Heidi Kipp

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.

Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children.

OBJECTIVE Little is known about the validity of the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children. Moreover, the results of the DSM-IV field trials raised concerns that inclusion of the new predominantly hyperactive-impulsive type of ADHD in DSM-IV might increase the likelihood of the diagnosis being given to active but unimpaired preschool and primary school children. METHOD The validity of DSM-IV criteria for each subtype of ADHD was evaluated in 126 children, aged 4 through 6 years, and 126 matched comparison children. Probands and controls were classified by using structured diagnostic interviews of the parent and a DSM-IV checklist completed by the teacher. RESULTS Children who met DSM-IV criteria for each subtype of ADHD according to parent and teacher reports differed consistently from controls on a wide range of measures of social and academic impairment, even when other types of psychopathology and other potential confounds were controlled. CONCLUSIONS When diagnosed by means of a structured diagnostic protocol, all three DSM-IV subtypes of ADHD are valid for 4- through 6-year-old children in the sense of identifying children with lower mean scores on measures of adaptive functioning that are independently associated with ADHD.

Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder.

Children with attention-deficit/hyperactivity disorder (ADHD) are at risk for adverse outcomes such as substance abuse and criminality, particularly if they develop conduct problems. Little is known about early predictors of the developmental course of conduct problems among children with ADHD, however. Parental psychopathology and parenting were assessed in 108 children who first met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ADHD at 4-7 years old. When demographic variables and baseline ADHD and conduct problems were controlled, maternal depression predicted conduct problems 2-8 years following the initial assessment, whereas positive parenting during the structured parent- child interaction task predicted fewer future conduct problems. These findings suggest that maternal depression is a risk factor, whereas early positive parenting is a protective factor, for the developmental course of conduct problems among children with ADHD.

Psychopathology and Substance Abuse in Parents of Young Children With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE To compare the prevalence of psychological disorders in parents of young children with and without attention-deficit/hyperactivity disorder (ADHD) and comorbid disruptive behavior disorders (DBD). METHOD Subjects included 98 three- to seven-year-old children with DSM-IV ADHD (68 with ADHD and comorbid oppositional defiant or conduct disorder [ADHD+ODD/CD]) and 116 non-ADHD comparison children recruited in 1995-96 during the first wave of a longitudinal study. Biological mothers were administered interviews to assess ADHD and DBD in their children and mood, anxiety, and substance use disorders in themselves. In addition, they were queried about symptoms of childhood ADHD and DBD, and antisocial personality disorder in themselves and their childrens biological fathers. RESULTS Child ADHD was associated with increased rates of maternal and paternal childhood ADHD relative to comparison children. Child ADHD+ODD/CD was associated with maternal mood disorders, anxiety disorders, and stimulant/cocaine dependence, and paternal childhood DBD. Mothers of children with ADHD+ODD/CD also reported increased drinking problems in their childrens fathers. CONCLUSIONS These findings indicate that many young children with ADHD, particularly those with comorbid ODD/CD, require comprehensive services to address both their ADHD and the mental health needs of their parents.

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.

The role of early childhood ADHD and subsequent CD in the initiation and escalation of adolescent cigarette, alcohol, and marijuana use.

Adolescents with attention deficit/hyperactivity disorder (ADHD) are at an increased risk for substance use but the pathways through which this risk emerges are insufficiently understood. Tobacco, alcohol, and marijuana outcomes were compared between adolescents diagnosed with ADHD in early childhood (N = 113) and demographically similar controls (N = 65). Participants were assessed from age 5 until age 18. A comprehensive history of adolescent substance use was compiled for each participant and growth in ADHD and conduct disorder (CD) were modeled as they related to substance use outcomes. Results indicated that when compared with controls, adolescents with ADHD were more likely to try cigarettes, initiate alcohol use at early ages, and smoke marijuana more frequently. Furthermore, adolescents with ADHD were 4 to 5 times more likely than controls to escalate to heavy cigarette and marijuana use after trying these substances once. Adolescents with ADHD who escalated to heavy use patterns were more likely to display early cigarette use and marked problems with family members, but displayed fewer peer problems. There was evidence of baseline effects (latent intercept, measured at age 5) for both ADHD and CD on substance use outcomes. Furthermore, growth in ADHD symptoms accounted for much of the growth in CD symptoms, and consequently, escalating CD symptoms in childhood (latent slope) were viewed as a mediator of the relationship between ADHD and cigarette and marijuana use. Maternal drinking in early childhood was the strongest predictor of early adolescent alcohol use. These findings are discussed with respect to the role of ADHD in the development of adolescent risk outcomes.

Implementation of a Comprehensive Schoolwide Behavioral Intervention: The ABC Program

The Academic and Behavioral Competencies (ABC) Program, a schoolwide program to reduce classroom disruption and encourage rule following, academic task completion, and homework completion, is described. The program was initially developed and implemented in an elementary school with a high-risk population. Data from teachers, parents, and children indicate high levels of satisfaction with the program. In addition, unobtrusive measures of program impact, reported as reductions in referrals to the principal’s office, suspensions, and increases in homework completion rates relative to the year prior to implementation of the program, suggest a preliminary positive impact of the program. A replication is reported for another school district, with teacher evaluations of satisfaction and effectiveness reported, supporting the flexibility and adaptability of the program. Although the present article does not constitute a systematic evaluation of the ABC Program, it presents preliminary data on the process of implementation and stakeholder satisfaction.

Risperidone Added to Parent Training and Stimulant Medication: Effects on Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Peer Aggression

OBJECTIVE In this study, we aimed to expand on our prior research into the relative efficacy of combining parent training, stimulant medication, and placebo (Basic therapy) versus parent training, stimulant, and risperidone (Augmented therapy) by examining treatment effects for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms and peer aggression, symptom-induced impairment, and informant discrepancy. METHOD Children (6-12 years of age; N = 168) with severe physical aggression, ADHD, and co-occurring ODD/CD received an open trial of parent training and stimulant medication for 3 weeks. Participants failing to show optimal clinical response were randomly assigned to Basic or Augmented therapy for an additional 6 weeks. RESULTS Compared with Basic therapy, children receiving Augmented therapy experienced greater reduction in parent-rated ODD severity (p = .002, Cohens d = 0.27) and peer aggression (p = .02, Cohens d = 0.32) but not ADHD or CD symptoms. Fewer children receiving Augmented (16%) than Basic (40%) therapy were rated by their parents as impaired by ODD symptoms at week 9/endpoint (p = .008). Teacher ratings indicated greater reduction in ADHD severity (p = .02, Cohens d = 0.61) with Augmented therapy, but not for ODD or CD symptoms or peer aggression. Although both interventions were associated with marked symptom reduction, a relatively large percentage of children were rated as impaired for at least 1 targeted disorder at week 9/endpoint by parents (Basic 47%; Augmented 27%) and teachers (Basic 48%; Augmented 38%). CONCLUSION Augmented therapy was superior to Basic therapy in reducing severity of ADHD and ODD symptoms, peer aggression, and symptom-induced impairment, but clinical improvement was generally context specific, and effect sizes ranged from small to moderate. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov/; NCT00796302.

Regionally specific alterations in membrane phospholipids in children with ADHD: An in vivo 31P spectroscopy study

This multi-voxel, phosphorus magnetic resonance spectroscopy ((31)P MRS) study examined the prefrontal cortex (PFC), basal ganglia (BG) and superior temporal (ST) region in 10 children with attention-deficit/hyperactivity disorder (ADHD) and 15 healthy controls. ADHD patients had lower PFC and BG phosphomonoester (PME) levels compared to healthy children. No differences were noted in the ST. These deficits in membrane phospholipid (MPL) precursor levels suggest reduced mass of cellular MPLs due to a possible underdevelopment of neuronal processes and synapses in ADHD.

Evidence of Developmental Alterations in Cortical and Subcortical Regions of Children With Attention-Deficit/Hyperactivity Disorder: A Multivoxel In Vivo Phosphorus 31 Spectroscopy Study

CONTEXT There is mounting evidence of neurodevelopmental alterations implicating the prefrontal cortex (PFC) and basal ganglia in children with attention-deficit/hyperactivity disorder (ADHD). The brain undergoes substantive structural and functional changes with a differential timing between brain regions during development from childhood to adolescence. In vivo phosphorus 31 magnetic resonance spectroscopy ((31)P MRS) is a noninvasive neuroimaging approach that is sensitive in assessing developmental changes of overproducing/pruning of synapses. OBJECTIVE To provide support for a developmental mechanism targeting a bottom-up dysfunction of the basal ganglia impairing the fine-tuning of prefrontal functions in ADHD. DESIGN Cross-sectional study. SETTING Pittsburgh, Pennsylvania, and the surrounding areas. PARTICIPANTS Thirty-one psychostimulant-naive children with ADHD (mean [SD] age, 8.1 [1.2] years; range, 6.1-10.0 years) and 36 healthy control subjects (mean [SD] age, 8.1 [1.3] years; range, 6.1-10.4 years). MAIN OUTCOME MEASURE Membrane phospholipid (MPL) precursor levels (ie, phosphomonoesters that are anabolic metabolites of MPL) were assessed in the PFC and basal ganglia as well as in 4 other brain regions using in vivo (31)P MRS. RESULTS Lower bilateral MPL precursor levels in the basal ganglia and higher MPL precursor levels in the inferior parietal region (primarily right side) were noted in the children with ADHD as compared with healthy control children. There was a group x age interaction in the PFC and inferior parietal region, with relatively older psychostimulant-naive children with ADHD showing significantly lower PFC and higher inferior parietal MPL precursor levels. No differences between groups were noted in the superior temporal, posterior white matter, or occipital regions. CONCLUSION Though based on cross-sectional data, these results are suggestive of possible progressive, nonlinear, and sequential alterations implicating a bottom-up developmental dysfunction in parts of the cortico-striato-thalamo-cortical network in ADHD.