Comparing Four Methods of Integrating Parent and Teacher Symptom Ratings of Attention-deficit/hyperactivity Disorder (ADHD)

Longitudinal relations of prematurity and fetal growth restrictions with hyperactivity/inattention and aggression/delinquency

BACKGROUND

It is the aim of this study to analyze the longitudinal relationship between premature birth and low birth weight and the reciprocal influence between hyperactive/inattentive behavior and aggressive/delinquent behavior problems in children from early to late childhood.

METHODS

This study contains data from the German Erlangen-Nuremberg Development and Prevention Study. It applies prospective longitudinal path analyses on data obtained from postnatal pediatric assessments as well as later psychosocial behavior assessments by teachers and parents on N = 667 children, out of which n = 83 children (12.44%) were born preterm/small for gestational age.

RESULTS

The results show direct effects of birth complications at the beginning of preschool on hyperactivity/inattentiveness (teacher rating: ß = 0.28; p = 0.017; parent rating: ß = 0.32; p = 0.005), but not on aggression/delinquency (teacher rating: ß = 0.002; p = 0.427; parent rating: ß = 0.12; p = 0.324). Reciprocal effects between aggression/delinquency and hyperactivity/inattentiveness were stable at the end of elementary school, but not at the end of preschool across informants.

CONCLUSION

Our results support a differentiated view on the potential development of behavior problems after birth complications and the demand for early prevention measures.

IMPACT STATEMENT

Our results extend to the existing body of research by providing insight into the longitudinal effects of prematurity and fetal growth restrictions on hyperactive and aggressive/delinquent behavioral problems throughout a rather long period of development in childhood. The results show direct effects of birth complications on the development of hyperactivity for boys, but not for girls across informants. No direct effects of birth complications on aggression/delinquency are found. Our findings speak against too simple views on behavioral consequences of birth complications and thus can relieve too anxious parents, however close monitoring of the behavioral development of respective children is indicated.

A Developmentally Informed Systematic Review and Meta-Analysis of the Strength of General Psychopathology in Childhood and Adolescence

Considerable support exists for higher-order dimensional conceptualizations of psychopathology in adults. A growing body of work has focused on understanding the structure of general and specific psychopathology in children and adolescents. No prior meta-analysis has examined whether the strength of the general psychopathology factor (p factor)-measured by explained common variance (ECV)-changes from childhood to adolescence. The primary objective of this multilevel meta-analysis was to determine whether general psychopathology strength changes across development (i.e. across ages) in childhood and adolescence. Several databases were searched in November 2021; 65 studies, with 110 effect sizes (ECV), nested within shared data sources, were identified. Included empirical studies used a factor analytic modeling approach that estimated latent factors for child/adolescent internalizing, externalizing, and optionally thought-disordered psychopathology, and a general factor. Studies spanned ages 2-17 years. Across ages, general psychopathology explained over half (~ 56%) of the reliable variance in symptoms of psychopathology. Age-moderation analyses revealed that general factor strength remained stable across ages, suggesting that general psychopathology strength does not significantly change across childhood to adolescence. Even if the structure of psychopathology changes with development, the prominence of general psychopathology across development has important implications for future research and intervention.

Enhanced Brief Motivational Intervention for College Student Drinkers With ADHD: Goal-Directed Activation as a Mechanism of Change

College students with attention-deficit/hyperactivity disorder (ADHD) are at risk for alcohol-related problems and disorders relative to their typically developing peers. Despite risk, the optimal therapeutic approach for reducing problem alcohol use in students with ADHD, and mechanisms of change underlying treatment effects in this population, are largely unknown. The current study evaluated putative mechanisms of change in a randomized controlled trial of two harm reduction interventions for college student drinkers with ADHD (N = 113; 49% male): brief motivational intervention plus supportive counseling (BMI + SC) versus brief motivational intervention plus behavioral activation (BMI + BA). Results showed that participants in the BMI + BA condition engaged in more goal-directed activation and less avoidant behavior over the course of treatment compared to those in the BMI + SC condition, in turn predicting reductions in alcohol-related negative consequences. Effects were more robust 1 month following intervention, and diminished by 3 months. Sensitivity analyses revealed a significant indirect effect of treatment condition on alcohol-related negative consequence via reductions in avoidance over treatment. Post hoc moderated mediations showed that BMI + BA engaged target mechanisms more robustly for students with more severe ADHD and depressive symptoms compared to BMI + SC. These findings support the application of BMI + BA intervention, particularly in targeting goal-directed activation and avoidance/rumination in at-risk student drinkers with ADHD.

Methylphenidate-Related Improvements in Math Performance Cannot Be Explained by Better Cognitive Functioning or Higher Academic Motivation: Evidence From a Randomized Controlled Trial

Objective: This study investigated whether improvements in working memory, reaction time, lapses of attention, interference control, academic motivation, and perceived competence mediated effects of methylphenidate on math performance. Method: Sixty-three children (ADHD diagnosis; methylphenidate treatment; age 8-13; IQ > 70) were randomly allocated to a 7-day methylphenidate or placebo treatment in this double-blind placebo-controlled crossover study and compared with 67 controls. Data were collected at schools and analyzed using mixed-model analysis. Methylphenidate was hypothesized to improve all measures; all measures were evaluated as potential mediators of methylphenidate-related math improvements. Results: Controls mostly outperformed the ADHD group. Methylphenidate did not affect measures of cognitive functioning (p = .082-.641) or academic motivation (p = .199-.865). Methylphenidate improved parent ratings of their child's self-perceived competence (p < .01), which mediated methylphenidate efficacy on math productivity. Conclusion: These results question the necessity of improvements in specific cognitive and motivational deficits associated with ADHD for medication-related academic improvement. They also stimulate further study of perceived competence as a mediator.

Longitudinal Trajectories of Sustained Attention Development in Children and Adolescents with ADHD

The present study characterizes changes in sustained attention ability over ages 9-14, and whether longitudinal trajectories of attention development differ between persistent ADHD, remitted ADHD and control groups. The Sustained Attention to Response Task (SART) was administered to 120 children with ADHD and 123 controls on three occasions between ages 9 and 14. Trajectories of sustained attention development, indicated by changes in SART performance (standard deviation of response time [SDRT], omission errors, and ex-Gaussian parameters sigma and tau), were examined using generalized additive mixed models. For all measures there was a significant main effect of age; response time variability and number of omission errors improved linearly as children aged. However, children with ADHD had significantly greater SDRT, tau and omission errors than controls across waves. There were no significant group differences in sigma, indicating that the greater overall response time variability (SDRT) observed in ADHD was likely driven by more intermittent long responses (larger tau). Trajectories of sustained attention performance did not differ between children with persistent ADHD or ADHD in remission. Longitudinal trajectories of sustained attention development are comparable between ADHD and controls, however children with ADHD (regardless of remission status) display a performance deficit equivalent to typical controls 1-3 years younger. Findings highlight the need for continued clinical support for children in remission from ADHD and provide support for tau as an endophenotype of ADHD.

Cross-Validation and Development of Empirically Derived ADHD Assessment Strategies: Insights From the National Longitudinal Study of Adolescent Health (Add Health)

Objective: There is replicated evidence that individual ADHD symptoms differentially predict ADHD diagnostic status, and that non-Diagnostic and Statistical Manual of Mental Disorders (DSM)-based symptom algorithms are superior to DSM criteria for ruling in or ruling out ADHD. However, these findings have been limited to case-control samples, despite the need to replicate them in independent and more representative samples and to increase their generalizability. Method: We analyzed the base rates and psychometric properties of ADHD symptoms in the population-based National Longitudinal Study of Adolescent Health (Add Health; http://www.cpc.unc.edu/projects/addhealth ) sample, and evaluated the predictive utility of empirically derived ADHD symptoms against the DSM approach with respect to academic, health, and relational functional outcomes. The sample consisted of 11,247 (54% female) ethnically diverse (45% non-White) individuals who retrospectively self-reported the severity of their ADHD symptoms from 5 to 12 years. Results: Individual ADHD symptoms variably predicted ADHD status, and whereas most symptoms were most predictive when endorsed at the two highest severity levels in previous studies, symptoms in Add Health were often most predictive of ADHD when endorsed at the highest severity level. Conclusion: The divergence in optimal severity thresholds for ADHD symptoms potentially reflects the different symptom base rates in clinical versus population-based samples. The accuracy of the different classification approaches also suggested that different symptom algorithms may be superior to evaluate ADHD depending on the assessment setting.

Executive Functioning Mediates Predictions of Youth Academic and Social Development from Parenting Behavior

Using multiple mediation with bootstrapping, dimensions of executive functioning (i.e., inhibitory control, working memory, set shifting) were tested as mediators of predictions of academic and social outcomes from observed positive and negative parenting in 131 children followed prospectively into early adolescence. Inhibitory control and working memory mediated predictions of academic achievement, whereas inhibitory control meditated predictions of school competence from positive parenting. Additionally, working memory mediated predictions of negative social preference, but not social competence, from positive parenting. Executive functioning did not mediate predictions from negative parenting. The role of parenting in shaping youth outcomes through executive functioning is considered.

The Influences of Multiple Informants' Ratings of Inattention on Preschoolers' Emergent Literacy Skills Growth

There is strong evidence that inattention is a correlate of reading-related skills; however, less research has examined the unique and longitudinal relations between multiple informants' ratings of inattention and the development of early reading skills across the preschool year. This study used latent growth curve analysis to examine whether ratings of inattention, completed by multiple informants, were unique predictors of emergent literacy development in preschoolers. Participants included 284 preschool children. ADHD-rating scales were completed by three different informants (i.e., classroom teachers, project teachers, and examiners) and measures of emergent literacy skills, a measure of working memory, and a measure of non-verbal cognitive ability were completed by the preschoolers. Each informant's rating of inattention uniquely predicted children's initial emergent literacy skills, but only the ratings of inattention made by project teachers were uniquely associated with growth in emergent literacy skills over the course of the preschool year.

Incremental Validity of Teacher and Parent Symptom and Impairment Ratings when Screening for Mental Health Difficulties

Although universal screening for mental health difficulties is increasingly recognized as a way to identify children who are at risk and provide early intervention, little research exists to inform decisions about screening, such as the choice of informants and the type of information collected. The present study examined the incremental validity of teacher- and parent-rated (primarily mothers) symptoms and impairment in a non-referred sample of early elementary school children (n = 320, 49 % boys, ages 6 to 9) in terms of predicting impairment as rated by a different teacher 1 year later. Teacher-rated symptoms and impairment and parent-rated impairment were each unique predictors of later impairment; however, parent-rated symptoms did not contribute to the prediction of later impairment above and beyond these other indicators. The results indicate that, when screening for mental health difficulties in the school system, impairment ratings collected across settings add useful information, but it may not be necessary to use parent symptom ratings when teacher symptom ratings are available.

Short-Term Effects of Methylphenidate on Math Productivity in Children With Attention-Deficit/Hyperactivity Disorder are Mediated by Symptom Improvements: Evidence From a Placebo-Controlled Trial

BACKGROUND

Although numerous studies report positive effects of methylphenidate on academic performance, the mechanism behind these improvements remains unclear. This study investigates the effects of methylphenidate on academic performance in children with attention-deficit/hyperactivity disorder (ADHD) and the mediating and moderating influence of ADHD severity, academic performance, and ADHD symptom improvement.

METHODS

Sixty-three children with ADHD participated in a double-blind placebo-controlled crossover study comparing the effects of long-acting methylphenidate and placebo. Dependent variables were math, reading, and spelling performance. The ADHD group performance was compared with a group of 67 typically developing children.

RESULTS

Methylphenidate improved math productivity and accuracy in children with ADHD. The effect of methylphenidate on math productivity was partly explained by parent-rated symptom improvement, with greater efficacy for children showing more symptom improvement. Further, children showing below-average math performance while on placebo profited more from methylphenidate than children showing above-average math performance.

CONCLUSIONS

The results from this study indicate positive effects of methylphenidate on academic performance, although these were limited to math abilities. In light of these results, expectations of parents, teachers, and treating physicians about the immediate effects of methylphenidate on academic improvement should be tempered. Moreover, our results implicate that positive effects of methylphenidate on math performance are in part due directly to effects on math ability and in part due to reductions in ADHD symptoms.

Comparative Validity of DSM-IV and Alternative Empirically Derived Approaches for the Assessment of ADHD

OBJECTIVE

To identify ADHD symptoms that are most highly predictive of ADHD diagnostic status and compare them against Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) algorithms in predictions of functional impairment.

METHOD

Parent and teacher ratings of ADHD were obtained from an ethnically diverse (46% non-White) sample of 151 five- to ten-year-old children (27% female) with ( n = 76) and without ( n = 75) DSM-IV ADHD. We calculated total predictive values to estimate how ratings of each ADHD symptom predicted ADHD diagnostic status based on a structured parent diagnostic interview. Optimal symptom thresholds (i.e., not at all, just a little, pretty much, very much) for predicting ADHD caseness differed for inattention and hyperactivity and parents versus teachers. Algorithms consisting of highly predictive symptoms were then created and compared against DSM-IV-based algorithms to predict independent measures of functional impairment.

RESULTS

Several empirically derived symptom algorithms were more strongly associated with functional impairment than DSM-IV-based algorithms.

CONCLUSION

These preliminary findings suggest that alternative methods to aggregating ADHD symptoms may improve predictions of impairment.

Equivalence of mother and father ratings of ADHD in children

Obtaining data from multiple informants provides a more comprehensive diagnostic picture in the assessment of attention deficit hyperactivity disorder (ADHD). Differences in symptom ratings have been observed between parent- and teacher-report scales, though less information is available regarding differences between mothers and fathers. To address this gap, this study examines the rater agreement between mothers and fathers on the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) ADHD Symptom Rating Scale (DSM-ADHD-SRS). The participants consisted of 337 children diagnosed with ADHD who underwent comprehensive neuropsychological assessment. Confirmatory factor analysis indicates that a three-factor model comprising inattention, hyperactivity, and impulsivity symptoms provides the best fit for both mothers' and fathers' ratings. Mothers provided higher mean ratings for the inattention scale. These results suggest that the factor structure for the DSM-ADHD-SRS is the same, regardless of parent gender. However, symptoms of inattention may vary depending upon which parent completes the ratings. This discrepancy could lead to differences in diagnostic impressions in clinical evaluations.

Pharmacological treatment of attention-deficit/hyperactivity disorder: assessing outcomes

A substantial body of evidence has supported the efficacy and safety of pharmacological treatment available for attention deficit/hyperactivity disorder (ADHD). There is increasing agreement that the important treatment outcomes for ADHD extend beyond improvement in core symptoms and that a more generic (or global) concept of remission is the overarching goal of treatment. However, there is no consensus on the best definition of remission or on how best to conceptualize and measure broader treatment outcomes. In this article, we provide an overview of the various methods and approaches to measuring treatment outcomes for ADHD with respect to symptoms, impairment, quality of life, adverse events and safety as well as cognition. We will describe the ways that they may be used within routine clinical practice and think ahead about the kinds of studies that are required to move the field forward.

Multi-Informant Assessment of ADHD Symptom-Related Impairments Among Children and Adolescents

Existing methods of assessing attention-deficit/hyperactivity disorder (ADHD) are limited because they do not examine impairments in relation to symptoms of ADHD. This study investigated parent and teacher ratings of multiple domains of impairment, assessed in relation to the symptom dimensions of ADHD using the ADHD Rating Scale-5. Nationally representative samples of children rated by parents and teachers were recruited through commercial research firms. One sample included 2,079 parents who rated one of their children of age 5 to 17 years. The second sample included 1,070 teachers in grades K to 12 who rated 2 randomly selected students on their class rosters. Informants rated the extent to which each child displayed the 18 behaviors symptomatic of ADHD over the previous 6 months, as well as symptom-related impairments in the areas of family/teacher relationships, peer relationships, academics, behavior problems, homework, and self-esteem. Respondents were asked to complete the 6 impairment items after rating each of the Inattention and Hyperactivity/Impulsivity symptom items. For both informants a 6-factor model that combined impairment items across source of impairment was adequate and superior to a 2-factor structure based on source of impairment (i.e., impairment due to Inattention vs. Hyperactivity-Impulsivity). Impairment ratings were impacted by child demographic factors, but effect sizes were low. In contrast, impairment ratings were strongly related to ratings on the ADHD symptom dimensions. The study provides support for assessing 6 symptom-related domains of impairment but does not support differentiating whether Inattention or Hyperactivity-Impulsivity is the source of impairment.

Predictive Utility of Four Methods of Incorporating Parent and Teacher Symptom Ratings of ADHD for Longitudinal Outcomes

Despite robust evidence that parents and teachers provide incremental validity in the assessment of attention-deficit/hyperactivity disorder (ADHD), far less is known about the predictive utility of various strategies for incorporating these multi-informant data. Thus, we compared the 2-year predictive validity of four common assessment methods (i.e., algorithms) for ADHD symptoms--(a) parent only, (b) teacher only, (c) parent or teacher ("or rule"), and (d) parent and teacher ("and rule")--with respect to psychopathology and multidomain functional outcomes. At baseline, separate parent and teacher ratings of ADHD were obtained from an ethnically diverse (53% non-White) sample of 195 6- to 10-year-old children (30% female) to classify children according to the 4 algorithms. We then evaluated the predictive validity of each baseline ADHD algorithm with respect to its prediction of separate measures of internalizing and externalizing psychopathology, as well as normed ratings of academic and social impairment obtained at a 2-year follow-up. The "or rule" algorithm, based on symptoms being endorsed by either informant, optimally predicted psychopathology and functional outcomes relative to the other algorithms. These findings converge with previous evidence that incorporating data from multiple informants, and more sensitive approaches in particular, provide incremental validity in the assessment of ADHD.

Correction of distortions in distressed mothers' ratings of their preschool children's psychopathology

The often-reported low informant agreement about child psychopathology between multiple informants has lead to various suggestions about how to address discrepant ratings. Among the factors that may lower agreement that have been discussed is informant credibility, reliability, or psychopathology, which is of interest in this paper. We tested three different models, namely, the accuracy, the distortion, and an integrated so-called combined model, that conceptualize parental ratings to assess child psychopathology. The data comprise ratings of child psychopathology from multiple informants (mother, therapist and kindergarten teacher) and ratings of maternal psychopathology. The children were patients in a preschool psychiatry unit (N=247). The results from structural equation modeling show that maternal ratings of child psychopathology were biased by maternal psychopathology (distortion model). Based on this statistical background, we suggest a method to adjust biased maternal ratings. We illustrate the maternal bias by comparing the ratings of mother to expert ratings (combined kindergarten teacher and therapist ratings) and show that the correction equation increases the agreement between maternal and expert ratings. We conclude that this approach may help to reduce misclassification of preschool children as 'clinical' on the basis of biased maternal ratings.