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16 Oct 2020

Monopoli WJ et al. Int J Methods Psychiatr Res 2020; Epub ahead of print

Children with ADHD may exhibit chronic emotional dysregulation (ED) (Rosen & Epstein, 2010). The goal of this study was to evaluate psychometric properties of a conceptually informed and developmentally appropriate parent-report ED rating scale in adolescents with ADHD. The first aim of this study was to determine whether a conceptual model of ADHD-related ED can be identified in the factor structure of a parent-report questionnaire. The second aim was to study the evidence of the validity of this questionnaire relative to other ADHD-related characteristics (impulsivity, anxiety and depression) and self-reported ED in adolescents with ADHD.

The conceptually informed measure of ED was created from the Emotion Regulation Index for Children and Adolescents-Parent Report (ERICA-P), Difficulties in Emotion Regulation Scale-Parent Report (DERS-P) and Disruptive Behaviour Disorders Rating Scale-Parent Report (DBD-RS). Barratt Impulsiveness Scale (BIS-11), Beck Youth Inventory II (BYI-II)-Anxiety and Reynolds Adolescent Depression Scale-II (RADS-2) were used to assess impulsivity, anxiety and depression. The authors developed a list from the items on the ERICA-P, DERS-P and oppositional defiant disorder items from the DBD-RS that corresponded to the three aspects of ED: speed of escalation, intensity and speed of de-escalation (Bunford et al, 2015).

The study sample was obtained from 209 high-school students* (mean [standard deviation (SD)] age 15.2 [0.91] years) with ADHD who were enrolled in a two-site treatment study. In total, 78% of participants were male and 34% of participants had a prescription for ADHD medication. Comorbidities included: oppositional defiant disorder (44.5%), generalised anxiety disorder (25.4%), major depressive disorder (11.5%), conduct disorder (8.6%) and social anxiety disorder (7.2%). Overall, 57.4% of the participants met criteria for one or more of the comorbid disorders of ADHD.

Assessment of the factor structure of a conceptually derived three-factor model of ED

Due to the results of the correlation matrix, it was determined that a two-factor solution better fit the data; 60% of the variance in all of the items included in the study were accounted for by the two-factor model and were correlated (r = 0.51; p < 0.05). The model fit indices for the two-factor structure were suggested to be an adequate fit (χ2 = 234.54, df = 103, p < 0.001, CFI = 0.94, RMSEA = 0.08, SRMR = 0.04). Speed and degree of escalation (intensity) was a conception of one factor after loading of 11 items. Speed of de-escalation (return to baseline) was a conception of a second factor after loading of six items. The reliability estimates (coefficient alpha) were calculated at α = 0.92 for speed and degree of escalation and α = 0.87 for speed of de-escalation (return to baseline).

Evaluation of the evidence for validity of the two-factor measure

The relationship between age, sex, medication use and ED were not associated with the scores on either of the ED factors. Symptoms of impulsivity in adolescents with ADHD were positively related to speed/degree of escalation (β = 0.45, p < 0.001) but not speed of de-escalation. Cognitive and behavioural impulsivity measured by BIS-11 were not related to either of the ED factors: ED-factor 1 versus BIS-1 (β = –0.3, p > 0.05), ED-factor 1 versus BIS-2 (β = 0.07, p > 0.05), ED-factor 2 versus BIS-1 (β = –0.9, p > 0.05) and ED-factor 2 versus BIS-2 (β = 0.16, p > 0.05). Additionally, symptoms of anxiety (β = 0.21, p = 0.02) and depression (β = 0.21, p = 0.02) were related to de-escalation but not speed/degree of escalation (β = 0.03, p > 0.05 and β = 0.02, p > 0.05). The ED factors accounted for 18% of the variance in ADHD impulsivity symptoms, 7% in anxiety and 7% in depression. After controlling for ERICA and DERS self-report scores, speed/degree of escalation remained a significant correlate of ARS impulsivity (β = 0.45, p < 0.001) but de-escalation did not remain a significant correlate of anxiety (β = 0.14, p = 0.13) or depressive symptoms (β = 0.12, p = 0.13).

The first limitation was that the number of questions assessing dysregulation of positive emotions was negligible, even though deregulation of positive emotions, such as excitement or happiness, may lead to negative peer appraisals. Additionally, there was some overlap with symptoms of oppositional defiant disorder and ADHD-related ED due to the results of item selection. Finally, the ERICA-P has not been validated unlike the DERS-P.

In summary, this study is the first to highlight the degree to which the empirical factor structure of a parent-report questionnaire of ADHD-related ED corresponds to a conceptual three-factor approach of ED. This structure is best represented by the two components (emotional escalation and intensity related to impulsivity and emotional de-escalation related to internalising of symptoms). The authors feel these results may help towards fulfilling the need for development and/or evaluation of additional, multi-informant measures of ADHD-related ED.

Read more about evaluation of ADHD-related emotional dysregulation here

*Inclusion criteria for the study were: attend one of the participating schools; meet diagnostic criteria for ADHD either on the Parent Children’s Interview for Psychiatric Syndromes or parent and teacher report on the ADHD Rating Scale-5; demonstrate an IQ ≥75 on a two-subset score of Weschler Abbreviated Scale of Intelligence-Second Edition; no probability of a substance abuse disorder and does not meet diagnostic criteria for bipolar disorder, obsessive-compulsive disorder or psychosis on the Children’s Interview for Psychiatric Syndromes-Parent Version

Bunford N, Evans SW, Wymbs F. ADHD emotion dysregulation among children and adolescents. Clin Child Fam Psychol Rev 2015; 18: 185-217.

Monopoli WJ, Evans SW, Benson K, et al. Assessment of a conceptually informed measure of emotion dysregulation: evidence of construct validity vis a vis impulsivity and internalizing symptoms in adolescents with ADHD. Int J Methods Psychiar Res 2020; Epub ahead of print.

Rosen PJ, Epstein JN. A pilot study of ecological momentary assessment of emotion dysregulation in children. J ADHD Related Dis 2010; 1: 39-52.

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