Study: Emotional Dysregulation in Emerging Adult ADHD and Practical Implications

Attention-Deficit/Hyperactivity Disorder (ADHD) has been primarily studied through the lens of inattention and hyperactivity/impulsivity. 

However, a growing body of research, including Goh et al. (2024), emphasizes the role of Emotional Dysregulation and Unawareness (EDU) in ADHD, particularly during the transition to emerging adulthood. This phase, defined as ages 18-29, is marked by increased functional impairment and the risk of internalizing problems such as depression and anxiety.

The study by Goh and colleagues sought to examine the incremental validity of EDU in emerging adults with ADHD, aiming to clarify its role in explaining the disorder's link with these impairments. Using machine learning techniques the researchers seek to uncover new dimensions of this link and ultimately to refine ADHD assessment protocols.

Methodology

The study involved 1,539 college students with self-reported ADHD diagnoses.

These students were assessed through various questionnaires that measured ADHD symptoms, emotional dysregulation, and the presence of co-occurring internalizing problems such as depression and anxiety.

Through random forest machine learning analysis, the researchers sought to determine whether EDU, when considered alongside traditional ADHD symptoms, improved the accuracy of predicting functional impairment and internalizing issues.

Emotional Dysregulation was broken down into multiple dimensions, including Limited Access to Emotional Regulation Strategies and Non-Acceptance of Emotional Responses, which were key to the study’s conclusions.

Key Findings

1. Incremental Validity of EDU: The study found that incorporating EDU into the classification of ADHD significantly improved the model's ability to predict impairment and internalizing problems. The inclusion of EDU dimensions boosted the classification accuracy, especially regarding domains such as social impairment, life skills, and self-concept.
2. Limited Access to Emotion Regulation Strategies: Among the various dimensions of EDU, Limited Access to Emotion Regulation Strategies was the most significant in predicting internalizing issues such as depression and anxiety. This dimension also ranked highly in explaining other impairments, surpassing hyperactivity/impulsivity as a key indicator.
3. Work Domain Challenges: Despite the generally high classification accuracy of the ADHD+EDU model, it performed less well in predicting work-related impairment. This suggests that other factors beyond EDU may play a more significant role in understanding work-related struggles in adults with ADHD.
4. Gender and ADHD Symptomatology: The study highlighted that while both males and females experience ADHD, females often report higher levels of emotional dysregulation, which might explain the higher co-occurrence of internalizing problems among women with ADHD. This finding calls for more gender-sensitive diagnostic criteria and interventions.

Practical Implications

1. Refining ADHD Assessments: One of the most significant takeaways from this study is the potential to refine ADHD diagnostic criteria by including assessments of emotional dysregulation. Currently, ADHD assessments often focus solely on inattention and hyperactivity/impulsivity. By integrating measures of emotional dysregulation, particularly Limited Access to Emotion Regulation Strategies, clinicians could more accurately assess ADHD and its related impairments.
2. Tailored Interventions: Beyond diagnosis, the findings also suggest that interventions should focus on improving emotional regulation strategies in adults with ADHD. Cognitive Behavioral Therapy (CBT), often used to treat ADHD, could be modified to focus more on emotional regulation. Techniques that help individuals develop better strategies to manage emotional responses could alleviate not only emotional dysregulation but also reduce the risk of internalizing problems like anxiety and depression.
3. Addressing Work-Related Challenges: The poor performance of the model in predicting work impairment suggests that other factors, possibly related to executive functioning, time management, or organizational skills, need to be addressed. Employers could offer accommodations such as flexible work hours, task management tools, or executive functioning coaching to help individuals with ADHD thrive in professional environments.
4. Gender-Sensitive Approaches: Given that emotional dysregulation appears to play a more prominent role in females with ADHD, assessments and interventions should be gender-sensitive. Females may benefit from interventions that specifically target emotional awareness and regulation, areas where they are more likely to experience difficulties.

Conclusion

Goh et al. (2024) make a compelling case for the inclusion of emotional dysregulation as a critical factor in understanding and managing ADHD, particularly in emerging adulthood.

The study's use of machine learning offers an innovative approach to refining ADHD diagnostic tools, emphasizing the importance of EDU in predicting functional impairment and internalizing problems. Practical applications of this research point to the need for revised diagnostic protocols and tailored interventions that focus on emotional regulation strategies.

By addressing these dimensions, clinicians and employers alike can provide more meaningful support to individuals with ADHD during a crucial stage of development.

Goh, P. K., A. Wong, A. W. W., Suh, D. E., Bodalski, E. A., Rother, Y., Hartung, C. M., & Lefler, E. K. (2024). Emotional Dysregulation in Emerging Adult ADHD: A Key Consideration in Explaining and Classifying Impairment and Co-Occurring Internalizing Problems. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547241284829

A Critique of Gender Bias and the Overlooked Link Between Emotional Dysregulation and Executive Dysfunction in ADHD

While the study provides valuable insight into the core role that emotion dysregulation plays in ADHD as a whole, I've noticed that researchers often fall into the same trap of viewing ADHD from the very traditional view they may be challenging.

Here I've challenged two elements that may be useful considering in further iterations of these studies.

1. Gender Bias in Emotional Dysregulation: Subtype vs. Social Norms

The study highlights that women tend to report higher levels of emotional dysregulation than men, raising an important question: Is this disparity genuinely a result of gender-based differences in ADHD presentation, or could it be influenced by societal expectations that label women as "more emotional"?

Subtype Bias and Neglect of Male Emotional Dysregulation
Historically, ADHD subtypes have been unevenly studied, with a focus on hyperactivity/impulsivity more associated with males and less on the Inattentive subtype. This may contribute to an underreporting of emotional dysregulation in men, particularly those with the Inattentive subtype.

Emotional dysregulation may be expressed differently in men with Inattentive ADHD (e.g., internalized struggles, irritability, or low motivation), but societal norms and diagnostic tools may overlook these signs, focusing more on hyperactivity and impulsivity, which are more visibly disruptive.

Given the lack of attention to emotional dysregulation in males with Inattentive ADHD, it's plausible that this creates a bias in how emotional dysregulation is reported across genders.

Men might underreport or externalize their emotional struggles in ways not captured by the conventional diagnostic criteria. Thus, the assumption that women are more emotionally dysregulated could be an artifact of societal expectations and diagnostic limitations, rather than a clear subtype difference.

Social Convention Influence
Societal norms that frame women as more emotionally expressive could reinforce this gender bias in ADHD studies. Women may feel more comfortable reporting emotional symptoms, while men may downplay or suppress them due to cultural pressures around masculinity and emotional restraint.

This dynamic could skew findings toward an overrepresentation of emotional dysregulation in females, potentially leading to a subtype bias that overlooks how emotional dysregulation manifests differently in men, especially in those with Inattentive ADHD.

2. Work Impairment and Executive Dysfunction: The Role of Emotional Dysregulation

The study’s finding that the model performed poorly in predicting work impairment suggests a disconnect between emotional dysregulation and work-related executive dysfunction.

However, it seems plausible to argue that emotional dysregulation and executive dysfunction are intertwined, rather than separate pathways.

Two Separate Pathways vs. Interconnected Mechanisms
In ADHD, executive functions—such as task initiation, organization, and time management—are closely tied to emotional regulation. Emotional dysregulation can exacerbate executive dysfunction by heightening anxiety, frustration, or demotivation, all of which impede the brain's ability to perform executive tasks.

For instance, when someone is overwhelmed by emotional stress, their ability to prioritize tasks or focus on work may diminish, leading to work impairment that appears "executive" in nature but is, in fact, deeply rooted in emotional dysregulation.

The study might have artificially separated emotional dysregulation from executive dysfunction when these issues often co-occur in real-world contexts.

Emotional dysregulation could contribute to task paralysis, procrastination, or disorganization at work, but the model may not fully account for this overlap.

For example, failing to regulate emotions can lead to avoidance behaviors or a struggle with decision-making, directly impacting executive function.

Thus, it's critical to recognize that emotional dysregulation doesn't just accompany executive dysfunction but could also be a primary contributor.

The model's failure to predict work impairment may stem from this oversimplified separation, missing how emotional dysregulation underpins many executive difficulties in real-world work environments.

While we still have a long way to go, these studies are important to building datasets specific to adult ADHD, and my critiques are simply part of a conversation I hope will add some value to future work.