Online Journal of Japanese Clinical Psychology
2024, April, Vol.8, 1-11

Research Article

Published on Web 04/30/2024

Relationship between attention deficit hyperactivity disorder andhighly sensitive person traits during the emotional Go/NoGo task:
A near-infrared spectroscopy study
Kana Matsuishi

Graduate School of Social and Cultural Sciences, Kumamoto University

Akira Yasumura

Graduate School of Humanities and Social Sciences, Kumamoto University

Abstract: Impaired response inhibition, a core symptom of attention deficit hyperactivity disorder(ADHD), significantly affects an individual’s overall quality of life. Nevertheless, the underlying
mechanism remains unclear. We conducted the emotional Go/NoGo task among university students to
explore the potential correlation between ADHD and highly sensitive person (HSP) traits. Hierarchicalmultiple regression analysis revealed that the increased commission errors when reacting to angry
faces could be better explained by HSP traits rather than by ADHD traits alone. Moreover, wesuggest heightened activity in the right prefrontal cortex is associated with these response inhibitiondifficulties. The results of this study align with those of prior studies, demonstrating that ADHD traits
exacerbate response inhibition difficulties in tasks that involve angry faces. However, we emphasize thesignificant role played by HSP traits compared to ADHD traits alone. This underscores the importanceof considering the presence or absence of an ADHD diagnosis and the intensity of ADHD traits andfocusing on HSP traits when supporting individuals with pronounced ADHD traits.
Keywords: attention deficit hyperactivity disorder (ADHD), highly sensitive person (HSP), response
inhibition, emotional Go/NoGo task, near-infrared spectroscopy (NIRS)Introduction

van Stralen, 2016), emotional impulsivity(Barkley & Fischer, 2010, p.512), emotional
lability, and sensory sensitivity (DeSerisy etal., 2019, p.324). As a pathological model,
ADHD involves executive dysfunction withdifficulties in response inhibition at its
core (Barkley, 1997, p.51). The numberof commission errors and reaction time
variability during a cognitive task in which
a series of stimuli are presented and theparticipant is asked to stop responding
only when a specific stimulus is presented
have been used to indicate response

Attention Deficit Hyperactivity Disorder(ADHD) is a developmental disorder that
results from impaired brain function and isestimated to affect 5.9% of adolescents and2.5% of adults (Faraone et al., 2021, p.792).
Symptoms of inattention, hyperactivity,and impulsivity primarily characterize it.
However, in recent years, researchers haveconsidered the inclusion of additional core
symptoms such as emotional dysregulation(Graziano & Garcia, 2016; Shaw et al., 2014;
1

Copyright © 2024 The Association of Japanese Clinical Psychology

Kana Matsuishi & Akira Yasumura

Pelc et al., 2006). Conversely, it has beenreported that the reward of smiling womenand smileys increases the performance ofindividuals with ADHD in Go/NoGo tasks
and other tasks (Kohls et al., 2009; Konrad
et al., 2000), and both positive and negative
stimuli are factors that influence cognitiveand behavioral accuracy in individuals with
ADHD (Jensen & Rosén, 2004; Manoli et al.,2021).
Similarly, a Highly Sensitive Person(HSP) is susceptible to positive andnegative stimuli (Aron et al., 2012, p.266).
Significant positive correlations between
the Adult ADHD Self-Report Scale (ASRS)
and the Highly Sensitive Person Scale(HSPS) have been reported (Panagiotidi
et al., 2020, p.4). HSP is fundamental traits
that represent differences in sensitivity andresponsiveness to environmental stimuli.
Highly sensitive individuals respond todeeper stimuli processing across various
situations (Aron & Aron, 1997, p.365).
Highly sensitive individuals positively
correlate with negative emotions (Benham,
2006; Lionetti et al., 2019; Yano et al., 2021)
and show significant amygdala activity inresponse to negative stimuli (Acevedo etal., 2017, p.368).
Thus, ADHD and HSP exhibit substantial
commonalities, particularly in theirassociation with emotional dysregulationand their responsiveness to positive
and negative stimuli. Furthermore, therecently demonstrated strong correlation
between ASRS and HSPS (Panagiotidi etal., 2020, p.4) sheds light on the increasing
convergence between ADHD and HSP. The
impairment of response inhibition by angry
facial expressions in ADHD, which has
been examined in the context of ADHD,
may be due to HSP rather than ADHD asa direct cause. The reason is that ADHD
is diagnosed by inattention, hyperactivity,

inhibition (Barkley & Murphy, 2010, p.163).
A study comparing children with ADHD
and typically developing children in a Go/
NoGo task showed that children with ADHD
had problems with response inhibition
and increased commission errors (Benikos& Johnstone, 2009; Johnstone & Clarke,
2009; Monden et al., 2012). Additionally,
difficulties in response inhibition (numberof commission errors during tasks) inindividuals with ADHD have been shownto contribute to self-control difficulties
in daily life and occupational difficulties(e.g., number of work experiences; Barkley& Murphy, 2010, p.169), indicating that
response inhibition may be a performanceindicator that influences the overall qualityof life.
Response inhibition in ADHD is affectedby facial expression processing. In theemotional Go/NoGo task, which requires
a response or response inhibition to
specific facial expressions, children with
ADHD and individuals with pronounced
ADHD traits have been found to havedifficulty with response inhibition (Köchel
et al., 2014; Manoli et al., 2021). Whenchildren with ADHD were asked to press
buttons in a Go/NoGo task with neutral,
angry, sad, and happy faces as stimuli, thenumber of errors made by children with
ADHD increased significantly compared
to typically developing children, from thenumber of commission errors when neutral
faces were presented to commission errors
when angry faces were presented (Köchel
et al., 2014, p.463). One possible reason
for the significant increase in response
inhibition difficulties with the additionof an angry facial expression component
is that children and adults with ADHD
experience difficulty with angry facial
expressions during discrimination tasks(Kara et al., 2017; Köchel et al., 2014;2

Relationship between attention deficit hyperactivity disorder and highly sensitive person traits during the emotional Go/NoGo task

1999/2012) is a self-report scale consistingof 66 items on a four-point scale (never:0, sometimes: 1, often: 2, very often: 3). A
cutoff point (t-score of 65 or higher) for the
CAARS was used. Among the 18 participants
included in the analysis, four participants
exceeded the cutoff on the DSM-IV Total
ADHD Symptoms subscale, and three on
the ADHD Index subscale.

and impulsivity without high sensitivity
in the diagnostic criteria, while HSP is aconcept that includes reactivity to negative
stimuli. HSP also comprises three factors:
ease of excitation, low sensory threshold,and esthetic sensitivity (Iimura et al., 2023,
p.90), and is likely to be a direct factor in
the difficulty of response inhibition. Thus,
HSP traits, but not ADHD traits, could
potentially cause changes in cerebral bloodflow in response to negative stimuli, leading
to issues with response inhibition.
This study aimed to clarify the causes of
response inhibition difficulties in individuals
with pronounced ADHD traits concerning
HSP traits, and to explore the mechanismsof these difficulties by measuring prefrontal
cortex (PFC) activity. This will help examine
effective interventions and support methods
for psychotherapy. As a performance index,
we measured the number of commission
errors in the emotional Go/NoGo task.
We clarified the neuropsychological basis
behind the difficulty in response inhibition
by measuring changes in cerebral blood flowusing near-infrared spectroscopy (NIRS)
during the response inhibition task.

The Japanese version of the HSP scale 10item version (HSP-J10) (Iimura et al., 2023)

is a seven-point self-report scale (1 = notat all applicable to 7 = very applicable)consisting of three factors: excitability, lowsensory threshold, and esthetic sensitivity,
which measures sensory processing
sensitivity in adults. A cutoff point has notbeen specified, but the mean score for theJapanese is shown to be 42.4 (Iimura etal., 2023, p.90). The mean score of the 18
participants included in the analysis was
47.44 points (SD = 8.65).
Procedure

Participants answered the CAARS and
HSP-J10 after performing the emotional
Go/NoGo task created in the AIST Facial
Expression Database 2017 (Fujimura &Umemura, 2018). Participants were seatedsuch that the distance between the monitor
and the participant was approximately 50
cm. They were asked to press a key with
the index finger of their dominant hand.
Stimuli were presented on a monitor with a
15.6-inch resolution of 1920 × 1080 pixels
at a viewing angle of approximately 10°.
One block consisted of a Go block and a
Go/NoGo block. The instruction was 3 s,
stimulus presentation was 0.8 s, and theinter-stimulus interval was 0.2 s. The block
set with the same conditions was repeated
six times with a break before moving on to
the next condition. The Go block consistedof 24 neutral trials in which the participantsMethods
Participants

A total of 20 undergraduate and graduates t u d e n t s p a r t i c i p a t e d i n t h i s s t u d y.
Informed consent was obtained. The study
protocol was approved by the Ethics Review
Committee of the Faculty of Humanities
and Social Sciences, Kumamoto University(reception number: 45).
Questionnaires
CAARS Japanese version (Conners’ Adult

ADHD Rating Scales [Japanese version];
hereafter CAARS; Conners et al.,3

Kana Matsuishi & Akira Yasumura

Figure1. Emotional Go/NoGo task
Note. Dummy illustrations were used.

of the task. The number of commission
errors during the NoGo block was recorded
for each condition. The average numberof commission errors in each emotional
condition minus the average numberof non-emotional conditions was used
as Δcommission errors data to capturechanges due to the addition of emotion. We
use the symbol Δ (delta), which represents
the difference or the amount of change,
to denote the change in the number ofcommission errors.

pressed the key for all presented faces. The
Go/NoGo block comprised 24 trials, 12 Go
trials, and 12 NoGo trials, in which theypressed the key for Go trials and did notpress the key for NoGo trials. There were
five conditions: three emotional conditions(Go: neutral and NoGo: anger) (Go: neutral
and NoGo: sadness) (Go: neutral andNoGo: happiness) and two non-emotional
conditions (Go: woman and NoGo: man)
(Go: man and NoGo: woman), in which all
stimuli were neutral (Fig 1). The order ofstimulus presentation was random, suchthat the same stimulus was not followed
more than once, and the order in which
the five conditions were performed wascounterbalanced across the participants.
Before the measurement, a practice
block was performed to check whether
the participants could identify facial
expressions and understand the content

Near-infrared spectroscopy measurement

Changes in oxygenated hemoglobin (oxyHb) concentrations in the PFC duringtask execution were recorded using a
multichannel NIRS system (OEG-16;
Spectratech Inc., Tokyo, Japan). The sensor
band of the OEG-16 comprised 16 channel
measurement points, of which six emitting4

Relationship between attention deficit hyperactivity disorder and highly sensitive person traits during the emotional Go/NoGo task

points and six detecting points werealternately arranged at intervals of 30 mm.
The temporal resolution is 0.65 s, and thesensor measures the change in oxy-Hb
concentration at a depth of approximately
3 cm from the scalp. The center of thesensor band was placed at the participant’s
Fpz according to the international 10-20
method. Channels 1-6 were additionallyaveraged for right PFC, channels 7-10
for middle PFC, and channels 11-16 forleft PFC concentration change. Based ona previous study (Yasumura et al., 2019,
p.580), to increase the signal-to-noise ratio,each recording was converted to a z-score.
The z-score was calculated using the meanand standard deviation of changes in the
oxy-Hb concentrations during the last 6 sof the Go block. The average signal for eachchannel during the NoGo blocks was usedas the data for analysis. Statistical software
R version 4.0.0. was used to calculate
z-values.

conducted to examine the difference in
the influence of ADHD and HSP. Further,
the amount of change in the coefficient ofdetermination when PFC activities wereadded using CAARS, HSP-J10, and PFC
activity as explanatory variables and anger
Δcommission errors as the dependent
variable in each emotion condition.
Hierarchical multiple regression analysis
was employed as the analytical method. The
data were analyzed using SPSS Windows
software version 26, with a significance levelof 5%.

Results

Based on the results of the one-factor
repeated measures ANOVA for several
commission errors, a significant main
effect was observed (F (3, 17) = 5.868,
p < 0.01, ηp2=.257). Based on Bonferroni
post hoc comparisons, anger and sadness
were significantly higher than in the nonemotional group (Fig 2).

Analysis methods

Before statistical analysis, considering
their attitude toward the task, we
excluded those who made more than
three standard deviations (SD) in thenumber of commission errors during the
Go/NoGo blocks. A total of 18 participants(Nine men and Nine women, 26.5 ± 8.9[SD] years old) were included in theanalysis. One-way ANOVA with Bonferroni
post hoc analysis was performed on thecommission errors in the Go/NoGo task. To
examine the relationship between CAARS,
HSP-J10, PFC activity (right PFC, middle
PFC, and left PFC), and Δcommission
errors in each emotional condition wereanalyzed using Spearman’s rank correlation
coefficient to examine associations.
Subsequently, a hierarchical multiple
regression analysis (stepwise method) was

Correlation analysis

Spearman’s correlation coefficient between
CAARS and HSP-J10 was determinedand had a significant positive correlation(ρ = .613, p = .007). There was apositive correlation between HSP-J10 and
Δcommission errors (ρ = .506, p =.032) andbetween right PFC and Δcommission errors(ρ =.489, p =.040) in the anger condition(Table 1). No significant correlations existed
between each questionnaire, Δcommission
errors, and PFC activity in the sadness andhappiness conditions.
Hierarchical multiple regression analysis

In Step 1, we examined the effect of the
CAARS scores on anger Δcommission
errors. Subsequently, in Step 2, the HSP-J10
5

Kana Matsuishi & Akira Yasumura

Figure 2. Mean number of commission errors in the Go/NoGo task; Error bars indicate standard
error
Note. **p <.01, *p <.05.

Table 1. Correlation of each questionnaire with prefrontal cortex activity and Δcommission errors
in anger conditionCAARS
HSP-J10CAARS

HSP-J10

Right PFC

Middle PFC

Left PFC

Δcommission
errors—.613**

.019

.217

.046

.309

—

.236

.018

-.045

.506*

—

.280

.220

.489*

—

.785**

.054

—

.054

Right PFC
Middle PFC
Left PFC
Δcommission errors—

Note. CAARS, Conners’ Adult ADHD Rating Scales [Japanese version]; HSP-J10, The Japanese version of the Highly
Sensitive Person scale 10-item version; Right PFC, right prefrontal cortex; Middle PFC, middle prefrontal cortex; Left
PFC, left prefrontal cortex.
**p <.01, *p <.05.

in Step 2, and the change in the coefficientof determination from Step 1 was alsosignificant, indicating that the HSP-J10
score significantly predicted anger
Δcommission errors. A significant model
was also obtained in Step 3, and the change
in the coefficient of determination fromscore was entered. In Step 3, PFC activity(right, middle, and left PFC) was added to
the variables in Step 2. The results showedthat the model in Step 1 was not significant,and the CAARS scores did not significantly
contribute to anger Δcommission errors.
However, a significant model was obtained6

Relationship between attention deficit hyperactivity disorder and highly sensitive person traits during the emotional Go/NoGo task

Table 2. Results of hierarchical multiple regression analysis in the anger condition
Standard Partial Regression Coefficient (β)

CAARSStep 1

Step 2

Step 3

.131

-.318

-.204

**

HSP-J10.724.528**.467**

Right PFC
Coefficient of determination (adjusted R2)-.044

Change in coefficient of determination (ΔR2)

.251*

.434*

.322**.195**

Note. CAARS, Conners’ Adult ADHD Rating Scales [Japanese version]; HSP-J10, The Japanese version of the Highly
Sensitive Person scale 10-item version; Right PFC, right prefrontal cortex.
**p <.01, *p <.05.

(Barkley & Fischer, 2010; DeSerisy et al.,2019; Graziano & Garcia, 2016; Shaw etal., 2014; van Stralen, 2016) encompasses
the ease of excitation and low sensory
thresholds on the HSP scale. Emotional
dysregulation in ADHD, increasingly
highlighted in recent years, can be viewed
as a comorbidity of HSP. The need forpsychological support focused on HSPs has
been suggested for individuals with ADHD
traits and ADHD.
Additionally, the decrease in reaction
accuracy due to emotional arousal uponseeing a negative facial expression is aphenomenon that is generally observedin Japanese university students, while
the ADHD trait itself was not correlatedwith anger Δcommission errors, the HSP
trait, which was correlated with ADHD,
was positively correlated with anger
Δcommission errors. Individuals withpronounced HSP traits responded to angry
faces because of their emotional reactions
when they detected angry faces, unable
to inhibit their behavioral reactions. In
the present case, activation of the rightprefrontal cortex was observed. Thissuggests that the factor that makes it
difficult for individuals to inhibit theirreactions to angry faces is not the strength

Step 2 was also significant, indicating asignificant effect of HSP-J10 scores andright PFC. The standard partial regression
coefficients (β) and the change in thecoefficient of determination (ΔR 2) whenthe variables were entered at each step areshown in Table 2. The residuals followed
a normal distribution, and no significant
multicollinearity was found based on the
VIF values and other factors.

Discussion

This study showed a correlation between
ADHD traits measured by the CAARS and
HSP traits measured by the HSP-J10. This
study confirms the results of a previous
study (Panagiotidi et al., 2020, p.4) thatshowed a correlation between ADHD and
HSP, in a Japanese population of university
students. The HSP-J10 included thefollowing questions: “Do other people’s
moods affect you?”, “Are you madeuncomfortable by loud noise?”, and “Areyou deeply moved by the arts or music?”. It
comprises three factors: ease of excitation,l ow s e n s o ry t h r e s h o ld , a n d e s t h e t ic
sensitivity (Iimura et al., 2023, p.90). The
emotional dysregulation noted in ADHD
7

Kana Matsuishi & Akira Yasumura

of ADHD traits, but rather the HSP traits
that are likely to coexist with ADHD andthe activation of the right PFC.
Regarding brain localization, brain activity
in ADHD mainly involves the right frontal
and parietal hemispheres (Köchel et al.,2014, p.465). The low activation of the rightlateral prefrontal cortex in children with
ADHD, as shown by NIRS measurements
during the reverse Stroop task (Yasumura
et al., 2014, p.104) and the normalizationof right inferior and middle prefrontal gyri
activity during Go/NoGo tasks brought
about by medication (Monden et al., 2012;
Nagashima et al., 2014) and absence ofincreased right PFC activation during angry
face observation (Ichikawa et al., 2014,p.56), it is widely believed that the brain
basis of response inhibition difficulties in
ADHD lies in reduced activity in the rightprefrontal cortex.
What are the implications of the increasein commission errors and the accompanying
increase in activity in the right PFC caused
by detecting angry faces? If we follow
the idea that PFC activity represents anincrease in emotional responses (Posner etal., 2011, p.159), the increased activationof the right PFC observed in this study may
be due to increased emotional reactivity
elicited by angry facial expressions. In
essence, a reasonable interpretation might
be that HSP traits amplified the emotional
response to angry faces, leading to an
excessive activation of right PFC activity
and this heightened activation could
have impaired performance in response
inhibition.
Similar to this study, an emotional Go/
NoGo task with eye movements in healthy
participants with pronounced ADHD traits
showed increased commission errors whenpresented with an angry face and difficulty
moving their gaze away from the angry facial

expression (Manoli et al., 2021, p.1926). The
difficulty in disengaging gaze from angry
faces indicates that individuals with ADHD
overinvest in processing resources when
encountering angry expressions, which may
make it difficult to inhibit their responses.
This study’s results also explain, from the
HSP perspective, the background of thehigh sensitivity of children with ADHD topunishment (Furukawa et al., 2021; Lumanet al., 2012) and the performance reduction
due to punishment (Baumann et al., 2021;
Furukawa et al., 2021) , which is a concern
in the context of nurturing and education.

Conclusion

The decrease in reaction accuracy
due to emotional arousal upon seeing anegative facial expression is also generally
observed in Japanese university students.
We hypothesized that HSP factors amplify
the decreased response accuracy, and ourhypothesis was proven. We also suggestthat high HSP may coexist among clientswith high ADHD traits. Among the clientswith pronounced ADHD traits who receive
psychotherapy and psychological support,
there is a high probability of individuals
with high HSP traits. As HSP traits influence
response inhibition, which determines thequality of daily life, there is a need to show
empathy for the difficulties caused by HSP
traits and address the theme of coping with
HSP traits.
This study supports the claim that
individual differences in HSPs should
be considered in psychotherapeuticinterventions and approaches to improving
mental health (Aron & Aron, 1997; DeSerisy
et al., 2019; Greven et al., 2019; Yano etal., 2021). HSP should not be disregarded
because it is not a diagnostic name but
8Relationship between attention deficit hyperactivity disorder and highly sensitive person traits during the emotional Go/NoGo task

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11(Accepted April 22, 2024)