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Consequences

Consequences

ADHD not only has symptoms that are acutely manifested in the behavior of the affected person, but also long-term consequences.

1. Consequential risks of ADHD

ADHD sufferers have to accept massive restrictions in their quality of life.

  • Depression increases1
    • 50% of all ADHD sufferers have a major depressive episode before adulthood. The risk is thus 5.5 times higher than for non-affected persons.2
  • Suicide rate increases3 by 2.3 times4 by 2.9 times5
    • Suicidal thoughts and suicide attempts increased6
      • In veterans with ADHD this was not confirmed7
  • Arrests increased by 105%8
    • ADHD sufferers are 6.4 times more likely to be perpetrators of domestic violence than non-affected individuals.9
  • Divorces
    • Increased by 878
    • Women (in Japan) with ADHD appear to have even higher divorce rates than men with ADHD.10
  • Injuries
    • Injuries increased
      • By 41 % for young adults11
      • By 250 % for children and adolescents12
    • Risk of bone fractures
      • increased by 60 % for girls 13
      • increased by just under 40 % in boys 13
      • Stress fractures increased by 17%.14
    • Concussions twice as common in children aged 11 to 14 with ADHD15
    • Children with eye injuries were 3.5 times more likely to have ADHD than children without eye injuries.16
    • Intentional self-poisoning increased 4.65 times.17
  • Significant professional disadvantages18
    • Job change increased by 598
    • Fewer full-time jobs, more part-time jobs
      • Women (in Japan) with ADHD appear even more likely to have only a part-time job than men with ADHD.10
    • Employment rate reduced by 288
  • Poorer educational opportunities1
    • University degrees 27% less common8
    • School-leaving qualifications 11 % less frequent8
    • Lower educational attainment6
    • Rare bachelor’s degree18
  • Health problems
    • 5-fold direct annual costs from age 14 to 17 related to child behavior (excluding treatment costs) and indirect costs related to caregiver burden19
    • Increased risk for most physical diseases (34 [97 %] of 35 diseases studied), independent of sex20
      • Nervous system disorders (1.5 to 4.6 times the risk), mainly caused by environmental hazards, e.g.
        • Sleep disorders
        • Epilepsy
        • Dementia
          • Parents of ADHD sufferers showed a 55% increased risk of Alzheimer’s disease or dementia in a Swedish cohort study. In grandparents, the risk was increased to an even lesser extent.21
      • Respiratory diseases (2.4 to 3.2 times the risk), mainly genetic, e.g.
        • Asthma
        • Chronic obstructive pulmonary disease
      • Stroke risk increased22
        • Risk of ischemic stroke increased by 15%
        • Risk of large-artery atherosclerotic stroke increased by 40%
    • Alcohol consumption increased6
    • Smoking more often62324251
      • ADHD-affected adults are 50% more likely to smoke (OR = 1.5)26 Conversely, young adult smokers are twice as likely to have ADHD.27
      • ADHD-affected youth have a doubled (OR = 2)26 to tripled28 risk of smoking
      • One study found no association between ADHD symptoms and smoking29
    • Marijuana use increased23
    • Up to 5-fold increased risk of neurodegenerative diseases, especially Lewy body dementia.30
  • More often a victim of physical and non-physical sexual abuse31
  • ADHD causes long-term decreased emotional school engagement, which is further moderated by student-teacher conflict.32
  • Reduced quality of life (QoL)33
    • Health-related QoL significantly reduced34
  • 4-fold increased risk of decreased length growth and weight gain at 8 and 10 years. Stimulant treatment increased this risk.35
  • ADHD in childhood predicts emotional problems later in life. These are genetically mediated.36

2. Risks of untreated ADHD

Untreated / inappropriately treated ADHD has massive lifetime implications,3738 e.g.:

  • 7 times the risk of ending up in prison due to crime
  • 3 to 5 times the risk of separation and divorce39
    • Females (in Japan) with ADHD appear to have an even higher rate of comorbidity than males with ADHD.40
  • 1.27- to 4.6-fold premature mortality. Depending on the study, between 1.27-fold (boys and men),41 2.85-fold (girls and women),41 1.4-fold (children and adolescents), and more than 4.6-fold (in adults),42 especially from accidents.4344 45 46 47 48 49 50 51
    ADHD medication reduces accident incidence in affected boys and girls, as children and as adolescents.5253 by 43%54 and traumatic brain injury reduced by 49%55 to 66%.56
    With the number of additional comorbidities, the likelihood of premature death increases up to 25-fold.4257
    4.25-fold risk of premature mortality with first ADHD diagnosis in adulthood.41
    In contrast, no increased mortality was found for ADHD medication use (stimulants or atomoxetine).58
  • 3.6-fold risk of eating disorders in girls59
  • 1.2 to 3.3-fold risk of anxiety disorders. Lifetime prevalence 10 - 15 % total population,60 12 to 50 % in ADHD39
  • 2.74-fold risk of motor vehicle crashes resulting in injury among those aged 65 and older61
  • 2.4-fold risk of suicide in ADHD overall, especially in women62 (up to 4.1-fold risk of suicide). Correspondingly higher in untreated ADHD.6339
  • 2.3-fold risk of early pregnancy in untreated teens with ADHD. Teenage pregnancies are 27% more common with untreated ADHD. The risk decreased very significantly with treated ADHD.64
  • 2.5-fold65 to 4-fold risk of depression in girls
    ADHD in children increases the risk of depression in adolescence.66
  • 2.35 times6728 to 8.61 times risk of smoking68
  • 2 times the risk of falling victim to murder69
  • More than 2-fold medical costs70
  • 1.77-fold risk of substance dependence (addiction)68
    The majority of research on ADHD and alcohol abuse finds a positive correlation.71
  • Increased risk behavior33
  • Increased likelihood of inpatient psychiatric treatment. Among 166 psychiatric inpatients, 59% were found to have ADHD.72

Adults who received individual ADHD therapy between the ages of 6 and 10 years were found 18 years later:73

  • An improvement in ADHD symptoms that corresponded to the follow-up after 8 years
    • 18% no longer had an ADHD diagnosis
    • 55% had partial remission; of these
      • ADHD-I 33 %
      • ADHD-HI 13 %
      • ADHD-C 54 %
    • 27% further had an ADHD diagnosis; of these
      • ADHD-I 67 %
      • ADHD-HI 17 %
      • ADHD-C 17 %
    • Functional impairment in terms of
      • Finance 28 %
      • Daily responsibilities 28 %
      • Community activities 23 %
      • Learning/acquiring new learning content 21 %
  • Worse school / professional results than expected
    • School and professional qualifications
      • As often as in total population
      • Significantly worse grades
      • Much less likely to have a high school diploma / university entrance qualification than the general population
    • Increased unemployment
      • Currently unemployed: 17 %
        • Approximately 30% more likely to be unemployed than total population (study compares to 2011, when unemployment was 30% higher than 2019)
      • 25 % were unemployed for more than one year
      • 52 % were unemployed once in the last few years
  • More frequent contact with judicial system than expected
    • Criminal judgments 33 %
  • Health impairments, comorbidities
    • Threefold rate of externalizing or internalizing disorders
      • Three and a half times the rate of medication for mental health problems
    • 27% had a personality disorder according to DSM-IV
      • Antisocial personality disorder 12%, RR 6.8 (about 6 times more common; total population: 2%)
      • Avoidant personality disorder RR 2.0 (twice as frequent)
      • Schizoid personality disorder RR 2.0 (twice as frequent)
      • Paranoid personality disorder RR 1.3 (30% more frequent)
    • Addiction problems
      • Drug use: 15 %; highly frequent
      • Smoking slightly more often
      • Alcohol slightly more often
    • Weight problems
      • Overweight one and a half times more common than in total population
      • Obesity 30% more frequent than in total population
  • Several social outcomes were favorable
    • Long-term relationship/marriage: 63 %
  • Low life satisfaction, especially in the areas of
    • Health
    • Profession/Career
    • Leisure/recreational activities
    • Own children
    • Own person
    • Sexuality
    • Relations with others
    • Overall life satisfaction

3. Protective effect of ADHD medication

ADHD medications reduce the risks of ADHD symptoms and sequelae. According to a metastudy, medication with stimulants reduces the aforementioned risks by 9 to 59 %.74

Another metastudy of 40 studies found a robust protective effect of ADHD medications in relation to75

  • Mood disorders
  • Suicidality
  • (Car) accidents
  • Injuries
  • Traumatic brain injuries
  • Education and academic outcomes. Indifferent, on the other hand:76
  • Substance Abuse
  • Crime

Stimulants reduced the risk of suicide attempts in several large studies in ADHD by77

  • 11.6 % (in all age groups)78
  • 19 %79
  • 42 %80
  • 59 % if taken for 3 months and half a year81
  • 72 % if taken for more than half a year81
  • Methylphenidate in ADHD was associated with a reduction in previously significantly increased suicide risk after 90 days.82
  • Other ADHD medications (non-stimulants) showed no or very little reduction in suicidality, e.g., 4%79

MPH reduced all-cause mortality by 20% in children with ADHD. Delayed use of MPH correlated with a 5% increase in mortality. Long-term use reduced all-cause mortality by 16%.83

ADHD medications reduce the risk of depression:84

  • 3 years after ingestion by 40
  • during the intake by 20

Treatment of ADHD with methylphenidate reduced the risk of

  • from stress fractures
    • by 22.4%, although this figure was even lower than for non-affected persons.85
    • to 16 % less than for non-affected persons14
  • of accidental fractures (trauma fractures)
    • to the same value as for non-affected persons.14
    • ADHD sufferers treated with nonstimulants doubled the risk increase for bone fractures to 37% compared with the risk of nonaffected individuals, which was 17% higher for all ADHD sufferers compared with nonaffected individuals.14
  • Of unintentional injuries by 15%86 or with an effect size of 0.8887
  • Of brain trauma by 7386
  • From poisoning88
  • Of injury-related emergency admissions by 9%89
  • of burns in adolescents with ADHD90
    • by 57% with MPH use for 90 days and longer by
    • by 30% for MPH use for less than 90 days by
  • from traffic accidents
    • for men by 38 % to 409192
    • for women by 4292
    • serious traffic accidents (for men) by 50%91
  • of sexually transmitted diseases
    • only for men by 30 to 4093
  • of teenage pregnancies64

ADHD sufferers who were not treated with MPH were more likely to be victims of bullying/cyberbullying (physical victimization, isolation, destruction of property by others, and sexual victimization), more likely to destroy others’ things, and more likely to exhibit bullying behaviors (perpetrator-side).94

ADHD medications reduce the risk for sufferers,

  • to start smoking.28
  • to smoking, by 5095
  • for substance abuse by 31%.96

ADHD medications do not increase the risk for affected individuals:97

  • for alcohol abuse or dependence (11 studies, over 1300 participants)
  • for nicotine abuse or dependence (6 studies, 884 participants)
  • for cocaine abuse or dependence (7 studies, 950 participants)
  • for cannabis abuse or dependence (9 studies, over 1100 participants) did not increase (Humphreys et al., 2013).

ADHD medication reduces for sufferers

  • the crime rate9899
    • For men by 31
    • For women by 41

ADHD medications improve academic performance.

  • Three months of treatment with AD(HHD) medication resulted in100
    • a grade improvement of more than nine points (scale: 0 to 320)
    • a 20% reduction in the risk of not receiving a recommendation for higher secondary education
  • ADHD sufferers’ test scores during the time they were taking medication were 4.8 points (scale: 1 to 200) higher than during the time they were not taking medication.101
  • Discontinuation of AD(HS medications correlated with a small significant decrease in grade point average102

Medication significantly mitigates the deterioration in health-related quality of life caused by ADHD.34
One meta-analysis found worsening quality of life when medications were discontinued in children and adolescents, but not in adults.103

4. Life risk changes due to treatment of ADHD

How many affected individuals would need long-term treatment with MPH to avoid any of the following long-term consequences of untreated ADHD?104 The results were independent of gender:

  • 3 affected persons treated = 1 class repetition avoided
  • 3 treated affected = 1 avoided oppositional deficit behavior
  • 3 affected persons treated = 1 avoided behavior disorder (conduct disorder)
  • 3 treated sufferers = 1 avoided anxiety disorder (with 2 impact types)
  • 4 affected persons treated = 1 major depression avoided
  • 4 affected persons treated = 1 serious car accident avoided (in simulation)
  • 5 sufferers treated = 1 bipolar disorder avoided
  • 6 affected persons treated = 1 smoker avoided
  • 10 persons treated = 1 addiction avoided

5. Financial consequences of ADHD

A long-term study over 20 years on 604 subjects showed that ADHD sufferers have a lower net income and greater financial dependence on parents at the age of 30 than non-affected persons. This is true even when DSM criteria are no longer met. This deficit persists throughout life, resulting in $1.27 million lower expected lifetime income for males and up to 75% lower net worth at retirement than for unaffected individuals.105 In addition, ADHD-affected adults, if undiagnosed and untreated in childhood, earn significantly less income than their unaffected twins and incur €20,000 higher costs per person per year.106 Another study cites $182,000 (as of 2015) higher costs from medical care, education, and crime consequences per ADHD case persisting into adulthood.107

Another study concludes that ADHD sufferers aged 14 to 17 incur 5 times the direct annual costs associated with the affected child’s behavior (excluding treatment costs) and indirect costs associated with caregiver burden.19

6. ADHD and profession

Occupational problems are a common consequence of ADHD.

  • Higher layoff rate 1.1 vs 0.3 jobs/time108
  • Frequent job changes 2.7 vs 1.3 jobs/ 2- 8 yrs SE108
  • Worse evaluations in the workplace108

7. ADHD and life (dis)satisfaction

Life dissatisfaction is a typical consequence of ADHD.

According to a study with n = 1000 participants, ADHD in adulthood leads to a significant reduction in life satisfaction (Quality of Life).109

In the areas

  • Family life
  • Partnership
  • Social life
  • Integration in society
  • Health and fitness
  • Professional life
  • Achieving life goals

aDHD sufferers scored on average about 20% worse than non-affected persons.

Adults with the highest 10% of ADHD symptom expression according to ADHD-E were 4.10 times more likely to experience distress from general life dissatisfaction and 3.3 times more likely to experience distress from lack of social support than unaffected adults.110111

8. ADHD and delinquency/crime/prison

A number of studies have found many times higher rates of ADHD among prison inmates.

  • 14 % to 45 % ADHD112113
  • 25 %114
  • 17.3%115 to 31%116 of juvenile inmates
  • 25 % of all prisoners in USA117
  • 28% of all incarcerated persons in U.S118
  • 17.5% of 244 correctional inmates studied (n = 244)119
  • 27.6% of 146 sex offenders studied (n=146, WURS 90 pts)119
  • 22% of patients in forensic psychiatry (n = 86)120
  • 9.1% of 55 Irish inmates studied121
  • 19% of all ADHD sufferers had committed crimes, 0% in control group122
  • 17% of all young men serving time for minor to moderate offenses in Lithuania.123 The ADHD-affected inmates were younger and had greater behavioral problems in prison. None of them had previously received an ADHD diagnosis.
  • 20 to 30% of all young adult prison inmates.124

Assuming a prevalence of ADHD among adults of 4%, this would be seven times higher at 28% among prison inmates. The risk of going to prison is thus 7 times higher for ADHD sufferers than for non-affected persons.

Interestingly, amphetamines are the drugs most commonly used by prison inmates affected by ADHD.125 Amphetamine is known to be an active ingredient in highly effective ADHD medications.

A study of the correlation of ADHD symptoms and criminogenic thinking styles found that126

  • Inattention was consistent and strongly associated with criminogenic mindsets, especially with
    • Cutoff
    • Cognitive inertia
    • Discontinuity
  • Impulsivity was positively correlated with criminogenic thinking patterns, with
    • Power orientation
  • Hyperactivity was not associated with criminogenic thinking.

ADHD medication reduced crime rates among ADHD sufferers98

  • For men by 31
  • For women by 41

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