Emotion Dysregulation Is Associated With Social Impairment Among Young Adolescents With ADHD

ADHD-related sex differences in emotional symptoms across development

To investigate developmental changes in emotion dysregulation (ED) and associated symptoms of emotional lability, irritability, anxiety, and depression, among girls and boys with and without ADHD from childhood through adolescence. Data were collected from a sample of 8-18-year-old children with (n = 264; 76 girls) and without (n = 153; 56 girls) ADHD, with multiple time-points from a subsample of participants (n = 121). Parents and youth completed rating scales assessing child ED, emotional lability, irritability, anxiety, and depression. Mixed effects models were employed to examine effects and interactions of diagnosis, sex [biological sex assigned at birth], age among boys and girls with and without ADHD. Mixed effects analyses showed sexually dimorphic developmental patterns between boys and girls, such that boys with ADHD showed a greater reduction in ED, irritability, and anxiety with age compared to girls with ADHD, whose symptom levels remained elevated relative to TD girls. Depressive symptoms were persistently elevated among girls with ADHD compared to boys with ADHD, whose symptoms decreased with age, relative to same-sex TD peers. While both boys and girls with ADHD showed higher levels of ED during childhood (compared to their sex-matched TD peers), mixed effects analyses revealed substantial sexually dimorphic patterns of emotional symptom change during adolescence: Boys with ADHD showed robust improvements in emotional symptoms from childhood to adolescence while girls with ADHD continued to show high and/or increased levels of ED, emotional lability, irritability, anxiety and depression.

Multimodal Assessment of Emotion Dysregulation in Children with and without ADHD and Disruptive Behavior Disorders

OBJECTIVE

We sought to explore if specific domains of emotion dysregulation (emotion regulation [EREG], emotional reactivity/lability [EREL], emotion recognition/understanding [ERU], and callous-unemotional [CU] behaviors) were uniquely associated with diagnostic classifications.

METHOD

This study utilized a multimodal (parent/teacher [P/T] reports and behavioral observations) approach to examine emotion dysregulation in a sample of young children (68.7% boys; mean age = 5.47, SD = 0.77, 81.4% Latinx) with attention-deficit/hyperactivity disorder (ADHD Only; n = 46), ADHD + disruptive behavior disorders (ADHD+DBD; n = 129), and typically developing (TD) children (n = 148).

RESULTS

All three diagnostic groups were significantly different from one another on P/T reports of EREG, EREL and CU. For the ADHD+DBD group, P/T reported worse EREG and EREL, and higher mean scores of CU, compared to both ADHD Only and TD groups. The ADHD+DBD group also performed significantly worse than the TD group (but not the ADHD Only group) on observed measures of EREG, EREL and ERU. P/T reported EREG, EREL and CU for the ADHD Only group were significantly worse than the TD group. Using multinomial logistic regression, P/T reported EREG, EREL, and CU were significantly associated with diagnostic status above and beyond observed measures of emotion dysregulation. The model successfully classified children with ADHD+DBD (91.3%) and TD (95.9%); however, children in the ADHD Only group were correctly identified only 45.7% of time.

CONCLUSION

Our findings suggest that measures of emotion dysregulation may be particularly helpful in correctly identifying children with ADHD+DBD, but not necessarily children with ADHD Only.

Examining daily stimulant medication use and sleep in adolescents with ADHD

Research has been inconclusive as to whether stimulant treatment causes or exacerbates sleep problems in adolescents with ADHD. This study examined sleep differences in adolescents with ADHD as a function of stimulant use. Participants were adolescents with ADHD (N = 159, ages 12-14). Parents reported on receipt of stimulant treatment (n = 92, 57.86%; n = 47 amphetamines, n = 45 methylphenidate). Adolescents wore actigraphs and completed daily diaries assessing sleep and daily use of stimulants for 2 weeks. Sleep parameters included daily-reported bedtime, sleep onset latency (SOL), sleep duration, daytime sleepiness, and difficulty waking the following morning; and actigraphy-measured sleep onset time, total time in bed, and sleep efficiency. We estimated between- and within-individual associations between stimulant medication use and sleep indices with all stimulants, after removing adolescents using sleep aids and weekend days, and as a function of stimulant type. Adolescent sleep did not differ between those receiving and not receiving stimulant treatment. Within individuals using stimulants, we largely observed no significant differences between medicated and unmedicated days, though findings were most often significant for school days only. Small effects were found indicating longer SOL, later sleep onset time, and more daytime sleepiness related to medication use. In contrast, there were slight improvements to sleep duration and sleep efficiency related to methylphenidate use, though methylphenidate was also associated with later sleep onset time and more daytime sleepiness. Given the inconsistent and small effects, findings suggest that stimulant medication may impact sleep, but does not appear to be a primary contributor to sleep problems in adolescents with ADHD.

Environmental enrichment promotes adaptive responding during tests of behavioral regulation in male heterogeneous stock rats

Organisms must regulate their behavior flexibly in the face of environmental challenges. Failure can lead to a host of maladaptive behavioral traits associated with a range of neuropsychiatric disorders, including attention deficit hyperactivity disorder, autism, and substance use disorders. This maladaptive dysregulation of behavior is influenced by genetic and environmental factors. For example, environmental enrichment produces beneficial neurobehavioral effects in animal models of such disorders. The present study determined the effects of environmental enrichment on a range of measures related to behavioral regulation using a large cohort of male, outbred heterogeneous stock (HS) rats as subjects. Subjects were reared from late adolescence onwards either in pairs in standard housing with minimal enrichment (n = 200) or in groups of 16 in a highly enriched environment consisting of a large multi-level cage filled with toys, running wheels, and shelters (n = 64). Rats were subjected to a battery of tests, including: (i) locomotor response to novelty, (ii) light reinforcement, (iii) social reinforcement, (iv) reaction time, (v) a patch-depletion foraging test, (vi) Pavlovian conditioned approach, (vii) conditioned reinforcement, and (viii) cocaine conditioned cue preference. Results indicated that rats housed in the enriched environment were able to filter out irrelevant stimuli more effectively and thereby regulate their behavior more efficiently than standard-housing rats. The dramatic impact of environmental enrichment suggests that behavioral studies using standard housing conditions may not generalize to more complex environments that may be more ethologically relevant.

Systematic Review and Meta-Analysis: Altered Autonomic Functioning in Youths With Emotional Dysregulation

OBJECTIVE

To systematically investigate if there is a significant association between markers of autonomic functioning and emotional dysregulation (ED) in children and adolescents.

METHOD

Based on a preregistered protocol (PROSPERO: CRD42021239635), PubMed, Web of Knowledge/Science, Ovid MEDLINE, Embase, and APA PsycInfo databases were searched until April 21, 2021, to identify empirical studies reporting indices of autonomic nervous system (ANS) functioning in youths meeting DSM (version III, IV, IV-TR, 5 or 5-TR) or International Classification of Diseases (ICD) (version 9 or 10) criteria for any psychopathological/neurodevelopmental condition and assessed for ED with a validated scale. Eligible outcomes included correlation coefficients between ED and ANS measures or differences in ANS measures between youths with and without ED. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random-effects meta-analyses were used for data synthesis.

RESULTS

There were 12 studies (1,016 participants) included in the descriptive review and 9 studies (567 participants) included in the meta-analyses. No evidence of a significant association between ED and altered cardiac or electrodermal functioning was found. However, exploratory meta-regressions suggested a possible association between reduced resting-state cardiac vagal control and increased ED.

CONCLUSION

This study did not find evidence of an association between ED and autonomic dysfunction. However, preliminary evidence that reduced vagal control at rest might be a transdiagnostic marker of ED in young people was found. Additional studies comparing autonomic measures in youths with and without ED are needed and should also assess the effects of interventions for ED on ANS functioning.

STUDY PREREGISTRATION INFORMATION

Systematic Review and Meta-Analysis: Is Autonomic Nervous System Functioning Atypical in Children and Adolescents With Emotional Dysregulation? https://www.crd.york.ac.uk/prospero/; CRD42021239635.

Stigma Related to Observable Symptoms, But Not Stimulant Medication Use, in Young Women With ADHD

OBJECTIVE

ADHD is associated with stigma, but whether stimulant medication use contributes to this is unknown. We examined how perception of a young woman may be influenced by visible ADHD symptoms and/or prescribed stimulant medication use (PSMU).

METHOD

Three-hundred-fourteen undergraduates were randomly assigned to watch one of four videos: a woman portraying (a) neither symptoms of ADHD nor PSMU, (b) no ADHD symptoms but disclosing PSMU, (c) ADHD symptoms but no PSMU, or (d) both ADHD symptoms and PSMU. Participants then completed measures of their liking of and desire for affiliation with the woman.

RESULTS

Analyses suggest that visible symptoms of ADHD were perceived negatively and are associated with less liking and desire for affiliation. PSMU was associated with negligible additive stigma.

CONCLUSION

This supports that noticeable ADHD symptoms may be the primary driver of the stigma associated with the disorder, and specifically that directed at young women with ADHD.

Inflammation and emotion regulation: a narrative review of evidence and mechanisms in emotion dysregulation disorders

Emotion dysregulation (ED) describes a difficulty with the modulation of which emotions are felt, as well as when and how these emotions are experienced or expressed. It is a focal overarching symptom in many severe and prevalent neuropsychiatric diseases, including bipolar disorders (BD), attention deficit/hyperactivity disorder (ADHD), and borderline personality disorder (BPD). In all these disorders, ED can manifest through symptoms of depression, anxiety, or affective lability. Considering the many symptomatic similarities between BD, ADHD, and BPD, a transdiagnostic approach is a promising lens of investigation. Mounting evidence supports the role of peripheral inflammatory markers and stress in the multifactorial aetiology and physiopathology of BD, ADHD, and BPD. Of note, neural circuits that regulate emotions appear particularly vulnerable to inflammatory insults and peripheral inflammation, which can impact the neuroimmune milieu of the central nervous system. Thus far, few studies have examined the link between ED and inflammation in BD, ADHD, and BPD. To our knowledge, no specific work has provided a critical comparison of the results from these disorders. To fill this gap in the literature, we review the known associations and mechanisms linking ED and inflammation in general, and clinically, in BD, ADHD, and BD. Our narrative review begins with an examination of the routes linking ED and inflammation, followed by a discussion of disorder-specific results accounting for methodological limitations and relevant confounding factors. Finally, we critically discuss both correspondences and discrepancies in the results and comment on potential vulnerability markers and promising therapeutic interventions.

Voluntary imitation of dynamic facial expressions in attention deficit hyperactivity disorder: a facial-behavior analysis

OBJECTIVE

The difficulties involved in social interaction among children with attention deficit hyperactivity disorder (ADHD) have been shown in many studies. Based on the knowledge that the imitation of facial expressions is a key factor in social interaction and functionality, the focus of prior studies has been on the evaluation of facial expressions in individuals with ADHD. However, little is known about voluntary facial mimicry in individuals with ADHD. In this context, we aimed to evaluate the voluntary-facial-imitation intensity of dynamic facial expressions in children with ADHD.

METHOD

Forty-one children with ADHD and 53 typically developing children were included in the study. Participants were presented with a video of six basic emotions and neutral facial expressions selected from the EU-Emotion Stimulus Set via a screen. After each emotion, the instruction "now imitate it" was given. While the children watched the video, their faces were recorded with a webcam. The intensity of the children's voluntary facial imitations was examined with a computer vision program (Openface) that performs facial analysis on recorded videos.

RESULTS

There was no significant difference between the groups in terms of facial emotion recognition accuracy. In group comparisons of voluntary facial mimicry, children with ADHD showed a significantly higher imitation intensity after emotional expressions of sadness, surprise and fear. There was no difference between the groups after the emotions of happiness, anger and disgust.

CONCLUSION

This non-obtrusive, noninvasive, and cost-effective method allowed us to measure the quantitative differences in facial mimicry between children with ADHD and typically developing children. Our results contribute new information to the literature by indicating which emotions can be used in the evaluation of social communication skills, as well as intervention targets for these skills, in children with ADHD.

Illuminating the daily life experiences of adolescents with and without ADHD: protocol for an ecological momentary assessment study

INTRODUCTION

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at elevated risk of a range of difficulties, among which emotion regulation, peer and co-occurring mental health problems are prominent challenges. To better support adolescents with ADHD, ecologically valid interventions that can be embedded in daily life to target the most proximal antecedents of these challenges are needed. Ecological momentary assessment (EMA) designs are ideally suited to meeting this need.

METHODS AND ANALYSES

In the mental health in the moment ADHD study, we will use an EMA design to capture the daily life experiences of approximately 120 adolescents aged 11-14 years with a clinical diagnosis of ADHD and the same number of age-matched and gender-matched peers without a diagnosis of ADHD. We will combine this with comprehensive information gathered from online surveys. Analysing the data using techniques such as dynamic structural equation modelling, we will examine, among other research questions, the role of emotion regulation and peer problems in mediating the links between characteristics of ADHD and commonly co-occurring outcomes such as anxiety, depression and conduct problems. The results can help inform interventions to support improved peer functioning and emotion regulation for adolescents with ADHD.

ETHICS AND DISSEMINATION

This study received a favourable ethical opinion through the National Health Service ethical review board and the University of Edinburgh PPLS Research Ethics panel. The results will be disseminated through journal publications, conferences and seminar presentations and to relevant stakeholders, such as those with ADHD, their families and clinicians.

Identifying different patterns of emotion dysregulation in adult ADHD

BACKGROUND

Emotion dysregulation (ED) is a core intrinsic feature of adult presenting Attention Deficit Hyperactivity Disorder (ADHD). However, the clinical expressions of ED are diverse and several questionnaires have been used to measure ED in adults with ADHD. Thus, to date, the characteristics of ED in adult ADHD remain poorly defined. The objective of this study is to identify the different patterns of ED in adults with ADHD.

METHODS

A large sample of 460 newly diagnosed adults with ADHD were recruited. Patients completed a total of 20 self-reported questionnaires. Measures consisted in the several facets of ED, but also other clinical features of adult ADHD such as racing thoughts. A factor analysis with the principal component extraction method was performed to define the symptomatic clusters. A mono-dimensional clustering was then conducted to assess whether participants presented or not with each symptomatic cluster.

RESULTS

The factor analysis yielded a 5 factor-solution, including "emotional instability", "impulsivity", "overactivation", "inattention/disorganization" and "sleep problems". ED was part of two out of five clusters and concerned 67.52% of our sample. Among those patients, the combined ADHD presentation was the most prevalent. Emotional instability and impulsivity were significantly predicted by childhood maltreatment. The ED and the "sleep problems" factors contributed significantly to the patients' functional impairment.

CONCLUSIONS

ED in ADHD is characterized along emotional instability and emotional impulsivity, and significantly contributes to functional impairment. However, beyond impairing symptoms, adult ADHD may also be characterized by functional strengths such as creativity.

Community Participation, Supports and Barriers of Adolescents with and without Attention Deficit Hyperactivity Disorder

AIM

To compare participation patterns, environmental supports, and barriers to community activities in adolescents with and without attention deficit hyperactivity disorder (ADHD) in Turkey.

METHODS

Participants were 94 adolescents with ADHD and 109 adolescents without ADHD ages 13-17 years (mean age 14.6, S.D 1.49 years) Participation frequency, involvement rate, mothers who desired change, and environmental supports and barriers in a community setting were assessed with the Participation and Environment Measure for Children and Youth (PEM-CY).

RESULTS

Adolescents with ADHD participated 20.3% less frequently in socializing with peers in the community than adolescents without ADHD. With moderate to large effect sizes, the mean involvement rate in four community activities, including neighborhood outings, community events, socializing with peers in the community, and religious activities, was significantly lower for adolescents with ADHD than for adolescents without ADHD.

CONCLUSION

Adolescents with ADHD participate less frequently and are less involved in socializing with peers in the community. Almost half of all ADHD adolescents never participate in community events. It was seen that cognitive difficulties, sensory qualities, and safety may prevent adolescents with ADHD from socializing with peers in the community.

Exploring the effect of ADHD traits on the moment-to-moment interplay between provocation and aggression: Evidence from dynamic structural equation modeling

The relation between attention deficit hyperactivity disorder (ADHD) symptoms and aggression is well documented; however, the processes that account for higher levels of aggression associated with ADHD in the course of daily life are little understood. The current study used ecological momentary assessment to explore how ADHD traits relate to individual differences in perceiving provocation from others and the resultant aggressive behaviors; and the strengths of the links between provocation and aggression in the flow of daily life. A dynamic structural equation model was fit using data from a subpopulation of young adults involved in the longitudinal z-proso study (n = 259, median-age 20). Data on provocation and aggression was collected at four quasi-random time periods per day over a 14-day period. Individuals with higher ADHD trait levels reported higher instances of provocation and aggression, with ADHD traits significantly moderating aggression inertia such that those with higher levels of ADHD traits showed greater persistence of aggressive behavior over time. However, ADHD trait levels did not significantly moderate any of the observed cross-lagged effects. Our findings suggest that individuals with higher levels of ADHD traits are at greater risk of exposure to interpersonal interactions involving interpersonal provocation, show higher levels of aggressive behavior in daily life, and find it more difficult to reduce their aggression once triggered. These findings support the importance of targeting factors such as social skills and emotion regulation that may underpin the increased difficulties in interpersonal interactions often experienced by individuals with high levels of ADHD symptoms.

Systematic Review: Questionnaire-Based Measurement of Emotion Dysregulation in Children and Adolescents

OBJECTIVE

Emotion dysregulation, understood as a critical transdiagnostic factor in the etiology and maintenance of psychopathology, is among the most common reasons youth are referred for psychiatric care. The present systematic review examined 2 decades of questionnaires used to assess emotion (dys)regulation in youth.

METHOD

Using "emotion (dys)regulation," PsycINFO, PubMed, and Web of Science were searched for empirical, peer-reviewed journal studies published before May 2021 in clinical and/or nonclinical youth. A total of 510 studies met selection criteria and were included.

RESULTS

Across the literature, 115 distinct self-, parent-, or other informant-reported measures of emotion (dys)regulation were used in cross-sectional (67.1%), longitudinal (22.4%), intervention (9.0%), and mixed design (1.6%) studies. Out of 115 different questionnaires, a subset of 5 measures of emotion (dys)regulation were used in most of the literature (ie, 59.6% of studies). Moreover, reviewed studies examined emotion (dys)regulation in more than 20 distinct clinical groups, further supporting emotion dysregulation as a transdiagnostic construct.

CONCLUSION

Numerous themes emerged. Broadly, measures differed in their ability to capture internal vs external components of emotion dysregulation, the use of adaptive vs maladaptive responses, and subjective experiences more broadly vs particular affective states. These findings serve to guide researchers and clinicians in selecting appropriate measurement tools for assessing specific domains of child and adolescent emotion dysregulation.

Emotional and sensory dysregulation as a possible missing link in attention deficit hyperactivity disorder: A review

Attention Deficit Hyperactivity Disorder (ADHD) is a common developmental disorder affecting 5-7% of adults and children. We surveyed the literature to examine ADHD through three pillars: developmental characteristics, symptomatology, and treatment strategies. Firstly, in terms of developmental characterstics, early life stress may increase the risk of developing ADHD symptoms according to animal models' research. Secondly, the current core symptoms of ADHD are comprised of inattention, hyperactivity, and impulsivity. However, the up-to-date literature indicates individuals with ADHD experience emotional and sensory dysregulation as well, which early-life stress may also increase the risk of. Finally, we discuss the therapeutic benefits of methylphenidate on both the current core ADHD symptoms and the sensory and emotional dysregulation found in those with ADHD. In summation, we surveyed the recent literature to analyze (i) the potential role of early-life stress in ADHD development, (ii) the involvement of emotional and sensory dysregulation in ADHD symptomatology and finally, (iii) the therapeutic intervention with methylphenidate, aiming to reduce the potential effect of early life stress in ADHD, and mainly emotional and sensory dysregulation. The apparent but currently less recognized additional symptoms of emotional and sensory dysregulation in ADHD call for further investigation of these possible causes and thus increasing treatments efficacy in individuals with ADHD.

Linking ADHD and ASD Symptomatology with Social Impairment: The Role of Emotion Dysregulation

Children with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) often experience social impairments. These children also frequently struggle with emotion regulation, and extant literature suggests that emotion dysregulation predicts social impairment in both clinical and neurotypical populations. However, the evidence base linking ADHD/ASD with social impairment comes primarily from samples meeting full diagnostic criteria for ADHD and/or ASD despite evidence that both syndromes reflect extreme ends of natural continuums that are normally distributed across the general population. To our knowledge, the present study is the first to concurrently examine unique and overlapping relations among ADHD/ASD symptoms, emotion regulation, and social difficulties using multi-informant measures (parent, teacher) with a clinically-evaluated sample of 108 children ages 8-13 (40 girls; 66% White/Non-Hispanic) with and without clinically-elevated ASD and ADHD symptoms and other common clinical disorders. Bias-corrected, bootstrapped conditional effects modeling revealed that ADHD-inattentive (β=-0.23) and ASD-social communication (β=-0.20) symptoms predicted social impairment directly, whereas ADHD-hyperactive/impulsive (β=-0.06) and ASD-restricted/repetitive behavior/interests (β=-0.06) symptoms predicted social impairment only via their shared associations with emotion dysregulation. Sensitivity analyses revealed that most relations were robust to control for item overlap across measures. In contrast, only the ADHD-inattention/social impairment link was robust to control for mono-informant bias, highlighting the importance of multi-informant methods and the potential for different determinants of social functioning across settings. Overall, this study implicates emotion regulation skills and all four ADHD/ASD symptom clusters as potential influences on children's social functioning, albeit with a more nuanced and potentially setting-specific pattern than suggested by prior work.

Real-time assessment of positive and negative affective fluctuations and mood lability in a transdiagnostic sample of youth

BACKGROUND

Emotional lability, defined as rapid and/or intense affect fluctuations, is associated with pediatric psychopathology. Although numerous studies have examined labile mood in clinical groups, few studies have used real-time assessments in a well-characterized transdiagnostic sample, and no prior study has included participants with disruptive mood dysregulation disorder (DMDD). The present study leverages ecological momentary assessment (EMA) to assess emotional lability in a transdiagnostic pediatric sample.

METHODS

One hundred thirty participants ages 8-18 with primary diagnoses of DMDD, attention-deficit/hyperactivity disorder (ADHD), an anxiety disorder (ANX), or healthy volunteers completed a previously validated 1-week EMA protocol. Clinicians determined diagnoses based on semi-structured interviews and assessed levels of functional impairment. Participants reported momentary affective states and mood change. Composite scores of fluctuations in positive and negative affect were generated. Affect fluctuations were compared between diagnostic groups and tested for their association with functional impairment.

RESULTS

Diagnostic groups differed in levels of negative and positive emotional lability. DMDD patients demonstrated the highest level of labile mood compared with other groups. Emotional lability was associated with global impairment in the whole sample.

CONCLUSIONS

Both positive and negative emotional lability is salient in pediatric psychopathology and is associated with functional impairment, particularly in DMDD youth.

Effect of short-term methylphenidate on social impairment in children with attention deficit/hyperactivity disorder: systematic review

Attention Deficit/Hyperactivity disorder (ADHD) is one of the most common disorders in school-age children. In addition to learning difficulties associated with the disorder's core symptoms of inattention and hyperactivity, children with ADHD display substantial social impairments. Methylphenidate (MPH) in formulations such as Ritalin or Concerta mitigates inattention and hyperactivity, but the effects of the therapy on social behavior in children with ADHD are not clear. This review aims to determine the effectiveness of short term (up to 6 months) MPH treatment on three domains of social skills in children aged 6-14 with ADHD: (i) Recognition of nonverbal emotional expressions, which are a marker of inherent (unlearned) social understanding, (ii) theory of mind (ToM) components that relate to learned cognition and social communication, and (iii) social competence in everyday environments. 15 relevant studies were identified based on inclusion/exclusion criteria. The results show mixed effects: the overall social performance as evaluated by parents, teachers or peers, and some components of ToM, were found to improve following a weeks-long course of MPH treatment. However, the effects of the medication are less clear when evaluating momentary/nonverbal social responses such as reactions to emotional facial expressions. While the findings of this review indicate that an MPH medication regime of order weeks to months could improve, to a degree, social impairment in children with ADHD, more studies are required to identify the medications' mechanism and confirm such a conclusion.

Maturation-dependent vulnerability of emotion regulation as a response to COVID-19 related stress in adolescents

BACKGROUND

The COVID-19 pandemic created unpredictable circumstances resulting in increased psychological strain. Here we investigate pandemic-related alterations in emotion regulation in adolescents assessed before and during the pandemic. We also take biological age into account in the response to the pandemic.

METHODS

Mann-Whitney U tests were conducted to compare baseline data on the Difficulties in Emotion Regulation Scale (DERS) total scores of a pre-pandemic adolescent cohort (n = 241) with those obtained during the second wave of the pandemic (n = 266). We estimated biological age based on an ultrasonic boneage assessment procedure in a subgroup of males, including grammar school and vocational school students in the 9th and 10th grades, and analyzed their data independently.

FINDINGS

There is a gender difference in the timing of vulnerability for pandemic-related stress in grammar school students: females are affected a year earlier than males. Vocational school male students mature faster than grammar school male students, and the timing of emotional vulnerability also precedes that of the grammar school students'.

DISCUSSION

We interpret our findings within a developmental model suggesting that there might be a window of highest vulnerability in adolescent emotion regulation. The timing of the window is determined by both chronological and biological age, and it is different for females and males.

APPLICATION TO PRACTICE

Defining the exact temporal windows of vulnerability for different adolescent cohorts allows for the timely integration of preventive actions into adolescent care to protect mental health during future chronic stressful situations.

Depressive Symptoms Account for Loss of Positive Attention Bias in ADHD Patients: An Eye-Tracking Study

OBJECTIVES

Depression and ADHD often co-occur and are both characterized by altered attentional processing. Differences and overlap in the profile of attention to emotional information may help explain the co-occurence. We examined negative attention bias in ADHD as neurocognitive marker for comorbid depression.

METHODS

Patients with depression (n = 63), ADHD (n = 43), ADHD and depression (n = 25), and non-psychiatric controls (n = 68) were compared on attention allocation toward emotional faces. The following eye-tracking indices were used: gaze duration, number of revisits, and location and duration of first fixation.

RESULTS

Controls revisited the happy faces more than the other facial expressions. Both the depression and the comorbid group showed significantly less revisits of the happy faces compared to the ADHD and the control group. Interestingly, after controlling for depressive symptoms, the groups no longer differed on the number of revisits.

CONCLUSION

ADHD patients show a relative positive attention bias, while negative attention bias in ADHD likely indicates (sub)clinical comorbid depression.

Longitudinal Associations of Children’s Hyperactivity/Inattention, Peer Relationship Problems and Mobile Device Use

Children with emotional, behavioral or relationship problems may be more inclined to use mobile touchscreen devices (MTSDs: mobiles and tablets) to regulate their emotions or compensate for the lack of social relationships, which, in turn, may affect their symptoms. Bi-directional longitudinal associations between behavioral difficulties and MTSD use were analyzed. Participants were parents of children aged 4–6 years old at first data collection (n = 173), and 7–9 years old at second data collection (n = 98). They reported on their child’s MTSD use and behavioral difficulties at two time points (T1 and T2). It was analyzed whether T1 MTSD use predicts T2 behavioral difficulties (controlling for demographics and T1 behavioral difficulties); and whether T1 behavioral difficulties predict T2 MTSD use (controlling for demographics and T1 MTSD use). Additionally, cross-sectional associations between behavioral difficulties and MTSD use were analyzed. Children’s T1 hyperactivity/inattention score positively associated with T2 MTSD use, and peer relationship problems and MTSD use positively associated in T2. Pre-schoolers with more hyperactive inattentive symptoms may use MTSDs more to regulate their emotions. The association between peer relationship problems and MTSD use in T2 is consistent with poorer socio-cognitive skills in MTSD user children and may be bi-directional.

Psychosocial functioning of adolescents with ADHD in the family, school and peer group: A scoping review protocol

Objective

The objective of this scoping review is to investigate what is known about the psychosocial functioning of adolescents with ADHD. All basic life environments (family, school and peer group) will be considered.

Introduction

Adolescence is especially critical for people with ADHD–natural maturation may be accompanied by changing symptoms of ADHD. A number of childhood difficulties transform during adolescence and contribute to problems in various areas that comprise psychosocial functioning. The available studies focus on selected domains of psychosocial functioning of adolescents with ADHD, however, to the authors’ best knowledge, there is no comprehensive description of this issue. The lack of such a description is the main rationale for conducting this scoping review.

Inclusion criteria

Pointing to the PCC elements (population, concept, context), the scoping review will include primary studies on the concept of psychosocial functioning (including functioning in the family, school and peer group). In the included studies, the term "psychosocial functioning" (or related) had to be used explicitly. The population will be adolescents (10 to 19 years old) with a formal diagnosis of ADHD (DSM classification) or Hyperkinetic Syndrome (ICD-9) or Hyperkinetic Disorders (ICD-10). There will be no restrictions on the research context.

Methods

The methodology of scoping reviews will be applied in accordance with the guidelines of the Joanna Briggs Institute (JBI). The following databases: Academic Search Ultimate, ERIC, MEDLINE, ProQuest Central, PsycInfo, Scopus, and databases under the Web of Science will be searched for primary studies in peer-reviewed journals, written in English and published since 1987. The analyses will be based mainly on frequency counts of the components of psychosocial functioning and population characteristics. The results will be presented in tabular form and supplemented with a descriptive summary. The protocol has been registered on the Open Science Framework: https://doi.org/10.17605/OSF.IO/MS82H [registration DOI].

Neural Correlates of Reactive Aggression in Adult Attention-Deficit/Hyperactivity Disorder

Despite not being part of the core diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), emotion dysregulation is a highly prevalent and clinically important component of (adult) ADHD. Emotionally dysregulated behaviors such as reactive aggression have a significant impact on the functional outcome in ADHD. However, little is known about the mechanisms underlying reactive aggression in ADHD. In this study, we aimed to identify the neural correlates of reactive aggression as a measure of emotionally dysregulated behavior in adults with persistent ADHD during implicit emotion regulation processes. We analyzed associations of magnetic resonance imaging-based whole-brain activity during a dynamic facial expression task with levels of reactive aggression in 78 adults with and 78 adults without ADHD, and also investigated relationships of reactive aggression with symptoms and impairments. While participants with ADHD had higher reactive aggression scores than controls, the neural activation patterns of both groups to processing of emotional faces were similar. However, investigating the brain activities associated with reactive aggression in individuals with and without ADHD showed an interaction of diagnosis and reactive aggression scores. We found high levels of activity in the right insula, the hippocampus, and middle and superior frontal areas to be particularly associated with high reactive aggression scores within the ADHD group. Furthermore, the limbic activity was associated with more hyperactivity/impulsivity symptoms. These results suggest a partly differential mechanism associated with reactive aggression in ADHD as compared to controls. Emotional hyper-reactivity in the salience network as well as more effortful top-down regulation from the self-regulation network might contribute to emotionally dysregulated behavior as measured by reactive aggression.

ADHD-inattentive versus ADHD-Combined subtypes: A severity continuum or two distinct entities? A comprehensive analysis of clinical, cognitive and neuroimaging data

The current study aimed to explore the multimodal differences between the inattentive ADHD (ADHD-I) subtype and the combined ADHD (ADHD-C) subtype. A large sample of medication-naïve children with pure ADHD (i.e., without any comorbidity) (145 with ADHD-I, 132 with ADHD-C) and healthy controls (n = 98) were recruited. A battery of multiple scales and cognitive tests were utilized to assess the clinical and cognitive profiles of each individual. In addition, structural and diffusion magnetic resonance imaging (MRI) were acquired for 120 subjects with ADHD and 85 controls. Regional gray matter volume, white matter volume, and diffusion tensors, e.g., axial diffusivity (AD), were compared among the three groups in a whole-brain voxel-wise manner. Compared with healthy controls, both ADHD groups exhibited elevated levels of behavioral and emotional problems. The ADHD-C group had more behavioral problems and emotional liability, as well as less anxiety, than the ADHD-I group. The two ADHD groups were equally impaired in most cognitive domains, with the exception of sustained attention. Compared with healthy controls, the ADHD-C group showed a high gray matter volume (GMV) in the bilateral thalamus and a high white matter volume in the body of the corpus callosum, while the ADHD-I group presented an elevated GMV mainly in the left precentral gyrus and posterior cingulate cortex. Compared with participants with ADHD-C and healthy controls, subjects with ADHD-I showed increased AD in widespread brain regions. Our study has revealed a distinct, interconnected pattern of behavioral, cognitive, and brain structural characteristics in children with different ADHD subtypes.

Online and Intellectual Awareness of Executive Functioning in Daily Life among Adolescents with and without ADHD

OBJECTIVE

Executive function deficits (EFD) are a central mechanism underlying negative outcomes in ADHD. This study examined awareness of EFD manifested in "real-time" task performance (Online Awareness) and in general self-knowledge of daily activities, outside the context of a specific task (Intellectual Awareness) among adolescents with and without ADHD.

METHODS

102 adolescents with (n = 52) and without (n = 50) ADHD were administered Weekly Calendar Planning Activity (WCPA) and Behavior Rating Inventory of Executive Function (BRIEF). Parents completed the BRIEF parent version. Awareness was defined using the discrepancy paradigm: performance versus estimation on WCPA for online awareness; self versus parent report on the BRIEF for intellectual awareness.

RESULTS

Adolescents with ADHD overestimated their performance on the WCPA and underestimated their EFD on the BRIEF compared to parent's ratings. The discrepancy scores in both types of awareness were significantly larger among ADHD than controls (p < .005).

CONCLUSIONS

Adolescents with ADHD demonstrate significantly lower rates of online and intellectual awareness of EFD compared to controls.

Distinct aspects of emotion dysregulation differentially correspond to magnitude and slope of the late positive potential to affective stimuli

ABSTRACTEmotion dysregulation (ED) is a transdiagnostic risk factor for several forms of psychopathology. One established, integrative conceptualisation of ED that has informed our understanding of psychopathology (Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation : development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41-54) was recently extended to account for state-level and specifically physiological aspects of ED. As such, the goal of the current study was to assess the degree to which this conceptualisation could be captured using a physiological, state-level index (i.e. the late positive potential; LPP). Participants (N=41; M_age=27.5 years, SD=11.0) completed a trait-based rating scale measure of the extended conceptualisation of ED and viewed a series of images that ranged in valence (i.e. unpleasant, pleasant, and neutral). Multilevel modelling indicated some points of convergence between rating scale scores and the LPP, and other points of divergence. Findings underscore the utility of a multi-method approach to improve understanding of key transdiagnostic characteristics across levels of analysis. Further, results are novel evidence supporting validity of the extended conceptualisation of ED.

Efficacy of Non-pharmacological Treatments on Emotional Symptoms of Children and Adults with Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis

BACKGROUND

The present meta-analysis aimed to evaluate the efficacy of various non-pharmacological interventions on comorbid emotional symptoms such as depression, anxiety, and emotional dysregulation (ED) in children and adults with ADHD.

METHOD

Forty-four randomized controlled trials (23 studies with ADHD children and 21 studies with ADHD adults) were included. Risk of bias, heterogeneity assessment, and subgroup analyses were conducted.

RESULTS

We found that therapies targeting the relationship between children and others (i.e., parent-training [on ED and depression] and social skills training [on ED]) were efficacious in the treatment of emotional symptoms in children with ADHD at post-intervention. As for adults with ADHD, cognitive behavioral therapy was found to be effective for the improvement of emotional symptoms at both post-intervention and follow-up.

CONCLUSION

Our findings demonstrate that the efficacy of non-pharmacological interventions varies substantially across children and adults with ADHD. These results provide important implications for the selection of non-pharmacological interventions for children with ADHD.

Developmental Trajectory of Inattention and Its Association With Depressive Symptoms in Adolescence: Peer Relationships as a Mediator

This study investigated the developmental trajectory of inattention symptoms as a predictor of later depressive symptoms in adolescence, and examined potential mediating role of peer relationships in this process. Participants were adolescents who were part of the large longitudinal panel study on Korean Youths, Korean Children & Youth Panel Survey 2010 (KCYPS 2010) of the National Youth Policy Institute (NYPI). Specifically, data were drawn from two cohorts of KCYPS that differed in participant age (Panel 1: 2003 birth cohort, n = 2,342, 48.2% girls; Panel 2: 2000 birth cohorts, n = 2,378, 40.0% girls). We analyzed data collected from 2010 to 2016 when children in panel 1 were 6-7 to 12-13 years old, and children in panel 2 were 9-10 to 15-16 years old. Results of latent growth modeling (LGM) were as follows. In Panel 1, the inattention symptoms increased from 9-10 to 12-13 years. Otherwise, the inattention symptoms decreased from 11-12 to 15-16 years in panel 2. Additionally, in both panels, initial status and slope of inattention significantly predicted later levels of depressive symptoms, and peer relationships partly mediated the association between inattention trajectory and depressive symptoms. The findings are discussed with respect to considering the growth of inattention and the quality of peer relationships as promising targets for early identification and intervention of depression in adolescents.

Deficient Emotional Self-Regulation and Sleep Problems in ADHD with and without Pharmacological Treatment

OBJECTIVE

The purpose of this study is to analyse DESR and its influence on sleep parameters in three different groups of children and adolescents: a group newly diagnosed with ADHD naïve, a group with ADHD under pharmacological treatment and a control group.

METHOD

Subjects were a total of 327 children and adolescents. Two groups diagnosed with ADHD: 108 medication-naïve and 80 under pharmacological treatment; and one group with 136 healthy subjects. DESR was defined using anxious/depressed, attention problems and aggressive behaviors (AAA) scales from the Child Behavior Checklist (CBCL), and sleep through the Sleep Disturbance Scale for Children.

RESULTS

Significant differences were found comparing the three groups (p = .001), with a significantly higher profile on DESR in ADHD subjects, especially those who did not undergo treatment, and a positive correlation between DESR and sleep.

CONCLUSION

Children and adolescents with ADHD without treatment present higher DESR than healthy controls and consequently higher sleep problems.

Radical Acceptance of Reality: Putting DBT®-A Skill Groups Online During the COVID-19 Pandemic: A Qualitative Study

INTRODUCTION

Emotion dysregulation is a common challenge pertaining to numerous psychiatric disorders in adolescence and is associated with increased morbidity and mortality. Dialectical Behavior Therapy for Adolescents (DBT®-A) has been shown to be an effective treatment, especially in the reduction of self-harm and suicidality. Measures in relation to the COVID-19 pandemic set strict limits on physical contacts with patients. In order to continuously provide evidence-based specialized care to patients suffering from emotion dysregulation, we offered two online DBT®-A skill groups in a video-group-call format.

OBJECTIVE

We aimed at assessing our online DBT®-A skills groups, collect according up- and downsides, and form a basis for advancement of this form of treatment provision. Also, the impact of the COVID-19 pandemic on patients was assessed.

METHODS

A physical DBT®-A skill group was switched to a video-group-call format and a second group was initiated de novo online. After five sessions, patients engaged in structured group discussions to reflect experiences. Discussion content was analyzed via Inductive Category Formation within the Framework of Qualitative Content Analysis.

RESULTS

Patients unanimously found the COVID-19 pandemic challenging, but also reported differentially on its impact. Downsides were balanced by subjective "gains" in time and a perceived reduction in stress. Technical problems of the online format were discussed, but did not limit the positive experience of still receiving treatment. Patients of both online DBT®-A skill groups valued the offer, felt connected, and reported benefits from the treatment. The transition group additionally discussed changes in structure and content of the group sessions after the switch to online meetings and reflected differential functions of the group.

DISCUSSION

Although the sample size is small, and conclusions are drawn from Inductive Qualitative Content Analysis, the presented results are of interest. In our investigation, video-group-calls were both safe and beneficial for patients. This alternative to physical meetings is not only interesting for further waves of the current pandemic but also for service provision in remote areas with limited access to specialized care. Further research is needed to challenge and refine our results and to explore extensions to "basic" video-group-calls, such as "break-out sessions," blended therapy, or real-time supervision within an online session.

Does central executive training and/or inhibitory control training improve emotion regulation for children with attention-deficit/hyperactivity disorder? A randomized controlled trial

INTRODUCTION

Approximately 48-54% of children with attention-deficit/hyperactivity disorder (ADHD) have impairing difficulties with emotion regulation, and these difficulties are not ameliorated by first-line ADHD treatments. Working memory and inhibitory control represent promising intervention targets given their functional, if not causal, links with ADHD-related emotion dysregulation.

METHODS

This preregistered randomized controlled trial tested whether two digital therapeutic training protocols that have been previously shown to improve working memory (Central Executive Training [CET]) and inhibitory control (Inhibitory Control Training [ICT]) can improve emotion regulation in a sample of 94 children with ADHD aged 8-13 years (M = 10.22, SD = 1.43; 76% White/non-Hispanic; 29 girls).

RESULTS

Results of Bayesian mixed model ANOVAs indicated both treatment groups demonstrated significant decreases in emotion dysregulation relative to pre-treatment at immediate post-treatment (parent report; d = 1.25, BF₁₀ = 8.04 × 10¹³, p < 0.001), at 1-2 months after completing treatment (teacher report; d = 0.99, BF₁₀ = 1.22 × 10⁶, p < 0.001), and at 2-4-months follow-up (parent report; d = 1.22, BF₁₀ = 1.15 × 10¹⁴, p < 0.001). Contrary to our hypotheses, the CET and ICT groups demonstrated equivalent reductions in emotion dysregulation and maintenance of effects. Exploratory analyses revealed that results were robust to control for informant expectancies, ADHD medication status/changes, in-person vs. at-home treatment, child age, and time from treatment completion to post-treatment ratings.

DISCUSSION

To determine whether working memory and inhibitory control are causally linked with ADHD-related emotion dysregulation, future studies should include active control conditions that do not train executive functions prior to making decisions about the clinical utility of CET/ICT for the treatment of emotion dysregulation in ADHD.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/], identifier [NCT03324464].

Facial emotion recognition impairment predicts social and emotional problems in children with (subthreshold) ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) symptoms often experience social and emotional problems. Impaired facial emotion recognition has been suggested as a possible underlying mechanism, although impairments may depend on the type and intensity of emotions. We investigated facial emotion recognition in children with (subthreshold) ADHD and controls using a novel task with children's faces of emotional expressions varying in type and intensity. We further investigated associations between emotion recognition accuracy and social and emotional problems in the ADHD group. 83 children displaying ADHD symptoms and 30 controls (6-12 years) completed the Morphed Facial Emotion Recognition Task (MFERT). The MFERT assesses emotion recognition accuracy on four emotions using five expression intensity levels. Teachers and parents rated social and emotional problems on the Strengths and Difficulties Questionnaire. Repeated measures analysis of variance revealed that the ADHD group showed poorer emotion recognition accuracy compared to controls across emotions (small effect). The significant group by expression intensity interaction (small effect) showed that the increase in accuracy with increasing expression intensity was smaller in the ADHD group compared to controls. Multiple regression analyses within the ADHD group showed that emotion recognition accuracy was inversely related to social and emotional problems, but not prosocial behavior. Not only children with an ADHD diagnosis, but also children with subthreshold ADHD experience impairments in facial emotion recognition. This impairment is predictive for social and emotional problems, which may suggest that emotion recognition may contribute to the development of social and emotional problems in these children.

Evaluation of a structured skills training group for adolescents with attention-deficit/hyperactivity disorder: a randomised controlled trial

Attention-deficit/hyperactivity disorder (ADHD) in adolescence is associated with behavioural, emotional and interpersonal problems, and non-pharmacological treatments targeting these difficulties have been requested. The objective of this study was to evaluate the effectiveness and acceptance of an age-adapted structured skills training group (SSTG) for adolescents with ADHD. Adolescents (n = 184, ages 15-18 years) with a diagnosis of ADHD were randomly assigned to either the SSTG, which is based on dialectical behavioural therapy, or an active control group based on psychoeducation. Symptoms of ADHD, behavioural and emotional problems, functional impairment, and health-related outcomes were assessed with self-ratings and parental ratings two weeks before, two weeks after, and six months after treatment. All participants who completed the pre-treatment measurements (n = 164) were included in the main analyses, which were conducted using a linear mixed model. Our results demonstrated no significant group differences in favour of the SSTG for any of the study outcomes. A majority of the participants in both groups reported that they had increased their knowledge about ADHD, improved their ability to manage problems related to the diagnosis, and would recommend the treatment to others. We conclude that the SSTG seems to be acceptable for adolescents with ADHD in a clinical context. However, the treatment was not proved to be more effective or more acceptable than the psychoeducational control intervention.Trial registration: http://www.isrctn.com/ISRCTN17366720,11/05/2016 , retrospectively registered.

Childhood ADHD Symptoms, Parent Emotion Socialization, and Adolescent Peer Problems: Indirect Effects Through Emotion Dysregulation

Although parent reactions to children's negative emotions are important to the development of adolescent social and emotional functioning, there is a lack of research examining this aspect of parenting in samples that include youth with attention-deficit/hyperactivity disorder (ADHD). This study addresses this gap in the research by examining the independent effects of childhood ADHD symptoms and parent reactions to negative emotions in the longitudinal prediction of adolescent emotion dysregulation and peer problems. A sample of 124 youth (52% female) with and without clinical elevations in ADHD symptoms were assessed in childhood (8-12 years; M = 10.50) and followed up 5-6 years later in adolescence (13-18 years; M = 16.15). Path models tested the direct effects of childhood ADHD symptoms, supportive parent reactions, and non-supportive parent reactions on adolescent peer problems (friendship quality, deviant peer affiliation, peer aggression) and the indirect effects via adolescent emotion dysregulation. Emotion dysregulation mediated the effects of greater ADHD symptoms and of less parent supportive reactions on adolescent peer problems; parent reactions also independently predicted specific adolescent peer problems. Even for youth with clinical elevations in ADHD symptoms, parent reactions to children's negative emotions may be important in understanding adolescent emotion dysregulation and peer problems.

A Meta-Analytic Review of Emotion Regulation Focused Psychosocial Interventions for Adolescents

Emotion regulation (ER) is the ability to monitor, evaluate, and modify one's emotional responses to be appropriate for environmental demands. Poor ER has been considered a transdiagnostic risk factor for a range of internalizing and externalizing disorders and overall decreased well-being in adolescents. A range of evidence-based interventions exist which may improve ER. However, much of the intervention research to date does not include a measure of ER to assess change pre and post treatment, with limited information about the efficacy of these interventions in youth across a range of sample types. There is a clear need for a comprehensive review of the literature examining ER-focused interventions in adolescents with a wide range of presenting disorders. A literature search was originally conducted in January 2020 and an updated search was conducted in February 2021 which elicited 1245 articles, of which 605 were duplicates and were removed. Abstracts of the remaining 640 articles were screened with 121 articles being reviewed in full. Of note, 16 additional articles were identified through references and other sources during this process and were also included in the full review. Of the 137 articles reviewed in full, 41 studies were ultimately included in the present review. The present paper provides a descriptive review of intervention approaches and findings from community prevention programs, programs for war-affected youth, programs for clinical populations, and programs for incarcerated and delinquent adolescents. The overall pooled effect was significantly different from zero based on the pre/post effects [Hedge's g = 0.29, 95% CI (0.22, 0.36)] and the intervention/control effects [Hedge's g = 0.19, 95% CI (0.06-0.32)]. Although neither sex nor age significantly accounted for heterogeneity in effect sizes, there were significant findings for population type (clinical vs. community), with community samples having significantly lower effect sizes on average. Impacts of the different ER measures used and significant methodological variability (e.g., use of control groups, length of intervention) across included studies are discussed. Implications and suggestions for future research are reviewed, specifically, that additional understanding of moderators of effects are needed and that measures used to assess change in ER, both dysregulation and adaptive skill use, may need to more directly align with the intervention's focus and the strategies taught as part of the intervention.

Equine-assisted activities and therapies in children with attention-deficit/hyperactivity disorder: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Attention-deficit/hyperactivity disorder (ADHD) is characterized by problems of inattention and impulsive hyperactivity in children. Equine-assisted activities and therapies (EAATs) have been used as alternative non-pharmacological intervention option in patients with ADHD. WHAT DOES THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nowadays, more studies of high methodological quality are needed to determine whether EAAT is an effective intervention for the treatment in children with ADHD. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Between 15 and 40 min of rising horses, 8-32 total sessions, for 4-32 weeks, seem to be beneficial to reduce the symptoms of ADHD.

ABSTRACT

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a disorder characterized by problems of inattention and impulsive hyperactivity. Equine-assisted activities and therapies (EAATs) have become an emerging non-pharmacological intervention option in patients with ADHD.

AIM

To perform a systematic review of updated literature about EAAT in children with ADHD.

METHOD

A systematic review was performed until 28 November 2019, in four electronic databases: PubMed, Web of Science, Embase and Google Scholar. The inclusion criteria were as follows: (a) intervention programme, with pre- and post-data, based on EAAT, (b) children with ADHD and (c) articles written in English.

RESULTS

A total of 9 articles were found that meet the inclusion criteria. The evidence level was C for 7 studies and B for 2 studies. The level of conclusion was 3.

DISCUSSION

There are few studies with high methodological quality, and there is a high heterogeneity in the variables included, what make that the level of evidence and conclusion are low.

CONCLUSION

There is no account with enough studies of high methodological quality to determine whether EAAT is an effective intervention for the treatment in children with ADHD.

Executive Functioning and Emotion Regulation in Children with and without ADHD

Difficulties with emotion regulation affect the majority of youth with attention-deficit/hyperactivity disorder (ADHD) and predict greater functional impairment than ADHD symptoms alone. Deficits in executive functioning are also present for most children with ADHD, and have been linked with emotion regulation difficulties in both clinical and neurotypical populations throughout development. The current study was the first to assess all three core executive functions (working memory, inhibitory control, set shifting) simultaneously in a clinically-diverse sample of children with and without ADHD and common comorbidities and investigate the extent to which they uniquely predict emotion dysregulation. A sample of 151 children ages 8-13 years (M = 10.36, SD = 1.52; 52 girls; 70.2% White/Non-Hispanic) were assessed using a criterion battery of executive functioning tasks, teacher-reported ADHD symptoms, and parent-reported emotion regulation. Results of the bias-corrected, bootstrapped conditional effects path model revealed that better-developed working memory predicted better emotion regulation (β = 0.23) and fewer ADHD symptoms (β = -0.21 to -0.37), that ADHD symptoms (β = -0.18 to -0.20) independently predicted emotion dysregulation, and that working memory exerted indirect effects on emotion regulation through both inattention and hyperactivity/impulsivity (β = 0.04-0.07). Sensitivity analyses indicated that these effects were generally robust to control for age, sex, executive function interrelations, and inclusion/exclusion of children with co-occurring ASD. These findings underscore the importance of working memory (relative to inhibitory control and set shifting) and its relations with ADHD symptoms for understanding children's emotion regulation skills, and may help explain the limited efficacy of first-line ADHD treatments, which do not target working memory, for improving emotion regulation skills.

White matter microstructural integrity correlates of emotion dysregulation in children with ADHD: A diffusion imaging tractography study

BACKGROUND

Emotion dysregulation (ED) is prevalent in youths with attention-deficit hyperactivity disorder (ADHD) and causes more social impairment and poor adaptive function. Alterations in the integrity of white matter (WM) tracts might have important implications for affective processing related to ED. However, little is known about the WM correlates underpinning ED in ADHD.

METHODS

Using diffusion spectrum image tractography, we obtained generalized fractional anisotropy (GFA) values of 76 WM tracts in 77 children with ADHD and 105 typically developing controls (TDC). ED severity was defined by the dysregulation profile from the child behavior checklist. Canonical correlation analysis (CCA) was performed to identify modes that relate WM microstructural property to ED severity and cognitive measures.

RESULTS

The application of CCA identified one significant mode (r = 0.638, FWE-corrected p = 0.046) of interdependencies between WM property patterns and diagnosis, ADHD total symptom levels, dysregulation by diagnosis interaction, and full-scale intellectual quotient (FIQ). GFA values of 19 WM tracts that were linked to affective-processing, sensory-processing and integration, and cognitive control circuitry were positively correlated with ED severity in TDC but negatively correlated with ED severity in ADHD. ADHD symptom severity and diagnosis were negatively associated with the GFA patterns of this set of tract bundles. In contrast, FIQ was positively correlated with this set of tract bundles.

CONCLUSIONS

This study used the CCA to show that children with ADHD and TDC had distinct multivariate associations between ED severity (diagnosis by ED interaction) and microstructural property in a set of WM tracts. These tracts interconnect the cortical regions that are principally involved in emotion processing, integration, and cognitive control in multiple brain systems. The WM microstructure integrity impairment might be an essential correlate of emotion dysregulation in ADHD.

Increased pupil dilation to happy faces in children with hyperactive/impulsive symptoms of ADHD

Attention-deficit/hyperactivity disorder (ADHD) is associated with disrupted emotional processes including impaired regulation of approach behavior and positive affect, irritability, and anger. Enhanced reactivity to emotional cues may be an underlying process. Pupil dilation is an indirect index of arousal, modulated by the autonomic nervous system and activity in the locus coeruleus-noradrenergic system. In the current study, pupil dilation was recorded while 8- to 12- year old children (n = 71, 26 with a diagnosis of ADHD and 45 typically developing), viewed images of emotional faces. Parent-rated hyperactive/impulsive symptoms were uniquely linked to higher pupil dilation to happy, but not fearful, angry, or neutral faces. This was not explained by comorbid externalizing symptoms. Together, these results suggest that hyperactive/impulsive symptoms are associated with hyperresponsiveness to approach-related emotional cues across a wide range of symptom severity.

Subconcussive Head Impacts and Neurocognitive Function Over 3 Seasons of Youth Football

OBJECTIVE

To determine the association between repetitive subconcussive head impacts and neurobehavioral outcomes in youth tackle football players.

METHODS

Using helmet-based sensors, we measured head impacts for 3 consecutive seasons of play in 29 male players age 9-11. Cumulative impact g's were calculated. Players completed a battery of outcome measures before and after each season, including neuropsychological testing, vestibular-ocular sensitivity, and self- and parent-reported measures of symptoms and attention-deficit hyperactivity disorder (ADHD).

RESULTS

Average cumulative impact over 3 seasons was 13 900g. High-intensity hits predicted worse change for self-reported social adjustment (P = .001). Cumulative impact did not predict change in any of the outcome measures. History of ADHD, anxiety, and depression predicted worse change for self-reported symptoms and social adjustment, independent of head impacts. When players were stratified into 3 groups based on cumulative impact across all 3 seasons, differences in outcome measures existed prior to the start of the first season. These differences did not further increase over the course of the 3 seasons.

CONCLUSION

Over 3 consecutive seasons of youth tackle football, we found no association between cumulative head impacts and neurobehavioral outcomes. Larger sample sizes and longer follow-up times would further assist in characterizing this relationship.

A novel multidimensional questionnaire for the assessment of emotional dysregulation in adolescents: Reactivity, Intensity, Polarity and Stability questionnaire-youth version (RIPoSt-Y)

BACKGROUND

The failure to regulate emotions, namely emotional dysregulation (ED), is a relevant construct in adolescent psychiatry, in terms of prognostic and developmental implications. We developed and validated a novel self-report questionnaire for the assessment of ED, the RIPoSt-Y, both in clinical and non-clinical samples.

METHODS

Items selection and subscales construction were conducted on healthy controls (n=374), while test-retest reliability was evaluated in a subsample (n=72); internal consistency was examined both in the control group and in two clinical samples, respectively including patients with Bipolar Spectrum Disorders (BSD; n=44) and ADHD (n=34). Construct, concurrent and convergent validity were also assessed.

RESULTS

Thirty-one items were finally retained, and three subscales were identified (Affective Instability, Emotional Reactivity, Interpersonal Sensitivity). Test-retest was significant for each subscale with moderate-to-good correlations, and internal consistency showed good-to-excellent coefficients. Construct validity was supported by significant differences between patients and controls and gender-related differences. Concurrent validity was confirmed through significant associations with two subscales of the CHT-Q, while convergent validity proved to be significant with the CBCL/YSR dysregulation-profile. Cut-offs were also computed to discriminate clinically significant scores of ED.

LIMITATIONS

The use of a school-based survey to recruit controls could have biased our results; gender distributions between clinical and non-clinical samples were significantly different.

CONCLUSIONS

Our novel questionnaire proved to be a valid and reliable tool able to assess the presence of ED in youths and to characterize this fundamental construct in its multidimensional facets.

The association between adverse childhood experiences and mental health problems in young offenders

High rates of adverse childhood experiences (ACEs, e.g., abuse and neglect) have been found in young offenders. Furthermore, ACEs seem to increase the risk of developing relevant mental health problems, in non-offending juveniles and adults. However, this association has only seldomly been addressed in offending juveniles and young adults. The present study aimed at evaluating the prevalence of ACEs and mental health problems as well as their association within a sample of male and female young offenders. Altogether, 161 adolescent and young adult offenders (16.8% females) from the youth detention center Worms (Germany) filled out questionnaires concerning ACEs and mental health problems with a focus on attention-deficit/hyperactivity disorder and intermittent explosive disorder. Considerable rates of mental health problems were found, e.g., a prevalence of 35.9% was found for intermittent explosive disorder. Furthermore, a greater proportion of the female offenders fell into the clinically significant category for somatic complaints, anxiety/depression, and attention problems than the male offenders. Female young offenders also reported more frequently about all forms of ACEs compared to the male offenders. Latent class analysis defined three subtypes of young offenders depending on their individual ACE patterns: (1) low ACEs, (2) mainly neglectful ACEs, and (3) multiple ACEs. ACEs were significantly associated with the occurrence of both internalizing and externalizing mental health disturbances, with the multiple-ACE subtype being most likely to report about significant mental health problems. The results of the present study point towards the relevance to routinely assess ACEs in young offenders to identify possible precursors of mental health problems and of future criminal behaviors.

Brain voxel-based morphometry correlates of emotion dysregulation in attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) has a high prevalence of co-occurring with emotion dysregulation (ED). Youths with ADHD and ED are more likely to have increased functional impairment. There is accumulating research on defining the features, behavioral, and physiological manifestations of ED, but there are currently few studies elucidating neuroanatomical correlations of ED in ADHD. Structural magnetic resonance imaging data from 118 children (aged 7-18 years) with ADHD (50 ADHD+high ED, 68 ADHD+low ED), and 104 typically developing controls (TDC) were processed using voxel-based morphometry. We used both dichotomous and continuous indices of ED to examine the possible correspondence between ED and ADHD. Relative to ADHD+high ED, ADHD+low ED had greater gray matter (GM) volumes over the left anterior prefrontal cortex (PFC). ADHD+low ED and ADHD+high ED shared a negative association of ED levels with the left middle temporal pole GM volume. TDC and ADHD+low ED also shared negative relationships of ED levels with the right temporal volume, and positive relationships with the left dorsolateral PFC volume. Besides, ED-by-group interactions were also noted. Specifically, medial PFC GM volumes increased and decreased with ED severity in ADHD+low ED and ADHD+high ED, respectively; and left cerebellum Crus GM volumes decreased and increased with ED severity in ADHD+low ED and ADHD+high ED, respectively. Our findings add to the evidence that some specific neural correlates are underpinning ED across ADHD and TDC. These findings suggest the importance of incorporating ED problems when considering heterogeneity in studies of ADHD.

Verbal working memory and processing speed: Correlations with the severity of attention deficit and emotional dysregulation in adult ADHD

Objectives

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), emphasizes symptoms severity with regard to the diagnosis of attention deficit hyperactivity disorder (ADHD). Many clinicians use neuropsychological test results as objective measures of cognitive functions as part of the diagnostic work‐up. The aim of this study was to investigate whether the psychometric test results regarding verbal working memory and processing speed are useful as indicators of the severity of attention deficits and emotional dysregulation in adults with ADHD.

Methods

This observational cross‐sectional clinical study included 418 adults diagnosed with ADHD according to the DSM‐5. Attention deficit severity was defined based on the inattentive subscale of the Adult ADHD Self‐Report Scale. Emotional dysregulation was assessed with the Deficient Emotional Self‐Regulation scale. Verbal working memory was measured with the Working Memory Index (WMI), and processing speed was measured with the Processing Speed Index (PSI) from the Wechsler Adult Intelligence Scale, third edition.

Results

The full‐scale intelligence quotients of the participants were in the normal range, with expected reductions in verbal working memory and processing speed. Only processing speed was associated with attention deficits (β = −.056, p = .003). The association between the psychometric test result for verbal working memory and processing speed and that between the severity of attention deficits and emotional dysregulation were weak (R² < .1) and mostly non‐significant.

Conclusion

The psychometric index scores for verbal working memory (WMI) and processing speed (PSI) seem to have limited utility as indicators of the severity of attention deficits and emotional dysregulation in adult ADHD patients.

Adult ADHD and romantic relationships: What we know and what we can do to help

It has been widely maintained that enduring and healthy romantic relationships are critical to quality of life in adulthood, and can buffer the impact of adversity, including psychological disorder. Unfortunately, much research points toward adults with attention-deficit hyperactivity disorder (ADHD) having short-lived and discordant romantic relationships. Despite this ample evidence, relatively little research has focused on identifying specific factors that may strengthen or explain their relational difficulties, which would have obvious relationship distress prevention and intervention implications. The current study reviews the state of the literature on romantic relationships in adults with ADHD, including differences that have been established between ADHD and non-ADHD populations as well as distal and proximal factors that appear to increase risk of relationship distress of adults with ADHD. Finally, notable gaps in the literature are identified and implications are raised with regards to prevention and intervention efforts designed to address functional impairment in adults with ADHD.

An observational study of emotion regulation in children with Tourette syndrome

BACKGROUND

Explosive outbursts occur in 25%-70% of children with Tourette syndrome (TS) and may cause more distress than the tics themselves. Previous studies have indicated that a comorbid diagnosis of attention-deficit/hyperactivity disorder (ADHD) is associated with emotional dysregulation in TS; however, this relationship has almost exclusively been studied using parent-reported questionnaires.

METHODS

We examined emotion regulation (ER) with an observational measure in 150 medication-naïve children aged 7-12 allocated to four groups: Forty-nine children with TS, 23 children with ADHD, 16 children with TS + ADHD, and 62 typically developing controls. We assessed participants' ER ability, as well as parent-child interactions in the context of a complex puzzle task, and coded the observed behavior with the Tangram Emotion Coding Manual (TEC-M). We examined group differences in ER, as well as associations between ER and severity of symptoms pertaining to TS and ADHD.

RESULTS

Children with TS did not differ from controls in their ER ability. However, children with ADHD and TS + ADHD had more problems with ER than those with TS only and controls. Finally, parents of children with ADHD displayed more tension during the experimental task. ER ability was not associated with tic severity nor premonitory urges; however, better ER ability was associated with less severe symptoms of ADHD.

CONCLUSIONS

This study is the first to evaluate ER with an observational, clinician-rated measure in a controlled social setting in children with TS. Our findings support earlier questionnaire-based studies by showing impaired ER in children with TS + ADHD, but not in children with TS without comorbidity. These findings inform our understanding of the phenomenology of emotional dysregulation in TS and the role of comorbid disorders.