title: A Systematic Review of Global Publication Trends Regarding Long-Term Outcomes of ADHD 3-year follow-up of the NIMH MTA study. Hyperactive boys almost grown up. I. Psychiatric status. Stimulant treatment in children with attention-deficit/hyperactivity disorder moderates adolescent academic outcome. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Computerized training of working memory in children with ADHD--a randomized, controlled trial. Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects. Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study. Hyperactive boys almost grown up. III. Methylphenidate effects on ultimate height. Predictors of persistent ADHD: an 11-year follow-up study. National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: 24-month outcomes of treatment strategies for attention-deficit/hyperactivity disorder. Hyperkinetic adult. Study of the "paradoxical" amphetamine response. Attention deficit disorder and methylphenidate: normalization rates, clinical effectiveness, and response prediction in 76 children. The stability of dimensions of behavior in ADHD and normal children over an 8-year followup Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Young adult outcome of hyperactive children who received long-term stimulant treatment.
abstract: There is increased global recognition of attention deficit hyperactivity disorder ( ADHD ) as a serious medical condition with long-term consequences . Although originally conceived of as a childhood disorder , ADHD is being increasingly recognized in adults . Individual geographic regions may have specific interests and objectives for the study of ADHD . A systematic review of  long-term outcomes ( LTOs ) in ADHD was conducted to evaluate research on ADHD LTOs  on a global scale . Studies that were at least 2 years in duration were examined . A total of 351 studies were identified in the final analysis . We identified nine outcomes of interest and classified studies by specific geographical regions , age groups studied and study design by region and over time . Published studies of LTOs in ADHD have increased in all geographical regions over the past three decades , with a peak number of 42 publications in 2008 . This rise in publications on ADHD LTOs may reflect a rise in global interest and recognition of consequences and impairment associated with ADHD . Although many world regions have published on ADHD LTOs , the majority of studies have emerged from the US and Canada , followed by Europe . While investigators in the US and Canada were predominantly interested in drug addiction as a LTO , European research ers were more interested in antisocial behavior , and Eastern Asian investigators focused on both of these LTOs as well as self-esteem . Geographical differences in the focus of ADHD LTO studies may reflect regional variations in cultural values . Proportionally fewer prospect i ve longitudinal studies and proportionally more retrospective and cross-sectional studies have been published in more recent decades . Finally , more studies focusing on ADHD in adolescents and adults have been conducted in recent years , and particularly adolescents in Eastern Asia . These changes in basic study design may reflect an increase in the recognition that ADHD is a lifetime chronic disorder . This systematic review analysis of publication trends in ADHD LTOs reflects geographically based interests that change over time OBJECTIVE In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD ( MTA ) , the effects of medication management ( MedMgt ) , behavior therapy ( Beh ) , their combination ( Comb ) , and usual community care ( CC ) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm ( Comb+MedMgt ) over those that did not ( Beh+CC ) . This report examines 36-month outcomes , 2 years after treatment by the study ended . METHOD For primary outcome measures ( attention-deficit/hyperactivity disorder [ ADHD ] and oppositional defiant disorder [ ODD ] symptoms , social skills , reading scores , impairment , and diagnostic status ) , mixed-effects regression models and orthogonal contrasts examined 36-month outcomes . RESULTS At 3 years , 485 of the original 579 subjects ( 83.8 % ) participated in the follow-up , now at ages 10 to 13 years , ( mean 11.9 years ) . In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months , treatment groups did not differ significantly on any measure at 36 months . The percentage of children taking medication > 50 % of the time changed between 14 and 36 months across the initial treatment groups : Beh significantly increased ( 14 % to 45 % ) , MedMed+Comb significantly decreased ( 91 % to 71 % ) , and CC remained constant ( 60%-62 % ) . Regardless of their treatment use changes , all of the groups showed symptom improvement over baseline . Notably , initial symptom severity , sex ( male ) , comorbidity , public assistance , and parental psychopathology ( ADHD ) did not moderate children 's 36-month treatment responses , but these factors predicted worse outcomes over 36 months , regardless of original treatment assignment . CONCLUSIONS By 36 months , the earlier advantage of having had 14 months of the medication algorithm was no longer apparent , possibly due to age-related decline in ADHD symptoms , changes in medication management intensity , starting or stopping medications altogether , or other factors not yet evaluated We report a prospect i ve longitudinal study of 101 male adolescents ( ages 16 to 23 years ) who had been diagnosed hyperactive in childhood ( ages 6 to 12 years ) , compared with 100 normal controls . The DSM-III diagnoses were made blind to group membership . Information was obtained for 98 % of the original cohort . The full attention deficit disorder with hyperactivity ( ADDH ) syndrome persisted in 31 % of the prob and s vs in 3 % of the controls . The only other two conditions that distinguished the groups significantly were conduct and substance use disorders . These disorders aggregated significantly among the prob and s with continued ADDH . The results indicate that the greatest risk factor for the development of antisocial behavior and drug abuse is the maintenance of ADDH symptoms . Substance use disorders followed the onset of conduct disorder in the overwhelming majority of the cases Treatment with psychostimulant medication has been shown to improve scholastic functioning in children with attention-deficit/hyperactivity disorder ( ADHD ) . However , the extent to which long-term academic gains are apparent in those having received such treatment remains elusive . This study examined prospect ively the relationship of childhood stimulant treatment to academic functioning during adolescence . Children ( n = 169 ) were initially recruited and diagnosed with ADHD when they were 7 - 11 years old . A sub sample of those with childhood ADHD ( n = 90 ) was reevaluated on average 9.13 ( SD = 1.5 ) years later . Prob and s who did and did not receive treatment with stimulant medication were compared to each other and to a never-ADHD comparison group ( n = 80 ) on three subtests from the Wechsler Individual Achievement Test-II ( WIAT-II ) , as well as high school grade point average ( GPA ) and number of retentions in school as derived from school records . Analyses of covariance controlling for severity of childhood ADHD symptoms indicated that prob and s treated with psychostimulant medication achieved better academic outcomes , as measured by WIAT-II subtests and high school GPA , than those not treated with psychostimulants ( p < .05 ) . However , treated prob and s did not fare as well as the never-ADHD comparison group . Psychostimulant treatment for children with ADHD may benefit long-term adolescent academic performance , although the extent of improvement is likely to vary as a function of multiple factors OBJECTIVES To determine any long-term effects , 6 and 8 years after childhood enrollment , of the r and omly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder ( MTA ; N = 436 ) ; to test whether attention-deficit/hyperactivity disorder ( ADHD ) symptom trajectory through 3 years predicts outcome in subsequent years ; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers ( local normative comparison group ; N = 261 ) . METHOD Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by  parent , teacher , and youth report . RESULTS In nearly every analysis , the originally r and omized treatment groups did not differ significantly on repeated measures or newly analyzed variables ( e.g. , grade s earned in school , arrests , psychiatric hospitalizations , other clinical ly relevant outcomes ) . Medication use decreased by 62 % after the 14-month controlled trial , but adjusting for this did not change the results . ADHD symptom trajectory in the first 3 years predicted 55 % of the outcomes . The MTA participants fared worse than the local normative comparison group on 91 % of the variables tested . CONCLUSIONS Type or intensity of 14 months of treatment for ADHD in childhood ( at age 7.0 - 9.9 years ) does not predict functioning 6 to 8 years later . Rather , early ADHD symptom trajectory regardless of treatment type is prognostic . This finding implies that children with behavioral and sociodemographic advantage , with the best response to any treatment , will have the best long-term prognosis . As a group , however , despite initial symptom improvement during treatment that is largely maintained after treatment , children with combined-type ADHD exhibit significant impairment in adolescence . Innovative treatment approaches targeting specific areas of adolescent impairment are needed BACKGROUND Previous studies have demonstrated the short-term efficacy of pharmacotherapy and behavior therapy for attention-deficit/hyperactivity disorder ( ADHD ) , but no longer-term ( i.e. , > 4 months ) investigations have compared these 2 treatments or their combination . METHODS A group of 579 children with ADHD Combined Type , aged 7 to 9.9 years , were assigned to 14 months of medication management ( titration followed by monthly visits ) ; intensive behavioral treatment ( parent , school , and child components , with therapist involvement gradually reduced over time ) ; the two combined ; or st and ard community care ( treatments by community providers ) . Outcomes were assessed in multiple domains before and during treatment and at treatment end point ( with the combined treatment and medication management groups continuing medication at all assessment points ) . Data were analyzed through intent-to-treat r and om-effects regression procedures . RESULTS All 4 groups showed sizable reductions in symptoms over time , with significant differences among them in degrees of change . For most ADHD symptoms , children in the combined treatment and medication management groups showed significantly greater improvement than those given intensive behavioral treatment and community care . Combined and medication management treatments did not differ significantly on any direct comparisons , but in several instances ( oppositional/aggressive symptoms , internalizing symptoms , teacher-rated social skills , parent-child relations , and reading achievement )  combined treatment proved superior to intensive behavioral treatment and /or community care while medication management did not . Study medication strategies were superior to community care treatments , despite the fact that two thirds of community-treated subjects received medication during the study period . CONCLUSIONS For ADHD symptoms , our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication . Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms , but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes OBJECTIVE Deficits in executive functioning , including working memory ( WM ) deficits , have been suggested to be important in attention-deficit/hyperactivity disorder ( ADHD ) . During 2002 to 2003 , the authors conducted a multicenter , r and omized , controlled , double-blind trial to investigate the effect of improving WM by computerized , systematic practice of WM tasks . METHOD Included in the trial were 53 children with ADHD ( 9 girls ; 15 of 53 inattentive subtype ) , aged 7 to 12 years , without stimulant medication . The compliance criterion ( > 20 days of training ) was met by 44 subjects , 42 of whom were also evaluated at follow-up 3 months later . Participants were r and omly assigned to use either the treatment computer program for training WM or a comparison program . The main outcome measure was the span-board task , a visuospatial WM task that was not part of the training program . RESULTS For the span-board task , there was a significant treatment effect both post-intervention and at follow-up . In addition , there were significant effects for secondary outcome tasks measuring verbal WM , response inhibition , and complex reasoning . Parent ratings showed significant reduction in symptoms of inattention and hyperactivity/impulsivity , both post-intervention and at follow-up . CONCLUSIONS This study shows that WM can be improved by training in children with ADHD . This training also improved response inhibition and reasoning and result ed in a reduction of the parent-rated inattentive symptoms of ADHD OBJECTIVE To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children With ADHD ( MTA ; N = 487 ) and those in a local normative comparison group ( n = 272 ) at 24 and 36 months postr and omization and to test whether these outcomes were predicted by the r and omly assigned treatments and subsequent self-selected prescribed medications . METHOD Most MTA children were 11 to 13 years old by 36 months .  Delinquency seriousness was coded ordinally from multiple measures /reporters ; child-reported substance use was binary . RESULTS Relative to local normative comparison group , MTA children had significantly higher rates of delinquency ( e.g. , 27.1 % vs. 7.4 % at 36 months ; p = .000 ) and substance use ( e.g. , 17.4 % vs. 7.8 % at 36 months ; p = .001 ) . Children r and omized to intensive behavior therapy reported less 24-month substance use than other MTA children ( p = .02 ) . R and om effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use . By 24 and 36 months , more days of prescribed medication were associated with more serious delinquency but not substance use . CONCLUSIONS Cause- and -effect relationships between medication treatment and delinquency are unclear ; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages . Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence OBJECTIVE To evaluate the predictors of persistence and the timing of remission of attention-deficit hyperactivity disorder ( ADHD ) . METHOD Subjects were 6- to 17-year old Caucasian , non-Hispanic boys with and without ADHD . DSM-III-R structured diagnostic interviews and blind raters were used to examine psychiatric diagnoses , cognitive achievement , social , school , and family functioning at a 4-year follow-up assessment . RESULTS At the 4-year follow-up assessment , 85 % of children with ADHD continued to have the disorder and 15 % remitted . Of those who remitted , half did so in childhood and the other half in adolescence . Predictors of persistence were familiality of ADHD , psychosocial adversity , and comorbidity with conduct , mood , and anxiety disorders . CONCLUSIONS The findings prospect ively confirm that the majority of children with ADHD will continue to express the disorder 4 years later . For a minority of children , ADHD was a transient disorder that remits early in development . In addition , we have shown that persistence of ADHD is predictable . Familiality , adversity , and psychiatric comorbidity may be clinical ly useful predictors of which children with ADHD are at risk for a persistent disorder The height of young adults who were treated with methylpheni date hydrochloride in childhood because of hyperactivity ( average daily dose , 45 mg ; duration of treatment , six months to five years ) was studied . There was no significant difference in height between the treated patients ( n = 61 ) and controls ( n = 99 ) ; both groups were at the national US norm in stature . The findings indicated that methylpheni date therapy does not compromise final height , even when it has an adverse impact on children 's growth rate during the active treatment phase . A compensatory growth rate , or growth rebound , appears to occur following discontinuation of stimulant therapy OBJECTIVE Despite the existence of several follow-up studies of children with ADHD followed up into adulthood , there is limited information on whether patterns of persistence and remission in ADHD can be predicted over the long term . The main aim of this study was to evaluate predictors of persistence of ADHD in a large sample of boys with and without ADHD followed prospect ively for 11 years into young adulthood . METHOD Subjects were Caucasian , non-Hispanic boys with ( N = 110 ) and without ( N = 105 ) ADHD who were 6 - 17 years old at the baseline assessment ( mean age 11 years ) and 15 to 31 years old at the follow-up assessment ( mean age 22 years ) . Subjects were comprehensively and blindly assessed with structured diagnostic interviews and assessment s of cognitive , social , school , and family functioning . RESULTS At the 11-year follow-up , 78 % of children with ADHD continued to have a full ( 35 % ) or a partial persistence ( subsyndromal ( 22 % ) , impaired functioning ( 15 % ) , or remitted but treated ( 6 % ) ) . Predictors of persistence were severe impairment of ADHD , psychiatric comorbidity , and exposure to maternal psychopathology at baseline . CONCLUSIONS These findings prospect ively confirm that persistence of ADHD over the long term is predictable from psychosocial adversity and psychiatric comorbidity ascertained 11 years earlier OBJECTIVE Intent-to-treat analyses of the Multimodal Treatment Study of ADHD ( MTA ) revealed group differences on attention-deficit/hyperactivity disorder symptoms ratings , with better outcome in groups of participants who were assigned the medication algorithm-medication alone ( MedMgt ) and combined (Comb)--than in those who were  not-behavior modification  ( Beh ) alone and community comparison ( CC ) . However , the effect size was reduced by 50 % from the end of treatment to the first follow-up . The convergence of outcomes suggests differential changes by treatment group beween 14 and 24 months , which this report explores , both for benefits of treatment and for side effects on growth . METHODS We documented reported medication use at 14- and 24-month assessment s and formed 4 naturalistic subgroups ( Med/Med , Med/NoMed , NoMed/Med , and NoMed/NoMed ) . Then we performed exploratory mediator analyses to evaluate effects of changes in medication use on 14- to 24-month change scores of effectiveness ( symptom ratings ) and growth ( height and weight measures ) . RESULTS The r and omly assigned groups with the greatest improvement at the end of the treatment phase ( Comb and MedMgt ) deteriorated during the follow-up phase , but the other 2 groups ( Beh and CC ) did not . There were no significant differences in the 14- to 24-month growth rates among the r and omly assigned groups , in contrast to significant growth suppression in the Comb and MedMgt at the end of the treatment phase . Changes in medication use mediated the 14- to 24-month change in attention-deficit/hyperactivity disorder symptom ratings : the subgroup that reported stopping medication ( Med/NoMed ) showed the largest deterioration , the subgroup that consistently reported ( Med/Med ) or never reported ( NoMed/NoMed ) medication use showed modest deterioration , and the subgroup that reported starting medication ( NoMed/Med ) showed improvement . Changes in medication use also mediated growth effects : the subgroup that consistently reported medication use ( Med/Med ) showed reduced height gain compared with the subgroup that never reported medication use ( NoMed/NoMed ) , which actually grew faster than predicted by population norms . CONCLUSION In the MTA follow-up , exploratory naturalistic analyses suggest that consistent use of stimulant medication was associated with maintenance of effectiveness but continued mild growth suppression OBJECTIVE In the Multimodal Treatment Study of ADHD ( MTA ) , the effects of medication management ( MedMgt ) and behavior modification therapy ( Beh ) and their combination ( Comb ) and usual community comparison ( CC ) in the treatment of attention-deficit/hyperactivity disorder ( ADHD ) differed at the 14-month assessment as a result of superiority of the MTA MedMgt strategy ( Comb or MedMgt ) over Beh and CC and modest additional benefits of Comb over MedMgt alone . Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention . METHODS Of 579 children who entered the study , 540 ( 93 % ) participated in the first follow-up 10 months after the end of treatment . Mixed-effects regression models explored possible persisting effects of the MTA medication strategy , the incremental benefits of Comb over MedMgt alone , and the possible superiority of Beh over CC on 5 effectiveness and 4 service use domains . RESULTS The MTA medication strategy showed persisting significant superiority over Beh and CC for ADHD and oppositional-defiant symptoms at 24 months , although not as great as at 14 months . Significant additional benefits of Comb over MedMgt and of Beh over CC were not found . The groups differed significantly in mean dose ( methylpheni date equivalents 30.4 , 37.5 , 25.7 , and 24.0 mg/day , respectively ) . Continuing medication use partly mediated the persisting superiority of Comb and MedMgt . CONCLUSION The benefits of intensive MedMgt for ADHD extend 10 months beyond the intensive treatment phase only in symptom domains and diminish over time A form of the hyperkinetic syndrome , assumed to be a juvenile condition , has been found in an adult with a previously undiagnosed condition . The pathognomonic paradoxical calming of the hyperkinetic by amphetamine was shown in a 22-year-old man and further eluci date d by quantitative self-estimation of mood following doubleblind administrations of dextroamphetamine sulfate and placebo . Compared to his response to placebo , he not only showed externally visible calming and depression , but also subjectively reported decreased anxiety , increased depression , and increased concentration , with no change in self-esteem OBJECTIVE To evaluate the magnitude and clinical significance of methylpheni date ( MPH ) effects on the classroom behavior and academic performance of 76 children with attention deficit disorder/hyperactivity ( ADDH ) . METHOD A double-blind , placebo controlled , within-subject ( crossover ) experimental design was used to evaluate acute MPH effects at four dose levels ( 5 mg , 10 mg , 15 mg , and 20 mg ) on children 's attention , academic functioning , and behavior in regular classroom setting s. Results were contrasted with a normal control sample . RESULTS St and ard statistical analysis revealed MPH effects on classroom functioning that were primarily linear . Analysis of the clinical significance of effects indicated that large proportions of treated children exhibited significantly improved or normalized classroom functioning ; however , a large subset of them failed to show improved academic functioning . Overall , children failing to respond at lower dose levels have a high probability of improving or becoming normalized as a function of increasing dose . CONCLUSIONS For a majority of children with ADDH , MPH results in significantly improved or normalized attention and classroom behavior . A significant subset , however , fail to realize gains in their academic functioning and will require supplemental interventions The present study reports on st and ardized behavioral ratings received by a large sample of hyperactive children meeting research diagnostic criteria ( n=108 ) and a community control sample of normal children ( n=61 ) who were followed prospect ively over 8 years into adolescence . On some parentreport measures both groups declined in the severity of their behavior problems across time , while on other measures only the hyperactive group declined , but the hyperactives always remained more deviant than the controls at followup . The hyperactives and controls also differed on most teacher and selfreport ratings at followup . The greatest degree of agreement between raters at adolescence was between parent and youth ratings . These results are consistent with previous research demonstrating more deviant scores for hyperactive children than controls on various rating scales at adolescent followup . They also are consistent with research showing significant longitudinal continuity of both internalizing and externalizing behavioral pathology OBJECTIVE The paucity of data concerning the long-term natural history of attention-deficit hyperactivity disorder ( ADHD ) , a common childhood psychiatric disorder , prompted a longitudinal study to investigate the adult sequelae of the childhood disorder . DESIGN Prospect i ve study , follow-up intervals ranging from 13 to 19 years ( mean , 16 years ) , with blind systematic clinical assessment s. SUBJECTS Ninety-one white males ( mean age , 26 years ) , representing 88 % of a cohort systematic ally diagnosed as hyperactive in childhood , and 95 ( 95 % ) of comparison cases of similar race , gender , age , whose teachers had voiced no complaints about their school behavior in childhood . RESULTS Prob and s had significantly higher rates than comparisons of ADHD symptoms ( 11 % vs 1 % ) , antisocial personality disorders ( 18 % vs 2 % ) , and drug abuse disorders ( 16 % vs 4 % ) . Significant comorbidity occurred between antisocial and drug disorders . Educational and occupational achievements were significantly compromised in the prob and s. These disadvantages were independent of psychiatric status . We did not find increased rates of affective or anxiety disorders in the prob and s. CONCLUSIONS Childhood ADHD predicts specific adult psychiatric disorders , namely antisocial and drug abuse disorders . In the adolescent outcome of this cohort , we found that these disturbances were dependent on the continuation of ADHD symptoms . In contrast , in adulthood , antisocial and drug disorders appeared , in part , independent of sustained ADHD . In addition , regardless of psychiatric status , ADHD placed children at relative risk for educational and vocational disadvantage . The results do not support a relationship between childhood ADHD and adult mood or anxiety disorders Prospect i ve young adult outcomes ( mean age 21.8 years ) of children who had been diagnosed as having attention deficit disorder with hyperactivity and who had been treated with methylpheni date for at least 3 years were compared with those of a matched normal control group and a group of hyperactive young adults who had not received any stimulant treatment .  Results suggest that in many areas , e.g. , school , work , and personality disorders , stimulant-treated hyperactives function significantly worse than matched normal controls but similar to untreated hyperactives . In some areas , e.g. , less car accidents , more positive view of childhood , later delinquency , and better social skills and self-esteem , stimulant-treated hyperactives did better than their untreated counterparts . Thus stimulant treatment for hyperactive children may not eliminate educational work or life difficulties , but may result in less social ostracism and improved feelings toward themselves and others
target: The following broad trends emerged : ( 1 ) without treatment , people with ADHD had poorer long-term outcomes in all categories compared with people without ADHD , and ( 2 ) treatment for ADHD improved long-term outcomes compared with untreated ADHD , although not usually to normal levels .
  Conclusions This systematic review provides a synthesis of studies of ADHD long-term outcomes .
  Current treatments may reduce the negative impact that untreated ADHD has on life functioning , but does not usually ' normalize ' the recipients
background: Background In childhood , attention deficit/hyperactivity disorder ( ADHD ) is characterized by age-inappropriate levels of inattentiveness/disorganization , hyperactivity/impulsiveness , or a combination thereof .
  Although the criteria for ADHD are well defined , the long-term consequences in adults and children need to be more comprehensively understood and quantified .
  We conducted a systematic review evaluating the long-term outcomes ( defined as 2 years or more ) of ADHD with the goal of identifying long-term outcomes and the impact that any treatment ( pharmacological , non-pharmacological , or multimodal ) has on ADHD long-term outcomes .