Researchers Can’t Predict Whether Childhood ADHD Will Impact Adult Functioning

New research has found that a childhood ADHD diagnosis is not predictive of adult functioning in boys.

Peter Simons
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New research finds that a childhood ADHD diagnosis in young boys is not predictive of adult functioning. In this new study, even the severity of ADHD in childhood did not predict any adult outcome measures. The researchers hypothesized that numerous predictive factors could be used—but found that only childhood IQ was able to predict multiple outcomes. This result was disappointing for the researchers, as IQ predicts these outcomes in all children, not just those diagnosed with ADHD.

“Unexpectedly, the severity of ADHD symptoms in childhood was not associated with any of the outcomes listed,” the researchers write. “Other than childhood IQ, which predicted better outcomes in several domains, there were no consistent prognosticators of adult function among children with ADHD.”

Photo credit: “Growing up,” by Marco (Flickr)

María A. Ramos-Olazagasti, of Columbia University, led the research and published it in the Journal of the American Academy of Child and Adolescent Psychiatry. The researchers found that childhood IQ was able to predict (at least better than chance) the following adult traits:

  • educational attainment
  • occupational rank
  • occupational adjustment
  • social adjustment

It should be noted that IQ is generally able to predict these particular outcomes in children without ADHD as well, so this finding adds little to the research. Additionally, these outcomes may not be as relevant as life satisfaction or quality of life outcomes, which are less linked to IQ.

Other findings in the study were that socioeconomic status and reading ability could (on average) predict future educational attainment, which is not a surprise, as this is a commonly used predictor in children without an ADHD diagnosis as well. Additionally, as is common in this research, conduct problems in childhood were associated with lower overall functioning, educational attainment, and occupational functioning in adulthood. Similar to children without an ADHD diagnosis, those children who were poorly behaved and did not engage in school were slightly more likely to be less educated and have less well-paying jobs as adults. Other slight correlations were found that were common in the literature:

“Antisocial behaviors predicted poorer educational attainment; educational goals were related to better overall function; early job functioning had a positive relation with social functioning; and early social functioning was positively related to occupational functioning.”

None of these had the kind of predictive power the researchers hoped to see, and none are unique to children with ADHD. Strangely, the authors did not report whether the children were prescribed medication. This makes it difficult to interpret their results, as children are frequently prescribed various types of psychoactive drugs for ADHD, including stimulants and antipsychotics. Any of these medications might have a positive or negative effect on future functioning.

Another limitation of the study is that it focused on White boys without a diagnosed conduct disorder. Conduct disorder is often diagnosed with ADHD, so this study missed a substantial portion of the population of children with an ADHD diagnosis. Additionally, by focusing on White boys, this study can tell us nothing about predictors (or lack thereof) of future functioning for girls and non-white people.

The researchers conclude that “predicting the course of children with ADHD remains a challenge.”

 

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Ramos-Olazagasti, M. A., Castellanos, F. X., Mannuzza, S., & Klein, R. G. (2018) Predicting the adult functional outcomes of boys with ADHD 33 years later. Journal of the American Academy of Child and Adolescent Psychiatry, 57(8), 571-582. doi: https://doi.org/10.1016/j.jaac.2018.04.015 (Link)

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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22 COMMENTS

  1. I just scratch my head when I read these things. Are they not scientists? They are SO biased, they are searching for certain results, and when they don’t get them, they are “disappointed.” This is actually a very helpful study, because it shows that “having ADHD” as a child is NOT associated with negative long-term outcomes. The conclusion should not be that “predicting the course of children with ‘ADHD’ remains a challenge.” It should be that “Our original hypothesis was disproven – an ‘ADHD’ diagnosis does not lead to worse outcomes as an adult.”

    As for the proviso about children with “conduct disorders,” that’s meaningless, because it’s been determined long before that kids with ‘ADHD’ and ‘conduct disorder’ diagnoses do have later troubles in live, while those who “just have ADHD” do just as well as their peers. And when you consider that “conduct disorder” just means kids who are mean and selfish, what we have is that mean and selfish kids grow into mean and selfish adults, a trivial result that should surprise no one. It was, in fact, very smart to isolate “ADHD” in kids not diagnosed with “conduct disorder,” because now we can see that having the “ADHD” characteristics in and of themselves has NO EFFECT on whether or not a kid turns out to be a successful adult.

    But I guess the authors just can’t accept the conclusion that the data tells them is true. They need to hold onto their reality despite the data, which means they’re not scientists after all.

    • Hi Steve, we’ve not met but I’ve followed MIA for a long time and enjoy your comments. I have a child who has been diagnosed with ADHD and has many conduct issues. The diagnosis was not my choice but the result of frantically trying to get some behavioural input and services for a child that suffers greatly. I know it is hard to be nuanced at all times but I wanted to pick you up on your use of language.

      To call a child ‘mean and selfish’ is unfair and dismissive of a great deal of pain. While at certain times of stress my child can be both mean and selfish the reasons for this are many and varied. Most importantly, he himself dislikes his reactions more than anyone. In my experience it is the children with conduct problems who most need help and understanding to turn their behaviours around but are also the most likely to be written of as just ‘naughty’, or in this case ‘mean and selfish’, without a future before them. I was surprised and disappointed to find this attitude here on MIA. Underneath all behaviour is someone trying to cope with the world, but sometimes without the skills to get their needs met in a socially appropriate way.

      I could go on about the intergenerational trauma that plays out in my family; about an oppressive school system that demands conformity; or about the crazy advancements in technology and media that leave us all overstimulated and frazzled, all of which add to a fight or flight system that is in constant hyper vigilance and that would reduce anyone’s abilities to empathise with others – but that is not news. For some poor children their response to a crazy world is a ‘fight’ reaction. I agree this is hard to empathise with, but it is just that, a response to the world like any other.

      It has also just occurred to me that calling any child mean and selfish is pretty much calling a spade a spade. Childhood is inherently egocentric, I myself was obnoxious and foul to my brother when we were young, amongst other things. I am no longer mean nor selfish in general although these are among the human traits that make up complex, nuanced individuals. Childhood is for maturing and learning these skills. To say that childhood traits ‘make the man’ is highly problematic and is a major contributing factor to the pathologising and medicalisation of childhood that MIA is critiquing. What stops some people from maturing into more socially acceptable responses is the question? I guess my philosophical position is that while ‘all people are fundamental good’ may be a bit of a stretch, this does not mean that ‘some people are just fundamentally bad’.

      • I’m sorry that my comment came across that way. I don’t believe and never have that “some people are fundamentally bad.” I agree 100% that intergenerational trauma is usually at the core of any misbehavior by children, and I’m the biggest advocate you can imagine for family work and attachment parenting and dealing with childhood trauma. I was perhaps being too flippant in my statements, as I was thinking more about the attempts to characterize “ADHD kids” as “needing treatment” to avoid bad outcomes. Two of my three met the criteria for ‘ADHD’ and we did a lot of work to avoid getting them enmeshed in the psychiatric system/paradigm, including some very creative discipline and home schooling. Lord knows what would have happened if we’d put the oldest in school – he probably WOULD have gotten at least an “ODD” diagnosis.

        Anyway, my intention was not to insult kids or their parents, but to point out that if a certain behavior occurs as a child, predicting that the same kind of behavior would continue as an adult is not really an accomplishment. I most certainly should have chosen my words more carefully, and I apologize for that.

        • Thank for replying, I suspected that this was just a throwaway comment. Sometimes my anger about the situation fuels me to comment where it’s least needed. Looks like I’m found guilting of teaching Grandmother to suck eggs!!

          We are probably looking at needing to homeschool. When he’s in school the pressure to medicate is enormous and the inference is that we are being belligerent and stopping his progression by not medicating! Indeed the assumption by all health professionals is that without meds future outcomes look poor. No one is interested in research like this that shows there is no difference in outcomes (or even worsening outcomes due to both the meds and the loss of agency that comes with meds). They have their doctrine and stick to it fiercely.

          What has shocked and saddened me is that we live in the UK where I thought (hoped) the diagnosis and treatment of ADHD was more nuanced and less driven by trends, ideology and pharmaceutical influence but I was wrong. The ADHD parent group I was sent to recently was sponsored by the drug companies and their literature written by them, with one page about star charts listed as the best behavioural options and when that fails ritalin, ritalin and more ritalin! Not sure whether it’s laziness, wider neo-liberal forces on children to perform or the cash-strapped health system here but ADHD has arrived in force and looks like it’s here to stay.

          Anyway, all the best and thanks again

          • You bet. It’s a very sore subject for me, too. We found that alternative schooling was absolutely essential to maintaining any kind of sanity, and home schooled for years. We also helped create a few different alternative school environments where kids got more control of their own educational goals and activities, as this has been proven long since to be the best environment by far for them (educators asked to distinguish between “ADHD” and “normal” kids back in the 70s were unable to do so in an open classroom, while they were 90+% accurate in a standard classroom environment). We also found that standard disciplinary tactics were often totally ineffective, and we had to be VERY creative. We used to often “bet” each other or our son that he could not or would not do what we wanted him to do. He hated us predicting anything about him and enjoyed making us “wrong,” so this worked pretty well. The best we ever came up with was what we called “energy points.” He started every day with zero energy points. If he did something to make me feel more energetic, or saved me energy in some way, he got “plus one.” If he did something to drain or waste my energy, he got “minus one.” If he got below zero, I stopped doing ANYTHING for him – talking, making lunch, driving him anywhere, playing with him – I did nothing at all. Of course, arguing about receiving a minus meant another negative point. He then had to do something to elevate my energy in order to get back up to zero or above. This usually meant some kind of work, and doing work in and of itself often brought him out of his negative state. In fact, I used to try and start the day giving him a useful task or two in order to set the tone. The only thing I had to remember was not to go more than minus two, because then he felt like he was so deep in, there was no point in trying.

            You know your child and will figure out what works. Schools don’t know your child or try to get to know them, and the DSM diagnoses simply make it easier for them to blame the child and evade any kind of professional responsibility for figuring out how to teach him what he needs to learn. I encourage you to seek alternatives. I don’t know that we would have survived if we had not.

            Thanks for sharing your story, and I wish you the best of luck in finding a better path forward!

      • Alice,

        As to your question, “What stops some people from maturing into more socially acceptable responses is the question?”

        There is evidence that stigmatizing a child with the “invalid” DSM disorders, and drugging them with the psychiatric drugs, is something which “stops some people from maturing into more socially acceptable responses.” Especially when it comes to childhood trauma survivors, because the psych drugs harm legitimately distressed child abuse or trauma survivors.

        https://www.madinamerica.com/2016/04/heal-for-life/

        And today’s “mental health professionals,” collectively, are taught to misdiagnose childhood trauma survivors with the billable DSM disorders, and change the subject basically. In other words, discuss the “lifelong, incurable, genetic” nature of the DSM disorder, while denying the effects of the trauma. Today’s “mental health professionals” can NOT even bill insurance companies for helping child abuse survivors, as a matter of fact.

        https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

        I am glad you have not drugged your child. I believe you are correct that home schooling your child is a better idea than drugging your child. You do sound like a strong and loving mother who stands up for her child, and that is what your child needs the most.

        Steve’s comment, “I agree 100% that intergenerational trauma is usually at the core of any misbehavior by children, and I’m the biggest advocate you can imagine for family work and attachment parenting and dealing with childhood trauma.”

        I agree with Steve, so long as you can find a family therapist who is willing to address the intergenerational trauma, rather than merely label your child. Which may be hard to find, because today’s “mental health professionals” can not bill insurance companies for such help, unless they first misdiagnose someone with the billable DSM disorders.

        Today’s DSM based “mental health” system is set up as a Catch 22 for child abuse and trauma survivors.

        As to the ADHD diagnosis in general, I agree with Thomas Insel, it’s an “invalid” diagnosis.

        https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

        And I believe it’s disgusting that children are being force fed amphetamines. It’s a shame today’s “mental health” researchers can’t come to grips with the reality of the invalidity of all the DSM disorders. Research funding should be taken away from these “biased,” I would say DSM deluded, “scientists.”

  3. What they are supposedly researching does not exist. ADHD was something trumped up by the drug companies and psychiatry in the mid-80’s and they created it to make a lot of money, at the expense of kids’ lives. Why are they wasting money and time on something like this when there are more important things to work on; things like helping people learn how to make quality relationships with other, things like working to lower the number of people suffering from poverty through no fault of their own, things like working to achieve affordable and safe housing for people who need it, things like creating respite houses in place of warehouse prisons known as “hospitals” where people are drugged to the gills. I am so tired of all this. Studies like this are a waste of good money and valuable time.

    • Stephen,
      I agree that more money needs to go into providing basic needs. I would also postulate that some people (kids and adults) have a combination of: a tremendously difficult time staying focused, feel like they have an inner restlessness causing them to be fidgety, being easily distracted, experience impulsive behaviors, often have trouble waiting their turn, also have a tendency to get hyper focused on one thing and ignore everything else around them.

      I suspect that some of this is neurological, but frankly we don’t know why some act this way and others don’t. In many cases people with this group of symptoms are very successful adults; I work with many of them in my office! The problem is that for some people this set of symptoms causes functional difficulties with work, relationships, school/learning, finances, etc., which can cause significant distress. I think schools should be structured differently to enable kids with these differences to learn in a manner which suits them, not the other way around.

      • And if it is sometimes “neurological,” so what? Species survival depends on genetic diversity. Everyone has challenges and strengths. My kids (two of which would definitely have qualified for “ADHD” diagnoses) always heard what they were good at and what they needed to work to improve, and THEY were a big part of deciding for themselves what those “work ons” were and what they were going to try and do to make improvements.

        And there are upsides to any personality tendencies as well. The unfortunate reality for so-called “ADHD” kids is that they are forced to contend with a school system that specifically does almost everything it can to frustrate them (albeit mostly without evil intent. Mostly.) “ADHD” is pretty much synonymous with “hates a standard classroom.” Put those same kids in an open classroom with freer choice and movement, and “ADHD” is almost invisible. That’s what we did with our kids (homeschooling or alternative schools with open classrooms) and all three are doing very well as adults, with nary a milligram of stimulants. Not saying it was easy, because it wasn’t, but just because a kid is frustrating for adult does not make him/her “mentally ill.” Sometimes they are just being normal and it’s inconvenient for the grown ups. I think it’s the adults’ job to adapt.

        • Steve,
          Your kids were lucky to have parents who were very invested in fitting the situation to their needs. Unfortunately, there are millions of kids who don’t have the same opportunity, and thus they struggle in the school environment which does not cater to their needs. Also, I’d venture to guess that the bulk of these kids are growing up in difficult households/communities, so of course trauma plays a role. The “identified patient” should not be the child.

          Because I’ve only worked with adults, I feel most comfortable in stating that ADHD symptomology seems like a legitimate construct for some people. One problem is that virtually everyone performs better on stimulants because of increased focus and concentration it provides. I think people can learn to cope in ways which are effective for them in adulthood, and that providing stimulants does more harm than good for those who struggle with these symptoms. I have had clients who get addicted to their stimulants and get quite depressed and lethargic off of them.

          If the world was set up to work for people with ADHD symptoms, there would not be a problem. Unfortunately, we live in an often inflexible and overstimulating environment which expects people to “act a certain way” otherwise they are deemed “a problem”, hence the appeal of psych drugs. Ironically in America we value conformity despite our ideal of individual freedom and personal choice.

          • You might be interested to know that a good study of employees who had been diagnosed with “ADHD” at some time in their lives. The employer ratings were compared to non-ADHD employees and were found to be essentially the same for both. The researchers posited that once the “ADHD” youth were freed from the bounds of the school system, they chose jobs that allowed them to take advantage of their strengths. So when they were able to select the environment, their “ADHD” had little to no impact on their ability to perform up to standards.

            And you’re right, our kids were fortunate in many ways. What I find sad is that our school systems are so rigid that they are unable/unwilling to do what is necessary to adapt to these kids’ needs. It’s already a known fact that open classrooms are the best setting for most of these kids. Instead of drugging them, why aren’t we creating open classroom environments so they can succeed in school?

      • As a former teacher and being a twelve year product of the American educational system I will say this. I never experienced a fellow student during my school days that I would ever say had ADHD. I never taught a student in my fifteen year teaching history that I would label as a person who supposedly had ADHD. I saw the beginnings of this movement to create problems for kids by labeling them as having this fake issue called ADHD. There were always kids who created problems of one sort or another but I would say that this is the nature of being a kid.

        I will also state this. The American classroom, for the most part, is one of the most boring places you’d ever want to experience. What kid wouldn’t be bored to tears and moved to do things he or she probably shouldn’t do? And another problem is that we’re sending kids to school at earlier ages and expecting them to achieve things that their age group isn’t capable of. Our demands on their time and their abilities are unrealistic and this creates problems for them.

        • Stephen,
          True enough. The classroom in America, similar to our prison system, is set up to fail. Bored kids act out (as do bored adults). We should be looking at more dynamic models of teaching around the world and realize that expecting kids to sit still in class and listen for 6-8 hours is ridiculous.

        • All very true. We seem to toss out any respect for all the good work on developmental expectations and the range of appropriate development as soon as they reach Kindergarten. Suddenly, everyone’s expected to be on the level the teacher wants, and if they are not, they have a “reading disorder” or “mathematics disorder” or “Oppositional defiant disorder” or “ADHD.” And I agree, school for me was AGONIZINGLY dull! It’s only because I was possessed of an extraordinary level of self control as a child that I didn’t run screaming from the room!

    • I think they were hoping to prove that “ADHD” kids did better when receiving “treatment.” They were, not surprisingly, sadly disappointed. But ever hopeful, rather than admitting that they have their answer and need to give it up, they will continue to apply for and receive grants to “study” this “condition” that is only definable in the vaguest and most subjective terms, and whose “treatment” apparently does little to nothing to improve the ostensible “condition” it is supposed to “treat.”

  4. Adult ADHD is now a category. Of course, when a child with ADHD grows into an adult with ADHD, expectations can only be so high.

    The problem I have here is these associated disorders. You bring up antisocial personality disorder and conduct disorder, and one could have mentioned oppositional defiance disorder. What bunk!

    Better functioning apparently grows out of one’s capacity to kiss ass.

    Oh, why do I not cease to have doubts about this, and all the bogus disorders that go along to support it? Success is a 5 digit (at least) salary. I would say you’re little program here favors those people afflicted with kiss-ass-citis. Nobody is asking how we can improve the outcomes of people with kiss-ass-citis, and many of those outcomes are, in my opinion, pretty bleak.

    • In other words, kids who are more likely to take risks as children are more likely to take risks as adults. Wow, enlightening results here. In other news, kids who run fast tend to run faster as adults, kids who like to paint are more likely to paint as adults, and the sun is very likely to come up in the East tomorrow morning.

      • The author (Peter Simons) mentioned that strangely it was not reported whether the participants took medication. You have to read the linked article to find out that 88% of the participants did take medication. It also points out that 3 of the 207 probands died by suicide. To some people, there is value in looking at the details. Different people will learn different things by doing so.

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