ADDitude for Professionals

The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations

Irritability, anger issues, and emotional dysregulation in general contribute significantly to the psychosocial burden of ADHD in children and adults. The latest research suggests that these problems are inherent to ADHD and may require specific treatment.

adhd and anger issues - Psychotherapy consulting, a conversation between a doctor and a patient, mental health problems and medical support
Psychotherapy consulting, a conversation between a doctor and a patient, mental health problems and medical support

Anger issues stemming from emotional dysregulation – while noticeably missing from diagnostic criteria for attention deficit hyperactivity disorder (ADHD or ADD) – are a fundamental part of the ADHD experience for a significant number of children and adults. Even when controlling for related comorbid conditions, individuals with ADHD experience disproportionate problems with anger, irritability, and managing other emotions. These problems walk in lock step with the general difficulties in self-regulation that characterize ADHD. Recent findings, however, suggest that problems with emotional regulation, including anger and negative emotions, are genetically linked to ADHD, too.

Ultimately, emotional dysregulation is one major reason that ADHD is subjectively difficult to manage, and why it also poses such a high risk for other problems like depression, anxiety, or addiction. Scientific and clinical attention are now increasingly turning to correct the past neglect of this integral aspect of ADHD.

Recognizing this inherent relationship between emotional dysregulation and ADHD is also important when discerning between related and similar conditions, like disruptive mood dysregulation disorder (DMDD), bipolar disorder, intermittent explosive disorder (IED), depression, anxiety disorders, and oppositional defiant disorder (ODD). In all, paying mind to anger issues and emotionality in patients with ADHD is crucial for successful treatment and symptom management in the long term.

Anger Issues and ADHD: Theories & Research

Though separated from ADHD in official nomenclature today, emotional dysregulation and anger were connected to ADHD in the mid-20th century before current diagnostic norms were created, and have continued to form part of personal and clinical experiences. Decades ago, when ADHD was known as “minimal brain dysfunction,” criteria for diagnosis actually included aspects of negative emotionality.

Anger problems and emotional dysregulation in individuals with ADHD are sometimes explained by co-occurring mood disorders, such as anxiety or depression. However, these associated disorders do not explain the near universal anger and emotional issues that ADHD individuals experience.

[Click to Read: When It’s Not Just ADHD: Symptoms of Comorbid Conditions]

A critical aspect to consider, then, is ADHD’s nature as a disorder of self-regulation across behavior, attention, and emotion. In other words, any difficulties in regulating our thoughts, emotions, and actions – as is common with ADHD – may explain the irritability, tantrums, and anger regulation issues these individuals experience. And the majority do.

About 70 percent of adults with ADHD report problems with emotional dysregulation1, going up to 80 percent in children with ADHD2. In clinical terms1, these problem areas include:

  • Irritability: issues with anger dysregulation – “tantrum” episodes as well as chronic or generally negative feelings in between episodes.
  • Lability: frequent, reactive mood changes during the day. .
  • Recognition: the ability to accurately recognize other people’s feelings. Individuals with ADHD may tend to not notice other people’s emotions until pointed out.
  • Affective intensity: felt intensity – how strongly an emotion is experienced. People with ADHD tend to feel emotions very intensely.
  • Emotional dysregulation: global difficulty adapting emotional intensity or state to situation.

Explaining ADHD and Anger via Emotional Profiles

Emotional dysregulation remains a constant in ADHD even when analyzing personality traits, making the case for emotional profiles or subtypes around ADHD.

[Read: Could High-Tech Brain Scans Help Diagnose ADHD?]

Our own study of children with ADHD that used computational methods to identify consistent temperament profiles found that about 30 percent of kids with ADHD clearly fit a profile strongly characterized by irritability and anger2. These children have very high levels of anger, and low levels of rebound back to baseline – when they get angry, they can’t get over it.

Another 40% had extreme dysregulation around so-called positive affect or hyperactive traits — like excitability and sensation-seeking. Children with this profile also had above-average levels of anger, but not as high as those with the irritable profile.

Thinking of ADHD in terms of temperament profiles also becomes meaningful when considering the role of brain imaging in diagnosing ADHD. Brain scans and other physiological measures are not diagnostic for ADHD because of wide variation in results among individuals with ADHD. However, if we consider brain scans based on temperament profiles, the situation may become clearer. Data from brainwave recordings makes the case that there is distinct brain functioning among children who fall under our proposed irritable and exuberant ADHD profiles2.

In eye-tracking tests among the participants, for example, children in this irritable subgroup struggled more than those in any other identified subgroup to take their attention off negative, unhappy faces shown to them. Their brains would activate in the same areas when they saw negative emotions; this did not happen when they saw positive emotions.

Genetic Basis for ADHD and Anger Issues

From a genetics standpoint, it appears that emotional dysregulation is strongly associated with ADHD. Our recent findings suggest that genetic liability for ADHD is related directly to most traits under emotional dysregulation, like irritability, anger, tantrums, and overly exuberant sensation-seeking3. What’s more, irritability appears to have the biggest overlap with ADHD versus other traits, like excessive impulsivity and excitement, in children.

These findings refute the idea that mood problems in ADHD are necessarily part of an undetected depression — even though they do indicate higher future risk for depression as well as higher possibility of depression being present.

Anger Issues: DMDD, Bipolar Disorder & ADHD

ADHD, DMDD, and bipolar disorder are all associated in different ways with anger and irritability. Understanding how they relate (and don’t) is critical to ensuring proper diagnosis and targeted treatment for anger issues in patients.

Anger Issues and Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a new disorder in the DSM-5 primarily characterized by:

  • Severe tantrums, either verbal or behavioral, that are grossly out of proportion to the situation
  • A baseline mood of persistent grumpiness, irritability, and/or anger

DMDD was established in DSM-5 after a crisis in child mental health in the 1990s in which rates of bipolar disorder diagnoses and associated treatment with psychotropic mediation in children skyrocketed – inaccurately. Clinicians at that time assumed, in error, that irritability in children could be substituted for actual mania, a symptom of bipolar disorder. We now know from further epidemiological work that, in the absence of mania, irritability is not a symptom of hidden bipolar disorder in children. When mania is present, irritability can also emerge as a side feature of the mania. But mania is the primary feature of bipolar disorder.

Mania means a notable change from normal in which a child (or adult) has unusually high energy, less need for sleep, and grandiose or elevated mood, sustained for at least a couple of days — not just a few hours. True bipolar disorder remains very rare in pre-adolescent children. The average age of onset for bipolar disorder is 18 to 20 years.

Thus, DMDD was created to give a place for children older than 6 years of age with severe, chronic temper tantrums who also do not have elevated risk for bipolar disorder in their family or in the long run. It opens the door for research on new treatments targeted these children, most of whom meet criteria for severe ADHD, often with associated oppositional defiant disorder.

DMDD is also somewhat similar to intermittent explosive disorder (IED). The difference is that a baseline negative mood is absent in the latter. IED is also usually reserved for adults.

As far as ADHD, it is important to recognize that most patients who meet criteria for DMDD actually have severe ADHD, sometimes with comorbid anxiety disorder or ODD. This diagnosis, however, is given to help avoid a bipolar disorder diagnosis and take advantage of new treatment insights.

[Self-Test: Could Your Child Have DMDD?]

Anger Issues and ADHD: Treatment Approaches

Most treatment studies for ADHD look at how core symptoms of ADHD change. Treating anger problems in individuals with ADHD has only recently become a major research focus, with useful insights revealed for patient care. Alternative and experimental approaches are also increasingly showing promise for patients with emotional dysregulation and anger issues.

Interventions for Children with Anger Issues

1. Behavioral Therapy4

  • Cognitive Behavioral Therapy (CBT): Some children with anger issues have a tendency to over-perceive threat – they over-react to an unclear or ambiguous situation (someone accidentally bumps you in line) when no threat is actually present. For these children, CBT can help the child with understanding that something ambiguous isn’t necessarily threatening.
  • Counseling: Anger problems can also be caused by difficulties with tolerating frustration. Counseling can help children learn how to tolerate normal frustrations and develop better coping mechanisms.
  • Parent Counseling: Parents have a role in how a child’s anger manifests. A parent’s angry reaction can lead to negative and mutual escalation, such that parents and kids both start to lose their balance. This can form a negative loop. With counseling, parents can learn to react differently to their child’s tantrums, which can help reduce them over time.

2. Medication:

Regular stimulant medication for ADHD helps ADHD symptoms much of the time, but is only about half as helpful with anger problems. Selective Serotonin Reuptake Inhibitors (SSRIs) may be next for treating severe anger problems. A recent double-blind study, for example found that children with severe tantrums, DMDD, and ADHD who were on stimulants saw a reduction in irritability and tantrums only after being given Citalopram (Celexa, an SSRI antidepressant) as a second medication5. While only one study, these findings do suggest that when mainline stimulant medications are not working, and severe anger problems are a core issue, then adding an SSRI may be a reasonable step.

Interventions for Adults with Anger Issues

Behavioral counseling (as in CBT) has clear evidence pointing to its benefits in treating emotional regulation problems for adults with ADHD. Specifically, these therapies improve skills in the following:

  • Interior regulation: refers to what individuals can do within themselves to manage out-of-control anger. The key element here is learning coping skills, practicing them, and checking back with a counselor for refining. Important for patients to understand is that learning about coping skills without practice, or trying some self-help without professional consultation is generally not as effective. Some examples of coping skills include:
    • anticipatory coping, or devising an exit plan to the triggering situation – “I know I’m going to get angry next time this happens. What am I going to plan ahead of time to avoid that situation?”
    • appraisals and self-talk to keep temper under control (“Maybe that was an accident, or they’re having a bad day.”)
    • shifting attention to focus elsewhere instead of on the upsetting situation.
  • Exterior supports
    • Social connections – talking to others and having their support –are tremendously beneficial for adults struggling with ADHD and anger
    • Exercise, stress reduction, and other self-care strategies can help.

Strategies with Limited Benefits

  • Typical ADHD medication helps with core symptoms, but has only modest benefits on emotional dysregulation for adults with ADHD6
  • Meditation classes offer some benefits7 for managing ADHD symptoms and emotional dysregulation for teens and adults (and for children if parents join in the practice too), but most studies on this intervention tend to be of low quality so it is difficult to draw strong conclusions.
  • High-dose micronutrients may help adults with ADHD emotionality, based on a small but robust study8. Omega-3 supplementation also appears to have a small effect in bettering emotional control in children with ADHD9.

Problems with emotional dysregulation, in particular with anger reactivity, are very common in people with ADHD. You are not alone in struggling in this area. Anger may indicate an associated mood problem but often is just part of the ADHD. Either way, changes in traditional ADHD treatment can be very helpful.

Anger Issues and ADHD: Next Steps

 

The content for this webinar was derived from the ADDitude Expert Webinar “You’re So Emotional: Why ADHD Brains Wrestle with Emotional Regulation” by Joel Nigg, Ph.D., which was broadcast live on July 28, 2020.


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Sources

1 Beheshti, A., Chavanon, M. & Christiansen, H. (2020). Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis. BMC Psychiatry 20, 120. https://doi.org/10.1186/s12888-020-2442-7

2 Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological Assessment, 31(2), 236–247. https://doi.org/10.1037/pas0000664

3 Nigg, J., et. al. (2019). Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD. Journal of Child Psychology and Psychiatry 61, 2. https://doi.org/10.1111/jcpp.13132

4 Stringaris, A., Vidal-Ribas, P., et. al. (2017). Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. Journal of Child Psychology and Psychiatry, 59 (7). https://doi.org/10.1111/jcpp.12823

5 Towbin, K., Vidal-Ribas, P., et. al. (2020). A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3). https://doi.org/10.1016/j.jaac.2019.05.015

6 Lenzi, F., Cortese, S. et. al. (2018). Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 84, 359-367. https://doi.org/10.1016/j.neubiorev.2017.08.010

7 Xue, J et. al. (2019). A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine 98(23). 10.1097/MD.0000000000015957

8 Rucklidge, J., Frampton, C., Gorman, B., & Boggis, A. (2014). Vitamin–mineral treatment of attention-deficit hyperactivity disorder in adults: Double-blind randomised placebo-controlled trial. British Journal of Psychiatry, 204(4), 306-315. doi:10.1192/bjp.bp.113.132126

9 Cooper, R., Tye, C. et.al. (2016). The effect of omega-3 polyunsaturated fatty acid supplementation on emotional dysregulation, oppositional behaviour and conduct problems in ADHD: A systematic review and meta-analysis. Journal of Affective Disorders 190, 474-482. https://doi.org/10.1016/j.jad.2015.09.053

Updated on September 24, 2020

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