Running head: SUBCLINICAL SYMPTOMS ADHD

Subclinical ADHD Symptoms and Social Wellbeing Travis Applebaum Boise State University

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Abstract Nearly 17 million people in the United States have ADHD. This study was done correlating

ADHD and Social wellbeing. Two hypotheses were tested. The first hypothesis is students with subclinical symptoms of ADHD (i.e. inattentiveness and hyperactivity) will have lower scores in social wellbeing. The second hypothesis is those with higher subclinical symptoms of ADHD will be correlated with spending more time interacting with their friends in social activity. The main variables are measured levels of ADHD and social wellbeing. The study was run using a survey on a group of 103 psychology students at a Northwestern university. Correlations were used to analyze the data. The results did not support the research hypothesis. Implications for future ADHD intervention discussed. Keywords: ADHD, Social Wellbeing, Survey

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Subclinical ADHD Symptoms and Social Wellbeing As of 2009, 9% of children were found to have attention-deficit/hyperactivity disorder (ADHD) which equates to about 6,676,000 children with ADHD in the United States (Akinbami, Liu, Pastor, & Reuben, 2011; Howden & Meyer, 2011). In 2006, it was estimated that 4.4% (or approximately 10,320,000) of the United States adult population has ADHD

(Kessler Et al., 2006). The present number of individuals in the United States with a diagnosis of ADHD, that are either children or adults, is approximately 16,997,151. Because nearly seventeen million people have the mental health disorder ADHD, it is important ADHD be studied. According to the current version of the Diagnostic and Statistical Manual of Mental Disorders (2000) (DSMIVTR), hyperactivity, impulsivity, and inattention are the three hallmark traits of ADHD. Using those traits, ADHD is broken down into three subtypes which are attention-deficit/hyperactivity disorder predominately inattentive (ADHD-I), attentiondeficit/hyperactivity disorder predominately hyperactive/impulsive (ADHD-HI), and attentiondeficit/hyperactivity disorder combined (ADHD-C). ADHD is correlated with poor academic performance (Painter, Prevatt, & Welles, 2008; Frazier, Youngstrom, Glutting, & Watkins, 2008). Individuals with ADHD avoid tasks which involve sustained mental effort or attention and have difficulty with organization (DSMIVTR, 2000). Often those who live with ADHD make careless mistakes on their school work or at their job. These careless mistakes cause them to perform poorly at school and work. ADHD has been found to be comorbid with many other psychiatric conditions including: depression, anxiety, substance abuse, bipolar disorder, and obsessive compulsive disorder (Arnold, 2010). These disorders can complicate the already difficult nature of ADHD.

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING ADHD decreases wellbeing in individuals who are diagnosed (Buchanan, 2011). Wellbeing is a nuanced construct composed of many facets. It is a measure of the subjective pleasure and happiness that a person feels (Buchann, 2011). Ryffs (1998) six scales of wellbeing are used in this study to measure a persons level of wellbeing (Buchann, 2011). Ryffs six scales of measurement are a good method of determining a subjects wellbeing because they have high reliability with the lowest score of the six scales being .81 (Ryff, 1989). A score of .81 is good because it shows highly consistent test-retest scores. The scales measure internal aspects of wellbeing such as positive relationships, autonomy, self-acceptance, and positive relations with others as well as external measures of wellbeing such as environmental mastery, personal growth, and purpose in life (Buchann, 2011). Studies have found college students with ADHD have lower self-acceptance and purpose in life scores but higher scores on positive relationships with others because they often have more interaction with their peers (Buchann, 2011; Reaser, Prevatt, & Prevatt, 2007). Research into wellbeing is important because it is important to not just survive in society but to thrive in it. Because people with ADHD are impaired in areas of attention and impulsivity, they run into more problems thriving, especially in college where they are likely to have a lower GPA than their non-impaired

classmates (Reaser et al., 2007). It is important to study college students with ADHD to find out what struggles they run into while attending school. Once researchers identify what issues college students with ADHD encounter, they can develop strategies to help those college students overcome their difficulties. Another area of wellbeing affected by ADHD is social interaction. Social activity is inherently recursive. It is a shaping process that evolves over time by making mistakes which teach a person what to do and what not to do based on the feedback they receive (Paulson,

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Buermeyer, & Nelson-Gray, 2005). The DSMIVTR (2000) states that those with ADHD are easily distracted, commonly have trouble attending to task, appear not to be listening when spoken to directly, and avoid engaging in tasks that require sustained mental effort. Furthermore, the DSMIVTR (2000) states those with ADHD often shift topics in conversations and have difficulty following the rules. Hall, Peterson, Webster, Bolen, and Brown (1999) found that children with ADHD had more trouble deciphering social cues than their peers. The study by Hall et al. (1999) used the Diagnostic Analysis of Nonverbal Accuracy (DANVA) to determine how well the children they tested were able to recognize social cues by identifying an emotion presented in a picture or a voice recording. Those with ADHD had the most trouble identifying emotions presented in a voice recording. The DANVA was calibrated on a large

sample size and has high internal consistency. It stands to reason that children with poor ability to interpret social behavior may become adults with poor ability to interpret social behavior. Unfortunately, there are very few studies correlating adult ADHD and poor ability to read nonverbal cues. Often those diagnosed with ADHD do not learn from mistakes (Painter et al., 2008). This inability to learn from past mistakes is coupled with an inability to detect the subtlety of body language which causes those with ADHD to miss many social cues that those without ADHD are able to identify (Overby, Snell, & Callis, 2009). In contrast to the above, one study found that college students with ADHD were more likely to over-indulge in social activity than college students without ADHD (Buchanan, 2011). Buchanan found that college students with ADHD were more likely to participate in sororities or fraternities, and that they visited friends more frequently than those who did not have ADHD. He states his sample may be suspect because it was not truly random because the sample was

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING selected from students at the college Buchanan teaches at. Also, the sample was fairly small, consisting of only 34 college students with ADHD (Buchanan, 2011). Furthermore, the study

was done at a university in the southern United States which may not generalize to other parts of the country (Buchanan, 2011). The DSMIVTR (2000) states that people with ADHD often talk excessively which may be part of the reason those in Buchanans study were found them to be more likely to engage in social activity. Those with ADHD may be approaching more people and thus socializing more. The more subclinical symptoms of ADHD that a person expresses the more likely that person exhibits dysfunctional coping methods and has increased stress in their life (Overby et al., 2009). It is therefore important to identify those people who exhibit symptoms of ADHD to teach them to effectively cope with their disability. One of the scales employed to study AHDH in the study by Overbey, Snell, and Callis (2009) was highly influential on the present study. In Overbys study, ADHD was operationalized as a continuum of ADHD related behaviors based off of a test called the Adult ADHD Self-Report Scale (ASRS), rather than using a psychiatric diagnosis. In another study by Barkley (2011), a similar method of studying ADHD was employed. In that study the ASRS was used to place people into categories of either having ADHD or not having ADHD based off their ASRS scores. The ASRS further breaks down ADHD symptoms into two domains: inattention and hyperactivity-impulsivity (Kessler et al., 2005). For the present study, it was beneficial to

use a continuum approach to determine the level of ADHD symptoms, so the ASRS questions were adapted to the survey that participants filled out. For this study, subclinical symptoms of ADHD are how often a person expresses one symptom of inattention (i.e. how hard it is for a person to focus on repetitive work) and how

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING often a person expresses one symptom of hyperactivity-impulsivity (i.e. how restless the person generally feels) (Kessler et al., 2005).

Because ADHD impairs a persons ability to function, the purpose of this study is to find out how subclinical symptoms of ADHD are related to a persons wellbeing (Buchanan, 2011). It is therefore hypothesized students with subclinical symptoms of ADHD (i.e. inattentiveness and hyperactivity) will have lower scores in social wellbeing even though some studies have concluded otherwise (Buchanan, 2011). It is secondly hypothesized those with higher subclinical levels of ADHD will spend more time socializing with others. To carry out this study, a survey will be given to a group of students at a Northwest university. The survey will include questions which measure two independent variables: inattentiveness and hyperactivity. The survey will also include questions which measure two dependent variables: time spent socializing with friends and social wellbeing. Methods Participants All participants were from an upper division psychology class at a northwestern university. Participants consisted of a non-random convenience sample. There were 103 participants. The percent of females who took the survey was 73.8, and the percent of males who took the survey was 27.2. The participants ages ranged between 19 years old at the bottom and 62 years old at the top. The breakdown of participants by school year was 0 % freshman, 4.9 % sophomores, 51.5 % juniors, and 43.7 % seniors. Ethnic composition of the participants were 5.8 % Asian American, 80.6 % White/ Caucasian, 1 % Native American, 0 % African American, 3.9 % Hispanic, and 2.9 % Other. In this study 26.2 % of the participants were psychology majors. All participants were ethically treated in accordance with the APA ethical

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guidelines and gave informed consent (American Psychological Association, 2010). Participants were told that results would be anonymous and were given the option to not perform the survey. Participants received extra credit for completing the survey. Measures Wellbeing. Questions were taken from Ryffs Six Scales of Wellbeing to be used in this survey. Of the six scales, only the sixth scale, positive relations with others, was used (Ryff, 1989). The positive relations subscale has six questions of which two were used in this study. The wording of the first question was altered to be clearer after piloting the question with two students at the university. The original wording for the survey item was double-barreled so the wording was of the survey question was changed to I feel that I connect with others well. The other question, I often feel lonely because I have few close friends with whom to share my concerns is reverse coded. Scores for both questions were based on a five point Likert scale (1 = strongly disagree, 5 = strongly agree). One question was written to find out how much time college students spend per week in the company of their friends. The question was Over the past week, how much time have you spent with your friends? This question was written for this study by the author. It was piloted with two college students. Each student that piloted the questions had variation in the amount of time spent with their friends. This question was included to see if there is a correlation of between time spent in social contact with others and severity of subclinical ADHD. This question was scored using a six point frequency scale (1 = less than 1 hour, 6 = greater than 13 hours). There was no negative feedback about the question. Subclinical ADHD Symptoms. Three questions were taken from the Adult ADHD SelfReport Scale (Kessler et al., 2005). One of the variables used in the study was the strength of

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING

ADHD symptoms a participant exhibited. The way that the variable was measured was by using subclinical symptoms of ADHD. The two subclinical symptoms of ADHD used in this study were inattentiveness and hyperactivity. Two questions were related to the inattentive subtype of ADHD. The remaining question pertains to the hyperactive subtype of ADHD. How often do you feel overly active and compelled to do things, like you were driven by a motor, is an example of measuring the hyperactivity component of ADHD. How often do you have difficulty getting things in order when you do a task that requires organization, and How often do you make careless mistakes when you have to work on a boring or difficult project are examples of questions measuring the inattentive component of ADHD. All questions are scored on a four-point scale based on occurrence (1 = never, 4 = always). Procedures Participants completed an omnibus survey composed of questions from students in another upper division psychology class. The survey was given during a regular class period. The participants were given 45 minutes to finish the survey. The instructor left the room as the survey was being filled out. No aspects of the classroom where the survey was given were altered from that of a normal class operation. Participants completed the survey as a group. All surveys were collected by the end of the class period. Those who completed the survey early presented the survey to teaching assistants in the front of the class. Those who completed the survey early were allowed to leave. After the survey was completed, participants were debriefed. Participants were made aware of the counseling center on campus. Once the data was collected, it was scored and then analyzed with the Statistical Package for the Social Sciences (SPSS). Results

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING There were 103 participants who took the survey. All participants were students at a

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northwestern university. All students who took the survey were in an upper division psychology course. While no participants were excluded from the study, not all survey questions were answered in their entirety. Three questions were missing two data points, one question had one missing data point, and two questions were answered with no missing data. All participant data from this survey was analyzed. All descriptive statistics are in Table 1. Coding was done by entering participant scores on the omnibus survey into SPSS. Statistical tests were done on the questions to determine if significant associations between variables were evident. It was hypothesized students with subclinical symptoms of ADHD (i.e. inattentiveness and hyperactivity) would have lower scores in social wellbeing. A Pearson correlation was run to test the hypothesized relationship about subclinical ADHD symptoms and social wellbeing. There were no significant findings to support this hypothesis. The data indicated that there was no significant relationship between severity of ADHD symptoms and social wellbeing scores. It was secondly hypothesized those with higher subclinical symptoms of ADHD would be correlated with spending more time interacting with their friends in social activity. There were marginally significant results showing that inattentive ADHD was correlated negatively with time spent socializing with friends, r (101) = -.18, p = .066. The data show the stronger subclinical inattentive ADHD symptoms a person presented the less likely that person was to spend time with their friends. The results do not support the second research hypothesis. Discussion The first hypothesis, students with subclinical symptoms of ADHD (i.e. inattentiveness and hyperactivity) will have lower scores in social wellbeing, was not supported by the data.

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The second hypothesis, those with higher subclinical symptoms of ADHD will be correlated with spending more time interacting with their friends in social activity, was not supported by the data. There was a marginally significant result related to the second hypothesis, however. The marginally significant result found a negative correlation between the severity of inattentive subclinical ADHD and amount of time spent socializing with friends. Even though a previous study found those with higher ADHD symptomology were more likely to over-indulge in the time they spent with their friends, my study found that those with higher ADHD symptoms were less likely to over-indulge in the amount of time spent with their friends (Buchanan, 2011). A possible explanation for the discrepancy between my results and Buchanans is that my study and the previous study differed in the way they looked at ADHD. The previous study looked at ADHD as a whole, not differentiating between ADHD-I and ADHD-HI. While not expressed in my hypothesis, I have questions specifically designed to look at ADHD-I and ADHD-HI symptomology. According to the DSMIVTR (2000), some hyperactive/impulsive symptoms of ADHD include talking excessively, feeling like being driven by a motor, and feeling restless. Because ADHD-C includes ADHD-HI, Buchanans (2011) study would be more likely to find people with ADHD over-indulging in social activity which may not be true of all subtypes of ADHD. Those with ADHD-HI may simply be approaching more people to relieve restlessness and thus socialize more. Breaking ADHD into subtypes allowed my study to see if ADHD subtypes affected social interaction independently of ADHD-C. Additionally there may be another condition that overlaps with ADHD-I symptoms. The condition is called Sluggish Cognitive Tempo (SCT), and it concurrently occurs in nearly 50% of

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING ADHD-I cases (Barkley, 2011). According to Barkley (2011), people who present with both ADHD and SCT have worse social, educational, and workplace life outcomes. The implication here is that more study needs to be done on attention disorders. The DSMIV does not include SCT as a disorder even though it occurs in nearly 50% of ADHD-I cases (Barkley, 2011). Women predominately have ADHD-I (Hinshaw et al., 2012). That means that a large group of those with ADHD-I, especially women, are not receiving proper clinical care.

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The current study was performed on a population of a single university pool of students from the northwestern region of the United States. Students were from a psychology class and thus may be more aware of psychological theory than the general population which may skew the results. The sample size was small and thus has poor statistical generalizability. If the study had been done with a larger sample, the results would be more robust and more significance might have been found. The variables are measured with very few survey questions, so there are few extra questions to provide reliability. For example, the independent variable of the hyperactive subtype of ADHD was measured using only one question. This example shows there are too few questions in my study to reliably determine the extent of subclinical symptoms expressed in a disorder as complex as ADHD. It would be interesting to run this study on people who have been formerly diagnosed with ADHD. It is likely that more significance would be found. Does being male or female affect the social wellbeing of a person with ADHD is a good question for future research because there has been little study into why men and women express ADHD differently. Men and women could be treated as separate independent variables. Furthermore, because the amount of people in the United States that express ADHD changes with age (i.e. 9 % of children vs. 4.4 %

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Adults) (Kessler Et al., 2006 ; Howden, & Meyer, 2011). The study could be set up longitudinally to see how ADHD affects social wellbeing over the lifetime of a diagnosed individual.

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Another issue that would be interesting to look at is how fulfilling social relationships are for people with ADHD. Even though research shows that those with ADHD spend more time socially interacting with others, those with ADHD may find their relationships unfulfilling which might lead to lower social wellbeing in spite of being more sociable (Buchanan, 2011). The implications of this study will lead to better intervention for those with ADHD. If those with ADHD-I can be identified then they can be given social skills training which can improve their social wellbeing. With better social wellbeing, they will be able to relate to their peers better, which will allow them to not just survive, but to thrive.

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Reference American Psychological Association . (2010). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx

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Akinbami, L. J., Liu, X., Pastor, P. N., & Reuben, C. A. (2011). Attention deficit hyperactivity disorder among children aged 5-17 years in the United States, 1998-2009. NCHS Data Brief, 70. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db70.htm Arnold, B., Easteal, P., Easteal, S., & Rice, S. (2010). It just doesn't add up: ADHD/ADD, the workplace and discrimination. Melbourne University Law Review, 34, 359-391. Retrieved from http://www.lexisnexis.com/hottopics/lnacademic/?verb=sr&csi=166019&sr=TITLE(IT+J UST+DOESN%27T+ADD+UP)+and+date+is+August+1%2C+2010 Barkley, R. A. (2011). Distinguishing sluggish cognitive tempo from attentiondeficit/hyperactivity disorder in adults. Journal of Abnormal Psychology, 121, 978-990. doi:10.1037/a0023961 Buchanan, T. (2011). Attention Deficit/Hyperactivity Disorder and well-being: Is social impairment an issue for college students with ADHD? Journal Of Postsecondary Education And Disability, 24, 193-210. Retrieved from http://www.eric.ed.gov/PDFS/EJ966124.pdf American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Frazier, T. W., Youngstrom, E. A., Glutting, J. J., & Watkins, M. W. (2007). ADHD and achievement: Meta-analysis of the child, adolescent, and adult literatures and a concomitant study with College Students. Journal Of Learning Disabilities, 40, 49-65.

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Retrieved from

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http://www.ingentaconnect.com/content/proedcw/jld/2007/00000040/00000001/art00004 Hall, C. W., Peterson, A. D., Webster, R. E., Bolen, L. M., & Brown, M. B. (1999). Perception of nonverbal social cues by regular education, ADHD, and ADHD/LD students. Psychology In The Schools, 36, 505-514. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ccd79498-1a42-4983-93ca8d4396b27627%40sessionmgr13&vid=3&hid=14 Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attentiondeficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80, 1041-1051. doi:10.1037/a0029451 Howden, L. M. & Meyer, J. A. (2011). Age and Sex Composition: 2010. (C2010BR-03). Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., & Walters, E. E. (2005). The World Health Organization adult ADHD self-report scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35, 245-256. doi:10.1017/S0033291704002892 Kessler R. C., Adler L., Barkley R., Biederman J., Conners C.K., Demler O. & Zaslavsky A.M.(2006) The prevalence and correlates of adult ADHD in the united states: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163, 716723. doi:10.1176/appi.ajp.163.4.716

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Overby, A. G., Snell, W. E., & Callis, K. E., (2009). Subclinical ADHD, stress, and coping in

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romantic relationships of university students. Journal of Attention Disorder, 15, 67-78. doi:10.1177/1087054709347257 Paulson, J. F., Buermeyer, C., & Nelson-Gray, R. O. (2005). Social rejection and ADHD in young adults: An analogue experiment. Journal Of Attention Disorders, 8, 127-135. doi:0.1177/1087054705277203 Painter, C. A., Prevatt, F., & Welles, T. (2008). Career beliefs and job satisfaction in adults with symptoms of attention-deficit/hyperactivity disorder. Journal Of Employment Counseling, 45, 178-188. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=c6afeeac-afd2-44f7-9266f26d50390fda%40sessionmgr11&vid=13&hid=10 Reaser, A., Prevatt, F., Petscher, Y., & Proctor, B. (2007). The learning and study strategies of college students with ADHD. Psychology In The Schools, 44, 627-638. doi: 10.1002/pits.20252 Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal Of Personality And Social Psychology, 57, 10691081. doi:10.1037/0022-3514.57.6.1069

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING Table I Descriptive Statistics for Study Variables (N = 103) Scale Social Wellbeing I feel that I connect with others well. I often feel lonely because I have few close friends with whom to share my concerns. ADHD How often do you feel overly active and compelled to do things, 101 like you were driven by a motor? How often do you have difficulty getting things in order when you do a task that requires organization? How often do you make careless mistakes when you have to work on a boring or difficult project? 102 2.49 (.74) 103 2.09 (.83) 2.47 (.82) 102 102 1.89 (.72) 3.67 (1.10) N

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M (SD)

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There was a third variable which was not addressed directly in this study but which was represented on the survey. The variable is which type of ADHD a person has. In this case ADHD- I was related to spending less time spent in social contact with friends than was ADHD HI.

ADHD is a subject that has much controversy. The diagnostic criteria are vague at best and do not capture the disease well. There is no answer for why women display less ADHD than men. ADHD is a disorder characterized by symptoms of Inattention, Hyperactivity, and Impulsiveness. It is mostly shown in children but now the research has been opened up to include adults with ADHD. Originally it was believed that adults would grow out of ADHD. Therefor it would be unnecessary to study what adult ADHD looked like because it did not exist. One longitudinal study involving adult women shows that ADHD is not occurring Further ADHD may not be a single disorder Attention may be dual disassocitedADHD is a disorder characterized by symptoms of Inattention, Hyperactivity, and Impulsiveness. It is mostly shown in children but now the research has been opened up to include adults with ADHD. Originally it was believed that adults would grow out of ADHD. Therefor it would be unnecessary to study what adult ADHD looked like because it did not exist. One longitudinal study involving adult women shows that ADHD is not occurring Further ADHD may not be a single disorder

Medicalization is not necessarily bad. Looking back at the past, people with alcoholism were considered to be lost causes. Now alcoholism is considered to be treatable. Without medicalization there is no way to treat a behavior. There are also many judgments about the relative character of a person suffering from a disease. Medicalization takes the shame out of having a disorder, problems with behavior, academics, relationship struggles and financial difficulties. It does not absolve a person from being

An interesting parallel might be drawn to the over-representation of antisocial personality disorder (ASPD) in males. Few females are ever diagnosed with ASPD most are diagnosed with Hisrionic personality disorder.

SUBCLINICAL ADHD SYMPTOMS AND SOCIAL WELLBEING WHAT DOES MY SIGNIFICAN RESULT MEAN:

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