Psychosocial Adjustment and Educational Outcomein Adolescents with a Childhood Diagnosis

of Attention Deficit Disorder

JULIE M. WILSON, PH.D., AND ANN C. MARCOTTE, PH.D.

ABSTRACT

Objective: To conduct a retrospective follow-up study of psychosocial adjustment and educational outcome in adoles­

cents with a childhood diagnosis of attention deficit disorder (ADD) and a group of clinical controls. Method: Groups

included male and female subjects aged 14 to 18 years at time of follow-up with childhood diagnosis of ADD (cases;

n =48) versus other neurodevelopmental disorders (clinical controls; n =37). Cases were also subdivided based on

the presence of conduct disorder (CD) at follow-up. All groups were compared on measures of academic performance,

self-esteem, behavior, alcohol and substance use, and adaptive functioning. Results: Cases had significantly lower

academic performance and poorer social, emotional, and adaptive functioning than clinical controls. Cases with CD

had significantly lower academic performance, greater externalizing behaviors and emotional difficulties, and lower

adaptive functioning than cases without CD. Cases with CD fared worse than clinical controls on self-report measures

of behavior, socialization skills, and alcohol and substance use. Conclusions: These academic and psychosocial

problems in adolescents with a childhood diagnosis of ADD suggest potential long-term ramifications for vocational and

psychological functioning into adulthood. In addition, the presence of CD in some of these cases during adolescence

appears to further increase the risk for maladaptive outcome. J. Am. Acad. Child Ado/esc. Psychiatry, 1996, 35(5):579­

587. Key Words: adolescents, attention deficit disorder, outcome.

Although attention deficit disorder (ADD) was origi­nally conceptualized as a disorder of childhood, morerecent researchers have proposed that this disorder canpersist in some patients into adolescence, and in others,even into adulthood (Wender, 1995). The clinicalmanifestations of the disorder, however, may changeas the patient passes through different developmentalstages. Specifically, it has been reported that while thehyperactivity and behavioral disinhibition may abate,

Accepted September 7, 1995.Dr. Wilson is Instructor, Department ofFamily Medicine, and Dr. Marcotte

is Clinical Assistant Proftssor, Department ofPsychiatry and Human Behavior,

Brown University School ofMedicine, Providence, Rl. Both are also with theDepartment of Pediatrics, Memorial Hospital of Rhode Island, Pawtucket.

This research was the basis of a dissertation submitted by j. Wilson inpartial fUlfillment flr a Ph.D. degree to the Department ofPsychology at theUniversity ofRhode Island. Portions of this paper were presented at the 103rdAnnual Meeting of the American Psychological Association, August 1995.

Reprint requests to Dr. Wilson, Department ofPediatrics, Memorial Hospitalof Rhode Island, 111 Brewster Street, Pawtucket, RI 02860.

0890-8567/96/3505-0579$03.00/0©1996 by the American Academyof Child and Adolescent Psychiatry.

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996

continued difficulties with the more "cognitive" fea­tures of this disorder may persist and may continueto interfere with effective functioning.

Several researchers (Fischer et al., 1990; Gittelmanet al., 1985; Weiss et al., 1985) have examined theoutcome of childhood diagnosis of ADD into adoles­cence and adulthood in long-term prospective studies,and they have found significant risk for the develop­ment of later psychopathology. These studies foundthat subjects with ADD continued to have symptomsof ADD into adolescence, and some, even into adult­hood, had a greater chance of developing a conductdisorder and demonstrated patterns of deficient behav­ioral inhibition and impaired academic achievementcompared with a group of normal controls. Otherresearchers have suggested that the hyperactive childmay develop more serious psychopathology in adoles­cence and adulthood (Hechtman, 1984; Satterfieldet al., 1982; Weiss et al., 1979).

Many studies addressing the long-term emotional,psychological, and social outcome of patients in whomADD was diagnosed in childhood have had method-

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WILSON AND MARCOTTE

ological shortcomings that limit their utility. There isoften a lack of consensus criteria for the diagnosis ofADD (Gittelman et al., 1985; Weiss et al., 1979).Another major methodological problem has been theselection of comparison control groups at the time offollow-up (Gittelman et al., 1985; Hechtman et al.,1980; Satterfield et al., 1982), with the frequent selec­tion of groups of normal, nonclinical controls (Barkleyet al., 1990; Gittelman et al., 1985; Hechtman et al.,1980). Ifone wants to prove that ADD is taxonomicallyvalid and distinct from other disorders, it must bedemonstrated that differences exist on variables externalto the diagnostic criteria.

Another limitation of many longitudinal studies ofADD has been the exclusion of female subjects. Infact, there are a limited number of studies that haveexamined ADD in girls at any period of development.McGee et al. (1990) found that girls identified byteacher ratings were equally prevalent and displayedsimilar cognitive deficits and early history of behaviorproblems in comparison with boys with ADD. Man­nuzza and Gittelman-Klein (1984), in a comparisonstudy of 12 girls and 24 boys with diagnosed hyperactiv­ity and 24 male controls, showed that there were nosignificant differences between the male and femalesubjects for any diagnosis using DSM-Ill Schaughencyet al. (1994) found that 50% of boys and 37% ofgirls with ADD symptoms at age 15 years had anearlier history of behavior disorder. In this study girls

reporting ADD symptomatology had outcomes similarto those of boys.

This investigation was developed to examine anddelineate the psychosocial and educational outcome inadolescence of patients in whom ADD was initiallydiagnosed in childhood (hereafter referred to as cases)while addressing some of the methodological shortcom­ings of prior research in this area. This study specificallydelineated diagnostic criteria for ADD inclusion. Bothmale and female subjects were enrolled in this study.In addition, we used a comparison clinical controlgroup of patients in whom other neurodevelopmentalproblems had been diagnosed during childhood (e.g.,clinical controls) rather than normal, nonclinical con­trol subjects. This comparison group consisted primar­ily of learning-disabled youngsters. By using clinicalcontrols, we hoped to be able to differentiate whetherprior reported psychosocial outcome problems in pa­tients with ADD diagnosed in childhood were unique

580

to this disorder, rather than being experiences sharedwith other patients with disorders diagnosed in child­hood. Finally, this study used measures obtained notonly from the actual subjects, but also their parent(s).

On the basis ofprevious research, it was hypothesizedthat cases would demonstrate poorer psychosocial func­tioning than clinical controls on several different di­mensions of academic performance, socialization skills,and adaptive behavior. It was further hypothesized thatof the adolescents with ADD diagnosed in childhood(cases), a subgroup meeting diagnostic criteria in lateradolescence for conduct disorder (cases+CD) wouldemerge. It was hypothesized that this cases+CD sub­group would fare worse on measures of psychosocialadjustment relative to cases not demonstrating symp­toms of conduct disorder in adolescence (cases-CD),as well as relative to clinical controls.

METHOD

Subjects

All subjects were originally seen for a comprehensive assessmentin a neurodevelopmental evaluation clinic at a large community­based teaching hospital in New England between 1980 and 1987.Comprehensive evaluation consisted of neuropsychological testingin concert with neurological examination. At time of initial referral,all subjects were between the ages of 6 and 12 years and had FullScale IQ scores >80. Potential subjects were excluded from thestudy if they were psychotic, had epilepsy, or had cerebral palsyat the time of initial evaluation. At the time of follow-up, allsubjects lived at home with at least one parent and were betweenthe ages of 14 and 18 years.

For this study, the charts of patients consecutively evaluatedbetween 1980 and 1987 in the clinic were reviewed to determinewhich former patients met study inclusionary criteria. In all, chartreview yielded a total of 260 patients meeting study inclusionatycriteria. Attempts subsequently made to locate and recruit potentialsubjects for study participation included telephone calls and lettersto parents and help from the patient's last known school department.A total of 92 patients (35% of all eligible subjects) were successfullylocated through these efforts. Of those contacted, only 7 refusedto participate in the study, yielding a study sample size of 85subjects. The follow-up interval from the time of initial evaluationto the time of this study ranged from 5 to 12 years, with a meanof 8.3 years.

Subjects were classified into two groups. The cases were 48subjects who at the time of initial evaluation had received thediagnosis of ADD according to DSM-IIIcriteria (American Psychi­atric Association, 1980), the diagnostic criteria used at the timeof their initial evaluation and diagnosis. Furthermore, all cases hadobtained a T score of >70 on the Hyperactivity Index of theConners Teacher Behavior Rating Scale (Conners, 1969). Thisadditional selection criterion was used to provide cross-situationalsupport for the clinic diagnosis and to improve the homogeneityof the ADD group. Several potential subjects could not be included

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996

in the study because they had Tscores on the Hyperactivity Indexof <70.

These 48 cases were drawn from a pool of 134 potential ADDsubjects identified through chart review. Fifty-two patients fromthis pool were successfully located, and only four refused toparticipate in the study. The clinical control group consisted of 37subjects. At time of initial evaluation, the clinical controls didnot have the ADD diagnosis but had other neurodevelopmentaldisorders, primarily learning disabilities. These 37 clinical controlsubjects were recruited from a pool of 126 potential subjects, ofwhom 40 were located, and only 3 refused to participate. Specificpatient diagnoses represented in this group included learning disabil­ity (74% of subjects), affective disorder (16%), encopresis (5%),and tic disorder (5%). These diagnoses were made in accordancewith diagnostic criteria delineated in the DSM-III(American Psychi­atric Association, 1980).

Procedures

Subjects were seen in follow-up in the clinic and were accompa­nied by one or both parents. All subjects and their parent(s) wereasked to complete a battety of inventories. This study reports thefindings obtained from a series of inventories assessing differentdimensions of psychosocial functioning. For this study, all adoles­cent subjects completed the following measures.

Youth Self-Report. The Youth Self-Report (YSR) (Achenbach andEdelbrock, 1987) is a self-rating measure that was designed forchildren aged I I to 18 years. It is a standardized inventoty of I 19items, assessing behavior problems and social competence whichyield scores on seven scales, grouped under two basic dimensions,Externalizing and Internalizing. These dimensions reflect the differ­ences between inhibited, overcontrolled behavior and aggressive,undercontrolled behavior. A total score is also calculated from thesubject's responses. The YSR items require a fifth-grade readinglevel. The YSR has shown acceptable reliability and validity.

Piers-Harris Children's Self-Concept Scale. This scale (Piers andHarris, 1969), used with children aged 8 to 18 years, consists of80 true-false items yielding scores on six dimensions: Behavior,Intellectual and School Status, Physical Appearance and Attributes,Anxiety, Popularity, Happiness and Satisfaction, and a Total Score.Mean test-retest reliability is .73, and internal consistency estimatesfor total score range from .89 to .93. This instrument is writtenat a third-grade reading level.

Alcohol and Substance Use Questionnaire. This inventory wasdeveloped for specific use in this research program by the authors.It is a 26-item inventoty that measures the frequency of alcoholand drug use on a 5-point Likert-type scale. Adolescents wereadvised of complete confidentiality in responding to this question­naire as protected by a Confidentiality Certificate obtained by theauthors prior to the initiation of the study from the US Departmentof Health and Human Services (MH-91-5IA2).

At least one parent was asked to separately complete writtenchecklists to assess his or her perception of the adolescent's currentbehavior and psychosocial functioning. Parent-report inventoriesused in this study included the following.

Child Behavior Checklist. The Child Behavior Checklist (CBCL)(Achenbach and Edelbrock, 1983) is a parent-report form thatdocuments behavior problems and social competency for childrenaged 4 to 18 years. Similar to the YSR, this checklist groupsbehaviors along Externalizing and Internalizing dimensions, and atotal score is also derived. Test-retest reliability values range from.69 to .97. This scale was selected because of its sound database,extensive norms, and acceptable reliability.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996

PSYCHOSOCIAL FUNCTIONING IN ADD

Stony Brook Child Psychiatric Checklist. The Stony Brook ChildPsychiatric Checklist (SBCPC) (Grayson and Carlson, 1989) is apaper-and-pencil psychiatric symptom review checklist completedby a parent which allows for DSM-III-R (American PsychiatricAssociation, 1987) classification ofa number ofchildhood psychiat­ric disorders. Grayson and Carlson (1989) compared this checklistto the structured Schedule for Affective Disorders and Schizophreniafor School-Age Children and to best-estimate diagnosis from psychi­atric interviews, and they determined that the scale has acceptablesensitivity and specificity. A dimensional approach using the totalsymptom severity score for each diagnosis was applied in this studyfor comparative purposes. Symptom categories include attention­deficit hyperactivity disorder (ADHD), conduct disorder, opposi­tional defiant disorder, overanxious disorder, major depressive epi­sode, schizophrenia, and manic episode.

Vineland Adaptive Behavior Scales. Each parent was also inter­viewed using the Vineland Adaptive Behavior Scales (VABS) (Spar­row et aI., 1984) regarding the adaptive functioning level of thechild in daily living, socialization, and communication skills. Ineach domain, behavior is evaluated in terms of typical performance,not ability, of the daily activities required for social sufficiency.Test-retest reliability, internal consistency estimates, and validitycoefficients are all adequate.

With each subject's permission, academic records were thenobtained ftom each adolescent's school. The grade point averagefrom the previous full academic year was accessed because it is auniformly used measure of determining a student's achievementat each grade level. Parents also were asked to provide informationpertaining to the number of school suspensions their child hadincurred.

RESULTS

Prior to the analysis of the data generated fromthe 85 subjects in this study, statistical analyses wereconducted to evaluate whether those subjects who couldnot be located or successfully recruited to participatein this study differed in their initial characteristics fromstudy subjects. Separate t tests were performed for caseand clinical control groups between subjects recruitedto participate versus those not recruited or located atthe time of follow-up study on IQ score, socioeconomicstatus, as well as the Hyperactivity Index score ofthe Conners Teacher Behavior Rating Scale (Conners,1969). Results revealed no significant differences be­tween recruited and unrecruited/not located patientson these measures.

Data were analyzed using SPSS-X. Multivariate anal­yses of variance were used on the conceptually relatedoutcome measures. These were followed by univariateanalyses of variance when the multivariate test resultwas significant. In the multivariate analysis, the p valuewas set at ex < .05. Bonferroni correction was appliedsetting the family-wise error for all tests to p < .05 .Thus, any single statistical test result had to have a p

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WILSON AND MARCOTTE

Gender0/0 Male 77.1 83.80/0 Female 22.9 16.2

Age (yr)Mean 15.4 16.3*SO 1.3 1.6

Race0/0 Caucasian 86 890/0 Hispanic 6 30/0 Portuguese 2 30/0 Other 6 5

IQMean 99.2 99.6SO 12.6 11.9

Hollingshead inde~

3.6Mean 3.7SO 1.2 0.9

*p<.OOI.

582

< .0025 to be considered significant, with trendsindicated by p > .01 and p < .10.

Subject demographics are summarized in Table 1.There were no statistically significant differences be­tween cases and clinical controls for socioeconomicstatus as measured by the Hollingshead Index (Hol­lingshead, 1965) nor Full Scale IQ scores. Controlswere slightly older (mean age = 16.3 years) than cases(mean age = 15.4 years). Male-female gender ratioswere also not significantly different between the twogroups, with each study group having three to fourtimes more males than females. Separate multivariateanalyses of covariance were carried out on the twogroups, using sex and age' as covariates. Results werenot statistically significant. Adolescent males and fe­males were therefore combined for all subsequentanalyses.

The performance of cases versus clinical controls onall of the study measures was first evaluated usingmultivariate analysis of variance. A significant overallmultivariate effect was obtained (Hotelling's T = 1.08,F = 3.5, P < .001), suggesting group differences alongthese measures. Univariate F statistics were then usedto compare groups on each scale. Results of theseanalyses are summarized in Table 2.

Consistent with the first study hypothesis, casesoverall had poorer psychosocial outcome than clinical

TABLE 1Subject Characteristics

Cases(n = 48)

Clinical Comrols(n = 37)

controls. With regard to academic functioning, univari­ate results indicate that cases had a significantly lowermean grade point average and more suspensions fromschool than clinical controls. It is interesting that therewere no statistically significant group differences on anyof the self-report measures (e.g., Piers-Harris Children'sSelf-Concept Scale, YSR, alcohol and substance usescales). In contrast, parental report yielded significantgroup differences, with parents ofcases overall reportingpoorer psychosocial and adaptive outcome in theirchildren. Specifically, parents of cases reported statisti­cally higher Internalizing and Externalizing T scoreson the CBCL; higher scores on the symptom categoriesof ADHD, oppositional defiant disorder, major de­pressive episode, overanxious disorder, and manic epi­sode on the SBCPC; and poorer socialization adaptiveabilities as assessed on the VABS. Unexpectedly,findings further revealed that both groups demonstratedimpairment in communication skills relative to theVABS normative sample. This may reflect expressivewritten output problems commonly reported in learn­ing-disabled and ADD adolescents.

For the next phase of data analysis, cases weresubsequently subdivided into two groups based on thepresence/absence of conduct disorder at the time offollow-up as determined by parental report of suchbehavioral problems using the SBCPC. Eighteen casesmet the diagnostic criteria for conduct disorder asdelineated by the SBCPC (cases+CD; n = 18). Thissubgroup was then compared to the remaining cases(cases-CD; n = 30) as well as to all clinical controls(n = 37) along all study outcome variables.

To test the hypothesis that cases who additionallymet the criteria for conduct disorder at the time ofthe study would fare worse in terms of psychosocialadjustment than those cases who did not meet thecriteria for conduct disorder in adolescence, and worsethan clinical controls, a multivariate analysis ofvariancewas performed. There was a significant difference inoutcome as a function of group status (F[2,82] = 2.75,P < .001, Hotelling's T = 1.69, P < .001). Analysisof variance was used to detect a main effect for groupfor each of the outcome variables. When the maineffect was significant, post hoc Tukey tests were used.Results of these analyses are summarized in Table 3.

Partial support for the second study hypothesis wasobtained. Results reveal that the cases+CD group faredworse than the cases-CD and the clinical controls on

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996

PSYCHOSOCIAL FUNCTIONING IN ADD

TABLE 2Summary Values for Outcome Variables: Cases versus Clinical Controls

Cases Clinical Controls(n ~ 48) (n ~ 37)

Mean SD Mean SD F Values

Academic variablesGPA 2.16 0.57 2.63 0.48 16.28***No. suspensions 0.65 1.2 0.14 0.42 6.01**

Subjeds self-ratingsASUQ total score 17.64 3.9 16.33 2.0 0.002PHCSCS total T score 54.95 10.5 56.94 11. I 0.69

YSRInternalizing T score 49.56 10.9 47.69 11.0 0.59Externalizing T score 53.78 10.2 47.4 10.3 8.11*'Total T score 51.95 10.9 46.91 11.9 4.12'

Parent ratingsCBCL

Internalizing T score 64.18 7.9 53.33 12.0 25.0***Externalizing T score 67.25 8.3 53.27 11.06· 44.47*'*Total T score 67.59 9.0 54.1 12.54 33.43*'*

SBCPCADHD score 20.61 8.0 9.18 8.8 39.41*'*CD score 2.32 2.9 1.54 4.2 1.01OPP score 13.21 7.2 5.96 5.8 25.27***DEP score 4.70 5.0 1.43 2.6 12.92***ANX score 5.68 4.0 2.69 3.0 14.24"*MANIC score 5.38 4.7 1.54 2.8 19.47***SCHIZ score 0.64 1.0 0.31 0.7 2.92

VABSDaily Living 89.03 12.5 95.42 13.2 5.20*Communication 79.07 17.0 80.36 17.2 0.12Socialization 87.57 13.2 97.39 15.6 9.85**

Note: GPA ~ grade point average; ASUQ ~ Alcohol and Substance Use Questionnaire; PHCSCS Piers-HarrisChildren's Self-Concept Scale; YSR ~ Youth Self-Repon; CBCL ~ Child Behavior Checklist; SBCPC ~ Stony BrookChild Psychiatric Checklist; ADHD ~ attention-deficit hyperactivity disorder; CD ~ conduct disorder; OPP ~ oppositionaldefiant disorder; DEP ~ major depressive episode; ANX ~ overanxious disorder; MANIC ~ manic episode; SCHIZ ~

schizophrenia; VABS ~ Vineland Adaptive Behavior Scales.* p < .05; ** P < .01; *** P < .0025.

many ofthe measures ofpsychosocial outcome. Plannedcomparisons indicated that the cases+CD group hada significantly lower grade point average than theother two groups. Parental report measures yieldedthe greatest differences between groups on the CBCLExternalizing dimension, with the cases+CD grouphaving higher scores on this dimension that the othercases, who in turn, had higher scores than clinicalcontrols. On the CBCL Internalizing dimension andTotal T score, the cases+CD group had significantlyhigher scores (indicating greater levels of symptomseverity) than either of the other two groups, who didnot statistically differ from one another. With regardto other symptom ratings on the SBCPC, plannedcomparison results reveal that the cases+CD group had

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 35:5. MAY 1996

higher scores on the symptom categories of conductdisorder, manic episode, and overanxious disorder thaneither of the other two groups. All cases, regardless ofsubgroup membership as defined by conduct disorder,achieved higher scores than clinical controls on SBCPCsymptom categories ADHD, oppositional defiant, andmajor depressive episode.

The cases with diagnosis of conduct disorder inadolescence as a group had a lower standard score onadaptive measures of daily living skills and socializationskills than either of the other two groups. Self-reportmeasures revealed that the cases+CD group rated them­selves as having significantly more behavior problemsas measured on the Externalizing dimension and TotalT score of the YSR and as using more alcohol and

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WILSON AND MARCOTTE

TABLE 3Summary Values for Clinical Controls versus Cases with and without Conduct Disorder

Cases-CD Cases+CD Clinical Controls(n = 30) (n = 18) (n = 37)

Mean SO Mean SO Mean SO FValues

Academic variablesGPA 2.25 0.57 2.01 0.56 2.63 0.48 9.47**MNo. suspensions 0.57 1.3 0.78 1.00 0.14 0.42 3.26*d

Subject's self-ratingsASUQ total score 16.83 2.89 18.72 5.04 16.33 2.0 3.54*'PHCSCS total T score 55.20 11.07 54.61 9.68 56.94 11.1 0.36YSR

Internalizing T score 48.22 1.86 51.72 10.97 47.69 11.0 0.87Externalizing T score 51.21 10.38 58.06 8.63 47.40 10.3 6.90**'Total T score 49.73 10.70 55.67 10.63 46.91 11.90 3.69*'

Parent ratingsCBCL

Internalizing T score 62.18 8.03 67.51 6.71 53.33 12.00 14.53***dExternalizing T score 64.47 8.23 71.91 6.09 53.27 11.06 27.58***cTotal T score 65.15 8.85 71.65 7.76 54.10 12.54 19.57***d

SBCPCADHD score 18.63 7.11 23.91 8.44 9.18 8.80 22.96***dCD score 0.60 0.72 5.18 2.99 1.54 4.2 12.76***bOPP score 12.63 8.57 14.18 3.80 5.96 5.8 12.88***dDEP score 4.30 5.13 5.38 4.95 1.43 2.6 6.82***dANX score 4.73 3.66 7.26 4.23 2.69 3.0 10.42***bMANIC score 4.33 4.58 7.13 4.50 1.54 2.8 13.26***cSCHIZ score 0.50 1.08 0.86 0.74 0.31 0.7 2.50

VABSDaily Living 93.67 12.03 81.30 9.23 95.42 13.2 8.87**MCommunication 83.01 17.69 72.51 13.82 80.36 17.2 2.27Socialization 90.34 14.07 82.95 10.44 97.39 15.6 6.59*M

Note: GPA = grade point average; ASUQ = Alcohol and Substance Use Questionnaire; PHCSCS = Piers-Harris Children's Self-ConceptScale; YSR = Youth Self-Report; CBCL = Child Behavior Checklist; SBCPC = Stony Brook Child Psychiatric Checklist; ADHD =

attention-deficit hyperactivity disorder; CD = conduct disorder; OPP = oppositional defiant disorder; DEP = major depressive episode;ANX = overanxious disorder; MANIC = manic episode; SCHIZ = schizophrenia; VABS = Vineland Adaptive Behavior Scales.

* p < .05; ** P < .01; *** P < .0025. Results of Tukey tests: a cases+CD < cases-CD = controls; b cases+CD > cases-CD = controls;C cases+CD > cases-CD> controls; d cases+CD = cases-CD> controls;' cases+CD > controls only.

drugs than the control group. Scores of all groups,however, were not clinically significant when com­pared to normative values (e.g., scores were withinnormal range). Finally, no significant group differencesemerged with regard to reports of self-esteem, withagain all groups endorsing items suggesting no problemsin this realm.

DISCUSSION

The results of this study, using well-delineated sub­ject selection criteria and information from multiplesources and multiple instruments, lend further supportto the hypothesis that individuals with a childhooddiagnosis of ADD are at high risk for psychosocial,

584

educational, and adaptive problems in adolescence.While most previous research studies lending supportto this hypothesis have used normal nonclinical com­parison groups, the ability of this study to detect groupdifferences between cases and clinical controls suggeststhis finding is robust. The data did not reveal significantgender differences in outcome for either group.

Differences found in the academic grade point aver­ages of cases and clinical controls are consistent withfindings of academic adjustment difficulties reportedin other longitudinal outcome research with ADDsubjects (Barkley et al., 1991; Lambert et al., 1987).Of particular importance is this study's finding that,despite average cognitive abilities as assessed by intelli­gence tests, the adolescents with a childhood diagnosis

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 35:5. MAY 1996

ofADD fared academically worse than clinical controlswith specific, diagnosed learning disabilities. In search­ing for possible explanations for this finding, a potentialanswer may lie in reviewing the school-based servicesthe different study groups may have received to addresstheir unique learning difficulties. During the periodof time from initial diagnosis to follow-up study, thespecial educational laws as interpreted in this geographicregion were such that it was not mandated nor usuallythe case that special education services or classroomaccommodations were made for students with the solediagnosis of ADD. Such services were generally onlyprovided to students with AD0 who carried a comorbiddiagnosis, such as a specific learning disability, asdelineated in Public Law 94-142. Thus, it is likelythat the clinical controls studied in our research receivedsignificantly more individualized educational assistanceand classroom accommodations that did cases. Thisin turn, may account for the discrepancy in academicperformance reported in this study. Further studiesinvestigating whether there are different academic out­comes for adolescents with ADD diagnosed in child­hood who receive classroom learning accommodationsand/or special educational assistance during their aca­demic career may help to shed further light on thisfinding.

Another significant finding of this study is thatchildren with ADD are by parental report at greaterrisk for the development of psychiatric/psychologicalproblems during adolescence than are children withother neurodevelopmental disorders. Thirty-eight per­cent of the cases in this study continued to meet thediagnostic criteria for ADHD according to the SBCPCguidelines. This rate is similar to that reported in thelongitudinal follow-up study of Lambert et al. (1987),who reported a rate of 43% of adolescents continuingto meet diagnostic criteria for ADHD. In contrast,Barkley et a!. (1990) reported that 80% of subjectsstudied continued to meet DSM-llI-R diagnostic crite­ria for ADHD in follow-up study, while Gittelmanet a!. (1985) reported a 68% rate.

This study reveals that while parents report greatersymptomatology in cases than controls, with caseshaving higher ratings of inattention, depression, anxi­ety, oppositionality, and mania than clinical controls,no differences emerged between groups on parent­reported measures of antisocial behaviors, which others

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996

PSYCHOSOCIAL FUNCTIONING IN ADD

have reported to commonly coexist with ADHD (An­derson et a!', 1987; Gittelman et a!', 1985). Thepercentage of cases who met the SBCPC criteria fora diagnosis of conduct disorder at the time of follow­up (17.6%) is relatively lower than those cited in otheroutcome research studies, with rates reported between25% and 50% (Barkley et aI., 1990; Brown and Borden,1986; Gittelman et aI., 1985).

It is possible that the lower rates of continuingsymptoms ofADHD as well as conduct disorder emerg­ing in adolescence found in this study may reflect thefact that these diagnoses made at the time of follow­up were determined using a parent-report paper-and­pencil inventory versus a semistructured clinical diag­nostic interview. During psychiatric interviews, answerscan be more readily probed, thereby possibly increasingthe reported frequencies and/or severities of particularsymptoms. Two other factors, however, may also inpart account for the discrepancies in the outcomestudies with regard to diagnoses present in adolescence.These potential contributory factors include referralsource bias and, relatedly, the site of the actual clinicsin which evaluations for ADD are conducted. Thesubjects studied in this investigation received theirdiagnosis and follow-up in a neurodevelopmental evalu­ation clinic located within a department of pediatricsat a medical school-affiliated teaching hospital. Themajority of referrals to this clinic come from schoolsin our geographic area as well as family doctors andpediatricians familiar with our practice. Clinics to evalu­ate children and adolescents for ADHD also frequentlyoperate in psychiatry-based sites and are often affiliatedwith departments ofpsychiatry at major medical schoolsand/or psychiatric hospitals. It may be the case thatchildren suspected of having ADHD, who also havecoexisting antisocial and psychiatric spectrum disorders,may more frequently be referred to a psychiatric sitefor evaluation. Future research efforts should moreclosely examine and attempt to clarify the possiblecontributions clinic location and related referral biasesmay have in the reporting of psychosocial outcomefor patients with a childhood diagnosis of ADD. Amultisite study of long-term outcomes for this disorderutilizing both medical and psychiatric sites may helpto further elucidate this issue and clarify the currentpsychiatric and behavioral sequelae discrepancies re­ported in the outcome literature.

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Another finding was that the adolescents studiedin this investigation reported fewer behavioral andpsychological problems than their parents did of theiradolescent offspring. Statistically significant T scoreson both the Internalizing and Externalizing factors andthe total scores from the CBCL reflect the depth andbreadth of adjustment difficulties of these cases asviewed by their parents compared to clinical controls.This discrepancy between parent and adolescent reportsuggests that adolescents in general may have a positivereport bias in their responses to self-report inventories.Thus, when adolescents themselves do report symp­toms, they are likely to be clinically significant. Theself-report of more behaviors of an externalizing natureand greater use of alcohol and drugs in those caseswith conduct disorder therefore warrants serious review.The present results imply that clinicians and researchersshould obtain, but not rely solely on, self-reports ofadolescents about their possible behavioral symptoms,level of self-esteem, and drug/alcohol use, as these self­reports may underestimate the true degree of impair­ment or severity of such problems. Future researchutilizing multimethod approaches to psychosocial datacollection will allow for greater specificity of thefindings.

There are several limitations to the current study.The design of this study has a retrospective cross­lagged element in that subjects were evaluated betweenages 6 and 12 years and then again at ages 14 to 18

years, yielding a possible maturation effect as the timelapse between evaluations varied for individual subjects.We recognize that longitudinal studies benefit if thesame measures are used at the time of initial evaluationand follow-up; however, this sample was identifiedfrom existing records with patients then studied inadolescence. External validity factors and selection biaswere affeCted by the inability to locate and gain coopera­tion from all potential subjects. However, the originaldara on all potential subjects allowed for speculationabout the direction of the bias resulting from thisinability to test these individuals. No differences werefound between potential subjects not recruited or foundfrom those who participated in the study on measuresof intelligence, socioeconomic status, or HyperactivityIndex scores on the Conners Teacher Behavior RatingScale, suggesting that there would likely have been nochange in the direction of the results due to our inabilityto recruit all potential subjects. Generalizability of

586

the results of this study is limited to the populationofadolescents with childhood diagnosis ofADD similarto those selected for this study, including females.Since our study sample also consisted almost entirelyof Caucasian subjects, the findings cannot be general­ized to minority populations with ADHD.

In summary, the results of this study lend supportto the hypothesis that individuals with ADD diagnosedin childhood are at substantially higher risk for psycho­logical, academic, and adaptive dysfunction in adoles­cence. Even those cases studied in this investigationwho did not continue to meet diagnostic criteria forcontinuing ADD problems into adolescence were seenas socially behaving and interacting less well thanclinical controls. Finally, the persistent impairments ineducational, social, and behavioral functioning willlikely have ramifications for the academic, vocational,and social adjustment of many of these adolescentsinto adulthood.

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Coming in June:

Special Article: Course of Major Depressive Disorder

Maria Kovacs

•Psychopathology in Children ofAlcoholic Women

Shirley Y Hill and Diane Muka

•Comorbidity in Juvenile Depression

Joseph Biederman et al.

•Alcohol Abuse in Depressed Adolescents

Cheryl A. King et al.

•Response of Families with Affective Disorder to Preventive Intervention

William R. Beardslee et al.

•Psychotherapy Effect of Mfective Language between Depressed Mothers

and Their ChildrenKathleen Free et al.

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:5, MAY 1996 587