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)
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


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
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
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, hyperactivity‐
impulsivity‐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 Square
DF
CFI
ΔCFI
RMSEA
90%CI
ΔRMSEA
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
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
Teacher
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‐
Impulsive
Total
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‐
Impulsive
Total
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
Perentage of Sample
100%
6
80%
5
60%
4
40%
3
20%
2
1
0%
Parent
Teacher
Respondent
Power, Watkins, Anastopoulos, Reid, Lambert, & DuPaul (under review)
0
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 5th 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 5th 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 ADHD
Reading 4‐Trajectories
70
65
Reading Standard Score
60
55
50
Class 1 (7.6%)
45
Class 2 (32.1%)
Class 3 (44.2%)
40
Class 4 (16.1%)
35
30
25
20
Fall‐K
DuPaul, Morgan et al. (in preparation)
Spring‐K
Spring‐1st
Assessment Phase
Spring‐3rd
Spring‐5th
Growth Mixture Model Latent Classes of Math for Children with ADHD
Math 8‐Trajectories
70
65
Math Standard Score
60
55
Class 1 (6.9%)
Class 2 (5.5%)
50
Class 3 (10.1%)
45
Class 4 (16.9%)
40
Class 5 (27.3%)
35
Class 6 (5.8%)
Class 7 (20.5%)
30
Class 8 (7.1%)
25
20
Fall‐K
DuPaul, Morgan et al. (in preparation)
Spring‐K
Spring‐1st
Assessment Phase
Spring‐3rd
Spring‐5th
Growth Mixture Model Latent Classes of Interpersonal Skills for Children with ADHD
Interpersonal 4‐Trajectories
Average Interpersonal Item Score
4
3.5
3
2.5
Class 1 (23.9%)
2
Class 2 (28.8%)
Class 3 (24.6%)
1.5
Class 4 (22.7%)
1
0.5
0
Fall‐K
Spring‐K
Spring‐1st
Assessment Phase
DuPaul, Morgan et al. (in preparation)
Spring‐3rd
Spring‐5th
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
Probability
0.8
0.6
Math‐Low
0.4
Math‐Improving
Math‐Ave
0.2
Math‐High
0
Rdg Class 1 Rdg Class 2 Rdg Class 3 Rdg Class 4
Reading Achievement Latent Trajectory Class
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
Probability
0.8
0.6
IP Class 1
0.4
IP Class 2
IP Class 3
0.2
IP Class 4
0
Rdg Class 1 Rdg Class 2 Rdg Class 3 Rdg Class 4
Reading Achievement Latent Trajectory Class
DuPaul, Morgan et al. (in preparation)
Probability of Reading Class Dependent on Interpersonal Skills Class
1
Probability
0.8
0.6
Rdg Class 1
0.4
Rdg Class 2
Rdg Class 3
0.2
Rdg Class 4
0
IP Class 1
IP Class 2
IP Class 3
IP Class 4
Interpersonal Skills Latent Trajectory Class
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., cross‐
temporal 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
4
3.48*
Mean Effect Size
3.5
3
2.5
2.2*
2
Behavior
1.5
Academic
1
0.5
0.72*
0.18
0.43
0.42
0
Betw‐Subj
DuPaul, Eckert, & Vilardo (2012)
Within‐Subj
47
Research Design
Single‐Case
Mean Effect Size
WSD: Mean Effect Size Across Intervention Type & Outcome
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
DuPaul, Eckert, & Vilardo (2012)
0.87
0.61
0.56
0.53
0.53
Acad Int
Cont Man
0.24
Academic
Behavior
Outcome Measure
48
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