ADHD: Developmental Course & Later Outcome

ADHD: Developmental Course & Later Outcome James H. Johnson, Ph.D. University of Florida This Material Draws Heavily on the book Attention-Deficit Hyperactivity Disorder A Handbook for Diagnosis and Treatment Barkley(1998; 2005)

ADHD: Developmental Issues • A defining feature of a clinical disorder is that it has a predictable natural course. • That is, given that one has the disorder, it is possible to predict whether the disorder will be short lived or more chronic in nature • Can one predict the ways in which symptoms of the disorder are manifest over time? • It should also be possible, to highlight risk factors for the development of the disorder and factors that lead to a good or poor prognosis of the disorder.

ADHD and Development • What do we know about the developmental course of ADHD? • First of all, we know that the initial development of ADHD is most often at a relatively early age. • Current diagnostic criteria demand that the symptoms of the disorder be present by age 7 - Some, however, have questioned the usefulness of this criterion. • In actuality the mean age of onset is probably around 3 to 4 years.

Age at Diagnosis • While ADHD is usually diagnosed fairly early, some children (especially very bright ones) have early symptoms but are not diagnosed until later because they fail to show obvious impairment until later in childhood. • Such children can often deal with the demands of their environment for a while despite their symptoms. • Only when they are confronted with the increasing academic demands of later grades do their symptoms result in observable impairment.

ADHD: Risk Factors • In considering the development of ADHD, a reasonable place to start is by briefly highlighting some of the factors thought to result in increased risk for developing this disorder. • Here we will simply highlight such risk factors, as these will be discussed in more detail when we discuss etiology.

Risk Factors: An Overview • A major risk factor is genetics. • If a parent has ADHD, the risk to their offspring may exceed 50 per cent. • Having a hyperactive sibling may also be a predictor of risk for hyperactivity in a specific child. • Some studies have found up to a 35% risk of hyperactivity in siblings of hyperactive children. • Thus, a child from a family with a history of ADHD is at significantly increased risk.

Risk Factors: An Overview • Other factors that increase the risk of ADHD include: • Pregnancy and birth complications • Cigarette smoking. • Evidence of fetal distress • Maternal alcohol consumption • Prematurity/Low birth weight • Maternal drug use • Meconium staining • Early illnesses and injuries. • Increased lead levels

Early Precursors of ADHD. • There are other factors of infancy and early childhood that can be thought of a early precursors of ADHD. • One of these is child temperament, as initially described by Thomas, Chess and Burch (1968). • These investigators have described a number of individual differences in behaviors style, that are thought to impact on child behavior and adjustment.

Dimensions of Child Temperament • ·Rhythmicity • ·Approach/Withdrawal • ·Adaptability • ·Mood • ·Intensity • ·Demandingness • ·Attention Span/Persistence • ·Activity Level • ·Distractibility

Temperament and ADHD • These temperament dimensions can be observed as early the first few months of life. • And, difficult temperament seems to be associated with a diagnosis of ADHD in the preschool years. • These characteristics, especially negative mood, low adaptability, high intensity emotional responses, inattention & overactivity also predict a continuation of ADHD (often with aggression and conduct problems) into the early elementary school years.

ADHD and Temperament • Difficult temperament is also linked with other types of adjustment problems in adolescents, such as other disruptive behavior disorders (although the relationships with temperament is not especially strong. • Temperament as a predictor of ADHD and other childhood problems is enhanced by considering temperament characteristics in combination with parental factors.

ADHD and Temperament:Goodness of Fit • Here, it is important to consider the Goodness of Fit between child behavior and parenting style. • Having a child with difficult temperament and a parent who displays a negative, critical, and domineering style of child management is associated with the development and continuance of hyperactivity at ages 4, 6 and 9 years.

ADHD: Preschool Years • Studies suggest that preschool age children are likely to be rated as inattentive and overactive. • In a study of children from birth to second grade Palfrey et al (1985) found up to 40% of children at age 4 to have sufficient problems with inattention to be of concern to parents and teachers. • Yet studies suggest that many of these concerns remit within 3 to 6 months. • Among those diagnosed with ADHD at this age, only 48% will warrant this diagnosis in later childhood or early adolescence.

ADHD: Preschool Years • These findings suggests that the appearance of inattentive and overactive behavior by 3 to 4, by itself, is not indicative of a persistent pattern of ADHD into childhood. • It is the presence of these problems to a significant degree, along with their persistence for a year or so, that predicts a continuance of ADHD in to later childhood. • It is the presence of ADHD symptoms and their continuance that predicts a chronic course.

Preschoolers with ADHD • Difficulties displayed by children with ADHD during the preschool years are numerous and place a heavy burden on parents. • They are more likely to experience unintentional injuries - need to childproof home • They are overly active, impulsive, don't pay attention • They are often noncompliant • As many as 30 - 60 % are actively defiant or oppositional

Preschoolers with ADHD • As children get older mothers feel less and less competent • Parents experience significant stress • There may be significant restrictions on social life - no going out to eat - no church • Can't get baby sitter, constantly explaining your child' behavior, helping child to stay out of trouble, etc. etc. • Many experience major problems with day care • Some may be kicked out of preschool

Preschoolers with ADHD • May approach end of preschool years at risk for academic failure. • Here, symptoms result in them having difficulties being able to learn, with most lagging behind in academic readiness skills. • The parental burden experienced by these problems may be enhanced with parents with low adaptability or those who have ADHD themselves. • The combination of child ADHD and certain parental characteristics may increase risk of physical abuse.

ADHD in Preschoolers • Increased parental stress resulting from ADHD related behaviors may enhance difficulties in dealing with ADHD child and increase probability of problems like accidental injury. • It may also contribute to a range of other family difficulties. • Examples likely include parental adjustment problems, marital dissatisfaction, and perhaps increases in alcohol use, etc.

ADHD IN MIDDLE CHILDHOOD • A major problem for the ADHD child in middle childhood is dealing with the demands of school. • They need to sit still, attend, obey, inhibit impulsive behavior. • They are expected to cooperate, follow instructions, share, and interact in positively with other children • This can impose a major burden on the child with ADHD. • Parents may continue to be stressed by the child’s ongoing behavioral problems both at home & at school.

ADHD IN MIDDLE CHILDHOOD • By this point a some children with ADHD will have developed a comorbid learning disability. • This may or may not be identified. • Those without diagnosed learning disabilities are likely to have problems learning due to their behavior. • They forget to bring home assignments, the lose their homework if they do it. • Conflict over issues of homework may be a real battleground with parents.

ADHD IN MIDDLE CHILDHOOD • At home, parents likely have problems getting the child to do chores and take on other responsibilities. • Relationship with siblings can be difficult and the child may experience social rejection by peers. • Given the social rejection and the feedback the ADHD child gets from his environment, it is not uncommon to begin to see the development of low levels of self esteem and possible depressive symptoms.

MIDDLE CHILDHOOD ADHD • By later childhood many will have ODD and a smaller number will have CD. • Those with pure ADHD (and whose problems are primarily with inattention) seem to have the best prognosis in adolescence. • By middle childhood 60 to 80% of children with ADHD will have been placed on stimulants or other medications. • Over half will have become involved in individual or family therapy. • 30 - 45 % will be receiving some sort of special educational assistance.

ADHD in Adolescence • We now know that the majority of children with ADHD do not grow out of this condition. • There is often a decline in level of hyperactivity and perhaps some improvement in impulse control and possibly attention. • Many if not most will continue to display symptoms into adolescence, that are severe enough to result in impaired functioning.

ADHD in Adolescence • As Barkley (2005) has noted, the adolescent years may be the most difficult for the ADHD child. • This is because of increasing demands for independent and responsible behavior as well as changes related to puberty. • Issues of personal identity, and peer group acceptance become sources of distress that must be dealt with. • Issues related to dating can also be a problem. • Problems with inattention to social cues • Problems with impulsivity • Stimulation seeking • Problems of self-esteem and depression often emerge or worsen, due to difficulties dealing with these situations.

ADHD in Adolescence • Follow up studies have consistently demonstrated that up to 80 % of children diagnosed as hyperactive in childhood continue to display symptoms into adolescence. • Between 30 to 80 % continue to meet current diagnostic criteria. • Many will show evidence of oppositional defiant or conduct disordered features. • Between 30 - 58 % will have failed at least one grade in school.

ADHD in Adolescence • Others will be significantly behind matched controls in academic performance. • While there are mixed findings, it seems likely that such children are at greater risk for alcohol and drug use. • This risk may be significantly greater for those children with ADHD and conduct problems.

Adolescent Outcome • Outcomes for children with ADHD in adolescents is highlighted by the results of a study by Barkley, Fischer, et al, (1990). • This study followed a large sample of ADHD (N = 158) and normal children (N= 81) prospectively for 8 years after diagnosis. • 123 hyperactive children and 66 “normals” were located, interviewed and complete questionnaires. • In the hyperactive group 12 (9.7%) were female and 111 were male. • In the normal group 4 of the subjects were female and 62 were male. • Note.This means that findings largely provide information on outcomes for males with ADHD.

Adolescent Outcome • The vast majority of the hyperactive subjects (71.5%) met DSM III-R criteria for ADHD at the 8 year follow-up (Note possible issues with ADHD-R criteria). • More than 59% met criteria for Oppositional Defiant Disorder as compared to only 11% of the controls. • Approximately 43 % of the hyperactive group could be diagnosed as CD as compared to 1.6% of the control group.

Adolescent Outcome • Hyperactive subjects were more likely to have had an auto accident, to have had more automobile accidents, to have had more bodily injuries in accidents, and to be at fault for accidents more often than did controls. • Adolescents in the hyperactive group were also more likely to have received traffic citations, especially for speeding.

Adolescent Outcome • Cigarette and alcohol use were the only categories of substance use that differentiated hyperactives and normals. • When the hyperactive sample was separated into groups (purely ADHD and ADHD + CD) purely ADHD subjects showed no greater use of cigarettes, alcohol, or marijuana than did normal controls. • Mixed hyperactive + Conduct disordered children displayed two to five times the rate of substance use as did pure hyperactives or normals.

Adolescent Outcome • Three times as many hyperactive children had failed a grade (29.3% versus 10%), had been suspended (46.3% versus 15.2%) or had been expelled (10.6% vs 1.5%). • Results suggested that hyperactivity alone increases the risk of suspension (30.6% vs 15.2%) & quitting school (4.8% vs 0% ) as compared to controls • However, CD greatly increases the risk (67% suspended, 13% dropped out). • The presence of CD accounted almost entirely for the > risk of expulsion within the hyperactive group

Adolescent Outcome • Here the pure hyperactive group did not differ from normals in expulsions rates (1.6% vs. 1.5%). • 21.7% of the mixed hyperactive/CD group had been expelled. • In contrast, the increased risk for grade retention in the hyperactive group was entirely accounted for by their hyperactivity with no further risk occurring among the mixed hypearactive/CD group.

Adolescent Outcome • More ADHD children had received medication and individual and group therapy, as well as special educational assistance, than had normal controls. • Hyperactive children had received an average of 36 months of medication, and an average of 16 months of individual therapy and 7 months of family therapy, as well as special educational assistance for learning, behavioral, and speech disorders during the previous 8 years (65, 59, and 40 months respectively.)

Adolescent Outcome: Conclusions • These findings, taken together with other follow-up studies suggest that • A significant number of children with ADHD in early childhood will continue to display ADHD symptoms into adolescence, and • having ADHD places the child at significant risk for a range of other problems in adolescence. • The risk may be further enhanced by comorbid conduct problems. • Other comorbid conditions may also increase the risk for adolescent problems, however, we know less about the magnitude of this risk.

ADHD In Adulthood • ADHD affects as many as 30 – 50% of adults diagnosed with ADHD in childhood. • With symptoms serious enough to interfere with academic, vocational and/or social functioning. • There are indications that ADHD persisting into adulthood is more highly genetic than that remitting in childhood. • Prevalence is thought to be 2 – 4% with sex ratio of 2 – 1 or lower).

Adult ADHD • While high levels of gross motor hyperactivity have likely declined by adulthood, deficits in sustained attention and concentration are likely present • These may become more apparent in early adulthood as family and work related responsibilities increase. • Appointments, social commitments and deadlines are frequently forgotten. • Impulsivity, which often takes the form of socially inappropriate behavior such as blurting out thoughts that are rude or insulting, may become a problem.

Adult ADHD and Disinhibition • There is growing consensus that the central feature of ADHD in adults is disinhibition (Barkley 2005). • Here the person is unable to inhibit immediate responding, and typically has deficits in monitoring his/her own behavior. • The "on the go" drivenness of many ADHD children is replaced in adulthood with restlessness, difficulty relaxing and a feeling of being chronically "on edge."

Adult ADHD • While a range of ADHD symptoms may be reported by others in the patient's life, the problem often expressed by adults with ADHD is frustration over the inability to be organized. • Prioritizing is another common source of frustration. • Important tasks are not completed while trivial distractions receive inordinate time and attention.

ADHD In Adulthood • It should be noted that it may be difficult to use standard DSM IV criteria in assessing adults for ADHD. • Existing criteria tend to reflect the presentation of ADHD in childhood. • The subtlety of ADHD symptoms among adults has led to several suggested modifications of existing criteria.

Adult ADHD • For example, rather than requiring six DSM-IV symptoms of inattention and/or Hyperactivity/impulsivity, some investigators have simply proposed requiring only five such behaviors for older patients.

ADHD: Proposed Adult Criteria • Others, have suggested specific criteria • For example, Wender (2000) developed, what is known as the Utah criteria, that were designed to reflect the distinct features of the disorder as reflected in adults. • The diagnosis of adult ADHD requires a longstanding history of ADHD symptoms, dating back to at least age seven. • In the absence of treatment, such symptoms should have been consistently present without remission.

ADHD: Proposed Adult Criteria • In addition to the criteria just listed, overactivity and poor concentration should be present in adulthood, along with two of five additional symptoms: • affective lability; • hot temper; • inability to complete tasks and disorganization; • stress intolerance; and • impulsivity.

Proposed Criteria: A Note • It is important to note that criteria such as the ones highlighted here are not well accepted criteria for diagnosis. • Rather they are attempts to distinguish the features of ADHD in adults from those seen in children. • They illustrate the possible inadequacies of DSM IV as a sensitive system for diagnosing ADHD in adults

Adult ADHD Outcomes • It is clear that ADHD symptoms persist and cause impairment for a significant group of adults throughout their adult years. • Research suggests that these adults with ADHD also display • greater self-reported psychological problems, • more driving problems • more frequent changes in employment. • a history of inconsistent educational experience and lower educational attainment, and • multiple marriages • lower levels of SES attainment than non ADHD siblings.

Adult ADHD Outcomes • Goldstein (2001) has suggested that by combining outcome studies it can be concluded that 10% to 20% of adults with histories of ADHD have relatively few problems. • ~ 60% continue to show symptoms that result in social, academic and emotional problems to at least a mild to moderate degree. • 10% to 30% develop anti-social problems in addition to their continued difficulty with ADHD and other comorbid problems such as depression & anxiety. • Many of these negative outcomes are linked to the continuity, severity and persistence of ADHD symptoms.

ADHD: Adult Outcomes • Outcome data for young adults have been provided in a recent study by Barkley, Fischer, Smallish and Fletcher (2006). • Here information was collected on a large sample of children, previously diagnosed with ADHD (N = 149) and a Community Control Group (N = 72). • Adult follow-up data was collected when the ADHD sample was 19 – 25 years of age (Mean = 20); all had been diagnosed at least 13 years earlier. • Age, duration of follow up, and IQ were statistically controlled as needed.

ADHD: Adult Outcomes • The ADHD group had significantly lower educational performance and attainment; 32% failed to complete high school. • Compared to controls, those previously diagnosed with ADHD • Had been fired from more jobs • Showed more employer-rated ADHD and ODD symptoms • And lower ratings of job performance

ADHD: Adult Outcomes • Socially those previously diagnosed with ADHD • Had fewer close friends • Had more trouble keeping friends • Had more social problems as rated by parents. • More had become parents (38% versus 4%) • More had been treated for sexually transmitted diseases (16% versus 4 %)

ADHD: Adult Outcomes • Severity of lifetime Conduct Disorder was predictive of several of the most salient outcomes: • Failure to graduate • Earlier sexual intercourse • Early parenthood. • ADHD and ODD symptoms at work were predictive of: • Poorer job performance • Increased risk of being fired

ADHD: Adult Outcomes • These findings support previous research suggesting frequent negative outcomes for individuals with ADHD and comorbid conditions. • They also suggest sexual activity and early parenthood as additional problems of adaptive functioning in adulthood

ADHD: Developmental Course & Later Outcome