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Ethical Economics

Ethical Economics Hyperactivity disorder called costly for adults
By Esther Landhuis
San Jose (Calif.) Mercury News Sept. 13, 2004

More than just classroom squirming and missed appointments, attention deficit hyperactivity disorder (ADHD) is taking a toll on relationships, employment -- and, ultimately, our wallets.

The first comprehensive analysis of the disorder's economic impact blames ADHD for $77 billion in lost household income nationwide each year, ahead of drug abuse ($58 billion) and depression ($44 billion), according to Harvard psychiatrist Joseph Biederman.

"ADHD is one of the costliest medical conditions that we have," Biederman said Thursday as he presented the study's findings at an American Medical Association media briefing in New York City. "The impact on quality of life is extraordinarily profound -- from marriage to friendship to ability to make a living."

Countering a long-held belief that the condition afflicts no one but children, the study estimates that 4 percent of adult Americans -- about 8 million people -- struggle with the inattention, impulsiveness and hyperactivity that characterize ADHD. These traits directly or indirectly make it harder for people to hold jobs, or to advance to better jobs, the study suggests.

According to the new analysis -- consisting of 25-minute phone interviews with 500 U.S. adults with ADHD and 501 controls matched for age, sex and educational level -- high school graduates with the disorder have average annual household incomes nearly $11,000 lower than those of their non-ADHD counterparts.

Adults with ADHD were less likely to have finished high school and more susceptible to substance abuse, the study found. They also had higher divorce rates and reported lower self-esteem than those without the condition.

Even worse, about 80 percent of adults with ADHD don't know they have it, Biederman said.

A debate still rages over whether ADHD is under-diagnosed or over-diagnosed. "There's evidence for both, in part because we keep changing the definition," said Glen Elliott, director of the Children's Center at Langley Porter Psychiatric Institute at the University of California-San Francisco.

Citing similar trends in the refinement of benchmark standards for other health conditions like blood pressure and cholesterol levels, he attributes the capricious ADHD definition to "a changing understanding of where something turns from normal to worrisome and potentially dangerous."

In the 1960s, experts estimated that up to 20 percent of schoolchildren had ADHD, Elliott said. Today, the National Institutes of Health places that figure closer to 5 percent. Intensifying the confusion was a steep rise in the number of prescriptions written for stimulant medications to treat ADHD in the 1990s.

The public's perception of how treatable a condition is could also prompt changes in the disorder's prevalence. "As a nation, we sometimes get diagnosis-happy," Elliott said. "We want a label for everything that isn't right."

At the other end of the spectrum are those who speculate that disorders are "created" so pharmaceutical companies can sell more drugs. The issue becomes especially acute for psychiatric conditions, such as ADHD, where an increasing number of cases are being treated with medications rather than with social and behavioral interventions.

Experts say it's important to get a comprehensive evaluation from a licensed medical professional. "We can't just put a label of ADHD on any child who's disruptive or has attention issues," said David Fassler, a child psychiatrist at the University of Vermont. "Individual criteria can apply to any child. We are looking for a cluster of symptoms."

Clinical studies have shown that 80 to 90 percent of children diagnosed with ADHD can be improved by medication -- the costs of which are generally covered by insurance -- but not everyone welcomes the changes wholeheartedly.

Santa Cruz resident Kurt Nickerson has a 17-year-old son who took ADHD medications when he was diagnosed with the condition in elementary school. "He was a little more attentive in class, but he was a little less alive," Nickerson said. "It kind of took the spunk out of him. It mellowed him down."

Nickerson, who has ADHD himself, feels similarly about the medications he tried initially. "I felt like my head was a little clearer," he said, "but I didn't feel the same old me and I missed that."

In the end, amid ongoing discussion over the social and economic impact of ADHD, "the key issue is therapeutics," Biederman said. "If you treat, then the person might be able to succeed more in school and in life."

Contact Esther Landhuis at elandhuis@mercurynews.com or (408) 920-5458.

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