What Predicts a Good Adolescent to Adult Transition in ADHD? The Role of Self-Reported Resilience

Abstract

Objective: ADHD is a disorder associated with impairment and comorbid psychiatric problems in young adulthood; therefore, factors that may imply a more favorable outcome among adolescents with ADHD are of interest. Method: This study used a longitudinal design to assess whether adolescent personal resilience characteristics during adolescence protected against psychosocial impairment, depression, and anxiety 3 years later. Self-reported protective factors were used as baseline measures in the assessment of 190 clinically referred adolescents with ADHD. A semi-structured diagnostic interview was performed at the follow-up. Results: In a group of youth with ADHD, personal resilience characteristics were associated with better psychosocial functioning in young adulthood, and less depression and anxiety. Conclusion: Although further research is needed, these results indicate that personal resilience characteristics may be protective factors in the transitional period from adolescence to early adulthood.

Keywords

ADHD personal resilience anxiety depression adolescence

ADHD is a persistent disorder, which confers an increased risk of developing additional psychiatric disorders, including depression and anxiety, and more psychosocial impairment in young adulthood (Barkley, Fischer, Smallish, & Fletcher, 2002, 2006; Biederman, Petty, O’Connor, Hyder, & Faraone, 2012). To date our understanding of ADHD has been predominantly deficit focused; therefore, identification of factors promoting a better adolescence to adult outcome among individuals with ADHD is of importance. The transition into young adulthood represents a particularly challenging period, as parental support declines and environmental demands increase (Fleming & McMahon, 2012). For individuals with ADHD, this period could be particularly demanding as they tend to have poorer social and organizational skills. Considering these developmental challenges, it is of considerable interest to know factors that promote a better psychosocial functioning and symptom remission in young adulthood for adolescents with ADHD. Recently, risk factors for persistent ADHD and a poor outcome in adolescence were identified, such as severity of ADHD, comorbidity, low social competence, and peer rejection (Mrug et al., 2012; Murray-Close et al., 2010; Weiss & Hechtman, 1993). Impairment could be explained by factors that are critical for functioning, and potentially be treated. However, protective factors might be important as they are known to promote resilience, and lessen child maladjustment after life events (Rutter, 2000). Adolescence is a period to achieve psychological independence, in which individual competencies are important for well-being. Individual competencies may include self-esteem, structured style, and social competence.

Resilience has been referred to as a stable coping style, adaptation, or response to stress (Luthar, Cicchetti, & Becker, 2000) and as a resistance to illness and the ability to positive adaptation (Smith et al., 2013). Rutter (2000) used the term resilience to refer only to persons who adapt well to high levels of environmental adversity. Protective factors that are thought to promote resilience include both individual and environmental factors, and can be measured (Friborg, Hjemdal, Rosenvinge, & Martinussen, 2003; von Soest, Mossige, Stefansen, & Hjemdal, 2010). The relevance of protective factors to individuals with ADHD is an emerging area of interest in recent literature (Modesto-Lowe, Yelunina, & Hanjan, 2011).

We previously examined whether individual competencies, social support, and family cohesion were mediators between emotional problems and quality of life (QoL) among adolescents with ADHD (Schei, Nøvik, Thomsen, Indredavik, & Jozefiak, 2015). Individual competencies, which included self-esteem, structured style, and social competence, were the strongest mediators of the relationship between emotional problems and QoL. We speculated that individual competencies could be more important than family cohesion and social support in the transitional period from adolescence to young adulthood among ADHD patients.

Self-esteem includes self-esteem and self-efficacy, addressing belief in oneself and one’s capability to organize and execute tasks. Multiple studies of adolescents have demonstrated the association between low self-esteem and depression and anxiety disorders (Costello, Swendsen, Rose, & Dierker, 2008; Izgic, Akyuz, Dogan, & Kugu, 2004). Individuals at risk with better self-efficacy have been shown to adapt better to past and present life events (Buckner, Mezzacappa, & Beardslee, 2009). ADHD patients commonly have interpersonal, academic, and occupational difficulties (Fischer, Barkley, Smallish, & Fletcher, 2002), and often grow up with negative feedback concerning their abilities and often lack self-efficacy (Young, Bramham, Gray, & Rose, 2008). They may feel incapable of managing their problems, and attempt to overcome them with inadequate coping strategies (Young et al., 2008). Adolescents with ADHD and a good self-esteem may have a better outcome in young adulthood.

Structured style measured by planning, and being organized and aim oriented relates in part to executive functioning skills. Executive functions are higher level cognitive operations that encompass prolonged, planned, goal-directed behaviors by resisting distractions and inhibiting inappropriate responses (Friedman et al., 2006). The evaluation of executive functions requires broad assessment, often using multiple sources of information, that is, neuropsychological tests, laboratory tests, and questionnaires. Questionnaires categorize executive functions, and are shown to be reliable (Malloy & Grace, 2005). Research has indicated that organization and planning abilities are executive functions important in adolescence (Jacobson, Williford, & Pianta, 2011; Langberg, Dvorsky, & Evans, 2013). A substantial proportion of ADHD patients have executive function deficits (Nigg, Willcutt, Doyle, & Sonuga-Barke, 2005; Roberts, Martel, & Nigg, 2013), which are heterogeneous (Lambek et al., 2011). Executive function deficits are associated with poor behavioral and social outcomes independent of the course of ADHD (Biederman et al., 2006). Thus, more structured style among adolescents with ADHD could be protective for a better outcome in young adulthood.

Social competence has been defined as the possession of skills and behaviors that allow for successful interaction in social situations (Vaughn et al., 2009), measured by, for example, social adeptness, ability to initiate activities, and flexibility in social matters. Prosocial skills among children are associated with peer popularity (Warden, 2003), while poor social skills are associated with peer rejection (Newcomb, Bukowski, & Pattee, 1993). Negative interactions between children with ADHD and other children occur so often that the child with ADHD may be rejected from his or her peer group (Hodgens, Cole, & Boldizar, 2000). ADHD and social difficulties in childhood predict an increased risk of depression and/or anxiety in early adolescence (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997; McQuade et al., 2014; Mikami & Hinshaw, 2006; Roy, Hartman, Veenstra, & Oldehinkel, 2014). Few studies have specifically assessed whether anxiety and depression in ADHD is related to social competence (Becker, Luebbe, & Langberg, 2012). A better understanding of the possible protective role of social competence among adolescents with ADHD in a longitudinal perspective study is called for (Becker et al., 2012; Nijmeijer et al., 2008).

The predictive role of good self-esteem, structured style, and social competence in adolescents with ADHD for outcomes in young adulthood needs to be clarified, and is addressed in the present study. Executive function difficulties are known to persist into young adulthood (Biederman et al., 2009), but the role of structured style in the outcome of adolescents with ADHD adulthood is still unclear. Furthermore, few studies have specifically assessed whether social competence is related to anxiety and depression in young adults with ADHD (Becker et al., 2012), and if this relation is stronger for girls than boys during adolescence (Becker, McBurnett, Hinshaw, & Pfiffner, 2013). Treatment studies of adults with ADHD have shown significant improvement of individual characteristics such as social functioning, self-esteem, and self-efficacy (Bramham et al., 2009; Emilsson et al., 2011); therefore, these characteristics could be considered plastic phenomena. Similar findings might apply to adolescents and young adults, and thus, the identification of factors related to a more favorable outcome is important. A previous report by our group showed that self-reports in adolescents with ADHD provided more detailed information about family functioning than parent proxy reports (Schei, Jozefiak, Nøvik, Lydersen, & Indredavik, 2013), thus results based on self-reports were used in the study.

The objective of the present study was to investigate whether self-reported self-esteem, structured style, and social competence were predictors of a more favorable outcome in clinically referred adolescents with ADHD, with better psychosocial functioning, and less anxiety and depression in young adulthood. We included key covariates in the analyses (age, gender, level of ADHD symptoms) to determine the specificity of protective factor outcome associations. We had the following hypotheses:

Hypothesis 1: Better self-esteem predicts better psychosocial functioning, and less depression and anxiety.

Hypothesis 2: A more structured style predicts better psychosocial functioning and less ADHD symptoms, depression, and anxiety.

Hypothesis 3: Better social competence predicts better psychosocial functioning, and less depression and anxiety at a follow-up 3 years after the first assessments.

Method

The Clinical Sample

The study was part of The Health Survey performed by the Department of Child and Adolescent Psychiatry (CAP), St. Olav’s University Hospital, Norway. The baseline study was of a defined clinical population. The catchment area was a county in Norway with 303,664 inhabitants, which includes urban and rural areas. The Department of CAP at the University Hospital covers all inhabitants in the county. Inclusion criteria were as follows: referred adolescents, age between 13 and 18 years, and presence of at least one attendance at the clinic between February 15, 2009, and February 15, 2011. Exclusion criteria were as follows: major difficulties in answering the questionnaire because of their psychiatric state, cognitive function, or lack of sufficient language skills. Emergency patients were invited to take part once stabilized. In the study period, 2,032 adolescent patients had at least one attendance at the CAP clinic. Of these, 289 were excluded on the basis of the exclusion criteria. In addition, 95 were lost in the registration process (i.e., missing). Among the 1,648 (81.1%) eligible and invited adolescents, 717 (43.5%) participated in the CAP baseline survey: 393 girls (54.8%) and 324 boys (45.2%).

To explore the representativeness of the study sample, anonymous information about the reference population was collected from annual reports from St. Olav’s University Hospital, 2009 to 2011. All adolescents in the study period (n = 2,032) minus those excluded (n = 289) were defined as the reference population (n = 1,743). In accordance with the permission given by the Norwegian Social Science Data Services, The Data Protection Official for Research, we compared age, sex, and main reason for referral between participants (n = 717) and non-participants (n = 1,026) of the reference population. Participants were 0.27 years (95% confidence interval [CI] = [0.10, 0.45]) older than non-participants (M = 15.66, SD = 1.65 vs. M = 15.39, SD = 1.95, p < .001). There were more girls in the study group than in the non-participating group: (n = 393, 54.8% vs. n = 509, 49.6%, p = .032). The main reason for referral did not differ between participants and non-participants (data not shown, Pearson exact chi-square test; p = .11). The sample was re-examined after 3 years. Of the 684 who had consented to be invited for follow-up, 575 (84.1%) participated of whom 550 (80.4%) took part in the diagnostic interview (Figure 1). Of the 717 participants in the CAP survey baseline, 243 adolescents were diagnosed with ADHD, of whom 104 were female. Of the ADHD patients from the baseline survey, 190 took part in the diagnostic interview (78.5%), of whom 79 were female (Figure 1).

Figure 1.

Flowchart of sample.

Procedures

Baseline

Newly referred patients and patients who were already enrolled in the CAP clinic received oral and written invitations to participate in the study at first attendance after commencement of the project. The participating adolescents responded to an electronic questionnaire and data were collected from clinical charts. The ADHD Rating Scale (ADHD-RS) was collected from the period of assessment prior to the initiation of medical treatment. Parents also responded to a questionnaire with items related to educational level.

Follow-up

Diagnoses were based on telephone interviews with the participants. The interviewers were blind to the participants’ baseline assessment. The interviewers had a graduate degree in medicine or psychology, and were experienced in child and adolescent psychiatric assessment. The interviewers were extensively trained and supervised, and a blinded experienced child and adolescent psychiatrist supervised the interviewers throughout the study. The inter-rater reliability study was designed as follows: Seven of the interviewers were used as second opinion raters of audio-taped telephone interviews. Each of the seven re-scored four interviews performed by four of the other six interviewers. Hence, the number of re-scored patients was 7 × 4 = 28. We excluded bipolar disorder from the analysis, as the agreement for bipolar disorder was very poor. The median Cohen’s kappa coefficient was .786, which is regarded as very good agreement. Kappa coefficients for individual diagnosis included ADHD = .825, depression = 1.000, and anxiety = .435. The variance between the raters for the Children’s Global Assessment Scale (CGAS) scores was not statistically significant (likelihood ratio test p = .19).

Baseline Measures

Clinical diagnosis

Diagnoses were collected from clinical charts at baseline according to the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10; World Health Organization [WHO], 1992) multiaxial diagnostic system (i.e., axes I-VI). All diagnoses were made by a clinical psychologist or a child and adolescent psychiatrist based on the available clinical information. The CAP clinic’s standardized procedure for the assessment and diagnosis of hyperkinetic disorders is based on the National Guideline for Assessment and Treatment of ADHD (Norwegian Directorate of Health, 2007). This guideline, similar to other established ADHD guidelines (Subcommittee on Attention-Deficit/Hyperactivity Disorder et al., 2011), requires a clinical diagnostic interview of the ADHD symptoms described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994), possible co-existing disorders, and a somatic assessment; it recommends the use of questionnaires filled out by the adolescent, parent, and teacher to ADHD symptom score (ADHD-RS). Diagnostic criteria for hyperkinetic disorder are nearly identical to criteria for ADHD-combined type in the DSM-IV; however, specifiers such as mainly attention problems or mainly hyperactivity or impulsivity problems are not used in the ICD-10. The guideline of Norwegian Health Authorities adjusted the diagnostics of hyperkinetic disorder to include those with inattentive subtype. In the present study, ADHD includes ICD-10 Hyperkinetic Disorder and DSM-IV inattentive subtype.

ADHD-RS IV

ADHD symptoms were measured using the ADHD-RS parent version (Dupaul et al., 1998). The instrument contains 18 items that address ADHD symptoms based on the DSM-IV criteria. The items are measured on a 5-point scale, in which higher scores reflect higher frequencies of symptoms. The scale is organized into two sections, each with its own sum score. One reflects symptoms of inattention, whereas the other reflects hyperactivity and impulsivity.

Strengths and Difficulties Questionnaire (SDQ)

Emotional problems were measured using the Norwegian version (Van Roy, Groholt, Heyerdahl, & Clench-Aas, 2006) of the SDQ (Goodman, 1997). This clinical and research instrument contains 25 items that address emotional and behavioral problems, as well as personal strengths (Goodman, 1997). To define emotional problems, we used the Norwegian cutoff points of borderline level (80th percentile; Van Roy et al., 2006). Thus, the ADHD group at baseline was divided into two groups, with and without emotional problems. The SDQ adolescent self-report exhibited satisfactory construct validity and internal consistency in a study performed by the original author; the Cronbach alphas of the self-report were as follows: total difficulties, .80; emotional problems, .66; conduct problems, .60; and hyperactivity or inattention, .67 (Goodman, 2001). Van Roy, Veenstra, and Clench-Aas (2008) found the SDQ self-report to be appropriate for children and adolescents aged 10 to 19 years. Another study performed by the same authors divided the sample according to the following age groups: 10 to 13 (preadolescent), 13 to 16 (early adolescent), and 16 to 19 (late adolescent) years. The early and late adolescent groups had the following Cronbach alphas, respectively: emotional problems, .71 and .70; conduct problems, .59 and .54; and hyperactivity, .65 and .66 (Van Roy et al., 2006).

Resilience Scale for Adolescents (READ)

Protective factors were measured using the READ, which is a 23-item self-report scale that is based on a 5-point Likert-type scale (von Soest et al., 2010). Higher scores on the READ reflect lower degrees of resilience. The construct and convergent validity was adequately assessed (von Soest et al., 2010). The READ is based on the Resilience scale for adults (Friborg et al., 2003), and consists of the same five subscales: (a) Self-Esteem, (b) Social Competence, (c) Structured Style, (d) Family Cohesion, and (e) Social Resources. The present study used the three dimensions assessing individual resiliencies: (a) Self-esteem measured self-esteem, self-efficacy, self-liking, hope, and determination and a realistic orientation to life; (b) Structured style measured the ability to uphold daily routines, to plan and organize; and (c) Social competence measured extraversion, social adeptness, humor, good communication skills, and flexibility in social matters.

Follow-Up Measures

Kiddie-Schedule for Affective Disorders and Schizophrenia (Present and Lifetime version; K-SADS-PL)

K-SADS-PL (Kaufman et al., 1997; translated to Norwegian by Sund, NTNU, Trondheim) is a well-established, semi-structured diagnostic interview designed to assess present and past episodes of psychopathology among children and adolescents on Axis I of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000). Diagnoses were based on interviews with the participants. Diagnosis of depression included major depressive episodes, dysthymia, and depression not otherwise specified (NOS) at present and during the last 3 years. Diagnosis of anxiety included panic disorder, separation anxiety, specific phobia, social phobia, agoraphobia, general anxiety, and anxiety disorder INA at present and during the last 3 years. Diagnosis of ADHD included ADHD inattentive and hyperactive/impulsive type and ADHD INA. Young adults currently taking medication prescribed for ADHD were classified with a diagnosis of ADHD whether or not they fulfilled symptom criteria.

CGAS

As a measure of overall functioning, we used the Norwegian version of the CGAS (Schorre & Vandvik, 2004; Shaffer et al., 1983), a summary score assigned by the interviewers based on information gathered during the diagnostic structured interview. The instrument yields a score on a 1 to 100 scale, in which 1 indicates the most severely disordered child and 100, the superior functioning child in all areas (at home, in school, and with friends). Scores above 70 indicate normal functioning (Bird et al., 1990). The CGAS has been validated against many different psychiatric assessment scales (Winters, Collett, & Myers, 2005), and has been shown to distinguish cases from non-cases (Bird et al., 1990).

Ethics

Written informed consent was obtained from adolescents and parents prior to inclusion, according to the study procedures in the CAP survey. Study approval was given by the Regional Committees for Medical and Health Research Ethics (Reference No. CAP survey: 4.2008.1393, present study: 2011/1772, and by the Norwegian Social Science Data Services [Reference No. CAP survey: 19976]).

Statistical Analysis

Binary regression was used to calculate the odds of being diagnosed with ADHD, depression, or anxiety disorder at the 3-year follow-up assessment depending on protective factors.

Linear regression analysis was used to assess the association between ADHD at baseline and psychosocial functioning at the 3-year follow-up assessment. To include the effects of protective factors and to control for potential confounders, adolescent age, gender, level of ADHD symptoms at baseline (ADHD-RS), and protective factors were included in the regression analyses separately.

We used expectation maximization algorithm procedures as recommended (Little & Rubin, 1987) on missing values and multiple imputations on missing cases. On the READ scale, 94 of 5,320 (1.8%) values were missing. We had missing cases on the READ scale (2 of 190), SDQ scale (42 of 190), and on the ADHD-RS (63 of 190). All relevant variables used in the analyses model in addition to variables in the data set and assumed to be relevant predictors for missing values were included in the imputation model. Variables used in the imputation model were associated with treatment, including stimulants, psychotherapy, family, and school therapy. We imputed with no restrictions to the range, and with no post-imputation rounding, as recommended by Rodwell, Lee, Romaniuk, and Carlin (2014). The normality of relevant variables was assessed by visual inspection of Q–Q plots; 95% CIs are reported. A two-sided p value < .05 was considered statistically significant. SPSS version 21 (SPSS Inc., Chicago, IL, USA) was used for data analyses.

Results

Analyses were performed to assess differences between participants and non-responders at follow-up, based on baseline data. There were no differences between participant and non-responders for the following variables: age, female ratio, SDQ emotional, conduct, hyperactivity/inattention scale problems, and impact score (Table 1). Table 2 shows correlations between variables included in the analyses, in addition to emotional problems at baseline.

Table 1.

ANOVA Analyses of Differences Between Participants and Non-Responders Based on Baseline Data.

	Participants at follow-up	Non-responders at follow-up	Differences
N	190 (78.2%)	53 (21.8%)
Age	15.41	15.36	n.s.
Female ratio	0.42	0.47	n.s.
SDQ emotional problems	4.14	4.54	n.s.
SDQ conduct problems	3.05	2.87	n.s.
SDQ hyperactivity/or inattention	6.40	5.93	n.s.
SDQ impact score	1.53	1.63	n.s.

Note. SDQ: Strengths and Difficulties Questionnaire.

Table 2.

Correlations Between Variables Used in Study 2 and 3.

	Emo	Self-esteem	Str. style	Soc. comp	Depr	Anx	ADHD	CGAS
Emo	1	.590**	.407**	.334**	.412**	.306**	.177*	−.565**
Self-esteem	.590**	1	.705**	.668**	.259**	.263**	.122	−0.313
Str. style	.407**	.705**	1	.452**	.153*	.177*	.166*	−.245**
Soc. comp	.334**	.668**	.452**	1	.081	.207**	.104	−.164
Depression	.412**	.259**	.153*	.081	1	.379**	.177*	−.565**
Anxiety	.306**	.263**	.177*	.207**	.379**	1	.043	−.407**
ADHD	.174*	.122	.166*	.104	.177*	.043	1	−.221**
CGAS	−.565**	−.313**	−.245**	−.164*	−.565**	−.407**	−.221**	1

Note. Emo is emotional problem scale from SDQ. Self-esteem, Str. style (Structured style), and Soc. comp. (Social competence) are from READ. Depression, anxiety, and ADHD diagnoses from K-SADS; CGAS = Children’s Global Assessment Scale SDQ = Strengths and Difficulties Questionnaire; READ = Resilience Scale for Adolescents; K-SADS = Kiddie-Schedule for Affective Disorders and Schizophrenia; CGAS = Children’s Global Assessment Scale.

p < .05. **p < .01.

Descriptive Data of the Study Sample

At baseline 80 (42.1%) of the adolescents with ADHD reported emotional problems above the 80th percentile on the SDQ questionnaire. Of these, 28 (35%) were diagnosed with an anxiety disorder and 35 (39%) with a depressive disorder at follow-up. Among adolescents with ADHD without emotional problems, 18 (16.4%) were diagnosed with an anxiety disorder and 19 (17.3%) with a depressive disorder at follow-up. For further descriptive data of the study sample, please see Table 3.

Table 3.

Descriptive Data of the Sample of Study 3 (190 Adolescents With ADHD).

	M	SD	N	%
Age at baseline	15.41	1.7
Female gender			79	41.6
ADHD-RS inattention	18.70	5.8
ADHD-RS hyperactivity	12.71	7.1
SDQ emotional problems at baseline			80	42.1
Psychotherapy			79	41.6
Family-oriented interventions			88	46.3
Environmental interventions (schools etc.)			60	31.6
Medicated during follow-up (no. of months)			127	66.8
Medicated at follow-up			85	44.7
CGAS at follow-up	72.42	13.4
Persistent ADHD at follow-up			118	62.1
Females with persistent ADHD diagnosis			55	46.6

Note. ADHD diagnosis using DSM-IV criteria. Emotional problems when above 80%. ADHD-RS = ADHD Rating Scale; SDQ = Strengths and Difficulties Questionnaire; CGAS = Children’s Global Assessment Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994).

Lower Psychosocial Functioning

Adolescents with ADHD and lower self-esteem (higher scores; B = −0.74, p = .005) and a lower degree of structured style (higher scores; B = −0.82, p = .048) had the most severe psychosocial functioning during the 3-year follow-up period. Female gender was associated with lower psychosocial functioning (B = 6.30, p = .005). Older age was associated with lower psychosocial functioning (B = −1.85, p = .005; Table 5).

Diagnoses of Depression and Anxiety at Follow-Up

Adolescents with ADHD and lower self-esteem (higher scores) had higher odds for depressive disorders during the follow-up period (odds ratio [OR] = 1.09, p = .038), while those with lower social competence (higher scores) had higher odds for anxiety disorders (OR = 1.12, p = .032). Females had higher odds for depressive disorders (OR 3.82, p < .001) and anxiety disorders (OR = 4.93, p < .001). Older age at baseline was associated with higher odds for anxiety disorders (OR = 1.33, p = .006; Table 6).

Diagnosis of ADHD at Follow-Up

Adjusted nominal regression analysis showed that adolescents with higher levels of inattention at baseline had higher OR for persistent ADHD at 3-year follow-up (OR = 1.08, p = .030). There were no associations between protective factors and persistence of ADHD (Table 4).

Table 4.

Adjusted Logistic Regression Analyses of Adolescents With ADHD at Baseline, With Persistent ADHD at 3-Year Follow-Up as the Dependent Variable (Independent Variables Adjusted for Age, Gender, Hyperactivity, and Inattention).

Independent variables	N	OR	95% CI	p
Personal competence	190	1.05	[0.97, 1.13]	.205
Personal structure	190	1.08	[0.96, 1.03]	.178
Social competence	190	1.08	[0.98, 1.17]	.159
Female gender	190	1.84	[0.97, 3.48]	.063
Age	190	0.95	[0.78, 1.14]	.568
ADHD-RS hyperactivity	190	0.97	[0.92, 1.03]	.295
ADHD-RS inattention	190	1.08	[1.01, 1.16]	.030

Note. OR = odds ratio; CI = confidence interval; ADHD-RS = ADHD Rating Scale.

Table 5.

Unstandardized Beta Coefficients of Linear Regression Analysis With Psychosocial Functioning During and at Follow-Up as Dependent Variables Among Adolescents With ADHD.

Independent variables	N	B	95% CI	p
Most severe psychosocial function during the last 3 years. Adjusted for age, gender, hyperactivity, and inattention
Personal competence	190	−0.74	[−1.25, 0.22]	.005
Personal structure	190	−0.82	[−1.63, 0.01]	.048
Social competence	190	−0.54	[−1.16, 0.08]	.090
Age	190	−1.85	[−3.15, 0.55]	.005
Female gender	190	6.30	[ 1.99, 10.74]	.005
ADHD-RS hyperactivity	190	−0.01	[−0.41, 0.39]	.612
ADHD-RS inattention	190	−0.13	[−0.61, 0.36]	.953
Psychosocial functioning at follow-up. Adjusted for age, gender, hyperactivity, and inattention
Personal competence	190	−0.75	[−1.20, 0.31]	.001
Personal structure	190	−0.56	[−1.26, 0.15]	.121
Social competence	190	−0.57	[−1.10, 0.03]	.040
Age	190	−1.43	[−2.56, 0.29]	.014
Female gender	190	5.66	[ 1.86, 9.46]	.004
ADHD-RS hyperactivity	190	0.01	[−0.33, 0.36]	.954
ADHD-RS inattention	190	−0.16	[−0.58, 0.25]	.438

Note. CI = confidence interval; ADHD-RS = ADHD Rating Scale.

Table 6.

Adjusted Logistic Regression Analyses of Adolescents With ADHD, With Depression, or Anxiety at 3-Year Follow-Up as the Dependent Variable.

Independent variables	N	OR	95% CI	p
Article I. Depression among ADHD patients on a 3-year follow-up. Adjusted for age, gender, hyperactivity, and inattention measured at baseline
Personal competence	190	1.09	[1.01, 1.18]	.036
Structured style	190	1.06	[0.93, 1.20]	.391
Social competence	190	1.03	[0.94, 1.13]	.568
Age	190	1.02	[0.84, 1.25]	.820
Female gender	190	3.81	[1.94, 7.61]	<.001
ADHD-RS hyperactivity	190	1.01	[0.95, 1.07]	.896
ADHD-RS inattention	190	1.01	[0.94, 1.09]	.839
Anxiety among ADHD patients on a 3-year follow-up. Adjusted for age, gender, hyperactivity, and inattention measured at baseline
Personal competence	190	1.07	[0.98, 1.16]	.136
Structured style	190	1.05	[0.92, 1.20]	.489
Social competence	190	1.12	[1.01, 1.24]	.032
Age	190	1.20	[0.97, 1.48]	.006
Female gender	190	4.92	[2.33, 10.37]	<.001
ADHD-RS hyperactivity	190	0.98	[0.91, 1.04]	.480
ADHD-RS inattention	190	1.00	[0.92, 1.08]	.966

Note. OR = odds ratio; CI = confidence interval; ADHD-RS = ADHD Rating Scale.

Gender Interactions

No interactions between female gender and protective factors were found (results not shown).

Discussion

In a clinical sample of ADHD patients, our 3-year follow-up study showed that better self-esteem in adolescence was a predictor of better psychosocial functioning in young adulthood. A more structured style and better social competence were also associated with this outcome. Furthermore, better self-esteem in adolescence was associated with fewer depressive disorders, while social competence in adolescence was associated with fewer anxiety disorders in young adulthood. Our results support the protective role of self-esteem, structured style, and social competence in a critical developmental period.

Consistent with our hypothesis, self-esteem was associated with the outcome of psychosocial functioning and depressive disorders in young adulthood. Worse psychosocial functioning and depression in young adulthood might have developed because of the ADHD symptomatology, rather than being independent phenomena. Several studies have indicated that ADHD symptoms affect the formation of self-esteem and self-efficacy, which are core elements of self-esteem, suggesting that underachievement and negative experiences about one’s abilities are often experienced by ADHD patients (Cook, Knight, Hume, & Qureshi, 2014; Young & Bramham, 2012). As a result, negative cognitions lead to continual disappointments (Newark & Stieglitz, 2010), which makes it less likely that adolescents with ADHD will use adaptive compensatory strategies (Knouse & Safren, 2010). A recent review indicates that lower self-esteem leads to frequent experiences of failure in childhood, and has consequences that persist into adulthood (Cook et al., 2014). Importantly though, children with ADHD do not always report low self-esteem even when they experience considerable difficulty in particular areas of functioning. Self-perceptions of boys and girls with ADHD tend to be characterized by positive illusions, called the positive illusory bias (Hoza et al., 2004). Furthermore, the adolescents tended to inflate their self-perception most in domains of greatest deficit, such as conduct problems (Hoza et al., 2004). However, in children with co-existing emotional problems self-perceptions were comparable with healthy controls (Hoza et al., 2004). In our sample, the level of emotional problems is relatively high compared with conduct problems, thus, the positive illusory bias may be less prominent in our study. Negative cognitions may enhance negative emotions and lead to dysfunctional behavior, highlighting the importance of improving self-esteem as a treatment goal (Newark & Stieglitz, 2010). Although further interventional studies are needed, the existing literature on cognitive behavior therapy in adults with ADHD has shown a treatment effect on ADHD symptoms and functioning (Bramham et al., 2009; Emilsson et al., 2011). A more thorough understanding of personal difficulties related to ADHD may constitute the basis for improvements in self-esteem, which may be important for a favorable long-term outcome. Our results add to the existing literature showing that self-esteem is an important and relevant measure during adolescence and indicating that ADHD patients with better self-esteem manage better in the long term. Thus, self-esteem should be assessed in clinical practice and be of concern as a treatment priority.

Our findings suggest that structured style is associated with better psychosocial functioning at the 3-year outcome. Rinsky and Hinshaw (2011) assessed girls with ADHD and found an association between executive functions in childhood and psychopathology in early adolescence. In line with our finding, college students with ADHD reported that organizational skills predicted academic functioning and overall impairment (Dvorsky & Langberg, 2014). A recent study found that planning and working memory skills predicted the presence of comorbid internalizing problems, and that executive functions and symptoms due to ADHD-combined type were additive in predicting adolescent psychopathology (Rinsky & Hinshaw, 2011). As poor structured style among ADHD patients is common, and considering the plasticity of brain functions with possibilities of learning and development, further studies of these relationships are recommended. A recent meta-analysis and other work has found cognitive training to be beneficial for improving working memory in individuals with ADHD (Cortese et al., 2015; Evans, Owens, & Bunford, 2013; Mitchell et al., 2013; Thompson et al., 2009). We also hypothesized that structured style would predict less depression and anxiety, but this was not verified. Impaired executive functions and emotional problems may be associated in younger populations as reported by parents, but not by teachers, although the latter finding may reflect methodological problems (Riggs, Blair, & Greenberg, 2003). Furthermore, a study assessing preschool children with ADHD failed to find a relationship between executive functioning and emotional problems (Wahlstedt, Thorell, & Bohlin, 2008). Thus, this relationship appears to be weak among younger children with ADHD. Our results lend support to the finding that structured style in adolescence may not be protective in regard to depression or anxiety in early adulthood.

We found an association between better social competence in adolescence and less anxiety in young adulthood. A recent study demonstrated cross-domain effects from early externalizing problems through effects on social and school competence into later internalizing problems (Burt & Roisman, 2010). Inattention is associated with anxiety (Hodgens et al., 2000; Maedgen & Carlson, 2000) and inattentive behavior, in addition to hyperactive and impulsive behavior, and may contribute to rejection by peers (Nijmeijer et al., 2008). Inattention manifests as being distracted, not listening, and having trouble switching roles. It has been suggested that ADHD symptoms may have a bigger impact on girls’ social status (Carlson, Tamm, & Gaub, 1997; Hinshaw et al., 2002). Nevertheless, in a study among boys with ADHD, social disability predicted more anxiety in early adolescence (Greene et al., 1997). Our results adjusted for gender indicate that social competence in adolescents with ADHD may protect from anxiety disorders from a developmental perspective, but further studies are needed to explore this association.

Our sample has 41.6% girls, which is a higher female to male ratio than expected, and to other clinical studies (Gershon, 2002). Gender ratios in referred ADHD samples differ between countries with higher female to male ratios in Scandinavian countries (Novik et al., 2006). However, although community-based studies assessing ADHD typically demonstrate a higher female ratio than clinical-based studies (Ramtekkar et al., 2010; Willcutt, 2012), the ratio in our study is still higher than expected. A referral bias is normal as girls are less likely to be referred for treatment than boys (Rucklidge, 2010). Thus, the ratio might be partially explained by the sample’s age as girls are often referred later than boys (Berry, Shaywitz, & Shaywitz, 1985). The levels of parent-reported inattention and hyperactivity are similar for boys and girls in our sample, in line with recent research (Arnett et al., 2014; Derks et al., 2007; Rucklidge, 2010). At our follow-up, even more girls compared with boys had a persistent ADHD diagnosis, however not significant. Female gender severely increased the risk of depression, anxiety, and worse psychosocial functioning. In line with our finding, follow-up studies of girls with ADHD found poor outcomes in early adulthood (Hinshaw et al., 2012) while it is speculated that comorbidity may emerge in early adulthood among boys with ADHD (Biederman, Petty, Woodworth, et al., 2012). It is well known that females of the normal population have an increased risk of anxiety and depression, and females with ADHD have 2.5 times higher risk of major depressive disorder than female peers (Biederman et al., 2008).

The findings of the present study are limited by the low response rate of the baseline sample, which could have led to imprecise results. However, the reason for referral did not differ from the population of patients treated in the clinic during the study period. Children and adolescents referred to the CAP department have to be referred by a medical doctor and most have been assessed by the school-based psychological and pedagogic service (Psykologisk Pedagogisk Tjeneste, PPT) before referral. Thus, children and adolescents with ADHD symptoms who are less impaired may not have been included in the present study.

Another limitation was that emotional problems and protective factors were based on self-reports. Studies of children with ADHD indicate that self-reports of competence are overinflated in comparison with reports of parents and teachers, called the positive illusory bias (Hoza et al., 2004). In recent studies of adolescents and adults with ADHD, self-reports of competencies were similar to that of other raters, for example, parents or peers (Fuermaier et al., 2014; Scholtens, Rydell, & Yang-Wallentin, 2013; Swanson, Owens, & Hinshaw, 2012). The illusory bias may become less as these children grow up. Furthermore, self-report scales may increase awareness of internalizing problems (Skogli, Teicher, Andersen, Hovik, & Oie, 2013). We have previously shown that adolescents with ADHD reported worse family functioning when co-existing emotional and conduct problems increased, while parent reports showed no association between family functioning and level of co-existing problems (Schei et al., 2012). Differences between child and parent information typically become greater with age (van der Ende, Verhulst, & Tiemeier, 2012); thus, self-reports of individual competencies should be considered in youth with ADHD.

We wanted to adjust for baseline levels of depression and anxiety in the analysis. Because this was an observational study and the factor of emotional problems could be a mediator, it could have been critical to the causal chain from the study factor to the study outcome (Christenfeld, Sloan, Carroll, & Greenland, 2004). Other problems arise because of different measures of anxiety and depression in the study, and only proxies for underlying constructs; at baseline, we used a self-reported emotional problems scale, and at the follow-up a categorical clinician-set diagnosis. A clinical interview with parents was not conducted and the family structure was not assessed. Therefore, we could not adjust for parental ADHD or other chronic conditions in the analyses. Finally, the ADHD diagnosis at baseline was based on clinical ICD-10 diagnoses; however, all diagnoses were made by an experienced child and adolescent psychiatrist or a clinical psychologist, and were based on standard national and international guidelines. In addition, we used parent-reported inattention, hyperactivity, and impulsive symptoms (ADHD-RS) to validate our data. Our results show similar mean scores as another Norwegian study assessing an ADHD sample (Egeland, Johansen, & Ueland, 2010), and a clinical ADHD sample in a Danish validity study of ADHD-RS, which is assumed to be representative for Scandinavia countries (Szomlaiski et al., 2009). At the 3-year follow-up, standardized semi-structured child psychiatric interviews were conducted, and the degree of persisting ADHD in our sample matches former studies (Barkley et al., 2002; Biederman, Petty, Clarke, Lomedico, & Faraone, 2011).

Conclusion

This study expands the current information about personal factors in adolescents with ADHD, which may be protective and provide for a more favorable longitudinal outcome. Better self-esteem in adolescence, younger age, and male gender were associated with better psychosocial functioning in early adulthood in the present study. Although further research is needed, our findings indicate that better self-esteem may protect from developing depression, better social competence may protect from developing anxiety, and better social competence and structured style may be of importance for psychosocial functioning. Knowledge of possible protective factors would be useful in the development of support and clinical interventions for ADHD patients in the transitional period from adolescence to early adult life.

Footnotes

Acknowledgements

We thank the adolescents who participated in the CAP survey.

Authors’ Note

Jorun Schei, Torunn Stene Nøvik, Thomas Jozefiak, and Marit S. Indredavik are affiliated with both St. Olavs Hospital Trondheim University Hospital and the Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology (NTNU). Per Hove Thomsen is affiliated with both Aarhus University Hospital, Denmark, and the Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology. Stian Lydersen is affiliated with the Regional Centre for Child and Youth Mental Health and Child Welfare (NTNU).

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Torunn Stene Nøvik received speaker’s fees from Eli Lilly. Per Hove Thomsen received speaker’s fees from Shire, Medice, and Novartis. The present work is unrelated to the above grants or relationships. The other authors report no conflicts of interest.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financed by a PhD grant awarded to the first author by the Department of Research and Development, St. Olav’s University Hospital, Medical Faculty. The CAP survey is a product of the collaboration between St. Olav’s University Hospital and Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), NTNU; it is also funded by Unimed Innovation at St. Olav’s University Hospital and the Liaison Committee between the Central Norway Regional Health Authority and NTNU.

Author Biographies

Jorun Schei, MD, is a PhD student and a resident in Child and Adolescent Psychiatry. Her clinical and research interests include resilience, comorbidity and long-term outcome of ADHD in addition to neurodevelopmental disorders in general.

Torunn Stene Nøvik, MD, PhD, is Consultant Child and Adolescent Psychiatrist and Associate Professor. Her current clinical and research interests include the assessment and treatment of children and adolescents with mood disorders and neurodevelopmental disorders.

Per Hove Thomsen, MD, PhD, is Consultant Child and Adolescent Psychiatrist and appointed Professor and head of the research unit. His main research areas are OCD, ADHD, eating disorders and autism.

Stian Lydersen, PhD, is a Professor of Medical Statistics. His research area is longitudinal epidemiological studies and clinical trials.

Marit S. Indredavik, MD, PhD, is a Consultant Child and Adolescent Psychiatrist and Professor. Research interests are biological risk and mental health, long-term outcome of low birth weight, and epidemiology.

Thomas Jozefiak is a Consultant Child and Adolescent Psychiatrist and associate Professor. His research interests include quality of life and psychopathology among children and adolescents, both in the general population and different clinical populations.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Arnett

A. B.

Pennington

B. F.

Willcutt

E. G.

DeFries

J. C.

Olson

R. K.

(2014). Sex differences in ADHD symptom severity. Journal of Child Psychology and Psychiatry, 56, 632-639. doi:10.1111/jcpp.12337

Berry

C. A.

Shaywitz

S. E.

Shaywitz

B. A.

(1985). Girls with attention deficit disorder: a silent minority? A report on behavioral and cognitive characteristics. Pediatrics, 76, 801-809.

Barkley

R. A.

Fischer

Smallish

Fletcher

(2002). The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. Journal of Abnormal Psychology, 111, 279-289.

Barkley

R. A.

Fischer

Smallish

Fletcher

(2006). Young adult outcome of hyperactive children: Adaptive functioning in major life activities. Journal of American Academy of Child & Adolescent Psychiatry, 45, 192-202. doi:10.1097/01.chi.0000189134.97436.e2

Becker

S. P.

Luebbe

A. M.

Langberg

J. M.

(2012). Co-occurring mental health problems and peer functioning among youth with attention-deficit/hyperactivity disorder: A review and recommendations for future research. Clinical Child and Family Psychology Review, 15, 279-302. doi:10.1007/s10567-012-0122-y

Becker

S. P.

McBurnett

Hinshaw

S. P.

Pfiffner

L. J.

(2013). Negative social preference in relation to internalizing symptoms among children with ADHD predominantly inattentive type: Girls fare worse than boys. Journal of Clinical Child Adolescent Psychology, 42, 784-795. doi:10.1080/15374416.2013.828298

Biederman

Ball

S. W.

Monuteaux

M. C.

Mick

Spencer

T. J.

McCreary

. . . Faraone

S. V.

(2008). New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of American Academy of Child & Adolescent Psychiatry, 47, 426-434. doi:10.1097/CHI.0b013e31816429d3

10.

Biederman

Petty

Fried

Fontanella

Doyle

A. E.

Seidman

L. J.

Faraone

S. V.

(2006). Impact of psychometrically defined deficits of executive functioning in adults with attention deficit hyperactivity disorder. American Journal of Psychiatry, 163, 1730-1738. doi:10.1176/appi.ajp.163.10.1730

11.

Biederman

Petty

C. R.

Ball

S. W.

Fried

Doyle

A. E.

Cohen

. . . Faraone

S. V.

(2009). Are cognitive deficits in attention deficit/hyperactivity disorder related to the course of the disorder? A prospective controlled follow-up study of grown up boys with persistent and remitting course. Psychiatry Research, 170, 177-182. Retrieved from https://dx-doi-org.web.bisu.edu.cn/10.1016/j.psychres.2008.09.010

12.

Biederman

Petty

C. R.

Clarke

Lomedico

Faraone

S. V.

(2011). Predictors of persistent ADHD: An 11-year follow-up study. Journal of Psychiatric Research, 45, 150-155. doi:10.1016/j.jpsychires.2010.06.009

13.

Biederman

Petty

C. R.

O’Connor

K. B.

Hyder

L. L.

Faraone

S. V.

(2012). Predictors of persistence in girls with attention deficit hyperactivity disorder: Results from an 11-year controlled follow-up study. Acta Psychiatrica Scandinavica, 125, 147-156. doi:10.1111/j.1600-0447.2011.01797.x

14.

Biederman

Petty

C. R.

Woodworth

K. Y.

Lomedico

Hyder

L. L.

Faraone

S. V.

(2012). Adult outcome of attention-deficit/hyperactivity disorder: A controlled 16-year follow-up study. Journal of Clinical Psychiatry, 73, 941-950. doi:10.4088/JCP.11m07529

15.

Bird

H. R.

Yager

T. J.

Staghezza

Gould

M. S.

Canino

Rubio-Stipec

(1990). Impairment in the epidemiological measurement of childhood psychopathology in the community. Journal of American Academy of Child & Adolescent Psychiatry, 29, 796-803. doi:10.1097/00004583-199009000-00020

16.

Bramham

Young

Bickerdike

Spain

McCartan

Xenitidis

(2009). Evaluation of group cognitive behavioral therapy for adults with ADHD. Journal of Attention Disorders, 12, 434-441. doi:10.1177/1087054708314596

17.

Buckner

J. C.

Mezzacappa

Beardslee

W. R.

(2009). Self-regulation and its relations to adaptive functioning in low income youths. American Journal of Orthopsychiatry, 79, 19-30.

18.

Burt

K. B.

Roisman

G. I.

(2010). Competence and psychopathology: Cascade effects in the NICHD Study of Early Child Care and Youth Development. Development and Psychopathology, 22, 557-567. doi:10.1017/S0954579410000271

19.

Carlson

C. L.

Tamm

Gaub

(1997). Gender differences in children with ADHD, ODD, and co-occurring ADHD/ODD identified in a school population. Journal of American Academy of Child & Adolescent Psychiatry, 36, 1706-1714. doi:10.1097/00004583-199712000-00019

20.

Christenfeld

N. J.

Sloan

R. P.

Carroll

Greenland

(2004). Risk factors, confounding, and the illusion of statistical control. Psychosomatic Medicine, 66, 868-875. doi:10.1097/01.psy.0000140008.70959.41

21.

Cook

Knight

Hume

Qureshi

(2014). The self-esteem of adults diagnosed with attention-deficit/hyperactivity disorder (ADHD): A systematic review of the literature. Attention Deficit Hyperactivity Disorder, 6, 249-268. doi:10.1007/s12402-014-0133-2

22.

Cortese

Ferrin

Brandeis

Buitelaar

Daley

Dittmann

R. W.

. . . European

A. G. G.

(2015). Cognitive training for attention-deficit/hyperactivity disorder: Meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials. Journal of American Academy of Child & Adolescent Psychiatry, 54, 164-174. doi:10.1016/j.jaac.2014.12.010

23.

Costello

D. M.

Swendsen

Rose

J. S.

Dierker

L. C.

(2008). Risk and protective factors associated with trajectories of depressed mood from adolescence to early adulthood. Journal of Consulting and Clinical Psychology, 76, 173-183. doi:10.1037/0022-006x.76.2.173

24.

Derks

E. M.

Dolan

C. V.

Hudziak

J. J.

Neale

M. C.

Boomsma

D. I.

(2007). Assessment and etiology of attention deficit hyperactivity disorder and oppositional defiant disorder in boys and girls. Behavioral Genetics, 37, 559-566. doi:10.1007/s10519-007-9153-4

25.

Dupaul

Power

Anastopoulos

Reid

(1998). ADHD Rating Scale–IV: Checklists, norms, and clinical interpretation. New York, NY: Guilford Press.

26.

Dvorsky

M. R.

Langberg

J. M.

(2014). Predicting impairment in college students with ADHD: The role of executive functions. Journal of Attention Disorders. Advance online publication. doi:10.1177/1087054714548037

27.

Egeland

Johansen

S. N.

Ueland

(2010). Do low-effort learning strategies mediate impaired memory in ADHD? Journal of Learning Disabilities, 43, 430-440. doi:10.1177/0022219409355473

28.

Emilsson

Gudjonsson

Sigurdsson

J. F.

Baldursson

Einarsson

Olafsdottir

Young

(2011). Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. BMC Psychiatry, 11, 116. doi:10.1186/1471-244x-11-116

29.

Evans

S. W.

Owens

J. S.

Bunford

(2013). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43, 527-551. doi:10.1080/15374416.2013.850700

30.

Fischer

Barkley

R. A.

Smallish

Fletcher

(2002). Young adult follow-up of hyperactive children: Self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. Journal of Abnormal Child Psychology, 30, 463-475.

31.

Fleming

A. P.

McMahon

R. J.

(2012). Developmental context and treatment principles for ADHD among college students. Clinical Child and Family Psychology Review, 15, 303-329. doi:10.1007/s10567-012-0121-z

32.

Friborg

Hjemdal

Rosenvinge

J. H.

Martinussen

(2003). A new rating scale for adult resilience: What are the central protective resources behind healthy adjustment? The International Journal of Methods in Psychiatric Research, 12, 65-76.

33.

Friedman

N. P.

Miyake

Corley

R. P.

Young

S. E.

Defries

J. C.

Hewitt

J. K.

(2006). Not all executive functions are related to intelligence. Psychology of Science, 17, 172-179. doi:10.1111/j.1467-9280.2006.01681.x

34.

Fuermaier

A. B.

Tucha

Koerts

Aschenbrenner

Weisbrod

Lange

K. W.

Tucha

(2014). Cognitive complaints of adults with attention deficit hyperactivity disorder. Clinical Neuropsychology, 28, 1104-1122. doi:10.1080/13854046.2014.964325

35.

Gershon

(2002). A meta-analytic review of gender differences in ADHD. Journal of Attention Disorders, 5, 143-154.

36.

Goodman

(1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581-586.

37.

Goodman

(2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of American Academy of Child & Adolescent Psychiatry, 40, 1337-1345. doi:10.1097/00004583-200111000-00015

38.

Greene

R. W.

Biederman

Faraone

S. V.

Sienna

Garcia-Jetton

(1997). Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: Results from a 4-year longitudinal follow-up study. Journal of Consulting and Clinical Psychology, 65, 758-767.

39.

Hinshaw

S. P.

Carte

E. T.

Sami

Treuting

J. J.

Zupan

B. A.

(2002). Preadolescent girls with attention-deficit/hyperactivity disorder: II. Neuropsychological performance in relation to subtypes and individual classification. Journal of Consulting and Clinical Psychology, 70, 1099-1111.

40.

Hinshaw

S. P.

Owens

E. B.

Zalecki

Huggins

S. P.

Montenegro-Nevado

A. J.

Schrodek

Swanson

E. N.

(2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80, 1041-1051. doi:10.1037/a0029451

41.

Hodgens

J. B.

Cole

Boldizar

(2000). Peer-based differences among boys with ADHD. Journal of Clinical Child Psychology, 29, 443-452. doi:10.1207/s15374424jccp2903_15

42.

Hoza

Gerdes

A. C.

Hinshaw

S. P.

Arnold

L. E.

Pelham

W. E.

Jr. Molina

B. S.

. . . Wigal

(2004). Self-perceptions of competence in children with ADHD and comparison children. Journal of Consulting and Clinical Psychology, 72, 382-391. doi:10.1037/0022-006X.72.3.382

43.

Izgic

Akyuz

Dogan

Kugu

(2004). Social phobia among university students and its relation to self-esteem and body image. Canadian Journal of Psychiatry, 49, 630-634.

44.

Jacobson

L. A.

Williford

A. P.

Pianta

R. C.

(2011). The role of executive function in children’s competent adjustment to middle school. Child Neuropsychology, 17, 255-280. doi:10.1080/09297049.2010.535654

45.

Kaufman

Birmaher

Brent

Rao

Flynn

Moreci

. . . Ryan

(1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of American Academy of Child & Adolescent Psychiatry, 36, 980-988. doi:10.1097/00004583-199707000-00021

46.

Knouse

L. E.

Safren

S. A.

(2010). Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder. Psychiatric Clinics of North America, 33, 497-509. doi:10.1016/j.psc.2010.04.001

47.

Lambek

Tannock

Dalsgaard

Trillingsgaard

Damm

Thomsen

P. H.

(2011). Executive dysfunction in school-age children with ADHD. Journal of Attention Disorders, 15, 646-655. doi:10.1177/1087054710370935

48.

Langberg

J. M.

Dvorsky

M. R.

Evans

S. W.

(2013). What specific facets of executive function are associated with academic functioning in youth with attention-deficit/hyperactivity disorder? Journal of Abnormal Child Psychology, 41, 1145-1159. doi:10.1007/s10802-013-9750-z

49.

Little

R. J. A.

Rubin

D. B.

(1987). Statistical analysis with missing data. New York, NY: Wiley

50.

Luthar

S. S.

Cicchetti

Becker

(2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543-562.

51.

Maedgen

J. W.

Carlson

C. L.

(2000). Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Child Psychology, 29, 30-42. doi:10.1207/S15374424jccp2901_4

52.

Malloy

Grace

(2005). A review of rating scales for measuring behavior change due to frontal systems damage. Cognitive and Behavioral Neurology, 18, 18-27.

53.

McQuade

J. D.

Vaughn

A. J.

Hoza

Murray-Close

Molina

B. S.

Arnold

L. E.

Hechtman

(2014). Perceived social acceptance and peer status differentially predict adjustment in youth with and without ADHD. Journal of Attention Disorders, 18, 31-43. doi:10.1177/1087054712437582

54.

Mikami

A. Y.

Hinshaw

S. P.

(2006). Resilient adolescent adjustment among girls: Buffers of childhood peer rejection and attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 34, 825-839. doi:10.1007/s10802-006-9062-7

55.

Mitchell

J. T.

McIntyre

E. M.

English

J. S.

Dennis

M. F.

Beckham

J. C.

Kollins

S. H.

(2013). A pilot trial of mindfulness meditation training for ADHD in adulthood: Impact on core symptoms, executive functioning, and emotion dysregulation. Journal of Attention Disorders. Advance online publication. doi:10.1177/1087054713513328

56.

Modesto-Lowe

Yelunina

Hanjan

(2011). Attention-deficit/hyperactivity disorder: A shift toward resilience? Clinical Pediatrics (Phila), 50, 518-524. doi:0009922810394836

57.

Mrug

Molina

B. S.

Hoza

Gerdes

A. C.

Hinshaw

S. P.

Hechtman

Arnold

L. E.

(2012). Peer rejection and friendships in children with Attention-Deficit/Hyperactivity Disorder: Contributions to long-term outcomes. Journal of Abnormal Child Psychology, 40, 1013-1026. doi:10.1007/s10802-012-9610-2

58.

Murray-Close

Hoza

Hinshaw

S. P.

Arnold

L. E.

Swanson

Jensen

P. S.

. . . Wells

(2010). Developmental processes in peer problems of children with attention-deficit/hyperactivity disorder in the Multimodal Treatment Study of Children With ADHD: Developmental cascades and vicious cycles. Developmental Psychopathology, 22, 785-802. doi:10.1017/S0954579410000465

59.

Newark

P. E.

Stieglitz

R. D.

(2010). Therapy-relevant factors in adult ADHD from a cognitive behavioural perspective. Attention Deficit Hyperactivity Disorder, 2(2), 59-72. doi:10.1007/s12402-010-0023-1

60.

Newcomb

A. F.

Bukowski

W. M.

Pattee

(1993). Children’s peer relations: A meta-analytic review of popular, rejected, neglected, controversial, and average sociometric status. Psychological Bulletin, 113(1), 99-128.

61.

Nigg

J. T.

Willcutt

E. G.

Doyle

A. E.

Sonuga-Barke

E. J.

(2005). Causal heterogeneity in attention-deficit/hyperactivity disorder: Do we need neuropsychologically impaired subtypes? Biological Psychiatry, 57, 1224-1230. doi:10.1016/j.biopsych.2004.08.025

62.

Nijmeijer

J. S.

Minderaa

R. B.

Buitelaar

J. K.

Mulligan

Hartman

C. A.

Hoekstra

P. J.

(2008). Attention-deficit/hyperactivity disorder and social dysfunctioning. Clinical Psychology Review, 28, 692-708. doi:S0272-7358(07)00182-1

63.

Norwegian Directorate of Health. (2007). Veileder i diagnostikk og behandling av AD/HD [ADHD diagnostic and treatment guideline]. Oslo, Norway: Sosial- og helsedirektoratet.

64.

Novik

T. S.

Hervas

Ralston

S. J.

Dalsgaard

Rodrigues Pereira

Lorenzo

M. J.

(2006). Influence of gender on attention-deficit/hyperactivity disorder in Europe—ADORE. European Child & Adolescent Psychiatry, 15, I15-I24.

65.

Ramtekkar

U. P.

Reiersen

A. M.

Todorov

A. A.

Todd

R. D.

(2010) Sex and age differences in attention-deficit/hyperactivity symptoms and diagnoses: implications fro DSM-V and ICD-11. Journal of American Academy of Child and Adolescent Psychiatry, 49, 217-228

66.

Riggs

N. R.

Blair

C. B.

Greenberg

M. T.

(2003). Concurrent and 2-year longitudinal relations between executive function and the behavior of 1st and 2nd grade children. Child Neuropsychology, 9, 267-276. doi:10.1076/chin.9.4.267.23513

67.

Rinsky

J. R.

Hinshaw

S. P.

(2011). Linkages between childhood executive functioning and adolescent social functioning and psychopathology in girls with ADHD. Child Neuropsychology, 17, 368-390. doi:10.1080/09297049.2010.544649

68.

Roberts

B. A.

Martel

M. M.

Nigg

J. T.

(2013). Are there executive dysfunction subtypes within ADHD? Journal of Attention Disorders. Advance online publication. doi:10.1177/1087054713510349

69.

Rodwell

Lee

K. J.

Romaniuk

Carlin

J. B.

(2014). Comparison of methods for imputing limited-range variables: A simulation study. BMC Medical Research Methodology, 14, Article 57. doi:10.1186/1471-2288-14-57

70.

Roy

Hartman

C. A.

Veenstra

Oldehinkel

A. J.

(2014). Peer dislike and victimisation in pathways from ADHD symptoms to depression. European Child & Adolescent Psychiatry, 24, 887-895. doi:10.1007/s00787-014-0633-9

71.

Rucklidge

J. J.

(2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 33, 357-373. doi:10.1016/j.psc.2010.01.006

72.

Rutter

(2000). Resilience reconsidered: Conceptual considerations, empirical findings, and policy implications. In Shonkoff

J. P.

Meisels

S. J.

Zigler

E. F.

(Eds.), Handbook of early childhood intervention (2nd ed., pp. 651-682). New York, NY: Cambridge University Press.

73.

Schei

Jozefiak

Novik

T. S.

Lydersen

Indredavik

M. S.

(2013). The impact of listing emotional and conduct problems on family functioning and quality of life among adolescents with ADHD. Journal of Attention Disorders. Advance online publication. doi:10.1177/1087054713507976

74.

Schei

Nøvik

T. S.

Thomsen

P. H.

Indredavik

M. S.

Jozefiak

(2015). Improved quality of life among adolescents with attention-deficit/hyperactivity disorder is mediated by protective factors: A cross sectional survey. BMC Psychiatry, 15, Article 108.

75.

Scholtens

Rydell

A. M.

Yang-Wallentin

(2013). ADHD symptoms, academic achievement, self-perception of academic competence and future orientation: A longitudinal study. Scandinavian Journal of Psychology, 54, 205-212. doi:10.1111/sjop.12042

76.

Schorre

B. E.

Vandvik

I. H.

(2004). Global assessment of psychosocial functioning in child and adolescent psychiatry. A review of three unidimensional scales (CGAS, GAF, GAPD). European Child & Adolescent Psychiatry, 13, 273-286. doi:10.1007/s00787-004-0390-2

77.

Shaffer

Gould

M. S.

Brasic

Ambrosini

Fisher

Bird

Aluwahlia

(1983). A Children’s Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.

78.

Skogli

E. W.

Teicher

M. H.

Andersen

P. N.

Hovik

K. T.

Oie

(2013). ADHD in girls and boys–gender differences in co-existing symptoms and executive function measures. BMC Psychiatry, 13, Article 298. doi:10.1186/1471-244X-13-298

79.

Smith

Epstein

E. M.

Ortiz

J. A.

Christopher

P. J.

Tooley

E. M.

(2013). The foundations of resilience: What are the critical resources for bouncing back from stress? In Prince-Embury

Saklofske

D. H.

(Ed.), Resilience in children, adolescents, and adults: Translating research into practice (pp. 167-187). New York, NY: Springer.

80.

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich

Brown

R.T.

DuPaul

. . . Visser

(2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007-1022. doi:10.1542/peds.2011-2654

81.

Swanson

E. N.

Owens

E. B.

Hinshaw

S. P.

(2012). Is the positive illusory bias illusory? Examining discrepant self-perceptions of competence in girls with ADHD. Journal of Abnormal Child Psychology, 40, 987-998. doi:10.1007/s10802-012-9615-x

82.

Szomlaiski

Dyrborg

Rasmussen

Schumann

Koch

S. V.

Bilenberg

(2009). Validity and clinical feasibility of the ADHD rating scale (ADHD-RS) A Danish Nationwide Multicenter Study. Acta Paediatrica, 98, 397-402. doi:10.1111/j.1651-2227.2008.01025.x

83.

Thompson

M. J.

Laver-Bradbury

Ayres

Le Poidevin

Mead

Dodds

. . . Sonuga-Barke

E. J.

(2009). A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder. European Child & Adolescent Psychiatry, 18, 605-616. doi:10.1007/s00787-009-0020-0

84.

van der Ende

Verhulst

F. C.

Tiemeier

(2012). Agreement of informants on emotional and behavioral problems from childhood to adulthood. Psychological Assessment, 24, 293-300. doi:10.1037/a0025500

85.

Van Roy

Groholt

Heyerdahl

Clench-Aas

(2006). Self-reported strengths and difficulties in a large Norwegian population 10-19 years: Age and gender specific results of the extended SDQ-questionnaire. European Child & Adolescent Psychiatry, 15, 189-198. doi:10.1007/s00787-005-0521-4

86.

Van Roy

Veenstra

Clench-Aas

(2008). Construct validity of the five-factor Strengths and Difficulties Questionnaire (SDQ) in pre-, early, and late adolescence. Journal of Child Psychology and Psychiatry, 49, 1304-1312. doi:10.1111/j.1469-7610.2008.01942.x

87.

Vaughn

B. E.

Shin

Kim

Coppola

Krzysik

Santos

A. J.

. . . Korth

(2009). Hierarchical models of social competence in preschool children: A multisite, multinational study. Child Development, 80, 1775-1796. doi:10.1111/j.1467-8624.2009.01367.x

88.

von Soest

Mossige

Stefansen

Hjemdal

(2010). A Validation Study of the Resilience Scale for Adolescents (READ). Journal of Psychopathology and Behavioral Assessment, 32, 215-225. doi:10.1007/s10862-009-9149-x

89.

Wahlstedt

Thorell

L. B.

Bohlin

(2008). ADHD symptoms and executive function impairment: Early predictors of later behavioral problems. Developmental Neuropsychology, 33, 160-178. doi:10.1080/87565640701884253

90.

Warden

D. S.

(2003). Prosocial children, bullies and victims: An investigation of their sociometric status, empathy and social problem-solving strategies. British Journal of Developmental Psychology, 21, 367-385.

91.

Weiss

Hechtman

(1993). Hyperactive children grown up: ADHD in children, adolescents, and adults (2nd ed.). New York, NY: Guilford Press.

92.

Willcutt

E. G.

(2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics, 9, 490-499. doi:10.1007/s13311-012-0135-8

93.

Winters

N. C.

Collett

B. R.

Myers

K. M.

(2005). Ten-year review of rating scales, VII: Scales assessing functional impairment. Journal of American Academy of Child & Adolescent Psychiatry, 44, 309-338; discussion 339-342. doi:10.1097/01.chi.0000153230.57344.cd

94.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland: Author.

95.

Young

Bramham

(2012). Cognitive-behavioural therapy for ADHD in adolescents and adults: A psychological guide to practice (2nd ed.). Oxford, England: Wiley-Blackwell.

96.

Young

Bramham

Gray

Rose

(2008). The experience of receiving a diagnosis and treatment of ADHD in adulthood: A qualitative study of clinically referred patients using interpretative phenomenological analysis. Journal of Attention Disorders, 11, 493-503. doi:10.1177/1087054707305172