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Paediatrics
Protocol
Relationships between experimental task and questionnaire measures of reward/punishment sensitivity in attention-deficit/hyperactivity disorder (ADHD): protocol for a scoping review
  1. Mana Oguchi1,2,
  2. Emi Furukawa1,
  3. Naano Nagahama1,3,
  4. Kokila Dilhani Perera1,
  5. Gail Tripp1
  1. 1Human Developmental Neurobiology Unit, Okinawa Institute of Science and Technology Graduate University, Onna, Okinawa, Japan
  2. 2Research Fellowship for Young Scientists, Japan Society for the Promotion of Science, Chiyoda-ku, Tokyo, Japan
  3. 3Laboratory of Behavioral Neuroendocrinology, University of Tsukuba, Tsukuba, Ibaraki, Japan
  1. Correspondence to Dr Mana Oguchi; oguchima394{at}gmail.com

Abstract

Introduction One of the purported underlying causal mechanisms of attention deficit hyperactivity disorder (ADHD) is altered motivational processes. Questionnaires have been used to identify the characteristics of reward and punishment sensitivity in individuals with ADHD. However, these questionnaires were initially developed to measure individual traits related to anxiety (inhibitory) and impulsivity (approach) tendencies or differences in pleasure-seeking. These reward and punishment sensitivity questionnaires are useful but might not capture all relevant aspects of altered motivational processes in ADHD. The proposed scoping review aims to: (1) examine which aspects of hypothesised altered reward and punishment sensitivity correspond to constructs measured by existing questionnaires, (2) characterise the relationships between ADHD symptomatology and reward and punishment sensitivity as measured by existing questionnaires and (3) evaluate the consistency between the altered reward and punishment sensitivity as measured by existing questionnaires and experimental task performance.

Methods and analysis Reporting of the scoping review results will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and the Joanna Briggs Methodology for Scoping Reviews. Published English-language literature was searched in three electronic databases (PubMed, Web of Science, APA PsycINFO) on 16 November 2023, with no restriction on the year of publication. Two researchers independently screened all identified titles/abstracts before proceeding to full-text review and additional handsearching of relevant studies. A narrative review and conclusions will be presented together with tables summarising the articles reviewed and the results organised by the three aims.

Ethics and dissemination This study reviews existing publications with ethical approval in place. Therefore, ethical approval is not required. Review results will be disseminated through academic conferences and peer-reviewed manuscripts. Scoping review results will also inform future research to measure and identify altered motivational processes in ADHD.

  • Psychometrics
  • Surveys and Questionnaires
  • Developmental neurology & neurodisability
  • Child & adolescent psychiatry
  • Impulse control disorders
http://creativecommons.org/licenses/by-nc/4.0/

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https://doi.org/10.1136/bmjopen-2023-078026

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • This study will review a broad range of questionnaires measuring reinforcement sensitivity, with no restriction on the year of publication.

  • This study will include the review of task-based study results when reported together with the questionnaire results.

  • This study will include research with clinical and population samples of all ages, with the sample characteristics included in the results.

  • The study results will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.

  • This study will only include English-language peer-reviewed studies.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterised by three cardinal symptoms, namely: inattention, hyperactivity and impulsivity.1 The prevalence of ADHD is approximately 7.6% in children and 2.6% in adults,2 3 with some symptom fluctuation across the lifespan.3–5 Altered motivational processes have been proposed to account for symptoms of ADHD.6–9 Behavioural studies have identified altered sensitivity to both reward and punishment in individuals with ADHD.10 Compared with typically developing peers, children with ADHD have been shown to prefer immediate over delayed reward,11–13 to show poorer adaptation to changing reinforcement contingencies14 15 and to demonstrate faster extinction after learning under partial (discontinuous) reinforcement.16 There have been fewer studies of sensitivity to punishment in those with ADHD, and the results are mixed. Some studies have shown similar sensitivity to punishment between those with and without ADHD,17 18 while others report increased sensitivity to punishment among those with ADHD.19 20

While most of the evidence on altered motivational processing in ADHD comes from experimental studies, questionnaires assessing sensitivity to reward and punishment have also been used. The only questionnaire developed specifically to assess for altered reward sensitivity is the Quick Delay Questionnaire, designed for use with adults, which assesses feelings/attitudes toward waiting and delayed rewards.21 Individuals with ADHD report higher levels of delay aversion and delay discounting,22 compared with their typically developing peers, which is consistent with the available experimental findings.11 23

Other reward and punishment sensitivity questionnaires have been developed for other pathological conditions or are based on reinforcement learning theories. Studies using these questionnaires report inconsistent results in terms of reward and punishment sensitivity in ADHD.24–26 It is unclear whether they are measuring the same motivational constructs as those evaluated in experimental studies. The most commonly used questionnaires on reward and punishment sensitivity27 were developed based on Gray’s reinforcement sensitivity theory (RST).28 This theory conceptualises reward sensitivity as a biologically based behavioural activation/approach system (BAS), that is, a temperamental trait to seek rewarding stimuli. Punishment sensitivity is thought to relate to the behavioural inhibition system (BIS), that is, an anxiolytic trait to avoid potentially aversive stimuli.29 An unbalanced BIS/BAS has been linked to increased risks of psychopathology,30 including ADHD.31 32 Quay33 assumed an underactive BIS leads to an inhibition deficit, poor attention and stimulus seeking in ADHD, while other researchers demonstrated that a high or a dysregulated BAS underlies elevated levels of hyperactive and impulsive behaviours.34–36

Other questionnaires measure reward anticipation (‘wanting’) and consumption (‘liking’) as expressed in behaviour37 and urges/pleasure seeking.38 Using a range of questionnaires, researchers have shown a link between excessive, or reduced, reward seeking, anticipation, and consumption and a range of pathological conditions, including addiction,39 40 eating disorders41 and anhedonia.42 43 Links between the constructs measured by these questionnaires and ADHD are unclear. Using the UPPS Impulsive Behaviour Scale,44 45 which measures levels of urgency, premeditation, perseverance and sensation seeking, some studies have reported greater urgency to obtain rewards in those with ADHD.46 47 Other measures have been developed to examine anhedonia. Many of these measures examine behaviour or mood symptoms associated with specific disorders (eg, depression) or have items that name specific reward stimuli (eg, social and food).42 48–50 In a study using the tripartite pleasure inventory, Meinzer et al51 suggested that a reduced capacity to attend to pleasurable stimuli/experiences lead to a disorganised pursuit of rewards in those with ADHD.

A smaller number of questionnaires are available to assess sensitivity to punishment in addition to those developed based on, or elaborated from, the RST. Some of these measures attempted to better differentiate responsiveness to punishment and motivation to avoid punishment,52 or removed mention of specific aversive stimuli from questionnaire items (eg, the Reward and Punishment Responsivity and Motivation Questionnaire).52 Using a measure of avoidance of negative outcomes (eg, Acceptance and Action Questionnaire-II) Bond et al53 report that individuals with ADHD show increased avoidance of negative thoughts, feelings and other internal experiences.54 In children, symptoms of disruptive behaviour disorders may imply reduced responsiveness to punishment, ie, repetitive and persistent patterns of inappropriate behaviour despite negative consequences. One questionnaire (Multidimensional Assessment Profile of Disruptive Behaviour)55 explicitly measures insensitivity to punishment. In this questionnaire, temper loss, irritability and frustration are also conceptualised as overreactions to aversive stimuli/results or non-reward.56 However, to our knowledge, the association between this questionnaire and ADHD symptoms has not been explored.

Finally, sensitivity to reward and punishment may relate to perceptions and calculation of benefits and risks. The Domain-Specific Risk Taking scale57 assesses risk taking, benefit perception and risk perception across multiple domains (health and safety, financial, recreational, social and ethical). Increased risk taking in ADHD has been associated with perception of greater benefits from engaging in risky behaviours58 and poor decision-making (eg, preferring a risky choice when it results in a suboptimal outcome).59

Despite the importance of motivational processes in identifying and describing the characteristics of ADHD, it is unclear whether experimental and questionnaire-based studies evaluate the same aspects of reward and punishment sensitivity or provide consensus. The objective of this study is to review and organise existing literature to help clarify how the concepts of motivational deficits in ADHD have been understood and measured to date. The review will also identify methodological and knowledge gaps in the field. This will allow the generation and testing of new hypotheses regarding altered reward and punishment sensitivity in ADHD.

Review questions

Specifically, this scoping review aims to answer the following questions:

  1. Which aspects of hypothesised altered reward and punishment sensitivity in ADHD correspond to the constructs measured by existing questionnaires?

  2. What are the relationships between ADHD symptomatology and reward and punishment sensitivity as measured by existing questionnaires?

  3. What is the degree of consistency between the experimental and questionnaire findings on reward and punishment sensitivity in ADHD?

By addressing the above questions, this study will identify the overlap and differences in the measurement of reinforcement sensitivity by experimental tasks and questionnaires.

Protocol design

This review protocol will follow the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.60 61 Further, the reporting of this scoping review will be formatted along the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines (PRISMA-ScR; online supplemental file 1).62 The iterative review process is being carried out according to the following steps: (1) defining the review objective and questions (completed), (2) creating the search strategies (initial strategies defined, need for additional search being identified), (3) conducting the literature search (initial search completed, handsearching ongoing), (4) selecting studies based on the eligibility criteria, (5) performing data extraction and (6) presentation of results. The eligibility criteria and methods are described below. This protocol will be registered with the Open Science Framework and the progress will be updated.

Eligibility criteria

Participants

This scoping review will include studies with participants of any age who have a clinical diagnosis of ADHD (all presentation types) or elevated inattention and/or hyperactivity/impulsivity symptoms as reported by parents and teachers in the case of children or adult self-report. The clinical diagnosis may be a diagnosis made by a licensed professional, or by researchers according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria. The degree of elevation in the symptoms of ADHD is as defined by the reviewed manuscript authors (may include above and subthreshold levels of ADHD). The ADHD samples may include individuals with comorbid conditions, or studies may focus on other conditions but include ADHD as a comparison or comorbid conditions. Studies will be included if they report the relationship between ADHD symptoms and reward/punishment sensitivity questionnaire responses or group differences in the questionnaire responses between individuals with and without ADHD. Results will be marked to indicate the evidence for ADHD with or without comorbid conditions. The ADHD samples may be described by other related terms, such as attention deficit disorder (ADD) and hyperkinetic syndrome (see online supplemental appendix 1 for a complete list of terms). Studies focused on non-human participants will not be included.

Concept

This scoping review will focus on the motivational processes in ADHD and will examine questionnaires that measure reward and punishment sensitivity in ADHD and where applicable their relationship to the results of experimental studies. Specifically, this review will include two types of studies: (1) studies that measure and report reward and punishment sensitivity using questionnaires and report their relationship with ADHD diagnosis/symptoms and (2) studies that measure and report reward and punishment sensitivity by both questionnaires and experimental tasks among individuals with an ADHD diagnosis or elevated symptoms. For experimental tasks to be included in the review, they must be designed to measure reward and/or punishment sensitivity.

We define reward as stimuli that increase the likelihood of future occurrence of the behaviour they follow (ie, positive reinforcement), and punishment as stimuli that decrease the likelihood of future occurrence of the behaviour they follow (including both positive and negative punishment). These definitions will be used in evaluating the inclusion of experimental tasks. For questionnaires, broader reward-related and punishment-related concepts will be considered, for example, pleasure, behavioural inhibition/activation and benefit/risk perception (see a complete list of terms considered in online supplemental appendix 1). Inclusion of these constructs is important as one of the aims of the study is to clarify how the concepts of reward and punishment are measured and described in relation to ADHD.

Context

This study’s context will be open; all geographical regions/settings, races and genders will be included. However, only English-language articles will be included, which may result in the exclusion of studies from some geographical locations and population groups. Studies conducted in both clinic and community settings will be included. Built-in filters were used to include English-language articles and to exclude systematic reviews and meta-analyses across all databases. The inclusion of human subjects and the publication type were checked using the combination of built-in filters (when available) and manual screening. It is possible that the use of these filters limited the search results.

Types of evidence

The review will consider only full-text articles of primary research published in English in peer-reviewed journals. These include studies with experimental and quasi-experimental designs, analytical observational studies and descriptive observational studies with quantitative analysis of the reward and punishment sensitivity questionnaires. Systematic reviews, meta-analyses, case reports, commentaries, posters, opinion pieces, editorials, comments, newsletters, letters to the editor with no empirical research, non-human studies and grey literature will be excluded. However, in the Introduction and Discussion sections, this additional literature may be discussed.

Methods

The expected review period is from 16 November 2023 (completion of initial searches) to January 2024 (estimated completion of data extraction).

Patient and public involvement

None.

Search strategy

The search is conducted across three databases using the search engine Google: PubMed (MEDLINE), Web of Science and APA PsycINFO (Ovid). Using these databases, preliminary searches were carried out to determine keywords, descriptors and Medical Subject Headings (MeSH), for the population (eg, ADD with hyperactivity), measurements (eg, surveys and questionnaires) and concepts (eg, reward sensitivity). The search terms used across the three databases varied slightly given the extent of their coverage of studies and their thesaurus functions. In particular, only certain phrase variations (ie, plural forms) were included in the Web of Science searches, whereas other variations (eg, scaled, scaling) were included in the two other databases. However, care was taken to ensure that the same inclusion and exclusion criteria were applied during the screening process. The asterisk function was used to exclude other related terms for both populations and measurements. All phrases considered are included in the search string with no restriction on the year of publication.

We first built the set of search terms to use in PubMed. We specified the search terms using quotation marks to exclude reordered word combinations and to include abbreviated, older and other terms that were not mapped in thesaurus functions. The term variations were captured using an asterisk where appropriate. The same set of search terms were used in Web of Science, although variations were specified using specific terms, rather than using asterisks. In PsycINFO, given the organisation of the thesaurus is different from PubMed, we repeated the checking of the thesaurus and included additional terms to ensure the consistency with the same set of terms identified by the PubMed MeSH terms. The hierarchies of the terms were considered and used in each database. The identified terms were integrated with the Boolean operators AND and OR for the subject heading and all field searches in all databases. No restriction was placed on the year of publication.

Built-in filters were used to include studies relevant to the research questions. Across all databases, filters were used to include English-language articles and to exclude systematic reviews and meta-analyses. The inclusion of human subjects only studies was managed using the filters in PubMed and PsycINFO and manually for articles identified in the Web of Science, which does not allow for filtering of human studies only. Document types were checked to include only published articles, first using the filters in PubMed (exclude preprints) and Web of Science (include Articles or Early Access) and only manually for articles identified in PsycINFO.

We will find related measurement reports via different databases or sources (eg, Google Scholar) and list all articles citing those papers. Searches from citations in papers that met the criteria will be included. The final scoping review report will include the detailed search strategies from all sources.

Study selection

To check the appropriateness of the search terms and inclusion/exclusion criteria, preliminary searches were conducted using several databases. We then conducted a search on 16 November 2023 using the integrated search strategy with Boolean operators AND and OR, in the three databases as described above, which identified 5180 papers without duplicates. The titles and abstracts are being screened before proceeding to full-text review and additional handsearching of relevant articles referenced in the identified studies via different databases and sources (eg, Google Scholar). We will check these additional papers against the eligibility criteria. We plan to finalise the article selection in December 2023.

All studies identified through the databases and handsearch are grouped and duplicates are removed using Covidence software, a web-based software for managing/streamlining systematic reviews.63 Using this software, screening of the identified articles is conducted by two independent researchers (MO and NN) according to the eligibility criteria described above, first based on titles and abstracts, prior to preceding to the full-text review. Any conflicts in screening will be resolved through discussion between the two researchers and consultation with the research team (protocol authors). Excluded studies and the reasons for exclusion will be reported. In particular, studies that are not peer-reviewed, do not include reward/punishment sensitivity questionnaires and do not include participants meeting the eligibility criteria will be excluded. Studies that do not report the relationship between ADHD symptoms and reward/punishment sensitivity questionnaire responses or group differences in the questionnaire responses between the ADHD and typically developing or other disordered groups will also be excluded.

Data extraction

Data on the selected studies are extracted by two independent researchers (MO and NN) using a data extraction form based on the JBI template.64 The data extraction items include source, eligibility, methods, population characteristics, information on the reward and punishment sensitivity questionnaire(s) (including constructs the questionnaires attempt to measure and how authors define reward and punishment sensitivity), information on the experimental task(s) (if any), results (relationship with ADHD symptoms/diagnosis and experimental task performance) and other relevant information, including conclusions (online supplemental appendix 2). We will use this data collection sheet with ten studies in the first instance and modify the items if necessary. We will report the modifications when reporting the review results. If necessary, the authors of the published papers will be contacted to request missing or additional data.

Presentation of results

All information regarding the selection of papers is presented in a flow chart according to PRISMA-ScR (online supplemental apendix 3). The results of all selected studies will be summarised in tables with descriptive data and in narrative form. We plan to include three results tables. The first table will summarise all studies that meet the eligibility criteria, including the study design, participant number and characteristics, questionnaire(s) used, experimental task(s) used and results. The second table will illustrate which aspects of hypothesised altered reward and punishment sensitivity in ADHD correspond to the constructs measured by existing questionnaires. The third table will characterise the association between the questionnaire results and ADHD symptomatology and experimental task performance, including correlation coefficients when available. The results will be marked to indicate whether they are for children/adolescents (under the age of 18) and adults (over 18),65 ADHD samples with or without comorbid condition(s), and whether they include clinically diagnosed samples or those with self-reports or other-reports of elevated ADHD symptoms. Any identified differences between the samples will be discussed. Depending on the results, figures may be created to map the concepts of reward and punishment sensitivity as measured by these questionnaires.

Critical Appraisal Skill Programme Checklists will be used to review and report the quality of the study designs and reliability and validity of the results of the selected studies. Limitations of the results will be discussed. These include the exclusion of non-English-language literature and grey (unpublished) literature. This may exclude some studies with culturally under-represented samples and those reporting non-significant results. There may also be other possible terms that are related to reward and punishment sensitivity that we do not use in the search strategy, resulting in missed studies that are relevant to the review questions. The study will focus on the relationship between reward and punishment sensitivity questionnaire responses and ADHD symptomatology but will not allow us to determine if these associations are unique to ADHD or shared by comorbid conditions. The quality and quantity of the studies included will depend on the available literature.

Implications for future research will be discussed based on the relationship between the findings from questionnaire research and hypothesised altered motivational processing as well as experimental task performance. The review will highlight current evidence gaps, as well as the need and appropriateness of additional questionnaire-based and experimental research and a further review, in the context of ADHD motivational processing.

Ethics and dissemination

Since this proposed study is a scoping review, there are no required ethical or safety considerations. The protocol and scoping review will not include members of the general public or patients. The results of the scoping review will be disseminated through publication in peer-reviewed journals and conference presentations.

Ethics statements

Patient consent for publication

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Footnotes

  • Twitter @Ma18238890

  • Contributors MO, EF and GT contributed to the conception and design of this protocol. MO and NN led the search strategy and pilot data mapping, supported by EF, KDP and GT. MO drafted the manuscript and EF and GT contributed to the revisions. KDP assessed this protocol along with the PRISMA-ScR checklist, which was reviewed by all authors. All authors (MO, EF, NN, KDP and GT) approved the final version of the manuscript for accuracy, completeness and publication.

  • Funding This study is supported by the Japan Society Promotion of Science (JSPS) KAKENHI, grant number 23KJ2130, and the internal subsidy funding from the OIST Graduate University, Japan.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.