Frustration Tolerance in Youth With ADHD

Abstract

Objective: The objective of this study was to compare children with ADHD with children without ADHD on frustration tolerance and to examine the role of oppositional defiant disorder (ODD) in frustration tolerance within the sample. Method: Participants included 67 children ages 10 to 14 years-old with (n = 37) and without (n = 30) Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) ADHD who completed the Mirror Tracing Persistence Task (MTPT), a validated computerized behavioral measure of frustration tolerance. Results: Children with ADHD were more likely to quit this task than children without ADHD, demonstrating lower levels of frustration tolerance. There were no differences in frustration tolerance between children with ADHD + ODD and those with ADHD – ODD. Moreover, ODD did not moderate the relationship between ADHD and frustration tolerance. Conclusion: Our results suggest that low frustration tolerance is directly linked to ADHD and not better accounted for by ODD. This research highlights specific behavioral correlates of frustration in children with ADHD.

Keywords

ADHD frustration emotion regulation emotional dysregulation oppositional defiant disorder

Introduction

Research shows that emotion dysregulation (ED) is a key impairment for many individuals with ADHD (Shaw, Stringaris, Nigg, & Leibenluft, 2014). Emotion regulation (ER) refers to “an individual’s ability to modify an emotional state so as to promote adaptive, goal-oriented behaviors,” and is essential to interpersonal, academic, and adaptive functioning (Shaw et al., 2014, p. 1; Thompson, 1994). As such, ED is conceptualized as (a) expressions of emotion that are excessive in relation to societal norms or situational context, (b) rapid and poorly controlled shifts in emotion (i.e., lability), and/or (c) atypical allocation of attention to emotional stimuli (Shaw et al., 2014). The prevalence of ED in clinical samples of ADHD ranges between 24% and 50% in children (Becker et al., 2006; Sjowall, Roth, Lindqvist, & Thorell, 2013; Spencer et al., 2011) and 34% and 70% in adults (Barkley & Fischer, 2010; Reimherr et al., 2005; Surman et al., 2013). However, it should be noted that prevalence estimates are significantly influenced by the definitions of ED used and the measurement of the construct (e.g., parent-report vs. self-report vs. observation). Longitudinally, ED in youth with ADHD is associated with increased psychiatric comorbidity (particularly with mood and anxiety disorders), greater social impairments, poorer quality of life, and greater academic and occupational difficulties (Althoff, Verhulst, Rettew, Hudziak, & van der Ende, 2010; Barkley & Fischer, 2010; Biederman et al., 2012; Seymour, Chronis-Tuscano, Iwamoto, Kurdziel, & Macpherson, 2014; Wehmeier, Schacht, & Barkley, 2010).

From a theoretical perspective, ED also is purported to be a core deficit in individuals with ADHD (Barkley, 1997). Barkley’s unified model of ADHD suggests that due to difficulties inhibiting a prepotent response (i.e., behavioral inhibition) and poor interference control, individuals with ADHD may be impaired in the regulation of arousal in the service of goal-directed activity (i.e., ER). As such, this theory stresses the importance of understanding ER in the context of ADHD as dysregulation of affect and motivation that can negatively affect one’s ability to complete goal-directed activity.

One form of ED of particular importance in ADHD is frustration, defined as “an affective response to blocked-goal attainment” (Leibenluft, 2011; Leibenluft, Blair, Charney, & Pine, 2003). Irritability, a mood state characterized by poor frustration tolerance is common in youth with ADHD (Leibenluft, 2011). Indeed, one study showed that 71.6% of youth with ADHD have clinically significant irritability compared with 3.2% of typically developing (TD) controls (Geller et al., 2002). While frustration is a normative affective response to blocked goal attainment, youth with increased levels of irritability display a lower threshold for frustration (i.e., low frustration tolerance). In particular, as approximately 41% of youth with ADHD also have comorbid oppositional defiant disorder (ODD), a disorder characterized by impairing irritability (Elia, Ambrosini, & Berrettini, 2008), it could be hypothesized that children with ADHD + ODD have poorer frustration tolerance than children with ADHD alone; however, the role of ODD has never been examined in relation to ADHD and frustration tolerance.

To date, there has been little empirical investigation of frustration tolerance in youth with ADHD. The only studies of frustration in youth with ADHD have been observational studies in which frustration is characterized using observer-based assessments during frustrating situations (e.g., unsolvable puzzle task, frustrating peer competition). For example, in an observational study of 6- to 11-year-old boys with and without ADHD, boys with ADHD were shown to be less effective in regulating their emotions during a frustrating peer competition than age-matched, non-ADHD comparison boys. That is, boys with ADHD displayed more signs of negative or frustrated emotion than non-ADHD comparison boys. Furthermore, in comparison with boys without ADHD, boys with ADHD demonstrated an enduring pattern of disinhibition (as measured by higher stop signal reaction time score) before and after the frustration task (Walcott & Landau, 2004). Another study of observed frustration demonstrated that 6- to 12-year-old youth with ADHD were more likely to quit a frustrating puzzle task before completion, more likely to report frustration, and less likely to engage in mood repair than non-ADHD comparison youth (Scime & Norvilitis, 2006). Increased levels of frustration and decreased task persistence by boys with ADHD have been reported during both academic and non-academic tasks (e.g., videogames, mapping task; Lawrence et al., 2002). In addition, youth with ADHD have difficulty identifying and processing negative emotions (Norvilitis, Casey, Brooklier, & Bonello, 2000; Singh et al., 1998), which may interfere with their ability to persist in goal-directed activity when frustrated.

Unfortunately, there are a number of limitations of the extant literature examining frustration in youth with ADHD. First, none of the existing studies of frustration in youth with ADHD have considered the role of comorbid ODD. Given high rates of comorbidity between ADHD and ODD, and the role of irritability (and therefore low frustration tolerance) in ODD, examination of frustration in ADHD youth with and without comorbid ODD is critical to understanding frustration tolerance in youth with ADHD. An additional limitation is that there have been few investigations of the behavioral correlates of frustration in youth with ADHD. That is, the majority of studies have relied on observational methodologies (i.e., studies in which child behavior is coded using observational coding systems) rather than the use of behavioral tasks to probe frustration. Observational methodologies may be subject to rater bias and therefore more objective means of probing frustration such as task persistence should be examined. Furthermore, in comparison with observational paradigms that may not reliably elicit frustration, behavioral tasks such as the Mirror Tracing Persistence Task (MTPT) used in this study have been shown to reliably elicit frustration in participants and to be predictive of difficulties with ER including substance use disorders and borderline personality disorder (BPD), as well as substance use treatment drop out (Daughters et al., 2005; Leyro, Zvolensky, & Bernstein, 2010). A final limitation is that a number of prior studies of frustration in youth with ADHD have included exclusively boys (Hoza, Pelham, Waschbusch, Kipp, & Owens, 2001; Lawrence et al., 2002; Walcott & Landau, 2004), which may not generalize to girls with ADHD.

The goal of the current study was to examine frustration tolerance in youth ages 10 to 14 years with and without ADHD using a behavioral task. We hypothesized that youth with ADHD would have lower frustration tolerance than their non-ADHD comparison peers. Furthermore, we sought to examine the role of comorbid ODD on MTPT performance in youth with ADHD. Therefore, we compared MTPT performance in youth with ADHD and ODD (ADHD + ODD, n = 12) with those with ADHD without ODD (ADHD – ODD, n = 23). We also examined ODD as a moderator in the relationship between ADHD and frustration tolerance.

Method

Participants

Participants included 67 youth between the ages of 10 and 14 years with (n = 37) and without (n = 30) Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) ADHD. The age range of 10 to 14 years was chosen due to the larger aims of the study (i.e., to examine the relationship between ER and depressive symptoms in youth at an age when depressive symptoms are likely to emerge; Seymour et al., 2012). Participants were recruited through mailings to pediatricians, schools, and community centers in the Washington DC metropolitan area, as well as university employees and families who had previously been seen in the laboratory. For inclusion in the study, youth were required to (a) be between the ages of 10 and 14 years, (b) be fluent in English so that they could understand and complete questionnaires; and (c) have at least one residential parent/guardian who was willing to participate and could complete the measures in English. Youth were excluded if there was evidence of mental retardation (estimated IQ <70) or evidence of psychosis, bipolar disorder, or pervasive developmental disorders (PDD).

For inclusion in the ADHD group, youth had to meet full DSM-IV criteria for ADHD according to evidence-based assessment procedures (i.e., parent-report on a semi-structured clinical interview and parent and teacher completion of ADHD rating forms; Pelham, Fabiano, & Massetti, 2005). For inclusion in the non-ADHD comparison group, youth could not have more than three total symptoms of DSM-IV ADHD or clinically significant impairment according to combined parent and teacher report. Participant characteristics are presented in Table 1.

Table 1.

Participant Demographic and Clinical Characteristics (n = 66).

Variable	ADHD (n = 37)	Control (n = 30)	Group differences
Demographics
Age, years	11.81 (1.47)	11.53 (1.25)	F(1, 65) = 0.67, p = .42
Sex (% male)	68% (n = 25)	47% (n = 14)	χ²(1, 67) = 2.98, p = .09
Race/ethnicity (% Caucasian)	41% (n = 15)	70% (n = 21)	χ²(1, 67) = 5.78, p = .02
WISC-IV scaled scores^a
Block design	10.37 (3.39)	11.57 (3.43)	F(1, 63) = 1.99, p = .16
Vocabulary	12.20 (2.85)	13.33 (3.20)	F(1, 63) = 2.28, p = .14
Medication status (% taking medication)	68% (25)	0% (0)	χ²(1, 67) = 32.34, p < .001
Stimulant	62% (23)	n/a
Non-stimulant	5% (2)	n/a
Clinical characteristics
Total ADHD symptoms	13.35 (3.68)	0.40 (0.77)	F(1, 65) = 357.24, p < .001
Inattentive symptoms	8.24 (1.36)	0.13 (0.35)	F(1, 65) = 1,007.81, p < .001
Hyperactive/impulsive symptoms	5.11 (3.05)	0.27 (0.69)	F(1, 65) = 72.24, p < .001
Parent-rated overall impairment	3.76 (1.82)	0.50 (1.25)	F(1, 65) = 69.51, p < .001
Teacher-rated overall impairment^b	3.54 (1.82)	0.55 (1.15)	F(1, 42) = 40.64, p < .001
ODD diagnosis (% positive)	32% (12)	3% (1)	χ²(1, 67) = 8.97, p = .003
MTPT-C errors^c	230.63 (479.28)	328.56 (424.18)	F(1, 60) = .01, p = .95
MTPT-C median distance^c	25.20 (27.40)	20.03 (13.30)	F(1, 60) = .81, p = .37
MTPT-C quit (% quit)^c	83% (n = 29)	59% (n = 16)	χ²(1, 62) = 4.27, p = .04

Note. Results presented as M (SD) or as percent (n). Total ADHD, inattention, hyperactivity/impulsivity are based on parent and teacher report on the Disruptive Behavior Disorders Checklist and clinician report on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL). The mean for WISC scaled scores is 10. WISC-IV = Wechsler Intelligence Scale for Children–4th edition; ODD = oppositional defiant disorder; MTPT-C = Mirror Tracing Persistence Task–Computerized Version.

Two ADHD participants were missing WISC-IV scores.

n = 24 and 20 for ADHD and Control groups, respectively.

Five participants (three Controls and two ADHD) were missing MTPT-C data due to technical errors.

Procedures

Participants were screened via telephone to determine initial eligibility and, if eligible, were scheduled for a single assessment session at the University of Maryland College Park. Written parent consent and child assent were obtained prior to participation. During the assessment, parents completed (a) a diagnostic interview about the youth’s past and current ADHD symptoms, (b) rating scales assessing the youth’s ADHD and disruptive behavior disorder (DBD) symptoms and functional impairment, and (c) a demographics questionnaire. Youth completed (a) a brief IQ screen using the Wechsler Intelligence Scale for Children, 4th Edition (WISC-IV) Block Design and Vocabulary subtests (Wechsler, 2003) and (b) a computerized behavioral task of frustration tolerance. Youth with ADHD who were taking stimulant medication were allowed to remain on their medication on the day of testing (for ethical reasons), but for diagnostic purposes, questions were asked about their behavior off medication. For the larger aims of the study, information was also collected from parents and youth about depressive symptoms and ER. Youth were paid US$25 for their participation and parents were offered a free workshop offered by the first author on “Parenting Adolescents.”

With parental permission, rating scales were sent to the teacher who spent the most time with the child and knew him or her the best. In total, teacher ratings were available for 66% (n = 44) of the sample, and there was no difference between groups on the presence of teacher ratings, χ²(1, N = 67) = 0.02, p = .89. If teacher data were unavailable, the ADHD diagnosis was made using clinician assessment and parent-report of school performance and difficulties, incorporating prior report cards and school records when available. Teachers received US$10 upon completion of these scales.

Assessment of parent and youth demographic information

Parents were asked to complete a basic demographic information form inquiring about parent and/or youth sex, age, ethnicity/race, income level, and medication status.

Assessment of youth ADHD

Parents/guardians were interviewed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1997), a semi-structured diagnostic interview assessing current and lifetime diagnoses of ADHD. The K-SADS-PL has well-established reliability (Ambrosini, 2000) and has been shown to be highly related to the Child Behavior Checklist and Conners’ Parent Rating Scale scores (Kaufman et al., 1997). Interviews were conducted by the first author who was extensively trained in the administration of the K-SADS, and who met weekly with a licensed clinical psychologist (the senior author) for supervision. Interviews were recorded for supervision purposes, and discrepancies were discussed by the clinical team until agreement was reached.

Parents and teachers also completed the DBD symptom checklist (Pelham, Gnagy, Greenslade, & Milich, 1992) that assesses ADHD, ODD, and conduct disorder (CD) symptoms on a scale from not at all to very much. Symptoms rated as occurring pretty much or very much were considered present to a clinically significant degree. Internal consistency for the DBD in this sample was adequate to high on the ADHD (α = .95), ODD (α = .90), and CD (α = .74) scales. Total ADHD symptoms (r = .92, p < .001), total inattentive symptoms (r = .94, p < .001), and total hyperactivity/impulsivity symptoms (r = .90, p < .001) as rated by parents and teachers on the DBD were highly correlated with the clinical interview (i.e., K-SADS). Parents and teachers were requested to report on the youth’s typical behavior while not actively medicated for ADHD.

As required for a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000) diagnosis of ADHD, cross-sectional impairment was measured using the parent and teacher versions of the Children’s Impairment Rating Scale (CIRS; Fabiano et al., 2006). On the CIRS, informants assess the youth’s level of impairment and need for treatment across multiple domains, including peer/sibling relations, self-esteem, academic achievement, and parent–child relations as well as an overall rating of impairment. Ratings are made on a 7-point scale, with scores above the midpoint indicating clinically significant impairment. The CIRS has demonstrated concurrent validity with other established measures of youth impairment and accurately discriminates between youth with ADHD and non-disordered youth (Fabiano et al., 2006). Internal consistency for both parent- and teacher-rated CIRS in this sample was high (α = .95 and .88, respectively).

Diagnoses of ADHD were made by counting symptoms endorsed by either parents or teachers as occurring to a clinically significant degree on either the K-SADS or DBD (“or” rule; Shemmassian & Lee, 2016). Furthermore, youth in the ADHD group were required to display cross-situational impairment as measured by parent or teacher report of overall impairment on the CIRS (Fabiano et al., 2006). When teacher ratings were unavailable, only parent DBD and clinician K-SADS ratings were used to count symptoms; however, parent-report about school behavior, prior report cards, and school records were used to establish cross-situational impairment. Diagnoses of ODD were made by counting symptoms (i.e., four out of eight) endorsed by parents as occurring to a clinically significant degree on either the K-SADS or DBD. Descriptive data for all scales are presented in Table 1.

Assessment of frustration tolerance

Frustration tolerance was assessed using a well-validated computerized measure of psychological distress tolerance, the Mirror Tracing Persistence Task–Computerized Version (MTPT-C; Strong et al., 2003). During this task, participants are instructed to trace the outline of a star (Figure 1) using the computer’s mouse (i.e., red dot shown in Figure 1). To elicit frustration, the mouse is programmed to move the cursor in the reverse direction of participant movement. For example, if the participant moves the mouse to the left, the red dot moves to the right. Furthermore, if the participant moves the red dot outside of the star’s lines or stalls for more than 2 s, a loud noise sounds and the red dot returns to the starting position. Participants can quit the task at any point but are told that their monetary prize is dependent upon how they do on the task. The primary outcome (i.e., frustration tolerance) is measured dichotomously (i.e., quit vs. no quit). In addition, total errors and median distance were recorded to assess participant skill on the task. Total task time is a maximum of 5 min depending on quit time. As a manipulation check, before and after the task, participants rated their current irritability, frustration, anxiety, difficulty concentrating, and bodily discomfort on a scale of 0 to 100. The MTPT-C has been shown to be a valid measure of psychological distress tolerance (i.e., the ability to persist in goal-directed activity when experiencing psychological distress) in adults engaged in smoking cessation (Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005), abstinence from drugs and alcohol (Daughters et al., 2005), treatment of eating disorders (Anestis, Selby, Fink, & Joiner, 2007; Waller, Corstorphine, & Mountford, 2007), and cessation of self-harm behaviors in individuals with BPD (Gratz, 2003). Prior studies of distress tolerance in adolescents (using a modified distress tolerance task) have shown that lower levels of distress tolerance have been associated with higher levels of internalizing symptoms in females, and externalizing behaviors including ADHD and ODD both cross-sectionally and longitudinally (Cummings et al., 2013; Daughters et al., 2009).

Figure 1.

Display for MTPT-C.

Data from five participants (three controls, two ADHD) were unusable on the MTPT-C due to technical errors. Youth with missing data did not differ from those with MTPT-C data in terms of age F(1, 65) = 1.32, p = .26; sex, χ²(1, 67) = 0.74, p = .39; ethnicity, χ²(1, 67) = 0.15, p = .70; or ADHD status χ²(1, 67) = 0.51, p = .48.

Data Analytic Plan

All analyses were conducted using IBM SPSS Statistics 23. First, to ensure the task elicited frustration, paired t tests were conducted on pre- and post-task reports of emotion (e.g., overall dysphoria, frustration). Next, partial correlational analyses, controlling for group differences in race/ethnicity (due to differences between the groups, see Table 1), were conducted to examine the relationship between the dependent variable (i.e., quit/no quit on the MTPT-C) and demographic variables, ADHD symptoms, and impairment within the entire sample.

To examine group differences in errors and median distance achieved on the frustration task as well as irritability, general linear model (GLM) ANOVA were conducted. Primary analyses to compare groups (ADHD vs. TD, and ADHD + ODD vs. ADHD – ODD) on frustration tolerance (i.e., quit status) were conducted using logistic regressions. Cox and Snell R-squared are reported for model fit. To test the moderating effect of ODD on frustration tolerance in youth with ADHD, the PROCESS macro in which all predictors are mean centered prior to analysis was employed (Hayes, 2012). For moderation analysis, latency to quit (continuous variable) rather than quit versus no quit was used as the dependent variable (i.e., to avoid having all dichotomous variables in the model). For all analyses significance was set to p < .05.

Results

Manipulation Check

To confirm that the MTPT-C elicited distress, a manipulation check was conducted on emotion ratings before and after the task. Using paired t tests, the manipulation check showed that all participants had an increase in dysphoria following the MTPT-C (mean before = 43.37 ± 51.90; mean after = 89.98 ± 68.59), t(61) = −8.24, p < .001, and in particular an increase in frustration (mean before = 14.53 ± 20.17; mean after = 44.90 ± 34.32), t(61) = −7.16, p < .001.

Correlational Analyses

First, we examined the relationship between frustration tolerance on the MTPT-C and demographic variables within the entire sample. Within the entire sample, MTPT-C quit status (i.e., quit vs. no quit) was not significantly related to any demographic variables including child sex (r = .14, p = .29), child age (r = −.17, p = .18), or child race (r = .00, p = .98).

Given that diagnostic groups differed on child race/ethnicity (Table 1), partial correlations controlling for child race were used to examine the relationship between MTPT-C quit status and ADHD symptoms and impairment. All partial correlations are presented in Table 2. MTPT-C quit status was significantly related to ADHD diagnosis (r = .28, p = .02), total ADHD symptoms (r = .28, p = .03), and total inattentive symptoms (r = .30, p = .02), but not hyperactive/impulsive symptoms (r = .21, p = .11) or ODD diagnosis (r = .13, p = .32). MTPT-C quit status was also significantly related to both parent-reported overall impairment (r = .28, p = .03) and teacher-rated overall impairment (r = .32, p = .04).

Table 2.

Partial Correlations Controlling for Group Differences in Child Race/Ethnicity Within the Whole Sample (n = 67).

Variable	1	2	3	4	5	6	7	8
1. MTPT-C quit	—
2. ADHD diagnosis	.276*	—
3. Total ADHD symptoms	.258*	.925**	—
4. IA symptoms	.275*	.989**	.942**	—
5. HI symptoms	.197	.707**	.914**	.726**	—
6. Parent-rated impairment	.256*	.533**	.655**	.715**	.480**	—
7. Teacher-rated impairment^a	.318*	.683**	.587**	.673**	.392*	.470**	—
8. ODD diagnosis	.216	.390**	.401**	.330*	.430**	.479**	.364*	—

Note. MTPT-C = Mirror Tracing Persistence Task–Computerized; IA = inattention; HI = hyperactive/impulsive; ODD = oppositional defiant disorder.

n = 39 for teacher ratings.

p < .05. **p < .01.

Group Differences

Comparisons between the ADHD and Control Group on MTPT-C variables are presented in Table 1. There were no significant group differences on number of errors made on the task, F(1, 60) = 0.01, p = .95, or median distance achieved on the task, F(1, 60) = 0.88, p = .35, demonstrating no group differences in skill. Furthermore, youth with ADHD did not demonstrate a greater change in self-reported frustration compared with non-ADHD youth, F(1, 61) = 2.62, p = .11. However, youth with ADHD were significantly more likely to quit the task than control participants (odds ratio [OR] = 3.32, Wald χ² = 4.07, p = .04; Table 2). Eighty three percent of the ADHD participants quit the task compared with 59% of non-ADHD control participants (Figure 2). In fact, youth with ADHD had 24.74 times increased odds of quitting compared with non-ADHD participants.

Figure 2.

Differences in frustration tolerance in children with ADHD and non-ADHD controls.

Next, we compared MTPT performance in youth with ADHD + ODD (n = 12) with those with ADHD – ODD (n = 23). Groups did not differ on number of errors made on the task F(1, 33) = .02, p = .89, or median distance achieved on the task, F(1, 33) = 2.19, p = .15. Moreover, there were no differences in frustration tolerance (quit vs. no quit) between ADHD + ODD and ADHD – ODD groups (OR = 1.05, Wald χ² = .003, p = .96).

Finally, we examined ODD as a moderator in the relationship between ADHD and latency to quit. ODD did not moderate the relationship between ADHD and MTPT latency to quit (Table 3, Figure 3).

Table 3.

Linear Model Predictors of MTPT Latency to Quit.

	b	SE B	t	p
Constant	134.81	34.12	3.95	<.001
ODD diagnosis	−25.54	75.87	−0.34	.74
ADHD diagnosis	−18.94	76.83	−0.25	.81
ADHD by ODD diagnosis	48.45	173.48	0.28	.78

Note. Model R² = .046. ODD = oppositional defiant disorder.

MTPT = Mirror Tracing Persistence Task.

Figure 3.

Examination of ODD as a moderator in the relationship between ADHD and MT time to quit; Note. ODD = oppositional defiant disorder.

Discussion

This study was the first to examine frustration tolerance, assessed using a computerized behavioral task, in youth with ADHD compared with youth without ADHD. Furthermore, it was the first study to examine the role of ODD in relation to frustration tolerance in youth with ADHD.

Our main finding was that youth with ADHD demonstrated lower levels of frustration tolerance (i.e., measured as the tendency to quit a frustrating behavioral task) compared with non-ADHD control youth regardless of comorbid ODD. Our results parallel observational studies of frustration, which have shown that, compared with TD youth, youth with ADHD are less effective in regulating their emotions and persisting in the face of frustration than their TD peers (Scime & Norvilitis, 2006; Walcott & Landau, 2004). Interestingly, we did not find that youth with ADHD reported greater levels of perceived frustration with this task compared with their TD peers as has been found in other studies (Scime & Norvilitis, 2006). This may be because youth in our study were asked to self-report on their affective state rather than have the affective state characterized by an independent observer. That is, youth with ADHD may be less aware of their internal affective states or be less valid reporters of those states (Smith, Pelham, Gnagy, Molina, & Evans, 2000; Zucker, Morris, Ingram, Morris, & Bakeman, 2002). Indeed, many studies using the MTPT-C find no correlations between quit status and self-reported emotional reactivity suggesting that MTPT-C measures tolerance of frustration in the moment while self-report measures likely tap trait-related frustration reactivity (Ameral, Palm Reed, Cameron, & Armstrong, 2014; McHugh et al., 2011). It may be that the primary difference in youth with ADHD compared with TD youth lies in the regulation of the behavioral response to frustration rather than in the subjectively rated intensity of the emotion itself. In addition, as affective responses can be affected by medication, it should be noted that some of the children with ADHD were taking stimulant medication during the task (n = 25), which may have altered their perception of task frustration. Furthermore, our results do not suggest that a skills deficit contributed to decreased frustration tolerance in youth with ADHD more so than their peers as there were no group differences in skill on the MTPT-C.

Our main finding is also interesting when considered in the context of the ADHD reward processing literature. Specifically, we found that despite being told that their reward was dependent upon their performance during the frustrating task, youth with ADHD were more likely to quit the task. This result is interesting in light of neuroimaging results that have shown that individuals with ADHD demonstrate hypoactivation of the ventral striatum during reward anticipation indicating that the salience of anticipated rewards is diminished in ADHD (Scheres, Milham, Knutson, & Castellanos, 2007; Strohle et al., 2008). For youth with ADHD, if anticipated rewards are less meaningful, it may negatively affect their ability to persist in the wake of goal-directed behavior when frustrated. For example, the ability to complete a frustrating task such as homework may not be worth the reward of getting a good grade or earning a reward at home for youth with ADHD. In fact, Sagvolden, Johansen, Aase, and Russell (2005) have suggested that due to dopamine hypofunction, youth with ADHD have deficits in the processing of reward cues, which likely contributes to the fact that behavioral symptoms of ADHD often appear resistant to operant conditioning. Alternatively, it may be that, for youth with ADHD, their dysregulated frustration response results in increased engagement of limbic regions, facilitating sensitivity to affective information at the expense of the engagement of cortical systems necessary for regulatory control, making it difficult to engage in goal-directed activity (Oei et al., 2012). Of course, both of these hypotheses require additional testing in youth with ADHD.

Given the high rates of comorbidity between ADHD and ODD, we compared frustration tolerance in youth with ADHD with and without comorbid ODD. Results showed no group differences in frustration tolerance. Furthermore, moderation analyses showed that ODD does not moderate the relationship between ADHD and frustration tolerance. Taken together, our results suggest that the difficulties that youth with ADHD have with frustration tolerance are likely independent of ODD. While these findings may reflect low power to detect this effect, they could also suggest that a lower threshold for frustration in youth with ADHD is more related to core characteristics of ADHD such as inattention, hyperactivity, and impulsivity rather than the associated features of oppositionality, anger, and irritability. Indeed, we found a positive relationship between frustration tolerance and total inattentive symptoms such that youth with higher levels of inattention were more likely to quit the task than those with lower levels of inattention. Surprisingly, we did not find a relationship between hyperactive/impulsive symptoms and frustration tolerance within our sample. It may be that in the wake of frustration, youth with ADHD “tune out” the aversive frustrating stimuli and give up on a task rather than persist, which can greatly impair their academic functioning. Additional research is needed to further explore the relationship between inattention and hyperactive/impulsive symptom dimensions and frustration tolerance.

Our results should also be examined in relation to prior studies of distress or frustration tolerance in youth with ODD. For example, a longitudinal study of distress tolerance in community sample of pre-adolescents (ages 9-13) found that greater persistence on a behavioral distress tolerance task at Year 1 was associated with lower levels of ADHD symptoms at Year 4, but increased levels of ODD symptoms at Year 4, suggesting a positive association between frustration tolerance and ODD symptoms (Cummings et al., 2013). In contrast, ODD was not related to frustration tolerance (i.e., quit status) in our sample. It should be noted that the distress tolerance task used by Cummings et al. (2013) was different from the one used in this study, which may have contributed to differential results. In addition, study design (i.e., Cummings et al. being a longitudinal study vs. this cross-sectional study) may have contributed to different findings.

Moving forward, behavioral frustration tolerance tasks should be used to probe the neural circuitry involved in low frustration tolerance in youth with ADHD. Frustration is a complex affective response that involves the interaction of multiple neural circuits involved in ER including (a) core limbic regions (amygdala [AMG], insula, and orbitofrontal cortex [OFC]) in circuit with reward regions (ventral striatum particularly nucleus accumbens [NAcc]) involved in the assessment of emotional/reward salience and generation of emotion responses, (b) frontal cortical (dorsolateral prefrontal cortex [dlPFC]) regions in circuit with dorsal striatal regions involved in the cognitive control of emotional responses, and (c) regions involved in the interface between emotional and cognitive control circuitry (especially those related to attentional control) including the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC; Abler, Walter & Erk, 2005; Haber & Knutson, 2010; Ochsner & Gross, 2005; Ochsner et al., 2009; Phillips, Drevets, Rauch, & Lane, 2003; Phillips, Ladouceur, & Drevets, 2008). Research has shown that deficits within these three circuits are associated with ED in youth with ADHD (Shaw et al., 2014). In TD youth, frustration is associated with increased dorsal and ventral mPFC recruitment suggesting the importance of “top-down” engagement of cognitive and attentional resources to assist in ER. Taken together, research in TD individuals suggests that frustration produces increased activity in both limbic and cognitive control regions, but decreased activity in reward anticipation centers. However, despite demonstrating difficulties with frustration tolerance, there has been no examination of the neural basis of low frustration tolerance in youth with ADHD. It may be that for youth with ADHD, an increased affective response in core limbic regions coupled with poor regulatory control in prefrontal regions results in a decreased threshold for frustration.

A number of limitations should be noted. First, our sample size is small, which may have limited our power to detect findings. Second, we characterized frustration using a singular behavioral task that may not adequately capture such a complex affective response. Moving forward, studies assessing frustration in youth with ADHD should consider a multimodal assessment of frustration (e.g., observational, behavioral, physiological assessment, neuroimaging).

Clinically, the results of this study suggest the importance of addressing poor frustration tolerance in youth with ADHD in treatment. To date, none of the evidence-based treatments for ADHD (i.e., stimulant medication, behavioral parent training) directly target affective responses in youth with ADHD (American Academy of Pediatrics, 2000; Wolraich et al., 2011); however, it could be argued that stimulant medication indirectly targets affective responding via assistance with executive functioning an integral aspect of ER. Although behavioral interventions may help decrease frustration tolerance by setting external parameters on a child’s behaviors, more treatments that target parental socialization of emotions within their youth need to be employed with youth with ADHD (Graziano & Garcia, in press). In fact, using frustrating behavioral paradigms during treatment could allow parents to act as in vivo coaches to their youth’s negative affective responses (Chronis-Tuscano et al., 2014). Biofeedback in which youth receive real-time measures of their own physiological reactivity may also be helpful in making youth with ADHD more attuned to their frustration levels.

Footnotes

Acknowledgements

The authors would like to thank Thorhildur Halldorsdottir, Kristian Owens, and Talia Sacks for all their assistance with the collection of data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Karen E. Seymour is an Assistant Professor in the Division of Child and Adolescent Psychiatry at Johns Hopkins University School of Medicine. Dr. Seymour’s research is focused on understanding emotion dysregulation in individuals with ADHD and elucidating biobehavioral mechanisms underlying emotion dysregulation in individuals with ADHD.

Richard Macatee is a doctoral candidate in the Clinical Psychology program at Florida State University. Richard’s research focuses broadly on transdiagnostic risk factors (e.g., distress intolerance) for anxiety and substance use disorders, particularly their co-occurrence.

Andrea Chronis-Tuscano is Professor of Psychology at the University of Maryland and Director of the Maryland ADHD Program. Dr. Chronis-Tuscano’s research focuses broadly on understanding early predictors of developmental outcomes for children with ADHD and developing/evaluating novel treatments which target these early risk and protective factors.

References

Abler

Walter

Erk

(2005). Neural correlates of frustration. NeuroReport, 16, 669-672.

Althoff

R. R.

Verhulst

F. C.

Rettew

D. C.

Hudziak

J. J.

van der Ende

(2010). Adult outcomes of childhood dysregulation: A 14-year follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 1105-1116. doi:10.1016/j.jaac.2010.08.006

Ambrosini

P. J.

(2000). Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). Journal of the American Academy of Child & Adolescent Psychiatry, 39, 49-58. doi:10.1097/00004583-200001000-00016

Ameral

Palm Reed

K. M.

Cameron

Armstrong

J. L.

(2014). A mixed-methods analysis of distress tolerance. Psychology of Consciousness: Theory, Research, and Practice, 1, 357-369.

American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158-1170.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Anestis

M. D.

Selby

E. A.

Fink

E. L.

Joiner

T. E.

(2007). The multifaceted role of distress tolerance in dysregulated eating behaviors. International Journal of Eating Disorders, 40, 718-726. doi:10.1002/eat.20471

Barkley

R. A.

(1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94.

10.

Barkley

R. A.

Fischer

(2010). The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 503-513.

11.

Becker

Steinhausen

H. C.

Baldursson

Dalsgaard

Lorenzo

M. J.

Ralston

S. J.

. . . Rothenberger

(2006). Psychopathological screening of children with ADHD: Strengths and Difficulties Questionnaire in a pan-European study. European Child & Adolescent Psychiatry, 15(Suppl. 1), I56-I62. doi:10.1007/s00787-006-1008-7

12.

Biederman

Spencer

T. J.

Petty

Hyder

L. L.

O’Connor

K. B.

Surman

C. B.

Faraone

S. V.

(2012). Longitudinal course of deficient emotional self-regulation CBCL profile in youth with ADHD: Prospective controlled study. Neuropsychiatric Disease and Treatment, 8, 267-276. doi:10.2147/NDT.S29670

13.

Brown

R. A.

Lejuez

C. W.

Kahler

C. W.

Strong

D. R.

Zvolensky

M. J.

(2005). Distress tolerance and early smoking lapse. Clinical Psychology Review, 25, 713-733. doi:10.1016/j.cpr.2005.05.003

14.

Chronis-Tuscano

Lewis-Morrarty

Woods

K. E.

O’Brien

K. A.

Mazursky-Horowitz

Thomas

S. R.

(2014). Parent–child interaction therapy with emotion coaching for preschoolers with attention-deficit/hyperactivity disorder. Cognitive and Behavioral Practice, 23, 62-78. doi:10.1016/j.cbpra.2014.11.001

15.

Cummings

J. R.

Bornovalova

M. A.

Ojanen

Hunt

MacPherson

Lejuez

(2013). Time doesn’t change everything: The longitudinal course of distress tolerance and its relationship with externalizing and internalizing symptoms during early adolescence. Journal of Abnormal Child Psychology, 41, 735-748. doi:10.1007/s10802-012-9704-x

16.

Daughters

S. B.

Lejuez

C. W.

Bornovalova

M. A.

Kahler

C. W.

Strong

D. R.

Brown

R. A.

(2005). Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility. Journal of Abnormal Psychology, 114, 729-734. doi:10.1037/0021-843X.114.4.729

17.

Daughters

S. B.

Reynolds

E. K.

MacPherson

Kahler

C. W.

Danielson

C. K.

Zvolensky

Lejuez

C. W.

(2009). Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity. Behaviour Research and Therapy, 47, 198-205. doi:10.1016/j.brat.2008.12.001

18.

Elia

Ambrosini

Berrettini

(2008). ADHD characteristics: I. Concurrent co-morbidity patterns in children & adolescents. Child and Adolescent Psychiatry and Mental Health, 2(1), Article 15. doi:10.1186/1753-2000-2-15

19.

Fabiano

G. A.

Pelham

W. E.

Jr. Waschbusch

D. A.

Gnagy

E. M.

Lahey

B. B.

Chronis

A. M.

. . . Burrows-Maclean

(2006). A practical measure of impairment: Psychometric properties of the Impairment Rating Scale in samples of children with attention deficit hyperactivity disorder and two school-based samples. Journal of Clinical Child & Adolescent Psychology, 35, 369-385.

20.

Geller

Zimerman

Williams

Delbello

M. P.

Bolhofner

Craney

J. L.

. . . Nickelsburg

M. J.

(2002). DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. Journal of Child and Adolescent Psychopharmacology, 12, 11-25. doi:10.1089/10445460252943533

21.

Gratz

K. L.

(2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192-205. doi:10.1093/clipsy/bpg022

22.

Graziano

P. A.

Garcia

(in press). Attention-deficit hyperactivity disorder and children’s emotion dysregulation: A meta-analysis. Clinical Psychology Review.

23.

Haber

S. N.

Knutson

(2010). The reward circuit: Linking primate anatomy and human imaging. Neuropsychopharmacology, 35, 4-26. doi:10.1038/npp.2009.129

24.

Hayes

A. F.

(2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. Available from http://www.afhayes.com/

25.

Hoza

Pelham

W. E.

Waschbusch

D. A.

Kipp

Owens

J. S.

(2001). Academic task persistence of normally achieving ADHD and control boys: Performance, self-evaluations, and attributions. Journal of Consulting and Clinical Psychology, 69, 271-283.

26.

Kaufman

Birmaher

Brent

Rao

Flynn

Moreci

. . . Ryan

(1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 980-988. doi:10.1097/00004583-199707000-00021

27.

Lawrence

Houghton

Tannock

Douglas

Durkin

Whiting

(2002). ADHD outside the laboratory: Boys’ executive function performance on tasks in videogame play and on a visit to the zoo. Journal of Abnormal Child Psychology, 30, 447-462.

28.

Leibenluft

(2011). Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. American Journal of Psychiatry, 168, 129-142. doi:10.1176/appi.ajp.2010.10050766

29.

Leibenluft

Blair

R. J.

Charney

D. S.

Pine

D. S.

(2003). Irritability in pediatric mania and other childhood psychopathology. Annals of the New York Academy of Sciences, 1008, 201-218.

30.

Leyro

T. M.

Zvolensky

M. J.

Bernstein

(2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136, 576-600. doi:10.1037/a0019712

31.

McHugh

R. K.

Daughters

S. B.

Lejuez

C. W.

Murray

H. W.

Hearon

B. A.

Gorka

S. M.

Otto

M. W.

(2011). Shared variance among self-report and behavioral measures of distress intolerance. Cognitive Therapy and Research, 35, 266-275. doi:10.1007/s10608-010-9295-1

32.

Norvilitis

J. M.

Casey

R. J.

Brooklier

K. M.

Bonello

P. J.

(2000). Emotion appraisal in children with attention-deficit/hyperactivity disorder and their parents. Journal of Attention Disorders, 4, 15-26.

33.

Ochsner

K. N.

Gross

J. J.

(2005). The cognitive control of emotion. Trends in Cognitive Sciences, 9, 242-249. doi:10.1016/j.tics.2005.03.010

34.

Ochsner

K. N.

Ray

R. R.

Hughes

McRae

Cooper

J. C.

Weber

. . . Gross

J. J.

(2009). Bottom-up and top-down processes in emotion generation: Common and distinct neural mechanisms. Psychological Science, 20, 1322-1331. doi:10.1111/j.1467-9280.2009.02459.x

35.

Oei

N. Y. L.

Veer

I. M.

Wolf

O. T.

Spinhoven

Rombouts

S. A. R. B.

Elzinga

B. M.

(2012). Stress shifts brain activation towards ventral “affective” areas during emotional distraction. Social Cognitive and Affective Neuroscience, 7, 403-412. doi:10.1093/scan/nsr024

36.

Pelham

W. E.

Jr. Fabiano

G. A.

Massetti

G. M.

(2005). Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 34, 449-476. doi:10.1207/s15374424jccp3403_5

37.

Pelham

W. E.

Jr. Gnagy

E. M.

Greenslade

K. E.

Milich

(1992). Teacher ratings of DSM-III-R symptoms for the disruptive behavior disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 31, 210-218. doi:10.1097/00004583-199203000-00006

38.

Phillips

M. L.

Drevets

W. C.

Rauch

S. L.

Lane

(2003). Neurobiology of emotion perception I: The neural basis of normal emotion perception. Biological Psychiatry, 54, 504-514. doi:10.1016/s0006-3223(03)00168-9

39.

Phillips

M. L.

Ladouceur

C. D.

Drevets

W. C.

(2008). A neural model of voluntary and automatic emotion regulation: Implications for understanding the pathophysiology and neurodevelopment of bipolar disorder. Molecular Psychiatry, 13, 829-857. doi:10.1038/mp.2008.65

40.

Reimherr

F. W.

Marchant

B. K.

Strong

R. E.

Hedges

D. W.

Adler

Spencer

T. J.

. . . Soni

(2005). Emotional dysregulation in adult ADHD and response to atomoxetine. Biological Psychiatry, 58, 125-131. doi:10.1016/j.biopsych.2005.04.040

41.

Sagvolden

Johansen

E. B.

Aase

Russell

V. A.

(2005). A dynamic developmental theory of attention-deficit/hyperactivity disorder (ADHD) predominantly hyperactive/impulsive and combined subtypes. Behavioral and Brain Sciences, 28, 397-419; discussion 419-368. doi:10.1017/S0140525X05000075

42.

Scheres

Milham

M. P.

Knutson

Castellanos

F. X.

(2007). Ventral striatal hyporesponsiveness during reward anticipation in attention-deficit/hyperactivity disorder. Biological Psychiatry, 61, 720-724. doi:10.1016/j.biopsych.2006.04.042

43.

Scime

Norvilitis

J. M.

(2006). Task performance and response to frustration in children with attention deficit hyperactivity disorder. Psychology in the Schools, 43, 377-386.

44.

Seymour

K. E.

Chronis-Tuscano

Iwamoto

D. K.

Kurdziel

Macpherson

(2014). Emotion regulation mediates the association between ADHD and depressive symptoms in a community sample of youth. Journal of Abnormal Child Psychology, 42, 611-621. doi:10.1007/s10802-013-9799-8

45.

Shaw

Stringaris

Nigg

Leibenluft

(2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171, 276-293. doi:10.1176/appi.ajp.2013.13070966

46.

Shemmassian

S. K.

Lee

S. S.

(2016). Predictive utility of four methods of incorporating parent and teacher symptom ratings of ADHD for longitudinal outcomes. Journal of Clinical Child & Adolescent Psychology, 45, 176-187. doi:10.1080/15374416.2014.971457

47.

Singh

S. D.

Ellis

C. R.

Winton

A. S.

Singh

N. N.

Leung

J. P.

Oswald

D. P.

(1998). Recognition of facial expressions of emotion by children with attention-deficit hyperactivity disorder. Behavior Modification, 22, 128-142.

48.

Sjowall

Roth

Lindqvist

Thorell

L. B.

(2013). Multiple deficits in ADHD: Executive dysfunction, delay aversion, reaction time variability, and emotional deficits. Journal of Child Psychology and Psychiatry, 54, 619-627. doi:10.1111/jcpp.12006

49.

Smith

B. H.

Pelham

W. E.

Jr. Gnagy

Molina

Evans

(2000). The reliability, validity, and unique contributions of self-report by adolescents receiving treatment for attention-deficit/hyperactivity disorder. Journal of Consulting and Clinical Psychology, 68, 489-499.

50.

Spencer

T. J.

Faraone

S. V.

Surman

C. B.

Petty

Clarke

Batchelder

. . . Biederman

(2011). Toward defining deficient emotional self-regulation in children with attention-deficit/hyperactivity disorder using the Child Behavior Checklist: A controlled study. Postgraduate Medicine, 123, 50-59. doi:10.3810/pgm.2011.09.2459

51.

Strohle

Stoy

Wrase

Schwarzer

Schlagenhauf

Huss

. . . Heinz

(2008). Reward anticipation and outcomes in adult males with attention-deficit/hyperactivity disorder. NeuroImage, 39, 966-972.

52.

Strong

D. R.

Lejuez

Daughters

S. B.

Marinello

Kahler

C. W.

Brown

R. A.

(2003). The Computerized Mirror Tracing Task (Version 1).

53.

Surman

C. B.

Biederman

Spencer

Miller

C. A.

McDermott

K. M.

Faraone

S. V.

(2013). Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: A controlled study. Attention Deficit and Hyperactivity Disorders, 5, 273-281. doi:10.1007/s12402-012-0100-8

54.

Thompson

R. A.

(1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59(2-3), 25-52.

55.

Walcott

C. M.

Landau

(2004). The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 33, 772-782. doi:10.1207/s15374424jccp3304_12

56.

Waller

Corstorphine

Mountford

(2007). The role of emotional abuse in the eating disorders: Implications for treatment. Eating Disorders, 15, 317-331. doi:10.1080/10640260701454337

57.

Wechsler

(2003). Wechsler Intelligence Scale for Children (4th ed.). San Antonio, TX: The Psychological Corporation.

58.

Wehmeier

P. M.

Schacht

Barkley

R. A.

(2010). Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. Journal of Adolescent Health, 46, 209-217. doi:10.1016/j.jadohealth.2009.09.009

59.

Wolraich

Brown

R. T.

DuPaul

Earls

Feldman

H. M.

. . . Visser

(2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents (Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement, Management). Pediatrics, 128, 1007-1022. doi:10.1542/peds.2011-2654

60.

Zucker

Morris

M. K.

Ingram

S. M.

Morris

R. D.

Bakeman

(2002). Concordance of self- and informant ratings of adults’ current and childhood attention-deficit/hyperactivity disorder symptoms. Psychological Assessment, 14, 379-389.