Validation of DSM-5 age-of-onset criterion of attention deficit/hyperactivity

disorder (ADHD) in adults: Comparison of life quality, functional

impairment, and family function
Yu-Ju Lin , Kuan-Wu Lo , Li-Kuang Yang , Susan Shur-Fen Gau

ADHD and functional impairment/quality of life

Adults with ADHD usually fail to fulfill their responsibilities, resulting in academic, occupational
underachievement interpersonal problems, social/emotional difficulties, and other psychiatric
comorbidities. The inability of adults with ADHD to fulfilling their social roles in several life domains
brings great distress and the subsequent emotional problems might in turn influence their
functions. Beside functional impairment, quality of life which reflects the subjective perception of
individuals is an important outcome measure in clinic and research settings and the main goal of
healthcare. Children and adolescents with ADHD were reported to have poorer quality of life in
several domains than non-ADHD controls, and the Adult ADHD Quality of Life Scale (AAQoL) has
been proven to be valid, responsive to ADHD symptom changes, and used in several studies. It is of
interest whether adults identified with ADHD via DSM-5 have similar severity and patterns of
functional impairment in various social roles and influences on quality of life as those identified via
DSM-IV that warrant medical attention and resources.

ANX/DPE and perceived family support as mediator from late-onset ADHD to functional
impairment/quality of life

Although ADHD symptoms have been reported to have a negative impact on the quality of life, the
explicit mechanism in between has not been well described. Identifying the modifiable factors is
clinically important to improve the well-being of individuals with ADHD (Agarwal, Goldenberg,
Perry, & IsHak, 2012). One study suggested that anxiety and depression symptoms serve as
mediators between childhood ADHD symptoms and decreased quality of life (Yang, Tai, Yang, &
Gau, 2013), and another reported the origin of family dynamics predicted the quality of life in
college students with ADHD (Grenwald-Mayes, 2002). Because there is strong correlation between
family functions and ANX/DEP, we wonder whether the family support and ANX/DEP
independently mediate the relationship between ADHD and functional impairment/quality of life
or one is more determining than the other, and whether there is difference between those who
recalled their symptoms by 7 and between 7 and 12 years.

Aim of this study

The primary aim of this study is to compare the perceived family support, functional impairment
and quality of life between the ADHD groups with the control group to validate the DSM-5
symptom threshold criterion and between two ADHD subgroups to validate the age-of-onset
criterion. Clinically, the individuals might perceive and recall their symptoms when their capacity
was challenged. If the time of symptom recalled, either before 7 or between 7 and 12 years, does
not change the influence of ADHD on various life domain of affected adults, then we could justify
the DSM-5 criteria to diagnose adults with ADHD. As far as we know, no previous study ever
compared the quality of life and perceived family function between ADHD with onset before 7
years and between 7 and 12 years using DSM-5 diagnostic criteria for adults.

The secondary aim of this study is to verify whether family functions and ANX/DEP also mediate the
DSM-5 diagnosis of ADHD with recalled onset between 7 and 12 years to quality of life and
functions as the DSM-IV did. If family and ANX/DEP have similar mediation effects between late-
onset ADHD and functional impairment, then late-onset ADHD might impact affected individuals
through similar mechanisms as previous reports in DSM-IV ADHD.
Participants: Participants were excluded if they had any systemic medical illness such as
cardiovascular disease, learning disability, autism spectrum disorder, or Full-scale IQ < 80. We
excluded the participants who had missing data in the adult ADHD quality-of-life scale in this study.
Finally, 189 (88.3%) adults with DSM-5 ADHD and 153 non-ADHD controls entered the analyses
and three groups, naming early-onset ADHD (n = 147), late-onset ADHD (n = 42) and the control (n
= 153) groups, were compared.

Measures:

1-Adult self report scales (ASRS),

2-The adult ADHD quality-of-life scale (AAQoL),

3-Weiss functional impairment rating scale self-report (WFIRS-S) - The WFIRS-S is a 70-item Likert
scale, ranging from 0 for ‘‘Never/Not at all’’ to 3 for ‘‘Very often/Very Much.’’ The WFIRS-S had
been used to assess seven domains of functional impairment, including family (8 items), work (11
items), school (11 items), life skills (12 items), self-concept (5 items), social (9 items), and risk (14
items) in clinical trials of ADHD (Stein et al., 2011).

4-Chinese version of the family adaptation, partnership, growth, affection and resolve (APGAR-C),

5- Adult self report inventory-4 (ASRI-4) - the ASRI-4 is a self-administered rating scale based in the
DSM-IV (Gadow, Sprafkin, & Weiss, 2004). It is a four-point Likert scale: 0 for never, 1 for
sometimes, 2 for often, and 3 for very often. Most items evaluate current (the last six months)
conditions, except those for impulsive disorder, depression, and manic episodes, which are rated
on a lifetime basis.

Results

Group comparisons of demographic data and ADHD symptoms: The demographics showed no
difference with respect to sex, intelligence, highest education level, and types of occupation
between any two of the three groups (Table 1). The non-ADHD adults tended to be single in
comparison with those with ADHD, which could possibly be due to the younger age of this group.
Significantly more parents of adults with ADHD were divorced or separated than controls. Fewer
fathers of late-onset ADHD adults had technical jobs than fathers of early-onset ADHD adults and
controls (Supplement Table S1). Both ADHD groups had higher self-report ANX/DEP symptom
scores and more severe current and recalled ADHD core symptoms – namely inattention,
hyperactivity, and impulsivity – than controls (Table 1). However, there was no significant
difference in ADHD symptom severity between the two ADHD groups except more current and
recalled hyperactivity symptoms in the early-onset group than in the late-onset one (Table 1).

Social role functional impairments, quality of life and family support: Both ADHD groups had
significantly different ratings from controls in the AAQoL (life quality), WFIRS (functional
impairment), and family APGAR (perceived family support) in both univariate and multivariate
analysis of covariance (controlling for age, sex, education, marital status, and any psychiatric
disorder, all p values <0.001, Table 2). No statistical difference was noted between the two ADHD
groups with the following exceptions. The late-onset ADHD group had more severe work
impairment assessed by the WFIRS and less perceived family support than the early-onset group (p
< 0.01) after adjusting for age, sex, education, marital status, and any psychiatric disorder (Table 2).

Family support and ANX/DEP on the relation of late-onset ADHD and social role functional
impairments and quality of life: Using Family APGAR as the single mediator, we found that it
significantly mediated the effect of late-onset ADHD on AAQoL/WFIRS impairment while the direct
effect between ADHD and AAQoL/WFIRS scores (path c0) remained significant (p < 0.01)
(Supplement Table S2). Further indirect effect analyses revealed partial mediation effect of family
support in all subscales of AAQoL and of WFIRS (Supplement Table S2). After adding ANX/DEP as
another mediator (two-mediator model, Fig. 1), family support only partially mediated the
association of late-onset ADHD and the ‘‘life outlook’’ of the AAQoL and ‘‘family’’, ‘‘school’’, and
‘‘self-concept’’ of the WFIRS. In contrast, ANX/DEP mediated the link from late-onset ADHD to all
subscales of the AAQoL and WFIRS (Table 3). The direct effect of late-onset ADHD decreased
significantly on the subscale ‘‘life productivity’’ and ‘‘relationship’’ of life quality and almost all
subscales of the WFIRS except ‘‘work’’ and ‘‘school’’. For comparison, we also conduct mediation
analysis for early-onset ADHD, which is presented in supplementary Table S3. Overall, there was no
difference in the mediation effect of ANX/DEP, yet the perceived family support mediated more
subscales of WFIRS from early-onset ADHD, including ‘‘life skill’’ and ‘‘risky behavior’’ independent
of ANX/DEP. It is probably because of lower power of the late-onset group to detect the effect of
family support.

Discussion

Major findings

As the first study measuring quality of life based on the DSM-5 ADHD criteria in Asia, our study
demonstrated that regardless of recalled age of symptom onset, adults with DSM-5 diagnosed
ADHD suffer from lower quality of life assessed by the Chinese version of the AAQoL and exhibited
greater functional impairments assessed by the Chinese version of the WFIRS-S than the controls
after controlling for age, sex, educational level and any psychiatric comorbidity. The domains of
functional impairments measured in this study are similar to the impairments reported by previous
adult ADHD studies in which ADHD was diagnosed via DSM-IV (Agarwal et al., 2012; Banaschewski
et al., 2013). There was no difference between early- and late-onset ADHD groups in quality of life
and most subscales of functional impairments, except the ‘‘work’’ subscale. Beyond our
expectation, adults with late-onset ADHD generally felt less competent at work and perceived less
family support than those with early-onset ADHD. Therefore, using DSM-5 criteria to diagnose
ADHD does not over-diagnose ADHD in adults.

Self-perceived family support partly mediated the effect from DSM-5 late-onset ADHD to life
quality and functional impairments, and some of this mediation effect could be explained by
current ANX/DEP, including psychological health, work performance, social activities, self-concept
and risky behavior. ANX/DEP substantially mediates the effects of late-onset ADHD on all domains
of life quality and functional impairments. Perceived family support and ANX/DEP both mediated
the effect of DSM-5 late-onset ADHD on life outlook in QoL and domains of family and school in
functional impairments.

Family support and ANX/DEP as mediators between late-onset ADHD and functional impairment
and quality of life

Several studies commented that ADHD symptoms would predict decreased quality of life to some
extent (Chao et al., 2008; Danckaerts et al., 2010; Yang et al., 2013), and the improvement of ADHD
symptoms after treatment with medication brings an improvement in life quality (Adler et al.,
2013; Fuentes et al., 2013; Mattos, Louza, Palmini, de Oliveira, & Rocha, 2013). We do not yet
understand the pathway connecting this relationship. In previous studies, anxiety/depression (Yang
et al., 2013) and family origin of dynamics (Grenwald-Mayes, 2002) predicted decreased quality of
life in adults with DSM-IV ADHD. We further confirmed such associations in adults with DSM-5
ADHD and recalled age of onset between 7 and 12 years. Similar mediation effects of family
support and ANX/DEP were also seen in the relationship between early- and late-onset ADHD and
ADHD-related functional impairment in our study. Furthermore, the effect of current ANX/DEP is
great enough to obliterate the direct effects from ADHD to life quality and self-perceived functional
impairment. Both ANX/DEP and family support have independent mediation effects and unique
roles that influence the life quality and functional impairment of ADHD despite significant
correlations between ANX/DEP and family support (r = 0.35, p < 0.0001 for the early-onset group
and r = 0.48, p = 0.002 for the late-onset group) (Harris & Molock, 2000). ADHD has been well
known to influence family functioning (Gau, 2007; Johnston & Mash, 2001), and has been linked to
anxiety/depression (Biederman et al., 1993), which in turn, brings further functional impairment
and decreased quality of life. The link are similar in early-and late-onset ADHD in our study. Thus,
aside from medication, enhancing family functions/cohesion and managing ANX/ DEP would be an
important facet in improving the overall well-being of adults with ADHD—regardless of using the
diagnostic criteria of DSM-IV or DSM-5. Furthermore, parents’ ADHD symptoms are strongly
correlated with their children’s ADHD symptoms, which are mediated by parents’ depressive
symptoms (Hong et al., 2014). Without addressing these problems, ADHD related functional
impairment and unsatisfactory quality of life would affect the offspring through genetic
transmission and poor family functions.