On the Reorganization of Incentive Structure to PromoteDelay Tolerance: A Therapeutic Possibility for AD/HD?

Abstract

SUMMARYThis paper brings together two recent insights into attention deficit/hyperactivity disorder (AD/HD) to provide the rationale for a novel approach to treatment. First is the suggestion, backed up by data from randomized trials, that training and practice in carefully selected cognitive activities (executive and attentional training) and tasks can provide a way of modifying the processes underlying cognitive, especially executive, deficits in AD/HD. Second, is the idea that AD/HD is a neuropsychologically heterogeneous disorder resulting from motivational alterations, specifically an increased intolerance for delay, as well as executive deficits. The paper builds on these two insights to explore the possibility that the motivational alterations underpinning delay aversion can be modified through specific training regimes in a way equivalent to that found with executive and attentional training. The requirements for such an approach are set out. Delay fading is proposed as a possible basis for reorganizing delay experience, altering the incentive value of delay (e.g., increasing tolerance for delay), thereby reducing AD/HD symptoms.

Contextual influence of highly valued rewards and penalties on delay decisions in children with ADHD

“…Keeping in mind the influential role of parental behavior, DA theory suggests that frequent and immediate reinforcement may be effective in reducing DA and associated dysfunctional behavior in children with ADHD (Sagvolden, Johansen, Aase, & Russell, 2005), and it has been proposed to successively implement strategies that may help the child to bridge even larger delays between behavior and associated consequences. In this sense, delay fading (i.e., the repeated presentation of predictable and rewarded delay of gradually increasing size) may reduce DA by increasing sensitivity to reinforcer amount and quality and thus may help the child to develop self-control (Neef, Bicarc, & Endo, 2001;Sonuga-Barke, 2004). Linking our study results with DA theory, we suggest that principal caregivers should provide highly valued behavioral contingencies to motivate children to show adaptive behavior in delay-rich settings and that, under these circumstances, immediate reinforcement of appropriate behavior appears to not necessarily always be required.…”

Attention deficit hyperactivity disorder: a review of the essential facts

“…A promising start has been made (Young 1999). Our greater understanding about the aetiology of ADHD, especially the role of delay aversion, indicates that novel interventions such as delay fading (Sonuga‐Barke 2004) as a means of increasing tolerance for delay may prove useful in future interventions for adults.…”

“…Clinically the dual pathway model suggests that there may be merit in targeting different sub‐types with specific treatments, as well as allowing the development of novel interventions, perhaps aimed at desensitizing delay (Sonuga‐Barke 2002). Sonuga‐Barke (2004) has suggested ways in which the greater understanding about the influence of delay aversion on the development of ADHD could be used to develop alternative interventions. His suggestions include the use of delay fading, a technique to systematically reorganize the child's delay experience, as a means of increasing tolerance for delay, and reducing ADHD symptoms.…”

Probing the limits of delay intolerance: Preliminary young adult data from the Delay Frustration Task (DeFT)

“…Finally, one can move away from the choice paradigms completely and try to develop other non-choice indices of delay sensitivity and intolerance. One approach of this type was used in a recent study of motivationally based attention biases to delay-related stimuli (Sonuga-Barke, 2004). In this paradigm participants are conditioned to associate one colour with delayed outcomes and another with immediate outcomes (or escape from delay).…”