Severity of Symptoms and Quality of Life in Medical Students With ADHD

Method

Participants were 33 preclinical medical students previously diagnosed with ADHD attending an international medical school located in the Caribbean. All participants were U.S. citizens and had completed their undergraduate education in the United States. Students were recruited for the study when visiting the University Counseling Center or the Academic Success Program after they had self-disclosed their ADHD diagnosis. The diagnosis of ADHD was not independently confirmed. Participants completed the Adult ADHD Quality of Life Scale (AAQoL), the Adult ADHD Self-Report Checklist (ASRS), and a demographic questionnaire in a single session via paper and pencil administration. Institutional Review Board approval was obtained.

The AAQoL is a patient-reported outcome measure containing 29 items used to assess the impact of ADHD on functional impairments and quality of life. The scale is divided into four domains based on “areas of impact”: life productivity, psychological health, life outlook, and relationships. The life productivity domain contains 11 items, including getting things done on time, completing tasks, remembering important things, and balancing multiple projects. The psychological health domain contains 6 items, including feeling anxious, overwhelmed, and fatigued. The life outlook domain contains 7 items, including perceptions that energy is well spent, people enjoy spending time with you, you can successfully manage your life, and you are as productive as you would like to be. The relationships domain contains 5 items, including tension, annoyance, and frustration in relationships. Participants rate the degree or frequency they find each item troublesome or problematic during the past 2 weeks on a 5-point Likert-type scale. The AAQoL is scored using an algorithm to create a total score and four subscale scores. A higher score indicates greater quality of life; lower scores indicate greater impairment in functioning. Brod, Johnston, Able, and Swindle (2006) conducted a validation study (n = 1,230) in which reliability was confirmed, and concurrent validity was established in relation to the Short Form-36 (a general health measure) and Endicott Work Productivity Scale. The AAQoL has recently been used in three investigations of ADHD medications; all report reliability and validity findings consistent with Brod, Johnston, Able, and Swindle (2006; see Able, Johnston, Adler, & Swindle, 2007; Adler, Spencer, Williams, Moore, & Michelson, 2008; Matza, Johnston, Faries, Malley, & Brod, 2007).

The Adult ASRS (Kessler et al., 2005), a World Health Organization instrument, is a six-item scale designed to screen for adult ADHD in community samples. Participants rate themselves on a 5-point Likert-type scale; a total score is obtained by summing the score for each item. The total score can be used as a proxy for ADHD severity (mild, moderate, and severe). The ASRS has been validated using the National Comorbidity Replication Survey (NCRS) subsample that reported childhood ADHD and adult persistence. Results demonstrated adequate sensitivity, excellent specificity, excellent total classification, and a good kappa (Kessler et al., 2005). Two recent investigations (Able et al., 2007; Adler et al., 2008) have used the ASRS in equivalent methods as the current study.

A researcher-designed questionnaire was used to collect data on individuals’ age, sex, age of ADHD diagnosis, ADHD treatment history, the use of support services, academic performance, and study strategies.

Results

Discussion

Beyond the academic impairments, medical students with ADHD experience significant functional impairment related to their daily life. As in previous research (Adler, Spencer, Levine, et al., 2008; Brod et al., 2006; Safren, Sprich, Cooper-Vince, Knouse, & Lerner, 2010), ADHD-related quality of life was negatively correlated with ADHD severity. Although this is not surprising, it does raise concern as the rigor and stress of medical education may hinder academically able students with ADHD from becoming physicians.

Women reported greater functional impairment than men although they did not report greater symptoms than men, indicating that women in the sample did not experience a more severe form of ADHD. The results of the current study that women are more impaired than men are similar to those found by Fedele, Lefler, Hartung, and Canu (2012), but quite different from the findings of other studies (Biederman et al., 2005; Biederman, Faraone, Monuteaux, Bober, & Cadogen, 2004). Interestingly, Fedele and colleagues reported greater functional impairment in women compared with men in a sample of college students using an ADHD-specific measure similar to the one used in the current study, whereas studies reporting no gender differences in impairment employed the Global Assessment of Functioning (GAF) Scale, which reflects a clinician’s judgment of a person’s ability to function in daily life.

Although the contradictions found in gender-specific impairments in adults with ADHD may be an artifact of measurement, alternative explanations to these findings deserve mention. Studies of adolescents have found that girls with ADHD feel more ineffective, have lower self-esteem, and are more affected by negative life events compared with boys with ADHD (Rucklidge, 2010; Rucklidge & Tannock, 2001) indicating that women with ADHD may experience greater functional impairment than men. The gender difference may reflect cultural expectations as women’s traditional gender role expectations may enhance distress as women struggle with ADHD (Waite, 2007). The spiraling effect of role expectations and symptoms of ADHD have been found to produce feelings of powerless and self-deprecation, which further minimize a woman’s capabilities (Rucklidge & Kaplan, 2000). Similarly, research examining gender differences in medical education have reported that when exposed to the same level of stress, women exhibit higher levels of symptomatology and are more susceptible to negative stressful life events than men (Hojat, Glaser, Xu, Veloski, & Christian, 1999; Moffat, McConnachie, Ross, & Morrison, 2004; Paro et al., 2010). Further research is needed on the functional impairments experienced by women with ADHD in medical school to clarify the basis of the discrepancy in impairment between men and women with ADHD.

As reported in previous research (Brod et al., 2006), the AAQoL overall score can be used to discriminate known groups: AAQoL scores were higher for participants with lower severity of symptom ratings on the ASRS, and lower for participants with one or more comorbid conditions. In the current study, students diagnosed with anxiety and/or learning disabilities in addition to ADHD reported significant functional impairment in the AAQoL psychological health domain. These students may be at greater risk for academic difficulties because the domain of psychological health provides the foundation on which decisions are made and acted on (Gjervan & Nordahl, 2010).

Students receiving accommodations reported significantly greater symptomatology than those not receiving accommodations, indicating that those students with the greatest severity of ADHD are receiving support. Although ADHD is considered a valid disability covered by the ADAAA legislation, affording college students access to educational accommodations, few investigations have looked at the effectiveness of specific educational accommodations in this population. Further research is needed to examine the impact of academic accommodations for medical students with ADHD, in particular, investigating a possible relation between academic performance, symptom severity, and the granting of extended time on exams or providing a limited distraction-testing environment.

The majority of the sample reported severe ADHD symptoms even though they are currently taking medication. Of those students taking medication, 25% reported taking ADHD medication sometimes, when needed. These findings are similar to those of Advokat, Lane, and Luo (2011) who found that college students with ADHD did not consistently take medication to treat their ADHD, although the majority of the sample agreed that medications helped them academically. Nonetheless, the current findings may indicate that treatment guidelines are insufficient to meet the demands of medical school, in which students routinely have 12- to 16-hr days. Further research is needed to establish appropriate medication treatment guidelines for medical students with ADHD.

The primary limitation of this study is the unique environment of an International Medical School. The stress of living in a foreign country may have affected the level of functional impairment experienced by students enrolled in the study. Despite this important limitation, this study serves as a starting point to examine the experience of students with ADHD in medical school. As the generation of ADA students progresses through undergraduate programs, more adults with ADHD can be expected to matriculate into medical schools. Further research will help determine the appropriate medication, academic accommodations, and gender modifications needed to help medical students with ADHD succeed.