Beyond ADHD Symptoms: Assessing & Treating Functional Impairments Across Development

Beyond ADHD Symptoms: Assessing & Treating Functional Impairments Across Development George J. DuPaul, PhD Lehigh University Research Seminar Bennett Pierce Prevention Research Center Pennsylvania State University January 28, 2015

DSM 5 CRITERIA FOR ADHD Significant problems with inattention Significant problems with hyperactivity impulsivity Symptoms persisted at least 6 mos to a degree inconsistent with developmental level and negative impact on social, academic, occupational activities Several symptoms present prior to age 12 Several symptoms present in two or more settings Symptoms interfere with or reduce quality of social, academic, or occupational functioning Not due to another disorder (e.g., mood disorder) Presentations: Combined, Predominantly Inattentive, Predominantly Hyperactive Impulsive Severity: Mild, Moderate, Severe American Psychiatric Association (2013)

Symptoms vs. Impairment Symptoms = Behavioral expressions associated with ADHD; actions believed to reflect the disorder (e.g., inattention) Impairment = Consequences that ensue for individual as a result of symptomatic behaviors (e.g., low GPA, losing friends) Symptoms + Impairment = Disorder However, vast preponderance of ADHD assessment and intervention studies focus on symptoms Presence of impairment, rather than symptoms, may drive who seeks treatment Life course model of care for ADHD emphasizes strategies to increase competencies & address functional impairment Angold et al. (1999); Barkley, Cunningham, Gordon, Faraone, Lewandowski, & Murphy (2006); Evans, Owens, Matoune, DuPaul, & Power (2014)

Importance of Functional Impairment: Three Interrelated Themes Importance of assessing impairment across domains of functioning & across settings Level of impairment varies across areas of functioning, individuals, and time (i.e., impairment is not a unitary phenomenon) School interventions that target impairment associated with moderate to large effects on functioning

Study #1 Importance of assessing impairment across domains of functioning & across settings

Multi Informant Assessment of ADHD Symptom Related Impairments Existing methods of assessing ADHD are limited b/c do not examine impairments specifically in relation to symptoms Current methods to assess impairment Measure of global impairment Separate measures of specific domain (e.g., social) Measure of multiple domains of impairment Broad band measure includes impairment items ADHD measure includes impairment items Do not assess impairments specifically related to ADHD symptoms and do not specify impairment related to each ADHD dimension (inattention; hyperactivity impulsivity) Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Purpose of Study Examine construct validity of impairment items of ADHD Rating Scale 5 (DuPaul, Power Anastopoulos, & Reid, 2015) Factor structure (one, two, or six factors?) Relationship between symptom and impairment ratings Impact of impairment on identification of ADHD Examine degree to which impairment ratings are predicted by symptom ratings relative to child characteristics (e.g., gender) Generate normative data for parent and teacher report of ADHD symptom related impairments Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Participants Sample 1: N = 2,079 parents/guardians (1,131 female) completed ARS 5 for one randomly selected child Predominantly White, non Hispanic (64.1%) Between 20 to 77 (M = 41.6, SD = 8.23) Most married (79.7%) Most at least HS education (89.9%) Employed (72.3%) Children (1,037 males, 1,042 females) between 5 to 17 (M = 10.68; SD = 3.75); most White, non Hispanic (53.9%) Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Participants Sample 2: N = 1,070 teachers (766 female, 304 male) completed ARS 5 for randomly selected boy and girl Predominantly White, non Hispanic (87.3%) Average of 17.88 yrs of teaching experience General (83.3%) and special (16.4%) education Students (1,070 males, 1,070 females) between 5 to 17 (M = 11.53; SD = 3.54) attended K 12 Most White non Hispanic (54.8%) Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Measure ADHD Rating Scale 5 Parent and teacher ratings of frequency of 18 ADHD symptoms (9 inattention, 9 hyperactivity impulsivity) using 4 pt Likert scale (never or rarely to very often) Parent and teacher ratings of impairment related to inattention (6 items) and hyperactivity impulsivity (6 items) using 4 pt Likert scale (no problem to severe problem) Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Measure How much do the above behaviors cause problems for your child (this student)? Areas of Impairment Relationships with significant others (family members for home version; teachers for school version) Peer relationships Academic functioning Behavioral functioning Homework Self esteem Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Procedures Parents and teachers recruited through GfK Knowledge Panel (national research firm) to provide sample of children representative of US population re: race, ethnicity, geographic distribution) Response rate 64.2% for parents, 67.5% for one teacher sample, 11.1% for second teacher sample Ratings collected on line April/May 2014 Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Data Analyses Confirmatory factor analysis (CFA) using polychoric correlations given ordered categorical nature of impairment data Two factors (inattention related impairment, hyperactivityimpulsivity related impairment) hypothesized Six factors (domains of impairment collapsed across symptom domains) One factor (all 12 impairment items) Logistic regression analyses to examined relationships among child characteristics, ADHD symptom ratings, symptom related impairment ratings Normative data using frequency distributions for each impairment factor Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Results Factor structure One and two factor models roughly equivalent in fit Hypothesized two factor structure inferior to six factor structure (e.g., Peer Relationships, Academics) for both parents and teachers Factor structure was invariant across child gender, age, parent gender, ethnicity/race Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Confirmatory Factor Analysis of Impairment Models Model Chi DF CFI ΔCFI RMSEA 90%CI ΔRMSEA Square Parent One 2779.88 54.959.156.151.161 Two 2559.98 53.962.003.151.146.156.005 Six 240.46 39.997.035.050.044.056.101 Teacher One 2900.58 54.971.157.152.162 Two 2707.72 53.973.002.153.148.158.004 Six 517.86 39.995.022.076.070.082.077 CFI is comparative fit index; RMSEA is root mean square error of approximation

Results Relationship between impairment & symptom ratings Both parents and teachers reported stronger relationships between IA symptoms & impairment for Academics, HW, & Self Esteem than for HI symptoms & impairment in these areas Higher correlation between HI symptoms & behavior impairment than for IA symptoms (teacher ratings only) Regardless of symptom dimension, relationships were stronger for teachers than for parents Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Correlations Between ADHD Symptom Ratings and Impairment: Parent Report Inattention Hyperactive Total Impulsive Family Relations.47.41.49 Peer Relations.42.44.47 Homework.63*.37*.59 Academics.61*.35*.56 Behavior.51.52.56 Self Esteem.44*.34*.44 *Differences in IA vs HI p <.05

Correlations Between ADHD Symptom Ratings and Impairment: Teacher Report Inattention Hyperactive Total Impulsive Teacher Relations.59.60.63 Peer Relations.61.64.65 Homework.76*.54*.73 Academics.82*.57*.78 Behavior.71*.77*.77 Self Esteem.60*.50*.60 *Differences in IA vs HI p <.05

Dx Status Based on Symptom Count, Impairment Count, & Combined Count (Teacher Report) No ADHD ADHD IA ADHD HI ADHD Comb Symptom 1735 (81.1%) 236 (11.0%) 39 (1.8%) 130 (6.1%) Impairment 1469 (68.6%) 131 (6.1%) 42 (2.0%) 498 (23.3%) Symptom + Impairment 1984 (92.7%) 32 (1.5%) 2 (0.1%) 122 (5.7%) DuPaul, Reid, Anastopoulos, & Power (2014)

Results Variations in impairment ratings due to child characteristics & ADHD symptom ratings Parent and teacher impairment ratings not impacted by child gender or race/ethnicity Older age associated with more impairment for Family/Teacher Relations, Homework, Peer Relations, Academics Effect sizes and group discrimination weak (minimal practical significance) Logistic regression models significantly improved by addition of mean item scores for each symptom dimension Satisfactory effect sizes and excellent group discrimination Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Results Normative data Scores on impairment factors created by selecting higher score on two factor items Most children had no or minor impairment problems, positively skewed distributions Parent ratings indicated betw 6.2% to 10.5% of sample displayed moderate to severe problems in at least one impairment dimension Teacher ratings indicated betw 10.5% to 27.0% of sample displayed moderate to severe problems in at least one impairment dimension Teachers reported more children to display more than one impairment than did parents Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Number of Impairments: Percentage of Parent & Teacher Report 100% Perentage of Sample 80% 60% 40% 20% 0% Parent Respondent Teacher 6 5 4 3 2 1 0 Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Conclusions Although areas of impairment are correlated, these represent separate domains, each of which is impacted by IA & HI symptoms More variance in impairment is accounted for by ADHD as whole than by separate symptom dimensions IA more strongly related to academic impairment & self esteem than HI symptoms; HI symptoms more related to behavior impairment than IA symptoms (at least for teachers) Symptoms account for more variance in impairment than found for child characteristics known to correlate with functioning In contrast to typical findings for ADHD symptom frequency, older age associated with more severe impairment particularly for areas emphasized in secondary schools (peer relations, homework) Teachers report more symptom related impairment than parents Conclusions are limited by non clinical sample, lower than desired response rate for part of teacher sample Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)

Study #2 Level of impairment varies across areas of functioning, individuals, and time (i.e., impairment is not a unitary phenomenon)

Academic & Social Functioning of Children with ADHD: Latent Class Trajectories K 5 ADHD associated with significant chronic impairment in academic & social functioning Most studies are cross sectional & do not address possible individual differences in level and trajectory of impairment Lack of knowledge re: within group heterogeneity in academic & social impairment may limit identification of most vulnerable subgroups of children with ADHD DuPaul, Morgan, Maczuga, Farkas, & Hillemeier (in preparation)

Purpose of Study Identify subgroups of children dxed with ADHD on basis of latent trajectories of reading, math, and interpersonal skills from K to 5 th grade Examine joint probabilities of membership in reading, math, and interpersonal skills trajectory classes Identify child demographic (e.g., gender, SES), academic, and behavioral characteristics in K that vary across latent trajectory classes DuPaul, Morgan et al. (in preparation)

Participant Sample N = 590 children (72.7% male; 76.1% White, non Hispanic) who rec d ADHD dx (by parent report) by 5 th grade From Early Childhood Longitudinal Study, Kindergarten (ECLS K; Tourangeau et al., 2009) Assessed at 5 time points (Kindergarten Fall, Kindergarten Spring, Gr. 1 Spring, Gr. 3 Spring, Gr. 5 Spring DuPaul, Morgan et al. (in preparation)

Measures of Academic & Social Functioning Direct assessment of reading and math skills Standardized T Scores (M = 50; SD = 10) Teacher ratings on Social Rating Scale Interpersonal Skills subscale (five items; e.g., forming & maintaining friendships; comforting or helping other children; showing sensitivity to feelings of others) Four point Likert scale (never to very often) Mean item rating used as dependent measure Note: M score for ECLS K sample was 3.0 (SD = 0.6) DuPaul, Morgan et al. (in preparation)

Data Analyses Growth mixture modeling analyses conducted separately for reading, math, & interpersonal skills using PROC TRAJ in SAS Model fit determined using Bayes Information Criteria (BIC) and conceptual/clinical utility of obtained solutions (Nagin, 2005) Dual trajectory analyses to examine joint probabilities for rdg/math; rdg/interpersonal; math/interpersonal Classes w/in each functioning area compared on child demographic, academic, and behavioral characteristics (in K) using chi square or ANOVA DuPaul, Morgan et al. (in preparation)

Results Growth mixture modeling analyses Four classes for Reading (Quadratic) Eight classes for Math (Quadratic) Four classes for Interpersonal Skills (Linear)

Growth Mixture Model Latent Classes of Reading for Children with 70 ADHD Reading 4 Trajectories 65 60 Reading Standard Score 55 50 45 40 35 30 Class 1 (7.6%) Class 2 (32.1%) Class 3 (44.2%) Class 4 (16.1%) 25 DuPaul, Morgan et al. (in preparation) 20 Fall K Spring K Spring 1st Spring 3rd Spring 5th Assessment Phase

Growth Mixture Model Latent Classes of Math for Children with ADHD 70 Math 8 Trajectories Math Standard Score 65 60 55 50 45 40 35 30 25 Class 1 (6.9%) Class 2 (5.5%) Class 3 (10.1%) Class 4 (16.9%) Class 5 (27.3%) Class 6 (5.8%) Class 7 (20.5%) Class 8 (7.1%) 20 Fall K Spring K Spring 1st Spring 3rd Spring 5th DuPaul, Morgan et al. (in preparation) Assessment Phase

Growth Mixture Model Latent Classes of Interpersonal Skills for Children with ADHD 4 Interpersonal 4 Trajectories Average Interpersonal Item Score 3.5 3 2.5 2 1.5 1 0.5 Class 1 (23.9%) Class 2 (28.8%) Class 3 (24.6%) Class 4 (22.7%) 0 Fall K Spring K Spring 1st Spring 3rd Spring 5th Assessment Phase DuPaul, Morgan et al. (in preparation)

Results (cont.) Dual trajectory analyses Each pairwise combination of variables (Reading Math, Reading Interpersonal, Math Interpersonal) Ascertain probability of membership in various classes on one area (e.g., Interpersonal) being conditional on membership in various classes in second area (e.g., Reading) Ascertain probability of group membership for reverse conditional relationship (e.g., Reading conditional upon Interpersonal) DuPaul, Morgan et al. (in preparation)

Results (cont.) Dual trajectory analyses Majority of children were in equivalent classes in Math conditional upon Reading class membership (e.g., 78% of children in lowest reading achievement class also in two lowest functioning math classes) DuPaul, Morgan et al. (in preparation)

Probability of Math Class Dependent on Reading Class 1 0.8 Probability 0.6 0.4 0.2 0 Rdg Class 1 Rdg Class 2Rdg Class 3Rdg Class 4 Reading Achievement Latent Trajectory Class Math Low Math Improving Math Ave Math High DuPaul, Morgan et al. (in preparation)

Results (cont.) Similar, albeit lower probability, outcomes for Reading conditional on Math class membership; Interpersonal conditional on Reading; & Interpersonal conditional on Math Interpersonal class membership did not strongly impact probability of membership in reading or math classes

Probability of Interpersonal Skills Class Dependent on Reading Class 1 0.8 Probability 0.6 0.4 0.2 0 Rdg Class 1 Rdg Class 2 Rdg Class 3 Rdg Class 4 Reading Achievement Latent Trajectory Class IP Class 1 IP Class 2 IP Class 3 IP Class 4 DuPaul, Morgan et al. (in preparation)

Probability of Reading Class Dependent on Interpersonal Skills Class 1 0.8 Probability 0.6 0.4 0.2 0 IP Class 1 IP Class 2 IP Class 3 IP Class 4 Interpersonal Skills Latent Trajectory Class Rdg Class 1 Rdg Class 2 Rdg Class 3 Rdg Class 4 DuPaul, Morgan et al. (in preparation)

Conclusions ADHD subgroups identifiable with respect to trajectories in reading, math, & interpersonal skills Consistently below average performance (i.e., crosstemporal impairment) found for Reading (60.3%), Math (39.4%), & Interpersonal Skills (23.9%) Some children showed diminished (27.3% Math; 24.6% Interpersonal Skills) or improved (5.8% Math; 28.8% Interpersonal Skills) performance over time Reading impairment identifiable early in elementary school with little change over time, while math and interpersonal skills impairment more likely to change over time DuPaul, Morgan et al. (in preparation)

Conclusions Similar performance levels in reading and math Interpersonal skills trajectory somewhat correlated with reading and math trajectory membership but not vice versa If a child with ADHD is impaired academically, highly likely (>60% probability) to be impaired socially but converse not necessarily true Trajectory classes differed in predictable ways (e.g., lowest functioning classes reported to display more ADHD, externalizing and internalizing symptoms) DuPaul, Morgan et al. (in preparation)

Conclusions Limitations ADHD dx status based on parent report No information on ADHD subtype (presentation) Change in teachers providing ratings x grades Clinicians cannot assume unitary effect of symptoms on school functioning and thus must always assess academic and social performance Reading may be keystone functioning area as significant impairment in reading can be chronic & is strongly linked to additional impairment in math and social skills Early screening and intervention critical especially for reading skills DuPaul, Morgan et al. (in preparation)

Study #3 School interventions that target impairment associated with moderate to large effects on functioning

Interventions for Students with ADHD Primary tx Psychotropic medication, chiefly CNS stimulants (e.g., methylphenidate) Contingency management/behavioral intervention Assumption: Reducing symptoms will improve functional impairments Often not the case (e.g., small effect size for academic achievement associated with medication in MTA study)

School Based Interventions for ADHD: Meta analysis 1996 2010 Systematic search of published and unpublished studies between 1996 2010 60 outcome studies yielding 85 effect sizes (academic and behavioral) Three different research designs: between subjects (k = 4), within subjects (k = 17), single case (k = 39) DuPaul, Eckert, & Vilardo (2012) 45

School Based Interventions for ADHD: Meta analysis 1996 2010 Examined outcomes for academic interventions (k = 15), contingency management (k = 26), combined academic and contingency management (k = 10), & cognitive behavioral (k = 9) Most studies in elementary school (k = 43) with the remainder middle school or combined elementary/middle Most studies (k = 43) in public school rather than private school or summer tx program Most studies (k = 53) reported medication status with approx. 51% of participants rec ing meds during tx; medication status held constant in 70% of studies Only 20% of studies included follow up assessment DuPaul, Eckert, & Vilardo (2012) 46

Mean Effect Size by Type of Research Design & Outcome Mean Effect Size 4 3.5 3 2.5 2 1.5 1 0.5 0.18 3.48* 2.2* 0.72* 0.43 0.42 0 Betw Subj Within Subj Single Case Research Design DuPaul, Eckert, & Vilardo (2012) 47 Behavior Academic

WSD: Mean Effect Size Across Intervention Type & Outcome Mean Effect Size 1 0.9 0.87 0.8 0.7 0.61 0.6 0.56 0.53 0.53 0.5 0.4 0.3 0.24 0.2 0.1 0 Academic Behavior Outcome Measure DuPaul, Eckert, & Vilardo (2012) 48 Acad Int Cont Man Combined

School Based Intervention for ADHD: Meta Analysis 1996 2010 Moderate to large effects of school based interventions on academic and behavioral outcomes Results vary across research design and moderated by intervention type, and, in some cases, publication status, school setting & educational placement Academic or combined AI/CM interventions had greatest effect on academic outcomes DuPaul, Eckert, & Vilardo (2012) 49

School Based Intervention for ADHD: Meta Analysis 1996 2010 General education equivalent to special education for both academic and behavioral change Findings limited by lack of between subjects studies (RCTs) and small ES for available BSD studies Very few studies beyond elementary school level (none at high school level!) Very few studies include follow up assessment Despite limitations, school based interventions should be a first line tx for ADHD, particularly regarding academic outcomes DuPaul, Eckert, & Vilardo (2012) 50

Importance of Functional Impairment: Three Interrelated Themes Importance of assessing impairment across domains of functioning & across settings Level of impairment varies across areas of functioning, individuals, and time School interventions that target impairment associated with moderate to large effects on functioning

Questions/Discussion