The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults

Emotion Regulation and Organizational Skills in Children With ADHD Symptoms Are Associated With Behavioral Parent Training Adherence

OBJECTIVE

Behavioral parent training (BPT) is a well-established treatment for ADHD; however, treatment response is variable. Consistency in parent skill use during BPT is known to influence child outcomes post-treatment, while less research has focused on specific child factors that may be impacting parent skill utilization during treatment. The current study examined associations between child organizational skills and emotion dysregulation (ED) with parent treatment adherence during BPT and post-treatment child impairment.

METHOD

Parents of 72 children (Mage = 8.31) with ADHD symptoms and impairment participated in BPT which was embedded in a 12-week, multicomponent, school-based intervention for children delivered by school mental health clinicians. Outcomes included parent treatment adherence and child improvements in global impairment post-treatment.

RESULTS

Greater pre-treatment child organizational problems were associated with less parent treatment adherence regardless of ADHD symptom severity. Worse pre-treatment child ED was associated with more impairment post-treatment regardless of ADHD symptom severity whereas the effects of child ED on parent treatment adherence were moderated by child ADHD symptom severity.

CONCLUSION

The current study suggests that pre-treatment child ED and organizational difficulties impact parent treatment adherence to behavioral interventions targeting ADHD symptoms, potentially in unique ways, and should be considered in future BPT treatment studies.

ADHD-related sex differences in emotional symptoms across development

To investigate developmental changes in emotion dysregulation (ED) and associated symptoms of emotional lability, irritability, anxiety, and depression, among girls and boys with and without ADHD from childhood through adolescence. Data were collected from a sample of 8-18-year-old children with (n = 264; 76 girls) and without (n = 153; 56 girls) ADHD, with multiple time-points from a subsample of participants (n = 121). Parents and youth completed rating scales assessing child ED, emotional lability, irritability, anxiety, and depression. Mixed effects models were employed to examine effects and interactions of diagnosis, sex [biological sex assigned at birth], age among boys and girls with and without ADHD. Mixed effects analyses showed sexually dimorphic developmental patterns between boys and girls, such that boys with ADHD showed a greater reduction in ED, irritability, and anxiety with age compared to girls with ADHD, whose symptom levels remained elevated relative to TD girls. Depressive symptoms were persistently elevated among girls with ADHD compared to boys with ADHD, whose symptoms decreased with age, relative to same-sex TD peers. While both boys and girls with ADHD showed higher levels of ED during childhood (compared to their sex-matched TD peers), mixed effects analyses revealed substantial sexually dimorphic patterns of emotional symptom change during adolescence: Boys with ADHD showed robust improvements in emotional symptoms from childhood to adolescence while girls with ADHD continued to show high and/or increased levels of ED, emotional lability, irritability, anxiety and depression.

Multimodal Assessment of Emotion Dysregulation in Children with and without ADHD and Disruptive Behavior Disorders

OBJECTIVE

We sought to explore if specific domains of emotion dysregulation (emotion regulation [EREG], emotional reactivity/lability [EREL], emotion recognition/understanding [ERU], and callous-unemotional [CU] behaviors) were uniquely associated with diagnostic classifications.

METHOD

This study utilized a multimodal (parent/teacher [P/T] reports and behavioral observations) approach to examine emotion dysregulation in a sample of young children (68.7% boys; mean age = 5.47, SD = 0.77, 81.4% Latinx) with attention-deficit/hyperactivity disorder (ADHD Only; n = 46), ADHD + disruptive behavior disorders (ADHD+DBD; n = 129), and typically developing (TD) children (n = 148).

RESULTS

All three diagnostic groups were significantly different from one another on P/T reports of EREG, EREL and CU. For the ADHD+DBD group, P/T reported worse EREG and EREL, and higher mean scores of CU, compared to both ADHD Only and TD groups. The ADHD+DBD group also performed significantly worse than the TD group (but not the ADHD Only group) on observed measures of EREG, EREL and ERU. P/T reported EREG, EREL and CU for the ADHD Only group were significantly worse than the TD group. Using multinomial logistic regression, P/T reported EREG, EREL, and CU were significantly associated with diagnostic status above and beyond observed measures of emotion dysregulation. The model successfully classified children with ADHD+DBD (91.3%) and TD (95.9%); however, children in the ADHD Only group were correctly identified only 45.7% of time.

CONCLUSION

Our findings suggest that measures of emotion dysregulation may be particularly helpful in correctly identifying children with ADHD+DBD, but not necessarily children with ADHD Only.

A Blended Intervention Targeting Emotion Dysregulation in Adults With Attention-Deficit/Hyperactivity Disorder: Development and Feasibility Study

BACKGROUND

Many adults with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotion regulation. Such difficulties are known to substantially impact quality of life and overall functioning. Yet, there is a lack of treatment interventions specifically designed to address these challenges.

OBJECTIVE

This study aimed to describe the development and assess the feasibility, along with the initial clinical outcomes, of a novel blended intervention for adults with ADHD. The blended intervention combines both face-to-face and digital components and is specifically designed to address emotion dysregulation in ADHD.

METHODS

This intervention was an 8-week blended intervention combining weekly face-to-face group sessions with a supplementary digital companion app. The intervention is based on elements from dialectic behavioral therapy skills training and positive psychology. To evaluate its feasibility, we performed a 10-week feasibility study with an uncontrolled pre-post study design, including 16 adults with ADHD and co-occurring emotion dysregulation. The feasibility measures encompassed adherence, satisfaction, and perceived credibility of the intervention. Clinical outcomes were evaluated by self-reported symptoms of emotion dysregulation, inattention, hyperactivity-impulsivity, executive function, depression, anxiety, and a measure of quality of life. Paired sample 2-tailed t tests were used to analyze clinical outcomes with a Bonferroni-corrected significance level.

RESULTS

Both treatment credibility and treatment satisfaction were rated favorably by the majority of the participants. In particular, the participants emphasized meeting others with ADHD as beneficial. In terms of adherence, 3 participants withdrew before initiating the intervention, while another 4 participants did not complete the intervention. On average, the participants who enrolled in the intervention attended 6.2 of the 8 group sessions and completed 6.7 of the 8 skills training modules in the companion app. In terms of clinical outcomes, there was a reduction in symptoms of emotion dysregulation from before to after the intervention (d=2.0). Significant improvements were also observed in measures of inattention (d=1.1) and hyperactivity-impulsivity (d=0.9). However, no significant improvements were found in the domains of depression, anxiety, quality of life, and executive functioning.

CONCLUSIONS

The results are encouraging, both in terms of feasibility and the preliminary clinical results on emotion dysregulation. The blended format, combining digital and face-to-face elements, may also seem to offer some advantages: the group-based format was valued as it facilitated peer interaction, while a rather high completion of modules in the companion app highlights its potential to enhance skills training between the group sessions. Future randomized controlled trials are called for to further evaluate the clinical effectiveness of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05644028; https://clinicaltrials.gov/study/NCT05644028.

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.

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.

Effect of Cognitive Training Programs Based on Computer Systems on Executive Functions in Children With ADHD: A Systematic Review

BACKGROUND

The purpose of this systematic review is to synthesize the existing literature reporting the effects of computerized cognitive trainings on the executive functions of children with ADHD.

METHOD

A systematic review was carried out following the PRISMA statement; the primary sources used were five electronic databases (Scopus, Science Direct, Pubmed, Springer, Taylor & Francis).

RESULTS

20 articles met the eligibility criteria, data on the training characteristics and the effects on executive functions were extracted, followed by an analysis of bias and the methodological quality of the studies. The results of the studies were widely heterogeneous, largely associated with the variety of training programs and the measurement instruments used. The most studied executive functions were working memory and inhibitory control. Some of the studies reported that the intervention led to significant effects on working memory and attention (N = 7), and improvements in inhibitory control (N = 5) and planning (N = 4) were also reported. At the same time, others did not report the effects of the intervention on these processes. The assessment of the quality of the evidence showed important risk biases among the reviewed studies.

CONCLUSION

Some training based on computer systems showed positive effects on the executive functions of working memory, attention, and inhibitory control in children with ADHD. However, other training sessions did not show significant effects. In general, the evidence shows mixed results, a high diversity of measurement instruments, and high risks of bias between the studies. Therefore, the evidence has not been consistent about the general benefits of computerized training on the executive functions of children with ADHD.

Construction of Meta-Thinking Educational Program Based on Mental-Brain Simulation (MTMBS) and Evaluating its Effectiveness on Executive Functions, Emotion Regulation, and Impulsivity in Children With ADHD: A Resting-State Functional MRI Study

OBJECTIVE

The aim of present research was to make a Meta-Thinking educational program based on mental-brain simulation and to evaluate its effectiveness on executive functions, emotion regulation and impulsivity in children with ADHD.

METHODS

The research method was Embedded Design: Embedded Experimental Model. The research sample included 32 children with ADHD who were randomly assigned to two experimental and control groups. The intervention was implemented for eight sessions of 1.5 hr for the experimental group, and fMRI images were taken from them, while the control group didn't receive any treatment. Finally, using semi-structured interviews, coherent information was collected from the parents of the experimental group about the changes made. Data were analyzed with SPSS-24, MAXQDA, fMRIprep, and FSL software.

RESULTS

The Meta-Thinking Educational Program had effect on performance of ADHD children and suppressed brain regions related to DMN.

CONCLUSION

The Implementation of this educational program plays a vital role in improving psychological problems of children with ADHD.

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.

Examining the structural equation modeling between intrinsic-motivation, emotion regulation and AHDH: the mediating role of problem-solving, time-management, and behavioral-inhibition

Although Executive Functions has been considered as the main correlation of ADHD few studies have examined the effect of EFs on ADHD symptoms, in the samples with ADHD. This study aimed to examine the structure of EFs on ADHD students in a hypothesized model. After careful screening of ADHD among 1368 university students (with stratified and multistage cluster sampling), out of them, 211 students with ADHD diagnosis were selected purposefully. They received scales on their emotion regulation, motivation, adult ADHD, deficits in EFs, and diagnostic interview. Emotion regulation and intrinsic motivation were considered as input; behavioral-inhibition, time-management, and problem-solving were the mediators and ADHD subscales were as the output variables. Results showed that the model adequately fit the data. The model fit indices were χ2 = 27.081, df = 1, CFI = 0.99, GFI = 0.97, and PGFI = 0.02. The direct effects of intrinsic-motivation and emotion-regulation on all three mediators and indirect effects of them to ADHD subscales were significant. Based on the results, time-management mediated the relationship between motivation and emotion regulation and ADHD. Among EFs, emotion-regulation and intrinsic-motivation had fundamental influence to other aspects of EFs factors such as behavioral-inhibition, time-management, problem-solving, and attention deficit/hyperactivity disorder.

Structural and diffusion-weighted brain imaging predictors of attention-deficit/hyperactivity disorder and its symptomology in very young (4- to 7-year-old) children

The current study aimed to identify the key neurobiology of attention-deficit/hyperactivity disorder (ADHD), as it relates to ADHD diagnostic category and symptoms of hyperactive/impulsive behaviour and inattention. To do so, we adapted a predictive modelling approach to identify the key structural and diffusion-weighted brain imaging measures and their relative standing with respect to teacher ratings of executive function (EF) (measured by the Metacognition Index of the Behavior Rating Inventory of Executive Function [BRIEF]) and negativity and emotion regulation (ER) (measured by the Emotion Regulation Checklist [ERC]), in a critical young age range (ages 4 to 7, mean age 5.52 years, 82.2% Hispanic/Latino), where initial contact with educators and clinicians typically take place. Teacher ratings of EF and ER were predictive of both ADHD diagnostic category and symptoms of hyperactive/impulsive behaviour and inattention. Among the neural measures evaluated, the current study identified the critical importance of the largely understudied diffusion-weighted imaging measures for the underlying neurobiology of ADHD and its associated symptomology. Specifically, our analyses implicated the inferior frontal gyrus as a critical predictor of ADHD diagnostic category and its associated symptomology, above and beyond teacher ratings of EF and ER. Collectively, the current set of findings have implications for theories of ADHD, the relative utility of neurobiological measures with respect to teacher ratings of EF and ER, and the developmental trajectory of its underlying neurobiology.

Behavioral symptoms among children and adolescents with attention deficit hyperactivity disorder during COVID-19 outbreak: a retrospective prospective cohort study

Background

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent neurodevelopmental conditions in children, and with the coronavirus pandemic, ADHD children now pose obvious challenges. This retrospective prospective cohort study was conducted on 150 ADHD children and adolescents that had previously attended the child unit of the Psychiatry Department, Zagazig University Hospitals, Sharkia, Egypt, and diagnosed as ADHD patients using the research diagnostic criteria of DSM-5 which administrated by experienced psychiatrists and evaluated by The Arabic version of Conner’s Parent Rating Scale Revised-short version (CPRS-48) before the onset of COVID-19 pandemic. We collected the other data of the study by applying an Arabic language questionnaire which included the data related to the COVID -19 pandemic and the Arabic version of CPRS-48 by which we reevaluated the behavioral symptoms of the subjects who participated in the study during COVID-19 pandemic. This research aimed to evaluate the behavioral symptoms among ADHD children and adolescents and detect the change in these symptoms during the COVID-19 pandemic by comparing them before and during the pandemic.

Results

One hundred fifty ADHD children were included in the study with a mean age of 10 years old. The male gender was predominant and represented 76.7% of the sample. Ninety percent were living in urban areas with more low social class (50%), 84.7% of parents were married, 60% of the family member of our subjects had COVID-19 while 12% lost one or more of their relative by the pandemic (64.7%). The fathers continued working as normal, while 40.7% of the mothers stopped working because of COVID-19. 62.7% of the parents were verbally and physically abusive to their children. Unfortunately, 100% of the subjects stopped attending their behavioral therapy center, 96.0% stopped their Follow up with a psychiatrist, and 55% stopped complying with their medications. As we presumed, we found a statistically significant change in the behavioral and psychological symptoms measured by Conner’s Parent Rating Scale Revised-short version (CPRS-48) during the COVID-19 pandemic compared to the period before. The worsening of the symptoms was associated with age, sex, residency, social class, father and mother present working and couple status, having positive cases or losses of COVID-19 among family members, and patient maltreatment.

Conclusions

To conclude, this study suggests that the lockdown caused by the COVID-19 pandemic has worsened symptoms in a significant number of children and adolescents with ADHD, which needs clinical attention. Moreover, the patients’ psychiatric follow-up and compliance with their medications were markedly affected. Additionally, the lockdown has also led to an increase in the abusive behavior of the parents towards their children.

Birds of a Feather: An Examination of ADHD Symptoms and Associated Concerns in Partners of Adults with ADHD

OBJECTIVE

Adults often select romantic partners who behave like they do (i.e. assortative mating). However, little is known about whether assortative mating is common among adults with attention-deficit/hyperactivity disorder (ADHD) and whether it is related to associated problems.

METHOD

About 94 adults without ADHD, 43 adults with childhood ADHD histories but without current symptoms or impairment (ADHD-Desist), 27 adults with childhood ADHD histories and elevated current symptoms and impairment (ADHD-Persist) rated their partners' ADHD symptoms and their own associated problems (e.g., intimate partner violence, financial difficulties).

RESULTS

The ADHD-Persist group reported that their partners exhibited more ADHD symptoms than the ADHD-Desist group and those without ADHD. Adults in the ADHD-Persist group who had partners with elevated ADHD symptoms endorsed high intimate partner violence and financial difficulties.

CONCLUSION

Assortative mating appears to be common among adults with ADHD, especially those with persistent symptoms, and to increase risk of additional problems.

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.

Emotional dysregulation and health related quality of life in young adults with ADHD: a cross sectional study

Objective

Attention Deficit Hyperactivity Disorder (ADHD) is associated with emotional dysregulation (ED) and impaired health related quality of life (HRQoL). However, the role of ED in explaining the relationship between ADHD and HRQoL is unclear. The purpose of the present study was to do so in a sample of non-referred young adults with and without ADHD.

Method

The study design was cross-sectional. A non-clinical sample of 63 young adults with ADHD (mean age = 24.86 years, SD = 3.25, 78% university students) and 69 gender-matched controls (mean age = 23.84 years, SD = 2.59, 89% university students) were recruited. The Adult ADHD Quality-of-Life scale was used to measure HRQoL; The Self-Report Wender–Reimherr Adult Attention Deficit Disorder Scale and the Difficulties in Emotion Regulation Scale were used to measure ED. Group differences on all measures were tested using univariate and multivariate analyses of covariance, while controlling for age. Finally, a moderation analysis was used in order to examine the impact of ED on HRQoL beyond that accounted for by ADHD symptoms.

Results

Both HRQoL and ED were significantly worse for the ADHD group compared to the control group. The medication status of the ADHD group participants had no significant effect on the level of ADHD symptoms, ED or HRQoL. ED moderated the effect of ADHD symptoms on HRQoL for the ADHD group.

Conclusion

The findings support the centrality of ED in ADHD and its crucial influence on HRQoL. Young adults with ADHD and high levels of ED are at risk for aversive impact on their well-being regardless of their ADHD symptoms level.

Young adults with Attention Deficit Hyperactivity Disorder (ADHD) struggle with poor quality of life (QoL). Emotional regulation is one’s ability to modify their emotional state to promote adaptive, goal-oriented behaviors. Emotional dysregulation is a common yet neglected feature of people with ADHD. Our results show that young adults with ADHD are twice more likely to suffer from emotional dysregulation then their peers. Moreover, higher levels of emotional dysregulation predicted lower levels of QoL. These findings support the centrality of ED in ADHD and their crucial influence on everyday QoL. These findings are important not only on the theoretical level, but may also contribute to the design of interventions that aim to promote quality of life.

Irritability in developmental age: A narrative review of a dimension crossing paediatric psychopathology

OBJECTIVE

Irritability is an important theme in paediatric psychiatry considering its high frequency in developmental age, its association with negative outcomes and consequently significant public health impact. Present as main or associated feature of several psychiatric diagnoses, irritability represents a challenge for clinicians who try to understand its origin and role in developmental psychopathology. In this review we try to: (1) get an overview of this dimension and its relationship with each of the main neuropsychiatric disorders in paediatric population and (2) provide a summary of currently available instruments to assess irritability in children and adolescents.

METHOD

In this narrative review, an overview of irritability in children and adolescents is proposed focusing on selected literature.

RESULTS

Irritability as feature of many paediatric psychiatric conditions has been evaluated by many authors and included in classifications of paediatric psychiatric diseases. Framework of irritability evolved over time and dimension of irritability has been investigated using different tools and methodologies, both qualitative and quantitative. Metrics of irritability as clinical dimension are important in the diagnostic process of paediatric diseases.

CONCLUSION

Investigating the presence of irritability in all children with related disorders is mandatory if we consider the risk for functional impairment and affective and behavioural disorders associated with high levels of irritability. Using rigid threshold in developmental age to differentiate physiological from pathological irritability could lead many children having subthreshold levels of irritability to receive no diagnosis and, consequently, no treatment where instead a dimensional approach to irritability could allow to identify prodromal phase and prevent the evolution towards clinical pathological expressions.

Targeting working memory to modify emotional reactivity in adult attention deficit hyperactivity disorder: a functional magnetic resonance imaging study

Understanding the neural mechanisms of emotional reactivity in Attention-Deficit/Hyperactivity Disorder (ADHD) may help develop more effective treatments that target emotion dysregulation. In adult ADHD, emotion regulation problems cover a range of dimensions, including emotional reactivity (ER). One important process that could underlie an impaired ER in ADHD might be impaired working memory (WM) processing. We recently demonstrated that taxing WM prior to the exposure of emotionally salient stimuli reduced physiological and subjective reactivity to such cues in heavy drinkers, suggesting lasting effects of WM activation on ER. Here, we investigated neural mechanisms that could underlie the interaction between WM and ER in adult ADHD participants. We included 30 male ADHD participants and 30 matched controls. Participants performed a novel functional magnetic resonance imaging paradigm in which active WM-blocks were alternated with passive blocks of negative and neutral images. We demonstrated group-independent significant main effects of negative emotional images on amygdala activation, and WM-load on paracingulate gyrus and dorsolateral prefrontal cortex activation. Contrary to earlier reports in adolescent ADHD, no impairments were found in neural correlates of WM or ER. Moreover, taxing WM did not alter the neural correlates of ER in either ADHD or control participants. While we did find effects on the amygdala, paCG, and dlPFC activation, we did not find interactions between WM and ER, possibly due to the relatively unimpaired ADHD population and a well-matched control group. Whether targeting WM might be effective in participants with ADHD with severe ER impairments remains to be investigated.

Enhanced Brief Motivational Intervention for College Student Drinkers With ADHD: Goal-Directed Activation as a Mechanism of Change

College students with attention-deficit/hyperactivity disorder (ADHD) are at risk for alcohol-related problems and disorders relative to their typically developing peers. Despite risk, the optimal therapeutic approach for reducing problem alcohol use in students with ADHD, and mechanisms of change underlying treatment effects in this population, are largely unknown. The current study evaluated putative mechanisms of change in a randomized controlled trial of two harm reduction interventions for college student drinkers with ADHD (N = 113; 49% male): brief motivational intervention plus supportive counseling (BMI + SC) versus brief motivational intervention plus behavioral activation (BMI + BA). Results showed that participants in the BMI + BA condition engaged in more goal-directed activation and less avoidant behavior over the course of treatment compared to those in the BMI + SC condition, in turn predicting reductions in alcohol-related negative consequences. Effects were more robust 1 month following intervention, and diminished by 3 months. Sensitivity analyses revealed a significant indirect effect of treatment condition on alcohol-related negative consequence via reductions in avoidance over treatment. Post hoc moderated mediations showed that BMI + BA engaged target mechanisms more robustly for students with more severe ADHD and depressive symptoms compared to BMI + SC. These findings support the application of BMI + BA intervention, particularly in targeting goal-directed activation and avoidance/rumination in at-risk student drinkers with ADHD.

Examining Link Between Childhood ADHD and Sexual Assault Victimization

Objective: Adults with ADHD are often victims of psychological and physical violence by romantic partners, but less is known regarding whether ADHD is associated with sexual assault victimization. Method: Adults with (n = 97) and without childhood histories of ADHD (n = 121) rated their experiences with sexual assault victimization and additional risk factors (i.e., alcohol abuse, illicit drug use, and experiencing child abuse). Results: Adults with ADHD histories were more likely to report being victims of sexual assault, especially attempted rape or rape, than adults without ADHD histories. The rate of rape victimization was not greater for adults with ADHD histories and persistent symptoms or additional risk factors. Conclusion: Research is needed to investigate potential mechanisms explaining the link between ADHD and sexual victimization. Clinicians seeking to prevent at-risk populations from becoming victims, or to provide services for victims, should consider screening adults for ADHD histories.

Emotion Regulation via the Autonomic Nervous System in Children with Attention-Deficit/Hyperactivity Disorder (ADHD): Replication and Extension

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent disorder characterized by symptoms of inattention, hyperactivity, and/or impulsivity, as well as executive dysfunction. Recent work underlines the importance in understanding the role of emotion reactivity and regulatory deficits in the context of the disorder. One study (i.e., Musser et al. 2011) utilized a positive and negative emotion induction and suppression task, as well as indexes of autonomic nervous system reactivity, to examine emotional functioning in youth with ADHD. This study revealed inflexible parasympathetic-based regulation across emotion conditions among youth with ADHD compared to typically developing youth. The present study sought to replicate and extend these findings to a clinically recruited, diverse sample, while also examining sympathetic functioning. Two hundred fifty-nine participants (160 youth with ADHD), aged 5 to 13, completed the task utilized in Musser et al. 2011, while indexes of parasympathetic (i.e., respiratory sinus arrhythmia [RSA]) and sympathetic (i.e., pre-ejection period [PEP] and electrodermal activity [EDA]) reactivity were obtained. ADHD was associated with significantly elevated parasympathetic (i.e., augmented RSA) and sympathetic (as indexed by EDA) reactivity. Overall, results replicate and extend Musser et al. 2011, revealing sympathetic-linked disruptions in emotion reactivity and parasympathetic-linked disruptions in emotion regulation among youth with ADHD. Future studies of behavioral therapies for ADHD should consider the efficacy of adding an emotion regulation skills training component.

Verbal working memory and processing speed: Correlations with the severity of attention deficit and emotional dysregulation in adult ADHD

Objectives

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), emphasizes symptoms severity with regard to the diagnosis of attention deficit hyperactivity disorder (ADHD). Many clinicians use neuropsychological test results as objective measures of cognitive functions as part of the diagnostic work‐up. The aim of this study was to investigate whether the psychometric test results regarding verbal working memory and processing speed are useful as indicators of the severity of attention deficits and emotional dysregulation in adults with ADHD.

Methods

This observational cross‐sectional clinical study included 418 adults diagnosed with ADHD according to the DSM‐5. Attention deficit severity was defined based on the inattentive subscale of the Adult ADHD Self‐Report Scale. Emotional dysregulation was assessed with the Deficient Emotional Self‐Regulation scale. Verbal working memory was measured with the Working Memory Index (WMI), and processing speed was measured with the Processing Speed Index (PSI) from the Wechsler Adult Intelligence Scale, third edition.

Results

The full‐scale intelligence quotients of the participants were in the normal range, with expected reductions in verbal working memory and processing speed. Only processing speed was associated with attention deficits (β = −.056, p = .003). The association between the psychometric test result for verbal working memory and processing speed and that between the severity of attention deficits and emotional dysregulation were weak (R² < .1) and mostly non‐significant.

Conclusion

The psychometric index scores for verbal working memory (WMI) and processing speed (PSI) seem to have limited utility as indicators of the severity of attention deficits and emotional dysregulation in adult ADHD patients.

Adult ADHD and romantic relationships: What we know and what we can do to help

It has been widely maintained that enduring and healthy romantic relationships are critical to quality of life in adulthood, and can buffer the impact of adversity, including psychological disorder. Unfortunately, much research points toward adults with attention-deficit hyperactivity disorder (ADHD) having short-lived and discordant romantic relationships. Despite this ample evidence, relatively little research has focused on identifying specific factors that may strengthen or explain their relational difficulties, which would have obvious relationship distress prevention and intervention implications. The current study reviews the state of the literature on romantic relationships in adults with ADHD, including differences that have been established between ADHD and non-ADHD populations as well as distal and proximal factors that appear to increase risk of relationship distress of adults with ADHD. Finally, notable gaps in the literature are identified and implications are raised with regards to prevention and intervention efforts designed to address functional impairment in adults with ADHD.

Comparison of Emotional Dysregulation Features in Cyclothymia and Adult ADHD

Background and Objectives: Emotional dysregulation is central to the problem of the overlap between attention-deficit/hyperactivity disorder (ADHD) and cyclothymia. The aim of the study was to evaluate comorbidity rates between ADHD and cyclothymic disorder and to explore demographic and clinical differences among the groups, focusing on affective temperament and emotional dysregulation. Materials and Methods: One hundred sixty-five outpatients attending the Second Psychiatry Unit at the Santa Chiara University Hospital (Pisa) were consecutively recruited: 80 were diagnosed with ADHD, 60 with cyclothymic disorder, and 25 with both conditions. Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS-M) and the 40-item version of Reactivity, Intensity, Polarity, and Stability questionnaire (RI-PoSt-40) were administered. Results: Cyclothymic patients were more frequently female and older with respect to the ADHD groups. Both comorbid and non-comorbid ADHD patients showed significantly lower educational attainment and more frequently had substance use disorders. Panic disorder was common in non-comorbid cyclothymic patients, who showed significantly higher rates of familial panic disorder, major depressive disorder and suicide attempts in comparison with patients only diagnosed with ADHD. Cyclothymic patients without ADHD were also characterized by fewer hyperthymic temperamental traits, higher depressive and anxious dispositions, and a greater negative emotionality. No significant differences among groups were observed for cyclothymic temperament and overall negative emotional dysregulation, but comorbid patients with both conditions scored the highest in these subscales. This group also showed significantly higher affective instability with respect to ADHD patients without cyclothymia and was less frequently diagnosed with bipolar disorder type II than patients from both the other groups. Conclusions: ADHD and cyclothymia often co-occur and show similar levels of emotional dysregulation. However, cyclothymic patients may be more prone to negative emotionality in clinical settings. Subjects with “sunny” cyclothymic features might escape the attention of clinicians unless ADHD is present.

Prevalence of criminal convictions in Norwegian adult ADHD outpatients and associations with ADHD symptom severity and emotional dysregulation

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) often co-occurs with antisocial behaviour. Several studies have shown high rates of ADHD among prisoners. However, the prevalence of crime among individuals with ADHD is less known. The aim of the present study was to estimate the prevalence of lifetime criminal conviction (CC) in a clinical sample of adults with ADHD, and the associations with the severity of ADHD and emotional dysregulation (ED).

METHODS

Patients were admitted to a private psychiatric outpatient clinic in Oslo between 2014 and 2018. Of the 656 patients diagnosed with ADHD, 629 (95.9%) agreed to participate in the study. CC was determined based on self-reporting of the lifetime history of criminal behaviour. ADHD was diagnosed according to the DSM-5 criteria, and ADHD severity was measured using the Adult ADHD Self-Report Scale (ASRS). ED was assessed by the eight-item version of Barkley's Current Behaviour Scale - Self-Report (CBS-SR).

RESULTS

The prevalence of self-reported CC in this clinical sample was 11.7% among women and 24.5% among men. CC was associated with hyperactive-impulsive severity (p < 0.001) and ED (p = 0.006).

CONCLUSIONS

The prevalence of self-reported lifetime criminal conviction was high for both genders. CC was associated with symptom severity of hyperactivity-impulsivity and emotional dysregulation. The findings suggest the need for greater research efforts on the avoidance of criminal activity in people with ADHD and targeted intervention for ADHD treatment and CC prevention.

An Exploratory Study of Emotional Dysregulation Dimensions in Youth With Attention Deficit Hyperactivity Disorder and/or Bipolar Spectrum Disorders

Emotional dysregulation (ED) is currently the most frequently used term to describe children with an impaired regulation of emotional states. Recent research studies speculate whether ED may be a neurodevelopmental disorder itself, a shared risk factor, or a common key feature of several psychiatric disorders, including, among others, attention deficit hyperactivity disorder (ADHD), and bipolar spectrum disorders (BSD). The association between ADHD and ED is one of the main reasons of misconceptions in the definition of boundaries between ADHD and BSD, leading to the frequent misdiagnosis of ADHD as BSD. Since ED is a multidimensional concept, a novel instrument-the Reactivity, Intensity, Polarity and Stability (RIPoSt) scale-was recently developed to assess the different dimensions of ED, which could help in detecting specific ED profiles in clinical youths. Our study included 154 patients, aged 13.8 ± 2.3 years, diagnosed with either ADHD, BSD, or comorbid condition, and a school-based sample of 40 healthy control (HC) adolescents, aged 12.5 ± 1.2 years. The RIPoSt scale and the Child Behavior Checklist were administered to both groups. Our results indicate that affective instability and negative emotionality subscales, as well as negative emotional dysregulation, are higher in BSD, both pure and comorbid with ADHD, while emotional impulsivity is higher in the comorbid condition and similar in the ADHD and BSD alone group; all clinical groups scored higher than HC. Conversely, positive emotionality is similar among clinical groups and within them and HC. Our findings also support the validity of the RIPoSt questionnaire, since the instrument proved to have good-to-excellent internal consistency, and strongly significant positive correlations were found with the CBCL-Dysregulation Profile, which is a commonly used, indirect measure of ED. Hence, the five subscales of the RIPoSt can be reliably used as an effective tool to study the emotional dysregulation in different clinical conditions, to help disentangle the complex relationship between ADHD and juvenile BSD and to provide clinicians with crucial evidence for better diagnostic characterization and therapeutic indications.

Financial judgment determination in adults with ADHD

ADHD has a debilitating influence on everyday functioning, including the capability to make financial decisions. The capability to make financial decisions is a multidimensional construct that includes financial knowledge, financial judgment, financial performance and related contextual factors. So far, the majority of studies in adults with ADHD focused on financial performance, while the other aspects of financial capability were less explored. The current study aims to partly bridge this gap by examining the ability of financial judgment in adults with ADHD. Thirty-nine adults with ADHD and 83 adults without ADHD were included. All participants were assessed with the Financial Competence Assessment Inventory (FCAI) and Financial Decision-Making Interview (FDMI) which both assess the four abilities of financial judgment, i.e., understanding, appreciation, reasoning and communication. The results show that adults with ADHD, compared to adults without ADHD, obtained significantly lower scores on understanding (according to the FCAI and FDMI). Furthermore, adults with ADHD showed a significantly lower appreciation, reasoning and communication (according to the FCAI) than adults without ADHD. In conclusion, adults with ADHD have difficulties with financial judgment especially with the ability to understand information that is relevant for a financial situation or transaction. Furthermore, adults with ADHD were found to have problems with appreciating, reasoning and communicating about practical information that partly relates to their own financial situation (as assessed with the FCAI). A careful assessment of financial capability in adults with ADHD, therefore, appears warranted in clinical practice.

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.

Irritability Predicts Hyperactive/Impulsive Symptoms Across Adolescence for Females

Irritability is common in Attention-Deficit Hyperactivity Disorder (ADHD), but little is known about whether irritability predicts the course of ADHD symptoms over time. Adolescence is a dynamic period of emotional development as well as shifts in ADHD symptoms; an important goal is to identify youth at risk of increasing or persisting symptoms. We examined irritability as a longitudinal predictor of change in adolescents' ADHD symptoms, as well as how this link may differ in females versus males. The sample included 108 youth (72 males) age 12-16 years (M = 14.21 years, SD = 1.44 years), 62 of whom met criteria for ADHD. Approximately 18 months later, 80 participants (48 males) were followed up at Time 2. A dimensional approach was used to examine changes over time in parent-reported inattentive and hyperactive/impulsive symptoms. Longitudinal path analysis revealed that irritability at Time 1 predicted higher relative hyperactive/impulsive symptoms at Time 2 after controlling for age and longitudinal stability in all variables. A multiple-group analysis examining moderation by sex/gender revealed that this association was significant only for females. These results suggest that irritability may play a key role in the persistence and worsening of hyperactive/impulsive symptoms across adolescence for females, with potential implications for the diagnosis and treatment of females with ADHD.

Symptomatological Variants and Related Clinical Features in Adult Attention Deficit Hyperactive Disorder

A large amount of the current literature has focused on the characteristic symptoms of attention deficit hyperactivity disorder (ADHD) in children and adolescents. In contrast, less attention has been devoted to ADHD clinical subtypes in adult patients. We evaluated 164 consecutive adult ADHD (A-ADHD) outpatients using DSM-5 criteria and many specific rating scales and questionnaires. A principal component factor analysis was performed on clinical and symptomatological variables to describe potential clinical variants. We sought to determine different A-ADHD variants focusing on demographic and clinical features. A four-factor solution was identified, and patients were clustered, according to their z-score, in 4 subgroups. The first was marked out by Emotional Dysregulation (ED), the second by Substance Use (SU), the third by Core-ADHD Symptoms (Co-ADHD) and the fourth by Positive Emotionality (PE). Predominantly ED patients showed worse overall function, early treatment with antidepressants and a greater presence of borderline personality disorder than predominantly Co-ADHD patients. Predominantly SU patients reported high rates of bipolar disorder and severe general psychopathology. The PE factor was related to hyperthymic temperament and hypomania and showed a higher level of functioning. Females with A-ADHD showed a lower risk of being included in SU, and A-ADHD patients with co-occurring delayed sleep phase had less risk of being included in the SU factor than the prevailing Co-ADHD group. Our empirically based description of four clinical A-ADHD variants shows several aspects beyond the definition given by the DSM-5 diagnostic criteria.

Sickness and sleep health predict frustration and affective responses to a frustrating trigger

Fluctuations in health and sleep are common, but we know surprisingly little about how these daily life stressors affect one's level of frustration and sensitivity to becoming frustrated. In this pre-registered study, 517 participants (Mage = 30.4, SD = 10.4) reported their current sickness symptoms, health status, sleepiness, and sleep duration and quality the previous night. They also rated their general frustration and mood before and after a mild frustration-eliciting task. In the task, participants were instructed to copy geometric shapes onto a piece of paper, without lifting the pen from the paper. Participants were given three minutes to copy the eight shapes, but in order to induce frustration half of them were unsolvable. The study was subsequently repeated in an independent sample (N = 113). Frustration increased in response to the task; however, those with the worst sickness symptoms or sleep health reduced or did not change their frustration levels. Instead, across both studies, frustration was already high at baseline for these individuals. These findings indicate that being sick or having poor sleep is related to high general frustration, but resilience to further frustration due to mild frustrating situations.

Current and Retrospective Childhood Ratings of Emotional Fluctuations in Adults With ADHD

Introduction: Emotional fluctuations and mood swings are common among adults with Attention Deficit/Hyperactivity Disorder (ADHD). Here we investigated if these problems could be retrospectively traced back to childhood behavior.

Methods: Adults with an ADHD diagnosis (n = 502, 48% female) and a population-based control sample (n = 818, 59% female) completed the Adult ADHD Self-report Scale (ASRS), the Wender Utah Rating Scale (WURS) and the Mood Disorder Questionnaire (MDQ). All participants also provided self-reported information about co-existent psychiatric and somatic diseases, and demographic data. Reports on the MDQ were used to define subgroups with [MDQ(+)] and without [MDQ(–)] life-time periods of emotional fluctuations and the WURS scale was used to retrospectively assess childhood ADHD related behaviors and symptoms.

Results: 50.2% of the ADHD group and 5% of the controls were defined with emotional fluctuations [MDQ(+)]. Childhood behavior ratings of “impulsivity,” “loosing of control,” and “trouble with authorities” independently predicted emotional fluctuations reported in adulthood via logistic regression analyses. Inclusion of these three items in a classification analysis gave an accuracy score around 70% in identifying each of the two MDQ categories in the ADHD group.

Discussion: The strong association between self-reported features of emotional problems in childhood and in adulthood suggests a trajectory that should be detected and remediated at an early age. Future longitudinal studies should prioritize the examination of developmental mechanisms explaining the persistence of emotional problems from childhood into adulthood.

Shared alterations in resting-state brain connectivity in adults with attention-deficit/hyperactivity disorder and their unaffected first-degree relatives

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a developmental condition that often persists into adulthood with extensive negative consequences on quality of life. Despite emerging evidence indicating the genetic basis of ADHD, investigations into the familial expression of latent neurocognitive traits remain limited.

METHODS

In a group of adult ADHD probands (n = 20), their unaffected first-degree relatives (n = 20) and typically developing control participants (n = 20), we assessed endophenotypic alterations in the default mode network (DMN) connectivity during resting-state functional magnetic resonance imaging in relation to cognitive performance and clinical symptoms. In an external validation step, we also examined the dimensional nature of this neurocognitive trait in a sample of unrelated healthy young adults (n = 100) from the Human Connectome Project (HCP).

RESULTS

The results illustrated reduced anti-correlations between the posterior cingulate cortex/precuneus and right middle frontal gyrus that was shared between adult ADHD probands and their first-degree relatives, but not with healthy controls. The observed connectivity alterations were linked to higher ADHD symptoms that was mediated by performance in a sustained attention task. Moreover, this brain-based neurocognitive trait dimensionally explained ADHD symptom variability in the HCP sample.

CONCLUSIONS

Alterations in the default mode connectivity may represent a dimensional endophenotype of ADHD, hence a significant aspect of the neuropathophysiology of this disorder. As such, brain network organisation can potentially be employed as an important neurocognitive trait to enhance statistical power of genetic studies in ADHD and as a surrogate efficacy endpoint in the development of novel pharmaceuticals.

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.

A Measure of Emotional Regulation and Irritability in Children and Adolescents: The Clinical Evaluation of Emotional Regulation-9

Objective: To develop a scale for emotional regulation using item response theory. Method: Eighteen Swanson Nolan and Pelham (SNAP-IV) items that loaded on an emotional dysregulation factor were submitted to Rasch analysis. After eliminating the items that violated Rasch criteria, the remaining items were examined for reliability and validated against the Conners' emotional lability index. Results: A nine-item scale for emotional regulation was developed that satisfies the Rasch model and reliably distinguishes emotionally dysregulated/irritable children and adolescents. A score of 4 or higher in this scale has optimal accuracy for identifying children and adolescents with current significant dysfunction in emotional regulation. Among youth with ADHD inattentive, hyperactive-impulsive, and combined types, 42%, 56%, and 71% met the Clinical Evaluation of Emotional Regulation-9 (CEER-9) threshold for emotional lability, respectively. Conclusion: A nine-item scale whose sum total is a measure of emotional regulation is proposed as a tool for clinical and research purposes.

Comorbid Internalizing and Externalizing Disorders Predict Lability of Negative Emotions Among Children With ADHD

Objective: A subset of children with ADHD experience more frequent, sudden, and intense shifts toward negative emotions. The current study utilized ecological momentary assessment (EMA) to provide a valid assessment of the impact of comorbid internalizing and externalizing disorders on negative emotional lability (EL) among children with ADHD. Method: Parents of 58, 8- to 12-year-old children with ADHD were administered a diagnostic interview to assess for ADHD and for the presence of comorbid disorders. Parents completed EMA-based ratings of their child's negative emotions three times daily for a total of 28 days. Results: Children with a comorbid internalizing disorder or children with comorbid oppositional defiant disorder (ODD) experienced significantly greater EMA-derived negative EL than children without comorbid disorders over time. Children with multiple comorbidities experienced greater EL than children with single comorbidities. Conclusion: Overall, this study suggested that both comorbid ODD and comorbid internalizing disorders contribute to negative EL among children with ADHD.

Emotional face processing across neurodevelopmental disorders: a dynamic faces study in children with autism spectrum disorder, attention deficit hyperactivity disorder and obsessive-compulsive disorder

Autism spectrum disorder (ASD) is classically associated with poor face processing skills, yet evidence suggests that those with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) also have difficulties understanding emotions. We determined the neural underpinnings of dynamic emotional face processing across these three clinical paediatric groups, including developmental trajectories, compared with typically developing (TD) controls. We studied 279 children, 5-19 years of age but 57 were excluded due to excessive motion in fMRI, leaving 222: 87 ASD, 44 ADHD, 42 OCD and 49 TD. Groups were sex- and age-matched. Dynamic faces (happy, angry) and dynamic flowers were presented in 18 pseudo-randomized blocks while fMRI data were collected with a 3T MRI. Group-by-age interactions and group difference contrasts were analysed for the faces vs. flowers and between happy and angry faces. TD children demonstrated different activity patterns across the four contrasts; these patterns were more limited and distinct for the NDDs. Processing happy and angry faces compared to flowers yielded similar activation in occipital regions in the NDDs compared to TDs. Processing happy compared to angry faces showed an age by group interaction in the superior frontal gyrus, increasing with age for ASD and OCD, decreasing for TDs. Children with ASD, ADHD and OCD differentiated less between dynamic faces and dynamic flowers, with most of the effects seen in the occipital and temporal regions, suggesting that emotional difficulties shared in NDDs may be partly attributed to shared atypical visual information processing.

Financial decision-making in a community sample of adults with and without current symptoms of ADHD

Research found that adults with attention deficit hyperactivity disorder (ADHD) have more problems with financial decision-making than healthy controls. The present study investigates the impact of symptoms of ADHD on impulsive buying and the use of financial decision styles. Furthermore, the influence of personality, symptoms of depression and demographics on the association between ADHD and these aspects of financial decision-making is evaluated. A community sample of 1292 participants (age range 18–93 years, 45.4% male) completed questionnaires related to ADHD, impulsive buying, financial decision styles, personal financial situation, depression and personality. Four groups were formed based on self-reported ADHD symptoms: an ‘ADHD’ group (n = 45), an ‘Adult-only ADHD’ group (n = 57), a ‘Subthreshold ADHD’ group (n = 162) and a ‘No ADHD’ group (n = 265). Groups were compared using ANOVA and chi-square tests. Furthermore, multiple regression analyses in the complete sample were employed to examine the association between ADHD and financial decision-making. The ADHD and Adult-only ADHD groups reported significantly more impulsive buying, used more often an avoidant or spontaneous decision style and less often saved money compared to the No ADHD group. Regression analyses revealed that impulsive buying and financial decision styles were not significantly associated with ADHD symptoms when controlling for personality, symptoms of depression and demographics. The present study confirms previous research on adults with ADHD by indicating more impulsive buying and a more frequent use of disadvantageous financial decision styles (i.e., avoidant and spontaneous styles) in individuals with an elevated number of current symptoms of ADHD compared to individuals without symptoms of ADHD. Personality and demographic variables were found to be related to both impulsive buying and the use of specific financial decision styles and might be of influence on the association between impulsive buying, the use of financial decision styles and ADHD.

Integrity of Amygdala Subregion-Based Functional Networks and Emotional Lability in Drug-Naïve Boys With ADHD

Objective: This study evaluated the functional networks of amygdala subregions (basolateral [BLA], centromedial [CMA], and superficial amygdala [SFA]) in ADHD and their association with emotional lability (EL) symptoms. Method: Resting-state functional connectivity (RSFC) of amygdala subregions and their correlations with EL scores were evaluated in 35 drug-naïve boys with ADHD and 30 age-matched healthy controls (HC). Results: Compared with HC, altered RSFC were detected differently for each amygdala subregion in ADHD: altered RSFC of BLA with the thalamus and vermis; aberrant RSFC of CMA with the superior temporal gyrus/pole and insula, precuneus and cerebellum; reduced RSFC of SFA with dorsal frontoparietal cortices. Within ADHD, higher EL scores were associated with reduced negative RSFC of SFA with the dorsolateral prefrontal cortex and inferior parietal lobe. Conclusion: Diffuse alterations of amygdala subregion-based networks are associated with ADHD, and the weaker SFA-frontoparietal networks might be involved in the hypothesized top-down effortful regulation of emotion.

Impact of sleep restriction on affective functioning in adolescents with attention-deficit/hyperactivity disorder

BACKGROUND

Shortened sleep and affective disturbances are both prevalent in adolescents with attention-deficit/hyperactivity disorder (ADHD), yet the causal link between these domains has not been examined. This study investigated whether shortened sleep duration is causally linked to affective functioning in adolescents with ADHD.

METHODS

Participants were 48 adolescents (75% male) aged 14-17 years with ADHD who successfully completed a three-week sleep protocol using an experimental crossover design. The protocol included a phase stabilization week, followed, in randomized counterbalanced order, by one week of sleep restriction (6.5 hr in bed) and one week of sleep extension (9.5 hr in bed). Sleep was monitored with objective actigraphy, and all participants included in this study obtained ≥1 hr actigraphy-measured sleep duration during extension compared to restriction. Parents and adolescents provided daily ratings of positive and negative affect during the extension and restriction conditions. Ratings of affect, internalizing symptoms, and emotion regulation were collected at laboratory visits conducted at the end of each week.

RESULTS

Both parents and adolescents reported greater depressive symptoms and lower positive affect during restriction compared to extension. Parents also reported greater negative affect and emotion dysregulation among adolescents during sleep restriction than extension. No effects were found for parent- or adolescent-reported anxiety symptoms or for adolescent-reported emotion regulation or negative affect.

CONCLUSIONS

Findings from this study provide the first evidence that shortened sleep duration is a causal contributor to the affect and mood disturbances frequently experienced by adolescents with ADHD, particularly as observed by parents. Targeting sleep may be important to reduce affective disturbances in adolescents with ADHD.

Depression and Suicidal Behavior in Young Adult Men and Women With ADHD: Evidence From Claims Data

OBJECTIVE

This study used commercial claims data to examine the effects of ADHD and sex on the prevalence of depression, suicidal ideation, and suicide attempts in a sample of young adult men and women (aged 18-25 years) with and without attention-deficit/hyperactivity disorder (ADHD). Patterns of treatment use for these conditions was also explored.

METHODS

Young adults with ADHD (162,263 women and 225,705 men) having at least 2 claims with the International Classification of Diseases, Ninth Revision (ICD-9), code for ADHD and a sex- and age-matched group of young adults without an ICD-9 code for ADHD (162,263 women and 225,705 men) were identified. The prevalence of ICD-9 depression and suicidal behavior along with the use and cost of related treatment were compared between young adults with and without ADHD using 2014 claims data.

RESULTS

Compared to young adults without ADHD, young adults with ADHD were more frequently identified with depression, suicidal ideation, and suicide attempts. Depression and suicidal ideation were identified more frequently among women with ADHD compared to all other groups. Young adults with ADHD were more frequently engaged in outpatient and inpatient mental health care compared to young adults without ADHD (P < .0001 in each instance). Furthermore, overall costs of outpatient and inpatient care were greater among young adults with ADHD compared to young adults without ADHD (P < .0001 in each instance).

CONCLUSIONS

These findings highlight the substantial burden of depression and suicidal behavior among young adults with ADHD, particularly women, and underlie the need for more research focused on mitigating risk for depression and suicidal behavior among both men and women with ADHD.

Alcohol and drug use disorders in adult attention-deficit/hyperactivity disorder: Prevalence and associations with attention-deficit/hyperactivity disorder symptom severity and emotional dysregulation

BACKGROUND

High risk of alcohol and drug use disorders in people with attention-deficit/hyperactivity disorder (ADHD) calls for exploratory research of relationships with clinical features of ADHD.

AIM

To estimate prevalence of alcohol/drug use disorders and associations with ADHD symptom severity and emotional dysregulation, in adults with ADHD.

METHODS

This observational cross-sectional clinical study consisted of patients admitted to a private psychiatric outpatient clinic in Oslo, Norway (2014-2018). Five-hundred and fifty-eight eligible patients diagnosed with ADHD (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria) agreed to participate. Alcohol and drug use disorders were diagnosed using the Mini International Neuropsychiatric Interview (MINI). Dependence and abuse were merged into "use" disorder as in MINI version 7.0/DSM-5. Questions were related both to lifetime and the past 12-mo. ADHD severity was assessed by the Adult ADHD Self Report Scale (ASRS). Subdivisions of the ASRS questionnaire as inattentive items and hyperactive/impulsivity items were recorded separately. Emotional dysregulation was assessed by the eight-item version of Barkley's Current Behavior Scale - Self Report.

RESULTS

The 12-mo prevalence was 5.3% for alcohol use disorder and 13.7% for drug use disorder. The lifetime prevalence was 12.0% for alcohol use disorder and 27.7% for drug use disorder. Men had higher rates of both alcohol use disorder and drug use disorder compared to women. The prevalence of drug use disorder was more than twice that of alcohol use disorder for both sexes. The drugs most participants reported having used were (in descending order): Amphetamine (19.1%), cannabis (17.1%), cocaine or ecstasy (7.4%), benzodiazepines (7.4%), and heroin or other opioids (2.9%). Lifetime drug use disorder was significantly associated with both hyperactivity-impulsivity symptoms and emotional dysregulation symptom severity. Lifetime alcohol use disorder, on the other hand, was not significantly associated with ADHD symptoms or emotional dysregulation when adjusted for gender and age.

CONCLUSION

Patients with ADHD have a high lifetime prevalence of drug use disorder, which is associated with higher levels of hyperactivity-impulsivity symptoms and emotional dysregulation.

Variability in Positive and Negative Affect Among Adolescents with and without ADHD: Differential Associations with Functional Outcomes

INTRODUCTION

This study examined whether adolescents with and without attention-deficit/hyperactivity disorder (ADHD) differed in affect variability and whether variability in positive and negative affect was associated with functional outcomes.

METHOD

Participants were 302 adolescents (12-14 years, Mage=13.17, 55% male; 54% diagnosed with ADHD; 82% white) and their caregivers who each completed the 10-item Positive and Negative Affect Scale via daily diaries for approximately two weeks. Multi-informant ratings of emotional, behavioral, social, and academic outcomes were assessed.

RESULTS

Adolescents with ADHD were found to experience greater variability in self- and parent-reported positive affect, fear, and distress. For adolescents with ADHD, greater variability in self- and parent-reported positive affect, fear, and distress were associated with more internalizing symptoms, greater variability in parent-reported positive affect was associated with worse social functioning, and greater variability in self- and parent-reported fear was associated with more externalizing symptoms. In contrast, greater variability in self- and parent-reported positive affect, fear, and distress were associated with better social functioning in adolescents without ADHD.

LIMITATIONS

Future work should examine affect variability in adolescents with ADHD within the same day rather than across days. The limited age range and demographic diversity of our sample may limit generalizability of findings.

CONCLUSIONS

Findings suggest the significant affect variability found among children with ADHD is also present in adolescents with ADHD and is associated with social and behavior impairment. Interventions for adolescents with ADHD should target emotion regulation abilities to help reduce the extremes of and shifts in affective experiences in this population.

Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women

BACKGROUND

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.

METHODS

The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.

RESULTS

A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.

CONCLUSIONS

This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Toward a Revised Nosology for Attention-Deficit/Hyperactivity Disorder Heterogeneity

Attention-deficit/hyperactivity disorder (ADHD) is among the many syndromes in the psychiatric nosology for which etiological signal and clinical prediction are weak. Reducing phenotypic and mechanistic heterogeneity should be useful to arrive at stronger etiological and clinical prediction signals. We discuss key conceptual and methodological issues, highlighting the role of dimensional features aligned with Research Domain Criteria and cognitive, personality, and temperament theory as well as neurobiology. We describe several avenues of work in this area, utilizing different statistical, computational, and machine learning approaches to resolve heterogeneity in ADHD. We offer methodological and conceptual recommendations. Methodologically, we propose that an integrated approach utilizing theory and advanced computational logic to address targeted questions, with consideration of developmental context, can render the heterogeneity problem tractable for ADHD. Conceptually, we conclude that the field is on the cusp of justifying an emotionally dysregulated subprofile in ADHD that may be useful for clinical prediction and treatment testing. Cognitive profiles, while more nascent, may be useful for clinical prediction and treatment assignment in different ways depending on developmental stage. Targeting these psychological profiles for neurobiological and etiological study to capture different pathophysiological routes remains a near-term opportunity. Subtypes are likely to be multifactorial, cut across multiple dimensions, and depend on the research or clinical outcomes of interest for their ultimate selection. In this context parallel profiles based on cognition, emotion, and specific neural signatures appear to be on the horizon, each with somewhat different utilities. Efforts to integrate such cross-cutting profiles within a conceptual dysregulation framework are well underway.

Is Increased Response Time Variability Related to Deficient Emotional Self-Regulation in Children With ADHD?

Objective: Elevated response time intrasubject variability (RT-ISV) characterizes ADHD. Deficient emotional self-regulation (DESR), defined by summating Child Behavior Checklist Anxious/Depressed, Aggressive, and Attention subscale scores, has been associated with worse outcome in ADHD. To determine if DESR is differentially associated with elevated RT-ISV, we examined RT-ISV in children with ADHD with and without DESR and in typically developing children (TDC). Method: We contrasted RT-ISV during a 6-min Eriksen Flanker Task in 31 children with ADHD without DESR, 34 with ADHD with DESR, and 65 TDC. Results: Regardless of DESR, children with ADHD showed significantly greater RT-ISV than TDC (p < .001). The ADHD subgroups, defined by presence or absence of DESR, did not differ from each other. Conclusion: Increased RT-ISV characterizes ADHD regardless of comorbid DESR. Alongside similar findings in children and adults with ADHD, these results suggest that RT-ISV is related to cognitive rather than emotional dysregulation in ADHD.

Temporal and Reciprocal Relations Between ADHD symptoms and Emotional Problems in School-Age Children

Objective: The study aimed to investigate the reciprocal and temporal relations between ADHD symptoms and emotional problems in school-age children. Method: This 1-year longitudinal study with a four-wave design included 1,253 children and adolescents (254 third graders, 281 fifth graders, and 718 eighth graders; 50.9% boys). ADHD symptoms and emotional problems were measured using parent report of the Swanson, Nolan, and Pelham, Version IV Scale and Strengths and Difficulties Questionnaire. Results: Cross-lagged panel analyses indicated that both inattention and hyperactivity/impulsivity symptoms were associated with emotional problems over the 1-year period. However, only inattention symptoms demonstrated a transactional relationship with emotional problems, such that inattention predicted future emotional problems, which in turn led to increases in inattention symptoms. Conclusion: Our findings highlight the transactional and dynamic interplay between inattention symptoms and emotional problems and support the mechanistic role of inattention symptoms in the development and persistence of emotional problems in school-age children.

Sex and Emotion Regulation Difficulties Contribute to Depression in Young Adults With Attention-Deficit/Hyperactivity Disorder

Many young adults with attention-deficit/hyperactivity disorder (ADHD) are at risk for depression. Yet, questions remain about factors associated with the development of depression in young adults with ADHD. This study examined the effects of sex and emotion regulation difficulties on depression in a sample of young adults with (n = 172) and without (n = 730) ADHD. Two aspects of emotion regulation difficulties were examined-impairments in emotional insight (i.e., lack of emotional awareness, nonacceptance of emotion, and lack of emotional clarity) and impairments in behavioral response to emotion (i.e., impulse control difficulties, difficulties engaging in goal-directed behavior, and limited access to emotion regulation strategies). Significant correlations between ADHD and all indices of emotion regulation difficulty emerged. Sex moderated the association between ADHD and lack of emotional awareness, difficulties engaging in goal-directed behavior, and limited access to emotion regulation strategies. Specifically, ADHD was significantly associated with limited emotion regulation awareness for women but not men, while ADHD was associated with greater difficulties engaging in goal-directed behavior and limited access to emotion regulation strategies for women compared to men. These three areas of emotion regulation dysfunction simultaneously mediated the association between ADHD and depression. The findings indicate the importance of considering emotion regulation and sex in understanding depression in young adults with ADHD.

Empirical examination of executive functioning, ADHD associated behaviors, and functional impairments in adults with persistent ADHD, remittent ADHD, and without ADHD

BACKGROUND

Previous studies suggest that childhood attention deficit hyperactivity disorder (ADHD) may continue in adulthood, producing adverse effects. Therefore, identifying factors that help to differentiate characteristics of ADHD persistence and remission has practical implications for evaluation and treatment. The first aim of this study was to analyze differences in executive functions (shift, working memory, inhibition, and plan/organize), symptoms associated with ADHD (inattention, hyperactivity, emotional lability, and self-concept), and functional impairments in adults with persistent ADHD (ADHD-P), with remittent ADHD (ADHD-R), and without ADHD (N-ADHD). The second aim was to study the contribution of functional impairments in these three groups based on executive functions and associated ADHD behaviors.

METHODS

Participants were 115 adults, 61 with a childhood ADHD diagnosis (40 persisters and 21 remitters) and 54 individuals with typical development. Self-reports were collected on executive functions, symptoms associated with ADHD, and functional impairments. Multivariate Analyses of Variance were conducted to test differences between the ADHD-P, ADHD-R, and N-ADHD groups on the evaluated variables. In addition, analyses were performed using two structural equation models with observed variables (path analyses).

RESULTS

The results indicated that significant executive and behavioral impairments and adverse functional outcomes in different life domains are related to the diagnostic persistence of ADHD. Recovery from the disorder is associated with better results, although hyperactivity/restlessness behaviors and plan/organize deficits continue to be present in remitter individuals.

CONCLUSIONS

The ADHD-P and ADHD-R groups showed some differences in their executive, behavioral, and functional impairments. Furthermore, the impairments in each group can be predicted by different executive functions and other symptoms associated with the disorder. These results should be taken into account in order to improve clinical practice.

Evidence against emotion inference deficits in children with ADHD

Inconsistent evidence suggests that pediatric attention deficit/hyperactivity disorder (ADHD) may be associated with impairments in the ability to use context clues to infer the emotion states of others. However, the evidence base for these impairments is comprised of data from laboratory-based tests of emotion inference that may be confounded by demands on nonaffective cognitive processes that have been linked with ADHD. The current study builds on our previous study of facial affect recognition to address this limitation and investigate a potential mechanism underlying children's ability to infer emotion state from context clues. To do so, we used a fully crossed, counterbalanced experimental design that systematically manipulated emotion inference and working memory demands in 77 carefully phenotyped children ages 8-13 (M_age = 10.46, SD = 1.54; 66% Caucasian/Non-Hispanic; 42% female) with ADHD (n = 42) and without ADHD (n = 35). Results of Bayesian mixed-model ANOVAs indicated that using context clues to infer the emotion state of others competed for neurocognitive resources with the processes involved in rehearsing/maintaining information within working memory (BF₁₀ = 1.57 × 10¹⁹, d = 0.72). Importantly, there was significant evidence against the critical Group × Condition interaction for response times (BF₀₁ = 4.93), and no significant evidence for this interaction for accuracy (BF₀₁ = 2.40). In other words, children with ADHD do not infer emotions more slowly than children without ADHD (d = 0.13), and their small magnitude impairment in accuracy (d = 0.30) was attributable to their generally less accurate performance on choice-response tasks (i.e., across both emotion and control conditions). Taken together, the evidence indicates that emotion inference abilities are likely unimpaired in pediatric ADHD and that working memory is implicated in the ability to infer emotion from context for all children-not just children with ADHD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD

BACKGROUND

A central nosological problem concerns the etiological relationship of emotional dysregulation with ADHD. Molecular genetic risk scores provide a novel method for informing this question.

METHODS

Participants were 514 community-recruited children of Northern European descent age 7-11 defined as ADHD or non-ADHD by detailed research evaluation. Parents-rated ADHD on standardized ratings and child temperament on the Temperament in Middle Childhood Questionnaire (TMCQ) and reported on ADHD and comorbid disorders by semi-structured clinical interview. Categorical and dimensional variables were created for ADHD, emotional dysregulation (implicating disruption of regulation of both anger-irritability and of positive valence surgency-sensation seeking), and irritability alone (anger dysregulation). Genome-wide polygenic risk scores (PRS) were computed for ADHD and depression genetic liability. Structural equation models and computationally derived emotion profiles guided analysis.

RESULTS

The ADHD PRS was associated in variable-centered analyses with irritability (β = .179, 95% CI = 0.087-0.280; ΔR²  = .034, p < .0002), but also with surgency/sensation seeking (B = .146, 95%CI = 0.052-0.240, ΔR² =.022, p = .002). In person-centered analysis, the ADHD PRS was elevated in the emotion dysregulation ADHD group versus other ADHD children (OR = 1.44, 95% CI = 1.03-2.20, Nagelkerke ΔR²  = .013, p = .033) but did not differentiate irritable from surgent ADHD profiles. All effects were independent of variation in ADHD severity across traits or groups. The depression PRS was related to oppositional defiant disorder but not to ADHD emotion dysregulation.

CONCLUSIONS

Irritability-anger and surgency-sensation seeking, as forms of negative and positively valenced dysregulated affect in ADHD populations, both relate principally to ADHD genetic risk and not mood-related genetic risk.