Motivation and emotion/Book/2024/ADHD and emotional regulation

ADHD and emotional regulation:
How does ADHD affect emotional regulation and how can this be managed?

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Overview

Figure 1. Fire.

Imagine

... something horrible has happened. A ferocious bushfire has torn through your property, leaving pile of rubble where your home once stood. Your family are alive and well, however, everything you own has been destroyed. This disaster rattles you. You're angry and heartbroken. Attempting to process these emotions, you seek ways to cope. Will you lash out at family members, binge drink alcohol, maybe run away? Or will you reach out to loved ones for support, reappraise the situation, and practice mindfulness?

Emotional regulation is like a muscle. It's a set of strategies we build and exercise throughout the lifespan to cope with the love, loss, joy, and fear associated with being human. Emotional regulation is an important area of study as well-developed emotional regulation skills can lead to happiness and health, whereas deficits can lead to maladaptive coping, poor mental health outcomes and antisocial behaviour.

People with ADHD are vulnerable to such deficits. Increased emotional sensitivity and executive function deficits can make emotions feel bigger, and strategies more difficult to access. This can lead to increased reliance on maladaptive coping strategies and poorer predicted outcomes.

However, there are treatments and strategies available to assist those with ADHD.

Focus questions:

What is emotional regulation and why is it important?
What is the relationship between ADHD and emotional regulation?
What emotional regulation strategies are recommended for those with ADHD?

Emotional regulation and its importance

Emotional regulation refers to the processes involved in monitoring, evaluating and modifying one's emotions (Thompson, 1994).

Stages of emotional regulation

Figure 2. Stages of emotional regulation according to Gross (1998)

One of the most prominent theories of emotional regulation is the process model, first published by Gross (1998; see Figure 2). The stages of the process model of emotional regulation (Gross, 1998) are listed in Table 1.

**Table 1.** Process model of emotional regulation
Situation Selection	Making a decision to approach or avoiding certain situations or stimuli. E.g. avoiding someone who often belittles you.
Situation Modification	Efforts made to alter the emotional impart of a stimuli or situation. E.g. if someone is acting in a way that irritates you, you could ask them to stop.
Attentional Deployment	Focus either given to or removed from an emotionally arousing stimuli. E.g. you may avoid thinking about something that makes you stressed, or you could ruminate on the situation and become increasingly upset.
Cognitive Change	Also referred to as 'appraisal'. This includes initial judgement as to whether the stimuli is deemed relevant (does this matter to me?), assumed implication (will it pose a threat?), and coping potential (can I handle it?).
Response Modulation	Often referred to as 'strategies'. The response stage of emotional regulation refers to behaviours a person utilizes once they feel the emotion. For example, if feeling stressed you may utilise mindfulness or drink a glass of wine to 'calm down'.

Capacity for emotional regulation

Emotional regulation skills are developed across the lifespan (Cole, 2014).

Extrinsic influences: Parents help an infant regulate their emotions by caring for them. Once in childhood, positive reinforcement and modelling become more relevant (Thompson, 1991), (Morris et al., 2007).

Consequences of emotional dysregulation

Emotion regulation deficits have been consistently linked to psychopathology in cross-sectional studies (McLaughlin et al., 2011).

Excessive attention can lead to rumination and exacerbation of negative emotions (Wadlinger & Isaacowitz, 2011).

Poor emotional regulation has been linked with negative health/social outcomes such as substance use disorders (Stellern et al., 2023), self harm (Slee et al, 2008) and increased aggression (Roberton et al., 2012).

Relationship between ADHD and emotional regulation

When first delving into the topic and searching for "ADHD emotional regulation", you will be confronted with an immediate reframing. Rather than articles related to "ADHD and emotional regulation", you'll instead find a plethora of information regarding ADHD and emotional dysregulation. This is the first hint that there might be an interaction here, and it may not be positive.

People with ADHD often exhibit symptoms of emotional dysregulation such as a hot temper, emotional lability, and over-reactivity (Retz, et al.,2012). A literature review undertaken by Shaw et al., (2014) concluded that 34–70% of adults with ADHD experience deficits in emotional regulation.

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by inattention and/or hyperactivity-impulsivity that interferes with functioning or development (American Psychiatric Association, 2013). It is estimated that prevalence of ADHD is approximately 2.5% worldwide (Simon et al., 2009).

ADHD Definition Breakdown
Inattention	Includes symptoms such as disorganisation and difficulty with focus.
Hyperactivity	Includes symptoms such as restlessness and excessive motor activity.
Impulsivity	Actions or decisions made quickly without forethought.

Bottom-up processing

Bottom-up processing refers to the generation of emotion based on the presentation of an external stimulus. This type of processing is often associated with activity from the amygdala (McRae et al., 2012). For example, you may be overwhelmed by an instant wave of fear when you see a snake slither across the floor. People with ADHD are prone to generating more intense emotions. A meta-analysis undertaken by by Graziano & Garcia (2016) found that children with ADHD had higher emotional reactivity, meaning the stimulus threshold required to illicit an emotional response was lower in children with ADHD than in their neurotypical peers. Discuss whether this has been shown in adults.

Top-down processing

Top-down processing refers to the regulation of emotion based on a more conscious appraisal of the stimuli. This process is related to executive function. Top-down processing is sometimes considered 'higher order' thinking as it recruits a wide range of brain regions, including the inferior frontal gyrus, medial frontal cortex, anterior cingulate cortex, supplementary motor area, and right temporoparietal junction. These brain regions are known to be involved in self regulation, action/response inhibition, and emotion processing (Langner et al., 2018). People with ADHD are known to have deficits in these executive neural networks (Christiansen et al., 2019).

Maladaptive emotional regulation strategies

People with ADHD are more likely to utilise maladaptive emotional regulation strategies than neurotypical peers (Barra et al., 2021). Avoidance is particularly prominent in the research (Torrente et al., 2014). Need to find other emotional regulation research featuring maladaptive strategies. Is there anything about drugs/alcohol?

ADHD has high comorbidity with habit-forming illnesses such as alcohol dependency and substance addiction (Ohlmeier et al., 2008), (Baker et al., 2012). However, neither study makes a link directly to emotional regulation, meaning this increased drug/alcohol use could be related to other features of ADHD.

Emotional regulation interventions for people with ADHD

Psychopharmacological treatments

Surman & Walsh (2022) undertook a systemic review and analysis of clinical trials investigating the affect of stimulant medication on emotional regulation in participants with ADHD. Methylphenidate (commonly known as Ritalin), Lisdexamfetamine (Vyvanse), and Atomoxetine (Strattera) have been found to improve emotional regulation. However, it was not concluded how or why that was the case. Future studies are required to determine whether emotional effects are due to change in the range or pattern of emotions individuals experience (bottom-up processing), or their ability to regulate expression of those emotions (top-down processing).

Mindfulness

Mindfulness is an active and focused awareness of one's surroundings and inner thoughts. Mindfulness has historically been used to treat anxiety and depression symptoms.

A pilot trial undertaken by (Mitchell, et al., 2017) found mindfulness practice assisted with emotional dysfunction in ADHD.

Cairncross & Miller (2020) undertook meta-analysis into mindfulness based therapies for ADHD and found that MBT was more effective for adults than children.

Reappraisal

Idk maybe there's a better one to add here. will reconsider.

Conclusion

Overall, available literature cements the relationship between ADHD and emotional regulation. Many sources recommend that emotional dysregulation should be added to the main diagnostic criteria of ADHD. This would perhaps lead to further studies into efficacy of emotional regulation interventions for those with ADHD.

Will flesh out conclusion further once content is finalised.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Baker, L., Prevatt, F., & Proctor, B. (2012). Drug and Alcohol Use in College Students With and Without ADHD. Journal of Attention Disorders, 16(3), 255–263. https://doi.org/10.1177/1087054711416314

Barkley, R.A. (2015). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th ed. New York: Guilford Publications.

Barra, S., Grub, A., Roesler, M., Retz-Junginger, P., Philipp, F., & Retz, W. (2021). The role of stress coping strategies for life impairments in ADHD. Journal of Neural Transmission, 128(7), 981–992. https://doi.org/10.1007/s00702-021-02311-5

Cairncross, M., & Miller, C. J. (2020). The Effectiveness of Mindfulness-Based Therapies for ADHD: A Meta-Analytic Review. Journal of Attention Disorders, 24(5), 627–643. https://doi.org/10.1177/1087054715625301

Christiansen, H., Hirsch, O., Albrecht, B., & Chavanon, M.-L. (2019). Attention-Deficit/Hyperactivity Disorder (ADHD) and Emotion Regulation Over the Life Span. Current Psychiatry Reports, 21(3), 17–17. https://doi.org/10.1007/s11920-019-1003-6

Cole, P. M. (2014). Moving ahead in the study of the development of emotion regulation. International Journal of Behavioral Development, 38(2), 203–207. https://doi.org/10.1177/0165025414522170

Graziano, P. A., & Garcia, A. (2016). Attention-deficit hyperactivity disorder and children’s emotion dysregulation: A meta-analysis. Clinical Psychology Review, 46, 106–123. https://doi.org/10.1016/j.cpr.2016.04.011

Gross, J. J. (1998). The Emerging Field of Emotion Regulation: An Integrative Review. Review of General Psychology, 2(3), 271-299. https://doi.org/10.1037/1089-2680.2.3.271

Langner, R., Leiberg, S., Hoffstaedter, F., & Eickhoff, S. B. (2018). Towards a human self-regulation system: Common and distinct neural signatures of emotional and behavioural control. Neuroscience and Biobehavioral Reviews, 90, 400–410. https://doi.org/10.1016/j.neubiorev.2018.04.022

McLaughlin, K. A., Hatzenbuehler, M. L., Mennin, D. S., & Nolen-Hoeksema, S. (2011). Emotion dysregulation and adolescent psychopathology: A prospective study. Behaviour Research and Therapy, 49(9), 544–554. https://doi.org/10.1016/j.brat.2011.06.003

McRae, K., Misra, S., Prasad, A. K., Pereira, S. C., & Gross, J. J. (2012). Bottom-up and top-down emotion generation: implications for emotion regulation. Social Cognitive and Affective Neuroscience, 7(3), 253–262. https://doi.org/10.1093/scan/nsq103

Mitchell, J. T., McIntyre, E. M., English, J. S., Dennis, M. F., Beckham, J. C., & Kollins, S. H. (2017). A Pilot Trial of Mindfulness Meditation Training for ADHD in Adulthood: Impact on Core Symptoms, Executive Functioning, and Emotion Dysregulation. Journal of attention disorders, 21(13), 1105–1120. https://doi.org/10.1177/1087054713513328

Morris, A. S., Silk, J. S., Steinberg, L., Myers, S. S., & Robinson, L. R. (2007). The Role of the Family Context in the Development of Emotion Regulation. Social Development (Oxford, England), 16(2), 361–388. https://doi.org/10.1111/j.1467-9507.2007.00389.x

Ohlmeier, M. D., Peters, K., Wildt, B. T. T., Zedler, M., Ziegenbein, M., Wiese, B., Emrich, H. M., & Schneider, U. (2008). Comorbidity of alcohol and substance dependence with attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism (Oxford), 43(3), 300–304. https://doi.org/10.1093/alcalc/agn014

Retz, W., Stieglitz, R.-D., Corbisiero, S., Retz-Junginger, P., & Rösler, M. (2012). Emotional dysregulation in adult ADHD: what is the empirical evidence? Expert Review of Neurotherapeutics, 12(10), 1241–1251. https://doi.org/10.1586/ern.12.109

Roberton, T., Daffern, M., & Bucks, R. S. (2012). Emotion regulation and aggression. Aggression and Violent Behavior, 17(1), 72–82. https://doi.org/10.1016/j.avb.2011.09.006

Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. The American journal of psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966

Simon, V., Czobor, P., Bálint, S., Mészáros, A., & Bitter, I. (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. The British journal of psychiatry : the journal of mental science, 194(3), 204–211. https://doi.org/10.1192/bjp.bp.107.048827

Stellern, J., Xiao, K. B., Grennell, E., Sanches, M., Gowin, J. L., & Sloan, M. E. (2023). Emotion regulation in substance use disorders: a systematic review and meta‐analysis. Addiction (Abingdon, England), 118(1), 30–47. https://doi.org/10.1111/add.16001

Surman, C. B. H., & Walsh, D. M. (2022). Do Treatments for Adult ADHD Improve Emotional Behavior? A Systematic Review and Analysis. Journal of Attention Disorders, 26(14), 1822–1832. https://doi.org/10.1177/10870547221110926

Thompson, R. A. (1991). Emotional Regulation and Emotional Development. Educational Psychology Review, 3(4), 269–307. https://doi.org/10.1007/BF01319934

Wadlinger, H. A., & Isaacowitz, D. M. (2011). Fixing our focus: training attention to regulate emotion. Personality and social psychology review: an official journal of the Society for Personality and Social Psychology, 15(1), 75–102. https://doi.org/10.1177/1088868310365565

External links

A new strategy to cope with emotional stress (MIT News)
Emotional dysregulation is part of ADHD. See how psychologists are helping (American Psychological Association)
Emotion Regulation (Psychology Today)