Poor learning or hyper-exploration?: A commentary on Hulsbosch et al. (2023).

In an outstanding paper, Hulsbosch et al. (Journal of Child Psychology and Psychiatry, 2023) tested major reinforcement learning theories of attention-deficit/hyperactivity disorder (ADHD). On a reinforcement learning task, children with ADHD needed more trials to reach the criterion in the learning phase and chose the target less often in the extinction phase. These results only partially support either of the theories and may be interpreted as reflecting a general deficit in learning. Still, distinguishing between learning and decision-making stages suggests that poor performance on reinforcement learning tasks by children with ADHD is accounted for by increased exploration or decreased choice consistency rather than deficient learning.

Features of attention deficit/hyperactivity disorder and antisocial behaviour in a general population-based sample of adults.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is known to be a risk factor for antisocial and delinquent behaviour, but there is still a lack of information on how features of ADHD relate to offending behaviour among adults not already defined by their offending. AIMS: Our aim was to add to knowledge about relationships between ADHD and antisocial behaviour among adults in the general population by answering the following questions: (A) Does the level of self-reported ADHD features relate to criminal and non-criminal antisocial behaviour? (B) To what extent are self-ratings of ADHD features independent of socio-demographic features previously identified as predictors of antisocial behaviour? METHODS: A sample of adults was originally recruited to study public response to the COVID-19 outbreak through an online panel to be representative of the Israeli population. Among other scales, the 2025 participants completed an ADHD self-report scale, an antisocial behaviour self-report scale and a socio-demographic questionnaire probing for age, gender, urbanity, place of birth, socioeconomic status (education and income), family status (being in a relationship and having children) and religiosity. RESULTS: Higher mean totals for the inattention and hyperactivity ADHD scale scores were associated with higher mean antisocial behaviour scores. These relationships were only slightly affected by socio-demographic variables, including sex, age, education and income. CONCLUSION: Our findings suggest that not only may features of ADHD, even below a diagnostic threshold, constitute a risk factor for antisocial behaviour, but also that the self-rated levels of these problems covary. These findings are important for informing the early detection of risk of antisocial behaviour in the general population and its prevention.

Risk-Taking Behaviors in Children with ADHD Compared to Children with Primary Headaches.

The study examined the engagement in risk-taking behaviors and their onset in children with attention-deficit/hyperactivity disorder (ADHD) compared with children with primary headaches. Whether ADHD is associated with higher engagement in risk-taking behavior compared with other neurodevelopmental disorders (and not only typical development) has yet to be demonstrated. A sample of 189 children, 10 to 18 years old, undergoing neurological surveillance for ADHD (N = 144) or primary headaches (N = 45) participated in the study. The children and their parents reported the children's engagement in various risk-taking behaviors. The ADHD group reported a higher level of general risk-taking behavior relative to the headache group. The differences remained significant even after controlling for demographic and clinical variables. No differences in the age of onset of risk-taking behaviors were found. It is concluded that risk-taking behavior is more common in children with ADHD under active neurological surveillance than in children followed for primary headaches.

Symptoms of Attention Deficit/Hyperactivity Disorder Are Associated with Sub-Optimal and Inconsistent Temporal Decision Making.

The link between Attention-Deficit/Hyperactivity Disorder (ADHD) and steeper delay discounting has been established and incorporated into theories of ADHD. This study examines a novel interpretation according to which ADHD is linked to sub-optimal temporal decision-making and suggests inconsistency as a potential underlying mechanism. In two experiments, MTurk workers completed a self-report questionnaire on symptoms of ADHD and a temporal decision making task consisting of choices between smaller-immediate and larger-delayed options. The delayed option was better in some items, whereas the immediate option was better in others. The rate of choices of the delayed option and the consistency of choices were measured. The results of both studies show that high symptoms of ADHD were linked to fewer choices of the delayed option when it was better, but also to more choices of the delayed option when it was not better. In addition, ADHD was linked to higher inconsistency in both conditions. The findings suggest that ADHD is linked to sub-optimal temporal decision-making rather than steeper delay discounting, and provide further support to the phenomenon of inconsistency in ADHD.

The Link between ADHD Symptoms and Antisocial Behavior: The Moderating Role of the Protective Factor Sense of Coherence.

Numerous studies have established the link between ADHD and antisocial behavior, one of the most serious functional impairments caused by the disorder. However, research on protective factors that mitigate this link is still lacking. The Salutogenic Model of Health offers the "Sense of Coherence" (SOC), establishing that individuals who see their lives as logical, meaningful, and manageable are more resistant to various risk factors and diseases. The present study examines for the first time whether SOC is also a protective factor against different ADHD-related types of antisocial behaviors (severe/mild violent behavior, verbal violence, property crimes, public disorder, and drug abuse). A total of 3180 participants aged 15−50 completed online questionnaires assessing the level of ADHD symptoms, antisocial behaviors, and SOC. Structural equation modeling was applied to examine the research hypothesis. An interaction between ADHD symptoms and SOC was found in predicting each type of antisocial behavior (beta = −0.06−−0.17, p < 0.01). The link between ADHD symptoms and antisocial behavior was significantly weaker for high than low SOC participants, regardless of age group. The current study found that people with high SOC are protected against the effect of ADHD symptoms on one of the most serious functional impairments, antisocial behavior. These findings suggest that SOC is a protective factor from the adverse effects of ADHD symptoms, justifying further prospective and intervention studies.

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) (Mage = 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.

Food Perceptions in Adults with and without ADHD.

INTRODUCTION: Adults with attention-deficit/hyperactivity disorder (ADHD) have unhealthy eating habits, associated with overweight/obesity. We explored whether they present with different food-related benefit/risk perceptions, compared to those without ADHD. METHODS: One hundred five university students with (n = 36) and without (n = 69) ADHD, aged 22-30, participated in the study. They rated the level of frequency and likelihood of food consumption, as well as the perceived attractiveness, convenience, and risk of 32 healthy and unhealthy food items. RESULTS: The findings revealed significantly lower healthy/unhealthy food frequency consumption ratios for the ADHD group compared with the non-ADHD one but no differences in the ratios of estimated likelihood of food consumption and perceptions (attractiveness, convenience, and risk). CONCLUSION: The results of this study demonstrated a discrepancy between the eating behavior (more unhealthy eating patterns in adults with ADHD compared with controls) and their food-related perceptions (same perceptions regarding the benefit and risk of foods in both groups).

Peer feedback decreases impulsive choice in adolescents with and without attention-deficit/hyperactivity disorder.

Background: Impulsivity is a core feature of attention-deficit/hyperactivity disorder (ADHD). Previous work using the delay discounting task to assess impulsivity reveals that adolescents with ADHD tend to prefer a smaller-immediate reward over a larger-delayed reward, and this relates to problematic choices in daily life. To gain a better understanding of daily decision-making in adolescence, it is important to examine the social context, as peers have a major influence on decisions. Peer influence often has a negative connotation, but also provides an opportunity to promote positive outcomes. To date, it is unclear if peers affect impulsive decision-making in adolescents with ADHD, for better or for worse. Methods: The aim of this preregistered study was to examine the effect of peer feedback on impulsive choice in male adolescents with and without ADHD (ages 13-23; N = 113). We utilized an adapted delay discounting task that was administered alone, in a social condition, and alone again. In the social condition, adolescents received either (between-subjects) manipulated impulsive or non-impulsive peer feedback. Impulsive peer feedback consisted of likes for choosing the smaller immediate reward, whereas non-impulsive peers endorsed choosing the larger delayed reward. Results: Preregistered analyses showed that non-impulsive peer feedback resulted in decreased impulsive choice, whereas impulsive peer feedback did not alter decision-making in adolescents with and without ADHD. Explorative analyses of inattention and hyperactivity-impulsivity symptoms in the total sample, irrespective of diagnosis, showed that lower hyperactivity-impulsivity and more inattention symptoms were associated with increased susceptibility to non-impulsive peer feedback. Conclusions: Together, these findings indicate that peers may provide an opportunity to decrease impulsivity and emphasize individual differences in susceptibility to non-impulsive peer feedback related to inattention and hyperactivity-impulsivity. Therefore, peer feedback may be a promising component in behavioral peer-supported interventions in adolescents with ADHD.

Religiosity as a moderator of ADHD-related antisocial behaviour and emotional distress among secular, religious and Ultra-Orthodox Jews in Israel.

BACKGROUND: ADHD predicts higher levels of antisocial behaviour and distress while religiosity is related to lower levels of both. This raises the hitherto unexplored question of how these variables interact. AIMS: The objective of this study was to explore how religious individuals with ADHD fare in terms of these psychosocial outcomes. METHOD: 806 secular, religious and Ultra-Orthodox Jewish adults in Israel completed measures of ADHD symptoms and treatment, emotional strengths and difficulties, religious belonging, religious behaviour and antisocial behaviour. RESULTS: Findings supported an additive-interactive model in which religiosity (a) correlates with lower levels of ADHD symptoms and diagnosis, (b) directly relates to less antisocial behaviour and less distress and (c) moderates the negative effects of ADHD on antisocial behaviour and distress. Findings further suggest that religious observance rather than religious belonging drives most of the moderating effect of religiosity, while religious belonging rather than religious observance drives negative attitudes towards ADHD. CONCLUSIONS: Implications include the importance of treating religious individuals with ADHD in a more nuanced manner and of providing more information on ADHD to religious communities.

Background and concurrent factors predicting non-adherence to public health preventive measures during the chronic phase of the COVID-19 pandemic.

BACKGROUND: To determine factors that predict non-adherence to preventive measures for COVID-19 during the chronic phase of the pandemic. METHODS: A cross-sectional, general population survey was conducted in Israel. Sociodemographic, health-related, behavioral and COVID-19-related characteristics were collected. RESULTS: Among 2055 participants, non-adherence was associated with male gender, young age, bachelorhood, being employed, lower decrease in income, low physical activity, psychological distress, ADHD symptoms, past risk-taking and anti-social behavior, low pro-sociality, perceived social norms favoring non-adherence, low perceived risk of COVID-19, low perceived efficacy of the preventive measures, and high perceived costs of adherence to the preventive measures. CONCLUSION: There appears to be a need for setting out and communicating preventive measures to specifically targeted at-risk populations.

Symptoms of ADHD Predict Lower Adaptation to the COVID-19 Outbreak: Financial Decline, Low Adherence to Preventive Measures, Psychological Distress, and Illness-Related Negative Perceptions.

OBJECTIVE: The COVID-19 outbreak created numerous multidimensional stressors, to which people show different levels of vulnerability. The current paper examines whether symptoms of ADHD are associated with poorer adaptation. METHOD: After the first quarantine in Israel, 2,055 adults participated in an online survey. Participants completed scales probing adaptation indicators: financial status, adherence to preventive measures, mental health, and COVID-19 related perceptions. Background measures, including the level of symptoms of ADHD, were collected. RESULTS: Adaptation indicators negatively correlated with the level of symptoms of ADHD. Financial decline explained a small portion of the link between ADHD and decreased mental health. Background risk-taking, anti-social, and pro-social behavior partially explained the link between ADHD and non-adherence to preventive measures. COVID-19 related perceptions also partially explained that link. CONCLUSION: This study suggests that people with ADHD are more vulnerable to the challenges created by the COVID-19 pandemic and therefore deserve special attention and care.

Intertwined associations among attachment styles, emotional dysregulation, and ADHD: examining unique associations with general risk-taking behavior.

Attachment insecurity, emotional dysregulation, and attention-deficit/hyperactivity disorder (ADHD) have all been implicated across the literature with various forms of negative life outcomes and increased risk-taking behavior (RTB). Furthermore, abundant research has demonstrated that the three seem to go together. Given these intercorrelations, it is unclear if any of them possess exclusive links with RTB independent of the others across multiple life domains. The present study examined the relations among attachment styles, emotional dysregulation, ADHD symptoms, and hypothetical RTBs across multiple real-life domains. Including a total of 155 mostly undergraduate students, we found in the main analysis that only ADHD symptoms were associated with RTB over and above all other variables. Specifically, the links between both attachment insecurity and emotional dysregulation with RTB disappeared when ADHD symptoms were included in the final model, but not vice versa. An exploratory analysis suggested that attachment insecurity was linked to romantic/sexual RTB over and above the others. These results further substantiate the link between ADHD symptoms and a general propensity for RTB and demonstrate that the link between the two seems to be inherent to the disorder and independent of its co-occurrence with attachment insecurity and emotional dysregulation.

Long-term weight control in adults with Prader-Willi syndrome living in residential hostels.

Hyperphagia leading to severe obesity with increased morbidity and mortality is the major manifestation of Prader-Willi syndrome. Caring for these individuals in a home environment is challenging and stressful for caregivers and families. Residential hostels specifically for PWS adults offer programs of diet, exercise, and vocational opportunities, but long-term effects of PWS hostel living have not been reported. We studied long-term changes in body mass index (BMI) for PWS adults living in residential hostels compared with age-matched controls living with families at home. The study included all 34 individuals (18 men) aged >17 years with genetically confirmed PWS living in residential hostels. BMI was recorded at the time of yearly clinic visits and compared to 23 PWS adults (10 men) living at home. BMI on entering the hostel was 36.3 ± 11.0 kg/m2 and decreased to 27.0 ± 5.6 kg/m2 (p < 0.001) after 6.9 ± 3.9 years. For 21 residents, a slight rise of BMI to 28.8 kg/m2 was observed 5.1 ± 2.5 years after the lowest value was achieved. BMI of 23 PWS adults at home was 36.8 ± 12.7 kg/m2 versus 27.9 ± 7.1 kg/m2 for hostel residents in the same age range (p = 0.008). From 2008 to 2019, there were five deaths among PWS individuals aged 18-40 years living at home, compared with one death (a 43-year-old man) among hostel residents. Adults with PWS living in hostels lose weight, maintain BMI values in a normal to mildly overweight range, and have lower mortality in contrast to individuals in a family home environment.

ADHD Is Associated With a Widespread Pattern of Risky Behavior Across Activity Domains.

Objective: ADHD has been linked to higher engagement in risky behaviors in circumscribed domains such as dangerous driving, substance abuse, and gambling. This study tests whether ADHD is associated with a pervasive tendency to engage in risky behavior across a spectrum of activities and domains, and whether this tendency is driven by comorbid disorders. Method: A sample of 97 adults with ADHD and 103 typically developing controls completed a self-report questionnaire measuring the likelihood and frequency of engaging in a broad range of risky behaviors. ADHD, comorbid psychiatric disorders, and demographic variables were extensively assessed using standardized instruments. Results: Participants with ADHD reported a pervasive tendency to engage in risky behaviors across multiple activities. This tendency was associated with ADHD over and above the contribution of comorbid psychiatric disorders. Conclusion: These results suggest that ADHD is uniquely linked to a pervasive pattern of engagement in risky behaviors.

Advertising Influences Food Choices of University Students With ADHD.

Objective: Previous research in adults with ADHD showed high rates of obesity and unhealthy food choices. There is evidence that contextual cues, for example, advertisements, influence food choices. This study assessed the sensitivity of university students with ADHD to advertised food. Method: University students (N = 457) with and without ADHD participated in a cafeteria field experiment. Food choices were examined in periods of advertising either healthy or unhealthy sandwiches. Results: Students with ADHD (a) chose less healthy food items, (b) were more influenced by advertising, (c) showed the same overall healthy food choices as controls when exposed to healthy advertising. Conclusion: Students with ADHD chose unhealthier foods at the cafeteria but were also more influenced by advertising. Healthy food advertisements raised their healthy food choices. As this population has strong association with unhealthy dietary patterns, it is important to investigate the influence of food cues on their eating habits.

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.

The impact of intrinsic and extrinsic features on delay discounting.

Delay discounting refers to the tendency of people to evaluate immediate rewards as being more valuable than those that are distant in time. Several models explain this phenomenon by a set of intrinsic and extrinsic features. Intrinsic features are related to the inherent traits and neurological conditions of the individual, whereas extrinsic features are related to the characteristics of the reward. In this study, we refer to extraversion and attention-deficit/hyperactivity disorder symptoms (attention and hyperactivity-impulsivity) as intrinsic features, and to fungibility, perishability, and magnitude of the reward as extrinsic features. Whereas there is a known main effect to these intrinsic and extrinsic features, the current research examines their additive and interactive contributions to delay discounting. A total of 222 participants filled out an online questionnaire measuring intrinsic features and presenting decision tasks with different types of rewards. The scores of the intrinsic variables and the delay discounting rate for each reward were calculated and analyzed. The results replicated previous findings showing main effects of hyperactivity, fungibility, perishability, and magnitude. They also provided new findings on an interaction between fungibility-perishability and hyperactivity-the effect of hyperactivity on delay discounting was larger when the rewards were fungible and nonperishable than when the rewards were perishable and nonfungible. This interaction has practical implications that can help in moderating delay discounting in clinical treatments of impulsivity as well as in constructing efficient economic models for consumers.

What Drives Risky Behavior in ADHD: Insensitivity to its Risk or Fascination with its Potential Benefits?

OBJECTIVE: ADHD is linked to increased engagement in risky behavior (ERB). Recent work suggests that this link is mediated by the perceived benefits of the behaviors, but not by the perceived risks or the attitudes toward the risks. Here we examine this hypothesis, using the psychological risk-return and psychometric multidimensional measurement models. METHOD: Adults with or without ADHD completed questionnaires measuring the likelihood of different risky behaviors and the perceived risks and benefits ascribed to these behaviors. Participants' ratings of 25 characteristics of various risky behaviors allowed us to derive two factors corresponding to perceived risk and perceived benefit of ERBs. Overall attitudes toward the perceived risks and benefits were extracted. RESULTS: Perceived benefit mediated the link between ADHD and ERB, in both models. Attitudes toward the perceived risks mediated that link in the psychometric model only. CONCLUSION: Perceived benefit plays an important role in the link between ADHD and ERB.

The influence of attractiveness and convenience cues on food appeal in adults with and without ADHD.

OBJECTIVE: Previous research on adults with ADHD revealed high rates of overweight and obesity, as well as unhealthy diet habits. Other studies demonstrated that social-affective contexts can influence food choice. This study examines the sensitivity of adults with ADHD to cues of food attractiveness and convenience, for healthy and unhealthy foods. METHOD: One hundred and seventy-two university students with (n = 59) and without (n = 113) ADHD, aged 19-40, participated in the study. Participants rated the level of appeal of 32 pictures of healthy and unhealthy foods, which varied in the degree of attractiveness and convenience. RESULTS: The findings reveal a higher level of appeal of attractive food items compared to non-attractive ones (p < .001), as well as of convenient compared to non-convenient food items (p = .005). Type of diagnostic group did not have an effect on the level of appeal. CONCLUSION: Increasing the attractiveness and convenience of food items increased the level of appeal for both students with and without ADHD. These findings emphasize the importance of environmental health intervention to potentially reduce abnormal eating pattern in the ADHD adult population, which may contribute in preventing the reported higher risk of obesity in this population.