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23 May 2017

Mulraney M et al. J Atten Disord 2017; Epub ahead of print

In addition to affecting physical health, previous studies have shown that ADHD can have a significant impact on quality of life (QoL) in children with ADHD. This longitudinal study aimed to describe the relationship between ADHD symptom severity and QoL at 3 time points over a 12‑month period, and to evaluate whether sleep problems affect this relationship, in children with ADHD.

Children aged 5–13 years meeting full DSM-IV criteria, and with a diagnosis of ADHD from their paediatrician, were recruited from 21 private and public paediatric practices across Victoria, Australia. The children were split to form 2 harmonised samples comprising those with a moderate/severe sleep problem, and those with no/mild sleep problem.* A parent-report survey and semi-structured diagnostic telephone interview based on the Anxiety Disorders Interview Schedule for Children IV (ADIS-C) were completed by the parents of eligible children at baseline, and if consent was provided, participation in a brief survey was also requested of the child’s teacher. Follow-up surveys were then completed at 6 and 12 months post-enrolment.

Child ADHD symptoms over the previous 6 months were measured using the ADHD-RS-IV (parent- and teacher-reported) at 0, 6 and 12 months, and child health-related QoL over the previous month was assessed using the 23-item parent-reported Paediatric Quality of Life Inventory 4.0. Child sleep was evaluated at baseline by asking “Has your child’s sleep been a problem for you over the past 4 weeks?” (a rating of mild, moderate or severe was required if the answer was yes). Potential confounding variables were identified a priori as age, administration of ADHD medication, trial arm and psychiatric comorbidities.

Of the 392 children who took part in the study: 335 were male (85.5%) with a mean (SD) age of 10.2 (1.9) years, the most common ADHD subtype was combined (64.4%), a large percentage were receiving ADHD medication (79.9%) and the majority had psychiatric comorbidities.

At each time point, moderate negative correlations between QoL and parent-reported ADHD symptoms were observed (r=–0.38 to –0.53). For teacher-reported ADHD symptoms, no significant correlation could be made at baseline; however, significant negative correlations were observed at 6 (r=–0.19) and 12 (r=–0.25) months, albeit these correlations were weak.

The models used to determine whether ADHD symptoms at baseline and 6 months could predict QoL at 6 and 12 months highlighted that:

  • For parent-reported ADHD symptoms and QoL ratings in children with ADHD, higher levels of ADHD symptoms predicted poorer QoL at each subsequent time point.
  • For teacher-reported ADHD symptoms and QoL ratings in children with ADHD, there were strong associations between symptoms and QoL across time points; however, weak cross-sectional associations between ADHD symptoms and QoL at baseline and 6 months were observed.
  • The existence of a moderate to severe sleep problem at baseline moderated the association between parent-reported ADHD symptoms and the child’s QoL (p<0.05).
  • For children with no/mild sleep problem, ADHD symptoms predicted a later QoL; however, this relationship was not significant for children with moderate/severe sleep problems.
  • No moderating effect of sleep on the teacher-reported ADHD symptoms and QoL model was evident.

This study had several limitations: 1) a lack of child-reported QoL; 2) QoL is a subjective measure based on internally generated standards, and so the validity of QoL ratings by an external responder is unclear; 3) only a small number of children were not receiving pharmacological treatment, meaning this variable could not be explored; 4) ADIS-C does not assess all psychiatric comorbidities associated with ADHD; 5) sample size did not allow robust evaluation of the inter-relationships between sleep, ADHD symptoms and QoL across the 3 time points; 6) children with lower QoL at baseline were less likely to complete the study, meaning that the results may not be generalised to children with ADHD with a poor QoL.

The authors conclude that in addition to changes in core ADHD symptoms over time, clinicians should consider other factors such as sleep problems when considering QoL improvements in children with ADHD.

Read more about ADHD symptoms and quality of life in children with ADHD here


ADHD-RS-IV, ADHD-Rating Scale, Fourth Edition; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
*Each child was participating in 1 of the following appropriate studies: a randomised controlled trial of a behavioural sleep intervention or a prospective cohort study.
This measure has been used in children with and without ADHD, and is in good agreement with the Children’s Sleep Habits Questionnaire.
Internalising and externalising psychiatric comorbidities were assessed via parent-report using the ADIS-C, a diagnostic interview focussing on mental health disorders according to DSM-IV criteria.

Mulraney M, Giallo R, Sciberras E, et al. ADHD symptoms and quality of life across a 12-month period in children with ADHD: a longitudinal study. J Atten Disord 2017; Epub ahead of print.

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