Psychiatry Research 254 (2017) 1–7

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Attentional control of emotional interference in children with ADHD and T

typically developing children: An emotional N-back study
⁎
Thomas Villemonteixa,b, ,1, Ivo Marxc,1, Mathilde Septierd,e, Christoph Bergerc, Thomas Hackerf,
Sara Bahadorid,e, Eric Acquavivad, Isabelle Massatb,g,h
a
EA 2007, Psychopathology and Neuropsychology Lab., Université Paris 8, Saint-Denis, France
b
UR2NF - Neuropsychology and Functional Neuroimaging Research Unit, Centre de Recherche Cognition et Neurosciences, Université Libre de Bruxelles (ULB), Bruxelles,
Belgium
c
Department of Child and Adolescent Psychiatry, Neurology, Psychosomatics and Psychotherapy, University Medicine Rostock, Rostock, Germany
d
Assistance Publique-Hôpitaux de Paris, Department of Child and Adolescent Psychiatry, Robert-Debré Hospital, Paris, France
e
Inserm, U894, Psychiatry and NeurosciXence Center, Paris, France
f
Department of Psychiatry and Psychotherapy, University Medicine Rostock, Rostock, Germany
g
Laboratory of Experimental Neurology, ULB, Bruxelles, Belgium
h
National Fund of Scientific Research (FNRS) Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Emotional interference control refers to the ability to remain focused on goal-oriented processes when
Attention-Deficit/Hyperactivity Disorder confronted with disrupting but irrelevant emotional stimuli, a process that may be impaired in children and
(ADHD) adults with attention deficit/hyperactivity disorder (ADHD). However, emotional interference levels are known
Emotion regulation to be associated with trait anxiety, and patients with ADHD often display elevated levels of trait anxiety, such as
Emotional interference
these may have confounded previous findings of decreased emotional interference control in this population. In
Working memory, Interference control
the present study, male and female 8–13 years old (mean =11.0 years) children with ADHD (n=33) and
typically developing (TD) children (n=24) performed a visual emotional working memory (n-back) task with 2
memory loads and three different background pictures (neutral/positive/negative), and trait anxiety measures
were obtained. Children with ADHD performed less well, and displayed increased emotional interference in the
presence of aversive distractors when compared with TD children. Contrary to our expectations, trait anxiety did
not mediate the association between diagnostic group membership and the degree of emotional interference
control; however, co-morbid ODD was associated with decreased levels of emotional interference in ADHD.
Future research should aim at characterizing the mechanisms subtending decreased emotional interference
control in the ADHD population.

1. Introduction towards negative emotions (Becker et al., 2006; Anastopoulos et al.,

Attention-deficit/hyperactivity disorder (ADHD) core clinical fea-
tures consist of developmentally inappropriate levels of inattention,
and/or hyperactivity /impulsivity (DSM-V, American Psychiatric
Association, 2013). Along with these characteristics, emotional dysre-
gulation symptoms are common in children and adolescents with ADHD
(Anastopoulos et al., 2011; Sjowall et al., 2013; Villemonteix et al.,
2015). A population study of 5326 youths reported mood lability in
38% of children with ADHD, which is ten times the population rate
(Stringaris and Goodman, 2009). In clinical samples, 44–47% of
children with ADHD exhibit significant symptoms of emotional lability,
such as irritability, hot temper, and/or sudden unpredictable shifts
2011; Spencer et al., 2011). Importantly, these emotional symptoms
have been negatively associated with social status, peer preference,
well-being and self-esteem, indicating that they may contribute to key
aspects of ADHD related daily life impairment (Riley et al., 2006;
Anastopoulos et al., 2011; Morstedt et al., 2015).
While emotional dysregulation has been known to be associated
with ADHD for years, studies have only recently started to investigate
the neuropsychological mechanisms underlying this association (Shaw
et al., 2014). Emotional regulation can be defined as an individual's
ability to modify an emotional state to promote adaptive, goal-oriented
behaviours (Thompson 1994). As such, it encompasses the processes
that allow the individual to select, attend and appraise emotionally

⁎
Correspondence to: Laboratoire de Psychopathologie et Neuropsychologie, Université Paris 8, 2 rue de la Liberté, 93526 Saint-Denis, France.
E-mail address: t.villemonteix@gmail.com (T. Villemonteix).
1
Thomas Villemonteix and Ivo Marx equally contributed to this manuscript.

http://dx.doi.org/10.1016/j.psychres.2017.04.027
Received 26 July 2016; Received in revised form 28 February 2017; Accepted 15 April 2017
Available online 18 April 2017
0165-1781/ © 2017 Elsevier B.V. All rights reserved.
T. Villemonteix et al.
arousing stimuli, and to do so flexibly (Shaw et al., 2014). Emotional
interference control, in particular, refers to the ability to control and
minimize the disrupting effect of irrelevant emotional stimuli on goal-
oriented processes (Cohen et al., 2016). In everyday life, people are
continually exposed to potentially emotion-arousing stimuli, ranging
from internal sensations like an upset stomach to external events, such
as facial expressions or verbal utterances. Due to its salience (i.e.
relevance for long-term goals and survival of the individual), this
emotional material tends to undergo preferential attentional processing
(Vuillemier et al., 2005). When not relevant for the on-going task, it
may cause emotional distraction, by interfering with appropriate task-
related cognitive, behavioural, or affective functioning (Iordan et al.,
2013).
Considering the core symptoms of ADHD and their association with
emotional dysregulation symptoms, it has been hypothesized that
children with ADHD may be characterized by deficits in emotional
interference control. An increased susceptibility to distraction is one of
the core behavioural diagnostic criteria of ADHD (American Psychiatric
Association, 2013), associated with broad impairment across multiple
domains, including cognitive functioning, interpersonal relationships,
and health (e.g. increasing risk for accidents and associated injuries;
Barkley and Cox, 2007; Higginbotham and Bartling, 1993; Maedgen
and Carlson, 2000). Deficits in emotional interference control may
contribute to distractibility, as well as to other core symptoms of the
inattentive cluster, such as careless mistakes, inattentive listening and
forgetfulness in daily activities. Furthermore, a frequent and/or more
intense automatic attentional capture by emotional stimuli could
multiply the risk of displaying inappropriate levels of emotional
responses, leading to emotional dysregulation symptoms. To identify
deficits in attentional control of emotional stimuli in children with an
ADHD diagnosis may therefore contribute to explain the core symptoms
of the disorder, in particular emotional dysregulation.
Recent research has started to use executive functioning tasks
together with distracting emotional components to study emotional
interference control in ADHD populations. For example, López-Martín
et al. (2013) first investigated the effect of irrelevant emotional
distractors on goal-directed information processing in children with
ADHD and typically developing (TD) children. Scalp event-related
potentials were recorded while participants performed a digit categor-
ization task with positive, neutral, and negative stimuli. Emotional
distractors were found to be associated with longer response times and
with greater anterior N2 amplitudes in the ADHD group only, support-
ing the hypothesis that emotional distractibility is increased in children
with ADHD. In a recent study characterized by a limited statistical
power (i.e. limited number of trials), Van Cauwenberge et al. (2015)
used an emotional working-memory task to study emotional interfer-
ence in children with ADHD and TD children and failed to report
significant group-by-diagnostic interaction, despite a noticeable trend
in the data for reaction times measures. Finally, in an adult sample,
Marx and colleagues (2011) implemented a working memory (‘n-back’)
task that requires attentional control of emotional distractors in
patients with ADHD vs. healthy controls. Lowly arousing distractors
were found to decrease performance accuracy in the ADHD group,
whereas healthy adults only showed decreased performance in the
presence of highly arousing negative distractors.
Taken together, a limited number of behavioural studies seem to
support the idea that a high level of emotional interference is associated
with ADHD. However, when investigating emotional interference
control in ADHD patients, one should take into account the increased
levels of anxiety symptoms that have been consistently reported in this
group (Graetz et al., 2001; Gonzalez-Castro et al., 2015; Skogli et al.,
2013). This seems especially important as subjects with high anxiety
levels are known to display dysfunctional emotional control (Bishop
et al., 2004; MacNamara et al., 2011). More precisely, high levels of
trait anxiety have been associated with increased response times in the
presence of emotional distractors and reduced top-down regulation of
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Psychiatry Research 254 (2017) 1–7
emotional responses in healthy (Klumpp et al., 2011; Krug and Carter,
2012) and clinical (Holtmann et al., 2013; Wessing et al., 2017)
samples. As subjects with ADHD display elevated levels of trait anxiety
(Gonzalez-Castro et al., 2015) and subjects with high trait anxiety
display increased susceptibility to interference, trait anxiety might
serve as a mediator between ADHD and impaired emotional interfer-
ence control.
In the present study, we seek to compare children with an ADHD
diagnosis and TD children in their ability to cope with emotional
distractors while performing an emotional n-back task, and to explore
the effect of trait anxiety on emotional interference measures in this
population. Our hypotheses are as follow: i) we expect all children to
display increased response times and decreased performance accuracy
as a function of task difficulty and when confronted with emotional
pictures. ii) we hypothesize that children with ADHD will display
increased response times and lower performance accuracy in compar-
ison to TD children (Martinussen et al., 2005). iii) we expect patients to
be more distractible by task-irrelevant emotional stimuli, as indicated
by longer response times and decreased performance accuracy under
emotionally arousing conditions in comparison to TD children. iv) we
hypothesize that trait and state anxiety will mediate the association
between ADHD and increased susceptibility to emotional distractors.
2. Methods
2.1. Participants
Fifty-eight children aged eight to thirteen years participated in the
study. Children with ADHD were recruited from the outpatient clinic at
Robert-Debré Hospital, Paris, France. TD participants were recruited
through word of mouth by the experimenters. The Kiddie Schedule for
Affective Disorders and Schizophrenia for School Aged Children-
Present and Lifetime Version (K-SADS-PL; Endicott and Spitzer, 1978)
was completed at screening for each participant to confirm the
diagnosis according to DSM-IV-R criteria in children with ADHD, and
to ensure that TD children presented no psychiatric condition. More-
over, parents of each child participant in the study completed the
ADHD Rating Scale IV (ADHD-RS-IV; DuPaul et al., 1998). Intellectual
quotient was evaluated using an abbreviated version of the Wechsler
Intelligence Scale for Children (fourth edition), including four subtests:
similarities, matrix reasoning, letter-number sequencing and symbol
search (Grégoire 2009). The exclusion criteria for all participants were
an IQ lower than 70, a current affective or anxiety disorder, a
neurological disorder, and previous head injury. One participant with
ADHD refused to pursue the experimental task after the first three
blocks and was therefore excluded from the study. The final sample
consisted of 33 children with ADHD (26 combined type, 7 inattentive
type) and 24 TD children. Seven children in the ADHD group had a
comorbid oppositional defiant disorder (ODD), and four families (two
children with ADHD and two TD children) also reported a learning
disorder. Seven children with ADHD were taking methylphenidate at
the time of the study but were out of medication for a minimum of 24 h
(immediate release methylphenidate) or 48 h (delayed release methyl-
phenidate) prior to testing. All children with combined type ADHD
scored above the 90th percentile on the total scale of the ADHD-RS-IV.
Participants with predominantly inattentive type of ADHD either scored
above the 90th percentile on the total scale of the ADHD-RS-IV, or
above the 90th percentile on the inattention subscale of the ADHD-RS-
IV. TD children all scored below threshold on the ADHD-RS-IV in total
score and in the subscales of inattention and impulsivity/hyperactivity.
Finally, both diagnostic groups did not differ with regard to gender, χ2
=.31, p=.58, ns. Demographic and clinical sample characteristics are
presented in Table 1.
The study was carried out in accordance with the latest version of
the Declaration of Helsinki. Each child and her/his parents gave their
consent to participate in this study reviewed and accepted by the local
T. Villemonteix et al. Psychiatry Research 254 (2017) 1–7

Table 1 2.4. Statistical analyses

Basic demographic and clinical characteristics.
The data were analyzed using SPSS version 17 (SPSS Inc., Chicago,
ADHD CON t (55)
IL, USA). Group differences in socio-demographic and clinical data
n =33 (85% males) n =24 (79% males) were tested with t-tests for independent samples and, in case of gender,
with the Chi-square (χ2) test. The mean of the response time for
M SD M SD correctly identified targets (RT) and the individual discrimination
Age 10.73 1.61 11.30 1.63 1.31 indices for performance accuracy (d′) were used as dependent variables,
IQ 107.13 12.74 111.92 9.34 1.55 with the d′ calculated based on the signal detection theory as follows: d′
ADHD RS-IV
= z (hits/number of targets) – z (false alarms/number of distractors).
Inattention 20.56 4.76 6.16 4.56 −11.39*** The resulting value range was −4.66≤ x≤+4.66, with more negative
Hyperactivity 14.87 7.80 3.00 2.98 −7.83*** values indicating poorer performance. The group differences in the
Total 35.43 9.88 9.16 6.75 −11.80*** dependent variables (RT, d′) were analyzed using repeated-measures
STAI-C (Trait) 35.49 5.75 29.88 5.51 3.70***
ANOVAs with the diagnostic group (subjects with ADHD; TD children)
STAI-C (State) 29.97 4.69 27.58 2.52 2.26*
as the between-subjects factor and the n-back level (1-back; 2-back) and
ADHD = Subjects with ADHD, CON = Controls. M = Mean, SD = Standard Deviation. emotional salience of the distractors (neutral; negative; positive) as the
*p < .05, **p < .01, *** p < .001. within-subject factors. Based on previous reports of decreased emo-
tional responsiveness in children with oppositional defiant disorder
ethics committee (Comité de Protection des Personnes Ile de France IV; (ODD) (Matthys et al., 2013; Masi et al., 2014), and a normalizing effect
2011/38NICB). of previous MPH medication on emotion processing in subjects with
ADHD (Schlochtermeier et al., 2011), these two variables were
examined as covariates of interest in our study, using repeated
2.2. Experimental task
measurements ANCOVAs and the corresponding post-hoc tests. Tests
for significance were performed using Pillai's trace statistic. In cases of
The emotional working memory task was preceded by a series of 52
significant main or interaction effects, for post-hoc group comparisons,
practice trials with a classical n-back task, consisting of two 1-back and
paired-samples t-tests (for the within-subjects effects) and independent
three 2-back blocks, which were presented randomly. The emotional n-
samples t-tests (for the between-subjects effects) were conducted, with
back task consisted of six 1-back and six 2-back blocks, and each n-back
multiple comparisons corrected using the Bonferroni procedure. Prior
condition consisted of two blocks of 14 neutral pictures (e.g. a chair, a
to the analyses, the raw data were z-transformed to examine extreme
fork), two blocks of 14 negative emotional pictures (e.g. a snake, a
outliers (z > 3.0). Four extreme outliers (one in the TD group and three
shark), and two blocks of 14 positive (e.g. adults smiling, children
in the ADHD group) were detected and were replaced by the respective
playing) emotional pictures. Each block contained 14 randomly pre-
group means. Furthermore, all variables were screened for violations of
sented letters (4 targets, 10 distractors), and both the pictures within
the assumptions associated with univariate and multivariate tests. The
the blocks and the blocks themselves where presented in random order.
Kolmogorov-Smirnov test showed a violation of the assumption of
Each picture was presented for a duration of 3000 ms. After 1250 ms
normal distribution for nine of the twelve dependent variables, and the
had elapsed, the n-back letter was presented in the middle of the screen
Levene test yielded a violation of the assumption of homogeneity of
for a duration of 500 ms. Children were told that they would see a
variance for five of the twelve variables. The assumption of homo-
sequence of letters in the middle of the screen and that they had to press
geneity of variance–covariance matrices was violated for the response
the space bar as soon as the letter they saw was identical as the previous
times, Box-M: F =2.97, p < .001, but not for the accuracy scores, Box-
one (1-back), or as the one before the previous one (2-back). A more
M: F =1.40, p=.10. However, as samples were sufficient in size (at
complete presentation of the task, procedure and instructions given is
least 70% more cases in each cell than dependent variables) and equal
available in the Supplementary material. Total duration of the task was
in terms of case number (χ2(1,57) =1.42, p=.23, ns), the F test can be
8 min 46 s. The pictures were selected from the International Affective
regarded as being robust (Tabachnick and Fidell, 1996). As two
Picture System (IAPS; Lang et al., 2008) and were ensured to be suitable
children (one in each group) failed to identify the targets in one of
for use in a paediatric population (Sterzer et al., 2005; Waters et al.,
the experimental blocks, no RTs could be assessed for these children.
2005; Sharp et al., 2006; Brotman et al., 2010). In total, 168 pictures
Therefore, sample sizes for d′ and RT analyses differ from each other.
were presented, with ratings ranging from “1” (negative valence; low
The significance level for all of the tests was p≤.05. The partial eta-
arousal) to “9” (positive valence, high arousal): 56 neutral pictures
squared (ηp2) is reported as a measure of the effect size.
(valence: M =5.2, SD =.43; arousal: M =3.21, SD =.63), 56 negative
Mediation analysis was performed using the R statistical software
pictures (valence: M =3.07, SD =.76; arousal: M =5.93, SD =.84),
package ‘mediation’ (Imai et al., 2010). In accordance with Tingley
and 56 positive pictures (valence: M =7.58, SD =.64; arousal: M
et al. (2014), average causal mediation effects and average direct
=5.06, SD =.90). Ratings were obtained from the IAPS manual and
effects were assessed via nonparametric bootstrapping bias-corrected
from two previous studies in children (McManis et al., 2001; Waters
and accelerated intervals (BCa), with 1000 cycles generating 95%
et al., 2005). For each emotional condition, the pictures were matched
confidence intervals. We used White's heteroskedasticity-consistent
with regard to the four experimental blocks (two blocks in the 1-back
estimator for the covariance matrix. The model-based causal mediation
condition, and two blocks in the 2-back condition) according to their
analysis proceeded in two steps. First, we specified two statistical
valence and arousal. Stimuli will be provided upon request to the
models, the mediator model for the conditional distribution of the
corresponding author.
mediator Mi (i.e. trait anxiety) given the psychiatric condition Ti (i.e.
ADHD versus TD) and a set of the observed pre-treatment covariates Xi
2.3. Measures of clinical symptoms (i.e. state anxiety, age, medication status, and ODD comorbidity) and
the outcome model for the conditional distribution of the outcome Yi
The French version of the self-report State-Trait Anxiety Inventory given Ti, Mi, and Xi. These models are fitted separately and then their
for Children (STAI–C) was used to measure state and trait anxiety fitted objects comprise the main inputs to the mediate function, which
(Spielberger, 1973). It consists of two separate 20-item self-report computes the estimated average causal mediation effect (ACME),
scales which both display high internal consistency (Turgeon and average direct effect (ADE) and other quantities of interest under these
Chartrand, 2003). models and the sequential ignorability assumption. As outcome mea-

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T. Villemonteix et al. Psychiatry Research 254 (2017) 1–7

Table 2
Descriptive statistics for the emotional N-back task performance.

ADHD CON Group N-back N-back x Group Emotion Emotion x Group

M SD M SD F (1,55) F (1,55) F (1,55) F (2,110) F (2,110)

Performance Accuracy (d′) 12.49*** 78.58*** 1.09 .56 .50

1-back
neu 1.92 .57 2.27 .34
neg 1.86 .57 2.11 .40
pos 1.97 .50 2.18 .33

2-back
neu 1.34 .60 1.77 .55
neg 1.39 .64 1.70 .55
pos 1.32 .74 1.75 .48
M SD M SD F(1,53) F(1,53) F(1,53) F(2,106) F(2,106)

Reaction Time (ms) 6.74** 10.02** .14 10.94*** 3.98*

1-back
neu 739.16 200.38 666.09 196.94
neg 867.70 273.56 656.53 109.77
pos 772.83 253.11 675.76 142.52

2-back
neu 801.23 258.62 706.74 193.95
neg 981.81 311.94 811.28 221.64
pos 811.81 259.14 752.38 191.69

ADHD = Subjects with ADHD, CON = Controls. Group = between-subjects effect of experimental group membership, N-back = within-subjects effect of task difficulty, N-back x Group
= within-between-subjects interaction effect, Emotion = within-subjects effect of the emotional salience of the background picture stimuli, Emotion x Group = within-between-subjects
interaction effect. M = Mean, SD = Standard Deviation. neu = neutral pictures, neg = negative emotional salience, pos = positive emotional salience. All values are raw uncorrected
means. *p < .05, **p < .01, *** p < .001. Descriptive statistics for hits and false alarms are reported in the Supplementary material.

sures for the mediation analyses, we calculated difference scores for RT
and d′ in the negative condition when compared with the neutral
condition (emotional interference scores). Correlations between state/
trait anxiety measures and emotional interferences scores were also
calculated. As associations between trait anxiety and dysfunctional
emotional interference control may be stronger under high executive
control demands (Choi et al., 2012), analyses were conducted for the 1-
back and 2-back conditions separately.
3. Results
3.1. Performance accuracy
Repeated measures ANOVA on performance accuracy with the
diagnostic group (subjects with ADHD; TD children) as the between-
subjects factor and working memory load (1-back; 2-back) and emo-
tional salience of the distractors (neutral; negative; positive) as the
within-subject factors revealed main effects for working memory load
and the diagnostic group: All children displayed higher performance
accuracy in the 1-back condition when compared with the 2-back
condition, F(1,55) =78.58, p < .001, ηp2 =.59 (Table 2). Overall,
children with ADHD displayed decreased performance accuracy when
compared with TD children, F(1,55) =12.49, p=.001, ηp2 =.19. The
same pattern of results emerged when hits and false alarms were
analyzed separately (see Supplementary material). No further signifi-
cant main or interaction effects emerged (all ps > .05).
3.2. Response times
The same analysis as described above was conducted on response
times. As a result, we found main effects for working memory load, F
(1,53) =10.02, p=.003, ηp2 =.16, and emotional salience, F(2,106)
=10.94, p < .001, ηp2 =.17. All subjects responded faster in the 1-back
condition when compared with the 2-back condition, and post-hoc
analyses revealed that all subjects responded faster in the neutral and in
the positive condition when compared with the negative condition
(neutral vs. negative: t(54) =−4.29, p < .001; neutral vs. positive: t
(54) =−1.07, p=.87, ns; positive vs. negative: t(54) =3.68, p=.002).
Children with ADHD responded slower than TD children, F(1,53)
=6.74, p=.01, ηp2 =.11 (Table 2).
Additionally, there was an interaction effect between diagnostic
group membership and emotional salience of the distractors, F(2,106)
=3.98, p=.02, ηp2 =.07. In the presence of negative distractors, t(54)
=3.49, p=.001, but not in the presence of neutral, t(54) =1.85,
p=.07, ns, or positive, t(55) =1.70, p=.10, ns, distractors, children
with ADHD displayed increased response times when compared with
TD children (ADHD; neutral: M =770.19 ms, SD =175.70 ms; nega-
tive: M =924.75 ms, SD =178.70 ms; positive: M =792.32 ms, SD
=156.74 ms; controls: neutral: M =686.41 ms, SD =175.70 ms;
negative: M =733.91 ms, SD =210.78 ms; positive: M =714.07 ms,
SD =184.87 ms). Post-hoc paired-samples t-tests revealed that this
effect was driven by differential response patterns between experi-
mental groups: While TD children displayed a stable response pattern
across all emotional conditions (all ps > .05), children with ADHD
displayed prolonged RTs in the negative condition when compared with
the neutral and positive distractor condition (negative vs. neutral: t(31)
=−4.30, p < .001; negative vs. positive: t(32) =3.64, p=.001; neutral
vs. positive: t(31) =−.64, p=.53, ns). No further significant effects
emerged (all ps > .05).
All significant between-subjects effects are displayed in Fig. 1, and
the between-within subjects interaction effect with regard to RT is
displayed in Fig. 2. Please note that for the response time, the adjusted
mean values from the ANCOVA were chosen to visualize the experi-
mental effects.
3.3. Analyses of covariates
Comorbid ODD status displayed a significant effect in the between-
subjects model, F(1,51) =7.63, p=.008, ηp2 =.13, and RT group
differences in effects size increased from ηp2 =.11 to ηp2 =.17.
Moreover, comorbid ODD status significantly interacted with the
emotional salience levels, F(2,102) =3.82, p=.03, ηp2 =.07. Post-hoc
univariate ANCOVAs which were conducted for each salience level
separately with the diagnostic group as the between-subjects factor and

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T. Villemonteix et al. Psychiatry Research 254 (2017) 1–7

Group Differences in Emotional N-back Task Performance

*** **

CON ADHD

Fig. 1. Group Differences in Emotional N-back Task Performance. CON = control group, ADHD = ADHD group. d′ = discriminability score, ms = response time in milliseconds. All
charts are based on estimated marginal means. *p < .05, **p < .01, ***p < .001.

ODD status as the covariate revealed a significant impact of ODD status
on RT in the negative, F(1,53) =10.42, p=.002, ηp2 =.16, and in the
positive, F(1,54) =6.72, p=.01, ηp2 =.11, but not in the neutral
condition, F(1,53) =2.85, p=.10, ns. As a result, the interaction effect
between diagnostic group membership and emotional salience level
increased from ηp2 =.07 to ηp2 =.17. In fact, it became evident that
response time differences between the diagnostic groups were no longer
present only in the negative condition, but now in all three emotional
conditions when ODD status was taken into account, but it was still
mostly pronounced in the negative condition (neutral: F(1,53) =5.42,
p=.02, ηp2 =.09; negative: F(1,53) =18.52, p < .001, ηp2 =.26;
positive: F(1,54) =6.35, p=.02, ηp2 =.11).
As an auxiliary analysis, we performed the same computations for
state anxiety, controlling for trait anxiety. Here, we found a direct effect
of diagnostic group membership on one of our two measures of
emotional interference (RT) in the 1-back condition (ADE =184.21,
BCa 95% CI =47.80; 375.35, p=.01) and in the 2-back condition (ADE
=173.73, BCa 95% CI =24.43; 353.21, p=.03), whereas the indirect
effects via state anxiety as a mediator were not significant (1-back:
ACME =−10.46, BCa 95% CI =−61.68; 13.49, p=.56; 2-back: ACME
=−8.04, BCa 95% CI =−65.19; 45.01, p=.84). No direct or mediated
effects emerged for d′.
Finally, correlations between state anxiety and emotional interfer-
ences measures, and trait anxiety and emotional interference measures
were not significant (all p's > .05).

3.4. Mediation and correlational analysis

Estimates from mediation analysis suggested a direct effect of
diagnostic group membership on both emotional interference measures
in the 2-back condition (d′: ADE =187.37, BCa 95% CI =50.18;
364.35, p=.01; RT: ADE =173.73, BCa 95%, CI =25.79; 348.53,
p=.02). The indirect effects via trait anxiety as a mediator were not
significant (d′: AMCE =−1.55, BCa 95% CI =−25.49; 4.18, p=.79;
RT: ACME =−1.55, BCa 95% CI =−34.95; 7.42, p=.89). No direct or
mediated effects emerged in the 1-back condition (all p's > .05).
4. Discussion
The aim of the present study was to compare children with ADHD
and TD children in their ability to cope with emotional distractors while
performing a working-memory task. In line with our hypotheses, we
found that all children, irrespective of their group membership,
displayed higher performance accuracy and responded faster in the 1-
back condition as compared to the 2-back condition (effect of WM
load), and that all subjects responded faster in the neutral when

Group Differences in Emotional N-back Task Performance

Depending on Emotional Distractor Quality

Within-Between-Subjects Interaction Effect Post-Hoc Comparisons

***

*
*

CON ADHD

Fig. 2. Group Differences in Emotional N-back Task Performance Depending on Emotional Distractor Quality. CON = control group, ADHD = ADHD group. ms = response time in
milliseconds. Neu = neutral pictures, Neg = negative emotional salience, Pos = positive emotional salience. All charts are based on estimated marginal means. *p < .05, **p < .01,
***p < .001.

5
T. Villemonteix et al.
compared with the negative condition (effect of emotional salience),
supporting validity of our experimental task. In addition, we found that
children with ADHD displayed prolonged response times and decreased
performance accuracy when compared with the TD children, thus
replicating WM deficits in children and adolescents with ADHD
(Martinussen et al., 2005).
More interestingly, we were able to detect increased emotional
interference in the ADHD group: When compared with TD children,
children with ADHD displayed increased response times in the presence
of aversive distractors, contingent on a salience-specific increase of
their response times in this condition: Whereas TD children displayed a
stable performance across all salience levels, children with ADHD
decelerated specifically in the presence of negative distractors. This
finding is in line with previous studies documenting an increased
emotional distractibility in children and adults with ADHD (Marx et al.,
2011; Lopez-Martin et al., 2013). In particular, similarly to one
previous study in children, we found emotional distractors to cause
prolonged response times in patients with ADHD while not affecting
performance accuracy (Lopez-Martin et al., 2013), whereas the oppo-
site pattern, i.e. decreased performance accuracy but normal response
times, has been reported in the only previous emotional n-back study on
ADHD in adults (Marx et al., 2011). We hypothesize that these age-
related differences may be explained by differences in task difficulty
between the age groups, as indicated by larger performance accuracy z-
scores in adults when compared with children (mean (SD) performance
accuracy in adults: 3.61 (.78), in children: 1.63 (.59); Marx et al.,
2011). Indeed, previous research suggests that increased task difficulty
may represent a shield against distraction, by promoting focal-task
engagement, reducing the neural processing of distracting stimuli, and
potentiating the capability to block their influence on attentional
processes (Halin et al., 2014; Hughes et al., 2013; Sörqvist et al., 2016).
Although both ADHD (Marx et al., 2011) and trait anxiety (Klumpp
et al., 2011; Krug and Carter, 2012) are associated with decreased
control of interfering emotional stimuli, and increased levels of trait
anxiety have been observed in those with ADHD (Gonzalez-Castro et al.,
2015), trait anxiety did not mediate the relationship between ADHD
diagnosis and decreased emotional interference control in our study.
Furthermore, in the present sample, we failed to evidence a correlation
between trait or state anxiety measures and emotional interference
scores. One possible explanation for this discrepancy with previous
findings lies in the type of negative emotional stimuli that were
presented. Here, negative stimuli comprised sad, threatening and
fearful stimuli of different types (e.g. faces, situations, animals),
whereas previous studies used threatening (Klumpp et al., 2011;
Wessing et al., 2017) or fearful (Klumpp et al., 2011) faces, which
may represent more salient stimuli for participants with high trait
anxiety levels. Taking the presence or absence of ODD into account, our
exploratory analyses suggest that comorbid ODD in the ADHD group
may mask a specific RT deficit in the presence of emotional distractors
when compared to non-emotional distractors. This finding is in line
with previous studies suggesting that reduced amygdala responsiveness
to aversive cues may play a role in the development of ODD and CD
(Herpertz et al., 2005; Sterzer et al., 2005; Masi et al., 2014; Matthys
et al., 2013). In particular, Sterzer et al. (2005) reported deactivations
in the left amygdala and in the anterior cingulate cortex in adolescents
with CD compared with control subjects when viewing negative
pictures, and Masi et al. (2014) found children and adolescents with
ADHD and ODD/CD to rate negative IAPS pictures as less aversive than
healthy subjects. However, contradictory findings have also been
reported in two previous studies documenting an increased emotional
responsiveness to (Herpertz et al., 2008) and an increased distractibility
by (Euler et al., 2014) negative picture stimuli in children and
adolescents with ODD/CD and different rates of comorbid ADHD when
compared with healthy populations. One recent review suggests that
these inconsistent results may partly result from variations in callous-
unemotional (CU) traits across samples. Indeed, youths with DBD and
6
Psychiatry Research 254 (2017) 1–7
low CU traits have consistently been found to exhibit hyperactivity in
the amygdala when processing negative stimuli, whereas the opposite
pattern has been found in youths with DBD and high CU traits (Baker
et al., 2015). Future studies should therefore examine ODD and CU
traits as potential mediators of increased vs. decreased emotion
interference in children with ADHD.
The results of the present study should be interpreted in the light of
several limitations. First, our sample was characterized by a limited
sample size to conduct mediation analyses (Fritz and McKinnon 2007),
although mediation effects have been reported in ADHD in samples of
similar (Mary et al., 2016) or smaller (Rints et al., 2015) sizes. The lack
of significant mediation effect may therefore reflect a type-2 error.
Second, the experimental design used in the present study consisted of
emotional blocks presented in a random order. In this context, potential
carry-over effects between positive vs. negative vs. neutral emotional
blocks could not be controlled for. Such carry-over effects may have
reduced the magnitude of our findings. Third, each experimental
condition (i.e. memory load X emotional condition) only consisted of
28 picture presentation. This number chosen to ensure that the task
duration was acceptable for children may have reduced the statistical
power to detect memory load X emotional condition and memory load
X emotional condition X group interactions. Fourth, data on the
physical properties of the images, such as luminance, color composi-
tion, contrast or complexity were not available for the IAPS pictures.
Uncontrolled differences associated with these parameters may have
represented a confounding factor when comparing different emotional
conditions in the present study (Marchewka et al., 2014). Fifth,
although several studies have shown that the pictures taken from the
IAPS elicit emotional responses in adults and children (McManis et al.,
2001; Waters et al., 2005; Sharp et al., 2006), it should be noted that
the participants of the present study did not subjectively rate the
pictures at the end of the task. It is therefore unclear whether a
particular set of pictures was responsible for the results obtained in this
study, and whether participants of different ages of gender may have
been differently affected. Finally, since our study was based on DSM-IV
criteria, we did not consider disruptive mood dysregulation disorder
(DMDD) as a potential comorbidity. Considering the key symptoms of
DMDD (i.e. chronic, severe irritability and anger), children with ADHD
+DMDD may represent a distinct group in terms of both emotion
regulation and emotional interference control deficits (Hommer et al.,
2014). Future studies should compare children with ADHD and children
with ADHD/DMMD in their ability to cope with emotional interfer-
ences, using more recent and better characterized picture datasets
(Marchewka et al., 2014). Nevertheless, our study was also character-
ized by several strengths, being conducted in an ADHD sample
comprising a majority of medication-naïve children (79%), ruling out
to a large degree potential MPH long-term effects in our data, and no
other DSM-IV-R psychiatric comorbidities than ODD, which contributes
to the specificity of our results.
In conclusion and in line with previous findings, we found that
children with ADHD displayed decreased emotional interference con-
trol, especially in the presence of aversive distractors (as measured by
our experimental task). Contrary to our expectations, the relationship
between ADHD diagnosis and decreased emotional interference control
was not mediated by trait anxiety, which was also increased in our
ADHD sample. Future research should investigate which psychological
and neurobiological processes may mediate the relationship between
the bottom-up processing of emotionally interfering stimuli and emo-
tion dysregulation symptoms.
Conflict of interest
We report no conflict of interest.
T. Villemonteix et al.
Source of funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at http://dx.doi.org/10.1016/j.psychres.2017.04.027.
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