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Consequences of ADHD

Consequences of ADHD

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

Health effects

  • Reduced life expectancy of 9 to 13 years possible
  • 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 those affected and reduce the need for medical treatment and healthcare costs

Economic impact on society

  • ADHD sufferers 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

ADHD sufferers have to put up with massive restrictions in their quality of life.
Untreated / inadequately treated ADHD has a massive impact on a person’s entire life,12 e.g:

1.1. Life expectancy shortened by 9 to 13 years

  • Life expectancy reduced by 9 to 13 years3, possibly due to genetic causes.4

  • 1.27- to 4.6-fold premature mortality. Depending on the study, between 1.27-fold (boys and men),5 2.85-fold (girls and women),5 1.4-fold (children and adolescents) and more than 4.6-fold (in adults),6 in particular due to accidents.789101112131415

  • With the number of additional comorbidities, the probability of premature death increases up to 25-fold.616

  • 4.25-fold risk of premature mortality when first diagnosed with ADHD in adulthood.5

  • 2.4-fold risk of suicide in ADHD overall, especially in women17 (up to 4.1-fold suicide risk). Correspondingly higher for untreated ADHD.1819

  • Suicide rate increases20 to 2.3 times21 to 2.9 times22

  • Suicidal thoughts and suicide attempts increased23

    • But not in veterans with ADHD24
  • 2-fold risk of falling victim to murder25

1.2. More frequent accidents and injuries

1.2.1. Injuries

  • Injuries increased2627
    • By 41 % for young adults28
    • By 250 % for children and adolescents29
  • Risk of bone fractures
    • increased by 60 % for girls 30
    • increased by almost 40 % in boys 30
    • Stress fractures increased by 17 %.31
  • Concussions
    • Twice as common in children between the ages of 11 and 14 with ADHD32
    • More frequent, with simultaneously prolonged healing time; healing time is normalized by stimulants33
  • Head injuries due to some types of accidents in ADHD up to more than twice34 to more than three times as often35
  • Children with eye injuries were 3.5 times more likely to have ADHD than children without eye injuries.36
  • Self-harming behavior
    • Intentional self-poisoning increased 4.65 times37

1.2.1. Traffic accidents and accident damage

  • Children with ADHD show riskier behavior when crossing the road38
  • 40% of drivers with ADHD had at least 2 accidents, compared to 6% of unaffected drivers.39
  • 60% of drivers with ADHD had an accident with personal injury, compared to 17% of unaffected drivers.39
    • this is more likely to be due to comorbid ODD and/or CD. A meta-study found a 23% higher accident rate for ADHD itself.40
  • The amount of damage suffered by drivers with ADHD was almost three times as high as the amount of damage suffered by unaffected drivers.39
  • Drivers with ADHD lost their driver’s license three times as often as unaffected drivers. This could also result from an impaired ability to defend themselves in court due to disorganization.39
  • 2.74 times the risk of car accidents with injuries in people aged 65 and over41
  • Riskier driving behavior42
  • More errors in driving simulators, especially with executive function problems43

A meta-analysis of 16 studies showed:40

  • 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 those without, 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.
  • ADHD sufferers are cautioned more frequently for speeding, but not more frequently for drunk or reckless driving

1.3. Frequent perpetrator and victim of violence and bullying

A meta-study of 14 studies with 1,111,557 subjects found a higher risk for ADHD sufferers with regard to:44

  • Violence in the relationship
    • as perpetrator (6 studies, OR 2.5 = approx. + 150 %)
      • according to another source, people with ADHD are 6.4 times more likely to be perpetrators of domestic violence than people without ADHD.45
    • 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 %46

Studies report an increased risk of child abuse.47

Children with ADHD report being bullied three times as often as children without ADHD.48

1.4. Higher crime rate

  • 4.8-49 to 9-fold risk of ending up in prison due to crime50
  • Arrests increased by 105 %51

A number of 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 ADHD52
  • 14 % to 45 %5354
  • 25 %55
  • 17.3 %56 of juvenile prisoners
  • 31 %57 of juvenile detainees
  • 25 % of all prisoners in the USA58
  • 28 % of all prisoners in the USA59
  • 17.5 % of 244 prisoners examined (n = 244)60
  • 27.6 % of 146 sex offenders examined (n=146, WURS 90 points)60
  • 22 % of patients in forensic psychiatry (n = 86)61
  • 9.1 % of 55 Irish prisoners examined62
  • 17% of all young men serving time for minor to moderate offenses in Lithuania.63 The ADHD-affected inmates 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.64

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

  • Hyperactive people have significantly higher arrest rates:65
    • Young people (46% compared to 11%)
    • Adults (21 % compared to 1 %)
  • 19% of ADHD sufferers had committed crimes, 0% in the control group66

Interestingly, amphetamines are the drugs most commonly used by prison inmates with ADHD.67 Amphetamine is known to be an active ingredient in highly effective ADHD medication.

A study on the correlation of ADHD symptoms and criminogenic thinking found that68

  • 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 ADHD sufferers69

  • 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:70

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

There was no evidence of a causal relationship between ADHD and70

  • 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.71

1.5.1.1. Neurodegenerative diseases

Up to 5-fold increased risk of neurodegenerative diseases.72

1.5.1.1.1. Dementia (up to 6-fold)

The overall risk of dementia is 4 times higher.73

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 dementia7374 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.74 In contrast, the same group of authors cited a significantly increased risk of Lewy body dementia with ADHD in an earlier publication.72
People with Lewy body dementia are 5.1 times more likely to have an ADHD diagnosis, regardless of age and gender.75

1.5.1.1.2. Parkinson’s (up to 2.5-fold)

Parkinson’s disease (1.5 to 2.5 times)74
Parkinson’s sufferers are 3.7 times more likely to have ADHD, regardless of age and gender.74

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.75
One study found a correlation between the ADHD-PRS (Polygenic Risk Score) and Alzheimer’s disease76
In a Swedish cohort study, parents of ADHD sufferers showed a 55% increased risk of Alzheimer’s disease. The risk was even lower in grandparents77

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 ADHD sufferers have one.78
  • Depression increases79
  • 4.12-fold risk (very large study, n = 1,250,000)80
  • 2.5-fold81 to 4-fold risk of depression in girls
  • ADHD in children increases the risk of depression in adolescence.82
  • Comorbidities further increase risk
    • 7.9-fold risk of clinically relevant depression symptoms with ADHD and a concussion suffered83
1.5.1.3. Eating disorders (3.6-fold)
  • 3.6 times the risk of eating disorders in girls84
  • Obesity (2-fold risk)3
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,85 12 to 50 % for ADHD19
  • Comorbidities further increase risk
    • 16.4-fold risk of clinically relevant anxiety symptoms in ADHD and a concussion suffered83
1.5.1.5. Post-traumatic stress disorder, PTSD (2.4-fold)

ADHD sufferers have 2.37 times the risk of suffering post-traumatic stress disorder as their non-ADHD-diagnosed siblings.86

1.5.2. Behavioral peculiarities

  • Increased risk behavior87

  • More frequent victims of physical and non-physical sexual abuse88

1.5.3. Physical illnesses

  • Increased risk of most physical diseases (34 [97%] of 35 diseases examined), regardless of gender89
1.5.3.1. Respiratory diseases (up to 3.2-fold)
  • Diseases of the respiratory tract (2.4 to 3.2 times the risk), mainly genetically caused, e.g:
    * Asthma
    * Chronic obstructive pulmonary disease
1.5.3.2. Infections (up to 2.8-fold)
  • Infections increased in childhood90
    - 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.
1.5.3.3. Risk of addiction (up to 2.3-fold)
  • Increased alcohol consumption23
  • Smoking more often2391929379
    • 2.35-fold9495 to 8.61-fold risk of smoking.96 Adults with ADHD have a 40% (OR 1.4)97 to 50% increased risk of smoking (OR = 1.5).98 Conversely, young adult smokers are twice as likely to have ADHD.99
    • Adolescents with ADHD have a doubled (OR = 2)98 to tripled95 risk of smoking
    • One study found no link between ADHD symptoms and smoking100
  • Increased marijuana consumption91
  • 1.77 times the risk of substance dependence (addiction)96
    The majority of studies on ADHD and alcohol abuse find a positive correlation.101
1.5.3.3. 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.102

1.5.3.4. Stroke risk (up to 1.4 times)
  • Increased risk of stroke103
    * Risk of ischemic stroke increased by 15
    * Risk of large-artery atherosclerotic stroke increased by 40
1.5.3.5. 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 4597

1.5.3.6. 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-19.104

1.6. More teenage pregnancies

  • 2.3 times the 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 reduced.105
  • 42 times as many maternities up to the age of 20 as non-affected persons (doubtful - data could not be verified so far)39

1.7. Educational disadvantages

  • Poorer educational opportunities79
    • 94% of children with ADHD have school problems (according to parent reports)106
    • University degrees 27 % less frequent51
    • School-leaving qualifications 11 % less frequent51
    • Lower educational qualifications23
    • Rare Bachelor’s degree107
    • More school absences (diagnosed ADHD, including ADHD treated with medication)108
      • 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)108
      • 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)108
      • Mental health 52.85 times
      • Social, emotional and behavioral disorders 19.97 times
      • Autism spectrum disorder 13.72 times
      • 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
    • In the long term, ADHD causes reduced emotional engagement at school, which is additionally moderated by student-teacher conflicts.109
    • A high polygenic risk score110
      • 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 ADHD107

  • Job changes increased by 5951
  • 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.111
  • Employment rate reduced by 2851
  • 3 times the risk of losing a job39
  • Higher layoff rate 1.1 vs 0.3 jobs/time112
  • Frequent job changes 2.7 vs 1.3 jobs/ 2- 8 y SE112 especially in old age113
  • Poorer evaluations in the workplace112
  • Not in employment, education or training 6 months after leaving school108
    • 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)114
  • No full participation in the labor market, especially for: (using Sweden as an example)115
    • 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 life87
    • Health-related QoL significantly reduced116
  • 4-fold increased risk of reduced length growth and lower weight gain at 8 and 10 years. Stimulant treatment increased this risk.117
  • ADHD in childhood predicts emotional problems later in life. These are genetically transmitted.118
  • 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.119 In the areas of

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

aDHD sufferers scored on average around 20 % lower than non-affected people.

In adults with the highest 10% of ADHD symptom severity according to ADHD-E, stress due to general life dissatisfaction occurred 4.10 times more frequently and stress due to lack of social support 3.3 times more frequently than in those not affected.120121

1.10. Divorces / separations more frequent

  • Divorces
    • Increased by 8751
    • Women (in Japan) with ADHD seem to have an even higher divorce rate than men with ADHD.111
  • 3 to 5 times the risk of separation and divorce19

1.11. Moving more often

Adults with ADHD move 2.35 times as often as those without.113

2. Protective effect through ADHD treatment

ADHD medication reduces the risks of ADHD symptoms and secondary effects. According to a meta-study, medication with stimulants reduces the aforementioned risks by 9 to 59%122

A meta-study of 40 studies found a robust protective effect of ADHD medications in relation to123

  • Mood disorders
  • Suicidal tendencies
  • (Car) accidents
  • Injuries
  • Traumatic brain injuries
  • Education and academic results. Indifferent, on the other hand:124
  • Substance abuse
  • Crime

2.1. Reduced premature mortality, fewer suicides

MPH reduced the overall mortality rate in children with ADHD by 20%. Delayed use of MPH correlated with a 5% increase in mortality. Long-term use reduced the overall mortality rate by 16%.125
No increased mortality was found when taking ADHD medication (stimulants or atomoxetine).126

Stimulants reduced the risk of suicide attempts in ADHD in several large studies:127

  • 11.6 % (in all age groups)128
  • 19 %129
  • 42 %130
  • 59 % if taken for 3 months and half a year131
  • 72 % if taken for more than half a year131
  • Methylphenidate for ADHD was associated with a reduction in the previously significantly increased risk of suicide after 90 days.132
  • Other ADHD medications (non-stimulants) showed no or very little reduction in suicidality, e.g. 4%129

2.2. Fewer accidents and injuries

2.2.1. Fewer accidents

ADHD medication reduces the frequency of accidents in affected boys and girls, as children and adolescents.133134 by 43%135 and traumatic brain injuries were reduced by 49%136 to 66%.137

2.2.2. Fewer traffic accidents

  • 38 % to 40 % for men138139
  • 42 % for women139
  • serious traffic accidents (for men) by 50138
  • of sexually transmitted diseases
  • by 30 to 40 % for men only140
  • of teenage pregnancies105

2.2.3. Fewer fractures (breaks)

Each drug treatment for ADHD reduced the risk of

  • of fractures in total141
    • by 39% to 74% according to 6 cohort studies, by both stimulants and non-stimulants142
    • by 32 to 41 according to the self-reporting study142

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 affected143
    • to 16 % less than those not affected31
  • of trauma fractures (accidental fractures)
    • by 23 % when taking MPH for at least 180 days144
    • to the same value as for non-affected persons31
    • In ADHD sufferers treated with non-stimulants, the risk increase for bone fractures doubled to 37% compared to the risk increase of non-affected persons, which was 17% higher than in non-affected persons31
  • Of unintentional injuries by 15 %145 or with an effect size of 0.88146
  • Of brain trauma by 73 %145
  • From poisoning147
  • Of injury-related emergency admissions by 9 %148
  • of burns in adolescents with ADHD149
    • 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

The increased recovery time of ADHD sufferers for concussions was normalized by stimulants33

2.4. Fewer comorbidities

ADHD medication reduces the frequency and severity of the following comorbidities.150

2.4.1. Less depression

ADHD medication reduces the risk of depression:151

  • by 40 % 3 years after ingestion
  • by 20 % during ingestion
  • MPH by around 30 % with long-term use in children and adolescents with ADHD152
  • Stimulants by over 60 % in the course of 10 years153

2.4.2. Fewer anxiety disorders

ADHD stimulants over 10 years reduced the risk of anxiety disorders by over 85%153

2.4.3. Fewer behavioral disorders and ODD

ADHD stimulants over 10 years reduced the risk of153

  • 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 in children and adolescents with ADHD by around 50%152 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.153

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%.152 Short-term use reduced the risk less significantly.

2.5. Reduced consumption of addictive substances

Reduce ADHD medication:

  • Tobacco consumption154
    • the number of smokers by 50155
    • the number of people who start smoking95
  • Substance abuse
    • by 31 %156
    • to the level of non-affected persons157
  • Alcohol consumption154
  • Cannabis use154
  • Use of illegal drugs154

ADHD medication does not increase the risk for those affected:158

  • 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).159 The risk of later addiction, whether to alcohol or other substances, was found to be 1.9 times lower (i.e. almost halved).160
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.161

2.6. Less obesity

Patients on stimulant medication were 26% less likely to be obese (BMI over 30) than unmedicated patients (30.5% to 41.2%).114
Patients on stimulant medication were 42% more likely to be of normal weight (BMI 18.5 to 25) than unmedicated patients (38.7% to 27.2%).114

2.7. Fewer victims of violence, bullying and abuse

ADHD sufferers 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).162

Children with ADHD who were treated with MPH or ATX were significantly less likely to suffer abuse than untreated sufferers.163

ADHD treatment reduced violence in the relationship.164

2.8. Lower crime rate

ADHD medication reduces the risk for sufferers

  • the crime rate69165
    • For men by 31 %
    • By 41 % for women
  • In particular for offenses committed on impulse166

2.9. Improved school performance and educational qualifications

ADHD medication improves academic performance:

  • Three months of treatment with ADHD medication resulted in167
    • 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 results of ADHD sufferers during the period in which they took medication were 4.8 points (scale: 1 to 200) higher than during the period in which they did not take medication.168
  • Discontinuation of ADHD medication correlated with a small significant decrease in grade point average169

Those affected who were treated with stimulants were almost one and a half times more likely to graduate from high school (around 58%) than those who were not treated with medication (41.3%)114

ADHD stimulants reduced the risk of remaining sedentary by almost 60% in the USA153

ADHD sufferers have a reduced motivation to exert themselves cognitively or physically. Amphetamine medication increased motivation evenly in both areas to close to the level of healthy control subjects170

2.10. Improved employability and income

Patients with a combination of sustained-release and non-retained medication were more than one and a half times as likely to be in full-time employment (52.9%) than those without medication (33.3%).114
People on stimulant medication were 30 % less likely to be unemployed than those not on medication (37.6 % to 53.5 %).114

People affected by stimulant medication earned114

  • 25% more often between 25,000 and 150,000 USD / year than unmedicated patients (63.7% to 50.9%)
  • almost 30 % less likely to receive less than USD 25,000 per year than unmedicated patients (24.5 % to 34.2 %)

2.11. More frequent regular health insurance

Commercial health insurance as opposed to state health insurance114

  • 44.7 % of unmedicated patients
  • 56.4 % of patients treated with untreated stimulants
  • 65.2 % of patients treated with slow-release stimulants
  • 79.4 % of patients treated with a combination of sustained-release and non-released stimulants

2.12. Less need for treatment, lower healthcare costs

The number of inpatient treatments is reduced by up to 82% with combined stimulant treatment114

  • Unmedicated ADHD sufferers: 0.629 / year
  • Treated with a combination of retarded and unretarded stimulants: 0.111 / year
  • Treated with delayed or unretarded stimulants: 0.27 / year

The number of outpatient treatments is reduced by up to half with combined stimulant treatment114

  • Unmedicated ADHD sufferers: 4.59 / year
  • Treated with a combination of retarded and unretarded stimulants: 2.3 / year
  • Treated with retarded or unretarded stimulants: 3.5 / year

The number of emergency room visits is reduced by up to 63% with combined stimulant treatment114

  • Unmedicated ADHD sufferers: 0.862 / year
  • Treated with a combination of retarded and unretarded stimulants: 0.380 / year

Annual healthcare costs are reduced by up to 70% ($12,740/year) with combined stimulant treatment114

  • Unmedicated ADHD sufferers: 18,200 USD / year
  • Treated with a combination of retarded and unretarded stimulants: USD 5,460 / year
  • Treated with slow-release stimulants: USD 8,970 / year
  • Treated with untreated stimulants: USD 9,190 / year

We interpret the difference in the combination of unretarded and retarded stimulants compared to taking retarded or unretarded stimulants alone as a sign of prolonged daily coverage and finer / more detailed drug adjustment,

2.13. Improved quality of life

Medication significantly mitigates the deterioration in health-related quality of life caused by ADHD.116

A meta-analysis found a deterioration in quality of life when discontinuing medication in children and adolescents, but not in adults.171

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 later172

  • 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% still had 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.173
  • 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 patients need to be treated with MPH in the long term to avoid one of the following long-term consequences of untreated ADHD?174 The results were independent of gender:

  • 3 patients treated = 1 class repetition avoided
  • 3 treated patients = 1 avoided oppositional defiant behavior
  • 3 treated patients = 1 avoided behavioral disorder (conduct disorder)
  • 3 treated patients = 1 avoided anxiety disorder (with 2 types of effects)
  • 4 patients treated = 1 major depression avoided
  • 4 victims treated = 1 serious car accident avoided (in simulation)
  • 5 patients treated = 1 bipolar disorder avoided
  • 6 smokers treated = 1 smoker avoided
  • 10 patients 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 cost of drug treatment, including the cost of visits to the doctor and laboratory tests, was estimated at between USD 1,710 and USD 2,567 for 2004.175

3.2. Healthcare costs for ADHD

In addition to the direct treatment costs of ADHD itself, healthcare costs also include the additional 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 ADHD sufferers (EUR 4,868 instead of EUR 1,912 = 2.55 times higher).176
In addition, there were a further EUR 477 higher annual healthcare costs for partners of ADHD sufferers.

ADHD more than doubles healthcare costs.177

A meta-study 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.178 In addition, healthcare costs for family members due to the care of 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 for ADHD sufferers in the USA:179

  • 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 US due to ADHD amounts to 20.6 billion USD annually180
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.181
The higher costs result from behavioral health services and medication.182

Annual additional costs to society of USD 1,635 per adult with ADHD were cited for 2018.183

Children with ADHD in Flanders (Belgium) required more intensive healthcare in 2002 than their unaffected siblings. The utilization of medical services was:184

  • 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 an unaffected sibling (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.185 It is likely that externalizing disorders such as ODD and CD made their own contribution.

The annual healthcare costs of ADHD sufferers were reduced by up to 70% ($12,740/year) with combined stimulant treatment:114
unmedicated ADHD sufferers: 18,200 USD / year
treated with a combination of retarded and unretarded stimulants: USD 5,460 / year
treated with slow-release stimulants: USD 8,970 / year
treated with untreated stimulants: USD 9,190 / year

3.3. Costs for relatives with ADHD

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

A Danish cohort study from 2016 calculated EUR 7,997 in additional annual direct and indirect costs per partner of an ADHD sufferer.176

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 17.186

A meta-study 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.178 Of this, 22% to 14% was due to loss of productivity among family members.

For adults with ADHD, the annual additional costs to society as a whole amounted to USD 14,092 per adult in 2018.183
Caregivers of adults with ADHD spend an additional 0.8 hours per week on ADHD-related care compared to adults in the US population as a whole.187188 This results in additional annual costs of $6.6 billion.

A meta-study 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).189 Of this, spillover costs borne by family members of individuals with ADHD accounted for USD 33 billion to USD 43 billion (0.22% to 0.29% of US GDP).

3.4. Education costs for ADHD

A meta-study 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.178 Education costs accounted for 62% and 42% respectively.

A meta-study 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):189

  • 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 ADHD sufferers and their partners were more likely to receive social benefits (sickness benefit or disability pension).176

3.6. Indirect damage caused by ADHD

3.6.1. Increased absenteeism, unemployment, incapacity to work

For adults with ADHD, the annual additional costs to society as a whole for 2018 amounted to USD 14,092 per affected adult.183
Of which

  • Additional unemployment costs: 54.4 % (USD 7,666 / person affected)
    • Adult men with ADHD are 2.1 times more likely to be unemployed than non-affected people. 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 without the condition. 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 affected)190
    • 13.6 working days of absence due to ADHD
    • 21.6 working days of ADHS 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)179

A Swedish register study conducted between 1998 and 2008 found that ADHD sufferers:191

  • 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.192

3.6.2. Premature mortality

For adults with ADHD, the annual additional costs to society as a whole amounted to USD 14,092 per adult in 2018.183
Adults with ADHD have a doubled annual mortality rate (primarily due to increased rates of traffic and other accidents.193
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:194

  • Children (28% compared to 18%)
  • Young people (32 % compared to 23 %)
  • Adults (38 % compared to 18 %)
    The follow-up costs for ADHD sufferers were only higher for adults (USD 483 compared to USD 146 = 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 affected. In view of the actual number of cases, the costs are considerably higher.)195 and in 2003 to a total of EUR 230,000,000.196 These figures only include treatment costs
  • One study found a total economic burden of $47.55 million for 69,353 diagnosed ADHD sufferers in Korea in 2012, equivalent to $684 per sufferer and 0.004% of Korea’s GDP (gross domestic product) in 2012.197

3.6.3. Income deficits with ADHD

3.6.3.1. Reduced income

A long-term study of 604 test subjects over 20 years showed that ADHD sufferers have a lower net income and greater financial dependence on their parents at the age of 30 than those who are not affected. 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.198 In addition, adults with ADHD who were not diagnosed and treated in childhood have significantly lower incomes than their unaffected twins and incur EUR 20,000 higher costs per person per year199

A Swedish register study from 1998 to 2008 found that ADHD sufferers had a 17% lower annual income.191

Americans with ADHD achieved fewer academic milestones beyond high school in 2003. Those 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%.200
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 result in 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 ADHD sufferers in the five years prior to initial diagnosis.176

ADHD-affected adults, if undiagnosed and untreated in childhood, earned significantly less income than their unaffected twins and paid less tax199

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 revenue of a non-affected person born in 2010 was found to be EUR 80,000 higher than that of a non-treated ADHD sufferer. ADHD interventions that improved educational attainment led to fiscal benefits through higher lifetime tax revenues.
For every euro spent on a new ADHS intervention, EUR 1.39 in discounted net tax revenues and EUR 3.02 in discounted gross tax revenues were calculated201
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 USD 182,000 (as of 2015) higher costs from medical care, education and the consequences of crime per ADHD case persisting into adulthood in the USA.202
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 affected of USD 15,664 per year (2018/2019).203 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 ADHD sufferer (as of 2016).176
Adult ADHD sufferers 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 childhood204

  • 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 at 2017/2018).205 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 ADHD sufferer (as of 2005) with an estimated range between USD 12,005 and USD 17,458.206


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