Metacognitive and motivation deficits, exposure to trauma, and high parental demands characterize adolescents with late-onset ADHD

  • Margaret H. SibleyEmail author
  • Mercedes Ortiz
  • Paulo Graziano
  • Anthony Dick
  • Elena Estrada
Original Contribution


The objective of this study is to evaluate support for three hypotheses about the etiology of adolescent-onset ADHD symptoms: (1) a “cool” cognitive load hypothesis, (2) a “hot” rewards processing hypothesis, and (3) a trauma exposure hypothesis. Participants (N = 50) were drawn from two public high schools in a culturally diverse metropolitan area. A detailed procedure for identifying and confirming late-onset ADHD cases is described. Adolescents with late-onset ADHD (n = 15) were identified and compared to childhood-onset (n = 17) and non-ADHD classmates (n = 18). Adolescents and parents completed measures of neurocognition, rewards’ processing, clinical profile, and environmental demands. Late-onset cases were clinically and neurocognitively indistinguishable from childhood-onset cases; however, they experienced higher demands from parents (d = 1.09). Compared to the non-ADHD group, late-onset cases showed significant deficits in metacognition (d = 1.25) and academic motivation (d = 0.80), as well as a pronounced history of multiple trauma exposure (OR 11.82). At 1-year follow-up, ADHD persisted in 67.7% of late-onset cases. Late-onset cases (26.7%) were more likely than childhood-onset cases (0.0%) to transfer to alternative schools by 1-year follow-up. Multiple factors may contribute to adolescent-onset ADHD. Adolescents with metacognition and motivation deficits may be at greatest risk for the late-onset ADHD phenotype, particularly in highly demanding environments. Exposure to traumatic stress may play a key role in the exacerbation of existing deficits or onset of new symptoms. Late-onset ADHD was persistent in most cases and associated with higher risk for school disengagement than childhood-onset ADHD. Further work is needed to better understand the etiologies of late-onset ADHD symptoms.


Adolescence ADHD Late-onset Cognition 



This project was funded by grants from the Institute of Education Sciences (R305A150433; Sibley, PI) and from Chantal D’Adesky Scheinberg, MD to the FIU Foundation. We also acknowledge Dr. Scheinberg’s scientific contributions to the initial conceptualization of this project’s research aims and methodology.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical standards

This study was approved by the local university ethics committee and have, therefore, was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.


  1. 1.
    Barkley RA (2006) Attention-deficit hyperactivity disorder. A handbook for diagnosis and treatment. Guilford, New YorkGoogle Scholar
  2. 2.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, ArlingtonCrossRefGoogle Scholar
  3. 3.
    Moffitt TE, Houts R, Asherson P et al (2015) Is adult ADHD a childhood-onset neurodevelopmental disorder? Evidence from a four-decade longitudinal cohort study. Am J Psychiatry 172:967–977CrossRefGoogle Scholar
  4. 4.
    Caye A, Rocha TB, Anselmi L et al (2016) Attention-deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort supporting a late-onset syndrome. JAMA Psychiatry 73:705–712CrossRefGoogle Scholar
  5. 5.
    Agnew-Blais JC, Polanczyk GV, Danese A et al (2016) Evaluation of the persistence, remission, and emergence of attention-deficit/hyperactivity disorder in young adulthood. JAMA Psychiatry 73:713–720CrossRefGoogle Scholar
  6. 6.
    Castellanos FX (2015) Is adult-onset ADHD a distinct entity? Am J Psychiatry 172:929–931CrossRefGoogle Scholar
  7. 7.
    Faraone SV, Biederman J (2016) Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry 73:655–656CrossRefGoogle Scholar
  8. 8.
    Solanto MV (2017) Child vs adult onset of attention-deficit/hyperactivity disorder. JAMA Psychiatry 74:421CrossRefGoogle Scholar
  9. 9.
    Sibley MH, Rohde LA, Swanson JM et al (2017) Late-onset ADHD reconsidered with comprehensive repeated assessments between ages 10 and 25. Am J Psychiatry 175:140–149CrossRefGoogle Scholar
  10. 10.
    Agnew-Blais JC, Polanczyk GV, Danese A et al (2018) Young adult mental health and functional outcomes among individuals with remitted, persistent and late-onset ADHD. Br J Psychiatry 213:526–534CrossRefGoogle Scholar
  11. 11.
    Cooper M, Hammerton G, Collishaw S et al (2018) Investigating late‐onset ADHD: a population cohort investigation. J Child Psychol Psychiatry 59:1105–1113CrossRefGoogle Scholar
  12. 12.
    Manfro AG, Santoro M, Polanczyk GV et al (2018) Heterotypic trajectories of dimensional psychopathology across the lifespan: the case of youth‐onset attention deficit/hyperactivity disorder. J Child Psychol Psychiatry 60:533–544CrossRefGoogle Scholar
  13. 13.
    Chambers RA, Taylor JR, Potenza MN (2003) Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability. Am J Psychiatry 160:1041–1052CrossRefGoogle Scholar
  14. 14.
    Kessler RC, Amminger GP, Aguilar-Gaxiola S et al (2007) Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry 20:359CrossRefGoogle Scholar
  15. 15.
    Andersen SL, Teicher MH (2008) Stress, sensitive periods and maturational events in adolescent depression. Trends Neurosci 31:183–191CrossRefGoogle Scholar
  16. 16.
    Castellanos FX, Sonuga-Barke EJ, Milham MP et al (2006) Characterizing cognition in ADHD: beyond executive dysfunction. Trends Cogn Sci 10:117–123CrossRefGoogle Scholar
  17. 17.
    Sonuga-Barke EJ (2003) The dual pathway model of AD/HD: an elaboration of neuro-developmental characteristics. Neurosci Biobehav Rev 27:593–604CrossRefGoogle Scholar
  18. 18.
    Eccles JS (2004) Schools, academic motivation, and stage-environment fit. Handb Adolesc Psychol 2:125–153Google Scholar
  19. 19.
    Zimmerman BJ (2002) Becoming a self-regulated learner: an overview. Theory Pract 41:64–70CrossRefGoogle Scholar
  20. 20.
    Daniel WA, Duke PM, Carlsmith JM et al (1982) Educational correlates of early and late sexual maturation in adolescence. J Pediatr 100:633–637CrossRefGoogle Scholar
  21. 21.
    Paas F, Renkl A, Sweller J (2003) Cognitive load theory and instructional design: recent developments. Educ Psychol 38:1–4CrossRefGoogle Scholar
  22. 22.
    Langberg JM, Epstein JN, Altaye M et al (2008) The transition to middle school is associated with changes in the developmental trajectory of ADHD symptomatology in young adolescents with ADHD. J Clin Child Adolesc Psychol 37:651–663CrossRefGoogle Scholar
  23. 23.
    Casey BJ, Jones RM (2010) Neurobiology of the adolescent brain and behavior: implications for substance use disorders. J Am Acad Child Adolesc Psychiatry 49:1189–1201Google Scholar
  24. 24.
    Casey BJ, Jones RM, Hare TA (2008) The adolescent brain. Ann N Y Acad Sci 1124:111–126CrossRefGoogle Scholar
  25. 25.
    Steinberg L, Albert D, Cauffman E et al (2008) Age differences in sensation seeking and impulsivity as indexed by behavior and self-report: evidence for a dual systems model. Dev Psychol 44:1764CrossRefGoogle Scholar
  26. 26.
    Steinberg L (2008) A social neuroscience perspective on adolescent risk-taking. Dev Rev 28:78–106CrossRefGoogle Scholar
  27. 27.
    Murray AL, Eisner M, Obsuth I et al (2017) Identifying early markers of “Late Onset” attention deficit and hyperactivity/impulsivity symptoms. J Atten Disord. Google Scholar
  28. 28.
    Moffitt TE (1993) A developmental taxonomy. Psychol Rev 100:674–701CrossRefGoogle Scholar
  29. 29.
    Engelmann JB, Maciuba B, Vaughan C et al (2013) Posttraumatic stress disorder increases sensitivity to long term losses among patients with major depressive disorder. PLoS ONE 8:e78292CrossRefGoogle Scholar
  30. 30.
    Buhusi M, Olsen K, Buhusi CV (2017) Increased temporal discounting after chronic stress in CHL1-deficient mice is reversed by 5-HT2C agonist Ro 60–0175. Neuroscience 357:110–118CrossRefGoogle Scholar
  31. 31.
    Cook A, Spinazzola J, Ford J et al (2017) Complex trauma in children and adolescents. Psychiatr Ann 35:390–398CrossRefGoogle Scholar
  32. 32.
    Fuhrmann D, Knoll L, Blakemore SJ (2015) Adolescence as a sensitive period of brain development. Trends Cogn Sci 19:558–566CrossRefGoogle Scholar
  33. 33.
    Iacono LL, Carola V (2018) The impact of adolescent stress experiences on neurobiological development. Semin Cell Dev Biol 77:93–103CrossRefGoogle Scholar
  34. 34.
    Barkley RA, Murphy KR, Fischer M (2010) ADHD in adults: what the science says. Guilford Press, New YorkGoogle Scholar
  35. 35.
    Szymanski K, Sapanski L, Conway F (2011) Trauma and ADHD—association or diagnostic confusion? A clinical perspective. J Infant Child Adolesc Psychother 10:51–59CrossRefGoogle Scholar
  36. 36.
    Fabiano GA, Pelham WE, Waschbusch DA et al (2006) A practical measure of impairment: psychometric properties of the Impairment Rating Scale in samples of children with attention deficit hyperactivity disorder and two school-based samples. J Clin Child Adolesc Psychol 35:369–385CrossRefGoogle Scholar
  37. 37.
    Sibley MH, Altszuler AR, Morrow AS et al (2014) Mapping the academic problem behaviors of adolescents with ADHD. School Psychol Q 29:422CrossRefGoogle Scholar
  38. 38.
    Sibley MH, Kuriyan AB (2016) DSM-5 changes enhance parent identification of symptoms in adolescents with ADHD. Psychiatry Res 242:180–185CrossRefGoogle Scholar
  39. 39.
    Wechsler D (2011) WASI II: Wechsler abbreviated scale of intelligence, 2nd edn. Psychological Corporation, San AntonioGoogle Scholar
  40. 40.
    Kaufman J, Birmaher B, Brent D et al (1997) Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988CrossRefGoogle Scholar
  41. 41.
    Sibley MH, Pelham WE, Molina BS et al (2012) Diagnosing ADHD in adolescence. J Consult Clin Psychol 80:139CrossRefGoogle Scholar
  42. 42.
    Chandra S, Biederman J, Faraone SV (2016) Assessing the validity of the age at onset criterion for diagnosing ADHD in DSM-5. J Atten Disord. Google Scholar
  43. 43.
    Robin AL, Foster SL (1989) Negotiating parent–adolescent conflict: a behavioral–family systems approach. Guilford Press, New YorkGoogle Scholar
  44. 44.
    Molina BS, Pelham WE (2003) Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. J Abnorm Psychol 112:497–507CrossRefGoogle Scholar
  45. 45.
    Weintraub S, Dikmen SS, Heaton RK et al (2013) Cognition assessment using the NIH toolbox. Neurology 80(11 Supplement 3):S54–S64CrossRefGoogle Scholar
  46. 46.
    Tulsky DS, Carlozzi NE, Chevalier N et al (2013) V. NIH toolbox cognition battery (CB): measuring working memory. Monogr Soc Res Child Dev 78:70–87CrossRefGoogle Scholar
  47. 47.
    Zelazo PD, Anderson JE, Richler J et al (2013) II. NIH toolbox cognition battery (CB): measuring executive function and attention. Monogr Soc Res Child Dev 78:16–33CrossRefGoogle Scholar
  48. 48.
    Carlozzi NE, Beaumont JL, Tulsky DS et al (2015) The NIH toolbox pattern comparison processing speed test: normative data. Archives of Clinical Neuropsychology. 30:359–368CrossRefGoogle Scholar
  49. 49.
    Gioia GA, Isquith PK, Guy SC et al (2000) BRIEF behavior rating inventory of executive function. Psychological Assessment Resources, OdessaGoogle Scholar
  50. 50.
    Yamamoto Y, Holloway SD (2010) Parental expectations and children's academic performance in sociocultural context. Educ Psychol Rev 22:189–214CrossRefGoogle Scholar
  51. 51.
    Crone EA, van der Molen MW (2004) Developmental changes in real life decision making: performance on a gambling task previously shown to depend on the ventromedial prefrontal cortex. Develo Neuropsychol 25:251–279CrossRefGoogle Scholar
  52. 52.
    Crone EA, Van Der Molen MW (2007) Development of decision making in school-aged children and adolescents: evidence from heart rate and skin conductance analysis. Child Dev 78:1288–1301CrossRefGoogle Scholar
  53. 53.
    Scheres A, Dijkstra M, Ainslie E et al (2006) Temporal and probabilistic discounting of rewards in children and adolescents: effects of age and ADHD symptoms. Neuropsychologia 44:2092–2103CrossRefGoogle Scholar
  54. 54.
    Scheres A, Lee A, Sumiya M (2008) Temporal reward discounting and ADHD: task and symptom specific effects. J Neural Transm 115:221–226CrossRefGoogle Scholar
  55. 55.
    Eccles A, Wigfield JS (2000) Expectancy–value theory of achievement motivation. Contemp Educ Psychol 25:68–81CrossRefGoogle Scholar
  56. 56.
    Langberg JM, Smith ZR, Dvorsky MR et al (2017) Factor structure and predictive validity of a homework motivation measure for use with middle school students with attention-deficit/hyperactivity disorder (ADHD). School Psychol Q 33:390–398CrossRefGoogle Scholar
  57. 57.
    Benjamini Y, Hochberg Y (1995) Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Ser B Methodol 57:289–300Google Scholar
  58. 58.
    Mitchell JT, Sibley MH, Hinshaw SP et al (2019) A qualitative analysis of contextual factors relevant to suspected late-onset ADHD. J Atten Disord. Google Scholar
  59. 59.
    Mahone EM, Hagelthorn KM, Cutting LE et al (2002) Effects of IQ on executive function measures in children with ADHD. Child Neuropsychol 8:52–65CrossRefGoogle Scholar
  60. 60.
    Lee NC, Krabbendam L, Dekker S et al (2012) Academic motivation mediates the influence of temporal discounting on academic achievement during adolescence. Trends Neurosci Educ 1:43–48CrossRefGoogle Scholar
  61. 61.
    Adler LA, Kunz M, Chua HC et al (2004) Attention-deficit/hyperactivity disorder in adult patients with posttraumatic stress disorder (PTSD): is ADHD a vulnerability factor? J Atten Disord 8:11–16CrossRefGoogle Scholar
  62. 62.
    Spann MN, Mayes LC, Kalmar JH, Guiney J et al (2012) Childhood abuse and neglect and cognitive flexibility in adolescents. Child Neuropsychol 18:182–189CrossRefGoogle Scholar
  63. 63.
    Voort JL, He JP, Jameson ND et al (2014) Impact of the DSM-5 attention-deficit/hyperactivity disorder age-of-onset criterion in the US adolescent population. J Am Acad Child Adolesc Psychiatry 53:736–744CrossRefGoogle Scholar
  64. 64.
    Bussing R, Zima BT, Gary FA et al (2003) Social networks, caregiver strain and utilization of mental health services among elementary school students at high risk for ADHD. J Am Acad Child Adolesc Psychiatry 42:842–850CrossRefGoogle Scholar
  65. 65.
    Bussing R, Koro-Ljungberg ME et al (2005) Exploring help-seeking for ADHD symptoms: a mixed-methods approach. Harv Rev Psychiatry 13:85–101CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Margaret H. Sibley
    • 1
    • 2
    Email author
  • Mercedes Ortiz
    • 1
  • Paulo Graziano
    • 1
  • Anthony Dick
    • 1
  • Elena Estrada
    • 1
  1. 1.Florida International UniversityMiamiUSA
  2. 2.Department of Psychiatry and Behavioral Sciences, University of Washington School of MedicineCenter for Child Health, Behavior, and Development, Seattle Children’s HospitalSeattleUSA

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