ADHD Symptoms Are Differentially Related to Specific Aspects of Quality of Life

Bjørn Gjervan, Terje Torgersen, Kirsten Rasmussen, and Hans Morten Nordahl

The disorder is defined by symptoms of inattentiveness, hyperactivity, and/or impulsivity. In

adults, these symptoms are associated with problems remaining focused for a longer period of
time, as well as with difficulties in organizing activities, prioritizing tasks, and time
management. The Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV)
diagnosis of ADHD (American Psychiatric Association [APA], 1994) describes three different
sub- types: the inattentive type, the hyperactive/impulsive type, and the combined type. An
age-dependent decline in hyper- activity and impulsivity has been described in adults
(Biederman, Mick, & Faraone, 2000). Adding to sustained symptoms, adults with ADHD have
an increased risk of lifelong psychiatric comorbidity (Halmoy, Fasmer, Gillberg, & Haavik, 2009;
Kessler, Berglund, et al., 2005; Rasmussen & Levander, 2008; Torgersen, Gjervan, &
Rasmussen, 2006). Studies suggest that up to 90% of adult patients with ADHD have one or
more comorbid psychiatric disorder (Nutt et al., 2007).

Quality of Life (QoL) in ADHD

The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36; Ware & Sherbourne,
1992) is a generic HRQoL measure that has frequently been used to assess QoL in adults with
ADHD, either alone or in combination with ADHD-specific HRQoL measures growing body of
research suggests that adult ADHD is generally associated with low disease-specific (Brod,
Johnston, Able, & Swindle, 2006; Matza, Johnston, Faries, Malley, & Brod, 2007; Weiss et al.,
2010) and generic HRQoL (Adler et al., 2006; Matza et al., 2006). Furthermore, Adler and
colleagues (2006) found that adults with untreated ADHD had significantly lower scores than
the U.S. norm on the SF-36 mental component scales (i.e., Vitality, Social Function, Role-
Emotional, and Mental Health). Symptom severity has been identified as one key determinant
of dis- ease-specific HRQoL outcome (Brod, Perwien, Adler, Spencer, & Johnston, 2005), and
the combined subtype has been associated with lower HRQoL than the inattentive type
(Gibbins et al., 2010). One recent study examining mediators and moderators of specific
HRQoL in adults with ADHD reported that symptoms of inattention were a stronger mediator
of ADHD-specific HRQoL than hyperactivity/ impulsivity (Weiss et al., 2010). Gjervan et al. (
2006; Matza, Stoeckl, Shorr, & Johnston, 2006; Weiss et al., 2010).

A growing body of research suggests that adult ADHD is generally associated with low disease-
specific (Brod, Johnston, Able, & Swindle, 2006; Matza, Johnston, Faries, Malley, & Brod, 2007;
Weiss et al., 2010) and generic HRQoL (Adler et al., 2006; Matza et al., 2006). Furthermore,
Adler and colleagues (2006) found that adults with untreated ADHD had significantly lower
scores than the U.S. norm on the SF-36 mental component scales (i.e., Vitality, Social Function,
Role-Emotional, and Mental Health). Symptom severity has been identified as one key
determinant of dis- ease-specific HRQoL outcome (Brod, Perwien, Adler, Spencer, & Johnston,
2005), and the combined subtype has been associated with lower HRQoL than the inattentive
type (Gibbins et al., 2010). One recent study examining mediators and moderators of specific
HRQoL in adults with ADHD reported that symptoms of inattention were a stronger mediator
of ADHD-specific HRQoL than hyperactivity/ impulsivity (Weiss et al., 2010).
The fact that HRQoL has been found to improve after central stimulant (CS) treatment (Adler
et al., 2006; Matza et al., 2006; Spencer et al., 2008; Weiss et al., 2010) suggests that HRQoL
and symptom severity is in some way associated. However, the literature does not reveal if
specific symptoms are associated with certain HRQoL aspects. Previous research suggests an
association between having one or more comorbid psychiatric conditions and low HRQoL
(Brod et al., 2006). A recent study reports the same effect in a general psychiatric population
of patients receiving psychiatric services where an increasing number of comorbid conditions
decreased the QoL (Watson, Swan, & Nathan, 2011).

An age-dependent decline in HRQoL has been described in the general child and adolescent
population in 12 European countries (Michel, Bisegger, Fuhr, & Abel, 2009). The same pattern
was found in a population of Swedish adolescents and young adults (Jö rngården, Wettergren,
& von Essen, 2006). To our knowledge, this impact of age on HRQoL in adult ADHD is not well
described in the literature . Thus, there is a need for more information about this possible
association. There is a growing understanding that symptoms are only part of the problem for
many patients with ADHD (Barkley & Murphy, 2010; Brod et al., 2006; de Graaf et al., 2008;
Safren, Sprich, Cooper-Vince, Knouse, & Lerner, 2010). Studies have shown that mental health
patients’ subjective perception of the impact of health and disease affects compliance and
evaluation of treatment (Hunt & McKenna, 1993).

Supporting these findings, Weiss and colleagues (2010) identified satisfaction with treatment
as a major mediator of symptom and HRQoL outcome in adults with ADHD. Empirical data also
suggest that comorbid mental illnesses have a pervasive effect on psychological state as well
as psychosocial and role functioning in ADHD (Brod et al., 2005; Brod et al., 2006; Matza et
al.,2007; Ormel et al., 1994; Weiss et al., 2010). The literature reveals that HRQoL is
increasingly being used to measure consequences of adult ADHD, thus considered an
important outcome in the assessment of ADHD. Following this, there is a need for research
addressing more specific relationships between symptoms and HRQoL. To our knowledge, the
relationships between the core symptoms of adult ADHD and the different domains of HRQoL
are still unclear. Clarifying how different types of ADHD symptoms affect specific aspects of
HRQoL in adults could provide a more comprehensive understanding of the disorder. This, in
turn, may help clinicians and patients to better understand and discuss important aspects of
the disorder and to define treatment targets and interventions.

Aim of the Study and Hypotheses

Our objective was to explore the relationships between ADHD inattentiveness and
hyperactivity/impulsivity and the four domains of HRQoL as measured by the SF-36 mental
component scales. Previous literature indicates that elevated levels of inattentiveness and
hyperactivity/impulsivity in adult ADHD are related to poor HRQoL. Thus, we hypothesized that
inattentiveness and hyperactivity/impulsivity would predict HRQoL scores. Based on the
previous literature, we also hypothesized that concurrent psychiatric disorders and age would
be significant predictors of HRQoL outcomes.
Method

Participants: Assessment and control of the patient list showed that of the total of 586
patients, 79 had been incorrectly diagnosed with ADHD and 30 diagnoses were found to be
subthreshold ADHD. In addition, 6 persons had died. Among the 471 patients invited to
participate in the study, 152. 3 Excluded due to specific learning difficulties.

The general Adult ADHD Symptom Checklist (Amen, 1995) was replaced by the ADHD Self-
Report Scale (ASRS; Kessler, Adler, et al., 2005), and the Mini- International Neuropsychiatric
Interview (MINI) was introduced as a mandatory tool for diagnosing comorbidity. In most
cases, the assessment was supplemented with additional information, such as structured
diagnostic inter- views, neuropsychological tests, computed tomography (CT)/magnetic
resonance imaging (MRI), and electroencephalogram (EEG). All relevant information about the
diagnostic assessment, patient history, and treatment was documented in the medical records.

Clinical Variables. From the patients’ medical records, we collected information about past
ADHD diagnoses and psychiatric comorbidity. A diagnosis of ADHD was a result from the
procedure, which was mandatory for all clinicians. The validity of previous diagnoses of
comorbid psychiatric dis- orders was controlled by an experienced psychiatrist. A comorbid
disorder was included in the data set only if the medical record confirmed that the DSM-IV
criteria were met. Information about treatment with CSs was collected from medical records.

Self-Report Questionnaires

Current ADHD-ASRS

Adult ASRS Full Edition (ASRS-v.1). The ASRS is the WHO’s self-report rating scale for adult
ADHD (Kessler, Adler, et al., 2005). The scale consists of 18 items, which are consistent with
the DSM-IV diagnostic criteria addressing ADHD symptoms. The items are measured on a 5-
point scale (0-4 = never/seldom to often), with a possible total range of 0 to 72. Higher scores
indicate higher frequencies of symptoms and symptom load. The scale is organized in two
sections, each with its own sum-score. Items 1 to 9 (Part A) reflect symptoms of inattention
and Items 10 to 18 (Part B) reflect symptoms of hyperactivity or impulsivity. Internal
consistency with Cronbach’s alpha for ASRS in the data set was .86 for Part A and .86 for Part
B.

The Medical Outcomes Study SF-36 (Ware & Sherbourne, 1992) is considered a cornerstone in
the assessment of functional deficits and QoL resulting from an illness. This instrument has two
components, each including subscales: a physical component and a mental component. The
latter is the one of relevance when assessing the psychological and functional aspects of
HRQoL in adults with ADHD.

The SF-36 Mental Component (MC) assesses HRQoL on four scales with a 4-week recall. The
Vitality scale assesses the amount of time that the responder experienced reduced vitality. The
Social Functioning scale describes to what extent physical health or emotional problems have
interfered with social activities. Furthermore, the Role- Emotional Functioning scale assesses
aspects associated with role performance due to emotional problems.
Higher scores indicate better perceived HRQoL or functioning. Internal consistency for the
mental component scales in the data set ranged from Cronbach’s alpha .74 to .86.

Sociodemographic Characteristics

Seventy-eight (52.3%) women and 71 (47.7%) men participated in the study. Mean age of the
total sample was 33.7 (SD = 10.7) with the median being 33.0 and age ranging from 18 to 63
years.

There were significant gender differences in ADHD subtypes as 20 (26.7%) women versus 5
(7.5%) men had the inattentive subtype (p < .05), whereas 53 (70.7%) women versus 62
(92.5%) men had the combined type (p < .001). Only two patients had the impulsive or
hyperactive subtype.

Lifetime depressive disorder was the most prevalent comorbid disorder with a total of 54
(37.8%) fulfilling the criteria. There were significant gender differences in sub- stance use
disorder, antisocial disorder, and borderline personality disorder (see Table 1). The total mean
for number of comorbid psychiatric disorders was 1.9 (SD = 1.7) with no significant gender
differences.

ADHD Symptoms, SF-36 MCS, Concurrent

Psychiatric Disorders, and Age

Relationships between ADHD symptoms, comorbidity, age, and the SF-36 mental component
scales were explored by two-tailed correlations with Pearson’s r coefficient. ASRS
inattentiveness and ASRS hyperactivity/impulsive- ness were significant and negatively
associated with all the SF-36 mental component scales. Inattentiveness was strongest
correlated with the Vitality scale, r = −.45 (p < .01), whereas hyperactivity/impulsiveness was
strongest correlated with the Mental Health scale, r = −.54 (p < .01). The number of comorbid
psychiatric disorders was associated with the Social Function scale, r = −.26 (p <.01), and the
Role-Emotional scale, r = −.17 (p < 05). Age and gender were not significantly associated with
any of the mental component scales (Table 2).

Discussion

Poor HRQoL is a major problem in adults with ADHD. Measures of QoL are now extensively
used to monitor safety and tolerability in pharmacological treatments as well as being a
treatment outcome itself. Therefore, it is important to clarify the relationships between ADHD
symptoms and different aspects of QoL. The current results show that ADHD symptoms might
be differentially related to specific HRQoL domains.

Inattentiveness was a strong predictor of vitality and explained a smaller but significant part of
the variance in the role-emotional outcome.

Symptoms of hyperactivity/impulsivity were a strong predictor of social function and mental

health. Previous research in children with ADHD has showed that disruptive symptoms are
associated with more social impairment as opposed to inattentiveness (Weiss, Worling, &
Wasdell, 2003). The present findings indicate that such a relationship might also be present in
adulthood. Comorbid psychiatric disorders also predicted the social function outcome
explaining a smaller part of the variance. Mental health is previously found to be strongly
associated with clinician-rated ADHD symptoms (Adler et al., 2006), and the current findings
specifies this relationship suggesting that mental health is primarily associated with
hyperactivity/impulsivity. Weiss et al. (2010) reported that inattentiveness might be a stronger
mediator of adult ADHD-specific QoL than hyperactivity/impulsivity. Our findings indicate that
there is a specific relationship between ADHD symptoms and domains of QoL.

More knowledge about the relationship between symptoms and specific HRQoL domains
expands the clinical significance of measuring QoL when assessing and treating adults with
ADHD. It is important to pay attention to the high prevalence of poor HRQoL in adults with
ADHD when planning interventions and measuring outcome. The differentiation of the
relationships between symptom types and HRQoL domains implies the possibility to define
more specific treatment targets and monitoring outcomes such as safety and tolerability in
pharmacological treatment with greater accuracy. Thus, the findings in the present study can
help clinicians in identifying and being aware of the possible impact of specific HRQoL domains
on ADHD symptoms. This offers the possibility to identify potential needs for combining
pharmacological treatment with psychosocial interventions to enhance treatment
effectiveness. Moreover, the differential relationships between symptoms and mental
component scales show that monitoring generic HRQoL is a useful supplement to symptom
assessment. In the present study, HRQoL has demonstrated its ability to assess issues of
clinical relevance.

There were significant gender differences in ADHD subtypes as more women than men had the
inattentive subtype, whereas more men than women had the combined type. Most studies
have found only minor gender differences in ADHD symptoms in adults. However, studies have
reported higher levels of current ADHD symptoms in women compared with men as well as
relatively more men than women being present in all subtypes. Thus, there are no consistent
findings of the relationship between ADHD subtype and gender.

We also found that significantly more men than women had the diagnoses of substance abuse
disorder and antisocial personality disorder. No significant gender differences were found in
the ASRS scores. The HRQoL scores showed the same tendency of poor HRQoL as reported
earlier, and the ADHD symptom scores were also comparable with earlier reports.

To summarize, findings in the present study suggest that different symptoms in adult ADHD
are associated with different HRQoL domains. Elevated levels of inattentiveness had a negative
impact on vitality and role-emotional function, and hyperactivity/impulsivity affected social
function and mental health. Thus, our hypothesis that symptoms of inattentiveness and
hyperactivity/impulsivity would predict HRQoL was confirmed.