More adults are diagnosed with attention-deficit/hyperactivity disorder

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Adults with attention-deficit/hyperactivity disorder die earlier than their counterparts in the general population, according to a recent study. At the same time, health care providers are diagnosing a growing number of adults with ADHD.

For help understanding what's going on. I'm talking with an expert ADHD researcher from Upstate, Dr. Stephen Faraone. He's a Distinguished Professor of psychiatry and behavioral sciences.

Welcome back to "The Informed Patient," Dr. Faraone.

Stephen Faraone, PhD: Happy to be here, Amber.

Host Amber Smith: This study about life expectancy is from the British Journal of Psychiatry.

Can you tell us about it?

Stephen Faraone, PhD: Yes. It's a study of 3,000 people in the United Kingdom where the researchers had access to their medical record data and their diagnosis of ADHD. And they did what several other researchers have done around the world. They looked at mortality, dying, and they found, as some other people have, that people who have ADHD have an increased risk for dying younger, compared to people who don't.

In the British study, it was about an average, I think, seven years earlier for men, and nine years earlier for women.

Host Amber Smith: So do you think similar results would be found if we looked at this in the U.S. population?

Stephen Faraone, PhD: In fact, similar results have already been found in the U.S. population. There's at least, I think there've been, four studies in the United States that looked at mortality in people with ADHD, and all of them except one found the same thing the British, my group, found: that if you have ADHD you're at higher risk for dying.

And in fact, there've been studies around the world, studies in Denmark, studies in Taiwan, other countries around the world, and these studies were recently pooled together in what's called a meta-analysis, where all the studies got put together in the same paper, to see what they say as a group.

And this meta-analysis concluded that not only was there an increased risk for mortality in ADHD, but it was essentially the same in males and females. So both males and females with ADHD are at increased risk.

Host Amber Smith: Well, let's talk about the possible reasons for that. What are the health risks associated with an ADHD diagnosis?

Stephen Faraone, PhD: So this is really interesting, Amber, because, the first thing I'll tell you is that in the meta-analysis, what they found was that the increased premature deaths in people with ADHD were due to accidental injuries or unnatural causes, not natural causes.

That's pretty interesting. It means that people with ADHD we know are at increased risk for accidents. Kids who are impulsive run into the street, chasing a ball, and maybe get hit by a car. Adults who are driving and have ADHD, not being attentive, can get into an accident. So these accidental causes certainly account for some of these deaths.

We also know there's increased risk for suicide among people with ADHD, and that's another reason for the increased mortality. Now, I was surprised that natural causes of death, meaning people dying from diseases like cardiovascular disease, diabetes, et cetera, were not increased in people with ADHD, because ADHD does carry with it an increased risk for a variety of disorders, including cardiometabolic disorders like diabetes.

Host Amber Smith: But people with ADHD are not dying in higher numbers because of that.

Stephen Faraone, PhD: Correct. They're not dying in higher numbers because of that. And that's, good news. It means, probably, that when they occur, their medical disorders are being appropriately treated.

Host Amber Smith: So are there things the healthcare system could do better that would help lengthen the lifespans of adults with ADHD?

Stephen Faraone, PhD: Essentially, treatment is what is needed. There's at least one study that shows that people with ADHD who are treated for their disorder are less likely to die young than people with ADHD who are not treated, and we know they're less likely to have accidents.

So it's very clear that the No. 1 thing that can be done is that people with ADHD are identified by the health care system, and they're appropriately treated with the current medications and therapies that we have available for them.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Upstate psychologist and ADHD researcher Dr. Stephen Faraone about attention-deficit/hyperactivity disorder.

We talked about life expectancy with this diagnosis, and now I'd like to ask you about an increase in first-time ADHD diagnoses among adults 30 and older.

A health care data and analytics company reports that the rate of first-time diagnoses rose about 61% among people aged 30 to 44 and 64% among people aged 45 to 64.

This was from a database of 30 health systems that included more than a million people who were diagnosed. Do you think this would hold true across the general population?

Stephen Faraone, PhD: I think it does. In fact, there were data that were published last year by our Centers for Disease Control, and they show the same thing.

There's been over the last number of years, few years, a gradual increase in the diagnosis of ADHD in adults. The good news is that the diagnostic rates are approaching the expected population rate. We know from population studies, where an epidemiologist goes out and knocks on doors and interviews people, that the true prevalence, if you will, of ADHD in the population is roughly 5%-6%.

The CDC rates are now approaching that level. and what's even more interesting is that the greatest increase in diagnoses we're seeing now is for females and not males. And the reason for that is because there is an under-diagnosis of girls at younger ages. Many children, adolescents with ADHD, even in their 20s, you're less likely to be diagnosed with ADHD if you're female than if you're male.

That switches when you're older. When you're older, females are more likely to be diagnosed than males.

Are you seeing more adults asking if they have ADHD, thinking that they've got some symptoms and maybe ought to be diagnosed? If we kind of rewind back to the 1990s, when I first started studying adult ADHD, back then, many people believed that ADHD disappeared in adulthood.

In fact, I had to write a paper that basically showed that that was wrong. There was a paper published in the American Journal of Psychiatry that said ADHD disappeared in adulthood. That was wrong. I knew that was wrong from my own clinical experience and research and published a paper that basically showed that it was wrong, that children with ADHD grow up; roughly two-thirds continued to have ADHD into adulthood.

So we know that ADHD in adulthood is real. What's happened is that because many people, including myself, have done lots of work studying adult AdHD from many perspectives, including treatment, genetics, neuroimaging, it's now very clear that it's a valid diagnosis to make in adults.

It takes a long time for that information to seep into the population, and also into the population of health care providers. But now it seems that most, if not many, health care providers know about this, and they're starting to diagnose and treat the disorder.

Host Amber Smith: So these adults that are diagnosed with ADHD now, were they just never diagnosed as children or do these ADHD symptoms just emerge later in life in some people?

Stephen Faraone, PhD: So what happens is that there are different kinds of ADHD in adulthood. There are some adults who have had ADHD since childhood and it was identified, treated, and so forth, and by adulthood, they continue to be treated.

There's another group of adults that had ADHD in childhood. They clearly had it from taking their history, but they just weren't treated. Those tend to be the females because girls with ADHD are, primarily inattentive, whereas boys with ADHD are more likely to be hyperactive, impulsive and very disruptive.

So when you're a child, you get referred to mental health (providers) if you cause problems for other people. If you're an adult, you refer yourself when you're feeling that you have problems. So when the girls grow up, they realize that, "Hey, I've got a problem. I'm going to refer myself for treatment."

Host Amber Smith: So do you think ADHD is overdiagnosed or underdiagnosed?

Stephen Faraone, PhD: I think neither is true. I think that for any medical disorder, sometimes people overdiagnose, certain doctors might overdiagnose it, certain doctors might underdiagnose it. What people need to understand: that ADHD, when you think of it as a disorder, it's very much like hypertension (high blood pressure) or obesity, or hypercholesterolemia, high cholesterol levels.

Everybody has a blood pressure. Everybody has a cholesterol level, and doctors have to decide: Where's that cut point where I decide to treat somebody? And that cut point, we have it clearly defined in our diagnostic manuals, but sometimes somebody comes in, an adult with ADHD, for example, might come in, and they might not quite meet the diagnostic criteria.

It's sort of like someone who has sub-threshold hypertension. They don't really meet the criteria for hypertension, but the doctor might decide to treat the hypertension because of other reasons. And so sometimes when people say there's overdiagnosis, they're referring to people who basically have lots of ADHD symptoms and are impaired. They just don't meet the full diagnostic criteria by the book. I think it's wrong to call it overdiagnosis because in many cases that's simply a physician or a nurse practitioner or a psychologist doing the right thing for the patient.

Host Amber Smith: I see. So what are the most common symptoms for adults? And that's going to differ between women and men, right?

Stephen Faraone, PhD: Well, actually the symptom complex does differ. What happens, though, is that in childhood, the three sets of symptoms for ADHD are inattention, impulsivity and hyperactivity. And they're all very apparent in childhood. Although with girls, they tend to be more, mostly inattentive. As children with ADHD age, what happens is that the symptoms of hyperactivity/impulsivity tend to attenuate.

So for example, a child with ADHD might be running around climbing on furniture, really being super hyperactive and disruptive because of it. Adults with ADHD don't run around and climb on furniture, but they do experience other effects of hyperactivity, such as they don't like sitting still.

So an adult with ADHD, for example, doesn't like to be in a conference room for an hour or two, just sitting still in the chair. And all of us who have been in conferences where we have to sit for a while, there are some people that just get up and pace around. I'm not saying they all have ADHD, but they might because that's a typical response of a person with ADHD.

Now, in adulthood, yes, the women tend to continue to be more attentive, but the men also tend to be more attentive as well. And so some of us have argued that in adulthood, we should also consider other symptoms or other features of ADHD that are not officially diagnostic, such as difficulties with regulating one's emotions.

That's currently under debate. And it may end up being in a future diagnostic manual.

Host Amber Smith: If children are diagnosed with ADHD early, as kids, can they be treated so that they're not experiencing symptoms of ADHD as adults, or is it a lifelong treatment that they are on?

Stephen Faraone, PhD: It differs for different kids. Some children who were treated will continue to have some symptoms, but the treatment will help them. But it won't help them completely. Those are the more severe cases of ADHD, and they will likely need lifelong treatment.

Other children with ADHD will remit their symptoms, and they won't need lifelong treatment.

And that's why sometimes in adolescence and young adulthood, the treatments will stop for a while. The doctor will say, let's stop treatment for a few weeks or a month, see how you're doing. Because the ADHD itself may have remitted.

there's some evidence that the kids who remit their ADHD are more likely to have changes in their brain that make their brains more typical than other kids with ADHD who don't remit, although we're not sure if those brain changes really cause the remission. And there's other evidence that suggests that kids that are treated in childhood and adolescence are more likely to remit their ADHD than others.

Host Amber Smith: How is ADHD typically treated in adults?

Stephen Faraone, PhD: In adults it's treated with, Basically the same medications that kids are treated with, and that's methylphenidate, which most people know as Ritalin or Concerta, and amphetamines, which most people know as Adderall or Vyvanse, although there are many other brand names for those medications. Those are are called the stimulant medications.

There's another set of medications called nonstimulant medications, such as atomoxetine, extended-release fluoxetine, guanfacine and clonidine. These are also used to treat ADHD in adults and children.

Host Amber Smith: Do the ADHD medicines work OK with other medications that adults may be taking? I'm thinking diabetes or heart disease. ...

Stephen Faraone, PhD: It's always important that when one is prescribed a new medication, that the doctor checks to make sure that medication is not going to cause a problem because it may interact in an adverse way with another medication.

It's very medication specific. There's sometimes two medications shouldn't go together. Usually it's not a problem, but people should always either ask their doctor, or actually, the pharmacists know a lot about this too, and they can always check with their pharmacist to be sure that If they're prescribed a medication for ADHD, it's not going to cause a problem. It typically does not cause problems.

Host Amber Smith: Well, getting back to longevity, if ADHD is properly treated, will that improve a person with ADHD's life expectancy?

Stephen Faraone, PhD: There are some data that suggests that yes, that people with ADHD that have been on medication are less likely to die younger than other people, which makes sense, because we know the medications protect them against accidental injuries, which is one of the major causes of premature death in ADHD.

Host Amber Smith: Well, this has been very interesting. I thank you for your time.

Stephen Faraone, PhD: Happy to be here. Thank you, Amber.

Host Amber Smith: My guest has been Dr. Stephen Faraone. He's a Distinguished Professor of psychiatry and behavioral sciences at Upstate, specializing in ADHD research.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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