Career, Relationship Instability Persists for Adults with ADHD: Study
In a study of the real-life instability experienced by adults with ADHD, researchers found a heightened risk of social and occupational impairments in participants with ADHD aged 30 to 52 compared to younger adults.
August 29, 2023
Adults diagnosed with ADHD are more likely to change jobs, move residences, and have unstable relationships, according to a new study in BMC Psychiatry, which showed that these risks increased from young to middle adulthood.1
ADHD Increasingly Impacts Real-Life Functioning
Using large national registers from Sweden, researchers followed adults with and without ADHD over 14 years and found that real-life instability was higher in people with the disorder. Three register-based indicators were used to measure real-life instability: residential moves, job switching, and relationship volatility. Adults with ADHD relocated more than twice as often as adults without ADHD. They also had a higher number of jobs and unstable relationships with romantic partners.
These associations tended to increase with age. Researchers compared individuals in the cohort by age group — 18 to 29 years, 30 to 39 years, and 40 to 52 years at the start of the follow-up period. After adjusting for covariates, adults with ADHD in the oldest age group had the highest increased risk of real-life instability (up to 69%) compared to same-age individuals without ADHD.
Young adults with ADHD had the lowest risk (up to 25%). Though they relocated more often, they did not change jobs or enter unstable relationships any more than individuals of the same age without the disorder. Researchers offer one explanation for this, saying that “real-life instability is more normative in young adults, even in those without a diagnosis of ADHD.” They did, however, relocate more frequently.
Researchers also found that women with ADHD were likelier to have unstable relationships across all three age groups compared to men with ADHD. Relationship instability was measured as the number of children a person had with different partners.
Lastly, compared to younger adults with ADHD (18 to 29 years), individuals with ADHD in the two older age groups (30 to 52 years) had higher rates of job shifting, residential moves, and relationship instability.
Diagnosis and Treatment in Adulthood
According to a review cited by the researchers and published in the European Neuropsychopharmacology Journal in 2018, a “severe lack of knowledge on lifespan aspects in ADHD still exists for nearly every aspect reviewed.”2
Adults with ADHD are being diagnosed at increasing rates — four times faster than children in the U.S.3, 4 Yet, most research on ADHD has been limited to children and young adults.5 Individuals in midlife or older are often left out of the equation. ADHD symptoms impact 2.2% of adults over the age of 50, but only 0.23% have a clinical diagnosis.6
The rate of treatment is less than half the rate of diagnoses in older adults, according to some studies.5 And to streamline research or meet criteria, most clinical trials of ADHD medication do not include adults over the age of 65, says David Goodman, M.D. These patients tend to have existing medical conditions and/or are taking non-ADHD medications which could confuse studies’ results.
“We also know that over the course of the lifespan, ADHD individuals have negative consequences,” Goodman said in an ADDitude webinar on diagnosing adults over 50. “Adults are twice as likely to be divorced, they’re much more likely to be arrested for criminal activity, they have increased debt. So, as you get older, these impairments also play out in regard to job promotion or frequent loss of job… [and] all kinds of paperwork that you have to keep track of and attend to, and that really becomes taxing for somebody who has untreated ADHD.”
This is the first study to associate register-based indicators of real-life instability with ADHD. Previous studies on social and occupational impairments are often limited by small sample sizes, a lack of gender-specific analyses, and self-report measures like interviews and rating scales, according to the researchers.
That said, an ADDitude survey of 1,829 adults with ADHD in early 2023 revealed that 59% of men aged 40 and older, and 51% of women aged 40 and older said they have experienced a “period of emotional turmoil in middle age frequently characterized by a strong desire for change.” For most, this meant career upheaval, infidelity, divorce, money problems, substance abuse, and burnout. Indeed, 81% of men and 71% of women who said they have experienced a midlife crisis attributed it to ADHD symptoms and attributes.
“An increased awareness of real-life instability in ADHD across the lifespan may help reduce problems related to under-diagnosis and failures to provide adequate support for relevant real-life functional impairments in ADHD beyond young adulthood,” wrote the study’s authors. “Increased awareness of these risks is important for individuals with a diagnosis [of] ADHD, their families, and health care professionals because these factors are in themselves associated with negative outcomes in life, such as lower income, worse living conditions, and potentially harmful effects on children.”
Women with ADHD Are Impacted Differently
Women with ADHD were found at greater risk of having children with multiple partners than were men with ADHD. Researchers acknowledged that “there is a possibility that outcome misclassification is more pronounced in fathers than in mothers for our indicator of relational instability. This could potentially explain why we only see an association in females but not in males.”
Additionally, “using the number of children with different partners as a measure of relational instability is a crude measure,” they wrote.
Nevertheless, previous studies have shown a similar pattern. A review led by Stephen Hinshaw and cited by the researchers found higher rates of relationship instability in females with ADHD.7 The impact of ADHD on women is unique; while they face many of the same symptoms as men, ADHD can take a much different toll. Women are more likely to be underdiagnosed, or misdiagnosed with conditions such as bipolar disorder, personality disorders, depression, and anxiety. Understanding how ADHD symptoms present in middle-aged and older adults, and making gender-based distinctions, is a critical step to achieving proper care.
An ADDitude survey conducted in 2021 helps shed some light on the lived experience of females with ADHD. Out of nearly 4,000 women surveyed, 70% said ADHD had a “life-altering” impact in their 40s and 50s. They classified their symptoms as “extremely severe” during menopause. Of those who had given birth to a child, 61% said they experienced postpartum depression — with symptoms that included crying spells and feelings of worthlessness, shame, guilt, and inadequacy. During menopause, ADHD manifested most frequently in the form of procrastination and time-management challenges; working memory problems; and feelings of overwhelm.
Comorbidities Complicate the Picture
Researchers also identified individuals with borderline personality disorder (BPD) and substance use disorder (SUD), citing an association between these conditions and ADHD. Adults with ADHD had a much higher prevalence of SUD (40% vs. 4.6%) and BPD (9.8% vs. 0.5%) than the general population. Criminal convictions were higher among individuals with ADHD, and parental income was lower.
Researchers found that adjusting for BPD, SUD, and criminal convictions had a significant impact on the risk of real-life instability. Additional covariates in the study included parental education and birth year.
A total of 3,448,440 adults with ADHD were identified using large national registers from Sweden. Of them, 17,088 males and 13,993 females were diagnosed with ADHD within the 14-year follow-up period (2000 to 2013). Individuals were identified as having ADHD if they had been diagnosed (based on the International Statistical Classification of Diseases and Related Health Problems) or at least four filled prescriptions of ADHD medication.
Among the study’s limitations were its register-based indicators. Though they “have the advantage of being concrete reflections of real-life functioning, which could be useful in clinical settings to guide discussions around the treatment plan,” they are also simplistic. Other indicators might better represent this population in future studies. Changing jobs, for example, is relatively normal in young adulthood, especially while attending a post-secondary institution. The age range given to young adulthood (18 to 29 years) in the study is broad and may benefit from a more specific definition. Additionally, register-based studies do not capture all people with ADHD—only treatment-seeking individuals. For this reason, they are not entirely representative of the general ADHD population.
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1Ahlberg, R., Du Rietz, E., Ahnemark, E. et al. Real-life instability in ADHD from young to middle adulthood: a nationwide register-based study of social and occupational problems. BMC Psychiatry 23, 336 (2023). https://doi.org/10.1186/s12888-023-04713-z
2 Franke, B., Michelini, G., Asherson, P., Banaschewski, T., Bilbow, A., et. al. (2018). Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. European Neuropsychopharmacology, 28(10): 1059-1088. https://doi.org/10.1016/j.euroneuro.2018.08.001.
3Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O., Faraone, S.V., et. al. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry, 163(4):716-23. doi: 10.1176/ajp.2006.163.4.716
4 Chung, W., Jiang, S., Paksarian, D., et al. (2019). Trends in the Prevalence and Incidence of Attention-Deficit/Hyperactivity Disorder Among Adults and Children of Different Racial and Ethnic Groups. JAMA Netw Open, 2(11):e1914344. doi:10.1001/jamanetworkopen.2019.14344
5Dobrosavljevic, M., Solares, C., Cortese, S., Andershed, H., Larsson, H. (2020). Prevalence of attention-deficit/hyperactivity disorder in older adults: A systematic review and meta-analysis, Neuroscience & Biobehavioral Reviews, 118: 282-289. https://doi.org/10.1016/j.neubiorev.2020.07.042.
6 B Thorell, L., Lehtonen T., Borg Skoglund L. Åren går. (2022). ADHD består – äldre får sällan diagnos och behandling [A review of current research on ADHD in older adults]. Lakartidningen, 22;119:21109. Swedish. https://pubmed.ncbi.nlm.nih.gov/36794412
7 Hinshaw, S.P., Nguyen, P.T., O’Grady, S.M. and Rosenthal, E.A. (2022), Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. J Child Psychol Psychiatr, 63: 484-496. https://doi.org/10.1111/jcpp.13480