This article investigates the social and moral dimensions of Attention Deficit/Hyperactivity Disorder (ADHD) diagnosis, asking what ADHD means in UK children’s everyday lives, and what children do with this diagnosis. Drawing on interviews with over 150 children, the analysis examines the influence of a UK state school-based culture of aggression on the form and intensity of diagnosed children’s difficulties with behavioral self-control. Diagnosed children’s mobilization of ADHD behaviors and their exploitation of the diagnosis shows how children’s active moral agency can support and compromise cognitive, behavioral and social resilience. The findings support a proposal for a complex sociological model of ADHD diagnosis and demonstrate the relevance of this model for national policy initiatives related to mental health and wellbeing in children. ► In the UK, ADHD is understood to be a disorder of anger and aggression. ► A UK state school-based culture of aggression intensifies children’s difficulty controlling their behavior. ► Children use ADHD diagnosis and symptomatic behaviors to social and moral ends. ► Children rely on friendships to help manage their difficulty with self-control. ► Mental health policy should address the social and moral, as well as the cognitive aspects of ADHD diagnosis. Attention Deficit/Hyperactivity Disorder (ADHD) has been a ‘hot’ sociological and ethical topic now for over a decade. The ambiguity of core symptoms – inattention, hyperactivity and impulsiveness – the international inconsistency of diagnostic processes and guidelines, and the growing global use of psychotropic drugs to treat ADHD mean that this disorder remains one of the world’s most debated childhood psychiatric diagnoses. A controversial but authoritative meta-analysis of ADHD prevalence rates by geographic region estimates that the world-wide prevalence of ADHD is approximately 5% of school age children. By this estimate ADHD is the most common child psychiatric disorder in the world .In the increasingly intersecting literatures of sociology and bioethics, the debate over ADHD has covered a range of themes, including medicalization , neurochThese analytic approaches make substantial contributions in their own right. However, they frequently misrepresent the phenomenological ground of ADHD, and bracket discussion of its biological dimensions. Although there have been important efforts to deal theoretically with the biological dimensions of complex human behaviors in sociology eg , neitherRecent health economic data indicates that ADHD diagnoses are increasing rapidly around the globe, a phenomenon which offers rich opportunities to diversify and to localize analyses of ADHD diagnosis . But intAs Margaret Lock’s seminal work has shown, analyses of ‘local biology’  problemaThis docility has also meant that analysis of the moral dimensions of diagnosis – which have been articulated in the sociological literature through important concepts like labeling theory, stigma and analyses of agency eg  - has teAs I have argued elsewhere, analyses of the moral dimensions of ADHD diagnosis that include no understanding of how children live with ADHD are inevitably short-sighted . As a grmean in the spaces and relationships that make up children’s everyday lives; and, what do children do with an ADHD diagnosis, and how do the spaces they inhabit – physical spaces, social spaces and national spaces – help to create and to constrain those possibilities? I am specifically interested in uncovering the social and moral dimensions of ADHD diagnosis, as manifested in the interplay of self-control, stigma and agency. In the concluding sections I use the empirical findings presented to propose a child–environment interaction model of ADHD diagnosis, and I demonstrate the importance of this model for UK policy.The analysis in this article is informed by an empirical bioethics approach, which integrates the empirical and theoretical tools of social science with bioethical concerns  in orderThe attention to ADHD diagnosis in this article complements two smaller studies that focused primarily on the implications of stimulant drug treatments for UK children . By puttThe experiences of children described in this article were gathered as part of the VOICES study, an international project broadly interested in the social and ethical impacts of ADHD diagnosis and stimulant drug treatments for children. Between 2007–2010 the research team interviewed over 150 children ages 9–14 in the US and the UK. Children fell into one of three groups: children diagnosed with ADHD and treated with stimulants; children diagnosed with ADHD but not taking stimulants; and children without a psychiatric diagnosis.Diagnosed children were recruited via university clinics in the US, and NHS Trusts in the UK; efforts were made in both countries to achieve geographic variety, within the limits imposed by time and budget considerations. Children without a psychiatric diagnosis were recruited using a variety of methods, including newspaper adverts, a market research company, posting flyers in schools and libraries, and word of mouth. We matched children broadly by age, gender and socio-economic status  within We recruited children through clinics and physicians because we wanted to achieve a group of diagnosed children whose diagnoses were of a high standard – quite possibly higher than in a non-clinically recruited cohort. Still, the resulting group of diagnosed children represented behavioral difficulties across a spectrum of intensity and impairment, thus verifying many clinical researchers’ claims that ADHD is a heterogeneous and dimensional disorder. Ethics approvals were obtained in the UK through the NHS Clinical Research Ethics Committee and in the US through relevant university IRBs .Methods and data analysis in the VOICES study were informed by Urie Bronfenbrenner’s model of the ecological niche . The modData collection, analysis and management strategies aimed at collecting sufficient information on each child to enable building an accurate portrait of the child and his or her ecological niche. In addition to interviewing children, the research team spoke to many parents, clinicians and teachers. We visited parent support groups, schools and clinics, both to give talks and to learn from the people present. Notes of these discussions were taken, and questions and comments were sometimes followed up in the case of discussions with professionals. Information about local services and communities was gathered during these conversations, as well as by site visits, and visits to children’s homes and neighborhoods.Parents filled out standardized questionnaires about their child’s behavior and diagnosis; and completed a demographic questionnaire. Children filled out the Harter’s Self-Perception Questionnaire at the end of the interview  which prChildren took part in a one hour, semi-structured one-on-one interview, which was comprised of questions, a guided drawing task, a vignette, standardized pictures, a sorting task and sentence completions. All these elements were intended to prompt and guide conversation with children around different topics; the interview guide had been developed during a pilot study .In all, four different female interviewers conducted the interviews in this study, thus diversifying the researcher-participant dynamics and contributing to the reliability of findings. Interviewers received training and were observed conducting at least two early interviews in order to ensure that they had a comprehensive understanding of the tasks and questions outlined in the semi-structured questionnaire. Interviews were digitally recorded and transcribed using a transcription service; standardized questionnaires were coded following manualized instructions and will not be discussed in this article. Each interview was read several times and then coded thematically by the primary investigator. Themes were further broken down into categories, and the relationships among categories were specified . An inteBy the end of the VOICES study, each folder on a child participant included the qualitative and quantitative data, notes on discussions with the child’s caregivers, any notes taken during or after the interview, and any relevant memos. For a subset of children we interviewed, this material was transformed into a case presentation, with an introduction crafted from the qualitative information we received, and a narrative of the child’s experience, using the child’s words as recorded at different points during the interview. To illustrate key characteristics of a dominant ecological niche we encountered in the UK, as well as common experiences of children within this niche, I present an abbreviated version of such a case below.ADHD is like behavior, just anger, like, temper; it’s like sometimes I feel really cross with other people and I just want to go lashing, lashing out. I’ll like kick or punch kids. [Other kids at school] know they can wind me up easily so they do it again and again and I can’t walk away that easy. [My dad says] not to throw the first punch, but if I get punched, I have to fight back. Teachers are not effective. They don’t help. They’re always shouting, but no one listens to them…about half of them forget that you’ve actually got ADHD when you’re in their classroom. My mates look out for me. If I’m running toward somebody they would either tackle me or hold me down or something. That’s what good mates do for each other. They know what I’m like. I’ll see them after school sometimes. Depends on whether I think I should do my homework… [My friends and I] play X-box and sometimes we’ll get out to a field to play footy.Shaun lives in a large village on the outskirts of a city in the middle of England, with his mother and father and two younger siblings. He is 12 years old, White, lower-middle class (Class III as measured by the Hollingshead index), and attends a state school. Shaun was diagnosed by a consultant psychiatrist with ADHD three years ago, and he has been taking extended release Concerta for the past 2 ½ years. Shaun’s mother gives him Omega-3 supplements and has experimented with dietary modifications to manage his symptomatic behaviors.To understand Shaun in the context of the ecological niche model, it is important not to focus solely on his demographic characteristics, eg. ethnicity, social class and gender. Shaun represents a dominant ecological niche rather than a dominant type of individual child, and individual demographic variables do not define the niche. Family, neighborhood and broader social dynamics are equally important to understanding an ecological niche.From the perspective of the children we interviewed, even larger village neighborhoods like Shaun’s are still rather intimate geographic and social settings. Children are more likely to be allowed to walk or bike the streets in order to get from one place to another; and they have access to local parks, high streets and playgrounds to hang out. We often hear about visits with grandparents and other relatives, or that relatives regularly help with childcare. Reports on family and community life from children in our study find support in larger studies, which document a continuing active exchange of support within the extended UK family and suggest that ‘the character of family life and of the relationships’ within UK communities has remained largely unchanged in 40 years , xii.Such intimacy and support can be beneficial for a child’s feeling of safety and belonging in a community. However, it also reflects a problem of low social mobility within UK society ; and corI got in a fight with someone and gave him a nosebleed because… I was in PE and I think someone was taking the mickey out of a kid [making fun of him] and I thought it was me… so I decided to punch him…at my last school that happened most days. Lionel, age 12The relative lack of academic aspiration, combined with the relative lack of social movement within Shaun’s ecological niche, means that longstanding social patterns are more difficult to shift, even if they are not encouraging individual and social flourishing. Schools, as repositories for community values, can have embedded negative social patterns . At leasMy dad was like my age, he got in a fight and got kicked in his privates so bad that he needed an operation… Last week this boy did the same to me but not as bad… My dad says don’t start a fight but fight back if you get hit. Aaron, age 12Parents who struggled through the same schooling system tell us that they feel little agency in tackling these negative social patterns; but they do instruct their children on the rules of engagement:[This boy] he keeps pushing me, pushing me to be, make me angry. And he hits me, he bribes me, he takes money from me. He does anything to annoy me. He knows I’m easy to wind up and he knows I’m easy to get my anger up. I just start hitting him like he hits me. Charlotte, age 11Bullying is widely reported to us by children in UK state schools. In our interviews bullying includes fighting, name-calling, pushing, shoving, stealing and ridiculing; it takes place in person or on the internet (cyber-bullying). About three-quarters of the diagnosed children we meet have been involved in physical fights at school, either as aggressor or as victim, or in both roles. Being a girl does not protect against bullying involving physical aggression; indeed, several of the diagnosed girls we meet in the UK have been severely bullied but are also aggressive.The experiences of children in the VOICES study intersect with national trends. Bullying has been a key UK national health and education policy agenda item for at least the past decade, but there are no official government statistics on the problem and national survey data is sparse, contentious, and limited in scope. The Tackling Bullying Report, which in 2003 surveyed just over 1000 students, found that 51% of Year 5 students (ages 9–10) and 28% of Year 8 students (ages 12–13) experience bullying during a school term. A substantial proportion of students in both age groups report bullying involving physical aggression, including pushing, hitting and kicking. Among Year 8 children, bullying is less frequent, but experiences of physical aggression as part of bullying are more common. The survey found no significant differences between male and female students in terms of frequency of bullying, although it found that reports of psychological bullying were higher among girls .http://news.bbc.co.uk/1/hi/education/6519455.stm). In the course of our interviews, children without diagnoses of ADHD frequently comment negatively on the extent to which loud arguments between teachers and ‘naughty’ or ‘rude’ children take up teachers’ energies:There’s kids that just do really rude stuff, like arguing with teachers… they’ll just do it for fun, or to get people wound up, like attention seekers… There’s a lot of shouting. Luka, age 13I wish people would notice that I’m, like, behaving well, but most people concentrate on bad behavior. Like teachers…they are too busy sorting out the naughty kids. Salma, age 10A further peculiar and troubling feature of the culture of aggression in UK state schools is that it extends into the classroom, where it can involve teachers. An occasionally harsh, disengaged teaching style in state schools is targeted in recent policies that aim to transform UK schools into a less conflict-oriented, less punitive culture . At the It’s normal for kids to get upset and shout at teachers. Nicholas, age 14My teacher shouts quite a lot. It’s a bit scary. Pablo, age 11I get stood up in front of the class and well, stand there, and he start shouting at me. Jared, age 11For children with ADHD diagnoses, shouted arguments with teachers are an everyday experience:I feel good about my behavior if I’d been, like, good all that time and if someone’s like rewarded me at school, like and said how good I am, or they write on their own to my parents saying how good I’ve been, something like that would make my day… It’s just like normal praise really. Like if I do good on tests and everything that is a bonus, but if I’ve been good because I’ve not been, like, disrupting or anything all day, because I’ve controlled my ADHD, that’s like, even better.In such classrooms, ADHD behaviors become part of an ongoing struggle between students and teachers over appropriate behaviors, with students alleging that teachers behave in ways that are disrespectful, aggressive, and out of control, leaving them little incentive to manage their own behaviors. Indeed, the intense focus on negative behaviors in UK state school classrooms may mean that behavior, not learning or academic performance, becomes children’s primary concern. Children like Salma, who are well behaved, feel ignored. Diagnosed children feel overwhelmed with loud, aggressive negative attention; they too long for praise for good behavior. As Shaun puts it, good academic performance under these circumstances is not a priority; it’s ‘a bonus’:In the future I guess I want to be less naughty.Like many diagnosed UK children we interviewed, Shaun even responds to a question about his future aspirations in terms of behavior:doing well and more about behaving well. As a point of comparison, doing well is a primary preoccupation in a dominant ecological niche represented in our US sample. This is a performance-focused niche in which children infrequently experience physical or verbal aggression from school peers or teachers, due in part to institutional prohibitions on such behaviors. These US children tend to view ADHD in terms of academic performance, associate good behavior with good grades, and they generally answer future-oriented questions in terms of their professional aspirations:n the future I, like, umm, I want to be a chef. Graham, age 11IUK children with ADHD diagnoses, who share the key characteristics of Shaun’s ecological niche, worry less about While it is possible to associate academic aspirations and levels of aggressive behavior in schools with social class, the overall niche ‘ethos’ seems more important to children’s experiences of ADHD behaviors, and to the expression of these behaviors, than any single demographic variable. For example, in a different US ecological niche, where economic and familial resources are more scarce and there are limited supports in place for young people, children report higher levels of aggressive behavior and bullying among peers and in schools. Children in these niches are more likely to experience their ADHD behaviors in the context of aggressive altercations. Still, in our limited sample, children from such US niches also reference the importance of school performance and future aspirations in relation to their ADHD behaviors.Similarly, UK students inhabiting well resourced, highly educated niches are more likely to mention the importance of school performance when discussing their ADHD behaviors. However, the small number of students we interviewed from such niches also report regular incidents of bullying and some participation in aggressive altercations at school. These students interpret their ADHD behaviors in light of these experiences, as well as in relation to academic performance expectations.I think I know one person in my school who has ADHD. He’s a bit mad, like, he gets really angry…. He like, if somebody teases him…he like, he can’t get it out of his head… He jumps on people’s backs and squeezes the backs of their necks. Olli, no diagnosis, age 10A cultural pattern of bullying and aggression in UK state schools  providesAt birthday parties I think, ‘well I’m a normal person like everyone else’… But then when someone’s being horrible to me that’s when I know that I’ve got it… because I get wound up so easily. My heart starts to beat faster and like I go red and clench my fists… Charlotte, age 11Children with ADHD diagnoses also experience their disorder in terms of poor self-control in response to taunts:emotional self-control in the UK. ‘Anger’ is, after all, not a behavior. This lack of control over emotions is arguably the most stigmatizing dimension of UK ADHD, in part because emotional self-control is highly valued in the UK. Children’s implicit understanding of the value of self-control is illustrated by a common, and unique (as compared to US children) experience among UK children with ADHD diagnoses: Other children go out of their way to ‘wind them up.’ The game is to get children known for having a short fuse to lose control and start fighting:Because I told [peers] about my ADHD, they thought if they could wind me up I’d get really upset and they love to do that. I thought if I just ignored it then they would get really bored of doing it and stop… But they didn’t… [Teachers don’t help]. They just say ignore it…[They] know what I’m like but I don’t think they really know how hard it is for me to cope. Heidi, age 11It is significant that ADHD is associated with a lack of While bullying involving some level of physical aggression is common in UK schools, children with a diagnosis of ADHD are especially likely to be drawn into aggressive altercations, more often as victims but also as victimizers. Not only are they more likely to be drawn into these situations, they are also more likely to experience a distressingly rapid escalation of anger and loss of self-control in the process. It is this loss of self-control – rather than aggressive behavior per say – that marks diagnosed children, both to others, and, as Charlotte says above, to themselves.1My brain beats really fast and that’s why I mess around and get in fights… I get really bad headaches when it’s happening. It’s not meant to go that fast. Simon, age 9My body starts feeling really rough and hot… it feels sort of really aggressive. Laurence, age 10When I’m angry my body feels like it’s going to explode… I just go around hitting anything I see. James, age 11This interplay of individual behavioral dispositions and environmental factors may also explain why ADHD symptoms in the UK are such an intensely – and again uniquely, as compared to most US children – somatic experience. UK children are often quite literally engaged in fight or flight scenarios:Among UK children occupying a dominant ecological niche, ADHD is not just a cognitive problem of focus and attention, it is a significantly impairing, highly somatized difficulty with self-control in the context of an actively hostile environment. But despite the stigmatizing association of ADHD diagnosis with uncontrolled anger and aggression, diagnosed children should not be seen as victims of their environment – or of their poor capacity for self-control. In the next section I turn to an investigation of what children do with an ADHD diagnosis – specifically, how diagnosed children negotiate moral agency in the complex terrain of the UK school playground.I’ll go and tell a teacher but the teacher says, ‘You keep telling us and it’s getting annoying.’ So there’s nothing really very much we can do. So it really just leaves us to sort it out. And then it just sorts it out over a fight. Ned, age 12UK children learn most of what they understand about their ADHD diagnosis on the school playground. Here children are left largely to their own devices when encountering and resolving conflicts; children tell us that there is little direct supervision by teachers while they are outside, and teachers who are there appear powerless or unwilling to interfere with bullying and aggression:[My friends will] jump on me and hold my arms back and just restrain me, a bit. And in the end I just end up just calming down… but sometimes I can’t and I break away. Pat, age 11In the absence of strong normative limits on interpersonal behavior, children depend on friendships to resolve playground conflicts. Because of their difficulty with self-control, children with ADHD rely particularly on their friends to stand up for them in a fight, or to talk them down from one:The frequency with which UK children reference the importance of friendships in helping them manage their behavior suggests the extent to which behavioral self-control, in reality, is rarely a matter of autonomous decision-making on UK school playgrounds. Sometimes fights can be prevented. Sometimes they cannot be. It depends on medication. It depends on mood. But it depends most heavily on friendships; and on what the bullies say.You’re a twat and your mum’s got a big fat ass; or if they say, What’s wrong little boy? Are you upset that your mum is dead? then a boy must fight; he has no choice. Girls do not seem beholden to this particular rule of engagement. For boys, however, mothers are off limits; and invoking her triggers a moral obligation to fight. This is true even if boys do not have good relationships with their mothers: I don’t let anyone curse her off; only I’m allowed to. All boys know this, so if winding up a boy with ‘anger problems’ is not working, this will be the final resort. Even boys who know they would end up on the worst end of a fight, or those who hate fighting, will fight under these circumstances, and hope that their friends will come to their defense.Sometimes what the bullies say means that it’s not possible to avoid fighting. If the bullies say, If they’re really bothering me, or bothering one of my mates, I’ll just go into my ADHD. I’ll flip on them and get really scary… They know not to mess with me; they know I’ll go mental and really hurt someone. Lionel, age 11Children with ADHD diagnoses do not just rely on their mates to come to their assistance in conflict situations. They also actively protect their friends. Although an ADHD diagnosis can invite bullying, we frequently hear that children use ADHD diagnosis to help avoid fights and protect friends:When a child ‘goes into his ADHD’ he consciously inhabits the label and mobilizes the behavioral and the social resources of the diagnosis. Lionel himself exploits the stigma of ADHD, and he draws upon his somatic capacity to ‘go mental’ and ‘to flip.’ He hopes the result will be that he and his friends will be left alone.My mates look out for me. If I’m running toward somebody they would either tackle me or hold me down or something. That’s what good mates do for each other. They know what I’m like. Shaun, age 12Such conscious habitation of the ADHD label by children tells us that tools such as ADHD diagnosis, developed to help manage and make sense of unruly and unproductive biology, are not hegemonic over identity or, indeed, over somatic experience. In fact I would argue that in the UK, children with ADHD diagnoses currently come to know and to control their behavior not primarily through the language, or even the tools, of psychiatry, neuroscience and genetics, but through the moral obligations conferred upon them by the bonds of friendship and loyalty. Those bonds are a primary motivation, and a primary vehicle, for modulating their capacity for self-control:and others, and by relationally-informed ideals of justice. In this space, children with ADHD can mobilize self-control creatively to resolve playground conflicts without aggression, and to protect friends:I had a mate who was always getting picked on, and you know, he wasn’t really strong enough to fight so I would like go in there and use my ADHD to get them to leave him alone. Aaron, age 12Under this ‘relational regime,’ the reflexive space is open to moral decision-making that is motivated by care for self Mobilizing ADHD in this way is prosocial; it fosters bonds between children who then ‘have each other’s backs’; they watch out for each other. Indeed, Aaron reminds us that excusing an individual child for aggressive behaviors on the basis of reduced capacity for self-control elides the social and relational processes that both incite and help to prevent that child from fighting. Self-control is indeed a finely tuned interaction between individual and environmental factors; and among UK school children, friendships help children make a mental space for moral deliberation, discover their moral and behavioral boundaries, and establish a framework for social justice.I don’t get punished for nothing. It’s easy to get away after fights because I have ADHD. I just make puppy eyes and it gets me round everything with my teachers. Alan, age 10Playing up the stigma of ADHD diagnosis is a double-edged sword: when used for prosocial ends it is a positive form of agency; when used for selfish ends, it ultimately diminishes agency. UK children report exploiting their ADHD diagnosis, primarily as an excuse for bad behavior:Unlike US children, who rarely admit to using ADHD as an excuse for their behavior , almost all UK children say they have used ADHD as an excuse. Frequently, it works, at least to a degree. From children’s perspectives, many teachers and headmasters seem to have categorical views about ADHD: either they believe the disorder is not real and they make no allowances for a child with ADHD; or they believe it is real and excuse diagnosed children’s aggressive behaviors . Children report that school personnel tell other children to stay away from them because they have ADHD, and they give lesser punishments to students with ADHD diagnoses.The headmaster just thinks ADHD means we’re violent. These ambivalent feelings are one reason why some children do not want to tell their friends about their disorder. Laurence explains:I’m afraid that if I tell my friends about ADHD they’ll use it as an excuse to like, help me get off after fights or something. But maybe I could control how I behaved. Laurence, age 10Children have ambivalent feelings about the practice of ADHD exploitation: they are glad for the opportunity to get out of punishments, but they know this practice encourages the narrow, stigmatizing conflation of ADHD, anger, and aggression: Yeah, I have like told people I got ADHD cos it makes them leave you alone. They’re nervous that you might really hurt them if you get wound up. Paul, age 13, no diagnosisAs Laurence suggests, the more ADHD is socially available as an excuse for behaviors, the less control a child with ADHD has over how he is seen, and indeed, how he sees himself. Even well-meaning friends threaten a child’s capacity for self-determination when they use ADHD as an excuse on his behalf. Exploiting ADHD fuels the short fuse stereotype, and may encourage a rather remarkable social phenomenon we encountered several times at particularly ‘hard’ schools -- ADHD-adoption:ADHD-adoption is when undiagnosed children spread the word that they have ADHD in order to build up their personal armament against harassment, thereby further instantiating the stereotype. In the process, ‘real’ ADHD is increasingly diluted in meaning and in value, while the short fuse stereotype is empowered.kids will just pretend that they have [ADHD] to get out of stuff. Such pretense also means that teachers’ suspicions about the validity of ADHD diagnoses have traction, given that ADHD is actually being used as an excuse by children who do not have a diagnosis. The practices of ADHD-adoption and ADHD exploitation translate into a perpetual discourse of suspicion in some UK schools, about who might have ADHD, whether diagnosed or undiagnosed, and who might be pretending to have it. It is difficult for children to know the true diagnostic status of other children in the school, even though many children are forthcoming about their diagnoses with other children. As Freddy, age 11, says: My friend says he has it [ADHD] too but I’m not really sure that he’s telling the truth. Maybe he just thinks he has it.Children with ADHD diagnoses complain that …Given the controversy over the validity of the ADHD diagnosis, it is tempting to argue that this presentation of what ADHD means in the UK, and children’s exploitation and mobilization of those meanings, suggests that ADHD diagnosis represents not a ‘real’ disorder but rather a de-valued set of behaviors. For example, one might say that in a context where self-control in response to aggressive situations is highly valued, a lack of self-control is more likely to be interpreted as a disorder – just as in contexts where school success is highly valued, poor school performance is more likely to be interpreted as a disorder (a common critique of ADHD diagnosis in the US).A further objection to the validity of ADHD diagnosis based on the data presented in this article, could be that in a different context, the aggressive behaviors of UK children would be associated not with ADHD but with Conduct Disorder , or with heroism . This too suggests that ADHD does not refer to a stable, universal disorder; rather it is a convenient catch-all category.I take it as a given that behavioral interpretation is to some extent culturally relative and that diagnostic practices index social values. But this does not necessarily invalidate ADHD diagnosis; it does mean that diagnostic practices should pay close attention to the environment and acknowledge, in a systematic and reflexive way, the substantial traces of context and culture that behavioral interpretation, and behavior itself, carry. To assist this, sociological models of diagnosis should move beyond reductive arguments that locate disorder either in the child or in the environment, towards more complex models that allow for the interplay between the two, and view diagnosis as part of that interplay, not separate from it.The discussion in this article suggests the following model: A child’s difficulty with behavioral self-control finds its expression in, is shaped by, and gives shape to, a normative behavioral channel. In the UK state school environment, one of these channels is aggression, which can intensify symptomatic behaviors and can inspire behaviors in diagnosed children that inflame the environment. Clearly environment plays a critical role in shaping children’s behavioral capacities – and children’s behaviors in turn shape the environment. In a modal US school environment, where peer aggression is low but pressure to perform well in school is higher, we found that difficulties with self-control were more likely to be expressed in the context of a ‘performance’ channel.Identifying these channels in the model illuminates the embodied nature of symptomatic behaviors themselves and suggests why a difficulty with self-control can look behaviorally (and feel) quite different across different contexts. For example, recent research in the US suggests the presence of another channel through which a difficulty with behavioral self-control can be expressed: food. In a US population study, ADHD symptoms were associated with an increased risk of obesity . Presumarelationships between behavioral dispositions and environmental factors, then it is possible to ask where early interventions and treatment should focus. What needs adjusting in order to ensure good outcomes? A child-focused model of ADHD often closes off environmental avenues of intervention and implies a causal logic that propels a series of psychotropic drug treatments. Children tell us that drug treatments work, at least in the earlier stages of treatment. But treatment adherence and effectiveness would surely be amplified if physicians were given more resources and incentives to also facilitate relevant environmental adjustments by working, in the UK example, with families and schools.Even this primitive articulation of the ‘channel model’ motivates more comprehensive thinking about intervention. A diagnosis of psychiatric disorder is meant to predict course and outcome, and to suggest the best treatment. If ADHD diagnosis refers to patterned [ADHD] produces an estimated lifetime earnings cost of £43,000, suggesting that substantial benefits would accrue to the individual (and to the economy) from interventions that would reduce these problems. (roblems. :101Moving to a sociologically informed model of ADHD is important in the UK. Recently, a conceptually coordinated series of UK policy reports has framed ADHD specifically as a deficit in ‘self-regulation skills’ and as a threat to national prosperity:character represents a set of life skills rather than a moral disposition’. (Painting a picture of a generation of alienated, unmotivated and anti-social youth, these UK policy reports focus on ‘character’ building as a necessary component of interventions. Character development is seen as part of the science of cognitive development, and not a moral issue: ‘sition’. :12As this article has shown, for many UK children self-regulation is not only a cognitive skill but also a moral behavior; and a child’s cognitive and behavioral capabilities – and thereby his moral potential - are intimately linked to relational obligations. Indeed, these obligations can motivate behavioral self-control: children report making a priori decisions to fight when morally obliged, and they report mobilizing their ADHD to avoid fighting in conflict situations. It is important that policy interventions capitalize on the available social mechanisms that potentiate children’s ‘character capabilities’. This route of capitalization is more likely to inspire behavioral change within communities by encouraging children to build on their capacity for agency, and their social and moral wisdom. At the same time, policy-makers should work to dismantle the school-based culture of aggression that is arguably a generative, and surely a sustaining ground for UK-style ADHD: a disorder of anger and aggression.The symptoms of ADHD do not emerge, grow and take shape solely, or even predominantly, as a consequence of primary biological deficits. The tools of social science in general, and of sociology in particular, can help to develop complex models of psychiatric diagnosis that deepen scientific and public understanding and promote relevant, dynamic and effective interventions.


ADHD is a common neurodevelopmental disorder that persists into adulthood. Its symptoms cause impairments in a number of social domains, one of which is employment. We wish to produce a consensus statement on how ADHD affects employment.This consensus development conference statement was developed as a result of a joint international meeting held in July 2010. The consensus committee was international in scope  and consisted of individuals from a broad range of backgrounds . The objectives of the conference were to discuss some of the occupational impairments adults with ADHD may face and how to address these problems from an inclusive perspective. Furthermore the conference looked at influencing policy and decision making at a political level to address impaired occupational functioning in adults with ADHD and fears around employing people with disabilities in general.The consensus was that there were clear weaknesses in the current arrangements in the UK and internationally to address occupational difficulties. More so, Occupational Health was not wholly integrated and used as a means of making positive changes to the workplace, but rather as a superfluous last resort that employers tried to avoid. Furthermore the lack of cross professional collaboration on occupational functioning in adults with ADHD was a significant problem.Future research needs to concentrate on further investigating occupational functioning in adults with ADHD and pilot exploratory initiatives and tools, leading to a better and more informed understanding of possible barriers to employment and potential schemes to put in place to address these problems. Attention Deficit Hyperactivity Disorder (ADHD) is characterised by pervasive symptoms of hyperactivity, inattentiveness and impulsivity. These sMorphological differences has been reported in children with ADHD for some time and volumetric[heritability of ADHD from simple genetic analyses ranges from 0.6 to 0.9[Research on the aetiology of ADHD has concentrated on three distinct strands: morphological differences, hereditary factors and functional differences. lumetric,11 and clumetric studies,6 to 0.9 and an a6 to 0.9.Functional abnormality in people with ADHD has also been documented in multiple domains; it is therefore suggested that ADHD is neuropsychologically heterogeneous[ogeneous,16. Howeogeneous-19. Bothogeneous,21; theyDespite this evidence, the general public associates ADHD with clear representations of a rampant child, rowdy and disobedient; brought on by the consumption of chemical additives. There is no doubt that ADHD has been under the spotlight of public scrutiny for a while, the majority of which has been negative. This publicity has resulted in defective and flawed representations of ADHD, and a disregard of Adult ADHD by some practitioners. It is our opinion that this neglect has resulted in policy makers, health professionals and businesses in general overlooking the occupational difficulties that can arise with ADHD. If we are to put in place the relevant framework and treatments to address these problems, Psychiatry, Occupational Medicine and Policy Makers must build bridges and focus on the needs of adults with ADHD and the barriers in employment that they face.The 'workplace' is a complex personal and social construct and indeed, occupation has been defined as “active process of living". Models In general, most employees in the second half of the 20th century, are paid for their “clock time” rather than specific outcomes with most of jobs designed as “mechanical” cogs in a larger production apparatus. It is in these “organisation ran by rules,” that aduADHD is seldom diagnosed as a single disorder. In fact for patients with no diagnosis of ADHD, it is the co morbid that will lead the person present for help. Co morbThe majority of research on adult ADHD has been conducted in the USA, and few studies have examined implications for social and occupational functioning. The fact that ADHD is associated with work-related problems in adulthood such as poor job performance, lower occupational status, less joIn comparison to clinical experience about adult ADHD, empirical evidence about the expression of the disorder and the impairment it creates is relatively sparse. A few longitudinal studies following children with ADHD into adulthood have documented impairment in scholastic, occupational, relationship, and daily life functioning,42-45 anAs expected, outcomes from studies of adults diagnosed with ADHD in childhood and followed to adulthood, differ somewhat from findings with samples of clinic-referred adults with cliThe poor performance and work loss for adults with ADHD is likely to have profound economic implications. One study quantified this impact by estimating the excess costs (i.e. the difference between adult ADHD patients and matched controls) related to work loss. IndirecA recent survey undertaken by the World Health Organisation in 10 countries reported that 3.5% of the workers suffered from ADHD resulting in 143 million days of lost production. Workers with ADHD had an average 8.4 excess sickness absence days per year and even higher annualised average excess numbers of work days associated with reduced work quantity (21.7 days) and quality (13.6 days) Furthermore, a small minority of these workers are treated for ADHD despite evidence that such treatment can be quite effective in improving functioning.The Consensus identified that ADHD adults experience impairment in all aspects related to employment, from the initial job search, to the interview and then in employment itself. When searching for a job they are disorganised and sporadic and find it difficult to interact with Employment Advisors at Job Centre. This difficulty in creating a working alliance with advisors most likely stems from the fact that adults with ADHD are disenfranchised and disengaged from the system in general. For example, their attentional problems and poor understanding of social conventions results in them avoiding ‘tedious’ tasks such as writing detailed application forms, completing them by missing out items and/or completing them without having read the question properly or reflected on their answer.At the interview the person may come across as very friendly and chatty. They may be a little inaccurate about their past history, and may overstate their ability to fulfil the requirements of the job. This is not the sole mandate of people with ADHD, nevertheless it is characteristic of many hopeful interviewees! An important problem however, is the decision of whether to disclose their ADHD status on application forms or in interviews. Most employers do not understand the implications of ADHD. They panic that it is a profound and prolonged condition and are not aware that it can be effectively treated and that reasonable adjustments can be easily made that will improve occupational functioning.Once employed and initially in post, ADHD adults may be highly motivated workers but, depending on the job, ADHD symptoms soon begin to hamper the person’s performance. Some people find functional employments that mask organisational problems , or have employment that complements their symptoms (e.g. highly creative work or sports). Nevertheless, most skilled and unskilled occupations (e.g. administration posts) will be hampered by symptoms of inattention, impulsivity and hyperactivity.Employees may have difficulties with time management, organising their schedule, keeping on top of their work load, following instructions and exhibit emotional liability. These are important symptoms to look out for when assessing the level of impairment above and beyond the norm. Individuals with ADHD may also be disadvantaged by poor social skills and procrastination, which make it hard for them to work effectively with colleagues, accept line management, and/or deal with the public. In trying to resolve the issue around lack of performance a line manager will most likely confront the employee, this critique will most likely be taken personally and from then on it will be difficult to re-motivate the person. Relationships with colleagues will become impulsive, abrasive and volatile. Information relayed in job appraisals will not be ensued and acted on as they are not in a position to adapt their behaviour. This most likely will result in another lost employment.Adults with ADHD can also become hyper-focused in activities especially if they are incentivised by it. Thus it is important to be aware of the potential for workaholism in adults with ADHD. An employer must harness the positives of ADHD and maintain the right balance, taking care to avoid burnout.Further research is required in order to fully understand the factors that influence occupational impairment and to develop specific and effective interventions. Identifying and treating ADHD in childhood is likely to improve long-term clinical and occupational outcome. Addressing co-morbidity is essential as this will further impair a patient’s functioning. It is vital that clinicians, when assessing occupational functioning of an adult, have a concise and detailed understanding of the situation they are in and to follow treatment outcome. This will facilitate the best treatment option, e.g. psychological or occupational therapy.The discussion above raises the question whether adult ADHD is a candidate for targeted work place screening and treatment programs. The argument is that ADHD among workers has non-trivial prevalence, high impairment and a low rate of treatment, whereas cost-effective therapies exist that are related to improvements in some objective aspects of role performance,55. In tThere are several adjustments that could accommodate the needs of adults with ADHD. These need not be expensive or time-consuming to organise. Generally managers should implement systems that include regular meetings, reviews, and structured feedback for the individual. Verbal information should be supplemented in written format with clear, concise instructions. More specifically, to optimise attention and reduce distraction, employees could be provided with a private office, located in quieter rooms or positioned to reduce likelihood of distraction. They could also be offered flexi-time to work at quieter times of the day, or provided with headphones to reduce external noise. Impulsivity could be accommodated by a buddy system, as teaming up with a colleague will help the individual to remain focused. Hyperactivity can be dealt with by allowing productive movements at work, encouraging staff to remain active, and ensuring structured breaks are included in long meetings. Adults with ADHD suffer with organisation, time management and memory problems, and employers can tackle these problems by providing alarms or beepers, the use of structured notes and agendas, and providing regular supervision or mentoring, delegating more tedious tasks such as paperwork, and/or introducing incentives and rewards for task-completion. Best practice is one that identifies the problem and then successfully implements reasonable adjustments Table .healthcare which includes a focus on work, incorporating the idea of vocational rehabilitation, early intervention, and intervention tailored to individual needs and second, workplaces that are accommodating incorporating a proactive approach to supporting return–to-work, and the temporary provision of modified work and accommodations. Currently, this approach is not applied for adults with ADHD in the same manner as it is applied for people with common health problems such as anxiety, depression, stress, musculoskeletal pain and this places them at immediate disadvantage.Taking the view that vocational rehabilitation is whatever helps someone with a health problem to stay at, return to and remain in work the stanThe United Kingdom Government approach to employment in relation to mental ill health did not start from a medical perspective but from a sociological perspective. In 2004, the Social Exclusion Unit published a report which brWorking for a Healthier Tomorrow’[A general review of the health of Britain’s working age population produced a document called ‘omorrow’ (Table Currently employers are ill-informed and wary of recruiting disabled people, resulting in negative attitudes and defensive recruitment practices. Therefore it is important to encourage employers to think positively about the benefits of recruiting disabled people, who are reported to stay in employment longer and do a better job. More importantly employers are oblivious to disabilities such as ADHD and therefore fail to pick up on crucial symptoms or even differentiate between ADHD and non-ADHD.Partnership working will be essential to address occupational functioning in adults with ADHD. Input from occupational health professionals, employers, government, clinicians, voluntary sector and service-users will help create an all inclusive solution focused directive.In order to maximise the employment and retention of adults with ADHD, it is imperative that, with the support of the Government, local strategic partnerships and employers develop tools for employers to better understand ADHD as a disability. Raising awareness amongst small and large businesses will result in employers feeling more confident about the skills, limitations, and ‘employability’ of adults with ADHD. The provision of vocational rehabilitation for adults with ADHD may reduce occupational dysfunction and co-morbid conditions, such as depression, anxiety. In particular, specific interventions could be developed to address core problems such as inattention, impulsivity, hyperactivity, distractibility, disorganisation, and time management problems in occupational settings.As the recommendations of the Black review become rThere is a lack of research on the topic of employment of adults with ADHD and in general, a lack of understanding on how to address these occupational issues still remains. Future research should focus in integrating findings using the Vocational Rehabilitation principles. As a first step, specialist occupational therapy interventions need to be developed specificDr P Hodgkins is an employee of Shire Development LLC. He also owns stock/stock options in the company. Shire develops are markets drugs to treat psychiatric disorders including ADHD. MA, SY, DC, MA, PA, GG and UM have received pharmaceutical funding for consultation, speaking, and/or conference support.DC, MP and SY have been involved in drafting the manuscript and revising it critically. All authors have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/59/prepub


Individuals with ADHD have been associated with more employment difficulties in early adulthood than healthy community controls. To examine whether this association is attributable specifically to disturbance of activity and attention (ADHD) or to psychopathology in general, we wanted to extend existing research by comparing the rate of mid-adulthood working disabilities for individuals diagnosed with ADHD as children with the rate for clinical controls diagnosed with either conduct disorder, emotional disorder or mixed disorder of conduct and emotions.Former Norwegian child-psychiatric in-patients (n = 257) were followed up 17–39 years after hospitalization by record linkage to the Norwegian national registry of disability pension (DP) awards. Based on the hospital records, the patients were re-diagnosed according to ICD-10. Associations between the diagnoses, other baseline factors and subsequent DP were investigated using Kaplan–Meier survival analyses and logrank testing.At follow-up, 19% of the participants had received a DP award. In the logrank testing, ADHD was the only disorder associated with a subsequent DP, with 30% being disabled at follow-up (p = 0.01). Low psychosocial functioning  at admission uniquely predicted future DP (p = 0.04).ADHD in childhood was highly associated with later receiving a DP. Our finding of worse prognosis in ADHD compared with other internalizing and externalizing disorders in mid-adulthood supports the assumption of ADHD being specifically linked to working disability. Assessment of psychosocial functioning in addition to diagnostic features could enhance prediction of children who are most at risk of future disability. Attention-deficit/hyperactivity disorder (ADHD) is generally recognized as a neurodevelopmental disorder with executive function deficits ,2. In nuThe use of clinical controls to delineate outcome differences across childhood diagnoses could therefore be useful when examining different developmental trajectories. In general, externalizing disorders have been associated with a more negative outcome than internalizing disorders ,19,20, wIn one study, Barkley et al. compared the outcomes of young adults with ADHD with individuals with internalizing disorders . They foIn sum, most studies are limited by follow-up periods that reach only into young adulthood and/or the lack of clinical control groups. Knowledge of the chronic course of work impairment into mid-adulthood relative to clinical controls is limited.In the present study, we wanted to compare outcome differences into mid-adulthood between children with ADHD and those with either internalizing and/or other externalizing disorders in an in-patient population. Studying child-psychiatric in-patients with excessive symptom loads could delineate outcome differences among diagnostic groups. By following the individuals into their mid-thirties, and by obtaining information about disability pension (DP) awards for these individuals, we could provide a comprehensive picture of occupational disability in adults with a childhood history of severe mental disorders. We wanted to see if working disability was associated specifically with ADHD, or whether it was an experience shared with other disorders diagnosed in childhood.We hypothesized that former child-psychiatric in-patients with ADHD would have a higher rate of working disability relative to other clinical groups. We also hypothesized that individuals with co-morbid ADHD and conduct disorder would be more disabled than individuals with co-morbid conduct disorder and emotional disorder, as we assumed that working disability is specifically associated with ADHD.As a diagnosis is only one component of the overall assessment process, and because symptoms and impairment are partly distinct dimensions that do not always correlate ,26-28, aThe study population consisted of 258 child-psychiatric in-patients with intellectual level within the normal range. They were part of a larger study population consisting of all consecutively admitted in-patients (n = 550) at the children’s unit at the National Centre for Child and Adolescent Psychiatry in Oslo (NCCAP), Norway, from January 1968 to October 1988. The complete study population has been described in detail elsewhere ,30. The The gender distribution in the group was 82 (32%) girls and 175 (68%) boys. The mean age at admission was 8.7 years , with no gender differences. Fifty-six per cent of the patients were admitted to the family ward, 40% to the in-patients long-term ward and 4% to the day care ward. The mean length of stay was 1.1 months  at the family ward, 8.2 months  at the in-patients long-term ward and 24.4 months  at the day-care ward. In total, 17% of the patients were admitted more than once. The mean age at follow-up (when those who had emigrated or died were excluded) was 36.9 years , with a mean follow-up period of 28.2 years . A total of 11 (4%) participants had died and four (2%) had emigrated.st 1998) to be granted DP for an acknowledged medical condition that causes >50% lasting reduction in work capacity. Entitlement to a DP is not means tested; it is solely a public responsibility.At follow-up in December 2005, the participants were identified by personal identification number in the population register at Statistics Norway. By record linkage, information about the DP award was obtained from Statistics Norway’s events database FD–Trygd, which includes information from the Norwegian Labour and Welfare Organization. All citizens of Norway are eligible after 18 years of age  was conducted to explore differences in age, CFD and CGAS between diagnostic groups.Categorical variables were examined using Pearson’s chi-square test and Fisher’s exact test, as appropriate. Continuous variables were examined using Student’s two-sample Possible associations between diagnostic groups and other characteristics of the children and a subsequent DP were tested using univariate survival analyses according to the Kaplan-Meier method and logrank testing. Using stratified logrank analyses, we examined the association between diagnosis and subsequent DP, adjusting for CGAS, CFD and gender.In the survival analyses, participants were followed from the age of 16 years, which was the youngest age for registration of a DP during the study period, until a DP award was first registered, or otherwise, until their date of emigration, death, or follow-up in December 2005 for those who did not receive a DP. The study group was compared with the average Norwegian population in 2005 by using tables statistics . SPSS veThe study was approved by the Regional Committee of Ethics in Medical Research, the Department of Health and Social Services, and the Norwegian Data Inspectorate.Conduct disorder (CD) (F91) was diagnosed in 39 children (15%) according to the ICD-10. Hyperkinetic disorder (ADHD) (F90) was diagnosed in 53 individuals (21%), corresponding to the ADHD of combined type according to the DSM-IV criteria [Characteristics of the diagnostic groups are given in Table At follow-up, 49 persons (19%) had received a DP award, with no significant gender differences Table . The disThe prevalence of DP awards and the p-value for the logrank test of diagnostic groups and other vulnerability factors are summarized in Table We made an overall diagnosis variable consisting of the four diagnostic categories  to be used in the Kaplan-Meier and logrank analyses Figure , Table 2The CGAS score was condensed to a three-level score to be used in the Kaplan-Meier plot and in the logrank test with linear trends for factor levels Figure , Table 2To adjust for the different CGAS scores between diagnostic groups, we ran stratified logrank analyses in which the diagnostic groups were stratified by the CGAS three-level score. Hyperkinetic disorder was still the only diagnosis associated with a DP award (data not shown). We also ran logrank analyses in which the diagnostic groups were stratified by gender and CFD. The results did not change (data not shown). Lastly, the relationship between CGAS and DP remained similar when the analysis was stratified by diagnostic groups (data not shown).In this study, we compared the disability outcomes of ADHD patients with outcomes for patients with other externalizing and internalizing disorders. In line with our hypotheses, ADHD in childhood was highly associated with working disability in mid-adulthood, with the disability rate being highest when there was a co-morbid conduct disorder. We also found that individuals with co-morbid ADHD and conduct disorder were more disabled than were those with co-morbid emotional and conduct disorder, which reinforces the assumption that working disability is specifically associated with ADHD symptoms. Furthermore, assessment of psychosocial functioning at admission provided unique information about children at risk of a poor outcome.At the end of a 28-years study period, 19% of the individuals in this study had received a DP award, a markedly higher rate than that for the general population. As a DP award is most often a permanent benefit, awarded when treatment and extensive rehabilitation have failed, it is indicative of the severity of the work impairment these individuals have.Our finding is in line with those from previous studies, which have shown that individuals with child and adolescent psychiatric disorders have disability rates ranging from 13% to 50% at follow-up -46. BecaADHD was the only disorder significantly associated with a subsequent DP award in the present study. The disability rate in the ADHD group was about twice that of groups with CD or ED, which suggests that work impairment is related to specific symptoms central to ADHD. Our finding thus extends previous research reporting this elevated risk for ADHD probands relative to non-clinical controls -13,48,49In two recent Norwegian studies of adult out-patients with ADHD, early intervention was an important predictor of being employed in adulthood ,50. EvenIf we take the co-morbidity into account, it could perhaps be argued that the high rate of DP at follow-up, was a function of CD rather than childhood ADHD. However, CD alone or combined with ED was not associated with a DP award within this study population, and the DP rate was more than twice as high in the ADHD only group relative to the rate in the CD group. Thus, it seems that ADHD was the main contributor of the high DP rate found at follow-up, and that co-morbid CD had no more than an additive effect.The lack of association between CD and DP is consistent with findings in previous follow-up studies of in-patients ,47. SimiIn the present study, the combination of conduct disorder and emotional disorder appeared to be more disabling than either disorder alone. Our findings are thus consistent with previous research showing that individuals with co-morbid disorders have worse outcomes than those without ,22. GiveIn line with our hypothesis, we found that individuals with combined ADHD and conduct disorder had a higher rate of DP than did those with combined emotional and conduct disorder, giving further support to the assumption that working disability is to some extend specifically associated with ADHD. The poor academic achievement reported for ADHD individuals may lead to low grade occupations ,63. DP hIn this study, psychosocial impairment (assessed by CGAS score) was an important vulnerability factor for a DP award, even when adjusting for the presence of an ICD-10 disorder. Our finding illustrates the importance of evaluating both symptoms and functional impairment as part of a diagnostic assessment when studying an individual’s developmental course. Attempts to link impairment to specific diagnoses have turned out to be difficult , and sevIn line with previous clinical research ,47, neitIn this study, data were collected over a period varying from 17 to 39 years in a longitudinal follow-up study to examine the link between psychiatric disorders in childhood and a later DP award. The study’s strengths are the long follow-up period and the relatively large number of patients included. It is a nationwide study, in which there should be no regional admission bias. Because of the egalitarian Norwegian society where all citizens are entitled the same health care system, the socio-economic position of the family was not the predominating factor when these patients were hospitalized.The scoring was performed blind to outcome, as re-diagnosis and scoring of the study population were completed before the outcome information was collected. The outcome variable, DP, is based on a high-quality national register.This study has several limitations, however. All information was based on chart reviews from hospital records, which are not always reliable scientific sources. However, the hospital records were of good quality, giving a detailed and thorough description of the patients’ symptoms, psychometric test results and family adversities. Experienced psychiatrists completed the re-diagnosis and scoring of the data from the study sample, and they ensured that consensus-based best-estimate diagnoses were made as accurately as possible according to the current ICD-10. Inter-rater reliability was high , in lineWe have no estimate of the persistence of symptoms into adulthood in our children, but previous research has shown that symptom persistence is associated with symptom severity and co-morbidity in childhood ,70,71. FThe DP award was the outcome measure in the present study, and this measure can never be sufficient to judge broader outcomes for individuals. However, the DP is an indicator of impairment in one major life activity that provides important information about adult outcomes.Our group of individuals who were awarded the DP at follow-up provided insufficient statistical power to predict DP in single and co-morbid states of ADHD. Replication with larger groups is needed to predict DP in these subgroups separately.Because we only had three individuals with ADD, we could not predict DP in the inattentive group relative to those with hyperactivity.The factors identified in this study are not causative, but they should be considered as possible vulnerability factors that increase the risk of receiving a DP in an in-patient population. It is important to realize that this population consisted of severe cases that might have worsened the long-term outcome, and the results cannot immediately be generalized to out-patients. As criteria for obtaining DP vary considerably between countries, generalization of the findings is limited to nations with similar welfare systems.In this longitudinal study of child-psychiatric in-patients, we found that working ability was severely affected in mid-adulthood. ADHD appeared to be specifically linked to working disability compared with other externalizing and internalizing disorders. Considering the early onset and often chronic course of ADHD, direct primary prevention programs in preschools and schools should be endeavoured to mitigate academic underachievement. Given the increased impairment in children with co-morbid conduct disorder, early targeting of conduct problems should be emphasized. Regardless of diagnostic features, the assessment of psychosocial functioning could improve identifying children being most at risk of future disability. The chronic course and high rate of disability in child-psychiatric in-patients illuminate the importance of improving early intervention among such patients. Further research is highly needed to identify factors preventing long-term disability.MM: Marianne Mordre; BG: Berit Groholt; BS: Berit Sandstad; AMM: Anne Margrethe Myhre.The authors declare that they have no competing interests.All authors (except BS) conceived of and designed the study. MM participated in the collection of data, performed statistical analyses and drafted the first manuscript. BG participated in the collection of data, helped with statistical analyses and made significant contribution to the final draft. BS made significant contribution to the statistically analyses and critically reviewed the manuscript. AMM participated in the collection of data, made significant contribution to the final draft and supervised the work and critically reviewed the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/12/174/prepub


The purpose of this study was to expand the understanding of the burden of illness experienced by adults with Attention Deficit-Hyperactivity Disorder (ADHD) living in different countries and treated through different health care systems.Fourteen focus groups and five telephone interviews were conducted in seven countries in North America and Europe, comprised of adults who had received a diagnosis of ADHD. The countries included Canada, France, Germany, Italy, The Netherlands, United Kingdom, and United States (two focus groups in each country). There were 108 participants. The focus groups were designed to elicit narratives of the experience of ADHD in key domains of symptoms, daily life, and social relationships. Consonant with grounded theory, the transcripts were analyzed using descriptive coding and then themed into larger domains.Participants’ statements regarding the presentation of symptoms, childhood experience, impact of ADHD across the life course, addictive and risk-taking behavior, work and productivity, finances, relationships and psychological health impacts were similarly themed across all seven countries. These similarities were expressed through the domains of symptom presentation, childhood experience, medication treatment issues, impacts in adult life and across the life cycle, addictive and risk-taking behavior, work and productivity, finances, psychological and social impacts.These data suggest that symptoms associated with adult ADHD affect individuals similarly in different countries and that the relevance of the diagnostic category for adults is not necessarily limited to certain countries and sociocultural milieus. Worldwide, adults are increasingly diagnosed with ADHD. Typically seen as a problem of childhood, and once thought to be something that people outgrow, clinical and epidemiological research have identified ADHD as a persistent condition in adulthood for at least a large minority -4. In chIn a meta-analysis of global prevalence in the general population, researchers estimated adult ADHD occurs at a rate of approximately 4% worldwide . PersistImportantly, the rate of recognition of ADHD contributes to the range of diagnosis estimates across regions and health systems. Recognition is, in turn, affected by many factors including challenges of diagnosis, varying definitions of functional impairments, adaptive strategies of individuals that may mask or minimize symptoms, problems of self-report and insight into childhood symptoms, and media representations that influence the perceptions of both doctor and patient . These fMany individuals are diagnosed with ADHD as adults without having been formally diagnosed in childhood. Currently, an adult diagnosis of ADHD requires a retrospective analysis of an individual’s childhood for behavioral aspects that meet the criteria of childhood ADHD. Researchers of ADHD in adulthood argue that the disorder does not occur spontaneously in adulthood . AlthougEvidence suggests that ADHD symptoms continue to impair functioning, well-being, and health-related quality of life in adulthood -24. AdulOver the past few decades, prevalence data have suggested that the United States incurs higher rates of diagnosis for ADHD generally, and this has catalyzed concern that ADHD might be an explicitly “American condition”, interpreted through specific socio-cultural structures and expectations for individuals. As researchers have noted, this may be due to the fact that research of ADHD has centered in the United States, and that there are discrepancies in the use of the diagnostic criteria . The aimThis analysis was derived from fourteen focus groups and five one-on-one telephone interviews held in seven countries: Canada, France, Germany, Italy, The Netherlands, United Kingdom, and United States (two focus groups in each country). The five telephone interviews were conducted in Italy in order to balance the sample size with that of the other countries. Adults with a medical diagnosis of ADHD were recruited for each group either through local clinical experts or ADHD advocacy groups. Participants were compensated for their time spent attending the group. The study was approved by an ethics committee.The focus groups were semi-structured and conversational, and constructed with an emphasis on the burden of illness for the participants. The focus group script was developed based on a literature review, feedback from expert clinicians from each country included in the study, and prior experience of the authors with this population. The guide was designed to elicit commentary in several areas, including how the participants were diagnosed, their childhood experience of ADHD, and daily life, social, psychological, and physical functioning. All focus groups in English speaking countries were conducted by the first author, an experienced group facilitator. In non-English speaking countries, the groups were conducted by native speakers who were experienced facilitators and trained by the first author on the focus and intent of the discussion guide. Transcripts were translated into English and transcribed by different transcribers, and then coded thematically by one analyst (the second author). A preliminary code list was derived from the focus group script, and codes were added to the list as new themes emerged during the review of each transcript. Transcripts were reviewed and coded at least three times. First, they were reviewed to assess basic content and the emergence of new themes. This was followed by a second in-depth coding session. Finally, they were reviewed a third time for accuracy and consistency in the coding process. Additional review of transcripts occurred when a new code was added, to insure that all incidences of that theme were captured during the coding process. This method is especially strong for revealing similarities across transcripts; however, the regular review and re-review of transcripts also potentially highlights differences between them. Throughout these comparisons, an effort was made to look for differences by country.When appropriate, codes were merged to avoid redundancy and/or split to reveal more specificity in the themes discussed by participants. Codes were then grouped into domains. The coding process was undertaken by one individual (the second author), in consult with the first author. The end result was a full coding schema that was descriptive of the collective experience of adult ADHD, spanning from physical symptoms to participants’ psychological and social responses to them. Representative sample comments are provided following each domain summary to support the qualitative findings. This descriptive coding method is consistent with grounded theory and other thematic analysis methodologies . These pA total of 103 focus group participants, 52 men and 51 women, participated in the 14 focus groups. The average size of a group was 7 participants, with a range of 3  to 9 participants. In addition, five telephone interviews were conducted in Italy in order to include more participants from that country. This brought the total number of participants to 108, representing 51 women and 57 men. The mean age of patients was 36 years, and the mean length of time since the diagnosis of ADHD was 8 years (range 0 to 46 years). Thirty-two percent of the study sample was diagnosed with ADHD in childhood. The self-reported lifetime average number of ADHD medications taken for the sample was 1.7, with 55% currently undergoing treatment with a prescribed ADHD medication. As expected in an ADHD population, 42% of the subjects reported that they also had other mental health diagnoses besides ADHD.See Table As noted earlier, the focus group script emphasized the burden of illness for ADHD. As a result, participants talked about dilemmas of life affected by ADHD. They also spoke of positive aspects of life with ADHD, although to a lesser degree because of the emphasis on the burden of illness. Their comments were grouped analytically into four domains: ADHD Medical History , Life Experience, Daily Life Impacts of ADHD and Psychological and Social Impacts of ADHD. Each broad domain contained several subdomains or themes. In the sections that follow, we detail the burden of illness associated with ADHD. The number of respondents and percentage of sample that discussed the issues explored in a given domain is listed with the table heading.Over half of the participants in the focus groups and interviews 62 or 57%) reported that they were diagnosed with ADHD as adults (n = 108). Twenty-nine participants (27%) were diagnosed as children. There were 17 participants (16%) for whom the exact timing of their diagnosis was not revealed by them in the focus groups. Participants from all seven countries described diagnosis of ADHD in adulthood as a process involving multiple attempts to locate the cause of self-perceived problems. These attempts included misdiagnosis and self-diagnosis based either upon public media or encountering others who had the diagnosis of ADHD, sometimes in participants’ own children  impacted their subsequent life. Many adults with ADHD feel that had they been diagnosed and/or treated differently in life, they would have completed school more successfully. This included acquiring more advanced degrees, affecting their career success and overall life experience Table .Dangerous or risky activities were described by participants in all focus groups, and included past and present misuse and abuse of alcohol and drugs, eating disorders, an altered ability to assess risk, and an enjoyment of extremes . Driving cars aggressively and recklessly, often accompanied by anger directed towards other drivers was commonly mentioned, consistent with the ADHD profile Tables  and 13.Work and career were topics of importance in all focus groups, and many individuals spoke of work as a troubled area of their life, one that required significant coping skills and supports in order to make it successful. Disorganization, forgetfulness, impulsive talking, problems with authority, and inattentiveness/distractibility were identified as obstacles in finding success in work. Participants in all focus groups spoke of difficulties in the daily activities of life, noting confusion, slowness, fatigue, inability to begin or prioritize, anxiety, and forgetfulness as obstacles to accomplishing tasks Tables  and 15.Financial management was an activity of significant trouble for participants in all focus groups. Problems with compulsive shopping or wasteful spending, in addition to the difficulties of money management , were noted in each focus group Table .Irritability, inattention, impulsive talking, and forgetting contribute to misunderstandings in social interaction. Participants across all focus groups reported difficulty with a wide range of relationships, including those with parents, partners, friends, work colleagues, and acquaintances. Many reported that they have family members who also have ADHD, and some are partnered with people who have ADHD Tables  and 20.The association of ADHD with behavioral traits accentuated participants’ reflections upon their self or person. Participants spoke of feeling different from others throughout life, regardless of country of origin, and they often spoke of having felt “not normal” or “wrong” as a result of this difference. They also spoke about positive personality attributes that they associated directly with having ADHD Table .In each focus group, participants were asked whether or not they would have their ADHD instantly “cured” or “taken away” if this were possible. Participants’ responses to this question ranged the entire spectrum from absolutely no to yes. Many respondents displayed ambivalence in their response, and they talked about ADHD being an important part of their personality structure and that it included both positive and negative qualities. In these focus groups and interviews, 30 (28%) reported that they would agree to having ADHD removed from their lives, 38 (35%) said that they would not agree, and 17 (16%) were ambivalent on the issue. The remaining 23 participants (21%) did not respond to the question Tables  and 23.These findings strongly suggest that, on an international scale, the experience of ADHD in daily life is consistent, despite the socio-cultural differences that may exist between these seven countries. These adults experienced the impacts of ADHD on functioning and well being similarly across national boundaries. Participants in these focus groups felt themselves to be different from others, often from childhood, and reported that receiving a diagnosis of ADHD as adults can be accompanied by substantial difficulty. They retrospectively identifed difficulty interacting with others in childhood, and noted a great deal of difficulty in school life and with the educational process. They also believed that ADHD has impacted their lives in very significant ways, especially with regard to education and career, and their statements support clinical research conclusions that people with ADHD are prone to troubles with addictive behaviors and other activities thought to be risky or dangerous. Navigating daily life presented considerable challenges for these adults as they reported difficulties with social relationships of all types, including with work colleagues, family, friends, and acquaintances. Together, these challenges appear to contribute to psychological conflict and diminished well-being for many. Given that 42% of these adults reported other mental health conditions along with their ADHD, some caution is suggested in attributing all impairments reported solely to their ADHD. However, in general, the statements of subjects who reported other mental health conditions and the greater majority (58%) who did not report other conditions were not substantively different.Furthermore, these adults agreed on the key presentation of symptoms of ADHD: hyperactivity, impulsivity, inattention, and disorganization without regard to their cultural and social biases. It may not be surprising that people who have been diagnosed with a condition, presumably in accordance to standardized symptom criteria, might agree on the symptoms most central to the condition itself. This is the situational background of this study, which recruited participants who had received a diagnosis of ADHD into focus groups to explore ADHD. This is also this study’s major limitation. Similarly, the fact that participants in these focus groups retrospectively identified problems in childhood also resonate with the explicit diagnostic criteria that a retrospective assessment of childhood is included in the diagnostic process. However, despite the standardized criteria of biomedicine, one might surmise that a condition that centers on observable behaviors might be experienced differently across national and cultural borders, resulting in different impairments in daily life and lifespan activities due to interpretation bias by society or culture. However, these focus groups suggest that this is not the case for these seven countries and that the burden of illness is, instead, quite similar for adults with ADHD.Limitations for this small study include a self-selection bias by the participants. As interested volunteers for the study, they may not have been an adequate representational sample for the entire national populations of adults with ADHD. In addition, the study’s focus on the burdens of ADHD may not have captured fully the perceptions these individuals may share with regard to its positive qualities. The emphasis on illness in the focus group script was concomitant with an emphasis on debility, rather than ability. Furthermore, these methodological limitations point to the need to confirm the results quantitatively.It should be noted that not all countries participating in this study have a medical system that relies on similar diagnostic categories, general criteria for diagnosis or the availability of ADHD medications for adults. For example, in Italy and France, ADHD is recognized primarily as a condition of childhood and commonly used medications for ADHD are not prescribed or generally available for adults. Thus the participants in the focus groups held in Italy spoke of the need to travel to other countries for both diagnosis and medicines, thus making their diagnosis experience and treatment somewhat more challenging and emotionally difficult than those of individuals in the United States, Canada, or the United Kingdom. Relatedly, health systems differences, while not explored to a great extent in these focus groups, may be the more salient difference across national boundaries than the diagnosis and experience of ADHD. In a world with global access to biomedical information and related media, coupled with international diagnostic guidelines, differences between countries may be less pronounced.An important finding of this study centers on medication use. Among those who are prescribed and use medication for their ADHD symptoms, there appeared to be general satisfaction that the medications were efficacious and helpful to them. However, these individuals generally did not take their medications in compliance with their prescriptions, but as they saw fit based upon their interpretation of their signs and symptoms. This opens up a potential area of investigation into the impacts of adherence and non-adherence to medications for ADHD and its effects on long-term burden of illness. Further study investigating the effects of intermittent and fluctuating use of medication for ADHD symptoms in adults, conducted through both qualitative and quantitative methodologies, may lend more insight into the complexities of adult ADHD treatment. Furthermore, although not definitive, the commentaries of these respondents identified that side effects, perceived by some to be deleterious, led to a refusal of the medication itself. These patient-reported outcomes should be considered in the development of future treatment modalities, whether these treatments are pharmaceutical or behavioral.Findings from this study suggest that additional qualitative research is needed to further elucidate socio-cultural differences across countries generally with regard to ADHD in order to better understand the context within which people experience their disease. This ethnographic research might include expert interviews with clinicians from each country, including those whose knowledge centers on ADHD and those whose practice may be more general, as well as attitudes from the lay public who do not have a diagnosis of ADHD. Parsing the role of social stigma from the symptoms themselves could be used to understand how social experiences impact the burden of illness in the case of ADHD. Focus groups segregated by the time of diagnosis (childhood or adulthood) and across multiple countries would provide additional insight into a very intriguing area of research.In addition to ethnographic investigation, there are many other intriguing questions associated with ADHD in adults, clinical recognition, and health system contributions to the burden of illness. These include the levels of knowledge and acceptance of ADHD in adults among potentially treating practitioners, the accessibility of medical intervention and services within specific health systems, and the availability of multiple treatment medications. Within patient experience, it would also be interesting to be able to understand 1.) the relationship between the numbers of years diagnosed with ADHD and burden of illness; 2.) co-morbid mental health conditions and adherence to treatments; and 3.) feelings of social isolation and burden of illness.Last, all of the countries selected for this study are considered “western” countries. As such, each has similar social and economic structures for education, work, and social relationships. It is not surprising, therefore, that participants in this study might have similar life stories to tell about the obstacles they faced as people with a diagnosis of ADHD. What is of importance, however, is the extent to which adults with a diagnosis of ADHD agree upon the burden of illness and general life impacts. Similar qualitative investigation into the burden of illness of ADHD in adults that includes countries outside North America and Europe would be an important contribution to this field.ADHD is a consistent and stable diagnostic category across North America and Europe among those who carry the diagnostic label as adults. This appears to be true even in countries in which doctors typically do not recognize ADHD among adults. As these data demonstrate, adults in the United States, Canada, United Kingdom, France, Germany, The Netherlands, and Italy shared similar narratives in primary domains of functioning and well-being and agreed on the fundamental symptoms of ADHD. This suggests that the burden of illness and impacts of ADHD are similar across these seven countries and not limited to the United States alone.ADHD: Attention Deficit-Hyperactivity Disorder.Meryl Brod, PhD and Betsy Pohlman, PhD are paid consultants to Shire Pharmaceuticals and do not own stock in the company. Robert Lasser, MD and Paul Hodgkins, PhD are paid employees of Shire Pharmaceuticals and own stock in the company.MB participated in study design, conducted focus groups, and participated in preparation of manuscript. BP conducted analysis of data and participated in preparation of manuscript. RL and PH participated in study design and preparation of manuscript. All authors read and approved the final manuscript.