The ADHD Label and Mortality

Philip Hickey, PhD
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On February 26, 2015, The Lancet published online an article by Soren Dalsgaard et al titled Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study.

The article describes a Danish study that was designed to assess “ADHD-related mortality in a large cohort of Danish individuals.”

The researchers describe their methods as follows:

“By use of the Danish national registers, we followed up 1·92 million individuals, including 32 061 with ADHD, from their first birthday through to 2013. We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, family history of psychiatric disorders, maternal and paternal age, and parental educational and employment status, by Poisson regression, to compare individuals with and without ADHD.”

Data for the study was obtained from The Danish Civil Registration system, The Danish Psychiatric Central Register, and the Danish National Patient Register.

Here’s the authors’ summary of their findings:

“During follow-up (24·9 million person-years), 5580 cohort members died. The mortality rate per 10 000 person-years was 5·85 among individuals with ADHD compared with 2·21 in those without (corresponding to a fully adjusted MRR of 2·07, 95% CI 1·70–2·50; p<0·0001). Accidents were the most common cause of death. Compared with individuals without ADHD, the fully adjusted MRR for individuals diagnosed with ADHD at ages younger than 6 years was 1·86 (95% CI 0·93–3·27), and it was 1·58 (1·21–2·03) for those aged 6–17 years, and 4·25 (3·05–5·78) for those aged 18 years or older. After exclusion of individuals with oppositional defiant disorder, conduct disorder, and substance use disorder, ADHD remained associated with increased mortality (fully adjusted MRR 1·50, 1·11–1·98), and was higher in girls and women (2·85, 1·56–4·71) than in boys and men (1·27, 0·89–1·76).” [Emphasis added]

So, essentially, the authors identified a cohort of almost 2 million people, 32,061 of whom had been assigned a “diagnosis of ADHD”.  During the follow-up period the death rate per 10,000 person-years was 5.85 in the ADHD group vs. 2.21 for the remainder.  These figures yield an adjusted risk ratio of 2.07.  In other words, the individuals who had been labeled ADHD had approximately double the mortality risk as those who had not been so labeled.

But many of the individuals who had been labeled ADHD had also been assigned the labels “oppositional defiant disorder,” “conduct disorder,” and “substance abuse disorder.”  These additional labels were also associated with increased mortality.  When the excess mortality associated with these additional labels was adjusted out, the ADHD individuals were found to have a 1.50 mortality risk ratio compared with individuals in the cohort who had acquired none of the psychiatric labels mentioned.

Discussion

The central problem in research of this kind is in the general concepts rather than the specific details.  In their final paragraph, the authors state that:

“ADHD is a common neurodevelopmental disorder known to cause impairment across the lifespan”

and indeed the entire article is written from a medical perspective, as if ADHD were a bona fide illness like pneumonia or kidney failure.

Note the perfect example of psychiatric “logic” in the above quote:  ADHD causes impairment.  So if a parent were to ask the authors why her child is so distractible, impulsive, and hyperactive, she will receive the reply: because he has ADHD; ADHD causes the distractibility, impulsivity, and hyperactivity.  But if she presses the issue and asks how the psychiatrist knows that the child has ADHD, the only possible answer is because he is so distractible, impulsive, and hyperactive.  The only evidence for the so-called disorder is the very behavior that it purports to explain.  Labeling a child ADHD explains nothing.  Its only purpose is the legitimatization of drugs.

ADHD is nothing more than the loose cluster of vaguely defined behaviors listed in the DSM and the ICD.  The APA describes these behaviors as “symptoms,” but this is a misnomer.  In real medicine the illness does indeed cause the symptoms, and provides an explanation for the symptoms.  Pneumonia, an infection of the lung, causes coughing, exhaustion, and nasty-looking phlegm.

But in ADHD, as in all so-called psychiatric illnesses, this is not the case.  In psychiatry, the “symptoms” are the “illness.”  There is no causative disease entity behind the “symptoms” as there is in real medicine.  In psychiatry, the so-called symptom list, with all its vagueness and polythetic variability is the illness.  And in particular, despite psychiatry’s routine claims to the contrary, there is no neurological pathology common to all, or even most, of the individuals who acquire this label.

The fact that the authors refer to ADHD as a neurodevelopmental disorder probably reflects the fact that in DSM-5 this “diagnosis” is in the section headed “Neurodevelopmental Disorders.”  But this is very misleading.  Most people on hearing that ADHD is a neurodevelopmental disorder would assume that a neurological pathology is implied.  This is emphatically not the case.  The chapter on Neurodevelopmental Disorders in DSM-5 begins:

“The neurodevelopmental disorders are a group of conditions with onset in the developmental period.  The disorders typically manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.  The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence.”

As the reader can see, there is no requirement of proven, or even suspected, neurological pathology.  All that’s required is that the individual be functioning below par (for any reason) in one or other of these areas.  The use of the term “neurodevelopmental disorders” is deceptive, and is another example of psychiatric assertion as a substitute for truth.

In the present study, the ICD lists were used to identify the ADHD group.  Here are some of the items on this list that might have a bearing on accident-related mortality.

  • unduly high distractibility…
  • undue lack of persistence at tasks…
  • very often runs about or climbs excessively in situations where it is inappropriate…
  • often has difficulty waiting turns…
  • excessive motor restlessness…
  • excessive levels of off-task activity…

It doesn’t take a great deal of imagination to see how children and adults whose habits and behaviors attract these kinds of descriptions might have a higher accident-related mortality than individuals who do not function in these ways.

“Unduly high distractibility,” for instance, is an obvious causal factor in motor vehicle accidents.  People who are distractible – i.e. who have not acquired the habit of screening out extraneous stimuli – will, other things being equal, have a higher accidental death rate than people who do screen out extraneous stimuli.

Similarly, “often has difficulty waiting turns”.  A great many traffic accidents are caused by people who become impatient in a line of traffic, and pull out to pass when it is not safe to do so.  And “excessive levels of off-task activity” would certainly include texting while driving – a known killer.

By defining ADHD by the presence of these behaviors, psychiatrists have, in effect, guaranteed that the group of people identified will have excess accident-related mortality.

In effect, all that Soren Dalsgaard et al have established is that people who engage in impulsive, high-risk behavior have a higher mortality rate than people who don’t.  That’s all there is to it.  The injection of ADHD, the “common neurodevelopmental disorder” adds nothing to the understanding of the matter, and in fact, serves to distract from the critical issue:  that we need to train children to pay attention, and not to be impulsive in matters that involve safety.

And Incidentally

Under the heading Acknowledgements, the article states:

“This study was supported by a grant from the Lundbeck Foundation.”

Four of the five authors, Drs. Dalsgaard, Østergaard, Mortensen, and Pedersen, are affiliated with the Lundbeck Foundation Initiative for Integrative Psychiatric Research.

And, predictably, the study generated a good deal of media attention.  Here are some media quotes:

Risk for Dying Young Increased With ADHD Diagnosis, Study Finds Psychiatry News:

“The results, published in Lancet, showed that of the 32,061 individuals with a diagnosis for ADHD, 107 died before the age of 33—a rate that is twice that for persons without the disorder, even after adjusting for factors that increase risk for premature death such as history of psychiatric disorders and employment status.”

A.D.H.D. Diagnosis Linked to Increased Risk of Dying Young The New York Times:

“People with a diagnosis of attention deficit disorder are at higher risk of dying young than those without the disorder, usually in automobile crashes and other accidents, suggests research reported on Wednesday, from the largest study of A.D.H.D. and mortality to date.”

“The risk was even higher in people who received a diagnosis at age 18 or later, the study found — possibly because of the severity of such cases, the authors wrote.”

A new study shows there’s a strong link between ADHD and premature death Vox Topics:

“When the researchers followed the group for the next three decades to learn about how they fared, they came to some startling conclusions. Compared to people without ADHD, those who had the disorder were twice as likely to die prematurely — and much more accident prone.” [Emphasis added]

People who are distractible and impulsive have a higher death rate from accidents.  That’s a startling conclusion!

ADHD linked to greater risk of dying young Science Nordic:

“People with ADHD face a risk of premature death 1.5 to 8 times greater than those without the disorder. That’s the conclusion of a new study involving 32,000 Danes with ADHD and more than a million Danes without the disorder.”

Study Finds People with ADHD More Likely to Die Prematurely Psychology Today:

“ADHD is more than just a learning disability or mental health condition. It does far more than just inhibit learning or make children more ‘difficult.’ According to one new study, it greatly increases its sufferers’ odds of dying young.”

ADHD Greatly Increases Risk of Premature Death Psychiatric Advisor:

“In an associated comment to the study, Stephen Faraone, PhD, Director of Child and Adolescent Psychiatry Research at SUNY Upstate Medical University in New York, wrote, ‘For too long, the validity of ADHD as a medical disorder has been challenged. Policy makers should take heed of these data and allocate a fair share of health care and research resources to people with ADHD. For clinicians, early identification and treatment should become the rule rather than the exception.'”

Note the very nice example of psychiatric logic:  because individuals who are distractible and impulsive have a higher mortality rate, then their label – ADHD – must be valid!  People who ride motorcycles routinely also have a higher than average accident-related mortality rate.  Should we therefore conclude that riding motorcycles is a “valid” illness?

And on a Personal Note

Recently my wife and I were taking our grandsons home   My wife was driving.  Our 6-year-old grandson was asking her lots of questions.  After a while I suggested that he ease up on the talk, and let his grandmother concentrate on driving.  He agreed readily.  “Otherwise,” he added, “we could have an accident, and we’d all be killed.”

Such startling wisdom – out of the mouths of babes.  As I’ve said many times, critiquing psychiatry is not quantum physics.

20 COMMENTS

  1. Philip,
    I guessed before reading it what your article was going to say, and it did not disappoint 🙂 When one realizes how obvious the conclusions are, reading this study becomes perversely humorous. I call it a “Duh” study, a la Simpsons.

    The opening quote should say, “”By use of the Danish national registers, we followed up 1·92 million individuals, including 32 061 with more difficulty concentrating than the majority of the 1.92 million; this subset of 32061 more frequently had conduct problems, substance abuse, and high family stress levels , from their first birthday through to 2013. We estimated mortality rate ratios (MRRs), adjusted for calendar year, age, sex, family history of psychiatric disorders, maternal and paternal age, and parental educational and employment status, by Poisson regression, to compare individuals with and without high levels of these behavioral-social factors.

    Also, here is a translation of the quote by Stephen Faraone about “the validity of ADHD as a medical disorder” into the common tongue:

    Translation: “Please support the faulty unscientific fabrications like ADHD that sustain my prestige and income. Please give money to us so that I, my colleagues, and the drug companies can make increasing amounts of profit by drugging children. Please, please exploit younger and younger children so that we won’t have to give up our comfortable lifestyles. Thank you.”

    And, we should certainly not rule out the possibility that Motorcycle Riding Disorder will appear in DSM 6. You know there is something wrong with the brain chemicals of people that ride motorcycles…

  2. I greatly enjoyed your analysis of this study. In my book “ADHD a Return to Psychology (2007), I also commented on the finding that people diagnosed with ADHD drive poorly. Here is a quote from the book.

    To continue our list of laboratory findings, we observe that diagnosed persons (as an aggregate) also express difficulty with the task of driving an automobile (actual and lab-simulated) compared to non-diagnosed persons (Barkley, 2004; Barkley, Murphy, and Kwasnik, 1996; Barkley, Guevremont et al., 1993). Barkley (2000) points to biological determinism as causal for this outcome because diagnosed persons have problems with interference control, impulsivity, distractibility, and the anticipation of the future, which all contribute to their high accident rates. Clumsiness with car pedals and controls is also seen as consistent with their fine motor sequencing problems.
    However, observations of driving difficulties can be accounted for very differently; driving can also be construed as a social behavior, not solely as a manifestation of neurobiology. Driving requires coordination with others, turn taking, and acquiescence. Not everyone is conditioned to operate acceptably as drivers. When persons are reinforced to take risks, or that they must be first relative to others (even at the expense of others), such individuals are likely to speed and suffer accidents. Individuals showing this patterning may be less obliging, not only to other people, but also to the physical limitations of the car, pedals and other controls (even without delays in coordination).
    They might be insensitive with the controls in the same ways that they bang, provoke, intrude, or behaved boisterously in social situations. These behaviors need not be neurologically delayed. Many of these children have obtained benefits throughout childhood when not heeding parental instruction to be careful with themselves and with objects in their environments. A case could be made that diagnosed persons simply repeat conditioned social behaviors while operating a vehicle. Since diagnosed persons are frequently not integrating their actions with the perspective of others, and often doing behavioral acts that require others to accommodate to them, one might claim that they are not conditioned to be collaborative out of the car, in the car, or with the car.
    Craig Wiener

  3. Thanks so much for this analysis, which I intend to forward to a member of the county school board where I am currently working. At the elementary school where I work, I have witnessed meetings in which teachers push and urge parents of preschool children to “take them to the doctor”to get drugs to “help with behavior and concentration”, and watched parents basically try to weakly fight back, saying such things as “I’d like to wait until he is a little older – it is an altered state, you know”. Such scenes break by heart, and are almost as heartbreaking as hearing parents describe their young children now on polypharmacy, with primary care physicians prescribing psychoactive drugs in combinations, willey nilley. Perhaps you will consider writing a book covering all these drugs, for parents, teachers, schools, etc., to counter this tragic trajectory of pharmaceutical marketing?

    • The American education system is boring. Why do we hold 4 and 5 year olds to ridiculous standards of achievement and then drug them when they don’t measure up to our expectations? We make small children sit in desks all day while we cut out time for recess, for art and music, and all the really creative things that kids should be doing in school. Parents and teachers hold children to ridiculous standards and then punish them with a label and toxic drugs when they can’t or refuse to measure up to what we expect from them. What has our country come to??????

      I myself am a former teacher and can attest to what you write about here. Teachers are too quick to push for drugs so that they don’t have to put up with rowdy behavior. I got out of teaching just as all this ridiculous ADHD stuff began. I couldn’t stand to stay and watch what was being done to kids and if anyone stood up and protested about it you found yourself on the street without a job because your “philosophy” of education didn’t fit in with the school that used to employ you. What we’re doing to our kids in this country is disgusting and is truly a crime and parents who go along with all the bs need their heads examined!

  4. The only reliable difference between the so-called ADHD group and the so-called normals is the drugging. There are over 700 varieties of so-called ADHD, and the field tests for DSM 5 showed that diagnosis is a very unreliable process. A child diagnosed as ADHD by one doctor may not be so diagnosed by another. But we can be fairly sure that if the child or youth has got the label, drugging will follow. Actually what this study shows very strongly is that ADHD medication can more than double the accident death rate for young people. Death from suicide and medical problems such as sudden cardiac death from Ritalin have already been demonstrated. So now we can add a doubling of accident deaths to the list.

  5. This reminded me of a study I read many years ago, comparing kids with the “ADHD” diagnosis AND aggressive behavior to those who were labeled “ADHD” and not aggressive. Predictably, the children in the “HA” (hyperactive-aggressive) group had more run-ins with the law and more delinquent behavior than the general public. However, those in the “H-NA” group (not aggressive) showed exactly the same levels of delinquency as those not labeled with “ADHD” at all.

    So in essence, studies finding that “ADHD” leads to more delinquent behavior are actually making the profound observation that young kids who are aggressive are more likely to continue to be aggressive when they are a few years older. (And they got PAID to discover this?)

    When you consider the high correlation between aggressiveness and early childhood abuse and neglect, and the very high frequency of abused kids being diagnosed with “ADHD” and having their trauma unrecognized, it’s quite possible to conclude that “ADHD” is completely unrelated to delinquency, except through the probability that many kids with abuse/neglect issues will get swept up into its subjective range.

    —– Steve

  6. Casual use of a search engine leads to plenty of sources that say the stimulants perscribed for ADHD can cause problems with the heart.

    Also I guess it might be convienient to focus specifically on mortality because then you don’t have to address the other thing that jumps out and that’s the impact on growth, which would be a pretty important side effect for kids on a “maintainance dose”.

  7. There’s plenty of “madness” but I’m not seeing any science. Only grandiose delusions.

    Interesting that you suddenly turn up, smatter years old articles and this one regarding ADHD with brief/one line personal attack quips in less than 10 minutes.

    You can’t expect anyone that uses this site to take you seriously if you’re just going to do this. There’s no way this site is an “echo chamber” or “hugbox”, i’ve never seen them censor anything.