Emotional dysregulation is part of ADHD. See how psychologists are helping

More and more teenagers and adults are turning to social media to share their experiences living with attention-deficit/hyperactivity disorder (ADHD). Amid that flurry of digital content, one regular theme is the idea that people with ADHD feel emotions more intensely than others. Those big feelings, it turns out, are not just a TikTok phenomenon.

“In the last 15 years or so, we’ve come to realize that emotion dysregulation is a key component of ADHD,” said Paul Rosen, PhD, a clinical psychologist and ADHD researcher at Norton Children’s Behavioral and Mental Health, affiliated with the University of Louisville School of Medicine. ADHD is diagnosed as one of three subtypes: primarily hyperactive/impulsive, primarily inattentive, and a combined type. Research suggests that emotion dysregulation is present in all three subtypes, though people with the combined type appear to be at the greatest risk for emotional symptoms (Hirsch, O., et al., Scientific Reports, Vol. 9, No. 5639, 2019opens in new window). “Not all people with ADHD have [emotional] difficulty, but it’s very common,” Rosen added.

There is increasing recognition of the emotional difficulties that often go along with an ADHD diagnosis, in both adults and children. In Europe, an updated 2019 consensus statement published by the European Psychiatric Association listed emotion dysregulation as one of six fundamental features of ADHD in adults (Kooij, J. J. S., et al., European Psychiatry, Vol. 56, No. 1, 2019opens in new window). In the United States, however, ADHD is still defined by its keystone features of inattention, hyperactivity, and impulsivity. Although the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) lists emotion dysregulation as an “associated feature” that supports an ADHD diagnosis, the emotional symptoms still are not always appreciated by clinicians or researchers, said Sarah Karalunas, PhD, a professor of psychology at Purdue University. “There’s growing awareness of emotional dysregulation, but it’s still often overlooked,” she said.

[Related: An ADHD diagnosis in adulthood comes with challenges and benefits]

Yet emotion dysregulation can lead to troubling consequences for people with ADHD. During the Covid-19 stay-at-home orders, researchers reported an increase in average rates of depression, anxiety, inattention, and defiant symptoms among all adolescents. For most youth, those symptoms eased after lockdown orders were lifted. But youth with any subtype of ADHD who also had poor emotion regulation continued to experience significant negative mental health symptoms over time (Breaux, R., et al., Journal of Child Psychology and Psychiatry, Vol. 62, No. 9, 2021opens in new window).

“Emotion dysregulation in ADHD has a broad impact across a lot of areas of life,” said Elizabeth Bodalski, a fifth-year doctoral student in clinical community psychology at the University of South Carolina who studies emotion regulation difficulties associated with ADHD. She has found emotional difficulties help explain the presence of depressive symptoms and relationship impairments in adults with ADHD, and may also contribute to anxiety, poor friendship quality, and greater functional impairments overall (Bodalski, E.A., et al., Journal of Psychopathology and Behavioral Assessment, Vol. 41, No. 1, 2019opens in new window).

Nearly 1 in 10 children in the United States has been diagnosed with ADHDopens in new window, according to the U.S. Centers for Disease Control and Prevention. Just knowing that the disorder can bring intense emotional challenges can be a relief to people who have been struggling with outsize emotions for a long time. By understanding the science of ADHD and emotion dysregulation, psychologists can better support both children and adults living with the disorder.

In adults, emotion dysregulation is correlated with the severity of other ADHD symptoms (Beheshti, A., et al., BMC Psychiatry, Vol. 20, No. 120, 2020opens in new window). Yet prevalence estimates vary widely. One analysis of several studies concluded that 30% to 70% of adults with ADHD, and 25% to 45% of children with the disorder, have significant emotion dysregulation (Shaw, P., et al., The American Journal of Psychiatry, Vol. 171, No. 3, 2014opens in new window). Even more might experience emotional difficulties that do not rise to the level of clinically significant dysregulation. “We consistently see that about 25% of kids with ADHD have normative emotional expression, while the remaining 75% have some type of emotion dysregulation,” said Karalunas, who is following children with ADHD and emotion dysregulation in longitudinal studies.

That dysregulation can look different from person to person. Karalunas’s work suggests there are two common presentations in children with ADHD. Kids in an “irritable” subtype have higher levels of anger, sadness, and fear. Those in the “surgent” subtype display a kind of emotional impulsivity and overexuberance (Psychological Assessment, Vol. 31, No. 2, 2019opens in new window). While children with combined ADHD are unsurprisingly more likely than those with inattentive ADHD to fall into the surgent group, all three subtypes are at increased risk of dysregulation, Karalunas said. “The irritable children have a short fuse. They get upset about small things, and take a long time to let it go,” she added. “Surgent children’s excitement can overwhelm their thinking and lead them to act without thinking about the consequences.”

Those categories track with Rosen’s clinical observations of children with ADHD. The emotionally impulsive children react very strongly to both positive and negative events. “Their emotions are turned up to 11. It’s either the greatest day of their life or the worst day of their life,” he said. “But typically, those emotions are not very long-lasting and don’t necessarily have significant impacts on their well-being.” Kids in the irritable group seem to experience longer-lasting reactions to minor setbacks. They appear to be more seriously dysregulated, Rosen added, and may be at the greatest risk for mental health problems like anxiety and depression.

Some of the risk of emotion dysregulation seems to be related to the underlying neurobiology of ADHD. “We know the brain networks that regulate things like attention, behavior, and impulse control are affected in kids with ADHD. Those networks probably play a role in emotion regulation as well,” Karalunas said.

Yet research suggests that is just one of the processes underlying emotional difficulties in children with ADHD. Such kids do experience deficits in regulatory control of their emotions, according to a meta-analysis of cognitive functioning studies. But they may have even greater weaknesses in emotional reactivity, the analysis showed. Contrary to the more top-down process of emotion regulation, emotional reactivity is a more bottom-up process that drives when you feel an emotional response to a stimulus, the intensity of that response, and how long the feeling lasts. In other words, kids with ADHD may indeed feel bigger feelings than their peers (Graziano, P. A., & Garcia, A., Clinical Psychology Review, Vol. 46, No. 1, 2016opens in new window).

Neurobiology probably is not the only factor at play. Some of the emotional difficulties may be learned responses to living with ADHD in a world designed for neurotypical brains. For instance, many people with ADHD report having difficulty receiving negative feedback—a phenomenon sometimes called rejection sensitivity, or rejection-sensitive dysphoria. Rejection sensitivity is less well studied than other types of emotion dysregulation, but it is easy to imagine how it might develop. As a natural consequence of both hyperactive and inattentive behavior, kids with ADHD get a lot of negative attention from parents and teachers, Rosen noted. They are also more likely to face rejection from peers, perhaps because of habits like interrupting, making impulsive comments, or being lost in their own worlds. “When kids get all that negative attention, they respond with negative emotions, and it becomes a feedback loop,” Rosen said. “These are kids who are sensitive to criticism and things going badly because they get a lot of criticism and experience a lot of things going badly.”

The good news is that these emotional difficulties are treatable. Many people with ADHD take stimulant medications to control inattention and hyperactivity, though stimulants’ role in treating emotional symptoms is less clear. Research has found that methylphenidate, used in brand-name medications such as Ritalin and Concerta, reduces emotional symptoms in adults with ADHD (Surman, C. B. H., et al., Journal of Attention Disorders, Vol. 26, No. 14, 2022opens in new window). Research suggests that methylphenidate can also reduce the risk of irritability, anxiety, and euphoria in children with ADHD. By contrast, amphetamines such as the commonly prescribed Adderall worsened the risk of emotional lability in children (Pozzi, M., et al., Journal of Affective Disorders, Vol. 238, No. 4, 2018opens in new window).

However, research shows that ADHD medication regimens are not well followed by patients. According to a recent study in which researchers analyzed the prescription data of more than 1.2 million patients who started ADHD medication in nine countries, including the United States, more than half of all teenagers, young adults, and adults who received ADHD medication had stopped taking it within the first year. At the 5-year follow-up, only 50% to 60% of children and 30% to 40% of adolescents and adults had continued taking their medication (Brikell, I., et al., The Lancet Psychiatry, Vol. 11, No. 1, 2024opens in new window).

“While there may be some benefit from medication, there is definitely room for improvement,” Bodalski said. “That’s where behavioral interventions could be really helpful.” In a review of factors associated with emotion dysregulation, she and her colleagues found that adults with ADHD were more likely to use maladaptive strategies such as suppressing or avoiding their emotions, and less apt to use adaptive strategies like reappraising the situation (Journal of Attention Disorders, Vol. 27, No. 13, 2023opens in new window). That suggests there is room to help people learn better ways to cope with their feelings, Bodalski said.

Existing behavioral treatments for ADHD can be beneficial. A meta-analysis of nondrug interventions suggested that cognitive behavioral therapy, social skills training, and parent training programs can ease emotional symptoms in children with ADHD (Guo, C., et al., Journal of Attention Disorders, Vol. 26, No. 4, 2022opens in new window). While such therapies may be helpful, interventions that specifically address emotion dysregulation could go even further, Rosen said. He developed the Managing Frustration for Children with ADHD intervention to meet that need. The therapist-led program includes 11 weekly group sessions for children, plus one session for parents.

The program starts with teaching kids to understand what they are feeling. “Kids with ADHD often have difficulty recognizing their own emotions. Partly that’s because their emotions can be so strong that they don’t recognize more mild emotions. Also, they often avoid their emotions, because they’ve learned that emotions lead to bad things,” Rosen said. During the intervention, children also work on considering consequences, reframing situations, developing healthy coping skills, and avoiding cognitive pitfalls that often go along with strong emotions, such as blaming others, exaggerating, or assuming the worst.

In an open trial with 44 9- to 11-year-olds, Rosen and colleagues found that kids who completed the program experienced significant reductions in internalizing behaviors, externalizing behaviors, and emotion-regulation difficulties (Cognitive and Behavioral Practice, Vol. 26, No. 3, 2019opens in new window). He will share the intervention with any clinician interested in helping children and families struggling with the challenges of ADHD, he said. “A lot of these children feel like they’re really bad kids. It’s important to help them learn to work with their emotions instead of against them and to help parents learn how to help their kids.”

Meanwhile, Rosen said, ADHD is still underdiagnosed and undertreated—and its emotional symptoms are even less likely to be managed appropriately. While awareness of emotion dysregulation in ADHD is growing, there is far more work to be done. “Many clinicians were trained to consider comorbid diagnoses like depression or anxiety when people have problems regulating emotion, rather than thinking of them as part of ADHD. As a result, it’s often overlooked,” Karalunas said. By recognizing the challenges faced by people with ADHD, clinicians can guide them toward effective solutions, she added. “The environment is often challenging for these kids. They do sometimes have to work harder to fit in, but they can learn strategies to feel more in control.”