Emotional Dysregulation and Quality of Life in Adolescents with Attention Deficit Hyperactivity Disorder: The Emotical Study

Research Article

J Pediatr & Child Health Care. 2020; 5(1): 1030.

Emotional Dysregulation and Quality of Life in Adolescents with Attention Deficit Hyperactivity Disorder: The Emotical Study

Mardomingo Sanz MJ1, Montañés Rada F2, Nebot Valenzuela E3 and Soler López B4*

1Especialista en psiquiatría del niño y del adolescente, Jefa de Psiquiatría y Psicología Infantil Hospital General Universitario Gregorio Marañón, Psiquiatría Infantil, Universidad Complutense, Madrid, Spain

2Servicio de psiquiatría, Hospital Universitario Fundación Alcorcón, Madrid, Spain; Psiquiatría URJC, Madrid, Spain

3Laboratorios Farmacéuticos ROVI, S.A., Madrid, Spain

4Medical Department, E-C-BIO, S.L., Las Rozas (Madrid), Spain

5The Emotical Study Group: Francisco Javier Aguirre Rodríguez; Patricia Alcindor Huelva; Raquel Anegon Medinabeitia; Juan Bastardas Sardans; Ignacio Basurte Villamor; Mariano Adrián Bellina; Manuel Oscar Blanco Barca; Hilario Blasco Fontecilla; María Cristina Casal Pena; Mariana Castrillo Pantín; Elena Catalá Ortuño; Rafael De Burgos Marín; Raquel Díaz Conejo; Lourdes Duño Ambros; Oscar Duran Forteza; Carla Falconi Valderrama; Manuel Alberto Fernández Fernández; Alberto Fernández Jaén; Fidel Jorge García Sánchez; Jesús Garcia Tena; Juan Carlos Giménez Morales; Lorena Gómez Guerrero; José Antonio Gómez Sánchez; Balma Gómez Vicente; Pablo González Domenech; Luis Alberto González Martínez; Olvido Granada Jiménez; Abigail Huertas Patón; Irma Isasa Finó; Silvia Mabry Paraiso; Ignacio Málaga Dieguez; Núria Manzanares Tesón; José María Martín Jiménez; Ricardo Alberto Migliorelli Toppi; María Dolores Morillo; José Juan Muro Romero; Enrique Ortega García; Juan Jairo Ortiz Guerra; Beatriz Paya González; José Carlos Peláez álvarez; Vanessa Pera Guardiola; Iván Pérez Eguiagaray; Uxue Picaza Ereño; Benjamín Piñeiro Diéguez; Jasna Raventós Simic; Núria Raya Chamorro; Andrés Rodríguez Sacristán Cascajo; Helena Romero Escobar; Javier Royo Moya; Jesús María Ruiz Aguado; María José Ruiz Lozano; César Luis Sanz De La Garza; José Augusto Viso Lorenzo

*Corresponding author: Soler López B, Medical Department, E-C-BIO, S.L., c/ Rosa de Lima, 1, Edificio ALBA, Office 016, 28230 – Las Rozas (Madrid), Spain

Received: February 08, 2020; Accepted: March 11, 2020; Published: March 18, 2020


Objective: Emotional disturbances in Attention Deficit Hyperactivity Disorder (ADHD) have been poorly explored. The lack of consensus in the definition of the patient with Emotional Dysregulation (ED), and the absence of a gold standard measure of the presence of emotional dysregulation contributes to this lack of knowledge

The aim of this study was to assess the presence of ED in ADHD adolescents and to measure its impact on patient quality of life.

Method: A cross-sectional observational study was designed. The ADHD severity was assessed using the Clinical Global Impression Scale of Severity (CGI-S). Patients with ED were those with scores 6-10 points in the emotional symptoms scale of the Strengths and Difficulties Questionnaire. Quality of life was assessed using the KIDSCREEN-10-INDEX.

Results: 270 adolescents were included. ED was present in 20.4% (95% CI 20.1-20.7). Psychiatric comorbidity was found in 48.9% (132). Methylphenidate was the treatment for 76.3% (184) and 20.7% (50) with lisdexamphetamine. Quality of life scores were worst as ADHD severity increased (p=0.005), if psychiatric comorbidity (p=0.008), and ED (p< <0.0001) are present.

Conclusions: Adolescents suffering from ADHD with ED are at increased risk of psychiatric comorbidity and impairment of their quality of life.

Keywords: ADHD; Attention deficit hyperactivity disorder; Emotional dysregulation; Comorbidity; Adolescents


Attention Deficit Hyperactivity Disorder (ADHD); Child Behaviour Checklist (CBCL); Clinical Global Impression Scale (CGI); Clinical Global Impression Scale global improvement (CGI-C); Clinical Global Impression Scale of Severity (CGI-S); Emotional Dysregulation (ED); Health-Related Quality of Life (HRQoL) ; Strengths and Difficulties Questionnaire (SDQ); Strengths and Difficulties Questionnaire Spanish Version (SDQ-cas); Youth Self Report (YSR)


Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological disorder that begins in childhood and affects 3-7% of school-age children. In Spain, 6.8% of children and adolescents suffer from ADHD [1]. The disorder is characterized by a level of impulsivity, activity, and attention inappropriate to the age of development. Many of these children and adolescents have difficulty regulating their behaviour and adjusting to the expected norms for their age and, as a result, have difficulty adapting in their family, school and relationships with their peers. They often perform below their abilities and may have emotional and behavioural disturbances [2].

Nuclear symptoms include inattention, hyperactivity and impulsivity, to which the symptoms secondary to psychiatric comorbidity that are very common in ADHD are added [3]. Children with ADHD have more oppositional defiant disorders, behavioural disorders and major depression. In the classroom, they have a higher rate of disruptive behaviours and hyperactivity. Girls with ADHD are less aggressive and impulsive than boys, have fewer symptoms of conduct disorder, but are at increased risk for anxiety disorders. In the school setting, girls show fewer behavioural problems and participate more in extracurricular activities [3,4]. These sex differences disappear after puberty [5].

Emotional disturbances in ADHD have hardly been explored compared with numerous studies assessing cognitive and behavioural symptoms. However, an increasing interest has emerged in recent years and the concept of Emotional Dysregulation (ED) has become part of the scientific interest in this entity. Children with ADHD have great difficulty modulating emotional responses, resulting in affective symptoms and impulsive and explosive behaviours, with unfavourable consequences in many areas of their life [6]. Assessing individual differences in emotion regulation is also a topic of special interest in ADHD, as children with ADHD and emotional dysregulation have been found to have more severe ADHD. It has also been reported that this group of children with ADHD and emotional dysregulation could be more homogeneous in their response to treatment than those without emotional dysregulation. However, there is a lack of consensus in both the definition of emotional dysregulation and the gold standard for its assessment [6-8].

The primary objective of the study was to assess the degree of emotional impairment in adolescents with ADHD, using a measurement method that can be compared to the healthy population. The secondary objectives were to assess the relationship between the presence of emotional dysregulation and impaired quality of life, the relationship between the presence of emotional dysregulation and age, sex, type of ADHD, and severity of the disease.

Material and Methods

Study design and ethical standards

A cross-sectional observational study was designed. The patients were included between February and October 2017. Participating specialists were from 54 child and adolescent psychiatry or neuropaediatrics centres from 30 Spanish provinces in 15 autonomous regions. The investigators completed the case report form specifically designed for the study. The study was approved by the Clinical Research Ethics Committee of Hospital Universitario Fundación Alcorcón, Madrid. All patients and the parents or guardians of minor patients received information about the study and agreed to participate by signing the informed consent form. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Selection criteria

Patient selection was performed on a consecutive random basis, selecting the first 5 patients visiting the clinic who met the screening criteria. The information sources were the case history and the data collected on the inclusion visit.

Patients of any race and sex, aged 12 to 18 years, with a confirmed diagnosis of ADHD according to DSM-5 criteria [2], with enough cognitive level to allow them to complete the study questionnaires, were included.

Sociodemographic and clinical variables

The date of birth, sex, weight, height, socioeconomic level (low: family income less than €15,000 per year; medium: family income between €15,000 and €45,000 per year, and high: family income greater than €45,000 per year) and alcohol use (more than 80 g of alcohol per day in men and 20 g/day in women), smoking and drugs intake were recorded. Information was collected on the presence of a history of psychiatric disease and ADHD in first-degree relatives.

The date of diagnosis of ADHD and the group in which the patient was classified according to the diagnosed ADHD subtype (DSM-5 criteria) were recorded: Predominantly inattentive ADHD, predominantly hyperactive-impulsive ADHD, or combined type ADHD, or the patient had not yet been classified. The presence of history of non-psychiatric or psychiatric disease was explored and if the patient has any suicide attempt.

Clinical assessment

The Strengths and Difficulties Questionnaire (SDQ) that was completed by the adolescents was used to determine the presence of emotional dysregulation (http://www.sdqinfo.com/). The questionnaire consists of 25 questions with three possible answers and assesses social, emotional, and behavioural functioning. Responses are grouped into five subscales: emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial scale [9, 10].

Scores for each of the five subscales can range from 0 to 10 points. The total score of the questionnaire (total difficulties score) is obtained by the sum of the scores of the four subscales, not including the prosocial scale, and ranges from 0 to 40 points. These results classify patients into three groups: normal, borderline, or abnormal (Table 1). In this regard, adolescents were classified such that 80% of adolescents in the population were within the normal range, 10% in borderline range, and the remaining 10% in the abnormal range [10]. The study classified adolescents with emotional problems or with emotional dysregulation if they obtained scores on the emotional scale of the SDQ-cas between 6 and 10 points.