The lethality of a controversial illness
Posted May 05, 2015
The boisterous hyperactivity along with the distractibility and impaired ability to sustain attention found in 5% to 10% of US elementary school aged children has led to embittered controversy among parent groups, advocacy organizations, and the medical psychiatric establishment about the diagnosis of ADHD and its treatment. Fears about the untoward consequences of medication treatment, and beliefs that the medication treatment of ADHD may be a conspiracy between the pharmaceutical industry and the medical establishment, may lead to failure to recognize and adequately treat the disorder.
There is far more at stake for the elementary school aged child with ADHD than bad behavior reports from school and poor learning. Other psychological problems associated with ADHD such as oppositional behaviors and possibly more severe antisocial behaviors such as stealing and lying are made worse by untreated ADHD. Accidents related to the child’s impulsivity and willingness to engage in risky behaviors are associated risks to the health of the ADHD child.
An important means for better understanding a disorder is to follow an adequate number of patients for a long enough time to be able to see patterns in the outcome of the illness. Scandanavian countries provide an ideal setting for follow up studies because of state mandated registries that record almost all delivery records, health histories, educational histories, and psychiatric illnesses diagnosed within a country over time. This provides researchers the opportunity to study the outcome of child psychiatric illness.
Lancet, a distinguished British medical journal, published an article online on February 26, 2015, using the national registers from Denmark. 1 .92 million individuals born between 1981 and 2011 from the overall population of Denmark were studied. 32,061 had ADHD.
5,580 members from the overall country wide sample died. 107 people with ADHD died. The subjects in the study were measured in person years (the number of years of study multiplied by the number of people studied). The death rate for 10,000 person years was 5.85 among individuals with ADHD compared with 2.21 per 10,000 person years for individuals without a diagnosis of ADHD. In other words, there was a two fold increase in death rates for those with ADHD.
Much of the data are reported in Mortality Rate Ratios (MRR) - the ratio of the observed deaths in a target population compared to those of a general population. If there is no difference between the two groups, the ratio is 1.0. If the number is above 1.0, it means the target group had more deaths than the general population group. In this study, the MRR for children with ADHD below the age of 6 was 1.86, for those between 6 and 17 years it was 1.58, and for those 18 years and older it was 4.25. By the design of the study, no subject of the study was more than 32 years old. The high MRR of those with ADHD did not reflect physical illness; it reflected an increase in accidents.
Women with ADHD in the oldest age range had higher mortality rates (per 10,000 patient years MRR 3.01) than men with ADHD (per 10,000 patient years MRR 1.93).
Those whose ADHD was diagnosed at an older age had a higher mortality rate than those whose ADHD was diagnosed at a younger age (per 10,000 patient years MMR 3.34 for age at first diagnosis of ADHD: 1-5 years; per 10,000 patient years MMR 4.34 for age at first diagnosis of ADHD: 6-17 years; per 10,000 patient years MMR 22.28 for age at first diagnosis greater than 17 years.
Antisocial behaviors that can accompany ADHD such as oppositional defiant disorder, conduct disorder, and substance abuse disorder increased mortality rates significantly. For example, for those with ADHD alone, the per 10,000 patient years MRR was 3.408; for those with ADHD + oppositional defiant disorder or conduct disorder the per 10,000 patient years MRR was 6.09, for those with ADHD + oppositional defiant disorder or conduct disorder + substance use disorder the per 10,000 patient years MRR was 40.48.
If there is no diagnosis of ADHD, oppositional defiant disorder, conduct disorder, or substance abuse disorder, the per 10,000 patient years MMR was 2.05.
The high per 10,000 patient years MMR of those diagnosed with ADHD after age 17 lends credence to the recent trend of diagnosing and treating ADHD in adults.
The data support the validity of Attention Deficit Hyperactivity Disorder as a diagnosis. Follow up studies are necessary for creating a scientific foundation for the existence of a psychiatric disorder. This study demonstrates that ADHD separates from the overall population by its higher death rate.
Copyright: Stuart L. Kaplan, M.D., 2015.
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.