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Cited by 66Attention Deficit Hyperactivity DisorderNeural and Behavioral Psychology StudiesChild and Adolescent Psychosocial and Emotional Development

Using Stimulants to Treat ADHD-Related Emotional Lability

Open access
Posner, Jonathan, Kass, Erica, Hulvershorn, Leslie·2014·Current psychiatry reports
DOI 10.1007/s11920-014-0478-4PMC PMC4243526
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Abstract

Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder. Although these symptoms are impairing and disruptive, relatively little research has addressed their treatment, likely due to the difficulty of reliable and valid assessment. Promising signals for symptom improvement have come from recent studies using stimulants in adults, children and adolescents. Similarly, neuroimaging studies have begun to identify neurobiological mechanisms underlying stimulants' impact on emotion regulation capacities. Here, we review these recent clinical and neuroimaging findings, as well as neurocognitive models for emotional lability in ADHD, issues of relevance to prescribers and the important role of psychiatric comorbidity with treatment choices.

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review synthesizes evidence that stimulants can reduce ADHD-related emotional lability in adults and youth, though effect sizes are generally smaller than for core ADHD symptoms. It also reviews competing neurobiological models and highlights unresolved issues in assessment, pediatric replication, and treatment of refractory or comorbid cases.

Key findings

  • Emotional lability is common in ADHD: parent-reported impairing levels were found in 38% of 5,326 children with ADHD, 40–49% in another clinical sample, and in 1,186 children, 25% had severe and an additional 50% had moderate emotional lability.
  • In the largest adult trial, 363 adults with ADHD treated with extended-release methylphenidate for 24 weeks showed significant reduction in emotional lability, with effect sizes of 0.28–0.4, lower than stimulant effects on diagnostic ADHD symptoms (meta-analytic range 0.6–0.8); other adult methylphenidate trials reported effect sizes up to 0.7.
  • In youth, lisdexamfetamine improved emotional lability in 283 children with ADHD and high emotional lability, and methylphenidate in 75 boys over a 12-week crossover trial reduced emotional lability with parent effect sizes of 0.42–0.46 and teacher effect sizes of 0.45–0.79.
  • Comorbid anxiety occurs in 20–40% of youth with ADHD; older studies suggested reduced stimulant response for core ADHD symptoms in ADHD+anxiety, but the MTA trial of 579 children found equally positive MPH response, with a more pronounced response when MPH was combined with behavioral intervention.

Methods

  • Design: narrative review of clinical and neuroimaging literature on emotional lability in ADHD and stimulant treatment; no systematic search or meta-analysis is described.
  • Data: five randomized, double-blind, placebo-controlled trials of stimulant treatment in children or adults with ADHD in which emotional lability or a similar construct was an outcome, plus neuroimaging and comorbidity studies.
  • Analysis: qualitative synthesis of clinical and neurobiological findings; no new primary data are reported.

Limitations

  • The authors state that empirical support for stimulant effects on emotional lability is less robust than for diagnostic ADHD symptoms, partly due to lack of reliable and valid assessment instruments.
  • The authors state that further replication is needed, particularly in pediatric samples, along with larger samples, placebo-controlled longitudinal designs, and studies of stimulant-refractory emotional lability and comorbidity mechanisms.
  • Evident from the text: as a narrative review, it does not systematically quantify the evidence or conduct meta-analysis, and many cited neuroimaging findings come from small samples that the authors note require replication.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s11920-014-0478-4

Cites

56 of 56 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

18 of 65 cited sources checked · 6 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Emotional lability commonly occurs in youth with attention-deficit/hyperactivity disorder.

    “Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder.”
    • Also stated in: § INTRODUCTION · plain
      “Although the diagnostic criteria of ADHD include inattention, hyperactivity, and impulsivity, many children with ADHD also demonstrate significant levels of emotional lability [2].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [2] Sobanski E et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry. 2010;51(8):915–23. This was one of the first papers to estimate the prevalence of emotional lability. It also related ratings of emotional lability to clinical features. source
  • Premisecitation

    Recent functional neuroimaging studies suggest that anomalies within frontolimbic circuits, which are not typically associated with executive functions, may underlie emotional lability in children with ADHD.

    “These studies have consisted of relatively small samples and require replication, but nonetheless, suggest that anomalies within frontolimbic circuits, which are not typically associated with executive functions, may underlie emotional lability in children with ADHD.”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [22] Brotman M et al. Amygdala activation during emotion processing of neutral faces in children with severe mood dysregulation versus ADHD or bipolar disorder. Am J Psychiatr. 2010;167(1):61. source

      The Discussion reports amygdala hyperactivity during face-emotion processing in youths with ADHD, supporting an emotion-processing neural anomaly. But the ADHD group was selected to have no significant irritability or other mood symptoms; the paper does not establish that frontolimbic anomalies underlie emotional lability in children with ADHD or contrast those circuits with executive-function circuits. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [23] Hulvershorn L et al. Abnormal amygdala functional connectivity associated with emotional lability in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2013. doi: 10.1016/j.jaac.2013.11.012 . source

      The Results (Amygdala IFC and Emotional Lability in ADHD; page unavailable) associate emotional lability in children with ADHD with altered connectivity between the amygdala and prefrontal and other cortical regions. The Discussion suggests that disruptions in these networks may underlie emotion-regulation difficulties. The paper does not establish that the implicated circuits are not typically associated with executive functions; its introductory passage instead describes prefrontal regions as involved in both cognitive and emotional control. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [24] Sonuga-Barke EJ et al. Hyperactivity and delay aversion–I. The effect of delay on choice. J Child Psychol Psychiatry. 1992;33(2):387–98. source
  • Premisecitation

    Preliminary neuroimaging studies suggest that stimulants may attenuate atypical emotional processing in regions including the amygdala and medial prefrontal cortex and through improvements in the inferior frontal gyrus.

    “Neuroimaging studies have only begun to test these competing hypotheses, but preliminary studies suggest that stimulants may attenuate atypical emotional processing in regions associated with emotion including the amygdala and medial prefrontal cortex [3, 27] and through improvements in regions associated with inhibitory control, such as the inferior frontal gyrus [28].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [3] Posner J et al. The attenuation of dysfunctional emotional processing with stimulant medication: an fMRI study of adolescents with ADHD. Psychiatry Res Neuroimaging. 2011. doi: 10.1016/j.pscychresns.2011.02.005 . source
    • cites [27] Hulvershorn, L. The impact of methylphenidate on frontal activation in youth with disruptive mood dysregulation disorder, in 60th Annual Meeting of the American Academy of Child and Adolescent Psychiatry 2013; Orlando, FL.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [28] Bradley C, Bowen M. Amphetamine (Benzedrine) therapy of children's behavior disorders. Am J Orthopsychiatry. 1941;11(1):92–103. source
  • Premisecitation

    Exacerbation of irritability is a reported side effect of stimulant treatment.

    “Clinical decision making in regards to emotional lability is complicated by the fact that exacerbation of irritability is a reported side effect of stimulant treatment [42, 43].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [42] Pliszka SR et al. A double-blind, placebo-controlled study of Adderall and methylphenidate in the treatment of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(5):619–26. source
    • cites [43] Blader JC et al. Stimulant-responsive and stimulant-refractory aggressive behavior among children with ADHD. Pediatrics. 2010;126(4):e796–806. source

      The Results (Tolerability and Adverse Effects; page unavailable) describe adverse-effect monitoring but do not identify exacerbated irritability as a stimulant side effect. The Results (Child Factors Associated With Aggression Outcome; page unavailable) say no child had worsening mood-relevant symptoms on their optimized stimulant regimen. I searched for irritability, worsening, and adverse effects; the study's finding does not establish or rule out whether irritability has been reported as a side effect elsewhere. (LLM, conf=0.73)

      Experimental — accuracy not yet measured
  • Interpretationcitation

    Empirical support for the dyscontrol hypothesis is somewhat lacking.

    “Empirical support for the dyscontrol hypothesis, however, is somewhat lacking.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [21] Posner J et al. Dissociable attentional and affective circuits in medication-naïve children with attention-deficit/hyperactivity disorder. Psychiatry Res Neuroimaging. 2013. doi: 10.1016/j.pscychresns.2013.01.004 . source
  • May combine two claims. 24
  • Classified as probably not a substantial claim. 14
  • The quote only partly states this claim. 1

  • May combine two claims.

    Premisecitation

    Children with high levels of emotional lability tolerate frustration poorly, have high levels of irritability, and demonstrate frequent crying spells or tantrums.

    “Children with high levels of emotional lability have been shown to tolerate frustration poorly, have high levels of irritability and demonstrate frequent crying spells or tantrums [2].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [2] Sobanski E et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry. 2010;51(8):915–23. This was one of the first papers to estimate the prevalence of emotional lability. It also related ratings of emotional lability to clinical features. source

  • May combine two claims.

    Premisecitation

    The presence of emotional lability in hyperactive children is associated with more severe ADHD symptoms, more frequent comorbid disorders, and higher rates of substance use disorders.

    “Studies have also shown that the presence of emotional lability in hyperactive children is associated with more severe ADHD symptoms, more frequent comorbid disorders, and higher rates of substance use disorders [2, 14, 15].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [2] Sobanski E et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry. 2010;51(8):915–23. This was one of the first papers to estimate the prevalence of emotional lability. It also related ratings of emotional lability to clinical features. source
    • cites [14] Barkley R. Deficient emotional self-regulation: a core component of attention-deficit/hyperactivity disorder. J ADHD Relat Disord. 2010;1:5–37.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [15] Hinshaw SP. Impulsivity, emotion regulation, and developmental psychopathology: specificity versus generality of linkages. Ann N Y Acad Sci. 2003;1008(1):149–59. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The affectivity hypothesis maintains that emotional lability in children with ADHD emerges through dysfunctional emotional processing itself, with emotional stimuli eliciting inordinately strong emotional responses.

    “An opposing hypothesis, which we term the “affectivity hypothesis,” maintains that emotional lability in children with ADHD emerges not from impaired executive functions, but rather through the more direct route of dysfunctional emotional processing itself.”
    • Also stated in: § NEUROBIOLOGICAL MODELS OF EMOTIONAL LABILITY IN ADHD · plain
      “Emotional stimuli, according to the affectivity hypothesis, elicit inordinately strong emotional responses in children with ADHD [25].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] Sonuga-Barke E, Bitsakou P, Thompson M. Beyond the dual pathway model: evidence for the dissociation of timing, inhibitory, and delay-related impairments in attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2010;49(4):345–55. source

      The Introduction and Results discuss inhibitory control, delay aversion, and timing deficits, but do not address the affectivity hypothesis or emotional lability. Searches for emotional processing, emotional stimuli, and strong emotional responses found no passage supporting the attributed claim. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Additional studies suggest that comorbid anxiety neither interferes in the response to stimulants on diagnostic symptoms of ADHD nor increases side effects.

    “Additional studies suggest that co-morbid anxiety neither interferes in the response to stimulants on diagnostic symptoms of ADHD, nor increases side effects.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [53] Wolraich M et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007–22. source

      The INTRODUCTION discusses stimulant efficacy for ADHD symptoms and lists adverse effects, but does not compare either outcome between children with and without comorbid anxiety. Its discussion of anxiety concerns the benefits of combined behavioral and medication treatment on academic and conduct measures, not whether anxiety changes stimulant response or side effects. Searched for comorbid anxiety, stimulant response, and adverse effects. (LLM, conf=0.73)

      Experimental — accuracy not yet measured
    • cites [32] Greenhill L et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–93. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Sobanski and colleagues found that in a clinical sample of 1,186 children with ADHD, 25% had severe levels of emotional lability and an additional 50% had moderate levels.

    “Based on the emotional lability subscale of the Parent and Teacher Conners’ ADHD rating scale, Sobanski and colleagues [2] found that in a clinical sample of 1186 children with ADHD, 25% had severe levels of emotional lability and an additional 50% had moderate levels.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [2] Sobanski E et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry. 2010;51(8):915–23. This was one of the first papers to estimate the prevalence of emotional lability. It also related ratings of emotional lability to clinical features. source

      The “Distribution and severity of emotional lability” section reports 296 of 1,186 probands (25%) in the severe group and 594 (50%) in the mild/moderate group. The citing sentence calls that entire 50% “moderate,” omitting the paper’s “mild” qualification. Page numbers are not available in the supplied copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Two competing hypotheses have been advanced to explain the neurobiological bases of emotional lability in ADHD.

    “Two competing hypotheses have been advanced to explain the neurobiological bases of emotional lability in ADHD [3, 16, 17].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [3] Posner J et al. The attenuation of dysfunctional emotional processing with stimulant medication: an fMRI study of adolescents with ADHD. Psychiatry Res Neuroimaging. 2011. doi: 10.1016/j.pscychresns.2011.02.005 . source
    • cites [16] Sonuga-Barke EJ. Psychological heterogeneity in AD/HD—a dual pathway model of behaviour and cognition. Behav Brain Res. 2002;130(1–2):29–36. source
    • cites [17] Barkley R. ADHD and the nature of self-control. New York: Guilford Press; 1997.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    After controlling for hyperactive/impulsive and inattentive symptoms, emotional lability independently contributed to higher rates of incarceration, poorer academic achievement, more driving accidents, and more problematic social and marital relations.

    “After controlling for the influence of hyperactive/impulsive and inattentive symptoms, the study found that emotional lability independently contributed to higher rates of incarceration, poorer academic achievement, more driving accidents, and more problematic poor social and marital relations.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [13] Spencer T et al. Toward defining deficient emotional self-regulation in children with attention-deficit/hyperactivity disorder using the Child Behavior Checklist: a controlled study. Postgrad Med. 2011;123(5):50. source

      The Results (Impact of CBCL-DESR on Social Functioning; page unavailable) report poorer peer functioning in children with ADHD and DESR after controlling for comorbid disorders, not after controlling for hyperactive/impulsive and inattentive symptoms. The Results (School and Family Functioning and Treatment History; page unavailable) found no added impairment in school or family functioning, and the Discussion explicitly says the study did not find added academic impairment. Our copy does not report incarceration, driving accidents, or marital outcomes. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Diamond and colleagues randomized 91 children with ADHD and ADHD plus anxiety to a titration trial of methylphenidate followed by a four-month extended trial; subjects with and without anxiety responded equally well, and there were no differences in side effects between groups.

    “Diamond and colleagues [53] randomized 91 children with ADHD and ADHD + anxiety to an acute and clinically applicable titration trial of MPH, followed by a four-month extended trial. Subjects with and without anxiety responded equally well to the stimulant, and there were no differences in side effects between groups.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [53] Wolraich M et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007–22. source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Emotional lability may be associated with an over-expression of positive emotions such as exuberance, excitability, and energy that are disproportionate to the eliciting circumstance and can be off-putting to peers.

    “Emotional lability may also be associated with an over-expression of positive emotions such as exuberance, excitability, and energy that are disproportionate to the eliciting circumstance, and can be off-putting to peers [5, 6].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Rydell A-M, Berlin L, Bohlin G. Emotionality, emotion regulation, and adaptation among 5-to 8-year-old children. Emotion. 2003;3(1):30. source
    • cites [6] Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    In a 12-week, placebo-controlled, double-blinded, crossover trial of 75 boys with ADHD, methylphenidate produced significant reductions in emotional lability on the Conners' Parent and Teacher ADHD rating scale, with effect sizes of 0.42-0.46 for parent reports and 0.45-0.79 for teacher reports.

    “Significant reductions in emotional lability were noted on the emotional lability subscale of the Conners’ Parent and Teacher ADHD rating scale. Effect sizes ranged from 0.42–0.46 and 0.45–0.79 for parent and teacher reports, respectively.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [41] Biederman J et al. Efficacy and tolerability of lisdexamfetamine dimesylate (NRP-104) in children with attention-deficit/hyperactivity disorder: a phase III, multicenter, randomized, double-blind, forced-dose, parallel-group study. Clin Ther. 2007;29(3):450–63. source

  • May combine two claims.

    Interpretationcitation

    The effect size of extended-release methylphenidate on emotional lability is lower than stimulants' effect size on diagnostic ADHD symptoms but is still clinically significant.

    “The effect size ranged from 0.28 to 0.4, which is lower than stimulants’ effect size on diagnostic ADHD symptoms (meta-analyses suggest a range of 0.6–0.8 [36, 37]), but it is still clinically significant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    A more recent study showed that methylphenidate had moderate beneficial effects on selective aspects of verbal-auditory working memory and on visual-spatial working memory in children with ADHD but showed no such improvements in children with ADHD and anxiety.

    “A more recent study showed that MPH had moderate but beneficial effects on selective aspects of verbal–auditory working memory and on a visual-spatial working memory in children with ADHD but showed no such improvements in children with ADHD and anxiety [52].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [52] Diamond IR, Tannock R, Schachar RJ. Response to methylphenidate in children with ADHD and comorbid anxiety. J Am Acad Child Adolesc Psychiatry. 1999;38(4):402–9. source

  • May combine two claims.

    Premisecitation

    Tannock and colleagues demonstrated that a single dose of methylphenidate improved verbal-auditory working memory in non-anxious children with ADHD, but had no beneficial effects in those with ADHD and comorbid anxiety.

    “Tannock and colleagues [51] demonstrated that even a single dose of MPH improved tasks of verbal–auditory working memory (digit span forward and backward) in non-anxious children with ADHD, whereas there were no beneficial effects on those with ADHD and comorbid anxiety.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51] Bedard A-C, Tannock R. Anxiety, methylphenidate response, and working memory in children with ADHD. J Atten Disord. 2008;11(5):546–57. source

  • May combine two claims.

    Premisenone given

    Withdrawal effects occur toward the end of the stimulant's duration of action, whereas stimulant-induced emotional lability typically occurs as stimulant levels are peaking.

    “This typically can be discerned based on the timing of the symptoms – withdrawal effects occur toward the end of the stimulant’s duration of action, whereas stimulant-induced emotional lability typically occurs as stimulant levels are peaking.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Improvement in emotional lability can be expected for many patients with ADHD, but in a small minority stimulants can induce or worsen emotional lability through increases in irritability.

    “Whereas improvement in emotional lability can be expected for many patients with ADHD, in a small minority, stimulants can induce or worsen emotional lability, through increases in irritability.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    According to the dyscontrol hypothesis, emotional processing is largely normal in children with ADHD, but their capacity to down-regulate or inhibit emotional responses is impaired.

    “According to the dyscontrol hypothesis, emotional processing is largely normal in children with ADHD; however, hyperactive children are impaired in their capacity to down-regulate, or inhibit, emotional responses and thus manifest highly emotional behaviors and reactions.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Barkley RA et al. Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). J Abnorm Child Psychol. 2001;29(6):541–56. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Texas Children's Medication Algorithm Project suggests that if a child has ADHD and anxiety, treatment should begin with either a stimulant or atomoxetine.

    “Similarly, the Texas Children’s Medication Algorithm Project (CMAP), a consensus conference that developed treatment algorithms for the pharmacotherapy of ADHD and comorbid conditions, suggests that if a child has ADHD and anxiety, treatment should begin with either a stimulant or atomoxetine (Strattera) [55].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    Stimulants' efficacy in reducing the diagnostic symptoms of ADHD has been repeatedly demonstrated, but studies of stimulant effects on emotional lability are far less numerous though suggestive.

    “In sum, whereas stimulants’ efficacy in reducing the diagnostic symptoms of ADHD has been repeatedly demonstrated, studies of stimulant effects on emotional lability, though suggestive, are far less numerous.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Few instruments have been developed for assessing emotional lability, whereas several well-validated parent- and teacher-report instruments are available to assess diagnostic symptoms of ADHD.

    “Whereas several well-validated, parent- and teacher-report instruments are available to assess diagnostic symptoms of ADHD, few instruments have been developed for similarly assessing emotional lability.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The reviewed studies are uniformly supportive of stimulant use to treat emotional lability in ADHD, although additional research in youth is needed to validate these findings.

    “These studies are uniformly supportive of stimulant use to treat emotional lability in ADHD, although certainly in youth, additional research to validate these findings is needed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Such neuroimaging findings are supportive of both the dyscontrol and affectivity hypotheses, suggesting stimulants may have a direct salutary effect on emotional processing regions and on regions traditionally associated with more cognitive functions that may influence emotion regulation.

    “Such findings are supportive of both hypotheses, suggesting that stimulants may have a direct salutary effect on emotional processing regions and regions traditionally associated with more cognitive functions, that may influence emotion regulation.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    The affectivity hypothesis has received less research and clinical focus than the dyscontrol hypothesis, perhaps because ADHD is conceptualized largely as a cognitive or non-affective disorder.

    “The affectivity hypothesis has received less research and clinical focus than the dyscontrol hypothesis perhaps because ADHD is conceptualized largely as a cognitive, or non-affective disorder.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Many youth with ADHD also struggle with significant levels of anxiety, and between 20-40% have a comorbid anxiety disorder.

    “In addition to emotional lability, many youth with ADHD also struggle with significant levels of anxiety, and between 20 – 40% have a comorbid anxiety disorder [45, 46].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [45] Jensen PS et al. ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry. 2001;40(2):147–58. source
    • cites [46] Schatz DB, Rostain AL. ADHD with comorbid anxiety a review of the current literature. J Atten Disord. 2006;10(2):141–9. source

  • May combine two claims.

    Premisecitation

    Children with comorbid anxiety also had higher rates of side effects, including tics, although there was no evidence that stimulants worsened symptoms of either ADHD or anxiety.

    “Children with comorbid anxiety also had higher rates of side effects, including tics, although there was no evidence that stimulants worsened symptoms of either ADHD or anxiety.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [48] Wolraich ML et al. Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics. 1990;86(1):95–101. source
    • cites [49] Martinussen R et al. A meta-analysis of working memory impairments in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2005;44(4):377–84. source

  • May combine two claims.

    Premisecitation

    In the Multimodal Treatment Study, 579 children with ADHD were randomized, and children with ADHD and anxiety showed an equally positive response to methylphenidate as those without anxiety.

    “Most notably, in the Multimodal Treatment Study (MTA)[32], 579 children with ADHD were randomized to community treatment, intensive behavioral intervention, medication management, or a combination of medication management and behavioral intervention. Children with ADHD and anxiety showed an equally positive response to MPH as those children with ADHD without anxiety [32].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] Greenhill L et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–93. source

  • May combine two claims.

    Premisecitation

    Anxiety associated with ADHD may emerge from an inability to function in daily life due to the social and cognitive limitations associated with ADHD, and this type of anxiety may differ etiologically from primary anxiety disorder.

    “Anxiety associated with ADHD may emerge from an inability to function in daily life due to the social and cognitive limitations associated with ADHD. This type of anxiety may differ etiologically from the worry and phobic behaviors characteristic of a primary anxiety disorder [47].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [47] Pliszka SR. Effect of anxiety on cognition, behavior, and stimulant response in ADHD. J Am Acad Child Adolesc Psychiatry. 1989;28(6):882–7. source

  • Classified as probably not a substantial claim.

    Premisecitation

    AAP guidelines note that if the diagnosis of ADHD is confirmed, appropriate treatment of ADHD can result in the resolution of comorbid symptoms such as anxiety.

    “If the diagnosis of ADHD is confirmed, the AAP guidelines note that appropriate treatment of ADHD can result in the resolution of comorbid symptoms such as anxiety [54].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [54] Pliszka SR et al. The Texas Children's Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2006;45(6):642–57. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The dyscontrol hypothesis attributes emotional lability in ADHD primarily to impairments in executive control.

    “The first, which we have termed the “dyscontrol hypothesis,” attributes emotional lability in ADHD primarily to impairments in executive control [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Barkley R. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. 1997;121(1):65–94. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Becker and colleagues reported that 40-49% of children with ADHD in a clinical sample had elevated levels of parent-reported emotional symptoms similar to emotional lability.

    “Using a clinical sample, Becker and colleagues [11] reported a slightly higher rate, with 40–49% of children with ADHD having elevated levels of parent-reported emotional symptoms (symptoms similar to emotional lability).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Strine TW, et al. Emotional and behavioral difficulties and impairments in everyday functioning among children with a history of attention-deficit/hyperactivity disorder. Preventing chronic disease, 2006; 3(2).

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a study of 5,326 children with ADHD, Stringaris and colleagues found that parents reported impairing levels of emotional lability in 38% of the sample.

    “In a study of 5,326 children with ADHD, Stringaris and colleagues [10] found that parents reported impairing levels of emotional lability (termed “mood lability” in this study) in 38% of the sample.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Becker A et al. Psychopathological screening of children with ADHD: strengths and difficulties questionnaire in a pan-European study. Eur Child Adolesc Psychiatry. 2006;15(1):i56–62. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Emotional reactions in ADHD-related emotional lability are typically brief, lasting minutes to hours, and thus differ from emotional lability associated with bipolar spectrum disorders, which have protracted episodes of days to weeks.

    “These emotional reactions, both for positive and negative emotions, are typically brief in duration, lasting on the order of minutes to hours, rather than days to weeks, and thus differ from emotional lability associated with bipolar spectrum disorders, which are characterized by protracted episodes (e.g., days-weeks) of low or high emotional states.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    The dyscontrol hypothesis is parsimonious because impairments in executive functions are well documented in ADHD.

    “This is a parsimonious hypothesis in that impairments in executive functions are well documented in ADHD [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Nigg JT et al. Causal heterogeneity in attention-deficit/hyperactivity disorder: do we need neuropsychologically impaired subtypes? Biol Psychiatry. 2005;57(11):1224–30. source
32 of 32

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The relationship between stimulant treatment and EL in individuals with ADHD remains unclear.

    “however the relationship between stimulant treatment and EL in individuals with ADHD remains unclear (Posner et al., 2014).”

    From A Post-Hoc Analysis of Emotional Lability With Delayed-Release/Extended-Release Methylphenidate in Children Aged 6 to 12 Years of Age Participating in Two Phase 3 Clinical Trials (2024) · cites this paper as Posner et al., 2014

    The Stimulant Effects on Emotional Lability section says empirical evidence is limited, and the Stimulant-Induced Irritability section calls for further replication and long-term follow-up (page numbers unavailable). But the Conclusions describe the available studies as uniformly supportive of stimulant treatment for emotional lability. Saying the relationship simply “remains unclear” captures the uncertainty while omitting that consistent positive signal. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Barkley R. Deficient emotional self-regulation: a core component of attention-deficit/hyperactivity disorder. J ADHD Relat Disord. 2010;1:5–37.

Cited by

Sorted by citations

Related

Authors
Posner, J., Kass, E., & Hulvershorn, L.
Affiliations
  • New York State Psychiatric Institute (US)
  • Columbia University (US)
  • Indiana University School of Medicine (US)
Corresponding author
Hulvershorn, Leslie
ORCID
Venue
Current psychiatry reports
Publisher
Springer Science and Business Media LLC
Published
2014-08-19
Volume
16
Issue
10
Pages
478-478
ISSN
  • 1523-3812 (ISSN-L)
  • 1535-1645
DOI
10.1007/s11920-014-0478-4
PMC
PMC4243526
OpenAlex
W1998193363
Semantic Scholar
07b8fd06cbd158268901f85b651e16e16d57a71d
Cited by
66
References
56
Citations by year
2026: 8 · 2025: 7 · 2024: 5 · 2023: 7 · 2022: 4 · 2021: 10 · 2020: 5 · 2019: 5 · 2018: 4 · 2017: 5 · 2016: 2 · 2015: 3 · 2014: 1
FWCI
2.82
Type
journal article
Language
en
Open access
Licence
www.springer.com/tdm (tdm)
Locations
  • Current Psychiatry Reports (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • IUScholarWorks (Indiana University) (submittedVersion)
  • PMC
Funders
  • National Institute of Mental Health (K23 MH091249, R01MH101172)
  • National Institute on Drug Abuse (K12 DA000357)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
emotional lability, attention deficit hyperactivity disorder, stimulant medication, emotion regulation, neurocognitive model, psychiatric comorbidity, treatment selection
MeSH terms
Adolescent, Affective Symptoms, Central Nervous System Stimulants, Attention Deficit Disorder with Hyperactivity, Brain, Child, Humans, Comorbidity, Mood Disorders, Neuroimaging

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-27.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-27.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

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