Tracey McDonagh; Department of Psychology, University of Southern Denmark, Odense M, Demark
Aine Travers; Department of Psychology, University of Southern Denmark, Odense M, Denmark
Jessica Bramham, Psychology, University College Dublin, Dublin, Ireland

Objective: To examine the relationship between anger and neuropsychological functioning in adults with ADHD.
Method: Seventy adults with ADHD were assessed. Correlational and hierarchical multiple regression analyses were performed using neurocognitive tasks and subscales of the State Trait Anger Expression Inventory (STAXI)-trait anger, anger out, anger control, while controlling for anxiety and depression (HADS), and full-scale IQ (WASI). Selective, divided, and shifting attention were assessed using the Test of Everyday Attention (TEA) subscales. Sustained attention was measured using Continuous Performance Test (CPT) scores. Response inhibition was measured using scores from the CPT and Matching Familiar Figures test (MFFT).
Results: Trait anger and anger out were both found to have a significant relationship to shifting attention (TEA – visual elevator task) and anxiety. Anger control was found to have a significant relationship to response inhibition (MFFT).
Conclusion: Anger was significantly related to two measures of neuropsychological functioning, and anxiety. Shifting attention was more significantly associated with trait anger and anger out than response inhibition, which was significantly related to anger control. These findings have the potential to inform targeted interventions in forensic psychiatry and may have implications regarding which model of ADHD best accounts for anger dysregulation.

Emotional regulation; attention deficit hyperactivity disorder (ADHD); neurocognition; anger; violent offending

“Individuals with the neurodevelopmental disorder Attention Deficit Hyperactivity Disorder (ADHD) are at greater risk of criminal offending, tend to be younger at the onset of offending, are over represented in forensic settings, and have higher rates of recidivism…Specific neuropsychological and affective issues may therefore lead to increased risk of forensic institutionalization and problematic experiences thereafter. ADHD individuals often remain untreated and experience psychiatric comorbidities that may be undiagnosed in prison…The association between ADHD and offending behavior is well documented…but explanatory frameworks for the mechanisms of this association are lacking…” (p.200).

“…Anger dysregulation may play a fundamental role in the dynamics that lead to offending, and understanding the relationship between anger and ADHD is of fundamental importance in providing effective intervention and treatment in forensic settings…The present study aimed to explore the relationship between ADHD, neurological deficits, and anger in order to further delineate the relationship between ADHD and offending…to our knowledge, no studies have specifically investigated the relationship between individual areas of deficient neuropsychological functioning and different aspects of anger experience, expression, or control, in an adult ADHD adult population” (p.203).

“It was hypothesized, based on the literature, that the experience, expression, and control of anger would be significantly associated with neuropsychological functioning. As this study had a focus on aspects of anger that may lead to offending behavior, we chose to focus on three subscales of the STAXI [State Trait Anger Expression Inventory]…trait anger, anger out, and anger control…we hypothesized that different areas of neuropsychological deficit may be implicated in different aspects of anger. We predicted that response inhibition and shifting attention would be significant in relation to anger in an adult ADHD population” (p.203).

“The participants were a clinical sample of 70 adults diagnosed with ADHD at a specialist clinic…After performing hierarchical multiple regression analysis on the three dimensions of anger-we found that while controlling for anxiety, depression, and IQ, each model explained significantly more of the variance when neuropsychological variables were included. For trait anger and anger out, a measure of shifting attention was found to be significant in the final model, as well as anxiety. For anger expression outwards, the same measure of shifting attention was the most significant variable in the regression model, and anxiety was the next most significant. Shifting attention may be important because anger impacts upon attention, by increasing attention towards anger inducing stimuli. Thus, if a person has difficulties in shifting attention, as in the case with someone with ADHD, they are unable to switch their attention away from anger inducing stimuli. This might lead to higher trait anger and increased rumination on anger provoking stimuli, which may prolong the experience of anger to the point of anger externalization outward” (p.203-207).

“The regression equation for anger control found a measure of response inhibition to be most significant. This finding may indicate that response inhibition plays a role in the ability to use coping strategies to manage anger for people with ADHD. Shifting attention also approached significance in the regression model of anger control, which may indicate that several areas of neuropsychological functioning are required to execute control strategies…the findings of the present study suggest that difficulties with shifting or switching attention may be more significantly related to trait anger and anger expression out, while response inhibition appears to be implicated in anger control. This may indicate that multiple aspects of neuropsychological functioning are important in anger regulation…” (p.207).

“…Further research and evidenced-based interventions targeting emotional dysregulation problems and, where possible, their antecedents, could improve treatment and prognosis for adults with ADHD. As measures of shifting attention and response inhibition were found to be significantly related to anger in the present study, intervention programs targeting these areas could prove useful. The relationship between affective difficulties and ADHD may be a bidirectional one, and there may be scope for reducing these difficulties if individuals with attentional problems can learn through intervention how to train their attention…If individuals with ADHD and emotional dysregulation can learn to use their attention as a regulatory tool, this may reduce the likelihood that they become involved in offending. Focus on attentional strategies may therefore have potential to improve treatment programs in forensic psychiatry, aid rehabilitation in forensic settings, and ultimately reduce recidivism and promote desistance from offending behavior” (p.208).

“…Future research could also expand anger research by constructing profiles for offending populations with ADHD and explore the use of anger in different contexts. For adults with ADHD in forensic settings, the accurate measurement and effective treatment of emotional dysregulation such as anger is of fundamental importance for risk assessment and management. Greater understanding of the pathways between clinical disorders such as ADHD, its comorbidities and dysfunctional anger is also critical, particularly due to heterogeneity among ADHD individuals” (p.208).

“Future research may also benefit from using more specific neurocognitive measures and experimental designs. It would also be desirable to examine neurocognition in contexts of high emotional valiance, in order to achieve greater ecological validity, since such contexts may have differential impacts neurocognitively or may involve varying systems/mechanisms. Certain other contextual factors, including trauma history, may also play a role in the measurement and reporting of emotions such as anger. Future research could investigate the impact of these factors in greater depth. Anger may also present or be reported differently due to gender…” (p.208-209).

“The significant relationship found between anger (trait and expression outwards) and anxiety in the present study, while not the focus of this research, was also a noteworthy finding. This may correspond with literature suggesting that aggressive and violent behavior is partially a consequence of disturbed emotional regulation. It has been suggested that an overlap may exist between brain circuitries and neurochemical systems regulating aggression and anxiety which may be influenced by neuropsychological deficits…However, interestingly, anxiety was not found to be significant in the present study for anger control. This could also lend evidence to the suggestion that anger experience, anger expression, and anger control, may involve separate processes that overlap differentially with other affective processes” (p.207-208).

“Certain personality disorders such as Antisocial Personality Disorder (ASPD) and Borderline Personality Disorder (BPD) are found more commonly in ADHD individuals…and these comorbidities are associated with elevated anger difficulties and violence. Considering that people in forensic settings commonly present with psychiatric comorbidities, future research should attempt to assess the relative impact of various comorbidities in relation to anger, as well as assessing the neuropsychological functioning associated with this anger…” (p.209).

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