Child Psychiatry & Human Development (2021) 52:586–595

https://doi.org/10.1007/s10578-020-01042-0

ORIGINAL ARTICLE

Impact of Motivation on Selected Aspects of Attention in Children

with ADHD
Sebastian Skalski1 · Grzegorz Pochwatko1 · Robert Balas1

Received: 20 February 2020 / Revised: 3 June 2020 / Accepted: 9 August 2020 / Published online: 20 August 2020
© The Author(s) 2020

Abstract
Earlier reports showed the co-occurrence of a motivation deficit in children with ADHD. The purpose of this study was to
assess the impact of extrinsic motivation on selected aspects of attention in children with ADHD, as well as to measure corti-
cal activity and dimensions of motivation as per the self-determination theory. The study included 30 children with ADHD
and 30 typically developing (TD) children aged 9–13 years. Children with ADHD exhibited a higher theta/beta power ratio
(TBR) in the midline and a lower regional cerebral blood oxygenation (­ rCBO2) level in prefrontal areas measured using
the HEG ratio compared to TD children. Children with ADHD were more likely to undertake activity under the pressure of
external stimuli and exhibited attention deficits regarding vigilance, visual search and divided attention. Differences between
groups regarding attention decreased in conditions of increased motivation, indicating that motivation can reduce cognitive
deficits in children with ADHD.

Keywords ADHD · Vigilance · Visual search · Divided attention · Motivation

Introduction activity, mainly dopamine and noradrenaline [11, 12]. More-

over, children with ADHD show a 3–4% decrease in the total
Attention Deficit Hyperactivity Disorder (ADHD) is the brain volume. However, this difference does not apply to the
most common neurobehavioral childhood disorder. Its inci- entire cerebral tissue, but primarily to the frontal lobe cortex,
dence is estimated at 3–8% in the age population of < 18 basal nuclei, cerebellum and the corpus callosum [13, 14].
[1–3]. ADHD is characterized by symptoms of impulsivity, Studies using diffusion tensor imaging (DTI) have revealed
hyperactivity and inattentive behavior which are incommen- widespread abnormalities regarding brain white matter
surate with a patient’s age [4]. ADHD may cause problems integrity in children with ADHD [15]. Studies of brain func-
in psychosocial functioning, such as deteriorated academic tion in children with ADHD have shown a decrease in blood
performance or problems in relations with family and peers. flow (hypoperfusion) in the frontal lobes and basal nuclei
The symptoms are often accompanied by low self-esteem, [16–18]. Other studies have shown increased theta activity
depressive states, anxiety disorder and oppositional defiant in the frontal areas, increased delta activity and decreased
disorder [5–8]. Three ADHD types of presentations can be alpha and beta activity in the occipital areas [19–21]. EEG
distinguished: the predominantly hyperactive-impulsive type (electroencephalography) recording also revealed the occur-
(ADHD-HI), the predominantly inattentive type (ADHD-I) rence of numerous epileptiform grafoelements [22]. Quan-
and the combined type (ADHD-C) [9]. When analyzing the titative EEG (QEEG) analysis is used to search for neuro-
underlying mechanisms of ADHD, special role is attributed markers in the diagnosis of ADHD, especially the analysis
to abnormalities in the functioning of neuronal connections of the theta/beta power ratio (TBR) (high in children with
between the cortex (mainly frontal lobes) and basal nuclei ADHD) in central areas [23, 24]. According to Snyder et al.
[10]. This is also associated with abnormal neurotransmitter [25], TBR analysis can improve the diagnostic accuracy of
attention deficit disorder by more than 25% compared to the
* Sebastian Skalski use of clinical interviews alone. However, the literature data
[email protected] are not unanimous—not all studies have confirmed signifi-
cant (large) TBR differences between children with ADHD
1
Institute of Psychology, Polish Academy of Sciences, 1 and typically developing (TD) children [26, 27]. According
Jaracza Street, 00‑378 Warsaw, Poland

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Child Psychiatry & Human Development (2021) 52:586–595 587

to recent studies, significant differences between the groups one defines individual, spontaneous interests of individu-
can also be observed using hemoencephalography (HEG) in als. The second one takes into account the consequences of
the prefrontal regions [28, 29], yet the number of reports in human behavior and has an instrumental function. The last
this respect is limited. Further research is needed to better one allows for explaining the non-autonomous activity of
understand the neuronal ADHD correlates. Moreover, the individuals with no regulation. In the literature on the sub-
determination of ADHD neuromarkers seems to be crucial in ject, amotivation is often compared to the concept of learned
the diagnosis of ADHD because it is an objective indicator helplessness according to Seligman [49]. Proper extrinsic
of ADHD, which may precede the detection of ADHD using motivation is a continuum of internally and externally
classical methods. The use of EEG and HEG recordings for regulated states of varying intensity: external, introjected,
this purpose seems reasonable, as these types of devices can identified, and integrated regulation. In the case of external
be widely used—they are inexpensive and low-maintenance, regulation, behavior occurs only under the influence of envi-
easy to operate, and do not require additional space in the ronmental stimuli. Introjected regulation initiates activity
clinic or laboratory. due to possible sanctions and awards. Identified regulation
Studies using functional magnetic resonance imaging allows for assigning personal meanings to the undertaken
(fMRI) have shown that reduced activation in the prefrontal behavior. In the case of integrated regulation, the activity is
cortex is associated with attention deficit in children with tailored to the objectives of the individual and undertaken in
ADHD [30]. Attention is considered the mechanism (sys- accordance with one’s sense of self. The self-determination
tem) responsible for selecting information and countering theory by Deci and Ryan allows for unifying the percep-
the undesirable effects of overloading the cognitive sys- tion of human behavior based on commitment [50]. In the
tem [31]. Its aspects include selective (focused) attention, literature on the subject, an increasing number of research-
visual search (scanning), vigilance, divided attention and ers are observing the co-occurrence of motivation deficits
alternating attention. Selective attention enables focusing in children with ADHD [44, 45, 51–53]. Children with
on selected stimuli and rejecting disruptive or irrelevant ADHD require stronger stimuli to change their behavior,
information [32]. Visual search allows for an active and and have difficulty in postponing gratification. They prefer
systematic search of the perceptive field in order to detect small and immediate reinforcement to larger and delayed
objects which fit an adopted criterion [33]. Vigilance enables reinforcement [54, 55]. Based on the described behavior
long-term monitoring of the environment to detect a specific samples, it seems that children with ADHD may exhibit a
signal while disregarding distractors [34]. Divided attention higher level of extrinsic motivation, introjected motivation
is responsible for the ability to focus on two or more sources and amotivation, as well as a lower level of intrinsic motiva-
of information at the same time [35]. Meanwhile, alternating tion and identified regulation; however, there are no studies
attention allows for relatively fast switching between two describing the activity of children with ADHD as per the
objects (tasks), which are carried out as part of independent self-determination theory.
information processing [36]. According to previous stud-
ies, children with ADHD may show impairment concern- Objective of the Study
ing vigilance, visual search and divided attention [37–42].
However, researchers reveal varying magnitude of effects, The purpose of this study was to assess the impact of extrin-
which may indicate neurocognitive heterogeneity in ADHD sic motivation on selected aspects of attention in children
[43]. It also seems that cognitive deficits in children with with ADHD, as well as to measure cortical activity and
ADHD are not permanent neuropsychological impairments. dimensions of motivation as per the self-determination
Extrinsic motivation (e.g. the prospect of receiving a reward) theory.
can increase the cognitive capacity in children with ADHD Based on the aforementioned articles, we assumed that:
[44, 45]. A positive impact of motivation was observed with (H1) children with ADHD may exhibit lower levels of corti-
regard to visual search, working memory and inhibitory con- cal activity as measured using (a) TBR in the midline and
trol. Studies on vigilance and divided attention have not yet the (b) HEG ratio in prefrontal areas than TD children; (H2)
been conducted. Furthermore, it is unclear whether motiva- children with ADHD may display lower levels of (a) intrin-
tion may completely eliminate attention deficits in children sic motivation and (b) identified regulation as well as higher
with ADHD. levels of (c) external regulation, (d) introjected regulation
Apart form neuronal ADHD correlates, researchers are and (e) amotivation to learning compared to TD children;
trying to establish how behavior patterns of children with (H3) children with ADHD may exhibit deficits regarding:
deficits are linked to motivation. Motivation helps to explain (a) vigilance, (b) visual search and (c) divided attention;
human behavior, its direction and duration [46]. Deci and (H4) increasing the motivation may reduce attention deficits
Ryan [47, 48] differentiate 3 types of motivation: intrinsic in children with ADHD with regard to: (a) vigilance, (b)
motivation, extrinsic motivation and amotivation. The first

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visual search and (c) divided attention. The obtained data TBR EEG was recorded using a 10-channel FlexComp
will enable a better understanding of ADHD issues. Infiniti encoder (up to 2048 samples/s) with impedance con-
trol (less than 5 kΩ). Two additional reference electrodes
were placed on the earlobes. Recording was conducted
in resting state with eyes open for 3 min. Data were pro-
Methods cessed in Biograph Infiniti 6.2. The signal was filtered in
the 0.50–30 Hz band. Artifacts were corrected by automatic
The study was conducted in the fall of 2019. The participa- elimination. Amplitudes above 70 µV were removed along
tion in the study was voluntary. Consent was required of with the artifacts. The results were subjected to the Fast Fou-
the patient and their parent or legal guardian. This study rier Transform (FFT) analysis. TBR was calculated from the
was approved by The Committee for Ethics in Scientific ratio of theta power (4–7 Hz waves) to beta power (13–30 Hz
Research of The Institute of Psychology, Polish Academy waves) based on the mean value registered using electrodes
of Science (Research project approval # 15/VIII/2019). placed in central areas: C3, Cz, C4, according to the 10:20
placement.
HEG Ratio The HEG system (32 samples/s) using near
Procedure
infrared spectroscopy (NIRS) was employed for recording
regional cerebral blood oxygenation (­ rCBO2). The meas-
The measurement of cortical activity, fluid intelligence and
urement method uses different optical properties of hemo-
motivation to learning was conducted at the beginning of
globin (Hb) and oxyhemoglobin (oxy-Hb). It was described
the study. The assessment of the impact of motivation on
in detail by Toomim et al. [57]. Reflected light penetrates
selected aspects of attention was carried out in a quasi-
to a depth of 1.5 cm and reaches the capillaries in the gray
experiment model with repeated measurement. The manip-
matter at the base of the cerebral cortex. Recording was con-
ulative technique consisted in increasing the motivation in
ducted in resting state with eyes open for one minute. Data
all of the examined participants. For a correct result as part
were processed in Biograph Infiniti 6.2. The HEG ratio was
of each of the tasks (gain), participants received a sweet
calculated using the following formula: HEG Red/HEG IR
reward (chocolate). In addition, a named record board for
× 200, where HEG Red denotes the values of reflected red
the top 10 results was introduced—competition effect. The
light (660 nm), while HEG IR denotes the values of reflected
manipulative technique corresponds with previous studies
infrared light (850 nm) based on the mean value recorded
by McInerney and Kerns [44], as well as Reijnen and Opwis
using optodes placed in prefrontal areas: Fp1, Fpz, Fp2,
[45] on the impact of motivation on cognitive function in
according to the 10:20 placement.
children with ADHD.
Moreover, the study used psychological tools to deter-
mine the level of intelligence, motivation and attention:
Participants Raven’s colored progressive matrices (CPM) in Pol-
ish standardization [58] for measuring educational capac-
The study involved 30 children (24 boys and 6 girls) aged ity (fluid intelligence) in children. CPM contains 36 tasks
9–13 years, diagnosed with ADHD by a specialist in pedi- in the form of incomplete patterns (matrices). The task of
atric psychiatry or neurology. Moreover, the diagnosis was the examined person is to select the missing fragment from
confirmed by a structured diagnostic interview for psycho- among the given proposals.
motor hyperactivity as per DSM-V [56], conducted by a Situational motivation scale (SMS-15) [59] for measur-
psychologist. Eight (8) children remained in pharmacother- ing motivation based on the self-determination theory [47,
apy (methylphenidate), but did not take drugs 48 h prior to 48]. The questionnaire consists of 15 statements grouped
the examination—at the doctor’s consent. The comparison under 5 factors: intrinsic motivation (Chronbach’s α = 0.82),
group consisted of 30 TD children (23 boys and 7 girls) aged external regulation (α = 0.82), introjected regulation
9–13. The recruitment conditions for both groups included (α = 0.84), identified regulation (α = 0.84) and amotivation
lack of neurological diseases as well as intellectual capacity (α = 0.82). The test taker expresses their attitude towards
within standard. Recruitment was conducted among patients each of the statements on a 7-point Likert scale, where 1—“I
of psychological and pedagogical support centers in Kraków strongly disagree” and 7—“I strongly agree”.
(Poland). Shortened version of the Mackworth clock task [60]
for measuring vigilance. The examined person observes a
clock hand moving on the screen. The hand moves in short
Measures jumps every 1 s, like the second hand of an analog clock. At
rare and irregular intervals, the hand makes a double jump
As part of the study, cortical activity was measured using: by two seconds. The task lasts 5 min (300 hand jumps).

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During the test, there are 18 irregular hand jumps (6% prob- Results
ability). The task of the examined person is to detect the
double (irregular) jumps by pressing a button. The number The study did not contain statistically significant differences
of omission and commission errors is recorded. between children with ADHD and TD children in terms of
Visual search task for assessing a conjunctive search, age and intellectual capacity measured using CPM (each
i.e. with a specific combination of two stimulus characteris- participant scored above the 50th centile).
tics (color and angle of rotation). The role of the examined The Student’s t-test confirmed the occurrence of statisti-
person is to scan the perception field in order to detect (by cally significant differences between children with ADHD
pressing a button) the red T letter among inverted red T and TD children regarding: TBR, HEG ratio and motiva-
letters and blue T letters. The probability of occurrence of tion dimensions. Detailed analysis results are presented in
an element complying with the criterion is 40%. The task Table 1.
consists of 48 boards with 5–20 elements on the screen. Next, a mixed design two-way MANOVA was conducted:
Recording takes place of the average reaction time (RT) 2 (group: children with ADHD versus TD children) × 2
and RT slope, which reflects the average RT increase at the (normal conditions versus increased motivation). The fac-
moment of each additional element appearing on the screen. tor measured between individuals was membership to one
Multitasking test for measuring divided attention. The of the research groups, whereas motivation was the factor
role of the examined person is to observe a screen divided measured internally. Dependent variables included selected
into 2 parts and to react according to the location of the aspects of attention. As a result of the analyses, a multidi-
stimulus. If a figure appears in the upper part of the screen, mensional interaction effect was obtained regarding group
the test taker should react (the appropriate button) accord- membership and motivation, F(6,53) = 8.13, p < 0.001, η² =
ing to the shape of the figure (square or rhombus), and if the 0.48. Due to the formulated research questions, main effects
figure is placed in the lower part, they should react accord- were not analyzed. Univariate F tests confirmed the interac-
ingly to the number of dots in the middle of the figure (two tion effects for the following dependent variables: omission
or three dots). The task consists of 48 items. 24 boards for errors, F(1,58) = 19.58, p < 0.001, η² = 0.25; RT in visual
single-tasking (reaction according to one stimulus feature) search of 5–20 elements, F(1,58) = 17.59, p = 0.001, η² =
and 24 boards for multi-tasking (reaction according to two 0.23; RT slope in visual search, F(1,58) = 7.84, p = 0.007,
stimulus features interlaced with one another). η² = 0.12; RT in single-tasking, F(1,58) = 18.76, p < 0.001,
The tests we selected are popular among neuropsycholo- η² = 0.24; as well as RT in multi-tasking, F(1,58) = 7.94,
gists and are often used to assess brain performance. The p = 0.007, η² = 0.12. No significant interaction effect was
measurement of selected attention aspects was carried out obtained for the commission errors dependent variable,
using computer applications in the Java environment. The F(1,58) = 0.09, p = 0.760, η² < 0.01.
tasks were presented on a 19-inch screen. The distance of In order to explain what the interaction effects involve, an
the examined person from the screen was about 70 cm. Each analysis of simple main effects was conducted (the compared
test was preceded by a short training session. mean values are presented in Table 2).
The group membership factor differentiated all of the
Data Analysis controlled attention indicators under normal conditions:
omission errors (t = 3.81, p < 0.001, r = 0.45), commission
Statistical data analysis was conducted in IBM SPSS Sta- errors (t = 2.66, p = 0.010, r = 0.33), RT in visual search of
tistics 26. The normality distribution was verified using the 5–20 elements (t = 5.09, p < 0.001, r = 0.56), RT slope in
Kolgomorov–Smirnov test. Levene’s test was used to assess visual search (t = 3.68, p = 0.001, r = 0.44), RT in single-
the homogeneity of variance. In most cases, the obtained tasking (t = 3.41, p = 0.001, r = 0.41) and RT in multi-tasking
results allowed for the use of parametric tests (except for the (t = 4.38, p < 0.001, r = 0.50).
participants’ age analysis). In order to determine the signifi- The group membership factor differentiated the indica-
cance of differences, the Student’s t-test, Mann–Whitney’s U tors of selected attention aspects in conditions of increased
test and the repeated measures multivariate analysis of vari- motivation: commission errors (t = 2.72, p = 0.009, r = 0.34)
ance ANOVA were used. The repeated measures ANOVA and RT in multi-tasking (t = 2.22, p = 0.031, r = 0.28). No
did not include the sphericity test due to two levels of inde- significant differences were observed between ADHD and
pendent variable within each effect. The level of significance TD children in conditions of increased motivation for the
was set at p < 0.05. The effect size was assessed on the basis following dependent variables: omission errors (t = 1.78,
of a partial eta square (η²) or the r coefficient. p = 0.081, r = 0.23), RT in visual search of 5–20 elements
(t = 1.65, p = 0.105, r = 0.21), RT slope in visual search

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590 Child Psychiatry & Human Development (2021) 52:586–595

Table 1  Differences in mean ADHD children TD children U/t r

values: age of participants, (N = 30) (N = 30)
intellectual capacity, cortical
activity, dimensions of M SD M SD
motivation in children with
ADHD and TD children Age 10.83 1.68 10.67 1.35 429 0.06
CPM 69.53 13.28 71.77 9.28 − 0.76 − 0.10
TBR (theta/beta power ratio)
C3 4.29 1.09 3.11 0.80 4.77*** 0.53
Cz 4.66 1.36 3.64 0.88 3.45** 0.41
C4 4.12 1.09 2.93 0.72 4.98*** 0.55
HEG ratio
Fp1 76.03 7.42 98.81 14.78 − 7.54*** − 0.70
Fpz 81.38 8.82 102.91 10.65 − 8.53*** − 0.75
Fp2 77.78 8.71 100.74 13.05 − 8.02*** − 0.73
Motivation
INM 10.07 4.21 14.43 3.80 − 4.22*** − 0.48
EXR 17.03 2.88 12.93 2.79 5.61*** 0.59
INTR 16.30 3.98 13.63 3.40 2.79** 0.34
IDE 15.07 3.62 17.73 3.31 − 2.97** − 0.36
AMO 14.17 4.24 11.83 3.44 2.34* 0.29

ADHD attention deficit hyperactivity disorder, TD children typically developing children, CPM Raven’s
colored progressive matrices (result in centiles), INM intrinsic motivation, EXR external regulation,
INTR introjected regulation, IDE identified regulation, AMO amotivation, M mean, SD standard deviation,
U/t Mann–Whitney’s U-test result for age (no normal distribution), Student’s t-test results for the other vari-
ables, r effect size
Significance levels: *p < 0.05; **p < 0.01; ***p < 0.001

Table 2  Mean scores obtained ADHD children TD children

in the interaction between the (N = 30) (N = 30)
group and motivation factors
Normal Increased motiva- Normal conditions Increased motiva-
conditions tion tion
M SD M SD M SD M SD

Vigilance
Omission errors 8.87 2.36 7.13 2.58 6.17 3.09 5.90 2.80
Commission errors 6.70 2.67 6.63 2.66 5.03 2.16 4.93 2.16
Visual search (5–20 items)
RT 4088.20 880.54 3192.70 757.78 3107.01 581.34 2927.80 443.49
RT slope 38.21 10.29 29.32 10.08 29.29 8.39 28.37 8.91
Multitasking RT
Single-tasking 2845.17 751.50 2317.97 737.29 2221.47 663.64 2195.83 671.33
Multi-tasking 4445.03 1009.58 3908.07 998.33 3417.60 795.50 3395.13 781.56

RT reaction time in ms. Key to other elements: see Table 1

(t = 0.38, p = 0.702, r = 0.05) and RT in single-tasking r = 0.51) and RT in multi-tasking (t = 4.33, p < 0.001,
(t = 0.67, p = 0.505, r = 0.09). r = 0.49). In the case of commission errors, no significant
The motivation factor significantly differentiated the differences in normal and increased motivation conditions
indicators of selected attention aspects in children with were observed (t = 0.81, p = 0.423, r = 0.11).
ADHD: omission errors (t = 4.12, p < 0.001, r = 0.48), In the case of TD children, all of the controlled attention
RT in visual search of 5–20 elements (t = 3.95, p < 0.001, indicators were similar in normal and increased motivation
r = 0.46), RT slope in visual search (t = 3.10, p = 0.004, conditions: omission errors (t = 1.61, p = 0.118, r = 0.21),
r = 0.38), RT in single-tasking (t = 4.49, p < 0.001, commission errors (t = 0.19, p = 0.854, r = 0.02), RT in

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visual search of 5–20 elements (t = 1.50, p = 0.145, r = 0.19), HEG/NIRS is a method of visualizing cerebral perfu-
RT slope in visual search (t = 0.46, p = 0.651, r = 0.06), RT sion and, consequently, brain activity. So far, few measure-
in single-tasking (t = 0.51, p = 0.613, r = 0.07) and RT in ments have been performed using this technology. In our
multi-tasking (t = 0.15, p = 0.886, r = 0.02). study, children with ADHD showed significantly lower
In order to illustrate the interaction effect of group mem- levels of hemoglobin saturation with oxygen within each
bership and motivation, Fig. 1 shows a chart of mean val- controlled location in the prefrontal areas, i.e.: Fp1, Fpz,
ues in ANOVA using the example of the time of the visual Fp2 (Hypothesis 1b). The obtained data are in line with the
search of 5–20 elements on screen. limited literature in this respect [28, 29, 57]. Hypoperfusion
in children with ADHD has also been confirmed by single-
photon emission computed tomography (SPECT)—accord-
Discussion ing to estimates, hypoperfusion affects 87% of children with
ADHD [63]. Reduced blood flow in the prefrontal lobes may
Elevated TBR in children with ADHD has been well stud- be associated with loss of inhibitory control, hyperactivity,
ied and described in the literature and has proven to be an impulsivity and inattentiveness, which is the clinical picture
effective aid in diagnosing attention deficits [6, 23, 24]. Our of ADHD [64, 65]. The obtained effects (r ∈ 〈0.70, 0.75〉)
results are in line with the findings so far. Children with turned out to be larger than in the case of TBR differences.
ADHD exhibited higher TBR in each of the controlled loca- Previous studies on motivation focused primarily on the
tions in the midline, i.e.: C3, Cz, C4 (Hypothesis 1a). The lower achievement needs of children with ADHD and their
obtained effects should be considered medium or large (r biological conditioning, i.e. the limited availability of dopa-
∈ 〈0.41, 0.55〉). In our study we did not correct individual mine receptors in the reward system [53, 55]. In our study,
alpha peaks. Some children with ADHD may display slow we looked at the differences in the dimensions of motiva-
alpha peak frequencies instead of increased theta activity. tion to learning between ADHD and TD children as per the
Lack of this correction may overstate the TBR value. Lang- self-determination theory (Hypothesis 2a–e). Children with
berg et al. [52] compared the TBR value in both conditions. ADHD were more likely to be active under pressure from
Although less pronounced, these differences still remain sig- external stimuli, for rewards or to avoid punishment (exter-
nificant. Moreover, it should be noted that most researchers nal and introjected regulation), and they also displayed a
reported greater effects for TBR measurement [61]. How- higher level of amotivation. TD children considered activ-
ever, our study involved a non-homogeneous group of par- ity more self-determined (intrinsic motivation, identified
ticipants due to the ADHD type of presentation, while the regulation). The obtained results varied. The lowest one
EEG measurement itself was limited to 3 min. The majority pertained to amotivation (r = 0.29), while the biggest one
of studies registered a 20-min recording, at different stages was noted in external regulation (r = 0.59). Our findings are
of cortical activity [62]. On the other hand, not all studies consistent with the behavioral model of motivation in chil-
confirmed clear TBR differences between ADHD and TD dren with ADHD [55, 66].
children [26, 27].

Fig. 1  Differences in visual 4300

search of 5–20 elements on
Reaction time (scale: 950-10,000 ms)

screen between ADHD and 4100

TD children in normal and
increased motivation conditions 3900
(reaction time in ms)
3700
3500
3300
3100
2900
2700
ADHD children TD children
Normal conditions Increased motivation

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Reports thus far have shown deficits in children with controlled aspects of attention. This impact did not apply
ADHD regarding vigilance [38, 41, 67]. Our study proved to TD children who, in conditions of increased motivation,
to support these findings (Hypothesis 3a). The obtained achieved the same results in normal conditions. Motivated,
effects should be considered medium (r = 0.45 for omission children with ADHD exhibited comparable performance
errors, r = 0.33 for commission errors). Omission errors to TD children regarding most tasks. Differences between
may indicate distraction, while commission errors may be a groups were maintained only in multitasking complex tasks
sign of impulsivity. It should be noted that some researchers (the effect decreased to r = 0.28) and in commission errors,
reported greater difference effects compared to TD children where no motivational impact was noted. Therefore, it seems
[43]. However, our task lasted 5 min. In everyday condi- that motivation, especially in simple cognitive tasks, can
tions, the effects can be much greater, e.g. when long hours increase perceptual sensitivity in children with ADHD,
of vigilance at school is required or when cognitive stimuli increase the quality of information obtained from a stimulus,
(characteristic of the laboratory) are joined by sensory ones. as well as the rate of collecting this information. However,
Children with ADHD displayed longer RT in the visual motivation is not able to eliminate the limitations of com-
search task—large effect: r = 0.56, as well as a bigger RT plex tasks which require the integration of many cognitive
slope—medium effect: r = 0.44 (Hypothesis 3b). Our results processes, especially those more closely related to inhibitory
are consistent with many earlier studies using the conjunc- control.
tive search method, which requires intensive selective visual Our conclusions are supported by the Barkley model
attention [39, 40, 68]. Some studies also controlled the dif- [72], which assumes that children with ADHD have limited
ficulty level of the task [39, 69, 70]. Interestingly, the largest capacity to self-regulate their affect and emotions and are
effects were obtained at the highest, but also at the lowest more dependent on immediate and external sources of moti-
level of difficulty. In the case of moderate complexity of a vation. Children with ADHD can improve their performance
task, the differences between ADHD and TD children turned under feedback control and from a reward perspective. Such
out to be small or insignificant. These data confirm the need relation was also observed by McInerney and Kerns [44]
to stimulate interest and use more frequent reinforcement in in the case of inhibitory control and working memory. In
children with ADHD for tasks perceived as less demanding their study, the results of children with ADHD improved
(motivational deficit), as well as to reduce requirements or under the influence of motivation, but they still differed from
divide complex (more difficult) tasks into smaller stages. those of the control group (children without disorders did
In the multitasking test for divided attention (Hypoth- not improve their performance under conditions of increased
esis 3c), children with ADHD showed longer RT in sin- motivation). In the Reijnen and Opwis study [45] in condi-
gle-tasking (medium effect: r = 0.41) and in multi-tasking tions of increased motivation, children with ADHD exhib-
(large effect: r = 0.50), which is consistent with many previ- ited comparable performance in visual search to those in
ous reports in this respect [37, 42, 71]. The difference in the control group. Therefore, it seems that self-regulation of
response time for single-tasking confirms our findings to effort may be one of the key deficits in children with ADHD.
date about the slower rate of information gathering in chil- Our study is affected by certain limitations. It was con-
dren with ADHD. A bigger effect in multi-tasking indicates ducted on a small number of participants. Further research
additional impairment of inhibitory control. It should be is needed to generalize conclusions. In the study, we did not
noted that, as per previous findings, the differences in mul- control the ADHD types of presentation or the co-occur-
titasking are not due to deficits in prospective memory [42]. rence of other disorders (e.g. behavioral disorders) that
Children with ADHD have a similar ability to remember could differentiate the results. The structure of the group
and recall test rules compared to TD children. In contrast, (age and sex) did not allow for assessing the demographic
researchers observe a limited capacity to plan, organize differences with respect to the controlled dependent vari-
behavior and monitor performance, which supports our find- ables. However, studies to date have indicated a statistically
ings on impairment of executive functions in children with insignificant or small impact of age and sex on the TBR and
ADHD [37, 42]. HEG ratio values [73–75]. At the same time, researchers
It should be noted that the identified deficits in selected have observed significant improvement in the brain function-
aspects of attention in children with ADHD are not related ing between children and adults with ADHD, which may
to intellectual deficits, as the groups did not differ in their explain the weakening of attention deficit symptoms with
performance in this respect. We used only a non-verbal intel- age—especially with respect to hyperactivity (the inatten-
ligence test, as all attention measurement tools were of a tiveness component seems to be more stable) [76]. The HEG
visual and spatial nature. System allowed for assessing rCBO‌2 in the brain tissue at a
Our study confirmed the positive impact of extrinsic depth of about 1.5 cm. The use of additional imaging tech-
motivation on selected aspects of attention in children with niques would allow for a better assessment of brain activity
ADHD, who have improved their capacity regarding most (e.g. SPECT). Two motivational techniques were applied in

13
Child Psychiatry & Human Development (2021) 52:586–595 593

the study in parallel: the reward effect and the competition Informed Consent Informed consent was obtained from all individual
effect. We are not able to determine which of them proved participants included in the study.
to be more effective. Taking these variables into account
may serve as an inspiration for further research. Despite the Open Access This article is licensed under a Creative Commons Attri-
aforementioned limitations, our report introduced new data bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
regarding cortical activity, motivation and attention deficits as you give appropriate credit to the original author(s) and the source,
in children with ADHD. provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
Summary permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
The study was conducted in the Fall of 2019 in Kraków copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
(Poland). It included 30 children with ADHD as well as
30 TD children. The study confirmed significant differences
between children with ADHD and TD children in terms of
TBR and HEG ratio, which indicate different patterns of cor- References
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