There is some evidence to indicate that organisation, time management and planning improve inattention, hyperactivity-impulsivity and academic impairment in adults with ADHD. So called compensatory behaviours can therefore be used to help adults reduce the functional impairments associated with ADHD. Compensatory behaviours include tools such as: to-do lists; calendars/planners; reminders; alarms; as well as engaging in checking behaviours to reduce forgetting or completing tasks when they are given. However, there is currently no scale to measure the use and effectiveness of these compensatory strategies. Therefore the Compensatory ADHD Behaviours Scale (CABS)* was designed, allowing individuals to report if they are employing compensatory strategies and whether their use is proving to be helpful. The purpose of this study is to report the development and initial validation of CABS in adults with ADHD.
CABS was developed using ADHD treatment manuals, clinical observations and scales measuring impairment, focusing on domains reported to be difficult for individuals with ADHD, such as time management, organisation and planning. These domains were selected based on the knowledge that cognitive behavioural therapy in adults focuses on these areas, and because executive functioning scales typically cluster around these domains. Within these areas, the CABS was designed to both assess the use and effectiveness† of compensatory strategies. As well as completing the CABS, participants were required to complete the Adult ADHD Self-Report Scale (ASRS), the Current Behaviours Scale (CBS), the Obsessive-Compulsive Inventory-Short Version (OCI-R), the Patient-Reported Outcomes Measurement Information System (PROMIS)-Anxiety and Depression-Short Forms and the Weiss Functional Impairment Rating Scale (WFIRS).
A total of 484 individuals were included in the study (mean age, 36.83 years; standard deviation 11.57; 57.3% female), 31 (6.4%) had a self-reported primary diagnosis of ADHD and 72 participants reported ≥1 current mental health diagnosis. Each participant completed a 376-question battery, composed of previously established measures and the CABS. Factor analysis revealed a 2-factor solution for both the use and effectiveness of compensatory behaviours,§ reflecting either present or future use, and confirmed that the CABS can accurately assess both factors in a parallel manner. Assessment of these subscales showed that present-oriented use and effectiveness of compensatory behaviours were negatively correlated with ASRS total score (r=-0.25 and r=-0.09, p=<0.001 and p<0.05, respectively) and CBS (r=-0.30 and r=-0.18, p<0.001 and p<0.01, respectively). Present-oriented use and effectiveness of the CABS was also significantly correlated with WFIRS (r=-0.24 and r=-0.14, p<0.001 and p<0.01, respectively). CABS future-oriented use and effectiveness subscales were not significantly related to ASRS, CBS or WFIRS (p>0.05 for all). Additionally the effectiveness, but not use, of these present-oriented compensatory behaviours showed validity in predicting impairment. Together, the results of this study show that present-oriented, but not future-oriented, compensatory behaviours were more associated with ADHD symptoms, executive functioning deficits and total functional ADHD-related impairment. Additionally, with regard to psychiatric comorbidities, this study showed that present-oriented use and effectiveness was significantly negatively correlated with the PROMIS-depression score (p<0.05), demonstrating that greater depressive symptoms were associated with less use and effectiveness of present-oriented compensatory behaviours. The CABS future-oriented use subscale was positively correlated with both OCI-R and PROMIS-Anxiety, and the future-oriented effectiveness subscale was positively correlated with OCI-R (all p<0.05), suggesting that greater use of future-oriented compensatory strategies was associated with obsessive-compulsive disorder (OCD) and anxiety symptomatology, but effectiveness of these strategies was only associated with OCD symptomatology.
There were several limitations to this study. The first relates to the sample of adults used; although the study utilised a large group, the financial incentive offered may have led to dishonest participation as well as repeat responders, despite the safeguards put in place (e.g. the inclusion of unannounced validity questions within the questionnaire). Additionally the sample was not limited to a clinical population, and consisted of predominantly female participants. The generalisability of these study results to a clinical group in a male-dominated disorder is therefore questionable. Moreover, as this study is the first to report the development and validation of the CABS, a confirmatory factor analysis could not be completed; therefore, future studies should look to confirm the factor structure of the CABS, in addition to investigations in a clinical sample.
This study provides preliminary evidence that the CABS has the ability to measure various compensatory behaviours associated with ADHD symptomatology, executive functioning and overall impairment. Future studies would benefit from the inclusion of a more homogenous clinical population with formal ADHD diagnoses. This tool, with some adaptation, may also prove useful in adolescent ADHD populations.
*The CABS is a ubiquitous behavioural measure, designed to have utility beyond assessing ADHD treatment progress and outcomes. This potentially gives it a wide range of uses, aiding adults with both clinical and non-clinical ADHD, students, and the general population who experience occupational, family and/or social functional impairment
†To create the CABS use subscale, participants were asked if they used specific compensatory behaviours. The CABS effectiveness subscale was created by changing the language of the CABS use subscale to reflect whether the behaviour had been helpful
‡Participants were recruited using Amazon’s Mechanical Turk (MTurk), a website providing payment for completing a specified task ($1.50 in this study). MTurk has been shown to provide data with sound psychometric properties and is similar demographically to national populations. It has been used in previous studies for clinical and measure development
§Compensatory behaviours included: checking things to make sure there are no mistakes; completing tasks as soon as possible so they aren’t forgotten; keeping things organised so things aren’t misplaced; keeping things in sight or in a specific spot to stay organised; using planners to keep track of day-to-day tasks or activities; using calendars to keep track of future tasks or activities; using to-do lists to keep track of tasks or activities; using reminders to keep track of important tasks or activities; asking friends or family to remind about important tasks or activities that I have; scheduling more time for certain tasks or activities to make sure they can be completed; using alarms to remind about important tasks or activities; creating organisational strategies to help manage day-to-day tasks or activities; creating budgets to help manage money/bank accounts; taking care of prior commitments before making new ones
Castagna PJ, Roye S, Calamia M. The Compensatory ADHD Behaviours Scale (CABS): development and initial validation. Assessment 2018; Epub ahead of print.