The powers that be who publish the Diagnostic and Statistical Manual of Mental Disorders (DSM), including its latest offering published in 2013, have thus far given little credence to the importance of emotional symptoms in Attention Deficit Hyperactivity Disorder (ADHD). Nonetheless, parents and practitioners alike are all too aware of how commonly the symptoms of irritability, frustration intolerance, temper tantrums, anxiety and defiance complicate the presentation of ADHD. And behind the scenes there is an increasing research focus being afforded to this matter.
Of course, the prototypical disorder of emotional regulation is Bipolar Disorder. What complicates matters is the marked degree of symptom overlap between this mood disorder and ADHD: inattentiveness, talkativeness and impulsivity occur in both. There is a long and raging transatlantic debate about the frequency of this diagnosis and the appropriate diagnostic criteria to use. Generally, the North Americans accept criteria which are broader, resulting in a greater number of diagnoses than in Europe, where a stricter definition is favoured. When I was training in child psychiatry my professor was once moved to issue a temporary ban on the Bipolar diagnosis, in an attempt to help us see beyond the face-value of presenting symptoms.
Current trainees now have another diagnosis to invoke for children who are particularly irritable and moody, namely Disruptive Mood Dysregulation Disorder (DMDD), which made its debut in the latest edition of the DSM. On the topic of new terminology, Russell Barclay, one of the leading international experts in the field, has introduced the term emotional impulsivity as an important symptom in many children with ADHD, describing their low frustration tolerance and quickness to anger.
Further evidence for the association between ADHD and emotional dysregulation comes from a fascinating face-emotion processing study. For some time now we have known that youths with Bipolar Disorder and severe mood dysregulation are deficient in their ability to identify and label facial emotions. In this recently published study, a group of ADHD subjects were also included. This group showed hyperactivity of the amygdala (an area of the brain known to be important in emotion processing) when completing subjective fear ratings of neutral faces, relative to healthy controls. I was always taught that the prefrontal cortex and cerebellum were the important neuroanatomical correlates of ADHD; it now seems that the amygdala must now be included in that list.
There is a well-described association between ADHD and Oppositional Defiant Disorder (ODD); in fact, around 40% of boys with ADHD meet criteria for ODD. Emotional dysregulation is implicit in several of the diagnostic criteria for ODD. Three subtypes of ODD have been described, namely irritable (temper outbursts, easily annoyed, angry/resentful), headstrong (argues with adults, rule violations, purposefully annoying others, blaming others) and hurtful (spiteful, vindictive). Further research has confirmed that these dimensions are stable across time and are also prognostically important. Specifically, the irritable type is predictive of depression in the teenage years, and headstrong with Conduct Disorder (a severe behavioural disturbance) in later adolescence. Separate research has flagged the co-occurrence of ADHD, Oppositional Defiant Disorder/Conduct Disorder and anxiety/depression at the age of six as being highly predictive of depression and suicidal behaviour in later life.
Where does all this leave us? Any ADHD assessment should routinely investigate for associated emotional symptoms. Even if there are no co-existing disorders per se, emotional dysregulation may very well be an important part of the clinical picture. Furthermore, symptoms such as low frustration tolerance, irritability and emotional impulsivity should be targeted and then specifically monitored once treatment is instituted. This requires education of parents and caregivers, who may not recognise that these symptoms are part of the broader landscape of ADHD. Both the stimulants (such as Ritalin and Concerta) and atomoxetine (Strattera) commonly alleviate the emotional dysregulation associated with ADHD, although both classes of medication can also aggravate emotional symptoms in certain children.
Finally, as we have seen, the co-occurrence of ADHD and emotional disorders has very important treatment implications, underscoring the importance of identifying comorbid (co-existing) emotional disorders in patients with ADHD. This should result in a more targeted management approach which could proactively address symptoms before they develop into more severe problems in later adolescence or adulthood.
Dr Brendan Belsham is a child psychiatrist and author. His book, What’s the Fuss about ADHD? is available from amazon(click here)