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.     

Assessment of executive function in ADHD adolescents: contribution of performance tests and rating scales

This study aimed to analyze performance on measures of neuropsychological and behavioral executive functions (EF) in adolescents with attention deficit hyperactivity disorder (ADHD), and to evaluate the utility of performance-based tests for predicting scores on behavioral EF ratings. One hundred eighteen adolescents (75 ADHD and 43 controls) aged 12–16 years performed neuropsychological tests and completed a behavior rating scale of EF. The ADHD group presented significantly lower scores than controls on Full Scale IQ (FSIQ) and all indexes of the WISC-IV, except the verbal comprehension index (VCI). The ADHD group had significantly lower scores on performance-based tests of working memory, planning and inhibition, and on EF rating scales. Scores on the cognitive EF working memory, planning and flexibility modestly predicted performance on behavioral EF. The results suggest that the combined use of performance-based tests and rating scales provides valuable complementary information that can improve the assessment of executive domains in ADHD.     

Examining the relationship between performance-based and questionnaire assessments of executive function in young preterm children: Implications for clinical practice

The aim of this study was to determine whether specific performance-based executive function assessment tools were associated with executive functioning in everyday life as reported by parents and teachers of four- to five-year-old preterm and term children. At the age of 4 years, 141 preterm children born <33 weeks’ gestation and 77 term children were assessed using performance-based intelligence (WPPSI-III) and executive function (EF) assessment tools (NEPSY-II, Day-Night and Shape School tasks). The assessment results were compared with the parent and teacher completed questionnaires of EF (BRIEF-P) when the children started kindergarten at the age of 4 to 5 years. The performance-based intelligence and EF assessment results were not consistently associated with the parent and teacher reports of EF in everyday life for either preterm or term groups. Clinical implications of using and interpreting performance-based EF assessment tools and EF questionnaires are discussed with a particular focus on young preterm children at the commencement of formal schooling.     

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.     

Concordance of teacher-rated and performance-based measures of executive functioning in preschoolers

The most common method used to evaluate child behavior and functioning is rating scales completed by parents and/or teachers. Given that executive functioning (EF) plays a fundamental role in the developing child’s cognitive, behavioral, and social-emotional development, it would be ideal if ratings of EF and performance-based EF measures assess the same construct. However, most studies report a small to negligible association between performance-based measures and ratings of EF. There are few studies investigating this association for preschoolers, and most only include parent ratings. Teachers may be more reliable reporters of EF behaviors due to the higher demand for EF skills in the preschool setting than at home and because teachers may have a better sense of what behaviors are normative. In this study, we reviewed the associations between three EF rating scales completed by teachers on 243 preschool children. Results showed small to moderate correlations with EF measures of inhibition and cognitive flexibility/switching for all three scales, with the strongest associations observed between Child Behavior Rating Scale (CBRS) Behavioral Regulation subscale and child EF measures. Exploratory multivariate path analyses showed that, after controlling for age, sex, and socioeconomic status (SES), Behavioral Regulation significantly predicted performance-based measures of EF and accounted for incrementally more variance in the models. We conclude that in ideal situations, it is best to measure EF using both rating scales and performance-based measures of EF. The CBRS seems to be a sensitive measure of EF in preschoolers and may be a helpful brief screening tool for use with teachers.     

Predictors of physical aggression in children with attention-deficit/hyperactivity disorder

The present investigation examined factors that predict physical aggression in children with attention-deficit/hyperactivity disorder (ADHD). Stepwise, multiple regression-analyses were used to examine predictors of children's physical aggression as rated by parents at a 1-year follow-up point and by teachers at both 1- and 2-year follow-up points. Early parent and teacher ratings of verbal aggression (ie, cursing, teasing, and threatening) accounted for the greatest proportion of the variance in physical aggression ratings obtained at follow-up. None of the other predictor variables, including early ratings of physical aggression and ADHD behaviors, contributed significant additional variance beyond that accounted for by early verbal aggression ratings. Temporal and cross-informant analyses revealed that the relationship between verbal aggression and later physical aggression was situation-specific for teacher ratings but not parent ratings. Although physical aggression may emerge early in development, these data suggest that verbal aggression represents a stable, temperamental characteristic that may be of greater value than early physical aggression for predicting later physically aggressive acts.     

Comparing Four Methods of Integrating Parent and Teacher Symptom Ratings of Attention-deficit/hyperactivity Disorder (ADHD)

Although parents and teachers are valid informants in the assessment of childhood attention-deficit/hyperactivity disorder (ADHD), there is relatively little systematic research on how these ratings should be optimally combined. We compared four methods of ADHD assessment to determine how well they identified impaired children: (1) parent only, (2) teacher only, (3) parent or teacher (‘or rule’), and (4) parent and teacher (‘and rule’). We obtained parent and teacher ratings of ADHD from the Disruptive Behavior Disorder Rating Scale on 232 5- to 10-year-old children (69% male; 47% Caucasian) with (n = 121) and without (n = 111) ADHD. We used receiver operating characteristic curves (ROC) and seemingly unrelated regression analyses (SUR) to evaluate how accurately each method identified categorically- and dimensionally-defined measures of functional impairment. Parent ratings of ADHD optimally identified globally impaired children based on categorical and dimensional measures. However, teacher ratings of ADHD most accurately identified children who were negatively regarded by peers using categorical, but not dimensional, measures. No ADHD assessment method effectively identified children with academic difficulties. Although multiple informants are valuable in the assessment of ADHD, no single method was consistently superior in identifying impaired children across domains. We consider alternative assessment strategies in ADHD as well as other potential factors that may contribute to modest agreement among informants.     

Effects of the EXAT neuropsychological multilevel intervention on behavior problems in children with executive function deficits

This is a clinical intervention study of children with executive function (EF ) deficits. A neuropsychological multimodal group intervention called EXAT (rehabilitation of EX ecutive function and AT tention) was developed at the Psychology Clinic of the University of Tampere. Based on the principles of neuropsychological rehabilitation and behavioral modification, EXAT combines child group training, parent training, and teacher consultations. The aims of this study were to investigate behavior problems before and after the intervention in children attending EXAT and in controls, and to compare intervention effects in hyperactive, inattentive, and EF subgroups based on the primary deficit described in the referral. The participants were 86 children (6–12 years) with a mean IQ of 91.4 attending EXAT and 45 controls. The participants’ parents and teachers completed the Conners’ Rating Scales‐Revised. In addition, the Strengths and Difficulties Questionnaire was completed by the parents attending EXAT . The parents reported statistically significant decreases with medium effect sizes for the CPRS ‐R subscales for impulsivity, hyperactivity, and oppositional behavior. In the controls within the same time interval, there was increase in restless and impulsive behavior, and a decrease in total problems. The teachers reported positive changes after the intervention in ADHD symptoms and anxiousness/shyness, but the effects sizes were small. The intervention effects were larger in the hyperactive subgroup. Positive intervention effects were related to a younger age, lower IQ , and simultaneous learning support. In conclusion, EXAT – a structured multilevel group intervention – has positive effects on children's behavior regulation skills by decreasing impulsivity and restless behavior.     

Interrater agreement on behavioral executive function measures in adolescents with Attention Deficit Hyperactivity Disorder

Background/ObjectiveThough most children with Attention Deficit Hyperactivity Disorder (ADHD) show difficulties in behavioral measures of executive functions (EF), few studies have examined interrater agreement in these measures.Objective: To analyze the agreement between parents, teachers and self-reports of behavioral EF in adolescents with ADHD and controls. Method: A sample of 118 adolescents (75 with ADHD and 43 controls) was rated by parents, teachers and the adolescents themselves using the Comprehensive Executive Function Inventory. The intraclass correlation coefficient (ICC) and Bland and Altman methods were used to evaluate agreement. Results: The ICC between parents, teachers and self-report was poor or moderate in the group with ADHD; in the control group the agreement was fair to good. The Bland and Altman graphs show that, in the control group, most of the scores are below to the clinical cut-off point, while in the group with ADHD they are above. Conclusions: Agreement between all raters was low. Parents, teachers and adolescents agreed on the absence of deficits in behavioral EF in the control group, and on the presence of deficits in the group with ADHD, although they did not agree on the frequency of these deficits.     

Predicting the Early Developmental Course of Symptoms of Attention Deficit Hyperactivity Disorder

Data from the National Institute of Child Health and Human Development Study of Early Child Care were examined to test whether: attention deficit/hyperactivity disorder (ADHD) symptoms remain stable from 54 months through early elementary school; behavioral inhibition and attention deficits assessed at 54 months predict ADHD symptoms in elementary school, even after controlling for their temporal stability; and early behavioral inhibition and attention deficits moderate the longitudinal stability in ADHD symptoms. Data were examined using continuous and categorical measures of symptoms. Modest stability in ADHD symptoms from 54 months to third grade was found. Measures of inhibition and inattention predicted later teacher ratings uniquely, but no evidence was found for moderation. Measures of preschool behavioral inhibition also predicted “persistently at risk status” defined by elevated teacher ratings over time. Results are discussed in terms of executive and motivational facets of inhibition that may be related to early signs of ADHD.     

Patterns of Parental Adherence and the Association to Child and Parenting Outcomes Following a Multicomponent School-Home Intervention for Youth With ADHD

The goal of the present study was to evaluate the role of parent adherence in the Collaborative Life Skills (CLS) program, a multicomponent school-home intervention, for predicting child and parenting outcomes. A sample of 129 children (63% male; M age = 8.22, SD = 1.10; grades 2–5) with attention-deficit/hyperactivity disorder (ADHD) and their parents participated in CLS, which included 10 weekly behavioral parent training group sessions. Each week, parents provided information on their CLS skill use between sessions (at home) as part of the intervention. Outcome measures included parent and teacher ratings of child behavior and parenting at post-intervention and 6 months follow-up. Growth mixture models examining weekly parent skill use trajectories throughout the intervention significantly predicted parent- and teacher-reported outcomes including parent-rated child behavior, teacher-rated academic competence, and positive parenting behaviors. Fifty-two percent of parents displayed moderate skill use throughout the intervention, whereas the remaining parents had either low (20%) or high (28%) initial levels of use but demonstrated high skill utilization by the middle of the intervention. Results highlight the importance of examining individual differences in parents between session strategy use for behavioral parent training interventions targeting child and parenting outcomes.     

The Predictive Validity of Parent and Teacher Reports of ADHD Symptoms

The objectives were to evaluate the ability of the Inattention and Hyperactivity–Impulsivity factors of the ADHD Rating Scale-IV to differentiate children with ADHD from a control group and to discriminate children with different subtypes of ADHD. Also, we sought to determine optimal cutoff scores on the teacher and parent versions of this scale for making diagnostic decisions about ADHD. In a sample of 92 boys and girls 6 to 14 years of age referred to a regional ADHD program, we assessed ADHD diagnostic status using categorical and dimensional approaches as well as parent- and teacher-report measures. Logistic regression analyses showed that the Inattention and Hyperactivity–Impulsivity factors of the ADHD Rating Scale-IV were effective in discriminating children with ADHD from a control group and differentiating children with ADHD, Combined Type from ADHD, Inattentive Type. Although both teacher and parent ratings were significantly predictive of diagnostic status, teacher ratings made a stronger contribution to the prediction of subtype membership. Using symptom utility estimates, optimal cutoff scores on the Inattention and Hyperactivity–Impulsivity scales for predicting subtypes of ADHD were determined.     

Modeling Rater Disagreement for ADHD: Are Parents or Teachers Biased?

The present study is the first to utilize twin modeling to examine whether parent-teacher disagreement for ADHD ratings is due to parent or teacher bias, or due to raters observing different but valid ADHD behaviors. A joint analysis was conducted with 106 twin pairs, including twins selected for ADHD and control twin pairs. Total ADHD scores were analyzed using multiple rater models that estimate genetic and environmental contributions common to both raters and unique to each rater. Results suggest that 1) disagreement in ADHD ratings is strongly due to parents and teachers observing different ADHD behaviors, some of which is valid and some of which is due to bias, and 2) parents may be more biased than teachers in their ADHD ratings.     

Associations Between Family Environment, Parenting Practices, and Executive Functioning of Children with and Without ADHD

We examined the relationships between executive functioning, family environment, and parenting practices in children diagnosed with ADHD as compared to children without ADHD. Participants were parents (N = 134) of 6- to 12-year-old ADHD and non-ADHD-diagnosed children. Compared to the control group, parents of children diagnosed with ADHD reported their children as exhibiting greater problems with behavioral control and metacognitive abilities, and described their family environments as less organized and higher in family conflict. Family environment and parenting practices were not correlated with behavioral control or metacognitive abilities in children with ADHD. In children without ADHD, higher levels of family cohesion, organization, and expressiveness, and lower levels of family conflict, were significantly correlated with greater behavioral control. Higher levels of family cohesion and organization were significantly and positively associated with regulation of metacognitive abilities in children without ADHD. In general, aspects of the family environment and parental limit setting appear to be associated with the development of executive functions in children not diagnosed with ADHD; however, family environment and parenting practices were not associated with executive functions in children diagnosed with ADHD.     

Factorial validity of the Behavior Rating Inventory of Executive Function (BRIEF)-Teacher form

Deficits in executive function (self-regulatory mechanisms) have been linked with many childhood disorders including attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder, and conduct disorder. Executive functioning is typically assessed by individually administering performance-based measures in a clinical setting. However, performance-based methods are inefficient for school psychologists. A more feasibly implemented measure for applied settings is the Behavior Rating Inventory of Executive Function (BRIEF), but researchers have raised questions about the internal validity and the proposed factors. In this study, we examined the factor structure of the teacher form of the BRIEF in a sample of 2,044 general education elementary students and 131 teachers in a multilevel design. Results revealed support for a model with three factors at Level 1 and one general factor at Level 2. The results of our study do not support the current two-factor model of the published BRIEF protocol.     

Can Executive Functions Explain the Relationship Between Attention Deficit Hyperactivity Disorder and Social Adjustment?

This study examined the ability of executive functions (EF) to account for the relationship between Attention Deficit Hyperactivity Disorder (ADHD) status and social adjustment as indexed by parent and teacher report and by performance on a standardized observational “chat room” task. Children with the Combined subtype (ADHD-C; n = 23), the Primarily Inattentive Subtype (ADHD-I; n = 33), and non-ADHD controls (n = 36) participated. EF did not mediate the relationship between ADHD status and parent or teacher report of social adjustment. EF accounted for about 40–50% of the variance between ADHD status and the ability of children to detect subtle verbal cues as well as memory for the conversation in the chat room task, but did not mediate the relationship between ADHD and the number of prosocial, hostile, or on-topic statements that were made. Results are consistent with other recent reports, and suggest that the role of EF deficits in the production of social skill deficits in ADHD may not be as prominent as is typically assumed. The implications for the development of intervention programs designed to target core cognitive etiologic factors are discussed.     

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.     

Brief report: Relationship between performance testing and parent report of attention and executive functioning profiles in children following perinatal arterial ischemic stroke

Children with perinatal arterial ischemic stroke (PAIS) have increased rates of attention and executive functioning (EF) weaknesses. Research in other pediatric disorders has documented poor consistency between parent report of these skills and performance-based measures. We compared these data sources in children with PAIS. Forty full-term (≥37 weeks) children ages 3–16 (median = 7.2 years; 58% male) with PAIS completed neuropsychological testing and composite scores were created for seven attention and EF domains (Processing Speed; Attention; Working Memory; Verbal Retrieval; Inhibitory Control; Flexibility/Shifting; Planning). Parents completed “real-world” functioning questionnaires (ADHD Rating Scale-IV, BRIEF). Correlational analysis were used to compare parent and performance measures. Correlations between ADHD Rating Scale-IV scores and the performance-based Attention and Inhibition composite scores were nonsignificant. Significant negative correlations were found between the BRIEF GEC and performance-based Verbal Retrieval and Processing Speed composites, but remaining GEC/composite comparisons were nonsignificant. Analyses between parent report BRIEF index scores and the corresponding performance-based domain identified one significant negative correlation between the BRIEF Working Memory Index and the Working Memory composite score. While children with PAIS demonstrate difficulties in attention and EF on both parent report and performance measures, little significance was found in comparisons of these two types of measures. There may be several explanations for this dissociation: measures assessing different aspects of the same underlying construct; performance-based measures lacking ecological validity; and parents underestimating/underreporting their child’s deficits. Thus, multiple sources of informant and performance data are necessary to make more accurate conclusions about functioning in these domains.     

Latent mean comparisons on the BRIEF in preterm children: Parent and teacher differences

Executive function is a heterogeneous construct applied to cognitive capacities that together enable individuals to effectively engage in activities toward a purposive goal. Children born at extremely low birth weight (ELBW) are at risk of executive dysfunction on performance-based measures. In natural contexts, executive function may be described using such parental and teacher questionnaires as the Behavior Rating Inventory of Executive Function (BRIEF). This study examined the factor structure of the BRIEF-parent form in 124 ELBW children and of the BRIEF-teacher form in 90 ELBW children. Although our data showed that the fit of a two-factor structure was adequate for the parent report, a three-factor model provided advantages over the two-factor model across all fit indices and best characterized the data. For teacher report, these data supported a three-factor but not a two-factor model. Using the three-factor model for both groups of informants, we compared parent and teacher reports (n = 90 pairs) between the three identified latent variables. Parents reported significantly more difficulty with Emotional Regulation (p < .05), and teachers reported significantly more difficulty with Behavioral Regulation (p < .05). No significant differences were found between parent and teacher reports for Metacognition.     

Objective measures of executive functioning are highly discrepant with parent-report in fetal alcohol spectrum disorders

The purpose of the current study was to evaluate the relationship between parent-report and objective measures of executive function in children diagnosed with Fetal Alcohol Spectrum Disorder (FASD). The participants were a clinical sample of 551 children who completed 597 evaluations, including initial and re-evaluations. Participants were 6–16 years old, with a mean age of 10. Pearson correlations were used to determine the relationship between performance-based measures and parent-report measures of executive functioning. Relationships among the same types of measures, that is, performance based or parent report, were also evaluated. The data largely demonstrate low nonsignificant correlations between performance-based measures and parental report of executive function. Parent-report measures were internally consistent as were objective measures. It is possible that a third variable, for example, parental frustration, significantly influences parent reports. It is also likely that objective measures, which are administered in a controlled environment, do not fully capture children’s day-to-day functioning. That is, a child may have the executive function abilities (i.e., good performance on objective measures) but may be unable to deploy the appropriate skills in their daily lives, as evidenced by parental report. Children with FASD who have executive function abilities but not implementation skills likely require different interventions than children who lack abilities and skills.