Levels of Proneness to Boredom in Children with Attention-Deficit/Hyperactivity Disorder On and Off Methylphenidate Treatment

Abstract

Objective:

To evaluate the relationship between attention-deficit/hyperactivity disorder (ADHD) severity and propensity for boredom in children with ADHD, both on and off methylphenidate (MPH).

Methods:

A group of children and adolescents with ADHD (n = 30), aged 7–18 years, were assessed using the Parent-Reported-ADHD Rating Scale-5 (PR-ADHD-RS-5) and Short Boredom Proneness Scale (SBPS), at baseline, after 3 months of MPH treatment, and again after 3 weeks of MPH treatment discontinuation.

Results:

Significant correlation was found at baseline between PR-ADHD-RS-5 and SBPS scores [n = 30, r = 0.40 (95% confidence interval {CI} = 0.048–0.67), p = 0.027]. Both ADHD and boredom levels decreased significantly after 3 months of MPH treatment. Significant correlation was found between the reductions in PR-ADHD-RS-5 and SBPS scores at this time [n = 30, r = 0.39 (95% CI = 0.035–0.66), p = 0.045]. MPH discontinuation for 3 weeks resulted in mild but statistically significant increases in ADHD and SBPS levels. No significant correlation was detected between the changes in PR-ADHD-RS-5 and SBPS scores after 3 weeks of MPH discontinuation.

Conclusions:

Three months of MPH treatment resulted in parallel improvement in ADHD severity and in the level of proneness to boredom (PtB), whereas discontinuation of MPH administration is associated with increases in the two parameters, causing them to approach pretreatment levels. Clinicians and parents should be aware of the possibility of increased PtB in children with ADHD who discontinue MPH treatment. Structured daily activity and continuation of MPH treatment may preserve the beneficial effects of MPH on academic and leisure activities and may prevent aggravation of subjective boredom sensations that could lead to risky sensation-seeking behaviors and overuse of electronic devices.

Introduction

Boredom is defined as dissatisfaction that is associated with an unpleasant transient state in which the individual feels a lack of interest in the currently available activities and difficulty concentrating on them (Watt and Vodanovich 1999). A dysfunction of broad attentional networks contributes to boredom (Eastwood et al. 2012). Increased boredom was reported among patients with attention-deficit/hyperactivity disorder (ADHD) associated with clinically significant cognitive impairment (Malkovsky et al. 2012). Hyperactivity, inattention, impulsivity, sensation seeking, and executive dysfunction in the context of ADHD were also reported to be significant predictors of proneness to boredom (PtB; Kass et al. 2003, Gerritsen et al. 2014, Maggini 2000, Watt and Vodanovich 1992).

Malkovsky et al. (2012) evaluated the relationship between PtB and sustained attention in adults with ADHD. They found that patients with higher levels of PtB performed poorer on tasks requiring sustained attention and demonstrated more symptoms of both, ADHD and depression. Adults and children with high Boredom Proneness Scale (BPS) scores and children who have ADHD have been reported to be inaccurate in their estimations of the passage of time (Watt and Davis 1991).

Stimulants, including methylphenidate (MPH) have agonistic dopamine and norepinephrine activity and are the treatment of choice in ADHD. In ADHD, novelty and sensation seeking as well as PtB may respond to stimulants (Hutchison et al. 1999; Dahlen et al. 2005; Gvirts et al. 2017).

Hutchison et al. (1999) examined the impact of a single challenge of d-amphetamine on measures of novelty and sensation seeking in the context of psychophysiological and subjective measures of excitement. They found that individuals with higher scores in novelty and sensation seeking are more sensitive to the effects of d-amphetamine.

The aims of this study were to evaluate ADHD severity and PtB levels in children with ADHD, when they are on MPH (during the academic year) and when they are off it during holidays.

Methods

Participants

Thirty children and adolescents (21 boys and 9 girls) from the pediatric outpatient clinic at the Geha Mental Health Center (GMHC), aged 7–18 (mean ± standard deviation [SD]: 12.2 ± 1.9) years participated in the study. Diagnosis of ADHD was established based on the criteria of the DSM-5 for ADHD and following individual interviews conducted by a senior child and adolescent psychiatrist, following the guidelines of Kiddie-SADS-Present and Lifetime Version DSM-5 (Kaufman et al. 2016). The severity of ADHD was assessed using the Parent-Reported-ADHD Rating Scale-5 (PR-ADHD-RS-5; DuPaul et al. 2016).

Subjects with diagnosis of intellectual disability, psychosis, bipolar disorder, or autism spectrum disorder were not included in the study.

Inclusion criteria were participants with ADHD who usually stop the MPH treatment during the holidays. Every patient was assessed three times, at baseline, after 3 months of MPH treatment, and again after having stopped MPH treatment for 3 weeks. All assessments were done using PR-ADHD-RS-5 and Short-BPS (SBPS).

Measures

The ADHD Rating Scale-5 (DuPaul et al. 2016).

ADHD symptoms severity was assessed using the PR-ADHD-RS-5. It includes nine items measuring symptoms of inattention and nine items measuring symptoms of hyperactivity and impulsivity, based on the diagnostic criteria for ADHD of the DSM-5. PR-ADHD-RS-5 has been widely used as a measure of ADHD severity in clinical trials in children and adolescents.

SBPS (Struk et al. 2017)

SBPS is a self-report questionnaire consisting of eight items with good internal consistency and construct validity comparable with the original BPS. It includes the following items: (1) I often find myself at “loose ends,” not knowing what to do; (2) I find it hard to entertain myself; (3) many things I have to do are repetitive and monotonous; (4) it takes more stimulation to get me going than most people; (5) I do not feel motivated by most things that I do; (6) in most situations, it is hard for me to find something to do or see to keep me interested; (7) much of the time, I just sit around doing nothing; and (8) unless I am doing something exciting, even dangerous, I feel half-dead and dull. The SBPS was validated in young subjects (Struk et al. 2017).

All patients received MPH in a fixed dose [1 mg/(kg·d)] until the 3-week discontinuation period. Informed consent was obtained from the participants and their parents and the study was approved by the GMHC review board.

Statistical analysis

Two-tailed paired and unpaired Student's t-tests and Spearman's correlation test were used as appropriate. All results are expressed as mean ± SD.

Results

Participants

Both pretreatment ADHD levels, as assessed by the PR-ADHD-RS-5 scale, and the PtB levels, as assessed by the SBPS, decreased significantly after 3 months of MPH treatment (PR-ADHD-RS-5: 33.9 ± 9.6 vs. 24.5 ± 5.9, df = 29, paired t = 7.5, p < 0.0001 and SBPS: 19.7 ± 6.5 vs. 17.6 ± 5.2, paired t = 3.3, df = 29, p < 0.0023, respectively).

MPH discontinuation for 3 weeks resulted in mild but statistically significant increases in PR-ADHD-RS-5 and SBPS compared with the second time point assessment values (PR-ADHD-RS-5: 24.5 ± 5.9 vs. 31.2 ± 7.1, paired t = 7.1, df = 29, p < 0.0001 and SBPS: 17.6 ± 5.2 vs. 18.5 ± 6.1, df = 29, paired t = 2.1, p = 0.045). The postdiscontinuation values of both scales approached the baseline values (33.9 ± 9.6 and 19.7 ± 6.5, respectively).

Correlations

Significant correlation was found at baseline between PR-ADHD-RS-5 and SBPS scores [n = 30, r = 0.40 (95% confidence interval {CI} = 0.048–0.67), p = 0.027].

Significant correlation was found also between the changes in PR-ADHD-RS-5 and SBPS scores after 3 months of MPH treatment [n = 30, r = 0.39 (95% CI = 0.035–0.66), p = 0.045].

No such significant correlation was detected in the changes in PR-ADHD-RS-5 and SBPS scores after 3 weeks of MPH discontinuation [n = 30, r = 0.03 (95% CI = 0.33–0.38), p = 0.86].

Discussion

We evaluated the relationship between ADHD severity and PtB levels in children with ADHD at three time points: pretreatment (i.e., baseline holiday), while treated with MPH (during schooltime), and when they are again off medication for 3 weeks (summer break).

Similar to previous studies (Kass et al. 2003; Gerritsen et al. 2014), a significant correlation was found at baseline between the levels of PR-ADHD-RS-5 and PtB (p = 0.027), indicating that high levels of ADHD symptoms, including inattention, hyperactivity, and impulsivity, are associated with PtB. Malkovsky et al. (2012) evaluated the relationship between PtB and sustained attention in adults with ADHD. They found that patients with higher levels of PtB performed poorer on a task of sustained attention and demonstrated more symptoms of both ADHD and depression. In this study, unsurprisingly a significant improvement was found in PR-ADHD-RS-5 levels after 3 months of MPH treatment (p = 0.0001), as well as in PtB levels as assessed by SBPS (p = 0.0023). Moreover, significant correlation was found between the improvements in the two scales after 3 months of MPH treatment (p = 0.045). The decrease in PtB levels after MPH treatment may be related to the attenuation of inattention, impulsiveness, and hyperactivity. Overlapping neurocognitive parameters that play a role in both ADHD and PtB may include impaired working memory and executive function as well as increased novelty-seeking parameters that improved after MPH treatment (Diamond 2005; Gerritsen et al. 2014; Danckert and Merrifield 2018) and may lead eventually to attenuation of PtB.

Notably, the correlation between the changes in PR-ADHD-RS-5 and SBPS scores was lost after MPH discontinuation for 3 weeks during summer break (p = 0.86). Thus it appears that the correlation between the improvements in the two scales exists only during the MPH-assisted academic activity. Evidence shows that higher PtB scores are associated significantly with poor academic satisfaction (Watt and Vodanovich 1999). MPH treatment is associated with better general functioning and academic achievements (Golubchik et al. 2018) that may be relevant to decreased PtB.

Children with ADHD may have a harder time filling their unstructured vacation time with interesting and exciting activities. Such feeling of boredom during free time may be ascribed to decreased social interactions and academic inactivity, leading to Internet overuse and other problematic behaviors that frequently amplify the sense of boredom (Weinstein et al. 2017). Moreover, the rise in the level of boredom during MPH discontinuation in the vacation period may be related to the absence of the structured nature of an academic activity, the lack of the regulatory effect of MPH on impulsivity, increased sensation/novelty-seeking/risk-taking behaviors, and Internet and online gaming overuse (Watt and Vodanovich 1992; Wegmann et al. 2017; Chou et al. 2018).

Previous studies (Han et al. 2009; Weinstein et al. 2017) found that MPH treatment can reduce the severity of problematic Internet gaming in children with ADHD. MPH improves core ADHD symptoms, such as impulse dyscontrol and inattention, working memory, and executive function, which may be relevant to PtB and overuse of Internet gaming as well as novelty seeking (Donfrancesco et al. 2015).

It is of note that the correlation between boredom and ADHD symptoms is lost when the children are off MPH treatment during vacation periods. Hence, it seems that additional ADHD-independent factors may contribute to boredom, including comorbid conditions, such as depression, anxiety, hostility, and anger (Vodanovich et al. 1991). Alternatively, if the correlation between ADHD and symptoms is lost during the summer vacation, when the patients are not receiving treatment and are more symptomatic, it is possible that when there are less academic demands and children are free to play outside, there is less boredom. If children experience less boredom when they are more symptomatic, which is contrary to the hypothesis of the study, it may imply that perceptions of boredom are highly sensitive to environmental demands, and to attempts to control the ADHD symptoms.

Limitations

The main limitations of this study are the open label design, the relatively small sample size, the use of a single instrument to evaluate PtB, the lack of neurocognitive assessments, and a control group that would not discontinue MPH treatment during holidays as well as a group that would interrupt MPH treatment during schooltime rather than during time off school. It is possible that the impact of MPH discontinuation on PtB during schooltime is different than it is during vacation periods.

MPH in this study was used in a fixed dose until the 3-week discontinuation period.

Giving all patients a fixed weight-based dose could not minimize variations in discontinuation. Hence, there is a wide interindividual variability in the optimal MPH dose. It is unknown how the outcome would have varied if each patient had been dose optimized.

No data was collected on other negative conditions of the participants, such as poor psychosocial functioning, behavioral problems, poor social adjustment, hostility and aggression, or subclinical anxiety or depression levels that may continue and even exacerbate during vacation time, leading to elevation in PtB levels. Moreover, we did not unfortunately collect data on possible improvement in PtB levels after restoration of MPH therapy.

Conclusions

Children with higher levels of ADHD also show higher levels of PtB, at least during schooltime. MPH treatment is associated with parallel improvements in ADHD severity and in propensity to experience boredom, whereas discontinuation of MPH administration during a school vacation is associated with increases in the two parameters, approaching baseline levels. Clinicians and parents should be aware of the possibility that MPH discontinuation, especially in children with ADHD, may be associated with increased PtB. Structured daily activity and continuation of MPH treatment may preserve the beneficial effects of MPH on academic and leisure activities and can prevent intensification of subjective boredom sensations that may lead to risky sensation-seeking behaviors and overuse of electronic devices.

Clinical Significance

Clinicians and parents should be aware that increased PtB in children with ADHD may be improved by MPH treatment. In our study, there are no data on the practical implications of boredom. However, PtB may be responsible for risky sensation-seeking behaviors as well as excessive gaming and dependence on the Internet for stimulation. Moreover, persistent feelings of boredom may be associated with or promote feelings of insecurity and lowered self-esteem. It is possible that structured daily activity and continuation of MPH treatment can prevent aggravation of subjective boredom sensations that may lead to risky sensation-seeking behaviors and overuse of electronic devices.

Footnotes

Disclosures

P.G., I.M., G.S., and A.W. have nothing to declare and have no financial relationships with any pharmaceutical company.

References

Chou

, Chang

, Yen

: Boredom proneness and its correlation with Internet addiction and Internet activities in adolescents with attention-deficit/hyperactivity disorder. Kaohsiung J Med Sci, 34:467–474, 2018.

Dahlen

, Martin

, Ragan

, Kuhlman

. Driving anger, sensation seeking, impulsiveness, and boredom proneness in the prediction of unsafe driving. Accid Anal Prev, 37:341–348, 2005.

Danckert

, Merrifield

Boredom, sustained attention and the default mode network. Exp Brain Res, 236:2507–2518, 2018.

Diamond

: Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity). Dev Psychopathol, 17:807–825, 2005.

Donfrancesco

, Di Trani

, Porfirio

, Giana

, Miano

, Andriola

: Might the temperament be a bias in clinical study on attention-deficit hyperactivity disorder (ADHD)?: Novelty Seeking dimension as a core feature of ADHD. Psychiatry Res, 227:333–338, 2015.

Dupaul

, Reid

, Anastopoulos

, Lambert

, Watkins

, Power

: Parent and teacher ratings of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data. Psychol Assess, 28:214–225, 2016.

Eastwood

, Frischen

, Fenske

, Smilek

: The unengaged mind: defining boredom in terms of attention. Perspect Psychol Sci, 7:482–495, 2012.

Gerritsen

, Toplak

, Sciaraffa

, Eastwood

: I can't get no satisfaction: Potential causes of boredom. Conscious Cogn, 27:27–41, 2014.

Golubchik

, Hamerman

, Manor

, Peskin

, Weizman

: Effectiveness of parental training, methylphenidate treatment, and their combination on academic achievements and behavior at school of children with attention-deficit hyperactivity disorder. Int Clin Psychopharmacol, 33:229–232, 2018.

10.

Gvirts

, Mayseless

, Segev

, Lewis

, Feffer

, Barnea

, Bloch

, Shamay-Tsoory

: Novelty-seeking trait predicts the effect of methylphenidate on creativity. J Psychopharmacol, 31:599–605, 2017.

11.

Han

, Lee

, Na

, Ahn

, Chung

, Daniels

, Haws

, Renshaw

: The effect of methylphenidate on Internet video game play in children with attention-deficit/hyperactivity disorder. Compr Psychiatry, 50:251–256, 2009.

12.

Hutchison

, Wood

, Swift

: Personality factors moderate subjective and psychophysiological responses to d-amphetamine in humans. Exp Clin Psychopharmacol, 7:493–501, 1999.

13.

Kass

, Wallace

, Vodanovich

: Boredom proneness and sleep disorders as predictors of adult attention deficit scores. J Atten Disord, 7:83–91, 2003.

14.

Kaufman

, Birmaher

, Axelson

, Perepletchikova

, Brent

, Ryan

: K-SADS-PL DSM-5 [Online]. Yale University, New Haven, CT, 2016. Available at: https://www.kennedykrieger.org/sites/default/files/library/documents/faculty/ksads-dsm-5-screener.pdf (accessed 2019).

15.

Maggini

: Psychobiology of boredom. CNS Spectr, 5:24–27, 2000.

16.

Malkovsky

, Merrifield

, Goldberg

, Danckert

: Exploring the relationship between boredom and sustained attention. Exp Brain Res, 221:59–67, 2012.

17.

Struk

, Carriere

, Cheyne

, Danckert

: A Short Boredom Proneness Scale. Assessment, 24:346–359, 2017.

18.

Vodanovich

, Verner

, Gilbride

: Boredom proneness: Its relationship to positive and negative affect. Psychol Rep, 69:1139–1146, 1991.

19.

Watt

, Davis

: The prevalence of boredom proneness and depression among profoundly deaf residential school adolescents. Am Ann Deaf, 136:409–413, 1991.

20.

Watt

, Vodanovich

: Relationship between boredom proneness and impulsivity. Psychol Rep, 70:688–690, 1992.

21.

Watt

, Vodanovich

: Boredom proneness and psychosocial development. J Psychol, 133:303–314, 1999.

22.

Wegmann

, Oberst

, Stodt

, Brand

: Online-specific fear of missing out and Internet-use expectancies contribute to symptoms of Internet-communication disorder. Addict Behav Rep, 5:33–42, 2017.

23.

Weinstein

, Livny

, Weizman

: New developments in brain research of internet and gaming disorder. Neurosci Biobehav Rev, 75:314–330, 2017.