ADHD’s Emotional Layer: The Dynamics of Dysregulation

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. These symptoms manifest differently across ADHD’s varied presentations: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Each subtype has also been associated with emotional dysregulation to varying degrees, with the combined presentation often exhibiting more severe difficulties¹.

What is emotional dysregulation?

Emotional dysregulation refers to patterns of experiencing or expressing emotions that interfere with goal-directed activity². Symptomatically, this can mean difficulties with experiencing and regulating intense emotions and adopting appropriate emotional responses. Emotional dysregulation is not unique to ADHD; it’s a transdiagnostic feature of several other psychological conditions. However, individuals with ADHD may experience even worse emotional regulation than those with other clinical conditions, like major depression or adjustment disorders³.

Difficulties with emotional dysregulation can appear as early as preschool and become more pronounced over time. While a child’s capacity to regulate their emotions as their range of emotions develops, those with ADHD may find this task more difficult. As children grow older and face greater academic and social demands, emotion regulation improves to a lesser degree for those with ADHD compared to their peers without ADHD⁴. This difficulty can continue to have consequences in adulthood, both in the context of ADHD and by increasing risk for later development of other psychiatric conditions. Emotional dysregulation is present in 24–50% of children and 34–70% of adults with ADHD, yet it is not currently considered a part of the diagnostic criteria^5–7. Though historically overlooked, emotional dysregulation is beginning to get more attention due to its vast impact.

What challenges are associated with emotion dysregulation?

Emotional dysregulation significantly impacts various aspects of life, contributing to impairments in social interactions, academic performance, and professional success. Understanding the role of emotional dysregulation in ADHD is crucial for mitigating its burden. For instance, children with ADHD and emotional dysregulation are at higher risk for peer rejection, risky behaviors, and self-harm. In adults, emotional dysregulation correlates with poor relationship maintenance, internalizing symptoms (i.e., anxiety and depression), and functional impairment. Additionally, challenges may show up in the following domains:

• Social Skills: Emotional regulation acts as a mediator between ADHD and social skills in youth. Particularly, lack of behavioral control when faced with strong emotions is associated with poor social functioning⁸. This connection may explain the higher degree of peer rejection observed in children with ADHD.
• Risky Behaviors: Emotional dysregulation is also associated with risky behaviors, such as high-risk sexual conduct and substance use, among those with ADHD highlighting its impact on decision-making and impulsivity⁹.
• Substance Use: Adults at risk for ADHD with emotional dysregulation are at a higher risk for substance use. Among these adults, those with severe emotional dysregulation and childhood maltreatment showed an increased risk of substance use problems later in life^10,11.
• Self-Harm: During stressful situations, such as childhood maltreatment, sexual abuse, or interpersonal problems, emotional dysregulation can trigger self-harm behaviors. This risk factor may be particularly prevalent among lesbian, gay, and bisexual youth facing bullying or harassment¹⁰. Read more about the relationship between ADHD and self-harm in adults here, and learn more about the need to address self-harm during youth ADHD assessment here.
• Relationship Impairments: Emotional dysregulation is associated with romantic relationship impairment and dissatisfaction, and poorer friendship quality in those with ADHD^12,13. These challenges may be due to difficulty managing intense emotions and avoidant coping strategies during conflict.

What factors affect emotional dysregulation?

Using scientifically validated tools, researchers have identified some potential contributors to and consequences of emotional dysregulation. While our understanding of emotional dysregulation is still evolving, research suggests that biological and environmental factors can play a role in its development. Some key factors include:

• Gender: Females with ADHD are more likely to present with emotional dysregulation compared to men with ADHD, particularly those with the Combined presentation^14,15.
• Early Temperament: At birth, infants exhibit varying reactivity, with some displaying a generally positive disposition, while others lean toward fearful or irritable distress, suggesting very early presence of emotional dysregulation symptoms⁴.
• Childhood Experiences: Negative childhood experiences, such as maltreatment and emotional neglect, have been linked to higher incidences of emotional dysregulation in children, further contributing to difficulties with emotion regulation later in life^4,11. Parental rejection and punishment significantly shape an individual’s acceptance of their own emotions³. A lack of acceptance may contribute to emotional dysregulation.
• Sleep Problems: Sleep problems can exacerbate emotional dysregulation and attention issues, perpetuating a cycle of challenges for affected individuals³.
• Emotion Regulation Strategies: Adults with ADHD may be more likely to engage in short-term emotion regulation strategies such as avoidance (denying or minimizing a crisis and its effects or escaping when faced with a stressor) or suppression (stopping oneself from expressing an emotion), rather than adopting long-term, functional strategies such as reappraisal (reframing an emotional stimulus or event in a more balanced way)³.
• Executive functioning (EF): Updating is an executive function that involves monitoring and manipulating incoming information during a task and replacing old information with newer, more relevant content in working memory. Early evidence suggests that children with ADHD who have well-developed working memory tend to exhibit better emotional regulation and fewer ADHD symptoms overall^16,17. This indicates that updating may play a crucial role in the emotion regulation strategy of reappraisal, with better executive functioning linked to more effective use of reappraisal¹⁷.

How do professionals assess emotional dysregulation?

Emotional dysregulation is a prevalent feature of ADHD that contributes to and appears in several comorbid conditions, leading to significant functional impairment across the lifespan. Identifying and understanding the risk factors for emotional dysregulation and its impact on those with ADHD can help psychologists prevent further harm and recommend targeted interventions for those at risk.

Despite emotional dysregulation receiving increased attention in research, it’s not an entirely novel concept within the realm of ADHD assessment. MHS’ well-established Conners suite of assessments help psychologists gain a more comprehensive understanding of not only the core ADHD symptoms of inattention, hyperactivity, and impulsivity, but also emotional dysregulation across the lifespan.

The newer revisions of these scientifically validated tools, particularly the Conners 4th Edition™ (Conners 4; for youth aged 6 to 18) and Conners Adult ADHD Rating Scales™ 2nd Edition (CAARS™ 2; for adults aged 18+) continue to explore the relationship between emotional dysregulation, ADHD, and other associated comorbidities and moderating factors. Many of the studies referenced in this article utilize CAARS to understand the relationship between emotional dysregulation and ADHD. Insights from this research have contributed to the development of a robust Emotional Dysregulation content scale for both the CAARS 2 and Conners 4.

In addition to the primary Emotional Dysregulation Content Scales, these tools include the following supplementary features that can aid in further understanding emotional dysregulation and identifying key areas for intervention.

• Assessment of Executive Dysfunction: Both tools include Executive Dysfunction content scales to help identify areas of EF that can be trained to improve emotional regulation.
• Assessment of Risk Factors: These tools identify risk factors for developing emotional dysregulation by assessing negative self-concept and sleep problem items.
• Assessment of Clinical Comorbidities: Given emotional dysregulation is a transdiagnostic feature, these tools include indicators of commonly co-occurring diagnoses such as Depression and Anxiety via Content Scales and screening items.
• Assessment of Impairment and Functional Outcomes: These tools measure impairments related to ADHD in specific (money management and driving for adults) and broad domains (work, school, and relationships for both adults and youth).
• Multi-Rater Perspectives: By including self-report and other-rated (observers for the CAARS 2; parents and teachers for Conners 4) reports, these tools provide a more complete representation of behaviors related to emotional dysregulation in various contexts. For example, the impact on romantic relationships may be better captured with the context provided by an observer such as a spouse or partner.
• Progress Monitoring: These tools can be used over time to track the effectiveness of treatments and interventions on emotional dysregulation.
• Scale- and Item-level Elevations: Reports from both tools include flags for elevated scores at the item-level and scale-level, including screening items and impairment and functional outcome items (i.e. self-harm, sleep problems, risky driving, problems in romantic relationships, etc.) that can inform specific areas for intervention.

What’s next after identifying problems with emotion regulation?

Once emotional dysregulation and its risk factors are identified, targeted treatments and interventions can be implemented by clinicians, parents, and educators. While our focus here is on emotional dysregulation within the context of ADHD, considering the transdiagnostic nature of this construct, these techniques can also improve the outcomes for other clinical diagnoses and emotional dysregulation in the general population. Strategies include education regarding mental health and emotion regulation strategies, behavioral therapy, medication, and executive function coaching, as well as accounting for treatments related to co-occurring diagnoses¹⁸.

Understanding and addressing emotional dysregulation in ADHD is crucial for improving the well-being of affected individuals. Tools like CAARS 2 and Conners 4 allow psychologists to gain a comprehensive understanding of both ADHD symptoms and emotional dysregulation. Early identification and intervention can mitigate further harm and enhance the quality of life for individuals with ADHD. Implementing targeted behavioral interventions and carefully considering medication options can significantly reduce the burden of comorbidities and improve overall functioning. By prioritizing emotional dysregulation in assessments and treatments, we can better support individuals with ADHD, helping them lead more balanced and fulfilling lives.

Have questions about this blog or want to learn more about CAARS 2 and Conners 4? Get in touch with a member of our team.

References

¹ Merwood, A. et al. Genetic Associations Between the Symptoms of Attention-Deficit/Hyperactivity Disorder and Emotional Lability in Child and Adolescent Twins. J. Am. Acad. Child Adolesc. Psychiatry 53, 209-220.e4 (2014).

² Thompson, R. A. Emotion dysregulation: A theme in search of definition. Dev. Psychopathol. 31, 805–815 (2019).

³ Bodalski, E. A., Flory, K. & Meinzer, M. C. A Scoping Review of Factors Associated With Emotional Dysregulation in Adults With ADHD. J. Atten. Disord. 27, 1540–1558 (2023).

⁴ Leaberry, K. D., Walerius, D. M., Rosen, P. J. & Fogleman, N. D. Emotional Lability. in Encyclopedia of Personality and Individual Differences (eds. Zeigler-Hill, V. & Shackelford, T. K.) 1319–1329 (Springer International Publishing, Cham, 2020). doi:10.1007/978-3-319-24612-3_510.

⁵ Shaw, P., Stringaris, A., Nigg, J. & Leibenluft, E. Emotion Dysregulation in Attention Deficit Hyperactivity Disorder. Am. J. Psychiatry 171, 276–293 (2014).

⁶ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (American Psychiatric Association, 2013).

⁷ICD-10: International Statistical Classification of Diseases and Related Health Problems : 10^th Revision. (World Health Organization, 2004).

⁸ Bunford, N., Evans, S. W. & Langberg, J. M. Emotion Dysregulation Is Associated With Social Impairment Among Young Adolescents With ADHD. J. Atten. Disord. 22, 66–82 (2018).

⁹ Bunford, N., Evans, S. W. & Wymbs, F. ADHD and Emotion Dysregulation Among Children and Adolescents. Clin. Child Fam. Psychol. Rev. 18, 185–217 (2015).

¹⁰ Paulus, F. W., Ohmann, S., Möhler, E., Plener, P. & Popow, C. Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review. Front. Psychiatry 12, 628252 (2021).

¹¹ Bunford, N., Wymbs, B. T., Dawson, A. E. & Shorey, R. C. Childhood Maltreatment, Emotional Lability, and Alcohol Problems in Young Adults At-Risk for ADHD: Testing Moderation and Moderated Moderation. J. Psychoactive Drugs 49, 316–325 (2017).

¹² Bruner, M. R., Kuryluk, A. D. & Whitton, S. W. Attention-Deficit/Hyperactivity Disorder Symptom Levels and Romantic Relationship Quality in College Students. J. Am. Coll. Health 63, 98–108 (2015).

¹³ Bodalski, E. A., Knouse, L. E. & Kovalev, D. Adult ADHD, Emotion Dysregulation, and Functional Outcomes: Examining the Role of Emotion Regulation Strategies. J. Psychopathol. Behav. Assess. 41, 81–92 (2019).

¹⁴ Hirsch, O., Chavanon, M. L. & Christiansen, H. Emotional dysregulation subgroups in patients with adult Attention-Deficit/Hyperactivity Disorder (ADHD): a cluster analytic approach. Sci. Rep. 9, 5639 (2019).

¹⁵ Soler-Gutiérrez, A.-M., Pérez-González, J.-C. & Mayas, J. Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review. PLOS ONE 18, e0280131 (2023).

¹⁶ Groves, N. B. et al. Executive Functioning and Emotion Regulation in Children with and without ADHD. Res. Child Adolesc. Psychopathol. 50, 721–735 (2022).

¹⁷ Mohammed, A.-R., Kosonogov, V. & Lyusin, D. Is emotion regulation impacted by executive functions? An experimental study. Scand. J. Psychol. 63, 182–190 (2022).

¹⁸ Nasri, B. et al. Group Treatment for Adults With ADHD Based on a Novel Combination of Cognitive and Dialectical Behavior Interventions: A Feasibility Study. J. Atten. Disord. 24, 904–917 (2020).