hyperactivity disorder (ADHD).

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J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01. Published in final edited form as: J Abnorm Psychol. 2016 February ; 125(2): 220–232. doi:10.1037/abn0000084.

Childhood Conduct Problems and Young Adult Outcomes Among Women with Childhood ADHD Elizabeth B. Owens and Stephen P. Hinshaw University of California, Berkeley

Abstract Author Manuscript Author Manuscript

We tested whether conduct problems predicted young adult functioning and psychiatric symptoms among women diagnosed with ADHD during childhood, in the context of three potential adolescent mediators: internalizing problems, peer rejection, and school failure and disciplinary problems. We controlled for childhood ADHD severity, IQ, and demographic factors, and in the mediational tests, for adolescent conduct problems. Data emanated from 140 participants in the Berkeley Girls with ADHD Longitudinal Study. We used bootstrapping methods to assess indirect effects (mediators). Both childhood (F1,118 change = 9.00, p = .003, R2 change = .069) and adolescent (F1,109 change = 10.41, p = .002, R2 change = .083) conduct problems were associated with worse overall functioning during young adulthood, controlling for initial ADHD severity, child IQ, and demographics. Results were similar when predicting psychiatric symptoms. Adolescent school failure and disciplinary problems mediated the relations between childhood conduct problems and both young-adult functioning and externalizing problems; adolescent internalizing problems and peer conflict mediated the relation between childhood conduct problems and young-adult internalizing problems. As is true for boys, childhood and adolescent conduct problems are associated with poor adult outcomes among girls with ADHD, with school failure and disciplinary problems, internalizing problems, and peer conflict functioning as mediators of these relations.

Keywords ADHD; longitudinal; females; conduct problems

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Accumulating findings from long-term longitudinal studies reveal psychiatric problems and specific functional impairments during adulthood for many, but not all, individuals who were diagnosed with attention-deficit/hyperactivity disorder (ADHD) as children. Substantial overall impairment or co-occurring deficits have also been documented in longitudinally followed samples of girls and boys with childhood ADHD. In Barkley and Fischer (2011), boys with ADHD followed into adulthood were more impaired than comparisons in all domains assessed, including work, social relationships, money management, and driving. Similarly, Klein et al. (2012) found that boys with ADHD

Correspondence should be addressed to: Elizabeth B. Owens, Tolman Hall, mc 1690, University of California, Berkeley, CA, 94720. [email protected]. Elizabeth B. Owens, Institute of Human Development, University of California, Berkeley; Stephen P. Hinshaw, Department of Psychology, University of California, Berkeley.

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followed into mid-adulthood showed deficits on 11 of 12 measures of functioning, as well as increased rates of substance use disorders, incarcerations, and psychiatric treatment. Among young-adult females with childhood ADHD, Babinski et al. (2011a, 2011b) documented impairments in social, occupational, and some educational measures via parent-, but not self-report, compared to girls without ADHD. Hinshaw et al. (2012) documented large (.98 to 1.14, depending on ADHD subtype) and significant deficits in overall functioning during young adulthood among girls with childhood ADHD. To our knowledge, no other reports of adult functional impairment following a childhood diagnosis of ADHD among females exist. Yet, overall functioning is an important construct because it is a primary driver of treatment seeking and is the basis by which treatment outcomes -- and by extension, developmental outcomes of child clinical conditions -- should be judged (Kazdin, 1999). In a study of relations between symptoms and impairment among individuals with ADHD, Gordon et al. (2006) suggested that a focus on overall functioning versus syndrome features might improve diagnosis, identify those most in need of services, and increase the effectiveness of disease management. Furthermore, such a comprehensive outcome is more relevant to parents, clinicians, and individuals with ADHD than are circumscribed outcomes. Thus, our primary focus herein is on predicting and explaining overall functioning among young adult women with childhood diagnoses of ADHD.

Specific Young Adult Outcomes


In addition, we examine internalizing and externalizing problems as outcomes during young adulthood. Understanding the development of internalizing problems in this population is important because such problems occur more frequently among girls versus boys, both with and without ADHD (Owens & Hinshaw, 2015). The primary studies of girls with ADHD followed into adulthood clearly and uniformly document heightened risk internalizing disorders. In Hinshaw et al. (2012), in which girls with and without childhood ADHD were followed for 10 years, the odds ratios for depressive and anxiety disorders ranged from 3.2 to 4.1, indicating significant increased risk for internalizing outcomes by young adulthood among girls with ADHD. Hinshaw et al. (2012) also reported large differences (.77 to 1.08, depending on ADHD subtype) in parent-reported internalizing problems during young adulthood, although self-reports were not significantly different. Babinski et al. (2011a, 2011b) also found parents, but not the young adult women themselves, to rate lower selfesteem among those with childhood ADHD. Similarly, Biederman et al. (2010) demonstrated lifetime hazard ratios of 6.8 for any mood disorder and 2.1 for any anxiety disorder among girls with versus without ADHD followed for 11 years. Significant differences maintained when controlling for other baseline psychopathologies. Although Yoshimasu et al. (2012) found risk for later internalizing and externalizing disorders to be equal among girls and boys with ADHD, girls were more likely than boys to have internalizing problems only. Among girls with childhood ADHD, the risk for developing later externalizing problems may actually greater than it is for developing internalizing problems. For example, in Biederman et al. (2010), the lifetime hazard ratio for developing an antisocial disorder was higher (7.2) than it was for developing a mood, anxiety, or addictive disorder. Similarly, in Hinshaw et al., (2012), the risk for a comorbid CD/ODD diagnosis during young adulthood

J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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was three- to six-times as high as it was for having a comorbid depressive or anxiety disorder. Babinski et al. (2011a) found girls with childhood ADHD to report higher levels of delinquency during young adulthood than did comparison females. Female risk for externalizing problems should also be investigated because it is the most frequently studied outcome among boys with ADHD (e.g., Biederman, Faraone, Milberger, & Guite, 1996; Biederman, Monuteaux, Mick, Spencer, Wilens, Silva et al., 2006; Klein et al., 2012; Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1998; Satterfield & Schell, 1997) and because of its potential for significant life impairment. Although serious externalizing problems may occur less frequently among girls than boys, they indicate significant dysfunction and maladaption for both genders (Silverthorn & Frick, 1999).

Predictors of Young Adult Outcome Author Manuscript Author Manuscript

Despite the substantial risk incurred by childhood ADHD, problematic outcomes are not obtained by all children with this condition. In other words, what may be typical for the group is not characteristic of every individual. Understanding this variability in outcome is imperative, as it informs both developmental theory and treatment efforts intended to target those most at risk. It begins with the identification of predictors (i.e., baseline characteristics associated with outcome) and mediators (i.e., temporally intervening explanatory variables) that account for individual differences in outcomes. The most-often-identified predictor, at least among males, is earlier conduct problems, usually operationalized as symptoms of oppositional defiant disorder and/or conduct disorder (ODD/CD). In multiple samples of children with ADHD followed longitudinally (almost exclusively boys), earlier conduct problems have been associated with adult criminality and aggression (Barkley, Fischer, Smallish, & Fletcher, 2004; DeSanctis et al., 2012; Klein et al., 2012; Satterfield & Schell, 1997; Wymbs et al., 2012), major depressive and personality disorders (Fischer, Barkley, Smallish, & Fletcher, 2002), substance use (Barkley et al., 2004; Biederman et al., 1997; Klein et al., 2012), poor educational outcomes (Barkley et al., 2006; Klein et al., 2012), and lower occupational functioning (Mannuzza et al., 1997). It is not yet known to whether earlier conduct problems explain outcome among females with ADHD. Girls with ADHD, like boys, are at significant risk for concurrent and later externalizing problems (Biederman and colleagues 2006, 2010; Hinshaw et al., 2012; Yoshimasu et al., 2012) and often show rates of comoribid externalizing problems that are comparable to rates among boys (Bauermeister et al., 2007; Gabel, Schmitz, & Fulker, 1996; Hinshaw, 2002; Levy, Bennett, & McStephen, 2004; Molina & Pelham, 2014). However, for boys with ADHD, the developmental significance of co-occurring childhood disruptive behavior is clear, whereas for girls with ADHD it is unknown.

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Also unresolved is whether childhood versus adolescent conduct problems better predict adult outcome. Childhood conduct problems may be more salient because they identify early-onset individuals with higher risk for poor developmental outcome (Moffitt, Caspi, Harrington, & Milne, 2002). However, Silverthorn and Frick (1999) argue that the earlyonset pathway is not characteristic of girls and that adolescent-onset antisocial behavior in girls is as pernicious as the early-onset type among boys. Furthermore, adolescent conduct problems may be more predictive because they are temporally proximal to adult outcomes,


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as shown by Bor, McGee, Hayatbakhsh, Dean, and Najman, (2010) among girls with ADHD. Only a few studies have been conducted with ADHD participants over a sufficiently long time frame to consider the relative significance of child versus adolescent conduct problems, with highly variable results. In two studies, adolescent conduct problems were more predictive of negative adult outcomes than childhood conduct problems (Fisher et al., 2002; Satterfield & Schell, 1997), but findings may depend on the outcome of interest (Barkley et al., 2004) or the persistence of conduct problems across developmental periods (Wymbs et a., 2012). Overall, it is not yet clear which is the more potent risk factor among boys; among girls, there have been no relevant tests. Therefore, we examined whether childhood versus adolescent conduct problems, as well as persistent versus transient conduct problems, better predicted adult outcomes.

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Mediators of Adult Outcome A pressing additional question involves how earlier conduct problems increase risk for poor outcome during young adulthood among children with ADHD. Two mechanisms are likely: (a) emotional dysregulation, which suggests an indirect pathway through and to internalizing problems or a direct pathway through continuing externalizing problems; and (b) interference with adolescent milestones or competencies, such as positive peer relations and success in school, which are necessary stepping stones to successful maturation in young adulthood. Thus, we tested three adolescent mediators: internalizing problems, peer rejection, and school failure and disciplinary problems.


To our knowledge, no one has investigated mediators of the link between early conduct problems and adult outcome among boys or girls with ADHD. Therefore, empirical support for our three mediators is derived primarily from associations between childhood conduct problems and the particular mediator in question, and between the putative mediator and adult outcome, in mostly non-ADHD samples. First, early conduct problems predict later internalizing problems (Keiley, Bates, Dodge, & Pettit, 2000; Lee & Hinshaw, 2006; Moilanen, Shaw, & Maxwell, 2010), especially among girls (Diamantopoulou, Verhust, & van der Ende, 2010; Lee & Bukowski, 2012; Lechter, Sanson, Smart, & Toumbourou, 2012). Furthermore, as considerable evidence attests, adolescent internalizing problems are associated with poor overall functioning in adulthood, as well as continuing internalizing problems, relationship problems, educational underachievement, substance use, poor selfesteem, and lower quality of life (e.g., Herrenkohl et al., 2010; Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2003; Steinhausen, Haslimeier, & Metzke, 2006; Visser, van der Ende, Koot, & Verhulst, 2000; Vujeva & Furman, 2011; Yaroslavsky Pettit, Lewinsohn, Seeley, & Roberts, 2013). Second, conduct problems can lead to short-term (Chen et al., 2011; Fanti & Henrich, 2010; Keiley et al., 2000; Pedersen, Vitaro, Barker, & Borge, 2007) and longer-term (Burke, Rowe, & Boylan, 2014) rejection by peers. Among children with ADHD, conduct problems may have a greater impact on peer relationships for girls than boys (Becker, Luebbe, & Langberg, 2012; Mikami & Lorenzi, 2011). In turn, peer rejection predicts poor adult


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adjustment (Parker & Asher, 1987), as demonstrated recently (Marion, Laursen, Zettergren, & Bergman, 2013). Molina et al. (2012) note that because social dysfunction is a major impairment among children with ADHD, it is important to include in models of vulnerability to negative outcomes.

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Third, associations between childhood conduct problems and later school failure and disciplinary problems are widely documented (Breslau et al., 2009; Campbell et al., 2006; Fergusson & Woodward, 2000; Ingoldsby et al., 2006; Masten et al., 2005; van Lier et al., 2012), including for girls with ADHD (Monuteaux, Faraone, Gross, & Biederman, 2007). Molina and Pelham (2014) point to poor school performance as a central problem for boys and girls with ADHD and as a likely mechanism through which poor outcomes are obtained. Poor achievement and school failure, as well as suspensions and school drop-out during adolescence, are clearly associated with a range of adult impairments, including lower levels of educational attainment (e.g., Huurre, Aro, Rahkonen, & Komulainen, 2006; Marjoribanks, 2005), occupational difficulties, lower life satisfaction (Liem, Lustig, & Dillon, 2010), and substance use (Crum et al., 2006; Fothergill et al., 2008; Haller, Handley, Chassin, & Bountress, 2010; Hayatbakhsh, Najman, Bor, Clavarino, & Alati, 2011).

Summary

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In sum, we expect the following regarding relations between earlier conduct problems and young adult outcomes: (1a) Among women diagnosed with ADHD as children, both childhood and adolescent conduct problems will predict poor outcome during young adulthood, over and above the effects of initial ADHD severity, family SES, and child IQ. (1b) Adolescent conduct problems will account for significant variance in young adult outcomes over and above childhood conduct problems (as well as initial ADHD severity, family SES, and child IQ). (1c) Persistent conduct problems will be more strongly associated with young adult outcomes than transient conduct problems. (2a) As for mediational processes, we predict that adolescent internalizing problems, peer rejection, and school failure and disciplinary problems will each, independently, mediate the association between childhood conduct problems and the three young adult outcomes, controlling for childhood ADHD severity, child IQ and family SES. (2b) The indirect effects of any identified mediators will remain significant while accounting for the indirect effect of adolescent conduct problems on young adult outcomes, also covarying initial ADHD severity, family SES, and child IQ.

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Participants and Procedures Data were obtained from 140 participants in the Berkeley Girls with ADHD Longitudinal Study (Hinshaw et al., 2012), who were initially recruited from schools, mental health centers, pediatric practices, and through direct advertisements to take part in a 5-week summer camp, which we refer to as Wave 1 (W1). Eligibility was established using a multigated teacher- and parent-report process, with participation contingent upon meeting full criteria for ADHD via the parent Diagnostic Interview Schedule for Children, 4th ed. (DISCIV; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). Participants included 93 girls


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who met criteria for ADHD-combined type and 47 who met criteria for ADHDpredominantly inattentive type. Common comorbidities were allowed (see Hinshaw, 2002, for details). A comparison group of girls without ADHD is not included in the present investigation.

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At W1, girls were between the ages of 6 and 12 (mean age = 9.6). They were socioeconomically and ethnically diverse (57% Caucasian, 28% African American, 11% Latina, and 4% Asian American). A wide variety of multi-method, ecologically valid measures were obtained from parents and teachers prior to the summer camp and from observers, peers, and participants during the camp. Five years later (Wave 2, or W2; mean age 14.3, range 11–18; see Hinshaw et al., 2006) and 10 years later (Wave 3, or W3; mean age 19.6, range 17–23) the girls were invited for follow up assessments that involved two blinded, half-day lab visits for participants, and a single half-day assessment for the participant’s parent. Measures administered were selected to assess ADHD-related and other psychiatric symptomatology, cross-domain impairment (educational, occupational, wellbeing, self-harm, social relationships, substance use, and driving), and service utilization. Retention at W2 was 91% and at W3 was 92%, although ns for particular measures were somewhat lower. Analysis of 17 W1 characteristics (seven demographic, seven clinical, and three cognitive) revealed that at W2, the retained sample had proportionally more two-parent families and slightly higher teacher-reported internalizing scores than those not retained. At W3, the retained subsample had somewhat higher family income and somewhat lower teacher-rated psychiatric symptoms than those not retained. Additionally, those lost showed statistically significant, but quite isolated (one of seven at each time point) sociodemographic disadvantages.

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Measures W1 ADHD severity—Initial ADHD severity was assessed via parent and teacher report on the Swanson, Nolan, and Pelham Rating Scale, 4th ed. (SNAP-IV; Swanson, 1992). The SNAP assesses the severity of the nine inattention and nine hyperactivity/impulsivity items from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., (DSM-IV; American Psychiatric Association, 1994). Means of the 18 items were averaged across parent and teacher to create a single ADHD symptom severity score (mean = 1.8; sd = 0.7).

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W1 demographic and cognitive covariates—Maternal education, rated on a 1 – 6 scale (mean = 4.7, sd = 1.0), and family income, rated on a 1 – 9 scale (mean = 6.2, sd = 2.7), were used as demographic covariates. Child Full Scale IQ from the Wechsler Intelligence Scale for Children, 3rd ed. (Wechsler, 1991) was also used as a covariate (mean = 99.7, sd = 13.7). W1 conduct problems—Parental ratings of symptoms of conduct and oppositional defiant disorders on the DISC-IV (Shaffer et al., 2000) were tallied to create a continuous measure of conduct problems at W1 (mean = 5.8, sd = 3.8). For hypothesis 1c only, we used past-year diagnosis of ODD or CD from the DISC-IV. The DISC-IV is a well-validated, highly structured interview yielding diagnoses and symptom counts for the major DSM-IV disorders. J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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W2 internalizing problems—It is widely acknowledged that a multi-method, multisource approach is usually optimal for assessing psychological problems, especially among children. Kraemer et al. (2003) argue that the best way to approximate the true score or real extent and nature of those problems is through the use of multiple, valid, and unique (i.e., uncorrelated) perspectives. Thus, according to recommendations from Kraemer et al. (2003), we integrated data from informants who would each offer a unique but valid perspective on the expression of internalizing problems in different settings. We also chose measures that differed in their form (interview versus rating scale) in order to optimize the ultimate validity of our internalizing measure.


Specifically, data from five variables were combined to assess adolescent internalizing problems: (1) the Internalizing T score from the Teacher Report Form (TRF, Achenbach, 1991a; mean = 54.7, sd = 9.1), and the (2) The Internalizing T score from the Child Behavior Checklist (CBCL, Achenbach, 1991b; mean = 56.4, sd = 11.3). The TRF and CBCL are extensively used and their component scales have excellent internal consistency, test-retest reliability, and validity. (3) The total score from the Child Depression Inventory (Kovacs, 1992; mean = 7.4, sd = 5.8). This 27-item self-report instrument is widely-used, with internal consistency ranging from .71 to .87 and test-retest reliability figures averaging .70 (Kovacs, 1992). (4) Youth report of anxiety and depressive symptoms from the DISC-IV (Shaffer et al., 2000; mean = 14.7, sd = 10.0). Finally, (5) parent report of anxiety and depressive symptoms from the DISC-IV (Shaffer et al., 2000; mean = 12.4, sd = 9). Scores on these five variables were standardized and summed to create a multiinformant, multi-method measure with a Cronbach alpha of .65. The computation procedure is highly similar to, and produces scores that are almost perfectly correlated with those generated by, the factor-analytic approach recommended by Kraemer et al. (2003), and retains cases with missing values for some of the individual internalizing measures.

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W2 peer rejection and conflict—Also according to recommendations from Kraemer et al. (2003), two measures of peer rejection and conflict were administered to different, valid informants: 1) The Social Relationships Interview was project-derived and provided three self-report items of peer rejection: “How easy/hard is it for you to make friends?”, “How often are you teased to your face?”, and “How often are you teased behind your back?” The intercorrelations of these items ranged from r = .17 to r = .49. We standardized and summed responses into a self-report measure of peer conflict, which correlated r = −.40 with the social preference measure from the Dishion Social Preference Scale (Dishion, 1990). 2) The Social Relationships Questionnaire is a 12-item parent-reported measure of an adolescent’s relationships with peers and friends. A principal components analysis with oblique rotation yielded two six-item factors with eigenvalues greater than 1, accounting for 44% and 11% of the variance, respectively. The first we termed Peer Conflict (alpha = .83). Scores on this factor correlated moderately with problem behavior and social competence scores in the current sample, as well as correlating r = −.46 with the Dishion social preference measure. Our two measures of peer rejection and conflict correlated r = .39 with each other; we standardized and summed them to create one multi-informant variable.


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W2 school failure and disciplinary problems—School failure and disciplinary problems were assessed by summing parent report of the number of suspensions/expulsions, grade failures or retention, placements in more restrictive settings, and school termination (dropping out) throughout childhood and adolescence. This construct reflects both serious academic underachievement (grade failure or retention), as well as serious disciplinary problems (suspensions/expulsions). Dropping out and placements in more restrictive settings, which in our sample included placements in schools for children with learning disabilities, placement in a full-time resource room, or independent study, as well as placements in residential centers, both may reflect academic failure and/or serious behavioral problems at school.

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W2 conduct problems—Parental ratings of symptoms of conduct and oppositional defiant disorders on the DISC-IV (Shaffer et al., 2000) were tallied to create a continuous measure of conduct problems at W2 (mean = 4.6, sd = 3.8). For hypothesis 1c only, we used past-year diagnosis of ODD or CD from the DISC-IV.

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W3 overall functioning—Overall functioning was derived by averaging two different clinician-rated Global Assessment of Functioning (GAF, APA, 1994) scores, one generated after a 4-hour parent assessment and one generated after an 8-hour participant assessment. The GAF ranges from 1 (worst) to 100 (best) and is intended to capture psychological, social, and occupational functioning. It reflects functional impairments and psychiatric symptoms. Clinicians used semi-structured interviews, rating scales, and objective tests to gather information across 11 primary domains of functioning: ADHD symptoms, externalizing and delinquent behavior, internalizing disorders and symptoms, substance use, eating disorder symptoms, academic achievement, well-being, service utilization, self-harm, problematic driving, and global impairment (Hinshaw et al., 2012). Clinicians also obtained information regarding personality, neuropsychological functioning, family relationships, peer and romantic relationships, coping and social support, social media use, and stressful life events before rating participants on the GAF. For 96 cases, the parent and girl clinicians convened to generate a consensus GAF rating. In 14 additional cases the separate parent and girl GAF ratings were averaged to create a single rating (thus, for 110 cases we have a multi-informant GAF rating). In 15 cases, only the parent or daughter was assessed and that single GAF rating was used. In all, we have GAF ratings in early adulthood for 125 of the original 140 participants with ADHD.

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In our sample, the correlation between GAF ratings made by separate clinicians working with the parent and the girl was .64 (p = .000). The mean clinician ratings were virtually identical, 66.1 (sd = 12.2) for clinician ratings based on parent report and 67.0 (sd = 12.6) for clinician ratings based on young adult report. Averaged GAF scores and mother-rated impairment on the Columbia Impairment Scale (Bird, 1999) were substantially correlated −. 57 (p = .000). Finally, our multi-informant GAF score had a mean of 66.2, a standard deviation of 12.2, a range of 37 to 94, and was normally distributed (skewness = −.231; kurtosis = −.438). No values were more than three standard deviations from the mean. W3 symptoms—At W3, parents completed the Adult Behavior Checklist (Achenbach & Rescorla, 2003), and young adults completed the Adult Self-Report (Achenbach & Rescorla, J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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2003). These two measures are widely-used with excellent psychometric properties. We averaged parent and young adult reports of Externalizing problems (r = .43, p = .000) to create our Externalizing Problems composite; we averaged parent and young adult report of Internalizing problems (r = .41, p = .000) to create our Internalizing Problems composite. Data Analytic Plan

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First, we computed zero-order correlations among the 12 study variables. To address hypothesis 1a we used linear regressions in which W1 and W2 conduct problems were entered in separate equations after the variance in adult outcomes attributable to W1 ADHD severity, child IQ, maternal education, and family income was accounted for. To address hypothesis 1b, we used linear regressions in which the contribution of each measure of conduct problems was entered last after the W1 ADHD severity, child IQ, maternal education, family income, and the other measure of conduct problems were entered. Hypotheses 1c was assessed using t-tests in which the adult outcome scores across groups with persistent (ODD/CD diagnosis present at W1 and W2) versus transient (ODD/CD diagnosis present at either W1 or W2) conduct problems were compared.

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Hypotheses 2a and 2b, involving mediators of the association between W1 conduct problems and W3 adult outcomes, were tested via a bootstrap method for identifying indirect effects using PROCESS (Hayes, 2013). The bootstrap method is a statistical simulation in which a new mathematical sample is created by randomly sampling observations from the original data with some replacement. Then, a point estimate of the indirect effect is generated for each random sampling and repeated 10,000 times, with all point estimates aggregated to arrive at an overall estimate of the indirect effect. The primary mediators (internalizing problems, peer rejection, and school failure and disciplinary problems) were entered as a set in three different equations, one for each young adult outcome. For each mediator, we calculated the point estimate of the indirect effect plus the 95% bias-corrected confidence interval based on the distribution of these effects, after accounting for the association between the W1 covariates (ADHD severity, child IQ, maternal education, and family income) and W3 outcomes. We inferred statistical significance if this interval did not contain 0 (see Hayes, 2013). For those mediators showing a significant indirect effect, we then re-computed their effects and confidence intervals in parallel with W2 ODD/CD symptoms, i.e., controlling for the indirect effect of W2 conduct problems (see hypothesis 2b). Finally, we evaluated our assumptions regarding the temporal ordering of variables by re-computing tests of significant mediators controlling for earlier measures of the same constructs, and by computing partial correlations to estimate whether over-time relations among variables were likely to be unidirectional or bidirectional.

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Results Preliminary analyses Preliminary analyses involved investigation of missing data, outliers, and computation of zero-order correlations. All W1 variables had complete data. At W2, missing data rates ranged from 4.3% (for School Failure and Disciplinary Problems) to 10.0% (for Conduct


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Problems). At W3, 10.7% of the GAF scores and 9.3% of the Internalizing and Externalizing Problem scores were missing. Of the 12 variables used in the analyses, W2 Peer Rejection, W2 School Failure and Disciplinary Problems, and W2 Internalizing Problems each had between one and three values greater than three standard deviations from the mean. In order to improve the properties of these distributions, outlying scores were changed to a value 3.1 standard deviations from the mean. Zero-order Pearson ProductMoment correlations among all variables are presented in Table 1. Of note, ODD/CD symptoms across W1 and W2 were moderately stable (r = .53, p = .000); the correlations between W1 ODD/CD symptoms and the potential W2 mediators--Internalizing Problems, School Failure and Disciplinary Problems, and Peer Rejection--were .31, .40, and .34, respectively. Tests of Hypotheses

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1a: To address whether, among women diagnosed with ADHD as children, childhood and adolescent conduct problems would be negatively associated with overall functioning during adulthood, we computed two linear regressions, the results of which are presented in Table 2. As can be seen, W1 ODD/CD Symptoms accounted for a significant and reasonably large amount of variance in W3 GAF scores (F1,118 change = 9.00, p = .003, R2 change = .069), over and above the contribution of W1 ADHD Severity, Maternal Education, Family Income, and Child IQ. The same pattern held for W2 ODD/CD Symptoms (F1,109 change = 10.41, p = .002, R2 change = .083). In both cases higher levels of conduct problems predicted poorer adult functioning.

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The same regressions were repeated using W3 Internalizing Problems and then W3 Externalizing Problems as the dependent variables. W1 ODD/CD Symptoms accounted for a significant amount of variance in W3 Internalizing Problems (F1,120 change = 4.73, p = . 032, R2 change = .037), as did W2 ODD/CD symptoms (F1,111 change = 6.41, p = .013, R2 change = .052). W1 ODD/CD Symptoms did not account for significant variance in W3 Externalizing Problems (F1,120 change = 0.42, p = .519, R2 change = .003), but W2 ODD/CD Symptoms did (F1,111 change = 14.70, p = .000, R2 change = .102). In all cases higher levels of conduct problems predicted higher levels of adult symptomatology.

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1b: To address whether adolescent conduct problems would account for significant variance in young adult functioning over and above childhood conduct problems (as well as W1 ADHD severity, family SES, and child IQ), and not vice-versa, we again computed two linear regressions, also presented in Table 2. W1 ODD/CD Symptoms accounted for significant variance (4.5%) in W3 GAF scores over and above the W1 covariates and W2 ODD/CD Symptoms (F1,108 change = 5.91, p = .017). Yet, the association between W2 ODD/CD Symptoms and W3 GAF scores was no longer significant once the W1 covariates and W1 ODD/CD Symptoms were included (F1,108 change = 3.50, p = .064, R2 change = . 027). These regression equations were repeated using Internalizing and then Externalizing Problems as the dependent variables. W1 ODD/CD Symptoms did not account for significant variance in W3 Internalizing scores over and above the W1 covariates and W2 ODD/CD symptoms (F1,110 change = 2.05, p = .155; R2 change = .017). Similarly, the J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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association between W2 ODD/CD Symptoms and W3 Internalizing Problems was not significant once the W1 covariates and W1 ODD/CD Symptoms were included (F1,110 change = 2.27, p = .102, R2 change = .022). W1 ODD/CD Symptoms did not account for variance in W3 Externalizing scores over and above the W1 covariates and W2 ODD/CD Symptoms (F1,110 change = 0.13, p = .720, R2 change = .001). However, W2 ODD/CD Symptoms did account for variance in W3 Externalizing scores over and above the W1 covariates and W1 ODD/CD Symptoms (F1,110 change = 12.86, p = .001, R2 change = . 090).

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1c: Regarding associations with transient versus persistent conduct problems, the mean W3 GAF score for those girls with an ODD/CD diagnosis at W1 or W2, i.e., transient conduct problems, was higher (mean = 66.3) than for those girls who had a persistent ODD/CD diagnosis at both the W1 and W2 assessments (mean = 61.7), but the difference was only marginally significant (p = .061) and the effect size small (d = .38). W3 Internalizing Problems did not differ significantly across transient (mean = 56.1) and persistent (mean = 59.8) conduct problem groups, and the difference was small (d = .34). W3 Externalizing Problems were lower for girls with transient (mean = 55.6) versus persistent (mean = 63.8) conduct problems, with the mean difference significant (p = .001) and large (d = .74).

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2a: To test whether our proposed adolescent mediators would each, independently, mediate the relation between childhood conduct problems and young adult overall functioning, we used Hayes’s (2013) bootstrap method. We computed three parallel multiple mediator models testing whether W2 Internalizing Problems, W2 Peer Rejection, and W2 School Failure and Disciplinary Problems each functioned as an indirect effect of the established relation (direct effect) between W1 ODD/CD Symptoms and each W3 outcome. In each, we also covaried W1 ADHD Severity, Maternal Education, Family Income, and Child IQ. Regarding the W3 GAF scores, and as depicted in Figure 1a, only W2 School Failure and Disciplinary Problems functioned as a significant, independent indirect effect of W1 ODD/CD Symptoms on W3 GAF (indirect effect = −.3747, se = .1760, CI95 = −.8265 to −. 1107). Twenty-five percent of the variance in W3 Failure and Disciplinary Problems scores was accounted for (R2 change = .25, F8,107 = 4.48, p = .001). Similarly, W2 School Failure and Disciplinary Problems mediated the relation between W1 ODD/CD Symptoms and W3 Externalizing Problems (indirect effect = −.4459, se = .1179, CI95 = −.8833 to −.1699). Twenty-five percent of the variance in W3 GAF scores was accounted for (R2 change = .25, F8,109 = 4.50, p = .005). Neither W2 Peer Rejection nor W2 Internalizing Problems mediated the associations between W1 ODD/CD Symptoms and either W3 GAF or W3 Externalizing scores, and they are not included in Figure 1a.

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As depicted in Figure 1b, the association between W1 ODD/CD Symptoms and W3 Internalizing Problems was mediated by W2 Internalizing Problems (indirect effect = .1364, se = .1015, CI95 = .0012 to .4277), and by W2 Peer Conflict (indirect effect = .1895, se = . 1179, CI95 = .0217 to .4996), accounting for 26% of the variance in W3 Internalizing Problems (R2 change = .26, F8,109 = 7.34, p = .001). W2 School Failure and Disciplinary Problems did not mediate the association between W1 ODD/CD Symptoms and W3 Internalizing Problems.


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2b: To address whether the indirect effects of identified mediators would remain significant after controlling for the indirect effect of adolescent conduct problems, we recomputed parallel multiple mediator models, including the significant mediators identified in 2a along with W2 ODD/CD Symptoms. Results were highly similar to the models computed without W2 ODD/CD Symptoms. For the W3 GAF model, W2 ODD/CD Symptoms did not function as a mediator but W2 School Failure and Disciplinary Problems did (indirect effect = −.3676, se = .1719, CI95 = −.7924 to −.1085). For W3 Externalizing scores also, W2 School Failure and Disciplinary Problems continued to function as a significant, indirect effect once W2 ODD/CD Symptoms were included in the model (indirect effect = .2750, se = .1224, CI95 = .0902 to .5914). In this case, W2 ODD/CD Symptoms also functioned as a significant indirect effect (indirect effect = .3495, se = .1594, CI95 = .0881 to .7298). Regarding W3 Internalizing Problems, W2 ODD/CD symptoms did not function as a mediator and both W2 Internalizing Problems (indirect effect = .1610, se = .1094, CI95 = . 0363 to .5557) and W2 Peer Rejection (indirect effect = .2103, se = .1245, CI95 = .0881 to . 7298) continued to function as a significant, indirect effects.

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Finally, mediational tests assume temporal ordering. Unlike W2 School Failure and Disciplinary Problems, which by definition occurred after the W1 assessment and prior to the W3 assessment, internalizing and peer problems were measured during adolescence but did not exist exclusively during that developmental period. Thus, we probed our assumptions regarding the temporal placement of these identified mediators. First, we found that W2 Internalizing Problems continued to mediate the relation between W1 ODD/CD Symptoms and W3 Internalizing Problems even covarying W1 Internalizing Problems (indirect effect = .2028 se = .1399, CI95 = .0110 to .5883). Furthermore, covarying W1 ODD/CD Symptoms, the relation between W1 Internalizing Problems and W2 ODD/CD Symptoms was nonexistent (partial r = .00, ns), whereas the relation between W1 ODD/CD Symptoms and W2 Internalizing Problems was significant, although small (partial r = .23, p = .013), covarying W1 Internalizing Problems. Our interpretation is that childhood conduct problems and adolescent internalizing problems are temporally ordered, supporting a causal interpretation.

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W2 Peer Rejection also continued to mediate the relation between W1 ODD/CD Symptoms and W3 Internalizing Problems even covarying W1 Peer Rejection, as measured by teachers (indirect effect = .3378, se = .1560, CI95 = .1020 to .7379). However, partial correlations show that with control of W1 ODD/CD Symptoms, the relation between W1 Peer Rejection and W2 ODD/CD symptoms (partial r = .22, p = .014) was quite similar to the partial correlation between W1 ODD/CD Symptoms and W2 Peer Rejection, partialing W1 Peer Rejection (partial r = .27, p = .003). These findings suggest that the over-time relation between these variables is bidirectional and that the assumption of temporal ordering might not be tenable.

Discussion Do earlier conduct problems predict young adult outcomes among girls with ADHD? Our first objective was to establish whether, as is true for males, childhood and/or adolescent conduct problems are associated with young adult outcomes among females with J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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ADHD. In this all-female sample, both childhood and adolescent conduct problems were significant predictors of overall functioning and internalizing problems during young adulthood, covarying initial ADHD severity, demographic factors, and child IQ. Thus, conduct problems accounted for unique variance in these young adult outcomes that was not due to their relation with these key covariates. However, for externalizing problems, adolescent, but not childhood, conduct problems accounted for significant variance. This surprising finding may relate to the potentially heterotypic nature of conduct and externalizing problems across age for girls. It could be that very early symptoms of CD and ODD predict young adult externalizing problems of a different sort, such as relational aggression (Crick, Ostrov, & Kawabata, 2007), rather than predicting more of the same. Overall, however, our results are generally consistent with literature showing conduct problems during childhood or adolescence to predict psychiatric symptoms and functional impairments during adulthood among (mostly) boys with ADHD (Barkley et al., 2004, 2006; Biederman et al., 1997; DeSanctis et al., 2012; Fischer et al., 2002; Klein et al., 2012; Mannuzza et al., 1997; Satterfield & Schell, 1997; Wymbs et al., 2012). To our knowledge, we are the first to document these patterns among a female sample.

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Contrary to our expectation, but consistent with one previous report (Barkley et al., 2004), childhood conduct problems were a somewhat more salient predictor of young adult overall functioning than adolescent conduct problems. One explanation might be that childhood conduct problems indicated early-onset or life-course-persistent antisocial behavior which may be more pernicious than the adolescent-limited type (Moffitt et al., 2002). However, in our sample, only 41% (12/29) of the girls who evidenced high levels of childhood conduct problems (ODD/CD symptom scores at least one standard deviation above the mean) continued to meet this criterion during adolescence, even though levels of ODD/CD symptoms were moderately stable. Thus, high levels of conduct problems during childhood were not isomorphic with a persistent pattern of such problems (see Moffitt, 2006, for explication). It may simply be that the negative effects of oppositionality and antisocial behavior evidenced during childhood accumulate over a longer period of time than those during adolescence. Furthermore, adolescent conduct problems were a stronger predictor of young adult externalizing problems than were childhood conduct problems, as is consistent with previous reports among boys with ADHD (Barkley et al., 2004; Fischer et al., 2002). For internalizing problems, the pattern was indeterminate. Thus, whether childhood versus adolescent conduct problems functions as a more somewhat more salient predictor depends on the outcome under consideration.

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Regarding persistent versus transient conduct problems, for externalizing outcomes, persistent conduct problems were associated with higher levels of young adult externalizing problems than were transient conduct problems. But for overall functioning the difference was small and only marginally significant, between girls with a comorbid diagnosis of ODD or CD at W1 or W2 versus those who had a diagnosis at both W1 and W2. For internalizing problems, there was no difference between transient and persistent groups. Girls with persistent comorbidity may be slightly worse off in terms of adult outcomes than girls whose comorbidity was transient, as has been suggested by findings regarding specific outcomes (e.g., educational attainment) in male samples (Barkley et al., 2006; Wymbs et al., 2012).


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Overall, it is clear that higher levels of conduct problems during either childhood and/or adolescence are significant in terms of predicting poorer adult functioning and greater psychiatric symptomatology among girls with ADHD. What mediates or explains associations between earlier conduct problems and young adult outcomes among girls with ADHD?

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The pressing question of why childhood oppositionality and antisocial behavior are related to young adult outcomes was addressed by our mediational analyses. For both overall functioning and externalizing problems during young adulthood, school failure and disciplinary problems – suspensions/expulsions, failing, dropping out, moving to a more restrictive setting -- during adolescence was the most salient pathway. In other words, oppositionality and antisocial behavior in childhood are linked to school failure and disciplinary problems, which then predict both overall impairment and externalizing problems during young adulthood. These indirect effects existed even controlling for the effects of other continuing conduct problems, as well as initial ADHD symptoms, child IQ, and demographic factors. Of course externalizing symptoms and overall impairment during young adulthood are not orthogonal, so these mediational findings should not be interpreted as if they are each unique. It is noteworthy, however, that school failure and disciplinary problems still functioned as a significant indirect effect on overall impairment, covarying young adult externalizing problems. It also functioned as a significant indirect effect on young adult externalizing problems, with control of overall impairment. Thus, school failure and disciplinary problems seems to be an important pathway from childhood conduct problems to both young adult externalizing problems and overall impairment.


Successfully managing the demands of school is a key developmental task of childhood and adolescence. Severe difficulties in this domain, related to but also over and above early conduct problems, partially account for failures to adapt to the demands of young adulthood in our sample. This finding is likely because successful schooling enables further education and contributes to occupational success, as well as provides a context for positive socialization. School engagement may also protect against mental health problems (Li & Lerner, 2011). Thus, because (a) school failure and disciplinary problems is a significant risk factor for poor adult adaption, and (b) children with ADHD often have particular trouble succeeding in school (Molina & Pelham, 2014), ensuring that children with ADHD complete school successfully, rather than treating only symptoms, comorbidities, or specific impairments such as disobedience at home, may be critical for improving adult outcomes. A program called “Check and Connect” (Anderson, Christenson, Sinclair, & Lehr, 2004) is one such example of a successful targeted intervention. In contrast, the unique mediational pathways between childhood conduct problems and young adult internalizing problems involved both adolescent internalizing problems and peer rejection. Regarding the first, although it is not surprising that internalizing problems during adolescence predicted later internalizing problems, it is noteworthy that adolescent internalizing problems apparently followed from childhood conduct problems in this allfemale sample, as is consistent with findings with previous findings among girls (Bor et al., J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

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2010; Diamantopoulou et al., 2010; Lee & Bukowski, 2012; Lechter et al., 2012). Among girls with ADHD, early conduct problems apparently spur the development of internalizing problems and not the other way around.

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Early conduct problems were also clearly related to peer rejection, as has been found in other samples of girls with ADHD (Becker et al., 2012; Mikami & Lorenzi, 2011). Moreover, peer rejection, as we measured it during adolescence, partially accounted for the relation between childhood conduct problems and young adult internalizing problems. In terms of reducing the likelihood of depression and anxiety among young women with ADHD, interventions aimed to improve peer acceptance and relationships may be particularly useful. However, the assumption of a temporally ordered pathway through peer rejection is not as well supported as it is for adolescent internalizing problems. Reciprocal causality or a developmental cascade may better represent this process (van Lier & Koot, 2010). Furthermore, although peer rejection may lead to depression, especially among girls (Brendgen, Wanner, Morin, & Vitaro, 2005), adolescents with depression are more sensitive to peer rejection (Silk et al., 2014) and may be more likely to be rejected by peers (Agoston & Rudolph, 2013). Thus, even though peer rejection statistically mediates the relation between childhood conduct problems and young adult internalizing problems, it is plausible that conduct problems and peer rejection, as well as peer rejection and internalizing problems, are reciprocally causal over short time periods or act in a cascading manner (Masten & Cicchetti, 2010). We were unable to test these possibilities with our three data collection points spaced at five-year intervals. Limitations

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As noted above, a limitation of this work is the significant interrelation among young adult overall functioning and both internalizing and externalizing problems. Although shared source variance may partially account for significant direct and indirect effects, we tried to mitigate this problem by combining multi-source data for most constructs. Although we were interested in, and did test, the relative importance of childhood versus adolescent conduct problems for adult outcomes, we could not address whether change in conduct problems across childhood and adolescence was related to outcome. Also note that we tested predictors of outcome among girls with ADHD, not moderators of the relation between ADHD and outcome. It is quite possible that these results would not apply to girls without ADHD. Without a comparison group exhibiting a suitably large range of conduct problem severity, this issue could not be addressed. Regardless of whether conduct problems predict outcome among girls not diagnosed with ADHD, their predictive validity among girls with ADHD is still quite significant.

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Conclusion In sum, among girls with ADHD, childhood and adolescent conduct problems predict overall functioning, internalizing problems, and externalizing problems during young adulthood. School failure and disciplinary problems functioned as a significant indirect effect of the relations between childhood conduct problems and both adult functioning and externalizing problems, whereas internalizing problems and peer rejection functioned as significant indirect effects of the relation between childhood conduct problems and adult


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internalizing problems. Future research should test these relations in additional samples of girls, as well as to more carefully sequence the temporal patterning of identified risk factors (childhood conduct problems) and mediators (school failure and disciplinary problems, internalizing problems, and peer rejection) in order to better understand whether and how these factors are reciprocally causal over time.

Acknowledgments This research was supported by National Institute of Mental Health Grant 45064. With deep gratitude we acknowledge the young women, as well as their caregivers, who have participated in this long-term investigation.

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Author Manuscript

Lay summary Our findings show that conduct problems among girls with ADHD portend poor young adult outcomes, as they do among boys. School failure and disciplinary problems, anxiety and depression, and peer rejection during adolescence may partly explain why childhood conduct problems are associated with poor outcomes during young adulthood among females with ADHD.

Author Manuscript Author Manuscript Author Manuscript J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

Owens and Hinshaw

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Figure 1.

Figure 1a. Indirect effect of adolescent school failure and disciplinary problems. I.E. = indirect effect (a * b), se = standard error, CI = bias-corrected confidence interval, c′ = direct effect.


Owens and Hinshaw

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Author Manuscript

Figure 1b. Indirect effect of adolescent internalizing problems and peer rejection. I.E. = indirect effect (a * b), se = standard error, CI = bias-corrected confidence interval, c′ = direct effect.

Author Manuscript Author Manuscript Author Manuscript J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01.

p < .001

p < .01,

***

**

p < .05,

*

11.

10.

9

8

7

6

5

4

3

2

1

.15

.31***

.23**

3. Child IQ

2. Family income

−.06

−.13

−.08

4. ADHD severity

.42*** −.58***

.40*** .29** −.65***

−.43*** −.25** −.33***

.36*** .46*** .42***

.48*** .42***

−.28**

−.30**

.36***

.37***

.23*

.70***

.31**

.41***

.15

.16

.29**

.13

.33***

.53***

.16

.08

.34***

−.18

.03

.40***

.32***

.14

.31***

.22*

−.01

.22**

.02

−.00

.22*

−.02

−.04

12. Externalizing problems

.34**

.02

.05

11. Internalizing problems

.09

−.04

.04

10. Global functioning

−.18*

−.03

−.03

9. Conduct problems

−.07

.05

8. Peer rejection

−.09

−.06

7. School failure/discipline

W3

−.11

−.01

.09

5. Conduct problems

6. Internalizing problems

Author Manuscript

1. Maternal education

W2

Author Manuscript

W1

Author Manuscript

Zero-order correlations among study variables

Author Manuscript

Table 1 Owens and Hinshaw Page 24


Author Manuscript

Author Manuscript .005

Child IQ

−.120

ADHD Severity

.027 −.051 −.195

Child IQ

ADHD Severity

W2 Conduct problems

J Abnorm Psychol. Author manuscript; available in PMC 2017 February 01. .027 −.051 −.261

Child IQ

ADHD Severity

W1 Conduct problems −.195

−.112

Family Income

W2 Conduct problems

.044

Maternal Education

Step 1

Step 2

Standardized Beta (final)

D

−.261

−.112

Family Income

W1 Conduct problems

.044

Maternal Education

Step 1

Step 2


C

−.307

.061

Child IQ

W2 Conduct problems

−.104

Family Income

Step 2

.016

Maternal Education

Step 1

−.283 Standardized Beta (final)

W1 Conduct problems

B

Step 2

−.008

Family Income

−.069

.071

Maternal Education

Step 1

ADHD Severity


A

3.50

3.90

F change

5.91

3.36

F change

10.41

1.47

F change

9.00

.992

F change

1,108

5,109

df

1,108

5,109

df

1,109

4,110

df

1,118

4,119

df

.064

.027

.152

R2 change p .003

.045

.017

.134

R2 change

p .007

.083

.002

.051

R2 change

p .215

.069

.032

R2 change

.003

.415

p

Author Manuscript

Relations between earlier conduct problems and young adult functioning

Author Manuscript

Table 2 Owens and Hinshaw Page 25

Hyperactivity Disorder (ADHD) Diagnosis: An Activation-Executive Model.

Attention deficit hyperactivity disorder (ADHD): review for primary care clinicians.

Prevalence of Adult Attention Deficit Hyperactivity Disorder (Adult ADHD): Tabriz.

hyperactivity disorder (ADHD) and high risk behaviors.

Hyperactivity Disorder (ADHD).

hyperactivity disorder (ADHD).

hyperactivity disorder (ADHD).

Personality profiles in adults with attention deficit hyperactivity disorder (ADHD).

Hyperactivity Disorder (ADHD) Symptoms Predict Alcohol Expectancy Development.

Pediatric Integrative Medicine Approaches to Attention Deficit Hyperactivity Disorder (ADHD).

Hyperactivity Disorder (ADHD) and Obesity: Update 2016.

Hyperactivity Disorder (ADHD): Impairing Deficit or Compensatory Behavior?

hyperactivity disorder (ADHD).

Attention deficit hyperactivity disorder (ADHD): an affect-processing and thought disorder?

Hyperactivity Disorder (ADHD).

Attention deficit hyperactivity disorder (ADHD) and conduct disorder in children of drug dependent parents.

Genome Wide Association Study (GWAS) between Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive Compulsive Disorder (OCD).

Comparison of Height and Weight of 5-6 Year-old Boys with Attention Deficit Hyperactivity Disorder (ADHD) and Non-ADHD.

Diagnosis of children's attention deficit hyperactivity disorder (ADHD) and its association with cytomegalovirus infection with ADHD: a historical review.

impulsive symptoms in children with ADHD.

hyperactivity disorder (ADHD) in the context of parental ADHD.

Evaluation of motor vehicle accident drivers for attention deficit hyperactivity disorder: hyperactivity and ADHD in traffic accidents.

Hyperactivity Disorder (ADHD).

hyperactivity disorder (ADHD) symptoms, anxiety symptoms, and executive functioning in emerging adults.