Peer Rejection and Friendships in Children with Attention-Deficit/Hyperactivity Disorder: Contributions to Long-Term Outcomes

Even after evidence-based treatment, Attention- Deficit/Hyperactivity Disorder (ADHD) is associated with poor long-term outcomes. These outcomes may be partly explained by difficulties in peer functioning, which are common among children with ADHD and which do not respond optimally to standard ADHD treatments. We examined whether peer rejection and lack of dyadic friendships experienced by children with ADHD after treatment contribute to long-term emotional and behavioral problems and global impairment, and whether having a reciprocal friend buffers the negative effects of peer rejection. Children with Combined type ADHD (N0300) enrolled in the Multimodal Treatment Study of Children with ADHD (MTA) were followed for 8 years. Peer rejection and dyadic friendships were measured with sociometric assessments after the active treatment period (14 or 24 months after baseline; M ages 9.7 and 10.5 years, respectively). Outcomes included delinquency, depression, anxiety, substance use, and general impairment at 6 and 8 years after baseline (Mean ages 14.9 and 16.8 years, respectively). With inclusion of key covariates, including demographics, symptoms ofADHD, ODD, and CD, and level of the outcome variable at 24 months, peer rejection predicted cigarette smoking, delinquency, anxiety, and global impairment at 6 years and global impairment at 8 years after baseline. Having a reciprocal friend was not, however, uniquely predictive of any outcomes and did not reduce the negative effects of peer rejection. Evaluating and addressing peer rejection in treatment planning may be necessary to improve long-term outcomes in children with ADHD

Discriminating Between Children With ADHD and Classmates Using Peer Variables

Objective: Impaired peer relationships have long been recognized as one of the major functional problems of children with ADHD, but no specific guidelines on clinical levels of impairment in this domain exist. Method: This study used Receiver Operating Characteristics methodology to determine what aspects of peer functioning best discriminate between children with ADHD and their classmates. Optimal cutoffs indicative of clinical levels of impairment associated with ADHD diagnosis were determined for all variables. The participants were 165 children with AD/HD who were part of the Multimodal Treatment Study of Children With ADHD and their 1,298 classmates. Results: Variables that best discriminated between children with ADHD and their classmates included peer rejection and negative imbalance between given and received liking ratings (i.e., children with ADHD liked others more than they were liked). Conclusion: Peer rejection and negative imbalance show most promise for identifying clinically significant levels of peer relationship impairment in children with ADHD. (J. of Att. Dis. 2009; 12(4) 372-380)

Maternal Personality Traits Moderate Treatment Response in the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder

Background: Some mothers of children with attention-deficit/hyperactivity disorder (ADHD) present with maladaptive personality profiles (high neuroticism, low conscientiousness). The moderating effect of maternal personality traits on treatment outcomes for childhood ADHD has not been examined. We evaluate whether maternal neuroticism and conscientiousness moderated response in the Multimodal Treatment Study of Children with ADHD. This is one of the first study of this type. Methods: In a randomized controlled trial (RCT), 579 children ages 7-10 (M=8.5); 19.7% female; 60.8% White with combined-type ADHD were randomly assigned to systematic medication management (MedMgt) alone, comprehensive multicomponent behavioral treatment (Beh), their combination (Comb), or community comparison treatment-as-usual (CC). Latent Class Analysis and Linear Mixed Effects Models included 437 children whose biological mothers completed the NEO Five-Factor Inventory at baseline. Results: A 3-class solution demonstrated best fit for the NEO: MN&MC=moderate neuroticism and conscientiousness (n=284); HN&LC=high neuroticism, low conscientiousness (n=83); LN&HC=low neuroticism, high conscientiousness (n=70). Per parent-reported symptoms: children of mothers with HN&LC, but not LN&HC, had a significantly better response to Beh than to CC; Children of mothers with MN&MC and LN&HC, but not HN&LC, responded better to Comb&MedMgt than to Beh&CC. Per teacher-reported symptoms, children of mothers with HN&LC, but not LN&HC, responded significantly better to Comb than to MedMgt. Conclusions: Children of mothers with high neuroticism and low conscientiousness benefited more from behavioral treatments (Beh vs. CC; Comb vs. MedMgt) than other children. Evaluation of maternal personality may aid treatment selection for children with ADHD, though additional research on this topic is needed

Child and Parent Predictors of Perceptions of Parent–Child Relationship Quality

Objective/Method: Predictors of perceptions of parent–child relationship quality were examined for 175 children with ADHD, 119 comparison children, and parents of these children, drawn from the follow-up phase of the Multimodal Treatment Study of Children with ADHD. Results/Conclusion: Children with ADHD perceived their mothers and fathers as more power assertive than comparison children. Children higher on depressive symptomatology also perceived their mothers and fathers as less warm and more power assertive. Mothers perceived themselves as more power assertive and fathers perceived themselves as less warm if they were higher on depressive symptomatology themselves or had children with ADHD or higher levels of depressive symptomatology. Several interactions indicated that the association between child factors and parental perceptions of warmth and power assertion often depended on parental depressive symptomatology. The findings resolve a previous contradiction in the literature regarding the relationship between child depressive symptoms and parental perceptions of parent–child relationship quality

ADHD in context: Young adults’ reports of the impact of occupational environment on the manifestation of ADHD

Does changing context play a role in the decline in ADHD symptoms in adulthood? Insufficient research has explored the functioning of adults with ADHD. As adults, individuals with ADHD have significantly more latitude to control aspects of their day-to-day environments. Do the new contexts young adults find themselves in alter their experience of ADHD? Are there particular occupational or educational contexts in which young adults report functioning better than others

Response to Methylphenidate in Children with Attention Deficit Hyperactivity Disorder and Manic Symptoms in the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder Titration Trial

Objective: Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children. Methods: Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two “mania proxies” were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies. Results: Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects. Conclusion: Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms

Parent Agreement on Ratings of Children's Attention Deficit/Hyperactivity Disorder and Broadband Externalizing Behaviors

Mothers and fathers often disagree in their ratings of child behavior, as evidenced clinically and as supported by a substantial literature examining parental agreement on broadband rating scales. The present study examined mother-father agreement on Diagnostic and Statistical Manual-based symptom-specific ratings of Attention-Deficit/Hyperactivity Disorder (ADHD), as compared to agreement on broadband ratings of externalizing behavior. Based on mother and father ratings of 324 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA), parental agreement was computed and patterns of disagreement examined. Mother-father ratings were significantly correlated; however, a clear pattern of higher ratings by mothers was present. Agreement on attention-deficit/hyperactivity disorder symptom-specific ratings was significantly lower than that for broadband externalizing behaviors and oppositional defiant disorder symptoms. Of several moderator variables tested, parental stress was the only one that predicted the discrepancy in ratings. Disagreement between parents is clinically significant and may pose complications to the diagnostic process

Evidence, Interpretation, and Qualification From Multiple Reports of Long- Term Outcomes in the Multimodal Treatment Study of Children With ADHD (MTA) Part II: Supporting Details

Objective: To review and provide details about the primary and secondary findings from the Multimodal Treatment study of ADHD (MTA) published during the past decade as three sets of articles. Method: In the second of a two part article, we provide additional background and detail required by the complexity of the MTA to address confusion and controversy about the findings outlined in part I (the Executive Summary). Results: We present details about the gold standard used to produce scientific evidence, the randomized clinical trial (RCT), which we applied to evaluate the long-term effects of two well-established unimodal treatments, Medication Management (MedMGT) and behavior therapy (Beh), the multimodal combination (Comb), and treatment “as usual” in the community (CC). For each of the first three assessment points defined by RCT methods and included in intent-to-treat analyses, we discuss our definition of evidence from the MTA, interpretation of the serial presentations of findings at each assessment point with a different definition of long-term varying from weeks to years, and qualification of the interim conclusions about long-term effects of treatments for ADHD based on many exploratory analyses described in additional published articles. Conclusions: Using a question and answer format, we discuss the possible clinical relevance of the MTA and present some practical suggestions based on current knowledge and uncertainties facing families, clinicians, and investigators regarding the long-term use of stimulant medication and behavioral therapy in the treatment of children with ADHD. (J. of Att. Dis. 2008; 12(1) 15-43