Studies that have followed children with ADHD into adolescence have yielded 3 overall conclusions: 1) ADHD does not "disappear" for most youth and symptoms levels frequently remain elevated; 2) many youth continue to experience impairment in multiple domains; and, 3) there is substantial variability in adolescent outcomes. 

Although such studies highlight the ongoing struggles that many children with ADHD experience during adolescence, less attention has been paid to the frequency with which children with ADHD show positive adjustment as teens.  Furthermore, few studies have examined positive adjustment across multiple domains simultaneously, e.g., academic, social, and psychological. Thus, the basic question of how often do children with ADHD show an overall positive adjustment in adolescence has rarely been addressed and never examined in a large sample of girls. 

A recently published study does a very nice job of addressing this important question [Owens, Hinshaw, Lee, & Lahey. (2009).Few girls with children ADHD show positive adjustment during adolescence. Journal of Clinical Child and Adolescent Psychology, 38, 132-143.]  Participants were 140 girls diagnosed with ADHD when they were 6-12-years old and 88 age and ethnicity-matched comparison girls.  Girls with ADHD had been recruited from community rather than clinic-based settings. Approximately 5 years after their initial diagnosis, when the average age of the girls was 14.2 years, 209 of the original 228 participants participated in a follow-up assessment.  At this assessment, the researchers examined girls adjustment in multiple domains including: ADHD symptoms, behavior problems, internalizing problems (i.e., depressive and anxiety symptoms), social skills, peer relationships, and academic functioning. 

Girls' ADHD symptoms, behavior problems, and social skills were assessed by having parents and teachers completed standardized behavior rating scales.  Internalizing symptoms, i.e., anxiety and depression were collected from parents using a structured psychiatric interview.  Peer relationships were measured by having teachers rate each girl's social acceptance by peers and academic achievement in reading and math was assessed using individually administered achievement tests.  At the follow-up assessment the researchers also learned whether girls had: 1) been treated with medication during the past year; 2) received school-based educational interventions since the baseline assessment; and, 3) received any psychological interventions outside of school since the baseline assessment.

As noted above, the researchers were interested in the percentage of girls with and without ADHD who were making positive adjustments in each domain, as well as the percentage making positive adjustments (PA) across multiple domains.  To avoid overly stringent criteria for establishing PA, cut-offs were set at the low end of the average range for social skills, academic achievement (girls were considered to show PA in these domains if there scores were not too far below average), and at the high end of the normal range for ADHD symptoms, behavior problems, internalizing problems, and peer relationship problems (PA in these domains were defined as not being too far above average).  The exact cut-off for PA in each domain was set at halfway between the average score of girls with ADHD and the average score for comparison girls.  In domains where parent and teacher ratings were collected, girls had to show PA from each source to be considered positively adjusted within the domain. In the academic domain, PA was defined as having an achievement score above 85 (100 is average) in both reading and
math.


- Results -

The percentage of girls in each group showing PA in the individual domains was as follows:


ADHD symptoms                     Girls with ADHD - 20%           Comparison girls - 86%

Behavior Problems                  Girls with ADHD - 42%           Comparison girls - 91%

Internalizing symptoms          Girls with ADHD - 49%           Comparison girls - 85%

Social Skills                              Girls with ADHD - 41%           Comparison girls - 83%

Peer Acceptance                     Girls with ADHD - 61%          Comparison girls - 87%

Academic Achievement           Girls with ADHD - 65%          Comparison girls - 96%


The percentage of girls in each group showing positive adjustment across different numbers of domains is shown below.


PA in 0 domains                      Girls with ADHD - 6%            Comparison girls - 0%

PA in at least 1 domain          Girls with ADHD - 94%          Comparison girls - 100%

PA in at least 2 domains        Girls with ADHD - 77%          Comparison girls - 98%

PA in at least 3 domains        Girls with ADHD - 52%          Comparison girls - 93%

PA in at least 4 domains        Girls with ADHD - 33%          Comparison girls - 93%

PA in at least 5 domains        Girls with ADHD - 16%           Comparison girls - 86%

PA in all 6 domains                 Girls with ADHD - 4%            Comparison girls - 15%


As seen above, girls with ADHD were substantially less likely to display PA in multiple domains than comparison girls.  The authors defined overall positive adjustment in adolescence at showing PA in at least 5 domains.  By this criteria, only 16% of girls in the ADHD group were positively adjusted.

The authors considered whether overall adjustment differed among girls originally diagnosed with the inattentive and combined subtypes of ADHD.  Interestingly, girls with the inattentive type tended to be less likely to show overall PA at follow-up (8% vs. 20%).  They also examined the association between treatment and overall PA in girls with ADHD. Girls treated with medication during the past year were less likely to show overall PA than other girls from the ADHD group; the same was true for girls who had received psychological treatment outside the school setting. 

Finally, the authors change over time in PA status using an overall adjustment measure disregarding the ADHD domain (this was excluded because by definition, all girls with ADHD were impaired in this domain at baseline and all comparison girls were not). In this analysis, overall PA was defined as PA in at least 4 of the 5 remaining domains.  At baseline, 17% of girls with ADHD met this criteria; at follow-up, this had increased to 29%.


- Summary and Implications -

Results indicate that between 20 and 65% of girls with ADHD were positively adjusted within each of six individual domains; in each domain, the percentage of comparison girls showing PA was substantially higher. Furthermore, only 16% of girls with ADHD showed an overall positive adjsutment compared to 86% of the comparison girls. Thus, most girls with ADHD did not 'grow out of it'. 

At the same time, however, a significant percentage of girls with ADHD were making satisfactory adjustments within each individual domain. And, a notable minority of girls were faring reasonably well during adolescence and met the overall criteria for PA. Thus, while the results are not as positive as one would hope for, one should not lose sight of how many girls were doing reasonably well.  Because the percentage of girls with ADHD showing an overall positive adjustment increased from baseline to follow-up, it is reasonable to speculate that this trend would continue over as they move into young adulthood and beyond.  Of course, this remains to be documented.

There were several findings that initially appear counter-intuitive.   It was somewhat surprising that girls with the inattentive type of ADHD were somewhat less likely to show an overall positive adjustment at follow-up than girls diagnosed with ADHD, Combined Type. However, accumulating evidence suggests that the inattentive type is associated with significant impairment and is less likely than the combined subtype to naturally remit over time.

A second counter-intuitive finding was that girls taking medication and girls who had received psychological intervention were less likely to show an overall positive adjustment.  However, this has been reported in several other studies and probably reflects the fact that girls receiving these treatments had more significant difficulties to begin with.  Although this helps explain these results, it also highlights significant limitations in the treatments that children with ADHD typically receive.

Overall, results speak to the chronic nature of the symptoms and impairments associated with childhood ADHD for girls. As noted above, however, a sizable minority were doing well despite their childhood ADHD and several had moved to the positively adjusted group. It is thus important to remember that although a childhood diagnosis of ADHD portends continuing difficulty, such outcomes are by no means inevitable.

A critical next step will be to identify predictors of positive adjustment in girls with ADHD (the same is true for boys) and how those characteristics can be enhanced. For example, if specific parenting practices were associated with increased PA rates, interventions aimed to promote such practices could be beneficial. Investigations of this issue will be exciting to see and will hopefully be forthcoming shortly.