The implications of this pilot, by Russell A. Barkley, PhD, clinical professor of psychiatry at the Virginia Commonwealth University Medical Center, are that primary care providers are dealing with this issue in their adult patient population, whether they realize it or not, he said during a session called Health Outcomes of ADHD: Do They Adversely Impact Life Expectancy?

Using a large database created by a center for actuarial studies, a psychologist and researcher is positing that people with the worst cases of attention-deficit/hyperactivity disorder (ADHD) will see a 25-year reduction in life expectancy, according to a presentation made Saturday at the annual meeting of the American Professional Society of ADHD and Related Disorders (APSARD).

During his talk, Barkley noted several earlier studies that support his underlying hypothesis, explaining that ADHD is linked to lower conscientiousness, and decreased child conscientiousness is associated with earlier death by all causes.1,2

Other studies have found an increased risk for suicide3—adults with ADHD are 1.8-times more likely to die within any 4-year period than the general population—and that the risk of mortality doubles as a child with ADHD transitions to adulthood.4

That makes sense, Barkley said, as “you are moving into more domains of risk.”

He also cited other studies that have found those with ADHD are more likely to have a less healthy diet, more likely to be overweight and eat impulsively, more likely to be obese, and that females are more likely to have a higher risk of eating disorders.

To arrive at his conclusion about reduced life expectancy, he used an existing cohort of ADHD patients he and his colleague, Mariellen Fischer, PhD, department of neurology, Medical College of Wisconsin, have been following for years.

The longitudinal cohort includes 158 patients who were diagnosed with hyperactive (H) child syndrome in 1978-1980, when they were 4 to 11 years of age.

They were matched with 81 control (C) children from the same schools and neighborhoods. Participants were mostly males (83%-94%).

Most children were re-evaluated at mean ages of 15 (C = 78%, H = 81%), 21 (C = 93, H = 90%), and currently at 27 years (C = 93%, H = 85%).

To be currently considered as having persistent ADHD (H+ADHD), participants had to have 4+ symptoms on either DSM-IV symptom list and 1+ domains of impairment (out of 8) by self-report (n = 55).

Remainder (n = 80) were grouped as H-ADHD, with 3 or fewer symptoms of ADHD, labeling them as nonpersistent into adulthood.

Barkley and his team entered mean data for each group into the Healthy Life Expectancy Data Calculator, which was launched last year by the Goldenson Center for Actuarial Research at the University of Connecticut. The calculator measures how many predicted years one has left to live, based on algorithms. It measures both total years and healthy years.

Variables were:

Male

Age 27 years (mean for all groups)

Mean height for group (5 feet 10 inches for all 3 groups)

Mean income (always $25,000—$50,000 categorization)

Type 2 diabetes (always No)

Current health (Good; options: poor, fair, very good, and excellent)

Driving accidents (always 0; options: 1 per year or 2-plus per year)

Fixed variables were adjusted for each group (C, H+, H-) in analysis of typical (average) group comparison:

Mean weight for group (194, 209, and 205, respectively)

Diet (Good for controls, fair for both ADHD groups)

Sleep (8+ hours per night for controls, <5 for H+ group, and 5-8 for H—; sleep concerns were 14%, 52%, and 32%, respectively)

Variables [binary] adjusted for analysis of worst- and best-case scenarios

Education (non-HS, HS, college, or graduate school)

Current smoker (No or Yes)

Alcohol use (No [rarely] or Yes [used mean drinks per week for group])

Diet (Good for controls, fair for both ADHD groups)

Regular exercise (No [rarely] or Yes [3-4 days per week]; other options: 1-2 days per week, 5+ days week)

At age 27, the control group had 65.6 years left to live, while the group with the worst cases of ADHD had 39 years left to live.

The worst case was derived by moving 1 standard deviation away from the mean in the categories of weight, income, education, smoking, alcohol use, diet, sleep, and sand exercise.

In an interview with The American Journal of Managed Care, Barkley said he intends to dig deeper into the claims database but is confident in the accuracy due to the large insurance databases that were combined to run algorithms on these outcomes. He said he intends to publish the data and will seek more information about the nonproprietary data the center uses.

Barkley’s key message is that unless primary care doctors recognize and treat ADHD effectively, efforts to treat conditions that are correlated with it will fail.

“If we didn’t see any differences I would question the calculator, but we did,” he said.

When patients walk into provider offices with unrelenting conditions linked to ADHD—such as obesity, substance use disorder, marital discord, motor vehicle accidents, or other poor health issues—the doctor is “trying to treat the medical problem, but he’s not looking underneath it,” Barkley said.

“Untreated ADHD will interfere with any attempt to fix the medical treatment plan,” he continued.

“If you have a self-regulation problem and rehabilitation requires self-control, you’re not going to rehabilitate.”

The H- group still did worse than controls on some measures as well, Barkley said. “There’s an enduring effect of growing up with ADHD even if you don’t have it anymore.”

Childhood ADHD persisting to young adulthood may typically shorten life expectancy by nearly 20 years and by 12 years in nonpersistent cases compared with concurrently followed control children.

Barkley called ADHD a “serious public health problem” and said ADHD is among the most treatable psychiatric disorders, but that it is challenged by under-recognition and treatment of adult ADHD and its health risks, access to evidence-based treatments, cost, and getting patients to remain in treatment through the critical adolescent and adult years.

During the question and answer session following his session, one person asked if parents should be told about this idea, particularly because some parents are resistant to putting children on ADHD medications.

Barkley’s response was an unequivocal “Yes!”

“I want to scare the hell out of you,” he said. “My job is not to be your friend.” Without that, he said, there will be no luck in getting the attention of their doctors, insurance companies, school systems, etc.

The key takeaway, he said, “is that you better get this kid treated.”

Studies that express mortality as an odds ratio, he told AJMC®, “are very hard for the average reader to wrap their mind around, other than there’s a 2- or 3-times greater risk of dying in the next 5-year period—that doesn’t quite hit you viscerally as expressing the same data as life expectancy prediction does.

“It’s not like I’m saying anything new that we didn’t know. We knew we had reduced life expectancy. But nobody calculated it the way we did, which is to put it in years left of life.”

There were several limitations to this early approach:

Group means or percentages served as data for entry into calculator, instead of individual entry for each participant’s factors, followed by an analysis.

The sample size was small

Clinical samples of ADHD cases are more severe than community samples and so may exaggerate differences in life expectancy

Severely limited number of females restricts results to male cases

The population was mostly white, male, and from the Midwest.

“I think it has face validity,” said Kenneth N. Sonnenschein, MD, of Kansas City Psychiatric Group from Overlook Park, Kansas, of Barkley’s early result.

“People with ADHD have higher risk behaviors, they’re more impulsive, they’re less attentive, so they have higher rates of motor vehicle accidents, higher substance use disorder, and all the consequences that come from that.”

“You hear all the time people are concerned about treating their child or themselves for ADHD because of the risks of medication, whereas the risks of the medication are incredibly small. There’s no lethality. And here what this tells us is, is that the condition itself exposes people to significant lethality and by treating the condition we’re significantly improving not just function and morbidity, we’re reducing mortality.”

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