Eur Child Adolesc Psychiatry

DOI 10.1007/s00787-017-0961-7

ORIGINAL CONTRIBUTION

What motivates individuals with ADHD? A qualitative analysis

from the adolescent’s point of view
Sarah Morsink1 · Edmund Sonuga‑Barke2,3 · Gabry Mies4 · Nathalie Glorie5 ·
Jurgen Lemiere6 · Saskia Van der Oord7,8 · Marina Danckaerts1,6

Received: 30 August 2016 / Accepted: 9 February 2017

© Springer-Verlag Berlin Heidelberg 2017

Abstract Individuals with ADHD appear to respond dif- effort to achieve a goal; (5) valuing social reinforcement;
ferently to incentives than their peers. This could be due to (6) desiring to be absorbed/forget problems; (7) feeling free
a general altered sensitivity to reinforcers. However, apart and independent, (8) attaining material reinforcement; and
from differences in the degree of motivation, individuals (9) an enjoyment of bodily stimulation. The theme struc-
with ADHD might also be motivated by qualitatively dif- ture was very similar for both groups. However, individu-
ferent factors. This study aimed to harvest a range of moti- als with ADHD differed in some specifics: their focus on
vational factors and identify ADHD-related qualitative the passing of time, the absence of preference for predict-
differences in motivation, from the adolescent’s point of able and familiar tasks, and their less elaborate description
view. Semi-structured interviews allowing participants to of the togetherness theme. A broad range of motivational
describe what motivates them in daily life were conducted themes was identified, stretching beyond the current focus
with young adolescents (9–16 years) with and without of ADHD research and motivational theories. Similarities
ADHD. Thematic analysis was undertaken using NVivo and differences in motivational values of individuals with
software. Major themes relating to motivation were identi- and without ADHD should be taken into account in reward
fied from the interview data. These were: (1) achieving a sensitivity research, and in psychological treatment.
sense of togetherness; (2) feeling competent; (3) fulfilling
a need for variation; (4) gaining pleasure from applying Keywords ADHD · Motivation · Qualitative research ·
Interview

* Edmund Sonuga‑Barke
edmund.sonuga‑barke@kcl.ac.uk
Introduction
1
Department of Neuroscience, Psychiatry Research, KU
Leuven, Louvain, Belgium Attention deficit/hyperactivity disorder (ADHD) is a devel-
2
Department of Child and Adolescent Psychiatry, Institute opmental disorder characterised by impulsivity, hyperac-
of Psychiatry, Psychology and Neuroscience, Kings College tivity and inattention [1–4]. It affects about 3–10% of the
London, London, UK
school-aged children and adolescents worldwide [4, 5].
3
Department of Experimental Clinical and Health Psychology, ADHD interferes with everyday activities and tasks, and
Ghent University, Ghent, Belgium
is, by definition, associated with suboptimal social, psy-
4
Behavioural Science Institute, Radboud University, chological, and academic functioning [2, 6, 7] and creat-
Nijmegen, The Netherlands
ing a major burden to health services across the life span
5
Faculty of Medicine, KU Leuven, Louvain, Belgium [8]. This suboptimal functioning is present across settings
6
Department of Child and Adolescent Psychiatry, UPC KU and tasks [9]. While such performance deficits may be the
Leuven, Louvain, Belgium result of fundamental impairments in cognitive processes
7
Clinical Psychology, KU Leuven, Louvain, Belgium [10], it seems that alterations in motivation to perform the
8
Developmental Psychology, University of Amsterdam, task at hand also play a role in the putative ADHD patho-
Amsterdam, The Netherlands physiology [11, 12]. Motivation can be broadly defined as

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Table 1  Interview schedule

with four questions on “What do you like?”
behavioural preferences (1–4), “What don’t you like?”
one question on motivation (5), “It is a typical day during the week. It is still morning, are there things you are looking forward to?”
and one open-ended (6) “It is a typical day during the week. It is still morning, are there things you are not looking forward to?”
“What does motivation mean to you?
“We talked about what you like and what you don’t like. Do you think we have covered everything?

being moved to do something [13]. Intrinsic motivation is sensitivity in ADHD. Second, psychological treatments,
defined as engaging in an activity for the inherent satisfac- designed to promote long-term behaviour change, often
tion of the activity itself [13], while extrinsic motivation include the manipulation of reinforcement contingencies
refers to the performance of an activity to attain some sepa- [26]. It is essential to understand the drives of children and
rate outcome [13]. Hence, a task can simultaneously impact adolescents, and adapt treatments to their (disorder) spe-
both intrinsic motivation (e.g. task is inspiring, interesting cific needs. This may be especially important in the case
or stimulating), as well as extrinsic motivation (e.g. task of ADHD, where maintaining motivation during non-phar-
outcomes such as money, points or praise) [13]. macological treatment may be crucial for behaviour change
Experimental research on motivational alterations in [27, 28].
ADHD has focused mainly on exploring extrinsic moti- The current study represents the first stage in a program
vational factors, operationalized in studies as external of research exploring potential differences in attitudes of
reinforcement of task performance [14–17]. Studies point children and adolescents with ADHD towards intrinsic and
to an altered reinforcement sensitivity in ADHD [18, 19]. extrinsic motivational factors, and how these might influ-
However, results are mixed with some studies suggesting ence performance. This first qualitative study, attempted to
hypo- and some hyper-sensitivity to reinforcement. Some uncover the motivational characteristics of everyday tasks/
studies showed that performance-contingent rewards have activities, outcomes and settings for individuals with and
more impact on the performance of children or adolescents without ADHD, from the adolescent’s point of view. We
with ADHD compared to their typically developing peers employed a broad-based ecological qualitative perspective
[14, 20], suggesting a hyper-sensitivity to rewards. At the to get a better idea of the motivational drives of children
same time, for individuals with ADHD to reach a compa- and adolescents with and without ADHD. More specifi-
rable level of performance as their peers, individuals with cally, we aimed to harvest an inventory of motivating fac-
ADHD may need more frequent or larger rewards, suggest- tors as comprehensive as possible, by asking children and
ing a hypo-responsiveness to rewards [21, 22]. These find- adolescents with and without ADHD about their motivation
ings might be due to inter-study variation of reward sali- and preferences in daily life, emphasizing the participants’
ence, e.g. different types or intensities of rewards can evoke own perspective and specific wording. Following from this
different motivational processes in individuals with ADHD, present study, we will develop items for a questionnaire to
compared to controls [20, 23]. In addition, the inherent study putative quantitative and qualitative differences in
properties of the tasks, and their influence on behaviour in motivational attitudes in children and adolescents with and
ADHD may also explain some of the inconsistencies and without ADHD.
these have rarely been studied. Only one study assessed
intrinsic motivation, and found that children with ADHD,
their parents, and teachers report a link for ADHD with Method
diminished intrinsic motivation for academic activities
[24]. Participants
We hypothesize that qualitative differences in motiva-
tional attitudes and drives of individuals with ADHD exist Participants were contacted via an advertisement on the KU
[25]. In this regard, the key questions are—What extrinsic Leuven University Hospitals’ website, in nearby schools,
and intrinsic factors motivate adolescents with ADHD? or via e-mail when they already participated in previous
And do they generate different motivational factors than research studies. Two groups were recruited: (1) children
a group of typically developing adolescents? Answering and adolescents (9–16 years) with an ADHD diagnosis
these questions is important for both scientific and clini- (n = 17; female = 3; mean age = 13.4, SD = 2.0), and (2)
cal reasons. First, assessing differential attitudes towards typically developing peers (no self- or parent-reported psy-
a range of motivational factors might help to elucidate chiatric diagnosis) (n = 22; female = 7; mean age = 13.2,
the inconsistent findings in research concerning reward SD = 4.1). The Schedule for Affective Disorders and

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Schizophrenia for School-Age Children (K-SADS) [29] knowledgeable of the literature concerning qualitative
was used to confirm ADHD diagnosis in the ADHD group. research and ADHD, and one novice to the field. To mini-
In the ADHD group, six inpatients were included, and three mize the influence of the researchers’ biases, preconcep-
of them had comorbid problems (1 major depression disor- tions were monitored in a diary (bracketing [33]). In both
der, 1 dyslexia, 1 autism spectrum disorder and dyslexia). groups, interviews were analyzed both iteratively and in
The other ADHD participants did not suffer from self- parallel, and saturation needed to be reached separately.
reported comorbidities. The participants received 8 euros First, researchers became familiar with the data during
for their voluntary participation. interview conduct, transcription and intensive rereading
of the interviews (step 1: data familiarisation). Second,
Procedure the researchers coded the interviews in parallel by means
of NVivo software (step 2: initial coding generation). A
A semi-structured interview was developed to allow par- code is a summary of an essential characteristic of (a part
ticipants to describe what motivates them in everyday life. of) the participants’ story. The contextual richness of the
After a series of pilot interviews (n = 12), an initial set of participant’s story was taken into account. One paragraph
open-ended questions tapping motivational factors was nar- can be characterised by multiple codes (For example: “I
rowed down to five easily understandable core questions like playing soccer, because you can be with friends, and
(Table 1: interview schedule). Participants were told that because I’m good at it” (male, 15 years) is coded with
the interview would be an investigation of their likes and ‘Togetherness’ and ‘Competence’). Coding terminology
dislikes. Through the techniques of affirmation, reflect- was kept as close to the participant’s phrasing as pos-
ing and summarizing [30], participants were prompted to sible. Every 3–5 interviews, the inter-researcher coding
elaborate upon their preferences and motivation for these schemes were compared. Only minor differences between
likes/dislikes. The interview, that lasted for about 40 min, the two coders existed (e.g. in code naming); these were
took place at the outpatient unit of the University Psychiat- resolved during thorough deliberation and integrated
ric Clinic KU Leuven (n = 38), or at the participant’s home into one scheme containing codes of both the research-
(n = 1), and was conducted by a researcher with a Master ers. Third, patterns in the data reflecting important and
degree in Clinical Psychology. Before giving informed con- distinct features of the interviews were organized into
sent, the interviewee and his/her guardian were made aware themes and subthemes (step 3: search for themes). A
that answers would remain confidential and data would be collection of codes was considered a (new) theme based
anonymized. Audio recordings of the interviews were tran- on; (1) its relevance for identifying motivational fac-
scribed verbatim. The NVivo 10 qualitative data analysis tors, (2) its centrality in the story of one or more partic-
software [31] was used to facilitate coding and analysis of ipants, (3) its uniqueness as compared to other themes.
the data. This study was approved by the ethics committee Fourth, the themes were continuously and iteratively
of UZ Leuven. cross-checked against the interview data, in an attempt to
grasp the full meaning of the themes, and to make sure
Analysis that other important themes were not overlooked (step 4:
review of themes). These first four steps were repeated
It was our goal to identify and describe the full range of with each new interview until saturation was reached.
motivating factors, for both groups. To this end, an induc- Saturation is an estimation that new data will not result
tive thematic analysis was used, guided by the six stages in new information, relevant for the research question.
of Braun and Clarke (2006) (Fig. 1) [32]. Through- As we did not want to miss certain motivational factors
out the process, two researchers were involved, one specific to groups of adolescents with ADHD, satura-
tion was estimated for each group separately. This point
was reached when no new themes could be identified in
four consecutive interviews. Interviews that were already
planned, were allowed to take place and included in the
analysis. The following questions were addressed: (a)
Does every code fit with the theme it is referred to? (b)
Does one theme convey only one message? (c) Can dif-
ferent themes be grouped into one overarching theme
pointing towards one underlying concept? (d) Which
themes are characteristic for most stories (key themes)?
Finally, themes were labeled and completed with a defini-
Fig. 1  Braun and Clarke’s model of thematic analysis (2006) tion based on the participant’s vocabulary (step 5: theme

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definition and labeling). Judgments on saturation, theme there is no quarrelling, and everybody is always laughing”
structuring and labeling were made through thoughtful (male, 15 years), “We were inside, we were together, we
insight involving all authors (step 6: report writing). laughed and played together. Everybody in one house”
(male, 15 years, ADHD). “Belonging to a group gives me
motivation and energy. I can trust them” (male, 16 years,
Results ADHD), “During a tough time they are there for you.
It is nice to know that they will always be there for you”
Participants reported a range of activities they either liked (female, 14 years), and “You can tell them things that you
or disliked. The main activities mentioned were doing can’t tell anyone else” (male, 14 years). In addition, the
sports, doing activities with friends or family, going to non-ADHD group highlighted that this bond was affective,
school and doing homework, participating in household and allowed them “to be themselves”: “If you love some-
activities, watching television, playing computer games, one, you can give him a hug” (male, 15 years), “To family
sleeping and getting up in the morning, eating, drawing and you can say everything, without saying something wrong”
painting, and going on vacation. When probed further why (female, 13 years),
they liked/disliked certain activities, a wide variety of moti- Individuals also reported being motivated to undertake
vational themes was identified (Fig. 2: tree structure of the activities that gave them ‘feelings of competence’. Often,
themes). Saturation was reached in the ADHD group after this was accompanied by feelings of pride. For example:
12 interviews, and in the non-ADHD group after 16 inter- Citations: “You are happy that you can make it [a specific
views. Interviews that were already planned, were allowed meal], and you make it again, because you know you are
to take place and included in the analysis (n = 5 for ADHD good at it” (male, 14 years), “It’s more fun when you are
and n = 6 for non-ADHD), without revealing new themes, good at it” (male, 15 years, ADHD). In contrast, incom-
or changing a theme’s interpretation. The identified struc- petence in an activity, often resulted in negative feelings;
ture of the motivational themes was very similar across the e.g. “I don’t like guitar lessons because I’m not good at it”
two groups, but some differences between the participants (female, 13 years).
with ADHD and those without could be seen. The current Participants also seemed to be ‘driven towards varia-
methodology did not allow for an assessment of the relative tion’, by switching between different activities—not nec-
importance of the different themes to different individuals. essarily inherently enjoyable themselves—that are each
Creating a ‘sense of togetherness’ was a motivational engaged in for short periods of time. In contrast, an ini-
concept in most participants’ stories. It seems that belong- tially enjoyable activity can also become aversive when
ing to a group of friends or family is in itself rewarding. too repetitive. Citations: “Variation is fun, when some-
Often, this is described in terms of “a bond” or an “atmos- thing new is about to happen (male, 15 years, ADHD),
phere”. This atmosphere seems to be created by feelings “It is fun to do badminton once, but each Saturday again
of mutual support and possibility to confide in someone. indoor… Every once in a while, however, when there
Citations: “It is fun because we are a tight group of friends, is variation, just so it is not always the same” (male,

Applying effort to Desire to be Feelings of Material reinforce- Social Feeling free and Sense of Enjoyment of
Need for variation
reach a goal absorbed/to forget competence ment reinforcement independent togetherness bodily stimulation
problems

frustration when To open up to

Attraction Aversion Boring/dull During waiting A band
time goes too slow someone

When no valuable Faimiliarity &

It's a challenge Competence Incompetence Just to keep busy Support Trust
goal predictability

Too much energy To learn or Time goes slowely

To reach a goal Making mistakes Being yourself Affection
and time investment improve when no variation

Engaging in Time flies when

competition Applying too much being together
physical or
cognitive effort

Applying physical
or cognitive effort
Difficult to start

Fig. 2  Tree structure of all themes present in both ADHD and non-ADHD groups (solid line), only present in non-ADHD group (dashed line),
and only present in ADHD group (double line)

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15 years), “Always doing the same would be boring” 15 years), “When you do gymnastics, you can relax and
(female, 13 years, ADHD). not think about school” (female, 13 years), “When I watch
Some participants described ‘an enjoyment of bod- TV, I’m not stressed, I don’t have to think about anything”
ily stimulation’: engaging in activities that are physically (male, 14 years, ADHD), “It’s irritating when you are doing
exciting to them seems to be rewarding and give them something, and others distract you” (male, 14 years).
extra energy. It is described as a “kick” or a “boost”, and Some participants described the drive to feel ‘free and
the bodily feelings that accompany this are highlighted. independent’, doing what they want to do, when they
Examples; “When you go fast, you get a kick, you feel the want to do it. This is often described in the context of
adrenaline” (male, 14 years), “Doing a death ride” (male, self-expression and creativity, and contrasted with school
11 years, ADHD), “It’s exciting you never know what obligations. For example: “I prefer deciding on my own”
comes across” (male, 15 years), “feels like you are float- (male, 14 years), “No more obligations” (male, 15 years),
ing” (male, 13 years). “When I paint, I feel free” (female, 16 years).
Sometimes, the likeability of a specific activity seemed While, as mentioned above, the motivational themes
to depend on the social response that it elicits. For example, were largely similar across both groups, some differences
social emotional reactions seemed to be particularly strong were manifest. First, children and adolescents with ADHD
reinforcers of behaviour (valuing social reinforcement). seemed to have a specific aversion towards the slow pass-
Examples: “Good grades make me and my parents proud” ing of time, exhibited throughout their stories. Citations:
(female, 10 years), “My parents were angry” (female, “And then for example you check the time, and it is 30, and
15 years), “When I have bad grades, my father gets angry” then you try to do something but then we’re one minute fur-
(male, 11 years, ADHD). ther. And that is kind of boring” (male, 15 years, ADHD),
Also, ‘attaining a material reinforcement’ seemed to “It takes so much time, for me everything has to go fast”
increase motivation, and such reinforcements are often (male, 14 years, ADHD). Also in the ‘applying effort to
used by parents to stimulate performance in school. Cita- reach a goal’ theme, the aspect of time investment seemed
tions: “If I have good grades, I will get a tablet” (male, to have a negative connotation to the ADHD group; “You
11 years, ADHD), “My parents take away my cell phone” have to invest time” (male, 15 years, ADHD), “It takes
(female, 14 years), “There must be a compensation, for so much time” (male, 14 years, ADHD). Less favourable
example, cleaning the house for one month equals a com- activities seemed to be associated with the slower passing
puter” (male, 14 years, ADHD). of time, while fun activities, such as being together, make
For some participants, the “journey” towards an out- time fly [“When you are with friends, time goes faster”
come seemed more important than the outcome itself. (male, 15 years, ADHD)]. Second, across both groups, the
‘Applying (physical and/or cognitive) effort to reach a need for variation in activities was present. However, in
goal’, was reported by some participants to be valued for contrast, participants without ADHD also seemed to value
its own sake. However, this only seemed to happen in par- activities that were ‘familiar and predictable’ [“I like bas-
ticular cases. When effort is not seen as useful, feasible, or ketball and football; you start with it during childhood, and
requires too much energy investment, it may be shunned. I like that” (male, 12 years), “I know my friend, and what
Examples: “I like this sport [skating] as you have to prac- he likes. So, I know in advance what we are going to do”
tice a lot to achieve something. You really have to apply (male, 11 years)]. This drive for familiarity and predictabil-
effort” (male, 14 years), “It’s a challenge” (male, 15 years, ity did not occur in the stories of participants with ADHD.
ADHD), “I don’t feel like doing anything that requires Third, ‘sense of togetherness’ was more elaborately
energy” (female, 13 years), “I don’t like applying effort described by children and adolescents without ADHD. For
during a boring activity (male, 15 years, ADHD). Initiating many of these adolescents, the possibility to be themselves
an activity can serve as a threshold itself. Some participants seemed a vital part of being together [“With them, I can
seemed to dislike the initiation of an activity; “Initiating really be myself” (female, 13 years)] and the fact that affec-
an activity is the hardest, once you started it’s tolerable” tion was shown in this togetherness [“I like cuddling, that
(male, 15 years). is very loving” (male, 15 years)], but this was not so men-
A number of participants mentioned that engaging in an tioned by individuals with ADHD.
activity is also motivating when it allows them to become
‘completely absorbed’ by it. Sometimes, this allowed the How did participants explain motivation?
individual to forget their problems for some time. These
participants described this as creating a calm and peace- Participants defined motivation in a general way [“Some-
ful feeling. Citations: “when you are doing something with thing that urges you to act” (male, 16 years)], as pursuing
your friends you don’t think about anything else than what a goal such as good grades [“Motivation is pursuing a goal
you are doing. Not about school, or other things” (male, like good grades or winning a game” (female, 14 years)],

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as social encouragement or pressure [“Someone saying you the ADHD group. First, participants with ADHD talked
can do it” (female, 11 years)], as extrinsic [“If I do that, I extensively about being motivated by the fast passage of
receive this” (male, 13 years)] or intrinsic [“When you are time. Activities that were aversive (“stupid”, “boring”)
interested in something you are more motivated” (male, were described as being slow and long-lasting. Such tasks
14)] motivation. A few found it difficult to give a descrip- might be experienced as more intrinsically negative for
tion of ‘motivation’ [“I don’t know what motivation is” individuals with ADHD, and, therefore, elicit less engage-
(female, 9 years)]. ment and effort. This theme maps well onto the delay aver-
sion theory of ADHD [35], which states that individuals
with ADHD have an aversion for delay-rich settings and
are motivated to escape or avoid slow and boring tasks
Discussion [35]. This aversion towards lengthy tasks or activities
might also indicate altered timing processes in ADHD.
Identifying factors that motivate the behaviour of children Indeed, in experimental research, time perception, pro-
and adolescents is important if we want to create contexts cessing, (re)production and time-management difficulties
that optimise their engagement with tasks and performance, have repeatedly been found in individuals with ADHD
or increase treatment effectiveness and induce long-term [36, 37]. Second, although participants in both groups
behaviour change. The aim of this study was to harvest the were drawn to stimulating and variable activities, only
descriptions of events, situations or outcomes that motivate participants without ADHD mentioned being attracted by
children and adolescents with and without ADHD in their familiar and predictable activities as well, suggesting that
daily lives. In the analysis, no predetermined structure was familiar and predictable activities may not be as enjoyable
imposed on the data and the focus was on the adolescent’s for children and adolescents with ADHD. This differential
own perspective. This study, therefore, generated bottom- attitude might be of importance when conducting scientific
up information on children and adolescents’ likes and dis- research. Research tasks are usually lengthy, repetitive and
likes in everyday life. In addition, as both groups needed to boring; factors that seem to be less appealing to individu-
reach data-saturation separately, we were able to determine als with ADHD. Thus, poor results of ADHD participants
whether there were ADHD-specific motivational themes. on such tasks may result from a lower intrinsic motivation
Saturation was reached sooner in the ADHD group (n = 12) to the task rather than specific cognitive deficits. Indeed,
than in the non-ADHD group (n = 16). As the two groups game-like versions of common research tasks (gamifica-
involved different participants, saturation-differences might tion) increase performance of participants with ADHD to
be a mere coincidence. However, based on the coders’ the level of control participants [38, 39]. Third, partici-
impression, another plausible explanation is that the differ- pants without ADHD described the ‘togetherness’ theme
ence might be related to a shorter and less elaborate answer- more elaborately than participants with ADHD, mention-
ing style of the participants in the ADHD group. In general, ing not only a bond characterised by mutual feelings of
participants mentioned a broad range of motivational fac- support and the possibility to open up to someone, but also
tors. This range included material and social factors pre- the seeking out of shared feelings of affection [“If you
viously used in the experimental studies of motivational love someone, you can give him a hug” (male, 15 years)]
effects on task performance in individuals with and without and the social intimacy that allows them the possibility
ADHD [14, 15, 17, 34]. However, the interviews revealed a of being themselves [“To family you can say everything,
much broader set of potentially motivating factors involving without saying something wrong” (female, 13 years)].
extrinsic as well as intrinsic motivational elements. ADHD is characterised by impairment in social function-
It was striking to see how similar the motivational ing including having less stable relationships with more
themes derived from the interviews of individuals with social rejection and conflict than typically developing
ADHD and those without ADHD were, even when the adolescents [40, 41]. This has previously been explained
motivational tree-structures were built up separately during in terms of their social behaviour, which is characterised
analysis. However, these overall qualitative similarities do by frequently not listening, interrupting others, disruptive
not necessarily imply that a similar preferences hierarchy and inappropriate behaviour [42], making other individu-
is in operation for the two groups. Even when the same als reluctant to relate to individuals with ADHD. However,
factors were mentioned in both groups, youngsters with the current findings underline the idea that children and
ADHD might still be motivated by these factors to differ- adolescents with ADHD might also value social relations
ent degrees—which were not examined in this qualitative in a different way. Indeed, in previous research, children
study. with ADHD reported that mutual entertainment was the
In addition to a majority of overlapping themes in both core aspect of friendship, while their peers highlighted the
groups, some motivational themes were only described by presence of emotional support, intimacy and security [43].

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Our findings are generally supportive of the sorts of adolescents with ADHD through motivational interviewing
external incentives used in current ADHD research to may, indeed, enhance the compliance and effectiveness of
increase task performance to motivate children and ado- treatments [46, 47].
lescents both with and without ADHD, as the themes of From a developmental psychopathology perspective,
‘attaining material reinforcement’ and ‘valuing social motivational alterations and ADHD symptoms might influ-
reinforcement’ reflect external incentives such as money, ence each other bi-directionally and transactionally over
gifts and praise. However, they also suggest that current time. In one direction, altered motivational drives might
experimental research on motivation in ADHD is limited in invoke ADHD symptoms, as they might prevent individu-
three ways. First, the influence of inherent task properties als with ADHD to fully engage in tasks, resulting into
on motivation and task performance is often neglected. As more hyperactivity/impulsivity and inattention [37, 48,
stated, research tasks might be less appealing for individu- 49]. In the reciprocal direction, ADHD symptomatology
als with ADHD because of their lengthy, boring and repeti- might impede extracting the full value from incentives
tive nature. These task characteristics might contribute to and experiences. First, concentration deficits might reduce
their lower level of intrinsic motivation which would reduce the opportunity to be absorbed/to forget problems. Sec-
performance in participants with ADHD. Second, adding ond, effort deficits [“dislikes tasks that require prolonged
an extrinsic incentive to the task contingent on performance mental effort” (DSM-5)] could render applying effort to
might influence motivation and performance of participants reach a goal more difficult and, as a result, less reward-
with ADHD differently than non-ADHD individuals. It has ing. Third, the error-proneness of individuals with ADHD
been demonstrated that under specific circumstances, an [“often makes careless mistakes, does not succeed in fin-
external incentive might undermine an individual’s intrin- ishing tasks” (DSM-5)], might impede striving for feelings
sic motivation to engage in an interesting task [44]. While of competence. Over time, both directions can play a role,
this effect is well studied in a general population [45], it as individuals with ADHD might not only be motivated
is not known how this effect might operate in individuals by different motivational drives, but might also encounter
with ADHD. Third, current research only employs a lim- more difficulties in trying to fulfil them.
ited range of external incentives to influence motivation As current scientific research about motivation of indi-
and task performance (e.g. money, gifts, points, social feed- viduals with ADHD is limited, it is important to evaluate
back), without considering other possible motivational fac- our motivational themes in the light of current motivational
tors such as competence, or autonomy. These issues may research, going beyond ADHD. A major theory in the
have confounded results in the previous research concern- motivational field is the self-determination theory (SDT)
ing hyper- or hyposensitivity towards rewards [25]. Hence, [50], which posits three universal innate basic psychologi-
studies assessing reinforcement sensitivity should take into cal needs of autonomy, competence and relatedness. The
account the motivational characteristics of (1) the external ‘need for autonomy’ refers to the ownership of behaviour
reinforcer, of (2) the task properties, and (3) situational ele- and experience of psychological freedom, the ‘need for
ments attributes of the study. All these characteristics might competence’ reflects effectiveness of the behaviour, and the
be differentially evaluated by adolescents with ADHD as ‘need for relatedness’ highlights the importance of recipro-
compared to controls. In future research, these motiva- cal care and concern for significant others [51]. Satisfaction
tional factors and the possible similarities and differences of these needs is a necessary precursor of an individual’s
between groups should be evaluated quantitatively in a positive affect, intrinsic motivation and psychological well-
representative sample of individuals with ADHD and their being [52]. These drives seem to be reflected to a large
peers to make conclusions about similarities and differ- extent in the current research’s themes of ‘feeling free and
ences in subjective evaluation of motivational factors. Also, independent’, ‘feeling competent’, and ‘achieving a sense
comorbidities have to be taken into account. ADHD-spe- of togetherness’. Vallerand et al. (1992) complemented
cific motivational factors may also need to be considered in the SDT research by differentiating intrinsic motivation in
clinical practice. The finding that adolescents with ADHD three types, focused on the educational context. The first
may not be motivated when the environment is too predict- type is ‘the motivation to experience stimulation’—doing
able and does not offer enough variation may be in contrast something to experience stimulating sensations [53]. This
with the instruction of predictability that is used in most motivation seems to parallel our theme of ‘enjoyment of
behaviour intervention programs. Its value in relation to the bodily stimulation’. Also, experiences of being in a flow
effectiveness of such behaviour intervention programs will are said to be part of this type [53]. In the interviews, chil-
need to be examined. Also, the fact that individuals with dren and adolescents mention a desire to ‘be absorbed and
ADHD might find routine intervention less enjoyable, may forget problems’, alluding to a broader experience that can
potentially affect their compliance. Some recent research take place when in an absorbed state. The second motiva-
shows that targeting these individual motivational values in tion is ‘motivation to know’—satisfaction experienced

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while learning, exploring or trying to understand something in further studies. Another possible limitation is that a few
new [53]. This is reflected in our subtheme ‘to learn’ (sub- participants with ADHD suffered from comorbidities such
theme of competence). The third motivation type is ‘moti- as depression, learning difficulties or autism spectrum dis-
vation to accomplish things’—the pleasure and satisfac- order. This might complicate the interpretation of findings
tion experienced when one attempts to reach a valued goal as being ADHD-specific. On the other hand, comorbidity
[51]. This highlights the process of ‘applying effort’. In is typical to ADHD [60], and including these individuals,
our interviews, this was typically described in the context therefore, increased the ecological validity of the study.
of ‘achieving a goal’. More specific themes, such as ‘need Third, no measurements of cognitive level, socioeconomic
for variation’ were not mentioned in the SDT tradition. It status or symptom severity were administered. The main
might be that these themes are specific to, and important aim of this study was to generate a wide range of possible
for, certain subgroups, such as adolescents with ADHD. motivational factors. However, inherent to the qualitative
Thus, motivational drives identified in our study can be nature of the study, findings are not necessarily generaliz-
linked with motivational literature, and provide a full spec- able to all individuals with ADHD. In a next step, these fac-
trum and rich description of potential motivational factors. tors will form the building blocks of a questionnaire that
Another relevant theoretical model is Cloninger’s psy- can be applied to a more representative sample of individu-
chobiological model of personality. Here, the concept of als with ADHD and their typically developing peers. In
novelty seeking is described [54]. On the one hand, nov- future studies, this questionnaire can give insight into indi-
elty seeking is characterised by a quick temper, excitability, vidual differences in task performance, and sensitivity to
urge to explore, curiousness, and impulsivity [55]. On the specific motivational factors.
other hand, it is associated with being easily bored, avoid- In conclusion, a wide range of common intrinsic and
ing monotony, intolerance of routine and non-preference extrinsic motivational themes were identified from the
for familiar places, or situations [55]. The first descrip- interview transcripts, suggesting that the behaviour of
tion parallels our theme of ‘variation seeking’, while the individuals with and without ADHD is largely driven by
second description seems to be the inverse of ‘familiar- similar factors. However, certain motivational factors were
ity and predictability’. In our study, both characterisa- quite specific to individuals with ADHD as they differed in
tions seem to apply to the ADHD group. Indeed, ADHD their focus on the passage of time, their absence of prefer-
seems to be consistently associated with higher levels of ence for predictable and familiar tasks, and their less elabo-
novelty seeking [56, 57]. However, the non-ADHD group rate description of the togetherness theme. Identifying this
was attracted towards stimulation activities, but preferred wide range of motivational factors moves beyond current
familiar and predictable activities as well. This raises the experimental research in ADHD and motivational theories.
question whether these activities are two ends of the same These findings are important if we want to understand the
dimension, or a dissociation can be made between the two. currently inconclusive research concerning the differen-
There may be some value in combining these two theoreti- tial sensitivity to incentives and differential task efficiency
cal frames in the context of understanding ADHD-related between individuals with ADHD and their peers. In clini-
motivation. cal practice, motivational interventions should take into
The current study is the first to use a bottom-up approach account the full spectrum of intrinsic and extrinsic motiva-
in motivation research in children and adolescents with tional factors, and include disorder-specific needs. Identify-
ADHD by focussing on the adolescent’s own perspective. ing these factors is a first step in comparing the possible
The use of an open, ecologically based interview format differential attitudes of individuals with ADHD to specific
ensured participants’ own wordings and experiences con- task characteristics, outcomes and contextual elements. A
cerning their likes and dislikes of everyday activities to further quantitative questionnaire study, based on the cur-
surface. The term motivation was avoided throughout the rent findings, will provide more insight into what the rela-
interviews, because, as expected, some adolescents had tive importance of these factors is for individuals with
difficulty grasping the meaning of this term. However, it ADHD as compared to controls.
could be that preferences for activities and states, revealed
in this study, have no bearing on what actually motivates
Compliance with ethical standards
the behaviour of ADHD individuals [58, 59]. For example,
with regard to food, it has been shown that liking can dif-
Conflict of interest Jurgen Lemiere received research Grants from
fer from wanting when the individual is not hungry [59]. In FWO (G.0738.14) and the research council KU Leuven (OT/12/096).
our study, it might be the case that although children and Saskia Van der Oord has been a paid speaker (Shire, MEDICE) and
adolescents enjoy other people’s company, they might not consultant (Janssen Cilag). Co-developer/author of a cognitive training
be motivated to change their behaviour to increase their game “Brain game Brian” and two cognitive-behavioural treatments
“Plan my Life” and “Solution Focused Treatment”. Grants received
sense of togetherness. However, this should be elucidated

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from ZonMW, FWO (G.0738.14), Kinderpostzegels, Research council 14. Luman M, Oosterlaan J, Sergeant JA (2005) The impact of rein-
KU Leuven (OT/12/096), Achmea, Nuts-Ohra. Marina Danckaerts has forcement contingencies on AD/HD: a review and theoretical
been a paid member of advisory boards organized by Shire and Neuro- appraisal. Clin Psychol Rev 25(2):183–213
tech Solutions, a paid speaker at conferences (not product-related) by 15. Modesto-Lowe V, Chaplin M, Soovajian V, Meyer A (2013) Are
Shire, Novartis, Medice and paid for consultancy for Neurotech Solu- motivation deficits underestimated in patients with ADHD? A
tions; she received research grants from Shire and Janssen-Cilag, from review of the literature. Postgrad Med 125(4):47–52
FWO (G.0738.14), and the research council KU Leuven (OT/12/096). 16. Ma I, van Duijvenvoorde A, Scheres A (2016) Interaction
Dr. Edmund Sonuga-Barke has received speaker fees from Shire between reinforcement and inhibitory control in ADHD: a
Pharma, Janssen-Cilag, and Medice. He has received consultancy fees review and research guidelines. Clin Psychol Rev [Internet].
from Shire Pharma, and Neurotech Solutions; research funding and Beschikbaar op: http://www.sciencedirect.com/science/article/
conference support from Shire Pharma, and speaker fees from Janssen- pii/S0272735816000027. geciteerd 3 februari 2016
Cilag, and Medice. He has also received book royalties from Open 17. Tripp G, Wickens JR (2009) Neurobiology of ADHD. Neurop-
University Press and Jessica Kingsley. All other authors reported no harmacology 57(7):579–589
financial interests or potential conflicts of interest. 18. Sagvolden T, Johansen EB, Aase H, Russell VA (2005) A
dynamic developmental theory of attention-deficit/hyperactiv-
ity disorder (ADHD) predominantly hyperactive/impulsive and
combined subtypes. Behav Brain Sci 28(3):397–418
19. Tripp G, Wickens JR (2008) Research review: dopamine transfer
References deficit: a neurobiological theory of altered reinforcement mecha-
nisms in ADHD. J Child Psychol Psychiatry 49(7):691–704
1. Able SL, Haynes V, Hong J (2014) Diagnosis, treatment, and 20. Dovis S, Van der Oord S, Wiers RW, Prins PJ (2012) Can moti-
burden of illness among adults with attention-deficit/hyperactiv- vation normalize working memory and task persistence in chil-
ity disorder in Europe. Pragmat Obs Res 5:21–33 dren with attention-deficit/hyperactivity disorder? The effects
2. American Psychiatric Association. (2013) Diagnostic and statis- of money and computer-gaming. J Abnorm Child Psychol
tical manual of mental disorders, 5th edn. VA: American Psychi- 40(5):669–681
atric Publishing, Arlington 21. Konrad K, Gauggel S, Manz A, Schöll M (2000) Lack of inhi-
3. Faraone SV, Asherson P, Banaschewksi T, Biederman J, Buite- bition: a motivational deficit in children with attention deficit/
laar J, Ramos-Quiroga JA et al (2013) Attention-deficit/hyperac- hyperactivity disorder and children with traumatic brain injury*.
tivity disorder. Nat Rev Dis Primers 1:15020 Child Neuropsychol 6(4):286–296
4. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA 22. Marx I, Höpcke C, Berger C, Wandschneider R, Herpertz SC
(2015) Annual research review: a meta-analysis of the worldwide (2013) The impact of financial reward contingencies on cogni-
prevalence of mental disorders in children and adolescents. J tive function profiles in adult ADHD. Beschikbaar op: http://
Child Psychol Psychiatry 56(3):345–365 dx.plos.org/10.1371/journal.pone.0067002. geciteerd 28 januari
5. Skounti M, Philalithis A, Galanakis E (2007) Variations in preva- 2016
lence of attention deficit hyperactivity disorder worldwide. Eur J 23. Demurie E, Roeyers H, Baeyens D, Sonuga-Barke E (2011)
Pediatr 166(2):117–123 Common alterations in sensitivity to type but not amount of
6. Danckaerts M, Sonuga-Barke EJ, Banaschewski T, Buitelaar J, reward in ADHD and autism spectrum disorders. J Child Psychol
Döpfner M, Hollis C et al (2010) The quality of life of children Psychiatry 52(11):1164–1173
with attention deficit/hyperactivity disorder: a systematic review. 24. Carlson CL, Booth JE, Shin M, Canu WH (2002) Parent-,
Eur Child Adolesc Psychiatry 19(2):83–105 teacher-, and self-rated motivational styles in ADHD subtypes. J
7. Wu S-Y, Gau SS-F (2013) Correlates for academic performance Learn Disabil 35(2):104–113
and school functioning among youths with and without persis- 25. Sonuga-Barke EJ (2011) Editorial: ADHD as a reinforcement
tent attention-deficit/hyperactivity disorder. Res Dev Disabil disorder—moving from general effects to identifying (six) spe-
34(1):505–515 cific models to test. J Child Psychol Psychiatry 52(9):917–918
8. Chorozoglou M, Smith E, Koerting J, Thompson MJ, Sayal K, 26. Daley D, Van der Oord S, Ferrin M, Danckaerts M, Doepfner M,
Sonuga-Barke EJ (2015) Preschool hyperactivity is associated with Cortese S et al (2014) Behavioral interventions in attention-def-
long-term economic burden: evidence from a longitudinal health icit/hyperactivity disorder: a meta-analysis of randomized con-
economic analysis of costs incurred across childhood, adolescence trolled trials across multiple outcome domains. J Am Acad Child
and young adulthood. J Child Psychol Psychiatry 56(9):966–975 Adolesc Psychiatry. 53(8):835–847
9. Frazier TW, Demaree HA, Youngstrom EA (2004) Meta-analysis 27. Boyer BE, Geurts HM, Prins PJ, Van der Oord S (2014) Two
of intellectual and neuropsychological test performance in atten- novel CBTs for adolescents with ADHD: the value of planning
tion-deficit/hyperactivity disorder. Neuropsychology. 18(3):543 skills. Eur Child Adolesc Psychiatry 24(9):1075–1090
10. Barkley RA (1997) Behavioral inhibition, sustained atten- 28. Evans SW, Timmins B, Sibley M, White LC, Serpell ZN, Schultz
tion, and executive functions: constructing a unifying theory of B (2006) Developing coordinated, multimodal, school-based
ADHD. Psychol Bull 121(1):65 treatment for young adolescents with ADHD. Educ Treat Child
11. Plichta MM, Scheres A (2014) Ventral–striatal responsiveness 29: 359–78
during reward anticipation in ADHD and its relation to trait 29. Kaufman J, Birmaher B, Brent D, Rao UMA, Flynn C, Moreci
impulsivity in the healthy population: a meta-analytic review of P et al (1997) Schedule for affective disorders and schizophrenia
the fMRI literature. Neurosci Biobehav Rev 38:125–134 for school-age children-present and lifetime version (K-SADS-
12. Sonuga-Barke EJ, Fairchild G (2012) Neuroeconomics of atten- PL): initial reliability and validity data. J Am Acad Child Ado-
tion-deficit/hyperactivity disorder: differential influences of lesc Psychiatry 36(7):980–988
medial, dorsal, and ventral prefrontal brain networks on subopti- 30. Bennett G. Miller, WR, Rollnick S (1991) Motivational inter-
mal decision making? Biol Psychiatry 72(2):126–133 viewing: preparing people to change addictive behavior. New
13. Deci EL, Ryan RM (2000) The “what” and“ why” of goal pur- York: Guilford Press, 1991. Pp. xvii+ 348.\pounds 24.95 hard-
suits: human needs and the self-determination of behavior. Psy- back,\pounds 11.50 paper. ISBN 0–89862–566–1 [Internet].
chol Inq 11(4):227–268 Wiley Online Library; 1992. Beschikbaar op: http://onlinelibrary.

13
 Eur Child Adolesc Psychiatry

wiley.com/doi/10.1002/casp.2450020410/abstract. geciteerd 28 47. Sibley MH, Graziano PA, Kuriyan AB, Coxe S, Pelham WE,
januari 2016 Rodriguez L et al (2016) Parent–teen behavior therapy+ moti-
31. Castleberry A (2014) NVivo 10 [software program]. Version 10. vational interviewing for adolescents with ADHD. Beschikbaar
QSR International; 2012. Am J Pharma Educ 78(1):25. http:// op: http://psycnet.apa.org/psycinfo/2016-18388-001/. geciteerd 4
doi.org/10.5688/ajpe78125 januari 2017
32. Braun V, Clarke V (2006) Using thematic analysis in psychology. 48. Slusarek M, Velling S, Bunk D, Eggers C (2001) Motivational
Qual Res Psychol 3(2):77–101 effects on inhibitory control in children with ADHD. J Am Acad
33. Tufford L, Newman P (2012) Bracketing in qualitative research. Child Adolesc Psychiatry 40(3):355–363
Qual Soc Work 11(1):80–96 49. Sonuga-Barke EJ, Dalen L, Remington B (2003) Do executive
34. Ma I, van Duijvenvoorde A, Scheres A (2016) Interaction deficits and delay aversion make independent contributions to
between reinforcement and inhibitory control in ADHD: a preschool attention-deficit/hyperactivity disorder symptoms? J
review and research guidelines. Clin Psychol Rev [Internet]. Am Acad Child Adolesc Psychiatry 42(11):1335–1342
Beschikbaar op: http://www.sciencedirect.com/science/article/ 50. Deci EL, Ryan RM (2008) Self-determination theory: a mac-
pii/S0272735816000027. geciteerd 14 maart 2016 rotheory of human motivation, development, and health. Can
35. Sonuga-Barke E, Bitsakou P, Thompson M (2010) Beyond the Psychol Can 49(3):182
dual pathway model: evidence for the dissociation of timing, 51. Vansteenkiste M, Niemiec CP, Soenens B (2010) The develop-
inhibitory, and delay-related impairments in attention-deficit/ ment of the five mini-theories of self-determination theory: an
hyperactivity disorder. J Am Acad Child Adolesc Psychiatry historical overview, emerging trends, and future directions. Adv
49(4):345–355 Motiv Achiev 16:105–166
36. Kerns KA, McInerney RJ, Wilde NJ (2001) Time reproduction, 52. Ryan RM, Deci EL (2000) Self-determination theory and the
working memory, and behavioral inhibition in children with facilitation of intrinsic motivation, social development, and well-
ADHD. Child Neuropsychol 7(1):21–31 being. Am Psychol 55(1):68
37. McInerney RJ, Kerns KA (2003) Time reproduction in chil- 53. Vallerand RJ, Pelletier LG, Blais MR, Briere NM, Senecal C,
dren with ADHD: motivation matters. Child Neuropsychol Vallieres EF (1992) The Academic Motivation Scale: a measure
9(2):91–108 of intrinsic, extrinsic, and amotivation in education. Educ Psy-
38. Dovis S, Van der Oord S, Wiers RW, Prins PJ (2015) Improv- chol Meas 52(4):1003–1017
ing executive functioning in children with ADHD: training mul- 54. Cloninger CR, Svrakic DM (1997) Integrative psychobiological
tiple executive functions within the context of a computer game. approach to psychiatric assessment and treatment. Psychiatry.
A randomized double-blind placebo controlled trial. PLoS One 60(2):120–141
10(4):e0121651 55. TEMPERAMENT APMO, CLONINGER’IN PMHVK (2003)
39. Shaw R, Grayson A, Lewis V (2005) Inhibition, ADHD, and Psychobiological model of temperament and character: TCI. In:
computer games: the inhibitory performance of children with Yeni Symposium [Internet], pp 86–97. Beschikbaar op: http://
ADHD on computerized tasks and games. J Atten Disord www.yenisempozyum.net/Pdf/EN-YeniSempozyum-91e271f5.
8(4):160–168 pdf. geciteerd 20 mei 2016
40. Mikami AY (2010) The importance of friendship for youth with 56. Melegari MG, Nanni V, Lucidi F, Russo PM, Donfrancesco R,
attention-deficit/hyperactivity disorder. Clin Child Fam Psychol Cloninger CR (2015) Temperamental and character profiles of
Rev 13(2):181–198 preschool children with ODD, ADHD, and anxiety disorders.
41. Blachman DR, Hinshaw SP (2002) Patterns of friendship among Compr Psychiatry 58:94–101
girls with and without attention-deficit/hyperactivity disorder. J 57. Donfrancesco R, Di Trani M, Porfirio MC, Giana G, Miano S,
Abnorm Child Psychol 30(6):625–640 Andriola E (2015) Might the temperament be a bias in clinical
42. de Boo GM, Prins PJ (2007) Social incompetence in children study on attention-deficit hyperactivity disorder (ADHD)?: nov-
with ADHD: possible moderators and mediators in social-skills elty seeking dimension as a core feature of ADHD. Psychiatry
training. Clin Psychol Rev 27(1):78–97 Res 227(2–3):333–338
43. Heiman T (2005) An examination of peer relationships of chil- 58. Demurie E, Roeyers H, Baeyens D, Sonuga-Barke E (2012) The
dren with and without attention deficit hyperactivity disorder. effects of monetary and social rewards on task performance in
Sch Psychol Int 26(3):330–339 children and adolescents: liking is not enough. Int J Methods
44. Deci EL, Koestner R, Ryan RM (1999) A meta-analytic review Psychiatr Res 21(4):301–310
of experiments examining the effects of extrinsic rewards on 59. Dai X, Brendl CM, Ariely D (2010) Wanting, liking, and prefer-
intrinsic motivation. Psychol Bull 125(6):627 ence construction. Emotion 10(3):324
45. Cerasoli CP, Nicklin JM, Ford MT (2014) Intrinsic motivation 60. Efron D, Bryson H, Lycett K, Sciberras E (2016) Children
and extrinsic incentives jointly predict performance: a 40-year referred for evaluation for ADHD: comorbidity profiles and
meta-analysis. Psychol Bull 140(4):980 characteristics associated with a positive diagnosis. Child Care
46. Boyer BE, Geurts HM, Prins PJ, Van der Oord S (2015) Two Health Dev [Internet]. Beschikbaar op: http://onlinelibrary.wiley.
novel CBTs for adolescents with ADHD: the value of planning com/doi/10.1111/cch.12364/full. geciteerd 15 juni 2016
skills. Eur Child Adolesc Psychiatry 24(9):1075–1090

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