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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 33
| Issue : 1 | Page : 39-44 |
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The reinforcement sensitivity of male adults with attention-deficit/hyperactivity disorder: The association with internet addiction
Tai- Ling Liu M.D. 1, Chen- Hsiang Su M.D. 1, Jia- In Lee M.D. 1, Chih- Hung Ko M.D., Ph.D. 2
1 Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
2 Department of Psychiatry, Kaohsiung Medical University Hospital; Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital; Department of Psychiatry, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| Date of Submission | 17-Dec-2018 |
| Date of Decision | 16-Jan-2019 |
| Date of Acceptance | 16-Jan-2019 |
| Date of Web Publication | 28-Mar-2019 |
Correspondence Address:
Chih- Hung Ko
No. 100, Tzyou First Road, Kaohsiung 807
Taiwan
 Source of Support: None, Conflict of Interest: None  | 1 |
DOI: 10.4103/TPSY.TPSY_7_19
Objective: In this study, we intended to evaluate the association between reinforcement sensitivity and male adults with attention-deficit/hyperactivity disorder (ADHD), as well as the association between reinforcement sensitivity and Internet addiction. Methods: We recruited 52 male adults with ADHD and 52 healthy male controls. All participants received a diagnostic interview for ADHD and completed ratings with the Behavior Inhibition Scale (BIS), Behavior Activation Scale (BAS), Adult ADHD Self-report Scale, and Chen Internet Addiction Scale to assess their reinforcement sensitivity, ADHD severity, and Internet addiction severity. Results: The study data showed that males with ADHD had significantly higher scores in BIS (22.06 ± 3.02 vs. 19.52 ± 2.49, p < 0.001), fun seeking (13.33 ± 2.03 vs. 11.10 ± 2.01, p < 0.001), BAS (44.42 ± 5.10 vs. 41.17 ± 4.79, p < 0.001), and Internet addiction (71.52 ± 14.60 vs. 51.98 ± 13.62, p < 0.001). Findings from the data showed that fun seeking was the most associated factor, followed by BIS. Furthermore, interpersonal and health problems were the most associated dimensions of Internet addiction associated with adult ADHD. The findings using the Pearson's correlation among adults with ADHD revealed that reward sensitivity, drive, and BAS were associated with the severity of hyperactivity. Additionally, BIS was associated with the severity of Internet addiction. Conclusion: Adult ADHD is associated with fun seeking, BAS, and BIS. We suggest that clinicians need to pay attention to reinforcement sensitivity when treating adults with ADHD. Furthermore, male adults with ADHD had higher severity of Internet addiction. Their BIS was positively associated with the severity of Internet addiction; thus, Internet addiction should be well assessed and treated among adults with ADHD, particularly among those with higher BIS.
Keywords: Adults, attention-deficit/hyperactivity disorder, fun-seeking, Internet addiction, reinforcement sensitivity
How to cite this article:
Liu TL, Su CH, Lee JI, Ko CH. The reinforcement sensitivity of male adults with attention-deficit/hyperactivity disorder: The association with internet addiction. Taiwan J Psychiatry 2019;33:39-44 |
How to cite this URL:
Liu TL, Su CH, Lee JI, Ko CH. The reinforcement sensitivity of male adults with attention-deficit/hyperactivity disorder: The association with internet addiction. Taiwan J Psychiatry [serial online] 2019 [cited 2023 Mar 25];33:39-44. Available from: http://www.e-tjp.org/text.asp?2019/33/1/39/255146 |
| Introduction | |  |
Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder that manifests inattentive, impulsive, and hyperactive symptoms from childhood[1]. Four to 66% of childhood ADHD persist into adulthood. Population-based studies estimate the prevalence of adult ADHD at 1%–7.3%[2]. The deficit in rewarding process has repeatedly been reported in brain imaging studies of adults with ADHD to explain their impulsive behaviors[3],[4]. The hyperactivation in the motivation-reward processing brain network can explain the high comorbidity of addictive disorder and ADHD[5]. Thus, reinforcement sensitivity of ADHD needs to be evaluated to understand its rôle in the comorbidity of ADHD.
The reinforcement sensitivity theory and attention-deficit/hyperactivity disorder
Based on the original Gray's reinforcement sensitivity theory, the Eysenck's arousal theory of extraversion[6] should be modified. The theory should have two systems: the Behavioral Inhibition System (BIS), reflecting anxiety, Behavioral Activation System (BAS), and reflecting impulsivity. The BIS is responsible for organizing behavior in response to stimuli that signal conditioned aversive events. These aversive stimuli elicit behavioral inhibition (interruption of any ongoing behavior), an increment in the level of arousal, and an increment in attention. The BAS is responsible for organizing behavior in response to appetitive stimuli. The BAS is appetitive and sensitive to stimuli that signal unconditioned reward. Activity in the BAS is involved in approach behavior. Higher BIS activity determines a vulnerability in internalizing disorders, such as anxiety, whereas elevated BAS activity has been assumed to make individuals vulnerable to externalizing problems, such as impulsivity[7].
Quay hypothesized that the hyporeactivity of BIS underlines hyperactivity and impulsivity observed in ADHD[8]. He suggests that lower responsiveness to aversive stimuli contributes to the impulsive behavior of ADHD. However, a later study has demonstrated an overresponsive BAS in a child of ADHD[9]. This result has also been reported in another behavioral task study[10]. Another study has shown the association between a motivation deficit of ADHD and the dysfunctional dopamine reward pathway[11]. This result may suggest how the individual's response to reward could play a rôle in the mechanism of ADHD. However, how the reinforcement theory is associated to ADHD has not been well evaluated among adults.
The association between reinforcement sensitivity and Internet addiction among adults with attention-deficit/hyperactivity disorder
The Internet addiction is associated with ADHD[12],[13],[14]. A two-year prospective study demonstrated that the severity of ADHD symptoms predicts the onset of Internet addiction among adolescents[15]. Furthermore, the impulsivity and hostility have been reported to mediate the association between Internet gaming disorder and adult ADHD[13]. These results may suggest some characteristics such as reinforcement sensitivity which determines the risk of comorbid Internet addiction among adults with ADHD.
The higher activity of BAS system makes individuals vigorously to pursue an action that might result in reward, with little attention to the possibility of negative consequences. Thus, higher BAS activity is expected to play a rôle in developing the addictive disorder, such as cocaine use disorder[16]. On the other hand, alcohol use has been reported to associate with higher BIS[17]. However, another study has demonstrated lower BIS among adults with alcohol use[18]. Thus, the rôle of BIS activity in the addictive process has not been clearly defined[19].
Higher fun seeking and BIS have been suggested to be associated with Internet addiction[20], and BIS has been reported to be associated with Internet addiction among adults with ADHD[20]. However, this finding has not revealed the association between BAS and Internet addiction among young adults with ADHD. Further, how BAS and BIS are related to the dimensions of Internet addiction has not been well evaluated.
As adults with ADHD are more prevalent in the male gender[21], in this study, we focused on male adults with ADHD. In this study, we intended to evaluate (a) the reinforcement sensitivity in male adults with ADHD; (b) the association between Internet addiction and adult ADHD; (c) the correlations between behavioral inhibition, behavioral activation, Internet addiction, and severity of ADHD among adults with ADHD; as well as (d) the correlations between behavioral inhibition, behavioral activation, and dimensions of Internet addiction among adults with ADHD.
| Methods | | |
Study participants
We recruited males with adult ADHD (ADHD group) and healthy age- and educational level-compatible male participants (control group) through advertisement. All recruited participants were screened by research assistants to be (a) Chinese speaking, (b) male, (c) having at least university education level, and (d) being right handed. The excluding criteria include lifetime substance use disorder other than nicotine dependence; current illegal substance use; major depressive episode; current psychotropic medication use; a history of bipolar I disorder, psychotic disorder, neurological illness and injury, mental retardation, or intolerability to magnetic resonance imaging; and were assessed by psychiatrists using the Chinese version of the Mini-International Neuropsychiatric Interview (MINI)[22] and psychiatric interviewing. After providing complete description of the study to the participants, we obtained written informed consents from those criteria-fulfilled individuals. A psychiatrist assessed adult ADHD diagnosis and childhood ADHD history of all the recruited individuals with the Diagnostic and Statistical Manual of Mental Disorders IV-TR criteria[23] and the Kiddie version of the Schedule for Affective Disorders and Schizophrenia-Present and Life Version (K-SADS-PL)[24], respectively. All participants were assessed using the diagnostic interview for adult ADHD. The interviewing questions about the ADHD diagnosis were according to the questionnaire on the adult ADHD Self-report Scale (ASRS)[25]. The study protocol was approved by the institutional review board of Kaohsiung Medical University, with the requirement of obtaining signed informed consents from the participating individuals.
Study measures
The diagnosis of adult attention-deficit/hyperactivity disorder
As stated previously, a psychiatrist assessed adult ADHD diagnosis and childhood ADHD history of all the recruited individuals based on the DSM-IV-TR[23] criteria and the K-SADS-PL[24], respectively. All the participants were assessed using the diagnostic interview for adult ADHD. The interviews were focused on the 18 DSM-IV-TR criteria for ADHD. We classified participants with childhood ADHD history and fulfilling the DSM-IV-TR criteria as adult ADHD group.
The Chinese version of the Mini International Neuropsychiatric Interview
We conducted a diagnostic interview based on the modules of psychotic disorders, bipolar I disorder, and substance use disorders on the Chinese version of the MINI[22] to determine the existence of these excluding psychiatric disorders.
Chen Internet Addiction Scale
The Chen Internet Addiction Scale (CIAS) is to assess five dimensions of Internet addiction, including symptoms of compulsive use, withdrawal, tolerance, problems with interpersonal and health problems, and time management problems comprising 26 items on a four-point Likert scale ranging from 26 to 104. The internal reliability of the scale and the subscales in the original study ranged from 0.79 to 0.93[26].
BIS and BAS scales
The BIS/BAS scales are designed to assess individual differences in the sensitivity of the two motivational systems proposed by Gray. The BIS is to measure the degree to which respondents expect to feel anxiety when confronted with cues for punishment. The BAS includes subscales of reward responsiveness, drive, and fun seeking, which measure the degree to which rewards lead to positive emotions, a person's tendency to actively pursue appetitive goals, and the tendency to seek out and impulsively engage in potentially rewarding activities, respectively. The Cronbach's alphas of the four subscales ranged from 0.66 to 0.76[27].
Adult ADHD Self-report Scale
The ASRS is a checklist of 18 questions about symptoms based on the World Health Organization Composite International Diagnostic Interview 2001, and the questions are consistent with the DSM-IV criteria, but reworded to reflect symptom manifestations in adults. The ASRS has been designed to evaluate the current manifestations of ADHD symptoms in people aged 18 years or older. Internal consistency is high for both patient- and rater-administered versions.[28] Its Cronbach's alphas are 0.88 and 0.89, respectively. An acceptable agreement exists for individual items (43%–72%) and kappa coefficients for all items[28].
Study procedures
A detailed explanation was given, and subsequently, informed consent was obtained from all the participants before the study. All the participants received diagnostic interviews by a psychiatrist to determine the existence of each diagnostic criterion of ADHD. All participants also completed assessments after the diagnostic interview. Then, they were arranged to complete the assessment and measures in this study.
Statistical analysis
We evaluated the difference in behavioral inhibition, behavioral activation, symptom severity of ADHD, and Internet addiction between adults with ADHD and those without ADHD. We evaluated the differences between groups with continuous variables with t-test. In addition, we evaluated the most associated factors of adult ADHD with logistic regression. Then, we evaluated the correlation between subscales of BIS/BAS, severity of ADHD, and CIAS score.
All the study data were computed using the Statistical Package for the Social Sciences software version 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The differences between groups were considered significant if p < 0.05.
| Results | | |
Totally, 52 participants with adult ADHD diagnosis and childhood-onset ADHD were classified as adult ADHD group, and 52 participants without adult ADHD diagnosis and ADHD history were classified into the control group.
[Table 1] summarizes the association of participants' age, education level, Internet addiction, behavioral inhibition, behavioral activation, and severity of adults with ADHD. [Table 2] describes the forward logistic regression model for adult ADHD with control of age and educational level. [Table 3] shows the forward logistic regression model of the predictive effect of dimensions of Internet addiction for adult ADHD with control of age and educational level. Finally, [Table 4] lists Pearson's correlation for the reinforcement sensitivity, severity of Internet addiction, and ADHD symptoms among male adults with ADHD. | Table 1: Age, education level, Internet addiction, behavioral inhibition, behavioral activation, and severity of adults with attention-deficit/hyperactivity disorder (n=104)
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 | Table 2: The forward logistic regression model for adult attention-deficit/hyperactivity disorder with control of age and educational level (n=104)
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 | Table 3: The forward logistic regression model of the predictive effect of dimensions of Internet addiction for adult attention-deficit/hyperactivity disorder with control of age and educational level (n=104)
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 | Table 4: Pearson's correlation for the reinforcement sensitivity, severity of Internet addiction, and attention-deficit and hyperactivity symptoms among male adults with attention-deficit/hyperactivity disorder
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| Discussion | | |
The association between reinforcement sensitivity and adult attention-deficit/hyperactivity disorder
ADHD has been hypothesized to be associated with reinforcement sensitivity[19]. Children with ADHD have been reported to have higher fun seeking as suggested in the hypothesis[29]. The association between BAS and ADHD symptoms has been found in healthy adults[30]. Our study [Table 1] first reported that the score of behavioral inhibition was significantly higher in the adult ADHD group compared to the control group (22.06 ± 3.02 vs. 19.52 ± 2.49, p < 0.001). To be compatible with a previous study,[30] the scores of adults with ADHD were higher in fun seeking (p < 0.001) and BIS (p < 0.001) than those of controls [Table 2], and the fun seeking was the most associated reinforcement sensitivity factor [Table 2]. Based on this observation, we suggest that BAS over BIS is dominant in ADHD disorder. The BAS system has been hypothesized to represent a response to reward. An overt response to reward can be a motivation system underlying impulsive behavior[19]. Thus, fun seeking has repeatedly been reported to be associated with risky decision-making[31]. Therefore, we suggest that the higher fun seeking characteristic of adult ADHD may partially account for their risky behavior.
In within-group analysis [Table 4], we found that higher reward responsiveness (p < 0.05), drive (p < 0.01), and BAS (p < 0.01) were significantly more associated with hyperactivity/impulsivity symptoms. The results are in line with previous results among the general population[29]. The BAS system represents the response to reward. Oversensitivity to rewarding makes individuals choose approach behavior to get reward. This might make individuals face difficulty in waiting or keeping sitting without adequate rewarding or stimuli, such as to wait for their turn. Taken together, we suggest that ADHD adults with higher BAS have demonstrated higher hyperactivity and impulsivity symptoms. This result may suggest the rôle of BAS involving the rewarding mechanism underlying hyperactivity. However, this claim should be tested in a future study.
From the study results [Table 2], we found that adult ADHD has significantly higher behavioral inhibition (Wald = 13.93, β =1.87, p < 0.001). The BIS system has been hypothesized to represent a sensitivity to aversive stimuli and contribute to vulnerability to anxiety[19]. Another study has demonstrated a higher punishment sensitivity among children with ADHD[30]. The higher BIS in adult ADHD may suggest their vulnerability to anxiety disorder and might partly account for the association between ADHD and anxiety disorder[32]. However, this claim needs to be validated in a future study.
Internet addiction among adults with attention-deficit/hyperactivity disorder
In the forward logistic regression model of the predictive effective of dimensions of Internet addition for adults with ADHD in this study [Table 3], we found that they had significantly higher Internet addiction symptoms rated with CIAS (Wald = 22.085, Exp [β] = 1.371 [1.202–1.564], p < 0.001). This finding in the present study [Table 4] also demonstrated that ADHD adults with hyperactivity symptoms had significantly higher scores in withdrawal (p < 0.01), tolerance (p < 0.05), compulsivity (p < 0.05), and time management problems of Internet addiction (p < 0.05). Those findings are in line with those in previous studies[33],[34]. Adults with ADHD have been reported to have higher impulsivity and hostility[34]. The impulsivity and hostility have been demonstrated to contribute to Internet gaming disorder[15],[35]. With all those characteristics, we suggest that adults with ADHD may contribute to their increased risk of Internet addiction. Furthermore, these interpersonal and health problems are the most significant associated dimension of adult ADHD. With this finding, we suggest that adults with ADHD show higher interpersonal and health problems in Internet addiction. As mentioned above, the higher BAS system and impulsivity of ADHD might contribute to loss of control in Internet use. The uncontrolled online gaming could result in an interpersonal and health problem, such as decreased sleep or conflict with parents. Additionally, this result might indicate higher functional impairment of Internet addiction among adults with ADHD. Thus, we suggest that more attention and intervention for Internet addiction should be provided when treating adults with ADHD.
The association between reinforcement sensitivity and Internet addiction among adults with attention-deficit/hyperactivity disorder
The present study [Table 2] demonstrated that ADHD adults have significantly higher behavioral inhibition (Wald = 13.93, Exp [β] = 1.487 [1.207–1.832], p < 0.001) and significantly higher Internet addiction severity (Wald = 22.085, β [95% confidence interval = 1.371] [1.202–1.564], p < 0.001) [Table 3]. These results are in line with those in another study with the same measures[20]. As mentioned above, we suggest that higher BIS may represent the vulnerability of anxiety disorder. To escape from emotional difficulty in maintaining online gaming to relieve the mood problem is one important mechanism and diagnostic criterion of Internet addiction[1]. Thus, BIS has been repeatedly reported to be associated with Internet addiction[18],[36]. Among adults with ADHD, they can experience many difficulties in their daily life, such as occupational problems[37]. Their high BIS may make them experience anxiety for these problems. Online gaming can provide a convenient and immediate route to engage and get an emotional reward after completing some task in these games. Furthermore, the change of identity can make people escape from the real world to forget their difficulties in the real world.
Study limitations
The readers are cautioned not to overinterpret the study results because this study has three limitations:
- Only males were included in this study to prevent gender effect on the results. Therefore, our study results have limitation in generalizing to the findings in female adults with ADHD
- The causal relationship between the reinforcement sensitivity, Internet addiction, and ADHD could not be confirmed in this cross-sectional study
- The diagnosis of ADHD was based on self-reported information only from participants at interview in this study. Further information obtained from family might contribute to better validity of the diagnosis.
Summary
Male adults with ADHD in this study had higher fun seeking, BIS, and behavior activation system. Those findings might suggest an overt responsiveness to rewarding or aversive stimuli. Those with higher behavioral activation have higher hyperactivity symptoms. Thus, we need to pay attention to the characteristics of reinforcement sensitivity when treating adults with ADHD. Furthermore, they are more likely to have higher severity of Internet addiction, particularly reflected in interpersonal and health problems. Those with higher BIS had higher severity of Internet addiction. We suggest that Internet addiction and interventions targeted at adults with ADHD should be well assessed, particularly for those with higher BIS system.
| Acknowledgment | | |
These institutions had no rôle in the design, process, analyses, and production of the present study.
| Financial Support and Sponsorship | | |
This study was supported by grants from the Ministry of Science and Technology (MOST105-2314-B-037-027-MY2), Kaohsiung Municipal Hsiao-Kang Hospital (KMHK-104-006), and the Kaohsiung Medical University Hospital (KMUH104-4R57).
| Conflicts of Interest | | |
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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