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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 Steven K. Reader, M.S. December 1, 2006
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)
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
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)
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
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)
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)
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)
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)
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)
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
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
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
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
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)
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
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
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
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
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)
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
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)
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
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
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
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
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)
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
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
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
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
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
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)
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
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