Complications

Emotional Disorders

More than half of children with attention-deficit disorder have accompanying disorders, including anxiety, depression, and conduct disorders. Children with ADHD who experience anxiety or depression are also more likely to suffer from low self-esteem. One study found that 25% of children with ADHD have or develop bipolar disorder (commonly called manic depression).

Social Problems

Anti-Social Behavior. Even if these emotional disorders are absent in childhood, the ADHD child's relationship with others is volatile, and he or she is often unhappy from a very young age. Research indicates that any ADHD boy or girl, particularly an aggressive child, has trouble getting along with others, and is less liked by his or her peers.

  • ADHD children with the inattentive subtype are more likely to be picked on and to spend time alone.
  • Children with the combined subtypes tend to have different problems. A best friend can turn into an enemy overnight when, for example, an ADHD boy does not perceive his friend's fearful response to over-aggressive roughhousing and fails to let up. The next day the ADHD child has forgotten the event; the ex-friend hasn't. This is a classic situation repeated time and again. When an ADHD child hurts someone, the child either may go into a state of denial or blame himself excessively. As ostracism, fear, and ridicule from peers persist from year to year, the unstable behavior, originally neurologic, becomes emotionally based. Unless this cycle is broken, serious adult problems can evolve.
  • A 2000 study found that boys with ADHD are less likely than others to empathize with people in difficult circumstances. One speculative explanation is that this is a self-protective reaction to prevent negative feelings, which ADHD children are highly prone to all the time.

Substance Abuse in Young People. Studies consistently report that ADHD young people--in particularly those with conduct or mood disorders--have a higher than average risk for substance abuse and that it starts in younger ages. In one study, for example, by age 11 nearly 20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. Biologic factors associated with ADHD may make these individuals susceptible to substance abuse. Many of these young people are self-medicating their condition. In fact, according to a major analysis, Ritalin or other stimulants used to treat ADHD may help protect such patients against substance abuse. (Boys with ADHD and conduct disorder, however, still face a high risk for substance abuse. Girls with ADHD and emotional disorders may also still have a higher risk.)

High-Risk Behavior. Impulsivity in ADHD young people can certainly cause them to take chances before thinking them through, putting them in situations where the consequences become clear only after the action has been taken. ADHD children with high levels of aggression are at higher risk for delinquent behavior in adolescents and criminal activity in adulthood. It should be strongly noted that ADHD children who are not aggressive have a lower and even normal risk for dangerous activities. Even in aggressive ADHD children, close parental attention and early treatment can limit the risk considerably.

Learning Problems

Although speech and learning disorders are common in children with ADHD, the disorder does not affect intelligence. People with ADHD span the same IQ range as the general population.

One study suggested, however, that 90% of ADHD children were underachievers, and that half were held back at least once. Some evidence suggests that inattention may be a major factor in low academic performance in these children. About 20% also have reading difficulties and 60% have serious handwriting problems. Adults with ADHD are also at very high risk for these conditions.

Persistence of ADHD into Adulthood

Some research suggests that ADHD persists in one- to two-thirds of those diagnosed with the condition in childhood. Many experts, in fact, describe the pattern of ADHD as they would a chronic illness, in terms of whether it goes into remission or not. They define this remission in three categories of severity:

  • Syndromatic Remission. Person does not have all the symptoms of full-fledged ADHD, but significant functional impairment in social or occupational activities is present.
  • Symptomatic Remission. Person has few symptoms and some functional impairment.
  • Functional Remission (Full Recovery). Few symptoms and no functional impairment.

In one study using these criteria, 60% of ADHD Caucasian boys were in syndromatic remission four years after the onset of the study, and 10% were fully recovered (in functional remission). Older individuals were more likely to retain symptoms of inattentiveness than those of impulsivity and hyperactivity. Because inattentiveness affects organizational skills, this could be a significant problem in adulthood. It should be noted, however, that the study lasted only 4 years and stopped between ages 18 and 20. The study did not include girls or boys in other ethnic groups, so it is not known if these results are generally applicable.

Effect on Family

The time and attention needed to deal with the ADHD child can change internal family relationships and have devastating effects on parents and siblings.

Effect on Parents. Studies increasingly suggest that any intervention for an ADHD child must include the parents. Parents who are responsive to their child in a positive way can help reduce the chances for oppositional behaviors. But it can be very difficult. The ADHD child is wonderful one day and terrible the next, for no apparent reason. The parent can feel betrayed and hurt, and believe they have no control over their child. Parents must protect themselves and their child by establishing tough but kind rules about where their space ends and the child's begins. The are many effects on parents:

  • Mothers generally get the brunt of the emotional and physical abuse that an ADHD child can produce, which is sadly ironic because the ADHD child tends to love the mother intensely and feel safe with her.
  • Parents may have to give up on the idea of an immaculate house and a hot meal every night. (One advantage of an ADHD child in the family is that the parents learn that they are not perfect, nor do they have to be. In fact, striving for perfection is among the most counterproductive goals to pursue in raising an ADHD, or any, child.)
  • Parents must face the hostility and anger of other parents and see their own child rejected. It is very easy to fall into an emotional black hole, and feel alone, inadequate, and helpless.
  • Marriages are often stressed to the breaking point because of exhaustion and disagreements between the husband and wife on how to raise the ADHD child.

Effect on Siblings. Siblings of ADHD children have particular difficulties, and are also at risk for psychologic impairment, depression, drug abuse, and language disorders. The non-ADHD sibling does not have the control a parent does in the management of the ADHD child's behavior and is very likely to feel alienated and alone. Non-ADHD children are often victimized by ADHD siblings who may be demanding or bullying.

A sibling who is not given attention in his or her own right may begin to imitate undesirable behaviors or to act out negatively in other ways. It is very important to make the brothers and sisters equally vital to the family's functioning. It should be strongly emphasized, however, that their value in the family should never be as fellow-caregivers of the ADHD sibling.

Review Date: 12/7/2005
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.