Mariellen Fischer

The Adolescent Outcome of Hyperactive Children Diagnosed by Research Criteria: I. An 8-Year Prospective Follow-up Study

The psychiatric outcome is reported for a large sample of hyperactive children (N = 123), meeting research diagnostic criteria, and normal control children (N = 66) followed prospectively over an 8-year period into adolescence. Over 80% of the hyperactives were attention deficit hyperactivity disorder (ADHD) and 60% had either oppositional defiant disorder and/or conduct disorder at outcome. Rates of antisocial acts were considerably higher among hyperactives than normals, as were cigarette and marijuana use and negative academic outcomes. The presence of conduct disorder accounted for much though not all of these outcomes. Family status of hyperactives was much less stable over time than in the normal subjects. The use of research criteria for diagnosing children as hyperactive identifies a pattern of behavioral symptoms that is highly stable over time and associated with considerably greater risk for family disturbance and negative academic and social outcomes in adolescence than has been previously reported.

The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder.

This study examined the persistence of attention-deficit/hyperactivity disorder (ADHD) into young adulthood using hyperactive (N = 147) and community control (N = 71) children evaluated at ages 19-25 years. ADHD was rare in both groups (5% vs. 0%) based on self-report but was substantially higher using parent reports (46% vs. 1.4%). Using a developmentally referenced criterion (+2 SD), prevalence remained low for self-reports (12% vs. 10%) but rose further for parent reports (66% vs. 8%). Parent reports were more strongly associated with major life activities than were self-reports. Recollections of childhood ADHD showed moderate correlations with actual parent ratings collected in childd hood, which suggests some validity for such recollections. The authors conclude that previous follow-up studies that relied on self-reports might have substantially underestimated the persistence of ADHD into adulthood.

Young adult follow-up of hyperactive children: Self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD

We report on the psychiatric disorders present at young adult follow-up (Mean age 20–21 years; 13 + year follow-up) and the comorbidity among them for a large sample of hyperactive (H; N = 147) and community control (CC; N = 71) children. The H group had a significantly higher risk for any nondrug psychiatric disorders than the CC group (59% vs. 36%). More of the H group met criteria for ADHD (5%); major depressive disorder (26%); and histrionic (12%), antisocial (21%), passive–aggressive (18%), and borderline personality disorders (14%) at follow-up than the CC group. Severity of childhood conduct problems contributed to the risk for passive–aggressive, borderline, and antisocial personality disorders. But it only affected risk for antisocial personality after controlling for severity of teen conduct disorder (CD), which also contributed to the risk for these same 3 disorders. Examination for comorbidity among these disorders indicated that presence of either borderline or antisocial personality disorder significantly increased the risk for major depression and the other significant personality disorders. More of the hyperactive group had received various forms of mental health treatment during and since leaving high school than the control group. Results suggest that hyperactive children are at significant risk for at least 1 nondrug disorder in young adulthood, principally major depression and several personality disorders, and that this risk is largely mediated by severity of CD at adolescence.

Follow-Up of a Preschool Epidemiological Sample: Cross-Age Continuities and Predictions of Later Adjustment with Internalizing and Externalizing Dimensions of Behavior.

The continuity of behavioral adjustment from preschool through elementary school and junior high school years was examined. 541 children aged 9-15 years from a preschool epidemiological study were relocated and behavior checklist data obtained. Analyses focused on the relationship between internalizing and externalizing behavior dimensions from the preschool to follow-up periods. It was found that preschool externalizing symptoms were positively correlated with later externalizing and internalizing symptoms in the entire sample. Preschool internalizing symptoms, however, were predictive of later internalizing symptoms only for 2-year-old girls and 5- and 6-year-old boys. Similar results were obtained for clinically disturbed preschoolers. Results are consistent with previous findings regarding the longitudinal continuity of externalizing behavior but are at odds with reports of equal or greater stability of internalizing behavior. Given the magnitude of obtained correlations, even when significant, the results support the view that discontinuity rather than continuity in behavioral adjustment from preschool to later ages is the rule. The importance of examining other mediating variables in the prediction of behavioral adjustment and the need for models of development that encompass both stability and change are discussed.

Executive Functioning in Hyperactive Children as Young Adults: Attention, Inhibition, Response Perseveration, and the Impact of Comorbidity

Tests of several executive functions (EFs) as well as direct observations of symptoms of attention deficit hyperactivity disorder (ADHD) during testing were collected at the young adult follow-up (M = 20 years) on a large sample of hyperactive (H; N = 147) and community control (CC; N = 71) children. The EF tasks included tests of attention, inhibition, and response perseveration. The H group was subdivided into those with and without ADHD (+ or w/o) at follow-up. The H+ADHD group made significantly more inhibition errors than the CC group on a Continuous Performance Test (CPT) and showed more ADHD symptoms while performing the CPT. The H+ADHD group also displayed more ADHD symptoms during a letter cancellation task than did both the hyperactive w/o ADHD and CC groups. Both H groups showed slower reaction times during a Card Playing Task. That subset of hyperactive probands with Conduct Disorder (CD) displayed significantly more perseverative responding on that task than did those without CD, but otherwise it did not differ on any other measures. Current level of anxiety contributed adversely to both CPT commission errors and ADHD behavior during the CPT. Comorbid depression did not contribute to any group differences on these tests. Although developmental improvements were found in both the H and the CC groups in their CPT inattention and inhibition scores since adolescence, the H groups remained distinguishable from the CC groups over this period. We conclude that formerly hyperactive children manifest greater EF deficits at follow-up in the areas of inattention, disinhibition, and slowed reaction time and greater ADHD behavior during testing, but these problems are mostly confined to those with current ADHD. Response perseveration, however, was limited to those hyperactive children with CD by follow-up, consistent with Quays theory of these two disorders.

Predicting Impairment in Major Life Activities and Occupational Functioning in Hyperactive Children as Adults: Self-Reported Executive Function (EF) Deficits Versus EF Tests

Hyperactivity in children, or attention deficit hyperactivity disorder (ADHD), is associated with impairments in various major life activities by adulthood, particularly occupational functioning. ADHD appears to involve deficits in executive functioning (EF). Prior studies have not examined the contribution of these deficits to adult impairment generally and occupational adjustment specifically in longitudinal studies of hyperactive/ADHD children. We did so assessing EF by both self-report and tests and using self and other-rated impairment in 10 domains of major life activities and 12 measures of occupational impairment. We studied hyperactive (H; N = 135) and community control children (C; N = 75) followed to adulthood (mean age 27 years). The H cases were subdivided into those whose ADHD did (ADHD–P) and did not persist (ADHD–NP) using modified DSM-IV criteria. Self-reported EF deficits were more severe on all five EF scales in the ADHD–P than both the ADHD–NP and C groups and on three scales in the ADHD–NP compared to C groups. Most ADHD–P cases fell in the clinically impaired range on self-reported EF as did a substantial minority of ADHD–NP cases but few were so classified on the EF tests. Impairments in occupational functioning were predicted by the EF ratings to a greater degree than by the EF tests. Most EF tests were unrelated to work history with the exception of the Five-Points Test. We conclude that EF ratings are better predictors of impairment in major life activities generally and occupational functioning specifically at adult follow-up than are EF tests. We hypothesize that this paradox arises from each method assessing different levels of a hierarchically organized EF meta-construct briefly discussed herein.

The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment.

OBJECTIVE To investigate predictors of adolescent outcome in a large sample of hyperactive children. METHOD 123 hyperactive children were followed prospectively over an 8-year period. Multiple linear and logistical regression equations were used to relate childhood predictor variables to adolescent academic, psychiatric, social, and emotional adjustment. RESULTS Adolescent academic skills were related to childhood cognitive and academic competence while school conduct was predicted by other variables including early family stress. Duration of mental health treatment received often was negatively related to outcome, apparently serving as a marker variable for severity of disturbance in the child. Childhood impulsivity-hyperactivity and paternal antisocial acts were associated with later oppositional-defiant behaviors. Only child defiance and not hyperactivity predicted later arrests, however. Emotional problems in adolescence were predicted by more special education enrollment. Adolescent social competence was associated with parental personal competence, whereas maternal mental health status at outcome was related to variables unassociated with child adjustment. CONCLUSIONS Various outcome domains had different sets of predictors; no single predictor cut across all domains. Although a limited amount of variance in outcome was explained, findings suggest that promoting family and parental competence as well as assessing and treating defiance and aggression very early may improve outcome.

The stability of dimensions of behavior in ADHD and normal children over an 8-year followup

The present study reports on standardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria (n=108) and a community control sample of normal children (n=61) who were followed prospectively over 8 years into adolescence. On some parentreport measures both groups declined in the severity of their behavior problems across time, while on other measures only the hyperactive group declined, but the hyperactives always remained more deviant than the controls at followup. The hyperactives and controls also differed on most teacher and selfreport ratings at followup. The greatest degree of agreement between raters at adolescence was between parent and youth ratings. These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup. They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology.

Association of the dopamine beta hydroxylase gene with attention deficit hyperactivity disorder: Genetic analysis of the Milwaukee longitudinal study

Attention deficit hyperactivity disorder (ADHD) is a highly heritable and common disorder that partly reflects disturbed dopaminergic function in the brain. Recent genetic studies have shown that candidate genes involved in dopamine signaling and metabolism contribute to ADHD susceptibility. We have initiated genetic studies in a unique cohort of 158 ADHD and 81 control adult subjects who have been followed longitudinally since childhood in the Milwaukee study of ADHD. From this cohort, genetic analysis was performed in 105 Caucasian subjects with ADHD and 68 age and ethnicity‐matched controls for the DRD4 exon 3 VNTR, the SLC6A3 (DAT1) 3′ UTR VNTR, dopamine beta hydroxylase (DBH) TaqI A polymorphism, and the DBH GT microsatellite repeat polymorphism that has been quantitatively associated with serum levels of DBH activity, but not previously studied in ADHD. Results indicate a significant association between the DBH TaqI A1 allele and ADHD (P = 0.018) with a relative risk of 1.33. The DBH GT repeat 4 allele, which is associated with high serum levels of DBH, occurred more frequently in the ADHD group than controls, but the difference did not reach statistical significance. Associations were not found with the SLC6A3 10 repeat or DRD4 7 repeat alleles. These results indicate that the DBH TaqI A allele, or another polymorphism in linkage disequilibrium with this allele, may confer increased susceptibility towards ADHD.

An examination of the behavioral and neuropsychological correlates of three ADHD candidate gene polymorphisms (DRD4 7+, DBH TaqI A2, and DAT1 40 bp VNTR) in hyperactive and normal children followed to adulthood.

Several candidate gene polymorphisms have been implicated in attention deficit hyperactivity disorder (ADHD), including DAT1 40bp VNTR, DRD4 7+, and DBH TaqI A2 alleles. We used the Milwaukee longitudinal study of hyperactive (n = 122) and normal (n = 67) children to compare participants with and without these respective polymorphisms on ADHD‐related behavioral ratings at childhood, 8 years later in adolescence, and 13+ years later into young adulthood. Neuropsychological tests were given at the adolescent and young adulthood follow‐up. No differences were found between the DRD4‐7+ and 7− repeat polymorphism. The DBH TaqI A2 allele, when homozygous, was associated with being more hyperactive in childhood, having more pervasive behavior problems at adolescence, and earning less money on a card playing task in adulthood. At adolescence, poorer test scores were also found only in the hyperactive group with homozygous for this allele. The DAT1 40bp VNTR heterozygous 9/10 repeat, however, differed from the 10/10 repeat pair in many respects, having greater ADHD and externalizing symptoms at all three follow‐ups, more cross‐situational behavioral problems at both childhood and adolescence, poorer mother‐teen relations at adolescence, and lower class rankings in high school. Participants with the 9/10 pair in the control group also had lower work performance, a lower grade point average in high school, greater teacher rated externalizing symptoms at adolescence, and greater omission errors on a continuous performance test in adulthood. The DAT1 40bp VNTR 9/10 polymorphism pairing appears to be reliably associated with greater symptoms of ADHD and externalizing behavior from childhood to adulthood, and with family, educational, and occupational impairments. We also present a contrary view on the appropriate endophenotypes for use in behavioral genetic research on ADHD.