The use of compensatory strategies in adults with ADHD symptoms

Abstract

This study examined the use of compensatory strategies reported by adults with ADHD symptoms and their relation to measures of functioning. Forty-nine adults (55.1 % female) completed a structured diagnostic interview to assess ADHD, and responses were coded for compensatory strategies: Adaptation, Paying Attention, Organization, External Support, and Avoidance. The majority of adults with ADHD symptoms reported using compensatory strategies, and their reported strategy use in childhood was related to their use in adulthood. No gender differences were found in the use of strategies, although Organization and External Support were used more often for inattention than for hyperactive/impulsive symptoms. Use of the compensatory strategy, Adaptation, was significantly related to measures of functioning, and the use of strategies reduced the negative relationship between ADHD symptoms and parenting difficulties. Results encourage the development of compensatory strategies among adults with ADHD symptoms, as well as provide recommendations for treatment programs.

Appendices

Appendix: Compensatory strategy coding manual for the Conner’s adult ADHD diagnostic interview for DSM-IV (CAADID)

Our objective is to code Part II of the Conner’s Adult ADHD Diagnostic Interview for DSM-IV (CAADID; Epstein et al. 2001) for adult participants’ self-report of compensatory strategies used to deal with their inattention and hyperactivity symptoms.

The CAADID is a 90-min structured interview that assists in the process of diagnosing adult ADHD. It assesses the presence of nine inattention symptoms and nine hyperactivity symptoms, in both adulthood and as retrospectively recalled in childhood.

Compensatory strategies are environmental modifications or behavioral/cognitive strategies used to overcome inattention and hyperactivity symptoms. This manual codes for spontaneous verbal reports of using compensatory strategies in response to the diagnostic interview questions asked during the CAADID.

General guidelines

Listen to the CAADID for each subject and for each symptom, both in adulthood and in childhood, place a ✓ on the coding sheet provided (p. 10) if the adult reports using a compensatory strategy in dealing with that symptom, or an X if the adult reports using a compensatory strategy that did not work. The format of the interview is as follows:

• Criteria A—Inattention symptoms

• Criteria B, C, D—Age of onset, pervasiveness, and level of impairment for inattention symptoms

• Criteria A—Hyperactivity symptoms

• Criteria B, C, D—Age of onset, pervasiveness, and level of impairment for hyperactivity symptoms

• Criteria B, C, D—Age of onset, pervasiveness, and level of impairment for all symptoms

Listen to the adult participants’ self-report audio recording and read along in the CAADID interview booklet. We will only be coding compensatory strategies mentioned in Criteria A—Inattention symptoms and Criteria A—Hyperactivity symptoms. This means you will fast forward over Criteria B, C, and D.

For each symptom, you will first code whether compensatory strategies were used in adulthood and then in childhood. If the participant mentions using a strategy in childhood when answering a symptom about adulthood, code for the strategy in childhood and vice versa.

If you hear a compensatory strategy that does not fit in one of the categories, check ‘Other’ and write a description of the strategy on the coding sheet.

When to code for a compensatory strategy

For each symptom, check the original CAADID booklet to see whether the interviewer coded the symptom as present or not. Then check the reliability coder’s booklet to see whether they agreed with the original interviewer or whether there was a discrepancy. If in either booklet the symptom is marked as present, you can go ahead and code for compensatory strategies. The rationale being that if the symptom is present, the strategies mentioned by the participant are used to compensate for said symptom. If neither interviewer nor reliability coder marked the symptom as present, the rule is to not code for compensatory strategies.

If a participant endorses a symptom, but does not report using any compensatory strategies place a ✓ for No Strategy by that symptom.

Strategy working or not

A compensatory strategy will be coded regardless if the participant sees it as helping them to compensate or not. If the individual mentions using a compensatory strategy and it seems to help them, place a ✓ on the coding sheet. We will set the bar relatively low to code for any mention of a compensatory strategy. If the individual mentions using a compensatory strategy and they explicitly state that it doesn’t work, place an X on the coding sheet.

Examples of when to place a ✓:

“My agenda helps me remember work deadlines and when to pick up the kids.”

“I multitask to help me get more things done at once.”

“I have to re-read a page several times to actually absorb what I read.”

Examples of when to place an X:

“I write a lot of to-do lists, but I rarely accomplish the tasks on them or I lose them.”

“I multitask, but it really doesn’t help, I find I accomplish nothing.”

Personality trait versus compensatory strategy

We will code compensatory strategies that individuals use to adapt to their inattentive and hyperactive symptoms so that they can better succeed in their lives. We will not code for individual personality traits that participants see as helping them succeed in their lives.

These are strategies:

“I try to stay organized by cleaning up the kitchen daily.”

“I try to stay organized by writing things down.”

These are personality traits:

“I’m a very detailed oriented person.”

“I’m more of the hyper-focus type.”

Symptoms versus compensatory strategies

We will code for compensatory strategies if the individual self-reports doing something to help them compensate. We will not code self-report of having a symptom or impairment related to a symptom.

These are strategies:

“In school, I asked for more time on tests because it took me longer to read the instructions.”

“I am disorganized, but I do try to clean up the kitchen.”

These are symptoms or reflections of symptoms:

“Reading a book takes me longer than others.”

“I could finish a puzzle, but it required more effort for me than my brother.”

“If I like what I’m doing I can focus, if I don’t like it I don’t focus.”

Coding same example of strategy for multiple symptoms

We will code for the same example of a strategy more than once if it helps the individual cope in different ways.

Example:

Do you have difficulty with follow through? “Yes, but I use my agenda to cope.” AND Do you have difficulty with organization? “Yes, but I use my agenda to cope.” → Place a ✓ for ‘Organization’ for both symptoms.

Coding one example of a strategy per symptom

We will only code for one example of a strategy per symptom.

Example:

Do you have difficulty sustaining attention? “At work yes, but as I’m a freelance graphic designer I can decide what tasks to work on when I want to. Also, I tend to take mini breaks throughout the day so I can stay focused.” Both ‘being able to choose what tasks to work on’ and ‘taking mini breaks’ are examples of Adaptation, but because these were both in response to one symptom we will only place one ✓ for Adaptation.

Compensatory strategy descriptions

Organization

We will code for this strategy if an individual mentions attempting to organize their environment and/or schedule, as well as using external organization aids to help compensate for inattentive or hyperactive/impulsive symptoms. For instance, we will code for this strategy if the individual mentions using a calendar, planner, agenda, to-do lists, alarms, or making notes. We will also code for this strategy if the individual has specific locations for items so as not to forget them or if the individual tries to compensate for their disorganization by organizing. Finally, we will code for this strategy if the individual says they plan out the time it takes for certain activities/distances, if they schedule their time, if they create deadlines for themselves, or if they establish routines for when certain things happen. Prioritizing could also be seen as Organization if the individual is choosing a task to do first.

Code even if the strategy is mentioned in passing, e.g., “Do you avoid difficult tasks?” “Well, I write down all the tasks I have , but I’m an adult now so I don’t really do things unless I enjoy them.”

These are strategies:

“I write instructions down.”

“I make a to-do list before I go to bed of what I want to do tomorrow.”

“I use alarms to remind me when to start a new task”

“I put my keys on a hook by the door.”

“I’m really messy so I try to keep my desk organized, but it seems to have gotten messy even 10 min later.”

“I’ve learnt to work out how long it’s going to take me to drive somewhere, but I still seem to be late.” (You would code for this strategy, but it would get an X as the individual states it doesn’t work)

“I have to set deadlines for myself, otherwise nothing gets done.”

Paying Attention

We will code for this compensatory strategy if an individual has an awareness of their impairment and is therefore attempting to control the behavior. Strategies include being extra focused, mindful, or doing more of a task to compensate. For instance, we will code attempts to visualize the end result of their actions, being mindful and aware of their automatic thoughts, paying extra attention to detail in order to avoid making mistakes, filtering things out internally, or saying they ‘control’ their behavior (e.g., having an urge to do that behavior, but then trying to prevent it.) We will also code for Paying Attention if an individual goes over something again or if they check their work over to compensate for rushing through.

Placing extra value on something, trying harder because they like the activity or trying harder if the project is for someone else will not be coded as paying more attention. These examples do not demonstrate compensation for their impairment.

These are strategies:

“I have good follow-through now because I’ve learnt to visualize how something’s going to turn out before it happens.”

“I try and be aware of when I jump in conversations, I’m really trying to stop.”

“I’ve developed a hold-back mechanism. I try not to blurt things out anymore.”

“I try to be more conscious.”

“I have to focus more.”

“I hyper focus; I really try to pay attention the first time.”

“I have to overcompensate and do more of a task to make sure it’s done right.”

“As a child I could control myself, I had self-discipline.”

“In certain situations like at work I can control it.”

“I’m aware I over schedule myself, I catch myself sometimes”

“I have to re-read a page several times to actually absorb what I read.”

“I just remember going over and over again all my schoolwork.”

This is not a strategy:

“I never had a lot as a child so the toys I did have were really special. I placed a lot of value on them so I rarely misplaced them.”

“If it’s for the benefit of helping someone else out I’m more inclined to focus and finish it- if it’s something for myself than I don’t view it as important.”

Adaptation (AD)

We will code for Adaptation if the individual says they compensate for their symptoms by altering tasks or demands to make them more manageable, as well as choosing environments best suited to their ADHD symptoms. Examples include breaking a problem or task down into manageable steps so they can accomplish it, accepting their weaknesses and focusing on their strengths, switching tasks or multitasking to stay productive, developing routines and systems, or reducing distractions to concentrate or focus more on something.

These are strategies:

“I know it’s rude, but if someone’s talking to me and I remember something important, I have to interrupt right then to say it, otherwise I’ll definitely forget.”

“I give my wife the papers, I like to focus on my strengths and that’s how we’ve worked it out.”

“I can’t give someone undivided attention when they’re talking to me, I have divided attention, but I find it actually helps me focus more on what they’re saying if I’m doing something at the same time.”

“I’ve learnt I do better visually. I have to see things or I won’t remember.”

“If we’re going shopping, I can’t handle waiting for everyone, so I’ve learnt it’s just better for me to go by myself.”

“I moved to a small town because I can focus better out here, the city was just too busy.”

“I carry little rocks in my pocket so I can be doing something with my hands while I’m talking to people. It helps me pay attention.”

“I have a lot of energy, so the only way I’ll sleep is if I’ve burnt myself out at the end of the day.”

“I couldn’t keep up with the other students in Math, so my teacher put me in a different class.”

“I buy shoes without buckles now because I have to bounce my legs up and down and I don’t want to annoy the people around me!”

“I’ve figured out systems that work- it’s almost 2nd nature to me.”

“I move from one project to the next when I get bored.”

“Sometimes things seem really overwhelming, like taxes, I have to break it down into little steps or else I won’t do anything.”

“If I’m watching the hockey game on TV everyone needs to be quiet, or else I can’t focus.”

External Support

We will code for this compensatory strategy if the individual mentions receiving support from family members, partners, friends, or professionals to compensate for impairment, for instance seeking therapy, going to learning assistance in school, the resource room, or meeting other adults with ADHD in support groups.

Help from someone else should provide lasting effects of compensation and it should be obvious that whatever the other individual is doing is meant to help the participant. Reminders from others can be seen as having someone compensate for them if it’s something they are doing to prevent future instances of that symptom, not if they are just reporting/describing a symptom or reacting to a symptom. Being told to listen in a classroom environment or to sit down will not be coded as compensation, even though they might help the individual get back on track they’re not compensating for future occurrences of that symptom.

This strategy also includes the use of medication.

These are strategies:

“I got a lot of help in school. I had a tutor and that’s how I got through.”

“I’ve learnt a lot of parenting techniques from my therapist. I think they’ve really helped.”

“My mom helped organize my backpack.”

“I always forget, so my wife reminds me every morning about picking up the kids.” (Developed a system)

“I get my husband to remind me when I cut my friends off in conversations.” (Preventative)

“I do have a place where I put my keys, but my husband still reminds before going out the door.”

“My teacher gave me breaks to walk around so I could stay seated.”

“Between my parents and the nuns I had several deterrents to not get out of my seat (this alone would not be coded), so I overcame my natural inclination.” (With this piece its preventative)

This is not a strategy:

“When I forget to pick up my kids, my wife calls to remind me.”

“My teacher always reminded me to sit down.” (In reaction to the symptom- not providing lasting compensation)

“My mom was always reminding me to pay attention while she was speaking to me.” (In reaction to the symptom- not providing lasting compensation)

“I was always the guy that my buddies were poking saying ‘ You’re going to get caught’” (In reaction to the symptom- not providing lasting compensation)

“Do you need supervision?” “If available, absolutely yes. But I always felt like when I was getting reminders I felt picked on by the teachers.” (In reaction- not helping them compensate)

“After being told two or three times, I usually paid attention for a while.” “So they’d help you redirect your attention?” “Yes” (Just helping get back on track- not preventing future occurrences)

Avoidance

We will code for this compensatory strategy if the individual reports escaping from a situation because of their symptoms or denies their existence/the extent of impairment. If the individual denies the extent of their difficulty, but the interviewer marked them as having the symptom, we will code for this strategy. As Avoidance is a strategy that doesn’t help an individual compensate, all examples will be coded with an X.

Examples of what to code with an X:

“I was squirmy at school, but that’s because I was always uncomfortable.”

“School was really boring. The boys in the class were distracted too.”

“I don’t think I forget things more than other people. People forget things too. I’m quick to remember, so it’s not really forgetting. “

“If I’m in a grocery store and I see a long line up, I just leave.”

“As a child, I found I couldn’t handle school so I just retreated to my room a lot.”

“I was squirmy at school, but that’s because I was always uncomfortable.”