Evidence for increased behavioral control by punishment in children with attention-deficit hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) in cultural context II: a comparison of the links between ADHD symptoms and waiting-related responses in Hong Kong and UK

The concept of attention-deficit/hyperactivity disorder (ADHD) is considered to have cross-cultural validity, but direct comparisons of its psychological characteristics across cultures are limited. This study investigates whether preschool children's ADHD symptoms expressed in two cultures with different views about child behaviour and parenting, Hong Kong and the UK, show the same pattern of associations with their waiting-related abilities and reactions, an important marker of early self-regulation. A community sample of 112 preschoolers (mean age = 46.22 months; 55 from UK, 57 from HK) completed three tasks measuring different waiting elements - waiting for rewards, choosing the amount of time to wait, and having to wait unexpectedly when a task is interrupted. Participants' waiting-related behavioural and emotional reactions were coded. Parents rated their children's ADHD symptoms and delay aversion. Our findings revealed that the associations between ADHD symptoms and waiting-related responses were comparable in both UK and HK samples. This suggests that the core psychological characteristics of ADHD, particularly in relation to waiting behaviours, may exhibit similarity across cultural contexts. Future research can extend this cross-cultural analysis to other ADHD-related psychological domains and explore additional cultural settings.

Behavioral and Emotional Responding to Punishment in ADHD: Is Increased Emotionality Related to Altered Behavioral Responding?

Children with ADHD are theorized to experience increased negative emotional responses to punishment, compared to typically developing (TD) children, resulting in altered behavioral responding (Amsel, 1992). However, this has not been empirically tested. The current study evaluated the effects of punishment and reward on the behavioral and emotional responding of children with and without ADHD. Fifty-three children with ADHD (64.15% boys) and 46 TD children (47.83% boys), age 6-12, completed a task in which they chose between playing two simultaneously available games. Reward was arranged symmetrically across the games; responses on one game were punished four times as often as responses on the other game. Children's negative and positive emotional expressions were assessed during task completion with facial expression coding. Results indicated both groups showed a preference for playing the less punished game. Children with ADHD took longer to respond after punishment and reward compared to TD children. Negative emotional expressions increased with time on task for those with ADHD, the opposite pattern was seen in TD children. Children with ADHD showed more positive emotional expressions overall. The effect of ADHD on increased response times after reward was statistically fully mediated by increased positive facial expressions. Findings indicate children with ADHD do not show an altered response bias under punishment compared to TD children, but their cumulative negative emotional responding may indicate problems with building frustration tolerance as hypothesized by Amsel (1992). Results are theoretically important as they suggest increased emotional responding in ADHD is associated with slower responding.

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Relationships between experimental task and questionnaire measures of reward/punishment sensitivity in attention-deficit/hyperactivity disorder (ADHD): protocol for a scoping review

INTRODUCTION

One of the purported underlying causal mechanisms of attention deficit hyperactivity disorder (ADHD) is altered motivational processes. Questionnaires have been used to identify the characteristics of reward and punishment sensitivity in individuals with ADHD. However, these questionnaires were initially developed to measure individual traits related to anxiety (inhibitory) and impulsivity (approach) tendencies or differences in pleasure-seeking. These reward and punishment sensitivity questionnaires are useful but might not capture all relevant aspects of altered motivational processes in ADHD. The proposed scoping review aims to: (1) examine which aspects of hypothesised altered reward and punishment sensitivity correspond to constructs measured by existing questionnaires, (2) characterise the relationships between ADHD symptomatology and reward and punishment sensitivity as measured by existing questionnaires and (3) evaluate the consistency between the altered reward and punishment sensitivity as measured by existing questionnaires and experimental task performance.

METHODS AND ANALYSIS

Reporting of the scoping review results will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and the Joanna Briggs Methodology for Scoping Reviews. Published English-language literature was searched in three electronic databases (PubMed, Web of Science, APA PsycINFO) on 16 November 2023, with no restriction on the year of publication. Two researchers independently screened all identified titles/abstracts before proceeding to full-text review and additional handsearching of relevant studies. A narrative review and conclusions will be presented together with tables summarising the articles reviewed and the results organised by the three aims.

ETHICS AND DISSEMINATION

This study reviews existing publications with ethical approval in place. Therefore, ethical approval is not required. Review results will be disseminated through academic conferences and peer-reviewed manuscripts. Scoping review results will also inform future research to measure and identify altered motivational processes in ADHD.

Knowledge and attitudes on attention deficit hyperactivity disorder (ADHD) among school teachers in Anuradhapura district, Sri Lanka: a descriptive cross-sectional study

OBJECTIVE

This study aimed to assess the knowledge and attitude of school teachers from a rural district in a developing country towards children with attention deficit hyperactivity disorder (ADHD).

DESIGN

A population-based descriptive cross-sectional study was conducted using probability proportionate to size cluster sampling.

SETTING

This study was conducted in 21 government schools in Anuradhapura district, Sri Lanka.

PARTICIPANTS

The study sample consisted of 458 teachers with a mean age of 41 completed years ranging from 24 to 59 years.

MAIN OUTCOME MEASUREMENTS

We assessed knowledge, attitudes and sources of information on ADHD using the self-administered, validated Knowledge of Attention Deficit Disorder Scale (KADD), Teacher Attitudes Towards Inclusion Scale (TAIS) and the Perceived and Actual Sources of Information questionnaires.

RESULTS

The median KADD score was 11 (IQR 8-14) and 45.5% (n=208) of participants lacked sufficient knowledge. Percentages of the correct answers, misconceptions and 'don't know' responses were 28.2%, 24.5% and 45.5%, respectively. The majority of teachers believed that the children with ADHD generally experience more problems in novel situations than in familiar situations (63.5%), a diagnosis of ADHD by itself makes a child eligible for placement in special education (61.1%), and children with ADHD do not often have difficulties organising tasks and activities (61.1%). Some participants (12%) stated that punishment would improve the outcome of the children with ADHD. The attitudes were positive with TAIS 1 and 2 median scores of 46 (IQR 36-58) and 49 (IQR 40-59). The majority of participants relied on informal knowledge gained through their personal experience in the classroom on ADHD (n=337, 76%). The majority of teachers (n=300, 67.7%) preferred to be educated through seminars.

CONCLUSIONS

School teachers possess a positive attitude. However, they have poor knowledge and significant misconceptions regarding ADHD which may affect the identification and management.

Effect of financial and non-financial reward and punishment for inhibitory control in boys with attention deficit hyperactivity disorder

BACKGROUND

The development of inhibitory processes is disturbed in children with attention deficit hyperactivity disorder (ADHD); however, little is known about the effect of negative punishment for inhibitory performance in this population.

AIMS

We investigated differences in the effects of reward and punishment, developmental changes, and response inhibition between children with and without ADHD, using financial (F-FB) and non-financial (NF-FB) feedback.

METHODS AND MATERIALS

We conducted financial and non-financial go/no-go tasks under reward and punishment conditions with 21 boys with ADHD and 21 healthy controls (HCs), in Japan.

OUTCOMES AND RESULTS

We found group-related significant interactions between group, feedback type, and punishment (p = .013), and group, feedback type, and age (p = .009). There were significant differences in inhibitory error under F-FB only in HCs between the punishment-absent and punishment-present conditions (p = .003). In the ADHD group, age-dependent effects were found for both feedback types (ps < .01), but only F-FB effects were found in HCs (p = .008).

CONCLUSIONS AND IMPLICATIONS

Punishment for inhibitory control had different effects on the ADHD and HC groups. Children with ADHD respond differently to external motivation than HCs, leading to difficulties with peers or confusion among teachers and caregivers.

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.

Serious Video Games: Angels or Demons in Patients With Attention-Deficit Hyperactivity Disorder? A Quasi-Systematic Review

OBJECTIVE

To carry out a quasi-systematic review of the use of serious video games for health as a cognitive rehabilitative tool in patients diagnosed with attention-deficit hyperactivity disorder.

METHOD

A quasi-systematic review of serious video games used as an evaluative and rehabilitative tool in patients with ADHD was conducted. It included behavioral patterns in the use of video games and addiction problems in this population. For its elaboration the PRISMA GUIDES were followed. The search was carried out in three PubMed databases, MEDLINE, and PsycInfo using the keywords: [game OR serious game OR computer game) AND (psychotherapy OR rehabilitation OR intervention OR mental disorders) AND (adhd)], [(adhd) AND (Video game addiction)]. All articles written in English, Spanish, or Portuguese from January 1970 to June 2021 were included: those in which reference was made to the use of video games and/or new technologies as a therapeutic and evaluative tool in children and adults diagnosed with ADHD, as well as those that referred to behavioral and clinical patterns in the use of video games.

RESULTS

We found 605 articles of which 128 were reviewed (44 observational studies, 26 quasi-experimental studies, 26 experimental studies, 8 systematic reviews, 9 narrative texts, 6 case reports, 7 pilot studies, 8 systematic reviews, and 2 meta-analyses). Serious video games can be used to ameliorate ADHD symptoms while improving adherence to treatment. Some serious video games show high accuracy properties assessing ADHD features.

CONCLUSION

Serious video games for health are increasingly being used as a cognitive rehabilitation tool in patients with attention-deficit hyperactivity disorder (ADHD).

SYSTEMATIC REVIEW REGISTRATION

[www.crd.york.ac.uk/prospero], identifier [CRD42021247784].

The Limits of Motivational Influence in ADHD: No Evidence for an Altered Reaction to Negative Reinforcement

Functional magnetic resonance imaging studies have reported a diminished response in the brain’s reward circuits to contingent cues predicting future monetary gain in adolescents with attention-deficit/hyperactivity disorder (ADHD). The situation with regard to monetary loss is less clear, despite recognition that both positive and negative consequences impact ADHD behaviour. Here, we employ a new Escape Monetary Loss Incentive task in an MRI scanner, which allows the differentiation of contingency and valence effects during loss avoidance, to examine ADHD-related alterations in monetary loss processing. There was no evidence of atypical processing of contingent or non-contingent monetary loss cues in ADHD — either in terms of ratings of emotional and motivational significance or brain responses. This suggests that the ability to process contingencies between performance and negative outcomes is intact in ADHD and that individuals with ADHD are no more (or less) sensitive to negative outcomes than controls. This latter finding stands in stark contrast to recent evidence from a similar task of atypical emotion network recruitment (e.g. amygdala) in ADHD individuals to cues predicting another negative event, the imposition of delay, suggesting marked specificity in the way they respond to negative events.

How to Improve Behavioral Parent and Teacher Training for Children with ADHD: Integrating Empirical Research on Learning and Motivation into Treatment

Attention deficit hyperactivity disorder [ADHD] is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively. Recommended psychosocial evidence-based treatment for preschool and school-aged children is behavioral parent and teacher training [BPT]. The core elements of BPT are instrumental learning principles, i.e., reinforcement of adaptive and the ignoring or punishment of non-adaptive behaviors together with stimulus control techniques. BPT is moderately effective in reducing oppositional behavior and improving parenting practices; however, it does not reduce blinded ratings of ADHD symptoms. Also after training effects dissipate. This practitioner review proposes steps that can be taken to improve BPT outcomes for ADHD, based on purported causal processes underlying ADHD. The focus is on altered motivational processes (reward and punishment sensitivity), as they closely link to the instrumental processes used in BPT. Following a critical analysis of current behavioral treatments for ADHD, we selectively review motivational reinforcement-based theories of ADHD, including the empirical evidence for the behavioral predictions arising from these theories. This includes consideration of children's emotional reactions to expected and unexpected outcomes. Next we translate this evidence into potential ADHD-specific adjustments designed to enhance the immediate and long-term effectiveness of BPT programs in addressing the needs of children with ADHD. This includes the use of remediation strategies for proposed deficits in learning not commonly used in BPT programs and cautions regarding the use of punishment. Finally, we address how these recommendations can be effectively transferred to clinical practice.

Is increased sensitivity to punishment a common characteristic of attention deficit/hyperactivity disorder? An experimental study of response allocation in Japanese children

Research on motivational processes in attention deficit/hyperactivity disorder (ADHD) focuses on reward. Studies with punishment are limited and findings mixed. This study evaluated the effects of punishment on response allocation in Japanese children with and without ADHD. Thirty-four children meeting DSM-IV criteria for ADHD and 59 typically developing control-group children completed an operant task in which they choose between playing two simultaneously available games. Reward was arranged symmetrically across the games under concurrent variable interval schedules. Asymmetric punishment schedules were superimposed with responses on one game punished four times as often as responses on the other. Children with ADHD showed greater behavioral sensitivity to punishment than controls. They allocated significantly more responses to the less frequently punished alternative and were more likely to play this game on consecutive trials and responded more slowly to the more punished game. Control group children allocated their responses evenly across games. Punishment exerted greater control over the behavior of Japanese children with ADHD than controls, similar to findings with children from Western countries, suggesting this is a common characteristic of the disorder. The behavior of typically developing Japanese children, while demonstrating awareness of punishment, was not controlled by the frequency of its occurrence.

Development of the frontal lobe

Development of the frontal lobe is critical to acquisition, execution, and control of a wide range of functions, from basic motor response to complex decision-making. These functions are influenced by contingency-based (e.g., reward and response-cost/punishment) feedback that is mediated through the adaptive integration of fronto-subcortical neural circuitry. The frontal lobe manages incoming information and chooses the appropriate action based on one's goals in a particular context. This aspect of frontal function, while only one component, is crucial to development and maintenance of approach and avoidance behavior central to all human (and animal) behavior. Furthermore, disruptions in fronto-subcortical circuitry governing motivated behavior appear to contribute to a range of developmental disorders, including attention-deficit/hyperactivity disorder (ADHD), and confer vulnerability for psychopathology more broadly. The particular deficits that manifest in altered behavior depend upon the specific circuitry that is compromised due to the functional specificity of distinct regions of the frontal lobe and its interconnections with subcortical structures. Neurobiologic models of motivated behavior provide a valuable framework for characterizing developmental disorders from a transdiagnostic dimensional systems perspective. Improved characterization of approach and avoidance motivation across neurodevelopmental disorders has the potential to inform the development of novel interventions and personalized medicine.

Children's Reward and Punishment Sensitivity Moderates the Association of Negative and Positive Parenting Behaviors in Child ADHD Symptoms

Atypical reward processing, including abnormal reward responsivity and sensitivity to punishment, has long been implicated in the etiology of ADHD. However, little is known about how these facets of behavior interact with positive (e.g., warmth, praise) and negative (e.g., hostility, harsh discipline) parenting behavior in the early expression of ADHD symptoms in young children. Understanding the interplay between children's reward processing and parenting may be crucial for identifying specific treatment targets in psychosocial interventions for ADHD, especially given that not all children benefit from contingency-based treatments (e.g., parent management training). The study consisted of a sample of kindergarten children (N = 201, 55% male) and their parents, who completed questionnaires about their parenting practices, their child's behaviors and participated in an observed parent-child play task in the laboratory. Children's reward responsivity and sensitivity to punishment were positively associated with child ADHD symptoms. However, children with high reward responsivity had more symptoms of ADHD but only under conditions of low negative parenting (self-reported and observed) and high self-reported positive parenting, compared to children with low reward responsivity. Children with high sensitivity to punishment had more ADHD symptoms relative to children with low sensitivity to punishment, but only under conditions in which observed praise was infrequent. Results provide evidence that individual differences in sensitivity to reward/punishment may be an important of marker of risk for ADHD, but also highlights how children's responses to positive and negative parenting behavior may vary by children's sensitivities. Clinical and treatment implications are discussed.

COMT Val158Met Polymorphism and Social Impairment Interactively Affect Attention-Deficit Hyperactivity Symptoms in Healthy Adolescents

The dopaminergic system has been shown to have substantial effects on the etiology of attention-deficit hyperactivity disorder (ADHD). However, while some studies found a significant direct effect, others did not. In this context, social behavior might play an important role as a factor that is related both to the dopaminergic system and ADHD. In a large epidemiological sample of adolescents (N = 462; 16-17 years), we assessed the level of ADHD symptoms using the Strengths and Difficulties Questionnaire, social behavior using the Social Responsiveness Scale, and the allelic distribution of the dopaminergic catechol-O-methyltransferase (COMT) Val158Met polymorphism. We found a significant association between COMT and social impairment, insofar as Met-allele carriers showed increased levels of social impairment. Moreover, social impairment significantly determined an association between COMT and ADHD (explained variance: 19.09%). This effect did not significantly differ between males and females. COMT and social impairment might interactively affect ADHD symptomatology, and could thus represent significant gene-phenotypic risk factors for ADHD symptomatology. This might have interesting implications for prevention and intervention strategies with a focus on social behavior in genetically at-risk individuals.

An electrophysiological investigation of reinforcement effects in attention deficit/hyperactivity disorder: Dissociating cue sensitivity from down-stream effects on target engagement and performance

Objective

Neural hypo-sensitivity to cues predicting positive reinforcement has been observed in ADHD using the Monetary Incentive Delay (MID) task. Here we report the first study using an electrophysiological analogue of this task to distinguish between (i) cue related anticipation of reinforcement and downstream effects on (ii) target engagement and (iii) performance in a clinical sample of adolescents with ADHD and controls.

Methods

Thirty-one controls and 32 adolescents with ADHD aged 10–16 years performed the electrophysiological (e)-MID task − in which preparatory cues signal whether a response to an upcoming target will be reinforced or not − under three conditions; positive reinforcement, negative reinforcement (response cost) and no consequence (neutral). We extracted values for both cue-related potentials known to be, both, associated with response preparation and modulated by reinforcement (Cue P3 and Cue CNV) and target-related potentials (target P3) and compared these between ADHD and controls.

Results

ADHD and controls did not differ on cue-related components on neutral trials. Against expectation, adolescents with ADHD displayed Cue P3 and Cue CNV reinforcement-related enhancement (versus neutral trials) compared to controls. ADHD individuals displayed smaller target P3 amplitudes and slower and more variable performance − but effects were not modulated by reinforcement contingencies. When age, IQ and conduct problems were controlled effects were marginally significant but the pattern of results did not change.

Discussion

ADHD was associated with hypersensitivity to positive (and marginally negative) reinforcement reflected on components often thought to be associated with response preparation − however these did not translate into improved attention to targets. In the case of ADHD, upregulated CNV may be a specific marker of hyper-arousal rather than an enhancement of anticipatory attention to upcoming targets. Future studies should examine the effects of age, IQ and conduct problems on reinforcement sensitivity in ADHD.