Turkish validity and reliability study of the Weiss Functional Impairment Rating Scale-Parent Report

Telerehabilitation of subjects with neurodevelopmental disorders during confinement due to COVID-19

INTRODUCTION

Social distancing measures due to the COVID-19 pandemic prevented many children with neurodevelopmental disorders from accessing face-to-face treatments. Telerehabilitation grew at this time as an alternative therapeutic tool. In this study we analysed remote cognitive rehabilitation in neurodevelopmental disorders.

METHODS

This was a prospective, quasi-experimental (before-after) study that included 22 patients (mean age 9.41 years) with neurodevelopmental disorders who had telerehabilitation for over six months.

RESULTS

After six months of telerehabilitation, a statistically significant improvement was found with a large effect size in these areas: attention (sustained, selective and divided), executive functions (verbal and visual working memory, categorisation, processing speed), visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia) and language (comprehensive and expressive). On the Weiss Functional Impairment Scale, all areas (family, learning and school, self-concept, activities of daily living, risk activities) improved with statistical significance. We found a positive correlation between the number of sessions and the improvement observed in executive functions (visual working memory, processing speed), attention (sustained attention, divided attention) and visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia). We did not find statistical significance between the family structure and the number of sessions carried out. A high degree of perception of improvement and satisfaction was observed in the parents.

CONCLUSIONS

Telerehabilitation is a safe alternative tool which, although it does not replace face-to-face therapy, can achieve significant cognitive and functional improvements in children with neurodevelopmental disorders.

A randomized controlled trial of effects of sleep hygiene training and progressive muscle relaxation training in children with ADHD

OBJECT

Sleep problems often accompany ADHD and negatively affect ADHD symptoms, however, there are not enough intervention studies on sleep interventions in children with ADHD. The present study investigated the effects of sleep hygiene training (SH) and progressive muscle relaxation exercises (PMR) in children with ADHD.

METHOD

57 children aged 6-12 years with ADHD were randomly assigned to the SH and SH + PMR groups and completed the intervention consisting of group training and eight weeks of telephone interviews. The effects of both intervenitons were evaluated via parent, child and clinician report scales and neuropsychological tests.

RESULTS

Both interventions resulted in significant positive changes in child sleep, ADHD symptoms, functioning, neuropsychological tests and parental sleep quality. Significant differences were found between the interventions in selective attention, peer problems and anxiety scores in favor of the SH + PMR group.

CONCLUSION

SH may have positive effects on various clinical parameters as well as sleep problems in children with ADHD. Addition of PMR to SH may lead to further improvements in anxiety, peer problems and selective attention. SH and PMR may be a useful tool in the clinical management of children with ADHD with sleep problems.

Validation of the Weiss Functional Impairment Rating Scale (WFIRS-P) as a Functional Impairment Measure in a General Population of Schoolchildren

Functional impairment rating scales are few in numbers and have mainly been examined in clinical populations. The Weiss Functional Impairment Rating Scale-Parent report (WFIRS-P) is a case in point. We tested the psychometric properties of the WFIRS-P in the largest general population study to date and for the first time examined the factor structure of the scale in a general population setting. Participants were 2,027 schoolchildren aged 6 to 11. Parents/caregivers completed the WFIRS-P and criterion measures of quality of life, attention-deficit/hyperactivity disorder, and behavioral/emotional symptoms. Confirmatory factor analysis and convergent/divergent validity analyses supported a six-factor structure: family, life skills, self-concept, social activities, and the separation of the school domain into two smaller domains covering school learning and school behavior. Children with and without a history of referral differed significantly on all six domains supporting the external validity. In conclusion, the WFIRS-P was found to generate valid scores in a general population sample.

Evaluation of p300 and spectral resolution in children with attention deficit hyperactivity disorder and specific learning disorder

This study aims to examine auditory processing, P300 values and functional impairment levels among children with Attention Deficit and Hyperactivity Disorder (ADHD), Specific Learning Disorder (SLD), ADHD+SLD and healthy controls. Children with ADHD (n = 17), SLD (n = 15), ADHD+SLD (n = 15), and healthy controls (n = 15) between the ages of 7-12 were evaluated with K-SADS, Weiss Functional Impairment Rating Scale, Turgay DSM-IV Disruptive Behavior Disorders Rating Scale, The Mathematics, Reading, Writing Assessment Scale and Children's Auditory Performance Scale (CHAPS). Auditory P300 event-related potentials and Spectral-Temporally Modulated Ripple Test (SMRT) were applied. Three patient groups were found to be riskier than healthy controls according to the CHAPS. There was no significant difference between the groups in the SMRT. In post-hoc analyses of P300 parietal amplitudes, ADHD, SLD, and ADHD+SLD were found to be significantly lower than the control group. The amplitudes of the ADHD+SLD were by far the lowest. It has been shown that auditory performance skills and p300 amplitudes are lower in children diagnosed with only ADHD or SLD compared to the control group, with the lowest values observed in ADHD+SLD. This study suggests that the difficulties with attention and cognitive functions in the ADHD+SLD are more severe than ADHD and/or SLD without comorbidity.

Functional outcomes of extended-release methylphenidate and atomoxetine in children: retrospective chart analysis

Background

Recent guidelines emphasize the importance of functional outcomes in children with attention-deficit/hyperactivity disorder (ADHD). Here, we assess the functional outcomes of the oral delivery system of osmotic-release methylphenidate (OROS-MPH) and atomoxetine (ATX) from the retrospective review of the chart for the last 2 years in the clinic.

Results

Linear mixed-effects models were performed with outcome measures of difference in ADHD symptoms and functional impairment. After 9–12 weeks, OROS-MPH and ATX were statistically equivalent for total Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) scores (difference in slope is β = 0.004, p = 1.000). However, OROS-MPH was superior to ATX in terms of school domain (difference in slope is β = 0.139, p < 0.001); ATX was superior in the family domain (slope difference in slope is β = 0.103, p < 0.001). The other domains of functioning both were not responsive to pharmacotherapy and were similar between the two medications.

Conclusions

Optimal management should monitor functional progress in ADHD beyond the core symptoms. As expected, ADHD medications provide a distinct pattern of functional improvement. Pharmacotherapy alone offers promising and reliable outcomes to improve school and family functions in ADHD. Some functional improvements did not respond to the medication; therefore, many of the techniques derived from behavioral interventions should be considered.

[Telerehabilitation of Subjects with Neurodevelopmental Disorders During Confinement due to COVID-19]

Introduction

Social distancing measures due to the COVID-19 pandemic prevented many children with neurodevelopmental disorders from accessing face-to-face treatments. Telerehabilitation grew at this time as an alternative therapeutic tool. In this study we analysed remote cognitive rehabilitation in neurodevelopmental disorders.

Methods

This was a prospective, quasi-experimental (before-after) study that included 22 patients (mean age 9.41 years) with neurodevelopmental disorders who had telerehabilitation for over six months.

Results

After six months of telerehabilitation, a statistically significant improvement was found with a large effect size in these areas: attention (sustained, selective and divided), executive functions (verbal and visual working memory, categorisation, processing speed), visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia) and language (comprehensive and expressive). On the Weiss Functional Impairment Scale, all areas (family, learning and school, self-concept, activities of daily living, risk activities) improved with statistical significance. We found a positive correlation between the number of sessions and the improvement observed in executive functions (visual working memory, processing speed), attention (sustained attention, divided attention) and visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia). We did not find statistical significance between the family structure and the number of sessions carried out. A high degree of perception of improvement and satisfaction was observed in the parents.

Conclusions

Telerehabilitation is a safe alternative tool which, although it does not replace face-to-face therapy, can achieve significant cognitive and functional improvements in children with neurodevelopmental disorders.

Study of Functional Impairment in Students of Elementary and Secondary Public Schools in Iran

OBJECTIVE

The current study aimed to investigate the frequency of impairment in different functional domains of life and the relationship between sex and age and functional impairment in school-based samples of Iranian children and adolescents.

METHOD

A sample of 270 children (ages 6-11) enrolled in two public elementary schools and a sample of 386 adolescents (ages 12-17) enrolled in four public secondary schools were selected by multistage sampling. The Persian version of the parent report form and self-report form of the Weiss Functional Impairment Rating Scale (WFIRS-P and WFIRS-S) were used for evaluating functional impairment in children and adolescents, respectively. Two-way analyses of variance (two-way ANOVAs) were conducted to explore the main effects and the interaction effect of sex and age on functional impairment.

RESULTS

11.9% of children and 29.5% of adolescents showed impairment in at least two functional domains of life. The most frequent impaired domain was life skills (22.6% of children and 30.3% of adolescents). While no significant sex and age effect was found during childhood, male adolescents showed more impairment in externalizing domains and female adolescents showed more internalizing difficulties. In addition, older adolescents showed more functional impairment relative to younger adolescents.

CONCLUSIONS

Detailed knowledge of the relationship between sex and age and functional impairment could be a starting point to target the major psychosocial elements of these challenges.

Health-related quality of life in Iranian adolescents: a psychometric evaluation of the self-report form of the PedsQL 4.0 and an investigation of gender and age differences

Background

Research on the psychometric properties of the Persian self-report form of the Pediatric Quality of Life Inventory Version 4.0 (PedsQL 4.0) in adolescents has several gaps (e.g., convergent validity) that limit its clinical application and therefore the cross-cultural impact of this measure. This study aimed at investigating the psychometric properties of the PedsQL 4.0 and the effects of gender and age on quality of life in Iranian adolescents.

Method

The PedsQL 4.0 was administered to 326 adolescents (12–17 years). A subsample of 115 adolescents completed the scale two weeks after the first assessment. Confirmatory Factor Analysis (CFA), correlation of the PedsQL 4.0 with the Weiss Functional Impairment Rating Scale-Self-report (WFIRS-S), and Item Response Theory (IRT) analysis were conducted to examine validity. Cronbach’s alpha, McDonald’s Omega, and Intra class correlation (ICC) were calculated as well to examine reliability. Gender and age effects were also evaluated.

Results

Internal consistency and test–retest reliability of the total PedsQL 4.0 scale was .92 and .87, respectively. The PedsQL 4.0 scores showed negative moderate to strong correlations with the WFIRS-S total scale. The four-factor model of the PedsQL 4.0 was not fully supported by the CFA—the root mean square error of approximation and the comparative fit index showed a mediocre and poor fit, respectively. IRT analysis indicated that all items of the PedsQL 4.0 fit with the scale and most of them showed good discrimination. The items and total scale provided more information in the lower levels of the latent trait. Males showed significantly higher scores than females in physical and emotional functioning, psychosocial health, and total scale. Adolescents with lower ages showed better quality of life than those with higher ages in all scores of the PedsQL 4.0.

Conclusion

The PedsQL 4.0 showed good psychometric properties with regard to internal consistency, test–retest reliability, and convergent validity in Iranian adolescents, which supports its use in clinical settings among Persian-speaking adolescents. However, factor structure according to our CFA indicates that future work should address how to improve fit. In addition, studies that include PedsQL 4.0 should consider gender and age effects were reported.

Psychometric properties of the Weiss Functional Impairment Rating Scale parent and self-reports in a Norwegian clinical sample of adolescents treated for ADHD

OBJECTIVE

To analyze the psychometric properties of the Norwegian version of the Weiss Functional Impairment Rating Scale parent and self-reports (WFIRS-P and WFIRS-S) in adolescents with ADHD.

METHODS

102 clinically referred patients, of which 86% were enrolled in an ongoing RCT program (Clinical trials NCT02937142), were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders version IV (DSM-IV). The conceptual framework of the WFIRS-P and the WFIRS-S was evaluated using confirmatory factor analysis (CFA), reliability was estimated using Cronbach's alpha, convergent and divergent validity was assessed using correlations with the Children's Global Assessment Scale (C-GAS) and the ADHD Rating Scale-IV (ADHD-RS-IV).

RESULTS

CFA supported the original factor structure of the questionnaires, both a first-order and a second-order model revealed acceptable model fit. Internal consistency was satisfactory across domains. The parent-adolescent agreement was moderate. The correlations between the C-GAS and the total scores of the WFIRS-P and WFIRS-S were low to moderate (r = -0.29 to -0.38). The ADHD-RS-IV correlated moderately (r = 0.49) with WFIRS-P, the correlation with WFIRS-S was weak (r = 0.28) supporting divergent validity. In multiple regression analyses, the ADHD-RS total score was the strongest predictor of the total score in both the WFIRS questionnaires, with internalizing disorder showing an additional small contribution. Age, gender and full-scale IQ gave no additional contribution in explaining the variance.

CONCLUSIONS

The findings support the use of the Norwegian version of the WFIRS-S and the WFIRS-P in the evaluation of functional impairment in adolescents with ADHD.

Functional impairment outcomes in clinical trials of different ADHD medications: post hoc responder analyses and baseline subgroup analyses

Several recent phase 3 clinical trials of attention-deficit/hyperactivity disorder (ADHD) medications have used the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P). Here, we assess WFIRS-P response in individual patients in two pivotal trials of lisdexamfetamine dimesylate (LDX) and guanfacine extended release (GXR). We also analysed pooled WFIRS-P data from seven phase 3 studies of ADHD medications to shed light on factors associated with baseline functional impairment. The proportion of patients with a change in WFIRS-P score that exceeded the minimal important difference (MID) criteria for response was greater for LDX than placebo in the Family, Learning and School, and Risky Activities domains, and was greater for GXR than placebo in the Social Activities, Learning and School, and Family domains. Responders had significantly worse baseline scores in all WFIRS-P domains (all p < 0.001) than non-responders. In the pooled analyses, baseline WFIRS-P scores in all domains were significantly worse in participants with oppositional defiant disorder (ODD) than in those without ODD. Having combined type or hyperactive-impulsive type ADHD, being enrolled into a study in Europe, being male and being younger also had modest negative effects on baseline WFIRS-P scores. The present analysis of WFIRS-P response shows that previously reported group-level improvements in WFIRS-P functional impairment score translated into clinically relevant improvements in many individual participants. Functional impairment is a diverse and subjective construct that is influenced by multiple factors. Optimal management of individuals with ADHD should involve monitoring improvements in functioning and quality of life, as well as symptomatic improvement.

The Functional Impact of Sleep Disorders in Children With ADHD

Objective: Children with ADHD display higher rates of sleep problems, and both sleep disorders and ADHD have been shown to affect functioning in childhood. The current study examines the frequency and relationship between sleep problems and ADHD, and their impact on quality of life (QoL) and functional impairment. Method: Parents of 192 children with ADHD (M = 10.23 years) completed measures regarding their child's ADHD symptoms (Swanson, Nolan and Pelham [SNAP]), sleep disorders (Pediatric Sleep Questionnaire [PSQ]), QoL (Child Health Illness Profile [CHIP-PE]), and functioning (Weiss Functional Impairment Rating Scale-Parent Report [WFIRS-P]). Results: Common sleep complaints in participants were insomnia, excessive daytime sleepiness (EDS), and variability in sleep schedule. Regression analysis indicated that sleep problems and ADHD symptoms independently predicted lower levels of QoL (ΔR² = .12, p < .001) and social functioning (ΔR² = .12, p < .001). Conclusion: The results suggest that ADHD may coexist with somnolence and that both conditions have a significant impact on a child's functioning and QoL.

Correlations Between Clinical Trial Outcomes Based on Symptoms, Functional Impairments, and Quality of Life in Children and Adolescents With ADHD

OBJECTIVE

To assess relationships between treatment-associated changes in measures of ADHD symptoms, functional impairments, and health-related quality of life in children and adolescents with ADHD.

METHOD

Pearson correlation coefficients were calculated post hoc for changes from baseline to endpoint in outcomes of one randomized, placebo- and active-controlled trial of lisdexamfetamine (osmotic-release methylphenidate reference) and one of guanfacine extended-release (atomoxetine reference).

RESULTS

Changes in ADHD Rating Scale IV (ADHD-RS-IV) total score generally correlated moderately with changes in Child Health and Illness Profile-Child Edition: Parent Report Form (CHIP-CE:PRF) Achievement and Risk Avoidance ( r ≈ .4), but weakly with Resilience, Satisfaction, and Comfort ( r ≈ .2); and moderately with Weiss Functional Impairment Rating Scale-Parent (WFIRS-P) total score ( r ≈ .5).

CHIP-CE

PRF Achievement and Risk Avoidance correlated moderately to strongly with WFIRS-P total score ( r ≈ .6).

CONCLUSION

The ADHD-RS-IV, CHIP-CE:PRF, and WFIRS-P capture distinct but interconnected aspects of treatment response in individuals with ADHD.

Psychometric Properties of the Persian Version of the Weiss Functional Impairment Rating Scale-Self-Report Form in Iranian Adolescents

OBJECTIVE

The Weiss Functional Impairment Rating Scale-Self-Report Form (WFIRS-S) was developed as a measure of functional impairment in adolescents and adults with ADHD. This study reports the psychometric properties of the Persian version of the WFIRS-S in a sample of normal Iranian adolescents.

METHOD

Internal consistency and factor structure of the WFIRS-S were tested on a sample of 386 students (Grades 7-12). The test-retest reliability and the convergent validity of the WFIRS-S were evaluated by using two different subsamples including 50 and 100 students, respectively.

RESULTS

The Cronbach's alpha values were between .72 and .94 for the WFIRS-S subdomains and total scale. The test-retest reliability was .80 for the total scale. The WFIRS-S subdomains had moderate to high significant correlations with the Pediatric Quality of Life total scale.

CONCLUSION

The Persian version of the WFIRS-S has acceptable psychometric properties and could be used as a functional impairment assessment for adolescents.

Is it possible to determine the level of functional impairment that distinguishes the patients with ADHD from those without ADHD?

INTRODUCTION

Functional impairment in attention deficit hyperactivity disorder (ADHD) can occur in many areas such as in family, social activities, and problems related to school and may also persist during adulthood. The Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P) is designed to measure the functional impairment related to ADHD symptoms. The aim of this study was to determine the level of functional impairment that distinguishes the patients with ADHD who were diagnosed through semi-structured interviews from those without ADHD.

METHOD

This study consists of ADHD patients who were diagnosed through semi-structured interview aged 5-18 years (n = 250) and same age gender-matched healthy controls (n = 250). A receiver operating characteristic (ROC) curve was constructed by calculating the sensitivity and specificity of the scale cut-off values.

RESULTS

An area under the curve (AUC) of 0.974 (95% CI 0.956-0.986) was found in this study. For WFIRS-P subdomains, AUC curves, which range from 0.76 to 0.95, were also having strong power for differentiation between groups. The optimal cut-off value for WFIRS-P using Youden's J Index is 0.32. There is no significant gender and age group differences in AUC for either the total or subdomain scores.

CONCLUSION

Our findings provide that Turkish version of WFIRS-P could be a reliable way of distinguishing the level of functional impairment in ADHD from controls.

Descriptive and psychometric properties of the Persian version of the Weiss functional impairment rating scale: parent report form in Iranian children

Background

This study evaluates the descriptive and psychometric properties of the Persian version of the Weiss Functional Impairment Rating Scale-Parent Report Form (WFIRS-P) in a normal sample of Iranian children.

Method

Parents of 282 students (grades 1–6) completed the WFIRS-P. Means and standard deviations were computed for the total scale, each domain, and each item of the WFIRS-P. Internal consistency, interdomain correlations, and test-retest reliability were used to assess the reliability of the scale.

Results

Among the WFIRS-P domains, life skills had the highest rated impairment (M = 0.50, SD = 0.37) and risky activities had the lowest. Internal consistency (α = .88) and test-retest reliability (r = 0.77) were strong for the WFIRS-P total scale. The correlation between the WFIRS-P domains and the total scale ranged from 0.52 to 0.81.

Conclusions

Results suggest that the Persian version of the WFIRS-P is a useful and psychometrically reliable measure for assessing functional skills in children.

Conceptual review of measuring functional impairment: findings from the Weiss Functional Impairment Rating Scale

Objective

This is a narrative review of validation and outcome studies using the Weiss Functional Impairment Rating Scale (WFIRS). The objective of the review is to establish a framework for understanding functional impairment and create a definition for functional response and remission.

Methods

We conducted a literature search via MEDLINE, EBSCO and Google Scholar with no date restrictions and reviewed bibliographies of selected publications. Publications found in languages other than English were translated and clarification obtained from the author(s) if needed. Inclusion criteria were any manuscript that was either a WFIRS psychometric validation study or a clinical trial using the WFIRS as an outcome. There were no exclusion criteria.

Results

The WFIRS has been validated in multiple cultures, and in clinical, research and control populations. The WFIRS has robust psychometric properties across ages, psychiatric status and informants. Outcome studies show variable improvement, with different response patterns between domains and among different interventions.

Conclusion

Symptom improvement and remission needs to be complemented with evaluation of functional improvement and remission to obtain a full picture of clinical status over the course of treatment.

Psychometric properties of a modified version of the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) in a clinical sample of children with aggressive behavior

PURPOSE

To evaluate the psychometric properties of a German modification of the Weiss Functional Impairment Rating Scale-Parent Report for children with aggressive and oppositional behavior problems (WFIRS-P for ODD/CD).

METHODS

Data were collected from a clinical sample of children (6-12 years; 96% boys) with oppositional defiant disorder (ODD) and conduct disorder (CD) (N = 219). The WFIRS-P conceptual framework was evaluated using confirmatory factor analyses (CFA). Reliability was estimated using internal consistency (Cronbach's alpha) and omega statistics. Validity was assessed through correlations between WFIRS-P for ODD/CD domain scores and parent-rated scales on symptoms of ODD, CD, attention-deficit/hyperactivity disorder (ADHD), a broad range of other behavioral and emotional problems, and scales on health-related quality of life and family burden.

RESULTS

CFA of the WFIRS-P for ODD/CD revealed that a bifactor model, with a general factor accounting for common variance (ω_H = 0.23-0.48) and independent specific group factors accounting for additional variance in item scores (ω_S = 0.37-0.60), best fits the data. Thus, CFA confirmed the theoretical assumption of a general construct of impairment (total scale) and additional specific impairments (subscales, e.g., family, social activities). Cronbach's alpha coefficient exceeded 0.70 for all subscales. Omega statistics showed that both the general construct and specific factors accounted for item variance. As expected, correlations with symptoms scales for ODD/CD and ADHD were low to moderate.

CONCLUSIONS

The use of the parent-rated WFIRS for ODD/CD in identifying ODD- and CD-related impairment in children is psychometrically supported. The scale can be employed to assess functional impairment in children with aggressive behavior problems.

Relationship Between Symptomatic and Functional Improvement and Remission in a Treatment Response to Stimulant Trial

OBJECTIVE

To evaluate the relationship between symptom and functional improvement and remission in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) enrolled in an 11-week open-label dose-optimization phase of an methylphenidate extended release (MPH-MLR) pivotal study.

METHODS

Assessments included the Weiss Functional Impairment Rating Scale-Parent (WFIRS-P) and ADHD Rating Scale, Fourth Edition (ADHD-RS-IV). Definitions included the following: symptom improvement (≥30% decrease in ADHD-RS-IV total score); symptom remission (ADHD-RS-IV total score ≤18); functional improvement (decrease in WFIRS-P total score ≥0.25 [minimally important difference]); and functional remission (WFIRS-P total score ≤0.65).

RESULTS

Two hundred children completed the open-label phase. At initial assessment, functional impairment was evident across all WFIRS-P domains and similar between children and adolescents. Those who were treatment naive had more functional impairment (WFIRS-P total: 0.82 vs. 0.70, p = 0.02). Significant improvements in all WFIRS-P domains were noted at open-label end (p < 0.001), with the largest improvement in Learning. At open-label end, 94% of children and adolescents demonstrated symptom improvement, of which 57% also showed functional improvement, and 75% of children and adolescents showed symptom remission, of which 81% also showed functional remission.

CONCLUSIONS

Children and adolescents treated with MPH-MLR showed moderate-to-large improvement in functioning during 3 months of treatment, both overall and in specific domains. However, a significant number of those who would be considered symptomatic responders failed to show improvement in functioning or continue to have significant functional impairment. Treatment with MPH-MLR showed that both symptomatic and functional remission are achievable goals. Identification of children and adolescents who have been successfully treated for their symptoms, but continue to suffer functional impairment, will allow us to offer additional targeted treatment interventions over and above medication to address residual difficulties.

Systematic review of quality of life and functional outcomes in randomized placebo-controlled studies of medications for attention-deficit/hyperactivity disorder

Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) experience functional impairment and poor health-related quality of life (HRQoL) in addition to symptoms of inattention/hyperactivity-impulsivity. To synthesize qualitatively the published evidence from randomized, double-blind, placebo-controlled trials of the effectiveness of pharmacotherapy on functional impairment or HRQoL in patients with ADHD, a systematic PubMed searching and screening strategy was designed to identify journal articles meeting pre-specified criteria. Post hoc analyses and meta-analyses were excluded. HRQoL outcomes, functional outcomes and the principal ADHD symptom-based outcome were extracted from included studies. An effect size of 0.5 versus placebo was used as a threshold for potential clinical relevance (unreported effect sizes were calculated when possible). Of 291 records screened, 35 articles describing 34 studies were included. HRQoL/functioning was usually self-rated in adults and proxy-rated in children/adolescents. Baseline data indicated substantial HRQoL deficits in children/adolescents. Placebo-adjusted effects of medication on ADHD symptoms, HRQoL and functioning, respectively, were statistically or nominally significant in 18/18, 10/12 and 7/9 studies in children/adolescents and 14/16, 9/11 and 9/10 studies in adults. Effect sizes were ≥0.5 versus placebo for symptoms, HRQoL and functioning, respectively, in 14/16, 7/9 and 4/8 studies in children/adolescents; and 6/12, 1/6 and 1/8 studies in adults. Effect sizes were typically larger for stimulants than for non-stimulants, for symptoms than for HRQoL/functioning, and for children/adolescents than for adults. The efficacy of ADHD medication extends beyond symptom control and may help reduce the related but distinct functional impairments and HRQoL deficits in patients with ADHD.

The Weiss Functional Impairment Rating Scale-Parent Form for assessing ADHD: evaluating diagnostic accuracy and determining optimal thresholds using ROC analysis

Purpose

The Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P) is a 50-item scale that assesses functional impairment on six clinically relevant domains typically affected in attention-deficit/hyperactivity disorder (ADHD). As functional impairment is central to ADHD, the WFIRS-P offers potential as a tool for assessing functional impairment in ADHD. These analyses were designed to examine the overall performance of WFIRS-P in differentiating ADHD and non-ADHD cases using receiver operating characteristics (ROC) analysis. This is the first attempt to empirically determine the level of functional impairment that differentiates ADHD children from normal controls.

Methods

This observational study comprised 5–19-year-olds with physician-diagnosed ADHD (n = 476) and non-ADHD controls (n = 202). ROC analysis evaluated the ability of WFIRS-P to discriminate between ADHD and non-ADHD, and identified a WFIRS-P cut-off score that optimises correct classification. Data were analysed for the complete sample, for males versus females and for participants in two age groups (5–12 versus 13–19 years).

Results

Area under the curve (AUC) was 0.91 (95% confidence interval 0.88–0.93) for the overall WFIRS-P score, suggesting highly accurate classification of ADHD distinct from non-ADHD. Sensitivity (0.83) and specificity (0.85) were maximal for a mean overall WFIRS-P score of 0.65, suggesting that this is an appropriate threshold for differentiation. DeLong’s test found no significant differences in AUCs for males versus females or 5–12 versus 13–19 years, suggesting that WFIRS-P is an accurate classifier of ADHD across gender and age.

Conclusions

When assessing function, WFIRS-P appears to provide a simple and effective basis for differentiating between individuals with/without ADHD in terms of functional impairment.

Classification

Disease-specific applications of QOL research.

Preschool hyperactivity specifically elevates long-term mental health risks more strongly in males than females: a prospective longitudinal study through to young adulthood

Evidence of continuities between preschool hyperactivity and adult mental health problems highlights the potential value of targeting early identification and intervention strategies. However, specific risk factors are currently unclear. This large-scale prospective longitudinal study aimed to identify which hyperactive preschoolers are at the greatest long-term risk of poor mental health. One hundred and seventy children (89 females) rated as hyperactive by their parents, and 88 non-hyperactive controls (48 females) were identified from a community sample of 4215 3-year-olds. Baseline data relating to behavioral/emotional problems and background characteristics were collected. Follow-up mental health and functional impairment outcomes were collected between 14 and 25 years of age. At age 3 years, males and females in the hyperactive group had similarly raised levels of hyperactivity and other behavior problems. In adolescence/young adulthood, these individuals showed elevated symptoms of ADHD, conduct disorder, mood disorder, anxiety and autism, as well as functional impairment. Preschool hyperactivity was strongly predictive of poor adolescent/adult outcomes for males across domains with effects being specifically driven by hyperactivity. For females, the effects of preschool hyperactivity were smaller and dropped to non-significant levels when other preschool problems were taken into account. Environmental risk factors also differed between the sexes, although these may also have been mediated by genetic risk. In conclusion, these results demonstrate marked sex differences in preschool predictors of later adolescent/adult mental health problems. Future research should include a measure of preschool inattention as well as hyperactivity. The findings highlight the potential value of tailored approaches to early identification strategies.

Does Guanfacine Extended Release Impact Functional Impairment in Children with Attention-Deficit/Hyperactivity Disorder? Results from a Randomized Controlled Trial

BACKGROUND

In clinical trials of medications to treat attention-deficit/hyperactivity disorder (ADHD) in children, effects on functional impairment have been less well-studied than changes in ADHD symptoms.

OBJECTIVE

Data regarding functional impairment were analyzed from a multicenter, double-blind, placebo-controlled study of guanfacine extended release (GXR) in children with ADHD, using the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P). The correspondence of changes in WFIRS-P scores with symptomatic and global response to GXR treatment was also examined, with treatment response defined by scores on both the ADHD Rating Scale IV (ADHD-RS-IV) and the Clinical Global Impressions-Improvement Scale (CGI-I).

METHODS

In this 8-week, double-blind, placebo-controlled, dose optimization study at 47 sites across the USA and Canada, children aged 6-12 years with a diagnosis of ADHD [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria, and an ADHD-RS-IV score ≥28 and CGI-Severity of Illness Scale score ≥4 at baseline], were randomized 1:1:1 into three groups: GXR AM [GXR (1-4 mg/day) in the morning, placebo in the evening], GXR PM [placebo in the morning, GXR (1-4 mg/day) in the evening], or twice-daily placebo. Parents rated their children on the WFIRS-P at screening, baseline, the end of dose optimization, and at the final on-treatment assessment.

RESULTS

The efficacy population was composed of 333 subjects (GXR AM: n = 107; GXR PM: n = 114; placebo: n = 112). At the final on-treatment assessment, there were significant improvements from baseline in the placebo-adjusted difference in least-squares (LS) mean (95 % confidence interval) WFIRS-P Total scores for both GXR treatment groups combined [GXR all-active: -0.16 (-0.25, -0.07), effect size (ES) = 0.448, P <0.001] and separately [GXR AM: -0.15 (-0.26, -0.05), ES = 0.417, P = 0.004; GXR PM: -0.18 (-0.28, -0.07), ES = 0.478, P = 0.001]. Significant improvements in WFIRS-P domain scores for Family, Learning and School (including Academic Performance and Behavior in School), Social, and Risky Behavior were found for both GXR cohorts compared with placebo. However, the Life Skills and Self-Concept domain scores of the WFIRS-P did not improve with GXR treatment. Post hoc stratification by responder status revealed that significant (P <0.001) improvements in WFIRS-P Total and all domain scores were associated with symptomatic treatment response in the GXR all-active group.

CONCLUSIONS

GXR treatment in children with ADHD was associated with reductions in WFIRS-P functional impairment scores compared with placebo, regardless of time of GXR administration. Changes in WFIRS-P scores were congruent with clinical response, as determined by both ADHD symptom reduction and CGI-I scores. CLINICALTRIALS.

GOV IDENTIFIER

NCT00997984.