Impact of Medication on Performance of Household Chores by Children with ADHD

Abstract

Objective:

To investigate associations between ADHD medication and household chore performance by children with ADHD.

Methods:

A parent questionnaire collected information about the adequacy and quality of their child’s performance of two self-care and six family-care chores. Parent perceptions of ADHD medication effect duration were used to identify children with after-school medication benefits (ASMB). Mann-Whitney U tests compared children with and without ASMB across measures of chore performance.

Results:

A total of 565 parents of children with ADHD that regularly take medication completed the questionnaire. Children with ASMB were more likely to meet parental expectations for five of eight household chores and were more likely to be able to independently complete both self-care and family-care chores than those without ASMB. No differences were noted regarding their need for reminders or assistance with chores.

Conclusion:

Improvement in chore performance may be an additional consideration with respect to medication selection for children with ADHD.

Keywords

ADHD impairment medication functional impairment

Background

Household task engagement has long been considered an important part of childrearing, acting as an integral part of the daily routine while promoting family cohesion. Evidence indicates that lower levels of depression and anxiety, as well as higher self-regulatory capacity, are associated with children’s participation in household tasks (Bridley & Jordan, 2012; Oaten & Cheng, 2006; Pennick, 2013). Additionally, studies indicate that household task engagement during childhood promotes prosocial behavior (Goodnow, 1988; Grusec et al., 1996; Rheingold, 1982) and heightens awareness of others’ needs (Eisenberg et al., 1985).

Despite the presumed social and developmental benefits of engaging children in household tasks, children with Attention-deficit/Hyperactivity Disorder (ADHD)—a condition characterized by significant inattention, impulsivity, and/or hyperactivity (American Psychiatric Association, 2013)—may have challenges participating in household chores. As noted in the DSM-V, children with ADHD often struggle to pay close attention to detail and make careless mistakes (American Psychiatric Association, 2013); although these symptoms are often considered in the context of schoolwork performance, they would likewise result in difficulties with performance of household tasks. Moreover, difficulties sustaining attention to tasks, failure to follow instructions, forgetfulness with daily activities, and failure to finish chores are additional symptoms in the DSM-V noted to be common among children with ADHD (American Psychiatric Association, 2013). Taken together, the symptoms of ADHD, particularly as they relate to inattention, suggest difficulties with participating in—and completing—household tasks, especially without reminders, supervision, and/or assistance from caregivers. Furthermore, studies have found that children with ADHD participate less frequently (Sytsma-Jordan et al., 2002) and often need more assistance (Dunn et al., 2009) with household tasks relative to their non-ADHD peers. In another study of household task participation in children with ADHD, it was found that children with ADHD often need more assistance relative to typically developing children (Dunn et al., 2009). In a more recent study of 797 school-age children with ADHD, it was reported that less than one-third of the children regularly completed chores independently, and only one quarter completed chores satisfactorily (Spaulding et al., 2020). In the same study, the majority of parents reported that they believe ADHD limits their child’s ability to do chores, and they indicated that their children need more reminders and assistance than do neurotypical peers to engage with household chores (Spaulding et al., 2020).

Due to the potential developmental benefits that household task engagement may offer, increasing participation in daily routines has been proposed as an important goal for children with ADHD. In 2013, Pennick demonstrated that household responsibilities are a moderator of internalizing and externalizing behavior in a sample of 49 children with ADHD. Subsequently, using a sample of 371 children with ADHD, Harris et al. (2014) provided evidence in support of increased engagement with household tasks, suggesting that daily routines (e.g., making the bed, completing homework at the same time every day) have beneficial effects on internalizing and externalizing behaviors in children with ADHD.

Psychostimulant medication, the most common treatment for school-age children with ADHD (Danielson et al., 2018), has been shown to improve task persistence (Carlson et al., 1993), and may thus represent a potential intervention for improving engagement with household tasks among children with ADHD. Although there is a gap in the literature around the relationship between medication and chore engagement in the household setting, many studies suggest that medications such as methylphenidate can be an effective intervention to improve task persistence. Placebo-controlled studies analyzing the responses of boys with ADHD taking methylphenidate during puzzle-solving tasks found that boys who were taking medication exhibited greater persistence and a more positive outlook when faced with novel or difficult tasks (Carlson et al., 1993; Pelham et al., 1997). Moreover, an abundance of research indicates that ADHD medication positively impacts persistence in more naturalistic settings, such as in school and at home. During the 14-month active treatment phase of the Multimodal Treatment of ADHD study, children with ADHD treated with medication showed significant decreases from baseline in parent reports of inattention and avoidance of homework (Langberg et al., 2010).

Although prior research has examined the benefits of stimulant medication on homework performance and behavior at home in children with ADHD, no study to date has investigated the impact of medication on the performance of household chores for children with ADHD. This study examines associations between the duration of medication effects and the frequency of engagement with chores, the need for assistance and reminders for engaging with chores, and the ability to complete chores independently and satisfactorily for children with ADHD treated with medication. Given the demonstrated benefits of medication on task completion in the classroom and at home, we expected to find that children that continue to benefit from the effects of medication after the end of the school day would initiate and complete household chores more independently and to a more satisfactory standard than do children that do not experience benefits from their medication after the school day.

Methods

Survey Instrument

An anonymous 72-item questionnaire was developed in Qualtrics to collect demographic and clinical information about school-age children with ADHD, as well as parent assessments of chore performance and medication duration. Parents were asked to rate the effect that ADHD medication has on their child’s attention span, behavior, and chore performance using 4-point Likert items. The effect of medication on chore performance was evaluated across three domains: (1) starting chores without reminders, (2) completing chores independently, and (3) quality of chore performance. Additionally, the questionnaire focused on two self-care (SC) chores (making the bed and cleaning the bedroom) and six family-care (FC) chores (e.g., setting or clearing the table, assisting with family meals/snack preparation) selected from the SC and FC subscales of Children Helping Out: Responsibilities, Expectations, and Supports, a research tool with strong reliability and validity designed to assess children’s participation and performance in household tasks (Dunn, 2009). Parents were asked to rate how often their child with ADHD does each of these chores relative to what is expected of them using 3-point Likert items. The questionnaire also solicited ratings for how often reminders or assistance are needed for SC and FC chores. 5-point Likert items were also used to evaluate how often children complete SC and FC chores independently and how satisfactorily these chores are completed by the child.

Parents of children who take prescription medication for their ADHD on school days were asked “how much longer does [their child’s] ADHD medication continue to work on a typical school day” after their child comes home. Children were considered to have after-school medication benefits (ASMB) if their parents reported that their child’s ADHD medication continues to last after their child returns home on a typical school day.

Survey Dissemination

CHADD (Children and Adults with Attention-deficit/Hyperactivity Disorder), a national non-profit organization that supports and advocates for individuals with ADHD, distributed information about the study to its members using e-mail, Facebook, and an electronic newsletter. Additionally, CHADD’s National Resource Center for ADHD, a CDC-supported public information center, disseminated information about the study through a separate newsletter.

Inclusion Criteria

Study participation was limited to parents of children ages 6–18 years with ADHD that regularly took prescription medication on school days to treat their ADHD. The sample was limited to U.S. families in which the child was living at home during the school year. Children with co-morbid Autism Spectrum Disorder, intellectual disability, or a serious disability/condition that significantly impaired their ability to do chores (e.g., cerebral palsy) were excluded. Parents with more than one child with ADHD were asked to answer questions for their child closest to 10 years of age.

Statistical Analyses

For each measure of medication effect and chore performance, Mann-Whitney U tests were used to compare the distributions of responses between children with and without ASMB, and mean Likert item scores were calculated as an approximate measure of centrality. Associations with p-values less than .05 were considered to be statistically significant, and all significance testing used 2-tailed tests. All calculations and analyses were conducted using the statistical software R, version 3.6.1 (R Foundation). This protocol was approved by the Institutional Review Board at Northwell Health.

Results

Overall 565 participants met inclusion criteria. A total of 70.1% of children in the final sample were male, and the mean age was 11.5 years (SD = 2.86). The majority of respondents were mothers (90.3%), and 87.3% of the parents identified as white. Complete information about medication duration on weekdays was available for 520 children. Of these 520 children, 381 (73.3%) were reported to have ASMB. Additional demographic characteristics of the sample are delineated in Table 1.

Table 1.

Participant/Household/Child Demographics, Online Survey of Parent/Guardians of Children with ADHD (n = 565).

Demographics	n	(%)
Sex of index child
Male	396	(70.1)
Female	169	(29.9)
ADHD sub-type
Combined subtype	405	(71.7)
Inattentive subtype	110	(19.5)
Hyperactive/impulsive subtype	47	(8.3)
Unsure of subtype	3	(0.5)
Comorbidities
Oppositional defiant disorder (ODD)	114	(20.2)
Learning disability	32	(5.7)
Psychiatric disorder (other than ODD)	19	(3.4)
Serious medical condition	22	(3.9)
Parent relationship to index child
Mother	510	(90.3)
Father	35	(6.2)
Other	20	(3.5)
Ethnicity of parent
Hispanic/Latino	37	(6.5)
Not Hispanic/Latino	500	(88.5)
Prefer not to answer	28	(5.0)
Race of parent
White	493	(87.3)
Black or African American	17	(3.0)
Other	17	(3.0)
Prefer not to answer	22	(3.9)
Highest education level of parent
No high school diploma	1	(0.2)
High school graduate	27	(4.8)
Some college, no degree	72	(12.7)
Associate degree (including occupational or academic degrees)	49	(8.7)
Bachelor’s degree	195	(34.5)
Graduate degree	219	(38.8)
Prefer not to answer	2	(0.4)
Approximate annual household income
Less than $20,000	14	(2.5)
$20,000 to $50,000	55	(9.7)
$50,000 to $100,000	131	(23.2)
$100,000 or more	290	(51.3)
Prefer not to answer	70	(12.4)
Not sure	2	(0.4)
Missing	3	(0.5)

Relative to children without ASMB, children with ASMB received significantly higher ratings on all measures of medication effect on attention span and behavior (all p < .001). With respect to performance of household chores, these children also received significantly higher parent ratings of medication effect on self-initiation, independence, and quality (all p < .001). Children with ASMB received significantly higher ratings in meeting parental expectations for both SC chores (making the bed: M_ASMB = 1.85 vs. M_non-ASMB = 1.64, U = 22,665, p = .007; cleaning the bedroom: M_ASMB = 1.70 vs. M_non-ASMB = 1.53, U = 23,017, p = .01). Children with ASMB also received significantly higher ratings in meeting parental expectations for three of the six specific FC chores (doing the laundry: M_ASMB = 2.16 vs. M_non-ASMB = 1.97, U = 23,102, p = .02; cleaning the house: M_ASMB = 2.03 vs. M_non-ASMB = 1.82, U = 22,514, p = .005; taking out the garbage: M_ASMB = 2.28 vs. M_non-ASMB = 2.09, U = 23,076, p = .02). Although no differences were noted with respect to need for reminders or assistance with either SC or FC chores, children with ASMB were rated significantly higher for ability to independently complete SC chores (M_ASMB = 3.07 vs. M_non-ASMB = 2.87, U = 23,493, p = .04) and FC chores (M_ASMB = 3.07 vs. M_non-ASMB = 2.81, U = 23,248, p = .03). Additional comparisons between children with and without ASMB are presented in Table 2.

Table 2.

Associations Between Chore Performance and After-School Benefits of ADHD Medication in Children with ADHD on Medication (n = 520).

	Mean rating		Mann-Whitney U statistic	p value^a
	Children without ASMB^b (n = 139)	Children with ASMB^b (n = 381)	Mann-Whitney U statistic	p value^a
After-school effect of ADHD medication on:^c
Starting chores without reminders	1.59	2.04	17,526	<.001
Completing chores independently	1.62	2.23	15,716	<.001
Quality of chore performance	1.61	2.28	14,240	<.001
Frequency of child doing chore relative to parent expectations^d
SC chores:
Child makes their bed	1.64	1.85	22,664	.007
Child cleans their bedroom	1.53	1.70	23,016	.01
FC chores:
Child sets or clears the table	2.11	2.24	23,900	.07
Child assists with meal/snack preparation	2.06	2.19	24,132	.10
Child washes or dries dishes	2.00	2.15	23,744	.06
Child does laundry	1.97	2.16	23,102	.02
Child does housecleaning	1.82	2.03	22,514	.005
Child takes out the garbage	2.09	2.28	23,076	.02
Chore performance metrics^e
Child needs assistance for:
SC chores	3.40	3.28	28,650	.14
FC chores	3.52	3.45	27,572	.46
Child needs reminders for:
SC chores	4.55	4.40	28,934	.07
FC chores	4.51	4.45	27,620	.39
Child independently completes:
SC chores	2.87	3.07	23,493	.04
FC chores	2.81	3.07	23,248	.03
Child satisfactorily completes:
SC chores	2.93	2.95	26,012	.74
FC chores	2.89	2.99	25,637	.55

Note. Bold emphasis denotes a p-value of <0.05.

p-values from the Mann-Whitney U test comparing children with and without ASMB.

After-School Medication Benefits (ASMB) was a binary measure defined by responses to the question: “When your child comes home from school, how much longer does the ADHD medication continue to work on a typical school day?” Children with a response of “0 hour (medication has worn off)” were defined to not have ASMB and children with a response with any non-zero duration were defined to have ASMB.

Scored using Likert item: (1) No effect, (2) Small effect, (3) Medium effect, (4) Large effect.

Scored using Likert item: (1) Much less than expected, (2) Less than expected, (3) As much or more than expected.

Scored using Likert item: (1) Very rarely, (2) Rarely, (3) Sometimes, (4) Often, (5) Very often.

Discussion

This study, analyzing a cohort of 520 children with ADHD being treated with medication, examined the relationship between medication and chore performance using a dichotomous comparison of chore performance between children with and without ASMB. The results from this approach indicate that medication for ADHD may reduce the need for reminders, increase independent completion of chores, and improve quality of chore completion. Children with ASMB were also more likely to do chores at a frequency which better satisfied parental expectations, suggesting that giving children medication that lasts after the end of the school day may help reduce elements of household tension and conflict associated with poor chore performance.

There were several strengths of this study. First, the study relied on a large and clinically diverse sample. Additionally, the male-to-female ratio of children with ADHD in this study was in line with those of other studies looking at children and adolescents with ADHD, enhancing the generalizability of our results (Gaub & Carlson, 1997; Novik et al., 2006; Willcutt, 2012). Finally, this is the first analysis of potential associations between ADHD medication and various measures of chore performance.

However, the limitations of this study must be noted. In particular, analyses were based on parent-report data; therefore, approximations of the duration and magnitude of the effects of medication were subjective and potentially imprecise. Moreover, parent report of the duration of their child’s ADHD medication’s effects may have been impacted by their child’s behavior at home, including behavior as it related to household chores. However, clinical goals for determining whether children with ADHD benefit from medication are not generally focused on household chore performance, and widely used ADHD-parent rating scales do not include items specifically examining chore performance (e.g., NICHQ Vanderbilt Assessment Scale, Conners 3), so it is likely that parents primarily relied on homework performance and overall behavior when approximating the duration of medication benefits. Concerns about endogeneity due to this limitation could be addressed in the future by gathering detailed information about medication formulation and time of administration and by including an objective measure of medication effects.

Another notable limitation relates to the specific chores examined in this study. Our study examined associations between medication and eight specific household chores; medication may have different associations with other SC chores (such as making oneself a snack and cleaning up one’s toys after play) and FC chores (such as cleaning the bathroom and dusting the house) than the ones included in this study.

An additional limitation is that the sample in this study—relative to the population of the U.S.—was disproportionately white, of a higher socioeconomic status, and of a higher educational background. These sample demographics may limit the generalizability of this study due to differences in parent expectations regarding chores among households of different socioeconomic and cultural backgrounds. Furthermore, the sample is skewed in terms of ADHD severity. In a recent, nationally representative sample of children in the U.S., approximately two-thirds of school-age children with ADHD currently being treated with medication were classified by their parents as having moderate or severe ADHD, whereas 94% of the children in our sample were classified as having moderate or severe ADHD (Child and Adolescent Health Measurement Initiative, 2019). These deviations from the national population may be a result of non-response bias given the focus of the questionnaire itself, or they may reflect underlying differences between the demographics of the general public and those of parents of children with ADHD that engage with CHADD resources.

Conclusion

Our findings suggest that medication may improve the ability of children with ADHD to engage with household chores. To the extent that previous research has demonstrated that medication improves task persistence in children with ADHD, these findings are not surprising. To contextualize our findings and better evaluate the efficacy of ADHD medication on chore performance, randomized controlled trials with objective measures of chore performance must be conducted. In particular, a crossover study design could allow prospective assessment of ADHD medication impact on chore performance while permitting each subject to serve as their own control, reducing the impact of confounders. Given the importance of participation in household routines such as chores for the development of prosocial behavior and the improvement of children’s feelings of confidence and self-efficacy, medication with longer-lasting effects may be beneficial for children with ADHD who struggle with performing household routines.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Eli Rapoport

Derek Soled

Andrew Adesman

Author Biographies

Faith Park, BS, was a research assistant at Cohen Children’s Medical Center of New York. She graduated from Cornell University with a Bachelor’s degree in Human Development and plans to pursue a career in healthcare.

Eli Rapoport, BS, is a research assistant at Cohen Children’s Medical Center of New York. He is now a medical student at the New York University Grossman School of Medicine.

Derek Soled, BA, MSc, was a research assistant at Cohen Children’s Medical Center of New York. He is now at Harvard University pursuing his medical degree and a Master’s in Business Administration.

Andrew Adesman, MD, is professor of Pediatrics at the Zucker School of Medicine at Hofstra/Northwell, and he is Chief of Developmental & Behavioral Pediatrics at Cohen Children’s Medical Center of New York.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publications.

Bridley

Jordan

S. S.

(2012). Child routines moderate daily hassles and children’s psychological adjustment. Children’s Health Care, 41(2), 129−144.

Carlson

C. L.

Pelham

W. E.

Milich

Hoza

(1993). ADHD boys’ performance and attributions following success and failure: Drug effects and individual differences. Cognitive Therapy and Research, 17(3), 269−287.

Child and Adolescent Health Measurement Initiative. (2019). 2016-2017 National survey of children’s health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the US Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved June 24, 2019, from www.childhealthdata.org. CAHMI: www.cahmi.org

Danielson

M. L.

Visser

S. N.

Chronis-Tuscano

DuPaul

G. J.

(2018). A national description of treatment among United States children and adolescents with attention-deficit/hyperactivity disorder. The Journal of Pediatrics, 192, 240−246.

Dunn

(2009). Validation of the CHORES: A measure of school-aged children’s participation in household tasks. Scandinavian Journal of Occupational Therapy, 11, 179−190.

Dunn

Coster

W. J.

Orsmond

G. I.

Cohn

E. S.

(2009). Household task participation of children with and without attentional problems. Physical & Occupational Therapy in Pediatrics, 29(3), 258−273.

Eisenberg

Lundy

Shell

Roth

(1985). Children’s justifications for their adult and peer-directed compliant (prosocial and nonprosocial) behaviors. Developmental Psychology, 21(2), 325.

Gaub

Carlson

C. L.

(1997). Gender differences in ADHD: A meta-analysis and critical review. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1036–1045.

10.

Goodnow

J. J.

(1988). Children’s household work: Its nature and functions. Psychological Bulletin, 103(1), 5.

11.

Grusec

J. E.

Goodnow

J. J.

Cohen

(1996). Household work and the development of concern for others. Developmental Psychology, 32(6), 999.

12.

Harris

A. N.

Stoppelbein

Greening

Becker

S. P.

Luebbe

Fite

(2014). Child routines and parental adjustment as correlates of internalizing and externalizing symptoms in children diagnosed with ADHD. Child Psychiatry & Human Development, 45(2), 243−253.

13.

Langberg

J. M.

Arnold

L. E.

Flowers

A. M.

Epstein

J. N.

Altaye

Hinshaw

S. P.

Swanson

J. M.

Kotkin

Simpson

Molina

B. S.

Jensen

P. S.

Abikoff

Pelham

W. E.

Jr Vitiello

Wells

K. C.

Hechtman

(2010). Parent-reported homework problems in the MTA study: Evidence for sustained improvement with behavioral treatment. Journal of Clinical Child & Adolescent Psychology, 39(2), 220−233.

14.

Novik

T. S.

Hervas

Ralston

S. J.

Dalsgaard

Pereira

R. R

Lorenzo

J. M.

& ADORE Study Group. (2006). Influence of gender on attention-deficit/hyperactivity disorder in Europe – ADORE. European Child & Adolescent Psychiatry, 15, i15−i24.

15.

Oaten

Cheng

(2006). Improved self-control: The benefits of a regular program of academic study. Basic and Applied Social Psychology, 28(1), 1−16.

16.

Pelham

W. E.

Hoza

Kipp

H. L.

Gnagy

E. M.

Trane

S. T.

(1997). Effects of methylphenidate and expectancy on ADHD children’s performance, self-evaluations, persistence, and attributions on a cognitive task. Experimental and Clinical Psychopharmacology, 5(1), 3.

17.

Pennick

M. R.

(2013). Understanding the relation between routines and problem behaviors in children with clinical diagnoses. The University of Alabama at Birmingham.

18.

Rheingold

H. L.

(1982). Little children’s participation in the work of adults, a nascent prosocial behavior. Child Development, 53(1), 114−125.

19.

Spaulding

S. L.

Fruitman

Rapoport

Soled

Adesman

(2020). Impact of ADHD on Household Chores. Journal of Attention Disorders. Advance online publication. https://doi.org/10.1177/1087054720903359

20.

Sytsma-Jordan

Kelley

M. L.

Henderson

(2002). Children’s routines, parenting stress, and maternal depression in parent-child dyads referred to a multidisciplinary ADHD clinic and nonreferred controls. A poster presented at the 36th annual meeting of the Association for the Advancement of Behavior Therapy, Reno, NV.

21.

Willcutt

E. G.

(2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics, 9, 490–499.