ADHD Atten Def Hyp Disord DOI 10.1007/s12402-015-0175-0
ORIGINAL ARTICLE
The association of emotional lability and emotional and behavioral difficulties among children with and without ADHD Paul J. Rosen1 • Danielle M. Walerius1 • Nicholas D. Fogleman1 • Perry I. Factor1
Received: 26 February 2015 / Accepted: 1 May 2015 Springer-Verlag Wien 2015
Abstract Children with ADHD often demonstrate a pattern of emotional lability characterized by sudden and intense shifts in affect. Emotional lability has been linked to emotional and behavioral problems in children with and without ADHD, but few studies have examined emotional lability over time. This study examined the effects of emotional lability over time on the behavioral and emotional difficulties of children with and without ADHD using an ecological momentary assessment (EMA) methodology. One hundred and two children aged 8–12 years (56 with ADHD and 46 without ADHD) and their parents completed baseline measures of the children’s behavioral and emotional difficulties. Parents then completed a 28-day 3-times daily EMA assessment protocol to rate their child’s emotional lability. Results suggested that emotional lability was associated with internalizing and/or externalizing diagnoses independent of ADHD diagnostic status, but was not directly associated with ADHD. Hierarchical regression analyses supported ADHD diagnostic status as a moderator of the association of greater EMAderived emotional lability with children’s behavioral difficulties, such that greater emotional lability was associated with greater behavioral difficulties among children with ADHD but not among children without ADHD. Results indicated that greater emotional lability was directly linked with greater emotional difficulties and that this relation was not moderated by ADHD diagnostic status. Overall, this study suggested that emotional lability is related to emotional difficulties independent of ADHD, but is
differentially related to behavioral difficulties among children with and without ADHD. Keywords Ecological momentary assessment ADHD Emotional lability Emotion regulation Emotional difficulties Behavioral difficulties
Introduction Emotion dysregulation is a complex and multidimensional transdiagnostic process that has proven hard to define (Cole et al. 2004; Zeman et al. 2006). Indeed, the term ‘‘emotion dysregulation’’ actually encompasses a broad range of processes occurring both discretely (i.e., maladaptive and poorly inhibited emotional reactivity) and longitudinally (i.e., instability of emotional state over time). Differential patterns of emotion dysregulation have been implicated in a broad range of impairment in children (Eisenberg et al. 2010). Emotional lability has been identified as a specific maladaptive pattern of emotion regulation that may be both frequent and impairing in children with ADHD (e.g., Shaw et al. 2014; Skirrow et al. 2009; Sobanski et al. 2010). Emotional lability has been proposed as a mechanism linking ADHD to emotional and behavioral distress (Anastopolous et al. 2011; Rosen and Factor 2012); however, little research has examined how emotional lability differentially impacts children with and without ADHD. Emotional lability
& Paul J. Rosen
[email protected] 1
Department of Psychological and Brain Sciences, University of Louisville, 353 Life Sciences, Louisville, KY 40292, USA
Emotional lability describes a specific maladaptive pattern of emotion dysregulation characterized by excessively rapid and/or intense emotional variability that results in an inability to maintain a consistent emotional state (i.e.,
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emotional ‘‘homeostasis’’) over time (Gross 2007; Larsen 2000; Sobanski et al. 2010). Notably, the term ‘‘emotional lability’’ is distinct from the broader term ‘‘emotion regulation’’ in that it describes a pattern of emotional variation but does not posit underlying causes or use of specific regulatory mechanisms (Sobanski et al. 2010). Emotional lability occurs as both an immediate and longitudinal phenomenon. Specifically, emotional lability may manifest immediately through rapid and intense emotional reaction to an internal or external stimulus. The immediacy and strength of these emotionally labile reactions may inhibit the use of both ‘‘upstream’’ regulatory strategies (i.e., cognitive reappraisal) and ‘‘downstream’’ regulatory behaviors (i.e., emotional suppression; Sheppes and Gross 2011), making them difficult to effectively regulate. Longitudinally, a child who is more emotionally labile will have more frequent and more intense shifts in emotion, leading to a more unstable and unpredictable emotional state and greater deviation from emotional homeostasis (Larsen 2000). Children high in emotional lability are often described as hot-tempered, emotionally excitable, unpredictable, and irritable (Barkley 2010; Skirrow et al. 2009). Emotional lability has been linked to poor frustration tolerance, higher levels of positive and negative affect, internalizing and externalizing difficulties, and greater functional impairment among children with and without ADHD (Anastopolous et al. 2011; Silk et al. 2003; Skirrow and Asherson 2013). Emotional lability and ADHD Emotional lability has long been identified as a common area of difficulty among children with ADHD (Shaw et al. 2014). Numerous studies have demonstrated greater emotional lability among children with ADHD than children without ADHD. Children with ADHD demonstrate more intense reactions to emotionally evoking stimuli (Jensen and Rosen 2004), more difficulty inhibiting negative emotional reactivity (Walcott and Landau 2004), more emotional variability (Anastopolous et al. 2011), and more intense shifts in emotion (Norvilitis et al. 2000) than do children without ADHD. Indeed, emotional lability was considered to be a cardinal symptom in initial formulations of the disorder that eventually became ADHD (i.e., ‘‘minimal brain dysfunction’’; see Shaw et al. 2014), and numerous recent reviews have suggested that emotion lability be incorporated into updated conceptualizations of ADHD (i.e., Barkley 2010; Martel 2009; Rosen et al. 2013; Shaw et al. 2014). Similarly, a review of adult literature supported the notion that impulsivity and impaired executive control were linked to poorer control of emotional responding (Teper et al. 2013). Indeed, Barkley (2010) and Skirrow et al. (2009) have suggested that emotional lability
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may be a core mechanism underlying the high rates of emotion dysregulation among children with ADHD. Given this link, it is not surprising that emotional lability has been associated with multiple forms of impairment among children with ADHD, including oppositional behavior (Sobanski et al. 2010), emotional difficulties, functional impairment (Anastopolous et al. 2011), social difficulties, and aggression (Melnick and Hinshaw 2000). A study by Anastopolous et al. (2011) indicated that emotional lability accounted for the relation of ADHD to concurrent functional impairment and comorbid emotional and behavioral difficulties. Others have speculated that emotional lability and other patterns of emotion dysregulation may account for the substantial rates of comorbid behavior, mood, and anxiety disorders among children with ADHD (Barkley 2010; Martel 2009; Skirrow et al. 2009). Indeed, a recent meta-analysis by Shaw et al. (2014) indicated that a range of emotional regulation difficulties (including emotional lability) had a greater impact on well-being and impairment than either hyperactivity or inattention. Emotional lability may be particularly impairing for children with ADHD given the high levels of behavioral and attentional impulsivity inherent to ADHD (APA 2013). Models of effective emotion regulation illustrate the importance of selectively directing attention, inhibiting emotional responding, and engaging in active strategies (i.e., cognitive reappraisal) to regulate emotions (i.e., Gross 2002). Children who are prone to emotional lability as well as attentional and/or behavioral impulsivity may be likely to demonstrate both increased impulsive emotional reactivity and decreased ability to inhibit and modulate this reactivity. Research has supported this link, as response inhibition accounted for a significant portion of the variance in emotionally dysregulated behavior in a study of children with and without ADHD (Walcott and Landau 2004). It is possible that emotional lability impacts the emotional and behavioral functioning of children with ADHD (Anastopolous et al. 2011; Rosen and Factor 2012) due to an interaction of emotional lability with the core self-control and emotion regulation deficits inherent to ADHD rather than solely due to the effects of emotional lability in isolation. Similarly, emotional lability may serve as a predisposing risk factor for negative urgency (the tendency to engage in emotionally driven behavior when distressed) in children who have impulse control deficits (as is core to ADHD), as variable and intense emotional reactions may be particularly likely to lead to rash action and behavioral difficulties when coupled with behavioral impulsivity (Zapolski et al. 2010). Indeed, Marmorstein (2013) noted a link between negative urgency and ADHD symptomatology. Thus, it may be that the interaction of emotional lability and behavioral impulsivity leads to
The association of emotional lability and emotional and behavioral difficulties among…
decreased ability to engage in higher-order emotion regulation processes and inhibition of emotionally driven behavioral reactivity in the presence of emotional distress (i.e., Cyders and Smith 2008; Marmorstein 2013). This is not to imply that emotion regulation deficits as a whole have no negative impact among children without ADHD. Rather, it suggests that the pattern of dysregulation represented by emotional lability may only be significantly impairing when experienced in the presence of the higher rates of attentional and behavioral impulsivity fundamental to ADHD. Thus, it is possible that the relation of emotional lability to emotional and behavioral difficulties is indeed specific to ADHD due to (a) markedly higher rates of emotional lability among children with ADHD than children without ADHD and/or (b) substantially greater impairment resulting from emotional lability. Research questions Given the evidence of the link between emotional lability and emotional and behavioral difficulties in children with ADHD (Anastopolous et al. 2011; Rosen and Factor 2012) and the likelihood that emotional lability will lead to greater difficulty regulating emotions and behavior among children with greater behavioral impulsivity (Walcott and Landau 2004), we sought to examine the association between emotional lability and emotional and behavioral difficulties among children with and without ADHD. The following hypotheses were posited: 1.
2.
Children with ADHD would demonstrate significantly greater emotional lability over a 28-day at home data collection than would children without ADHD, and ADHD would moderate the association of emotional lability with emotional and behavioral difficulties, such that greater emotional lability would be linked to greater emotional and behavioral difficulties among children with ADHD but not among children without ADHD.
Methods Participants One hundred and two children aged 8–12 and their families participated in the present study. Participants in the current study included 56 children with ADHD (35 boys and 21 girls; M age = 9.61, SD age = 1.24) and 46 children without ADHD (25 boys and 21 girls; M age = 9.98, SD age = 1.28). All children in the study were recruited through advertisements distributed through local schools in a midsized midwestern metropolitan area. To ensure
consistency across the EMA protocol, children were only eligible for participation if they were resident in a single home (i.e., two-parent or single-parent family) full time over the course of the study. Additionally, given studies suggesting greater emotional lability and greater emotion regulation difficulties among children with ADHD-Combined Type (both clinical and subclinical presentations) than among children with the ADHD-Inattentive subtype (particularly as relates to the ‘‘Sluggish Cognitive Tempo’’ presentation of ADHD proposed by Barkley 2013 and others), children were only included within the ADHD arm of the study if they met full criteria for ADHD with at least three hyperactive–impulsive symptoms. The 3-symptom cutoff was selected to distinguish children with the ADHDCombined Type (and subclinical ADHD-Combined Type) presentation from children with the proposed ‘‘Sluggish Cognitive Tempo’’ presentation, given Barkley’s (2013) findings that children with the ‘‘Sluggish Cognitive Tempo’’ presentation averaged 1–2 hyperactive/impulsive symptoms. The Diagnostic Interview Schedule for Children (DISC; Shaffer et al. 2000) was used to assess ADHD status. All children in the ADHD group met full criteria for ADHD (Combined Type = 39, Inattentive Type = 17), while 29 children (51.7 %) in the ADHD group also met full criteria for oppositional defiant disorder (ODD) and 17 children (30.3 %) also met full criteria for at least one comorbid mood or anxiety (excluding specific phobia) diagnosis, consistent with literature, suggesting approximately 40–60 % of children with ADHD also met criteria for an externalizing diagnosis and approximately 30 % also met criteria for an internalizing diagnosis (Strine et al. 2006). Of note, only 32 children (57.1 %) of the ADHD group met criteria for any comorbid diagnosis, as 14 children met criteria for both internalizing (mood or anxiety) disorder and ODD (Conduct disorder was not assessed in the current study). Twenty-seven of the 56 children with ADHD were receiving medication treatment for ADHD concurrent to participation, medication status and dose remained consistent throughout the study for all participants. Children without ADHD represented a community sample rather than a healthy control sample; thus, children were not excluded from the study if they had symptoms of ADHD but did not meet criteria for diagnosis. Children in the non-ADHD group ranged from 0 to 5 symptoms of inattention (M = 1.26, SD = 1.80) and 0–5 symptoms of hyperactivity/impulsivity (M = 0.78, SD = 1.63). To ensure that the non-ADHD sample represented a true community sample rather than an artificial ‘‘healthy control’’ sample, children in the non-ADHD group were included in the study regardless of the presence of internalizing and externalizing disorders other than ADHD. Eight of the 47 children (17.0 %) in the non-ADHD group met criteria for
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at least one behavioral, mood, or anxiety (excluding specific phobia) diagnosis, with three children meeting criteria for oppositional defiant disorder, four children meeting criteria for a mood or anxiety disorder, and one child meeting criteria for both ODD and an anxiety disorder. The ethnicity of the sample was reflective of the area from which the population was drawn (United States Census Bureau 2010) with 63.7 % of the children described as non-Hispanic White/Caucasian, 25.5 % of the children described as non-Hispanic Black/African-American, 3.9 % of the sample described as Hispanic/Latino, 5.9 % of the sample described as having more than one racial/ethnic background, and 1.0 % described as Asian/ Pacific Islander. Procedures Baseline session Parents provided informed consent, and children provided assent prior to the initiation of any study procedures. During a baseline session, parents completed a structured diagnostic interview to assess for the presence of ADHD and other anxiety, mood, and behavior disorders (DISC; Shaffer et al. 2000). Parents and children also completed questionnaires regarding the child’s emotional and behavioral problems at the time of the baseline assessment. Parents received a 30-min ‘‘hands-on’’ training session using a demonstration version of the ecological momentary assessment (EMA) protocol. Parents and children each received compensation for completing the baseline session, with parents receiving $15 and children receiving a $25 gift card. EMA protocol Ecological momentary assessment (EMA) describes methodologies developed to collect real-time data from participants within the context of their typical daily lives (Stone and Shiffman 1994). EMA provides substantially more accurate response data than retrospective or summary report even when compared to end-of-day recall, as EMA ratings reflect ‘‘in the moment’’ report and are thus not influenced by cognitive recall biases (Stone and Shiffman 1994). Ebner-Priemer and Trull (2009) note that accurate assessment of patterns of emotional variability (such as emotional lability) requires methodologies that account for amplitude, variability, and temporal dependency. By allowing for repeated assessment over time, EMA methodologies allow the researcher to ‘‘map out’’ the variability of an individual’s emotional state to account for both frequency and intensity of emotional shifts (Ebner-Priemer
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and Trull 2009). EMA has been successfully used to assess emotional lability in children with and without ADHD in previous studies (Rosen and Factor 2012; Silk et al. 2003; Suveg et al. 2010; Whalen et al. 2009). EMA was thus selected to measure emotional lability in the current study. Parents completed EMA-based ratings three times daily for a period of 28 days (84 total time points). The 28-day assessment period was selected over the shorter (i.e., 1 week) periods utilized in previous studies (i.e., Whalen et al. 2009; Suveg et al. 2010) to ensure that assessments captured a full temporal range of emotional variation. All ratings were completed using Palm Tungsten E2 Personalized Data Assistants (PDA) that had been programmed using Purdue Momentary Assessment Tool software (PMAT; Weiss et al. 2004). The PDA set off alerts at three specific predetermined intervals (i.e., before school, after school, and evening) requested by parents to be compatible with the family schedule within specific windows (between 7 and 10 AM, between 3 and 6 PM, and between 6 and 9 PM). Specific predetermined alert times were chosen over random alerts as it was determined that random alerts were not practical for a parent-report protocol. Specifically, the parent-report EMA protocol in the current study required parents to be in the presence of their child when completing ratings so as to allow for accurate ‘‘spot-moment’’ ratings of emotional state. Accordingly, random assessment intervals were not practical given the typical variation in parent’s and school-aged children’s daily schedules. Parents were asked to complete ratings at all time points. Parents were instructed that one parent was to be responsible for completing all EMA intervals to allow for assessment of within-informant variability and that the parent EMA ratings were to be completed by the same individual as the baseline ratings. Parents indicated their identity (i.e., mother, father, and guardian) prior to completing ratings at each time. At each time point, parents were asked to complete a 10-item version of the Positive and Negative Affect Scale (PANAS)—Parent Report (Ebesutani et al. 2012) regarding their perception of their child’s positive and negative affect at the specific time of the assessment. Child-report EMA was not used in the current study as two previous studies have indicated that children are less likely to complete ratings during intervals in which they are experiencing negative emotion (Rosen et al. 2013; Rosen and Factor 2012) and thus are not appropriate for assessing emotional lability over time. To enhance participant adherence to the EMA protocol, parents were provided with compensation that was commensurate with their completion of EMA ratings. Specifically, each week parents could receive up to $10 ($40 total over the 4 weeks) dependent on the percentage of completed rating intervals. Parents were asked to attend
The association of emotional lability and emotional and behavioral difficulties among…
weekly follow-up visits to have data uploaded from the PDA and were allowed to request weekly changes to the schedule of alerts at these visits to enhance adherence and prevent disruption to the family’s daily life. All procedures within the present studies were approved by the local institutional review board. Measures Measures of overall emotional and behavioral difficulties The Diagnostic Interview Schedule for Children-Version IV, Parent Report (DISC-P; Shaffer et al. 2000) was used to conduct a diagnostic assessment of children in the study. The DISC-P is a diagnostic structured interview that provides a reliable means of assessing for the presence of psychological disorders in children. The DISC-P has demonstrated reliability and validity in a broad array of settings (Shaffer et al. 2000). The ADHD module of the DISC-P contains a question related to current use of psychotropic medications to treat ADHD (stimulant and nonstimulant); this question was used to assess active ADHD medication usage. The Child Behavior Checklist (CBCL; Achenbach 2001) was used to assess parent’s perceptions of emotional and behavioral difficulties in children. The CBCL is a 113-item parent-report measure of children’s emotional and behavioral difficulties, yielding two composites (internalizing problems and externalizing problems). The CBCL provides T-scores that are normed by age and gender (Achenbach 2001). The CBCL-Internalizing and CBCL-Externalizing scales were used in the current study as an index of the parent’s perceptions of their child’s emotional and behavioral difficulties, respectively. The CBCL-Internalizing and CBCL-Externalizing scales demonstrated excellent internal consistency in this study (alphas = .88–.94). The Emotion Regulation Checklist (ERC; Shields and Cicchetti 1997) was used to assess parent perceptions of emotional reactivity in children. The ERC is a 24-item parent-report measure of children’s emotional reactivity, negativity, and dysregulation. The ERC was used in the current study as an index of parents’ perceptions of their children’s emotional reactivity. The ERC demonstrated excellent reliability (alpha = .92) in the current study. The Children’s Depression Inventory-Short Form (CDIS; Kovacs 1992) was used to assess children’s perceptions of their affective functioning. The CDI-S is a 10-item child-report measure that assesses the presence of depressive symptoms in children. The CDI-S has been clinically normed and provides T-scores that are normed by age and gender (Kovacs 1992). The CDI-S is a brief version of the 27-item self-report inventory and is substantially correlated with the long-form CDI (Kovacs 1992). The CDI-S was
used in the current study as an index of children’s perceptions of their own emotional difficulties. The CDI-S demonstrated excellent internal consistency in the current study (alpha = .82). The Reactive-Proactive Aggression Questionnaire (RPAQ; Raine et al. 2006) was used to assess children’s perceptions of their aggressive behavior and reactivity. The RPAQ is a 23-item self-report measure that assesses the frequency of aggressive and reactive behavior in children. Research has suggested that reactive and proactive aggressions are independent constructs, with proactive aggression linked with behavior difficulties and reactive aggression linked with emotionally dysregulated behavior. The RPAQ scales demonstrated excellent internal consistency in the current study (alphas = .82–.84). EMA measures of emotional lability The Positive and Negative Affect Scale—Parent Report (PANAS, Ebesutani et al. 2012; Watson et al. 1988) was used in the EMA assessments to assess lability of emotional states over time in children. The PANAS was selected as it allowed for independent assessment of lability of negative, positive, and overall affect. At each time point, parents filled out a 10-item PANAS-parent report to assess their perceptions of their children’s positive, negative, and total affect. The 10-item PANAS-parent report was used for the EMA assessment intervals in this study to reduce the time demands of the EMA assessment protocol and minimize the interference of the study procedures on the participants’ daily lives. The PANAS has previously demonstrated utility in studies utilizing an EMA methodology (Shrier et al. 2005), and the 10-item PANAS-parent report demonstrated feasibility and validity as a means of assessing emotional lability in previous studies (Factor et al. 2014; Rosen and Factor 2012). Prior to creating EMA variables, each EMA assessment time point was examined to ensure that it had been completed by the primary rater in the presence of the child. Parent-report time points were removed from the dataset if (a) they were not completed by the primary rater, or (b) the parent indicated that the child was asleep or not physically present. Negative (NA), Positive (PA), and Total Affect (TA) scores were created for the PANAS-PR at each EMA interval by summing all responses from that particular EMA time point to the PANAS-PR. Mean Squared Successive Difference (MSSD) scores were then created from the PANAS-PR to represent the lability of the child’s affect across all intervals. MSSD scores were created using the procedures recommended by Solhan and colleagues (2009). Scores were created by (1) taking the difference of each successive within-day rating point (i.e., morning– afternoon and afternoon–evening), (2) squaring each of the
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successive within-day difference scores, and (3) averaging the within-day MSSDs across all 28 days of the study. This procedure creates a single score that represents the frequency of within-day variability over a 28-day period. MSSD scores have demonstrated reliability and validity as a means of assessing variability within EMA data series (Jahng et al. 2008), as they account for the frequency, amplitude, and temporal dependency of change within an EMA data series (Miller et al. 2009). MSSD scores are also robust to systematic time trends and do not require that time series data be detrended or that missing data be imputed or estimated prior to analysis. MSSD scores were created exclusively from successive intervals; intervals were dropped if the preceding and/or succeeding intervals were not completed. MSSD scores were created from the PANAS to assess parent report of the lability of NA, PA, and TA. All data were analyzed using SPSS 21 software. Power analysis Power analyses were conducted using G*Power to determine the strength of the analyses to detect a medium effect size (f2 = .15, a = .05, n = 102). Power analyses supported the study as adequately powered to detect both R2 deviations from zero (Power = .85) and R2 increases at each step of the model (Power = .91–.97).
Results Adherence to EMA protocol Overall, parents demonstrated excellent adherence to the EMA protocol. Parents completed an average of approximately 82 % of the 84 possible assessment intervals (M = 82.18 %, SD = 16.0), with 93 % of parents completing at least 50 % of all possible intervals and 88 % of all parents completing at least 75 % of all possible intervals. Of note, these statistics were computed after the removal of rating points that violated the study procedures (i.e., completed by person other than the primary rater, completed while child was asleep or not physically present). Hypothesis 1 Children with ADHD would demonstrate significantly greater emotional lability than would children without ADHD. Analyses of covariance (ANCOVA) were used to examine the hypothesis that emotional lability would be primarily associated with ADHD. ADHD was entered in the analysis as an independent variable and PANAS TA, NA, and PA MSSD scores were entered as dependent
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variables. Given that a previous research study suggested that emotional lability might be more closely associated with comorbid internalizing/externalizing disorders than ADHD (Factor et al. 2014), the presence or absence of a comorbid mood (major depressive disorder, dysthymia), anxiety (generalized anxiety disorder, social anxiety disorder, separation anxiety disorder), or behavioral (oppositional defiant disorder) diagnosis was also entered as an independent variable to examine the differential relation of emotional lability to ADHD and internalizing/externalizing diagnoses. Gender and age were entered into the analyses as covariates to control for potential developmental differences in emotional development. Active ADHD medication use was also entered into the analyses as a covariate to account for the potential impact of stimulant medications on emotional lability. Analyses did not indicate any group-level differences among children with and without ADHD, in overall emotional lability (F (1, 96) = 2.17, p [ .10, g2 = .02), negative emotional lability (F (1, 96) = 0.07, p [ .70, g2 = .001), or positive emotional lability (F (1, 96) = 0.99, p [ .30, g2 = .01). By contrast, small but significant relations were observed between presence of an internalizing/externalizing disorder and both overall emotional lability (F (1, 96) = 4.48, p \ .05, g2 = .05) and negative emotional lability (F (1, 96) = 15.69, p \ .001, g2 = .14), such that greater overall and negative emotional lability was observed among children who met criteria for at least one internalizing or externalizing disorder. No relation was observed between presence of an internalizing/externalizing disorder and positive emotional lability, and no interaction was observed between ADHD and presence of an internalizing/externalizing disorder in any of the analyses. Analyses also did not indicate any meaningful differences in emotional lability by age, gender, or active ADHD medication use. Supplemental analyses examined whether the greater rates of emotional lability among children with an internalizing or externalizing diagnosis were specific to internalizing or externalizing disorders. ANCOVAs were conducted replicating the structure of the primary analyses, albeit with presence of an internalizing disorder and presence of an externalizing disorder entered separately. Results suggested similar patterns of relations of internalizing and externalizing disorders. Specifically, the presence of an internalizing disorder and the presence of an externalizing disorder were both uniquely related to greater negative emotional lability (gs2 = .06–.11, ps \ .05); however, neither internalizing disorders nor externalizing disorders were uniquely related to overall or positive emotional lability (gs2 \ .04, ps [ .10). Accordingly, given the similar pattern of results, the combined internalizing/externalizing variable was used in all further analyses.
The association of emotional lability and emotional and behavioral difficulties among…
Hypothesis 2 ADHD would moderate the relation of emotional lability over time to emotional and behavioral difficulties. Multivariate hierarchical linear regression analyses were conducted to examine the impact of parent-reported EMAderived emotional lability and ADHD on children’s internalizing and externalizing difficulties, as well as to examine how the relation of emotional lability and emotional and behavior problems was moderated by ADHD diagnostic status. Each of the indicators of behavioral difficulties (CBCL-Externalizing, RPAQ-Proactive Aggression), emotional difficulties (CBCL-Internalizing, CDI), and emotional reactivity (ERC, RPAQ-Reactive Aggression) was regressed on the EMA-derived indicator of emotional lability (parent-reported PANAS Total Affect MSSD), ADHD, and an ADHD 9 emotional lability interaction term. ADHD was entered into the first step to examine the direct relation of ADHD and the indicators of behavioral and emotional difficulties and emotional reactivity. Active ADHD medication use was entered into the first step to control for the impact of psychostimulant medication on emotional and behavioral functioning. The presence or absence of an internalizing/externalizing diagnosis was also entered into the first step to control for the substantially higher rates of internalizing and externalizing disorders among children with ADHD (Strine et al. 2006) and allows for the assessment of the impact of ADHD and emotional lability on emotional and behavioral difficulties above and beyond the impact of comorbid internalizing or externalizing disorders. Age and gender were initially considered as covariates, but were excluded from the final model as bivariate correlation analyses did not indicate any meaningful relation between age or gender with any of the dependent variables (see Table 1; absolute rs = .02–.13, ps = .18–.79) or independent variables (absolute rs = .01–.13, ps = .12–.92). PANAS Total Affect MSSD scores were entered into the second step to assess the main effect overall emotional lability on children’s emotional and behavioral functioning, and an ADHD 9 emotional lability interaction term was entered into the third step to assess for the differential impact of emotional lability on the emotional and behavioral difficulties of children with ADHD versus children without ADHD. Akaike information criteria (AIC) was used to assess model fit, with DAIC representing the difference between the AIC in the first step, emotional lability, and the ADHD 9 emotional lability interaction term and the next best-fitting model. Negative DAIC scores indicated lower AIC and thus improved fit for the inclusion of the main effects and/or the interaction term in the overall model.
Relation of emotional lability to behavioral difficulties Results supported the hypothesis that emotional lability was differentially linked to behavioral difficulties among children with ADHD but not among children without ADHD (see Table 2). Examination of the variables entered into the first step suggested that they contributed significant variance to the estimation of parent-reported behavioral difficulties, DR2 = .43, p \ .001, AIC = 402.22, and child-reported behavioral difficulties, DR2 = .12, p \ .01, AIC = -282.85. Specifically, greater parent-reported (b = .36, t = 3.94, p \ .001) and child-reported behavioral difficulties (b = .28, t = 2.41, p \ .05) were reported among children with ADHD. Greater parent-reported behavioral difficulties were also observed among children who met criteria for an internalizing or externalizing diagnosis (b = .38, t = 4.58, p \ .001); however, no relation was observed between internalizing or externalizing diagnosis and child self-reported behavioral difficulties in the current study. No significant relation was observed between ADHD medication status and either parent- or child-reported behavioral difficulties in the present study. Results indicated small but significant contributions of emotional lability to the estimation of parent-reported behavior difficulties, DR2 = .03, p \ .05, AIC = 399.26, DAIC = -2.96, and child-reported behavior difficulties, DR2 = .06, p \ .01, AIC = -288.109, DAIC = -5.25. Specifically, greater emotional lability was related to higher rates of parent-reported (b = .17, t = 2.20, p \ .05) and child-reported behavioral difficulties (b = .25, t = 2.67, p \ .01). However, results suggested that the model fit was improved by inclusion of an emotional lability 9 ADHD interaction term in the estimation of parent-reported behavioral difficulties, DR2 = .02, p \ .05, AIC = 396.95, DAIC = -2.31, such that emotional lability was related to greater parent-reported behavioral problems among children with but not without ADHD, (see Fig. 1a). Similarly, results suggested that the model fit was improved by inclusion of an emotional lability 9 ADHD interaction term in the estimation of child self-reported behavioral difficulties, DR2 = .08, p \ .005, AIC = -296.39, DAIC = -8.29, such that emotional lability was related to greater child self-reported behavioral problems among children with but not without ADHD (see Fig. 1b). Overall, results suggested that emotional lability was significantly related to behavioral difficulties among children with ADHD but not children without ADHD. Encouragingly, this effect was evident in both within-rater and across-rater analyses, as parent-reported emotional lability across the EMA protocol was related to both parent- and child-reported behavioral difficulties on retrospective recall questionnaires among children with ADHD.
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P. J. Rosen et al. Table 1 Bivariate correlations of emotional lability, ADHD status, emotional difficulties, and behavioral difficulties Measure
1
2
3
1. ADHD diagnosis (0 = No, 1 = Yes)
–
2. ADHD medication status (0 = No, 1 = Yes)
.50***
–
3. Internalizing–externalizing diagnosis (0 = No, 1 = Yes)
.41***
.22*
4
5
6
7
8
9
–
4. Parent-report Total Affect MSSD (emotional lability)
.04
.03
.40***
–
5. CBCL-Externalizing
.58***
.35***
.54***
.20*
–
6. RPAQ-Proactive Aggression
.37***
.23*
.16
.24**
.41***
–
7. CBCL-Internalizing
.47***
.17
.61***
.20*
.65***
.29**
8. Emotion regulation checklist
.70***
.52***
.53***
.17
.80***
.38***
.60***
–
9. CDI-Total
.27**
.30**
.19*
.10
.39***
.54***
.24**
.41***
–
10. RPAQ-Reactive Aggression
.31***
.36***
.33***
.10
.40***
.62***
.33***
.38***
.46***
–
N = 102
p \ .10; * p \ .05; ** p \ .01; *** p \ .001
Table 2 Summary of hierarchical regressions for estimating of behavioral difficulties Step/Variable
R2
DR2
AIC
B
SE B
t
b
(a) Hierarchical regression estimating parent-reported behavioral difficulties (CBCL-Externalizing scale) by ADHD 9 emotional lability (parent-report PANAS Total Affect MSSD) Step 1
.44
.44***
399.89
ADHD (no = 0, yes = 1)
7.24
1.70
4.30
.39***
Internalizing/externalizing
6.72
1.54
4.36
.36***
Stimulant medication use (no = 0, yes = 1)
1.67
1.73
0.97
.08
0.03
0.01
2.09
.16**
0.06
0.03
2.28
.21*
Step 2
.47
.03*
397.37
.501
.03*
394.01
Emotional lability Step 3 Emotional lability 9 ADHD
(b) Hierarchical regression estimating child-reported behavioral difficulties (RPAQ-proactive) by ADHD 9 emotional lability (parent-report PANAS Total Affect MSSD) Step 1 ADHD (no = 0, yes = 1)
.14
.14**
-284.72 0.16
0.06
2.80
Internalizing/externalizing
0.01
0.05
0.11
.01
Stimulant medication use (no = 0, yes = 1)
0.04
0.06
0.61
.07
0.01
0.01
2.60
.24**
0.01
0.01
3.47
.40***
Step 2
.20
.06**
-289.61
Emotional lability Step 3
.29
.09***
Emotional lability 9 ADHD
.33**
-299.63
N = 102
p \ .10; * p \ .05; ** p \ .01; *** p \ .001
Supplemental analyses were conducted to deconstruct the impact of overall emotional lability and allow for examination of the differential contributions of negative and positive emotional lability on parent- and child selfreported behavioral difficulties. Each of the indicators was regressed on negative and positive emotional lability, with
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ADHD, ADHD medication status, and presence of an internalizing or externalizing diagnosis entered into the first step so as to replicate the structure of the primary analyses. Results of supplemental analyses suggested that parent-reported behavioral difficulties were uniquely associated with negative emotional lability (b = .19,
The association of emotional lability and emotional and behavioral difficulties among…
Fig. 1 ADHD 9 emotional lability in the estimation of behavioral difficulties. a Estimation of parent-reported behavioral difficulties (CBCL-Externalizing). b Estimation of child-reported externalizing difficulties (RPAQ-proactive)
t = 2.26 p \ .05) but not positive emotional lability, while child self-reported behavioral difficulties were not uniquely associated with negative or positive emotional lability. No significant ADHD 9 negative or positive emotional lability interaction was observed in the estimation of parent- or child self-reported behavioral difficulties. Relation of emotional lability to emotional difficulties and reactivity Results provided mixed and limited support to the hypothesis that emotional lability was linked to internalizing difficulties, with the results varying according to reporter
(see Table 3). Examination of the variables entered into the first step suggested that they contributed significant variance to the estimation of parent-reported emotional difficulties (DR2 = .44, p \ .001, AIC = 390.73) and emotional reactivity (DR2 = .58, p \ .001, AIC = -188.77). Specifically, greater parent-reported emotional difficulties (b = .31, t = 3.47, p \ .001) and emotional reactivity (b = .41, t = 5.28 p \ .001) were reported among children with ADHD. Greater parent-reported emotional difficulties (b = .50, t = 6.13, p \ .001) and emotional reactivity (b = .32, t = 4.47, p \ .001) were also observed among children who met criteria for an internalizing or externalizing diagnosis. Parent-reported emotional difficulties were not associated with ADHD medication status; however, greater parent-reported emotional reactivity was observed among children taking ADHD medication in the current study (b = .27, t = 3.59, p \ .001). Results indicated small but significant contributions of emotional lability to the estimation of parent-reported emotional difficulties, DR2 = .03, p \ .05, AIC = 387.82, DAIC = -2.19, and emotional reactivity, DR2 = .02, p \ .05, AIC = -191.53, DAIC = -2.76. Specifically, greater emotional lability was related to higher rates of parent-reported emotional difficulties (b = .17, t = 2.18, p \ .05) and emotional reactivity (b = .14, t = 2.15, p \ .05). Results did not support inclusion of an emotional lability 9 ADHD interaction term in the estimation of parent-reported emotional difficulties or emotional reactivity (DR2 = .00), indicating that the model was best fit by separate main effects of ADHD and emotional lability. In contrast, while variables entered into the first step did contribute significant variance to the estimation of child self-reported emotional difficulties (DR2 = .11, p \ .05, AIC = 475.33) and emotional reactivity (DR2 = .19, p \ .001, AIC = -185.41), results did not indicate significant effects of ADHD, emotional lability, or ADHD 9 emotional lability in the estimation of child-reported emotional difficulties (bs \ .10, ps [ .20) or emotional reactivity (bs \ .10, ps [ .20). Indeed, ADHD medication status was the only variable to uniquely contribute meaningful variance to the estimation of child selfreported emotional difficulties (b = .21, t = 1.84, p \ .07), while medication status and internalizing/externalizing each contributed unique variance to the estimation of child self-reported emotional reactivity (bs = .23–.25, ts = 2.31–2.37, ps \ .05). Overall, results suggested that emotional lability contributed unique variance to the estimation of parent-reported emotional difficulties and reactivity that was not moderated by ADHD. By contrast, neither ADHD nor overall emotional lability contributed meaningful variance
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P. J. Rosen et al. Table 3 Summary of hierarchical regressions for estimation of parent-reported emotional difficulties and reactivity Step/variable
R2
DR2
AIC
B
SE B
b
t
(a) Hierarchical regression estimating parent-reported emotional difficulties (CBCL-Internalizing scale) by ADHD 9 emotional lability (parentreport PANAS Total Affect MSSD) Step 1
.44
.44***
390.41
ADHD (no = 0, yes = 1)
5.70
1.62
3.52
Internalizing/externalizing
8.75
1.47
5.96
-1.48
1.66
-0.90
0.02
0.01
2.05
.16*
0.02
0.02
0.67
.06
Stimulant medication use (no = 0, yes = 1) Step 2
.47
.03*
388.07
Emotional lability Step 3
.47
.00
389.60
Emotional lability 9 ADHD
.33*** .49*** -.08
(b) Hierarchical regression estimating parent-reported emotional reactivity (ERC) by ADHD 9 emotional lability (parent-report PANAS Total Affect MSSD) Step 1
.60
.60***
-194.58
ADHD (no = 0, yes = 1)
0.55
0.09
5.94
Internalizing/externalizing
0.35
0.08
4.21
.29***
Stimulant medication use (no = 0, yes = 1)
0.30
0.09
3.18
.23**
0.01
0.01
2.06
.13*
.01
.01
0.66
.05
Step 2
.62
.02*
-196.95
.62
.00
-195.42
Emotional lability Step 3 Emotional lability 9 ADHD
.46***
N = 102
p \ .10; * p \ .05; ** p \ .01; *** p \ .001
to the estimation of child self-reported emotional difficulties or reactivity. Supplemental analyses were conducted to deconstruct the impact of overall emotional lability and allow for examination of the differential contributions of negative and positive emotional lability on emotional difficulties and reactivity. Each of the indicators was regressed on negative and positive emotional lability, with ADHD, ADHD medication status, and presence of an internalizing or externalizing diagnosis entered into the first step so as to replicate the structure of the primary analyses. Results suggested that parent-reported emotional difficulties were associated with negative emotional lability (b = .16, t = 2.00 p \ .05) but not positive emotional lability, but that this association was moderated by ADHD diagnostic status (DR2 = .04, p \ .05) such that negative emotional lability was associated with greater emotional difficulties among children with but not without ADHD. Results also suggested that parent-reported emotional reactivity was associated with negative emotional lability (b = .22 t = 3.14, p \ .005) but not positive emotional lability; however, this effect was not moderated by ADHD diagnostic status (DR2 = .01, p [ .40). No relation was observed between negative or positive emotional lability and child self-reported emotional difficulties or reactivity.
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Discussion The current findings present a step toward understanding the impact of emotional lability on the emotional and behavioral functioning of children with and without ADHD by examining emotional lability over time through use of ecological momentary assessment. Contrary to expectations, no group differences were observed regarding the emotional lability of children with and without ADHD. Instead, results suggested that both overall and negative emotional lability were more closely associated with the presence of an internalizing or externalizing disorder. However, results did support the hypothesis that emotional lability was related to emotional and behavioral difficulties of children among with and without ADHD. Specifically, results supported an across-rater interaction between emotional lability over time and ADHD in the estimation of concurrent behavior difficulties, such that greater parentreported emotional lability was significantly related to greater parent- and child-reported behavioral difficulties among children with ADHD but not children without ADHD. These results support the contention that the interaction of emotional lability and the core cognitive and behavioral self-control deficits inherent in ADHD may be uniquely related to behavioral difficulties in children
The association of emotional lability and emotional and behavioral difficulties among…
(Barkley 2010). Results were less clear when examining the relation of emotional lability and ADHD to emotional difficulties. Specifically, parent-reported emotional lability was independently related to both parent-reported emotional difficulties and parent-reported emotional reactivity above and beyond the impact of ADHD, while neither parent-reported emotional lability nor ADHD was related to child self-reported emotional functioning. Notably, these results were determined through use of a longitudinal EMA-based assessment of emotional lability over time, which represents a more ecologically valid assessment of emotional lability than retrospective report measures. Implications Theoretical implications Emotional lability describes a specific pattern of emotional variation characterized by excessively rapid and/or intense emotional variability that results in an inability to maintain a consistent emotional state (i.e., emotional ‘‘homeostasis’’) over time (Gross 2007; Larsen 2000; Sobanski et al. 2010). Emotional lability has been described as a hallmark of ADHD (Barkley 2010); however, the current study suggested that emotional lability may be more closely related to comorbid internalizing and externalizing pathology than ADHD itself. Indeed, Shaw et al. (2014) comprehensive review of emotion regulation and ADHD presented evidence in support of multiple models of ADHD and emotion regulation, such that emotion regulation difficulties (including emotional lability) in children with ADHD may represent either a distinct syndromic subset of ADHD or a discrete but overlapping construct that increases risk of psychopathology. Similarly, Anastopolous et al. (2011) noted that emotional lability mediated the relation of ADHD to emotional and behavioral impairment in children. Emotional lability and other forms of emotion dysregulation have been consistently linked to a wide range of emotional and behavioral disorders in children with and without ADHD (Martel 2009; Silk et al. 2003; Sobanski et al. 2010; Zeman et al. 2006); thus, it is perhaps not surprising that emotional lability (particularly as relates to negative emotions) would be more closely related to comorbid internalizing and externalizing pathology than it is to ADHD. Consistent with these findings, the current study suggested that the interrelation of emotional lability and ADHD differs in the estimation of concurrent emotional and behavioral functioning. Emotional lability over time was directly associated with concurrent parent-reported emotional difficulties and emotional reactivity such that children who experienced more overall emotional lability over the 28-day assessment period also experienced more concurrent emotional difficulties and emotionally reactive
behavior. These were rather small effects; however, it is notable that these effects were evident above and beyond the impact of ADHD and/or comorbid internalizing/externalizing pathology and were not moderated by ADHD. Not surprisingly, this relation was most evident when examining lability of negative rather than positive emotions. These results are consistent with Silk et al. (2003) study suggesting greater emotional lability over time is consistent with greater emotional difficulties in children. A different pattern of results emerged when examining the relation of emotional lability to concurrent behavioral difficulties among children with and without ADHD. ADHD consistently moderated the relation of emotional lability to behavior problems in children in this study, such that emotional lability was related to both parent-reported and child self-reported behavior problems among children with but not without ADHD. Research has consistently demonstrated greater behavioral impulsivity, more intense reactivity to emotionally evocative events, and poorer physiological and behavioral regulation of activated emotions in children with ADHD (Barkley 2010; Martel and Nigg 2006; Musser et al. 2011) and linked these emotion regulation difficulties to the behavioral difficulties that are common to ADHD (Anastopolous et al. 2011; Martel, 2009). The present study presented evidence suggesting that it is may be interaction of ADHD and emotional lability that best accounts for the link to behavioral difficulties. The higher rate of impulsivity that is fundamental to ADHD (Barkley 2010) may provide an explanation for the interactive nature of the relation of ADHD and emotional lability. Models of emotion regulation frequently differentiate between emotional expression and behavioral reactions. Indeed, children engage in numerous cognitive and behavioral strategies to inhibit behavioral reactivity to emotional arousal and allow for activation of subdominant (i.e., non-emotional) adaptive behaviors (Eisenberg et al. 2010). Individuals that have more difficulty inhibiting their behaviors may thus be less able to engage in effortful control of behavioral reactivity to aroused emotions, resulting in a greater likelihood of engaging in maladaptive emotionally driven behavior (Marmorstein 2013). It follows that emotional lability would thus lead to greater impairment when paired with the greater behavioral impulsivity that is common to ADHD, as children with ADHD and greater emotional lability likely have more difficulty inhibiting their behavioral reactivity to their labile emotions. The results of the present study lend support to this theory, as ADHD diagnostic status consistently moderated the relation of emotional lability to behavioral difficulties across both child report and parent report. Of note, these effects were evident above and beyond the impact of ADHD alone, medication treatment, and presence of comorbid internalizing/externalizing diagnoses.
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P. J. Rosen et al.
Clinical implications The present study has significant implications for the treatment of emotional and behavioral difficulties in children with ADHD. Results of this study suggest that children with ADHD are more likely to experience emotional and behavioral difficulties in the context of frequent and intense variability in affect. Research has overwhelmingly supported the efficacy of stimulant medications and behavioral parent training for the treatment of the core symptoms of ADHD (Pelham and Fabiano 2008). While these approaches have well-documented effects on the inattention, hyperactivity, impulsivity, and related functional difficulties of children with ADHD, a paucity of research exists regarding interventions for the specific emotionally driven internalizing and externalizing difficulties that are common to children with ADHD (Shaw et al. 2014). Indeed, studies (Shaw et al. 2014; Waxmonsky et al. 2013) note that no established treatment to date specifically addresses the emotional difficulties of children with ADHD. The results of the present study emphasize the importance of developing interventions for children with ADHD that address both behavioral impulsivity and emotional lability. Indeed, studies have implicated dysregulation in emotional functioning as a key factor in the emotional and behavioral difficulties, functional impairment (Anastopolous et al. 2011), and parental stress experienced by children with ADHD (Graziano et al. 2013). Similarly, studies have indicated that children with ADHD who show improved emotional and behavioral functioning in response to psychosocial treatment show concordant changes in neurological regions associated with emotion regulation (i.e., ventral prefontral activation; Lewis et al. 2008). The current study suggests that emotional lability in the presence of the impulsivity characteristic to ADHD is specifically linked with behavioral difficulties. It is thus particularly important that interventions focus on helping children with ADHD recognize and cope with emotional lability to allow them to reduce the frequency and intensity of their impairing emotional variability. Encouragingly, initial pilot studies of a multidimensional cognitive-behavioral intervention for children with ADHD (Rosen et al. 2010) and a mindfulness-based intervention for adults with ADHD (Mitchell et al. 2013) have suggested that interventions may improve the emotional and behavioral functioning of individuals with ADHD through improved emotional awareness and emotional control. Limitations This study provided encouraging support for the relation of EMA-derived emotional lability with emotional and
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behavioral difficulties among children with and without ADHD. However, several limitations must be acknowledged. Although this study demonstrated a robust relation of emotional lability and ADHD to emotional and behavioral difficulties, all data in this study were obtained concurrently. It is thus not possible to deconstruct the direction of the effects demonstrated in this study. Furthermore, while this study demonstrated a robust interaction of ADHD and emotional lability, the concurrent data collection prevented further investigation as to why emotional lability differentially related to behavioral difficulties among children with and without ADHD. Further studies are needed to disentangle the longitudinal direction of this relation to determine whether the emotional lability assessed in this study is a cause or result of greater internalizing and externalizing behavior in children with ADHD. While the use of EMA allows for an ecologically valid assessment of emotional lability, it presents limitations as well. EMA-based ratings allow for multiple assessments of mood but do not provide information about context of the ratings. It was thus not possible to draw conclusions regarding why a child’s ratings were elevated or decreased at any time point. However, as Sobanski et al. (2010) note, emotional lability merely describes a pattern of emotional variability and ‘‘does not posit any particular deficits or underlying causes’’ (p. 916). Similarly, the parents’ emotional state while completing ratings was not assessed. This is particularly relevant given both the substantial body of research suggesting that parents of children with ADHD experience significantly greater stress (Theule et al. 2010) and the impact of parenting stress on parent ratings of children’s mood (Gartstein et al. 2009). However, it is notable that no significant differences between children with and without ADHD were evident on the EMA-derived ratings of emotional lability. Additionally, the study did not have the capacity to collect EMA data during the school day. As school is often an area of significant difficulty for children with ADHD, the procedures may have underestimated emotional lability among children with ADHD in the current study. However, given that the statistic used in this study to determine emotional lability (MSSD) can be artificially inflated when there is environmental or reporter variance between consecutive intervals, the present results may best be interpreted as an accurate representation of the child’s emotional lability within the home setting. Similarly, this study relied on a single (parent) rater for the EMA-derived measure of emotional lability. While previous research has suggested that child EMA ratings are unreliable given that children are more likely to refuse to complete ratings when distressed (Rosen and Factor 2012; Rosen et al. 2013), it is possible that the ratings of emotional lability were skewed according to parent
The association of emotional lability and emotional and behavioral difficulties among…
characteristics. However, it is notable that the parent-reported EMA measure of emotional lability was related to both parent- and child-reported measures of behavioral difficulties among children with ADHD. Finally, this study relied on a predictable rather than a random schedule of assessment intervals. While it was necessary to allow parents to dictate the schedule of alerts to ensure that parents would be able to actively observe their children while completing ratings, it is possible that this predictable schedule influenced the results by attenuating parent or child behavior in anticipation of the assessment intervals.
Conclusions The current study represents a critical step toward understanding the relation of temporal emotional lability to the emotional and behavioral functioning of children with and without ADHD. Emotional lability is consistently related to parent-perceived emotional difficulties and emotional reactivity among children with and without ADHD but appears to uniquely negatively impact behavior in children with ADHD, as their inability to regulate and control their intense and variable emotional reactions inhibits their ability to cope with distress, control their emotions, and engage in prosocial behavior. Instead, children with ADHD who are more emotionally labile respond to emotionally evoking stimuli with excessively intense emotional reactions, leading to a pattern of emotionally driven processing and behavior (Rosen et al. 2012). This suggests that it is the interaction of emotional lability with the more generalized pattern of impulsivity and dysregulation inherent to children with ADHD rather than the pattern of emotional lability itself that produces the negative behavioral impact. Our hope is that by improving our understanding of how emotional reactivity, variability, and intensity impact children with ADHD, we can improve our ability to assess and treat this difficulty and improve the emotional and behavioral functioning of children with ADHD.
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