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Lifestyle in adult ADHD

Bron, T.I.

2017

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Bron, T. I. (2017). Lifestyle in adult ADHD: From a Picasso point of view.

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Risk factors for adverse

driving outcomes in

Dutch adults with ADHD

and controls

6

CHAPTER

Tannetje I. Bron, Denise Bijlenga, Minda Breuk, Marieke Michielsen, Aartjan T.F. Beekman, and J.J. Sandra Kooij

ABSTRACT

Objective: To identify risk factors for adverse driving outcomes and unsafe driving among adults with and without ADHD in a Dutch sample.

Methods: In this cross-sectional study, validated self-report questionnaires were used to compare driving history and current driving behavior between 330 adults diagnosed with ADHD and 330 controls.

Results:&HYPXW [MXL&)-) LEH WMKRMǻGERXP] QSVI EHZIVWI HVMZMRK SYXGSQIW [LIRGSQTEVIHXSGSRXVSPW-EZMRKER&)-)HMEKRSWMWWMKRMǻGERXP]MRGVIEWIH the odds for having had 3 or more vehicular crashes (OR=2.72; p=.001). Driving frequency, male gender, age, high anxiety levels, high hostility levels, and EPGSLSPYWIEPPWMKRMǻGERXP]MRǼYIRGIHXLISHHWJSVYRWEJIHVMZMRKFILEZMSVJSV LEZMRKLEHSVQSVIXVEǽGGMXEXMSRWERHSVJSVLEZMRKLEHSVQSVIZILMGYPEV crashes.

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INTRODUCTION

The neurodevelopmental disorder attention-deficit/hyperactivity disorder (ADHD) is characterized by symptoms of poor sustained attention, distractibility, impaired impulse control, and hyperactivity [301]. Many adults with ADHD have impaired neurocognitive functions leading to difficulties with selecting, registering, retaining, organizing and integrating relevant environmental information, and they often experience problems in decision-making [19,59]. Impairment in any of these functions may compromise driving behavior [57,58, 302]. Multiple studies link ADHD to risky driving behavior and, likewise, adults with ADHD have an increased rate of adverse driving outcomes, such as a greater number of traffic citations, more traffic accidents, greater likelihood of license suspension, more frequent severe vehicular crashes, and a higher likelihood of illegal driving when compared to persons without ADHD [55, 56]. Driver inattention and impulsivity are considered the most common causes of adverse driving outcomes [303-305].

Numerous risk factors for adverse driving outcomes are also common conditions in adults with ADHD [306]. The behavioral characteristics anger and aggression are highly prevalent in adults with ADHD, and both correlate to loss of vehicle control, (near-)vehicular crashes, and aggressive driving (e.g. risk taking) [307, 308], mostly by reduced concentration while driving [55, 304]. Low anxiety levels are associated with fearlessness and with an increased number SJXVEǽGGMXEXMSRWMREHYPXW[MXL&)-)?A[LMPILMKLER\MIX]MWEWWSGMEXIH with driving in an angry or tense distressed state [307, 310]. Also, alcohol use increasingly reduces concentration behind the wheel as blood alcohol levels rise [56, 311-313], and induces aggressive driving habits [314]. Substance abuse is associated with sensation seeking behavior in general, including risky driving [312, 315]. Conversely, the use of stimulant medication has shown to improve driving in adults with ADHD in studies using self-reports, driving simulators, and driving performance on the road [316-320]. However, in another study methylphenidate only reduced the risk of serious transport accidents in males [321], possibly because males have worse driving outcomes [55, 56] and may XLYWFIRIǻXQSVIJVSQ&)-)QIHMGEXMSR

driving in relationship to other factors remains unclear. This cross-sectional study aimed at identifying characteristics that comprise an increased risk for unsafe driving and adverse driving outcomes in a group of adults with ADHD and controls.

METHODS

Participants

All participants were between 18 and 65 years of age, and licensed to drive a car. The group with ADHD consisted of 330 adults, who were diagnosed with ADHD by a trained psychologist at one of 14 participating outpatient adult ADHD clinics of PsyQ in The Netherlands. ADHD diagnoses were based on having at least six out of nine DSM-IV-TR symptoms of inattention and/or hyperactivity/ impulsivity in childhood, persistence of symptoms and impairments into adulthood, and at least six out of nine current DSM-IV symptoms of inattention and/or hyperactivity/impulsivity [301], using the semi-structured Diagnostic Interview for ADHD in adults, second edition (DIVA 2.0) [75]. The age- and gender matched control group consisted of 330 adult civilians who were recruited at XLIGIRXVEPQYRMGMTEPSǽGIMR8LI-EKYI8LI3IXLIVPERHW[LMPI[EMXMRKMRPMRI JSV EVVERKIQIRXW GSRGIVRMRK GMZMP EǺEMVW XS VIUYIWX EWWMWXERGI ERHSV PIKEP EHZMGISRWSGMEPEǺEMVWSVIQTPS]QIRX5EVXMGMTEXMSRXSXLMWWXYH][EWZSPYRXEV] and without incentive. No medical ethical approval was needed for this study, following the Dutch Medical Research Involving Human Subjects Act.

Measures

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the ADHD group, the ADHD-RS total score and their medication history were derived from their medical records. The Driving Questionnaire was completed in 15 minutes.

Driving outcomes

Current safe driving behavior was assessed with the DBS, where higher WGSVIW MRHMGEXIH WEJIV HVMZMRK 8LI GYXSǺ JSV YRWEJI HVMZMRK [EW WIX EX  following Barkley and Murphy [102]. Adverse driving outcomes in the past were investigated with the DHS. As adopted from Barkley et al. [57], adverse driving SYXGSQIW[IVI HIǻRIH EW LEZMRK IZIV HVMZIR MPPIKEPP] LEZMRK LEH E PMGIRWI WYWTIRWMSRSVVIZSGEXMSRLEZMRKLEHSVQSVIXVEǽGGMXEXMSRWLEZMRKLEHǻZI or more speeding citations, having had three or more vehicular crashes while driving, or having had three or more vehicular crashes at fault.

Statistical analyses

LSD, other drugs, and illegal use of medication) in the past month (all: no/ yes), use of automatic transmission mode (no/yes), use of ADHD medication (no/yes), and use of antidepressants (no/yes). SPSS 23.0 (Chicago, IL) was used for data analysis. An ƋPIZIP SJ Ƿ MRHMGEXIH WXEXMWXMGEP WMKRMǻGERGI

RESULTS

General characteristics

The general characteristics of the ADHD group and control group are presented in Table 1. The ADHD and control groups were matched in advance and thus comparable with regards to age and gender. As would be expected, the ADHD KVSYTLEHEWMKRMǻGERXP]LMKLIVWGSVISRXLI&)-)7 ZW p!&PWS they more often had a low vocational status (p![IVIPIWWSJXIRIQTPS]IH (52.2% vs. 62.7%; p=.007), had a higher anxiety score (19.6 vs. 13.7; p! ERH hostility score (10.5 vs. 7.9; p!YWIHWMKRMǻGERXP]QSVIHVYKW  ZW 

p"WTIGMǻGEPP]QSVIGERREFMW  ZW p=.011), had more illegal use

of medication (2.2% vs. 0.3%; p=.037), and more often used ADHD medication (11.8% vs. 0.0%; p!ERXMHITVIWWERXW  ZW p!ERHER\MSP]XMGW (2.7% vs. 0.0%; p"8LIVI[IVIRSKVSYTHMǺIVIRGIWMRXLI[IIOP]EPGSLSP consumptions, and the use of cocaine, LSD, or other drugs.

Driving history and behavior

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4 persons (1.2%) had too many missing data on the ADHD-RS, but 35 persons  LEHGLVSRMGLMKL&)-)WGSVIWEFSZIXLIGYXSǺSJ[LMGLQE]FIHYI to undiagnosed ADHD. Nevertheless, comparisons between the ADHD and the control group without cases with high ADHD risk were highly similar to the results from the total control group. Therefore, no corrections for ADHD severity were needed in our logistic regression analysis.

TABLE 1. General characteristics of the ADHD (N=330) and control group (N=330)

ADHD group N=330 Control group N=330 Comparison ADHD vs. control group p Sex, % female 45.5% 51.1% .150

Age in years (range 18-65), mean (SD) 34.9 (10.5) 34.6 (11.7) .756 ADHD rating scale, mean (SD) 34.1 (8.9) 14.4 (8.8) ! Vocational status, %

- Elementary school - Lower secondary school - Higher secondary school - Pre-university education - Higher professional school - University 4.9% 16.0% 38.0% 7.4% 27.6% 6.1% 2.5% 7.2% 23.3% 3.8% 29.6% 33.6% ! Occupation, % a - Employed - Student - Retired - No occupation 52.2% 19.3% 0.9% 27.6% 62.7% 16.3% 1.3% 19.6% .007 .340 .654 .002 SCL-90 anxiety score, mean (SD) 19.6 (7.4) 13.7 (4.6) ! SCL-90 hostility score, mean (SD) 10.5 (4.0) 7.9 (2.8) ! Alcohol use, mean weekly units (SD) 4.3 (5.9) 4.2 (6.0) .961 Substance abuse in past month, % a

- Any drugs - Cannabis - Cocaine - LSD - Other drugs

- Illegal use of medication

16.1% 13.1% 2.8% 1.5% 1.2% 2.2% 8.2% 7.0% 1.9% 2.9% 1.3% 0.3% .002 .011 .478 .249 .957 .037 Current medication use, % a

- ADHD medication - Anti-depressants - Anxiolytics 11.8% 13.6% 2.7% 0.0% 0.6% 0.0% ! ! .003 Note. N, sample size; SD, standard deviation; n, group size; %, percentage of group size.

TABLE 2. Comparisons between the ADHD group (N=330) and the control group (N=330)

on proportions of adverse driving outcomes in the past (DHS) and current driving behavior (DBS) ADHD group N=330 Control group N=330 Comparisons ADHD vs. control group RR valuea _p

DHS adverse driving in the past, %

Illegal driving License suspended/revoked 8VEǽGGMXEXMSRW SJ[LMGLǸXVEǽGGMXEXMSRWb Speeding citations SJ[LMGLǸWTIIHMRKGMXEXMSRWb

Citations for drunk driving Citations for ignoring red light Citations for reckless driving Vehicular crashes while driving

SJ[LMGLǸZILMGYPEVGVEWLIWb

Vehicular crashes at fault

SJ[LMGLǸZILMGYPEVGVEWLIWEXJEYPXb 8.6% 6.7% 90.3% 24.7% 83.0% 37.2% 6.2% 28.0% 2.4% 68.8% 29.0% 34.2% 5.0% 10.7% 6.1% 78.5% 20.9% 65.8% 26.9% 5.5% 20.4% 3.7% 50.0% 10.0% 19.1% 0.3% 0.81 1.09 1.15 1.18 1.26 1.38 1.13 1.37 0.67 1.38 2.89 1.79 16.25 0.8 0.1 17.5 1.2 25.8 7.4 0.1 5.0 0.8 24.1 36.8 19.2 13.8 .381 .765 ! .265 ! .006 .702 .025 .364 ! ! ! !

Current driving behavior

DBS total score, mean (SD) SJ[LMGLXSXEPWGSVI! 84.6 (11.6) 24.5% 86.9 (9.6) 13.3% n/a 1.84 21.5 13.5 .005 ! Number of licensed years, mean (SD)

Driving frequency in km/week, mean (SD) of which >125 km per week,c _%

14.1 (10.1) 294.4 (497.0) 52.3% 14.1 (11.6) 1157.8 (9735.5) 51.1% n/a n/a 1.02 0.1 7.7 0.1 .954 .123 .773 Note. DBS, driving behavior survey; N, total sample size; n, group size; %, percentage of group; SD, standard deviation; n/a, not applicable.

a _{Analyses of variance for continuous variables and chi-square comparisons for categorical variables.} b_{'EWIHSRXLIGYXSǺWYWIHF]'EVOPI]IXEP?A}

c _{Based on the distribution of driving frequency in the total sample.}

Risky driving

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TIVWSREPMX]PMJIWX]PIERHQIHMGEXMSRYWISRGYVVIRXYRWEJIHVMZMRKFILEZMSV )'! Odds ratio for unsafe driving behavior

Model 1 Model 2 Model 3

OR (95% CI) OR (95% CI) OR (95% CI)

ADHD and driving frequency

ADHD diagnosis: yes Driving frequency: high

Sociodemographics

Gender: male Age, in years

Vocational status: high

Personality, lifestyle and medication use

Anxiety level: high Hostility level: high Alcohol use: high Substance abuse: yes

Automatic transmission mode: yes ADHD medication use: yes Antidepressants use: yes

2.07 (1.32-3.24)** 1.74 (1.11-2.73)* 2.08 (1.29-3.35)** 1.65 (1.03-2.64)* 2.06 (1.27-3.34)** 0.97 (0.94-0.99)** 0.94 (0.59-1.50) 21 (0.69-2.12) 1.21 (0.69-2.12) 1.71 (1.04-2.83)* 2.68 (1.59-4.51)*** 0.97 (0.95-1.00)* 0.97 (0.59-1.59) 2.68 (1.43-5.00)** 1.91 (1.10-3.35)* 3.26 (1.68-6.34)*** 1.32 (0.70-2.52) 1.25 (0.63-2.48) 0.41 (0.13-1.27) 1.03 (0.43-2.41) * pǷpǷpǷ

8EFPI ' TVIWIRXW XLI SHHW JSV LEZMRK LEH  SV QSVI XVEǽG GMXEXMSRW ERH having had three or more vehicular crashes, using ADHD, sociodemographics, personality, lifestyle and medication use as independent factors, resulting from the logistic regression analysis. Having a high driving frequency (OR=2.39;

p=.003), male gender (OR=2.53; p=.001), an older age (OR=1.11 per year; p!

and a high hostility level (OR=2.15; p" WMKRMǻGERXP] MRGVIEWIH XLI SHHW JSV LEZMRK E LMKL RYQFIV SJ XVEǽG GMXEXMSRW -EZMRK ER&)-) HMEKRSWMW SRP] RIEVWMKRMǻGERXP]MRGVIEWIHXLISHHWJSVELMKLRYQFIVSJXVEǽGGMXEXMSRWEJXIV correcting for lifestyle and medication use (OR=1.87; p=.060). The odds for having ELMKLRYQFIVSJZILMGYPEVGVEWLIW[IVIWMKRMǻGERXP]MRGVIEWIHF]LEZMRKER ADHD diagnosis (OR=2.72; p=.001), a high driving frequency (OR=2.95; p! having an older age (OR=1.04 per year; p!ERHLEZMRKELMKLLSWXMPMX]PIZIP (OR=1.78; p=.046).

Sociodemographics

Gender: male Age, in years

Vocational status: high

T ABLE 3B. 1SKMWXMG VIKV IWWMSR EREP ]WMW S J XLI I ǺIGXW S J &)-) WSGMSHIQSKV ETLMGW TIVWSREPMX] PMJ IWX]PI ERH QI HMGE XMSR YWI SR EHZ IVWIHVMZMRKSYX GSQIWMRXLITEWXLE ZMRKLEHX[ IP ZISV QSV IXV EǽGGMXE XMSRWERHLE ZMRKLEHXLV II SV QSV I ZILMGYPEV GV EWLIW 4HHWV EXMSJ SV XV EǽGGMXE XMSRWǸ 4HHWV EXMSWJ SV Z ILMGYPEV GV EWLIWǸ M odel 1 M odel 2 M odel 3 M odel 1 M odel 2 M odel 3 OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) A DHD and drivin g f requenc y ADHD diagnosis: y es Driving fr equenc y: high S ociodemo g ra p hic s

Gender: male Age, in

y ears V oca tional sta tus: high Per sonalit y, li fe st y le and medic ation u se Anxie ty le v el: high H ostility le v el: high Alc ohol use: high Substanc e abuse: y es A ut oma tic tr ansmission mode: y es ADHD medica tion use: y es An tidepr essan ts use: y es 2.45 (1.46-4.10 )*** 3.14 (1.86-5.30 )*** 2.35 (1.34 -4.14)** 2.36 (1.36-4.11)** 2.35 (1.3 7 -4.05)** 1.10 (1.06-1.14)*** 0.66 ( 0.38-1.1 7) 1.87 ( 0.9 7 -3.59) 2.39 (1.35 -4.20 )** 2.53 (1.44 -4.45)*** 1.11 (1.0 7 -1.15)*** 0.68 ( 0.38-1.21) 0.91 ( 0.4 7 -1. 76) 2.15 (1.10-4.20 )* 1.24 ( 0.52-2.96) 1.26 ( 0.53-3.00 ) 0.83 ( 0.39-1. 76) 0.62 ( 0.15 -2.53) 3.38 ( 0.38-29. 72) 3.63 (2.26-5.83)*** 3.34 (2.05 -5.42)*** 3. 7 0 (2.24 -6.12)*** 3.10 (1.88-5.12)*** 1.11 ( 0.69-1. 7 9) 1.04 (1.02-1.06)*** 0.91 ( 0.5 7 -1.4 7) 2. 72 (1.52-4.85)*** 2.95 (1. 77 -4.92)*** 1.24 ( 0. 76-2.04) 1.04 (1.02-1.06)*** 0.98 ( 0.60-1.59) 1.11 ( 0.60-2.04) 1. 78 (1.01 -3.14)* 0.88 ( 0.41 -1.91) 0. 74 ( 0.44 -1.80 ) 0.58 ( 0.28-1.20 ) 0. 77 ( 0.30-1.92) 1.89 ( 0.86-4.19) 3 S XI'FI XEG SI ǽGMIR X *WXERHEV HIVV SV 47SHHWV EXMS  (. G SR ǻHIRG IMR XIVZ EP JSV SHHW V EXMS * p Ƿ p Ƿ p Ƿ S ociodemo g ra p hic s

Gender: male Age, in

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DISCUSSION

This cross-sectional study investigated current driving behavior and driving history in a large sample of Dutch adults with ADHD and controls, in order to identify characteristics that increase the risk of unsafe driving and adverse driving outcomes. Adults with ADHD rated their driving behavior as less safe, and they had more often encountered adverse driving outcomes. However, in general, male gender, young age, anxiety, hostility, and alcohol use, and not ADHD were the strongest predictors of unsafe driving.

.RGSVVIWTSRHIRGI[MXLǻRHMRKWJVSQWXYHMIWMRXLI9SYVWXYH]JSYRHLMKLIV rates of adverse driving outcomes in adults with ADHD when compared to GSRXVSPW?A4YVTVIZEPIRGIVEXIWSJXVEǽGERHWTIIHMRKGMXEXMSRWEVIMR line with European results from a case-control study on driving in ADHD [326]. SFERWOMIXEP?AJSYRHXLEXXVEǽGGMXEXMSRW[IVITVIZEPIRXMR SJEHYPXW with ADHD and in 74% of controls amounting to a relative risk of 1.25, which is GSQTEVEFPIXSXLI XVEǽGGMXEXMSRWMR&)-)ZIVWYW MRGSRXVSPW 77" that were found in the current study. Also, they found 63% speeding citations in ADHD versus 52% in controls, which is lower than our rates of 83% in ADHD and 66% in controls. However, relative risks were comparable (RR=1.21 vs. RR=1.26). Moreover, in accordance with Sobanski et al. [326], the adults with ADHD in our study had a 2.5 times increased rate of having had three or more vehicular crashes compared to controls (29% vs. 10%; RR=2.89).

other words, adults with ADHD with high alcohol use, and high levels of hostility or anxiety are an at-risk group for road safety.

;LIR GSRWMHIVMRK EHZIVWI HVMZMRK MR XLI TEWX &)-) HMH LEZI E WMKRMǻGERX IǺIGX SR MRZSPZIQIRX MRZILMGYPEV GVEWLIW VITVIWIRXMRK ER SHHW VEXMS SJ  8LMW SHHW VEXMS GSRGYVW [MXL ǻRHMRKW JVSQ SXLIV WXYHMIW [LIVI E X[S XS fourfold-increased odds was found for ADHD in comparison to controls, even after adjusting for important covariates [57, 318]. Also, a 1.38 relative risk was found for vehicular crashes in adults with ADHD, corresponding to the earlier established 1.23 weighted relative risk resulting from the meta-analysis of Vaa [329]. Surprisingly, in our study ADHD alone did not increase the odds for a LMKLRYQFIVSJXVEǽGGMXEXMSRW8LISHHWJSVXVEǽGGMXEXMSRW[IVITEVXMGYPEVP] MRǼYIRGIHF]ELMKLHVMZMRKJVIUYIRG]ERHLIRGIQSVIVSEHI\TSWYVIERH by high hostility levels that may have caused a tense, aggressive driving style ERHQSVIVMWOXEOMRKFILEZMSV?AYVTVMWMRKP]RSMRXIVEGXMSRIǺIGX[EW found between ADHD and high levels of hostility. In contrast to prior studies ?A &)-) QIHMGEXMSR HMH RSX EǺIGX GYVVIRX HVMZMRK FILEZMSV SV TEWX adverse driving outcomes. Since adults with ADHD participated to this study directly after diagnostic assessment, the small group of 39 patients who were using any ADHD medication at the time of assessment was likely not adequately titrated yet. Also, an extensive systematic review of the literature by Gobbo and 1SY^E?AVIKEVHMRKTLEVQEGSPSKMGEPXVIEXQIRXIǺIGXWSRHVMZMRKFILEZMSV WLS[IH LMKLP] ZEVMEFPI IǺIGX WM^IW VERKMRK FIX[IIR  ERH  (SLIRwW d) JSVQIXL]PTLIRMHEXI[LMGLQMKLXI\TPEMR[L]RSIǺIGXJSV&)-)QIHMGEXMSR was found in our study. Also, it has been argued that ADHD medication may improve neurocognitive functions and driving behavior but might not be able to RSVQEPM^IFILEZMSV?A-IRGIHVMZMRKHMǽGYPXMIWVIQEMRMQTEMVIH

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WTIGMǻGEXMSR[MXLVIKEVHWXSWYFWXERGIEFYWI[EWFI]SRHXLIEMQSJXLMWWXYH] Finally, correction for ADHD medication was only possible in a small group of adults with ADHD, as none of the controls used ADHD medication.