Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity

Abstract

Objective Longitudinal studies of children diagnosed with ADHD report widely ranging ADHD persistence rates in adulthood (5-75%). This study documents how information source (parent vs. self report), method (rating scale vs. interview), and symptom threshold (DSM vs. norm-based) influence reported ADHD persistence rates in adulthood. Method 579 children were diagnosed with DSM-IV ADHD-Combined Type at baseline (ages 7.0-9.9 years) and 289 classmates served as a local normative comparison group (LNCG), 476 and 241 of whom respectively were evaluated in adulthood (Mean Age= 24.7). Parent and self reports of symptoms and impairment on rating scales and structured interviews were used to investigate ADHD persistence in adulthood. Results Persistence rates were higher when using parent rather than self reports, structured interviews rather than rating scales (for self report but not parent report), and a norm-based (NB) threshold of 4 symptoms rather than DSM criteria. Receiver-Operating Characteristics (ROC) analyses revealed that sensitivity and specificity were optimized by combining parent and self reports on a rating scale and applying a NB threshold. Conclusion The interview format optimizes young adult self-reporting when parent reports are not available. However, the combination of parent and self reports from rating scales, using an “or” rule and a NB threshold optimized the balance between sensitivity and specificity. With this definition, 60% of the ADHD group demonstrated symptom persistence and 41% met both symptom and impairment criteria in adulthood.

Life Span Studies of ADHD—Conceptual Challenges and Predictors of Persistence and Outcome

“…One study evaluated how differences in case definition might impact persistence estimates in the 16-year clinical follow-up of the Multimodal Treatment Study of ADHD (MTA) [27•]. Persistence estimates varied widely from 1.9 % (requiring DSM-IV criteria, combining parent and self-report in the Diagnostic Interview Schedule for Children (DISC) with an item-level AND rule) to 61.4 % (requiring norm-based symptom count, combining parent and self-report in the DISC with an item-level OR rule).…”

Investigating late‐onset ADHD: a population cohort investigation

“…Symptoms tend to attenuate with age, although around 60% of individuals have symptom persistence into adulthood and 40% show both symptom persistence and impairment (Sibley, Swanson et al., 2017). Adult ADHD has been assumed to be a continuation of childhood ADHD.…”

Commentary: Important design features to consider in observational research on the long‐term outcomes of ADHD – reflections on Sibley et al. (2017) and Swanson et al. (2017)

“…Using parent reports and self-reports of symptoms and impairment on rating scales and structured interviews from MTA, Sibley et al (2017) found that when using combined parent reports and selfreports, the balance between diagnostic sensitivity and specificity was optimized by a rating scale method and a norm-based symptom threshold (i.e., four symptoms of either IN or HI). The findings suggest that a thorough assessment of ADHD in adulthood should ideally include reports by other informants and self-ratings.…”

“…The occurrence and prediction of developmental trajectories of persisting and remitting ADHD, as well as late-onset ADHD, are very hot topics in the field of ADHD, and thorough assessments of ADHD in adulthood will be crucial for the field to move forward. Sibley et al (2017) reported that the persistence of ADHD in young adulthood was approximately 60%, and 41.1% of the ADHD group met both the optimized persistence criteria and presence of impairment. This adds to the ongoing and somewhat polarized debate, where ADHD on one hand is conceptualized as a condition that children will eventually outgrow, and on the other hand, as a chronic neurodevelopmental disorder that does not change with development.…”

“…In this issue of the Journal, Sibley et al (2017) presented some important insights into how different assessment approaches influence ADHD persistence rates into adulthood, while Swanson et al (2017) presented interesting hypotheses regarding the longterm benefits (adult symptom reduction) and costs (adult height suppression) associated with the treatment of ADHD with stimulant medication. Both studies relied on the well-known Multimodal Treatment Study of Children with ADHD (MTA; MTA Cooperative Group, 1999).…”