by Sal Mannuzza, Ph.D.

Adult Outcome

Prospective, controlled studies that have followed children with ADHD into adulthood have reported primarily on educational attainment, occupational history, self-esteem and social functioning, and mental status.

Educational Attainment

It is not surprising that significant deficits in educational achievement have been a consistent finding, since children with ADHD characteristically struggle in school, partly because their symptoms fare most poorly in structured settings.

Compared to controls, ADHD subjects complete significantly less formal schooling, 2-3 years less, on average. One-quarter to one-third of subjects (vs. 1-9% of controls) drop out of high school. Only about 15% of subjects (vs. half of comparisons) complete a bachelor ’s degree or higher. And only 3% of subjects (vs. 15-16% of controls) are enrolled in, or had completed, a graduate degree by their mid-twenties.

Occupational History

Two studies (New York and Montreal) reported that ADHD subjects had significantly lower occupational ranks than controls. This difference primarily was attributed to a greater proportion of comparisons occupying higher-level positions (e.g., lawyer, accountant, stockbroker) than ADHD subjects. Interestingly, both of these studies also found no significant difference between ADHD subjects and comparisons on rate of employment. About 90% of ADHD subjects were either gainfully employed or full-time students at mean age 25 years.

Self-Esteem and Social Functioning

Problems in self-esteem and social functioning persist into adulthood. The Montreal study administered the same self-esteem and social skills tests at young adult and adult follow-ups. ADHD subjects scored significantly worse than controls at both time periods.

Mental Status

Prospective, controlled studies (in Milwaukee, Montreal, New York, and Iowa) that have followed children with ADHD into adulthood (Barkley, Weiss & Hechtman, Klein & Mannuzza, Loney) have consistently reported that antisocial personality disorder is significantly more prevalent among ADHD subjects than comparisons at follow-up. ADHD subject rates across studies average around 26% (vs. 2-7% in comparisons).

An important question is whether conduct disorder in the initial childhood groups of subjects might account for these findings. The New York study excluded children if the primary reason for school referral involved aggressive or other antisocial behaviors.

Therefore, we suspect that our sample was relatively pure with respect to ADHD and the absence of conduct disorder. In fact, other clinical data collected in childhood (e.g., parent and teacher behavior ratings) support this contention. Conversely, the other follow-up studies did not exclude these cases, and investigators of these studies have estimated relatively high rates of conduct disorders in their initial samples. Interestingly, compared to the other studies, the New York study reported the lowest rate of APD among ADHD subjects at adult follow-up (15%), although still significantly greater than among control subjects in that study (2%).

Two conclusions follow. First, based on the results of the New York study (which were found in two, independent samples), childhood ADHD with or without conduct disorder is at significantly increased risk for antisocial personality disorder in adulthood. Second, as suggested by the rates of APD in other studies, childhood conduct disorder may increase risk for APD among children with ADHD even further.

The relationship between child ADHD and adult substance abuse is less clear. The New York study reported that non-alcohol substance use disorder was significantly more prevalent among ADHD subjects than comparisons (14% vs. 4%), whereas, the Milwaukee, Montreal, and Iowa studies did not.

Regarding the persistence of ADHD symptoms at mean age 25, the Montreal study found that one-third of ADHD subjects vs. 2% of comparisons reported at least one symptom as moderately or severely disabling at adult follow-up; 64% of ADHD subjects vs. 29% of comparisons were rated by psychiatrists as exhibiting restlessness during the interview. In marked contrast, the New York study reported that 7% of ADHD subjects vs. 1% of comparisons had the full or partial ADHD syndrome in adulthood.

The Milwaukee study found that, when self reports were used, only 3% of ADHD subjects met full criteria for ADHD. However, this rate rose to 27% when diagnoses were based on parent reports. These widely discrepant findings are most likely due to numerous factors. For example, the Montreal study lost nearly 40% of subjects to follow-up, whereas, attrition was only 15% in the New York study. Also, different from the New York study, interviewers were not blind to group membership in either the Montreal or the Milwaukee follow-ups.

In addition, as discussed in other publications, ascertainment procedures differed across studies. Furthermore, mean age at follow-up was 20 in the Milwaukee study, and 25 in the New York and Montreal studies. Finally, as demonstrated by Barkley and others, rates vary within the informant interviewed. The New York study evaluated the subjects, themselves, whereas the Montreal study queried subjects and their partners.

None of the follow-up studies showed significant differences between ADHD subjects and comparisons in the rates of anxiety or mood disorders.

Summary and Conclusions

The course of ADHD from childhood to adulthood is a bumpy road for many. In early-middle adolescence, relative deficits are seen in academic, cognitive, and social functioning, ADHD symptoms remain problematic in the overwhelming majority of these youths, and conduct problems are common.

Many of these same difficulties persist into young adulthood. As a group, these individuals continue to exhibit significant deficits in the academic and social domains. Half continue to experience disruptive or distressing symptoms of the childhood syndrome.

Nearly a third fulfill criteria for an antisocial disorder, and two-thirds of these individuals become known to the criminal justice system. Drug abuse is also problematic among a significant minority of these youths.

Childhood ADHD continues to affect important functional domains in adulthood. Compared to their non-ADHD counterparts, these individuals complete fewer years of formal education, hold lower-ranking occupational positions, and continue to suffer from low self-esteem and poor social skills. In addition, they are at significantly increased risk for having an antisocial personality disorder.

There is no doubt that childhood ADHD persists into adulthood in a proportion of children with the syndrome. However, at this time, there is no stable estimate of the prevalence of “adult ADHD”. Numerous differences across studies (rate of attrition, data collection procedure, type of informant, knowledge of childhood classification, age at follow-up, symptom definitions, etc.) may account for the disparate rates that have been reported.

Also, a more basic question is, What is adulthood? The New York study has been cited as showing that up to 40% of children with ADHD continue to exhibit the childhood syndrome in “adulthood”. This statement is somewhat misleading since it refers to results of the young adult follow-up (mean age, 18 years), and some subjects in that study were as young as 16 when evaluated.

Also, certain estimates of “adult ADHD” in the lay press are based on the results of retrospective diagnoses, which are often unreliable, and whose validity frequently cannot be assessed, e.g., by comparing adult self-reports of childhood memories to those obtained from a knowledgeable informant such as the subject’s parent. Clearly, more work is needed in this very important area to determine the risk for persistent ADHD in adulthood, given specified parameters.

Although children with ADHD, as a group, fare poorly compared to non-ADHD controls, these relative deficits do not tell the whole story. Based on the findings of the New York study, nearly all of these individuals were gainfully employed as adults, many as proprietors of successful businesses (auto repair shops, burglar alarm businesses, cookie franchises, bicycle stores, etc.). Furthermore, compared to their young adult fate, substantially fewer experienced emotional and behavioral problems as adults.

Indeed, a full two-thirds of these children showed no evidence of any mental disorder in adulthood. Finally, childhood ADHD did not regularly preclude the chances of obtaining a higher-level education or profession; some attended law school and medical school, while others became accountants and stockbrokers. In conclusion, not all children with ADHD are doomed to failure.

About the author:

Sal Mannuzza, Ph.D. is Professor of Psychiatry at NYU School of Medicine, and Research Scientist at NYU Child Study Center and Nathan S. Kline Institute for Psychiatric Research. For over 20 years, he has collaborated with Dr. Rachel Klein on major prospective follow-up studies of children with ADHD, separation anxiety disorder, and developmental reading disorders; and on high-risk studies of the offspring of parents with anxiety and mood disorders.

This article is courtesy of AboutOurKids.org

Originally posted 2005-10-21 10:26:12.

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