Childhood Diagnosis of ADHD and Adult Psychiatric Disorders, 1998

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Clinical Question: Are adults who were diagnosed in childhood with ADHD more prone to psychiatric disorders such as antisocial personality disorder, non alcoholic substance abuse. ADHD syndromes, mood and anxiety disorders?

Reference: Salvatore Mannuzza PhD, Rachel Kelin PhD et a1, "Adult Psychiatric Status of Hyperactive Boys Grown Up" The American Journal of Psychiatry. 4/1998, volume 155 (4), 493-498.

Introduction: Previous studies of young adults who have grown up with ADHD have shown that arrest history, conduct problems, poor academic history, and continued ADHD symptoms are common. To the date of this article there have been 2 published controlled prospective studies of psychiatric status into late adolescence and young adulthood. One of these studies was by Manuza et al. Between 1970 to 1977, they evaluated 1.000 children between 6-12 years of age. Of these, 207 subjects met inclusion criteria (under methods). 103 of these subjects had reached age 16 by the time of an adolescent flu study published in 1985. These 103 subjects were then studied in adulthood (avg. 25y/o). and were found to have higher prevalence of ongoing ADHD, antisocial personality, and drug abuse, but not mood and anxiety disorders. The other study by Weiss et al took 61 previously diagnosed childhood ADHD patients and evaluated them at the average age of 25. They found increased prevalence of at least one symptom of ADHD. This article follows Manuza's 104 subjects who had not yet reached age 16 at time of his previous study to gain further understanding of the natural course of ADHD.

Methods:

Design: Prospective cohort study

Subjects:

• Predominantly middle class, white hyperactive boys of average intelligence (mean full scale IQ 105, SD 13) referred to a no cost child psychiatric research clinic.
• 207 subjects met the following 8 criteria (104 of these subjects targeted for this study): 1)Referred by a teacher because of behavior problems, 2)Judged hyperactive by a teacher with a score of at least 1.8 on Conners Teacher Rating Scale, 3)Judged hyperactive by parents or clinic staff; 4)dx. as having DSM-II hyperkinetic reaction of childhood by a psychiatrist, 5) IQ of at least 85.6) free of psychosis and neurological d/o, 7) Without clinically significant presenting problems involving aggression or other antisocial behaviors, 8) English speaking parents with phone.
• Comparison Subjects: 64 from nonpsychiatric outpatient clinics within the medical center. Charts reviewed for white middle class males of appropriate age. Those treated for accidental injuries or chronic serious illnesses or those with behavior problems before age 13 were not included. Parents of selected subjects were called. If school teachers had complained about the child's behavior, they were not included. An additional 14 recruited from community sampling service using same inclusion/exclusion criteria. Mean age 18.6 SD 1.5.
• Adult Vu: 85 (of 104) probands administered semistructured interview that included DSM-III antisocial personality, attention deficit, anxiety. mood, substance use, and psychotic d/o. Probable and definitive diagnoses were included in this study. Blind assessments were conducted by a clinical psychologist and a psychiatric social worker (written narratives reviewed by senior investigator) with correlative kappa values as follows: ADHD (0.70), Antisocial (0.69), substance use d/o (0.80), major depression (.1.00). Analysis: Logistic regression analyses. Odds ratio adjusted for age and socioeconomic status since probands had lower SES and age was older (24.1. SD1.2).

Outcome:

1. Probands had more ongoing mental do than comparison (33% v. 19%)
2. The most common dx. in probands were antisocial personality (OR 4.0, CI 1.01-15.65) and substance use d/o (Nonalcohol OR3.8, CI 1.18-13.12). Antisocial and substance abuse aggregated significantly (60% of antisocial probands displayed substance abuse v. only 13% of non antisocial probands)
3. The rates of mood and anxiety dlo didn't differ significantly (MDD OR 1.0, CI 0.2-5.55).
4. Only 4% of probands had full ADHD syndrome (OR 49. CI 0.61-38.96. not statistically significant).

Completeness of follow-up: Duration of follow up ranged from 15-21 years (mean 17, SD 1.4). Of the original 104 probands, 85 were interviewed (of those not interviewed, 15 refused to participate, 3 couldn't be located, and 1 died). Of the 78 comparison subjects, 73 were interviewed (5 refused to participate).

Validity:

1. Patient sample was clearly defined (age and criteria for inclusion stated), representative of clinical practice.
2. All patients accounted for.
3. Outcome criteria objective (blinded social worker and psychologist) and unbiased relative to the prognostic factors (used DSMIII-R criteria).
4. Was their adjustment for linked prognostic factors?
5. Were patients in the study treated similarly? Appear to have been since all were interviewed by same clinicians under the same blinded conditions.
6. Do the study population characteristics describe your patient? No. No ethnic, gender, socioeconomic diversity. Clinic-referred patients tend to be more ill. Only "Pure" ADHD children's adult outcome were included in this study (no comorbid conduct d/o children)..

Results: Antisocial and nonalcoholic substance abuse are the only diagnoses with P values less than 0.05 indicating a significant difference between probands and comparison in these two categories. At the same time, the CI is wide. A larger sample size would have provided more power to the study. There's no indication by this study that ADHD children would have a higher prevalence of mood or anxiety d/o.

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