Psychometrics of rating scales for externalizing disorders in Japanese outpatients: The ADHD-Rating Scale-5 and the Disruptive Behavior Disorders Rating Scale.

OBJECTIVES: This study validated the Japanese version of the Attention-Deficit/Hyperactivity Disorder-Rating Scale-5 (ADHD-RS-5) and the Disruptive Behavior Disorders Rating Scale. We extended the ADHD-RS-5 by adding the oppositional defiant disorder and conduct disorder subscales to compare the two rating scales psychometrically. METHODS: We examined the internal consistency, test-retest reliability, construct validity and criterion validity of the two rating scales in 135 Japanese outpatients aged 6-18 years. RESULTS: The internal consistency and test-retest reliability were good for all the subscales of the two rating scales except for the conduct disorder subscale of the ADHD-RS-5 extended. Good construct validity was revealed by expected correlational patterns between subscales from the two rating scales and the Children Behavior Checklist. The criterion validity was good for all the subscales of the two rating scales rated by parents, while teacher-ratings revealed substantially lower predictive ability for all the subscales. Agreement between parent- and teacher-ratings of the two rating scales was generally moderate and using predictive ratings alone of both ratings showed the best predictive ability among the integration methods examined. CONCLUSION: The two rating scales have sound psychometric properties and will aid in screening and severity assessment of externalizing disorders in Japanese clinical settings.

Effects of Compliance to a Training Intervention for High School Students with ADHD.

OBJECTIVE: We evaluated the effects of treatment compliance with the Challenging Horizons Program (CHP) for high school aged adolescents with attention-deficit hyperactivity disorder (ADHD). METHOD: Participants were 185 high school aged adolescents (65% non-Hispanic White; 79% male) with a diagnosis of ADHD who were randomly assigned to either CHP or community control. Outcomes included parent-rated academic functioning, parent- and self-rated social-emotional functioning, and GPA. The complier average causal effect (CACE) was estimated using propensity-weighted models for youth engaging in ≥ 30 CHP individual sessions (15-20 min) across the academic year. RESULTS: Most (78%) CHP participants engaged in≥30 CHP sessions. CACE analyses using latent growth curve modeling revealed significant treatment effects among treatment compliers across ratings of academic and social outcomes relative to similar control participants. For most outcomes, CACE estimates were larger than those found in intent-to-treat analyses, especially at 6-months follow-up. CONCLUSIONS: Compliance with 30 or more individual CHP sessions appeared to be an attainable threshold associated with incremental gains across several academic and social outcomes. Effects of compliance were amplified at 6-months follow-up, supporting the hypothesized theory of change of training interventions. Future work should focus on facilitators of treatment engagement and feasibility of the CHP as delivered by high school personnel.

Longitudinal Examination of Sexual Risk Behavior in College Students With and Without Attention-Deficit/Hyperactivity Disorder.

The present study sought to identify differences in the rates and predictors of risky sexual behavior among college students with and without attention-deficit hyperactivity disorder (ADHD). Current ADHD diagnosis, medication status among those with ADHD, executive functioning, substance use, comorbid anxiety, comorbid depression, and gender were identified as potential predictors of increased risky sexual behavior. Multiple group latent growth curve modeling was used to estimate trajectories of risky sexual behavior across four years of college among college students with ADHD (nmedicated = 99, nunmedicated = 105) and a comparison group (n = 217) recruited from colleges throughout the eastern United States (M age = 18.23 years, 53% female, 70% White). First-year college students with ADHD reported significantly higher rates of sexual risk behavior than their peers without ADHD, with no significant differences found based on medication status. Students with ADHD who were taking medication for ADHD reported significant decreases in risky sexual behavior over time. Among college students with ADHD, anxiety was related to increased current risky sexual behavior in the medicated group, while depression was predictive of decreased future risky sexual behavior in the unmedicated group. Alcohol and cannabis use were significantly associated with increased mean levels of risky sexual behavior across all three groups, and cannabis use was associated with decreased future risky sexual behavior within the comparison group. Executive functioning deficits and male gender were predictive of risky sexual behavior within the comparison group. The results demonstrate that college students with ADHD, regardless of medication status, are at an increased likelihood of engaging in risky sexual behavior.

Social Functioning Outcomes of a High School-Based Treatment Program for Adolescents with ADHD.

OBJECTIVE: We evaluated the extent to which receiving the multi-component treatment of the Challenging Horizons Program (CHP) would lead to significant improvements in social functioning, as well as in inattention, internalizing symptoms, parent stress, and emotion dysregulation for high-school-aged adolescents with attention-deficit hyperactivity disorder (ADHD). METHOD: Participants were 186 high-school-aged adolescents (74% White) with a diagnosis of ADHD who were randomly assigned to either CHP (n = 92; 80% boys; M age = 15.0; SD = 0.8) or Community Care (CC; n = 94; 78% boys; M age = 15.1; SD = 0.9) within each of 12 participating schools. Parent and adolescent reports of social functioning were the primary outcome measures. Secondary outcomes included ratings of symptoms of ADHD and related disorders, parent stress, and emotion regulation. RESULTS: Intent-to-treat analyses using hierarchical linear modeling revealed significant group-by-time interactions of medium magnitude (d range = .40 to .52) on parent-rated social skills. Significant group-by-time benefits were also identified for adolescent self-rated social skills as well as the secondary outcomes of parent-rated inattention symptoms, emotion regulation, and parenting stress. DISCUSSION: CHP appears to benefit social skills along with related characteristics for adolescents with ADHD. Understanding these unique findings for this population informs additional research related to treatment mechanisms and effectiveness trials.

Educational diagnostic label and teacher self-efficacy: Impact on classroom intervention choice.

Children with attention-deficit/hyperactivity disorder (ADHD) and specific learning disabilities (SLD) face similar academic and behavioral challenges. Although combined behavioral and academic interventions (AIs) are among the most effective for each disability, a child's diagnostic label and teacher self-efficacy may influence teacher intervention choice. This study examined the relationship between diagnostic label and teacher self-efficacy on intervention choice using a sample of 206 general education elementary school teachers (female = 69.9%; White = 60.7%). Results showed that teachers were significantly more likely to endorse AIs for children with SLD as compared to ADHD (ds = 0.29-0.35), even when children had identical academic needs. Furthermore, self-efficacy did not moderate this relationship but was an individual predictor of intervention endorsement. Findings indicate the need to increase teacher awareness of academic impairments related to ADHD and to further identify teacher factors that could impact choice of intervention and decrease intervention selection biases. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factor Structure of the Sexual Risk Survey Among U.S. College Students with and without ADHD: Assessing Clinical Utility with a High-Risk Population.

Young adults, particularly college students, report a higher prevalence of risky sexual behavior than the general population, increasing their likelihood for unplanned pregnancy, sexually transmitted infections (STIs), and negative psychological outcomes. Although sexual risk behavior and its consequences are a major public health concern, current prevention literature is insufficient and relies on sexual risk measures with limited psychometric support. The present study, therefore, examined the psychometric properties of a sexual risk survey (SRS; Turchik, Garske, in Arch Sex Behav 38:936-948, 2009), using data from the first year of a longitudinal study following the outcomes of college students with and without attention-deficit/hyperactivity disorder (ADHD; N = 410). Principal components analyses were conducted to assess the factorial structure of the SRS comparing results from a general college population and a college population considered to be high-risk (ADHD). Results revealed four components across both samples. Internal consistency estimates for component scores and total scores ranged from .627 to 918. Implications of the findings are discussed and suggestions for future studies are advanced.

Outcomes and Predictors of Stimulant Misuse in College Students with and Without ADHD.

In recent years, rates of prescription stimulant misuse have increased among young adults ages 18 to 25 along with increases in dispensing rates of these medications. Preliminary studies suggest that college students with Attention-Deficit Hyperactivity Disorder (ADHD) may be more likely to misuse their stimulant medication than their non-ADHD peers. Research is needed to further explore possible rates, correlates, and outcomes of prescription stimulant misuse among college students with and without ADHD. Data regarding study strategies, psychological functioning, stimulant misuse, and GPA were collected from students from universities within the US (N = 144), showing significantly higher rates of misuse among college students with ADHD. With depression and anxiety entered into the predictive model, inattentive symptoms were the only significant predictor of misuse in the full sample. The present findings have implications for academic interventions aimed at supporting the success of college students with and without ADHD and inform academic outcomes of prescription stimulant misuse.

The conceptual and diagnostic importance of ADHD-related impairment: a Commentary on Arildskov et al. (2021).

Arildskov et al. (2021) provide compelling evidence regarding the importance and nature of functional impairment in advancing diagnostic assessment and treatment of attention-deficit/hyperactivity disorder (ADHD). Their findings indicate that (a) ADHD is dimensional for both symptom severity and impairment, (b) symptoms and impairment are related but separate constructs, (c) diagnostic assessment should focus equally on symptoms and impairment, and (d) the symptom threshold for ADHD diagnosis is arbitrarily defined with respect to presence of impairment. Results from this study can be extended to raise the profile of functional impairment in research and clinical practice in terms of diagnostic assessment, treatment outcome measurement, improvements to diagnostic systems, and advancements in our understanding of ADHD as a disorder.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited. METHOD: We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood. RESULTS: For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children. CONCLUSION: Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

Impact of COVID-19 on Youth With ADHD: Predictors and Moderators of Response to Pandemic Restrictions on Daily Life.

We examined COVID-19 symptoms and infection rates, disruptions to functioning, and moderators of pandemic response for 620 youth with ADHD and 614 individually matched controls (70% male; Mage = 12.4) participating in the Adolescent Brain and Cognitive Development study. There were no group differences in COVID-19 infection rate; however, youth with ADHD were more likely to exhibit COVID-19 symptoms (d = 0.25), greater sleep problems (d = -0.52), fear and negative emotions to infection risk (d = -0.56), trouble with remote learning (d = -0.54), rule-breaking behavior related to COVID-19 restrictions (d = -0.23), family conflict (d = -0.13), and were less prepared for the next school year (d = 0.38). Youth with ADHD were less responsive to protective environmental variables (e.g., parental monitoring, school engagement) during the pandemic and may need more specialized support with return to in-person schooling and daily activities.

School-Based Interventions for Elementary School Students with Attention-Deficit/Hyperactivity Disorder.

Children with attention-deficit/hyperactivity disorder experience significant academic, social, and behavioral impairments in elementary school settings. Although psychopharmacologic treatments can improve symptomatic behaviors, these rarely are sufficient for enhancing school performance. Thus, medication should be supplemented by one or more school interventions, including behavioral strategies, academic interventions, behavioral peer interventions, organizational skills training, and self-regulation strategies. Although all of these school interventions have been found effective, classroom behavioral strategies, organizational skills training, and self-regulation strategies have the strongest empirical support. Clinicians should collaborate with school mental health professionals to encourage implementation of effective school interventions across school years.

School-based intervention for adolescents with attention-deficit/hyperactivity disorder: Effects on academic functioning.

Multi-component training interventions such as the Challenging Horizons Program (CHP) improve organization skills and academic functioning of middle school students with attention-deficit/hyperactivity disorder (ADHD); however, few studies have investigated treatment for high school students. We explored the extent to which CHP adapted for high school would improve proximal (e.g., organization skills, homework performance) and distal (e.g., report card grades) academic outcomes through 6-month follow-up relative to a community care (CC) condition. Participants included 186 adolescents who were randomly assigned to CHP (n = 92; 80% male; M age = 15.0; SD = 0.8) or CC (n = 94; 78% male; M age = 15.1; SD = 0.9) with CHP delivered over one school year. Parent, teacher, and self-report ratings of organization skills and academic performance, report card grades, and achievement tests were collected across multiple occasions. Intent-to-treat analyses using hierarchical linear modeling revealed significant improvements of small to medium magnitude (d range = 0.32 to 0.58) for parent-rated organization skills, homework performance, and academic functioning at 6-month follow-up. CHP effect on grades was small, but associated with a less steep decline than that found for CC. No statistically significant effects on teacher or self-report ratings were obtained. CHP appears efficacious for ameliorating organization skills and homework performance deficits exhibited by high school students with ADHD and can protect against decline in report card grades experienced by these students. CHP may require supplementation with academic skills instruction for some students and may need implementation beyond one school year to produce durable effects.

Academic Trajectories of College Students with and without ADHD: Predictors of Four-Year Outcomes.

Objective: Completing a college degree is associated with success in employment, financial earnings, and life satisfaction. Mental health difficulties, including attention-deficit/hyperactivity disorder (ADHD), can compromise degree completion.Method: We examined 4-year academic performance trajectories of 201 college students with ADHD (97 receiving medication [ADHD-Med], 104 not receiving medication [ADHD-NoMed]) relative to 205 non-ADHD Comparison students. Demographic (e.g., sex, race/ethnicity), psychological (e.g., self-reported depression and anxiety symptoms), and service-related (e.g., receipt of academic support) variables were included as predictors of intercept (i.e., Year 1 performance) and slope (yearly change) of semester GPA, progress toward graduation, and self-reported study skill strategies.Results: College students with ADHD obtained significantly lower GPAs (Hedge's g = -0.46 and -0.63) and reported less frequent use of study skills strategies (Hedge's g range from -1.00 to -2.28) than Comparison students. Significantly more Comparison students (59.1%) persisted through eight semesters relative to ADHD-NoMed students (49%). Multiple variables predicted outcomes with parent education, fewer depressive symptoms, better executive functioning, and receipt of high school Section 504 accommodations and college academic support services among the strongest predictors.Conclusions: Findings suggest support services for students with ADHD should begin prior to college matriculation and focus on improving executive functioning skills and depressive symptoms to increase chances of academic success.

Romantic Relationships and Sexual Behavior Among Adolescents With ADHD.

Objective: Both qualitative and quantitative analyses were used to (a) describe the romantic and sexual relationships of adolescents with ADHD and (b) examine how ADHD-related impairments (e.g., social skill deficits and emotion dysregulation [ED]) are associated with romantic relationship outcomes in this group. Method: Adolescents with ADHD (N = 171; 80% male; 70% White) responded to questions about their romantic and sexual relationship experiences and ED. Parents provided ratings of ADHD symptoms, ED, and social skills. Results: Adolescents with ADHD reported high rates of romantic relationship turnover and low rates of physical intimacy. More severe self-reported ED was associated with increased likelihood of engaging in romantic relationships, having more romantic relationship partners, increased likelihood of engaging in sexual intercourse, and increased likelihood of engaging in unprotected sex. Conclusion: Early intervention programs that alter the developmental trajectory of romantic relationships among individuals with ADHD may benefit from targeting ED among these youth.

Assessment of a conceptually informed measure of emotion dysregulation: Evidence of construct validity vis a vis impulsivity and internalizing symptoms in adolescents with ADHD.

OBJECTIVES: Despite advances in understanding associations among attention-deficit hyperactivity disorder (ADHD), emotion dysregulation (ED), and related outcomes, there is incongruity between ADHD-relevant conceptualizations of ED and available measures of ED. To assess the psychometric properties of a parent-report questionnaire of ED conceptualized as deficits in the ability to modulate the (a) speed/degree of emotion escalation; (b) expression intensity; and (c) speed/degree of de-escalation. METHODS: Participants were 209 adolescents with ADHD (78% male; 13.5-17.8 years old [M = 15.2 SD = 0.91]). Questionnaire items were selected from parent-report scales of ED and oppositional defiant disorder and subjected to exploratory factor analysis (EFA) and validity analyses. RESULTS: The EFA revealed two factors, with speed/degree of escalation combined with intensity as factor one, and speed/degree of de-escalation as factor two. Factor one scores were related to ADHD impulsivity symptoms but not to anxiety and depression symptoms and they remained predictors of impulsivity even in the presence of self-report ED, evincing convergent, discriminant, and incremental validity. Factor two scores were related to anxiety and depression but not impulsivity, evincing convergent and discriminant validity. CONCLUSION: These results inform our understanding of ADHD-relevant ED in adolescence and offer avenues for future research in measurement development, as well as for understanding ED and ADHD-related impairment.

Social deficits in high school students with attention-deficit/hyperactivity disorder and the role of emotion dysregulation.

Attention-deficit/hyperactivity disorder (ADHD) is strongly associated with social functioning deficits in adolescents. However, the factors underlying this relationship are not well understood. Prior research has established that emotion dysregulation (ED) mediates the relationship between ADHD symptoms and social skills in middle school students and that the mediational role of ED is moderated by youth's level of depression. The current study examined whether this model holds true in high school students with ADHD, despite developmental and environmental changes during maturation. Cross-sectional measures of ADHD symptoms, emotion regulation, depression, and social functioning were collected from 174 high school students with ADHD (M age = 14.51; 81.4% male). Analyses were conducted using the PROCESS macro for SPSS. Bootstrapping results of the omnibus effect of a multiple-mediational model indicated that ADHD and ED jointly account for 49% of the variance in parent-rated social skills (i.e., evidence of mediation by ED). However, counter to our hypothesis, depression did not moderate this relationship. This study provides evidence that ED accounts for the relationship between ADHD and social deficits in an older adolescent population. Results have significant implications for intervention strategies to improve emotional self-awareness and control in adolescents with ADHD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The role of emotion regulation in alcohol use among adolescents with attention-deficit/hyperactivity disorder.

The purpose of the present study was to determine the role of emotion regulation in the pathway to problematic alcohol use among adolescents with attention-deficit/hyperactivity disorder (ADHD), specifically investigating the total effect of emotion regulation on problematic alcohol use and the indirect effect of emotion regulation through social skills on problematic alcohol use within a 2-wave longitudinal design. The potential protective effect of parent knowledge of these effects was assessed. Participants were 149 adolescents with ADHD (mean [M] = 15.11 years old; 78% male), and approximately 19% endorsed problematic alcohol use at Time 2. Contrary to our hypothesis, emotion regulation was not associated with subsequent problematic alcohol use without social skills in the model, and parent knowledge did not moderate this pathway. The results supported an indirect effect of emotion regulation on problematic alcohol use via social skills, although the direction of this effect was unexpected. Greater emotion regulation skills were associated with greater social skills, which in turn were associated with a higher likelihood of problematic alcohol use. Parent knowledge was protective against this indirect effect, such that the indirect effect was only present in the context of low parent knowledge. The findings delineate the roles of risk and protective factors associated with the progression from experimentation to alcohol use disorder among adolescents with ADHD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

ADHD Parent and Teacher Symptom Ratings: Differential Item Functioning across Gender, Age, Race, and Ethnicity.

Parent and teacher ratings of the two attention-deficit/hyperactivity disorder (ADHD) symptom dimensions (i.e., inattention, hyperactivity-impulsivity) have been found to differ across child gender, age, race, and ethnicity. Group differences could be due to actual variation in symptomatic behaviors but also could be due to measurement items functioning differently based on child characteristics. This study extended prior investigations establishing measurement invariance at the symptom dimension and item levels, by examining possible measurement variance across child demographic characteristics at the item level (i.e., differential item functioning [DIF]) in two large national samples. Using the Rasch rating scale model (Andrich Psychometrika, 43, 561-73, 1978), we examined DIF of the 18 ADHD symptoms in samples of 2079 children (n = 1037 males) from 5 to 17 years old (M = 10.7; SD = 3.8) rated by parents and 1070 children (n = 535 males) aged from 5 to 17 years old (M = 11.5; SD = 3.5) rated by teachers. All but six ADHD symptom items showed DIF across child age, gender, race (Black vs. White), and ethnicity with more items showing DIF for age than for gender, race, or ethnicity. For child gender and age, more items showed DIF for parent than for teacher ratings. More items showed DIF across racial groups for teacher than for parent ratings. Only two parent- and teacher-rated items showed DIF for ethnicity. Implications of findings for practice, research, and future iterations of ADHD diagnostic criteria are discussed.