The Economic Impact of Attention-Deficit/Hyperactivity Disorder
in Children and Adolescents
William E. Pelham,1 PHD, E. Michael Foster,2 PHD and Jessica A. Robb,1 BA
1
Department of Psychology, Center for Children and Families, State University of New York at Buffalo,
Buffalo, NY and 2School of Public Health, University of North Carolina, Chapel Hill, NC.
Using a cost of illness (COI) framework, this article examines the economic impact of attention-deficit/
hyperactivity disorder (ADHD) in childhood and adolescence. Our review of published literature identified
13 studies, most conducted on existing databases by using diagnostic and medical procedure codes and
focused on health care costs. Two were longitudinal studies of identified children with ADHD followed into
adolescence. Costs were examined for ADHD treatment-related and other health care costs (all but 1 study
addressed some aspect of health care), education (special education, 2 studies; disciplinary costs: 1 study),
parental work loss (2 studies), and juvenile justice (2 studies). Based on this small and as yet incomplete
evidence base, we estimated annual COI of ADHD in children and adolescents at $14,576 per individual
(2005 dollars). Given the variability of estimates across studies on which that number is based, a reasonable
range is between $12,005 and $17,458 per individual. Using a prevalence rate of 5%, a conservative estimate
of the annual societal COI for ADHD in childhood and adolescence is $42.5 billion, with a range between
$36 billion and $52.4 billion. Estimates are preliminary because the literature is incomplete; many
potential costs have not been assessed in extant studies. Limitations of the review and suggestions for
future research on COI of ADHD are provided.
Key words attention-deficit/hyperactivity disorder; cost of illness; economic impact.
Attention-deficit/hyperactivity disorder (ADHD) is among
the most common mental health (MH) disorders of
childhood; prevalence rates range from 2% to 9%.1 By
definition, children with ADHD lag children of the same
age in sustained attention, impulse control, and modulation of activity level. These symptoms begin at an early
age, are displayed across environments, and continue
throughout the lifespan.2 Importantly, they lead to a host
of limitations within multiple domains of life, including
adult relationships (e.g., noncompliance with parent and
teacher requests), school functioning (e.g., classroom
disruption and poor achievement), and peer and sibling
relationships (e.g., annoying, intrusive, overbearing, and
aggressive behaviors). These difficulties lead to serious
limitations in life functioning not only for the children
with ADHD but also for their peers, families, and schools.
Further, for the great majority of children with ADHD,
these limitations in daily functioning persist across
adolescence and into adulthood (e.g., vocational underachievement, interpersonal problems, substance use, and
criminal activity), even though their core symptomatology
(e.g., inattention) may improve with age.3–6
Children and youth with ADHD use services across
a range of child-serving systems. The disorder is among
the most common referring problems in primary care
settings.7 In the educational system, ADHD is among the
most common diagnoses in special educational settings
and is the major behavioral problem regular education
teachers face.8 In addition, ADHD is one of the most
common diagnoses in MH settings for children.9 Its high
prevalence, chronicity, and substantial impact on daily
life functioning for children, their parents, peers, and
teachers has made ADHD a major public health
concern.10
As a result, ADHD is arguably the most wellresearched MH disorder of childhood. As detailed in
All correspondence concerning this article should be addressed to William E. Pelham, Jr., PhD, UB Distinguished Professor
of Psychology, Pediatrics, and Psychiatry, Director, Center for Children and Families, State University of New York at
Buffalo, 318 Diefendorf Hall, 3435 Main Street, Building 20, Buffalo, NY 14214. E-mail: [email protected].
Journal of Pediatric Psychology 32(6) pp. 711–727, 2007
doi:10.1093/jpepsy/jsm022
Advance Access publication June 7, 2007
Journal of Pediatric Psychology vol. 32 no. 6 ADHD Special Issue, reprinted by permission from Ambulatory Pediatrics, Vol. 7, Number 2 (Supplement),
Jan./Feb. 2007,
Copyright ß 2007 by the Ambulatory Pediatric Association, published by Elsevier Inc.
712
Pelham, Foster, and Robb
other papers in this issue, many hundreds of papers,
reviews, and texts have focused on the diagnosis, etiology,
psychopathology, presentation, treatment, and outcome
of the condition over the last 3 decades.11–13 Surprisingly,
this voluminous body of research generally has ignored
the economic impact of ADHD. Studies of the economic
impact to society (or so-called costs of illness) have
reported a long history for physical diseases, with
prominent analytic models existing, for example,
for coronary heart disease.14 Among adults, it is well
established that MH disorders are important determinants
of disability and related costs.15
In contrast, relatively little is known about the
economic cost of disability resulting from childhood
MH disorders.16 Most of the extant work has focused on
the economic costs associated with conduct disorder,
presumably because of the clear link to later crime and
substance use—two of the mostly costly social ills of
western society. A handful of studies document that
childhood conduct disorder produce very large costs for
the family and society during childhood and into
adulthood.17–19 In one longitudinal study in London,
by age 28, children with childhood conduct problems
had cost society 3.5 to 10 times more than a comparison
group, mainly for costs associated with crime and
education.18
An accurate understanding of the societal costs of
conditions such as ADHD is critically important for
policy makers. Information about costs of illness is the
necessary prerequisite for justifying and planning prevention and intervention. This paper considers the economic
impact of ADHD. It describes a framework for thinking
about the costs of ADHD and describes the extant,
though small, literature. We conclude by identifying
needs for future research in this crucial area.
Costs of Illness as a Framework for
Understanding Economic Impact
In addressing the economic consequences of an illness or
disorder, economists have developed 2 main approaches:
willingness to pay and cost of illness (COI). COI
generally focuses on tangible resource consequences on
an illness, whereas willingness to pay methodology
typically estimates subjective costs. COI estimates are
generally lower than willingness to pay estimates,20,21 and
the difference reflects intangible effects such as pain and
suffering. In their analysis of the costs of violence, Cook
and Ludwig22 illustrate this point well. The COI estimate
of a crime like rape captures the related medical costs
and lost work experienced by the victim as well as the
costs of incarcerating the perpetrator. Of course, this
estimate is many, many times lower than what a woman
would be willing to pay to avoid experiencing this crime.
That estimate would reflect intangible effects, such as the
pain and suffering stemming from being violated.
Another alternative is to use jury verdicts to capture
these intangible costs.23 This practice is controversial
within economics because such verdicts do not reflect
market forces nor are they solicited from jurors in
a structured process.
The analyses presented below reflect a COI approach.
COI estimates have been generated for a wide range of
illnesses, conditions, and disorders, including substance
abuse,24 epilepsy,25 and diabetes.26
Framing the COI
The first step in estimating the costs of illness is to frame
the scope of the analysis. Doing so involves specifying
several key dimensions of the analysis: the perspectives
included, the categories or types of costs included,
and the time frame.
A first dimension of the scope of analysis involves
perspectives from which costs will be assessed.27,28
This step is critical—the value of an input used in
delivering a program may depend on the perspective from
which that value is assessed. For example, the parents
of a youth in trouble may be called to the principal’s
office. From the perspective of the school, the relevant
costs involve the time of school personnel. From a social
perspective, the time parents spend away from work or
home to respond to school-related issues represents
additional costs.29 The costs to that particular parent
may involve lost pay.
Economists generally focus their analyses on the
societal perspective. Assessed from this perspective,
the costs of an activity represent the net or total effect
of an activity on all members of society. The standard
texts in this area recommend the societal perspective as
the perspective for an economic analysis. For example,
the ‘‘gold standard’’ for economic analysis in health
is the report of the panel on cost effectiveness.30,31
This perspective is complemented by other perspectives,
which can identify who bear the costs of the program
or service. In addition, such analyses can illumine the
incentives shaping the behavior of key agents such
as participating families.
In our COI application below, in an effort to most
accurately capture the societal perspective, we include
the perspective of health care providers or insurers,
Costs of ADHD
education, other nonhealth systems in the public sector
(such as juvenile justice), and other members of society
(e.g., victims of crime, children in the same classroom,
and taxpayers). There is clearly a cost associated with
ADHD for the individual families (e.g., parental work
loss, parental stress-related illnesses, and increased
childcare expenses) that fall under the general rubric of
quality of life. However, there are no data currently
available that quantify and enable monetization of these
issues. This is a major limitation in the literature, which
we discuss below.
The second dimension of the scope of a COI analysis
involves the types or categories included. Economists
typically group costs into 3 categories: health-sector costs,
productivity-related costs, and other costs, such as costs
borne by other public systems (e.g., education and
juvenile justice). Economists sometimes refer to these
costs as ‘‘indirect’’, but this practice is confusing for
several reasons. These include the use of the term by
accountants to describe overhead.30 Our analysis below
will attempt to identify and measure all categories of costs
currently available within the literature. This dimension
of the study’s scope is separate from that of the study’s
perspective. In particular, costs in each sector can be
estimated from each of the study’s perspectives.
The third and final dimension of a COI study
involves specifying a time frame. One could estimate
the costs of illness for a single year or for a cohort of
individuals over a lifetime. This issue is especially
important in considering a chronic condition such as
ADHD. A longer time frame raises a key issue involving
discounting, or the conversion of future costs into today’s
dollars.32 For this study, our time frame is childhood
and adolescence. We do not capture the costs of ADHD
extending into adulthood. We summarize costs annually
for individuals with ADHD, and we compute costs
associated with the entire cohort of children and
adolescents with ADHD by using commonly accepted
prevalence estimates.
Required Information
For each of the affected sectors (e.g., health care costs)
and the timing of the effects, estimating the costs of
illness requires 2 types of information. The first involves
the quantity of the behavior or outcome that creates the
costs (e.g., number of special education placements).
The second involves the per-unit costs of that behavior or
outcome. The distinction is important because the
information often is derived from rather different sources
(e.g., school budgets vs the records of specific students).
As noted above, these per-unit costs could vary depending on the perspective involved.
Costs of illness for ADHD
A review of literature was conducted using combined key
word searches from the following list: cost, cost of illness,
cost benefit, cost effectiveness, attention-deficit disorder,
attention-deficit hyperactivity disorder, education, substance use, health care, MH care, education, discipline,
pharmacotherapy, medication, and pharmaceuticals.
Additionally, a review of references as well as cited
reference searches were conducted. Further, researchers
in the field of ADHD were contacted and asked about
studies in progress of cost data for ADHD and its
associated domains, including our own laboratories.
Studies were included if they utilized an identified
attention-deficit disorder or ADHD sample and included
outcome domains that were monetized.
To our knowledge, only 13 studies have been
conducted which met the aforementioned criteria.
The 13 relevant studies are presented in Tables I
and II. Table I describes study characteristics, including
sample characteristics, ages, comorbidities, cost outcomes
assessed, and estimated total costs per year. Table II
breaks down the costs into several categories representing
the different sectors where costs are incurred: health
costs (medication for ADHD and emergency room care/
routine physician costs), educational costs, and other
resource use.
The studies vary considerably, from those utilizing
large databases from which ADHD cases and associated
costs were obtained33 to those that involved diagnosed
clinic cases of ADHD in treatment outcome studies
or longitudinal studies.34 As is clear from examining
Tables I and II, the range of cost sectors assessed and the
ways costs were obtained similarly varied considerably.
In the following sections, we shall summarize the
key domains listed in Tables I and II. For purposes of
comparison, all costs discussed below have been inflated
to 2005 prices by using the Consumer Price Index
(www.bls.gov) to enable comparison across studies.
Health and Mental Health Systems
Costs of Pharmacological Treatment
As shown in the Tables, 5 studies have assessed the cost
of medication separately from total or general medical
costs. Primarily, the per-unit cost (for all studies but
Jones et al34 and Jensen et al35) are based upon health
insurance claims data. In Jones et al,34 the per-unit cost
713
714
Study
Guevara et al., 2001
Sample Characteristics
Ages
Through diagnosis codes;
Combines ages 3 through
based on at least one
17 (mean age 11.7)
ambulatory visit or
Comorbidity
Externalizing condition,
Cost Outcomes
Primary care; MH;
Estimated Total Cost
(year of dollar)
Estimated Total Cost
(2005 dollar)
$1465 total health care
$1783 total health care
internalizing condition,
ED; Pharmacy;
cost, per patient
SUD
Hospitalizations
(1997 dollars)
cost, per patient
hospitalization (n=2992)
Leibson et al., 2001
Through observer review of
school and medical
records for evidence of
ADD diagnosis (n=309)
Chan et al., 2002
Through MEPS HC
(Household component);
Combines children born
between 1976 and 1982
[Total medical
$4306 (9-year median
$5518 (9-year median
care costs]
cost; per patient
cost; per patient)
(mean age=7.3)
Combines ages 5
through 20
self-report coded by
1995 dollars)
Anx, tics, Dep, CD,
OP; ED; Prescriptions;
emotional disturbance,
Home visits; Hospital
LD.
stay; Out-of-pocket
$1151, per patient
$1433, per patient
(1996 dollars)
interviewer (weighted
n=2,175,155)
Kelleher, Child and
Harman, 2001
Burd et al., 2003a,b
Through Medicaid diagnosis Combines ages 7–20,
code or stimulant
prescription fills (n=1602)
None; ADHD v. asthmatics
IP, OP, prescriptions
from 1994–1995
a,b Through North Dakota
a,b Combines ages 0–21
Department of Health,
(mean age 10) from
identified based on ICD-9
1996–1997
code (n=3872a)
$2300 per patient
(1995 dollars)
a, none
b, health related (vision,
epilepsy) & mental health
a, Health care
(non-prescription),
IP, OP
related (Dep, ODD, bipolar, b, Total health mean
(n=7745b)
$1795 per patient
CD, adjustment disorder,
cost difference
a, $649 per patient
(1997 dollars)
b, from low $149 (tics)
to $653 nondependent
a, $790 per patient
b, from low $181 (tics)
to $795 nondependent
drug use.
drug use.
LD, Anx, nondependent drug
use, tics, personality disorder
Mandell
et al., 2003
Through Medicaid claims
data between year
Combines ages 3 through
ED; IP; MH
15 (mean age 7.7)
$1895 for total health care, $2271 for total health
per patient (1998 dollars)
care, per patient
1993–1996
Swensen et al., 2003 Identified based on at least
Children (18 and under)
Dep, adjustment reaction,
one medical or disability
observed between 1996
disturbances of childhood,
insurance claim related
and 1998 (mean age 12.4)
to ADD (n=1175)
Medical office; IP; OP;
Pharmacy; Indirect costs
$1574 healthcare costs to
$1886 healthcare costs to
patient; $2728 for other
patient; $3269 for other
other psychoses, ODD,
costs (health care
costs (health care
CD substance use, Anx.
utilization and work loss)
utilization and work
to family members of
ADHD patient.
loss) to family members
of ADHD patient.
(1998 dollars)
Swensen et al., 2004 Identified based on at least
Patients 0–64 (mean
one medical or disability
age 16) observed
insurance claim related
between 1996–1998
Medical claims due to
accidents
$209 per patient
$250 per patient
(accident-specific cost)
(accident-specific cost)
$2172 per patient (overall
$2602 per patient (overall
to ADD note: sample same
costs: office visit, OP, IP,
costs: office visit,
as Swensen et al. (2003)
disability, absenteeism)
OP, IP, disability,
(1998 costs)
absenteeism)
Continued
Pelham, Foster, and Robb
Table I. Summary and characteristics of cost studies
Table I. Continued
Study
Birnbaum
et al., 2005
Sample Characteristics
Administrative health
Ages
Comorbidity
Patients (between
Cost Outcomes
Medical claims, prescription
Estimated Total Cost
(year of dollar)
Children with ADHD and
Estimated Total Cost
(2005 dollar)
Children with ADHD
insurance claims,
ages 7–44) observed
drug claims, all other
adults and family
and adults and family
Identified based on at least
one medical claim for
between 1996–1998
healthcare costs, medically
related work absence time
members $31.6 billion
(total cost reported)
members $35.8 billion
(total cost reported)
for ADHD patients and
(2000 dollars)
ADHD (ICD-9) (n=1219)
family members
Secnick et al. (2005) Diagnosed with ADHD and
Jensen et al. (2005)
Patients over age of 18
SUD; bipolar; Dep.;
(mean age 31.8 years)
Anx; antisocial disorder;
prescription drug service);
database (n=2252)
diagnosed between
social phobia; ODD
Productivity costs
Identified with ADHD as
1999–2001 and
(absenteeism, short-term
continuously insured.
disability, worker’s
compensation)
Patient between ages of
part of Multimodal
7–9.9 years (Community
Treatment of ADHD
Control (CC) group only
Internalizing disorder;
externalizing disorder
Gottschall, under
Medical mangement cost
$5651, per patient
$6232, per patient
(2001 dollar)
$1071 per patient
$1215 per patient for all
(i.e.medication cost and
(2000 dollar) for all
ADHD and comorbid;
medication visits);
ADHD and comorbid;
$1283 ADHD only;
mental health cost
$ 1131 ADHD only;
$814 ADHD plus
around the country
$718 ADHD plus
internalizing; $1366
(MTA, 1994) (n=144)
internalizing; $1204
ADHD plus
ADHD plus externaliaing;
$976 ADHD plus both.
externaliaing; $1107
ADHD plus both.
(MTA) study from 7 cites
Jones, Foster &
Direct medical cost (IP, OP,
entered into medical claim
Subset of FastTrack Project
Between ages 12–15
CD
data (n=84)
IP; OP; General health
(ED, general practice,
review
$7600 annually, per
patient (2000 dollars)
$8620 annually,
per patient
hospital); JJ (detention
center, arrest cost);
School (grade retention,
special education,
Robb, Pelham,
Children with ADHD
Between ages 5–17 at
CD, ODD, LD,
counseling)
School (acts of discipline,
Foster, Molina &
identified in childhood
recruitment, and
Gnagy, in
and treated in clinic,
between 14–30
education); Juvenile
preparation
followed into adolescence
at follow-up
delinquency (self-report)
internalizing
grade retention, special
$4900 for incremental
$4900
costs of education
as part of PALS; controls
(n=364)
IP-Inpatient care; OP-Outpatient care; MH-Mental Health care; ODD-Oppositional Defiant Disorder; CD-Conduct Disorder; Dep-Depression; Anx-Anxiety; LD-Learning Disorder/Disability, JJ-Juvenile Justice, ED-Emergency
Department.
Costs of ADHD
recruited separately
715
716
Table II. Summary of study costs, by type of cost
Guevara et al., 2001
(1997 dollars)
Medication
Prescription: $335
Work Loss
—
($408)
ER/ED/IP/OP/Urgent
Care/Physician Contact
Primary Care: $427 $(520)
Education
—
Other Resource
Use
—
OP mental health: $222
$(270)
ED: $38 ($46)
IP: $115 ($140)
By comorbidity type
ADHD alone: $375
($456)
Internalizing: $1012
($1231)
Externalizing: $898
($1093)
Substance use: $847
($1031)
Kelleher, Childs &
Harman, 2001
Pharmacy use: $508
—
($651)
Other services: $1287
—
—
—
—
—
—
—
—
($1649)
(1995 dollars)
Psychiatric services: $1135
($1455)
Leibson et al., 2001
(1995 dollars)
—
—
Total Cost= physician billed,
expense, hospital care:
$4306 (9:year median cost)
($5518)
Chan et al., 2002
—
—
(1996 dollars)
Total Cost (collapsed across
all expenses) = $1151
($1433);
Comorbid $2367 ($2946)
v. ADHD alone $997
($1241)
Burd et al., 2003a,b
(1997 dollars)
—
—
a, Health Care $649 ($790)
IP $8861 ($10782)
OP $1597 ($1943)
b, Dep $1330 ($1618);
ODD $1451 ($1766);
CD $1576 ($1918);
bipolar $1733 ($2109)
Adjustment $1280
($1558); Anx $1399
($1702); Tics $848
($1032); Personality
$1943 ($2364);
Continued
Pelham, Foster, and Robb
Study
Table II. Continued
Study
Medication
ER/ED/IP/OP/Urgent
Care/Physician Contact
Work Loss
Education
Other Resource
Use
—
—
—
—
—
—
—
—
Nondependent drug use
$1866 ($2271)
Mandell et al., 2003
(1998 dollars)
—
Swensen et al., 2003
Prescription: $401
—
Total median cost (ER, IP,
MH): $1728 ($2070)
Ambulatory: $167 ($167)
(1998 dollars)
($480)
For family members:
IP: $388 ($465)
Absenteeism $233, ($279)
OP: $433 ($519)
Disability $435 ($521)
Provider: $286 ($343)
Other: $66 ($79)
Swensen et al., 2004
Prescription: $551
(1998 dollars)
Children and Adolescents
($660)
CAD: $787 (0)
Absenteeism: CAD $0 (0)
Disability: CAD $0 (0)
combined (CAD)
IP
CAD: $759 ($49),
($909($59))
OP
CAD: $847 ($176)
($1015(211))Provider
CAD: $575 ($40)
($689($48)
Birnbaum et al., 2005
—
(2000 dollars)
Work loss cost to ADHD
family members:
$112 ($127)
Treatment of ADHD
(combined medical claim
and prescription drug
claim): $1013.78
($1149)
All other healthcare costs:
$1393 ($1580)
$603 to family members
Jones, Foster & Gottschall,
under review (2000 dollars)
Prescription: $84
($96)
—
($684)
IP: $2388.88 ($2710)
OP: $648.32 ($735)
General Health: $385.50
Schooling (special education
and retention): $3681
JJ: $390 ($443)
($4175)
($438)
Robb, Pelham & Foster,
in preparation (2005 dollars)
—
—
—
Schooling: (special education,
retention, discipline) $4900
$6597.35
Costs of ADHD
IP-Inpatient care; OP-Outpatient care; MH-Mental Health care; ODD-Oppositional Defiant Disorder; CD-Conduct Disorder; Dep-Depression; Anx-Anxiety, JJ-Juvenile Justice
Cost presented in year of dollar reported (2005 dollar)
Cost computed for each year of child’s age. For reporting purposes, costs were averaged across each of the five reported years
Juvenile Delinquency:
717
718
Pelham, Foster, and Robb
was based upon parental report of annual medication
use, and the Multimodal Treatment Study of Children
with ADHD (MTA) costs were computed using medication costs for children in the community comparison
group. Estimated annual cost has ranged from a low of
$96 (Jones et al34) to a high of $1283 (Jensen et al35),
with a mean of $459. As we discuss below, the variation
of costs across studies is likely due to a number of
factors, including age of sample, comorbidities, source of
sample, Socioeconomic Status (SES) of families, physician
costs, and medication regimen and brand. For example,
only 2 studies described ‘‘physician’’ in such a way that
they could be considered a portion of pharmacological
treatment.
Costs of Psychosocial Mental Health Treatments
Only a few studies have evaluated the costs of
psychosocial MH treatments. Across their 4 waves of
young adolescents, Jones et al34 reported that the use
of outpatient MH services—$500 to $800 per year,
depending on age—was relatively low. Through age 15,
slightly more was spent on inpatient MH, where the cost
of inpatient treatment increased dramatically to more
than $6000 per child (mean $3036), with the bulk of
this being spent on a small percentage of the children.
Similar increased costs are apparent in other studies for
inpatient treatment.36,37 These estimates are based on
parental reports of service use. Per-unit costs were based
on reports from the facilities where individuals were
treated; those costs represent the costs of those services
from the payor perspective. Notably, in Jones et al,34
comorbid Conduct Disorder (CD) did not noticeably
increase cost of MH services in this sample, and the cost
of MH services for children with ADHD met or exceeded
service costs for children with CD only. Two other
studies estimate nonpharmacological MH costs. Guevara
et al38 reported a mean of $270, with incrementally
higher MH costs for children with ADHD (even higher
for comorbid children with ADHD), and Kelleher et al33
reported a mean of $1455. Per-unit costs were based
upon insurance diagnostic code reimbursements and
represent the employer perspective.
Use of Other Health Services
Treatment for conditions other than ADHD varied across
studies, both in terms of reporting categories and
in terms of cost. Several studies reported on total
health care cost,39–42 while others differentiated cost
by type (inpatient, outpatient, emergency department,
etc),33,34,36,38,42–44 and still others differentiated cost
based on comorbidity status.34,37,38 These reporting
differences make it difficult to separate MH from other
health services. When studies that separated MH and
pharmacotherapy from other health care costs are
examined, the estimates for all other health care range
from $438 (Jones et al34) to $1580 (Birnbaum et al41).
Summary
Averaging these estimates for ADHD treatment and other
health care costs across studies yields an annual per child
cost of $2636, with a range from $790 to $5518. As can
be seen in Tables I and II, the range is due to a number
of factors, including the types of services that were
included in the estimates, whether the ADHD child
had comorbid disorders, and the nature of the database
utilized.
Educational Costs
The incremental costs of education accrue from a variety
of sources that mirror the educational system’s response
to the children’s dysfunctional outcomes. Thus, many
children with ADHD are eligible for special education
services under Section 504 of the Rehabilitation Act of
1973 or the Individuals with Disabilities with Education
Act (IDEA) and receive related services at rates higher
than those for children without ADHD.45 Factors
contributing to cost include whether the child has an
individualized education plan and is in a part-time or fulltime special education classroom or a more restrictive
setting (e.g., a special school), as well as whether the
child is receiving accommodations in a regular setting
(e.g., through a section 504 plan).
Only 2 studies have examined samples in which
education costs can be computed for children with
ADHD by using information regarding their school
placements. In one study reported by our group,
Jones et al34 examined existing data from the Fast
Track study46 for education services utilization. They
used standard parent interview data to make diagnoses
of ADHD (and CD) in children from the original sample
(across both normative and at-risk groups), and they
examined parental report of special education utilization,
school counseling, and retention over a 4-year period
(ages 12–15). They used national estimates of cost of
special education services and computed educational
costs for their ADHD, CD, comorbid, and comparison
groups. Collapsing across costs for grade retention,
school counseling, and special education use, average
school expenditures were significantly higher for
ADHD—averaging $4175 per ADHD child annually.
The other study is also one that has just been
completed by our group.47 The cost analysis relies on
Costs of ADHD
Table III. Total costs across sectors
Sector
Annual per-child cost
Range
Aggregate annual costs
Aggregate Range
Health and Mental Health
$2,636
$790–5,518
$7.9 billion
$2.4 to $16.6 billion
Education
Crime and Delinquency
$4,900
$7,040
$4,175–4,900
No range
$13.6 billion
$21.1 billion
$12.5 to 14.7 billion
$21.1 billion
Total
$14,576
$12,005–17,458
$42.5 billion
$36-$52.4 billion
Assuming ADHD prevalence of 5% and 60 million school aged children (2000 census), in 2005 dollars.
a prospective longitudinal study, the Pittsburgh ADHD
Longitudinal Study (PALS),48 of individuals with and
without diagnosed ADHD in childhood (and comparison
children). In this sample, a substantial number of
individuals have completed their educational careers,
and the remainder is in midadolescence to late
adolescence. Measures included parental annual reports
of special education services, retention, and disciplinary
referrals. Costs associated with the utilization of special
education were derived from national estimates from the
US Department of Education. The average incremental
annual cost to educate a child with ADHD from
kindergarten through grade 12 is approximately $4900
annually over that of regular education, as compared with
$265 annually for control children. The bulk of this
amount was due to special educational placement
and retention.
Crime, Delinquency, and Substance Use
Only a single study to date34 has examined the nonvictim
cost of delinquency and/or criminal behavior in ADHD
samples. Jones et al again examined existing data
from the Fast Track study45 for juvenile justice system
utilization and costs. Juvenile justice use was derived
from the Service Assessment for Children and
Adolescents,49 and per-unit cost estimates were computed by combining the cost of arrest and the cost of
placement in a juvenile justice center. For ADHD
individuals regardless of comorbidity, the annual cost in
2005 dollars ranged from $11 to $935, with a mean
of $440.
A broader analysis included cost to victims, which is
a major portion of crime-related costs.28 We computed
victimization costs for the 14 to 17-year-olds in the
PALS ADHD sample47 by using self-reported acts of
delinquency.50 Applying Cohen’s28 victim costs for
different acts, nearly $6600 annually in costs is incurred
by victims of crime for each ADHD youth in the
PALS sample.
Only a single study addressed each perspective
(perpetrator and victim) and it is inappropriate to average
across perspectives. Therefore, the appropriate estimate
is the sum of the two studies, yielding an estimate
for the cost of delinquency of $7040.
To date, no COI studies on the cost of alcohol abuse
and/or drug abuse by ADHD youth (e.g., the cost of
treatment in a sample) were identified. Given the high
costs of drug and alcohol abuse and the increased risk
for these outcomes in ADHD individuals,6 it is reasonable
to expect an increase in COI from substance use/abuse in
ADHD adolescents.
Total COI for ADHD
Table III shows the total COI for an ADHD child based
on the studies and cost sectors reviewed in Tables I and
II. The mean estimated annual cost for a child/adolescent
with ADHD is $14,576, with a range from a low estimate
of $12,005 to a high estimate of $17,458 by using the
lowest and highest estimates from the review. Using
the 2000 census of 60 million school-aged children in
the US and assuming a commonly accepted prevalence
rate of 5%, these individual estimates translate to an
annual aggregate COI of $42.5 billion for the schoolaged ADHD cohort in the United States (range,
$36–$52.4 billion). The range of prevalence estimates
for ADHD is 2% to 9%, so the cohort annual aggregate
could range from 60% less to 80% more than our
estimate of $42.5 billion.
Discussion
Although the number of studies is small and most have
evaluated only a few domains, this review provides a
preliminary estimate of the COI for ADHD—particularly
in the areas of treatment costs, other health care costs,
education, and juvenile justice. The review also highlights
the areas in which little information is available and
provides direction for future research needed to more
comprehensively quantify the COI of ADHD.
Notably, the COI estimate we derived is considerably
higher than that reported in any one of the articles
reviewed. That difference is a result of the fact that most
studies examined only a single sector COI, for example,
719
720
Pelham, Foster, and Robb
health care or education—but not both. As Table III
illustrates, the COI of ADHD is distributed across at
least the 3 sectors we examined, with substantial costs
in each. Further, there are important cost sectors that
have yet to be examined—most notably the cost to
families of ADHD (e.g., parental work loss, parental stress
and substance use, and extra child-care costs). There are
no estimates of the costs of substance abuse associated
with ADHD despite the fact that problems in this domain
begin early and intensify through adolescence.4–6 Further,
as we discuss below, it is likely that the estimates in
2 of these sectors—health care (specifically treatment)
costs and educational costs are substantial underestimates
of the COI of ADHD in childhood and adolescence.
Costs of Health and Mental Health Systems
Let us first consider the most common treatment for
ADHD—pharmacotherapy. At an aggregate level, current
cost of pharmacotherapy for ADHD will depend primarily
on1 how many children are medicated,2 whether they
take a patented long-acting formulation,3 how many
days per year they take medication,4 whether they are
medicated for school hours only or for evening hours
also, and for how many years they take medication.5
The costs for pharmacological treatment of ADHD
reported in the studies reviewed herein are a substantial
underestimate of current pharmacological practices.
The main reason for this is that all extant studies were
conducted a) before the new wave of patented ADHD
formulations began in 1999/2000 with the FDA approval
of Concerta and Adderall XR and (b) before guidelines
that call for more frequent prescribing physician contact
with ADHD families.7,51 The vast majority (80%) of
children with ADHD and adolescents who are medicated currently receive 1 of these 2 long-acting (12-hour)
formulations of methylphenidate/amphetamine.52 Still
under patent protection, these formulations have
substantially higher costs ($1440 annually for typical
dosing at 2005 retail pricing) than the generic formulations that were most prevalent when the medication cost
data in all of the published studies were gathered
(mean prescription cost of $459). For example, twicedaily generic methylphenidate costs only one fourth as
much as Concerta or Adderall XR at 2005 retail prices.
If a prescribing physician (e.g., family practitioner) sees
the child quarterly, the cost of physician time will be
$332 annually.34 Thus, the annual cost of medication
for ADHD currently is likely to be nearly $1775 to $1316
more annually than the estimate that we used in
Table III. Assuming that 70% of children with ADHD
are medicated at any one point in time,51,53 aggregate
costs for pharmacotherapy for children with ADHD is
likely to be $5.3 billion.54
Because pharmacological treatment is the most
commonly used evidence-based treatment for ADHD,
more information on the cost of this intervention is sorely
needed. Given the dramatic difference in cost between
short-acting generics and long-acting patented formulations, studies that compare the cost effectiveness of the
2 formulations in practice settings is needed. Although
industry marketing argues that the newer long-acting
stimulants produce better effects than short-acting
generics, head-to-head comparisons suggest that the
effects are similar.55 Further, longitudinal studies that
relate lifetime costs to long-term benefits of stimulants
are needed.
The other approach to intervening with ADHD
involves behavioral interventions.56 The cost estimates
for psychosocial treatments in the studies we reviewed
are quite low, especially when compared with current
recommendations for such interventions.7 Bussing et al57
and Hoagwood et al58 have shown that children with
ADHD are woefully underserved with respect to MH
treatments, and that is reflected in these costs.
One possible contributor to this fact is that payor
policies restrict access to mental health services.59 For
example, in the Guevara HMO sample (Table I),
the average ADHD child had only 1.3 mental health
visits per year56 with a median of zero. Since the
evidence-based behavioral treatments for ADHD involve
numerous sessions (e.g, 12 for group parenting training
and 12 separate ones for child social skills training),
these low numbers suggest that evidence-based practices
were not being offered or covered by the plan, or that
plan physicians were not recommending them. Only
1 study has reported the cost of evidence-based
behavioral treatment for ADHD; the mean cost of the
comprehensive behavioral treatment (a year’s worth of
parent training, teacher consultation, and a summer
treatment program) for the children in the MTA study
was reported as a cost of $6988 for a year of treatment.35
Thus, the extant literature on the cost of psychosocial
treatments for ADHD is not informative regarding
what the cost would be if evidence-based behavioral
treatments were as widely used as is medication.
As with different medication formulations, COI
research in this domain needs to focus on the cost
effectiveness of evidence-based behavioral approaches
versus and in combination with medication. In addition,
analysis of the costs of different models of service
Costs of ADHD
provision of evidence-based interventions need to be
conducted (e.g., clinic-provided vs school-provided
services). Finally, studies are needed of the impact
of clinic-provided interventions on the school-based
COI noted above.
As Tables I and II illustrate, nontreatment-related
health care costs for ADHD have been most widely
studied. At the same time, additional research is needed
to fully describe the health-related COI of ADHD.
For example, it is difficult to discern from the published
studies whether physician visits are for ADHD medication
prescription or for other purposes. It would also be useful
for future studies to differentiate costs associated with
various types of health care use (e.g., emergency room
visit or outpatient pediatric visit).
Future research needs to study a sample in which
the education of the subjects has been entirely since the
1992 change in the IDEA began to be widely implemented. Additionally, neither Foster et al29 nor Robb et al47
had data regarding 504 plan implementation and
associated costs. Future research should obtain such
estimates, as well as more precise estimates of the costs
of disciplinary infractions (e.g., lost instructional time and
school administrator time). Finally, since the bulk of
incremental educational cost is due to special education,
research is needed that examines whether evidence-based
treatments (both pharmacological and behavioral)
influence subsequent special education utilization
(see discussion below).
Crime, Delinquency, and Substance Use
Educational Costs
The incremental costs of education noted in the 2 studies
reviewed are remarkable. In the only previous estimate
of educational costs of ADHD, Forness and Kavale45 used
a variety of national prevalence estimates and standard
national cost data to derive an annual estimated cost of
special education for ADHD of $3.2 billion (in 1995
dollars; $4.1 billion in 2005 dollars), Robb et al47 and
Jones et al34 followed actual samples of children with
ADHD and reported annual costs more than 4 times
higher—$13.6 billion. Robb et al report that the
educational costs for ADHD were not a result of a few
severely disturbed children; 48% of the sample had
at least 1 year of special education, and 80% of the
sample had at least 1 serious disciplinary infraction each
quarter. Clearly, the incremental cost of educating a child
with ADHD is enormous. Based on this number,
the lifetime incremental cost of educating a cohort of
children with ADHD through high school would be
$176.8 billion.
Despite their enormity, there are several reasons
that these educational costs may be underestimates.
The Foster et al34 sample was young adolescents followed
through the middle school years where special education
utilization is less than in elementary school. Further,
the PALS sample that Robb et al47 analyzed had half of
its collective education after 1992, when ADHD was
first officially recognized under the IDEA as eligible for
special education. Forness and Kavale45 estimated that
there was a 68% increase in the number of children with
ADHD by using special educational services in the
4 years after 1992. Thus, the Robb et al47 reports of
special educational services may well be dramatic
underestimates.
Crime and delinquency contributed substantial cost
to the COI of ADHD. However, only 2 studies were
identified. More research is clearly needed in the COI of
these domains. Foster et al29 reported useful treatment
costs for young adolescents; information regarding
treatment/incarceration costs for older adolescents is
needed. A broader analysis in future studies would also
include both the cost of treatment and the cost to victims,
as noted above. Replication of the analysis of the victim
costs of the PALS study is needed in other studies with
comparable data that can be used to compute victim
costs.4 Finally, studies of COI of substance abuse in
ADHD samples are needed.
Psychiatric Comorbidity
It was evident in several studies reviewed that children
with ADHD with comorbidities might incur greater COI.
This was evident in treatment and health cost studies
that reported on comorbidities.40 Similarly, Jones el al34
reported that the crime/delinquency-related costs were
greater for children with ADHD with comorbid CD
than for children with ADHD who were not comorbid
(Robb et al47 did not report victim costs by comorbidity).
Forness and Kavale45 speculated that children with
ADHD with comorbid learning disabilities would have
higher educational COI due to higher rates of special
education, but this has not yet been systematically
evaluated. Jensen et al35 reported that costs for medication treatment were lowered by comorbid anxiety and
raised by comorbid aggression. ADHD adolescents with
comorbid aggression are at greater risk for substance
abuse6 and thus should have higher associated costs.
Future research—particularly longitudinal studies that
follow children with ADHD into the teen years when
721
722
Pelham, Foster, and Robb
delinquency is evident—should routinely examine COI
in ADHD as a function of psychiatric comorbidity.
Limitations and Extensions
This study is limited by the small amount of literature on
which our estimates are based. The variability in
methods, outcomes, and estimates across the studies
we reviewed make it clear that work on COI is difficult
if one relies on a single source for data. For example,
our cost estimates for education and crime are based on
only 2 studies, and psychosocial treatment on a similarly
small number. These studies are methodologically sound,
but estimates may change with larger, more geographically or socioeconomically diverse samples, and more
studies in each cost sector as well as neglected sectors
are needed.
Existing methodology developed in the field of
medical decision-making offers the potential to combine
different data sources of different types to develop
improved estimates of the costs of illness.60–63 These
methods also provide a comprehensive assessment of
the uncertainty associated with the estimated costs of
illness—something that we cannot do with this small
number of studies.
The estimate of impact of children with ADHD on
their parental and family function11 represents the area
with the greatest need of further study. Existing studies
have shown little direct estimated cost, but there are
arguably large indirect costs. Indeed, a considerable
literature shows that parents of children with ADHD
suffer very high levels of distress, depressed affect, and
substance use caused by their children’s behavior,64–66
but these outcomes have not been monetized. For
example, although a few of the studies in Tables I and
II examined parental work loss, they did not provide
enough information to separate work loss incurred by
parents of children with ADHD from that of ADHD
adults. Furthermore, they relied on official absenteeism
and disability claims. As is the case with other MH
disorders,15 official records are unlikely to reflect the
main source of work loss for the parent of an ADHD
child. Instead, family members likely incur unexcused
and nonmedically related absences due to factors such as
school suspension or difficulty obtaining after-school care
or day care, as well as lost time at work due to phone
calls from teachers or principals and anxiety-related
inefficiency. Future research investigating this domain
should include instruments designed to gather the kind
of information that is used in workplace studies to
facilitate accurate monetization of this component of
COI.15 In addition, because the parents of children
with ADHD are more likely to be depressed, anxious,
and to have marital and alcohol problems relative to
control groups,64–66 the economic impact of ADHD on
these parental outcomes needs to be measured and
included in COI (e.g., reports of parental MH services).
Similarly, the impact of ADHD individuals on these
domains has not been studied in their siblings.
There are many other domains that have not yet been
evaluated, including whether ADHD families include
individuals on disability or welfare at a differential rate.
We noted above that information on increased substance
use and abuse and associated costs needs to be
monetized. In addition, one recent study shows that
ADHD teens are more likely to engage in risky sexual
activity and cause early pregnancies,67 and these data,
as well as other data regarding risky activities with
associated costs (e.g., risky driving) need to be included
in a COI of ADHD.
We noted at the outset that our analysis focuses
only on children and adolescents. It is clear that ADHD
is a chronic condition and that ADHD individuals
continue to have a host of difficulties that have associated
costs in adulthood.5 Two of the studies in Table I
involved mostly, or exclusively, adults.41,71 Birnbaum
et al41 provided the only estimate of the COI of ADHD
in adults of which we are aware (although their
study included some children and adolescents), at
$31.6 billion. Those studies are also limited by the
breadth of sectors evaluated (e.g., no assessment of
the cost of substance abuse or criminal activity) and the
work-loss assessment issues noted above. Extension
of COI work into the field of adult ADHD is clearly
indicated. When combined, our estimate and that of
Birnbaum et al41—albeit preliminary and incomplete—
suggest that the cost of ADHD across the lifespan is at
least $74.1 billion.
It is instructive to put this COI for ADHD in the
context of other conditions. For example, a recent
analysis suggests that the annual COI for major
depressive disorder in the US is $44 billion. The annual
aggregate cost of substance abuse in the United States has
been estimated to be $180 billion.23 The annual aggregate
COI of stroke in the US was $53.6 billion in 2004.
Kelleher et al33 reported that the annual health care costs
of children with ADHD were comparable to those of
children with asthma, and a recent report on the COI
of asthma in the European Union reported an annual per
child health care cost of $820 (2004 dollars)—similar to
the health care costs for ADHD shown in Table II,
Costs of ADHD
reinforcing the conclusion of Kelleher et al. It is clear that
the COI of ADHD is of a similar magnitude as these other
conditions—some of the most prominent in the professional literature and the public consciousness.
Finally, consider the fact that we employed a
prevalence rate of 5% in our estimates. The upper
bound of prevalence rates for ADHD is 9%.51 If the true
prevalence rate of ADHD or children with ADHD
symptoms and/or and impairments were 9%, then the
societal costs of our estimates would increase
substantially.
Implications for the Cost-Effectiveness
of Treatment and Prevention
These high costs of illness have important implications
for treatment and prevention of ADHD. It is crucial to
note that when costs of ADHD are computed, a relatively
small amount is for direct medication or psychosocial
treatment for ADHD, compared with much higher costs
for education, crime, and costs to others. Therefore,
any analysis of cost-effectiveness of treatments should
prioritize these costs, both direct and indirect.
Additional research is needed on variation among
children with ADHD and various comorbidities. The
calculations provided here indicate that some behaviors
are very costly, and we know from research in other areas
(such as aggression) that a few youth account for
a disproportionate share of costly behaviors and costs.34
On the other hand, as noted above, the costs of
educational problems for children with ADHD applies
to the majority of individuals. Additional studies that
are comprehensive, have large sample sizes, and are
longitudinal could provide information on whether
the children and youth who are mostly costly in
education are also more costly in other sectors such
as juvenile justice. Once identified, such children could
be the focus of early identification and prevention efforts
or later intensive—though costly—intervention. Similarly,
children whose characteristics suggest that they are the
least costly might be treated with low-intensity treatments
(e.g., low-cost classroom management tips for teachers
and/or low-dose medication) before more costly treatments are implemented.68
One can think of the costs of illness as an upper
limit for what society might save through intervention.
How much of the costs would be recouped, even by
an effective program, may depend on the mediating
mechanism targeted. For example, medications for ADHD
have very large acute effects on symptoms but may
generate a smaller reduction in COI than behavioral
interventions that target the mechanisms (e.g., peer
relationships, parenting, school functioning) linked most
closely to costly outcomes and behaviors.69–72 Similarly,
medication must be continued chronically, while behavioral treatments are applied over a limited period with
subsequent adaptations designed to maintain initial
gains.56 Though more expensive acutely than medication
in the MTA—nearly 3 times as much—the effects of the
behavioral treatments appeared to maintain better than
medication, which required continuation.35 Over a 3-year
period, the costs of the 2 modalities would become
roughly comparable. Notably, a cost-effective treatment
likely only has to capture a portion of the costs of illness
demonstrated here. Even a relatively expensive treatment
like the behavioral therapy offered in the MTA study
might be cost effective because the costs of illness for
ADHD are clearly several orders of magnitude larger than
even the cost of the behavioral treatment.35 Which would
be more cost effective in the long run is a key empirical
question that has not yet been answered.
Summary
A preliminary, incomplete, and conservative estimate
of the annual COI of ADHD is $14,576 per child in
2005 dollars, with a very wide range across a small
number of studies. Using an ADHD prevalence of 5%,
this translates into a minimum annual aggregate COI
of $42.5 billion, with a more likely estimate being twice
that amount. These costs are staggering and comparable
in magnitude to other serious medical and MH problems
in both children and adults. It is noteworthy that ADHD
is somewhat unique among chronic childhood conditions
because its impact, and therefore COI, cuts across a
broader range of sectors than other conditions. For
example, learning disabilities affect primarily the educational domain, while conduct problems impact the
juvenile justice domain, and asthma primarily the health
care and family domains. The functional difficulties for
children with ADHD occur in all of these domains,11–13
so the COI would arguably be expected to be higher than
many other conditions. The fact that multiple sectors are
involved also highlights the need for interdisciplinary
cooperative in the research and management of ADHD.
The magnitude of this COI estimate highlights the
public health importance of ADHD for families, schools,
and health care providers. Thus, this COI analysis not
only justifies—but argues for—an expansion of evidencebased services for ADHD56 and an NIH commitment to
growth both in research that compares the relative costs
and effectiveness of evidence-based interventions and in
723
724
Pelham, Foster, and Robb
major public health initiatives focused on this common
and refractory condition.68,69
Acknowledgments
This study was supported in part by the National
Institute of Alcohol Abuse and Alcoholism (AA11873),
the National Institute on Drug Abuse (DA12414,
DA12986), the National Institute on Mental Health
(MH62946, MH53554, MH065899, MH62988), the
Institute of Education Science (LO30000665A), and the
National Institute of Child and Human Development
(HD040935).
Received January 19, 2006; accepted August 15, 2006
References
1. American Academy of Child & Adolescent
Psychiatry. (1997). Practice parameters for the
assessment and treatment of children, adolescents,
and adults with attention-deficit/hyperactivity
disorder. J Am Acad Child Adolesc Psychiatry,
36(10 suppl), 85S–121S.
2. American Psychiatric Association. (1994). Diagnostic
and Statistical Manual of Mental Disorders (4th ed.),
Washington, DC: Author.
3. Barkley, R. A., Anastopoulos, A. D.,
Guevremont, D. C., & Fletcher, KE. (1991).
Adolescents with ADHD: patterns of behavioral
adjustment, academic functioning, and treatment
utilization. J Am Acad Child Adolesc Psychiatry, 30,
752–761.
4. Barkley, R. A., Fischer, M., Smallish, L.,
& Fletcher, K. (2004). Young adult follow-up of
hyperactive children: antisocial activities and drug
use. J Child Psychol Psychiatry, 45, 195–211.
5. Mannuzza, S., & Klein, R. G. (1999). Adolescent and
adult outcomes in attention deficit/hyperactivity
disorder. In: H. C. Quay, & A. E. Hogan (Eds.),
Handbook of Disruptive Behavior Disorder
(pp. 279–294). New York: Kluwer Academic/Plenum
Publishers.
6. Molina, B. S. G., & Pelham, W. E. (2003).
Childhood predictors of adolescent substance use in
a longitudinal study of children with ADHD.
J Abnorm Psychol., 112, 497–507.
7. American Academy of Pediatrics. (2001). Clinical
practice guideline: treatment of the school-aged child
with attention-deficit/hyperactivity disorder.
Pediatrics, 108, 1033–1044.
8. DuPaul, G. J., & Stoner, G. (2003). ADHD in
the Schools: Assessment and Intervention Strategies.
2nd ed. New York: Guilford.
9. Barkley, R. A. (1997). Attention-deficit/hyperactivity
disorder. In E. J. Mash & L. G. Terdal (Eds.),
Assessment of Childhood Disorders. 3rd ed.
(pp. 71–129). New York: Guilford.
10. Jensen, P. S., & Cooper, J. R. (2002). Attention
Deficit Hyperactivity Disorder, State Of Science,
Best Practices. Kingston, NJ: Civic Research Institute.
11. Cunningham, C. E. (2007). A Family-Centered
Approach to Planning and Measuring the Outcomes
of Interventions for Children with ADHD. Ambulatory
Pediatrics, 7(Suppl), 60–72.
12. Hoza, B. (2007). Peer Functioning in Children with
ADHD. Ambulatory Pediatrics, 7(Suppl), 101–106.
13. Loe, I. M., & Feldman, H. M. (2007). Academic and
Educational Outcomes of Children with ADHD: A
Literature Review and Proposal for Future Research.
Ambulatory Pediatrics, 7(Suppl), 82–90.
14. Weinstein, M. C., Coxson, P. G., Williams, L. W.,
et al. (1987). Forecasting coronary heart disease
incidence, morality and cost: the coronary heart
disease model. Am J Pub Health, 77, 1417–1426.
15. Stewart, W. F., Ricci, J. A., Chee, E., et al. (2003).
Cost of loss productivity work time among US
workers with depression. JAMA, 289, 3135–3144.
16. Knapp, M. J. (1997). Economic evaluations and
interventions for children and adolescent with
mental health problems. J Child Psychol Psychiatry,
38, 3–25.
17. Knapp, M., Scott, S., & Davies, J. (1999). The cost of
antisocial behavior in younger childern. J Clin Child
Psychol Psychiatry, 40, 457–473.
18. Scott, S., Knapp, M., Henderson, J., & Maughan, B.
(2001). Financial cost of social exclusion: follow up
study of antisocial children into adulthood.
Br Med J., 323, 1–5.
19. Foster, E. M., & Jones, D. Conduct Problems
Prevention Research Group. The high costs of
aggression: public expenditures on conduct disorder.
Am J Public Health In press.
20. Kenkel, D. (1994). Cost of illness approach.
In: D. Kenkel, & R. Fabian (Eds.), Valuing Health for
Policy: An Economic Approach (pp. 42–71). Chicago,
Ill: University of Chicago Press.
21. Kenkel, D., Berger, M., & Blomquist, G. (1994).
Contingent valuation of health. In: D. Kenkel,
& R. Fabian (Eds.), Valuing Health for policy: An
Economic Approach (pp. 72–104). Chicago, Ill:
University of Chicago Press.
Costs of ADHD
22. Cook, P. J., & Ludwig, J. (2000). Gun Violence: The
Real Costs. New York: Oxford University Press.
23. Office of National Drug Control Policy. (2001). The
Economic Costs of Drug Abuse in the United States,
1992-1998. Washington, DC: Executive Office of the
President, Publication NCJ-190636.
24. Tetto, A., Manzoni, P., Millul, A., et al. (2002). The
costs of epilepsy in Italy: a prospective cost-of-illness
study in referral patients with disease of different
severity. Epilepsy Res, 48, 207–216.
25. Lin, T., Chou, P., Lai, M. S., et al. (2001). Direct
costs-of-illness of patients with diabetes mellitus in
Taiwan. Diabetes Res Clin Pract, 54, S43–S46.
26. Plotnick, R. D. (1994). Applying benefit-cost analysis
to substance use prevention programs. Int J
Addictions, 29, 339–359.
27. Thompson, M. S. (1980). Benefit-Cost Analysis for
Program Evaluation. Beverly Hills, Calif: Sage
Publications.
28. Cohen, M. A. (2005). The Costs of Crime and Justice,
London, New York: Oxford University Press.
29. Foster, E. M., Shelton-Johnson, D., & Taylor, T.
(2005). Measuring Time Costs in Psychosocial
Interventions: How and Why. University Park, Pa:
The Pennsylvania State University, The Methodology
Center, Tech Rep No 05-67.
30. Gold, M. R., Russell, L. B., Siegel, J. E.,
& Weinstein, M. C. (1996). Cost-Effectiveness in Health
and Medicine. New York: Oxford University Press.
31. Siegel, J. E., Weinstein, M. C., Russell, L. B.,
& Gold, M. R. (1996). Recommendations for
reporting cost-effectiveness analyses. JAMA, 276,
1339–1341.
32. Smith, D. H., & Gravelle, H. (2001). The practice of
discounting in economic evaluations of healthcare
interventions. Int J Technol Assess Health Care, 17,
236–243.
33. Kelleher, K. J., Childs, G. E., & Harman, J. S. (2001).
Healthcare costs for children with attention-deficit
hyperactivity disorder. Econ Neurosci, 3, 60–63.
34. Jones, D. E., Foster, E. M., & Gottschall, A. The
public cost of attention problems. J Am Acad Child
Adolesc Psychiatry. In press.
35. Jensen, P. S., Garcia, J. A., Glied, S., et al. (2005).
Cost-effectiveness of ADHD treatments: findings
from the Multimodal Treatment Study of
Children with ADHD. Am J Psychiatry, 162,
1628–1636.
36. Burd, L., Klug, M. G., Coumbe, M. J.,
& Kerbeshian, J. (2003). Children and
adolescents with attention deficit-hyperactivity
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
disorder: prevalence and cost of care. J Child Neurol,
18, 555–561.
Burd, L., Klug, M. G., Coumbe, M. J.,
& Kerbeshian, J. (2003). The attention-deficit
hyperactivity disorder paradox: 2. Phenotypic
variability in prevalence and cost of comorbidity.
J Child Neurol, 18, 653–660.
Guevara, J., Lozano, P., Wickizer, T., et al. (2001).
Utilization and cost of health care services for
children with attention-deficit/hyperactivity disorder.
Pediatrics, 108, 71–79.
Leibson, C. L., Katusic, S. K., Barbaresi, W. J., et al.
(2001). Use and costs of medical care for children
and adolescents with and without attention-deficit/
hyperactivity disorder. JAMA, 285, 60–66.
Chan, E., Zhan, C., & Homer, C. J. (2002). Health
care use and costs for children with attention-deficit/
hyperactivity disorder: national estimates from the
Medical Expenditure Panel Survey. Pediatr Adolesc
Med, 156, 504–511.
Birnbaum, H. G., Kessler, R. C., Lowe, S. W., et al.
(2005). Costs of attention deficit-hyperactivity
disorder (ADHD) in the US: excess cost of persons
with ADHD and their family members in 2000.
Curr Med Res Opin, 21, 195–205.
Mandell, D. S., Guevara, J. P., Rostain, A. L.,
& Hadley, T. R. (2003). Medical expenditures among
children with psychiatric disorders in a Medicaid
population. Psychiatr Serv, 54, 465–467.
Swensen, A., Birnbaum, H. G., Ben-Hamadi, R., et al.
(2004). Incidence and costs of accidents among
attention-deficit/hyperactivity disorder patients.
J Adolesc Health, 35, 346–347.
Swensen, A. R., Birnbaum, H. G., Secnik, K., et al.
(2003). Attention-deficit/hyperactivity disorder:
increased costs for patients and their families. J Am
Acad Child Adolesc Psychiatry, 42, 1415–1423.
Forness, S. R., & Kavale, K. A. (2002). Impact of
ADHD on school systems. In: P. S. Jensen,
& J. R. Cooper (Eds.), Attention Deficit Hyperactivity
Disorder (pp. 24-1–24-30). Kingston, NJ: Civic
Research Institue.
Conduct Problems Prevention Research Group.
(1992). A developmental and clinical model for the
prevention of conduct disorders: the Fast Track
Program. Dev Psychopathol., 4, 509–527.
Robb, J. A., Pelham, W. E., Foster, E. M., et al.
Assessing the direct and indirect cost of ADHD and
the disruptive behavior disorders. Poster presented
at: Annual Metting of the Association for Behavioral
725
726
Pelham, Foster, and Robb
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
and Cognitive Therapies; the 39th AABT Annual
Convention, November 18–20, 2005;
Washington, DC.
Faden, V. B., Day, N. L., Windle, M., et al. (2004).
Collecting longitudinal data through childhood,
adolescence, and young adulthood: methodological
challenges. Alcohol Clin Exp Res., 28, 330–340.
Stiffman, A. R., Horwitz, S. M., Hoagwood, K.,
et al. (2000). The Service Assessment for
Childern and Adolescents (SACA): adult and child
reports. J Am Acad Child Adolesc Psychiatry, 39,
1032–1039.
Loeber, R., Farrington, D. P., Stouthamer-Loeber, M.,
& VanKammen, W. B. (1998). Antisocial Behavior
and Mental Health Problems: Explanatory Factors in
Childhood and Adolescence. Mahwah, NJ: Lawrence
Erlbaum.
American Academy of child and Adolescent
Psychiatry. (2002). Practice parameters for the use of
stimulant medications in the treatment of childern,
adolescents, and adults. J Am Acad Child Adolesc
Psychiatry, 41, 26S–49S.
Medco Publications. Online Drug Report Trend (May
2004, vol 6, issue 1) www.medco.com.
Rowland, A. S., Umbach, D. M., O’Callaghan, J. P.,
et al. (2002). Public health and toxicological issues
concerning stimulant treatment for ADHD.
In: P. S. Jensen, & J. R. Cooper (Eds.), Attention
Deficit Hyperactivity Disorder: State of the science-Best
Practices (pp. 10-1–10-16). Kingston, NJ: Civic
Research Institue.
Marchetti, A., Magar, R., Lau, H., et al. (2001).
Pharmacotherapies for attention-deficit hyperactivity
disorder: expected cost-analysis. Clin Therapeutics,
23, 1904–1021.
Pelham, W. E., Gnagy, E. M., Burrows-MacLean, L.,
et al. (2001). Once-a-day ConcertaTM methyphenidate versus t.i.d. methyphenidate in laboratory and
natural settings. Pediatrics [serial online]. 107.
www.pediatrics.org/cgi/content/full/107/6/e105.
Pelham, W. E., & Fabiano, G. A. Empirically
supported treatments for ADHD. J Clin Child Adolesc
Psychol. In press.
Bussing, R., Zima, B. T., Perwien, A. R., et al. (1998).
Children in special education programs:
attention deficit hyperactivity disorder, use of
services, and unmet needs. Am J Public Health, 88,
880–886.
Hoagwood, K., Kelleher, K. J., Feil, M.,
& Comer, D. M. (2000). Treatment services for
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
children with ADHD: a national perspective. J AM
Acad Child Adolesc Psychiatry, 39, 198–206.
Leslie, L. K., & Wolraich, M. D. (2007). ADHD
Service Use Patterns in Youth. Ambulatory Pediatrics,
7(Suppl), 107–120.
Lipscomb, J., Ancukiewicz, M., Parmigiani, G., et al.
(1998). Predicting the cost of illness: a comparsion
of alternative models applied to stroke. Med Decis
Making, 18, S39–S56.
Parmigiani, G. (2002). Measuring uncertainty in
complex decision analysis models. Stat Methods Med
Res., 11, 513–537.
Parmigiani, G. (2002). Modeling in Medical
Decision Making: a Bayesian Approach. Chichester,
NY: J Wiley.
Samsa, G. P., Reutter, R. A., Parmigiani, G., et al.
(1999). Performing cost-effectiveness analysis by
integrating randomized trial data with a
comprehensive decision model: application to treatment of acute ischemic stroke. J Clin Epidemiol, 52,
259–271.
Anastopoulos, A. D., Guevremont, D. C.,
Shelton, T. L., & DuPaul, G. J. (1992). Parenting
stress among families of children with attention
deficit hyperactivity disorder. J Abnorm Child Psychol,
20, 503–520.
Johnston, C., & Mash, E. J. (2001). Families of
children with attention-deficit/hyperactivity
disorder: review and recommendations for future
research. Clin Child Fam Psychol Rev, 4, 183–207.
Pelham, W. E., Lang, A. R., Atkeson, B., et al.
(1997). Effects of deviant child behavior on parental
distress and alcohol consumption in laboratory
interactions. J Abnorm Child Psychol, 25, 413–422.
Flory, K., Molina, B., Pelham, W., et al. Childhood
ADHD predicts risky sexual behavior in adolescence
and young adulthood. J Clin Child Adolesc Psychol.
In press.
Pelham, W. E., Massetti, G. M., Wilson, T., et al.
(2005). Implementation of a comprehensive schoolwide behavioral intervention: the ABC program.
J Attention Def Dis, 9, 248–260.
Chamberlain, P., & Patterson, G. R. (1995).
Discipline and child compliance in parenting. In
M. Bornstein (Ed.), Handbook of Parenting, Applied
and Practical Parenting, Vol 4 (pp. 205–225).
Mahwah, NJ: Lawrence Erlbaum Associates.
Angold, A., Costello, E. J., Farmer, E. M. Z., et al.
(1999). Impaired but undiagnosed. J Am Acad Child
Adolesc Psychiatry, 38, 129–137.
Costs of ADHD
71. Jimerson, S. R., Egeland, B., Sroufe, L. A.,
& Carlson, B. (2000). A prospective longitudinal
study of high school dropouts: examining multiple
predictors across development. J School Psychol, 38,
525–549.
72. Pelham, W. E., Fabiano, G. A., & Massetti, G. M.
(2005). Evidence-based assessment of attentiondeficit/hyperactivity disorder in children and
adolescents. J Clin Child Adolesc Psychol, 34,
449–476.
727