Cogmed has developed a computerized training program to improve working memory, which is a frequent problem for children and adults with ADHD.  Research has shown that Cogmed's program can enhance working memory, and that improvements in working memory are associated with reductions in attention and learning problems.  You can learn more at Cogmed.com.  Clinicians interested in learning about the benefits of incorporating working memory training into their practice are invited to request an information

QUALITY OF LIFE IN ADOLESCENTS WITH ADHD

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 - 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.
 

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 according.

(Note: To receive a report on research-based procedures for maximizing the benefits of medication treatment, go to www.helpforadd.com/medreport.htm.  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.  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 SELF-REPORT 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.

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.

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.