Title: Real-life instability in ADHD from young to middle adulthood: a nationwide register-

based study of social and occupational problems

Version: 1 Date: 15 Dec 2022

Reviewer's report:

Using a large register-based dataset, the authors investigated whether adults with ADHD
experienced an increased risk of instability across several domains, based on several indices
(residential moves, relationships, and job shifting). Results indicated heightened instability
across domains for individuals with ADHD, with the highest risk for the oldest group. Strengths
of this study include the large and presumably representative sample, inclusion of a broad age
range of individuals with ADHD, and sufficient power to examine gender differences. The topic
will likely be of interest to researchers and clinicians who focus on adults with ADHD. The
following clarifying questions and recommendations are offered.

INTRODUCTION

1) In the first paragraph, can the authors briefly comment on whether this instability uniquely
characterizes ADHD/if it is thought to be more prominent in individuals with ADHD than in
individuals with other disorders?
2) The justification provided for adjusting for parent education is that there are strong
associations between ADHD and educational level. So is parent education being used as a proxy
for individuals’ education level then? Or why not use the individual’s own education level?
Please clarify that discrepancy in the paper.

METHOD

3) The follow-up period is described as “12 years” but specified “between January 2000 and
December 2013” – isn’t that actually 14 years?
4) Covarying for criminal convictions – can the authors justify/clarify in the Covariates section
why this was covaried? Can some information be provided on the range of convictions that this
might include? E.g., in the U.S. this could reflect a huge range of offenses, from minor crimes
and drug charges to more serious and violent offenses. More context would be helpful.
5) Age categories – Why did the authors choose to dichotomize age into 3 groups versus treat
age as a continuous variable? Further, how were these age group cut-offs chosen? Why are there
fewer years included in the 30-39 group than in the other two? Elsewhere throughout the paper,
the age ranges are described slightly differently (30-40, 41-52), so those discrepancies need to
be corrected. Lastly, if age is going to be dichotomized based on a reasoned approach, the 18-29
group likely includes quite different populations with the younger ages in that range reflecting
the transition to adulthood, entrance into workforce and/or university years, etc. versus the older
ages in the range. It’s not clear that individuals at the younger and older ends of this range should
be considered to be in the same age category.

RESULTS
6) It is not clear whether the authors actually tested age and gender interactions, and if so, please
report the coefficients and p-values of the interactions themselves. If the entire regression was
run separately within age and gender groups, I recommend instead doing a unified regression in
which gender X ADHD and age X ADHD interactions are tested. It also is not clear if there are
both 2-way (gender X ADHD, age X ADHD) and 3-way interactions (gender X age X ADHD)
interactions that were tested?
7) Sensitivity analyses – should “convicted” be “incarcerated”?
8) It would be helpful to see the average number of job shifts, children with different partners,
and residential moves for individuals with vs without ADHD somewhere in the Results, perhaps
in Table 1, just to understand what the overall rates are in each group.
9) Do the registry data contain information on ADHD presentation (inattentive, hyperactive/
impulsive, combined)? If so, it would at minimum be helpful to report the distribution of the
presentations in the sample. It would be even more informative to conduct a post-hoc analysis
examining the associations with the outcomes by presentation type.

DISCUSSION

10) Can the authors speak to the effect sizes/clinical and practical significance of the findings?
11) Regarding the finding that women were more likely to experience the relational instability
outcome (which the authors note is a crude measure that is likely capturing a lot more than
“relational instability”), is it probable that women are more likely to know and/or endorse having
had children with different partners than are men, which could partially account for this finding?
12) Limitations – the authors note the low rate of ADHD in the sample. Can they compare the
rates to population estimates to contextualize this for readers?