Aaron M. Luebbe

Co-occurring mental health problems and peer functioning among youth with attention-deficit/hyperactivity disorder: a review and recommendations for future research.

It is well established that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) frequently experience co-occurring mental health problems in addition to difficulties in their peer relationships. Although substantial research has focused on the extent to which peer functioning contributes to subsequent co-occurring mental health problems, much less research has considered how co-occurring mental health problems affect peer functioning domains. Therefore, the purpose of this review is to examine the effect of co-occurring mental health problems on the peer functioning of youth with ADHD. The impact of co-occurring externalizing (i.e., oppositional defiant disorder, conduct disorder) and internalizing (i.e., anxiety, depression) symptoms are reviewed, with a focus on whether these co-occurring symptoms exacerbate, attenuate, or have no effect across peer domains of social skills/competence, peer status, and friendship among youth with ADHD. Drawing from a developmental psychopathology framework, this review then draws attention to relevant causal processes and developmental cascades (including social-cognitive, affective, and family and parenting factors) in offering promising avenues for future work.

Sluggish cognitive tempo is associated with academic functioning and internalizing symptoms in college students with and without attention‐deficit/hyperactivity disorder.

OBJECTIVES The purposes of the present studies were to (a) examine the factor structure of sluggish cognitive tempo (SCT) and attention-deficit/hyperactivity disorder (ADHD) in college students and (b) examine the associations between SCT and academic functioning and internalizing symptoms in college students with and without ADHD. METHOD In Study 1, a confirmatory factor analysis of the Barkley Adult ADHD Rating Scale-IV (BAARS-IV) was conducted in a sample of 768 college students (aged 17-34 years, 68% female). In Study 2, we examined the relation of SCT to academic functioning and internalizing symptoms in a sample of 72 college students rigorously diagnosed with ADHD (aged 17-35 years, 44% female). RESULTS Study 1 results supported the factor structure of the BAARS-IV, with the optimal model comprising 4 correlated but distinct factors: SCT, Inattention, Hyperactivity, and Impulsivity. After controlling for correlated demographic variables and ADHD symptoms, SCT was significantly related to academic impairment (including grade point average), anxiety, and depression. In Study 2, SCT again contributed unique variance to internalizing symptoms and academic impairment after controlling for correlated participant characteristics (i.e., sex, age, race, parent education level, family income, ADHD medication use, and mental health service utilization) and ADHD symptom severity. CONCLUSIONS These results fill an important gap in the literature by (a) confirming SCT to be distinct from ADHD in emerging adulthood, (b) demonstrating SCT to be strongly linked to college student adjustment, and (c) providing support for the hypothesis that SCT is associated with psychosocial functioning in both individuals with and without ADHD.

Does Emotion Dysregulation Mediate the Association Between Sluggish Cognitive Tempo and College Students' Social Impairment?

Objective: Studies demonstrate an association between sluggish cognitive tempo (SCT) and social impairment, although no studies have tested possible mechanisms of this association. This study aimed to (a) examine SCT in relation to college students’ social functioning; (b) test if SCT is significantly associated with emotion dysregulation beyond depressive, anxious, and ADHD symptoms; and (c) test if emotion dysregulation mediates the association between SCT symptoms and social impairment. Method: College students (N = 158) completed measures of psychopathology symptoms, emotion dysregulation, and social functioning. Results: Participants with elevated SCT (12%) had higher ADHD, depressive, and anxious symptoms in addition to poorer emotion regulation and social adjustment than participants without elevated SCT. Above and beyond other psychopathologies, SCT was significantly associated with social impairment but not general interpersonal functioning. SCT was also associated with emotion dysregulation, even after accounting for the expectedly strong association between depression and emotion dysregulation. Further analyses supported emotion dysregulation as a mediator of the association between SCT and social impairment. Conclusion: These findings are important for theoretical models of SCT and underscore the need for additional, longitudinal research.

Are Sluggish Cognitive Tempo and Daytime Sleepiness Distinct Constructs

Sluggish cognitive tempo (SCT) and daytime sleepiness are both common in individuals with attention-deficit/hyperactivity disorder (ADHD). There appears to be considerable overlap between the tired and lethargic aspects of SCT and behaviors frequently exhibited by individuals with daytime sleepiness. However, no studies have examined the degree to which these constructs overlap and whether or not they are empirically distinct. In Study 1, a confirmatory factor analysis with the SCT subscale of the Barkley Adult ADHD Rating Scale-IV (BAARS-IV) and the Epworth Sleepiness Scale (ESS) was conducted in a sample of 768 college students. Results demonstrated that SCT and daytime sleepiness exhibit considerable overlap but are empirically distinct. In Study 2, we examined the relation between SCT and daytime sleepiness and also the impact of comorbid SCT and sleepiness on the functioning of 58 college students rigorously diagnosed with ADHD. Regression analyses in both Study 1 and Study 2 showed that SCT predicts daytime sleepiness above and beyond symptoms of ADHD, anxiety, and depression. The 2 constructs were significantly related (r = .51), with the highest correlations occurring between the SCT tired and lethargic items with daytime sleepiness. College students with ADHD + SCT and daytime sleepiness were significantly more impaired than college students diagnosed with ADHD without SCT or daytime sleepiness. Together, these results fill an important gap in the literature by confirming SCT to be overlapping but empirically distinct from daytime sleepiness and demonstrating that SCT and daytime sleepiness are associated with functioning in college students with ADHD.

The Child Concentration Inventory (CCI): Initial validation of a child self-report measure of sluggish cognitive tempo.

Sluggish cognitive tempo (SCT) is characterized by excessive daydreaming, mental confusion, slowness, and low motivation. Several teacher- and parent-report measures of SCT have recently been developed but a child self-report measure of SCT does not yet exist despite clear links between SCT and internalizing psychopathology (for which self-report is often desired). This study examined the initial reliability and validity of the Child Concentration Inventory (CCI), a child self-report measure of SCT symptoms, in a school-based sample of 124 children (ages 8-13; 55% female). Children completed the CCI and measures of academic/social functioning, emotion regulation, and self-esteem. Teachers completed measures of psychopathology symptoms (including SCT) and academic/social functioning. Although exploratory structural equation modeling (ESEM) supported a 3-factor model of the CCI (consisting of slow, sleepy, and daydreamer scales closely resembling the factor structure of the parent-report version of this measure), bifactor modeling and omega reliability indices indicated that the CCI is best conceptualized as unidimensional. CCI scores were significantly correlated with teacher-rated SCT and were statistically distinct from teacher-rated ADHD and child-rated anxiety/depression. After controlling for sex, grade, and other psychopathology symptoms, the CCI total score was significantly associated with poorer child-reported academic/social functioning and self-worth in addition to increased loneliness and emotion dysregulation. Child ratings on the CCI were moderately to strongly correlated with poorer teacher-rated academic/social functioning but these associations were reduced to nonsignificance after controlling for demographics and other psychopathology symptoms. Findings provide preliminary support for the CCI, and future directions include replication with adolescents and clinical samples in order to further examine the CCIs factor structure, reliability, validity, and clinical utility.

Predicting Difficulties in Youth's Friendships: Are Anxiety Symptoms as Damaging as Depressive Symptoms?

Youths friendships serve important functions in development; however, internalizing symptoms may undermine these relationships. Two studies are presented that examine the association of depressive and anxiety symptoms with friendship adjustment. Study 1 tested concurrent effects and Study 2 tested prospective effects over 6 months. Like past studies, depressive symptoms predicted greater problems in friendships. However, anxiety symptoms generally did not and, in some cases, actually predicted positive friendship adjustment. The results suggest that the friendships of youth with depressive symptoms should be targeted for intervention, but that incorporating the friendship strengths of anxious youth in interventions could be helpful for reducing these youths anxiety. The results also caution researchers studying the interplay between friendships and internalizing symptoms against collapsing across assessments of depressive and anxiety symptoms.

Aggression Among Children with ADHD, Anxiety, or Co-occurring Symptoms: Competing Exacerbation and Attenuation Hypotheses

Competing hypotheses for explaining the role of anxiety in the relation between attention-deficit/hyperactivity disorder (ADHD) symptoms and childhood aggression were evaluated. Two studies tested whether anxiety exacerbated, attenuated, or had no effect on the relation between ADHD and aggression subtypes among psychiatrically hospitalized children. In Study 1 (N = 99), children who scored above clinical cut-off levels for anxiety only, ADHD only, and co-occurring ADHD and anxiety were compared on aggression subtypes (i.e., reactive, proactive, overt, and relational aggression). In Study 2, the moderating role of anxiety on the relation between ADHD and aggression subtypes was examined with a larger sample (N = 265) and with continuous variables. No support was found for either the attenuation or exacerbation hypothesis, and results remained consistent when separately examining hyperactivity/impulsivity and inattention symptoms of ADHD. Although ADHD symptoms were significantly associated with all aggression subtypes, this association did not remain when including symptoms of oppositional defiant disorder.

Aggression and the Risk for Suicidal Behaviors among Children

Two subtypes of aggression--reactive and proactive--were examined to see how they relate to suicidal behaviors among young children admitted for acute psychiatric inpatient care. The children and their parents completed self-report questionnaires/interviews. Regression analyses revealed that depressed girls who scored higher on reactive aggression reported more suicidal behaviors; whereas proactive aggression did not relate to suicidal behaviors for either boys or girls.

Hospitalized youth and child abuse: a systematic examination of psychiatric morbidity and clinical severity.

Many children and adolescents who require psychiatric hospitalization have been physically or sexually abused, yet the association between reported histories of abuse and the complexity and severity of mental illness among psychiatrically hospitalized youth is poorly described with regard to current inpatient psychiatric practice. We sought to determine the association between histories of abuse and psychiatric complexity and severity in psychiatrically hospitalized youth including comorbidity patterns, psychotropic medication use, reason for admission and length of hospitalization. A systematic chart review was performed on 1433 consecutive psychiatric hospitalizations of children and adolescents that occurred over a 10-month period. Children with a history of abuse were more likely to be diagnosed with multiple DSM-IV-TR disorders than non-traumatized children. A history of sexual abuse was associated with more medication use than in their non-traumatized peers and a higher likelihood of treatment with antipsychotic medications, both at admission and discharge. Physical and sexual abuse were independently associated with increased length of stays, with exposure to both physical and sexual abuse associated with a 2-day increase in duration of hospitalization compared to non-traumatized patients. The findings from this study draw attention to the adverse impact of abuse on psychiatric morbidity and complexity and suggest the need for trauma-informed treatment in psychiatric hospital settings.

Sluggish Cognitive Tempo in Adults: Psychometric Validation of the Adult Concentration Inventory.

As interest in sluggish cognitive tempo (SCT) increases, a primary limitation for the field is the lack of a unified set of symptoms for assessing SCT. No existing SCT measure includes all items identified in a recent meta-analysis as optimal for distinguishing between SCT and attention-deficit/hyperactivity disorder (ADHD) inattention. This study evaluates a new self-report measure for assessing SCT in adulthood, the Adult Concentration Inventory (ACI), which was developed in response to the meta-analytic findings for assessing SCT. Using a large, multiuniversity sample (N = 3,172), we evaluated the convergent and discriminant validity and reliability of the ACI. We also evaluated the ACI measure of SCT in relation to self-reported demographic characteristics, daily life executive functioning, socioemotional adjustment (i.e., anxiety/depression, loneliness, emotion dysregulation, self-esteem), and functional impairment. Exploratory confirmatory factor analyses resulted in 10 ACI items demonstrating strong convergent and discriminant validity from both anxiety/depressive and ADHD inattentive symptom dimensions. SCT was moderately to-strongly correlated with daily life EF deficits, poorer socioemotional adjustment, and greater global functional impairment. Moreover, SCT remained uniquely associated in structural regression analyses with most of these external criterion domains above and beyond ADHD. Finally, when internalizing symptoms were also covaried, SCT, but not ADHD inattention, remained significantly associated with poorer socioemotional adjustment. These findings support the use of the ACI in future studies examining SCT in adulthood and make a major contribution in moving the field toward a unified set of SCT items that can be used across studies.