ADHD Impairments in Interpersonal Lives 2009

so the two areas that we found to be impaired in our adults were school followed by the third domain was interpersonal and you can see here the kinds of complaints we got in interviewing our adults with ADHD and notice that these adults are aware that this may be happening in their relationships but find it very difficult to inhibit this behavior anyway so that they may be very sincere when they say I really will try harder I'll try not to say things off-the-cuff I'll try not to say offensive things and then find that they do it anyway because of the inhibitory deficit that you see here and as we've talked about problems with verbal eloquence if you will with getting to the point with being able to explain things the inability to regulate emotion by the way the most impairing deficit out of all of these in terms of its social impact is the emotion one people forgive distractibility they forgive verbage they will forgive impulsive decision-making they will not forgive anger and so we found the single best predictor both in our children and our adults of friendship problems marital difficulties and dating problems was the emotional aspect of the disorder not the cognitive or executive aspect of the disorder so something to keep in mind because we I think undervalue the importance of emotion and ADHD as I taught yesterday it's a very important piece of the ADHD puzzle because it brings with it its own impairments and its own risk independent of the working memory and executive problems and you can see here the difficulties with following through and promises and commitments I was interviewing a young man once and he said you know I can't tell you how many dates I have lost because of my inability to deal with time I would make a date to meet a young woman in front of the movie theater at 8 o'clock on a Friday night and this was someone I was really interested in and she seemed to reciprocate that interest and it looked like this might go somewhere and then I forgot one 8 o'clock was and on Friday night at 8 o'clock this woman is standing alone in front of the theater waiting for someone who promised her a date people don't forgive that it doesn't matter what you say happened and you can say I have ADHD I lost track of time I didn't build in the time it would take me to get across town I wasn't thinking about the weather or the traffic or the density or the fact that parking was going to be a problem because other people are coming to this megaplex doesn't matter what your excuses are the dates over it is very unlikely you would be given a second chance people interpret this lack of timeliness as a moral failing or as a lack of interest in the other person and it's very hard for them to forgive that kind of social slight so you can begin to see the kind of things that are affecting the social quality of social life of these individuals I probably don't need to tell you these things other things we heard from our adults as you see here was the talking too much too loudly and not listening to other people's side of the conversation the spouses we interviewed the married partners of our adults with ADHD often said that they felt unappreciated unlistenable day th d to someone else and not a lot of reciprocity and turn taking and sharing and this too can contribute to relationship to satisfaction so just something to pay attention to here this is one that most adults with ADG don't seem to appreciate but those of us who deal with them certainly do and that is the social stickiness the inability to take social cues and to terminate the interaction when it's most appropriate this is that perseverate of behavior we talked about you may find a conversation with somebody very interesting and you may continue it on and on but the person is giving you a lot of not so subtle cues that we need to wrap this up and I need to get on with this but instead the conversation just continues and I've had adults follow me out of conference rooms all the way into the parking lot not realizing I got to get to my plane you know it's all very innocent enough but it can add to the social difficulties of individuals with this disorder so you can see some of the things we've already talked about here now one of the things that our group was one of the first to discover probably because we're all perverts but we looked at sexual activity in our children growing up and then again in these clinic referred adults as well and we found exactly the same pattern they mapped onto each other beautifully there is no increase in sexual deviance among people with ADHD not as teenagers growing up and certainly not as adults what there was was this striking pattern of risk-taking seen in having sexual encounters earlier than other people did about a year earlier starting their sexual lives their sexual intercourse we found that they were far less likely to employ contraception because they tended to have impulsive encounters with other people even if they were in a committed relationship they were five times more likely to have had affairs outside the relationship on impulse than other people were likely to do if you have more encounters sexually and you don't use contraception well the result is babies and so there was a 9 to 10 fold increase in having had a teen pregnancy or having initiated one as the father or had one as the mother 38 percent of our boys had had a baby before 19 years of age and 68 percent of our girls so we were among the first and it's now been documented in three other studies that having ADHD results in starting your family nearly eight years earlier than the general population sometimes 10 most people wait until their late 20s to early 30s these days to begin having children people with ADHD tend to have their children quite young and their children with ADHD go on to grow up and have their children quite young so we have shown in our longitudinal studies this is a cross generational effect starting to have children when you may not be necessarily ready to have children or to be able to support them in the way that you would like to do so by the way teen pregnancies are very costly to society there are some of the highest risk pregnancies of all pregnancies and so it's no surprise that there is a huge economic impact of these adolescent pregnancies so we have now found that the single best predictor of who's going to have a teen pregnancy is ADHD so my friend Eric mash at Calgary has now gone into homes for unwed mothers and screened all of these teenage pregnant girls and it's finding a nearly eight fold increase in the prevalence of ADHD in these homes it's probably even higher than that because he's using self-report and self reports of ADHD are not reliable until you're about thirty years of age most of our follow-up studies have found that people growing up with ADHD have a very limited awareness of their ADHD and often have a positive bias about their lives and their functioning that doesn't really resolve itself until they get into their third or fourth decade of life when they start to agree with other people about how serious their impairments actually are but prior to that time most of the kids we followed into adulthood and their late teens and 20s did not see themselves as having a disorder or symptoms of a problem it wasn't until they hit their late 20s to early 30s that they began to wake up and smell the coffee and realize that much of what was happening in their life was the result of this disorder that could no longer be denied and we still see this even in adults after 30 this is somewhat positive ilusory bias about how well versus how poorly they're functioning in certain areas of life so for this reason don't be surprised if when you see a clinician they will want to interview someone who knows you well and that is to make sure that we are detecting the degree of the disorder accurately whether it's interviewing parents siblings friends partners spouses or just looking for the paper trail of impairment in your life it needs to be corroborated and we teach that now as part of our teaching clinicians about assessing adults with ADHD you always corroborate their reports because the tendency isn't for malingering and over reporting the tendency is for under reporting of symptoms and impairments and you don't want to be dismissing the disorder when it's really there now there is one exception to the rule and that is college students one in four college students in the US and also here in Canada seeking accommodations in the university around eggs Sam's and other aspects of college life is malingering so we teach people if you work in a University Counseling Center and these college students are coming in one in four is faking the disorder to get the vyvanse to get the adderall to get the ritalin to get the concerta to get the accommodations the extra time and all the other things that at least in the u.s. University students are eligible for under the Americans with Disabilities Act so we teach people that there is a very special area where malingering seems to be at its highest and that is on the college campus driving is an area that has been well studied in adult ADHD probably better than any other domain believe it or not we have more research on driving than any other and when we look at driving we see that even at operating the vehicle itself even at this very basic cognitive motor level we see differences between ADHD and the general population poor steering not able to keep the car in its lane as well as other people whether that's inattention or the motor coordination or both but there is a little bit of veering with the vehicle and we even pick it up in our simulators also very poor reaction time to critical events that happen around the individual I had $100,000 simulator for awhile that I was using to assess adults with ADHD and we're able to pick up all of these very minor differences in just how they maneuver the vehicle one of the things that was striking that I haven't seen other people talk about so much but we saw it in our simulator firsthand we would start to throw critical events I could sit at a computer and I could start to create hazards around you while you're driving in our simulated Ford Victoria Crown Victoria and what we found is that when a critical event happened the general population slows down and allows the event to play out in front of them so that they can deal with it the individuals with ADHD were likely to have a critical event and their reaction what's get the hell out of here and so they would speed up and drive around it and pass it or there'd be a guy coming onto the side ramp and instead of moving over slowing down and waving amends you can take charge of this situation they're racing the guy right oh you think you're getting in here doing your buddy Bora on the speedometer there he goes and the two of them are fighting to let this guy in on the 401 or whatever your freeway is out here we would have pedestrians walk out in front of them and they would veer and go up on the sidewalk instead of just braking for a moment and allowing the guy to pass it was like I can't be bothered with this you know my way up on the sidewalk no wonder that one of my dissertation students Tracy Richards showed that road rage is a very common problem in adult ADHD driving this use of the vehicle to express anger at other people and to coerce other people if you've been frustrated while you're driving so that's something to keep in mind as well and it was very much predicted by the emotional dimension of ADHD in one of our studies we took our adult drivers out for an hour around the City of Milwaukee with a driving instructor who had a 55 page checklist of driving behavior two of them quit and the rest rated the drivers as being extraordinarily impulsive and several of them recommended that the people have their licenses revoked we're not going to do that because it was a research project but nevertheless it is palpable these driving problems this is not subtle in what we see about the driving in these individuals and of course we also found when we interviewed their parents that these children had taken the cars of their parents even before they were licensed to drive even at 14 15 the parents would go out there'd be a vehicle left there was set a car keys and kids to go joyriding with the vehicle as a result of all of these problems with driving people with ADHD have two to three times the accident rate of other drivers they have more crashes in their career and they have more speeding citations as well and the accidents they have are nearly three times as bad in terms of the damage caused and the injuries to other people so this is not trivial it's very severe area of impairment produced by this disorder so no surprise over the first eight years of their driving careers they had a license suspended three times more often than other adults are likely to do this is unmedicated and in fact everything I'm telling you is unmedicated okay yes oh no no no we're going to talk about that okay so I want you to appreciate that while driving is a very boring area to discuss in an audience like this this is a very life-threatening area of adult functioning some of our patients are now doing jail time for vehicular homicide because of their killing other people case in January in Atlanta is a young seventeen year old girl off her adderall on the weekend as some pediatricians are still want to do by the way that's out of date practice we don't do drugs holidays anymore but this young lady was off her medication out joyriding and text messaging while she was driving and she hit a pedestrian and she killed him now no court in the US has ever used or allowed ADHD to be used as an excuse for homicide for vehicular on for negligence in this case so she's doing 8 to 10 years now for this particular and I have other patients in Massachusetts who are doing much the same thing so I just want you to appreciate that this is a serious area of impairment that needs to be treated so serious in fact that the Canadian pediatric Association has now recommended that if pediatricians in your countries see a teenager who's ADHD is at least of moderate severity they are compelled to medicate that teenager while they start their driving career it is something with which I handily agree because you see this struck my life it will be three years ago July the 25th when at two o'clock in the morning I get a call from the state police in upstate New York and the Adirondack Mountains telling me that my twin brother with ADHD is dead and he has died in a car accident and he has office medication he had been drinking he was speeding he was out joyriding at about ten o'clock at night on a dirt road in the Adirondack Mountains a dirt road that can only tolerate about 25 miles an hour he was only doing 40 and he should have survived the accident but you see my brother never wore a seatbelt and he didn't drive particularly safe and he was usually highly distracted he was a musician and he usually had music playing in the car as well we don't quite know what happened what we do know is that his II descended through a turn he rolled his vehicle and he was thrown out and crushed and so I can speak personally to the adverse outcomes that the effect of ADHD can have in people's lives on driving my brother isn't the only one to die in an accident from their ADHD a study published just a month ago shows that if you have ADHD you are three times more likely to be dead before you're 43 years of age so this is a life-threatening disorder and most of that at least in the earlier years is coming through accidental injury in the later years it's going to come from two other sources but suffice to say I very personally now believe that people with ADHD need to be treated when they drive and I hope you take it seriously as well you can see here the results of our study at UMass once again the adults with ADHD not only are more likely to experience a driving problem but to do so much more often it's the frequency everybody has an accidents including little fender-bender but they don't have as many and their accidents aren't as severe and they don't encounter speeding tickets anywhere near the degree that other people do by the way parking is another frequent violation and you know why because you're too impatient to find a parking spot so you double park a lot so when you're getting your dry cleaning when you just want to run in and get a carton of milk or whatever if there's no spot there well you make your own and then you get ticketed for doing so so that was the second biggest area other than speeding and associated crashes many studies including my own have found children with ADHD as they grow up to participate in a variety of antisocial activities the satterfield studies are among the first to show this it's been found in every longitudinal study now I do want to emphasize that most of this activity is predicted by the onset of conduct disorder in the adolescent years so that ADHD alone is not as likely to predispose to these activities as ADHD is with conduct disorder but even allowing for that the subset of kids who go on to become raging delinquents in the community we did find there was a subset of antisocial activity that ADHD alone was sufficient to be disposed to and that was using drugs possessing drugs selling drugs and stealing to get the drugs or the money they needed for their substance use problems so while you may think of these as largely victimless crimes which for the most part they are there is a set of antisocial activities that ADHD alone does predispose people to but as far as the violent crimes the muggings the rapes the fire setting the caring and using weapons the bar fights and so on it's pretty much determined by whether or not you also had developed conduct disorder when you were young ADHD alone was not a predictor of these sorts of things and by the way it wasn't just in their adolescent or adult years this is going back below age 12 and you can see here the black bar is higher than the other bars in terms of frequency with which these individuals were likely a not frequency but rather the percentage with which they were likely to have engaged in these encounters now this is whether or not you've ever used a particular drug and of course if not an awful lot of differences here across these bars except you see cocaine and LSD but that's because this is did you ever once try these things and even the general population tries some of this stuff so do people with other psychiatric disorders it's the frequency that separates the adult with ADHD so let me tell you the three drugs of choice that we found were problematic for most of the adults we saw nicotine was number one ADHD in adulthood predisposes to nicotine addiction why because nicotine treats ADHD in fact we have three drug companies now that are exploring variations of the nicotine molecule as the next wave of drugs for treating ADHD the problem they're having is that when they split off the part of the molecule that is addictive it also tends to be the part of the molecule that is also beneficial so they still have some work to do but there are drugs in the pipeline that are nicotinic receptor drugs so we find that when teens with ADHD start smoking for the various reasons people start whether it's peer influence or to be cool or because some celebrity is doing it they will rapidly accelerate their reliance on nicotine because it they self-medicate it does treat their disorder but they're treating their disorder with a highly addictive and carcinogenic drug but it does work and so one reason we find that they are predisposed to nicotine use is that it does help them but alcohol was the second best drug that they were using in terms of its frequency okay and alcohol is not a form of self-medication it does not help ADHD it actually makes it worse because the initial phase of the biphasic effect of alcohol is disinhibition so that when you first start drinking the effect on the brain is disinhibitory only when you've consumed enough alcohol does it become sedative but its initial effects are a releasing effect you've already got somebody with an inhibition deficit you can expect to see a lot of disinhibition in the first phase of alcohol use so we found that mainly the adults with ADHD were drinking for the same reason that other adults were drinking excessively and that is that alcohol narrows the scope of time the more you drink the more you live in the now and alcohol has this wonderful telescoping effect on our sense of time and the future so probably the reason they're doing it is to forget they've had a lot of trouble they've had some failures and they start to use alcohol to just block out all of the rest of that life and just kind of live in the moment here in the bar peeling the label off the Bud Light and kind of enjoying the company you know it's a means of forgetting your problems but it's certainly not self medication the third drug of choice which we believe acts the same way that alcohol does was marijuana adults with ADHD we're using marijuana far in excess of other adults even if they hadn't developed a dependency or an addiction to it under the DSM rules they were still using it much more frequently than other people do again probably to help with their coping of their lives of failures and other problems that they might be experiencing now we were the first study to do complete physical exams on all of our adults with ADHD including urinalysis and lipid profiles and what we found in the life course of these individuals was a growing risk for primary care health disorders and you can see it here across the board sleeping problems difficulties with medications by the way medical is the illegal use of prescription drugs so across the board their lifestyle and their health risks were becoming increasing concerns to them and to us the older that they were getting so we found there was an increased risk of accidental injuries even in adult life that was producing medical problems for them we also found that there was a drift toward a more couch potato leisurely lifestyle that people with ADHD were more likely to allow visual media to be sources of distraction in their lives whether it's text messaging or cell phone or video gaming or watching television they were more likely to be doing those things than other people do and they were less likely to be engaged in advanced education reading for pleasure self-improvement exercising the other things for which we usually believe self-discipline is going to be required so if you were in primary care and I described that lifestyle to you there would be things that you might predict as a consequence of that one of them is obesity and that's what we found as we followed our kids into adulthood and as we studied the adults who came to our clinic we found that there was a growing risk for increased body mass index and frank obesity in fact there are now three studies that have found that women with ADHD have a markedly higher rate of bulimia the the impulsive eating disorder not anorexia not the restrictive kind but the impulsive kind the binge eating purging that is often the case with bulimia sixteen to twenty two percent of adult women with ADHD are bulimics so there are eating disorders that are associated with this and whether you're male or female there is a growing risk of obesity problems in these adults not with all of them and by the way this is the first generation we've seen that earlier follow-up studies did not document that but it may have to do with the availability of fast food over the last twenty to forty years as becoming more and more ubiquitous in life the impulsive foods that are there all the time and can be garnered very easily may be contributing to this it's not clear we did find that there were more dental problems in our adults that they were less likely to be engaged in preventive medical and dental care leading to difficulties my brother was a classic example of that allowing his teeth to become so badly decayed that he developed infections and damn near killed himself a few years earlier than he finally did because of sepsis one of his teeth had become so infected that he had to be treated for a systemic infection that had developed you can die from infected teeth so they seem to not take the steps to engage the preventive aspect of medicine the annual visits to the physician the six-month dental cleanings and so on some of this has to do with financial differences as we found adults with ADHD weren't earning quite as much money as other adults in our studies but some of it also has to do with the forethought the four sightedness that is required in order to use preventive metal medical and dental care we found extraordinary money problems among our adults as you will see here particularly in these areas many of them weren't saving anything for retirement found it difficult to save at all for anything impulse buying with credit cards was a major problem for some of our adults having their utilities shut off for non-payment very common story in the history the adults that we saw and then of course having their cars repossessed which you don't see here well what's another aspect of these financial problems so no surprise when you give impulsive people access to money and credit you may find that they don't necessarily manage that as responsibly or as well as they should finally as you see down here we are the first study to document a growing risk for coronary heart disease ADHD predisposes to CHD making it a public health problem not just a public mental health problem in fact we also now have data to show that it's going to predisposed to cancer if it's not treated because of the increased smoking and drinking and poor nutrition on top of that of course the problems with weight it's easy to see how those would contribute to risk for coronary heart disease and and even at as young as 27 we are showing that young people with ADHD have a market increased risk for heart disease even at this very young age then do people in the general population so we have now written in our book that ADHD if it is left untreated will probably shorten an individual's life expectancy we have several studies that attest to that let me explain one to you there's a life course study that was done in California that followed thousands of individuals from birth to death and documented the death by all causes and found that the single best predictor from childhood onward that beat out all other predictors of life expectancy was childhood impulsiveness the more impulsive you are as a child the shorter your life is going to be now they classified impulsive people as falling in the bottom 25% of their population and they found that it had shortened the life of these individuals by eight years that's the lowest 25% ADHD is the most severe five percent so it doesn't take a genius to see that if being in the lowest quartile shortens your life by eight years being in the lowest 5% is probably shortening it even more so we are now arguing that adult ADHD if left untreated is a public health issue not just a mental health issue we studied the offspring of our adults with ADHD because it's a genetic disorder for the most part as I explained this morning and we found what everybody else is found including the Montreal Children's Hospital study of adult ADHD and all other studies of families with ADHD 40% of the children that had been born to our adults with ADHD had ADHD themselves by the way the next highest disorder besides ADHD was oppositional disorder whether the children had ADHD or not Oh didi was likely to be there in nearly half of the children born to adults with ADHD now why might that be because part of the risk for oppositional disorder is disrupted parenting parents who use consequences inconsistently and impulsively and parents who use high rates of expressed emotion with an individual and all of those would be predicted if we knew that a parent had adult ADHD we would expect them to be more impulsive more emotional less consistent in the way they manage their children and so no surprise we would see OD D as a correlate of this parenting pattern not just the genetic risk for ADHD as well

Channel: CADDAC Centre for ADHD Awareness Canada

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Length: 29min 22sec (1762 seconds)

Published: Tue Jan 12 2016