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J Atten Disord. Author manuscript; available in PMC 2020 September 01.
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Published in final edited form as:

J Atten Disord. 2019 September ; 23(11): 1229–1239. doi:10.1177/1087054716653216.

Frustration Tolerance in Youth With ADHD

Karen E. Seymour1, Richard Macatee2, Andrea Chronis-Tuscano3
1Johns Hopkins University School of Medicine, Baltimore, MD, USA
2Florida State University, Tallahassee, FL, USA
3University of Maryland, College Park, MD, USA
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Abstract
Objective: The objective of this study was to compare children with ADHD with children
without ADHD on frustration tolerance and to examine the role of oppositional defiant disorder
(ODD) in frustration tolerance within the sample.

Method: Participants included 67 children ages 10 to 14 years-old with (n = 37) and without (n =
30) Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) ADHD who
completed the Mirror Tracing Persistence Task (MTPT), a validated computerized behavioral
measure of frustration tolerance.

Results: Children with ADHD were more likely to quit this task than children without ADHD,
demonstrating lower levels of frustration tolerance. There were no differences in frustration
tolerance between children with ADHD + ODD and those with ADHD – ODD. Moreover, ODD
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did not moderate the relationship between ADHD and frustration tolerance.

Conclusion: Our results suggest that low frustration tolerance is directly linked to ADHD and
not better accounted for by ODD. This research highlights specific behavioral correlates of
frustration in children with ADHD.

Keywords
ADHD; frustration; emotion regulation; emotional dysregulation; oppositional defiant disorder

Introduction
Research shows that emotion dysregulation (ED) is a key impairment for many individuals
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with ADHD (Shaw, Stringaris, Nigg, & Leibenluft, 2014). Emotion regulation (ER) refers to
“an individual’s ability to modify an emotional state so as to promote adaptive, goal-oriented
behaviors,” and is essential to interpersonal, academic, and adaptive functioning (Shaw et
al., 2014, p. 1; Thompson, 1994). As such, ED is conceptualized as (a) expressions of

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Corresponding Author: Karen E. Seymour, Division of Child and Adolescent Psychiatry, Johns Hopkins University School of
Medicine, 550 North Broadway, Suite 943, Baltimore, MD 21205, USA. kseymou2@jhmi.edu.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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emotion that are excessive in relation to societal norms or situational context, (b) rapid and
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poorly controlled shifts in emotion (i.e., lability), and/or (c) atypical allocation of attention
to emotional stimuli (Shaw et al., 2014). The prevalence of ED in clinical samples of ADHD
ranges between 24% and 50% in children (Becker et al., 2006; Sjowall, Roth, Lindqvist, &
Thorell, 2013; Spencer et al., 2011) and 34% and 70% in adults (Barkley & Fischer, 2010;
Reimherr et al., 2005; Surman et al., 2013). However, it should be noted that prevalence
estimates are significantly influenced by the definitions of ED used and the measurement of
the construct (e.g., parent-report vs. self-report vs. observation). Longitudinally, ED in youth
with ADHD is associated with increased psychiatric comorbidity (particularly with mood
and anxiety disorders), greater social impairments, poorer quality of life, and greater
academic and occupational difficulties (Althoff, Verhulst, Rettew, Hudziak, & van der Ende,
2010; Barkley & Fischer, 2010; Biederman et al., 2012; Seymour, Chronis-Tuscano,
Iwamoto, Kurdziel, & Macpherson, 2014; Wehmeier, Schacht, & Barkley, 2010).
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From a theoretical perspective, ED also is purported to be a core deficit in individuals with

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

One form of ED of particular importance in ADHD is frustration, defined as “an affective

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

To date, there has been little empirical investigation of frustration tolerance in youth with
ADHD. The only studies of frustration in youth with ADHD have been observational studies
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in which frustration is characterized using observer-based assessments during frustrating

situations (e.g., unsolvable puzzle task, frustrating peer competition). For example, in an
observational study of 6- to 11-year-old boys with and without ADHD, boys with ADHD
were shown to be less effective in regulating their emotions during a frustrating peer
competition than age-matched, non-ADHD comparison boys. That is, boys with ADHD
displayed more signs of negative or frustrated emotion than non-ADHD comparison boys.
Furthermore, in comparison with boys without ADHD, boys with ADHD demonstrated an
enduring pattern of disinhibition (as measured by higher stop signal reaction time score)

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before and after the frustration task (Walcott & Landau, 2004). Another study of observed
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frustration demonstrated that 6- to 12-year-old youth with ADHD were more likely to quit a
frustrating puzzle task before completion, more likely to report frustration, and less likely to
engage in mood repair than non-ADHD comparison youth (Scime & Norvilitis, 2006).
Increased levels of frustration and decreased task persistence by boys with ADHD have been
reported during both academic and non-academic tasks (e.g., videogames, mapping task;
Lawrence et al., 2002). In addition, youth with ADHD have difficulty identifying and
processing negative emotions (Norvilitis, Casey, Brooklier, & Bonello, 2000; Singh et al.,
1998), which may interfere with their ability to persist in goal-directed activity when
frustrated.

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

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

Method
Participants
Participants included 67 youth between the ages of 10 and 14 years with (n = 37) and
without (n = 30) Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV;

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American Psychiatric Association [APA], 1994) ADHD. The age range of 10 to 14 years
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was chosen due to the larger aims of the study (i.e., to examine the relationship between ER
and depressive symptoms in youth at an age when depressive symptoms are likely to
emerge; Seymour et al., 2012). Participants were recruited through mailings to pediatricians,
schools, and community centers in the Washington DC metropolitan area, as well as
university employees and families who had previously been seen in the laboratory. For
inclusion in the study, youth were required to (a) be between the ages of 10 and 14 years, (b)
be fluent in English so that they could understand and complete questionnaires; and (c) have
at least one residential parent/guardian who was willing to participate and could complete
the measures in English. Youth were excluded if there was evidence of mental retardation
(estimated IQ <70) or evidence of psychosis, bipolar disorder, or pervasive developmental
disorders (PDD).

For inclusion in the ADHD group, youth had to meet full DSM-IV criteria for ADHD
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according to evidence-based assessment procedures (i.e., parent-report on a semi-structured

clinical interview and parent and teacher completion of ADHD rating forms; Pelham,
Fabiano, & Massetti, 2005). For inclusion in the non-ADHD comparison group, youth could
not have more than three total symptoms of DSM-IV ADHD or clinically significant
impairment according to combined parent and teacher report. Participant characteristics are
presented in Table 1.

Procedures
Participants were screened via telephone to determine initial eligibility and, if eligible, were
scheduled for a single assessment session at the University of Maryland College Park.
Written parent consent and child assent were obtained prior to participation. During the
assessment, parents completed (a) a diagnostic interview about the youth’s past and current
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ADHD symptoms, (b) rating scales assessing the youth’s ADHD and disruptive behavior
disorder (DBD) symptoms and functional impairment, and (c) a demographics
questionnaire. Youth completed (a) a brief IQ screen using the Wechsler Intelligence Scale
for Children, 4th Edition (WISC-IV) Block Design and Vocabulary subtests (Wechsler,
2003) and (b) a computerized behavioral task of frustration tolerance. Youth with ADHD
who were taking stimulant medication were allowed to remain on their medication on the
day of testing (for ethical reasons), but for diagnostic purposes, questions were asked about
their behavior off medication. For the larger aims of the study, information was also
collected from parents and youth about depressive symptoms and ER. Youth were paid US
$25 for their participation and parents were offered a free workshop offered by the first
author on “Parenting Adolescents.”
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With parental permission, rating scales were sent to the teacher who spent the most time
with the child and knew him or her the best. In total, teacher ratings were available for 66%
(n = 44) of the sample, and there was no difference between groups on the presence of
teacher ratings, χ2(1, N = 67) = 0.02, p = .89. If teacher data were unavailable, the ADHD
diagnosis was made using clinician assessment and parent-report of school performance and
difficulties, incorporating prior report cards and school records when available. Teachers
received US$10 upon completion of these scales.

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Assessment of parent and youth demographic information.—Parents were asked

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

Assessment of youth ADHD.—Parents/guardians were interviewed using the Kiddie

Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and
Lifetime Version (K-SADS-PL; Kaufman et al., 1997), a semi-structured diagnostic
interview assessing current and lifetime diagnoses of ADHD. The K-SADS-PL has well-
established reliability (Ambrosini, 2000) and has been shown to be highly related to the
Child Behavior Checklist and Conners’ Parent Rating Scale scores (Kaufman et al., 1997).
Interviews were conducted by the first author who was extensively trained in the
administration of the K-SADS, and who met weekly with a licensed clinical psychologist
(the senior author) for supervision. Interviews were recorded for supervision purposes, and
discrepancies were discussed by the clinical team until agreement was reached.
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Parents and teachers also completed the DBD symptom checklist (Pelham, Gnagy,
Greenslade, & Milich, 1992) that assesses ADHD, ODD, and conduct disorder (CD)
symptoms on a scale from not at all to very much. Symptoms rated as occurring pretty much
or very much were considered present to a clinically significant degree. Internal consistency
for the DBD in this sample was adequate to high on the ADHD (α = .95), ODD (α = .90),
and CD (α = .74) scales. Total ADHD symptoms (r = .92, p < .001), total inattentive
symptoms (r = .94, p < .001), and total hyperactivity/impulsivity symptoms (r = .90, p < .
001) as rated by parents and teachers on the DBD were highly correlated with the clinical
interview (i.e., K-SADS). Parents and teachers were requested to report on the youth’s
typical behavior while not actively medicated for ADHD.
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As required for a Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.;
DSM-IV-TR; APA, 2000) diagnosis of ADHD, cross-sectional impairment was measured
using the parent and teacher versions of the Children’s Impairment Rating Scale (CIRS;
Fabiano et al., 2006). On the CIRS, informants assess the youth’s level of impairment and
need for treatment across multiple domains, including peer/sibling relations, self-esteem,
academic achievement, and parent–child relations as well as an overall rating of impairment.
Ratings are made on a 7-point scale, with scores above the midpoint indicating clinically
significant impairment. The CIRS has demonstrated concurrent validity with other
established measures of youth impairment and accurately discriminates between youth with
ADHD and non-disordered youth (Fabiano et al., 2006). Internal consistency for both
parent- and teacher-rated CIRS in this sample was high (α = .95 and .88, respectively).

Diagnoses of ADHD were made by counting symptoms endorsed by either parents or

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

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four out of eight) endorsed by parents as occurring to a clinically significant degree on either
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the K-SADS or DBD. Descriptive data for all scales are presented in Table 1.

Assessment of frustration tolerance.—Frustration tolerance was assessed using a

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

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

Data Analytic Plan

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

To examine group differences in errors and median distance achieved on the frustration task
as well as irritability, general linear model (GLM) ANOVA were conducted. Primary

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

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

Correlational Analyses
First, we examined the relationship between frustration tolerance on the MTPT-C and
demographic variables within the entire sample. Within the entire sample, MTPT-C quit
status (i.e., quit vs. no quit) was not significantly related to any demographic variables
including child sex (r = .14, p = .29), child age (r = −.17, p = .18), or child race (r = .00, p = .
98).
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Given that diagnostic groups differed on child race/ethnicity (Table 1), partial correlations
controlling for child race were used to examine the relationship between MTPT-C quit status
and ADHD symptoms and impairment. All partial correlations are presented in Table 2.
MTPT-C quit status was significantly related to ADHD diagnosis (r = .28, p = .02), total
ADHD symptoms (r = .28, p = .03), and total inattentive symptoms (r = .30, p = .02), but not
hyperactive/impulsive symptoms (r = .21, p = .11) or ODD diagnosis (r = .13, p = .32).
MTPT-C quit status was also significantly related to both parent-reported overall impairment
(r = .28, p = .03) and teacher-rated overall impairment (r = .32, p = .04).

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

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ADHD control participants (Figure 2). In fact, youth with ADHD had 24.74 times increased
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odds of quitting compared with non-ADHD participants.

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

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

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

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

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

Alternatively, it may be that, for youth with ADHD, their dysregulated frustration response
results in increased engagement of limbic regions, facilitating sensitivity to affective
information at the expense of the engagement of cortical systems necessary for regulatory
control, making it difficult to engage in goal-directed activity (Oei et al., 2012). Of course,
both of these hypotheses require additional testing in youth with ADHD.

Given the high rates of comorbidity between ADHD and ODD, we compared frustration
tolerance in youth with ADHD with and without comorbid ODD. Results showed no group
differences in frustration tolerance. Furthermore, moderation analyses showed that ODD
does not moderate the relationship between ADHD and frustration tolerance. Taken together,
our results suggest that the difficulties that youth with ADHD have with frustration tolerance
are likely independent of ODD. While these findings may reflect low power to detect this
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effect, they could also suggest that a lower threshold for frustration in youth with ADHD is
more related to core characteristics of ADHD such as inattention, hyperactivity, and
impulsivity rather than the associated features of oppositionality, anger, and irritability.
Indeed, we found a positive relationship between frustration tolerance and total inattentive
symptoms such that youth with higher levels of inattention were more likely to quit the task
than those with lower levels of inattention. Surprisingly, we did not find a relationship
between hyperactive/impulsive symptoms and frustration tolerance within our sample. It
may be that in the wake of frustration, youth with ADHD “tune out” the aversive frustrating
stimuli and give up on a task rather than persist, which can greatly impair their academic
functioning. Additional research is needed to further explore the relationship between
inattention and hyperactive/impulsive symptom dimensions and frustration tolerance.
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Our results should also be examined in relation to prior studies of distress or frustration
tolerance in youth with ODD. For example, a longitudinal study of distress tolerance in
community sample of pre-adolescents (ages 9–13) found that greater persistence on a
behavioral distress tolerance task at Year 1 was associated with lower levels of ADHD
symptoms at Year 4, but increased levels of ODD symptoms at Year 4, suggesting a positive
association between frustration tolerance and ODD symptoms (Cummings et al., 2013). In
contrast, ODD was not related to frustration tolerance (i.e., quit status) in our sample. It
should be noted that the distress tolerance task used by Cummings et al. (2013) was different

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from the one used in this study, which may have contributed to differential results. In
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addition, study design (i.e., Cummings et al. being a longitudinal study vs. this cross-
sectional study) may have contributed to different findings.

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

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

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

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 Seymour et al. Page 11

Tuscano et al., 2014). Biofeedback in which youth receive real-time measures of their own
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physiological reactivity may also be helpful in making youth with ADHD more attuned to
their frustration levels.

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

Funding

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

Author Biographies
Karen E. Seymour is an Assistant Professor in the Division of Child and Adolescent
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Psychiatry at Johns Hopkins University School of Medicine. Dr. Seymour’s research is

focused on understanding emotion dysregulation in individuals with ADHD and elucidating
biobehavioral mechanisms underlying emotion dysregulation in individuals with ADHD.

Richard Macatee is a doctoral candidate in the Clinical Psychology program at Florida

State University. Richard’s research focuses broadly on transdiagnostic risk factors (e.g.,
distress intolerance) for anxiety and substance use disorders, particularly their co-
occurrence.

Andrea Chronis-Tuscano is Professor of Psychology at the University of Maryland and

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

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Figure 1.
Display for MTPT-C.
Note. MTPT-C = Mirror Tracing Persistence Task–Computerized Version.
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Figure 2.
Differences in frustration tolerance in children with ADHD and non-ADHD controls.
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Figure 3.
Examination of ODD as a moderator in the relationship between ADHD and MT time to
quit.
Note. ODD = oppositional defiant disorder.
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Table 1.

Participant Demographic and Clinical Characteristics (n = 66).

Variable ADHD (n = 37) Control (n = 30) Group differences

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

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c 83% (n = 29) 59% (n = 16) χ2(1, 62) = 4.27, p = .04
MTPT-C quit (% quit)

Note. Results presented as M (SD) or as percent (n). Total ADHD, inattention, hyperactivity/impulsivity are based on parent and teacher report on the Disruptive Behavior Disorders Checklist and clinician
report on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL). The mean for WISC scaled scores is 10. WISC-IV =
Wechsler Intelligence Scale for Children–4th edition; ODD = oppositional defiant disorder; MTPT-C = Mirror Tracing Persistence Task–Computerized Version.
a
Two ADHD participants were missing WISC-IV scores.
b
n = 24 and 20 for ADHD and Control groups, respectively.
c
Five participants (three Controls and two ADHD) were missing MTPT-C data due to technical errors.
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Table 2.

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

Variable 1 2 3 4 5 6 7 8
1. MTPT-C quit —
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2. ADHD diagnosis .276* —

3. Total ADHD symptoms .258* .925** —

4. IA symptoms .275* .989** .942** —

5. HI symptoms .197 .707** .914** .726** —

6. Parent-rated impairment .256* .533** .655** .715** .480** —

a .318* .683** .587** .673** .392* .470** —

7. Teacher-rated impairment
8. ODD diagnosis .216 .390** .401** .330* .430** .479** .364* —

Note. MTPT-C = Mirror Tracing Persistence Task–Computerized; IA = inattention; HI = hyperactive/impulsive; ODD = oppositional defiant disorder.
a
n = 39 for teacher ratings.
*
p < .05.
**
p < .01.

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Table 3.

Linear Model Predictors of MTPT Latency to Quit.

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

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

MTPT = Mirror Tracing Persistence Task.

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