Attention Deficit-Hyperactivity Disorder, Depression, and Self- and Other-Assessments of Social Competence: A Developmental Study

This study examined whether others (i.e., teachers and parents) and self-appraisals of social competence mediated the relationship between Attention-Deficit/Hyperactivity Disorder (ADHD) and depression. To determine whether age moderated the effects of the mediation, the total sample was divided into younger (under 9) and older (at or above 9 years) age levels. The total sample (age range 6.6 to 11.7 years) was primarily male (194 boys and 52 females) and consisted of 148 children diagnosed with ADHD and 98 community controls. Three central findings were derived from this study. First, there was a strong relationship between ADHD (with and without comorbid ODD/CD) and depression in both younger and older aged children. Among younger children with ADHD, there was no differential influence on the level of depression depending on whether or not ADHD was comorbid with ODD/CD; in contrast, with older children, comorbid ODD/CD had higher levels of depression than was the case for children with ADHD that did not display such comorbidity. Second, with younger children approximately half of the relationship between ADHD (with and without comorbid ODD/CD) and depression was exclusively mediated by others appraisal of social competence. Third, a more complex relationship between ADHD and depression emerged during the later part of the childhood years. As such, the relationship between ADHD, others appraisals of social competence, and depression was further mediated by self-appraisals of social competence. Findings are discussed in terms of developmental theory and theoretical models of childhood depression.Rick Ostrander and David S. Crystal contributed equally to this article, and the order of authorship was determined by a coin toss.     

Risk Taking and Sensitivity to Punishment in Children with ADHD,ODD, ADHD+ODD,and Controls

We used the Balloon Analog Risk Task (BART) to examine risk taking and sensitivity to punishment, two relevant aspects of behavioral inhibition, in 203 school-age children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), ADHD+ODD, and controls. Participants earned points on the BART by pumping 30 separate balloons that exploded at variable intervals. No points were earned on a trial when a balloon exploded. The number of pumps across all balloons estimated risk taking and the reduction in pumps following balloon explosions was interpreted as an indicator of sensitivity to negative punishment. We found that all groups significantly differed from one another on risk taking. The ADHD+ODD group pumped the most, followed by the ODD, ADHD, and the control group, respectively. For sensitivity to negative punishment, all groups performed differently, with the ODD group showing the least sensitivity to an exploded balloon, followed by the ADHD, control, and ADHD+ODD groups, respectively. Children with ADHD+ODD demonstrated significantly different patterns of risk taking and sensitivity to negative punishment than children with either ADHD-only or ODD-only. ADHD youth with comorbid ODD had the greatest levels of risk taking, but they were also the most sensitive to negative punishment. The relationship between ADHD and ODD, as well as the nature of comorbidity in constructs related to risk taking and related behaviors, are discussed.     

Significance of Childhood Conduct Problems to Later Development of Conduct Disorder Among Children With ADHD: A Prospective Follow-Up Study

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.     

Neurocognitive performance of 5- and 6-year-old children who met criteria for attention deficit/hyperactivity disorder at 18 months follow-up: results from a prospective population study

The aim of this prospective study was to examine whether neurocognitive performance of children aged 5–6 years distinguished children who were later diagnosed with attention deficit/hyperactivity disorder (ADHD) or borderline ADHD from children without ADHD after adjustment for behavioral measures and to examine the influence of comorbid psychopathology. Out of a general population of 1,317 children, 366 children were selected on the basis of their scores on the Child Behavior Checklist (CBCL). Eighteen months later, the parents were interviewed using a standardized child psychiatric interview: 33 children were classified as ADHD and 75 children as borderline ADHD, and there were 258 children without ADHD. Children with rated ADHD were significantly impaired on measures of visuomotor ability and working memory compared to children without ADHD after adjustment for CBCL results. The performance of borderline ADHD children was in between that of children with and without ADHD. In addition, 4 groups of children were analyzed: 9 ADHD, 24 ADHD with comorbid oppositional defiant disorder/conduct disorder (ODD/CD), 59 ODD/CD, and 274 controls. Children with rated comorbid ADHD and ODD/CD performed significantly worse on these tasks compared to children with rated ODD/CD and control children while they did not differ from ADHD children. Our results imply that neurocognitive measures can contribute to the early identification of ADHD with and without comorbid ODD/CD.     

Do Executive Function Deficits Differentiate Between Adolescents with ADHD and Oppositional Defiant/Conduct Disorder? A Neuropsychological Study Using the Six Elements Test and Hayling Sentence Completion Test

Two neuropsychological measures of executive functions—Six Elements Tests (SET) and Hayling Sentence Completion Test (HSCT)—were administered to 110 adolescents, aged 12–15 years. Participants comprised four groups: Attention Deficit Hyperactivity Disorder (ADHD) only (n = 35), ADHD and Oppositional Defiant Disorder/Conduct Disorder (ODD/CD) (n = 38), ODD/CD only (n = 11), and a normal community control group (n = 26). Results indicated that adolescents with ADHD performed significantly worse on both the SET and HSCT than those without ADHD, whether or not they also had ODD/CD. The adolescents with ADHD and with comorbid ADHD and ODD/CD were significantly more impaired in their ability to generate strategies and to monitor their ongoing behavior compared with age-matched controls and adolescents with ODD/CD only. It is argued that among adolescents with clinically significant levels of externalizing behavior problems, executive function deficits are specific to those with ADHD. The findings support the sensitivity of these two relatively new tests of executive functions and their ecological validity in tapping into everyday situations, which are potentially problematic for individuals with ADHD.     

A sequential analysis of the mother-adolescent interactions of ADHD,ADHD/ODD,and normal teenagers during neutral and conflict discussions

The sequential interactions of three groups of teenagers conversing with their mothers during both neutral and conflict discussion situations were evaluated. Groups consisted of (1) attention deficit hyperactivity disorder (ADHD) alone (n =21), (2) ADHD with comorbid oppositional defiant disorder (ADHD/ODD; n =40), and (3) a community control group of adolescents (n =49). All groups had been followed concurrently for the past 8 to 10 years before being reevaluated in this study. Results indicated that (1) teens and parents in all groups interacted in a tightly linked manner, with the behavior of each member being significantly related only to the immediate antecedent behavior of the other; (2) mothers in all groups were more likely than teens to initiate positive behaviors; (3) teen interactions could be characterized as tit-for-tat while mothers could be typified as be-nice-and-forgive; (4) mother-teen dyads in the ADHD/ODD group displayed significantly higher rates of conflict behaviors than dyads in the other two groups, who did not differ significantly from each other on most measures; and (5) mothers in the ADHD/ODD group responded in a manner similar to their teens (greater negativity) and less like that of mothers in the other groups. The majority of conflict between ADHD children and their parents seemed due to comorbid ODD and such ODD is a family, not just a teen, characteristic.     

ODD dimensions, ADHD, and callous-unemotional traits as predictors of treatment response in children with disruptive behavior disorders

To answer several questions pertinent to DSM-V, the authors examined the predictive validity of pretreatment oppositional defiant disorder (ODD) dimensions, attention-deficit/hyperactivity disorder (ADHD), and callous-unemotional (CU) traits in relation to several treatment outcomes in 177 children diagnosed with ODD or conduct disorder (CD). Multiple informants completed diagnostic interviews and rating scales at 6 assessment points (pretreatment to 3-year follow-up) to document emotional and behavioral outcomes. After controlling for pretreatment CD, the ODD dimension of hurtfulness was related to treatment-resistant CD, delinquent behaviors, and externalizing problems. In contrast, the ODD dimension tapping irritability was associated with treatment-resistant ODD, internalizing problems, and global functional impairment following treatment. Whereas pretreatment ADHD was associated with posttreatment ODD and social problems, it was unrelated to posttreatment CD symptoms and diagnosis. Contrary to predictions, CU traits were unrelated to any posttreatment outcomes after controlling for other covariates. These findings remained after controlling for measures of pretreatment global functional impairment.     

Effects of background anger,provocation, and methylphenidate on emotional arousal and aggressive responding in attention-deficit hyperactivity disordered boys with and without concurrent aggressiveness

We investigated the effects of background anger, provocation, and methylphenidate on emotional, physiological, and behavioral responding in children with attentiondeficit hyperactivity disorder (ADHD) with and without concurrent aggression. Our study revealed that ADHD boys showed more emotional and physiological distress when exposed to an interaction in which an administrator chastised each boy's favorite counselor, compared to a friendly interaction between the two adults. The background anger manipulation did not affect the aggressive behavior of the boys against an opponent in an aggressive game. High-aggressive (HA) ADHD boys were more likely to respond to provocation with aggression than low-aggressive (LA) ADHD boys, but only LA boys showed increased physiological reactivity with increasing provocation. Methylphenidate resulted in increased heart rates under all conditions and did not interact with any of the other findings.This project was conducted while the first author had the support of National Institute of Alcohol Abuse and Alcoholism grant AA 06267.The authors wish to thank the staff members of the 1987 Summer Day Treatment Program who assisted in conducting this project. The authors also express their appreciation to Karen Guthrie for coordinating the medication assessment and to Hart Blanton for computer programming.     

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.     

Effects of Alcohol Intoxication on Parenting Behavior in Interactions With Child Confederates Exhibiting Normal or Deviant Behaviors

Experimental analogue methods were used to study how acute alcohol intoxication in parents influences their perceptions of and reactions to child behaviors, as well as their strategies for management of those behaviors. All participating parents had a grade school-aged son, but in half the cases this target child had a diagnosed externalizing disorder, whereas for the remaining half neither the target son nor any other offspring of the parents evidenced any psychopathology. Equal numbers of married fathers, married mothers, and single mothers from each of these groups received either alcoholic or nonalcoholic beverages prior to videotaped interactions with male child confederates who, depending on condition, enacted behaviors characteristic of either normal boys or boys with attention deficit hyperactivity/conduct/oppositional defiant disorders (ADHD/CD/ODD). Results indicated that intoxicated parents rated their ADHD/CD/ODD child partners as less deviant than did sober parents. Alcohol intoxication caused all participant groups to exhibit less attention and productive work and more commands, indulgences, and off-task talk in the interactions. Implications for better understanding of the role of psychosocial factors in the correlation between adult drinking problems and childhood behavior disorders are discussed.     

Negative Halo Effects in Parent Ratings of ADHD,ODD, and CD

Attention-deficit/hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD) are highly comorbid, with symptoms that share some similarities. The evidence-based diagnostic process for these disorders includes ratings from adults in the child’s life to assess behavior across settings, so it is important to understand how these raters think about potentially overlapping symptoms. Researchers have identified negative halo effects in ratings of ADHD and ODD symptoms, but ratings of CD have not been examined in these prior studies. Thus, the current study extended past research to examine negative halo effects in parent ratings of the predominantly hyperactive-impulsive presentation of ADHD (i.e., ADHD/HI), ODD, and CD. Parent participants read one of four vignettes that portrayed an 11-year-old boy displaying symptoms of ADHD/HI, ODD, CD, or typical development, and then completed a disruptive behavior scale. The general trend we found was that the presence of a relatively more severe disorder (i.e., CD) artificially inflated ratings of - or showed a negative halo effect for - the relatively less severe disorder (i.e., ADHD/HI), but with some nuance as discussed in the paper. These findings explain and validate how important it is that clinicians conduct evidence-based psychological assessments to decrease the chance of misdiagnosis.

     

Clinical Usefulness of the Kiddie-Disruptive Behavior Disorder Schedule in the Diagnosis of DBD and ADHD in Preschool Children

The aim of the present study was to investigate the clinical usefulness of a semi-structured diagnostic parent interview, i.e., the Kiddie-Disruptive Behavior Disorder Schedule (K-DBDS), in preschool children. For Oppositional Defiant Disorder (ODD), to define symptoms two coding methods were compared, i.e., one based on the threshold “often” and the other based on the frequency of behaviors in combination with the presence of clinical concern. For Attention-Deficit/Hyperactivity Disorder (ADHD), to define symptoms, two coding methods were compared, i.e., one with and one without consideration of pervasiveness across contexts. Participants were referred preschool children with externalizing behavioral problems (N?=?193; 83% male) and typically developing (TD) children (N?=?58; 71% male). The referred children were given a diagnosis of either ODD/CD (N?=?39), or ADHD (N?=?58) or comorbid ODD/CD+ADHD (N?=?57) or no diagnosis (N?=?39) based on best-estimate diagnosis. Receiver Operating Characteristic curve analyses showed that a cutoff score of four ODD symptoms using “often” as the threshold for frequency of behaviors led to a sensitivity of 87% and a specificity of 93%; the coding method which included the frequency of behaviors yielded a sensitivity of 56% and a specificity of 100%. For ADHD, a clinical cutoff score of five symptoms without the pervasiveness criterion yielded a sensitivity of 83% and a specificity of 98%; when the pervasiveness criterion was included sensitivity was 77% and specificity 98%. In the clinical assessment of ODD and ADHD in preschool children, the K-DBDS may be used with ODD symptom definition based on the threshold “often” and ADHD pervasiveness across contexts not included.     

Instrumental and hostile aggression in childhood disruptive behavior disorders

An analogue task of instrumental and hostile aggression during a competitive game was evaluated in a sample of clinically-referred 8-to 12-year-old aggressive boys. Similar to a prior task in a normative sample (Having, Wallace, & La Forme, 1979), both types of aggression increased during provocation as compared to baseline, indicating the success of the provocation manipulation, with moderate correlations between the two aggressive responses. The aggressive group with attention-deficit hyperactivity disorder (ADHD) and the aggressive group without ADHD each had higher rates of instrumental aggression than controls. Only the aggressive/ADHD group had higher rates of hostile aggression than controls. Parent Child Behavior Checklist ratings indicated a modest but significant unique relationship between instrumental aggression and delinquency. The high rate of both types of aggression in the aggressive/ADHD group suggests that comorbid ADHD and aggression may result in qualitative differences in aggressive behavior. The high rate of hostile aggression in the aggressive-ADHD group supports theoretical assumptions regarding the relationship of hostile aggression to poor impulse control.This research was supported in part by grants to the first author from the Medical College of Pennsylvania, the Allegheny-Singer Research Institute, NIMH First Award (MH4682), and support from NICHD Mental Retardation Research Center Core Center Grant (DH26979); and NIMH grants (MH40364 and MH00590) awarded to the second author. The authors are grateful to Marianne Torchinsky and Abby Michaleski for assistance in data collection. Preliminary data were presented at the annual meetings of the Association for Advancement of Behavior Therapy, New York, November 1988, and the Society for Research in Child and Adolescent Psychopathology, Costa Mesa, CA, January 1990.     

Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family,parenting, and behavioral correlates

This community study assigned 129 4-year-olds to groups at risk for attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), both ADHD and ODD, or no problems. Mothers of children at risk for ODD reported more family dysfunction, felt less competent as parents, suggested fewer solutions to child behavior problems, demonstrated a less assertive approach to child management, and reported more child internalizing problems than did mothers of children not elevated on ODD symptoms. Mothers of children at risk for ADHD reported higher personal depression scores than did those of the non-ADHD subgroup. Children at risk for ADHD evidenced the most difficulties in school where teachers reported more social behavior, classroom management, and internalizing problems relative to other children not at risk for ADHD. When solving child management problems, mothers of children in all groups suggested twice as many controlling/negative management strategies as positive/preventive strategies. In addition, faced with oppositional and conduct problems, mothers of children in all groups increased controlling/negative suggestions and decreased positive/preventive suggestions. Mothers of girls at risk for ADHD, ODD, and ADHD/ODD gave more rewards per positive behavior than did mothers of boys.     

Inhibition and working memory in young preschool children with symptoms of ADHD and/or oppositional-defiant disorder

Background: Early symptoms of attention deficit/hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) are associated with deficits in cognitive self-regulatory processes or executive functions (EF)s. However, the hypothesis that neurocognitive deficits underlying the two disorders are already evident during early preschool years still has limited empirical support. The present study investigated associations between symptoms of ADHD and/or ODD and two core EFs, inhibition and working memory, in a large nonclinical sample of 3-year old children. Method: Participants were 1045 children (554 boys, age 37–47 months), recruited from the population based Norwegian Mother and Child Cohort Study (MoBa). Relations between behavioral symptoms and measures of inhibition and working memory were studied both categorically and dimensionally. Results: Children with co-occurring symptoms of ADHD and ODD performed at a significantly lower level than typically developing children in 4 out of 5 EF measures. Symptoms of ADHD, both alone and in combination with ODD, were associated with reduced performance on tests of inhibition in the group comparisons. Dimensional analyses showed that performance within both EF domains contributed to variance primarily in ADHD symptom load. The associations between test results and behavioral symptoms remained significant after gender and verbal skills had been controlled. Conclusion: Young preschoolers show the same pattern of relations between EF and behavioral symptoms of ADHD and/or ODD as previously described in older children diagnosed with ADHD and/or ODD. Effect sizes were generally small, indicating that measures of EF have limited clinical utility at this stage in development.     

Unintentional Injury Risk in Children with Externalizing Behavior Disorders at Summer Camp

Children with externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) have greatly increased risk of unintentional injury, but it is unclear what mechanisms are responsible for that increased risk. This study followed 22 children participating in a summer camp for children with ADHD. Injury incidents were recorded daily and a set of primary symptoms of behavioral disorders were recorded at 15-min intervals over the course of the 6-week summer camp experience (roughly 300 h of observing each child). We predicted symptoms of ODD and CD would be more strongly related to injury incidence than symptoms of ADHD. Results from univariate Poisson regression models confirmed our prediction. Symptoms of ODD and CD—violations and intentional aggression in particular—were related to injury incidence but symptoms of ADHD were not. This finding is consistent with a growing body of evidence that oppositional, noncompliant, and aggressive behavior patterns might be primarily responsible for increased risk for injury among children with externalizing behavior disorders. Thanks to Sylvie Mrug, Peter Winslett, and the other staff members of the STP camp for their cooperation.     

Diversity in Pathways to Common Childhood Disruptive Behavior Disorders

Oppositional-Defiant Disorder (ODD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are highly comorbid, a phenomenon thought to be due to shared etiological factors and mechanisms. Little work has attempted to chart multiple-level-of-analysis pathways (i.e., simultaneously including biological, environmental, and trait influences) to ODD and ADHD, the goal of the present investigation. 559 children/adolescents (325 boys) between the ages of 6 and 18 participated in a multi-stage, comprehensive diagnostic procedure. 148 were classified as ODD; 309 were classified as ADHD, based on parent, teacher, and clinician ratings. Children provided buccal or salivary samples of DNA, assayed for select markers in DRD4 and 5HTT. Parents completed the Alabama Parenting Questionnaire and the California Q-Sort. Children completed the Child Perception of Interparental Conflict Scale. Correlational associations consistent with multiple-level-of-analysis pathways to ODD and ADHD emerged. For ODD, children with the short allele of the 5HTT promoter polymorphism had higher neuroticism and ODD symptoms regardless of level of self-blame in relation to inter-parental conflict, whereas children without this allele had more ODD symptoms only in the context of more self-blame for inter-parental conflict. For ADHD (and ODD), children homozygous for the long allele of DRD4 120?bp insertion polymorphism had lower conscientiousness when exposed to inconsistent parenting, whereas children without this genotype were more resilient to effects of inconsistent discipline on conscientiousness. Thus, ODD and ADHD appear to demonstrate somewhat distinct correlational associations between etiological factors and mechanisms consistent with pathway models using a multiple-level-of-analysis approach.     

Developmental pathways in oppositional defiant disorder and conduct disorder

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) specifies a developmental relationship between oppositional defiant disorder (ODD) and conduct disorder (CD). Evidence for this link is mixed, however, and recent studies suggest that different symptom dimensions in ODD may have different outcomes. The authors examined links between ODD, CD, and their young adult outcomes in the Great Smoky Mountains Study (E. J. Costello et al., 1996), a longitudinal data set with over 8,000 observations of 1,420 individuals (56% male) covering ages 9-21 years. ODD was a significant predictor of later CD in boys but not in girls after control for comorbid CD and subthreshold CD symptomatology. Transitions between ODD and CD were less common than anticipated, however, particularly during adolescence. The authors examined characteristics and outcomes of children with pure ODD, pure CD, and combined CD/ODD. Alongside many similarities in childhood and adolescent correlates, key differences were also identified: CD largely predicted behavioral outcomes, whereas ODD showed stronger prediction to emotional disorders in early adult life. Factor analysis identified irritable and headstrong dimensions in ODD symptoms that showed differential prediction to later behavioral and emotional disorders. Overall, the results underscore the utility of retaining separate ODD and CD diagnoses in DSM-V.