Emotional and behavioral problems in children with attention deficit-hyperactivity disorder: impact of age and learning disabilities.
Attention deficit-hyperactivity disorder (ADHD) is one of the most frequently diagnosed childhood disorders, affecting approximately 5% of school-aged children (American Psychiatric Association, 2000). ADHD almost never occurs in a pure state, but is associated with other psychological problems (PP) at a rate much higher than would he found by mere chance. These behavioral and emotional problems present a serious obstacle to the academic, social, and emotional development of children with ADHD and negatively affect their adjustment to adult life. Thus, data have shown that emotional lability and social problems are better indicators of impairments in the daily life of the individual than the level of ADHD symptomatology per se due to the negative impact these problems have on academic, family, and work domains (Melia et al., 2006). Studies have provided valuable information about the moderator role comorbidity plays in interventions designed for students with ADHD. One of the objectives of the Multimodal Treatment Study of Children with ADHD (MTA; Jensen et al., 2001), in which 579 children participated, was to determine whether the clinical significance of potential ADHD + anxiety disorder (ADHD+ANX) or ADHD + oppositional disorder/conduct disorder (ADHD+ODD/CD) syndromes would yield better diagnostic decision-making, treatment planning, and treatment outcomes. Moderate evidence of interactions between parent-reported anxiety and ODD/CD status was noted in the response to treatment, indicating that children with ADHD and anxiety disorders (but without ODD/CD) were likely to respond equally well to the behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), whereas children with multiple comorbid disorders (anxiety and ODD/CD) responded best to combined (medication and behavioral) treatments (Jensen et al.). There is also evidence indicating that children with pure ADHD generally obtain more benefits from cognitive-behavioral training in self-control than those with ADHD + ODD, who tend to function better with treatment combining psychological techniques with the administration of medication (Miranda & Presentacion, 2000).
In a review of 15 years of the literature on the most frequent comorbidity patterns, Jensen, Martin, and Cantwell (1997) concluded that the clinical course and evolution of ADHD generally worsened in the presence of comorbid problems, including conflictive parent-child interactions, poor school performance, risky driving behaviors, or risk of substance abuse and antisocial personality disorder. More recent studies have found that the severity of the symptoms of inattention and hyperactivity-impulsivity, as rated by parents and teachers, was related to externalizing and internalizing comorbid psychopathologies (Connor et al., 2003). In fact, Klassen, Miller, and Fine (2005) showed that comorbidity and the severity of ADHD symptoms have differential impacts on quality of life. Specifically, these researchers found that the children with ADHD in their study who had two or more comorbid disorders differed significantly from those with no comorbidity on the majority of the quality-of-life indicators such as physical health, mental health, self-esteem, general behavior, impact on the parents, and limitations of the family's activities.
Comorbidity also plays a role in the persistence of ADHD into adulthood, which occurs in between 35% and 60% of the cases (Faraone et al., 2000). The presence of associated problems, together with other factors like severity of the symptoms, traumatic childhood experiences, and conflictive family relationships, has been found to predict the persistence of the disorder (Barkley, Fisher, Smallish, & Fletcher, 2004; Kessler et al., 2005). A prospective clinical study documented the effectiveness of childhood and adolescent anxiety and mood and impulse-control disorders in predicting ADHD persistence (Biederman et al., 1996). Further, Peterson, Pine, Cohen, and Brook (2001) have shown an effect of adolescent obsessive-compulsive disorder (OCD) in predicting adult persistence of ADHD symptoms. Smalley et al. (2007) also provide data on this topic in a recent study. Specifically, in their adolescent sample, the lifetime diagnosis of ADHD was significantly associated with anxiety (odds ratio 2.4), as well as mood (odds ratio 2.9) and disruptive behavioral disorders (odds ratio 17.3).
With these considerations in mind, the objective of psychological evaluations in the school setting must not exclusively focus on identifying students who are experiencing ADHD. It is important also to identify possible socio/emotional and behavioral problems as a preliminary step in designing well-founded effective intervention programs. As Riccio and Rodriguez (2007) highlighted in general terms, "Integration of information relating to personality, behavior, and social-emotional competence as part of the psychological assessment with psychoeducational data can better inform service delivery and the outcomes of children and families served" (p. 243).
The focus of the present study was (a) to examine the PP that often accompany ADHD, as well as their relationship with the severity of the disorder; and (b) to analyze the role of learning disabilities and age in PP comorbidity. The following brief review of the literature on PP and ADHD consists of three parts: (a) the types and prevalence of PP that usually appear associated with ADHD; (b) the role of age in psychological problems and in the severity of ADHD; and (c) the relationships among ADHD, learning disabilities, and psychological problems.
ADHD and Comorbid Problems
More than half of the children diagnosed with ADHD have at least one other disorder, and according to community based-sampling, between 23% and 43% have two or more additional disorders (August, Realmuto, MacDonald, Nuget, & Crosby, 1996; Romano, Tremblay, Vitaro, Zoccolillo, & Pagani, 2005; Szatmari, Oxford, & Boyle, 1989). Much more worrisome is the situation observed in clinical samples, where 87% of the subjects with ADHD have a comorbid disorder, and 67% have two or more associated disorders (Kadesjo & Gillberg, 2001).
Between 30% and 67% of the children with a clinical diagnosis of ADHD meet the diagnostic criteria for oppositional/defiant disorder or dissocial disorder (Loeber, Burke, Lahey, Winters, & Zera, 2000; Rosello, Amado, & Bo, 2000). This subgroup of children with associated behavior problems are at risk of experiencing social rejection and maladjustment. In fact, these children produce more family stress and have more interpersonal conflicts with their parents, classmates, and teachers (Johnston & Mash, 2001; Miranda, Marco, & Grau, 2007).
In agreement with the numbers related to disruptive behavior problems, about 40% of children with ADHD with a clinical referral experience some type of internalization disorder (Rosello et al., 2000). The degree of overlap between the anxious psychopathologies (excessive anxiety, separation anxiety, social and simple phobias) and ADHD varies between 10% and 40% (Biederman, Newcom, & Sprich, 1991).
With regard to mood disorders (depression, dystimia), the findings are more inconsistent. Some studies have found that the comorbidity of these two types of psychopathologics lies between 20% and 30% (Spencer, Biederman, & Wrens, 1999), whereas others show lower prevalence, around 5% (MTA Coorperative Group, 1999a, 1999b). This divergence may be explained by, among other factors, the fact that the relationship between ADHD and depressive disorders is mediated by the presence of behavioral problems. In fact, when the behavioral problems are controlled, the association between ADHD and mood disorders is no greater than what is found in the typical population (Angold, Costello, & Erkanli, 1999).
Therefore, in the literature on ADHD, differences are observed with regard to the rates of comorbidity. Those differences may be due to factors like the age of the subjects, the nature of the disorder being studied, or even the informants or evaluation procedures used. Agreement on the perception of the comorbid problems in ADHD is commonly low to moderate between raters, school and home (Antrop, Roegers, Oosterland, & Van Oost, 2002). Furthermore, type of disorder seems to be viewed differently by parent versus teacher informants. Specifically, in some studies, parents seemed to be less reliable evaluators of the internalizing problems than teachers (Barldey, 1998), whereas other studies have shown parents to be more sensitive to detecting internalizing problems than teachers (Crystal, Ostrander, Chen,& August, 2001). Consequently, multiple ratings are recommended as they collectively provide more information about a child than a single rating.
Severity of ADHD, Developmental Course, and Comorbid Problems
Without a doubt, ADHD involves a delay in the maturation of different processes. However, this dimension has not been specified, nor has it been included in any of the explanatory models of the disorder. According to some experts (e.g., Barkley, 1998), the expression of ADHD problems changes with age. For example, while hyperactive symptoms tend to decrease with age, inattention symptoms represent a relatively pervasive developmental characteristic and are more frequent in older children.
The possible interrelationships between age, the severity of the symptoms of inattention and hyperactivity-impulsivity, and the PP of children with ADHD have aroused special interest among researchers. The results of studies using broad samples of subjects have been especially valuable in this respect. Using the Strengths and Difficulties Questionnaire for parents (SDQ) in a community sample, Strine et al. (2006) concluded that it is six times more likely that children with a history of ADHD will have more emotional and behavioral problems and more conflicts with classmates than children without ADHD. Furthermore, they are nine times more likely to experience difficulties in their daily lives (e.g., family life, friendships, learning, spare time). "Without a doubt, the most interesting result is that, according to the parent ratings on the SDQ (Goodman, 2001), younger children with ADHD experience higher levels of PP.
However, the data in this area are not fully consistent. For example, Pierrehumbert, Bader, Thevoz, Kinal, and Halfon (2006), using short versions of Conners' revised rating scales (1997a, 1997b), compared the perceptions of parents and teachers from two different countries (Switzerland and United States/Canada) about a sample of children with ADHD. Although, in general terms, the patterns of reported problems were similar in both countries, a point of disagreement arose with regard to the evolution of the symptoms throughout childhood. Specifically, the parents and teachers from the United States/Canada indicated that the severity of the symptoms of ADHD was lower in the older children, coinciding with Strine et al.'s (2006) findings, whereas the Swiss parents and teachers found the opposite pattern; that is, greater severity in the symptomatology of the older children.
One issue that has frequently been overlooked in the research on ADHD is the variation that occurs in the perception of the severity of the disorder depending on informants' sensitivity and tolerance. Various studies have reported a low rate of agreement between parents and teachers in their evaluations of the frequency and severity of the symptomatology of the disorder, with the correlation values between the two informant groups varying from 0.30 to 0.52 (Antrop et al., 2002; Hartman, Rhee, Willcutt, & Pennington, 2007; Jane et al., 2006; Wolraich et al., 2004).
To examine rater disagreement about ADHD between parent and teachers, Hartman et al. (2007) utilized multiple rater models in selected and control samples of twins. The results suggest that parents and teachers observed different ADHD phenotypes in the children, which may contribute to rater disagreement. Thus, the low correlation between parents and teachers may not be due to a lack of valid judgment by either group, but to the situational variance in behavior captured by each rater. Therefore, both informants may be considered valid raters of the problems in their respective settings.
In summary, using a general index of ADHD severity in which parent and teacher ratings are combined would provide valuable information about ADHD as well as associated psychological problems. This is the procedure adopted in the current study.
ADHD, Learning Disabilities, and Psychological Problems
ADHD is frequently associated with low academic performance, which usually worsens as the behavioral manifestations of the disorder become more severe (Barry, Lyman, & Klinger, 2002). Research offers abundant documentation of the adverse educational outcomes of students with ADHD. For example, the existence of high percentages of association between ADHD and learning disabilities (LD) is well documented in reading, writing, and mathematics (DuPaul et al., 2004; Faraone, Biederman, Monuteaux, Doyle, & Seidman, 2001; Riccio, Gonzalez, & Hynd, 1994).
Globally, around 70% of children with ADHD present some type of learning difficulty (Mayes, Calhoun, & Crowell, 2000), and they are three to seven times more likely than other children to receive special education services, be expelled or suspended from school, or repeat a grade (LeFever, Villers & Morrow, 2002). Furthermore, although the ADHD diagnosis does not constitute its own separate special education category, three quarters of the students receiving special education services for behavioral difficulties (Dery, Toupin, Pauze, & Verlaan, 2005), and about a fourth of the children in programs for LD (Forness & Kavale, 2001), meet the criteria for ADHD.
This subgroup of children with ADHD+LD usually experiences more cognitive problems and more academic difficulties than children with either of the two disorders independently (Miranda, Melia, Marco, Rosello, & Mulas, 2006; Smith & Adams, 2006). This pattern of findings supports the comorbidity hypothesis of the etiological subtype. This hypothesis predicts that the comorbid group (ADHD+LD) will exhibit a different pattern of external correlates than would be expected based on the additive combination of the correlates of each disorder when they occur separately.
In a longitudinal study with children diagnosed with ADHD and reading learning disabilities (RLD), Maughan, Rowe, Loeber, and Stouthamer-Loeber (2003) found three times more comorbid problems of an emotional nature in the general sample. They concluded that these problems co-occurred with disruptive behaviors and low self-esteem and that they were much more frequent in younger than in older children, possibly because the older children had received some type of intervention when the problem was detected.
As Carroll, Maughan, Goodman, and Meltzer (2005) concluded in a recent study carried out with an extensive sample of children from 9 to 15 years of age, the relationships between reading disabilities and psychiatric disorders are complex. The results of their study pointed out that the specific RLD were more common in children from lower socio-economic backgrounds and were significantly associated with increased risk of ADHD (especially inattentive symptomatology), conduct disorders, and anxiety disorders. However, the link between specific reading difficulties and anxiety was of a different nature, suggesting that RLD constituted a risk factor for anxiety disorders. Definitively, these findings suggest that reading difficulties are significantly associated with externalizing disorders through inattention. But they may constitute a more immediate risk factor, whereby the children who are naturally anxious develop a clinically significant level of anxiety.
Synthesizing, the findings from numerous studies strongly suggest that children with ADHD are more vulnerable to a broad range of externalizing and internalizing disorders than peers without ADHD. However, the influence of different variables must be considered to achieve a more in-depth understanding of the issue of comorbidity. Some of these factors stand out, such as age of the subjects, severity of the symptoms, evaluation instruments used, extraction of the sample, informants (parents versus teachers), and the culture of the participants. Based on these considerations, we proposed the following three objectives for the present study:
1. To study the prevalence of psychological problems in children with a clinical diagnosis of ADHD using the ratings of parents and teachers, and to determine the cross-informant consistencies on those ratings.
2. To identify the predictive capacity of psychological problems on the severity with which ADHD symptoms are manifested.
3. To analyze the influence of LD and age in the psychological problems of the children with ADHD.
The sample was composed of 72 subjects, 67 males and 5 females, with ADHD, between the ages of 6 and 14 years old (M = 9.40; SD = 2.06). Participants' mean IQ was 103.76 (SD = 17.11). Most of the children were from families with a low socioeconomic status, but with no cultural or environmental disadvantages. All subjects were Caucasian and spoke Spanish as their primary language. The children had been diagnosed as having ADHD in the Neuropediatric Service of the Children's Hospital "La Fe" in Valencia (Spain), based on the concordant assessment of a neuropediatrician and a clinical psychologist.
All the participants met the following criteria: a clinical diagnosis of combined subtype ADHD (DSM-IV-TR; American Psychiatric Association, 2000), with strict agreement between a parent and teacher about the presence of at least six symptoms of inattention and at least six symptoms of hyperactivity/impulsivity, including the following: the symptoms had been evident for more than one year; the problem had appeared before the age of 7; the child had an IQ score of 80 or more as measured by the WISC-R (Wechsler, 1993); the exclusion criteria included psychosis, autism, neurological damage, epilepsy, or sensory or motor deficits. Of the total sample, 48% were receiving methylphenidate.
The presence of learning disabilities (LD) was determined using an adaptation of the multifaceted approach developed by Pereira-Laird, Deane, and Bunnell (1999). Assessment included the following: (a) information provided by teachers about low reading or math achievement in the classroom; (b) IQ scores of 80 or more; (c) no evidence or history of neurological damage, environmental disadvantage, emotional disturbance, hearing and vision abnormalities, or any other major handicapping condition. These are in accordance with the conventional exclusion criteria for LD.
Similarly, the achievement criteria adopted in the study have been commonly used in the LD literature. Specifically, to define mathematics learning disabilities (MLD), a score on the subtests on calculation and/or problem solving from the EVALUA Battery (Garcia-Vidal & Gonzalez-Manjon, 2003) was used, corresponding to the 25th percentile or less on the global index of mathematical knowledge. This scale has high internal consistency, with an overall coefficient alpha of .87. A cut-off point two deviations below the mean on the word retrieval and/or comprehension subtests from the reading-writing analysis test (Test de Analisis de la Lectoescritura; TALE; Toro & Cervera, 1984) was used to determine RLD. The reliability of this test is .82.
To carry out the third objective of the study, the sample was divided according to two factors: age and LD. In relation to age, students were split into two groups, children aged between 6 and 9 years (n = 42) and children aged between 10 and 14 years (n = 30). The second factor was the presence vs. absence of LD. Regarding the LD factor, 36 children (50%) from the total sample had LD in mathematics (calculation and/or problem solving) and/or reading (word retrieval and/or reading comprehension). The LD group was composed of 12 children with MLD, 17 with RLD, and 7 with both types of LD (see Table 1).
The study was approved by the Research Ethics Committee at La Fe Hospital in Valencia. The first author conducted an initial interview with each child's parents in order to clarify the objectives of the research. After the parents and children had given their written consent to participate, the evaluation process was initiated. Once it had been shown that the children met the DSM IV-TR conditions for a combined subtype ADHD diagnosis, the parents were assisted in filling out the Conners Questionnaire (CPKS-RL; Conners, 1997a) and the Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001) about their child. The questionnaires were filled out in most cases by both parents in an office in the hospital. A clinical psychologist was present to clarify possible doubts related to the questionnaires. Later, in another session, the subjects were given the WISC-R (Wechsler, 1993) and the Mathematics and Reading-Writing tests to determine the presence-absence of LD.
In addition, the children's classroom teachers were contacted by phone, for the purpose of asking them to collaborate by filling out the teacher versions of the CTRS-RL (Conners, 199719) and SDQ (Goodman, 2001) questionnaires. They received a stamped addressed envelope at school for returning the completed questionnaires.
Conners' Parent Rating Scale-Revised (CPRS-RL, 1997a) and Conners' Teacher Rating Scale-Revised (CTRS-RL, 1997b). The CPRS-RL and CTRS-RL have been validated for children ages 3 to 17. The parent rating scales contain 80 items, and the teacher version, 59 items. Items are rated on a 4-point Likert-type scale; each item receives a score between 0 (never) and 3 (very often). Items are organized into 14 scales for parents and 13 scales for teachers. These scales are the same, except for the psychosomatic scale, which is only included in the parent version (e.g., stomachaches before school). The 13 scales included in both questionnaires consist of the following: oppositional (e.g., defiant), cognitive problems/inattention (e.g., forgets things s/he has already learned), hyperactivity (e.g., restless in the squirmy sense), anxious-shy (e.g., feelings easily hurt), perfectionism (e.g., is a perfectionist), social problems (e.g., appears to be unaccepted by group), Conners' Global Index: restless-impulsive (e.g., excitable, impulsive), Conners' global index: emotional lability (e.g., cries often and easily), Conners' global index: Total; Conners' ADHD index (e.g., disturbs other children), DSM-IV inattentive (e.g., does not seem to listen to what is being said to him/her), DSM-W hyperactive-impulsivity (e.g., has difficulty waiting his/her turn), and the DSM IV Total to more accurately reflect the DSM-IV ADHD criteria.
The conclusions from a recent review underscore the fact that the Conners scales are among the ADHD rating scales with the strongest standardization of samples and evidence of reliability and validity (Demaray, Elting, & Schaefer, 2003).
Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001). This questionnaire consists of 25 questions designed to gather information on emotional and behavioral difficulties experienced by children ages 3 to 17, as well as information on impairments in daily functioning (available for view and download from www.sdqinfo.com). For scoring purposes, the SDQ categorizes strengths and difficulties into five scales: emotional problems (e.g., often unhappy, down-hearted or tearful); conduct problems (e.g., often has temper tantrums or hot temper); hyperactivity (e.g., restless, overactive, cannot stay still for long); peer problems (e.g., rather solitary, tends to play alone); and prosocial behavior (e.g., considerate of other people's feelings). Each item receives a score between 0 (complete disagreement) and 2 (complete agreement).
The test has been shown to have criterial validity and good test-retest reliability after four and six months (mean: 0.62). In addition, the internal consistency is satisfactory; it varies from a Cronbach's alpha of .57 on the peer problems (parents) scale to .88 on the hyperactivity scale for teachers (Goodman, 2001).
Psychological Problems and ADHD: Cross-Informant Consistencies on Psychological Problem Ratings
Table 2 presents data on the incidence of behavioral and emotional problems of the subjects, according to the ratings of the parents and teachers. The cut-off point or abnormal score for all the subscales of the Conners' Rating Scale was a score equivalent to T [greater than or equal to] 63. On the SDQ, the cut-off points for abnormal scores were as follows: emotional symptoms, [greater than or equal to] 5 for parents and [greater than or equal to] 6 for teachers; conduct problems and prosocial behavior, [greater than or equal to] 4; hyperactivity/inattention, [greater than or equal to] 7, and peer relationship problems, [greater than or equal to] 4 for parents and [greater than or equal to] 5 for teachers. To calculate the percentage of agreement between parents and teachers, the cases were only considered positive when the estimation of the PP from both informants reached (or surpassed) the cut-off point established for each scale on the questionnaires.
As illustrated in Table 2, differences were found between the two sources of information used, parents and teachers, in their ratings of the internalization disorders. Thus, according to the parents, 17% of the children experienced problems with anxiety, compared to 63% perceived by the teachers; 13% were concordant cases. Likewise, 43% of the subjects demonstrated excessive emotional lability in the opinion of the parents, whereas the percentage rose to 72% in the opinions of the teachers, for 33% agreement. On the contrary, the emotional symptoms (rated using the SDQ scale) affected 53% of the children from the perspective of the parents, whereas only 14% of the sample had emotional symptoms according to the teachers. The interrater agreement in the domain of emotional symptoms was low, in that only 11% of the cases were identified by the two sources of information used.
The agreement between parents and teachers increased substantially for externalization' problems. The agreement of their perceptions of hyperactive behaviors was high (85% agreement on the Conners' hyperactivity scales and 90% on the SDQ hyperactivity/inattention scale). Specifically, we found very high percentages in the observation of restless/impulsive problems by parents (99%) and teachers (91%), with an agreement rate of 90%. The agreement between parents and teachers was also appreciable in their ratings of conduct problems (75% by parents versus 60% by teachers, and 43% agreement). Finally, the tendency of Parents and teachers to agree was less strong in their perception of social problems (49% by parents and 53% by teachers, with 29% agreement), and with regard to peer relationship problems (49% by parents vs. 36% by teachers; 28% agreement).
Predictive Power of the Psychological Problems in the Severity of ADHD
To carry out the second objective, first a factorial analysis was performed to obtain a general severity index (GSI) combining the ratings of parents and teachers. Next, a regression analysis was performed to determine the predictive capacity of the psychological problems on the GSI.
To calculate the GSI, the three scales from the Conners questionnaire (for parents and teachers) that are most directly related to ADHD were used; that is, DSM-IV inattentive, DSM-IV hyperactive-impulsivity and DSM IV total. A principal-components analysis yielded a solution of only one factor, according to the Kaiser criterion (eigenvalues > 1), with its own value of 3.53, which explained 58.86 % of the variance. Furthermore, the factorial saturations were satisfactory, varying between a minimum of .713 and a maximum of .810.
Next, to determine the predictive power of the PP on the GSI, multiple-regression analyses were conducted. The PP introduced as predictor variables were all the scales from the Conners' questionnaire and from the SDQ for parents and teachers that were not used to calculate the GSI. The variable inclusion method was stepwise, with an inclusion criterion of p < .05 and an exclusion criterion of >. 1. This statistical selection criterion was chosen due to the size of the sample.
The results of the multiple-regression analyses of the psychological problems rated by the parents on the GSI (see Table 3) pointed to the important predictive power of the cognitive/inattention ([beta] = 0.587, p < .01), emotional lability ([beta] = 0.404, p < .01), and conduct problems ([beta] = -0.213, p < .05) variables. Together, these three variables accounted for 50.5% ([R.sup.2] =.505) of the variance in the GSI. Likewise, the multiple-regression analyses using the ratings of the PP by the teachers on the GSI (see Table 3) showed that, as for the parents, cognitive/inattention ([beta] = 0.586, p < = .01), emotional lability ([beta] = 0.493, p < .01,) and conduct problems ([beta] = -0.324, p < .01) were the most predictive variables, explaining 54.8% of the total variance ([R.sup.2] = .548).
Influence of Learning Disabilities and Age on the Psychological Problems of Children with ADHD
Finally, an analysis was performed to determine whether LD and age exerted any influence on the behavioral and emotional problems experienced by the children with ADHD. To address this question, the sample was divided into four groups, two groups according to condition (ADHD-only and ADHD+LD) and two groups according to age (from 6 to 9 years and from 10 to 14 years). Multivariant analysis of variance (MANOVA 2x2) was performed, based on the variables included in the Conners and SDQ questionnaires filled out by the parents and the teachers.
The results of the MANOVA of the Conners scales for parents indicated no significant main effects for the LD condition (Wilks' Lambda ([lambda]) = .776; F(14, 55) = 1.136; p = .349; [[eta].sup.2] = .224), or for age (Wilks' Lambda ([lambda]) = .668; F(14, 55) = 1.954; p = .057; [[eta].sup.2] = .332), although the value of the effect size in both cases was moderate. There was, however, a significant interaction between LD condition and age (Wilks' Lambda ([lambda]) = .617; F(14, 55) = 2.435; p < .05; [[eta].sup.2] = .383).
The ANOVAs carried out later to interpret these findings (see Table 4) showed a statistically significant effect in the cognitive/inattention, F(1, 68) = 7.881; p < .01; [[eta].sup.2] = .104, and Conners' ADHD index, F(1, 68) = 5.824; p < .05; [[eta].sup.2] = .079, variables. Specifically, post-hoc comparisons showed that, according to the parents, the older children with ADHD but without LD had more cognitive/inattention problems and obtained significantly higher scores on the Conners' ADHD index than the younger children with ADHD but without LD. In contrast, the younger children with ADHD and LD showed more cognitive/inattention symptoms and higher scores on the Conners' ADHD index than the older children with ADHD and LD.
However, the MANOVA performed with the parent SDQ questionnaire did not show a main effect of LD condition (Wilks' Lambda ([lambda]) = .895; F(5, 64) = 1.509; p = .199; [[eta].sup.2] = .105), or age (Wilks' Lambda (A) = .967; F(5, 64) = 0.432; p = .825; [[eta].sup.2] = .033). Nor was the LD condition x age interaction statistically significant (Wilks' Lambda ([lambda]) = .925; F(5, 64) = 1.035; p = .405; [[eta].sup.2] = .075),
On the other hand, the MANOVA performed with the ratings of the teachers on the Conners' questionnaire revealed no significant main effects for the LD condition (Wilks' Lambda ([lambda]) = .744; F(13, 56) = 1.483; p = .153; [[eta].sup.2] = .256), or for interactions between LD and age (Wilks' Lambda ([lambda]) = .778; F(13, 56) = 1.231; p = .283; [[eta].sup.2] = .222). However, the analysis showed a significant main effect for age (Wilks' Lambda ([lambda]) = .655; F(13, 56) = 2.269; p < .05; [[eta].sup.2] = .345).
According to the ANOVAs performed later (see Table 5), the teachers gave the older children with ADHD significantly higher ratings than the younger children with ADHD on the following variables: cognitive/inattention, F(1, 68) = 7.556; p < .05; [[eta].sup.2] = .100, restless-impulsive, F(1, 68) = 7.471; p < .05; [[eta].sup.2] = .099, and the Conners' ADHD index, F(1, 68) = 9.663; p < .01; [[eta].sup.2] = .150.
As for the parents, the MANOVA carried out with the scores from the SDQ questionnaire for teachers did not yield significant effects: for the condition (Wilks' Lambda ([lambda]) = .857; F(5, 64) = 2.128; p = .073; [[eta].sup.2] = .143), for age (Wilks' Lambda ([lambda]) = .913; F(5, 64) = 1.219; p = .310; [[eta].sup.2] = .087), or for the interaction between condition and age (Wilks' Lambda ([lambda]) = .934; F(5, 64) = 0.907; p = .482; [[eta].sup.2] = .066).
The results of the present study showed that the children with combined subtype ADHD experienced a high rate of associated psychopathologies. These findings are similar to those found in previous studies (e.g., Connor et al., 2003; Rosello et al., 2000; Strine et al., 2006). As Barkley (2007) pointed out, research carried out in the past decade has shown that the broad and varied comorbid problems with ADHD have important implications for understanding its nature and impairments, as well as responses to prevailing treatments.
School psychologists who work with students with ADHD must be prepared to address a complex constellation of problems beyond the core symptoms of inattention and impulsivity/hyperactivity, as these problems generally have pervasive effects on an individual's functioning. Specifically, oppositional and anxious behaviors cause social dysfunction, although through different pathways (Green, Gilchrist, Burton, & Cox, 2000). Oppositional behavior is a significant correlate of social dysfunction at school, as well as problems with parents and peers. Likewise, anxiety stands out as a significant correlate of difficulties in interactions with classmates (spare-time activities, spare-time problems, activities with peers and problems with peers).
As also detected in previous studies (Antrop et al., 2002; Hartman et al., 2007; Jane et al., 2006), agreement between the ratings of the parents and teachers with regard to externalizing problems reached values between moderate and high, because these problems tend to be more observable, more chronic and serious, easier to judge, and more consistent across situations. However, the rate of agreement between parents and teachers on internalizing problems (emotional lability, anxiety, and emotional problems) was low, probably because they are often not visible, and the adult, therefore, may not be aware of them.
There may be other explanations for the discrepancy observed, such as (a) the teachers may be more familiar with appropriate behaviors for children, and they may be more sensitive to developmental difficulties, even when they are less evident, as in the case of internalization problems; (b) the perception thresholds of parents and teachers with regard to internalization problems may be different, and this type of problem may worry the parents less; (c) the problems may be expressed in different ways in different contexts (family versus school), because the behavioral demands of the classroom tend to be more stringent than those at home (Biederman, Faraone, Milberger, & Doyle, 1993; Hartman et al., 2007). This means that neither the teacher nor the parent ratings are invalid; instead, each offers a unique perspective on the child's behavior (Smith, 2007).
The second objective of this study focused on identifying the predictive capacity of comorbid psychological problems on the severity with which the ADHD symptoms are manifested. Our findings point to agreement between raters when the index used to rate the ADHD severity combined the perceptions of parents and teachers who interact with the child in different contexts. Specifically, both the parents' and teachers' ratings of three variables, behavior problems, cognitive/inattention problems and emotional lability, adequately predicted the severity of ADHD. In other words, the children whose parents and teachers rated them as having more cognitive and inattention problems, as being more emotionally labile, and as showing more behavior problems, demonstrated the symptomatology of inattention and hyperactivity-impulsiveness with greater intensity. One possible explanation for these findings is that difficulties in emotional control and comorbid behavioral problems may influence the intensity with which ADHD is manifested (Barry et al., 2002; Connor et al., 2003).
The third objective was to study the influence of age and LD on the behavioral and emotional problems of children with ADHD. With regard to age, the results, coinciding with those of Pierrehumbert et al. (2006), indicated that teachers perceived the older children with ADHD to experience more psychological problems than the younger ones. Specifically, cognitive/inattention problems, restless/impulsive symptoms, and the symptoms included in the Conners' ADHD index (attention problems, hyperkinesis, disorganization, distractibility, lack of persistence) occurred with a significantly greater severity in the older children with ADHD.
However, Strine et al. (2006) found the inverse pattern; that is, the younger children with ADHD in their study demonstrated greater psychological problems. The discrepancy between our results and those of Strine et al. may be due to the fact that the subjects with ADHD in our sample had benefited less from previous interventions, or they may not have been capable of developing strategies for dealing with their difficulties. It is also possible that, over time and with increases in instructional demands, teachers become more aware of and, in general, become less tolerant of attentional problems and the difficulties older children with ADHD have in controlling their restlessness and impulsivity. In other words, as the academic level increases, the number of tasks that require sustained concentration and attention also increases. Thus, the teachers can identify failures in these executive functions better than parents can.
Smith and Adams (2006), Carroll et al. (2005), and Wilcutt and Pennington (2000), among others, have shown that the presence of LD together with ADHD implies a significantly greater risk of experiencing psychological problems. However, these studies did not analyze whether age played a role in this association. Regarding the influence of LD in the evolution of the behavioral and emotional problems of children with ADHD, our findings show, based on the opinions of the parents, an interaction between the condition (with or without LD) and age. Thus, according to the parents, when there was no associated LD, the older children experienced more psychological problems, as found by Pierrehumbert et al. (2006). However, consistent with the findings of Strine et al. (2006) and Maughan et al. (2003), when an LD as associated with the ADHD, the younger children experienced more cognitive/inattention problems and higher Conners' ADHD scores.
One possible explanation for our results is that, due to the continuous interaction with their children, parents acquire a degree of desensitization, developing a greater tolerance to the behaviors of the children with ADHD who have LD. Another possibility is that the parents' awareness of the negative impact of LD on older children's academic progress, and the worry about their future that this situation produces, causes them to be more lenient about psychological problems.
For the students with ADHD but without LD, the opposite situation occurs. In those cases, it is possible that the parents tend to assess their children's psychological problems more negatively as time passes because, when their preadolescent children with ADHD do not suffer learning disabilities, their psychological problems become parents' main worries. It is also possible that the treatments the children with ADHD+LD received from early childhood, due to the fact that they required more help to meet their special educational needs, have reduced the problems. At this time, we can only make conjectures, as we lack information that could provide a definitive answer to this question.
The results of this study must be interpreted in the context of several methodological limitations. First, the psychological problems of the children with ADHD were examined using rating scales, which are subject to a number of limitations, including subjectivity and reporter bias. In order to counteract these problems, we gathered information from multiple informants, parents and teachers. The use of multiple ratings is considered beneficial by experts in evaluation, as they collectively provide more information about a child than a single rating does (Mandal, Olmi, & Wilczynski, 1999).
A second limitation is that the approach used in this study to identify the psychological problems was not based on an exhaustive clinical diagnosis. Therefore, our conclusions cannot be extrapolated to the field of psychiatric disorders of children with ADHD, but rather to types of problems they often experience in their development.
Third, due to the relative low number of subjects included in the analyses of the factors of age and LD, the results in this regard may be spurious. Consequently, although novel, our findings are basically exploratory for now. Research using larger samples (grouped by age and presence/absence of LD) is needed to increase the statistical power. Furthermore, to fitly explore the implications of the findings in relation to the role of age and LD in the psychological problems of children with ADHD, a longitudinal design is not only desirable but also necessary.
One final limitation of this study is that it is not possible to generalize its results or conclusions to girls with ADHD due to the low representation of the female sex in our sample. This fact has special importance, given the differential vulnerability of males and females to experiencing psychological problems observed in the general population.
Implications for Practice
In spite of the limitations, the results of this study have several practical implications. Its most outstanding merit is that it provides a comprehensive panorama of the frequency and types of psychopathologies experienced by students with ADHD, as well as their implications for the severity with which the disorder is manifested. The high rate of psychological problems in children with ADHD found in this and other studies should alert education professionals to the possibility that, along with the ADHD, other psychological problems co-exist that must be urgently attended to.
Currently, clinical practice focuses on the three core symptoms of ADHD to determine a diagnosis (Mares, McLuckie, Schwart, & Saini, 2007). However, data from the present study highlight the fact that, although ADHD itself is a risk factor for personal development, its symptoms are much more severe in the presence of behavior problems, cognitive/inattention problems, and emotional lability. Thus, evaluation of children with ADHD in the framework of school must be comprehensive and include the academic, behavioral and emotional domains. The information obtained in this meticulous evaluation process will help teachers to design individualized instruction and efficient educational accommodations.
Our findings showing the moderately low rate of agreement between parents and teachers point to the importance of gathering information from more than one informant to obtain a complete picture of the true functioning of children with ADHD. From an interdisciplinary approach, in order to arrive at a reliable diagnosis and achieve an effective intervention for children with ADHD, communication among parents, teachers, and physicians is necessary. It is clear that teacher, parent, and direct information about child performance is useful clinically, in other words, a close collaboration between professionals working in different settings is critical for optimal diagnosis and intervention for children with ADHD.
Because active coordination plays such a vital part in the diagnosis and management of the disorder, improving the amount and quality of communication among the caregivers of children with ADHD is an area that warrants our attention. Unfortunately, this is not an easy task. Complicating ongoing communication among parents, teachers, and physicians is the fact that, with each passing year, parents must often educate another teacher about their child's disorder and recreate channels of communication (Reid, Hertzog, & Snyder, 1996).
In summary, this study provided information that helps to better understand the externalizing and internalizing problems of children with ADHD, as well as the variables that influence comorbidity (e.g., age, severity, LD). We trust that these findings will be useful in optimizing prevention and intervention procedures for students with ADHD, providing them with a better personal and social adjustment in the long term.
This study was funded by a grant assigned to Ana Miranda, SEJ2005-06160/EDUC project subsidized by FEDER funds.
The authors thank all of the parents, teachers, and children who participated in this research and the IMAGE project (NIMH grant no. R01 MH62873-01A1, assigned to Steve Faraone).
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Please address correspondence regarding this article to: Ana Miranda, Department of Developmental and Educational Psychology. University of Valencia, Avda. Blasco Ibanez, 21. 46010 Valencia, Spain; e-mail: Ana.Miranda@uv.es
ANA MIRANDA, Ph.D., Department of Developmental and Educational Psychology, University of Valencia, Spain.
MANUEL SORIANO, Ph.D., Department of Developmental and Educational Psychology, University of Valencia, Spain.
INMACULADA FERNANDEZ, Ph.D,, Department of Developmental and Educational Psychology, University of Valencia, Spain.
AMANDA MELIA, Ph.D., Department of Developmental and Educational Psychology, University of Valencia, Spain.
Table 1 Descriptive Data--Age, IQ Means, and Standard Deviations ADHD-Only (N = 36) ADHD+LD (N = 36) 6-9 years 10-14 years 6-9 years 10-14 years N 19 17 23 13 IQ M 109.18 106.47 102.95 93.46 SD (18.36) (17.18) (14.14) (17.18) Age M 8.01 11.41 7.91 11.38 SD (1.18) (1.41) (0.9) (1.33) Sex Male 19 15 21 12 Female 0 2 2 1 Table 2 Incidence of Psychological Problems in Children with ADHD Based on the Conners and the SDQ Rating Scales Parent Teacher (N = 72) (N = 72) Agreements N % N % N % Conners Rating Scales Oppositional 43 60 61 85 41 57 Cognitive/inattention 68 94 50 69 47 65 Hyperactivity 72 100 61 85 61 85 Anxious-shy 12 17 46 63 9 13 Perfectionism 6 8 26 36 4 6 Social problems 35 49 38 53 21 29 Psychosomatic 28 39 -- -- -- -- Restless-impulsive 71 99 66 91 65 90 Emotional lability 31 43 52 72 24 33 Conners Global 68 94 65 90 62 86 Index total SDQ Rating Scales Emotional symptoms 38 53 10 14 8 11 Conduct problems 54 75 43 60 31 43 Hyperactivity/ 72 100 65 90 65 90 inattention Peer relationship 35 49 26 36 20 28 problems Prosocial behavior 7 10 19 26 5 7 Table 3 Multiple-Regression Analysis: Psychological Problems as Predictor of Severity Global Index (SGI) B [beta] s.e. Parents' Rating Scales Cognitive/inattention (Conners) 0.083 0.587 0.013 Emotional lability (Conners) 0.038 0.404 0.009 Conduct problems (SDQ) -0.097 -0.213 0.046 R = 0.711, [R.sup.2] = 0.505, Adjusted [R.sup.2] = 0.484. * p <.05, ** p <. 01. Teachers' Rating Scales Cognitive/inattention (Conners) 0.062 0.586 0.009 Emotional lability (Conners) 0.042 0.493 0.010 Conduct problems (SDQ) -0.162 -0.324 0.059 R = 0.740, [R.sup.2] = 0.548, Adjusted [R.sup.2] = 0.528. * p <.05, ** p <.01. p t Parents' Rating Scales Cognitive/inattention (Conners) 0.000 ** 6.378 Emotional lability (Conners) 0.000 ** 4.152 Conduct problems (SDQ) 0.038 * -2.119 R = 0.711, [R.sup.2] = 0.505, Adjusted [R.sup.2] = 0.484. * p <.05, ** p <. 01. Teachers' Rating Scales Cognitive/inattention (Conners) 0.000 ** 6.954 Emotional lability (Conners) 0.000 ** 4.059 Conduct problems (SDQ) 0.008 ** -2.728 R = 0.740, [R.sup.2] = 0.548, Adjusted [R.sup.2] = 0.528. * p <.05, ** p <.01. Table 4 Means, Standard Deviation, and F-Values of Comparisons of ADHD Groups in Terms of Psychological Problems (Parent Scales) ADHD-Only 6/9 years 10/14 years Oppositional M 62.11 67.47 SD (13.61) (10.13) Cognitive/ M 69.74 74.35 inattention SD (5.96) (9.37) Hyperactivity M 81.47 85.53 SD (6.83) (7.72) Anxious-shy M 51.95 55.24 SD (8.05) (8.23) Perfectionism M 51.74 52.53 SD (11.17) (9.05) Social problems M 67.16 59.82 SD (15.58) (9.95) Psychosomatic M 58.59 60.12 SD (15.23) (16.75) Conners M 70.63 74.34 ADHD Index SD (4.60) (8.47) Restless- M 76.47 77.24 impulsive SD (6.94) (8.43) Emotional M 60.21 65.00 lability SD (11.19) (11.62) Conners M 73.26 75.41 Global Index SD (8.00) (9.44) ADHD+LD 6/9 years 10/14 years Oppositional M 64.78 59.59 SD (10.13) (11.70) Cognitive/ M 75.48 70.92 inattention SD (4.66) (7.12) Hyperactivity M 82.78 84.69 SD (6.72) (9.41) Anxious-shy M 53.3 57.85 SD (9.44) (10.58) Perfectionism M 51.43 51.08 SD (7.76) (9.08) Social problems M 68.65 65.77 SD (16.02) (16.74) Psychosomatic M 60.30 54.85 SD (14.24) (11.91) Conners M 73.70 71.69 ADHD Index SD (3.35) (4.40) Restless- M 77.52 74.77 impulsive SD (5.06) (9.59) Emotional M 60.52 65.31 lability SD (10.6) (8.17) Conners M 74.09 74.23 Global Index SD (6.00) (8.88) ANOVAS F-Value Condition Age CxA Oppositional M 0.860 0.003 3.614 SD Cognitive/ M 0.501 0.000 7.881 ** inattention SD Hyperactivity M 0.017 2.711 0.351 SD Anxious-shy M 0.831 3.237 0.083 SD Perfectionism M 0.154 0.009 0.066 SD Social problems M 1.085 2.046 0.388 SD Psychosomatic M 0.295 0.355 0.883 SD Conners M 0.005 0.777 5.824 * ADHD Index SD Restless- M 0.161 0.317 0.986 impulsive SD Emotional M 0.015 3.501 0.000 lability SD Conners M 0.009 0.357 0.273 Global Index SD Post-hoc comparisons Oppositional M ns SD Cognitive/ M ADHD-Only 10/14> inattention ADHD-Only 6/9 SD ADHD+LD 6/9>ADHD+ LD 10/14 Hyperactivity M ns SD Anxious-shy M ns SD Perfectionism M ns SD Social problems M ns SD Psychosomatic M ns SD Conners M ADHD-Only 0/14> ADHD Index ADHD-Only 6/9 SD ADHD+LD 6/9>ADHD+ LD 0/14 Restless- M ns impulsive SD Emotional M ns lability SD Conners M ns Global Index SD * p<.05.** p<.01, ns = not significant. Table 5 Means, Standard Deviation, and F-Values of Comparisons of ADHD Groups in Terms of Psychological Problems (Teacher Scales) ADHD-Only 6/9 years 10/14 years Oppositional M 76.21 75.12 SD (11.02) (13.66) Cognitive/ M 60.53 69.35 inattention SD (5.57) (12.37) Hyperactivity M 73.21 74.82 SD (6.99) (11.02) Anxious-shy M 68.89 70.41 SD (9.96) (13.79) Perfectionism M 62.00 59.41 SD (12.60) (10.55) Social problems M 62.68 63.18 SD (14.73) (11.25) Conners M 69.74 73.88 ADHD Index SD (5.47) (9.92) Restless- M 71.37 74.18 impulsive SD (5.68) (11.31) Emotional M 69.68 69.47 lability SD (12.28) (14.43) Conners M 74.74 76.41 Global Index SD (7.94) (13.06) ADHD+LD 6/9 years 10/14 years Oppositional M 75.13 74.31 SD (12.27) (10.42) Cognitive/ M 69.13 71.69 inattention SD (7.52) (8.07) Hyperactivity M 70.00 74.77 SD (8.69) (21.40) Anxious-shy M 64.57 71.92 SD (10.46) (15.12) Perfectionism M 56.70 58.62 SD (8.35) (7.23) Social problems M 63.87 74.62 SD (13.18) (16.66) Conners M 70.26 77.08 ADHD Index SD (7.74) (5.07) Restless- M 71.04 78.69 impulsive SD (7.93) (4.85) Emotional M 69.70 70.69 lability SD (12.82) (15.07) Conners M 74.43 79.23 Global Index SD (10.20) (6.22) ANOVAS F-Value Condition Age CxA Oppositional M 0.107 0.110 0.002 SD Cognitive/ M 6.977 7.556 ** 2.287 inattention SD Hyperactivity M 0.313 1.198 0.293 SD Anxious-shy M 0.233 2.315 2.003 SD Perfectionism M 1.605 0.019 0.876 SD Social problems M 3.573 2.832 2.357 SD Conners M 1.112 9.663 ** 0.574 ADHD Index SD Restless- M 1.200 7.471 ** 1.601 impulsive SD Emotional M 0.036 0.015 0.035 lability SD Conners M 0.281 1.855 0.432 Global Index SD Post-hoc comparisons Oppositional M ns SD Cognitive/ M ADHD-10/14>ADHD-6/9 inattention SD Hyperactivity M ns SD Anxious-shy M ns SD Perfectionism M ns SD Social problems M ns SD Conners M ADHD 0/14>ADHD 6/9 ADHD Index SD Restless- M ADHD 0/14>ADHD 6/9 impulsive SD Emotional M ns lability SD Conners M ns Global Index SD * p<.05. ** p<.01, ns = not significant.