Impulsivity as key bridge symptoms in cross-sectional and longitudinal networks of ADHD and ODD.

BACKGROUND: Impulsivity is viewed as key to attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (DBD). Yet, to date, no work has provided an item-level analysis in longitudinal samples across the critical developmental period from childhood into adolescence, despite prior work suggesting items exhibit differential relevance with respect to various types of impairment. The current study conducted a novel longitudinal network analysis of ADHD and oppositional defiant disorder (ODD) symptoms between childhood and adolescence, with the important applied prediction of social skills in adolescence. METHODS: Participants were 310 children over-recruited for clinical ADHD issues followed longitudinally for six years in total with gold standard diagnostic procedures and parent and teacher ratings of symptoms and social outcomes. RESULTS: Findings from baseline, Year 3, and Year 6 suggested Difficulty waiting turn, Blurts, and Interrupts/intrudes were key bridge items across cross-sectional and longitudinal parent-reported DBD networks. Furthermore, shortened symptom lists incorporating these symptoms were stronger predictors of teacher-rated social skills 5 years later compared to total DBD scores. CONCLUSIONS: Such findings are consistent with the trait impulsivity theory of DBD and ADHD and may inform useful screening tools and personalized intervention targets for children at risk for DBD during adolescence.

Evidence-Based Assessment for Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects individuals from all life stages, genders, and races/ethnicities. Accurate assessment of ADHD across different populations is essential as undiagnosed ADHD is associated with numerous costly negative public health outcomes and is complicated by high comorbidity and developmental change in symptoms over time. Predictive analysis suggests that best-practice evidence-based assessment of ADHD should include both ADHD-specific and broadband rating scales from multiple informants with consideration of IQ, academic achievement, and executive function when there are concerns about learning. For children under age 12, parent and teacher ratings should be averaged. For adolescents and adults, informant reports should be prioritized when self- and other-report are inconsistent. Future research should provide more stringent evaluation of the sensitivity of measures to treatment response and developmental change over time as well as further validate measures on historically understudied populations (i.e., adults, women, and racial/ethnic minorities).

Data-Driven Methods for Predicting ADHD Diagnosis and Related Impairment: The Potential of a Machine Learning Approach.

Current diagnostic criteria for ADHD include several symptoms that highly overlap in conceptual meaning and interpretation. Additionally, inadequate sensitivity and specificity of current screening tools have hampered clinicians' ability to identify those at risk for related outcomes. Using machine learning techniques, the current study aimed to propose a novel algorithm incorporating key ADHD symptoms to predict concurrent and future (i.e., five years later) ADHD diagnosis and related impairment levels. Participants were 399 children with and without ADHD; multiple informant measures of ADHD symptoms, global impairment, academic performance, and social skills were included as part of an accelerated longitudinal design. Results suggested eight symptoms as most important in predicting impairment outcomes five years later: (1) Has difficulty sustaining attention in tasks or play activities, (2) Does not follow through on instructions and fails to finish work, (3) Has difficulty organizing tasks and activities, (4) Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort, (5) Is often easily distracted, (6) Is often forgetful in daily activities, (7) Fidgets with hands or feet or squirms in seat, and (8) Interrupts/intrudes on others. The algorithm comprising this abbreviated list of symptoms performed just as well as or significantly better than one comprising all 18 symptoms in predicting future global impairment and academic performance, but not social skills. It also predicted concurrent and future ADHD diagnosis with 81-93% accuracy. Continued development of screening tools will be key to ensuring access to clinical services for youth at risk for ADHD.

Clarifying Relations Between ADHD and Functional Impairment in Adulthood: Utilization of Network and Machine Learning Approaches.

Using network analysis and random forest regression, this study identified attention-deficit/hyperactivity disorder (ADHD) symptoms most important for indicating impairment in various functional domains. Participants comprised a nationally representative sample of 1249 adults in the United States. Bridge symptoms were identified as those demonstrating unique relations with impairment domains that, in total, were stronger than those involving other symptoms. Results suggested three inattentive (i.e., difficulty organizing; does not follow through; makes careless mistakes) and one hyperactive (difficulty engaging in leisure activities) bridge symptoms. Random forest regression results supported bridge symptoms as most important (compared to other symptoms) for predicting global and specific impairment domains. Hyperactive/impulsive symptoms appeared more strongly related to impairment in women, whereas difficulty organizing and easily distracted appeared more related to impairment in men. Clarification of bridge symptoms may help identify core characteristics of ADHD in adulthood and specify screening and intervention targets to reduce risk for related impairment.

Utility of the Limited Prosocial Emotions Specifier in Preschoolers With Conduct Problems.

This study examined the clinical utility of the "Limited Prosocial Emotions" (LPE) specifier (i.e., prevalence rates, group differences, and predictive utility) in a high-risk preschool sample (N = 109, M age = 4.77) presenting with conduct problems (CPs; n = 59). First, LPE prevalence rates ranged from 7.7% to 89.8%. Next, few group differences were observed between with CP-only and CP+LPE; youth with CP+LPE differed from youth with CP-only on callous-unemotional (CU) traits and verbal ability, but not on externalizing or internalizing psychopathology, nor on parenting experiences. In the full sample, youth with LPE differed from youth without LPE on externalizing and internalizing psychopathology, parenting, and verbal ability. Finally, LPE predicted greater baseline CP but did not predict trajectories of CP. Findings highlight the clinical utility of the LPE specifier during early childhood and call for a refinement of the LPE specifier to improve its clinical value.

Etiological Networks of Attention-Deficit/Hyperactivity Disorder during Childhood and Adolescence.

OBJECTIVE: The purpose of the current study was to use network analysis techniques to parse relations between attention-deficit/hyperactivity disorder (ADHD) symptom domains, domains of executive function, and temperament traits. METHODS: Participants were 420 children aged 6-17 years (55% boys). The majority of the participants were Caucasian (72.86%) and 50% of the sample met diagnostic criteria for ADHD. Both parents and teachers provided ratings of participants' ADHD symptom severity. Parents completed questionnaires pertaining to participants' temperament traits, and participants completed well-validated laboratory measures of executive function. RESULTS: Results suggested effortful control as demonstrating the strongest relations with ADHD, particularly the parent-reported inattentive symptom domain. Additionally, negative effects appeared to demonstrate weaker but still notable relations primarily with the parent-reported hyperactive/impulsive symptom domain. Measures of executive function did not appear to demonstrate relations with any measures of ADHD symptoms or temperament traits. The results were generally replicated in a distinct sample (n = 732, 7-13 years, 63% boys, 81% White), although differences emerged pertaining to the role of surgency (i.e., related to the hyperactive/impulsive symptom domain in the replication but not the primary sample). CONCLUSIONS: Overall, findings provided support for the primary role of effortful control, as well as secondary roles for negative affect and surgency, as key risk markers for the characterization of ADHD. Additional exploration of the overlap between temperament and executive function, as pertaining to ADHD, may help clarify heterogeneity in phenotypes and suggest priorities for targeted interventions outside of traditional symptoms.

Associations among ADHD symptoms, ODD symptoms, and borderline personality features: A network analysis.

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are common childhood syndromes that exhibit a high degree of comorbidity. Both ADHD and ODD symptoms in childhood predict higher levels of borderline personality features (BPF) later in development. Yet ADHD, ODD, and BPF each consist of a heterogeneous group of symptoms, and symptom-level associations between these groups remain unclear. The present study examined symptom-level associations, as well as sex differences in symptom-level associations, among ADHD, ODD, and BPF using network analysis. Caregivers of 962 children between the ages of 5 and 12 completed rating scales of ADHD, ODD, and BPF. Assessment of Bridge Expected Influence indicated a number of bridge symptoms linking ADHD to ODD; these bridge symptoms were primarily from the hyperactive-impulsive (rather than the inattentive) dimension of ADHD (e.g., blurts out answers, leaves seat, runs excessively). A smaller number of bridge symptoms were identified linking ADHD and ODD to BPF, and these bridge symptoms were different for girls versus boys. Overall, several ADHD hyperactive-impulsive symptoms were related to the BPF item gets in trouble for doing things without thinking, and the ODD item touchy/easily annoyed was related to the BPF item goes back and forth between different feelings. Moreover, whereas we observed stronger links between ODD antagonistic symptoms (e.g., blames others) and BPF among girls, we observed stronger links between ODD oppositional symptoms (e.g., defies/refuses to comply) and BPF among boys. Taken together, results provide a more nuanced, symptom-level understanding of the overlap among ADHD, ODD, and BPF.

Longitudinal Temperament Pathways to ADHD Between Childhood and Adolescence.

The current investigation extended prior cross-sectional mapping of etiological factors, transdiagnostic effortful and affective traits, and ADHD symptoms to longitudinal pathways extending from two etiological domains: polygenic and prenatal risk. Hypotheses were (1) genetic risk for ADHD would be related to inattentive ADHD symptoms in adolescence and mediated by childhood effortful control; (2) prenatal smoking would be related to hyperactive-impulsive ADHD symptoms during childhood and mediated by childhood surgency; and (3) there would be age-related variation, such that mediation of genetic risk would be larger for older than younger ages, whereas mediation of prenatal risk would be larger in earlier childhood than at later ages. Participants were 849 children drawn from the Oregon ADHD-1000 Cohort, which used a case control sample and an accelerated longitudinal design to track development from childhood (at year 1 ages 7-13) through adolescence (at year 6 ages 13-19). Results showed the mediational pathway from prenatal smoking through surgency to hyperactivity-impulsivity at Year 1 was significant (indirect effect estimate = .053, p < .01). The mediational pathway from polygenic risk through effortful control to inattention at Year 6 was also significant (indirect effect estimate = .084, p < .01). Both results were independent of the association between inattention and hyperactivity-impulsivity and control for the alternative etiological input and held across parent- and teacher-report of ADHD symptoms. In line with dual pathway models of ADHD, early prenatal risk for hyperactivity-impulsivity appears to operate through surgency, while polygenic genetic risk for inattention appears mediated by effortful control.

Psychometric Properties of Parent Ratings on the Inventory of Callous-Unemotional Traits in a Nationally Representative Sample of 5- to 12-Year-Olds.

The psychometric properties of the parent-report version of the Inventory of Callous-Unemotional Traits (ICU) in school-aged children requires further examination. In a nationally representative sample of U.S. children (N = 1,064, M age = 8.42, 51.7% boys), the current study examined the factor structure, measurement invariance, and the moderating role of parent rated ICU scores on conduct problems. Results supported (a) a two-factor model consisting of a CU factor and a limited prosocial emotions (LPE) factor; (b) an invariant structure of the ICU across child sex, as well as (to a lesser extent) across child age and parent sex; and (c) the moderating role of the LPE factor on the relationship between conduct problems and relevant outcomes (i.e., impairment, need for treatment). Normative data on the parent-report version of the ICU for elementary-aged school children in the United States were also presented. Clinical implications regarding use of the parent-report version of the ICU for school-aged children are discussed.

Identifying the Inter-Domain Relations Among ODD, CD, and CU Traits in Preschool Children Using Network Analysis.

Oppositional defiant disorder (ODD) and conduct disorder (CD) are two of the most common forms of disruptive behavior disorders during childhood. Callous-unemotional (CU) traits are an important factor in understanding the presentation of these externalizing forms of psychopathology. ODD, CD, and CU traits are highly related constructs, yet little work has examined how these externalizing forms of psychopathology are related at the domain level. The current study utilized network analysis to identify the distinct domains that explain the associations among ODD, CD, and CU traits. In a sample of 104 preschoolers (M age = 4.76), results demonstrated that the symptom domains of (a) angry/irritable mood and argumentative/defiant behavior, (b) aggression to people and animals, and (c) callousness were the primary bridge domains for ODD, CD, and CU traits, respectively. Findings of the current study offer a more nuanced insight into the relations amongst ODD, CD, and CU traits. Identification of bridge symptom domains can inform intervention practices by targeting specific symptom domains that are contributing to the maintenance of such aggressive and disruptive behaviors.

A Review of the Evidence Base for Psychosocial Interventions for the Treatment of Emotion Dysregulation in Children and Adolescents.

Many children with a range of psychiatric diagnoses manifest impaired levels of emotion dysregulation (ED). Over the past decade, there has been increasing examination of psychosocial interventions for ED. We found preliminary evidence of positive effects for a wide range of psychosocial treatments that were associated with improvements in emotion recognition, emotional reactivity, and emotion regulation. More studies are needed because results are limited by the small number of controlled trials, heavy reliance on parent ratings, and heterogeneity of the samples.

Multiple informant average integration of ADHD symptom ratings predictive of concurrent and longitudinal impairment.

To date, there remains no consensus about the best evidence-based method for integrating multiple informant data in the diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). Several approaches exist, including the psychometrically sound approach of averaging scores, as well as the use of "OR" and "AND" algorithms, which are still commonly used in research. The current study tested these major integration methods in their concurrent and longitudinal prediction of clinician-rated impairment, teacher-rated academic, and parent- and self-rated social skill ratings in children overrecruited for ADHD across a 6-year span from childhood to adolescence. The sample included a total of 800 children, 480 with ADHD, ages 6 to 13, who completed a "gold standard" assessment of ADHD and associated impairment. Overall, the "OR," "AND," and average integration approaches showed significantly high interrelations with one another (r range from .78 to .96) and were all significantly and strongly related to impairment measures concurrently and longitudinally. Multivariate regressions demonstrated that the average integration approach concurrently and longitudinally out predicted the other two approaches. Results demonstrated that the average approach slightly outperformed the other two in its prediction of concurrent and longitudinal clinician-rated impairment, teacher-rated academic skills, and parent- and self-rated child social skills across childhood and adolescence. Evidence-based assessment integration of parent and teacher ratings of ADHD in childhood might best utilize an averaging approach, as it is most related to later impairment ratings, particularly if such findings are replicated by other groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Conceptualizing Callous-Unemotional Traits in Preschool through Confirmatory Factor and Network Analysis.

Callous - unemotional (CU) traits are a key factor in understanding the persistence and severity of conduct problems. Most research has used confirmatory factor analysis (CFA) to examine the structure of CU traits; however, most CFA models have yielded marginally acceptable fit, and little research has examined the structure of CU traits in preschool. This gap highlights the need for a more nuanced approach in understanding the structure of CU traits during preschool via statistical examination of inter - item relationships (i.e., network analysis). Therefore, the current study used both CFA and network analysis in a sample of 104 preschool children (M age = 4.76). CFA results best supported a two - factor structure of the ICU, comprised of callous and uncaring factors, using 12 of the original 24 items from the ICU, although fit was only marginally acceptable. Network community analyses identified four clusters of items characterized as Uncaring, Lack of Remorse, Unconcerned, and Callous. Items identified as most central to the network were: Does not care who he/she hurts to get what they want, Does not care if he/she is in trouble, and Seems very cold and uncaring. Overall, network analysis suggests several important potential refinements to CU structure including possible alternative factor models which merit consideration in future work. In addition, the identified central items could be useful for screening.

Behavioral Treatment for the Social-Emotional Difficulties of Preadolescent and Adolescent Girls with ADHD.

Girls with attention-deficit/hyperactivity disorder (ADHD) are at high risk for peer difficulties that often persist into adolescence and adulthood and portend risk for additional difficulties, such as depression, anxiety, and borderline personality disorder. However, very little research has examined interventions that address the widespread peer difficulties of girls with ADHD. This paper describes two open trials of behavior therapy aimed at addressing their social-emotional difficulties. The first trial includes 33 preadolescent girls (ages 7-11) with ADHD enrolled in an eight-week treatment and the second trial includes 22 adolescent girls (ages 12-16) with ADHD enrolled in a 12-week treatment. Measures of treatment feasibility and acceptability and measures of social functioning and psychopathology were collected in both trials. High levels of treatment feasibility and acceptability were reported in both the preadolescent and adolescent trial. In addition, improvements were reported in areas of social functioning and reductions in psychopathology, although the magnitude and specific areas of improvement differed somewhat in the preadolescent versus adolescent group. These preliminary findings provide a first step towards addressing the widespread social-emotional difficulties of girls with ADHD and offer insight into continuing efforts to address their treatment needs.

A Pilot Study of Emotional Response to Time-Out in Children With Conduct Problems and Callous-Unemotional Traits.

Little research has examined how children with conduct problems and concurrent callous-unemotional traits (CPCU) emotionally and behaviorally respond to time-out. This pilot study examined the distribution and stability of emotions during time-out as well as the association between emotions and negative behaviors. Participants were 11 children (Mage = 9.8 years) with CPCU who participated in a summer treatment program designed specifically for children with CPCU. Summer treatment program counselors rated each child's emotion when time-out was first assigned and then as the time-out progressed and indicated whether the child had negative behavior during time-out. These ratings were completed for approximately 30% of time-outs that occurred. Results showed that children were mostly rated as "unemotional" or "calm" and that these emotions were relatively stable throughout time-out. Furthermore, negative behaviors were most common during time-outs when children's emotions were rated as "amused." Results provide groundwork for future research to extend upon the methods used in the current study to further examine the emotional and behavioral response to time-out in children with CPCU.

Effects of Intensive Behavioral Treatment for Children With Varying Levels of Conduct Problems and Callous-Unemotional Traits.

The purpose of this study was to examine whether callous-unemotional (CU) traits moderated the effects of intensive behavior therapy in elementary school-age children with varying levels of conduct problems (CP). Both treatment response (magnitude of change between pre- and posttreatment) and treatment outcomes (likelihood of normalization from treatment) were examined. Participants were 67 children (n = 49 boys, Mage = 9.6 years) with varying levels of CP and CU who participated in an intensive 8-week summer treatment program (STP) in which behavior therapy was delivered to children in recreational and classroom settings and to parents via weekly parent training sessions. Effects of treatment were measured using parent and teacher ratings of oppositional defiant disorder (ODD), conduct disorder (CD), callous behavior, and impairment. Results showed that CU moderated treatment effects for CD and callous behavior but not ODD or impairment. The moderating effects showed some evidence that participants with high CP and high CU before treatment had better treatment responses (larger change between pre- and posttreatment) but worse treatment outcomes (lower likelihood of normalization after treatment). These results suggest that intensive treatment, such as the STP, may be necessary but not sufficient for children with CP and CU traits.

Degree of anxiety in food allergic children in a tertiary care center.

BACKGROUND: The link between internalizing psychiatric disorders, such as anxiety and depression, and allergic diseases has attracted a high level of interest from psychiatrists and immunologists. Recent studies have found increased anxiety in children with asthma, but findings in children with food allergy (FA) have been inconsistent. OBJECTIVE: It was hypothesized that children with FA would score significantly higher on a standardized anxiety screen than general pediatric (GP) patients but not as high as patients with diagnosed anxiety disorders. METHODS: A total of 114 patients aged 8 to 16 years (37 with confirmed anxiety disorder from a pediatric psychiatry clinic, 40 with confirmed FA from a pediatric allergy clinic, and 43 well-care patients from a GP clinic) and their mothers completed the Screen for Child Anxiety Related Emotional Disorders (SCARED). RESULTS: Children and mothers in the allergy group did not report increased levels of anxiety in children on total SCARED scores or subscales compared with children and mothers from the GP group. There was a trend toward increased panic disorder symptoms reported in children by mothers of children in the allergy group, but this finding did not reach statistical significance. CONCLUSION: Children with FA did not have increased anxiety; however, there was a trend for mothers of children with allergies to report more symptoms of panic disorder in their children. It remains important to screen families for anxiety-related symptoms and refer them to mental health services when indicated.