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Attention deficit hyperactivity disorder (ADHD), or attention deficit disorder, as it is perhaps more commonly known, is a psychiatric disorder characterized by pervasive difficulties with tasks that require sustained attention and impulse control, such as focusing on important life tasks, fulfilling responsibilities, staying organized, listening to others, remaining still in one’s seat, and keeping appropriately quiet. Prevalence of ADHD is estimated at 9 percent among children aged between 13 and 18 years, with boys affected in significantly greater numbers than girls. ADHD leads to problems in social, economic, and psychological adjustment that frequently persist into adulthood.
A diagnosis of ADHD is made based on the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition. Six out of 18 possible symptoms must be present for a diagnosis, five of which must have been evident before the child was 12 years of age. Symptoms must cut across the contexts of school, home, and elsewhere and lead to more severe difficulties than would be expected for a child of a similar age and developmental phase. Depending on a child’s particular presentation of ADHD symptoms, professionals may specify that a child exhibits primarily inattentive, hyperactive-impulsive, or combined symptoms.
Economics is a key contextual clue to under- standing the diagnosis and treatment of ADHD. The lower a child’s socioeconomic status (SES), the greater the likelihood that he or she will be diagnosed with the disorder. The reasons are unclear; both low SES and ADHD may share common causes, or the stresses of living in economically disadvantageous circumstances may give rise to the symptoms. Social services intended to help families adjust to the disorder require considerable public expenditures in the areas of health care, education, and the justice system. Moreover, the research, development, and marketing of drug treatments have led to sizeable profits for the pharmaceutical industry.
Health Care Costs
Children with ADHD have more emergency room visits than other children on average. They also have twice as much contact with mental health providers and visit outpatient mental health clinics 10 times more often than those who are undiagnosed. This creates higher costs within the health care system and greater out-of-pocket expenses for families with children diagnosed with ADHD.
Adolescents with ADHD who are of driving age have significantly higher traffic-related incidents. They also show higher rates of risky or impulsive driving behaviors, speeding, and crashes. These drivers are more easily distracted when a secondary stimulus is present, increasing traffic-related health care and insurance costs.
Diagnosis of ADHD is determined by qualified health care professionals, including primary care physicians, psychiatrists, psychologists, social workers, counselors, and family therapists. Families receive mental health services most commonly through their primary care physician. Diagnosis and treatment can be costly. In an average year, health care for ADHD in children and adolescents may cost each family struggling with the disorder between $621 and $2,720. Nationally, estimates for these costs range from $4.12 billion to $18.04 billion.
ADHD displays itself within the classroom through impulsivity, lack of sustained attention, and disruption. There are multiple ways in which this disorder affects educational costs. Many children with ADHD have an individualized education plan, which involves a team of people, including teachers, parents, and mental health professionals.
Preschool-age children who have been diagnosed with ADHD use specialized educational resources at a rate four times greater than their undiagnosed peers. These resources include speech therapy, occupational therapy, special education, and physiotherapy. Children with ADHD in elementary, middle, and high school have higher utilization of school counseling. Fifty percent of those who are using special education have an ADHD diagnosis, and 77 percent of these students use additional educational resources that include tutoring, counseling, special class placement, and additional monitoring.
ADHD in children may have a negative impact on educational achievement. In the United States, a study showed that boys who were diagnosed with ADHD completed 2.5 years less of school than other children. Throughout adolescence, ADHD can have a negative impact on self-efficacy and choosing a career path. There is evidence that adolescents with a diagnosis of ADHD may be at greater risk of struggling academically and psychologically. Children with ADHD have lower levels of achievement, are less productive, and score somewhat lower on intelligence tests and other measures of intellectual development. At least 40 percent receive special educational services. Costs of educational services for children and adolescents with ADHD may average between $2,222 and $4,690 per person annually, with a nationwide cost of $9.36 billion to $19.75 billion.
Adolescents who are diagnosed with ADHD show significantly higher rates of injury on the job. This leads to economic loss due to missed work, workman’s compensation claims, and health care costs. A Canadian study shows that workers diagnosed with ADHD are twice more likely to have an accident on the job than workers without such a diagnosis. An increased report of somatic symptoms within this population can also burden the system through absenteeism and health care costs. Problems relating to ADHD in children each year cause families to lose between $142 and $339 annually because of productivity losses. Nationally, productivity losses total $1.03 billion to $2.45 billion annually.
ADHD has an impact on the justice system with an estimated annual expenditure of $3 billion to $6 billion annually. This cost accrues from criminal offenses committed by individuals with ADHD, expenditures related to juvenile detention centers, arrests, burglaries, robberies, drug charges, and convictions. There is a significant correlation between bullying and behavior deemed as violent, and hyperactivity.
Medications to treat ADHD in children are commonly stimulants that increase the activity of the central nervous system. These medications usually work by increasing the activity of dopamine, a neurotransmitter that reinforces pleasurable behaviors. The activity of dopamine in individuals with ADHD may be generally lower than normal. Increasing this activity has a paradoxically calming effect on children with the disorder. Although the best treatment outcomes are frequently seen in patients using a combination of drugs and behavioral psychotherapy, psychiatric medications alone continue to be the most common way of treating ADHD. Increased demand for these medications over the past few decades has led to an explosion of research and marketing by the pharmaceutical industry.
Globally, ADHD medication expenditures increased from $332 million in 1994 to $2.26 billion in 2003, with the vast majority of such medications consumed in the United States. Over that period, the sales volume experienced a 104-percent increase. The United States remains the most important market for ADHD medications, perhaps because of the higher prevalence rates due to the use of the DSM, which is chiefly used in the United States and has diagnostic criteria that are generally more relaxed than those used in European countries and elsewhere.
Many parents use the Internet to find information regarding their children’s impulsive and disruptive behavior. One study suggests that 37 percent of popular search engine responses to searches for information about the causes and treatment of ADHD lead to sites that are funded by drug companies. These sites tend to favor biological and genetic explanations for what causes ADHD, supporting the use of pharmaceutical interventions rather than psychosocial ones (counseling, behavior modification). If the number of children who are prescribed ADHD medications continues to increase, these companies are well positioned to reap the financial rewards.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Publishing, 2013.
- Doshi, Jalpa A., Paul Hodgkins, Jennifer Kahle, Vanja Sikirica, Michael J. Cangelosi, Juliana Setyawan, M. Haim Erder, and Peter J. Neumann. “Economic Impact of Childhood and Adult Attention-Deficit/ Hyperactivity Disorder in the United States.” Journal of the American Academy of Child & Adolescent Psychiatry, 51/10 (2012).
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