Traci M. Kennedy

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

OBJECTIVEnAdolescents 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.nnnMETHODnIndividuals 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.nnnRESULTSnApproximately 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.nnnCONCLUSIONSnIndividuals 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.

Substance use through adolescence into early adulthood after childhood-diagnosed ADHD: findings from the MTA longitudinal study

BACKGROUNDnInconsistent findings exist regarding long-term substance use (SU) risk for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The observational follow-up of the Multimodal Treatment Study of Children with ADHD (MTA) provides an opportunity to assess long-term outcomes in a large, diverse sample.nnnMETHODSnFive hundred forty-seven children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD and 258 classmates without ADHD (local normative comparison group; LNCG) completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25.nnnRESULTSnIn adulthood, weekly marijuana use (32.8% ADHD vs. 21.3% LNCG) and daily cigarette smoking (35.9% vs. 17.5%) were more prevalent in the ADHD group than the LNCG. The cumulative record also revealed more early substance users in adolescence for ADHD (57.9%) than LNCG (41.9%), including younger first use of alcohol, cigarettes, marijuana, and illicit drugs. Alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early SU predicted quicker SU escalation and more SU in adulthood for both groups.nnnCONCLUSIONSnFrequent SU for young adults with childhood ADHD is accompanied by greater initial exposure at a young age and slightly faster progression. Early SU prevention and screening is critical before escalation to intractable levels.

Cigarette Smoking Progression Among Young Adults Diagnosed With ADHD in Childhood: A 16-year Longitudinal Study of Children With and Without ADHD

INTRODUCTIONnChildren with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for smoking cigarettes, but there is little longitudinal research on the array of smoking characteristics known to be prognostic of long-term smoking outcomes into adulthood. These variables were studied into early adulthood in a multisite sample diagnosed with ADHD combined type at ages 7-9.9 and followed prospectively alongside an age- and sex-matched local normative comparison group (LNCG).nnnMETHODSnCigarette smoking quantity, quit attempts, dependence, and other characteristics were assessed in the longitudinal Multimodal Treatment Study of Children with ADHD (MTA) eight times to a mean age of 24.9 years: ADHD n = 469; LNCG n = 240.nnnRESULTSnIn adulthood, the ADHD group had higher rates of daily cigarette smoking, one or more quit attempts, shorter time to first cigarette of the day, and more severe withdrawal than the LNCG. The ADHD group did not appear to have better smoking cessation rates despite a higher proportion quitting at least once. Smoking quantity and nicotine dependence did not differ between groups. The ADHD group reported younger daily smoking onset and faster progression from smoking initiation to daily smoking across assessments. Finally, ADHD symptom severity in later adolescence and adulthood was associated with higher risk for daily smoking across assessments in the ADHD sample.nnnCONCLUSIONSnThis study shows that ADHD-related smoking risk begins at a young age, progresses rapidly, and becomes resistant to cessation attempts by adulthood. Prevention efforts should acknowledge the speed of uptake; treatments should target the higher relapse risk in this vulnerable population.nnnIMPLICATIONSnAlthough childhood ADHD predicts later smoking, longitudinal studies of this population have yet to fully characterize smoking behaviors into adulthood that are known to be prognostic of long-term smoking outcome. The current study demonstrates earlier and faster progression to daily smoking among those with a childhood ADHD diagnosis, as well as greater risk for failed quit attempts. Prevention efforts should address speed of smoking uptake, while treatments are needed that address smoking relapse risk. The current study also demonstrates ADHD symptom severity over development increases daily smoking risk, implicating the need for continuous ADHD symptom management.

Fathers with Childhood ADHD, Parenting, and Their Young Children’s Behavior: Offspring of the Pittsburgh ADHD Longitudinal Study (PALS)

Despite high heritability, no research has followed children with ADHD to parenthood to study their offspring and parenting behaviors. Given greater prevalence of ADHD in males and lack of research involving fathers, this study evaluated offspring of fathers with and without ADHD histories for ADHD and disruptive behavior and compared fathers’ parenting behaviors. Male fathers (Nu2009=u200929) from the Pittsburgh ADHD Longitudinal Study (PALS) participated with their preschool-aged offspring. Fathers completed self-reported measures, and father-child dyads completed an interaction task. ADHD offspring had elevated ADHD symptoms and behavior dysregulation. All fathers displayed positive parenting. ADHD fathers reported lower supportive responses to their child’s negative emotions than comparison fathers, yet rated their parenting as more efficacious. ADHD offspring were distinguishable as early as age 3; thus, earlier diagnosis and intervention may be feasible for this at-risk population. Future research should investigate the acceptability and efficacy of parent training for fathers with ADHD.

78 The role of relationship proximity to witnessed community violence and youth outcomes

US Statement of Purpose Youth exposure to community violence is associated with adverse outcomes, yet not all exposed youth respond adversely. Dimensions of exposure may relate to response; evidence suggests that having a relationship with the victim and perpetrator of community violence is connected to worse outcomes, yet is limited by cross-sectional designs and sparse attention to the perpetrator of violence. This study examined the relationship proximity to the victim and perpetrator of violence and adolescent outcomes in a high-risk sample. Sex differences in these relations are also explored. Methods We used the LONGSCAN dataset, a 5-site, pooled sample of children. Our sample was limited to youth ages 12 and 14 who reported some lifetime violence exposure (n=720). This sample was approximately half male, predominantly low-income, and of diverse ethnic backgrounds. Six items assessed witnessed violence, including details about the victim and perpetrator. The Child Behaviour Checklist assessed internalising and externalising symptoms. Regression analyses determined whether relationship proximity to the perpetrator and victim of community violence differentiated youth outcomes and whether sex moderated these associations. Results Witnessed violence perpetrated by a stranger was associated with lower social competency, but only among females. Witnessed parental victimisation predicted higher externalising and internalising problems among both males and females. Conclusions That witnessed community violence against a parent negatively impacted both males and females underscores the traumatic nature of seeing a parent harmed. In contrast, the female-specific relation between witnessed violence perpetrated by a stranger and social competency may reflect that males are desensitised to witnessing violence by strangers given their higher rates of involvement in violence. Contributions to Prevention Science Together, our results suggest that understanding relationships with victims and perpetrators of community violence is an important to understanding response. Future research should further elucidate sex differences in youths’ responses to witnessed violence.

76 Preventing the cycle of violence: community violence exposure and attitudes toward violence among latino adolescents

Purpose Community violence exposure (CVE) places youth at risk for developing aggressive/externalising behaviour, perpetuating the cycle of violence. One pathway may occur through the adoption of normative beliefs accepting of violence ‘“ a malleable, feasible intervention target for preventing community violence. This pathway is not well understood among Latino adolescents, despite their elevated CVE rates. This study examined whether positive attitudes toward violence mediates the link between CVE and externalising behaviours among Latino youth. Methods This sample comprised 193 low-income Latino adolescents (Mage=15.5, 53% female), primarily Mexican-American (81%), living in urban neighbourhoods; 90% received free/reduced lunch. Youth completed survey measures of past-year CVE (adapted Things I Have Seen and Heard scale), attitudes toward violence (Youth Attitudes toward Guns and Violence Questionnaire), and externalising behaviours (Youth Self Report). Results Hierarchical OLS regressions indicated that both community violence victimisation (ß=0.30) and witnessing (ß=0.28) was associated with positive attitudes about the use of violence (p<0.001), controlling for demographic covariates (sex, age, SES, grade retention). Further, CVE positively predicted externalising problems (ßvictimization=0.26; ßwitnessing=0.28; p<0.001), and the relations were partially mediated by positive attitudes about violence (ß=0.32, p<0.001). These results extended to specific beliefs that retaliatory aggression is necessary to protect one’s pride or family. Conclusions Latino youth with high levels of CVE tend to endorse positive attitudes about the use of violence, which in turn predicts externalising behaviours. A cycle of violence may explain these findings, with CVE leading youth to value violence as normative and acceptable, prompting their own aggression. Longitudinal data collection is pending to more rigorously test this potential mechanism. Significance/contributions to injury/violence prevention science Violence prevention interventions should target youths’ malleable attitudes toward violence that have developed to normalise their violence exposure in high-crime neighbourhoods. Such interventions would offer low-cost, feasible, and potentially high-impact solutions for preventing community violence.

156 Childhood adhd as a risk factor for violence victimisation in adulthood

Purpose Childhood ADHD increases risk for maladaptive adult outcomes, including substance abuse and violence perpetration (Buitelaar et al., 2015). However, ADHD risk for violence victimisation is not well understood. ADHD is cross-sectionally associated with interpersonal victimisation in childhood (Lewis et al., 2015), and longitudinally predicts adult intimate partner victimisation (Wymbs et al., 2016). ADHD may prompt victimisation via impulsive involvement in violence/delinquency (Low & Espelage, 2014), but support for mediation is absent (Gibson, 2011). This study tests: (1) Whether childhood ADHD predicts adult interpersonal victimisation; and (2) Whether aggression/delinquency mediates this association. Methods Participants were 579 children rigorously diagnosed with ADHD-Combined Type (ages 7–9.9) and 289 age- and sex-matched comparison children from the Multimodal Treatment of ADHD Study (MTA). Prospective assessments followed baseline and a 14u2009month randomised controlled treatment trial. Six victimisation types (e.g., attacked with weapon; theft) were assessed 12, 14, and 16 years post-enrollment (Mage 20–25) and totaled for analysis. Conduct was assessed with the caregiver-report Aggression and Conduct Problems Scale (Mage 10), and the Self-Reported Delinquency scale (Mage 18). Results One-third of participants experienced any victimisation as adults. Poisson regression indicated that probands experienced significantly more victimisation types (OR=1.32, p=0.009), controlling for demographics (sex, race, SES, familial psychopathology, grade retention) and neighbourhood quality. Mage 10 aggression predicted more adult victimisation (OR=2.26, p=0.001) and fully mediated the ADHD-victimisation association. Separately, Mage 18 delinquency predicted adult victimisation (OR=1.14, p<0.001), but did not mediate the ADHD-victimisation link. Victimisation did not predict adult alcohol outcomes. Conclusions Childhood ADHD prospectively forecasts adult victimisation mediated by childhood, but not young-adult, aggression/delinquency. Significance/contributions to injury/violence prevention science ADHD is a double whammy: it increases risk for both violence perpetration and victimisation, making ADHD a critical violence prevention target. Researchers should elucidate how this risk unfolds developmentally and isolate malleable ADHD-related intervention priorities.