CCPR: To start, tell us about how the thinking has changed in terms of health consequences from ADHD.
Dr. Barkley: In the 1970s, we saw ADHD as an educational disorder with impacts on school behavior and academic achievement. Around that same time, there was a parallel path recognizing ADHD as a social problem in family functioning and peer relationships. Later it was viewed by some in terms of predisposing children and teens to aggression, conduct disorder, delinquency, and substance disorders. Recently, we have broadened our view even further to incorporate the health-related consequences of the disorder (Nigg JT, Clin Psychol Rev 2013;33(2):215–228). For instance, decades of research show a predisposition to accidental injuries in children and adolescents, and in the adult workplace—not just falls, scrapes, burns, and broken bones, but pedestrian cyclist accidents and car crashes. And then, of course, we also see an increased likelihood of sports-related injuries, such as traumatic brain injuries (Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 4th ed. New York, NY: Guilford Press; 2015). But about a decade ago, we began to focus on other adverse health consequences associated with ADHD. For instance, people with ADHD were reporting twice the level of obesity, particularly by adolescence and adulthood.

CCPR: Can you give us some specifics on ADHD’s effect on health?
Dr. Barkley: Forty percent of all ADHD children and adults have sleep difficulties, including night waking, insomnia, inefficient sleeping, and daytime sleepiness. We see problems with nutrition and diet—a predisposition to high-carbohydrate “junk” or fast food and, relatedly, to obesity and increased risk for type 2 diabetes. Many people with ADHD are leading a sedentary lifestyle, drawn to social media and gaming, and less likely to exercise. The Swedes saw problems in dental health: increased likelihood of cavities, infections, and dental trauma (Sabuncuoglu O & Irmak MY, Dent Traumatol 2017;33(2):71–76). Headache and vague bodily complaints emerged in a variety of studies on the outcomes of children with ADHD (Barkley, 2015). Finally, ADHD was showing up across many predisposing factors for cancer, heart disease, and most recently a shortened life expectancy.

CCPR: Tell us more about the specific research on life expectancy.
Dr. Barkley: Drawing from large databases, Sweden, Denmark, and Taiwan found high risks of accidental injury and increased suicide, leading to a marked rise in mortality risk at all ages. Dalsgaard in Denmark showed that children with ADHD were nearly twice as likely to die before age 10 from accidents and that by age 45, the rate of accidental death was nearly 5 times greater than normal (Dalsgaard S, Lancet 2015;385:2190–2196). This was replicated in the subsequent Swedish and Taiwanese research. More recently, we wondered about the health factors that are well-established correlates of ADHD—smoking, drinking, sleep issues, risk for seizures and migraines, etc. It doesn’t take a life insurance agent to see that they all adversely affect life expectancy. In my Milwaukee study of children followed to ages 27–32, we did a comprehensive physical exam and lab studies but couldn’t put the findings together into a single picture. Then two years ago, the Goldenson Center for Actuarial Research at the University of Connecticut made publicly available a life expectancy equation for calculating life expectancy based on very large data sets, and so we used it to analyze our data. No one had ever done this before.

CCPR: What did you find?
Dr. Barkley: When the computer algorithm results were analyzed, I had one of those gut-punch aha moments—truly stunning. What we found was that if you were diagnosed with ADHD in childhood, regardless of whether you outgrew your disorder or not, there was a 9- to 10-year reduction in life expectancy regardless of having received treatment as a child. We found roughly a 13-year reduction in life expectancy if your ADHD persisted, and 7 or 8 years if the ADHD was no longer present, compared to the control group. And there was a greater number of unhealthy years of life (Barkley RA & Fischer M, J Atten Disorders 2019;23:907–923).

CCPR: That’s disturbing to say the least. How does ADHD stack up against other health risk factors?
Dr. Barkley: Compared to other killers from a public health standpoint, it’s bad. Smoking, for example, reduces life expectancy by 2.4 years, and if you smoke more than 20 cigarettes a day, you’re down about 6.5 years. For obesity and diabetes, it’s a couple of years. For elevated blood cholesterol, it’s 9 months. So ADHD is worse than the top 5 killers in the US combined, coming in at nearly 13 years of reduced healthy life if it persists to adulthood.

CCPR: What you are saying is that ADHD is truly a major public health issue.
Dr. Barkley: Yes, and that’s on top of all of the findings on a greater risk for accidental injury and suicide. The range around that 13-year figure goes from 4 up to 29 years or more, with about two-thirds of people with ADHD having a life expectancy reduced by up to 21 years (Barkley & Fischer, 2019).

CCPR: What about other mental illnesses?
Dr. Barkley: Some psychiatric disorders have worse life expectancy than ADHD, such as schizophrenia, which has higher associations with homelessness, disease, and suicide. But ADHD is clearly worse than depression, anxiety, and bipolar disorder, and more like what you see in the psychotic disorders.

CCPR: But with higher prevalence rates, correct?
Dr. Barkley: Yes, 5%–8% of children and 5% of adults have ADHD. Autism, for instance, is 1 in 66, and schizophrenia is even lower, according to the DSM-5.

CCPR: How do these ADHD outcome statistics frame our thinking?
Dr. Barkley: The way I see it, there are four vectors of change that we need to address. First, we need to make families aware of these consequences. Talk with them about health, wellness, sleep, nutrition, exercise, substance use, and so on. This is beyond the already well-known psychiatric, educational, social, and emotional aspects of ADHD. Priority number two is encouraging mental health clinicians to look at health and wellness variables—you don’t have to have a black bag or a stethoscope to ask about these—then refer patients with ADHD to community resources for smoking, weight, sleep, coaching, and so on as needed. Third, primary care providers need to be more aware of ADHD as a background factor when treating patients for these sorts of adverse health conditions. And vector number four is awareness on the part of government agencies—if ADHD is unrecognized and untreated, they’re not going to be very successful in helping people change health behaviors, which drives up the cost of care.

CCPR: So people with ADHD come to primary care with other health problems, but their ADHD is not recognized?
Dr. Barkley: The disinhibition and impulsivity in ADHD are the gorilla behind the curtain here. The health factors that lead to reduced life expectancy are related to poor conscientiousness, which comprises these sorts of disinhibitory traits. So the primary care providers, who are tasked to deal with obesity, smoking, cholesterol, exercise, sleep problems, and so on, need to look for ADHD when patients present with these problems, particularly if the patients have failed in prior attempts at self-improvement. Providers need to use a screener, which can be easily done.

CCPR: Is there a specific screener that you recommend?
Dr. Barkley: The World Health Organization has the Adult ADHD Self-Report Screening Scale (ASRS). It’s a 6-item screener, more for adults than kids. It’s well normed and has good data on its ability to detect. A high score is cause to refer for a thorough evaluation. Using the 6-item ASRS isn’t going to break the bank when it comes to time or expense. (Ed note: There are many scales that are helpful for tracking patient progress, but they are no substitute for your clinical assessment. Unfortunately, there is a lack of current research on most except the Attention Deficit Disorder Evaluation Scale [ADDES] and the better but longer NICHQ Vanderbilt Assessment Scales. My personal favorite is the CAP—quick for teachers, quick to score, and informative.)

CCPR: Compliance is still tough, whether it’s primary care or psychiatry referring for intervention.
Dr. Barkley: Yes. I teach our residents: “You are only as good as your Rolodex.” Know your area resources for people specializing in reducing these various health risks who can assist your ADHD patients. You need to start there and address compliance at follow-up. (Ed note: See CCPR Sept/Oct 2019 for articles on motivational interviewing.)

CCPR: Switching gears, meds work over the long haul, and we are often the ones managing them. There have been mixed findings about the impact of ADHD and medication on growth in kids. Can you speak to this concern?
Dr. Barkley: A failure to gain about 2–4 pounds a year and about 1 centimeter in height is typical in children with ADHD on medication. These growth effects are limited to the first few years of treatment, with no evidence of medications affecting predicted adult stature. There’s some catching up that eventually occurs.

CCPR: What about Parkinsonian syndromes with chronic use of stimulants?
Dr. Barkley: Two studies were published last year that showed people with ADHD were between 2 and 4 times more likely to develop Parkinson’s (Tzeng NS et al, J Atten Disorders 2017;23(9):995–1006). And that’s also true for ADHD predisposing to other basal ganglia and cerebellar late-stage disorders (Goodwin RD et al, Psychol Med 2009;39(2):301–311). So later upper-motor neuron difficulties and cerebellar problems may have some link with ADHD earlier in life. It’s not the medication creating this risk—the disorder arises from those brain structures, and those are the ones that decay during the latter part of life. One study showed an eight-fold increase in Parkinson’s if people had been on an ADHD stimulant medication. But the authors noted that medication is a marker for severity of ADHD, so their study couldn’t show that it was the stimulant creating that risk (Curtin K et al, Neuropsychopharmacol 2018;43:2548–2555). We have to be careful not to sensationalize that finding. Other than growth lag during the first 2–4 years of treating children, we have no evidence that there’s a lasting effect on height, weight, or other physical parameters.

CCPR: Good to know. What other interventions should we consider?
Dr. Barkley: Cognitive behavioral therapy (CBT) targeting executive-functioning deficits in adults with ADHD is very beneficial, and studies are promising for use in older teens (Knouse LE et al, J Consult Clin Psychol 2017;85(7):737–750). Mary Sollanto, Russ Ramsey, Steve Safren, and others have published clinical manuals on this intervention. For example, Sollanto’s CBT manual for adult ADHD helps with daily problems with decision-making, planning, organizing, emotion regulation, and stress control that are triggers for other health problems like overeating, drug use, smoking, and sleep difficulty (Sollanto MV. Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. New York, NY: Guilford Press; 2013). And the adult ADHD coaching network is blossoming in the US. Coaching can help initiate and sustain gains in managing ADHD, typically by staying in touch with people daily or near daily and thus providing increased accountability for their plans for self-improvement.

CCPR: What are your thoughts about exercise and meditation?
Dr. Barkley: A growing body of evidence shows physical exercise may be more beneficial for ADHD management than for any other psychiatric disorder. It’s not curative, but routine aerobic exercise seems especially beneficial for symptomatic management of ADHD. It also provides weight control or loss, stress reduction, and improved sleep. But the beneficial effects of exercise also include what I call micro-exercising: any kind of movement during class or homework or meetings, such as having a stress ball in one hand or working at a standing desk. Even small amounts of movement are very beneficial to work productivity and attention for these individuals. Mindfulness meditation may be helpful, but it’s not well researched for ADHD at the moment. Personally, I think it’s mainly for the emotion dysregulation and stress experienced by adults with ADHD. It’s not so much for improving other executive deficits like time management and self-organization—no one would expect meditation to touch those. (Ed note: A systematic review and meta-analysis suggests there is evidence of benefit from meditation: Chimiklis AL et al, J Child Fam Stud 2018;27(10):3155–3168. doi:10.1007/s10826-018-1148-7)

CCPR: You’ve outlined a full plan.
Dr. Barkley: Yes, but treating ADHD boils down to five components in the treatment package: diagnosis, patient education, medication, behavior and lifestyle modification, and accommodation—meaning how the patient changes the environment to reduce impairment. The specific evidence-based treatments for adult ADHD would be medication, CBT, exercise, coaching, and maybe mindfulness meditation practice.

CCPR: Any final thoughts you’d like to share?
Dr. Barkley: ADHD is the most treatable disorder in psychiatry, bar none. We have more medications with (in most studies) larger effect sizes, greater response rates, and more delivery systems that change people’s lives more than any other disorder. They’re some of the safest medications in psychiatry. The risks for coronary problems, seizures, sudden death, and drug abuse later in life from these medications—well, they’re not there. The epidemiological studies published on large populations in the last three years have eviscerated those concerns. For me, as I come to the end of my career, if I have to go out with one last gasp, it’s going to be about ADHD as a public health disorder, not just a mental health disorder.

CCPR: Thank you for your time, Dr. Barkley.