Adults can have ADHD too
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.
Women and girls with ADHD
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.
ADHD in underwriting
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.
- Hallowell, Edward M. (1994) Driven to distraction. New York: Pantheon Books.
- [Platyhelminthes88]. (2022, 14 June) Metaphor: driving the ADHD car. [Onlineforum Eintrag]. https://www.reddit.com/r/ADHD/comments/vboa07/metaphor_driving_the_adhd_car/.
- Sibley et al. (2022) Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. Vol. 179 (2): 142‑151.