Dear Dr. Slobodin,

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Lu Hua Chen, PhD, M.D.

Academic Editor

PLOS ONE

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- https://doi.org/10.1007/s11920-024-01492-6

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: The manuscript addresses a pertinent issue related to emotional dysregulation in adult women with ADHD. The manuscript is structured. The study is grounded in relevant theoretical models and supported by a thorough review of literature. The use of validated scales such as ASRS, DERS, BRIEF-A alongwith appropriate statistical analyses viz. hierarchical regressions etc. strengthens the methodological rigor of this study.

Reviewer #2: I think the paper is relevant, about a relevant topic and still not sufficiently researched. It is well written and organized. However, the following features should be improved.

Introduction:

P.5, line 115: “The second model perceives ADHD with emotional dysregulation as qualitatively different from pure ADHD, which has a distinct etiological entity and ADHD course”.- There is no reference for this model.

Methods:

P.9, line 205: “All participants signed a written informed consent”. – By the position this statement is in the text, it seems only the first group (women with ADHD) signed this consent.

P.10, line 225: “The three groups were found to have very similar characteristics, and were not significantly different in age, years of education and employment”.- The variable “employment” is not present in the preious sample characterization, the mean age and SD are also absent…a table with all the information about the sample should be presented.

P.12, line 285: “In the current study, the reliability of the subscales was .88, .80, and .59…”.- this last value is not acceptable, and the authors have already removed a subscale of the Emotion Regulation scale due to a value of .57. I think this should be removed too.

P.13, line 296: Data Analysis: The analysis on the normality of distribution and homogeneity of variance should be presented.

P.13, line 298: “To examine the second hypothesis, we conducted a Univariate Analysis of Variance with post-hoc comparisons using the Bonferroni range correction”. – why didn´t the authors use MANOVA? That’s the adequate analysis for multiple dependent variables and protects against Type I errors; ANOVA has Bonferroni correction for post-hoc tests only, but not for the initial composite.

Discussion:

The authors do not discuss results that were not expected. Namely, the fact that positive affect does not correlate with ADHD symptoms severity, and that there are no significant differences in positive affect between Groups 1 and 3.

P.16, line 370: “emotional liability” – typo.

P.17, limitations: there is, in my view, a major limitation that the authors did not state: the executive functions should not be accessed by self-report, but by performance-based tests.

P.17, line e 410: “Third, reliance on self-report measures may involve problems of shared method variance”.- The authors can assess this with statistical methods, I recommend this.

P.18, line 427: Shifting clinical attention to emotional dysregulation symptoms, rather than core ADHD symptoms of hyperactivity and impulsivity which are usually less dominant in women, may improve identification and intervention”.- I agree with the fact that it may improve intervention. However, how can it improve identification of ADHD? By itself, it can´t, because emotional dysregulation is present in several disorders…; the authors should reflect on this and reframe.

Reviewer #3: This manuscript presents an important contribution to the field of ADHD research, particularly focusing on its manifestation in females. The authors have conducted a comprehensive study exploring the prevalence, symptomatology, and executive functioning aspects of ADHD in female populations. While the overall structure and content of the manuscript are well presented, the paper would benefit from a review for minor topographical errors (e.g. line 303 should read a-priori) and there are some areas that could benefit from revision to enhance its clarity and impact.

The authors provide a thorough background on ADHD, but there are opportunities to strengthen the presentation of current data. The prevalence statistics cited are predominantly from 2012, which is now over a decade old. It would significantly enhance the paper's relevance to update these figures with more recent epidemiological data on ADHD prevalence, especially in females. This update would provide a more accurate representation of the current landscape of ADHD diagnosis and prevalence.

A key strength of this manuscript is its focus on ADHD in females, an often-underrepresented group in ADHD research, and differences in terms of gender-specific manifestations are included. However, the discussion on potential differences in ADHD types in females could be expanded slightly, by elaborating on whether females tend to exhibit more inattentive or internalizing symptoms. This exploration could provide valuable insights into why ADHD might be less frequently detected in females, possibly due to inattentive symptoms being less outwardly visible.

The theoretical framework of the study is well-constructed, but there are areas that require clarification. For instance, the second theoretical model mentioned on line 115 lacks a clear reference. Adding this reference would strengthen the theoretical underpinnings of the study. Additionally, while the authors provide a comprehensive discussion on emotional regulation and executive functioning, it would be beneficial to offer a more explicit rationale earlier in the section for choosing shifting and working memory as the two executive functioning components to examine. This would help readers better understand the study's focus and its potential implications.

The methodology of the study is generally sound, although there are some concerns regarding sampling selection. It is commendable that the authors acknowledge these limitations in the discussion section, demonstrating a critical awareness of the study's constraints. Given another limitation of the study is the use of self- report measures, it would be beneficial to include a discussion on the limitations of self-report measures and any steps taken to mitigate their influence

Reviewer #4: This manuscript presents a well-designed and timely investigation into emotional dysregulation in adult women with ADHD. The paper is generally well-structured and clearly written, with appropriate statistical methods and transparent reporting. However, there are several issues that require clarification or revision before the manuscript can be considered for publication. The study relies on self-reported ADHD diagnosis and ASRS cut-off scores. While this is common in large-scale surveys, it raises concerns about diagnostic validity. Please clarify whether any clinical interviews or verification methods were used to confirm diagnoses. If not, consider discussing in more depth the limitations of this approach.

The creation of a “probable ADHD” group is innovative but may introduce interpretative complexity. Please elaborate on the rationale for including this group in primary analyses and whether statistical validation supports treating it as a separate category.

Emotional dysregulation often co-occurs with depression and anxiety, both of which were not controlled for in your analysis. This is a significant limitation, particularly given the centrality of emotional symptoms in your outcome measures. Please address this issue in the discussion and consider its implications for interpreting your results.

The CERI scale is a promising ADHD-specific tool, but you note low reliability of subscales. Was the total score validated independently? Please clarify why it was used in spite of the reliability issues and consider discussing the implications of this choice. The mediation analyses are well-executed using Hayes’ PROCESS macro. However, it would strengthen the manuscript to report indirect effect sizes (e.g., standardized β) and explicitly state whether the mediation is full or partial.

Minor issue: Line 29: Likely a typo—please confirm if “emotional liability” should be “emotional lability.”

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Reviewer #1: Yes:  Dr. Syed Sajid Husain Kazmi

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Attachments

Attachment

Submitted filename: Review A Controlled Study of Emotional Dysfunction....docx

A Controlled Study of Emotional Dysfunction in Adult Women with ADHD

PONE-D-25-21388R1

Dear Dr. Slobodin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Lu Hua Chen, PhD, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: (No Response)

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #4: I have reviewed the authors’ responses and revisions. I accept the comments provided and have no further questions or additional concerns regarding the manuscript.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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