Webinar: Does physical activity improve ADHD symptoms?

There is a lot of anecdotal evidence that physical activity reduces ADHD symptoms. Some athletes, like Michael Phelps and Louis Smith, have said that their intenstive training helped them loose excessive energy and gain structure in their lives. But what is the scientific evidence for this?

Researcher dr. Jonna Kuntsi and her team from King’s College London have done a lot of reserach on this topic. They have reviewed the available literature on physical activitiy and ADHD, conducted analyses on twin-data and are conducting several experiments to test this. In this webinar she explains what’s known and what’s not yet known about whether physcial activity can improve ADHD symptoms

We previously wrote blogs about this topic as well:

Beneficial effects of high-intensity exercise on the attentive brain

Living day-to-day with ADHD and experience of the CoCA clinical trial

CoCA-PROUD trial ready to roll

How psychiatric genetics can help to guide diagnostic practice and therapy

Recently, professor Stephen Faraone from SUNY Upstate University in the USA gave a webinar about genetic research in psychiatry (especially ADHD) and how this can help to better understand diagnosis and provide better treatment. In this blog I will share with you some highlights from this webinar.

  1. ADHD is a continuous trait in the population

ADHD is not something that you either have or don’t have. Rather, symptoms or characteristics of ADHD are present in the entire population, in varying severity. The system for psychiatric diagnoses is however based on categorical definitions that determine when a certain combination of symptoms and severity can be classified as a particular disorder. Although these categories can be of great help to provide public health data or determine insurance coverage, they often don’t really match individual cases. Hence there arise problems with heterogeneity, subtypes, subthreshold cases and comorbidity.

Genetic research has shown that psychiatric conditions such as ADHD are not caused by a few single genes, but rather by thousands or tens of thousands genetic variants that each contribute slightly to the ADHD risk. These so-called polygenic risk scores form a normal distribution across the entire population, with the majority of people having low polygenic risk scores (so a low to average risk of ADHD), while a small portion of individuals have a very low or very high risk. This adds to our understanding that ADHD is a continuous trait in the population.

Image from the webinar by prof. Stephen Faraone. The higher the number on the x-axis, the higher the genetic risk of having ADHD. Negative numbers mean reduced genetic risk of ADHD.

2. Comorbidity in psychiatry is the norm, rather than the exception

In the webinar, Stephen Faraone explains that in 90’s it was thought impossible that an individual can have both ADHD and depression. Now, we know better than that. There are substantial genetic correlations between different psychiatric disorders, meaning that the genes that increase the risk of for instance ADHD, also increase the risk of schizophrenia, depression, bipolar disorder, autism and tic disorder. This is further evidence that psychiatric conditions are not separate, categorial entities but rather arise from similar biological mechanisms.

3. Personalised medicine and pharmacogenetics are not yet sufficiently established to adopt widely and replace current medication on a broad scale

The second part of the webinar was about pharmacogenetic testing. This means that an individual’s genetic profile is used to determine whether a drug will be effective, and in what dose. Although this sounds promising, there is still a lot of discussion about the validity of such tests. This is due to varying results, differing protocols and large heterogeneity between studies. In some cases, pharmacogenetic testing can help to find the right treatment for an individual, for instance when this person is not responding well to regular treatment, but it is definitely not a fool-proof method yet. Better randomized controlled clinical trials are needed to improve reliability of these tests.

You can watch the full webinar here: https://www.youtube.com/watch?v=DLgqdJWZKIo

Why following instructions is essential for treatment success (and why this is really difficult)

 

Clara Hausmann, Mental mHealth Lab / Chair of Applied Psychology, Karlsruhe Institute of Technology



When visiting your doctor due to a simple cold you’ve caught, you will probably get the following advice: Get a rest from work, stay in bed for a week, drink a lot of herbal tea and go for a slow walk once a day. Well, you might follow the advice as you’ve been told. But possibly, you can’t stand tea or you are currently under pressure to finish some urgent work and anyway, you don’t feel that bad anymore after one day in bed. The degree to which a patient correctly follows medical advice is called compliance.

            Compliance is also an important term in the psychological and medical research, we are conducting – especially in our ambulatory settings where patients are treated outside of the hospital. In contrast to doing research in very well controlled laboratory settings, embedding research into everyday life  avoids  a lot of methodological disadvantages. For example, participants’ behavior won’t be biased by the presence of a researcher or the artificial situation in the lab. Another great feature of ambulatory assessment lays within the opportunity to gather real time or near real time data. Participants will be regularly asked about their current state of mind, so researchers don’t have to take into account the inaccuracy of patients’ retrospective reports [1] .  Still, we are facing some difficulties when using ambulatory settings – reaching a good compliance is part of it.

            In the CoCA PROUD study, for instance, we are ambulatorily monitoring our ADHD-diagnosed participants’ mental and physical state. Therefore, they are equipped with a smartphone and a small activity sensor. Participants keep an eDiary, by fulfilling repeated questionnaires on the smartphone while the activity sensor on their wrists measures physical activity. Meanwhile, they will take part in some non-pharmalogical interventions (daily physical exercise training or bright light therapy), which promise to alleviate some core symptoms of ADHD and it’s comorbidities such as depression.

            In this study, „compliance“ is what we call the percentage of prompts, that were answered, in order to fulfill the eDiary. All in all, participants receive four prompts per day, including questions about their current mood, social context and ADHD symptomatology. Furthermore, we can analyze how often the sensor was worn. Additionally, checking for the compliance during the interventions allows us to calculate how much time was spend on actively carrying out the instructions (e.g. doing strengthening and aerobic exercises).

In general, we aim to reach a good compliance. The more our participants contribute, the better the quality of data and the understanding of ADHD can be. However, one can imagine that general facts of life such as situational distraction or simple forgetting can be a hindrance for participants, to answer prompts [2].  Apart from this, researchers must be aware, that ambulatory assessment is inherently disruptive to participants’ daily lives. For instance, the activity trackers that participants wear are quite big, and getting daily prompts from the eDiary can be a real nuisance. The art lies in the design of the research: It is unquestionably essential to find a good balance between participants’ expenditure in time and energy and the amount and quality of data collected [3]. In order to find this balance, we’re always first testing the research study on ourselves to check for the feasibility, comfort, and ease of participation.

            Besides that, there are specific challenges for participants diagnosed with ADHD. For instance, the tendency to show irregularities in the day-and-night-rhythm might not always match the time of the smartphone prompts, that are sent in regular intervals. Furthermore, some patients tend to have problems in keeping their belongings organized. Especially for young patients, it might be challenging to keep the phone both charged and on their person. Inattention and lack of concentration as core symptoms of ADHD, are additional burdens to the conscientious and constant work on the questionnaires. Particularly young patients are expected to be quickly bored by the repeated questions, incoming day by day.

            We encounter those difficulties in multiple ways. An important tool is the smartphone’s chat function. Participants can easily reach a contact person and vice versa. Hence, individual or technical problems can be detected and solved quickly. In order to facilitate the start, we send reminding and motivating messages during the first four days of the measurement. To keep participants’ motivation high, they receive daily feedbacks, visualizing how they have performed when exercising.

            Taken as a whole, compliance, whether good or not, provides a lot of important information about the quality of the intervention. A treatment can only be considered as promising and helpful, when patients are able and motivated to include it into their daily lives. Therefore, the combination of ambulatory assessment and compliance monitoring gives us a realistic idea of a treatment’s actual feasibility and – in the consequence – it’s quality.

 

References:

[1] Trull, T. J., & Ebner-Priemer, U. W. (2013). Ambulatory Assessment. Annual review of clinical psychology, 9, 151–176. doi:10.1146/annurev-clinpsy-050212-185510 

[2] Piasecki et al. (2007). Assessing Clients in Their Natural Environments With Electronic Diaries: Rationale, Benefits, Limitations, and Barriers. Psychological Assessment,19(1), 25-43. doi:10.1037/1040-3590.19.1.25


[3] Carpenter, R. W., Wycoff, A. M., & Trull, T. J. (2016). Ambulatory assessment: New adventures in characterizing dynamic processes. Assessment, 23(4), 414–424. https://doi.org/10.1177/1073191116632341


 

Is it safe to use ADHD medications during pregnancy?

“Should I discontinue stimulants when I am pregnant?” “Is it harmful to my developing baby if I take ADHD medications during my pregnancy?” “What are the risks both to me and my baby if my ADHD goes untreated?” “What is the best way to manage my ADHD during pregnancy?” – For women with ADHD who become pregnant, especially those with moderate or severe ADHD symptoms, the next few months are filled with questions. One important decision for the pregnant women and their clinician is whether to remain on or cease their ADHD medication treatment before or during pregnancy, or while breastfeeding. Unfortunately, there is no clear ADHD treatment guidelines for pregnant women, which further complicates these decisions. Therefore, there is a need for high-quality evidence to support guidelines for the use of ADHD medication during pregnancy.

Given that, it is unethical to include pregnant and breastfeeding women in clinical trials, evidence-based guidelines need to rely on findings from naturalistic studies. So, what does the available findings from naturalistic studies tell us?  

In our newly published paper in CNS Drugs (https://doi.org/10.1007/s40263-020-00728-2), we conducted a systematic review to synthesize all available evidence regarding the safety of ADHD medication use while pregnant, with a focus on how these studies have handled the influence of confounding, which may bias the estimates from observational studies.

We identified eight cohort studies that estimated adverse pregnancy-related and offspring outcomes associated with exposure to ADHD medication during pregnancy. These studies varied a lot in data sources, type of medications examined, definitions of studied pregnancy-related and offspring outcomes etc. Overall, there was no convincing evidence for an association between maternal ADHD medication use during pregnancy and adverse pregnancy and offspring outcomes. Some studies suggested a small increased risk of low Apgar scores, preeclampsia, preterm birth, miscarriage, cardiac malformations, admission to a NICU, and central nervous system (CNS)-related disorder, but other available studies failed to detect similar associations. Because of the limited number of studies and inadequate confounding adjustment, it is currently unclear whether these small associations are due to a causal effect of prenatal exposure to ADHD medication or confounding.

In conclusion, the current evidence does not suggest that the use of ADHD medication during pregnancy results in significant adverse consequences for mother or offspring. However, the data are too limited to make an unequivocal recommendation. Therefore, physicians should consider whether the advantages of using ADHD medication outweigh the potential risks for the developing fetus according to each woman’s specific circumstances.

More information here:

Li, L., Sujan, A.C., Butwicka, A. et al. Associations of Prescribed ADHD Medication in Pregnancy with Pregnancy-Related and Offspring Outcomes: A Systematic Review. CNS Drugs (2020). https://doi.org/10.1007/s40263-020-00728-2

Authors:

Lin Li, MSc, PhD student in the School of Medical Science, Örebro University, Sweden.

Henrik Larsson, PhD, professor in the School of Medical Science, Örebro University and Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Sweden.

Prevalence and cost of ADHD comorbidity

Do individuals with ADHD more often suffer from depression, anxiety, substance abuse or severe obesity, than individuals without ADHD? Are there differences between men and women in how often this is the case? Does having ADHD in addition to one of these conditions result in higher health care costs?

The short answers to these questions, are yes, yes and yes. In the CoCA-project, researchers have investigated these questions using very large datasets including Scandinavian birth registries that contain information of millions of people. This allows us to get a better understanding of how often conditions occor, how often they occur together, and how often they occur in men vs women. Furthermore, we have investigated health insurance data from Germany to study patterns of health care costs associated with ADHD and its comorbid conditions.

The interpretation of these data is however not simple. That is why we have recorded a webinar with dr. Catharina Hartman from Groningen, The Netherlands. She is the leader of these studies and can explain what these findings can and cannot tell us. The webinar ends with implications for policy makers and health care professionals, based on these findings.

From genes to driving schools: an Estonian program to reduce traffic accidents

Image by Netto Figueiredo from Pixabay

Driving is dangerous. 1.35 million people die from road accidents every year, according to the World Health Organization [1]. Young people who just obtained their driving license, and especially young men,  are at the highest risk for accidents. They are often seeking sensation, are more likely to take risks, and are more prone to take impulsive or thoughtless decisions while driving. To target this specific group, Estonian researchers have developed a training program for driving schools to make people aware of their impulsive tendencies.

Genetic predictors of traffic accidents

Interestingly, this Estonian research group that is led by professor Jaanus Harro specializes in genetics. Next to studying rats, Harro wanted to also investigate impulsive and aggressive behavior in humans. To measure this objectively outside of a laboratory setting they used data on traffic offences and accidents. Harro and his group found that a particular variation in the gene called 5-HTTLPR was associated with the number of speeding offences and traffic accidents [2]. People who have the short version of this variant are less likely to be caught for speeding or be involved in accidents, compared to those with the long variant.

The gene 5-HTTLPR is an important player in the serotonin system in the brain. Serotonin is a messenger molecule with many functions, one of them being the regulation of mood, impulsivity and aggression. Some people are more prone to act without thinking, or without considering the consequences, and this can partly be explained by genetics.

Reducing impulsive driving behavior

So should only people with the short version of 5-HTTLPR be allowed to drive? No, Harro and his team came up with something better: a program to reduce impulsive behavior on the road. They gave this to students who were learning to drive. In the training, students discussed their own impulsive tendencies, and ways to overcome these tendencies. There was also a control group that did not receive this extra lesson. Four years after obtaining their licenses, the group that received the training had been less involved in traffic violations and accidents than the control group. What’s more, those individuals with the long variant of 5-HTTLPR – so the ones who are more likely to be impulsive, based on this gene – benefited from the training the most.

For the driving schools the main implication of this experiment is that it is very beneficial to incorporate awareness training about impulsivity into driving lessons. Already eight driving schools in Estonia are providing the program to their students. The genetic findings however are mainly of interest to the researchers, who are hoping to gain a better understanding of impulsive and aggressive behavior. In addition to the serotonin-gene, they have found that genetic variations in the noradrenaline and dopamine system are also linked to traffic offenses and speeding, and to the effectiveness of the training [3, 4]. And just recently, they found that the neuropeptide orexin is linked to both aggression and to the prevalence of drunk driving and traffic accidents [5].

Beyond genetics

In addition to genes, other factors such as age, intelligence, and stressful life events influence the risk of offences and accidents as well, but we still know very little about how this works. That is why Harro and his team are now investigating the interactions between genes and environment. This research is part of the horizon2020 projects CoCA and Eat2beNICE. Ultimately, through a better understanding of our biology they hope to improve the way that people behave on the road, thereby reducing the number of accidents.

Meanwhile, Jaanus Harro travels to ministries and other governmental organizations in Estonia and Finland, to convince them to implement the training program on a national level, and to provide funds for further research. And in case you wonder about Harro’s own driving habits: although he acknowledges that he is quite impulsive, he assures us that he has learned to keep this under control while driving.

Jaanus Harro was recently interviewed by Science Business about this topic. Parts of this blogpost ar based on this interview. You can read the article here: https://sciencebusiness.net/keeping-drivers-impulses-check

References

[1] https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries (accessed 3 January 2020).

[2] Eensoo, Paaver, Vaht, Loit & Harro (2018). Risky driving and the persistent effect of a randomized intervention focusing on impulsivity: The role of the serotonin transporter promoter polymorphism. Accident Analysis and Prevention, 113, 19-24. https://www.ncbi.nlm.nih.gov/pubmed/29407665

[3] Paaver, Eenso, Kaasik, Vaht, Mäestu & Harro (2013). Preventing risky driving: A novel and efficient brief intervention focusing on acknowledgement of personal risk factors. Accident Analysis and Prevention, 50, 430-437. https://www.ncbi.nlm.nih.gov/pubmed/22694918

[4] Luht, Tokko, Eensoo, Vaht & Harro (2019). Efficacy of intervention at traffic schools reducing impulsive action, and association with candidate gene variants. Acta Neuropsychiatrica, 31, 159 – 166. https://www.ncbi.nlm.nih.gov/pubmed/31182183

[5] Harro, Laas, Eensoo, Kurrikoff, Sakala, Vaht, Parik, Maëstu & Veidebaum (2019). Orexin/hypocretin receptor gene (HCRTR1) variation is associated with aggressive behaviour. Neuropharmacology, 156. https://www.ncbi.nlm.nih.gov/pubmed/30742846

 

Mythbusters: artificial food colours and ADHD

When I was a kid, there was a boy in my class called Jeroen. At times I found him friendly and funny, but other times he would drive me insane with his hyperactive behaviour, jumping around and pulling my hair. Then one day, he told us that we wasn’t aloud to eat anything with artificial food colours anymore. This was supposed to reduce his hyperactivity. I was hopeful, but also sceptical if this would work.

Now that I’m involved in an international consortium investigating food and behaviour, I finally had the chance to learn about food colours and ADHD. Turns out, there is some truth to the claim, although it may only be true for some children, and it may not be specific to ADHD.

A shitty story

To better understand the effects of food on behaviour, we need to start at the end. Your poo can actually tell us a lot about the billions of microbes that live in your gut and help to digest the food you eat. For a long time, we didn’t know much about this micro-wildlife, until scientists developed techniques to analyse large amounts of DNA very quickly and cheaply. As every species has unique DNA, researchers can identify all the different species that live in your gut by analysing their DNA from poo. This helps us to better understand the many important roles that the gut bacteria play in your body, including your brain. For instance, certain bacteria produce neurotransmitters from digesting fibres. These neurotransmitters are important for the communication between brain cells.

ADHD

What does this have to do with ADHD? ADHD is a neurodevelopmental condition, which means that the brain develops differently compared to typically developing children. This influences the functioning of the brain and hence people with ADHD have problems focussing their attention, controlling their impulses and regulating their activity. A disruption in the neurotransmitter system is thought to play a key role in this. While the main cause of ADHD is genetic, environmental factors are also known to increase the risk of the condition, such as smoking during pregnancy, toxins in the environment, and food allergies. Since recently, researchers are investigating the gut bacteria (aka the poo) to better understand how food allergies may trigger ADHD [1].

Food allergies

The microbes in the gut interact closely with the immune system. During development the immune system has to learn that many foreign substances in the intestines (i.e. food and bacteria) are good and should not be attacked. In a way, it has to learn not to overreact. And this is what happens with food allergies. The over-reaction of the immune system is harmful for both the gut environment and for the brain, especially if it happens very often. Hence, an allergic reaction to food colourings may trigger small changes in the brain that in turn may trigger behaviour such as hyperactivity. How this works exactly is still unknown.

Based on this theory, clinicians and nutritionists are now investigating if special diets can reduce ADHD symptoms [2]. In such a diet, a child is put on a very restrictive diet that eliminates any potentially allergenic substances. To see which food types trigger the symptoms, specific foods are introduced one by one. For some children, this really seems to work well and they can manage their symptoms by not eating certain foods the rest of their lives. The elegance of this method is that it is based on the individual. While one person may need to eliminate food colourings, for another it could be certain fruits, or cow’s milk.

Myth busted?

Do artificial food colours cause ADHD? This may be the case for some children. In others, other types of food may trigger ADHD symptoms. And in yet another group of children, their ADHD has nothing to do with food allergies. At the moment, the only way to find out is through trial and error. But only try this under supervision of trained nutritionists and clinicians!

Back to Jeroen. I don’t remember him getting less annoying. Perhaps he was not allergic to food colourings at all, and he should have tried the complete elimination diet or different medication. Or perhaps I was just an eight-year old girl allergic to all boys.

References

  1. Dam, S. et al. (2019) The Role of the Gut-Brain Axis in Attention-Deficit/Hyperactivity Disorder. Gastroenterol Clin N Am, 48, 407–431
  2. Ly, V. et al. (2017) Elimination diets’ efficacy and mechanisms in attention deficit hyperactivity disorder and autism spectrum disorder. European Child and Adolescent Psychiatry, 26, 1067-1079.

This blog was written by dr. Jeanette Mostert. She is a neuroscientist and science communicator. She is involved in the CoCA-project and Eat2beNICE project. In the latter she is learning all about the links between food and mental health. 

Light therapy and its influence on ADHD: An interview

 

Nina (27 years, Dutch) participated in the PROUD-study and followed our light therapy. In this interview she describes the influences light therapy had on her ADHD symptoms.

What is it like to live with ADHD?

Please describe your main symptoms.

The symptom I experience as the most troublesome is making new friends. It is harder for me to make new friends, knowing I have fewer emotional and cognitive skills than peers. I am more sensitive to persons and situations and I experience them as more severe.

Besides, it is harder for me to see things in perspective and my perspectives change a lot over short periods of time. This makes it harder to look further in the future when making decisions. I also have less patience and it is harder for me to concentrate on a task. 

How does ADHD influence your life?

As I explained in the question before it can be tough to make friends. Concerning work, my ADHD has positive and negative effects. The negative effects are my lack of concentration, sometimes a job has to be done at a certain moment when I have no concentration, which can be a real struggle. The positive side is that I am creative and my spatial development is good. These are qualities that come handy at my job. Also my intelligence helps me. Because I am smart I can work fast at the moments my concentration is good, in order to compensate for the moments where my concentration is lost.

Do you think ADHD has any positive influences in your life?

It sure has, but these influences often last for a short period of time. I can be really enthusiastic and I am good at identifying people. This quality makes me a really good friend. Also my creativity is a positive effect of ADHD.

How have you been treated (medication/ psychotherapy)? What are the effects?

For a year and a half I have lived internally in a group especially for adolescents with ADHD and/or autism. Here I followed a training to improve my social abilities, how to engage in relationships with others and to be more independent.

From my 16th I take medication. I have switched a lot and tried different kinds of medication. Much of them did not work well for me, I even tried anti-depressants which made me feel sad. I am currently taking Stratera (short acting) and this works well for me. I don’t take it regularly but only at moments where I think I need it.

Study and intervention

How did you learn about the study?

I am regularly searching the internet to learn more about ADHD. This time I was searching information about comorbidity and neurodiversity and this is how I found your website, by chance.

What motivated you to participate?

It is a good thing that more research is done and I find it important to contribute. The more research is being conducted, the better others with ADHD can be helped. It is of great importance of me to be able to be a part in this. As long as we do not contribute to this kind of research, nothing will chance.

What were your expectations about the study before you started?

To be honest I did not have any expectations because I did not want to be affected by them.

What intervention did you participate in? When?

I participated in the bright light therapy from the 18th of October (2018) until the 10th of January (2019).

What did you like about the intervention? What did you dislike about the intervention?

At the beginning it was kind of hard, I found it really hard to be sitting still half an hour in the morning. Normally I rush through the mornings and do not really sit still at all. My solution was to put the lamp at my nightstand and sit in bed for half an hour in the morning, waking up next to the lamp. You can adjust the brightness of the lamp so I started with dimmed light and increased brightness step by step. Important is to sit upright because otherwise there is a chance of falling back to sleep!

In the beginning I had not realized what an impact this therapy has on your daily life, you really need the motivation to sit through, every day. After some time I got adapted to a new rhythm which made it easier to follow the light therapy for 6 times week. Only on Saturdays I skipped the sessions because of the weekend.

Was the intervention helpful?

It definitely has positive influences. The biggest change I have experienced is the adaptation to a more natural day/night rhythm. I was hoping a side effect would be falling asleep faster but unfortunately this was not the case for me.

The first days I experienced some negative side effects, which are explained in the bright light manual. Maybe it would be better if I had not read the manual because I was so focused on the experience of these side effects. What I felt was a really grumpy mood in the mornings. Luckily it only lasted for a few days.

Are you planning on continuing the intervention?

No, I have no plans of buying a lamp myself. Looking back at the intervention I think I would benefit more by participating in the aerobic exercise intervention, because sitting still for half an hour without a clear purpose is tough. Of course I did adapt to a better and more natural day/night rhythm because of the bright light therapy, but I think this could also be accomplished by going to bed at the same time every day.

Was it difficult/easy to use the App?

Definitely not difficult. The researches informed me about the sensor and how it might be inconvenient in the beginning but I only had to get used to it during the nights. The app was really clear and straight-forward, easy to use. I did forget the phone a few times, making me drive back home, but if you wear pants with pockets this should not be a problem.

Would you recommend other people with ADHD to participate in the study? Why?

I would definitely recommend it to people who are interested in this study and are motivated to participate. You really have to do it because you want it, not only because you want to help others.

Any suggestions/ways that the researchers could improve the experience for people in this study?

In my experience the study is set up well. Sometimes something went wrong (system was not installed right so they had to send me a new set, this set came without a wristband, red.) but the researchers handled it well and professionally. The researchers were cooperative and I liked participating in this study.

Lisa Bos, MSC works at Karakter Child and Youth Psychiatry and Radboud UMC (Nijmegen, the Netherlands) where she works as a researcher for the TRACE project and the PROUD-study. Both studies focus on additional treatments for ADHD and a healthy lifestyle which are also her main interests. She finds importance in studying socially relevant topics and improving the quality of care for ADHD patients.

German study first to show direct medical costs of ADHD and its comorbid conditions across the lifespan

Having ADHD is expensive. A study of German insurance data has shown that the medical costs of a person with ADHD are 1500 euro higher per year, compared to a person without ADHD. But that’s not all; individuals with ADHD are far more likely to suffer from additional conditions such as mood and anxiety problems, substance abuse or obesity. Treatment of these conditions can cost up to an additional 2800 euro per year. As ADHD – especially in adults – is still poorly recognised and diagnosed, these numbers may not reflect the complete picture of ADHD medical costs. Improving diagnosis and adult mental healthcare may prevent mental health problems later in life and actually reduce costs, argue Berit Libutzki and her co-authors.

ADHD (Attention Deficit / Hyperactivity Disorder) is a developmental condition. Symptoms arise before the age of 12 and are characterised by age-inappropriate and impairing behaviour in terms of problems with attention, impulsivity and hyperactivity. World-wide prevalence of children with ADHD is estimated around 5%, while in adults this is around 2.5%. This means that in about half of the children problems do not subside with age. For these people, ADHD is a lifelong condition that often impairs health, career and social life.

To estimate the economical costs of ADHD, Berit Libutzki and her colleagues from HGC Healthcare Consultants GmbH analysed the (anonymised) health insurance data of almost four million Germans. They compared the medical costs of people with an ADHD diagnosis to those of a well-matched group without ADHD.

medical costs per person_figure

The results showed that the medical costs of a person with ADHD are on average 1508 euro higher than those of a person without ADHD. These costs are mainly due to treatments in hospitals and by psychiatrists. ADHD medication itself (such as Methylphenidate) are in third place, contributing to only 11% of the additional costs. Other interesting findings from the study are that medical costs are a bit higher in women compared to men, and that costs are much higher in individuals over 30 years old compared to younger age groups. After the age of 18, the costs of for example ADHD medication drop, while psychiatrist costs and costs for other (non-ADHD) medications increase notably. Also sick payment is high in adult ADHD patients, leading to a significant increase in costs. One of the explanations for these cost increases could be a gap in care after leaving the regular care of a paediatrician at age 18, and the development of disorders that arise in addition to ADHD.

medical costs increase_figure

ADHD plus additional (mental) health problems

It has been shown before that having ADHD puts you at a much higher risk of developing additional (comorbid) disorders. Mood disorders – such as depression – and anxiety are most frequent; in the German data two-thirds of ADHD individuals over 30 had such an additional diagnosis (compared to only a fifth of adults without ADHD). Substance abuse and obesity are more common in people with ADHD as well. These comorbidities should not be underestimated as they add strongly to the burden of disease. The study shows that substance abuse and morbid obesity are even the most costly, especially in adulthood. In total, the surplus costs associated with these conditions are 1420-2715 euro higher for ADHD individuals, compared to individuals who suffer from mood or anxiety disorder, substance abuse, or obesity alone.

comorbid disorders_figure

Scientists think that certain genetic factors that play a role in ADHD also make a person more vulnerable for these comorbid health conditions. Libutzki and her team are part of the European research consortium Comorbid Conditions of ADHD (CoCA) that investigates the shared biological mechanisms of ADHD and these additional disorders. “Through this research we hope to find leads to prevent these disorders from developing, and improve mental health care.”, says the leader of the CoCA consortium Prof. Dr. Andreas Reif of the University Hospital Frankfurt.

“It is intriguing to speculate that these comorbidities, which were shown to be the important cost drivers in adulthood, could be prevented if mental healthcare were provided more constantly over the lifespan” write the authors. “The prevention of the development of comorbidities with age should be the focus of mental health care. Early treatment starting in childhood and continued treatment of adolescents into adulthood seem therefore advisable.”

Improving diagnosis and adult mental health care

There is one caveat in the study by Libutzki, that is also acknowledged by the authors: many people, especially adults, are not diagnosed with ADHD, even though they experience the symptoms. “Our knowledge gap is especially large in adulthood”, says Dr. Catharina Hartman from the University Medical Centre Groningen, The Netherlands. “The prevalence of adult ADHD in the health insurance data was very low (0.2 %). Given that the population prevalence for adult ADHD is 2,5 %, this indicates that many adults with ADHD are currently not diagnosed or treated. They may nonetheless make high direct costs since their ADHD may not be recognised, or they make indirect costs through unemployment or criminality.” This would indicate that the costs reported by the study are underestimated. On the other hand, adults often find out about their ADHD only after consulting a psychiatrist for other mental health problems. This would indicate that estimated costs and prevalence of comorbid disorders with ADHD in adulthood are overestimated, compared to when you were to include also all undiagnosed people with ADHD, and diagnosed persons who do not make costs (i.e. milder cases of ADHD).

The study thus provides a partial view on the costs of ADHD during the lifespan. That said, it is among the first to show in detail the lifespan medical costs of ADHD and comorbid disorders in Germany. These findings are likely to be representative of other western-European countries. Policy makers in these countries are strongly advised to investigate ways to improve the transition from child to adult mental healthcare and increase awareness about adult ADHD. This will not only improve the quality of life of many adults but may also save money.

Further reading

Libutzki, Ludwig, May, Jacobsen, Reif and Hartman (2019). Direct medical costs of ADHD and its comorbid conditions on basis of claims data analysis.  European Psychiatry, 58: 38-44. https://www.europsy-journal.com/article/S0924-9338(19)30019-7/abstract

The findings from this study are also summarised in an infographic: https://my.visme.co/projects/1jok0qg8-medical-costs-adhd

PROUD study interview with participants, part 3: Managing ADHD with light

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This month we interviewed a 22 year old female college student who took part in the CoCA-PROUD study in Frankfurt. I would like to thank her for sharing her valuable experience as a participant in our study and what is it like to live with ADHD.

What is it like to live with ADHD?

I’m usually very chaotic and it’s difficult for me to keep organized and remember appointments. I get distracted quickly and it’s hard to concentrate. My fellow students and friends find it sometimes annoying. I had difficulty with concentration and organization even in elementary school and not much has changed since then. But today I do have conscious strategies to organize myself a bit better. That helps in some situations.

I was only diagnosed with ADS 1.5 years ago at the age of 20. I was examined in elementary school because of similar problems and my parents decided me to take part in a psychological therapy but a diagnosis wasn’t given. On the one hand it was a relief when I got diagnosed, because I always thought I have problems in these things. But on the other hand, it also feels strange to have a diagnosis. Nobody really knows about it except my parents, my boy-friend and some best friends. I find it uncomfortable to talk about and I don’t want everyone to know that I have problems in these things, because so many people have prejudices.

For 1.5 years I’ve been taking medicine regularly. In some situations, I can tell that it helps, like to be able to concentrate better. In other situations, the effect isn’t as clear. But my boy-friend notices immediately if I haven’t taken my medication.

For me the positive side of ADS is that I often have more ideas than other people do and I also react more emotionally, for example when I’m happy. But still, on the medication, however, I also notice that most of the time I’m not as emotional as I normally would be.

Light therapy to manage ADHD

I saw the flyer that was posted on the homepage of the Department of Child and Adolescent Psychiatry at the Goethe University Hospital Frankfurt. I was searching online about research on ADHD because I was interested in research on ADHD in general and I wanted to learn more about the types of interventions investigated in the clinical study. Actually, I was most interested in the light therapy. I had read about it before and wanted to give it a try. So naturally I was excited when they told me that I was assigned to the light therapy group. I did the light therapy for 10 weeks starting in June 2018. They gave me a specific lamp and a smartphone with an app. I also had to wear the light sensor day and night, but it didn’t bother me. At work I wasn’t allowed to wear the sensor. The lamp was easy to use, however the light therapy needed to be done very early in the morning before I went to work. During the week, it was sometimes hard to find the time to do the light therapy early in the morning before heading to work. It was really hard to get up that early on Saturdays for it. That’s something that I didn’t like about the therapy. The app was easy to use. The feedback didn’t always work right, but that wasn’t important for me. During the 10 weeks of light therapy I felt much better in the mornings; it was easier to start the day and to get into the day. So in that way it was very helpful for me. I did not recognize any effects on my difficulties to concentrate or being organized. I would definitely recommend to participate in this study and to use the light. I am planning to buy one and to do light therapy on my own.

The interview was done by Jutta Mayer. She is a psychologist and psychotherapist at the University Hospital Frankfurt and the clinical project manager of the PROUD study which is part of the CoCA project (www.coca-project.eu).