Annual Research Review: Transdiagnostic neuroscience of child and adolescent mental disorders – differentiating decision making in attention‐deficit/hyperactivity disorder, conduct disorder, depression, and anxiety

Abstract

BackgroundIneffective decision making is a major source of everyday functional impairment and reduced quality of life for young people with mental disorders. However, very little is known about what distinguishes decision making by individuals with different disorders or the neuropsychological processes or brain systems underlying these. This is the focus of the current review.Scope and methodologyWe first propose a neuroeconomic model of the decision‐making process with separate stages for the prechoice evaluation of expected utility of future options; choice execution and postchoice management; the appraisal of outcome against expectation; and the updating of value estimates to guide future decisions. According to the proposed model, decision making is mediated by neuropsychological processes operating within three domains: (a) self‐referential processes involved in autobiographical reflection on past, and prospection about future, experiences; (b) executive functions, such as working memory, inhibition, and planning, that regulate the implementation of decisions; and (c) processes involved in value estimation and outcome appraisal and learning. These processes are underpinned by the interplay of multiple brain networks, especially medial and lateralized cortical components of the default mode network, dorsal corticostriatal circuits underpinning higher order cognitive and behavioral control, and ventral frontostriatal circuits, connecting to brain regions implicated in emotion processing, that control valuation and learning processes.Findings and conclusionBased on clinical insights and considering each of the decision‐making stages in turn, we outline disorder‐specific hypotheses about impaired decision making in four childhood disorders: attention‐deficit/hyperactivity disorder (ADHD), conduct disorder (CD), depression, and anxiety. We hypothesize that decision making in ADHD is deficient (i.e. inefficient, insufficiently reflective, and inconsistent) and impulsive (biased toward immediate over delayed alternatives). In CD, it is reckless and insensitive to negative consequences. In depression, it is disengaged, perseverative, and pessimistic, while in anxiety, it is hesitant, risk‐averse, and self‐deprecating. A survey of current empirical indications related to these disorder‐specific hypotheses highlights the limited and fragmentary nature of the evidence base and illustrates the need for a major research initiative in decision making in childhood disorders. The final section highlights a number of important additional general themes that need to be considered in future research.

Investigating the Impact of Cognitive Load and Motivation on Response Control in Relation to Delay Discounting in Children with ADHD

“…Deficient cognitive control or atypical motivation may contribute to greater delay discounting often observed in ADHD (Peters & Buchel, 2011; Sonuga-Barke et al, 2015). The purpose of the present study was to directly investigate the relationship between the effects of cognitive load and motivation on response control and delay discounting.…”

“…Cognitive control is crucial in the stages of decision-making that involve comparing and deciding between choices as well as those that tap into reinforcement learning processes (Sonuga-Barke et al, 2015), both of which would be implicated in decisions between smaller-sooner and larger-later rewards. The complex GNG task requires significant cognitive control due to the greater demands on working memory (i.e., counting green spaceships and monitoring whether the count is even or odd) to guide response inhibition (i.e., to select or inhibit response to select a red spaceship).…”

“…A valuable area for future research is to examine whether delay discounting is related to an individual’s response to contingency management. Also, given the implication of interacting neural pathways underlying both cognition and motivation in contributing to our understanding of ADHD (Sonuga-Barke, 2002, 2003), delay discounting (Peters & Buchel, 2011), and decision-making (Sonuga-Barke et al, 2015), future research including neuroimaging measures may be particularly informative. Collectively, these findings contribute to our understanding of deficient impulse control in children with ADHD both in terms of motor response control and reward-based decision-making, and the relationships between these neurocognitive processes.…”

“…The extent to which an individual engages in delay discounting may reflect interindividual variability in the neural mechanisms underlying delay discounting, including reward valuation, cognitive control, and prospection (see review by Peters & Buchel, 2011). Despite the growing evidence that delay discounting involves multiple interacting brain systems related to self-referential, executive, and reinforcement processes (Sonuga-Barke, Cortese, Fairchild, & Stringaris, 2015), the mechanisms of delay discounting in ADHD are poorly understood. The prevailing models suggest that the behavioral preference for immediate rewards observed in individuals with ADHD may be related to an atypical response to reward, deficient cognitive control, or both.…”

The triple challenge of mental health

“…Distinguishing between types of mental disorder, SonugaBarke et al [18] examined the decision-making capacity of children and adolescents with: (1) attention-deficit/hyperactivity disorder, (2) conduct disorder, (3) depression, and (4) anxiety. Group (1) was typically too quick in reaching a decision, (2) underestimated the impact of negative future events, (3) put excessive emphasis on negative past experience, while group (4) was characterized by excessive risk aversion.…”