Caregivers' perspectives on the contextual influences within family management for ethnically diverse children with ADHD.

PURPOSE: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder affecting over 9% of children in the United States. Family caregivers are often responsible for the management of their child's ADHD. Contextual influences, such as healthcare providers, systems, and resources, are factors contributing to the ease or difficulty of family management. The purpose of this article is to qualitatively describe the major contextual influences that impact family management for ethnically diverse children with ADHD. DESIGN AND METHODS: This analysis is part of a mixed methods study using a concurrent nested design (QUAL + quant) to understand the phenomenon of family management from a contextual and socioecological perspective. In this analysis, cross-sectional data from caregivers of children with ADHD (N = 50) within a large northeastern city in the United States were collected, analyzed, and interpreted in the qualitative descriptive tradition. Semistructured interviews were conducted with participants to understand the contextual influences within family management. Conventional content analysis resulted in the emergence of barrier and facilitator domains and subdomains. RESULTS: Caregivers were predominantly female (98%) and between 24 and 61 years with a mean age of 37.54 (SD = 1.18). Caregivers identified their children as Black or African American (56%), White (26%), Multi-Racial (16%), Hispanic or Latinx (8%), and Asian (2%). Contextual influences within family management emerged as barrier or facilitator domains. Barrier domains included: (1) family, (2) healthcare systems, (3) educational systems, (4) stigma, and (5) financial, insurance, and policy issues. Facilitator domains included: (1) family and community, (2) healthcare providers, and (3) educational providers. Subdomains within each domain are expanded in the article. PRACTICE IMPLICATIONS: Specialists in pediatric nursing should consider contextual influences within family management for ethnically diverse children with ADHD. As healthcare providers, it is important to recognize system-level barriers or facilitators for caregivers and their children and find creative ways to overcome obstacles and leverage strengths within families, communities, and care systems. Another important area for pediatric specialists to consider is understanding how stigma impacts children with ADHD. Policy-level engagement and advocacy should maximize the political will of nurses, families, and educators to create change within communities.

Family Management in Childhood Attention Deficit Hyperactivity Disorder: A Qualitative Inquiry.

PURPOSE: The purpose of this study was to better understand how caregivers and families manage childhood Attention Deficit Hyperactivity Disorder (ADHD) in their everyday lives and explore family management factors most relevant to child outcomes, including the child's daily life, condition management effort, condition management ability, and view of condition impact. DESIGN AND METHODS: Cross-sectional data from caregivers (N = 50) of children with ADHD (ages 5-12 years) within a large northeastern city were collected, analyzed, and interpreted using directed content analysis and qualitative methods. This inquiry was part of a larger mixed method study which examined the impact of family management on childhood ADHD and how family management factors were related to children's level of impairment across a spectrum of child functioning. RESULTS: Thematic summaries based on qualitative descriptive methods highlighted four aspects of family management including: 1) how caregivers contextualized their child's condition in everyday family life, 2) the significant effort required by caregivers to manage their child's ADHD, 3) how caregivers perceived their ability to manage their child's condition, and 4) the impact of ADHD on their child and family's future. CONCLUSIONS: Family management is an important concept within pediatric literature and may be extended to further research and practice changes for children with ADHD and their caregivers. PRACTICE IMPLICATIONS: Pediatric nurses are at the forefront of working with children and families. Understanding caregiver perspectives in regard to family management is important for strengthening collaborative partnerships with families and improving the care of children with ADHD.

Social and academic impairment in youth with ADHD, predominately inattentive type and sluggish cognitive tempo.

Sluggish cognitive tempo (SCT) was originally identified as a construct that characterized the inattention problems of some children with attention deficit disorder (ADD). Research has indicated that using SCT symptoms to identify a subset of youth with attention-deficit/hyperactivity disorder, predominately inattentive type (ADHD-IT) may elucidate distinct patterns of impairment and thereby improve the external validity of ADHD subtypes. The objective of the current study was to investigate whether youth with clinically-assessed ADHD-IT and high levels of SCT exhibit unique social and academic impairments. In a clinic-referred sample of youth (N = 209; 23 % female) aged 6 to 17 years, participants who met criteria for three different groups were identified: ADHD, Combined Type (ADHD-CT; n = 80), ADHD-IT with low SCT symptoms (n = 74), and ADHD-IT with high SCT symptoms (n = 55). These groups were compared on indicators of social and academic functioning while considering the effects of co-occurring internalizing and disruptive behavior disorders. Youth with ADHD-IT high in SCT exhibited uniquely elevated withdrawal, as well as low leadership and low peer-directed relational and overt aggression, which were not accounted for by co-occurring disorders. This high-SCT group was also the only group to have more homework problems than the ADHD-CT group, but only when other disruptive behavior disorders were absent. The distinctiveness of the high-SCT group, which was primarily evident in social as opposed to academic functioning, provides partial support for the external validity and clinical utility of SCT.

Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder.

An extensive amount of research has demonstrated the effectiveness of psychosocial interventions for children with ADHD. Historically, the research has focused on interventions targeting problems in the home or school setting, but more recent research has highlighted the importance of family ­ school partnerships and conjoint approaches to intervention involving family and school. Effective approaches to psychosocial intervention consist of strategies to address performance deficits, promote adaptive behavior, and improve children's self-control and academic and social skills. Considerable evidence exists to indicate that combined approaches are more effective in reducing ADHD symptoms and related academic and social impairments than separate treatments.

Development of a Family-School Intervention for Young Children With Attention Deficit Hyperactivity Disorder.

Although numerous studies have evaluated the effectiveness of multi-modal psychosocial interventions for children with attention deficit hyperactivity disorder, these programs are limited in that there has not beeti an explicit focus on the connection between fatnily and school. This study was designed to develop and pilot test a family-school ititervention, Family-School Success-Early Elementary (FSS-EE), for kindergarten and first-grade studetits with attention deficit hyperactivity disorder. Key components of FSS-EE were family-school behavioral consultatioti, daily report cards, and strategies to improve parent-child relationships atid family involvement in educatioti. FSS-EE was developed using a multistep iterative process. The piloted version consisted of 12 weekly sessions including 6 group meetings, 4 individualized family sessions, and 2 school-based consultations. Families participating in the study were given the choice of placing their childreti on medication; 25% of children were on medication at the time of random assignmetit. Childreti (n = 61) were randomly assigned to FSS-EE or a comparison group controlling for nonspecific treatment effects. Outcomes were assessed at post interventioti and 2-month follow-up. Study findings indicated that FSS-EE was feasible to implement and acceptable to paretits atid teachers. In addition, the findings provided preliminary evidence that FSS-EE is effective in improving parenting practices, child behavior at school, and the student-teacher relationship.

Identifying learning problems in children evaluated for ADHD: the Academic Performance Questionnaire.

OBJECTIVE: The objective of this study was to assess the usefulness of the Academic Performance Questionnaire (APQ) to identify low reading and math achievement in children who are being evaluated for attention-deficit/hyperactivity disorder (ADHD). METHODS: Charts of 997 patients who were seen in a multidisciplinary ADHD evaluation program were reviewed. Patients who were in first-through sixth-grade and had complete APQ and Wechsler Individual Achievement Test II Basic Reading and Numerical Operations subtests were enrolled in this study. The 271 eligible patients were randomly assigned to a score-development group (n = 215) and a validation group (n=56). By using data from the score-development sample, APQ questions that predicted low academic achievement were identified and the scores for these questions were entered into a logistic regression to identify the APQ questions that independently predicted low achievement. RESULTS: Only 2 APQ questions, 1 about reading and 1 about math, independently predicted low achievement. By using these 2 questions, the area under the receiver operating characteristic curve was 0.834, and the optimal combination of sensitivity and specificity occurred when the total score for the 2 items was >4. This cutoff had a sensitivity of 0.86 and a specificity of 0.63 in the score-development group and a sensitivity of 1.0 and a specificity of 0.53 in the validation sample. CONCLUSIONS: The APQ may be a useful screening tool to identify children being evaluated for ADHD who need additional testing for learning problems. Although the predictive value of a negative screen on the APQ is good, the predictive value of a positive test is relatively low.

Standardized Observational Assessment of Attention Deficit Hyperactivity Disorder Combined and Predominantly Inattentive Subtypes. II. Classroom Observations.

Trained classroom observers used the Direct Observation Form (DOF; McConaughy & Achenbach, 2009) to rate observations of 163 6- to 11-year-old children in their school classrooms. Participants were assigned to four groups based on a parent diagnostic interview and parent and teacher rating scales: Attention Deficit Hyperactivity Disorder (ADHD)-Combined type (n = 64); ADHD-Inattentive type (n = 22); clinically referred without ADHD (n = 51); and nonreferred control children (n = 26). The ADHD-Combined group scored significantly higher than the referred without ADHD group and controls on the DOF Intrusive and Oppositional syndromes, Attention Deficit Hyperactivity Problems scale, Hyperactivity-Impulsivity subscale, and Total Problems; and significantly lower on the DOF On-Task score. The ADHD-Inattentive group scored significantly higher than controls on the DOF Sluggish Cognitive Tempo and Attention Problems syndromes, Inattention subscale, and Total Problems; and significantly lower on the DOF On-Task score. Implications are discussed regarding the discriminative validity of standardized classroom observations for identifying children with ADHD and differentiating between the two ADHD subtypes.

Standardized Observational Assessment of Attention Deficit Hyperactivity Disorder Combined and Predominantly Inattentive Subtypes. I. Test Session Observations.

Test examiners used the Test Observation Form (McConaughy & Achenbach, 2004) to rate test session behavior of 177 6- to 11-year-old children during administration of the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) and Wechsler Individual Achievement Tests-Second Edition (WIAT-II). Participants were assigned to four groups based on a parent diagnostic interview and parent and teacher rating scales: attention deficit hyperactivity disorder (ADHD)-Combined type (n = 74); ADHD-Inattentive type (n = 25); clinically referred without ADHD (n = 52); and controls (n = 26). The ADHD-Combined type group scored significantly higher than the other three groups on six Test Observation Form scales: (1) Attention Problems; (2) Oppositional; (3) Attention Deficit/Hyperactivity Problems scale; (4) Inattention sub-scale; (5) Hyperactivity-Impulsivity subscale; and (6) Externalizing. The two ADHD groups also scored significantly lower than controls on all WISC-IV and WIAT-II composites and lower than those clinically referred without ADHD on WISC-IV Working Memory Index and Full Scale Intelligence Quotient. Implications are discussed regarding the discriminative validity of standardized test session observations for identifying children with ADHD and differentiating between the two ADHD subtypes.

Service Utilization among ethnic minority children with ADHD: a model of help-seeking behavior.

Despite a significant increase in the number of children and adolescents who receive clinical services for attention deficit hyperactivity disorder (ADHD), there is still a considerable level of unmet need. Children of ethnic minority status continue to lag well behind their non-minority counterparts in the rate of diagnosis and treatment for the disorder. Racial/ethnic disparities in service use are the result of a combination of access barriers and individual, cultural, and societal factors. The ADHD Help-Seeking Behavior Model is proposed as a framework for understanding factors that may be predictive of service use. Variables specific to ADHD and ethnic-minority populations are integrated within the framework of a four-stage pathway model encompassing problem recognition, decision to seek help, service selection, and service use. The authors argue that by systematically addressing factors related to service use for each ethnic minority group, more effective intervention initiatives can be developed to improve identification and treatment for ADHD among underserved children.

Variations in anxiety and depression as a function of ADHD subtypes defined by DSM-IV: do subtype differences exist or not?

Concerns have been raised about the ability of diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) to distinguish subtypes that are clearly distinct from each other with regard to clinical correlates. One area of concern is that research regarding differences in anxiety and depression as a function of ADHD subtype has produced discrepant findings. This study was designed to systematically evaluate whether the ADHD subtypes differ with regard to level of internalizing symptoms. From a large pool of children referred to an ADHD center based in a pediatric hospital, children were differentiated into three groups: ADHD, Combined Type (ADHD/COM); ADHD, Inattentive Type (ADHD/I); and a non-ADHD, comparison group (COMP). Parent- and child-report measures using both dimensional and categorical methods were used to assess internalizing symptoms. The results indicated that children with ADHD/COM and ADHD/I had similar levels of anxiety and depression. Subtype differences related to parent-reported depression were accounted for by group differences in level of externalizing problems. The results were discussed with regard to their implications for refining the criteria used to differentiate children with ADHD into subtypes.