1
Adult Outcomes of Children withAdult Outcomes of Children with
ADHD: The Milwaukee StudyADHD: The Milwaukee Study
Russel...
2
ObjectivesObjectives
• Summarize the results of research on the
life course outcomes of children withlife course outcome...
3
Qualifying IssuesQualifying Issues
• Results reflect only what is known about the ADHD-
Combined (and Hyperactive) Subty...
4
Milwaukee Study MethodsMilwaukee Study Methods
• 158 children ages 4-11 years diagnosed as hyperactive child
syndrome in...
5
Persistence of DisorderPersistence of Disorder
• Into adolescence: (by parent reports)
– 50% persistence (1970-80s) usin...
6
Developmental Persistence and RecoveryDevelopmental Persistence and Recovery
(parent and parent/other reports; MKE Study...
7
ADHD Across DevelopmentADHD Across Development
(Based on parent/other reports)(Based on parent/other reports)
Childhood ...
8
Developmental Changes (selfDevelopmental Changes (self--reports; MKE Study)reports; MKE Study)
Developmental Changes in ...
9
Domains of ImpairmentDomains of Impairment
(self(self--reported by interview at age 27 followreported by interview at ag...
10
Childhood Academic ImpairmentsChildhood Academic Impairments
• Poor School Performance (90%+)
– reduced productivity is...
11
Educational OutcomesEducational Outcomes
• More grade retention (20-45%; MKE: 42 vs. 13)
– Pagani et al. (2001) & Hause...
12
Educational Outcomes (age 27)Educational Outcomes (age 27)
(Milwaukee Study)(Milwaukee Study)
Educational Outcomes
60
7...
13
Learning Disorders at Age 27Learning Disorders at Age 27
(<14(<14thth percentile; MKE Study)percentile; MKE Study)
Lear...
14
Psychiatric DisordersPsychiatric Disorders (by age 27)(by age 27)
• Current ODD (12%+ by self-report)
• Conduct Disorde...
15
Psychiatric DisordersPsychiatric Disorders
• Anxiety Disorders (MKE)
– 33% for H+ADHD vs. 11% for H-ADHD, 8% controls
E...
16
Oppositional Defiant Disorder (40Oppositional Defiant Disorder (40--80%)80%)
• ADHD cases are 11x more likely to have O...
17
Conduct Disorder (20Conduct Disorder (20--56%)56%)
• If starts early, represents a unique family subtype
– More severe,...
18
Employment ProblemsEmployment Problems
• Enter workforce at unskilled/semi-skilled level
• Greater periods of unemploym...
19
Workplace ProblemsWorkplace Problems
(MKE(MKE -- age 27)age 27)
Workplace Problems
bsHeldPercentofJob
H+ADHD
H-ADHD
Com...
20
ConclusionsConclusions
• ADHD is a valid disorder that is highly persistent into
adulthood – 65-86%
• ADHD in children ...
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Estudio Milwaukee Study

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Russell A. Barkley.
Clinical Professor of Psychiatry Medical University of South Carolina, Charleston SC, and Research Professor, Departament of Psychiatry Suny Upstate Medical University Syracuse, NY.

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Estudio Milwaukee Study

  1. 1. 1 Adult Outcomes of Children withAdult Outcomes of Children with ADHD: The Milwaukee StudyADHD: The Milwaukee Study Russell A. Barkley, Ph.D.Russell A. Barkley, Ph.D. Clinical Professor of PsychiatryClinical Professor of Psychiatry Medical University of South CarolinaMedical University of South Carolina Charleston, SCCharleston, SC andand Research Professor, Department of PsychiatryResearch Professor, Department of Psychiatry SUNY Upstate Medical UniversitySUNY Upstate Medical University Syracuse NYSyracuse NYSyracuse, NYSyracuse, NY ©©Copyright by Russell A. Barkley, Ph.D., 2007Copyright by Russell A. Barkley, Ph.D., 2007 Email:Email: russellbarkley@earthlink.netrussellbarkley@earthlink.net Website: russellbarkley.orgWebsite: russellbarkley.org Sources:Sources: Barkley, R. A. (2006).Barkley, R. A. (2006). Attention deficit hyperactivity disorder: a handbook for diagnosis and treatmentAttention deficit hyperactivity disorder: a handbook for diagnosis and treatment (3(3rdrd ed.)ed.). New York: Guilford.. New York: Guilford.(3(3 ed.)ed.). New York: Guilford.. New York: Guilford. Barkley R. A., Murphy, K. R., & Fischer, M. (2008).Barkley R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in Adults: What the Science Says.ADHD in Adults: What the Science Says. New York: GuilfordNew York: Guilford
  2. 2. 2 ObjectivesObjectives • Summarize the results of research on the life course outcomes of children withlife course outcomes of children with ADHD • Report the latest findings from my own follow-up study of ADHD childrenp y (Milwaukee Study) at age 27 (ages 22-32) • Demonstrate the validity of ADHD as a life course disorder having major adverse effects on education, mental health, and occupational-employment outcomes
  3. 3. 3 Qualifying IssuesQualifying Issues • Results reflect only what is known about the ADHD- Combined (and Hyperactive) Subtypes; InattentiveCombined (and Hyperactive) Subtypes; Inattentive subtype (SCT) remains to be studied for mental health outcomes in any follow-up studies • May not represent girls with ADHD adequately given their under-representation in most adult follow-up studies • May not represent middle age groups and older stages of the disorder (>35 years) • Does not do justice to some important disparities between hyperactive kids followed to adulthood and adults with ADHD who are clinic (self) referred at adulthoodadulthood.
  4. 4. 4 Milwaukee Study MethodsMilwaukee Study Methods • 158 children ages 4-11 years diagnosed as hyperactive child syndrome in 1978-1980 – Had significant symptoms of inattention impulsiveness andHad significant symptoms of inattention, impulsiveness, and hyperactivity as reported by parents – Were +2SDs on Conners Hyperactivity Index & Werry-Weiss-Peters Activity Rating Scale, and +1SD (6 or more settings) on Home Situations Questionnaire – Onset of symptoms by 6 years of age – Excluded children with autism, psychosis, deafness, blindness, epilepsy, significant brain damage, etc.epilepsy, significant brain damage, etc. • 81 control children from same schools and neighborhoods matched on age and obtained via a “snowball” sampling procedure • Most children re-evaluated at mean ages of 15 (C=78% & H=81%), 21 (C=93 & H=90%), and now 27 years (C=93% & H=85%). • To be currently ADHD (H+ADHD), participants had to have 4+ symptoms on either DSM-IV symptom list and 1+ domains of impairment (out of 8) by self report (N=55). Remainder (N=80) were grouped as H-ADHD. • Groups were 83-94% males
  5. 5. 5 Persistence of DisorderPersistence of Disorder • Into adolescence: (by parent reports) – 50% persistence (1970-80s) using clinical symptoms50% persistence (1970 80s) using clinical symptoms – 70-80% persistence (1990s onward) using DSM • Young Adulthood (Mean Age 21) (Barkley et al. 2002) – Depends on whom you ask (self vs. parents): • 3-8% Full disorder (self-report using DSM3R) • 46% Full disorder (parent reports using DSM3R)46% Full disorder (parent reports using DSM3R) – Depends on what diagnostic criteria you use: • 12% - Using 98th percentile (+ 2SDs; self-report) • 66% - Using 98th percentile (parent report) • 85-90% remain functionally impaired • Who to believe? Parent reports have greater veracity – they correlate more highly with various domains of major life activities than do selfmore highly with various domains of major life activities than do self reports • What Happens By Adulthood (Mean age 27 yrs.)???
  6. 6. 6 Developmental Persistence and RecoveryDevelopmental Persistence and Recovery (parent and parent/other reports; MKE Study)(parent and parent/other reports; MKE Study) Developmental Persistence and RecoveryDevelopmental Persistence and Recovery 80 100 120 Syndromal 20 40 60 Percent y Symptomatic 2SD Symptomatic 1.5SD Normalized < 1 SD 0 Child Age15 Age21 Age27 Evaluation Ages
  7. 7. 7 ADHD Across DevelopmentADHD Across Development (Based on parent/other reports)(Based on parent/other reports) Childhood Age 15 Age 21 Age 27g g g Syndromal 100 72 46 26 +2 SDs 98th % 100 83 66 49 98th % +1.5 SDs 93rd % 100 89 70 54 Normal 0 11 30 46 <84th% (+1 imprt) (0) (35)
  8. 8. 8 Developmental Changes (selfDevelopmental Changes (self--reports; MKE Study)reports; MKE Study) Developmental Changes in ADHD (Self-Reports) 40 50 60 HD 10 20 30 PercentADH Syndromal Symptomatic 1.5SD Symptomatic 2SD 0 Child Age15 Age21 Age27 Follow-up Point
  9. 9. 9 Domains of ImpairmentDomains of Impairment (self(self--reported by interview at age 27 followreported by interview at age 27 follow--up; MKE Study)up; MKE Study) 70 80 90 100 d Domains of Impairment 10 20 30 40 50 60 PercentImpaired H+ADHD H-ADHD Controls 0 Work Home Social Community Education Dating Any Domain Domains H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments); H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome; Controls = Community control group
  10. 10. 10 Childhood Academic ImpairmentsChildhood Academic Impairments • Poor School Performance (90%+) – reduced productivity is greatest problemp y g p – accuracy is only mildly below normal (85%) • Low Academic Achievement (10-15 pt. deficit) – May be deficient even in preschool readiness skills • Learning Disabilities (24-70%) – Reading (8-39%); (effect size (ES) = 0.64) – Spelling (12-30%) (ES = 0.87) – Math (12-27%) (ES = 0.89) – Handwriting (60%+) – Reading, viewing, & listening comprehension deficits • Likely due to impact of ADHD on working memory
  11. 11. 11 Educational OutcomesEducational Outcomes • More grade retention (20-45%; MKE: 42 vs. 13) – Pagani et al. (2001) & Hauser (2007) show retention is harmful • More placed in special educational (25-50%) • More are suspended (40-60%; MKE: 60 vs. 19) – Reflects disciplinary action; more associated with CD • Greater expulsion rate (10-18%; MKE: 14 vs. 6) • Higher drop out rate (23-40%; MKE 32 vs 0) • Lower academic achievement test scores • Lower Class Ranking (MKE: 66% vs. 53%) • Lower GPA (MKE: 1.8 vs. 2.4)Lower GPA (MKE: 1.8 vs. 2.4) • Fewer enter college (MKE: 22 vs. 77%) • Lower college graduation rate (5-10 vs. 35%) MKE = Milwaukee Young Adult Outcome Study
  12. 12. 12 Educational Outcomes (age 27)Educational Outcomes (age 27) (Milwaukee Study)(Milwaukee Study) Educational Outcomes 60 70 80 90 100 Group Educational Outcomes 0 10 20 30 40 50 PercentofG H+ADHD H-ADHD Community HS Graduate Retained in Grade College Graduate Diagnosed LD Diagnosed BD Spec. Ed. Type of Outcome H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments); H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome; Controls = Community control group
  13. 13. 13 Learning Disorders at Age 27Learning Disorders at Age 27 (<14(<14thth percentile; MKE Study)percentile; MKE Study) Learning Disabilities 25 30 35 40 roup Learning Disabilities 0 5 10 15 20 PercentofGr H+ADHD H-ADHD Community Reading Spelling Math Reading Comprehension Type of Disability H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments); H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome; Controls = Community control group
  14. 14. 14 Psychiatric DisordersPsychiatric Disorders (by age 27)(by age 27) • Current ODD (12%+ by self-report) • Conduct Disorder (26%+ by self-report)Conduct Disorder (26% by self report) • Depression or Mood Disorders (27% age 21) – 9% H+ ADHD by age 27 vs. 5% H-ADHD, 3% controls – But 18% (H+ADHD) have depressive personality disorder at age 27 vs. 6% (H-ADHD) Suicidal ideation:• Suicidal ideation: – High school (33% of all ADHDs vs. 22% controls) – Post-high school (25% vs 9% controls) • Suicide Attempts: – High school (16 vs. 3% controls)g ( % ) – Post-high school (6 vs 3% controls)
  15. 15. 15 Psychiatric DisordersPsychiatric Disorders • Anxiety Disorders (MKE) – 33% for H+ADHD vs. 11% for H-ADHD, 8% controls E i di d 16% % f i l• Eating disorders: 16% vs. 5% of girls (MGH Boston Study)* – 50% bulimia, 30% anorexia, and 20% mixed anorexia & bulimia • Substance Use/Abuse Disorders (MKE) – 24% for H+ADHD vs. 16% for H-ADHD, 7% control – Alcohol Dependence (11 vs. 4 vs. 3%); Abuse (18 vs. 8 vs. 5%) Alcohol Tobacco and Marijuana used more frequently– Alcohol, Tobacco and Marijuana used more frequently – Hard drug use related to CD & deviant peers • Personality Disorders (H-ADHD vs. H+ADHD vs. Control) - Antisocial (28 vs. 15 vs. 3%)(H+ADHD, H-ADHD, Controls) - Passive Aggressive (33 vs. 19 vs. 3%) - Avoidant (18 vs. 5 vs. 3%)( ) - Borderline (30 vs. 13 vs. 0%) - Paranoid (28 vs. 11 vs. 1%) *Biederman et al. (2007). Journal of Developmental and Behavioral Pediatrics, 28, 302-307.
  16. 16. 16 Oppositional Defiant Disorder (40Oppositional Defiant Disorder (40--80%)80%) • ADHD cases are 11x more likely to have ODD • ADHD contributes to and likely causes ODDy – This likely occurs through the impact of ADHD on emotional self-regulation (an executive function) – This can account for the well-established findings that ADHD medications reduce ODD as much as they do ADHDADHD • Some ODD is related to disrupted parenting – Inconsistent, indiscriminate, emotional, and episodically harsh and permissive (lax) consequences teaches social coercion as a means of social interaction – Poor parenting can arise from parental ADHD and other high risk parental disorders in ADHD families • Early ODD predicts persistence of ADHD and increases risk for CD/MDD and anxiety disorders
  17. 17. 17 Conduct Disorder (20Conduct Disorder (20--56%)56%) • If starts early, represents a unique family subtype – More severe, more persistent antisocial behavior – Worse family psychopathologyWorse family psychopathology • Antisocial personality, substance use disorders, major depression • Parent hostility, depression, & low warmth and monitoring interact reciprocally with child conduct problems over time to adolescence** – Greater association with ADHD (especially inattention symptoms) – Less responsive to behavioral or family interventions • Increased risk of psychopathy (20%) • Father desertion, parent divorce more common • Major depression more likely to precede/co-exist with CD • If CD starts late (>12), related to social disadvantage, family disruption & affiliation with deviant peersfamily disruption, & affiliation with deviant peers • School drop out, drug use, and teen pregnancy are more likely in comorbid cases than in ADHD alone* *Barkley, R. A. et al. (2008). ADHD in Adults: What the Science Says. New York: Guilford. ** Special issue on reciprocal influence across development, Journal of Abnormal Child Psychology (2008), vol. #36 (July).
  18. 18. 18 Employment ProblemsEmployment Problems • Enter workforce at unskilled/semi-skilled level • Greater periods of unemployment – at age 21 (22 vs. 7%) – At age 27 (25% currently ADHD, 9% for controls and no longer ADHDs) • More likely to be dismissed or fired – 55 of ADHD cases vs. 23% of controls had been fired by age 27 – Fired from 16% vs. 6% of all jobs held • Change jobs more often – 2.6 vs. 1.4 times over 8-12 years since leaving high school • More ADHD/ODD symptoms on the job – As rated by current supervisors • Lower work performance ratings – As reported by current supervisors • Lower job status rating and overall socio-economic status• Lower job status rating and overall socio-economic status • By 30s, 35% may be self-employed (NY Study by Mannuzza et al.)
  19. 19. 19 Workplace ProblemsWorkplace Problems (MKE(MKE -- age 27)age 27) Workplace Problems bsHeldPercentofJob H+ADHD H-ADHD Community Trouble Others Behavior Problems Fired Quit - Hostility Quit - Boredom Disciplined Problem Type H+ADHD = Hyperactive as a child and still ADHD at adult outcome (4+ symptoms and 1+ impairments); H-ADHD = Hyperactive as a child but is not diagnosable as ADHD at adult outcome; Controls = Community control group
  20. 20. 20 ConclusionsConclusions • ADHD is a valid disorder that is highly persistent into adulthood – 65-86% • ADHD in children produces immediate and long-term adverse effects on educational performance and final educational levels whether or not it persists to age 27 • ADHD increases the risk for other psychiatric disorders including ODD CD Anxiety Disorders Majorincluding ODD, CD, Anxiety Disorders, Major Depression, and Suicidal Thinking and Attempts • ADHD produces a negative impact on occupational level and employment functioning • These educational, psychiatric, and occupational risks, p y , p are associated with significant economic costs and burdens to society, to government agencies, and to employers

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