Co-occurring Aggressive and Depressive Symptoms as Related to Overestimations of Competence in Children with Attention-Deficit/Hyperactivity Disorder

Research indicates that on average, children with attention-deficit/hyperactivity disorder (ADHD) overestimate their competence in various domains. ADHD also frequently co-occurs with disorders involving aggressive and depressive symptoms, which themselves seem to influence estimations of self-competence in social, academic, and behavioral domains. In particular, high levels of aggressive behavior are generally associated with overestimations of competence, and high levels of depressive symptoms are related to underestimations of competence. This paper reviews studies of overestimations of competence among children with ADHD and examines the extent to which comorbid aggressive or depressive symptoms may be influencing these estimates. Although significant challenges arise due to limited information regarding comorbidities and problematic methods used to assess overestimations of competence, existing evidence suggests that ADHD may be associated with overestimations of competence over and above co-occurring aggression. As well, studies suggest that comorbid depression may reduce the appearance of overestimations of competence in children with ADHD. Underlying mechanisms (e.g., neuropsychological deficits or self-protection) of overestimations in children with ADHD are discussed, each with particular clinical implications for the assessment and treatment of ADHD. Future research would do well to carefully consider and explicitly describe the comorbid aggressive and depressive characteristics among individuals with ADHD when overestimations of competence are examined.     

A Review of: “Bear,G. G. (2010). School Discipline and Self-Discipline: A Practical Guide to Promoting Prosocial Student Behavior.”

Previous research demonstrates that children with attention-deficit/hyperactivity disorder (ADHD) can experience social difficulties. Therefore, the current study examined the effects of cross-age peer coaching on social behaviors of first graders with significant symptoms of ADHD using a multiple baseline design. Four students who met criteria for ADHD participated, along with four third- or fourth-grade coaches without ADHD. Coaching pairs met each morning to establish a goal for the younger child to meet during free time. Although results were variable, findings suggested that the cross-age coaching program led to decreases in negative social behavior, and was highly acceptable to participants.     

Parental Influence on Children with Attention-Deficit/Hyperactivity Disorder: I. Relationships Between Parent Behaviors and Child Peer Status

We examined associations between children’s peer relationships and (a) their parents’ social competence as well as (b) their parents’ behaviors during the children’s peer interactions. Participants were families of 124 children ages 6–10 (68% male), 62 with ADHD and 62 age- and sex-matched comparison youth. Children’s peer relationships were assessed via parent and teacher report, and sociometric nominations in a lab-based playgroup. Parental characteristics were assessed via parent self-report and observations of behavior during their child’s playgroup. After statistical control of relevant covariates, parents of children with ADHD reported poorer social skills of their own, arranged fewer playdates for their children, and displayed more criticism during their child’s peer interaction than did parents of comparison youth. Parents’ socialization with other parents and facilitation of the child’s peer interactions predicted their children having good peer relationships as reported by teachers and peers, whereas parental corrective feedback to the child and praise predicted poor peer relationships. Parents’ ratings of their child’s social skills were positively associated with ratings of their own social skills, but negatively associated with criticism and facilitation of the child’s peer interactions. Relationships between parental behaviors and peer relationships were stronger for youth with ADHD than for comparison youth. The relevance of findings to interventions is discussed.     

Psychosocial adjustment and peer competence of siblings of children with Attention-Deficit/Hyperactivity Disorder

Preliminary data examined the relationships between mothers, their sons with Attention-Deficit/Hyperactivity Disorder (ADHD), and younger siblings. We hypothesized that the conflict between the mother and the son with ADHD would also occur in the relationship between the child with ADHD and the younger sibling. Significant associations were found among ADHD behaviors, family conflict variables, conflict in the relationship between mother and child with ADHD, conflict in the relationship between mother and younger sibling, and conflict in the relationship between the child with ADHD and the younger sibling. Further, significant associations were found between behavior symptoms associated with ADHD and more problematic family relationships. Of particular interest was the finding of an unexpected inverse association between siblings' peer competence and mother-ADHD conflict; specifically, that conflict occurring at home from ADHD accounted for a greater percentage of the variance in peer competence as rated by teachers. Recommendations are made for future research with larger samples, alternative designs, older siblings, and fathers.     

Social competence and conduct problems in young children: issues in assessment

Examined the differences in various facets of social competence in 2 groups of young children (ages 4-7 years)--a clinic-referred group of aggressive children (N = 60) diagnosed with oppositional defiant disorder or conduct problems and a matched comparison group of typically developing children (N = 60). Four aspects of social competence were assessed: social information processing, actual observations of conflict management skills and social play interactions during peer interactions, positive social interactions with mothers and fathers at home, and teacher reports of social competence. The social information processing assessed included problem-solving skills (hypothetical skills as demonstrated on a social problem-solving test), self-perceptions (child's awareness of his or her own social self and feelings of loneliness), perceptions of others (attributions), and perceptions of others' attitudes toward oneself. To determine the construct validity of various means of assessing child social competence, we correlated children's social information processing measures with parent and teacher reports of social adjustment and with actual observations of interactions during peer play and at home with parents. Results comparing the 2 groups suggest that young children with conduct problems have deficits in their social information processing awareness or interpretation of social cues--they overestimate their own social competence and misattribute hostile intent to others. Tests of cognitive problem solving and observations of peer play interactions indicated that the children with conduct problems had significantly fewer positive problem-solving strategies and positive social skills, more negative conflict management strategies, and delayed play skills with peers than the comparison children. Correlation analyses indicated significant correlations between children's negative attributions and the ratio of positive to negative problem-solving strategies with observations of peer play interactions.     

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.     

Psychiatric Comorbidity in Children with Autism Spectrum Disorders: A Comparison with Children with ADHD

The present study was conducted with the aim to identify comorbid psychiatric disorders in children with autism spectrum disorders (ASD) (n = 40) and to compare those comorbidity rates to those in children with attention deficit hyperactivity disorder (ADHD) (n = 40). Participants were clinically referred children aged 7–18 years. DSM-IV classifications were used for the primary diagnosis (ASD/ADHD), while comorbid psychiatric disorders were assessed using a structured diagnostic interview, the structured clinical interview for DSM-IV, childhood diagnoses (KID-SCID). Twenty-three children with ASD (57.5 %) had at least one comorbid disorder, whereas 16 children with ADHD (40.0 %) were classified as having at least one comorbid disorder. No group differences were found with respect to this comorbidity rate or for the rate of comorbid externalizing disorders (ODD and/or CD). However, children with ASD had more comorbid internalizing disorders compared to children with ADHD. More specifically, children with ASD had higher rates of anxiety disorders, but not mood disorders. No associations between comorbidity and age or between comorbidity and the intelligence quotient was found. It is important for clinicians to always be aware of, and screen for, comorbidity, and to consider treatment for these comorbid disorders. In addition, research should focus on establishing valid and reliable screening tools as well as effective treatment options for these comorbid disorders.     

Peer status and social competence in child psychiatric inpatients: A comparison of children with depressive,externalizing, and concurrent depressive and externalizing disorders

Social competence, peer status, and clinical symptomatology were evaluated in 54 child psychiatric inpatients. Aims were (a) to evaluate whether social competence deficits and peer rejection within an inpatient setting were associated with particular childhood disorders, and (b) to identify predictors of peer status in emerging groups of child inpatients. Results indicated that children with externalizing disorders (conduct or attention deficit disorders) and children with concurrent depressive and externalizing disorders were the most rejected, least liked, and least socially competent children. Depressed children without externalizing disorders had the highest scores on the social status and competence measures. Predictors of peer rejection and acceptance in the hospital differed, with measures of symptomatology predicting peer rejection, and measures of social and intellectual competence predicting peer acceptance. Implications of the results for understanding the role of peer adjustment and social competence in developmental psychopathology were discussed.This research was supported in part by Biomedical Research Support Grant RR756 awarded to the author. The author wishes to thank Donald Guthrie and Sondra Purdue for their statistical consultation, Gwen Gordon for her computer assistance, and Joan Trumbull for her assistance with data collection.     

Gender and Age Differences in Social Skills Among Children with ADHD: Peer Problems and Prosocial Behavior

Abstract

Gender differences in peer problems and prosocial behavior among children with attention-deficit hyperactivity disorder (ADHD) were examined. Parents and teachers rated social functioning on the Strengths and Difficulties Questionnaire (SDQ) among 592 children (age 5–10?years) with ADHD and among 215 children (age 6–10?years) in a community sample. Results in the clinical group revealed significant interaction effects where older boys showed fewer peer problems than younger boys, but older girls had similar peer problems as younger girls. Teachers reported less prosocial behavior among younger girls than older girls. No gender differences in social problems emerged for the nonclinical comparison group.     

Personality Traits Elucidate Sex Differences in Attention-Deficit/Hyperactivity Disorder Comorbidity During Early Childhood

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly comorbid with other childhood disorders, and there are striking sex differences in this comorbidity, particularly during early childhood. For example, boys with ADHD are more likely to exhibit comorbid disruptive behavior and neurodevelopmental disorders, compared to girls, during early childhood. Yet, explanations for these well-established sex differences remain in short supply. The current study evaluated the novel hypothesis that personality traits may serve as intermediate phenotypes that help explain sex differences in common ADHD comorbidity profiles during early childhood. Study participants were 109 children between the ages of 3 and 6 and their primary caregivers and teachers/daycare providers, recruited from the community and over-recruited for ADHD-related problems. Primary caregivers completed the Child Behavior Checklist, and teachers/daycare providers completed the Teacher Report Form as a measure of child behavior problems. Examiners completed the California Q-Sort as a measure of child personality traits. Moderated mediation analyses suggested that personality traits explain associations between ADHD and oppositional-defiance, aggression, and language problems in a sex-specific manner. While high neuroticism mediated associations between ADHD and oppositional-defiance in girls, disagreeableness mediated associations between ADHD and aggression and low conscientiousness mediated associations between ADHD and neurodevelopmental language problems in boys. Sex differences in trait-psychopathology associations may help explain sex differences in comorbidity profiles with possible implications for child assessment and personalized early intervention.     

儿童忽视与同伴接受：消极社会行为的中介作用

运用问卷调查法和同伴提名法,考察小学4、5年级共503名儿童的消极社会行为（攻击行为、退缩行为、受欺负行为）、同伴接受和儿童忽视间的关系。结果发现,儿童忽视与退缩行为、受欺负行为之间存在显著正相关,与攻击行为之间相关不显著;儿童忽视与同伴接受有显著负相关。忽视通过消极社会行为的两组中介变量作用于儿童的同伴接受。     

Differences in memory functioning between children with attention-deficit/hyperactivity disorder and/or focal epilepsy

Prior research has shown that attention-deficit/hyperactivity disorder (ADHD) and epilepsy are frequently comorbid and that both disorders are associated with various attention and memory problems. Nonetheless, limited research has been conducted comparing the two disorders in one sample to determine unique versus shared deficits. Hence, we investigated differences in working memory (WM) and short-term and delayed recall between children with ADHD, focal epilepsy of mixed foci, comorbid ADHD/epilepsy and controls. Participants were compared on the Core subtests and the Picture Locations subtest of the Children’s Memory Scale (CMS). Results indicated that children with ADHD displayed intact verbal WM and long-term memory (LTM), as well as intact performance on most aspects of short-term memory (STM). They performed worse than controls on Numbers Forward and Picture Locations, suggesting problems with focused attention and simple span for visual-spatial material. Conversely, children with epilepsy displayed poor focused attention and STM regardless of the modality assessed, which affected encoding into LTM. The only loss over time was found for passages (Stories). WM was intact. Children with comorbid ADHD/epilepsy displayed focused attention and STM/LTM problems consistent with both disorders, having the lowest scores across the four groups. Hence, focused attention and visual-spatial span appear to be affected in both disorders, whereas additional STM/encoding problems are specific to epilepsy. Children with comorbid ADHD/epilepsy have deficits consistent with both disorders, with slight additive effects. This study suggests that attention and memory testing should be a regular part of the evaluation of children with epilepsy and ADHD.     

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.     

Reformulating infant and toddler social competence with peers

Efforts to identify children at risk for social and academic difficulties at an early age have begun to apply conceptualizations of social competence with peers from childhood to infancy and toddlerhood. These attempts have had limited success, in part because social behaviors studied in later childhood such as negative or aggressive acts may not capture relevant dimensions of social competence with peers during the infant and toddler years. The present study conducted an exploratory factor analysis to begin developing a conceptualization of social competence with peers that is appropriate for use with infants and toddlers, and that captures individual differences capable of predicting later social functioning. Results indicate three dimensions of infant and toddler social competence with peers: peer sociability, active peer refusal, and passive peer avoidance. Negative and aggressive behaviors loaded on each of the three factors rather than emerging as a unique dimension of social competence. Each factor demonstrated both convergent and predictive validity, indicating that early identification of social skills remains a reasonable goal for practitioners and researchers alike. Finally, antecedents within children, families, and out-of-home child care environments helped to explain individual variability in each of these three factors of social competence with peers.     

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.This study was supported by grant MN-46584 from the National Institute of Mental Health.     

Attention,play, and social behavior in ADHD preschoolers

We investigated attention, play and nonplay behavior in preschool children with attention deficit hyperactivity disorder (ADHD) and a matched control group of non-ADHD children. Forty 4- to 5-year-old children (20 ADHD and 20 matched control) participated. Across a 6-week-period, children's social and play interactions as well as nonplay behaviors were videotaped in the classroom. Videotape recordings were analyzed for the level of attention, cognitive play, and social participation. In addition, children's level of attention and cooperative behavior were observed during two group activities. Findings indicated that ADHD, relative to non-ADHD, children engaged in less overall play and greater functional or sensorimotor play. ADHD children also engaged in more transitional behavior, were less competent with peers, and were less attentive and cooperative during group activities.This research was supported in part by an MCP grant awarded to Dr. Steven Alessandri. The author wishes to thank the children, parents, and the MCP/EPPI preschool staff for their assistance and cooperation.     

Parenting in mothers with and without attention-deficit/hyperactivity disorder

The authors examined the impact of maternal attention-deficit/hyperactivity disorder (ADHD) on parenting behaviors. Sixty mothers between the ages of 31 and 50 with (n = 30) and without (n = 30) ADHD and their 8- to 14-year-old children with ADHD completed self-report and laboratory measures of monitoring of child behavior, consistency in parenting, and parenting problem-solving abilities. These parenting behaviors were selected because of their established links to the development of child behavior problems. As predicted, mothers with ADHD were found to be poorer at monitoring child behavior and less consistent disciplinarians compared with mothers without ADHD. There was some evidence to support the prediction that mothers with ADHD were less effective at problem solving about childrearing issues than control mothers. The differences between the 2 groups of mothers persisted after child oppositional and conduct-disordered behavior were controlled. These results indicate that parenting is an area of functioning that requires more attention in adult ADHD research.     

Social Anxiety in Children with Anxiety Disorders: Relation with Social and Emotional Functioning

Investigated the psychometric properties of the Social Anxiety Scale for children-Revised (SASC-R) as well as relations between social anxiety and children's social and emotional functioning. Participants were a clinic sample of children, ages 6–11 with anxiety disorders (N = 154) who completed the SASC-R. For a subset of these children, parent ratings of social skills, and self-ratings of perceived competence and peer interactions were also obtained. Factor analysis of the SASC-R supported the original three-factor solution and internal consistencies were in the acceptable range. Among children with simple phobia, scores on the SASC-R differentiated those with and without a comorbid social-based anxiety disorder. Social anxiety was also associated with impairments in social and emotional functioning. Specifically, highly socially anxious children reported low levels of social acceptance and global self-esteem and more negative peer interactions. Girls with high levels of social anxiety were also rated by parents as having poor social skills, particularly in the areas of assertive and responsible social behavior.     

Anxiety as a Predictor and Outcome Variable in the Multimodal Treatment Study of Children with ADHD (MTA)

Initial moderator analyses in the Multimodal Treatment Study of Children with ADHD (MTA) suggested that child anxiety ascertained by parent report on the Diagnostic Interview Schedule for Children 2.3 (DISC Anxiety) differentially moderated the outcome of treatment. Left unanswered were questions regarding the nature of DISC Anxiety, the impact of comorbid conduct problems on the moderating effect of DISC Anxiety, and the clinical significance of DISC Anxiety as a moderator of treatment outcome. Thirty-three percent of MTA subjects met DSM-III-R criteria for an anxiety disorder excluding simple phobias. Of these, two-thirds also met DSM-III-R criteria for comorbid oppositional-defiant or conduct disorder whereas one-third did not, yielding an odds ratio of approximately two for DISC Anxiety, given conduct problems. In this context, exploratory analyses of baseline data suggest that DISC Anxiety may reflect parental attributions regarding child negative affectivity and associated behavior problems (unlike fearfulness), particularly in the area of social interactions, another core component of anxiety that is more typically associated with phobic symptoms. Analyses using hierarchical linear modeling (HLM) indicate that the moderating effect of DISC Anxiety continues to favor the inclusion of psychosocial treatment for anxious ADHD children irrespective of the presence or absence of comorbid conduct problems. This effect, which is clinically meaningful, is confined primarily to parent-reported outcomes involving disruptive behavior, internalizing symptoms, and inattention; and is generally stronger for combined than unimodal treatment. Contravening earlier studies, no adverse effect of anxiety on medication response for core ADHD or other outcomes in anxious or nonanxious ADHD children was demonstrated. When treating ADHD, it is important to search for comorbid anxiety and negative affectivity and to adjust treatment strategies accordingly.     

Children’s ADHD Symptoms and Friendship Patterns across a School Year

Symptoms of attention-deficit/hyperactivity disorder (ADHD) in elementary school-age children are associated with poor relationships with classroom peers, as indicated by poor social preference, low peer support, and peer victimization. Less is known about how friendship patterns relate to ADHD symptoms, or how friendships may buffer risk for negative peer experiences. Participants were 558 children in 34 classrooms (grades K-5). At the beginning (fall) and end (spring) of an academic year, children completed (a) sociometric interviews to index friendship patterns and social preference, and (b) self-report questionnaires about their support and victimization experiences from classmates. In fall, higher teacher-reported ADHD symptoms were associated with children having more classmates with no friendship ties (non-friends) and who the child nominated but did not receive a nomination in return (unreciprocated friends), and with having fewer classmates with mutual friendship ties (reciprocated friends) and who nominated the child but the child did not nominate in return (unchosen friends). Higher fall ADHD symptoms predicted more non-friend classmates, poorer social preference, and more victimization in the spring, after accounting for the same variables in fall. However, having many reciprocated friends (and to a lesser extent, many unchosen friends) in fall buffered against the trajectory between fall ADHD symptoms and poor peer functioning in spring. By contrast, having many unreciprocated friends in fall exacerbated the trajectory between fall ADHD symptoms and poor peer functioning in spring. Thus, elevated ADHD symptoms are associated with poorer friendship patterns, but reciprocated friendship may protect against negative classroom peer experiences over time.