Although children with ADHD and their families confront daily challenges across many different tasks and circumstances, even a child's most challenging behaviors tend to wax and wane.  And, even though many parents of children with ADHD can readily identify specific high-risk "triggers" for problematic behavior, there has been little research designed to identify specific situational or temporal contexts in which the behavioral symptoms of ADHD are most likely to be exacerbated.  This is a limitation in the literature, as documenting these "triggering" circumstances could help to better identify important intervention targets.

To a certain extent, efforts to identify particularly difficult contexts for children with ADHD at school have been conducted.  Situations that are particularly challenging for many children with ADHD have been found to be those in which task difficulty is high, ambient noise levels are high, peer cooperation is required, teachers are not readily available, and children are expected to modulate their behaviors in response to shifting circumstances or social demands.  These situations have been identified through the use of classroom observers who are able to code the behavior of children with and without ADHD in different circumstances across the school day.

Until recently, obtaining a similar understanding of how the problems of children with ADHD and their families wax and wane at home has not been possible, as placing observers in the homes of many families is not a feasible research task.  Recently, however, the advent of Personal Digital Assistants (e.g., PDAs such as Palm Pilots) has enabled researchers to obtain a more detailed and fine-grained view of how children with ADHD and their parents experience their day-to-day lives. 

The manner in which PDAs are used to learn about individuals' daily experience is really quite clever.  The devices are programmed to beep at random intervals throughout the day, and study participants are trained to complete an electronic diary record of their activities, mood, and context each time they are prompted by a beep.  This enables researchers to obtain a previously unavailable record of the daily experiences of children with and without ADHD and their families, and how this may differ from how children without ADHD and their families experience their daily lives.

In a prior study using this technology that was summarized in a recent issue of Attention Research Update it was found that children with ADHD - even though their symptoms were reportedly being managed well by medication - displayed higher rates of symptomatic behaviors, including restlessness, excessive talk and loudness, impatience, and difficulty concentrating. Mothers of children with ADHD experienced more anger when with their children, and were also more likely to report feeling ineffective as a parent and that their child was limiting their activities.

In a follow up to this intriguing study that was published recently in the Journal of the American Academy of Child and Adolescent Psychiatry (Whalen et al 2006. An electronic diary study of contextual triggers and ADHD: Get ready, get set, get mad. JAACAP, 45, 166-174) the authors dug deeper into their data to learn how particular contexts may be particularly challenging for children with ADHD and their moms.  The context they were most interested in is one aspect of daily living that has surfaced repeatedly in anecdotal reports as especially challenging, i.e., "getting ready", which the authors define as preparing for an upcoming activity or making the transition from one task to the next.
 

- Participants -

Participants were 27 children with ADHD (average age 10.5 years, 18 boys, 9 girls) and their moms as well as 25 children without ADHD (average age 10.5 years, 15 boys, 10 girls) and their moms.  Unfortunately, a sufficient number of fathers could not be recruited to participate, which the authors recognize as a limitation of their study.

All children in the ADHD group were being treated with a long acting stimulant - either Concerta or Adderall XR - at the time of the study and parents reported that the response to medication had been positive.  Children in the comparison group had no known learning or behavioral problems.  Because the authors were interested in examining mother-child relationship issues, enrollment was limited to mother-child dyads together for at least 4 hours each day.

To learn about participants' day to day experience, electronic diary monitoring using Personal Digital Assistants - PDAs - was scheduled across 7 consecutive days during nonschool hours.  The PDAs were programmed to beep at random intervals approximately every 30 minutes to signal that it was time to complete a diary checklist.  Both mothers and children had their own PDA, which were programmed to beep at different times, and each completed their own electronic diary.  The PDAs were programmed to beep when mothers and children were likely to be together - before school, after school, and on weekends.  Before starting in the study, parents were interviewed about upcoming activities for the week so that the PDAs could be programmed to avoid beeping during times that would be particularly disruptive.

The diary items were selected to "...tap contexts, behaviors, and moods that are relevant to the daily lives of parents and school age children, to capture the quality of their interactions, and to include dimensions that often prove problematic for children with ADHD.

Each time the PDA beeped, participants used the PDA to identify their location, social context, i.e., by themselves, with each other, with peers, and their current activity.  Then, mother and child rated the child's symptomatic behaviors (e.g., impatient, restless), and moods (.e.g., angry, good mood).  Mothers also rated their own moods.  Each also rated the difficulty of the activity they were currently engaged in and evaluated their ability to do it successfully.  These ratings were all made by checking boxes that reflected different options for each question, and could thus be completed quickly and easily. Mothers and children were each paid $100 for successfully completing the study.

Despite the frequent recording demands, moms and children did a good job of completing the diary entries.  Mothers received an average of 91 signals to complete a diary entry during the 7-day period while children received an average of 95 signals.  Completion rates were approximately 90% for mothers and children, and did not differ between the ADHD and comparison group.  Thus, even though some children in the study were as young as 8, the use of a PDA to learn about children's ongoing experience appears to be a very viable research method.

Because moms and children recorded the current activity/context each time they were beeped, the researchers could later examine whether consistent differences in behavior, mood, and quality of interaction emerged across different contexts.  As noted above, they were particulalry interested in how the experience of mothers and children during "getting ready" times compared to other contexts in which they interacted, e.g., meals, homework chores, watching tv, etc.  Seventy-five percent of these "getting ready" activities involved getting children ready to go to school in the mornings, which may have been before children's medication had reached peak effectiveness.


- Results -

Group differences were apparent in moms' reports of their children's behavior and moods while getting ready.  Specifically, relative to mothers of comparison children, mothers of children with ADHD reported higher rates of impatience, anger or frustration, and sadness or discouragement in their children when having to "get ready".  Their reports also revealed that children with ADHD were less likely during these times than their peers to be concentrating or in a good mood, or more likely to be talking too much and too loudly.

In terms of moms' own experience during times of getting their child ready, mothers of children with ADHD were more than 7 times more likely than comparison moms to report feeling angry, and did so on over 26% of diary entries completed during a "getting ready" activity.  Interestingly, during other types of activities, moms of children with ADHD were not more likely than other moms to report feelings of anger.  For example, during activities besides getting ready, the reported rates of anger/frustration were similar for moms in both groups, e.g., 12.9% of the time for moms of children with ADHD vs. 11.8% of the time for other moms.

The quality of mother-child interaction during "getting ready" times was also characterized by significant differences.  While getting their children ready, moms of children with ADHD reported 5 times as likely to report disagreements and the frequency of disagreements was much higher during getting ready times than during other activities.  Consistent with their mothers' report, children with ADHD were more than 4 times more likely than peers to report disagreeing or arguing with their moms while getting ready. Although they were also more likely to report arguing during other activities, the difference was most pronounced during the getting ready context.

In addition to the differences between groups summarized above, it is also interesting to note differences within groups that were evident during "getting ready" vs. other activities.  For comparison moms, there were essentially no differences in the mood they reported during "getting ready" times relative to other activities.  Thus, regardless of whether they were getting their child ready for school, or engaged in various other activities, they reported experiencing anger, stress, sadness, and happiness at similar rates.

For moms of children with ADHD, the situation was quite different.  Thus, even though other activities included such typically challenging ones as getting homework and chores done, during getting ready times they were still significantly more likely to be angry (26.9% of the time when getting ready vs. 12.9% of the time during other activities), and stressed (44.7% vs. 22.4%), and less likely to be in a good mood (46.5% vs. 70.4%). As noted above, they were also more likely to report being in an active disgreement/argument with their child.

Reports provided by the children themselves also indicated that negative moods were more likely to be experienced during getting ready times than during other times.  Interestingly, however, this was true for both children with ADHD as well as for comparison children.


- Summary and Implications -

Results from this study document that getting ready activities pose special challenges for children with ADHD and their families.  During these times, their mothers are far more likely than other mothers to feel angry and stressed, less likely to be in a good mood, and more likely to be engaged with their child in an active argument/disagreement.  Even though parenting a child with ADHD can present challenges in a wide variety of contexts, it appeared the context of "getting ready" is one where mothers are most likely to experience difficulty. 

In interpreting these findings, several things are important to consider.  First, it should be kept in mind that the "other activities" category included not only leisure times such as games or watching tv, but also notoriously difficult circumstances such as homework and chores.  The fact that getting ready times were still more difficult more moms of children with ADHD suggests that it may be the sense of time urgency that characterizes these times that may create special difficulty.

It is also possible that because getting ready for school constituted about 75% of getting ready activities in the study, and this obviously occurs in the morning, children's medication may not have yet reached peak effectiveness.  Thus, it would be interesting to know whether this may have contributed to the special challenges posed by getting ready. 

Even if this were the case, however, it is well known that stimulant treatment frequently falls far short of normalizing behavior and that medication effectiveness can also wax and wane during the day. Thus, the important point is that "...even when children with ADHD receive a standard regimen of stimulant pharmacotherapy, situational and temporal factors play a critical role in their social adjustment and family harmony."

The value of this interesting work is that it provides new information on the daily lived experience of children with ADHD and their families, and clearly documents that the challenges experienced by moms of children with ADHD are tied to particular tasks during the course of a typical day.  One implication of these findings suggested by the authors is that as is often done in the medical treatment of asthma, parents and children could be taught to recognize their own situational triggers, and learn specific ways to anticipate these triggers and take preventive action. 

Thus, rather than providing a set of parenting strategies to be employed across a range of circumstances, families would work together to hone in on those particularly challenging contexts, and develop plans to short-circuit these problems from occurring.  This, of course, is something that experienced clinicians often already do, and this study highlights the potential value of taking such a context specific approach.