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Reviews and Overviews   |    
Emotion Dysregulation in Attention Deficit Hyperactivity Disorder
Philip Shaw, M.B.B.Ch., Ph.D.; Argyris Stringaris, M.D., Ph.D.; Joel Nigg, Ph.D.; Ellen Leibenluft, M.D.
Am J Psychiatry 2014;171:276-293. doi:10.1176/appi.ajp.2013.13070966
View Author and Article Information

Dr. Stringaris is a Wellcome Trust Fellow and also receives funding from the U.K. Department of Health and the Biomedical Research Centre of the National Institute of Health Research, U.K.; he receives royalties from Cambridge University Press. The other authors report no financial relationships with commercial interests.

From the Section on Neurobehavioral Clinical Research, Social and Behavioral Research Branch, Division of Intramural Research Programs, National Human Genome Research Institute, Bethesda, Md.; the Section on Bipolar Spectrum Disorders, Emotion and Development Branch, Division of Intramural Research Programs, NIMH, Bethesda; the NIMH Intramural Program, Bethesda; the Institute of Psychiatry, King’s College London; and the Division of Psychology, Department of Psychiatry, Oregon Health and Science University, Portland.

Address correspondence to Dr. Shaw (shawp@mail.nih.gov).

Copyright © 2014 by the American Psychiatric Association

Received July 23, 2013; Revised October 21, 2013; Accepted November 18, 2013.

Abstract

Although it has long been recognized that many individuals with attention deficit hyperactivity disorder (ADHD) also have difficulties with emotion regulation, no consensus has been reached on how to conceptualize this clinically challenging domain. The authors examine the current literature using both quantitative and qualitative methods. Three key findings emerge. First, emotion dysregulation is prevalent in ADHD throughout the lifespan and is a major contributor to impairment. Second, emotion dysregulation in ADHD may arise from deficits in orienting toward, recognizing, and/or allocating attention to emotional stimuli; these deficits implicate dysfunction within a striato-amygdalo-medial prefrontal cortical network. Third, while current treatments for ADHD often also ameliorate emotion dysregulation, a focus on this combination of symptoms reframes clinical questions and could stimulate novel therapeutic approaches. The authors then consider three models to explain the overlap between emotion dysregulation and ADHD: emotion dysregulation and ADHD are correlated but distinct dimensions; emotion dysregulation is a core diagnostic feature of ADHD; and the combination constitutes a nosological entity distinct from both ADHD and emotion dysregulation alone. The differing predictions from each model can guide research on the much-neglected population of patients with ADHD and emotion dysregulation.

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FIGURE 1. Forest Plots With Standardized Mean Difference Between ADHD and Comparison Groups in Measures of Aggression, Emotion Recognition, and Reward Processinga

a In panel A, more aggressive behavior is seen in the ADHD groups (the effect size for boys in the Abikoff study [9] was 14). In panel B, emotion recognition deficits are seen in ADHD. In panel C, reward processing is measured by the tendency to prefer immediate small rewards over larger delayed ones; the ADHD participants show a tendency to prefer immediate, small rewards. Further details are provided in the online data supplement.

b SMD=standardized mean difference, inverse variance, random effects, with 95% confidence intervals.

FIGURE 2. Correlations Between Infantile Temperament and Later Externalizing and ADHD Symptomsa

a n.s.=not significant.

*p<0.05. **p<0.01.

FIGURE 3. Neural Circuits Implicated in Emotion Dysregulation in ADHDa

a The circuitry that underpins deficits in early orienting to emotional stimuli and their perception is shown in red. Regions that interface between emotional and cognitive circuits, allocating attention to emotional stimuli, are shown in yellow. Circuitry implicated in cognitive control, motor planning, and attention is shown in blue. ACC=anterior cingulate cortex; pOFC=posterior orbitofrontal cortex; PFC=prefrontal cortex; VLPFC=ventrolateral prefrontal cortex.

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TABLE 1.Prevalence Estimates of Emotion Dysregulation in Children and Adults With ADHDa
Table Footer Note

a ADHD=attention deficit hyperactivity disorder; ODD=oppositional defiant disorder; RRR=relative risk ratio.

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TABLE 2.Summary of Functional MRI Studies of Emotion Perception, Reward Processing, and the Allocation of Attention to Emotional Stimulia
Table Footer Note

a ADHD=attention deficit hyperactivity disorder; ODD=oppositional defiant disorder.

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TABLE 3.Randomized Controlled Treatment Studies in Children and Adults With ADHD in Which Change in Measures Reflecting Emotion Dysregulation Was Measureda
Table Footer Note

a All medication studies were randomized, placebo-controlled, double-blind trials.

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TABLE 4.Three Models to Explain the Overlap Between ADHD and Emotion Dysregulation
+

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