Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

ADHD from a socio-economic perspective

Lars Bernfort1 , Sam Nordfeldt (sam.nordfeldt@lio.se)1,2 , Jan Persson1
1.Center for Medical Technology Assessment, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
2.Division of Child and Adolescent Psychiatry, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden

Keywords
ADHD, Costs, Neuropsychiatric disorders, Outcome,
Socio-economic perspective
Correspondence
Dr. S. Nordfeldt, Division of Child and Adolescent
Psychiatry, Department of Clinical and Experimental
Medicine, Faculty of Health Sciences, Linköping
University, S-581 85 Linköping, Sweden.
Tel: +46-13-222000 | Email: sam.nordfeldt@lio.se
Received
18 June 2007; revised 26 October 2007; accepted
29 October 2007.
DOI:10.1111/j.1651-2227.2007.00611.x
Abstract
Aim: Attention deficit hyperactivity disorder (ADHD) and related disorders affect children’s ability to
function in school and other environments. Awareness has increased in recent years that the same
problems often persist in adulthood. Based on previous studies, we aimed to outline and discuss a
descriptive model for calculation of the societal costs associated with ADHD and related disorders.
Methods: Following a literature review including childhood and adult studies, long-term outcomes of
ADHD and associated societal costs were outlined in a simple model.
Results: The literature concerning long-term consequences of ADHD and related disorders is scarce.
There is some evidence regarding educational level, psychosocial problems, substance abuse,
psychiatric problems and risky behaviour. The problems are likely to affect employment status,
healthcare consumption, traffic and other accidents and criminality. A proposed model structure
includes persisting problems in adulthood, possible undesirable outcomes (and their probabilities)
and (lifetime) costs associated with these outcomes.

Conclusions: Existing literature supports the conclusion that ADHD and related disorders are associated with a
considerable societal burden. To estimate that burden with any accuracy, more detailed long-term data are
needed.

der (ODD) and conduct disorder (CD). Individuals in this

INTRODUCTION
subgroup with persisting problems often suffer in adulthood
Symptoms of attention deficit hyperactivity disorder
from antisocial personality disorder (ASPD) and risk expe-
(ADHD) appear in more than 5% of children starting
riencing long-term difficulties regarding education, work life
as early as preschool age. ADHD often disturbs affected
and relations. These individuals have a markedly increased
children’s function and development in several important
risk of undesired outcomes such as severe accidents, drug
respects. Children with ADHD frequently experience diffi-
abuse and serious criminality. About 15% of the children di-
culties in social relations and in school environments. These
agnosed with ADHD are in this high-risk subgroup, which
difficulties imply problems in adolescence and undesirable
comprises about 1% of the population (6). Although eco-
outcomes in adulthood to a much greater extent than for
nomic evaluations are relatively few, the societal burden of
children without ADHD. As indicated by others, there seems
ADHD and related disorders can be expected to be consid-
to be a great need of early identification and specialized ser-
erable (7,8).
vices for children at risk of ADHD and related disorders
In health economic assessments costs are usually divided
(1–4).
into direct and indirect costs. Direct costs refer to consump-
ADHD is no longer looked upon as a disorder that affected
tion of resources as a direct consequence of a state or disease,
individuals automatically outgrow. How large a proportion
such as medical treatment. Indirect costs refer to indirect
of children with ADHD have continuing symptoms in ado-
consequences due to a state or disease, such as the inability
lescence and adulthood depends on the criteria used and
to perform work, thereby resulting in costs to society due to
who makes the judgement (5). Some symptoms may fade
production loss. It is often the case that all costs and sac-
out, at least to some extent, with increasing age (impulsivity,
rifices of relevance from a societal perspective are not in-
hyperactivity), while others more often persist (inattention,
cluded in assessments due to difficulties in measuring and
poor concentration). Therefore, adults do not always fulfil
quantifying them. Examples of costs that are often omit-
the diagnostic criteria for ADHD even if disabling symptoms
ted are the time relatives spend in giving care and support,
obviously remain. Significant difficulties persist in 50% or
psychological distress of patients and relatives (intangible
more of those diagnosed with ADHD in childhood.
costs), etc. In this paper, the term costs comprises all of the
Although ADHD during childhood does not preclude at-
above, even though data were not available for all of them.
taining high educational and vocational goals, ADHD chil-
The total societal cost of schizophrenia in the United
dren as a group fare poorly compared with their non-ADHD
Kingdom in 2004/2005 was recently estimated at 2 billion
counterparts. The difficulties as well as the risk of undesired
pounds for the direct cost of treatment and care, and at
long-term outcomes become markedly worse in the pres-
4.7 billion pounds for indirect costs (of which 3.4 billion
ence of the comorbid states of oppositional defiant disor-


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ADHD from a socio-economic perspective Bernfort et al.

pounds was for lost productivity due to unemployment,
absence from work and premature mortality) (9). Less is
known about the societal costs associated with ADHD.
The aim of this paper is to outline and discuss as a first step
a rough model for calculating the societal costs associated
with ADHD and related psychiatric disorders. Ideally, such
a model could be used in future analyses of cost-effectiveness
of treatments aimed at mitigating the symptoms of these dis-
orders. In order to create a model, possible long-term conse-
quences must be identified. Therefore, the literature dealing
with ADHD and outcomes in adulthood was reviewed.
METHODS
Based on findings from a previous literature study (10) and
recent reviews covering long-term outcomes (5,11), the Med-
line database was searched for the following terms: ADHD –
attention deficit hyperactivity disorder combined with costs
(152 hits), psychiatric outcomes (67), psychosocial problems
(98), addiction (78), risk behaviour (29), health care con-
sumption (78), criminality (28), injuries (200) and life years
(103). Closer examination resulted in a smaller number of
studies of real interest to this paper; childhood and adult
studies dealing with long-term consequences of ADHD and
related disorders (compared to a control group) were in-
cluded. Cost-effectiveness studies (of medication) not incor-
porating long-term consequences were excluded.
Considering the limited long-term primary data, we settled
on outlining a simple descriptive structure of the long-term
process of ADHD and related disorders, and estimations of
potential cost savings were not performed.
RESULTS
Difficulties and problems associated with ADHD
Some earlier studies of various long-term consequences as-
sociated with ADHD and related disorders are briefly sum-
marized in Table 1 and reviewed in the following section.
Whether children or adults were studied is indicated where
applicable.
Psychosocial problems
Individuals with ADHD often have difficulties fitting in and
functioning in social relations. These problems are most ob-
vious concerning relations and communication with others
in workplaces and within the family. The problems seem
to depend on emotional factors and communicative ability
rather than a lack of understanding of how to behave accord-
ing to social norms (12). Problems with low self-esteem and a
limited circle of friends have been reported in children with
ADHD, and those problems also persist into young adult-
hood (11).
Low educational level
Symptoms associated with ADHD and related disorders in
childhood and adolescence often imply problems concern-
ing schooling. These consist both of difficulties in acquir-
ing knowledge and lack of adaptability to school rules and
routines.
Studies have shown that individuals with ADHD and re-
lated disorders have on average a shorter education, fewer
higher degrees, poorer grades and more failed courses. This
contributes to the fact that as adults they have employ-
ment of lower status compared to control groups (13,14).
In one study (14), 85 persons with ADHD (mean follow-up
17 years) and 73 controls were interviewed. Mean age was 24
years in both groups. ADHD subjects had on average more
than 2 years less education than controls. Furthermore, 25%
in the ADHD group did not finish high school (1% of con-
trols), and only 15% in the ADHD group had a Bachelor’s
degree (over 50% of controls). These results are supported
by other studies (5,11,13).

Table 1 Summary of long-term consequences associated with ADHD

Difficulty/cost item Effects of ADHD Comment

Psychosocial problems Lower self-rated social and emotional abilities. Evidently there are problems, but little calculable data
Lower self-esteem (11,12)
Low educational level Shorter education (on average about 2 years). Less high Evident problems and some quantified data exist
exams (13,14)
Substance abuse Earlier onset. More long-term abuse. Heavier drugs more Worse with ODD/CD. Well-documented problem
usual (13,15,20,22)
Psychiatric problems More often psychiatric disturbances. Increased risk of ASPD Results not all consistent. Increased risk of ASPD established
(25,29)
Risk behaviour More of traffic accidents and various violations (30) Evidence almost exclusively concerning traffic
Production loss Lower employment status. More often self-employed (14) A potentially large cost item, but data are scarce
Healthcare costs Costs doubled even when adjusted for psychiatric Some data exist. Significantly higher costs with ADHD
treatment (33)
Material costs No evidence found Costs should be higher with ADHD (accidents, material
damage)
Criminality More of arrests, convictions and incarcerations (36) Data difficult to use. Significantly increased risk with
ODD/CD
Life years lost Imperfect impulse control important predictor for No existing data, but probably a significant and important
premature death (5) cost item
Intangibles and other costs Data are scarce. Sleeping problems have been For instance impaired quality-of-life for patient and family
observed (40)

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Bernfort et al.
Substance abuse
Individuals with ADHD seem to be over-represented among
substance abusers (narcotics, alcohol). Whether this de-
pends on biological factors or on the fact that these indi-
viduals often have difficult situations is somewhat unclear
(15). Some have speculated that substance abuse is found in
individuals with CD in particular rather than ADHD per se
(16,17). However, ADHD and CD overlap to a great extent
(18,19).
It has been reported that up to 50% of those with per-
sistent ADHD symptoms suffer from substance abuse (13).
Various studies have shown that persons with ADHD and/or
CD have earlier drug debuts, abuse of longer duration, that
they more often progress from alcohol abuse to heavier drug
abuse, have a shorter interval between debut and addiction,
and larger risk of treatment failure (15).
One study (20) investigated the prevalence of ADHD and
related disorders among adults admitted to two chemical de-
pendency treatment centres. Prevalence was established us-
ing interviews and DSM-IV diagnostic criteria for ADHD. It
was found that 24% (48/201) fulfilled the criteria for ADHD
and that 39% (79/201) fulfilled the criteria for CD. Most of
those diagnosed with ADHD were also diagnosed with CD.
Persons diagnosed with CD had earlier alcohol debuts, more
treatment sessions and were more inclined to use heavy
drugs than those without CD.
Flory et al. (21) studied 481 young adults and found that
both ADHD and CD were associated with a significantly
increased risk of developing substance abuse. Interestingly,
overlapping ADHD and CD symptoms implied the highest
risks, especially concerning dependency on marijuana and
heavier drugs. Earlier studies in which CD and ODD comor-
bidity were not analysed found that 35% of cocaine abusers
had a history of ADHD (22), 34% of persons with ADHD
were addicted to alcohol (23), and that among adults with
ADHD, 17–45% were addicted to alcohol and 9–30% were
addicted to narcotics (24).
Psychiatric problems
A few follow-up studies have examined psychiatric status
in adulthood in children diagnosed with ADHD (13,25–
28). In all of these studies, subjects were young adults (20–
30 years) at follow-up and comparisons were made with
control groups, but the results varied. Although childhood
ADHD is associated with an increased risk in adulthood
of developing ASPD, most children no longer exhibit clin-
ically significant emotional or behavioural problems once
they reach their mid-twenties. The risk of ASPD is increased
with CD in childhood and particularly in adolescence. Only
one of the above studies (25) found a significant difference
concerning mood disorders, which might be explained by
the fact that the other studies excluded children with severe
CD.
A recent retrospective study (29) reported that adult
ADHD subjects have a significantly increased risk of devel-
oping comorbidity such as anxiety, depression and substance
abuse. Some found that 59% of ADHD subjects had some
psychiatric disturbance compared to 36% of controls (25).

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ADHD from a socio-economic perspective
Risk behaviour
Symptoms associated with ADHD and related disorders of-
ten imply less controlled behaviour, which in turn can be
expected to lead to increased risks in certain activities. In
this respect, research concerning adults has primarily been
focused on behaviour and risks in traffic.
ADHD subjects have been found to have significantly
higher risks than controls when it comes to accidents, driv-
ing under the influence of alcohol and drugs, driving without
a license and speeding. When controlled for confounders
(i.e. other diagnoses, time with license), significant differ-
ences remained only for accidents with bodily injuries and
driving without a license (30). However, Barkley et al. used
interviews, driving simulators and official records, and con-
cluded that the problems concerning driving and traffic be-
haviour remained after controlling for confounders (6,31).
They found that license loss was three times more common
in ADHD subjects as compared to controls, that 40% had
been in at least two traffic accidents as adults (6% of con-
trols) and 60% had been in an accident with bodily injuries,
respectively (17% of controls).
Cost items associated with ADHD
In this section, the major costs to society associated with
ADHD in adulthood are briefly discussed based on available
studies.
Production loss
In cost-of-illness studies with a societal perspective, produc-
tion loss is often a very large cost item, especially regard-
ing chronic diseases. The symptoms associated with ADHD
and related disorders and the chronic nature of these dis-
orders make it reasonable to assume that production loss is
substantial. Psychosocial and psychiatric problems, low ed-
ucational level and substance abuse are characteristics that
contribute to this picture. Interviews with adults who expe-
rienced ADHD-related problems in childhood showed that
these individuals more often had lower-status employment
than controls and also they were more often self-employed
(14).
An American study (32) estimated that the annual excess
production loss costs due to ADHD were $ 690 per male
with ADHD, while the difference for females was not signif-
icant. There is also production loss associated with the sit-
uation of family members of both children and adults with
ADHD.
Healthcare costs
Individuals with ADHD and related disorders can be ex-
pected to consume more healthcare resources compared
to the average individual. Psychiatric problems, substance
abuse, risky behaviour and the overall situation contribute
to this assumption. Studies of children and adolescents
have shown that ADHD is associated with higher health-
care costs, even when controlling for psychiatric treatment.
Leibson et al. (33) found that children/adolescents with
ADHD had more diagnoses, more healthcare contacts and
cost twice as much as controls. Findings were consistent for
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ADHD from a socio-economic perspective
boys and girls as well as for different ages. One study found
that costs for ADHD children were slightly, but not signifi-
cantly, higher than for children with asthma (34).
A retrospective study found that even when controlling
for comorbidity, adult ADHD subjects compared to con-
trols had significantly higher annual costs for outpatient care
($ 3009 vs. $ 1492), inpatient care ($ 1259 vs. $ 514) and
drugs ($ 1673 vs. $ 1008) (32). Another study calculated the
costs per year for adult ADHD subjects at $ 4929 compared
to $ 1473 for controls (35). Family members of subjects with
ADHD have also been shown to consume more healthcare
resources (32,35).
Material costs
Studies explicitly addressing the issue of material costs seem
to be lacking. However, the risky behaviour often associated
with ADHD subjects is likely to imply material costs result-
ing from traffic accidents and various damages in workplaces
and other areas of society. This assumption is further en-
forced by the fact that substance abuse is more common in
ADHD subjects. As already mentioned, persons with ADHD
have a greater number of traffic accidents.
Criminality
Individuals with ADHD and related disorders are over-
represented in crime statistics and among prison inmates,
which is likely to result from risk behaviour, psychosocial
problems and substance abuse. Societal costs of criminality
impact the law enforcement and judicial systems, the crimi-
nal care system, and damage/suffering among crime victims.
Hyperactive boys with CD (n = 89) were compared to
controls (n = 87) regarding criminality in adolescence and
young adulthood (36). Official records showed that hyper-
active boys with CD had significantly higher arrest rates in
both adolescence (46% vs. 11%) and young adulthood (21%
vs. 1%). Others found that more individuals with ADHD,
compared to controls, had been arrested (39% vs. 20%),
convicted (28% vs. 11%) and incarcerated (9% vs. 1%) (37).
ADHD subjects had committed more crimes and had more
often been convicted several times. Similar results have been
presented in other studies (38).
A study of 100 adult prison inmates who had commit-
ted serious crimes showed that 63% fulfilled the diagnostic
criteria for CD. The study also found CD, but not ADHD,
significantly associated with adult criminality (39).
Life years lost
Life years lost can be difficult to quantify, but it is an im-
portant item in cost-of-illness analyses. Although no study
showed that ADHD and related disorders were associated
with life years lost, we assume that this is the case. Stud-
ies have shown that poor impulse control per se is the sin-
gle most important factor in prediction of early death (5).
Substance abuse and psychiatric problems are factors that
strengthen the assumption that ADHD and related disor-
ders may be associated with life years lost.
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Intangibles and other costs
Intangible costs are hard to quantify and might be under-
stood as somewhat vague. Here, intangible costs mainly
consist of impaired quality of life for persons affected by
ADHD and related disorders. Other examples are suffer-
ing/impaired quality of life of others such as family members,
crime victims, etc.
Impairments in quality of life in ADHD are the result of
a complicated overall situation, but can be linked to psy-
chosocial and psychiatric problems, sleeping problems and
substance abuse. One study showed that irrespective of age,
persons with ADHD had greater problems than controls in
falling asleep and sleeping all night, and that due in part to
this, they had more difficulty concentrating during the day-
time (40). It has also been shown that family members of
persons with ADHD consume significantly more healthcare
and have a significantly poorer economic situation in their
households than other families (41,42).
Several studies of ADHD in childhood report a heavy
emotional burden on the family. Life with an ADHD child
has been described as chaotic, filled with conflicts and ex-
hausting (43–45).
The findings regarding long-term consequences are sum-
marized in Table 1.
DISCUSSION
The long-term outcomes associated with living with ADHD
and related disorders seem to imply heavy burdens both for
individuals and society. Therefore efforts to comprehend the
issue in a societal perspective are in great need. We found,
however, that such information in the literature is rather
scarce and that it is hampered by methodological limitations.
First of all, the degree of later impairments found in cases
referred to clinics or included in follow-up studies may not
be representative for all cases in the population. Second,
the methods used in the studies are mixed and are difficult
to summarize. Moreover, increasing knowledge about the
developmental course of ADHD needs to be considered in
prognostic models (46). The extent to which the reported
outcomes should be attributed to ADHD or to comorbid-
ity, possibly with ADHD as a mediator, remains unclear.
For example, more information is needed in order to dis-
tinguish between the impact of ADHD and that of CD. The
cost of antisocial behaviour has been investigated in a pi-
lot study in which detailed primary data were collected by
semi-structured interview (47). Within wide ranges, substan-
tial costs and other impacts related to CD were reported.
Long-term outcome and costs in a societal perspective need
more attention in clinical cohort studies of ADHD and re-
lated disorders. As of today, it is clearly difficult to outline
the life course of persons with ADHD in any detail.
Health economic modelling is often used when clinical
or other data are lacking, and it is therefore necessary to
apply well-grounded estimates of certain variables. Natu-
ral courses of chronic diseases are best simulated by use of
Markov models, in which a patient has certain probabilities
during each cycle (usually a year) of either remaining in the
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Bernfort et al. ADHD from a socio-economic perspective

Unwanted outcomes
/societal costs

Production loss
18 years Costsa
pa
Persistent severe Healthcare
problems (about 1%
Costsb
pb consumption
of the population)
3-5 years
• Psychosocial
pc Material damage Costsc
Diagnosis • Education
• Drug abuse pd
AD/HD Criminality
5-7% of the • Psychiatric Costsd
population • Risk behaviour pe

Problems and Lost life years Costse

pf
costs during
childhood and
adolescence p = probabilities of Intangible and Costsf
different outcomes other costs

Figure 1 A rough structure of long-term consequences of ADHD.

present state or moving to one of a number of other states.
Data detailed enough to set up a Markov model were not
available concerning ADHD. Therefore, while keeping the
limitations in mind, a proposed rough model to describe the
course of ADHD is discussed (Fig. 1).
In order to produce results from this model, one would
need probabilities of different outcomes, and reliable pri-
mary data for (lifetime) costs associated to the different
outcomes. Such data are currently unavailable. Some data,
mainly American, exist concerning certain problems and
certain consequences. For instance, individuals with ADHD
and related disorders as a group are over-represented among
criminals have lower educational level and more often have
lower-status employments. There are also strong indications
that ADHD subjects consume more healthcare resources,
cause more material damage and they are at risk of losing
life years.
Our model was derived from a health-economic perspec-
tive and might perhaps seem simplistic. Future research is
expected to add important knowledge regarding factors af-
fecting the outcomes. Clearly, a wider study covering the
impact of proposed mediating and moderating factors and
their interactive mechanisms in a development perspective
would be valuable.
Recently, some rough estimations of societal costs for psy-
chiatric disorders were presented in a Swedish governmental
agency report (48). Annual costs to society were suggested
as in Table 2. An illustrative example was outlined showing
that targeted preventive parental education could be given
to 6900 parents at the 30-year cost (discount rate 2%) for
one single person with drug abuse – even without taking into
account any production losses.
Although very little specific hard data is available, it is rea-
sonable to assume that the overall burden on society from
ADHD and related disorders is considerable. In order to
estimate, at least roughly, the societal burden of these dis-
orders, future research would need to answer the following
questions:
1. How large are the proportions of men and women with
ADHD who experience different kinds of undesired life
outcomes?
2. How large are the lifetime costs associated with different
undesired life outcomes?
3. What is the influence on quality of life for individuals with
ADHD and for family members?
4. Are there other consequences/undesired life outcomes
that affect persons with ADHD to a greater extent than
they affect others?
In conclusion, although more detailed data on the proba-
bilities and costs of different outcomes are needed in order
to calculate the burden and costs to society of ADHD and
related disorders, we found compelling reasons for believing
that the impact is considerable.

Table 2 Previously calculated rough examples of annual costs to society, excluding production losses due to inability to work (48)

Yearly cost per person-year 30 years’ cost at 2% discount rate∗

Work-impeding psychosocial problems Eur 10 650 (SEK 100 000) Eur 254 350 (SEK 2 390 000)
Mental illness Eur 37 250 (SEK 350 000) Eur 916 100 (SEK 8 606 000)
Drug abuse Eur 66 000 (SEK 620 000) Eur 1 620 050 (SEK 15 215 000)

∗
Loss of production estimated at an additional Eur 702 650 (SEK 6 600 000) at 2% discount rate.


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ADHD from a socio-economic perspective
Further, considering the early onset and natural course,
the need of further research and stronger efforts from schools
and healthcare providers must be stressed. If carried out in a
long-term perspective, such priorities probably have the po-
tential to reduce both individual human suffering and major
societal costs.
ACKNOWLEDGEMENTS
We thank Per A. Gustafsson M.D., Associate Professor, Di-
vision of Child and Adolescent Psychiatry, Department of
Clinical and Experimental Medicine, Faculty of Health Sci-
ences, Linköping University for valuable viewpoints, and the
Ostergotland County Council and the Faculty of Health Sci-
ences at Linköping University for support.
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