QUALITY OF LIFE IN ADOLESCENTS WITH ADHD

[Beth W]

Although the behavioral, social, emotional, and academic functioning of
children and adolescents with ADHD has been examined in many studies, there
has been surprisingly little work on how individuals with ADHD evaluate
their own quality of life.

How individuals with ADHD experience their lives is critically important
information for developing a fuller appreciation of how ADHD affects
development. The absence of such "first person" accounts of the disorder is
thus an important gap in our understanding of the disorder.

What makes this especially important is the ongoing perception among many
individuals that ADHD is simply a label that is inappropriately attached to
behaviors that many children and teens commonly engage in. If this were the
case, i.e., if ADHD were really nothing more than a medical label attached
to normal behavior, than those diagnosed with ADHD would not be expected to
experience a lower quality of life than individuals without the diagnosis.
If ADHD describes a condition that has a significant adverse impact on
individuals' lives, however, than we would expect this to be reflected in
reports of lower quality of life among those with the diagnosis.

What is the quality of life experienced by adolescents with ADHD and how
does this compare to the quality of life experienced by peers without ADHD
or by those with another chronic medical condition? This important question
was examined in a study published recently in the Journal of Attention
Disorders - www.mhs.com/jad
<http://parentsubscribers.c.topica.com/maab6Ykaa5JgTb3hAeae/> - the only
peer reviewed journal exclusively devoted to ADHD and related disorders
(Topplski, T., et al., 2004. Quality of life of adolescent males with ADHD.
Journal of Attention Disorders, 7, 163-173.)

Participants included 68 adolescents ages 11-18 with ADHD recruited from
ADHD specialty clinics, 116 adolescents without ADHD recruited from the same
communities, and 52 adolescents recruited from specialty clinics for
treating mobility impairments. By including these 2 comparison groups, the
researchers could examine how quality of life in adolescents with ADHD
compared to adolescents both with and without a chronic health condition.
Nearly all adolescents with ADHD were currently being treated with
medication. However, only 14 were receiving some form of therapy in addition
to their medication treatment.

Adolescents with mobility impairments were selected as a comparison group
because among adults, those with mobility limitations generally report the
lowest quality of life when compared to "well adults" and to adults with
other chronic health conditions. All participants with ADHD were males
because of difficulty obtaining an adequate sample of females with ADHD.
Participants in the other 2 groups included males and females.

[Beth W]

(contd)

- MEASURES -

To assess perceived quality of life, adolescents completed the Youth Quality
of Life Instrument. This measure asks the adolescent to rate their quality
of life in 4 domains: social relationships, sense of self, environment, and
overall quality of life.

The relationship domain assesses both family relationships (e.g., "I feel I
am getting along with my parents or guardians") and peer relationships
(e.g., "I am satisfied with my social life").

The self domain provides a perspective on the adolescent's sense of who they
are. It is comprised of items that inquire about adolescents' physical
health, mental health, belief in themselves, and how they feel about
themselves.

The environment domain includes items that ask adolescents about multiple
areas including the quality of their school, their engagement in interesting
activities, their available monetary resources, their sense of personal
safety, and their view of their future.

The general quality of life scale is comprised of items pertaining to
adolescents' overall satisfaction with their lives including the amount of
enjoyment adolescents' experience on a day-to-day basis, their feelings
about life being worthwhile, and their general level of satisfaction with
how their life is going.

In addition to completing the quality of life instrument, adolescents
completed a self-report measure of depressive symptoms. This was done so
that the researchers could examine whether quality of life differences were
evident between adolescents in the 3 groups even after controlling for group
differences in depression. This is important to do because adolescents who
report more depressive symptoms would also be expected to report a lower
quality of life.

Finally, parents completed the Conners ADHD scales so that the adolescent's
current level of ADHD symptoms could be assessed. The adolescents also
completed a self-report version of this instrument.


- RESULTS -

Before describing the quality of life results, it is interesting to note
that 55 of the 68 adolescents with ADHD had scores on the parent version of
the Conners ADHD scales that fell in the atypical range. These adolescents
were excluded from the remaining analyses.

What is striking about this result is that nearly all adolescents were being
treated with medication. This speaks to the fact that although medication
can be very helpful in managing core ADHD symptoms when it is administered
in a systematic manner, and when ongoing response to treatment is carefully
monitored, the results of medication treatment in community settings may
often fall short of this standard. It is also worth noting that although the
combination of medication treatment and behavior therapy is often more
helpful than medication treatment alone, only 14 of the 68 adolescents were
receiving any intervention besides medication.

[Beth W]

(Note: To receive a report on research-based procedures for maximizing the
benefits of medication treatment, go to www.helpforadd.com/medreport.htm
<http://parentsubscribers.c.topica.com/maab6Ykaa5JgUb3hAeae/> . For a
convenient method for monitoring the ongoing effectiveness of children's
treatment - regardless of what treatment(s) are being used - go to
www.helpforadd.com/monitoring.htm
<http://parentsubscribers.c.topica.com/maab6Ykaa5JgVb3hAeae/> . Both the
medication report and the monitoring tool are free).


- GROUP DIFFERENCES IN QUALITY OF LIFE RATINGS -

Adolescents with ADHD reported lower quality of life ratings than comparison
adolescents without ADHD or mobility impairment in every single domain. In
fact, the quality of life ratings provided by adolescents with ADHD were
comparable to those provided by adolescents with significant mobility
impairments.

It is important to note that these results were found even though levels of
self-reported depressive symptoms were controlled for. This means that the
lower quality of life ratings reported by adolescents without ADHD can not
be explained by their having higher rates of depression. (Note: The authors
did not report group differences in depression, so it is not clear whether
this was the case.) It should also be noted that although all adolescents
with ADHD were males, and adolescents in the remaining 2 groups included
females, the exact same pattern of results was obtained when only males from
all 3 groups were included in the analyses.


- QUALITY OF LIFE DIFFERENCES IN ADOLESCENTS WITH TYPICAL VS. ATYPICAL
RATINGS OF ADHD SYMPTOMS -

The authors also examined quality of life differences reported by
adolescents with normal vs. atypical ratings on the self-report ADHD scale.
(As noted above, adolescents who had parent ratings of ADHD symptoms in the
normal range were excluded from all subsequent analyses). These analyses
were conducted to learn whether adolescents who experienced themselves as
having fewer ADHD symptoms also experienced a higher quality of life.

Results indicated that this was the case. Adolescents with self-reported
ADHD symptoms in an elevated range reported a lower quality of life than
other adolescents with ADHD in all areas surveyed. In terms of specific
items, these adolescents indicated that they more frequently needed help
with emotional/mental health problems, that they were in a good mood less
often, and that their problems were more likely to create problems in their
family.


- SUMMARY AND IMPLICATIONS -

Results from this study are clear: despite the fact that the adolescents
with ADHD were currently receiving treatment, they reported a lower quality
of life in specific domains, and in general, compared to other adolescents
recruited from the same communities. In fact, the quality of life they
reported was comparable to that reported by adolescents with significant
mobility impairments. When adolescents own reports of the severity of ADHD
symptoms were taken into account, those who reported less severe symptoms
reported having a higher quality of life than those reporting more severe
symptoms.

Results from this study demonstrate that ADHD is not simply a diagnostic
label that is inappropriately assigned to individuals engaging in "normal"
behavior. Instead, it is a constellation of symptoms that are associated
with significantly reduced quality of life, even among individuals who are
receiving treatment. Thus, although the disorder is often initially
identified by parents and teachers who may be struggling to manage the
child's behavior, ADHD not only creates difficulties for the adults in an
adolescents life; it creates difficulties that adolescents experience as
well.

One of the more disconcerting aspects of this study is that despite the fact
that nearly all diagnosed adolescents were receiving medication treatment,
they still reported a lower quality of life than other adolescents. In part,
this result may reflect the fact that the researchers excluded participants
who received parent ratings of ADHD symptoms that fell in the normal range,
a group whose symptoms were apparently being effectively managed by
treatment.

Nonetheless, the vast majority of adolescents, i.e., 55 of 68 or 81%,
provided quality of life ratings. Clearly, this suggests that many
adolescents treated for ADHD in community settings - in addition to
continuing to display elevated levels of ADHD symptoms - also experience a
lower quality of life than their peers. This highlights the need to
evaluate adolescents' own perception of their lives when assessing treatment
effectiveness, rather than focusing more exclusively on parent and teacher
ratings of the child's behavior. Unfortunately, this is an area that is
typically not considered in treatment research on ADHD.

Does ADHD actually directly cause individuals to experience a lower quality
of life? This important question is really not possible to answer based on
the study reviewed here, and it is possible that factors that often go along
with ADHD - rather than ADHD itself, per se - were responsible for lower
quality of life in the adolescents who participated in this study.
Nonetheless, the fact that ADHD is often associated with a lower quality of
life highlights the importance of attending to this in the treatment of
individuals with ADHD.

It remains unclear whether effective management of ADHD symptoms via
medication and/or other interventions necessarily translates into
adolescents experiencing a higher quality of life. This question is not
fully addressed in the current study because adolescents with normalized
levels of ADHD symptoms when assessed by parent behavior ratings were
excluded from the sample. However, adolescents who reported less severe
levels of ADHD symptoms themselves did report higher quality of life
ratings, suggesting that this may be the case. Unfortunately, adolescents
may not be the most accurate reporters of their own ADHD symptoms, however,
so this important issue requires further study. It is certainly reasonable
to expect that effectively treating core ADHD symptoms would result in an
improved quality of life for adolescents with ADHD, but one cannot assume
that this would be the case. This would be an important issue to pursue in
subsequent research.

How can the quality of life in individuals with ADHD be enhanced?
Certainly, as suggested above, it is reasonable to hypothesize that
effective management of ADHD of symptoms may result in a better quality of
life. Quality of life is also enhanced when children/teens maintain good
relationships with parents and peers, experience success in school, and
participate in activities that are pleasurable and in which they are
successful. To the extent that parents, professionals, and educators can
help children and teens with ADHD have these kinds of experiences, they are
likely to contribute to their experiencing a higher quality of life.

In future work on this issue, the inclusion of females with ADHD would
obviously be an important addition as well. Although ADHD is less common
among females than among males - at least when current diagnostic criteria
are used - it appears that the condition is also associated with a number of
adverse outcomes in girls. How females with ADHD experience the quality of
their lives would thus be important to pursue. It would also be important
to examine quality of life issues in both younger and older individuals.
Hopefully, this study will encourage other researchers to pursue studies in
this interesting area.

Thanks again for your interest in the newsletter. I hope you enjoyed the
above article and found it to be useful to you.

Sincerely,

David Rabiner, Ph.D.
Senior Research Scientist
Duke University



(c) 2003 David Rabiner, Ph.D.

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