Is ADHD a Serious Condition?

The short answer is “yes”.  The US Center for Disease Control’s (CDC) review of ADHD starts with the statement: “Attention-deficit/hyperactivity disorder (ADHD) is a serious public health problem affecting a large number of children and adults” (http://www.cdc.gov/ncbddd/adhd/research.html).  My colleagues and I recently reviewed the ADHD literature.  That let us to describe ADHD as “…a seriously impairing, often persistent neurobiological disorder of high prevalence…” (Faraone et al., 2015).  Figure 1, which comes from that paper provides an overview of the lifetime trajectory of ADHD associated morbidity.

Figure 1: Lifetime Morbidity Associated with ADHD (Click to Enlarge)

Figure 1: Lifetime Morbidity Associated with ADHD (Click to Enlarge)

Figure2

Figure 2: ADHD, Injuries and Pharmacologic Treatment

 

Especially compelling data about ADHD and injuries comes from a recent paper, in Lancet Psychiatry, which used the Danish national registers to follow a cohort of 710,120 children (Dalsgaard et al., 2015a).   Compared with children not having ADHD, those with ADHD were 30% more likely to sustain injuries than other children.  Pharmacotherapy for ADHD reduced the risk for injuries by 32% from 5 to 10 years of age.  Pharmacotherapy for ADHD reduced emergency room visits by 28.2% at age 10 and 45.7% at age 12.

These results are shown in Figure 2, taken from the publication.  The Figure compares the prevalence of injuries among three groups.  ADHD children treated with medication, ADHD children not treated with medication and children without ADHD.  The Figure shows how the ADHD risk for injuries occurs for all age groups.  It also shows how the risk for injuries drops with treatment so that by age 12, the prevalence of injuries among treated ADHD children is the same as the prevalence of injuries for children without ADHD.

Documented examples of ADHD-associated injuries which impact day-to-day functioning include: severe burns (Fritz and Butz, 2007), dental injuries (Sabuncuoglu, 2007), penetrating eye injuries (Bayar et al., 2015), hospital treated injuries (Hurtig et al., 2013), and head injuries (DiScala et al., 1998).  In one study (DiScala et al., 1998), when compared to other children admitted to hospital for injuries, ADHD children were more likely to sustain injuries to multiple body regions (57.1% vs 43%), to sustain head injuries (53% vs 41%), and to be severely injured as measured by the Injury Severity Score (12.5% vs 5.4%) and the Glasgow Coma Scale (7.5% vs 3.4%).

Injuries are a substantial cause of ADHD-associated premature death.  This assertion comes from the work of Dalsgaard et al. (2015b) based on the same Danish registry discussed above.   In this second study, ADHD was associated with an increased risk for premature death and 53% of those deaths were due to injuries.  They reported the risk for premature death in three age groups: 1-5, 6-17 and >17.  For all three age groups, they found a greater risk for death in the ADHD group.  For ages 6 to 17 and greater than 17.  The ADHD associated risk for mortality in remained significant after excluding individuals with antisocial or substance use disorders.

There are currently no data about the effect of ADHD treatment on ADHD-associated premature death.  We do, however, know from the data reviewed above that ADHD treatment reduces injuries and that half the deaths in the ADHD group were due to injuries.  From this, we infer that ADHD treatments could reduce the risk for ADHD-associated premature death.

Two other ADHD-associated morbidities, obesity and cigarette smoking, have clear medical consequences.  In a meta-analysis of 42 cross-sectional studies comprising 48,161 people with ADHD and 679,975 controls, my colleagues and I reported that the pooled prevalence of obesity was increased by about 40% in ADHD children compared with non-ADHD children and by about 70% in ADHD adults compared with non-ADHD adults (Cortese et al., 2015). The association between ADHD and obesity was significant for ADHD medication-naïve subjects but not for those medicated for ADHD (, which suggests that medication reduces the risk for obesity.

Likewise, a meta-analysis of 27 longitudinal studies assessed the risk for several addictive disorders with sample sizes ranging from 4142 to 4175 for ADHD and 6835 to 6880 non-ADHD controls (Lee et al., 2011).   Children with ADHD were at higher risk for disorders of abuse or dependence for nicotine, alcohol, marijuana, cocaine, and other unspecified substances.  Another meta-analysis (42 studies totaling 2360 participants) showed that medications for ADHD reduced the ADHD-associated risk for smoking (Schoenfelder et al., 2014).   The authors concluded that, for ADHD patients, “Consistent stimulant treatment for ADHD may reduce the risk of smoking”.  This finding is especially notable given that, for ADHD youth, cigarette smoking is a gateway drug to more serious addictions (Biederman et al., 2006).

Yes, ADHD is a serious disorder.  Although most ADHD people will be spared the worst of these outcomes, they must be considered by parents and patients when weighing the pros and cons of treatment options.

 

REFERENCES

 

Bayar, H., Coskun, E., Oner, V., Gokcen, C., Aksoy, U., Okumus, S. & Erbagci, I. (2015). Association between penetrating eye injuries and attention deficit hyperactivity disorder in children. Br J Ophthalmol 99, 1109-11.

Biederman, J., Monuteaux, M., Mick, E., Wilens, T., Fontanella, J., Poetzl, K. M., Kirk, T., Masse, J. & Faraone, S. V. (2006). Is cigarette smoking a gateway drug to subsequent alcohol and illicit drug use disorders? A controlled study of youths with and without ADHD. Biol Psychiatry 59, 258-64.

Cortese, S., Moreira-Maia, C. R., St Fleur, D., Morcillo-Penalver, C., Rohde, L. A. & Faraone, S. V. (2015). Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. Am J Psychiatry, appiajp201515020266.

Dalsgaard, S., Leckman, J. F., Mortensen, P. B., Nielsen, H. S. & Simonsen, M. (2015a). Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study. Lancet Psychiatry 2, 702-9.

Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B. & Pedersen, M. G. (2015b). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet 385, 2190-6.

DiScala, C., Lescohier, I., Barthel, M. & Li, G. (1998). Injuries to children with attention deficit hyperactivity disorder. Pediatrics 102, 1415-21.

Faraone, S. V., Asherson, P., Banaschewski, T., Biederman, J., Buitelaar, J. K., Ramos-Quiroga, J. A., Rohde, L. A., Sonuga-Barke, E. J. S., Tannock, R. & Franke, B. (2015). Attention deficit hyperactivity disorder. In Nature Reviews: Disease Primers.

Fritz, K. M. & Butz, C. (2007). Attention Deficit/Hyperactivity Disorder and pediatric burn injury: important considerations regarding premorbid risk. Curr Opin Pediatr 19, 565-9.

Hurtig, T., Ebeling, H., Jokelainen, J., Koivumaa-Honkanen, H. & Taanila, A. (2013). The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986. J Atten Disord.

Lee, S. S., Humphreys, K. L., Flory, K., Liu, R. & Glass, K. (2011). Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev 31, 328-41.

Sabuncuoglu, O. (2007). Traumatic dental injuries and attention-deficit/hyperactivity disorder: is there a link? Dent Traumatol 23, 137-42.

Schoenfelder, E. N., Faraone, S. V. & Kollins, S. H. (2014). Stimulant treatment of ADHD and cigarette smoking: a meta-analysis. Pediatrics 133, 1070-1080.

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