Caregiver Outcomes in Response to Child Medication

Treatment for ADHD

Steven K. Reader, M.S.

December 1, 2006

Attention Deficit Hyperactivity Disorder (ADHD) diagnostic criteria

Developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity

Clear evidence of impairment in social, academic, or occupational functioning across at least two settings

Subtypes:– Primarily Inattentive– Primarily Hyperactive-Impulsive– Combined

(APA, 1994)

ADHD

Prevalence:– 3-5% in general child population (APA, 1994), – 4-12% in general pediatric settings (AAP, 2000), – Up to 50% in some child psychiatry clinics

(Cantwell, 1996)

Symptoms often persist into adolescence and adulthood

Comorbid disorders

Oppositional Defiant Disorder (ODD): – up to 50%

Conduct Disorder (CD): 30-50% Anxiety Disorder: 20-25% Mood Disorder: 15-20% Learning Disability: 19-26%

(AACAP, 1997)

Childhood ADHD:common problems

Academic difficulties Lower adaptive functioning Poor peer relationships Higher risk for unintentional injury

These problems can present significant challenges for many parents

Caregiver adjustment:ADHD vs. normal controls

Caregivers of children with ADHD have more psychological difficulties (Mash & Johnston, 2001)

Higher levels of:– Caregiver stress (Fischer, 1990; Johnson & Reader, 2002)– Isolation (Beck et al., 1990; Breen & Barkley, 1988)– Role restriction (Byrne et al., 1998; Mash & Johnston, 1983)– Depression (Befera & Barkley, 1985; Brown & Pacini, 1989)

Lower levels of:– Attachment to child (Breen & Barkley, 1988; Byrne et al., 1990)– Satisfaction in parenting role (Lange et al., 2005; Sonuga-Barke

et al., 2001)– Sense of efficacy in parenting role (Bryne et al., 1998)

Caregiver outcomes:ADHD subtypes

Mixed findings to date with minimal studies– Caregiver stress

No differences (using PSI-SF Parent Distress score) (Podolski & Nigg, 2001)

Combined > Inattentive (using DBSI) (Johnson & Reader, 2002)

– Depression Combined > Inattentive (West et al., 1999)

Impact of comorbid ODD/CD

Associated with poorer caregiver adjustment, often contributing variance over and above core ADHD symptoms– Caregiver stress (Anastopoulos et al., 1992;

Bussing et al., 2003; Podolski & Nigg, 2001; Ross et al., 1998; Vitanza & Guarnaccia, 1999)

– Satisfaction and efficacy (Johnston, 1996; Podolski & Nigg, 2001; Shelton et al., 1998)

– Depression (Chronis et al., 2003)

Demographic factors

Few studies have examined how demographic factors are related to caregiver adjustment (Johnston & Mash, 2001)

Low SES found to be associated with ADHD families (Scahill et al., 1999), but mixed findings related to caregiver stress (Baker, 1994; Baldwin et al., 1995)

Mixed findings related to total number of children in family (Baker, 1994; Ostberg & Hagekull, 2000)

Single caregiver status linked to increased parenting stress (Baker, 1994; Webster-Stratton, 1990)

Behavioral treatment of ADHD/ disruptive behaviors: caregiver outcomes

ADHD-specific behavioral treatments– Decreased PSI Child/Parent Domain– Increased satisfaction and efficacy in parenting role

(Anastopoulos et al., 1993; Pisterman et al., 1992)

PCIT– Decreased PSI Child/Parent Domain– Increased satisfaction and efficacy in parenting role

(Nixon et al., 2003; Schuhmann et al., 1998)

No effects on caregiver depression (Schuhmann et al., 1998)

Medication treatment of ADHD:caregiver outcomes

MTA Cooperative Study: Wells et al. (2000)– Meds only vs. Behavior tx vs. Comb Meds/Beh tx vs

Standard Community care– Baseline vs 14 month follow-up– Found no treatment group x time interaction for PSI-

SF, BDI, and Dyadic Adjustment Scale– Cited treatment overlap as one reason for lack of

significant findings (26% of Beh tx group and 66% of Standard care group received meds)

– No description of within group changes on PSI-SF

Medication treatment of ADHD:caregiver outcomes (cont.)

Chronis et al. (2003)– 6-week period of medication treatment– Found improvements in caregiver perceptions of

pleasantness in parent-child interactions and parenting efficacy

– No effects on caregiver mood

Medication treatment of ADHD:caregiver outcomes (cont.)

Jones (2000)– Assessed maternal parenting stress using PSI at pre-

treatment and 1 and 3 month follow-up– Significant decrease in PSI Child Domain score over time but

not for PSI Parent Domain– Family income accounted for significant variance in PSI

change (marital status and maternal education did not)– Some limited support for baseline levels of ADHD symptoms

and oppositional behavior in predicting change on PSI Child/Parent Domain

– No differences in stress b/w parents who did and did not receive some additional form of psychotherapy

Study primary objective

Examining the following caregiver adjustment outcomes in response to child stimulation medication treatment for ADHD

– Parenting stress– Attachment to child– Isolation– Role restriction– Sense of satisfaction in parenting role– Sense of efficacy in parenting role– Depression

Study rationale

Poor caregiver adjustment linked to:– negative parent-child interactions (Webster-Stratton, 1990)– Decreased treatment effectiveness for ADHD (Owens et al.,

2003), and premature termination from treatments for ODD/CD (Forehand et al., 1984; Kazdin et al., 1993)

Interventions to improve caregiver adjustment in conjunction with parent management training leads to improved treatment effectiveness and maintenance (Griest et al., 1982)

Study rationale (cont.)

Very few studies assessing caregiver adjustment outcomes in response to stimulation medication treatment for ADHD

Such studies can help inform whether additional interventions might be necessary

Participants

32 caregivers completed baseline– 30 female, 2 male

Mean age 37.66 years (range 23-60) 63% Caucasian, 23% African Amer, 13% Hispanic Two-caregiver homes 57% Lower middle SES range Mean number of children in home = 2.14

– 24 boys, 8 girls Mean age 7.94 years (range 5-12) Primary diagnosis of ADHD Exclusions: MR, PDD, psychosis, sensory impairment

Participants (cont.)

ADHD subtypes– Inattentive n = 5– Hyperactive/Impulsive n = 1– Combined: n = 26

Comorbid ODD/CD– ADHD-only n = 14– Oppositional Defiant Disorder n = 12– Conduct Disorder n = 6

Child either starting on stimulant medication or undergoing change (med type or dosage) in existing stimulant medication regimen

Child behavior measures

Conners’ Parent Rating Scale - Revised: Long Version (CPRS-R:L)– DSM-IV Inattentive– DSM-IV Hyperactive-Impulsive– DSM-IV Total– Oppositional

Disruptive Behavior Disorders Rating Scale (DBDRS)– Conduct Disorder

Caregiver adjustment measures

Disruptive Behavior Stress Inventory (DBSI)– Stress Experience and Stress Degree subscales

Parenting Stress Index (PSI)– Attachment, Isolation, Role Restriction from Parent Domain

Parenting Sense of Competence Scale (PSOC)– Satisfaction– Efficacy

Beck Depression Inventory Second Edition (BDI-II)

Procedures

Baseline and follow-up assessments– In person at health science center– By mail

Follow-up assessment (mean 8.82 weeks after stimulant medication started or changed)

20 caregivers completed follow-up assessment

Baseline analyses (Objective 1):Baseline levels of child behavior and caregiver adjustment

Clinically significant levels of core ADHD and ODD symptoms

High frequency of stressors experienced (z = 2.40) and high degree of stressfulness (z = 2.98) (DBSI)

PSI Attachment to child (65%ile), Isolation (75%ile), Role Restriction (65%ile) all within normative range

PSOC Satisfaction (z = -.66) and Efficacy (z = .44) both within normative range

Depressive symptoms within mild range (BDI-II)

Baseline analyses II (Objective 2):Demographic variables

Increased feelings of attachment to child, sense of parenting efficacy, and less role restriction, were significantly related to having more children in the home

SES and single caregiver status not related to caregiver adjustment

Caregivers of boys with ADHD reported experiencing more stressors

Caregivers who were involved in ongoing psychotherapy were less satisfied in parenting role and more depressed

Baseline analyses II (cont.):Correlations between child behavior and caregiver adjustment

Increased hyperactive-impulsive ADHD symptoms, and to a larger extent, ODD and CD behaviors, were related to higher frequency and intensity of caregiver stress, higher role restriction, decreased parenting satisfaction, and higher depressive symptoms

Inattentive ADHD symptoms only related to less parenting satisfaction

Levels of ODD/CD behaviors, but not ADHD symptoms, were related to caregiver perceived attachment to child and isolation

Levels of child behavior not related to caregiver sense of efficacy

Baseline analyses II (cont.)ADHD subtype comparison

Significantly poorer adjustment on all caregiver measures except isolation and sense of efficacy for ADHD Combined/Hyperactive-Impulsive group compared to Inattentive group

Baseline analyses II (cont.)ADHD-only vs ADHD + ODD/CD

ADHD + ODD or CD group showed significant levels of:

– Caregiver stress experience (z = 3.24) and degree (z = 4.08)– Isolation (z = 1.16)– Decreased parenting satisfaction (z = -1.23)– Depressive symptoms in moderate range

Significantly poorer adjustment on all caregiver measures except efficacy for caregivers in ADHD + ODD or CD group compared to ADHD-only group

Baseline analyses II (cont.)Main conclusions

Results from correlational and group comparison analyses suggest that, in general, levels of hyperactive-impulsive ADHD symptoms are more related to caregiver adjustment than inattentive symptoms

– Consistent with studies indicating higher levels of caregiver stress (Johnson & Reader, 2002) and depression in ADHD Combined compared to ADHD Inattentive group (West et al., 1999)

Stronger association of comorbid ODD/CD symptoms, compared to ADHD symptoms, with caregiver adjustment

– Consistent with previous studies (Anastopoulos et al., 1992; Bussing et al., 2003; Podolski & Nigg, 2001; Vitanza & Guarnaccia, 1999)

Follow-up analyses (Objective 3)

Study non-completers had significantly higher role restriction and depressive symptoms– Limits generalizability of follow-up findings

Significant reductions in core ADHD, ODD, and CD symptoms from baseline to follow-up– Inattentive, oppositional symptoms in normative range– Hyperactive-impulsive symptoms borderline at-risk

range

Follow-up analyses (cont.)

Significant reductions in:– Caregiver stressors experienced (d = .82)– Caregiver stress degree (d = 1.04)– Isolation (d =.73)– Depressive symptoms (d = .69)

Significant increase in parenting Satisfaction (d = .61) Only caregiver stress decreased from significantly

elevated level SES, single caregiver status, and number of children in

home not related to change scores

Follow-up analyses (cont.)

Change score correlations (controlling for baseline level on respective caregiver measure)

– Decreases in inattentive and hyperactive-impulsive ADHD symptoms were related to decreases in frequency of stressors experienced

– Decreases in core ADHD symptoms and ODD symptoms comparably related to decreases in degree of stress

– Decreases in ODD symptoms primarily, and to lesser extent core ADHD symptoms, related to decreases in depressive symptoms

– Changes in child behavior not related to changes in perceived isolation or parenting satisfaction

Study limitations

Only 20 caregivers completed follow-up assessment– Reduced power– Non-completers higher role restriction, depression– Caregiver ADHD

Lack of consistent/reliable diagnosis of comorbid ODD/CD– DBDRS lack of parent norms

Study limitations (cont.)

Single method of data collection– Potential rater bias, as caregiver adjustment can

influence child behavior ratings

Lack of comparison control group– Cannot attribute study effects to stimulant

medication treatment solely

Study implications

Screen caregivers for adjustment problems, particularly stress and depression, during child ADHD assessments

– Caregiver adjustment problems can lead to negative caregiver-child interactions and premature termination from child treatment

– Interventions to help caregivers can improve child treatment effectiveness

Assess levels of comorbid disruptive behavior during child ADHD assessments

– Available effective treatments for young children with ODD (e.g. PCIT)

Future directions

Increasing sample size could lead to:– More reliable group comparisons, based on ADHD

subtype and ODD/CD comorbidity– Multiple regression or structural equation modeling

to look at relative contributions of various predictors to caregiver adjustment change, including mediating and moderating variables

– Temporal relationship between various caregiver adjustment variables, in response to treatment

Future directions (cont.)

Other constructs of possible interest:– Caregiver attributions of child behavior– Social support for caregiver– Cultural influences– Adjustment of other family members

Male caregiver, siblings– Different dimensions of global factors

Stress: social, academic, spousal Depression: cognitive, physical

Impact of comorbid disorders Using multiple assessment methods to reduce

confounds and increase reliability