802015

research-article2018
JADXXX10.1177/1087054718802015Journal of Attention DisordersMak et al.

Article
Journal of Attention Disorders

Diagnostic Outcomes of Childhood

2020, Vol. 24(1) 126­–135
© The Author(s) 2018
Article reuse guidelines:
ADHD in Chinese Adults sagepub.com/journals-permissions
DOI: 10.1177/1087054718802015
https://doi.org/10.1177/1087054718802015
journals.sagepub.com/home/jad

Arthur D. P. Mak1 , Alicia K. W. Chan1, Phyllis K. L. Chan2,

C. P. Tang3, Kelly Lai1, Sheila Wong1, Patrick Leung1,
S. F. Hung1, Linda C. W. Lam1, and Sing Lee1

Abstract
Objective: We examined adulthood diagnostic, functioning, and social outcomes of childhood ADHD in a Hong Kong
Chinese clinical sample. Method: We identified from the central registry 499 Chinese adults clinically diagnosed with
ADHD aged 6 to 12 in 2002-2005 in four Hong Kong child psychiatric centers. Assessments included ADHD Clinical
Diagnostic Scale (ACDS), Structured Clinical Interview for DSM Disorders (SCID), and World Health Organization
Disability Assessment Schedule (WHO-DAS). Results: Eligible participants = 499. One hundred forty-five completed
assessments, two deceased, six incarcerated, 100 had invalid contact, 83 declined, 34 emigrated, and 129 unable to attend.
Mean follow-up duration = 14.9 years. Nonrespondents were slightly younger (19.78 vs. 20.53, p < .001). In all, 83.1%
of all participants currently met Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) ADHD criteria
(36.8% inattentive subtype (IA), 43% combined, 3.3% hyperactive/impulsive subtype (H/I) ). One third of persistent ADHD
participants currently received care. ADHD persistence was associated with significantly increased psychiatric comorbidity
(49.5% vs. 22.7%, p = .02) and poor academic and social outcomes. ADHD persistence and comorbidity independently
predicted impairment. Conclusion: Adulthood-persistence of clinically presented childhood ADHD is common and
impairing in Hong Kong Chinese. (J. of Att. Dis. 2020; 24(1) 126-135)

Keywords
adult ADHD, ADHD, longitudinal study, comorbidity, functional impairment

Recent World Mental Health Survey data suggested that
only 1% of adults in China suffered from ADHD (Fayyad
et al., 2017), contrasting sharply with the global adult
ADHD prevalence figure of 4.4% (Fayyad et al., 2007). In
fact, reported prevalence figures of ADHD in Chinese chil-
dren were substantially higher in the range of 4% to 6%
(Zheng & Zheng, 2015), while a school-based study in
Hong Kong reported 8.9% of the Chinese schoolboys to
suffer from the condition (Leung et al., 1996). These find-
ings may suggest ADHD in Chinese communities to have
lower adulthood persistence or have better adulthood out-
comes. As such, ADHD in the Chinese may appear to be a
less serious condition than that known in the West, possibly
consistent with the fact that common comorbidities of adult
ADHD, such as depression, alcoholism, and other substance
use are also less common in Chinese than Western people
(Lee et al., 2009; Shen et al., 2006). Given the high adult-
hood persistence rate (60%-70%) of ADHD found in
Western clinical prospective studies (Biederman et al.,
2006; Biederman et al., 2012), examination of the apparent
discrepancy in Chinese versus Western adulthood outcomes
of clinical cohorts of childhood ADHD may shed light on
the etiology and cross-cultural validity of adult ADHD.
Before we accept the above possibility that adult ADHD
is a somewhat Western “culture-bound” pathology, several
issues deserve attention. First, there has been no published
Chinese longitudinal data on adulthood ADHD persistence
in clinical or population samples. Second, mental disorders
such as depression and substance use have become increas-
ingly common in Chinese communities (Huang et al.,
2016). Third, owing to limited treatment resources, under-
treatment of children with ADHD in Chinese communities
is common (Fayyad et al., 2017; Zheng & Zheng, 2015).
This should increase rather than diminish adult persistence.
These considerations suggest that the prevalence of adult
ADHD in China could have been underestimated. In the
West, adult ADHD leads to significant occupational and
1
The Chinese University of Hong Kong, Tai Po, Hong Kong
2
Queen Mary Hospital, Pok Fu Lam, Hong Kong
3
Kwai Chung Hospital, Hong Kong
Corresponding Author:
Arthur D. P. Mak, Department of Psychiatry, The Chinese University of
Hong Kong, G/F Multicentre, Tai Po Hospital, 9 Chuen On Road, Tai Po,
New Territories, Hong Kong.
Email: arthurdpmak@cuhk.edu.hk
Mak et al. 127
social role impairment, criminal behavior (Barkley, Fischer,
Smallish, & Fletcher, 2006; Biederman et al., 1996; Kessler
et al., 2006; Klein, 1991; Mannuzza, Klein, Bessler, Malloy,
& LaPadula, 1998), as well as psychiatric comorbidity
(Biederman et al., 2012). If 4.4% of the 1.4 billion Chinese
population had adult ADHD as in the West, over 50 million
adults in China could be suffering from ADHD but have yet
to receive proper treatment.
To examine the persistence of childhood-diagnosed
ADHD in a Hong Kong Chinese clinical sample, we com-
prehensively recruited and systematically assessed a sam-
ple of children aged 6 to 12 who were clinically diagnosed
with ADHD in 2002-2005 in four major children’s mental
health services in Hong Kong to examine their current
early-adulthood clinical symptomatology and diagnostic
subtypes including inattention and hyperactivity/impul-
sivity, and the impact of adulthood persistence of ADHD
on psychiatric comorbidity, functional impairment and
social outcomes.
Method
Procedures
Recruitment began after ethical approval from the Clinical
Research Ethics Committee of the Hong Kong New
Territories East cluster, Hong Kong West cluster, and
Kowloon West cluster hospitals. After initial record search
for diagnostic compatibility, addresses and/or telephone
numbers of the included patients were retrieved with the
following methods:
i. Directly from case records
ii. Two parallel computer databases of the Hong Kong
Hospital Authority, which is the only public hospi-
tal service provider in Hong Kong. The databases
allow access to address and telephone numbers of
the patient or next-of-kin as of the patient’s latest
public hospital attendance across the territory in
Hong Kong. All participants were then contacted
by phone at least 5 times with each phone number
availed, at different times of the day/week. Text
messages were sent to those who did not respond
to the phone calls, failing which letters were sent to
most updated addresses available from computer
records. To compare respondent and nonrespon-
dent characteristics, an electronic Chinese version
of the Adult ADHD Self-Report Scale (ASRS;
Yeh, Gau, Kessler, & Wu, 2008) for self-rating of
current ADHD symptom severity was given to all
respondents as well as those who either declined
the interview or were unavailable for research
interview, but agreed to complete the electronic
screening.
Participants
We consecutively identified all clinic attendances of 6- to
12-year-old (Klein et al., 2012) Chinese children in years
2002 to 2003 to four tertiary-referral Child and Adolescent’s
Mental Health Centers in Hong Kong who had at least
reached the age of 18 by the date of recruitment (up to
November 2017) (see Figure 1). Five hundred sixty patient
records had clinical diagnosis entered on the registry of
Diagnostic and Statistical Manual of Mental Disorders
(DSM)-ADHD or International Statistical Classification of
Diseases and Related Health Problems 10th Revision (ICD-
10) Hyperkinetic Disorder at baseline and further evidenced
by case records showing (a) diagnosis made by a specialist
child psychiatrist, (b) inattention or hyperactivity reported
by both parents and teachers (Adler & Spencer, 2004), and
(c) evidence of functional impairment, for example, under-
achievement, behavioral problems, and disciplinary conse-
quences. We excluded those who did not have any Chinese
parents (n = 3), those whose hospital record showed evi-
dence of mental retardation (n = 29), childhood autism
requiring special school placement (n = 23), major senso-
rimotor handicap (paralysis, deafness or blindness; n = 2),
and those who were adopted children as their developmen-
tal history may be incomplete (n = 0) (Biederman et al.,
2006; Biederman et al., 2012; Klein et al., 2012). Finally,
those who were able to make valid informed written con-
sent were recruited for follow-up assessment (n = 499).
Successful phone contact was made with 397 patients or
their parents. Eighty-three declined (16.6%), of which 18
were by the parents who refused for investigators to con-
tact the patients for further recruitment procedures. Three
hundred fourteen (62.9%) expressed interest to participate
in the study. We were unable to schedule research inter-
views for 122 of these participants, 82 of which were
unable to commit into any scheduled slots despite contin-
ued expression of interest in the study. Six of them were
incarcerated according to their parents. We were able to
successfully visit one of them in prison, who expressed
interest in further participation in the study, but owing to
regulatory difficulties research interview could not be con-
ducted, and all six have remained in prison at the time of
writing. Thirty-four were studying abroad and have not
been able to return to Hong Kong to attend research inter-
views up till the time of writing.
We were able to schedule assessments for 192 partici-
pants, of which 45 did not turn up, two did not complete
ADHD Clinical Diagnostic Scale (ACDS) assessments (one
arrived late and was not able to complete assessment, or
further schedule an appointment; the other came for first
half of the assessment, but became incarcerated since).
Eventually, 145 were successfully interviewed for adult-
hood ADHD persistence. Participation rate was therefore
29% (145/499).
128 Journal of Attention Disorders 24(1)

Idenfied from Registry with a chief

diagnosis of ADHD/Hyperkinec
Disorder at the age of 6-12 at 2002-
2005a (n = 560)

Excluded (n = 61)
Mental retardaon: 29
Asperger’s: 10
Ausm: 13
Auditory impairment: 2
Non-Chinese: 3
Underage: 4

Eligible paents (n = 499)

Deceased (n = 2)
overdosed and
jumped from height : 1 Contacted by phone (n = 497)
suicide a‡empt: 1

Unable to reach Successfully reached

paents and/or family despite phone calls, paents and/or family
text messages and invitaon le‡er (n = 100) (n = 397)

Invalid phone number

(n = 56) Expressed interest
Successfully arranged
Declined (n = 83) but unavailable for
assessment (n = 192)
assessments (n = 122)

No one answered
(n = 44)
By paents’ parents Incarcerated and Defaulted
(n = 18) unavailable (n = 6) appointment (n = 45)

By paents (n = 65) Emigrated/ Study Assessment

abroad (n = 34) Incomplete (n = 2)

agreed to join but

Successfully
unable to fix a date
interviewed (n = 145)
(n = 82)

Figure 1.  Recruitment flowchart.

a
In two of the sites, only patients attending in 2002 were approached.

Assessments ADHD symptoms followed by an expanded assessment of

Childhood baseline data including age, sex, school year, spe-
cial education, family constitution, immigration status, diag-
noses, comorbidities, and drug prescription records, province
of origin and/or birth, and family and family socioeconomic
variables—parents’ age, sex, educational attainment, occupa-
tion at the time of intake—were documented.
Early Adulthood Outcome Assessment
The Adult ACDS v1.2 (Lara et al., 2009), a semistructured
interview for retrospective assessment of all DSM childhood
recent (12-month) adult ADHD symptoms including nine
DSM Criterion A symptoms of inattention and nine hyperac-
tivity/impulsivity symptoms, along with 14 non-DSM symp-
toms relevant to adult ADHD clinical manifestations, were
validated and used for adult ADHD assessment (Biederman,
Petty, Clarke, Lomedico, & Faraone, 2011). For the Chinese
validation, two-way translation was made with endorsement
by the original authors to Chinese understandable to both
Mandarin and Cantonese speakers, by two separate and
independent mental health professionals fluent in both
Chinese and English. Before arriving on a finalized version,
the working translated version were tested with five adults
Mak et al. 129
under clinical care with ADHD to test and improve compre-
hensibility of the wordings used. An independent panel of
academic psychiatrists examined the back-translated instru-
ment for semantic and content equivalence with the original
instrument. All interviewers received clinical training as
well as training on the administration of the ACDS v1.2 by a
representative panel of psychiatrists experienced in adult
and childhood ADHD diagnosis. Each trained interviewer
completed five practice interviews where symptom ratings
agree with those of trainers before formal interview took
place. For assessing childhood symptomatology and sever-
ity and early adulthood ADHD diagnosis, each participant
was interviewed individually, supplemented by a parent
interview using the ACDS v1.2 for
a. Current 1-year Diagnostic and Statistical Manual of
Mental Disorders (5th ed.; DSM-5; American
Psychiatric Association, 2013) diagnosis and sever-
ity of ADHD by enquiring on developmentally sen-
sitive areas of ADHD symptomatology.
b. Retrospective childhood ADHD diagnosis and
severity using the childhood-ADHD module of the
ACDS v1.2.
To assess the reliability of the adult module of the Chinese
version of ACDS v1.2, 20 participant–parent pairs were sepa-
rately interviewed by a panel of two specialist psychiatrists
blind to ACDS results for assessing criterion validity for
ADHD assessment. We found complete ACDS-clinician
agreement in current ADHD diagnosis. The panel of clinician
experts and academic psychiatrists examined and reviewed
the ADHD diagnostic data with the interviewers to resolve
ambiguities and discrepancies, and further in-depth clinical
interviews with the participant–parent pairs as indicated,
before adult-persistent ADHD was confirmed. Monthly cali-
bration meetings were held to prevent rater drift.
Semistructured psychiatric diagnostic assessment was
made by trained clinician interviewers blind to the results
of current ADHD symptomatology using the validated
Chinese-bilingual version of the Structured Clinical
Interview for DSM Mental Disorders (So et al., 2003), for
lifetime and current diagnoses of Affective disorders,
Schizophrenia, Anxiety, and phobic disorders, Substance
use disorders, and Eating disorders.
We measured role impairment with the official validated
Chinese version of the World Health Organization (WHO)
Disability Assessment Schedule (DAS; Chwastiak & Von
Korff, 2003). This measure assesses the frequency and inten-
sity of difficulties experienced over the past 30 days in each
of three areas of basic functioning—mobility (e.g., walking a
mile), self-care (e.g., getting dressed), and cognition (e.g.,
remembering to do important things)—and three areas of
instrumental functioning—time out of role (i.e., number of
days totally unable to carry out normal daily activities and
number of days of cutting back on amount done or time spent
on daily activities), productive role performance (e.g., cutting
back on quality of work), and social role performance (e.g.,
controlling emotions when around other people). WHO-DAS
2.0 data were scored based on item response theory (IRT)
with an algorithm (available from WHO) that determines a
summary score by differentially weighting the items and lev-
els of severity. Population norms were derived from general
population samples from 10 countries (including China).
WHO-DAS 2.0 has been shown to be cross-culturally stable
showing a similar two-level factor structure across the 19
countries where it was tested.
Socio-Demographic, Occupational, and
Educational Outcomes
Parents’ and the participant’s educational attainment, occu-
pation and monthly income, and experience of expulsion
from school and work were documented on a standardized
list. All these information was confirmed with the patients
and parents during the interview. Adverse behavioral/social
outcomes, including criminal offense, involvement in
fights, violence leading to personal injury with or without
criminal consequences, theft, felony requiring conviction,
and financial problems, such as failure to settle bills, owing
debts, inability to save up to pay for debts, teenage parent-
hood, were documented from direct interview with parents
and patients.
Statistical Analysis
SPSS v24.0 was used for statistical analysis. Baseline socio-
demographic data and number of participants who could be
traced and those who could not be traced, as well as those
included and excluded from the study based on case note
perusal, were compared using Pearson’s chi-square tests for
binary variables and t tests for dimensional variables. All p
values are two-tailed. Fisher’s exact test were used where
appropriate. For nonparametric data, Mann–Whitney U test
was used to delineate group differences. The primary out-
come measure in this study was current 6-month prevalence
of persistent ADHD (including full and subthreshold
ADHD) in the ADHD follow-up group with 95% confi-
dence interval (CI) of the proportion, weighted for age and
sex distribution in the study population. To assess the psy-
chiatric status of persistent ADHD at early adulthood, we
used logistic regression models to compare ADHD-
persistent and nonpersistent participants on the lifetime
prevalence of each disorder at follow-up. Simple statistics,
such as Pearson’s chi-square tests, t tests, ANOVAs, and
Pearson correlation analyses, were used to compare differ-
ences in comorbidity, and socioeconomic variables between
those with persistent ADHD against nonpersistent ADHD.
Owing to the nonparametric nature of the WHO-DAS IRT
130 Journal of Attention Disorders 24(1)
Table 1.  Comparison of Characteristics Between Respondents and Nonrespondents.
Nonrespondents
(n = 354)
Age (estimated)at time of recruitment (SD) 20.53 (2.17)
Gender, male (%) 300 (85.2)
On medications for ADHD before 12 (%) 304 (86.4)
Current ASRS score (SD) 28.0 (12.1)
Note. ASRS = ADHD Self-Report Scale.
**p < .01.
scores, univariate comparisons of WHO-DAS role impair-
ment scores in persistent and remitted ADHD participants
were performed with Mann–Whitney U test. Bootstrapped
linear regression was performed to identify independent
predictors of WHO-DAS role impairment scores.
Results
Two participants were deceased. Both were male and in the
age group of 20 to 24 at the time of death. According to
hospital records, one jumped from height while intoxicated
with illicit substances, the other committed suicide by drug
overdose. Crude mortality rate was 2/499 = 0.004.
According to Hong Kong Census and Statistics Department
(2016) data, age/sex specific mortality ratio of male aged 20
to 24 in 2015 was 0.0004. Standardized mortality ratio was
therefore = 10% to 1 (95% CI = [3.10, 18.48]) (Census &
Statistics Department, 2016). Six of the eligible pool of 499
participants were imprisoned at the time of recruitment.
One hundred forty-five patients (29% of 499) completed
current ADHD assessments. Their mean age at the time of
assessment was 22.18 (18.11-27.9), mean duration of fol-
low-up being 14.9 years (Figure 1). About 84% were male,
and 78.6% had received medications for ADHD by age of
12. Nonresponders (n = 352) had similar gender distribu-
tion but were significantly older and more likely to have
received medication prescription in childhood compared
with the responders (n = 147). We invited all potential par-
ticipants who declined or were not able to schedule an inter-
view (n = 205) to complete an online version of the ASRS
sent to their mobile phone by text messenger. Only half of
them consented to receive the questionnaire (n = 103), and
only 24 responses were received. Their ASRS scores did
not significantly differ from those of the successfully inter-
viewed respondents (28.0 vs. 31.9, p = .15; Table 1).
ADHD Persistence
After weighting for age and sex distribution of nonrespon-
dents, 83.1% (121 of 145) participants currently met DSM-
5 criteria for ADHD. Fifty-three (36.8%) met the criteria for
ADHD-inattentive subtype, five (3.3%) met criteria for
All respondents
(n = 147) t/df p
19.78 (2.31) 3.46/497 .001**
120 (81.6) .35
117 (79.6) .08
31.9 (12.3) 1.45 .15
hyperactivity/impulsivity subtype, and 62 (43%) met crite-
ria for combined subtype.
Treatment and Medication History
Median age of first psychiatric appointment was 7, and
median age of last appointment was 15 (see Table 2).
Participants on average received approximately 8 years
(95.17 months) of outpatient psychiatric service for ADHD.
Persistent ADHD participants were more likely to stay in
care than those who remitted. However, whereas 75.8% of
the persistent ADHD participants continued to receive out-
patient care after age of 12, only 31.7% continued to receive
care past the age of 18. Persistent ADHD participants had
on average been out of care for 6.84 years already.
Over 78.3% of all participants had received medications
for ADHD before the age of 12, mainly methylphenidate and
a minority received atomoxetine. They on average received
6.5 years of drug treatment. Median age of commencement
and discontinuation of prescription were 9 years and 15
years, respectively. Only 31.7% of persistent ADHD partici-
pants received drug treatment past age of 18, not signifi-
cantly higher than those without ADHD persistence.
Social Outcomes
All but two of the participants were single. Academically,
about half had experienced grade retention, one tenth were
expelled from school. Roughly one fifth were unable to
complete secondary school education. About 39.2% were
currently students, and 12.5% were currently unemployed.
About 5.9% of the persistent ADHD participants received
education up to Form 3 or below, slightly higher than the
4.76% of young adults in the Hong Kong population (age
group 20-29; Census & Statistics Department, the
Government of the Hong Kong Special Administrative
Region, 2017b). One tenth of the participants reported
criminal history, substantially higher than the arrest rate of
0.67% (age group 21-29; Census & Statistics Department,
the Government of the Hong Kong Special Administrative
Region, 2017a) in the Hong Kong population. Although
there are no comparable population-level statistics, 16% in
Mak et al. 131

Table 2.  Sociodemographic Data, Treatment History, and Social Outcomes of Remitted and Persistent ADHD.

All participants Remitted ADHD Persistent ADHD

(n = 145) (n = 24) (n = 121) χ2 t df p
a
Age (SD) 22.18 (2.27) 22.20 (1.87) 22.69 (2.26) 1.00 143 .32
Gender, male (%)b 122 (85.5) 21 (83.3) 101 (86) 0.27 .60
Education, n (%)b
  Form 3 or below 7 (4.9) 0 7 (5.9) 1.61 1 .21
  Not completing secondary 28 (21.4) 1 (4.2) 27 (24.8) 4.86 .03*
  Received tertiary education 85 (59.6) 19 (76) 66 (56.2) 2.73 1 .13
Employment, n (%)b 0.09 3 .99
 Unemployed 17 (11.7) 3 (8) 14 (12.5)  
 Student 64 (40) 12 (44) 52 (39.2)  
 Part-time 19 (13.1) 3 (12) 16 (13.3)  
 Full-time 44 (35.2) 8 (36) 36 (35)  
Income, n (%)b
  <10,000 HKD/month 43 (56) 5 (41.7) 38 (58.3) 1.16 1 .28
Married, n (%)b 2 (1.4) 0 2 (1.7) 1
Treatment history, n (%)b
  Duration of ADHD drug 81.27 (53.61) 68.64 (52.98) 79.79 (54.29) 0.83 119 .41
treatment, months (SD)a
  Received drugs before 12 114 (78.5) 19 (79.2) 95 (78.3) 0.58 1 .45
  Received medications after 12 87 (71.1) 12 (63.2) 75 (72.5) 0.99 1 .40
  Received medications after 18 29 (19.3) 2 (8.3) 27 (21.5) 4.16 2 .13
  Outpatient care after 12 105 (73.1) 14 (60) 91 (75.8) 5.47 1 .02*
  Outpatient care after 18 42 (29) 3 (16) 39 (31.7) .03*
  Years out of care (SD)a 6.84 (5.99) 8.68 (5.19) 6.89 (5.99) −1.38 143 .17
Social outcomes, n (%)b
  Early parenthood 2 (1.4) 0 (0) 2 (1.7) 1.00
  Unplanned pregnancy 3 (2.1) 0 (0) 3 (2.5) 1.00
 Abortion 2 (1.4) 0 (0) 2 (1.7) 1.00
  Grade retention 76 (52.7) 15 (56) 61 (52.1) 0.35 1 .55
  School expulsion 14 (11) 3 (12) 11 (10.8) .72
  Finance handling problem 18 (13.3) 0 18 (16) .04*
  Criminal records 15 (11.7) 2 (8.3) 13 (12.4) 1
a
Weighted mean and SD reported.
b
Data are number (%). Reported numbers are actual numbers rather than weighted estimates. Weighted percentages are in parentheses.
*p < .05.

our participants reported significant difficulties handling
financial problems. Fewer than one tenth reported adverse
family outcomes such as early parenthood, unplanned preg-
nancy, and abortion.
Significantly more persistent ADHD participants failed
to complete secondary school education (24.8% vs. 4.2%,
p = .03) and reported significant problems handling finan-
cial matters (p = .04) compared with those who remitted.
All other adverse social outcomes appeared more frequent
in persistent compared with remitted ADHD participants
but the differences did not reach statistical significance.
Psychiatric Comorbidities
About 45.5% of the participants met the criteria for a life-
time psychiatric diagnosis (Table 3). About 29.9% had a
depressive illness, 3.7% had a bipolar disorder, and 27.6%
met criteria for an anxiety disorder. Four patients had alco-
hol use disorder. None met criteria for substance use disor-
ders, eating disorders, or nonaffective psychoses. Persistent
ADHD participants were significantly more likely to suffer
from a comorbid mental disorder (49.5% vs. 22.7%, p =
.02) and among all mental disorders, depressive disorder
(33.3% vs. 9.1%, p = .02).
Role Impairment
Persistent ADHD participants had significantly increased
impairment in various domains of life as measured with the
WHO-DAS, including understanding and communicating,
getting around, getting along with people, life activities,
participation in society, and overall scores (equivalent to
132 Journal of Attention Disorders 24(1)

Table 3.  Psychiatric Comorbidity in Remitted and Persistent ADHD.

All participantsa (n = 133) Remitted ADHD (n = 22) Persistent ADHD (n = 111) p (two-sided)
b,c
Any mental disorder 60 (45.5) 5 (22.7) 55 (49.5) .02*
Any depressiveb 39 (29.9) 2 (9.1) 37 (33.3) .02*
Any bipolarb 4 (3.7) 0 4 (3.6) 1.0
Any anxietyb 37 (27.6) 4 (18.2) 33 (29.7) .31
Any eating disorderb 0 0 0 —
Nonaffective psychosesb 0 0 0 —
Substance  
Alcohol use disorderb 4 (3.7) 0 4 (3.6) 1.0
Substance use disorderb 0 0 0 —
Reported substance useb 10 (8.2) 0 10 (9.0) .21
a
Reported numbers are actual numbers rather than weighted estimates.
b
Data are number (%).
c
Includes any depressive, bipolar, anxiety, alcohol use disorder.
*Two-sided exact significance < .05.

Table 4.  Impairment Across Six Domains in WHO Disability Assessment Schedule Between Remitted and Persistent ADHD, and
Combined and Inattentive Subtypes.

Remitted ADHD Persistent ADHD Mann Whitney U Inattentive Combined

(n = 22) (n = 111) p (two-sided) (n = 50) (n = 57) p
a a
Understanding and 5 (22.7) 22 (14.64) <.001** 19.08 (14.56) 25.58 (14.21) <.001**
communication
Getting around 4.55 (7.70) 14.19 (15.95) .01* 10.10 (13.46) 16.93 (16.98)a .002**
Self-care 0.57 (1.84) 3.72 (8.77) .07 4.38 (11.31) 2.96 (5.80)a .21
Getting along with people 6.14 (6.89) 17.79 (16.8) .01* 16.80 (15.54)a 19.56 (17.96)a .01*
Life activities 8.95 (8.96) 23.45 (18.99) <.001** 19.56 (16.56)a 26.92 (20.68)a <.001**
Participation in society 6.82 (8.71) 17.62 (16.55) .004** 13.44 (15.19) 21.27(16.88)a, b .001**
Overall score 6.02 (5.46) 16.54 (11.6) <.001** 13.89 (11.15)a 18.87 (11.55)a .001**

Note. WHO = World Health Organization.

a
p < .05 for subtype > no current ADHD.
b
p < .05 for Combined > inattention subtype.
*p < .05. **p < .01.

78th population percentile versus 65th population percen- Table 5.  Bootstrapped Linear Regression of the Association
tile in nonpersistent participants; Tables 4 and 5). In all of Between ADHD Persistence, Any Mental Disorder and Basic
these domains combined, subtype individuals had signifi- Sociodemographic Data, and WHO-DAS.
cant increase in impairment compared with remitted partici- p (two-tailed) Lower CI Upper CI
pants, while inattentive subtype participants had significant
increase in impairment only in understanding and commu- Age 0.30 −1.15 0.53
nication, getting along with people, life activities, and over- Gender 0.98 −5.38 5.18
all score. In a bootstrapped linear regression model adjusted Completing 0.08 −11.83 0.30
for age, gender, and education level, current ADHD (p = secondary school
.003) and history of mental disorders (p = .004) indepen- Any mental disorder 0.004** 1.56 5.54
dently predicted current WHO-DAS scores. Current ADHD 0.003** 2.79 10.98
persistence
Care after age of 18 0.16 −0.66 6.917
Discussion
Note. Dependent variable: WHO-DAS overall complex scoring score.
Our study has several limitations. First, we were only able to CI = confidence interval; WHO-DAS = World Health Organization
successfully interview 29% of the target sample. Respondents Disability Assessment Schedule.
were slightly younger on average but just as likely to have **p < .01.
Mak et al. 133
received medication treatment before 12, suggesting similar
childhood illness severity. The high persistence rate of
ADHD found in the recruited sample may be attributable to
participant-derived sampling bias, where participants with
less severe ADHD-related problems may be less likely to
participate in the study. Note, however, that only 83 (16.6%)
declined, and we were able to get in touch with a further 122
(24.4%) participants and their parents who had expressed
interest in joining the study but repeatedly failed to turn up
for appointments despite numerous attempts at rescheduling.
Without proper clinical assessment, it would be difficult to
speculate how time management difficulties common to
ADHD patients and other illness-related behaviors may
explain the scheduling difficulties and refusal to participate
in the study (Kessler et al., 2006). It was unfortunate that we
were unable to obtain ASRS ratings from more nonrespon-
dents, but the ASRS scores obtained did not suggest any dif-
ference in ADHD symptom severity between those who were
successfully interviewed. Second, we were unable to provide
prospective and structured assessment of ADHD symptoms,
impairment, comorbidities, and functioning at earlier time
points during adolescence. This precluded a more accurate
estimate of the chronology of key ADHD symptoms and
related impairments throughout adolescence, where critical
changes in psychopathology, family influences, and aca-
demic challenges may have occurred. We were also unable to
examine the adulthood impact of childhood ADHD severity
and other clinical variables in lieu of prospective data collec-
tion in the childhood phase. Third, we could only identify
children whose ADHD diagnoses were entered in the hospi-
tal registry and with compatible childhood symptoms docu-
mented in the case records. We would not be able to access
those with milder or subthreshold ADHD that escaped clini-
cal attention, especially when presenting with a non-ADHD
primary diagnosis such as Major Depressive Disorder.
Finally, we did not seek ratings from employers (Barkley
et al., 2006), owing to fear of stigma and participants’ con-
cerns consequences about disclosure. This may have led to
underestimation of functioning impairment in the work place.
Nevertheless, our findings were important because we
showed that Chinese children who received a diagnosis of
ADHD in the clinic, like their Western counterparts (Biederman
et al., 2012), have a high risk of suffering from persistent
symptoms in adulthood. The vast majority of our participants
with persistent ADHD met criteria for the inattentive subtype,
half of whom also meeting criteria for hyperactive/impulsivity
subtype, consistent with Western findings of inattention as the
most persistent and probably core deficit in ADHD. Similar to
Western findings, ADHD persistence was also associated with
increased affective comorbidity (Biederman et al., 2012; Klein,
1991), both independently predicting impairment in broad
areas of functioning (Klein, 1991).
We found that ADHD persistence in our cohort was asso-
ciated with poorer academic outcomes, namely, noncomple-
tion of secondary school studies, school expulsion, and
grade retention, similar to those reported in the West (Barkley
et al., 2006; Biederman et al., 1996; Kessler et al., 2006;
Klein, 1991; Mannuzza et al., 1998). The high rate of
reported criminal history compared with the local popula-
tion, as well as problems in financial self-management also
appeared consistent with Western data (Barkley et al., 2006).
These broad cross-national similarities in ADHD outcomes
support the universality and validity of adult persistence of
inattention as a core feature of ADHD that predicts impair-
ment and psychiatric comorbidity. The significant morbidity
and adverse socio-educational outcomes may also reflect the
diverse health care and social welfare needs incurred from
ADHD persistence in young adults.
The lower rates of teenage or unplanned pregnancy and
substance use (Barkley et al., 2006; Biederman et al., 1996;
Kessler et al., 2006; Klein, 1991; Mannuzza et al., 1998)
appeared consistent with previous reports of lower rates of
teenage pregnancy (10 in 1,000 in Hong Kong vs. 57 in
1,000 15- to 19-year-old females in the United States;
Sedgh, Finer, Bankole, Eilers, & Singh, 2015) and sub-
stance use in Hong Kong adolescents (Lau, Kim, & Tsui,
2005) and ADHD patients (Lam & Ho, 2010). However,
our recruited sample could have under-represented people
with substance use problems, who may have more chaotic
lifestyles and therefore more difficult to engage in the study.
Of concern is the finding that most participants with
persistent ADHD had ceased to receive care. This is rele-
vant to not only China but also many areas in the world,
where child mental health services deliver care only up to
the age of 18 when transition to generic adult psychiatric
service would occur. Discontinuation of care may occur
owing to lack of resource provisions and training for gen-
eral adult psychiatrists in the clinical assessment and man-
agement of ADHD in adulthood, as well as lack of
awareness about the nature of ADHD, related impairments
and salience of continued treatment on the part of patients
and their caregivers.
In summary, cross-national adulthood persistence of
ADHD, especially attention deficit, is supported by our
clinical data on Chinese participants in Hong Kong with
those of the clinical cohorts in the West. Although we still
lack population-based cohort data, it is likely that the preva-
lence of adult ADHD in Chinese communities was previ-
ously underestimated (Fayyad et al., 2017). Further research
effort should go into prospective measurement of childhood
predictors of persistence and impairments in different
national samples, as well as cross-national comparison of
middle and later adulthood outcomes related to ADHD.
Acknowledgments
The authors would like to thank all the young men and women and
their parents for participating in this study, and colleagues in the
various sites—Candi Leung, Daphne Ng, Harriet Tang, Marina
Wong, Shelly Leung, Veronica Chow and Katy Wong, for their
contribution with conducting this study.
134 Journal of Attention Disorders 24(1)
Author Contributions
Arthur D. P. Mak contributed in the conception and design of
study, research interviews and blind clinical reappraisal, analysis,
and write-up; Alicia K. W. Chan contributed in conducting
research interviews and data collection and analysis; Phyllis K. L.
Chan contributed with the site logistics, study conception, advice
on analysis, and manuscript approval; C. P. Tang contributed in
the recruitment logistics, clinical diagnoses, and manuscript
approval; Kelly Lai contributed in advice on logistics and clinical
assessment and support of recruitment logistics; Sheila Wong did
the analysis, data management, manuscript preparation, and revi-
sion; Patrick Leung contributed in the study conception, advice on
ADHD Clinical Diagnostic Scale (ACDS) analysis, and advice on
manuscript; S. F. Hung contributed in the study conception, prog-
ress monitoring, project management, and analysis; Linda C. W.
Lam contributed in the study logistics and design, progress moni-
toring, and editing of manuscript; and Sing Lee contributed with
the conception and design of study and clinical reappraisal.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported by a grant from Health and Medical Research
Fund (12130681) of the Government of Hong Kong Special
Administrative Region.
ORCID iD
Arthur DP MAK   https://orcid.org/0000-0003-1627-6434
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Author Biographies
Arthur D. P. Mak is an assistant professor at the Department of
Psychiatry, the Chinese University of Hong Kong (CUHK), with
broad interests in developmental, psychosomatic and affective
neurosciences and epidemiology.
Alicia K. W. Chan is a research assistant at the CUHK Department
of Psychiatry devoted to research in Attention-deficit Hyperactivity
Disorder.
Phyllis K. L. Chan is chief of Service and Consultant in Child and
Adolescent Psychiatry at the Department of Psychiatry in Queen
Mary Hospital, Hong Kong. She is devoted to clinical service
development and research for ADHD and other neurodevelopme-
nal disorders.
C. P. Tang is consultant in Child and Adolescent Psychiatry at
Kwai Chung Hospital, Hong Kong with extensive clinical and
teaching experiences.
Kelly Lai is associate professor at the CUHK Department of
Psychiatry and heads the Child and Adolescent Mental health ser-
vice in the University hospital department. Her research interests
include ADHD services and eating disorders.
Sheila Wong is a research assistant at the CUHK Department of
Psychiatry, with expertise in statistics, bioinformatics, computer
programming and neuroimaging analysis.
Patrick Leung was chairman and professor at the CUHK
Department of Psychology until his retirement in August 2018,
and is now Honorary Professor at the Center of Genomic
Studies, University of Hong Kong. He has published exten-
sively on neurodevelopmental disorders with substantial contri-
bution to local child and adolescent mental health research and
service development.
S. F. Hung is Honorary professor at the CUHK Department of
Psychiatry, previously Chief of Service of Kwai Chung Hospital,
overseeing major developments in child and adolescent mental
health services in Hong Kong over the past decades.
Linda C. W. Lam is a professor at the CUHK Department of
Psychiatry, and coordinator of clinical services at the New
Territories East Cluster Hospital in Hong Kong. She has published
extensively on neuromodulation, neurocognitive research and
psychiatric epidemiology.
Sing Lee is a professor at the CUHK Department of Psychiatry,
and is the Asia-Pacific Coordinator of the World Mental Health
Initiative. He is an experienced clinician with research interests in
social, cultural and epidemiological psychiatry, with over 300 aca-
demic publications as well as a series of books written in Chinese
for the local community.