Margaret H. Sibley

Young Adult Educational and Vocational Outcomes of Children Diagnosed with ADHD

Decreased success at work and educational attainment by adulthood are of concern for children with ADHD given their widely documented academic difficulties; however there are few studies that have examined this empirically and even fewer that have studied predictors and individual variability of these outcomes. The current study compares young adults with and without a childhood diagnosis of ADHD on educational and occupational outcomes and the predictors of these outcomes. Participants were from the Pittsburgh ADHD Longitudinal Study (PALS), a prospective study with yearly data collection. Significant group differences were found for nearly all variables such that educational and occupational attainment was lower for adults with compared to adults without histories of childhood ADHD. Despite the mean difference, educational functioning was wide-ranging. High school academic achievement significantly predicted enrollment in post-high school education and academic and disciplinary problems mediated the relationship between childhood ADHD and post-high school education. Interestingly, ADHD diagnosis and disciplinary problems negatively predicted occupational status while enrollment in post-high school education was a positive predictor. Job loss was positively predicted by a higher rate of academic problems and diagnosis of ADHD. This study supports the need for interventions that target the child and adolescent predictors of later educational and occupational outcomes in addition to continuing treatment of ADHD in young adulthood targeting developmentally appropriate milestones, such as completing post-high school education and gaining and maintaining stable employment.

When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment

OBJECTIVE This study examined several questions about the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young adults using data from a childhood-diagnosed sample of 200 individuals with ADHD (age M = 20.20 years) and 121 demographically similar non-ADHD controls (total N = 321). METHOD We examined the use of self- versus informant ratings of current and childhood functioning and evaluated the diagnostic utility of adult-specific items versus items from the Diagnostic and Statistical Manual of Mental Disorders (DSM). RESULTS Results indicated that although a majority of young adults with a childhood diagnosis of ADHD continued to experience elevated ADHD symptoms (75%) and clinically significant impairment (60%), only 9.6%-19.7% of the childhood ADHD group continued to meet DSM-IV-TR (DSM, 4th ed., text rev.) criteria for ADHD in young adulthood. Parent report was more diagnostically sensitive than self-report. Young adults with ADHD tended to underreport current symptoms, while young adults without ADHD tended to overreport symptoms. There was no significant incremental benefit beyond parent report alone to combining self-report with parent report. Non-DSM-based, adult-specific symptoms of ADHD were significantly correlated with functional impairment and endorsed at slightly higher rates than the DSM-IV-TR symptoms. However, DSM-IV-TR items tended to be more predictive of diagnostic group membership than the non-DSM adult-specific items due to elevated control group item endorsement. CONCLUSIONS Implications for the assessment and treatment of ADHD in young adults are discussed (i.e., collecting informant reports, lowering the diagnostic threshold, emphasizing impairment, and cautiously interpreting retrospective reports).

Diagnosing ADHD in Adolescence

OBJECTIVE This study examines adolescent-specific practical problems associated with current practice parameters for diagnosing attention-deficit/hyperactivity disorder (ADHD) to inform recommendations for the diagnosis of ADHD in adolescents. Specifically, issues surrounding the use of self- versus informant ratings, diagnostic threshold, and retrospective reporting of childhood symptoms were addressed. METHOD Using data from the Pittsburgh ADHD Longitudinal Study (PALS), parent, teacher, and self-reports of symptoms and impairment were examined for 164 adolescents with a childhood diagnosis of ADHD (age M = 14.74 years) and 119 demographically similar non-ADHD controls (total N = 283). RESULTS Results indicated that 70% of the well-diagnosed childhood ADHD group continued to meet Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) diagnostic criteria for ADHD in adolescence; however, an additional 17% possessed clinically significant impairment in adolescence but did not qualify for a current ADHD diagnosis. The optimal source of information was combined reports from the parent and a core academic teacher. Adolescents with ADHD met criteria for very few symptoms of hyperactivity/impulsivity, suggesting a need to revisit the diagnostic threshold for these items. Additionally, emphasis on impairment, rather than symptom threshold, improved identification of adolescents with a gold-standard childhood diagnosis of ADHD and persistent ADHD symptoms. Parent retrospective reports of baseline functioning, but not adolescent self-reports, were significantly correlated with reports collected at baseline in childhood. CONCLUSIONS Recommendations are offered for diagnosing ADHD in adolescence based on these findings.

The Delinquency Outcomes of Boys with ADHD with and without Comorbidity.

This study examined the association between childhood ADHD and juvenile delinquency by examining data from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of individuals diagnosed with ADHD in childhood (ages 5–12) and recontacted in adolescence and young adulthood for yearly follow-up (age at first follow-up interview M = 17.26, SD = 3.17). Participants were 288 males with childhood ADHD and 209 demographically similar males without ADHD who were recruited into the follow-up study. Delinquency information gathered yearly during the second through eighth follow-up provided a comprehensive history of juvenile delinquency for all participants. Four childhood diagnostic groups [ADHD-only (N = 47), ADHD + ODD (N = 135), ADHD + CD (N = 106), and comparison (N = 209)] were used to examine group differences on delinquency outcomes. Analyses were conducted across three dimensions of delinquency (i.e., severity, age of initiation, and variety). Individuals with childhood ADHD + CD displayed significantly worse delinquency outcomes than the other three groups, across almost all indices of offending. When compared to comparison participants, boys with ADHD-only and ADHD + ODD in childhood displayed earlier ages of delinquency initiation, a greater variety of offending, and higher prevalence of severe delinquency. These findings suggest that although childhood ADHD + CD creates the greatest risk for delinquency, boys with ADHD-only and ADHD + ODD also appear at a higher risk for later offending. The patterns of offending that emerged from the PALS are discussed in the context of the relationship between ADHD, comorbidity, and delinquency.

Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed.

Functional adult outcomes 16 years after childhood diagnosis of Attention-Deficit/Hyperactivity Disorder:MTA results

OBJECTIVE To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA). METHOD Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments. RESULTS Three patterns of functional outcomes emerged. Post-secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG. CONCLUSION Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.

The role of early childhood ADHD and subsequent CD in the initiation and escalation of adolescent cigarette, alcohol, and marijuana use.

Adolescents with attention deficit/hyperactivity disorder (ADHD) are at an increased risk for substance use but the pathways through which this risk emerges are insufficiently understood. Tobacco, alcohol, and marijuana outcomes were compared between adolescents diagnosed with ADHD in early childhood (N = 113) and demographically similar controls (N = 65). Participants were assessed from age 5 until age 18. A comprehensive history of adolescent substance use was compiled for each participant and growth in ADHD and conduct disorder (CD) were modeled as they related to substance use outcomes. Results indicated that when compared with controls, adolescents with ADHD were more likely to try cigarettes, initiate alcohol use at early ages, and smoke marijuana more frequently. Furthermore, adolescents with ADHD were 4 to 5 times more likely than controls to escalate to heavy cigarette and marijuana use after trying these substances once. Adolescents with ADHD who escalated to heavy use patterns were more likely to display early cigarette use and marked problems with family members, but displayed fewer peer problems. There was evidence of baseline effects (latent intercept, measured at age 5) for both ADHD and CD on substance use outcomes. Furthermore, growth in ADHD symptoms accounted for much of the growth in CD symptoms, and consequently, escalating CD symptoms in childhood (latent slope) were viewed as a mediator of the relationship between ADHD and cigarette and marijuana use. Maternal drinking in early childhood was the strongest predictor of early adolescent alcohol use. These findings are discussed with respect to the role of ADHD in the development of adolescent risk outcomes.

Implications of Changes for the Field ADHD

This article provides a thorough discussion of the proposed DSM-5 changes and their implications for current and future approaches to assessment, identification, and service delivery for children and adolescents with ADHD. Educational and clinical implications are discussed with special attention to the individual impact of the changes, diagnostic prevalence rates, and associated societal costs. Developmental period is considered as an important factor in the potential impact of the DSM-5 changes. The authors conclude that the DSM-5 proposed revisions may improve diagnostic sensitivity and specificity; yet the overall impact of these changes remains largely unknown as many were not empirically validated. The authors suggest that the cumulative impact of the set of changes be considered when finalizing the DSM-5 revisions.

Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies

Several studies have questioned the stability of attention-deficit hyperactivity disorder (ADHD) from childhood to adulthood. This systematic review illustrates how variability in diagnostic methods influences adult ADHD persistence estimates. Systematic database searches identified studies reporting adult ADHD persistence rates that were published in English between Jan 1, 1992, and May 31, 2016. Study inclusion criteria were systematic childhood diagnosis of attention-deficit disorder, ADHD, or a research diagnostic protocol that matched DSM-III, DSM-III-R, or DSM-IV standards; mean childhood age of younger than 12·0 years with no participants older than 18·0 years; and mean adult age of 18·0 years or older with no participants younger than 17·0 years. Across 12 included samples, we identified 41 estimates of ADHD persistence, which ranged from 4·0% to 77·0%. Methods of diagnosing ADHD in adulthood varied widely with respect to source of information, diagnostic instruments (eg, rating scales, interviews), diagnostic symptom threshold, and whether impairment was required for diagnosis. Sole reliance on self reports and a strict threshold of six DSM symptoms led to very low persistence estimates. To minimise false-negative and false-positive classifications, recommended methods for determining adult persistence of ADHD include collecting self and informant ratings, requiring the presence of impairment, and using an age-appropriate symptom threshold. Very few persistence estimates utilised these methods, but those that did indicated persistence rates of 40-50%.

Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25

OBJECTIVE Adolescents and young adults without childhood attention deficit hyperactivity disorder (ADHD) often present to clinics seeking stimulant medication for late-onset ADHD symptoms. Recent birth-cohort studies support the notion of late-onset ADHD, but these investigations are limited by relying on screening instruments to assess ADHD, not considering alternative causes of symptoms, or failing to obtain complete psychiatric histories. The authors address these limitations by examining psychiatric assessments administered longitudinally to the local normative comparison group of the Multimodal Treatment Study of ADHD. METHOD Individuals without childhood ADHD (N=239) were administered eight assessments from comparison baseline (mean age=9.89 years) to young adulthood (mean age=24.40 years). Diagnostic procedures utilized parent, teacher, and self-reports of ADHD symptoms, impairment, substance use, and other mental disorders, with consideration of symptom context and timing. RESULTS Approximately 95% of individuals who initially screened positive on symptom checklists were excluded from late-onset ADHD diagnosis. Among individuals with impairing late-onset ADHD symptoms, the most common reason for diagnostic exclusion was symptoms or impairment occurring exclusively in the context of heavy substance use. Most late-onset cases displayed onset in adolescence and an adolescence-limited presentation. There was no evidence for adult-onset ADHD independent of a complex psychiatric history. CONCLUSIONS Individuals seeking treatment for late-onset ADHD may be valid cases; however, more commonly, symptoms represent nonimpairing cognitive fluctuations, a comorbid disorder, or the cognitive effects of substance use. False positive late-onset ADHD cases are common without careful assessment. Clinicians should carefully assess impairment, psychiatric history, and substance use before treating potential late-onset cases.