Does 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 treatment.

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.
– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

–> For relat­ed arti­cles by Dr. David Rabin­er on atten­tion deficits, click Here.