April 1, 2021
We know from many studies that ADHD is associated with a slightly lower intelligence quotient (IQ) and with problems in thinking known as executive function deficits. If that's the case, you might think that people with a high IQ cannot have ADHD. You would be wrong. Data on groups sometimes mislead us about individuals. Although on average, ADHD people have IQ scores that are about 9 points lower than others, there is a wide spread of IQs in both ADHD and non-ADHD people. So many people with ADHD have higher IQs than those without ADHD and vice-versa. Moreover, studies of people with high IQs support the idea that ADHD can be validly diagnosed among very intelligent individuals.
A series of studies using Antshel and colleagues showed that the clinical profile of high IQ ADHD was very similar to what has been observed for ADHD in general. For example, like their less intelligent counterparts, high IQ ADHD children have an increased risk for mood, anxiety, and disruptive behavior disorders. Children with a high IQ and ADHD showed a pattern of familial transmission as well as cognitive, psychiatric, and behavioral impairments consistent with the diagnosis of ADHD. The degree to which ADHD persisted into adulthood was also similar between the two groups.
In studies of adults with ADHD, the same group concluded that "adults with ADHD and a high IQ display patterns of functional impairments, familiarity and psychiatric co-morbidities that parallel those found in the average-IQ adult ADHD population." Of particular interest, despite their high intelligence, High-IQ adults with ADHD show impaired executive functioning, and their performance on tests of executive functioning predicted life impairments.
Why are these data important? Milioni and colleagues argue that among higher IQ adults with ADHD, a higher degree of intellectual efficiency may compensate for deficits in executive functions. This ability to compensate allows them to succeed in many tasks, which otherwise might have been impaired by their ADHD symptoms. But, in many cases, such compensation is not sufficient or is too burdensome. When compensation fails, ADHD symptoms and other impairments emerge. When this occurs later in life, some clinicians are reluctant to diagnose ADHD. Caution is warranted, but clinicians need to know that the diagnosis of ADHD among high IQ is valid.
Antshel, K. M., S. V. Faraone, et al. (2008). "Temporal stability of ADHD in the high-IQ population: results from the MGH Longitudinal Family Studies of ADHD." J Am Acad Child Adolesc Psychiatry47(7): 817-825.
Antshel, K. M., S. V. Faraone, et al. (2009). "Is adult attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ?" Psychol Med39(8):1325-1335.
Antshel, K. M., S. V. Faraone, et al. (2010)."Executive functioning in high-IQ adults with ADHD."Psychol Med40(11): 1909-1918.
Antshel, K. M., S. V. Faraone, et al. (2007). "Inattention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ? Results from the MGH Longitudinal Family Studies of ADHD."child Psychol Psychiatry48(7): 687-694.
Katusic, M. Z., R. G. Voigt, et al. (2011)."Attention-deficit hyperactivity disorder in children with high intelligence quotient: results from a population-based study." JDevBehavPediatr32(2): 103-109.
Maternal infections and inflammatory responses during pregnancy have been proposed as risk factors for neurodevelopmental disorders such as ADHD.
Taiwan has a single-payer health insurance system that covers virtually the entirety of its population. Its Ministry of Health and Welfare maintains the National Health Insurance Research Database (NHIRD), with detailed information on outpatient services, hospitalizations, and medical treatment for nearly 99% of all residents.
A Taiwanese study team used NHIRD to examine to examine the relationship between maternal hospitalization for infection, and early childhood infection, and subsequent ADHD in offspring. The study cohort originated with all 3,260,879 individuals born between 2001 and 2018.
The team excluded births from foreign mothers, still births, births with congenital defects, low birth weights, abnormally late births, twins, triplets, and other multiple births, culminating in a final population cohort of 2,885,662 live-born single infants across 1,893,171 families, and 1,864,660 individuals with full siblings from 872,169 families comprising the full sibling cohort.
Study participants were followed until diagnosis of a neurodevelopmental disorder, their death, or the end of 2021.
After adjusting for sex, birth year, paternal and maternal ages, birthweight, birth season, parity, delivery method, 1 minute APGAR score (evaluating baby’s appearance, pulse, grimace, activity and respiration at birth), gestational age, pregnancy and delivery complications, parental history of neurodevelopmental disorders, maternal asthma and diabetes, urbanization level of the residential area, and family’s insurance amount, offspring of mothers hospitalized for infections had 14% greater odds of being subsequently diagnosed with ADHD.
However, in the full sibling cohort of over 1.8 million, this association vanished. That held true for each of the three trimesters of pregnancy. It also held true for bacterial infections. Surprisingly, offspring of mothers hospitalized for viral infections were 24% less likely to be diagnosed with ADHD than their siblings not exposed to maternal viral infection. Because of that, they also had a 6% lower risk overall.
After the same adjustments, early childhood infection was associated with 16% greater odds of being diagnosed with ADHD.
Nevertheless, in the full sibling cohort of over 1.8 million, this association again vanished. That held true overall, as well as separately for childhood infections in months 1-6 and months 7-12. The association vanished altogether both for bacterial infections as well as for viral infections.
The authors concluded, “the results of this nationwide birth cohort study with population and sibling analyses suggest that the association between maternal infection during pregnancy and offspring neurodevelopmental risk is largely due to familial confounding factors.”
Most previous studies of suicide and self-harm risk among persons with ADHD have focused on adolescents and adults. They’ve also tended to be cross-sectional, analyzing data from a population at a specific point in time.
An Australian study team took a different approach, conducting a before-and-after study through the birth cohort of the Longitudinal Study of Australian Children (LSAC), comprising 5,107 children who have been followed up every two years since birth.
The diagnosis of ADHD was based on parents reporting that their child had received a diagnosis of ADHD at or before age ten.
Suicide and self-harm were defined as children’s self-report at age 14 of any thought or attempt of suicide and self-harm respectively over the past year.
The team adjusted for the following confounders: socioeconomic status, birth weight, ADHD medication history, maternal education level, maternal age at birth, experience in bullying victimization at age 12, and depression score based on Short Mood and Feelings Questionnaire (SMFQ).
Of the 5,107 participants, 3,696 had all the valid data required for analysis and were included in the final cohort. Of these, 3.6% were diagnosed with ADHD by age 10.
With diagnosis of ADHD at age 10 and all other factors held constant:
Both depression and exposure to bullying were statistically significant mediators for the relationship. Nevertheless, depression and exposure to bullying each accounted for well under 10% of the overall effect.
Neither socioeconomic status nor maternal factors had any significant mediating effect on outcomes.
Conclusion:
The authors concluded, “This study provides compelling evidence that children diagnosed with ADHD at the age of 10 years face significantly elevated risks of experiencing suicidal thoughts, planning, or attempts, as well as self-harm, by the age of 14 years, which underscores the critical importance of recognizing and addressing these heightened risks in children with ADHD.”
While factors like depression and bullying contribute, ADHD itself remains a key risk factor. Early intervention and strong mental health support are crucial to protecting these children’s well-being.
Noting that “Recent research has demonstrated that some gut bacteria can affect the nervous system,” and speculating that “dysregulation in the gut microbiota may increase the incidence of ADHD by overproducing reactive oxygen and nitrogen species, thereby causing neuroinflammation and oxidative stress”, a Taiwanese study team decided to explore whether early-life use of antibiotics – in the first two years – is associated with increased risk of subsequent diagnosis of ADHD.
Because Taiwan has a single-payer national health insurance system that covers 99.8% of the island’s population, they were able to use the system’s National Health Insurance Research Database (NHIRD) and Maternal and Child Health Database (TMCHD) to include all 1.6 million children born between 2004 and 2012.
Of these, a little over 1.1 million were given antibiotics before turning two years old, and just over 460,000 were not given antibiotics in the same time frame.
The mean follow-up period for records of subsequent ADHD diagnoses was seven years.
The team adjusted for confounding variables: sex, gestational age at birth (weeks), and birth weight (grams) of the children, and age at birth (years), insurance amount (New Taiwan Dollar (TWD)), insurance location, method of delivery, comorbidities, and medication used during pregnancy.
With these adjustments, early-life antibiotics use was associated with a 12% increase in likelihood of being subsequently diagnosed with ADHD.
However, looking at the effects of antibiotics as an undifferentiated grouping turned out to be misleading, because the association was limited to only some classes of antibiotics.
Penicillins were associated with a 22% increase in risk of subsequent ADHD diagnosis, cephalosporins with a 10% increase.
On the other hand, there was absolutely no such association for tetracyclines, macrolides, and quinolones.
The Take-Away:
This study found that children in Taiwan who took certain types of antibiotics before age 2 had a slightly higher risk of developing ADHD later in life. More work is needed to determine if this finding is due to unmeasured confounding before a causal link can be concluded.
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