Emotional Dysregulation And Quality of Life In Young Adults With ADHD- A Cross Sectional Study


 Objective: Attention Deficit Hyperactivity Disorder (ADHD) is associated with emotional dysregulation (ED) and impaired quality of life (QoL). However, the role of ED in explaining the relationship between ADHD and QoL is unclear. The purpose of the present study was to do so in a sample of non-referred young adults with and without ADHD.Method: The study design was cross-sectional. A non-clinical sample of 62 young adults with ADHD (mean age = 24.86 years, SD = 3.25) and 69 controls (mean age = 23.84 years, SD = 2.59) were recruited. The Adult ADHD Quality-of-Life scale was used to measure QoL; The Adult ADHD Self-Report Scale was used to measure ADHD symptoms. The Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale and the Difficulties in Emotion Regulation Scale were used to measure ED. Group differences on all measures were tested using univariate and multivariate analyses of covariance, while controlling for age. Univariate analyses of variance were conducted to investigate the possible effect of medication on all outcome measures in the ADHD group. Finally, a moderation analysis was used in order to examine the impact of ED on QoL beyond that accounted for by ADHD symptoms.Results: Both QoL and ED were significantly worse for the ADHD group compared to the control group. The medication status of the ADHD group participants had no significant effect on the level of ADHD symptoms, ED or QoL. ED moderated the effect of ADHD symptoms on QoL for the ADHD group.Conclusion: The findings support the centrality of ED in ADHD and its crucial influence on QoL. Young adults with ADHD and high levels of ED are at risk for aversive impact on their well-being regardless of their ADHD symptoms level.

QoL in college students with and without an ADHD diagnosis found that young adults with ADHD reported low QoL compared to their non-ADHD peers (5,15). In addition, ADHD symptom severity and functional impairment have been shown to predict lower QoL in adults with ADHD (16)(17)(18)(19)(20)(21). Yet, the relatively moderate effect sizes of the associations between ADHD symptoms and QoL imply that there may be additional factors contributing to QoL in adult ADHD (22). Speci cally, pharmacological and psychosocial treatments, comorbid psychopathology, and drug use did not moderate the relationship between ADHD and QoL (15). Further investigation is therefore needed in order to better understand which ADHD-associated factors signi cantly impact QoL in young adults with ADHD.
Emotion dysregulation (ED), an individual's inability to modify one's emotional state to promote adaptive, goal-oriented behaviors (23) has been hypothesized as a factor which may impact QoL in ADHD (2,24).
ED is highly prevalent in adults with ADHD, with recent clinic-based studies reporting impaired ED in 32%-86% of adults with ADHD (25)(26)(27)(28)(29)(30). The de nition and measurement of ED are in substantial disarray in general, and speci cally in ADHD, re ecting different perspectives on the relationship between ED and ADHD (31). On the one hand, ED was suggested to be an additional core symptom speci c to ADHD or at least to a subtype of ADHD with which certain facets of ED are uniquely associated (such as temper control, affective lability, emotional over reactivity, emotional impulsivity and de cient emotional selfregulation) (31)(32)(33)(34)(35). This perspective is supported by the high prevalence of ED in ADHD, regardless of comorbidities (27,34). Moreover, ED is associated with ADHD symptom severity and respond to pharmacological and psychotherapeutic treatments in adults, similarly to ADHD core symptoms (29,(36)(37)(38)(39)(40). On the other hand, however, ED is proposed as another dimensional key factor within the Research Domain Criteria Initiative (RDoc) that could distinguish between people with and without many mental disorders (18). This may imply that ADHD-associated ED is not speci c to ADHD; instead, it has transdiagnostic mechanisms and etiology which are shared with other clinical conditions (such as the ability to monitor and accept one's emotional state, to control impulsive reaction and to use effective strategies in order to engage in goal-directed behaviors) (41). This ongoing debate regarding the ADHDspeci c vs. transdiagnostic nature of ED in ADHD, and the lack of agreed upon measurement approaches, warrants combining different measures to capture both perspectives on ED.
Regardless of the exact de nition of ED in the context of ADHD, the presence of ED in ADHD is associated with multiple functional impairments (such as, social participation, marital status, driving, money management and arrests). ED, as measured by ADHD-related instruments, is associated with higher levels of impairment in clinical samples of adults and young adults with ADHD, beyond what could be predicted by ADHD symptoms and comorbidity (25,34,42). Using a general transdiagnostic assessment tool, ED was found to mediate the relationship between ADHD and functional impairment in adults with ADHD (43). Also, the negative effect of ADHD symptoms level on the quality of romantic relationships was no longer signi cant when ED was added as a mediator in a sample of college students (44).
Interestingly, only a handful of studies have examined the direct contribution of ED to QoL in ADHD, yielding mixed results. Using a clinical sample of adults with ADHD, two studies reported that ED severity was signi cantly associated with ADHD symptoms severity and with QoL, regardless of medication status (42,45). On the other hand, in a study which examined the neuropsychological factors in a general population of young adults, ED was not found to be a unique contributor to QoL beyond other neuropsychological de cits (46). No study to date, to the best of our knowledge, has directly examined the impact of ED on QoL in a sample of young adults with ADHD beyond that of ADHD symptoms. Understanding the unique impact of ED on QoL is expected to deepen our understanding of the highly varied clinical picture of young adults with ADHD and its effects on one's daily living experiences and well-being.
In the current study, we examined the potential moderating effect of ED on the relationship between ADHD symptoms and QoL in non-referred young adults with ADHD. We rst examined the differences in ED between adults with and without ADHD using two different self-report measures, collectively re ecting both the transdiagnostic and the ADHD-related nature of ED. Next, we examined the moderating role of ED in explaining QoL in young adults with ADHD beyond the scope of ADHD symptoms. This study should contribute to understanding of the variance of QoL among the heterogenic population of young adults with ADHD.

Participants
Over a period of 1 year (from January 2018 to January 2019) 159 young adults were recruited for the study. Inclusion criteria for the ADHD group were a valid medical diagnosis of ADHD and a score above the clinical cutoff (≥ 51) on the Adult ADHD Self-Report Scale (ASRS) (47,48). Inclusion criterion for the healthy comparison group was an ASRS score below the clinical cutoff. Exclusion criteria for both groups were a diagnosis of a psychiatric or neurological disorder or other major health conditions as determined by self-report. Twenty-eight participants were excluded: in the control group, two participants reported a diagnosis of a psychiatric disorder and eight participants scored above the clinical cutoff of the ASRS. In the ADHD group, 13 participants scored below the clinical cutoff of the ASRS. 132 young adults (ages [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] were included in the current study: sixty-two adults with ADHD and 69 gender-matched (at the group level) controls. Inclusion criteria for the ADHD group were a valid medical diagnosis of ADHD and a score above the clinical cutoff (≥ 51) on the Adult ADHD Self-Report Scale (ASRS) (47,48). Inclusion criterion for the healthy comparison group was an ASRS score below the clinical cutoff. Exclusion criteria for both groups were a diagnosis of a psychiatric or neurological disorder or other major health conditions as determined by self-report. The sample was balanced across the two groups with respect to gender. However, since the ADHD group was slightly older, age was entered as a covariate in group comparison analyses (see Table 1). Medication status for ADHD group participants was recorded and controlled for in data analyses (see Table 2).

Study design
The current study is a part of a larger cross-sectional study which included ecological momentary assessments for 5 days in addition to baseline assessments. Here we report the results of the baseline data. Participants were recruited for the study via online advertisements in student organization groups and via posts in social media. Eligible participants were invited to the Computerized Neurotherapy Laboratory at the Hebrew university where baseline assessments took place. All participants signed an informed consent form prior to participation in any study-related activities. Participants were compensated for their participation in the study, receiving US$100 for completion of the entire study. The study was approved by the Institutional Review Board (IRB) Ethics Committee of the Hebrew University of Jerusalem (reference ID: 08112017). WRAADS ED, ED severity was assessed using 3 sub-scales from the Self-Report Wender-Reimherr Adult
Each item is measured on a 5-point scale (0 = None or slightly, 4 = very much), yielding scores that may range from 0 to 44. The scale calculation is based on Wender's theoretical de nition (1995), resulting ED cutoff achieved with a sum ≥ 11 (50). The SR-WRAADDS is based on the interviewer-administered Wender Reimberr Adult Attention De cit Disorder Scale (WRAADDS; (51)). Similar ED scale based on the WRAADS has been used in several previous studies (27,28,36,37,52). The internal consistency re ected the homogeneity of all the WRAADDS subscales, including ED. Cronbach's α for the entire WRAADDS was .88. ED indicated the highest internal consistency (Cronbach's α = .78) compared to the other WRAADDS subscales (α = .65-.73) (27). The SR-WRAADDS was translated to Hebrew by our study team with permission from the scale's authors. In the current study the internal consistency (i.e., coe cient α) for the ED subscales ranged from .80 to .91 and .92 for the total score.
The Di culties in Emotion Regulation Scale (DERS; (41)) was developed to assess ED more comprehensively than existing measures. The DERS 36 items were chosen to re ect di culties within the following dimensions of emotion regulation: (a) lack of awareness of emotional responses (awareness), (b) lack of clarity of emotional responses (clarity), (c) non-acceptance of emotional responses (nonacceptance), (d) limited access to emotion regulation strategies perceived as effective (strategies), (e) di culties controlling impulses when experiencing negative emotions (impulse), and (f) di culties engaging in goal-directed behaviors when experiencing negative emotions (goals). Each item is measured on a 5-point scale (1 = almost never, 5 = almost always), yielding scores that may range from 36 to 180, with higher scores indicating greater di culties in emotion regulation (i.e., greater ED). The DERS has high internal consistency (α = .93) (41). Here we used the validated Hebrew version (53). The scale's internal consistency for the current study ranged from.70 to .89 for the various subscales and .95 for the total score.
The Adult ADHD Quality-of-Life scale (AAQoL; (4)) is one of the most commonly used disease-speci c instruments to measure QoL in adults with ADHD in both research and clinical practice (54,55). The AAQoL consists of 29 items rated on a ve-point scale describing frequency of occurrence, yielding a total score and four subscale scores: productivity, life outlook, relationships and psychological health.
Total and subscale raw scores are transformed to a 0-to 100-point scale with higher scores indicating better QoL. The AAQoL has good internal consistency (Cronbach alpha = .93) and good test-retest reliability (ICC alpha = .86) and is able to discriminate between groups with and without ADHD (4, 13). The Hebrew version used here has demonstrated validity in Israeli adults with ADHD (7). The internal consistency for the current study ranged from .74 to .90 and .94 for the total score.

Statistical Analysis
All analyses were conducted using the IBM SPSS software Version 25.0 (56). Group differences in demographic variables were examined using chi-square, Fisher's exact tests or independent samples t tests. Univariate analyses of variance (ANOVA) were conducted to investigate the possible effect of medication on the level of ADHD symptoms, ED and QoL in the ADHD group. We rst assessed the differences between ADHD and controls on WRAADS ED, DERS and AAQoL total scores using univariate analyses of covariance (ANCOVA), while controlling for age. Next, the differences between groups in ED, DERS and QoL subscales were examined using multivariate analyses of covariance (MANCOVA), while controlling for age. Finally, we conducted moderation analysis using PROCESS analysis by Hayes (2017;58). The distributions of all study variables met normality criteria of Kolmogorov Smirnoff test. The signi cance level for general hypothesis testing was set at α = .05.

Participants' Characteristics
A total of 155 participants were considered for eligibility, but the nal study sample included 132 participants. Thirteen (n = 13) participants were excluded from the ADHD group due to an ASRS score below the clinical cutoff. In addition, ten participants were excluded from the control group: 2 due to a psychiatric diagnosis and 8 due to an ASRS score above the cutoff. The nal study sample therefore included a total of 132 participants: 63 in the ADHD group and 69 participants in the healthy comparison group.
The demographic characteristics of the study sample are shown in Table 1. Gender, current productive role and family status were comparable in the two groups. However, the average age in the ADHD group was slightly higher than that of the comparison group (24.86 ± 3.25 vs. 23.84 ± 2.59 for ADHD and comparison groups, respectively; p = .048). As expected, the ASRS scores and the ED scores were signi cantly worse for the ADHD group, and participants in the ADHD group were less educated. The medication status of the ADHD group participants had no signi cant effect on the level of ADHD symptoms, ED or QoL (see Table 2).

ADHD, ED and QoL
Total scores for the WRAADS ED, DERS and AAQoL in the two groups are presented in Table 3. A one-way ANCOVA, controlling for age, showed signi cantly higher (i.e., worse) scores in WRAADS ED and in DERS and signi cantly lower (i.e., worse) scores in the AAQoL in the ADHD compared with the comparison group. Speci cally, 73% of ADHD group participants scored above WRAADS ED cutoff (a total score sum

Moderating role of ED
To test the hypothesis that ED moderates the relationship between ADHD symptoms and QoL for individuals with ADHD, we used moderating model 1 of the PROCESS analysis by Hayes (2013). We found a signi cant interaction (B = .045, SE = .022, t = 2.076, p = .042) between ASRS total score and WRAADS ED total score, indicating that the effect of ADHD symptoms on QoL (AAQoL total score) is moderated by ED (see Table 4). As can be seen in Fig. 1, as the level of ED gets higher, the relationship between ADHD symptoms and QoL is weakened. The interaction was signi cant also for the DERS as a measure of ED (B = .027, SE = .009, t = 2.958, p = .004).

Discussion
The present study had two main goals: to assess the severity of ED among young adults with and without ADHD, and to measure the potential moderating role of ED on the association between ADHD symptoms and QoL in young adults with ADHD. Our results show that young adults with ADHD are twice more likely to suffer from ED and that their QoL is signi cantly worse than that of matched non-ADHD controls. In addition, for the ADHD group, ED signi cantly moderated the relationship between ADHD symptoms and QoL, suggesting that high ED levels can overshadow the impact that ADHD symptoms have on QoL. These ndings support the centrality of ED in ADHD and their crucial in uence on everyday QoL.
Our study provides novel ndings regarding the likelihood of young adults with ADHD to experience ED. The high prevalence of self-reported ED found in our sample (73%) is noteworthy, particularly given the non-clinical nature of the sample. Thus far, clinic-based studies have reported a wide range (34%-86%) of ED in adults with ADHD (25)(26)(27)(28)(29)(30). A recent study conducted in a clinical sample of adults with ADHD (aged 18-75) reported a similar prevalence of ED as was found in our study (70.5%) using the WRAADS scale (27). The disparity between the lower expected prevalence in a non-clinical sample and the actual high prevalence that was found, might be attributed to the younger age of our sample. Indeed, younger age was associated with higher ED severity on the sub-scales of temper control and affective lability in a recent study on adults with ADHD using the WRAADS-SR scale (32). The prominence of ED in young adults with ADHD in the current study adds to the existing literature which favors the inclusion of ED as a central dimension in ADHD (2, 25, 33-35, 42, 45).
The signi cant impairments in all domains of QoL (productivity, life outlook, psychological health and relationships) in ADHD are in line with the large body of literature emphasizing the negative impact of ADHD on daily health outcomes (2,4,13,14). So far, studies on adults with ADHD focused mainly on the adverse impact that ED has on functional impairments in ADHD, which goes well beyond ADHD symptoms (25,34,42). In contrast to the measurement of functional impairment, which measures individual performance parameters in a speci c task or context, such as work or driving performance, QoL assessment allows for a wider perspective on productivity, relationships and well-being. However, only two studies to date reported signi cant associations between QoL in ADHD and a subset of ED constructs, namely emotional impulsivity and de cient emotional self-regulation (42,45). The current study adds an additional component by showing the unique contribution of multiple ED aspects to QoL, beyond the contribution of ADHD symptoms.
The signi cant moderating role of ED as measured by both an ADHD-speci c tool and a general transdiagnostic tool provides a broader perspective of the impact of different aspects of ED on QoL in young adults with ADHD. The impact of the basic characteristics of the emotional experience and expression of ED, speci cally in ADHD as re ected by the WRAADS ED subscales on QoL, should be noted. The frequent shifts between emotional states, the disproportional over-reactivity to daily triggers, and the lack of control in face of intense negative emotions causes constant unpredicted interferences in daily life. In addition, the resulted sense of lack of control and coherence regarding the ability of an individual to react as expected might explain the harmful impact of ED on all aspects of QoL. The DERS, focusing on the cognitive and behavioral responses to negative emotional states may further explain the negative impact of ED on QoL. The di culties in monitoring one's emotional state might obscure the identi cation of the need to detect and implement effective regulatory strategies and control the reaction to negative stimuli. All of these taken together might explain the severe impact of ED on goal-directed behavior. This in turn, resonates with theories of ADHD emphasizing inherent contribution of ED to the executive failure, suggesting constructs such as emotional impulsivity as another core symptom of the disorder (31,33). Moreover, the non-acceptance of one's emotional state may point to a secondary mechanism which further exacerbates of the impact of ED on QoL, by impeding an adaptive coping process. This notion is supported by a moderating role of non-acceptance that was found in the relationship between ADHD, depressive symptoms and suicidal ideation (58). To conclude, the signi cant moderating role of ED found in both DERS and WRAADS ED represents the joint contribution of multiple emotional, cognitive, and behavioral ED aspects to the impaired QoL in young adults with ADHD.
The broader perspective on ED in the current study can also be discussed in light of the question whether there are facets of ED that are uniquely associated with ADHD (23,31,33,35,59). Here, we used two different tools to assess ED in ADHD: an ADHD-speci c tool (WRAADS ED) and a general transdiagnostic tool (DERS) and show substantial ED in ADHD compared to controls using both scales. However, a slightly different picture emerges for the unique ED de cits characterizing ADHD from each tool. For the ADHD-speci c ED scale, the subscales of temper control, affective lability and emotional over-reactivity have all yielded large effect sizes for the between-group difference. These ndings are consistent with a recent meta-analysis which found large effect sizes for ED severity of ADHD vs. controls (60), speci cally in the domains of temper control, affective lability, emotional over reactivity, emotional impulsivity and de cient emotional self-regulation (31)(32)(33)(34)(35)45). In comparison, the more general, transdiagnostic measure of ED (DERS) yielded a more varied picture, wherein only the goals subscale showed a large effect size for group differences; the awareness subscale showed a small effect size and the remaining subscales of clarity, non-acceptance, impulse, and strategies showed medium effect sizes. These ndings may re ect a unique pro le of ED in young adults with ADHD. Yet, they require further replication and examination in a larger sample, testing whether there are facets of ED that are uniquely associated with ADHD.
The debate regarding the speci city of ED to ADHD vs its transdiagnostic nature could also be addressed by our ndings of signi cant interaction between ED and ADHD in explaining QoL. Our ndings show that the strength of association between ADHD symptoms and QoL depends on the severity of ED. Thus, higher levels of ED account for the reduced QoL seen in individuals who posit lower levels of ADHD symptoms. The high prevalence of ED in the ADHD group and the large effect size compared to the control group might support the positioning of ED as a central core symptom in ADHD (27,31,33). Yet, the different pattern of clinical outcomes that depends on ED severity in young adults with ADHD might support the notion that those that have both ADHD and high levels of ED form a distinct entity or sub-type (35,45,61).
The results of our study have a few clinical implications which underscore the need for the inclusion of a broader assessment addressing ED (among other impairing factors associated with ADHD) (24) and QoL in adults with ADHD. Neglecting the potentially harmful impact of ED on the well-being of young adults with ADHD in clinical practice may lead to an inaccurate appraisal of the global clinical severity among young adults. Moreover, this understanding, in turn, should encourage further research targeting the underlying mechanisms of ED and the development of effective interventions aimed to improve ED and QoL among individuals with ADHD. Speci cally, the inclusion of self-compassion might serve as a protective mechanism from the possible negative effect of heightened awareness and non-acceptance, reducing the secondary effect of ED on QoL (62-65).
Despite its strengths, which included the use of multiple ED assessments and the non-referred sample of young adults with and without ADHD, in contrast to the majority of studies in this eld which sample participants from clinics, our study had a few limitations that should be noted. First, the ADHD diagnosis was based on a self-reported valid medical diagnosis of ADHD con rmed by ASRS scores above clinical cutoff, rather than on a clinical interview based on DSM-5 criteria. In addition, our study included only self-report measures of ED and QoL, whereas more objective measures might have yielded different outcomes and should be considered in future studies. Finally, university students in Israel are typically older than elsewhere, due to the obligatory 2-or 3-year national service, potentially limiting this study's external validity.

Conclusion
Our results point to the high prevalence of ED in non-referred young adults with ADHD, and to the importance of ED in moderating the association between ADHD symptoms and QoL. Thus, high levels of ED explain the signi cant burden on QoL in ADHD beyond symptomatology. Our study is consistent with the literature which found a more severe clinical picture in adults with ADHD who also have high levels of ED (35,45,61). These results stress the signi cance of ED in everyday life of those struggling with ADHD and call for a more systematic evaluation of ED in the ADHD population.  Interactions of ED and ADHD symptoms predicting QoL