Community-Delivered Evidence-Based Practice and Usual Care for Adolescent Attention-Deficit/Hyperactivity Disorder: Examining Mechanistic Outcomes.

Previous research suggests that routine psychosocial care for adolescents with attention-deficit/hyperactivity disorder (ADHD) is an eclectic and individualized mix of diluted evidence-based practices (EBPs) and low-value approaches. This study evaluated the extent to which a community-delivered EBP and usual care (UC) for adolescents with ADHD produce differential changes in theorized behavioral, psychological, and cognitive mechanisms of ADHD. A randomized community-based trial was conducted with double randomization of adolescent and community therapists to EBP delivery supports (Supporting Teens' Autonomy Daily [STAND]) versus UC delivery. Participants were 278 culturally diverse adolescents (ages 11-17) with ADHD and caregivers. Mechanistic outcomes were measured at baseline, post-treatment, and follow-up using parent-rated, observational, and task-based measures. Results using linear mixed models indicated that UC demonstrated superior effects on parent-rated and task-based executive functioning relative to STAND. However, STAND demonstrated superior effects on adolescent motivation and reducing parental intrusiveness relative to UC when it was delivered by licensed therapists. Mechanisms of community-delivered STAND and UC appear to differ. UC potency may occur through improved executive functioning, whereas STAND potency may occur through improved teen motivation and reducing low-value parenting practices. However, when delivered by unlicensed, community-based therapists, STAND did not enact proposed mechanisms. Future adaptations of community-delivered EBPs for ADHD should increase supports for unlicensed therapists, who comprise the majority of the community mental health workforce.

Temporal discounting in children and adolescents with and without attention-deficit/hyperactivity disorder: a comparison of four scoring methods.

Temporal discounting (TD) tasks measure the preference for immediate rewards over larger delayed rewards and have been widely used to study impulsivity in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). Relatively impulsive individuals tend to show high inconsistency in their choices, which makes it difficult to determine commonly used TD outcome measures (e.g., area under the curve, AUC). In this study, we leveraged two published datasets to compare four methods to compute TD outcome measures in children and adolescents (8-17 years) with (n = 107) and without ADHD (n = 128): two predetermined rules methods, a proportion method, and logistic regression. In both datasets, when using the two predetermined rules methods and the proportion method, TD outcomes were highly correlated and group differences in TD were similar. When using logistic regression, a large proportion of AUCs (95% in dataset 1; 33% in dataset 2) could not be computed due to inconsistent choice patterns. These findings indicate that predetermined rules methods (for studies with small sample sizes and experienced raters) and a proportion method (for studies with larger sample sizes or less experienced raters) are recommended over logistic regression when determining subjective reward values for participants with inconsistent choice patterns.

Studying Motivation in ADHD: The Role of Internal Motives and the Relevance of Self Determination Theory.

OBJECTIVE: Motivation is what moves us to act, what engages us in goal-directed behavior. The Self Determination Theory (SDT) is a motivational framework conceptualizing motivation-or internal motives-as a continuum of motivation qualities fueled by satisfaction of the three basic psychological needs Autonomy, Relatedness, and Competence. ADHD has been associated with motivational alterations that contribute to academic difficulties. However, ADHD theories and research are mainly focused on the effects of reinforcement on behavior, with little attention for the broader definition of motivation, that is, internal motives. Therefore, the main objective here was to introduce the SDT as theoretical framework within which we can develop relevant research questions about motivation in the field of ADHD. METHOD: To this end, we (i) present the SDT as a comprehensive motivational framework, and (ii) describe current motivation-related ADHD theories and research. RESULTS: Based on this, we suggest how SDT can be used as a guiding framework in generating relevant research questions that can help broaden our understanding of the role motivation plays in individuals with ADHD. CONCLUSION: We conclude that ADHD research on motivation would benefit from (i) including internal motives as potential key mediators in the relation between environmental factors and behavior/symptoms; (ii) studying potential negative effects of external reinforcers intrinsic motivation, affect, and well-being. Finally, we conclude that this framework carries value for further development of clinical interventions for those with ADHD.

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.

Do ADHD Symptoms, Executive Function, and Study Strategies Predict Temporal Reward Discounting in College Students with Varying Levels of ADHD Symptoms? A Pilot Study.

The purpose of this study was to examine the relationship between temporal reward discounting and attention deficit hyperactivity disorder (ADHD) symptoms in college students. Additionally, we examined whether temporal reward discounting was associated with executive functioning in daily life and with learning and study strategies in this group. Thirty-nine college students (19 with ADHD and 20 controls) participated after meeting criteria for ADHD or non-ADHD based on standardized assessment. Strong preferences for small immediate rewards were specifically associated with the ADHD symptom domain hyperactivity-impulsivity. Additionally, these preferences were associated with daily life executive function problems and with weak learning and study strategies. This suggests that steep temporal discounting may be a key mechanism playing a role in the daily life challenges that college students with ADHD symptoms face. If these findings are replicated in larger samples, then intervention strategies may profitably be developed to counteract this strong preference for small immediate rewards in college students with ADHD symptoms.

Feasibility, Acceptability, and Effectiveness of a New Cognitive-Behavioral Intervention for College Students with ADHD.

OBJECTIVE: This purpose of this study was to assess the feasibility, acceptability, and effectiveness of a new group cognitive-behavioral treatment (CBT) to enhance executive function (EF) in college students with ADHD. METHODS: Eighteen students meeting rigorous DSM-5 criteria for ADHD were enrolled in two nine-member groups. The treatment targeted time-awareness, distractibility, procrastination, and failure to plan, and included strategies to facilitate academic EF skills. RESULTS: Eighty-four percent of students attended nine or more of the 12 weekly sessions. Repeated measures analyses of change from pre- to posttreatment yielded improvement in clinician- and self-ratings of DSM-5 ADHD inattentive symptoms, with robust effect sizes. Also improved were scores on standardized scales of time-management, concentration, and total EF. DISCUSSION: Results provide support for the feasibility, acceptability, and effectiveness of a CBT program in reducing inattentive symptoms and enhancing EF in college students with ADHD, and warrant investigation on a larger scale.

Effects of Substance Misuse and Family History of Substance Use Disorder on Delay Discounting in Adolescents and Young Adults with Attention-Deficit/Hyperactivity Disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) often co-occur. Both disorders are characterized by impulsive choice. However, little is known about the effects of substance misuse (SM) and family history of SUD (FH) on impulsive choice in ADHD-SUD comorbidity. Impulsive choice is also linked to callous-unemotional (CU) traits, which are suggested to play a role in ADHD-SUD comorbidity. Our aim was to examine the effects of (1) FH and (2) SM on impulsive choice, while exploring the role of CU traits. METHODS: Impulsive choice was assessed with the delay discounting (DD) task. We compared task performance across (1) ADHD patients and controls with or without FH of SUD (ADHD FH+: n = 86; ADHD FH-: n = 63; control FH+: n = 49; control FH-: n = 72; mean age of the whole sample [n = 270]: 16.39, SD: 3.43) and (2) family history-matched ADHD groups with and without SM and controls (ADHD + SM: n = 62; ADHD-only: n = 62; controls: n = 62; mean age of the whole sample [n = 186]: 18.01, SD: 2.71). Effects of CU traits were explored by adding this as a covariate in all analyses. RESULTS: (1) There was no main effect of FH on DD. (2) We found increased DD in ADHD + SM compared to ADHD-only and no difference between ADHD-only and controls. Finally, increased DD was associated with increased callous traits only in ADHD FH+ and control FH+. CONCLUSIONS: In adolescents and young adults with ADHD, high impulsive choice might only be present in those with comorbid SM and in an FH+ subgroup with high callous traits. This suggests that impulsive choice in ADHD might result from (1) effects of SM and (2) a combined effect of SUD vulnerability and high callousness. Future studies should investigate efficacy of early interventions, targeting CU traits.

Cognitive-motivational, interpersonal, and behavioral functioning in relationship to treatment and research engagement in forensic patients with ADHD.

OBJECTIVES: To provide more insight into treatment and research responsivity in offenders with attention-deficit hyperactivity disorder (ADHD). METHOD: Via self-reports and patients' scores on cognitive computer tasks, it was examined whether poorer cognitive-motivational, interpersonal, and behavioral functioning were related to treatment no-shows, longer treatment time duration intervals, and no-show at the research appointment in 52 forensic outpatients with ADHD (Mage = 35.3, SD = 9.38). Treatment adherence was tracked for 10 appointments after research participation. RESULTS: Regression analyses showed that higher self-reported impulsivity was associated with research no-show, and more alcohol use with longer treatment time intervals. Yet, self-reported delay aversion was associated with fewer treatment no-shows, and, uncontrolled for alcohol use, impulsivity was associated with shorter treatment time intervals in a subsample of patients. CONCLUSIONS: These preliminary results indicate that externalizing behaviors increase the risk for nonadherence in forensic ADHD patients, but that cognitive-motivational problems also motivate patients to be more engaged.

A Dyadic Test of the Association Between Trait Self-Control and Romantic Relationship Satisfaction.

Previous research has demonstrated that trait self-control is related to a range of positive romantic relationship processes, suggesting that trait self-control should be positively and robustly linked to relationship satisfaction in both partners in a romantic relationship. However, the existing empirical evidence is limited and mixed, especially regarding partner effects (i.e., the effect of one's self-control on the partner's relationship satisfaction). With three datasets of heterosexual couples (S1: N = 195 newlyweds, longitudinal; S2: N = 249 couples who transition into first parenthood, longitudinal; S3: N = 929 couples, cross-sectional), the present pre-registered studies examined: (1) the dyadic associations between trait self-control and relationship satisfaction both cross-sectionally and longitudinally, and (2) whether these effects hold when controlling for both partners' relationship commitment. The results indicated a cross-sectional positive actor effect, some support for a positive cross-sectional partner effect, and only little support for a longitudinal actor (but not partner) effect. After controlling for relationship commitment, all effects of trait self-control on satisfaction diminished except for a longitudinal actor effect among women in Study 2. Potential explanations for the current results, and implications for theory and practice, are discussed.

Behavioral trainings and manipulations to reduce delay discounting: A systematic review.

In everyday decision-making, individuals make trade-offs between short-term and long-term benefits or costs. Depending on many factors, individuals may choose to wait for larger delayed reward, yet in other situations they may prefer the smaller, immediate reward. In addition to within-subject variation in the short-term versus long-term reward trade-off, there are also interindividual differences in delay discounting (DD), which have been shown to be quite stable. The extent to which individuals discount the value of delayed rewards turns out to be associated with important health and disorder-related outcomes: the more discounting, the more unhealthy or problematic choices. This has led to the hypothesis that DD can be conceptualized as trans-disease process. The current systematic review presents an overview of behavioral trainings and manipulations that have been developed to reduce DD in human participants aged 12 years or older. Manipulation studies mostly contain one session and measure DD directly after the manipulation. Training studies add a multiple session training component that is not per se related to DD, in between two DD task measurements. Ninety-eight studies (151 experiments) were identified that tested behavioral trainings and manipulations to decrease DD. Overall, results indicated that DD can be decreased, showing that DD is profoundly context dependent and changeable. Most promising avenues to pursue in future research seem to be acceptance-based/mindfulness-based trainings, and even more so manipulations involving a future orientation. Limitations and recommendations are discussed to identify the mechanistic processes that allow for changes in discount rate and behavior accordingly.

Prospective memory (partially) mediates the link between ADHD symptoms and procrastination.

Individuals with attention deficit hyperactivity disorder (ADHD) often show poor planning and poor organization of tasks and activities which has been related to reduced memory for delayed intentions (prospective memory) and procrastination-in addition to other cognitive or motivational factors. This study set out to bring the fields of prospective memory and procrastination research together and to explore possible relations between the two constructs in ADHD. Twenty-nine adults with ADHD and 24 healthy controls performed several laboratory-based and real-life prospective memory tasks and filled in questionnaires measuring their symptom severity and procrastination behaviour. Overall, individuals' with ADHD showed clear deficits in everyday prospective memory performance. Individuals with ADHD recalled and executed less of their own real-life intentions. Moreover, there were clear links between everyday prospective memory performance and reported procrastination behaviour, and everyday prospective memory performance mediated the link between ADHD symptoms and procrastination behaviour.

Delay discounting of monetary gains and losses in adolescents with ADHD: Contribution of delay aversion to choice.

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are known to have stronger preferences for smaller immediate rewards over larger delayed rewards in delay discounting tasks than their peers, which has been argued to reflect delay aversion. Here, participants performed a delay discounting task with gains and losses. In this latter condition, participants were asked whether they were willing to wait in order to lose less money. Following the core assumption of the delay aversion model that individuals with ADHD have a general aversion to delay, one would predict adolescents with ADHD to avoid waiting in both conditions. Adolescents (12-17 years) with ADHD (n = 29) and controls (n = 28) made choices between smaller immediate and larger delayed gains, and between larger immediate and smaller delayed losses. All delays (5-25 s) and gains/losses (2-10 cents) were experienced. In addition to an area under the curve approach, a mixed-model analysis was conducted to disentangle the contributions of delay duration and immediate gain/delayed loss amount to choice. The ADHD group chose the immediate option more often than controls in the gain condition, but not in the loss condition. The contribution of delay duration to immediate choices was stronger for the ADHD group than the control group in the gain condition only. In addition, the ADHD group scored higher on self-reported delay aversion, and delay aversion was associated with delay sensitivity in the gain condition, but not in the loss condition. In sum, we found no clear evidence for a general aversion to delay in adolescents with ADHD.

Waiting and working for rewards: Attention-Deficit/Hyperactivity Disorder is associated with steeper delay discounting linked to amygdala activation, but not with steeper effort discounting.

OBJECTIVE: Children and adolescents with ADHD have a relatively strong preference for smaller immediate rewards over larger delayed rewards (steep delay discounting). It is unknown whether such steep discounting of rewards is specific for delayed rewards, i.e., supporting the delay aversion account of ADHD, or whether it is also present for effortful rewards, i.e., representing general reward insensitivity. Therefore, this study examined behavioral and BOLD responses during delay discounting (DD) and effort discounting (ED) in ADHD. METHOD: Thirty adolescents with ADHD and 28 controls (12-17 years) were scanned while performing a DD-ED task (fMRI findings were based on 21 and 25 participants, respectively). During DD, participants were presented with a series of choices between a small reward delivered immediately and a larger reward delivered after 5-25s. During ED, participants were presented with choices between a small reward that was delivered after exerting 15% of their maximal hand grip strength and a larger reward delivered after exerting 30-90% of their strength. RESULTS: Analyses on the subjective values of delayed and effortful rewards and on the Area Under the discounting Curves (AUCs) indicated that adolescents with ADHD showed steeper discounting than controls for DD, but not for ED. This was accompanied by a slightly stronger delay dose-response relationship in the amygdala for adolescents with ADHD who reported to be more delay averse in daily life. CONCLUSION: Together, these results-steeper DD in the ADHD group and a stronger delay dose-response relationship in the amygdala, while no evidence for group differences in ED was found-support the delay aversion account of ADHD.

Does an attention bias to appetitive and aversive words modulate interference control in youth with ADHD?

Interference control refers to the ability to selectively attend to certain information while ignoring distracting information. This ability can vary as a function of distractor relevance. Distractors that are particularly relevant to an individual may attract more attention than less relevant distractors. This is referred to as attention bias. Weak interference control and altered reward sensitivity are both important features of attention deficit hyperactivity disorder (ADHD). However, interference control is typically studied in isolation. This study integrates both. Youths (aged 9 to 17 years) with ADHD (n = 37, 25 boys) and typically-developing controls (n = 38, 20 boys) completed a Stroop task using appetitive words and matched neutral words to assess whether appetitive distractors diminished interference control more in youths with ADHD than controls. In order to test for specificity, aversive words were also included. As expected, appetitive words disrupted interference control but this effect was not stronger for youths with ADHD than the controls. Aversive words, on the other hand, facilitated interference control. Dimensional analyses revealed that this facilitation effect increased substantially as a function of ADHD symptom severity. Possible mechanisms for this effect include up-regulation of interference control as a function of induced negative mood, or as a function of increased effort. In conclusion, appetitive words do not lead to worse interference control in youths with ADHD compared with controls. Interference control was modulated in a valence-specific manner, concurrent with mood-induced effects on cognitive control.

A Pilot Study of Behavioral, Physiological, and Subjective Responses to Varying Mental Effort Requirements in Attention-Deficit/Hyperactivity Disorder.

Background: Attention-deficit/hyperactivity disorder (ADHD) is presumed to involve mental effort application difficulties. To test this assumption, we manipulated task difficulty and measured behavioral, as well as subjective and psychophysiological indices of effort. Methods: Fifteen adolescent ADHD boys and 16 controls performed two tasks. First, subjective estimates and behavioral and pupillary measures of effort were recorded across five levels of N-back task difficulties. Second, effort discounting was assessed. In the latter, participants made repeated choices between performing a difficult N-back task for a high reward versus an easier N-back task for a smaller reward. Results: Increasing task difficulty led to similar deteriorations in performance for both groups - although ADHD participants performed more poorly at all difficulty levels than controls. While ADHD and control participants rated the tasks equally difficult and discounted effort similarly, those with ADHD displayed slightly different pupil dilation patterns with increasing task difficulty. Conclusion: The behavioral results did not provide evidence for mental effort problems in adolescent boys with ADHD. The subtle physiological effects, however, suggest that adolescents with ADHD may allocate effort in a different way than controls.

Neural responses to social exclusion in adolescents: Effects of peer status.

We examined whether adolescents' neural responses to social exclusion and inclusion are influenced by their own popularity and acceptance and by the popularity of their excluders and includers. Accepted adolescents are highly prosocial. In contrast, popular adolescents, who are central and influential, show prosocial as well as antisocial behaviors, such as peer exclusion. Fifty-two 12-16 year-old adolescents underwent an functional magnetic resonance imaging (fMRI) scan while playing the ball-tossing game Cyberball in which they received or did not receive the ball from other virtual players. The other virtual players were described as either highly popular or average in popularity. Participants' own popularity and acceptance were assessed with peer nominations at school (n = 31). Participants' acceptance was positively correlated with activity of the dorsal anterior cingulate cortex (ACC) during exclusion. Participants' popularity was positively associated with ventral striatum and medial prefrontal cortex activity during exclusion, but only when the excluders were popular virtual players. Participants showed increased rostral ACC activation to inclusion by players who were average in popularity. These findings indicate that peer status plays an important role in adolescents' neural processing of social exclusion and inclusion. Moreover, these findings underscore that popularity and acceptance are distinct types of high peer status in adolescence, with not only distinct behavioral correlates, but also distinct neural correlates.

Neural mechanisms of individual differences in temporal discounting of monetary and primary rewards in adolescents.

Adolescents are generally characterized as impulsive. However, impulsivity is a multi-dimensional construct that involves multiple component processes. Which of these components contribute to adolescent impulsivity is currently unclear. This study focused on the neural mechanisms underlying individual differences in distinct components of temporal discounting (TD), i.e., the preference for smaller immediate rewards over larger delayed rewards. Participants were 58 adolescents (12-16 years-old) who performed an fMRI TD task with both monetary and snack rewards. Using mixed-effects modeling, we determined participants' average impatience, and further decomposed TD choices into: 1) amount sensitivity (unique contribution of the magnitude of the immediate reward); and 2) delay sensitivity (unique contribution of delay duration). Adolescents' average impatience was positively correlated with frontoparietal and ventral striatal activity during delayed reward choices, and with ventromedial prefrontal cortex activity during immediate reward choices. Adolescents' amount sensitivity was positively associated with ventral striatal and dorsal anterior cingulate cortex activity during immediate reward choices. Delay sensitivity was positively correlated with inferior parietal cortex activity during delayed reward choices. As expected, snacks were discounted more steeply than money, and TD of both reward types was associated with overlapping activation in the inferior parietal cortex. Exploring whether testosterone or estradiol were associated with TD and its neural correlates revealed no significant associations. These findings indicate that distinct components contribute uniquely to TD choice and that individual differences in amount sensitivity are uniquely associated with activation of reward valuation areas, while individual differences in delay sensitivity are uniquely associated with activation of cognitive control areas.

Quick Delay Questionnaire: Reliability, validity, and relations to functional impairments in adults with attention-deficit/hyperactivity disorder (ADHD).

The Quick Delay Questionnaire (QDQ) is a self-report measure of delay-related behaviors in adults, and the present study aimed at investigating the psychometric properties of QDQ scores, how well they can discriminate between ADHD adults and both clinical and nonclinical controls, as well as their relations to measures of functional impairments. In the present study, QDQ ratings, a laboratory measure of delay discounting, and ratings of functional impairments were collected from adults diagnosed with attention-deficit/hyperactivity disorder (ADHD; n = 51), a clinical control group with other psychiatric disorders (n = 46), and a nonclinical control group (n = 105). Results showed that the QDQ scores showed adequate reliability. Adults with ADHD had higher scores compared with normal controls on both QDQ subscales, and they also reported higher levels of delay aversion than the clinical controls. Logistic regression analyses showed high specificity but low sensitivity when trying to discriminate between adults with ADHD and nonclinical controls. QDQ scores were not associated with a laboratory measure of delay discounting, but with functional impairments such as substance use, criminality, and money management. Our findings indicate that QDQ scores are reliable, but this instrument should be regarded as a complement rather than as a replacement for laboratory measures. The relatively low sensitivity of QDQ scores is in line with current models of heterogeneity stating that only a subgroup of individuals with ADHD has high levels of delay-related behaviors. Our findings further indicate that this subgroup may be at particularly high risk for problems in everyday life. (PsycINFO Database Record

Decision-making in social contexts in youth with ADHD.

This study examined reward-related decision-making in children and adolescents with ADHD in a social context, using economic games. We furthermore examined the role of individual differences in reward-related decision-making, specifically, the roles of reward sensitivity and prosocial skills. Children and adolescents (9-17 years) with ADHD-combined subtype (n = 29; 20 boys) and healthy controls (n = 38; 20 boys) completed the ultimatum game and dictator game as measures of reward-related decision-making in social contexts. Prosocial skills were measured with the Interpersonal Reactivity Index. The ADHD group had a larger discrepancy between ultimatum game and dictator game offers than controls, indicating strategic rather than fairness driven decisions. This finding was supported by self-reports showing fewer individuals with ADHD than controls who considered fairness as motive for the decisions. Perspective taking or empathic concern did not differ between groups and was not significantly associated with offers. In conclusion, the results suggest that rather than a failure to understand the perspective of others, children and adolescents with ADHD were less motivated by fairness than controls in simple social situations. Results encourage the use of economic games in ADHD research.

Intelligence moderates the benefits of strategy instructions on memory performance: an adult-lifespan examination.

Whether older adults can compensate for their associative memory deficit by using memory strategies efficiently might depend on their general cognitive abilities. This study examined the moderating role of an IQ estimate on the beneficial effects of strategy instructions. A total of 142 participants (aged 18-85 years) received either intentional learning or strategy ("sentence generation") instructions during encoding of word pairs. Whereas young adults with a lower IQ benefited from strategy instructions, those with a higher IQ did not, presumably because they already use strategies spontaneously. Older adults showed the opposite effect: following strategy instructions, older adults with a higher IQ showed a strong increase in memory performance (approximately achieving the level of younger adults), whereas older adults with a lower IQ did not, suggesting that they have difficulties implementing the provided strategies. These results highlight the importance of the role of IQ in compensating for the aging-related memory decline.