Consequences

ADHD not only has symptoms that are acutely manifested in the behavior of the affected person, but also long-term consequences.

• 1. Consequential risks of ADHD
  • 1.1. Life expectancy shortened by 9 to 13 years
  • 1.2. More frequent accidents and injuries
    • 1.2.1. Injuries
    • 1.2.1. Traffic accidents and accident damage
  • 1.3. Higher crime and violence
  • 1.4. Comorbid health problems
    • 1.4.1. Mental illness
      • 1.4.1.1. Depression (up to 5.5 times)
      • 1.4.1.2. Nervous system disorders (up to 5-fold)
      • 1.4.1.3. Eating disorders (3.6-fold)
      • 1.4.1.4. Anxiety disorders (up to 3.3 times)
    • 1.4.2. Behavioral peculiarities
    • 1.4.3. Physical diseases
      • 1.4.3.1. Respiratory diseases (up to 3.2 times)
      • 1.4.3.2. Infections (up to 2.8-fold)
      • 1.4.3.3. Risk of addiction (up to 2.3 times)
      • 1.4.3.3. Birth complications in mothers with ADHD (up to 1.8-fold)
      • 1.4.3.4. Risk of stroke (up to 1.4-fold)
  • 1.5. More teenage pregnancies
  • 1.6. Educational disadvantages
  • 1.7. Professional disadvantages and loss of income
  • 1.8. Reduced quality of life
  • 1.9. Divorces / separations more often
• 2. Protective effect through ADHD treatment
• 3. Financial consequences of ADHD
  • 3.1. Treatment costs for ADHD
  • 3.2. Health care costs for ADHD
  • 3.3. Relative costs in ADHD
  • 3.4. Education costs for ADHD
  • 3.5. Increased social benefits
  • 3.6. Indirect damage caused by ADHD
    • 3.6.1. Increased work absenteeism, unemployment, disability
    • 3.6.2. Premature mortality
    • 3.6.3. Income deficits in ADHD
      • 3.6.3.1. Reduced income
      • 3.6.3.2. Tax and social security contributions not due from reduced income
  • 3.7. Total economic cost

1. Consequential risks of ADHD¶

ADHD sufferers have to accept massive restrictions in their quality of life.
Untreated / inappropriately treated ADHD has massive lifetime implications,¹² e.g.:

1.1. Life expectancy shortened by 9 to 13 years¶

• Life expectancy reduced by 9 to 13 years³

• 1.27- to 4.6-fold premature mortality. Depending on the study, between 1.27-fold (boys and men),⁴ 2.85-fold (girls and women),⁴ 1.4-fold (children and adolescents), and more than 4.6-fold (in adults),⁵ especially from accidents.^{67891011121314}

• With the number of additional comorbidities, the likelihood of premature death increases up to 25-fold.⁵¹⁵

• 4.25-fold risk of premature mortality with first ADHD diagnosis in adulthood.⁴

• 2.4-fold risk of suicide in ADHD overall, especially in women¹⁶ (up to 4.1-fold risk of suicide). Correspondingly higher in untreated ADHD.¹⁷¹⁸

• Suicide rate increases¹⁹ by 2.3 times²⁰ by 2.9 times²¹

• Suicidal thoughts and suicide attempts increased²²

  • Not, however, in veterans with ADHD²³

• 2-fold risk of falling victim to murder²⁴

1.2. More frequent accidents and injuries¶

1.2.1. Injuries¶

• Injuries increased²⁵
  • By 41 % for young adults²⁶
  • By 250 % for children and adolescents²⁷
• Risk of bone fractures
  • increased by 60 % for girls ²⁸
  • increased by just under 40 % in boys ²⁸
  • Stress fractures increased by 17%.²⁹
• Concussions twice as common in children aged 11 to 14 with ADHD³⁰
• Head injuries due to some types of accidents in ADHD to more than twice³¹ to more than three times as common³²
• Children with eye injuries were 3.5 times more likely to have ADHD than children without eye injuries.³³
• Intentional self-poisoning increased 4.65 times³⁴

1.2.1. Traffic accidents and accident damage¶

• 40% of drivers with ADHD had at least 2 crashes, compared with 6% of unaffected drivers.³⁵
• 60% of drivers with ADHD had an injury accident, compared to 17% of unaffected drivers.³⁵
  • this is more likely to be due to comorbid ODD and/or CD. For ADHD itself, a meta-study found a 23% increased accident rate.³⁶
• The claim amount for drivers with ADHD was nearly three times the claim amount for unaffected drivers.³⁵
• Drivers with ADHD were three times more likely to lose their driver’s license than unaffected drivers. This could also result from an impaired ability to defend oneself in court due to disorganization.³⁵
• 2.74-fold risk of motor vehicle crashes resulting in injury among those aged 65 and older³⁷

A meta-analysis of 16 studies showed:³⁶

• the accident risk for drivers with ADHD is increased by 23
• this corresponds to the increase in risk from cardiovascular disease
• ADHD sufferers seem to drive more often than non-affected persons, which is why the actual value is likely to be below the 23 %
• the claim of an almost fourfold risk of accidents from a study by Barkley et al. (1993) is likely to be due to comorbid ODD and/or CD. It does not hold for ADHD itself.
• ADHD sufferers are warned more often for speeding, but not more often for drunk or reckless driving

1.3. Higher crime and violence¶

• 9 times the risk of ending up in prison due to crime³⁸
• Arrests increased by 105%³⁹
  • ADHD sufferers are 6.4 times more likely to be perpetrators of domestic violence than non-affected individuals.⁴⁰

Quite a few studies have found massively increased rates of ADHD in prison inmates.

• Up to 72% of prison inmates in Asian, Western European, and North American countries have been diagnosed with ADHD, he said.⁴¹

• 14 % to 45 % ADHD⁴²⁴³
• 25 %⁴⁴
• 17.3%⁴⁵ of juvenile inmates
• 31 %⁴⁶ of juvenile inmates
• 25 % of all prisoners in USA⁴⁷
• 28% of all incarcerated persons in U.S⁴⁸
• 17.5% of 244 correctional inmates studied (n = 244)⁴⁹
• 27.6% of 146 sex offenders studied (n=146, WURS 90 pts)⁴⁹
• 22% of patients in forensic psychiatry (n = 86)⁵⁰
• 9.1% of 55 Irish inmates studied⁵¹
• 17% of all young men serving time for minor to moderate offenses in Lithuania.⁵² The ADHD-affected inmates were younger and had greater behavioral problems in prison. None of them had previously received an ADHD diagnosis.
• 20 to 30% of all young adult prison inmates.⁵³

As a result, the crime rate among ADHD sufferers is massively increased.

• Hyperactive individuals have significantly increased arrest rates:⁵⁴
  • Adolescents (46% vs. 11%)
  • Adults (21% vs. 1%)
• 19% of ADHD sufferers had committed crimes, 0% in control group⁵⁵

Interestingly, amphetamines are the drugs most commonly used by ADHD-affected prison inmates.⁵⁶ Amphetamine is known to be an active ingredient in highly effective ADHD medications.

A study of the correlation of ADHD symptoms and criminogenic thinking found that⁵⁷

• Inattention was consistent and strongly associated with criminogenic mindsets, especially with
  • Cutoff
  • Cognitive inertia
  • Discontinuity
• Impulsivity was positively correlated with criminogenic thinking patterns, with
  • Power orientation
• Hyperactivity was not associated with criminogenic thinking.

ADHD medication reduced crime rates among ADHD sufferers⁵⁸

• For men by 31
• For women by 41

1.4. Comorbid health problems¶

1.4.1. Mental illness¶

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

1.4.1.1. Depression (up to 5.5 times)¶

• 5.5-fold risk of a major depressive episode before adulthood. 50% of all ADHD sufferers have one.⁶⁰
• Depression increases⁶¹
• 2.5-fold⁶² to 4-fold risk of depression in girls
• ADHD in children increases the risk of depression in adolescence.⁶³

1.4.1.2. Nervous system disorders (up to 5-fold)¶

• Nervous system disorders (1.5 to 4.6 times the risk), mainly caused by environmental hazards, e.g.:
  • Sleep disorders
  • Epilepsy
  • Dementia
    • Parents of ADHD sufferers showed a 55% increased risk of Alzheimer’s disease or dementia in a Swedish cohort study. Grandparents showed an even smaller increase in risk.⁶⁴ One study found a correlation between ADHD PRS and Alzheimer’s disease⁶⁵
• Up to 5-fold increased risk of neurodegenerative diseases, especially Lewy body dementia.⁶⁶

1.4.1.3. Eating disorders (3.6-fold)¶

• 3.6-fold risk of eating disorders in girls⁶⁷
• Obesity (2-fold risk)³

1.4.1.4. Anxiety disorders (up to 3.3 times)¶

• 1.2 to 3.3 times the risk of anxiety disorders. Lifetime prevalence 10 - 15 % total population,⁶⁸ 12 to 50 % in ADHD¹⁸

1.4.2. Behavioral peculiarities¶

• Increased risk behavior⁶⁹

• More often a victim of physical and non-physical sexual abuse⁷⁰

1.4.3. Physical diseases¶

• Increased risk for most physical diseases (34 [97 %] of 35 diseases studied), independent of sex⁷¹

1.4.3.1. Respiratory diseases (up to 3.2 times)¶

• Respiratory diseases (2.4 to 3.2 times the risk), mainly genetic, e.g.:
  * Asthma
  * Chronic obstructive pulmonary disease

1.4.3.2. Infections (up to 2.8-fold)¶

• Infections increased in childhood⁷²
  - Salmonellosis (180% more frequent)
  - Acute respiratory infections (40% more common)
  - Acute gastroenteritis (30% more frequent)
  - Urinary tract infections (30% more frequent)
  - All anti-infectives were prescribed significantly more often to children with ADHD
  - The number of doctor visits was significantly higher in children with ADHD.

1.4.3.3. Risk of addiction (up to 2.3 times)¶

• Alcohol consumption increased²²
• Smoking more often^2273747561
  • 2.35-fold⁷⁶⁷⁷ to 8.61-fold risk of smoking⁷⁸ ADHD-affected adults have a 50% increased risk of smoking (OR = 1.5)⁷⁹ Conversely, young adult smokers are twice as likely to have ADHD.⁸⁰
  • ADHD-affected youth have a doubled (OR = 2)⁷⁹ to tripled⁷⁷ risk of smoking
  • One study found no association between ADHD symptoms and smoking⁸¹
• Marijuana use increased⁷³
• 1.77-fold risk of substance dependence (addiction)⁷⁸
  The majority of research on ADHD and alcohol abuse finds a positive correlation.⁸²

1.4.3.3. 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.⁸³

1.4.3.4. Risk of stroke (up to 1.4-fold)¶

• Stroke risk increased⁸⁴
  * Risk of ischemic stroke increased by 15%
  * Risk of large-artery atherosclerotic stroke increased by 40%

1.5. More teenage pregnancies¶

• 2.3-fold risk of early pregnancy in untreated teens with ADHD. Teenage pregnancies are 27% more common with untreated ADHD. With treated ADHD, the risk decreased very significantly.⁸⁵
• 42 times as many maternities by age 20 as non-affected (Doubtful - data could not be verified so far)³⁵

1.6. Educational disadvantages¶

• Poorer educational opportunities⁶¹
  • University degrees 27% less common³⁹
  • School-leaving qualifications 11 % less frequent³⁹
  • Lower educational attainment²²
  • Rare bachelor’s degree⁸⁶
  • More school absenteeism (diagnosed ADHD, including ADHD treated with medication)⁸⁷
    • Up to 10 years: 7
    • 11 to 14 years: 24 %
    • From 15 years: 23 %
  • More school expulsions (diagnosed ADHD, including ADHD treated with medication)⁸⁷
    • 4.97-fold in the quintile with highest deprivation
    • 14.75-fold in the quintile with lowest deprivation
    • 5.4 times for boys
    • 9.42 times for girls
  • Increased special education needs (diagnosed ADHD, including ADHD treated with medication)⁸⁷
  • 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 times
  • Sensory impairment 3.62-fold
  • ADHD causes decreased emotional school engagement over the long term, which is further moderated by student-teacher conflict.⁸⁸

1.7. Professional disadvantages and loss of income¶

Significant occupational disadvantage is a common consequence of ADHD⁸⁶

• Job change increased by 59³⁹
• Fewer full-time jobs, more part-time jobs
  • Women (in Japan) with ADHD appear even more likely to have only a part-time job than men with ADHD.⁸⁹
• Employment rate reduced by 28³⁹
• 3 times the risk of losing a job³⁵
• Higher layoff rate 1.1 vs 0.3 jobs/time⁹⁰
• Frequent job changes 2.7 vs 1.3 jobs/ 2- 8 yrs SE⁹⁰
• Worse evaluations in the workplace⁹⁰
• Not in employment, education, or training 6 months after leaving school⁸⁷
  • Total 1.39 times
  • Boys 1.40 times
  • Girl 1.59 times

1.8. Reduced quality of life¶

• Reduced quality of life (QoL)⁶⁹
  • Health-related QoL significantly reduced⁹¹
• 4-fold increased risk of decreased length growth and weight gain at 8 and 10 years. Stimulant treatment increased this risk.⁹²
• ADHD in childhood predicts emotional problems later in life. These are genetically mediated.⁹³
• Life dissatisfaction is a typical consequence of ADHD.

According to a study with n = 1000 participants, ADHD in adulthood leads to a significant reduction in life satisfaction (Quality of Life).⁹⁴ In the domains

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

aDHD sufferers scored on average about 20% worse than non-affected persons.

Adults with the highest 10% of ADHD symptom expression according to ADHD-E were 4.10 times more likely to experience distress from general life dissatisfaction and 3.3 times more likely to experience distress from lack of social support than unaffected adults.⁹⁵⁹⁶

1.9. Divorces / separations more often¶

• Divorces
  • Increased by 87³⁹
  • Women (in Japan) with ADHD appear to have even higher divorce rates than men with ADHD.⁸⁹
• 3 to 5 times the risk of separations and divorces¹⁸

2. Protective effect through ADHD treatment¶

Adults who received individualized ADHD therapy between the ages of 6 and 10 were found 18 years later:⁹⁷

• An improvement in ADHD symptoms that corresponded to the follow-up after 8 years
  • 18% no longer had an ADHD diagnosis
  • 55% had partial remission; of these:
    • ADHD-I 33 %
    • ADHD-HI 13 %
    • ADHD-C 54 %
  • 27% further had an ADHD diagnosis; of these:
    • ADHD-I 67 %
    • ADHD-HI 17 %
    • ADHD-C 17 %
  • Functional impairment in terms of
    • Finance 28 %
    • Daily responsibilities 28 %
    • Community activities 23 %
    • Learning/acquiring new learning content 21 %
• Worse school / professional results than expected
  • School and professional qualifications
    • As often as in total population
    • Significantly worse grades
    • Much less likely to have a high school diploma / university entrance qualification than the general population
  • Increased unemployment
    • Currently unemployed: 17 %
      • Approximately 30% more likely to be unemployed than total population (study compares to 2011, when unemployment was 30% higher than 2019)
    • 25 % were unemployed for more than one year
    • 52% have been unemployed once in the last few years
• More frequent contact with judicial system than expected
  • Criminal judgments 33 %
• Health impairments, comorbidities
  • Threefold 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 (about 6 times more common; total population: 2%)
    • Avoidant personality disorder RR 2.0 (twice as frequent)
    • Schizoid personality disorder RR 2.0 (twice as frequent)
    • Paranoid personality disorder RR 1.3 (30% more frequent)
  • Addiction problems
    • Drug use: 15 %; highly frequent
    • Smoking slightly more often
    • Alcohol slightly more often
  • Weight problems
    • Overweight one and a half times more common than in total population
    • Obesity 30% more frequent than in total 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 decreased the rate of chronic pain. Another study found decreased pain perception in adolescents with ADHD, which disappeared with stimulant treatment.⁹⁸
• 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
  • Relations with others
  • Overall life satisfaction

ADHD medications reduce the risks of ADHD symptoms and sequelae. According to a metastudy, medication with stimulants reduces the aforementioned risks by 9% to 59%⁹⁹

A metastudy of 40 studies found a robust protective effect of ADHD medications in relation to¹⁰⁰

• Mood disorders
• Suicidality
• (Car) accidents
• Injuries
• Traumatic brain injuries
• Education and academic outcomes. Indifferent, on the other hand:¹⁰¹
• Substance Abuse
• Crime

Stimulants reduced the risk of suicide attempts by in several large studies in ADHD:¹⁰²

• 11.6 % (in all age groups)¹⁰³
• 19 %¹⁰⁴
• 42 %¹⁰⁵
• 59 % if taken for 3 months and half a year¹⁰⁶
• 72 % if taken for more than half a year¹⁰⁶
• Methylphenidate for ADHD was associated with a reduction in previously significantly increased suicide risk after 90 days.¹⁰⁷
• Other ADHD medications (non-stimulants) showed no or very little reduction in suicidality, e.g., 4%¹⁰⁴

ADHD medication reduces accident incidence in affected boys and girls, as children and as adolescents.¹⁰⁸¹⁰⁹ by 43%¹¹⁰ and traumatic brain injury reduced by 49%¹¹¹ to 66%.¹¹²

MPH reduced all-cause mortality by 20% in children with ADHD. Delayed use of MPH correlated with a 5% increase in mortality. Long-term use reduced all-cause mortality by 16%.¹¹³
No increased mortality was observed with the use of ADHD medications (stimulants or atomoxetine).¹¹⁴

ADHD medications reduce the risk of depression:¹¹⁵

• 3 years after ingestion by 40
• during the intake by 20

Any medication treatment for ADHD reduced the risk of

• of fractures in total¹¹⁶

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 non-affected persons.¹¹⁷
  • to 16 % less than for non-affected persons²⁹
• of trauma fractures (accidental fractures)
  • by 23% when taking MPH for at least 180 days¹¹⁸
  • to the same value as for non-affected persons²⁹
  • ADHD sufferers treated with non-stimulants doubled the risk increase for bone fractures to 37% compared to the risk of non-affected individuals compared to the risk increase of all ADHD sufferers, which was 17% higher than non-affected individuals²⁹

• Of unintentional injuries by 15%¹¹⁹ or with an effect size of 0.88¹²⁰
• Of brain trauma by 73¹¹⁹
• From poisoning¹²¹
• Of injury-related emergency admissions by 9%¹²²

• of burns in adolescents with ADHD¹²³
  • by 57% with MPH use for 90 days and longer by
  • by 30 % if MPH has been taken for less than 90 days by
• from traffic accidents
  • for men by 38 % to 40¹²⁴¹²⁵
  • for women by 42¹²⁵
  • serious traffic accidents (for men) by 50%¹²⁴
• of sexually transmitted diseases
  • only for men by 30 to 40¹²⁶
• of teenage pregnancies⁸⁵

ADHD sufferers who were not treated with MPH were more likely to be victims of bullying/cyberbullying (physical victimization, isolation, destruction of property by others, and sexual victimization), more likely to destroy others’ things, and more likely to exhibit bullying behaviors (perpetrator-side).¹²⁷

ADHD medications reduce the risk for sufferers,

• to start smoking.⁷⁷
• to smoking, by 50¹²⁸
• for substance abuse by 31%.¹²⁹

ADHD medications do not increase the risk for affected individuals:¹³⁰

• 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) did not increase (Humphreys et al., 2013).

ADHD medications reduce for sufferers

• the crime rate⁵⁸¹³¹
  • For men by 31
  • For women by 41

ADHD medications improve academic performance:

• Three months of treatment with ADHD medications produced¹³²
  • a grade improvement of more than nine points (scale: 0 to 320)
  • a 20% reduction in the risk of not receiving a recommendation for higher secondary education
• ADHD sufferers’ test scores 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.¹³³
• Discontinuation of AD(HS medications correlated with a small significant decrease in grade point average¹³⁴

Medication significantly mitigates the deterioration in health-related quality of life caused by ADHD.⁹¹
One meta-analysis found worsening quality of life when medications were discontinued in children and adolescents, but not in adults.¹³⁵

How many affected individuals would need long-term treatment with MPH to avoid any of the following long-term consequences of untreated ADHD?¹³⁶ The results were independent of gender:

• 3 affected persons treated = 1 class repetition avoided
• 3 treated affected = 1 avoided Oppositional Deficit Behavior
• 3 affected persons treated = 1 avoided behavior disorder (conduct disorder)
• 3 treated sufferers = 1 avoided anxiety disorder (with 2 impact types)
• 4 affected persons treated = 1 major depression avoided
• 4 victims treated = 1 serious car accident avoided (in simulation)
• 5 affected persons treated = 1 bipolar disorder avoided
• 6 affected persons treated = 1 smoker avoided
• 10 persons 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 doctor visits for the purpose of ADHD diagnosis and ADHD treatment.

The annual cost of drug treatment, including the cost of physician visits and laboratory tests, was estimated to range from $1,710 to $2,567 in 2004.¹³⁷

3.2. Health care costs for ADHD¶

Health care costs include not only the direct treatment costs of ADHD itself, but also the additional medical costs for comorbidities resulting from ADHD (e.g., addiction problems) and the increased risk of accidents.

A 2016 Danish cohort study identified €2,636 higher annual health care costs for ADHD sufferers (€4,868 instead of €1,912 = 2.55 times).¹³⁸
In addition, there was a further €477 increase in annual health care costs for partners of ADHD sufferers.

• More than 2 times health care costs¹³⁹

A meta-study for Europe between 1990 and 2013 calculated annual health care costs for ADHD of EUR 2,022 to EUR 2,390 per affected child/adolescent with ADHD.¹⁴⁰ Added to this, health care costs for family members attributable to caring for an ADHD child/adolescent ranged from EUR 1339 to EUR 1826 per affected person.

For 1999 to 2001, higher annual health care costs were found among ADHD sufferers in the United States:¹⁴¹

• doubled total medical costs ($5,651 vs. $2,771), including
  • outpatient costs ($3,009 vs. $1,492)
  • inpatient costs ($1,259 vs. $514)
  • Prescription drug costs ($1,673 vs. $1,008)

Per adult ADHD sufferer, annual total societal incremental health care costs of $1,635 were cited for 2018.¹⁴²

Children with ADHD in Fleming (Belgium) required more intensive health care than their unaffected siblings in 2002. The utilization of medical services was:¹⁴³

• General practitioner (60.3 % vs. 37.4 %)
• Specialist (50.9 % vs. 12.9 %)
• Emergency room (26% vs. 12.1%)
• Hospital admissions (14% vs. 8.4%)
  The annual health care costs for a child with ADHD were 6 times those of the unaffected sibling (588 EUR vs. 92 EUR). Public costs were doubled (779 EUR compared to 371 EUR).

Primary school children with hyperactivity incurred 17.6 times higher average annual costs (£562 rather than £30) across all domains (except nonmental health costs). Costs were consistently explained by male gender and, for some cost codes, by conduct disorder.¹⁴⁴ It is likely that externalizing disorders such as ODD and CD contributed in their own right.

3.3. Relative costs in ADHD¶

Relative costs are the costs incurred by the parent or caregiver for the additional expense resulting from the individual’s ADHD.

A 2016 Danish cohort study identified €7,997 in annual additional direct and indirect costs per partner of an ADHD sufferer.¹³⁸

One study calculated 5 times the direct annual family costs (“related to caregiver burden”) excluding treatment costs and indirect costs for ADHD sufferers aged 14 to 17.¹⁴⁵

A meta-study for Europe between 1990 and 2013 calculated total annual costs of ADHD of 9,860 euros per child and 14,483 euros per adolescent with ADHD.¹⁴⁰ Of this, productivity losses of family members accounted for 22% to 14%.

For adult ADHD sufferers, annual total societal incremental costs of $14,092 per adult were cited for 2018.¹⁴²
Caregivers of adults with ADHD require an additional 0.8 hours per week for ADHD-related care compared to adults in the U.S. general population.¹⁴⁶¹⁴⁷ This results in an additional annual cost of $6.6 billion.

A meta-study of 19 studies identified total annual costs of ADHD in the U.S. (in 2010 dollars) ranging from $176 billion to $309 billion (1.17% to 2.05% of U.S. GDP).¹⁴⁸ 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 U.S. GDP).

3.4. Education costs for ADHD¶

A meta-study for Europe between 1990 and 2013 calculated total annual costs of ADHD of 9,860 euros per child and 14,483 euros per adolescent with ADHD.¹⁴⁰ Of this, education costs accounted for 62% and 42%, respectively.

A meta-study of 19 studies identified total annual costs of ADHD in the U.S. (in 2010 dollars) between $176 billion and $309 billion (1.17% to 2.05% of U.S. GDP):¹⁴⁸

• for adults: $105 billion to $194 billion (0.7% to 1.29% of U.S. GDP)
  • especially productivity and income losses ($87 billion to $138 billion) (0.58% to 0.92% of U.S. GDP)
• for children/youth: $38 billion to $72 billion (0.25% 0.48% of U.S. GDP)
  • especially health care: $21 billion - $44 billion (0.14% 0.29% of U.S. GDP)
  • of which education accounted for: $15 billion - $25 billion (0.1% to 0.17% of U.S. 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 2016 Danish cohort study identified more frequent receipt of social benefits (sick pay or disability pension) by ADHD sufferers and their partners.¹³⁸

3.6. Indirect damage caused by ADHD¶

3.6.1. Increased work absenteeism, unemployment, disability¶

For adult ADHD sufferers, annual total societal incremental costs of $14,092 per affected adult were cited for 2018.¹⁴²
Of this amount

• Additional unemployment costs: 54.4 % (7,666 USD / person affected)
  • Adult males with ADHD are 2.1 times more likely to be unemployed than non-affected individuals. Their unemployment rate is thus increased by 22.1 percentage points.
  • Adult women with ADHD are 1.3 times more likely to be unemployed than those not affected. Their unemployment rate is thus increased by 9.7 percentage points.
  • The annual incremental cost in the U.S. is $66.8 billion ($55.8 billion for men and $11 billion for women with ADHD). This is equivalent to 0.325% of GDP.
• Productivity losses: 23.4 % (3,298 USD / affected person)¹⁴⁹
  • 13.6 Working days ADHD-related absenteeism
  • 21.6 working days ADHD lost during attendance
  • The 35 days of lost productivity were distributed among
    • Workers: 55.8 days
    • Service workers: 32.6 days
    • Technician: 19.8 days
    • Skilled worker: 12.2 days
  • Lost productivity costs due to ADHD of $28.8 billion ($19.9 billion for men and $8.9 billion for women with ADHD). This is equivalent to 0.14% of GDP.

A Swedish registry study from 1998 to 2008 found in ADHD sufferers:¹⁵⁰

• 12.19 days more unemployment (252 working days would be 4.84%)
• 19 times the probability of receiving a disability pension
  • Incapacities were largely explained by comorbid mental retardation and developmental disability, so are limited to improvement through more consistent treatment.

A rather small German study found unemployment to be 24.8% higher.¹⁵¹

3.6.2. Premature mortality¶

For adult ADHD sufferers, annual total societal incremental costs of $14,092 per adult were cited for 2018.¹⁴²
Adults with ADHD have a doubled annual mortality rate (primarily due to increased rates of traffic and other accidents.¹⁵²
This results in a total societal productivity loss of about $3.2 billion in 2018 (0.016% of 2018 GDP).

ADHD sufferers are 1.7 times more likely to have at least one accident:¹⁵³

• Children (28% vs. 18%)
• Adolescents (32% vs. 23%)
• Adults (38% vs. 18%)
  Follow-up costs for ADHD sufferers were increased only in adults ($483 vs $146 = 3.3-fold).

3.6.3. Income deficits in ADHD¶

3.6.3.1. Reduced income¶

A long-term study over 20 years on 604 subjects showed that ADHD sufferers have a lower net income and greater financial dependence on their parents at the age of 30 than non-affected persons. This is true even when DSM criteria are no longer met. This deficit persists throughout life, resulting in $1.27 million lower expected lifetime income for males and up to 75% lower net worth at retirement than for unaffected individuals.¹⁵⁷ In addition, ADHD-affected adults, if undiagnosed and untreated in childhood, earn significantly lower incomes than their unaffected twins and incur €20,000 higher costs per person per year¹⁵⁸

A Swedish registry study from 1998 to 2008 found a 17% lower annual income among ADHD sufferers.¹⁵⁰

American ADHD sufferers achieved fewer academic milestones beyond high school in 2003. ADHD-affected individuals were 42.3% less likely to have a full-time job, at 34%, than were nonaffected individuals, at 59%. Except for 18- to 24 -year-olds, mean household income was significantly reduced, regardless of academic achievement or personal characteristics. The national labor productivity loss associated with ADHD was estimated to be $67 billion to $116 billion (0.58% to 1.01% of U.S. GDP), assuming a prevalence of 2.3%.¹⁵⁹
Income with ADHD in 2003 was:

• Men: $45,645 vs. $54,399 (16.1% less)
• Women: $37,607 vs. $49,738 (24.4% less)

With current prevalence figures of 5% for adults, this would be more than double. The consumer price index in the U.S. increased by 40% from 2003 to 2020. Assuming income and GDP had increased at the same rate, this would result in $183 to $322 billion (0.87% to 1.54% of GDP) in 2020.

A 2016 Danish cohort study identified lower earned income among ADHD sufferers in the five years prior to initial diagnosis.¹³⁸

ADHD-affected adults, if undiagnosed and untreated in childhood, earned significantly lower incomes than their unaffected twins and paid less in taxes¹⁵⁸

3.6.3.2. Tax and social security contributions not due from reduced income¶

So far, we know of only one study that calculated the resulting lost tax and social security contributions for Germany.
The German net tax and social security revenue of a non-affected person born in 2010 was found to be €80,000 higher than that of a non-treated ADHD person. ADHD interventions that improved educational attainment resulted in fiscal benefits through higher lifetime tax revenues.
For every euro spent on a new ADHD intervention, €1.39 in discounted net tax revenue and €3.02 in discounted gross tax revenue was calculated¹⁶⁰
Converted to untreated adults in Germany and to 2020 values, we have calculated annual losses in net tax and social contribution revenues of EUR 5.916 billion. This corresponds to 1.63% of the federal budget.
This does not include savings from

• reduced crime
  • eUR 111 million saved in prison costs annually
  • eUR 500 million in reduced damage from crime annually
• reduced premature mortality: EUR 580 million annually
• Relative costs: EUR 2 billion annually
• Productivity losses in the workplace: EUR 11 billion annually

3.7. Total economic cost¶

One study cites $182,000 (as of 2015) higher costs from medical care, education, and crime consequences per ADHD case persisting into adulthood in the United States.¹⁶¹
An Australian study named total social and economic costs of ADHD of between $8.40 and $17.44 billion, with a cost per affected person of $15,664 per year (2018/2019).¹⁶² Of the total costs, the following accounted for

• Productivity costs 81 %
• Carrying losses 11 %
• Costs for the health care system 4
  The loss of well-being was substantial, valued at $5.31 billion.

A 2016 Danish cohort study identified €22,721 in annual additional direct and indirect costs per ADHD sufferer (as of 2016).¹³⁸
Adult ADHD sufferers accounted for €23,072 per year.

Another Danish study of same-sex twins showed for adults with ADHD, if undiagnosed and untreated in childhood¹⁶³

• higher total annual costs of €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 name the annual total societal ADHD-related additional costs at $6,799 per child ($19.4 billion) and $8,349 per adolescent ($13.8 billion) (as of 2017/2018).¹⁶⁴ The costs were distributed among

• Education costs (59.9% for children, 48.8% for youth)
• direct health care costs (25.9% for children, 29.0% for adolescents)
• Care costs (14.1% for children, 11.5% for youth).

One study identified $14,576 per ADHD sufferer (as of 2005) with a range of estimates between $12,005 and $17,458.¹⁶⁵