Emotion Dysregulation in adults with ADHD is associated with self-concept and impulsivity

By Bengi Semerci

Hirsch O, Chavanon ML, Riechmann E, Christiansen H. Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD). J Affect Disord 2018; 232: 41-47


Background: Clinical observations suggest that adults have more diverse deficits than children with Attention Deficit/Hyperactivity Disorder (ADHD). These seem to entail difficulties with emotionality, self-concept and emotion regulation in particular, along with the cardinal symptoms of inattention, impulsivity, and hyperactivity for adult patients. Here, we probed a model that explicitly distinguished positive and negative affect, problems with self-concept and emotion regulation skills as distinct but correlating factors with the symptom domains of inattention, hyperactivity, and impulsivity.

Methods: Participants were 213 newly diagnosed adults with ADHD (62.9% male, mean age 33.5 years). Symptoms were assessed via self-report on the Conners’ Adult ADHD Rating Scales, a modified version of the Positive and Negative Affect Scale and the Emotion Regulation Skill Questionnaire. A confirmatory factor analysis with the R package lavaan, using a robust Maximum Likelihood estimator (MLR) for non-normal data, was conducted to test our new non-hierarchical 7-factor model.

Results: All calculated model-fit statistics revealed good model-fit (χ2/df ratio = 2.03, robust RMSEA = .07). The SRMR in our model reached .089, indicating an acceptable model fit. Factor loadings on the postulated factors had salient loadings ≥ .31 except for one item on the hyperactivity factor. Latent factor associations were especially salient between emotional dysregulation and problems with self-concept, and also partially with impulsivity/emotional lability.

Limitations: The three models of ADHD and emotion regulation as suggested by Shaw et al. (2014) could not be disentangled in this study, though the overall results support the model with shared neurocognitive deficits. Further, we did not separately analyze ADHD with or without comorbid disorders. As our sample of clinical cases with ADHD is highly comorbid (47.9%), other disorders than ADHD might account for the emotion regulation deficits, though a sensitivity analysis revealed no such differences.

Conclusions: Our model adequately characterizes the relations between and among clinically and therapeutically relevant symptoms in adult ADHD, thus potentially informing future therapeutic interventions by targeting the successful and flexible use of adaptive emotion regulation skills.

Short comment
ADHD is a common condition which affects 5% of children and 2.5% of adults with conservative estimates. Although there is high diagnostic stability in ADHD, symptoms often change depending on the developmental stage. Symptoms of inattention and hyperactivity/impulsivity may not be as easily observed and quantified in adulthood. Moreover, clinical observations have long suggested that patients with adult ADHD have more diverse deficits that children with ADHD.

Main research interest around adult ADHD have traditionally been the effects of core symptoms (inattention, hyperactivity and impulsivity) on psychological, occupational and social functioning. In the recent years, there has also been a focus on investigating symptoms other than the core symptoms, mainly emotional dysregulation. Shaw and colleagues (Shaw et al., 2014) conclude that 34–70% of adults with ADHD have some emotional regulation deficits, whereas the rate is smaller 25–45% for children. Some suggest that dysfunctional emotion regulation should be considered as a key symptom of ADHD, from which other impairing symptoms stem. (Barkley, 2015). Furthermore, some authors argue that emotion regulation deficits influence self-concept and quality of life more negatively than the ADHD core symptoms alone (Riley et al., 2006).

This study aims to expand upon the findings on ADHD core symptoms as assessed via self and observer ratings with those of emotion regulation, and to determine whether emotion regulation impairments contribute independently to adult ADHD symptoms. To understand this, they test a model that distinguishes positive and negative affect, problems with self-concept and emotion regulation skills as factors that are distinct but most likely correlate with the symptom domains of inattention, hyperactivity, and impulsivity. The study utilizes DIVA 2.0 (Kooij et al 2013; www.divacenter.eu), Conners adult ADHD rating scales, an EMO-Check battery that uses an extension of Positive and Negative Affect Schedule and Emotion Regulation Skills Questionnaire, runs a detailed factor analysis and uses different model-fit statistics. They demonstrate positive and negative affect and emotional regulation skills as distinct dimensions. The study also suggests that negative affect and failure to apply adaptive emotion regulation skills are indicative of adult ADHD.

It is still unclear whether emotion regulation deficits stem from similar or separable neurocognitive developmental deficits or are separate entities, and this topic remains an interesting area of future research. However, keeping in mind that emotion dysregulation is a key factor in adult ADHD, monitoring change in emotion regulation and its effects on functioning during treatment, and consideration of augmenting treatment with therapeutic interventions focusing on emotion regulation skill-building will surely improve treatment outcomes.