Attention-Deficit Hyperactivity Disorder and the Dysregulation of Emotion Generation and Emotional Expression

Annual Research Review: What processes are dysregulated among emotionally dysregulated youth? - a systematic review

Proliferation of the term "emotion dysregulation" in child psychopathology parallels the growing interest in processes that influence negative emotional reactivity. While it commonly refers to a clinical phenotype where intense anger leads to behavioral dyscontrol, the term implies etiology because anything that is dysregulated requires an impaired regulatory mechanism. Many cognitive, affective, behavioral, neural, and social processes have been studied to improve understanding of emotion dysregulation. Nevertheless, the defective regulatory mechanism that might underlie it remains unclear. This systematic review of research on processes that affect emotion dysregulation endeavors to develop an integrative framework for the wide variety of factors investigated. It seeks to ascertain which, if any, constitutes an impaired regulatory mechanism. Based on this review, we propose a framework organizing emotion-relevant processes into categories pertaining to stimulus processing, response selection and control, emotion generation, closed- or open-loop feedback-based regulation, and experiential influences. Our review finds scant evidence for closed-loop (automatic) mechanisms to downregulate anger arousal rapidly. Open-loop (deliberate) regulatory strategies seem effective for low-to-moderate arousal. More extensive evidence supports roles for aspects of stimulus processing (sensory sensitivity, salience, appraisal, threat processing, and reward expectancy). Response control functions, such as inhibitory control, show robust associations with emotion dysregulation. Processes relating to emotion generation highlight aberrant features in autonomic, endocrine, reward functioning, and tonic mood states. A large literature on adverse childhood experiences and family interactions shows the unique and joint effects of interpersonal with child-level risks. We conclude that the defective closed-loop regulatory mechanisms that emotion dysregulation implies require further specification. Integrating research on emotion-relevant mechanisms along an axis from input factors through emotion generation to corrective feedback may promote research on (a) heterogeneity in pathogenesis, (b) interrelationships between these factors, and (c) the derivation of better-targeted treatments that address specific pathogenic processes of affected youth.

Stimulant Medication Shortens the Duration of Impairing Emotional Outbursts

Objective

Emotional dysregulation, often presenting as severe emotional outbursts, is being increasingly recognized as a source of considerable impairment for individuals with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to conduct a secondary analysis of data examining the impact of standing stimulant medication on the duration of emotional outbursts.

Method

The as needed (PRN)-medicated outbursts of psychiatrically hospitalized children, 5 to 12 years of age, were tracked by psychiatric nurses using the Behavioral Activity Rating Scale from the time of PRN administration until the child became calm. The impact of extended-release (ER), immediate-release (IR) stimulant and dose, type and reason for outburst/PRN (aggression, agitation, distress), standing concomitant psychotropic medications and time of day, and days since admission were examined.

Results

Forty-seven children had a total of 405 outbursts, 96 of which occurred when no stimulant was prescribed and 309 with stimulant medication. Controlling for time of day and standing neuroleptic dose, outbursts that occurred on an ER stimulant medication were statistically significantly shorter than those that occurred on no stimulant by about 20 minutes (52.7 vs 72.4 minutes), or 30 minutes for aggressive outbursts. Results were unchanged when further controlling for stimulant type and dose, α-agonist, days since admission, PRN medication type, or reason for PRN/outburst. Immediate-release stimulants and short-acting stimulants did not shorten outburst duration.

Conclusion

In children with ADHD with severe outbursts, ER stimulants were associated with shorter outburst duration than IR stimulants.

Indirect effect of ADHD on parenting stress through increased child anxiety and decreased emotional regulatory coping

Parents of children with ADHD experience significantly more parenting stress in comparison to parents of typically developing children due to the emotional and behavioral difficulties related to ADHD. Additionally, approximately 30% of children with ADHD experience co-occurring anxiety. Parents of children with co-occurring anxiety and ADHD report increased stress due to role restriction and isolation compared to parents of children with ADHD alone. Poor emotional regulatory coping in children with ADHD has been linked to elevated negative affect and irritability, which also contributes to increased stress among parents. The present study examined the direct and indirect associations of child anxiety symptoms and emotional regulatory coping on elevated ADHD symptoms and parenting stress. Participants were 203 children aged 7-12-years-old and their parents. Parents completed a self-report measure of parenting stress and measures of their child's ADHD symptoms, anxiety, and emotional regulatory coping. Additionally, children completed self-report measures of emotional regulatory coping. Model testing indicated that the overall model demonstrated excellent fit to the data. Parameter testing supported an indirect effect of child ADHD symptoms on parenting stress through child anxiety symptoms and an indirect effect of child ADHD symptoms on parenting stress through child emotional regulatory coping. These results suggest that child anxiety and emotion dysregulation in children with ADHD have a negative impact on parental stress. The current study adds to the understanding of the important roles emotional regulatory coping and anxiety play in children with ADHD to contribute to increased parenting stress.

Complementary and Integrative Treatments of Aggressiveness/Emotion Dysregulation: Associated with Disruptive Disorders and Disruptive Mood Dysregulation Disorder

Youth with emotional dysregulation (ED) and irritability/aggression, common in disruptive disorders (frequently comorbid with attention-deficit/hyperactivity disorder), are underserved by conventional treatments. Anger dysregulation is usually the core feature of ED. Complementary and integrative Medicine (CIM) treatments for youth with disruptive disorders and ED are reviewed. Broad-spectrum micronutrient supplementation has a medium effect and is supported by two double-blind randomized controlled trials using similar formulations. Other CIM treatments supported by controlled data but needing further research, include omega-3 fatty acid supplementation, music therapy, martial arts, restricting exposure to media violence, decreasing sleep deprivation, and increased exposure to green-blue spaces.

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

OBJECTIVE

Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking.

METHOD

The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis.

RESULTS

Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses.

CONCLUSION

Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

Factors Associated With Police Bringing Children to a Psychiatric Emergency Room

OBJECTIVE

Sensational headlines describing police entanglements with young children have prompted questions about how often these incidents occur and why. The authors of this cross-sectional study examined the factors associated with police versus nonpolice arrivals to the psychiatric emergency room and those predicting subsequent police arrivals.

METHODS

Electronic medical records of children ages 5.0-12.9 years brought to a comprehensive psychiatric emergency program (CPEP) at a university hospital were reviewed to determine whether a child was brought by police ("police arrival") in response to a 911 call by school personnel, a mental health or other medical professional, or a caregiver. Extracted data included the child's age, sex, race-ethnicity, family makeup, insurance status, arrival status, referral source, diagnosis, disposition, treatment, number of CPEP and police encounters, and occurrences of aggression and suicidality. Multilevel and ordinary logistic regression models were used to identify factors associated with a first and subsequent police arrival.

RESULTS

Of 339 children with CPEP encounters from September 2017 to April 2018, 103 (30%) had had at least one police arrival. Children brought by police were more likely than peers brought by caregivers to be Black or Latinx, have Medicaid, come from families without two parents, and have aggressive outbursts or suicidal behavior. Results from multilevel logistic regression indicated that aggressive outbursts and suicidality were most significantly and consistently associated with experiencing both a first and subsequent police arrival.

CONCLUSIONS

Clinical and sociodemographic differences in police arrivals highlight the need for a comprehensive systems approach for children, especially marginalized youths, who need psychiatric emergency care.

Emotional Cognitive Expression in Lacquer Colors Based on Prior Knowledge

Since lacquer painting first appeared in the world of art, research into it has grown steadily. People have developed a keen interest in modern lacquer painting as a result of the extensive study of lacquer culture in both domestic and international academic circles. Many artists and art enthusiasts have contributed significantly to the study and research of lacquer painting and have made helpful attempts at modern lacquer painting. But it is challenging to describe the emotion that a lacquer painting's color conveys. This paper presents a decision-making framework for emotional cognitive learning based on the theory of emotional cognitive evaluation because there are relatively few researchers who have specifically studied the relationship between the creation of lacquer paintings and emotions and because there are also few research materials and documents for reference. The assessment of an emotional state is the central component of this framework. The observation module in the model framework is used to gather the emotional data that the lacquer painting expresses. The issue of emotional expression in lacquer painting is resolved by the emotional evaluation system, which combines the preprocessed information with prior knowledge to evaluate. The importance of affective cognitive expression in lacquer painting and the necessity of affective computing in the fields of machine learning and decision control is obtained on the basis of discussing the research status and content of affective cognition and affective computing. The efficiency of expression was increased by 1.3 percent as a result.