Examining the relationship between ADHD and self-harm in adults
ADHD is associated with increased rates of self-harm1, 2. These behaviors include non-suicidal self-injury (i.e., self-directed, deliberate harm of self in the absence of suicidal intent, such as cutting or burning), as well suicidal ideation, suicide attempts, and dying by suicide (i.e., direct, self-injurious behavior with the intent to end one’s life, such as hanging, or jumping from extreme heights). Self-injurious behaviors exist on a spectrum of severity, and numerous studies have observed that non-suicidal self-harm behavior often predicts suicide3, 4.
Individuals with ADHD are at a greater risk of both non-suicidal and suicidal self-injury. An international study described the risk of a suicide event as 30% greater for ADHD patients than non-ADHD patients5, 6, and a recent study of first-year post-secondary students found that rates of suicide attempts were four times higher for students with ADHD than a matched control group6. Alarmingly high rates of self-injurious behavior and suicide attempts have been reported in studies of young women with ADHD, whereas completed suicides occur more often in men with the disorder7, 8, 1.
The associations between ADHD, self-injurious behavior, and suicidality are believed to result from complex interactions between impulsivity and emotional dysregulation, which are central features of the disorder. High rates of depression, anxiety, substance abuse, as well as associated features, such as poor self-esteem and strained social relationships, are commonly co-occurring with ADHD diagnoses—and all of these factors increase the risk for self-harm behavior 9, 10, 11, 12.
Although the specific pathways are likely complex and multifactorial, it is clear there is a link between ADHD symptoms, especially impulsivity, and both suicidal and non-suicidal self-harm, strengthened or mediated by certain factors such as additional diagnoses7. Impulsivity can predict suicide events even more strongly than other clinical diagnoses6. A growing body of research has called for clinicians to recognize the increased risk of self-harm (both non-suicidal and suicidal) for individuals with ADHD in particular1. The risk may rise and fall in certain age groups (e.g., higher for young adults), but it is a concern across the lifespan, with reported rates of two to three times more lifetime risk for suicide than those without ADHD6.
Insights from MHS research with the CAARS™ 2
As the developer of leading tools for the assessment of ADHD, MHS conducted research to better understand the relationships between ADHD and self-harm in adults. Large, nationally representative samples from the general population were collected, along with targeted clinical samples of adults with an ADHD diagnosis. These data were collected for the purposes of developing the Conners Adult ADHD Rating Scale 2nd Edition (CAARS™ 2) 13.
The CAARS 2 focuses on symptoms of ADHD and related impairments, as well as content regarding commonly co-occurring disorders that could serve as screeners and indicators for differential diagnosis. Additionally, items are included to screen for self-harm (e.g., deliberate self-harm and suicide ideation, plans, or attempts).
Results revealed that in a sample of 101 adults diagnosed with ADHD (Combined Presentation), 48.50% endorsed suicidal thoughts, compared to 13.10% of a demographically matched general population sample. In addition, 16.75% of the ADHD sample had deliberately engaged in self-harming behavior, compared to 7.76% of the general population sample. Observations from those close to the individual with ADHD revealed elevated rates of these self-harm behaviors; data gathered from spouses, family members, and friends, revealed similar results, with endorsement up to four times greater than observers rating adults with ADHD Combined Presentation (N = 76) as compared with observers’ ratings of adults from the general population. Suicidal thoughts were reported 5 times as often for individuals with ADHD as compared to individuals without any diagnosis, according to data from observer ratings.
These results, along with the growing body of evidence in the research literature, make it clear that ADHD measures must include content related to self-harm. As such, the CAARS 2 features an Associated Clinical Concern section that includes items that capture thoughts and behaviors related to self-harm, aiding in this important aspect of an ADHD evaluation.
What can you do?
Ask
Include questions about self-harm during clinical interviews, especially when speaking with the adult client directly. Probe as needed to follow up on responses. Other raters, such as spouses or other adult observers, may have a limited view into these sensitive and intimate topics, but their perspectives may provide additional insight or corroborating evidence. Include an investigation of risk factors during routine ADHD assessments, given the prevalence rate of self-harm behaviors for individuals with ADHD.
Although these conversations may feel uncomfortable, research shows that asking about suicidality and self-harm behaviors, both in research and in clinical settings, does not increase the risk of these behaviors14. In fact, there was no significant increase in suicidal thoughts, and—perhaps most importantly—talking openly about suicide may reduce the risk. There is a much larger risk associated with not asking and following up about these potentially lethal behaviors.
Measure
It is recommended practice that ADHD evaluations include screening for self-harm, initially and throughout treatment15. Standardized behavior rating scales, such as the CAARS 2, provide a great option for screening for self-harm behaviors. These tests can gather information from self-reported and observer ratings (such as a spouse, friend, or co-worker). Ratings from multiple perspectives can help shed more light on concerning behaviors or associated impairments.
By using norm-referenced standardized tools, an individual’s behaviors, actions, symptoms, thoughts, and feelings can be compared to others like them (e.g., same age and gender). This comparison can help inform what is typical or concerning relative to one’s peers or expected developmental trends. These measures quantify the reported problems, which can also help steer treatment planning to focus on the area(s) of greatest concern by examining the most extreme scores and capturing when presentations change over time.
The CAARS 2 is a focused measure pertaining to ADHD symptoms and impairments, but screening items are included in both tools that can help highlight risks related to self-harm, because the data so clearly indicate the importance of screening for these concerns.
Observe
In addition to formal clinical interviews and standardized measures, one can educate parents, teachers, peers, and spouses to identify early warning signs or indicators of struggle.
For self-harm and suicide risk detection, it is important for those close to the individual to make note of behavior changes, such as moodiness, withdrawing from friends or favorite activities, appearing agitated or unsettled, or expressing that they feel hopeless. Other potential signs could be unexplained scratches and bruises or avoidance of situations that may reveal such injuries (e.g., swimming).
Early intervention is only possible with early detection. Raising awareness of these warning signs can help identify at-risk adults, which in turn can trigger an evaluation or triage. Additional tips and warning signs can be found here.
Learn More
You may wish to consult experts, academic literature, and additional resources to learn more about recent findings and recommendations related to these topics.
To learn more about the CAARS 2 or purchase today, click here.
Acknowledgements
MHS would like to acknowledge the contributions of Elizabeth P. Sparrow, Ph.D., and Drew Erhardt, Ph.D.
References
[1] Septier, M., Stordeur, C., Zhang, J., Delorme, R., & Cortese, S. (2019). Association between suicidal spectrum behaviors and attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 103, 109–118.
[2] Simioni, A. R., Pan, P. M., Gadelha, A., Manfro, G. G., Mari, J. J., Migel, E. C., Rohde, L. A., & Salum, G. A. (2017). Prevalence, clinical correlates and maternal psychopathology of deliberate self-harm in children and early adolescents: Results from a large community study. Brazilian Journal of Psychiatry, 40(1). https://doi.org/10.1590/1516-4446-2016-2124
[3] Allely, C. S. (2014). The association of ADHD symptoms to self-harm behaviors: A systematic PRISMA review. BMC Psychiatry, 14. https://doi.org/10.1186/1471-244X-14-133
[4] Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., & Appleby, L. (2005). Suicide after deliberate self-harm: A 4-year cohort study. American Journal of Psychiatry, 162(2) 297–303. doi:10.1176/appi.ajp.162.2.297
[5] Faraone, S. (2020). ADHD and the risk for suicide. https://apsard.org/adhd-and-the-risk-for-suicide/
[6] Eddy, L. D., Eadeh, H.-M., Breaux, R., & Langberg, J. M. (2020). Prevalence and predictors of suicidal ideation, plans, and attempts, in first-year college students with ADHD. Journal of the American College Health Association, 68(3) 313–319. https://doi-org.library.smu.ca/10.1080/07448481.2018.1549555
[7] Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with Attention-deficit/Hyperactivity Disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting Clinical Psychology, 80(6), 1041–1051. doi:10.1037/a0029451
[8] Nigg, J. T. (2013). Attention-deficit/hyperactivity disorder and adverse health outcomes. Clinical Psychology Review, 33(2), 215–228. doi:10.1016/j.cpr.2012.11.005
[9] Brezo, J., Paris, J., & Turecki, G. (2006). Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: A systematic review. Acta Psychiatrica Scandinavica, 113(3), 180–206. https://doi.org/10.1111/j.1600-0447.2005.00702.x
[10] Hu, H-F., Chou, W-J., & Yen, C-F. (2016). Anxiety and depression among adolescents with attention-deficit/hyperactivity disorder: The roles of behavioral temperamental traits, comorbid autism spectrum disorder, and bullying involvement. The Kaohsiung Journal of Medical Sciences, 32(2), 103–109.
[11] Moran, P., Coffey, C., Romaniuk, H., Olsson, C., Borschmann, R., Carlin, J. B., & Patton, G. C. (2012). The natural history of self-harm from adolescence to young adulthood: A population-based cohort study. The Lancet, 379, 236–243.
[12] Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., & Bridge, J. A. (2016). Suicide in elementary school-aged children and early adolescents. Pediatrics, 138(4). doi:10.1542/peds.2016-0436
[13] Conners, C. K., Erhardt, D. & Sparrow, E. (2023). Conners Adult ADHD Rating Scales 2nd Edition (CAARS 2). Multi-Health Systems, Inc.
[14] Dazzi T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviors induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361–3363. doi:10.1017/S0033291714001299
[15] Weiss, M. D., & McBride, N. M. (2018). ADHD: A 24-hour disorder. Psychiatric Times, 35(10). https://www.psychiatrictimes.com/view/adhd-24-hour-disorder
