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14/12/2008




Impact of ADHD on Major Life Activities – The Current
                    and Future
     Need for Integrated Multi-Level Treatment
                         Multi-
                               Russell A. Barkley, Ph.D.
                                       Clinical Professor of Psychiatry
                                    Medical University of South Carolina
                                                Charleston, SC
                                                      and
                                Research Professor, Department of Psychiatry
                                      SUNY Upstate Medical University
                                                 Syracuse, NY

                             ©Copyright by Russell A. Barkley, Ph.D., 2007
                                 Email: russellbarkley@earthlink.net
                                     Website: russellbarkley.org

                                                  Sources:
 Barkley, R. A. (2006). Attention d f
    kl          (     )           deficit h
                                          hyperactivity disorder: a handbook for diagnosis and treatment
                                                        d d         h db k f d               d
                                         (3rd ed.). New York: Guilford.
       Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says.
                                             New York: Guilford




                                                                                                             1
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-




                                                       2
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




                                                                  3
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




                                                                         4
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




                                                                                       5
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




                                                     6
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




                                                                                                                               7
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




                                                                                                                               8
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




                                                                                                        9
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).




                                                                              10
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




                                                                    11
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




                                                                  12
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




                                                                                                                              13
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




                                                                                                                14
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
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




                                                        16
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




                                                                        17
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




                                                                18
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




                                                                 19
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




                                                                20
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




                                                                                   21
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




                                                                                22
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




                                                          23
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)




                                                     24
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




                                                             25

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Impacto del TDAH en las actividades importantes de la vida - Presente y Futuro.

  • 1. 14/12/2008 Impact of ADHD on Major Life Activities – The Current and Future Need for Integrated Multi-Level Treatment Multi- Russell A. Barkley, Ph.D. Clinical Professor of Psychiatry Medical University of South Carolina Charleston, SC and Research Professor, Department of Psychiatry SUNY Upstate Medical University Syracuse, NY ©Copyright by Russell A. Barkley, Ph.D., 2007 Email: russellbarkley@earthlink.net Website: russellbarkley.org Sources: Barkley, R. A. (2006). Attention d f kl ( ) deficit h hyperactivity disorder: a handbook for diagnosis and treatment d d h db k f d d (3rd ed.). New York: Guilford. Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says. New York: Guilford 1
  • 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- 2
  • 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 3
  • 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 4
  • 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 5
  • 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 6
  • 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 7
  • 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 8
  • 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 9
  • 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). 10
  • 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 11
  • 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 12
  • 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 13
  • 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 14
  • 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 16
  • 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 17
  • 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 18
  • 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 19
  • 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 20
  • 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 21
  • 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 22
  • 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 23
  • 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) 24
  • 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 25