Can ADHD be a Deadly Disorder?

Can ADHD be a Deadly Disorder?

By: Stephen V. Faraone, Ph.D.

In the world of research, it is unusual for a single study to be definitive.    A possible exception is a recent report in the highly esteemed Lancet, which concluded that people diagnosed with ADHD were about two times more likely to die early than people without ADHD.  The data came from the medical registers of Denmark that include 1.92 million people of which 32,061 have ADHD.  The registers included the times and causes of deaths spanning 32 years.   It is a remarkable resource.

We know that people with very severe ADHD are at high risk for substance use disorders and antisocial behaviors.  In the Danish study, these disorders also increased the risk for premature death but the risk was even higher if people with those disorders also had ADHD.   ADHD also increased the risk for early death among people without these extra problems.  This latter finding points to an ADHD specific pathway to premature death.  What is it?   Well, we know that ADHD people are at risk for injuries, traffic accidents and traumatic brain injury.   We don’t know for certain why,  but two symptom clusters of ADHD, inattention and impulsivity, would be expected in increase the risk for accidents and injuries.   For example, adults who are distracted while driving are clearly at risk for accidents.  In fact, accidents accounted for most of the early deaths in the Danish study.  But the study also found an increase in natural causes of death due to having ADHD.  This may be due to the well replicated association between ADHD and obesity or the possibility that ADHD symptoms lead to poor health habits.

In the Danish study, the mean age at diagnosis was 12.3, which means that many of the ADHD people in the study were not treated for many years subsequent to the onset of symptoms.   The risk for early death increased with the age at diagnosis.  This suggests that failing to diagnoses and treat ADHD early makes the disorder worse and increases the risk for the types of behaviors that lead to premature death.

Will these data change public policy or clinician behavior?  I hope so.  Perhaps the media will stop trivializing ADHD and accept it as a bona fide disorder in need of early identification and treatment.   Policy makers should allocate to ADHD people their fair share of healthcare and research resources.  For clinicians, early identification and treatment should become the rule rather than the exception.

Talk of premature death will worry parents and patients.  That is understandable, but such worries can be alleviated by focusing on two facts:  the absolute risk for premature death is low and this risk can be greatly reduced by seeking and adhering to evidenced-based treatments for the disorder.


Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B. & Pedersen, M. G. (2015). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet.

Vaa T. ADHD and relative risk of accidents in road traffic: a meta-analysis. Accident; analysis and prevention. 2014; 62: 415-25.

Adeyemo BO, Biederman J, Zafonte R, Kagan E, Spencer TJ, Uchida M, et al. Mild Traumatic Brain Injury and ADHD: A Systematic Review of the Literature and Meta-Analysis. J Atten Disord. 2014; 18(7): 576-84.

Cortese S, Faraone SV, Bernardi S, Wang S, Blanco C. Adult attention-deficit hyperactivity disorder and obesity: epidemiological study. Br J Psychiatry. 2013; 203: 24-34.

Spencer TS, Faraone SV, Tarko L, McDermott K, Biederman J. ADHD and Adverse Health Outcomes in Adults: Results from a Large Controlled Study. 2013.

Faraone SV. The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry. 2005; 14: 1-10.

ADHD and the Risk for Suicide

Suicide is one of the most feared outcomes of any psychiatric condition.  Although its association with depression is well known, a small but growing research literature shows that ADHD is also a risk factor for suicidality.   Suicide is difficult to study. Because it is relatively rare, large samples of patients are needed to make definitive statements.  Studies of suicide and ADHD must also consider the possibility that medications might elevate that risk.  For example, the FDA placed a black box warning on atomoxetine because that ADHD medication had been shown to increase suicidal risk in youth.   A recent study of 37,936 patients with ADHD now provides much insight into these issues (Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B. M., Lichtenstein, P. & Larsson, H. (2014). Drug treatment for attention-deficit/hyperactivity disorder and suicidal behavior: register based study. BMJ 348, g3769.).    In Sweden, such large studies are possible because researchers have computerized medical registers that describe the disorders and treatments of all people in Sweden.  Among 37,936 patients with ADHD, 7019 suicide attempts or completed suicides occurred during 150,721 person years of follow-up.  This indicates that, in any given year, the risk for a suicidal event is about 5%.  For ADHD patients, the risk for a suicide event is about 30% greater than for non-ADHD patients.  Among the ADHD patients who attempted or completed suicide, the risk was increased for those who had also been diagnosed with a mood disorder, conduct disorder, substance abuse or borderline personality.  This is not surprising; the most serious and complicated cases of ADHD are those that have the greatest risk for suicidal events.  The effects of medication were less clear.   The risk for suicide events was greater for ADHD patients who had been treated with non-stimulant medication compared with those who had not been treated with non-stimulant medication.  A similar comparison showed no effect of stimulant medications.  This first analysis suffers from the fact that the probability of receiving medication increases with the severity of the disorder.  To address this problem, the researchers limited the analyses to ADHD patients who had had some medication treatment and then compared suicidal risk between periods of medication treatment and periods of no medication treatment.  This analysis found no increased risk for suicide from non-stimulant medications and, more importantly, found that for patients treated with stimulants, the risk for suicide was lower when they were taking stimulant medications.  This protective effect of stimulant medication provides further evidence of the long-term effects of stimulant medications which have also been shown to lower the risks for traffic accidents, criminality, smoking and other substance use disorders.

ADHD and Emotional Dysregulation

ADHD and Emotional Dysregulation

By Stephen V. Faraone, PhD

One of the many great contributions of Dr. Russell Barkley was his conceptualization of ADHD as a disorder of self-regulation.   ADHD people have difficulties regulating their behavior, which lead to the classic diagnostic criteria of hyperactivity and impulsivity and they have problem regulating cognitive processes which leads to the well-known inattentive diagnostic criteria for the disorder.    In a 2010 paper, Dr. Barkley argued persuasively that deficient emotional self-regulation should also be considered a core component of ADHD alongside deficient behavioral and cognitive self-regulation.  Although the DSM 5 did not add any emotional symptoms to the revised criteria for ADHD a new paper by Graziano and Garcia supports Dr. Barkley’s position.   They conducted a meta-analysis of 77 studies of emotional dysregulation that comprised a total of 32,044 participants.  They defined emotional dysregulation as the failure to modify emotional states in a manner that promotes adaptive behavior and leads to the success of goal directed activities.  They identified three types of emotional dysregulation: emotion recognition and understanding (ERU), emotional reactivity/negativity/lability (ERNL) and empathy/callous-unemotional traits (ECUT).   ERU refers to the ability to perceive, process and infer one’s own emotions and the emotions of others.  ERNL refers to the intensity and valence of the emotional response.  Reactivity refers to the rapidity of the emotional response (e.g., is a person quick tempered rather than reflective); negativity refers to the valence of the emotion.  Is it extreme or appropriate to the situation; and lability refers to how quickly emotional states shift or cycle over time.  The ECUT dimension has two poles.  At one extreme is the empathic person whose reactions are guided by a clear understanding of the emotional states of others.  At the other pole is the psychopath who shows little or no emotion to stimuli that evoke strong emotional reactions in the average person.    When the data from the 77 studies was sorted into these three categories, the authors found that ADHD people had impairments in all three domains.   The magnitude of impairment was a bit greater for ERNL than it was for ECUT and ERU, but not dramatically so.  The association between ADHD and these domains of emotional dysregulation increased with increasing age.  It is for this reason that some ADHD experts think that emotional dysregulation should be included in the diagnostic criteria for adult ADHD.  Because behavioral hyperactivity diminishes with age, these criteria are less sensitive for adult ADHD than they are for child ADHD.  Substituting emotional dysregulation items for hyperactivity items could, potentially, improve diagnoses of adult ADHD.  Future work will address this issue.  In the meanwhile, those who screen and diagnose adult ADHD should be aware that symptoms of emotional dysregulation might be the most prominent for some adults with the disorder.


Barkley, R. A. (2010). Deficient Emotional Self-Regulation: A Core Component of Attention-Deficit/Hyperactivity Disorder. Journal of ADHD and Related Disorders 1, 5-37.


Graziano, P. A. & Garcia, A. (2016). Attention-deficit hyperactivity disorder and children’s emotion dysregulation: A meta-analysis. Clin Psychol Rev 46, 106-23.


ADHD and Eating Disorders

ADHD and Eating Disorders

By Stephen V. Faraone, PhD

A relatively new area of ADHD research has been examining the association between ADHD and eating disorders (i.e., anorexia nervosa, bulimia nervosa and binge eating disorder).   Nazar and colleagues conducted a systematic review and meta-analysis of extant studies.   They found only twelve studies that assessed the presence of eating disorders among people with ADHD and five that examined the prevalence of ADHD among patients with eating disorders.  Although there were few studies, the total number of people studied was large, 4,013 ADHD cases and 29,404 controls for the first set of studies and 1,044 eating disorder cases and 11,292 controls for the second set of studies.   The meta-analyses of these data found that ADHD people had a 3.8 fold increased risk for and eating disorder compared with non-ADHD controls.   The level of risk was similar for each of the eating disorders.   Consistent with this, their second meta-analysis found that people with eating disorders had a 2.6 fold increased risk for ADHD compared with controls who did not have an eating disorder.  The risk for ADHD was highest for those with binge eating disorder (5.8 fold increased risk compared with controls).   This bi-directional association between ADHD and eating disorders provides converging evidence that this association is real and, given its magnitude, clinically significant.   The results were similar for males and females and for pediatric and adult populations.   We cannot tell from these data why ADHD is associated with eating disorders.  Nazar et al. note that other work implicates both impulsivity and inattention in promoting bulimic symptoms whereas inattention and hyperactivity are associated with craving.  The association may also be due to the neurocognitive deficits of ADHD, which could lead to a distorted sense of self awareness and body image.   Given that ADHD is also associated with obesity, it is possible that some obese ADHD patients have an underlying eating disorder, such as binge eating, which has been associated to obesity in prospective studies.    Also, lisdexamphetamine is FDA approved for treating both binge eating and ADHD, which suggests the possibility that the two conditions share an underlying etiology involving the dopamine system.   We do not know if treating ADHD would reduce the risk for eating disorders as that hypothesis has not yet been tested.  But such an effect would seem likely if ADHD behaviors mediate the association between the two disorders.


Nazar, B. P., Bernardes, C., Peachey, G., Sergeant, J., Mattos, P. & Treasure, J. (2016). The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Int J Eat Disord 49, 1045-1057.

Does Acetaminophen use During Pregnancy Cause ADHD in Offspring?

Many media outlets have reported on a study suggesting that mothers who use acetaminophen during pregnancy may put their unborn child at risk for ADHD.   Given that acetaminophen is used in many over-the-counter pain killers, correctly reporting such information is crucial.  As usual, rather than relying on one study, looking at the big picture using all available studies is best.  Because it is not possible to examine this issue with a randomized trial, we must rely on naturalistic studies.

One registry study ( reported that fetal exposure to acetaminophen predicted an increased risk of ADHD with a risk ratio of 1.37.  The risk was dose-dependent in the sense that it increased with increased maternal use of acetaminophen.  Of particular note, the authors made sure that their results were not accounted for by potential confounds (e.g., maternal fever, inflammation and infection).  Similar results were reported by another group (, which also showed that risk for ADHD was not predicted by maternal use of aspirin, antacids, or antibiotics.  But that study only found an increased risk at age 7 (risk ratio = 2.0) not at age 11.  In a Spanish study, (, children exposed prenatally to acetaminophen were more likely to show symptoms of hyperactivity and impulsivity later in life.  The risk ratio was small (1.1) but it increased with the frequency of prenatal acetaminophen use by their mothers.

We can draw a few conclusions from these studies.  There does seem to be a weak, yet real, association between maternal use of acetaminophen while pregnant and subsequent ADHD or ADHD symptoms in the exposed child.  The association is weak in several ways: there are not many studies, they are all naturalistic and the risk ratios are small.   So mothers that have used acetaminophen during pregnancy and have an ADHD child should not conclude that their acetaminophen use caused their child’s ADHD.  On the other hand, pregnant women who are considering the use of acetaminophen for fever or pain should discuss other options with their physician.  As with many medical decisions, one must balance competing risks to make an informed decision.

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What is Evidenced Based Medicine?

What is Evidenced Based Medicine?

With the growth of the Internet, we are flooded with information about attention deficit hyperactivity disorder from many sources, most of which aim to provide useful and compelling “facts” about the disorder.   But, for the cautious reader, separating fact from opinion can be difficult when writers have not spelled out how they have come to decide that the information they present is factual.

My blogs several guidelines to reassure readers that the information they read about ADHD is up-to-date and dependable.  They are as follows:

Nearly all the information presented is based on peer-reviewed publications in the scientific literature about ADHD.  “Peer-reviewed” means that other scientists read the article and made suggestions for changes and approved that it was of sufficient quality for publication.  I say “nearly all” because in some cases I’ve used books or other information published by colleagues who have a reputation for high quality science.

When expressing certainty about putative facts, I am guided by the principles of evidenced based medicine, which recognizes that the degree to which we can be certain about the truth of scientific statements depends on several features of the scientific papers used to justify the statements such as the number of studies available and the quality of the individual studies.    For example, compare these two types of studies.   One study gives drug X to 10 ADHD patients and reports that 7 improved.   Another gave drug Y to 100 patients and a placebo to 100 other patients and used statistics to show that the rate of improvement was significantly greater in the drug treated group.  The second study is much better and much larger, so we should be more confident in its conclusions.  The rules of evidence are fairly complex and can be viewed at the Oxford Center for Evidenced Based Medicine (OCEBM;

The evidenced-based approach incorporates two types of information: a) the quality of the evidence and b) the magnitude of the treatment effect.  The OCEBM levels of evidence quality are defined as follows (higher numbers are better:

  1. Mechanism based reasoning. For example, some data suggest that oxidative stress leads to ADHD and we know that omega-3 fatty acids reduce oxidative stress.  So there is a reasonable mechanism whereby omega-3 therapy might help ADHD people.
  2. Studies of one or a few people without a control group or studies that compare treated patients to those that were not treated in the past.
  3. Non-randomized, controlled studies. In these studies the treatment group is compared to a group that receives a placebo treatment, which is a fake treatment not expected to work.   Non-randomized means that the comparison might be confounded by having placed different types of patients in the treatment and control groups.
  4. Single randomized trial. This type of study is not confounded.
  5. Systematic review and meta-analysis of randomized trials. This means that many randomized trials have been completed and someone has combined them to reach a more accurate conclusion.

It is possible to have high quality evidence proving that a treatment ‘works’ but the treatment might not work very well.  So it is important to consider the magnitude of the treatment effect, also called the “effect size” by statisticians.  For ADHD, it is easiest to think about ranking treatments on a ten point scale.   The stimulant medications have a quality rating of 5 and also have the strongest magnitude of effect, about 9 or 10.  Omega-3 fatty acid supplementation ‘works’ with a quality rating of 5, but the score for magnitude of effect is only 2 so it doesn’t work very well.  We have to take into account patient or parent preferences, comorbid conditions, prior response to treatment and other issues when choosing a treatment for a specific patient, but we can only use an evidenced-based approach when deciding which treatments are well supported as helpful for a disorder.