ADHD, delay aversion and waiting behaviour in preschool children : family and cultural processes

Abstract

The delay aversion hypothesis proposed by Sonuga-Barke (1994) views attention deficit/ hyperactivity disorder (ADHD) symptoms as a functional expression of delay aversion which enables them to escape from or avoid the delay rich situations that they find emotionally aversive (Sonuga-Barke et al., 1992a; 1992b; 2010). Further, according to the model, one way that this motivational orientation develops is through the conditioned paring of delay situations with the negative affective states arose from parental criticism and/or punishment for failures to wait or maintain attention. This second part of the delay aversion model has not been tested to date.

In this thesis, we aimed to explore this model of the social conditioning of delay aversion and ADHD by exploring the relationship between preschool children’s ADHD symptoms, their sensitivity to delay (i.e., delay aversion) and their waiting behaviours in two communities known for their different attitudes to children’s behaviour and self-regulation – Hong Kong and the United Kingdom – in four studies.

A community sample of 112 preschoolers (mean age = 46.22 months; 55 from UK, 57 from HK) completed a battery of three tasks measuring different waiting elements– waiting for rewards, judging how long to wait and having to wait unexpectedly when task is interrupted and another waiting task jointly with their parents. Children’s and parents’ behavioural and emotional responses were observed and coded during task performance. Actometers were also used to track children’s task-related activity. Parents and teachers rated the children’s ADHD symptoms and sensitivity to delay at T1 and T2 (12 to 18 months later).

There were several important findings to note. First, we found strong evidence that parents’ perceptions and reports of ADHD-related behaviours are culturally determined, with HK parents appeared to have lower rating threshold than UK parents, that is, less waiting-related activity is required for HK parents before considering it as an ADHD symptom. Second, our findings showed that children’s maladaptive waiting-related responses increased as a function of delay duration and significantly associated with their levels of ADHD symptoms. Moreover, children’s frustration experienced during the waiting period affected their responses in a later post delay waiting period. Third, we found a strong positive correlation between children’s maladaptive waiting-related responses and parental negative responses during delay at T1. Parents’ negative behaviours and affect displayed during the joint waiting task at T1 significantly predicted the children’s ADHD symptom and delay sensitivity level as rated by their teachers at T2, even after controlling for their symptoms level at T1. This pattern did not hold for parental negative response in non-waiting settings. Fourth, despite cultural differences found in parents’ rating threshold and children’s waiting-related responses, our findings suggested that the relationship between pre-schoolers’ ADHD, delay aversion and waiting behaviours was not moderated by national group.

The differences between UK and HK communities in parents’ rating thresholds and children’s waiting behaviours reflected the value of including a cross-cultural comparison element in the research on the ADHD prevalence, assessment tool, parents’ symptom endorsement and attributions. The cultural invariance in the relationship between ADHD, waiting and delay aversion provided insights for early intervention efforts that could be effective across cultures. Most importantly, longitudinal data highlighted the way parenting in relation to delay can increase the risk for delay aversion and ADHD-related difficulties. Intervention should not only focus on the children’s tolerance and reactivity to waiting situations, but also help parents to understand the potential impact of their negative delay-related behavioural and emotional expressions.