Gloria Kay Vanderhorst, Ph.D.
ADHD is a life long condition. Like other chronic conditions, interventions lead to improvements and early interventions are beneficial. Edward Hallowell, M.D., a leading expert in ADHD, is a strong advocate for early identification because he recognizes the emotional damage caused by the child’s experience of frustration and failure and the pain of being labeled as ‘stupid’ or ‘difficult’. When identification is delayed, emotional costs easily translate into higher social costs. The price we all pay can be examined by looking at four areas of social significance: work force productivity costs, direct and indirect medical costs, auto accident related costs, and incarceration costs.
Work force productivity can be examined by looking at educational success and household income figures. According to studies conducted by Joseph Bierderman, M.D., professor of psychiatry at Harvard Medical School, ADHD is present in over 8 million adults or 4.3% of the adult population in the United States. These adults tend to be undereducated with fewer graduating from high school. Those who do graduate are less likely to finish college or go on to complete graduate degrees. Therefore, they end up under-employed and more frequently experience periods of unemployment throughout their working years, resulting in a dramatic loss of household income. A 2003 survey estimated that the annual loss of household income attributable to ADHD ranged from $67 billion to $116 billion. For an impact comparison, consider that the medical cost associated with cigarette smoking in the United States in 1998 was approximately this same amount when the country began to declare legal warfare on the tobacco industry.
The direct and indirect medical costs associated with ADHD are related to work force productivity and comorbid conditions. Workers Compensation claims are higher among adults with ADHD and unofficial absences from work are four times more prevalent in this population. A 2000 study extrapolated to the national level from data for a large corporation indicated that employers spend $13.7 billion for medical costs related to employees with ADHD. When you add in the cost of comorbid disorders, the price nearly triples. Adults with ADHD are more often diagnosed with asthma, anxiety, bipolar disorder, depression, drug or alcohol abuse, antisocial or oppositional behavior. The medical impact of these comorbidities costs an employer three times more medical dollars than they would spend on an employee without ADHD. The estimated total cost for employers in the United States for the year 2000 was $31.6 billion.
The social impact of lost work productivity and associated medical costs should cause us to mobilize our resources to intervene earlier. However, neither of these has the life threatening impact that has been associated with auto accidents. Automobile accidents are the leading cause of death among teens between the ages of 15 and 20. This statistic has resulted in some states increasing the legal age for obtaining a driver’s license. According to a study at the University of Virginia, teens with ADHD are two to eight times more likely to have an auto accident and four times more likely to be at fault for the accident. When teenage passengers are in the car, the likelihood of an accident increases along with the fatality rate. According to Russell Barkley, Ph.D. teens with untreated ADHD have a higher incidence of traffic violations than their peers, especially speeding. In 2005, the Insurance Information Institute noted the average cost of an auto accident involving bodily injury was more than $10,000. Jury awards in auto liability cases are also a factor in the social cost of auto accidents. According to Jury Verdict Research in 2003, which is the most recent year for complete data, the average jury award in personal injury auto accident cases was $261,000. The insurance industry spent over $4.1 billion defending their policy holders in liability cases in 2004 and that cost has continued to rise in 2005 and 2006. For insurance premiums that translates into about 60% of the cost. None of these surveys can calculate the social cost of the lives lost.
Lost lives are also visible in the justice system where people with ADHD comprise almost 40% of the population. A recent study by Dr. Paul H. Wender in the state of Utah prison system indicated that inmates with ADHD are often misdiagnosed with bipolar disorder or depression. The total prison population across ages and types of incarceration in the United States today is approximately 1.71 million people. This is the highest rate of incarceration for any industrialized nation in the world today. The only nation to remotely approach this rate was South Africa during apartheid. In fiscal year 2005, maintaining one inmate in a Federal Bureau of Prisons facility cost $23,431.92 and $20,843.78 to keep a Federal inmate incarcerated in a community correction center. That means that the country was spending over $40 trillion to house Federal prisoners in 2005 and if 40% of those have ADHD, we are spending over $16 trillion on that population alone.
Each of these social costs is significant by themselves: lost income of $67 billion to $116 billion, corporate medical costs of $31.6 billion, incarceration costs of $16 trillion and uncountable loss of life due to auto accidents. Where is the outcry for early identification and intervention to aid us in reducing these costs? Most children are not identified until they attend elementary school at age six and here the identification favors boys who are physically acting out or have difficulty following the rules. Often children are not identified until the 4th grade when the child’s performance is no longer heavily dependent on memorization, repetition and basic skills. This pattern of later identification still neglects the needs of most girls as well as boys who are academically gifted and more inattentive than hyperactive. Many girls go undiagnosed until late high school or college.
Why don’t we require screening for ADHD at the preschool level? A major deterrent for early identification has been fueled by parents, teachers and pediatricians who see the symptoms of ADHD as too close to the developmental characteristics of the typical preschool child: high energy, impulsivity, and a short attention span. The lack of knowledge about the life long cost of ADHD also contributes to this failure of early identification and intervention. Multiple research studies clearly point out that early experience is critical in brain development and shaping later behavior; therefore, early assessment for ADHD is critical for later success. A thorough physical examination, neuropsychological battery, full family history and clinical observation of the child can discern between the normal exuberance of a preschooler and the processing difficulties of an ADHD child. The cost of delaying assessment is too high a price for the individual and for our society.
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