The American Medical System Fails Patients With ADHD

ADHD: Disparate Disease or Disparate Care?

Attention-deficit/hyperactivity disorder (ADHD) is well recognized for its deleterious effects on the medical and social well-being of children and adults, and it constitutes a major public health concern in the United States. However, a recent study^[1] by McDonald and Jalbert suggests that there are substantial disparities in the prevalence of ADHD in different geographic regions of the country. Some of this effect is a consequence of economic factors and the distribution of providers, but the data make it clear that we need a more equitable approach to the problem of ADHD.

A Common and Costly Diagnosis

ADHD is one of the most common psychiatric diagnoses in the United States. In a 2012 meta-analysis of 86 studies that included a total of nearly 164,000 children, the prevalence of ADHD was between 5.9% and 7.1% among children and adolescents.^[2] This value remained consistent when researchers evaluated different diagnostic tools for ADHD.

ADHD persists from childhood into adulthood in 40%-60% of patients. While the ratio of boys to girls with ADHD is approximately 4:1, the prevalence of adult ADHD is more evenly balanced among adult men and women.^[3] The authors of this recent study examining geographic variations in prevalence estimate that the overall prevalence of ADHD among adults in the United States is 2.9%-5.2%.^[1] However, in a study evaluating the Kaiser Permanente Southern California health database, with a total of more than 3.5 million members, the prevalence of ADHD was only 0.36% in 2006, though the figure increased to 0.65% in 2009.^[4] This very low prevalence overall speaks to some of the challenges in accurately assessing ADHD.

ADHD is associated with substantial reductions in quality of life. A study of 165 Canadian children found that ADHD negatively affected emotional well-being, behavior, and self-esteem.^[5] Parents of children with ADHD had worse emotional health compared with their peers, and ADHD damaged family communication and cohesion. Comorbid psychiatric illness was prevalent among 68.7% of children with ADHD, with learning disorders and conduct/oppositional-defiant disorders accounting for most of these conditions.

ADHD also has a significant effect on education. A study comparing 404 children with ADHD with 394 children without ADHD found respective rates of having to repeat a grade during high school of 28% and 7%.^[6] The risk for poor academic performance associated with ADHD persisted after adjustment for multiple variables, and ADHD had a more profound effect on girls' school performance than on boys'.

ADHD carries other risks for youth. In a longitudinal study of 1615 children with ADHD, children with ADHD were more than 3 times more likely to be involved with the criminal justice system, and ADHD increased the risk of dropping out of school when compared with control children without ADHD.^[7] The odds ratio for significant functional impairment in these children was 3.4. ADHD during adolescence is not only associated with worse subjective ratings of mental and physical health during adulthood but with impaired work performance and greater financial stress as well.^[8]

Nonetheless, a recent study suggested that ADHD during childhood is not an independent risk factor for early mortality or mortality from accidents. However, ADHD is associated with a more than 4-fold increase in the risk for suicide compared with controls.^[9]

In addition to the negative consequences for individual patients, ADHD also exacts a heavy toll on families and society. ADHD among adults does not necessarily result in greater marital and family dysfunction, but one study found a greater proportion of maladjustment among the spouses of adults with ADHD.^[10] Moreover, the person in the relationship who had ADHD was more likely to view the marriage negatively.

The estimated annual cost of ADHD to the US economy is between $143 and $266 billion.^[11] Adult ADHD accounts for more than double the economic cost of childhood ADHD, with most of the loss coming in the form of reduced work productivity.

Given the high prevalence and significant consequences of ADHD, there should be a concerted public health effort to identify and treat this disease appropriately. However, as a result of the substantial variability in epidemiologic studies of ADHD, diagnosis is not always commensurate with treatment. The 2013 study examining geographic distribution highlights disturbing findings with respect to the treatment of ADHD, and it describes the underpinnings of these disparities in diagnosis.^[1]

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