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Prevalence and diagnostic validity of motivational impairments and deficits in visuospatial short-term memory and working memory in ADHD subtypes

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Abstract

Deficits in working memory (WM) and reinforcement sensitivity are thought to give rise to symptoms in the combined (ADHD-C) and inattentive subtype (ADHD-I) of ADHD. Children with ADHD are especially impaired on visuospatial WM, which is composed of short-term memory (STM) and a central executive. Although deficits in visuospatial WM and reinforcement sensitivity appear characteristic of children with ADHD on a group-level, the prevalence and diagnostic validity of these impairments is still largely unknown. Moreover, studies investigating this did not control for the interaction between motivational impairments and cognitive performance in children with ADHD, and did not differentiate between ADHD subtypes. Visuospatial WM and STM tasks were administered in a standard (feedback-only) and a high-reinforcement (feedback + 10 euros) condition, to 86 children with ADHD-C, 27 children with ADHD-I (restrictive subtype), and 62 typically developing controls (aged 8–12). Reinforcement sensitivity was indexed as the difference in performance between the reinforcement conditions. WM and STM impairments were most prevalent in ADHD-C. In ADHD-I, only WM impairments, not STM impairments, were more prevalent than in controls. Motivational impairments were not common (22 % impaired) and equally prevalent in both subtypes. Memory and motivation were found to represent independent neuropsychological domains. Impairment on WM, STM, and/or motivation was associated with more inattention symptoms, medication-use, and lower IQ scores. Similar results were found for analyses of diagnostic validity. The majority of children with ADHD-C is impaired on visuospatial WM. In ADHD-I, STM impairments are not more common than in controls. Within both ADHD subtypes only a minority has an abnormal sensitivity to reinforcement.

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Notes

  1. Loo et al. [26] (in adolescents), Sjöwall et al. [22] and Wahlstedt et al. [27] generally find a somewhat lower prevalence of working memory deficits in the ADHD population than Lambek et al. [25]. However, this lower prevalence might be explained by the fact that these three studies only use a composite score of both visuospatial and phonological working memory measures.

  2. This relative difference between the ADHD groups in medication-use was significant, χ 2(1) = 13.814, p < 0.001. However, including medication-use as a covariate in analyses where the ADHD groups were compared (and covariation was possible) did not change the pattern of the results.

  3. Reinforcement sensitivity index = [(WM + STM 10 euros] – (WM + STM FO)] × [100/(WM + STM 10 euros)]. WM = age-corrected mean score on WM task; STM = age-corrected mean score on STM task; FO = feedback-only condition.

  4. Participants were excluded from analyses when both of the following criteria were met: (1) a standardized residual on any of the dependent measures with an absolute value >2, and (2) a Cook’s distance ≥1 [51]. Based on this criterion none of the participants had to be excluded.

  5. For the sake of completeness prevalence using a 5 % cut-off is reported in ESM Appendix 3.

  6. WM FO, Λ = 0.67, χ 2(1, N = 148) = 59.12, p < 0.001; WM 10 euros, Λ = 0.70, χ 2(1, N = 148) = 52.25, p < 0.001; STM FO, Λ = 0.78, χ 2(1, N = 148) = 36.25, p < 0.001; STM 10 euros, Λ = 0.81, χ 2(1, N = 148) = 30.73, p < 0.001; reinforcement sensitivity index, Λ = 0.94, χ 2(1, N = 148) = 8.42, p = 0.004.

  7. WM FO, Λ = 0.85, χ 2(1, N = 89) = 14.57, p < 0.001; WM 10 euros, Λ = 0.89, χ 2(1, N = 89) = 9.80, p = 0.002; STM FO, Λ = 0.93, χ 2(1, N = 89) = 6.26, p = 0.012.

  8. WM FO, Λ = 0.96, χ 2(1, N = 113) = 4.71, p = 0.030; WM 10 euros, Λ = 0.94, χ 2(1, N = 113) = 6.96, p = 0.008; STM FO, Λ = 0.96, χ 2(1, N = 113) = 5.09, p = 0.024; STM 10 euros, Λ = 0.94, χ 2(1, N = 113) = 6.88, p = 0.009.

  9. Impaired on WM (10 euros), and/or STM (10 euros), and/or reinforcement sensitivity; using the 10 % cut-off.

  10. Future studies should be aware that impaired inhibitory performance can also have a small impact on the central executive performance of children with ADHD [see 12].

  11. In ADHD-C only the mean IQ score of the impaired subsample was significantly lower than that of the TD group.

  12. The 10 euros condition was previously found to optimize task performance in children with ADHD-C [33].

  13. These evidence-based interventions [77, 78] aim at improving behavioral control in children with ADHD by teaching parents and teachers to use token (reward) systems and techniques to unburden the WM of these children (e.g., providing reminders and a structured environment).

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Acknowledgments

We are grateful to the participating mental-healthcare centers [Jeugdriagg Noord Holland Zuid, GGz Noord Holland Noord (Centrum voor Kinder- en Jeugdpsychiatrie), Regionaal Centrum voor Kinder en Jeugdpsychiatrie Gooi en Vechtstreek, Bosman GGz, Stichting De Praktijk, Stichting Kram, PuntP, Academisch Behandelcentrum UvA Minds, & Kinderpraktijk VIS] and the participating schools (OBS De Weidevogel, Amsterdam; OBS De Witte Olifant, Amsterdam; De Dr. E. Boekmanschool, Amsterdam; OBS Jules Verne, Alkmaar; PCBS Van der Brugghenschool, Huizen; Montessorischool De Boog, Nieuw-Vennep; and De Willemsparkschool, Amsterdam), to Jasper Wijnen for programming the task, to Tim van den Broek, Josje de Bont, Annette Brouwer, Tycho Dekkers, Lucie van den Eertwegh, Roza van der Heide, Lisanne Klink, Astrid Nauta, Inge Meulenberg, Muriël Musa, Pascale Riaskoff, Elise Tilma, Marije Voermans, Ida de Vries, and Pamina Warmbrunn for their help with data collection, and to all participating children and families.

Conflict of interest

SvdO has been a paid consultant for Janssen pharmaceuticals in the development and evaluation of a serious game “Healseeker” aimed at training cognitive functions. Other authors report no conflicts of interest.

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  1. Developmental Psychology, University of Amsterdam, Weesperplein 4, 1018 XA, Amsterdam, The Netherlands

    Sebastiaan Dovis, Saskia Van der Oord, Hilde M. Huizenga, Reinout W. Wiers & Pier J. M. Prins

  2. Clinical Psychology, KU Leuven, Leuven, Belgium

    Saskia Van der Oord

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Dovis, S., Van der Oord, S., Huizenga, H.M. et al. Prevalence and diagnostic validity of motivational impairments and deficits in visuospatial short-term memory and working memory in ADHD subtypes. Eur Child Adolesc Psychiatry 24, 575–590 (2015). https://doi.org/10.1007/s00787-014-0612-1

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