How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD
Introduction
Despite the existence of several prospective studies of children with attention-deficit hyperactivity disorder (ADHD) growing up, very few longitudinal studies examined the adult outcome of this disorder and those that did reported inconsistent results (Barkley et al., 1990, Barkley et al., 2008, Mannuzza et al., 1993, Weiss et al., 1985). For example, in independent samples of hyperactive boys grown up, Mannuzza et al. (1998) reported only 4% persistence of ADHD by a mean age of 24.1 years, while Weiss et al. (1985) reported 66% persistence of ADHD by a mean age of 25.1 years. Hill and Schoener (1996) fit a mathematical model to the rates of persistence of ADHD reported in previous studies that had followed ADHD children from childhood to adolescence or adulthood. Their analyses suggested that ADHD is a highly remitting disorder. These findings are difficult to reconcile with emerging epidemiological data that estimates the prevalence of adult ADHD to be up to 5% (Faraone and Biederman, 2005, Fayyad et al., 2007, Kessler et al., 2006). Given that long-term outcome studies are the touchstone for judging the course of a disorder, a better understanding of the true course of ADHD from childhood into adulthood is critical to evaluate whether ADHD is a lifelong disorder for children afflicted with this disorder and helps link the paediatric and adult literature on the subject.
In a previous report of our large longitudinal sample of boys with ADHD ascertained from paediatric and psychiatric sources (Biederman et al., 2000), our group examined patterns of persistence and remission at the 4-year follow-up using different definitions of remission. We found that the proportion of subjects experiencing remission varied considerably with the definition used (highest for syndromatic remission, lowest for functional remission). Our prior study also found that persistence of ADHD was associated with higher rates of psychiatric co-morbidity and familiality (Biederman et al., 1996b).
Similar findings were reported by Faraone et al. (2006a) who used a meta-analysis regression model to separately assess the syndromatic and symptomatic persistence of ADHD from the published literature. They found that while the rate of syndromatic persistence (subjects meeting full criteria for ADHD) was quite low (15% at age 25 years), the rate of symptomatic persistence (subjects meeting subthreshold criteria for ADHD) was much higher (65%). These results further supported the idea that estimates of ADHD's persistence are heavily dependent on how one defines persistence. Yet, regardless of definition, these analyses show that ADHD lessens with age, supporting the need for additional studies examining this issue.
To this end, the main aim of this study was to reassess the age-dependent decline of ADHD at the 10-year follow-up when most of our sample had reached young adult years. In addition, we compared familiality, psychiatric comorbidity and measures of functioning (educational, legal, driving and sexual history) between persistent ADHD, remittent ADHD and control subjects in order to understand the correlates of persistent ADHD into young adult years. Based on our work and the literature we predicted that ADHD would be persistent at the 10-year follow-up into young adult years, and inattentive symptoms, in particular, would be most persistent. We further hypothesised that persistence of ADHD into young adult years would be associated with higher rates of psychiatric co-morbidity, more family history of ADHD, and poorer functioning. This is one of the very few studies examining patterns of persistence and remission in ADHD children grown up.
Section snippets
Subjects
Detailed study methodology has been previously reported (Biederman et al., 1996a, Biederman et al., 2006). Briefly, subjects were derived from a longitudinal case–control family study of referred youth with and without ADHD. At baseline, we ascertained male Caucasian subjects aged 6–17 years with (N = 140) and without (N = 120) Diagnostic and Statistical Manual of Mental Disorders, third edition, Text Revision (DSM-III-R) ADHD from paediatric and psychiatric clinics. Potential subjects were excluded
Results
Of the 140 ADHD and 120 control subjects recruited at baseline, 112 (80%) and 105 (88%), respectively, were re-assessed at the 10-year follow-up. The rate of successful follow-up did not differ between groups (P = 0.11). The average follow-up time was 11.2 years (S.D. = 0.9 years); ages at follow-up ranged from 15 to 31 years (mean = 22.2, S.D. = 3.7, 90% were 18 years of age or older). There were no significant differences between those successfully followed-up and those lost to follow-up on baseline
Discussion
Results of this prospective and blind 10-year follow-up study of 110 boys with ADHD and 105 non-ADHD controls revealed that, while 65% of boys with ADHD no longer met full DSM-IV criteria for ADHD at the 10-year follow-up, 78% of subjects met at least one of our definitions of persistence: 35% continued to meet full DSM-IV criteria for ADHD, 22% met subthreshold criteria, 15% were functionally impaired and 6% while not meeting criteria for ADHD and functioning well, were treated for the
Conflict of interest
Dr. Joseph Biederman is currently receiving research support from the following sources: Alza, AstraZeneca, Bristol Myers Squibb, Eli Lilly and Co., Janssen Pharmaceuticals Inc., McNeil, Merck, Organon, Otsuka, Shire, NIMH, and NICHD.
In previous years, Dr. Joseph Biederman received research support, consultation fees, or speaker's fees for/from the following additional sources: Abbott, AstraZeneca, Celltech, Cephalon, Eli Lilly and Co., Esai, Forest, Glaxo, Gliatech, Janssen, McNeil, NARSAD,
Acknowledgements
This work was supported, in part, by National Institute of Child Health and Human Development (NICHD) grant 5R01HD036317-10, the Lilly Foundation Fund, and the Pediatric Psychopharmacology Philanthropic Fund.
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