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Attention deficit disorder was identified as long ago as 1775, but the concept has only relatively recently entered the public consciousness. Let’s take a look at some common misconceptions and learn more about this often misunderstood diagnosis in regards to underwriting.
Most people are familiar with the term ADHD. It is shorthand for a mental and behavioral diagnosis known as attention deficit/hyperactivity disorder. Its name is misleading because even though it points to a deficit, we now know that it is not a deficit in the true sense, but rather a problem of regulation.
Put simply, people with ADHD do not have too little attention capacity: their problem is that they have a lot of attention but can’t prioritize and filter incoming stimuli. The psychiatrist and author Dr. Ned Hallowell compares the ADHD brain to a sports car with only bicycle brakes:1 there’s a lot of power, but it’s difficult to dial down or target that power efficiently.
Patients who suffer less from hyperkinetic symptoms (motoric hyperactivity) have modified this metaphor. For them it “feels like driving a sluggish car in a snowstorm, on slippery roads and in poor visibility. The petrol tank is almost empty, and the dashboard is flashing and beeping. Add to that a couple of rowdy kids in the back seat and an angry spouse in the passenger seat.”2
There is simply too much going on at once and the actual task, such as arriving safely at the destination, is hardly possible without making errors and arriving completely exhausted.
The symptoms of ADHD can be divided into three main areas: 1) hyperactivity; 2) attention issues; and 3) impulsivity.
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In a study involving more than 550 subjects who were diagnosed as children and followed over a period of up to 16 years, ADHD was found to be both fluctuating and recurrent in many adolescents and young adults.3 Although about 30% of the study participants reported a complete remission of ADHD symptoms during the study, 60% of these subjects showed clinically significant symptoms again at a later point in time.
Only 9% of the participants reported an actual long-lasting remission of symptoms and about 10% a stable symptomatology. A large proportion experienced fluctuating symptoms (almost 64%).
As the subjects of this study were on average 25 years old at the end of data collection, it is not certain whether the findings can be applied to older cohorts. However, it is known from clinical practice that many patients do not experience a symptom-free daily life.
Despite the inclusion of adult ADHD in the ICD and DSM diagnostic manuals and study results that include adult ADHD, the idea that it affects only children and no longer occurs in adults persists in society.
Most children who are diagnosed early are sent to a specialist after the parents are advised to do so by a teacher. They disrupt school lessons and experience interpersonal issues with other children. Children with ADHD who do not have clear motorical hyperactivity are often rather quiet, however, and are thus less likely to be referred to a child psychiatrist for diagnosis.
These “daydreamers” also experience significant problems, but ADHD is rarely suspected as the underlying factor in their forgetful and introverted behaviour. Women and girls, more often than boys, experience hyperactivity mentally rather than motorically and are therefore diagnosed much later, or not at all.
However, when these patients have to plan a regular daily routine for themselves, e.g. when leaving for university, it quickly becomes apparent how difficult it is for them to be self-motivated, to plan and organize. If the parents did not notice any symptoms during early childhood, a diagnosis was almost impossible until now.
Many women who are not diagnosed until adulthood have already been diagnosed with depression or anxiety, which turns out to be a side-effect or sequela of the untreated ADHD. With successful ADHD therapy put in place, their symptoms usually improve significantly or become subclinical.
How should insurers deal with applicants who declare a diagnosis of ADHD? First, it depends on the product being underwritten. With life insurance, it’s important to record whether the person is receiving treatment. If not, a chief medical officer should look at the individual circumstances of the case. For applicants receiving treatment (e.g. Ritalin), the excess mortality of ADHD alone is minimal and thus not necessarily subject to a premium.
In occupational disability, several factors play a role. First, it’s important to determine whether the applicant is an adult or a child/adolescent. In the case of children and adolescents without psychological comorbidities, we advise postponing until they enter working life. For adult applicants, we ask for the age of diagnosis. Applicants who were diagnosed in adulthood usually have a slightly lower risk of becoming unable to work.
Here, too, we look at the treatment regimen. For adults, we know that a combination of pharmacological interventions and psychotherapeutic treatment has a significant positive influence on the risk.
Finally, we consider factors that can positively or negatively influence the risk, such as qualifications (e.g. a high school diploma), psychiatric comorbidities and addiction problems. As mentioned, some comorbidities may have been diagnosed before the ADHD was discovered. Therefore, in the case of depression and anxiety disorders, it is important to determine whether they are still being treated or whether they were sequelae of the undiagnosed/untreated ADHD.
In summary, ADHD will play a role in the daily life of adult applicants even if the condition was diagnosed early in life. Factors such as medication status and mental comorbidities should be taken into account when underwriting such cases.
