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ADHD: A Brief Introduction

ADHD: A Brief Introduction. A neurodevelopmental disorder of childhood characterized by developmentally inappropriate levels of hyperactivity and impulsivity and/or attention problems. Prevalence rate is from 3 - 5% in the general population (APA, 1994)

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ADHD: A Brief Introduction

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  1. ADHD: A Brief Introduction • A neurodevelopmental disorder of childhood characterized by • developmentally inappropriate levels of hyperactivity and impulsivity and/or • attention problems. • Prevalence rate is from 3 - 5% in the general population (APA, 1994) • Prevalence is estimated to be between 4 and 12 % in pediatric primary care settings (American Academy of Pediatrics, 2000). • A common reason for referral to pediatricians, child psychiatrists & psychologists

  2. ADHD: Common Comorbid Conditions • Oppositional Defiant Disorder (ODD): up to 50% • Conduct Disorder (CD): 30-50% • Anxiety Disorder: 20-25% • Mood Disorder: 15-20% • Learning Disability: 19-26% (AACAP, 1997)

  3. ADHD-related Behavior: As a Source of Family Stress • The behavior of children with ADHD, can be highly disruptive and contribute to increased levels of parental/family stress. • This stress results from: • core symptoms themselves • comorbid features that often accompany this disorder • the demands and family disruptions experienced by parents as a result of the child’s behavior.

  4. ADHD: Common Family Stressors • Parents often get calls from teachers regarding their child behavior or school difficulties. • They are often restricted socially. • They often feel they must “explain” their child’s behavior to others. • They often have to miss work to attend clinic appointments. • Many worry incessantly (with some justification) about the possibility of accidental injury to their child as a result of his/her behavior. • These represent only a few of the stressors experienced by parents of children with ADHD.

  5. Parenting and Caretaker Stress • Relevant to the disruptive behaviors often seen in children with ADHD, research has suggested that even everyday parenting events can be sources of caretaker stress. • Crnic and Acevedo (1995) describe "daily parenting hassles as “routine childrearing tasks that parents may find irritating, frustrating, annoying, and distressing. • Research by Crnic & Acevedo, (1995) and Crnic & Greenberg (1990) has shown high levels of parenting hassles to relate to lower life satisfaction, more negative mood and affect, and increased maternal distress

  6. ADHD and Family Stress • Crnic and Greenberg (1990) have also found that parenting hassles are more stressful to parents than major life events. • Other studies (Dumas (1986; Patterson, 1983) have suggested that parents experiencing high levels of daily parenting hassles • tend to display more negative affect towards their children • respond in ways that increase child negativity and • engage in more aversive or irritable/coercive interactions with their children when experiencing high rates of parenting hassles. • Given these findings with normal families, it would not be surprising that parents of children with ADHD display even greater stress

  7. ADHD and Family Stress • This concept of daily parenting stress or family burdenis important to understanding the functioning of families of children with ADHD. • Parents of children with ADHD often have to deal with problem behaviors at much higher rates and at a higher level of intensity than is found in families of normal children. • Parenting stressors may be of special significance in terms of their impact on parent, child, and family functioning. • Outcomes may include: • the development of parenting styles that increase negative child behavior • parental psychopathology • strained marital relationships • other negative outcomes.

  8. ADHD and Parent Adjustment • Regarding the potential impact of ADHD-related stress on parents, studies have shown that • Mothers of children with ADHD have higher rates of psychological difficulties (Fischer, 1990) • They seek treatment for psychological difficulties significantly more often than mothers of normal children (Gillberg, Carlstrom, and Rasmussen, 1983). • In the latter study, treatment-seeking behavior was also found to be correlated with the severity or pervasiveness of the child's hyperactivity (Gillberg, et al., 1983).

  9. ADHD and Parent Adjustment • Several studies have shown • That mothers of children with ADHD show higher rates of depressive symptoms than mothers of normal children (Befera & Barkley, 1985; Brown & Pacini 1989; Cunningham, Benness, & Siegel, 1988). • That parents of children with ADHD display increased levels of alcohol consumption (Cunningham et al., 1988; Pelham & Lang, 1999). • That parents of children with ADHD show increased marital discord and strained interpersonal relationships (Johnston, 1996). • While not actually measuring “stress” these findings suggest that having a child with ADHD in the home is often associated with a range of psychological, interpersonal and family difficulties.

  10. ADHD and “Parenting Stress” • Other studies have attempted to study stress in families of children with ADHD, using the Parenting Stress Index (PSI) developed by Abidin(1995). • The PSI is designed to assess sources of stress resulting from the Child, the Parent, and the Environment that place strain on the parent-child system. • This measure includes: • Child Domain Adaptability Acceptability Demandingness Mood Distractibility/Hyperactivity Child Reinforces Parent • Parent Domain Depression Attachment Parental Role Restriction Sense of Competence Social Isolation Relationship with Spouse Parent Health • Life Stress (optional).

  11. ADHD “Parenting Stress” Findings • Breen and Barkley (1988) have found mothers of hyperactive clinic-referred girls to display higher PSI stress levels than mothers of normal girls. • Severity of child aggression, conduct problems, and hyperactivity were found to be most highly related to parent stress levels. • These findings suggest that stress levels, not only increase with the severity of ADHD symptoms, but also as a function of comorbid features that often accompany ADHD.

  12. ADHD “Parenting Stress” Findings • Mash and Johnston (1983), found mothers of hyperactive children to report higher levels of overall parenting stress than parents of normal children. • Child characteristics such as “distractibility” & “perceived degree of bother” accounted for the most variance in parenting stress scores. • Mothers of hyperactive children also reported more feelings of social isolation and role restriction on the PSI compared to parents of normal children.

  13. ADHD “Parenting Stress” Findings • The view that parenting stress can be increased by comorbid conditions is also supported by findings from Anastopoulos, et al (1992). • In addition to finding increased levels of stress among parents of children with ADHD, they also found the severity of ADHD symptoms and aggressive and oppositional-defiant behavior to account for some 43% of the variance in parenting stress scores. • Such studies these provide general support for the view that ADHD-related behavior is associated with significant levels of parental stress.

  14. On The Assessment of Specific Stressors • Despite studies suggesting a link between ADHD and “parenting stress”, these studies with the PSI provide little information regarding the specific types of day-to-day stressors experienced by parents of children with ADHD. • Indeed, a careful look at the nature of the PSI Parent Domain scale suggests that scores on this measure are probably best viewed as indirect reflections of stress resulting from having a child with ADHD. • These measures may be best thought of as “stress related outcomes” that may also be influenced by factors other than child behavior.

  15. So What Do Findings to this Point Suggest? • That children with ADHD display a range of behaviors that can serve as stressors. • That parents of children with ADHD often display negative outcomes in terms of personal adjustment and family functioning. • That measures designed to assess specific stressors, resulting from ADHD-related behavior, are needed.

  16. Centers for Disease Control: Focus on ADHD and Family Burden • The need for research related to ADHD family stress has been most obviously highlighted by the proceedings of a Centers for Disease Control conference, convened in 1999. • The purpose of the conference was to develop a research agenda for studying the public health costs of ADHD. • This conference resulted in a range of conclusions and recommendations

  17. Centers for Disease Control: Focus on ADHD and Family Burden • Here the conference proceedings suggested that it is reasonable to assume – • That family members of a child with ADHD are significantly impacted by this condition, • That the magnitude of the social and economic burden of ADHD on the family has not been systematically documented, and • That families of children with ADHD may be more likely to experience conflict and increased family stress.

  18. Centers for Disease Control: Focus on ADHD and Family Burden • It was also suggested • That, to understand the nature of ADHD, it is imperative to understand its effects on families. • That increased research is needed to clarify those aspects of the family it impacts and in what ways the family is impacted. • Finally, it was suggested, • That since the development of effective interventions for ADHD is dependent on having reliable and valid measures to assess the impact of the disorder, • the development of standardized burden measures are central to this process.

  19. Assessing ADHD-Related Stress • In line with the CDC recommendations, we have focused on developing a reliable and valid measure of ADHD-related stress (e.g. family burden). • The goal has been to develop a measure that provides information regarding the occurrence and perceivedstressfulness of family changes, family disruptions, and other circumstances resulting from having a child with ADHD. • The focus has been on assessing specific ADHD behavior-related family stressors, rather than more global indices of family stress or measures of stress-related outcomes experienced by family members.

  20. Assessing ADHD-Related Stress • Our belief has been that a measure of this type • Should be of value in providing family assessment data for comprehensive ADHD clinical assessments. • Should serve as a useful treatment outcome measure, and • Should be useful as a research tool in studying the impact of ADHD related stress on the family. • Indeed, the development of such a measure appears to be a prerequisite for conducting meaningful research on the nature and impact of ADHD on families.

  21. Development of the Disruptive Behavior Inventory: Item Selection • Our work on this measure, the Disruptive Behavior Stress Inventory (DBSI; Johnson & Reader 2000, Reader, McCallister and Johnson, in press), began with the development of an initial item pool. • Here, preliminary items were obtaining from parents of children with ADHD (the population of interest) • Parents, bringing their children to the clinic for evaluation, were asked to complete an open-ended “Family Stress Survey”by listing the five most significant stressors or family disruptions experienced as a result of their child's behavior. • This survey generated a total of 134 items described as highly stressful by parents.

  22. Assessing ADHD Related Stress:Item Refinement • Irrelevant items were discarded and items with similar content and meaning were joined into single items. • Items that described child behavior problems and symptoms of ADHD were excluded. • The reduced item pool was then given to three doctoral-level, clinical-child/pediatric psychologists for evaluation and input regarding item wording, relevance, and appropriateness. • 40 items were retained for the final measure.

  23. Format of the DBSI DBSI Instructions Listed below are a range of potential stressors that are sometimes experienced as a result of having a child who displays behavioral difficulties. Read each of the following items carefully and indicate those situations you have experienced as a result of your child’s behavior during the past six months. Circle "Yes" if you have experienced what is described in the item. Circle "No" if you have not. For each item circled "Yes", indicate on the following 4 point scale the extent to which it was/is stressful to you:0 (Not at all Stressful); 1 (Somewhat Stressful); 2 (Moderately Stressful); 3 (Very Stressful). Please be sure to respond to each item.

  24. Sample Items From the DBSI • Getting complaints from teachers about your child’s behavior. • Problems paying for services your child needs. • Having other parents complain about your child’s behavior. • Getting calls from teachers regarding your child’s school performance. • Disagreement with spouse about managing child’s behavior. • Having your child embarrass you in front of others. • Not having enough time for yourself due to child’s behavior. • Having to miss work because of your child’s behavior • Not being able to work outside of home due to child’s behavior. • Having other parents tell you how to manage your child. -------------- When scored, the DBSI yields a Stress Experience score (number of stressors experienced) and a Stress Degree score (sum of the ratings for each reported stressor). Click to Download Measure

  25. Development of the DBSI: Initial Findings • Preliminary validity and reliability data for the DBSI were obtained from two groups of parents; • 1) A group of 55 parents of children (47 boys and 8 girls), age 4 - 15, with a primary diagnosis of ADHD – Mean age 9.6 (SD = 2.84. • 2) A comparison group of 38 parents of children (20 boys and 18 girls) without ADHD or other diagnosed disorder - Mean age 8.0 (SD = 3.11). • Twenty-two parents of children with ADHD completed the measure a second time (1-2 week interval) to provide test-retest reliability data. Note. Preliminary analyses suggested significant group differences regarding child age; as a result group comparisons involved covariance analyses with age as the covariate.

  26. Reliability Assessment • Initial analyses evaluated aspects of the reliability of the Stress Experience and Stress Degree scales completed by parents in the ADHD group. • Corrected item-total correlations were obtained to assess the degree of relationship between individual items and the total scale scores. • The internal consistency of the Stress Experience and the Stress Degree scale was analyzed to determine the degree of scale homogeneity (e.g. the degree to which items in each of the two scales measure similar constructs (Cronbach's alpha). • Test-retest reliability was evaluated by examining the Pearson’s product moment correlation coefficients for both scale scores over a 1-2 week interval.

  27. DBSI Reliability Findings • Corrected item-total correlations were calculated for all 40 items on both the Stress Experience and Stress Degree scales. • The mean corrected item-total correlation for the Stress Experience scale was .48 (range = .09 - .72) • For the Stress Degree scale it was .58 (range = .23 - .81). • Based on analyses of 43 measures, Cronbach’s coefficient alpha was .93 for the Stress Experience scale. • Based on analyses of 41 measures (due to the failure of two parents to complete the Stress Degree scale) coefficient alpha for the Stress Degree scale was .96. • Test-retest reliability coefficients for both scales were based on analyses of 22 completed measures. • The test-retest reliability coefficient for the Stress Experience Scale was .76 (p < .001) • Test-retest reliability for the Stress Degree scale was .65 (p < .001).

  28. Development of the DBSI: DiscriminativeValidity Findings • Tests of discriminative validity involved overall comparisons of the ADHD and Comparison groups in terms of scores on the DBSI Stress Experience and the Stress Degree scales. • As preliminary analyses found significant differences between groups in terms of child age, analyses involved ANCOVA’s with age considered as the covariate. • Group comparisons indicated that both the DBSI Stress Experience and Stress Degree scale scores differentiated between groups • In the case of both, Stress Experience and Stress Degree scales scores provided by parents of children with ADHD were significantly higher.

  29. Development of the DBSI: DiscriminativeValidity Findings • Subsequent ANCOVA’s, with child age as covariate, were also used to test for group differences on the Stress Experience and Stress Degree scales, as a function of ADHD subtype. • Post-hoc analyses (with Bonferroni correction) were employed, following the finding of overall significant differences in group means (p<.001). • For both measures, stress scores of parents of children with Combined type ADHD were found to be significantly higher than those of parents of children with Inattentive type ADHD, as well as those in the comparison group. • Stress scores of the Predominately Inattentative type group did not differ from the non-ADHD comparison group.

  30. Comparison of DBSI Mean Scale Scores between Normal and ADHD Groups *** p < .001 Note. Cohen’s d = Effect size

  31. Comparison of DBSI Mean Scale Scores Across Normal and ADHD Subtype Groups *** p < .001 Note. Means in a row sharing subscripts are significantly different

  32. Frequencies of Specific ADHD Family Stressors • Since items included in the DBSI were derived from reports of family stressors, experienced by parents of children with ADHD, it was of interest to look at the frequency with which specific stressors were reported by parents of children with and without ADHD. • This data is provided in following slides.

  33. Frequencies of Specific ADHD Family Stressors • (N = 126) • Age Range (Patient): 4 – 15; Mean Age = 8.86 • Age Range (respondent): 24 – 72; Mean Age = 36.79 • 76.4% Male; 23.6% Female • Medication: 73.2% Yes; 25.2% No • Ethnicity: Caucasian 35.4 %; African American 11.8%; Latino-American 4.7%; Mixed/Other 3.1% • Family Income Range: $5,772 - $170,000; Mean Income = $38,699 • ADHD Subtype: Combined 35.4%; Hyperactive-Impulsive 6.3%; Inattentive 8.6%; Unknown 48.8%

  34. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Conflicts with your child over homework 81.1 • Dealing with teachers’ complaints about your child. 80.3 • Dealing with your child’s academic difficulties. 78.0 • Having to explain your child's behavior to others. 78.0 • Spending an excessive helping child with homework 74.0 • Not knowing how to deal with your child’s behavior 74.0 • Having to watch child so he/she doesn’t get into trouble 68.5 • Having your child embarrass you in front of others 67.7 • Being concerned about your child being injured 63.0 • Being interrupted when taking care of other children. 62.2 • Not able to take your child shopping because of behavior 60.6 • Disagreements with spouse about child’s behavior 59.8 • Calls from school regarding your child's behavior 59.1 • Dealing with your child’s conflicts with other children 59.1 • Other people telling you how to parent your child 58.3

  35. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Not having enough time for self due to child’s behavior 57.5 • Calls from school regarding child's academic problems 57.5 • Not getting work done at home due to child’s behavior 53.5 • Difficulties getting school-based services for your child 48.7 • Not knowing how to explain child’s behavior to others 46.5 • Not being able to go out to eat because of child’s behavior 46.5 • Difficulties finding professional services for your child 44.1 • Not getting support from others for child’s problems 42.5 • Not able to spend enough time with your other children 40.9 • Having less time with partner because of child’s behavior 40.9 • Not being able to leave your child with a baby sitter 40.2 • Not able to get to bed at decent hour due to behavior 39.4 • Having to miss work because of your child’s problems 38.6 • Problems paying for services your child needs 38.6 • Problems related to medication side effects38.6

  36. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Being unable to take your child to public places 37.8 • Difficulties getting your child to appointments 35.4 • Dealing with complaints from other parents about child 34.6 • Having to miss important social events due to 29.1 • Having to miss/leave church because of child’s behavior 25.2 • Getting complaints from school bus driver 24.4 • Difficulties finding adequate after school placement 22.8 • Difficulties dealing with your child’s doctors 20.5 • Dealing with complaints from neighbors about behavior 18.1 • Not able to work outside home due to child’s behavior 17.3

  37. Frequencies of Specific ADHD Family Stressors • As can be seen, very high frequencies of many specific stressors are found in this group of children with ADHD. • 18 of 40 items were endorsed by at least 50% of the sample.

  38. Frequency of Specific Family Stressors in Non-ADHD Families • The frequency data just presented can be contrasted with the frequency of experiencing these same family stressors by parents of children without ADHD (N = 119). • These data are presented in the following slides.

  39. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Conflicts with your child over homework 46.8 • Being interrupted when taking care of other children. 46.8 • Disagreements with spouse about child’s behavior 46.8 • Not knowing how to deal with your child’s behavior 43.5 • Dealing with teachers’ complaints about your child 39.5 • Other people telling you how to parent your child 37.9 • Dealing with your child’s conflicts with other children 37.1 • Being concerned about your child being injured 34.7 • Having your child embarrass you in front of others 33.9 • Dealing with your child’s academic difficulties. 31.5 • Spending excessive time helping with homework 29.8 • Having to explain your child's behavior to others 25.8 • Not being able to take your child shopping 24.2 • Not being able to leave your child with a baby sitter 23.4 • Calls from school regarding your child's behavior 21.8

  40. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Not able to spend enough time with your other children 21.0 • Not having enough time for self because of behavior 20.2 • Having less time with partner because of child’s behavior 20.2 • Having to watch your child so doesn’t get into trouble 19.4 • Not being able to go out to eat because of behavior 18.5 • Not able to get to bed at decent hour because of behavior 18.5 • Not getting work done at home because of behavior 16.9 • Calls from school regarding child's academic problems 13.7 • Having to miss work because of your child’s problems 12.9 • Problems paying for services your child needs 12.1 • Having to miss or leave church because of your behavior 12.1 • Difficulties finding adequate after school placement 9.7 • Not knowing how to explain child’s behavior to others 8.9 • Difficulties getting your child to appointments 8.9 • Difficulties finding professional services for your child 8.9

  41. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Not getting support from others with child’s problems 8.9 • Being unable to take your child to public places 8.1 • Difficulties dealing with your child’s doctors 6.5 • Getting complaints from school bus driver 5.6 • Difficulties getting school-based services for your child 4.8 • Dealing with complaints from other parents about child 4.8 • Problems related to medication side effects 4.0 • Having to miss social events due to your child’s behavior 4.0 • Dealing with complaints from neighbors about behavior 3.2 • Not able to work outside home because of child’s behavior .8

  42. Family Correlates of ADHD-Related Stress: Some Preliminary Findings • Given preliminary findings from two studies supporting the validity of the DBSI as a measure of ADHD-related stress, we have begun to focus on collecting data to look at the relationship between DBSI stress scores and measures of family functioning. • To date, we have obtained preliminary data on a small sample of children with Combined type ADHD and have begun to look at the correlations between DBSI stress indices and • 1) ADHD symptom severity measures, • 2) PSI Parent Domain Measures, and • 3) Indices of marital satisfaction

  43. Assessing ADHD Related Stress:A Replication and Extension • In second recently completed study (Reader, McCalister & Johnson, In Press), we attempted to replicate and extend the initial DBSI findings with an additional larger sample. • One focus was on replicating some of our initial reliability and validity findings. • A second focus was on determining the degree to which each of the 40 individual DBSI items differentiated parents of children with and without ADHD. • That is - how well do individual DBSI item discriminate between parents of children with and without ADHD?

  44. Replication Study: ADHD Group Characteristics • The ADHD Caregiver Group consisted of 71 primary caregivers (68 female and 3 male), with a mean age of 37.37 years (SD = 10.09) and range between 24 and 71 years. • Caucasians (70%) made up the majority of primary caregivers in the ADHD group, with African-American (23%) and Latino American (7%) caregivers also included in the sample. • Measures were completed on 49 boys and 22 girls (N = 71), made up of 63% Caucasians, 23% African-Americans, 7% Latino-Americans, and 7% of Mixed/Other race. • The mean age of children in the ADHD group was 8.21 (SD = 2.53), with a range between 4 and 15 years.

  45. Replication Study: Comparison Group Characteristics • The Comparison Group was made up of 79 primary caregivers (68 females and 11 males), with a mean age of 37.37 years (SD = 6.91); (range 25 – 51). • Caucasians (73%) made up the majority of primary caregivers in this group, with African-American (18%), Latino American (5%), Asian American (1%), and Mixed/Other (1%) race caregivers also included in the sample (2% missing data). • Measures were completed based on 39 boys and 40 girls (N = 79), made up of 68% Caucasians, 20% African-Americans, 5% Mixed/Other race, 4% Latino-Americans, and 1% Asian-Americans (2% missing data). • Mean age of children in this group was 8.19 (SD = 2.25), with a range of between 4-14 years.

  46. Replication Study: Reliability Findings • For the ADHD sample, the mean corrected item-total correlation for the Stress Experience scale was .41 (range = .07 - .60); for the Stress Degree scale it was .49 (range = .24 - .67). • Item 18 (“Disagreements with spouse about managing child behavior”) consistently showed the lowest item-total correlation. • The internal consistency of both scales was analyzed, using Cronbach’s coefficient alpha. • For the ADHD sample, Cronbach’s coefficient alpha was found to be .90 (n = 69) for the Stress Experience scale and .93 (n = 68) for the Stress Degree scale.

  47. Replication Study: Preliminary Analyses • The discriminative validity of the Stress Experience and Stress Degree scales was again assessed by comparing scores of primary caregivers of children with and without ADHD. • Preliminary analyses indicated no significant group difference in terms of child age. • A significant difference in Stress Experience scores of boys and girls in the ADHD group was found (Boys > Girls). • Given these findings, subsequent group comparisons involved analyses of covariance with gender as a covariate. • Given the small number of children diagnosed with the primarily hyperactive/impulsive (n = 1) and inattentive (n = 4) subtypes of ADHD, analyses based on subtype were not conducted.

  48. Replication Study: Discriminative Validity • Stress Experience Scale • An analysis of covariance was used to determine whether scores on the Stress Experience scale differentiated between caregivers of children with and without ADHD. • The ANCOVA showed significant mean score differences between groups, F (1, 147) = 94.95, p < .001., with caregivers of children with ADHD experiencing more stressors (M = 20.45, SD = 8.34) than caregivers of children in the comparison group (M = 7.47, SD = 7.17). • The Cohen’s f value of .84 represented a large effect size (Cohen, 1988). • Child gender was a significant covariate (p < .05), and explained approximately 3% of the variance in the Stress Experience index scores.

  49. Replication Study: Discriminative Validity • Stress Degree Scale Again using child gender as a covariate, an ANCOVA found that mean scores on the Stress Degree scale significantly differentiated caregivers of children with ADHD from caregivers of children from the comparison group, F (1, 147) = 80.22, p < .001. • Caregivers of children with ADHD showed higher mean Stress Degree scores (M = 40.45, SD = 22.92) than caregivers in the comparison group (M = 11.39, SD = 14.50). • The Cohen’s f value of .77 represented a large effect size (Cohen, 1988). • Child gender was not found to be a significant covariate (p = .22).

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