Research in Developmental Disabilities 59 (2016) 428–436

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Research in Developmental Disabilities

Emotional dysregulation of ADHD in childhood predicts poor

early-adulthood outcomes: A prospective follow up study
Ying Qian a,b,1 , WeiLi Chang c,1 , Xiaoxiao He a,b , Li Yang a,b , Lu Liu a,b , Quangang
Ma c , Yueling Li a,b , Li Sun a,b , Qiujin Qian a,b,∗,2 , Yufeng Wang a,b,∗,2
a
Institute of Mental Health, Sixth Hospital, Peking University, Beijing, China
b
Key laboratory of Ministry of Health (Peking University), Beijing, China
c
The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

a r t i c l e i n f o a b s t r a c t

Article history:
Received 25 October 2015 Backgroud: Emotional dysregulation (EDR) is commonly seen in individuals with attention
Received in revised form 28 July 2016 deficit hyperactive disorder (ADHD). But few are known about the influence of EDR on
Accepted 30 September 2016
early-adulthood outcomes.
Aims: To detect the relationship between emotional dysregulation (EDR) in childhood and
Keywords: the outcomes in early-adulthood of participants with attention deficit hyperactive disorder
ADHD
(ADHD).
Adult
Methods and procedures: Han Chinese children who met DSM-IV ADHD criteria were fol-
Emotional dysregulation
Outcomes lowed up into early adulthood. The subjects were divided into two groups (with or without
Oppositional defiant disorder EDR) according to the emotion control subscale of Behavior Rating Scale of Executive Func-
tion in childhood. In the follow-up interview, their clinical outcomes were assessed by
the Conner’s Adult ADHD Diagnostic Interview and the Structured Clinical Interview for
DSM-IV-TR Axis I and II Disorders. Information on after-school tutoring and suspension of
schooling was also collected as indices of educational outcomes.
Outcomes and results: We followed up 68 out of 90 individuals when they reached early
adulthood. Data analysis showed that EDR predicted HI symptoms of ADHD both in
childhood (OR = 10.28, p < 0.01) and in early-adulthood (OR = 4.07, p = 0.01). And EDR in
childhood had trend to predicted adult ODD (X2 = 3.93, p = 0.05). The suspension of schooling
was also predicted by EDR (OR = 9.31, p = 0.04).
Conclusions and implications: This study illustrated that EDR of children with ADHD, inde-
pendent of co-occurring ODD, predicted poor long-term clinical and educational outcome
in early-adulthood.
© 2016 Elsevier Ltd. All rights reserved.

∗ Co-corresponding authors at: Hua yuan bei lu 51, Hai Dian district, Beijing, China,100191.
E-mail addresses: wangyufeng@bjmu.edu.cn (Q. Qian), qianqiujin@bjmu.edu.cn (Y. Wang).
1
Ying Qian and Weili Chang provided equal contribution to this study as the co-first authors. Ying Qian was in charge of the study design, analysis and
interpretation of data and the writing of the report. Weili Chang was in charge of the data collection.
2
Professor Yufeng Wang and Qiujin Qian provided equal contribution to this study as the co-corresponding authors. Yufeng Wang was in charge of the
study design and provided help on the writing of the report. Qiujin Qian was in charge of recommendation of the participants and revised the final report.

http://dx.doi.org/10.1016/j.ridd.2016.09.022
0891-4222/© 2016 Elsevier Ltd. All rights reserved.
 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436 429

1. Introduction

Emotional regulation is defined as an individual’s ability to modify an emotional state so as to promote adaptive, goal-
oriented behaviors (Thompson, 1994). Emotional dysregulation (EDR) arises when the adaptive processes are impaired,
leading to behavior that defeats the individual’s interests. It encompasses 1) emotional expressions and experiences that are
excessive in relation to social norms and are context inappropriate; 2) rapid, poorly controlled shifts in emotion (lability);
and 3) the anomalous allocation of attention to emotional stimuli (Shaw, Stringaris, Nigg, & Leibenluft, 2014).
Emotional dysregulation is found in some 25%–45% of children and 30%–70% of adults with attention deficit hyperactivity
disorder (ADHD) (Barkley & Fischer, 2010; Shaw et al., 2014; Stringaris & Goodman, 2009; Surman et al., 2013). Individuals
with both ADHD and EDR were shown to be more impaired in peer relationships, family life, occupational attainment, and
academic performance than those with ADHD alone (Wehmeier, Schacht, & Barkley, 2010). Although it has been recognized
that many individuals with ADHD also have difficulties with emotional regulation, no consensus has been reached on how
to conceptualize this clinically challenging domain (Shaw et al., 2014).
Some researchers consider EDR as a core diagnostic feature of ADHD (Barkley & Fischer, 2010; Vidal et al., 2014), but many
ADHD patients are not shown to exhibit impairing levels of EDR (Shaw et al., 2014). So the evidence is not sufficient enough
for EDR to be seen as another core diagnostic dimension of ADHD. However, in recent years, several studies have reported
that, both in children (Sobanski et al., 2010) and adults (Skirrow & Asherson, 2013) with ADHD, EDR is linked more specifically
to hyperactivity–impulsivity (HI) rather than inattention, and the combined rather than inattentive ADHD presentation. And
further study found that such a relationship cannot be explained by the neuropsychological parameters (Banaschewski et al.,
2012). In addition, another hypothesis (Villemonteix, Purper-Ouakil, & Romo, 2014) is raised that emotion dysregulation
might represent a criterion for the diagnosis of HI domain of ADHD. But there is also a negative result on this theory. One
study shows emotion dysregulation is commonly associated with either symptom domain of ADHD (Becker et al., 2006). It
is thus proposed that longitudinal studies are required to explore the developmental trajectories of both the EDR and the
core symptoms of ADHD and how they interact with each other (Banaschewski et al., 2012; Shaw et al., 2014; Skirrow &
Asherson, 2013).
The Conners’ Rating Scales (Conners, Sitarenios, Parker, & Epstein, 1998), the Child Behavior Checklist (CBCL) (Achenbach
& Dumenci, 2001), the Behavior Rating Scale of Executive Function (BRIEF) (Gioia, Isquith, Kenworthy, & Barton, 2002) are
the most frequently used tools for the assessment of EDR in ADHD (Banaschewski et al., 2012;Shaw et al., 2014;Sorensen,
Plessen, Nicholas, & Lundervold, 2011). As EDR in individuals with ADHD is likely to have a number of clinically important
components, such as irritability and mood lability (Shaw et al., 2014), and Conners’ scale, CBCL, and BRIEF may assess different
components of emotional regulation, it has been proposed to develop consensus measures to operationalize each component
(Shaw et al., 2014). Before that, different measures for EDR are required to be used for the same or similar studies to see
whether these measures could assess what we indeed to assess or not. However, we have not found longitudinal studies
assessing emotion dysregulation of ADHD by BRIEF. As BRIEF has been shown to be an ecological valid tool, the current study
decides to use the emotional control subscale of BRIEF to detect the characteristics of emotional regulation of children with
ADHD. To exclude the impact of gender and development, raw scores are converted to gender- and age- standardized scores
for Han Chinese. Children with ADHD who scored higher than 60 (1 SD higher than norm) (Biederman et al., 2012) were
considered to have EDR.
The relationship between EDR and ODD is another controversial topic. ADHD shows a high comorbidity with oppositional
defiant disorder (ODD, 54%–67%) (Barkley, Fischer, Edelbrock, & Smallish, 1990), a disorder that features symptoms of EDR.
Due to this comorbidity, EDR was considered a secondary consequence of ADHD, which could arise under the influence of
environmental factors such as inefficient parenting practices, as part of an ODD diagnosis. However, recent studies indicated
that a large number of children with ADHD and without any comorbid disorder exhibit symptoms of EDR (Villemonteix
et al., 2014). Therefore, it is necessary for further study to provide further evidence that EDR is an important component of
ADHD which is independent of ODD.
Since the transition to young adulthood is known to be a time of critical importance and increased demand (Arnett, 2000)
and individuals with ADHD in China have been reported to be different from their western counterparts on clinical charac-
teristics (Yang, Wang, Qian, & Gu, 2001), the current study followed up Han Chinese children with ADHD aged 10–15 into
their early-adulthood. We compared not only the baseline clinical variables but also the clinical and educational outcomes
in the early-adulthood between children with ADHD and those with ADHD + EDR.
Therefore, the primary aim of the current study is to detect the relationship between EDR and HI symptoms of individuals
with ADHD with a developmental perspective. The second aim of this study is to explore the long-term influence of EDR on
other clinical outcomes, such as diagnosis of adult mood disorder and ODD, and the educational outcomes in children with
ADHD. The hypothesis of this study is that EDR of children with ADHD, dependent of ODD comorbidity, is likely to be an
important component of ADHD and might further represent a criterion for the diagnosis of HI domain of ADHD.
430 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436

2. Materials and methods

2.1. Participants

Ninety children diagnosed with ADHD who came consecutively to Institute of Mental Health Peking University and gave
us their contact information, aged ten to fifteen years old, were followed into early-adulthood, at which point 68 (75%)
assented to reassessment. The baseline demographic and clinical information of the follow-up group were similar to the
drop-out group (Table 1). For all participants at baseline, exclusion criteria were history of (a) pervasive developmental
disorder or psychosis, (b) traumatic brain injury with loss of consciousness, (c) uncorrected hearing or visual impairment
on screening tests, (d) IQ below 80, and (e) concurrent treatment with medication other than a stimulant and/or treatment
with medication within 24 h of testing.
At baseline, each child was diagnosed as ADHD by DSM-IV criteria based on the semi-structured parent and child inter-
views (details of the instruments (Barkley, 1998) are in the measure part) with two expert child psychiatrists. Among children
diagnosed with ADHD, 46 were inattentive presentation (ADHD-I), 1 was hyperactive-impulsive presentation (ADHD-HI),
and 21 were combined presetation (ADHD-C). For co-occurring disorder, 25(37%) had oppositional defiant disorder (ODD),
3(4%) had mood disorder (including major depressive disorder and bipolar disorder), 40(59%) had learning difficulties, 9(13%)
had tic disorder and 12(18%) had other disorders.
At follow-up, participants were eighteen to twenty-four years old and they were categorized into subgroups of ADHD
based on symptoms and impairment associated with the disorder according to the Conners’ Adult ADHD Diagnostic Interview
for DSM-IV (CAADID) (Conners, Erhardt, & Sparrow, 1999). In early-adulthood, 54 participants were considered to have
persistent ADHD (21 meeting full DSM-IV criteria and 33 fitting sub-threshold DSM-IV criteria) and 14 were seen as remitted
ADHD. For different symptom domains of ADHD, 52 individuals were seen to have persistent inattentive symptoms and 29
participants have persistent HI symptoms. All participants were interviewed by The Structured Clinical Interview for DSM-IV
(SCID-I) and the Structured Clinical Interview for DSM-IV Personality Disorders Questionnaire (SCID-II) (First, Spitzer, Gibbon,
Williams, & Benjamin, 1997; Li et al., 2013) to see the diagnosis of other psychiatric disorder in early-adulthood. Among
them, 11(16%) were mood disorder, 7(10%) were anxiety disorder, 4 (6%)were substance abuse, 1(1%) was eating disorder,
16(24%) were adult ODD and 27(40%) were personality disorder (PD). Among the 27 PD, 3(4%) were avoidant PD, 1(1%) was
dependent PD, 9(13%) were obsessive-compulsive PD, 8(12%) were passive aggressive PD, 2(3%) were depressive PD, 4(6%)
were paranoid PD, 1(1%) was schizotypal PD, 1(1%) was schizoid PD, 2(3%) were histrionic PD, 6(9%) were narcissistic PD,
4(6%) were borderline PD, 1(1%) was antisocial PD.

Table 1
Comparison of demographic and clinical characteristics between follow-up and drop-out groups.

drop-out group follow-up group t/X2 p

n = 22 n = 68
M/n SD M/n SD

Emotional regulation
emotional control subscale of BRIEF
72.79 16.15 65.70 15.18 1.87 0.06

IQ 105.55 17.34 104.52 14.78 0.27 0.79

Age baseline 13.19 1.10 12.98 1.06 0.80 0.43

Gender male 20 56 0.97 0.32

female 2 12

ADHD severity DQ 53.41 8.65 50.64 8.75 1.29 0.20

ADHD comorbidity
ADHD + ODD yes 12 25 0.46 0.50
no 10 43

ADHD presentation
ADHD-I yes 15 46 0.68 0.71
no
ADHD-HI yes 0 2
no
ADHD-C yes 7 20
no

Notes: ADHD = Attention deficit hyperactivity disorder; ODD = oppositional and defiant disorder; BRIEF = behavior rating scale of executive function; ADHD-
I = Attention deficit hyperactivity disorder inattentive presentation; ADHD-C = Attention deficit hyperactivity disorder combined presentation; ADHD-
HI = Attention deficit hyperactivity disorder Hyperactive- impulsive presentation.
 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436 431

2.2. Procedures

This study was approved by the local clinical research ethics committee. Informed consent was obtained from both
participants and parents.
During the baseline interview, all the participants and their parents were interviewed by using the Chinese CDIS and the
parents also filled in the Behavior Rating Inventory of Executive Function (BRIEF) by themselves. Every child received the IQ
tests, in a standard order. Each child with ADHD was seated comfortably in a quiet room in the hospital.
The follow-up interview was carried out four to seven years after the baseline interview. Subjects were face to face inter-
viewed (30 of them) or telephoned (38 of them) with the CAADID and SCID-I/II. The CAADID and SCID-I/II were administered
by three PhD-level psychiatric graduate students who had received formal standardized training. The kappa consistency for
them was 0.97, 0.90, 0.95 for CAADID, SCID-I and SCID-II.

2.3. Measures

2.3.1. Baseline measures

2.3.1.1. Clinical diagnostic interview scale. The CDIS (Barkley, 1998) is a structured interview instrument based on the DSM-
IV assessing behavioral and emotional disorders during childhood, including ADHD, ODD, CD, tics, and emotional, affective,
and learning disorders. The CDIS was introduced to mainland China in 2000 (Yang et al., 2001).

2.3.1.2. ADHD rating scale–IV (ADHD RS-IV). The instrument used to measure symptom severity was the ADHD Rating Scale
−IV (ADHD RS-IV), an eighteen-item scale with one item for each of the eighteen symptoms contained in the DSM-IV
diagnosis of ADHD.

2.3.1.3. Measure for emotional regulation. The emotional control subscale of The Behavior Rating Inventory of Executive
Function (BRIEF) Parent Form were used to measure EDR(Gioia et al., 2002). Raw scores were converted to gender- and age-
standardized scores (t scores having a mean of 50 and a SD of 10) to exclude the influence of development and gender. EDR
was defined positive if the T scores were higher than 60. The BRIEF parent form for children aged 5–18 years consists of 86
items based on theoretically and empirically based definitions of the executive function construct and the emotional control
subscale consists 10 items (Gioia et al., 2002). A higher score indicates more problems in that area. The Mandarin version of
the BRIEF parent form was introduced into China by our group in 2006(Qian & Wang, 2007). For the results of the emotional
control subscale, the test-retest reliability and Cronbach’s coefficient were 0.68 and 0.90. The correlation coefficients were
0.42–0.51 between subscales of ADHD RS-IV and emotional control subscale (Qian & Wang, 2007).

2.3.1.4. IQ estimates. IQ was assessed by the Chinese-Wechsler Intelligence Scale for Children (C-WISC) The Intelligence
Quotient (IQ) of the participants was assessed using the Chinese-Wechsler Intelligence Scale for Children (C-WISC)(Gong,
1993).

2.3.2. Follow-up measures

2.3.2.1. The conners’ adult ADHD diagnostic interview for DSM-IV (CAADID). It assesses the presence of ADHD symptoms and
functional impairment in adults and the Chinese version of CAADID has been used by our group for a few years (Conners et al.,
1999; Li et al., 2013). Each of the 18 items of the scale corresponds to each of the 18 DSM-IV ADHD symptoms is rated on a yes-
or-no scale. Four domains (family relationship, interpersonal relationship, function of schooling or working and self −value)
of functional assessment are evaluated on a yes-or-no scale. ADHD that met either full or sub-threshold DSM-IV criteria at
the follow-up assessment was considered to be Persistent ADHD. ADHD that did not meet at least sub-threshold criteria for
ADHD was considered to be Remittent ADHD (Biederman et al., 2009). Sub-threshold ADHD was defined as never having
met DSM-IV criteria for ADHD but having three or more chronic symptoms in either inattentive or hyperactive-impulsive
domain along with significant impairment in functional assessment (Biederman et al., 2009; Faraone et al., 2006).

2.3.2.2. The structured clinical interview for DSM-IV (SCID-I) and the structured clinical interview for DSM-IV personality disorders
questionnaire (SCID-II). The SCID-I (First et al., 1997) and SCID-II (First et al., 1997) are designed to assess the Axis I or Axis
II disorders.

2.4. Data analysis

Data were missing for 7 participants in the diagnosis of adult ODD and 1 participant in the educational outcome. We did
analysis by excluding the participants whose data were missing instead of replacing them.
To exclude the potential confounding variables during childhood, we collected the following information at baseline
as well: ADHD severity, co-occurring diagnosis of ODD or mood disorder, treatment, IQ and the demographic information.
Treatment was a two degree variable in this study. Those taking medicine for over six months or having non-pharmacological
therapy for over three months were referred as having systematic treatment.
432 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436

Table 2
Comparison of demographic and clinical characteristics between ADHD and ADHD + EDR In childhood.

ADHD ADHD + EDR

(n = 29) (n = 39)
M/n SD M/n SD t/X2 p

IQ 104.34 14.50 106.05 14.47 −0.48 0.63

Age (month) baseline 13.06 1.17 13.13 1.11 0.22 0.82

Gender male 24 32 0.01 1.00

female 5 7

ADHD severity DQ 53.56 8.05 47.14 8.37 −3.20 <0.01*

ADHD symptoms
Inattention yes 29 37 2.00 0.16
no 0 2
Hyperactivity-impulsivity yes 4 18 10.83 <0.01*
no 25 21

ADHD comorbidity
ODD yes 9 16 0.71 0.40
no 20 23
Mood disorder
yes 1 2 0.11 1.00
no 28 37

systematic therapy
yes 7 16 2.12 0.20
no 22 23

Notes: ADHD = Attention deficit hyperactivity disorder; EDR = emotional dysregulation; ODD = oppositional and defiant disorder; BRIEF = behavior rating
scale of executive function
*
p < 0.05.

The clinical outcomes in childhood which were studied were the HI symptoms of ADHD, the co-occurring diagnosis of
ODD, the mood disorder comorbidity and ADHD severity.
Two groups of outcome variables in early-adulthood were studied: Clinical and educational. The diagnosis of adult mood
disorder, adult ODD and persistence of HI symptoms was seemed as the index of the clinical outcome. And requirement of
after-school tutoring or suspension of schooling was the index of the educational outcome.
Each variable both in childhood and early-adulthood was analyzed between children with ADHD and those with ADHD
plus EDR independently. The chi square test was used for qualitative variables while the difference in mean t−test was
employed for quantitative variables. Whenever possible, the effect was quantified by means of further logistic analysis.
All analyses were two-tailed with a significance level of 0.05.

3. Results

3.1. 1 ADHD versus ADHD + EDR in childhood

Children with ADHD + EDR were more likely to have HI symptoms (n = 39:29, X2 = 10.83, p < 0.01) and had higher score
(n = 39:29, t = −3.20, p < 0.01) than those without EDR on assessment of symptom severity.
No significant difference was found on mood disorder comorbidity between ADHD children with and without EDR (see
Table 2).

3.2. 2 ADHD versus ADHD + EDR in early-adulthood

Children with ADHD + EDR were more likely to have persistent HI symptoms (n = 39:29, X2 = 7.08, p = 0.01) when they
grew into early adulthood than those with ADHD only. No difference was found on persistent ADHD or persistent inattentive
symptoms between these two groups.
As far as the outcomes of diagnosis of other psychiatric disorders in early-adulthood is concerned, children with
ADHD + EDR had trend to be more likely to suffer from adult ODD (n = 29:39, X2 = 3.93, p = 0.05) when compared with children
with ADHD only.
For educational outcome, at follow-up, suspension of schooling (n = 39:29, X2 = 5.75, p = 0.02) was more frequently among
children with ADHD + EDR than those without EDR (see Table 3).
 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436 433

Table 3
Comparison of demographic and clinical characteristics between ADHD and ADHD + EDR In early-adulthood.

ADHD ADHD + EDR ADHD ADHD + ODD

(n = 29) (n = 39) (n = 43) (n = 25)

M/n SD M/n SD t/X2 p M/n SD M/n SD t/X2 p

Clinical outcome
persistence of hyperactive-impulsive symptoms
yes 7 22 7.08 0.01 18 11 0.03 0.86
no 22 17 25 14

persistence of inattentive symptoms

yes 22 30 0.01 0.92 34 18 0.44 0.51
no 7 9 9 7

ADHD persistence
yes 22 32 0.39 0.56 36 18 1.33 0.25
no 7 7 7 7

ODD
yes 3 13 3.93 0.05 5 11 8.55 <0.01
no 22 25 34 13

Mood disorder
yes 3 8 1.27 0.33 4 7 4.08 0.04
no 26 31 39 18

Educational outcome
suspension of schooling
yes 1 10 5.79 0.02 5 6 1.67 0.20
no 27 29 37 19

after school tutoring

yes 21 25 0.90 0.34 29 17 0.01 0.93
no 7 14 13 8

Table 4
logistic regression analysis for baseline variables and hyperactive-impulsive symptoms in childhood.

Beta S.E. P OR 95.0% C.I.

Lower Upper

emotional control subscale of BRIEF 2.33 0.73 <0.01 10.28 2.46 43.00

Model P = 0.009.

3.3. 3 ADHD versus ADHD + ODD in early-adulthood

At baseline, no significant difference was found on symptom severity and HI symptoms of ADHD between children with
ADHD and those with ADHD + ODD.
At follow-up, children with ADHD + ODD were more likely to be suffered from adult ODD (n = 43:25, X2 = 8.55, p < 0.01)
and mood disorder (n = 43:25, X2 = 4.08, p = 0.04) than those with ADHD only (see Table 3).

3.4. Logistical regression

To exclude the influence of the confounding factors, we entered the emotional control subscale of BRIEF, ODD comorbidity,
ADHD presentation, IQ, gender, age, time span between the first and the follow-up interview, and systematic therapy as
covariates and HI symptoms in childhood as dependent variable in the subsequent logistic regression. The results suggested
that HI symptoms in childhood was significantly correlated with EDR (OR = 10.28, p < 0.01) (see Table 4).
We did previous logistical regression for persistence of HI symptoms, adult ODD, adult mood disorder and suspension
of schooling as well. The result indicated that persistence of HI symptoms in early-adulthood was only predicted by the
EDR (OR = 4.07, p = 0.01) (see Table 5). And suspension of schooling was only predicted by the EDR (OR = 9.31, p = 0.04) (see
Table 7). On the other hand, adult mood disorder (OR = 3.79, p = 0.05) (see Table 6) was only predicted by co-occurring ODD.
Although p for the prediction of adult mood disorder was 0.05 (not less than 0.05), the OR was big enough to demonstrate
that co-occurring ODD have trend to predict adult mood disorder in early adulthood.
434 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436

Table 5
logistic regression analysis for baseline variables and persistence of hyperactive-impulsive symptoms in early-adulthood.

Model P = 0.043

Beta S.E. P OR 95.0% C.I.

Lower Upper

emotional control subscale of BRIEF 1.40 0.54 0.01 4.07 1.41 11.74

Model P = 0.007.

Table 6
logistic regression analysis for baseline variables and mood disorder in early-adulthood.

Beta S.E. P OR 95.0% C.I.

Lower Upper

ODD comorbidity 1.33 0.69 0.05 3.79 0.98 14.62

Model P = 0.047.

Table 7
logistic regression analysis for baseline variables and suspension of schooling at follow-up.

Beta S.E. P OR 95.0% C.I.

Lower Upper

emotional control subcale of BRIEF 2.23 1.08 0.04 9.310 1.12 77.68

Model P = 0.009.

4. Discussions

4.1. Relationship between EDR and the HI symptoms of ADHD

The result of the current study indicated that children with ADHD + EDR were more likely to have HI symptoms not only
in childhood but also in early-adulthood than those with ADHD only.
The relationship between EDR and HI symptoms has been reported in previous cross-sectional studies (Banaschewski
et al., 2012; Maedgen & Carlson, 2000; Sobanski et al., 2010). Sobanskietal et al. (Sobanski et al., 2010) found that in children
with ADHD, EDR was linked more specifically to hyperactivity- impulsivity rather than inattention, and the combined rather
than inattentive ADHD presentation. As previous longitudinal research revealed a greater developmental decline in HI than
inattentive symptoms (Biederman, Mick, & Faraone, 2000), it was hypothesized that problems with emotional regulation
might diminish alongside hyperactivity- impulsivity during development and be less problematic in adults. However, indi-
viduals with ADHD and EDR were shown to be more likely to have more severe and complex symptoms(Reimherr et al.,
2010). Furthermore, Reimherr et al. (2010) found EDR appeared to be more prevalent in adults with the HI symptoms.
Similarly, Skirrow et al. revealed (Skirrow & Asherson, 2013) EDR in adult ADHD could not be accounted for by other psychi-
atric disorders or sub-threshold syndromes co-occurring with ADHD but by the HI symptoms of ADHD. Thus an alternative
hypothesis was raised that EDR in childhood might predict poorer prognosis for remission of ADHD symptoms (Skirrow &
Asherson, 2013) and represent a criterion to the diagnosis of HI domain of ADHD (Villemonteix et al., 2014). The result of
the current follow-up study further confirmed the evident relationship between EDR and HI symptoms both in childhood
and in early-adulthood. Alternatively, the findings of this study supported the hypothesis that EDR in childhood is an impor-
tant component of ADHD and might further represent a criterion to HI domain of ADHD diagnosis. Furthermore, studies
found that pharmacological and psychotherapeutic interventions for core symptoms of ADHD can lead to amelioration of
EDR (Corbisiero, Stieglitz, Retz, & Rosler, 2013; Retz, Stieglitz, Corbisiero, Retz-Junginger, & Rosler, 2012). Thus, besides an
important component of diagnosis, EDR both in children and adults with ADHD is also an important aspect for treatment.
There was one study (Becker et al., 2006) showing that emotion dysregulation is commonly associated with either
symptom domain of ADHD. It is possibly due to the different instruments used to assess EDR. Therefore, it is vital for future
study to compare the psychometric property of different instrument on the assessment of EDR.

4.2. EDR predicts poor long-term clinical and educational outcomes in early-adulthood

Besides predictive validity of EDR on HI symptoms, the current study also showed that children with ADHD + EDR had
more severe symptoms in childhood and had trend to predict the diagnosis of adult ODD and had poorer educational outcome
in early-adulthood. These results confirmed what most previous studies found (Barkley & Fischer, 2010;Wehmeier et al.,
2010). And such results provided further evidence for the hypothesis that EDR might be important component of ADHD.
 Y. Qian et al. / Research in Developmental Disabilities 59 (2016) 428–436 435

4.3. EDR and the comorbidity of ODD, different features of children with ADHD or just the same?

It is controversial (Villemonteix et al., 2014) whether the EDR of children with ADHD is due to the combination of ODD
or not. The findings of this study provided evidence for the difference between the EDR and ODD comorbidity of children
with ADHD.
In the current study, at baseline, no difference was shown between children with ADHD and ADHD + EDR on the prevalence
of ODD comorbidity in childhood. Furthermore, at follow-up, it was not the co-occurring ODD but the EDR that predicted
the persistence of HI symptoms and poor educational outcome for children with ADHD. And it was the co-occurring ODD
instead of EDR in childhood that predicted the diagnosis of adult mood disorder for children with ADHD. So the results of
the current study showed the EDR and the comorbidity of ODD were not only non-correlated at baseline but also predicted
different outcomes in early-adulthood. The results were consistent with what western study(Skirrow & Asherson, 2013)
and the cross-sectional study by our group (Liu et al., 2016). Thus it is better for them to be seen as independent features of
children with ADHD.

4.4. Limitations and future directions

This study just provided the clinical and educational outcomes of children with ADHD in their early-adulthood but lacking
the assessment of emotional regulation during the follow-up interview. Thus, we cannot see the developmental trajectory of
emotional regulation in children with ADHD and the interaction between the emotional regulation and the core symptoms
of ADHD with development.
As EDR in individuals with ADHD is likely to have a number of clinically important components, such as irritability
and mood lability (Shaw et al., 2014). It has been proposed to use consensus measurement techniques which can address
all components of EDR. However, no such consensus measurements have been proved. The current study used one of the
existing measures, the emotional control subscale of BRIEF. It is thus crucial for future study to use different assessments
for EDR and to compare their psychometric properties.
Small sample is another limitation. For example, p of the prediction of co-occurring ODD to adult mood disorder was
0.05. If more participants were recruited in future study, the p might be less than 0.05.

4.5. Conclusion

In sum, this follow-up study demonstrated that children with ADHD accompanied with EDR were more predictable for
HI symptoms in both childhood and early-adulthood than those with ADHD only. The current study also discovered EDR of
children with ADHD, dependent of co-occuring ODD, predicted poor long-term clinical and educational outcomes into early-
adulthood. This finding provided further evidence to support the hypothesis that EDR in childhood might be an important
component of ADHD and could further represent a criterion to HI domain of ADHD diagnoses.

Acknoledgements

This research is funded by the National Natural Science Foundation of China [81101014], the National Basic Research
Development Program of China [973 program 2014CB846104], the Beijing Municipal Science and Technology Commission
(Z151100004015103) and the Program for New Century Excellent Talents in University [NCET-11-0013]. These funding
agents had no role in the study design; collection, analysis, and interpretation of the data; writing of the manuscript; or
decision to submit the paper for publication.

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