Journal of ADHD

69 Pages·2010·3.58 MB·English

Volume 1, Number 4, 2010
Journal of ADHD
& Related Disorders
Editors: Joseph Biederman, MD • Stephen V. Faraone, PhD
Special Issue
Deficient Emotional Self-Regulation in
Children and Adults With Attention-
Deficit/H0yper activity Disorder
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5 DeficiMent Emotional Self-Regulation in Adults With Attention-
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Dteficit/Hyperactivity Disorder (ADHD): The Relative Contributions
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e of Emotional Imipulsiveness and ADHD Symptoms to Adaptive
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E Impairmentus in Major Life Activities
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ht r Russeill A. Barkley, PhD, and Kevin R. Murphy, PhD
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py f 29 Tshe Use of Emotional Dysregulation as an Endophenotype for
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C ot D Genetic Studies in Adults With Attention-Deficit/Hyperactivity
N Disorder
Reid J. Robison, Fred W. Reimherr, Barrie K. Marchant, Doug Kondo,
Gholson J. Lyon, John Olsen, Doug Christopherson, Camille Pommerville,
Solongo Tuya, Amber Johnson, and Hilary Coon
39 A Pilot Study of Ecological Momentary Assessment of Emotion
Dysregulation in Children
Paul J. Rosen, PhD, and Jeffery N. Epstein, PhD
53 Emotional Dysregulation as a Core Feature of Adult ADHD:
Its Relationship With Clinical Variables and Treatment Response
in Two Methylphenidate Trials
Frederick W. Reimherr, MD, Barrie K. Marchant, MS, John L. Olson, MD,
Corinne Halls, MS, Douglas G. Kondo, MD, Erika D. Williams, MSW, and
Reid J. Robison, MD
www.adhdjournal.com
www.APSARD.org
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
JOURNAL OF ADHD & RELATED DISORDERS
EDITORS
Joseph Biederman, MD Stephen V. Faraone, PhD
Harvard University SUNY Upstate Medical University
Massachusetts General Hospital Syracuse, NY
Boston, MA
ASSOCIATE EDITORS
Lenard Adler, MD Aude Henin, PhD Luis Augusto Rohde, MD
New York University School of Medicine Massachusetts General Hospital Federal University of Rio Grande do Sul
New York, NY Boston, MA Porto Alegre, Brazil
Jay Giedd, MD Scott H. Kollins, PhD E.J. Sonuga-Barke, PhD
Brain Imaging Unit, Child Psychiatry Branch Duke University Medical Center University of Southampton
Bethesda, MD Durham, NC Southampton, UK
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Christopher J. Kratochvil,0 MD a
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University of Nebraska Mediac,a l Centceri
Omaha, NE c
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EDITORIALM BOAmRD
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Tobias Banaschewski, MD, PhD Frances Rudtnick Levin, MD Philip Shaw, BA, MB, BCh, PhD
p m o
Central Institute of Mental Health Columbiae Urniversity Collegie of Child Psychiatry Branch
Mannheim, Germany Phxycsicianso & Surgeonst National Institute of Mental Health
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Russell A. Barkley, PhD New ©Y ork StaCte Psychiabtric Institute Bethesda, MD
Medical University of South Carolina ht r New Yorki, NY
g r Mary V. Solanto, PhD
Charleston, SC riLawroence Lewtandowski, PhD
The CHaotshpiyt aLl .f oBr aSrirc,k PChhDildren C opyot f SyDriSaycrusasec uUsen, iNveYrsity The DMepouanrttm Seinnta oif MPseydcihcaial tCryenter
New York, NY
The Toronto Western Research Institute N James J. McGough, MD, MS
Toronto, Ontario, Canada
UCLA Semel Institute for Neuroscience & Mark Stein, PhD
Oscar G. Bukstein, MD, MPH Human Behavior University of Illinois at Chicago
University of Pittsburgh Medical Center
Los Angeles, CA Chicago, IL
Western Psychiatric Institute and Clinic
Jeffrey H. Newcorn, MD
Pittsburgh, PA
Ben Vitiello, MD
Mount Sinai Medical Center
David Coghill, MD National Institute of Mental Health
New York, NY
University of Dundee Bethesda, MD
Steven R. Pliszka, MD
Dundee, UK
Division of Child and Adolescent Psychiatry Timothy Wilens, MD
Sarah Durston, PhD
University Medical Center Utrecht University of Texas Health Science Center Harvard Medical School
Utrecht, The Netherlands San Antonio, TX Massachusetts General Hospital
Richard Rubin, MD Boston, MA
Jeff Epstein, PhD
Vermont Clinical Study Center
Cincinnati Children’s Hospital
Erik Willcutt, PhD
Medical Center Burlington, VT
Department of Psychology
Cincinnati, OH Steven A. Safren, PhD, ABPP
University of Colorado
Harvard Medical School
Michael Gordon, PhD Boulder, CO
Upstate Medical University Massachusetts General Hospital
Syracuse, NY Boston, MA Mark Wolraich, MD
Russell Schachar, MD, FRCP Child Study Center
Mara Hutz, PhD
Departamento de Genética University of Toronto University of Oklahoma Health
Instituto de Biociências The Hospital for Sick Children Sciences Center
Porto Alegre, Brazil Toronto, Ontario, Canada Oklahoma City, OK
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
JOURNAL OF ADHD & RELATED DISORDERS
DISCLOSURES
It is the policy of Excerpta Medica Inc. to require the disclosure of anyone who is in a position to control the content
of a publication. All relevant financial relationships with any commercial interests and/or manufacturers must be
disclosed to readers. The contributors to this publication disclose the following:
Faculty Member Corporation/Manufacturer Relationship
Russell A. Barkley, PhD Eli Lilly and Company; Janssen-Cilag; Speakers’ Bureau
Janssen-Ortho Inc.; Medicine; Novartis;
Shire Pharmaceuticals
Eli Lilly; Shire Consultant
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Eli Lilly (Canada) 1 l Expert Witness
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Adult ADHD Rating Scale (AaD, HD icni Adults: Royalties
What the Science Says, Guilfodridc Pubrlications)
e e
Doug Christopherson None M None
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Hillary Coon None pt m o None
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Jeffery N. Epstein, PhD None xc o t None
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Corinne Halls, MS None © C b None
ht r i
Amber Johnson TK rig o tr TK
Douglas G. Kondo, MD Noopnye f is None
C t D
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Gholson J. Lyon None None
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Barrie K. Marchant, MS None None
Kevin R. Murphy, PhD None None
John L. Olsen, MD None None
Camille Pommerville None None
Frederick W. Reimherr, MD Eli Lilly; Johnson & Johnson; Shire Research Support
Eli Lilly; Shire Consultant
Celgene Stock Ownership
Reid J. Robison, MD None None
Paul J. Rosen, PhD None None
Solongo Tuya None None
Erika D. Williams, MSW None None
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
JOURNAL OF ADHD & RELATED DISORDERS
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
JOURNAL OF ADHD & RELATED DISORDERS
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
Deficient Emotional Self-Regulation in
Adults With Attention-Deficit/Hyperactivity
Disorder (ADHD): The Relative
Contributions of Emotional Impulsiveness
and ADHD Symptoms to Adaptive
Impairments in Major Life Activities
Russell A. BARkley, PhD1; AnD kevin R. MuRPhy, PhD2
1Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina and SUNY
Upstate Medical University, Syracuse, New York; and 2Adult ADHD Clinic of Central Massachusetts,
Northborough, Massachusetts 0
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ABSTRACT di r
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Background: Recent reviews have argued that emoMtionalm impulsiveness (EI) and deficient emotional self-
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regulation are central components in attention-detficit/hyperactivity disorder (ADHD), not merely associ-
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ated features or the consequence of comorbiditeyr. i
Objectives: Our study has 2 aims: (1) toE xdcetermoine theu ftrequency/severity of EI in adults with ADHD
relative to these control groups; and (2) ©t o evaluCate theb degree to which EI contributed to impairment in
various domains of major life activitgihets beyro nd tharti made by severity of the traditional 2 dimensions of
ADHD (inattention, hyperactiviptyyr-iimpfulsoivity). st
Methods: We examined theC ofrequten cy andD sieverity of problems with EI in 3 groups: adults with ADHD
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(n = 146), clinical-control adults not diagnosed with ADHD (n = 97), and a community-control group
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(n = 109). Self- and other ratings of EI were utilized.
Results: Results indicated that adults with ADHD had significantly more EI than either clinical or com-
munity controls, whether by self- or other reports, and whether symptoms were studied individually or in
total. We also evaluated the extent to which EI contributed to the prediction of global ratings of self- and
other rated impairments in 10 different domains beyond the contribution made by the traditional 2 dimen-
sions of ADHD symptoms. EI uniquely contributed to 6 of 10 domains and overall impairment. We then
evaluated this issue using more detailed measures of occupational impairment, educational history, criminal
history, adverse driving outcomes, marital satisfaction, parenting stress, and offspring severity of ADHD,
oppositional defiant disorder, and conduct disorder. Severity of EI independently contributed to most mea-
sures of impairment beyond severity of the 2 ADHD symptom dimensions and, in many cases, was the only
predictor of some impairments.
Conclusions: Our results indicate that EI is as central a component of ADHD as are its 2 traditional
symptom dimensions. EI severity is not merely redundant with the other ADHD symptom dimensions, but
adds additional explanatory and predictive power to understanding various forms of adult impairment.
(J ADHD Relat Disord. 2010;1[4]:5–28) © 2010 Excerpta Medica.
Key words: emotional impulsiveness, attention-deficit/hyperactivity disorder, ADHD, adults, adaptive
impairment.
Accepted for publication October 5, 2009. 1877-5365
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
INTRODUCTION orders, dating back to the first medical descriptions
Attention-deficit/hyperactivity disorder (ADHD) is in 1798 by Crichton and later by Still (1902) up to
traditionally characterized as representing develop- 1976 (see Barkley 20102 for a review); current neu-
mentally inappropriate levels of symptoms in 2 di- ropsychological models of ADHD (combined type)
mensions of neuropsychological functioning: inat- that include poor emotional self-regulation as a key
tention and hyperactivity-impulsivity.1 Recent component8-12; current evidence from neuroimag-
reviews of the scientific literature, however, have ing studies that the prefrontal brain networks likely
challenged this conceptualization of ADHD on the involved in ADHD13-17 also include those that
basis that it excludes an equally central feature that serve to self-regulate emotions in the service of
involves emotional impulsivity and deficient emo- larger, longer-term goals (especially the linkage of
tional self-regulation.2-4 Emotional self-control is the lateral prefrontal cortex to the anterior cingulate
believed to comprise a 2-stage process that includes: cortex and subsequently the amygdala/limbic sys-
(1) the inhibition of strong emotional reactions to tem)18-21; and the small but growing body of evi-
events, and (2) the subsequent engagement of self- dence that symptoms of EI are frequently observed
regulatory actions that include self-soothing, refo- in association with ADHD, whether on rating
cusing attention away from the provocative event, scales or direc0t beha vioral observations.2-4
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reducing and moderating the initial emotion, and Barkley20 has aragued that there is great value in
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organizing the eventual emotional expression so the expal,i cit inccilusion of EI and subsequent deficits
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that it is more consistent with and supportive of in emdiotionral self-regulation in the conceptualiza-
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individual goals and long-term welfare.2,3,5-7 It is tioM n of mADHD beyond the arguments made previ-
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argued that deficits in both of these components tously. That is because it better explains the high
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of emotional self-control lead to impulsive emoe-r comorbidiity of ADHD with oppositional defiant
tional expression and the subsequent deficient Esxelcf- odisordeur t(ODD) and possibly other related disor-
regulation of those emotions. Both problems ©c an be C ders.b It also may better account for certain impair-
mapped directly onto the 2-dimensionagl hst tructru re mrients evident in ADHD not as readily apparent or
of ADHD and explain the existencpe yroif emfotoional steasily explained by the traditional 2-symptom di-
impulsiveness (EI) and its subseCqouent tp oor seDlfi- mensions now included in ADHD (inattention and
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regulation as additional core features of the disorder. hyperactivity-impulsivity). Such impairments may
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Deficits in behavioral inhibition (hyperactivity- include problems with peer relationships and social
impulsivity) in ADHD result in the expression of rejection, parent-child interaction conflicts and as-
raw, unmoderated, and strong initial emotional re- sociated parenting stress, driving anger and aggres-
actions (both positive and negative). Deficits in ex- sion, a greater risk of employment problems, mari-
ecutive functioning (inattention) interfere with the tal conflict and dissatisfaction, and offspring
subsequent effortful actions needed to downregulate behavioral problems, among others. All of these
and moderate the subsequent emotional state of the problems occur with greater frequency in ADHD
individual to make it more age-appropriate, socially than in control groups. Some evidence implies that
acceptable, and consistent with the individual’s they may be related to the degree of poor emotional
longer-term welfare.3,8,9 regulation evident in the disorder and not just the
The specific impulsive emotions evident in inattention and hyperactivity-impulsivity.2,22 Yet
ADHD are impatience, low frustration tolerance, the body of evidence that bears on this issue is
hot-temperedness, quickness to anger or volatility, small, limited primarily to children with ADHD,
irritability, and a general propensity for being easily largely studied in research on peer relationships,
emotionally excitable.2,4 The lines of argument sup- and nearly absent in research on adults with the
porting the central placement of EI in the concep- disorder. Also, prior research typically did not in-
tualization of ADHD have been reviewed recently2 tentionally examine the relative contribution of EI
and include the long history of inclusion of EI in symptoms beyond the severity of ADHD symptoms
conceptualizations of ADHD and its precursor dis- alone to explaining variance in the domain of adap-
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
tive functioning under study. It is quite possible ing, and parenting, among others,22 we have a
that EI symptoms do not explain any further vari- unique opportunity in the present study to evaluate
ance in impairments in major life activities than the contribution of EI symptoms to impairment in
those already accounted for by ADHD severity. Af- these domains. We did not have measures of the
ter all, if the 2 components of EI and emotional deficient emotional self-regulation component and
self-control map onto the 2-dimensional structure so this must be left to future research to
of ADHD, then the contributions of the former may investigate.
already be included in measures of ADHD symptom
severity. The former EI would therefore add little or METHODS
no additional utility to explaining or predicting Participants
variance in adaptive impairments beyond the tradi- Three groups of participants were used: (1) ADHD:
tional 2 dimensions now included in ADHD. 146 adults clinically diagnosed with ADHD; (2)
We do not believe this is the case, however, and clinical controls: 97 adults evaluated at the same
we hypothesize that, given the limited available clinic but not diagnosed with ADHD; and (3) com-
evidence, symptoms of EI make separate, additional munity controls: 109 adult volunteers from the local
contributions to impairment in various major life communi0ty. Bot h the ADHD and clinical-control
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activities beyond just the 2 recognized dimensions groups 0were aobtained from consecutive referrals to
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of ADHD symptoms. The present study therefore the aA, dultc AiDHD Clinic in the Department of Psy-
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sought to examine this issue more thoroughly, us- cdihiatry rat the University of Massachusetts Medical
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ing not only large samples of both adults with M Schmool, Worcester, Massachusetts. The community-
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ADHD and a general community of adults tradti- control group was recruited from advertisements
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tionally included in typical research, but alesro a postedi throughout the medical school lobbies and
clinical-control group of adults not diagnoEsexdc witho fromut periodic advertisement in the regional newspa-
ADHD but having other psychiatric diso©r ders. TChe pber. The project was reviewed and approved by the
latter group was self-referred to thgeht samre adult riUniversity of Massachusetts Institutional Review
ADHD clinic as that used to rpeycrriuit ftheo ADHsDt Board for Research on Human Participants, and all
sample and believed they may Choave hatd ADHDDi, but participants signed statements of informed consent.
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this group did not receive a subsequent clinical di- To be eligible, all subjects were required to have
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agnosis of such. Thus, they comprise a better con- an IQ of 80 or higher. They also had to have no evi-
trol group than just a general community sample in dence of deafness, blindness, or other significant
helping to control for referral biases that may have sensory impair ment; significant and obvious brain
affected the nature of the adult ADHD sample. damage or neurological injury, or epilepsy; signifi-
Such a clinical group also permits a better determi- cant language disorders that would interfere with
nation of the degree of specificity of EI symptoms comprehension of verbal instructions in the proto-
associated with ADHD beyond that seen in other col; a chronic and serious medical condition such as
clinical outpatient disorders. Our study, therefore, diabetes, thyroid disease, cancer, heart disease, etc;
had 2 aims: (1) to determine the frequency/severity or a childhood history of mental retardation, au-
of EI in adults with ADHD relative to these control tism, or psychosis. To be placed in the ADHD
groups; and (2) to evaluate the degree to which EI group, clinic-referred participants had to meet the
contributed to impairment in various domains of Diagnostic and Statistical Manual of Mental Disorders,
major life activities beyond that made by severity of Fourth Edition (DSM-IV) criteria for ADHD,1 ex-
the traditional 2 dimensions of ADHD (inatten- cepting the age of onset criterion, as judged by an
tion, hyperactivity-impulsivity). Having previously experienced clinical psychologist using a structured
conducted an extensive evaluation of the impair- interview for ADHD created by the authors. For
ments associated with ADHD across many major more information on the process used in making
life activities such as education, occupation, driv- these clinical judgments, see Barkley et al.22 Par-
ing, money management, crime, marriage and dat- ticipants in the clinical-control group were evalu-
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Journal of ADHD & Related Disorders  Vol. 1, No. 4
ated at this same clinic but did not receive a clinical measure and, if significant, used it as a covariate.
diagnosis of ADHD. The ADHD group had significantly less education
No precise age of symptom onset producing im- (14 years) than the 2 control groups (clinical = 16
pairment was required for placement within the years; community = 15 years), a finding consistent
ADHD group, as one purpose of this study, report- with prior research on the impact of ADHD on the
ed elsewhere,22 was to examine the value of specify- educational outcomes of children followed to adult-
ing various age ranges of onset for the diagnosis of hood.22 The groups did not differ in their IQ scores,
ADHD in adults. Also, the results of prior studies but the clinical group had a significantly higher oc-
do not support the validity of the age of onset of cupational index than the other 2 groups on the
7 years currently included in the DSM-IV diagnos- Hollingshead Index of Social Position (unpublished
tic criteria for ADHD.22,23 All had the onset of data, A.B. Hollingshead, 1975). The groups did not
their symptoms prior to age 21 years; mean age of differ significantly in the percentage who were cur-
onset was 7 years. Of the 146 adults assigned to the rently employed (ADHD, 73%; clinical, 71%;
ADHD group, 30 were inattentive types (21%), community, 77%). The groups differed significant-
6 were residual (4%), and 110 were combined types ly in gender composition (c2 = 11.60; P = 0.003),
(75%) according to clinician diagnosis. with the ADH0D gro up having a significantly high-
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The clinical-control group comprised patients not er composi0tion ofa males than the 2 control groups
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clinically diagnosed as having ADHD. The primary (ADHDa,, 68%c imale and 32% female; clinical, 56%
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diagnoses given by the clinician to members of this maled iand 4r4% female; community, 47% male and
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group were varied, but comprised the following: an- 53M% femmale). This finding is similar to many stud-
xiety disorders (43%), drug use disorders (15%), ta ies of adults wnith ADHD,24,25 where the ratio of
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mood disorders (12%), learning disorders (4%), parte-r males:femiales is 2:1. As a result, in any group com-
ner relationship problems (4%), adjustment disorEdxecrs oparisonus tconducted here, sex is used as a second fac-
(4%), personality disorders (1%), and ODD© (1%); C tor abfter that of the group in the statistical analyses.
17% of these subjects received no diagnosgish.t r Aris for the ethnic composition of the groups, 94% of
The community-control group copnysriistedf ofo rela- steach group identified themselves as European-
tively normal adults drawn fromC tohe lotc al centDrail American (Caucasian) descent.
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Massachusetts region via advertisements. To be eli- Upon enrollment, 17% of the ADHD group,
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gible for this group, subjects must have met the 30% of the clinical group, and none of the commu-
criteria noted earlier for all participants. In addi- nity group were treated with psychiatric medica-
tion, they had to have a score on the Adult ADHD tion. To evaluate the potential effect that medica-
Rating Scale (see Measures—Interviews and Rating tion status may have had on our results, we
Scales) based on current symptoms (by self-report) compared those ADHD cases that were on medica-
below the 84th percentile (within +1 SD of mean) tion with those not on medication in the following
for their age (using norms reported in Barkley and measures: frequency of their ADHD symptoms
Murphy24). Community controls also had to be free from the interview, age of onset, number of domains
of any ongoing medication for treatment of a medi- of impairment from the interview, number of child-
cal condition or psychiatric disorder that could be hood ADHD symptoms (interview), total score for
judged to interfere with the measures to be col- ADHD symptoms from self-ratings in adulthood
lected here. and in childhood, self-rated impairment total scores
The demographic characteristics of our 3 groups on these same scales, total score for ADHD symp-
have been previously reported.22 Participants in the toms from ratings provided by others for both cur-
ADHD group were significantly younger (mean rent and childhood behavior, and total impairment
age, 32 years) than that of the other 2 groups (clini- scores provided by others for both current and
cal = 37 years; community = 36 years). Therefore, childhood functioning. None of these comparisons
in all of the analyses of continuous measures con- were significant. We conducted the same analyses
ducted on these groups, we correlated age with the for the subjects in the clinical-control group who
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