Background. This study examined the persistence of attention deficit hyperactivity disorder (ADHD) into adulthood.Method. We analyzed data from published follow-up studies of ADHD. To be included in the analysis, these additional studies had to meet the following criteria: the study included a control group and it was clear from the methods if the diagnosis of ADHD included subjects who did not meet full criteria but showed residual and impairing signs of the disorder. We used a meta-analysis regression model to separately assess the syndromatic and symptomatic persistence of ADHD.Results. When we define only those meeting full criteria for ADHD as having ‘persistent ADHD’, the rate of persistence is low, ~15% at age 25 years. But when we include cases consistent with DSM-IV's definition of ADHD in partial remission, the rate of persistence is much higher, ~65%.Conclusions. Our results show that estimates of ADHD's persistence rely heavily on how one defines persistence. Yet, regardless of definition, our analyses show that evidence for ADHD lessens with age. More work is needed to determine if this reflects true remission of ADHD symptoms or is due to the developmental insensitivity of diagnostic criteria for the disorder.

The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies

Objective Attention deficit hyperactivity disorder is a heterogeneous disorder of unknown etiology Little is known about the comorbidity of this disorder with disorders other than conduct Therefore, the authors made a systematic search of the psychiatric and psychological literature for empirical studies dealing with the comorbidity of attention deficit hyperactivity disorder with other disorders Data collection The search terms included hyperactivity, hyperkinesis, attention deficit disorder, and attention deficit hyperactivity disorder, cross-referenced with antisocial disorder (aggression, conduct disorder, antisocial disorder), depression (depression, mania, depressive disorder, bipolar), anxiety (anxiety disorder, anxiety), learning problems (learning, learning disability, academic achievement), substance abuse (alcoholism, drug abuse), mental retardation, and Tourette's disorder Findings The literature supports considerable comorbidity of attention deficit hyperactivity disorder with conduct disorder, oppositional defiant disorder, mood disorders, anxiety disorders, learning disabilities, and other disorders, such as mental retardation, Tourette's syndrome, and borderline personality disorder Conclusions Subgroups of children with attention deficit hyperactivity disorder might be delineated on the basis of the disorder's comorbidity with other disorders These subgroups may have differing risk factors, clinical courses, and pharmacological responses Thus, their proper identification may lead to refinements in preventive and treatment strategies Investigation of these issues should help to clarify the etiology, course, and outcome of attention deficit hyperactivity disorder

Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders.

This study examined the persistence of attention-deficit/hyperactivity disorder (ADHD) into young adulthood using hyperactive (N = 147) and community control (N = 71) children evaluated at ages 19-25 years. ADHD was rare in both groups (5% vs. 0%) based on self-report but was substantially higher using parent reports (46% vs. 1.4%). Using a developmentally referenced criterion (+2 SD), prevalence remained low for self-reports (12% vs. 10%) but rose further for parent reports (66% vs. 8%). Parent reports were more strongly associated with major life activities than were self-reports. Recollections of childhood ADHD showed moderate correlations with actual parent ratings collected in childd hood, which suggests some validity for such recollections. The authors conclude that previous follow-up studies that relied on self-reports might have substantially underestimated the persistence of ADHD into adulthood.

The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder.

In this article, the author highlights the need for early intervention for chronic offenders He reviews evidence suggesting that children who manifest symptoms of hyperactivity-impulsivity-attention problems (HIA) and conduct problems (CP) are at the greatest risk for chronic offending He reviews existing theories of the relations among constructs: (a) HIA increases risk in those already at risk and (b) HIA leads to symptoms of CP In addition, he advances a third theory that children with symptoms of HIA and CP are afflicted with a virulent strain of conduct disorder best described as fledgling psychopathy The author discusses treatment implications and supporting evidence for each model Finally, he recommends that the subtype theory receive further consideration and examination

Early identification of chronic offenders: who is the fledgling psychopath?

• We examined 140 probands with attention deficit hyperactivity disorder, 120 normal controls, and their 822 firstdegree relatives using "blind" raters and structured diagnostic interviews. Compared with controls, probands with attention deficit hyperactivity disorder were more likely to have conduct, mood, and anxiety disorders. Compared with relatives of controls, relatives of probands with attention deficit hyperactivity disorder had a higher risk for attention deficit hyperactivity disorder, antisocial disorders, major depressive disorder, substance dependence, and anxiety disorders. Patterns of comorbidity indicate that attention deficit hyperactivity disorder and major depressive disorders may share common familial vulnerabilities, that attention deficit hyperactivity disorder plus conduct disorder may be a distinct subtype, and that attention deficit hyperactivity disorder and anxiety disorders are transmitted independently in families. These results extend previous findings indicating family-genetic influences in attention deficit hyperactivity disorder by using both pediatrically and psychiatrically referred proband samples. The distributions of comorbid illnesses in families provide further validation for subgrouping probands with attention deficit hyperactivity disorder by comorbidity.

Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder: Patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred samples.

Cognitive functioning was assessed in diabetic patients during hypoglycemia (60 mg/dl), euglycemia/control (110 mg/dl), and hyperglycemia (300 mg/dl). Blood glucose levels were set and maintained to within 4% of targeted levels by an artificial insulin/glucose infusion system (Biostator). Attention and fine motor skills, assessed by visual reaction time, was slowed at altered glucose levels. Performance was less impaired during hyperglycemia than hypoglycemia when a longer interstimulus interval was used, although it was still slower than normal. The time required to solve simple addition problems was increased during hypoglycemia, although reading comprehension was not affected. The possibility that some automatic brain skills are disrupted at altered glucose concentrations is discussed, while associative or inferential skills may be less affected.

A survey of cognitive functioning at difference glucose levels in diabetic persons.

A four-year follow-up of clinically selected hyperactive boys with and without associated conduct disorder investigated their outcome during early adolescence and was taken from a structured behavioural interview and standard psychological testing. Boys originally diagnosed as "purely" hyperactive continued to be inattentive and impulsive at follow-up, but showed very few aggressive and antisocial behaviours. Hyperactive boys who had earlier been undersocialized and aggressive continued to have problems with attention and impulsivity, were reported to be aggressive, noncompliant, egocentric, exhibiting antisocial behaviours and using alcohol. These findings suggest that antisocial and delinquent behaviour often reported in follow-up studies of hyperactive boys may be linked to childhood aggression and unsocialized behaviour, rather than the syndrome of hyperactivity.

A four-year follow-up of hyperactive boys with and without conduct disorder.

The effect of serum glucose alterations on selected verbal skills was examined in a group of diabetic men between 18 and 35 yr of age. An artificial insulin infusion system was used to set and maintain glucose concentrations during testing at each of three levels: hypoglycemia (55 mg/dl), euglycemia (110 mg/dl), and hyperglycemia (300 mg/dl). Subjects were used as their own controls, with performance at euglycemia serving as the comparison standard. A double-blind crossover design was employed as described in Holmes et al. (see ref. 14). Results showed significantly disrupted naming or labeling skills at hypoglycemia, with a trend toward poorer performance at hyperglycemia. During hypoglycemia, rate of responding was slowed from 6% to 18%, compared with euglycemic performance, but accuracy was not impaired. In contrast, word recognition skills were not affected by deviations in glucose. These performance effects were not correlated with duration of disease except for one of the five tests administered. This one exception, on the most difficult task, was less notable than the general finding of no relation between disease duration (from 6 mo to 17.5 yr) and test performance. Thus, in addition to considering long-term consequences of blood glucose alterations, clinicians and diabetic patients may wish to consider acute neuropsychological consequences of disrupted euglycemia.

Verbal Fluency and Naming Performance in Type I Diabetes at Different Blood Glucose Concentrations

Intellectual and reading skills were evaluated and related to disease variables in 42 children with Type I (insulin-dependent) diabetes. A significant interaction revealed lower Wechsler Intelligence Scale for Children-Revised (WISC-R) Performance IQ for children with early disease onset (>7

Cognitive Profiles of Children with Insulin-dependent Diabetes

Two groups of adolescents with cleft lip and palate were compared on their self-ratings of facial appearance and behavior. The two groups were identified as well adjusted (N = 19) or poorly adjusted (N = 17), based on their parents' ratings of behavior. T-test comparisons indicate that the group with good adjustment have realistic perceptions of facial appearance (based on independent ratings by their teachers), and their self-perceptions of behavior are similar to those of their parents. The poorly adjusted group have unrealistic perceptions of facial appearance and perceive their behavior as more socially acceptable than do their parents.

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Clarissa S. Holmes

Papers

A survey of cognitive functioning at difference glucose levels in diabetic persons.

A four-year follow-up of hyperactive boys with and without conduct disorder.

Verbal Fluency and Naming Performance in Type I Diabetes at Different Blood Glucose Concentrations

Cognitive Profiles of Children with Insulin-dependent Diabetes

Adolescents with cleft lip and palate: self-perceptions of appearance and behavior related to personality adjustment.