Therapy in LA - Article of the Month

We will feature a new article here each month written by one of our group members. These articles are offered free for your information and are not meant to provide individual advice or psychotherapy.

http://therapyinla.com/book-review/

January 2008

ADHD – Do Symptoms Really Have Long-term Effects?

by Alan Solomon, Ph.D.

As discussed in a couple of previous articles on therapyinla.com, Attention Deficit-Hyperactivity Disorder is a very real phenomenon. See “ADHD: Myth or Reality?” and “ADHD: A More Precise Description“. One of the major questions, however, only partially answered in this area is: To what degree do the symptoms of ADHD actually translate into significant impairment? In other words, do the problematic behaviors associated with ADHD actually have long-term consequences in a person’s life?

Parents may phrase this in more day-to-day terms: “I know Johnnie is an active kid – much like I was as a child – ‘all boy’. But is this really the cause of:

- his difficulties in school, or
- his struggles to play on his soccer team, or
- his inconsistency with making and keeping friends, or
- his failure to take care of responsibilities at home?”

In a more worrisome way perhaps, from a longer-term perspective, parents may say: “I’m reluctant to label him and begin a negative process in his life. If we do nothing about this, will he have more serious problems as an adolescent or adult?”

A leading researcher in this field, Russell A. Barkley, Ph.D. and his colleagues, recently summarized some critical findings that help answer this question: “Yes. The symptoms of ADHD are often associated with significant impairments in major life activities.” The ADHD REPORT, edited by Dr. Barkley (The Guilford Press, April 2006) presents these findings, in very detailed fashion. Two of their analyses will be summarized below.

One long-term study in Milwaukee followed 239 children for more than 13 years into their young adulthood (from 19 to 25 years old): 158 were hyperactive, 81 were “controls” (children without any problematic symptoms of similar ages and socio-economic backgrounds, to allow for a fair comparison). Barkley and his associates re-analyzed the data with specific measures of outcome/consequences:

- ever retained a grade in school;
- failed to graduate high school;
- received special education in high school;
- fired from a job, 2 or more times;
- few close friends, 2 or less;
- trouble keeping friends;
- driver’s license ever suspended or revoked;
- excessive self-reported car crashes, 3 or more;
- excessive self-reported speeding citations, 5 or more;
- excessive citations on official driving record, 7 or more;
- excessive arrests, 3 or more;
- 1 or more felony arrests;
- 1 or more misdemeanor arrests;
- low grade point average on high school transcript, 1.6 or lower;
- low class ranking in high school, 89th percentile or worse (meaning that 89 percent of fellow students
ranked higher);
- employer-rated work performance of below-average or poor, rating of 2 or lower on scale of 1 to 5;
- involvement in teenage pregnancy as father or mother; and
- sent to jail for any crime.

While a lot of details to wade through, this list provides a clear understanding of how ADHD might translate into serious, concrete outcomes for a young adult. The relationship between these outcomes and ADHD was a “moderate correlation”, all a thousand times less likely than by chance (probability of less than .001). It is important to keep in mind that correlation is not causation: because two conditions occur together with some frequency, it does not mean that one condition causes the other. Thus, we cannot say, scientifically with certainty, that ADHD causes some of these outcomes. But, we can say that ADHD and some of the problematic outcomes above do occur together in the lives of many individuals. ADHD symptoms and serious problems in young adulthood seem to be related to each other, much more than we would expect by chance alone.

A second study focused on adults: 149 with ADHD, 97 who did not have ADHD but primarily anxiety or depression, and 109 “control” adults in the community without diagnosed difficulties. Those with ADHD were identified through clinical interview, self-report rating scales, scales completed by others who knew the participant, and employer ratings. Both self and other reports were used to assess childhood functioning for those with ADHD as adults.
Impairment for all three groups was measured by:

- self-report in the interview of current functioning in six areas – work, home responsibilities, social activities,
community activities, educational activities, and dating or marriage;
- self-rated impairment in these six areas, plus four more (total of ten) – money management, driving,
leisure activities, and daily responsibilities;
- impairment as rated by others in the ten areas;
- self-rated impairment in childhood history in seven areas – home activities, social activities, community
activities, school, sports, clubs and organizations, self-care, and daily chores/responsibilities;
- other-rated impairment in these same seven areas for childhood functioning;
- a clinician rating on a scale measuring social and occupational functioning;
- a rating scale completed by parents in eight areas of school impairment;
- employer ratings in ten areas – relations with co-workers, relations with supervisors, relations with
clients/customers, completing assigned work, educational activities, punctuality, meeting deadlines,
operating equipment, operating vehicles, managing daily responsibilities.

Again, a lot of details to help you appreciate how thorough this study was in its effort to truly investigate the day-to-day, very real impact of ADHD on adults. The correlations between ADHD and impairment outcomes were very substantial, more so than with the first study actually. The greater the number of ADHD symptoms an adult experiences, a greater number of areas of major life activities will be reported as impaired, and the impairments will be more severe. This is based upon reports by the individual themselves, others/parents, clinicians, or employers. Symptoms of inattention actually are slightly more correlated than hyperactivity symptoms – difficulties with concentration and focus are more powerful than being overly active as a possible source of impairment for adults.

Thus, when Johnnie’s parents ask if his possible ADHD really is related to difficulties he is having in school, at home, in his social life, and his handling responsibilities, the answer if a clear-cut, “Yes.” Similarly, if parents ask about the risks of not seeking help, the answer is also a clear, “Yes. The long-term risks of a child with ADHD who is not helped are very substantial.” We now have reliable research to support both of these conclusions. Please read some of the other articles on this website on ADHD, Assessment, and the initial efforts to seek help.