Severity of Children’s ADHD Symptoms and Parenting Stress: A Multiple Mediation Model of Self-Regulation

The goal of the current study was to determine the extent to which the perceived self-regulation deficits across behavioral, cognitive, and emotional domains seen in children with ADHD explain the association between the severity of ADHD symptoms and parenting stress. Participants for this study included 80 children (mean age = 10 years, 9 months) with a DSM-IV diagnosis of ADHD confirmed by a comprehensive clinical diagnostic assessment. Parents reported their own stress levels as well as the severity of their children’s ADHD symptoms, aggression, emotional lability, and executive functioning difficulties. Results indicated that the severity of children’s hyperactivity/impulsivity symptoms but not their inattention related to parenting stress. Multiple mediational analyses indicated that the association between hyperactivity/impulsivity and parenting stress was explained by children’s perceived comorbid aggression levels, emotional lability, and executive functioning difficulties. No significant differences in the strength of the mediators were found. The current study provides initial data showing that the perceived impairments in children’s self-regulation across emotional, cognitive, and behavioral domains are what parents report as stressful, not simply the severity of ADHD symptoms. Due to the cross-sectional nature of this study and shared variance from relying solely on parent report, it will be critical for future research to replicate our findings using longitudinal and multi-informant data such as teacher reports and standardized assessments.     

Developmental change in the relation between executive functions and symptoms of ADHD and co‐occurring behaviour problems

In a sample of 92 children aged 6–13 years this study investigates the normal developmental change in the relation between executive functioning (EF) and the core behavioural symptoms associated with attention deficit hyperactivity disorder (ADHD) (hyperactivity/impulsivity and inattention) as well as symptoms often co‐occurring with childhood hyperactivity (conduct‐ and internalizing problems). EF was assessed by using multiple tests grouped through prior factor analysis, resulting in cognitive measures relating to disinhibition, speed/arousal, verbal working memory, non‐verbal working memory, and fluency. The results showed that although disinhibition was positively related to hyperactivity/impulsivity and inattention mainly for the youngest age group, there were no significant age effects for these relations. Instead, age effects were found for the relations between speed/arousal and inattention as well as for the relations between verbal working memory/fluency and inattention. In the oldest age group poor performance on these cognitive measures was associated with high ratings of inattention. For the total sample a relation was obtained between disinhibition and hyperactivity/impulsivity as well as between both working memory measures and internalizing problems. In conclusion, the results from this study suggest that poor inhibition is most clearly associated with ADHD symptoms for younger children, whereas poor functioning with regard to later developing and more complex executive functions such as working memory and fluency is associated with ADHD symptoms for older children. Copyright © 2006 John Wiley & Sons, Ltd.     

Dimensions and Correlates of Attention Deficit/Hyperactivity Disorder and Sluggish Cognitive Tempo

The present study examined Sluggish Cognitive Tempo (SCT) in relation to ADHD symptoms, clinical diagnosis, and multiple aspects of adjustment in a clinical sample. Parent and teacher reports were gathered for 322 children and adolescents evaluated for behavioral, emotional, and/or learning problems at a university clinic. Confirmatory factor analyses (CFA) supported the presence of three separate, but correlated factors (SCT, inattention, and hyperactivity/impulsivity) in both parent and teacher ratings. As expected, SCT symptoms were greatest in youth with ADHD Inattentive type, but were also found in non-ADHD clinical groups. SCT symptoms were related to inattention, internalizing, and social problems across both parent and teacher informants; for parent reports, SCT was also related to more externalizing problems. Findings support the statistical validity of the SCT construct, but its clinical utility is still unclear.     

Do Parent and Teacher Report of ADHD Symptoms in Children Differ by SES and Racial Status?

Parent and teacher reports of symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in children often differ from each other. These informant report differences may occur in systematic ways that vary by child socioeconomic status (SES) and race, but little is known about how SES and race together relate to parent and teacher report of ADHD symptoms in school-aged children. We examined the relationship between child SES, child race and parent and teacher reports of ADHD symptoms in two samples of school-aged Caucasian and African American children being evaluated for ADHD (N = 1056; N = 317). Multivariate regression was used to predict parent and teacher reports of ADHD symptoms from child SES, race, age, gender and interaction terms. The Wald test of parameter constraints was used to test the contrast between the predictors of interest and parent and teacher report of symptoms. In the second sample, we also examined observer report measures of ADHD symptoms during one-to-one testing and in the classroom. In both samples, lower SES was associated with higher levels of inattention symptoms, as reported by teachers, but not by parents. Lower SES was also associated with higher levels of hyperactivity/impulsivity symptoms, as reported by both teachers and parents. African American race was associated with higher levels of inattention and hyperactivity/impulsivity symptoms reported by teachers than reported by parents. Observer report measures showed a different pattern of associations with SES and race. Investigating how children’s SES and race influence cross-informant agreement on ratings of children’s behavior might lead to the development of better assessment practices and more accurate diagnoses for diverse child populations.     

Parental Cognitive Errors Mediate Parental Psychopathology and Ratings of Child Inattention

We investigate the Depression‐Distortion Hypothesis in a sample of 199 school‐aged children with ADHD‐Predominantly Inattentive presentation (ADHD‐I) by examining relations and cross‐sectional mediational pathways between parental characteristics (i.e., levels of parental depressive and ADHD symptoms) and parental ratings of child problem behavior (inattention, sluggish cognitive tempo, and functional impairment) via parental cognitive errors. Results demonstrated a positive association between parental factors and parental ratings of inattention, as well as a mediational pathway between parental depressive and ADHD symptoms and parental ratings of inattention via parental cognitive errors. Specifically, higher levels of parental depressive and ADHD symptoms predicted higher levels of cognitive errors, which in turn predicted higher parental ratings of inattention. Findings provide evidence for core tenets of the Depression‐Distortion Hypothesis, which state that parents with high rates of psychopathology hold negative schemas for their child's behavior and subsequently, report their child's behavior as more severe.     

Are Elevations in ADHD Symptoms Associated with Physiological Reactivity and Emotion Dysregulation in Children?

The present study examined whether children with elevated attention-deficit/hyperactivity disorder (ADHD) symptoms display a unique pattern of emotion dysregulation as indexed by both parent report and physiological reactivity during experiences of failure. A sample of 61 children (9 to 13 years; M?=?11.62, SD?=?1.29; 48 % male) with and without clinical elevations in ADHD symptoms participated. Parent and teacher report of ADHD and oppositional defiant disorder (ODD) symptoms and parent report of internalizing problems were collected. Parents also provided ratings of children’s emotional negativity/lability and emotion regulation. Children’s physiological reactivity, based on changes in respiratory sinus arrhythmia (RSA) and skin conductance level (SCL), were assessed while they completed a manipulated social rejection task and impossible puzzle task. Regression analyses indicated that ADHD symptoms were associated with higher parent-rated emotional negativity/lability and with blunted RSA withdrawal in response to social rejection; these effects were not accounted for by co-occurring ODD symptoms or internalizing problems. ODD symptoms also were uniquely associated with parent ratings of poor emotion regulation. Internalizing problems were uniquely associated with emotional negativity/lability, poor emotion regulation, and increased SCL activity in response to social rejection. Results suggest that there may be a pattern of emotion dysregulation that is specific to ADHD symptomatology. The importance of contextual factors when examining physiological reactivity to stress in youth with ADHD is discussed.     

The Role of Maternal and Child ADHD Symptoms in Shaping Interpersonal Relationships

The current study investigated the influence of maternal ADHD symptoms on: (a) mothers’ own social functioning; (b) their child’s social functioning; and (c) parent–child interactions following a lab-based playgroup involving children and their peers. Participants were 103 biological mothers of children ages 6–10. Approximately half of the children had ADHD, and the remainder were comparison youth. After statistical control of children’s ADHD diagnostic status and mothers’ educational attainment, mothers’ own inattentive ADHD symptoms predicted poorer self-reported social skills. Children with ADHD were reported to have more social problems by parents and teachers, as well as received fewer positive sociometric nominations from playgroup peers relative to children without ADHD. After control of child ADHD status, higher maternal inattention and hyperactivity/impulsivity each predicted children having more parent-reported social problems; maternal inattention predicted children receiving more negative sociometric nominations from playgroup peers. There were interactions between maternal ADHD symptoms and children’s ADHD diagnostic status in predicting some child behaviors and parent–child relationship measures. Specifically, maternal inattention was associated with decreased prosocial behavior for children without ADHD, but did not influence the prosocial behavior of children with ADHD. Maternal inattention was associated with mothers’ decreased corrective feedback and, at a trend level, decreased irritability toward their children with ADHD, but there was no relationship between maternal inattention and maternal behaviors for children without ADHD. A similar pattern was observed for maternal hyperactivity/impulsivity and mothers’ observed irritability towards their children. Treatment implications of findings are discussed.     

Are sluggish cognitive tempo symptoms associated with executive functioning in preschoolers?

The aim of this study is to investigate whether sluggish cognitive tempo (SCT) symptoms are associated with neurocognitive task performance and ratings of real-world executive functioning (EF) in preschoolers at risk for attention-deficit/hyperactivity disorder (ADHD). The associations between parent- and teacher-rated SCT symptoms and neuropsychological task performance and ratings of EF in 61 4-year-old preschool children (51 boys, 10 girls) with self-regulation difficulties were examined, with regression analyses controlling for the effects of ADHD inattention symptoms. In the study sample, higher teacher-rated SCT symptoms are significantly associated with poorer performance on tasks of visual-perceptual abilities, auditory and visual attention, sustained and selective attention, inhibitory control, pre-numerical/numerical concepts, and slower processing speed, but SCT symptoms are not significantly associated with working memory, attention shifting or cognitive flexibility when controlling for ADHD inattention. Higher parent-rated SCT symptoms are significantly associated with visual-perceptual abilities. ADHD inattention symptoms are more strongly associated than SCT with daily life EF ratings; neither parent- nor teacher-rated SCT symptoms are significantly associated with daily life ratings of inhibition, working memory, or planning/organization after controlling for ADHD inattention. This study suggests that SCT symptoms contribute to EF deficits at least on neurocognitive tasks assessing visual-perceptual/spatial abilities, attention to detail and processing speed, as observed in this sample of young children at risk for ADHD, and may be an important intervention target.     

Reliable Ratings or Reading Tea Leaves: Can Parent,Teacher, and Clinician Behavioral Ratings of Preschoolers Predict ADHD at Age Six?

To assess the relative ability of parent, teacher, and clinician behavioral ratings of preschoolers to predict ADHD severity and diagnosis at 6 years of age. Hyperactive/inattentive preschoolers [N?=?104, 75 % boys, Mean (SD) age?=?4.37 (0.47) years] were followed over 2 years (mean?=?26.44 months, SD?=?5.66). At baseline (BL), parents and teachers completed the ADHD-RS-IV and clinicians completed the Behavioral Rating Inventory for Children following a psychological testing session. At age 6, [Mean (SD) age?=?6.62 (0.35) years], parents were interviewed with the K-SADS-PL; teachers completed the ADHD-RS-IV; and laboratory measures of hyperactivity, impulsivity, and inattention were obtained from children. Hierarchical logistic and linear regression analyses examined which combination of BL ratings best predicted 6-year-old ADHD diagnosis and severity, respectively. At age 6, 56 (53.8 %) children met DSM-IV criteria for a diagnosis of ADHD. BL ratings from parent/teacher/clinician, parent/teacher and parent/clinician combinations significantly predicted children who had an ADHD diagnosis at age 6. Parent and clinician, but not teacher, behavior ratings were significant independent predictors of ADHD diagnosis and severity at 6-years-old. However, only clinician reports of preschoolers’ behaviors predicted laboratory measures of over-activity and inattention at follow-up. Cross-situationality is important for a diagnosis of ADHD during the preschool years. Among parents, teachers and clinicians, positive endorsements from all three informants, parent/teacher or parent/clinician appear to have prognostic value. Clinicians’ ratings of preschoolers’ inattention, impulsivity and hyperactivity are valid sources of information for predicting ADHD diagnosis and severity over time.     

What Specific Facets of Executive Function are Associated with Academic Functioning in Youth with Attention-Deficit/Hyperactivity Disorder?

The purpose of the study was to evaluate the relation between ratings of Executive Function (EF) and academic functioning in a sample of 94 middle-school-aged youth with Attention-Deficit/Hyperactivity Disorder (ADHD; Mage = 11.9; 78 % male; 21 % minority). This study builds on prior work by evaluating associations between multiple specific aspects of EF (e.g., working memory, inhibition, and planning and organization) as rated by both parents and teachers on the Behavior Rating Inventory of Executive Function (BRIEF), with multiple academic outcomes, including school grades and homework problems. Further, this study examined the relationship between EF and academic outcomes above and beyond ADHD symptoms and controlled for a number of potentially important covariates, including intelligence and achievement scores. The EF Planning and Organization subscale as rated by both parents and teachers predicted school grades above and beyond symptoms of ADHD and relevant covariates. Parent ratings of youth’s ability to transition effectively between tasks/situations (Shift subscale) also predicted school grades. Parent-rated symptoms of inattention, hyperactivity/impulsivity, and planning and organization abilities were significant in the final model predicting homework problems. In contrast, only symptoms of inattention and the Organization of Materials subscale from the BRIEF were significant in the teacher model predicting homework problems. Organization and planning abilities are highly important aspects academic functioning for middle-school-aged youth with ADHD. Implications of these findings for the measurement of EF, and organization and planning abilities in particular, are discussed along with potential implications for intervention.     

Emotion Dysregulation and Emotional Impulsivity among Adults with Attention-Deficit/Hyperactivity Disorder: Results of a Preliminary Study

Recent reviews argue that emotion dysregulation is an important feature of attention-deficit/hyperactivity disorder (ADHD) and involves a failure to inhibit negative emotions that leads to negative affectively-driven impulsive behavior (i.e., emotional impulsivity). The goal of the current study was to assess (a) whether emotion dysregulation and emotional impulsivity was higher in a group of adults diagnosed with ADHD and (b) if the relationship between core ADHD symptoms (i.e., inattention and hyperactivity-impulsivity) and emotional impulsivity is mediated by emotion dysregulation symptoms. A group of adults with (n?=?18) and without (n?=?23) ADHD completed measures of core ADHD symptoms, emotion dysregulation, and emotional impulsivity. A series of one-way analyses of covariance indicated significant between-group differences in emotion dysregulation and emotional impulsivity when current depression and oppositional defiant disorder ratings were covaried. In addition, the relationship between ADHD symptoms and emotional impulsivity was mediated by emotion dysregulation symptoms. These findings suggest that emotion dysregulation and emotional impulsivity are higher in adults diagnosed with ADHD and that emotion dysregulation symptoms have predictive value beyond core ADHD symptoms.     

Agreement Between Parent and Teacher Ratings of Disruptive Behavior Disorders in Children with Clinically Diagnosed ADHD

This study investigated the agreement between parent and teacher ratings of DSM-IV symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and related disorders: Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). A sample of 55 children in the age range of 6–12 years with clinically diagnosed ADHD participated in the study. Parents and teachers were asked to complete the Disruptive Behavior Disorder Rating Scale (DBDRS; W. E., Pelham, E. M., Gnagy, K. E., Greenslade, & R. Milich, 1992). No association was found between parent and teacher ratings of inattention and hyperactivity/impulsivity. However, moderate to high levels of agreement were obtained for ratings of symptoms that characterized ODD and CD. The observed low levels of agreement between parent and teacher ratings of ADHD symptoms may be attributed to different perceptions of the problem behavior by parents and teachers, medication effects, or the situation specificity of children's behavior. It is recommended that the diagnostic criterion of symptom pervasiveness for the diagnosis of ADHD be operationalized more clearly.     

Validity of the Sluggish Cognitive Tempo, Inattention, and Hyperactivity Symptom Dimensions: Neuropsychological and Psychosocial Correlates

This study examined the latent structure and validity of inattention, hyperactivity-impulsivity, and sluggish cognitive tempo (SCT) symptomatology. We evaluated mother and teacher ratings of ADHD and SCT symptoms in 140 Puerto Rican children (55.7% males), ages 6 to 11?years, via factor and regression analyses. A three-factor model (inattention, hyperactivity-impulsivity, and SCT) provided the best fit for both sets of ratings. Inattention was the strongest correlate of lower scores on neuropsychological, achievement, and psychosocial measures. Externalizing problems were most strongly associated with hyperactivity-impulsivity, and internalizing problems were most strongly associated with parent-rated SCT and teacher-rated Inattention. SCT was not associated with executive function but was negatively associated with math. Inattention accounted for a disproportionate amount of ADHD-related impairment, which may explain the restricted discriminant validity of DSM-IV types. The distinct factors of hyperactivity-impulsivity and SCT had unique associations with impairing comorbidities and are roughly equivalent in predicting external correlates of ADHD-related impairment.     

Impulsivity Symptoms as Core to the Developmental Externalizing Spectrum

Impulsivity is posited to be a key part of the externalizing spectrum during childhood, but this idea has received minimal empirical attention. The goal of the present investigation was to utilize network analysis to determine whether behavioral impulsivity symptoms are key components of the externalizing network across several developmental periods from preschool into adolescence. Participants were 109 preschoolers (64 % male) ages 3 to 6, 237 children (59 % male) ages 6 to 9, 372 children (59 % male) ages 10 to 13, and 357 adolescents (59 % male) ages 13 to 17 and their parents. Parents completed ratings of Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) symptoms on a well-validated rating scale. Network analyses indicated that ADHD and ODD were somewhat differentiated in preschool, becoming united by behavioral impulsivity symptoms during early childhood, and then differentiating into inattention versus externalizing clusters later during childhood and in adolescence. Behavioral impulsivity symptoms were core to the externalizing spectrum across most developmental periods, but core inattentive and ODD symptoms were also identified in line with progressive differentiation. These results suggest the increasing importance of impulsivity symptoms across development, explaining externalizing comorbidity and potentially serving as a viable target for childhood interventions for externalizing problems.     

The Role of ADHD and Negative Emotional Lability in Predicting Changes in Parenting Daily Hassles

The present study examined the extent to which children’s negative emotional lability (measured via ecological momentary assessment—EMA) and ADHD diagnostic status predicted changes in the frequency of daily parenting hassles and the stress resulting from daily hassles at one-week follow-up when controlling for baseline parenting hassles. Parents of 84 children 8–12 years-old (47 with ADHD, 37 without ADHD) completed a measure of parenting daily hassles at baseline and follow-up and participated in EMA assessment protocol ratings of their child’s mood (3-times daily) for one week. Analyses of covariance indicated that parents of children with ADHD reported significantly greater frequency of daily parenting hassles and intensity of parenting stress resulting from daily hassles than parents of children without ADHD at baseline and follow-up. Hierarchical regression analyses suggested that children’s negative emotional lability was a significant predictor of the intensity of parenting stress resulting from daily hassles, but not the frequency of daily parenting hassles. There was also an interaction of ADHD diagnostic status and greater EMA-derived negative emotional lability in the prediction of the frequency of daily parenting hassles due to children’s challenging behaviors. Specifically, greater negative emotional lability predicted more frequent daily parenting hassles due to children’s challenging behaviors among parents of children without ADHD but not among parents of children with ADHD. Overall, this study suggests that children’s negative emotional lability is a significant predictor of aspects of daily parenting hassles across parents of children with and without ADHD.     

Inattentive and noninattentive ADHD children: Do they constitute a unitary group?

Teacher-rated ADHD and normal control children were administered a continuous performance test (CPT), and were then further subdivided based upon the presence or absence of objectively assessed attentional deficits. In addition, children were assessed using several measures of cognitive and behavioral functioning. Attentional deficits were signficantly more prevalent among the ADHD group, but about half of the ADHD children showed no evidence of objectively assessed attentional dysfunction. Further group analyses indicated that ADHD children with objectively assessed attentional dysfunction appeared cognitively impaired, while ADHD children without objective evidence of attentional dysfunction had more conduct problems. CPT inattention was not related to the presence of cognitive impairments or conduct problems in the control group. These data must be considered preliminary because teacher ratings were the only source of diagnosis and a single measure of inattention was used. However, they suggest that two subtypes of ADHD children can be identified, one characterized by inattention and learning problems, and the other by conduct problems.The authors gratefully acknowledge the assistance of Sister Hildegard Kogler and the St. Francis DeSales School, and the parents and children who participated in this study.     

A multitrait-multisource confirmatory factor analytic approach to the construct validity of ADHD rating scales

Confirmatory factor analysis was used to model a multitrait-multisource design to evaluate the construct validity of attention-deficit/hyperactivity disorder (ADHD) rating scales. The 2 trait factors were the ADHD inattention and hyperactivity/impulsivity dimensions. The 2 source factors were parents and teachers. In Study 1, parents and teachers rated 1,475 Australian elementary school children on the ADHD symptoms. In Study 2, parents and teachers rated 285 Brazilian elementary school children on the ADHD symptoms. Similar results occurred in both studies with most of the ADHD symptoms containing more source than trait variance, thus providing weak evidence for the convergent and discriminant validity of the symptoms as measured by rating scales. The study outlines the implications of such strong source effects for understanding ADHD.     

Do Childhood Emotional Lability and ADHD Symptoms Have Shared Neuropsychological Roots?

Emotional Lability (EL) is a source of impairment in multiple mental disorders of children, including attention-deficit/hyperactivity disorder (ADHD). It has been proposed that the overlap between EL and ADHD symptoms is the result of common neuropsychological deficits. The aim of the present study was to test this hypothesis by using a multi-method approach. In a mixed sample of 61 children (49 community sample and 12 children with an ADHD diagnosis) aged between 8 and 12 years, we examined the relationship between parental reports of ADHD and EL, real-time children’s emotional expressions in an experimental context, children’s performance on neuropsychological tasks and parental ratings of neuropsychological functioning. Parental EL ratings were significantly predicted by task-based reaction time variability and by questionnaire measures of Self-Direction & Organization and Arousal Regulation. Parental EL ratings were also significantly related to both ADHD symptom dimensions. After controlling for shared neuropsychological factors, ADHD symptoms no longer predicted parental EL ratings. Neuropsychological task performance was not significantly related to real time emotional expressions. However, positive emotional expressions were significantly predicted by higher parental ratings of Cognition and negative emotional expressions by parental ratings of low Effort engagement – accounting for some of the correlation with ADHD symptoms. The current results highlight the plausible role of cognitive energetic processes in explaining the EL and ADHD symptom association.

     

The Relation Between Sluggish Cognitive Tempo and DSM-IV ADHD

To test the relation between sluggish cognitive tempo (SCT) and DSM-IV ADHD symptoms, parent and teacher ratings of the 18 DSM-IV ADHD items and five potential SCT items were obtained in a community sample of 8-18 year-old twins that was overselected for ADHD and learning disabilities (n = 296). Confirmatory factor analyses revealed that a three-factor model provided the best fit to the data for both parent and teacher ratings. DSM-IV inattention and hyperactivity-impulsivity symptoms loaded on two factors consistent with the DSM-IV model, and five SCT symptoms loaded primarily on a third factor. The SCT and inattention factors were highly correlated, whereas SCT and hyperactivity-impulsivity were weakly related. Both raters indicated that children meeting symptom criteria for the combined and inattentive subtypes exhibited significantly more SCT symptoms than those meeting symptom criteria for hyperactive-impulsive type and the comparison group without ADHD. Children meeting symptom criteria for the inattentive type exhibited significantly more SCT symptoms than those meeting criteria for the combined type, based on teacher ratings. These results suggest that SCT is an internally consistent construct that is significantly associated with DSM-IV inattention.