The ADHD Label and Mortality

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.