J Abnorm Child Psychol (2015) 43:669–680

DOI 10.1007/s10802-014-9942-1

Neuropsychological Heterogeneity in Preschool

ADHD: Investigating the Interplay between Cognitive, Affective
and Motivation-Based Forms of Regulation
Douglas Sjöwall & Anna Backman & Lisa B. Thorell

Published online: 21 September 2014

# The Author(s) 2014. This article is published with open access at Springerlink.com

Abstract There is a trend toward diagnosing ADHD prior to factors that have been linked to the disorder in older children
school entry. Despite this, there is a lack of studies investigat- and adults.
ing ADHD in the preschool years, at least studies including a
large range of different neuropsychological functions. Our Keywords ADHD . Executive functions . Delay aversion .
knowledge of the independent effects of different neuropsy- Emotion regulation and preschool
chological functions in relation to preschool ADHD is there-
fore limited. In order to address this issue, the present study
investigated cognitive, affective, and motivation-based regu- Attention deficit/hyperactivity disorder (ADHD) is often
lation in relation to ADHD symptoms in 104 preschool chil- diagnosed in middle childhood, but there is a trend toward
dren (age M=67.33 months, SD=10.10; 65 % boys). Results diagnosing children prior to school entry (see Egger,
showed that these regulatory processes were all significantly Kondo, and Angold 2006 for a review). One reason for
related to ADHD symptoms and that most of these relations earlier diagnosis may be research findings showing that
remained after controlling for comorbid conduct problems. preschool ADHD is a serious condition that is linked to
Most previous preschool studies have only included cognitive severe negative outcomes both concurrently and longitu-
regulation, and to some extent motivation-based regulation. dinally (e.g., Sonuga-Barke, Thompson, Abikoff, Klein,
By also including affective regulation, we were able to explain and Brotman 2006). It is therefore important that we gain
a larger proportion of the variance in ADHD symptoms. more knowledge about the neuropsychological underpin-
However, it should be noted that the amount of variance nings of the disorder and, thereby, become better able to
explained was still small in comparison with what has been identify children at risk. One possible benefit of preschool
found in previous studies of school-aged children. This find- identification is that early intervention could moderate the
ing could be taken as an indication that further studies exam- course of the disorder, and perhaps do so more efficiently
ining the nature of preschool ADHD are needed, and that it before strong behavioral habits have been formed and
may be necessary to look beyond the neuropsychological before the disorder has resulted in secondary deficits
(see Sonuga-Barke, and Halperin 2010 for a review).
Despite this, there is a lack of studies investigating
D. Sjöwall : L. B. Thorell
Department of Clinical Neuroscience, Karolinska Institutet,
ADHD in the preschool years, at least studies including
Stockholm, Sweden a large range of different neuropsychological functions.
Cognitive, affective, and motivation-based forms of regu-
D. Sjöwall : L. B. Thorell lation have been shown to be inter-related, and have all
Stockholm Brain Institute, Karolinska Institutet, Stockholm, Sweden
been linked to ADHD in previous research on school-
A. Backman aged children (Nigg, Willcutt, Doyle, and Sonuga-Barke
Stockholm ADHD-Center, Stockholm, Sweden 2005; Shaw et al. 2014; Sjöwall, Roth, Lindqvist, and
Thorell 2013). However, the interplay between these three
L. B. Thorell (*)
forms of self-regulation in relation to preschool ADHD
Division of Psychology, Department of Clinical Neuroscience,
Karolinska Institutet, Nobels Väg 9, 171 65 Solna, Sweden has not been investigated, and this was therefore the aim
e-mail: [email protected] of the present study.
670 J Abnorm Child Psychol (2015) 43:669–680

ADHD as a Neuropsychologically Heterogeneous by neuropsychological heterogeneity both in preschool and

Disorder school age, the relative impact of each deficit may vary with
age, which makes it important to conduct further studies of
Previous research has clearly demonstrated that ADHD in- independent effects in preschool samples.
volves deficits in multiple neuropsychological functions, such
as executive functioning (Barkley 1997) and reaction time
variability (e.g., Castellanos, et al. 2005) as well as ADHD and Affective Regulation Deficits
motivation-based forms of regulation, such as delay aversion
(i.e., the tendency to choose a smaller immediate reward rather In addition to deficits in executive functioning, delay aversion
than wait for a larger delayed reward; Sonuga-Barke 2002). and reaction time variability, it has been emphasized that
These deficits have been shown to be partly overlapping, but deficient emotion regulation should be considered an impor-
there is also research indicating that they explain unique tant aspect of ADHD (see Martel 2009; Shaw et al. 2014 for
variance in ADHD (e.g., Sjöwall et al. 2013; Solanto et al. reviews). Findings from several studies of school-aged chil-
2001). It has therefore been argued that ADHD is best de- dren have shown that poor emotion regulation is related to
scribed as a heterogeneous disorder involving several different ADHD (e.g., Anastopoulos et al. 2011; Maedgen and Carlson
neuropsychological pathways (e.g., Nigg et al. 2005). 2000; Walcott and Landau 2004). In addition, these deficits
It is important to emphasize that the notion of ADHD as a have been shown to be at least partly independent of deficits in
heterogeneous disorder is primarily based on the results of other neuropsychological functions in relation to ADHD (e.g.,
studies on school-aged children. However, two meta-analyses Berlin, Bohlin, Nyberg, and Janols 2004; Blaskey, Harris, and
on preschoolers have recently been presented. Schoemaker Nigg 2007; Sjöwall et al. 2013).
et al. (2012) conducted a meta-analysis of executive function- Very few extant studies have investigated the link between
ing in preschool children with ADHD and found a medium emotion regulation deficits and ADHD symptoms in pre-
effect size for inhibition and small effect sizes for working school children, at least studies taking the effect of cognitive
memory and cognitive flexibility. Another meta-analysis, deficits into account. One exception is the study by Martel
studying a broader range of neuropsychological deficits in et al. (2013), which showed that both cognitive and affective
relation to ADHD, found a similar pattern of results for regulation were related to ADHD symptoms. They conducted
executive functioning, but also a large effect size for delay a factor analysis in which all included measures formed one
aversion and a medium effect size for vigilance/arousal (Pauli- factor labeled “control”, and they therefore did not investigate
Pott and Becker 2011). Interestingly, both meta-analyses to what extent affective and cognitive regulation explained
showed that most deficits interacted with age such that asso- overlapping variance in ADHD symptoms. Healey et al.
ciations to ADHD were stronger for older compared to youn- (2011), however, examined both additive and interactive ef-
ger participants. However, the reverse pattern was true for fects of cognitive and affective functioning. First, their results
delay aversion. showed that executive functioning deficits and negative emo-
With regard to independent effects of different neuropsy- tionality were independently related to ADHD symptoms.
chological functions in relation to ADHD, very few previous Second, it was shown that symptom levels were high, except
studies have examined this issue among preschool children. when the child had both well-functioning executive functions
However, Thorell and Wåhlstedt (2006) found an independent and low levels of negative emotionality. Thus, good executive
effect of inhibition, but not of working memory or fluency, in functioning was protective when negative emotionality was
relation to preschool ADHD symptoms. In addition, Skogan low, but not when negative emotionality was medium or high.
et al. (2014) showed independent effects of both inhibition Neither of the two above-mentioned studies included mea-
and working memory in relation to ADHD symptoms in their sures of motivation-based regulation such as delay aversion,
sample of 3 years olds, but effects sizes were very small (rs and the measures of affective regulation did not include reg-
ranging from 0.06 to 0.17) and effects were significant mainly ulation of positive emotions, which should be regarded as a
due to the large sample size (n=1,045). To our knowledge, limitation, as regulation of happiness/exuberance has been
only two previous studies examining independent effects have shown to be linked to externalizing behavior problems both
included motivation-based regulation. In one study, indepen- in a non-clinical preschool sample (Rydell, Berlin, and Bohlin
dent effects of cognitive and motivation-based regulation were 2003) and a clinical school-aged sample (Sjöwall et al. 2013).
found in relation to ADHD symptoms (Sonuga-Barke, Dalen, As shown above, studies of school-aged children suggest
and Remington 2003). However, another study showed an that affective regulation is related to ADHD symptoms inde-
effect only for motivation-based regulation and not for pendent of cognitive regulation, but little is known regarding
cognitive/motor regulation in relation to ADHD symptoms to what extent this finding can also be applied to preschool
when using a latent variable approach (Willoughby et al. children. Affective regulation is typically viewed as develop-
2011. In sum, although ADHD appears to be characterized ing earlier than cognitive regulation due to its reliance on
J Abnorm Child Psychol (2015) 43:669–680 671

subcortical structures (Nigg and Casey 2005). It has therefore and that allowed us to study regulation of specific emotions,
been argued that it may be particularly useful to investigate including happiness/exuberance. ADHD symptoms were
affective regulation in relation to ADHD in preschool children studied using ratings spanning from low to high symptom
(Martel 2009). This is in line with the idea that differences levels as it has been argued that ADHD is best characterized
between ADHD children and controls are largest when inves- as a dimension rather than as a discrete category (e.g., Marcus
tigating neuropsychological functions that have had a chance and Barry 2011; Sonuga-Barke and Halperin 2010). This
to develop sufficiently among normally developing children, indicates that there is a quantitative rather than a qualitative
but not among children with ADHD as they are developmen- difference between children diagnosed with ADHD and con-
tally delayed (cf. Barkley 1997). trols, and that clinical studies need to be complemented with
An important issue with regard to the link between ADHD studies examining the full range of symptom severity in order
and emotional functioning is that previous research has often to fully understand the neuropsychological heterogeneity in
used relatively general measures, which have included both ADHD. We hypothesized that all three forms of regulation
emotion regulation as well as how often and how intensely the would explain unique variance in ADHD symptoms. With
child reacts emotionally (i.e., emotional reactivity). Separating regard to affective regulation, we hypothesized that the regu-
these two constructs is difficult. However, a child with infre- lation of both negative and positive emotions would be sig-
quent and flat emotional reactions may display poor regulation nificantly related to ADHD symptoms.
and an emotional child may be a relatively good regulator. It
has therefore been argued that it is important to distinguish
emotion regulation from emotional functioning in general in Method
order to better understand which aspect of emotional func-
tioning that is related to different behavior problems in chil- Participants
dren (e.g., Cole, Martin, and Dennis 2004 for a review).
A final issue of importance when measuring emotion reg- The present study included 104 preschool children (36 girls)
ulation is that some of the rating scales used in previous between 4-6 years of age (see Table 1 for demographic data).
studies (e.g., Conners Rating Scale) include items that overlap In order to obtain a sample of children scoring across the full
with symptoms of Oppositional Defiant Disorder (ODD) and/ range of ADHD symptom severity, about 1/3 of the sample
or Conduct Disorder (CD). As ADHD and ODD/CD often co- was clinically referred. These children had been formally
occur (e.g., Waschbusch 2002), it has been argued that it is
important to investigate the role of ODD/CD symptoms when Table 1 Demographic data
examining the relation between affective dysregulation and
ADHD Controls Total sample
ADHD (e.g., Martel 2009). A large population based study on
(n=37) (n=67) (n=104)
preschool children even showed that negative emotionality is Mean (SD) Mean (SD) Mean (SD)
not primarily linked to ADHD, but to the combination of
ODD and internalizing problems (Stringaris, Maughan, and Age in months 69.89 (9.88) 65.91 (10.01) 67.33 (10.10)
Goodman 2010). In sum, previous ADHD studies have gen- Inattention
erally been unclear concerning exactly what aspect of emo- Teachers 1.44 (0.61) 0.53 (0.53) 0.86 (0.71)
tional functioning they have investigated. In our opinion, Parents 1.99 (0.63) 0.59 (0.41) 1.09 (.84)
future research should employ measures that are as specific Hyperactivity/impulsivity
as possible, as this would lead to more in-depth knowledge Teachers 1.55 (0.85) 0.59 (0.73) 0.95 (0.90)
about the link between affective regulation, ADHD, and co- Parents 2.01 (0.64) 0.56 (0.43) 1.09 (0.87)
morbid disorders such as ODD and CD. Conduct problems 2.24 (0.71) 1.57 (0.64) 1.81 (0.74)
Parental education 2.49 (0.52) 2.64 (0.44) 2.59 (0.47)
Intelligence: block design 22.46 (8.98) 21.13 (8.31) 21.61 (8.54)
Aim of the Present Study % % %
Boys 81 57 65
The aim of the present study was to investigate multiple forms Parental origin
of regulation and their independent associations with ADHD Immigrant (mother) 16 20 18
symptoms in preschool children. As described above, previ- Immigrant (father) 23 22 22
ous studies have operationalized the construct ‘affective reg-
ulation’ in different ways, and the major focus has been on Inattention and hyperactivity/impulsivity = ADHD rating scale IV
(DuPaul et al. 1998), Conduct problems=Strengths and Difficulties
negative emotions. In order to address these limitations, we Questionnaire (SDQ; Goodman 1997), Parental education was measured
studied emotion regulation using a questionnaire that focused on a scale ranging from 1 to 3, Intelligence=block design subtest from the
specifically on the regulatory aspect of emotional functioning WISC-III (Wechsler 1991)
672 J Abnorm Child Psychol (2015) 43:669–680

diagnosed with ADHD by a psychiatrist, and the children’s backward condition of the digit span subtest (Wechsler 1991).
diagnostic status was confirmed at the time of the study using The score used was the total number of correct trials.
both parent and teacher ratings on the ADHD Rating Scale IV Inhibition was measured with two tasks using the Psytools
(DuPaul et al. 1998). The five children receiving software (Delosis, London). The first task was based on the
psychostimulant treatment for ADHD were asked to withdraw go/no-go paradigm. The particular version used here was
medication 24 h prior to testing and all children except one originally developed by Berlin and Bohlin (2002) and consists
adhered to this. The remaining 2/3 of the sample were typi- of pictures depicting a blue square, a blue triangle, a red
cally developing children recruited through local preschools. square, and a red triangle, which are presented on a computer
No exclusion criterion with regard to ADHD symptoms was screen. During the first part of the task, the child is instructed
used for these children, and some children were rated by to press a key (“go”) when a frequent stimulus appears on the
teachers as having a relatively large number of ADHD screen, but to make no response (“no-go”) when an infrequent
symptoms. The total sample is therefore best characterized stimulus appears. Altogether the task includes 60 stimuli with
as spanning the full range of ADHD symptom severity a “go-rate” of 77 %. The score derived from this task was
rather than as two discrete groups (i.e., skewness= 0.53 number of commission errors (pressing the key when a “no-
and kurtosis=- 0.76 for inattention; skewness=0.75 and go” target was presented).
kurtosis=- 0.56 for hyperactivity/impulsivity, which indi- The second measure of inhibition was a Navon task
cates normality; Kline 1998). The children’s parents pro- (Miyake, Friedman, Emerson, Witzki, and Howerter 2000).
vided informed written consent for participation and the In our version, which has been previously used by Sjöwall
local ethics committee approved the study. et al. (2013), a circle consisting of small squares, or the
opposite, a square consisting of small circles, was displayed
Measures on the computer screen (see Fig. 1), and the participants were
instructed to respond to local stimuli in one session (e.g., the
The laboratory tests were administered in a separate room at small squares making up the circle) and global stimuli in the
the child’s preschool with the administrator present in the other (e.g., the circle made up by the squares). Thus, for the
room during the entire procedure. The neuropsychological stimulus to the left, the correct response would be “square”
measures described below were standardized, and some mea- when asked to respond to global stimuli and “circle” if asked
sures were reversed so that high values always indicated poor to respond to local stimuli. The children made a response by
performance. If more than one measure was available within a pressing a key to the left on the keyboard to respond “circle”
domain, the mean value of the different measures was used in or a key to the right to respond “square”. In order to make the
the analyses. correct response clear to the children, and to decrease the
memory demands of the task, a circle was displayed in the
Cognitive Regulation lower left corner of the computer screen and a square in the
lower right corner (see Fig. 1). The children were presented
Working memory was measured using three tasks. Spatial with one local and one global session with 20 stimuli in each
working memory was measured with the “Find the phone session. The score used was the total number of errors for the
task” (Sjöwall et al. 2013) using the Psytools software two sessions (maximum=40).
(Delosis, London). This task is similar in design to the spatial Shifting was measured using the Navon task (see de-
working memory task included in the Cambridge scription above). A third session was performed in which
Neuropsychological Test Automated Battery (CANTAB; participants were asked to shift between responding to local
Owens et al. 1990). In our version of the task, telephones are or global stimuli. A total of 40 trials were presented, and a
shown on the computer screen and the task is to remember square and a circle in the lower corners of the computer
which telephone has already rung to avoid selecting the same screen indicated what stimulus to respond to (local trials=
phone several times. The number of times the children small circle/square, global trials = large circle/square).
returned to a phone that had already rung was used as a Number of errors during this last session was used to
measure of spatial working memory. The Children’s Size- measure shifting.
Ordering Task (McInerney, Hrabok, and Kerns 2005) was Reaction time variability was measured using the standard
used to measure verbal working memory. In this task, the deviation of participants’ reaction times for correct answers on
administrator reads aloud progressively longer lists of com- the non-shifting trials in the Navon task and correct answers
mon objects (e.g., pencil, train, ball) and the child is asked to on the go/no-go task (see descriptions above).
repeat them in order of object size, from smallest to largest. Sustained attention was measured using the go/no-go task
The total number of word pairs organized in the correct order described above under the heading “inhibition”. As a measure
was used to measure verbal working memory (maximum= of sustained attention, we used number of omissions (i.e.,
42). Verbal working memory was also measured using the failure to respond to a go stimulus) on the go/no-go task.
J Abnorm Child Psychol (2015) 43:669–680 673

Fig. 1 The two stimuli used for

the Navon task

Motivation-Based Regulation often (3). The mean scores for symptoms of inattention and
hyperactivity/impulsivity were used in the analyses. Teacher
Delay aversion was measured using the Choice Delay Task ratings were used to assess ADHD symptoms, as parents
(Sonuga-Barke et al. 1992). In this task, the child is asked to assessed emotion regulation and we wanted to avoid source
make 25 choices between an immediate small reward (two bias. Reliability, measured by consistency, was found to be
seconds for one point) and a delayed large reward (30 s for 2 very high for both symptoms of inattention (α=0.93) and
points). Delay aversion is measured as the number of times the symptoms of hyperactivity/impulsivity (α=0.96).
child chooses the small, immediate reward during the final 10
trials. This task has been previously used in, for example, the Covariates
NIMH Multimodal Treatment Study of ADHD (Solanto et al.
2001). Conduct problems were measured using teacher ratings on the
Strengths and Difficulties Questionnaire (SDQ; Goodman
Affective Regulation 1997). The SDQ is available in over 30 languages (www.
sdqinfo.org/) and has been widely used in epidemiological,
Emotion regulation was measured using parent ratings on the developmental and clinical research, as well as in routine
Emotion Questionnaire developed by Rydell et al. (2003). In clinical and educational practice. The conduct problem
the present study, we included the questions measuring how subscale used in the present study includes questions about
well the child can self-regulate his/her own emotions. This temper tantrums, lying, stealing, aggression, bullying, and
includes a total of 12 questions related to regulation of anger, disobedience. As described in the introduction, it has been
fear, sadness and happiness/exuberance. For each emotion, argued that the role of symptoms of ODD/CD needs to be
one general and two specific statements are presented (all taken into account when examining the relation between
items are included in an appendix in Rydell et al. 2003). affective regulation and ADHD (Martel 2009). In the present
Ratings are made on a scale ranging from 1 (do not agree at study, we therefore aimed to address this issue by using the
all) to 5 (fully agree), with higher values indicating greater SDQ conduct problem subscale as a covariate when investi-
problems with emotion regulation. The mean score of the gating the relation between neuropsychological functioning
items for each emotion was used in the analyses. This instru- and ADHD symptoms.
ment has been shown to have high test-retest reliability and Intelligence was measured using the block design subtest
has been validated against both other rating instruments from the WISC-III (Wechsler 1991), a test that has been
(Rydell et al. 2003) and self-report measures (Rydell, shown to correlate highly with full-scale IQ (r=0.93; Groth-
Thorell, and Bohlin 2007). Marnat 1997).

ADHD Symptoms Statistical Analyses

ADHD-symptoms were measured with the ADHD Rating Very little data were missing in the present study: two children
Scale IV (DuPaul et al. 1998), which includes the 18 symp- did not complete the shifting trial, one child had no ratings for
toms of ADHD as presented in DSM-IV (American emotion regulation, and four children lacked ratings for
Psychiatric Association 1994). Items are rated on a 4-point ADHD symptoms. First, all data were screened for extreme
scale: never or rarely (0), sometimes (1), often (2), or very values (>3 SD) and all outliers (3 for reaction time variability,
674 J Abnorm Child Psychol (2015) 43:669–680

and 1 for inhibition) were replaced with the value at three SD. correlated with reaction time variability and these two vari-
To further establish data integrity, we analyzed the detailed ables were significantly correlated with executive functioning.
computer files generated by the cognitive tasks to make sure Delay aversion was significantly correlated with working
that there were no systematic errors in the data (e.g., children memory, but not with any other variables. Measures of emo-
making many omissions in a row, pressing the same button tion regulation showed a few significant relations to cognitive
over and over again, or switching between right or left button regulation, but these were all small in magnitude.
presses). However, no such systematic errors were identified.
In line with the reasoning that ADHD is better captured as a Correlations Between Regulation and ADHD Symptoms
continuous trait rather than as two discrete categories (e.g.,
Marcus and Barry 2011; Sonuga-Barke and Halperin 2010), Second, we wanted to investigate how the different forms of
and because our sample was normally distributed with regard regulation were related to ADHD-symptoms (see Table 3).
to ADHD symptoms (see more information under “partici- Inhibition, working memory, reaction time variability,
pants” above), the data were analyzed using a dimensional sustained attention, as well as delay aversion were all signif-
approach. To study interrelations between cognitive, affective icantly related to symptoms of inattention. However, only
and motivation-based forms of regulation, we computed par- inhibition and working memory were significantly related to
tial correlation analyses with control for age and sex. These hyperactivity/impulsivity. In addition, all measures of emotion
two covariates were included as they were significantly relat- regulation except for regulation of sadness were associated
ed to several of the predictors, as well as the outcome vari- with both inattention and hyperactivity/impulsivity. All sig-
ables. Next, we investigated how the different forms of regu- nificant effects remained when controlling for IQ.
lation were related to ADHD symptoms by conducting partial
correlations between the different forms of regulation and the Independent Effects
two symptom domains while controlling for age and sex. We
also re-ran these analyses controlling for IQ. The reason for Third, we examined to what extent measures of affective
not including IQ as a covariate in all analyses was that such regulation could contribute significantly to the explained var-
procedure has been questioned (e.g., Dennis et al. 2009), as iance in ADHD symptoms beyond the influence of the other
one runs the risk of removing variance that is of relevance for forms of regulation. Using hierarchical regression analyses,
the dependent variable in question (i.e., ADHD). It has there- we entered the two covariates (i.e., age and sex) in Step 1, and
fore been recommended that results are presented both with all variables that were significantly correlated with the two
and without control for IQ, thereby letting the reader make his/ ADHD dimensions (except emotion regulation) in Step 2. In
her own interpretation of the results (e.g., Barkley 1997). Step 3, all significant emotion regulation variables were in-
To investigate independent effects of the three forms of cluded. As shown in Table 4, the variables entered in Step 2
regulation in relation to symptoms of inattention and hyperac- were significantly associated with inattention. Altogether,
tivity/impulsivity, we performed hierarchical regression analy- they explained 26 % of the variance, with both working
ses. This way, we were able to study to what extent affective memory and delay aversion contributing independently.
regulation can explain additional variance in preschool ADHD Adding the emotional regulation variables in Step 3 increased
symptoms, beyond the more established cognitive and the explained variance to 37 %, and only regulation of
motivation-based pathways presented in current ADHD theo- happiness/exuberance contributed independently. For symp-
ries (e.g., Castellanos, Sonuga-Barke, Milham, and Tannock toms of hyperactivity/impulsivity, 14 % of the variance was
2006; Nigg et al. 2005). Finally, interaction effects between all explained by the variables entered in Step 2, with an indepen-
three forms of regulation were investigated using regression dent contribution only for working memory. Emotion regula-
analyses, with the main effects being entered in the first step tion increased the explained variance to 25 %, with none of the
and the interaction effect in the second step. In line with Cohen variables contributing independently except for a trend to-
(1992), correlation coefficients were interpreted as small wards a significant effect for regulation of happiness/
(r=0.10), medium (r=0.30) or large (r=0.50). exuberance.

Interaction Effects

Results Fourth, we investigated whether there were any significant

interactions between cognitive, affective and motivation-
First, we investigated interrelations between the different based regulation. A significant interaction effect would indi-
forms of regulation that were included in the study. As can cate that the different neuropsychological deficits combine
be seen in Table 2, correlations between the three executive synergistically (i.e., that the combination of two deficits has
functions were weak. Sustained attention was significantly an effect on ADHD symptoms that is larger than the sum of its
J Abnorm Child Psychol (2015) 43:669–680 675

Table 2 Intercorrelations between all variables included in the study, controlling for age and sex (two-tailed)

1 2 3 4 5 6 7 8 9

1. Inhibition
2. Working memory 0.21*
3. Shifting 0.14 0.02
4. Sustained attention 0.36*** 0.33*** - 0.31**
5. Reaction time variability 0.30** 0.28** -0.20 0.47***
6. Delay aversion - 0.03 0.20* 0.08 0.10 -0.00
7. Regulation of anger 0.11 0.23* -0.10 0.22* 0.10 0.12
8. Regulation of fear 0.22* 0.14 0.04 0.22* 0.11 0.03 0.63***
9. Regulation of sadness 0.14 0.07 -0.05 0.14 0.02 0.06 0.72*** 0.65***
10. Regulation of happiness/exuberance 0.13 0.25** -0.12 0.24* 0.08 -0.03 0.63*** 0.54*** 0.55***

* p<.05, ** p<.01, *** p<.001

two parts). Of all possible interactions, only the effect of problems. The results showed that most of the relations
reaction time variability and regulation of happiness/ remained the same as those presented in Table 3. The excep-
exuberance in relation to inattention reached significance tions were that there were no effects of inhibition, regulation
(β=- 0.21, p<0.05). This significant interaction indicated that of fear, or regulation of anger on symptoms of hyperactivity
the combination of high levels of affective regulation of (see cursive numbers in Table 3).
happiness/exuberance and low reaction time variability was
associated with especially low levels of inattention. However,
it should be noted that this could have been a chance finding Table 4 Regression analyses examining predictors of ADHD symptoms
due to the very large number of interactions investigated (i.e.,
ß R2 change
58 interactions altogether).
Inattentive symptoms
Step 1 0.061*
The Role of Comorbid Conduct Problems Sex - 0.143
Age - 0.192+
Finally, we wanted to investigate whether any of the measures Step 2 0.258***
of regulation were related to ADHD symptoms mainly due to
Inhibition 0.149
the large overlap between ADHD symptoms and conduct
Working memory 0.346**
Sustained attention 0.042
Table 3 Cognitive, affective and motivation-based regulation in relation
to symptoms of inattention or hyperactivity/impulsivity (one-tailed) Reaction time variability 0.164
Delay version 0.187*
Inattention Hyperactivity/impulsivity
Step 3 0.111***
Cognitive regulation deficits Anger 0.139
Inhibition 0.258** 0.241* Fear 0.045
Working memory 0.428*** 0.363*** Happiness/exuberance 0.248*
Shifting 0.055 0.136 Hyperactive/impulsive symptoms
Sustained attention 0.268** 0.083 Step 1 0.107**
Reaction time variability 0.292** 0.152 Sex - 0.176+
Motivation-based regulation deficits Age - 0.263**
Delay version 0.261** 0.092 Step 2 0.144***
Affective regulation deficits Inhibition 0.179+
Anger 0.417*** 0.389*** Working memory 0.365***
Sadness 0.166 0.191 Step 3 0.111**
Fear 0.334*** 0.325*** Anger 0.140
Happiness/exuberance 0.417*** 0.424*** Fear 0.043
Happiness/exuberance 0.232+
*p<.05, **p<.01, ***p<.01. Cursive numbers indicate relations that
+
changed to non-significance when controlling for symptoms of ODD <.10, *p<.05; **p<.01; *** p<.001
676 J Abnorm Child Psychol (2015) 43:669–680

Discussion (clinical versus non-clinical) could be of importance. It has

also been shown (e.g., Martel et al. 2013) that relations be-
The present study investigated neuropsychological heteroge- tween neuropsychological functioning and ADHD can vary
neity in preschool ADHD by studying cognitive, affective, as between symptom domains depending on whether teachers or
well as motivation-based forms of regulation. Results showed parents make the ratings, and this may also explain inconsis-
that these regulatory processes were all significantly related to tencies in findings.
ADHD symptoms. Most previous preschool studies have only With regard to independent effects, both cognitive and
included cognitive regulation, and to some extent motivation- motivation-based regulation were shown to have independent
based regulation. By also including affective regulation, we effects in relation to symptoms of inattention, which is in line
were able to explain a larger proportion of the variance in with a previous preschool study (Sonuga-Barke et al. 2003).
ADHD symptoms. However, it should be noted that the Further, we found no significant interaction effects of execu-
amount of variance explained was still small in comparison tive functioning and delay aversion in relation to ADHD
with what has been found in studies of school-aged children. symptoms. These results imply that these two forms of regu-
The implications of these results are discussed below. lation do not combine synergistically and that they can act
alone in producing an effect. This can be taken as further
Cognitive Regulation in Relation to Preschool ADHD support for the dual-pathway model of ADHD, in which it is
stated that these two processes should be regarded as consti-
In line with previous meta-analyses on different executive tuting two separate pathways to ADHD (cf. Sonuga-Barke
functions, our results showed that the effect sizes varied 2002).
substantially between different functions, with a small effect
size being found for the more complex measure of shifting and Affective Regulation in Relation to Preschool ADHD
close to medium effect size for inhibition. The effect size for
working memory was somewhat stronger in the present study In addition to cognitive and motivation-based regulation, we
compared to that found in the previous meta-analyses (i.e., included measures of emotion regulation. In line with two
medium compared to small), but well within the range of the previous studies on emotional functioning and ADHD in
studies included in these analyses (Pauli-Pott and Becker preschool children (Healey et al. 2011; Martel et al. 2013),
2011; Schoemaker et al. 2012). Furthermore, our study found we found that emotion regulation was significantly associated
medium, or close to medium, effect sizes for sustained atten- with symptoms of both inattention and hyperactivity/impul-
tion and reaction time variability, which is in line with the sivity. In contrast to the study by Healey and colleagues, we
effect size reported for vigilance/arousal in the meta-analysis focused on the regulatory aspect of emotional functioning,
by Pauli-Pott and Becker (2011). whereas they measured negative emotionality. Thus, our find-
ings could be taken as an indication that ADHD symptoms in
Motivation-Based Regulation in Relation to Preschool ADHD preschool are not only related to pronounced and often occur-
ring negative emotions, but also specifically to the regulation
The effect size for delay aversion was marginally smaller (i.e., of both negative and positive emotions. The finding, that
close to medium compared to close to large) than that reported significant relations to ADHD symptoms were observed for
in the meta-analysis by Pauli-Pott and Becker (2011). both negative and positive emotions, is in line with a previous
However, more surprising was our finding that delay aversion clinical study on school-aged children (Sjöwall et al. 2013), as
was primarily related to inattention rather than to hyperactiv- well as with one study on a non-clinical sample of pre-
ity/impulsivity. Few previous studies have investigated sepa- schoolers (Rydell et al. 2003), which demonstrated relations
rate relations between delay aversion and the two ADHD between the regulation of positive emotions and externalizing
symptom domains. However, Castellanos et al. (2006) pro- problems in general (i.e., a measure including both ADHD
posed that cool executive functions (e.g. inhibition, working symptoms and conduct problems). Thus, it is important that
memory and shifting) are primarily associated with inatten- future research not use measures that only capture the negative
tion, whereas hot executive functions (i.e. delay aversion and aspect of emotion regulation. In order to better understand the
decision-making measured by gambling tasks) have a stronger importance of regulation of positive emotions, it might be
link to hyperactivity/impulsivity. Some empirical support for useful to know more about the rating instrument used in the
this notion has also been found in a non-clinical study of present study. In particular, it should be noted that it does not
kindergarten children (Thorell 2007) and a clinical sample of ask whether the child is often happy or reacts intensely when
adolescents (Toplak, Jain, and Tannock 2005). It is difficult to happy (i.e., emotional reactivity). Instead, the parent is asked
explain the inconsistency between the present study and pre- to rate the child’s ability to regulate happiness in general as
vious studies with regard to this issue, but one could speculate well as in two specific situations (i.e., when the child wins a
that the age of the participants or the nature of the sample game/contest and when the child is playing a game that he/she
J Abnorm Child Psychol (2015) 43:669–680 677

enjoys very much; see Rydell et al. 2003 for the complete variance remains unexplained. The importance of this finding
questionnaire). We therefore speculate that the difference be- can be discussed both in relation to previous ADHD studies of
tween adaptive and problematic exuberance lies in the child’s school-aged children and in relation to current models of
ability to regulate his/her emotions in a socially acceptable heterogeneity.
manner. If we compare our findings with those of older children, we
Another important finding of the present study was that see that effects for both cognitive and affective regulation
significant independent effects of emotion regulation were have generally been larger in school-aged samples (e.g.,
seen beyond those of cognitive and motivation-based regula- Berlin et al. 2004; Sjöwall, et al. 2013; Sonuga-Barke et al.
tion in relation to ADHD symptoms. Thus, affective dysreg- 2010). However, we found a relation between ADHD and
ulation in preschool ADHD is not simply a secondary conse- delay aversion, whereas several studies of school-aged chil-
quence of deficient cognitive control. Finally, the present dren have failed to show such an effect (e.g., Karalunas, and
study does not find support for interaction effects of cognitive Huang-Pollock 2011; Solanto et al. 2007). Together, these
and affective regulation. These results are not in line with results are in line with the conclusion of two recent meta-
Healey et al. (2011), who showed that negative emotionality analyses showing that the relation between cognitive regula-
and cognitive functioning interact in predicting ADHD symp- tion and ADHD becomes more pronounced with age, whereas
tom severity. The reason for this inconsistency may be ex- the relative importance of motivation-based regulation shows
plained by differences in the type of measures used. As the reverse pattern (Pauli-Pott and Becker 2011; Schoemaker
emphasized by Shaw et al. (2014), it is important that future et al. 2012). One reason for this could be that cognitive
research clearly operationalizes each component of affective regulation has not yet had a chance to develop sufficiently in
regulation, develop consensus measurement techniques, and the preschool years, even among controls. This would indicate
investigate how these components interact with one another that the ability to detect group differences between controls
and with ADHD. and children with ADHD (i.e., who are thought to show a
developmental delay with regard to self-regulation) is more
The Role of Comorbid Conduct Problems in Affective limited in preschool children (cf. Barkley 1997). Another
Regulation possibility is that ADHD symptoms are not particularly stable
over time when assessed in preschool. For example, Lahey
After controlling for conduct problems, regulation of and colleagues showed that as many of 45 % of the children
happiness/exuberance was still significantly related to both with ADHD diagnosed in preschool did not meet the diag-
ADHD symptom domains, and regulation of both anger and nostic criteria at follow-up at age 8 (Lahey, Pelham, Loney,
fear were still significantly related to inattention. These results Lee, and Willcutt 2005).
are in line with Sjöwall et al. (2013), who showed that rela-
tions between ADHD and emotion regulation remained after Future Directions and Practical Implications
controlling for conduct problems in a clinical sample of
school-aged children. In addition, Martel et al. (2013) showed Based on the discussion above, we would like to suggest that
that emotion regulation, as measured using the Gift Delay an important avenue for future research could be to examine to
Task, was significantly related to ADHD, but not to ODD in what extent neuropsychological functioning in preschool can
preschoolers. Together, these results show that the link be- help in identifying children who will show stability in ADHD
tween affective dysregulation and ADHD cannot be explained symptoms over time or develop ADHD later on in life. We
as a result of the overlap between ADHD and ODD/CD. would also like to suggest that a comprehensive theoretical
However, due to the small number of studies in this area of model of ADHD needs to not only account for the link
research that have controlled for ODD/CD, replication of between neuropsychological deficits and ADHD symptom
these results are needed before any firm conclusions can be levels, but also for the extent to which such deficits can
drawn. explain the functional impairments associated with the disor-
der. The link between poor executive functioning and aca-
The Importance of Neuropsychological Deficits in Preschool demic achievement has been well established in previous
ADHD ADHD research on school-aged children (e.g., Biederman
et al. 2004; Miller and Hinshaw 2010; Rogers, Hwang,
A limited amount of variance in inattention (26 %) and Toplak, Weiss, and Tannock 2011), but there is still a need
hyperactivity/impulsivity (14 %) was explained, even though to conduct more person-oriented research that allows for
a wide range of cognitive and motivation-based deficits were identification of which neuropsychological subtypes in pre-
included. By adding emotion regulation, we could explain school that are most at risk for poor academic achievement
additional variance in both inattention (37 %) and over time. In addition, the role of emotion regulation deficits
hyperactivity/impulsivity (25 %), but still a large amount of as a significant mediator between ADHD symptoms and
678 J Abnorm Child Psychol (2015) 43:669–680

social problems has been acknowledged (Sjöwall and Thorell is a risk that the relation between ADHD and emotion regu-
2014), but seldom examined in preschool samples. However, lation is overestimated when using questionnaires for measur-
there is one non-clinical study available, which showed that it ing both the dependent and the independent variable. Another
was primarily children with a combination of high levels of limitation concerns the size of our sample. The present study
ADHD symptoms and poor regulation of happiness/ had the advantage of including multiple forms of regulatory
exuberance at age 5 who were rejected by their peers at age deficits, but due to the large number of factors included, our
9 (Thorell et al. 2014). More research addressing this issue is sample was not large enough to define discrete subgroups
clearly needed. with single or multiple deficits. Finally, the fact that we could
Regarding the practical implications of our findings, it only explain a relatively small part of the variance in ADHD
should be acknowledged that measures of executive function- symptoms may indicate that there are other aspects that
ing, delay aversion, as well as regulation of emotion may be need to be taken into consideration if we are to more fully
useful as screeners for ADHD in the preschool age and should understand the nature of preschool ADHD and be better able
be further investigated. Also, these aspects should be consid- to predict long-term outcomes. In our opinion, one of the most
ered when developing early intervention and prevention pro- important issues for future research is to examine to what
grams for ADHD. In previous research, computerized pro- extent environmental factors interact with neuropsychological
grams have been shown to strengthen working memory in deficits to influence the course of ADHD.
preschool children (e.g., Thorell et al. 2009). However, due to
the neuropsychological heterogeneity in ADHD, programs
that target a broader range of regulatory functions might be
Acknowledgements This study was supported by a grant from the
more appropriate. An example of this is the New Forest
Swedish Research Council to the last author. The authors wish to thank
Parenting Program, which relies on the parent as the agent- Linda Udo for her valuable help with the data collection.
of-change for promoting better regulatory skills in the child
(e.g., Sonuga-Barke, Daley, Thompson, Laver-Bradbury, and Potential conflict of interest Dr Thorell has served as a consultant for
Weeks 2001; Thompson et al. 2009). We would also like to Shire and is on the advisory board for PRIMA. Mr Sjöwall and Ms
Backman have no potential conflict of interest to report.
acknowledge the promising results from another parent pro-
gram, The Parenting Your Hyperactive Preschooler Program. Open Access This article is distributed under the terms of the Creative
This 14-week intervention has an especially strong emphasis Commons Attribution License which permits any use, distribution, and
on strengthening emotion regulation in hyperactive pre- reproduction in any medium, provided the original author(s) and the
source are credited.
schoolers and it has been shown to reduce ADHD symptoms
and associated behavior in preschool-aged children (Herbert,
Harvey, Roberts, Wichowski, and Lugo-Vandelas 2013). The
results of the present study could indicate that even larger References
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