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Attention-deficit/hyperactivity disorder (ADHD) is often linked with difficulties in social interactions. Recent research published in Scientific Reports has shed light on how decision-making deficits, particularly impulsivity and the inability to delay gratification, play a crucial role in the social challenges faced by children and adolescents with ADHD. The study reveals that these decision-making challenges are consistent over time and significantly predict social difficulties.

Previous research has primarily focused on the overt symptoms of ADHD, such as inattention and hyperactivity, and their impact on social skills. However, these aspects alone do not fully explain the extent of social difficulties. Furthermore, while medications for ADHD help manage these primary symptoms, they do little to enhance social skills directly. This gap in understanding prompted researchers to explore whether underlying decision-making processes could better explain and predict social challenges in ADHD.

In previous research, Lin Sørensen and her colleagues observed that children with ADHD often engage in risk-seeking behaviors, primarily because they find it difficult to remain in unstimulating or tedious situations, or when there is a delay in receiving rewards. This tendency, known as delay aversion, is less prevalent among their typically developing peers and is linked to increased impulsivity in children with ADHD.

“In the new longitudinal follow-up study, we were interested in studying if the poorer regulation of motivation when being in tedious and stimulus-poor situations (delay aversion), leading to poorer risk-related decision making skills, predicted social difficulties in the longer run,” explained Sørensen, a professor of clinical neuropsychology at the University of Bergen.

The initial participant group consisted of 70 children, ranging in age from 8 to 12 years old. This group included 36 children diagnosed with ADHD and 34 typically developing peers, ensuring a comparison between the two groups. The children with ADHD were not on any medication at the start of the study to avoid its influence on their cognitive functions.

The key method for assessing decision-making was the Cambridge Gambling Task. This task, part of the Cambridge Neuropsychological Test Automated Battery, measures decision-making under risk. Participants are shown a series of boxes, some colored blue and others red, with a yellow token hidden behind one of the boxes. They must bet on where they believe the token is, with the stakes varying in terms of risk and potential reward.

The Cambridge Gambling Task quantifies several aspects of decision-making: risk adjustment (how well participants adapt their betting strategy based on the level of risk), delay aversion (preference for immediate rewards over higher but delayed rewards), reflection time (time taken to make a decision), and risk proneness (tendency to choose high-risk options).

Data were collected at two points: baseline and follow-up four years later. At each time point, the Cambridge Gambling Task was administered, and parents completed the Child Behavior Checklist to report on their children’s social behaviors and any conduct or emotional issues.

One of the central findings was the persistence of suboptimal decision-making in children with ADHD across the study period. Specifically, these children continued to show poor risk adjustment, meaning they struggled to adapt their decision-making strategies according to the level of risk involved. This trait was stable over the four years between baseline and follow-up, suggesting that difficulties with evaluating and managing risk are a consistent feature of ADHD that extends into adolescence.

Interestingly, while delay aversion was pronounced at the baseline, it did not significantly differ from the control group at follow-up. This might indicate some developmental changes in how children with ADHD perceive and react to delays as they grow older. However, despite this shift, delay aversion remained a significant predictor of social problems, indicating its impactful role in the daily interactions and decisions of these individuals.

The researchers also found a robust connection between certain decision-making deficits and social difficulties as reported by parents through the Child Behavior Checklist. In particular, greater social problems were associated with poorer risk adjustment and higher delay aversion. These findings suggest that the way children with ADHD make decisions in risky or delayed situations directly affects their ability to manage social interactions effectively.

“Our study indicates that children and adolescents with ADHD may appear impulsive in social interactions with others when they are bored and what is happening in the social interaction or in the situation in general is not interesting enough to capture their attention,” Sørensen told PsyPost. “This could mean that they know how to behave in social interactions with others but struggle with the effort in certain situations to use those skills.”

The research also highlighted that not all aspects of decision making equally predicted social outcomes. For instance, risk proneness and reflection times at baseline did not show a clear correlation with social difficulties at follow-up, suggesting that specific elements of decision-making are more critical in influencing social behavior in ADHD.

Sørensen was surprised to find “that delay aversion was the most important predictor of social difficulties in ADHD. I would have expected also other aspects of cognition such as time used to process information would have associated with difficulties in social interactions.”

The study provides compelling evidence that decision-making processes play a critical role in the social problems experienced by children with ADHD. But there are limitations to consider. The sample size was relatively small, which may affect the generalizability of the findings. Additionally, most children with ADHD were on medication at the follow-up, which could have influenced the results, especially regarding their decision-making abilities.

Future research should aim to involve larger groups and possibly include neuroimaging to observe brain activity during decision-making tasks. Also, investigating whether interventions aimed at improving decision-making skills could lead to better social outcomes in ADHD would be valuable.

Despite the limitations, the results underscore the importance of addressing decision-making processes in interventions aimed at improving social skills in children with ADHD. Traditional treatments that focus primarily on reducing hyperactivity and improving attention might not adequately address the complex social challenges these children face.

“There is a need for improved understanding of the reasons for children with ADHD to struggle with social interactions,” Sørensen said. “The treatment typically provided today does not seem to be effective. Therefore, continuing to better understand difficulties in social interactions using experimental paradigms are one important step to disentangle the specific mechanisms causing these difficulties.”

The study, “Suboptimal decision making and interpersonal problems in ADHD: longitudinal evidence from a laboratory task,” was authored by L. Sørensen, S. Adolfsdottir, E. Kvadsheim, H. Eichele, K. J. Plessen, and E. Sonuga-Barke.

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