economic impact of childhood and adult attention-deﬁcit ... · ﬁculties, criminal activity,...

REVIEW

Economic Impact of Childhood and AdultAttention-Deficit/Hyperactivity Disorder in

the United StatesJalpa A. Doshi, Ph.D., Paul Hodgkins, Ph.D., Jennifer Kahle, Ph.D.,

Vanja Sikirica, Pharm.D., Michael J. Cangelosi, M.P.H., Juliana Setyawan, Pharm.D.,M. Haim Erder, Ph.D., Peter J. Neumann, Sc.D.

Objective: Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalentmental disorders in children in the United States and often persists into adulthood withassociated symptomatology and impairments. This article comprehensively reviews studiesreporting ADHD-related incremental (excess) costs for children/adolescents and adults andpresents estimates of annual national incremental costs of ADHD. Method: A systematicsearch for primary United States-based studies published from January 1, 1990 through June30, 2011 on costs of children/adolescents and adults with ADHD and their family memberswas conducted. Only studies in which mean annual incremental costs per individual withADHD above non-ADHD controls were reported or could be derived were included.Per-person incremental costs were adjusted to 2010 U.S. dollars and converted to annualnational incremental costs of ADHD based on 2010 U.S. Census population estimates, ADHDprevalence rates, number of household members, and employment rates by age group. Re-sults: Nineteen studies met the inclusion criteria. Overall national annual incremental costs ofADHD ranged from $143 to $266 billion (B). Most of these costs were incurred by adults($105B!$194B) compared with children/adolescents ($38B!$72B). For adults, the largest costcategory was productivity and income losses ($87B!$138B). For children, the largest costcategories were health care ($21B!$44B) and education ($15B!$25B). Spillover costs borneby the family members of individuals with ADHD were also substantial ($33B!$43B). Conclusion: Despite a wide range in the magnitude of the cost estimates, this studyindicates that ADHD has a substantial economic impact in the United States. Implications ofthese findings and future directions for research are discussed. J. Am. Acad. Child Adolesc.Psychiatry, 2012;51(10):990–1002. Key Words: ADHD, cost of illness, societal costs, chil-dren, adults

A ttention-deficit/hyperactivity disorder(ADHD) is defined by the DSM-IV-TR asa persistent set of inattentive, hyperac-

tive, and impulsive symptoms that impairs func-tion in at least two settings (e.g., home, work,and/or school).1 It has been reported to be one ofthe most prevalent mental disorders in children

in the United States,2 with a current prevalencerate of 5.5% to 9.3%3 in children and adolescents4 to 17 years old. Children and adolescents withthis disorder experience educational difficulties,4

problems with self-esteem,5 significantly im-paired family and peer relationships,6 and anoverall decrease in quality of life.7

Although traditionally thought of as a condi-tion of childhood, ADHD often persists intoadulthood with associated symptomatology andimpairments. Prevalence rates in U.S. adults 18 to44 years old are reported to be 4.4%8 and high-light the chronicity of this disorder. ADHD-related impairments may underlie subsequentproblems in adulthood such as occupational dif-

This article is discussed in an editorial by Dr. A. Reese Abright onpage 987.

Clinical guidance is available at the end of this article.

Supplemental material cited in this article is available online.

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 51 NUMBER 10 OCTOBER 2012990 www.jaacap.org

ficulties, criminal activity, substance abuse prob-lems, and traffic accidents and citations.9 More-over, the difficulties faced by children and adultswith ADHD may have spillover effects and cannegatively affect the health and work productiv-ity of family members.10

Although hundreds of studies have reportedon the negative outcomes of ADHD in childhoodand adulthood in areas such as health, education,occupation, and antisocial behavior, few havemonetized these outcomes to provide an estimateof the economic impact of ADHD in the differentsectors of society. For instance, the two mostrecent systematic reviews of the economic costsof ADHD found only 12 to 13 original researchstudies addressing this topic11,12 compared with351 original research studies found in a recentreview of long-term outcomes of ADHD.9 Acomprehensive understanding of the incrementalcosts of ADHD (i.e., excess costs over and abovethose of individuals without ADHD) from asocietal perspective is important to inform, plan,and justify policies and interventions to helpalleviate the numerous negative consequencesassociated with this disorder. In addition to beingdated, prior systematic reviews of the economicimpact of ADHD have been limited in scope,examining a restricted population or a few sec-tors of the economy.11-13 Pelham et al.12 (2007)only reviewed costs in children and adolescentswith ADHD. Leibson and Long13 (2003) consid-ered only health care costs. Matza et al.11 (2005)examined children and adults and additionalcost sectors besides health care, but studies ofeducation costs were not available. Furthermore,results reported across the reviewed studies werenot consolidated to present an overall estimate ofincremental costs of individuals with ADHD atthe national level.

The present study uses a societal perspective, com-prehensively reviews studies reporting ADHD-related incremental costs for children/adolescentsand adults, and computes estimates of overallannual national incremental costs of ADHD inthe United States. Estimates are also stratified byage group, cost sectors, and patient versus familymember.

METHODA systematic review was conducted using guidelinesfrom the Cochrane Handbook for Systematic Reviewsof Interventions.14 Four large databases (MEDLINE,EMBASE, ERIC, and PsycINFO) were searched for

articles published from January 1, 1990 through June30, 2011 using the following abstracted search strategy:(terms describing ADHD) AND ((terms describing costanalysis or economic impact) OR (terms describing areas ofcost due to ADHD)). An extensive list of terms describ-ing cost areas of interest was used to identify studieson health care resource use, productivity losses, acci-dents, education, substance abuse, and criminal behav-ior (Table S1, available online). Studies were alsoidentified by examining the reference lists of priorpublications and by follow-up directly with the studyauthors. This identification method deviated fromstrict Cochrane guidelines but was in line with inter-national systematic review guidelines.15

A primary screen retained all articles published inEnglish and classified as original research studies ofhuman participants conducted in the United Statesthat included a study group of participants withADHD and monetized ADHD-related outcomes. In afinal screen, the full text of the articles were reviewedto exclude studies in which mean annual incrementalcosts of individuals with ADHD compared with acontrol group of patients without ADHD were notreported (or could not be derived).16-18 Studies usingspecific disease groups (e.g., asthma or depression) asthe only control group were excluded.19,20 Studies notreporting mean costs (e.g., only median costs re-ported21) and studies from which it was not possible toseparately estimate contributions from different costcategories (e.g., combined costs of health care andproductivity losses22) were also excluded.

Study characteristics and cost measurements wereextracted and tabulated for the included studies. Forone study,23 numeric data underlying the publishedgraphs were obtained from the study author. A fewcalculations and adjustments were made on the datareported in the studies. Per-person annual costs werecomputed by dividing the aggregate annual nationalcosts by the estimated size of the population in onestudy.24 Weighted average estimates for the overallpopulation were calculated for two studies that re-ported only cost estimates stratified by patient gen-der.10,25 Costs were annualized for three studies esti-mating costs over 1 month or multiple years.23,26,27 Allcost estimates across the included studies were in-flated to 2010 U.S. dollars using the consumer priceindex from the U.S. Bureau of Labor Statistics.28 Themedical care component of the consumer price indexwas used to inflate reported health care cost estimates.

For the national incremental cost calculations, the stud-ies were compiled by age group (children/adolescentsversus adults) and cost category (health care, produc-tivity and income losses, education, and justice sys-tem). The health care and productivity cost categorieswere separated into subcategories of costs incurred bypatients with ADHD versus those by family membersof patients with ADHD. Except for the minimal re-quirements that each study had to meet for inclusion

ECONOMIC IMPACT OF ADHD IN THE US

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 51 NUMBER 10 OCTOBER 2012 991www.jaacap.org

in the review as outlined earlier in the selectioncriteria, this review did not identify and adjust fordifferential quality of studies. The number of studies ineach age group and cost category combination was toosmall, often only a single study, to permit such anapproach. Instead, for each age group and cost cate-gory, the lowest and highest reported incremental costestimates across all included studies were identified.For the cost categories with a sufficient number ofstudies, namely those examining costs related to healthcare in children/adolescents (n " 9) and adults (n " 6)with ADHD and productivity losses in adults withADHD (n " 7), reported adjusted estimates were usedto identify the range of incremental cost estimates. Forall remaining cost categories, the number of relevantstudies was three or fewer and, hence, estimates ad-justed by regression or matched controls or unadjustedestimates were used to identify the range. The range ofper-person incremental cost estimates within each agegroup and cost category were then converted to arange of annual national incremental costs of ADHDusing 2010 U.S. Census population estimates, ADHDprevalence rates, number of household members,and employment rates by age group as describedbelow.29,30

First, the national counts of individuals with ADHDwithin each age group and cost category in the UnitedStates were estimated as the product of the nationwideU.S. population count reported by the 2010 U.S. Cen-sus31 corresponding to the age range of the patientswith ADHD across the studies specifically examiningthat age group (i.e., children/adolescents or adults)and cost category and the ADHD prevalence ratecorresponding most closely to this age range. Forchildren/adolescents, prevalence rates of currentADHD diagnosis reported by the Centers for DiseaseControl and Prevention were used.3 For adults, apublished and commonly cited rate of 4.4% in 18 to 44year olds8 was applied given that the Centers forDisease Control and Prevention has not reportedADHD prevalence rates in adults. For the category ofproductivity (i.e., absenteeism and low productivitywhile at work, referred to as #presenteeism# in somestudies) costs in adult patients with ADHD, which isapplicable only to employed patients, an employmentrate of 67.6% was applied, assuming employment ratessimilar to those in the general 18- to 64-year-oldpopulation reported by the 2010 U.S. Bureau of LaborStatistics.32

Second, the national counts of family members ofindividuals with ADHD who would be affected undereach of the subcategories of health care and produc-tivity costs in family members of patients with ADHDwas estimated. For the subcategory of health care costsamong family members of the patients with ADHD,the national count of patients with ADHD was multi-plied by 2.92 to compute the total number of familymembers (adults and children) affected by ADHD.

This figure obtained from the 2010 U.S. Census33

represents the average size of the U.S. household lessone (representing the one patient with ADHD in thehousehold.) For the subcategory of productivity costsamong adult family members of children/adolescentswith ADHD, the national count of patients withADHD was multiplied by 2.0, which represents theaverage number of adult household members in theUnited States in 2010. Similarly, for the subcategory ofproductivity costs among adult family members ofadults with ADHD, the national count of patients withADHD was multiplied by 1.0. For the two categoriesrelated to productivity costs, the same employmentrate of 67.6% was applied.32

Third, the range of national incremental costs ofADHD was estimated by multiplying the lowest andhighest reported per-person incremental cost estimatesfor each age group and cost category by the corre-sponding national counts of individuals. Overall na-tional incremental costs of ADHD in 2010 were com-puted by summing the costs across age groups andcategories. The estimates were also stratified by agegroup, cost sectors, and patient versus family member.

RESULTSThe initial literature search identified 4,580 cita-tions. After the screening process, only 19 studiesmet all inclusion criteria (Figure S1, availableonline). Table 110,23-27,34-45 lists the key character-istics of these 19 studies. Eleven studies exam-ined costs incurred by children with ADHDor their family members and 10 studies exam-ined costs incurred by adults with ADHD ortheir family members (two studies examinedchildren/adolescents and adults). Most studiesevaluated health care costs (n " 13). Nine studiesexamined costs related to income and productiv-ity losses. Only three studies examined educationcosts and two studies examined justice systemcosts. None of the studies meeting the inclusioncriteria evaluated costs related to traffic accidentsor substance abuse problems.

Table 23,8,10,23-26,31,33-37,41-46 presents the analy-sis resulting in the range of national incrementalcosts of ADHD under each combination of costcategory and age group of interest. The range ofages considered across all studies was 0 to 64years old, including individuals with ADHD andtheir family members. In the health care costcategory, wide ranges of per-person incrementalcost estimates were reported across the studiesevaluating children/adolescents ($621 to $2,720)and adults ($137 to $4,100) with ADHD. Thisvariability was a function of the characteristics

DOSHI et al.


TABL

E1

Key

Char

acte

ristic

sof

Stud

ies

Mee

ting

Inclu

sion

Crite

ria

Stud

yDe

sign,

Setti

ng,a

ndSa

mpl

eSi

zeYe

arof

Data

Colle

ctio

nId

entifi

catio

nof

ADHD

Patie

nts

Age

Gro

up(a

ndAg

eRa

nge

Cons

ider

ed)o

fPa

tient

sw

ithAD

HDCo

stCa

tego

ries

Eval

uate

dRe

gres

sion

Adju

stm

ent

orM

atch

edCo

ntro

ls

Gue

vara

etal

.,20

0137

retro

spec

tive

anal

ysis

ofG

roup

Hea

lthC

oope

rativ

eof

Puge

tSo

und

HM

Oda

ta(n

"14

,960

)

1997

ICD-

931

4.xx

or!

1pr

escr

iptio

nfo

rasti

mul

ant

child

ren/

adol

esce

nts

(3–1

7yo

)he

alth

care

(pat

ient

)re

gres

sion

and

mat

ched

cont

rols

Cha

net

al.,

2002

38

cros

s-sec

tiona

lana

lysis

ofM

edic

alEx

pend

iture

Pane

lSu

rvey

(n"

5,43

9)

1996

ICD-

9-C

M31

4.xx

or!

2pr

escr

iptio

nsfo

rneu

rosti

mul

ant

child

ren/

adol

esce

nts

(5–2

0yo

)he

alth

care

(pat

ient

)re

gres

sion

Burd

etal

.,20

0339

retro

spec

tive

anal

ysis

ofN

orth

Dako

taDe

partm

ento

fH

ealth

clai

ms

(n"

129,

138)

1996

!19

97IC

D-9

diag

nosis

of31

4.00

,314

.01,

314.

8,31

4.9

child

ren/

adol

esce

nts

(0!

21yo

)he

alth

care

(pat

ient

)no

ne

Man

dell

etal

.,20

0327

retro

spec

tive

anal

ysis

ofpe

diat

ricM

edic

aid

patie

nts

inPh

ilade

lphi

a,PA

(n"

76,6

62)

1993

!19

96!

2cl

aim

sas

soci

ated

with

ICD-

931

4.xx

orpa

rent

alre

port

ofsy

mpt

oms

atdi

agno

stic

inte

rvie

w

child

ren/

adol

esce

nts

(3!

15yo

)he

alth

care

(pat

ient

)re

gres

sion

Swen

sen

etal

.,20

0325

retro

spec

tive

anal

ysis

ofa

rand

omsa

mpl

eof

heal

thpl

anen

rolle

esof

ala

rge

Fortu

ne10

0co

mpa

ny(n

"2,

172)

1998

ICD-

931

4.0x

with

!1

ADH

Dm

edic

alor

disa

bilit

ycl

aim

child

ren/

adol

esce

nts

(0!

18yo

)he

alth

care

(pat

ient

),he

alth

care

(fam

ily),

prod

uctiv

ity(fa

mily

)

mat

ched

cont

rols

Swen

sen

etal

.,20

0440

retro

spec

tive

anal

ysis

ofa

rand

omsa

mpl

eof

heal

thpl

anen

rolle

esof

ala

rge

Fortu

ne10

0co

mpa

ny(n

"2,

616)

1998

ICD-

931

4.0x

with

!1

ADH

Dm

edic

alor

disa

bilit

ycl

aim

child

ren/

adol

esce

nts

(0!

18yo

)and

adul

ts(1

8!64

yo)

heal

thca

re(p

atie

nt),

prod

uctiv

ity(p

atie

nt)

mat

ched

cont

rols

Birn

baum

etal

.,20

0510

retro

spec

tive

anal

ysis

ofhe

alth

plan

enro

llees

in1

larg

eco

mpa

nyan

das

soci

ated

disa

bilit

yda

ta(n

"9,

822)

1998

ICD-

9-C

M31

4.0x

with

!1

ADH

Dm

edic

alcl

aim

child

ren/

adol

esce

nts

(7!

18yo

)and

adul

ts(1

9!44

yo)

heal

thca

re(p

atie

nt),

heal

thca

re(fa

mily

),pr

oduc

tivity

(pat

ient

),pr

oduc

tivity

(fam

ily)

mat

ched

cont

rols



TABL

E1

Cont

inue

d

Stud

yDe

sign,

Setti

ng,a

ndSa

mpl

eSi

zeYe

arof

Data

Colle

ctio

nId

entifi

catio

nof

ADHD

Patie

nts

Age

Gro

up(a

ndAg

eRa

nge

Cons

ider

ed)o

fPa

tient

sw

ithAD

HDCo

stCa

tego

ries

Eval

uate

dRe

gres

sion

Adju

stm

ent

orM

atch

edCo

ntro

ls

Kess

lere

tal.,

2005

41

retro

spec

tive

anal

ysis

of2

larg

ehe

alth

care

clai

ms

and

empl

oyer

-repo

rted

prod

uctiv

ityda

taba

ses

(n"

2,39

9)

2001

!20

03IC

D-9-

CM

314.

0,31

4.00

,or

314.

01w

ith!

1ev

alua

tion

orcl

aim

forA

DHD

diag

nosis

adul

ts(1

8!44

yo)

prod

uctiv

ity(p

atie

nt)

regr

essio

n

Secn

iket

al.,

2005

42

retro

spec

tive

anal

ysis

ofcl

aim

sfro

msix

Fortu

ne20

0em

ploy

ers

(n"

4,50

4)

1999

!20

01IC

D-9

314.

00or

314.

01ad

ults

(18!

64yo

)he

alth

care

(pat

ient

)pr

oduc

tivity

(pat

ient

)

regr

essio

nan

dm

atch

edco

ntro

ls

Bied

erm

anan

dFa

raon

e,20

0634

cros

s-sec

tiona

lana

lysis

usin

gna

tionw

ide,

rand

om,

tele

phon

e-ad

min

ister

edsu

rvey

(n"

1,00

1)

2003

self-

repo

rtof

prio

rad

ultd

iagn

osis

adul

ts(1

8!64

yo)

inco

me

loss

esdu

eto

unem

ploy

men

tan

dw

age

diffe

renc

es(p

atie

nt)

regr

essio

n

Fisc

hera

ndBa

rkle

y,20

0626

patie

nts

rece

ivin

gps

ycho

logy

serv

ice

with

inM

ilwau

kee

Chi

ldre

n’s

Hos

pita

l(n

"22

3)

1992

!19

96DS

M-II

I-Rad

ults

(19!

25yo

)in

com

elo

sses

due

tow

age

diffe

renc

es(p

atie

nt)

regr

essio

n

Ray

etal

.,20

0643

Kaise

rPer

man

ente

(Nor

ther

nC

A)H

MO

(n"

11,3

56)

1996

!20

04DS

M-IV

,IC

D-9-

CM

314.

0ch

ildre

n/ad

oles

cent

s(2

!10

yo)

heal

thca

re(p

atie

nt)

regr

essio

nan

dm

atch

edco

ntro

lsFi

shm

anet

al.,

2007

44

grou

phe

alth

coop

and

grou

phe

alth

optio

nsm

embe

rsin

WA

and

ID(n

"24

9,87

4)

2001

ICD-

9-C

M31

4.xx

and

!1

AD[

H]D

inpa

tient

orou

tpat

ient

enco

unte

r

adul

ts(!

18yo

)he

alth

care

(pat

ient

)re

gres

sion

Flet

cher

and

Wol

fe,

2009

24

natio

nally

repr

esen

tativ

esa

mpl

edu

ring

scho

olye

ars

1994

!19

95,1

995!

1996

,an

d20

01!

2002

(n"

13,5

72)

1994

!20

02DS

M-IV

(inat

tent

ive,

hype

ract

ive,

and

com

bine

dsu

btyp

esin

clud

ed)

adul

ts(1

8!28

yo)

justi

cesy

stem

(pat

ient

)re

gres

sion

DOSHI et al.


TABL

E1

Cont

inue

d

Stud

yDe

sign,

Setti

ng,a

ndSa

mpl

eSi

zeYe

arof

Data

Colle

ctio

nId

entifi

catio

nof

ADHD

Patie

nts

Age

Gro

up(a

ndAg

eRa

nge

Cons

ider

ed)o

fPa

tient

sw

ithAD

HDCo

stCa

tego

ries

Eval

uate

dRe

gres

sion

Adju

stm

ent

orM

atch

edCo

ntro

ls

Jone

san

dFo

ster,

2009

23

long

itudi

nala

naly

sisof

aco

hort

ofki

nder

gartn

ers

from

Durh

am,N

C;

Nas

hvill

e,TN

;Sea

ttle,

WA

;an

dce

ntra

lPA

(n"

650)

1997

!20

04pa

rent

alse

lf-re

port

ofch

ild’s

sym

ptom

son

the

Diag

nosti

cIn

terv

iew

Sche

dule

for

Chi

ldre

n(id

entifi

edhy

pera

ctiv

ity/

impu

lsivi

tyor

inat

tent

ion)

child

ren/

adol

esce

nts

(12!

17yo

)he

alth

care

(pat

ient

),ed

ucat

ion

(pat

ient

),ju

stice

syste

m(p

atie

nt)

regr

essio

n

Kess

lere

tal.,

2009

41

larg

eU

.S.m

anuf

actu

ring

firm

(n"

8,56

3)20

05!

2006

DSM

-IVcr

iteria

for

adul

tADH

Dad

ults

(40!

51yo

IQR)

heal

thca

re(p

atie

nt),

prod

uctiv

ity(p

atie

nt)

regr

essio

n

Mar

kset

al.,

2009

35

68pr

esch

ools

with

ingr

eate

rN

ewYo

rkC

ityar

ea(n

"20

6)

2004

!20

05DS

M-IV

crite

riafo

rpe

diat

ricA

DHD

child

ren/

adol

esce

nts

(3!

4yo

)ed

ucat

ion

(pat

ient

)re

gres

sion

Hod

gkin

set

al.,

2011

45

2la

rge

heal

thca

recl

aim

san

dpr

oduc

tivity

data

base

s,10

0la

rge

empl

oyer

sth

roug

hout

US

(n"

127,

008)

2006

ICD-

931

4.0,

314.

00,o

r31

4.01

with

!1

eval

uatio

nor

clai

mof

ADH

Ddi

agno

sisw

ithco

ntin

ued

treat

men

t

adul

ts(1

8!64

yo)

heal

thca

re(p

atie

nt),

prod

uctiv

ity(p

atie

nt)

regr

essio

nan

dm

atch

edco

ntro

ls

Robb

etal

.,20

1136

Wes

tern

Psyc

hiat

ricIn

stitu

tean

dC

linic

,Pitt

sbur

gh,P

A(n

"60

4)

1999

!20

08DS

M-II

I-Ror

DSM

-IV,

child

hood

diag

nosis

child

ren/

adol

esce

nts

(5!

18yo

)ed

ucat

ion

(pat

ient

)no

ne

Not

e:AD

HD

"at

tent

ion

defic

it/hy

pera

ctivi

tydi

sord

er;C

A"

Cal

iforn

ia;D

SM-III

-R"

Diag

nosti

can

dSt

atist

ical

Man

ualo

fMen

talD

isord

ers—

3rdEd

ition

(Rev

ised)

;DSM

-IV"

Diag

nosti

can

dSt

atist

ical

Man

ualo

fMen

tal

Diso

rder

s—4th

Editi

on;

HM

O"

heal

thm

aint

enan

ceor

gani

zatio

n;IC

D-9

"In

tern

atio

nalC

lass

ifica

tion

ofDi

seas

es,

Nin

thEd

ition

;IC

D-9-

CM

"In

tern

atio

nalC

lass

ifica

tion

ofDi

seas

es,

Nin

thEd

ition

,C

linic

alM

odifi

catio

n;IQ

R"

inte

rqua

rtile

rang

e;ID

"Id

aho;

NC

"N

orth

Car

olin

a;PA

"Pe

nnsy

lvani

a;TN

"Te

nnes

see;

US"

Unite

dSt

ates

;WA

"W

ashi

ngto

n;yo

"ye

ars

old.



TABL

E2

Nat

iona

lInc

rem

enta

lCos

tsof

Atte

ntio

n-De

ficit/

Hype

ract

ivity

Diso

rder

(ADH

D)by

Cost

Cate

gory

and

Age

Gro

up

Cost

Cate

gory

Age

Gro

upof

Patie

nts

with

ADHD

Num

ber

ofSt

udie

s

Age

Rang

eac

ross

Stud

ies

Popu

latio

nco

rres

pond

ing

toAg

eRa

nge3

1,3

3

ADHD

Prev

alen

cefo

rAg

eRa

nge

Oth

erM

ultip

liers

a

Popu

latio

nIn

curr

ing

Cost

Per-

Pers

onIn

crem

enta

lCo

st,2

010

U.S.

Dolla

rs

Nat

iona

lIn

crem

enta

lCos

t,20

10U.

S.Do

llars

(Bill

ions

)

Hea

lthca

reH

ealth

care

(pat

ient

)ch

ildre

nan

dad

oles

cent

s9

0!21

92,1

40,9

797.

2%3

—6,

634,

150

$621

37!

$2,7

202

3$4

.12!

$18.

04H

ealth

care

(pat

ient

)ad

ults

618

!64

194,

296,

087

4.4%

8—

8,54

9,02

8$1

37(N

S)46!

$4,1

0042

$1.1

7!$3

5.05

Hea

lthca

re(fa

mily

)ch

ildre

nan

dad

oles

cent

s2

0!18

74,1

81,4

677.

2%3

2.92

15,5

95,9

12$1

,088

10!

$1,6

5825

$16.

97!

$25.

86H

ealth

care

(fam

ily)

adul

ts1

19!

4410

8,30

5,78

74.

4%8

2.92

13,9

15,1

28$1

,051

10

$14.

62su

btot

al$3

7B!

94B

Prod

uctiv

ityan

din

com

elo

sses

Inco

me

loss

es(lo

wer

wag

es)

adul

ts1

19!

2530

,433

,583

4.4%

8—

1,33

9,07

8$(

3,74

4)26

$(5.

01)

Inco

me

loss

es(u

nem

ploy

men

tan

dlo

wer

wag

es)

adul

ts1

18!

6419

4,29

6,08

74.

4%8

—8,

549,

028

$10,

5323

4!

$12,

1893

4$9

0.04

!$1

04.2

0

Prod

uctiv

itylo

sses

(pat

ient

)ad

ults

618

!64

194,

296,

087

4.4%

867

.6%

5,77

9,14

3$2

0945!

$6,6

994

1$1

.21!

$38.

71

Prod

uctiv

itylo

sses

(fam

ily)

child

ren

and

adol

esce

nts

20!

1874

,181

,467

7.2%

32.

0,67

.6%

7,22

1,12

1$1

4210!

$339

25

$1.0

3!$2

.45

Prod

uctiv

itylo

sses

(fam

ily)

adul

ts1

19!

4410

8,30

5,78

74.

4%8

1.0,

67.6

%3,

221,

447

$174

10

$0.5

6

subt

otal

$88B

!$1

41B

Educ

atio

nch

ildre

n1

3!4

8,18

2,21

05.

5%3

—45

0,02

2$1

2,44

735

$5.6

0ch

ildre

nan

dad

oles

cent

s2

5!18

58,4

80,9

607.

2%3

—4,

210,

629

$2,2

2223!

$4,6

9036

$9.3

6!$1

9.75

subt

otal

$15B

!$2

5BJu

stice

syste

mad

oles

cent

s1

13!

1721

,238

,249

9.3%

3—

1,97

5,15

7$2

67(N

S)23

$0.5

3ad

ults

118

!28

47,5

50,8

614.

4%8

—2,

092,

238

$1,2

0424!

$2,7

4224

$2.5

2!$5

.74

subt

otal

$3B!

$6B

tota

l$1

43B!

$266

B

Not

e:B

"bi

llions

;NS

"di

ffere

nce

was

nots

tatis

tical

lysig

nific

anti

nth

eor

igin

alstu

dy.

aFi

gure

sus

edin

“Oth

erM

ultip

liers”

are

desc

ribed

inth

eM

etho

dse

ctio

n.

DOSHI et al.


of the studies including setting, design, andcost components included. Conversely, forhealth care costs incurred by family membersof patients with ADHD, there was little vari-ability in these estimates, given that there wereonly one or two relevant studies. The estimatesacross the 13 studies evaluating health carecosts translate into annual national incrementalcosts ranging from approximately $37 billion(B) to $94B among individuals with ADHD andtheir families.

For costs due to income losses, two studiesexamined costs to patients with ADHD owingto lower wages and/or unemployment. Onestudy found that young adults (19-25 years)with current or childhood ADHD had a signif-icantly higher incremental mean annual salary($3,744) than non-ADHD controls, likely be-cause a significantly smaller proportion wasenrolled in college and thus more likely em-ployed.26 The second study reported that theannual household income was lower by $10,532to $12,189 per adult with ADHD when exam-ined across the entire typical working agerange of 18 to 64 years.34

Productivity losses for adults with ADHDowing to absenteeism, poor performance while atwork, disability payments, and/or worker’scompensation ranged from $209 to $6,699 annu-ally per 18- to 64-year-old employee across sixstudies. Although the cost components includedacross these studies varied, poor performancewhile at work was clearly the major driver ofcosts to employers. Per-person incremental costestimates were smaller in magnitude for produc-tivity losses for family members of children/adolescents ($142 to $339) and adults ($174) withADHD across the one or two relevant studies.The estimates across the nine studies on incomeand productivity losses translated to annual na-tional incremental costs ranging from approxi-mately $88B to $141B.

For the category of education costs, one studyreported the annual ADHD-related incrementalcosts of education in 3 to 4 year olds at $12,447per student and included costs related to specialeducation, occupational, speech, and physicaltherapy.35 The annual incremental costs in 5 to 18year olds ranged from $2,222 to $4,690 per stu-dent across two studies; the former estimateincluded costs related to special education, graderetention, and school counseling,23 whereas thelatter included costs related to special education,

grade retention, and disciplinary incidents.36 Theestimates across the three studies on educationcosts translated to annual national incrementalcosts ranging from approximately $15B to $25Bin 3 to 18 year olds.

For justice system costs, two studies reportedcosts related to criminal offenses by individualswith ADHD. The per-person annual incrementalcosts of detention center and arrest expendituresderived from one study of 13- to 17-year-oldadolescents with ADHD was $267.23 Anotherstudy of 18- to 28-year-old young adults reportedannual incremental costs ranging from $1,204 to$2,742 to the victim and society owing to bur-glary, robbery, larceny, arrests/convictions, andselling of drugs.24 The estimates across these twostudies translated to annual national incrementalcosts ranging from approximately $3B to $6B in13 to 28 year olds.

Summing the estimates across the various costcategories resulted in overall national incremen-tal costs of ADHD ranging from $143B to $266Bin 2010. Figure 1 (left) highlights that $105B to$194B (73%!74%) of these overall costs wereattributable to adults with ADHD or to adultfamily members of patients with ADHD. Spill-over costs borne by the family of children andadults with ADHD ranged from $33B to $43B(16%!23%; Figure 1 [right]). For adults withADHD, the largest cost component was produc-tivity and income losses ($87B!$138B, 71%!83%;Figure 2 [left]). For children with ADHD, thelargest cost components were health care($21B!$44B, 56%!61%) and the educational sec-tor ($15B!$25B, 35%!40%; Figure 2 [right]).

FIGURE 1 Annual national incremental costs ofattention-deficit/hyperactivity disorder (ADHD) (inbillions) by population groups. Note: The inner circlerepresents the lower end of the range of costs ($143B).The outer circle represents the higher end of the rangeof costs ($266B).



DISCUSSIONThis review included 19 studies examining theincremental costs of ADHD in the United States.Recognizing the variance introduced by hetero-geneous methodologies across these studies, therange of costs rather than point estimates wascalculated. Despite a wide range in the annualnational incremental costs computed in the pres-ent analysis (overall $143B!$266B), the lowerend estimate alone indicates that ADHD has asubstantial economic impact in the United States.Although large in magnitude, these results maybe an underestimate of the true societal costs ofADHD in the nation for several reasons. First,there were no studies identified in the literaturereporting analyzable cost information within thecost categories of substance abuse and trafficaccidents, and patients with ADHD have beenshown to have a higher risk of these prob-lems.47-51 Second, within the remaining cost cat-egories, some included studies did not captureall relevant cost components within that sectorwherein individuals with ADHD or their familiesmay have incurred higher costs. Third, withincost categories of the justice system, education,and health care and productivity losses of familymembers of adult patients with ADHD, onlystudies for a restricted age group were found andthus the national incremental cost estimates donot include costs incurred by individuals withADHD beyond that limited age range. Fourth,

within the cost category of education, the period,study samples, and cost components in the in-cluded studies may have underrepresented theincreased use of special educational services bychildren with ADHD under the Individuals withDisabilities with Education Act and Section 504of the Rehabilitation Act.

Although these limitations point to an under-estimation of the cost figures, a few caveats thatmay influence the present computed estimates ineither direction also deserve mention. First, be-cause studies varied in whether and how theycontrolled for comorbidities commonly associ-ated with ADHD (i.e., anxiety, depression, ma-nia, and oppositional-defiant disorder52), esti-mates of the cost of “pure” ADHD in the absenceof comorbidities were not derivable for everystudy and thus the costs of ADHD alone mayhave been overestimated. Nevertheless, the earlyage of onset of ADHD makes the majority ofthese comorbidities secondary in terms of tem-porality. To the extent that ADHD affects therisk, persistence, or severity of these comorbidi-ties, the costs associated with these comorbiditiesmay be considered long-term indirect effectsassociated with ADHD and thus appropriatelyconsidered costs of patients with ADHD.53,46

Thus, use of adjusted estimates, where available,from studies that controlled for such comorbidi-ties may have indeed resulted in an underesti-mate of the true costs associated with ADHD.Second, most of the included studies did notprovide sufficient information on the prevalenceand length of treatment for ADHD in their studysubjects. The economic burden of ADHD may behigher or lower based on treatment status. Third,the present results reflect clinical practice in thesettings and time observed within the includedstudies. For example, several studies predatedthe emergence of newer ADHD treatments orincreased off-label usage, which may have re-sulted in the true costs associated with ADHDbeing overestimated (if such new treatmentsand/or usage save costs) or underestimated (ifsuch new treatments and/or usage do not offsetall their additional costs). Furthermore, the prev-alence of ADHD has been reported to be increas-ing over time.3 It is unclear whether this isbecause the incidence of ADHD itself has in-creased or if the recognition and diagnosis ofADHD has increased over time in the U.S. pop-ulation.3 If the former, then the total incrementalcosts associated with ADHD in the United States

FIGURE 2 Annual national incremental costs ofattention-deficit/hyperactivity disorder (ADHD) (inbillions) by cost sectors within age groups. Note: Theinner circle represents the lower end of the range ofcosts. The outer circle represents the higher end of therange of costs.

DOSHI et al.


may have also increased over time (because thepopulation with ADHD times the mean incre-mental costs equals the total incremental costs). Ifthe latter, then the incremental costs of ADHDmay be lower than estimated to the extent thatpreviously undiagnosed patients had less severeADHD (and, hence, went unrecognized) orhigher than estimated if these patients indeedhad more severe ADHD (because their ADHDwas not recognized and treated early on). Fourth,the prevalence of ADHD has been reported tovary considerably across the United States. Thepresent study estimated the average economicimpact of ADHD at the national level; however,the costs in individual states (and counties) maybe higher or lower.

Nevertheless, the present results underscore thatthe economic cost of ADHD is substantial. Themagnitude of this burden can be put into perspec-tive by comparing it with the burden imposed byother chronic conditions, although such compari-sons should be made with caution because meth-odologies differ across studies and other studies donot always include all costs outside the healthsector. Greenberg et al.54 estimated that major de-pression costs $83.1B annually ($$124B in 2010 U.S.dollars). Wittchen55 estimated that generalized anx-iety disorder costs range from $42B to $47B($$139B!$155.5B in 2010 U.S. dollars). Weiss andSullivan56 estimated the total societal cost ofasthma as $12.7B ($$20.4B in 2010 U.S. dollars).

Several noteworthy findings of this study haveimportant clinical and policy implications. Unlikemany other conditions, health care costs constituteonly one fourth to one third of the overall incre-mental costs associated with ADHD. The remain-der of the costs occurred in non-health care sectors.Thus, the decreases in the cost burden of ADHDowing to additional investments in improving thediagnosis and management of this condition arenot all accrued by the third-party payer or healthinsurer, thus decreasing their incentive to bear theentire cost of such investments. Given the substan-tial societal costs of ADHD incurred in the work-force, education, and justice system sectors, it isnecessary to develop public policies to lessen theburden associated with this condition.

The present results are also the first to highlightthe magnitude of the large share of costs associatedwith ADHD as it progresses into adulthood. Nota-bly, the national incremental costs for adults werealmost three times higher than those for childrenand adolescents. This is due to a combination of a

larger absolute number of adults than children andadolescents and the differences in cost sectorswherein the costs are incurred by these groups. Thelatter point suggests that a “one size fits all” ap-proach to decreasing the burden of ADHD is un-likely to be successful and one should consider theage group and cost sector and target policies orinitiatives accordingly.

Workforce productivity costs in adults withADHD are the single largest contributor to theeconomic burden associated with the condition,amounting to $87B to $138B and accounting formore than 70% to 80% of the overall adult ADHDcosts. The vast majority of these costs were attrib-utable to income losses owing to lack of full timeemployment and/or lower wages when employed,as estimated by Biederman and Faraone.34 Thesame study also reported that individuals withADHD were significantly more likely to reportpoorer grades in high school, less likely to graduatefrom high school or college, or less likely to havecompleted a postgraduate degree compared withcontrol subjects.34 This implies that the lack of anearly or accurate diagnosis of ADHD or medicaltreatment and educational interventions duringchildhood or adolescence extracts a substantial eco-nomic burden in adulthood. Appropriate policiesor interventions need to be targeted in childhood/adolescence to increase the potential for improvingeducational milestones and decreasing workforceproductivity losses in adulthood.

The remainder of the workforce productivitycosts were largely incurred owing to decreasedproductivity at work in employed adults withADHD compared with healthy controls withoutADHD. Despite the substantial toll of ADHD onthe workplace, some private insurers do not coverany costs for ADHD treatments for adult patients.57

Such policies create barriers to care and may de-crease workplace productivity. Ideally, policiesshould be created that incentivize third-party pay-ers to consider all types of economic costs of adultADHD when evaluating the cost-effectiveness ofcoverage and treatments. Self-insured employers inparticular should consider these various economiceffects, because increases in health care costs thateffectively diagnose and treat ADHD may decreaselosses in worker productivity. Because most eco-nomic costs are incurred by adults with ADHDwithin the workplace, efforts to decrease the overalleconomic burden of ADHD should focus withinthis area. Opportunities to create partnerships be-tween payers, employers, and patients would be an



effective first step and would better align all partiestoward the goal of reducing ADHD burden.

The study is also the first to highlight that familyspillover costs are a substantial proportion of totalADHD costs (16%!23%). The vast majority ofthese costs ($95%) are incurred within the healthcare system and point to the larger potential bene-fits of improved diagnosis and management ofADHD. Swensen et al.25 suggested these familymembers use more office services, outpatient ser-vices, and mental-disorder-specific care. Further,the symptomatology associated with improperlytreated ADHD can carry an emotional burden tothe patient7,58 and the patient’s family59 beyond theeconomic burden described here.

Educational costs amounting to $15B to $25B werea large contributor of incremental costs in children/adolescence after health care-related costs. Althoughthese amounts are likely underestimates for thereasons noted earlier, the vast majority of the incre-mental costs of education identified in the includedstudies were still due to special education. Thus,research is clearly needed to examine whether earlydiagnosis and evidence-based medication and be-havioral treatments in childhood decrease the fu-ture need for special education services and down-stream costs. Moreover, research to identifyappropriate interventions within the educationalsettings could provide an evidence base to betterunderstand whether such programs save or in-crease costs in children and adolescents withADHD, and if such programs do increase costs,whether the benefits to education produce down-stream savings through adult ADHD worker pro-ductivity and/or salary gains. Research to provideeducators and parents the information to betteridentify early signs of ADHD would be helpful tolimiting the impact of the illness in early life andpossible future life trajectory.

Future research should also focus on better un-derstanding the ADHD costs and the costs andbenefits of interventions in targeted age groups andcost sectors. Specifically, research is needed to bet-ter understand the economic impact of ADHD inunstudied or understudied areas such as substanceabuse, traffic accidents, and justice system use. Inaddition, studies using more recent data areneeded to capture costs in light of the increasingprevalence and/or diagnosis of ADHD over time3

and current ADHD treatment patterns includingthe increasing use of newer ADHD medications,adjunctive therapy, and off-label prescribing. Fur-ther research is also needed to understand how the

early diagnosis and treatment of ADHD can ame-liorate these costs and inform future policies andinterventions.

In conclusion, this comprehensive review pointsto the large economic burden of ADHD in theUnited States and to the multifaceted nature ofADHD costs. Given the substantial societal costsof ADHD, public policy to address the burden ofthe condition is warranted. Moreover, furtherresearch to better understand ADHD costs andthe costs and benefits of interventions is warranted.Programs to facilitate collaboration among payers,patients, employers, and educational institutionsmay provide opportunities to create strategies toconsider the societal impact of ADHD and strate-gies to mitigate its burden. &

Clinical Guidance

• Overall, the national annual incremental costs ofADHD were substantial, ranging from $143B to$266B. Patients with ADHD and families ofpatients with ADHD incurred costs associated withADHD.

• The present results highlight the societal costs ofADHD as it progresses into adulthood. Most ofthese costs were incurred by adults($105B!$194B) compared withchildren/adolescents ($38B!$72B).

• The societal costs of ADHD were multifaceted,including four major cost categories: health care,education, productivity, and justice system costs.For adults, the largest cost category wasproductivity and income losses ($87B!$138B).For children, the largest cost categories werehealth care ($21B!$44B) and education($15B!$25B).

• Given the substantial and multifaceted societal costsof ADHD, the development of public policies toaddress the burden of the condition is warranted.

Accepted July 17, 2012.

Dr. Doshi is with the Perelman School of Medicine, University ofPennsylvania. Drs. Hodgkins, Sikirica, Erder, and Setyawan are withGlobal Health Economics and Outcomes Research, Shire Develop-ment LLC. Dr. Kahle is with BPS International. Dr. Neumann and Mr.Cangelosi are with the Center for the Evaluation of Value and Risk inHealth, Tufts Medical Center.

This work was funded by Shire Development LLC. Dr. Doshi’s consul-tancy work on this project was supported by Shire Development LLC.

The authors thank Dr. Joshua T. Cohen, Tufts Medical Center, for hishelpful comments on an earlier draft of this article.

Disclosure: Dr. Doshi has served as a consultant to Shire, Forest, andBristol-Myers Squibb, has received research support from Pfizer, and

DOSHI et al.


reports stock ownership in Merck and Co. Dr. Kahle has receivedconsultancy fees from Shire. Drs. Hodgkins, Sikirica, Erder, andSetyawan report stock ownership in Shire and/or have been grantedShire stock options. Dr. Neumann is the founding director of the TuftsMedical Center Cost-Effectiveness Analysis (CEA) Registry, a publiclyavailable database of published cost-utility analyses. The databasehas been supported through a variety of grants from the Agency forHealth Research and Quality, the National Library of Medicine, andthe National Science Foundation. It also receives unrestricted grantfunding from external sponsors listed on the registry’s website (http://www.cearegistry.org), including Amgen, Bayer Healthcare, Biogen,Bioscience, Boston Scientific, Covidien, Daichi-Sankyo, EMD Serono,

Endo, Express-Scripts, GE Healthcare, Johnson and Johnson, LundbeckSA, Medtronic, Merck, Millennium, Novartis, Teva North America,Shire, and Pfizer. Mr. Cangelosi reports no biomedical financialinterests or potential conflicts of interest.

Correspondence to Jalpa A. Doshi, Ph.D., University ofPennsylvania, Blockley Hall, Room 1222, 423 Guardian Drive,Philadelphia, PA 19104-6021; e-mail: [email protected]

0890-8567/$36.00/©2012 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2012.07.008

REFERENCES1. American Psychiatric Association. Diagnostic and Statistical Man-

ual of Mental Disorders. 4th ed; text revision ed. Washington, DC:American Psychiatric Association; 2000.

2. O’Connell ME, Boat T, Warner KE. National Research Council(US) and Institute of Medicine (US) Committee on the Preventionof Mental Disorders and Substance Abuse Among Children,Youth and Young Adults. Preventing Mental, Emotional, andBehavioral Disorders Among Young People: Progress and Possi-bilities. Washington, DC: National Academy of Sciences; 2009.

3. US Centers for Disease Control. Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep.2010;59:1439-1443.

4. Loe M, Feldman HM. Academic and educational outcomes ofchildren with ADHD. Ambul Pediatr. 2007;7:82-90.

5. Biederman J, Faraone SV, Spencer TJ, Mick E, Monuteaux MC,Aleardi M. Functional impairments in adults with self-reports ofdiagnosed ADHD: a controlled study of 1001 adults in thecommunity. J Clin Psychiatry. 2006;67:524-540.

6. Hoza B. Peer functioning in children with ADHD. Ambul Pediatr.2007;7:101-106.

7. Coghill D. The impact of medications on quality of life inattention-deficit hyperactivity disorder: a systematic review. CNSDrugs. 2010;24:843-866.

8. Kessler RC, Adler L, Barkley R, et al. The prevalence andcorrelates of adult ADHD in the United States: results from theNational Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716-723.

9. Hodgkins P, Arnold LE, Shaw M, et al. A systematic review ofglobal publication trends regarding long-term outcomes ofADHD. Front Psychiatry. 2011;2:84.

10. Birnbaum HG, Kessler RC, Lowe SW, et al. Costs of attentiondeficit-hyperactivity disorder (ADHD) in the US: excess costs ofpersons with ADHD and their family members in 2000. Curr MedRes Opin. 2005;21:195-206.

11. Matza LS, Paramore C, Prasad M. A review of the economicburden of ADHD. Cost Eff Resour Alloc. 2005;3:5-13.

12. Pelham WE, Foster EM, Robb JA. The economic impact ofattention-deficit/hyperactivity disorder in children and adoles-cents. J Pediatr Psychol. 2007;32:711-727.

13. Leibson CL, Long KH. Economic implications of attention-deficithyperactivity disorder for healthcare systems. Pharmacoeconom-ics. 2003;21:1239-1262.

14. Higgins JPT, Green S. Cochrane Handbook for Systematic Re-views of Interventions Version 5.0.2. Baltimore, MD: The Co-chrane Collaboration; 2009.

15. Centre for Reviews and Dissemination. Systematic Reviews:CRD’s Guidance for Undertaking Reviews in Health Care. 16.York, UK: University of York; 2009.

16. Barkley RA, Murphy KR, Dupaul GI, Bush T. Driving in youngadults with attention deficit hyperactivity disorder: knowledge,performance, adverse outcomes, and the role of executive func-tioning. J Int Neuropsychol Soc. 2002;8:655-672.

17. Meyers J, Classi P, Wietecha L, Candrilli S. Economic burden andcomorbidities of attention-deficit/hyperactivity disorder amongpediatric patients hospitalized in the United States. Child AdolescPsychiatry Ment Health. 2010;4:31.

18. Forness S, Kavale K. Impact of ADHD on school systems. In:Jensen P, Cooper J, eds. Attention Deficit Hyperactivity Disorder.Kingston, NJ: Civic Research Institute; 2002:21-30.

19. Kelleher KJ, Childs GE, Harman JS. Healthcare cost for childrenwith attention-deficit/hyperactivity disorder. Econ Neurosci.2001;3:60-63.

20. Hinnenthal JA, Perwien AR, Sterling KL. A comparison of serviceuse and costs among adults with ADHD and adults with otherchronic diseases. Psychiatr Serv. 2005;56:1593-1599.

21. Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O’Brien PC. Useand costs of medical care for children and adolescents with andwithout attention-deficit/hyperactivity disorder. JAMA. 2001;285:60-66.

22. Kleinman NL, Durkin M, Melkonian A, Markosyan K. Incremen-tal employee health benefit costs, absence days, and turnoveramong employees with ADHD and among employees withchildren with ADHD. J Occup Environ Med. 2009;51:1247-1255.

23. Jones DE, Foster EM. Service use patterns for adolescents withADHD and comorbid conduct disorder. J Behav Health Serv Res.2009;36:436-449.

24. Fletcher J, Wolfe B. Long-term consequences of childhood ADHDon criminal activities. J Ment Health Policy Econ. 2009;12:119-138.

25. Swensen AR, Birnbaum HG, Secnik K, Marynchenko M, Green-berg P, Claxton A. Attention-deficit/hyperactivity disorder: in-creased costs for patients and their families. J Am Acad ChildAdolesc Psychiatry. 2003;42:1415-1423.

26. Fischer M, Barkley R. Young adult outcomes of children withhyperactivity: leisure, financial, and social activities. Int J DisabilDev Educ. 2006;53:229-245.

27. Mandell DS, Guevara JP, Rostain AL, Hadley TR. Economicgrand rounds: medical expenditures among children with psy-chiatric disorders in a Medicaid population. Psychiatr Serv.2003;54:465-467.

28. US Department of Labor. Consumer price index. ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt. Accessed November 16,2011.

29. American Diabetes Association. Economic costs of diabetes in theU.S. in 2007. Diabetes Care. 2008;31:596-615.

30. Choi BK, Pak AW. A method for comparing and combiningcost-of-illness studies: an example from cardiovascular disease.Chronic Dis Can. 2002;23:47-57.

31. US Census Bureau. 2010 Census summary file 1: QT-P1 age groups andsex: 2010. US Census Bureau; 2010. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid"DEC_10_SF1_QTP2&prod. Accessed on October 8, 2011.

32. US Bureau of Labor Statistics. Employment status of the civiliannoninstitutional population by age, sex, and race; 2010. http://bls.gov/opub/ee/2011/cps/annavg3_2010.pdf. Accessed on Oc-tober 27, 2010.

33. US Census Bureau. AVG3. Average number of people per familyhousehold with own children under 18, by race and Hispanicorigin, marital status, age, and education of householder: 2010;2010. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid"DEC_10_SF1_QTP11&prod. Accessed onOctober 28, 2011.

34. Biederman J, Faraone SV. The effects of attention-deficit/hyperactivity disorder on employment and household income.Med Gen Med. 2006;8:12.



http://www.cearegistry.org

http://www.cearegistry.org

mailto:[email protected]

http://dx.doi.org/10.1016/j.jaac.2012.07.008

ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt

ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt

http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_SF1_QTP2%26prod



http://bls.gov/opub/ee/2011/cps/annavg3_2010.pdf

http://bls.gov/opub/ee/2011/cps/annavg3_2010.pdf



35. Marks DJ, Mlodnicka A, Bernstein M, Chacko A, Rose S, HalperinJM. Profiles of service utilization and the resultant economicimpact in preschoolers with attention deficit/hyperactivity disor-der. J Pediatr Psychol. 2009;34:681-689.

36. Robb J, Sibley M, Pelham W, et al. The estimated annual cost ofADHD to the US education system. School Mental Health.2011;3:169-177.

37. Guevara J, Lozano P, Wickizer T, Mell L, Gephart H. Utilizationand cost of health care services for children with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:71-78.

38. Chan E, Zhan C, Homer CJ. Health care use and costs for childrenwith attention-deficit/hyperactivity disorder: national estimatesfrom the medical expenditure panel survey. Arch Pediatr AdolescMed. 2002;156:504-511.

39. Burd L, Klug MG, Coumbe MJ, Kerbeshian J. Children andadolescents with attention deficit-hyperactivity disorder: 1. Prev-alence and cost of care. J Child Neurol. 2003;18:555-561.

40. Swensen A, Birnbaum HG, Ben Hamadi R, Greenberg P, Cre-mieux PY, Secnik K. Incidence and costs of accidents amongattention-deficit/hyperactivity disorder patients. J AdolescHealth. 2004;35:346-349.

41. Kessler RC, Adler L, Ames M, et al. The prevalence and effects ofadult attention deficit/hyperactivity disorder on work perfor-mance in a nationally representative sample of workers. J OccupEnviron Med. 2005;47:565-572.

42. Secnik K, Swensen A, Lage MJ. Comorbidities and costs of adultpatients diagnosed with attention-deficit hyperactivity disorder.Pharmacoeconomics. 2005;23:93-102.

43. Ray GT, Levine P, Croen LA, Bokhari FA, Hu TW, Habel LA.Attention-deficit/hyperactivity disorder in children: excess costsbefore and after initial diagnosis and treatment cost differencesby ethnicity. Arch Pediatr Adolesc Med. 2006;160:1063-1069.

44. Fishman PA, Stang PE, Hogue SL. Impact of comorbid attentiondeficit disorder on the direct medical costs of treating adults withdepression in managed care. J Clin Psychiatry. 2007;68:248-253.

45. Hodgkins P, Montejano L, Sasane R, Huse D. Cost of illness andcomorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis [published onlineApril 14, 2011]. Prim Care Companion CNS Disord. 2011;13. doi:10.4088.

46. Kessler RC, Lane M, Stang PE, Van Brunt DL. The prevalence andworkplace costs of adult attention deficit hyperactivity disorderin a large manufacturing firm. Psychol Med. 2009;39:137-147.

47. Thompson AL, Molina BS, Pelham W Jr, Gnagy EM. Riskydriving in adolescents and young adults with childhood ADHD.J Pediatr Psychol. 2007;32:745-759.

48. Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years:prospective follow-up of children treated for combined-type ADHD ina multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48:484-500.

49. Tarter RE, Kirisci L, Feske U, Vanyukov M. Modeling the path-ways linking childhood hyperactivity and substance use disorderin young adulthood. Psychol Addict Behav. 2007;21:266-271.

50. Mannuzza S, Klein RG, Moulton JL III. Young adult outcome ofchildren with “situational” hyperactivity: a prospective, con-trolled follow-up study. J Abnorm Child Psychol. 2002;30:191-198.

51. Hinshaw SP, Owens EB, Sami N, Fargeon S. Prospectivefollow-up of girls with attention-deficit/hyperactivity disorderinto adolescence: evidence for continuing cross-domain impair-ment. J Consult Clin Psychol. 2006;74:489-499.

52. Spencer TJ, Biederman J, Mick E. Attention-deficit/hyperactivitydisorder: diagnosis, lifespan, comorbidities, and neurobiology.Ambul Pediatr. 2007;7:73-81.

53. Burd L, Klug MG, Coumbe MJ, Kerbeshian J. The attention-deficit hyperactivity disorder paradox: 2. Phenotypic variabil-ity in prevalence and cost of comorbidity. J Child Neurol.2003;18:653-660.

54. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economicburden of depression in the United States: how did it changebetween 1990 and 2000? J Clin Psychiatry. 2003;64:1465-1475.

55. Wittchen HU. Generalized anxiety disorder: prevalence, burden,and cost to society. Depress Anxiety. 2002;16:162-171.

56. Weiss KB, Sullivan SD. The health economics of asthma andrhinitis. I. Assessing the economic impact. J Allergy Clin Immu-nol. 2001;107:3-8.

57. Aldridge AP, Kroutil LA, Cowell AJ, Reeves DB, Van Brunt DL.Medication costs to private insurers of diversion of medicationsfor attention-deficit hyperactivity disorder. Pharmacoeconomics.2011;29:621-635.

58. Danckaerts M, Sonuga-Barke EJ, Banaschewski T, et al. Thequality of life of children with attention deficit/hyperactivitydisorder: a systematic review. Eur Child Adolesc Psychiatry.2010;19:83-105.

59. Angold A, Messer SC, Stangl D, Farmer EM, Costello EJ, BurnsBJ. Perceived parental burden and service use for child andadolescent psychiatric disorders. Am J Public Health. 1998;88:75-80.

DOSHI et al.


Table S1Search TermsOutcomes of Interest Search Terms to Capture Outcomes

ADHD subjects in allcountries

ADHD or ADD or attention deficit or hyperkine* or TDAH or DAH or DAA

Cost analysis or economicimpact

cost* or burden or econom* or expen* or budget or financ* or pharmacoeconom*

Productivity losses productiv* or absen* or presen* or inefficien* or efficien* or work performance or jobperformance or work loss or lost work or human capital or income or employ* orunemploy* or socioeconomic status or SES or occupational scale or public assistanceor disability benefit* or *term disability or workm?ns comp* or workers comp*

General services use resource use or resource utili* or service*Health care use care or physician visit* or doctor visit* or physician encounter* or doctor encounter*

or outpatient visit* or inpatient visit* or inpatient admission* or emergency orhospital* or day case or *care

Accidents accident* or injur* or casualty or traffic behave* or traffic violationEducation special education or special need* or Section 504 or IDEA or education plan or

school psych* or remedial education or special class*Drug abuse drug rehab* or Substance-Related Disorders/epidemiology/psychology/rehabilitation

or treatment seek* or seeking treatment or substance abuse treatment facilit* orsubstance abuse program or (illicit drug or substance abuse or substance-relateddisorders and treatment)

Criminal behavior justice system or juvenile or incarcerat* or delinquen* or institution* or prison* oroffender pathway or criminal behavior

Note: ADD " attention-deficit disorder; ADHD " attention deficit/hyperac-tivity disorder; DAA " déficit de l’attention/activité in French or déficit deatención y actividad in Spanish; DAH " déficit de l’attention/hyperactivité inFrench or déficit de atención con hiperactividad in Spanish; IDEA " Individ-uals with Disabilities Education Act; TDAH " trouble déficit de l’attention/hyperactivité in French or trastorno por déficit de atención con hiperactividadin Spanish.


JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 51 NUMBER 10 OCTOBER 2012 1002.e1www.jaacap.org

Figure S1Consort diagram of articles meeting inclusion criteria. Note: ADHD" attention deficit/hyperactivity disorder.

DOSHI et al.

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 51 NUMBER 10 OCTOBER 20121002.e2 www.jaacap.org

economic impact of childhood and adult attention-deﬁcit ... · ﬁculties, criminal activity,...

Documents