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Caregiver Outcomes in Response to Child Medication Treatment for ADHD

Caregiver Outcomes in Response to Child Medication Treatment for ADHD. Steven K. Reader, M.S. December 1, 2006. Attention Deficit Hyperactivity Disorder (ADHD) diagnostic criteria. Developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity

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Caregiver Outcomes in Response to Child Medication Treatment for ADHD

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  1. Caregiver Outcomes in Response to Child Medication Treatment for ADHD Steven K. Reader, M.S. December 1, 2006

  2. Attention Deficit Hyperactivity Disorder (ADHD) diagnostic criteria • Developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity • Clear evidence of impairment in social, academic, or occupational functioning across at least two settings • Subtypes: • Primarily Inattentive • Primarily Hyperactive-Impulsive • Combined (APA, 1994)

  3. ADHD • Prevalence: • 3-5% in general child population (APA, 1994), • 4-12% in general pediatric settings (AAP, 2000), • Up to 50% in some child psychiatry clinics (Cantwell, 1996) • Symptoms often persist into adolescence and adulthood

  4. Comorbid disorders • 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)

  5. Childhood ADHD:common problems • Academic difficulties • Lower adaptive functioning • Poor peer relationships • Higher risk for unintentional injury These problems can present significant challenges for many parents

  6. Caregiver adjustment:ADHD vs. normal controls • Caregivers of children with ADHD have more psychological difficulties (Mash & Johnston, 2001) • Higher levels of: • Caregiver stress (Fischer, 1990; Johnson & Reader, 2002) • Isolation (Beck et al., 1990; Breen & Barkley, 1988) • Role restriction (Byrne et al., 1998; Mash & Johnston, 1983) • Depression (Befera & Barkley, 1985; Brown & Pacini, 1989) • Lower levels of: • Attachment to child (Breen & Barkley, 1988; Byrne et al., 1990) • Satisfaction in parenting role (Lange et al., 2005; Sonuga-Barke et al., 2001) • Sense of efficacy in parenting role (Bryne et al., 1998)

  7. Caregiver outcomes:ADHD subtypes • Mixed findings to date with minimal studies • Caregiver stress • No differences (using PSI-SF Parent Distress score) (Podolski & Nigg, 2001) • Combined > Inattentive (using DBSI) (Johnson & Reader, 2002) • Depression • Combined > Inattentive (West et al., 1999)

  8. Impact of comorbid ODD/CD • Associated with poorer caregiver adjustment, often contributing variance over and above core ADHD symptoms • Caregiver stress (Anastopoulos et al., 1992; Bussing et al., 2003; Podolski & Nigg, 2001; Ross et al., 1998; Vitanza & Guarnaccia, 1999) • Satisfaction and efficacy (Johnston, 1996; Podolski & Nigg, 2001; Shelton et al., 1998) • Depression (Chronis et al., 2003)

  9. Demographic factors • Few studies have examined how demographic factors are related to caregiver adjustment (Johnston & Mash, 2001) • Low SES found to be associated with ADHD families (Scahill et al., 1999), but mixed findings related to caregiver stress (Baker, 1994; Baldwin et al., 1995) • Mixed findings related to total number of children in family (Baker, 1994; Ostberg & Hagekull, 2000) • Single caregiver status linked to increased parenting stress (Baker, 1994; Webster-Stratton, 1990)

  10. Behavioral treatment of ADHD/ disruptive behaviors: caregiver outcomes • ADHD-specific behavioral treatments • Decreased PSI Child/Parent Domain • Increased satisfaction and efficacy in parenting role (Anastopoulos et al., 1993; Pisterman et al., 1992) • PCIT • Decreased PSI Child/Parent Domain • Increased satisfaction and efficacy in parenting role (Nixon et al., 2003; Schuhmann et al., 1998) • No effects on caregiver depression (Schuhmann et al., 1998)

  11. Medication treatment of ADHD:caregiver outcomes • MTA Cooperative Study: Wells et al. (2000) • Meds only vs. Behavior tx vs. Comb Meds/Beh tx vs Standard Community care • Baseline vs 14 month follow-up • Found no treatment group x time interaction for PSI-SF, BDI, and Dyadic Adjustment Scale • Cited treatment overlap as one reason for lack of significant findings (26% of Beh tx group and 66% of Standard care group received meds) • No description of within group changes on PSI-SF

  12. Medication treatment of ADHD:caregiver outcomes (cont.) • Chronis et al. (2003) • 6-week period of medication treatment • Found improvements in caregiver perceptions of pleasantness in parent-child interactions and parenting efficacy • No effects on caregiver mood

  13. Medication treatment of ADHD:caregiver outcomes (cont.) • Jones (2000) • Assessed maternal parenting stress using PSI at pre-treatment and 1 and 3 month follow-up • Significant decrease in PSI Child Domain score over time but not for PSI Parent Domain • Family income accounted for significant variance in PSI change (marital status and maternal education did not) • Some limited support for baseline levels of ADHD symptoms and oppositional behavior in predicting change on PSI Child/Parent Domain • No differences in stress b/w parents who did and did not receive some additional form of psychotherapy

  14. Study primary objective • Examining the following caregiver adjustment outcomes in response to child stimulation medication treatment for ADHD • Parenting stress • Attachment to child • Isolation • Role restriction • Sense of satisfaction in parenting role • Sense of efficacy in parenting role • Depression

  15. Study rationale • Poor caregiver adjustment linked to: • negative parent-child interactions (Webster-Stratton, 1990) • Decreased treatment effectiveness for ADHD (Owens et al., 2003), and premature termination from treatments for ODD/CD (Forehand et al., 1984; Kazdin et al., 1993) • Interventions to improve caregiver adjustment in conjunction with parent management training leads to improved treatment effectiveness and maintenance (Griest et al., 1982)

  16. Study rationale (cont.) • Very few studies assessing caregiver adjustment outcomes in response to stimulation medication treatment for ADHD • Such studies can help inform whether additional interventions might be necessary

  17. Participants • 32 caregivers completed baseline • 30 female, 2 male • Mean age 37.66 years (range 23-60) • 63% Caucasian, 23% African Amer, 13% Hispanic • Two-caregiver homes 57% • Lower middle SES range • Mean number of children in home = 2.14 • 24 boys, 8 girls • Mean age 7.94 years (range 5-12) • Primary diagnosis of ADHD • Exclusions: MR, PDD, psychosis, sensory impairment

  18. Participants (cont.) • ADHD subtypes • Inattentive n = 5 • Hyperactive/Impulsive n = 1 • Combined: n = 26 • Comorbid ODD/CD • ADHD-only n = 14 • Oppositional Defiant Disorder n = 12 • Conduct Disorder n = 6 • Child either starting on stimulant medication or undergoing change (med type or dosage) in existing stimulant medication regimen

  19. Child behavior measures • Conners’ Parent Rating Scale - Revised: Long Version (CPRS-R:L) • DSM-IV Inattentive • DSM-IV Hyperactive-Impulsive • DSM-IV Total • Oppositional • Disruptive Behavior Disorders Rating Scale (DBDRS) • Conduct Disorder

  20. Caregiver adjustment measures • Disruptive Behavior Stress Inventory (DBSI) • Stress Experience and Stress Degree subscales • Parenting Stress Index (PSI) • Attachment, Isolation, Role Restriction from Parent Domain • Parenting Sense of Competence Scale (PSOC) • Satisfaction • Efficacy • Beck Depression Inventory Second Edition (BDI-II)

  21. Procedures Baseline and follow-up assessments • In person at health science center • By mail • Follow-up assessment (mean 8.82 weeks after stimulant medication started or changed) • 20 caregivers completed follow-up assessment

  22. Baseline analyses (Objective 1):Baseline levels of child behavior and caregiver adjustment • Clinically significant levels of core ADHD and ODD symptoms • High frequency of stressors experienced (z = 2.40) and high degree of stressfulness (z = 2.98) (DBSI) • PSI Attachment to child (65%ile), Isolation (75%ile), Role Restriction (65%ile) all within normative range • PSOC Satisfaction (z = -.66) and Efficacy (z = .44) both within normative range • Depressive symptoms within mild range (BDI-II)

  23. Baseline analyses II (Objective 2):Demographic variables • Increased feelings of attachment to child, sense of parenting efficacy, and less role restriction, were significantly related to having more children in the home • SES and single caregiver status not related to caregiver adjustment • Caregivers of boys with ADHD reported experiencing more stressors • Caregivers who were involved in ongoing psychotherapy were less satisfied in parenting role and more depressed

  24. Baseline analyses II (cont.):Correlations between child behavior and caregiver adjustment • Increased hyperactive-impulsive ADHD symptoms, and to a larger extent, ODD and CD behaviors, were related to higher frequency and intensity of caregiver stress, higher role restriction, decreased parenting satisfaction, and higher depressive symptoms • Inattentive ADHD symptoms only related to less parenting satisfaction • Levels of ODD/CD behaviors, but not ADHD symptoms, were related to caregiver perceived attachment to child and isolation • Levels of child behavior not related to caregiver sense of efficacy

  25. Baseline analyses II (cont.)ADHD subtype comparison • Significantly poorer adjustment on all caregiver measures except isolation and sense of efficacy for ADHD Combined/Hyperactive-Impulsive group compared to Inattentive group

  26. Baseline analyses II (cont.)ADHD-only vs ADHD + ODD/CD • ADHD + ODD or CD group showed significant levels of: • Caregiver stress experience (z = 3.24) and degree (z = 4.08) • Isolation (z = 1.16) • Decreased parenting satisfaction (z = -1.23) • Depressive symptoms in moderate range • Significantly poorer adjustment on all caregiver measures except efficacy for caregivers in ADHD + ODD or CD group compared to ADHD-only group

  27. Baseline analyses II (cont.)Main conclusions • Results from correlational and group comparison analyses suggest that, in general, levels of hyperactive-impulsive ADHD symptoms are more related to caregiver adjustment than inattentive symptoms • Consistent with studies indicating higher levels of caregiver stress (Johnson & Reader, 2002) and depression in ADHD Combined compared to ADHD Inattentive group (West et al., 1999) • Stronger association of comorbid ODD/CD symptoms, compared to ADHD symptoms, with caregiver adjustment • Consistent with previous studies (Anastopoulos et al., 1992; Bussing et al., 2003; Podolski & Nigg, 2001; Vitanza & Guarnaccia, 1999)

  28. Follow-up analyses (Objective 3) • Study non-completers had significantly higher role restriction and depressive symptoms • Limits generalizability of follow-up findings • Significant reductions in core ADHD, ODD, and CD symptoms from baseline to follow-up • Inattentive, oppositional symptoms in normative range • Hyperactive-impulsive symptoms borderline at-risk range

  29. Follow-up analyses (cont.) • Significant reductions in: • Caregiver stressors experienced (d = .82) • Caregiver stress degree (d = 1.04) • Isolation (d =.73) • Depressive symptoms (d = .69) • Significant increase in parenting Satisfaction (d = .61) • Only caregiver stress decreased from significantly elevated level • SES, single caregiver status, and number of children in home not related to change scores

  30. Follow-up analyses (cont.) • Change score correlations (controlling for baseline level on respective caregiver measure) • Decreases in inattentive and hyperactive-impulsive ADHD symptoms were related to decreases in frequency of stressors experienced • Decreases in core ADHD symptoms and ODD symptoms comparably related to decreases in degree of stress • Decreases in ODD symptoms primarily, and to lesser extent core ADHD symptoms, related to decreases in depressive symptoms • Changes in child behavior not related to changes in perceived isolation or parenting satisfaction

  31. Study limitations • Only 20 caregivers completed follow-up assessment • Reduced power • Non-completers higher role restriction, depression • Caregiver ADHD • Lack of consistent/reliable diagnosis of comorbid ODD/CD • DBDRS lack of parent norms

  32. Study limitations (cont.) • Single method of data collection • Potential rater bias, as caregiver adjustment can influence child behavior ratings • Lack of comparison control group • Cannot attribute study effects to stimulant medication treatment solely

  33. Study implications • Screen caregivers for adjustment problems, particularly stress and depression, during child ADHD assessments • Caregiver adjustment problems can lead to negative caregiver-child interactions and premature termination from child treatment • Interventions to help caregivers can improve child treatment effectiveness • Assess levels of comorbid disruptive behavior during child ADHD assessments • Available effective treatments for young children with ODD (e.g. PCIT)

  34. Future directions • Increasing sample size could lead to: • More reliable group comparisons, based on ADHD subtype and ODD/CD comorbidity • Multiple regression or structural equation modeling to look at relative contributions of various predictors to caregiver adjustment change, including mediating and moderating variables • Temporal relationship between various caregiver adjustment variables, in response to treatment

  35. Future directions (cont.) • Other constructs of possible interest: • Caregiver attributions of child behavior • Social support for caregiver • Cultural influences • Adjustment of other family members • Male caregiver, siblings • Different dimensions of global factors • Stress: social, academic, spousal • Depression: cognitive, physical • Impact of comorbid disorders • Using multiple assessment methods to reduce confounds and increase reliability

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