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Functional Adult Outcomes 16 Years After Childhood Diagnosis of Attention-Deficit/Hyperactivity Disorder: MTA Results

https://doi.org/10.1016/j.jaac.2016.07.774Get rights and content

Objective

To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA).

Method

Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments.

Results

Three patterns of functional outcomes emerged. Post−secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG.

Conclusion

Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.

Section snippets

Study Sample

The MTA was originally designed to evaluate effects of treatments in a 14-month randomized clinical trial of 579 children (7−9.9 years old) assigned to 4 conditions: systematic medication management, multicomponent behavioral treatment, their combination, and treatment as usual in community care. After this treatment-by-protocol phase, the MTA continued as a naturalistic follow-up study. At the first follow-up (2 years postbaseline), the LNCG (289 classmates [258 without ADHD] matched on age

Educational Outcomes

Overall, the LNCG had higher educational attainments than participants with ADHD (Table S1, available online). The majority of participants with ADHD (61.7%) had a high school degree or less, whereas the majority of LNCG participants completed at least some college (60.8%). Showing a stepwise pattern, 37.1% of the LNCG obtained a bachelor’s degree compared to 17.8% (odds ratio [OR] = 2.7) of the symptom-desistent subgroup and 8.0% of the symptom-persistent subgroup (OR = 7.4) (Figure 1).

Occupational Outcomes

In four

Discussion

The MTA, with 579 childhood-diagnosed, combined-type ADHD participants and 258 sex- and age-matched comparison participants without ADHD, provides the largest sample of prospectively followed young adults to date; it is very ethnically and socioeconomically diverse, and thus by and large generalizable to an ADHD (combined-subtype) population. However, one needs to keep in mind that the participants lost to follow-up (18% of the ADHD sample) were characterized by lower family income and parental

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    This article is discussed in an editorial by Dr. James J. McGough on page 925.

    The work reported was supported by cooperative agreement grants and contracts from the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) to: University of California–Berkeley: U01-MH50461, N01MH12009, and HHSN271200800005-C; DA-8-5550; Duke University: U01-MH50477, N01MH12012, and HHSN271200800009-C; DA-8-5554; University of California–Irvine: U01MH50440,N01MH12011 and HHSN271200800006- C; DA-8-5551; Research Foundation for Mental Hygiene (NY State Psychiatric Institute/Columbia University): U01-MH50467, N01-MH12007, and HHSN271200800007-C; DA-8-5552; Long Island–Jewish Medical Center: U01-MH50453; New York University: N01MH 12004 and HHSN271200800004-C; DA-8-5549; University of Pittsburgh: U01 MH50467, N01 MH 12010, and HHSN271200800008-C; DA-8-5553; DA039881; McGill University: N01MH12008 and HHSN271200800003-C; DA-8-5548. Funding support for Dr. Mitchell was provided by NIDA K23-DA032577.

    The Multimodal Treatment Study of Children with ADHD (MTA) was an NIMH cooperative agreement randomized clinical trial, continued under an NIMH contract as a follow-up study and finally under a NIDA contract. Collaborators from NIMH: Benedetto Vitiello, MD (Child and Adolescent Treatment and Preventive Interventions Research Branch), Joanne B. Severe, MS (Clinical Trials Operations and Biostatistics Unit, Division of Services and Intervention Research), Peter S. Jensen, MD (currently at REACH Institute and the University of Arkansas for Medical Sciences), L. Eugene Arnold, MD, MEd (currently at Ohio State University), Kimberly Hoagwood, PhD (currently at Columbia); previous contributors from NIMH to the early phases: John Richters, PhD (currently at National Institute of Nursing Research); Donald Vereen, MD (currently at NIDA). Principal investigators and co-investigators from the sites are: University of California, Berkeley/San Francisco: Stephen P. Hinshaw, PhD (Berkeley), Glen R. Elliott, PhD, MD (San Francisco); Duke University: Karen C. Wells, PhD, Jeffery N. Epstein, PhD (currently at Cincinnati Children's Hospital Medical Center), Desiree W. Murray, PhD; previous Duke contributors to early phases: C. Keith Conners, PhD (former PI); John March, MD, MPH; University of California, Irvine: James Swanson, PhD, Timothy Wigal, PhD; previous contributor from UCLA to the early phases: Dennis P. Cantwell, MD (deceased); New York University: Howard B. Abikoff, PhD; Montreal Children's Hospital/McGill University: Lily Hechtman, MD; New York State Psychiatric Institute/Columbia University/Mount Sinai Medical Center: Laurence L. Greenhill, MD (Columbia), Jeffrey H. Newcorn, MD (Mount Sinai School of Medicine); University of Pittsburgh: Brooke Molina, PhD, Betsy Hoza, PhD (currently at University of Vermont), William E. Pelham, PhD (PI for early phases, currently at Florida International University). Follow-up phase statistical collaborators: Robert D. Gibbons, PhD (University of Illinois, Chicago); Sue Marcus, PhD (Mt. Sinai College of Medicine); Kwan Hur, PhD (University of Illinois, Chicago). Original study statistical and design consultant: Helena C. Kraemer, PhD (Stanford University). Collaborator from the Office of Special Education Programs/US Department of Education: Thomas Hanley, EdD. Collaborator from Office of Juvenile Justice and Delinquency Prevention/Department of Justice: Karen Stern, PhD.

    Disclosure: Dr. Hechtman has received research support, served on advisory boards, and served as a speaker for Eli Lilly and Co., GlaxoSmithKline, Ortho-Janssen, Purdue, Shire, and Ironshore. Dr. Arnold has received research funding from Curemark, Forest, Eli Lilly and Co., Neuropharm, Novartis, Noven, Shire, YoungLiving, NIH, Autism Speaks, and Supernus; has consulted with or been on advisory boards for Arbor, Gowlings, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, Roche, Seaside Therapeutics, Sigma Tau, Shire, Tris Pharma, and Waypoint; and has received travel support from Noven. Dr. Jensen has received unrestricted educational grants from Shire, Inc., has served as a consultant to Shire, Inc., and is a shareholder of an evidence-based practices consulting company (CATCH Services, LLC). Drs. Swanson, Sibley, Owens, Mitchell, Molina, Hinshaw, Abikoff, Perez Algorta, Howard, Hoza, Lakes, Mss. Stehli, Etcovitch, Houssais, and Mr. Nichols report no biomedical financial interests or potential conflicts of interest.

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