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

based study of social and occupational problems

Version: 1 Date: 11 Jan 2023

Reviewer's report:

The manuscript titled ‘Real-life instability in ADHD from young to middle adulthood: a
nationwide register-based study of social and occupational problems’ describes instabilities in
lives of adults with ADHD using large observational data set. The study has a very interesting
and timely topic, and the data set used offers possibilities for valuable new insights. However, I
still have few remarks to consider, that I hope will help the authors to strengthen and clarify the
manuscript further. My two main remarks and some minor considerations are presented below.
Main remarks

1) My main concern is related to the justification of the outcome measures used in the
study. The measure used for occupational stability (job shifting) likely captures the desired
phenomenon (though as the authors note in the Limitations-chapter, there might be some age-
related differences), but this seems to be somewhat more in doubt for the measure used for
relationship instability. I would suggest that the authors clarify the discussion on the merits and
limitations of the measures chosen to represent occupational and relationship stability further. In
a study where secondary data sources are used, the careful consideration of the measures chosen
to represent phenomena is very important.

The justification of residential moves as an outcome measure is should be clarified in the text.

2) The chapter Statistical analysis, the authors should describe more clearly the analyses plan:
were the three age groups analysed separately, to what models interaction terms were included
etc. In its current, very brief, form, the analysis plan is a bit difficult to follow. Also, this would
make it easier to follow the Results –section, as especially model(s) presented in table 3 are a
bit difficult to interpret in their current forms.

Minor considerations
1) The abbreviations SUD and BPD should appear in the text for the first time with the concepts
they represents (ie. Substance Use Disorder (SUD) )

2) In Methods, sub-chapter Covariates discusses psychiatric diagnoses and measures for criminal
convictions. As these measures seem to be used in analyses as controls, together with measures
of parental education, I would, for clarity, consider presenting all these measures together as eg.
Controls. I would also encourage the authors to describe used controls with some more detail
(eg. how where criminal convictions used in the analyses).

3) In describing the study population (table 1), information on parental income and educational
level is used. Is all the information from parental income from the same year (2000) and in EUR?

4) Based on the current study, I would be somewhat hesitant to draw the conclusions related to
sexual education, (‘This suggests that beyond symptom reduction interventions for women with
ADHD should also focus on relational skills, education around sexuality, and protected sex.’))
as the authors note in the Limitations –chapter ‘Using the number of children with different
partners as a measure of relational instability is a crude measure. Important nuances of relational
instability might be missing using such a measure.’