[Show abstract][Hide abstract] ABSTRACT: Background: When comparing the health of two populations, it is not enough to compare the prevalence of chronic diseases. The objective of this study is therefore to propose a metric of health based on domains of functioning to determine whether the English are healthier than the Americans. Methods: We analysed representative samples aged 50 to 80 years from the 2008 wave of the Health and Retirement Study (N = 10 349) for the US data, and wave 4 of the English Longitudinal Study of Ageing (N = 9405) for English counterpart data. We first calculated the age-standardized disease prevalence of diabetes, hypertension, all heart diseases, stroke, lung disease, cancer and obesity. Second, we developed a metric of health using Rasch analyses and the questions and measured tests common to both surveys addressing domains of human functioning. Finally, we used a linear additive model to test whether the differences in health were due to being English or American. Results: The English have better health than the Americans when population health is assessed only by prevalence of selected chronic health conditions. The English health advantage disappears almost completely, however, when health is assessed with a metric that integrates information about functioning domains. Conclusions: It is possible to construct a metric of health, based on data directly collected from individuals, in which health is operationalized as domains of functioning. Its application has the potential to tackle one of the most intractable problems in international research on health, namely the comparability of health across countries.
International Journal of Epidemiology 09/2014; 44(1). DOI:10.1093/ije/dyu182 · 9.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans.
A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012.
Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings.
Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.
Quality of Life Research 12/2013; DOI:10.1007/s11136-013-0585-4 · 2.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.
International Journal for Quality in Health Care 10/2013; 25(6). DOI:10.1093/intqhc/mzt074 · 1.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To understand the full burden of a health condition, we need the information on the disease and the information on how that disease impacts the functioning of an individual. The ongoing revision of the International Classification of Diseases (ICD) provides an opportunity to integrate functioning information through the International Classification of Functioning, Disability and Health (ICF).
Part of the ICD revision process includes adding information from the ICF by way of "functioning properties" to capture the impact of the disease on functioning. The ICD content model was developed to provide the structure of information required for each ICD-11 disease entity and one component of this content model is functioning properties. The activities and participation domains from ICF are to be included as the value set for functioning properties in the ICD revision process.
The joint use of ICD and ICF could create an integrated health information system that would benefit the implementation of a standard language-based electronic health record to better capture and understand disease and functioning in healthcare.
BMC Public Health 08/2013; 13(1):742. DOI:10.1186/1471-2458-13-742 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: How many people with disabilities are in the world? How is disability defined? How can we measure disability in an accurate and comparable way? These are some of the key questions which the recently published World Bank/WHO World Report on Disability (WRD) addresses. Method: Multiple data sources and methods were used by WHO and the World Bank to estimate a global figure, with the ICF as the underlying data standard. Key international data sources were the World Health Survey of 2002-2004 and the 2004 updates from the Global Burden of Disease study. The World Report on Disability also includes a compilation of country-reported prevalence from census and surveys. This paper presents and discusses key findings of the Irish National Disability Survey (2006) to illustrate the value of the ICF framework for disability statistics and most especially the environmental factors component. Results: The World Report estimates that globally one billion people or 15% of the world's population experience disabilities. Between 110-190 million people (2% of the world's population) experience severe or extreme difficulties in functioning. Definitions and measures of disability vary widely across countries. The Irish Disability Survey shows the substantial impact of environmental factors on people's functioning. For example, attitudes, and the presence or absence of facilitating equipment, support services, flexible working arrangements and transport significantly affect participation of people with disabilities in Irish society. Conclusions: To improve the quality of disability information, the World Report recommends the use of a common definition and concepts of disability based on WHO's International Classification of Functioning Disability and Health (ICF). Furthermore, disability measurement needs to apply a multidimensional approach, in particular, measuring disability in terms of the level of difficulty a person is experiencing in multiple areas of life, rather than head counting severe impairment types in a dichotomous way. Environmental factors have significant effects on individual functioning and should be considered as an integral part in disability measurement. [Box: see text].
Disability and Rehabilitation 06/2013; 35(13):1065-1069. DOI:10.3109/09638288.2012.720354 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity.
To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the World Health Organization World Mental Health Surveys.
Nationally or regionally representative community surveys.
A total of 21 229 survey respondents.
First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the World Health Organization Composite International Diagnostic Interview.
Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (ie, internalizing or externalizing) associations were generally stronger than between-domain associations. Most time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity and oppositional defiant disorders (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables.
The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered herein. These common pathways should be the focus of future research on the development of comorbidity, although several important pairwise associations that cannot be accounted for by latent variables also exist that warrant further focused study.
Archives of general psychiatry 01/2011; 68(1):90-100. DOI:10.1001/archgenpsychiatry.2010.180 · 13.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the development of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for measuring functioning and disability in accordance with the International Classification of Functioning, Disability and Health. WHODAS 2.0 is a standard metric for ensuring scientific comparability across different populations.
A series of studies was carried out globally. Over 65,000 respondents drawn from the general population and from specific patient populations were interviewed by trained interviewers who applied the WHODAS 2.0 (with 36 items in its full version and 12 items in a shortened version).
The WHODAS 2.0 was found to have high internal consistency (Cronbach's alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e. sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions.
The WHODAS 2.0 meets the need for a robust instrument that can be easily administered to measure the impact of health conditions, monitor the effectiveness of interventions and estimate the burden of both mental and physical disorders across different populations.
Bulletin of the World Health Organisation 11/2010; 88(11):815-23. DOI:10.2471/BLT.09.067231 · 5.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders.
To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries.
Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI).
Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries.
Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.
The British journal of psychiatry: the journal of mental science 11/2010; 197(5):378-85. DOI:10.1192/bjp.bp.110.080499 · 7.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To propose the joint use of the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF) and to illustrate this proposal using musculoskeletal (MSK) conditions.
In light of the MSK conditions as classified in the ICD, categories from existing ICF core sets for MSK conditions were pooled to specify functioning. Another approach was to consider other categories from measures or instruments already linked in the literature.
ICF Categories have been pooled from six core sets for MSK conditions, two specific care settings, one MSK clinical trial setting and eight instrument linkage papers.
The ICD-ICF joint use would be able to capture the impact of a health condition by taking into account the disease and functioning status which would facilitate clinical care. Therefore, there is reasonable ground to demonstrate the operational linkage and complementary role of the ICD and the ICF in the context of the ICD revision.
Disability and Rehabilitation 10/2010; 33(13-14):1281-97. DOI:10.3109/09638288.2010.526165 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The paper reviews recent findings from the WHO World Mental Health (WMH) surveys on the global burden of mental disorders.
The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders.
The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4-6.8% in half the countries, 2.3-3.6% in one-fourth, and 0.8-1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions in the WMH data. Adult mental disorders are found to be associated with such high role impairment in the WMH data that available clinical interventions could have positive cost-effectiveness ratios.
Mental disorders are commonly occurring and often seriously impairing in many countries throughout the world. Expansion of treatment could be cost-effective from both employer and societal perspectives.
[Show abstract][Hide abstract] ABSTRACT: The paper presents an overview of the WHO World Mental Health (WMH) Survey Initiative and summarizes recent WMH results regarding the prevalence and societal costs of mental disorders. The WMH surveys are representative community surveys that were carried out in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, burden, and unmet need for treatment of common mental disorders. Results show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25(th)-75(th) percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, disruptive behavior, and substance disorders) is 18.1-36.1%. The IQR of 12-month prevalence estimates is 9.8-19.1%. Analysis of age-of-onset reports shows that many mental disorders begin in childhood-adolescence and have significant adverse effects on subsequent role transitions. Adult mental disorders are found in the WMH data to be associated with high levels of role impairment. Despite this burden, the majority of mental disorders go untreated. Although these results suggest that expansion of treatment could be cost-effective from both the employer perspective and the societal perspective, treatment effectiveness trials are needed to confirm this suspicion. The WMH results regarding impairments are being used to target several such interventions.
[Show abstract][Hide abstract] ABSTRACT: Advocates of expanded mental health treatment assert that mental disorders are as disabling as physical disorders, but little evidence supports this assertion.
To establish the disability and treatment of specific mental and physical disorders in high-income and low- and middle-income countries.
Community epidemiological surveys were administered in 15 countries through the World Health Organization World Mental Health (WMH) Survey Initiative.
Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to the commonly occurring physical disorders included in the surveys. This pattern held for all disorders and also for treated disorders. Disaggregation showed that the higher disability of mental than physical disorders was limited to disability in social and personal role functioning, whereas disability in productive role functioning was generally comparable for mental and physical disorders.
Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.
The British Journal of Psychiatry 06/2008; 192(5):368-75. DOI:10.1192/bjp.bp.107.039107 · 7.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Data are presented on patterns of failure and delay in making initial treatment contact after first onset of a mental disorder in 15 countries in the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Representative face-to-face household surveys were conducted among 76,012 respondents aged 18 and older in Belgium, Colombia, France, Germany, Israel, Italy, Japan, Lebanon, Mexico, the Netherlands, New Zealand, Nigeria, People's Republic of China (Beijing and Shanghai), Spain, and the United States. The WHO Composite International Diagnostic Interview (CIDI) was used to assess lifetime DSM-IV anxiety, mood, and substance use disorders. Ages of onset for individual disorders and ages of first treatment contact for each disorder were used to calculate the extent of failure and delay in initial help seeking. The proportion of lifetime cases making treatment contact in the year of disorder onset ranged from 0.8 to 36.4% for anxiety disorders, from 6.0 to 52.1% for mood disorders, and from 0.9 to 18.6% for substance use disorders. By 50 years, the proportion of lifetime cases making treatment contact ranged from 15.2 to 95.0% for anxiety disorders, from 7.9 to 98.6% for mood disorders, and from 19.8 to 86.1% for substance use disorders. Median delays among cases eventually making contact ranged from 3.0 to 30.0 years for anxiety disorders, from 1.0 to 14.0 years for mood disorders, and from 6.0 to 18.0 years for substance use disorders. Failure and delays in treatment seeking were generally greater in developing countries, older cohorts, men, and cases with earlier ages of onset. These results show that failure and delays in initial help seeking are pervasive problems worldwide. Interventions to ensure prompt initial treatment contacts are needed to reduce the global burdens and hazards of untreated mental disorders.
World psychiatry: official journal of the World Psychiatric Association (WPA) 11/2007; 6(3):177-85. · 12.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Data are presented on the lifetime prevalence, projected lifetime risk, and age-of-onset distributions of mental disorders in the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Face-to-face community surveys were conducted in seventeen countries in Africa, Asia, the Americas, Europe, and the Middle East. The combined numbers of respondents were 85,052. Lifetime prevalence, projected lifetime risk, and age of onset of DSM-IV disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI), a fully-structured lay administered diagnostic interview. Survival analysis was used to estimate lifetime risk. Median and inter-quartile range (IQR) of age of onset is very early for some anxiety disorders (7-14, IQR: 8-11) and impulse control disorders (7-15, IQR: 11-12). The age-of-onset distribution is later for mood disorders (29-43, IQR: 35-40), other anxiety disorders (24-50, IQR: 31-41), and substance use disorders (18-29, IQR: 21-26). Median and IQR lifetime prevalence estimates are: anxiety disorders 4.8-31.0% (IQR: 9.9-16.7%), mood disorders 3.3-21.4% (IQR: 9.8-15.8%), impulse control disorders 0.3-25.0% (IQR: 3.1-5.7%), substance use disorders 1.3-15.0% (IQR: 4.8-9.6%), and any disorder 12.0-47.4% (IQR: 18.1-36.1%). Projected lifetime risk is proportionally between 17% and 69% higher than estimated lifetime prevalence (IQR: 28-44%), with the highest ratios in countries exposed to sectarian violence (Israel, Nigeria, and South Africa), and a general tendency for projected risk to be highest in recent cohorts in all countries. These results document clearly that mental disorders are commonly occurring. As many mental disorders begin in childhood or adolescents, interventions aimed at early detection and treatment might help reduce the persistence or severity of primary disorders and prevent the subsequent onset of secondary disorders.
World psychiatry: official journal of the World Psychiatric Association (WPA) 11/2007; 6(3):168-76. · 12.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this article is to review recent epidemiological research on age-of-onset of mental disorders, focusing on the WHO World Mental Health surveys.
Median and inter-quartile range (IQR; 25th-75th percentiles) of age-of-onset is much earlier for phobias (7-14, IQR 4-20) and impulse-control disorders (7-15; IQR 4-35) than other anxiety disorders (25-53, IQR 15-75), mood disorders (25-45, IQR 17-65), and substance disorders (18-29, IQR 16-43). Although less data exist for nonaffective psychosis, available evidence suggests that median age-of-onset is in the range late teens through early 20s. Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three quarters by the mid-20s. Later onsets are mostly secondary conditions. Severe disorders are typically preceded by less severe disorders that are seldom brought to clinical attention.
First onset of mental disorders usually occur in childhood or adolescence, although treatment typically does not occur until a number of years later. Although interventions with early incipient disorders might help reduce severity-persistence of primary disorders and prevent secondary disorders, additional research is needed on appropriate treatments for early incipient cases and on long-term evaluation of the effects of early intervention on secondary prevention.
Current Opinion in Psychiatry 08/2007; 20(4):359-64. DOI:10.1097/YCO.0b013e32816ebc8c · 3.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper discusses the description of attention-deficit/hyperactivity disorder (ADHD) as a possible "disease entity" and the "disabilities" associated with it. It builds on the nosological descriptions of ADHD from International Classification of Disease (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) perspectives and introduces the distinct disability dimension from the International Classification of Functioning, Disability and Health (ICF) perspective. It advocates for separating assessment of disease and disability dimensions and then utilizing these constructs jointly by using both the ICD and ICF classifications. The ICF analyzes functioning in relation to a health condition in terms of 1) body functions and body structures, 2) activities of the person and participation of the person in society, and 3) contextual factors such as environmental factors and personal factors. The separation of signs/symptoms and consequences permits better understanding of the disease pathophysiology on the one hand and the consequences (eg, its impact on the person, family, peers, school, work, and social life) on the other hand. It will therefore enable us to better understand the nature of ADHD because the core body functions associated with the disorder will be better delineated. In addition, capturing environmental factors may help people with ADHD by modifying their environments. The ICF provides a good outcome monitoring and evaluation tool for the assessment of treatment response. As in many other disorders, diagnosis alone is not a sufficient predictor of health care needs, utilization, costs, or outcomes. When one adds disability as a predictor, our capacity to predict these parameters is increased dramatically. It is therefore suggested that the ICF framework be considered in future ADHD research activities.
[Show abstract][Hide abstract] ABSTRACT: To present an overview of the World Health Organization World Mental Health (WMH) Survey Initiative. The discussion draws on knowledge gleaned from the authors' participation as principals in WMH. WMH has carried out community epidemiological surveys in more than two dozen countries with more than 200,000 completed interviews. Additional surveys are in progress. Clinical reappraisal studies embedded in WMH surveys have been used to develop imputation rules to adjust prevalence estimates for within- and between-country variation in accuracy. WMH interviews include detailed information about sub-threshold manifestations to address the problem of rigid categorical diagnoses not applying equally to all countries. Investigations are now underway of targeted substantive issues. Despite inevitable limitations imposed by existing diagnostic systems and variable expertise in participating countries, WMH has produced an unprecedented amount of high-quality data on the general population cross-national epidemiology of mental disorders. WMH collaborators are in thoughtful and subtle investigations of cross-national variation in validity of diagnostic assessments and a wide range of important substantive topics. Recognizing that WMH is not definitive, finally, insights from this round of surveys are being used to carry out methodological studies aimed at improving the quality of future investigations.
[Show abstract][Hide abstract] ABSTRACT: The prevalence and workplace consequences of adult attention deficit/hyperactivity disorder (ADHD) are unknown.
An ADHD screen was included in a national household survey (n = 3198, ages 18-44). Clinical re-interviews calibrated the screen to diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition ADHD. Diagnoses among workers were compared with responses to the WHO Health and Work Performance Questionnaire (HPQ).
A total of 4.2% of workers had ADHD. ADHD was associated with 35.0 days of annual lost work performance, with higher associations among blue collar (55.8 days) than professional (12.2 days), technical (19.8 days), or service (32.6 days) workers. These associations represent 120 million days of annual lost work in the U.S. labor force, equivalent to dollar 19.5 billion lost human capital.
ADHD is a common and costly workplace condition. Effectiveness trials are needed to estimate the region of interest of workplace ADHD screening and treatment programs.
Journal of Occupational and Environmental Medicine 07/2005; 47(6):565-72. DOI:10.1097/01.jom.0000166863.33541.39 · 1.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood.
A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders).
Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD.
No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.