Children and adolescents can be easily overwhelmed by emotions. This holds in particular for children and adolescents with mental disorders. There is increasing research and clinical interest in Emotion Dysregulation (ED) as a cross-disorder trait. ED is commonly defined as emotional impulsivity and deficient emotional self-regulation (1) and in most definitions includes symptoms of heightened reactivity and quickness to angry, anxious or depressed affect (2, 3). Successful emotion regulation is associated with good mental and somatic health outcomes, social relationships, academic performance and work functioning (4, 5). ED may potentially be relevant in understanding the general risk for the development of psychopathology [“p-factor”; (6, 7)] as well as be a relevant target for treatment regardless of disorder (8–10). Indeed, ED is more prevalent in youth with Attention Deficit/Hyperactivity Disorder [ADHD; (2)], Autism Spectrum Disorder [ASD; (11)], Conduct Disorder/Oppositional Defiant Disorder [CD/OCC; (12)], mood disorders (13) and anxiety disorders (14). In addition, ED signals a more persistent treatment course and poorer prognosis (15, 16). Despite the promising transdiagnostic and treatment value of ED, previous findings indicate the complexity of emotion regulation processes and outcomes [e.g., subjective feelings, motivated behavior, physiological reactivity; (17)]. That is, ED unfolds in myriad ways that might have different functional relations with symptom development (18). The strong temporal comorbidity between internalizing and externalizing conditions requires a more nuanced approach to emotion regulation processes in the various developmental stages (17). Therefore, the aims of this study were to scrutinize the overlapping and distinct characteristics of ED for internalizing, externalizing and neurodevelopmental disorders and to identify the most pertinent ED characteristics to guide clinicians in treatment choice. The shared and specific features of parent-reported ED were examined in a large sample of youth (N = 8,803; 1.5–18 years) clinically diagnosed with ADHD, ASD, ODD/CD, Anxiety and/or Mood disorders. The predictive relevance of ED was examined in relation to quality of life and treatment duration in addition to—and in interaction with—clinical diagnosis.

The aims of this study were to scrutinize the overlapping and distinct characteristics of ED for internalizing, externalizing and neurodevelopmental disorders in a large sample of clinically referred youth (N = 8,803, 1.5–18 years) and to identify the most pertinent ED characteristics to guide clinicians in treatment choice. The total level of ED-behaviors was comparable across disorders and in both age groups, with several behaviors being highly prevalent across all disorders. At preschool age, ED typically manifested as externalizing behaviors: “stubborn/irritable,” “screams a lot,” “temper tantrums” and “sudden changes in mood/feelings.” Over 30% of pre-schoolers often/clearly showing these behaviors regardless of diagnosis, with highest prevalence rates in preschoolers with ODD. Other ED behaviors were considerably less prevalent and/or more disorder specific, such as “clings/too dependent” and “nervous/tense” (anxiety) or “destroys own things” and “destroys belongings of others” (ODD). At school age, less cross-disorder ED-behaviors were found. Only “stubborn/irritable” was present often/clearly in over 30% of the clinical sample regardless of diagnosis. Other-predominantly externalizing-typical manifestations of ED were “argues a lot,” “temper tantrums,” “sudden changes in mood/feelings” and “screams a lot,” although these behaviors were prototypical and highly prevalent in children/adolescents with ODD/CD (>50%), ASD and ADHD (both >30%) but not for children/adolescents with anxiety or mood disorder. Anxiety and mood disorder were best characterized by internalizing manifestation of ED: “unhappy/sad/depressed,” “worries,” “nervous/tense” and “too fearful/anxious” were present in >30%. Examining specific domains of Qol showed that more ED on top of ADHD or ASD was related to lower Qol in Social support and more ED on top ADHD and anxiety related to lower Qol in the domain School environment. In addition, a longer treatment duration was found for children that experienced more ED on top of ASD and mood disorders. Our findings suggest that ED is an important cross-disorder marker as it is associated with several childhood disorders, characterized by several commonly shared features, present from early age onwards and predicting a lower quality of life and longer treatment duration. These findings are in line with claims for ED as the core feature in childhood onset disorders (26, 27) and its importance in treatment for improving quality of life (10) and overall outcome (16). Moreover, our findings suggest that the existence of externalizing behaviors of ED in early childhood are to be taken seriously by mental health professionals and to be reluctant of calling such behavior “typical temper tantrums.” Although the behaviors in itself are normative, a high frequency based on parental reports should raise clinical concern given the likelihood a non-normative development is ongoing. Moreover, the current study showed that with increasing age, a more internalizing manifestation of ED is unfolding. This may be caused by the fact that the externalizing manifestation of ED in preschoolers elicit more negative, unresponsive or punitive reactions from caregivers (28). This may pave the way for the development of lower self-esteem and feelings of guilt and shame, until finally by late adolescence these become “incorporated” into a stable negative sense of self-worth (29). Developing effective emotion regulation is highly dependent on safe and supportive parent–child relationships (i.e., secure attachment) in which parents provide a safe context and support and stimulate children’s emotion regulation abilities (28). Offering easy-access parent–child interaction interventions to reduce ED at preschool age may be considered an effective strategy to prevent this vicious cycle (30, 31). Furthermore, our findings suggest that ED on top of ADHD and ASD results in lower Qol in social support/peers and not in ODD/CD, anxiety and mood. The fact that ODD/CD, anxiety and mood have emotional symptoms incorporated in its diagnostic criteria, whereas for ADHD and ASD this is not the case (20), likely contributes to this finding. Additionally, we found thawt ED on top of ADHD or anxiety results in lower Qol in school environment. For ADHD, the defining features already put a strain on the teacher-student relationship and the addition of ED behaviors can simply be “too much to handle” for a teacher, resulting in a cumulation of negative school-related experiences and explaining a decreased the likelihood of graduating from high school or college (32). For anxiety, symptoms are predominantly internalizing. Accompanied by externalizing behaviors of ED (e.g., “Stubborn/irritable”), a similar negative teacher-student interaction pattern can develop, forming a risk factor in school disengagement in childhood and adolescence (33). These findings suggest that despite the predominantly disorder specific colorings of ED in school age, ED manifestations that are not “disorder-defining,” deserve clinical concern and intervention to prevent additional significant problems at school that may have a long-lasting impact on life. The main strengths of this study were two large clinical samples that were available for analyses of both pre-schoolers and children and adolescents. All data were derived from a Routine Outcome Monitoring (ROM) system and electronic health records (EHR), and were therefore highly clinically relevant for studying ED. ED was studied in multiple disorders, shedding light on the cross-disorder nature of this concept. Longitudinal data on treatment duration was available to study the predictive value of ED in clinical practice. A limitation was that our study had no typical developing control group. As a result, relative comparisons were made between disorder categories. However, relative comparisons are well suited to compare shared and specific features of ED, which was our aim. Furthermore, the samples originated from a child psychiatry organization specialized in the treatment of children with neurodevelopmental disorders. As a result, youth with ADHD and/or ASD were overrepresented and comorbidity rates were high. However, sensitivity analyses showed that the results were highly similar in a single-disorder subsample (e.g., ADHD only, ASD only) compared to the full sample (e.g., participant could be in two or more diagnostic category), suggesting findings were not substantially influenced by sample characteristics. Another limitation was that clinical diagnoses were not confirmed using structured interviews. However, similarly for all disorders, a golden standard clinical consensus diagnosis was obtained (21). Therefore, it is unlikely that diagnostic method has influenced the main results. When interpreting the Qol results, caution is necessary as this measure was administered to parents of children 8 years and older. Additionally, more detailed information regarding the types of treatments and services-as well as more refined analyses regarding the association between ED and type of treatment-would have been of additive value. However, this information could not accurately be extracted from the EPD due to several reasons (i.e., change in EPD system during the period of studied records, variation in registration procedures across locations within the institute). Also the definition of “direct” and “indirect” treatment underwent changes during the period of studied records. Therefore, we used the total amount of time as most robust indicator of treatment “complexity.” Taken together, this study showed that at preschool age, ED is commonly present in children with non-normal developmental patterns and mostly manifests as cross-disorder externalizing behaviors (e.g., stubborn/irritable, screams a lot, temper tantrums). At school age, a more disorder-specific manifestation of ED emerged, with externalizing behaviors predominating in youngsters with ODD/CD, ADHD and ASD and internalizing in youngsters with anxiety and mood. However, “stubborn/irritable” was one of few ED behaviors present regardless of diagnosis, indexing the inability to flexible adapt to/cope with situations that evoke difficult emotions (e.g., disappointment, humiliation, shame, anxiety). Higher levels of ED related to a lower quality of life and longer treatment duration and disproportionally influenced school functioning in youngsters that showed ED behaviors that were “out of character” (i.e., stubborn/irritable in youngsters with anxiety disorder). As learning to regulate emotions is primarily based on co-regulation with attachments figures, offering easy-access parent–child interaction interventions to reduce ED at preschool age may be considered an effective strategy to prevent a vicious cycle. Future research should focus on the environmental susceptibility of ED and interventions for high risk children and caregivers.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The studies involving human participants were reviewed and approved by Karakter Child and Adolescent University Centre. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. In the methods section we describe how data was anonymized upon withdrawal from electronic health records.

MB, NR, CH, and JB wrote the research proposal and data analysis plan. HK conveyed all data to SPSS. MB created the data set, executed data analysis, and wrote the manuscript. SD, NR, CH, and JB supervised the roles in this process. All authors contributed to the article and approved the submitted version.

MB is part of the Eat2BeNice consortium (EU). Eat2BeNICE (H2020 grant agreement number 728018).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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