Abstract
Intolerance of uncertainty (IU) has often been studied in the context of internalizing disorders, but no studies to our knowledge have explored the relation between IU and externalizing disorders. Given the proposed link between IU and emotion regulation, the current study sought to examine levels of IU in an externalizing clinical population with known emotion regulation difficulties—attention-deficit/hyperactivity disorder (ADHD). IU levels in this population were compared to a clinical population known to experience elevated levels of IU. Participants in present study were ninety-three children (36 anxiety disorder, 28 ADHD, 29 unaffected children) ages 7–13, who completed the Intolerance of Uncertainty Scale—Short Version (IUS). Responses on the IUS were converted to total IU, prospective IU, and inhibitory IU. A linear mixed model analysis of covariance was conducted while controlling for age, sex, and ADHD medications. A significant interaction was observed between diagnostic status and IU scale. Planned contrasts indicated that children with anxiety disorders and ADHD reported significantly higher levels of IU relative to unaffected children, and children with ADHD reported comparable levels of inhibitory IU relative to children with anxiety disorders. The current results contribute to a growing literature on the link between IU and psychopathology. IU appears to be a transdiagnostic construct present among children with internalizing and externalizing disorders, and may be broadly associated with emotion regulation deficits rather than specific disorder symptoms.
Similar content being viewed by others
References
Albano AM, Silverman WK (1996) The anxiety disorders interview schedule for children for DSM-IV: clinician manual (child and parent versions). Psychological Corporation, San Antonio
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, Arlington. https://doi.org/10.1176/appi.books.9780890425596.744053
Antony MM, Orsillo SM, Roemer L (2001) Practitioner’s guide to empirically based measures of anxiety. New York. https://doi.org/10.1007/b108176
APA (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Publishing, Washington, DC, pp 69–81
Bar-Anan Y, Wilson TD, Gilbert DT (2009) The feeling of uncertainty intensifies affective reactions. Emotion 9(1):123–127. https://doi.org/10.1037/a0014607
Barkley RA (1997) Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull 121(1):65–94. https://doi.org/10.1037/0033-2909.121.1.65
Barkley R (2014) Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment, vol 628. Guilford Press, New York
Barkley RA (2015) Emotional dysregulation is a core component of ADHD. Atten Deficit Hyperact Disord Handb Diagn Treat 4:81–115
Birrell J, Meares K, Wilkinson A, Freeston M (2011) Toward a definition of intolerance of uncertainty: a review of factor analytical studies of the intolerance of uncertainty scale. Clin Psychol Rev 31(7):1198–1208. https://doi.org/10.1016/j.cpr.2011.07.009
Blair KS, Vythilingam M, Crowe SL, Mccaffrey DE, Ng P, Wu CC et al (2015) Cognitive control of attention is differentially affected in trauma-exposed individuals with and without post-traumatic stress disorder. Psychol Med 43(1):85–95. https://doi.org/10.1017/S0033291712000840.Cognitive
Boswell JF, Thompson-Hollands J, Farchione TJ, Barlow DH (2013) Intolerance of uncertainty: a common factor in the treatment of emotional disorders. J Clin Psychol 69(6):1–16. https://doi.org/10.1002/jclp.21965
Bylsma LM, Morris BH, Rottenberg J (2008) A meta-analysis of emotional reactivity in major depressive disorder. Clin Psychol Rev 28(4):676–691. https://doi.org/10.1016/j.cpr.2007.10.001
Carleton RN (2012) The intolerance of uncertainty construct in the context of anxiety disorders: theoretical and practical perspectives. Expert Rev Neurother 12(8):937–947. https://doi.org/10.1586/ern.12.82
Carleton RN (2016a) Fear of the unknown: one fear to rule them all? J Anxiety Disord 41:5–21. https://doi.org/10.1016/j.janxdis.2016.03.011
Carleton RN (2016b) Into the unknown: a review and synthesis of contemporary models involving uncertainty. J Anxiety Disord 39:30–43. https://doi.org/10.1016/j.janxdis.2016.02.007
Carleton RN, Norton MAPJ, Asmundson GJG (2007) Fearing the unknown: a short version of the intolerance of uncertainty scale. J Anxiety Disord 21(1):105–117. https://doi.org/10.1016/j.janxdis.2006.03.014
Carleton RN, Mulvogue MK, Thibodeau MA, McCabe RE, Antony MM, Asmundson GJG (2012a) Increasingly certain about uncertainty: intolerance of uncertainty across anxiety and depression. J Anxiety Disord 26(3):468–479. https://doi.org/10.1016/j.janxdis.2012.01.011
Carleton RN, Thibodeau MA, Osborne JW, Asmundson GJG (2012b) Exploring item order in anxiety-related constructs: practical impacts of serial position. Pract Assess Res Eval 17(7):1–15
Cisler JM, Olatunji BO, Feldner MT, Forsyth JP (2010) Emotion regulation and the anxiety disorders: an integrative review. J Psychopathol Behav Assess. https://doi.org/10.1007/s10862-009-9161-1
Cole PM, Martin SE, Dennis TA (2004) Emotion regulation as a scientific construct : methodological challenges and directions for child development research. Chil Dev 75(2):317–333
Douglas VI, Parry PA (1994) Effects of reward and nonreward on frustration and attention in attention deficit disorder. J Abnorm Child Psychol 22(3):281–302. https://doi.org/10.1007/BF02168075
Dugas MJ, Freeston MH, Ladouceur R (1997) Intolerance of uncertainty and problem orientation in worry. Cogn Ther Res 21(6):593–606. https://doi.org/10.1023/A:1021890322153
Edwards L, Muller K, Wolfinger R, Qaqish B, Schabenberger O (2008) An R2 statistic for fixed effects in the linear mixed model. Stat Med 27(29):6137–6157. https://doi.org/10.1002/sim.3429.An
Ehring T, Ehlers A (2014) Does rumination mediate the relationship between emotion regulation ability and posttraumatic stress disorder? Eur J Psychotraumatol 5:1–7. https://doi.org/10.3402/ejpt.v5.23547
Einstein DA (2014) Extension of the transdiagnostic model to focus on intolerance of uncertainty: a review of the literature and implications for treatment. Clin Psychol Sci Pract 21(3):280–300. https://doi.org/10.1111/cpsp.12077
Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39(2):175–191. https://doi.org/10.3758/BF03193146
FeldmanHall O, Glimcher P, Baker AL, Phelps EA (2016) Emotion and decision-making under uncertainty: physiological arousal predicts increased gambling during ambiguity but not risk. J Exp Psychol Gen 145(10):1255–1262. https://doi.org/10.1037/xge0000205
Fetzner MG, Horswill SC, Boelen PA, Carleton RN (2013) Intolerance of uncertainty and PTSD symptoms: exploring the construct relationship in a community sample with a heterogeneous trauma history. Cogn Ther Res 37(4):725–734. https://doi.org/10.1007/s10608-013-9531-6
Fialko L, Bolton D, Perrin S (2012) Applicability of a cognitive model of worry to children and adolescents. Behav Res Ther 50(5):341–349. https://doi.org/10.1016/j.brat.2012.02.003
Freeston MH, Rhéaume J, Letarte H, Dugas MJ, Ladouceur R (1994) Why do people worry? Personal Individ Differ 17(6):791–802. https://doi.org/10.1016/0191-8869(94)90048-5
Gentes EL, Ruscio AM (2011) A meta-analysis of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Clin Psychol Rev 31(6):923–933. https://doi.org/10.1016/j.cpr.2011.05.001
Greco V, Roger D (2003) Uncertainty, stress, and health. Personal Individ Differ 34(6):1057–1068. https://doi.org/10.1016/S0191-8869(02)00091-0
Hannesdottir DK, Ollendick TH (2007) The role of emotion regulation in the treatment of child anxiety disorders. Clin Child Fam Psychol Rev 10(3):275–293. https://doi.org/10.1007/s10567-007-0024-6
Hong RY, Lee SSM (2015) Further clarifying prospective and inhibitory intolerance of uncertainty: factorial and construct validity of test scores from the intolerance of uncertainty scale. Psychol Assess 27(2):605–620. https://doi.org/10.1037/pas0000074
Hsu KJ, Beard C, Rifkin L, Dillon DG, Pizzagalli DA, Björgvinsson T (2015) Transdiagnostic mechanisms in depression and anxiety : the role of rumination and attentional control. J Affect Disord 188:22–27. https://doi.org/10.1016/j.jad.2015.08.008
Huettel SA, Song AW, McCarthy G (2005) Decisions under uncertainty: probabilistic context influences activation of prefrontal and parietal cortices. J Neurosci 25(13):3304–3311. https://doi.org/10.1523/JNEUROSCI.5070-04.2005
Jensen WA, Birch JB, Woodall WH (2008) Monitoring correlation within linear profiles using mixed models. J Qual Technol 40:167–183
Kertz S, Woodruff-Borden J (2013) The role of metacognition, intolerance of uncertainty, and negative problem orientation in children’s worry. Behav Cogn Psychother 41(2):243–248. https://doi.org/10.1017/S1352465812000641
Mahoney AEJ, McEvoy PM (2012) A transdiagnostic examination of intolerance of uncertainty across anxiety and depressive disorders. Cogn Behav Ther 41(3):212–222. https://doi.org/10.1080/16506073.2011.622130
Martel MM (2009) Research review: a new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry 50(9):1042–1051
McEvoy PM, Erceg-Hurn DM (2015) The search for universal transdiagnostic and trans-therapy change processes: evidence for intolerance of uncertainty. J Anxiety Disord 41:96–107. https://doi.org/10.1016/j.janxdis.2016.02.002
Milich R, Okazaki M (1991) An examination of learned helplessness among attention-deficit hyperactivity disordered boys. J Abnorm Child Psychol 19(5):607–623. https://doi.org/10.1007/BF00925823
Mogg K, Salum GA, Bradley BP, Gadelha A, Pan P, Alvarenga P et al (2015) Attention network functioning in children with anxiety disorders, attention-deficit/hyperactivity disorder and non-clinical anxiety. Psychol Med 45:2633–2646. https://doi.org/10.1017/S0033291715000586
Mushtaq F, Bland AR, Schaefer A (2011) Uncertainty and cognitive control. Front Psychol 2:1–14. https://doi.org/10.3389/fpsyg.2011.00249
Osmanagaoglu N, Creswell C, Dodd HF (2017) Intolerance of uncertainty, anxiety, and worry in children and adolescents: a meta-analysis. J Affect Disord. https://doi.org/10.1016/j.jad.2017.07.035
Paulus MP, Yu AJ (2012) Emotion and decision-making: affect-driven belief systems in anxiety and depression. Trends Cogn Sci 16(9):133–149. https://doi.org/10.1016/j.tics.2012.07.009.Emotion
Pelham WE, Fabiano GA (2008) Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol. https://doi.org/10.1080/15374410701818681
Peugh JL (2010) A practical guide to multilevel modeling. J Sch Psychol 48(1):85–112. https://doi.org/10.1016/j.jsp.2009.09.002
Polanczyk G, De Lima MS, Horta BL, Biederman J, Rohde LA (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164(6):942–948. https://doi.org/10.1176/appi.ajp.164.6.942
Read KL, Comer JS, Kendall PC (2013) The intolerance of uncertainty scale for children (IUSC): discriminating principal anxiety diagnoses and severity. Psychol Assess 25(3):722–729. https://doi.org/10.1037/a0032392
Reinholdt-Dunne ML, Mogg K, Vangkilde SA, Bradley BP, Esbjorn BH, Esbjørn BH, Esbjorn BH (2015) Attention control and attention to emotional stimuli in anxious children before and after cognitive behavioral therapy. Cogn Ther Res 39(6):785–796. https://doi.org/10.1007/s10608-015-9708-2
Rive MM, van Rooijen G, Veltman DJ, Phillips ML, Schene AH, Ruhe HG (2013) Neural correlates of dysfunctional emotion regulation in major depressive disorder. A systematic review of neuroimaging studies. Neurosci Biobehav Rev 37(10 Pt 2):2529–2553. https://doi.org/10.1016/j.neubiorev.2013.07.018
Rodgers J, Hodgson A, Shields K, Wright C, Honey E, Freeston M (2016) Towards a treatment for intolerance of uncertainty in young people with autism spectrum disorder: development of the coping with uncertainty in everyday situations (CUES??) programme. J Autism Dev Disord 0(0):1–8. https://doi.org/10.1007/s10803-016-2924-0
Rosen JB, Donley MP (2006) Animal studies of amygdala function in fear and uncertainty: relevance to human research. Biol Psychol 73(1):49–60. https://doi.org/10.1016/j.biopsycho.2006.01.007
Rosen PJ, Epstein JN (2010) A pilot study of ecological momentary assessment of emotion dysregulation in children. J ADHD Relat Disord 1(4):39–52
Rosen PJ, Factor PI (2015) Emotional impulsivity and emotional and behavioral difficulties among children with adhd: an ecological momentary assessment study. J Atten Disord 19(9):779–793. https://doi.org/10.1177/1087054712463064
Rosen PJ, Walerius DM, Fogleman ND, Factor PI (2015) The association of emotional lability and emotional and behavioral difficulties among children with and without ADHD. ADHD Atten Deficit Hyperact Disord 7(4):281–294. https://doi.org/10.1007/s12402-015-0175-0
Salters-Pedneault K, Roemer L, Tull MT, Rucker L, Mennin DS (2006) Evidence of broad deficits in emotion regulation associated with chronic worry and generalized anxiety disorder. Cogn Ther Res 30(4):469–480. https://doi.org/10.1007/s10608-006-9055-4
Schatz DB, Rostain AL (2006) ADHD with comorbid anxiety: a review of the current literature. J Atten Disord 10:141–149. https://doi.org/10.1177/1087054706286698
Scime M, Norvilitis JM (2006) Task performance and response to frustration in children with attention deficit hyperactivity disorder. Psychol Sch 43(3):377–386. https://doi.org/10.1002/pits.20151
Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME (2000) NIMH diagnostic interview schedule for children version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry 39(1):28–38. https://doi.org/10.1097/00004583-200001000-00014
Shaw P, Stringaris A, Nigg J, Leibenluft E (2014) Emotional dysregulation and attention-deficit/hyperactivity disorder. Am J Psychiatry 171(3):276–293. https://doi.org/10.1176/appi.ajp.2013.13070966
Shihata S, McEvoy PM, Mullan BA, Carleton RN (2016) Intolerance of uncertainty in emotional disorders: what uncertainties remain? J Anxiety Disord 41:115–124. https://doi.org/10.1016/j.janxdis.2016.05.001
Silverman WK, Saavedra LM, Pina AA (2001) Test-retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule for DSM-IV: child and parent versions. J Am Acad Child Adolesc Psychiatry 40(8):937–944. https://doi.org/10.1097/00004583-200108000-00016
Snyder HR, Kaiser RH, Warren SL, Heller W (2015) Obsessive-compulsive disorder is associated with broad impairments in executive function: a meta-analysis. Clin Psychol Sci 3(2):301–330. https://doi.org/10.1177/2167702614534210
Sobanski E, Banaschewski T, Asherson P, Buitelaar J, Chen W, Franke B et al (2010) Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiatry Allied Discip 51(8):915–923. https://doi.org/10.1111/j.1469-7610.2010.02217.x
Stern ER, Gonzalez R, Welsh RC, Taylor SF (2010) Updating beliefs for a decision: neural correlates of uncertainty and underconfidence. J Neurosci 30(23):8032–8041. https://doi.org/10.1523/JNEUROSCI.4729-09.2010
Stern MR, Nota JA, Heimberg RG, Holaway RM, Coles ME (2014) An initial examination of emotion regulation and obsessive compulsive symptoms. J Obsessive Compuls Relat Disord 3(2):109–114. https://doi.org/10.1016/j.jocrd.2014.02.005
Suveg C, Zeman J (2004) Emotion regulation in children with anxiety disorders. J Clin Child Adolesc Psychol 33(4):750–759. https://doi.org/10.1207/s15374424jccp3304_10
Tan PZ, Forbes EE, Dahl RE, Ryan ND, Siegle GJ, Ladouceur CD, Silk JS (2012) Emotional reactivity and regulation in anxious and nonanxious youth: a cell-phone ecological momentary assessment study. J Child Psychol Psychiatry Allied Discip 53(2):197–206. https://doi.org/10.1111/j.1469-7610.2011.02469.x
Thielsch C, Andor T, Ehring T (2015) Do metacognitions and intolerance of uncertainty predict worry in everyday life? an ecological momentary assessment study. Behav Ther 46(4):532–543. https://doi.org/10.1016/j.beth.2015.05.001
Tolin DF, Abramowitz JS, Brigidi BD, Foa EB (2003) Intolerance of uncertainty in obsessive-compulsive disorder. J Anxiety Disord 17(2):233–242. https://doi.org/10.1016/S0887-6185(02)00182-2
Volz KG, Schubotz RI, Von Cramon DY (2003) Predicting events of varying probability: uncertainty investigated by fMRI. NeuroImage 19(2):271–280. https://doi.org/10.1016/S1053-8119(03)00122-8
Walcott CM, Landau S (2004) The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder the relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder. J Clin Child Adolesc Psychol 33(4):772–782. https://doi.org/10.1207/s15374424jccp3304
Wehmeier PM, Schacht A, Barkley RA (2010) Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. J Adolesc Health. https://doi.org/10.1016/j.jadohealth.2009.09.009
Acknowledgements
Colette Gramszlo and Nicholas D. Fogleman contributed equally to this manuscript.
Author information
Authors and Affiliations
Corresponding authors
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Rights and permissions
About this article
Cite this article
Gramszlo, C., Fogleman, N.D., Rosen, P.J. et al. Intolerance of uncertainty in children with attention-deficit/hyperactivity disorder. ADHD Atten Def Hyp Disord 10, 189–197 (2018). https://doi.org/10.1007/s12402-017-0244-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12402-017-0244-7