# Presentation: 092913

## Childhood ADHD, Comorbidity, and Risk for Late-Adolescent Drug Abuse

**Ken Winters, Ph.D.**
***Center for Adolescent Substance Abuse Research,***
***Department of Psychiatry, University of Minnesota***
**2004 APA Annual Meeting**
**New York**

## Lake Wobegon Staff:

**U of Minnesota,**
**Center for Adolescent**
**Substance Abuse Research**

**Lake Wobegon Staff:**
**All above average.**
**Women are strong.**
**Men are good looking.**

**Our Ex-Governor was a**
**professional wrestler.**

##  Acknowledgements

**Funding provided by ****NIMH**** and ****NIDA**** ****(DA 12995)**** ****	**
**Special thanks to the staff who made this study and presentation possible:**
**	****Gerry August, Ph.D. (co-Investigator)**
**	****George Realmuto, M.D. (co-Investigator)**
**	****Tamara Fahnhorst, M.P.H.**
**	****Andria Botzet, M.A.**
**	****Jessie Breyer, B.A.**
**	****Jodi Helseth, M.A.**

## Timeline:  NIMH – NIDA 

**	****	****Baseline****	****Follow-up ****	****Follow-up**** ****	****Follow-up****                                              **
**	****	****	****	****       ****1****	****	****     2****	****                  ****3****	**
***Year******	*****	****1991****	****	****1994****	****	****1995****	****	****2001**
***Age******	******	*****7-9****	****	****10-12****	****	****11-13****	****	****18-19**

## Samples 

_**ADHD sample**_** initially identified at baseline with a multigate screening procedure; over 7,000 students (21 urban elementary schools) received scores on Conner’s HI scales  **
**	****Revised Conner’s ****T****eacher & ****P****arent Rating Scales-****H****yperactivity ****I****ndex**
**	****	****Gate 1 - Teacher (****HI-T****) cut off score > 1.75 SD  **
**	****	****Gate 2 -  Parent (****HI-P****) cut off score > 1.75 SD**** **
**  **
_**Comparison sample**_**  screened from same schools**
** ****	****	****HI-T ****< 1.0 SD**
**Screened youth assessed with parent DICA-R at Baseline, F-UP 1, F-UP 2****	**

## Eligibility for current study

**ADHD group**
** ****DSM-III-R diagnosis of ADHD **
** “****High Water Mark” diagnosis (Baseline, F-UP 1, F-UP 2)**
** ****included: ADHD only and ADHD w/externalizing**** **
** ****excluded:  ADHD w/internalizing and subclinical ADHD**** **
** ****Data collected at F-UP 3**
**Comparison group**
** ****Absence of any DSM-III-R diagnosis**** ****(Baseline, F-UP 1, F-UP 2)**
** ****Data collected at F-UP 3**

##  Groups for the Analysis

**	****	****	****	****	****	****	****	****	****n****	****	****attrition**
**	****ADHD Group**
**	****	****	****	****ADHD only**** ****	****	****	****29****	****	****    ****6**
**	****	****	****	****ADHD  w/externalizing**** ****	****96****	****	****   ****13**
**	****Comparison****	****	****	****	****99****	****	****    ****5**

**Overall attrition:  9.7****%**

## Attrition Effects at F-UP 3 for the                ADHD Sample – Baseline HI-T/HI-P

**	****	****	****	****	****	****                                                **
**	****	****Assessed**		**Attrition****	**				**(n = 125)****	****	**** (n = 19)****	****	**
**Baseline ****	****Mean (SD)****	****	****Mean (SD)****	****   *****t******	***
**HI-T               ****	****2.18 (.39)****	****	****2.22 (.43)****	**** ns****	**
**HI-P****	****	****1.97 (.42)****	****	****2.15 (.41)****	****1.99 ****(.05)**
**	****	**

## Attrition Effects at F-UP 3 for the                ADHD Sample – Other Variables

** ...****. **_**a trend toward**_** **
** ****lower IQ, **
** ****lower baseline SES, **
** ****more frequently in a single-parent household, **
** ****having younger parents **
** ...****. **_**at a significant level**_
** ****biological mother with a lower level of **
**education**

**Attrition Effects at ****F-UP 3**** for the                ****ADHD Sample – ****Other Variables**

## Outcome Assessment Measures 

**  ****Follow-up 3:**
**	****1. *****Drug Use Frequency*****     ****	****    ****	****	****     ****	****	****   ****	****	****    ****Monitoring the Future Survey (Johnston et al., 2000)****	****	****	****	****	**
**	****	****	****all major drug categories (including tobacco)**
**	****	****	****1=never; 7=40+**
**        ****	****	****2. *****DSM-IV SUD ***
***	******   *****Adolescent Diagnostic Interview (Winters et al., 1993)**
**	****	****   ****	****Alcohol Abuse/Dependence**
**	****     ****	****Marijuana Abuse/Dependence**
**	****	****    ****	****Other Drug Abuse/Dependence**
**	****	****	****Use consequences****	****	**

## Outcome Assessment Measures 

**Follow-up 3:**
** ****Focus of the outcome variables: **
** ****lifetime drug use**
** ****prior year drug use**
** ****SUD diagnostic data  ****	****	**

## Demographics

- 			    **ADHD-only        ADHD w/ext.        Comp**
**n****	****	****	****	****  29  ****	****	****       96****	****	****        99 ****	**
**Gender ****(% male)****	****    ****	****86.3%     ****	****    77.9%****	****     69.2%**
**Mean age ****	****	****            18.1****	****	****    18.5 ****	****     18.2 **
**% grad high school or current****	****95.2% ****	****    89.3%****	****     98.6%  **
**Mean IQ  ****(KBIT)****	****	****105.1 ****	****	****    100.6****	****     106.7    **
**Mean SES ****(baseline)*********	****	****48.1 ****	****	****    45.2****	****	****     50.4      ****(.01)**
**% single parent family****	****24.1%****	****	****    26.3%****	****     7.1%    ****(.01)**
**Ethnicity:  88% Caucasian****	**
*** Hollingshead, 1975, (occupation  code x 5) x (education code x 3); Range 17 - 66**

**Demographics**

## Research questions

**1.  What are the late adolescent drug use behavior outcomes of children with ADHD?**
**2.  Do ADHD children with comorbid CD/ODD report greater drug use than ADHD children without comorbid CD/ODD?**
**3.  What other childhood and adolescent characteristics distinguish drug-abusing from non-drug-abusing ADHD participants?**

## LIFETIME DRUG USE (Y/N)

**F-UP 3: Youth self-report*****                                  ***

** ****	****	****	****      ****ADHD-only      ADHD w/ext             Comp ****	****        ********2  **** ****	****         Variables                          ****	****                %                        %****	****               %**
**Used alcohol ****	****	****95.7****	****       ****	****88.7****	****    ****	****84.1 ****	****      ns ****	**
**Used marijuana ****	****	**_**73.9**__** **_**	****	**_**71.0**_**	****	****51.2****	****     7.52 ****(.02)**
**Used cocaine ****	****	****  ****8.7****	****	**_**32.8**_**	****	****15.0****	****     9.02 ****(.01)**
**Used amph. ****	****	****  8.7****	****	****24.6****	****	****15.0****	****      ns**
**Used ecstasy ****	****	****  4.3****	****	**_**31.1**_**	****	****17.5****	****     8.29 ****(.02)**
**Used any other drug       ****17.4****	****	**_**47.5**_**	****	****28.8****	****     8.77 ****(.01)**
**Used tobacco ****	****	**** ****73.9****	****        ****	****83.3****	****    ****	****68.8****	****      ns**

## PRIOR YEAR DRUG USE (Y/N)

**F-UP 3: Youth self-report***** ***

** ****	****	****	****     ****ADHD-only   ADHD w/ext    Comp ****	****  ********2      ****	****         Variables****	****              ****	****	****%                  %****	****                %**
**Used alcohol ****	****	****87.0****	****     80.6           75.6****	****  ns****	****    ****	**
**Used marijuana ****	****	****52.2          **_**61.3**_**           43.9****	**** 4.3 ****(.02)**** ****	**
**Used cocaine ****	****	****8.7            **_**26.2**_**           13.8****	**** 5.2 ****(.02)**** ****	**** **
**Used amphet.****	**** ****	****4.3            13.1           10.0****	****  ns****	****         **
**Used ecstasy ****	**** ****	****0   ****	****     14.8           10.0****	****  ns****	**
**Used any other drug      ****8.7            **_**29.5**_**           13.8****	**** 7.4 ****(.02)****  **
**Used tobacco ****	****	****81.3****	****     94.0           81.5        ns**
**	**

## OTHER DRUG USE VARIABLES (Y/N)

**F-UP 3: Youth self-report***** ***

** ****	****	****	**** ****	****ADHD-only    ADHD w/ext    Comp ****	**** ********2        ****	****         Variables****	****	****      ****	****         %                    %****	****          %**
**Tobacco - ****daily users              ****	****         ****24.1          31.3           27.3     ****    ****  ns **
**Heavy alcohol ****(40+/ past yr)****           ****13.0****	****24.2****	****      29.3****	****ns**
**Binge Drinking**** ****	****	****       17.9****	****32.6****	****      20.9****	****ns**
**(girls=4+ drinks per sitting, boys=5+ drinks per sitting)**
**Heavy marij. ****(40+/ past yr)** **	****       ****8.7  ****	**_**29.0**_** ****	****      15.9           5.9  ****(.05)**** **
**Heavy other drug ****(40+/ past yr)****          ****0****	****  3.3****	****        0****	****	****ns**
**Early onset (<13 years) ****	****       ****9.1****	**_**27.9**_**	****      15.4****	****5.1****  ****(.05)**

## OTHER DRUG USE VARIABLES  - continuous measures of use history where significance found

**F-UP 3: Youth self-report**

**	****            ****	****	****ADHD-only       ADHD w/ext.             Comp****             *****F******	***
**Variables****	*****	****** ******	******         M******	******                     M                          M******	***
_**Lifetime use**_
**Total frequency****	****	****     ****18.8                   **_**23.6**_**                     19.0           3.4 ****(.03)**
**Marijuana****   ****	****                          ****3.2       ****	****     **_**4.6**_**      ****	****    3.3            3.1 ****(.05)**
**Ecstasy****	****	****	****      ****1.0****	****                **_**1.8**_**	****	****   ****1.3            4.5 ****(.01)**
_**Prior year use**_
**Total frequency****	****	****     ****16.8                   **_**21.5**_**                     18.4            3.2 ****(.04)**
**Amphetamine****                          ****1.3       ****	****     **_**1.8**_**      ****	****    1.3             3.4 ****(.04)**
**Ecstasy****	****	****	****      ****1.0****	****                **_**1.6**_**	****	****   ****1.2             3.9 ****(.02)**

**Notes:**
What is not on the list:
alcohol, cocaine, hallucinogens, barbiturates

## SUD DIAGNOSES

**F-UP 3: Youth self-report**

** ****	****	****	**** ****	****ADHD-only      ADHD w/ext.              Comp**** ****	****     ********2 ****	****     ****	****  Variables****	****	****      ****	****        %                      %****	****                 %**
**	****	****	**** **
**Alcohol abuse/dep   ****	****   ****17.2  ****	****28.7****	****     ****	****22.4****	****   ns**
**Marijuana abuse/dep    ****	****   ****13.8****	****            **_**31.3**_**	****     ****	****20.6****	****   5.0****  ****(.05)**
**Other drug abuse/dep ****    ****	****         ****3.4****	****             6.4****	****      ****	****4.0****	****   ns****	**
**Dep.on 1+ substances    ****	****   ****13.8             21.9                ****	****18.2****	****   ns****	**

## Other SUD and RELATED VARIABLES

**F-UP 3: Youth self-report**

**	****            ****	****	****ADHD-only       ADHD w/ext.              Comp****             *****F******	***
**Variables****	*****	****** ******	******        M******	******	******   M                             M ******	***
**# Alcohol sym ****(0-11)****	****   ****	****     ****0.9      ****	****  1.4       ****	****                 1.2               ns**
**# Marij. sym ****(0-11)**** ****   ****	****   ****	****     ****0.9      ****	****  **_**1.9**_**       ****	****                 1.1****	****        3.3 ****(.05)**** **
**# Other Drug sym ****(0-11)****                ****0.1      ****	****  0.4                         0.2              ns**
**# Total Drug sym ****(0-11)**** ****	****     ****1.9      ****	****  **_**3.4**_**          ****	****   2.4           ****   **** 3.8 ****(.05)**
**Dependence Vulnerability ****	****      ****0.9                   1.4 ****	****	****   1.0 ****	****        ns**
**(# dep sym/ # drugs used)**
**Use Consequences ****(0-14)****	****       1.0 ****	****	****  1.9****	****	****    1.3 ****	****        ns**

## Research questions

**1.  ****What are the late adolescent drug use behavior outcomes of children with ADHD?**
**2.  Do ADHD children with comorbid CD/ODD report greater drug use than ADHD children without comorbid CD/ODD?**
**3.  What other childhood and adolescent characteristics distinguish drug-abusing from non-drug-abusing ADHD participants?**

## VARIABLES DISTINGUISHING ADHD SUBJECTS: SUD+ (n = 40)  vs  SUD- (n = 85)

**Significant Variables ****(*****p***** < .01)****	****	****	****	**
_**Childhood:**_
**	****BASC -Aggression ****	****(> score SUD+)**
**	****BASC - Anxiety ****	****(> score SUD+)**
**	****BASC - Depression ****	****(> score SUD+)**
**	****Early onset ****(< 13-years)**** drug use ****	****(> SUD+)****	****	****	****	****	**
**	****	****	****	****	**
**	****	****	****	****	****	**

## VARIABLES DISTINGUISHING ADHD SUBJECTS: SUD+ (n = 40)  vs  SUD- (n = 85)

**Significant Variables ****(*****p***** < .01)****	****	****	****	**
_**Adolescence:**_
**	****BASC - Aggression ****	****(> score SUD+)**
**	****BASC - Conduct ****	****(> score SUD+)****	**** **
**	****BASC - Hyperactivity ****	****(> score SUD+)**
**	****BASC - Attention ****	****(> score SUD+)****	**
**	****Woodcock Johnson ****	****(< performance SUD+)****	**
**	****High school drop-out ****	****(> SUD+)****	****	**
**	****Life stress events****	****(> events SUD+)**
**	****Psychostimulant medication ****	****(> SUD+)****	****	****	**

## VARIABLES NOT DISTINGUISHING ADHD SUBJECTS: SUD+  vs  SUD-

**Non-Significant Variables****	****	**
**Childhood BASC - Hyperactivity, Conduct & Attention**
**Adolescent BASC – Anxiety, Depression**
**SES**
**Maternal depression **
**Maternal control/coping**
**Maternal locus of control**
**Single parent family****	**
**IQ**
**Childhood WJ **
**Childhood WRAT **
**Childhood psychostimulant medication****	**

## Summary

**Late adolescent drug use outcomes were assessed from a community-based sample diagnosed as ADHD in their youth.**
**Drug use behaviors, including drug use history and SUD diagnoses, were generally elevated in the ADHD w/externalizing compared to the ADHD only and Comparison groups (small to medium effect sizes)**
** ****In terms of drug specificity, marijuana and ecstasy, to a lesser degree, emerged as two drugs with relatively consistent elevations among the ADHD w/externalizing group.**

## Summary

**ADHD youth with a late adolescent SUD diagnosis showed some distinguishing characteristics**
** ****childhood: internalizing cluster, aggression, early drug use onset**
** ****adolescence: externalizing cluster,** **stressful life events, school/learning problems**** **

## Thank You

## Extras

## Summary of Baseline Demographic Data for the Groups

**Significant differences painted a more severe picture for the **
***ADHD w/externalizing***** group; they more frequently...**
** ****came from single-parent households**
** ****had a lower SES **
** ****lower IQ **
** ****a greater number of ADHD symptoms **
** ****scored less favorably on all parent-rated BASC scales, **
**The *****comparison***** group almost always scored more favorably on the**
**baseline demographic and psychosocial variables.**

**Summary of Baseline Demographic Data for the Groups**

## Diagnostic Assessment Measures

**Baseline, Follow-up 1, & Follow-up 2:**
**	*****Diagnostic Interview for Children & Adolescents***
**	**** ****(Reich, 1992; DICA-R) *****DSM-III-R - Based***
**	****	****ADHD**
**	****	****Oppositional Defiant Disorder**
**	****	****Conduct Disorder**
**	****	****Overanxious Disorder**
**	****	****Avoidant Disorder**
**	****	****Separation Anxiety Disorder**
**	****	****Major Depressive Disorder (Past & Present)**
**	****	****Dysthmia**
**	****	****Adjustment Disorder**** ****	**

## Stimulant Medication Grouping 

**Never Used Stimulants vs. Childhood Use vs. Adolescent Use vs. Extended Use **

_**Inclusion criteria **_***(must have positive ADHD diagnosis):***
***	******	******Never Used Stimulants: *****No stimulant use reported at all time points (Follow-ups 1994, 1995, 1997, & 2000)**
**	****	*****Childhood Use: *****Stimulant medication use reported only at 1994 and/or 1995 time points**
**	****	*****Adolescent Use*****: ****Stimulant medication use reported only at 1997 and/or 2000 time points**
**	****	*****Extended Use*****: ****Stimulant medication use reported during at least one time point in each of the childhood and adolescent years**

## Demographics (by Stimulant Medication Groupings)

- 					_Child_	   _Adol._      _Extend_	 _Never_
- n					26	    24	          22	  53
- Gender	 (%male)			85.7	    79.2	          81.8	  78.7
- Mean age 				18.9	    18.4	          18.1	  18.4
- % grad high school or current		100	    87.5	          87.5	  90.6
- Mean IQ  (KBIT)		            102.7	    103.5         104.6	  105.7
- Mean SES (baseline)*			41.2	    48.9	          50.3	  45.2
- % from div/sep family		23.1	    29.2	          22.7	  26.9
- Ethnicity:  groups > 88% Caucasian
- * Hollingshead, 1975, (occupation  code x 5) x (education code x 3); Range 17 - 66

**Demographics ****(by Stimulant Medication Groupings)**

## Association Between Stimulant Medication Groups and Various Mediating or Moderating Variables

**Significant differences did not emerge for most variables **
**across the 4 stimulant medication groups **
**Significant differences emerged between the groups on:**
**SES (childhood < adolescent & extended stimulant use)  **
**early onset of marijuana use (childhood < extended) **
**Barkley parent scales of inattention and hyperactivity **
**(******** inattention and hyperactivity = never used stimulants **
**or childhood-only use) **

**Association Between Stimulant Medication Groups and Various Mediating or Moderating Variables**

## Stimulant Medication Grouping Categorical Outcome Variables PRIOR YEAR DRUG USE (Y/N)                                

-  Variables			           **Child****	****Adol.****	****Extend****	****     Never     ********2****	**** *****	******	******	******             ******	******   ******	******   %*****	****   %              *****%******	******        %***
- Used alcohol prior year		92.9	94.7	 88.9	    88.2    .8
- Used marijuana prior year	57.1	73.7	 78.9	    73.5    1.9
- Used cocaine prior year		28.6	36.8	 17.6	    23.5    1.9
- Used amphetamines prior year	14.3	21.1	 17.6	    23.5     .6
- Used ecstasy prior year		21.4	26.3	 17.6	    26.5	    .6
- Used any other drug prior yr. 	35.7	47.4	 29.4	    35.3	   1.35
- Used tobacco prior year		80.0	100	 100	    85.2	    5.4

## Stimulant Medication Grouping                      Continuous Outcome Variables                       SYMPTOM COUNT (0-11; 4 abuse, 7 dependence )          

- Variables			  **Child****	****        ****Adol.****       Extend****	****Never****          F     ****	**** *****	******	******	******             ******	******   *****M(sd)****	****        ****M(sd)****       M(sd)****	****M(sd)**
- # Alcohol ab/dep symp	  **1.0 (2.1)****   ****1.8 (3.1)    ****1.5 (2.0)****    1.1 (2.1)       ****.9****	**
- # Marijuana ab/dep sym	  **1.4 (3.0)****    2.1 (3.1)    ****1.3 (2.4)****     1.2 (2.4)      ****.7**
- # Other Drug ab/dep sym  **0.1 (.6)****	****      1.2 (2.9)    ****0.3 (1.3)****     0.1 (.5)      ****3.3 *****(p<.02)***** **
- #  Total Drug ab/dep sym	  **2.5 (5.0)****    5.1 (7.4)    ****3.1 (4.6)****     2.3 (4.4)     ****1.7****	**

## Stimulant Medication Groupings                    Categorical Outcome Variables

-   **Variables****	****	****        ****   Child****	****Adol.****	****Extend****	****    **** Never****     ****	********2****	**** *****	******	******	******             ******	******   ******	******   %*****	****  **** %****              *****%******	******        ******%***
- Alcohol abuse/dep	         	**19.2****	****30.4****	**** ****36.4****	****    23.1****	****	****2.3**
- Marijuana ab/dep	    	**19.2****	****37.5****	****.****22.7****	****    28.3****	****	****2.4**
- Other drug ab/dep	    	**3.8****	****16.7****	**** ****4.5****	****    2.0****	****	****6.9**
- Dep.on 1+ substances	**15.4****	****37.5****	**** ****22.7****	****    13.2****	****	****6.6**
- Tobacco - daily users 	     	**7.7****	****50.0****	**** ****45.5****	****    24.5****	****	****14.1 *****(p<..00)***

## Initial Screening

**7,231 1st - 4th grade children screened from 22 suburban elementary schools**
**Participated in a brief intervention program for children with disruptive behavior  **
_**Multigate screen**_** ****	**
**	****Revised Conner’s ****T****eacher & ****P****arent Rating Scales- ****	****H****yperactivity ****I****ndex**
**	****	****Gate 1 - Teacher (****HI-T****) cut off score 1.6***** **
**	****	****Gate 2 -  Parent (****HI-P****) cut off score 1.3*******
*** 1.75 standard deviation units above the mean      **
***  scores range from 0 - 3**** **

## Screening and Initial Sample cont.

**148 refused consent after Gate 1**
**494 screened at Gate 2**
**400 screened positive with HI-P (5.5% of orig. sample)**
**91 lost mostly due to school boundary change**
**Thus, 309 disruptive children were eligible for the intervention  **

## 10-Year Tracking  Method 

**Letter was sent to parents outlining follow-up study**
**Phone call to parents/youth detailing protocol **
**Youth and parents interviewed individually at nearby library or research office**
**Participants were compensated for their participation ($75 youth, $25 parent)**
**Web-based tracking techniques utilized for hard-to-find participants **

## ADHD Status Grouping Criteria

**ADHD-only vs. ADHD with externalizing vs. Comparisons **

- _Inclusion criteria for the ADHD-only and ADHD w/ext. groups_
- DICA-R Parent used to diagnose disorders
- DSM-III-R-Based
- Conducted at Baseline (1991), FU-1 (1994), & FU-2 (1995)
- Diagnosis endorsed at least once during the 3 time points
- ADHD-only group had no co-morbid diagnoses
- ADHD w/ext. includes ODD/CD diagnosis at 1 of 3 time points
- _Inclusion criteria for the Comparison Group_
- HI-P & HI-T negative (<1 SD from the mean, score = <1.1)
- No Diagnosis of ADHD, ext. or int. disorders at FU-1 & FU-2

## Diagnostic Assessment Measures

- Baseline, Follow-up 1, & Follow-up 2:
- 	***Diagnostic Interview for Children & Adolescents***
- 	 (Reich, 1992; DICA-R) *DSM-III-R - Based*
- 		ADHD
- 		Oppositional Defiant Disorder
- 		Conduct Disorder
- 		Overanxious Disorder
- 		Avoidant Disorder
- 		Separation Anxiety Disorder
- 		Major Depressive Disorder (Past & Present)
- 		Dysthmia
- 		Adjustment Disorder

## Outcome Assessment Measures 

**  ****Follow-Up 3 (2001)**
- 	1. *Drug Use Frequency* (DUF) (including tobacco )        	    		     Based on Monitoring the Future Survey items:                                           	    	*1 **= never**	**	**	**5 **= 10-19 times*
*	**	**	**2 **= 1-2 times**	**	**6 **= 20-39 times*
*	**	**	**3 **= 3-5 times** **	**	**7 **= 40+ *
*	**	**	**4 **= 6-9 times*
- 		2. *DSM-IV Diagnostic Interview*
*	**     *Adolescent Diagnostic Interview (Winters et al., 1993)
- 		   Alcohol Abuse/Dependence
- 	     Marijuana Abuse/Dependence
- 		    Other Drug Abuse/Dependence                                                  		     (not including tobacco)

## Outcome Assessment Measures 

**Follow-Up 3 (2001)**
-  Focus of the outcome variables for this presentation...
-  prior year drug use (yes/no)
-  diagnostic data

## Categories of Analyses

- 	#1. _Grouping (Standard)_
- 			 ADHD vs.Comparisons (no diagnosis)
-    #2. _Grouping (Externalizing)_
- 			 ADHD only  vs.  ADHD/ODD/CD vs. Comp.
- 	#3	_Grouping (Internalizing) _
- 			ADHD/Anxiety/Depression vs. Comparisons

## #1 Grouping (Standard)

- ADHD vs. Comparisons (no diagnosis)

- _Inclusion criteria for the ADHD Group_
- DICA-R Parent used to diagnose ADHD
- DSM-III-R-Based
- Conducted at Baseline (1991), FU-1 (1994) & FU-2 (1995)
- Diagnosis endorsed at 1 of the 3 timepoints
- _Inclusion criteria for the Comparison Group_
- HI-P & HI-T negative (<1 SD from the mean, score = <1.1)
- No Diagnosis at FU-1 & FU-2  (no ADHD, depression, anxiety, oppositional defiant, or conduct disorder)

## Slide 45

## Thank You