Why We Must Treat ADHD
Do you believe that Attention-Deficit/Hyperactivity Disorder (ADHD) is a significant medical disorder and/or public health issue? Or, do you think that the disorder is over diagnosed and overtreated? In 2012 focus groups with parents of children with ADHD at a large U.S. northeastern suburban teaching hospital found that parents showed a great deal of ambivalence about placing their child on medication. Parents “faced significant family pressures to avoid medication, experienced guilt and concern that their child required medication, and held distorted ideas about treatment risks.” This is not surprising given that many people are not aware of the extensive body of science that underlies both the diagnosis and treatment of ADHD. In 2021, the World Federation of ADHD issued an International Consensus Statement which laid out the serious consequences of ADHD and imperatives of treatment.
Large-scale population studies in Denmark, Taiwan and Sweden involving millions of people showed that ADHD is associated with an increased risk of premature death, usually due to suicide and accidents. A Taiwanese study of over 50,000 showed youth with ADHD to have a greater than 70% increased risk of accidental burn injuries. High school athletes with ADHD are three times more likely to suffer a concussion. A meta-analysis of 16 studies encompassing over 175,000 people showed that those with ADHD were 23% more likely to be involved in automobile accidents. Youth and young adults with ADHD are far more likely to engage in criminal behavior, with this risk compounded if they have associated behavioral or psychiatric disorders. People with ADHD are at greater risk for developing video gaming addiction. People with ADHD fail to finish high school, do not complete college, and tend to be under employed and unemployed relative to peers matched for all the relevant psychosocial factors. The World Federation of ADHD estimated the annual economic losses due to ADHD to be in the billions of dollars, worldwide.
What are the real-world impacts of ADHD treatment? The emergence of “Big Data” is a useful way to address this question. Electronic Health Records can be linked to other databases regarding health status, criminal behavior, educational status, and driving and financial records. This enables data scientists to look at the health and social outcome of millions of people with ADHD and the impact of medication treatment. Paul Lichtenstein and colleagues at Karolinska Institute obtained information on 25,656 patients with ADHD along with records of their pharmacologic treatment and subsequent criminal convictions during the period 2006-2009. The authors compared the rate of criminal convictions during the periods the individuals were receiving ADHD medication with the rate while they were not receiving the medication. Compared to periods when the individuals with ADHD were not on medication, there was a reduction of 32% in criminality for men and 41% for women while on treatment. These reductions were found across all types of crime, whether violent, property or drug related.
People with ADHD are far more likely to use substances than those without ADHD, and there has been debate over the years as to the impact of treating children with ADHD with stimulants on future substance use. Does exposing children to controlled substances, such as methylphenidate and amphetamine, potentially set them up for future substance us? Commercial healthcare claims from nearly 3 million ADHD patients were examined over the period 2005-2014. They compared the risk of substance-related events during the months in which the patients received medication relative to the months when they did not. Strikingly, men with ADHD had 35% lower odds of substance-related events when taking medication; female patients’ odds of such events were 31% lower. The authors concluded, “these results provide evidence that receiving ADHD medication is unlikely to be associated with greater risk of substance related problems in adolescence or adulthood. Rather, medication was associated with concurrent lower risk of substance related events.”
Treatment of ADHD with medication appears to be associated with several improvements in the health of ADHD individuals. A study of over 7,500 Taiwanese adolescents with ADHD and 30,000 controls found that long-term use of ADHD medication was associated with a 30% reduction in teenage pregnancy. Another Taiwanese study found that treatment of ADHD with medication was associated with a 30% reduction in sexually transmitted infections among males. There is a very strong effect of ADHD medication treatment on reduction in injury rates. Big data studies in Denmark, Sweden, Taiwan, and Hong Kong involving over 300,000 people all consistently showed that when individuals with ADHD were on their medication, they had reduced rates of fractures and injury by burns. Studies in the U.S. and Sweden found reductions in the number of motor vehicle accidents of 38-43% and 58%, respectively when patients were on medication compared to when they were not. Treatment of ADHD actually improves life expectancy. A study using Taiwan’s National Health Insurance Research Database identified over 68,000 individuals with ADHD who were prescribed medication and compared them with an identical number who were not treated. People with ADHD who were treated with medication had a one-fifth lower rate of all-cause mortality than individuals not treated. Another 2023 study showed that treating ADHD results in a reduced risk of child abuse for the child with ADHD.
Does treatment of ADHD improves school performance? In 2019, a group led by Andreas Jangmo at the Karolinska Institute integrated measures of school performance with prescriptions of ADHD medication. They found that a larger proportion of students with ADHD graduated later than expected and were less likely to qualify for admission to college level classes. Students who remained on ADHD medication for 15 months or longer showed a 30% increase in their GPA. Treatment of ADHD with medication reduced the rate of ineligibility for admission to a college level program by 50%.
Is ADHD overtreated or undertreated? The National Survey of Children’s Health (NSCH) estimates) that the prevalence of ADHD in US children is about 10%, and prevalence of treatment of ADHD in children ranges from less than 8% in Western states and more than 15% in the Deep South and Appalachia. Much of this treatment is very short lived or may not have occurred at all, as this study is based on parent recall. In the national Adolescent Brain and Cognitive Development (ABCD) Study used direct interviews of parents and children to determine rates of treatment; only 13% were currently receiving medication and 26% of children with ADHD had never been treated. Thus for children, undertreatment of ADHD is a significant health problem, one worsened by the recent ADHD medication shortages. Moreover, for five decades the safety of medication for ADHD has been researched. Examining these extensive studies, the World Federation of ADHD’s Consensus Statement concluded, “the adverse effects of medication for ADHD are typically mild and can be addressed by changing the dose or the medication.”
We could have many discussions of the best practices for treating ADHD, including which non-medication interventions are beneficial, but it is very clear that medication is the mainstay of ADHD intervention. This is why manufacturing shortages of stimulants, insurance barriers and misinformation regarding supposed harms of ADHD treatment will worsen outcomes for those with ADHD and shorten their lifespans. Health professionals and the media should also treat ADHD like any other medical disorder, thus ensuring that the benefits of treatment of ADHD are better known by patients and their families.
Future issues will focus on controversies over adult ADHD as well as a realistic discussion of the risks around ADHD medications which, in fact, no greater than medications used for other common medical conditions.