Consequences of ADHD

tAuthor: Ulrich Brennecke
Review (April 2024): Dipl.-Psych. Waldemar Zdero

Untreated ADHD not only has acute behavioral symptoms, but also has massive long-term consequences that often affect the entire life of the person with ADHD.

Health effects

• Reduced life expectancy by 8.4 to 11.1 years
• Increased risk of suicide, (traffic) accidents, serious injuries and broken bones
• Increased risk of crime and violence

Comorbid diseases

• Psychiatric illnesses such as depression, anxiety disorders, bipolar disorder and post-traumatic stress disorder more common
• Physical illnesses such as sleep disorders, respiratory diseases, infections and addictions more common

Behavioral problems and social Consequences

• Increased risk behavior and a higher risk of becoming a victim of abuse and bullying
• Educational problems and occupational disadvantages, including poorer educational opportunities, reduced school performance, lower employability and lower income

Advantages of drug treatment

• Medications such as stimulants and atomoxetine not only improve symptoms, but also protect against the above-mentioned risks by improving symptoms
• They improve the quality of life of people with ADHD and reduce the need for other medical treatment and healthcare costs

Economic impact on society

• People with ADHD have a lower income and pay less tax and social security contributions
• They cause higher health and education costs as well as damage due to absenteeism, unemployment, occupational disability and crime

• 1. Consequential risks of ADHD
  • 1.1. Life expectancy shortened (by 8.4 to 11.1 years)
  • 1.2. More frequent accidents and injuries
    • 1.2.1. Risk of injury increased (+ 40 % to + 250 %)
    • 1.2.2. Increased accident risk (+ 57 % to + 65 %)
    • 1.2.2. Traffic accidents and accident damage (+ 23 %)
  • 1.3. More frequent perpetrator (+ 160 %) and victim (+ 100 %) of violence and bullying
  • 1.4. Higher crime rate (+ 120 % to + 800 %)
  • 1.5. Comorbid health problems
    • 1.5.1. Mental illnesses
      • 1.5.1.1. Neurodegenerative diseases (up to + 400 %)
        • 1.5.1.1.1. Dementia (up to + 500 %)
        • 1.5.1.1.2. Parkinson’s disease (up to + 150 %)
        • 1.5.1.1.3. Alzheimer’s (+ 390 %)
      • 1.5.1.2. Depression (+ 450 %)
      • 1.5.1.3. Eating disorders (+ 260 %)
      • 1.5.1.4. Anxiety disorders (up to + 230 %)
      • 1.5.1.5. Post-traumatic stress disorder, PTSD (+ 137 %)
    • 1.5.2. Behavioral peculiarities
    • 1.5.3. Cognitive impairments
    • 1.5.4. Physical illnesses
      • 1.5.4.1. Sexually transmitted diseases (+ 300 %)
      • 1.5.4.2. Respiratory diseases (up to + 220 %)
      • 1.5.4.3. Risk of addiction (up to + 190 %)
      • 1.5.4.4. Infections (up to + 180%)
      • 1.5.4.5. Periodontitis (+ 129 %)
      • 1.5.4.6. Fatigue (+ 118 %)
      • 1.5.4.7. Caries (+ 116 %)
      • 1.5.4.8. Birth complications in mothers with ADHD (up to + 80%)
      • 1.5.4.9. Stroke risk (up to + 40 %)
      • 1.5.4.10. Gliomas (+ 15 % to + 33 %)
      • 1.5.4.11. Slightly elevated blood pressure in old age
      • 1.5.4.12. COVID-19 risk higher, progression more difficult
  • 1.6. More teenage pregnancies (+ 130 to + 530 %)
  • 1.7. Educational disadvantages
  • 1.8. Professional disadvantages and loss of income
  • 1.9. Reduced quality of life
  • 1.10. Divorces / separations more frequent (+ 87 % to + 400 %)
  • 1.11. Relocations more frequent (+ 135 %)
  • 1.12. Depression increased in parents of children with ADHD (+ 330 %)
• 2. Protective effect of ADHD treatment (- 9 % to - 59 %)
  • 2.1. Reduced premature mortality, fewer suicides (- 20 %)
  • 2.2. Fewer accidents and injuries
    • 2.2.1. Fewer accidents (- 43 % to - 66 %)
    • 2.2.2. Fewer traffic accidents (- 38 to - 50 %)
    • 2.2.3. Fewer fractures (breaks) (- 32 % to - 74 %)
    • 2.2.4. Normalized healing time for concussion
    • 2.2.5. Fewer emergency admissions (- 45 %)
  • 2.3. Fewer sexually transmitted diseases and teenage pregnancies (up to - 40 %)
  • 2.4. Fewer comorbidities
    • 2.4.1. Reduced psychiatric hospitalization (- 7 % to - 26 %)
    • 2.4.2. Less depression (- 20 % to - 60 %)
    • 2.4.3. Fewer anxiety disorders (- 85 %)
    • 2.4.4. Fewer behavioral disorders and ODD (- 55 % to - 70 %)
    • 2.4.5. Fewer bipolar disorders (- 50 %)
    • 2.4.6. Fewer psychoses (- 17 %)
  • 2.5. Reduced consumption of addictive substances (- 30 % to - 90 %)
  • 2.6. Less obesity (- 26 %)
  • 2.7. Periodontitis (- 58 %)
  • 2.8. Reduced general hospitalization (- 16 % to - 38 %)
  • 2.9. Fewer victims of violence, bullying and abuse
  • 2.10. Lower crime rate (- 31 % to - 41 %)
  • 2.11. Improved school performance and educational qualifications
  • 2.12. Improved employability and income
  • 2.13. More often regular health insurance (+ 26.2 % to + 77.6 %)
  • 2.14. Less need for treatment, lower healthcare costs (- 63 % to - 82 %)
  • 2.15. Improved quality of life
  • 2.16. No lasting protective effect of treatment carried out a long time ago
  • 2.17. Numbers needed to treat
• 3. Financial Consequences of ADHD
  • 3.1. Treatment costs for ADHD
  • 3.2. Healthcare costs for ADHD
  • 3.3. Costs for relatives with ADHD
  • 3.4. Education costs for ADHD
  • 3.5. Increased social benefits
  • 3.6. Indirect damage caused by ADHD
    • 3.6.1. Increased absenteeism, unemployment, incapacity to work
    • 3.6.2. Premature mortality
    • 3.6.3. Income deficits with ADHD
      • 3.6.3.1. Reduced income (- 16.1 % to - 24.4 %), lower assets (- 75 %)
      • 3.6.3.2. Tax and social security contributions resulting from reduced income
  • 3.7. Total economic costs

1. Consequential risks of ADHD¶

People with ADHD have to put up with massive restrictions in their quality of life.
Untreated / inadequately treated ADHD has a massive lifelong impact.¹²
Without treatment, people with ADHD had worse long-term outcomes in all categories than people without ADHD (meta-analysis, k = 351)³

• 244 studies (74%) showed worse results
• 89 studies showed comparable results (26 %)
• no study found better results for ADHD

1.1. Life expectancy shortened (by 8.4 to 11.1 years)¶

• Life expectancy reduced by 8 to 11 years⁴⁵
  • 8.4 years for childhood ADHD that does not persist⁴
  • 11.1 years for ADHD that persists into adulthood⁴
  • Possibly due to genetic causes.⁶
  • Also (but not only) due to reduced conscientiousness⁴
    • The lowest quartile (25%) of conscientiousness is associated with a 7 to 8 year shorter life expectancy (even in gifted individuals and independent of ADHD)
    • People with ADHD among the 5 to 7% with the lowest conscientiousness levels
  • For comparison: life expectancy reduced by 5 to 6 years with ASD⁷
• 1.27 to 4.6 times premature mortality. Depending on the study, between
  • more than 4.6 times (for adults)⁸ in particular due to accidents.^{91011121314151617}
  • Up to 25-fold with a high number of additional comorbidities ⁸¹⁸
  • 4.25-fold risk of premature mortality when first diagnosed with ADHD in adulthood.¹⁹
  • 2.85 times (girls and women)¹⁹
  • 1.8 times the risk of premature mortality overall²⁰
  • 1.7 times the risk of premature mortality due to traffic accidents²⁰
  • 1.4-fold (children and adolescents)¹⁹
  • 1.27 times (boys and men)¹⁹
• Increased risk of suicide²¹
  • 4.83 times the overall suicide risk²⁰
  • 4.1 times the suicide risk for women²²
  • 2.9 times the risk²³
  • 2.4-fold risk of suicide with ADHD overall²²
  • 2.3-fold risk²⁴
  • Even higher in the case of untreated ADHD²⁵²⁶
• Suicidal thoughts and suicide attempts increased²⁷
  • But not in veterans with ADHD²⁸
• 10-fold risk of premature mortality in people with ADHD, addiction, ODD or CD, but not due to the disorders themselves, but due to comorbid increased psychopathic traits²⁹
• 2-fold risk of falling victim to murder³⁰

1.2. More frequent accidents and injuries¶

1.2.1. Risk of injury increased (+ 40 % to + 250 %)¶

• Injuries increased³¹³²
  • By 41 % for young adults³³
  • By 250 % for children and adolescents³⁴
• Increased risk of bone fractures³⁵
  • increased by 60 % in girls³⁶
  • increased by almost 40 % in boys³⁶
  • Stress fractures increased by 17³⁷
• Concussions
  • Twice as common in children with ADHD³⁸³⁹
  • More frequent, with simultaneously prolonged healing time; healing time is normalized by stimulants⁴⁰
• Head injuries due to some types of accidents in ADHD up to more than twice⁴¹ to more than three times as frequent⁴²
• Children with eye injuries were 3.5 times more likely to have ADHD than children without eye injuries.⁴³
• Self-harming behavior
  • 58 % more frequently⁴⁴
  • Increased in 12- to 13-year-olds with ADHD⁴⁵
  • Intentional self-poisoning increases
    • 1.52-fold⁴⁴
    • 4.65 times⁴⁶

At one injury clinic, the risk of having ADHD was doubled for patients 12 to 13 years old.⁴⁵
The risk of visiting an emergency room was increased compared to controls⁴⁷

• for ADHD
  • 45 % in total
  • due to physical injuries by 18 %
• for ASS
  • 48 % in total
  • due to injuries caused by ingestion or inhalation by 57 %
  • due to physical injuries reduced by 4
  • due to orthopedic injuries decreased by 22
  • due to injuries caused by animals reduced by 56
• for comorbid ADHD and ASD
  • 29 % in total
  • due to injuries caused by ingestion or inhalation by 80
  • due to physical injuries decreased by 9
  • due to orthopedic injuries decreased by 17
  • due to injuries caused by animals reduced by 8

1.2.2. Increased accident risk (+ 57 % to + 65 %)¶

ADHD was found to increase the risk of accidents by

• 60 to 89 %⁴⁸
• 65 % among n = 18,416 children aged 6 to 17 years⁴⁹
• 57 % of n = 3,202 schoolchildren aged around 15⁴⁹
• 47% in the parent report, 36% in the teacher report, 53% in the combined parent and teacher report⁵⁰

1.2.2. Traffic accidents and accident damage (+ 23 %)¶

A meta-analysis of 16 studies showed:⁵¹

• the accident risk for drivers with ADHD is 23% higher
• this corresponds to the risk increase caused by cardiovascular diseases
• Persons with ADHD apparently drive more often than people without ADHD, which is why the actual figure is more likely to be below 23%
• the claim of an almost fourfold accident risk from a study by Barkley et al. (1993) is probably due to comorbid ODD and/or CD. It cannot be held for ADHD itself.
• People with ADHD are cautioned more often for speeding, but not more often for drunk or reckless driving

Individual studies:

• Children with ADHD show riskier behavior when crossing the road⁵²
• 40% of drivers with ADHD had at least 2 accidents, compared to 6% of drivers not affected by ADHD.⁵³
• 60% of drivers with ADHD had a personal injury accident, compared to 17% of drivers who were not affected.⁵³
  • this is more likely to be due to comorbid ODD and/or CD. For ADHD itself, a meta-analysis found a 23% increased accident rate.⁵¹
• The amount of damage suffered by drivers with ADHD was almost three times as high as the amount of damage suffered by drivers who were not people with ADHD.⁵³
• Drivers with ADHD lost their driver’s license three times as often as drivers without ADHD. This could also result from an impaired ability to defend themselves in court due to disorganization.⁵³
• 2.74 times the risk of car accidents with injuries for people with ADHD aged 65 and over⁵⁴
• 93% increased risk of traffic accidents with untreated ADHD among adolescents and young adults⁵⁵
• Riskier driving behavior⁵⁶
• More errors in driving simulators, especially with executive function problems⁵⁷

1.3. More frequent perpetrator (+ 160 %) and victim (+ 100 %) of violence and bullying¶

People with ADHD have a higher risk of:

• Violence in the relationship⁵⁸
  • as a perpetrator:
    • 2.5-fold risk (OR 2.5, meta-analysis, k = 6 studies)⁵⁹
    • 6.4 times more perpetrators of domestic violence than non-victims⁶⁰
    • increased regardless of gender⁶¹
  • as a victim:
    • 1.78-fold risk (OR 1.78, meta-analysis, k = 4 studies)⁵⁹
    • increased regardless of gender⁶¹
• Sexualized violence
  • as a perpetrator:
    • 2.73-fold risk (OR 2.73, meta-analysis, k = 3 studies)⁵⁹
  • as a victim:
    • 1.84-fold risk (OR 1.84, meta-analysis, k = 6 studies)⁵⁹
    • 2.01-fold risk (OR 2.01)⁶²

• Child abuse
  • Studies report an increased risk of child abuse.⁶³
• Bullying
  • Children with ADHD are bullied more often⁶⁴
  • Children with ADHD report being bullied 3 times as often as children without ADHD⁶⁵
  • Children with ADHD are more likely to suffer anxiety disorders or depression as a result of bullying than people with ADHD who are not bullied.⁶⁴

1.4. Higher crime rate (+ 120 % to + 800 %)¶

The crime rate among people with ADHD is massively increased. 19% of people with ADHD had committed crimes, compared to 0% of the control group (average age 22 years)⁶⁶

• Risk of prison sentences due to criminality
  • 9-fold risk⁶⁷
  • 4.8-fold risk⁶⁸
  • 2.9-fold risk⁶⁹
• Arrests / detentions increased
  • 21-fold risk for adults with hyperactivity (21% vs. 1%)⁷⁰
  • 4.18-fold risk for adolescents with hyperactivity (46% vs. 11%)⁷⁰
  • 2.2-fold risk⁶⁹
  • 2.05-fold risk⁷¹
• Convictions for criminal offenses
  • 3.3-fold risk⁶⁹
  • Men⁷²
    • 6.03 times the risk of violent crime
    • 3.57 times the risk of non-violent crime
  • Women⁷²
    • 10.5 times the risk of violent crime
    • 4.04 times the risk of non-violent crime

Massively increased ADHD rate among prison inmates:

• Up to 72% of prison inmates in Asian, Western European and North American countries have been diagnosed with ADHD⁷³

• 14 % to 45 %⁷⁴⁷⁵
• 31 %⁷⁶ of juvenile detainees
• 20 to 30 % of all young adult prison inmates.⁷⁷
• 28 % of all prisoners in the USA⁷⁸
• 27.6 % of 146 sex offenders examined (n=146, WURS 90 points)⁷⁹
• 25 % of all prisoners in the USA⁸⁰
• 25 %⁸¹
• 22 % of patients in forensic psychiatry (n = 86)⁸²
• 17.5 % Prison inmates (n = 244)⁷⁹
• 17.3 % of juvenile prisoners⁸³
• 17% of all young men serving time for minor to moderate offenses in Lithuania.⁸⁴ The inmates with ADHD were younger and had major behavioral problems in prison. None of them had previously received an ADHD diagnosis.
• 9.1 % of 55 Irish prisoners examined⁸⁵

Interestingly, amphetamines are the drugs most commonly used by people with ADHD in prison.⁸⁶ Amphetamine is known to be the drug with the highest Effect size against ADHD in adults.

A study on the correlation of ADHD symptoms and criminogenic thinking found that⁸⁷

• Carelessness was consistently and strongly associated with criminogenic mindsets, especially with
  • Cutoff
  • Cognitive inertia
  • Discontinuity
• Impulsivity correlated positively with criminogenic thinking, namely with
  • Power orientation
• Hyperactivity was not associated with criminogenic thinking

ADHD medication reduced the crime rate of people with ADHD⁸⁸

• For men by 31 %
• By 41 % for women

1.5. Comorbid health problems¶

There is evidence that ADHD has a causal effect for an increased risk of:⁸⁹

• severe clinical depression
• post-traumatic stress disorder
• Suicide attempts
• Anorexia nervosa

No evidence was found of a causal relationship between ADHD and⁸⁹

• bipolar Disorder
• Fear
• Schizophrenia

1.5.1. Mental illnesses¶

Increased probability of inpatient psychiatric treatment. Among 166 psychiatric inpatients, 59% were found to have ADHD.⁹⁰

1.5.1.1. Neurodegenerative diseases (up to + 400 %)¶

Up to 5-fold increased risk of neurodegenerative diseases.⁹¹
According to a meta-analysis, 12 of 16 studies found an increase in the risk of neurodegenerative disorders due to ADHD, albeit with a low absolute risk⁹²

1.5.1.1.1. Dementia (up to + 500 %)¶

The overall risk of dementia with ADHD is increased

• 4-fold⁹³ Review: Hedges et al.⁹⁴
• 2.23-fold⁹⁵

Vascular dementia causes severe cognitive impairment that interferes with daily functioning and can be diagnosed by imaging techniques.
People with ADHD have a 6-fold higher risk of vascular dementia⁹³⁹⁶ regardless of other risk factors for vascular dementia, such as diabetes, high blood pressure, coronary heart disease and stroke.
The reason for the increased risk of vascular dementia could be the significantly poorer cardio- and cerebrovascular health of adults with ADHD.

The risk of Lewy body dementia / Lewy body dementia is increased with ADHD⁹⁷, whereby the risk increase was sometimes cited as only 6%⁹⁶ and sometimes by the same group of authors in an earlier publication as being significantly increased for Lewy body dementia.⁹¹
People with Lewy body dementia are 5.1 times more likely to have an ADHD diagnosis, regardless of age and gender.⁹⁸

1.5.1.1.2. Parkinson’s disease (up to + 150 %)¶

Parkinson’s disease:

• 1.5 to 2.5-fold⁹⁶
• 2.3-fold⁹⁵

People with ADHD are 3.7 times more likely to have ADHD, regardless of age and gender.⁹⁶

1.5.1.1.3. Alzheimer’s (+ 390 %)¶

People with Alzheimer’s have 4.9 times the risk of ADHD, regardless of age and gender.⁹⁸
One study found a correlation between the ADHD-PRS (Polygenic Risk Score) and Alzheimer’s disease⁹⁹
In a Swedish cohort study, parents of people with ADHD showed a 55% increased risk of Alzheimer’s disease. The risk was even lower in grandparents¹⁰⁰

1.5.1.2. Depression (+ 450 %)¶

• 5.5 times the risk of a major depressive episode before adulthood. 50% of all people with ADHD have one.¹⁰¹
• Depression increases¹⁰²
• 4.12-fold risk (very large study, n = 1,250,000)¹⁰³
• 2.5-fold¹⁰⁴ to 4-fold risk of depression in girls
• ADHD in children increases the risk of depression in adolescence.¹⁰⁵
• Comorbidities further increase the risk:
  • 7.9-fold risk of clinically relevant depression symptoms with ADHD and a concussion suffered¹⁰⁶

1.5.1.3. Eating disorders (+ 260 %)¶

• 3.6 times the risk of eating disorders in girls¹⁰⁷
• Obesity (2-fold risk)¹⁰⁸
• ADHD symptoms in early childhood increase the risk¹⁰⁹
  • Of a high BMI in middle childhood by 19
• 1.24 times the consumption of fast food¹¹⁰

1.5.1.4. Anxiety disorders (up to + 230 %)¶

• 1.2 to 3.3 times the risk of anxiety disorders. Lifetime prevalence 10 - 15 % overall population,¹¹¹ 12 to 50 % for ADHD²⁶
• Comorbidities further increase risk
  • 16.4-fold risk of clinically relevant anxiety symptoms in ADHD and a concussion suffered¹⁰⁶

1.5.1.5. Post-traumatic stress disorder, PTSD (+ 137 %)¶

People with ADHD have 2.37 times the risk of suffering post-traumatic stress disorder as their non-ADHD-diagnosed siblings.¹¹²

1.5.2. Behavioral peculiarities¶

• Increased risk behavior¹¹³

• More frequent victims of physical and non-physical sexual abuse¹¹⁴

1.5.3. Cognitive impairments¶

In a long-term observation of children with ADHD, children with subclinical ADHD, children with perinatal risks and unaffected children, they were examined at the age of 40 in the areas of verbal reasoning, perceptual ability, memory, working memory, attention, executive functions and speed. The results showed that¹¹⁵

• Participants who had ADHD as a child
  • lower performance in 13 of 21 measured variables
  • 23% showed deficient performance in more than 3 measures (versus 4 to 6% in the other three groups)
• Participants who had subclinical ADHD as a child:
  • lower performance in 5 of the 21 measured variables

1.5.4. Physical illnesses¶

• Increased risk of most physical diseases (34 [97%] of 35 diseases examined), regardless of gender¹¹⁶

1.5.4.1. Sexually transmitted diseases (+ 300 %)¶

ADHD correlates with an increased risk of sexually transmitted diseases.¹¹⁷
People with ADHD were 4 times more likely to be treated for sexually transmitted diseases than non-affected people (16% vs. 4%).¹¹⁸

1.5.4.2. Respiratory diseases (up to + 220 %)¶

• Diseases of the respiratory tract (2.4 to 3.2 times the risk), mainly genetically caused, e.g:
  * Asthma
  * Chronic obstructive pulmonary disease

1.5.4.3. Risk of addiction (up to + 190 %)¶

• Alcohol consumption increases²⁷. The majority of studies on ADHD and alcohol abuse find a positive correlation.¹¹⁹
• Smoking more often^{27120121122102}
  • 8.61 times the risk¹²³
  • 3-fold risk for adolescents ¹²⁴
  • 2.36 times the risk¹²⁵¹²⁴
  • 2-fold risk for young people with ADHD (OR = 2)¹²⁶
  • 1.6 to 1.8-fold risk (+ 60 to 80 %)¹²⁷
  • 1.5-fold risk (+ 50 %)¹²⁶
  • 1.4-fold risk (+ 40 %) in adults {{Thapar AK, Riglin L, Blakey R, Collishaw S, Davey Smith G, Stergiakouli E, Tilling K, Thapar A (2023) Childhood attention-deficit hyperactivity disorder problems and mid-life cardiovascular risk: prospective population cohort study. Br J Psychiatry. 2023 Jul 6:1-6. doi: 10.1192/bjp.2023.90. PMID: 37408455.}
  • One study found no link between ADHD symptoms and smoking¹²⁸
  • Conversely, young adult smokers are twice as likely to have ADHD.¹²⁹
• Cannabis
  • Cannabis dependence increased 2.85 to 2.91-fold¹³⁰
  • Increased marijuana consumption¹²⁰
• Substance dependence (addiction)
  • 1.77 times the risk¹²³

1.5.4.4. Infections (up to + 180%)¶

• Infections increased in childhood¹³¹
  - Salmonellosis (180 % more frequent)
  - Acute respiratory tract infections (40% more frequent)
  - Acute gastroenteritis (30 % more frequent)
  - Urinary tract infections (30 % more frequent)
  - All anti-infectives were prescribed significantly more frequently to children with ADHD
  - The number of visits to the doctor was significantly higher for children with ADHD.

Bacterial or viral infections can also be a contributory cause of ADHD.

1.5.4.5. Periodontitis (+ 129 %)¶

Adolescents with ADHD had a 2.29 times greater risk of developing periodontitis later in life than control subjects.¹³²

1.5.4.6. Fatigue (+ 118 %)¶

Children with ADHD at ages 7 and 9 were 2.18 times more likely to have chronic, disabling fatigue at age 18. Children with ASD: 1.78 times the risk¹³³

1.5.4.7. Caries (+ 116 %)¶

Children with ADHD symptoms in Spain at higher risk of¹³⁴

• Caries (OR: 2.16)
• Extraction (OR: 1.42)
• Restoration (OR: 1.47)
• Bleeding gums (OR: 1.64)
  The increased caries risk persisted even when the analyses were restricted to middle/higher social class families and children with low sugar consumption, good oral hygiene habits and regular visits to the dentist.

ADHD symptoms in early childhood increased the risk of tooth decay in adolescence by 10%¹⁰⁹

1.5.4.8. Birth complications in mothers with ADHD (up to + 80%)¶

Mothers with ADHD have 1.2. to 1.8 times the risk of almost every type of birth complication.¹³⁵

1.5.4.9. Stroke risk (up to + 40 %)¶

• Increased risk of stroke¹³⁶
  * Risk of ischemic stroke increased by 15
  * Risk of large-artery atherosclerotic stroke increased by 40

1.5.4.10. Gliomas (+ 15 % to + 33 %)¶

ADHD is associated with a 1.15-fold risk of gliomas and a 1.33-fold risk of benign gliomas.¹³⁷ A glioma is a tumor in glial cells.

1.5.4.11. Slightly elevated blood pressure in old age¶

ADHD in childhood correlated with an average increase of 3.5 mmHg in systolic blood pressure and 2.2 mmHg in diastolic blood pressure at the age of 45¹³⁸

1.5.4.12. COVID-19 risk higher, progression more difficult¶

ADHD and Tourette’s are associated with an increased risk of COVID-19 and a more severe course of COVID-9.¹³⁹

1.6. More teenage pregnancies (+ 130 to + 530 %)¶

• 2.3-fold risk of early pregnancy in untreated adolescents with ADHD. Teenage pregnancies are 27% more common in untreated ADHD. With treated ADHD, the risk is significantly reduced¹⁴⁰
• 6.3 times the risk of teenage pregnancies¹⁴¹ Risk
• 42 times as many maternities up to the age of 20 as non-affected persons (doubtful - data could not be verified so far)⁵³

1.7. Educational disadvantages¶

• Poorer educational opportunities¹⁰²
  • 94% of children with ADHD have school problems (according to parent reports)¹⁴²
  • 32% of people with ADHD do not graduate from high school (secondary school, 12th grade)¹¹⁸
  • University degrees 27 % less frequent⁷¹
  • School-leaving qualifications 11 % less frequent⁷¹
  • Lower educational qualifications²⁷
  • Rare Bachelor’s degree¹⁴³
  • More school absences (diagnosed ADHD, including ADHD treated with medication)¹⁴⁴
    • Up to 10 years: 7 %
    • 11 to 14 years: 24 %
    • From 15 years: 23 %
  • More school exclusions (diagnosed ADHD, including ADHD treated with medication)¹⁴⁴
    • 4.97-fold in the quintile with highest deprivation
    • 14.75-fold in the quintile with lowest deprivation
    • 5.4-fold for boys
    • 9.42-fold for girls
  • Increased special educational needs (diagnosed ADHD, including ADHD treated with medication)¹⁴⁴
    • Mental health 52.85 times
    • Social, emotional and behavioral disorders 19.97 times
    • Autism Spectrum Disorder 13.72-fold
    • Learning disability 8.10-fold
    • Physical health 6.97 times
    • Physical or motor impairment 6.28 times
    • Learning difficulties 5.44 times
    • Communication problems 4.78-fold
    • Sensory impairment 3.62-fold
  • ADHD causes long-term reduced emotional engagement in school, which is additionally moderated by student-teacher conflict.¹⁴⁵
  • A high polygenic risk score¹⁴⁶
    • For ADHD correlated with lower grades in language and math
    • For anorexia nervosa or bipolar Disorder correlated with better grades in language and math
    • For schizophrenia and major depression showed variable influence on school grades
    • For Autism Spectrum Disorders had no influence on school grades

A Norwegian cohort study found 32.3% of parents of n = 8,051 subjects with ADHD who had only attended elementary school compared to 7.9% in the catchment area (plus 308%).¹⁴⁷

1.8. Professional disadvantages and loss of income¶

Significant professional disadvantages are a frequent consequence of ADHD¹⁴³

• Job changes increased by 59⁷¹
• Fewer full-time jobs, more part-time jobs
  • Women (in Japan) with ADHD appear to be even more likely to have only a part-time job than men with ADHD.¹⁴⁸
• Employment rate reduced by 28⁷¹
• 3 times the risk of losing a job⁵³
• Higher layoff rate 1.1 vs 0.3 jobs/time¹⁴⁹
• Frequent job changes 2.7 vs 1.3 jobs/ 2- 8 y SE¹⁴⁹ especially in old age¹⁵⁰
• Poorer evaluations in the workplace¹⁴⁹
• Not in employment, education or training 6 months after leaving school¹⁴⁴
  • Total 1.39-fold
  • Boys 1.40 times
  • Girls 1.59 times

• one and a half times as often impaired work ability (approx. 30 % compared to approx. 20 % for those not affected)¹⁵¹
• No full participation in the labor market, especially for: (using Sweden as an example)¹⁵²
  • Elementary school as the highest educational qualification (OR: 4.03)
  • comorbid mental disorders (OR: 2.77)
  • living in villages/small towns (OR: 1.77)
  • Men less often than women (OR: 0.55)

A Norwegian cohort study found an average income of $41,637 (approximate) among parents of n = 8,051 subjects with ADHD compared to $48,019 in the catchment area (down 13.3%).¹⁴⁷

1.9. Reduced quality of life¶

• Reduced quality of life¹¹³
  • Health-related QoL significantly reduced¹⁵³¹⁵⁴
• 4-fold increased risk of reduced length growth and lower weight gain at 8 and 10 years. Stimulant treatment increased this risk.¹⁵⁵
• ADHD in childhood predicts emotional problems later in life. These are genetically transmitted.¹⁵⁶
• Life dissatisfaction is a typical consequence of ADHD.

According to a study with n = 1000 participants, ADHD in adulthood leads to a considerable reduction in life satisfaction (quality of life).¹⁵⁷ In the areas of

• Family life
• Partnership
• Social life
• Integration into society
• Health and fitness
• Professional life
• Achieving life goals

persons with ADHD scored on average around 20% lower than people without ADHD.

Adults with the highest 10% of ADHD symptom severity according to ADHD-E were 4.10 times more likely to experience distress due to general life dissatisfaction and 3.3 times more likely to experience distress due to lack of social support than non-affected adults.¹⁵⁸¹⁵⁹
ADHD-C showed a greater impairment of quality of life than ADHD-I or ADHD-HI.¹⁵⁴

Children with ADHD were 6-4 times more likely to experience fewer close friendships and greater peer rejection.¹⁶⁰

1.10. Divorces / separations more frequent (+ 87 % to + 400 %)¶

• Divorces
  • Increased by 87⁷¹
  • Women (in Japan) with ADHD seem to have an even higher divorce rate than men with ADHD.¹⁴⁸
• 3 to 5 times the risk of separation and divorce²⁶

A Norwegian cohort study found a 47% married rate among the mothers of the n = 8,051 subjects with ADHD compared to 60.4% in the catchment area (minus 22.2%).¹⁴⁷

1.11. Relocations more frequent (+ 135 %)¶

Adults with ADHD move 2.35 times as often as non-affected people.¹⁵⁰

1.12. Depression increased in parents of children with ADHD (+ 330 %)¶

Parents of children with ADHD had 4.3 times the risk of depression as parents of unaffected children.¹⁶¹

2. Protective effect of ADHD treatment (- 9 % to - 59 %)¶

ADHD medication reduces the risks of ADHD symptoms and secondary effects. According to a meta-analysis, medication with stimulants reduces the aforementioned risks by 9 to 59 %¹⁶²

ADHD medications showed a robust protective effect in relation to (meta-analysis, k = 40):¹⁶³

• Mood disorders
• Suicidal tendencies
• (Car) accidents
• Injuries
• Traumatic brain injuries
• Education and academic results. Indifferent, on the other hand:¹⁶⁴
• Substance abuse
• Crime

Treatment of ADHD improved long-term outcomes compared to untreated ADHD in 55 of 76 studies analyzed (72%), although generally not to normal levels (meta-analysis, k = 351).³ Improvement rates were broken down by area:

• Driving: 100 %
• Obesity: 100 %
• Self-esteem: 90
• Social functioning: 82 %
• Academic functioning: 71 %
• Drugs/addiction: 66 %
• Antisocial behavior: 50 %
• Need for support: 50%
• Professional activity: 33 %

There was an improvement in 85% of areas in Europe, but only 50% in North America.³

2.1. Reduced premature mortality, fewer suicides (- 20 %)¶

MPH reduced the overall mortality rate by 20% in children with ADHD. Delayed use of MPH correlated with a 5% increase in mortality. Long-term use reduced the overall mortality rate by 16%.¹⁶⁵
No increased mortality was found with the use of ADHD medication (stimulants or atomoxetine)¹⁶⁶ and a 22.2% reduction in mortality from unnatural causes¹⁶⁷.

Stimulants reduced the risk of suicide attempts in ADHD in several large studies:¹⁶⁸

• 11.6 % (in all age groups)¹⁶⁹
• 19 %¹⁷⁰
• 42 %¹⁷¹
• 59 % if taken for 3 months and half a year¹⁷²
• 72 % if taken for more than half a year¹⁷²
• Methylphenidate for ADHD was associated with a reduction in the previously significantly increased risk of suicide after 90 days.¹⁷³
• Other ADHD medications (non-stimulants) showed no or very little reduction in suicidality, e.g. 4%¹⁷⁰

A Swedish registry study examined all n = 22,714 adolescents and adults who received an ADHD diagnosis between 2006 and 2021.
ADHD medications reduced the risk of suicidality/deaths during periods of use compared to periods of no use:¹⁷⁴
Reduced risk of subsequent suicidality:

• Dextroamphetamine: reduced by 31% (aHR 0.69)
• Lisdexamfetamine: reduced by 24 % (aHR 0.76)
• Combination medication: reduced by 15 % (aHR 0.85)
• Methylphenidate: reduced by 8 % (aHR 0.92)
  Increased risk of subsequent suicidal behavior:
• Atomoxetine increased the risk by 20 % (aHR 1.20)
• Guanfacine: increased the risk by 65% (aHR 1.65)
• Clonidine: increased the risk by 92% (aHR 1.92)

2.2. Fewer accidents and injuries¶

2.2.1. Fewer accidents (- 43 % to - 66 %)¶

ADHD medication reduces the frequency of accidents in people with ADHD, both as children and as adolescents ¹⁷⁵¹⁷⁶

• by 43 %¹⁷⁷
• traumatic brain injuries reduced
  • by 49 %¹⁷⁸
  • up to 66 %.¹⁷⁹

One study found a 3% reduction in the risk of accidents (not statistically significant).¹⁸⁰
One study found a 28% increased risk of accidents (not statistically significant).¹⁸⁰

2.2.2. Fewer traffic accidents (- 38 to - 50 %)¶

• fewer traffic accidents¹⁸¹
  • 38 % to 40 % for men¹⁸²¹⁸³
  • 42 % for women¹⁸³
• 50 % fewer serious road accidents (for men)¹⁸²
• 50% fewer car accidents in driving simulators due to short-acting amphetamine drug¹⁸⁴
  • Economic savings for lifetime at a cost of 80 of USD / 30 days:
    • 332 660 USD over lifetime compared to untreated people with ADHD
    • 194,278 US dollars compared to standard treatment (which remained unnamed)
• improved driving performance¹⁸⁵ in the simulator¹⁸⁶

2.2.3. Fewer fractures (breaks) (- 32 % to - 74 %)¶

Each drug treatment for ADHD reduced the risk of

• of fractures in total¹⁸⁷
  • by 39% to 74% according to 6 cohort studies, by both stimulants and non-stimulants¹⁸⁸
  • by 32 % to 41 % according to the self-reporting study¹⁸⁸

Treatment of ADHD with methylphenidate reduced the risk of

• of stress fractures (fatigue fractures)
  • by 22.4%, whereby this value was even lower than for those not affected¹⁸⁹
  • 16 % less than for those not affected³⁷
• of trauma fractures (accidental fractures)
  • by 23 % when taking MPH for at least 180 days¹⁹⁰
  • to the same value as for non-affected persons³⁷
  • In persons with ADHD treated with non-stimulants, the risk increase for bone fractures doubled to 37% compared to the risk of non-stimulants in comparison to the risk increase of all people with ADHD, which was 17% higher than in non-stimulants³⁷

• Of unintentional injuries by 15 %¹⁹¹ or with an Effect size of 0.88¹⁹²
• Of brain trauma by 73 %¹⁹¹
• From poisoning¹⁹³
• Of injury-related emergency admissions by 9 %¹⁹⁴

• of burns in adolescents with ADHD¹⁹⁵
  • by 57 % when taking MPH for 90 days or longer
  • by 30 % if MPH has been taken for less than 90 days

2.2.4. Normalized healing time for concussion¶

Increased recovery time for concussions in people with ADHD was normalized by stimulants⁴⁰

2.2.5. Fewer emergency admissions (- 45 %)¶

The use of emergency rooms decreased

• by 45 %¹⁷⁷

2.3. Fewer sexually transmitted diseases and teenage pregnancies (up to - 40 %)¶

• fewer sexually transmitted diseases¹¹⁷
  • for men by 30 to 40 %¹⁹⁶
• fewer teenage pregnancies¹⁴⁰

2.4. Fewer comorbidities¶

Many studies show that ADHD medications reduce the frequency and severity of the following comorbidities¹⁹⁷
Only a Norwegian cohort study found an unchanged comorbidity rate after 4 years and a slightly increased comorbidity rate after 9 years in n = 8,051 subjects with ADHD on ADHD medication (87.5% MPH; 11.5% ATX, 1.4% AMP).¹⁴⁷ However, the study design could not differentiate between the medicated and unmedicated group by severity of ADHD. Medication correlates with higher severity. Furthermore, people who have already experienced that medication can help them are likely to be more willing to undergo an additional diagnosis in the event of further problems. It is also regrettable that amphetamine medication is strongly underrepresented.

A long-term analysis of 8,051 cases of ADHD that were diagnosed but not severe enough to require medication showed that medication almost completely eliminated the occurrence of reactive disorders in females during the first 2 years of follow-up and significantly reduced the incidence of tic disorders in males during the first 3 years.¹⁹⁸ There were no other advantages or disadvantages¹⁹⁹

2.4.1. Reduced psychiatric hospitalization (- 7 % to - 26 %)¶

A Swedish registry study examined all n = 22,714 adolescents and adults who received an ADHD diagnosis between 2006 and 2021.
ADHD medications reduced the risk of psychiatric hospitalization during periods of use compared to periods of no use:¹⁷⁴

• Amphetamine drugs: by 26 % (aHR 0.74)
• Lisdexamfetamine: by 20 % (aHR 0.80)
• Combination medication: by 15 % (aHR 0.85)
• Dextroamphetamine: by 12 % (aHR 0.88)
• Methylphenidate: by 7 % (aHR 0.93)
• Atomoxetine: unchanged
• Guanfacine: unchanged
• Modafinil: unchanged
• Clonidine: unchanged.

2.4.2. Less depression (- 20 % to - 60 %)¶

ADHD medication reduces the risk of depression:²⁰⁰

• by 40 % 3 years after ingestion
• by 20 % during ingestion
• MPH by around 30 % with long-term use in children and adolescents with ADHD²⁰¹
• Stimulants by over 60 % in the course of 10 years²⁰²

2.4.3. Fewer anxiety disorders (- 85 %)¶

ADHD stimulants over 10 years reduced the risk of anxiety disorders by over 85%²⁰²

2.4.4. Fewer behavioral disorders and ODD (- 55 % to - 70 %)¶

ADHD stimulants over 10 years reduced the risk of²⁰²

• Conduct disorder by almost 70 %
• ODD (Oppositional Deficit Disorder) by around 55 %

Long-term use of MPH reduced the risk of CD and ODD by around 50% in children and adolescents with ADHD²⁰¹ Short-term use reduced the risk less significantly.

2.4.5. Fewer bipolar disorders (- 50 %)¶

ADHD stimulants reduced the risk of bipolar Disorder by over 50% over 10 years.²⁰²

2.4.6. Fewer psychoses (- 17 %)¶

Long-term use of MPH reduced the risk of psychotic disorders¹⁴⁷ by around 17% in children and adolescents with ADHD.²⁰¹ Short-term use reduced the risk less significantly.

2.5. Reduced consumption of addictive substances (- 30 % to - 90 %)¶

Reduce ADHD medication:

• Tobacco consumption²⁰³
  • the number of smokers by 50²⁰⁴
  • the number of people who start smoking¹²⁴
• Substance abuse
  • by 31 %²⁰⁵
  • to the level of non-affected persons²⁰⁶
• Alcohol consumption²⁰³
• Cannabis use²⁰³
• Use of illegal drugs²⁰³

ADHD medication does not increase the risk for people with ADHD:²⁰⁷

• for alcohol abuse or dependence (11 studies, over 1300 participants)
• for nicotine abuse or dependence (6 studies, 884 participants)
• for cocaine abuse or dependence (7 studies, 950 participants)
• for cannabis abuse or dependence (9 studies, over 1100 participants) (Humphreys et al., 2013).

A meta-analysis of 6 studies with n = 1,014 subjects showed a significantly reduced risk of later addiction for participants medicated with stimulants (here: MPH).²⁰⁸ The risk of later addiction, whether to alcohol or other substances, was found to be 1.9 times lower (i.e. almost halved).²⁰⁹
Another meta-analysis found a reduction in craving and an increase in abstinence with ADHD medication (stimulants as well as atomoxetine) in addicts with ADHD.²¹⁰

2.6. Less obesity (- 26 %)¶

Persons with ADHD on stimulant medication were 26% less likely to be obese (BMI over 30) than unmedicated people (30.5% to 41.2%).¹⁵¹
People with ADHD on stimulant medication were 42% more likely to be of normal weight (BMI 18.5 to 25) than unmedicated people (38.7% to 27.2%).¹⁵¹

2.7. Periodontitis (- 58 %)¶

Atomoxetine reduced the risk of developing periodontitis at a later stage by 58%¹³²

2.8. Reduced general hospitalization (- 16 % to - 38 %)¶

A Swedish registry study examined all n = 22,714 adolescents and adults who received an ADHD diagnosis between 2006 and 2021.
ADHD medications reduced the risk of non-psychiatric hospitalization during periods of use compared to periods of no use:¹⁷⁴

• Amphetamine drugs: by 38 % (aHR 0.62)
• Lisdexamfetamine: by 36 % (aHR 0.64)
• Combination medication: by 33% (aHR 0.67)
• Dextroamphetamine: by 28 % (aHR 0.72)
• Methylphenidate: by 20 % (aHR 0.80)
• Modafinil: by 19 % (aHR 0.81)
• Atomoxetine: by 16 % (aHR 0.84)
• Guanfacine: unchanged
• Clonidine: unchanged

2.9. Fewer victims of violence, bullying and abuse¶

People with ADHD who were treated with MPH were less likely to be victims of bullying/cyberbullying (physical victimization, isolation, destruction of property by others, and sexual victimization), less likely to destroy other people’s things, and less likely to exhibit bullying behavior (perpetrator-side).²¹¹

Children with ADHD who were treated with MPH or ATX were significantly less likely to suffer abuse than untreated persons with ADHD.²¹²

ADHD treatment reduced violence in the relationship.²¹³

2.10. Lower crime rate (- 31 % to - 41 %)¶

ADHD medication reduces the risk for people with ADHD

• the crime rate⁸⁸²¹⁴
  • For men by 31 %
  • By 41 % for women

• In particular for offenses committed on impulse²¹⁵

2.11. Improved school performance and educational qualifications¶

ADHD medications improve academic performance:

• Three months of treatment with ADHD medication resulted in²¹⁶
  • a grade improvement of more than nine points (scale: 0 to 320)
  • a 20% reduction in the risk of not receiving a recommendation for upper secondary school
• The test scores of people with ADHD during the time they were taking medication were 4.8 points (scale: 1 to 200) higher than during the time they were not taking medication.²¹⁷
• Discontinuation of ADHD medication correlated with a small significant decrease in grade point average²¹⁸
• ADHD medication had a slightly positive effect on test scores in English (SMD 0.037), numeracy (0.063) and reading (0.071)²¹⁹

Persons with ADHD who were treated with stimulants were almost one and a half times more likely to graduate from high school (around 58%) than people with ADHD who were not treated with medication (41.3%)¹⁵¹

ADHD stimulants reduced the risk of being sedentary by almost 60% in the USA²⁰²

People with ADHD have a reduced motivation to exert themselves in the cognitive or physical domain. Amphetamine medication increased motivation equally in both areas to close to the level of healthy control subjects²²⁰

2.12. Improved employability and income¶

People with ADHD with a combination of sustained and immediate release medication were more than one and a half times as likely to be in full-time employment (52.9%) than those with no medication (33.3%).¹⁵¹
Persons with ADHD on stimulant medication were 30 % less likely to be unemployed than unmedicated people (37.6 % to 53.5 %).¹⁵¹

People with ADHD on stimulant medication earned¹⁵¹

• 25% more often between 25,000 and 150,000 USD / year than unmedicated people with ADHD (63.7% to 50.9%)
• almost 30 % less often less than 25,000 USD / year than unmedicated people with ADHD (24.5 % to 34.2 %)

2.13. More often regular health insurance (+ 26.2 % to + 77.6 %)¶

Commercial health insurance as opposed to state health insurance¹⁵¹

• 44.7 % of the unmedicated people with ADHD
• 56.4 % of persons with ADHD treated with immediate release stimulants (+ 26.2 %)
• 65.2 % of persons with ADHD treated with sustained release stimulants (+ 45.9 %)
• 79.4 % of persons with ADHD treated with a combination of sustained and immediate release stimulants (+ 77.6 %)

2.14. Less need for treatment, lower healthcare costs (- 63 % to - 82 %)¶

The number of inpatient treatments is reduced by up to 82% with combined stimulant treatment¹⁵¹

• Unmedicated people with ADHD: 0.629 / year
• Treated with a combination of sustained release and immediate release stimulants: 0.111 / year
• Treated with sustained or immediate release stimulants: 0.27 / year

The number of outpatient treatments is reduced by up to half with combined stimulant treatment¹⁵¹

• Unmedicated people with ADHD: 4.59 / year
• Treated with a combination of sustained release and immediate release stimulants: 2.3 / year
• Treated with sustained or immediate release stimulants: 3.5 / year

The number of emergency room visits is reduced by up to 63% with combined stimulant treatment¹⁵¹

• Unmedicated people with ADHD: 0.862 / year
• Treated with a combination of sustained release and immediate release stimulants: 0.380 / year

Annual healthcare costs are reduced by up to 70% ($12,740/year) with combined stimulant treatment¹⁵¹

• Unmedicated people with ADHD: 18,200 USD / year
• Treated with a combination of sustained release and immediate release stimulants: USD 5,460 / year
• Treated with sustained release stimulants: USD 8,970 / year
• Treated with immediate release stimulants: USD 9,190 / year

We interpret the difference of combining sustained and immediate release stimulants versus taking sustained release or immediate release stimulants alone as a sign of extended daytime coverage and finer/more detailed medication adjustment,

2.15. Improved quality of life¶

Medication significantly mitigates the deterioration in health-related quality of life caused by ADHD.¹⁵³

A meta-analysis found a deterioration in quality of life by SMD = 0.2 when discontinuing medication in children and adolescents, but not in adults.²²¹ The discontinuation of ADHD medication is likely to occur disproportionately frequently in people with ADHD who suffer side effects. If discontinuation nevertheless impairs the overall quality of life, the gain in quality of life due to stimulants for ADHD should normally be greater than 0.2.

2.16. No lasting protective effect of treatment carried out a long time ago¶

Adults who received individualized ADHD therapy between the ages of 6 and 10 were found to have very mixed results 18 years later²²²

• An improvement in ADHD symptoms that corresponded to the follow-up after 8 years
  • 18% no longer had an ADHD diagnosis
  • 55 % had a partial remission; of these:
    • ADHD-I 33 %
    • ADHD-HI 13 %
    • ADHD-C 54 %
  • 27% continued to have an ADHD diagnosis; of these:
    • ADHD-I 67 %
    • ADHD-HI 17 %
    • ADHD-C 17 %
  • Functional impairment with regard to
    • Finances 28 %
    • Daily responsibilities 28 %
    • Community activities 23 %
    • Learning/acquiring new learning content 21 %
• Poorer educational / professional results than expected
  • School and professional qualifications
    • As often as in the total population
    • Significantly lower grades
    • Much less likely to have Abitur / Fachhochschulreife than the overall population
  • Increased unemployment
    • Currently unemployed: 17 %
      • Approx. 30 % more frequent than the overall population (study compares with 2011, when unemployment was 30 % higher than in 2019)
    • 25 % were unemployed for over a year
    • 52 % have been unemployed at some point in the past few years
• More frequent contact with the justice system than expected
  • Criminal convictions 33 %
• Health impairments, comorbidities
  • Triple rate of externalizing or internalizing disorders
    • Three and a half times the rate of medication for mental health problems
  • 27% had a personality disorder according to DSM-IV
    • Antisocial personality disorder 12 %, RR 6.8 (approx. 6 times as frequent; total population: 2 %)
    • Avoidant personality disorder RR 2.0 (twice as often)
    • Schizoid personality disorder RR 2.0 (twice as frequent)
    • Paranoid personality disorder RR 1.3 (30 % more frequent)
  • Addiction problems
    • Drug use: 15 %; much more frequent
    • Smoking slightly more often
    • Alcohol slightly more often
  • Weight problems
    • Overweight one and a half times as common as in the general population
    • Obesity 30% more common than in the general population
  • Chronic pain
    • Children with ADHD showed a prevalence of chronic pain of up to 66% (at least weekly pain for more than 3 months). Stimulant treatment reduced the rate of chronic pain. Another study found a reduced perception of pain in adolescents with ADHD, which disappeared with stimulant treatment.²²³
• Several social outcomes were favorable
  • Long-term relationship/marriage: 63 %
• Low life satisfaction, especially in the areas of
  • Health
  • Profession/Career
  • Leisure/recreational activities
  • Own children
  • Own person
  • Sexuality
  • Relationships with others
  • Overall life satisfaction

2.17. Numbers needed to treat¶

How many persons with ADHD need long-term treatment with MPH to avoid one of the following long-term consequences of untreated ADHD?²²⁴ The results were independent of gender:

• 3 people with ADHD treated = 1 class repetition avoided
• 3 treated people with ADHD = 1 avoided ODD (Oppositional Deficit Disorder)
• 3 treated persons with ADHD = 1 avoided behavior disorder (Conduct Disorder)
• 3 treated persons with ADHD = 1 avoided anxiety disorder (with 2 types of impact)
• 4 people with ADHD treated = 1 major depression avoided
• 4 people with ADHD treated = 1 serious car accident avoided (in simulation)
• 5 people with ADHD treated = 1 avoided bipolar Disorder
• 6 people with ADHD treated = 1 smoker avoided
• 10 people with ADHD treated = 1 addiction avoided

3. Financial Consequences of ADHD¶

3.1. Treatment costs for ADHD¶

Treatment costs are the pure costs of therapy, medication and visits to the doctor for the purpose of ADHD diagnosis and ADHD treatment.

The annual costs for drug treatment, including the costs of doctor’s visits and laboratory tests, were stated as follows:

• 1998 for adults: USD 1,262²²⁵
• 2001 for adults: USD 1,673²²⁵
• 2004: USD 1,710 to USD 2,567²²⁶
• 2024: EUR 1,505 for children and adolescents in the first year after diagnosis. The ADHD group caused 2.86 times the costs compared to peers without ADHD. Age and comorbidities significantly influenced the costs.²²⁷

3.2. Healthcare costs for ADHD¶

In addition to the direct treatment costs of ADHD itself, healthcare costs also include the other medical costs for comorbidities resulting from ADHD (e.g. addiction problems) and the increased risk of accidents.

A Danish cohort study from 2016 calculated EUR 2,636 higher annual healthcare costs for people with ADHD (EUR 4,868 instead of EUR 1,912 = 2.55 times higher).²²⁸
In addition, there were a further EUR 477 higher annual healthcare costs for partners of people with ADHD.

ADHD more than doubles healthcare costs.²²⁹

A meta-analysis for Europe between 1990 and 2013 calculated annual healthcare costs for ADHD of EUR 2,022 to EUR 2,390 per affected child/adolescent with ADHD.²³⁰ In addition, healthcare costs for family members due to the care of a child/adolescent with ADHD ranged from EUR 1339 to EUR 1826 per person with ADHD.

For 1999 through 2001, higher annual health care costs were found for people with ADHD in the United States:²³¹

• doubled total medical costs (USD 5,651 vs. USD 2,771), including
  • outpatient costs (USD 3,009 vs. USD 1,492)
  • inpatient costs (USD 1,259 vs. USD 514)
  • Cost of prescription drugs (USD 1,673 vs. USD 1,008)

Healthcare spending in the U.S. due to ADHD amounts to $20.6 billion annually²³²
Children with ADHD represent 5.4% of New York State’s Medicaid population, but account for more than 18% of total costs, a 3.2-fold increase.²³³
The higher costs result from behavioral health services and medication.²³⁴

For each adult person with ADHD, the annual additional costs to society as a whole for healthcare services amounted to USD 1,635 in 2018.²³⁵

Children with ADHD in Flanders (Belgium) required more intensive health care in 2002 than their non-affected siblings. The utilization of medical services was:²³⁶

• General practitioner (60.3 % compared to 37.4 %)
• Specialist doctor (50.9 % compared to 12.9 %)
• Emergency room (26 % compared to 12.1 %)
• Hospital admissions (14 % compared to 8.4 %)
  The annual healthcare costs for a child with ADHD were 6 times higher than for a sibling without ADHD (EUR 588 compared to EUR 92). The public costs were more than double (EUR 779 compared to EUR 371).

Primary school children with hyperactivity incurred 17.6 times higher average annual costs (£562 instead of £30) in all domains (except non-mental health costs). Costs were consistently explained by male gender and, for some cost codes, by conduct disorder.²³⁷ It is likely that externalizing disorders such as ODD and CD made their own contribution.

The annual healthcare costs of people with ADHD were reduced by up to 70% ($12,740/year) with combined stimulant treatment:¹⁵¹
unmedicated people with ADHD: 18,200 USD / year
treated with a combination of sustained release and immediate release stimulants: USD 5,460 / year
treated with sustained release stimulants: USD 8,970 / year
treated with immediate release stimulants: USD 9,190 / year

3.3. Costs for relatives with ADHD¶

Relatives’ costs are the costs incurred by parents or guardians for the additional expenses arising from the person with ADHD.

A Danish cohort study from 2016 calculated EUR 7,997 in additional annual direct and indirect costs per partner of a person with ADHD.²²⁸

One study calculated 5 times the direct annual family costs (“related to caregiver burden”), excluding treatment costs and indirect costs, for people with ADHD aged 14 to 17.²³⁸

A meta-analysis for Europe between 1990 and 2013 calculated the total annual costs of ADHD to be €9,860 per child and €14,483 per adolescent with ADHD.²³⁰ Of this, 22% to 14% was due to loss of productivity among family members.

For adult people with ADHD, the annual total societal cost per adult was reported to be $14,092 in 2018.²³⁵
Caregivers of adults with ADHD require an additional 0.8 hours per week of ADHD-related care compared to adults in the overall U.S. population.²³⁹²⁴⁰ This results in additional annual costs of $6.6 billion.

A meta-analysis of 19 studies found the total annual cost of ADHD in the US (in 2010 dollars) to be between $176 billion and $309 billion (1.17% to 2.05% of US GDP).²⁴¹ Of this, spillover costs borne by family members of individuals with ADHD accounted for $33 billion to $43 billion (0.22% to 0.29% of US GDP).

3.4. Education costs for ADHD¶

A meta-analysis for Europe between 1990 and 2013 calculated total annual costs for ADHD of EUR 9,860 per child and EUR 14,483 per adolescent with ADHD.²³⁰ Education costs accounted for 62% and 42% respectively.

A meta-analysis of 19 studies found the total annual cost of ADHD in the US (in 2010 dollars) to be between $176 billion and $309 billion (1.17% to 2.05% of US GDP):²⁴¹

• for adults: USD 105 to 194 billion (0.7 % to 1.29 % of US GDP)
  • in particular productivity and income losses (USD 87 billion to USD 138 billion) (0.58% to 0.92% of US GDP)
• for children/adolescents: USD 38 to 72 billion (0.25 % 0.48 % of US GDP)
  • healthcare in particular: USD 21 billion - USD 44 billion (0.14 % 0.29 % of US GDP)
  • of which education accounted for: USD 15 billion - USD 25 billion (0.1% to 0.17% of US GDP)
• Spillover costs borne by family members of individuals with ADHD: $33 billion to $43 billion (0.22% to 0.29% of U.S. GDP)

3.5. Increased social benefits¶

A Danish cohort study from 2016 found that people with ADHD and their partners were more likely to receive social benefits (sickness benefit or disability pension).²²⁸

3.6. Indirect damage caused by ADHD¶

3.6.1. Increased absenteeism, unemployment, incapacity to work¶

For adult people with ADHD, the annual total additional costs to society in 2018 amounted to USD 14,092 per affected adult.²³⁵
Of which

• Additional unemployment costs: 54.4 % (USD 7,666 / person with ADHD)
  • Adult men with ADHD are 2.1 times more likely to be unemployed than non-affected persons. Their unemployment rate is therefore 22.1 percentage points higher.
  • Adult women with ADHD are 1.3 times more likely to be unemployed than those not affected. Their unemployment rate is therefore 9.7 percentage points higher.
  • The annual additional costs in the USA amount to USD 66.8 billion (USD 55.8 billion for men and USD 11 billion for women with ADHD). This corresponds to 0.325% of GDP.
• Productivity losses: 23.4 % (USD 3,298 / person with ADHD)²⁴²
  • 13.6 working days of absence due to ADHD
  • 21.6 working days of ADHD lost during attendance
  • The 35-day average of lost productivity was distributed across
    • Laborers: 55.8 days
    • Service workers: 32.6 days
    • Technician: 19.8 days
    • Skilled workers: 12.2 days
  • Lost productivity costs due to ADHD of USD 28.8 billion (USD 19.9 billion for men and USD 8.9 billion for women with ADHD). This corresponds to 0.14% of GDP.
  • Employees with ADHD were 3.5 times more likely to be absent due to “unofficial” absences (4.33 vs. 1.13 days)²³¹
  • 22.1 days annual productivity loss²⁴³

A Swedish register study from 1998 to 2008 found that people with ADHD:²⁴⁴

• 12.2 days more unemployment (252 working days would be 4.84 %)
• 19 times the probability of a disability pension
  • Incapacity to work was largely explained by comorbid mental disability and developmental disorder, meaning that improvement through more consistent treatment is only possible to a limited extent.

A relatively small German study found that unemployment was 24.8% higher.²⁴⁵

3.6.2. Premature mortality¶

For adult people with ADHD, the annual total societal cost per adult was reported to be $14,092 in 2018.²³⁵
Adults with ADHD have a doubled annual mortality rate (primarily due to increased rates of traffic and other accidents.²⁴⁶
In 2018, this resulted in a total social productivity loss of around USD 3.2 billion (0.016% of GDP in 2018).

People with ADHD are 1.7 times more likely to have at least one accident:²⁴⁷

• Children (28% compared to 18%)
• Young people (32 % compared to 23 %)
• Adults (38 % compared to 18 %)
  The follow-up costs for people with ADHD were only increased in adults (483 USD vs. 146 USD = 3.3-fold).

3.6.3. Income deficits with ADHD¶

3.6.3.1. Reduced income (- 16.1 % to - 24.4 %), lower assets (- 75 %)¶

A long-term study of 604 subjects over 20 years showed that people with ADHD have a lower net income and greater financial dependence on their parents at the age of 30 than non-affected people. This also applies if the DSM criteria are no longer met. This deficit persists throughout life and leads to a 1.27 million dollar lower expected lifetime income for men and up to 75% lower net worth at retirement than for non-affected individuals.²⁵¹ In addition, if people with ADHD were not diagnosed and treated in childhood, they earn significantly less income than their non-affected counterparts and incur EUR 20,000 higher costs per person per year²⁵²

A Swedish register study from 1998 to 2008 found a 17% lower annual income among people with ADHD.²⁴⁴

American people with ADHD were less likely to achieve academic milestones beyond high school in 2003. People with ADHD were 42.3% less likely to have a full-time job (34%) than those without ADHD (59%). Except for 18- to 24-year-olds, average household income was significantly reduced, regardless of academic achievement or personal characteristics. The national labor productivity loss associated with ADHD was estimated to be between $67 billion and $116 billion (0.58% to 1.01% of US GDP), assuming a prevalence of 2.3%.²⁵³
The income with ADHD in 2003 was:

• Men: USD 45,645 compared to USD 54,399 (16.1 % less)
• Women: USD 37,607 compared to USD 49,738 (24.4 % less)

At the current prevalence of 5% for adults, this figure is likely to be more than double. The consumer price index in the USA rose by 40% between 2003 and 2020. Assuming income and GDP had risen at the same rate, this would amount to USD 183 to 322 billion (0.87 % to 1.54 % of GDP) in 2020.

A Danish cohort study from 2016 found lower earned income among people with ADHD in the five years prior to initial diagnosis.²²⁸

ADHD-affected adults, if undiagnosed and treated in childhood, earned significantly less income than their unaffected twins and paid less tax²⁵²

3.6.3.2. Tax and social security contributions resulting from reduced income¶

So far, we only know of one study that calculated the tax and social security contributions lost in Germany as a result.
The German net tax and social security revenues of a non-person with ADHD born in 2010 were found to be EUR 80,000 higher than those of a non-treated person with ADHD. ADHD interventions that improved educational attainment led to fiscal benefits through higher lifetime tax revenues.
For every euro spent on a new ADHD intervention, EUR 1.39 in discounted net tax revenues and EUR 3.02 in discounted gross tax revenues were calculated²⁵⁴
Converted to the untreated adults in Germany and to 2020 values, we have calculated annual losses in net tax and social security revenue of EUR 5.916 billion. This corresponds to 1.63% of the federal budget.
Not included are savings from

• reduced crime
  • eUR 111 million saved annually in prison costs
  • eUR 500 million reduction in damage caused by crime each year
• reduced premature mortality: EUR 580 million per year
• Relatives’ costs: EUR 2 billion per year
• Productivity losses in the workplace: EUR 11 billion per year

3.7. Total economic costs¶

One study cites $182,000 (as of 2015) higher costs from medical care, education and criminal justice consequences per ADHD case persisting into adulthood in the US.²⁵⁵
An Australian study estimates the total social and economic costs of ADHD at between USD 8.40 and 17.44 billion, with costs per person with ADHD of USD 15,664 per year (2018/2019).²⁵⁶ Of the total costs

• Productivity costs 81 %
• Deadweight losses 11 %
• Costs for the healthcare system 4 %
  The loss of well-being was considerable and was estimated at USD 5.31 billion.

A Danish cohort study from 2016 calculated EUR 22,721 in additional annual direct and indirect costs per person with ADHD (as of 2016).²²⁸
Adult people with ADHD accounted for EUR 23,072 per year.

Another Danish study on same-sex twins showed for adults with ADHD if they were not diagnosed and treated in childhood²⁵⁷

• higher total annual costs of EUR 20,134 than for his siblings (as of 2010)
• a significantly lower disposable income
• lower taxes paid
• higher receipt of state benefits
• higher costs for health and social care
• higher crime rate

Two American studies put the annual additional costs of ADHD to society as a whole at USD 6,799 per child (USD 19.4 billion) and USD 8,349 per adolescent (USD 13.8 billion) (as of 2017/2018).²⁵⁸ The costs were divided between

• Education costs (59.9% for children, 48.8% for young people)
• direct healthcare costs (25.9% for children, 29.0% for adolescents)
• Childcare costs (14.1% for children, 11.5% for young people).

One study calculated USD 14,576 per person with ADHD (as of 2005) with an estimated range between USD 12,005 and USD 17,458.²⁵⁹