become an important issue. This study, in which we analyzed data from a predictive pharmaco-EEG-trial, aimed to examine whether symptoms of ED in adult ADHD affect ADHD symptom severity, brain arousal regulation as measured by resting EEG, and the response to stimulant medication.

Methods

ED is defined as having a sex- and age-corrected T-score of >70 on the emotional lability subscale of the German version of Conners' Adult ADHD Rating Scale. A total of 115 participants were included in the study, 56 of whom had ED. Participants with ED were more impaired in terms of the severity of core ADHD symptoms, especially inattentive symptoms, comorbid depressive symptoms, interpersonal relationships, and quality of life. In addition, participants with ED were more likely to report a total score above 13 on the Beck Depression Inventory-II, which was considered to be the cutoff for mild depression.

Results

No differences were found between the ED and non-ED groups in response to stimulant medication or in brain arousal regulation. In addition, there was no significant effect of ED with comorbid depressive symptoms on treatment response. There was a trend for subgroups that showed a change in brain arousal regulation associated with symptom improvement.

Discussion

Our findings may support the assumption that ED may be an important feature of ADHD. The use of EEG-based brain arousal regulation as a diagnostic and predictive tool in ADHD in the presence of ED and comorbid depressive symptoms should be further investigated.

Factors Influencing the Medication Adherence in Adults With Attention-Deficit/Hyperactivity Disorder (ADHD) and Its Impact on Healthcare Utilization

OBJECTIVE

This study aims to investigate the factors influencing medication adherence among adults with Attention-Deficit/Hyperactivity Disorder (ADHD) and impact of central nervous system stimulants (CNS) adherence on healthcare utilization (HCU). Methods: This was a cross-sectional study using Medical Expenditure Panel Survey 2013 to 2019, with participants (≥18 years of age) with ADHD and had at least one CNS prescription. Multivariate logistic and linear regression were utilized to evaluate the medication adherence and its impact on HCU, respectively.

RESULT

Total 798 (10,718,005 weighted) ADHD patients, were mostly White (81%), aged between 18 and 25 (35%), and non-adherent to CNS (65%). The use of extended-release medications (OR = 1.51 [1.03, 2.23]) and new users (OR = 3.46 [2.12, 5.63], p ≤ .05) were positively associated with medication adherence. The adherent group utilized more outpatient visits (0.04 vs. 0.46) and prescription refills (18.38 vs. 31.25) compared to non-adherent.

CONCLUSION

Our findings can be applied to improve the medication adherence, patient education, and optimize intervention for adults with ADHD.

Association of Psychopharmacological Medication Preference with Autistic Traits and Emotion Regulation in ADHD

Background

This study intends to evaluate the relationship between medication switching and autistic traits, emotion dysregulation, and methylphenidate side effects in children with attention deficit hyperactivity disorder (ADHD).

Methods

Children with ADHD, ages 9-18, treated with methylphenidate (MTP) (n = 23), and switched to atomoxetine (ATX) (n = 20) were included. All participants were interviewed with K-SADS-PL to confirm ADHD diagnosis and exclude comorbid psychiatric disorders. The participants then completed Difficulty in Emotion Regulation Scale (DERS) and Autism-Spectrum Quotient (AQ) and their parents completed Autism Spectrum Screening Questionnaire (ASSQ) and Barkley Stimulant Side Effect Rating Scale(BSSERS).

Results

The MTP group scored higher than the ATX group in ASSQ, AQ, and the lack of emotional clarity subscale of DERS, while the ATX group had higher scores in the emotional non-acceptance subscale of DERS. No differences were found between the MTP and ATX groups in methylphenidate side-effect severity. Multiple regression analyses revealed that non-acceptance of emotions predicted the switch to ATX while lack of emotional clarity predicted the maintenance of MTP therapy, rather than autistic traits.

Conclusions

This study highlights emotion regulation difficulties and how different emotional profiles may influence medication selection in children with ADHD.

Identifying different patterns of emotion dysregulation in adult ADHD

BACKGROUND

Emotion dysregulation (ED) is a core intrinsic feature of adult presenting Attention Deficit Hyperactivity Disorder (ADHD). However, the clinical expressions of ED are diverse and several questionnaires have been used to measure ED in adults with ADHD. Thus, to date, the characteristics of ED in adult ADHD remain poorly defined. The objective of this study is to identify the different patterns of ED in adults with ADHD.

METHODS

A large sample of 460 newly diagnosed adults with ADHD were recruited. Patients completed a total of 20 self-reported questionnaires. Measures consisted in the several facets of ED, but also other clinical features of adult ADHD such as racing thoughts. A factor analysis with the principal component extraction method was performed to define the symptomatic clusters. A mono-dimensional clustering was then conducted to assess whether participants presented or not with each symptomatic cluster.

RESULTS

The factor analysis yielded a 5 factor-solution, including "emotional instability", "impulsivity", "overactivation", "inattention/disorganization" and "sleep problems". ED was part of two out of five clusters and concerned 67.52% of our sample. Among those patients, the combined ADHD presentation was the most prevalent. Emotional instability and impulsivity were significantly predicted by childhood maltreatment. The ED and the "sleep problems" factors contributed significantly to the patients' functional impairment.

CONCLUSIONS

ED in ADHD is characterized along emotional instability and emotional impulsivity, and significantly contributes to functional impairment. However, beyond impairing symptoms, adult ADHD may also be characterized by functional strengths such as creativity.

Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD)

INTRODUCTION

Emotional dysregulation (ED) symptoms are present in a considerable portion of patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, an increasing number of studies investigated the effects of stimulant medications on ED in patients with ADHD.

AREAS COVERED

A narrative review of the literature on stimulant treatment for ED is provided, including controlled and observational clinical studies conducted on pediatric and adult samples and neurobiological investigations. Positive effects of stimulants on irritability have been demonstrated in children. Comorbidity with disruptive behavior disorders (DBD) and disruptive mood dysregulation disorder does not prevent stimulant effectiveness. Methylphenidate has also been found to reduce temper problems, affective instability, and emotional over-reactivity in adults with ADHD, although with variable effect sizes. A variety of adverse emotional effects have been reported, especially at high doses and in special populations. However, several possible confounders of treatment-emergent ED have been highlighted. Finally, according to neuroimaging studies, stimulants may mitigate emotional processing anomalies associated with ADHD.

EXPERT OPINION

The findings are consistent with models including ED within the core features of ADHD. Stimulant treatment should be prioritized over antipsychotics in ADHD-DBD. It remains to be elucidated whether other medications may be more effective in specific populations with ADHD and/or ED.

Functional connectivity based brain signatures of behavioral regulation in children with ADHD, DCD, and ADHD-DCD

Behavioral regulation problems have been associated with daily-life and mental health challenges in children with neurodevelopmental conditions such as attention-deficit/hyperactivity disorder (ADHD) and developmental coordination disorder (DCD). Here, we investigated transdiagnostic brain signatures associated with behavioral regulation. Resting-state fMRI data were collected from 115 children (31 typically developing (TD), 35 ADHD, 21 DCD, 28 ADHD-DCD) aged 7-17 years. Behavioral regulation was measured using the Behavior Rating Inventory of Executive Function and was found to differ between children with ADHD (i.e., children with ADHD and ADHD-DCD) and without ADHD (i.e., TD children and children with DCD). Functional connectivity (FC) maps were computed for 10 regions of interest and FC maps were tested for correlations with behavioral regulation scores. Across the entire sample, greater behavioral regulation problems were associated with stronger negative FC within prefrontal pathways and visual reward pathways, as well as with weaker positive FC in frontostriatal reward pathways. These findings significantly increase our knowledge on FC in children with and without ADHD and highlight the potential of FC as brain-based signatures of behavioral regulation across children with differing neurodevelopmental conditions.

Does emotion dysregulation mediate the association between ADHD symptoms and internalizing problems? A longitudinal within-person analysis in a large population-representative study

BACKGROUND

Previous research has suggested that children with attention-deficit/hyperactivity disorder (ADHD) symptoms commonly show emotion dysregulation difficulties. These difficulties may partly explain the strong tendency for internalizing problems such as anxiety and depression to co-occur with ADHD symptoms. However, no study has yet provided a longitudinal analysis of the within-person links between ADHD symptoms, emotion dysregulation, and internalizing problems necessary to examine this hypothesis from a developmental perspective.

METHODS

We used data from the age 3, 5, and 7 waves of the large UK population-representative Millennium Cohort Study (n = 9,619, 4,885 males) and fit gender-stratified autoregressive latent trajectory models with structured residuals (ALT-SR) to disaggregate within- and between-person relations between ADHD symptom, emotion dysregulation, and internalizing problem symptoms.

RESULTS

We found that emotion dysregulation significantly mediated the longitudinal within-person association between ADHD symptoms and internalizing problems.

CONCLUSIONS

Results underline the promise of targeting emotion dysregulation as a means of preventing internalizing problems co-occurring with ADHD symptoms.

Common and Distinct Neural Patterns of Attention-Deficit/Hyperactivity Disorder and Borderline Personality Disorder: A Multimodal Functional and Structural Meta-analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have partially overlapping symptom profiles and are highly comorbid in adults. However, whether the behavioral similarities correspond to shared neurobiological substrates is not known.

METHODS

An overlapping meta-analysis of 58 ADHD and 66 BPD whole-brain articles incorporating observations from 3401 adult patients and 3238 healthy participants was performed by seed-based d mapping. Brain maps were subjected to meta-analytic connectivity modeling and data-driven functional decoding analyses to identify associated neural circuit alterations and relations to behavioral dimensions.

RESULTS

Both groups exhibited hypoactivated abnormalities in the left inferior parietal lobule, and altered clusters of the bilateral superior temporal gyrus were disjunctive in ADHD and BPD. No overlapping structural abnormalities were found. Multimodal alterations of ADHD were located in the right putamen and of BPD in the left orbitofrontal cortex.

CONCLUSIONS

The transdiagnostic neural bases of ADHD and BPD in temporoparietal circuitry may underlie overlapping problems of behavioral control, while disorder-specific substrates in frontostriatal circuitry may account for their distinguishing features in motor and emotion domains, respectively.

Reciprocal Developmental Relations Between ADHD and Anxiety in Adolescence: A Within-Person Longitudinal Analysis of Commonly Co-Occurring Symptoms

Objective: Significant anxiety often occurs in the presence of ADHD symptoms; however, the reasons are not well understood. We aimed to establish whether the relations between ADHD symptons and anxiety are bidirectional or unidirectional.

METHOD

Weexamined the developmental relations between ADHD and anxiety symptoms across adolescence (ages 13, 15, and 17) in a community-ascertained, normative longitudinal sample of 1,483 youth (52% male). We used an autoregressive latent trajectory model with structured residuals (ALT-SR) to examine within-person developmental relations between ADHD and anxiety symptoms to determine whether it is ADHD symptoms that lead to anxiety symptoms and/or the reverse.

RESULTS

Results suggested that there are reciprocal within-person developmental relations between ADHD and anxiety symptoms.

CONCLUSIONS

Our findings support the recommendation that targeting ADHD symptoms can be fruitful for addressing anxiety symptoms; however, they suggest that targeting anxiety symptoms may also benefit ADHD symptoms. Results also underline the importance of careful assessment for underlying ADHD symptoms among adolescents presenting with anxiety.

Pseudo-seizure, an Atypical Presentation of Attention-Deficit Hyperactivity Disorder in a Female: A Case Report

Background

This paper describes pseudo-seizure as an atypical presentation of attention-deficit hyperactivity disorder (ADHD) in an adolescent female in the context of psychosocial difficulties. We present the case, which explains the clinical dilemma in such situations, along with selective literature review.

Case Presentation

An adolescent female, who is an academic high achiever, living with parents, presented with unresponsive spells which were initially treated with antiepileptics by the paediatrician without any significant improvement. Later, after further assessments and revision of her diagnosis to conversion disorder, she was referred to the child and youth mental health service team. Further evaluation revealed her symptoms to be a result of multiple psychosocial stressors in the context of her having undiagnosed ADHD. Individual therapy, treatment with stimulant, resulted in significant improvement in her school and home adjustments.

Conclusions

This case demonstrates the diagnostic challenges that high-functioning girls with ADHD coloured by psychosocial stressors can pose and raises the need for reviewing our diagnostic approaches in these situations.

Phasic Versus Tonic Irritability: Differential Associations With Attention-Deficit/Hyperactivity Disorder Symptoms

OBJECTIVE

Irritability is a multifaceted construct in pediatric psychopathology. It has been conceptualized as having a phasic dimension and a tonic dimension. Disruptive mood dysregulation disorder is defined by the presence of both dimensions. Severe irritability, or disruptive mood dysregulation disorder, is highly comorbid with attention-deficit/hyperactivity disorder (ADHD). However, it is unknown whether the presence of ADHD modulates the expression of phasic and tonic irritability.

METHOD

A data-driven, latent variable approach was used to examine irritability and ADHD symptoms in a transdiagnostic pediatric sample (N = 489) with primary disruptive mood dysregulation disorder, ADHD, subclinical irritability symptoms, or no diagnosis. Using latent profile analyses, we identified 4 classes: high levels of both irritability and ADHD symptoms, high levels of irritability and moderate levels of ADHD symptoms, moderate levels of irritability and high levels of ADHD symptoms, and low levels of both irritability and ADHD symptoms. Confirmatory factor analysis operationalized phasic irritability and tonic irritability.

RESULTS

As expected, the 2 latent classes characterized by high overall irritability exhibited the highest levels of both phasic and tonic irritability. However, between these 2 high irritability classes, highly comorbid ADHD symptoms were associated with significantly greater phasic irritability than were moderately comorbid ADHD symptoms. In contrast, the 2 high irritability groups did not differ on levels of tonic irritability.

CONCLUSION

These findings suggest that phasic, but not tonic, irritability has a significant association with ADHD symptoms and that phasic and tonic might be distinct, though highly related, irritability dimensions. Future research should investigate potential mechanisms underlying this differential association.

Biological Bases of Empathy and Social Cognition in Patients with Attention-Deficit/Hyperactivity Disorder: A Focus on Treatment with Psychostimulants

In recent years, there has been growing interest in investigating the effect of specific pharmacological treatments for ADHD not only on its core symptoms, but also on social skills in youths. This stands especially true for ADHD patients displaying impulsive aggressiveness and antisocial behaviors, being the comorbidity with Disruptive Behavior Disorders, one of the most frequently observed in clinical settings. This systematic review aimed to synthesize research findings on this topic following PRISMA guidelines and to identify gaps in current knowledge, future directions, and treatment implications. Search strategies included the following terms: ADHD; methylphenidate and other ADHD drugs; empathy, theory of mind and emotion recognition. Full-text articles were retrieved and data from individual studies were collected. Thirteen studies were finally included in our systematic review. Ten studies assessing changes in empathy and/or theory of mind in patients with ADHD treated after pharmacological interventions were identified. Similarly, seven partially overlapping studies assessing changes in emotion recognition were retrieved. Despite a great heterogeneity in the methodological characteristics of the included studies, most of them reported an improvement in emphatic and theory of mind abilities in youths with ADHD treated with psychostimulants and nonstimulant drugs, as well as positive but less consistent results about emotion recognition performances.

The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG)

ADHD is the most common neurodevelopmental disorder presenting to child and adolescent mental health, paediatric, and primary care services. Timely and effective interventions to address core ADHD symptoms and co-occurring problems are a high priority for healthcare and society more widely. While much research has reported on the benefits and adverse effects of different interventions for ADHD, these individual research reports and the reviews, meta-analyses and guidelines summarizing their findings are sometimes inconsistent and difficult to interpret. We have summarized the current evidence and identified several methodological issues and gaps in the current evidence that we believe are important for clinicians to consider when evaluating the evidence and making treatment decisions. These include understanding potential impact of bias such as inadequate blinding and selection bias on study outcomes; the relative lack of high-quality data comparing different treatments and assessing long-term effectiveness, adverse effects and safety for both pharmacological and non-pharmacological treatments; and the problems associated with observational studies, including those based on large national registries and comparing treatments with each other. We highlight key similarities across current international clinical guidelines and discuss the reasons for divergence where these occur. We discuss the integration of these different perspective into a framework for person/family-centered evidence-based practice approach to care that aims to achieve optimal outcomes that prioritize individual strengths and impairments, as well as the personal treatment targets of children and their families. Finally, we consider how access to care for this common and impairing disorder can be improved in different healthcare systems.

Effects of prolonged methylphenidate treatment on amygdala reactivity and connectivity: a randomized controlled trial in stimulant treatment-naive, male participants with ADHD

Background

Problems with emotional processing are widely reported in individuals with attention-deficit/hyperactivity disorder (ADHD). Although methylphenidate (MPH) effectively alleviates inattention and hyperactivity symptoms in ADHD, its effects on emotional processing and internalizing symptoms have remained elusive. While we previously found that acute MPH administration modulated neural mechanisms underlying emotional processing in an age-dependent manner, the effects of prolonged administration remained unknown.

Objectives

Therefore, we investigated: (i) whether prolonged MPH treatment influences neural substrates (amygdala reactivity and connectivity) of emotional processing, and (ii) whether these effects are modulated by age.

Methods

The "effects of Psychotropic drugs On Developing brain-MPH" ("ePOD-MPH") randomized controlled trial was a 16-week double-blind, placebo-controlled, multi-center trial with MPH in 50 boys (10-12 years of age) and 49 men (23-40 years of age), all stimulant treatment-naive and diagnosed with ADHD. Participants performed an emotional face-matching task during functional magnetic resonance imaging. We assessed their symptoms of ADHD and internalizing symptoms at baseline, during the trial (8 weeks), and 1 week after the trial end (17 weeks).

Results and Conclusions

We did not find effects of prolonged MPH treatment on emotional processing, as measured by amygdala reactivity and connectivity and internalizing symptoms in this trial with stimulant treatment-naive participants. This differs from our findings on emotional processing following acute MPH administration and the effects of prolonged MPH treatment on the dopamine system, which were both modulated by age. Interestingly, prolonged MPH treatment did improve ADHD symptoms, although depressive and anxiety symptoms showed a medication-independent decrease. Furthermore, our data indicate that baseline internalizing symptoms may be used to predict MPH treatment effects on ADHD symptoms, particularly in (male) adults with ADHD.

Rationale and validation of a novel mobile application probing motor inhibition: Proof of concept of CALM-IT

Identification of behavioral mechanisms underlying psychopathology is essential for the development of novel targeted therapeutics. However, this work relies on rigorous, time-intensive, clinic-based laboratory research, making it difficult to translate research paradigms into tools that can be used by clinicians in the community. The broad adoption of smartphone technology provides a promising opportunity to bridge the gap between the mechanisms identified in the laboratory and the clinical interventions targeting them in the community. The goal of the current study is to develop a developmentally appropriate, engaging, novel mobile application called CALM-IT that probes a narrow biologically informed process, inhibitory control. We aim to leverage the rigorous and robust methods traditionally used in laboratory settings to validate this novel mechanism-driven but easily disseminatable tool that can be used by clinicians to probe inhibitory control in the community. The development of CALM-IT has significant implications for the ability to screen for inhibitory control deficits in the community by both clinicians and researchers. By facilitating assessment of inhibitory control outside of the laboratory setting, researchers could have access to larger and more diverse samples. Additionally, in the clinical setting, CALM-IT represents a novel clinical screening measure that could be used to determine personalized courses of treatment based on the presence of inhibitory control deficits.

Emotions or attention – what are predictors for the development of childhood psychopathology? A longitudinal study with pre- and elementary school children

Current debate has identified the factors emotion knowledge (EK) and attention as specific trajectories longitudinally influencing psychopathological development in childhood. The “Emotion Knowledge Hypothesis” assumes that children with great emotion skills have high self-regulating abilities that result in lower cognitive load and stronger attention capacities. Attention problems are thus perceived as a consequence of reduced EK. According to the competing “Attention Effect Hypothesis”, attention problems and EK deficits are associated because of impaired learning capacities due to attention problems. According to this hypothesis, attention problems are predictive of impaired EK. If those specific trajectories are disrupted, this might attenuate the development of later behavior problems. The present study tests those competing hypotheses replicating previous studies in this field to shed light on potential psychopathology trajectories. A total of 136 pre- and elementary school children as well as their teachers participated in this study. Children’s symptoms of inattention as well as their emotional competences were assessed 3 times over a 12-month period. We applied multilevel structural equation modelling and cross-lagged panel models for data analysis. Overall, we noted a drop in inattention scores and rise in emotional competences over the one-year course, indicating maturation effects. There was a significant but very small effect for attention scores predicting emotional competences. With respect to the question whether interventions should focus on the “Emotion Knowledge” or “Attention Effect” hypothesis, our findings imply that none of them has superiority over the other. Therefore, both emotion knowledge and attention are crucial for development, and that children with deficits in either domain should receive targeted interventions in order to disrupt potentially harmful developmental pathways.

An ecological momentary assessment study of the role of emotional dysregulation in co-occurring ADHD and internalising symptoms in adulthood

Previous ecological momentary assessment (EMA) research in children has suggested that emotional dysregulation problems are commonly associated with ADHD symptoms and may help explain their relatively strong co-occurrence with anxiety and depression (collectively referred to as 'internalising problems'); however, this has yet to be replicated for adults. In this study, we used data from a n=260 longitudinal cohort and EMA study, to evaluate the hypothesis that emotional dysregulation mediates the association between ADHD symptoms and internalising problems in emerging adulthood. Emotional dysregulation was based on affect data collected in near real time and in ecological context over a 14-day period, providing a measure of emotional lability in the context of participants' daily lives. Cross-sectional mediation was tested using structural equation modelling. Emotional lability significantly mediated the association between ADHD symptoms and internalising problems. Results suggest that interventions that address the emotional dysregulation aspects of ADHD are likely to be beneficial for preventing and managing secondary internalising symptoms.

Recommendations for occupational therapy interventions for adults with ADHD: a consensus statement from the UK adult ADHD network

BACKGROUND

ADHD is neurodevelopmental disorder which persists into adulthood. Presently, therapeutic approaches are mainly pharmacological and psychological whilst the role, scope and approaches of occupational therapists have not been adequately described.

RESULTS

In this consensus statement we propose that by assessing specific aspects of a person's occupation, occupational therapists can deploy their unique skills in providing specialist interventions for adults with ADHD. We also propose a framework with areas where occupational therapists can focus their assessments and give practice examples of specific interventions.

CONCLUSIONS

Occupational therapists have much to offer in providing interventions for adults with ADHD. A unified and flexible approach when working with adults with ADHD is most appropriate and further research on occupational therapy interventions is needed.

The Characteristics and Age Effects of Emotional Lability in ADHD Children With and Without Oppositional Defiant Disorder

Objective: This study evaluated the concurrent validity of emotional lability (EL) in children with ADHD. Method: A total of 2,015 children with ADHD and 745 typically developed controls (TDCs) were assessed and compared on EL. Results: ADHD participants expressed higher EL scores than TDCs, not influenced by gender or IQ. Higher levels of EL symptoms were found in children with comorbid oppositional defiant disorder (ODD) and with ADHD-combined subtype. Receiver operating characteristic (ROC) analyses showed a strong screening efficacy of EL symptoms on ADHD. The effect of developmental age on EL showed a desisting pattern in TDCs, as opposed to a persisting pattern in ADHD (not influenced by ODD comorbid status). ODD symptoms in ADHD showed an ascending pattern. Conclusion: EL can potentially serve as a sentinel index for the presence of ADHD, especially when the ADHD presentation is atypical. ODD may embody a developmental entity distinct from EL.

Emotional dysregulation and callous unemotional traits as possible predictors of short-term response to methylphenidate monotherapy in drug-naïve youth with ADHD

BACKGROUND

Emotional dysregulation (ED) and callous unemotional (CU) traits can be associated with ADHD in youth, influencing its natural history and outcome, but their effect on medication efficacy is unexplored. We examined whether two measures of baseline ED and CU traits, the Child Behavior Checklist-Dysregulation Profile (CBCL-DP) and the Antisocial Process Screening Device (APSD), respectively, were predictors of change of ADHD-Rating Scale (ADHD-RS) after a 4-week methylphenidate (MPH) monotherapy.

METHODS

43 patients (37 males, 8-16 years, mean 9.9 ± 2.7 years) were included. Hierarchical linear regression models were used to explore whether CBCL-DP and APSD might predict ADHD-RS score, controlling for baseline severity.

RESULTS

Baseline CBCL-DP predicted higher post-treatment ADHD-RS scores in total and hyperactivity-impulsivity, but not in inattention subscale. Baseline APSD was not significantly related to ADHD-RS scores at the follow-up.

LIMITATIONS

Small sample size, lack of gender diversity, non-blind design and short period of observation.

CONCLUSION

ED, assessed with that CBCL-DP, might be a negative predictor of change of hyperactive-impulsive symptoms after MPH treatment and should be systematically assessed at baseline.

Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis

BACKGROUND

Emotional symptoms are increasingly considered a core feature of attention deficit/hyperactivity disorder (ADHD). We aimed to quantify the evidence of emotional dysregulation and its respective facets in individuals with adult ADHD compared to healthy controls using meta-analysis.

METHODS

Two electronic databases (PubMed, PsycINFO) were reviewed to identify studies. Studies were eligible for inclusion that had reports on any measure of emotion (dys) regulation in adults (> 18 years of age) in clinically diagnosed patients with ADHD as well as healthy control participants. We included a total of 13 studies (N = 2535) to assess (1) the standardized mean difference in emotion dysregulation (ED) as a general factor and its specific facets (i.e., emotional lability, negative emotional responses, and emotion recognition) between adults with ADHD and healthy controls; and (2) the association between ADHD symptom severity and ED.

RESULTS

Compared to healthy controls, adults with ADHD revealed significantly higher levels of general ED (Hedges' g = 1.17, p < 0.001; Hedges' g is the adjusted effect size). With regard to intermediate dimensions of ED, emotional lability exhibited the strongest weighted effect (Hedges' g = 1.20, CI [0.57, 1.83], p < 0.001). Furthermore, symptom severity and general ED correlated significantly (r = 0.54, p < 0.001). Regarding intermediate dimensions of ED, negative emotional responses correlated closely with ADHD symptom severity (r = 0.63, p < 0.001) and emotional lability (r = 0.52, p < 0.001).

CONCLUSIONS

Our findings support ED symptoms as a core feature of ADHD's psychopathology. With respect to dimensions of ED, emotional lability, and negative emotional responses play a more definitive role in the psychopathology of adults with ADHD. Due to insufficient statistical reports in the included studies, we could not perform meta-regressions to control the role of moderator variables.

Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD)

BACKGROUND

Emotional dysregulation (ED) is now considered as an important symptom of attention deficit hyperactivity disorder (ADHD). It is believed to have a considerable impact on the severity of the disorder, one's global functioning, and the prognosis. Our research aimed to evaluate and compare ED and cognitive emotional regulation strategies between ADHD and borderline personality disorder (BPD) patients.

METHODS

Four hundred six French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 BPD + ADHD) were assessed with the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), The Basic Empathy Scale (BES-A), the Adult ADHD Self-Report Scale (ARSV-v1.1) and the Beck Depression Inventory II (BDI-II). ADHD, BPD and comorbid patients were compared with each other and with samples of controls extracted from already published data.

RESULTS

ADHD patients, although having higher ED than samples derived from the general population, had less ED, better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients. However, ADHD subjects had similar scores as BPD subjects when looking at difficulties in perceiving self and others. ED generated considerable distress in all groups and was also positively associated with ADHD symptomatology. ADHD patients with comorbid BPD had the highest scores of ED.

CONCLUSIONS

Our results suggest that there may be similarly inefficient cognitive emotional regulation skills leading to ED in both disorders (ADHD and BPD). However, ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than BPD patients.

Editorial: Transcutaneous Trigeminal Nerve Stimulation for Children With Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with a prevalence of 9.5% of school-aged children and 4.4% of adults in the United States. ADHD is defined by clinically significant and developmentally inappropriate levels of inattention and hyperactivity/impulsivity. Executive functioning and control and attention regulation are the neuropsychological deficits commonly associated with ADHD.¹.

Attention-Deficit/Hyperactivity Disorder (ADHD) and Emotion Regulation Over the Life Span

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.

RECENT FINDINGS

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.

Pharmacological treatment of attention-deficit hyperactivity disorder comorbid with an anxiety disorder: a systematic review

The purpose of this study was to conduct a systematic review of the pharmacological options available to treat patients diagnosed with attention-deficit hyperactivity disorder and anxiety disorder, for generating evidence on the safest, most-effective and tolerable pharmacotherapy. To this end, a systematic search was performed in three electronic databases (Medline, Scopus and Directory of Open Access Journals; December 2017). Randomized, double-blind, parallel-design clinical trials evaluating the efficacy, safety or tolerability of therapies for attention-deficit hyperactivity disorder and anxiety disorder in children and adolescents or adults were considered. A total of 1960 articles were retrieved from the databases, of which five studies were included in the qualitative synthesis. Two of these studies evaluated the drug atomoxetine, another study evaluated desipramine, and the remaining two studies evaluated methylphenidate, with fluvoxamine being associated with methylphenidate in one of the trials. Owing to the high heterogeneity among studies, it was not possible to combine data for meta-analyses. Although only few studies have been evaluated in this systematic review, the results point to a more significant benefit of atomoxetine. This is probably because this drug was studied in a wider age range and evaluated by more specific scales for both disorders. To further strengthen this evidence, randomized, controlled and multicenter clinical trials with larger sample sizes should be conducted.

Attention Deficit Hyperactivity Disorder And Borderline Personality Disorder In Adults: A Review Of Their Links And Risks

Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are particularly common disorders, that are highly comorbid in adult populations. The symptomatic overlap between adult ADHD and BPD includes impulsivity, emotional dysregulation and interpersonal impairment, which makes the differential diagnosis difficult. Our review aims at focusing on recent data on the comorbid ADHD+BPD form, as well as the risk factors involved in the emergence of the two disorders. While adult ADHD and BPD share some genetic and temperamental risk factors, adult ADHD is characterized by more severe trait-impulsivity compared to non-comorbid BPD; BPD patients display more severe trait-emotion regulation symptoms compared to non-comorbid ADHD. Patients with the comorbid ADHD+BPD form have severe symptoms in both dimensions. Early-life exposure to adverse events is a shared risk factor for the development of ADHD and BPD, but type and timing of adversity seem to play a differential role in the development of BPD and ADHD symptoms. Age of onset used to be a discriminative diagnostic criterion between ADHD, an early-onset neurodevelopmental disorder, and BPD, a late-onset psychological disorder. However, this distinction has been recently called into question, increasing the need for more research aiming at delineating the disorders from a developmental and clinical standpoint. Clinicians should carefully consider the comorbidity, and consider ADHD and BPD dimensionally, in order to provide more effective patient management. This might improve early preventive interventions, and treatment for comorbid conditions in adulthood.

Electrophysiological evidence of an attentional bias towards appetitive and aversive words in adults with attention-deficit/hyperactivity disorder

OBJECTIVE

Emotional dysregulation has emerged as a core symptom domain in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, the pathophysiological underpinnings remain poorly understood. This study investigated attentional biases to positive and negative emotional words as possible contributing mechanisms.

METHODS

Event-related potentials (ERPSs) and behavioral attention bias indices were recorded from 39 adult patients with ADHD and 41 healthy controls during a verbal dot-probe task with positive-neutral, negative-neutral, and neutral-neutral word pairs.

RESULTS

Cue-locked N2pc amplitudes indicated a significant attentional bias towards emotional words in patients with ADHD and healthy controls. In healthy controls, the bias was only significant in positive trials. In patients, the bias was associated with ADHD severity and self-reported poor emotion regulation skills. ADHD patients also exhibited reduced target-locked P1 amplitudes and inferior behavioral performance compared with healthy controls.

CONCLUSIONS

Our findings provide evidence of an attention bias to positive and negative emotional stimuli in adult patients with ADHD and adverse effects of emotional stimuli on task performance.

SIGNIFICANCE

An attentional bias to emotional stimuli might contribute to emotional reactivity and dysregulation in adult patients with ADHD.

Exploring deficient emotion regulation in adult ADHD: electrophysiological evidence

Emotional dysregulation (ED) is being increasingly recognized as a core feature of attention-deficit/hyperactivity disorder (ADHD), but the pathophysiological underpinnings remain unclear. In this study, we provide meaningful electrophysiological evidence of ED in adult patients with ADHD (n = 39) compared to healthy controls (n = 40) by exploring the electrophysiological correlates of the emotion regulation strategies reappraisal, distraction, and expressive suppression. Event-related potentials (ERPs) were recorded during passive viewing of neutral and negative images, as well as during emotion regulation. The patients with ADHD exhibited increased frontal late positive potential (LPP) amplitudes during passive viewing of the aversive images and during emotion regulation. Compared with the healthy controls, a subgroup of medication-naïve patients with ADHD (n = 25) also exhibited larger centroparietal LPP amplitudes and provided more negative ratings of the aversive and neutral images. Both the frontal and centroparietal LPP amplitudes were associated with ADHD symptom severity. However, no significant deficit in LPP modulation during emotion regulation was found. These findings strongly support the clinical observation of increased emotional responsivity toward negative stimuli and difficulty during the implementation of emotion regulation strategies and thus encourage the implementation of emotion regulation modules in the treatment of adult patients with ADHD.

The Neural Correlates of Emotional Lability in Children with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is exceptionally heterogeneous in both clinical and physiopathological presentations. Clinical variability applies to ASD-specific symptoms and frequent comorbid psychopathology such as emotional lability (EL). To date, the physiopathological underpinnings of the co-occurrence of EL and ASD are unknown. As a first step, we examined within-ASD inter-individual variability of EL and its neuronal correlates using resting-state functional magnetic resonance imaging (R-fMRI). We analyzed R-fMRI data from 58 children diagnosed with ASD (5-12 years) in relation to the Conners' Parent Rating Scale EL index. We performed both an a priori amygdala region-of-interest (ROI) analysis, and a multivariate unbiased whole-brain data-driven approach. While no significant brain-behavior relationships were identified regarding amygdala intrinsic functional connectivity (iFC), multivariate whole-brain analyses revealed an extended functional circuitry centered on two regions: middle frontal gyrus (MFG) and posterior insula (PI). Follow-up parametric and nonparametric ROI-analyses of these regions revealed relationships between EL and MFG- and PI-iFC with default, salience, and visual networks suggesting that higher-order cognitive and somatosensory processes are critical for emotion regulation in ASD. We did not detect evidence of amygdala iFC underpinning EL in ASD. However, exploratory whole-brain analyses identified large-scale networks that have been previously reported abnormal in ASD. Future studies should consider EL as a potential source of neuronal heterogeneity in ASD and focus on multinetwork interactions.

Six months methylphenidate treatment improves emotion dysregulation in adolescents with attention deficit/hyperactivity disorder: a prospective study

PURPOSE

Individuals with attention deficit/hyperactivity disorder (ADHD) may suffer from emotional dysregulation (ED), although this symptom is not listed among the diagnostic criteria. Methylphenidate (MPH) is useful in reducing emotional symptoms in ADHD. The aim of the present study was to determine both psychosocial risk factors and presence of ED in adolescents with ADHD before and after MPH treatment.

PARTICIPANTS AND METHODS

Eighty-two patients aged 12-18 years with ADHD were included as participants. The Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime, the Difficulties in Emotion Regulation Scale (DERS), sociodemographic form, and the Inventory of Statements About Self-Injury were administered. Results were compared before and after 6 months MPH treatment.

RESULTS

A significant improvement was detected on DERS for impulsivity (15.9±6.8 initial vs 14.2±6.5 final test, p<0.01) and total score (88.4±23.3 initial vs 82.4±2.7 final test, p<0.05) across all patients taking MPH regardless of subtype and sex. Despite treatment, a significant difference remained for impulsivity, strategies, and total score in patients with comorbid oppositional defiant disorder (ODD) compared with those without ODD, but no difference was detected for conduct disorder comorbidity. In patients who self-harm, scores for goals, impulsivity, strategies, clarity, and total score were higher before treatment: furthermore, impulsivity and total score remained high after treatment. In maltreated patients, goals, impulsivity, strategies, and total scores were significantly higher before treatment; however, their symptoms were ameliorated after treatment with MPH.

CONCLUSION

Individuals with severe ED may "self-medicate" by smoking and/or self-harming. MPH led to significant improvements in ED possibly owing, in part, to a decrease in impulsivity, so that individuals felt more able to supervise their emotions and engage in goal-directed behaviors. ED should be considered particularly in patients with additional psychosocial factors and ODD comorbidity, and included in the treatment plan.

Emotion dysregulation in attention-deficit/hyperactivity disorder and borderline personality disorder

There is ongoing debate on the overlap between Attention-Deficit/Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD), particularly regarding emotion dysregulation (ED). In this paper, we present a narrative review of the available evidence on the association of these two disorders from several standpoints. First, we discuss the unique and shared diagnostic criteria for ADHD and BPD, focusing particularly on ED. We consider the methodology of ecological momentary assessment and discuss why this approach could be an alternative and more accurate way to qualitatively distinguish between ADHD and BPD. We summarise key findings on the genetic and environmental risk factors for ADHD and BPD and the extent to which there are shared or unique aetiological and neurobiological risk factors. Finally, we discuss the clinical relevance of considering both disorders in the assessment of patients presenting with trait-like behavioural syndromes, distinguishing the two conditions and implications for treatment.

Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic review and meta-analysis

Emotional dysregulation (ED) is a dysfunction in modifying an emotional state in an adaptive and goal oriented way, with excitability, ease anger, and mood lability. It is present in up to 70% of adults with ADHD, regardless of other comorbidities, and substantially worsens the psychosocial outcomes of the disorder. Besides fronto-parietal circuits mediating top-down control, brain regions involved in bottom-up processes (e.g., amygdala, orbitofrontal cortex, and ventral striatum) are implicated in ED. We performed a systematic review/meta-analysis of double-blind randomized controlled trials of ADHD medications to assess their effects on ED in adults with ADHD. We searched an extensive set of databases, international trials registries, and contacted study authors/drug companies for unpublished data. We retained 21 trials. We found small-to-moderate effects (methylphenidate: SMD=0.34, 95% CI=0.23-0.45; atomoxetine: SMD=0.24, 95% CI=0.15-0.34; lisdexamfetamine: SMD=0.50, 95% CI=0.21-0.8). We suggest that, whilst ADHD medications are effective on ADHD core symptoms, they may be less effective on bottom-up mechanisms underlying ED. Further research on novel pharmacological and non-pharmacological strategies for ED in adults with ADHD is warranted.

PROSPERO

CRD42017068426.

Effects of stimulants and atomoxetine on emotional lability in adults: A systematic review and meta-analysis

BACKGROUND

Emotional lability (EL) is an associated feature of attention-deficit/hyperactivity disorder (ADHD) in adults, contributing to functional impairment. Yet the effect of pharmacological treatments for ADHD on EL symptoms is unknown. We conducted a systematic review and meta-analysis to examine the effects of stimulants and atomoxetine on symptoms of EL and compare these with the effects on core ADHD symptoms.

METHODS

A systematic search was conducted on the databases Embase, PsychInfo, and Ovid Medline^® and the clinicaltrials.gov website. We included randomised, double-blind, placebo-controlled trials of stimulants and atomoxetine in adults aged 18-60 years, with any mental health diagnosis characterised by emotional or mood instability, with at least one outcome measure of EL. All identified trials were on adults with ADHD. A random-effects meta-analysis with standardised mean difference and 95% confidence intervals was used to investigate the effect size on EL and compare this to the effect on core ADHD symptoms.

RESULTS

Of the 3,864 publications identified, nine trials met the inclusion criteria for the meta-analysis. Stimulants and atomoxetine led to large mean weighted effect-sizes for on ADHD symptoms (n=9, SMD=-0.8, 95% CI:-1.07 to -0.53). EL outcomes showed more moderate but definite effects (n=9, SMD=-0.41, 95% CI:-0.57 to -0.25).

CONCLUSIONS

In this meta-analysis, stimulants and atomoxetine were moderately effective for EL symptoms, while effect size on core ADHD symptoms was twice as large. Methodological issues may partially explain the difference in effect size. Reduced average effect size could also reflect heterogeneity of EL with ADHD pharmacotherapy responsive and non-responsive sub-types. Our findings indicate that EL may be less responsive than ADHD symptoms overall, perhaps indicating the need for adjunctive psychotherapy in some cases. To clarify these questions, our findings need replication in studies selecting subjects for high EL and targeting EL as the primary outcome.

Moving towards causality in attention-deficit hyperactivity disorder: overview of neural and genetic mechanisms

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by developmentally inappropriate levels of inattention and hyperactivity or impulsivity. The heterogeneity of its clinical manifestations and the differential responses to treatment and varied prognoses have long suggested myriad underlying causes. Over the past decade, clinical and basic research efforts have uncovered many behavioural and neurobiological alterations associated with ADHD, from genes to higher order neural networks. Here, we review the neurobiology of ADHD by focusing on neural circuits implicated in the disorder and discuss how abnormalities in circuitry relate to symptom presentation and treatment. We summarise the literature on genetic variants that are potentially related to the development of ADHD, and how these, in turn, might affect circuit function and relevant behaviours. Whether these underlying neurobiological factors are causally related to symptom presentation remains unresolved. Therefore, we assess efforts aimed at disentangling issues of causality, and showcase the shifting research landscape towards endophenotype refinement in clinical and preclinical settings. Furthermore, we review approaches being developed to understand the neurobiological underpinnings of this complex disorder, including the use of animal models, neuromodulation, and pharmacoimaging studies.

Delineating ADHD and bipolar disorder: A comparison of clinical profiles in adult women

OBJECTIVE

Overlapping symptoms can make the diagnostic differentiation of attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) challenging in adults using current clinical assessments. This study sought to determine if current clinical measures delineate ADHD from BD in adults, comparing relative levels of ADHD, BD and emotional lability (EL) symptoms.

METHODS

Sixty adult women with ADHD, BD or controls were compared on self-report and interview measures for ADHD symptoms, mania, depression, EL, and impairment.

RESULTS

ADHD interview measures and self-ratings of ADHD symptoms best discriminated between ADHD and BD. Self-report measures of EL and depression showed non-specific enhancement in both clinical groups. BD-specific items may distinguish BD from ADHD if a retrospective time-frame is adopted.

CONCLUSIONS

Using measures which capture specific symptoms of ADHD and chronicity/episodicity of symptoms facilitates the delineation of ADHD from BD in adult women.

Emotional Lability in Patients with Attention-Deficit/Hyperactivity Disorder: Impact of Pharmacotherapy

Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder defined by persistent inattention and/or hyperactivity and impulsivity. These symptoms occur more frequently and are more severe in individuals with ADHD compared with those at a similar developmental level without ADHD, and can be conceptualized as deficits in executive functioning (EF). EF includes domains of metacognition and inhibition, which influence the ability to regulate responses elicited by emotional stimuli. EF deficits can lead to emotional lability (EL), which is characterized by sudden changes in emotion and behaviors of inappropriately high intensity that may include sudden bouts of anger, dysphoria, sadness, or euphoria. EL is common and estimated to occur in about 3.3-10% of the population. Recent estimates of EL prevalence in children and adolescents with ADHD range from 38 to 75%. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not include EL in diagnostic criteria for ADHD, but does include ADHD-associated features of low frustration tolerance, irritability, or mood lability. The neurobiological basis of EL is not well understood, but brain imaging studies support dividing EF into "cool" cognitive networks encompassing attention and planning activities, and "hot" motivational networks involved in temporal discounting, reward processing, and reward anticipation. Dysfunction in "hot" networks is thought to be related to EL. EL symptoms are associated with more severe ADHD and co-morbidities, have significant impact on functioning, and may respond to treatment with medications frequently used to treat ADHD. Treatment outcomes and areas for future research are discussed.