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ADHD in the long term
Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),1 and about 50% of people are estimated to continue to meet criteria for ADHD as adults.2 Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.3 This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.
What predicts persistence of ADHD symptoms in adolescence?
Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.
What does ADHD predict for adolescents?
Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.7 This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.8 Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.9
What predicts persistence of ADHD symptoms in adulthood?
A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.
What does ADHD predict for adults?
It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.
How does this affect how we approach treatment?
Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.10 With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.11
For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. Psychol Med. 2006 Feb;36(2):159-65.
2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.
3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.
4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.
5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.
6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.
7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.
8. J Atten Disord. 2016 May;20(5):383-9.
9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.
10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.
11. PLoS One. 2015 Feb 25;10(2):e0116407.
Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),1 and about 50% of people are estimated to continue to meet criteria for ADHD as adults.2 Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.3 This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.
What predicts persistence of ADHD symptoms in adolescence?
Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.
What does ADHD predict for adolescents?
Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.7 This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.8 Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.9
What predicts persistence of ADHD symptoms in adulthood?
A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.
What does ADHD predict for adults?
It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.
How does this affect how we approach treatment?
Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.10 With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.11
For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. Psychol Med. 2006 Feb;36(2):159-65.
2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.
3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.
4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.
5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.
6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.
7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.
8. J Atten Disord. 2016 May;20(5):383-9.
9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.
10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.
11. PLoS One. 2015 Feb 25;10(2):e0116407.
Parents whose kids are diagnosed with ADHD face important questions about what to expect in the long term and how that might inform treatment. Studies find that ADHD diagnosed in childhood tends to persist in up to 65% of adolescents (some estimates are lower depending on criteria used),1 and about 50% of people are estimated to continue to meet criteria for ADHD as adults.2 Many studies have attempted to understand what long-term risks are associated with ADHD, as well as the factors that help better predict which characteristics in childhood might predict those risks. A recent article was published on a cohort of boys followed over 33 years.3 This, as well as other large prospective studies, such as the Multimodal Treatment of ADHD (MTA) provide us with helpful long-range data that inform this article.4-6 This article reviews risks in adolescence and adulthood and the factors thought to be associated with them.
What predicts persistence of ADHD symptoms in adolescence?
Several factors emerge consistently, including higher symptom severity, comorbid conduct disorder, and lower childhood IQ; other findings include family-related factors, such as lower parental mental health, less-positive parenting, and lower rates of parental education. In general, hyperactivity and impulsivity wanes, while inattention symptoms remain more stable.
What does ADHD predict for adolescents?
Adolescents with ADHD are more than twice as likely to be involved in pregnancies under the age of 18 years, true for both male and female genders.7 This finding also is associated with increased substance use and low academic achievement but not completely explained by it. Adolescents with persistent ADHD symptoms experience poorer educational success than do kids without ADHD symptoms, according to teacher reports of performance and measurements of grade point average. They are more likely to repeat a grade.8 Related but independent is the relationship of substance use disorders in kids with ADHD. Adolescents with ADHD are more likely to use nicotine or marijuana or meet criteria for any substance use disorder than adolescents without ADHD. Finally, adolescents aged 12-18 years with ADHD are at higher risk for motor vehicle accidents and all types of accidental injuries.9
What predicts persistence of ADHD symptoms in adulthood?
A follow-up study of the MTA trial 16 years later looked at ADHD diagnosed before age 12 years and the association with symptom persistence in adulthood, defined by the DSM-5 cutoff criteria of five symptoms. The following factors related to symptom persistence: childhood psychiatric comorbidity, higher ADHD symptom severity, and parental mental health problems. Notably, family socioeconomic status, child IQ, and parental education were not associated. In addition to looking at symptom persistence, other studies have looked at predictors of functional impairment in adulthood following a childhood ADHD diagnosis (independent of whether people continue to meet criteria for the disorder). The main findings that seem consistently related to all functional outcomes, including social, occupational, and educational, are lower childhood IQ and history of conduct problems (in the absence of meeting criteria for full childhood conduct disorder). Educational family-related factors, such as socioeconomic status and lower parental education, were related to lower educational functioning only.
What does ADHD predict for adults?
It appears that overall, adults who were diagnosed with ADHD as children show poorer functional outcomes than did those who weren’t, and there is a step-wise relationship when considering adults whose symptoms persist, with more severe outcomes compared with adults whose symptoms have desisted, who in turn have worse outcomes than adults who were never diagnosed with ADHD. Educational attainments follow this pattern with the highest average levels of education in the non-ADHD group and the lowest average years in the group with persistent symptoms. Occupational success and percent receiving public assistance again separated between each group, with the symptom persisters faring the worst, the symptom desisters better, and those never affected by ADHD, the best. In terms of emotional disorders, it was only the symptom persisters who suffered from higher rates of mood and anxiety disorders. Similarly, only the symptom persisters had significantly more marijuana use disorders. No other substance use disorders or legal outcomes were significant.
How does this affect how we approach treatment?
Clinicians and researchers who specialize in ADHD have been arguing for ADHD to be treated as more of a chronic disease and for impairment to be the focus of treatment, rather than simply symptom control.10 With what we know about long-term functional impairment, there is reason to consider a more holistic picture of a child or an adolescent and how they are functioning in their academic, emotional, and social domains. A meta-analysis of treatment and long-term outcomes suggests that psychostimulant treatment, psychotherapy treatment, and combined treatment all improve long-term functioning, especially self-esteem, social functioning, and academic functioning, with combined psychotherapeutic and pharmacologic treatments associated with the highest effect sizes.11
For those who treat ADHD, it is our job to provide education to families about the chronic risks associated with the diagnosis, and the importance of offering multimodal therapy that can address family factors that might be contributing to risks, as well as the child’s overall well-being. If we are to make sense of how adults may experience impairment even in the absence of ongoing symptoms, we might look at how their overall wellness was interrupted during development. Maybe they fell into a different crowd of kids? Maybe they stopped achieving at school in a way that changed the achievement trajectory they were on? Maybe they impulsively picked up substances or got in trouble with the law? These events can have lasting impacts on well-being. We must use medicine and psychotherapy to help with symptoms, but we must look beyond treating illness and use evidence-based strategies to promote wellness at the level of the entire family.
Dr. Guth is an assistant professor in the department of psychiatry at the University of Vermont Medical Center and the University of Vermont, both in Burlington. She works with children and adolescents as well as women in the perinatal period. She has no relevant financial disclosures.
References
1. Psychol Med. 2006 Feb;36(2):159-65.
2. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):937-44.e4.
3. J Am Acad Child Adolesc Psychiatry. 2018 Aug;57(8):571-82.e1.
4. J Am Acad Child Adolesc Psychiatry. 2017 Aug;56(8):687-95.e7.
5. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):945-52.e2.
6. J Am Acad Child Adolesc Psychiatry. 2009 May;48(5):484-500.
7. J Atten Disord. 2017 Sep 1:1087054717730610. doi: 10.1177/1087054717730610.
8. J Atten Disord. 2016 May;20(5):383-9.
9. Eur Child Adolesc Psychiatry. 2014 Feb;23(2):95-102.
10. JAMA Pediatr. 2018 Aug 13. doi: 10.1001/jamapediatrics.2018.1642.
11. PLoS One. 2015 Feb 25;10(2):e0116407.