Is ADHD warning justified? A follow-up clinical practice study in a Spanish sample

doi:10.21203/rs.3.rs-1765885/v1

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Is ADHD warning justified? A follow-up clinical practice study in a Spanish sample

https://doi.org/10.21203/rs.3.rs-1765885/v1

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Background

ADHD is described as a chronic condition with associated social, academic, and mental risks. The present work analyses the current clinical state, occupation, and daily life interference of children detected with ADHD symptoms in two cohorts (2004 and 2009).

Methods

134 clinical subjects with ADHD diagnosis detected in 2004 or 2009, were asked to run voluntary interviews. Ninety-four (94) cases answered questions about their current clinical and occupational statement, symptoms (SNAP-IV), and difficulties (Strengths and Difficulties Questionnaire).

Results

60.70% of the sample has no current treatment. Rates for inattention and hyperactive/impulsivity symptoms subsets went down. A total of 66.2% shows current difficulties but with a moderate interference in their daily life. The working/academic dimension is the most affected sphere in terms of impairment.

Conclusions

hyperactive/impulsivity subset and global ADHD rates go down as people grow up. Even if patients retain some difficulties, these are not serious enough for forcing them into clinical treatment. Main points in Public Health Significance are the followings: (a) these results question ADHD chronicity and higher risk of mental conditions in adulthood. Hyperactive and impulsivity, inattention, and global ADHD symptoms remain in one-third of the sample after 5 or 10 years after the diagnosis, (b) the higher risk of mental disorders and academic failure should be also questioned as most of the sample did not receive any treatment for a psychological condition after 5 or 10 years of ADHD diagnosis and most of them had a productive occupation at the follow-up moment, (c) ADHD rates are were higher when they are assessed by a relative caregiver. This might be linked with a possible cultural “psychopathologization” of childhood.

Attention Deficit Disorder with Hyperactivity

Longitudinal Studies

Clinical Evolution

Psychosocial Impact

Clinical guidelines define the Attention Deficit Hyperactivity Disorder (ADHD) as a chronic condition (Guía Nacional de Práctica Clínica sobre el Trastorno por Déficit de Atención con Hiperactividad (TDAH) en Niños y Adolescentes). However, ADHD prevalence rates vary as time passes depending on the child's development stage, the time elapsed after diagnosis, and how or who makes the assessment report. An 18-month follow-up study of children with mental health problems (Goodman et al., 2002) showed that symptoms and impairment scores tend to keep up in adulthood for behavioral and hyperkinesia problems. However, ADHD research like Miller et al. (2004) show decreasing rates as time elapses from the time diagnosis takes place; in fact, rates went down 20–30% after 2–3 years from the diagnosis moment, and 40–80% after 3–8 years. Among teenagers, studies report 70% prevalence of ADHD rates (Sibley et al., 2012), although for adults, ADHD rates vary from 5% (Fischer et al., 2002; McCormick, 2004) to 45.7% (Kessler et al., 2010). Some authors point out that prevalence rates in adults might be underestimated when using self-reports (rates would be around 1.4% in this case) instead of information provided by relatives (rates would rise to 46%) (Barkley et al., 2002). ADHD rates also vary depending on the time of rates under study, whether symptoms, syndrome, or impairment rates (Biederman et al., 2000). However, impairment or interference criteria are the best factors when predicting ADHD symptoms persistence (Sibley et al., 2012).

Previous literature shows consistent data about ADHD clinical symptoms development. Inattention and hyperactive symptoms have a different progress as time elapses, and specific symptoms appear in adults with ADHD. Inattention symptoms might continue into adulthood (94.9% of the population retain these symptoms), while hyperactivity/impulsivity symptoms may decrease (34.6% of the population retain these symptoms) (Biederman et al., 2000; Kessler et al., 2010). Previous studies point out the need of reviewing ADHD diagnosis criteria in adults. On the one hand, the level of performance in executive tasks (e.g., time management, setting priorities, etc.) should receive more attention in adult population compared to inattention or hyperactive symptoms (Kessler et al., 2010), while adult ADHD may also be related to inner restlessness feelings. Therefore, specific adult tasks and criteria are proposed to address ADHD adult diagnosis (Barkley et al., 2008). On the other hand, in adult ADHD, as opposed to child ADHD, impairment severity appears to be positively related to symptom severity (Kessler et al., 2006; Mannuzza et al., 2011).

Several previous studies point out a higher risk of mental illness in adulthood for those who suffered ADHD in their childhood, especially for depression disorder (26%), histrionic personality disorder (12%), antisocial personality disorder (21%), passive-aggressive personality disorder (18%), and borderline personality disorder (1%) (Fischer et al., 2002). Other studies point that adults do not maintain ADHD diagnosis nor treatment, but they suffer other adult mental disorders like personality disorders or drugs abuse (Mannuzza et al., 1993, 1998) and receive clinical treatment for those (Fayyad et al., 2007). Understanding ADHD as a behavioral and contextual problem, ulterior mental health diagnosis and comorbidities would be understood as a sign of a common dysfunctional pattern. This pattern would be built on the lack of behavioral repertoire in self-regulation that needs to be trained (Ayllón y Milan, 1996; Luciano y Gómez, 1998; Paniagua, 1987; Ruiz et al., 2012; Willis y Loovas, 1977). This general dysfunctional pattern experienced in every mental health disorder has been denominated experiential avoidance pattern (Hayes et al., 1996) from a functional-contextual perspective.

ADHD has also been related to major social, academic, and working problems. Among teenagers, ADHD diagnosis in childhood has been related to lower academic results and higher rates of behavioral disorders (Lambert, 1988), antisocial behavior, cigarette and marijuana use, less stable family status (Barkley et al., 1990), school failure and academic dropout (Kent et al., 2011), and behavioral disinhibition (Fischer et al., 1990) compared to the nonclinical adolescent population. Children with ADHD have been related in young adulthood to a higher risk of drugs and substance abuse, arrests for possession or selling those substances (Fischer et al., 2002), lower academic goals (just a minority might finish high/secondary school), lower academic and working achievements (Mannuzza et al., 1993), lower working conditions (Biederman & Faraone, 2006), and difficulties in personal relationships and social roles (Fayyad et al., 2007; Rösler et al., 2010). Some previous studies point out the appearance of difficulties in personal relationships for those adults who maintain ADHD symptoms (Moyá et al., 2014). All these associated difficulties would be linked to a lack of behavioral repertoire in self-regulation under medium and long-term conditions present in children with ADHD difficulties (Ayllón y Milan, 1996; Luciano y Gómez, 1998; Paniagua, 1987; Ruiz et al., 2012; Willis y Loovas, 1977).

The clinical course and long-term risks described above might be influenced by psychosocial factors and the severity of ADHD disorder and other comorbidities in childhood. Family and academic experiences in kindergarten and primary school children with hyperactivity were related to behavioral disorders and the appearance of later substance abuse (Lambert, 1988). Moreover, those ADHD children who had experienced psychosocial adversity tend to maintain ADHD symptoms in the future (Biederman et al., 1996). Besides, comorbid behavioral disorders associated with ADHD seem to be related to academic, behavioral, and mental difficulties in adolescence (Lambert, 1988) and adulthood (Fischer et al., 2002). The co-occurrence of family mental disorders is also related to the persistence of ADHD symptoms (Biederman et al., 1996).

Additionally, there are social factors that needs to be considered when understanding ADHD. There are previous works that points out that current cultural management (based on immediate reward, digitalization and urgency to avoid discomfort) might be related to dysfunctional mental health patterns such as ADHD (García de Vinuesa et al., 2014; Timimi y Taylor, 2004). Moreover, there is a cultural-social tendency to deal with aberrant behavior or emotions in children through technical (particularly pharmaceutical) interventions (García de Vinuesa et. al, 2014), a phenomenon has been referred to as the 'McDonaldization' of children's mental health (Timimi, 2010). These factors might be linked to a “psychopathologization” of childhood and the upward trend of ADHD diagnosis (García de Vinuesa et al., 2014).

Despite all these data, this work presents a long-term study in which, after 5 or 10 years from the onset of ADHD symptoms. Specific objectives of this paper are three: (a) to describe the current clinical state of children detected with ADHD symptoms in 2004 and 2009; (b) to analyze their current occupation; (c) to know about their current interference in their everyday life.

Participants

The sample was taken from the digital database of cases attended at the Public Health Service in Oviedo (SESPA), Spain, based on the following criteria:

a) Inclusion criteria: consultations on ADHD diagnosis in PC (registered as P21 code in the database) during 2004 or 2009.

b) Exclusion criteria: consultations on ADHD symptoms made as a punctual contact for displaced patients (patients who do not usually reside in the sampled area).

The initial sample consisted of 134 clinical cases (55 cases from 2004, 79 cases from 2009; 106 males, 28 females). Characteristics of the initial sample are shown in Table 1. The final sample consisted of 95 cases who voluntarily participated in a telephone interview. Characteristics of the final sample employed in the interview are shown in Table 2. This sample is considered equivalent to the initial sample because there are no specific differences in the variables of interest (comparative Table 1-Table 2).

Table 1

*Description of the initial sample for the study*
			YEAR OF DETECTION IN PRIMARY CARE		Total
			2004	2009	Total
Valid cases		Frequency	55	79	134
Valid cases		%	41%	59%	100%
Sex	Male	Frequency	45	61	106
	Male	%	81.8%	77.2%	79.1%
	Female	Frequency	10	18	28
	Female	%	18.2%	22.8%	20.9%
Age at onset of the clinical episode		Mean	8.69	11.03	9.88
		Median	8.48	9.54	8.50
		95% CI	7.61–9.77	9.48–12.57	8.88–10.88
Presence of prior psychosocial factors		Frequency	21	33	54
Presence of prior psychosocial factors		%	38.2%	41.8%	40.3%
Current age		Mean	19.16	17.09	17.55
		Median	19.06	15.43	16.50
		95% CI	18.03–20.29	15.56–18.62	16.55–18.55

Table 2

*Description of the interviewed sample*
			YEAR OF DETECTION IN PRIMARY CARE		Total
			2004	2009
Interviewed cases		Frequency	42	53	95
Interviewed cases		%	76.4%	67.1%	70,9%
Sex	Male	Frequency	33	43	76
	Male	%	78.6%	81.1%	80.0%
	Female	Frequency	9	10	19
	Female	%	21.4%	18.9%	20.0%
Interviewed person	Direct user	Frequency	14	10	24
	Direct user	%	33.3%	18.9%	25.3%
	User's relatives	Frequency	28	43	71
	User's relatives	%	66.7%	81.1%	74.7%
Age at onset of the clinical episode		Mean	7.76	10.64	9.37
		Median	8.00	9.00	8.00
		95% CI	6.64–8.88	8.96–12.32	8.29–10.45
Presence of prior psychosocial factors		Frequency	17	25	42
Presence of prior psychosocial factors		%	40.5%	47.2%	44.2%
Current age		Mean	18.24	16.49	17.26
		Median	18.00	15.00	17.00
		95% CI	17.07–19.41	14.75–18.23	16.17–18.36

Procedure

The clinical route patients following consultation on ADHD symptoms at PC services was investigated in a follow-up study (retrospective-prospective) of their Clinical History (CH). The Ethics Committee of the Central University Hospital of Asturias granted permission for the research on May 2014. Data were collected during June and July 2014. A telephone voluntary interview inquired about the current state (treatment statement, occupation, symptoms, difficulties, and impairment). Phone interviews were addressed directly to ADHD adult patients. In the case of under-age ADHD patients or unreachable patients, interviews were addressed to a relative caregiver. Interviews were run between August 2014 and January 2015. Data sheets and digital data base are guarded by the corresponding author.

Variables and Instruments

The following variables were collected from CH:

a. Presence of factors influencing health status and contact with health services as listed in ICD-10 (World Health Organization, 1992).

b. Presence of psychostimulants prescription.

c. Public clinical professional responsible for the treatment (Primary Care, Mental Health, Neuropediatrician or another clinical professional).

The following variables were collected from telephone interview

a. Current clinical and occupational statement. Patients were asked about their current clinical statement (“Do you receive any treatment or clinical consultation for any psychological difficulty in the present moment?”) and occupation (“what occupation do you currently have? if studying, which educational stage are you enrolled in?”).

b. Current symptoms. Assessed by Swanson, Nolan, and Pelham Rating Scale (SNAP-IV). Clinical cut-off scores were taken from ADHD national guidelines. Cut-off scores were set at 1.78 for the inattention subset, 1.44 for the hyperactivity/impulsivity subset, and 1.67 for ADHD global scale. Results on SNAP-IV and SDQ questionnaires cannot be compared with the rest of non-clinical Spanish population as there are no standard scores.

c. Current difficulties and impairment. Assessed by “Strengths and Difficulties Questionnaire” (SDQ, Goodman 1999), follow-up impact supplement, Spanish version.

All data for this project, along with relevant code and codebooks, have been made publicly available and guarded by the corresponding author and at can be accessed at https://drive.google.com/file/d/1hnnxBL3BBEcfbzulnYaJ5rmJqUP1S5nR/view?usp=sharing. Part of these research and data has been presented in a Conference at Asturias´ University Hospital and at Psicofundación Research National Award in 2015.

a. Current treatment statement (n = 89): 60.70% of the population who answered this question (54 people) has no current treatment for psychological difficulties, 33.70% (30 people) has psychopharmacological treatment, 4.50% (4 people) follows psychological treatment and 1.10% (1 person) follows a combined treatment (psychological and psychopharmacological). Distribution among cohorts is shown in Table 3.

b. Current occupation: data from this variable was classified into seven categories: five studying categories according to the Spanish educational system (primary school, secondary school, pre-bachelor, working program, and bachelor), a working category, and none occupation category. Current occupation in the different cohorts is shown in Fig.

Table 3

*Current treatment statement in cohorts (2004 and 2009)*
	No treatment	Psychopharmacological treatment	Psychological treatment	Combined treatment
10 years follow-up (2004 symptoms detection)	57.50%	32.50%	7.5%	2.5%
5 years follow-up (2009 symptoms detection)	63.30%	34.70%	2%	0%

c. Clinical situation: symptoms were assessed through the SNAP-IV in 71 people: 1.3145 was the average rate for inattention subset (95% CI [1.153, 1.475); 1.007 was the average rate for the hyperactivity/impulsivity subset (95% CI [0.820, 1,193); 1.161 was the average rate for the global ADHD scale (95% CI [1.007, 1.315). Data is above the clinical cut-off scores for suggesting ADHD in 31% of the population in the inattention subset, 32.40% in the hyperactivity/impulsivity subset, and 25.40% for the global ADHD scale. A statistically significant difference was found in ratings for the global ADHD scale related to who answered the questionnaire and to the current age of the patient. There were more cases above clinical cut-off scores for the global ADHD scale when the SNAP-IV was answered by a relative caregiver (Fisher, 1gl, 0,042) than when answered directly by the patient. The average rates for the inattention subset and global scale were higher when answered by a relative caregiver (Table 4). There were more cases above the clinical cut-off scores for global ADHD scale when the SNAP-IV was assessing an under-age person (in Spain this means under 18 years-old) than when the patient was an adult (Fisher, 1gl, 0,030). Average rates for inattention and hyperactivity/impulsivity subsets and global scales were higher when answered by the caregiver of an under-age person (Table 5).

d. Clinical difficulties and impairment: a total of 88.80% of the subjects interviewed reported that their problems are better (“a bit better” or “much better”) since coming to the clinic for the first time, while 66.2% (47 people) answered they still had difficulties in one or more areas (emotions, concentration, behavior or being able to interact with other people). A total of 63.4% (45 people) answered that they had difficulties that interfered with their daily life. Furthermore, 95.7% of those with current difficulties feel impairment in their life. Interference appears in one or several areas as shown in Fig. 2.

A statistically significant difference was found related to current difficulties (χ2,1gl, 0.042) and interference (χ2,1gl, 0.045), which is assessed by the impact supplement of the SDQ questionnaire related to the age of the patient. More cases declared current difficulties and current impairment in under-age interviewed people.

e. Symptoms and impairment relation: There is a moderate positive correlation between current interference (assessed by SDQ) and higher ADHD ratings (assessed by SNAP-IV) (Pearson = 0.393 between interference and inattention subset, sig.bilateral = 0.01; Pearson = 0.356 between interference and hyperactivity/impulsivity subset, sig.bilateral = 0.002; Pearson = 0.420 between interference and global ADHD, sig.bilateral = 0.000).

Concerning previous works related to this dataset and being prepared for publication, 95.5% of the total population at the onset point of the study (n = 134) received stimulant drugs treatment during some point of the follow-up study. Those who were treated with stimulants appear to have more current difficulties (measured with the SDQ) than those who were not treated with stimulants (χ2,1gl, 0.018). From the total sample at the onset point of the study (n = 134), 29,9% of participants were treated exclusively at Primary Care Services. Those cases appear to have fewer current difficulties than those treated by Mental Health or Neuropediatric Service (χ2,1gl, 0.024). There is no statistically significant relationship for those who had experienced psychosocial adversity (according to the ICD-10) compared to those who had no psychosocial adversity in childhood in the follow-up variables such as current occupation, clinical cut-off scores suggestive of ADHD or impairment.

Table 4

*Symptoms rates (SNAP-IV) related to the person interviewed*
		PERSON INTERVIEWED		p
		Patient	Relative carer	p
Inattention subset	Average rate	.9895	1.4604	.006
Inattention subset	CI95%	.7383-1.2408	1.2653–1.6555
Hyperactivity/impulsivity subset	Average rate	.8700	1.0678	Not valid .332
Hyperactivity/impulsivity subset	CI95%	.5941-1.1459	.8234-1.3121
Global ADHD	Average rate	.9323	1.2635	.047
Global ADHD	CI95%	.6980-1.1666	1.0681–1.4588

Table 5

*Symptoms rates (SNAP-IV) related to the age of the patient interviewed*
		UNDER-AGE vs. ADULTS		p
		Under-age	Adult
Inattention subset	Average rate	1.5044	1.0831	.008
	CI95%	1.3060-1,7027	.8330-1.3332
Hyperactivity/impulsivity subset	Average rate	1.1738	.8025	.047
	CI95%	.9125-1.4352	.5409-1.0641
Global ADHD	Average rate	1.3379	.9450	.010
	CI95%	1.1406–1.5353	.7121-1.1779

Previous literature (Goodman, Ford, & Meltzer, 2002) and some clinical guidelines (Guía Nacional de Práctica Clínica sobre el Trastorno por Déficit de Atención con Hiperactividad (TDAH) en Niños y Adolescentes) propose ADHD as a chronic condition. Apparently, symptoms do not improve over time. Moreover, previous literature presents higher rates of mental disorders in adulthood for adults/children with ADHD (Fischer et al., 2002; Mannuzza et al., 1993, 1998; Fayyad et al., 2007). The present study questions ADHD chronicity and higher risk of mental conditions. Chronicity is also questioned by other previous studies (Miller, Lalonde & McGrail, 2004) which shows decreasing ADHD rates as time elapses from the diagnosis moment.

Regarding chronicity and clinical course, previous literature points out that hyperactive/impulsivity subset and global ADHD rates (SNAP-IV) go down as people grow up, but inattention subset rates remain in adulthood (Kessler et al., 2010; Biederman et al., 2000; Miller, Lalonde & McGrail, 2004). In contrast, data shown in the present study reports dropping rates in hyperactive/impulsivity subset, inattention subset, and global ADHD rate, and as time elapses; ADHD difficulties behave as a unique clinical entity during the clinical course, and these difficulties remain in one-third of the sample after 5 or 10 years after the symptoms’ onset. In addition, the present study shows that ADHD global rates and ADHD subsets rates go down as people grow up.

Regarding the higher risk of mental adult disorders, the present follow-up study shows that most of the sample does not receive any treatment for a psychological condition after 5 or 10 years after detecting ADHD symptoms. This result diverts from previous warnings about adult mental health risks in children diagnosed with ADHD.

According to previous literature, some variables are related to adult ADHD rates. These rates vary according to several factors, such as the nature of the informant (patient vs. relative) or social adversity experienced in childhood. Regarding the latter, and in opposition to previous studies (Biederman et al., 1996), data shows no link between social adversity experienced in childhood and ADHD prevalence at present. According to previous studies, reported ADHD difficulties, symptom rates are higher when reported by a relative than when reported by the patient (Barkley et al., 2002). This previous work points out that this data is evidence of an underdiagnoses tendency in adulthood when assessing adult ADHD without a close relative’s opinion. However, there could be another interpretation for this pattern, since what constitutes a problem for a relative can be an adaptive pattern for the patient. Then, when consulting an adult patient directly about what constitutes a problem in their lives, ADHD rates drop. Regarding this subject, it might be interesting to address the importance of differences among models of interpretation for childhood difficulties. Different models support different opinions of what constitutes a clinical problem in childhood, and these differences affect noticeably parents’ expectations and thoughts about the upbringing of their children. The fact of ADHD dropping rates when asking to adult patients directly might be in accordance with the cultural “psychopathologization” of childhood described before (Marino, Timimi, 2010).

Previous literature also points out to high rates of school failure, academic dropout and delinquency in those children with ADHD (Barkley et al., 1990; Kent et al., 2011; Fischer et al., 1990, 2002; Lambert, 1988; Mannuzza et al., 1993). The present study does not allow to stablish the success in current occupation of patients detected with ADHD symptoms in their childhood, but most of them have a productive occupation in a 5–10 years follow-up time, at least in the Spanish socio-cultural context where the study has been run. These results call into question the academic and social alarm that ADHD disorder has raised.

Regarding difficulties and impairment in adulthood for people diagnosed for ADHD, present data suggest that most people with ADHD in the past still have problems at the present time. The remain of difficulties could be understood as a sign of a general dysfunctional pattern in self-regulation due to the lack of learning experiences in their childhood and youth (véase Ayllón y Milan, 1996; Luciano y Gómez, 1998; Paniagua, 1987; Ruiz et al., 2012; Willis y Loovas, 1977). In correlation to previous studies (Kessler et al., 2011), there is a link between the intensity of current ADHD symptoms (SNAP-IV) and their interference with everyday activities. Despite the difficulties and the interference, they seem to be quite adapted to their lives: they continue with their occupations and the impact in cohabitation, friendship and leisure activities is low; the most affected sphere seems to be the academic/working area. Despite this fact, the results indicate that, at last in a sociocultural Spanish context, patients tend to adapt to these difficulties and continue with a productive life with no clinical treatment involved. While the present study does not allow to record in detail their working conditions or the level of success in this area this as this question was not a goal in the present paper, these results indicate the need of further research about how ADHD difficulties can affect working areas. Working and academic details and related tasks should be incorporated in the follow-up protocols assessment regarding ADHD research. Previous works pointed out to the need of specific tasks and criteria when assessing adult ADHD (Barkley, Murphy & Fischer, 2008), but they did not suggest the need of assessing working/academic performance or inquiring about the need of non-pharmacological support in people previously diagnosed with ADHD.

Some other variables related to current difficulties in the present study might be discussed. Those cases treated with psychostimulant drugs or cases treated by a specialist health professional (usually a neuropediatrician or mental health professional) appear to have more difficulties at present. Reasons for these results could not be clarified due to the limitations of the present study since we lack data regarding the severity of ADHD conditions in their onset. Those cases which have more difficulties at the present moment could be simply those who did have more difficulties also at the beginning of the problem (so they were treated by a specialist health professional and more likely to be prescribed stimulant drugs). It could be also linked to previous studies showing poorer long-term academic results for ADHD children treated with psychostimulant drugs (Currie et al., 2013). Long-term studies assessing ADHD treatments and their long-term responses need to be done to clarify this aspect.

Data in the present work suggests that the presence of symptoms and interference vary depending on the age. This data supports previous literature when describing the downward tendency ADHD rates experiment as people grow up (Miller, Lalonde & McGrail, 2004). This fact could be pointing out the importance of maturity factors (for example, certain abilities appear as the regular neurological development takes place) or social factors. The ADHD condition could constitute a problem for social and cultural childhood dynamics but can be an adaptive pattern in a grown-up cultural adult context (e.g. what constitutes or not a problem in a child behavior always depends on the judgment of an adult; adult working tasks could be more adapted to personal interests and do not bring to light an attentional difficulty) as pointed out in previous literature (Timimi 2010, Garcia de Vinuesa et al., 2014). The persistence of certain difficulties might be understood as lack of a functional psychological pattern related to the lack of learning experiences in their vital history (véase Ayllón y Milan, 1996; Luciano y Gómez, 1998; Paniagua, 1987; Ruiz et al., 2012; Willis y Loovas, 1977).

Some limitations need to be addressed in the present study. ADHD cases are derived from a real clinical practice sample, so they do not have a unified diagnosis procedure (as different health professionals have different assessment procedures). The sample was selected by a clinical criteria: consultations on ADHD symptoms in PC. This fact establishes a significant difference with the majority of ADHD previous literate, based on academic and/or highly controlled contexts. The sample selection procedure leaves out those who did not consult in the public healthcare system. This procedure can entail a bias when studying ADHD. Finally, it is important to consider that this study has been run in a specific cultural and healthcare context and that different contexts may affect the output of similar studies.

Summarizing previous points, we can say that proposing ADHD as a chronic condition, linked in adulthood to higher risk of mental disorders, academic and working failure, and social risk factors, creates an important alarm about the importance of treating (particularly pharmaceutical treatment) ADHD symptoms from their onset. These setting justify children ADHD treatment (often psychotropic drugs as proposed in clinical guidelines) so is presented as the only solution for a chronic condition and in order to avoid dangerous long-term risks. However, the present study presents a less alarming perspective regarding ADHD clinical and social course. Data shown in present work presents a new framework for clinicians and families deciding if and how the treatment of ADHD symptoms in childhood should be taken.

Ethics approval and consent to participate: the research was approved by the Asturias´ University Hospital Ethics Committee where the plan is guarded. The committee can be contacted by email at: [email protected].

Consent for publication: participants were asked for permission to use the data for research and publications.

Data transparency: the raw and/or processed data on which study conclusions are based, are available and sent as an attachment in .sav format. Data sheets in paper are guarded by the corresponding and main author.

Research Materials Transparency: materials described in the method section (questionaries) are available in the net.

Funding: no funding to declare.

Authors´ contributions:

M. Eugenia de la Viuda Suárez. Study design, data analyses, writing article.

Julio Cesar Alonso Lorenzo. Study design and data analyses.

Carmen Luciano Soriano. Study design.

Part of these research and data has been presented in a Conference at Asturias´ University Hospital and at Psicofundación Research National Award in 2015. The research received both research Awards (Hospital Mental Health Residence Program Award and Psicofundacion National Award).

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No competing interests reported.

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Is ADHD warning justified? A follow-up clinical practice study in a Spanish sample

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