Dissecting daily distress in mothers of children with ADHD: an electronic diary study.

It is well known that parents of children with attention-deficit/hyperactivity disorder (ADHD) experience elevated levels of caregiver stress, but little is known about the ebb and flow of parental distress as it happens, or the degree of synchrony between short-term oscillations in child behaviors and maternal distress. Electronic diaries (eDiaries) were used to dissect daily distress in natural settings. Across 7 days during nonschool hours, half-hourly eDiaries were completed independently by mothers and their 8- to 12-year-old children (51 receiving medication for ADHD and 58 comparison peers). Diary items tapped behaviors, moods, and contexts, with children reporting their own behaviors and mothers reporting on themselves and their children. Maternal distress and child ADHD-type behaviors exhibited moderate to strong associations "in the moment," whether child behaviors were reported by mothers or children. This mother-child synchrony emerged for the comparison as well as the ADHD group, although the associations were stronger when the dyad included a child with ADHD. Because fixed-effects analyses were conducted, these patterns are not attributable to levels of psychopathology or other stable individual differences in mothers or children. Further moderation analyses revealed that the links between child behaviors and maternal distress were strengthened by maternal risk and attenuated by child behavioral self-esteem; these effects were modest but detectable. These findings can help guide not only interventions targeted on improving quality of life in families of children with ADHD, but also programs designed to help all parents identify and manage their own parenting stressors.

Atomoxetine versus stimulants in the community treatment of children with ADHD: an electronic diary study.

OBJECTIVE: To compare the morning and afternoon/evening functioning of children with ADHD treated in the community with either atomoxetine or long-acting stimulants and reported to be doing well. METHOD: 109 8- to 12-year-olds and their mothers participated in one of three groups: stimulants (STIM, N = 26), atomoxetine (ATMX, N = 25), or comparison (COMP, N = 58). Mothers completed morning and evening electronic diaries installed on personal digital assistants throughout an entire week, rating the child's behaviors and moods as well as their own moods and perceptions. RESULTS: There was no evidence that ongoing pharmacotherapy fully normalized the behaviors of children with ADHD: Mothers in both ADHD groups reported higher rates of child inattention, hyperactivity/impulsivity, oppositionality, and negative affect and lower levels of parenting efficacy and positive affect than did COMP mothers. Although the behavioral profiles were generally comparable for the STIM and ATMX groups, there were indications of better functioning in the ATMX group during mornings only. CONCLUSION: Children treated in the community with either STIM or ATMX appear to have similar behavioral profiles, suggesting that medication decisions be guided by other factors such as comorbid disorders, child and parent preferences, and effects on nontargeted behaviors and moods.

ADHD and anger contexts: electronic diary mood reports from mothers and children.

OBJECTIVE: Using electronic diaries (eDiaries), this study examined temporal links between child and maternal anger, as well as positive mood and perceived stress, in children with attention-deficit/hyperactivity disorder (ADHD) versus comparison peers. METHODS: Across 7 days, half-hourly eDiaries were completed independently by mothers and their 8-12-year-old children (51 receiving medication for ADHD and 58 comparison peers). RESULTS: Cross-informant analyses revealed systematic patterns of negative maternal moods in relation to child anger in both groups along with evidence of slower recovery in the ADHD group. Analogously, for both groups, children's anger reports increased and good-mood reports decreased in relation to maternal anger, whereas elevated stress in relation to maternal anger was restricted to children with ADHD. CONCLUSIONS: The findings indicate that a negative affective climate is more likely to persist in ADHD than in comparison families. They also affirm the utility of child as well as parent eDiary reports and suggest that children may be willing to report low positive mood when reluctant to report negative mood. The promise of incorporating real-time data on mood patterning into tailored treatments for children with ADHD and their families is discussed.

Toward mapping daily challenges of living with ADHD: maternal and child perspectives using electronic diaries.

Attention-deficit/hyperactivity disorder (ADHD) has an impact on the family as well as the affected child. This study developed and tested an electronic diary for mapping the challenges of everyday family life in a sample of children with ADHD being treated with pharmacotherapy. Across 7 days, mothers and children (27 ADHD; 25 non-ADHD) independently reported their moods, behaviors, and social contexts every 30 min during nonschool hours. Symptomatic behaviors and negative moods were elevated in the ADHD group, combined with maternal perceptions of lower parenting effectiveness and quality of life. Differences in the contexts of maternal anger were salient, with mothers in the ADHD group more often angry when with their children and comparison mothers more often angry when not. Although mothers' diaries were more informative, children's diaries also distinguished the two groups, especially during mornings and weekends. The need for family-wide interventions, the utility of child self-reports, and the promise of electronic diaries are discussed.

An electronic diary study of contextual triggers and ADHD: get ready, get set, get mad.

OBJECTIVE: This study was designed to examine context effects or provocation ecologies in the daily lives of children with ADHD. METHOD: Across 7 days, mothers and children (27 children with attention-deficit/hyperactivity disorder [ADHD] taking stimulant medication; 25 children without ADHD; ages 7-12 years) provided electronic diary reports every 30 +/- 5 minutes during non-school hours. Child and maternal perceptions of behaviors, moods, and interaction quality during preparatory and transitional ("getting ready") activities were compared with those during other activities. RESULTS: Maternal reports revealed that child symptomatic behaviors and negative moods, maternal negative moods, and parent-child disagreement were elevated in the ADHD but not in the comparison group while getting ready versus other activities. Children's self-ratings also revealed situational effects, indicating that school-age children with ADHD can give meaningful self-reports using carefully structured electronic diaries. CONCLUSIONS: Even when children with ADHD are receiving stimulant pharmacotherapy, the preparatory tasks of daily living are especially challenging and linked disproportionately to child behavior problems, parent negative affect, and contentious interactions. Treatment targeted on these transitional hurdles may improve child behavior patterns and enhance parent-child relationships and family harmony.

Using ecologic momentary assessment to measure physical activity during adolescence.

OBJECTIVE: Examine the validity of using high-density electronic ecologic momentary assessment (EMA) to assess physical activity. EMA was further used to explore within- and between-subject variability in adolescent physical activity (PA) patterns. METHODS: Adolescents (n=526, 51% male) participated in EMA waves occurring approximately every 6 months between the 9th and 12th grade. Each wave extended over 4 consecutive days (Thursday to Sunday). Using a Palm III handheld computer, each participant reported his or her primary activity (e.g., exercise, walking, homework) every 30 (+/-10) minutes during waking hours. Heart rate (via Polar heart rate monitor) and activity counts (via wrist accelerometer) were simultaneously assessed during the EMA intervals. RESULTS: Overall, heart rates and accelerometer counts were greater for diary-reported exercise and walking than for nonphysical activities (p's<0.001). EMA revealed that the typical duration of exercise sessions was longer than walking sessions (p<0.05). Rates of walking and exercise were more consistent between waves (i.e., across high school) than within waves (i.e., across the 4 days of monitoring), most likely due to the significantly higher rates of walking and exercise occurring on weekdays as compared to weekend days (p's<0.001). Average rates of walking were greater for girls than boys, and the reverse was true for exercise. Rates of both walking and exercise declined steadily between 9th and 12th grade (p's<0.001). CONCLUSIONS: Physical activity reported via EMA corresponded to objective activity indicators. EMA yielded information about within-person variability in PA that cannot be obtained readily from traditional self-report instruments. Given its potential for simultaneously assessing important physiologic, psychological, and contextual factors, EMA presents a promising approach to studying adolescent physical activity.

Adolescents react to the events of September 11, 2001: focused versus ambient impact.

This study examined the perceived impact of the events of September 11, 2001, on adolescents distant from the disaster sites and compared these perceptions with changes in everyday moods. A survey of reactions to September 11 was completed 2-5 months after the events by 171 adolescents participating in a longitudinal study of stress and health. Electronic diary ratings of contemporaneous moods before and after the attacks were also compared. Many adolescents distant from the disaster sites reported changes in everyday activities and signs of distress along with some positive outcomes. Elevated levels of negative affect emerged when adolescents were asked directly about the event (focused impact), but no changes were detected in their ongoing, momentary mood reports before and after September 11 (ambient impact). Trait and electronic diary measures of anxiety independently predicted posttraumatic distress. Refined assessments are needed to evaluate the degree to which self-reported traumatic symptoms reflect significant clinical distress versus an attentional focus generated by the question-asking process.

Is there a link between adolescent cigarette smoking and pharmacotherapy for ADHD?

There is continuing concern that pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) may raise the risk of smoking (the gateway hypothesis). Alternatively, unmedicated people with ADHD may use nicotine to improve attentional and self-regulatory competence (the self-medication hypothesis). From a community sample of 511 adolescents participating in a longitudinal health study, 27 were identified as having ADHD, and 11 of these were receiving pharmacotherapy. Self-report surveys, electronic diaries, and salivary cotinine all indicated that adolescents treated with pharmacotherapy for ADHD smoked less than their untreated counterparts over 2 years of high school. These convergent findings from 3 disparate indicators lend support to the self-medication hypothesis over the gateway hypothesis, although alternative explanations need further study. The findings also suggest that early treatment of psychological and behavioral problems may prevent or delay smoking initiation.

Anxiety, affect, and activity in teenagers: monitoring daily life with electronic diaries.

OBJECTIVE: The everyday experiences of a community sample of adolescents differing in anxiety level were compared by means of electronic diaries. METHOD: One hundred fifty-five ninth-grade adolescents completed electronic diaries every 30 minutes for two 4-day intervals, reporting their moods, activities, social settings, dietary intake, smoking, and alcohol use. Teenagers were stratified into low-, middle-, or high-anxiety groups on the basis of diary ratings and, separately, questionnaire scores. RESULTS: High-anxiety teenagers, compared with low-anxiety teenagers, expressed higher levels not only of anxiety and stress but also of anger, sadness, and fatigue, along with lower levels of happiness and well-being. They reported fewer conversations and less recreational activity relative to achievement-oriented pursuits, stronger eating and smoking urges, and more tobacco use. There were few gender differences. Despite a tendency to spend less time with peers, high-anxiety teenagers were more likely to show reduced anxiety when in the company of friends. Sharper differentiations among anxiety subgroups emerged when stratification was based on diary reports rather than on questionnaire scores. CONCLUSION: Even when anxiety problems fall below diagnostic thresholds, the daily lives of anxious adolescents differ meaningfully from those of their peers in affective, behavioral, and contextual domains.

The ADHD spectrum and everyday life: experience sampling of adolescent moods, activities, smoking, and drinking.

Using an experience sampling methodology, the everyday lives of 153 adolescents with low, middle, or high levels of attention-deficit/hyperactivity disorder (ADHD) characteristics as assessed by either parent or teen were examined. Twice each hour, across two 4-day recording intervals, participants in a longitudinal study of stress and health risks logged their behaviors, moods, and social contexts. Those with high, in contrast to low, ADHD symptom levels recorded more negative and fewer positive moods, lower alertness, more entertaining activities relative to achievement-oriented pursuits, more time with friends and less time with family, and more tobacco and alcohol use. Fewer associations emerged with parent-defined than with teen-defined subgroups, although the differences in alertness, peer and family contexts, entertainment versus achievement activities, and substance use were consistent across sources. Even at subclinical levels, ADHD characteristics were associated with behavioral patterns and contexts that may promote peer deviancy training, unhealthy lifestyle behaviors, and vulnerability to nicotine dependence.

Messages of medication: effects of actual versus informed medication status on hyperactive boys' expectancies and self-evaluations.

After 15 boys with attention-deficit hyperactivity disorder (ADHD) were informed that they had taken either medication or placebo, they completed computer tasks, self-assessments, and causal judgments. The boys predicted better performance when told they were on medication versus placebo. For self-evaluations, medication status and information interacted, with boys actually taking placebo rating themselves more positively when told they had taken medication versus placebo. These effects were more apparent following failure than success. Both ADHD and comparison boys overestimated future classroom performance, with the former more unrealistic. Discussion focused on difficulties in assessing children's causal reasoning and the need to monitor emanative effects of pharmacotherapy on self-cognitions.

Therapies for hyperactive children: comparisons, combinations, and compromises.

Comparative treatment studies of attention-deficit hyperactivity disorder (ADHD) are impeded by methodological quandaries, constricted focus, and the heterogeneity of ADHD children, research designs, measures, and treatment responsiveness. Comparisons are drawn among three major treatment modalities for ADHD: stimulant treatments, primarily methylphenidate; behavioral treatments, including contingency management and parent training; and cognitive-behavioral or self-regulation therapies. We identify a dozen "...abilities," such as communicability, controllability, and constrainability, that compel consideration and that convert either-or questions about the single best treatment into more comprehensive assessment and intervention strategies. The profusion of problems called ADHD mandates multimodal approaches not only to optimize therapeutic impact but also to inform theories of developmental psychopathology and therapeutic change.

Aggressive, prosocial, and nonsocial behavior in hyperactive boys: dose effects of methylphenidate in naturalistic settings.

Given the importance of interpersonal interactions for hyperactive children, we evaluated the impact of methylphenidate on specific categories of social behavior in 25 boys, aged 6-12, with attention deficit-hyperactivity disorder (ADHD). These children participated in a 3-week, double-blind, crossover trial with placebo and low (0.3 mg/kg) and moderate (0.6 mg/kg) dosages of methylphenidate during a naturalistic summer research program. Fifteen comparison boys, without problems in attention and behavior, were also observed. In addition to decreasing noncompliance, methylphenidate reduced a combined category of physical and verbal aggression for the ADHD boys, with a significant linear trend across dosages. The medication decreased aggression to levels comparable with those of the comparison boys. There were no medication effects on the frequency of nonsocial or prosocial behaviors. Results are discussed in light of the need to effect durable change in both the quantity and quality of social behavior for hyperactive children.