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i

Attention Deficit Hyperactivity Disorder

ii
iii

Attention Deficit
Hyperactivity Disorder

Adult Outcome and Its Predictors

E D I T E D B Y L I LY H E C H T M A N , M D , F R C P,
ABPN
PR OFE SSOR OF PSYC H IAT RY AN D PEDIAT RIC S
DIREC T OR OF RESEARC H
D I V I SI ON OF C H IL D PSYC H IAT RY
M CGI LL UNI VERSIT Y H EALT H C EN T RE
M ONTR E A L C H IL DREN ’S H OSPITAL

1
iv

1
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You must not circulate this work in any other form

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Library of Congress Cataloging-in-Publication Data

Names: Hechtman, Lily Trokenberg, editor.
Title: Attention deficit hyperactivity disorder : adult outcome and its predictors /
edited by Lily Hechtman.
Other titles: Attention deficit hyperactivity disorder (Hechtman)
Description: Oxford ; New York : Oxford University Press, [2017] |
Includes bibliographical references.
Identifiers: LCCN 2016014436 | ISBN 9780190213589 (pbk. : alk. paper)
Subjects: | MESH: Attention Deficit Disorder with Hyperactivity | Adult |
Treatment Outcome | Longitudinal Studies | Case Reports
Classification: LCC RC394.A85 | NLM WM 165 | DDC 616.85/89—dc23
LC record available at http://lccn.loc.gov/2016014436

This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
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9 8 7 6 5 4 3 2 1
Printed by WebCom, Inc., Canada
v

I would like to dedicate this book to my inspiring mentor Dr. Gabrielle Weiss
who started me on this exciting journey, my wonderful supportive colleagues
who contributed chapters and with whom it is a pleasure to work, and our
patients who share their courageous struggles and teach us so much.

Finally, this book and much of my career would not be possible without the
encouragement, humour, and support of my husband Peter, who usually
sees the glass as half-full.
vi
vii

CONTENTS

CONTRIBUTORS ix

1. Introduction 1
Lily Hechtman

2. Adolescent and Adult Outcomes of Childhood Attention Deficit

Hyperactivity Disorder: The Montreal Study 5
Mariya V. Cherkasova, Gabrielle Weiss, and Lily Hechtman

3. Long-​term Outcomes of Childhood Attention Deficit Hyperactivity

Disorder: The New York Study 31
Sylviane Houssais, Lily Hechtman, and Rachel G. Klein

4. The Milwaukee Longitudinal Study of Hyperactive

(ADHD) Children 63
Russell A. Barkley and Mariellen Fischer

5. The Pittsburgh ADHD Longitudinal Study (PALS) 105

Brooke S. G. Molina, Margaret H. Sibley, Sarah L. Pedersen,
and William E. Pelham, Jr.

6. Young Adult Outcome of Attention Deficit Hyperactivity

Disorder: Results from the Longitudinal Massachusetts General
Hospital Sample of Pediatrically and Psychiatrically Referred Youth
with and without ADHD of Both Sexes 157
Mai Uchida and Joseph Biederman

7. The Berkeley Girls with ADHD Longitudinal Study 179

Elizabeth B. Owens, Christine A. Zalecki, and Stephen P. Hinshaw
viii

viii Contents

8. The Multimodal Treatment of Children with ADHD (MTA)

Follow-​up Study: Outcomes and Their Predictors 231
Arunima Roy and Lily Hechtman

9. Influences of Treatment on Long-​term Outcome 261

Lily Hechtman

10. Summary 271

Lily Hechtman

INDEX 291
ix
Russell A. Barkley, PhD
Clinical Professor of Psychiatry
Medical University
of South Carolina
Charleston, South Carolina
Joseph Biederman, MD
Chief, Clinical and Research
Programs in Pediatric
Psychopharmacology and
Adult ADHD
Director, Bressler Program for
Autism Spectrum Disorders
Massachusetts General Hospital
Professor of Psychiatry
Harvard Medical School
Boston, Massachusetts
Mariya V. Cherkasova, PhD
University of British Columbia
Vancouver, British
Columbia, Canada
CONTRIBUTORS
Mariellen Fischer, PhD
Associated Mental Health
Consultants
Milwaukee, Wisconsin
Lily Hechtman, MD, FRCP, ABPN
Professor of Psychiatry and
Pediatrics
Director of Research
Division of Child Psychiatry
Montreal Children’s Hospital
McGill University Health Centre
Montréal, Québec, Canada
Stephen P. Hinshaw, PhD
Professor of Psychology, University
of California, Berkeley
Berkeley, California
Professor of Psychiatry, University
of California, San Francisco
San Francisco, California
x
x
Sylviane Houssais, MA
McGill University Health Centre
Montréal, Québec, Canada
Rachel G. Klein, PhD
New York University School
of Medicine
New York, New York
Brooke S. G. Molina, PhD
Professor of Psychiatry and
Psychology
University of Pittsburgh
Pittsburgh, Pennsylvania
Elizabeth B. Owens, PhD
Institute of Human Development
University of California, Berkeley
Berkeley, California
Sarah L. Pedersen, PhD
Department of Psychiatry
University of Pittsburgh
Pittsburgh, Pennsylvania
William E. Pelham, Jr., PhD
Department of Psychology
Center for Children and Families
Florida International University
Miami, Florida
Arunima Roy, MBBS
McGill University Health Centre
Montréal, Québec, Canada
Contributors
Margaret H. Sibley, PhD
Florida International University
Department of Psychiatry and
Behavioral Health
Center for Children and Families
Miami, Florida
Mai Uchida, MD
Psychiatry Department
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
Gabrielle Weiss, MD
Former Professor of Psychiatry
(Retired)
McGill University
Montréal, Québec, Canada
University of British Columbia
Vancouver, British
Columbia, Canada
Christine A. Zalecki, PhD
University of California,
San Francisco
Children’s Center at
Langley Porter
San Francisco, California
University of California, Berkeley
Institute of Human Development
Berkeley, California
1

18
16.9
16
14.8
14

12

10 nonADHD

8 ADHD

4
2.1 1.8
2 1.6
0.3
0
Times drank 5+ drinks Times drunk AUD symptom score
Figure 5.1

26
From Molina and Pelham From Rhodes et al. (in press);
(2003); M age 15 M age 18
24

22 21.58
non-ADHD
20 ADHD 19.55

18 17.39
16.99
16.32
15.91
16 15.33

13.9
14

12
M age first tried a M age first daily M age first tried a M age first daily
cigarette smoking cigarette smoking
Figure 5.2
2

Figure 5.3
3

Figure 5.4

100
Syndromatic
78% Remission
80
65% 13% Functional
60 8% Persistence
Medicated
%

22%
40 Symptomatic
Persistence
20 35%
Syndromatic
Persistence
0
Syndromatic Persistence
Remission
Figure 6.1
 4
(A) 70

Interval Lifetime
*
60
* p < 0.05 Lifetime
p < 0.05 Interval
50 *

40 *
%

*
30 *
*
20
*
10

0
Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD

MOOD Major Bipolar ANXIETY Agoraphobia Social Obsessive- Specific Panic Generalized
DISORDERS depressive disorder DISORDERS phobia compulsive phobia disorder anxiety
disorder disorder disorder
Figure 6.2a
 5
(B) 90

80 Interval Lifetime

70
p < 0.05 Lifetime
60
* p < 0.05 Interval
50
%

40

30
* *
20 *
10

0
Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD Controls ADHD

ANTISOCIAL Oppositional Antisocial SUBSTANCE Alcohol Drug Smoking

DISORDERS defiant personality DEPENDENCE dependence dependence dependence
disorder disorder DISORDERS
Figure 6.2b
6

40
ADHD Baseline
ADHD Follow-up
30
Control Follow-up

20
%

10
p < 0.05 vs. p < 0.05 vs.
ADHD females ADHD males

0
Control Females Control Males ADHD Females ADHD Males
Figure 6.3

Age by Sex Interaction: NS

Standardized ADHD symptom count

–1

–2
7.5 11 14 17.5 21
Age in years

Male sample (n = 260) Female sample (n = 199)

Figure 6.4
7

(A) Percentage of Those Who Attended High School

52%
“C” average or lower*
27%

37%
Had a tutor*
13%

37%
Had special classes*
10%
ADHD (N = 464)

30% Non-ADHD (N = 487)

Had to repeat a grade*
8%

*p ≤ .001

(B) Percentage of Each Group

52%
Currently employed*
72%

34%
Employed full-time*
57%

48%
Not currently employed*
27%

ADHD (N = 500)
14%
Looking for work*
5% Non-ADHD (N = 501)

*p ≤ .001
Figure 6.5ab
8

(C) A. Parental support

40
35 38
z = 2.13 z = 2.45
30
p = 0.03 p = 0.01
Percent 25 26.6
20
15
15.9
10 13.3
5
0
Financially dependent on parents Lives with parents

C. Overall SES
3
z = 3.47
(higher score = lower SES)
Hollingshead mean score

p = 0.001
2.5
2.5

2
1.9
1.5

B. College graduate
100

80 84.6 z = –4.78
p < 0.001
60
Percent

40
37.9
20

D. Educational and occupational level

7
(higher score = higher SES)
Hollingshead mean score

z = –3.12
6.5 6.6 p = 0.002
z = –5.36
6
6.1 p < 0.001
5.5

5 5.2
5.1
4.5

4
Educational level (1 to 7) Occupational level (1 to 9)

Controls ADHD

Figure 6.5c
 9
Figure 6.6
 10
Major Depression Multiple Anxiety
(A) 1.00 1.00
No Stimulant Therapy Lifetime Stimulant Therapy No Stimulant Therapy Lifetime Stimulant Therapy

0.75 0.75
Failure function

Failure function
2 χ2(1) = 17.8, p < 0.001
χ (1) = 19.7, p < 0.001
0.50 0.50

0.25 0.25

0.00 0.00
0 5 10 15 20 25 30 0 5 10 15 20 25 30
Age at Onset Age at Onset

Bipolar Disorder
1.00
No Stimulant Therapy Lifetime Stimulant Therapy

0.75
Failure function

χ2(1) = 3.5, p = 0.063

0.50

0.25

0.00
0 5 10 15 20 25 30
Age at Onset
Figure 6.7a
 11
ASPD Conduct Disorder
(B) 1.00 1.00
No Stimulant Therapy Lifetime Stimulant Therapy No Stimulant Therapy Lifetime Stimulant Therapy

0.75 0.75
Failure function

Failure function
χ2(1) = 1.3, p = 0.258 χ2(1) = 21.4, p < 0.001
0.50 0.50

0.25 0.25

0.00 0.00
0 5 10 15 20 25 30 0 5 10 15 20 25 30
Age at Onset Age at Onset
Oppositional Defiant Disorder
1.00
No Stimulant Therapy Lifetime Stimulant Therapy

0.75
Failure function

0.50 χ2(1) = 19.9, p < 0.001

0.25

0.00
0 5 10 15 20 25 30
Age at Onset
Figure 6.7b
 12
(C) Repeated Grade (D)
1.00 100 Stimulant
*p < 0.05 vs. Controls Therapy* No Stimulant
Therapy*
0.75 75
Failure function

χ2(1) = 18.4, p < 0.001

0.50 50

%
0.25 25 Controls

0.00
0 5 10 15 20 25 30 0 10 20 30
Age at Onset Age
No Stimulant Therapy Lifetime Stimulant Therapy
Figure 6.7cd
13

Rates of Deficient Emotional Self-Regulation (DESR, sum of CBCL Attention,

Aggression, and Anxious/Depressed t-scores ≥ 180 and < 210)
(A) 50
45
40
35
χ2(1) = 108.4, p < 0.001
30
25
%

20
15
10
5
0
Controls ADHD

Percent of subjects with ADHD-associated severe impairment

60

50
z = 2 .49, p = 0.01
40

30
%

20

10

0
ADHD ADHD+DESR
(B) 25%

20%
18.0%

15%
p < 0.001
10%

5%
1.0%
0%
ADHD Probands Control Probands
Figure 6.8
14

Seed Region (A) Control (N = 17) (B) Control > Persistent ADHD

Remitting ADHD (N = 20) MPFC

(C) Remitting ADHD > Persistent ADHD

Persistent ADHD (N = 10)

t=
2.2 5.0 MPFC

Figure 6.9

B(SE) = 1.29 B(SE) = .48 B(SE) = 1.69 B(SE) = .98

(.16) p < .001 (.19) p = .014 (.42) p < .001 (.30) p = .001
30
40
Percentage individuals on

25
with a bachelor’s degree
Percentage individuals

public assistance

30 20

15
20
10
10
5

0 0
LNCG MTA Persistent Remittent LNCG MTA Persistent Remittent
ADHD ADHD ADHD ADHD

B(SE) = 7.96 B(SE) = 4.4 (2.1)

(2.1) p < .001 p = .05
20
Mean number of sexual

15
partners

10

0
LNCG MTA Persistent Remittent
ADHD ADHD

Figure 8.2
15

B(SE) = .44 B(SE) = 1.05

B(SE) = .23 B(SE) = 1.52 (.24) p = .70 (.26) p < .001
(.43) p = .59 (.57) p = .007 18
14
16

reporting marijuana use

Percentage individuals
Percentage individuals

12 14
with depression *

10 12
8 10
8
6
6
4
4
2 2
0 0
LNCG MTA Persistent Remittent LNCG MTA Persistent Remittent
ADHD ADHD ADHD ADHD

Figure 8.3

B(SE) = .58 (.26) B(SE) = .06 B(SE) = .07 B(SE) = .03 (.24)
p = .028** (.29) p = .84 (.21) p = .73 p = .88
18
14
with alcohol use problems
16
reporting any police contact

Percentage individuals
Percentage individuals

12 14
10 12
8 10
8
6
6
4
4
2 2
0 0
LNCG MTA Persistent Remittent LNCG MTA Persistent Remittent
ADHD ADHD ADHD ADHD

Figure 8.4
16
1

Introduction

L I LY H E C H T M A N

A
good deal of interest and controversy currently exist regarding the
high rate of diagnosis of Attention Deficit Hyperactivity Disorder
(ADHD). Some reports by specialists in the field and in the media
have suggested that ADHD is overdiagnosed and thus overtreated. This
sentiment is particularly true for ADHD in adulthood. In fact, there is
some skepticism regarding the existence of ADHD in adults, given that
early on it was believed that children outgrew this condition as the hyper-
activity and impulsivity tended to decrease with age.
However, well-​controlled prospective follow-​up studies (which will be
reviewed in this book) first showed that symptoms of ADHD, particu-
larly symptoms of inattention, continued into adulthood and caused sig-
nificant functional and clinical impairment, thus laying the groundwork
for the diagnosis of ADHD in adulthood. These prospective follow-​up
studies have appeared in the literature intermittently over the last 20 to
30 years and, therefore, did not have the impact they deserved in help-
ing establish the validity of the diagnosis in adulthood. No other publi-
cation to date brings together in one place these various well-​controlled
2

2 Attention D eficit H yperactivity D isorder

prospective follow-​up studies, which show that more than half of the chil-
dren with ADHD continue to have significant symptoms and impairment
in adulthood.
This book thus addresses an important controversy—​namely the
validity of an ADHD diagnosis in adults, which is of great interest
currently. The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-​5) has contributed to the support of this diag-
nosis, not only by providing an Adult ADHD diagnostic category but
also recognizing that the symptom criteria requiring six out of nine
symptoms in either the Inattentive or Hyperactive–​Impulsive symptom
category was not appropriate for adults because it required adults to
score above the 99th percentile whereas most conditions require scores
above the 93rd percentile. DSM-​5 thus lowered the symptom criteria
to five out of nine symptoms for anyone over the age of 17 years. This
modification in symptom criteria for adults clearly recognized the pres-
ence of ADHD in adulthood and does much to validate the diagnosis
in this age group.
These studies also show, however, that not all children with ADHD go
on to have the symptoms and impairment in adulthood. Professionals;
researchers; pediatricians; child, adolescent, and adult psychiatrists; fam-
ily physicians; psychologists; social workers; and teachers frequently are
asked about the prognosis of this condition. Will the child always be
impaired? Will he grow up to be a delinquent or addict? Will he be able
to complete school? Go on to university? These studies provide a compre-
hensive view of the prognosis of this condition—​a view that professionals
cannot obtain elsewhere.
Finally, what factors may influence long-​term outcome and progno-
sis? Identifying such prognostic factors is critical because this has current
treatment implications if more positive outcomes are sought. Again, pro-
fessionals (outlined above) will be able to access these relevant factors in
one place and use them in their treatment planning.
At this point in time no other book brings all these diverse studies
together and provides a sound basis for the diagnosis of ADHD in adult-
hood. These chapters offer a clear view of possible outcomes and progno-
sis, which professionals require to address patient concerns adequately,
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