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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:
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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
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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
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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