Decision-Making Deficits Predict Social Problems in Children with ADHD: Study

June 16, 2024

Decision-making deficits may signal and lead to social problems for children with ADHD. Strong feelings of delay aversion — which cause individuals with ADHD to choose the option most likely to avoid delays and wait times — drive poor decision making for youth with ADHD, according to a two-phased longitudinal study published by Nature in March.¹

The study is the first to investigate and link general deficits in decision making to social problems in ADHD. Children aged 8 to 12 completed the Cambridge Gambling Task (CGT) in 2016 and again four years later.² At both time points, poorer risk adjustment and stronger delay aversion were associated with social problems for participants with ADHD, but not for typically developing children.

The CGT is a computerized test developed to assess decision-making and risk-taking behavior across a variety of disorders, including ADHD, mood disorders, and traumatic brain injury. Participants were shown 10 boxes — some red, some blue — and asked to guess which of the two colors hid a yellow token. The proportion of red to blue boxes varied between rounds.

Participants also estimated the likelihood of their choice being correct by clicking on a wager value displayed on the screen, in ascending or descending order, as a percentage of total points. Points were either awarded or deducted from the participant’s starting score of 100 based on the accuracy of their bets.

Four outcomes were measured using the CGT: delay aversion, risk adjustment, reflection time, and risk proneness. Delay aversion at baseline was the main predictor of social problems in children with ADHD. Although the difference in delay aversion between the ADHD and control groups was not significant at follow-up, performance at baseline still predicted greater social problems over time. Risk adjustment was the only trait that remained consistently poorer in children with ADHD over four years. At both points in the study, their ability to weigh risks by learning from previous choices was significantly worse than controls.

Delay Aversion & Social Problems

More than half of children with ADHD struggle with peer relationships.³ In a 2022 ADDitude survey on youth mental health, children and teens with ADHD were twice as likely to be bullied compared to neurotypical students. Bullying most often occurs in middle or high school.⁴

According to lead author and researcher Lin Sorenson, delay aversion — recognized as a factor of ADHD since the 1980s — has been shown to cause social problems by leading to impulsive and disruptive behavior. In the present study, social impulsivity in ADHD was not due to longer reflection times or risk proneness, but rather the ability to adapt to changing social situations. Inconsistent social performance, not deficits in social skill acquisition, impact social outcomes in children with ADHD.⁵

“The inconsistency in motivation and performance is the most puzzling aspect of ADHD,” writes clinical psychologist Thomas E. Brown, Ph.D. “It seems like the child or adult with the disorder who can show strong motivation and focus very well for some tasks should be able to do the same for most other tasks… However, ADHD is not a matter of willpower. It is a problem with the dynamics of the chemistry of the brain.”

The delay aversion hypothesis suggests that ADHD behaviors are triggered, at least in part, by the motivation to escape or avoid negative emotions that surface when confronted by wait times, prior to receiving a reward or completing a task.⁶ In the ADHD brain, the imposition of a delay activates the amygdala’s fight or flight response and can overpower other motivating factors.⁷ Delay aversion has also been associated with a preference for smaller immediate rewards and with inattentive symptoms, and may be stronger in boys with ADHD.⁵

Conduct & Mood Problems

As in previous studies, parents of children with ADHD reported greater social, mood, and conduct problems over the course of the study. Researchers measured negative affect using the Child Behavior Checklist (CBCL), a widely used parent-report instrument with subscales for social problems, conduct problems, and anxiety/depression problems. While none of the CGT parameters predicted negative outcomes, all but risk proneness were associated with social, conduct, and mood problems.

Limitations & Future Research

“Our results indicate that these [social] problems are predicted by difficulties in adapting dynamically to changing contextual conditions,” Sorenson wrote. “On the CGT, this can be observed by difficulties in adapting choices to the changing patterns of outcome probabilities (poorer risk adjustment).”

Study limitations included a low sample size and medication inconsistency. Of the 70 participants present at baseline, 47 participated in the follow-up. Most of the children in the ADHD group were on medication but were drug-naive at baseline. Participants were aged 11 to 17.

The authors encourage future studies to test the prediction of suboptimal decision-making driven by delay aversion on social competence in ADHD. Identifying and understanding poor decision-making driven by delay aversion can help inform psychoeducation and training programs for caregivers and children.

Actionable Strategies

Parents and teachers can use the following strategies to help improve social outcomes among children with ADHD:

• Incorporate timers into your child’s routine. “Parents can help improve delay aversion by using timers that chunk work into smaller bits,” says psychologist Carla Counts Allan, Ph.D. “If the whole homework routine, which lasts an hour, is too painful for your child, set the timer for 10 minutes of active work and then let him take a short break or earn a small piece of a reward for later.”
• Use reflective listening with your child. “Let’s say you have a kid who doesn’t necessarily read the room and alienates people,” said Caroline Maguire, M.Ed., in her webinar, “Why Will No One Play with Me?” “He may have some opinions about school that drive you nuts or that just don’t seem true. You use this reflective listening technique by simply repeating back their words and what they say…. If you repeat back someone’s words, they feel very validated and they have the chance to clarify.”
• Provide positive feedback for good behavior and special talents. Doing this in front of classmates can help improve self-esteem and peer recognition.
• Watch for problematic screen time. Teens with ADHD are more vulnerable to the risks of social media such as depression, anxiety, and self-harm than same-age peers without ADHD, according to an ADDitude survey on social media use. Teens are also more likely to become addicted to video games.⁸
• Enroll in behavioral parent training. The American Academy of Pediatrics recommends this as a first-line treatment for ADHD in young children. “Kids with ADHD need to be taught in the moment, which is why parents and educators can be most helpful in building social executive function skills,” said Ryan Wexelblatt, LCSW, in his webinar, “The Social Reboot: Helping Tween and Teen Boys with ADHD Make Friends.”

“Your child may make a social breakthrough one day and appear to take several steps back the next – and that’s perfectly normal,” says Wexelblatt. “Be patient. Results will come slowly and with time – not overnight.”

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