Stephen P. Hinshaw

Externalizing Behavior Problems and Academic Underachievement in Childhood and Adolescence: Causal Relationships and Underlying Mechanisms

Conceptual and measurement issues surrounding externalizing behavior problems and academic underachievement, the strength and specificity of the covariation between these domains, and the viability of explanatory models that link these areas are reviewed. In childhood, inattention and hyperactivity are stronger correlates of academic problems than is aggression; by adolescence, however, antisocial behavior and delinquency are clearly associated with underachievement. Whereas investigations with designs that allow accurate causal inference are scarce, unidirectional paths from 1 domain to the other have received little support. Indeed, the overlap of externalizing problems with cognitive and readiness deficits early in development suggests the influence of antecedent variables. Low socioeconomic status, family adversity, subaverage IQ, language deficits, and neurodevelopmental delay are explored as possible underlying factors.

The MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study

OBJECTIVES To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). METHOD Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. RESULTS In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. CONCLUSIONS Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.

The ecological validity of delay aversion and response inhibition as measures of impulsivity in AD/HD: a supplement to the NIMH multimodal treatment study of AD/HD

Impulsivity is a primary symptom of the combined type of Attention Deficit/Hyperactivity Disorder (AD/HD). The Stop Signal Paradigm is premised upon a primary deficit in inhibitory control in AD/HD, whereas the Delay Aversion Hypothesis, by contrast, conceptualizes impulsivity in AD/HD, not as an inability to inhibit a response, but rather as a choice to avoid delay. This study compared the ecological validity of the Stop Signal Task (SST) and Choice-Delay Task (C-DT) measure of delay aversion, with respect to their relative utility in discriminating AD/HD children from normal control participants, and their correlations with classroom observations and with ratings of impulsivity and other core AD/HD symptoms on the Conners and SNAP-IV checklists. The tasks exhibited modest discriminant validity when used individually and excellent discriminant validity when used in combination. The C-DT correlated with teacher ratings of impulsivity, hyperactivity, and conduct problems, and with observations of gross motor activity, physical aggression, and an AD/HD composite score. The SST correlated with the observations only. These results suggest that delay aversion is associated with a broad range of AD/HD characteristics whereas inhibitory failure seems to tap a more discrete dimension of executive control

Academic Underachievement, Attention Deficits, and Aggression: Comorbidity and Implications for Intervention.

Although comorbidity with specific learning disabilities is less frequent than commonly reported, externalizing behavior disorders--particularly attention-deficit hyperactivity disorder (ADHD)--often overlap with various indices of academic underachievement during childhood. Furthermore, by adolescence, delinquency is clearly associated with school failure. Because the link between behavioral and learning problems often appears before formal schooling, and because the co-morbid problems predict a negative course, early intervention is a necessity. Controlled treatment investigations with youngsters who show these combined problems are rare, and such studies present a host of methodologic and practical problems. I discuss issues surrounding multimodality treatment programs and the potential for long-term interventions to break cycles of school failure and externalizing behavior.

Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers

In 1992, the National Institute of Mental Health and 6 teams of investigators began a multisite clinical trial, the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study. Five hundred seventy-nine children were randomly assigned to either routine community care (CC) or one of three study-delivered treatments, all lasting 14 months. The three MTA treatments-monthly medication management (usually methylphenidate) following weekly titration (MedMgt), intensive behavioral treatment (Beh), and the combination (Comb)-were designed to reflect known best practices within each treatment approach. Children were assessed at four time points in multiple outcome. Results indicated that Comb and MedMgt interventions were substantially superior to Beh and CC interventions for attention-deficit hyperactivity disorder symptoms. For other functioning domains (social skills, academics, parent-child relations, oppositional behavior, anxiety/depression), results suggested slight advantages of Comb over single treatments (MedMgt, Beh) and community care. High quality medication treatment characterized by careful yet adequate dosing, three times daily methylphenidate administration, monthly follow-up visits, and communication with schools conveyed substantial benefits to those children that received it. In contrast to the overall study findings that showed the largest benefits for high quality medication management (regardless of whether given in the MedMgt or Comb group), secondary analyses revealed that Comb had a significant incremental effect over MedMgt (with a small effect size for this comparison) when categorical indicators of excellent response and when composite outcome measures were used. In addition, children with parent-defined comorbid anxiety disorders, particularly those with overlapping disruptive disorder comorbidities, showed preferential benefits to the Beh and Comb interventions. Parental attitudes and disciplinary practices appeared to mediate improved response to the Beh and Comb interventions.

What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder?

Participants included 165 children with attention-deficit/hyperactivity disorder (ADHD; 130 boys, 35 girls) and their 1,298 same-sex classmates (1,026 boys, 272 girls) who served as raters. For each child with ADHD, a child of the same sex was randomly selected from the same classroom to serve as a comparison child, which yielded 165 dyads. Consistent with predictions, contrasted with the comparison children, those with ADHD were lower on social preference, higher on social impact, less well liked, and more often in the rejected social status category; they also had fewer dyadic friends. When liking ratings that children made versus received were examined, children with ADHD had less positive imbalance and greater negative imbalance relative to comparison children. Analyses that considered the types of peers who chose children with ADHD as friends or nonfriends demonstrated that children with ADHD were nominated as nonfriends by children of higher social preference and who were better liked by others.

Issues of taxonomy and comorbidity in the development of conduct disorder

A developmental approach to the classification of antisocial behavior is necessary for two reasons. First, although the continuity of antisocial behavior is strong for many individuals, the topography of antisocial behavior changes during the course of development. Second, antisocial behavior apparently develops in at least two separate pathways — child-onset versus adolescent-onset — that differ markedly regarding types of antisocial behavior displayed, persistence, and perhaps etiology. The development of antisocial behavior must also be understood within the context of co-occurring disorders and conditions. Comorbid attention-deficit hyperactivity disorder appears to be associated with greater aggression and a worse prognosis, and comorbid academic underachievement is also associated with a negative course. Emerging evidence also suggests that comorbid anxiety disorder is associated with level of aggression, but the direction of the correlation appears to differ at different ages. In all, full understanding of conduct disorder requires developmentally sensitive classification as well as consideration of comorbid conditions.

Observed Classroom Behavior of Children with ADHD: Relationship to Gender and Comorbidity

Examined hypothesized gender and comorbidity differences in the observed classroom behavior of children with attention deficit hyperactivity disorder (ADHD). The behavior of 403 boys and 99 girls with ADHD, ages 7–10, was compared (a) to observed, sex-specific classroom behavior norms, (b) by sex, and (c) by comorbid subgroups. Boys and girls with ADHD deviated significantly from classroom norms on 15/16 and 13/16 categories, respectively. Compared to comparison girls, girls with ADHD had relatively high rates of verbal aggression to children. Boys with ADHD engaged in more rule-breaking and externalizing behaviors than did girls with ADHD, but the sexes did not differ on more “neutral,” unobtrusive behaviors. The sex differences are consistent with notions of why girls with ADHD are identified and referred later than boys. Contrary to hypothesis, the presence of comorbid anxiety disorder (ANX) was not associated with behavioral suppression; yet, as hypothesized, children with a comorbid disruptive behavior disorder (DBD) had higher rates of rule-breaking, and impulsive and aggressive behavior, than did children with ADHD alone and those with ADHD+ANX. Elevated rates of ADHD behaviors were also observed in children with comorbid DBD, indicating that these behaviors are truly present and suggesting that reports of higher ADHD ratings in this subgroup are not simply a consequence of negative halo effects and rater biases.

Preadolescent girls with attention-deficit/hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices

This study investigated a diverse sample of girls (6-12 years of age) with attention-deficit/hyperactivity disorder (ADHD), combined type (n = 93) and inattentive type (n = 47), plus age- and ethnicity-matched comparison girls (n = 88), who participated in research summer programs. Speech and language problems, grade retention, and adoption characterized the ADHD sample; documented abuse characterized the combined type. Girls with ADHD showed dysfunction in terms of externalizing and internalizing behaviors and comorbidities, cognitive and academic performance, authoritarian parenting, and peer status. The inattentive type was more socially isolated but less rejected by peers than the combined type. ADHD-related impairment was independent of age and disruptive comorbidity. Further examination of processes related to psychopathology and competencies in girls with ADHD is needed.

Self-perceptions of competence in children with ADHD and comparison children

The self-perceptions of children with attention-deficit/hyperactivity disorder (ADHD; n = 487) were compared with those of children in a local normative comparison group (n = 287), relative to teacher- and parent-rated perceptions of their competence. Children were participants in the ongoing follow-up portion of the Multimodal Treatment Study of Children with ADHD. Children with ADHD were much more likely than comparison children to overestimate their competence relative to adult report, regardless of who was used as the criterion rater (teacher, mother, or father). Examination by comorbidity subgroups revealed that children with ADHD inflated their self-perceptions the most in domains of greatest deficit. Gender effects also are reported.