Attention deficit hyperactivity disorder (ADHD) in adults is a relatively new and complex disorder. It was not diagnosed until the mid-1970s due to a general lack of awareness. All that has changed in the last decade as clinicians are better prepared to recognize and treat this disorder. This newsletter looks at the latest findings on adult ADHD and discusses its impact on the underwriting of life insurance.
Childhood ADHD is a common, genetically transmitted disorder (i.e. occurring in 50% of first degree relatives). It affects 6% to 9% of all children. Childhood ADHD core symptoms are hyperactivity, inattention and impulsivity. The American Psychiatric Association recognizes three types of ADHD:
- Predominately hyperactive, impulsive type
- Predominately inattentive type
- Combined type
ADHD was once thought to disappear as children grow up. New data suggests that one to two thirds of children with ADHD continue to have significant symptoms throughout life. It is estimated that 4% of the adult population has ADHD.
There are two main groups of adults with ADHD:
- Those who were diagnosed as children and still have symptoms.
- Those who were never diagnosed.
There are no definitive tests for ADHD. Diagnosing ADHD in an adult requires the following:
- Verification of onset of symptoms by age 7
- Impairment from symptoms in at least two settings
- Significant impairment in social, academic or occupational functioning.
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“Adult-onset” ADHD is not a valid diagnosis and most likely represents another condition. |
It is important to remember that the diagnosis of ADHD in adults can be a complex process. By definition, ADHD has it onset in childhood. However, not everyone has an accurate recall of his of her early life and verification may prove difficult. In addition, there is a decrease in the observable symptoms of ADHD with age. The formal restlessness and hyperactivity that occurs in children becomes internal restlessness for adults with ADHD. Lastly, comorbidity (having two or more diagnosable conditions at the same time) is widely prevalent in adult ADHD, affecting up to 3 out of 4 individuals with the disorder. These comorbid conditions include:
- Major depression
- Bipolar disorder
- Dysthymia (chronic, low level depression)
- Anxiety disorders
- Substance abuse
- Learning disorders
In order to diagnose adult ADHD, some level of childhood core symptoms (hyperactivity, inattention and impulsivity) must be present.
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Treatment of adult ADHD usually involves both medication and psychosocial therapy. |
Medications proven effective in treating childhood ADHD have been found useful in treating the adult version. It is important to remember that no medications are specifically approved for the treatment of adult ADHD. Medications currently used to treat adult ADHD are all considered “off label” treatment (i.e. clinical uses of medications that have not been approved by the US Food and Drug Administration). In addition, it appears that these medications are better at addressing hyperactivity and inattention than impulsivity.
Stimulant preparations, including Ritalin, Concerta, Metadate and Adderall are usually used first in treating adult ADHD. In the last several years, several long acting form of these medications have been introduced and allowed patients once a day dosing.
In addition to stimulants, non-stimulants can be used to treat adult ADHD. These include:
- Effexor
- Wellbutrin
- Strattera
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Strattera may prove to be the first FDA medication for adult ADHD. |
Psychosocial therapy for adults ADHD usually involves:
- Psychotherapy addressing how ADHD affects the person’s life (relationships and functioning).
- Education about the disorder.
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Underwriting Q & A |
Q: What are the underwriting concerns for adult ADHD?
A: There are three primary areas of concern.
- There is a high incidence of depression with adult ADHD. Depression carries its own underwriting risks. In addition, stimulants have been known to increase the severity of depression, which could pose an additional underwriting risk.
- There is a motor vehicle driving risk with adult ADHD. This includes a higher risk for accidents, more citations for speeding and worse accidents.
- There is higher incidence of substance abuse with adult ADHD. This includes an earlier onset of substance abuse, a longer period of active abuse and a lower rate of recovery.
Q: How do you screen applicants with known ADHD?
A: The screening process involves obtaining answers to the following questions:
- When the client was diagnosed with ADHD
- What are the client’s current medications
- What is the client’s driving history (i.e. any accidents, speeding citations, DUI incidents)
- Does the client have any history of depression or substance abuse?
Q: Can these individuals with adult ADHD get preferred rates?
A: Yes. The diagnosis of ADHD in adults does preclude preferred rates in applicants who do not have comorbid conditions that represent an additional underwriting risk.
Q: Are there any underwriting “clues” that suggest an applicant has ADHD?
A: The only clue that may point to adult ADHD is the client’s medications. Stimulants like Ritalin are uncommon in adults outside of treating ADHD. Some times an applicant will suggest that Ritalin is being used to treat depression. In most cases a closer look will uncover an ADHD diagnosis.
