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The Detrimental Impact of Unmanaged Attention Deficit Hyper-Activity Disorder

Rob Mullins, a 25-year-old living in a small suburb of Michigan, grew up in a single-

parent home with his father. He experienced sexual abuse and extreme emotional neglect in

his childhood, failing in school, and early drug use. Currently, he works as a server in a local

restaurant and has a girlfriend. Although Rob shows up to work and seems to enjoy his job, he

struggles to maintain “normal” functioning in life. Managing his time, bills, physical health,

emotions, and everyday stress feels paralyzing to him. Rob is clinically depressed, usually

ends his day with alcohol, has a sugar addiction, and can't kick his smoking habit. Although in

a long-term relationship, Rob would describe himself as being irritable and having a temper,

the relationship is toxic and unmanageable. At 10, Rob was clinically diagnosed with Attention

Deficit Hyper-Activity Disorder. His father chose not to treat the disorder with medication or

other forms of treatment. Today, we are finding that people like Rob are suffering at the hand

of their unmanaged disorder. Undiagnosed or untreated ADHD has harsh consequences for

those living with the disorder. When coupled with adverse childhood experiences and/or

poverty, the severity of the disorder increases significantly.

Attention Deficit Hyperactivity Disorder is a mental disorder affecting 8.4% of children

and 2.5% of Adults. ADHD is separated into three types: inattentive type,

hyperactive/impulsive, or combined type. For each individual, the disorder presents in different

ways and at different times. Oftentimes symptoms go undiagnosed into adulthood, and the
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implications of untreated ADHD are causing a public health crisis. Dr. Russel A. Barkley,

Ph.D., an internationally recognized authority on ADHD in children and adults, presented

research showing that “ADHD is much more than a developmental disorder; it is a significant

public health issue.”

Recognized now for over two centuries, symptoms of ADHD have been the star of the

show. The early documentation of the disorder did not use the term “ADHD”; they simply

described the children and their “impairments” (Vincent J. Felitti, MD, FACP, et al. 2021).

Symptoms present in various ways: difficulty sustaining attention, struggling to follow

instructions, disorganization, fidgeting, difficulty taking turns, talking excessively, losing things,

and interrupting (Siegfried, C. B., Blackshear, K.). Some of the more detrimental symptoms

include but are not limited to school failure, depression, anxiety, emotional dysregulation, failed

relationships, and substance abuse. In 1917, ADHD was recognized as a brain disorder with

genetic origins (Vincent J. Felitti, MD, FACP, et al. 2021). The development of research

surrounding the impact of genetics on ADHD has improved substantially in recent years. In

1990, the long-awaited decision was made to include ADHD in the Americans with disabilities

act (ADA). This update gave those diagnosed with the disorder more access to needed

accommodations (Laws and Legal Protections).

As our knowledge of ADHD grows, we can more effectively advocate for things like

better accommodations in the workplace or trauma-informed care from our practitioners. For

example, In a recent study on stress-related biomarkers and cognitive functioning in

adolescents with ADHD, findings suggested that “HPA axis (plays an important role in the

bodies response to stress) hormone levels are associated with the severity of cognitive and
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inattention symptoms of patients with ADHD” (Llorens et al.) In addition, there are dozens of

studies shedding light on ACEs (Adverse Childhood Experiences) and the impact those

experiences have on someone with a predisposition for Attention Deficit Hyperactivity

Disorder. Stressful family contexts, such as low-quality home environments or insensitive

parenting, may impair the development of attentional control in early life (Schilpzand et al.).

According to the Trauma-Informed Care implementation resource center, trauma is

defined as a “pervasive problem resulting from exposure to an incident or series of events that

are emotionally disturbing or life-threatening with lasting adverse effects on the individual’s

functioning and mental, physical, social, emotional, and/or spiritual well-being.” The presence

of ACEs alone substantially increases the risks for STDs, COPD, self-medicating with drugs

and alcohol, nicotine addiction, mental illness, and attempted suicide. ACEs are the exposure

to childhood emotional, physical, or sexual abuse, and household dysfunction. 62% of US

adults have one or more ACEs, and 25% of US adults report three or more adverse childhood

experiences. (Vincent J. Felitti, MD, FACP, et al. 2021) Combining traumatic experiences with

an already cognitively debilitating disorder is certain to produce significant challenges for the

affected.

With academic, emotional, and social functioning heavily impaired, adolescents with

ADHD alone grew to have a lower quality of life than those of their neurotypical peers. A meta-

analysis of 22 studies and over 21,000 participants found that youths with ADHD were strongly

impaired in their ability to modulate their reactivity to novel or stressful events. (Strine et

al.,2006) A pre-existing deficit in an ADHD brain to handle a stressful event is going to magnify

the effect of any encountered trauma. A meta-analysis found that persons with ADHD

attempted suicide at twice the rate of typically developing people, had over three times the rate
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of suicidal ideation, and over six times the rate of completed suicide (Septier et al.,219). Using

Nationwide registers in Denmark, 2.9 million people reported a fourfold higher rate of suicide

attempts and deaths in patients with ADHD. The risk was over tenfold in those with comorbid

diagnoses, such as PTSD (Fitzgerald et al.,2019). These numbers are alarming and make the

need for practitioners to be trauma-informed that much more vital to administer correct

diagnoses and proper management of the disorder.

Although, there may be another speed bump in proper diagnosis and treatment. Studies

show that low socioeconomic status (SES) also has a significant impact on the development

and severity of ADHD. A nationwide study of over 18,000 children from South Korea found that

lower levels of family income were associated with increased rates of ADHD. (Larsson et al.,

2014) The low SES population is at a greater risk for lower educational attainment,

unemployment, hunger, and exposure to harmful situations. The disadvantages that are faced

create a lack of resources for the young people living in these communities. For example, a

child may have three ACEs by the time they are 7, inadequate intervention specialist employed

by the school system, an absent father/mother resulting in a single-parent home, and zero

resources to consistently get to the Dr. This would undoubtedly leave this child incredibly

vulnerable to the difficulties of unmanaged ADHD.

The risks of unmanaged, undiagnosed ADHD are life-threatening. Dr. Barkley Ph.D.

gives his Keynote address at the 2018 Annual International Conference on ADHD in St. Louis,

Missouri; he presents new research suggesting that untreated ADHD reduces life expectancy.

Dr. Barkley and his team conducted a study that documented young men with an ADHD

diagnosis from childhood into their adult years. They used an actuarial-based life expectancy

calculator created by the University of Connecticut. They used this to analyze the documented
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data and found that over time “ADHD adversely affects every aspect of quality of life and

longevity. This is due to the inherent deficiencies in self-regulation associated with ADHD that

lead to poor self-care and impulsive high-risk behavior.” The statement Barkley makes that

should induce the greatest call to action deduces that ADHD presents a greater health risk

than poor diet, insufficient exercise, obesity, and smoking…combined!

Fig 1. Graph showing risks and consequences. (Barkley et al. 2008)

Like Rob, there is a huge population of adults living with undiagnosed or untreated

Attention Deficit Hyperactivity Disorder. Being recognized as a disability in 1973 should change

the perception of ADHD being an overdiagnosed exaggeration of kids that just can't sit still. Yet

still, there is a stigma surrounding the disorder preventing proper diagnosis and proper

treatment. Having been found to be connected with aggressive behavior in childhood, it can

morph into violent and chronic antisocial behavior in young adults. Chadd et al.,2019

documented that adults with untreated ADHD are three to nearly five times more likely to die in

adulthood by middle age than a neurotypical individual. The most significant cause of death is

accidental injury and suicide. In Barkley and Fisher's 2019 study, they found that those living

with untreated persistent ADHD from childhood had a 12.7-year reduction in healthy life

expectancy. Smoking 20 cigarettes a day, there is a reduction of 6.8 years in life expectancy.
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When the two are measured against one another, it is clear that treatment and trauma-

informed care is vital.

The less morbid but possibly more paralyzing impacts of ADHD, presenting even when

treated and exacerbated when untreated are the executive dysfunctions. Executive function is

a heavily impactful deficit often presenting in ways of impulsivity and/or disinhibition. This plays

into the overall quality of one's life living with ADHD. Executive dysfunction could be as simple

as losing your keys, not remembering what you walked into the room to do, or zoning out while

someone is speaking. The more severe presentations could look like paralyzing overwhelm

when needing to shower because first, you need to: clean the bathroom, fold the clean towels,

and organize the shampoo. Another example would be oversharing personal information in

conversations or an inability to pay bills because the process produces so much anxiety. While

these things are a daily challenge for those with managed cases of ADHD: those who are

untreated will struggle that much more. These struggles can be the precursor to

homelessness, severe depression, lack of education, and self-medicating. Which begins to

leave a serious financial burden on the communities and families of the affected.

In the report; The Adverse Health Outcomes, Economic Burden, and Public Health

Implications of Unmanaged ADHD A call to Action to Improve the Quality of Life and Life

Expectancy of People with ADHD presented by CHADD (Children and Adults with Attention

Deficit Hyperactivity Disorder). They present the direct economic impact associated with the

disorder. In an assessment of work loss, it was found that adults with ADHD earn $543,000 to

$616,000 less in the span of their life than that of an average adult. That is approximately 25%

less income monthly. ADHD as a disorder also heavily impacts work performance, resulting in

sick days and lost work performance, costing the employer $4,336 per employee annually. In
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assessing an ADHD child's family over a 12-year period the financial impact was that of 5 x the

typical family, $15,036 compared to $2,848. This cost included injuries, legal involvement,

accidents, and discipline. This did not include the cost of medication or extra treatment, it also

did not include childcare, parental mental health concerns, or missed work.

The total overall national cost ranges from $143 billion to $266 billion, with adults

accounting for $105 to $194 billion, and child and young adult costs accounting for $38-$72

Billion. Of these numbers, the most significant of these costs for adults was attributed to lost

productivity and income, and for children the most significant cost was healthcare. “Thus

research to date clearly demonstrates that ADHD poses a substantial economic impact in the

United States besides the adverse health outcomes, increased mortality risk, and reduced life

expectancy (CHADD et al.,2019).” If we more effectively addressed ADHD in adolescents with

more cognitive treatment, we could impact those numbers significantly by teaching ADHD

children how to better manage their impulses and executive dysfunction. How could we

continue to ignore or undertreat such a costly public health issue?

ADHD still carries this stigma of a childhood isolated issue of inattention and

hyperactivity with little implications for future quality of life. There is a major awareness issue

surrounding the disorder, bleeding into the homes, schools, medical facilities, houses of

worship, and communities. The scariest population of those still believing the stigma and

uneducated on the issue are those who are actually living with the disorder. The report from

CHADD states that 50% of the individuals diagnosed as children with the condition are missing

from the healthcare system as “ADHD cases” in their adulthood. CHADD and its contributors

go on to make the comparison to those with childhood diabetes or other conditions. If 95% of

those cases did not get or continue treatment as adults, the medical community would make
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adjustments and look at potential contributing factors. “These Major gaps in US health services

- especially in recognition and treatment of the large population of adults with ADHD - will

require not just “awareness” but also changes in US health care practices and health care

quality standards, with the participation of the major professional organizations and residency

training programs to bring about these changes.” (CHADD et al.,2019)

From another perspective, there is a growing concern of overdiagnosis resulting in

overmedicating children and adults. Katherine Ellison and Stephen Hinshaw, PH.D. weigh in

on this stance, stating that “the majority of ADHD diagnoses are made with the kind of

attention you wouldn't accept from an automobile service department.” With an apparent 15-

minute session with your pediatrician, you can receive a diagnosis of ADHD. Ellison calls this

approach “quick- and- dirty”. When citing a recent CDC survey, she states that between 2003

and 2012, ADHD diagnosis skyrocketed by 41%, totaling more than 6 million children

diagnosed with ADHD and almost 4 million prescribed and taking medication.

Today, medical news attributes overdiagnosis to a list of issues, including growth

delays, anxiety, rapid heart rate, high blood pressure, loss of appetite, and trouble sleeping.

Many of the symptoms they listed are generally attributed to medication side effects. The

article even goes on to state that “Although it is true that overdiagnosis means that some

people without ADHD receive treatment, on the whole, people with ADHD are actually

undertreated.” There is little research to support the claim of overdiagnosis, although

improperly diagnosing any disorder and potentially providing unnecessary treatment could be

harmful. In the case of such a serious disorder, its overdiagnosis pales in comparison to the

current implications of underdiagnosing.

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Imagine the possibility of a child encountering a trauma-informed clinician, educated in

ADHD and other learning disabilities, educated in the best treatment options, and one who

took the time to gather imperative information. Imagine parents, families, and educators of

those children were educated in-depth about the disorder and the kinds of things that impact

the severity. CHADD and its contributors, in their 2019 report, make a call to patients with adult

ADHD and parents of diagnosed children to be more informed about the risks to their health

and apply better management to the disorder to reduce the impact of those risks. They

encourage adults to make their primary health care providers aware of unhealthy choices,

activities, and habits and partner with them on reducing their potential for future negative

health consequences. As well as parents of diagnosed children, urging them to “assume

responsibility for their condition as they transition to independence and adulthood.”

Independence in adulthood with treated and managed ADHD is possible! When an

ADHD individual leads their life from a “strengths” perspective, living life with ADHD can be a

very colorful and meaningful existence. When healthy, those with ADHD can thrive and excel

in unstructured environments, have incredible intuition, be willing to take risks to build their

dreams, and can effectively and enthusiastically lead others to build their dreams and create

masterful art. The benefits of correct ADHD diagnosis and treatment could literally be life-

saving. Changing the trajectory of someone's life by providing wholeness, not only changes

their life but begins the repair for those that will come behind them. Picking up a legacy of

wholeness is a much easier life to walk and pass down.

Undiagnosed or untreated ADHD has harsh consequences for those living with the

disorder, with adverse childhood experiences and/or poverty making it more severe. When we

consider the life of Rob Mullins, how different could his life have been if someone conveyed to
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him the importance of understanding the diagnosis he received at age 10? He would have a

significantly better chance at healthy executive functioning, sobriety, graduating, acquiring a

degree, better employment, and a functional relationship. Improving any of these things

significantly increases a person's quality of life. Equipping our schools, medical and mental

health professionals, and families with more information and resources on ADHD is absolutely

imperative if we are going to slow down and end the public health crisis that is unmanaged

ADHD. How drastically could we reduce the number of casualties? How much of a withdrawal

would we make in the staggering numbers of addicts and homeless?

Works Cited

Barkley, Ph.D., Russell A. “New Research Suggests Untreated ADHD Reduces Life
Expectancy.” CHADD, 17 Jan. 2019, https://chadd.org/advocacy-blog/new-research-
suggests-untreated-adhd-reduces-life-expectancy/.
CHADD. The Adverse Health Outcomes, Economic Burden, , and Public Health
Implications of Unmanaged Attention Deficit Hyperactivity Disorder (ADHD): A Call
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to Action to Improve the Quality of Life and Life Expectancy of People with ADHD.
2019, https://chadd.org/wp-content/uploads/2021/08/CHADD-Health-Outcomes-
White-Paper_8-5-21-FINAL.pdf.
Ellison, Katherine, and Ph.D. Stephen Hinshaw. “The Scandal of ADHD Diagnosis in the
U.S.” ADDitude, ADDitude, 21 Jan. 2022, https://www.additudemag.com/the-
scandal-of-adhd-diagnosis-in-the-u-s/.
Faraone SV;Banaschewski T;Coghill D;Zheng Y;Biederman J;Bellgrove MA;Newcorn
JH;Gignac M;Al Saud NM;Manor I;Rohde LA;Yang L;Cortese S;Almagor D;Stein
MA;Albatti TH;Aljoudi HF;Alqahtani MMJ;Asherson P;Atwoli L;Bölte S;Buitelaar
JK;Crunelle CL;Daley D;Dalsg. “The World Federation of ADHD International
Consensus Statement: 208 Evidence-Based Conclusions about the Disorder.”
Neuroscience and Biobehavioral Reviews, U.S. National Library of Medicine, 4 Feb.
2021, https://pubmed.ncbi.nlm.nih.gov/33549739/.
Hittler, John. “Council Post: The Underlying Gift of Having Add or ADHD.” Forbes, Forbes
Magazine, 3 Jan. 2019,
https://www.forbes.com/sites/forbescoachescouncil/2019/01/03/the-underlying-gift-
of-having-add-or-adhd/?sh=2adb4a741600.
Kottler, Susan. “A Social Worker’s Guide to Attention Deficit .” Https://Www.naswma.org,
May 2000, https://www.naswma.org/page/362/A-Social-Workers-Guide-to-Attention-
DeficitHyperactivity-Disorder.htm.
“Laws and Legal Protections.” CHADD, 4 June 2021, https://chadd.org/for-adults/laws-
and-legal-protections/.
Llorens, Marta, et al. “Stress-Related Biomarkers and Cognitive Functioning in
Adolescents with ADHD: Effect of Childhood Maltreatment.” Journal of Psychiatric
Research, vol. 149, 2 Mar. 2022, pp. 217–225.,
https://doi.org/10.1016/j.jpsychires.2022.02.041.
Malhi, Prahbhjot, and Bhavneet Bharti. “Traumatic Stress or ADHD? Making a Case for
Trauma-Informed Care in Pediatric Practice.” Doi.org, The Indian Journal of
Pediatrics, 29 Aug. 2020.
Parekh M.D., M.P.H., Ranna . “What Is ADHD.” What Is ADHD? American Psychiatric
Association, 2017, https://www.psychiatry.org/patients-families/adhd/what-is-adhd.
Schilpzand, Elizabeth J., et al. “Trauma Exposure in Children with and without ADHD:
Prevalence and Functional Impairment in a Community-Based Study of 6–8-Year-
Old Australian Children.” European Child & Adolescent Psychiatry, vol. 27, no. 6, 30
Oct. 2017, pp. 811–819., https://doi.org/10.1007/s00787-017-1067-y.
Siegfried, C. B., Blackshear, K. “Is It ADHD or Child Traumatic Stress? .”
Https://Www.nctsn.org/, National Child Traumatic Stress Network, with assistance
from the National Resource Center on ADHD: 2016,
https://www.nctsn.org/sites/default/files/resources/is_it_adhd_or_child_traumatic_str
ess.pdf?source=post_page---------------------------.
Van Pelt, Jennifer. “Adult ADHD — Hidden Diagnosis.” Adult ADHD - Hidden Diagnosis,
Social Work Today, June 2010,
https://www.socialworktoday.com/archive/052010p14.
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Villines, Zawn. “ADHD: Is It Overdiagnosed and Overtreated?” Medical News Today,

MediLexicon International, 16 Nov. 2021,
https://www.medicalnewstoday.com/articles/is-adhd-overdiagnosed-and-
overtreated#issues-with-overdiagnosis.
Vincent J. Felitti, MD, FACP, Robert F. Anda, MD, MS, Dale Nordenberg, MD, David F.
Williamson, MS, PhD, Alison M. Spitz, MS, MPH, Valerie Edwards, BA, Mary P.
Koss, PhD, James S. Marks, MD, MPH. The Adverse Childhood Experiences (ACE)
Study. American Journal of Preventive Medicine, 1998,
https://www.ajpmonline.org/action/showPdf?pii=S0749-3797%2898%2900017-8.
“What Is Trauma? - Trauma-Informed Care Implementation Resource Center.” Trauma-
Informed Care Implementation Resource Center, Center for Health Care Strategies.,
2020, https://www.traumainformedcare.chcs.org/what-is-trauma/.