Studies on the hyperactive child. 8. Five-year follow-up

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.

The Relationship between Adult Symptoms of Attention-Deficit/Hyperactivity Disorder and Criminogenic Cognitions

The relationship between ADHD-in particular hyperactivity-and criminal behavior is well documented. The current study investigated the role of criminogenic cognitions in the explanation of this relationship by examining which symptoms of ADHD are associated with criminogenic cognitions. Community-recruited adults (N = 192) completed self-report questionnaires for symptoms of ADHD and criminogenic cognitions. Symptoms of inattention were consistently and strongly related to criminogenic cognitions. In particular, inattention was significantly related to cutoff, cognitive indolence, and discontinuity. There was also evidence that impulsivity was positively related to criminogenic cognitions, and specifically, to the power orientation subscale. In contrast, and contrary to expectations, symptoms of hyperactivity were not related to criminogenic cognitions. These results indicate that in community-recruited adults, inattention rather than hyperactivity is related to criminogenic cognitions. We discuss the implications of these findings contrasting with those of previous studies that used forensic and clinical samples.

Bone Age in Children with Minimal Brain Dysfunction

53 children diagnosed as having minimal brain dysfunction by the criteria of Clements had X-rays of their left wrist and hand for the determination of bone age. All X-rays were read independently by three physicians skilled in radiology. The films were read blind, that is, sex and case numbers but not age were available. The degree of inter-rater reliability was very high ( r = 0.87). Bone age for the minimal brain dysfunction group was significantly retarded ( p < 0.01) compared with the standard group's norms. Bone ages of more than 2 SD below the mean occurred in 10 children, while only one child showed a bone age of more than 2 SD above the mean. Two-thirds of the children in the minimal brain dysfunction group fell below the mean of the standard norms. No correlation was found between bone age and thyroid level. These findings suggest that children diagnosed as having minimal brain dysfunction may be physiologically retarded in their bone age, although marked individual variations remain. The concept of physiological immaturity should be considered by professionals in the education and social planning for the child with minimal brain dysfunction.

Home-Based Treatment of Severe Disruptive Behaviors

A home-based reinforcement package was implemented to decrease serious disruptive and aggressive behaviors in three groups of six pre-school and kindergarten-age children, who participated across successive summers in an intensive nine-week remedial program. For each group, the effectiveness of experimental treatment was evaluated in a multiple baseline design across three target behaviors: off-area, physical aggression, and negative statements. Results showed that the home-based package was highly effective for all target responses of all children in the first two groups, but failed to modify disruptive responses of two children in the third group. Potential explanations for the discrepant results, as well as supplementary findings on untreated variables and some individual treatment components, are discussed.

A Promblem Solving Training Program for Parents of Children with Attention Deficit Hyperactivity Disorder

A behavior management approach is presented that is designed to enhance the active involvement of children with ADHD in managing their own behavior. In this program emphasis is placed on parents presenting behavior management situations as those where their child must make a choice between compliance and noncompliance. Each of these alternatives is linked to a consequence that is meaningfully connected to the antecedent behavior. Parents are also given instruction in acknowledging feelings, the use of process questions, anger management, and communication skills. The intervention is being delivered in both an individual program of therapy in which pairs of parents meet with the therapists and a group program in which 8-10 parent pairs meet with a pair of therapists. Preliminary findings indicate that the program is effective in reducing parental stress, improving the parents' perception of the child, and improving parental problem solving skills in behavior management situations. The effects appear to be stronger for individual as compared to group therapy.

Psychopharmacological treatment of ADHD in adults aged 50+: an empirical study

OBJECTIVE

To study pharmacotherapy in adults aged 50+ with ADHD.

METHOD

A survey was administered to adults with ADHD (≥ 50 years old). Participants on medication for ADHD were compared with those not on medications.

RESULTS

Mean age of participants was 55.8 years, and mean age when diagnosed with ADHD was 50.3 years. Ninety-five participants (63.8%) reported current psychopharmacological treatment for ADHD, 36 (24.2%) had stopped psychopharmacological treatment, and 18 (12.0%) were psychopharmacological treatment naive for ADHD. Those currently being treated psychopharmacologically for ADHD reported significantly improved attention relative to the two nonmedicated groups (p < .01). Among examined sample characteristics (including current psychopharmacological treatment for ADHD), employment was associated with a better outcome (odds ratio = 3.3, p = .006).

CONCLUSION

The majority of adults aged 50+ with ADHD reported regular pharmacotherapy for ADHD. Participants currently receiving psychopharmacological treatment for ADHD reported better attention than those not receiving pharmacotherapy. Employment was associated with more favorable outcomes.

Attention-deficit/hyperactivity disorder: a shift toward resilience?

Children with attention-deficit/hyperactivity disorder (ADHD) present a concern across clinical, academic, and social domains. However, a subset of these children does fairly well symptomatically and functionally. This article employs a resilience framework to organize the research on factors that promote favorable outcomes in ADHD. A PubMed search was conducted using key words: resilience and ADHD. Of particular interest were articles focusing on modifiable protective factors, such as parenting and pharmacotherapy. There is consensus that genetics strongly contributes to the etiology of ADHD. Parental, peer, and environmental factors may interact with genes to moderate the developmental expression of ADHD. Pharmacotherapy research reveals that medications exert positive effects of modest magnitude in academic achievement, social functioning and quality of life. However, there is insufficient evidence to determine whether treatment can modify developmental outcomes. Efforts to strengthen family support along with access to health and educational resources may also optimize outcomes.

Predictive factors for persistent use and compliance of immediate-release methylphenidate: a 36-month naturalistic study

AIM

The objective of this study was to evaluate predictors of long-term adherence to treatment with methylphenidate (MPH).

METHODS

A total of 134 children (ages 4-16) with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) determined by specific protocols, including a semistructured parent interview, Conners' Teacher/Parent Rating Scales, cognitive and learning evaluation, and child self-reports for anxiety and depression, were assessed monthly for up to 36 months. At the end of the study (36 months), three outcomes were evaluated (continuing medication, medication withdrawn due to functional remission, and medication withdrawn for other reasons including poor compliance). Outcomes were first analyzed by mean of the chi-squared test, Mann-Whitney-U test, or t-test, and predictive models were subsequently generated using Cox proportional hazards model analysis. Age, ADHD subtype, co-morbidity, cognitive functioning, side effects, and family and social characteristics were considered as independent variables.

RESULTS

Thirty-six months after starting MPH, 62 children (46%) were still on treatment, 32 (24%) had stopped MPH due to functional remission, and 40 (30%) had suspended MPH for other reasons. Within the last group, 20 suspended for poor compliance, 10 for decrease of efficacy, 5 for side effects, and 5 because they entered in an atomoxetine clinical trial. The presence of associated disorders, younger age, female gender, and not living with both parents were predictors for continuing medication until end of the study (36 months); absence of associated disorders and older age were predictors of discontinuation medication due to functional remission before the end of study, older age, and hyperactive subtype were predictors of discontinuing medication for other reasons.

CONCLUSION

Clinical outcome of ADHD treatment is heterogeneous: Specific clinical and social predictive parameters for long-term MPH use and compliance can be identified. An accurate tailoring of clinical intervention to the individual child appears crucial for good outcome.

Treatment of a 7-Year-Old Hyperactive Boy with Educational Problems

A 7-year-old hyperactive boy with multiple problems was treated using a combination of interventions, applied sequentially over 14 months. The first phase of treatment was participation in a drug trial (placebo, then drug) and this was followed by cognitive-behavioural training designed to teach strategies with which to approach academic work. Teacher and parent behaviour ratings showed improvement over the drug trial period and educational gains were made during the cognitive-behavioural training, both in the area specifically taught and other academic subjects. The problems choosing appropriate targets and of disentangling the effects of different treatment components are discussed.

3-year follow-up of the NIMH MTA study

OBJECTIVE

In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD (MTA), the effects of medication management (MedMgt), behavior therapy (Beh), their combination (Comb), and usual community care (CC) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm (Comb+MedMgt) over those that did not (Beh+CC). This report examines 36-month outcomes, 2 years after treatment by the study ended.

METHOD

For primary outcome measures (attention-deficit/hyperactivity disorder [ADHD] and oppositional defiant disorder [ODD] symptoms, social skills, reading scores, impairment, and diagnostic status), mixed-effects regression models and orthogonal contrasts examined 36-month outcomes.

RESULTS

At 3 years, 485 of the original 579 subjects (83.8%) participated in the follow-up, now at ages 10 to 13 years, (mean 11.9 years). In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months, treatment groups did not differ significantly on any measure at 36 months. The percentage of children taking medication >50% of the time changed between 14 and 36 months across the initial treatment groups: Beh significantly increased (14% to 45%), MedMed+Comb significantly decreased (91% to 71%), and CC remained constant (60%-62%). Regardless of their treatment use changes, all of the groups showed symptom improvement over baseline. Notably, initial symptom severity, sex (male), comorbidity, public assistance, and parental psychopathology (ADHD) did not moderate children's 36-month treatment responses, but these factors predicted worse outcomes over 36 months, regardless of original treatment assignment.

CONCLUSIONS

By 36 months, the earlier advantage of having had 14 months of the medication algorithm was no longer apparent, possibly due to age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated.

Long-term treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD)

Only 7% to 50% of children with attention-deficit/hyperactivity disorder actually are treated. Of those who begin treatment, only 18% to 50% persist in the treatment for any length of time (eg, 2 to 3 years). Thus, available data on effects of long-term medication and psychosocial treatment are sparse and problematic. This article reviews available data on long-term effects of medication (stimulant and nonstimulant) and psychosocial treatment.

Transtorno do déficit de atenção e hiperatividade (TDAH): aspectos relacionados à comorbidade com distúrbios da atividade motora

A presente revisão aborda aspectos fisiopatológicos e clínicos referentes ao Transtorno do Déficit de Atenção com Hiperatividade (TDAH), em especial aqueles que concernem à associação desse transtorno com o Distúrbio do Desenvolvimento da Coordenação (DDC). Utilizou-se a base de dados Medline para levantamento de artigos indexados a partir de 1965 até 2004. Aos artigos selecionados dessa forma, outros foram obtidos pela relevância atribuída a eles nas fontes iniciais. A pré-disposição hereditária desse transtorno é indiscutível, bem como a presença da disfunção nora-drenégica e dopaminérgica no córtex pré-frontal e suas conexões. Apesar desse conhecimento, o diagnóstico da condição se baseia em dados clínicos. As associações mórbidas ocorrem em cerca de metade dos indivíduos, sendo as principais comorbidades de natureza psiquiátrica. A presença de uma comorbidade pode modificar a terapêutica e o prognóstico. O Distúrbio do Desenvolvimento da Coordenação, condição também de diagnostico clínico, confere pior prognóstico às crianças que partilham ambos os quadros. Recomenda-se que uma busca ativa de condições associadas seja realizada em cada criança diagnosticada como portadora de TDAH.

Adjustment, social skills, and self-esteem in college students with symptoms of ADHD

Many studies of ADHD have shown that the problems associated with the disorder continue into adolescence and beyond for 10% to 60% of patients. The present study assesses several aspects of college adjustment, social skills, and self-esteem in a nonreferred sample of college students meeting criteria for a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of ADHD. Twenty-one undergraduate students with symptoms of ADHD are compared to 20 students without significant ADHD symptoms, who match the ADHD students on age, gender, and grade point average. Students with ADHD symptoms show decreased functioning in several areas of college adjustment as well as lower levels of self-reported social skills and self-esteem. The results also suggest that the relation between ADHD and college adjustment is partially mediated by self-reported levels of self-esteem.

Long-term use of stimulants in children with attention deficit hyperactivity disorder: safety, efficacy, and long-term outcome

The purpose of this review is to summarize existing data on the long-term safety and efficacy of stimulant treatment, and how long-term stimulant treatment of children with attention deficit hyperactivity disorder (ADHD) affects their outcome. Existing controlled studies of children with ADHD treated and untreated with stimulants, as well as long-term prospective follow-up studies, are reviewed. Children with ADHD treated with stimulants for as long as 2 years continue to benefit from the treatment, with improvements observed in ADHD symptoms, comorbid oppositional defiant disorder, and academic and social functioning, with no significant problems of tolerance or adverse effects. Long-term, prospective follow-up studies into adulthood show that stimulant treatment in childhood has slight benefits regarding social skills and self-esteem. Long-term adverse effects from stimulant treatment in childhood regarding adult height or future substance abuse have not been supported by existing studies.

Persistence of Attention-Deficit/Hyperactivity Disorder into adulthood: what have we learned from the prospective follow-up studies?

OBJECTIVES

Longitudinal studies of children with Attention-Deficit/Hyperactivity Disorder (ADHD) into adolescence have all reported high rates of ADHD. However, findings from studies into adulthood are inconsistent. This article reviews factors that may account for disparate rates found in adult follow-ups, and recommends optimal methodologies for prospective studies of children with ADHD in particular and childhood mental disorders in general.

METHOD

Follow-up studies of children with ADHD into adulthood are critically reviewed to identify factors that influence adult ADHD prevalence estimates.

RESULTS

Four factors are identified: (1) ascertainment procedure, (2) attrition rate, (3) reporting source, and (4) disorder criteria.

CONCLUSIONS

Estimates of the proportion of children with ADHD who will experience symptoms of the childhood syndrome in adulthood are likely to vary considerably, as a function of multiple factors. Several recommendations are made for designing future follow-up investigations.

Child and familial pathways to academic achievement and behavioral adjustment: a prospective six-year study of children with and without ADHD

This longitudinal study examined familial and child predictors of academic achievement and behavioral adjustment. Participants included 115 children with ADHD and 59 normative comparisons. Data analyses spanned three assessment waves from elementary- through secondary-school grades. We evaluated the degree to which child and familial factors present during middle school mediated relationships between childhood ADHD, subsequent academic achievement, and behavioral adjustment during high school. We found that emotional and behavioral well-being of ADHD children during middle school mediated relations between childhood ADHD and adverse academic and behavioral outcomes during high school. In addition, familial factors in middle school years predicted the behavioral adjustment of children in both the ADHD and non-ADHD groups. Academic achievement during high school was strongly associated with previous achievement levels. Our results provide support for tailoring preventive interventions to the unique needs of children with ADHD and their parents at various stages of adolescent development.

Developmental course of ADHD symptomatology during the transition from childhood to adolescence: a review with recommendations

Although historically conceptualized as a disorder that was limited to males during middle childhood, ADHD is currently conceptualized as a chronic disorder that persists into adolescence and adulthood for both sexes. Nonetheless, the veracity of adult ADHD continues to be the source of debate. In order to frame this debate, research leading to the conceptualization of ADHD as a chronic disorder is reviewed. A distinction is made between the developmental outcomes versus the developmental course of ADHD. It is concluded that although childhood ADHD is associated with negative developmental outcomes in adolescence and adulthood, questions about the developmental course of ADHD remain. Although it appears that ADHD diminishes with advancing age, a number of methodological limitations prohibit firm conclusions. Recommendations for future studies are made with an emphasis on 1) overcoming extant methodological limitations in the literature and 2) the need for theoretically derived hypotheses regarding continuity and change in ADHD symptomatology over time.

Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD

OBJECTIVE

To identify moderators and mediators of long-term adherence to stimulant medication in children with attention-deficit hyperactivity disorder (ADHD).

METHOD

Seventy-one children with ADHD were prescribed methylphenidate, followed prospectively on an annual basis for 3 years, and evaluated for adherence to stimulant treatment. The study occurred in Toronto between 1993 and 1997. Adherents were those who took methylphenidate, or another psychostimulant, for 5 or more days per week throughout the follow-up period, except for "drug holidays." Children who adhered at consecutive evaluations were compared with those who did not. Severity of ADHD, presence of oppositional defiant disorder/conduct disorder, learning difficulties, anxiety, age, family dysfunction, and socioeconomic adversity at baseline were investigated as moderators of adherence. Response to treatment at school, measured at 12 months, was investigated as a mediator of adherence.

RESULTS

Fifty-two percent of children adhered to stimulant treatment for 3 years. Absence of teacher-rated oppositional defiant disorder, more teacher-rated ADHD symptoms, and younger age at baseline predicted adherence.

CONCLUSIONS

Adherence to stimulant medications is a significant factor in the long-term treatment of children with ADHD.

A four-fold model for subgrouping the hyperkinetic/MBD syndrome

The major finding of this study is that the presence or absence of aggressive symptomatology differentiates a group of 84 six to twelve year-old Hyperkinetic/MBD boys on a number of important measures at initial referral, during treatment with methylphenidate, and at subsequent five-year-follow-up. When the sample is sorted into high and low aggression groups, several findings emerge which would otherwise have been obscured. Furthermore, there are no significant interactions between aggression (control deficits, negative affect, aggressive interpersonal behavior) and hypertactivity (judgment deficits, hyperactivity, inattention). The value of differentiating between exclusive hyperactivity with aggression) is indicated by the present study.

Patterns of remission and symptom decline in conduct disorder: a four-year prospective study of an ADHD sample

OBJECTIVE

To evaluate systematically the longitudinal course of conduct disorder (CD) in a sample of youths with attention-deficit hyperactivity disorder (ADHD) to determine the effects of a persistent course on outcome.

METHOD

One hundred forty children with ADHD and their nuclear families were assessed at baseline and again at 1 and 4 years. Subjects were examined by means of DSM-III-R-based structured interviews. They were also evaluated for cognitive and social functioning. Persistent (exhibiting symptoms of CD at either follow-up) and desistent (symptoms of CD at neither follow-up) cases were identified.

RESULTS

Forty-two percent of CD cases followed a persistent course. Although both persistent and desistent subjects had high rates of antisocial disorders in relatives, increased family conflict and decreased family cohesion were selectively associated with a persistent course. In addition, subjects with persistent symptoms of CD exhibited more impaired ratings on the Aggression and Delinquency subscales of the Child Behavior Checklist, as well as higher rates of bipolar, oppositional defiant, and substance use disorders.

CONCLUSIONS

These findings suggest that the poor prognosis associated with CD is limited to an identifiable subgroup with a persistent course.

Attention deficit-hyperactivity disorder and its deceivers

There is a myriad of disorders that can mimic ADHD. Often parents or teachers, through their own investigation, will determine the diagnosis for their child's school problems as ADHD, when in fact, the difficulties are unrelated to ADHD. A carefully taken history, observation, and interaction with the child are needed. An evaluation of the school situation will help to indicate if the child's primary problem is behavioral, academic, medical, psychiatric, social, or attentional. Psychologic and educational testing is necessary to completely delineate the child's problems and needs. The greatest service that a physician can give children with academic problems is to approach each child in a systematic, scientific, and professional manner to determine the best treatment for the child and to demonstrate the most favorable outcome.

Predictors of long-term outcome in children with attention-deficit/hyperactivity disorder

In determining the influence of various factors on outcome, one must keep in mind that these parameters do not act alone but probably exert their influence in a cumulative and interactive manner. Thus, characteristics of the child such as severity of symptoms, comorbidity, and IQ interact with family parameters such as parental pathology, socioeconomic status, family adversity, and treatment to influence long-term outcome. Some of these variables (e.g., comorbid CD, low IQ, parental pathology) have been important in influencing negative outcome. Treatment, particularly stimulant treatment, has been shown to be effective in many short-term studies, but the long-term impact of treatment remains uncertain. The continuation of treatment may be crucial in influencing positive long-term outcome. Particular treatment modalities or combinations (e.g., multimodal treatment) may be required for specific patient subgroups (e.g., subjects comorbid for LD, CD, or anxiety; subjects with low socioeconomic status or high parental pathology). Research in the area continues to evolve. New findings hopefully will continue to improve both the quality of life for patients and families and positive influence of long-term outcome.

Educational and occupational outcome of hyperactive boys grown up

OBJECTIVE

Little is known about the adult outcome of attention-deficit hyperactivity disorder (ADHD), a very prevalent childhood disorder that is known to affect deleteriously academic performance and other areas of child functioning. This study represents a third wave of evaluations that examine the long-term educational achievement and occupational rank of children with ADHD.

METHOD

This is a prospective follow-up of white boys of average intelligence whose ADHD was clinically diagnosed according to systematic criteria at an average age of 7 years. Follow-up intervals range from 15 to 21 years (mean, 17 years). At average age 24 years, 85 probands (representing 82% of the childhood cohort) and 73 controls (84%) were directly interviewed by trained clinicians who were blind to group membership.

RESULTS

First, probands completed significantly less formal schooling than controls (about 2 years less, on average). Second, probands had lower-ranking occupational positions than controls. Finally, these disadvantages were not accounted for by adult mental status.

CONCLUSIONS

The present study suggests that childhood ADHD predisposes to specific disadvantages and continues to affect important functional domains unrelated to current psychiatric diagnosis.

Accomplishments during young adulthood of children originally diagnosed with minimal cerebral dysfunction: a ten-year follow-up study

To gather data about the adult accomplishments of persons diagnosed with minimal cerebral dysfunction this retrospective study evaluated 57 subjects at ten-year follow-up. Two-thirds of the subjects graduated from high school with an average of 11.8 years of education. Factors correlating with educational outcome included intelligence quotient, age at initial evaluation, and parental socioeconomic status. Adult accomplishments appear related to intelligence and to the presence of family or behavior problems.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Future of child psychiatry. II: A personal perspective

This paper provides an overview of key future directions that child psychiatry may follow. It then focuses on the potential value of longitudinal studies in general and on those involving attention deficit hyperactive disorder in particular, with the aim of delineating how such studies may enable us to proceed toward some of the future directions outlined.

Neurobehavioural relationships after the onset of puberty

The behavioural and cognitive development were studied of 68 children with and 259 without minor neurological function (MND) at 14 years, when the majority of children showed three or more physical signs of puberty. MND was differentiated into fine manipulative disability, co-ordination problems, choreiform dyskinesia and hypotonia. The normal group was subdivided into those who had been normal at 12 years and those who had had MND. All types of MND were related to cognitive and behavioural problems. Fine manipulative disability was related to behavioural and cognitive difficulties; co-ordination problems to learning difficulties; and choreiform dyskinesia and hypotonia were related to attention difficulties and school failure, notwithstanding normal IQ. Besides MND, socio-economic class, family adversities and female gender contributed to the development of behavioural and cognitive problems. The behaviour of children with MND at 12 years who were normal at 14 years did not differ from that of normal children.

The stability of dimensions of behavior in ADHD and normal children over an 8-year followup

The present study reports on standardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria (n = 108) and a community control sample of normal children (n = 61) who were followed prospectively over 8 years into adolescence. On some parent-report measures both groups declined in the severity of their behavior problems across time, while on other measures only the hyperactive group declined, but the hyperactives always remained more deviant than the controls at followup. The hyperactives and controls also differed on most teacher and self-report ratings at followup. The greatest degree of agreement between raters at adolescence was between parent and youth ratings. These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup. They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology.

Is minor neurological dysfunction at 12 years related to behaviour and cognition?

Behavioural and cognitive development at 12 years were studied in 172 children with and 174 children without minor neurological dysfunction (MND). MND could be differentiated into fine manipulative disability, co-ordination problems, hypotonia and choreiform dyskinesia. Fine manipulative disability related significantly to problems of cognition and behaviour; co-ordination problems to cognitive problems; and hypotonia and choreiform dyskinesia to behavioural problems, the former more than the latter. Socio-economic status and family adversity contributed to the risk for development of both cognitive and behavioural problems; gender did not. The onset of puberty seemed to change these relationships: follow-up is needed for definite conclusions.

Adolescents with learning disabilities at risk? Emotional well-being, depression, suicide

As recently as 5 years ago, very little information on the emotional well-being of adolescents with learning disabilities (LD) was available. However, a great deal of research has been conducted recently and some of the implications are unnerving. Research on self-concept, attributions, anxiety, depression, and suicide among adolescents with LD is examined for the purpose of detecting consistency of indicators concerning these emotional and developmental variables. The research indicates that the emotional development of many adolescents with LD is not notably positive, and these students appear to be at increased risk for severe depression and suicide. The discussion highlights methodological pitfalls and developmental issues. Practical implications are suggested.

The adolescent outcome of hyperactive children: predictors of psychiatric, academic, social, and emotional adjustment

OBJECTIVE

To investigate predictors of adolescent outcome in a large sample of hyperactive children.

METHOD

123 hyperactive children were followed prospectively over an 8-year period. Multiple linear and logistical regression equations were used to relate childhood predictor variables to adolescent academic, psychiatric, social, and emotional adjustment.

RESULTS

Adolescent academic skills were related to childhood cognitive and academic competence while school conduct was predicted by other variables including early family stress. Duration of mental health treatment received often was negatively related to outcome, apparently serving as a marker variable for severity of disturbance in the child. Childhood impulsivity-hyperactivity and paternal antisocial acts were associated with later oppositional-defiant behaviors. Only child defiance and not hyperactivity predicted later arrests, however. Emotional problems in adolescence were predicted by more special education enrollment. Adolescent social competence was associated with parental personal competence, whereas maternal mental health status at outcome was related to variables unassociated with child adjustment.

CONCLUSIONS

Various outcome domains had different sets of predictors; no single predictor cut across all domains. Although a limited amount of variance in outcome was explained, findings suggest that promoting family and parental competence as well as assessing and treating defiance and aggression very early may improve outcome.

Family functioning as perceived by parents of boys with attention deficit disorder

The purpose of this study was to describe adaptability, cohesion, and family type in families of boys with attention deficit disorder. Comparisons were made across diagnostic groups for boys with and without hyperactivity and aggressive symptoms. Parents (N = 123) of 79 boys with attention deficit disorder (ADD), attention deficit hyperactivity disorder and attention deficit hyperactivity disorder plus aggressive symptoms participated in the study. The families were not significantly different in their functioning when compared to family norms established by Olson, Portner, and Lavee (1985). There were, however, significant differences in functioning across diagnostic categories. Parents of boys with ADD only, without the additional problem of hyperactivity or aggressive symptoms, reported the highest level of family functioning, and a larger percentage of parents whose child had hyperactivity or hyperactivity plus aggression reported extreme family functioning.

Attention deficit

Attention deficit, among the most commonly diagnosed functional deficits in pediatric neurology, is, like epilepsy, most often idiopathic. It can also be a symptom of many neuropathologic states. Although a lifelong problem, attention deficit is most troublesome during school years, because, like asthma, it is highly sensitive to environmental influence. The neurologist can consider attention deficit in its own right, apart from hyperkinesis and other associated behavior disorders, as a cognitive limitation and handicap to academic progress.

Resilience and vulnerability in long term outcome of attention deficit hyperactive disorder

Follow-up studies of children with attention deficit hyperactive disorder show that they continue to have problems with restlessness, over-activity, impulsive behaviour and inattention, often resulting in serious academic, social and emotional problems in adolescence. Outcome in adulthood generally falls into three groups: fairly normal outcome, persistent attentional, social, emotional and impulse problems, and serious psychiatric and/or social pathology. Factors affecting outcome include characteristics related to the child (for example, health, temperament, IQ) and characteristics of the family (for example, socioeconomic status, emotional and psychological aspects of the family, family composition and structure, and the larger social and physical environment.

Long-term outcome of hyperactive children: a review

Reports of adolescent outcome in attention deficit hyperactivity disorder have uniformly indicated high rates of behavioral problems including cognitive impairment. Dysfunction is markedly reduced in adulthood, but the pattern of outcome remains unchanged except for failure to document cognitive deficits. In adulthood, dysfunction is characterized by antisocial personality and substance (nonalcohol) use disorders. These are in turn associated with criminality. The little existing information on girls with attention deficit hyperactivity disorder does not suggest a worse outcome than for boys. Attempts to identify the children most likely to have a poor outcome have been largely unsuccessful.