9. Motivational problems with ADHD

Author: Ulrich Brennecke
Review: Dipl.-Psych. Waldemar Zdero

Motivation is a willingness to act as an activating moment to achieve a specific goal. The conversion of motivation (willingness to act) into action takes place through the drive.¹ Another definition of motivation is the process of initiating, controlling and maintaining physical and mental activities, including the mechanisms for favoring an activity and controlling the strength and persistence of reactions.²

Problems with intrinsic and extrinsic motivation are a typical symptom of ADHD.³
Attention problems in ADHD are primarily a problem of lack of self-motivation. While intrinsically interesting topics can arouse attention, intrinsically uninteresting topics create attention problems. This also applies to motor restlessness. A Time-lapse video showing a person with ADHD watching a video that is intrinsically interesting and one that is not intrinsically interestingillustrates that hyperactivity problems in ADHD can be caused by motivational factors.

Procrastination, devaluation of later rewards and delay aversion are closely linked to ADHD and stress.

Procrastination is a common ADHD symptom in which tasks and actions are put off for an unnecessarily long time.
In people with ADHD, it is not the basic ability to prioritize that is impaired, but rather an inappropriate prioritization program that is activated, which means that unimportant things cannot be distinguished from important ones. Procrastination can also be seen as a symptom of stress. Under stress, people with ADHD focus on the things that are important in the here and now and ignore everything else. This can lead to things that do not need to be done immediately being perceived as less important and worthwhile.

The devaluation of later rewards, also known as delay discounting, is another symptom of ADHD. People with ADHD value delayed rewards less than people without ADHD. Immediate rewards are valued just as much as by non-affected individuals. This may be related to a dysfunction of the reward system in the brain.

Delay aversion is manifested in the fact that people with ADHD find waiting unpleasant and have difficulty postponing things that are intrinsically interesting or important or exercising patience. Delay aversion correlates with other symptoms of ADHD such as inner restlessness and frustration intolerance. Delay aversion is not solely due to an inhibition problem, but is also related to emotional dysregulation. Stress-reducing measures can reduce delay aversion.

ADHD can also be described as a dysfunction of the reward perception system (“reward defency syndrome”).⁴

• 9.1. Procrastination (procrastination)
  • 9.1.1. Procrastination as an ADHD symptom
  • 9.1.2. Procrastination: not being able to do things until the last minute
  • 9.1.3. Procrastination: Not being able to get started
  • 9.1.4. Procrastination as a symptom of stress
• 9.2. Devaluation of later rewards (delay discounting / reward discounting)
  • 9.2.1. Devaluation of later rewards as an ADHD symptom
  • 9.2.2. Devaluation of later rewards as a stress symptom
• 9.3. Delay aversion
  • 9.3.1. Delay aversion in ADHD
    • 9.3.1.1. Impatience; waiting is perceived as unpleasant
  • 9.3.2. Correlation of delay aversion with other symptoms
  • 9.3.2. Delay aversion as a stress symptom

9.1. Procrastination (procrastination)¶

9.1.1. Procrastination as an ADHD symptom¶

We consider procrastination to be a consequence of the devaluation of distant rewards (delay discounting) on the one hand and an altered perception of what is intrinsically interesting on the other. Procrastination could represent the opposite pole of delay aversion in the sense of a regulatory disorder.

9.1.2. Procrastination: not being able to do things until the last minute¶

Not being able to do things until the last minute is another description of procrastination. The explanation arises from the stress benefit of procrastination, that in times of existential stress, things that are not immediately necessary are ignored in order to focus on the things that are acutely important now. Those who can distinguish unimportant things from important ones in acute distress have a survival advantage. It was not so helpful for survival to admire the beautiful flowers at the side of the path while fleeing from the sabre-toothed tiger or to want to take the ripe fruit from the bush behind as a supply for the winter.

The problem with ADHD is not a fundamentally incorrect prioritization (in the sense of a general “technical” inability to do so), but an inappropriate prioritization program (stress reactions without adequate stressors). In people with ADHD, it is not the neurophysiological ability to distinguish the important from the unimportant that is impaired, but rather an emergency program that is activated without an appropriate reason. This emergency program is useful (for all higher organisms) in the event of acute stress that threatens survival. In this case, the focus is shifted to the things that are important in the immediate here and now - everything else is blocked out or postponed.

The actual ability to concentrate and pay attention is not impaired in ADHD. It is the ability to direct attention that works differently in persons with ADHD than in people without ADHD.

9.1.3. Procrastination: Not being able to get started¶

People with ADHD often have a problem starting things. This can go as far as a complete block on starting things.
This is probably due to the fact that in ADHD, the brain’s motivational system, the striatum, has reduced (extracellular) dopamine and noradrenaline levels.
While in non-affected people, the motivation to start things is controlled by environmental influences alone via the dopamine level in the brain’s reward center, in ADHD this control element, the extracellular dopamine level, is skewed due to genetic disposition. Consequences are that some people with ADHD feel an excessive reluctance to engage with anything that does not represent environmental conditions. (Other persons with ADHD may have an excessive affinity for starting things, rather than the problem of not being able to finish them. This will be discussed elsewhere)

Emotions are a powerful source of control for human behavior. The feeling “I don’t want this” also conveys meaning. Similar terms are “automatic”, “behavioral pathways” or “highways in the mind”.
Such evaluations are vital. People are not in a position to constantly analyze the entire environment cognitively and consciously control their entire behavior. The PFC, which is more like a microscope and can take a closer look at individual aspects of the outside world, is not designed for this. A microscope is excellent for recognizing individual small aspects of the environment. However, it is unsuitable for controlling all decisions because the amount of information generated would be far too large.

The lack of drive to start things is one such subjectively perceived meaning/automatism. Such automatisms can be deceptive (just as you should never believe everything you think when you lie awake at night…). With ADHD, this evaluation is flawed.
Knowing this can help people with ADHD. It doesn’t change the fact that the aversion continues to feel just as unpleasant - it doesn’t make the moment itself any easier. However, knowing that only feels like this for the first step and that it will be easier afterwards than it felt before can help some people not to be completely at the mercy of the feeling caused by this dysfunctional lack of drive.

The sentence: If you’re having trouble starting something, just start it, sounds at first like the kind of stultifying rhetoric that people with ADHD have to endure all too often.
For once, however, there is a little something to this, because starting itself already leads to an activity that releases dopamine, which then makes it much easier to continue the activity than it was before
For example, people with ADHD report that their children who cannot bring themselves to brush their teeth report that starting together overcomes the inhibition and that continuing the activity is then easier than it previously seemed subjectively.

9.1.4. Procrastination as a symptom of stress¶

Many sources, especially from management literature, report that procrastination causes stress due to the resulting time pressure.
However, medical studies show that procrastination can also be a consequence of stress,⁵ although the correlation is somewhat weaker than with anxiety, depression or fatigue.⁶⁷

In our opinion, the evolutionary-biological stress benefit of procrastination, as with the inability to enjoy life, is a focus on the most important stressor. Less important things are devalued in terms of their subjective significance, while the immediately important things are valorized, as would be the case in survival-relevant situations. The evaluation of what is important and what is unimportant for one’s own survival must inevitably always be carried out by the people with ADHD themselves. In survival-threatening situations, it is helpful to evaluate one’s own needs (survival) more strongly than the needs and requirements of others (extrinsic motives). Therefore, attention follows personal interests, while less interesting requirements are devalued. More on this at ⇒ Stress benefits - the survival-promoting purpose of stress.
Consequences are that all things that do not have to be done immediately will be perceived as less important and worthwhile by stressed people with ADHD than by people without ADHD.
Subjectively unpleasant things are therefore postponed proportionately more and often only dealt with at the last minute - only then do they slip into the focus that has been shifted to the here and now due to stress. By then, they are too far away to be interesting enough to become the focus.
Severe stress says: survive now - you can enjoy and recover later.
In the case of a healthy (short-term) stress reaction, this is correct and helpful.

9.2. Devaluation of later rewards (delay discounting / reward discounting)¶

Other names for “delay discounting” are “temporal discounting”, “intertemporal choice” or “impulsive choice”.⁸

Devaluation of later rewards / delay discounting can be seen as a reversal of delay aversion (aversion to waiting, impatience). Both can be seen as an expression of a stress-related change in motivation. One review considers delay discounting to be a subtype of impulsivity.⁹ The core message is: Survival is now. Now is the time to defend oneself against relevant dangers, everything that is later is currently unimportant. Everything that is important must happen immediately. Anything that is not so important that it doesn’t need to happen immediately can wait until the stressor is defeated.

9.2.1. Devaluation of later rewards as an ADHD symptom¶

People with ADHD typically suffer from a reward deferral aversion: a smaller reward immediately rather than a larger reward later.⁹¹⁰¹¹ This is compounded by inconsistent decision-making patterns.¹²

For everyone, immediate rewards are intuitively more rewarding than delayed rewards. However, the decrease in the value of later, delayed rewards is significantly higher for people with ADHD than for non-affected people. While immediate rewards are rated the same by people with ADHD as by non-affected people, people with ADHD rate later rewards as significantly lower or less attractive than non-affected people.

However, the devaluation of distant rewards in ADHD is less related to motivational problems than to impulsivity. Impatience correlates very strongly with impulsivity and is therefore a phenotypic symptom of ADHD-HI and ADHD-C, but less so of ADHD-I. Impatience also correlates very strongly with impulsivity.

Manifestations of the preference for immediate rewards / devaluation of delayed rewards are:

• Addiction problems

• Procrastination
  The devaluation of tasks that are not immediately important is a related reaction.

9.2.2. Devaluation of later rewards as a stress symptom¶

Also known as Discounting of Delayed Rewards or Temporal Discounting^15161718

Rewards that are immediate are valued by people with ADHD in the same way as by people without stress.
Rewards that are further away in time are seen as even less attractive than by people without stress.

Forms of expression:

• Procrastination
• Addictive tendencies
• Disorder
• Poorer ability to self-regulate
  • Self-regulation ability is an even better predictor of professional success than intelligence

Addiction problems are closely linked to the preference for immediate rewards. Mental or physical effort is not necessary to obtain the reward. The addictive substance leads to an immediate reward, e.g. relaxation. Addiction problems are typical symptoms of stress

• Drug / nicotine / alcohol abuse (addiction)¹⁹²⁰
• Smoking correlates with stress¹⁶

9.3. Delay aversion¶

Delay aversion can be described as the mirror image of the devaluation of later rewards (delay discounting) and represents the opposite pole of procrastination in the sense of a regulatory disorder.
Delay aversion occurs in both children and adults with ADHD. Delay aversion is a persistent motivational deficit that can be reduced or eliminated by increasing subjective motivational incentives.²¹

9.3.1. Delay aversion in ADHD¶

9.3.1.1. Impatience; waiting is perceived as unpleasant¶

• When others are slow to understand, it drives you crazy
• Parents get upset when their children are slow to understand homework²²
• Tasks are started without first listening to the instructions or reading the manual.
  This is one of the 9 most common symptoms of ADHD in adults²³
  • Operating instructions are read diagonally at best before commissioning devices
  • People don’t like to read furniture assembly instructions
• Particularly strong aversion to traffic jams, queues; up to the point that these can make them aggressive,²² whereby the latter is probably less likely to affect the ADHD-I subtype
• Difficulties waiting for your turn
• Inner restlessness when you are not supposed to act yourself but accompany the actions of others
  • E.g. tendency to carry out tasks of others themselves instead of letting them do it (possibly slower / worse, because first learning)
• Tendency to interrupt others
• Answers are given before the question has been heard to the end
• Exuberant ideas must be communicated quickly before they are in danger of being forgotten²²
• Drive faster than others²²
  This is also one of the 9 most accurate symptoms of ADHD in adults.²³

The fact that boredom is perceived as extremely unpleasant is more likely to be due to dysphoria caused by inactivity

9.3.2. Correlation of delay aversion with other symptoms¶

According to the current data status of the ADxS symptom test (June 2020, n = 1,889), delay aversion does not appear to result solely from an inhibition problem, as is the case with impulsivity, but correlates significantly more strongly with inner restlessness and frustration intolerance than with impulsivity and than impulsivity with these. The correlation with emotional dysregulation also appears to be higher than with impulsivity
Interestingly, the correlation of procrastination aversion with procrastination appears to be significantly lower than with impulsivity and the correlation of procrastination with impulsivity is the same as with procrastination aversion.

Symptoms	Delay aversion / impatience	Impulsiveness
Inner restlessness	0.85	0.69
Frustration intolerance	0.79	0.57
Impulsiveness	0.67
Delay aversion / impatience		0.67
Reward deferral problems	0.58	0.46
Inability to recover	0.57	0.45
Inattention	0.56	0.53
Hyperactivity	0.55	0.59
increased sensitivity	0.53	0.43
Rejection sensitivity	0.53	0.41
Procrastination	0.34	0.34

As of June 2020. n = 1,889- The values given reflect the correlation of the symptoms relative to each other.this is a non-validated online self-test (screening).

9.3.2. Delay aversion as a stress symptom¶

Delay aversion is also understood as an impulsivity reaction. It correlates with impulsivity under stress and, in women, with an increasing heart rate.²⁴²⁵

Stress-reducing measures also reduce delay aversion.¹⁵