Aparajita B. Kuriyan

Young Adult Educational and Vocational Outcomes of Children Diagnosed with ADHD

Decreased success at work and educational attainment by adulthood are of concern for children with ADHD given their widely documented academic difficulties; however there are few studies that have examined this empirically and even fewer that have studied predictors and individual variability of these outcomes. The current study compares young adults with and without a childhood diagnosis of ADHD on educational and occupational outcomes and the predictors of these outcomes. Participants were from the Pittsburgh ADHD Longitudinal Study (PALS), a prospective study with yearly data collection. Significant group differences were found for nearly all variables such that educational and occupational attainment was lower for adults with compared to adults without histories of childhood ADHD. Despite the mean difference, educational functioning was wide-ranging. High school academic achievement significantly predicted enrollment in post-high school education and academic and disciplinary problems mediated the relationship between childhood ADHD and post-high school education. Interestingly, ADHD diagnosis and disciplinary problems negatively predicted occupational status while enrollment in post-high school education was a positive predictor. Job loss was positively predicted by a higher rate of academic problems and diagnosis of ADHD. This study supports the need for interventions that target the child and adolescent predictors of later educational and occupational outcomes in addition to continuing treatment of ADHD in young adulthood targeting developmentally appropriate milestones, such as completing post-high school education and gaining and maintaining stable employment.

When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment

OBJECTIVE This study examined several questions about the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young adults using data from a childhood-diagnosed sample of 200 individuals with ADHD (age M = 20.20 years) and 121 demographically similar non-ADHD controls (total N = 321). METHOD We examined the use of self- versus informant ratings of current and childhood functioning and evaluated the diagnostic utility of adult-specific items versus items from the Diagnostic and Statistical Manual of Mental Disorders (DSM). RESULTS Results indicated that although a majority of young adults with a childhood diagnosis of ADHD continued to experience elevated ADHD symptoms (75%) and clinically significant impairment (60%), only 9.6%-19.7% of the childhood ADHD group continued to meet DSM-IV-TR (DSM, 4th ed., text rev.) criteria for ADHD in young adulthood. Parent report was more diagnostically sensitive than self-report. Young adults with ADHD tended to underreport current symptoms, while young adults without ADHD tended to overreport symptoms. There was no significant incremental benefit beyond parent report alone to combining self-report with parent report. Non-DSM-based, adult-specific symptoms of ADHD were significantly correlated with functional impairment and endorsed at slightly higher rates than the DSM-IV-TR symptoms. However, DSM-IV-TR items tended to be more predictive of diagnostic group membership than the non-DSM adult-specific items due to elevated control group item endorsement. CONCLUSIONS Implications for the assessment and treatment of ADHD in young adults are discussed (i.e., collecting informant reports, lowering the diagnostic threshold, emphasizing impairment, and cautiously interpreting retrospective reports).

Diagnosing ADHD in Adolescence

OBJECTIVE This study examines adolescent-specific practical problems associated with current practice parameters for diagnosing attention-deficit/hyperactivity disorder (ADHD) to inform recommendations for the diagnosis of ADHD in adolescents. Specifically, issues surrounding the use of self- versus informant ratings, diagnostic threshold, and retrospective reporting of childhood symptoms were addressed. METHOD Using data from the Pittsburgh ADHD Longitudinal Study (PALS), parent, teacher, and self-reports of symptoms and impairment were examined for 164 adolescents with a childhood diagnosis of ADHD (age M = 14.74 years) and 119 demographically similar non-ADHD controls (total N = 283). RESULTS Results indicated that 70% of the well-diagnosed childhood ADHD group continued to meet Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) diagnostic criteria for ADHD in adolescence; however, an additional 17% possessed clinically significant impairment in adolescence but did not qualify for a current ADHD diagnosis. The optimal source of information was combined reports from the parent and a core academic teacher. Adolescents with ADHD met criteria for very few symptoms of hyperactivity/impulsivity, suggesting a need to revisit the diagnostic threshold for these items. Additionally, emphasis on impairment, rather than symptom threshold, improved identification of adolescents with a gold-standard childhood diagnosis of ADHD and persistent ADHD symptoms. Parent retrospective reports of baseline functioning, but not adolescent self-reports, were significantly correlated with reports collected at baseline in childhood. CONCLUSIONS Recommendations are offered for diagnosing ADHD in adolescence based on these findings.

Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed.

Maternal ADHD, Parenting, and Psychopathology Among Mothers of Adolescents With ADHD

Objective: This study describes the parenting and psychopathology of mothers with ADHD of adolescents with ADHD (MCA), non-ADHD mothers of adolescents with ADHD (CA), and non-ADHD mothers of adolescents without ADHD (COMP). Method: Two sets of pairwise comparisons: (a) COMP versus CA and (b) CA versus MCA were conducted. We hypothesized that CA would experience greater distress in parenting and psychopathology compared with COMP and that MCA would experience even more impairment compared with CA. Results: Few differences emerged in comparisons of CA and COMP, with the exception of CA reporting greater parent–adolescent conflict and internalizing problems. In contrast, differences consistently emerged in comparisons of MCA and CA showing more difficulty for MCA in parenting and psychopathology. Conclusion: These findings underscore the need for treatments that address parental ADHD when adolescent ADHD is the intended target.

The Effect of Video Feedback on the Social Behavior of an Adolescent With ADHD

Objective: The social functioning of adolescents with ADHD is characteristically impaired, yet almost no interventions effectively address the peer relationships of these youth. This study evaluates the preliminary effects of a video-feedback intervention on the social behavior of a 16-year-old male with ADHD–combined type in the context of a summer treatment program for youth with ADHD. Method: The intervention was administered in a teen-run business meeting designed to mimic the context of group-based activities such as student government, service clubs, and group projects. During each video-feedback session, the adolescent viewed a 5-min clip of his behavior in the previous business meeting, rated the appropriateness of his own social behavior in each 30-s interval, and discussed behavior with a summer program counselor. Results: Results indicated that while the video-feedback intervention was in place, the adolescent displayed improvements in social behavior from baseline. Results also indicated that the adolescent exhibited relatively accurate self-perceptions during the intervention period. The authors present preliminary evidence for cross-contextual and cross-temporal generalization. Conclusion: The results of this study and future directions for intervention development are discussed in the context of the broader conversation about how to treat social impairment in adolescents with ADHD.

Concordance between parent and physician medication histories for children and adolescents with attention-deficit/hyperactivity disorder.

OBJECTIVE It is necessary for both clinicians and researchers who study attention-deficit/hyperactivity disorder (ADHD) to obtain a medication history for patients/participants for a variety of purposes. Because of the complexity of constructing medication histories using official records, parental report of medication for children with ADHD is the most commonly used source of information. However, the reliability and validity of parent reports of medication history have not been thoroughly studied. Previous studies have only examined the psychometrics of interview assessments of medication use for a maximum of a 12 month recall period. The current study compares parent report provided by a questionnaire and physician records for children and adolescents with ADHD. This is the first study to examine validity of retrospective recall for an extended medication history (prekindergarten-12th grade) using a questionnaire, and the first to examine validity of parental report of dosage. METHODS Participants with ADHD were part of the Pittsburgh ADHD Longitudinal Study. The current study utilized data from those in the ADHD group who had at least 1 year of data from the physicians records and corresponding records from the parent (n=178). RESULTS Percent agreement for medication use was >80%. Intraclass correlation coefficients for parent-provider agreement on total daily dosage of ADHD medications were in the good to excellent range. There were no significant predictors of agreement. CONCLUSIONS Our findings indicate that it is acceptable for clinics and research studies to obtain information about medication use for children with ADHD retrospectively solely based on parental report.

DSM-5 changes enhance parent identification of symptoms in adolescents with ADHD

This study evaluates the impact of the DSM-5 ADHD symptom wording changes on symptom endorsement among adolescents with ADHD. Parents of adolescents with systematically diagnosed DSM-IV-TR ADHD (N=78) completed counterbalanced DSM-IV-TR and DSM-5 ADHD symptom checklists in a single sitting. General linear models were conducted to evaluate whether the new DSM-5 symptom descriptors influenced the total number of ADHD symptoms and overall ADHD symptom severity endorsed by parents, how demographic factors were associated with noted changes in symptom endorsement when moving to the DSM-5, and which DSM ADHD items displayed notable changes in endorsement rates under the new wording. On average, parents identified 1.15 additional symptoms of ADHD in adolescents when moving from the DSM-IV-TR to the DSM-5. Increased symptom identification was not specific to age, sex, ethnicity, race, or socioeconomic status. Over half of the sample experienced increased symptom endorsement when changing texts (59.0%). Under the new DSM-5 wording, four symptoms had statistically significant endorsement increases (range: 11.2-16.7%): difficulty sustaining attention, easily distracted, difficulty organizing tasks and activities, and does not seem to listen.

Early Intervention for Children With Behavior Problems in Summer Settings Results From a Pilot Evaluation in Head Start Preschools

The objective of this study was to evaluate two early intervention packages to promote successful transitions to kindergarten for preschoolers with behavior problems recruited from Head Start preschools. Fifty children (Mage = 61 months; 76% male; 98% minority) referred by teachers due to early externalizing behavior problems were randomly assigned to one of the two groups. Group 1 (high intensity; HI) received a 4-week intensive summer program before the start of kindergarten, weekly parent workshops, and monthly school consultation and parent workshops throughout kindergarten. Group 2 (low intensity; LI) received only parent workshops. Program feasibility, child improvement, and parental satisfaction data were collected along with parent and teacher reports and measures of school readiness. Children in the HI group demonstrated fewer problem behaviors and less student–teacher conflict as reported by teachers. Early intensive summer interventions prior to kindergarten were found to be a promising avenue to promote successful transitions to school for children from Head Start preschools with behavior problems.