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A day in the life of a child with attention deficit hyperactivity disorder

This article has been cited by other articles in PMC. QoL has become an increasingly important measure of outcome in child mental health clinical work and research.

Here we provide a systematic review of QoL studies in children and young people with attention deficit hyperactivity disorder ADHD and address three main questions. Thirty six relevant articles were identified. Robust negative effects on QoL are reported by the parents of children with ADHD across a broad range of psycho-social, achievement and self evaluation domains.

Children with ADHD rate their own QoL less negatively than their parents and do not always seeing themselves as functioning less well than healthy controls. ADHD has a comparable overall impact on QoL compared to other mental health conditions and severe physical disorders. Increased symptom level and impairment predicts poorer QoL.

The presence of comorbid conditions or psychosocial stressors helps explain these effects.

Introduction

There is emerging evidence that QoL improves with effective treatment. QoL outcomes should be included as a matter of course in future treatment studies. Almost all QoL definitions and measures include physical, social and psychological domains although similar domains are often labelled differently.

A cognitive domain is also commonly included [ 24 ]. Although QoL is influenced by many proximal i. In addition to the effects of physical illness on QoL, there is now substantial evidence that mental illness has major impact [ 75070 ].

  1. Keep a few rules and enforce them consistently. All of this carries enormous social cost in school and on the playground.
  2. The minute Saorla learned to walk she climbed—everything, and not skillfully. Many of those, along with dysfunctional behavior conditions such as oppositional defiant disorder, characterized by aggression, tantrums and a propensity to argue with adults, and learning disabilities such as dyslexia, are often diagnosed as co-illnesses with ADHD.
  3. Try to focus on your child's good qualities.
  4. As a consequence there is a considerable degree of inter-instrument non-overlap and we cannot simply assume equal coverage by different measures or that all generic QoL measures cover the necessary ground. Studies in adults were excluded.

A comprehensive discussion of the issues relating to the QoL concept in child and adolescent mental health is beyond the scope of the current review but can be found in a recent paper by the authors [ 18 ]. However, a number of key conceptual and measurement are discussed below. However, the distinctions between symptoms and their associated functional impairments are often not as clear and one would wish and their relationships with QoL, remain under-specified. For example some QoL items, designed for patients with physical illness, tap psychiatric symptoms e.

As a consequence there is significant potential for overlap between instruments designed to measure QoL and those used to measure either symptomatology or impairment. It is therefore vital that, as far as possible, we draw clear distinctions between symptoms e. Otherwise there is a clear risk that apparent QoL effects are so closely related to symptoms and impairment that their association with the disorder will become a tautology.

Current approaches suggest the employment of quantitative e. While these procedures have been increasingly used in the development of instruments to measure QoL in children and young people the process has not yet been repeated in different patient groups.

And in particular there has been little work conducted to demonstrate validity in children with mental health problems. Another consideration concerns the usefulness of both generic and disorder-specific measures of QoL and the relationships between these two very different types of measure.

Generic measures are designed to be more comprehensive in their coverage, but may as a consequence be less sensitive to treatment-related change.

The quality of life of children with attention deficit/hyperactivity disorder: a systematic review

Disorder-specific measures, or modules, focus in on areas of particular concern in relation to a specific disorder and may therefore be more sensitive to treatment effects but do readily not allow comparison with other disorders.

While it is generally accepted that QoL is a multi-dimensional concept and that the core domains tap into physical, psychological, cognitive and social aspects of functioning it is still the case that different QoL measures define these domains in different ways and then go on to divide them up into different sub-domains.

As a consequence there is a considerable degree of inter-instrument non-overlap and we cannot simply assume equal coverage by different measures or that all generic QoL measures cover the necessary ground. This often makes it difficult to make direct comparisons between studies that have employed different instruments. QoL is seen primarily as a patient-reported outcome [ 4879 ] with a key distinction being between independent assessment e.

However, this is complicated by several issues. This may be accentuated in the case of; children with learning disabilities; those for whom mental health conditions impact on their ability to reflect and report upon their internal state accurately e. In these cases one may have to rely on a proxy rating by a parent or a carer.

As a consequence measures of QoL designed for child populations usually have both a child and parent completed versions. Clearly a proxy rating will allow only a partial sense of the overall impact of the condition on QoL which may place important constraints on the validity of studies that do not directly ask the child about their QoL.

It is also important to note that the levels of agreement between child and other informants are modest [ 39 ], especially with regard to the non-observable aspects of QoL.

However, this does raise important issues about how information from different informants is combined or compared. The developmental aspects of QoL have not been well studied. It is likely that there will be major age-related differences in the way individuals value different aspects of QoL, the ways in which they can express these and the ways that these two factors interact.

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It is inevitable that in selecting an instrument for a particular age group one will have to trade-off the age specificity of item content with the benefits of potential comparability across ages [ 48 ]. If one focuses too much on adapting instruments for use by a specific age group then it is likely to become difficult to compare or to pool data collected from subjects of different ages. On the other hand, if an instrument does not cover the necessary constructs within an age then the validity of that instrument will inevitably be compromised.

Careful piloting of proposed instruments within the age range to be studied is therefore essential. There are various ways that instruments can be tailored to make them more age appropriate. In addition to these general issues relating to the measurement of QoL in children there are issues which are more specifically related to mental health problems in children.

Mental health disorders will interact in complex ways with QoL. A reduced sense of well-being can also impact on mental health by, for example, further lowering mood.

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In childhood, the effects of mental health difficulties on QoL are perhaps most obvious in the more severe or extreme forms of mental health problem e. The goal of this review is to address the issue of QoL in ADHD through a systematic review of the published literature.

ADHD is a high prevalence disorder of childhood and adolescence marked by early onset, persistent and pervasive patterns of inattention, overactivity and impulsivity. It is associated with impairment across a range of domains. More specifically ADHD is associated with educational under-achievement [ 94 ], family-related and peer relationship problems [ 2325 ] and increased anti-social and delinquent activity [ 72 ].

Long term adverse outcomes include increased risk of substance abuse [ 14 ], reduced vocational opportunities [ 5 ] and increased criminal activity [ 73 ]. ADHD can be successfully managed by a combination of stimulant medication and psychosocial approaches which reduce both symptoms and global levels of impairment. While generally well tolerated stimulant medication has a range of side-effects in a substantial minority of children [ 4630 ]. Understanding the impact of mental disorder in general and ADHD in particular on QoL can be informative on a number of levels.

QoL has the potential to be an important outcome measure. Indeed Spitzer and colleagues have suggested that the main goal of healthcare is to improve patients perceptions of their health and the extent to which health problems interfere with their QoL [ 79 ].

It could be argued that QoL outweighs simple short-term symptom reduction as the most important treatment outcome for ADHD. Thus QoL, if able to be measured reliably could be an important outcome measure in both clinical research and routine patient care. On a more general level the use of QoL data by individual child and adolescent mental health services could assist with service planning and audit—and help focus attention on outcomes that patients themselves feel are important.

Taking this one step further the assessment of QoL across different mental and physical health domains can allow for direct comparisons to be made between the impacts of these conditions on either individuals or populations—which in turn has the potential to provide an evidence base for a more rational reconsideration of the ways that resources are allocated within health services than is typically the case.

QoL measurement is already acknowledged as being central to the calculation of cost-effectiveness of different treatments and hence to the choices between treatments, both at an economic level e. In order that these goals can be achieved, with respect to ADHD, several key questions need to be addressed.

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This paper will address progress to date in trying to find answers to these questions through a systematic review of the published literature pertaining to QoL in ADHD, identify gaps in knowledge and make suggestions about the future lines of investigation that will be required to further the field. Text word and thesaurus searches were used to minimize the chance of missing relevant articles. The following keywords were searched: The reference lists of identified papers and previous reviews of QoL in children were searched manually.

Other inclusion criteria were; publication in a peer reviewed journal; a study, of any design, focusing on QoL in children or adolescents with ADHD that contained at least some empirical data on QoL measurement in children or adolescents with ADHD and used a QoL instrument. Studies in adults were excluded. The titles and abstracts of all papers identified from the first search were read by two authors MD, DC where there was disagreement at this stage the paper was retained.

The full text of those papers passing this screen was read independently by two of the authors MD, DC. There was full agreement between these two authors at this stage. Where there were several publications from single studies these were included where there was not repetition in the data presented.

  1. Thus QoL, if able to be measured reliably could be an important outcome measure in both clinical research and routine patient care.
  2. Studies in adults were excluded. Today we have brain scans, genetic studies, twin studies that show that this is a highly inherited neurobiological disorder, not some made-up condition.
  3. It is associated with impairment across a range of domains.
  4. Yet the majority of children with ADHD are getting only medication.
  5. Yet the majority of children with ADHD are getting only medication.

Where there were meta-analyses these were included and discussed before the individual studies. The results of identified studies are described in a descriptive manner with effect sizes reported where available. As a guide to interpreting the clinical meanings of these effect sizes Norman et al.