ADHD Symptoms and the Daily Experience of Adolescents

Although it was once commonly believed that ADHD generally ended with the transition to adolescence, there is no longer any doubt that many children diagnosed with ADHD continue to have difficulties throughout adolescence. For some adolescents with ADHD, these difficulties are pervasive, and evident in academic, social, and occupational domains. They also may be apparent in substance use or abuse and other forms of illicit activity.

Despite this knowledge of the difficulties that many adolescents with ADHD experience, there is virtually no information currently available on the day-to-day experience of adolescents with ADHD. How, and with whom, do these youth spend their time? What are their typical mood states and do these differ from adolescents without ADHD? How frequently do they experience urges to engage in health-threatening behaviors like smoking and drinking?

Answers to such questions would provide us with a better appreciation for how adolescents with ADHD experience the world and could also assist in the development of more effective interventions to prevent the development of secondary emotional and behavioral difficulties that often accompany ADHD in teens. For these reasons, learning more about the daily experience of teens with ADHD is an important research task.

Recently, a fascinating study was published in Child Development in which the daily experience of adolescents with high levels of ADHD symptoms was explored (Whalen, C. et al., (2002). The ADHD spectrum and everyday life: Experience sampling of adolescent moods, activities, smoking, and drinking. 73, 209-227).

Participants in this study were 153 adolescents (average age 14.5) from predominantly middle-income, well-educated families. Approximately 60% of the sample was female. These participants were selected based on the results of a health behavior survey administered to all freshmen in three southern-California high schools. Efforts were made to include as many self-reported smokers as possible (the current investigation is part of a larger project on teen smoking) and to recruit non-smokers matched for gender and ethnicity. 67 of the participants were smokers, representing 43% of the self-reported smokers who had been invited to participate.

All participants completed a Teen Health Screening Survey that inquired about a variety of health-related behaviors including smoking, diet, sleep patterns, and seatbelt usage. Each adolescent and his or her parent(s) also completed an ADHD-symptom rating scale. This was used to identify adolescents with low, medium, and high levels of ADHD symptoms, based on their own report and those of their parents. Thus, no participant was formally diagnosed with ADHD and the data reported below was examined in relation to self- and parent-reported ADHD symptom levels.

The procedure used to gather information about the daily experience of participants is called Experience Sampling (ES), and is a clever and innovative method. Each adolescent was provided with a Palm III handheld computer on which a customized personal diary program was installed. For two four-day periods, an auditory signal was emitted every 30 minutes during the students' waking hours. When they heard the signal, students were instructed to stop what they were doing and take approximately one minute to complete a diary record for that 30-minute period. (They were of course instructed to ignore any signal that occurred during an incompatible activity such as bike riding, taking a test, etc.) The four-day ES periods were spaced six months apart.

The diary record that students completed contained 24 items to tap contexts, activities, and emotional reactions that are relevant to the daily lives of adolescents. For example, when the signal went off, they were asked to indicate where they were, what they were doing, and whether they had smoked cigarettes or consumed alcohol since the prior entry. They also were asked to rate the current intensity of various emotions, and to indicate whether they were experiencing an urge to smoke or eat. Answers to these items were keyed directly into the Palm Pilot and became part of the experience record for the adolescents.

Over the course of each Experience Sampling period, each participant completed multiple diary reports. In fact, the mean number of reports per student across the two periods was just over 171, with reports being made on about 80% of possible occasions. Thus, this is an enormously rich data set that provides a unique window into the lives of these students, and a terrific opportunity to learn how the daily experience of adolescents may vary in relation to their level of ADHD symptoms.

Results

Adolescents with ADHD symptoms ratings that fell in the lower third, middle third, and upper third of the distribution were placed into low-, middle-, and high-symptom groups, respectively. As noted above, this classification was based on both self and parent ratings. The correlation between these ratings -- although statistically significant -- was relatively modest. Thus, whether participants were assigned to the low-, middle-, or high-symptom group depended on which source was used to make the classifications, and the data was analyzed using both methods of classification.

Question 1: How Do The Daily Moods Of Adolescents Vary In Relation To Their Levels Of ADHD Symptoms?

When ADHD classification was based on adolescents' self-ratings, both the middle- and high-ADHD groups were between 1.5 and 2 times more likely than the low-symptom group to report feeling anxious, sad, angry, and stressed, and about half as likely to report feelings of happiness and well-being. They also were half as likely to report feeling alert.

When parent ratings were the basis of the classification, in contrast, there were no associations between ADHD-symptom levels and any of the mood items.

Question 2: How Do The Typical Social Contexts Of Adolescents Vary In Relation To Their Level Of ADHD Symptoms?

In examining social contexts, the researchers were interested in learning about the kinds of individuals with whom the adolescents were most likely to spend time (i.e. how frequently did they report being alone, with friends, with a boyfriend/girlfriend, by themselves, or in class or other organized activity.)

When teen ratings were used, the researchers found that those in the high-ADHD group were more likely than those in the low-symptom group to report spending time with friends or a boyfriend/girlfriend. They also were less likely to report spending time with their families. Results based on parent ratings were highly similar, although the researchers found no association between ADHD group and the likelihood of being with a boyfriend/girlfriend.

Question 3: How Do The Typical Activities Of Adolescents Vary In Relation To Their Level Of ADHD Symptoms?

For self-rated classifications, high-ADHD adolescents were about one-third more likely than their low-ADHD counterparts to be talking or engaged in other types of entertaining activities. Parent-rated, high-ADHD adolescents were only about one-third as likely as the low group to be reading or writing and were almost 1.5 times more likely to be engaged in entertaining activities.

Question 4: How Do Adolescents' Smoking And Drinking Behaviors, And The "urges" They Experience To Smoke And Drink, Vary In Relation To Their Level Of ADHD Symptoms?

When self-ratings were used for classification, robust group differences emerged in relation to these variables. Compared to those in the low group, adolescents in the high-ADHD group were 10 times more likely to have smoked, 8 times more likely to report an urge to smoke, and almost 4 times more likely to have consumed alcohol. Results based on parent classifications were essentially identical, as were results obtained for those in the "agreement" sample.

To place these results in the appropriate context, it is important to note that even among the high-ADHD group, the absolute level of smoking and drinking behavior reported was relatively low -- 2.3% of the time for drinking and 5.8% of the time for smoking. Of course, since these are illegal activities for adolescents, they are problematic at any level. Among adolescents in the low-ADHD group, these behaviors were reported for less than 1% of the diary entries.

Question 5: To What Extent Is The Association Between ADHD Symptom Levels And Daily Experience Modified By Gender?

In general, there was little consistent evidence that gender played a significant role in moderating the relationship between ADHD symptom levels and daily experience, although several noteworthy differences between males and females were reported. The association between anxiety and symptom level was only found among males, while the association between alertness and symptom level was restricted to females. Interestingly, although findings for smoking and alcohol consumption, as well as the urge to smoke, were significantly associated with symptom levels for both genders, the results were even more pronounced among girls.

Summary And Implications

These results provide an interesting window into the lives of teenagers with varying levels of ADHD symptoms. Among adolescents reporting high levels of ADHD symptoms, daily life was characterized by significantly more negative emotional experiences. They also experienced feelings of happiness and well being less often than their peers. Smoking and drinking were more frequent occurrences, as was the urge to smoke.

These findings are especially interesting in light of the fact that adolescents reporting high levels of ADHD symptoms also were spending more time with friends and engaged in entertaining activities with greater frequency. One would expect this would be associated with more frequent positive emotional states, but this was not the case. The fact that these teens also were spending less time with their families raises concerns about whether parents were able to monitor their whereabouts and activities as carefully as they would like to. This is an important concern because close monitoring and supervision is especially important for teenagers beginning to engage in antisocial activities. Additionally, a reduced level of parental monitoring is known to predict escalation in such behavior.

Findings for the relationship between ADHD-symptom level and mood were not evident when symptom level was based on parent ratings, and the reasons for this discrepancy are not clear. Because the more overt indicators of ADHD (e.g. excessive activity level) are less pronounced among adolescents -- an age range at which problems with inattention and feelings of restlessness are typically more prominent -- it is possible that parents are less aware of a child's ADHD symptoms at this age. If so, then parent ratings of ADHD symptoms among adolescents may underestimate the difficulties the youth are experiencing. This would partially explain why associations between parent-rated ADHD symptoms and negative-mood states were not found. It is also possible that adolescents who reported high levels of ADHD symptoms are youngsters who are simply more troubled in a variety of areas, and this explains why the associations between teen-reported ADHD symptoms and more frequent negative emotional states were found.

Regardless of the reason for the different pattern of associations between ADHD symptoms and emotional states for parent and teen ratings, there seems to be a subgroup of emotionally reactive adolescents who see themselves as having problems with attention, impulsivity, and hyperactivity, but who are not viewed by their parents as having these difficulties. This points to the importance of attending to the emotional well-being of adolescents who experience problems related to ADHD, and the need for a thorough assessment of emotional functioning to be part of ADHD evaluations.

This study represents a first step towards understanding the differences in everyday feelings and activities between adolescents with ADHD characteristics and their peers. A follow-up study that compared adolescents with and without the formal diagnosis of ADHD -- rather than simply comparing adolescents with different symptom levels as was done in the current study -- would be an important next step. Such a study could shed additional light on how the daily experiences of teens with ADHD contribute to many of the negative outcomes these youth experience, and how such outcomes could be prevented.

The important message from the current study, however, is that many adolescents with high levels of ADHD symptoms are moving along a non-optimal developmental trajectory, even though they might not qualify for a formal diagnosis. Helping these teens move to a healthier developmental path may require efforts in multiple domains, including enhancing emotion regulation, improving family relations, and helping them refrain from smoking and drinking. Information obtained in studies such as this can be critically important to those efforts, and one hopes the authors will continue this important line of work.

Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.

Reproduced with permission of David Rabiner, Ph.D. - HelpforADD.com