Russell A. Barkley.
Clinical Professor of Psychiatry Medical University of South Carolina, Charleston SC, and Research Professor, Departament of Psychiatry Suny Upstate Medical University Syracuse, NY.
2. 14/12/2008
Objectives
To review the impact of ADHD on major
life activities outside of educational and
occupational settings
To highlight recent results of the
g g
Milwaukee follow-up study concerning
follow-
outcomes at age 27
To discuss the treatment implications of
these findings
h fi di
To illustrate the need for multidisciplinary
treatment and multi-agency involvement
multi-
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3. 14/12/2008
Motor Vehicle Driving Risks
Poorer steering, slower braking reaction time
Rated by self, others, and driving instructors as using fewer
safe d i ing habits
driving
More likely to drive before legally licensed
More accidents (and more at faults) (2-3x risk)
(2-
% with 2+ crashes: 40 vs. 6
% with 3+ crashes: 26 vs 9
More citations (Speeding - mean 4-5 vs. 1-2)
4- 1-
Worse accidents ($4200-5000 vs $1600-2200)
($4200- $1600-
(% having a crash with injuries: 60 vs 17%)
More Suspensions/Revocations (
p / (Mean 2.2 vs 0.7))
(% suspended: 22-24 vs. 4-5%)
22- 4-
Greater adverse impact of alcohol on driving
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4. 14/12/2008
Sexual-
Sexual-Reproductive Risks
No Higher Incidence of Sexual Disorders
Begin Sexual Activity Earlier (15 vs 16 yrs.)
More Lifetime Sexual Partners (13.6 vs. 5.4)
M Lif ti S lP t
% having more than 4 partners by early adulthood 60 vs. 28%
More Partners in Prior Year (2.4 vs. 1.6)
Less Time with Each Partner
More casual sex (outside relationships)(37 vs. 19%)
Less Likely to Employ Contraception
Greater Teen Pregnancies (24-38 vs. 4-5%)
(24- 4-
32% males, 68% females
Ratio for Number of Births by age 21(37:1)
54% Do Not Have Custody of Offspring
By age 2 51% have children vs. 13% for controls
27, % h h ld 3% f l
Higher Risk for STDs (17 vs. 4%)
Overall riskier sexual behavior
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5. 14/12/2008
Antisocial Activities
(age 21; Milwaukee Study)
Self-
Self-reports for lifetime occurrences
Hyper Control Hyper Control
Antisocial Activities Mean Mean % %
Stolen Property 18.6 5.1 85 64
Stolen Money 6.0 2.3 50 36
Disorderly Conduct 18.5 8.3 69 53
Assaulted with Fists 13.8 4.1 74 52
Assaulted with a 2.7 0.3 22 7
Weapon
Carries Concealed 15.1 4.9 38 11
Weapon
Illegal Drug Possession 234.5 130.6 51 42*
Illegal D
Ill l Drug S l
Sales 14.3
14 3 4.5
45 24 20*
Breaking and Entering 2.1 0.5* 20 8
Sets Fires 0.4 0.1* 15 6
Runaway from home 3.9 2.0* 31 16
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6. 14/12/2008
Dimensions of Antisocial Acts
Predatory:
Mugs, fights, carries & uses weapons
Related chiefly to CD
Self-
Self-sufficiency:
Runs away, steals money, prostitution
away money
Associated with CD
Drug-
Drug-related:
Possesses, uses, & sells drugs; steals
Related to both CD and ADHD
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7. 14/12/2008
Antisocial Activities (age 27)
Lifetime Antisocial Acts
80
70
60
Percent of Group
50
f
40
H+ADHD
30
H-ADHD
20 Community
10
0
Stolen Breaking Assault - Assault - Carried Sold DisorderlyArrested Jailed
Property + Fists WeaponsWeapons Drugs
Entering
Type of Act
H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);
H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;
Controls = Community control group
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8. 14/12/2008
Antisocial Activities (lifetime)
UMASS Study
Criminal Activities
60
50
40
Percent 30 ADHD
Clinical
20 Community
10
0
Shoplifted Stolen Money Breaking/Entering Assault Sold Illegal Drugs Arrested Jailed
Specific Crimes and Outcomes
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9. 14/12/2008
Childhood Antisocial Activities
(retrospectively recalled)
Childhood Conduct Disorder Symptoms
45
40
35
30
25
Pe rce nt
20 ADHD
Clinical
15
Community
10
5
0
Bullied Fights Break-ins Stolen Violate Ran Away Truant
Valuables Curfew
Sym ptom
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10. 14/12/2008
Judicial Costs of ADHD (by age 21)
ADHD children followed to young adulthood are
more than twice as likely to be arrested as control
children (48% vs. 20%)
Mean judicial costs have been estimated to be
$8,814 per ADHD person vs. $341 per control.
Regression modeling placed the total criminal costs
at $37,830 per ADHD person having CD. CD.
45-
45-80% of teenagers in juvenile custody
have ADHD
25-
25-40% of adult prisoners have ADHD
Data from the Milwaukee follow-up study as reported in the paper by
follow-
Secnik, Swensen, Buesching,
Secnik, Swensen, Buesching, Barkley, Fischer, & Fletcher (submitted for
publication).
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11. 14/12/2008
Social Impairments
Increased parent-child conflict & stress
parent-
Greater parental commands, hostility, reduced
responsiveness, more lax yet harsh discipline
More child noncompliance, hostility, disruption
Poorer sense of competence in parental role
Greater parenting stress and maternal depression
Especially problematic for ODD/CD subgroup
Peer Relationship Problems (50-70%+)
ee e at o s p ob e s (50- 0% )
Less sharing, cooperation, turn-taking
turn-
Intrusive, angry; reduced empathy and guilt
Most serious in ODD/CD subgroup
More likely to be bullied and to be bullies in childhood
More likely to be beaten up, mugged, or assaulted with a
y p, gg ,
weapon by young adulthood
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12. 14/12/2008
Social & Lifestyle
Fewer close friends; shorter duration of relations
Rated by p
y parents as more socially impaired
y p
Lower levels of marital satisfaction by both
proband and partner
Greater parenting stress in parental role
Differences in leisure time use:
Spend more time talking on phone, watching TV,
S d lk h h
playing videogames, and socializing
Spend less time reading, getting adult education, and
exercising
Greater money management problems
Lower current savings, less saving for retirement,
exceed credit card limits more often, buy on impulse
more often, less debt repayment, low credit rating,
greater risk of car repossessions and losing utilities
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13. 14/12/2008
Money Problems (age 27; MKE)
Money Problem Areas
80
70
60
P ercent of Group
50
f
40
H+ADHD
30
H-ADHD
20 Community
10
0
Managing Impulse Missed Missed Exceeded No Savings Poor Credit
Money Buying Paying Paying Card Limit Rating
Rent Card
Problem Type
H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);
H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;
Controls = Community control group
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14. 14/12/2008
Health Risks and Concerns
Skinner Health and Lifestyle Interview – MKE Study
Health Concerns
90
80
70
60
oup
Percent of Gro
50
H+ADHD
40 H-ADHD
30 Community
20
10
0
Eating Sleep Social Tobacco Drugs Emotional
Spe cific He a lth Are a
H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments);
H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome;
Controls = Community control group
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15. 14/12/2008
Medical and Health Concerns
Greater risk for accidental injuries, nonsurgical hospitalizations, ER
utilization, and driving accidents
Greater medical and dental health problems
More sick days off from work
Greater workman’s compensation claims
Poorer preventive dental care and more cavities as children
Greater sleeping problems
Higher frequency of vague medical complaints
Related to somatization and anxiety levels on SCL-90-R
SCL-90-
Greater likelihood of smoking, alcohol, and marijuana use and greater
frequency of using these substances
Conduct disorder increases risk for hard drug use (cocaine, heroine,
methamphetamine, illegal use of prescription drugs, etc.)
Growing risk of cardiovascular disease
Greater body mass index (higher percent obese)
Lower HDL cholesterol and higher Total/HDL ratio
Higher atherosclerotic risk to coronary arteries
Higher Framingham CHD risk percent over next 5 and 10 years
Possibly greater risk for cancer
Shortened life expectancy as a consequence ????
15
16. 14/12/2008
Areas for Future Research
Determine if outcomes are different for SCT type
Further examine for sex differences
Extend findings past age 35
Determine occupational costs (e.g., sick days,
absenteeism, accidents on job, workman’s
compensation claims, etc.)
etc.)
Study accident rates at home and community
Examine impact in more detail on child-rearing and
E amine mo e child- ea ing
marriages
Further evaluate growing risk for medical illnesses
Somatization disorders
cardiovascular disease
cancer
Obesity and eating disorders (females)
Further evaluate risks for earlier mortality
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17. 14/12/2008
Summation of Impairments
Follow-
Follow-up studies provide convincing evidence that ADHD is
associated with impairment in many major life activities over
development
p
Poor Educational Performance, Reduced Years of Education,
Greater Risk for Learning Disabilities
Increased Risk for Comorbid Psychiatric Disorders
Lower Occupational Levels and Poorer Workplace Performance
Higher Rates of Antisocial Activities, Crime, Arrests, and
Incarcerations
Greater Risks for Teen Pregnancy , STDs, and Earlier Parenthood
Greater Driving Risks (Speeding, Crashes, Injuries
Increased Health Risks for Obesity, Cardiovascular Disease and
Cancer; Possibly Reduced Life Expectancy
This Demonstrates a Great Need for Government,
Educational, Health Care, Mental Health Care, and Judicial
Departments and Professionals to Work More Closely
Together to Reduce Such Impairments and the Obvious Social
and Financial Burden They Create for Society
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18. 14/12/2008
Managing Educational Risks
Educating teachers and school administrators on
ADHD and associated academic risks
Teacher training in classroom behavior management
T h t i i i l b h i t
strategies
Implement ADHD school liaison
Early screening and identification of ADHD cases at school
entry
Pre-
Pre f
P -referral assistance to regular classroom teachers on
l i t t l l t h
behavior management tactics
Pre-
Pre-referral curriculum adjustments
If necessary, eventual referral for formal special
educational services
Earlier implementation of extended release medications as
necessary
Vocational assessment and job skills training during high
school
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19. 14/12/2008
Addressing Employment Risks
Educate employers on nature of ADHD, workplace
impact & risks, & workplace management
Vocational assessment i high school for placement
V i l in hi h h l f l
in technical training classes
Counseling teen/adult for ADHD-friendly jobs
ADHD-
Post-
Post-high school technical training if no plans for
college enrollment
If college bound, consider community college as first
step
Military enlistment if not going on to college
Make reasonable workplace adjustments
Similar to school behavior management tactics
Medication management across longer periods
Extended release formulations; supplement with IR
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20. 14/12/2008
Treating Child/Teen ODD
Both stimulants and atomoxetine reduce defiance when
it is comorbid with ADHD; not when ODD occurs alone
Higher doses may be needed for comorbid cases
Implement adjunctive parent training in behavior
management methods; but positive responding is age-
age-
related:
60-
60-75% successful for children
f lf hild
25-
25-35% treatment response after 13+ yrs. of age
May need to treat parent’s ADHD first to succeed
May need to add problem-solving communication training of
problem-
teen and parents after age 14 years
Severely explosive anger may be a sign of childhood
BPD or SMD; may require use of atypical antipsychotics
or antihypertensives
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21. 14/12/2008
Treatment of Antisocial Risks
Stimulants and atomoxetine reduce aggressive behavior and
antisocial activities
Stimulants can be titrated more rapidly if management need is urgent
Higher doses often required in comorbid cases
Stimulant effectiveness may deteriorate with duration of treatment (3+
yrs) in this subset of ADHD cases (MTA study)
Parent and family interventions often required
Problem-
Problem-solving, communication training and parent BMT
Multi-
Multi-systemic therapy where available
Treatment of parental depression and other psychiatric disorders
Terminate deviant peer relationships
Family relocation to better neighborhoods advisable
If psychopathy (callous-unemotional traits) is present there is limited
(callous-
or no response to behavior therapy alone – medication is necessary
first, then follow up with behavioral treatments*
Avoid group treatment due to deviancy training by aggressive peers
who train less aggressive peers to become more aggressive
Involvement of social service and juvenile justice agencies is highly
likely – educate them about ADHD with this CD comorbidity
Mood stabilizers, atypicals, or antihypertensives may be needed for
atypicals,
highly aggressive/explosive cases representing severe mood or
bipolar disorders
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22. 14/12/2008
Implications for Driving Risks
Educate parents, teens, primary care physicians
and motor vehicle agencies on driving risks
Longer learner’s permit period
Graduated licensing approach
G d d li i h
Daytime with adults, night-time with adults, alone, with peers, full
night-
independence (3-6 months at each stage, gradual independence)
(3
No (!) cell phone use/text messaging while
driving
Greater supervision of vehicle use
p
Chart intended vehicle use
Random spot checking on destinations
Critical incident cameras in vehicle (DriveCam Inc., San Diego, CA),
(DriveCam
or GPS car monitoring devices (MobileTeen GPS, AIG Insurance
(MobileTeen
Co.).
Behavior contracting for safe driving
(Barkley Safe Driving Program, Compact Clinicals, Kansas City, MO;
Clinicals,
Maureen Synder’s book on ADHD and driving, addwarehouse.com)
Synder s driving addwarehouse com)
Medication management
Extended release formulations with supplemental immediate release
as needed
Avoid alcohol use while driving
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23. 14/12/2008
Implications for
Risky Sexual Conduct
Educate parents, primary medical care providers,
and appropriate social service agencies on ADHD
and risks for teen pregnancy & STDs
Greater parental supervision of teen social and
dating activities
Delay couples dating in favor of group
y p g g p
dating with multiple peers
Educate teens on sex and risks
Discuss use of contraception with teens & parents
Medication management to reduce impulsive
conduct and increase self-control
d d self-
lf l
HPV immunization for females with ADHD
To reduce future risks for cervical cancer
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24. 14/12/2008
Implications for Health Risks
Educate primary care providers and
government health agencies on ADHD and
related health and lifestyle risks
Encourage greater use of preventive medical
& dental care
Provide assistance with managing legal
substances
Smoking cessation programs
Alcohol abuse treatments
Substance abuse rehabilitation programs
Discuss with parents and ADHD teens/adults
the growing cardiovascular and cancer risks
with age
Encourage b tt h lth maintenance
E better health i t
practices (better diet, routine physical
exercise)
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25. 14/12/2008
Conclusions
ADHD is associated with impairment in every major life
activity studied to date
ADHD results in greater impairment, more domains of
impairment
impairment, and more sustained impairment than other
outpatient psychiatric disorders
The impairments from ADHD are associated with
substantial economic costs, greater burdens on society,
and greater risk for early mortality
g y y
ADHD is among the most treatable psychiatric or
developmental disabilities having more treatments
available producing greater improvements in a higher
percentage of cases with higher rates of normalization
Reducing these huge societal costs will require multi-
g g q multi-
disciplinary management and better integrated
government social services, health and mental health
care, and educational services
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