How do children with ADHD make sense of their problematic behavior? Do they feel in control of how they behave or believe that their behavior is often out of their control? How bothersome do they believe their problematic behavior is to parents, teachers, and peers? These are interesting and important questions about which relatively little is currently known.
Answers to questions like these would enhance our understanding of how children with ADHD experience themselves and their disorder, and may assist in the development of effective interventions. Although little research has been conducted in these areas, a recent study published in the Journal of Attention Disorders provides interesting preliminary information on these questions [Kaider, et al. (2003). The attributions of children with ADHD for their problem behaviors, 6, 99-109).
Participants were 32 7-12 year old children - 16 with a confirmed diagnosis of ADHD and 16 non-diagnosed children who served as comparison subjects. Across the two groups, there were 19 boys and 13 girls. Because the number of participants is relatively small, the results reported below should be considered preliminary and would benefit from replication with a larger sample.
Participants were shown a series of pictures that depicted a same-gender child engaging in behaviors that are characteristic of ADHD. The behaviors depicted examples of attention problems, hyperactivity, and impulsivity. After viewing the pictures, children were asked to identify the behavior they believed was most problematic behavior for them. Because many of the children were receiving medication at the time of the study, they were told to consider how they behaved when not on medication.
After each child's identified his or her primary behavior problem, they were asked a series of questions to assess their understanding for why they engaged in that behavior. These questions were intended to tap the child's beliefs about the following:
1) Is the behavior under my control?
2) Is the behavior stable - i.e., likely to continue?
3) How pervasive is the behavior - i.e., does it occur all the time, only some of the time, or very rarely?
4) How does this behavior affect parents/teachers/peers - i.e. to what extent are they bothered by this behavior?
Children with and without ADHD did not differ in the behaviors they chose as their most problematic. The most frequently endorsed behaviors by children with ADHD were losing things, being easily distracted, fidgeting and squirming, and talking too much. The behaviors identified as most problematic for children without ADHD were similar. It would have been interesting to see how child and parent ratings of the child's most problematic behavior compared, but this was not examined.
Children with ADHD reported that they were less able to control their most problematic behavior than children without ADHD. Children with ADHD also perceived their problematic behavior as being more stable and were more likely to believe that it would persist in the future. They were also more likely than children to report that their behavior occurred almost all the time.
When asked about how parents, peers, and teachers felt about their behavior, an interesting difference was found between boys and girls. Boys with and without ADHD did not differ in the likelihood of reporting that others were bothered by their most problematic behavior. Within both groups, boys were more likely to believe that parents and teachers were bothered by their behavior than peers. For example, very few boys with ADHD believed that parents and teachers were never bothered by their behavior but a large percentage reported that their peers were never bothered.
Among girls, there was a clear difference in the reports of children with and without ADHD. None of the girls without ADHD believed that parents and teachers were never bothered by their behavior, and very few believed that peers were never bothered. Among girls with ADHD, however, 4 out of 6 believed that parents and teachers were never bothered by their behavior and 6 of 6 reported that peers were never bothered.
SUMMARY AND IMPLICATIONS
Results from this study suggest that children with ADHD view their most problematic behavior as less within their control, more stable, and more pervasive across situations than children without ADHD. Given what we know about ADHD - i.e., that it is characterized by difficulties with behavioral control that tend to be stable over time and across settings - this finding is not surprising and suggests that children in this study were accurate in how they perceived their own behavior.
Although accurate self-perceptions are generally construed to be a good thing, the authors point out that children who view their behavior as beyond their control, stable in time, and pervasive across situations are more likely to feel that change is hopeless. One can imagine how this could lead to a negative self-concept and feelings of distress, both of which could contribute to the development of depression. It is important to note, however, that feeling hopeless about change was not directly examined in this study, and the authors' hypothesis would need to be tested in subsequent research.
A surprising result is that children with ADHD were no more likely than other children to feel that parents, teachers, and peers were bothered by their behavior. In fact, girls with ADHD were less likely than other girls to feel this way. Because the problematic behavior of children with ADHD is generally more intense and pervasive than the problematic behavior of other children, it is likely that it is also more aversive to others. Thus, this result suggests that children with ADHD may not be fully aware of the impact their behavior has on others.
What are the implications of children with ADHD believing that their problematic behavior is often beyond their ability to control but not especially bothersome to others? One possibility is that this combination of beliefs would reduce the motivation that children have to work on changing their behavior - i.e., if I can't control it and it does not bother others, why bother?
This suggests several areas that may be helpful to attend to in efforts to assist children with ADHD. First, it may be important to make sure that a belief about having little control over behaviors that reflect core ADHD symptoms (e.g. difficulty attending, blurting out answers) that truly are difficult for children with ADHD to control does not generalize to a more pervasive belief about having little control over one's behavior. Children may benefit from discussions that help them understand and differentiate between behaviors that will be easier and more difficult from them to control.
In addition, children could benefit from learning strategies to help them feel more in charge of behaviors that are difficult for them to control. For example, a child who frequently loses things and feels unable to control this could be taught ways to help organize and keep track of their belongings. An older child who often forgets things could be taught how to use lists to keep track of what needs to be done. Although such efforts may not completely solve the problems associated with core symptoms of ADHD, they could help children feel more in charge of areas that are difficult for them.
It may also be helpful to assess the degree to which children are aware that their behavior is bothersome to others. If a child is oblivious to how others are affected by his/her behavior, helping the child develop a more realistic understanding of this could be an important step in enlisting the child's cooperation with efforts to change. Of course, this would need to be done in a sensitive and careful manner so that children do not come to feel that they are always bothering people.
In summary, results from this study provide interesting new insights into how many children with ADHD may perceive and understand their own actions. As always, it is important to recognize that the patterns identified in this study would not apply to all children with ADHD and that individual assessment of such issues is required. It is also important to note that this was an initial study of these issues in which a relatively small number of children participated. Thus, the results obtained should be regarded as tentative and the issues raised clearly require additional investigation.
With these important caveats in mind, however, these findings can serve as useful guides for issues that parents, teachers, and professionals should consider in efforts to assist children with ADHD.