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 up to 9 to 13 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 and post-traumatic stress disorder more common
- Physical illnesses such as 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 risks mentioned above
- They improve the quality of life of people with ADHD and reduce the need for 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¶
People with ADHD have to put up with massive restrictions in their quality of life.
Untreated / inadequately treated ADHD has massive lifelong implications, e.g.:
1.1. Life expectancy shortened by 9 to 13 years¶
-
Life expectancy reduced by 9 to 13 years, possibly due to genetic causes.
-
1.27- to 4.6-fold premature mortality. Depending on the study, between 1.27-fold (boys and men), 2.85-fold (girls and women), 1.4-fold (children and adolescents) and more than 4.6-fold (in adults), in particular due to accidents.
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With the number of additional comorbidities, the probability of premature death increases up to 25-fold.
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4.25-fold risk of premature mortality when first diagnosed with ADHD in adulthood.
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2.4-fold risk of suicide in ADHD overall, especially in women (up to 4.1-fold suicide risk). Correspondingly higher for untreated ADHD.
-
Suicide rate increases to 2.3 times to 2.9 times
-
Suicidal thoughts and suicide attempts increased
- But not in veterans with ADHD
-
2-fold risk of falling victim to murder
1.2. More frequent accidents and injuries¶
1.2.1. Injuries¶
- Injuries increased
- By 41 % for young adults
- By 250 % for children and adolescents
- Increased risk of bone fractures
- increased by 60 % in girls
- increased by almost 40 % in boys
- Stress fractures increased by 17
- Concussions
- Twice as common in children between the ages of 11 and 14 with ADHD
- More frequent, with simultaneously prolonged healing time; healing time is normalized by stimulants
- Head injuries due to some types of accidents in ADHD up to more than twice to more than three times as frequent
- Children with eye injuries were 3.5 times more likely to have ADHD than children without eye injuries.
- Self-harming behavior
- Intentional self-poisoning increased 4.65 times
1.2.2. Traffic accidents and accident damage¶
- Children with ADHD show riskier behavior when crossing the road
- 40% of drivers with ADHD had at least 2 accidents, compared to 6% of drivers not affected by ADHD.
- 60% of drivers with ADHD had a personal injury accident, compared to 17% of drivers who were not affected.
- 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.
- 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.
- Drivers with ADHD lost their driver’s license three times as often as drivers who were not affected. This could also result from an impaired ability to defend themselves in court due to disorganization.
- 2.74 times the risk of car accidents with injuries for people with ADHD aged 65 and over
- Riskier driving behavior
- More errors in driving simulators, especially with executive function problems
A meta-analysis of 16 studies showed:
- the accident risk for drivers with ADHD is 23% higher
- this corresponds to the increased risk of cardiovascular disease
- People 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
1.3. Frequent perpetrator and victim of violence and bullying¶
A meta-analysis of 14 studies involving 1,111,557 subjects found a higher risk for people with ADHD in terms of:
- Violence in the relationship
- as perpetrator (6 studies, OR 2.5 = approx. + 150 %)
- according to another source, persons with ADHD are 6.4 times more likely to be perpetrators of domestic violence than people without ADHD.
- as victim (4 studies, OR 1.78 approx. + 78 %)
- Sexualized violence
- as perpetrator (3 studies, OR 2.73 approx. + 273 %)
- as victim (6 studies, OR 1.84 approx. + 84 %); 1 new study, OR 2.01, approx. + 100 %
Studies report an increased risk of child abuse.
Children with ADHD report being bullied 3 times as often as children without ADHD.
1.4. Higher crime rate¶
- 4.8- to 9-fold risk of ending up in prison due to crime
- Arrests increased by 105 %
- Convictions for criminal offenses
- Men:
- 6.03 times the risk of violent crime
- 3.57 times the risk of non-violent crime
- Women:
- 10.5 times the risk of violent crime
- 4.04 times the risk of non-violent crime
Several studies have identified a massively increased rate of ADHD among prison inmates.
- Up to 72% of prison inmates in Asian, Western European and North American countries have been diagnosed with ADHD
- 14 % to 45 %
- 25 %
- 17.3 % of juvenile prisoners
- 31 % of juvenile detainees
- 25 % of all prisoners in the USA
- 28 % of all prisoners in the USA
- 17.5 % of 244 prisoners examined (n = 244)
- 27.6 % of 146 sex offenders examined (n=146, WURS 90 points)
- 22 % of patients in forensic psychiatry (n = 86)
- 9.1 % of 55 Irish prisoners examined
- 17% of all young men serving time for minor to moderate offenses in Lithuania. The inmates with ADHD were younger and had major behavioral problems in prison. None of them had previously received an ADHD diagnosis.
- 20 to 30 % of all young adult prison inmates.
Consequences are that the crime rate among people with ADHD is massively increased.
- Hyperactive people have significantly higher arrest rates:
- Young people (46% compared to 11%)
- Adults (21 % compared to 1 %)
- 19% of people with ADHD had committed crimes, 0% in the control group
Interestingly, amphetamines are the drugs most commonly used by prison inmates with ADHD. Amphetamine is known to be an active ingredient in highly effective ADHD medications.
A study on the correlation of ADHD symptoms and criminogenic thinking found that
- Carelessness was consistently and strongly associated with criminogenic mindsets, especially with
- Cutoff
- Cognitive inertia
- Discontinuity
-
Impulsivity correlated positively with criminogenic thinking, namely with
- Hyperactivity was not associated with criminogenic thinking.
ADHD medication reduced the crime rate of people with ADHD
- 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:
- severe clinical depression
- post-traumatic stress disorder
- Suicide attempts
- Anorexia nervosa
No evidence was found of a causal relationship between ADHD and
- 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.
1.5.1.1. Neurodegenerative diseases¶
Up to 5-fold increased risk of neurodegenerative diseases.
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 risk
1.5.1.1.1. Dementia (up to 6-fold)¶
The overall risk of dementia is 4 times higher.
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 dementia 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 only 6% higher with ADHD. In contrast, the same group of authors cited a significantly increased risk of Lewy body dementia with ADHD in an earlier publication.
People with Lewy body dementia are 5.1 times more likely to have an ADHD diagnosis, regardless of age and gender.
1.5.1.1.2. Parkinson’s disease (up to 2.5-fold)¶
Parkinson’s disease (1.5 to 2.5 times)
People with ADHD are 3.7 times more likely to have ADHD, regardless of age and gender.
1.5.1.1.3. Alzheimer’s disease¶
People with Alzheimer’s have 4.9 times the risk of ADHD, regardless of age and gender.
One study found a correlation between the ADHD-PRS (Polygenic Risk Score) and Alzheimer’s disease
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 grandparents
1.5.1.2. Depression (up to 5.5-fold)¶
- 5.5 times the risk of a major depressive episode before adulthood. 50% of all people with ADHD have one.
- Depression increases
- 4.12-fold risk (very large study, n = 1,250,000)
- 2.5-fold to 4-fold risk of depression in girls
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ADHD in children increases the risk of depression in adolescence.
- Comorbidities further increase risk
- 7.9-fold risk of clinically relevant depression symptoms with ADHD and a concussion suffered
1.5.1.3. Eating disorders (3.6-fold)¶
- 3.6 times the risk of eating disorders in girls
- Obesity (2-fold risk)
1.5.1.4. Anxiety disorders (up to 3.3 times)¶
- 1.2 to 3.3 times the risk of anxiety disorders. Lifetime prevalence 10 - 15 % overall population, 12 to 50 % for ADHD
- Comorbidities further increase risk
- 16.4-fold risk of clinically relevant anxiety symptoms in ADHD and a concussion suffered
1.5.1.5. Post-traumatic stress disorder, PTSD (2.4-fold)¶
People with ADHD have 2.37 times the risk of suffering post-traumatic stress disorder as their non-ADHD-diagnosed siblings.
1.5.2. Behavioral peculiarities¶
1.5.3. Physical illnesses¶
- Increased risk of most physical diseases (34 [97%] of 35 diseases examined), regardless of gender
1.5.3.1. Respiratory diseases (up to 3.2-fold)¶
- Diseases of the respiratory tract (2.4 to 3.2 times higher risk), mainly genetically caused, e.g:
* Asthma
* Chronic obstructive pulmonary disease
1.5.3.2. Risk of addiction (up to 2.9-fold)¶
- Increased alcohol consumption
- Smoking more often
- 2.35-fold to 8.61-fold risk of smoking. Adults with ADHD have a 40% (OR 1.4) to 50% increased risk of smoking (OR = 1.5). Conversely, young adult smokers are twice as likely to have ADHD.
- People with ADHD have a doubled (OR = 2) to tripled risk of smoking
- One study found no link between ADHD symptoms and smoking
- Cannabis
- Cannabis dependence increased 2.85 to 2.91-fold
- Increased marijuana consumption
- 1.77 times the risk of substance dependence (addiction)
The majority of research on ADHD and alcohol abuse finds a positive correlation.
1.5.3.3. Infections (up to 2.8-fold)¶
- Infections increased in childhood
- 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.
1.5.3.4. Birth complications in mothers with ADHD (up to 1.8-fold)¶
Among 45,737 pregnant women with ADHD compared with 42,916 women without ADHD, mothers with ADHD were found to have higher rates of almost every type of birth complication, most of which were 1.2 to 1.8 times more likely to occur.
1.5.3.5. Stroke risk (up to 1.4 times)¶
- Increased risk of stroke
* Risk of ischemic stroke increased by 15
* Risk of large-artery atherosclerotic stroke increased by 40
1.5.3.6. 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 45
1.5.3.7. 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.
1.6. More teenage pregnancies¶
- 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 decreased very significantly.
- 42 times as many maternities up to the age of 20 as non-affected persons (doubtful - data could not be verified so far)
1.7. Educational disadvantages¶
- Poorer educational opportunities
- 94% of children with ADHD have school problems (according to parent reports)
- University degrees 27 % less frequent
- School-leaving qualifications 11 % less frequent
- Lower educational qualifications
- Rare Bachelor’s degree
- More school absences (diagnosed ADHD, including ADHD treated with medication)
- Up to 10 years: 7 %
- 11 to 14 years: 24 %
- 15 years and older: 23 %
- More school exclusions (diagnosed ADHD, including ADHD treated with medication)
- 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)
- 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
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ADHD causes long-term decreased emotional engagement in school, which is additionally moderated by student-teacher conflict.
- A high polygenic risk score
- 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
1.8. Professional disadvantages and loss of income¶
Significant professional disadvantages are a frequent consequence of ADHD
- Job changes increased by 59
- 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.
- Employment rate reduced by 28
- 3 times the risk of losing a job
- Higher layoff rate 1.1 vs 0.3 jobs/time
- Frequent job changes 2.7 vs 1.3 jobs/ 2- 8 y SE especially in old age
- Poorer evaluations in the workplace
- Not in employment, education or training 6 months after leaving school
- 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)
- No full participation in the labor market, especially for: (using Sweden as an example)
- 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)
Translated with www.DeepL.com/Translator (free version)
1.9. Reduced quality of life¶
- Reduced quality of life
- Health-related QoL significantly reduced
- 4-fold increased risk of reduced length growth and lower weight gain at 8 and 10 years. Stimulant treatment increased this risk.
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ADHD in childhood predicts emotional problems later in life. These are genetically transmitted.
- Life dissatisfaction is a typical consequence of ADHD.
According to a study with n = 1000 participants, ADHD leads to a considerable reduction in life satisfaction (quality of life) in adulthood. 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.
1.10. Divorces / separations more frequent¶
- Divorces
- Increased by 87
- Women (in Japan) with ADHD seem to have an even higher divorce rate than men with ADHD.
- 3 to 5 times the risk of separation and divorce
1.11. Moving more often¶
Adults with ADHD move 2.35 times as often as non-affected people.
1.12. Depression increased in parents of children with ADHD¶
Parents of children with ADHD had 4.3 times the risk of depression as parents of unaffected children.
2. Protective effect of ADHD treatment¶
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%
A meta-analysis of 40 studies found a robust protective effect of ADHD medications in relation to
- Mood disorders
- Suicidal tendencies
- (Car) accidents
- Injuries
- Traumatic brain injuries
- Education and academic results. Indifferent, on the other hand:
- Substance abuse
- Crime
2.1. Reduced premature mortality, fewer suicides¶
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%.
No increased mortality was found with the use of ADHD medication (stimulants or atomoxetine) and a 22.2% reduction in mortality from unnatural causes.
Stimulants reduced the risk of suicide attempts in ADHD in several large studies:
- 11.6 % (in all age groups)
- 19 %
- 42 %
- 59 % if taken for 3 months and half a year
- 72 % if taken for more than half a year
- Methylphenidate for ADHD was associated with a reduction in the previously significantly increased risk of suicide after 90 days.
- Other ADHD medications (non-stimulants) showed no or very little reduction in suicidality, e.g. 4%
2.2. Fewer accidents and injuries¶
2.2.1. Fewer accidents¶
ADHD medication reduces the frequency of accidents among people with ADHD, both as children and adolescents. by 43% and traumatic brain injuries reduced by 49% to 66%.
2.2.2. Fewer traffic accidents¶
- 38 % to 40 % for men
- 42 % for women
- 50% reduction in serious road accidents (among men)
- improved driving performance in the simulator
2.2.3. Fewer fractures (breaks)¶
Each drug treatment for ADHD reduced the risk of
- of fractures in total
- by 39% to 74% according to 6 cohort studies, by both stimulants and non-stimulants
- by 32 to 41 according to the self-reporting study
Treatment of ADHD with methylphenidate reduced the risk of
- of stress fractures (fatigue fractures)
- by 22.4%, although this figure was even lower than for those not affected
- to 16 % less than those not affected
- of trauma fractures (accidental fractures)
- by 23 % when taking MPH for at least 180 days
- to the same value as for non-affected persons
- 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-stimulants
- Of unintentional injuries by 15 % or with an Effect size of 0.88
- Of brain trauma by 73 %
- From poisoning
- Of injury-related emergency admissions by 9 %
- of burns in adolescents with ADHD
- 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 stimulants
2.3. Fewer sexually transmitted diseases and teenage pregnancies¶
- fewer sexually transmitted diseases in men by 30 to 40 %
- fewer teenage pregnancies
2.4. Fewer comorbidities¶
ADHD medication reduces the frequency and severity of Consequences comorbidities.
2.4.1. Less depression¶
ADHD medication reduces the risk of depression:
- by 40 % 3 years after ingestion
- by 20 % during ingestion
-
MPH by around 30 % with long-term use in children and adolescents with ADHD
- Stimulants by over 60 % in the course of 10 years
2.4.2. Fewer anxiety disorders¶
ADHD stimulants over 10 years reduced the risk of anxiety disorders by over 85%
2.4.3. Fewer behavioral disorders and ODD¶
ADHD stimulants over 10 years reduced the risk of
- Behavioral disorder (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 ADHD Short-term use reduced the risk less significantly.
2.4.4. Fewer bipolar disorders¶
ADHD stimulants reduced the risk of bipolar Disorder by over 50% over 10 years.
2.4.5. Fewer psychoses¶
Long-term use of MPH reduced the risk of psychotic disorders in children and adolescents with ADHD by around 17%. Short-term use reduced the risk less significantly.
2.5. Reduced consumption of addictive substances¶
Reduce ADHD medication:
- Tobacco consumption
- the number of smokers by 50
- the number of people who start smoking
- Substance abuse
- by 31 %
- to the level of non-affected persons
- Alcohol consumption
- Cannabis use
- Use of illegal drugs
ADHD medication does not increase the risk for people with ADHD:
- 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). The risk of later addiction, whether to alcohol or other substances, was found to be 1.9 times lower (i.e. almost halved).
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.
2.6. Less obesity¶
Persons with ADHD on stimulant medication were 26% less likely to be obese (BMI over 30) than unmedicated people (30.5% to 41.2%).
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%).
2.7. 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), more likely to destroy other people’s property, and more likely to exhibit bullying behavior (perpetrator-side).
Children with ADHD who were treated with MPH or ATX were significantly less likely to suffer abuse than untreated persons with ADHD.
ADHD treatment reduced violence in the relationship.
2.8. Lower crime rate¶
ADHD medication reduces the risk for people with ADHD
- the crime rate
- For men by 31 %
- By 41 % for women
- In particular for offenses committed on impulse
2.9. Improved school performance and educational qualifications¶
ADHD medication improves academic performance:
- Three months of treatment with ADHD medication resulted in
- 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.
- Discontinuation of ADHD medication correlated with a small significant decrease in grade point average
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%)
ADHD stimulants reduced the risk of being sedentary by almost 60% in the USA
People with ADHD have a reduced motivation to exert themselves in the cognitive or physical domain. Amphetamine medication increased motivation evenly in both areas to close to the level of healthy control subjects
2.10. 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%).
Persons with ADHD on stimulant medication were 30 % less likely to be unemployed than unmedicated people (37.6 % to 53.5 %).
People with ADHD on stimulant medication earned
- 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 USD 25,000 / year than unmedicated people with ADHD (24.5 % to 34.2 %)
2.11. More frequent regular health insurance¶
Commercial health insurance as opposed to state health insurance
- 44.7 % of the unmedicated people with ADHD
- 56.4 % of people with ADHD treated with immediate release stimulants
- 65.2 % of people with ADHD treated with sustained release stimulants
- 79.4 % of people with ADHD treated with a combination of sustained release and immediate release stimulants
2.12. Less need for treatment, lower healthcare costs¶
The number of inpatient treatments is reduced by up to 82% with combined stimulant treatment
- Unmedicated people with ADHD: 0.629 / year
- Treated with a combination of sustained release and immediate release stimulants: 0.111 / year
- Treated with sustained release or immediate release stimulants: 0.27 / year
The number of outpatient treatments is reduced by up to half with combined stimulant treatment
- 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 treatment
- 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 treatment
- 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,
2.13. Improved quality of life¶
Medication significantly mitigates the deterioration in health-related quality of life caused by ADHD.
A meta-analysis found a deterioration in quality of life when discontinuing medication in children and adolescents, but not in adults.
2.14. 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 later
- 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 often)
- 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.
- 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
2.15. 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? The results were independent of gender:
- 3 people with ADHD treated = 1 class repetition avoided
- 3 treated people with ADHD = 1 avoided oppositional defiant behavior
- 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 1,262
- 2001 for adults: USD 1,673
- 2004: USD 1,710 to USD 2,567
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).
In addition, there were a further EUR 477 higher annual healthcare costs for partners of people with ADHD.
ADHD more than doubles healthcare costs.
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. 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:
- total medical costs doubled (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 annually
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.
The higher costs result from behavioral health services and medication.
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.
Children with ADHD in Flanders (Belgium) required more intensive health care in 2002 than their non-affected siblings. The utilization of medical services was:
- 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. 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:
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.
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.
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. 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 in 2018 was USD 14,092.
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. 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). 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. 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):
- 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).
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.
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)
- 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 absent 3.5 times as often due to “unofficial” absences (4.33 vs. 1.13 days)
A Swedish register study from 1998 to 2008 found that people with ADHD:
- 12.19 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.
3.6.2. Premature mortality¶
For adult people with ADHD, the annual total societal cost per adult in 2018 was USD 14,092.
Adults with ADHD have a doubled annual mortality rate (primarily due to increased rates of traffic and other accidents.
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:
- 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 compared to 146 USD = 3.3 times).
Some studies only look at the costs to the healthcare system and are therefore not suitable for adequately describing the economic impact of ADHD.
- There are no current figures for Germany. Older studies, which are of historical value at best, put the healthcare costs for ADHD in Germany in 2002 at EUR 142,000,000 (EUR 630 per patient, i.e. for 225,000 people with ADHD. In view of the actual number of cases, the costs are considerably higher.) and in 2003 to a total of EUR 230,000,000. These figures only include treatment costs
- One study found a total economic burden of $47.55 million among 69,353 diagnosed people with ADHD in Korea in 2012, which was equivalent to $684 per person with ADHD and 0.004% of Korea’s GDP (gross domestic product) in 2012.
3.6.3. Income deficits with ADHD¶
3.6.3.1. Reduced income¶
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 assets at retirement than for non-affected persons. 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 year
A Swedish register study from 1998 to 2008 found a 17% lower annual income among people with ADHD.
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 at $67 billion to $116 billion (0.58% to 1.01% of US GDP), assuming a prevalence of 2.3%.
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.
ADHD-affected adults, if undiagnosed and treated in childhood, earned significantly less income than their unaffected twins and paid less tax
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 calculated
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 less 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.
An Australian study identifies total social and economic costs of ADHD of between USD 8.40 and 17.44 billion at a cost per person with ADHD of USD 15,664 per year (2018/2019). 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).
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 childhood
- 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). 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.
