Attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), can have a significant social impact on patients’ lives causing disruption at school,1-4 work1,5-8 and in relationships.1,3,5,9,10 Symptoms of ADHD may also increase risk-taking behaviour.1,11,12
ADHD across the lifespan
ADHD can have a significant social impact on patients’ lives, disrupting education, employment, finances, family life and relationships.
Symptoms of ADHD — hyperactivity, impulsivity and inattentiveness — may negatively impact functioning and behaviour in children and adolescents in school, and adults in the workplace.13
In a Swedish cohort study of 544 children, considerable association was observed between symptoms of inattentiveness (as measured by the Conners 10-item scale) in children aged 7 and 10 years, and academic underachievement at age 16 years.14
It has been found that adolescents and adults with ADHD are less likely to have graduated from high school or have achieved a college degree.1,2
Results of the large, cross-sectional, European Lifetime Impairment Survey (sponsored by Shire, now part of Takeda), which assessed parent-reported impairment and symptoms of ADHD in children and adolescents with ADHD (n=535) compared with children and adolescents without ADHD (n=424), indicated that more parents of children with ADHD tended to report impairment at school compared with parents of children without ADHD (Figure).3
Figure: Impairment at school: statements that more parents/caregivers of children with ADHD agreed with compared with parents of children without ADHD in the European Lifetime Impairment Survey. Reproduced with kind permission from Caci H et al. Eur Psychiatry 2014; 29: 316-323.3
Research has indicated that adults with ADHD may have had disrupted education in earlier life.1,4
- One US study of 500 adults (aged ≥18 years) with self-reported ADHD compared with 501 healthy controls found that the adults with ADHD were significantly less likely to have graduated from high school (83% vs 93%; p≤0.001) or achieved a college degree (19% vs 26%; p<0.01).1
- Potential reasons for this included the inability to handle large workloads, inattention, disorganisation, difficulty following instructions and making careless errors.1
- Furthermore, in one Norwegian study of 250 adults (aged 18–60 years) with ADHD, childhood factors that were associated with non-completion of secondary school included:4
- Being more likely to fight with peers (p=0.03)4
- Being more likely to have received assessment by educational psychology services during primary school (p<0.01)4
- Having more ADHD symptoms in childhood* (p<0.01)4
- Having higher ADHD symptom severity during childhood† (p<0.01).4
Adults with ADHD have been found to have occupational difficulties that may impact on their productivity in the workplace and their reputation as an employee, with high job turnover and unemployment frequently observed.1,5-7,15
A consensus conference statement developed by an international committee of experts from Europe and the United Arab Emirates summarised the challenges that adults with ADHD may face in obtaining and maintaining employment, and potential solutions to address these challenges.15
- Adults with ADHD may be sporadic and disorganised in their job searches.15
- If they do manage to secure an interview, the decision whether to disclose their ADHD status may compromise the application, because employers may have negative perceptions of ADHD.15
- In the workplace itself, ADHD symptoms may hamper some forms of employment, with difficulties in time management and impaired social skills potentially causing problems and perhaps meaning that adults with ADHD find it difficult to retain a job; on the other hand, some forms of employment may be well suited to adults with ADHD, particularly more creative or active jobs.15
- There are adjustments that could be made in the workplace to accommodate adults with ADHD, such as the option of working in a private space to reduce distraction, or the use of incentives for task completion as encouragement.15
A Norwegian cross-sectional study of 414 adults (aged ≥18 years) with ADHD and 357 control subjects assessed multiple sociodemographic factors including education level and employment status by self-reported questionnaire.8
- The ADHD and control groups differed significantly in the proportions of adults who reported being in work (24.3% vs 78.8%, respectively; p<0.001), were receiving a disability pension (32.1% vs 2.2%; p<0.001), were under vocational rehabilitation (20.6% vs 2.8%; p<0.001) or were unemployed (4.8% vs 1.9%; p=0.024).8
Figure: A comparison of self-reported occupational status in adults with ADHD compared with control subjects. Reproduced with kind permission from Halmøy A et al. J Atten Disord 2009; 13: 175-187.8
Family and relationships
Symptoms of ADHD can negatively affect family life and relationships.
The European Lifetime Impairment Survey3 (sponsored by Shire, now part of Takeda) assessed parent/caregiver-reported home and relationship impairments in 535 children and adolescents with ADHD and 424 children and adolescents without ADHD. Significant impairments were reported in all seven questions within the relationship impairment scale, and in three of seven questions in the home impairment scale (Figure).3
Figure: Impairment of relationships with peers and siblings at home in children/adolescents with ADHD compared with controls. Reproduced with kind permission from Caci H et al. Eur Psychiatry 2014; 29: 316-323.3
An Australian study reported poorer family functioning in children (aged 6–9 years) with ADHD (n=30), compared with children without ADHD (n=156).9
Outcome variables negatively affected by ADHD included:9
- Family quality of life (emotional impact and family activities)
- Parental psychopathology (depression, anxiety and stress)
- Parental warmth
- Consistency of parenting
- Parental hostility.
These measures were all significantly worse in children with ADHD compared with children without ADHD.9
Adults with ADHD may have difficulty in maintaining relationships with the people around them.1,5,10
In a series of European and North American focus groups‡ (sponsored by Shire, now part of Takeda), adults with ADHD reported that irritability, inattention, impulsive talking and forgetfulness contributed to misunderstandings in social interactions.5
In addition, UK results from the European Lifetime Impairment Survey§ (sponsored by Shire, now part of Takeda) indicated that impairments in partner relationships and social functioning were associated with adult ADHD (Figure).10
Figure: Partner relationship difficulties associated with adult ADHD: UK results from the European Lifetime Impairment Survey. Reproduced with kind permission from Pitts M et al. Arch Psychiatr Nurs 2015; 29: 56-63.11
Problematic risk-taking behaviour
A study of 5–10-year-old children (ADHD group: n=103; non-ADHD group: n=100) suggested that symptoms of ADHD were associated with greater risk-taking and reduced sensitivity to punishment in the Balloon Analogue Risk Task (a computer analogue that presents participants with 30 separate balloons to pump up for points; each balloon explodes at variable intervals [more pumps = greater points earned]).11
Children with ADHD and comorbid oppositional defiant disorder (ODD) showed greater levels of risk-taking than children with ADHD alone, or ODD alone.11
However, a Norwegian study has suggested that children with ADHD are not particularly risk-prone, but may not respond well to changing probabilities of success in a given task.12
In total, 36 children with ADHD (aged 8–12 years) were assessed for decision-making under uncertainty using the Cambridge Gambling Task. This computer-based neuropsychological test instructs participants to bet on the likelihood of a token being located under a red or blue box on screen. The probabilities of different outcomes are presented explicitly, and the test is designed to measure risk-adjustment, risk-proneness, reflection time and delay-aversion.12
Compared with an age-matched control group of 34 children without ADHD, the children with ADHD showed:12
- Significantly poorer risk-adjustment (p<0.01)
- Significantly more delay-aversion (p<0.01).
However, reflection time and risk-proneness did not differ between the two groups.12
Symptoms of ADHD, such as impulsivity and increased risk-taking behaviour,13 may lead to adults breaking societal rules and norms.
According to some studies, symptoms of ADHD in adults were associated with a higher incidence of the following compared with people without ADHD:
- Criminality and arrests1,16-18
- Substance abuse5,19
- Aggressive/reckless driving5,16
- Traffic violations16,18
- Suspension of driving licence16
- Crash risk.20
A US study that comprehensively evaluated driving in 105 adults with ADHD (aged 17–28 years) versus driving in 64 community control adults on five domains of driving ability and a battery of executive function tasks found that compared with community controls, adults with ADHD were associated with significantly more traffic violation tickets (p<0.001), driving licence suspensions (p<0.001) and speeding tickets (p<0.006), as per self-reports and official Department of Motor Vehicle records.16
Furthermore, in a series of European and North American focus groups‡ (sponsored by Shire, now part of Takeda), some adults with ADHD reported aggressive or reckless driving, which was often accompanied by anger directed at other drivers.5
An analysis of 2479 adolescents and young adults with ADHD and 15,865 without ADHD found that the adjusted risk for first crash among licensed drivers with ADHD was 1.36 times higher than those without ADHD (95% confidence interval 1.25–1.48).20
*Number of ADHD symptoms as assessed by the Diagnostic Interview for ADHD in Adults (DIVA) with childhood and adulthood assessed separately4
†ADHD severity as assessed by the Wender Utah Rating Scale4
‡The average size of a focus group was 7 participants (range: 3–9 participants) with a mean age of 36 years. During the focus group, participants were asked questions based on a script/guide which had been designed for the focus group based on a literature review, and feedback/prior experience from expert clinicians from each country. The guide was designed to elicit commentary from the participants in several areas, including how the participants were diagnosed, their childhood experience of ADHD and daily life, social, physiological and physical functioning5
§This survey was an online, cross-sectional, opinion-based survey conducted in adults and designed to assess experiences of ADHD in childhood and adulthood (e.g. impact on work, social life and relationships), and experiences of impairment and general well-being in childhood/adolescence. It was conducted in France, Germany, Italy, the Netherlands, Spain and the UK10
- Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. J Clin Psychiatry 2006; 67: 524-540.
- Kuriyan AB, Pelham WE, Jr., Molina BS, et al. Young adult educational and vocational outcomes of children diagnosed with ADHD. J Abnorm Child Psychol 2013; 41: 27-41.
- Caci H, Doepfner M, Asherson P, et al. Daily life impairments associated with self-reported childhood/adolescent attention-deficit/hyperactivity disorder and experiences of diagnosis and treatment: results from the European Lifetime Impairment Survey. Eur Psychiatry 2014; 29: 316-323.
- Fredriksen M, Dahl AA, Martinsen EW, et al. Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD. Atten Defic Hyperact Disord 2014; 6: 87-99.
- Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes 2012; 10: 47.
- De Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med 2008; 65: 835-842.
- Shifrin JG, Proctor BE, Prevatt FF. Work performance differences between college students with and without ADHD. J Atten Disord 2010; 13: 489-496.
- Halmøy A, Fasmer OB, Gillberg C, et al. Occupational outcome in adult ADHD: impact of symptom profile, comorbid psychiatric problems, and treatment: a cross-sectional study of 414 clinically diagnosed adult ADHD patients. J Atten Disord 2009; 13: 175-187.
- Cussen A, Sciberras E, Ukoumunne OC, et al. Relationship between symptoms of attention-deficit/hyperactivity disorder and family functioning: a community-based study. Eur J Pediatr 2012; 171: 271-280.
- Pitts M, Mangle L, Asherson P. Impairments, diagnosis and treatments associated with attention-deficit/hyperactivity disorder (ADHD) in UK adults: results from the lifetime impairment survey. Arch Psychiatr Nurs 2015; 29: 56-63.
- Humphreys KL, Lee SS. Risk taking and sensitivity to punishment in children with ADHD, ODD, ADHD+ODD, and controls. J Psychopathol Behav Assess 2011; 33: 299-307.
- Sørensen L, Sonuga-Barke E, Eichele H, et al. Suboptimal decision making by children with ADHD in the face of risk: poor risk adjustment and delay aversion rather than general proneness to taking risks. Neuropsychology 2017; 31: 119-128.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
- Holmberg K, Bölte S. Do symptoms of ADHD at ages 7 and 10 predict academic outcome at age 16 in the general population? J Atten Disord 2014; 18: 635-645.
- Adamou M, Arif M, Asherson P, et al. Occupational issues of adults with ADHD. BMC Psychiatry 2013; 13: 59.
- Barkley RA, Murphy KR, Dupaul GI, et al. Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc 2002; 8: 655-672.
- Lichtenstein P, Larsson H. Medication for attention deficit-hyperactivity disorder and criminality. N Engl J Med 2013; 368: 776.
- Torgersen T, Gjervan B, Rasmussen K. ADHD in adults: a study of clinical characteristics, impairment and comorbidity. Nord J Psychiatry 2006; 60: 38-43.
- Piñeiro-Dieguez B, Balanzá-Martinez V, García-García P, et al. Psychiatric comorbidity at the time of diagnosis in adults with ADHD: the CAT study. J Atten Disord 2016; 20: 1066-1075.
- Curry AE, Metzger KB, Pfeiffer MR, et al. Motor vehicle crash risk among adolescents and young adults with attention-deficit/hyperactivity disorder. JAMA Pediatr 2017; 171: 756-763.