Motivation and emotion/Book/2022/ADHD and motivation

ADHD and motivation:
How does ADHD impact on motivation and what can be done about it?

Overview

Figure 1. Common positive and negative stigmas associated with ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a common psychological disorder that stems from impairments and deficits in the human brain. This affects behaviour, thoughts and emotions (ADHD Australia, 2019), which can cause challenges with motivation. Due to stigmas and stereotypes, people can mistake these motivation challenges for laziness, carelessness, or a lack of dedication (see Figure 1). Providing education about ADHD and its impact on motivation is an effective way to make treatment more accessible, combat stereotypes and stigmas, and create lasting change in the lives of those with ADHD (Retz et al., 2021).

Extensive literature has developed in more recent years that investigates the causes of ADHD and treatments and interventions. This chapter focuses on reviewing current literature about ADHD and motivation. Based on this research this chapter's content aims to provide the reader with an understanding of what ADHD is, and how it affects motivation and to explore solutions and treatments to help reduce motivation challenges for those with ADHD.

Case study: Meet Frank and his mum

This case study is used throughout the chapter to assist readers in understanding and applying the following chapter's content.

Meet Frank. Frank is a teenager in Year 12 who has ADHD. Frank experiences challenges at college and at home, [grammar?] he finds himself zoning out during class and struggling to complete his assignments. At home, Frank feels like he disappoints his mum when he can't seem to bring himself to clean and maintain his room. These challenges and behaviours frustrate Frank as he doesn't understand why he can't just 'do what he needs to do'.

Meet Frank's mum. She loves Frank very much and tries to be patient with him but sometimes she just 'can't take it anymore!'. Frank forgets her instructions or tasks he needs to do, and can't motivate himself to do his assignments or clean his room. She finds herself wishing he would just 'stop being lazy' and 'get his act together'.

ADHD explained

Figure 2. The DSM-5 used to diagnose ADHD

ADHD is a common mental health disorder that is typically characterised by patterns of impulsive and sometimes hyperactive behaviour, inattentiveness, and impaired emotion regulation. Figure 3 includes a list of common ADHD symptoms. Many who struggle with the disorder will experience deficits in areas or tasks that involve memory, recalling information, planning, self-monitoring and self-soothing and problem-solving[factual?]. These behavioural and emotional symptoms can make it challenging for someone with ADHD to complete everyday tasks and routines. ADHD often presents with other co-occurring mental health disorders such as anxiety, depression and addiction (Wilens & Spencer, 2010). The diagnosis of ADHD involves the individual meeting criteria outlined in the DSM-5 (see Figure 2) (ADHD Australia, 2019).

Figure 3. List of ADHD symptoms[*factual?*]
Behavioural	Physiological	Psychological
Impaired emotion regulation Impaired impulse control Hyperactivity Inattention Mood swings Impaired focus and concentration Poor time management and task prioritisation	Impaired brain regions Frontal cortex Limbic system Basal ganglia Reticular activating system Neurochemical imbalances Norepinephrine Dopamine	Impaired executive function Emotionally reactive Problem-solving challenges Poor sensory relegation and processing Impaired memory and recall Interrupted sleep

How does ADHD impact motivation?

This section explores the specific neurological differences in brain chemistry and biology observed in the ADHD brain that are believed to impact motivation. [factual?]

Brain chemistry

One of the main reasons people with an ADHD diagnosis can experience a lack of motivation is an imbalance in their brain chemistry stemming from deficits in dopamine and norepinephrine production and processing.

Dopamine

Figure 3. The chemical structure of dopamine

Dopamine (see Figure 3) is a neurotransmitter that is released during or in anticipation of pleasurable experiences. It helps people to identify events and actions that can lead to a reward or pleasurable experience and motivate them to take action to experience these results. The pleasurable experience from a dopamine release helps the brain make a connection between the action and pleasure, making the individual likely to repeat the behaviour to experience the pleasure again, i.e. like the brain saying "doing that felt good... do it again!" (Arias-Carrión & Pŏppel, 2007).

For people with ADHD, their brains have lower levels of dopamine than a neurotypical brain. This deficit of dopamine causes motivation challenges regarding the completion of tasks and goals as those with ADHD can identify that completing a task will lead to a reward later, but their brain doesn't release dopamine in anticipation of that reward, meaning the individual doesn't experience the boost in motivation to complete the task for the reward.[factual?]

When someone with ADHD does receive a reward, the associated dopamine release and motivation boost is weaker and shorter than it is for the neurotypical brain. This weaker reaction makes it harder for the brain to connect the action to the pleasurable reward, making the individual less likely to repeat the behaviour (Levy & Swanson, 2001).

Case study example 1

Frank is wanting to apply for university and knows he needs to fill out an application. In normal circumstances, a person would be able to link the filling out of the application with the anticipation of the pleasurable feeling that will come with graduating and the dopamine from the anticipation of the reward would motivate the action of filling out the form.

In Frank's case, he knows that filling out the application will lead to graduating but his brain doesn't 'light up' in anticipation of that reward, meaning he doesn't experience the dopamine fuelled motivation boost to help him fill out the form.

Norepinephrine

Figure 4. Norepinephrine helps control attention

Norepinephrine is a neurotransmitter that provides a trigger to 'get the brain going', and is responsible for controlling attention, alertness and arousal (see figure 4). Norepinephrine assists with motivation as it can control or increase the brain and body's responses, perception and processing of stimuli and changes in situations by adjusting the input and processing of the prefrontal cortex. This controls the brain's levels of attentiveness and alertness towards specific stimuli and initiates actions towards the stimuli, such as listening to instructions and then taking action to follow the instruction to complete a task (Sara, 2015).

Research surrounding the connection between norepinephrine, ADHD and motivation is still developing, but has shown evidence of lower levels of norepinephrine in the ADHD brain resulting from altered production and processing and suggests that norepinephrine deficits could be responsible for a lack of motivation to complete tasks experienced by people with ADHD[factual?]. Evidence suggests a disconnect between the recognition of a task, the planning of task completion and the actual motivation to take action to complete the task as there are insufficient levels of norepinephrine to motivate and 'get the brain going' to work to achieve a pleasurable experience or reward (Faraone et al., 2014).

Case study example 2

Frank's struggle with wanting to clean and maintain his room or fill out his university application but being unable to get motivated to do either task could be explained by an imbalance of norepinephrine, leading him to not have the means to physically be motivated to complete these tasks.

Neurobiology

Figure 5. Location of the frontal cortex in the human brain

The ADHD brain experiences impaired functioning in four main areas. It affects their functions and the role they play in motivation are discussed below.[factual?]

Frontal Cortex

The frontal cortex (see figure 5) plays a key role in motivation, more specifically in areas including high-level functioning, executive function, attention and organisation (Kouneiher et al., 2009). Studies have identified weaker connections, functions and structure of the frontal cortex, resulting in impaired attention delegation and weakened links between internal goals and behaviour in the ADHD brain. Deficits in norepinephrine and dopamine are believed to contribute to the impaired function of this brain region (Arnsten, 2009) (F. T. Arnsten, 2009).

Limbic System

The limbic system regulates emotion and attention and is connected to the reward pathway. Research has found size differences [between?] in structures in the limbic system (Plessen et al., 2006). Evidence suggests that a link between ADHD and differences in the limbic system could cause restlessness and inattentiveness, resulting in impaired motivation.

Basal Ganglia

The basal ganglia (BG) assists with inter-brain communication and controls the giving or withdrawal of energy to or from actions, depending on if the action is deemed 'worth it' or not by the individual[factual?]. Evidence shows size and volume differences in the BG in the ADHD brain and suggests this could cause impaired brain processing capacity, leading the individual to feel overwhelmed, resulting in 'zoning out' and inattentiveness (Qiu et al., 2009) (Lauren, 2013). Research suggests these differences could cause over or underactive energy delegation towards tasks, causing hyper-fixation on a specific task resulting in struggles with effective task prioritisation and motivation challenges for completing tasks (Lauren, 2013).

Reticular activating system

The reticular activating system (RAS) acts as an 'on and off switch' for the brain, [grammar?] it controls what messages enter and leave the brain and the arousal and regulation of thoughts, behaviour and emotions, which directly influences concentration and focus. Individuals with ADHD have an impaired RAS, resulting in impaired focus and behaviour control, [grammar?] this can result in 'over or under-arousal'[factual?]. This causes challenges with sustaining focus on a task due to the state of arousal becoming too high to focus on a task, resulting in hyperactivity, or the arousal is not high enough to produce enough energy to motivate the individual to complete a task.

Theoretical underpinnings about ADHD and motivation

This section explores theories underpinning the connection between ADHD and motivation.

Executive function

Concerning motivation, executive function refers to a person's ability to control concentration, attention and identification of rewards to then direct and adapt behaviour towards achieving that reward. These skills allow the organisation of thoughts and actions so the individual can effectively prioritise and perform actions to achieve goals and rewards.[factual?]

Individuals with ADHD struggle to exercise their executive function (this is called executive dysfunction), meaning they can struggle and get overwhelmed by the ordering and planning of the 'what', 'why', 'when' and 'how' in regards to tasks, goals and actions and then struggle to direct energy and emotion effectively to fuel their motivation and use this energy to work towards an action to achieve a goal.[factual?]

Self-determination theory

wikipedia:Self-determination_theory (SDT) provides a framework for motivation suggesting that to achieve psychological growth, an individual needs to feel like they have control over their behaviours and goals, the individual needs to acquire skills and knowledge to enable them to gain a sense of independence and to help them achieve their goals, and the individual needs to feel connected to other people (Pesantez, 2021).

Previously, ADHD therapy has focused on positive reinforcement to increase motivation, [grammar?] this approach usually involves extrinsic motivation. Intrinsic motivation has been found to be as effective as intrinsic motivation. The new application of SDT in ADHD therapy will change the focus to increasing and targeting intrinsic motivation, creating sustainable longer-lasting change for individuals with ADHD in a way that accommodates their symptoms but allows for growth in their coping strategies and behaviour in regards to increasing or working around motivation challenges (Morsink et al., 2021).

Reward pathway and the pleasure-pain principle

The reward pathway is an avenue in the brain that allows for connections to be made between behaviour and events that bring a pleasurable feeling or experience and then increased the likelihood of the behaviour being repeated. Due to impaired and imbalances, the reward pathway can be impaired, making it challenging for people with ADHD to form connections between pleasurable experiences and behaviours or events, meaning they are less likely to repeat actions that lead to a pleasurable experience or reward (Volkow et al., 2009).

The pleasure-pain principle suggests that humans decide their actions based on the avoidance of pain or the pursuit of pleasure. People decide what they consider to be pain or pleasure based on their beliefs and values. Due to an impaired reward pathway, individuals with ADHD can struggle to identify which actions and events will or will not bring pleasure or pain.[factual?]

Solutions and treatment

Figure 6. Various pills as an example of stimulant, SSRI or SNRI medication

This section explores different treatments and strategies used to treat or address motivation challenges in ADHD. The most successful treatment cases of ADHD are treatment plans that have used an integrated approach and used multiple treatments together, according to the client's unique circumstances (Johnson & Safranek, 2005) (Pelham & Gnagy, 1999).

Medication

Table 1 summarises information on ADHD medication, what the medications do and the types of medication in each category (see example in Figure 6).

Table 1. Medications for ADHD
	Stimulant	Non-stimulant
What does it do?	Stimulant medications for ADHD target specific cells in the brain that produce dopamine and norepinephrine and stimulate the cells to increase the production of both neurotransmitters to create and maintain healthy levels of these neurotransmitters. These effects work to lessen or alleviate the effects that insufficient levels of both neurotransmitters have on motivation.	The most common non-stimulant drugs that are used to treat ADHD fit into the categories of either SSRIs or SNRIs - these medications can be used to treat symptoms of co-occurring psychological disorders (e.g. anxiety or depression) and help balance out dopamine and norepinephrine levels in the ADHD.
Common types of medication	Stimulant medications can be short-acting, intermediate-acting or long-acting according. Short-acting stimulants: Methylphenidate, also known as Ritalin Dextroamphetamine, also known as Dexedrine, ProCentra and Zenzedi Amphetamine/dextroamphetamine also known as Adderall Dexmethylphenidate, also known as Focalin Intermediate-acting stimulants: Methylphenidate, also known as Ritalin SR, Metadate ER, Methylin ER Amphetamine sulfate, also known as Evekeo Long-acting stimulants: Amphetamine, also known as Dyanavel XR and Adzenys XR-ODT Dexmethylphenidate, also known as Focalin XR Dextroamphetamine, also known as Adderall XR Lisdexamfetamine, also known as Vyvanse Methylphenidate, also known as Concerta, Ritalin LA and Quillivant XR	Common non-stimulant ADHD medications: Atomoxetine, also known as Strattera Viloxazine, also known as Qelbree Clonidine, also known as Catapres and Kapvay Guanfacine, also known as Tenex, Intuniv Buproprion, also known as Wellbutrin Qelbree Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) such as phenelzine and tranylcypromine
How these medications help with motivation	These medication treatments, by balancing out the levels of dopamine and/or norepinephrine neurotransmitters in the brain, can lessen or alleviate the effects and impacts on motivation caused by deficiencies of these neurotransmitters.

(Bhandari, 2021), (Non-Stimulant ADHD Medication Overview, 2019)

Therapies and training

The therapies and training discussed below are used to treat motivation challenges in ADHD.

Behaviour modification

Behaviour modification for ADHD uses rewards to reinforce positive behaviours that are challenging for the individual, such as completing a task or doing 20 minutes of an assignment. By reinforcing these actions, the individual is more likely to repeat the behaviour. Reinforcements are usually in response to small behaviours or progress, in shorter intervals, to account for difficulties with attention and the reward pathway. The more these actions are reinforced, the simpler and easier it is for the individual to make a connection between the action and the reward and pleasurable experience, which helps the individual get motivated for these actions and to be more likely to repeat them.

Cognitive therapy

This therapeutic approach focuses on thought patterns. The individual and therapist role-play situations and associated thoughts and then practice using different reactions and thoughts to the given situation. For example, this could look like, [grammar?] being given a task for school, catching the thought processes associated with 'leaving it till later' or 'being overwhelmed and not knowing where to start' and instead thinking and acting on breaking the task into smaller bits and staggering the completion of each little task. Other thoughts and actions can involve using behaviour modification techniques of using rewards and positive reinforcement.

Education and training

Figure 8. Some treatments involve education and training workshops for ADHD

Education and training focus on educating the client and possibly people in their support network, about the AHDH and strategies to overcome and cope with motivation challenges through therapy sessions, workshops (see figure 8), group therapy sessions and many more avenues. When the client or parents of a child with ADHD are equipped with this knowledge, they can notice thoughts, behaviours etc associated with motivation challenges and then use their knowledge of possible coping strategies to find a solution that works for them to help motivate them in different scenarios.

Strategies

People with ADHD often can be overwhelmed by tasks and experience challenges with their executive function which can inhibit motivation for short-term and long-term goals. These challenges can be addressed through strategic goal setting and achievement, this could involve ideas such as breaking tasks down into smaller tasks, setting time limits and working for shorter periods, using rewards to reinforce the completion of small tasks or goals.[factual?]

Case study example 3

An example of an ADHD treatment for Frank could be the use of stimulant medication, coupled with education for him and his mum, allowing them both to be equipped to create change and ensure Frank is supported in working on his motivation challenges. Frank could attend cognitive therapy to identify his thought patterns and when they occur. He could then implement behaviour modification strategies such as breaking his assignment into small parts and rewarding the completion of each part.

Quiz

Conclusion

This chapter provides an understanding of what ADHD is, how it affects motivation and explores solutions and treatments to help reduce motivation challenges for those with ADHD. ADHD is a common psychological disorder with symptoms that are linked to motivation challenges (ADHD Australia, 2019). These challenges are caused by neurological impairments and deficits in the human brain that occur when the individual has ADHD. The research surrounding treatments and knowledge of the disorder has grown extensively in recent years, leading to the creation and improvement of interventions and treatment and helping to combat the stigmas and stereotypes associated with ADHD (Retz et al., 2021). The use of stimulant and non-stimulant medication are some of the main treatment approaches and are often used in a combined approach with therapy, education and training to equip people with ADHD with strategies and tools to overcome or lessen their challenges with motivation. ADHD research and applications of this research still have room to develop, however, the current knowledge available provides the public with opportunities to seek treatment to be able to overcome motivation challenges or be equipped to support people in their life with ADHD in their treatment journey as they explore and overcome their struggles with motivation. The more information about ADHD and motivation is shared, the more support becomes accessible for those living with or supporting someone with ADHD and the more negative stigmas and stereotypes associated with ADHD and motivation challenges can be challenged and reduced.

References

ADHD Australia. (2019). What is Attention Deficit Hyperactivity Disorder (ADHD)? ADHD Australia. https://www.adhdaustralia.org.au/about-adhd/what-is-attention-deficit-hyperactivity-disorder-adhd/

Arias-Carrión, O., & Pŏppel, E. (2007). Dopamine, learning, and reward-seeking behaviour. Acta Neurobiologiae Experimentalis, 67(4), 481–488. https://pubmed.ncbi.nlm.nih.gov/18320725/

Arnsten, A. F. T. (2009). ADHD and the Prefrontal Cortex. The Journal of Pediatrics, 154(5), I-S43. https://doi.org/10.1016/j.jpeds.2009.01.018

F. T. Arnsten, A. (2009). The Emerging Neurobiology of Attention Deficit Hyperactivity Disorder: The Key Role of the Prefrontal Association Cortex [Review of The Emerging Neurobiology of Attention Deficit Hyperactivity Disorder: The Key Role of the Prefrontal Association Cortex]. The Journal of Paediatrics, 5. National library of medicine. https://doi.org/10.1016/j.jpeds.2009.01.018

Faraone, S. V., Bonvicini, C., & Scassellati, C. (2014). Biomarkers in the Diagnosis of ADHD – Promising Directions. Current Psychiatry Reports, 16(11). https://doi.org/10.1007/s11920-014-0497-1

Johnson, L. A., & Safranek, S. (2005). What is the most effective treatment for ADHD in children? Mospace.umsystem.edu. https://mospace.umsystem.edu/xmlui/handle/10355/3377

Kouneiher, F., Charron, S., & Koechlin, E. (2009). Motivation and cognitive control in the human prefrontal cortex. Nature Neuroscience, 12(7), 939–945. https://doi.org/10.1038/nn.2321

Levy, F., & Swanson, J. M. (2001). Timing, Space and ADHD: The Dopamine Theory Revisited. Australian & New Zealand Journal of Psychiatry, 35(4), 504–511. https://doi.org/10.1046/j.1440-1614.2001.00923.x

McGoey, K. E., Eckert, T. L., & DuPaul, G. J. (2002). Early intervention for preschool-age children with ADHD: a literature review. In www.ncbi.nlm.nih.gov. Centre for Reviews and Dissemination (UK). https://www.ncbi.nlm.nih.gov/books/NBK69230/

Morsink, S., Van der Oord, S., Antrop, I., Danckaerts, M., & Scheres, A. (2021). Studying Motivation in ADHD: The Role of Internal Motives and the Relevance of Self Determination Theory. Journal of Attention Disorders, 108705472110509. https://doi.org/10.1177/10870547211050948

Pelham, W. E., & Gnagy, E. M. (1999). Psychosocial and combined treatments for ADHD. Mental Retardation and Developmental Disabilities Research Reviews, 5(3), 225–236. https://doi.org/10.1002/(SICI)1098-2779(1999)5:3<225::AID-MRDD9>3.0.CO;2-E

Plessen, K. J., Bansal, R., Zhu, H., Whiteman, R., Amat, J., Quackenbush, G. A., Martin, L., Durkin, K., Blair, C., Royal, J., Hugdahl, K., & Peterson, B. S. (2006). Hippocampus and Amygdala Morphology in Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry, 63(7), 795–807. https://doi.org/10.1001/archpsyc.63.7.795

Qiu, A., Crocetti, D., Adler, M., Mahone, E. M., Denckla, M. B., Miller, M. I., & Mostofsky, S. H. (2009). Basal Ganglia Volume and Shape in Children With Attention Deficit Hyperactivity Disorder. American Journal of Psychiatry, 166(1), 74–82. https://doi.org/10.1176/appi.ajp.2008.08030426

Retz, W., Ginsberg, Y., Turner, D., Barra, S., Retz-Junginger, P., Larsson, H., & Asherson, P. (2021). Attention-Deficit/Hyperactivity Disorder (ADHD), antisociality and delinquent behaviour over the lifespan. Neuroscience & Biobehavioral Reviews, 120, 236–248. https://doi.org/10.1016/j.neubiorev.2020.11.025

Sara, S. J. (2015). Locus Coeruleus in time with the making of memories. Current Opinion in Neurobiology, 35, 87–94. https://doi.org/10.1016/j.conb.2015.07.004

Sara, Susan J., & Bouret, S. (2012). Orienting and Reorienting: The Locus Coeruleus Mediates Cognition through Arousal. Neuron, 76(1), 130–141. https://doi.org/10.1016/j.neuron.2012.09.011

Volkow, N. D., Wang, G.-J., Kollins, S. H., Wigal, T. L., Newcorn, J. H., Telang, F., Fowler, J. S., Zhu, W., Logan, J., Ma, Y., Pradhan, K., Wong, C., & Swanson, J. M. (2009). Evaluating Dopamine Reward Pathway in ADHD. JAMA, 302(10), 1084. https://doi.org/10.1001/jama.2009.1308

Wilens, T. E., & Spencer, T. J. (2010). Understanding Attention-Deficit/Hyperactivity Disorder from Childhood to Adulthood. Postgraduate Medicine, 122(5), 97–109. https://doi.org/10.3810/pgm.2010.09.2206