ADHD Medication Treatment in Childhood Increase Adult Employment?
Although ADHD used to be considered a disorder of childhood, follow-up studies
indicate that between 30% and 60% of children with ADHD continue to experience
symptoms and impairment in adulthood. And, even when ADHD symptoms decline
over time, many individuals continue to experience significant impairment
in important areas of functioning.
For example, children with ADHD have poorer academic achievement as adolescents
compared to their peers and this trend continues into adulthood. Research
pertaining to occupational functioning is limited but available data clearly
points to poorer employment histories in adults with ADHD. Predictors of occupational
outcomes in individuals with ADHD have not been carefully investigated, however.
A recent study conducted in Norway with a large sample of adults with ADHD
begins to address some of the important gaps in our knowledge of these issues
[Halmoy et al.(2009). Occupational outcome in adult ADHD: Impact of symptom
profile, comorbid psychiatric problems, and treatment. Journal of Attention
Disorders, 13, 175-187].
Participants were 414 adults (198 women and 216 men) who were diagnosed
with ADHD and whose clinician was seeking to treat them with stimulant medication.
As recently as 2005 in Norway, physicians looking to prescribe stimulant medication
for adults needed to conduct a comprehensive assessment based on national
guidelines and have their findings reviewed by an expert committee.
The committee needed to support the request to prescribe stimulants before
the physician could do so. This was the required procedure even for individuals
who were treated with stimulants prior to turning 18. The 414 participants
with ADHD were recruited from nearly 2000 adults whose information was sent
for committee review between 2004 and 2006. Comparison subjects (n=357)
were drawn from a random sample of adults from across the country.
Both groups of adults completed a number of self-report measures to assess
their current functioning in multiple areas including their educational attainment,
occupational status, and psychiatric symptoms. For the adults with ADHD,
information on whether they were treated with stimulant medication as children
was also obtained.
- Results -
As expected, a number of important differences were found between adults
with and without ADHD. Key among these were the following:
- Only 23% of the ADHD group had attained a university level education compared
to 59% of controls.
- 29% of the ADHD group had only a junior high school education vs. only
6% of controls.
- Lifetime rates of significant anxiety or depression was reported by 70%
of the ADHD group vs. only 17% of controls.
- Lifetime problems with alcohol were reported by nearly 30% of the ADHD
group compared to less than 3% of controls.
Group differences in the occupational realm were also striking. At
the time of the assessment, only 24.3% of adults in the ADHD group reported
being employed compared to nearly 80% of the comparison adults. More
than half of adults with ADHD were either receiving disability or were in
vocational rehabilitation compared to only 5% of comparison adults.
These differences were consistent across gender.
- Correlates of occupational outcome -
The researchers were interested in testing factors related to the occupational
status of participants with ADHD. The factors that they tested included
severity of ADHD symptoms, ADHD subtype (inattentive, combined, or hyperactive-impulsive),
symptoms of depression and anxiety, alcohol or drug problems, and whether
the adult had been treated with stimulant medication in childhood.
After controlling for all variables in the model, only ADHD subtype and
medication treatment in childhood was associated with current employment
status. Adults with the inattentive or combined subtype were more likely
to be out of work than those with the hyperactive-impulsive subtype.
Thus, high rates of attention difficulties - either with or without hyperactivity
- was a risk factor for being unemployed.
Results pertaining to childhood medication treatment were quite interesting.
Adults with ADHD who had not received medication treatment as children (n=329)
were over three times as likely to be unemployed than those who had (n=75).
This finding remained even when educational attainment was controlled for.
Adults who had not been treated with medication in childhood also reported
significantly higher rates of anxiety and depressive symptoms.
- Summary and implications -
Results from this study clearly indicate that adults with ADHD have poorer
educational outcomes, report more psychiatric difficulties, and are more likely
to be unemployed than other adults. The difference in employment status
was especially striking and highlights the significant impairment that frequently
accompanies ADHD into adulthood.
An especially intriguing finding was the strong relationship between medication
treatment in childhood and employment status in adulthood, as those who had
been treated were far more likely to be employed. What makes this finding
particularly striking is that individuals treated with medication as children
would be likely to have had more severe cases of ADHD to begin with, particularly
since medication treatment is less common in Norway than in the US.
If this were the case, it would have worked against more positive occupational
outcomes in adulthood, thus suggesting an especially important role for medication
The authors are careful to note that no definitive conclusion can be made
about whether childhood medication treatment was responsible for higher employment
rates. One important reason for this is that there is no way to determine
whether other factors associated with receiving treatment, rather than treatment
itself, led to the obtained result. For example, parents who obtained
medication treatment for their child may have obtained other treatment services
or supports for their child that contributed to greater occupational success.
This possibility, however, was not investigated and efforts to rule out this
alternative explanation would have strengthened the study.
It is also important to note that the lower employment rates and greater
psychiatric difficulties of adults with ADHD in this study is likely to overestimate
what is true for the general population of adults with ADHD. Adults
with ADHD in this study were struggling sufficiently to have their physician
initiate the complex and time consuming procedure required in Norway to obtain
permission to prescribe stimulants. Thus, these adults were likely to
be more impaired by their ADHD than the general population of adults with
ADHD. Had a more representative sample of adults with ADHD been included
as participants, I suspect that differences with the comparison subjects would
have been attenuated.
It is also the case that results found in one country may not necessarily
generalize to other countries, and this should be kept in mind as well.
These limitations not withstanding, the findings reported highlight the
important struggles that many adults with ADHD experience and emphasize the
need for effective treatment of ADHD during the adult years. It is
especially interesting that adults who received medication treatment as children
had better occupational outcomes as adults. Although a causal relationship
cannot be definitively established from these data, the importance of early
identification and treatment of ADHD in promoting more positive long-term
outcomes is certainly supported.
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(c) 2011 David Rabiner, Ph.D.