Ethics

The study was approved by the Swedish Ethics Review Authority (registration number 2020–01414). One month before the interviews, information letters were sent to the potential participants, which included an invitation to participate in the interview. They were then contacted by phone and invited to take part in the TaMa–ADHD study. Oral and written consent was obtained from the adolescents before the interviews started. In Sweden, consent from parents or guardians is not required for adolescents who have reached the age of 15 years. The interviews were recorded and saved in a file on the secure hospital server. All data were handled confidentially, and no individual participant could be identified. The participants were informed that they could withdraw their participation at any time before submission without giving a reason or without any consequences for their care. Adolescents who were interested in the results were informed that they could contact the first author for information.

Study design

The study is part of the Tactile Massage (TaMa)-ADHD research project. Other results from this research will be presented elsewhere. Here we present results from an interview study with semi-structured questions. In qualitative content analysis, the researchers strive to make the participants’ voices heard [20]. The rationale behind adopting a qualitative study design is to capture variations in experiences within a population, in this case, adolescents with ADHD. The purpose of employing this design was to interpret and comprehend adolescents’ perspectives and how the diagnosis influences their lives. Qualitative content analysis considers a text in its context and the interpretation of participants’ narratives should be done with an awareness of their life conditions, history, and prevailing culture [21].

Participants

The participants were retrieved from the patient registration system of a child and adolescent psychiatry clinic in Western Sweden, based on diagnosis and medication. To obtain a homogeneous group, the inclusion criteria were: 1) age 15:0–17:11 years; 2) previously diagnosed with ADHD in combined form F90.0B according to the International Classification of Diseases (ICD-10) [22]; 3) unmedicated or medicated with central stimulants and/or atomoxetine without modifications in the medication for the last six months. Sleep medication such as melatonin or promethazine was allowed; 4) able to speak, write and read Swedish. Exclusion criteria were: 1) ongoing suicidality; 2) ongoing substance abuse; 3) other severe mental disorders, such as autism, severe depression, epilepsy, manic episode or psychosis and intellectual disability; 4) involvement in other ongoing psychological treatment such as psychotherapy, group therapy and parent training. In September 2021 the clinic registration system contained 377 adolescents aged 15–17 years diagnosed with ADHD and comorbid conditions. From these, a homogenous group of 195 with combined type ADHD who did not have any of the excluded diagnoses was chosen. After a review of each patient’s record (from September to October 2021) to check for the inclusion and exclusion criteria, 78 adolescents were selected. An invitation letter was sent to all 78 adolescents containing information about the study and informing them that the first author would contact them from a randomised list or that they could contact the first author themselves. The recruitment ended after 14 adolescents had agreed to participate in the whole TaMa-ADHD study. No additional adolescents volunteered after the inclusion period ended, eliminating the necessity to exclude anyone from participation. In qualitative content analysis, research questions frequently appear to be adequately addressed with 10–15 participants [23]. This validates the acceptability of the chosen sample size of 14 participants. All 14 participants, five girls and nine boys, were aged from 15.5 to 17.5 years, with a mean age of 16.4 years. Two male participants were unable to attend the interview part of friendships. Thus, a total of 12 adolescents participated.

Data collection

An appointment was arranged for a first visit in December 2021, where their ADHD diagnosis was double-checked with the ADHD section of the MINI-KID. This is a standardised diagnostic interview with children and adolescents under the age of 18 years [24]. The MINI-KID interview contains 24 diagnostic parts, but only the section related to ADHD (section O) was included in this study. The interviews started with the following questions: O4 Did you have problems with inattention, overactivity, or impulsiveness before you turned 12? and O5 Did this cause problems with your friends? In addition to these two questions from the MINI-KID the interviews were based on an interview guide with the opening question ‘How do you view your peer relationships?’ and other key questions were ‘How do your peer relationships affect your well-being?’ and ‘What is a good peer relationship for you?” The interviews were conducted from the 7^th to the 27^th of December 2021. Two psychiatry master students each performed six one-to-one interviews. Eleven interviews were performed in face-to-face meetings and one over the telephone. The interviews were recorded, each lasting between 15 to 40 minutes; (mean 27.5).

Analysis

Qualitative content analysis was used [25]. The approach involved an unbiased analysis of the text, where patterns were sought in the material based on the adolescents´ experiences. The analysis process in qualitative content analysis is not linear but characterised by a de-contextualisation and re-contextualisation [21]. The text was transcribed verbatim by the master students and they as well as the last author read through the text several times to gain an overview, after which they condensed the text while remaining close to the content. In the next step, they created meaning units. The meaning units were then abstracted and brought together under different codes based on the aim of the study. The codes were labelled with a descriptive code close to the original text and then grouped into sub-categories by the master students. The analysis was then reviewed critically by the first, second and third authors. After this, all authors discussed the analysis together on several occasions and three main categories were constructed.

Bonding with friends

This category revolves around the multifaceted dynamics and factors influencing the formation and maintenance of friendships among the participants. It encompasses the qualities, shared experiences, activities, and digital interactions that contribute to the formation and maintenance of their friendships, highlighting the importance of understanding, shared interests, and adaptability in the face of external challenges such as the COVID-19 pandemic. The participants stated that a friend should be kind, humble and caring. It was important to be invited to participate in an activity and being with friends who made no demands was appreciated. Having fun together and paying attention to each other when socialising was seen as positive.

“It’s that you… so you’re always kind… and you ask, do you want to hang out? … and … yes caring … like and … always thinking of each other.” Participant 1

It was described as easier to talk about everyday problems with friends of the same age than with adults. In this respect, friends could be seen as a complement to parents, especially when talking about relationship problems, love problems or when adolescents have difficulties at home. Another important factor for friendships was growing up together. Other adolescents with ADHD were also valuable, as they had a better understanding of the situation.

"It’s probably one who has it [ADHD] confirmed, but I think the rest of the guys also have something if I’m completely honest." Participant 7

"Most people in my group of friends have problems sitting still so… most of them are the same so… it turns out that you fit better together because you… everyone is the same." Participant 5

Sports and other leisure interests were described as an important basis for friendship. Common leisure activities after school were talking, watching TV, playing games, applying make-up, trying on outfits, or listening to music. Other leisure activities included meeting up at shopping centres, going out to eat or driving A-tractors (low-speed vehicles that can be driven from the age of 15 years) and hanging out in large groups. What mattered was not so much the kind of activity, but that the adolescents socialised and took the day as it came. It also emerged that it could be nice to be alone sometimes, but they more often wanted to meet friends.

Social media was described as the main way of socialising, which could be via text messages, scrolling on different applications or online games. However, some adolescents did not use social media at all. Social media was a way to keep in touch with friends, but also a way to meet new friends. Certain steps in the friendship-building process could be skipped, which made it quicker to get to know each other. Participants stated that when things were difficult it was sometimes easier to open up to their old friends online than in real life. An online friendship could last several years and was valued just as much as physical friendships.

“I think it’s easier, you don´t feel like you are being judged or something… if you were to be judged, it’s nothing more than your friend on Snapchat disappearing. Nothing changes in the group of friends or anything.” Participant 4

When the interviews were conducted, the COVID-19 pandemic had been ongoing for two years. The pandemic and subsequent distance learning were something that affected friendships, especially for those adolescents who had just started secondary school and had not had time to get to know their new classmates. They perceived that the process of making new friends and assimilating into the new social context of secondary school took significantly more time.

"Over the past year, it’s like… when I feel, ’Now I need to talk to someone,’ then there have been fewer and fewer people I could turn to… I haven’t really noticed until it was needed that I don’t have anyone to talk to." Participant 4.

One’s own role

The essence of this category concerns the participants actively managing their roles in friendships and navigating challenges associated with impulsivity, insecurity, and conflicts. The category highlights the active role the participants play in shaping and maintaining friendships. The essence revolves around the dynamic interplay of self-perception, coping mechanisms, and interpersonal skills in the context of friendships. In new friendships, it was important that the socialising continued to be interesting and that friends were active and wanted to do things, otherwise the participants became bored and moved on to new friends. If the friend continued to be interesting, it could become a long-term relationship. The participants often took on the role of the happy one who tried to lighten the mood of the group when someone was feeling bad and attempted to entertain their friends. When the adolescents described themselves in relation to their friends, they talked about themselves as being outgoing and having the ability to make new friends easily.

“I’ve always heard, and I know it myself… that I’m like… very easy to be friends with and make friends. It’s like an interest” Participant 4

"So, I’ve never had any problems making friends because I’m quite social, so…" Participant 5

However, some adolescents described themselves as introverted or shy, which made it harder for them to make new friends. They might prefer a few close friends rather than many acquaintances. Overall, there was a range of attitudes concerning friendship and socializing among the participants.

"I’m not exactly the friend expert…" Participant 13

Being spontaneous or impulsive could be perceived as both positive and negative. It was described that impulsivity could be expressed through, for example, quick comments and by amusing their friends with witty attacks. One difficulty that emerged was controlling their impulses, including in the performance of team sports. One way to deal with this was to carefully plan the intake of ADHD medication so that the effect occurred during the sport period. This could be perceived as limiting and frustrating as it required careful planning, sometimes several days in advance. The fact that their peers did not realise their need to take medication before a team activity could also be annoying for the adolescents.

"Because I don’t have enough impulse control, I think, to manage if something goes against me or if something unplanned happens. Because it will go to hell if I can’t control myself”. Participant 11

Insecurity in the relationship with friends was described, an example being when friends did not respond immediately to text messages. That created a feeling that the friends did not want to socialise, which could lead to negative thoughts and not having the courage to get in touch again. Another description was that it took a long time to become attached to and trust people, resulting in a sense of not having many real friends but only superficial ones. It could also be difficult to initiate contact with friends from school to do things in their leisure time, even if they had common interests. There was also uncertainty about seeking contact with new people and it could take several terms before a relationship felt secure.

“I didn’t really know how to… what to say… how to be a friend, that’s how it was. And how to be… without saying anything, without someone getting hurt or sad like.” Participant 1

Conflicts could arise due to misunderstandings in communication, which could complicate new friendships. They stated that it could be difficult to interpret situations that had led to conflicts in the past and still did. The tone in different situations with friends could also be difficult to interpret, which, among other things, made it challenging to decide when it was appropriate to be serious and not take jokes too far. It could also be difficult to determine when something was wrong in a friendship.

“What can I say… not drama but things happen all the time. Because I don’t understand that I have…done anything wrong but… Then it became a big misunderstanding and I just…well…” Participant 4

There was a fear of conflict and withdrawal was a way of trying to avoid it. There were also statements about being drawn into conflicts between friends against their will. Participants expressed that they avoided conflicts with friends at school and in their leisure time as much as possible but sometimes took their irritation out at home instead.

“I must always have something to argue about, sort of. I’m not really that addicted to drama, but I kind of always get drawn into drama because I’m kind of in the middle. So, I always get drawn into it anyway.” Participant 2

It could be difficult to withdraw from friends in their leisure time and might be easier to say yes and meet up for a while, even if they did not want to. It was easier to keep in touch with friends by phone or online when they did not have enough energy to meet up. Friends were important even when energy levels were low but there was a fear of using friends as therapists. Being a positive and social person in a friendship could be associated with demands, making it difficult to keep up that facade as it required a great deal of energy on the part of the young person. One way to deal with this was to retreat from their friends during periods when they were unable to cope.

"I’m known as the positive one and so when you’re having a bit of a bad day, you just… yup… Because I kind of can’t stand it if I’m not… happy or how to put it… then I can’t stand being social … because it takes so much energy.” Participant 4

At times it was necessary to prioritise schoolwork, mainly on weekdays but also at weekends. The school took a lot of energy and sometimes the participants had to take a nap in the afternoons. They needed to study while the ADHD medication was active. There was a fear of falling behind in school, especially at the beginning of the last years of secondary school.

"Go home and sleep… . I kind of do, I’m completely exhausted after school, so I can’t take it… it’s so tough at school so… you have to go home and rest." Participant 10

How friendship matters

This category describes the multifaceted impact and diversity of experiences of friendships on the lives of the participants. In essence, it captures the nuanced nature of friendships in the lives of the participants, encompassing both positive and challenging aspects and highlighting the evolution of these relationships over time. The influence of friends varied, but socialising with friends was invigorating and provided relaxation in an otherwise hectic life. Friendships could also negatively affect their behaviours, such as when they felt vulnerable or were provoked by their friends.

"Some people screw up, are annoying and irritating… just because they know that even if you get angry that day, you’re not angry the next day… They always think it’s fun to be annoying to those who get the angriest." Participant 2.

Some participants described having long-standing friendships and never feeling that they had been left out or had no one to socialise with. Living in a small community with small classes at school contributed positively to friendships. As they had always been social and chatty, it facilitated their ability to make friends. An occasion when it was difficult to make friends was when a sense of alienation occurred and led to conflicts with classmates. This evoked negative feelings of being different or weird, resulting in anger.

"When I was smaller and around the 2nd and 4th class… then I had a very hard time with friends or I was often frozen out and like that, fought a lot with my friends because they shut me out… so that time was tough… but now it’s much easier. I was frozen out… It was harder for me at school, I didn’t finish as quickly, so the others ran out and played." Participant 10

Relationships with friends often improved as the participants became older, although the opposite also occurred in some cases. Why it became easier over time was due to a greater awareness of their diagnosis, starting ADHD medication, getting help from supportive adults such as parents and teachers and the fact that they themselves and their friends had become older and more mature.

“I was thirteen years old when I was diagnosed with ADHD… Yes, so I was very late. I guess they thought I was a little weird… or I don’t really know. I couldn’t really control myself when I was younger. I didn’t really know how to say or not say and… well, so it was a bit tough at times with my friends when I was younger.” Participant 1

Strengths and limitations

Rich data were obtained from the sample, which included approximately equal numbers of girls (n = 5) and boys (n = 7), as well as being relatively evenly distributed in terms of age and where the participants served as a good source of information. All participants were recruited from the same hospital in western Sweden. Because the study was conducted during the COVID-19 pandemic, there was a requirement to use face masks. This may have influenced participants’ perception of safety but also the interviewer’s ability to read their facial expressions. However, there was a photo and a brief presentation of the interviewers in the information letter sent to the participants before the interview. The participants came from a limited geographical area, mostly from small towns or medium-sized cities. The results might have been different if the geographical distribution had been larger. To achieve trustworthiness, the COREQ checklist [47] was consulted throughout the study to optimize the quality.

Conclusion

This study is one of the few in its investigation of the perspectives of young individuals, conveyed through personal narratives shared in interviews. From their reflections, three categories of peer relationships have been discerned: Bonding with friends, One’s own role and How friendship matters. The result indicates that despite perceiving themselves as having good relationships with friends, the participants experienced difficulties understanding and reading situations involving friends. Experiences of conflict were described, where they had been misunderstood and excluded. The adolescents with ADHD were drawn to other adolescents with the same diagnosis or similar energy levels, as they expressed having an increased understanding of each other. Friends of the same age play a central role in the identity formation of adolescents with ADHD. It is crucial to comprehend the challenges these adolescents face in managing their daily lives, such as the necessary planning to function. They struggle with impulsivity, a challenge often misunderstood by others who may not grasp the constant energy waste it causes. Friendships are seen as essential, impacting the participants’ well-being and providing support when navigating the challenges associated with ADHD. For guardians and healthcare providers, support involves considering the adolescents’ entire lifeworld in which relationships are an important aspect, by, for example supporting the adolescents to develop strategies in their interactions with friends and helping them build self-esteem. Healthcare providers can additionally provide psychosocial treatment, contribute to the understanding of ADHD symptoms, and teach strategies to cope with them. Creating an environment that embraces neurodiversity and fosters inclusion is essential. Educators, parents, and peers play a pivotal role in building a supportive community that encourages the development of strengths while providing understanding and accommodation for challenges. By doing so, we empower young people with ADHD to navigate the world confidently, armed with a sense of self-worth and the knowledge that their differences are not limitations but can also be valuable assets.