There’s a widespread view that attention-deficit hyperactivity disorder (ADHD) is grossly over-treated in kids, especially boys, and will eventually be outgrown. But the results of the first large, long-term population-based study, published recently in Pediatrics, suggest that couldn’t be further from the truth.
While other studies have indicated dire outcomes when children with ADHD grow up, most of these have been small and have focused on the severe end of the spectrum—for instance, boys referred to psychiatric treatment facilities. This new study, started at the Mayo Clinic and led by William Barbaresi, MD, looked at the general population of kids with ADHD and found a greater likelihood of their having other psychiatric disorders as adults, doing jail time or committing suicide.
“Only 37.5 percent of the children we contacted as adults were free of these really worrisome outcomes,” says Barbaresi, now at Boston Children’s Hospital. “That’s a sobering statistic that speaks to the need to greatly improve the long-term treatment of children with ADHD and provide a mechanism for treating them as adults.”
Barbaresi, lead Mayo Clinic investigator, Slavica Katusic, MD, and colleagues followed all children born in Rochester, Minn., from 1976 through 1982, who were still in Rochester at age 5, and whose families allowed access to their medical records. That amounted to 5,718 children.
Of these children, 367 were diagnosed with ADHD, and 232 of them took part in the follow-up study. About three-quarters had received treatment as children. Yet at follow-up:
- 29 percent still had ADHD as adults, diagnosed through structured neuropsychiatric interviews.
- 57 percent had at least one other psychiatric disorder as compared with 35 percent of controls. Most common were substance abuse/dependence, antisocial personality disorder, hypomanic episodes, generalized anxiety and major depression. That number was even higher—81 percent—in the children who still had ADHD as adults, versus 47 percent of those who no longer had ADHD.
- Seven children (1.9 percent) had died by the time of study recruitment, three of them from suicide. Of the 4,946 controls whose outcomes could be ascertained, only 37 children (0.01 percent) had died, five by suicide.
- 10 children with ADHD (2.7 percent) were incarcerated at the time of study recruitment.
Barbaresi thinks the study findings may actually underestimate the bad outcomes of childhood ADHD. The study population in Rochester, Minn., was relatively heterogeneous and largely middle class, and the children tended to have good educations and good access to health care. “One can argue that this is potentially a best-case scenario,” Barbaresi says. “Outcomes could be worse in socioeconomically challenged populations.”
But he feels that bad outcomes can be avoided. Parents of children with ADHD should seek high-quality treatment and have their kids stay in treatment as they enter adolescence—a time when many drift away.
“Data indicate that the stimulant medications used to treat ADHD in children are also effective in adults, although adults tend not to be treated and may not be aware they have ADHD,” Barbaresi says.
Pilot work for a portion of the study was funded by McNeil Pharmaceuticals, a fact cynics may use to discredit the findings. Over-diagnosis is a problem, but when it really is ADHD, treatment can help, and that doesn’t—and shouldn’t—exclusively mean drug treatment. Children should also be closely monitored for other conditions associated with ADHD, including substance use, depression and anxiety; and they should be assessed for learning disabilities, which commonly accompany ADHD, Barbaresi says. Unfortunately, insurance often doesn’t cover these neuropsychological assessments.
As for adults, Barbaresi tells me that many learn they have ADHD only when their child is diagnosed. There are some excellent resources to help them and their spouses live with the disorder—the website of CHADD (Children and Adults with Attention Deficit Disorder), the newly released book Fast Minds and adhdmarriage.com are just a few examples. Parents of kids should read this excellent advice from pediatrician/blogger Claire McCarthy, MD.