Review: Adult Outcome as Seen Through Controlled Prospective Follow-up Studies of Children With Attention-Deficit/Hyperactivity Disorder Followed Into Adulthood.

OBJECTIVE: To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA). METHOD: All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes. RESULTS: The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders. CONCLUSION: Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

Design and rationale of controlled study of long-term methylphenidate and multimodal psychosocial treatment in children with ADHD.

OBJECTIVE: To describe the rationale, methodology, and sample characteristics of a dual-site treatment study (New York and Montreal) of children with attention-deficit/hyperactivity disorder (ADHD) conducted between 1990 and 1995. The hypotheses were that (1) methylphenidate combined with comprehensive multimodal psychosocial treatment was superior to methylphenidate alone in improving multiple functions and (2) the efficacy of the psychosocial intervention resulted from its specific components and not from nonspecific treatment effects. METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to methylphenidate, were randomized for 2 years to (1) methylphenidate treatment alone; (2) methylphenidate combined with multimodal psychosocial treatment that included parent training and counseling, academic assistance, psychotherapy, and social skills training; or (3) methylphenidate plus attention control treatment that excluded specific aspects of the psychosocial intervention. Children were switched to single-blind placebo after 12 months; methylphenidate was reinstituted when clinically indicated. Assessments included ratings by parents, teachers, children, and psychiatrists; school observations in academic and gym classes; and academic performance tests. Almost 80% of families completed the 2-year study. Companion papers present treatment effects. CONCLUSIONS: A comprehensive 2-year psychosocial treatment was delivered successfully to children with ADHD and their families.

Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment.

OBJECTIVE: To test the hypothesis that intensive multimodal psychosocial intervention (that includes academic assistance and psychotherapy) combined with methylphenidate significantly enhances the academic performance and emotional status of children with attention-deficit/hyperactivity disorder (ADHD) compared with methylphenidate alone and with methylphenidate combined with nonspecific psychosocial treatment (attention control). METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to receive one of three treatments: (1) methylphenidate alone, (2) methylphenidate plus psychosocial treatment that included academic remediation, organizational skills training, and psychotherapy as well as parent training and counseling and social skills training, or (3) methylphenidate plus attention control treatment. Children's function was assessed through academic testing, parent ratings of homework problems, and self-ratings of depression and self-esteem. RESULTS: No advantage was found on any measure of academic performance or emotional status for the combination treatment over methylphenidate alone and over methylphenidate plus attention control. Significant improvement occurred across all treatments and was maintained over 2 years. CONCLUSIONS: In stimulant-responsive young children with ADHD without learning and conduct disorders, there is no support for academic assistance and psychotherapy to enhance academic achievement or emotional adjustment. Significant short-term improvements were maintained over 2 years.

Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment.

OBJECTIVE: To test the hypotheses that in children with attention-deficit/hyperactivity disorder (ADHD) (1) symptoms of ADHD, oppositional defiant disorder, and overall functioning are significantly improved by methylphenidate combined with intensive multimodal psychosocial treatment compared with methylphenidate alone and with methylphenidate plus attention control and (2) more children receiving combined treatment can be taken off methylphenidate. METHOD: One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate were randomized for 2 years to (1) methylphenidate alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, psychotherapy, and academic assistance, or (3) methylphenidate plus attention psychosocial control treatment. Assessments included parent, teacher, and psychiatrist ratings, and observations in academic and gym classes. RESULTS: Combination treatment did not lead to superior functioning and did not facilitate methylphenidate discontinuation. Significant improvement occurred across all treatments and continued over 2 years. CONCLUSIONS: In stimulant-responsive children with ADHD, there is no support for adding ambitious long-term psychosocial intervention to improve ADHD and oppositional defiant disorder symptoms. Significant benefits from methylphenidate were stable over 2 years.

Adults with attention-deficit/hyperactivity disorder: current concepts.

In recent years, the validity of attention-deficit/hyperactivity disorder (ADHD) in adulthood has gained acceptance among mental health researchers and clinicians. This article will outline the history of this process, provide our best understanding of the characteristics of ADHD in adulthood, review current guidelines and controversies in the assessment of adult ADHD, and summarize pharmacological and psychosocial treatment options. Despite the strides gained in understanding adult ADHD, the authors encourage more research on this population and caution that current conceptualizations of the disorder are based on a limited amount of empirically based knowledge.

Hyperactives as young adults: school, employer, and self-rating scales obtained during ten-year follow-up evaluation.

A ten-year prospective follow-up of hyperactive adolescents and young adults indicates that they are rated as markedly inferior to normal controls by teachers but not by employers. On self-rating scales, they view themselves as inferior to controls on a personality test, but no different than controls on a psychopathology scale.

Hyperactives as young adults: past and current substance abuse and antisocial behavior.

In a ten-year prospective follow-up study, young adults who had been diagnosed as hyperactive in childhood were found to have had greater involvement with alcohol and drug use and with courts and police than did matched controls during the five years preceding evaluation. However, differences between groups were generally not significant in the year prior to evaluation, and tests indicate that they had attained similar levels of moral development. Results suggest a more encouraging adult outcome than has previously been expected for hyperactive children.

Antisocial disorders in hyperactive subjects from childhood to adulthood: predictive factors and characterization of subgroups.

A comprehensive chart review of 66 hyperactive patients, who were followed prospectively for 15 years at five-year intervals, identified four subgroups in the developmental course of antisocial behavior in adulthood: those who never presented with antisocial problems, those with continuing antisocial problems from childhood to adulthood, those who showed initial antisocial behavior that did not continue, and those who exhibited antisocial behavior initially and in adolescence, but not in adulthood.

A two-year follow-up of hyperactive preschoolers.

Twenty hyperactive children and 21 controls, studied in a research nursery at age four, were followed up at six-and-a-half. Hyperactives were still reported to have more behavior problems. Those rated extremely active in the nursery requested more feedback and made more comments in interactions with their mothers, and also made more immature moral judgments; children rated only moderately active did not differ from controls on these measures.

Hyperactivity in preschoolers and the effect of methylphenidate.

Observations of nursery behavior and tests of cognitive style and motor impulsivity were carried out with 28 hyperactive preschool children of normal intelligence and 26 matched control children. The hyperactive group was also observed and tested on methylphenidate and placebo. Methylphenidate was found to reduce hyperactivity at home, but it did not improve nursery behavior or psychological functioning. Unwanted side effects made the drug less useful at this age than in older hyperactive children.