548034

research-article2014

JADXXX10.1177/1087054714548034Journal of Attention DisordersNg et al.

Article

Clinical and Functional Outcomes in Young Adult Males With ADHD

Journal of Attention Disorders 1­–10 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714548034 jad.sagepub.com

Jared Wei Lik Ng1, Rui Kwan1, and Christopher Cheng Soon Cheok2

Abstract Objective: To investigate clinical and functional outcomes in military men with ADHD. Method: Clinical outcomes were measured via the Zung Self-Rating Depression Scale (Zung SDS) and the Zung Self-Rating Anxiety Scale (Zung SAS). Functional outcomes were measured using the “Car, Relax, Alone, Forget, Friends, Trouble” (CRAFFT) questionnaire and questionnaires about relationships, conduct problems, substance use, and sleep. Results: Men with ADHD (n = 52) reported more depressive (34 [67.3%] vs. 19 [38%], p = .008) and anxiety symptoms (31 [61.5%] vs. 14 [28%], p = .009) compared with those without (n = 50). They had relationships lasting less than 1 year (24 [80%] vs. 9 [37.5%], p = .006), were more likely to smoke (17 [32.7%] vs. 5 [10%], p = .005), were most likely to use illicit substances (6 [11.5%] vs. 0 [0%], p < .001), had more conduct problems at school (27 [51.9%] vs. 5 [10%], p < .001), and had longer sleep latency (53.96 min ± 46.48 vs. 25.78 min ± 25.93, p = .006). Conclusion: Military men with ADHD are significantly associated with worse clinical and functional outcomes. They should be screened and monitored for depression, anxiety, sleep disorders, and substance use. (J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords ADHD, depression, anxiety, sleep problems, substance use

Introduction ADHD is a condition primarily characterized by “the coexistence of attention problems and hyperactivity, with each behavior occurring infrequently alone” with symptoms starting before 7 years of age (Biederman, 1998). ADHD is associated with work difficulty (Kessler, Adler, Ames, Barkley, et al., 2005), driving accidents (Woodward, Fergusson, & Horwood, 2000), a twofold increase in smoking (Molina & Pelham, 2003; Pomerleau, Downey, Stelson, & Pomerleau, 1995; Upadhyaya, Deas, Brady, & Kruesi, 2002), and alcohol and drug abuse (Biederman, Wilens, Mick, Faraone, & Spencer, 1998; Charach, Yeung, Climans, & Lillie, 2011). Youths with ADHD have greater peer rejection, poorer social skills, greater problems with the quantity and quality of their friendships (Coleman, 2008; Mikami, 2010), and increased risky sexual behavior (Barkley, Fischer, Smallish, & Fletcher, 2006; Flory, Molina, Pelham, Gnagy, & Smith, 2006). Follow-up studies have shown that children with ADHD often continue to have inattention and/ or hyperactivity symptoms into their adulthood (Weiss & Hechtman, 1993). Those with ADHD presented a significant higher lifetime risk of major depression, bipolar disorder, separation anxiety, oppositional-defiant disorder, conduct disorder, antisocial personality disorder, tics/ Tourette disorder, nicotine dependence, regular substance use (Elkins, McGue, & Iacono, 2007), substance use disorders (Arias et al., 2008), and sleep problems (Owens, 2005).

In Singapore, all male Singaporean citizens and secondgeneration permanent residents who have reached the age of 18 are mandated by law to enlist in the military (Enlistment Act [1970]). They serve a 2-year period as Full Time National Servicemen (NSFs), either in the Singapore Armed Forces (SAF), Singapore Police Force (SPF), or the Singapore Civil Defense Force (SCDF). Unlike voluntary militaries where personnel are more likely to self-select themselves into their careers, a universal conscript military such as the SAF will recruit the entire population. In Singapore, all servicemen are screened for medical and psychiatric problems at least 6 months before enlistment into the military. The SAF uses a rigorous and comprehensive Physical Employment Status (PES) classification framework, which takes into account the servicemen’s past and existing medical and psychiatric conditions. Servicemen with ADHD are carefully evaluated, with their symptoms and comorbidities taken into consideration when assigning their PES grading. The PES grading, among other factors, is used to determine the type of training and vocation that 1

Institute of Mental Health, Singapore Khoo Teck Puat Hospital, Singapore

2

Corresponding Author: Jared Wei Lik Ng, Department of Child and Adolescent Psychiatry, Institute of Mental Health, 10 Buangkok View, Singapore 539747. Email: [email protected]

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Journal of Attention Disorders 

servicemen undergo during the 2 years of National Service. For servicemen who are assigned a “non-combat” PES grading, their role in National Service would be sedentary, and they are usually tasked to handle administrative duties. Despite extensive scientific studies done to evaluate comorbidities in patients with ADHD, most of these were done in Western populations and relatively few in Asian populations (Takahashi et al., 2007). Even fewer studies investigated comorbidities in adolescence or adulthood (Gau et al., 2010). This study investigates the relationship between ADHD and various clinical and functional outcomes among a group of young Singaporean males diagnosed with ADHD currently serving in the military. Clinical outcomes include depressive and anxiety symptoms while functional outcomes include length of relationships, substance use, conduct problems in school, and sleep problems. It is hypothesized that young military men with a previous diagnosis of ADHD will have worse clinical and functional outcomes compared with those without ADHD.

Method

from a certified psychiatrist detailing the diagnosis was required. Fifty-six cases were identified that fit the inclusion criteria. Three participants were excluded (one participant was awaiting discharge from National Service for schizophrenia, one participant was detained in the detention barrack [military jail] at that time, and one participant refused to give consent). Fifty controls were recruited. Their medical records were checked to ensure that they were not previously diagnosed with ADHD. Controls were matched for gender, age, nature of work, and educational level. Written informed consent by all participants was obtained. For participants below 21 years of age, additional consent was obtained from their parent or legal guardian.

Assessment Procedure Apart from answering an extensive questionnaire regarding their demographics, lifestyle, and ADHD history, participants were required to complete a series of questionnaires and scales.

Tools Used

Study Design This cross-sectional study collected data from participants who enlisted between 2008 and 2009. The aim was to include an equal number of servicemen with and without ADHD. This study was approved by the SAF Medical Corps ethics review board.

Inclusion and Exclusion Criteria All servicemen with “Attention Deficit Disorder,” “Attention Deficit Hyperactivity Disorder,” or “Hyperkinesis” recorded in the SAF electronic medical system were included in this study. The exclusion criteria were as follows: a. Servicemen discharged from National Service1 b. Servicemen with a history of schizophrenia and other psychotic disorders c. Servicemen held in prison/military jail Other studies looking at ADHD and their comorbidities had similar exclusion criteria (Biederman, Faraone, Milberger, Curtis, et al., 1996).

Participants Servicemen with a diagnosis of ADHD were identified via comprehensive electronic medical records as described above. For a diagnosis of ADHD to be recorded into the SAF electronic medical system, an official medical report

Adult ADHD Self-Report Scale, Version 1.1 (ASRS).  The ASRS is an 18-item, validated screening tool for ADHD in adults and adolescents (Adler et al., 2006; Adler & Newcorn, 2011; Kessler, Adler, Ames, Demler, et al., 2005). The questions in the ASRS are consistent with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) criteria. Participants rated ADHD symptoms over the past 6 months on a 5-point Likert-type scale of symptom frequency. Content of the questionnaire also reflects the importance that DSM-IV-TR places on symptoms, impairments in various settings, and history of childhood symptoms for a correct diagnosis. If four or more marks appear in pre-identified boxes within the questionnaire, the patient would be considered to have symptoms highly consistent with ADHD in adults (Kessler, Adler, Ames, Demler, et al., 2005). Zung Self-Rating Depression Scale. The Zung Self-Rating Depression Scale (Zung SDS; Zung, 1965) is a 20-item self-administered measure of depression severity. It has been widely used in primary care and community settings and as a screen for depression (Biggs, Wylie, & Ziegler, 1978). Participants rated depressive symptoms over past several days on a 4-point Likert-type scale of symptom frequency. Items were selected to assess affective, cognitive, behavioral, and physiological aspects of depression. Scores range from 25 to 100. Scores 25 to 49 denote normal range, 50 to 59 denote mildly depressed, 60 to 69 denote moderately depressed, and 70 to 100 denote severely depressed.

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Ng et al. Zung Self-Rating Anxiety Scale.  The Zung Self-Rating Anxiety Scale (Zung SAS) is a 20-item self-administered measure of anxiety severity (Zung, 1974). Participants rated anxiety symptoms over past several days on a 4-point Likert-type scale of symptom frequency. Scores range from 20 to 80. Scores 20 to 44 denote normal range, 45 to 59 denote mildly anxious, 60 to 73 denote moderately anxious, and 70 to 100 denote severely anxious. CRAFFT screening tool for alcohol and substance abuse. “Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) is a 6-item self-rated screening tool to screen adolescents for high-risk alcohol and other drug use disorders. It is meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted (Knight et al., 1999). A score of 2 or greater indicates that the participant is at highrisk of having an alcohol- or drug-related disorder (Dhalla, Zumbo, & Poole, 2011).

Other Procedures Individuals noted to be at risk of significant psychiatric problems based on the scores (e.g., severely anxious or severely depressed) were referred to the psychiatrists for subsequent management.

Statistical Analysis Statistical analysis was performed using SPSS Version 17.0 (SPSS Inc, Chicago, Illinois). Mean and standard deviations were calculated for continuous variables. Frequencies and percentages were computed for categorical variables. Baseline clinical and demographic characteristics of patients were compared between the two groups for any baseline differences by using one-way ANOVA, Kruskal Wallis Test, and chi-square test for continuous normal variables, continuous non-normal variables, and categorical variables respectively.

Results All 53 participants and 50 controls eventually recruited for this study were asked to complete the questionnaire and scales. One patient who only completed the questionnaire and not the scales was excluded from the analyses. As such, the study included 52 “cases” and 50 controls.

Characteristics of the Participants In both groups, the participants were male with mean age of 21 years. Majority of the participants were Chinese, of noncombat status, and had more than 10 years of formal education (Table 1). The ADHD group had a higher proportion of

servicemen staying in five-room apartments and private property (52 [100%] vs. 33 [86%], p < .001). The ASRS showed that most of the participants continued to have ADHD symptoms. Forty-five (90%) of them were assessed as “likely” ADHD while five (10%) participants were noted as “unlikely ADHD.” The average age of diagnosis of ADHD was 12.02 ± 4.57. Most participants (43 [82.7%]) were treated with medications for ADHD before, but only 7 (13.5%) of them were still on medication at the time of the study. The mean duration of medication use was 5.16 ± 2.51 years. The most common medication used was generic methylphenidate (27 [51.9%]). Two (3.8%) of the participants were taking Atomoxetine (Strattera). The group with ADHD was more likely to have family members who were also diagnosed with ADHD (Table 2). There were significant differences between the scores for Zung Depression Scale and Zung Anxiety Scale when the two groups were compared (Table 3). The ADHD group was found to have significantly more participants scored as depressed (34 [67.3%] vs. 19 [38%], p = .008) and anxious (31 [61.5%] vs. 14 [28%], p = .009) compared with the control group.

Personal Relationships The average relationship length for the ADHD group was significantly shorter compared with the controls, with majority lasting less than a year (24 [80%] vs. 9 [37.5%], p = .006). The number of close friends and romantic partners between the two groups was similar. More men with ADHD were sexually active compared with the controls, although not statistically significant (20 [38.5%] vs. 11 [22%], p = .07). The number of sexual partners and age of first sexual intercourse were not statistically significant between both groups (Table 4).

Substance Use More men with ADHD smoked compared with controls (17 [32.7%] vs. 5 [10%], p = .005). However, there were no statistical differences between the number of cigarettes smoked per day and the age when they first started smoking. More men with ADHD were screened positive for possible alcohol problem compared with the controls although this was not statistically significant (26 [50%] vs. 16 [32%], p = .053). Six individuals in the ADHD group used illegal substances before with an average age of first use at 15.60 ± 1.14. No one from control group reported substance use. Participants with ADHD had more conduct problems in school, compared with controls (27 [51.9%] vs. 5 [10%], p < .001).

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Journal of Attention Disorders 

Table 1.  Baseline Demographic and Clinical Characteristics of Patients. Characteristics Male, n (%) Age Ethnicity  Chinese, n (%)  Malay, n (%)  Indian, n (%)  Others, n (%)   Non-Chinese, n (%) PES status  Combat, n (%)  Non-combat, n (%) Education level   10 years of formal education or less, n (%)   More than 10 years of formal education, n (%) Housing category   Three-room public housing apartment, n (%)   Four- and five-room public housing apartment, n (%)   Private housing, n (%)

Case

Control

p value

52 (100) 21.35 ± 1.17

50 (100) 21.04 ± 1.40

47 (90.4) 2 (3.8) 2 (3.8) 1 (1.9) 5 (9.6)

44 (88) 2 (4) 3 (6) 1 (2) 6 (12)

3 (5.8) 49 (94.2)

2 (4) 48 (96)

8 (15.4) 44 (84.6)

6 (12) 44 (88)

0 22 (42.3) 30 (57.7)

7 (14) 35 (70) 8 (16)

  .233 .937         .698 .681     .621    

Clinical and Functional Outcomes in Young Adult Males With ADHD.

To investigate clinical and functional outcomes in military men with ADHD...
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