Depressive symptoms in youth with ADHD: the role of impairments in cognitive emotion regulation

Emotion regulation beyond executive and attention difficulties: impact on daily life impairments in community adolescents

BACKGROUND

It is becoming widely recognized that emotion regulation difficulties are an essential feature present along the continuum from subclinical to clinical Attention Deficit/Hyperactivity Disorder (ADHD). Yet, it remains unclear whether and how specific processes related to emotion regulation contribute to daily life impairments, across different domains of functioning. The aim of this cross-sectional study in community adolescents was to investigate whether three processes commonly implicated in adaptive emotion regulation-emotion recognition, emotion reactivity and use of cognitive emotion regulation strategies-uniquely contribute to adolescent-rated functional impairment, above and beyond the effects of age and gender, ADHD symptoms, and individual differences in verbal ability and executive functions.

METHODS

161 adolescents from the general population (mean age = 15.57; SD = 1.61) completed the Weiss Functional Impairment Scale, the Emotion Reactivity Scale, the Cognitive Emotion Regulation Questionnaire and the Geneva Emotion Recognition Test. Hierarchical regression analysis examined the unique contributions of candidate predictors to impairment scores.

RESULTS

Total impairment scores were best predicted by older age, inattention symptoms, higher emotion reactivity, and higher use of maladaptive cognitive emotion regulation strategies. Emotion regulation processes were associated with interpersonal difficulties and self-concept impairments, whereas inattention symptoms were associated with school and life skills impairments.

CONCLUSIONS

This study stresses that emotion reactivity and maladaptive cognitive emotion regulation represent major sources of perceived social and emotional difficulties in community adolescents. Our results also support the continuum hypothesis of attention difficulties, where emotion regulation abilities may at least partially explain the association between ADHD symptoms and social impairments. Together, these findings highlight the vital importance of targeting emotion regulation in psychotherapeutic interventions aiming to improve socio-emotional outcomes in adolescents.

Central Med23 deficiency leads to malformation of dentate gyrus and ADHD-like behaviors in mice

Attention-deficit hyperactivity disorder (ADHD) is a prevalent psychiatric disorder with high heritability, while its etiology and pathophysiology remain unclear. Med23 is a subunit of the Mediator complex, a key regulator of gene expression by linking transcription factors to RNA polymerase II. The mutations of Med23 are associated with several brain diseases including microcephaly, epilepsy and intellectual disability, but its biological roles in brain development and possible behavioral consequence have not been explored in the animal model. In this study, Emx1-Cre mice were used to generate Med23 conditional knockout (Med23 CKO) mice that showed severe hypoplasia of the dentate gyrus (DG) with malformation of the dendritic tree and spines along with impaired short-term synaptic plasticity. Interestingly, Med23 CKO mice exhibited ADHD-like behaviors as shown by hyperactivity, inattention and impulsivity, as well as impaired sensory gating and working memory. Importantly, methylphenidate (MPH), a common drug for ADHD ameliorated these deficits in the CKO mice. Furthermore, we also revealed that the impaired synaptic plasticity was partially restored by MPH in an N-methyl-d-aspartate (NMDA) receptor-dependent way. Collectively, our data demonstrate Med23 deficiency causes DG malformation and ADHD-like behaviors, suggesting a novel mechanism underlying relevant brain diseases.

Drug Holidays May Attenuate Beneficial Effects of Treatment on Emotion Regulation and Recognition Among Children with ADHD: A Single-Center, Prospective Study

Background

In this study, we aimed to evaluate the effects of drug holidays during summer vacations on children with attention deficit/hyperactivity disorder (ADHD) treated with methylphenidate in terms of ADHD symptoms and emotion regulation (ER).

Methods

This single-center, naturalistic, prospective cohort study included pre-, post-, and post-drug holiday evaluations. All patients diagnosed with ADHD and included in our study were administered the Clinical Global Impression Scale, Affective Reactivity Index-parent and child, reading the mind in the eyes test (RMET), Faces test and Cognitive Emotion Regulation Questionnaire for Children 3 times. Fifty-six patients met the inclusion criteria and ten were lost to follow-up. Thirty-nine participants had complete evaluations at all time points.

Results

Both parent and self-report ratings of child irritability were significantly reduced after methylphenidate (MPH) treatment (P=.003 and .002, respectively), although they returned to baseline after drug holidays (P=.618 and .974, respectively). The use of self-blame as a cognitive emotion regulation strategy increased significantly after treatment and remained significantly elevated even after drug holidays (P=.024 and .022, respectively). Children used planning as a cognitive strategy significantly more frequently during MPH treatment (P=.034), although this elevation was temporary and returned to baseline levels after the drug holidays (P=.890). Reading the mind in the eyes test performance was significantly improved after MPH treatment and did not change after drug holidays (P=.009 and .006, respectively), while there was a tendency for facial emotion recognition abilities to improve at the last visit (P=.051).

Conclusion

Our results suggest that MPH treatment improves child- and parent-reported irritability, clinician-rated disorder severity, RMET performance, and the use of planning as a cognitive ER strategy, although only improvement in RMET performance continued after drug holidays. Our results may support the importance of continuing treatment over the holidays for most children with ADHD unless necessitated by adverse events, growth problems, or development of tolerance.

Review of Clinical Considerations in the Management of Adolescents with ADHD During Ramadan

Background:

Fasting in Ramadan, a holy month in Islam, is considered a religious obligation to Muslims after puberty. Fasting during Ramadan entails abstinence from consuming food and liquids, as well as abstaining from other activities, including smoking and sexual activity, from dawn until sunset. Literature exists regarding the management of multiple medical conditions impacted by the month of fasting; however, limited literature exists to guide the management of Attention-Deficit/Hyperactivity Disorder (ADHD) during Ramadan.

Methods:

This systematic review employed a PUBMED search which was conducted using keywords ((ADHD) AND (Muslims)) OR ((ADHD) AND (FASTING)) OR ((ADHD) AND (RAMADAN)) OR ((RAMADAN) AND (MANAGEMENT)) and search strategies to find existing literature on ADHD management during Ramadan or while fasting.

Results:

Eight hundred and sixty-one results were obtained. Of these, full texts of clinical trials, systematic reviews, reviews, randomized control trials, and metaanalyses resulted in 303 results that were screened by title or abstract for relevance to the topic. The duplicate articles were removed. Eighty-nine results were incorporated into this paper, including full articles, book excerpts, and online articles.

Discussion:

Muslim adolescents may face challenges with academic and social functioning as they navigate psychosocial changes in the context of Ramadan. ADHD management options should be discussed with individuals who are planning to fast. Pharmacologic management options include continuing on the current regimen, dose adjustment to mitigate side effect exacerbation, a change in medication class, or a change in medication formulation. For severe cases or cases with comorbid conditions, continued fasting may not be recommended. In these cases, the patient should attempt to seek counsel with their community’s religious scholar in collaboration with their medication provider. Ultimately, there are limitations in the available data, and there is a need for further investigation into the impacts of fasting during Ramadan on individuals with ADHD and the effectiveness of interventions to promote treatment adherence.

The Ambiguous Cue Task: Measurement reliability of an experimental paradigm for the assessment of interpretation bias and associations with mental health

Interpretation biases in the processing of ambiguous affective information are assumed to play an important role in the onset and maintenance of emotional disorders. Reports of low reliability for experimental measures of cognitive biases have called into question previous findings on the association of these measures with markers of mental health and demonstrated the need to systematically evaluate measurement reliability for measures of cognitive biases. We evaluated reliability and correlations with self-report measures of mental health for interpretation bias scores derived from the Ambiguous Cue Task (ACT), an experimental paradigm for the assessment of approach-avoidance behavior towards ambiguous affective stimuli. For a non-clinical sample, the measurement of an interpretation bias with the ACT showed high internal consistency (rSB = .91 - .96, N = 354) and acceptable 2-week test-retest correlations (rPearson = .61 - .65, n = 109). Correlations between the ACT interpretation bias scores and mental health-related self-report measures of personality and well-being were generally small (r ≤ |.11|) and statistically not significant when correcting for multiple comparisons. These findings suggest that in non-clinical populations, individual differences in the interpretation of ambiguous affective information as assessed with the ACT do not show a clear association with self-report markers of mental health. However, in allowing for a highly reliable measurement of interpretation bias, the ACT provides a valuable tool for studies considering potentially small effect sizes in non-clinical populations by studying bigger samples as well as for work on clinical populations, for which potentially greater effects can be expected.

Emotional dysregulation and stimulant medication in adult ADHD

BACKGROUND

Emotional dysregulation affects up to two-thirds of adult patients with attention-deficit/hyperactivity disorder (ADHD) and is increasingly seen as a core ADHD symptom that is clinically associated with greater functional impairment and psychiatric comorbidity. We sought to investigate emotional dysregulation in ADHD and explored its neural underpinnings.

METHODS

We studied emotion induction and regulation in a clinical cohort of adult patients with ADHD before and after a stimulant challenge. We compared patients with age- and gender-matched healthy controls using behavioural, structural, and functional measures. We hypothesized that patients would demonstrate aberrant emotion processing compared with healthy controls, and sought to find whether this could be normalized by stimulant medication.

RESULTS

Behaviourally, the ADHD group showed reduced emotion induction and regulation capacity. Brain imaging revealed abberant activation and deactivation patterns during emotion regulation, lower grey-matter volume in limbic and paralimbic areas, and greater grey-matter volume in visual and cerebellar areas, compared with healthy controls. The behavioural and functional deficits seen in emotion induction and regulation in the ADHD group were not normalized by stimulant medication.

CONCLUSION

Patients with ADHD may have impaired emotion induction and emotion regulation capacity, but these deficits are not reversed by stimulant medication. These results have important clinical implications when assessing which aspects of emotional dysregulation are relevant for patients and if and how traditional ADHD pharmacotherapy affects emotion induction and emotion regulation.

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.

Bidirectional associations between maladaptive cognitions and emotional symptoms, and their mediating role on the quality of life in adults with ADHD: a mediation model

Background/objectives

Adults with attention-deficit/hyperactivity disorder (ADHD) have more maladaptive cognitions, emotional problems and a poorer quality of life (QoL). A verification of the psychological model in clinical samples is needed for a better understanding of the mechanisms of ADHD diagnosis on QoL via maladaptive cognitions, emotional symptoms, and their interactions.

Methods

299 ADHD participants and 122 healthy controls were recruited. ADHD core symptoms, maladaptive cognitions, emotional symptoms and psychological QoL were rated. Pearson's correlation and structural equation modeling were analyzed to explore the relationship and influence of ADHD diagnosis on QoL.

Results

More maladaptive cognitions, emotional symptoms, and poorer QoL were found in the ADHD group, and the dysfunctional attitudes were on par between ADHD with or without medication (p = 0.368). Moderate to strong correlations were found between emotional symptoms, maladaptive cognitions and QoL, and ADHD core symptoms presented correlations among the above scores (r = 0.157 ~ 0.416, p < 0.01) in ADHD participants. The influence of ADHD diagnosis on QoL was mediated through maladaptive cognitions, emotional symptoms, and their bidirectional interactions (p < 0.05), especially those with stable medication.

Conclusion

Our study is the first to verify the psychological model in adults with ADHD in China. The findings determined the direct influence of ADHD diagnosis on QoL and the indirect influence through maladaptive cognitions, emotional symptoms, and their interactions, emphasizing the importance of interventions for emotional symptoms and maladaptive cognitions for ADHD patients both with or without medication for a better QoL outcome.

Mindfulness and cognitive emotion regulation in pediatric misophonia

Misophonia is characterized by decreased tolerance of ordinary human-generated trigger sounds and associated visual stimuli (e.g., chewing, sniffing, lip smacking), coupled with intense affective reactions. The disorder often begins during childhood or adolescence and is associated with impairment and distress in numerous life domains. Research has begun to examine the underlying psychological mechanisms of misophonia in adults, but studies in youth are limited. Trait mindfulness (i.e., nonjudgmental and nonavoidant present-moment awareness) and cognitive emotion regulation (i.e., cognitive processing, or responding to, emotionally arousing situations) are two proposed mechanisms that may underpin pediatric misophonia and associated functional impairment. In the present exploratory cross-sectional study, we examined trait mindfulness and cognitive emotion regulation and their relations with misophonia features and adaptive functioning in 102 youth with misophonia (Mage = 13.7; SD = 2.5; range = 8-17). More severe misophonia was significantly associated with decreased levels of both trait mindfulness and adaptive functioning across domains, in addition to deficits in certain facets of cognitive emotion regulation, particularly self-blame. Neither trait mindfulness nor facets of cognitive emotion regulation moderated the association between misophonia severity and adaptive functioning across domains, with the notable exception that difficulties with adaptive functioning in peer relationships was attenuated in those high in mindfulness. Findings suggest that trait mindfulness- and to a lesser extent cognitive emotion regulation- may be potentially relevant processes in pediatric misophonia. However, more research is needed to uncover the precise nature of these processes to aid future characterization and intervention efforts, especially in light of equivocal findings in the present study.

Annual Research Review: Perspectives on progress in ADHD science - from characterization to cause

The science of attention-deficit/hyperactivity disorder (ADHD) is motivated by a translational goal - the discovery and exploitation of knowledge about the nature of ADHD to the benefit of those individuals whose lives it affects. Over the past fifty years, scientific research has made enormous strides in characterizing the ADHD condition and in understanding its correlates and causes. However, the translation of these scientific insights into clinical benefits has been limited. In this review, we provide a selective and focused survey of the scientific field of ADHD, providing our personal perspectives on what constitutes the scientific consensus, important new leads to be highlighted, and the key outstanding questions to be addressed going forward. We cover two broad domains - clinical characterization and, risk factors, causal processes and neuro-biological pathways. Part one focuses on the developmental course of ADHD, co-occurring characteristics and conditions, and the functional impact of living with ADHD - including impairment, quality of life, and stigma. In part two, we explore genetic and environmental influences and putative mediating brain processes. In the final section, we reflect on the future of the ADHD construct in the light of cross-cutting scientific themes and recent conceptual reformulations that cast ADHD traits as part of a broader spectrum of neurodivergence.

Sleep patterns, sluggish cognitive tempo, and daytime sleepiness - a commentary on Fredrick et al. (2022)

Fredrick et al. (Journal of Child Psychology and Psychiatry, 2022) showed in their cross-sectional and observational study that higher Sluggish Cognitive Tempo (SCT) traits were associated with more impaired subjective and objective sleep parameters. Importantly, data were gathered from adolescents and their parents, thus, enhancing the validity of the findings. In addition, the observed pattern of associations was unrelated to ADHD traits, age, sex, medication, or pubertal development. In the present commentary, we acknowledge the scientific value and practical and clinical implications of these findings. For future studies, we propose seven research avenues, which might help to further clarify the neurophysiological, psychological, and behavioral associations between SCT traits and sleep patterns.

Testing the Impact of Depressive and Anxiety Features on the Association between Attention-Deficit/Hyperactivity Disorder Symptoms and Academic Performance among University Students: A Mediation Analysis

Attention deficit/hyperactivity disorder (ADHD) is associated with poor academic performance also among university students. This relationship may be made more complex by comorbid conditions. The aim of this study was to evaluate the mediating role of anxiety and depressive symptoms in the relationship between ADHD and academic performance. Data were drawn from the CAMPUS study (registration number: 0058642/21), an ongoing survey on university students’ mental health. Using a logit model, mediation analyses were carried out to test whether the relationship between ADHD symptoms (assessed by ASRS-5) and academic performance might be mediated by depressive (assessed by PHQ-9) and anxiety (assessed by GAD-7) symptoms. Our results showed that worse academic performance is associated with ADHD symptoms (p < 0.001). However, about 24% of the overall association between ADHD symptoms and academic performance was mediated by depressive symptoms (indirect effect: 0.065, 95%CI 0.022; 0.100), whereas the contribution of anxiety symptoms to the model was not significant. Along with the association between ADHD symptoms and poor academic performance, our findings highlight the key mediating role of depressive symptoms, which may be targeted with tailored support, ultimately improving both the academic performance and the well-being of university students with ADHD.