ADHD Symptoms Manifest in Automatic and Controlled Processing

ADHD Symptoms Manifest in Automatic and Controlled Processing

Jennifer Lee, Doctoral Candidate

Beth Krone, PhD

Long Island University Post Campus

Investigating and understanding the underlying nature of attention processes in ADHD can help drive improvements in treatment. In a new study, Caprì, Santoddi, and Fabio (2020)1 examined whether children with ADHD exhibited deficits in automatic and controlled attentional processes, compared to typically developing (TD) children. They administered the Multi-Source Interference Task (MSIT2,3) to characterize automatic and controlled attention among 60 youth: ADHD-Inattentive presentation: boys = 17, girls = 3; M = 8.50 years, SD = 4.52; ADHD-Combined presentation: boys = 16, girls = 4; M = 8.50 years, SD = 4.51; and typically developing controls: boys = 33, girls = 7; M = 8.50 years, SD = 4.53. The MSIT measures responses to task with incongruent (associated with controlled processing) and congruent (associated with automatic processing) stimulus conditions over the course of 3 hours.

On congruent trials characterizing automatic processing, despite some variability between the ADHD-I and ADHD-C group’s performance, the team found no significant differences between clinical groups and controls in accuracy of responses. The ADHD-I group responded significantly more slowly to these task prompts, indicating difficulty with processing speed. On congruent trials characterizing controlled processing, the ADHD-I group’s accuracy was lower than the TD group. Further, both ADHD groups scored significantly lower than the TD group for attentional processing overall, indicating more difficulty with attentional processes in the clinical groups.

The authors suggested that differences in performance across groups for congruent and incongruent trials indicate that automatic and controlled processing are linked entities, in support of findings from a prior study from their lab4. Findings such as these support the literature surrounding executive control problems among individuals with ADHD, and add to the body of evidence supporting the neuropsychological hierarchy of attentional processes.

All clinicians, and particularly clinicians-in-training, benefit from a strong understanding of the underlying mechanisms driving attention and performance in ADHD. We may not currently, as a field, have the tools to elucidate all mechanisms of ADHD. We do, however, have well-validated and reliable tools that allow us to objectively characterize certain aspects of cognitive processing that transfer to behaviors. These behaviors translate to symptom profiles, although not always neatly or uniformly for all individuals. By characterizing what we can, we find targets for intervention and begin to personalize treatments. Where bottom-up (automatic) and top-down (controlled) deficits may not precisely model performance measured within or across all ADHD presentations, future work should continue to examine the factors that differ between ADHD presentations and with co-occurring disorders, and across developmental stages. Youth who exhibit deficits in these cognitive functions may benefit from high quality assessment and clinical treatment planning targeting their needs.



  1. Caprì, T., Santoddi, E., & Fabio, R. A. (2020). Multi-Source Interference Task paradigm to enhance automatic and controlled processes in ADHD. Research in Developmental Disabilities, 97, 103542.
  2. Bush, G., & Shin, L. M. (2006). The Multi-Source Interference Task: an fMRI task that reliably activates the cingulo-frontal-parietal cognitive/attention network. Nature protocols, 1(1), 308.
  3. Bush, G., Shin, L. M., Holmes, J., Rosen, B. R., & Vogt, B. A. (2003). The Multi-Source Interference Task: validation study with fMRI in individual subjects. Molecular psychiatry, 8(1), 60.
  4. Fabio, R. A., & Caprì, T. (2019). Automatic and controlled attentional capture by threatening stimuli. Heliyon, 5(5), e01752.




Adult ADHD is a Risk Factor for Broken Bones

Adult ADHD is a Risk Factor for Broken Bones

Although some people view the impulsivity and inattentiveness of ADHD adults as a normal trait, these symptoms have adverse consequences, which is why doctors consider ADHD to be a disorder. The list of adverse consequences is long and now we can add another: broken bones.   A recent study by Komurcu and colleagues examined 40 patients who were seen by doctors because of broken bones and forty people who had not broken a bone.  After measuring ADHD symptoms in these patients, the study found that the patients with broken bones were more impulsive and inattentive than those without broken bones.  These data suggest that, compared with others, adults with ADHD symptoms put themselves in situations that lead to broken bones.  What could those situations be?  Well, we know for starters that ADHD adults are more likely to have traffic accidents.   They are also more likely to get into fights due to their impulsivity.   As a general observation, it makes sense that people who are inattentive are more likely to have accidents that lead to injuriers.  When we don’t pay attention, we can put ourselves in dangerous situations.  Who should care about these results?  ADHD patients need to know about this so that they understand the potential consequences of their disorder.  They are exposed to so much media attention to the dangers of drug treatment that it can be easy to forget that non-treatment also has consequences.  Cognitive behavior therapy is also useful for helping patients learn how to avoid situations that might lead to accidents and broken bones.    This study also has an important message for administrators how make decisions about subsidizing or reimbursing treatment for ADHD.  They need to know that treating ADHD can prevent outcomes that are costly to the healthcare system, such as broken bones.   For example, in a study of children and adolescents, Leibson and colleagues showed that healthcare costs for ADHD patients were twice the cost for other youth, partly due to more hospitalizations and more emergency room visits.  Do these data mean that every ADHD patient is doomed to a life of injury and hospital visits?   Certainly not.  But they do mean that patients and their loved ones need to be cautious and need to seek treatments that can limit the possibility of accidents and injury.


Komurcu, E., Bilgic, A. & Herguner, S. (2014). Relationship between extremity fractures and attention-deficit/hyperactivity disorder symptomatology in adults. Int J Psychiatry Med 47, 55-63.

Leibson, C. L., S. K. Katusic, et al. (2001). "Use and Costs of Medical Care for Children and Adolescents With and Without Attention-Deficit/Hyperactivity Disorder." Journal of the American Medical Association 285(1): 60-66.

What is Sluggish Cognitive Tempo and is it Relevant to ADHD?

What is Sluggish Cognitive Tempo and is it Relevant to ADHD?

By Stephen V. Faraone, PhD

Over the past few decades, a consensus has emerged among psychopathologists that some patients exhibit a well-defined syndrome referred to as sluggish cognitive tempo or SCT.   There are no diagnostic criteria for SCT because it has not yet been accepted as a separate disorder by the American Psychiatric Association.  People with SCT are slow-moving, indolent and mentally muddled.  They often appear to be lost in thoughts, daydreaming, drowsy or listless.  In reviewing these symptoms and the literature, Barkley suggested that SCT be referred to as Concentration Deficit Disorder (CDD).  This term is less pejorative but is not yet commonly used.  Becker and colleagues recently evaluated the internal and external validity of SCT via a meta-analysis of 73 studies.  Internal validity addresses the consistency of SCT symptoms as measure of an underlying construct.  Based on factor analytic studies using more than 19,000 participants, the authors concluded that the items purported to measure SCT are sufficiently correlated with one another to justify the idea that they measure the same underlying construct.  Further support for internal validity was found in studies reporting high test-retest and interrater reliability.    As regards ADHD, the authors found that SCT correlated significantly with both inattentive (r = 0.72) and hyperactive-impulsive (r = 0.46) symptoms in adults.  The greater correlation with inattentive symptoms makes sense given the nature of SCT symptoms.  So these data confirm two key points about SCT: 1) it is definitely associated with ADHD symptoms and 2) it is a meaningful construct in its own right.  Very little is known about the implications of SCT for the treatment of ADHD.   In a naturalistic study of 88 children and adolescents with ADHD, Ludwig and colleagues examined the effect of SCT on the response of ADHD symptoms to methylphenidate. They found no significant differences in treatment response between subjects with and without SCT. McBurnett and colleagues tested the effects of atomoxetine on SCT in children with ADHD and dyslexia (ADHD+D) or dyslexia only. Atomoxetine treatment led to significant reductions in both ADHD symptoms and SCT outcomes.  Because controlling for changes in ADHD symptoms did not predict changes in SCT outcomes, the authors concluded that change in SCT in response to atomoxetine is mostly independent of change in ADHD.  Although these data are preliminary and in need of replication, they do provide some guidance for clinicians dealing with ADHD patients who also have SCT.


Becker, S. P., Leopold, D. R., Burns, G. L., Jarrett, M. A., Langberg, J. M., Marshall, S. A., McBurnett, K., Waschbusch, D. A. & Willcutt, E. G. (2016). The Internal, External, and Diagnostic Validity of Sluggish Cognitive Tempo: A Meta-Analysis and Critical Review. J Am Acad Child Adolesc Psychiatry 55, 163-78.


Ludwig, H. T., Matte, B., Katz, B. & Rohde, L. A. (2009). Do sluggish cognitive tempo symptoms predict response to methylphenidate in patients with attention-deficit/hyperactivity disorder-inattentive type? J Child Adolesc Psychopharmacol 19, 461-5.


McBurnett, K., Clemow, D., Williams, D., Villodas, M., Wietecha, L. & Barkley, R. (2016). Atomoxetine-Related Change in Sluggish Cognitive Tempo Is Partially Independent of Change in Attention-Deficit/Hyperactivity Disorder Inattentive Symptoms. J Child Adolesc Psychopharmacol.


Barkley, R. A. (2014). Sluggish cognitive tempo (concentration deficit disorder?): current status, future directions, and a plea to change the name. J Abnorm Child Psychol 42, 117-25.

Emotion Dysregulation: A Major Problem For Adolescents With ADHD   


By: Joel Young

The consequences of emotion dysregulation (ED) is a major problem for adolescents with ADHD, whether the behavior is shrieking at a teacher who confiscates a cell phone not allowed during class or punching another student who crashed into the teen, maybe not on purpose. But does it matter which subtype of ADHD the adolescent carries, whether the child is male or female, or if the adolescent also has oppositional defiant disorder (ODD)? Researcher Nora Bunford and colleagues studied 180 adolescents with ADHD, ages 12-16 years old to evaluate aspects of emotion dysregulation affecting adolescents with ADHD.

In this study, the adolescent subjects were previously diagnosed with ADHD with either the inattentive subtype of ADHD or the ADHD combined type. Some subjects were comorbid for  ODD. The subjects were recruited by flyers sent to middle schools in Ohio. All children had a minimum intelligence quotient of 80 on the Wechsler Abbreviated Scale of Intelligence. The study occurred over 1 academic year and six months.

The researchers found three key aspects of emotion dysregulation were predictive for both parent-reported and child-reported social impairment, regardless of the ADHD subtype, gender, or presence or absence of ODD. These factors were the following:

  • A low threshold for emotional excitability/impatience
  • Behavioral dyscontrol accompanying strong emotions
  • Inflexibility/slow return to baseline

The researchers explained ED is comprised of two main deficits. “These are an inhibitory deficit, which manifests in socially inappropriate behavioral responses to strong emotion, and a self-regulatory deficit, which manifests in an inability to (a) self-soothe physiological arousal that strong emotion induces, (b) refocus attention, and (c) organize the self for coordinated action in the service of an external goal.”

Many different scales were used to evaluate the adolescents, such as the Difficulties in Emotion Regulation Scale (DERS), the Emotion Regulation Index for Children and Adolescents (ERICA), the Social Skills Improvement System-Rating Scales (SSIS-RS), and others. The researchers also compared the teens with ADHD to those from a community sample of youth without ADHD.

There were no significant differences between subtypes of ADHD in the subjects in terms of social impairment and emotion dysregulation, nor was it significant if the adolescent had ODD.

The researchers did discover that, compared to females in the community, females with ADHD and emotion dysregulation exhibited a lack of awareness and inattention to emotional responses. They also experienced difficulties in controlling their behavior in the face of negative em0tions and lacked confidence in their ability to control their emotions. Among the males with ADHD experiencing ED, compared to a community sample of males without ADHD, the ADHD males were significantly more emotionally inflexible with a slower return to emotional baseline. They had difficulty with socially appropriate emotional responses, lacked awareness and were inattentive emotional responses. In addition, the ADHD males struggled to control their behavior while experiencing negative emotions and lacked knowledge and clarity about the emotions they were experiencing.

The researchers noted psychosocial interventions with adolescents resembling the subjects in the study may fail because such an intervention could miss the importance of emotion dysregulation. The researchers recommended mindfulness mediation or dialectical behavior therapy as possible therapeutic techniques for these subjects.

It is unknown if the adolescents in this study were medicated, but it seems likely at least some were receiving ADHD medications. A further study on subjects taking ADHD medications and considering their levels of ED would be useful to determine if ADHD medications may help affected subjects improve their emotion dysregulation. In addition, including a group of teens with  the predominantly hyperactive-impulsive subtype as a comparison basis with the other subtypes could provide useful information. One wonders if hyperactive and impulsive teens might be more emotionally labile than adolescents who are inattentive or have the mixed subtype of ADHD.

The researchers provided important food for thought in this unique study.

Nora Bunford, Steven W. Evans, and Joshua M. Langberg, “Emotion Dysregulation Is Associated with Social Impairment Among Young Adolescents with ADHD,” Journal of Attention Disorders 32, n. 1 (2018):66-82.



9 Questions to Ask When You Suspect Your Preschooler May Have ADHD

Tanya Froehlich, M.D., M.S.
Associate Professor of Pediatrics
Cincinnati Children's Hospital Medical Center

This post originally appeared on Cincinnati Children’s blog. (or copy and paste the link:

Typically, ADHD is diagnosed during the school years, particularly around age 7. But it is possible to diagnose it as early as four years old. However, it is a difficult diagnosis to make at this young age.

All preschoolers, by nature, are active, impulsive, oppositional and defiant, which are also descriptors of kids with ADHD (attention-deficit/hyperactivity disorder). Kids around this age are impatient, learning how to handle themselves, forgetful, and what we adults would call “careless.”

So how can parents tell if their child’s behavior is “typical,” or if there is an underlying neurodevelopmental issue like ADHD?

The answer is not clear-cut, and it’s much easier to identify hyperactivity in preschoolers than it is inattention. It is not developmentally appropriate to expect children this age to perform effort-filled tasks for extended periods of time. Asking yourself the below nine questions may help you differentiate between “typical” preschool behavior, ADHD, and some other conditions which can masquerade as ADHD.


Are you getting calls about your child’s behavior a couple of times a month? Or is it multiple times a week? Typical preschoolers push boundaries and may get in trouble occasionally. However, preschoolers with ADHD are more disruptive and get into things they shouldn’t much more often than their peers. Preschool teachers are concerned because they frequently can’t sit in one place and have problems with impulse control.

Preschoolers with ADHD often have difficulty with circle time. The teacher isn’t reading directly to your child. Rather, he or she is interacting with the whole class. Because they’re not being spoken to directly, kids with ADHD get lost in these situations and their attention wanders. They do much better with one-on-one learning situations in which they get immediate feedback.

Preschoolers should be able to follow one- and two-step directions, such as, “Hang up your coat and put your shoes away.” Sure, there are some “typical” preschoolers who won’t follow instructions because they’re feeling defiant. But kids with ADHD often have more problems with working memory than other children. They may want to do what you’ve asked, and may begin to attempt it, but get distracted by something else.

Kids with ADHD will frequently “dart.” They’re flight risks. They’re supposed to be in line at school, moving from class to recess, but go in another direction. This could be an indicator of your child’s distractibility and impulsivity.

Children with ADHD can’t sit still and will frequently run off and get into things. This can become so problematic that parents avoid taking them to family-friendly restaurants. Some refrain from short trips to the store because of the disastrous results.

One ADHD symptom is “not seeming to listen when spoken to directly.” However, there can be many reasons why your child doesn’t seem to listen or has trouble following directions. One principle reason may be that your child has a hearing problem. This is why the AAP recommends that kids have their hearing checked as a part of a diagnostic evaluation.

Sometimes parents chalk up their child’s inability to follow through on directions as inattention or impulsivity, and therefore assume that the cause is ADHD. However, children with language or learning issues can show the same behaviors. They don’t follow through on instructions because they have difficulty comprehending them. Along these lines, kids may not sit still to listen to a story because they can’t understand it. As part of an evaluation, your doctor should consider whether a language or learning issue might be mimicking ADHD, or co-existing with ADHD. Children with this condition have higher rates of language and learning difficulties compared to the general population.

We also need to rule out other potential health conditions that can affect a child’s behavior before considering ADHD. For example, sleep problems can mimic the condition because children who are not well-rested will not behave well, and are often hyper. Therefore, if your preschooler snores, which is not typical, it could be a sign of sleep apnea and you should report this to your doctor.

If you’re seeing an acute behavioral problem on the heels of a big family stressor, I would wait it out – and get your child help for dealing with this stressor – before considering ADHD. For example, a recent death in the family, an illness, a parental separation, or a new baby can all impact a child’s behavior negatively. But this is still considered “normal.” Behavioral issues should be going on for six months or longer before we would consider ADHD as a possibility. Furthermore, if ADHD is the cause, the behavior problems will persist even after the child has recovered from the acute stressor.

Adding to the complexity when trying to differentiate ADHD from typical preschool behavior is one hallmark of the condition: variability. The same child may behave well at certain times but not at others, so parents may wonder why the child can’t “get it together” more consistently. This likely has something to do with the fact that children with ADHD are often: More sensitive to environmental factors than other children; tend to do better in one-on-one situations; and act differently in the presence of an authority figure and when rewards or high-interest motivators are present. Despite this day-to-day or moment-to-moment variability in performance, children with condition show ADHD-related behaviors in more than one setting. Not just at home or just at school, but in both.

As you’re answering the above questions and considering whether your child’s behavior is consistent with ADHD or not, think about how often the behavior is happening and how intense it is. When a child has ADHD, there is a long-standing, high frequency, chronic nature to the concerning behaviors. If this is the case for your child, it may be time to contact your doctor. He or she can point you in the right direction from there, and may recommend a consultation with an ADHD Center or developmental-behavioral specialist.

Females with ADHD: Can we increase diagnostic accuracy by shifting our conceptual model?

Ellen Littman, Ph.D.

Until 2013, ADHD was still grouped with the Disruptive Behavior Disorders of Childhood in the DSM-IV. Early clinic referrals revolved around the management of hyperactive, impulsive young boys. Treatment focused on minimizing the negative impact of their behaviors on others. Over time, criteria were modified and exemplars constructed in efforts to reflect the changing literature. As long as observable behaviors serve as our yardstick, the females presenting most similarly to hyperactive boys are most likely to be diagnosed. Indeed, in the early 90’s, a keynote speaker concluded that so few girls were diagnosed because girls were simply "ADD wannabees". In other words, most girls failed to meet the male-based criteria by age 7. Still, the presumption is that the criteria pertain as accurately to females as to males.

We come by this unintended gender bias honestly—and it is embedded in the very fabric of our science. Unfortunately, one of the consequences of this bias is that combined type females are still more likely to be diagnosed than inattentive females because they are more likely to meet criteria by age 12. They are also more likely to comprise the majority of female clinic subjects chosen for study samples. As a result, we’re honing our skills in recognizing the impulsive girls; however, recognizing the subtle and complex presentations of inattentive females remains far more elusive.

Gender differences?

The research says that there are no significant gender differences in terms of number of symptoms, severity, persistence, academic achievement, number of comorbidities, efficacy and tolerability of meds; even the manifestations of symptoms are similar. Indeed, the disorder itself does not differ by gender--but the genders themselves differ--physiologically, psychologically, socio-culturally. For example, women with ADHD exhibit more anxiety and depression than men with ADHD, but women in general exhibit more anxiety and depression than men. The same symptoms are experienced, but females perceive greater impairment than males. Some wonder if females are more vulnerable to the impairing effects of ADHD symptoms because it is often their functional challenges rather than the symptoms themselves that cause them to seek treatment. Misattributing their difficulties to characterological flaws, females judge themselves harshly and label themselves as inadequate relative to peers.

A unique trajectory

Several factors contribute to our diagnostic challenges. The greater likelihood of inattentive symptoms results in subtler gender-typical presentations. Internalized symptoms like anxiety and depression often contribute to misdiagnosis. Gender role expectations reward those conforming to the feminine ideal without complaint. Women with poorly choreographed executive functions mask their struggles and are too ashamed to ask for help. Ironically, the result of compensating successfully is that their plight remains secret but no less damaging to their sense of self.

Stable over time?

Historically, ADHD has been considered a neurodevelopmental disorder that is stable over time, but the women’s story is more complex. Actually, across the lifespan, symptoms tend to improve, as do executive functions. However, their qualitative experience varies considerably in response to hormonal fluctuations. Diagnosis is often delayed until girls’ symptoms intensify after puberty. Within a given month, the motivated and assertive woman presenting 4 days after her period has little resemblance to the insecure and demoralized woman presenting 4 days before her period. Hormones also mediate the emotional volatility of adolescent girls, exacerbating observable anxiety and depression, which can easily lead to misdiagnosis. Estrogen exacerbates ADHD symptoms while also affecting sleep, verbal memory, mood, and the dopamine reward system.

Undiagnosed, dysfunctional coping strategies segue into comorbid disorders that are cumulative over time across multiple domains; self-esteem plummets, anxiety paralyzes, depression deepens, and stigma is internalized. Demoralization can lead to despair, which contributes to the shocking gender differences in impact: poor self-care, self-harm, intimate partner violence, suicidality, and early mortality. The severity of these potential outcomes underscores our responsibility to address this public health crisis.

Increasing inclusiveness

Despite the fact that girls are less frequently referred, less frequently identified, and less frequently meet DSM criteria, more females than ever are being diagnosed. However, rather than disrupt, most struggle with increasingly complex quality of life issues that primarily affect them and their sense of self. The daunting array of potential negative outcomes highlights a developmental trajectory that differs significantly from those of control women and ADHD men. Recent studies compare females with ADHD to female controls, with an eye towards reducing bias. Using population samples may enlarge the subset of females that are studied. Perhaps the behavior of one gender cannot be the standard by which the other is measured. By assessing functional impairment and internalized symptoms in addition to behavior, it may be possible to create a system that can recognize symptoms in a far greater percentage of our population with equal accuracy and simultaneously allow us greater attunement to the impairments that color their quality of life.


Haimov-Kochman, R., & Berger, I. (2014). Cognitive functions of regularly cycling women may differ throughout the month, depending on sex hormone status; a possible explanation to conflicting results of studies of ADHD in females. Frontiers in human neuroscience, 8, 191.

Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of consulting and clinical psychology, 80(6), 1041.

Nadeau, K. G., Littman, E., & Quinn, P. O. (2015). Understanding girls with ADHD: How they feel and why they do what they do. Advantage Books: Washington, DC .

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Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3).

Williamson, D., & Johnston, C. (2015). Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review. Clinical psychology review, 40, 15-27.