The Trump administration is shuttling immigrants around the US in irregular and unprecedented ways, according to the findings of a Guardian investigation, effectively vanishing people into a “purgatory” that denies them constitutionally-protected rights.
A review of leaked flight records and passenger manifests from Global Crossing Airlines (GlobalX), the charter company that operates the majority of deportation flights for US Immigration and Customs Enforcement (Ice), has provided a rare look at the winding journeys of more than 44,000 immigrants detained or deported by the Trump administration.
The leaked data was provided to the Guardian, which has verified its authenticity. It encompasses about 100 days from late January to early May.
Note: About 370 flight routes from 19 January 2025 to 2 May 2025.
The Guardian reviewed GlobalX deportation flights as well as government detention data and interviewed attorneys, advocates, former officials and immigrants who have been through the system. The analysis has revealed that:
GlobalX carried out more than 1,700 flights for Ice, the vast majority of them between domestic US airports. The airline transported nearly 1,000 children, including nearly 500 children under the age of 10, and 22 infants.
For many immigrants, the flight paths were long, with multiple legs and layovers. Nearly 3,600 people were moved around repeatedly, forced to board five or more GlobalX flights.
Immigrants were also moved between detention facilities more than before. The average number of transfers per person has markedly increased in the past six months, and some detained immigrants have been moved as many as 10 or 20 times.
Detainees were moved around the US without notice, to locations far from their families, communities and legal counsel – leading to apparent violations of constitutional due process rights.
Along their journeys, immigrants say they were repeatedly kept in the dark about where they were going. Some say they were threatened by immigration agents with long-distance transfers and separation from their families if they did not accept voluntary deportation.
“It just seems so fundamentally inhumane,” said Sirine Shebaya, executive director of the National Immigration Project, a non-profit legal advocacy group. “The administration is using the system to make it as prohibitively cruel as it possibly can for the people going through.”
Immigrants are being moved around via chartered flights operated by various private contractors, as well as by commercial airlines, buses and cars.
But perhaps more so than any other transportation company, GlobalX, a Miami-based charter airline, has become a crucial tool of the US deportation machine – operating more than half of Ice deportation flights in 2024 and 2025. The company, which had initially marketed itself to sports teams and rock bands seeking to travel in luxury, now earns most of its revenue from its Ice contract.
It was the airline the Trump administration tapped to movehundreds of Venezuelan men to El Salvador, despite a judicial order blocking the flight. It was also the operator of a now infamous deportation flight to Brazil during which multiple passengers fainted from heat exhaustion.
GlobalX did not respond to a request for comment.
The leaked GlobalX flight manifests provide one of the most detailed views available of the scale and scope of Trump’s mass deportation scheme.
Quick Guide
How the Guardian reported on leaked GlobalX flight data
Show
Infants sent overseas. People shuttled to different detention centers across the country five, 10, 15 times over a period of a few weeks. Lawyers desperate to find their clients. Detention centers exceed capacity as people wait for their deportation flights. A Guardian US investigation has revealed new details about the US government’s chaotic mass deportation effort, including exclusive analysis of deportation flights during the first months of the Trump administration.
Our reporting relied in part on details of over 1,700 flights and passenger lists encompassing more than 44,000 people that were anonymously leaked to the Guardian in May 2025, following a hack of Global Crossing, the charter airline that provides deportation flights across and outside the US. The hacking group Anonymous claimed to be responsible for the breach.
The leaked information included passenger names, personally identifying information for those passengers, flight numbers, flight details, and other data for deportation flights that occurred in the first 100 days of Donald Trump’s presidency, between January and May. The data was leaked to a number of media outlets, including the Guardian, unprompted.
On 5 May, GlobalX confirmed in a letter to the SEC that it had learned of recent “unauthorized activity within its computer networks and systems supporting portions of its business applications”, which it determined was the result of a “cybersecurity incident”.
Reporters verified the authenticity of the data in a few different ways, using public and previously unreported deportations, as well as public flight info and file metadata.
We verified the deportation journeys of every person interviewed for the series, like Andry José Hernández Romero, and checked to make sure that their journeys matched the data in the leaked manifests. Each person’s recollection of their deportations match the origins, destinations and times listed in the leaked data.
Reporters also located individuals whose names and stories were not public, and confirmed that the flight patterns described in the data were accurate. In one case, the details of which have never been made public, reporters looked up the flights of a person deported to Colombia after being apprehended at the northern border and matched the person by name and birthday within the GlobalX data. Reporters then verified each step of the individual’s deportation journey in the leaked data.
The Guardian also found other details that supported the authenticity of the data. An analysis of file metadata found that the files were created at various points in time between 3 May and 4 May, matching the approximate time frame GlobalX said its records were breached. We also verified that flights labeled with “CANCEL” or “CANCELED” in the messages field were canceled by comparing the tail numbers of flights in FlightAware with flights in our data. Flight details in our data match publicly available flight data.
In addition to the manifests and flight logs from GlobalX, the Guardian’s reporting relied on additional data from the Deportation Data Project, a group of academics and lawyers using records requests to obtain and release anonymized immigration enforcement data to support our findings. The data was used to calculate daily populations at different detention facilities and to analyze the frequency of transfers between detention centers, which helped support other findings of the Guardian’s investigation.
GlobalX did not respond to a request for comment.
The US has always moved immigrants around – most commonly, when a detention center reaches capacity, officials transfer detainees to facilities with more available beds. But the Trump administration is now shuffling immigrants around more frequently than before.
In some cases, lawyers believe that the government is deliberately moving their clients to jurisdictions where immigration judges are less likely to grant asylum, or where legal injunctions blocking Trump immigration policies do not apply.
DHS said that immigrants in custody are informed about their transfers and allowed to contact their families throughout. “Claims that transfers of detainees are being ‘weaponized’ or ‘hidden’ are also categorically false,” said Tricia McLaughlin, the DHS assistant secretary for public affairs.
“Despite a historic number of injunctions, DHS is working rapidly and overtime to remove these aliens from detention centers to their final destination – home,” McLaughlin said. “All transfers are made in accordance with strict guidelines.”
According to protocols established in 2012, Ice is supposed to minimize long-distance transfers, and generally avoid moving detainees away from their immediate family and attorneys. The American Immigration Council and Rocky Mountain Immigrant Advocacy Network (RMIAN) have filed a lawsuit to determine whether Ice is adhering to those policies, or whether transfer rules have been changed.
For immigrants in the system, these chaotic transfers can feel like a punishment, designed to wear people down, said Faisal Al-Juburi, head of external affairs at the legal aid group Raíces.
“You end up in a continuous state of unknown for an indefinite period of time,” he said. “Families are being put into a purgatorial state.”
The plane made a stop, but he never knew where
Andry José Hernández Romero, one of 252 Venezuelan men that the US expelled to El Salvador’s most notorious megaprison, is still trying to make sense of why and how he ended up where he did.
He had come to the US southern border in August 2024, arriving just after his 31st birthday. After an initial screening, US officials determined that Hernández Romero, a queer makeup artist who had faced discrimination in his home country, could have a valid claim to asylum. They placed him at a detention center near San Diego, California, while he awaited a hearing to decide his case.
About a month into the second Trump administration, everything started to go topsy turvy. At the crack of dawn on 8 March, an official told him to get ready – he was being moved. When he asked where he was going, an official responded: “To a much better place.”
He was given no specifics.
He was first moved to Phoenix, and then loaded onto a GlobalX plane. Leaked records show that flight stopped – unbeknownst to his lawyers – in Phoenix, then Las Vegas, then Seattle and finally Harlingen, Texas.
None of this made sense. Hernández Romero was due to appear in immigration court, in California, the following week.
Map showing the path of Andry José Hernández Romero
Lindsay Toczylowski, the co-founder of Immigrant Defenders Law Center (ImmDef) and Hernández Romero’s lawyer, thought it was strange. She figured the government would fly him back to San Diego for his court appointment. But the appointment came, and Hernández Romero wasn’t there. “This is highly unusual, but again, at the time, Ice didn’t seem to have any information,” she said.
She believed it was a bureaucratic mix-up. It was a Friday, and she assumed the government would reschedule his hearing for the upcoming Monday.
And yet, something seemed off.
That weekend, lawyers from ImmDef called the detention center to which Hernández Romero had been transferred, and they were told he was no longer there. “They actually said to us it might be that he has just left for a little while and is coming back,” said Toczylowski. “We had no idea what to make of it.”
Hernández Romero, meanwhile, came to suspect that the officials around him were lying. Many of his compatriots – others who had been shuttled to the same Texas detention center – were starting to get suspicious as well.
José Manuel Ramos Bastidas was worried he would be sent to the US naval base in Guantánamo Bay, Cuba – where the US government had already sent a group of Venezuelan men accused of criminal violations and gang membership.
In February – after months of being detained at the Stewart Detention Center in Lumpkin, Georgia – Bastidas was transferred to an Ice facility in El Paso, Texas. From there, he called his wife, and told her to record his message, to share with the public should anything happen to him. “They detained me simply because of my tattoos. I am not a criminal. I have been here for 10 months,” he said. “This is simply in case something happens to me … if they keep transferring me to another detention center.”
A few weeks later, he was moved to a facility in Raymondville, Texas. Officials initially told him he would be going to Mexico. “At the end they said we were going to make a stop in Honduras and then go on to Venezuela,” he said.
He felt a moment of hope then – maybe, finally, he would see his two-year-old son, his wife, his mother.
On board the plane – an Airbus A320 with 179 seats – staff told the shackled detainees not to open any of the shades. “But we thought, it’s fine, we’re going to Venezuela – that was the goal,” he said. At least, that’s what he and the others kept saying to each other, almost, in a way, to reassure one another.
The plane made a stop, but he never knew where.
It refueled, took off again, and finally landed. “We opened the window [shades], and there we saw blue letters that said El Salvador. And we saw many, many police and soldiers, and tanks, helicopters, drones. That’s when the terror began.”
Map showing the path of José Manuel Ramos Bastidas
For the next four months, Hernández Ramos, Ramos Bastidas and 250 other Venezuelan men were cut off from the outside world. The US government never released a full list of all the men it had condemned to Cecot – leaving dozens of families to guess at whether their loved ones had been sent there.
“The government has never done something like this before, taking an asylum seeker and disappearing them – putting them on a plane to a third country,” said Toczylowski. “I had never seen that happen. So it wasn’t something we were anticipating.”
Human rights and legal aid groups, in the meantime, were noticing it was becoming increasingly difficult to keep track of many of their other clients. “It really is very strange, you get someone who’s picked up, they go to a hold cell, they stay there for seven days – which is completely outrageous. They then get moved to Florida. From there, they get taken to Arizona, then they end up in Texas,” said Shebaya of the National Immigration Project. “It’s like this wild goose chase, trying to follow where the person is and what the reasons are even for moving them.”
For lawyers, hours spent searching for clients
People in Ice detention have always been transferred between facilities, but transfers increased in frequency after Trump took office. A Guardian analysis of anonymized detention data from the Deportation Data Project, a group of academics and lawyers focused on immigration enforcement data, has found that the people who entered Ice detention between September 2023 and January 2025 – during the Biden administration – were transferred twice, on average. Immigrants that were booked into Ice detention since the start of the second Trump administration have been transferred more frequently, an average of three times per person.
Chart showing an increase in the average number of transfers of a person in ice detention beginning after Trump’s inauguration.
It has become routine for immigration attorneys to spend hours each day trying to find their clients. Increasingly, they said, searches in Ice’s online detainee locator system – which is meant to provide real-time updates on where migrants are being held – were proving futile.
Often, the system was wrong, or out of date.
At one point, it logged that a number of people were being held in Washington DC – which does not have any Ice detention centers. “At some point we realized that some of them had been sent to Guantanamo Bay,” Shebaya said.
During the militarized immigration raids in Los Angelesin June, lawyers from ImmDef and other groups compiled a list of about 1,200 people arrested. They have been unable to find about 400 of them, said Toczylowski.
“We have an entire team that is just looking every single day to try to locate people, so then we can communicate with them, offer them representation, and try and get them help,” she said.
At times, attorneys said, the government has moved clients to states and locations where immigration judges tend to grant asylum at lower rates, or where petitions for a writ of habeas corpus challenging detentions are harder to obtain.
In some cases, when the administration has tried to use unconventional or obscure procedures to expel immigrants, attorneys have filed legal complaints accusing DHS of moving people to judicial districts that were more likely to side with the Trump administration. In March, administration used a cold war-era provision to arrest pro-Palestine student activists – and swiftly shuttled them to detention centers in Louisiana and Texas, triggering a series of legal battles about which judges should oversee the students’ cases.
In April, a federal judge in the southern district of Texas banned the government from using the Alien Enemies Act, an 18th century wartime law, to deport Venezuelans accused of gang membership. Ice soon moved two Venezuelan men from a south Texas detention center to a different one in northern Texas, where the ban didn’t apply. Attorneys for the American Civil Liberties Union accused the DHS of “shipping” the men to a friendlier jurisdiction.
Previously, it was not uncommon for immigrants who arrived at the southern border to be moved to detention centers all over the US. But in June and July, the number of Ice chartered flights between US cities increased two-fold compared with prior months, according to flight data compiled by Tom Cartwright, an immigration advocate who has been tracking Ice flights for nearly six years.
“There is a lot of movement, and it really has accelerated significantly,” Cartwright said.
The DHS has moved to arrest record numbers of immigrants and keep them detained rather than releasing people on bond. In the aftermath of ramped up raids in cities across the US, immigration officials are scrambling to find space in the detention system to hold arrestees.
“It’s hard to say how much of that is due to capacity issues at detention centers, and how much of that is for other reasons. But I don’t think the numbers lie at all,” Cartwright said.
A ‘particularly cruel’ fate
For immigrants inside the system – the chaos is punishing.
When LW, a 37-year-old mother who came to the US with her 10-year-old son in April seeking asylum, immigration agents told her she must either return to China with her kid – or the government would separate them.
She tried to explain to border patrol agents in San Diego that she had faced political persecution back home, that both she and her son could be killed if they ever went back. It was to no avail.
She and her son spent about a week at a Customs and Border Patrol (CBP) facility, sleeping on a thin mattress on the floor. They weren’t able to make any calls. “No contact with the outside world. I was still not able to let my boyfriend know that we were alive,” she said in a sworn declaration in her immigration case, shared with her permission by her lawyers at Raíces.
Eventually, they presented her with deportation documents. She refused to sign.
Two days later, at about 4am, LW said, agents forced her and her son into an unmarked blue car. They were driven to the airport.
“According to them, if I did not get on this plane, I would have to be taken on a military aircraft back to China,” she said. “My heart dropped.”
She was frantic – using all the English she could muster to plead her case. She said they grabbed both of her arms and began pulling her toward the terminal. . “Desperate and terrified of what might happen, I dropped to the ground ,” she said.
Eventually, she said, after conferring among themselves, the agents loaded LW and her son back into the blue car. By then, she said, both were crying – and the agents told them to shut up.
Two days later, LW and her son were moved to a family detention center in Dilley, Texas – where they were able to connect with lawyers at Raíces.
Two weeks after that, LW disappeared from Ice’s online detainee locator system.
Her lawyers scrambled to piece together what had happened. LW had been moved to an Ice detention facility in Newark, New Jersey, while her son was sent to a shelter for unaccompanied minors, managed by the Office of Refugee Resettlement.
The agents told her the only way she could see her son again was if she returned to China. “We cannot return to China. My life and my son’s life will be at risk,” LW said. “It took great sacrifices and risk to even be able to escape and get here.”
Before her lawyers were able to meet with her in New Jersey, LW was moved again – to El Paso, Texas. And then again, to Chaparral, New Mexico. It took LW’s legal team at Raíces 11 weeks to make contact with her. She and her son have now been separated for 16 weeks.
“Based upon everything that we can see, this is punishment… a punishment for not acquiescing,” said Al-Juburi of Raices. “The system is designed to make you, as an immigrant, give up, to make you more likely to self deport.”
DHS defended current practices.
“Parents, who are in the US illegally, can take control of their departure. Through the [Customs and Border Control] Home App, the Trump administration is giving parents illegally in the country a chance to take full control of their departure and self-deport, with the potential ability to return the legal, right way and come back to live the American dream,” said McLaughlin, the DHS assistant secretary of public affairs.
She added: “Rather than separate families, Ice asks parents if they want to be removed with their children or if the child should be placed with someone safe the parent designates.”
Immigration attorneys across the US have reported that clients are given ultimatums, rather than a real choice. During the LA raids, at least four pregnant women were picked up and transferred to detention centers in Florida, said Toczylowski of ImmDef.
Another of her clients was arrested in LA, in front of his eight-year-old son and flown, almost immediately afterwards, to Tacoma, Washington. “I saw his son crying and devastated,” she said. The family has remained separated since then.
“It seems the goal is to make people desperate enough so they decide not to fight their case, so they decide that the quickest way to see their other children or make sure they don’t have to deliver their babies in shackles is to accept a voluntary deportation,” said Tocylowski. “It is particularly cruel.”
Additional reporting by Raima Amjad
Contributors
Graphics: Andrew Witherspoon
Illustrations: Angelica Alzona
Visuals editing: Marcus Peabody
Copy editor: Rusha Haljuci
Quick Guide
Contact us about this story
Show
The best public interest journalism relies on first-hand accounts from people in the know.
If you have something to share on this subject you can contact us confidentially using the following methods.
Secure Messaging in the Guardian app
The Guardian app has a tool to send tips about stories. Messages are end to end encrypted and concealed within the routine activity that every Guardian mobile app performs. This prevents an observer from knowing that you are communicating with us at all, let alone what is being said.
If you don’t already have the Guardian app, download it (iOS/Android) and go to the menu. Select ‘Secure Messaging’.
SecureDrop, instant messengers, email, telephone and post
If you can safely use the tor network without being observed or monitored you can send messages and documents to the Guardian via our SecureDrop platform.
Finally, our guide at theguardian.com/tips lists several ways to contact us securely, and discusses the pros and cons of each.
For the 21st-century Jane Austen fan, the images of Colin Firth’s Mr Darcy in the beloved BBC series Pride of Prejudice or Anya Taylor-Joy’s big-screen portrayal of Emma may be the first to leap to mind.
But an exhibition opening in Bath celebrates the varied ways illustrators of Austen’s work and adapters of her novels have depicted some of her most cherished characters.
They include work by Hugh Thomson, who was tasked with providing 160 images for the first fully illustrated edition of Pride and Prejudice in the late 19th century.
There are sketches for Helen Jerome’s lively 1936 theatre version of Pride and Prejudice, credited with turning Darcy into a smouldering heart-throb that may have led to Firth and the famous sodden shirt scene.
Also featured are more restrained pieces by the wood engraver and illustrator Joan Hassall, who produced elegant illustrations for the Folio Society’s series of Austen novels in the 1950s and 1960s.
Pride and Prejudice frontispiece by Joan Hassall, wood engraving, 1957. Photograph: The Holburne Museum, Jo Hounsome Photography
The exhibition at the Holburn Museum coincides with the launch of the Jane Austen festival in Bath on Friday, a 10-day celebration that will be even more vibrant given that it is the 250th anniversary of the writer’s birth.
Austen lived in Bath between 1801 and 1806 – one of her addresses is just across the road from the Holburne – though another exhibition taking place on the other side of the city argues that, actually, she wasn’t very fond of the place.
Hannah N Mills, the exhibition’s curator, said brilliant illustrations have helped make Austen one of the UK’s most celebrated and long-lasting authors.
She said: “In our modern age it is the film and TV adaptations that influence our impressions of the characters. For Austen’s fans in the 19th and 20th centuries, it was the illustrations on the page. We wanted to look at how the illustrations married with the words.”
Mills said among the images she was particularly fond of is a 19th-century Thomson pen and ink drawing of a scene from Mansfield Park featuring Fanny Price and Edmund Bertram. “It’s just so beautiful and there’s such sentiment there.”
Thomson was an Irish artist who had made his name in the 1880s illustrating Mrs Gaskell’s Cranford. He went on to become one of the most popular and successful book illustrators of the Victorian era.
Mills is also keen on the woodcuts done by Hassall for the Folio Society’s editions. “They are iconic and constantly being reproduced. Early on there were a lot of male illustrators but as you move towards the 21st century it’s more female illustrators.”
She said she wanted to feature costume sketches for the Jerome play partly because it threw forward to the modern incarnations of Darcy, where he starts to become “portrayed as a heart-throb”.
Bringing the show almost bang up to date is the sketchbook Coralie Bickford-Smith used to create a modern iteration – Penguin’s “clothbound classic” version of Sense and Sensibility. “I love what Penguin are doing with Coralie Bickford-Smith, taking motifs from the books and making beautiful covers out of them. They are for the modern age but still harking back to the history.”
Shadow tankers’ transport of Russian oil rebounded in August, as G7+ tankers’ share dropped by 8 percentage points month-on-month
Russia’s monthly fossil fuel export revenues dropped for a third consecutive month in August, recording a 2% month-on-month decline to EUR 564 mn per day.
Revenues from coal exports increased by 7% month-on-month to the highest levels of the year.
Russian coal exports increased this month mainly because South Korea’s purchases went up, driven by higher electricity use in the country. South Korea’s imports of Russian coal rose 36% month-on-month to their highest levels ever.
In August 2025, the five largest EU importers of Russian fossil fuels — China, India, Turkiye, the EU, and South Korea — paid Russia a combined EUR 979 mn for fossil fuels.
In August 2025, just over half (53%) of Russian oil shipments were carried on G7+ tankers, an 8 percentage point decline from July — suggesting a renewed reliance on the ‘shadow’ fleet.
In August 2025, a quarter of the oil delivered by ‘shadow’ tankers was transported on tankers currently under sanctions. These sanctioned tankers carried 12% of Russian oil exports in August.
A lower price cap of USD 30 per barrel (still well above Russia’s production cost, which averages USD 15 per barrel) would have slashed Russia’s oil export revenue by 40% (EUR 153 bn) from the start of the EU sanctions in December 2022 until the end of August 2025. In August alone, a USD 30 per barrel price cap would have slashed Russian revenues by 38% (EUR 3.71 bn).
In August, Russia’s monthly fossil fuel export revenues saw a 2% month-on-month decline to EUR 564 mn per day — a third consecutive month in which Russia’s fossil fuel export revenues have dropped.
Seaborne crude oil revenues saw a sharp 12% month-on-month decrease to EUR 170 mn per day, whereas volumes dropped by 10%. Russian seaborne crude oil revenues have declined for the third consecutive month, reaching their lowest levels of 2025.
Revenues from crude oil via pipeline marginally increased by 2% month-on-month, to EUR 62 mn per day.
Liquefied natural gas (LNG) revenues increased by 4% to EUR 31 mn per day, corresponding to a 7% increase in exported volumes.
Pipeline gas revenues increased by 8% to EUR 75 mn per day, albeit volume increased by 10% month-on-month.
Revenues from exports of seaborne oil products saw a 2.5% month-on-month increase, reaching EUR 147 mn per day, while volumes marginally increased by 2% even in the face of Ukrainian drone strikes on Russian oil refineries.
Coal revenues rose by 7% month-on-month to EUR 76 mn per day, with exported volumes increasing by 6%. This month, coal export revenues reached their highest level of 2025.
Russia’s fossil fuel exports remain highly concentrated, with China dominating coal and crude oil purchases, Turkiye dominating purchases of oil products, and the EU still the largest buyer of LNG and pipeline gas — showing Moscow’s dependence on a narrow set of key customers.
Coal: From 5 December 2022 until the end of August 2025, China purchased 44% of all of Russia’s coal exports. India (20%), Turkiye (11%), South Korea (10%), and Taiwan (4%) round off the top five buyers list.
Crude oil: China has bought 47% of Russia’s crude exports, followed by India (38%), the EU (6%), and Turkiye (6%).
Oil products: Turkiye, the largest buyer, has purchased 26% of Russia’s oil product exports, followed by China (13%) and Brazil (12%) and Singapore (7%).
LNG: The EU was the largest buyer, purchasing 50% of Russia’s LNG exports, followed by China (21%) and Japan (18%).
Pipeline gas: The EU was the largest buyer, purchasing 35% of Russia’s pipeline gas, followed by China (30%) and Turkiye (28%).
In August 2025, China remained the largest global buyer of Russian fossil fuels, accounting for 40% (EUR 5.7 bn) of Russia’s export revenues from the top five importers. Crude oil made up the largest share of China’s purchases at 58% (EUR 3.1 bn), followed by coal at 15% (EUR 855 mn), pipeline gas at 12% (EUR 676 mn), and oil products at 10% (EUR 553 mn).
India remained the second-largest buyer of Russian fossil fuels, importing a total of EUR 3.6 bn. Crude oil dominated India’s purchases at 78% (EUR 2.9 bn), followed by coal at 14% (EUR 510 mn) and oil products at 8% (EUR 282 mn).
Turkiye was the third-largest importer of Russian fossil fuels, accounting for 21% (EUR 3 bn) of Russia’s export revenues from its top five buyers. Pipeline gas constituted the largest share of Turkiye’s imports at 39% (EUR 1.2 bn), followed by oil products at 34% (EUR 1 bn), crude oil at 20% (EUR 596 mn), and coal at 7% (EUR 225 mn).
The EU was the fourth-largest buyer of Russian fossil fuels, accounting for 8% (EUR 1.2 bn) of Russia’s export revenues from the top five importers. The majority of imports, 66% (EUR 773 mn), consisted of LNG and pipeline gas, followed by crude oil at 32% (EUR 379 mn).
South Korea became the fifth-largest importer of Russian fossil fuels. Coal dominated its imports at 73% (EUR 413 mn), followed by LNG at 21% (EUR 118 mn) and oil products at 6% (EUR 33 mn). Due to high temperatures and increased electricity consumption, South Korea’s coal imports saw a 19% month-on-month increase. Russian coal supplied to South Korea shot up in turn — recording a 36% month-on-month rise to their highest volumes ever — and constituted 30% of the total imports while also dominating other sources for the first time.
In August 2025, the five largest EU importers of Russian fossil fuels paid Russia a combined EUR 979 mn for fossil fuels. Natural gas — unsanctioned by the EU — accounted for more than 61% of these imports, delivered mainly by pipeline or as liquefied natural gas (LNG). The remainder was largely crude oil, which continues to flow to Hungary and Slovakia through the southern branch of the Druzhba pipeline under an EU exemption.
Hungary was the EU’s largest importer, purchasing EUR 416 mn worth of Russian fossil fuels. This included EUR 176 mn of crude oil and EUR 240 mn of pipeline gas.
Slovakia ranked second, with imports totaling EUR 276 mn. Crude oil delivered via the Druzhba pipeline made up 74% of the total (EUR 204 mn), while pipeline gas accounted for EUR 72 mn. The derogation allowing Slovak refineries to process Russian crude into oil products and re-export them to Czechia expired on 5 June.
France was the third-largest buyer, importing EUR 157 mn of Russian fossil fuels, all in the form of LNG. However, not all of this gas is consumed domestically — a study shows that some LNG entering through the Dunkerque terminal is subsequently delivered to Germany.
The Netherlands was the fourth biggest importer, importing EUR 65 mn of Russian LNG, while Belgium, in fifth place, purchased EUR 64 mn, also entirely in LNG.
In August 2025, the average price of Urals crude stood at USD 63.4 per barrel, down 2.3% from July.
The discount on Urals crude narrowed by 6% month-on-month, averaging USD 3.7 per barrel against Brent in August.
In August 2025, Russia exported 25 mn tonnes of oil by sea. Just over half (53%) of these shipments were carried on G7+ tankers, an 8 percentage point decline from July — suggesting a renewed reliance on the ‘shadow’ fleet.
G7+ tankers carried 36% of Russian crude oil exports in August, while the share of ‘shadow’ tankers rose by 11% month-on-month. Oil products, by contrast, remain less dependent on ‘shadow’ vessels, with G7+ tankers transporting 78% of shipments — a marginal increase compared to July.
In August 2025, a quarter of the oil delivered by ‘shadow’ tankers was carried on tankers currently under sanctions. These sanctioned tankers transported 12% of Russian oil exports in August.
In August 2025, 400 vessels exported Russian crude oil and oil products, of which 125 were ‘shadow’ tankers. Thirty-eight ‘shadow’ tankers were at least 20 years or older.
Older ‘shadow’ tankers transporting Russian oil and petroleum products across EU Member States’ exclusive economic zones, territorial waters, or maritime straits raise environmental and financial concerns due to their age, questionable maintenance records, and insurance coverage. Their insurance potentially lacks sufficient protection & indemnity (P&I) coverage to cover the cost in the event of an oil spill or other catastrophe. In the event of accidents, coastal countries may bear the financial burden of cleanup, as well as the repercussions of damage to their marine ecosystems.
The cost of cleanup and compensation resulting from an oil spill from tankers with dubious insurance could amount to over EUR 1 bn for coastal country’s taxpayers.
In August 2025, an estimated EUR 121 mn worth of Russian oil was transferred daily via ship-to-ship (STS) transfers in EU waters — a 9% decrease from the previous month. G7+ tankers conducted 94% of these transfers, while the rest involved ‘shadow’ vessels, which are often uninsured or registered under flags of convenience.
Russia’s fossil fuel export revenues have fallen since the sanctions were implemented, subsequently constricting Putin’s ability to fund the war. However, much more should be done to limit Russia’s export earnings and constrict the funding of the Kremlin’s war chest. This includes lowering the oil price cap, increasing monitoring and enforcement of sanctions, and banning unsanctioned fossil fuels such as LNG and pipeline fuels that are legally allowed into the EU.
Lowering the oil price cap
A lower price cap of USD 30 per barrel (still well above Russia’s production cost, which averages USD 15 per barrel) would have slashed Russia’s oil export revenue by 40% (EUR 153 bn) from the start of the EU sanctions in December 2022 until the end of August 2025. In August alone, a USD 30 per barrel price cap would have slashed Russian revenues by 38% (EUR 3.71 bn).
Lowering the price cap would be deflationary, reducing Russia’s oil export prices and inducing more production from Russia to make up for the drop in revenue.
Since introducing sanctions until the end of August 2025, thorough enforcement of the price cap would have cut Russia’s export revenues by 11% (EUR 40 bn). In August 2025 alone, full enforcement of the price cap would have reduced revenues by 6% (approximately EUR 0.68 bn).
Restrict the growth of ‘shadow’ tankers & tighten regulations targeting the refining loophole
Frequent sanctioning of Russian ‘shadow’ vessels has shifted Russian oil back to tankers owned or insured in G7+ countries. Nonetheless, Russian ‘shadow’ tankers still hold sway on the transport of Russian crude oil. In addition, many sanctioned vessels continue to deliver oil to ports globally, with EU and UK sanctions in particular, frequently violated. Sanctioning countries must align their vessel lists, and enforcement paradigms for a magnified effect on their operations.
Maritime coastal states should intensify efforts to monitor, inspect, and detain ‘shadow’ fleet vessels that lack legal passage rights, such as those unflagged, unlawfully idle, or posing security risks. Authorities must enforce and improve environmental and navigation laws within their territorial waters, investigating and boarding suspicious vessels when justified. Crews involved in criminal activity should face prosecution, with noncompliant ships and personnel subject to international arrest warrants.
In its 18th sanctions package, the EU has banned the imports of ‘oil refined from Russian crude’. The regulation bans imports from countries that are ‘net importers’ of crude oil. Net export status does not preclude the import and refining of Russian-origin crude, especially in jurisdictions with flexible or opaque crude sourcing practices. To close this enforcement gap, the exemption should be applied at the refinery level, not the national level. Refined petroleum products should be subject to import restrictions if produced at facilities that have processed Russian crude within the past six months, regardless of the final product’s declared origin or the host country’s net export position.
The current grace period provides Russia as well as traders buying oil refined using Russian crude with excessive time to adjust supply chains and maintain oil revenue. A shorter 60-day wind‑down period, focused on high‑risk refined products like diesel and jet fuel, would reduce Russia’s fiscal gains and limit circumvention opportunities. It would also give the EU sufficient time to secure alternative suppliers.
The exemption of countries including the UK, USA, Canada, Norway, and Switzerland creates an opportunity for oil products refined from Russian crude to be re-exported to the EU. This gap should be closed to ensure the sanctions are comprehensive and watertight.
Stronger enforcement & monitoring of the price cap
Despite clear evidence of violations, agencies must do more to enforce penalties against shippers, insurers, or vessel owners. This information must be shared widely in the public domain. Penalties against violating entities increase the perceived risk of being caught and serve as a deterrent.
Penalties for violating the price cap must be significantly harsher. Current penalties include a 90-day ban on vessels from securing maritime services after violating the price cap, a relatively minor sanction. If found guilty of violating sanctions, vessels should be fined and banned in perpetuity.
The G7+ countries should ban STS transfers of Russian oil in G7+ waters. STS transfers undertaken by old ‘shadow’ tankers with questionable maintenance records and insurance pose environmental and financial risks to coastal states and support Russia logistically in exporting high volumes of crude oil. Coastal states should require oil tankers suspected of being ‘shadow’ tankers transporting Russian oil through their territorial waters to provide documentation showing adequate maritime insurance. Upon failing to do so, having been identified as a ‘shadow’ tanker, they should be added to the OFAC, UK, and European sanctions list. This policy could limit Russia’s ability to transport its oil on ‘shadow’ tankers, which are not required to comply with the oil price cap policy.
To strengthen the integrity of maritime operations, it is imperative that the International Maritime Organization (IMO) revises its guidelines to enhance transparency regarding maritime insurance. The IMO should mandate that flag states require shipowners and insurers to publicly disclose key financial information, including insurer solvency data, credit ratings from recognized agencies, and audited financial statements. Maritime authorities of coastal states should be legally able and encouraged to detain tankers that fly false flags which therefore pose environmental and security threats.
Relevant reports:
Note on methodology:
This monthly report uses CREA’s fossil shipment tracker methodology.
The data used for this monthly report is taken as a snapshot at the end of each month. The data provider revises and verifies data on trades and oil shipments throughout the month. We subsequently update this verified data each month to ensure accuracy. This might mean that figures for the previous month change in our updated subsequent monthly reports. For consistency, we do not amend the previous month’s report; instead, we treat the latest one as the most accurate data for revenues and volumes.
Russia’s daily revenues for commodities used in this report are derived as an average, using CREA’s pricing methodology.
CREA’s estimates of the impact of a revised and lowered price cap have been updated since February 2025. These numbers are a more accurate representation of the revenue losses Russia would incur. Our earlier numbers severely underestimated the impact of a lower price cap due to a bug that we identified that mislabelled commodities in our model.
NASP (previously known as SEL-212) – clinical program overview and uncontrolled gout disease landscape.
Investors, analysts, and members of the media are invited to a conference call on Tuesday, 16 September, at 16:30 CEST, 15:30 BST, and 10:30 EDT. The call will present insights from management and Dr. Herbert Baraf on the NASP program, following the US FDA acceptance of the filing submission of NASP for the potential treatment of uncontrolled gout.
The presentation can be followed live here or afterwards on sobi.com. The slides will be made available on sobi.com before the conference call.
To participate in the conference call, please use the following dial-in details:
Sweden: +46 8 5051 0031
United Kingdom: +44 207 107 06 13
United States: +1 631 570 56 13
For other countries, please find the detailshere.
Sobi®
Sobi is a global biopharma company unlocking the potential of breakthrough innovations, transforming everyday life for people living with rare diseases. Sobi has approximately 1,900 employees across Europe, North America, the Middle East, Asia and Australia. In 2024, revenue amounted to SEK 26 billion. Sobi’s share (STO:SOBI) is listed on Nasdaq Stockholm. More about Sobi at sobi.com and LinkedIn.
Contacts
For details on how to contact the Sobi Investor Relations Team, please click here. For Sobi Media contacts, click here.
Amongst 592 models developed from 143 articles, including 140,767 HNC patients, only 49 (8%) models from six articles were judged to have low ROB and low concerns for applicability. No external validation was performed for 480 models (81%). For the remaining 112 models and six additional models which were not eligible for the present review, 152 external validations were performed in 34,304 patients with HNC in 41 articles. The results of models externally validated at least twice are discussed below.
Models for xerostomia
Amongst 275 models for xerostomia, two models were externally validated at least twice.
The Beetz 2012b model for xerostomia six months after radiotherapy was validated in two studies. C-statistics ranged from 0.70 to 0.74. Calibration performance was reported in one study. One validation study was rated as having low ROB in all domains, while the other was rated as having high ROB in the analysis domain.
The Cavallo 2021 model for acute xerostomia during radiotherapy for patients with nasopharyngeal cancer was externally validated in the same study, using two different types of cohorts. C-statistics ranged from 0.68 to 0.73 and calibration plots were reported in both cohorts. Both validations were rated as having unclear ROB in the participants’ domain because no detailed information about recruiting was provided.
Models for dysphagia
Amongst 86 models for dysphagia, two models were externally validated at least twice.
The Christianen 2012 model for dysphagia six months after radiotherapy was validated in five studies. C-statistics ranged from 0.66 to 0.75. Calibration performance was assessed in all of them, while four of them were rated as having high ROB in the analysis domain due to the small sample size.
The Wopken 2014b model for tube feeding dependence six months after radiotherapy was validated in three external validation studies. C-statistics ranged from 0.79 to 0.95, while calibration was evaluated in all studies. Due to the small size of the validation datasets, they were judged as having high ROB in the analysis domain.
Models for hypothyroidism
Of 66 models for hypothyroidism, two models were externally validated at least twice. In addition, there was another model which was not originally developed for patients with HNC, but validated in this domain.
The Boomsma 2012 for hypothyroidism within two years after radiotherapy was externally validated in two studies. C-statistics ranged from 0.64 to 0.74, while only one study reported its calibration performance. Both validation studies were rated as having high ROB in the analysis domain.
The Ronjom 2013 model for radiation-induced hypothyroidism was validated in three studies. C-statistics ranged from 0.65 to 0.69 and calibration plots were reported in only one study. Two validation studies were judged as having high and the other was rated as having unclear ROB in the analysis domain.
The Cella 2012 model was originally developed to predict radiation-induced hypothyroidism in patients with Hodgkin’s lymphoma. In two validation studies in patients with HNC, c-statistics ranged from 0.65 to 0.68, but calibration performance was not reported. One validation study was rated as having a high ROB and the other was rated as being unclear in the analysis domain.
Models for temporal lobe injury
Amongst six models for temporal lobe injury, two were externally validated at least twice.
The OuYang 2023 model, using deep learning in patients with nasopharyngeal cancer, was validated in the same paper using two different cohorts. C-statistics ranged from 0.80 to 0.82, while calibration performance was assessed in both cohorts. Both validations were judged as having low ROB in all domains.
The Wen 2021 model was developed to predict temporal lobe injury in newly diagnosed nasopharyngeal cancer patients. The model was validated by OuYang 2023 using two cohorts. C-statistics ranged from 0.77 to 0.79, while calibration performance was not reported. Both validations were judged as having unclear ROB in the analysis domain.
Models for outcomes related to hoarseness, fatigue, nausea-vomiting, throat pain, aspiration
No models were externally validated at least twice.
We included 40 studies that described models for T1DM care in 19 LMICs across the different WHO regions.
African Region
We identified models of care in Cameroon, Kenya, Rwanda, Tanzania, and Uganda, largely supported by international initiatives like Changing Diabetes in Children (CDiC) and Life for a Child (LFAC). Models were implemented between 2004 and 2012, and aimed to enhance infrastructure and care delivery, including access to insulin, glucose monitoring supplies, and diabetes education for patients and caregivers. Multidisciplinary teams provided care across urban and rural settings, with some countries offering tele-support and diabetes camps. Financial and logistical barriers persisted despite governmental and humanitarian support.
Region of the Americas
We identified models of care in Brazil and Cuba, focusing on reducing complications, training human resources, and supporting psychosocial development. In Brazil, care was delivered at a secondary-level facility by a multidisciplinary team. In Cuba, care was provided by a tertiary-level childhood diabetes clinic. Both models emphasised diabetes education for patients and families, regular specialist consultations, and community awareness initiatives. Unique features included holiday camps in Cuba and internship programs for healthcare professionals in Brazil. Diabetes care in Brazil was free, with additional resources for those in need.
South-East Asia Region
We identified models of care in Bangladesh, India, Myanmar, Sri Lanka, and Thailand, with implementation between 2009 and 2015. These models aimed to improve access to care, self-management education, and awareness amongst healthcare workers and communities, particularly for children below the poverty line. Supported by initiatives such as CDiC, LFAC, and Action4Diabetes (A4D), the models delivered outpatient care through multidisciplinary teams, providing free insulin and supplies in most countries. Regular HbA1c monitoring, diabetes education, and psychological support were key components, along with community awareness initiatives in four countries. Financial barriers remained significant, particularly in Bangladesh and Thailand.
European Region
We identified models of care in Kazakhstan and Turkey, aiming to provide comprehensive diabetes care and improve patient well-being. In Kazakhstan, care included free insulin, glucose meters and test strips, and a monitoring system for hypoglycaemia and diabetic ketoacidosis was in place. Turkey’s National Childhood Diabetes Program, initiated from 1994 onwards, delivered care through multidisciplinary healthcare teams and included initiatives like the Diabetes at School Program to raise awareness. Financial barriers persisted in both countries concerning certain supplies and technologies.
Eastern Mediterranean Region
We identified a model of care in Morocco, implemented in 1986, that had expanded from a single tertiary-level facility to nine provincial secondary-level hospitals, covering a third of the country’s young patients with T1DM. Care was delivered by multidisciplinary teams and included initial in-hospital treatment, followed by outpatient consultations every three months. Education in self-management was emphasised, with group sessions, holiday camps, and tailored resources for illiterate parents. A database system supported electronic data monitoring. Financial support was provided for low-income families through sponsors and associations, although insurance coverage was limited to insulin costs.
Western Pacific Region
We identified models of care for Cambodia, Malaysia, Vietnam, and Laos, supported by the A4D program. T1DM care included free insulin, glucose meters, HbA1c testing, and emergency funds, with care delivered through tertiary and secondary-level facilities, except in Vietnam where a single tertiary-level clinic provided care. Multidisciplinary teams were present in Cambodia, Malaysia, and Vietnam, but not in Laos. Screening for diabetes complications varied, with the most comprehensive screening offered in Cambodia and Laos. Ongoing diabetes training for healthcare workers, and electronic patient databases were integral to the model of care. Financial barriers persisted in Laos, where certain screening assessments required out-of-pocket payment.
India’s PV Sindhu faltered in the opening round of the women’s singles event once again as she exited the Hong Kong Open 2025 badminton tournament on Wednesday.
Competing at the Hong Kong Coliseum, two-time Olympic medallist PV Sindhu, 14th in the women’s singles badminton rankings, won the opening game but lost the match 15-21, 21-16, 21-19 against world No. 27 Line Christophersen of Denmark.
This was Sindhu’s first defeat in six meetings against European Championships silver medallist Line Christophersen and her sixth first-round exit on the BWF World Tour this year.
Anupama Upadhyaya was also ousted from the women’s singles after a 21-17, 20-22, 21-14 loss against fourth seed Tomoka Miyazaki of Japan.
In the men’s section, India’s top-ranked singles player Lakshya Sen progressed to the second round after a hard-fought win over Olympian Wang Tzu-wei of Chinese Taipei.
A Paris 2024 semi-finalist, Lakshya Sen held his nerve to win the opening game in a tie-break before losing the second.
However, the Indian badminton player regrouped to open up a healthy lead en route to clinching the deciding game and winning the match 22-20, 16-21, 21-15 in an hour and 13 minutes.
Lakshya Sen’s compatriots in the men’s singles draw, HS Prannoy and Kiran George also advanced to the second round after straight-game victories.
While world No. 34 HS Prannoy stunned 14th-ranked Lu Guangzu of the People’s Republic of China, Kiran George got the better of Singapore’s Jason Teh. HS Prannoy will meet countryman Lakshya Sen in the next round.
Ayush Shetty, who is the only Indian to win a BWF Tour title this year at the US Open in June, rallied from a game down to progress to the next round with a 15-21, 21-19, 21-13 win over Chinese Taipei’s Su Li-yang.
India’s sole entry in the women’s doubles, Rutaparna Panda and Swetaparna Panda. kept their campaign alive with a 21-17, 21-9 win against local favourites Oi Ki Vanessa Pang and Sum Yau Wong.
Meanwhile, Dhruv Kapila/Tanisha Crasto were ousted in the first round of the mixed doubles after a 21-16, 21-11 defeat to Chinese Taipei’s Chen Cheng Kuan/Hsu Yin-Hui.
Hong Kong Open 2025 badminton: Day 2 India results
Men’s singles
Lakshya Sen bt Wang Tzu-wei (TPE) 22-20, 16-21, 21-15
HS Prannoy bt Lu Guangzu (CHN) 21-17, 21-14
Kiran George bt Jason Teh (SGP) 21-16, 21-11
Ayush Shetty bt Su Li-yang (TPE) 15-21, 21-19, 21-13
Women’s singles
PV Sindu lost to Line Christophersen (DEN) 15-21, 21-16, 21-19
Anupama Upadhyaya lost to Tomoka Miyazaki (JPN) 21-17, 20-22, 21-14
Rakshitha Ramraj lost to Ratchanok Intanon (THA) 21-13, 21-7
Women’s doubles
Rutaparna Panda/Swetaparna bt Oi Ki Vanessa Pang/Sum Yau Wong (HKG) 21-17, 21-9
Mixed doubles
Dhruv Kapila/Tanisha Crasto lost to Chen Cheng Kuan/Hsu Yin-Hui (TPE) 21-16, 21-11
Rohan Kapoor-Ruthvika Gadde lost to Feng Yan Zhe/Huang Dongping (CHN) 21-14, 21-17
Lloyd’s Register (LR) has awarded Approval in Principle (AiP) to HD Hyundai Heavy Industries (HHI) for its next-generation LNG carrier design featuring a forward accommodation layout and integrated Wind Challenger, wind-assisted propulsion system (WAPS) developed by Mitsui O.S.K. Lines, Ltd. (MOL).
Developed in collaboration with MOL and the Republic of the Marshall Islands Maritime Administrator, the new design relocates the accommodation and bridge block from its conventional aft position to the bow. This fore-deckhouse configuration offers the opportunity for reduced aerodynamic drag, improved propulsion efficiency and potential lower fuel consumption.
The forward accommodation layout provides a clear and unobstructed open deck space above cargo area, allowing for optimal placement and increasing number of WAPS technologies such as MOL’s Wind Challenger. This open deck space provides flexibility to accommodate varying sail numbers, types and spacing.
The design also supports future integration of alternative fuel modules, and battery storage, making it adaptable to evolving fuels, regulations and owner requirements.
The AiP follows LR’s extensive technical evaluation of the concept’s safety, feasibility and regulatory compliance. This included a full review of applicable IMO requirements, class rules and industry guidelines, supported by structured risk assessments including HAZID.
Panos Mitrou, LR’s Global Gas Segment Director, said: “This AiP reflects LR’s commitment to enabling the safe deployment of innovative technologies that support the maritime industry’s transition to net zero. By working closely with our project partners, we help demonstrate the technical feasibility and commercial value of forward-thinking vessel design.”
Hong-Ryeul Ryu, CTO of HD Hyundai Heavy Industries, stated: “This AiP highlights HHI’s pioneering forward accommodation LNG carrier design, underscoring our unwavering commitment to sustainability and readiness to embrace advanced decarbonization technologies, including WAPS.”
Yoshihiko Sugimoto, Deputy Chief Technical Officer of MOL, said: “With the valued collaboration of Lloyd’s Register and the Republic of the Marshall Islands, we are delighted to receive this AiP for HHI’s next-generation LNG carrier design featuring MOL’s Wind Challenger technology. This milestone highlights our unwavering commitment to leading the decarbonisation of the maritime industry and accelerating progress toward our medium- to long-term target of achieving net zero GHG emissions by 2050.”
David Wamsley, Deputy Commissioner of Maritime Affairs, Republic of the Marshall Islands Maritime Administrator, said:“This AiP for a next-generation vessel is a great example of what can be achieved when industry leaders align. By proactively integrating the latest innovations with the clear regulatory direction for decarbonization, stakeholders are not just designing a ship they are creating a sustainable and profitable future for maritime transport. This partnership allows us to pool our expertise, mitigate risks, and accelerate the development of solutions that would be impossible to achieve alone.”
1Children’s Healthcare and Mental Health Center, Shenzhen Children’s Hospital, Shenzhen, Guangdong, People’s Republic of China; 2Children’s Healthcare and Mental Health Center, Affiliated Shenzhen Children’s Hospital of Shantou University Medical College, Shenzhen, Guangdong, People’s Republic of China; 3NHC Key Laboratory of Mental Health (Peking University), Peking University Sixth Hospital, Institute of Mental Health, Beijing, People’s Republic of China
Correspondence: Binrang Yang, Children’s Healthcare and Mental Health Center, Shenzhen Children’s Hospital, Shenzhen, Guangdong, People’s Republic of China, Tel +86 18938691619, Email [email protected]
Background: Emotional lability (EL), characterized by excessive emotional fluctuations and intense outbursts, frequently co-occurs with attention deficit hyperactivity disorder (ADHD) and may exacerbate functional impairments. This study aimed to explore the disparities in ADHD-related symptoms and functional impairments in children with ADHD who exhibited EL and those without it and to examine the unique contribution of EL to functional impairments. Methods: A total of 427 children with ADHD, aged 6– 14 years, were recruited from Shenzhen Children’s Hospital. EL was assessed using the Conners’Parent Rating Scale, while ADHD-related symptoms were measured using the ADHD Rating Scale (ADHD-RS) and Child Behavior Checklist (CBCL). Functional impairment was assessed using the Weiss Functional Impairment Scale-Parent Form (WFIRS-P). Group comparisons were conducted between ADHD with EL and ADHD without EL, and correlations and multiple linear regressions were performed to explore the associations between EL, ADHD-related symptoms, and functional impairment. Results: EL prevalence in the study sample was 33.96%. Children with ADHD and EL exhibited significantly higher scores for inattention (P< 0.001), hyperactivity/impulsivity (P< 0.001), CBCL factors (P< 0.001), and all domains of functional impairment (P< 0.05) than those without EL. The two groups differed substantially in their distribution of ADHD subtypes (P=0.012). Moderate correlations were found between EL and functional impairment (r=0.40– 0.45, P< 0.001). After adjusting for ADHD-related symptoms, EL independently predicted impairments in family (P=0.001), life skills (P=0.001), self-concept domains (P=0.001), and total functional impairment (P=0.002). EL, along with attention scores, social problems, and delinquent behaviors, significantly predicted the overall functional impairment. Conclusion: EL is a significant contributor to functional impairment in children with ADHD, exerting its influence independently of the core symptoms of ADHD. Our findings highlight the need for targeted interventions to address emotional regulation in ADHD and mitigate long-term functional impairments.
Attention deficit/hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder with core symptoms of inattention, hyperactivity, and impulsivity.1 It affects approximately 5.29% of school-age children globally.2 Despite the tendency for these core symptoms to improve as children age,3 ADHD often co-occurs with other psychiatric disorders, such as conduct disorder, pervasive developmental disorder, oppositional-defiant disorder,4 depression and anxiety disorder,5,6 which significantly disrupt a child’s academic progress, family harmony, and social integration.7–9 As a result, children with ADHD are at a high risk of long-term and far-reaching impairments across multiple aspects of their daily lives.
Emotional lability (EL) generally describes exaggerated emotional responses that are disproportionate to the situation, abrupt and unpredictable shifts in mood, and heightened sensitivity to emotional stimuli.10 EL has also been referred to as mood instability, affective lability, emotional impulsiveness, emotional dysregulation (ED), or deficient emotional self-regulation (DESR).11–13 EL is characterized by excessive and rapidly shifting emotions and is often associated with an inappropriately high intensity.13–15 In addition to the core symptoms of inattention, hyperactivity, and impulsivity, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists EL symptoms separately as associated features of ADHD,1 although it is not part of the diagnostic criteria. The neurobiological mechanisms underlying EL in ADHD remain incompletely understood. Two distinct hypotheses have emerged to explain the neurobiological foundations of EL in ADHD: (1) Dyscontrol hypothesis: Posits that EL arises from impaired executive function, particularly deficits in prefrontal cortical regulation of subcortical limbic structures like the amygdala. This model emphasizes top-down regulatory failures that lead to exaggerated emotional responses. (2) Affectivity hypothesis: EL stems from primary abnormalities in emotional processing within the limbic system itself rather than secondary to executive dysfunction. This framework highlights the bottom-up hyper-reactivity of the amygdala to emotional stimuli.13,16,17
EL is common among individuals with ADHD, and a comprehensive review concluded that the prevalence of EL in youth with ADHD ranges from 24% to 50%.18 However, the clinical characteristics of patients with ADHD and EL, and the differences between those with and without EL are not fully understood. Children with ADHD typically experience functional impairments in various aspects of daily life, extending beyond core symptoms, and a paucity of studies have demonstrated an association between EL and functional impairment in ADHD.18,19 However, previous studies have mainly focused on the impact of EL on the social functioning of children with ADHD,20–22 neglecting critical domains such as family functioning and adaptive skills; thus, there is an urgent need for more in-depth research to clarify the relationship between EL and other subdomains of functional impairment, such as family relationships, school performance, and life skills, in children with ADHD.
In this study, we set out to achieve two main aims. First, we aimed to compare the severity and functional impairment between children with comorbid ADHD and EL and those with ADHD-only. Second, we sought to examine whether EL independently predicts functional impairment after controlling for core ADHD symptoms and hypothesized that children with ADHD and EL would exhibit more severe symptomatology across behavioral and emotional domains and that EL would have a significant impact on all subdomains of functional impairments in children with ADHD.
Methods
Participants
Children with ADHD were recruited from the Children’s Health Care and Mental Health Center at Shenzhen Children’s Hospital. The sample size was determined through an a-priori power analysis using G*Power 3.1. Based on a previous study showing a moderate effect size (d* = 0.61) in functional impairment (WFIRS-P) between ADHD with and without EL,23 with α = 0.05 and 1-β = 0.90, the analysis indicated a minimum requirement of 116 participants. Accounting for 20% potential attrition, we planned to recruit 145 participants. During recruitment, we expanded the sample size to enhance generalizability. Figure 1 summarizes the recruitment and screening workflow. Clinicians diagnosed ADHD based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children’s Present and Lifetime versions (K-SADS-PL). The diagnosis process was conducted through a semi-structured clinical interview. Eligible children with ADHD were between 6 and 18 years old, with a full-scale IQ of 70 or above, as measured by the Wechsler Intelligence Scale for Chinese Children-IV (WISC-IV). Children were excluded if they met any of the following criteria: having any severe physical illness or neurological irregularities (eg, seizures, brain injury); use of any prescribed medications for ADHD or other medical conditions. A total of 427 samples were included in the analysis for this study, and the project was approved by the Ethics Committee of Shenzhen Children’s Hospital. The study was conducted in accordance with the Declaration of Helsinki and complied with the ethical standards of the institutional and/or national research committee for all procedures involving human participants. Written informed consent was obtained from both parents and children.
Figure 1 Flowchart of participant recruitment and enrollment for the study.
Evaluation of Emotional Lability (EL)
EL was assessed using Conners’ Parents Rating Scale (CPRS). The EL construct was composed of the following items in the CPRS: (a) cries often and easily, (b) has temper outbursts, (c) experiences mood changes quickly and drastically, and (d) gets easily frustrated in effort. The items were rated directly on a 4-point Likert-type scale (0 = never, 1 = sometimes, 2 = often, and 3 = always) by their parents. The EL score was calculated by summing the scores for these four items. A score of 6 or above was used to identify EL cases.24
Evaluation of ADHD Related Symptoms
The core symptoms and severity of ADHD were measured using the ADHD Rating Scale (ADHD-RS), which consists of 18 items and adopts a 4-point Likert scale. The total scores range from 0 to 54, with higher scores indicating more severe ADHD symptoms, comprising two symptom subscales: inattention and hyperactivity-impulsivity (Cronbach’s α=0.746).25 Child Behavior Checklist (CBCL) was utilized to assess behavior outcomes of children with ADHD. This is a 113-item parent-report measure of behavioral problems in children and adolescents aged 4–16 years. Items are rated on a 3-point Likert-type scale (0 = “Behavior absent”, 1 = “Behavior presents sometimes”, 2 = “Behavior presents frequently”). It measures children and adolescents’ emotional, behavioral, and social problems and consists of eight syndrome scales: withdrawal, somatic complaints, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior (Cronbach’s α=0.797).26
Evaluation of Functional Impairment
Functional impairment was evaluated using Chinese version of Weiss Functional Impairment Scale-Parent form (WFIRS-P).27 This scale provides a comprehensive evaluation of functional impairment across various aspects of daily life. The scale consisted of six dimensions: family (10 items), learning and school (10 items), life skills (10 items), self-concept (3 items), social activities (7 items), and risk-taking activities (10 items), with a total of 50 items. Each item is rated on a scale from 0 (never) to 3 (always). The average score for each domain is calculated by summing the scores of all rated items within that domain and dividing by the number of valid items (excluding items rated as “not applicable”). A domain average score of ≥ 1.5 indicates the presence of clinically significant functional impairment. The WFIRS-P demonstrated good reliability (Cronbach’s α=0.768).
Statistical Analyses
Statistical analyses were performed using SPSS version 24.0. Participants were stratified according to their EL status (CPRS score ≥6). Categorical variables were described by reporting frequencies and percentages, and differences among groups were assessed using the chi-square test. Continuous variables were presented as mean and standard deviation, and differences among groups were analyzed using Two Independent samples T test (normally distributed continuous variables) or Mann–Whitney U-tests (non-normal distributions) for symptom severity and functional impairment (reported as mean±SD). Pearson correlations were used to examine bivariate associations between EL, ADHD-related symptoms (ADHD-RS and CBCL), and functional impairment (WFIRS-P). Hierarchical linear regression models quantified EL’s unique contribution to impairment domains after controlling for ADHD core symptoms. Separate regressions were run for each impairment domain. A two-tailed hypothesis test was used for all statistical analysis and p<0.05 was set as the level of statistical significance.
Results
Participants’ Characteristics
A total of 427 participants aged 6–14 years were included in the study. The majority of the sample were male (358 individuals, 83.8%). Among the participants, 186 (43.6%) were diagnosed with the predominantly inattentive subtype of ADHD (ADHD-I), and 223 subjects (52.2%) were identified as having a combined subtype of ADHD (ADHD-C). A relatively small number, 18 subjects (4.22%) belonged to the predominantly hyperactive-impulsive subtype of ADHD (ADHD-HI). Notably, 145 participants were classified as having ADHD with EL, accounting for 33.96% of the cohort.
Group Differences in Clinical Characteristics and Functional Impairment
As presented in Table 1, no significant differences were found in sex or age between the ADHD with EL and ADHD without EL groups (all P>0.05). However, the groups differed significantly in the ADHD subtype distribution (P=0.012). Specifically, the ADHD with EL group showed significantly higher scores than the ADHD without EL group in inattention, hyperactivity/impulsivity, and all CBCL factors (all P < 0.001). Furthermore, across all functional impairment domains—family, school, life skills, self-concept, social activities, and risky activities—as well as the total score, the ADHD with EL group demonstrated markedly elevated scores relative to the ADHD without EL group (all P<0.05).
Table 1 Clinical Characteristics and Functional Impairment in ADHD with and without EL
Correlation Among Functional Impairment, EL and Symptoms of ADHD
Positive correlations were observed across all domains and total functional impairment scores with EL and ADHD-related symptoms (Table 2). Moderate correlations were found between the total score of functional impairment and EL, inattention scores, social problems, attention problems, delinquent behaviors and aggressive behaviors, with the correlation(r) ranging from 0.40 to 0.45 (all P<0.001). After adjusting for ADHD-related symptoms, EL independently demonstrated positive and significant associations with the scores on the family domain (P=0.001)), life-skill domain (P=0.001), self-concept domain (P=0.001), and total score (P=0.002), as shown in Table 3. On average, a 1-point increase in EL score was associated with a 0.75-point increase in total functional impairment score (95% CI, 0.26–1.23). EL, attention scores, social problems, and delinquent behaviors emerged as significant predictors of overall functional impairment with a relatively high coefficient of determination (R2) of 0.41.
Table 2 Pearson Correlations Between Functional Impairment, EL and ADHD Symptoms
Table 3 Summary of Multiple Linear Regression Results of EL, ADHD-Related Symptoms on Functional Impairments
Discussion
Principal Findings
This study investigated the demographic and clinical characteristics of children with ADHD, focusing on the functional impairment differences between ADHD groups with and without EL. Additionally, it explored the associations among functional impairment, EL, and ADHD symptoms, and found that EL was prevalent among participants with ADHD and exhibited significant differences in ADHD subtype distribution. Compared to children with ADHD alone, those with EL displayed greater severity in ADHD-related symptoms and functional impairment. After adjusting for ADHD-related symptoms, EL remained independently and positively associated with multiple subdomains and the total score of functional impairment. This suggested that EL exerts a unique influence on functional impairment, extending beyond the influence of ADHD symptoms alone.
Epidemiology of EL in ADHD
Our study found that the prevalence of EL was 33.96% among participants with ADHD. This finding is consistent with previous research, although the reported prevalence rates vary.13,18,28,29 For instance, one study defined EL as a T-score ≥ 65 on emotional lability items of the parent completed Conners’ Rating Scale-Revised (CRS-R) and reported a prevalence of 46.92% in children with ADHD, compared with 15.38% of their non-ADHD siblings.19 Similarly, two other studies used parent-rated items from the CBCL anxious-depressed, attention, and aggression scales to assess EL, which was defined as positive if a subject’s sum of attention, aggression, and anxious/depressed CBCL scales was > 180 (> 60 on average on each scale) but <210 (average t-score of > 60 < 70 on each scale). They found that 40.4–44.0% of children with ADHD exhibited EL, while only 2–3.5% of controls did.30,31 Turkia et al defined severe EL as a child with an aggregated cut-off score of >210 on the attention, aggression, and anxious/depressed CBCL, and found that 63% of children with ADHD had a severe EL.28 These discrepancies may have arisen from differences in assessment tools and sample characteristics; although the prevalence of EL in our study was slightly lower than in some previous studies, the results collectively underscore the high prevalence of EL in individuals with ADHD.
In this study, the ADHD with EL group exhibited a lower proportion of the ADHD-I subtype (33.79%) than did the ADHD without EL group (48.58%), whereas the ADHD-C subtype was more prevalent in the ADHD with EL group (62.07% vs 47.17%). These findings challenge the traditional view of ADHD subtypes as being independent of emotional factors.1 Previous research demonstrated that EL was more strongly associated with hyperactive-impulsive than with inattentive symptoms.14,15,29,32 Hyperactivity-impulsivity symptoms may lead to more frequent emotional fluctuations and difficulties in self-regulation, thereby increasing the likelihood of EL. In contrast, individuals with ADHD-I may exhibit more internalizing symptoms such as inattention and daydreaming, which may have less direct impact on emotional expression. Traditionally, ADHD subtypes (ADHD-I, ADHD-HI, ADHD-C) are mainly classified based on behavioral symptoms, and emotional factors (such as EL) are not included in the classification criteria.1 However, our findings indicate that EL may be closely related to specific subtypes (eg, ADHD-C), highlighting the potential significance of emotional factors in ADHD subtype classification.
Impact of EL on Functional Impairment in Children with ADHD
Our findings showed that the ADHD with EL group scored significantly higher on inattention, hyperactivity/impulsivity, and all factors of the CBCL compared to ADHD without EL group. This aligns with the hypothesis that EL exacerbates ADHD symptoms and is consistent with prior studies,15,29,32 indicating that EL may exacerbate the core symptoms of ADHD and additional emotional and behavioral difficulties. The worsening of inattention and hyperactivity/impulsivity symptoms may be due to EL interfering with patients’ self-regulation abilities, making it more difficult for them to control their behavior and attention. Moreover, the higher scores on all CBCL factors in the ADHD with EL group further indicated that EL can trigger or intensify broader emotional and behavioral challenges in patients, which include increased internalizing (eg, anxiety, depression) and externalizing (eg, aggression, rule-breaking) problems. While our findings suggest that EL may exacerbate ADHD symptoms, an equally plausible interpretation is that core ADHD symptoms-particularly hyperactivity-impulsivity (HI) may directly contribute to EL.33 This aligns with evidence that HI disrupts prefrontal-amygdala connectivity, impairing emotion regulation.34,35 However, as our study is cross-sectional, causal inferences remain tentative. Future longitudinal or experimental designs are needed to disentangle this relationship. This bidirectional possibility warrants further longitudinal investigation. In terms of functional impairment, the ADHD with EL group scored higher in various domains, including family, school, life skills, self-concept, social activities, risky activities, and overall total scores. This clearly demonstrates that EL has a more extensive and severe effect on daily functioning in patients with ADHD. These findings are consistent with the notion that EL in ADHD is a marker for greater overall impairment.18,20,36 Recent studies have highlighted that EL exacerbates functional deficits across multiple domains, including family, school, social activities, and risk-taking behaviors.11,37 The pervasive nature of these difficulties underscores the importance of addressing EL in ADHD interventions,38 as it may contribute to more severe symptomatology and poorer functional outcomes.
The findings of the study reveal significant positive correlations between EL and all domains of functional impairment, and moderate correlations were identified between the total score of functional impairment and EL, inattention scores, social problems, attention problems, delinquent behaviors, and aggressive behaviors. The consistent associations between EL and various domains of functional impairment highlight the pervasive impact of EL on daily functioning in individuals with ADHD. Notably, even after adjusting for ADHD-related symptoms, EL independently demonstrated significant positive relationships with functional impairment in the family domain, life-skills domain, self-concept domain, and the total score. This finding underscores the unique contribution of EL to functional impairment beyond the effects of core ADHD symptoms. Previous studies have similarly highlighted the role of EL in ADHD, noting its association with poorer outcomes in the academic, social, and family domains.11,18,36 For instance, EL may lead to heightened interpersonal conflict, reduced ability to cope with stress, and difficulties in maintaining consistent performance on daily tasks. These findings align with our results, particularly the strong association between EL and family functioning, which may reflect the disruptive impact of emotional outbursts or mood instability on family dynamics.21,39,40 Furthermore, the observed link between EL and life skills deficits likely reflects shared reliance on executive functions. Elevated EL may overwhelm cognitive resources (eg, working memory, inhibitory control), impairing planning and self-care.41 Alternatively, executive dysfunction in ADHD could predispose individuals to both EL (via poor emotion regulation) and life skills deficits.42 Therefore, the inclusion of EL in predictive models of functional impairment could enhance the identification of individuals at risk of severe outcomes and inform the development of targeted interventions. For example, interventions that focus on improving emotion regulation skills, such as mindfulness-based therapies or cognitive-behavioral strategies, may help mitigate the negative impact of EL on daily functioning.43–45
Limitations
This study has some limitations. First, the cross-sectional design restricts its ability to establish causal relationships. Future longitudinal studies are needed to determine whether EL directly contributes to the development or exacerbation of functional impairment in patients with ADHD. Second, the sample was mainly from a specific region, which may limit the generalizability of the results. Broader sampling from different geographical areas and cultural backgrounds enhanced the external validity of the findings. Third, the lack of a non-ADHD control group precludes conclusions about whether the observed EL levels are ADHD-specific or reflect general variability. Future studies should include non-ADHD controls to establish normative benchmarks for EL and symptom levels. This would help distinguish disorder-specific effects from general individual differences.
Conclusions
This study emphasizes the need to assess EL, and highlights EL as a clinically significant correlation of multidimensional impairment in ADHD. Interventions targeting emotion regulation, such as cognitive-behavioral therapy (CBT) or emotion-focused strategies, may be particularly beneficial for this population.46 Future research should explore the mechanisms underlying the relationship between EL and functional impairment as well as the long-term effects of interventions targeting EL in ADHD.
The data are available under reasonable request to the corresponding author.
Ethics Approval
This study was approved by the Ethics Committee of Shenzhen Children’s Hospital (201701805) and written informed consent was obtained from all participants and legal guardians.
Consent to Participate
Informed consent was obtained from all participants or their legal guardians before filling the questions in the survey was completed. Participants were informed that their personal information was not identified or collected, and that all data were anonymous.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Funding
This study was supported by the Shenzhen Science and Technology Program (Grant No. RCYX20221008092849069; JCYJ20220818102800001), the National Natural Science Foundation of China (82101613 to Zhao-Min Wu), and the Guangdong High-Level Hospital Construction Fund.
Disclosure
The authors declare that they have no conflicts of interest in this work.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
2. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiat Allied Discipline. 2015;56(3):345–365. PubMed PMID: 25649325. doi:10.1111/jcpp.12381
3. Johns-Mead R, Vijayakumar N, Mulraney M, et al. Categorical and dimensional approaches to the developmental relationship between ADHD and irritability. J Child Psychol Psychiat Allied Discipline. 2023;64(10):1422–1431. PubMed PMID: 37170636. doi:10.1111/jcpp.13818
4. Patil M, Konda S, Ganti L. Assessing ADHD prevalence and comorbidities in the United States: insights from the Substance Abuse and Mental Health Services (SAMHSA) data. Glob Ment Health. 2024;11:e121. PubMed PMID: 39776993. doi:10.1017/gmh.2024.104
5. Jarrett MA, Ollendick TH. A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: implications for future research and practice. Clinic Psychol Rev. 2008;28(7):1266–1280. PubMed PMID: 18571820. doi:10.1016/j.cpr.2008.05.004
6. Siddiqui U, Conover MM, Voss EA, Kern DM, Litvak M, Antunes J. Sex differences in diagnosis and treatment timing of comorbid depression/anxiety and disease subtypes in patients with ADHD: a database study. J Atten Disord. 2024;28(10):1347–1356. PubMed PMID: 38756010. doi:10.1177/10870547241251738
7. Wehmeier PM, Schacht A, Barkley RA. Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. J Adolesc Health. 2010;46(3):209–217. PubMed PMID: 20159496. doi:10.1016/j.jadohealth.2009.09.009
10. DeSerisy M, Hirsch E, Roy AK. The contribution of sensory sensitivity to emotional lability in children with ADHD symptoms. Evid-Based Pract Child Adolesc Ment Health. 2019;4(4):319–327. PubMed PMID: 33033744. doi:10.1080/23794925.2019.1647122
11. Rosello B, Berenguer C, Raga JM, Baixauli I, Miranda A. Executive functions, effortful control, and emotional lability in adults with ADHD. Implications for functional outcomes. Psychiatry Res. 2020;293:113375. PubMed PMID: 32798933. doi:10.1016/j.psychres.2020.113375
12. Biederman J, Spencer TJ, Petty C, et al. Longitudinal course of deficient emotional self-regulation CBCL profile in youth with ADHD: prospective controlled study. Neuropsychiatr Dis Treat. 2012;8:267–276. PubMed PMID: 22848182. doi:10.2147/ndt.S29670
13. Childress AC, Sallee FR. Emotional lability in patients with attention-deficit/hyperactivity disorder: impact of pharmacotherapy. CNS Drugs. 2015;29(8):683–693. PubMed PMID: 26267739. doi:10.1007/s40263-015-0264-9
14. van Stralen J. Emotional dysregulation in children with attention-deficit/hyperactivity disorder. Attent Deficit Hyperact Disord. 2016;8(4):175–187. PubMed PMID: 27299358. doi:10.1007/s12402-016-0199-0
15. Sobanski E, Banaschewski T, Asherson P, et al. Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. J Child Psychol Psychiat Allied Discipline. 2010;51(8):915–923. PubMed PMID: 20132417. doi:10.1111/j.1469-7610.2010.02217.x
16. Posner J, Maia TV, Fair D, Peterson BS, Sonuga-Barke EJ, Nagel BJ. The attenuation of dysfunctional emotional processing with stimulant medication: an fMRI study of adolescents with ADHD. Psychiatry Res. 2011;193(3):151–160. PubMed PMID: 21778039. doi:10.1016/j.pscychresns.2011.02.005
17. Posner J, Kass E, Hulvershorn L. Using stimulants to treat ADHD-related emotional lability. Curr Psychiatry Rep. 2014;16(10):478. PubMed PMID: 25135778. doi:10.1007/s11920-014-0478-4
18. Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171(3):276–293. PubMed PMID: 24480998. doi:10.1176/appi.ajp.2013.13070966
19. Anastopoulos AD, Smith TF, Garrett ME, et al. Self-regulation of emotion, functional impairment, and comorbidity among children with AD/HD. J Atten Disord. 2011;15(7):583–592. PubMed PMID: 20686097. doi:10.1177/1087054710370567
20. Bunford N, Evans SW, Wymbs F. ADHD and emotion dysregulation among children and adolescents. Clin Child Fam Psychol Rev. 2015;18(3):185–217. PubMed PMID: 26243645. doi:10.1007/s10567-015-0187-5
21. Bunford N, Evans SW, Langberg JM. Emotion dysregulation is associated with social impairment among young adolescents with ADHD. J Atten Disord. 2018;22(1):66–82. PubMed PMID: 24681899. doi:10.1177/1087054714527793
22. McQuade JD, Taubin D, Mordy AE. Positive emotion dysregulation and social impairments in adolescents with and without ADHD. Res Child Adolesc Psychopathol. 2024;52(12):1803–1815. PubMed PMID: 39180616. doi:10.1007/s10802-024-01237-2
23. Yang Y, Li S, Wang M, et al. Executive function and clinical characteristics in children with attention-deficit hyperactivity disorder and emotional dysregulation (in Chinese). Sichuan Ment health. 2024;37(4):307–311. doi:10.11886/scjsws20240423002
24. Liu L, Chen W, Vitoratou S, et al. Is emotional lability distinct from “Angry/Irritable Mood”, “Negative Affect”, or other subdimensions of oppositional defiant disorder in children with ADHD? J Atten Disord. 2019;23(8):859–868. PubMed PMID: 26842831. doi:10.1177/1087054715624228
25. Su YE, Wang H, Geng YG, et al. Parent ratings of ADHD symptoms in Chinese urban schoolchildren: assessment with the Chinese ADHD rating Scale-IV: home version. J Atten Disord. 2015;19(12):1022–1033. PubMed PMID: 23142853. doi:10.1177/1087054712461177
26. Chen WJ, Faraone SV, Biederman J, Tsuang MT. Diagnostic accuracy of the Child Behavior Checklist scales for attention-deficit hyperactivity disorder: a receiver-operating characteristic analysis. J Consult Clin Psychol. 1994;62(5):1017–1025. PubMed PMID: 7806710. doi:10.1037/0022-006x.62.5.1017
27. Qian Y, Du Q, Qu S, Wang Y. The reliability and validity of the parent version of the weiss functional impairment scale. Chin Mental Health J. 2011;25(10):767–771.
28. Turkia IB, Brahim T, Guedria A, Bousleh S, Gaddour N. Emotional dysregulation and attention deficit hyperactivity disorder (ADHD). Eur Psychiatry. 2021;64(S1):S217–S217. doi:10.1192/j.eurpsy.2021.579
29. Overgaard KR, Oerbeck B, Aase H, Torgersen S, Reichborn-Kjennerud T, Zeiner P. Emotional lability in preschoolers with symptoms of ADHD. J Atten Disord. 2018;22(8):787–795. PubMed PMID: 25804545. doi:10.1177/1087054715576342
30. Spencer TJ, Faraone SV, Surman CB, et al. Toward defining deficient emotional self-regulation in children with attention-deficit/hyperactivity disorder using the child behavior checklist: a controlled study. Postgraduate Med. 2011;123(5):50–59. PubMed PMID: 21904086. doi:10.3810/pgm.2011.09.2459
31. Donfrancesco R, Innocenzi M, Marano A, Biederman J. Deficient emotional self-regulation in ADHD assessed using a unique profile of the Child Behavior Checklist (CBCL): replication in an Italian study. J Atten Disord. 2015;19(10):895–900. PubMed PMID: 23212599. doi:10.1177/1087054712462884
32. Komijani S, Ghosal D, Singh MK, Schweitzer JB, Mukherjee P. A novel framework to predict ADHD symptoms using irritability in adolescents and young adults with and without ADHD. Front Psychiatry. 2024;15:1467486. PubMed PMID: 40013023. doi:10.3389/fpsyt.2024.1467486
33. McQuade JD, Breaux RP. Are elevations in ADHD symptoms associated with physiological reactivity and emotion dysregulation in children? J Abnorm Child Psychol. 2017;45(6):1091–1103. PMID: 27838892. doi:10.1007/s10802-016-0227-8
34. Lee H, Heller AS, van Reekum CM, Nelson B, Davidson RJ. Amygdala-prefrontal coupling underlies individual differences in emotion regulation. Neuroimage. 2012;62(3):1575–1581. PMID: 22634856. doi:10.1016/j.neuroimage.2012.05.044
35. Yang Y, Yang B, Zhang L, Peng G, Fang D. Dynamic functional connectivity reveals abnormal variability in the amygdala subregions of children with attention-deficit/hyperactivity disorder. Front Neurosci. 2021;15:648143. PMID: 34658751. doi:10.3389/fnins.2021.648143
36. Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. J Affect Disord. 2013;147(1–3):80–86. PubMed PMID: 23218897. doi:10.1016/j.jad.2012.10.011
37. McKay E, Cornish K, Kirk H. Impairments in emotion recognition and positive emotion regulation predict social difficulties in adolescent with ADHD. Clin Child Psychol Psychiatry. 2023;28(3):895–908. PubMed PMID: 36440882. doi:10.1177/13591045221141770
38. Agapoff JA, Chong Z, Meek M, van Schalkwyk GI. Pharmacologic and non-pharmacologic interventions for emotional lability: a meta-analysis. Neurosci Biobehav Rev. 2023;149:105184. PubMed PMID: 37085024. doi:10.1016/j.neubiorev.2023.105184
39. Harold GT, Leve LD, Sellers R. How can genetically informed research help inform the next generation of interparental and parenting interventions? Child Dev. 2017;88(2):446–458. PubMed PMID: 28160281. doi:10.1111/cdev.12742
41. Groves NB, Wells EL, Soto EF, et al. Executive functioning and emotion regulation in children with and without ADHD. Res Child Adolesc Psychopathol. 2022;50(6):721–735. PMID: 34762251. doi:10.1007/s10802-021-00883-0
42. Lee YC, Chen CR, Lin KC. Effects of mindfulness-based interventions in children and adolescents with ADHD: a systematic review and meta-analysis of randomized controlled trials. Int J Environ Res Public Health. 2022;19(22):15198. PubMed PMID: 36429915. doi:10.3390/ijerph192215198
43. Oliva F, Malandrone F, Di Girolamo G, et al. The efficacy of mindfulness-based interventions in attention-deficit/hyperactivity disorder beyond core symptoms: a systematic review, meta-analysis, and meta-regression. J Affect Disord. 2021;292:475–486. PubMed PMID: 34146899. doi:10.1016/j.jad.2021.05.068
44. Lopez PL, Torrente FM, Ciapponi A, et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2018;3(3):Cd010840. PubMed PMID: 29566425. doi:10.1002/14651858.CD010840.pub2
45. Evans S, Bhide S, Quek J, et al. Mindful parenting behaviors and emotional self-regulation in children with ADHD and controls. J Pediatric Psychol. 2020;45(9):1074–1083. PubMed PMID: 32929486. doi:10.1093/jpepsy/jsaa073
46. Hepark S, Janssen L, de Vries A, et al. The efficacy of adapted MBCT on core symptoms and executive functioning in adults with ADHD: a preliminary randomized controlled trial. J Atten Disord. 2019;23(4):351–362. PubMed PMID: 26588940. doi:10.1177/1087054715613587
