Risky decision making in Attention-Deficit/Hyperactivity Disorder: A meta-regression analysis

The moderating role of gender on the relationship between childhood attention deficit and hyperactivity symptoms and functional impairment

This study aimed to examine the link between childhood attention deficit and hyperactivity symptoms (CAS) and functional impairment in university students, while also investigating whether gender moderates this relationship. Six hundred and eighty university students participated in this cross-sectional study. The assessment was conducted using the Wender-Utah Rating Scale-25 (WURS), the Brief Symptom Inventory (BSI), and the Weiss Functional Impairment Rating Scale - Self Report (WFIRS-S). The relationship between CAS and general and domain-based functional impairment was evaluated using eight moderation models. Control variables, including age and concomitant psychiatric symptoms (five BSI scores), were added to the models. We observed positive associations between WURS and all WFIRS-S scores. In addition, WURS significantly interacted with gender in explaining WFIRS-S total (t = -2.26, p =.024). Gender also moderated the link between WURS and impairments in social (t = -2.00, p =.046) and risk domains (t = -2.86, p =.004). Accordingly, the associations between CAS and overall functional impairment, as well as impairments in social and risk domains, were stronger in men than in women. These findings highlight the significant role of CAS in functional impairments among university students, with gender emerging as a key moderating factor, particularly in social and risk-related domains.

Does Mind-Wandering Explain ADHD-Related Impairment in Adolescents?

Currently, diagnostic criteria for ADHD mainly reflect behavioral symptoms, neglecting internal phenomena like mind-wandering. Recent studies found that mind-wandering explains impairment beyond ADHD symptoms in adults. To better capture ADHD-related impairment in adolescents, we aimed to elucidate whether mind-wandering is associated with impairments that are prevalent in adolescents (i.e., risk-taking behavior, homework problems, emotional dysregulation, and general impairment) beyond ADHD symptoms. Furthermore, we sought to validate the Dutch translation of the Mind Excessively Wandering Scale (MEWS). We assessed a community sample of 626 adolescents on ADHD symptoms, mind-wandering, and the impairment domains. The Dutch MEWS had good psychometric properties. Mind-wandering was linked to general impairment and emotional dysregulation beyond ADHD symptoms, but was not linked to risk-taking behavior and homework problems beyond ADHD symptoms. Internal psychological phenomena such as mind-wandering may add to the behavioral symptoms of ADHD in explaining part of the impairment that adolescents with ADHD characteristics experience.

Increasing Health Literacy on ADHD: A Cross-Disciplinary Integrative Review Examining the Impact of ADHD on Brain Maturation, Composition and Function and Cognitive Processes Across the Life Course

There is a significant need to improve ADHD health literacy. This cross-disciplinary integrative review was conducted to synthesise the evidence on the impact ADHD has on brain maturation, composition and function as well as cognitive processes, across the life course. Although results are highly heterogenous, ADHD appears to be associated with (1) a significant delay in cortical maturation and differences in neuroanatomy that do not appear to fully resolve in adulthood, (2) atypical brain function, and (3) atypical cognitive processes. The cognitive processes implicated include working memory, inhibitory control, cognitive flexibility, alerting attention, reward processing, long-term memory, reaction time, time perception and estimation, planning, and complex decision making/problem-solving. We aim to use this data to develop a 'framework/checklist" that parents, adults and clinicians can use to identify the possible mechanisms that may be contributing to an individual with ADHD's challenges. This information can also be used to inform the content of ADHD education programs to ensure participants receive empirically-determine information from high quality review studies and meta-analysis that accurately reflects the rigor and limitations of study findings.

Investigating behavioural addictions in adults with and without attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) confers greater risk of alcohol and substance use disorders, which may be linked to altered compulsivity and impulsivity within the condition. However, no study has investigated the link between these constructs and behavioural addictions in ADHD. The aim of this study was to investigate whether individuals with ADHD show increased impulsivity, compulsivity, and associated distress, as well as addictive behaviour for gambling, exercise, and internet use, and to assess the relationship between these factors. Adults with and without ADHD were recruited from across the UK and completed an online survey measuring impulsivity, compulsivity, gambling, internet use and exercise addiction. Three hundred and forty-six adults took part (Healthy control = 137, ADHD-medicated = 110, ADHD-unmedicated = 99). Those declaring a diagnosis of ADHD reported greater internet use problems and greater withdrawal from exercise. Medicated individuals also reported higher exercise continuance and were more likely be symptomatic for exercise dependency. Individuals identifying with ADHD had greater levels of impulsivity and compulsivity, with impulsivity correlated with all behavioural addictions, whilst compulsivity correlated only with exercise and internet use. Regression analyses indicated that the distress caused by impulsivity and compulsivity was associated with internet use. Although further research is needed, this study indicates that the greater risk of behavioural addictions found in those with ADHD may relate to impulsivity and compulsivity, and that this should be considered when managing ADHD.

Challenges and Opportunities: Identification and Monitoring of Attention-Deficit/Hyperactivity Disorder in Pediatrics

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that typically presents in childhood and can cause significant impairment from youth into adulthood across multiple settings (eg, school, home). Pediatricians are the most likely health professionals to identify and treat ADHD. However, ADHD symptoms often overlap with other common mental health disorders, making accurate identification challenging. The diagnosis of ADHD relies on a combination of history gathering, screening tools, and clinical judgment. In this article, we review tools and strategies for ADHD identification, assessment, and treatment monitoring in primary care pediatrics. [Pediatr Ann. 2025;54(1):e6-e11.].

Differences in impulsivity between adolescents with ADHD and those with comorbidity of ADHD and IGD

BACKGROUND

Numerous studies have demonstrated that patients with attention deficit hyperactivity disorder (ADHD) have high impulsivity. However, few studies have been published on the differences in impulsivity between patients presenting with comorbidity of ADHD and Internet gaming disorder (IGD) and ADHD alone.

AIM

The present study designed an experiment to address this significant question, to explore the differences in impulsivity between individuals with ADHD and those with comorbid ADHD and IGD, specifically focusing on various dimensions of impulsivity.

METHODS

A total of 81 adolescents with ADHD alone and 59 patients with comorbidity of ADHD and IGD were included in this study, and all of them were assessed using the Stop-signal Task (SST), Delay Discount Task (DDT), and Balloon Analogue Risk Task (BART).

RESULTS

Patients with comorbid ADHD and IGD had higher impulsivity than those with only ADHD, and it was expressed in different dimensions. Additionally, response inhibition, delayed discount rate, risky decision-making behavior, inattention, and hyperactivity were identified as risk factors for comorbid ADHD and IGD.

CONCLUSION

These findings can help distinguish whether ADHD is comorbid with IGD in clinical settings. They will also be helpful in the implementation of more precise treatments.

Sleep deprivation alters utilization of negative feedback in risky decision-making

Background

Sleep loss has sometimes catastrophic effects on risky decision-making. However, it is unknown to what extent such deficits are exacerbated with increasing duration of sleep deprivation (SD) and whether sustained vigilant attention mediates this sleep deprivation-induced deficit.

Methods

The present study aimed to investigate the effect of 36 hours of SD on 37 male college students' arousal, emotion, vigilant attention, and risky decision-making, using the Psychomotor Vigilance Test, the Game of Dice Task, and scales assessing fatigue, sleep, and emotions.

Results

Compared to baseline, SD significantly increased sleepiness, fatigue, and negative emotions, decreased positive emotions and vigilant attention, and led to a shift toward risky decision-making, and these effects often appeared 15 or 20 hours after SD. Interestingly, participants' ability to employ positive feedback was maintained, whereas their performance to utilize negative feedback was impaired even after 8 hours of sleep deprivation. Meanwhile, vigilant attention acted as a mediator between SD and risky decision-making (z = -1.97, 95% [-6.00, -0.30]).

Discussion

These results suggest that sleep-deprived individuals are unable to use negative feedback to optimize their judgments, which may account for their poor decision-making under risk.

Sex differences in physiological correlates of affectively driven decision-making behavior in adult ADHD

BACKGROUND

Sex differences in the symptomatology of adults with attention-deficit/hyperactivity disorder (ADHD) have often been overlooked when studying behavioral abnormalities. However, it is known that women exhibit considerably more stronger symptoms related to emotional competence than men. Since affective functions significantly influence the processing of risky decision-making and risk-engagement, we assume that risky behavior in ADHD is affected by sex differences. Therefore, we specifically investigated sex-specific effects on the interaction between emotionally induced changes in physiology and behavioral performance on a decision-making task.

METHODS

Skin conductance responses of twenty-nine adults with ADHD (n = 16 male; n = 13 female) and thirty-three adults in the control group (n = 14 male; n = 19 female) were recorded during the performance in a modified version of the Balloon Analogue Risk Task (BART). Additional questionnaires were used to reveal insights in the self-assessment of emotional competence, risk perception, and feedback sensitivity. Emotional arousal and decision-making behavior were analyzed using linear mixed-effects models.

RESULTS

Results showed different effects of sex on risk behaviors in controls and ADHD. In contrast to healthy controls, female adults with ADHD showed a significantly greater risk engagement in the BART compared to males with ADHD. This contrary sex relation was not observed in skin conductance responses and revealed a significantly different sex-dependent correlation of body response and behavioral task performance in ADHD. Comparisons with results from self-assessments furthermore indicate a reduced behavioral self-perception in women with ADHD, but not in men.

CONCLUSION

In summary, we found an altered interaction between physiological activity and risky behavior in women with ADHD. Thus, the present study indicates a reduced sensitivity towards the own bodily responses in women with ADHD, which could consequently cause increased risky DM behavior in daily life. The current results suggest that more consideration needs to be given to sex-specific effects on physiological processes and behavior in adults with ADHD.

Assessing Brain Iron and Its Relationship to Cognition and Comorbidity in Children With Attention-Deficit/Hyperactivity Disorder With Quantitative Susceptibility Mapping

BACKGROUND

Quantitative susceptibility mapping is a neuroimaging technique that detects local changes in magnetic susceptibility induced by brain iron. Brain iron and the dopaminergic system are linked because iron is an important cofactor for dopamine synthesis. Attention-deficit/hyperactivity disorder (ADHD) is associated with dysregulation of dopaminergic transmission. Therefore, we applied quantitative susceptibility mapping on subcortical structures to study potential alterations in brain iron and its impact on cognition and mental health in children with ADHD.

METHODS

Quantitative susceptibility mapping data (3T) of 111 participants (nADHD = 58, mean [SD] age = 13.2 [0.63] years; nControl = 53, mean [SD] age = 13.2 [0.51] years) were analyzed. Subcortical regional brain iron values were extracted. Analysis of variance was used to examine group differences for each region of interest. For dimensional approaches, Pearson correlation analysis was performed across the cohort to examine the association of brain iron with symptoms, mental health, and cognition.

RESULTS

No significant differences were found in iron susceptibility between children with ADHD and control children, between children with persistent ADHD and those with remitted ADHD, or between medicated and medication-naïve children. An unexpected finding was that children with an internalizing disorder had significantly higher iron susceptibility, but the result did not survive multiple comparison correction. Higher brain iron was associated with sustained attention, but not inhibition, IQ, or working memory.

CONCLUSIONS

This is the first study to address brain iron susceptibility and its association with comorbidities and cognition in ADHD. Alterations in brain iron may not fully account for a diagnosis of ADHD but may be an indicator of internalizing problems in children. Alterations in brain iron content in children were linked to detrimental sustained attention and may represent developmental variation in cognition.

Cognitive Correlates of Risky Decision-Making in Individuals with and without ADHD: A Meta-analysis

This meta-analytic study aims to investigate the cognitive correlates of risky decision-making in individuals with attention-deficit/hyperactivity disorder (ADHD) and typically developing (TD) individuals. A systematic analysis of existing literature was conducted, encompassing 38 studies (496 ADHD and 1493 TD). Findings revealed a consistent propensity for riskier decision-making in individuals with ADHD, supported by significant correlations with attention, cognitive flexibility, inhibitory control, time perception, and working memory. The study underscores the relevance of these cognitive functions in shaping decision-making tendencies, with nuanced patterns observed within the ADHD and TD subgroups. Individuals with ADHD often demonstrate altered patterns of correlation, reflecting the specific cognitive challenges characteristic of the disorder.

A critical review of hot executive functioning in youth attention-deficit/hyperactivity disorder: Methodological limitations, conceptual considerations, and future directions

Hot executive functioning (EF) - EF under emotionally or motivationally salient conditions - is a putative etiology of attention-deficit/hyperactivity disorder (ADHD), disruptive behavior problems (DBPs), and their related impairments. Despite two decades of research, the present study is the first review of the construct in youth ADHD, with a particular focus on the role of task design, age, and DBPs, as well as relevant conceptual and methodological considerations. While certain hot EF tasks have been investigated extensively (e.g., choice impulsivity), substantial inconsistency in measurement of the broader construct remains, severely limiting conclusions. Future research should a) consider the extent to which various hot EF tasks relate to one another, a higher order factor, and other related constructs; b) further investigate task design, particularly the elicitation of emotion or motivation and its anticipated effect on EF; and c) incorporate multiple levels of analysis to validate similarities and differences among tasks with regard to the affective experiences and cognitive demands they elicit. With improved measurement and conceptual clarity, hot EF has potential to advance the literature on etiological pathways to ADHD, DBPs and associated impairments and, more broadly, may represent a useful tool for understanding the influence of emotion and motivation on cognition.

Effect of Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder on Criminality

OBJECTIVE

Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes.

METHOD

We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference.

RESULTS

Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges.

CONCLUSION

This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning.

STUDY PREREGISTRATION INFORMATION

The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

Individual differences, ADHD diagnosis, and driving performance: effects of traffic density and distraction type

The present study examined the impact of individual differences, attention, and memory deficits on distracted driving. Drivers with ADHD are more susceptible to distraction which results in more frequent collisions, violations, and licence suspensions. Consequently, the present investigation had 36 participants complete preliminary questionnaires, memory tasks, workload indices, and four, 4-min simulated driving scenarios to evaluate such impact. It was hypothesised ADHD diagnosis, type of cellular distraction, and traffic density would each differentially and substantively impact driving performance. Results indicated traffic density and distraction type significantly affected the objective driving facets measured, as well as subjective and secondary task performance. ADHD diagnosis directly impacted secondary task performance. Results further showed significant interactions between distraction type and traffic density on both brake pressure and steering wheel angle negatively impacting lateral and horizontal vehicle control. Altogether, these findings provide substantial empirical evidence for the deleterious effect of cellphone use on driving performance.Practitioner summary: This study examined how ADHD diagnosis, traffic density, and distraction type affect driver behaviour. Participants completed driving behaviour questionnaires, memory tasks, workload indices, and driving scenarios. Results showed that ADHD diagnosis impacted secondary task performance, while traffic and distractions significantly impacted driving performance as well secondary task performance and workload.

Risky decision-making in major depressive disorder: A three-level meta-analysis

Background

Individuals with major depressive disorder (MDD) are usually observed making inappropriate risky decisions. However, whether and to what extent MDD is associated with impairments in risky decision-making remains unclear. We performed a three-level meta-analysis to explore the relationship between risky decision-making and MDD.

Method

We searched the Web of Science, PubMed, Scopus, and PsycINFO databases up to February 7, 2023, and calculated Hedges' g to demonstrate the difference in risky decision-making between MDD patients and healthy controls (HCs). The moderating effect of sample and task characteristics were also revealed.

Results

Across 73 effect sizes in 39 cross-sectional studies, MDD patients exhibited greater risk-seeking than HCs (Hedges' g = 0.187, p = .030). Furthermore, age (p = .068), region (p = .005), and task type (p < .001) were found to have moderating effects. Specifically, patients preferred risk-seeking over HCs as age increased. European patients showed significantly increased risk-seeking compared to American and Asian patients. Patients in the Iowa Gambling Task (IGT) exhibited a notable rise in risk-seeking compared to other tasks, along with an increased risk aversion in the Balloon Analogue Risk Task (BART). The multiple-moderator analysis showed that only task type had significant effects, which may be explained by a tentative framework of "operationalization-mechanism-measure" specificity.

Conclusions

MDD patients generally exhibit higher risk-seeking than HCs. It implies that impaired risky decision-making might be a noteworthy symptom of depression, which should be placed more emphasis for clinical management and psycho-education.

Reciprocal associations between affective decision-making and mental health in adolescence

Poor affective decision-making has been shown to associate cross-sectionally with poor mental health in clinical populations. However, evidence from general population samples is scarce. Moreover, whether decision-making is prospectively linked to mental health in youth in the general population and whether such associations are reciprocal have yet to be examined. The present study examined bidirectional associations between various aspects of affective decision-making and emotional and behavioural problems at ages 11 and 14 years in 13,366 members of the Millennium Cohort Study. Decision-making (delay aversion, deliberation time, quality of decision-making, risk adjustment, risk-taking) and emotional (emotional symptoms, peer problems) and behavioural (conduct problems, hyperactivity/inattention) problems were measured using the Cambridge Gambling Task and the Strengths and Difficulties Questionnaire, respectively. Results of cross-lagged panel models adjusted for confounding revealed a negative reciprocal association between hyperactivity and quality of decision-making but also positive reciprocal associations between conduct problems and delay aversion, and between peer problems and deliberation time. Emotional problems and peer problems predicted a decrease in risk-taking, conduct problems predicted an increase in risk-taking, and hyperactivity predicted an increase in delay aversion and deliberation time. Furthermore, hyperactivity and conduct problems predicted less risk adjustment, and risk adjustment predicted fewer peer problems. The results suggest that behavioural problems are prospectively linked to greater risk-taking and lower risk adjustment in adolescence. Moreover, adolescents with behavioural problems tend to make poorer decisions and be more delay-averse, but also poorer quality of decision-making and increased delay aversion are associated with more behavioural problems over time.

Transcranial direct current stimulation alters the process of reward processing in children with ADHD: Evidence from cognitive modeling

BACKGROUND

The ventromedial prefrontal cortex (vmPFC) and dorsolateral prefrontal cortex (dlPFC) are the neural underpinnings of reward processing, which is impaired in individuals with attention deficit hyperactivity disorder (ADHD). In the present study, we aimed to explore the impact of the vmPFC and the dlPFC regulation on reward processing.

METHODS

Twenty-six children with ADHD performed the balloon analogue risk-taking task (BART) and chocolate delay discounting task (CDDT) during five different sessions of transcranial direct current stimulation (tDCS), separated by a one-week interval: anodal left dlPFC/cathodal right vmPFC, the reversed electrode positioning, anodal left dlPFC stimulation with extracranial return electrode, anodal right vmPFC stimulation with extracranial return electrodes, and sham stimulation. Four-parameter and constant-sensitivity models were used to model the data.

RESULTS

In the BART, anodal dlPFC/cathodal vmPFC stimulation facilitated conservative decision making, anodal tDCS over dlPFC with extracranial return electrode increased positive beliefs about the explosion of a balloon, and anodal vmPFC/cathodal dlPFC stimulation reduced ongoing learning in the process of decision making. In the CDDT, anodal vmPFC stimulation with extracranial return electrode decreased impatience in the process of the task.

CONCLUSION

These results suggest a role of the left dlPFC and right vmPFC in the outcome of decision making and the process of risky decision making and delay discounting.

Cognitive mechanisms underlying decision making involving risk of explicit punishment in male and female rats

Individuals engage in the process of risk-based decision making on a daily basis to navigate various aspects of life. There are, however, individual differences in this form of decision making, with some individuals exhibiting preference for riskier choices (risk taking) and others exhibiting preference for safer choices (risk aversion). Recent work has shown that extremes in risk taking (e.g., excessive risk taking or risk aversion) are not only cognitive features of neuropsychiatric diseases, but may in fact predispose individuals to the development of such diseases. To better understand individual differences in risk taking, and thus the mechanisms by which they confer disease vulnerability, the current study investigated the cognitive contributions to risk taking in both males and females. Rats were first behaviorally characterized in a decision-making task involving risk of footshock punishment and then tested on a battery of cognitive behavioral assays. Individual variability in risk taking was compared with performance on these tasks. Consistent with prior work, females were more risk averse than males. With the exception of the Set-shifting Task, there were no sex differences in performance on other cognitive assays. There were, however, sex-dependent associations between risk taking and specific cognitive measures. Greater risk taking was associated with better cognitive flexibility in males whereas greater risk aversion was associated with better working memory in females. Collectively, these findings reveal that distinct cognitive mechanisms are associated with risk taking in males and females, which may account for sex differences in this form of decision making.

Risk of accidents and unintentional injuries in men and women with attention deficit hyperactivity disorder across the adult lifespan

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is associated with risk-taking behavior, leading to accidents and unintentional injuries (summarized here as incidents). Main aim of this study is to determine if men and women with and without ADHD differ in the risk of mild (treated outpatient) and severe (treated inpatient) incidents across the adult lifespan (age groups: 18-29; 30-59, and ≥60 years). Secondary aim: investigate the role of comorbid mental disorders and drugs for the treatment of these comorbidities, and ADHD-medication.

METHODS

Using anonymized German claims data (N = 4,575,027), adults with ADHD diagnosis during 2016-2019 (N = 17,041) were compared with a 1:4 age and sex-matched group without ADHD diagnosis. Regression analyses statistically tested group differences.

RESULTS

Incidents occur in a U-shaped form across the adult lifespan. Individuals with ADHD show the same pattern but at a substantially increased risk of both mild and severe incidents throughout the lifespan. Women without ADHD are at lower risk in young adulthood than men but at higher risk in older adulthood. Women with ADHD show the same pattern for severe incidents, but for mild incidents they have the highest risk throughout the lifespan. Co-occurring anxiety disorder and the use of psycholeptics and ADHD-medication decreased the incident risk.

CONCLUSION

We extend available knowledge which has hitherto focused on young adult males and traffic accidents. ADHD is associated with increased incidents across the adult lifespan, with distinct patterns regarding age, sex, and incident severity. An accurate diagnosis of ADHD in adulthood provides the first step towards prevention of accidents and unintentional injuries.

Altered interaction of physiological activity and behavior affects risky decision-making in ADHD

Background

Adult attention-deficit/hyperactivity disorder (ADHD) is often associated with risky decision-making behavior. However, current research studies are often limited by the ability to adequately reflect daily behavior in a laboratory setting. Over the lifespan impairments in cognitive functions appear to improve, whereas affective functions become more severe. We assume that risk behavior in ADHD arises predominantly from deficits in affective processes. This study will therefore aim to investigate whether a dysfunction in affective pathways causes an abnormal risky decision-making (DM) behavior in adult ADHD.

Methods

Twenty-eight participants with ADHD and twenty-eight healthy controls completed a battery of questionnaires regarding clinical symptoms, self-assessment of behavior and emotional competence. Furthermore, skin conductance responses were measured during the performance in a modified version of the Balloon Analogue Risk Task. A linear mixed-effects model analysis was used to analyze emotional arousal prior to a decision and after feedback display.

Results

Results showed higher emotional arousal in ADHD participants before decision-making (β = -0.12, SE = 0.05, t = -2.63, p < 0.001) and after feedback display (β = -0.14, SE = 0.05, t = -2.66, p = 0.008). Although risky behavior was greater in HC than in ADHD, we found a significant interaction effect of group and anticipatory skin conductance responses regarding the response behavior (β = 107.17, SE = 41.91, t = 2.56, p = 0.011). Post hoc analyses revealed a positive correlation between anticipatory skin conductance responses and reaction time in HC, whereas this correlation was negative in ADHD. Self-assessment results were in line with the objective measurements.

Conclusion

We found altered changes in physiological activity during a risky decision-making task. The results confirm the assumption of an aberrant relationship between bodily response and risky behavior in adult ADHD. However, further research is needed with respect to age and gender when considering physiological activities.

Associations between Early Psychosocial Deprivation, Cognitive and Psychiatric Morbidity, and Risk-taking Behavior in Adolescence

OBJECTIVE

Early psychosocial deprivation increases the risk of later cognitive and psychiatric problems, but not all deprived children show these difficulties. Here, we examine the extent to which psychosocial deprivation increases the risk of later cognitive and psychiatric difficulties and the downstream consequences of this for risk-taking behavior in adolescence.

METHOD

Children abandoned to institutions early in life were randomly assigned to care-as-usual or a foster care intervention during infancy. A separate group of never-institutionalized children was recruited as a comparison sample. The current follow-up study included 165 children (51% female), 113 with a history of institutionalization and 52 with no such history. At age 12, caregivers reported on children's psychiatric difficulties, and their IQ was assessed by standardized testing. At 16 years, risk-taking behavior was assessed from youth self-reports.

RESULTS

Latent profile analysis revealed three subgroups of children with varying levels of cognitive and psychiatric difficulties: Low-Morbidity (n = 104, 62.7%), Medium-Morbidity (n = 46, 27.9%), and High-Morbidity (n = 15, 9.4%). Nearly half of the institutionalized children belonged to the High- or Medium-Morbidity subgroups; and institutionally-reared children were significantly more likely to belong to one of these profiles than never-institutionalized children. Compared to the Low-Morbidity subgroup, membership in the Medium-Morbidity profile was associated with higher levels of risk-taking behavior at age 16 years.

CONCLUSIONS

Children who experience psychosocial deprivation are considerably more likely to present with elevated cognitive and psychiatric difficulties in early adolescence and, for some children, this elevation is linked to heightened risk-taking behavior in later adolescence.

Pediatric Off-Label Antipsychotic Use for Attention-Deficit/Hyperactivity Disorder

PURPOSE

Off-label antipsychotic use for behavioral symptoms in pediatric attention-deficit/hyperactivity disorder (ADHD) poses safety concerns, and evidence to support such use is limited. This study aims to investigate the risk of off-label antipsychotic use associated with comorbid disruptive behavior disorder (DBD) among a cohort of youth with ADHD.

METHODS

A cohort study was conducted using IQVIA PharMetrics Plus for Academics data from 2007 to 2020. Youth 5 to 15 years of age at the index ADHD visit were included in the cohort. The index ADHD visit meets at least 1 of the following criteria: (1) 1 inpatient ADHD visit, (2) 2 outpatient ADHD visits within 90 days, or (3) an ADHD medication prescription fill within 30 days of an outpatient ADHD visit. We excluded youth who had a diagnosis of DBD or a US Food and Drug Administration (FDA)-approved indication for antipsychotics at baseline. Youth were followed up until antipsychotic initiation or were censored at a loss of coverage, receipt of an FDA-indicated diagnosis, or end of the study. A Cox proportional hazards regression model with DBD as a time-varying covariate estimated the hazard of antipsychotic use after the index ADHD visit.

FINDINGS

Of 41,098 youth with ADHD who met the study criteria, 4557 were diagnosed with DBD during follow-up. The incidence of antipsychotic initiation was 19.6 (95% CI, 18.7- 20.5) per 1000 person-years. After adjustment for baseline covariates, the hazard ratio of antipsychotic initiation associated with DBD was 4.64 (95% CI, 4.15-5.18).

IMPLICATIONS

Antipsychotic use among youth with ADHD is more likely in the presence of DBD, suggesting that an off-label use is for behavior problems.

Psychosocial functioning of adolescents with ADHD in the family, school and peer group: A scoping review protocol

OBJECTIVE

The objective of this scoping review is to investigate what is known about the psychosocial functioning of adolescents with ADHD. All basic life environments (family, school and peer group) will be considered.

INTRODUCTION

Adolescence is especially critical for people with ADHD-natural maturation may be accompanied by changing symptoms of ADHD. A number of childhood difficulties transform during adolescence and contribute to problems in various areas that comprise psychosocial functioning. The available studies focus on selected domains of psychosocial functioning of adolescents with ADHD, however, to the authors' best knowledge, there is no comprehensive description of this issue. The lack of such a description is the main rationale for conducting this scoping review.

INCLUSION CRITERIA

Pointing to the PCC elements (population, concept, context), the scoping review will include primary studies on the concept of psychosocial functioning (including functioning in the family, school and peer group). In the included studies, the term "psychosocial functioning" (or related) had to be used explicitly. The population will be adolescents (10 to 19 years old) with a formal diagnosis of ADHD (DSM classification) or Hyperkinetic Syndrome (ICD-9) or Hyperkinetic Disorders (ICD-10). There will be no restrictions on the research context.

METHODS

The methodology of scoping reviews will be applied in accordance with the guidelines of the Joanna Briggs Institute (JBI). The following databases: Academic Search Ultimate, ERIC, MEDLINE, ProQuest Central, PsycInfo, Scopus, and databases under the Web of Science will be searched for primary studies in peer-reviewed journals, written in English and published since 1987. The analyses will be based mainly on frequency counts of the components of psychosocial functioning and population characteristics. The results will be presented in tabular form and supplemented with a descriptive summary. The protocol has been registered on the Open Science Framework: https://doi.org/10.17605/OSF.IO/MS82H [registration DOI].

Decision-making and Risky Behavior in Individuals with Attention-Deficit/Hyperactivity Disorder: A 10-year Longitudinal Study

We assessed 85 children with Attention-Deficit/Hyperactivity Disorder (ADHD) and 50 typically developing children (TD) (M_age = 11.59, 57.8% boys) with the Hungry Donkey Task (HDT) at baseline and 2-year follow-up, and the Iowa Gambling Task at 10-year follow-up (75% retention). Improvement in the proportion of advantageous choices was observed from two- to 10-year follow-up, but the ADHD group improved less and was outperformed by the TD group at the 10-year follow-up. More advantageous choices on the HDT at baseline predicted less risky behavior at 10-year follow-up. Male sex and more inattentive or externalizing symptoms at baseline predicted more risky behavior.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes

BACKGROUND

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

METHODS

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

RESULTS

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

CONCLUSIONS

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

METHOD

A search was performed for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N = 2,345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

RESULTS

Parent training had robust small- to medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psychoeducation were negatively related to parental outcomes.

CONCLUSION

Although techniques were not investigated in isolation, the results suggested that manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

Investigating the associations between irritability and hot and cool executive functioning in those with ADHD

BACKGROUND

Irritability is especially pertinent to those with Attention Deficit Hyperactivity Disorder (ADHD) as it is highly prevalent and associated with a more severe clinical presentation and poorer longitudinal outcomes. Preliminary evidence suggests that top-down cognitive processes taking place in emotional contexts (i.e., hot executive functions) as opposed to those evoked in abstract scenarios (i.e., cool executive functions) may be relevant to the presentation of irritability in ADHD. This study explored the cognitive mechanisms underlying irritability in young people with ADHD, hypothesising that irritability would be associated with hot, but not cool, executive function impairments.

METHODS

Our sample included 219 individuals with ADHD. A composite irritability score was derived extracting items from a parent interview, with scores ranging from 0 to 5. Associations were investigated using linear regression analyses, between irritability and four hot tasks measuring sensitivity to risk, risk-taking behaviour following reward or punishment, acceptance of reward delay and reaction to unfair behaviour from others, and two cool tasks measuring set-shifting and motor inhibition.

RESULTS

As hypothesised, there were no significant associations between irritability and cool executive functions in those with ADHD; however, contrary to expectations, there was also no significant evidence that hot executive functions were associated with irritability.

CONCLUSIONS

These results, in a large well characterised sample and using a comprehensive task battery, suggest that the variation in irritability in those with ADHD may not be associated with differences in hot or cool executive function performance.

Impulsive and risky decision-making in adolescents with attention-deficit/hyperactivity disorder (ADHD): The need for a developmental perspective

Impulsive and risky decision-making peaks in adolescence, and is consistently associated with the neurodevelopmental disorder Attention-Deficit/Hyperactivity Disorder (ADHD), regardless of age. In this brief review, we demonstrate the similarity of theoretical models explaining impulsive and risky decision-making that originate in two relatively distinct literatures (i.e., on adolescence and on ADHD). We summarize research thus far and conclude that the presence of ADHD during adolescence further exacerbates the tendency that is already present in adolescents to make impulsive and risky decisions. We also conclude that much is still unknown about the developmental trajectories of individuals with ADHD with regard to impulsive and risky decision making, and we therefore provide several hypotheses that warrant further longitudinal research.

Transcranial Direct Current Stimulation Improves Reward Processing in Children With ADHD

Objective: Individuals with ADHD have deficits in reward processing and related cognitive tasks such as delay discounting and risky decision-making. The ventromedial prefrontal cortex (vmPFC) and dorsolateral prefrontal cortex (dlPFC) are two distinct cortical areas that are involved in reward processing. Methods: Twenty children with ADHD received transcranial direct current stimulation (tDCS) in three separate sessions with one of three montages each, including anodal/cathodal tDCS over the left dlPFC and right vmPFC respectively, the reversed montage, and a sham stimulation condition. During stimulation, in each session, participants performed the balloon analogue risk taking and chocolate delay discounting tasks. Results: A significant effect of stimulation condition on emotional processing was observed. Specifically, anodal tDCS over the right vmPFC, coupled with cathodal tDCS over the left dlPFC, reduced risky decision-making and delay discounting. Conclusion: These results imply that the left dlPFC and right vmPFC are involved in reward processing in children with ADHD. This finding is discussed in the light of the delay aversion theory of ADHD.

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

BACKGROUND

Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.

METHODS

We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.

RESULTS

We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents.

CONCLUSIONS

Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.

The Monash Autism-ADHD genetics and neurodevelopment (MAGNET) project design and methodologies: a dimensional approach to understanding neurobiological and genetic aetiology

Background

ASD and ADHD are prevalent neurodevelopmental disorders that frequently co-occur and have strong evidence for a degree of shared genetic aetiology. Behavioural and neurocognitive heterogeneity in ASD and ADHD has hampered attempts to map the underlying genetics and neurobiology, predict intervention response, and improve diagnostic accuracy. Moving away from categorical conceptualisations of psychopathology to a dimensional approach is anticipated to facilitate discovery of data-driven clusters and enhance our understanding of the neurobiological and genetic aetiology of these conditions. The Monash Autism-ADHD genetics and neurodevelopment (MAGNET) project is one of the first large-scale, family-based studies to take a truly transdiagnostic approach to ASD and ADHD. Using a comprehensive phenotyping protocol capturing dimensional traits central to ASD and ADHD, the MAGNET project aims to identify data-driven clusters across ADHD-ASD spectra using deep phenotyping of symptoms and behaviours; investigate the degree of familiality for different dimensional ASD-ADHD phenotypes and clusters; and map the neurocognitive, brain imaging, and genetic correlates of these data-driven symptom-based clusters.

Methods

The MAGNET project will recruit 1,200 families with children who are either typically developing, or who display elevated ASD, ADHD, or ASD-ADHD traits, in addition to affected and unaffected biological siblings of probands, and parents. All children will be comprehensively phenotyped for behavioural symptoms, comorbidities, neurocognitive and neuroimaging traits and genetics.

Conclusion

The MAGNET project will be the first large-scale family study to take a transdiagnostic approach to ASD-ADHD, utilising deep phenotyping across behavioural, neurocognitive, brain imaging and genetic measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-021-00457-3.

Decision-Making Deficits in Adolescent Boys with and without Attention-Deficit/Hyperactivity Disorder (ADHD): an Experimental Assessment of Associated Mechanisms

Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD) demonstrate increased levels of real-life risk-taking behavior like substance abuse and reckless behavior in traffic, which potentially originates in decision-making deficits. Using experimental gambling tasks, the current study investigated three potential underlying mechanisms: (1) risky vs. suboptimal decision making, (2) the complexity of decision-making strategies and (3) the influence of feedback. Participants were 181 male adolescents (81 ADHD, 100 Typically Developing (TD); M_age = 15.1 years). First, we addressed a common confound in many gambling tasks by disentangling risk seeking from suboptimal decision making, and found that ADHD-related decision-making deficits do not originate in increased risk seeking but in suboptimal decision making. Second, we assessed decision-making strategies with a Bayesian latent mixture analysis and found that ADHD-related decision-making deficits are characterized by the use of less complex strategies. That is, adolescent boys with ADHD, relative to TD adolescent boys, less often adopted strategies in which all characteristics relevant to make an optimal decision were integrated. Third, we administered two gambling task conditions with feedback in which adolescents experience the outcomes of their decisions and found that adolescents with ADHD performed worse relative to TD adolescents on both conditions. Altogether, this set of studies demonstrated consistent decision-making deficits in adolescent boys with ADHD: The use of less complex decision-making strategies may cause suboptimal decision making, both in situations with and without direct feedback on performance.

Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study

Objective: ADHD potentially leads to risky sexual behaviors, and is considered a major risk factor for early pregnancy (EP). However, the association between ADHD and subsequent EP remains unknown. Method: Seven thousand five hundred five adolescents with ADHD and 30,020 age- and sex-matched individuals without ADHD were enrolled from 2001 to 2009 and were followed until the end of 2011. Adolescents who developed any pregnancy (at age ≤30 years) or EP (at age <20 years) during the follow-up period were identified. Results: Adolescents with ADHD were found to be prone to pregnancy (hazard ratio [HR] = 1.27) and EP (HR = 2.30) compared with those without ADHD. Long-term ADHD medication use was related to a lower risk of subsequent any pregnancy (HR = 0.72) and EP (HR = 0.69). Conclusion: Adolescents with ADHD had an increased risk of any pregnancy and EP compared with their non-ADHD counterparts. Long-term ADHD medication use was associated with a lower subsequent EP risk.

A pilot study on the association between the blood oxygen level-dependent signal in the reward system and dopamine transporter availability in adults with attention deficit hyperactivity disorder

BACKGROUND

It is well-known that attention deficit hyperactivity disorder (ADHD) is associated with changes in the dopaminergic system. However, the relationship between central dopaminergic tone and the blood oxygen level-dependent (BOLD) signal during receipt of rewards and penalties in the corticostriatal pathway in adults with ADHD is unclear.

METHODS

Single-photon emission computed tomography with [99mTC]TRODAT-1 was used to assess striatal dopamine transporter (DAT) availability. Event-related functional magnetic resonance imaging was conducted on subjects performing the Iowa Gambling Test.

RESULT

DAT availability was found to be associated with the BOLD response, which was a covariate of monetary loss, in the medial prefrontal cortex (r = 0.55, P = .03), right ventral striatum (r = 0.69, P = .003), and right orbital frontal cortex (r = 0.53, P = .03) in adults with ADHD. However, a similar correlation was not found in the controls.

CONCLUSIONS

The results confirmed that dopaminergic tone may play a different role in the penalty-elicited response of adults with ADHD. It is plausible that a lower neuro-threshold accompanied by insensitivity to punishment could be exacerbated by the hypodopaminergic tone in ADHD.

Can Attention and Working Memory Impairments of Intimate Partner Perpetrators Explain Their Risky Decision Making?

Intimate partner violence (IPV) perpetrators commonly exhibit deficits in a wide range of cognitive domains, such as attention, memory, and executive functions. Executive dysfunctions tend to be related to a preference for disadvantageous decisions, which could be explained by a pattern of focusing on positive outcomes (gains) while disregarding negative ones. Nonetheless, it is less clear whether risk-taking and decision-making problems should be attributed to motivational and/or emotional causes or to cognitive deficits in attention and/or working memory. The main goal of the present study was to examine whether IPV perpetrators can be distinguished from non-violent controls based on their performance on attention, working memory, and decision-making tests from a computerized battery of tests. In addition, this study investigated the potential relationship between attention and working memory impairments in the decision-making abilities of IPV perpetrators. Our data indicated that IPV perpetrators perform worse than controls on measures of attention and sustained attention, processing speed, working memory, spatial span, and decision making. Moreover, IPV perpetrators' preference for disadvantageous and risky decisions could be partially explained by attention and working memory impairments. Our study has enabled us to explore the cognitive deficits underlying IPV perpetration as key factors in reducing IPV risky decisions. Moreover, it reinforces the need to develop specific neuropsychological training in the attention-switching ability in general and working memory, which could lead to improvements in decision-making processes or other executive functions.

Attention-deficit/hyperactivity disorder and risk-taking: A three-level meta-analytic review of behavioral, self-report, and virtual reality metrics

Meta-analytic methods were used to examine ADHD-related risk-taking in children and adults, and to compare the magnitude of risk taking across behavioral, self-report, and virtual reality metrics. Potential moderators of effect size heterogeneity were also examined via a three-level multi-level approach and a hybrid meta-analytic/systematic review approach. Aggregated effect sizes obtained from 56 behavioral-task studies (82 effect sizes; ADHD_N = 2577; TD_N = 2606), 51 self-report studies (130 effect sizes; ADHD_N = 18,641; TD_N = 113,163), and 8 virtual reality studies (16 effect sizes; ADHD_N = 382; TD_N = 436) suggest that children and adults with ADHD exhibit moderately more risk-taking compared to children and adults without the disorder. Notably, the aggregated effect size obtained from virtual reality simulations (Hedges', g = 0.43) was 30-40% larger than effect sizes obtained from self-report and behavioral task metrics (Hedges' g = 0.31 and 0.27), respectively. Suboptimal Decision Making was the only significant moderator identified via multi-level modeling; however, comparison of subgroup effect sizes revealed potential moderating effects of ADHD presentation and trial-by-trial feedback on behavioral tasks. Collectively, findings suggest that ADHD is reliably associated with small to moderate magnitude greater risk-taking behavior and virtual reality simulations appear be the most sensitive currently available metric.

A Meta-Analytic Review of Sex Differences on Delay of Gratification and Temporal Discounting Tasks in ADHD and Typically Developing Samples

Objective: To examine whether males and females with ADHD differ in their preferences for delayed rewards, since there is some evidence that suggests a sex difference with typically developing (TD) samples. Method: We used meta-analyses to examine sex differences on delay of gratification and temporal discounting tasks in both TD and ADHD samples. We identified 28 papers with 52 effect sizes for children and adults, and calculated the average effect size for sex comparisons within TD and ADHD samples. Results: The estimated mean difference between TD males and TD females was negligible, but males with ADHD were more likely to choose the larger delayed rewards than females with ADHD. Meta-regressions indicated that task type, age, and reward type did not significantly predict sex differences. Conclusion: These findings suggest that females referred for ADHD may make less adaptive choices by preferring smaller immediate rewards over larger delayed rewards more often than males with ADHD. Implications of our findings are discussed.

Decision-Making Deficits in ADHD Are Not Related to Risk Seeking But to Suboptimal Decision-Making: Meta-Analytical and Novel Experimental Evidence

Objective: ADHD is related to decision-making deficits in real-life (e.g., substance abuse) and on experimental tasks (increased preference for risky options). In most tasks, risk and expected value are confounded (risky options have lowest expected value), making it impossible to disentangle risky from suboptimal (i.e., not choosing highest expected value) decision-making. We differentiated between risky and suboptimal decision-making in ADHD in two studies. Method and Results: First, on a multilevel meta-regression analysis (k = 48, n_ADHD = 1,144, n_Control = 1,108), ADHD and controls differed if the risky option was suboptimal (ADHD choosing more risky/suboptimal), whereas groups performed similar if the risky option was not suboptimal. Second, an empirical study showed that adults with ADHD (n = 40) made more suboptimal, but not more risky choices than controls (n = 40). Conclusion: These results contribute to a growing body of evidence that decision-making deficits in ADHD are driven by suboptimal decision-making and not by risk seeking.

Risk variants and polygenic architecture of disruptive behavior disorders in the context of attention-deficit/hyperactivity disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is a childhood psychiatric disorder often comorbid with disruptive behavior disorders (DBDs). Here, we report a GWAS meta-analysis of ADHD comorbid with DBDs (ADHD + DBDs) including 3802 cases and 31,305 controls. We identify three genome-wide significant loci on chromosomes 1, 7, and 11. A meta-analysis including a Chinese cohort supports that the locus on chromosome 11 is a strong risk locus for ADHD + DBDs across European and Chinese ancestries (rs7118422, P = 3.15×10⁻¹⁰, OR = 1.17). We find a higher SNP heritability for ADHD + DBDs (h²_SNP = 0.34) when compared to ADHD without DBDs (h²_SNP = 0.20), high genetic correlations between ADHD + DBDs and aggressive (r_g = 0.81) and anti-social behaviors (r_g = 0.82), and an increased burden (polygenic score) of variants associated with ADHD and aggression in ADHD + DBDs compared to ADHD without DBDs. Our results suggest an increased load of common risk variants in ADHD + DBDs compared to ADHD without DBDs, which in part can be explained by variants associated with aggressive behavior.

ADHD is often found to be comorbid with disruptive behavior disorders, but the genetic loci underlying this comorbidity are unknown. Here, the authors have performed a GWAS meta-analysis of ADHD with disruptive behavior disorders, finding three genome-wide significant loci in Europeans, and replicating one in a Chinese cohort.

Shifting uncertainty intolerance: methylphenidate and attention-deficit hyperactivity disorder

Risk evaluation is a critical component of decision making. Risk tolerance is relevant in both daily decisions and pathological disorders such as attention-deficit hyperactivity disorder (ADHD), where impulsivity is a cardinal symptom. Methylphenidate, a commonly prescribed drug in ADHD, improves attention but has mixed reports on risk-based decision making. Using a double-blinded placebo protocol, we studied the risk attitudes of ADHD patients and age-matched healthy volunteers while performing the 2-step sequential learning task and examined the effect of methylphenidate on their choices. We then applied a novel computational analysis using the hierarchical drift-diffusion model to extract parameters such as threshold ('a'-amount of evidence accumulated before making a decision), drift rate ('v'-information processing speed) and response bias ('z' apriori bias towards a specific choice) focusing specifically on risky choice preference. Critically, we show that ADHD patients on placebo have an apriori bias towards risky choices compared to controls. Furthermore, methylphenidate enhanced preference towards risky choices (higher apriori bias) in both groups but had a significantly greater effect in the patient population independent of clinical scores. Thus, methylphenidate appears to shift tolerance towards risky uncertain choices possibly mediated by prefrontal dopaminergic and noradrenergic modulation. We emphasise the utility of computational models in detecting underlying processes. Our findings have implications for subtle yet differential effects of methylphenidate on ADHD compared to healthy population.

Executive Function Outcome of Treatment with Viloxazine Extended-Release Capsules in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Post-Hoc Analysis of Four Randomized Clinical Trials

AIM

The aim of this study was to evaluate the effect of viloxazine extended-release capsules (viloxazine ER; Qelbree™) on executive function deficits (EFDs) in pediatric subjects (6-17 years of age) with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Data from four phase III placebo-controlled trials of 100-600 mg/day viloxazine ER (6-8 weeks of treatment) were used to evaluate the change from baseline (CFB) in the Conners 3rd Edition Parent Short Form-Executive Function (C3PS-EF) content scale T-score. Subjects were defined as EFD responders if they had C3PS-EF T-score > 70 at baseline and < 65 at end of study. ADHD symptoms were assessed with ADHD Rating Scale 5th Edition (ADHD-RS-5). Subjects were defined as ADHD symptom responders if they had a ≥ 50% reduction in CFB ADHD-RS-5 Total score at Week 6. The number needed to treat (NNT) and Cohen's d effect sizes were estimated for EFD and ADHD symptoms.

RESULTS

A total of 1154 subjects were included in the analysis. Statistically significant improvements in EFDs were observed with viloxazine ER versus placebo (p = 0.0002). There were 52.5% of EFD or ADHD symptom responders in the viloxazine ER treatment group and 35.4% in the placebo group (p < 0.0001). The NNT was 5.8. The Cohen's d effect size for EFD and ADHD symptoms was 0.31.

CONCLUSION

Consistent with the efficacy of viloxazine ER demonstrated in pivotal trials, viloxazine ER significantly reduced EFDs in subjects with ADHD. Moreover, a substantial proportion of subjects treated with viloxazine ER had large improvements in EFDs, ADHD symptoms, or both.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT03247530, NCT03247517, NCT03247543, NCT03247556.

Using quantitative trait in adults with ADHD to test predictions of dual-process theory

Dual-process theory is a widely utilized modelling tool in the behavioral sciences. It conceptualizes decision-making as an interaction between two types of cognitive processes, some of them fast and intuitive, others slow and reflective. We make a novel contribution to this literature by exploring differences between adults with clinically diagnosed ADHD and healthy controls for a wide range of behaviors. Given the clinical picture and nature of ADHD symptoms, we had a strong a priori reason to expect differences in intuitive vs reflective processing; and thus an unusually strong case for testing the predictions of dual-process theory. We found mixed results, with overall weaker effects than expected, except for risk taking, where individuals with ADHD showed increased domain sensitivity for gains vs losses. Some of our predictions were supported by the data but other patterns are more difficult to reconcile with theory. On balance, our results provide only limited empirical support for using dual-process theory to understand basic social and economic decision-making.

Decision-making inflexibility in a reversal learning task is associated with severity of problem gambling symptoms but not with a diagnosis of substance use disorder

BACKGROUND

Decisions made by individuals with disordered gambling are markedly inflexible. However, whether anomalies in learning from feedback are gambling-specific, or extend beyond gambling contexts, remains an open question. More generally, addictive disorders-including gambling disorder-have been proposed to be facilitated by individual differences in feedback-driven decision-making inflexibility, which has been studied in the lab with the Probabilistic Reversal Learning Task (PRLT). In this task, participants are first asked to learn which of two choice options is more advantageous, on the basis of trial-by-trial feedback, but, once preferences are established, reward contingencies are reversed, so that the advantageous option becomes disadvantageous and vice versa. Inflexibility is revealed by a less effective reacquisition of preferences after reversal, which can be distinguished from more generalized learning deficits.

METHODS

In the present study, we compared PRLT performance across two groups of 25 treatment-seeking patients diagnosed with an addictive disorder and who reported gambling problems, and 25 matched controls [18 Males/7 Females in both groups, Mage(SDage) = 25.24 (8.42) and 24.96 (7.90), for patients and controls, respectively]. Beyond testing for differences in the shape of PRLT learning curves across groups, the specific effect of problematic gambling symptoms' severity was also assessed independently of group assignment. In order to surpass previous methodological problems, full acquisition and reacquisition curves were fitted using generalized mixed-effect models.

RESULTS

Results showed that (1) controls did not significantly differ from patients in global PRLT performance nor showed specific signs of decision-making inflexibility; and (2) regardless of whether group affiliation was controlled for or not, gambling severity was specifically associated with more inefficient learning in phases with reversed contingencies.

CONCLUSION

Decision-making inflexibility, as revealed by difficulty to reacquire decisional preferences based on feedback after contingency reversals, seems to be associated with gambling problems, but not necessarily with a substance-use disorder diagnosis. This result aligns with gambling disorder models in which domain-general compulsivity is linked to vulnerability to develop gambling-specific problems with exposure to gambling opportunities.

Driving Accidents, Driving Violations, Symptoms of Attention-Deficit-Hyperactivity (ADHD) and Attentional Network Tasks

Background: Iran has serious problems with traffic-related injuries and death. A major reason for traffic accidents is cognitive failure due to deficits in attention. In this study, we investigated the associations between traffic violations, traffic accidents, symptoms of attention-deficit/hyperactivity disorder (ADHD), age, and on an attentional network task in a sample of Iranian adults. Methods: A total of 274 participants (mean age: 31.37 years; 80.7% males) completed questionnaires covering demographic information, driving violations, traffic accidents, and symptoms of ADHD. In addition, they underwent an objective attentional network task (ANT), based on Posner’s concept of attentional networks. Results: More frequent traffic violations, correlated with lower age and poorer performance on the attentional network tasks. Higher symptoms of ADHD were associated with more accidents and more traffic violations, but not with the performance of the attentional tasks. Higher ADHD scores, a poorer performance on attentional network tasks, and younger age predicted traffic violations. Only higher symptoms of ADHD predicted more traffic accidents. Conclusions: In a sample of Iranian drivers, self-rated symptoms of ADHD appeared to be associated with traffic violations and accidents, while symptoms of ADHD were unrelated to objectively assessed performance on an attentional network task. Poor attentional network performance was a significant predictor of traffic violations but not of accidents. To increase traffic safety, both symptoms of ADHD and attentional network performance appear to merit particular attention.

Autistic traits in young adults who gamble

BACKGROUND.

Little is known about the relationship between autistic traits and addictive behaviors such as problem gambling. Thus, the present study examined clinical characteristics and multiple facets of cognition in young adults who gamble and have autistic traits.

METHODS.

A total of 102 young adults who gamble were recruited from two Mid-Western university communities in the United States using media advertisements. Autistic traits were examined using the brief Autism-Spectrum Quotient (AQ-10). Clinician rating scales, questionnaires, and cognitive tests were completed. Relationships between AQ10 scores and demographic, gambling symptom, and neurocognitive measures were evaluated.

RESULTS.

Autistic traits were correlated with disordered gambling symptoms, attention-deficit/hyperactivity disorder (ADHD) symptoms, trait impulsivity, and some types of obsessive-compulsive symptoms. In regression, ADHD no longer significantly related to autistic traits once disordered gambling symptoms were accounted for; whereas the link between autistic traits and disordered gambling symptoms was robust even controlling for ADHD.

CONCLUSIONS.

These data suggest a particularly strong relationship between autistic traits and problem gambling symptoms, as well as certain aspects of impulsivity and compulsivity. The link between ADHD and autistic traits in some prior studies may have been attributable to disordered gambling symptoms, which was likely not screened for, and since individuals may endorse ADHD instruments due to other impulsive/compulsive symptom types (eg, gambling). The contribution of autistic traits to the emergence and chronicity of disordered gambling now requires further scrutiny, not only in community samples (such as this) but also in clinical settings.

Risk Taking by Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): a Behavioral and Psychophysiological Investigation of Peer Influence

Adolescents with ADHD demonstrate increased risk-taking behavior (RTB) like substance abuse and dangerous traffic conduct. RTB in adolescence is more likely under peer influence. The current investigation (1) tests the hypothesis that adolescents with ADHD are particularly susceptible to such influence and (2) tests whether groups differed in autonomic reactivity to peer influence. Adolescent boys between 12 and 19 years with (n = 81) and without (n = 99) ADHD performed the Balloon Analogue Risk Task twice. In the peer condition, a highly credible virtual peer manipulation that encouraged risk taking was added, in the solo condition this was absent. Autonomic reactivity was indexed by heart rate (HR), pre-ejection period (PEP) and respiratory sinus arrhythmia (RSA). All adolescents engaged in more risk taking in the peer condition relative to solo condition. Autonomic differences between groups were only found on PEP: a stronger sympathetic response to peer influence was observed in typically developing adolescents relative to adolescents with ADHD. Increased physiological stress (as indexed by PEP) in the peer relative to the solo condition predicted peer-induced risk taking in all adolescents. We conclude that susceptibility to peer influence is not exaggerated in ADHD but rather reflects a general tendency of adolescents. As adolescents experiencing peer influence as stressful are most susceptible to peer influence, we suggest that increasing resistance to peer influence may be an important treatment aim for these adolescents specifically.

When Do those "Risk-Taking Adolescents" Take Risks? The Combined Effects of Risk Encouragement by Peers, Mild-to-Borderline Intellectual Disability and Sex

Adolescents with mild to borderline intellectual disability (MBID) show more daily life risk taking than typically developing adolescents. To obtain insight in when these "risk-taking adolescents" especially take risks, we investigated main and interaction effects of (a) MBID, (b) sex, and (c) type of peer influence on risk taking. The Balloon Analogue Risk Task (BART) was used as a proxy of real-life risk taking. 356 adolescents (12-19 years, 51.7% MBID, 63.4% boys) were randomly assigned to one of three BART peer-influence conditions: solo (no peers), positive risk encouragement (e.g., 'You are cool if you continue') or negative risk encouragement (e.g., 'You are a softy if you do not continue'). The main finding was that boys with MBID took more risks than typically developing boys in the negative risk encouragement condition. Boys with MBID also took more risks in the negative risk encouragement condition compared to the solo condition, whereas typically developing boys did not. There were no such effects for girls. Surprisingly, boys with MBID took less risks in the solo condition than typically developing boys. We conclude that boys with MBID especially show high risk taking when peers belittle or threat with exclusion from the peer group. Prevention and intervention programs should specifically target boys with MBID to teach them to resist negative risk encouragement by peers.

The Association of Non-obscene Socially Inappropriate Behavior With Attention-Deficit/Hyperactivity Disorder Symptoms, Conduct Problems, and Risky Decision Making in a Large Sample of Adolescents

Non-obscene socially inappropriate behavior (NOSI) is recognized as part of the tic disorder spectrum but has received little attention from researchers to date. A study in 87 patients with Tourette syndrome showed that comorbid attention-deficit/hyperactivity disorder (ADHD) and conduct disorder were also associated with an increase in socially inappropriate behavior. This study used data from the Millennium Cohort Study to investigate the relationship between NOSI and emotional symptoms, conduct problems, and hyperactivity/inattention as assessed by the Strengths and Difficulties Questionnaire (SDQ) in 1,280 youths, aged 14 years. Furthermore, the relationship between NOSI and decision-making processes as assessed by the Cambridge Gambling Task (CGT) was investigated. Hyperactivity/inattention and conduct problems were significantly associated with NOSI; emotional problems were not. Risk taking was significantly associated with misbehaving in lessons but not with being rude or noisy in public. The results replicate and confirm the association of NOSI with ADHD and conduct problems in a large sample, although it should be stressed that the size of the association was small. The results also suggest that some inappropriate behaviors are related to risk-taking behavior, while others are not.

Neurodevelopmental Trajectories Related to Attention Problems Predict Driving-Related Risk Behaviors

Objective: Investigate neurodevelopmental trajectories related to attention/hyperactivity problems (AP) in a community sample of adolescents and whether these trajectories predict later-emerging health risk behaviors. Method: One hundred sixty-six participants underwent up to three magnetic resonance imaging (MRI) scans (n = 367) between 11 and 20 years of age. AP were measured during early adolescence using the Child Behaviour Checklist, and engagement in risk behaviors was measured during late adolescence using the "DRIVE" survey (i.e., driving risks) and items assessing alcohol-harms. Results: Greater AP scores during early adolescence were related to less reduction over time of left dorsal prefrontal, left ventrolateral prefrontal, and right orbitofrontal thickness. Less thinning of the orbitofrontal cortex was related to greater driving-related risk behaviors at late adolescence. Conclusion: Findings highlight altered neurodevelopmental trajectories in adolescents with AP. Furthermore, altered orbitofrontal development was related to later-emerging driving-related risk, and this neurobiological change mediated the association between attention problems and risk behaviors.