Attention-deficit/hyperactivity disorder and adverse health outcomes
Highlights
► Health-related outcomes of ADHD are not well understood. ► ADHD is associated with elevated morbidity and mortality. ► ADHD is related to obesity but prospective data are lacking. ► ADHD is associated with elevated risk of accidental injury. ► Research on interventions targeting secondary health correlates of ADHD is necessary.
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by a pattern of severe inattention–disorganization and/or hyperactivity–impulsivity beyond that observed in individuals at a comparable level of development (American Psychiatric Association, 2000). Worldwide, prevalence is estimated at about 5% for children (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007) and 2.5% for adults (Simon, Czobor, Balint, Meszaros, & Bitter, 2009). For a diagnosis of ADHD, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) required that symptoms must cause impairment.
It is important to note that impairment is not the same thing as severity, at least conceptually. Severity can be thought of as the intensity or frequency of symptoms, whereas impairment is the consequence of those symptoms. Depending on the degree of support in the environment, even a severe condition might bring very little impairment. That said, untangling severity from impairment in practice is notoriously difficult. Scheduled for released in 2013, DSM-5 will likely reflect an enhanced effort to distinguish disorder (and severity) from impairment to some extent, but impairment must still be evaluated (American Psychiatric Association, 2012a, American Psychiatric Association, 2012b). The consideration of physical health outcomes of ADHD may assist in this regard, as these are outcomes that are conceptually quite different from the core symptoms of ADHD. As context, this article briefly comments on key areas of impairment that are already well-documented or else beyond the scope of this review, then explores the relatively new area of ADHD-related physical health impairments and physical health outcomes.
Clinicians are increasingly evaluating ADHD symptoms in adults, but because the DSM-IV criteria were developed primarily for children, ADHD symptoms in adults present additional clinical and conceptual challenges (Adler, Shaw, Sitt, Maya, & Morrill, 2009). Whereas childhood hyperactive behaviors may subside in intensity with age or may be replaced by restlessness, which is difficult to quantify, characteristics such as inattentiveness, organizational (executive) dysfunction, and impulsivity often persist (Adler and Chua, 2002, Barkley, Murphy and Fischer, 2008, Gallagher and Blader, 2001). Although health issues for children and adults are quite different, the literature is sufficiently small that studies of both children and adults were surveyed here.
Insights about ADHD can include study of the diagnosis of ADHD, or of population patterns of the correlates of inattention, impulsivity, and hyperactivity. Because ADHD appears to be an extreme of a continuously varying trait in the population, studies of symptomatic variation are considered to be informative about etiology and risk/morbidity even in the absence of formal diagnosis. This is important because establishing formal diagnosis of ADHD by research criteria in large populations is very costly and thus rarely done. However, studies of symptom variation in the population are also limited by the fact that the universe of influences on symptoms of inattention may be broader than the influences on ADHD itself. That is, ADHD diagnosis requires ruling out many of the known health influences on inattention. This review considers studies of both dimensional and categorical diagnosis, highlighting whenever these approaches do not converge.
It also is crucial to recognize that ADHD is often associated with comorbid psychiatric disorders that may be independently associated with impairment. Oppositional defiant disorder and conduct disorder, in particular, are commonly comorbid with ADHD (Barkley, 2002). In adolescents and adults, mood disorders (Baron, 2007) and substance use problems can complicate the picture (Baron, 2007, Goodman, 2007). Relatedly, ADHD's varying severity and comorbidity results in widely varying course of treatment for different individuals; further, many individuals discontinue treatment in adolescence and adulthood just as many health risks take hold. Thus, both clinically and scientifically, it is often difficult to be certain of the specificity of impairment to ADHD, and to foreshadow the conclusions, one important area of research is to try to identify component functional domains of ADHD and other disorders, as well as course and treatment moderators, that mediate and moderate particular health outcomes.
Section snippets
Well documented impairments and conditions
Several well documented associated problems and/or impairments warrant brief mention here, both to set the stage for the new domain of health impairments but also because any interpretation of health impairments ultimately has to consider the potential interplay of ADHD and associated problems with outcome.
First, cognitive and emotional problems are well documented in ADHD. ADHD is associated, at least at a group level, with reduced executive functions (e.g., working memory, response
Context for health outcomes in ADHD
Turning to health problems per se, it has been suggested that the early treatment of primary psychiatric conditions may prevent the development of future disorders (Hazell, 2007). Indeed, ADHD is usually the first of the several comorbid psychiatric disorders to emerge during development (Mannuzza, Klein, Abikoff, & Moulton, 2004), suggesting that it may be a risk condition that often can progress to antisocial behavior, substance use disorders and, in some instances, mood disorders and other
Methods
Although this is a selective review intended to illustrate new directions for investigation, the following literature search strategy was undertaken to ensure that the literature was adequately surveyed. Electronic searches were performed in PubMed using the base terms “ADHD” or “attention deficit hyperactivity disorder” and the following limits: “humans, clinical trial, meta-analysis, practice guideline, randomized controlled trial, review, English.” Electronic searches were also performed in
Smoking and substance use
Substance use disorders and smoking (cigarette use) are health outcomes that are well recognized to co-occur with ADHD. Based on a recent meta-analysis, about one in four substance dependent patients had or have ADHD (van Emmerik-van Oortmerssen et al., 2012). Two recent meta-analyses (Charach et al., 2011, Lee et al., 2011) focused on prospective cohort studies that directly address the question of future risk posed by having ADHD. I therefore simply note those results and add brief caveats
Conclusion
By virtue of its standing as an early onset, developmental condition that is often persistent, ADHD may be understood as an important gateway not only to psychiatric comorbidity and poor life outcome but to at least some poor health outcomes as well. As trends in health change, risks associated with ADHD may also evolve further. In particular, the findings for obesity, although still in need of causal evaluation, may open new questions about etiology and early developmental influences. In
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