Richard E. A. Loren

Parent Agreement on Ratings of Children's Attention Deficit/Hyperactivity Disorder and Broadband Externalizing Behaviors.

Mothers and fathers often disagree in their ratings of child behavior, as evidenced clinically and as supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother—father agreement on Diagnostic and Statistical Manual—based symptom-specific ratings of Attention-Deficit/Hyperactivity Disorder (ADHD), as compared to agreement on broadband ratings of externalizing behavior. Based on mother and father ratings of 324 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA), parental agreement was computed and patterns of disagreement examined. Mother—father ratings were significantly correlated; however, a clear pattern of higher ratings by mothers was present. Agreement on attention-deficit/hyperactivity disorder symptom-specific ratings was significantly lower than that for broadband externalizing behaviors and oppositional defiant disorder symptoms. Of several moderator variables tested, parental stress was the only one that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process.Mothers and fathers often disagree in their ratings of child behavior as evidenced clinically and supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother-father agreement on DSM-based, ADHD symptom-specific ratings, as compared to agreement on broadband ratings of externalizing behavior. Using mother and father ratings from 324 children who participated in the Multimodal Treatment Study of Children with ADHD, parental agreement was computed and patterns of disagreement were examined. Mother-father ratings were significantly correlated. However, a clear pattern of higher ratings by mothers compared to fathers was present across ratings. Agreement on ADHD symptom-specific ratings was significantly lower than agreement for broadband externalizing behaviors or ODD symptoms. Of several moderator variables tested, parental stress was the only variable that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process.

Does Sluggish Cognitive Tempo Fit Within a Bi-Factor Model of ADHD?

Objective: Studies demonstrate sluggish cognitive tempo (SCT) symptoms to be distinct from inattentive and hyperactive-impulsive dimensions of ADHD. No study has examined SCT within a bi-factor model of ADHD, whereby SCT may form a specific factor distinct from inattention and hyperactivity/impulsivity while still fitting within a general ADHD factor, which was the purpose of the current study. Method: A total of 168 children were recruited from an ADHD clinic. Most (92%) met diagnostic criteria for ADHD. Parents and teachers completed measures of ADHD and SCT. Results: Although SCT symptoms were strongly associated with inattention, they loaded onto a factor independent of ADHD g. Results were consistent across parent and teacher ratings. Conclusion: SCT is structurally distinct from inattention as well as from the general ADHD latent symptom structure. Findings support a growing body of research suggesting SCT to be distinct and separate from ADHD.

Assessing children with ADHD in primary care settings

Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been established that provides best practice diagnostic procedures for primary care physicians. These assessment recommendations emphasize the importance of collecting parent and teacher rating scales, using Diagnostic and Statistical Manual of Mental Disorders IV criteria as the basis for making an ADHD diagnosis, and evaluating for comorbid conditions. The ADHD diagnostic process is complicated by several factors including the subjectivity of the ADHD diagnosis, differential diagnosis with comorbid conditions, and the inconsistent manifestation of ADHD symptomatology across development. The present article provides recommendations for addressing these complex diagnostic issues. ADHD assessment methods and tools, the process of assessing for comorbid conditions and making differential diagnosis, and when to make a referral to specialists are reviewed.

Effects of an 8-Session Behavioral Parent Training Group for Parents of Children With ADHD on Child Impairment and Parenting Confidence

Objective: This study examined the feasibility and effectiveness of a behavioral parent training (BPT) group intervention implemented in an outpatient mental health setting in reducing child impairments and increasing parenting confidence in managing child behavior. Method: Parents of 241 children with ADHD participated in the eight-session parent group program, completing the Impairment Rating Scale (IRS) and a measure of parenting confidence at the first and last session. Results: Parents reported improvements in child behavior across all domains of the IRS, with the largest improvements in terms of overall impairment, parent–child relationship, and impact of child behavior on the family. Parents also reported increased confidence in managing their child’s behavior. Conclusion: These findings suggest that brief BPT group programs administered to a diverse range of attendees in a typical outpatient setting result in improvements in functional impairments comparable with those produced in controlled studies, as well as improved parenting confidence.

Slow sluggish cognitive tempo symptoms are associated with poorer academic performance in children with ADHD

Sluggish cognitive tempo (SCT) symptoms may confer risk for academic impairment in attention-deficit/hyperactivity disorder (ADHD). We investigated SCT in relation to academic performance and impairment in 252 children (ages 6-12, 67% boys) with ADHD. Parents and teachers completed SCT and academic impairment ratings, and achievement in reading, math, and spelling was assessed. Simultaneous regressions controlling for IQ, ADHD, and comorbidities were conducted. Total SCT predicted parent-rated impairments in writing, mathematics, and overall school but not reading. Parent-rated SCT Slow predicted poorer reading and spelling, but not math achievement. Teacher-rated SCT Slow predicted poorer spelling and math, but not reading achievement. Parent-rated SCT Slow predicted greater academic impairment ratings across all domains, whereas teacher-rated SCT Slow predicted greater impairment in writing only. Age and gender did not moderate these relationships with the exception of math impairment; SCT slow predicted math impairment for younger but not older children. Parent and teacher SCT Sleepy and Daydreamy ratings were not significant predictors. SCT Slow appears to be uniquely related to academic problems in ADHD, and may be important to assess and potentially target in intervention. More work is needed to better understand the nature of SCT Slow symptoms in relation to inattention and amotivation.

Comparing treatments for children with ADHD and word reading difficulties: A randomized clinical trial.

Objective: This trial compared attention-deficit/hyperactivity disorder (ADHD) treatment alone, intensive reading intervention alone, and their combination for children with ADHD and word reading difficulties and disabilities (RD). Method: Children (n = 216; predominantly African American males) in Grades 2–5 with ADHD and word reading/decoding deficits were randomized to ADHD treatment (medication + parent training), reading treatment (reading instruction), or combined ADHD + reading treatment. Outcomes were parent and teacher ADHD ratings and measures of word reading/decoding. Analyses utilized a mixed models covariate-adjusted gain score approach with posttest regressed onto pretest. Results: Inattention and hyperactivity/impulsivity outcomes were significantly better in the ADHD (parent Hedges’s g = .87/.75; teacher g = .67/.50) and combined (parent g = 1.06/.95; teacher g = .36/41) treatment groups than reading treatment alone; the ADHD and Combined groups did not differ significantly (parent g = .19/.20; teacher g = .31/.09). Word reading and decoding outcomes were significantly better in the reading (word reading g = .23; decoding g = .39) and combined (word reading g = .32; decoding g = .39) treatment groups than ADHD treatment alone; reading and combined groups did not differ (word reading g = .09; decoding g = .00). Significant group differences were maintained at the 3- to 5-month follow-up on all outcomes except word reading. Conclusions: Children with ADHD and RD benefit from specific treatment of each disorder. ADHD treatment is associated with more improvement in ADHD symptoms than RD treatment, and reading instruction is associated with better word reading and decoding outcomes than ADHD treatment. The additive value of combining treatments was not significant within disorder, but the combination allows treating both disorders simultaneously.

Generating Attention, Inhibition, and Memory: A Pilot Randomized Trial for Preschoolers With Executive Functioning Deficits

This goal of this study was to assess the initial feasibility and efficacy of a play-based intervention targeting executive functions (EF) and parent–child relationships in preschoolers compared with an active control group. Preschoolers with EF deficits (M age = 3.7 ± 0.47, predominantly White boys) and their parents were randomized to intervention (n = 36) or active control (n = 32) conditions. Child performance on EF tasks, parent and masked teacher ratings of EF and behavior, and masked clinician ratings of severity were collected at baseline and at 3 and 6 months postbaseline. Partial eta-squared effect sizes at .02 or higher comparing performance across the two groups was considered evidence of meaningful, albeit small, intervention effects. Intervention effects were observed for parent ratings of inattention, hyperactivity/impulsivity, and number/severity of problems experienced in various home situations, teacher ratings of severity of problems in various school situations, parent and teacher ratings of overall impairment, and clinician ratings of impairment. Intervention effects for functional improvements were maintained at the 6-month follow-up. No effect of the intervention was observed on the objective EF measures, although parent ratings of emotional control were improved for children in the intervention group. An intervention utilizing play-based activities targeting EF, when administered in a structured way by parents, is a promising approach for improving behavior in preschoolers with self-regulation deficits. More work is needed to investigate potential impact on EF and to disentangle mechanisms of action. It may be that the intervention’s focus on the structure and quality of parent–child interactions is a mediator of outcomes, rather than improved EFs.

Behavioral parent training groups for ADHD in clinical settings: Does offering a concurrent child group add value?

There is strong evidence for the efficacy of behavioral parent training (BPT) for attention deficit/hyperactivity disorder (ADHD). However, BPT can be difficult to access in many communities, which may be due to practical considerations including whether to offer concurrent child groups. Few studies have specifically examined whether concurrent child treatment is beneficial for ADHD—particularly in real-world clinical settings (i.e., not in a formal research context). Concurrent child groups may improve adherence as they address a practical barrier to attendance, and may boost treatment outcomes given the additional treatment provided directly to children. However, this should be empirically verified given that offering concurrent child treatment poses a number of practical and costly challenges (e.g., extra staff, extra space) that are not recouped by insurance reimbursement. This preliminary study explores whether offering concurrent child treatment groups provides added treatment benefits in a sample of convenience obtained from an outpatient clinic. Data was collected from 241 parents of 6- to 12-year-old children with ADHD who attended 1 of 37 8-session BPT groups, of which 15 offered a concurrent child group. Parents completed ratings of child impairment and parenting confidence at the first and last BPT session. Results showed that clinical improvement was equitable regardless of whether a concurrent child group was attended, and there were no demographic or clinical differences between those who opted to attend the parent+child groups and those who did not. Suggestions are provided for clinicians who may decide to discontinue offering concurrent child groups.

The Conceptualization and Treatment Plan of a Child Diagnosed With Disruptive Mood Dysregulation Disorder: A Case Report

ABSTRACT One of the new diagnoses added to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), disruptive mood dysregulation disorder (DMDD), is a condition that is not currently well studied or understood. Although some work has proposed options for psychosocial and psychopharmacological intervention, very limited research exists to guide clinicians in developing an evidence-informed conceptualization and treatment for children with DMDD. The current case report details the integration of the available literature to create a conceptualization and multimodal treatment plan designed to alleviate the negative mood and disruptive behaviors associated with DMDD in an 11-year-old boy. Twenty-three sessions included components of psychoeducation, family-based behavior management training, individual cognitive-behavioral therapy techniques, and medication. From pre- to postassessment, both verbal report and rating scales suggested significant gains including improved compliance, decreased outbursts, and improved mood, despite some persisting negativistic bias. Overall, the created multimodal treatment plan demonstrated preliminary evidence for the reduction of symptoms for a child diagnosed with DMDD. Treatment complications and implications for future work are discussed.