Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

Latino Family Participation in Youth Mental Health Services: Treatment Retention,Engagement, and Response

Although researchers have identified a multitude of factors that contribute to family participation in mental health services, few studies have examined them specifically for Latino youth and their families in the U.S., a population that continues to experience significant disparities related to the availability, accessibility, and quality of mental health services. Latino youth and their families are at greater risk of dropping out of treatment prematurely and demonstrating poor treatment engagement, both of which have subsequent negative effects on treatment response outcomes. In order to help to guide efforts to improve the accessibility and quality of mental health services for Latino youth and their families, the current paper integrates modern conceptualization of family participation in youth mental health services and provides a summary of contextual factors within an ecological framework (Bronfenbrenner in The ecology of human development: experiments by nature and design, Harvard University Press, Cambridge, 1979). The current review aims to integrate empirical research on the impact of various contextual factors across multiple levels (i.e., culture, community, mental health system, family, parent/caregiver, and child/adolescent) on Latino family participation in youth mental health services, including treatment retention, engagement, and response. Clinical implications will be discussed, and an integrated, conceptual model will be presented. Not only does this model help to demonstrate the way in which existing literature is conceptually linked, but it also helps to highlight factors and underlying processes that health care providers, administrators, and policy makers must consider in working to improve mental health services for Latino youth and their families living in the U.S.     

Functional Impairment in Latino Children with ADHD: Implications for Culturally Appropriate Conceptualization and Measurement

Conceptualizing and measuring functional impairment related to childhood ADHD, particularly within the rapidly growing, yet underserved, Latino population, is an important area of research that is in its infancy in the field of psychology. The functional impairments related to academic achievement, social competence, and familial relations experienced by children with ADHD lead to long-lasting and debilitating difficulties that adversely affect the individuals themselves, their families, and society. In addition, limited available research suggests that Latino children are at a great or greater risk for developing ADHD, although they are much less likely to be identified by their parents as displaying problematic behavior and subsequently are less likely to receive proper assessment and treatment due to several practical and cultural factors. Fortunately, initial evidence suggests that the construct of functional impairment may be a more universal notion than the potentially culturally biased measurement of symptomatology. Therefore, in order to provide the best possible outcomes for all children with ADHD, research needs to be expanded to include examination of functional impairment related to ADHD, particularly when working with Latino children and their families. Thus, the primary aim of the current review is to examine and critique how the field of psychology has understood and measured functional impairment in school-aged Latino children with ADHD to date. Based on information reviewed, suggestions for moving toward a culturally modified assessment of functional impairment related to ADHD in Latino children will be proposed. This work is a necessary step toward providing culturally appropriate services for a currently underserved, yet rapidly growing, Latino population in our country.     

Review of the Evidence for Motivation Deficits in Youth with ADHD and Their Association with Functional Outcomes

Preeminent theories of attention-deficit/hyperactivity disorder (ADHD) suggest that motivation deficits are core underlying features of the disorder. However, it is currently unclear whether empirical evidence supports the assertion that significant group (ADHD v. comparison) differences in motivation exist or that problems with motivation contribute to the functional impairments that youth with ADHD experience. Accordingly, this review focused on evaluating and summarizing the empirical literature on the presence of motivation deficits and their association with functional outcomes in samples of youth with ADHD. Twenty studies met the review inclusion criteria. Results support the assertion that youth with ADHD have lower academic-related motivation in comparison to their peers and that motivation plays an important role in academic outcomes, with the strongest evidence to date for reading achievement. However, the available evidence is limited, and few existing studies are aligned with the much larger theoretical and empirical motivation literature in typically developing youth. Given preliminary evidence that motivation plays a role in the academic impairments of youth with ADHD, the review concludes with a discussion of whether current ADHD interventions adequately target motivation and highlights important future directions.     

The Relationship Between Child-Reported Positive Affect and Parent-Reported Emotional and Behavioral Problems in ADHD Youth

Although the adaptive role of positive affect (PA) in childhood internalizing disorders is well-established, less is known about PA in children with Attention-Deficit/Hyperactivity Disorder (ADHD). In this cross-sectional study, we examined associations between child-reported PA and parent-reported emotional and behavioral problems in youth with ADHD using multiple hierarchical regression analyses. Participants included 848 ethnically diverse youth (253 youth with ADHD, 595 with other or no diagnoses; age range 6.12–19.65) referred for mental health assessments. Study measures included the Child Behavior Checklist (CBCL) and the Positive and Negative Affect Scale for Children (PANAS-C). Results indicated that higher levels of child-reported PA were associated with greater parental reports of total and internalizing problems among youth with ADHD but not in other clinic-referred youth. Specifically, child self-reports of PA were positively associated with parental reports of anxious/depressed and somatic problems in youth with ADHD. In addition, associations between child-reported PA and parent-reported problems differed by type of ADHD comorbidity. Findings suggest that at higher levels, PA in youth with ADHD might exert a paradoxical effect and be a subtle risk factor for or an indicator of parent-reported internalizing problems among youth with ADHD only and youth with ADHD and a comorbid externalizing disorder but not for youth with ADHD and a comorbid internalizing disorder or youth without ADHD. Discrepancies between child-reported PA and parent-reported problems may influence treatment planning and treatment response. Further clinical and theoretical implications for child therapists and parents are discussed.     

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.     

Emotion Regulation Mediates the Relationship between ADHD and Depressive Symptoms in Youth

A significant literature suggests that youth diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) are at increased risk for later depression relative to youth without ADHD. Youth with co-occurring ADHD and depression experience more serious impairments and worse developmental outcomes than those with either disorder alone, including increased rates of suicidal ideation and suicide completion. Despite these very serious outcomes, few studies have examined the mechanisms underlying the relationship between ADHD and depression in youth. The present study examined emotion regulation (ER) as a mediator of the relationship between ADHD and depressive symptoms in 69 youth between the ages of 10 and 14, with (n?=?37) and without (n?=?32) ADHD. Parent and youth ratings of depressive symptoms and ER were collected. Youth with ADHD reported significantly more depressive symptoms and poorer ER ability relative to youth without ADHD. ER fully mediated the relationship between ADHD and depressive symptoms. Limitations and clinical implications are discussed.     

The Importance of Friendship for Youth with Attention-Deficit/Hyperactivity Disorder

It is well-established that youth with attention-deficit/hyperactivity disorder (ADHD) are often peer-rejected and rated by parents, teachers, and observers to have poor social skills, when compared to typically developing peers. Significantly less research, however, has been devoted to the experiences youth with ADHD have in their close friendships. The aim of this article is to draw attention to friendship as a distinct construct from peer rejection and social skills and to summarize what is known about youth with ADHD in their friendships. The potential for stable, high-quality friendships to buffer the negative outcomes typically conferred by peer rejection in this population is discussed. This article concludes with recommendations for interventions that specifically target improving the close friendships of youth with ADHD as a treatment strategy.     

Externalizing Outcomes of Youth with and without ADHD: Time-Varying Prediction by Parental ADHD and Mediated Effects

Although parental attention-deficit/hyperactivity disorder (ADHD) is a risk factor for multiple negative youth outcomes, it is unknown how change in parental ADHD symptoms over time affects change in child ADHD symptoms; moreover, mediators of these predictions are largely unknown. Parents of 230 5–10 year-old children (68 % male) with (n = 120) and without ADHD (n = 110) were followed prospectively for 6–7 years across three separate waves. Parents self-reported their ADHD and depression symptoms and similarly rated offspring ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms; youth self-reported their substance use. Temporally-ordered mediators consisted of parental expressed emotion (EE), derived from the Five Minute Speech Sample, and self-reported positive and negative parenting behavior. Controlling for key demographics and parental depression symptoms, increasing parental ADHD symptoms were a time-varying predictor of worsening youth ADHD and ODD, although it was unrelated to change in CD and alcohol/substance use. Next, although EE facets (i.e., criticism, emotional over-involvement) did not mediate these predictions, negative parenting behavior significantly mediated predictions of youth ADHD (and marginally in predictions of ODD) from parental ADHD symptoms. These quasi-experimental findings suggest that parental ADHD symptoms are a potential unique causal risk factor for offspring ADHD and ODD; also, preventing negative parenting behavior secondary to parental ADHD symptoms is critical to improve trajectories of youth ADHD and ODD. We consider parental ADHD symptoms and family factors underlying emergent externalizing problems utilizing a developmental psychopathology framework, including implications for intervention and prevention.     

Trajectories of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder Symptoms as Precursors of Borderline Personality Disorder Symptoms in Adolescent Girls

Little empirical evidence exists regarding the developmental links between childhood psychopathology and borderline personality disorder (BPD) in adolescence. The current study addresses this gap by examining symptoms of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) as potential precursors. ADHD and BPD share clinical features of impulsivity, poor self-regulation, and executive dysfunction, while ODD and BPD share features of anger and interpersonal turmoil. The study is based on annual, longitudinal data from the two oldest cohorts in the Pittsburgh Girls Study (N = 1,233). We used piecewise latent growth curve models of ADHD and ODD scores from age 8 to 10 and 10 to 13 years to examine the prospective associations between dual trajectories of ADHD and ODD symptom severity and later BPD symptoms at age 14 in girls. To examine the specificity of these associations, we also included conduct disorder and depression symptom severity at age 14 as additional outcomes. We found that higher levels of ADHD and ODD scores at age 8 uniquely predicted BPD symptoms at age 14. Additionally, the rate of growth in ADHD scores from age 10 to 13 and the rate of growth in ODD scores from 8 to 10 uniquely predicted higher BPD symptoms at age 14. This study adds to the literature on the early development of BPD by providing the first longitudinal study to examine ADHD and ODD symptom trajectories as specific childhood precursors of BPD symptoms in adolescent girls.     

Addressing Barriers to Change in the Treatment of Childhood Obsessive Compulsive Disorder

Although considerable evidence supports the use of cognitive behavior therapy (CBT) for the treatment of childhood obsessive compulsive disorder, large numbers of youth fail to respond and clinical remission is often elusive. Poor family functioning frequently is implicated as an obstacle for youth undergoing CBT, with features such as symptom accommodation, family conflict, and blame known to attenuate outcomes. These features are common in child and adolescent obsessive compulsive disorder (OCD) and they may pose particular challenges for exposure-based treatments. Nonetheless, interventions that focus specifically on family functioning have, to date, been limited. This paper reviews the literature on family features associated with childhood OCD and discusses their links to treatment outcome. It then describes the development of a brief family intervention tailored to address the needs of highly distressed families of youth with OCD in the service of improving individual child CBT outcomes. Preliminary pilot data are presented and clinical implications are discussed.     

Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD

Children diagnosed with attention-deficit/hyperactivity disorder (ADHD; n = 142) were prospectively monitored into adolescence (13-18 years old) to evaluate their risk for elevated substance use relative to same-aged adolescents without ADHD (n = 100). Probands reported higher levels of alcohol, tobacco, and illicit drug use than did controls. Group differences were apparent for alcohol symptom scores but not for alcohol or marijuana disorder diagnoses. Within probands, severity of childhood inattention symptoms predicted multiple substance use outcomes: childhood oppositional defiant disorder/conduct disorder (ODD/CD) symptoms predicted illicit drug use and CD symptoms. Persistence of ADHD and adolescent CD were each associated with elevated substance use behaviors relative to controls. Further study of the mediating mechanisms that explain risk for early substance use and abuse in children with ADHD is warranted.     

Yoga,Mindfulness, and Meditation Interventions for Youth with ADHD: Systematic Review and Meta-Analysis

Attention-deficit/hyperactivity disorder (ADHD) is a chronic developmental disorder affecting 3–7% of children. In light of the growing utilization of yoga, mindfulness, and meditation in ADHD populations and potential benefits it has on ADHD symptoms, executive function deficits, and social functioning, we sought to evaluate these interventions for youth with ADHD. The primary aim of this review paper is to identify the efficacy of these programs for the treatment of youth with ADHD through a systematic review and meta-analysis. A systematic literature search was conducted in the following electronic databases: PsychINFO, ERIC, PubMed, and MEDLINE. Studies were included in the meta-analytic review if participants were between 5–17 years old, had a diagnosis of ADHD or met symptom threshold on psychometrically-validated measure of ADHD symptoms, was a treatment outcome study, and was published in a peer-reviewed English-language journal. The effect sizes of eleven studies demonstrate that yoga, mindfulness-based interventions, and/or meditation had a statistically significant effect on the outcomes of ADHD symptoms, hyperactivity, and inattention (parent and teacher report), as well as parent-child relationship, executive functioning, on-task behavior, parent stress, and parent trait-mindfulness (p?<?0.05). The effect sizes range from small to large effects across these outcomes. Considerable risk for bias was found across studies. Given significant methodological limitations of the literature, positive effect sizes found in studies should be interpreted with caution; these interventions should not be considered first-line interventions for ADHD. However, preliminary findings suggest yoga, mindfulness, and meditation may be beneficial for youth with ADHD, but extensive research is required to validate the efficacy of these interventions.     

Evaluating a Comprehensive Strategy to Improve Engagement to Group-based Behavioral Parent Training for High-risk Families of Children with ADHD

Behavioral parent training (BPT) is an evidence-based intervention for the treatment of attention-deficit/hyperactivity disorder (ADHD) and related disruptive behavioral disorders of childhood. Despite convincing data on effectiveness, engagement to BPT, particularly for high-risk families, has been a long standing, yet understudied, issue. Data from a clinical trial of a comprehensive BPT approach to enhance engagement and outcomes (the Strategies to Enhance Positive Parenting [STEPP] program) are presented herein. The STEPP program was compared to a traditional group-based BPT program on propensity to attend treatment, propensity to complete homework over the course of treatment, and dropout from BPT. Additionally, factors empirically related to engagement to treatment and targeted by the STEPP program were analyzed to determine whether these factors were enhanced by participation in the STEPP program. In a randomized cohort of 80 single-mothers of school-age children with ADHD, analyses demonstrated that the STEPP program lead to greater propensity to attend treatment over time and a greater propensity to complete homework over the course of treatment. Furthermore, participation in the STEPP Program was associated with a lower rate of dropout. Finally, data suggested that parents assigned to the STEPP program reported significant improvements in factors empirically related to engagement that were targeted within the STEPP program (i.e., amount and quality of social support from their group members, expectations for treatment, and perceived barriers to treatment participation). Results of the study have implications for targeting engagement throughout the process of BPT, particularly for high-risk families.     

Substance use and delinquency among adolescents with childhood ADHD: The protective role of parenting

Several domains of parenting have been identified as important for adolescent well-being. Whether these same domains are equally beneficial for adolescents with ADHD histories remains an empirical and clinically important question. This study examined whether parental knowledge of their teen's activities and whereabouts, consistency, support, and parent-adolescent conflict are associated with substance use and delinquency similarly for adolescents with and without a diagnosis of ADHD in childhood. A sample of 242 adolescents, 142 diagnosed with ADHD in childhood and prospectively followed into adolescence, and 100 without ADHD in childhood, were the focus of study. The relations between adolescent-reported outcomes (i.e., substance use and delinquency) and parenting behaviors were tested using latent variable modeling to determine both the effects of general (common) and specific (unique) parenting behaviors for participants with and without a history of ADHD. Adolescents' report of parental knowledge was a significant correlate of delinquency and substance use above and beyond other parenting variables and the variance in common across the parenting variables. More knowledge was associated with less delinquency and substance use for all participants, but parental knowledge was more strongly associated with alcohol use for adolescents with versus without childhood ADHD. These correlational findings suggest that, despite the increased difficulty of parenting youths with ADHD histories, actions taken by parents and youth to increase parental awareness may provide some protection against behavioral transgressions known to be elevated in this population. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

The Accuracy of Retrospective Recall of Childhood ADHD: Results from a Longitudinal Study

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset condition that may continue into adulthood. When assessing adult patients, clinicians usually rely on retrospective reports of childhood symptoms to evaluate the age-of-onset criterion. Since inaccurate symptom recall may impede the diagnosis and treatment of ADHD, knowledge about the factors influencing retrospective reports is needed. This longitudinal study investigated (a) the accuracy of retrospective symptom ratings by adult participants with a childhood diagnosis of ADHD (self-ratings) and parents or significant others (proxy ratings), and (b) the influence of current ADHD symptom severity and ADHD-associated impairments on retrospective symptom ratings. Participants (N =?55) were members of the Cologne Adaptive Multimodal Treatment (CAMT) study who had been referred and treated for ADHD in childhood and were reassessed in adulthood (average age 27 years). Participants’ retrospective self-ratings were substantially lower than, and did not correlate with, parents’ ADHD symptom ratings provided at study entry, while retrospective symptom ratings provided by proxy respondents correlated moderately with parents’ childhood ratings. In addition, participants were more likely to underreport childhood symptoms (79%) and more frequently denied the presence of three or more childhood symptoms (17%) compared to proxy respondents (65% underreporting, 10% false-negative recall). Proxy respondents’ symptom recall was best predicted by childhood ADHD, while participants’ symptom recall was best predicted by current ADHD symptom severity. ADHD-associated impairments were not correlated with symptom recall after controlling for childhood ADHD. Together, these findings suggest a recall bias in adult patients and question the validity of retrospective reports, even in clinical samples.

     

Examining the Potential of Community-Based After-School Programs for Latino Youth

Results are presented from two pilot studies examining the potential influence of community-based after-school programs (ASPs) on regionally diverse Latino youth of varying ages. Study 1 examined relations between dimensions of ASP attendance and content, and ethnic identity development, and self-worth in urban Latino adolescents. In this study, higher ratings of the ASP’s emphasis on ethnic socialization were associated with a more developed ethnic identity, while greater intensity of ASP participation and perceptions of ASP quality were associated with higher levels of self-worth. Study 2 examined relations between ASP participation and development of concentration and emotion regulation skills in rural Latino grade-school youth. In this study, youth who regularly attended the ASP demonstrated significantly better concentration and regulation skills than those who did not regularly attend, if they exhibited preexisting concentration and regulation problems. Findings illustrate how ASPs with varying strategies, activities, and assessment tools can be evaluated in the interest of designing future large-scale investigations into ASPs and Latino positive youth development.     

Mother-Child Relationship in Youths with Attention-Deficit Hyperactivity Disorder and their Siblings

Despite impaired mother-child interactions noted in youth with attention-deficit/hyperactivity disorder (ADHD), there is no such information for their siblings. This study aimed to test whether the affected and unaffected siblings, like youth with ADHD, also encountered impaired mothering and mother-child relationships as compared to typically developing youth (TD). The sample consisted of 122 probands (107 males, 87.7 %), aged 10–16, with DSM-IV ADHD, 44 affected (26 males, 59.1 %) and 78 unaffected (28 males, 35.9 %) siblings, and 122 TD youth. Both participants and their mothers received psychiatric interviews (K-SADS-E) about the participants and reported maternal parenting style, mother-child interactions and child behavioral problems at home. Based on both reports, probands with ADHD and affected siblings (only youth report) had more impaired relationships, more behavioral problems at home, and less perceived family support than unaffected siblings and TD youth. Probands with ADHD had higher maternal authoritarian control than unaffected siblings. The findings suggest that impaired mothering, mother-child interactions, and family support are related to the presence of ADHD diagnosis in both probands and their affected siblings.     

Factors Associated with Healthy and Impaired Social Functioning in Young Adolescents with ADHD

There is variability in the extent to which adolescents with attention-deficit/hyperactivity disorder (ADHD) exhibit social impairment, as the same diagnosis does not necessarily entail impairment in the same area(s) of functioning. The current study entailed a cross-sectional examination of enhancers to healthy social functioning and risk factors to parent- and self-rated social impairment in 324 middle school youth (ages 10–14 years) with ADHD. A series of binary logistic regression analyses were conducted to evaluate a risk-resilience model for social functioning, including testing compensatory (i.e., main; buffering) and protective (i.e., interaction) effects of enhancers in the presence of identified risk factors. Youth conduct problems, youth depression, and negative parenting emerged as risk factors. Self-rated social acceptance, activity participation (breadth and intensity), and parent involvement were enhancers of healthy social functioning. Of these enhancers, activity participation (breadth and intensity) and parent involvement showed buffering effects against the negative impact of the risk factors on social functioning. None of the enhancers displayed protective effects. The findings of this study enhance our understanding of the social functioning of young adolescents with ADHD, who comprise an understudied population relative to younger children with similar problems.