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ADHD is a common, neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity which affect functioning in academic, social, and family contexts. Its clinical presentation evolves across the lifespan, and the developmental course largely determines the disorder’s impact on everyday functioning. Coexisting problems or disorders are common across development, and worsen the outcomes. Adolescents with ADHD and co-existing emotional and conduct problems have increased risk of psychiatric disorders, functional impairment and QoL. Although ADHD is considered a strongly hereditary disorder, environmental factors may also be important risk factors for the development and course of this condition. Protective factors are thought to promote resilience, and include both individual and environmental factors. Risk and protective factors important for outcomes among adolescents with ADHD should be investigated. The main objective of this thesis was to assess factors that may be of importance in achieving better outcomes in adolescents with ADHD. In the first study we assessed the adolescents’ perceptions of family functioning and QoL according to level of coexisting emotional and conduct problems. We added parent reports to compare with the self-report, and included perspectives of both informant. To investigate these aims, we used a sample obtained from a cross-sectional survey of clinical adolescents with ADHD, aged 13-18 years. The sample of 194 adolescent with ADHD were divided into four groups; 1. Without additional emotional and conduct problems; 2. With additional emotional problems; 3. With additional conduct problems; 4. With additional emotional and conduct problems. The findings showed that adolescents with both emotional and conduct problems reported lower QoL and family functioning. On the other hand, parents reported a significant impact of coexisting problems on adolescents’ QoL, but not on family functioning. The findings of the study suggest that the self-perceptions of adolescents with ADHD generate useful information that may help to optimize clinical assessment. In the second study we assessed the mediating and moderating effects of personal and environmental protective factors on the relationship between coexisting emotional and conduct problems and QoL. Individual competencies, which include self-esteem, structured style, and social competence, were the strongest mediator between coexisting emotional problems and QoL among adolescents with ADHD, including those who were prescribed psychostimulants. Social resources mediated the relationship between conduct problems and QoL. These findings indicate that assessment of protective factors, in addition to risk factors, may identify potential treatment goals. In the third study, using a longitudinal design, we investigated whether the personal protective factors; self-esteem, structured style and social competence, were predictors of more favorable outcomes. Outcomes were psychosocial functioning, anxiety, depression and ADHD diagnoses three years later. Better self-esteem in adolescence was a predictor of better psychosocial functioning in young adulthood. A more structured style and better social competence were also associated with this outcome. Furthermore, better self-esteem in adolescence was associated with fewer depressive disorders, while social competence in adolescence was associated with fewer anxiety disorders in young adulthood. Further knowledge of protective factors might be useful in the development of support and clinical interventions for ADHD patients in the transition period from adolescence to emerging adulthood.

Sammendrag Bakgrunn for studien: Det foreligger ikke tilstrekkelig kunnskap om hvordan søvnvansker påvirker ungdom med ADHD og om søvnvansker forverrer komorbide vansker og funksjonsnivå ved ADHD i et langtidsperspektiv. Målet med denne studien var å undersøke om søvnvansker påvirker nivået av komorbide emosjonelle vansker og atferdsvansker hos ungdom med ADHD sammenlignet med dem uten søvnvansker. Metode: Denne kohort-studien innhentet data fra et klinisk utvalg i Helseundersøkelsen i Barne- og Ungdomspsykiatrisk klinikk, St. Olavs hospital (HelBUP). 257 ungdommer i alderen 13 til 18 år med ADHD ble inkludert i studien ved start (T1) og rapporterte om søvn på et spørreskjema. Ved oppfølging tre år senere (T2) deltok 200 av ungdommene fra T1 i et psykiatrisk intervju (Kidde-SADS). Informasjon om emosjonelle vansker og atferdsvansker ved T2 ble innhentet ved at foreldrene fylte ut Child Behavior Checklist (CBCL). Resultater: Analysen viste at søvnproblemer øker emosjonelle vansker og atferdsvansker tre år senere når det kontrolleres for alder, kjønn og ADHD-symptomskåre. Konklusjon: Det er av stor betydning å utrede og behandle søvnproblemer blant ungdom med ADHD, for å redusere emosjonelle vansker og atferdsvansker i et langtidsperspektiv. Abstract Background: There is insufficient knowledge about how sleep problems affect adolescents with ADHD and whether sleep problems aggravate comorbid difficulties and functional levels in a long-term course. The aim of the present study was to examine if sleep problems affect the level of comorbid emotional and behavioral problems in adolescents with ADHD compared to adolescents with ADHD without sleep problems. Methods: This prospective study obtained data from a health survey in the Department of Child and Adolescent Psychiatry, St. Olavs hospital, Trondheim University Hospital, Norway. At baseline, 257 adolescents with ADHD between the ages of 13 to 18 were included and filled out a self-report about sleep problems. At follow-up three years later 200 subjects participated in a psychiatric interview (Kidde-SADS). Information about emotional and behavioral problems was obtained by parent reports on the Child Behavior Checklist (CBCL). Results: Analyses showed that sleep problems predicted more internalizing problems and externalizing problems three years later when controlling for age, sex and ADHD-symptom score. Conclusion: Assessing and treating sleep problems is important to reduce emotional and behavioral problems in adolescents with ADHD in a long-time perspective.

Bakgrunn I ungdomstiden er det økte sosiale og akademiske krav, og det er viktig å identifisere de faktorer som kan påvirke og redusere psykososial funksjon og selvfølelse. Søvnforstyrrelser hos ungdommer med ADHD er veletablert, og er vist å svekke skoleprestasjon og selvfølelse. Det er fortsatt ingen endelige resultater som kartlegger interaksjonen mellom søvnforstyrrelse og ADHD, og om søvnforstyrrelse er en risiko for supplerende vansker i et lang-tidsperspektiv. Bakgrunn for denne studien var å undersøke om det er en assossiasjon mellom søvnforstyrrelse og psykososial fungering, samt mellom søvnforstyrrelse og selvoppfattelse av skolefaglig kompetanse, sosial aksept, atletisk kompetanse, fysisk utseende, romantisk tiltrekning, nære venner og global selvfølelse, tre år senere. Metode Longitudinelle data ble hentet fra et utvalg på 200 ungdommer – i alderen 13 til 18 år – henvist til Barne- og ungdomspsykiatrisk klinikk i Trondheim, Norge. I utgangspopulasjonen målte vi insomni ved selv-rapportering og mengde ADHD-symptomer ble målt ved foreldre-rapportering. Deltakernes psykososiale fungering og selv-opplevelse ble målt tre år senere. Psykososial funksjonsskår ble satt ved klinisk psykiatrisk intervju og selv-opplevelse i syv sub-domener ble angitt ved bruk av spørreskjema. Resultat Analyser viste at søvnforstyrrelse i utgangspopulasjonen er assosiert med lavere selvrapportert selvfølelse, fysisk utseende, opplevelse av å ha nære venner og sosial aksept, og lavere observert psykososial funksjon tre år senere, kontrollert for alder, kjønn og ADHD-symptomskår. Konklusjon Resultatene belyser relevansen av å identifisere insomni blant ungdommer med ADHD i klinisk praksis, da søvnforstyrrelser predikerer lavere psykososial funksjon og selv-følelse i et langtidsperspektiv. Purpose In adolescence, there are increased environmental demands and it is important to identify factors that may impair psychosocial function and self-worth in the transition from adolescence to young adulthood. Sleep disorders, including insomnia, in adolescents with ADHD is well established and is shown to impair academic performance and self-esteem. Although there are no conclusive results of the interaction of insomnia and ADHD and if insomnia is a risk factor for additional difficulties in a long-term perspective. The aim of the study was to investigate if there were an association with insomnia and psychosocial function, and insomnia and self-perception of scholastic competence, social acceptance, athletic competence, physical appearance, romantic appeal, close friends, and global self-worth, three years later. Methods Longitudinal data were obtained from a sample of 200 adolescents – aged 13 to 18 – referred to the Department of Child and Adolescent Psychiatry in Trondheim, Norway. In the baseline study, insomnia was measured by the means of self-report, and the amount of ADHD symptoms was measured by parental report. Participants´ psychosocial function and self-perception were assessed three years later; Psychosocial function by clinical psychiatric interview and self-perception by questionnaire. Results Analysis shows that reported insomnia at baseline predicted lower self-perception of self-worth, physical appearance, close friends and social acceptance, and a lower psychosocial functioning, three years later. Adjusted for age, gender, and ADHD symptom score. Conclusion The results highlight the relevance of identifying sleep disorders amongst adolescents with ADHD in clinical practice, and which associations sleep disorder can have with psychosocial function and self-worth, physical appearance, close friends, and social acceptance in a long-term perspective.