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The association between attention-deficit/hyperactivity (ADHD) symptoms and self-employment



Attention-deficit/hyperactivity (ADHD) symptoms have been associated with the decision to become self-employed. Although these symptoms are generally regarded as disadvantageous, there may also be a bright side. To our knowledge, however, there has been no systematic, epidemiological evidence to support this claim. This paper examines the association between ADHD symptoms and self-employment in a population-based sample from the STAGE cohort of the Swedish Twin Registry (N = 7208). For replication, we used a sample of Dutch students who participated in the Global University Entrepreneurial Spirit Students' Survey (N = 13,112). In the Swedish sample, we found a positive association with self-employment for both general ADHD symptoms [odds ratio (OR) 1.13; 95 % confidence intervals (CI) 1.04-1.23] and hyperactivity symptoms [OR 1.19; 95 % CI 1.08-1.32], whereas no association was found for attention-deficit symptoms [OR 0.99; 95 % CI 0.89-1.10]. The positive association between hyperactivity and self-employment was replicated in the Dutch student sample [OR 1.09; 95 % CI 1.03-1.15]. Our results show that certain aspects of ADHD, in particular hyperactivity, can have a bright side, as they are positively associated with self-employment.
The association between attention-deficit/hyperactivity (ADHD)
symptoms and self-employment
Ingrid Verheul
Wim Rietdijk
Joern Block
Ingmar Franken
Henrik Larsson
Roy Thurik
Received: 24 February 2015 / Accepted: 4 May 2016 / Published online: 13 May 2016
ÓThe Author(s) 2016. This article is published with open access at
Abstract Attention-deficit/hyperactivity (ADHD) symp-
toms have been associated with the decision to become
self-employed. Although these symptoms are generally
regarded as disadvantageous, there may also be a bright
side. To our knowledge, however, there has been no sys-
tematic, epidemiological evidence to support this claim.
This paper examines the association between ADHD
symptoms and self-employment in a population-based
sample from the STAGE cohort of the Swedish Twin
Registry (N =7208). For replication, we used a sample of
Dutch students who participated in the Global University
Entrepreneurial Spirit Students’ Survey (N =13,112). In
the Swedish sample, we found a positive association with
self-employment for both general ADHD symptoms [odds
ratio (OR) 1.13; 95 % confidence intervals (CI) 1.04–1.23]
and hyperactivity symptoms [OR 1.19; 95 % CI
1.08–1.32], whereas no association was found for atten-
tion-deficit symptoms [OR 0.99; 95 % CI 0.89–1.10]. The
positive association between hyperactivity and self-em-
ployment was replicated in the Dutch student sample [OR
1.09; 95 % CI 1.03–1.15]. Our results show that certain
aspects of ADHD, in particular hyperactivity, can have a
bright side, as they are positively associated with self-
Keywords Attention-deficit Hyperactivity Symptoms
ADHD Self-employment
Prominent entrepreneurs have publicly credited their
attention-deficit hyperactivity (ADHD) symptoms as a
driver of their decision to become self-employed [13].
Examples include Ingvar Kamprad (founder of IKEA) and
Richard Branson (founder of the Virgin Group) [2,3]. The
Economist recently published a short article addressing the
suitability of self-employment for people who experience
ADHD symptoms [4].
ADHD is a neurodevelopmental disorder characterised
by attention-deficit and hyperactivity [57]. The onset of
ADHD is typically during childhood (before the age of 12),
and it is therefore often regarded as a childhood disorder.
Studies following children with a diagnosis of ADHD have
shown that ADHD symptoms are persistent over time, at
least into early adulthood [6,811], with 65 % of indi-
viduals still having a full ADHD diagnosis or partial
remission at the age of 25 [12]. Recent research has
&Ingrid Verheul
Rotterdam School of Management, Erasmus University
Rotterdam, P.O. Box 1738, 3000 DR Rotterdam,
The Netherlands
Erasmus School of Economics, Erasmus University
Rotterdam, Rotterdam, The Netherlands
Institute for Behavior and Biology (EURIBEB), Erasmus
University Rotterdam, Rotterdam, The Netherlands
Professur fu
¨r Unternehmensfu
¨hrung, Universita
¨t Trier, Trier,
Erasmus Research Institute of Management (ERIM), Erasmus
University Rotterdam, Rotterdam, The Netherlands
Institute of Psychology, Erasmus University Rotterdam,
Rotterdam, The Netherlands
Montpellier Business School, Montpellier, France
Department of Medical Epidemiology and Biostatistics,
Karolinska Institutet, Stockholm, Sweden
Karolinska Institutet Center of Neurodevelopmental
Disorders (KIND), Stockholm, Sweden
Eur J Epidemiol (2016) 31:793–801
DOI 10.1007/s10654-016-0159-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
devoted more attention to increasing our understanding of
the persistence of ADHD symptoms in (young) adults [13].
Furthermore, the most recent DSM criteria were adjusted to
enable a diagnosis across the lifespan and not only during
childhood [14].
Although prior research has mainly focused on the
negative consequences of ADHD for individual perfor-
mance in formal education and wage employment [1519],
recent studies have highlighted positive aspects of ADHD
symptoms, such as its association with resilience and well-
being [20], close friendship [21], and third-party inferences
about an individual’s generative qualities (being creative,
visionary, good at generating ideas) [22]. In the present
study, we focus on a potential positive aspect of ADHD:
self-employment as a career choice. Self-employment is
not just any career choice but is a manifestation of
entrepreneurship that is essential for employment creation,
innovation and the economic growth of modern societies
[23,24]. It can be used as an economic instrument in the
business cycle [25] and to lift people out of unemployment
In the popular press, it has been suggested that indi-
viduals with ADHD symptoms are able to break through
organisational inertia due to their ability to envision and
create new ‘realities’ and (successfully) start their own
ventures [24]. Allegedly, when individuals who experi-
ence ADHD symptoms succeed in developing mechanisms
to cope with their ‘weaknesses’, they would be able to
exploit their extraordinary talents and perform just as well
as or even better than their peers in business [2,27,28].
Academic research has found only circumstantial evidence
linking ADHD symptoms to self-employment when
examining the association with entrepreneurial intentions
[29], creativity [3032], risk-taking [33], and proactivity
[5]. To our knowledge, there is no systematic, epidemio-
logical evidence supporting a link between ADHD symp-
toms and self-employment.
The present study was designed to examine the associa-
tion between self-reported ADHD symptoms and self-em-
ployment in a population-based sample of 7208 individuals
from the STAGE cohort of the Swedish Twin Registry of the
Karolinska Institute. The findings were replicated in a
sample of 13,119 students participating in the Global
University Entrepreneurial Spirit Students’ Survey
(GUESSS) 2011 in the Netherlands. Given the discussions
in the (popular) literature and the circumstantial scholarly
evidence, we expected a positive association between
ADHD symptoms and the decision to become self-em-
ployed [14,29]. We should emphasise that the present
study does not focus on ADHD as a full-blown psychiatric
disorder. For the purpose of the present research, self-re-
ported psychiatric symptoms are defined along a continuum
[34] and not as a psychiatric classification.
Swedish twin registry: STAGE cohort
as the discovery sample
We used the STAGE (Swedish Twin Studies on Adults:
Genes and Environment) cohort from the Karolinska
Institute in Stockholm, Sweden, as the discovery sample.
The STAGE cohort is part of the population-representative
Swedish Twin Registry (STR), which was established in
the 1950s to study the effects of smoking and drinking on
cancer and cardiovascular diseases [35]. At present, the
STR contains rich data about biological and clinical
markers together with the socio-economic background of
twins living in Sweden [35]. For a full account of the
design and execution of the STR project and details of the
ADHD data in the STAGE cohort, we refer to Lichtenstein
et al. [35] and Larsson et al. [10], respectively.
All twins born between 1959 and 1985 (a total of 42,582
twins) received an invitation letter with information about
the project in May and June 2005. The response rate was
59.6 % (N =25,364, 56 % female, age[mean] =41.56,
age[sd] =7.6). The entire questionnaire contained
approximately 1300 questions, of which the respondents
answered 800–900 questions on average [35]. Dropouts
could be explained by a general unwillingness to respond
to a lengthy survey [10]. Non-respondents were signifi-
cantly more often male, had at least one parent born outside
Sweden, and were more likely to have been diagnosed with
a psychiatric disorder and convicted of any type of crime
[10,36,37], which may indicate that the most severe cases
did not respond to the questionnaire. This limits generali-
sations to the more severe cases of the ADHD spectrum.
Informed consent was obtained from all individual partic-
ipants included in the study. This project was reviewed and
approved by the ethics committee of the Karolinska
Self-employment measure
Participants answered two questions about their involve-
ment in self-employment: whether they were self-em-
ployed full-time (yes/no) and whether they were self-
employed part-time (yes/no). We constructed one measure
of self-employment (yes/no), which was coded 1 if the
participant was self-employed part-time or full-time and 0
if (s)he was not self-employed. In the STAGE cohort,
14,039 out of 25,364 participants (&55 %) provided their
self-employed status (yes/no). A total of 2096 participants
(&14 %) were self-employed, of whom 1270 (&9%)
were self-employed full-time and 826 (5 %) were self-
employed part-time. Three participants answered ‘yes’ to
both the part-time and full-time self-employment question
794 I. Verheul et al.
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and were excluded from the analysis. Furthermore, we
randomly dropped one twin from each pair because their
similarity would violate the assumption of independent
observations, resulting in a final sample of 7208 partici-
pants (58 % female, age[mean] =43.9, age[sd] =6.7). Of
these respondents, a total of 897 (&12 %) were self-em-
ployed, of whom 515 (&7 %) were self-employed full-
time and 382 (&5 %) were self-employed part-time, which
was similar to the total sample distribution.
Attention-deficit/hyperactivity (ADHD) symptoms
ADHD symptoms were assessed using the Adult ADHD
Self-Report Scale (ASRS-v1.1), which consists of 18 items
reflecting the DSM-IV-TR criteria [10]. Attention-deficit
symptoms and hyperactive symptoms were measured by 9
items each.
Answers for each item were given on a 3-point
Likert scale (0 =‘no’; 1 =‘yes, to some extent’; and
2=‘yes’). The 18 ASRS-v1.1 items were slightly modified
to allow for the assessment of ADHD symptoms in adults
[35]. As can be expected from a non-clinical population
sample, many participants reported having no or few ADHD
symptoms. The average percentage of respondents reporting
inattentive symptoms and hyperactive symptoms (with the
answer ‘yes’) was 3.6 and 4.6 %, respectively. Approxi-
mately one-third of the respondents reported no symptoms
[10]. This result closely resembles the prevalence rate of
adult ADHD reported in Kessler et al. [38].
The symptom scores were added to create a scale of
ADHD symptoms and two sub-scales of attention-deficit
and hyperactivity [10]. Values for the reliabilities of these
three scales in our sample were a=0.84, a=0.78, and
a=0.78, respectively. These reliabilities were similar to
those reported in Larsson et al. [10]. Because the three
scales were highly skewed (skewness: ADHD, 1.66;
attention-deficit, 1.77; hyperactivity, 1.72), the scales were
log-transformed (Log10[x ?1], where x is the initial
value) to normalise their distributions (skewness after log
transformation: ADHD, -0.16; attention-deficit, 0.27;
hyperactivity, 0.26). As indicated in Larsson et al. [10,
p. 199], the sum score of the 18 ADHD items used in this
study yielded results similar to those reported in other
studies using self- or parent-reported measures of ADHD.
Control variables
In the STAGE cohort, we included the following demo-
graphic variables: age, gender, and whether the participant
attended university (0 =no, 1 =yes) as an initial test to
control for additional effects.
GUESSS study: replication
We attempted to replicate the analysis linking ADHD
symptoms to self-employment in a student sample from the
Global University Entrepreneurial Spirit Students’ Survey
2011 in the Netherlands. GUESSS is an
international research consortium that studies the career
objectives of students in higher education. In the Nether-
lands, students at 14 universities and 24 polytechnics
received a link to the online survey through email. After
1 month, a reminder was sent. Two randomly drawn par-
ticipants received an iPad 2.0 to reward their participation.
To prevent self-selection of students with entrepreneurial
intentions, the topic of the survey was announced as future
career paths. The GUESSS Netherlands study was in line
with the Erasmus Research Institute of Management
review board’s standards and did not include clinical or
patient data [29].
The response rate for the GUESSS study was 7.6 % for
educational institutions that systematically recruited par-
ticipants [29], leading to an overall database of 13,119
students (56 % female, age [mean] =22.96, age
[sd] =0.49), of whom 374 were student entrepreneurs
(i.e., reported having their own business during their
studies). Comparing the GUESSS Netherlands sample with
the global GUESSS sample reported in Sieger et al. [39],
we found that our (Dutch) sample was representative in
terms of socio-demographic characteristics and the preva-
lence of student entrepreneurs. Specifically, in our sample,
56 % of the respondents were female compared to a global
average of 55.2 %, and the average age of 23 was within
the mid-range age of the international average, which is
between 20 and 27 years [39]. Furthermore, 2.9 % of the
students in our study had their own company, compared to
a global average of 2.5 % student entrepreneurs [39].
In the GUESSS study, self-employment was measured as
a dichotomous variable indicating whether students were
self-employed in their own founded firm during their studies.
ADHD symptoms were measured using the six-item Adult
ADHD Self-Report Scale v1.1 (ASRS v1.1) screener,
developed by Kessler et al. [38,40], which consists of the six
most predictive ADHD symptoms of the 18 DSM-IV-TR
criteria used in the STAGE study. This enabled us to repli-
cate the analysis in the STAGE cohort. Each item was
answered on a 5-point Likert scale (1 =never to 5 =al-
ways). Although the measures were different, the screener
and the full 18-item measure were found to be highly
Throughout the paper we refer to hyperactivity symptoms, although
the ASRS v1.1 measure is slightly broader given that it includes three
items related to impulsivity.
For more information about GUESSS, we refer to http://www.
The association between attention-deficit/hyperactivity (ADHD) symptoms and self-employment 795
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correlated [38,40]. Average scores were computed for
ADHD symptoms (based on six items, a=0.59), attention-
deficit (based on four items, a=0.62), and hyperactivity
(based on two items, a=0.43). Although these scales had
low to moderate reliability, they were still close to the lower
bound of reported reliabilities for the ASRS screener ques-
tions in Kessler et al. [40] (see Verheul et al.) [29]. The three
scales were only moderately skewed: sample skewness for
the ADHD symptom scale, the attention-deficit scale, and
the hyperactivity scale amounted to 0.21, 0.35, and 0.06,
respectively, with a standard error of 0.02. These skewness
measures indicated that log-transformation of the variables
was not necessary. Given that the GUESSS study consisted
of only students from universities and polytechnics, we only
included age and gender as control variables in the model.
Statistical analysis
To examine the association between ADHD symptoms and
self-employment, we estimated binary logistic regressions.
First, in the STAGE cohort, we examined the association
between the sum score on the DSM-IV diagnostic criteria
items for all ADHD symptoms (18 items), attention-deficit
and hyperactivity symptoms (each 9 items), and self-em-
ployment (part-time/full-time). Second, we replicated this
analysis using data from the GUESSS study. Specifically, we
estimated the associations between the sum score on the
ASRS-6 v1.1 screener items for all ADHD symptoms (6
items), attention-deficit symptoms (4 items), hyperactivity
symptoms (2 items), and self-employment. We report the
effect sizes in terms of odds ratios (OR) and the associated
95 % confidence intervals (95 % CI). In the tables, we denote
statistical significance (pvalues at 5, 1, and 0.1 % levels,
respectively) using asterisks (*, **, and ***, respectively).
STAGE cohort
In Table 1, we present the results of the binary logistic
regressions explaining self-employment (part-time/full-
time). We found a positive association with self-employ-
ment for both general ADHD symptoms (OR 1.13; 95 %
CI 1.04–1.23) and hyperactivity symptoms (OR 1.19; 95 %
CI 1.08–1.32) but not for attention-deficit symptoms (OR
0.99; 95 % CI 0.89–1.10).
GUESSS study: replication
We attempted to replicate the association between ADHD
symptoms and self-employment using the GUESSS 2011
data. The results of the binary logistic regressions are
presented in Table 2. We found no evidence of an asso-
ciation between general ADHD symptoms and self-em-
ployment (OR 1.00; 95 % CI 0.97–1.02). However, when
we separated attention-deficit and hyperactivity, we found
a negative association between self-employment and
attention-deficit symptoms (OR 0.95; 95 % CI 0.92–0.99)
and a positive association between self-employment and
hyperactivity symptoms (OR 1.09; 95 % CI 1.03–1.15).
To summarise, we found a positive association between
(general) ADHD symptoms and self-employment in the
STAGE cohort that could not be replicated (i.e.,
Table 1 STAGE cohort; Binary logistic regressions with self-em-
ployment (part-/full-time) as dependent variable and general ADHD
symptoms, and the two sub-scales attention-deficit symptoms and
hyperactivity symptoms as independent variables
(1) (2)
General ADHD symptoms 1.13**
Attention-deficit symptoms 0.99
Hyperactivity symptoms 1.19***
N 7208 7208
Log-likelihood -2599 -2597
df 4 5
Chi-square 209.2 222.7
Pseudo R-square 0.04 0.04
The coefficients are odds ratios (ORs) and 95 % confidence intervals
(CI) are in parentheses; *** p\0.001, ** p\0.01, * p\0.05
Both models control for age, gender, and university education
(0 =no and 1 =yes)
Table 2 GUESSS study; Binary logistic regressions with self-em-
ployment (part-/full-time) as dependent variable and general ADHD
symptoms, and the two sub-scales attention-deficit symptoms and
hyperactivity symptoms as independent variables
(1) (2)
General ADHD symptoms 0.99
Attention-deficit symptoms 0.89*
Hyperactivity symptoms 1.13*
N 13,119 13,119
Log-likelihood -3189 -3183
df 3 4
Chi-square 208.5 214.8
Pseudo R-square 0.07 0.07
The coefficients are odds ratios (ORs) and 95 % confidence intervals
(CI) are in parentheses; *** p\0.001, ** p\0.01, * p\0.05
Both models control for age, and gender
796 I. Verheul et al.
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insignificant) in the GUESSS study. Furthermore, the
association between attention-deficit symptoms and self-
employment was significantly negative in the GUESSS
study and insignificant in the STAGE cohort. Finally, the
association between hyperactivity symptoms and self-em-
ployment was significantly positive in both the STAGE
cohort and the GUESSS study.
Sensitivity and additional analyses
We performed a series of sensitivity analyses using both
the STAGE and GUESSS data. First, we reran the logistic
regressions using the entire STAGE database, including
pairs of twins instead of randomly dropping one twin, and
clustered the standard error at the family level to account
for the joint characteristics of twins. In the larger sample of
approximately 11,000 respondents, the association between
ADHD symptoms and self-employment remained intact
(OR 1.23; 95 % CI 1.13–1.34). Furthermore, the results of
the sub-scales remained stable: attention-deficit was not
significantly associated with self-employment (OR 1.02;
95 % CI 0.94–1.11), and hyperactivity was positively
associated with self-employment (OR 1.19; 95 % CI
Second, to compare the results of the GUESSS study
with those of the STAGE cohort, we examined the asso-
ciations between ADHD symptoms and self-employment
in the STAGE cohort using the 6 items from the ASRS-6
v1.1 screener instead of the 18 item ASRS-v1.1 score. In
line with the GUESSS findings, we found no evidence of a
significant association between general ADHD symptoms
and self-employment (OR 1.04; 95 % CI 1.00–1.09).
However, we did not find support for a significant (nega-
tive) association between self-employment and attention-
deficit symptoms (OR 0.97; 95 % CI 0.9–1.03). We did
find a positive association between hyperactivity symptoms
and self-employment (OR 1.04; 95 % CI 1.00–1.09), which
is in agreement with the analyses.
Third, we examined the association between ADHD
symptoms and self-employment using a stricter definition
of ADHD that was closer to an actual psychiatric diagnosis
[10]. In the STAGE data, we used the ‘‘strict criteria’
score: in the responses to the DSM-IV 18 items, 1 (‘‘yes’’)
was recoded to yes and 2 or 3 (‘‘yes, to some extent’’ or
‘no’’) were recoded to no. The outcomes supported those
of the initial analysis. The association between ADHD
symptoms and self-employment became stronger (OR:
1.35; 95 % CI 1.00–1.81), which was also true for hyper-
activity (OR: 1.54; 95 % CI 1.03–2.29). In the GUESSS
data, for each of the ASRS-6 v1.1 items, we examined
whether the score was beyond the threshold level
(‘yes =1’ and ‘no’ =‘0’) and constructed new scale
variables for ADHD symptoms, attention-deficit and
hyperactivity based on the sum of the dummy (0,1) scores
on six, four and two items, respectively. The findings
remained stable for ADHD symptoms (not significant, OR:
1.00; 95 % CI 0.93–1.07), attention-deficit (significant,
OR: 0.90; 95 % CI 0.82–0.98), and hyperactivity (signifi-
cant, OR: 1.27; 95 % CI 1.11–1.47).
Fourth, we re-estimated the logistic regressions includ-
ing additional control variables. Specifically, because
unemployment is an important push factor for self-em-
ployment [26] and because individuals who experience
ADHD symptoms have a higher chance of unemployment
[38,41], we added a control variable in the analyses with
the STAGE data that captured whether the individual had
mainly been unemployed or hardly worked in the 3 years
preceding the survey. The association between ADHD and
self-employment remained positive and significant (OR:
1.15; 95 % CI 1.06–1.25). This was also true for hyper-
activity (OR: 1.19; 95 % CI 1.07–1.32). Furthermore, we
controlled for personality characteristics of people with
ADHD symptoms. We included measures for extraversion
and neuroticism to account for the fact that ADHD
symptoms have been linked to (higher) neuroticism [42,
43] and extraversion [44]. These Big Five Factor traits have
also been linked with self-employment [45,46]. When
controlling for these two personality factors, both gen-
eral ADHD symptoms (OR: 1.17; 95 % CI 1.06–1.29) and
hyperactivity (OR: 1.14; 95 % CI 1.02–1.28) remained
significantly positive. In the analyses with the GUESSS
data, we were able to control for factors that are generally
associated with self-employment status, including self-
employed parents, study field and level. In particular,
parental role models have been linked with the decision to
become self-employed [47,48]. Accounting for the afore-
mentioned factors in the analyses, the results were stable,
and only attention-deficit and hyperactivity were signifi-
cantly associated with self-employment (attention-deficit,
OR: 0.96; 95 % CI 0.92–0.99; hyperactivity, OR: 1.07;
95 % CI 1.01–1.13).
Overall, the association between ADHD symptoms and
self-employment remained intact but became insignificant
when more controls were added. In the STAGE data, this
For the analyses including the ADHD symptom scale (plus
controls), the log pseudo likelihood was -2705, the pseudo R-square
was 0.06, and the Wald Chi-square was 319.4. Standard errors were
adjusted for 8434 clusters in pair ID (identifying twins). For the
analyses separating attention-deficit and hyperactivity, the log pseudo
likelihood amounted to -4118, the pseudo R-square was 0.04, and the
Wald Chi-square was 354.8. Standard errors were adjusted for 8771
clusters in pair ID.
In line with Kessler et al. [38,40], the reliability coefficients
(Cronbach’s alpha) for general ADHD symptoms, attention-deficit
symptoms and hyperactivity symptoms were 0.59, 0.58, and 0.50,
respectively, indicating that the scales were moderately reliable.
The association between attention-deficit/hyperactivity (ADHD) symptoms and self-employment 797
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was the case when considering whether someone was
mainly wage employed in the past 3 years. This is not
surprising given the fact that approximately 60 % of the
respondents were currently wage employed and had mainly
been working in wage jobs in the past 3 years. In the
GUESSS data, the association between ADHD symptoms
and self-employment appeared sensitive to the inclusion of
career motives (e.g., challenge, realising a dream, income,
financial security, innovation, opportunity exploitation,
high position, flexibility, own boss, social mission), which
may be related to the importance of the person-occupation
fit for individuals with ADHD symptoms [29].
Finally, using the STAGE data, we tested for linkages
between ADHD symptoms and other occupations. The
findings showed no association with wage employment
(OR: 0.96; 95 % CI 0.90–1.03), suggesting that a regular
wage job may not be as suitable as self-employment for
people with high levels of ADHD symptoms. Together
with our finding that ADHD symptoms are positively
associated with unemployment (OR: 1.24; 95 % CI
1.12–1.37), we are unable to reject a potential push effect
by which people with ADHD symptoms become self-em-
ployed because of a lack of (suitable) alternative
The present study moved beyond the clinical view of
ADHD as a pathological disorder and used the symptoms
of ADHD across the entire measurement spectrum to
examine a potentially positive aspect: the association of
ADHD with the involvement in self-employment. Hence,
the aim of this study was not to diagnose individuals with
ADHD and then examine the viability of self-employment
as a career option. Instead, we investigated whether indi-
viduals who exhibit higher levels of ADHD symptoms–but
who do not necessarily screen positive for ADHD in a
clinical sense–are positively associated with self-employ-
ment. In line with previous research, special attention was
paid to whether this association involved general ADHD
symptoms or the separate attention-deficit and hyperactiv-
ity symptom dimensions [10,34,4951].
The present research is part of a series of investigations
on the relation between ADHD and entrepreneurship. In
Verheul et al. [29], the intention to become self-employed
was found to be associated with ADHD symptoms in a
survey of Dutch students. In Thurik et al. [52], the entre-
preneurial orientation, measured using innovativeness, risk
aversion and proactivity [53], was found to be associated
with ADHD symptoms in a survey of French business
owners. The present study investigates involvement in self-
employment. All three studies report a positive association,
although the hyperactivity part seems to dominate. Future
studies should also take into account entrepreneurial per-
formance, such as growth, profits, longevity, and
Two independent samples were used for the present
analysis: Swedish adults (STAGE cohort) and Dutch stu-
dents (GUESSS study). In the Swedish sample, we found a
positive association of both general ADHD symptoms and
hyperactivity symptoms with self-employment, whereas
this association could not be found for attention-deficit
symptoms. The positive association between hyperactivity
symptoms and self-employment was replicated in the
Dutch sample. The effects remained intact in a series of
sensitivity analyses.
ADHD is typically characterised by high energy levels
that are expressed as severe and persistent attention-deficit
and hyperactivity and that are driven by behavioural ‘dis-
inhibition’ or a lack of restraint [22,41,54]. Less attention
is paid to ADHD symptoms for adult decision-making [55],
but it is generally recognised that high levels of attention-
deficit and hyperactivity have negative consequences in the
workplace. Individuals who demonstrate such behaviours
tend to show low job performance and a high chance of
becoming unemployed [5658]. However, the present
results show that ADHD symptoms, particularly hyperac-
tivity, are associated with aspects that may be beneficial for
the individual and society at large.
The present study has implications for further research.
Our results may be an initial step towards establishing a
link between ADHD symptoms and career choices, such as
self-employment, or other manifestations of entrepreneur-
ship. The outcomes of this study may help to ‘destigmatise’
ADHD as a disorder, particularly given the positive asso-
ciations with self-employment in view of its contribution to
socio-economic life. Given the high occurrence of mod-
erate psychiatric symptoms, it is plausible (from a Dar-
winian perspective) that psychiatric symptoms not only
confer risks but can also be beneficial for the individual.
For the field of psychopathology, it is important to study
the potential benefits of demonstrating a high level of
ADHD symptoms [21,32,59,60] across the lifespan [11,
14,27,61]. Such a focus on the value (rather than the cost)
of ADHD is at the heart of a recent stream of literature in
the field of psychiatry (i.e., Darwinian Psychiatry), which
argues that the persistence of such mental ‘disorders’
serves a purpose [27,6163]. According to this research
stream, psychiatric symptoms or genetic variations that are
mostly or currently disruptive for an individual’s work and
private life can–under some circumstances or in mild
forms–be beneficial for the ‘adaptation’ or survival of the
individual. Hence, (young) adults who experience mild to
severe ADHD symptoms may benefit rather than suffer
from them provided they find ways to cope with the
798 I. Verheul et al.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
negative consequences in general and in relation to an
entrepreneurial context [22]. Benefits may be particularly
salient when individuals with ADHD symptoms find a
suitable work environment, such as self-employment,
where the ‘disorder’ is not harmful but instead can be
valuable and help them to function well in society [21,27,
Although the present study only investigates one single
outcome, self-employment as a possibly positive aspect of
ADHD symptoms, it highlights some promising avenues
for future research. First, the current data do not enable us
to examine the association between ADHD symptoms and
the performance of self-employed individuals. The ques-
tion that arises is whether self-employed individuals who
score higher on ADHD symptoms also have better-per-
forming ventures [53]. Second, the decision to become
self-employed may not be the only association with ADHD
symptoms; underlying entrepreneurial behaviours such as
risk-taking and proactivity may share this association [52].
ADHD symptoms may also have ‘positive’ associations
with other socio-economic behaviours for occupational
choice, such as in management and consultancy positions
[24]. Third, to generalise the results of this study, it is
worthwhile to examine the association between ADHD
symptoms and self-employment in other, preferably non-
European, population-based cohorts. It is also important to
distinguish between individuals with a different occupa-
tional status in the control group, including wage
employment and unemployment. A first attempt is reported
in our section on sensitivity analyses. For future research, it
is important to distinguish between these (alternative)
occupations to effectively examine the association with
different control groups.
To conclude, our results indicate that the positive
association between ADHD symptoms and the decision to
become self-employed primarily hinges on the hyperac-
tivity symptoms of ADHD, whereas the overall association
between ADHD symptoms and self-employment is only
significant in one of our two samples. For future research, it
is important to understand how ADHD symptoms are
associated with more specific self-employment and
entrepreneurship behaviours, such as the level of risks
taken or performance in self-employment or as a business
owner. This research may enhance our understanding of the
positive effects of ADHD symptoms or even ‘destigmatise’
ADHD as a disorder that always deserves treatment.
Compliance with ethical standards
Conflicts of interest The authors have no conflicts of interest to
Ethical statement This study was conducted according to the
guidelines in the Declaration of Helsinki. The STAGE cohort study
was approved by the ethics committee of Karolinska Institutet,
Stockholm, Sweden, and all participants provided written informed
consent. The GUESSS study was in line with the Erasmus Research
Institute of Management (ERIM) review board’s standards and did
not include clinical or patient data.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea, which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
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... Indeed, increasing evidence indicates that entrepreneurship is becoming a popular job strategy for people with psychiatric disabilities. In a sample of Swedish twins, Verheul et al. (2016) found that the likelihood of becoming an entrepreneur was positively associated with ADHD symptoms, specifically hyperactive and impulsive symptoms. In another study, Verheul et al. (2015) identified a positive association between ADHD symptoms and entrepreneurial intention among graduate students participating in a global survey, with risk-taking propensity mediating this relationship. ...
... Average ADHD score: Following previous entrepreneurship research on ADHD (e.g., Kessler, et al., 2006;Verheul et al., 2016), we measured ADHD symptoms as a continuous variable that reflects the dimensional view of ADHD-that is, individuals differ in degree in their underlying ADHD trait. Specifically, we relied on the established Adult ADHD Self-report Scale (ASRS-v1.1) ...
Full-text available
Adopting the person-environment (P-E) fit theory, this study examines the relationship between physical (i.e., hearing and mobility) and psychiatric (i.e., attention deficit / hyperactivity disorder, dyslexia, depression and anxiety) disabilities and entrepreneurial intention in 302 graduate and undergraduate students from a business school at a private university in the northeastern United States. In contrast to prior studies, we found no relationship between physical and psychiatric disabilities and entrepreneurial intention. However, data supported relationships between gender and race and entrepreneurial intention. Female students had lower entrepreneurial intention than male students, while students of Color had higher entrepreneurial intention than their White counterparts.
... For the last seven years, ADHD has received rising attention from entrepreneurship scholars. An emerging line of research has emphasized the relationship between ADHD symptoms and various entrepreneurial outcomes including entrepreneurial intentions, entry into entrepreneurship, entrepreneurial orientations and firm performance (e.g., Dimic & Orlov, 2014;Verheul & Rietdijk, 2016;Wiklund et al., 2017;Yu et al., 2021). However, there is still a limited understanding of how the presence of ADHD may interfere with entrepreneurial team functioning. ...
... ADHD symptoms: Following previous entrepreneurship research on ADHD (e.g., Watters, 2018;Verheul & Rietdijk, 2016), we measured ADHD symptoms as a continuous variable using the established Adult ADHD Self-report Scale (ASRS-v1.1) (Kessler et al., 2005). ...
Full-text available
This study examines how entrepreneurial team conflict is influenced by Attention-Deficit Hyperactivity Disorder (ADHD) symptoms and gender factor as well as how team conflict impacts entrepreneurial well-being and firm performance. Surveying 1,053 entrepreneurs in the U.S and Australia, we found that ADHD symptoms are negatively associated with both cognitive team conflict and emotional team conflict. Moreover, although women entrepreneurs experience less both cognitive team conflict and emotional team conflict than men entrepreneurs, gender factor has no moderating effect on the relationship between ADHD and the two types of team conflict. In terms of the outcomes of team conflict, emotional conflict is negatively related to entrepreneurial well-being while cognitive conflict has no significant relationship with well-being. In addition, our findings suggested that both cognitive conflict and emotional conflict are negatively associated with firm performance. Overall, our study advances literature on entrepreneurial team (new venture team) as well as contributes to growing entrepreneurship research on ADHD, gender and well-being.
... As with autism, difficulties associated with ADHD are context-dependent and may decrease in adulthood as individuals select environments that promote their strengths (Lasky et al., 2016;Verheul et al., 2016). The difficulties people with ADHD experience focusing attention on mundane tasks are often no longer apparent when they are stimulated by novel, challenging and fast-paced tasks. ...
Full-text available
The gap between autistic people’s potential and their employment outcomes is a pressing societal issue. This report focuses on the first workshops in a three-year-long NSF-funded program of research that seeks to empower autistic youth to move toward their dream jobs by helping educators more effectively guide them. In the Summer of 2021, educators at an award-winning NYC-based, not-for-profit, technology education program, Tech Kids Unlimited (TKU) collaborated with researchers, including autistic students, to iteratively develop and assess two online video game design workshops for autistic youth. Participants selected which workshop they were available for. Eighteen students (M = 16.78 years) participated in Workshop 1. Sixteen participants (M = 16.56 years) completed Workshop 2. Students in Workshop 2 had more varied support needs and were significantly less motivated by an interest to learn video game design than students in Workshop 1. Students completed assessments before and after each workshop and rated their interest in specific workshop activities after each activity. Guided by data from the first workshop, we revised instructional strategies before conducting a second workshop later that same summer. We hypothesized that students with more focused attention would prefer unimodal instruction while students with less focused attention would prefer multimodal instruction. However, we found little evidence that attention contributed to teens’ engagement with workshop activities. Instead, video game design self-efficacy and self-determination were often positively associated with engagement. Two industry speakers, one of whom was autistic, were among the highest-rated activities. Video game design self-efficacy, self-determination, and spatial planning improved from pre- to post-test following Workshop 1. Despite our collaborative efforts to use what we learned in Workshop 1 to improve in Workshop 2, Workshop 2 did not lead to statistically significant improvements in any outcomes. However, students highlighted instructional strategies as a strength of Workshop 2 more often than they had for Workshop 1. Educators highlighted the importance of group “temperature checks,” individualized check-ins, social-emotional support for students and educators, and fostering a positive classroom atmosphere. Findings suggest that interactive multimodal activities, stimulating discussions, and opportunities to engage with neurodivergent industry professionals may engage and empower diverse autistic youth.
... To date few researchers have heeded these calls. A review of the literature does show a number of studies have assessed creativity in children and adults with ADHD (5), while the business sector has considered the potential advantages of ADHD symptoms for entrepreneurship (6)(7)(8). A small number of studies have focused on the characteristics of successful adults with ADHD (9,10). ...
Full-text available
Understanding the desires and motivations of children with ADHD is important in helping them thrive. Their inner worlds, however, have not been well captured. The Three Wishes task provides minimal cues and structure to elicit their desires and hopes in an unbiased manner. The wishes of 299 school-aged children with ADHD (193 boys, aged 6–12) were elicited during a research diagnostic assessment. We developed a coding scheme to characterize different aspects of their wishes, including beneficiary, valence, and immediacy. Maslow’s hierarchy of needs, adapted to take account of the participants’ ages, was used to identify the motivations underlying the children’s wishes. As expected, many of the wishes reported were for immediate fulfillment, with many reflecting material desires. Affiliative wishes, highlighting the children’s desire for positive interpersonal relationships, were also common. There was some evidence for self-actualization/self-betterment goals and a small number of altruistic wishes. A word cloud presents the content of the children’s wishes grouped according to this hierarchy. This study highlights the diversity and typicality of the self-reported needs, desires and hopes of children with ADHD. It also serves as a timely reminder of the value of seeking such information directly from children themselves.
... They may think outside the box, and bring energy and fun to group situations. Empirical research into the strengths of children with ADHD is lacking and findings are mixed, although associations have been noted between ADHD and entrepreneurship [11]. ...
Full-text available
Background Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have impairing levels of difficulty paying attention, impulsive behaviour and/or hyperactivity. ADHD causes extensive difficulties for young people at school, and as a result these children are at high risk for a wide range of poor outcomes. We ultimately aim to develop a flexible, modular ‘toolkit’ of evidence-based strategies that can be delivered by primary school staff to improve the school environment and experience for children with ADHD; the purpose of this review is to identify and quantify the evidence-base for potential intervention components. This protocol sets out our plans to systematically identify non-pharmacological interventions that target outcomes that have been reported to be of importance to key stakeholders (ADHD symptoms, organisation skills, executive-global- and classroom-functioning, quality of life, self-esteem and conflict with teachers and peers). We plan to link promising individual intervention components to measured outcomes, and synthesise the evidence of effectiveness for each outcome. Methods A systematic search for studies published from the year 2000 that target the outcomes of interest in children and young people aged 3–12 will be conducted. Titles and abstracts will be screened using prioritisation software, and then full texts of potentially eligible studies will be screened. Systematic reviews, RCTs, non-randomised and case-series studies are eligible designs. Synthesis will vary by the type of evidence available, potentially including a review of reviews, meta-analysis and narrative synthesis. Heterogeneity of studies meta-analysed will be assessed, along with publication bias. Intervention mapping will be applied to understand potential behaviour change mechanisms for promising intervention components. Discussion This review will highlight interventions that appear to effectively ameliorate negative outcomes that are of importance for people with ADHD, parents, school staff and experts. Components of intervention design and features that are associated with effective change in the outcome will be delineated and used to inform the development of a ‘toolkit’ of non-pharmacological strategies that school staff can use to improve the primary school experience for children with ADHD. Trial registration PROSPERO number CRD42021233924
... Verheul et al. (2015) suggest that a higher level of ADHD behaviour is positively associated with entrepreneurial intentions. Also, a particular aspect of hyperactivity is associated with self-employment (Verheul et al. 2016). Henceforth, critical examination of ADHD accounts for understanding entrepreneurial intention. ...
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There is emergent literature that converges from neuroscience and entrepreneurship research, but the definitions and interlinkages are still inconsistent. We conduct a systematic literature review of 167 papers on the interface between neuroscience and entrepreneurship to address this. We observe the literature trends examining the interlinkages between neuroscience and entrepreneurial intention through six antecedents, namely - molecular neuroscience, systems neuroscience, behavioral neuroscience, cognitive neuroscience, social neuroscience, and computational neuroscience. Our findings suggest that entrepreneurial intention impacts entrepreneurial activity through five factors, including (1) opportunity recognition, (2) evaluation and risk-taking, (3) entrepreneurial cognition, (4) entrepreneurial behavior, and (5) entrepreneurial decision-making. From our discussions, the links among the neural factors affecting entrepreneurship are identified, and a research agenda highlighting a pathway for future studies is proposed.
Cette thèse s’inscrit au croisement de l’entrepreneuriat de la psychologie cognitive, ainsi que de la psychologie de la santé. Elle contribue au récent courant de la santé des dirigeants de PME qui vise à mieux comprendre l’impact de la fonction entrepreneuriale sur la santé des indépendants. Cette recherche s'intéresse plus particulièrement à la question de leur santé mentale au travers du risque de burnout et du risque suicidaire. Pour cela, elle mobilise une approche cognitive afin de mieux appréhender l’impact du stress entrepreneurial sur la santé mentale des dirigeants de PME, et de voir pourquoi certains entrepreneurs s’épuisent au travail, voire en viennent à se suicider. L’objectif de ce travail est donc de contribuer à une meilleure compréhension de la souffrance psychique patronale. Pour ce faire, cette thèse réalisée sur travaux s’articule autour de quatre contributions académiques et s’appuie sur une méthodologie principalement quantitative. Une étude qualitative est néanmoins menée de manière exploratoire sur la question du suicide, un sujet encore tabou et très peu étudié dans le monde patronal. La recherche est construite en trois étapes, la première s’intéresse à l’étude des spectres émotionnels de deux stresseurs de la fonction entrepreneuriale. La seconde s’intéresse à deux risques en santé mentale subséquents aux deux facteurs de stress de la fonction entrepreneuriale (risques de burnout et suicidaire). Enfin, la troisième et dernière étape vise quant à elle, à étudier la motivation entrepreneuriale comme facteur modérateur des deux risques en santé mentale ciblés. Les résultats montrent une ambiguïté émotionnelle dans la surcharge de travail des dirigeants de PME. La perception de l’événement accompagnant la surcharge va ainsi avoir un rôle déterminant dans l’impact de ce stresseur sur la santé. Aussi, au quotidien, les dirigeants de PME ne sont pas à l’abri d’un risque de burnout. Et selon les contextes, celui-ci peut être modéré par la motivation entrepreneuriale. Enfin, les résultats mettent également en évidence le caractère tragique que peut prendre l’échec entrepreneurial ainsi que l’omniprésence de l’endettement dans le risque suicidaire patronal.
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Estimates suggest as much as 17% of the U.S. workforce may be neuroatypical (CIPD, 2018; Sargent, 2019), a term used to describe individuals whose neurological functioning is at the tail ends of the distribution of naturally occurring variation. Although the neuroatypical population has a history of under- and un- employment (Roux et al., 2015; Taylor & Seltzer, 2011; Austin & Pisano, 2017), their inclusion in the modern workplace (i.e., promotion of neurodiversity within organizations) is gaining recognition by scholars and organizations as an important dimension of organizational diversity (Brinzea, 2019). Despite this burgeoning interest in examining neuroatypicality in the context of organizational diversity, surprisingly little research has been conducted that bridges these two research areas. The literature that does exist is scattered across several different academic disciplines, largely outside of industrial-organizational psychology, and rarely examines the employment of neuroatypical workers explicitly from a diversity perspective. In this article we argue that as the nature of work evolves and jobs continue to become more specialized, neurodiversity will become an increasingly relevant dimension of organizational diversity, and is likely to play a key role both in terms of individual employees’ well-being and performance outcomes, as well as organizational success.
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Entrepreneurship scholarship finds itself in something of a quandary concerning rationality. While an increasingly large body of empirical work has found evidence of less-deliberative and even impulsive drivers of business venturing, the dominant theories of entrepreneurial action remain anchored to the assumption that intended rationality is a defining attribute of entrepreneurship. The growing schism between entrepreneurial action theory (EAT) on the one hand, and empirics and practice on the other hand, represents a consequential and exciting opportunity for the field to revisit its core assumptions regarding rationality, particularly the presence, role, and function of rational intentionality. In this study, we undertake a review and exploratory investigation of the assertion that without reasoned intentionality there is no entrepreneurship. Our work generates three important insights that contribute to rethinking key facets of the most prominent and influential EATs: alternative, non-rational pathways to business venturing exist with a non-ignorable prevalence; a proclivity towards reasoned intentionality is not invariably prescriptive; and, less-reasoned, less-deliberative tendencies do not constitute an entrepreneurial death sentence. Rather, entrepreneurs (including highly successful ones) embody a shifting blend of rational and non-rational proclivities, motivations, decisions, and actions.
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Little is known about the relation between entrepreneurship and the extent of psychiatric symptoms. Validated psychiatric symptom scores are seldom used for non-clinical reasons. One prevalent symptom that deserves our interest is Attention Deficit and Hyperactivity Disorder (ADHD). ADHD is a developmental disorder characterized by inattentiveness and hyperactivity that has been linked to occupational choice and performance. Building on the person–environment fit literature, we hypothesize that individuals who exhibit behavior associated with ADHD are more likely to have entrepreneurial intentions. Using a sample of 10,104 students enrolled in higher education, we can confirm our prediction that students with a higher level of ADHD-like behavior are more likely to have entrepreneurial intentions. Additionally, we show that risk taking propensity is a mediator that partly explains this positive effect. Our study points to the importance of behavioral tendencies associated with developmental disorders, when making entrepreneurship decisions. Our study contributes to the literature on the determinants of entrepreneurship, which so far has largely neglected the effects of psychiatric symptoms on entrepreneurship.
Technical Report
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The economic and social relevance of entrepreneurship in general and new ventures in particular is well-established across the world. Students, as they could be the entrepreneurs of tomorrow, have attracted considerable scholarly and public attention in the last decades. Despite strong research efforts in the past, many questions are still not sufficiently answered. Which individual, societal, family- and university-related factors enhance students' intention to found their own company? How do students' entrepreneurial intentions and activities compare across a multitude of nations? Are there globally applicable best practices? To generate unique insights and contributions that address these gaps, it is thus imperative to further investigate students' entrepreneurial intentions, activities and their antecedents on a global level. This is the overarching goal of the GUESSS research project (Global Universiy Entrepreneurial Spirit Students' Survey). At GUESSS, we not only focus on new venture creation, but we take a broader perspective to include different interesting variations of entrepreneurial intentions and activities. For instance, we are interested in students' intention to take over an existing company or to succeed in their parents' family firm. This report presents the results and insights of the 2011 edition of the GUESSS project on the global level. In Spring 2011, a large-scale quantitative survey was conducted in 26 different countries, addressing more than 1 Million students from 489 Universities, leading to a data set with more than 93'000 responses (N=93’265).
The urge for physical play in mammals, including humans, is built into the nervous system (Panksepp, 2008). This has been rigorously demonstrated in laboratory animals (Ikemoto & Panksepp, 1992). Although the precise functions of physical play remain unspecified, it is likely essential for optimal childhood development, both body and mind, with many demonstrated benefits (Burgdorf, Kroes, Beinfeld, Panksepp, & Moskal, 2010; Panksepp, 1993, 2010). We propose that play forms the backbone of young children’s daily life through spontaneous social learning that enhances social interactions, promotes learning, and provides positive affect that may increase psychological resilience. In fact, we now know that play provides considerable benefits in young animals, where the necessary detailed behavioral work can be done (as summarized in Burgdorf et al., 2010; Burgdorf, Panksepp, & Moskal, 2011; Gordon, Burke, Akil, Watson, & Panksepp, 2003; Panksepp, Siviy, & Normansell, 1984; Pellis & Pellis, 2009; Vanderschuren, 2010).
This study investigates the link between attention deficit hyperactivity disorder (ADHD) symptoms and entrepreneurial orientation (EO). EO is known to be a crucial factor for small firm survival and growth, conceptualised as a business characteristic but influenced by the personality of the small business owner and measured at her individual level. There is ample anecdotal evidence claiming that ADHD symptoms have helped entrepreneurs in their careers. Using a data set of French small firm owners, we are the first to go beyond the anecdotal level in linking ADHD symptoms and EO. Our study contributes to our understanding of entrepreneurship, particularly the determinants of EO, and to “destigmatising” ADHD, which is considered solely a clinical disorder that should be treated.
The purpose of this paper is to document the fundamental shift that is taking place in OECD countries. This shift is from the managed economy to the entrepreneurial economy. While politicians and policymakers have made a plea for guidance in the era of entrepreneurship, scholars have been slow to respond. This paper attempts to make a first step identifying and articulating these differences. We do this by contrasting the most fundamental elements of the newly emerging entrepreneurial economy with those of the managed economy. We identify 14 trade-offs confronting these two polar worlds. The common thread throughout these trade-offs is the increased role of new and small enterprises in the entrepreneurial economy. A particular emphasis is placed on changes in economic policy demanded by the entrepreneurial economy vis-à-vis the managed economy.
Problems related to executive function (EF) are frequently reported in adults with ADHD. However, only a subgroup of patients show deficits on common neuropsychological tests designed to measure EF. We investigated whether this subgroup also had higher levels of functional impairments, including unemployment, than the ADHD group without such deficits. We defined executive function deficit (EFD) from selected tests from the Delis-Kaplan Executive Function System (D-KEFS) and assessed ADHD symptoms and psychiatric comorbidity with the use of questionnaires in 79 ADHD patients and 77 controls (IQ above 80 in both groups). In the ADHD group, 24.3% had EFD. This subgroup showed significantly higher frequency of unemployment, more reading and writing problems, lower IQ scores, and more self-reported ADHD symptoms in childhood than the ADHD subgroup without EFD. These findings indicate that it may be possible to identify individuals at risk of functional impairments, and emphasizes the importance of effective treatment programs targeting EF. © 2015 SAGE Publications.