Download Stimulant Treatment of ADHD: Parent Outcomes

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
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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:
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Primarily Inattentive
Primarily Hyperactive-Impulsive
Combined
(APA, 1994)
ADHD
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Prevalence:
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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
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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
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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
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Caregivers of children with ADHD have more
psychological difficulties (Mash & Johnston, 2001)
Higher levels of:
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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:
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Attachment to child (Breen & Barkley, 1988; Byrne et al., 1990)
Satisfaction in parenting role (Lange et al., 2005; SonugaBarke et al., 2001)
Sense of efficacy in parenting role (Bryne et al., 1998)
Caregiver outcomes:
ADHD subtypes
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Mixed findings to date with minimal studies
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Caregiver stress
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–
No differences (using PSI-SF Parent Distress score)
(Podolski & Nigg, 2001)
Combined > Inattentive (using DBSI) (Johnson & Reader,
2002)
Depression
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Combined > Inattentive (West et al., 1999)
Impact of comorbid ODD/CD
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Associated with poorer caregiver adjustment,
often contributing variance over and above
core ADHD symptoms
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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
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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
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ADHD-specific behavioral treatments
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Decreased PSI Child/Parent Domain
Increased satisfaction and efficacy in parenting role
(Anastopoulos et al., 1993; Pisterman et al., 1992)
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PCIT
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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
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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 PSISF, 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.)
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Chronis et al. (2003)
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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
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Examining the following caregiver adjustment
outcomes in response to child stimulation medication
treatment for ADHD
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Parenting stress
Attachment to child
Isolation
Role restriction
Sense of satisfaction in parenting role
Sense of efficacy in parenting role
Depression
Study rationale
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Poor caregiver adjustment linked to:
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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.)
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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
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32 caregivers completed baseline
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30 female, 2 male
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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
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Mean age 7.94 years (range 5-12)
Primary diagnosis of ADHD
Exclusions: MR, PDD, psychosis, sensory impairment
Participants (cont.)
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ADHD subtypes
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Comorbid ODD/CD
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Inattentive n = 5
Hyperactive/Impulsive n = 1
Combined: n = 26
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
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Conners’ Parent Rating Scale - Revised: Long
Version (CPRS-R:L)
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DSM-IV Inattentive
DSM-IV Hyperactive-Impulsive
DSM-IV Total
Oppositional
Disruptive Behavior Disorders Rating Scale
(DBDRS)
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Conduct Disorder
Caregiver adjustment measures
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Disruptive Behavior Stress Inventory (DBSI)
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Parenting Stress Index (PSI)
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Attachment, Isolation, Role Restriction from Parent Domain
Parenting Sense of Competence Scale (PSOC)
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Stress Experience and Stress Degree subscales
Satisfaction
Efficacy
Beck Depression Inventory Second Edition (BDI-II)
Procedures
Baseline and follow-up assessments
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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
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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
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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
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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
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Significantly poorer adjustment on all caregiver
measures except isolation and sense of
efficacy for ADHD Combined/HyperactiveImpulsive group compared to Inattentive group
Baseline analyses II (cont.)
ADHD-only vs ADHD + ODD/CD
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ADHD + ODD or CD group showed significant levels
of:
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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
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Results from correlational and group comparison
analyses suggest that, in general, levels of hyperactiveimpulsive ADHD symptoms are more related to caregiver
adjustment than inattentive symptoms
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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)
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Study non-completers had significantly higher role
restriction and depressive symptoms
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Limits generalizability of follow-up findings
Significant reductions in core ADHD, ODD, and
CD symptoms from baseline to follow-up
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Inattentive, oppositional symptoms in normative range
Hyperactive-impulsive symptoms borderline at-risk
range
Follow-up analyses (cont.)
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Significant reductions in:
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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.)
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Change score correlations (controlling for baseline
level on respective caregiver measure)
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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
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Only 20 caregivers completed follow-up
assessment
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Reduced power
Non-completers higher role restriction, depression
Caregiver ADHD
Lack of consistent/reliable diagnosis of
comorbid ODD/CD
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DBDRS lack of parent norms
Study limitations (cont.)
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Single method of data collection
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Potential rater bias, as caregiver adjustment can
influence child behavior ratings
Lack of comparison control group
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Cannot attribute study effects to stimulant
medication treatment solely
Study implications
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Screen caregivers for adjustment problems, particularly
stress and depression, during child ADHD
assessments
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Caregiver adjustment problems can lead to negative caregiverchild 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
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Available effective treatments for young children with ODD
(e.g. PCIT)
Future directions
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Increasing sample size could lead to:
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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.)
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Other constructs of possible interest:
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Caregiver attributions of child behavior
Social support for caregiver
Cultural influences
Adjustment of other family members
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Different dimensions of global factors
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Male caregiver, siblings
Stress: social, academic, spousal
Depression: cognitive, physical
Impact of comorbid disorders
Using multiple assessment methods to reduce
confounds and increase reliability