ADHD, Anger, and Emotional Regulation
Managing anger is a problem for people with ADHD, but solutions are available.
Posted Aug 04, 2020
The criticisms people with ADHD often hear include “too emotional,” “overreacting,” “over-sensitive,” and “too much drama.” Recent research shows that problems with anger, tantrums, and managing emotions are a common part of ADHD that need to be better recognized. During these days of unusually high societal pressures on families and individuals, visiting what we know about emotions and ADHD is timely. Fortunately, solutions are available.
First, a bit of jargon to note from the psychological literature. “Emotional regulation” means a set of abilities that include our ability to recognize our own and others’ emotions, to adjust our emotional intensity to match the situation, and to modify our emotional reactivity in line with our own goals, intentions, and social demands.
This doesn’t just mean willpower or biting our tongue when we feel provoked. It also means using strategies like self-talk, changing our interpretation or attribution about something, or anticipating ahead of time how we might feel in a situation. It can even mean avoiding provocative situations. (For example, some people are very provoked by the constant drama of political news. They can regulate their emotions these days by checking the news once a week instead of daily).
“Irritability” means problems handling anger. It refers to two things. One is a tendency to be grouchy and touchy most of the time. This is considered background irritability. Two is a tendency to frequent explosions of anger, usually without very fast recovery. For children, this means tantrums that are out of proportion to the situation, happening several times a week, and persisting for a period of time. For adults, it is similar. These may be restricted to verbal outbursts or may coincide with physical aggression—another layer of a severe problem if it occurs.
Sometimes these difficulties are due to an undetected mood disorder, like depression or anxiety. (Contrary to what was once believed, severe anger problems are not a sign of bipolar disorder risk in people with ADHD). People with ADHD, however, often have these difficulties even when they don’t have another condition. It’s really a part of ADHD too.
About 70% of adults report problems with anger or emotion as part of their ADHD. Among children, in our research, we find that 70-80% of children with ADHD have atypical emotion regulation. About 30% of kids had severe anger and tantrum problems, often along with elevated moodiness and anxiety. Another 40% were very active, energetic, risk-taking, and had a more positive mood, but were also prone to anger outbursts.
Our team also reported earlier this year on the genetic links. We examined molecular genetic scores for liability for ADHD and liability for depression in over 400 children. We noted that genetic liability for ADHD, but not for depression, was related to anger regulation problems in individuals with ADHD.
All of this suggests that emotional regulation in general, including problems managing anger, is really part of ADHD. This is part of the reason that individuals with ADHD are prone to much higher rates of anxiety and depression during adolescence and adulthood too. We and others have found that the kids with negative emotionality and anger were four times as likely to have these problems emerge in the future compared to kids with ADHD with more typical emotional profiles.
How can these challenges be helped? The answer depends on the developmental stage. For children, a clinical intervention has three parts. First, parents can benefit from counseling to help them not get caught up in negative or angry exchanges with their child. Research shows that those dynamics, while understandable, seem to contribute to perpetuating the problem. In other situations, parents have fallen into a habit of giving additional attention or another unintended "reward" that is contributing to the child’s tantrum habit. In either situation, counseling can help identify alternative ways of handling a child’s tantrums so they can phase out.
Second, counseling of the child (if they are willing) will help them to do less over-interpreting of situations that lead to needless anger. Often, they are misattributing the meaning of a situation. With counseling, they can decrease that. Kids can also develop more mature ways of coping with frustration — their usual anger trigger — when they don’t get what they want.
As a final note, typical stimulant medications for ADHD are often not effective in helping with anger problems. (If the dose is wrong, stimulants can even make the problem worse). A clinical trial published earlier this year indicates that when stimulants alone are not working, children with severe anger problems may benefit from adding a type of antidepressant called an SSRI (selective serotonin reuptake inhibitor).
For adults, a lot more rests on your own counseling and skill-building. Once again, typical ADHD meds are only partially helpful; even when they help the ADHD, they don’t help anger or emotional coping as much. We don’t have any good data on other meds in adults.
However, cognitive-behavioral therapy has proven quite beneficial. This type of counseling both helps with attributions (“maybe that guy is tailing me because he has a medical emergency and not because he’s an idiot, so I’ll just relax and pull over so he can pass”) and with developing other coping skills like anticipating situations and planning around them. A modification that adds mindfulness principles, like learning to observe emotions in ourselves before we react, can sometimes bring additional benefit.
The jury is still out on newer tools like meditation, omega-3 fatty acid supplementation, or therapeutic vitamin-mineral supplementation. These all appear promising and are safe, so you can try them. However, they do not yet have an expert consensus behind them. Certain other hyped treatments, like hypnosis, neurofeedback, or learning about emotions without doing skill-building practice, are not effective.
As always, for kids and adults, a healthy lifestyle — plenty of exercise, making sure sleep is adequate, eating fresh and healthy food, mitigating stress, and for adults, avoiding alcohol or drugs — is going to help soften the edges around any emotional struggle.
In summary, here are your best moves:
For Children with ADHD and severe tantrums
- Evaluation to rule out depression or other cause
- Parenting counseling to add skills to your toolkit
- Child skill-building counseling to help learn how to cope with frustration
- Medically, adjust ADHD medication or adding an SSRI can be considered
- Good nutrition and omega-3, supplementation may partially help
- CBT focused on coping skills
- Meditation training (group or solitary) may provide an ancillary benefit
- Consider medication, although it is often only partially effective for anger
- Manage stress with exercise, sleep, recreation breaks, social supports
- Eliminate alcohol and recreational drugs
So, take care of yourself, attend to your own mental and physical health, believe the best, and go easy on each other during these challenging times for kids, families, and people with ADHD.
For more information on this topic, I recently presented a webinar on “Why ADHD Brains Wrestle with Emotional Regulation.”
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
Cooper, R.E., Tye, C., Kuntsi, J., 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
Karalunas, S.L., Gustafsson, H.C., Fair, D. et al. (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://psycnet.apa.org/doi/10.1037/pas0000664
López-Pinar, C., Martínez-Sanchís, S., Carbonell-Vayá, E. et al. (2020). Efficacy of nonpharmacological treatments on comorbid internalizing symptoms of adults with Attention-Deficit/Hyperactivity Disorder: A meta-analytic review. Journal of Attention Disorders, 24(3), 456–478. https://doi.org/10.1177/1087054719855685
Nigg, J.T., Karalunas, S.L., Gustafsson, H.C. et al. (2020). Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD. J Child Psychol Psychiatr, 61: 205-214. https://doi.org/10.1111/jcpp.13132
Rucklidge, J., Frampton, C., Gorman, B. et al. (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. https://doi.org/10.1192/bjp.bp.113.132126
Stringaris, A., Vidal-Ribas, P., Brotman, M.A. et al. (2018). Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. Journal of child psychology and psychiatry, and allied disciplines, 59(7), 721–739. https://doi.org/10.1111/jcpp.12823
Towbin, K., Vidal-Ribas, P., Brotman, M.A., 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 and Adolescent Psychiatry, 59(3), 350–361. https://doi.org/10.1016/j.jaac.2019.05.015
Xue, J., Zhang, Y., & Huang, Y. (2019). A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine, 98(23), e15957. https://doi.org/10.1097/MD.0000000000015957