Everyday emotional experience of adults with attention deficit hyperactivity disorder: evidence for reactive and endogenous emotional lability

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.

Children's emotional reactivity and negative affect predict future ADHD symptom severity beyond initial ADHD symptom severity

Children with Attention-Deficit/Hyperactivity Disorder (ADHD) often experience significant emotion dysregulation. However, there is limited longitudinal data on associations between multiple aspects of emotion dysregulation and ADHD symptoms. Additionally, given substantial evidence that increased levels and variability of negative affect (NA) are identified in children with ADHD, it is important to examine the role of NA in this relationship. The present study used momentary and longitudinal data to examine the relation between two aspects of emotion dysregulation (emotional lability and emotional reactivity), the two ADHD symptom clusters separately (inattentive and hyperactive/impulsive), total ADHD symptom severity, and NA variability over a period of six months. Participants (N = 68) were parents of children aged 7-12 years old (M = 9.80, SD = 1.34) who completed baseline and 6-month follow-up reports of children's ADHD symptoms and emotion dysregulation as well as ecological momentary assessments (EMA) of their children's NA for one week. Results were threefold: (1) children's emotional reactivity predicted inattentive, hyperactive/impulsive, and total ADHD symptom severity above and beyond initial ADHD symptom severity, but emotional lability did not significantly predict severity of any ADHD symptom cluster; (2) NA variability predicted hyperactive/impulsive and total ADHD symptom severity, but not inattentive severity; and (3) initial ADHD symptom severity did not predict emotion dysregulation at follow-up. The current study provides novel insight regarding the longitudinal influence of specific aspects of emotion dysregulation and NA on ADHD symptom severity in children and suggests that targeting emotional reactivity could minimize ADHD symptom severity.

Coping with emotional dysregulation among young adults with ADHD: A mixed-method study of self-awareness and strategies in daily life

BACKGROUND

Emotional dysregulation (ED) impacts functional outcomes among individuals with attention-deficit hyperactivity disorder (ADHD). Self-awareness and strategies may enhance coping with ED yet are rarely studied in ADHD.

OBJECTIVES

To explore ED-related self-awareness and strategies in daily life of adults with ADHD, and to examine the interrelations between them and their association with symptoms.

METHODS

Sixty young adults with ADHD participated in a mixed-method study. At baseline, self-awareness and strategies were assessed using the Self-Regulation Skills Interview (SRSI); ADHD symptoms were self-rated using the ASRS symptom checklist. Then, symptoms were rated over 5-days using ecological momentary assessment (EMA).

RESULTS

Significant challenges in self-awareness and strategies were demonstrated quantitatively and qualitatively. Awareness of ED was associated with variability of ADHD symptoms on EMA yet not with symptom severity. Qualitative content analysis revealed a range of self-awareness levels, which were related to noticing ED-related cues and understanding contextual factors predictive of ED. Self-awareness and strategies were significantly associated. Strategies varied regarding effort, individual preference and temporality.

CONCLUSIONS

Variability of ADHD symptoms was negatively associated with self-awareness of ED. Strategy selection in daily-life among adults with ADHD may be affected by self-awareness and by a possible trade-off between short-term effort and long-term effectiveness.

A Scoping Review of Factors Associated With Emotional Dysregulation in Adults With ADHD

OBJECTIVE

Emotion dysregulation is frequently seen in adults with ADHD and is associated with many adverse outcomes. We conducted a scoping review of factors associated with emotion dysregulation in adults with ADHD.

METHOD

PubMed and PsycInfo (EBSCO) were searched. Articles were included if they measured ADHD, emotional dysregulation or some aspect of emotional dysregulation, and at least one other construct. Studies examining physiological underpinnings as well as clinical trials examining the effect of ADHD medications on emotional dysregulation were excluded because recent reviews have already examined these topics.

RESULTS

Thirty-five studies were included in the review. Factors such as biological sex, comorbidities, attachment style, using certain emotional regulation strategies, and ADHD subtype tend to be related to emotion dysregulation.

CONCLUSION

Clinicians working with adults with ADHD can collect information on these factors to better understand risk for emotion dysregulation, and emotion regulation skills may be one area for intervention.

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.

Everyday Cognitive Control and Emotion Dysregulation in Young Adults With and Without ADHD: An Ecological Momentary Assessment Study

OBJECTIVE

This study examined the contribution of the temporal dynamics of two cognitive control mechanisms-inhibitory control (IC) and working memory (WM)-to emotion dysregulation (ED) in attention-deficit/hyperactivity disorder (ADHD) in ecological settings.

METHOD

One hundred twenty-two participants (age 18-33 years; 60 with ADHD) reported their ED at baseline, followed by a 5-day ecological momentary assessment (EMA) study, with short behavioral IC and WM tasks performed five times/day.

RESULTS

For IC, mean and lability of performance over EMA significantly accounted for differences in ED but not baseline performance. For WM, both baseline and mean of EMA, but not EMA lability, accounted for ED variance. ADHD status further contributed to the explained variance of ED.

CONCLUSIONS

Our results support the contribution of dynamic IC processes to ED in ADHD, in addition to WM performance level, and highlight the importance of dynamic and ecological investigation of different cognitive control components.

The role of self-compassion in the mental health of adults with ADHD

OBJECTIVE

Evidence suggests that the poorer mental health associated with attention deficit hyperactivity Disorder (ADHD) is partially explained by adverse psychosocial correlates of the condition. As recent studies show that self-compassion is negatively associated with ADHD, this study investigates if levels of self-compassion may explain the mental health outcomes in people with ADHD compared to people without ADHD.

METHOD

A total of 543 adults with ADHD (62.72% female, 18-67 years), and 313 adults without ADHD (66.45% female, 18-82 years) completed questionnaires online to measure levels of self-compassion and mental health. A Structural Equation Model assessed the mediating effect of self-compassion on the relationships between ADHD and well-being (psychological, emotional, and social), and ADHD and ill-being (depression, anxiety, and stress).

RESULTS

Findings suggest that low self-compassion contributes to poorer mental health in adults with ADHD compared to adults without ADHD.

CONCLUSIONS

Thus, self-compassion may be a potential target to improve mental health in this population.

PUBLIC HEALTH SIGNIFICANCE

This study shows that self-compassion is an important factor in the mental health of adults with ADHD and provides preliminary evidence for the use of self-compassion interventions to improve mental health outcomes in adults with ADHD.

An overactive mind: Investigating racing thoughts in ADHD, hypomania and comorbid ADHD and bipolar disorder via verbal fluency tasks

BACKGROUND

Adults with Attention Deficit Hyperactivity Disorder (ADHD) often report mental restlessness akin to racing thoughts found in hypomanic and mixed episodes of bipolar disorder (BD). Past research has suggested that racing thoughts in BD can be tackled via process-oriented verbal fluency measures. In ADHD, it is still unknown whether racing thoughts is due to comorbid BD, and its neuropsychological underpinnings remain to be investigated. To this aim, this study investigates process-oriented verbal fluency measures in adults with ADHD compared to adults with BD in a hypomanic episode, adults with ADHD + BD and healthy controls.

METHODS

Three verbal fluency tasks, i.e., the free, the letter and the semantic conditions, were administered to 37 adults with ADHD, 25 adults with BD in a hypomanic episode, 22 adults with comorbid ADHD + BD (euthymia) and 31 healthy subjects. Word production, clustering, and switching were analysed in verbal fluency tasks.

RESULTS

Adults with ADHD, ADHD + BD and hypomania showed increased switches in the free verbal fluency task, compared to healthy controls, despite equivalent number of words produced. Unlike the ADHD and ADHD + BD groups, phonological clustering measures in the semantic task were increased in the hypomanic group compared to healthy controls.

LIMITATIONS

BD groups were under medication.

CONCLUSIONS

Semantic overactivation, reflected by increased switches in the unconstrained verbal fluency task, appear to be a common mechanism involved in racing thoughts in both ADHD and BD. By contrast, unusual sounds-based associations are specific of hypomanic speech and might contribute to the distinction trait and state racing thoughts.

ADHD in Children and Adults: Diagnosis and Prognosis

Attention-Deficit Hyperactivity Disorder (ADHD) is a prevalent neuropsychiatric disorder associated with significant impairment and distress throughout the lifespan. Recent investigations have shed light on different aspects regarding the trajectory of ADHD, including reports on risk factors in childhood, that are associated with remission or persistence in adulthood. Despite significant advances in our understanding of the pathophysiology of the disorder, the diagnosis of ADHD remains strictly clinical and is based on behavioral symptoms of inattention, impulsivity, and hyperactivity. In this chapter we review the diagnostic process of ADHD, discuss the clinical presentation of the disorder across the lifespan, and examine patterns of comorbidity and longitudinal predictor of outcomes.

Using e-diaries to investigate ADHD - State-of-the-art and the promising feature of just-in-time-adaptive interventions

Attention-deficit/hyperactive disorder (ADHD) is characterized by symptoms which are dynamic in nature: states of hyperactivity, inattention and impulsivity as core symptoms, and emotion dysregulation as associated feature. Although tremendous work has been done to investigate between-subject differences (how patients with ADHD differ from healthy controls or patients with other disorders), little is known about the relationship between symptoms with triggers and contexts, that may allow us to better understand their causes and consequences. Understanding the temporal associations between symptoms and environmental triggers in an ecologically valid manner may be the basis to developing just-in-time adaptive interventions. Fortunately, recent years have seen advances in methodology, hardware and innovative statistical approaches to study dynamic processes in daily life. In this narrative review, we provide a description of the methodology (ambulatory assessment), summarize the existing literature in ADHD, and discuss future prospects for these methods, namely mobile sensing to assess contextual information, real-time analyses and just-in-time adaptive interventions.

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.

Comparable emotional dynamics in women with ADHD and borderline personality disorder

BACKGROUND

Emotional dysregulation (ED) is a core diagnostic symptom in borderline personality disorder (BPD) and an associated feature of attention-deficit/hyperactivity disorder (ADHD). We aimed to investigate differences in dynamical indices of ED in daily life in ADHD and BPD.

METHODS

We used experience sampling method (ESM) and multilevel modelling to assess momentary changes in reports of affective symptoms, and retrospective questionnaire measures of ED in a sample of 98 adult females with ADHD, BPD, comorbid ADHD+BPD and healthy controls.

RESULTS

We found marked differences between the clinical groups and healthy controls. However, the ESM assessments did not show differences in the intensity of feeling angry and irritable, and the instability of feeling sad, irritable and angry, findings paralleled by data from retrospective questionnaires. The heightened intensity in negative emotions in the clinical groups compared to controls was only partially explained by bad events at the time of reporting negative emotions, suggesting both reactive and endogenous influences on ED in both ADHD and BPD.

CONCLUSIONS

This study supports the view that ED is a valuable trans-diagnostic aspect of psychopathology in both ADHD and BPD, with similar levels of intensity and instability. These findings suggest that the presence or severity of ED should not be used in clinical practice to distinguish between the two disorders.

Wandering minds in attention-deficit/hyperactivity disorder and borderline personality disorder

Attention-deficit/hyperactivity Disorder (ADHD) and borderline personality disorder (BPD) have overlapping symptoms. We proposed that excessive spontaneous mind wandering (MW-S) might reflect a component of psychopathology that distinguishes ADHD from BPD. Using a questionnaire measure of MW-S and an experience sampling method, we investigated MW-S in daily life, in 28 ADHD, 19 BPD, 22 comorbid ADHD+BPD, and 29 control females. The clinical groups reported heightened frequency and intensity of MW-S compared to controls, but no differences from each other. When controlling for depression and anxiety, significant differences only persisted between controls and ADHD, who also showed elevated intensity of MW-S compared to BPD and comorbid ADHD+BPD. We found no MW-S instability differences amongst clinical cases as well as cases versus controls. Negative content of MW-S was higher in BPD and comorbid ADHD+BPD compared to controls, with no differences between ADHD and controls. When controlling for depression/anxiety, the differences between BPD and comorbid ADHD+BPD and controls dissipated. MW-S is a trans-diagnostic process present in both ADHD and BPD. Yet, the underlying mechanisms of this experience may be driven by anxiety/depression in BPD but reflect a core process in ADHD.

Parsing the effects of comorbid adult ADHD and substance misuse on affective lability in bipolar disorder

INTRODUCTION

Attentional deficits, substance misuse, and affective lability are all common features among adults with bipolar disorder, but little research has attempted to parse their inter-relationships.

METHODS

Using standardized scales and semi-structured interviews, we evaluated adult ADHD features and affective lability in 113 dually-diagnosed mood/substance use disorder inpatients (mean age 32.6 years, 63% female) drawn from one private suburban academically affiliated inpatient treatment program.

RESULTS

24% of bipolar subjects had above-threshold ADHD screens. Affective Lability Scale (ALS) total and subscores were significantly associated with ADHD scores (univariate r's ranging from 0.38-0.63). ALS total and most subscale scores were significantly higher among bipolar subjects having above- (versus below-) threshold ADHD ratings. Linear regressions to predict affective lability revealed significant partial correlations between bipolar diagnoses and ALS total, depression, elation, and anger subscores, while controlling for significant effects from ADHD comorbidity. Inclusion of current substances of abuse did not change goodness-of-fit.

LIMITATIONS

Subjects were drawn from a single private institution, potentially limiting generalizability.

CONCLUSIONS

Comorbid ADHD appears to moderate multiple domains of affective lability in bipolar disorder inpatients, independent of current substance misuse.

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.

Emotional lability and irritability have specific associations with symptomatology in children with attention deficit hyperactivity disorder

Irritability and emotional lability have been shown to be severity and impairment factors in community and clinical sample studies and are frequent comorbid features of Attention Deficit Hyperactivity Disorder (ADHD). However, while irritability and emotional lability seem to be closely linked, the differential effect of these two features has received little attention. This study assessed the distinct associations of irritability and emotional lability on symptomatology in children with ADHD. One hundred and eight children diagnosed with ADHD participated in the study. Children were rated by parents on ADHD and comorbid symptomatology with the Conners Rating Scale - Revised. Irritability was the most significant predictive factor of the severity of anxiety and oppositional symptoms. Regarding emotional lability, it was significantly predictive of the severity of hyperactivity symptoms. While emotional lability shares common theoretical characteristics with irritability, each seems to be associated with specific areas. Irritability is a symptom of Oppositional Defiant Disorder, a frequent ADHD comorbidity, and also seems to be related to internalizing disorder (e.g. anxiety). Emotional lability seems to be related to ADHD severity symptoms per se. Both could be clinically informative in the diagnosis of ADHD and its comorbidities.

Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD

Objective: Affective lability is an important dimension of adult ADHD, associated with marked impairments and worse outcomes. A valid and quick tool to measure affective lability may therefore be of interest. Method: In 187 adult ADHD patients, we explored psychometric properties of the Affective Lability Scale-Short Form (ALS-18 items). We analyzed the construct validity and the external validity of the scale. Patients were compared with 48 healthy adult controls. Results: The three-factor structure of the ALS-18 presented a good fit and a good internal consistency. The correlations between the ALS-18 and ADHD symptoms and other psychological dimensions were, respectively, low and moderate. ALS-18 scores were higher in patients than in healthy adults. Conclusion: ALS-18 showed good psychometric properties in ADHD adult patients, allowing us to recommend the implementation of ALS-18 in assessing affective lability for clinical and research purposes. Use of ALS-18 should improve the clinical assessment of affective lability in adult ADHD patients.

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.

Emotional dysregulation subgroups in patients with adult Attention-Deficit/Hyperactivity Disorder (ADHD): a cluster analytic approach

Emotion regulation deficits (ERD) are evident in about 34–70% of the adults with ADHD. In contrast to this, they are not considered in the diagnostic criteria of the disorder. In a recent study of our research group using confirmatory factor analysis, we modeled positive and negative emotion as well as emotion regulation skills along with the classical ADHD-core symptoms. We showed that negative affect and the failure to apply adaptive emotion regulation skills were distinct and indicative dimensions in adult ADHD. In this study, we used a person-centered approach based on cluster analysis to subtype patients on the presence or relative absence of ERD. This results in important information to individualize treatment decisions. We found two clusters, with cluster 2 showing high ERD that were associated with higher impairments indicated by depressive mood, negative affect and elevated psychological distress. There were also higher rates of comorbidity in cluster 2 such as somatoform disorders which were associated with ERD. Women were overrepresented in this cluster 2. Neuropsychological variables did not contribute significantly to cluster formation. In conclusion, ADHD in adults is a heterogeneous disorder with specific subgroups that need differential treatment approaches.

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.

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.

Measuring child and adolescent emotional lability: How do questionnaire-based ratings relate to experienced and observed emotion in everyday life and experimental settings?

OBJECTIVES

Emotional lability (EL) is an important trans-diagnostic concept that is associated with significant functional impairment in childhood and adolescence. EL is typically measured with questionnaires, although little is known about the ecological validity of these ratings. In this paper, we undertook 2 studies addressing this issue by examining the relationship between rating-based measures of EL and directly measured emotional expressions and experiences. Furthermore, the associations between directly measured emotional expressions and experiences and attention-deficit/hyperactivity disorder (ADHD) symptomatology were also examined, given the clear association of EL with ADHD in former research.

METHODS

In Study 1, we examined the relationship between parental report of children's EL and ADHD, and children's emotional expressions in an experimental context (N = 67). In Study 2, we examined the relationship between parental ratings and real-time measures of emotional experiences in daily life in adolescents (N = 65).

RESULTS

EL ratings were associated with different elements of real-time emotional experiences and expressions. Elements of emotional expressions but not emotional experiences were also associated with ADHD symptom reports.

CONCLUSIONS

These studies provide evidence for the ecological validity of EL ratings. Furthermore, they add evidence for the associations between EL and ADHD.

Attention-deficit/hyperactivity disorder symptoms and happiness among adults in the general population

Despite an increasing focus on the role of mood and emotions in attention-deficit/hyperactivity disorder (ADHD), as yet, there has been comparatively little research on positive emotions. To address this research gap, the current study examined the association between ADHD symptoms and happiness using data from the 2007 Adult Psychiatric Morbidity Survey. The analytic sample comprised 7274 adults aged 18 and above residing in private households in England. Information was collected on ADHD symptoms using the Adult ADHD Self-Report Scale (ASRS) Screener, while happiness was assessed with a single (3-point) measure. Multivariable ordinal logistic regression analysis and a mediation analysis were performed to examine associations. Greater ADHD symptom severity was associated with higher odds for feeling less happy. Mood instability (percentage mediated 37.1%), anxiety disorder (35.6%) and depression (29.9%) were all important mediators of the association between ADHD and happiness. Given that happiness has been linked to a number of beneficial outcomes, the results of this study highlight the importance of diagnosing ADHD in adults and also of screening for and treating any comorbid psychiatric disorders in these individuals.

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.

Depressive symptoms and the role of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD): A comparison with bipolar disorder

OBJECTIVES

To investigate the characteristics of depressive symptoms and the influence of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD), in comparison with bipolar disorder (BD) patients and healthy controls (HCs).

METHOD

Sixty patients with ADHD, 50 patients with BD, and 30 HCs were assessed with instruments for measuring depressive symptoms (Beck Depression Inventory-II), and affective temperaments (Temperament Scale of Memphis, Pisa and San Diego, self-administered version; TEMPS-A). In addition, participants were evaluated with scales for measuring ADHD symptoms, impulsiveness, anxiety, executive dysfunction, and quality of life.

RESULTS

ADHD patients showed levels of depressive symptoms similar to BD patients and higher than HCs. Only neurovegetative symptoms of depression differentiated ADHD and BD groups (BD > ADHD). Depressive symptoms in ADHD patients correlated positively with core ADHD, impulsivity, anxiety, and dysexecutive symptoms and negatively with quality of life. Thirty-eight percent of patients with ADHD scored above the cutoff for at least one affective temperament. Cyclothymic was the more common affective temperament (25%). ADHD patients with affective temperamental traits were more depressed and impulsive than patients without those traits and showed a symptomatic profile analogous to BD patients.

LIMITATIONS

The small size of resultant samples when ADHD group was stratified by the presence of affective temperament. In addition, results may not generalize to less severe ADHD patients from the community.

CONCLUSIONS

Concomitant depressive symptoms constitute a common occurrence in adults with ADHD that carries significant psychopathological and functional consequences. The concept of affective temperaments may be an interesting link for explaining depressive symptomatology and emotional impulsivity in a subgroup of patients with ADHD, beyond the classic idea of comorbidity.

Reduced emotional empathy in adults with subclinical ADHD: evidence from the empathy and systemizing quotient

Studies in children with ADHD suggest impairments in social cognitive functions, whereas studies in adults with ADHD are scarce and inconclusive. The aim of this study was to investigate the relationship between ADHD traits and self-reported social cognitive style in a sample of adults from the general population. For this purpose, a community sample of 685 adults filled out online self-report questionnaires about ADHD symptoms (ADHD Rating Scale, ARS), social cognitive functioning and friendships. The Empathy Quotient (EQ) with the subscales Cognitive Empathy (CE), Emotional Empathy (EE) and Social Skills (SS), and the Systemizing Quotient (SQ) were included for measuring social cognitive style and the Friendship Questionnaire (FQ) for the quality of friendships. Participants who met the DSM-5 criteria on the ARS (‘subclinical ADHD’; n = 56) were compared regarding their social cognitive functioning scores with a control group (n = 56) that was matched for age, sex and student status. With small effect sizes, the subclinical ADHD group showed reduced EE scores on the EQ and a more male social cognitive profile. This result was not influenced by sex or ADHD subtype. This study points to a relationship between traits of ADHD and the emotional aspect of empathy, whereas more complex aspects of empathy were unrelated. These findings should be corroborated in clinical patients with ADHD, employing neuropsychological tests rather than self-report questionnaires.

Anger-irritability as a mediator of attention deficit hyperactivity disorder risk for adolescent alcohol use and the contribution of coping skills

BACKGROUND

Research on susceptibility to alcohol use disorder within the attention deficit/hyperactivity disorder (ADHD) population has begun to expand examination of putative moderators and mediators in order to develop effective treatments. Specific dysregulated emotions have been separately associated with ADHD and with alcohol use difficulties. The current study is the first to conjointly study these variables by testing anger-irritability as a mediator of ADHD risk for adolescent alcohol use.

METHODS

Frequency of binge drinking, drunkenness, and alcohol problems were examined for 142 children with ADHD followed into adolescence and compared to 100 demographically similar youth without ADHD. Parent-rated anger-irritability was tested as a mediator. Behavioral and cognitive coping skills, which are key clinical treatment targets, were studied as moderators of these associations.

RESULTS

Childhood ADHD was positively associated with anger-irritability and the drinking outcomes in adolescence. Anger-irritability mediated the association between ADHD and alcohol use problems, but not binge drinking or drunkenness. Behavioral and cognitive, but not avoidant, coping played a moderating role, but only of the association between childhood ADHD and anger-irritability.

CONCLUSIONS

Active coping strategies by adolescents with ADHD may reduce the vulnerability to alcohol problems through a reduction of negative emotions. Future research on additional mediators and treatments that target these skills is encouraged.

The wandering mind in borderline personality disorder: Instability in self- and other-related thoughts

Diagnostic criteria for borderline personality disorder (BPD) include instability in identity and interpersonal relationships. Here, we probed whether instability is already present in BPD patients' thoughts about themselves and others. We tested BPD patients (N=27) and healthy controls (N=25) with a mind-wandering task that assesses content and variability of stimulus-independent self-generated thoughts. Multi-level modeling revealed that while BPD patients and healthy controls mind-wander to a similar extent, BPD patients' thoughts are colored predominantly negatively. Most importantly, although their thoughts concerned the self and others as much as in controls, they fluctuated more strongly in the degree to which their thoughts concerned themselves and others and also gave more extreme ratings. Self- and other related thoughts that were more extreme were also more negative in valence. The increased variability supports current conceptualizations of BPD and may account for the instability in identity and interpersonal relationships.

Commonalities in EEG Spectral Power Abnormalities Between Women With ADHD and Women With Bipolar Disorder During Rest and Cognitive Performance

While attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) denote distinct psychiatric conditions, diagnostic delineation is impeded by considerable symptomatic overlap. Direct comparisons across ADHD and BD on neurophysiological measures are limited. They could inform us on impairments that are specific to or shared between the disorders and, therefore, potential biomarkers that may aid in the identification of the diagnostic boundaries. Our aim was to test whether quantitative EEG (QEEG) identifies differences or similarities between women with ADHD and women with BD during resting-state and task conditions. QEEG activity was directly compared between 20 ADHD, 20 BD and 20 control women during an eyes-open resting-state condition (EO) and a cued continuous performance task (CPT-OX). Both ADHD (t₃₈ = 2.50, p = 0.017) and BD (t₃₈ = 2.54, p = 0.018) participants showed higher absolute theta power during EO than controls. No significant differences emerged between the two clinical groups. While control participants showed a task-related increase in absolute theta power from EO to CPT-OX (t₁₉ = −3.77, p = 0.001), no such change in absolute theta power was observed in the ADHD (t₁₉ = −0.605, p = 0.553) or BD (t₁₉ = 1.82, p = 0.084) groups. Our results provide evidence for commonalities in brain dysfunction between ADHD and BD. Absolute theta power may play a role as a marker of neurobiological processes in both disorders.

Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients

BACKGROUND

Emotional dysregulation in subjects with attention deficit and hyperactivity disorder (ADHD) is a topic of growing interest among clinicians and researchers. The present study aims at investigating components of emotional dysregulation in adults ADHD compared to subjects suffering from bipolar disorder (BD).

METHODS

A total of 150 adults ADHD, 335 adults BD subjects and 48 controls were assessed using the Affective Lability Scale (ALS) and the Affect Intensity Measure (AIM), measuring respectively emotion lability and emotion responsiveness.

RESULTS

ADHD and BD subjects scored significantly higher on the ALS compared to controls (p=0.0001). BD subjects scored above ADHD ones (3.07 (SD=0.66) vs. 2.30 (SD=0.68); p<0.0001). The average total scores achieved on the AIM were significantly different for the three groups (p=0.0001) with significantly higher scores for ADHD subjects compared to BD ones (3.74 (SD=0.59) vs. 3.56 (SD=0.69); p<0.0001).

LIMITATIONS

Suspected cases of ADHD in the BD and control groups were derived from the Wender Utah Rating Scale (WURS). This study is a retrospective one.

CONCLUSION

Our study thus highlights the importance of emotional dysregulation in adults suffering from ADHD, showing that they display higher emotional intensity than bipolar disorder subjects and controls. Although the current diagnostic criteria of ADHD do not contain an emotional dimension, a better recognition of the significance of emotional responsiveness in ADHD patients can improve the care afforded to these patients, beyond the inattentive and hyperactive/impulsive components.

Where the depressed mind wanders: Self-generated thought patterns as assessed through experience sampling as a state marker of depression

BACKGROUND

Self-generated thoughts (SGTs), such as during mind wandering, occupy much of our waking life. Individuals with Major Depressive Disorder (MDD) are less in the "here and now" and prone to rumination. Few studies have looked at SGTs in depression using experience sampling methods and no study has so far investigated the specific contents of depressive SGTs and how they vary from one time point to another.

METHODS

MDD patients (n=25) and matched healthy controls (n=26) performed an established mind wandering task, involving non-demanding number discriminations. Intermittent probe questions ask for participants' current SGTs, that is, how off-task the thoughts are, how positive or negative, self- or other-related, and past- or future-oriented.

RESULTS

Multi-level modelling revealed that MDD patients engaged in more mind wandering than healthy controls. Their SGTs were predominantly negative and less positive, more self-related and past-oriented. Strongest predictor of depressive SGT was the decreased positive valence of thoughts. MDD patients' future and past-oriented thoughts were particularly more negative compared to healthy controls. Within MDD patients, the less positively valenced thoughts they had and the less variable these thoughts were, the more depressive symptoms they showed.

LIMITATION

No other measures of rumination and worry were used.

CONCLUSION

MDD patients show a very specific SGT pattern, possibly reflecting ruminative and anxious thoughts. This SGT pattern in depression might represent a useful state marker and even constitute an etiological factor of this debilitating disease, considering the importance of current SGT on and individual's cognitive processes and affective states.

Adult attention-deficit hyperactivity disorder: key conceptual issues

For many years, attention-deficit hyperactivity disorder (ADHD) was thought to be a childhood-onset disorder that has a limited effect on adult psychopathology. However, the symptoms and impairments that define ADHD often affect the adult population, with similar responses to drugs such as methylphenidate, dexamphetamine, and atomoxetine, and psychosocial interventions, to those seen in children and adolescents. As a result, awareness of ADHD in adults has rapidly increased and new clinical practice has emerged across the world. Despite this progress, treatment of adult ADHD in Europe and many other regions of the world is not yet common practice, and diagnostic services are often unavailable or restricted to a few specialist centres. This situation is remarkable given the strong evidence base for safe and effective treatments. Here we address some of the key conceptual issues surrounding the diagnosis of ADHD relevant to practising health-care professionals working with adult populations. We conclude that ADHD should be recognised in the same way as other common adult mental health disorders, and that failure to recognise and treat ADHD is detrimental to the wellbeing of many patients seeking help for common mental health problems.

Six-year follow-up study of combined type ADHD from childhood to young adulthood: Predictors of functional impairment and comorbid symptoms

BACKGROUND

ADHD in childhood is associated with development of negative psychosocial and behavioural outcomes in adults. Yet, relatively little is known about which childhood and adulthood factors are predictive of these outcomes and could be targets for effective interventions. To date follow-up studies have largely used clinical samples from the United States with children ascertained at baseline using broad criteria for ADHD including all clinical subtypes or the use of DSM III criteria.

AIMS

To identify child and adult predictors of comorbid and psychosocial comorbid outcomes in ADHD in a UK sample of children with DSM-IV combined type ADHD.

METHOD

One hundred and eighteen adolescents and young adults diagnosed with DSM-IV combined type ADHD in childhood were followed for an average of 6years. Comorbid mental health problems, drug and alcohol use and police contact were compared for those with persistent ADHD, sub-threshold ADHD and population norms taken from the Adult Psychiatric Morbidity Study 2007. Predictors included ADHD symptomology and gender.

RESULTS

Persistent ADHD was associated with greater levels of anger, fatigue, sleep problems and anxiety compared to sub-threshold ADHD. Comorbid mental health problems were predicted by current symptoms of hyperactivity-impulsivity, but not by childhood ADHD severity. Both persistent and sub-threshold ADHD was associated with higher levels of drug use and police contact compared to population norms.

CONCLUSIONS

Young adults with a childhood diagnosis of ADHD showed increased rates of comorbid mental health problems, which were predicted by current levels of ADHD symptoms. This suggests the importance of the continuing treatment of ADHD throughout the transitional years and into adulthood. Drug use and police contact were more common in ADHD but were not predicted by ADHD severity in this sample.

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.

Disorder-specific and shared neurophysiological impairments of attention and inhibition in women with attention-deficit/hyperactivity disorder and women with bipolar disorder

BACKGROUND

In adults, attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BD) have certain overlapping symptoms, which can lead to uncertainty regarding the boundaries of the two disorders. Despite evidence of cognitive impairments in both disorders separately, such as in attentional and inhibitory processes, data on direct comparisons across ADHD and BD on cognitive-neurophysiological measures are as yet limited.

METHOD

We directly compared cognitive performance and event-related potential measures from a cued continuous performance test in 20 women with ADHD, 20 women with BD (currently euthymic) and 20 control women.

RESULTS

The NoGo-N2 was attenuated in women with BD, reflecting reduced conflict monitoring, compared with women with ADHD and controls (both p < 0.05). Both ADHD and BD groups showed a reduced NoGo-P3, reflecting inhibitory control, compared with controls (both p < 0.05). In addition, the contingent negative variation was significantly reduced in the ADHD group (p = 0.05), with a trend in the BD group (p = 0.07), compared with controls.

CONCLUSIONS

These findings indicate potential disorder-specific (conflict monitoring) and overlapping (inhibitory control, and potentially response preparation) neurophysiological impairments in women with ADHD and women with BD. The identified neurophysiological parameters further our understanding of neurophysiological impairments in women with ADHD and BD, and are candidate biomarkers that may aid in the identification of the diagnostic boundaries of the two disorders.

[Minimal cerebral dysfunctions and ADHD in adulthood]

Attention deficit hyperactivity disorder (ADHD) is of great importance not only in children but also in adults; however, despite extensive research there are still many unsolved questions with respect to the diagnosis. Patients not only suffer from attention deficits and hyperactivity but also a variety of other problems, such as dyspraxia, problems with stimulus discrimination, dysgrammatism, legasthenia, or motor coordination problems. Furthermore, there are also psychopathological disorders, such as problems with memory, formal thinking, emotional modulation, drive and vegetative stability, in the sense of a psycho-organic syndrome. Such syndromes have long been known in psychiatry under terms, such as complex capacity disorders, minimal cerebral dysfunction (MCD), minimal brain dysfunction (MBD), mild psycho-organic syndrome, psycho-organic axis syndrome, mild cognitive impairment, developmental disorder and developmental biological syndrome. Etiological data with respect to genetics and early childhood brain trauma support the notion of a psychobiological disorder for complex cerebral dysfunction in the sense of a psycho-organic syndrome. Depending on the individual life and work situation, these additional symptoms of ADHD are in many cases of greater relevance for life adjustment than the core symptoms, depending on the individual life and work situations. The concept of minimal cerebral dysfunction describes the ADHD problem better and has a direct bearing on the diagnosis, therapy and sociomedical care of the patients.

Attention-deficit/hyperactivity disorder symptoms and suicide ideation and attempts: Findings from the Adult Psychiatric Morbidity Survey 2007

BACKGROUND

Adults with attention-deficit/hyperactivity disorder (ADHD) may have an increased risk of engaging in suicidal behavior. This study examined this association in the general adult population where there has been little research.

METHODS

Data came from the Adult Psychiatric Morbidity Survey 2007. This was a representative sample of the English adult household population aged ≥16 years (N=7403). The Adult ADHD Self-Report Scale (ASRS) was used to obtain information on ADHD symptoms. The Clinical Interview Schedule Revised (CIS-R) was used to assess six forms of common mental disorder (CMD). Information was also obtained on the lifetime and past 12-month occurrence of suicide ideation and attempts. Logistic regression analysis was used to examine these associations.

RESULTS

After adjusting for comorbid disorders, adults with more ADHD symptoms had significantly higher odds for suicidal behavior. When a single cut-off point was used to classify ADHD (ASRS score ≥14), odds ratios ranged from 1.62 (lifetime suicide attempt) to 2.43 (past 12-month suicide ideation). When ADHD symptoms were categorized by strata (I: a score of 0-9; II: 10-13; III: 14-17; IV: 18-24), compared to adults in stratum I, those in stratum IV had odds ratios ranging from 2.16 (lifetime suicide ideation) to 3.68 (past 12-month suicide attempt).

LIMITATIONS

ADHD and suicide data came from self-reports which may have been affected by socially desirable responding.

CONCLUSIONS

ADHD symptoms were linked to suicidal behavior after controlling for comorbid conditions. Health care professionals should be alerted to the increased suicide risk among adults with ADHD symptoms.

"Turning down the heat": Is poor performance of children with ADHD on tasks tapping "hot" emotional regulation caused by deficits in "cool" executive functions?

Emotional dysregulation in daily life is very common in children with attention deficit hyperactivity disorder (ADHD). It is however not clear whether this reflects a specific deficit or that it may be the result of generic executive function (EF) deficits. The current study addresses this question by means of an emotional working memory (WM) task with 2 memory load conditions and four possible backgrounds (blank screen, neutral, positive or negative picture), which was administered to 38 typically developing children and 29 children with ADHD. Children responded slower on trials when negative pictures were presented at the background versus when neutral pictures were presented, indicating an emotional interference effect; however crucially, groups did not differ in this respect. Reaction times were also slower on trials with a neutral picture as background versus trials without a picture, with children with ADHD showing an enhanced interference effect. There was a main effect of WM load on performance, but it did not interact with interference or group effects. To summarize, the findings indicate a generic interference control deficit in the children with ADHD in the current sample, while they could not provide support for an emotional interference deficit.

Driving behaviour in adults with attention deficit/hyperactivity disorder

BACKGROUND

Little is known about the impact of cognitive impairments on driving in adults with ADHD. The present study compared the performance of adults with and without ADHD in a driving simulator on two different routes: an urban route which we hypothesised would exacerbate weak impulse control in ADHD and a motorway route, to challenge deficits in sustained attention.

METHODS

Adults with (n = 22, 16 males) and without (n = 21, 18 males) ADHD completed a simulated driving session while eye movement data were recorded simultaneously. Participants also completed the Manchester Driving Behaviour Questionnaire (DBQ) and the Conners Adult ADHD Rating Scale (CAARS). Measures of driving performance included average speed, proportion distance travelled over speed limit (speeding) and lane deviation. These variables and the eye movement measures (spread of fixations, mean fixation duration) were compared between groups and routes. Also, driving behaviours, including responses to programmed events, were categorised and the frequencies within categories were compared between groups. Finally, speech analysis was performed to compare emotional verbal expressions during driving between groups.

RESULTS

ADHD participants reported significantly more Violations and Lapses on the DBQ than control participants and significantly more accidents. Average speed and speeding were also higher but did not interact with route type. ADHD participants showed poorer vehicle control, greater levels of frustration with other road users (including greater frequencies of negative comments) and a trend for less safe driving when changing lanes/overtaking on the motorway. These effects were predicted by hyperactive/impulsive CAARS scores. They were also more likely to cause a crash/near miss when an event occurred on the urban route.

CONCLUSIONS

The results suggest that difficulty regulating and controlling impulsive behavior, reflected in speeding, frustration with other road users, less safety when changing lanes on the motorway and a greater likelihood of an accident following an unexpected event, underlie impaired driving in ADHD. Hyperactivity/impulsivity symptoms correlated with these indices. Deficits in sustained attention seemed to play a lesser role in this particular study, although further research is needed to determine whether effects on attention emerge over longer periods of time and/or are influenced by the novelty of the simulator environment.