The adolescent outcome of hyperactive girls

Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions

Attention-deficit/hyperactivity disorder (ADHD) - and its underlying behavioral dimensions of inattention and hyperactivity-impulsivity - have been understudied in females. We first cover the conceptual issues of prevalence, diagnostic practices, diversity, comorbidity, and causal factors, plus forces limiting awareness of ADHD in females. After a narrative review of cross-sectional and longitudinal findings, we conclude the following. (a) Girls meet diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by adulthood. (b) Girls and women with ADHD show a predominance of inattention and associated internalizing problems; boys and men display greater levels of hyperactive-impulsive symptoms and associated externalizing problems. (c) Sex differences in ADHD symptoms and related outcomes depend heavily on the clinical versus nonreferred nature of the samples under investigation. (d) Females with ADHD experience, on average, serious impairments, with a particularly heightened risk for problems in close relationships and engagement in self-harm. (e) Clinicians may overlook symptoms and impairments in females because of less overt (but still impairing) symptom manifestations in girls and women and their frequent adoption of compensatory strategies. Our review of predictors and mediators of adult outcomes highlights (a) the potential for heterotypically continuous pathways in females with childhood ADHD and (b) developmental progressions to self-harm, intimate partner violence, unplanned pregnancy, and comorbid psychopathology. Focusing on ADHD in females is necessary to characterize causal and maintaining mechanisms with accuracy and to foster responsive interventions, as highlighted in our closing list of clinical implications and research priorities.

Refining Diagnostic Procedures for Adults With Symptoms of ADHD

Attention deficit/hyperactivity disorder (ADHD) is a chronic disorder that afflicts individuals into adulthood. The field continues to refine diagnostic standards for ADHD in adults, complicated by the disorder's heterogeneous presentation, subjective symptoms, and overlap with other disorders. Two key diagnostic questions are from whom to collect diagnostic information and which symptoms should be contained on an adult diagnostic checklist. Using a trifactor model, Martel et al. examine these questions in a sample of adults with and without self-identified ADHD symptoms. In this response, we highlight the importance of their finding that self and informant symptom reports differ in a sample of adults who acknowledge ADHD symptoms. We also review issues that continue to face the field related to model specification, evaluating symptom utility, and sample composition, discussing how these issues influence conclusions that may be drawn from Martel et al. and similar investigations. We conclude that the article makes an important research contribution about the nature of self and informant ADHD symptom reports but emphasize that symptom checklist refinement must occur through a broad lens that considers work from a range of sample types and clinically informative analytic strategies.

Persistence of Parent-Reported ADHD Symptoms From Childhood Through Adolescence in a Community Sample

OBJECTIVE

To examine ADHD symptom persistence and factors associated with elevated symptom counts in a diverse, longitudinal community-based sample.

METHOD

Parents reported demographics and completed a diagnostic interview repeatedly over a 6-year period. At Time 1, 481 interviews were completed about children (5-13 years); all participants were invited to four annual follow-up interviews, and 379 (79%) completed at least one. Inattentive (IA) and hyperactive-impulsive (HI) symptom counts were modeled with logistic quantile regression, while accounting for study design complexities.

RESULTS

The prevalence of seven IA symptoms remained stable from early childhood through late adolescence. The prevalence of eight HI symptoms decreased by more than half over time. After demographic adjustment, the upper quartile of HI symptom counts decreased with age (p < .01). High HI symptom counts persisted more among those with high IA symptom counts (p = .05).

CONCLUSION

This study further characterizes and provides insights into ADHD symptom trajectory through adolescence.

Predictors of persistence in girls with attention deficit hyperactivity disorder: results from an 11-year controlled follow-up study

OBJECTIVE

  This study sought to examine the age-dependent persistence of attention deficit hyperactivity disorder (ADHD) and its predictors in a large sample of girls with and without ADHD followed prospectively for 11 years into young adulthood.

METHOD

  Participants were girls with (N=96) and without (N=91) ADHD and were 6-17 years old at the baseline assessment (mean age, 11 years) and 15-30 years old at the follow-up assessment (mean: 22 years). Participants were comprehensively and blindly assessed with structured diagnostic interviews and assessments of cognitive, social, school, and family functioning.

RESULTS

  At the 11-year follow-up, 33.3% met full criteria for ADHD, 29.2% showed partial persistence of the disorder, 10.4% had impaired functioning, and 4.2% were remitted but treated (77.1% of the sample). Predictors of persistence were psychiatric comorbidity, family history of psychopathology, and family and school functioning at baseline.

CONCLUSION

  These long-term, prospective, follow-up findings extend to girls findings that ADHD is persistent over the long term and can be predicted from psychosocial adversity and psychiatric comorbidity ascertained 11 years earlier.

Delinquency in context; neighbourhood and gender interactions among adolescents

Aim – Delinquency among adolescents and antecedent conduct disorder among children has been recognized as a growing public mental health problem in contemporary societies. The contribution of the neighbourhood environment to delinquent behaviour was examined in a cohort of Dutch adolescents (aged approximately 11 years at baseline; n=394). Methods – Multilevel regression analyses estimated associations between baseline neighbourhood socioeconomic status and social capital, and delinquent behaviour two years later controlling for individual-level variables. Results – A significant interaction effect was found between neighbourhood environment variables and gender in models of delinquency, indicating that associations between neighbourhood environment variables and delinquency were apparent, for the most part, in girls only. However, higher level of neighbourhood informal social control was associated with increased delinquency rates in boys. Conclusion – In girls there is a longitudinal association between neighbourhood characteristics and delinquency, suggesting complex gender differences in the way the wider social environment impacts on behavioural outcomes.

Predictors of ADHD persistence in girls at 5-year follow-up

OBJECTIVE

The main aim of this study was to examine the age-dependent remission from ADHD in girls transitioning through childhood into adolescence and early adulthood.

METHOD

We conducted a 5-year prospective follow-up study of 123 girls with ADHD and 106 non-ADHD control girls aged between 6 and 17 years at ascertainment. ADHD was considered persistent at follow-up if participants met full diagnostic criteria for DSM-IV ADHD or met residual criteria for DSM-IV ADHD with associated impairment (Global Age Forum [GAF] score < 60).

RESULTS

By age 16 years, ADHD was persistent in 71% (95% CI = 61-79%) of girls with ADHD. Participants with persistent ADHD at follow-up had more psychiatric comorbidity, behavior problems, and functional impairment than girls with ADHD in remission. Remitted ADHD, however, continued to be associated with functional impairment relative to non-ADHD controls. Persistence at 5 years was predicted by increased behavioral impairment at baseline.

CONCLUSION

This 5-year follow-up suggests that many girls with ADHD experience persistent symptoms and/or functional impairment through late adolescence and into early adulthood.

Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology

In this report, we provide an evidence-based overview of attention-deficit/hyperactivity disorder (ADHD), including diagnosis, prevalence, developmental expression of symptoms, persistence, the heterogeneity of functional outcome, impairment in afflicted adults, psychiatric comorbidity, pathophysiology, genetics, psychosocial and biologic risk factors, and neurobiology. Attention-deficit/hyperactivity disorder is an early-onset, highly prevalent neurobehavioral disorder, with genetic, environmental, and biologic etiologies, that persists into adolescence and adulthood in a sizable majority of afflicted children of both sexes. It is characterized by behavioral symptoms of inattention, hyperactivity, and impulsivity across the life cycle and is associated with considerable morbidity and disability. Comorbidity is a distinct clinical feature of both childhood and adult ADHD. Although its etiology remains unclear, emerging evidence documents its strong neurobiologic and genetic underpinnings. Despite the high diagnostic reliability and the robust evidence of the validity of ADHD, there are many underlying issues that remain to be resolved. These include establishing developmentally appropriate diagnostic criteria at older ages, further elaborating the impact of gender on symptom expression, and examining risk and protective factors in relationship to prevention or amelioration of ADHD as well as related functional impairments.

Do we know which interventions are effective for disruptive and delinquent girls?

Disruptive and delinquent girls are not well served by the mental health and juvenile justice systems. Interventions that have been developed for the behavior problems of boys are frequently applied to girls despite growing evidence for a female-specific phenotype, developmental course, and set of risk factors from middle childhood onwards. The current review demonstrates that evidence of the effectiveness of treatments for girls with disruptive and delinquent behaviors is extremely limited, with relatively few studies including sufficient numbers of females or reporting on treatment effects by gender. However, a small body of evidence suggests that interventions specifically designed to address female behavior problems or risk factors can be effective in ameliorating disruptive and delinquent behaviors in both pre-adolescence and adolescence. Multi-modal interventions that target interacting domains of risk also show promise. Methodological issues are discussed and recommendations are made for the development and evaluation of future interventions to prevent and reduce girls' disruptive and delinquent behavior.

Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study

BACKGROUND

Despite the importance of understanding the long-term outcome of children with attention-deficit/hyperactivity disorder (ADHD), the available literature is predominantly based on male samples. This study estimated the lifetime burden of comorbid psychopathology in a large sample of girls with and without ADHD followed up over five years.

METHODS

We conducted a blind, five-year prospective longitudinal study of girls with (n=140) and without (n=122) ADHD, aged 6-18 years at baseline, consecutively ascertained from either community pediatricians or psychiatrists at an academic medical center. At the five-year follow-up, 123 (88%) and 112 (92%) of the ADHD and control children, respectively, were re-assessed at a mean age of 16.7 years. Psychiatric disorders were assessed using blinded structured diagnostic interviews.

RESULTS

At follow-up, females with ADHD were at significantly higher risk than controls to manifest disruptive behavior, mood and anxiety disorders, and substance dependence. The magnitude of increased risk was greatest for major depression and oppositional-defiant disorder, followed by substance dependence and anxiety disorders.

CONCLUSIONS

These prospective follow-up findings documenting high morbidity associated with ADHD extend to females previously reported findings in male samples and underscore the importance of early recognition and intervention efforts for youth with ADHD of both genders.

Neuropsychological studies of late onset and subthreshold diagnoses of adult attention-deficit/hyperactivity disorder

BACKGROUND

Diagnosing attention-deficit/hyperactivity disorder (ADHD) in adults is difficult when the diagnostician cannot establish an onset prior to the DSM-IV criterion of age 7 or if the number of symptoms recalled does not achieve the DSM-IV threshold for diagnosis. Because neuropsychological deficits are associated with ADHD, we addressed the validity of the DSM-IV age at onset and symptom threshold criteria by using neuropsychological test scores as external validators.

METHODS

We compared four groups of adults: 1) full ADHD subjects met all DSM-IV criteria for childhood-onset ADHD; 2) late-onset ADHD subjects met all criteria except the age at onset criterion; 3) subthreshold ADHD subjects did not meet full symptom criteria; and 4) non-ADHD subjects did not meet any of the above criteria.

RESULTS

Late-onset and full ADHD subjects had similar patterns of neuropsychological dysfunction. By comparison, subthreshold ADHD subjects showed few neuropsychological differences with non-ADHD subjects.

CONCLUSIONS

Our results showing similar neuropsychological underpinning in subjects with late-onset ADHD suggest that the DSM-IV age at onset criterion may be too stringent. Our data also suggest that ADHD subjects who failed to ever meet the DSM-IV threshold for diagnosis have a milder form of the disorder.

Prospective follow-up of girls with attention-deficit/hyperactivity disorder into adolescence: Evidence for continuing cross-domain impairment

The authors performed 5-year prospective follow-up (retention rate = 92%) with an ethnically diverse sample of girls, aged 11-18 years, who had been diagnosed in childhood with attention-deficit/ hyperactivity disorder (ADHD; N = 140) and a matched comparison group (N = 88). Hyperactive-impulsive symptoms were more likely to abate than inattentive symptoms. Across multiple domains of symptoms and functional impairment, girls with ADHD continued to display deficits of moderate to large effect size in relation to the comparison girls, but few differences emerged between the inattentive versus combined types. Follow-up effects withstood statistical control of crucial covariates for most outcomes, meaning that there were specific effects of childhood ADHD on follow-up status; in other instances, baseline disruptive disorders accounted for adolescent effects. For outcomes identical at baseline and follow-up, girls with ADHD showed more improvement across time than comparison girls (except for math achievement). Overall, ADHD in girls portends continuing impairment 5 years after childhood ascertainment.

Psychopathological rating scales for diagnostic use in adults with attention-deficit/hyperactivity disorder (ADHD)

The diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults is a complex procedure which should include retrospective assessment of childhood ADHD symptoms either by patient recall or third party information, diagnostic criteria according to DSM-IV, current adult ADHD psychopathology including symptom severity and pervasiveness, functional impairment, quality of life and comorbidity. In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. This article reviews rating instruments that have found general acceptance. The Wender-Utah Rating Scale (WURS) and the Childhood Symptoms Scale by Barkley and Murphy try to make a retrospective assessment of childhood ADHD symptoms. The Connors Adult ADHD Rating Scales (CAARS), the Current Symptoms Scales by Barkley and Murphy (CSS), the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. or the Attention Deficit Hyperactivity Disorder--Self Report Scale (ADHD-SR by Rösler et al.) are self report rating scales focusing mainly on the DSM-IV criteria. The CAARS and the CSS have other report forms too. The Brown ADD Rating Scale (Brown ADD-RS) and the Attention Deficit Hyperactivity Disorder--Other Report Scale (ADHD-OR by Rösler et al.) are instruments for use by clinicians or significant others. Both self rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3. This makes the instruments useful to follow the course of the disease quantitatively. Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. The most comprehensive procedures are the Brown ADD Diagnostic Form and the Adult Interview (AI) by Barkley and Murphy. An instrument of particular interest is the Wender Reimherr Interview (WRI) which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. Other instruments focus on functional impairment, quality of life, comorbid disorders, gender effects and specific psychopathological models.

Attention-deficit hyperactivity disorder in girls: epidemiology and management

Attention-deficit hyperactivity disorder (ADHD) in girls is a topic of growing research and clinical interest. For many years, girls with ADHD have been ignored and overshadowed by hyperkinetic and impulsive boys, but they are now attracting interest in an effort to understand the similarities and differences in the prevalence, symptoms, familial risk, comorbidities and treatment of ADHD in the two sexes. A review of past and current literature finds that the symptoms of ADHD are not sex specific, but that identification of girls with ADHD is hampered by parental and teacher bias, and confusion. Girls are more likely to be inattentive without being hyperactive or impulsive, compared with boys. Girls and boys share the same familial risk patterns, as well as similar, although not identical, comorbidity or impairment patterns. The risk of non-treatment is as great in girls as it is in boys; up to 70-80% of identified children will have persistent symptoms and impairment that extends into adolescence and adulthood. Treatment modalities are equally effective in girls and boys. Stimulants, non-stimulants and behavioural modalities are the mainstays of effective treatment.

The adolescent outcome of hyperactive girls: self-report of psychosocial status

BACKGROUND

The aim of the study was to clarify the developmental risk associated with hyperactive behaviour in girls in a longitudinal epidemiological design.

METHODS

This was investigated in a follow-up study of girls who were identified by parent and teacher ratings in a large community survey of 6- and 7-year-olds as showing pervasive hyperactivity or conduct problems or the comorbid mixture of both problems or neither problem. They were later investigated, at the age of 14 to 16 years, with a detailed self-report interview technique.

RESULTS

Hyperactivity was a risk factor for later development, even allowing for the coexistence of conduct problems. Hyperactivity predicted academic problems and interpersonal relationship problems. Relationships with parents, by contrast, were not portrayed to be as problematic as relationships with peers and the opposite sex. Their psychological, social and occupational functioning was objectively rated to be more deviant and their self-report showed them to be more ambivalent about their future. There was a trend for hyperactivity to be self-reported as a risk for the development of continuing symptomatology but neither hyperactivity nor conduct problems were self-reported to be a risk for antisocial behaviour, substance misuse or low self-esteem in adolescence. However, they were at risk for the development of state anxiety.

CONCLUSIONS

The results suggested girls' pattern of functioning may differ from that of boys because girls self-report a more pervasive range of social dysfunction than that previously reported in boys.

Is neighborhood context differently related to externalizing problems and delinquency for girls compared with boys?

Although a number of reviews of gender differences in conduct problems and delinquency exist, this paper fills a gap in reviewing neighborhood influences on gender differences in conduct problems and delinquency. These influences are known to be important for boys in childhood and adolescence, but cannot be assumed to be influential in the same manner for girls. The paper starts with several conceptualizations of the association between gender, neighborhoods and juvenile delinquency. It then addresses 4 key questions. Is residing in a disadvantaged neighborhood associated with problem behavior in girls? Are neighborhood effects independent of girls' age? Are girls in disadvantaged neighborhoods exposed to more risk factors than girls in advantaged neighborhoods? Can mediating risk factors explain gender differences in neighborhood effects on children's and adolescents' conduct problems and delinquent behavior? Answers to these questions are important to steer research and elucidate aspects of interventions that can be optimized for girls.

ADHD and sleep in homicidal men with antisocial personality disorder

A history of attention deficit hyperactivity disorder (ADHD) is commonly found in subjects with antisocial personality disorder (ASP). Besides ASP, childhood ADHD also predicts drug abuse disorders and criminal activity in adulthood. Childhood ADHD and ASP appear to be the only psychiatric disorders reported to be associated with an increase in deep sleep. The aims of the present study were to retrospectively measure the childhood ADHD of habitually violent men with ASP and Cloninger type 2 alcoholism, and to characterize the possible relationship between childhood ADHD and sleep architecture in these men. The subjects of the study consisted of 14 homicidal offenders recruited from a forensic psychiatric examination. Ten age- and gender-matched healthy volunteers served as controls. Childhood ADHD symptoms were measured using the Wender-Utah Rating Scale (WURS). The main findings were that violent offenders with ASP had significantly higher mean WURS scores compared with controls, and both the absolute and percentage amount of stage 4 sleep as well as delta and theta powers in this sleep stage were positively correlated with the WURS scores. The present study supports the idea that childhood ADHD is associated with the abnormal sleep architecture in habitually violent men with ASP. These two disorders seem to share, at least partly, the same central nervous system deficit.

Differential psychostimulant-induced activation of neural circuits in dopamine transporter knockout and wild type mice

Dopamine (DA) is a neurotransmitter that has been implicated in a wide variety of psychiatric disorders that include attention deficit-hyperactivity disorder (ADHD), schizophrenia, and drug abuse. Recently, we have been working with a mouse in which the gene for the DA transporter (DAT) has been disrupted. This mouse is hyperactive in the open field, displays an inability to inhibit ongoing behaviors, and is deficient on learning and memory tasks. Psychostimulants such as amphetamine and methylphenidate attenuate the hyperlocomotion of the mutants, but stimulate activity of the wild type (WT) controls. The objective of the present study is to examine the neural basis for the differential responses to psychostimulants in these mice. WT and DAT knockout (KO) animals were given vehicle or methylphenidate, amphetamine, or cocaine and brain sections were immunostained for Fos. In WT mice, methylphenidate induced Fos-like immunoreactivity (Fos-LI) in the mesostriatal and mesolimbocortical DA pathways that included the anterior olfactory nucleus, frontal association cortex, orbitofrontal cortex, cingulate cortex, caudate-putamen, globus pallidus, claustrum, lateral septum, nucleus accumbens, basolateral and central nuclei of the amygdala, bed nucleus of stria terminalis, subthalamic nucleus, substantia nigra, ventral tegmental area, and dorsal raphe. Additional areas of activation included the granular dentate gyrus, Edinger-Westphal nucleus, and periaqueductal gray. While the mutants showed little response in most of these same areas, the anterior olfactory nucleus, caudal caudate-putamen, lateral septum, basolateral and central nuclei of the amygdala, and bed nucleus of stria terminalis were activated. Amphetamine and cocaine produced similar changes to that for methylphenidate, except these psychostimulants also induced Fos-LI in the nucleus accumbens of the KO animals. Since the DAT gene is disrupted in the KO mouse, these findings suggest that dopaminergic mechanisms may mediate the WT responses, whereas non-dopaminergic systems predominate in the mutant. In the mutants, it appears that limbic areas and non-dopaminergic transmitter systems within these brain regions may mediate responses to psychostimulants. Inasmuch as the KO mouse may represent a useful animal model for ADHD and because psychostimulants such as cocaine are reinforcing to these animals, our results may provide some useful insights into the neural mechanisms-other than DA-that may contribute to the symptoms of ADHD and/or drug abuse in human patients.

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.

Conduct problems, gender and adult psychiatric outcome of children with attention-deficit hyperactivity disorder

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a common childhood condition, and is more prevalent in boys. The adult outcome of girls with ADHD has never been studied.

AIMS

To identify predictors for adult psychiatric outcome of children with ADHD, including gender and comorbidity.

METHOD

Children aged 4-15 years, referred for hyperactivity/inattention and treated with stimulants were included (n=208). The Psychiatric Case Register provided follow-up data on psychiatric admissions in adulthood until a mean age of 31 years.

RESULTS

A total of 47 cases (22.6%) had a psychiatric admission in adulthood. Conduct problems in childhood were predictive (hazard ratio HR=2.3; 95% CI 1.22-4.33). Girls had a higher risk compared with boys (HR=2.4; 95% CI 1.1-5.6).

CONCLUSIONS

Girls with ADHD had a higher risk of adult psychiatric admission than boys. Conduct problems were also associated with a higher risk. Girls with ADHD with conduct problems had a very high risk of a psychiatric admission in adulthood.

A meta-analytic review of gender differences in ADHD

The present study examined gender differences in ADHD through a meta-analysis. Effect size estimates for the primary symptoms and correlates of ADHD were calculated in an attempt to replicate and extend a previous meta-analysis on gender differences in the disorder. Relatively lenient inclusion criteria were used in order to maximize the number of studies included in the effect sizes. The results indicated that in comparison to ADHD boys, ADHD girls had lower ratings on hyperactivity, inattention, impulsivity, and externalizing problems. In addition, ADHD girls had greater intellectual impairments and more internalizing problems than ADHD boys. Overall, the results of the current meta-analysis indicated general agreement with the previous meta-analysis. The clinical implications of these gender differences and future research considerations are discussed.

Natural outcome of ADHD with developmental coordination disorder at age 22 years: a controlled, longitudinal, community-based study

OBJECTIVE

There is a need for controlled longitudinal studies in the field of attention disorders in the general population.

METHOD

In a community-based follow-up study, 55 of 61 subjects aged 22 years, who had attention-deficit/hyperactivity disorder (ADHD) with and without comorbid developmental coordination disorder (DCD) at initial workup at age 7 years, were compared, on a multitude of outcome variables, with 46 of 51 age-matched subjects without such diagnoses. None of the subjects had received stimulant treatment. Psychiatrists performing the follow-up study were blind to original diagnostic group status.

RESULTS

In the ADHD/DCD group 58% had a poor outcome compared with 13% in the comparison group (p < .001). Remaining symptoms of ADHD, antisocial personality disorder, alcohol abuse, criminal offending, reading disorders, and low educational level were overrepresented in the ADHD/DCD groups. The combination of ADHD and DCD appeared to carry a particularly gloomy outlook.

CONCLUSIONS

Childhood ADHD and DCD appears to be a most important predictor of poor psychosocial functioning in early adulthood. It would seem appropriate to screen for such disorders in schools and clinics so that therapies may be started early.

ADHD in girls: clinical comparability of a research sample

OBJECTIVE

The investigation of attention-deficit/hyperactivity disorder (ADHD) in girls raises complex questions of referral bias and selection criteria. The authors sought to determine whether they could recruit a research sample of comparably affected girls using a combination of sex-independent diagnostic criteria and sex-normed cutoffs on teacher ratings. They also report on the largest placebo-controlled crossover comparison of methylphenidate and dextroamphetamine in girls with ADHD.

METHOD

Subjects were 42 girls with DSM-III-R/DSM-IV ADHD (combined type) contrasted to 56 previously studied boys with ADHD on comorbid diagnoses, behavioral ratings, psychological measures, psychiatric family history, and stimulant drug response.

RESULTS

Girls with ADHD were statistically indistinguishable from comparison boys on nearly all measures. Girls exhibited robust beneficial effects on both stimulants, with nearly all (95%) responding favorably to one or both drugs in this short-term trial. Dextroamphetamine produced significantly greater weight loss than methylphenidate.

CONCLUSIONS

This highly selected group of ADHD girls was strikingly comparable with comparison boys on a wide range of measures. The results confirm that girls with ADHD do not differ from boys in response to methylphenidate and dextroamphetamine and that both stimulants should be tried when response to the first is not optimal.

Sex differences in ADHD: conference summary

Clinical samples of attention deficit hyperactivity disorder (ADHD) have been dominated by males. Consequently, female manifestations and sex differences have been relatively neglected in the extensive ADHD research. Because ADHD is so common (3% to 5% of school children) and chronic (lifelong in many cases), even a small proportion of females multiplied by such a large base means hundreds of thousands of girls and women with ADHD, a significant public health problem. An NIMH conference concluded that research is needed not only on sex differences related to ADHD, but also on manifestations of ADHD in females as such. Areas of focus should include differences in life course (sex-differential age effects); effects of hormones; effects of ADHD parenting (in utero and postnatal) on the next generation; response to and implications for design of psychosocial treatment; effects of differential comorbidity; normative "background" sex differences that influence the manifestation of ADHD; differences in development of verbal fluency and social behavior; possible interactions of sex and ethnicity; a prospective study of both sex offspring of ADHD adults; and such methodological issues as appropriate instruments and diagnostic thresholds, power to prevent false negatives, valid impairment measures, validity and reliability of child self-reports, and more inclusive samples (all three subtypes: inattentive, hyperactive-impulsive, and combined).

New phenotype definition of attention deficit hyperactivity disorder in relatives for genetic analyses

The goal of the present investigation was to create a phenotype definition in relatives of probands that reflects a more genetic form of attention deficit hyperactivity disorder (ADHD). Logistic regression was applied to the first-degree relatives of ADHD and normal control probands to create a quantitative phenotype that combined information across psychiatric, cognitive, and demographic domains. Models were run separately in mothers, fathers, sisters, and brothers. Although there was some overlap between the variables retained in each model, no two models had exactly the same variables. Our results suggest that the use of fitted logits may be valuable as a potential index of caseness. Since different characteristics were included in different groups of relatives, our results suggest that gender and generation may moderate the expression of ADHD.

Psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder

OBJECTIVE

To conduct a retrospective follow-up study of psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder (ADD) and a group of clinical controls.

METHODS

Groups included male and female subjects aged 14 to 18 years at time of follow-up with childhood diagnosis of ADD (cases; n = 48) versus other neurodevelopmental disorders (clinical controls; n = 37). Cases were also subdivided based on the presence of conduct disorder (CD) at follow-up. All groups were compared on measures of academic performance, self-esteem, behavior, alcohol and substance use, and adaptive functioning.

RESULTS

Cases had significantly lower academic performance and poorer social, emotional, and adaptive functioning than clinical controls. Cases with CD had significantly lower academic performance, greater externalizing behaviors and emotional difficulties, and lower adaptive functioning than cases without CD. Cases with CD fared worse than clinical controls on self-report measures of behavior, socialization skills, and alcohol and substance use.

CONCLUSIONS

These academic and psychosocial problems in adolescents with a childhood diagnosis of ADD suggest potential long-term ramifications for vocational and psychological functioning into adulthood. In addition, the presence of CD in some of these cases during adolescence appears to further increase the risk for maladaptive outcome.

Reduced brain metabolism in hyperactive girls

OBJECTIVE

This study assesses the effect of attention-deficit hyperactivity disorder (ADHD) and gender on cerebral glucose metabolism (CMRglu), using positron emission tomography and 18F-fluorodeoxyglucose.

METHOD

Nineteen normal (6 females; 14.3 +/- 1.3 years old) and 20 ADHD adolescents (5 females; 14.7 +/- 1.6 years old) participated in the study. An auditory continuous performance task was used during the 30-minute uptake of 18F-fluorodeoxyglucose.

RESULTS

There were no statistically significant differences in global or regional CMRglu between ADHD (N = 20) and normal (N = 19) adolescents. However, the global CMRglu in ADHD girls (N = 5) was 15.0% lower than in normal girls (N = 6) (p = .04), while global CMRglu in ADHD boys was not different than in normal boys. Furthermore, global CMRglu in ADHD girls was 19.6% lower than in ADHD boys (p = .02) and was not different between normal girls and normal boys. Clinical rating scales did not differentiate ADHD girls from ADHD boys, nor normal girls from normal boys.

CONCLUSIONS

The greater brain metabolism abnormalities in females than males strongly stress that more attention be given to the study of girls with ADHD.

An exploratory study of ADHD among second-degree relatives of ADHD children

Family-genetic studies consistently show that attention deficit hyperactivity disorder (ADHD) aggregates in nuclear families. Little is known about the aggregation of ADHD in second-degree relatives. We examined the prevalence of ADHD in second-degree relatives of 140 ADHD probands and 120 normal controls. Information pertinent to the diagnosis of ADHD in second-degree relatives was collected from the probands' parents. The second-degree relatives of ADHD probands were at increased risk for ADHD compared with the second-degree relatives of normal control probands. These risks were greatest when the second-degree relative was biologically related to an ADHD parent of an ADHD proband. Consistent with the greater prevalence of ADHD among boys compared with girls, grandfathers were at greater risk than grandmothers and uncles were at greater risk than aunts. Our results support the usefulness of ascertaining information from second-degree relatives in studies evaluating the genetic epidemiology of ADHD. If confirmed, such studies may help clarify the mechanism of familial transmission of ADHD.

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.

Gender differences in a clinic-referred sample of attention-deficit-disordered children

This study of attention-deficit-disordered children revealed that females were more frequently retained in school and evidenced greater impairment on spatial memory tasks. Moreover, there was a trend for girls to be older at the time of referral. With age, the girls evidenced more severity across a wider array of measures, including cognitive functioning, poorer academic achievement, and more problems with peers.

A twin study of hyperactivity--II. The aetiological role of genes, family relationships and perinatal adversity

In a large representative sample of 13-year-old twins, monozygotic pairs were more alike than same-sex dizygotic pairs on objective measures of attentiveness and on parent and teacher ratings of hyperactivity. Comparison of recognized and unrecognized monozygotic pairs indicated that parents and teachers rated twins more similarly when the twins were perceived as "identical" rather than "non-identical". After allowing for this stereotyping, genetic effects accounted for approximately half of the explainable variance of hyperactivity and inattentiveness. Data from mixed-sex pairs did not support a 2-threshold genetic explanation for the male excess of hyperactivity. The link between adverse family factors and hyperactivity was weak. Perinatal adversity was not related to later hyperactivity.