Elizabeth M. Gnagy

Teacher Ratings of DSM-III-R Symptoms for the Disruptive Behavior Disorders

Ratings were collected on a rating scale comprised of the DSM-III-R diagnostic criteria for disruptive behavior disorders. Teacher ratings were obtained for 931 boys in regular classrooms in grades K through 8 from around North America. Means and standard deviations for attention-deficit hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), and conduct disorder (CD) scales are reported by age. Frequencies of DSM-III-R symptoms are reported by age, and suggested diagnostic cutoffs are discussed. A factor analysis revealed three factors: one reflecting ODD and several CD symptoms, one on which ADHD symptoms of inattention loaded, and one comprised of ADHD impulsivity/overactivity symptoms. Conditional probability analyses revealed that several hallmark symptoms of ADHD had very poor predictive power, whereas combinations of symptoms from the two ADHD factors had good predictive power. Combinations of ODD symptoms also had very high predictive power. The limited utility of teacher ratings in assessing symptoms of conduct disorder in this age range is discussed.

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.

A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder

There is currently controversy regarding the need for and the effectiveness of behavior modification for children with attention-deficit hyperactivity disorder (ADHD) despite years of study and multiple investigations reporting beneficial effects of the intervention. A meta-analysis was conducted by identifying relevant behavioral treatment studies in the literature. One-hundred seventy-four studies of behavioral treatment were identified from 114 individual papers that were appropriate for the meta-analysis. Effect sizes varied by study design but not generally by other study characteristics, such as the demographic variables of the participants in the studies. Overall unweighted effect sizes in between group studies (.83), pre-post studies (.70), within group studies (2.64), and single subject studies (3.78) indicated that behavioral treatments are highly effective. Based on these results, there is strong and consistent evidence that behavioral treatments are effective for treating ADHD.

Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program.

As part of the behavioral treatment in the Multimodal Treatment Study of Children with ADHD (MTA), children participated in an intensive summer treatment program (STP). This study examined the differences between 57 children in the combined treatment (Comb) group, who were medicated, and 60 children in the behavioral treatment (Beh) group, who were unmedicated throughout the STP. Comb children were significantly better than Beh on 5 measures: rule following, good sportsmanship, peer negative nominations, and STP teacher posttreatment ratings of inattention/overactivity. Groups did not differ on any of the other 30 measures, and responded similarly to the STP over time. Comparisons to normative data revealed that Comb children were more likely to fall within the normative range on 6 measures. The differences between these results and the main MTA results, in which Comb was always superior to Beh, are discussed in terms of the relative intensity of combined treatments. The implications for future studies of pharmacological and behavioral treatment for ADHD are discussed.

Childhood ADHD Predicts Risky Sexual Behavior in Young Adulthood

This study compared young adults (ages 18 to 26) with and without childhood attention deficit hyperactivity disorder (ADHD) on self-reported risky sexual behaviors. Participants were 175 men with childhood ADHD and 111 demographically similar men without ADHD in the Pittsburgh ADHD Longitudinal Study (PALS). Childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. Although childhood conduct problems did contribute significantly to risky sexual behaviors among participants with ADHD, there was also an independent contribution of ADHD, suggesting that the characteristic deficits of the disorder or other associated features may be useful childhood markers of later vulnerability.

Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD.

The effects of methylphenidate on the academic performance and classroom behavior of 45 adolescents with attention deficit hyperactivity disorder were studied. During a 6-week, placebo-controlled medication assessment in the context of a summer treatment program, participants received a double-blind, crossover trial of 3 doses of methylphenidate. Dependent measures included note-taking quality, quiz and worksheet scores, written language usage and productivity, teacher ratings, on-task and disruptive behavior, and homework completion. Group data showed positive effects of methylphenidate on academic measures; however, the greatest benefit came with the lowest dose. Although additional benefit did occur for some participants with higher doses, the largest increment of change usually occurred between the placebo and 10-mg dose. Many adolescents did not experience added benefit with increased dosages, and in some cases they experienced deterioration. Guidelines for assessment of medication effects are discussed.

Effects of Deviant Child Behavior on Parental Distress and Alcohol Consumption in Laboratory Interactions

Levels of adult distress and ad lib alcohol consumption following interactions with child confederates were investigated in parents of children with no diagnosable psychiatric disorders. Sixty parents (20 married couples and 20 single mothers) interacted with boys trained to enact behaviors characteristic of either normal children or “deviant” children with externalizing behavior disorders — attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD). Relative to the normal child role, interactions with deviant confederates were rated as significantly more unpleasant, resulted in feelings of role inadequacy, and produced significantly more anxiety, depression, and hostility. After the interactions, parents were given the opportunity to drink as much of their preferred alcoholic beverage as they desired while anticipating a second interaction with the same child. The participants consumed more alcohol following exposure to deviant as opposed to normal confederates.

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.

Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD

Stimulant medication and behavioral treatments are evidence-based for children with attention-deficit/hyperactivity disorder, but the combination of the 2 treatments has been understudied. In this investigation, methylphenidate (MPH) was crossed with 2 levels of behavior modification (BMOD) in a summer treatment program. Twenty-seven children with attention-deficit/hyperactivity disorder, aged 6-12, participated. Children received placebo and 3 doses of transdermal MPH (12.5 cm(2), 25.0 cm(2), and 37.5 cm(2)). BMOD was implemented on alternating weeks. Both treatments produced large and significant effects. Combined treatment was superior to either treatment alone. The effects of transdermal MPH were comparable to those found in this setting in previous studies with multiple stimulant medications and formulations. Consistent with other research, low doses of MPH--even lower than in previous studies--yielded enhanced effects in combination with behavior modification.

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.