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Original Investigation |

Evaluation of the Persistence, Remission, and Emergence of Attention-Deficit/Hyperactivity Disorder in Young Adulthood

Jessica C. Agnew-Blais, ScD1; Guilherme V. Polanczyk, MD, PhD2; Andrea Danese, MD, PhD1,3,4; Jasmin Wertz, MSc1; Terrie E. Moffitt, PhD1,5,6; Louise Arseneault, PhD1
[+] Author Affiliations
1Medical Research Council Social, Genetic, and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
2Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
3Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
4National and Specialist Child Traumatic Stress and Anxiety Clinic, South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
5Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
6Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
JAMA Psychiatry. 2016;73(7):713-720. doi:10.1001/jamapsychiatry.2016.0465.
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Importance  Attention-deficit/hyperactivity disorder (ADHD) is now recognized to occur in adulthood and is associated with a range of negative outcomes. However, less is known about the prospective course of ADHD into adulthood, the risk factors for its persistence, and the possibility of its emergence in young adulthood in nonclinical populations.

Objective  To investigate childhood risk factors and young adult functioning of individuals with persistent, remitted, and late-onset young adult ADHD.

Design, Setting, and Participants  The study sample was the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative birth cohort of 2232 twins born in England and Wales from January 1, 1994, to December 4, 1995. Evaluation of childhood ADHD (ages 5, 7, 10, and 12 years) included prenatal and perinatal factors, clinical characteristics, and aspects of the family environment. Among participants aged 18 years, ADHD symptoms and associated impairment, overall functioning, and other mental health disorders were examined. Data analysis was conducted from February 19 to September 10, 2015.

Main Outcomes and Measures  Attention-deficit/hyperactivity disorder according to DSM-IV diagnostic criteria in childhood and DSM-5 diagnostic criteria in young adulthood.

Results  Of 2232 participants in the E-Risk Study, 2040 were included in the present analysis. In total, 247 individuals met diagnostic criteria for childhood ADHD; of these, 54 (21.9%) also met diagnostic criteria for the disorder at age 18 years. Persistence was associated with more symptoms (odds ratio [OR], 1.11 [95% CI, 1.04-1.19]) and lower IQ (OR, 0.98 [95% CI, 0.95-1.00]). At age 18 years, individuals with persistent ADHD had more functional impairment (school/work: OR, 3.30 [95% CI, 2.18-5.00], home/with friends: OR, 6.26 [95% CI, 3.07-12.76]), generalized anxiety disorder (OR, 5.19 [95% CI, 2.01-13.38]), conduct disorder (OR, 2.03 [95% CI, 1.03-3.99]), and marijuana dependence (OR, 2.88 [95% CI, 1.07-7.71]) compared with those whose ADHD remitted. Among 166 individuals with adult ADHD, 112 (67.5%) did not meet criteria for ADHD at any assessment in childhood. Results from logistic regressions indicated that individuals with late-onset ADHD showed fewer externalizing problems (OR, 0.93 [95% CI, 0.91-0.96]) and higher IQ (OR, 1.04 [95% CI, 1.02-1.07]) in childhood compared with the persistent group. However, at age 18 years, those with late-onset ADHD demonstrated comparable ADHD symptoms and impairment as well as similarly elevated rates of mental health disorders.

Conclusions and Relevance  We identified heterogeneity in the DSM-5 young adult ADHD population such that this group consisted of a large, late-onset ADHD group with no childhood diagnosis, and a smaller group with persistent ADHD. The extent to which childhood-onset and late-onset adult ADHD may reflect different causes has implications for genetic studies and treatment of ADHD.

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Groups of Individuals With Childhood, Adult, and Subgroups of Attention-Deficit/Hyperactivity Disorder (ADHD)

Proportion and number of study participants who met diagnostic criteria for childhood ADHD only, adult ADHD only, and both childhood and adult ADHD.

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Alternative hypothesis: Inattentive vs. hyperactive-impulsive ADHD
Posted on May 19, 2016
Robert Stallmann
Tarrant County College
Conflict of Interest: None.
The lack of a childhood diagnosis of ADHD in many adult individuals with the disorder could be due to manifestation of ADHD as the \"predominantly inattentive type.\" This type of ADHD is often missed in childhood because such children tend not to be disruptive in a classroom setting. Such disruptions (generally caused by children with mixed or hyperactive-impulsive forms of ADHD) frequently lead school teachers and principals to ask parents to have their children evaluated.

In the present study, although children were assessed at regular intervals for signs of ADHD, the more attention-getting symptoms of hyperactive-impulsive ADHD are still more likely to be noticed in children. Children who have the predominantly inattentive form of ADHD, particularly if they are intelligent, are likely not to experience major problems until the greater cognitive and organizational demands of adulthood (college and career) commence. This possibility is supported by the relatively high IQ of those individuals thought to have \"adult-onset\" ADHD.

There are two underlying problems. First, the hyperactive-impulsive form of ADHD can be difficult to distinguish from normal levels of hyperactivity and impulsivity in children, particularly in very young boys (reflected in the decreasing rates of ADHD diagnosis with increasing age in the present study). Second, some forms of ADHD are more subtle than others, especially in childhood. These two problems in concert can lead to over-diagnosis of hyperactive-impulsive ADHD and under-recognition of inattentive ADHD, especially in the very young.
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