Daniel A. Waschbusch

A Practical Measure of Impairment: Psychometric Properties of the Impairment Rating Scale in Samples of Children With Attention Deficit Hyperactivity Disorder and Two School-Based Samples

Assessing impairment is an explicit component of current psychiatric diagnostic systems. A brief parent and teacher rating scale for assessing impairment was developed and studied using attention deficit hyperactivity disorder (ADHD) as an exemplar disorder. The psychometric properties of the Impairment Rating Scale (IRS) were measured in 4 samples. Two included ADHD and matched comparison children and the other 2 a school sample. Overall, IRS ratings exhibited very good temporal stability. They correlated with other impairment ratings and behavioral measures and displayed evidence of convergent and discriminant validity. The IRS was highly effective in discriminating between children with and without ADHD. Evidence that the parent and teacher IRS accounted for unique variance beyond ratings of ADHD symptoms is also presented. The scale is brief, practical, and in the public domain. The results of the studies and implications for the assessment of impairment are discussed.

The Academic Experience of Male High School Students with ADHD.

This study compared the high school academic experience of adolescents with and without childhood ADHD using data from the Pittsburgh ADHD Longitudinal Study (PALS). Participants were 326 males with childhood ADHD and 213 demographically similar males without ADHD who were recruited at the start of the follow-up study. Data were collected yearly from parents, teachers and schools. The current study used assessment points at which the participants were currently in or had recently completed grades 9, 10, 11, and 12. Results indicated that adolescents with ADHD experienced significant academic impairment in high school relative to comparison adolescents, including lower overall and main academic subject grade point averages (GPA), lower levels of class placement (e.g. remedial vs. honors), and higher rates of course failure. In addition, teacher reports indicated that adolescents with ADHD completed and turned in a significantly lower percentage of assignments and were significantly less likely to be working up to their potential. Adolescents with ADHD were also significantly more likely to be absent or tardy during the academic year, and they were over eight times more likely than adolescents without ADHD to drop out of high school. These findings demonstrate that children with ADHD continue to experience severe academic impairment into high school.

Reactive aggression in boys with disruptive behavior disorders: behavior, physiology, and affect.

This study examined responses to peer provocation in boys ages 9–13 years who met symptomatic criteria for ADHD-only, ODD/CD-only, comorbid ADHD/ODD/CD, or no diagnosis. Boys participated in a reaction-time game that included standardized verbal and behavioral provocation. Their behavioral, physiological, and affective responses to this task were measured. Results showed that groups did not differ following high levels of provocation because all boys behaved aggressively. However, following low provocation boys with comorbid ADHD/ODD/CD had higher levels of behavioral aggression, had greater heart rate acceleration, and were rated as angrier than all other boys. In addition, boys with comorbid ADHD/ODD/CD held a grudge longer than other children. Results suggest that boys with comorbid ADHD/ODD/CD are especially reactive to provocation from their peers.

A review of the validity of laboratory cognitive tasks used to assess symptoms of ADHD.

Reviewed the validity of frequently used laboratory assessment measures of ADHD symptoms using research published since 1991. Emphasized examining the validity of the tasks as they are commonly used by clinicians and researchers. Tasks evaluated included the Continuous Performance Test (CPT) and the Gordon Diagnostic System (GDS), the Childrens Checking Task (CCT), Delay of Gratification Tasks, the Choice-Delay Task, (C-DT), and the Stop Signal Task (SST). Results showed that the CPT, C-DT, and the SST had the most support, yet further efforts to evaluate the validity of these measures are needed before they can be used for more than experimental purposes.

The Efficacy, Safety, and Practicality of Treatments for Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD)

Studies examining interventions for adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) were reviewed to evaluate their efficacy. These efficacy findings were supplemented with a preliminary system for judging safety and practicality. Results suggest that the stimulant drug methylphenidate (MPH) is safe and well-established empirically, but has some problems with inconvenience and noncompliance. Preliminary research supports the efficacy, safety, and practicality of some psychotherapeutic interventions, including behavioral classroom interventions, note-taking training, and family therapy. Treatment with tricyclic antidepressants was judged to have minimal empirical support and debatable safety. Very little is known about long-term effectiveness of treatments, long-term compliance, or multimodal treatments for adolescents such as stimulants plus behavior therapy.

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).

Developing a Measure of Sluggish Cognitive Tempo for Children: Content Validity, Factor Structure, and Reliability

Sluggish cognitive tempo (SCT) is a construct that some researchers believe may be extremely useful in understanding the inattentive subtype of attention-deficit/hyperactivity disorder, and may even help define a completely new disorder. However, the construct of SCT is as yet inadequately operationally or theoretically defined. The authors took the first steps toward developing an empirically supported measure of SCT in children. In Study 1, potential items to measure SCT were identified from a literature review, content validity of the items was evaluated by a group of experts, and a preliminary set of SCT items were selected. In Study 2, ratings completed by parents and teachers of 335 children (ages 4-13) were used to further develop and evaluate the SCT items by computing factor analyses, item-level analyses, reliability analyses, and preliminary validity analyses. The final SCT scale (14 items) produced a total scale score and 3 subscale scores: Slow, Sleepy, and Daydreamer. These scales were constructed with good content validity and were found to have strong reliability. Future directions include replication, extension into a clinical population, and further examination of validity.

Effects of Methylphenidate and Behavior Modification on the Social and Academic Behavior of Children With Disruptive Behavior Disorders: The Moderating Role of Callous/Unemotional Traits

This study examined whether response to behavior modification with and without methylphenidate differed for children with attention-deficit/hyperactivity disorder (ADHD) and conduct problems (CP) depending on the presence of callous/unemotional (CU) traits. Participants were 37 children ages 7 to 12, including 19 with ADHD/CP-only and 18 with ADHD/CP-CU, referred to a university-based summer treatment program. Results showed that ADHD/CP-CU children had worse behavior in the behavior-therapy-only (BT-only) condition, especially on measures of CP, noncompliance, and rule violations, but these differences largely disappeared when medication was added to BT. Children with ADHD/CP-CU were also less likely to be normalized by treatment than were children with ADHD/CP-only. These findings, though tentative, suggest that children with ADHD/CP-CU may not show a sufficient positive response to BT alone and that the combination of medication and BT may be especially important for them.

Academic task persistence of normally achieving ADHD and control boys: performance, self-evaluations, and attributions.

The authors examined academic task persistence, pretask expectancies, self-evaluations, and attributions of boys with attention-deficit/hyperactivity disorder (ADHD) as compared with control boys. Participants were 83 ADHD boys and 66 control boys, all normally achieving. Prior to the task, performance expectancies were assessed. After a success-failure manipulation with find-a-word puzzles, performance on subsequent trials, self-evaluations, and attributions were evaluated. Compared with controls, ADHD boys solved fewer test puzzles, quit working more often, and found fewer words on a generalization task. Consistent with these behavioral findings, research assistants rated ADHD boys as less effortful and less cooperative than control boys. Although ADHD boys did not differ significantly from controls in their posttask self-evaluations, they did differ significantly from controls in some aspects of their attributions. Attributional data indicated that ADHD boys endorsed luck as a reason for success more strongly and lack of effort as a reason for failure less strongly than controls.