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Impact of ADHD on Major Life Activities Impact of ADHD on Major Life Activities –– The Current The Current and Futureand Futureand Future and Future

Need for Integrated MultiNeed for Integrated Multi--Level TreatmentLevel TreatmentRussell A. Barkley, Ph.D.Russell A. Barkley, Ph.D.

Clinical Professor of PsychiatryClinical Professor of PsychiatryMedical University of South CarolinaMedical University of South Carolina

Charleston, SCCharleston, SCandandandand

Research Professor, Department of PsychiatryResearch Professor, Department of PsychiatrySUNY Upstate Medical University SUNY Upstate Medical University

Syracuse, NYSyracuse, NY

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

Website: russellbarkley.orgWebsite: russellbarkley.org

Sources: Sources: kl ( )kl ( ) d f h d d h db k f d dd f h d d h db k f d dBarkley, R. A. (2006). Barkley, R. A. (2006). Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment Attention deficit hyperactivity disorder: a handbook for diagnosis and treatment

(3(3rdrd ed.)ed.). New York: Guilford.. New York: Guilford.Barkley R. A., Murphy, K. R., & Fischer, M. (2008). Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says.ADHD in Adults: What the Science Says.

New York: GuilfordNew York: Guilford

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ObjectivesObjectivesTo review the impact of ADHD on majorTo review the impact of ADHD on majorTo review the impact of ADHD on major To review the impact of ADHD on major life activities outside of educational and life activities outside of educational and occupational settingsoccupational settingsTo highlight recent results of the To highlight recent results of the g gg gMilwaukee followMilwaukee follow--up study concerning up study concerning outcomes at age 27outcomes at age 27To discuss the treatment implications of To discuss the treatment implications of h fi dih fi dithese findings these findings

To illustrate the need for multidisciplinary To illustrate the need for multidisciplinary treatment and multitreatment and multi--agency involvementagency involvement

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Motor Vehicle Driving RisksMotor Vehicle Driving RisksPoorer steering, slower braking reaction timePoorer steering, slower braking reaction timeRated by self, others, and driving instructors as using fewer Rated by self, others, and driving instructors as using fewer safe d i ing habitssafe d i ing habitssafe driving habitssafe driving habitsMore likely to drive before legally licensedMore likely to drive before legally licensedMore accidents (and more at faults) (2More accidents (and more at faults) (2--3x risk) 3x risk)

% with 2+ crashes: 40 vs. 6% with 2+ crashes: 40 vs. 6% with 3+ crashes: 26% with 3+ crashes: 26 vsvs 99% with 3+ crashes: 26 % with 3+ crashes: 26 vsvs 99

More citations (Speeding More citations (Speeding -- mean 4mean 4--5 vs. 15 vs. 1--2)2)Worse accidents ($4200Worse accidents ($4200--5000 5000 vsvs $1600$1600--2200)2200)

(% having a crash with injuries: 60 (% having a crash with injuries: 60 vsvs 17%)17%)More Suspensions/Revocations (Mean 2.2 More Suspensions/Revocations (Mean 2.2 vsvs 0.7)0.7)p / (p / ( ))

(% suspended: 22(% suspended: 22--24 vs. 424 vs. 4--5%)5%)Greater adverse impact of alcohol on drivingGreater adverse impact of alcohol on driving

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SexualSexual--Reproductive RisksReproductive RisksNo Higher Incidence of Sexual DisordersNo Higher Incidence of Sexual DisordersBegin Sexual Activity Earlier Begin Sexual Activity Earlier (15 vs 16 yrs.)(15 vs 16 yrs.)M Lif ti S l P tM Lif ti S l P tMore Lifetime Sexual Partners More Lifetime Sexual Partners (13.6 vs. 5.4)(13.6 vs. 5.4)

% having more than 4 partners by early adulthood 60 vs. 28%% having more than 4 partners by early adulthood 60 vs. 28%More Partners in Prior Year More Partners in Prior Year (2.4 vs. 1.6)(2.4 vs. 1.6)Less Time with Each Partner Less Time with Each Partner More casual sex More casual sex (outside relationships)(37 vs. 19%)(outside relationships)(37 vs. 19%)Less Likely to Employ ContraceptionLess Likely to Employ ContraceptionGreater Teen Pregnancies Greater Teen Pregnancies (24(24--38 vs. 438 vs. 4--5%)5%)

32% males, 68% females32% males, 68% femalesRatio for Number of Births by age 21Ratio for Number of Births by age 21(37:1)(37:1)

54% Do Not Have Custody of Offspring54% Do Not Have Custody of Offspring2 % h h ld 3% f l2 % h h ld 3% f lBy age 27, 51% have children vs. 13% for controlsBy age 27, 51% have children vs. 13% for controls

Higher Risk for STDs Higher Risk for STDs (17 vs. 4%)(17 vs. 4%)Overall riskier sexual behaviorOverall riskier sexual behavior

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Antisocial Activities Antisocial Activities (age 21; Milwaukee Study)(age 21; Milwaukee Study)

SelfSelf--reports for lifetime occurrencesreports for lifetime occurrences

Antisocial ActivitiesHyper Mean

Control Mean

Hyper %

Control %Antisocial Activities Mean Mean % %

Stolen Property 18.6 5.1 85 64Stolen Money 6.0 2.3 50 36Disorderly Conduct 18.5 8.3 69 53Assaulted with Fists 13.8 4.1 74 52Assaulted with a Weapon

2.7 0.3 22 7

Carries Concealed Weapon

15.1 4.9 38 11

Illegal Drug Possession 234.5 130.6 51 42*Ill l D S l 14 3 4 5 24 20*Illegal Drug Sales 14.3 4.5 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

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Dimensions of Antisocial Acts Dimensions of Antisocial Acts Predatory:Predatory:Predatory:Predatory:

Mugs, fights, carries & uses weaponsMugs, fights, carries & uses weaponsRelated chiefly to CDRelated chiefly to CD

SelfSelf--sufficiency:sufficiency:Runs away steals money prostitutionRuns away steals money prostitutionRuns away, steals money, prostitutionRuns away, steals money, prostitutionAssociated with CDAssociated with CD

DrugDrug--related:related:Possesses, uses, & sells drugs; stealsPossesses, uses, & sells drugs; stealsRelated to both CD and ADHDRelated to both CD and ADHDRelated to both CD and ADHDRelated to both CD and ADHD

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Antisocial Activities (age 27)Antisocial Activities (age 27)Lifetime Antisocial Acts

40

50

60

70

80

f Gro

up

0

10

20

30

40

Perc

ent o

f

Stolen Breaking Assault - Assault - Carried Sold DisorderlyArrested Jailed

H+ADHDH-ADHDCommunity

Property +Entering

Fists WeaponsWeapons Drugs

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

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Antisocial Activities (lifetime)Antisocial Activities (lifetime)UMASS StudyUMASS Study

50

60

Criminal Activities

10

20

30

40

Percent ADHDClinicalCommunity

0

10

Shoplifted Stolen Money Breaking/Entering Assault Sold Illegal Drugs Arrested Jailed

Specific Crimes and Outcomes

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Childhood Antisocial ActivitiesChildhood Antisocial Activities(retrospectively recalled)(retrospectively recalled)

35

40

45

Childhood Conduct Disorder Symptoms

10

15

20

25

30

35

PercentADHDClinicalCommunity

0

5

Bullied Fights Break-ins StolenValuables

ViolateCurfew

Ran Away Truant

Symptom

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Judicial Costs of ADHD Judicial Costs of ADHD (by age 21)(by age 21)

ADHDADHD children followed to young adulthood arechildren followed to young adulthood areADHD ADHD children followed to young adulthood are children followed to young adulthood are more than twice as likely to be arrested as control more than twice as likely to be arrested as control children (48% vs. 20%)children (48% vs. 20%)Mean judicial costs have been estimated to be Mean judicial costs have been estimated to be $8,814 per ADHD person vs. $341 per control. $8,814 per ADHD person vs. $341 per control. Regression modeling placed the total criminal costsRegression modeling placed the total criminal costsRegression modeling placed the total criminal costs Regression modeling placed the total criminal costs at $37,830 per ADHD person having CDat $37,830 per ADHD person having CD..4545--80% of teenagers in juvenile custody 80% of teenagers in juvenile custody have ADHDhave ADHD2525--40% of adult prisoners have ADHD40% of adult prisoners have ADHD2525 40% of adult prisoners have ADHD40% of adult prisoners have ADHD

Data from the Milwaukee followData from the Milwaukee follow--up study as reported in the paper by up study as reported in the paper by SecnikSecnik, , SwensenSwensen, , BueschingBuesching, Barkley, Fischer, & Fletcher (submitted for , Barkley, Fischer, & Fletcher (submitted for publication). publication).

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Social ImpairmentsSocial ImpairmentsIncreased parentIncreased parent--child conflict & stress child conflict & stress

Greater parental commands, hostility, reduced Greater parental commands, hostility, reduced responsiveness, more lax yet harsh disciplineresponsiveness, more lax yet harsh disciplineresponsiveness, more lax yet harsh disciplineresponsiveness, more lax yet harsh disciplineMore child noncompliance, hostility, disruption More child noncompliance, hostility, disruption Poorer sense of competence in parental rolePoorer sense of competence in parental roleGreater parenting stress and maternal depressionGreater parenting stress and maternal depression

Especially problematic for ODD/CD subgroupEspecially problematic for ODD/CD subgroup

Peer Relationship Problems (50Peer Relationship Problems (50--70%+)70%+)ee e at o s p ob e s (50ee e at o s p ob e s (50 0% )0% )Less sharing, cooperation, turnLess sharing, cooperation, turn--takingtakingIntrusive, angry; reduced empathy and guiltIntrusive, angry; reduced empathy and guiltMost serious in ODD/CD subgroupMost serious in ODD/CD subgroupMore likely to be bullied and to be bullies in childhoodMore likely to be bullied and to be bullies in childhoodMore likely to be beaten up, mugged, or assaulted with a More likely to be beaten up, mugged, or assaulted with a y p, gg ,y p, gg ,weapon by young adulthoodweapon by young adulthood

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Social & LifestyleSocial & LifestyleFewer close friends; shorter duration of relationsFewer close friends; shorter duration of relationsRated by parents as more socially impairedRated by parents as more socially impairedy p y py p y pLower levels of marital satisfaction by both Lower levels of marital satisfaction by both proband and partnerproband and partnerGreater parenting stress in parental roleGreater parenting stress in parental roleDifferences in leisure time use:Differences in leisure time use:

S d lk h hS d lk h hSpend more time talking on phone, watching TV, Spend more time talking on phone, watching TV, playing videogames, and socializingplaying videogames, and socializingSpend less time reading, getting adult education, and Spend less time reading, getting adult education, and exercisingexercising

Greater money management problemsGreater money management problemsLower current savings, less saving for retirement, Lower current savings, less saving for retirement, exceed credit card limits more often, buy on impulse exceed credit card limits more often, buy on impulse more often, less debt repayment, low credit rating, more often, less debt repayment, low credit rating, greater risk of car repossessions and losing utilitiesgreater risk of car repossessions and losing utilities

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Money Problems Money Problems (age 27; MKE)(age 27; MKE)

Money Problem Areas

50

60

70

80

f Gro

up

0

10

20

30

40

Per

cent

of

Managing Impulse Missed Missed Exceeded No Savings Poor Credit

H+ADHDH-ADHDCommunity

Money Buying PayingRent

PayingCard

Card Limit Rating

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

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Health Risks and ConcernsHealth Risks and ConcernsSkinner Health and Lifestyle Interview Skinner Health and Lifestyle Interview –– MKE StudyMKE Study

Health Concerns

60

70

80

90

oup

Health Concerns

10

20

30

40

50

Perc

ent o

f Gro

H+ADHDH-ADHDCommunity

0Eating Sleep Social Tobacco Drugs Emotional

Specific Health Area

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

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Medical and Health ConcernsMedical and Health ConcernsGreater risk for accidental injuries, nonsurgical hospitalizations, ER Greater risk for accidental injuries, nonsurgical hospitalizations, ER utilization, and driving accidentsutilization, and driving accidentsGreater medical and dental health problemsGreater medical and dental health problems

More sick days off from workMore sick days off from workGreater workman’s compensation claimsGreater workman’s compensation claimsPoorer preventive dental care and more cavities as childrenPoorer preventive dental care and more cavities as children

Greater sleeping problemsGreater sleeping problemsHigher frequency of vague medical complaintsHigher frequency of vague medical complaints

Related toRelated to somatizationsomatization and anxiety levels on SCLand anxiety levels on SCL--9090--RRRelated to Related to somatizationsomatization and anxiety levels on SCLand anxiety levels on SCL 9090 RRGreater likelihood of Greater likelihood of smoking, alcohol, and marijuana smoking, alcohol, and marijuana use and greater use and greater frequency of using these frequency of using these substancessubstances

Conduct disorder increases risk for hard drug use (cocaine, heroine, Conduct disorder increases risk for hard drug use (cocaine, heroine, methamphetamine, illegal use of prescription drugs, etc.)methamphetamine, illegal use of prescription drugs, etc.)

Growing risk of cardiovascular diseaseGrowing risk of cardiovascular diseaseGreater body mass index (higher percent obese)Greater body mass index (higher percent obese)Lower HDL cholesterol and higher Total/HDL ratioLower HDL cholesterol and higher Total/HDL ratioHigher atherosclerotic risk to coronary arteriesHigher atherosclerotic risk to coronary arteriesHigher Framingham CHD risk percent over next 5 and 10 yearsHigher Framingham CHD risk percent over next 5 and 10 years

Possibly greater risk for cancer Possibly greater risk for cancer Shortened life expectancy as a consequence ????Shortened life expectancy as a consequence ????

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Areas for Future ResearchAreas for Future ResearchDetermine if outcomes are different for Determine if outcomes are different for SCT SCT typetypeFurther examine for sex differencesFurther examine for sex differencesExtend findings past age 35Extend findings past age 35Extend findings past age 35Extend findings past age 35Determine occupational costs (e.g., sick days, Determine occupational costs (e.g., sick days, absenteeism, accidents on job, absenteeism, accidents on job, workman’s workman’s compensation claims, etccompensation claims, etc.).)Study accident rates at home and communityStudy accident rates at home and communityE amine impact in mo e detail on childE amine impact in mo e detail on child ea ing andea ing andExamine impact in more detail on childExamine impact in more detail on child--rearing and rearing and marriagesmarriagesFurther evaluate Further evaluate growing risk growing risk for medical illnesses for medical illnesses

SomatizationSomatization disordersdisorderscardiovascular diseasecardiovascular diseasecancercancerObesity and eating disorders (females)Obesity and eating disorders (females)Obesity and eating disorders (females)Obesity and eating disorders (females)

Further evaluate risks for earlier mortalityFurther evaluate risks for earlier mortality

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Summation of ImpairmentsSummation of ImpairmentsFollowFollow--up studies provide convincing evidence that ADHD is up studies provide convincing evidence that ADHD is associated with impairment in many major life activities over associated with impairment in many major life activities over developmentdevelopmentpp

Poor Educational Performance, Reduced Years of Education, Poor Educational Performance, Reduced Years of Education, Greater Risk for Learning DisabilitiesGreater Risk for Learning DisabilitiesIncreased Risk for Increased Risk for ComorbidComorbid Psychiatric DisordersPsychiatric DisordersLower Occupational Levels and Poorer Workplace PerformanceLower Occupational Levels and Poorer Workplace PerformanceHigher Rates of Antisocial Activities, Crime, Arrests, and Higher Rates of Antisocial Activities, Crime, Arrests, and IncarcerationsIncarcerationsGreater Risks for Teen Pregnancy , STDs, and Earlier ParenthoodGreater Risks for Teen Pregnancy , STDs, and Earlier ParenthoodGreater Driving Risks (Speeding, Crashes, InjuriesGreater Driving Risks (Speeding, Crashes, InjuriesIncreased Health Risks for Obesity, Cardiovascular Disease and Increased Health Risks for Obesity, Cardiovascular Disease and Cancer; Possibly Reduced Life ExpectancyCancer; Possibly Reduced Life Expectancy

This Demonstrates a Great Need for Government, This Demonstrates a Great Need for Government, Educational, Health Care, Mental Health Care, and JudicialEducational, Health Care, Mental Health Care, and JudicialEducational, Health Care, Mental Health Care, and Judicial Educational, Health Care, Mental Health Care, and Judicial Departments and Professionals to Work More Closely Departments and Professionals to Work More Closely Together to Reduce Such Impairments and the Obvious Social Together to Reduce Such Impairments and the Obvious Social and Financial Burden They Create for Societyand Financial Burden They Create for Society

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Managing Educational RisksManaging Educational RisksEducating teachers and school administrators on Educating teachers and school administrators on ADHD and associated academic risksADHD and associated academic risksT h t i i i l b h i tT h t i i i l b h i tTeacher training in classroom behavior management Teacher training in classroom behavior management strategiesstrategiesImplement ADHD school liaisonImplement ADHD school liaisonEarly Early screening and identification of ADHD cases at school screening and identification of ADHD cases at school entryentryPP f l i t t l l t hf l i t t l l t hPrePre--referral assistance to regular classroom teachers on referral assistance to regular classroom teachers on behavior management behavior management tacticstacticsPrePre--referral curriculum adjustmentsreferral curriculum adjustmentsIf necessary, eventual referral for formal special If necessary, eventual referral for formal special educational educational servicesservicesEarlierEarlier implementation of extended release medications asimplementation of extended release medications asEarlier Earlier implementation of extended release medications as implementation of extended release medications as necessarynecessaryVocational assessment and job skills training during high Vocational assessment and job skills training during high schoolschool

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Addressing Employment RisksAddressing Employment RisksEducate employers on nature of ADHD, workplace Educate employers on nature of ADHD, workplace impact & risks, & workplace managementimpact & risks, & workplace managementV i lV i l i hi h h l f li hi h h l f lVocational Vocational assessment assessment in high school for placement in high school for placement in technical training classesin technical training classesCounseling teen/adult for Counseling teen/adult for ADHDADHD--friendly jobsfriendly jobsPostPost--high school technical training if no plans for high school technical training if no plans for college enrollmentcollege enrollmentcollege enrollmentcollege enrollment

If If college bound, college bound, consider community consider community college as first college as first stepstep

Military enlistment if not going on to Military enlistment if not going on to collegecollegeMake reasonable workplace adjustmentsMake reasonable workplace adjustments

Similar to school behavior management tacticsSimilar to school behavior management tacticsSimilar to school behavior management tacticsSimilar to school behavior management tacticsMedication management across longer periodsMedication management across longer periods

Extended release formulations; supplement with IRExtended release formulations; supplement with IR

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Treating Child/Teen ODDTreating Child/Teen ODDBoth stimulants and Both stimulants and atomoxetineatomoxetine reduce defiance when reduce defiance when it is it is comorbidcomorbid with ADHD; not when ODD occurs alonewith ADHD; not when ODD occurs alone

Higher doses may be needed for Higher doses may be needed for comorbidcomorbid casescases

Implement adjunctive parent training in behavior Implement adjunctive parent training in behavior management methods; but positive responding is agemanagement methods; but positive responding is age--related:related:

6060 75% f l f hild75% f l f hild6060--75% successful for children75% successful for children2525--35% treatment response after 13+ yrs. of age35% treatment response after 13+ yrs. of ageMay need to treat parent’s ADHD first to succeedMay need to treat parent’s ADHD first to succeedMay need to add problemMay need to add problem--solving communication training of solving communication training of teen and parents after age 14 yearsteen and parents after age 14 yearsteen and parents after age 14 yearsteen and parents after age 14 years

Severely explosive anger may be a sign of childhood Severely explosive anger may be a sign of childhood BPD or SMD; may require use of atypical antipsychotics BPD or SMD; may require use of atypical antipsychotics or or antihypertensivesantihypertensives

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Treatment of Antisocial RisksTreatment of Antisocial RisksStimulants and Stimulants and atomoxetineatomoxetine reduce aggressive behavior and reduce aggressive behavior and antisocial activities antisocial activities

Stimulants can be titrated more rapidly if management need is urgentStimulants can be titrated more rapidly if management need is urgentHigher doses often required inHigher doses often required in comorbidcomorbid casescasesHigher doses often required in Higher doses often required in comorbidcomorbid casescasesStimulant effectiveness may deteriorate with duration of treatment (3+ Stimulant effectiveness may deteriorate with duration of treatment (3+ yrs) in this subset of ADHD cases (MTA study)yrs) in this subset of ADHD cases (MTA study)

Parent and family interventions often requiredParent and family interventions often requiredProblemProblem--solving, communication training and parent BMTsolving, communication training and parent BMTMultiMulti--systemic therapy where availablesystemic therapy where availableTreatment of parental depression and other psychiatric disordersTreatment of parental depression and other psychiatric disordersTerminate deviant peer relationshipsTerminate deviant peer relationshipsFamily relocation to better neighborhoods advisableFamily relocation to better neighborhoods advisable

If If psychopathypsychopathy (callous(callous--unemotional traits) is present there is limited unemotional traits) is present there is limited or no response to behavior therapy alone or no response to behavior therapy alone –– medication is necessary medication is necessary first, then follow up with behavioral treatments* first, then follow up with behavioral treatments* Avoid group treatment due to deviancy training by aggressive peers Avoid group treatment due to deviancy training by aggressive peers who train less aggressive peers to become more aggressivewho train less aggressive peers to become more aggressivewho train less aggressive peers to become more aggressivewho train less aggressive peers to become more aggressiveInvolvement of social service and juvenile justice agencies is highly Involvement of social service and juvenile justice agencies is highly likely likely –– educate them about ADHD with this CD educate them about ADHD with this CD comorbiditycomorbidityMood stabilizers, Mood stabilizers, atypicalsatypicals, or , or antihypertensivesantihypertensives may be needed for may be needed for highly aggressive/explosive cases representing severe mood or highly aggressive/explosive cases representing severe mood or bipolar disordersbipolar disorders

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Implications for Driving RisksImplications for Driving RisksEducate parents, teens, primary care physicians Educate parents, teens, primary care physicians and motor vehicle agencies on driving risks and motor vehicle agencies on driving risks Longer Longer learner’s permit periodlearner’s permit periodG d d li i hG d d li i hGraduated licensing approachGraduated licensing approach

Daytime with adults, nightDaytime with adults, night--time with adults, alone, with peers, full time with adults, alone, with peers, full independence (independence (33--6 months at each stage, gradual independence)6 months at each stage, gradual independence)

No (!) cell phone use/text messaging while No (!) cell phone use/text messaging while drivingdrivingGreater supervision of vehicle useGreater supervision of vehicle usepp

Chart intended vehicle useChart intended vehicle useRandom Random spot checking on spot checking on destinationsdestinationsCritical Critical incident cameras in vehicle (incident cameras in vehicle (DriveCamDriveCam Inc., San Diego, CA), Inc., San Diego, CA), or GPS car monitoring devices (or GPS car monitoring devices (MobileTeenMobileTeen GPS, AIG Insurance GPS, AIG Insurance Co.).Co.).

Behavior contracting for safe Behavior contracting for safe drivingdriving(Barkley (Barkley Safe Driving Program, Compact Safe Driving Program, Compact ClinicalsClinicals, Kansas City, MO; , Kansas City, MO; MaureenMaureen Synder’sSynder’s book on ADHD and driving addwarehouse com)book on ADHD and driving addwarehouse com)Maureen Maureen Synder sSynder s book on ADHD and driving, addwarehouse.com)book on ADHD and driving, addwarehouse.com)

Medication managementMedication managementExtended release formulations with supplemental immediate release Extended release formulations with supplemental immediate release as neededas needed

Avoid alcohol use while drivingAvoid alcohol use while driving

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Implications for Implications for Risky Sexual ConductRisky Sexual Conduct

Educate parents, primary medical care providers, Educate parents, primary medical care providers, and appropriate social service agencies on ADHDand appropriate social service agencies on ADHDand appropriate social service agencies on ADHD and appropriate social service agencies on ADHD and risks for teen pregnancy & STDsand risks for teen pregnancy & STDsGreater Greater parental supervision of teen parental supervision of teen social and social and dating activitiesdating activitiesDelay couples dating in favor of group Delay couples dating in favor of group y p g g py p g g pdating with multiple peersdating with multiple peersEducate teens on sex and risksEducate teens on sex and risksDiscuss Discuss use of contraception use of contraception with teens with teens & parents& parentsMedication management to reduce impulsive Medication management to reduce impulsive

d d lfd d lf llconduct and increase selfconduct and increase self--controlcontrolHPV immunization for females with ADHDHPV immunization for females with ADHD

To reduce future risks for cervical cancerTo reduce future risks for cervical cancer

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Implications for Health RisksImplications for Health RisksEducate primary care providers and Educate primary care providers and government health agencies on ADHD and government health agencies on ADHD and related health and lifestyle risksrelated health and lifestyle risksrelated health and lifestyle risksrelated health and lifestyle risksEncourage greater use of preventive medical Encourage greater use of preventive medical & dental care& dental careProvide assistance with managing legal Provide assistance with managing legal substancessubstances

Smoking cessation programsSmoking cessation programsSmoking cessation programsSmoking cessation programsAlcohol abuse treatmentsAlcohol abuse treatmentsSubstance abuse rehabilitation programsSubstance abuse rehabilitation programs

Discuss with parents and ADHD teens/adults Discuss with parents and ADHD teens/adults the growing cardiovascular and cancer risks the growing cardiovascular and cancer risks with age with age E b tt h lth i tE b tt h lth i tEncourage better health maintenance Encourage better health maintenance practices (better diet, routine physical practices (better diet, routine physical exercise)exercise)

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ConclusionsConclusionsADHD is associated with impairment in every major life ADHD is associated with impairment in every major life activity studied to dateactivity studied to dateADHD results in greater impairment more domains ofADHD results in greater impairment more domains ofADHD results in greater impairment, more domains of ADHD results in greater impairment, more domains of impairment, and more sustained impairment than other impairment, and more sustained impairment than other outpatient psychiatric disordersoutpatient psychiatric disordersThe impairments from ADHD are associated with The impairments from ADHD are associated with substantial economic costs, greater burdens on society, substantial economic costs, greater burdens on society, and greater risk for early mortalityand greater risk for early mortalityg y yg y yADHD is among the most treatable psychiatric or ADHD is among the most treatable psychiatric or developmental disabilities having more treatments developmental disabilities having more treatments available producing greater improvements in a higher available producing greater improvements in a higher percentage of cases with higher rates of normalization percentage of cases with higher rates of normalization Reducing these huge societal costs will require multiReducing these huge societal costs will require multi--g g qg g qdisciplinary management and better integrated disciplinary management and better integrated government social services, health and mental health government social services, health and mental health care, and educational servicescare, and educational services