Adolescents with ADHD

ABSTRACT

Adolescents with ADHD engage in more risk-taking behaviour than adolescents without ADHD. Mind-wandering is an underlying process of ADHD and a potential underlying process of risk-taking behaviour in ADHD. The aim of this study was to test if mind-wandering predicted risk-taking behaviour above and beyond ADHD symptoms. 315 adolescents (age: M = 17.2, range = 16 – 22) participated in this study, and filled in a questionnaire about mind-wandering, ADHD symptoms, and risk-taking behaviour. The results show that ADHD symptoms predict risk-taking behaviour, and a combination of ADHD symptoms and mind-wandering predict risk-taking behaviour.

However, mind-wandering does not predict risk-taking behaviour above and beyond ADHD symptoms. These findings suggest that mind-wandering is not the underlying process of risk-taking behaviour in ADHD. In clinical practice, there should be a focus on risk-taking behaviour in ADHD. Further research should focus on the different characteristics of ADHD as a predictor for risk-taking behaviour.

Introduction

Attention Deficit and Hyperactivity Disorder (ADHD) is a well-known mental disorder and represents a concern for mental health (Kupfer, 2000). In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ADHD is presented as a neurobiological developmental disorder. This disorder is characterised by a persistent pattern of inattention, hyperactivity, and impulsivity, significantly obstructing daily functioning and development (American Psychiatric Association, 2013). Besides these general ADHD symptoms, it is widely acknowledged that other problems, such as risk-taking behaviour, can be associated with ADHD (Mohr-Jensen & Steinhausen, 2016).

Different types of risk-taking behaviour are more commonly seen among individuals with ADHD than those without. In daily life, for example, they engage more frequently in risky sexual behaviour (Flory, Molina, Pelham, Gnagy, & Smith, 2010), substance abuse (Steve S. Lee, Humphreys, Flory, Liu, & Glass, 2011), and gambling (Dai, Harrow, Song, Rucklidge, & Grace, 2016), and commit offenses more often than people without ADHD (Mohr-Jensen & Steinhausen, 2016). These aforementioned types of risk-taking behaviour can have effects on various levels, both societal and individual.

The effects of risk-taking behaviour, occurring at both the societal and individual levels, are predominantly destructive. For instance, individuals who engage in this behaviour are more likely to be involved in car accidents (Jonah, 1986). Additionally, the leading cause of death among adolescents is risk-taking behaviour (Dahl, 2004). Both car accidents and higher death rates result in increased healthcare costs and can greatly impact the individual and their family (Harpin, 2005). An individual with ADHD incurs higher healthcare costs (Hakkaart-van Roijen et al., 2007), and is more often expelled from school or dismissed from their job (Harpin, 2005). All these effects can be triggered by risk-taking behaviour (Dahl, 2004). Sadly, the reason why individuals with ADHD engage in more risk-taking behaviour than those without is not clear. However, one possible explanation could be the chronic low arousal experienced by individuals with ADHD, potentially associated with risk-taking behaviour. When an individual experiences chronic low arousal, they commonly have problems with attention control (Matthies, Philipsen, & Svaldi, 2012). This issue may be related to an underlying mental process of ADHD.
Mind-wandering is associated with functional problems and is linked to psychopathologies like ADHD (Franklin et al., 2014). In addition, mind-wandering is an evident underlying mental process of ADHD (Mowlem et al., 2016). The thoughts of people in the general population are unrelated to their environment or current activities 24 to 50 percent of the time (Kane et al., 2016; Killingsworth & Gilbert, 2010). When these unrelated thoughts are deliberate, there is no problem. However, the problem arises when the mind-wandering is spontaneous (Smallwood & Schooler, 2015). Mowlem et al. (2016) studied the prediction of risk-taking behaviour through mind-wandering. 108 participants filled in self-report questionnaires, concerning ADHD symptoms, mind-wandering, and impairment. Risk-taking behaviour was covered in a part of the impairment questionnaire. They found that mind-wandering is an independent predictor for risk-taking behaviour. Mind-wandering may be the underlying process which links risk-taking behaviour and ADHD.

Mind-wandering can cause difficulties for someone to focus on a relevant task or event, which can make it more difficult to ensure good performance. Because someone’s thoughts are constantly ‘on the go’, it can be difficult to think through and plan activities. When this happens, possible risks may be overlooked. Furthermore, it is possible that people who engage in a lot of mind-wandering due to chronically low arousal seek distraction to reduce this problem. Risk-taking behaviour can be seen as highly salient activities, which result in an increase of arousal. When the arousal is experienced, the excessive mind-wandering will reduce, leading to a sense of relief (Mowlem et al., 2016). Although Mowlem et al. (2016) show that mind-wandering can predict risk-taking behaviour, there needs to be more evidence to show to what extent mind-wandering can predict risk-taking behaviour.

In this study, we investigate whether mind-wandering can predict risk-taking behaviour beyond ADHD symptoms. Most research on this topic focuses on adults (Franklin et al., 2014; Jonkman, Markus, Franklin, & Van Dalfsen, 2017; Mowlem et al., 2016; Seli, Smallwood, Cheyne, & Smilek, 2015). However, this research focuses on adolescents, as they engage in riskier decision-making than adults (Defoe, Dubas, Figner, & Van Aken, 2015). All the participants will fill out self-report questionnaires about ADHD symptoms, mind-wandering, and risk-taking behaviour. Firstly, we will check whether ADHD symptoms predict risk-taking behaviour. Secondly, we will check if mind-wandering can predict risk-taking behaviour beyond ADHD symptoms.

We expect that mind-wandering can predict risk-taking behaviour beyond ADHD symptoms. Additionally, we expect a positive prediction of risk-taking behaviour through ADHD symptoms. Furthermore, we expect mind-wandering to predict risk-taking behaviour beyond ADHD symptoms.

Method

Participants
A total of 315 adolescents participated in this study, their ages ranged from 16 to 22 with an average age of 17.2 (SD = 1.3). Among them, 104 were male, 205 were female, one identified as gender-neutral and six did not wish to disclose this information. A total of 49 participants disclosed being diagnosed with AD(H)D and 19 were on AD(H)D medication. The participants were recruited from public high schools and secondary vocational schools, known in Dutch as Middelbaar Beroepsonderwijs. There was no reward offered for participation in the study. All participants signed an informed consent form and were given the option to withdraw from participating in the questionnaire at any given time.

Materials

The ADHD self-report questionnaire (Kooij & Buitelaar, 1997) was used to identify ADHD symptoms. Participants were asked if they felt restless and if they were easily distracted, among other things. The questionnaire included 23 items, as five symptoms were reformulated into two items. All items were scored on a four-point Likert scale (0 never or rarely to 3 very often) (cf. Kooij, Boonstra, Swinkels, Bekker, de Noord, & Buitelaar, 2008). The scores were totaled for analysis, with the maximum score being 69.

The risk-taking behaviour self-report questionnaire was used to gauge participants' propensity to engage in risky behaviour, such as drinking alcohol and engaging in unsafe sex. This questionnaire consisted of 28 items on a five-point Likert scale (0 never to 4 weekly). The scores were added together to create a total, with the maximum score being 112. This questionnaire was based on previously established surveys (Figner & Weber, 2011; Pat-Horenczyk et al., 2007; Pollak, Poni, Gershy, & Aran, 2017).

The Mind Excessively Wandering Scale (MEWS) (Mowlem et al., 2016) was utilized to monitor mind-wandering. Participants were asked if they had difficulty controlling their thoughts or switching off their thoughts. The MEWS consisted of 12 items on a four-point Likert scale (0 never or rarely to 3 almost always or constantly). The points were combined for the analysis with the maximum score being 36. This questionnaire was translated from English to Dutch.

In addition to the questionnaires, participants were asked to answer some demographic questions regarding their age, sex, diagnosis, and medication use.

Procedure

During school hours, the participants filled in the questionnaires in place of their regular curriculum. As this study is part of a larger research project, participants filled in four additional questionnaires. The complete questionnaire process took approximately 15 to 25 minutes. Participants were requested to answer all questions completely. Where laptops or computers were available, online questionnaires were utilized via the Qualtrics website. Those without access completed the questionnaire in a paper booklet. During the questionnaire session, participants were not permitted to speak with one another or use their cell phones.

Analyses

The data were analyzed using multiple regression blockwise entry. In the initial block, ADHD symptoms were classed as the independent variable and risk-taking behaviour was deemed the dependent variable. The second block used risk-taking behaviour as the dependent variable, and mind-wandering along with ADHD symptoms as the independent variables.
The following assumptions will be checked: (1) the independent variable is continuous; (2) the sample is random; (3) the independent variable has variance; (4) multicollinearity; (5) correlations outside the model; (6) homoscedasticity; (7) uncorrelated residues; (8) normally distributed; (9) independent participants; (10) linearity. Possible outliers will be detected using the MAD method (Leys, Ley, Klein, Bernard, & Licata, 2013), using the moderately conservative version of 2.5. When outliers are detected, the analysis will be run with and without outliers, and both will be reported. If less than 25% of the items of a questionnaire are missing, the data will be included; the total score will be imputed by the mean score of the filled-in items of that participant on that questionnaire. If the participant completed less than 25% of the questionnaire, the data on that questionnaire of that participant will be discarded.

Results
One participant did not complete the ADHD and risk-taking behaviour questionnaire, and two participants did not complete the risk-taking behaviour questionnaire. These three participants are not included in the data analysis. The Median Absolute Deviation (MAD) method was used to detect outliers (Leys et al., 2013). Since there were no outliers according to the MAD method, no participants needed to be excluded in the further analysis. Table 1 presents the mean, median, standard deviation (SD), and range of ADHD, mind-wandering, and risk-taking behaviour.

A block-wise multiple regression analysis was used to test if mind-wandering predicts risk-taking behaviour above and beyond ADHD symptoms. The assumptions of multicollinearity and homoscedasticity were violated. Because the mind-wandering and ADHD questionnaire have a strong linear relationship, shown in Table 2, the assumption of multicollinearity is violated. Typically, one of the independent variables will be excluded in the analysis, but because the main question is based on the prediction of both variables, they are both included in the analysis. Despite violating the homoscedasticity assumption, we did not use a non-parametric alternative because we are interested only in parameter estimation, not significance testing (Field, 2013).

The first regression tested whether ADHD symptoms significantly predict risk-taking behaviour. The regression indicates that ADHD symptoms are a significant predictor of risk-taking behaviour, F(1,310) = 79.87, p < .001, with an R2 of .205, meaning that ADHD symptoms can predict 20.5% of the risk-taking behaviour in adolescents. The second regression tested whether mind-wandering adds significantly to the prediction of ADHD symptoms and risk-taking behaviour. The regression indicates that the combination of ADHD symptoms and mind-wandering is a significant predictor of risk-taking behaviour, F(2,309) = 40.53, p < .001, with an R2 of .208, suggesting that ADHD symptoms and mind-wandering can predict 20.8% of the risk-taking behaviour in adolescents. However, upon further analysis, it becomes clear that mind-wandering is not significant in this prediction, ? = -.08, p = .29. The prediction of risk-taking behaviour through ADHD symptoms remains significant. These results are partially in line with the expectations. It was expected that ADHD symptoms would predict risk-taking behaviour. However, it was also anticipated that mind-wandering would predict risk-taking behaviour above and beyond ADHD symptoms, which is not in line with the results. Table 1: Descriptives of ADHD, mind-wandering, and risk-taking behaviour questionnaires. Mean Median Standard deviation Range: ADHD 19.707 18 11.142 0 - 59 Mind-wandering 14.098 14 8.8082 0 - 36 Risk taking behaviour 18.897 16.5 12.623 0 - 73 Table 2: Correlations of ADHD, mind-wandering, and risk-taking behaviour questionnaires. ADHD Mind-wandering Risk taking behaviour Pearson correlation ADHD 1.00 .756 .453 Mind-wandering .756 1.00 .307 Risk taking behaviour .453 .307 1.00 Significance ADHD . >.001 .001

Mind-wandering .001 . .001

Risk taking behaviour .001 .001 .

Discussion:

In this study, we investigated the prediction of risk-taking behaviour. The primary question was whether mind-wandering predicts risk-taking behaviour above and beyond ADHD symptoms. We conducted this study through self-report questionnaires in adolescents. However, this study did not detect any evidence that mind-wandering predicts risk-taking behaviour above and beyond ADHD symptoms. Nevertheless, the results do show that ADHD symptoms predict risk-taking behaviour.

These results are not in line with the data obtained in the study of Mowlem et al. (2016). They suggested that mind-wandering could be used to predict risk-taking behaviour instead of ADHD. However, they based the degree of risk-taking behaviour on an impairment questionnaire, which may have resulted in a limited presentation of risk-taking behaviour. Risk-taking behaviour is possibly better operationalized in this study than in the study of Mowlem et al. (2016). Mind-wandering may predict those limited parts of risk-taking behaviour above and beyond ADHD symptoms. However, when all aspects of risk-taking behaviour are taken into account, mind-wandering does not predict risk-taking behaviour above and beyond ADHD symptoms. This different operationalisation of risk-taking behaviour may explain the divergent results.

All the questionnaires used in this study are self-report questionnaires, which can be a limitation. Adolescents have a tendency to report more or less than the reality due to selective memory, attribution or exaggeration. The deviant answers can vary for each question (Brener, Billy, & Grady, 2003). In other words, an adolescent may report more problems than he actually experiences on the first question, fewer problems on the second question and quite accurately on the third question, which could result in an inaccurate representation of the ADHD symptoms, degree of mind-wandering or degree of risk-taking behaviour and lead to an inaccurate conclusion. A second limitation in this study is that there exists a strong linear relationship between the mind-wandering and ADHD questionnaires. It is possible that they both measure roughly the same problems, but the ADHD questionnaire is more widespread. When the ADHD questionnaire is more widespread, it may contain more aspects crucial for the prediction of risk-taking behaviour than the mind-wandering questionnaire. Therefore, mind-wandering may miss important aspects for the prediction of risk-taking behaviour.
Furthermore, besides the role of mind-wandering as an underlying process, it overlaps with regular ADHD symptoms. The main characteristics of ADHD are inattention, hyperactivity, and impulsivity. Mind-wandering is strongly related to the inattention part of ADHD. So maybe it is not the inattention part of ADHD that can predict mind-wandering, but one of the other characteristics. In the study of Lee & Hinshaw (2006), they found that inattention symptoms could not predict risk-taking behavior. This is in contrast to hyperactivity and impulsivity symptoms, which could predict risk-taking behavior. An explorative analysis was run to check if this is the same case with our data.

There are several implications for both clinical practice and further research based on the results of the current study. Regarding clinical practice, when an individual is diagnosed with ADHD, clinicians should always keep risk-taking behavior in mind as a potential threat. In terms of further research, the operationalisation could be objectified. For example, instead of a self-report questionnaire of risk-taking behavior, the participants could keep score of certain behavior for a period of time. Furthermore, research could focus on the different characteristics of ADHD in combination with risk-taking behavior. Once it is more clear which characteristics - inattentiveness, hyperactivity, or impulsivity - can best predict risk-taking behavior, prevention of this behavior can be focused on.

Overall, this study shows an evident link between ADHD and risk-taking behavior. However, there is no evidence for mind-wandering as an underlying process for this problem. In clinical practice, it is crucial to directly assess risk-taking behavior when ADHD is diagnosed.

Did you like this example?

529

28