European Child & Adolescent Psychiatry

9:26±38 (2000) Ó Steinkop€ Verlag 2000 ORIGINAL CONTRIBUTION

M. Danckaerts A natural history of hyperactivity and

E. Heptinstall
O. Chadwick conduct problems: self-reported outcome
E. Taylor

Abstract At the age of 16±18 years, predicted di€erent patterns of con-

Accepted: 28 April 1999
M. Danckaerts, Ph. D., M.D.
Department of Child
and Adolescent Psychiatry
University Hospital Gasthuisburg
Herestraat 49
B-3000 Leuven, Belgium
E. Taylor á O. Chadwick á E. Heptinstall
Medical Research Council's
Child Psychiatry Unit, London, UK
outcome was prospectively assessed
in a general population sample of
four behavioural groups, de®ned at
6±7 year old: a pure pervasively
hyperactive group (N ˆ 31), a
mixed hyperactive conduct problem
group (N ˆ 20), a pure conduct
problem group (N ˆ 18) and a nor-
mal control group (N ˆ 29). The
objective of the present paper is to
describe outcome in those domains
for which self-report is recognised as
a valid source of information. Dif-
ferential e€ects for hyperactivity and
conduct problems on outcome were
studied. It was found that early
hyperactivity and conduct problems
duct problems in adolescence. Drug
use in adolescence was not predicted
by either type of behavioural prob-
lem in childhood. Overall social
adjustment was worse in the hyper-
active groups, whereas no di€erences
in self-esteem were found. Hyper-
activity was a strong predictor of
relationships problems in adoles-
cence. The results suggest that
hyperactivity and conduct problems
in childhood are di€erential predic-
tors of outcome in adolescence.
Key words Hyperactivity ± conduct
problems ± adolescence ± outcome ±
self-report

Introduction clinical cases evidently is relevant to similar referred

Well-documented outcome studies into adolescence and
early adulthood have provided us with a wealth of
knowledge on the prognosis for hyperactive children
(7, 27, 59±62, 93). These children are reported to be at risk
for continuity of their core symptomatology, for conduct
problems and antisocial personality characteristics as well
as delinquency, for school failure and lower academical
achievement due to behavioural and/or cognitive prob-
lems, for higher rates of cigarette-smoking and drug
experimentation and for relationship problems. However,
several methodological considerations, important for a
correct interpretation of these ®ndings, need to be made.
I. The vast majority of outcome research on hyper-
activity is based on samples of children referred to
clinical settings. The study of the prognosis for these
populations and can be used by clinicians to inform
parents about later adjustment problems for which their
children are at risk. However, due to the inherent
complexity of clinical cases, it is much harder to control
for all sorts of confounding factors in order to explore
the relationships between early factors and later out-
come. Clinical outcome studies are subject to several
kinds of bias, making it quite unlikely that they are
representative of the general population:
 Referral bias implies the fact that the quality and
quantity of problem behaviour in children are not the
only determinants of referral to clinics, but other
characteristics within the child or the environment
(100) or characteristics of the referral agent or the
agency to which a child is referred (22) also in¯uence the
referral process of ADHD children.
 M. Danckaerts et al.
A natural history of hyperactivity and conduct problems: self-reported outcome
 Berkson bias (8) whereby the referral likelihood for
a person with disorders ``A'' and ``B'' is a function of the
combined likelihood of referral for each disorder
separately. In hyperactive children, it was found that
learning problems, emotional disorder and aggressive
behaviour precipitate referral (54, 96, 100).
Other types of bias, not only may result in a non-
representative sample of hyperactive children, but also
may directly in¯uence the prognosis of the hyperactive
children involved, thereby not providing us with a
natural history of the disorder:
 Labelling bias whereby a diagnostic label may result
in di€erences in perceptions and attitudes of all people
involved with the child and of the child itself which in
itself may in¯uence the behavioural development, most
likely in the direction of continuity.
 Treatment bias. It is to be expected that children
referred to clinics, after their diagnostic assessment,
would have received at least some form of treatment.
As such, the global outcome picture of clinical cases
presents a prognostic view despite treatment.
A natural history can only be built from prospective
follow-up studies of samples recruited by a general
population screen, applying clinically relevant criteria.
Such studies can reveal (A) whether the outcome picture
typical of clinically referred samples also applies to a
non-referred sample, and (B) which risk and protective
factors need to be addressed for prevention of a poor
outcome. Longitudinal epidemiological data are neces-
sary to guide the management of resources and planning
of services for treatment and prevention. In recent years,
large scale longitudinal epidemiological surveys, using
behavioural questionnaires in children, have published
data on the developmental continuity of behavioural
dimensions in childhood, some of which are quite
informative on the hyperactivity dimension (24, 87±
89). Other surveys have studied relationships between
questionnaire de®ned behavioural pro®les and later
outcome (23, 25, 26, 55, 56, 91) or have studied the
outcome of speci®c subtypes such as the DAMP concept
(de®cits in attention, motor control and perception) (35).
However, general population studies, using clinically
valid research criteria and in depth assessments at
several points in time are still lacking.
II. Follow-up studies beyond the age of 13 mainly
rely on self-reported and parental measures, but often do
not explain which source they have used for the di€erent
outcome domains and are therefore lacking in clarity.
Kazdin et al. (42) suggested that children and parents
may emphasize di€erent aspects of the child's dysfunc-
tioning and both, therefore, may be partially accurate.
With regard to symptoms of depression, for example,
children have been found to be better informants than
their parents (69, 72); for behavioural problems, reli-
ability and/or validity of adolescent's self report
27
obviously depends on the type of problem reported.
Self-report of hyperactivity and inattention in young-
sters seems to be quite inaccurate (17), whereas self-
report of antisocial conduct problems is considered to be
far more valid. Loeber (50, 51) states that ``Many
caretakers are unaware of children's concealing, non-
aggressive conduct problems, such as theft and truancy
(41, 52), making children themselves better informants''.
In the Kashani et al. study (41) on informant variance,
a diagnosis of conduct disorder, according to DSM-III
criteria, was obtained more frequently on the basis of
self-report (12% versus 4% according to maternal
report), while oppositional de®ant behaviour was iden-
ti®ed more often by parents (22% versus 8% according
to self-report). Studies on adolescents' self-reported
delinquency appear to have reasonable validity when
compared to ocial arrest records (36). In a follow-up
of hyperactive youngsters, Mannuzza et al. (59) found
that arrests were accurately reported in 83% of arrested
subjects and in 76% of their parents.
Lack of self-report measurement, thus, might miss
out on crucial information on more covert types of
conduct problems and could also miss additional
discriminative validity to group membership in other
domains of outcome, such as substance use, self-esteem
and peer-relationships.
III. High rates of comorbidity between hyperactivity
and conduct disorder in clinical cases, have hampered
the interpretation of outcome studies. Longitudinal
studies conducted so far are inconclusive about the true
nature of the risk factors, because of the contamination
of samples that have been selected, including high rates
of comorbid cases without using a methodology that
takes them into account. Those few studies that have
assessed the e€ect of hyperactivity in conduct disorder
have found that it worsens the prognosis (57, 58, 78).
Similarly, when attention de®cit hyperactivity disorder
is complicated with aggression, a worse outcome is
demonstrated (6, 64). The few studies that have included
both types of disruptive behaviour patterns have con-
cluded that they have independent di€erential detrimen-
tal e€ects on development (23, 25, 26). However, the
latter studies have considered dimensions of problem
behaviour, rather than diagnostic categories.
To complement the outcome picture for hyperactive
children, a ten-year prospective follow-up was under-
taken of a community sample of 6±7 year old perva-
sively hyperactive children, to evaluate the risk for
psychopathology and psychosocial adjustment, in a
sample free from referral bias. The comorbidity issue
with conduct problems was explicitly dealt with: diag-
nostic groups, classi®ed according to presence or
absence of pervasive hyperactivity and presence or
absence of conduct problems were selected for in depth
assessment, both initially and at the age of 16±18 years.
The follow-up assessment consisted of parental inter-
28 European Child & Adolescent Psychiatry, Vol. 9, No. 1 (2000)
Ó Steinkop€ Verlag 2000
viewing, a parent questionnaire, cognitive testing and a
semi-structured interview and self report scales for the
youngster. The present paper will focus on the self-
reported outcome.
Materials and methods
Subjects
The methodology of the follow-up study is outlined in
detail in Taylor et al. (85). In summary: subjects were
selected for follow-up from a large-scale epidemiolog-
ical survey of 6±7-year old boys in a London borough
(84). Four groups were de®ned by the presence or
absence of hyperactivity and conduct problems. Hyper-
activity was considered present if both teachers and
parents gave a score of three or more on the hyperac-
tivity scale of the Rutter A/B (2) questionnaires (77).
Conduct problems were considered present if the score
on the teacher scale was nine or greater, or that on the
parent scale was 13 or greater, and the score on the
conduct disorder subscale was greater than that for
emotional disorder. These cut-o€ scores are not arbi-
trary, but have been validated against standardised
interview measures and psychiatric diagnoses, both for
conduct problems (77) and for hyperactivity (78, 84). In
the original survey from which these cases were taken,
the rating scale scores of hyperactivity were shown to be
good predictors of objective measures of activity and
attention (84).
Subjects were excluded if they had an IQ less than 50
or a neurological handicap or disease or if they had high
scores (®ve or greater) on the emotional disorder subscale
of either teacher or parent questionnaire, because we
think they might form etiologically distinct groups (82),
which could have confounded the comparison of the
other groups. Di€erential associations are found in
comorbid groups of children with ADHD and emotional
symptoms (48, 83, 84) as well as di€erential medication
e€ects (21). The same holds true for children with a
severe mental handicap (1). It should, however, be noted
that the results of this study should not be generalised to
hyperactive children with comorbid anxiety or depres-
sion, nor to hyperactive children with a severe mental
handicap or a neurological disturbance. Finally, immi-
grant families were excluded, because it has been shown
that a strong rater bias is operating in these children (79).
Measures
To explore whether an attrition bias was introduced,
groups were compared on initial measures of IQ and
social adversity. Intelligence was tested using a short-
ened version from the Revised Wechsler Intelligence
Scales for Children (92), consisting of two subtests from
the verbal part (similarities and vocabulary) and two
from the performance scale (block design and object
assembly). A social factors index was calculated for each
child by scoring one point for the presence of each of
the following: overcrowding, unskilled or semiskilled
manual occupation of breadwinner, unemployment of
breadwinner, unsatisfactory housing (84).
At follow-up, all adolescents were interviewed by a
trained child psychiatrist (M.D.), blind to the initial
group membership of the adolescents. The interview
was based on the Child and Adolescent Functioning and
Environment Schedule (CAFE-schedule) (39), a semi-
structured interview designed to give a pro®le of the
family life, social functioning, psychiatric state, plan-
ning behaviour and attitudes of 15±18 year old
children. These semi-structured sections yield interview-
er-based ratings of behaviour and psychiatric disorder,
based on prorated descriptions in a manual. The
speci®c scales referred to in the results section are
following:
Conduct disorder scale: Adolescents were interviewed
about aggressive behaviour, de®ant antisocial behaviour
and more covert antisocial behaviours such as truancy,
vandalism, theft and breaking into other's property. All
items were rated on a four-point scale (0-3) of severity
with a rating of ``0'' representing absence of the
behaviour, ``1'' representing minor and isolated presence
of the problem, ``2'' representing frequent minor or
isolated serious problems and ``3'' representing a chronic
and more serious pattern of problems.
Contact with the police: A four-point scale coded
quantity and quality of contact with the police over
the past year, with a ``0''-coding for ``no contact ever'',
a ``1''-coding for ``minor and isolated contact such as
being stopped by the police for questioning, a coding of
``2'' for ``frequent minor contacts or a single serious
contact'' and a coding of ``3'' for ``more than one serious
contact'', such as being arrested.
Emotional problem scales: Adolescents were interviewed
about the presence of fears, worries and feelings of
unhappiness. Di€erent types of fears and worries were
coded on four-point scales with ``0'' being absence of the
problem, ``1'' being only a mild presence of the fear or
worry, ``2'' being a moderate presence with impact on
normal functioning and ``3'' being a severe problem.
Moodiness was rated on four-point scales of severity
and frequency.
The in-depth questioning sections are grafted upon
the Social Adjustment Inventory for Children and Ado-
lescents (SAICA) (40), which covers both competent and
problem behaviours in the di€erent social roles which
 M. Danckaerts et al.
A natural history of hyperactivity and conduct problems: self-reported outcome
young people are expected to take on. Concurrent
validity of the SAICA has been demonstrated in ADHD
children (9).
The Self-Perception Pro®le for Adolescents (32) was
administered as a questionnaire at the end of the
interview.
Towards the end of the Adolescent Social Function-
ing Interview, a rating on the Global Assessment of
Functioning Scale is made by the interviewer according
to DSM-III-R-guidelines (2).
In addition to the use of self-report measures,
parental interview and questionnaire measures, as well
as psychological testing and clinical diagnoses were
applied (85). The present paper, however will focus on
self-report data.
Results
Characteristics of the follow-up sample
Self-reports were obtained from 98 (83.1%) out of 118
cases selected for follow-up. Four adolescents could not
be traced (3.4%) and sixteen youngsters (13.5%) refused
to participate.
Of the 98 adolescents who took part in the follow-up,
18 belonged to the pure conduct problem group (CP),
20 belonged to the mixed hyperactive-conduct problem
group (HACP), 31 belonged to the purely hyperactive
group (HA) and 29 were normal controls (NL).
Comparisons were made between the cases who were
interviewed and the ones that were not seen at follow-up
on the initial measures of age, IQ, social adversity, and
on initial ratings on the behavioural scales from the
parent A(2) and teacher B(2) Rutter questionnaires.
No signi®cant di€erences were found indicating that no
systematic bias had been introduced by selective attri-
tion of cases.
There was a tendency for both conduct problem
groups to have higher attrition rates than the purely
hyperactive and the normal control group as shown in a
logistic regression estimating the e€ect for presence or
absence of conduct disorder and presence or absence of
hyperactivity on the drop-out rates (Wald ˆ 2.97,
df ˆ 1, p < 0.09). To explore whether attrition had
introduced any selective bias within the diagnostic
groups, separate comparisons were made between the
recruited and not recruited subjects on all the above
measures within the four groups. The adolescents in the
pure CP group who were not assessed at follow-up had a
lower IQ than the adolescents who were interviewed at
follow-up (t = 2.94, df ˆ 22, p < 0.01). The results
suggest that, although there does not seem to be any
systematic bias within the sample as a whole, a selective
bias towards a sample with a higher cognitive ability has
apparently a€ected the pure CP-group.
29
The four behavioural groups that participated in the
follow up were compared on initial measures of IQ and
social adversity. A one-way ANOVA was signi®cant for
IQ (F ˆ 3.01, df ˆ 97, p < 0.05). Post-hoc Sche€e-
comparisons showed a signi®cantly higher IQ for the
pure CP-group than for the mixed HACP-group (post-
hoc Sche€e comparison signi®cant at p < 0.05). No
di€erences between the groups were found on the social
adversity index.
Conduct problems
Groups were compared on the CAFE-interview conduct
problem scale. Two-way analysis of variance was carried
out in which the independent predictor variables were
the presence or absence of hyperactivity and that of
conduct problems according to the parent and teacher
questionnaires at the initial screening. The total number
of self-reported conduct problems at follow-up was
weakly, although non-signi®cantly, predicted by the
presence of conduct problems according to the ques-
tionnaires previously (F ˆ 2.86, df ˆ 1.97; p < 0.09);
hyperactivity was not predictive (F ˆ 1.56) and the
interaction between hyperactivity and conduct problems
was not signi®cant (F ˆ 0.12).
Loeber and Schmaling (53) have proposed a di€er-
entiation of conduct problems into overt and covert
types. Overt conduct problems are those acts of
aggression and violence performed in the open; covert
conduct problems are those behaviours which young-
sters themselves try to conceal. Following these con-
cepts, a separate scale for overt aggressive behaviour
was constructed by adding de®nite problems in the
following domains: verbal aggression to peers, aggres-
sion to teachers, ®ghting, cruelty to animals, assaulting
people and use of a weapon. A similar scale of more
covert antisocial behaviours was also constructed in-
cluding the following: vandalism, theft, breaking and
entering into someone else's property, ®resetting and
truancy.
The scale of self-reported openly aggressive behav-
iour was signi®cantly predicted by the previous presence
of hyperactivity (F ˆ 4.06, df ˆ 1.97; p < 0.05), but
not by conduct disorder (F ˆ 2.02) and the interaction
between hyperactivity and conduct disorder was not
signi®cant (F ˆ 0.35). The scale of self-reported more
covert antisocial behaviour was weakly predicted by the
early presence of conduct disorder (F ˆ 3.53, df ˆ 1.97;
p < 0.06), but not by hyperactivity (F ˆ 1.53) and there
was no interaction e€ect (F ˆ 0.09).
To explore whether di€erences between the diagnos-
tic groups would be more explicit applying a categorical
diagnosis of conduct disorder, DSM-III-R criteria were
applied to the self-report data. A diagnosis of Conduct
Disorder applied to 13.3% of the total sample. In those
30 European Child & Adolescent Psychiatry, Vol. 9, No. 1 (2000)
Ó Steinkop€ Verlag 2000
Fig. 1 DSM-III-R conduct disorders at 16±18 years of age
children who had conduct problems when 6±7 year old,
the prevalence ®gure in adolescence was 21%. The
diagnosis was most prevalent in the mixed HACD-group
(25%) and the pure CD-group (16.7%), somewhat less
frequent in the pure HA-group (12.9%) and least
prevalent in the group of normal controls (3.4%)
(Fig. 1). Logistic regression with the presence/absence
of self-reported DSM-III-R conduct disorder diagnosis
as the dependent variable and presence/absence of
questionnaire de®ned hyperactivity and conduct prob-
lems as the predictive variables showed a trend for
conduct problems at 6±7 years to be predictive of a
DSM-III-R diagnosis of conduct disorder based on self
report at 16±18 years (Wald ˆ 3.08, df ˆ 1, p < 0.08).
Initial hyperactivity, however, was not predictive
(Wald ˆ 1.72).
Early conduct problems were predictive of contacts
with the police in adolescence. A two-way ANOVA
showed a main predictive e€ect for the presence of early
CP (F ˆ 5.47, df ˆ 1.80; p < 0.02)1. Hyperactivity was
not predictive (F ˆ 0.03) and the interaction was not
signi®cant (F ˆ 0.49). Of the pure CP-group 21.4% had
several serious contacts with the police, in contrast to
12.5% of the mixed HACD-group and 7.4% of the pure
HA-group. None of the controls obtained a score of ``3''
on this measure.
Emotional problems
Two-way analysis of variance was performed with
presence or absence of CP and that of HA as the
independent variables and with the three emotional scale
scores as dependent measures. Neither CP (F ˆ 0.53)
1
Due to missing data, the number of cases in this analysis was
smaller than that in the full sample.
nor HA (F ˆ 0.32) were predictive of the scale score for
worrying and the interaction was non-signi®cant
(F ˆ 0.02). Moodiness was also not associated with
previous CP (F ˆ 0.33) or HA (F ˆ 0.12) and there was
no interactive e€ect (F ˆ 0.05). The scale for total fear
was also not predicted by the former presence of CP
(F ˆ 1.92) nor the former presence of HA (F ˆ 0.23),
but the interaction between both types of behaviour
problems was signi®cant (F ˆ 4.53, df ˆ 1.94;
p < 0.04). Inspection of the data suggested that it was
the absence of both types of behavioural problems in
early childhood, which put children at a greater risk for
fears in adolescence.
Substance use
Adolescents were interviewed about their level of
alcohol consumption2, cigarette smoking and involve-
ment with drugs. Two-way ANOVA testing for main
e€ects of CP and HA did not show any predictive e€ect
for the presence of CP at 6±7 years (F ˆ 0.00), nor for
HA (F ˆ 0.11), for the level of alcohol use at 16±18
years. The interaction also was non-signi®cant
(F ˆ 0.25). The age at which the youngsters reported
to have started to consume alcohol outside the family
was predicted by early CP (F ˆ 3.88, df ˆ 1.81;
p < 0.05)3 and not by HA (F ˆ 2.33), but in contrast
with our expectations, boys with early conduct problems
started drinking at an older age than pure hyperactives
and controls. The mean ages and standard deviations for
the groups are shown in Table 1.
Early CP were positively associated with the number
of cigarettes the youngsters were smoking per day at
16±18 years (F ˆ 4.95, df ˆ 1.94; p < 0.03). HA was
not predictive (F ˆ 0.01) and the interaction was non-
signi®cant (F ˆ 1.69). There were no di€erences be-
tween the groups in the mean age at which they started
smoking regularly as shown in Table 1.
Fifty-four percent of the total sample reported they
had never taken any drugs, whereas 23.5% of the
sample were regular users at the time of the interview.
2
Scale for the assessment of the level of alcohol consumption from
the CAFE-schedule:
Never uses 0
Less than three beeers or equivalent at a time 1
Moderate drinking, no evidence of abuse 2
Occasssional drunkenness; no or minor adverse consequences 3
Occasssional drunkenness; moderate or serious consequences 4
Frequent drunkenness; no minor adverse consequences 5
Frequent drunkenness; moderate or serious consequences 6
Serious drinking problem; evidence of dependence 7
3
Due to missing data, the number of cases in this and some of the
following analyses was somewhat smaller than that in the total
sample.
 M. Danckaerts et al. 31
A natural history of hyperactivity and conduct problems: self-reported outcome

Table 1 Self-reported sub-

stance abuse at follow-up CD HACD HA NL ANOVA
N = 18 N = 20 N = 31 N = 29
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Level of alcohol use 1.89 (1.08) 1.65 (1.35) 1.77 (1.28) 1.76 (1.12)
Age started drinking 14.88 (1.09) 15.00 (0.93) 13.88 (2.07) 14.72 (0.84) *
Number of cigarettes 4.61 (6.07) 6.60 (8.28) 2.06 (4.01) 3.48 (6.88) *
per day
Age started smoking 13.00 (2.11) 12.78 (2.99) 12.76 (2.05) 12.80 (3.16)
Level of drug use 1.17 (1.50) 1.20 (1.61) 1.13 (1.41) 1.00 (1.41)
Age started drugs 14.63 (0.52) 13.63 (2.20) 14.50 (1.70) 14.77 (1.54)
SD = Standard deviation
* Two-way ANOVA: main e€ect for presence of CP: signi®cance level p < 0.05

Some of these boys started using drugs as early as nine
years old, but the mean age of introduction to drugs
was 14.4 years. Early CP were not predictive of the
level4 of involvement with drugs at 16±18 years old
(F ˆ 0.15) or the age at which children tried drugs for
the ®rst time (F ˆ 1.02). HA at 6±7 years was also not
predictive for the level of drug use in adolescence
(F ˆ 0.10) nor the age of introduction to drugs
(F ˆ 1.21). The interaction between HA and CP was
also non-signi®cant for these outcome measures
(F ˆ 0.03 and F ˆ 0.52 respectively).
Social adjustment
Means and standard deviations for the questionnaire-
de®ned groups on four outcome scales of global
adjustment are shown in Table 2. Two-way analysis
of variance with presence/absence of HA and CP as
independent variables and the social adjustment scales
as dependent measures showed a signi®cant predictive
e€ect for HA for the GAF rating5 (F ˆ 4.98, df ˆ 1.97;
p < 0.03). CP were not predictive (F ˆ 0.49) and there
was no interactive e€ect between both types of behav-
iour problems (F ˆ 0.02). According to the de®nition,
subjects scoring below 61 show moderate to severe
diculties in their social functioning. Only 1 subject in
the normal control group (3.4%) was moderately to
severely maladjusted, whereas 11.1% of the early CP-
group, 12.2% of the HA-group and 25% of the mixed
4
Scale for the assessment of level of drug use from the CAFE-
schedule:
Never used
Tried once or twice; didn't like
Occasssional use; intends to use again
Regular use; no evidence of consequences/impairment
Regular use; resulted in minor consequences/impairment
Regular use; impairment; important alterations in life
Regular use; incapacitation; major alterations in life
5
The GAF rating was purely based on social dysfunction, not
severity of symptomatology.
HACP-group had GAF-scores of 60 or less. A logistic
regression analysis with presence/absence of HA and CP
as independent variables was non-signi®cant for both
hyperactivity (Wald ˆ 2.69) and conduct disorder
(Wald ˆ 2.12).
The self-reported global SAICA scales6 all showed
higher (i.e. worse) scores for the behaviourally disor-
dered groups as compared to the normal control group,
but the two-way ANOVAs were all non-signi®cant.
Whereas the GAF-score takes account of malfunc-
tioning in any social role which adolescents are supposed
to take up, the overall SAICA scales are composed of
diverse subscales, each representing functioning in a
di€erent domain and therefore it is possible that normal
functioning in several domains compensates for severe
dysfunction in others. Thus, it is necessary to explore the
SAICA subscales separately.
Neither HA nor CP in childhood were associated
with later diculties in SAICA subscales of home,
school, spare-time or job functioning.
Early HA, however, was a strong predictor of rela-
tionship problems, both problems with boys (F ˆ 0.14,
df ˆ 1.97; p < 0.002) and girls (F ˆ 8.56, df ˆ 1.97;
p < 0.004).
Self esteem
The means and standard deviations on all subscales
and on the total self-perception scale are presented in
Table 37. A two-way ANOVA showed a signi®cant main
e€ect for the presence/absence of early HA for the scale
of ``close friendships'' (F ˆ 5.87, df ˆ 1.95; p < 0.02).
There was no signi®cant predictive e€ect for conduct
0 disorder (F ˆ 0.18) nor was the interaction signi®cant
1 (F ˆ 2.41). None of the other two-way ANOVAs
2
3
4 6
Overall scores on the SAICA were computed as the number of
5 de®nite problems (value `4' on the 4-point ratings).
6
7
Adolescents rarely rated themselves at the worst extreme and thus
items were recorded giving a weight of `1' to all `3-values' and a
weight of `2' to all `4-values'.
32 European Child & Adolescent Psychiatry, Vol. 9, No. 1 (2000)
Ó Steinkop€ Verlag 2000

Table 2 Self-reported social

adjustment CD HACD HA NL ANOVA
N = 18 N = 20 N = 31 N = 29
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

GAF-score 79.50 (9.52) 74.55 (13.96) 75.97 (13.71) 81.52 (8.82) *

SAICA problems 5.78 (4.54) 5.60 (5.24) 5.03 (4.29) 3.38 (2.38)
SAICA competence 6.78 (3.14) 7.25 (2.51) 6.74 (3.61) 6.00 (3.24)
SAICA total score 13.22 (7.35) 13.55 (6.88) 12.48 (7.50) 9.83 (5.25)
SAICA school functioning 4.17 (3.50) 3.85 (3.92) 3.35 (3.32) 3.00 (2.46)
SAICA spare-time functioning 4.44 (2.38) 4.50 (1.91) 4.06 (1.73) 3.66 (1.59)
SAICA peer functioning 1.22 (1.17) 2.05 (2.14) 1.90 (2.21) 0.62 (0.86) **
SAICA heterosexual functioning 0.83 (1.04) 1.65 (1.31) 1.58 (1.78) 0.79 (0.94) **
SAICA home functioning 2.39 (2.33) 1.10 (1.07) 1.32 (1.49) 1.62 (1.95)
SAICA job functioning 0.33 (0.84) 0.40 (0.99) 0.26 (0.86) 0.28 (0.75)
SD = Standard deviation
* Two-way ANOVA: main e€ect for presence of hyperactivity: signi®cance level p < 0.05
** Two-way ANOVA: main e€ect for presence of hyperactivity: signi®cance level p < 0.005

Table 3 Adolescent self-per-

ception pro®le at follow-up CD HACD HA NL ANOVA
N = 18 N = 20 N = 31 N = 29
Mean (SD) Mean (SD) Mean (SD) Mean (SD)

School performance 1.89 (2.14) 2.70 (2.23) 2.37 (1.83) 2.14 (1.96)
Social competence 0.78 (1.48) 1.05 (0.91) 1.87 (2.73) 0.97 (1.50)
Athletic competence 1.72 (1.78) 2.25 (1.83) 2.37 (2.70) 2.07 (3.07)
Physical appearance 1.59 (2.79) 2.15 (2.30) 2.46 (1.99) 2.48 (1.86)
Job competence 1.78 (1.06) 2.11 (1.59) 2.07 (1.62) 2.33 (1.96)
Romantic appeal 2.65 (2.78) 3.29 (2.23) 3.00 (2.14) 3.59 (2.57)
Conduct and morality 2.89 (2.03) 2.47 (1.65) 2.30 (1.97) 2.10 (1.82)
Close friendships 0.61 (1.20) 2.15 (1.76) 1.76 (2.17) 1.34 (1.49) *
General self-worth 1.00 (1.19) 0.85 (0.81) 1.53 (1.96) 1.38 (1.29)
Depressive symptoms 2.24 (1.82) 1.35 (1.60) 2.07 (1.80) 2.52 (1.81)
Total scale 14.19 (8.79) 17.71 (5.57) 19.56 (11.79) 18.12 (9.93)
SD = Standard deviation
* Two-way ANOVA: main e€ect for presence of hyperactivity: signi®cance level p < 0.02

showed signi®cant e€ects for the presence/absence of
either type of problem behaviour or their interaction on
the other self-esteem scales.
Discussion
Strengths and weaknesses of the study
The methodology of the present study combined several
strengths, which allowed for a clear examination of the
issue whether hyperactivity is a true risk factor to
adverse outcome. The study consisted of a real-time
prospective follow-up over ten years, of children from a
total-population sample in a geographically de®ned area.
Cases were selected on the basis of predetermined cut-
o€s on standardised rating scales and classi®ed accord-
ing to presence or absence of pervasive hyperactivity and/
or conduct problems in childhood. Construct validity had
been demonstrated for the de®nition of pervasive
hyperactivity in the original survey, in that a strong
relationship was found with objective measures of
inattention and overactivity (84), while the scale of
conduct problems showed di€erential associations.
Thus, scienti®cally valid criteria were applied and the
classi®cation into four behavioural groups according to
presence/absence of both hyperactivity and conduct
problems made it possible to disentangle the develop-
mental risk for both types of disruptive behaviour
disorders. At follow-up, the attrition rate was low (17%),
considering the length of the interval between assess-
ments, and no systematic bias was apparent in the
dropout analysis of the total sample. Several possible
confounding factors were controlled for: age-e€ects were
minimized by restricting the sample to a narrow age-
band; children with severe learning disabilities, with
evidence of a neurological or psychotic disorder, were
excluded, as well as children attending special schools at
the time of recruitment, children from Asian immigrant
families and children with high levels of emotional
problems. The investigator was blind to the original
group membership of cases.
 M. Danckaerts et al.
A natural history of hyperactivity and conduct problems: self-reported outcome
Even though the study was carefully designed, several
¯aws could not be avoided. First, representativeness for
the general population was a€ected to some degree by
the initial non-compliance of 22.5% of parents, whose
children had been rated by teachers as slightly more
deviant. The expected bias, in this case, would be one
towards normality. This implies that the deviance in
outcome demonstrated within the present sample is
likely to be a rather conservative estimate of the full risk
at outcome, since the most disturbed cases at outset did
not comply. Second, the study was limited by the
relatively small numbers of cases in the respective
diagnostic groups, especially in the groups with conduct
problems. Because of this, trends as well as signi®cant
®ndings were reported. Third, the loss of cases in the
pure conduct disorder group resulted in a selective bias
towards a higher cognitive ability in this group in
comparison with the hyperactive and normal cases.
Such a cognitive di€erence might, in theory, confound
the observed di€erences between groups. Fourth, for
clinicians working with DSM diagnostic schemes, the
type of measures used to de®ne the groups initially may
seem like a weakness. They were chosen because they
were valid measures, taking account of developmentally
appropriate behaviours for 6±7 year olds. For hyperac-
tivity, the inclusion criteria required pervasiveness of
severe levels of both inattentive and overactive behav-
iours, making them more stringent than DSM-III-R
criteria (84). Nevertheless, one must note that ®ndings
on these cases do not automatically generalise to
children diagnosed with disruptive behaviour disorders
according to DSM-III-R (2) or DSM-IV (3). The
criteria for conduct problems probably led to a selection
of less severe cases than the ones that would be selected
on the basis of DSM conduct disorder criteria. The low
cut-o€ for conduct problems was deliberately chosen so
that the purely hyperactive cases would not include
children showing a substantial level of aggression in
childhood. It may of course have led to an underesti-
mation of the degree of risk from clinical levels of
conduct disorder. All these limitations need to be taken
into account, when interpreting the results from the
study and when comparisons with similar research
®ndings are made.
Conduct problems at follow-up
The continuity of antisocial problems within the conduct
problem groups is certainly consistent with ®ndings in
follow-up studies of behaviourally disordered children
(13, 38, 49, 51, 75). The extent of continuity within the
conduct problem groups (one in ®ve children obtained a
DSM-III-R conduct disorder diagnosis in adolescence)
is comparable to that in samples of children with an
oppositional de®ant disorder in childhood (45). Few
33
additional cases were identi®ed by including information
from the parents (85), increasing the prevalence rate to
23%.
With regard to one of the main questions of the
study, whether hyperactivity in childhood constitutes
a risk for antisocial behaviour in adolescence, when
comorbid conduct problems are controlled for, a more
complex picture has arisen. Most of the risk was due to
the association with early conduct problems. However,
hyperactivity per se was predictive of a subset of conduct
problems, namely those acts that are usually confron-
tational, rather than concealed. With hindsight, it would
have been desirable to include a diagnosis of opposi-
tional de®ant disorder at follow up to catch the full
range of risk for children with behaviour problems. It is
interesting to note that in the meta-analysis of 22 factor
analytic studies performed by Loeber and Schmaling
(53) to assess the likelihood that a given antisocial
behaviour would load on the same factor as each
remaining antisocial behaviour, it was ascertained that
hyperactivity and impulsiveness appeared at one end of
the bipolar single dimension which resulted from
multidimensional scaling, where the behaviours were
anchored together with confrontational antisocial be-
haviour such as ®ghting, temper tantrums, assault,
irritability, etc. Another relevant ®nding in the literature
that links hyperactivity to overt aggression was reported
by Mot (68), who compared 13-year old ADD- and
non-ADD delinquents in a two year follow-up and
found that the groups di€ered in that the ADD-
delinquents showed a higher rate of aggressive behav-
iour, whereas no di€erence in the rate of covert
antisocial behaviour was found.
The ®nding of di€erential predictive e€ects for
hyperactivity and conduct disorder in childhood, may
well be important for adolescents' further development.
It is hypothesised that overt antisocial behaviours tend
to decline in adolescence while more covert antisocial
behaviours may be a far more stable route into
delinquency (49). Both types of antisocial behaviour
may warrant di€erent therapeutic programs, both for
prevention and treatment.
Emotional problems at follow-up
In the literature, the developmental relationship be-
tween hyperactivity and emotional disorders is still a
speculative one and longitudinal data are scarce. Weiss
et al. (95) reported that signi®cantly more formerly
hyperactive young adults reported neurotic symptoms
and there were signi®cantly more suicide attempts in
the hyperactive group. Within that sample, the
presence of emotional symptoms was linked with the
continuation of hyperactivity (29). In a retrospective
study, Brent et al. (11) compared the psychiatric
34 European Child & Adolescent Psychiatry, Vol. 9, No. 1 (2000)
Ó Steinkop€ Verlag 2000
histories of youngsters who committed suicide to those
who attempted suicide and found a six-fold increase of
ADD in those who succeeded in their attempts.
Gittelman et al. (28), to the contrary, found no
di€erences at the diagnostic level for a€ective and
anxiety disorders at the time of follow-up and more
lifetime diagnoses of major a€ective disorder in the
control group and replicated their results in an
independent sample (60). Similar ®ndings were report-
ed by Morrison (70). Unfortunately, none of these
follow-up studies compared their samples on initial
measures of emotional disturbance. In the screening
stage of the current epidemiological survey, hyperac-
tivity carried a relative risk of 1.3 for a high score of
emotional symptoms (84). Cases with high levels of
emotional disturbance in childhood were excluded
from the follow-up to separate out the e€ects of
behaviour problems. No continuity was found between
problems of hyperactivity (or conduct problems) in
childhood and higher rates of self-reported emotional
problems in adolescence. Early behaviour problems
rather may be protective against emotional distur-
bance in adolescence. These ®ndings, again were
endorsed in the parental questionnaire and interview
ratings (85). The latter ®nding also parallels outcome
studies of depressed children with and without con-
duct disorder, where a strong trend is found for those
children with depression and conduct disorder to have
lower rates of depression in adulthood than depressed
children without conduct disorder (31).
Substance use at outcome
Hyperactivity in childhood is thought to be a risk factor
for later substance abuse for several reasons. First,
familial associations of hyperactivity and alcoholism or
drug use have been demonstrated (12, 71). However,
later research pointed out that hyperactive children
with comorbid conduct disorder were the ones most
likely to have a father with substance abuse (5, 44, 81).
Second, the prescription of stimulants, often over
several years of treatment, has been considered as a
possible stepping-stone into substance use, not least in
the lay-press. However, there are no indications from
cross-sectional studies of abuse of stimulant medication
speci®cally, nor of an excess of alcohol use or use of
illegal substances by ADD-adolescents (86). Third, data
from longitudinal studies are quite inconclusive. In
retrospective studies of alcoholics, childhood symptoms
of hyperactivity and attention de®cits are more fre-
quently present than in controls (43). In prospective
studies, most authors reported no relationship between
childhood hyperactivity and later alcohol abuse, where-
as a few found an association with cigarette use (7, 10).
Findings for drug abuse are most contradictory:
whereas the majority of follow-up studies did not ®nd
any relationship with later drug use, the New York
research group repeatedly found a signi®cantly higher
prevalence of drug abuse in formerly hyperactive young
adults (28, 60). However, in one of their studies, they
controlled for the di€erence in socio-economic status
between the hyperactive and the control group and
found that the outcome di€erence in drug abuse was no
longer present (60).
The present data also did not support the idea of a
link between hyperactivity in childhood and later
alcohol or drug abuse. Moreover, the ®ndings suggested
that the risk for cigarette-use found in other studies may
have been due to the presence of comorbid conduct
disorder within those samples, rather than to hyperac-
tivity per se. It should be recognized, however, that the
adolescents within the present study were still rather
young and thus, the full risk for substance use and abuse
had certainly not subsided yet.
Peer relationship problems at follow up
In cross-sectional studies, a clear association between
hyperactivity and social relationship problems with
peers has been found, with some 50% of hyperactive
children having signi®cant problems (76). Observations
of peer-interactions in hyperactive children have re-
vealed that their core-symptomatology of inattentive,
disruptive, o€-task and impulsive behaviour elicits
controlling and directive behaviour from their peers
and that there is less reciprocity in their social exchanges
with peers (14, 16, 46, 97±99). Grenell et al. (30) have
reported that hyperactive boys have less knowledge
about social skills. Relationship problems with peers
have also been reported in several long-term follow-up
studies of hyperactive youngsters (10, 63, 94), together
with persisting social skills de®cits (34).
Again, however, the problem of comorbidity between
hyperactivity and conduct disorder raises questions
about the true risk factor for peer relationship problems.
There are ®rm reports of aggression being a clear elicitor
of peer rejection (15, 18) and of social cognitive biases
and de®cits in aggressive boys leading to inappropriate
aggressive responses (19, 20). The aggressive samples
investigated by Dodge, however, also were probably a
mixed hyperactive-aggressive group, as argued by Milich
and Dodge (65).
There is some evidence that non-aggressive ADHD
youngsters also have peer-relationship diculties (76).
Milich and Landau (66) have reported that both
ADHD-youngsters and mixed ADHD-aggressive chil-
dren were highly likely to be rejected by peers, whereas
purely conduct disordered children obtained high rates
of both negative and positive nominations from their
peers.
 M. Danckaerts et al.
A natural history of hyperactivity and conduct problems: self-reported outcome
The present longitudinal data based on adolescent
self-report about their peer-contacts and meaningful
relationships were consistent with these cross-sectional
results. Moreover, they demonstrated that the main risk
factor for poor peer-relationships was hyperactivity per
se rather than associated conduct problems. On the basis
of the parental interview, the same risk was shown (85).
Peer rejection itself is known to be a strong predictor of
later personal adjustment in relevant domains such as
school achievement, delinquency and psychopathology
(73). As such, it should be a focus for treatment in
hyperactive children.
Self-esteem at follow-up
Self-esteem is regarded as an important outcome mea-
sure in its own right, re¯ecting feelings of general well
being and happiness within the individual. It is also
deemed to be a risk factor for further development of
mental illness, in interaction with other factors (67). In
cross-sectional studies of hyperactive samples, lower self-
esteem has been found in clinical cases as compared to
normal controls (90) and in a community sample,
Anderson et al. (4) found 11-year old children with
ADD to have lower self-esteem than those with conduct
disorder and normal controls. Longitudinal studies,
however, have shown a less straightforward picture.
Stewart et al. (80) reported that 40% of formerly
hyperactive adolescents had low self-esteem; a control
group, however, was lacking. In two subsamples of
adolescents from the Montreal follow-up (37, 93)
formerly hyperactive subjects scored signi®cantly worse
on a self-esteem scale compared to normal controls.
Another follow-up study, however, taking account of the
overlap between hyperactivity and conduct disorder,
found that childhood aggression and not hyperactivity
gave rise to self-esteem de®cits in adolescence (47). As
such, there still is controversy over the true risk factor for
low self-esteem in behaviourally disordered youngsters.
With the exception of a perceived lower social
competence in hyperactive youngsters, the present study
failed to ®nd any di€erences on a well-established
measure of self-esteem between di€erent types of
behaviourally disturbed groups and controls. It may
35
therefore be hypothesized that other factors, associated
with the de®ned problem behaviour in other studies may
have accounted for the di€erences in self-esteem, rather
than the behavioural problems per se. Socio-economic
di€erences, emotional problems or parenting styles may
be valid candidates for such an association, since these
were factors identi®ed in a study by Paternite et al. (74)
to be predictive of both self-esteem and aggressive
behaviour.
General conclusions
The present study clearly demonstrated that a substan-
tial part of the risk in behaviourally disturbed children
was attributable to hyperactivity per se, rather than to
associated conduct problems. The di€erential risk pat-
tern for outcome associated with hyperactivity and
conduct disorder in childhood serves as discriminatory
validating evidence for the separate recognition of both
types of problems. On the one hand, it was clear that
hyperactivity, independently from conduct disorder, was
a major risk factor for adverse outcome in adolescence.
This conclusion should alert U.K.-diagnosticians specif-
ically, since it has been demonstrated that, when they are
confronted with comorbid cases, they are more likely to
classify them as conduct disorder (82). On the other
hand, it was also clearly demonstrated that early
conduct problems had their own detrimental e€ects on
outcome and likewise warrant separate recognition and
therapeutic interventions. This is more of a hint (or
reprimand) to clinicians who restrict their therapeutic
e€orts for hyperactive cases (who often have associated
conduct problems) to the administration of stimulant
medication. Medication does not necessarily alter the
negative prospects for hyperactive cases in clinical
follow-up studies (33). One reason may be that comor-
bid problems, which are in part responsible for later
maladjustment, are not the targets for intervention.
Acknowledgements Dr. Danckaerts was supported by the Belgian
F.W.O. (Foundation for Scienti®c Research) and by the U.K.
Royal Society. This research was supported by the Medical
Research Council, initially as a project grant and later as part of
the work of its Child Psychiatry Unit and the Centre for Genetic,
Social and Developmental Psychiatry.
36
Ó Steinkop€ Verlag 2000
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