A New Subtype of ADHD?
Emotion regulation, executive functioning, and what the latest research actually tells us
A new study in JAMA Psychiatry is making the rounds, and based on the headlines, you’d think researchers had discovered an entirely new subtype of ADHD. I want to push back on that framing since it’s a bit misleading.
Here’s what the researchers actually did: Using brain imaging data from over a thousand children, they identified structural differences in brain networks that were associated with different clinical profiles and trajectories of ADHD. One of the networks they identified was associated with a profile characterized by emotion dysregulation, and people who fit that profile tended to have the worst outcomes over time.
That is a meaningful neuroimaging contribution. But they didn’t identify a brand new “subtype” of ADHD that includes emotion dysregulation. We have known for decades—clinically and empirically—that a substantial proportion of people with ADHD struggle with managing their emotions. Ask any parent of a child with ADHD or any professional who works with these kids. Emotion dysregulation is an extremely common and impairing feature of the disorder.
The fact that emotion dysregulation is commonly identified in people with ADHD makes a lot of sense. Emotion regulation is a core component of executive functioning, and ADHD, at its heart, is a disorder of executive functioning.
Let me back up a little bit and explain what I mean.
Executive functioning is the set of higher-order cognitive processes that allows for self-regulation. Self-regulation has three distinct components:
Cognitive regulation involves managing attention and thinking: things like shifting focus when something changes, holding information in mind, and filtering out irrelevant distractions. This is the domain most people associate with ADHD since it encompasses inattention, poor focus, and mind wandering.
Behavior regulation is the ability to manage and modulate your actions: things like stopping yourself from blurting something out, waiting your turn, and not slamming a door when you’re frustrated. Kids who struggle here often look impulsive or oppositional.
Emotion regulation is the ability to modulate emotional responses so they are proportional to the situation. People who struggle with emotion regulation have trouble tolerating frustration without falling apart, recovering from disappointment, and not letting a bad mood derail an entire afternoon. They tend to have explosive reactions, experience prolonged distress over seemingly small things, and struggle to soothe themselves after getting upset.
All three parts of EF are compromised to varying degrees in people with ADHD. The neuroimaging study confirms this at the level of brain structure, which is valuable. And it confirms that emotion dysregulation puts people with ADHD at elevated risk for persistent problems over time, as well as for higher rates of comorbidities with other psychopathologies, which should raise red flags for everyone involved in treatment.
So I think the takeaway about this study is: Emotion dysregulation is a core, neurobiologically distinct feature of ADHD for a great many kids, and therefore, emotion dysregulation must be a main treatment target.
Therapists must work with kids with ADHD to help them recognize when an emotion is escalating, to tolerate frustration, to understand why they react the way they do, and to repair relationships after an outburst. These are all learnable skills, and therapy should build them with deliberate, supported practice.
Also, we should consider reframing how we discuss ADHD more generally. When we talk about it primarily as an attention disorder, we implicitly signal that the emotional dimensions of the diagnosis are secondary. They’re not. For many kids, they’re the part that does the most damage to friendships, family relationships, and self-concept over time.
So, ultimately, I’m glad this study is getting some press. But the moral of the story isn’t “there’s a new subtype”; it’s that the emotional dimension of ADHD is real. Research keeps pointing us toward a more comprehensive model of treatment, so it seems about time that we act on it.
I still haven’t seen Ragtime, but I loved Caissie Levy in this! So excited about her Tony!
"Therapists must work with kids with ADHD to help them recognize when an emotion is escalating, to tolerate frustration, to understand why they react the way they do, and to repair relationships after an outburst. These are all learnable skills, and therapy should build them with deliberate, supported practice."
Yes, yes, and yes! Therapy has been so incredibly helpful for this aspect of life for my child with ADHD. She's now 15, and I think she has better mastery over every skill you mentioned than most adults, and all because of therapy.
Love this. And you should definitely see Ragtime ASAP! Joshua Henry playing piano on stage is truly remarkable, the staging is moving and incredible; it's so good!