Running head: EMOTIONAL COMPETENCE IN YOUNG CHILDREN

EMOTIONAL COMPETENCE IN YOUNG CHILDREN WITH SYMPTOMS OF

ATTENTION-DEFICIT HYPERACTIVITY DISORDER

An Honors Thesis

Presented by

Lawrence Stevenson

Completion Date: May 2015

Approved By:

______________________________Elizabeth Harvey Ph.D., Psychology

________________________________Jennifer McDermott Ph.D., Psychology

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ABSTRACT

Title: Emotional Competence in Young Children with Symptoms of Attention-Deficit Hyperactivity Disorder Author: Lawrence Stevenson Thesis/Project Type: Honors Thesis Approved By: Elizabeth Harvey Ph.D., Psychology Approved By: Jennifer McDermott Ph.D., Psychology

Past studies indicate that older children and adults with attention deficit hyperactivity disorder experience impairments in emotion competence. However, no studies have directly evaluated emotional competence in preschool aged children. The present study was aimed at assessing group differences between preschool-aged children with ADHD symptoms and age-matched typically developing children in three domains of emotional competence: emotion understanding, emotion reactivity, and emotion regulation. The measure of emotion understanding was mean scores on four tasks, in which children were instructed to match facial expressions of like-emotions, match facial expressions to emotional situations, and verbally label pictures of children expressing basic emotions. An induced frustration task was used as a measure of emotion reactivity, which also included a task in which children were asked to suppress their emotions. Results indicated that children with ADHD symptoms experienced significant impairment in understanding emotions in social context and expressed higher levels in negative affect during frustration and when asked to suppress their emotion expression. Findings and implications are discussed in the context of preschool, and suggestions for future research are provided.

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Emotional Competence in Young Children with Symptoms of Attention-Deficit Hyperactivity

Disorder

Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder

characterized by disabling inattention, hyperactivity, and impulsivity. It is the most commonly

diagnosed psychological disorder amongst school-aged children and is known to cause deficits in

social functioning, academic success, and emotional competence (American Psychiatric

Association, 2013). The latest version of the Diagnostic and Statistical Manual (DSM 5)

classifies ADHD into three presentations: The Hyperactive-impulsive presentation, the

inattentive presentation, and the presentation of combined hyperactivity-impulsive and

inattention. The Hyperactive-impulsive (ADHD-PH) presentation includes symptoms such as

frequent fidgeting of the hands or feet, difficulty remaining seated, running or climbing

excessively, acting as if driven by a motor, talking excessively, blurting out answers before

questions have been completed, and difficulty waiting or taking turns. An individual diagnosed

with Inattentive (ADHD-PI) presentation might fail to pay close attention to details or make

careless mistakes, have difficulty sustaining attention, and/or appear to not listen when spoken

to. He or she may also struggle to follow through on instructions, and experience difficulty with

organization. ADHD-PI symptomology could also include avoidance or dislike of tasks requiring

intense thinking, misplacing possessions, becoming easily distracted, and becoming forgetful in

daily activities. The most common presentation is combined hyperactivity-impulsive and

inattention (ADHD-C), which includes symptoms from both above presentations (DSM-V; APA,

2013). According to a 2011 epidemiological study, 11% of children four to seventeen years of

age are currently diagnosed with the disorder—a statistic that is increasing every year. The study

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also revealed that boys are four times more at risk for diagnosis when compared to girls of the

same age (Visser et al., 2011).

Multiple studies indicate that symptoms of ADHD emerge as early as 4 years of age (e.g.,

Brown et al., 2005). Egger and colleagues (2006) reported occurrence of ADHD in 2.0-7.9% of

preschool aged children. Moreover, studies have shown that these symptoms remain stable at

least through later childhood (Greene et al., 1996; Ingram, Hechtman, & Morgenstern, 1999). As

such, in 2011, the American Academy of Pediatrics expanded guidelines for diagnosis to include

children as young as four (Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering

Committee on Quality Improvement and Management, 2011). However, much of the research

literature focuses on older children and adolescents. Many preschoolers with ADHD symptoms

experience impairments in social, academic, and emotional functioning— thus more research on

young children is necessary.

Investigators have not yet determined the exact etiology of ADHD, however, studies have

pointed to both genetic and environmental causes of the disorder. Studies on twins and familial

patterns of ADHD provide strong evidence of genetic components (McLoughlin et al., 2007).

Specifically, genes such as DAT1, DRD4, and DRD5 are postulated to be responsible for

dopaminergic transmission deficits in those with ADHD (Gizer, Ficks and Waldman, 2009).

Genetic factors HTT, HTR1B, and SNAP25 have been linked with ADHD as well (Gizer, 2009).

Additional studies have found correlations between ADHD and thin cortical tissue in the

midbrain, cerebellum, and other areas associated with attention (Gizer, 2009). Environmental

factors that are associated with ADHD include cigarette smoking and alcohol consumption

during pregnancy and brain injury during childhood (Shaw et al., 2014).

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Behavioral inhibition is thought to be the core deficit underlying symptoms of ADHD

(Barkley, 1997). Behavioral inhibition is an executive function that is essential for self-control. It

allows us to orient to stimuli that are most salient or important, and inhibit stimuli and responses

that are inappropriate (Barkley, 1997). Four important cognitive processes are thought to be

dependent on behavioral inhibition. These include working memory, internalization of speech,

reconstruction, and emotional regulation (Barkley, 1997). When these systems are impaired,

such as in the cases of people with ADHD, it obstructs academic and social functioning

(American Academy of Pediatrics, 2011). Emotional regulation—a key component of emotional

competence—is of particular importance because it plays a critical role in social and emotional

functioning.

Emotional Competence

Susan Denham’s model of emotional competence (2007) specifies three main

competencies: emotional knowledge/understanding, emotional reactivity, and emotional

regulation. Emotional understanding is the ability to identify emotion in one’s self and others, as

well as recognizing how emotions are appropriately employed. This theory suggests that the

process by which we learn to recognize emotions (facial and vocal expression) in others, serves

as a model for how we appropriately identify, evaluate, and regulate our own emotions (2007).

Emotional reactivity is the manner in which we emotionally, behaviorally, and physiologically

react to emotional stimuli (2007). Emotional regulation is our ability to modulate the degree to

which we emotionally react to a stimulus, and control which emotions are expressed, how they

are expressed, and when they are expressed. Such processes arise at both conscious and

unconscious levels (Gross, 1999). Development of emotional competence begins in toddlerhood,

when toddlers begin to employ regulatory skills such as self-soothing, attention manipulation,

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and play engagement to manage negative emotion (Stansbury & Sigman, 2000). However, these

skills become increasingly important as children enter preschool and rely less on adult support.

When children struggle with this developmental process, emotional, cognitive, and social

development becomes compromised (Zeman & Shipman, 1996).

Emotional Competence in Children with ADHD

Children with ADHD are thought to be at an increased risk for impaired development of

emotional competence (Shaw et al., 2014), which may play an important role in the development

of co-occurring psychopathology (Barkley, 2010). An estimated 60 to 70 % of children with

ADHD meet criteria for a comorbid condition (Jensen et al., 2001; August, Realmuto,

MacDonald, & Nugent, 1996). Oppositional Defiant Disorder (ODD) is the most common

comorbid diagnosis, co-occurring in as much as 84% of cases in some samples (Barkley, 2010).

Impairments in emotional competence have been consistently linked to a wide range of

psychiatric disorders including ADHD, ODD, Major Depressive Disorder, and anxiety (Barkey,

2010; Larsen & Ketelaar, 1989; Leen‐Feldner, Zvolensky, Feldner, & Lejuez, 2004; Zvolensky

& Eifert, 2000). Kim and Cicchetti (2010) documented that children who do not develop the

necessary emotional competency skills are at increased risk of later psychopathology. Thus,

understanding of emotional competence in children with ADHD is paramount because we can

use this understanding to detect and prevent and such comorbidities (Biederman et al., 2008).

Theoretical Underpinnings

Both theory and research suggest that children with ADHD experience impairments in

emotional competence. It is thought that children with ADHD experience problems

understanding, reacting, and regulating emotions due to deficits in executive functions.

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Executive attention is needed to attend to and process emotional stimuli. Behavioral inhibition is

required to suppress our automatic reaction to emotional stimuli. Working memory is needed to

recall emotion regulation strategies such as self-talk and visualization to reduce arousal and

regain control over emotional states. Because a child with ADHD likely experiences dysfunction

in each of these areas, he or she would struggle throughout the entire emotional processes and

would likely act less appropriately (Barkley, 2010). Literature suggests that the cognitive

mechanisms involved in this emotion regulatory process are managed through frontolimbic

cortical networks (Nigg & Casey, 2005). The anterior cingulate cortex – an important area of the

prefrontal cortex highly interconnected with the limbic system- is likely to account for deficits in

emotional competence in children with ADHD (Nigg & Casey 2005). When frontolimbic

pathways are disrupted it is thought to give rise to the impulsive and hyperactive, as well as

emotion lability symptoms of ADHD. There also may be a reciprocal top down/ bottom up

relationship between ADHD symptoms and emotional competence. Inability to control and

suppress maladaptive emotions mediated by limbic structures like the amygdala may impede pre-

frontal attention systems and vice-versa (Barkley, 1997; Shaw et al., 2014).

Evidence of Impaired Emotional Competence in Older Children with ADHD

Neurophysiological. There is a variety of neurophysiological evidence that supports the

idea that children with ADHD experience deficits in emotional competence. Some neurological

findings suggest that children with ADHD show deficits in limbic structures that are important

for emotion processing, including the amygdala (Shaw et al., 2014). In a neurobehavioral fMRI

study, Posner and colleagues (2011) compared adolescents with ADHD on and off medication

during an emotion Stroop task. In this task subject were presented with positive, negative, and

neutral words that serve as distractors as they were timed responding to the color of that word.

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Results indicated that while subjects off medication experienced prefrontal hyperactivity with

positive distracters and hypoactivity with negative distractors, functioning was normalized in

subjects medicated with psychostimulants. Thus, when presented with a negative emotional

stimulus, attention and regulatory processes were impaired. Passarotti and colleagues (2010)

used fMRI during an emotional Stroop task to study brain activation as well. Subjects with

ADHD showed less activation in the ventrolateral prefrontal cortex, and higher activation in

dorsolateral prefrontal and parietal cortexes compared to the other groups. In an

electrophysiological study, Musser and colleagues (2013) examined emotional regulation in

children with ADHD during an emotion induction/suppression task. They found that children

with ADHD experienced high levels of parasympathetic and sympathetic response during

induction and suppression of emotion further indicating that children with ADHD experience

disrupted regulation. Additionally, Brotman and colleagues (2010) surveyed the neurocorrelates

of emotional understanding during an fMRI study in which subjects rated passive viewing of

happy, angry, fearful, and neutral faces. Results indicated that during the rating of fearful faces,

subject with non-comorbid ADHD had much higher left amygdala activation compared to

subjects with Bipolar Disorder and typically developing subjects. Similarly, another fMRI study

included subjects with ADHD either medicated with psychostimulants or not medicated at all. In

this study subjects participated in a subliminal fearful face-viewing task. Results from the post-

scan face memory test revealed that medication naïve subjects experienced greater amygdala

activation and functional connectivity between the lateral prefrontal cortex (Posner et al., 2011).

Thus, although the body of literature is small, there is evidence that the biological systems

underlying emotion regulation are impaired in children with ADHD.

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Parent report/self report. There is substantial evidence that children with ADHD

experience impairment in emotional reactivity and regulation. Anastopoulos et al. (2011) found

that almost half of children with ADHD in their sample had elevated levels of parent-reported

lability compared to only 15 % of children without ADHD. Likewise, a recent meta-analytic

study found that 25%-45% of children and 30%-70% of adults with ADHD struggle with

emotional dysregulation based on a self or parent report (Shaw et al., 2014). Similarly, cross

sectional data from over 5000 8-19 year old subjects in the UK documented that almost 30% of

participants cited themselves as struggling with emotional labiality (Stringaris & Goodman,

2009). In sum, parents and child reports provide converging evidence that many children with

ADHD experience difficulties with emotion reactivity and regulation.

Observational. Observational studies provide further evidence of regulatory deficiencies

using different paradigms. Keltner and colleagues (1995) were interested in comparing

regulatory skills in children with and without symptoms of ADHD in the context of social

interactions. In this study, subjects were administered an IQ test and their facial expressions were

recorded. Children with symptoms of ADHD showed a higher expression of frustration

indicating that they were less able to regulate their emotions, despite the presence of an authority

figure. Additionally, several studies used a difficult or impossible problem-solving task to induce

a negative affect. In a study of school-aged boys, researchers randomly assigned half of the boys

to suppress their frustrating emotions during an insoluble puzzle task (Walcott & Landau, 2004).

Children with ADHD were significantly more reactive, especially when asked to suppress

emotions. Similarly, when children were ask to complete a puzzle while blindfolded,

experimenters observed that children with ADHD were more likely to quit before completion,

comparable with the congruent self-report evidence that children with ADHD were less likely to

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tolerate their frustration (Scime & Norvilitis, 2006). These findings support the theory that

children with ADHD experience considerably higher rates of anger and frustration dysregulation

compared to their typically developing counterparts.

Emotion knowledge. There is a substantial body of research that indicates that

emotional perception is impaired in children with ADHD. Shaw (2014) conducted a meta-

analytic study revealing emotional labeling impairment in children with ADHD with an effect

size of 0.65 across 19 studies. Children with ADHD are less able to recognize emotions in still-

facial, auditory, and live expressions of negative emotion (Scime & Norvilitis, 2006; Sjowell,

Lindqvist & Thorwell, 2013). Interestingly, one study showed that children with ADHD were

better at rating feelings of happiness compared to sadness or anger (Sjowell, Lindqvist &

Thorwell, 2013). David Da Fonseca and colleagues (2009) were also interested in how children

with ADHD were able to recognize facial expression; however, they emphasized the importance

of contextual cues when examining emotional knowledge and they ran an experiment in which

they compared children with ADHD to typically developing children on their ability to predict

the facial expression that matched with a contextual cue. Results indicated that children with

ADHD were worse at matching the facial expression that appropriately fit the situation (Da

Fonseca et al., 2009). In sum, there has been consistent evidence that children with ADHD have

greater difficulty recognizing emotions than typically developing children.

Early Childhood Evidence

Although there has been substantial research that suggests emotional competence is a

common deficit in older children with ADHD, there has been very little research confirming the

linkage to ADHD in early childhood. Yet, there is a large body of indirect evidence that young

children with or at risk for ADHD have difficulties with emotion regulation. For instance, a

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meta-analysis of temperament studies of young children reported a .6-.7 correlation between

ADHD symptoms and emotionally related temperament rating. Similarly, early temperament

traits like hostility and anger have been found to predict ADHD in kindergarten students

(Goldsmith et al., 2004). Congruently, Campbell et al. (1994) found a frequent grouping of

negative affectivity, poor self-regulation, and impulsivity in toddlers with externalizing behavior

problems. There have also been longitudinal studies that have tracked children’s temperament

over time to examine if it leads to later ADHD (Shaw et al., 2014; Stringaris, Maughan, &

Goodman, 2010). Stringaris, Maughan, and Goodman (2010) tracked 7,140 children from ages 3

through 7 using a community-based sample. They found that indicators of high temperamental

emotionality and activity as measured by the Emotionality Activity Sociability (EAS) Scale were

predictors of later childhood comorbid ADHD. In sum, although there is no evidence that

directly links dysregulation and ADHD in early childhood, indirect evidence suggest that it is

likely.

Present Study

The current literature provides a substantial amount of evidence that school-aged children

with ADHD struggle on multiple levels of emotional competence. There is evidence that

preschool-aged children at risk of ADHD might experience similar impairments. However, there

is a gap in the literature examining emotional competency in young children who meet criteria

for ADHD. The present study examines emotional knowledge, expression, and regulation in

young children with ADHD symptoms, with a focus on emotion in the context of frustration.

Managing frustration is an important process for preschool-age children because of its impact on

social and educational situations. We studied the following research questions:

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1. Do preschool children who meet criteria for ADHD have poorer emotion knowledge

than typically developing children? It is hypothesized that children with ADHD

symptoms will exhibit impaired emotional understanding on a test of emotion

knowledge, which measures the ability to identify affect in others and match

emotions to affectively charged situations.

2. Are preschool children who meet criteria for ADHD more emotionally reactive than

typically developing children during a frustrating task? It is hypothesized that

children with ADHD symptoms will have higher rates of expression of negative

emotions during the frustration block.

3. Are preschool children who meet the criteria for ADHD less able to regulate their

emotions than typically developing children during a frustrating task? It is

hypothesized that children with ADHD symptoms will be less able to regulate their

negative expression of emotion when ask to practice emotion suppression.

Method

Participants for this study included 60 children (41 boys) between 4 and 7 years of age.

The mean age for all subjects in this study was 6.39 years (M = 76.72 months, SD = 9.78). There

were no significant differences in age, F (1, 59) = 0.01, p = .94, or gender. X2 (1) = 1.38, p = .24.

Participants included both children with (n = 27) and without (n = 33) ADHD symptoms. In

order to be included in the ADHD group, children were required to present with at least 6 ADHD

hyperactive-impulsive symptoms, and could not have taken ADHD medications within 48 hours

prior to the experiment. We chose to specifically target ADHD-PH and ADHD-C because

ADHD-PI has a typically later age of onset. The group of typically developing children was

matched for gender and age with the group of children with ADHD, and they could not

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experience more than 3 symptoms of ADHD. All subjects in this study could not demonstrate

intellectual, hearing, visual, language receptive disabilities, nor could they suffer from cerebral

palsy, epilepsy, Autism or psychosis.

Procedure

After being recruited via the Child Studies Database, families of typically developing

children were sent a letter inviting them to participate in the study. It was a similar process for

children with ADHD, but they were recruited via referrals and advertisement postings

throughout the Pioneer Valley. For both groups, a phone interview assessing the child’s

eligibility to participate was conducted using the ADHD and ODD sections of the Diagnostic

Interview Schedule for Children (NIHM DISC-IV; Shaffer et al., 2000), in addition to a set of

questions assessing inclusion criteria. Eligible families were scheduled for a time to participate in

the experiment and asked to mail back the consent form for the screening interview. All families

who participated received $20 for their participation. Parents of children with ADHD were also

offered 4 training sessions free of charge on hyperactive behavior management. Upon arrival,

parents signed consent documents and children provided verbal assent. One graduate student and

one undergraduate research assistant conducted all sessions. This study was approved by the

UMass institutional review board.

Measures

Emotion Matching Task. The EMT is a measure of emotional understanding. It consists

of four parts. In the first section, subjects are asked to match different expressions with the same

emotion. For instance, the experimenter says, “Show me which one of these children (in a set of

four photographs) feels the same way as this one (target photograph).” In the second part,

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children are asked to match an expression with a particular situation. For example, the

experimenter says, “Show me the one who got a pretty puppy for a birthday present.” The third

condition entails participants labeling expressions of a single photo. A child is told, “Look at

her/his face. How does she/he feel?” In part four (verbal emotion matching) a child would be

told to identify the picture that matches a given emotion label. For example, the experimenter

might say, “Show me the one who feels happy” (Izard et al., 2003). Scores were calculated for

each subtest by calculating the number correct out of 12. Morgan and colleagues published a

study examining the reliability of the Emotion Matching Task as a measure of emotion

knowledge in young children. They divided the original test into two separate 24-item tests both

balanced in items from each of the four parts. Results indicated that split half internal reliability

was strong (a = .87; Morgan, Izard & King, 2010).

Frustration Task. We induced frustration by instructing subjects to play a rigged

computer game. We video recorded their reactions in order to later code children's affective

expression and regulatory strategies. Children were wearing an EEG cap during this task as part

of the larger study. Subjects completed a modified Affective Posner Task— a task in which they

had to press a button to indicate which side of a computer screen a star was on. The task

consisted of four different conditions: Baseline, Frustration, Regulation, and Recovery. In the

Baseline condition, the children were told that for every incorrect response that they gave, a star

would be taken away and for every correct response that they gave, they would gain a star.

Because this was not complex, by the end of the task the children typically accumulated a

number of stars. This condition consisted of approximately 50 trials. After this block, the

children were given a stamp to place inside their passbook. The Reactivity block was identical to

the Baseline condition as far as the structure, but it was designed to create a form of frustration

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similar to that in which children experience on a day to day basis when a game or a toy does not

work properly. This task consisted of 100 trials. In 30 of these trials the button was “not

working" and the choice that the child selected was not marked as selected. They received

feedback that their response was incorrect. During this block, the children were informed that

they did not collect enough points to be given a stamp, and were given another chance. The

children were reminded that we are experiencing problems with the computer but to keep on

playing even when the button does not work. Our measure of emotional reactivity was how the

children behaved during the Frustration block. The Regulation condition was identical to the

Reactivity condition with the added concept that the children were specifically asked to suppress

any display of their emotions. This task consisted of 100 trials. In 30 of these trials, the button

did not work, and the choice that was selected was not marked, and they received feedback that

their response was incorrect. This condition was intended to elicit negative affect from children

but the children this time were asked to regulate their emotions; as such, it served as the measure

of emotional regulation. At the end of this block, children were also told that because the

computer was malfunctioning they would get a stamp for both this block, as well as the one

previously completed. The Recovery condition was designed to allow the children to engage in

the game again without frustration in order to allow them to return to a more positive state before

leaving the laboratory. The button worked once again during this task. This task consisted of 50

trials, and the children were also given a stamp on their passbook after this block. At the end of

the study, the subjects were compensated for their participation and thanked for taking part in the

study.

For each block, participants' affect and behavior were coded. Blocks were coded in 5

second epochs. The present study focuses on negative affect codes. In each epoch, the presence

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of negative affect was coded, and the intensity of that affect was rated. If negative affect was

coded, the coder specified whether the affect was anger/frustration/annoyance, sadness, or

worry/distress. Ratings were summed across epochs for each block and divided by the total

number of epochs in each block.

Two coders overlapped for 15 of the participants. In order to assess interrater reliability

we conducted an AC1 analysis for each category of negative affect. The AC1 is similar to kappa,

and is a measure of percent agreement, correcting for chance agreement (Wongpakaran et al.,

2013). However, it calculates chance agreement differently than kappa, and is better suited for

codes that have low prevalence rates (2013). AC1 scores were .77 for overall negative affect, .87

for anger/frustration/annoyance, .99 for sadness and .90 for distress/worry.

Data Analysis

To assess group differences in emotion understanding between typically developing

children and children with ADHD symptoms, we conducted a one-way ANOVA with group

entered as a between-subjects factor for each measure of emotion understanding. The Emotion

Matching task yields four subscores which served as dependent variables: 1) matching

expressions, 2) expression-situation matching, 3) expression labeling, and 4) expression label

matching.

To assess group differences in emotional reactivity between typically developing children

and children with ADHD symptoms, we conducted a one-way ANOVA with group entered as a

between-subjects factor for the measure of emotional reactivity. Emotional reactivity was

defined as the frequency with which children demonstrate negative affect during the Frustration

block of the Affective Posner Task.

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To assess group differences in emotion regulation between typically developing children

and children with ADHD symptoms, we conducted a one-way ANOVA with group entered as

between-subjects factor for the measure of emotion regulation. We also conducted paired sample

t-tests separately for each group, comparing expression of negative affect during the Frustration

block and during the Regulation black.

Results

Emotional Understanding

To assess competency in emotional understanding, subjects’ scores on the Emotion

Matching Task were compared on all four parts individually. One-way ANOVAs indicated

significant differences between children with ADHD symptoms and typically developing

children in two out of the four parts. Typically developing children (M = 10.06, SD = 1.50)

scored higher than children with ADHD symptoms (M = 8.96, SD = 1.79) at matching

expression, F(1, 57) = 6.60, p = .01. Similarly, children with ADHD symptoms (M = 8.52, SD =

1.93) scored lower in expression-situation matching task, F(1, 57) = 4.69, p = .04, than typically

developing children (M = 9.53, SD = 1.67). However, there were no significant differences on

the expression labeling, F(1, 57) = 0.61, p = .44, and expression-label matching F(1, 57) = 0.40,

p = .53, tasks. Results are displayed in Table 1.

Negative Affect During the Baseline and Recovery Blocks

Group differences in emotional expression were examined during Baseline and Recovery

blocks, to provide a context for examining differences during the Frustration and Regulation

blocks. Because there was no induced emotion during these blocks we would have expected to

discover very little group differences between typical developing children and children with

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ADHD symptoms. During the Baseline block there was no significant group difference in the

expression of overall negative affect, F(1, 43) = 2.40, p = .13, sadness, F(1, 43) = 1.95, p = .17,

anger/frustration/annoyance, F(,43) = 1.26, p = .27, or distress/worry, F(1,43) = 1.04, p = .31.

Similarly, during the Recovery block there were no significant group differences in overall

negative affect, F(1, 43) = 2.82, p = .10, sadness, F(1, 43) = 2.88, p = .10,

anger/frustration/annoyance, F(1, 43) = 1.36, p = .25, or distress/worry, F(1, 43) = 1.88, p = .18.

Results are presented in Table 2

Negative Affect During the Frustration Block

To examine group differences in emotion reactivity between typically developing

children and children with ADHD symptoms, children’s displays of overall negative affect,

sadness, anger/frustration/annoyance, and distress/worry were compared during the Frustration

block using a one-way ANOVA. Results indicated significant differences between groups in

expression of overall negative affect, F(1, 43) = 4.49, p = .04, and sadness, F(1, 43) = 4.06, p

= .05. As hypothesized, children with ADHD symptoms (M = 0.25, SD = 0.185) had higher

scores in overall negative affect during the Frustration block than typically developing children

(M = 0.14, SD = 0.17). Additionally, children with ADHD symptoms (M = 0.03, SD = 0.06)

displayed higher scores on sadness than typical developing children (M = 0.01, SD = 0.01).

Children with ADHD symptoms (M = 0.18, SD = 0.15) exhibited higher scores in

anger/frustration/annoyance than typically developing children (M = 0.10, SD = 0.14) at a

probability level that approached significance, F(1, 43) = 3.32, p = .08. However, there were no

significant group differences in distress/worry, F(1, 43) = 0.52, p = .47. Results are displayed in

Table 2.

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Negative Affect During the Regulation Block

To evaluate group differences in emotion regulation abilities between typically

developing children and children with ADHD symptoms, we compared children’s expression of

overall negative affect, sadness, anger/frustration/annoyance and distress/worry during the

Regulation block of the Affective Posner Task using a one-way ANOVA. There were significant

differences in the expression of overall negative affect, F(1,43) = 6.58, p = .01, and

anger/frustration/annoyance, F(1,43) = 7.14, p = .01. In line with predictions, children with

ADHD symptoms (M = 0.25, SD = 0.19) scored higher in overall negative affect during the

regulation block than typically developing children (M = 0.12, SD = 0.17). Children with ADHD

symptoms (M = 0.17, SD = 0.14) scored higher in expression of anger/frustration/annoyance

during the Regulation block than typically developing children (M = 0.07, SD = 0.13).

Difference approached significance in the expression of sadness, F(1,43) = 3.35, p = .07, and

there were no significant difference in the expression of distress/worry, F(1, 43) = 0.28, p = .60.

Children with ADHD symptoms (M = 0.06, SD = 0.11) scored higher in the expression of

sadness, compared to typically developing children (M = 0.01, SD = 0.05). Results are displayed

in Table 2.

Block Interactions

To assess group by block interactions, we conducted a mixed designs ANOVAs with

group as a between-subjects factor and block entered as a within subject factors. There were no

significant Group X Block interactions in overall negative affect, F(1, 43) = 1.16, p = .33,

sadness F(1, 43) = 1.39, p = .25, anger/frustration/annoyance F(1, 43) = 1.49, p = .22, or

distress/worry F(1, 43) = 0.26, p = .86. We also examined whether instructing participants to

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suppress their emotional expression during the Regulation block resulted in a significant

reduction in negative emotion compared to the Frustration block. As such, we conducted

separate paired sample t-tests, comparing expression in the Frustration block with expression in

the Regulation block. For typically developing children there was no significance in overall

negative affect, t(25) = 0.79, p = .44 , sadness t(26) = -0.78, p = .44, anger/frustration/annoyance,

t(25) = 1.33, p = .19, or distress/worry, t(25) = -2.22, p = .83. For children with ADHD there was

no significance in overall negative affect, t(19) = 0.39, p = .97, sadness t(22) = -1.40, p = .18,

anger/frustration/annoyance, t(19) = 0.20, p = .84, or distress/worry, t(19) = -1.48, p = .88. See

Figures 1 through 4 for affect ratings across blocks.

Discussion

The goal of this study was to determine if young children with ADHD symptoms

experience more difficulty than typically developing children in emotion competence.

Specifically, we examined group differences in emotion understanding, emotion reactivity, and

emotion regulation. As hypothesized, typically developing children exhibited better emotion

understanding than children with ADHD symptoms on two subscales of the Emotion Matching

Task. Results also suggested that children with ADHD symptoms showed more negative affect

during a frustration tasks than typically developing children. Children with ADHD symptoms

also demonstrated more negative affect than typically developing children when asked to

regulate their emotions, but neither group showed significant reductions in negative affect

expression compared to the simple frustration block.

Prior research evidence suggests that older children and adults with ADHD experience

deficits in emotional knowledge. However, to our knowledge, this is the first study to document

21

that these deficits exist in children with ADHD as young as age four. These results suggest that

even as young as age 4 deficits brought upon by ADHD can be observed as early as preschool.

The present study revealed two findings that are in line with studies of older children and adults.

First, compared to typically developing children, children with ADHD symptoms struggled to

match pictures of a child expressing an emotion with pictures of other children expressing that

same emotion. Second, compared to typically developing children, children with ADHD

symptoms struggled to recognize which emotional expression was the appropriate emotional

response to a given situation. Findings that children with ADHD symptoms are underperforming

in their ability to recognize when an emotion should be appropriately employed suggests that

children with ADHD may be impaired in a key aspect of emotion knowledge that is important

for social development. This is in line with the previously findings of Da Fonseca and colleagues

(2009) who noted higher impairment in older children with ADHD on measures of emotion

understanding on the basis of contextual information. This is also in line with the body of

literature indicating that children with ADHD widely demonstrate social deficits. (Alessandri,

1992; Barkley, 1997; Becker & Langberg, 2013).

The finding that children with ADHD symptoms scored relatively high in emotion

labeling task is inconsistent with many studies indicating that children with ADHD do

experience deficits in emotion labeling (Singh et al., 1998; Cadesky, Mota & Schachar, 2000;

Pelc et al., 2006). However, these studies used methods of emotion labeling that do not require

verbal labeling, while our study does. An explanation for this could be that children with ADHD

may be better at verbally labeling emotions than non-verbally labeling emotions. But to our

knowledge, there are no other studies assessing verbal emotion labeling in children with ADHD.

22

In this study, children with ADHD symptoms exhibited more negative affect during

frustration than typically developing children, supporting the theory that preschool-aged children

with ADHD symptoms exhibit impairments in emotion reactivity. This finding is consistent with

previous studies that have induced frustration in older children with ADHD and found greater

expression of negative affect (e.g., Maedgen & Carlson, 2000; Walcott & Landau, 2004). The

replication of these findings in preschool-age children is a valuable addition to the literature

because we suspect that at this age, even typically developing children are highly emotionally

reactive; thus it is essential to establish that preschool-aged children with ADHD experience

emotional reactivity that is distinguishable from typically developing children of the same age.

This study also replicated past research indicating that children with ADHD self-report and are

observed to experience high levels of frustration during induced frustration tasks (Milich &

Okazaki, 1991; Douglas & Perry, 1994; Keltner et al., 1995), and extends these findings to

demonstrate that children with ADHD also experience more sadness. Replication of these

findings in preschool aged children is relevant because both highly reactive frustration and

sadness have potential to impact how children fit in with their peers or resolve academic

challenges.

This is the first study to examine emotion expression in preschool aged children with

ADHD symptoms when instructed to practice emotion suppression. Similar to the Frustration

block, as expected, young children with ADHD symptoms also expressed more overall negative

emotion, frustration, and sadness than typically developing children when instructed to suppress

their emotion during the regulation block. However, there was no significant group by block

interaction. Moreover, neither group of children showed significant decreases in negative affect

when asked to suppress their emotions compared to the frustration condition. It may be that,

23

because children were asked to stay still throughout the task because they were wearing an EEG

cap, children were already suppressing their expression of emotions during the frustration

condition, leaving little room for further suppression of emotion. The fact that rates of expression

of negative affect were relatively low throughout the task is consistent with this possibility.

Limitations

This study had several limitations. First, the procedure may not have allowed subjects to

stabilize back to baseline between the frustration and regulation block; thus they began with

more negative emotion in the regulation block than they had in the frustration block.

Additionally, the study was limited by the subtle nature of emotion expression. This study was

part of a larger study in which children were wearing caps to measure event-related potentials,

and were asked to be very still during the task. Therefore, children's emotion expression may

have been dampened. Thus, prevalence of some types of emotion expression were quite low,

likely due to the nature of the task. The emotion-matching task was also limited in the sense that

we did not collect data regarding the understanding of specific emotions like sadness and anger.

An additional limitation of our study was that our sample size was relatively small; we would

expect a bigger sample size to yield more robust results, which may have allowed for the

detection of significant interactions or differences between conditions. Our small sample size

also did not allow us to examine within group differences such as the presence of co-occurring

symptoms of psychopathology.

Implications and Future Studies

Findings of the present study could have implications for early functioning, treatment of

ADHD and for future research. In the context of preschool, this evidence has considerable

24

bearing as deficits in emotion regulation has potential to impact how children with ADHD

symptoms are able to socialize with their peers, resolve academic challenges, and meet important

developmental milestones. For instance, if a child with ADHD has had a turn playing with a toy

and the teacher tells the child it’s time for another child to have a turn, the child with ADHD may

become emotionally liable which may interfere with peer relationships. Further, in light of

findings that children who do not reach necessary developmental landmarks in emotion

processing are at increased risk of developing persistent and co-occurring psychopathology, such

evidence has implications for future mental health (Kim & Cicchetti, 2010).

This study adds to the substantial body of evidence that suggests that children with

ADHD symptoms struggle with multiple facets of emotional competence. One of our findings

supports the idea that the misunderstanding of emotional “appropriateness” or how affect is used

within the social context may be a particular area of difficulty for children with ADHD

symptoms. Treatment could address this deficit by teaching children skills that would allow them

to understand when to use emotions.

There is much research remaining to be done on ADHD and emotion competencies.

Based on our findings, a study investigating emotional competence as it relates to more complex,

more socially dependent secondary emotions such as shame, pride, guilt, or embarrassment could

be quite telling. Another research question of particular interest is whether impairments in

emotional competence in children with ADHD symptoms are related to comorbid emotional and

behavior problem; a future study could examine if there are any group differences in emotional

competence between children with ADHD symptoms who do and do not experience

comorbidities. Additionally, we are unsure if deficits in emotional competence are linked to the

different presentations of ADHD. As such it would informative if a future study assessed group

25

difference in emotion competence between children with primarily hyperactive symptoms versus

children with primarily inattentive symptoms.

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Table 1

Emotion Matching Tasks Group Scores

Characteristics Children with ADHD Symptoms (n = 27)

Typically Developing Children (n = 32)

Mean SD Mean SD F pMatching Expressions (Part 1)

8.96 1.79 10.06 1.50 6.60 .01

Expression-situation Matching (Part 2)

8.52 1.93 9.53 1.67 4.69 .04

Expression Labeling (Part 3)

10.56 1.28 10.78 0.94 0.61 .44

Expression-label Matching (Part 4)

10.78 1.83 10.50 1.55 0.40 .53

34

TABLE 2

Children’s expression of negative affect during the Affective Posner Task.

Affect by Block Children with ADHD Symptoms (n = 20)

Typically Developing Children (n = 24)

Mean SD Mean SD F pBaseline Negative Affect 0.10 0.14 0.05 0.10 2.40 .13 Sadness 0.02 0.04 0.001 0.01 1.95 .17 Anger/Frustration 0.07 0.10 0.05 0.09 1.26 .27 Distress/Worry 0.02 0.07 0.01 0.02 1.04 .31Frustration

Negative Affect 0.25 0.19 0.14 0.17 4.49 .04 Sadness 0.03 0.06 0.001 0.01 4.06 .05 Anger/Frustration 0.18 0.15 0.10 0.14 3.32 .08 Distress/Worry 0.05 0.09 0.04 0.08 0.52 .47Regulation

Negative Affect 0.25 0.19 0.12 0.17 6.58 .01 Sadness 0.06 0.11 0.01 0.05 3.35 .07 Anger/Frustration 0.17 0.14 0.07 0.13 7.14 .01 Distress/Worry 0.05 0.09 0.04 0.10 0.28 .60Recovery

Negative Affect 0.13 0.21 0.05 0.10 2.82 .10 Sadness 0.02 0.04 0.002 0.01 2.88 .10 Anger/Frustration 0.09 0.19 0.04 0.09 1.36 .25 Distress/Worry 0.04 0.08 0.02 0.05 1.88 .18

35

FIGURE 1. Children’s Mean Expression of Overall Negative Affect During the Affective Posner task.

36

FIGURE 2. Children’s Mean Expression of Anger/frustration/annoyance During the Affective

Posner task.

37

FIGURE 3. Children’s Mean Expression of Sadness During the Affective Posner Task.

38

FIGURE 4. Children’s Mean Expression of Distress/Worry During the Affective Posner Task.