Emotion dysregulation is a core component of ADHD, study finds

An analysis of data from the Adolescent Brain Cognitive Development Study (ABCD) study found that emotion dysregulation mediates the association between a smaller surface area of the right pars orbitalis region of the inferior frontal gyrus and ADHD symptoms one year later. This finding suggests that emotion dysregulation is a core component of ADHD and may also serve as a pathway leading to the development of the disorder. The research was published in Nature Mental Health.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning. Individuals with ADHD often struggle to focus on tasks, organize activities, and regulate their impulses. Symptoms typically begin in childhood, though they can persist into adolescence and adulthood. Most often, the disorder is diagnosed when a child starts school, as the symptoms interfere with expected behaviors in school settings.

ADHD affects approximately 6%-7% of children and adolescents, but its causes are not fully understood. The predominant view is that ADHD results from a combination of specific cognitive impairments and motivational dysfunctions. However, these characteristics are absent in about 30% of ADHD cases, and they cannot reliably predict how ADHD symptoms will progress over time.

Study author Wenjie Hou and colleagues hypothesized that emotion dysregulation might represent a third neuropsychological pathway to ADHD, distinct from cognitive impairment and motivational dysfunction. The authors explain that critical brain regions for emotion regulation include the inferior frontal gyrus, the orbitofrontal cortex, the anterior cingulate cortex, the amygdala, and the ventral striatum. Many of these regions are not part of the classic cognitive control neural circuits previously linked to ADHD in other studies.

The researchers analyzed data from 672 individuals with ADHD who participated in the ABCD study, a large longitudinal study tracking brain development and mental health in 11,877 children from 22 sites across the United States.

Additionally, the researchers conducted a separate analysis using data from the ADHD-200 study, which included 263 individuals with ADHD and 409 children without the disorder. The participants in this group had an average age of 11-12 years.

Participants completed assessments of ADHD symptoms using the ADHD scale of the Child Behavior Checklist. Cognitive functioning was measured through a battery of seven cognitive tasks, while motivational dysfunction was assessed using the Reward Sensitivity Scale, adapted from the PhenX toolkit. Emotion dysregulation was reported by parents/guardians using the Difficulty in Emotion Regulation Scale. In the ABCD group, emotion dysregulation was assessed when the children were 13 years old, while cognitive and motivational data were collected when they were 12.

The researchers also used participants’ magnetic resonance imaging (MRI) data and white blood cell counts from the ABCD study. Gene expression in the cerebral cortex was analyzed using data from the Allen Human Brain Atlas.

The results showed that emotion dysregulation was not associated with cognitive performance or motivational dysfunction from the previous year. In the ABCD group, ADHD symptom severity was more strongly associated with emotion dysregulation than with cognitive performance or motivational dysfunction. Among the 350 children with very severe ADHD symptoms, 21% exhibited neither cognitive nor motivational deficits. Furthermore, children with persistent ADHD symptoms did not differ significantly in cognitive or motivational assessments from those whose symptoms had remitted. However, the group with persistent symptoms showed stronger emotion dysregulation scores, indicating that emotion dysregulation can be considered a core symptom of ADHD.

Analysis of neuroimaging data revealed that emotion dysregulation has a distinct neural correlate. Children with more severe emotion dysregulation tended to have a smaller surface area (but not cortical thickness) in the right orbital part of the inferior frontal gyrus.

The researchers tested a statistical model suggesting that a smaller surface area in this brain region leads to stronger emotion dysregulation, which, in turn, contributes to worse inattention symptoms. According to the model, while this pathway is plausible, there is also a direct link between inattention and the surface area of this brain region that is not mediated by emotion dysregulation.

The researchers also identified and tested similar statistical models linking the structural characteristics of specific brain areas to inattention through cognitive functioning and motivational dysfunction.

“We have shown, using a large sample and a second independent clinical sample, that emotion dysregulation is a core symptom and a route to ADHD, which may not respond to the current pharmacological treatments for ADHD,” the study authors concluded.

The study provides new insights into the neuropsychological underpinnings of ADHD symptoms. However, the design of the study does not allow for definitive cause-and-effect inferences to be drawn from the results.

The paper, “Emotion dysregulation and right pars orbitalis constitute a neuropsychological pathway to attention deficit hyperactivity disorder,” was authored by Wenjie Hou, Barbara J. Sahakian, Christelle Langley, Yuqing Yang, R. A. I. Bethlehem, and Qiang Luo.