Predicting the Adult Functional Outcomes of Boys With ADHD 33 Years Later

A longitudinal investigation of parental ratings and performance metrics for executive functioning and symptom severity in clinically referred youth with ADHD

There remains a knowledge gap concerning the persistence of attention deficit hyperactivity disorder (ADHD) over the longer term. The current study aimed to investigate the change in parent-rated, and performance-based metrics of executive functioning (EF) and the relationship between these EF metrics and ADHD symptoms in individuals with ADHD from childhood/adolescence to young adulthood. This was done by examining possible improvements in parent-rated EF and performance-based measures of inattention and inhibition over a three-year interval and their relationship to ADHD outcomes in 137 clinically referred youth with ADHD (mean age = 12.4 years, SD = 3.1). Participants' parents completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Swanson-Nolan-Pelham Scale at baseline and follow-up. Participants completed the Conners' Continuous Performance Test, Version II (CPT II) at baseline and follow-up. Statistical analyses were performed with Linear Mixed Models. The sex- and age-standardized measures Commission and Hit reaction time (RT) subscales of the CPT II and parent-rated metacognitive, and behavior regulation composites of the BRIEF were largely stable between measuring points. CPT Omissions, Hit RT standard error (reaction time variability), and parent-rated ADHD symptom scores improved slightly. BRIEF composites and reaction time variability were related to ADHD symptoms using longitudinal data. Overall, behavioral aspects of EF, as observed by parents in the home context, appear to play a significant role in the trajectory of childhood ADHD.

Youth Polygenic Scores, Youth ADHD Symptoms, and Parenting Dimensions: An Evocative Gene-Environment Correlation Study

Parenting practices and parental symptoms of attention-deficit/hyperactivity disorder (ADHD) have been linked to severity and course of youth ADHD. However, genetically influenced behaviors related to ADHD in youth may also influence parenting behaviors. Polygenic scores (PGS) have been widely used to quantify genetic vulnerability for ADHD but has rarely been used to examine gene-environment correlation effects. The current study examined the direct effects of youth ADHD PGS and its evocative effects on parenting behaviors via youth ADHD symptoms. 803 youth aged 6-18 years (58.5% male) completed a multistage, multi-informant assessment that included measures of parenting practices and youth and parental ADHD symptoms. A mediation model was used to evaluate direct and evocative effects. Furthermore, we examined if these evocative effects remain after controlling for parental ADHD symptoms. Sensitivity analyses across age, sex, and socioeconomic status (SES) as well as restricting ancestry groups to European only ancestry were also conducted. Results indicated that youth ADHD PGS reliably predicted youth ADHD symptoms across all models (βs ranging from 0.18 to 0.26), including across age, sex, and SES and held even with ancestry restricted to the largest group (northern European). Evocative effects emerged such that higher youth PGS significantly predicted more youth ADHD symptoms, which in turn, significantly predicted lower levels of parental involvement and higher levels of poor supervision/monitoring and inconsistent discipline. These effects remained after controlling for parent ADHD symptoms.

Gene-by-Environment Interaction Effects of Social Adversity on Externalizing Behavior in ABCD Youth

This study tested whether multiple domains of social adversity, including neighborhood opportunity/deprivation and life stress, moderate genetic (A), common environmental (C), and unique environmental (E) influences on externalizing behaviors in 760 same-sex twin pairs (332 monozygotic; 428 dizygotic) ages 10-11 from the ABCD Study. Proportion of C influences on externalizing behavior increased at higher neighborhood adversity (lower overall opportunity). A decreased and C and E increased at lower levels of educational opportunity. A increased at lower health-environment and social-economic opportunity levels. For life stress, A decreased and E increased with number of experienced events. Results for educational opportunity and stressful life experiences suggest a bioecological gene-environment interaction pattern such that environmental influences predominate at higher levels of adversity, whereas limited access to healthcare, housing, and employment stability may potentiate genetic liability for externalizing behavior via a diathesis-stress mechanism. More detailed operationalization of social adversity in gene-environment interaction studies is needed.

Is genetic liability to ADHD and ASD causally linked to educational attainment?

BACKGROUND

The association patterns of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) with educational attainment (EA) are complex; children with ADHD and ASD are at risk of poor academic outcomes, and parental EA has been associated with risk of ADHD/ASD in the offspring. Little is known on the causal links between ADHD, ASD, EA and the potential contribution of cognitive ability.

METHODS

Using the latest genome-wide association studies (GWAS) summary data on ADHD, ASD and EA, we applied two-sample Mendelian randomization (MR) to assess the effects of genetic liability to ADHD and ASD on EA. Reverse direction analyses were additionally performed. Multivariable MR was performed to estimate any effects independent of cognitive ability.

RESULTS

Genetic liability to ADHD had a negative effect on EA, independently of cognitive ability (MVMRIVW: -1.7 months of education per doubling of genetic liability to ADHD; 95% CI: -2.8 to -0.7), whereas genetic liability to ASD a positive effect (MVMRIVW: 30 days per doubling of the genetic liability to ASD; 95% CI: 2 to 53). Reverse direction analyses suggested that genetic liability to higher EA had an effect on lower risk of ADHD, independently of cognitive ability (MVMRIVWOR: 0.33 per SD increase; 95% CI: 0.26 to 0.43) and increased risk of ASD (MRIVWOR: 1.51 per SD increase; 95% CI: 1.29 to 1.77), which was partly explained by cognitive ability (MVMRIVWOR per SD increase: 1.24; 95%CI: 0.96 to 1.60).

CONCLUSIONS

Genetic liability to ADHD and ASD is likely to affect educational attainment, independently of underlying cognitive ability.

Children With ADHD Are at Risk for a Broad Array of Adverse Adult Outcomes That Cross Functional Domains: Results From a Population-Based Birth Cohort Study

OBJECTIVE

To identify patterns ("classes") of outcomes for adults with and without childhood ADHD.

METHOD

Subjects were 232 childhood ADHD cases and 335 non-ADHD referents from a 1976 to 1982 birth cohort. We used latent class analyses to identify classes based on a broad array of adult psychosocial outcomes and determined the proportion of subjects with childhood ADHD within each class.

RESULTS

A three class solution provided optimal model fit; classes were termed "good," "intermediate," and "poor" functioning. Subjects with childhood ADHD comprised 62.8% of the "poor," 53.5% of the "intermediate," and 24.9% of the "good" functioning class. The "poor" functioning class was distinguished by increased likelihood of legal trouble and substance use disorders and included more individuals with childhood ADHD and psychiatric disorder than the "intermediate" class (45.5% vs. 30.6%).

CONCLUSION

Children with ADHD are at risk for adverse adult outcomes in multiple domains and co-morbid childhood psychiatric disorders increase risk.

Associations between sleep, daytime sleepiness and functional outcomes in adolescents with ADHD

OBJECTIVE/BACKGROUND

Adolescents with attention-deficit/hyperactivity disorder (ADHD) experience greater difficulties in the domains of sleep, daytime sleepiness, and functioning compared to their peers. However, the relationship between these domains has not been fully elucidated. This study aimed to examine the relationship between sleep problems (including daytime sleepiness), ADHD severity, and functional outcomes (irritability, sluggish cognitive tempo, homework difficulties, and substance use) in a sample of adolescents with ADHD.

PATIENTS/METHODS

Eighty-two adolescents (13-17 years) and their families participated in the study. Sleep was measured by both adolescent and parent-report. Adolescent irritability and sluggish cognitive tempo were reported by both adolescents and parents, while other variables were reported by a single reporter (homework difficulties - parent; ADHD severity - parent; substance use - adolescent). Analyses controlled for demographic factors and internalising and externalising comorbidities.

RESULTS

A weak relationship was found between adolescent-reported sleep problems and daytime sleepiness, which became non-significant in adjusted analyses (β = -0.19, p = 0.115). In adjusted analyses, there was an association between adolescent-reported sleep problems and adolescent-reported irritability (β = -0.27, p = 0.023) as well as between adolescent-reported daytime sleepiness and parent-reported sluggish cognitive tempo (β = 0.28, p = 0.033). In adjusted analyses, parent-reported adolescent sleep problems were associated with ADHD severity (β = 0.54, p = <0.001), parent-reported sluggish cognitive tempo (β = 0.64, p = <0.001), both reporters of irritability (parent-report: β = 0.32, p = 0.004; adolescent-report: β = 0.29, p = 0.022), and homework problems (β = 0.37, p = 0.003). Parent-reported daytime sleepiness was associated with parent-reported sluggish cognitive tempo (β = 0.34, p = 0.024).

CONCLUSIONS

This study demonstrates the importance of a holistic assessment of adolescents with ADHD, not only focusing on symptomatology but also on sleep problems and functional outcomes. The importance of multi-informant assessment of sleep problems is also reinforced.

Basic and complex cognitive functions in Adult ADHD

Background

Many clinical studies reported deficits in basic and complex cognitive functions in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, the extent in which deficits in basic functions (i.e., processing speed and distractibility) contribute to complex cognitive impairments (i.e., working memory, planning, cognitive flexibility, memory functions) in adults with ADHD is not well-studied. So far, literature show only one study, revealing that basic functions explain 27–74% of executive dysfunctions. Yet, the authors reported that findings could be affected by the selection of neuropsychological tests. The goal of the present research is to replicate such a finding using a different sample and a different set of neuropsychological tests.

Methods

Forty-eight adult patients with ADHD were compared with 48 healthy controls in basic cognitive functions, namely processing speed and distractibility and more complex cognitive functions, namely selective attention, cognitive flexibility, planning, working memory, verbal fluency, and verbal memory. Basic and complex cognitive functions were assessed using the Vigilance and Sustained Attention, Selective Attention, N-Back, Tower of London, Trail Making Test, Word Fluency, and Verbal Learning and Memory.

Results and conclusion

Logistic regression analyses showed that impairments in complex cognitive functions explained 25% of the variance in ADHD diagnosis. The explained variance dropped from 25% to 9% after considering basic functions of processing speed and distractibility. This 64% reduction highlights the importance of basic functions for impairments in complex functions in patients with ADHD.

A longitudinal investigation of cognitive functioning and its relationship to symptom severity and academic functioning in treatment seeking youth with AHDH

Background:

Children with ADHD tend to present with poorer cognitive functioning leaving them more vulnerable to a range of negative outcomes. To date, only a handful of longitudinal studies have examined the stability of Wechsler composite scores in children and adolescents with ADHD, and none of them used a more recent version of the Wechsler Intelligence Scales for Children (WISC), than the WISC-III.

Objective:

The present study investigates the cognitive stability and its longitudinal relationship with the severity of the child’s ADHD symptoms and school grades.

Method:

Cognitive functioning was measured with the fourth editions of the WISC-IV or the Wechsler Adult Intelligence Scales (WAIS-IV) at baseline and at a 3-4-year follow-up in children with ADHD (n = 125, mean age = 11.40 years, SD = 3.27) and a Control group of schoolchildren (n = 59, mean age = 11.97 years, SD = 2.15). The stability of cognitive functioning and the relationship between cognitive functioning, ADHD and grades were evaluated using linear mixed models and logistic regression.

Results:

Standardized composite scores of Full scale IQ, Verbal Comprehension, and Processing Speed declined between baseline and follow-up in the ADHD group. ADHD symptom scores were associated with Working Memory scores. Together, the severity of concurrent ADHD symptoms and lower scores for verbal comprehension at baseline and follow-up were associated with an increased risk of not achieving grades at follow-up in youth with ADHD.

Conclusions:

Youth with ADHD often present with cognitive impairments, not improved over time. Together these increase the risk of poorer academic outcomes. Concurrent evaluation of symptom severity and cognitive functions can add potentially useful information in terms of treatment planning, and school supports to prevent school failure.

Retrospective symptoms and learning difficulties predicting ADHD in adults: Differences between prison inmates and the clinical population

People who suffer from ADHD in their childhood are more likely to be involved in criminal acts in late adolescence and adulthood. This study analyses the association between retrospective ADHD symptoms and associated problems (somatic and learning difficulties), and current symptoms in a sample of adults from imprisoned and clinical populations. Four hundred and fifty-seven participants, aged between 17 and 69 years, were divided into four groups: ADHD prison group without clinical history of symptoms (n = 61), prison group (n = 162), ADHD clinical group (n = 176) and clinical group (n = 58). The ADHD-IV scale and Wender Utah Rating Scale (WURS) were administered to the four groups and demonstrated high rates of persistence of ADHD symptoms into adulthood. ADHD groups reported significantly higher impairment both during childhood (symptoms, somatic and learning difficulties) and at present, with the ADHD clinical group being the most severely impaired. Finally, current symptoms of ADHD, along with childhood ADHD symptoms and learning difficulties, significantly predicted current impairments, but only in the clinical group. These findings represent some initial steps into the identification of predictors of ADHD symptomatology in adulthood in order to elucidate its etiopathogenesis and better identify high-risk groups for targeted prevention.

Predicting the Adult Clinical and Academic Outcomes in Boys With ADHD: A 7- to 10-Year Follow-Up Study in China

Background: Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood and causes adverse effects on social functioning. The present study aimed to widely investigate the predictors, particularly childhood intelligence quotient (IQ) and family environment factors, on adult clinical and academic outcomes in boys with ADHD. Methods: A total of 101 boys with ADHD in a Chinese Han ADHD cohort were followed up 7-10 years later. Baseline ADHD symptoms were evaluated using the parent version of the ADHD Rating Scale-IV (ADHD-RS-IV) and the Chinese version of the Conners' Parent Rating Scale-Revised (CPRS-48). The intelligence of the child was tested by the China-Wechsler Intelligence Scale for Children (C-WISC), and family function was assessed by the Family Environment Scale-Chinese Edition (FES-CV). Adult ADHD persistence was defined using DSM-IV criteria for ADHD, and academic outcome fell into two categories: higher academic level group (studying in senior middle school or above) and lower academic level group (studying in vocational secondary schools or below). Results: Stepwise multiple logistic regression analysis revealed that the father's character, impulsive-hyperactive index as measured by the CPRS-48, and intellectual-cultural index as measured by the FES-CV independently predicted clinical outcomes in adults, with an AUC of 0.770 (p < 0.001, 95% CI = 0.678-0.863). The corresponding sensitivity and specificity were 0.743 and 0.727, respectively. The father's education level, family economic level, and verbal IQ (VIQ) on the C-WISC independently predicted adult academic outcomes, with an AUC of 0.870 (p < 0.001, 95% CI = 0.796-0.944). The corresponding sensitivity and specificity were 0.813 and 0.783, respectively. Conclusion: Initial ADHD symptom severity and IQ, father's character and education level, and family atmosphere and function affect adult clinical and academic outcomes. Addressing these areas early may help to improve the prognosis of ADHD into adulthood.

Interventions for Improving Reading Comprehension in Children with ASD: A Systematic Review

Children with autism spectrum disorder (ASD) often have comorbid learning difficulties in reading comprehension, an essential skill in accessing any area of the curriculum. The aim of this systematic review is to analyze the effectiveness of reading comprehension interventions in students with ASD. We conducted a search for scientific articles published from 2000 to 2019 using the keyword "autis*" in combination with the terms "reading comprehension" and "intervention" or "instruction" in Psyc Info and Scopus databases. After applying inclusion and exclusion criteria, a total of 25 studies were selected. The content analysis of these studies shows that when specific interventions are carried out, students with ASD are able to take advantage of the instruction they receive and compensate for difficulties. Understanding inferences and the main idea of the text are the most common reading comprehension topics, and direct instruction is the most widely-used intervention method in the reviewed studies. Nonetheless, it must be kept in mind that some of the reviews do not specify which sub-processes are addressed in the intervention. Future work should include this aspect, consider the importance of the interventions being implemented by teachers, and take specific aspects of ICT into account that can contribute to improving reading comprehension.

Associations of executive and functional outcomes with full-score intellectual quotient among ADHD adults

Associations between executive and functional impairment, intelligence, and attention deficit hyperactivity disorder (ADHD) have been scarcely investigated among adult populations and lead to inconsistent results. This study tested the impact of intellectual level on executive and functional impairment in a clinical sample of adults diagnosed with ADHD. Participants were recruited in a specialized center for the diagnosis and treatment of ADHD (n=66, mean age=27.9 ± 10.8). Measures included intellectual quotient (IQ, Wechsler Adult Intelligence Scale) categorized as ≤110 or >110, the continuous performance test (CPT3^TM), grade retention, educational attainment, and having an activity (job or studies). Participants with a higher IQ had significantly better functional outcomes than participants with a standard IQ: higher educational attainment, lower grade retention, and often having an activity. Participants with higher IQ performed significantly better on all CPT variables assessing executive functioning. Intelligence seemed to work as a protective factor for executive and functional outcomes in a clinical population of ADHD adults and might reduce long-lasting detrimental consequences in life.

Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals.

METHODS

The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review.

RESULTS

According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching.

CONCLUSION

The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.

Dopaminergic gene analysis indicates influence of inattention but not IQ in executive dysfunction of Indian ADHD probands

Organizational inefficiency and inattention are speculated to be the reason for executive deficit (ED) of ADHD probands. Even with average IQ, probands often perform poorly due to higher inattention. Pharmacotherapy, cognitive behavioural therapy, and counselling provide only symptomatic relief. Several candidate genes showed involvement with ADHD; the most consistent are dopamine receptor 4 (DRD4) and solute carrier family 6 member 3 (SLC6A3). We analyzed association of rarely investigated DRD4 and SLC6A3 variants with ADHD core traits in Indo-Caucasoid probands. ED, inattention, organizational efficiency, and IQ were measured by Barkley Deficit in Executive Functioning-Child & Adolescent scale, DSM-IV-TR, Conners' Parent Rating Scale-revised, and WISC respectively. Target sites were analyzed by PCR, RFLP, and/or Sanger sequencing of genomic DNA. DRD4 variants mostly affected inattention while SLC6A3 variants showed association with IQ. Few DRD4 and SLC6A3 variants showed dichotomous association with IQ and inattention. DRD4 Exon3 VNTR >4R showed negative impact on all traits excepting IQ. Inattention showed correlation with attention span, organizational efficiency, and ED, while IQ failed to do so. We infer that IQ and attention could be differentially regulated by dopaminergic gene variants affecting functional efficiency in ADHD and the two traits should be considered together for providing better rehabilitation.

Hyperactive Boys Grown Up

What happens when hyperactive little boys grow up? Drs. Klein, Mannuzza, and their research team have been examining this important question for more than three decades. Ramos-Olazagasti et al., published in this issue of JAACAP, provide details regarding early predictors of adult functioning for children with attention-deficit/hyperactivity disorder (ADHD).¹ Starting with publications in the 1980s, the research team reported on a cohort of boys of white ethnicity, 6 to 12 years of age with what we now call ADHD, of average intelligence, but without conduct disorder, and compared them as older adolescents to boys with no childhood behavior problems. This seminal study was among the first to document that a substantial proportion of boys with ADHD continue to show the core symptoms of inattention, impulsiveness, and hyperactivity at a mean age of 18 years as well as worse educational, social, and psychiatric outcomes, including non-alcohol substance use disorder, than do comparison boys, thus setting the stage for continued poor functioning as adults. Since the 1980s, there have been major efforts to develop interventions to address the difficulties for children with ADHD and to avert negative outcomes, including an explosion in the controversial use of psychostimulant medications to treat what many in the lay public still see as active little boys. In recent years, ADHD as a disorder has remained at the forefront of the nature-versus-nurture discussion in the field of neurodevelopmental psychiatry, as researchers strive to uncover the neuroanatomic, cognitive, physiologic, genetic, and epigenetic etiologies of the disorder.

Social function of adult men with attention-deficit/hyperactivity disorder in the context of military service

PURPOSE

This study examined the characteristics of adult men with attention-deficit/hyperactivity disorder (ADHD) on social outcomes with particular focus on social function in the context of military service.

SUBJECTS AND METHODS

Eighty-nine adult male outpatients diagnosed with ADHD in adulthood were included in this retrospective chart review study. Participants were divided into two groups: "military service group (MS)" (those who had completed military duty) and "nonmilitary service group (NMS)" (those who were exempted from conscription or engaged in public service). MS included 50 subjects and NMS included 39 subjects. The age at first ADHD diagnosis, intelligence quotient (IQ), occupation, and psychiatric comorbidities were compared between the two groups.

RESULTS

The age at first diagnosis, IQ, and number of employed participants were significantly higher in MS than in NMS. NMS had significantly more psychiatric comorbidities than those in MS. In both groups, depression was the most common psychiatric comorbidity. Logistic regression analysis showed that the subjects' IQ, psychiatric comorbidity, and age at first diagnosis were determinants of military duty completion.

CONCLUSION

The results strongly suggested that IQ and psychiatric comorbidities are the most crucial factors affecting military service in male adults with ADHD, independent of ADHD.