ADHD: From Cradle to Grave

ADHD is known to be associated with a wide array of comorbid psychiatric disorders and somatic diseases, which greatly influences both life quality and expectancy. Lately, some landmark studies have proven just how important, early intervention, diagnosis and medicinal treatment is for long-term outcome, life quality and life expectancy.


Summary

ADHD was considered for many years to be a disorder limited to childhood due to diminishing externalizing behaviors. However, as longitudinal studies have demonstrated, the symptoms remain clinically significant for the majority of ADHD patients well into adulthood (Weiss and Hechtman, 1993).

Recent evidence suggests that almost sixty-six percent (60%) of individuals diagnosed as children with ADHD, report at least one ADHD symptom causing clinically significant impairment during adulthood (Weiss et al., 2002).

Newly published papers on Estimated Life Expectancy (ELE) shows that ADHD shortens the ELE by 12.7 years (Barkley et al., 2018) and in a major review of ADHD across the lifespan, (Franke et al., 2018) it is made painstakingly clear just how influential treatment of ADHD across the lifespan is, to quality of life.

Earlier studies have shown that ADHD is associated with a 50% increase in mortality compared to the general public (Dalsgaard et al., 2015) and with 43% higher risk of childhood injuries as well as 45% more visits to the ER (Dalsgaard et al., 2015).


Introduction

ADHD is characterised by substantial comorbidity including substance use, depression, anxiety, and accidents. However, course and symptoms of the disorder and the comorbidities may fluctuate and change over time, and even age of onset in childhood has recently been questioned (Franke et al., 2018).

Available evidence to date is poor and largely inconsistent with regard to the predictors of persistence versus remittance. Likewise, the development of comorbid disorders cannot be foreseen early on, hampering preventive measures. These facts call for a lifespan perspective on ADHD from childhood to old age (Franke et al., 2018).

In this article, we summarise current knowledge of the long-term course of ADHD, with an emphasis on clinical symptom and cognitive trajectories, treatment effects over the lifespan, and the development of comorbidities. Also, we summarise current knowledge and important unresolved issues on biological factorsunderlying different ADHD trajectories. We conclude that a severe lack of knowledge on lifespan aspects in ADHD still exists for nearly every aspect reviewed (Franke et al., 2018).


Defining ADHD

Attention-deficit/hyperactivity disorder (ADHD) is highly heritable and the most common neurodevelopmental disorder in childhood. In recent decades, it has been appreciated that in a substantial number of cases the disorder does not remit in puberty, but persists into adulthood. (Franke et al., 2018).

The clinical disorder is defined by age-inappropriate levels of inattention and/or hyperactivity-impulsivity interfering with normal development, or functioning, of a person. ADHD is a common neuropsychiatric disorder defined by a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development (American Psychiatric Association [APA], 2013).

Although ADHD carries the stigma of being a consequence of modern lifestyle, the first mentioning of the syndrome dates back to the late 18th century where we find the first mentioning of the symptomatology of ADHD as seen in literature dating as far back as the German Melchior Adam Weikard in 1775 (Faraone et al., 2015) and the first systematic studies of ADHD focused on school-aged boys (Still, 1902).

Later, it was recognised that many girls have similar problems – yet often remain unrecognised and, consequently, undiagnosed, and that symptoms persist into adulthood in the majority of cases, with worldwide prevalence estimates of ADHD around 2.5% to 3% in the adult population (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007Simon, Czobor, Balint, Meszaros, & Bitter, 2009).

During the past decades, it has been demonstrated that ADHD is common in all countries studied (Fayyad et al., 2017Polanczyk et al., 2014), and that it seriously affects the productivity, life expectancy, and quality of life throughout the lifespan of patients (Erskine et al., 2013).

Importantly, it took until the late 20th. century before it could convincingly be shown that ADHD also exists in adults, and that continuity exists from childhood to adulthood (Wood et al., 1976) calling for a lifespan perspective on the disorder, embracing clinical course and presentation as well as according research on the underlying neurobiology.


Diagnosing ADHD

In addition to the core clinical symptoms of ADHD, psychiatric and non-psychiatric coexisting problems and clinical conditions have been described in ADHD patients (Angold, Costello, & Erkanli, 1999). In particular, psychiatric comorbid conditions are recognized in both children and adults, and pose considerable clinical and public health challenges (Angold et al., 1999Halmoy et al., 2010). Recognition of medical/somatic conditions is also a key component in the routine clinical assessment of psychiatric patients. Failure to diagnose medical conditions can lead to misdiagnosis or incorrect treatment, with potentially serious consequences.

According to the current diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5APA, 2013), the diagnosis of ADHD is only considered appropriate if the disturbance is not judged to be the direct pathophysiological consequence of a specific medical condition (e.g., multiple sclerosis, stroke, hypothyroidism). However, in the ICD-10 version of the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992), it is also emphasized that psychiatric syndromes may be causally related to cerebral and systemic diseases, and that proper diagnosis will require two codes: one for the psychopathological syndrome and the other for the underlying disorder. Compared with the extensive descriptions of psychiatric comorbidity, somatic comorbidity in ADHD has received less attention in the research literature, particularly among adults. This discrepancy is obvious in the recent diagnostic definition of ADHD (APA, 2013), where many psychiatric disorders are listed either as possible differential diagnoses or as comorbid conditions. The only non-psychiatric disorder specifically mentioned is medication-induced symptoms of ADHD. Associated medical conditions have been studied more in other psychiatric disorders, where they are also considered to contribute to a lower quality of life and reduced life expectancy.


WHO’s upcoming International Classification of Diseases and Related Health Problems (ICD-11, WHO, 2020) states that ADHD is defined as;

Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood.

The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age and level of intellectual functioning and significantly interferes with academic, occupational, or social functioning.

Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of stimulation or frequent rewards, distractibility and problems with organization. Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in structured situations that require behavioural self-control. Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of the risks and consequences.

The relative balance and the specific manifestations of inattentive and hyperactive-impulsive characteristics varies across individuals, and may change over the course of development. In order for a diagnosis of disorder the behaviour pattern must be clearly observable in more than one setting. ICD-11 (WHO, 2020)


In schizophrenia, it is known that weight gain, diabetes, metabolic syndrome, and cardiovascular disease are common, and it is speculated that a shared vulnerability for psychosis and medical conditions can explain some of this comorbidity (Ringen, Engh, Birkenaes, Dieset, & Andreassen, 2014).

Population-based prospective studies have documented an increased risk of premature death and reduced life expectancy also for ADHD patients (Dalsgaard, Ostergaard, Leckman, Mortensen, & Pedersen, 2015), but it is unclear if this risk is mediated by coexisting medical diseases.

Franke B. et al. 2018

Treating ADHD

A majority of school-aged children and adolescents with ADHD received medication treatment and school supports, whereas fewer received recommended psychosocial interventions (Danielson ML., et al., 2017).

Efforts to increase access to psychosocial treatments may help close gaps in service use by groups currently less likely to receive treatment, which is important to ensure that the millions of school-aged US children diagnosed with ADHD receive quality treatment (Danielson ML., et al., 2017).

Medication treatment and parent- and teacher-delivered behavior therapy are evidence-based strategies for ADHD treatment; behavior therapy is recommended as the first-line treatment for children younger than 6 years, whereas combination therapy (behavior therapy and medication treatment) is recommended for children aged 6–11 years and preferred for children aged 12 years and older (Danielson ML., et al., 2017).

A previous study of national parent survey data indicated that less than one-half of children with current ADHD (44%) received behavior therapy within the past year, whereas 74% received medication in the past week, with differences in treatment receipt by demographic factors such as age, race/ethnicity, and poverty status (Danielson ML., et al., 2017).

However, these data did not allow for estimates by particular type of behavioral intervention (eg, peer interventions, parent training, school-based treatments), specifically forms that have empirical support as ADHD treatment (Danielson ML., et al., 2017).

Other studies have shown trends in psychotherapy use relative to medication usage among children with ADHD, though there is limited published information available regarding specific types of psychological treatment received by children and adolescents with ADHD in the community (Danielson ML., et al., 2017).

Treatment rates varied independently by child age, race, ethnicity, socioeconomic status, and health insurance status but were similar across child sex and primary language in the home (Danielson ML., et al., 2017).

Younger children and those who had received the ADHD diagnosis at a younger age were generally more likely to receive each type of treatment, suggesting a potential gap in services for adolescents and children diagnosed at older ages, particularly for lifetime receipt of psychosocial treatment (Danielson ML., et al., 2017).

Similar to prior investigations, Hispanic children were less likely to receive medication than non-Hispanic children, possibly attributable to cultural attitudes toward ADHD medication use. Interestingly, black children and those from families with lower socioeconomic status were more likely to have received peer interventions and CBT, perhaps as a function of public insurance coverage (Danielson ML., et al., 2017).

Not surprisingly, treatment rates were highest for children with severe ADHD, although approximately 20% of children with severe symptoms did not currently receive medication or school supports and more than one-quarter had never received psychosocial treatment (Danielson ML., et al., 2017).

Receipt of care in a medical home was associated with lower rates of psychosocial treatment and school supports, potentially because of the previously documented inverse relationship of having a medical home and severity of condition; children without a medical home were more likely to have severe or multiple behavioral health conditions (Danielson ML., et al., 2017).

Children with severe ADHD have more complex healthcare needs than children with milder ADHD and may benefit more from having patient-centered, comprehensive, and coordinated care, yet these are the children with ADHD least likely to have a medical home (Danielson ML., et al., 2017).

Franke B. et al., 2018

In 2018, a large consortium of international scientists finally succeeded in discovering the first genome-wide significant risk loci for ADHD (Demontis D. et al., 2018), that contains ADHD-related genes and this along with another landmark discovery of how the dopamine system in the brain works (Vendelboe et al., 2016), makes a promising outlook on treatment of ADHD in the short-term future.

During a meeting with Dr. Russell A. Barkley, PhD. in Copenhagen in November 2018, I was explained, that there is now scientific evidence supporting that long-term medicinal treatment, in 15% of all cases where medication was administered from early childhood and continuously up through adolescence and early adulthood, had made permanent changes within the neuronal networks in the brain (due to plasticity) which normalised the functioning of the person with ADHD, so that the symptoms causing impairments had subsided and the person no longer met the diagnostic criteria for ADHD – in short – they no longer had ADHD.

Peter ‘ADDspeaker’ Vang (venstre), and Dr. Russell A. Barkley, Ph.D. (højre)

Conclusion

ADHD is something which we are born with. It stems from biological causes and needs early intervention, long-term medicinal treatment combined with psychosocial support, and guidance in living a healthy lifestyle.

With the peer-reviewed, scientific evidence, which I have provided in this article, it is clear that ADHD is treatable, with immediate positive results on cognitive and social functioning as well as long-term positive results for Estimated Life Expectancy and Quality of Life.

It is also very obvious that not following these suggested guidelines, will, note not may but will, result in severe reduction in Quality of Life and most likely will shorten the Estimated Life Expectancy with 12.7 years, if you are not dead already due to accidents, addiction, violence, suicide or physical comorbid disorders and/or diseases!

When the mortality rate of people with ADHD is 50% higher than the general public, and the children are 43% more prone to accidents in childhood, combined with the increased risk of traffic accidents, addiction disorders (alcohol, drugs, smoking, gambling, gaming, hyper sexuality), crime (violence, imprisonment, death), and comorbid disorders (anxiety, depression, PTSD, Diabetes Type-2, Thyroid Disorders, Asthma and Allergies, Obesity, Dental Trauma, Crohn’s Disease, IBS and cardiovascular risk factors (not related to ADHD-medication), it do not take a genius to see that we can treat ADHD much more effective and efficient, if we can convince the public opinion that ADHD-medication is not dangerous, addictive or cause long-term side effects, and have them understand that ADHD is a biological rooted disorder, not a behavioural personality disorder, then maybe we can save the coming generations from ending up like myself;

Now 47 years old, unemployed since age 40, suffering from untreated ADHD from birth to age 40, diagnosed with ADHD, Autism, Anxiety, Depression, Diabetes Type-2, Dental Trauma and Obesity …

ADDspeaker

References

ADHD-Europe: 2018 ADHD Awareness Month Promo

Danielson ML et al., (2017)
A National Description of Treatment among United States Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. 
J Pediatr. 2017;192:240-246.e1.
https://www.ncbi.nlm.nih.gov/pubmed/29132817

OBJECTIVE: To characterize lifetime and current rates of attention-deficit/hyperactivity disorder (ADHD) treatments among US children and  adolescents with current ADHD and describe the association of these treatments with demographic and clinical factors.
STUDY DESIGN: Data are from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome, a follow-back survey of parents from the 2011-2012 National Survey of Children's Health. Weighted analyses focused on receipt of ADHD treatment among children aged 4-17 years with current ADHD (n = 2495) by 4 treatment types: medication, school supports, psychosocial interventions, and alternative treatments.
RESULTS: Medication and school supports were the most common treatments received, with two-thirds of children and adolescents with ADHD currently receiving each treatment. Social skills training was the most common psychosocial treatment ever received (39%), followed by parent training (31%), peer intervention (30%), and cognitive behavioral therapy (20%). Among alternative treatments, 9% were currently taking dietary supplements, and 11% had ever received neurofeedback. Most children (67%) had received at least 2 of the following: current medication treatment, current school supports, or lifetime psychosocial treatment; 7% had received none of these 3 treatment types.
CONCLUSIONS: A majority of school-aged children and adolescents with ADHD received medication treatment and school supports, whereas fewer received recommended psychosocial interventions. Efforts to increase access to psychosocial treatments may help close gaps in service use by groups currently less likely to receive treatment, which is important to ensure that the millions of school-aged US children diagnosed with ADHD receive quality treatment.

Barkley R. A., et al. (2018)
Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. J Atten Disord. 2018 Dec 10.
https://doi: 10.1177/1087054718816164

Childhood ADHD-C was associated with a 9.5-year reduction in healthy ELE, and a 8.4-year reduction in total ELE relative to control children by adulthood. The persistence of ADHD to adulthood was linked to a 12.7-year reduction in ELE. Several background traits accounted for more than 39% of variation in ELE.Childhood ADHD-C was associated with a 9.5-year reduction in healthy ELE, and a 8.4-year reduction in total ELE relative to control children by adulthood. The persistence of ADHD to adulthood was linked to a 12.7-year reduction in ELE. Several background traits accounted for more than 39% of variation in ELE.

Barkley, R. A. (1997)
Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD.
Psychological Bulletin, 121(1), 65-94.
http://dx.doi.org/10.1037/0033-2909.121.1.65

Attention deficit hyperactivity disorder (ADHD) comprises a deficit in behavioral inhibition. A theoretical model is constructed that links inhibition to 4 executive neuropsychological functions that appear to depend on it for their effective execution: (a) working memory, (b) self-regulation of affect-motivation-arousal, (c) internalization of speech, and (d) reconstitution (behavioral analysis and synthesis). Extended to ADHD, the model predicts that ADHD should be associated with secondary impairments in these 4 executive abilities and the motor control they afford. The author reviews evidence for each of these domains of functioning and finds it to be strongest for deficits in behavioral inhibition, working memory, regulation of motivation, and motor control in those with ADHD. Although the model is promising as a potential theory of self-control and ADHD, far more research is required to evaluate its merits and the many predictions it makes about ADHD.

Instanes, J. T., et al. (2018)
Adult ADHD and Comorbid Somatic Disease: A Systematic Literature Review. Journal of Attention Disorders, 22(3), 203–228. https://doi.org/10.1177/1087054716669589

Objective: To systematically review, synthesize, and appraise available evidence, connecting adult ADHD with somatic disease. Method: Embase, Psychinfo, and Medline databases were searched for studies published from 1994 to 2015 addressing adult ADHD and somatic comorbidity. Somatic conditions were classified according to International Classification of Diseases (ICD-10) codes. Levels of evidence were graded as inconclusive, tentative, or well documented. Results: Most of the 126 studies included in the qualitative synthesis were small and of modest quality. Obesity, sleep disorders, and asthma were well-documented comorbidities in adult ADHD. Tentative evidence was found for an association between adult ADHD and migraine and celiac disease. In a large health registry study, cardiovascular disease was not associated with adult ADHD. Conclusion: There are few large systematic studies using standardized diagnostic criteria evaluating adult ADHD and somatic comorbidities. Significant associations are found between adult ADHD and several somatic diseases, and these are important to consider when assessing and treating either adult ADHD or the somatic diseases.

Franke B et al. (2018)
Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan.
Eur Neuropsychopharmacol. 2018 Oct;28(10):1059-1088. Epub 2018 Sep 6. Review. doi.: 10.1016/j.euroneuro.2018.08.001. https://www.ncbi.nlm.nih.gov/pubmed/30195575

Attention-deficit/hyperactivity disorder (ADHD) is highly heritable and the most  common neurodevelopmental disorder in childhood. In recent decades, it has been appreciated that in a substantial number of cases the disorder does not remit in  puberty, but persists into adulthood. Both in childhood and adulthood, ADHD is characterised by substantial comorbidity including substance use, depression, anxiety, and accidents. However, course and symptoms of the disorder and the comorbidities may fluctuate and change over time, and even age of onset in childhood has recently been questioned. Available evidence to date is poor and largely inconsistent with regard to the predictors of persistence versus remittance. Likewise, the development of comorbid disorders cannot be foreseen early on, hampering preventive measures. These facts call for a lifespan perspective on ADHD from childhood to old age. In this selective review, we summarise current knowledge of the long-term course of ADHD, with an emphasis on  clinical symptom and cognitive trajectories, treatment effects over the lifespan, and the development of comorbidities. Also, we summarise current knowledge and important unresolved issues on biological factors underlying different ADHD trajectories. We conclude that a severe lack of knowledge on lifespan aspects in  ADHD still exists for nearly every aspect reviewed. We encourage large-scale research efforts to overcome those knowledge gaps through appropriately granular  longitudinal studies.

 

Dalsgaard S. et al., 2015
Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study.
Lancet. 2015 May 30;385(9983):2190-6. doi: 10.1016/S0140-6736(14)61684-6. Epub 2015 Feb 26.
https://www.ncbi.nlm.nih.gov/pubmed/25726514

ADHD was associated with significantly increased mortality rates. People diagnosed with ADHD in adulthood had a higher MRR than did those diagnosed in childhood and adolescence. Comorbid oppositional defiant disorder, conduct disorder, and substance use disorder increased the MRR even further. However, when adjusted for these comorbidities, ADHD remained associated with excess mortality, with higher MRRs in girls and women with ADHD than in boys and men with ADHD. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents.

Dalsgaard S. et al. 2015
Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study.
Lancet Psychiatry. 2015 Aug;2(8):702-709. doi: 10.1016/S2215-0366(15)00271-0. Epub 2015 Jul 22.
https://www.ncbi.nlm.nih.gov/pubmed/26249301

Children with ADHD had an increased risk of injuries compared with other children. Treatment with ADHD drugs reduced the risk of injuries by up to 43% and emergency ward visits by up to 45% in children with ADHD. Taken together with previous findings of accidents being the most common cause of death in individuals with ADHD, these results are of major public health importance.