The Experience OF Effort In ADHD: A Scoping Review

People with Attention-Deficit/Hyperactivity Disorder (ADHD) often struggle with tasks requiring sustained mental effort. This difficulty is so significant that it’s included as a diagnostic criterion for ADHD.

Individuals with ADHD may find it challenging to initiate, persist with, or complete tasks that demand prolonged concentration or cognitive exertion.

This struggle could stem from differences in brain function, particularly in areas responsible for motivation, attention regulation, and executive functioning.

The experience of effort for those with ADHD may be more intense or aversive, leading to avoidance behaviors.

Understanding this aspect of ADHD is crucial for developing effective interventions and support strategies.

Wagner, D., Mason, S. G., & Eastwood, J. D. (2024). The experience of effort in ADHD: a scoping review. Frontiers in Psychology, 15, 1349440. https://doi.org/10.3389/fpsyg.2024.1349440

Key Points

1. The primary methods of studying the experience of effort in ADHD include self-report measures and effort preference paradigms.
2. Factors like age, task type, and measurement approach significantly affect the observed patterns of effort experience in ADHD.
3. The research, while enlightening, has certain limitations such as inconsistent definitions of effort, limited sample sizes, and lack of diversity in study populations.
4. Understanding the experience of effort in ADHD is universally relevant as it impacts diagnosis, treatment, and daily functioning of individuals with ADHD across the lifespan.

Rationale

The study aims to comprehensively review the literature on the experience of effort in Attention-Deficit/Hyperactivity Disorder (ADHD).

This focus is justified by several key factors:

1. Diagnostic Significance: The avoidance or dislike of tasks requiring sustained mental effort is a diagnostic criterion for ADHD in the DSM-5 (APA, 2022).
2. Theoretical Relevance: Sergeant’s cognitive-energetic model of ADHD proposes that deficiencies in effort regulation underpin ADHD deficits (Sergeant, 2000, 2005).
3. Limited Previous Research: Despite its diagnostic and theoretical importance, the experience of mental effort in ADHD has not been extensively studied.
4. Potential Impact: Understanding the experience of effort in ADHD could inform clinical practice, research, and interventions for individuals with ADHD.

The next step in advancing this field is to systematically review and synthesize the existing literature to identify patterns, gaps, and directions for future research.

Method

This study employed a systematic scoping review methodology, adhering to the Joanna Briggs Institute Methodology for Scoping Reviews and the PRISMA-ScR guidelines.

The review aimed to identify, appraise, synthesize, and identify gaps in the literature on the experience of effort in individuals with ADHD across the lifespan.

Search strategy and terms: Databases searched: PsycINFO (OVID), PsycINFO (ProQuest), and PubMed Search terms: (“ADHD” or “Attention-Deficit/Hyperactivity Disorder”) AND (“effort” or “mental effort” or “cognitive effort” or “physical effort” or “mental load” or “cognitive load” or “workload” or “cognitive workload” or “task load” or “mental work” or “work”) Date range: No restrictions; final search conducted on February 14, 2023

Inclusion and exclusion criteria

Inclusion:

• Empirical studies published in peer-reviewed journals
• Written and published in English
• Included a group with ADHD or a measure of ADHD symptomatology
• Measured the conscious experience of effort through self-report or effort preference paradigms

Exclusion:

• Studies that only included physiological indices of effort without self-report or effort preferences
• Non-English language publications

Statistical measures

The review did not employ quantitative statistical analyses. Instead, it used a qualitative approach to synthesize and analyze the included studies, identifying patterns, gaps, and inconsistencies in the literature.

Results

1. Study Characteristics:

• 12 studies met the inclusion criteria
• Considerable variation in definitions and measurements of effort across studies
• Studies included various age groups: children, adolescents, and adults

2. Definitions of Effort:

• 75% of studies conceptualized effort as volitionally exerted
• 16.7% defined effort as task-elicited
• One study focused on the affective component of effort

3. Self-Report Findings:

• 25% of studies used multi-faceted self-report measures
• 41.6% employed single-item self-report measures
• Mixed results, with some studies finding differences between ADHD and control groups, while others did not

4. Effort Preference Paradigm Findings:

• 41.5% of studies used effort preference paradigms
• 60% of these used physical effort paradigms, 40% used mental effort paradigms
• No consistent differences found between ADHD and control groups in physical effort preferences
• Limited research on mental effort preferences

5. Demographic Factors:

• Gender: 25% of studies focused exclusively on males; no studies specifically on females or gender-nonconforming individuals
• Age: 33% examined adults, 25% focused on adolescents, 41.7% concentrated on children
• Limited reporting of race, ethnicity, and socioeconomic status

6. ADHD Diagnosis:

• 58.3% of studies employed formal ADHD diagnoses based on DSM criteria
• 23% relied on self-report measures of ADHD symptomatology
• Two studies did not clearly describe how ADHD diagnosis was confirmed

Insight

This scoping review reveals several key insights into the current state of research on the experience of effort in ADHD:

1. Limited Research: Despite the diagnostic significance of effort avoidance in ADHD, only 12 studies met the inclusion criteria, indicating a significant gap in the literature.
2. Inconsistent Definitions: The review highlights considerable variation in how effort is conceptualized and measured across studies, making it difficult to draw coherent conclusions.
3. Measurement Approaches: Studies using multi-faceted self-report measures tended to find more nuanced differences between ADHD and control groups compared to single-item measures or effort preference paradigms.
4. Age-Related Patterns: The review suggests that age may influence the pattern of results, with more consistent differences found in adult and child samples compared to adolescent samples.
5. Gender Bias: The review reveals a bias towards male participants, with a notable absence of studies focusing on females or gender-nonconforming individuals with ADHD.
6. Task-Type Differences: The experience of effort in ADHD may differ depending on the type of task (e.g., mental vs. physical, working memory vs. sustained attention).

These findings extend previous research by providing a comprehensive overview of the current state of knowledge on effort experience in ADHD.

They highlight the need for more consistent and comprehensive approaches to studying this phenomenon.

Future research should focus on:

1. Developing standardized, multi-faceted measures of effort experience
2. Investigating the experience of effort across different types of cognitive tasks
3. Examining the influence of gender and diverse demographic factors
4. Exploring the relationship between effort experience and ADHD symptoms across the lifespan

Strengths

The study had several methodological strengths:

1. Comprehensive search strategy using multiple databases
2. Adherence to established guidelines for scoping reviews (PRISMA-ScR and JBI)
3. Inclusion of both self-report and behavioral measures of effort experience
4. Consideration of studies across the lifespan, from childhood to adulthood
5. Critical analysis of the conceptualization and measurement of effort across studies

Limitations

The study also had several methodological limitations, including:

1. Limited number of studies meeting inclusion criteria (N = 12)
2. Potential bias in article selection, as only one reviewer was responsible for full-text review
3. Exclusion of non-English language publications
4. Lack of quantitative synthesis due to heterogeneity of included studies
5. Limited reporting of demographic factors (race, ethnicity, socioeconomic status) in included studies

These limitations restrict the generalizability of the findings and highlight the need for more extensive and diverse research in this area.

Implications

The results of this scoping review have several significant implications:

1. Clinical Practice: The inconsistent findings across studies suggest that clinicians should be cautious in interpreting effort avoidance in ADHD and consider multiple factors (e.g., task type, age, measurement approach) when assessing this symptom.
2. Diagnostic Criteria: The review raises questions about the conceptualization of effort avoidance in ADHD diagnostic criteria, suggesting a need for a more nuanced understanding.
3. Research Methods: The findings highlight the need for more standardized and comprehensive approaches to measuring effort experience in ADHD research.
4. Treatment Approaches: Understanding the nuances of effort experience in ADHD could inform the development of targeted interventions to improve task engagement and performance.
5. Lifespan Perspective: The age-related patterns observed suggest that effort-related interventions may need to be tailored differently for children, adolescents, and adults with ADHD.
6. Gender Considerations: The lack of research on females and gender-nonconforming individuals with ADHD points to a critical gap that needs addressing to ensure equitable understanding and treatment.

References

Primary reference

Wagner, D., Mason, S. G., & Eastwood, J. D. (2024). The experience of effort in ADHD: a scoping review. Frontiers in Psychology, 15, 1349440. https://doi.org/10.3389/fpsyg.2024.1349440

Other references

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Sergeant, J. (2000). The cognitive-energetic model: an empirical approach to attention-deficit hyperactivity disorder. Neuroscience & Biobehavioral Reviews, 24(1), 7-12. https://doi.org/10.1016/S0149-7634(99)00060-3

Sergeant, J. A. (2005). Modeling attention-deficit/hyperactivity disorder: a critical appraisal of the cognitive-energetic model. Biological psychiatry, 57(11), 1248-1255. https://doi.org/10.1016/j.biopsych.2004.09.010

Keep Learning

Socratic Questions for Discussion:

1. How might the experience of effort differ between individuals with predominantly inattentive ADHD versus predominantly hyperactive-impulsive ADHD?
2. In what ways could societal and cultural expectations influence the perception and reporting of effort experiences in individuals with ADHD?
3. How might the relationship between effort experience and ADHD symptoms change across different developmental stages?
4. What ethical considerations should researchers keep in mind when designing studies to measure effort experience in individuals with ADHD?
5. How could a better understanding of effort experience in ADHD inform the development of assistive technologies or environmental modifications?
6. In what ways might comorbid conditions (e.g., anxiety, depression) interact with ADHD to influence the experience of effort?
7. How might the concept of “hyperfocus” in ADHD relate to the experience of effort, and how could this be studied systematically?