Are you curious about the natural history of ADHD? How does it manifest and present across the lifespan? We know that people with ADHD may have symptoms throughout their lifetime, but does it look the same from preschool to school-age to adolescence and adulthood? ADHD is often missed and underidentified and therefore undertreated.
In this Pocket MD podcast, Russell Schachar, MD, offers expert insight and advice on the various ADHD presentations found in different stages of human development, the impact of ADHD on life expectancy and quality of life, and understanding how interventions affect ADHD outcomes.
Russell Schachar, MD
Dr. Schachar is a practicing child and adolescent psychiatrist, a professor in the department of psychiatry at the University of Toronto, and senior scientist in the research institute at the Hospital for Sick Children in Toronto, Canada, where he holds the Toronto Dominion Bank Chair in Child and Adolescent Psychiatry. He is the head of a cognitive neurosciences laboratory which focuses on psychiatric disorders of childhood and adolescence.
Listeners will be able to:
- Identify ADHD symptoms throughout the lifespan.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You are listening to Pocket MD, training on ADHD in children and adults.
Dr. Max Wiznitzer: This is a session on the natural history of ADHD. I am Max Wiznitzer, a physician at Rainbow Babies and Children's Hospital and moderator for this session, with Russell Schachar, MD, a child and adolescent psychiatrist. Welcome, Dr. Shachar.
Dr. Russell Schachar: Thank you for inviting me to participate in this podcast. I'm a child psychiatrist from the University of Toronto, trained in medicine at the University of Toronto, in psychiatry at McMaster University, and then a postdoc in child and adolescent psychiatry at the University of London in England. I have run a clinical research program in ADHD and related neurodevelopmental disorders at the Hospital for Sick Children for many years.
Dr. Max Wiznitzer: Thank you. Well, let us get to our topic. And, the key thing here is, does ADHD look the same throughout the lifespan? In other words, are there differences in the manifestations of ADHD, depending on the age at which we look? For instance, when we are looking in the preschool and the childhood years.
Dr. Russell Schachar: Yes, there certainly are. I would like to preface my comments by saying that ADHD is missed and underidentified and therefore, undertreated at each of these age periods. So, in the childhood-preschool period, the typical ADHD child would present with quite a lot of hyperactivity, restlessness, trouble settling to any single play activity, possibly impulsive, have difficulty in preschool sitting in a group interacting with other children.
And there may be some other associated features, such as language impairment or developmental delays of other kinds, like slow to talk or slow to walk. But many preschool children, or many children who have ADHD diagnosed later in life actually have very few manifestations during the preschool period and it's only looking back from the school-age vantage that you can identify some of those phenomena.
Dr. Max Wiznitzer: What about the childhood years? In other words, when they first enter school and in the primary grades in school, if they are first going to present, what do they look like at that time?
Dr. Russell Schachar: This is the typical age at which children with ADHD present, and for the most part, we think of it as a mismatch between their temperament and behavior, learning style, on one hand and the expectations of formal schooling on the other hand. So, these are children, who in the early years, senior kindergarten, grade one, grade two, have difficulty in all areas that require... well…sitting still and paying attention. So, these are kids who have difficulty putting away their objects in their cubbyholes at the beginning of class, getting to their seats, paying attention, keeping themselves from interrupting. They have difficulty following some of the instruction that goes on at the front of the classroom, and pretty soon you find the teachers identifying these children and bringing them up to the front of the class, giving them more direct attention and noticing that they're having these kinds of difficulties.
Dr. Max Wiznitzer: When they enter the adolescent years, do the manifestations stay the same or do we start seeing some differences?
Dr. Russell Schachar: Through development, you see a waning of gross motor activity issues. Children, as they get older, seem to be less and less hyperactive, if you will. That is, not all of them; many of them remain restless and fidgety, right through adolescence and even into adulthood. But one of the more stark characteristics that does persist, right from the preschool years through the school-age years and into adolescence and adulthood, is difficulty paying attention, and with what we generally call executive function skills, which are these higher level cognitive skills that allow us to self-regulate, process information, make judgments, delay our responses, and manage our emotions and behavior.
Dr. Max Wiznitzer: What happens with these adolescents in terms of risk taking?
Dr. Russell Schachar: Well, the evidence is that children who have diagnosis of ADHD during preschool years are at an elevated risk for risk-taking behaviors of various kinds. When you look at individual risks, the relative risk is not huge, but collectively, this is a group of individuals who are much more likely to take risks. So, they are earlier to smoke, earlier to use soft drugs, more likely to use other kinds of substances, and they tend to have earlier intimate relationships and more of them as a group. But that is a gross generalization, it does not pertain to all of the children by any stretch of the imagination. In fact, the majority of school-aged children, who look like they have uncomplicated ADHD in school age, tend to have fairly uncomplicated ADHD in adolescence. But even an uncomplicated ADHD has major impacts on their scholastic attainment, the success of their social interactions, and in particular, on their self-esteem, where they really will often take a real battering because of the problems that they get into with peers, with family members and with teachers.
Dr. Max Wiznitzer: Does ADHD remain symptomatic throughout the entire lifespan, and if so, what would it look like in the typical adult?
Dr. Russell Schachar: If you follow children forward from school age, which is the typical kind of work that's been done to look at the natural history of ADHD, you find that about a third to a half of children with ADHD at say age eight to ten, will pretty much meet criteria for ADHD when they're adolescents and continue to do so into young adulthood. Some others seem to lose the... they fall below the diagnostic thresholds. They do not have sufficient symptoms to make a diagnosis, but many of those individuals continue to be impaired, possibly by their cognitive attentional problems. And where they experience them, those difficulties are in the workplace, in social relations, and in higher education.
There is a group of 25 or 35% of individuals, who seem to no longer have impairment or symptoms as they get older, and those would be, you know, that’s a good outcome and we would consider them pretty much fully remitted. But even fully remitted teens and young adults will tell you that they still have difficulty in certain environments that place substantial demands on their attention span. So, they don't like cocktail parties, where they have to track what one person is saying to them and rule out what other people are saying to them. So, even people who are no longer meeting criteria or consider themselves tremendously or particularly impaired, will complain about some of these symptoms.
Dr. Max Wiznitzer: In the adult years, what is the outcome of ADHD? For example, how does it impact the educational attainment, their employment, social relations, and such?
Dr. Russell Schachar: ADHD children pay a price in all those domains. Like I said, it is not a universal outcome. But from a public health point of view, when you consider how prevalent ADHD is, ADHD is definitely a factor that's accounting for a good deal of the academic underachievement, the low self-esteem, the poor workplace and employment prospects of individuals, as they get older. There is also this continued risk for secondary psychiatric problems, such as depression and anxiety, because these people continue to feel badly about themselves and their achievement. And then they present as having depression or anxiety, and even amongst adult psychiatrists, the fact that they had a childhood history of ADHD may easily be overlooked. And so, they become treated or identified and diagnosed as exclusively depressed or anxious or having some sort of learning disability not specified.
Dr. Max Wiznitzer: With these factors, what is the impact or the public health ramification of ADHD regarding life expectancy and quality of life?
Dr. Russell Schachar: Well, quality of life, as I have described, is impaired, especially amongst the ones with persistent behavioral as well as cognitive symptoms. There is more and more evidence that individuals with ADHD have increased healthcare costs, which suggests that they are having a variety of different kinds of medical as well as mental health problems. And the long-term prospects of ADHD suggest that individuals with ADHD have an overall shorter lifespan than do individuals who don’t have ADHD. It is not entirely clear what accounts for all of that, but some of it is due to risk taking and accident proneness. But there is more and more evidence that there could be shared biological genetic risk between conditions like ADHD and some medical conditions that put individuals at higher risk.
Dr. Max Wiznitzer: Can this outcome be changed through intervention?
Dr. Russell Schachar: Probably some can be. I do not think we know the full extent of what we can do with intervention. For the most part, the interventions that we have in place now are sparse and unidimensional, at least in my opinion. So, the most readily available interventions for ADHD are medications. They are effective, and more effective when used effectively, but stimulant medication for ADHD will play a substantial role in the care of an individual with ADHD. They are not acceptable to a substantial number of individuals who don't take them and they are only a partial intervention and they don't always deal with all of the other problems that I mentioned, such as academic underachievement, self-esteem, social relationship problems. Some of those problems do have established interventions in the psychiatry world, but it is not altogether easy for individuals, the vast majority of individuals with ADHD, to get access to those kinds of treatments. Really what is required is a long-term, wraparound care package, and as most young physicians will know, that is not easily obtained in the healthcare system in general, regardless of what the diagnosis is, not just ADHD or mental illness.
Dr. Max Wiznitzer: If you have a final message for our listeners about the natural history of ADHD, what would it be?
Dr. Russell Schachar: That there's change, but consistency. That one should always look for the progress that people are making in care or in their adjustment in life, and support them and reward them and be positive about that, but to be vigilant about remaining and residual problems that they have if you're providing care for them, so that you can offer other forms of intervention as needed.
Dr. Max Wiznitzer: Thank you very much, Doctor Schachar. We appreciate the time that you spent with us today.
Dr. Russell Schachar: You're welcome.
Announcer: Pocket MD is brought to you by CHADD, with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.
- ADHD Across the Lifespan (infographic)
- Franke, Barbara et al. (2018). Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. European Neuropsychopharmacology 28(10):1059-1088.
- Cabral M, Liu S, Soares N (2020) Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics 9(S1):S104–S113
- Special Presentation: Health and Life Expectancy in ADHD. Treatment Matters More Than You Think https://www.youtube.com/watch?v=fP2DhUtYJ5s (video)
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