The effect of reinforcement on sustained attention among adolescents with and without Attention-Deficit/Hyperactivity Disorder
Bubnik, Michelle Georgette
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Background: Although sustained attention is central in clinical and theoretical accounts of Attention-Deficit/Hyperactivity Disorder (ADHD), there are major gaps in the literature. We evaluated ADHD-control differences on three indices of sustained attention, extending the literature in three critical ways: a) we evaluated the impact of reinforcement, which is implicated in ADHD psychopathology and treatment, b) we provided novel data on the durability of group differences and reinforcement effects across two visits, and c) we focused on late adolescence, a surprisingly understudied developmental period in the ADHD literature. Methods: 16- to 19-year-olds with ADHD (n=18; 15 male) and a group of typically developing controls without ADHD (n=21; 13 male) completed two lab sessions, approximately one week apart. During each session, participants completed two tests of sustained attention that yielded three indices of sustained attention (Hits-Overall, Hits-Over-Time, and tau (an index of occasional, very long reaction times) under reinforcement (trialwise feedback and points redeemed for money at the end of the session) and no-reinforcement (uninformative “feedback” after each trial; reinforcement order counterbalanced between subjects). Results: As predicted, both Hits-Overall and tau indicated adolescents with ADHD exhibited poorer sustained attention than controls; however, evidence that the problem with sustained attention grew over time (Hits-Over-Time) was limited to a post-hoc examination of only males. Reinforcement significantly improved Hits-Overall and tau ( d’s =.60 and .91, respectively). Evidence for stronger reinforcement effects in ADHD adolescents was limited to tau, and only among participants randomly assigned to receive reinforcement first. Nevertheless, post-hoc comparisons of ADHD-reinforcement and control-no-reinforcement data suggested that reinforcement partially normalized Hits-Overall and fully normalized tau for adolescents with ADHD. Most effects did not vary between sessions, and individual differences in Hits-Overall and tau, but not vigilance trajectories across epochs, exhibited good to excellent test-retest reliability between sessions. Conclusions: This study suggests that the deficit in sustained attention observed in younger children with ADHD persists throughout adolescence, consistent with a core deficit model. The present work is the first to demonstrate that reinforcement improves, and partially normalizes, laboratory indices of sustained attention in adolescents with ADHD. This work draws attention to the clinically and theoretically interesting intersection of reinforcement and sustained attention during adolescence; it provides a foundation for sophisticated developmental approaches to ADHD as well as potential linkages between basic and intervention research using reinforcement.