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Deficient Emotional Self-Regulation and Adult Attention Deficit Hyperactivity Disorder: a Family Risk Analysis

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Deficient Emotional Self-Regulation and Adult Attention Deficit Hyperactivity Disorder: a Family Risk Analysis Deficient Emotional Self-Regulation and Adult Attention Deficit Hyperactivity Disorder: A Family Risk Analysis Item Type Article Authors Surman, Craig B.H.; Biederman, Joseph; Spencer, Thomas; Yorks, Dayna; Miller, Carolyn A.; Petty, Carter R.; Faraone, Stephen V. DOI 10.1176/appi.ajp.2010.10081172 Publisher American Psychiatric Association Publishing Rights Attribution-NonCommercial-NoDerivatives 4.0 International Download date 02/10/2021 02:39:29 Item License http://creativecommons.org/licenses/by-nc-nd/4.0/ Link to Item http://hdl.handle.net/20.500.12648/2021 Article Deficient Emotional Self-Regulation and Adult Attention Deficit Hyperactivity Disorder: A Family Risk Analysis Craig B.H. Surman, M.D. Objective: A growing body of research sug- elevated in siblings of ADHD plus DESR gests that deficient emotional self-regula- probands but not in siblings of ADHD pro- Joseph Biederman, M.D. tion (DESR) is prevalent and morbid among bands. ADHD and DESR cosegregated in patients with attention deficit hyperactivity siblings. The risk for other psychiatric dis- disorder (ADHD). Family studies provide a orders was similar in siblings of the ADHD Thomas Spencer, M.D. method of clarifying the co-occurrence of proband groups. clinical features, but no family studies have Dayna Yorks, B.A. yet addressed ADHD and DESR. Conclusions: The pattern of inheritance of ADHD with DESR preliminarily suggests Carolyn A. Miller, B.A. Method: Participants were 83 probands that DESR may be a familial subtype of with and without ADHD and 128 siblings. ADHD. Our data suggest that DESR is not All were assessed for axis I DSM-IV con- Carter R. Petty, M.S. an expression of other axis I DSM-IV disor- ditions with structured diagnostic inter- ders or of nonfamilial environmental fac- views. The authors defined DESR in adult tors. The authors cannot exclude contribu- Stephen V. Faraone, Ph.D. probands and siblings using items from tion of non-axis-I DSM-IV disorders to risk the Barkley Current Behavior Scale. Analy- for DESR and cannot determine whether ses tested hypotheses about the familial the cosegregation of ADHD in DESR within relationship between ADHD and DESR. families is a result of genes or familial en- Results: Siblings of ADHD probands were vironmental risk factors. Further investiga- at elevated risk of having ADHD, irrespec- tion of DESR and its correlates and treat- tive of the presence or absence of DESR ment both in and outside the context of in the proband. The risk for DESR was ADHD is warranted. (Am J Psychiatry 2011; 168:617–623) Adults with attention deficit hyperactivity disor- (e.g., the other mood symptoms of bipolar disorder and der (ADHD) are at elevated risk for deficient emotional the hyperarousal of severe mood dysregulation). self-regulation (DESR) (1–6). DESR refers to 1) deficits in The difference between DESR associated with ADHD self-regulating the physiological arousal caused by emo- and the mood instability of pediatric bipolar disorder is tions, 2) difficulties inhibiting inappropriate behavior in of particular importance given that these two disorders response to either positive or negative emotions, 3) prob- respond to different pharmacologic treatments. Notably, lems refocusing attention from strong emotions, and 4) bipolar disorder is far less prevalent than DESR in ADHD disorganization of coordinated behavior in response to patients, with approximately 15% of clinically referred emotional activation (4). DESR traits include low frustra- ADHD adults having a lifetime history of bipolar disorder tion tolerance, impatience, and quickness to anger as well (12). In contrast, Barkley et al. (3) found that 60% of adults as being easily excited in response to emotional reactions. with ADHD in a clinical sample reported traits of DESR, Although Wender (7) and subsequently others (4, 8, 9) relative to 15% of comparison subjects. Similar symptoms have identified these traits as common in presentations of were seen in one-third of adults with ADHD participat- ADHD in adulthood, in DSM-IV they are not considered ing in registration trials for atomoxetine (13) and in more diagnostic of the disorder. than one-half of adult patients in a smaller clinical trial of Understanding the nature of DESR among ADHD pa- osmotic-release oral system methylphenidate (2). Bark- tients is consequential because DESR can be confused ley and Fischer (14) showed a higher prevalence of DESR with mood disorder symptoms that can be comorbid with in adults with ADHD with persistent symptoms relative ADHD. DESR is distinct from severe mood dysregulation, to those without persistent symptoms. In their sample, as described by Leibenluft et al. (10), and also differs from DESR was correlated with functional impairment beyond the persistent and severe aggressive irritability often seen that accounted for by ADHD. We recently found that 61% in pediatric bipolar disorder (11). Unlike DESR, these lat- of a sample of community-ascertained adults with ADHD ter conditions are not defined by poor self-regulation, and reported DESR of greater severity than 95% of compari- their definition includes features that are not part of DESR son subjects (6). DESR was only partially accounted for This article is featured in this month’s AJP Audio. Am J Psychiatry 168:6, June 2011 ajp.psychiatryonline.org 617 DEficiENT EMOTIOnaL SELF-REGULATION AND ADULT ADHD by other comorbid psychiatric conditions and was associ- probands should be at higher risk for such disorders com- ated with significant adverse effect on quality of life. pared with the relatives of ADHD probands. Because little is known about the mechanisms underly- ing the association of DESR with ADHD, we sought to use Method family study data to determine whether familial transmis- sion could clarify the co-occurrence of these conditions, Participants as it has for other disorders (15, 16). Family studies can de- Probands were men and women between the ages of 18 and 55 termine whether two conditions share familial risk factors years who had children or siblings eligible for participation in the study. We excluded potential probands with major sensorimotor or whether their co-occurrence is a result of nonfamilial disabilities, psychosis, inadequate command of the English lan- environmental risk factors. Based on models proposed by guage, or a full-scale IQ <75. No ethnic or racial group was exclud- Pauls et al. (17), we tested five competing hypotheses. ed. We recruited ADHD patients and comparison subjects using Hypothesis 1 posits that ADHD and DESR are etiologi- separate ascertainment methods. The following two ascertain- cally independent and co-occur as a result of chance. It ment sources were employed to recruit ADHD probands: refer- rals to psychiatric clinics at Massachusetts General Hospital and predicts equally high rates of ADHD in relatives of ADHD advertisements in the greater Boston area. We recruited potential probands and ADHD plus DESR probands (relative to non-ADHD (comparison) probands through advertisements in comparison probands), but DESR should be increased the greater Boston area. All available relatives of probands were only among relatives of adults with ADHD plus DESR (rel- recruited to participate in the study after contact information ative to comparison probands). Additionally, ADHD and from the proband was obtained. Following description of the study to the participants, written informed consent was obtained DESR should not cosegregate in families of ADHD plus separately from probands and relatives under procedures ap- DESR probands (i.e., the ADHD relatives should not be at proved by the Massachusetts General Hospital Institutional Re- increased risk for DESR). Refuting this hypothesis would view Board. eliminate any hypothesis suggesting that the association Based on our previous work, we included probands as having between ADHD and DESR is a result of a referral bias (such ADHD if they met full DSM-IV criteria for the disorder (N=127) or for late-onset ADHD (N=79; participants meeting full DSM-IV cri- as Berkson’s bias) in which patients with multiple condi- teria for ADHD except for the age at onset criterion). We previous- tions are overrepresented in referrals because of the great- ly demonstrated that these full and late-onset ADHD groups have er severity of their clinical picture. Given that there are no similar clinical correlates (12, 18–20). The late-onset patients had population studies of ADHD and DESR to discount such onset in adolescence. The remaining participants were defined as biases, testing this hypothesis is essential to rule out this not having ADHD (N=123). To study familial risk in adult relatives, we examined a subset potential artifact, which could explain the association of of probands who had information available about both DESR and the two conditions. ADHD for themselves and their siblings. Information on ADHD Hypothesis 2 theorizes that ADHD with DESR is a dis- and DESR was available from 27 probands with ADHD and DESR tinct subtype or an entirely separate condition. It predicts (ADHD plus DESR probands) and 45 of their adult siblings; from the same pattern as hypothesis 1, with the exception that 23 probands with ADHD who did not have DESR (ADHD pro- bands) and 40 of their adult siblings; and from 33 probands with- it predicts strong evidence for cosegregation among rela- out ADHD or DESR (comparison probands) and 43 of their adult tives of ADHD plus DESR adults (i.e., ADHD and DESR siblings. should be comorbid among relatives). Hypothesis 3 postulates that ADHD plus DESR requires Assessments more familial transmissible etiologic factors for its expres- Participants were assessed with the Structured Clinical Inter- view for DSM-IV Axis I Disorders (21). We used modules from the sion compared with ADHD without DESR. This would be Schedule for Affective Disorders and Schizophrenia for School- consistent with the greater severity of ADHD plus DESR Age Children–Epidemiologic version (22) to assess childhood dis- observed in prior studies (6, 14).
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