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23 Jul 2018

DuPaul GJ et al. J Abnorm Child Psychol 2018; 46: 979-992

Children with ADHD are at a higher risk for academic underachievement, special education and school drop-out, and often experience difficulties in building and sustaining friendships as well as interacting with peers and adult figures of authority. This suggests that early intervention for children with ADHD who are at risk of significant academic and/or social impairment might be beneficial. This study examined trajectories of academic and social functioning in children with ADHD to identify those who may be at risk of severe academic and social impairment.

Using data from the NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD (MTA Study), two datasets were created, one for reading and mathematics and the other for social skills. Children meeting Diagnostic and Statistical Manual of Mental Disorders–4th Edition criteria for ADHD were assessed pre-treatment (baseline; at age 7–9.9 years), and then through 14-, 24-, 36-, 72- and 96-month follow-up surveys (such that the participants were aged 15–17.9 years at endpoint). To be included in these analyses, children must have had at least baseline and endpoint data for reading and mathematics achievement (assessed using the Weschler Individual Achievement Test [WIAT])* or social skills ratings (assessed using the teacher-rated Social Skills Rating System). Trajectories of ADHD symptom severity were measured using the Swanson, Nolan and Pelham Rating Scale. Child demographic and diagnostic characteristics, family status and receipt of treatment§ were also included in the analyses, and children’s cognitive abilities and externalising and internalising behavioural difficulties were also measured at baseline. A local normative comparison group (LNCG) of children without ADHD, who were randomly selected from the same schools and grades as children with ADHD, were also included in the MTA study, and were initially assessed at the 24-month timepoint.

A total of 392 children with ADHD had baseline and endpoint data available for reading and mathematics achievement (77.3% male, mean [standard deviation (SD)] age 7.7 [0.8] years) and 259 children had data available for social skills ratings (74.9% male, mean [SD] age 7.6 [0.8] years). The LNCG comprised 289 children without ADHD (80.6% male, mean [SD] age 9.9 [1.1] years). Trajectory analyses indicated that there were six trajectory classes for reading, six classes for mathematics, four classes for social skills and three classes each for inattention and hyperactivity-impulsivity. Almost all children (95.6%) in the lowest functioning reading achievement trajectory class were also in the two lowest functioning mathematics achievement trajectory classes, and 46.3% of children in the lowest reading class were also in the lowest functioning teacher-rated social skills class. On the other hand, 88.2% of children in the highest functioning reading trajectory class were also in the three highest functioning mathematics trajectory classes.

The children with ADHD who were at the greatest risk for impaired academic and social trajectories were identified as follows:

  • Reading skills: At baseline, four of the six trajectory classes (66.3% of the sample) were below the population and LNCG means, and remained there across the assessment period. Three trajectory classes showed significant change over time, and by the end of the study (96 months), children with ADHD belonging to the two lowest functioning trajectory classes (Classes 1 and 2) displayed reading achievement that was 1.5 to 3 standard deviations below that of children with ADHD in Classes 5 and 6. Reading trajectory groups were significantly different in terms of child race, IQ, parental education, family income, conduct disorder, delinquent total, percentage of days receiving medication, and hours per week receiving special education and counselling.
  • Mathematics skills: At baseline, three of the six trajectory classes (53.9% of the sample) were below the population and LNCG means, and remained there across the assessment period. Additionally, children in Class 4 had scores below those for the LNCG, despite being slightly above the population mean throughout the assessment period. Classes 2 and 4–6 showed non-linear growth. By the end of the study (96 months), children with ADHD in the three lowest functioning classes (Classes 1–3) showed mathematics achievement that was 1 to 3 standard deviations below the children in Classes 4–6. Mathematics trajectory groups were significantly different regarding child race, IQ, parental education, family income, ADHD combined type diagnosis, delinquent total, internalising total, and receipt of special education and counselling.
  • Social skills: At baseline, all four trajectory classes were below the LNCG mean, although the second-lowest initial functioning class (Class 2) and the highest initial functioning class (Class 4) displayed improvement that met or exceeded the LNCG mean over time. The two highest initial functioning classes (Classes 3 and 4) showed non-linear growth. Social skills trajectory groups were significantly different for child gender, IQ, end-of-treatment impairment, race, maternal education, family income, conduct disorder, delinquent total, aggressive total, and WIAT reading and mathematics scores.

One limitation of this study was that the full MTA dataset was not included in these analyses, as there were missing baseline data for either reading and mathematics achievement or social skills ratings. In addition, social skills ratings were determined by different teachers across different school grades, and although data on the quantity of treatment and service use were available, the quality of services was not measured, and may have been associated with children’s inclusion in the lowest trajectory classes.

The authors concluded that in terms of growth trajectories, children with ADHD exhibit significant heterogeneity in reading, mathematics and social skills. Children with behavioural and sociodemographic disadvantages are particularly likely to have severe academic and social impairment, which is likely to continue over time. The authors indicated that evidence-based early screening and intervention is warranted in children with ADHD to directly address academic and school-based social impairments.

Read more about academic and social impairments in children with ADHD here

 

*The Weschler Individual Achievement Test is a norm-referenced, individually administered achievement test that has demonstrated adequate consistency, test-retest reliability and criterion-related validity. Standard scores for reading and mathematics achievement (M=100; SD 15) were used in these analyses
The Social Skills Rating System (SSRS) is a widely used measure of social skills with established internal consistency, test-retest reliability and criterion-related validity. Mean raw scores were used in these analyses to assess children’s social behaviours and interpersonal competence
Teachers indicated symptom frequency using a 4-point Likert scale (0, “not at all”; 1, “just a little”; 2, “pretty much”; and 3, “very much”). Mean item scores for the nine inattention symptoms and the nine hyperactivity-impulsivity symptoms were used in these analyses. The SNAP Rating Scale has shown adequate internal consistency and construct validity
§In the MTA study, children were randomly assigned to one of four treatment conditions: (1) systematic medication management that included initial placebo-controlled titration (MedMgt); (2) multicomponent behaviour therapy (Beh); (3) combination MedMgt and Beh; or (4) usual community care which mainly consisted of psychotropic medication

DuPaul GJ, Morgan PL, Farkas G, et al. Eight-year latent class trajectories of academic and social functioning in children with attention-deficit/hyperactivity disorder. J Abnorm Child Psychol 2018; 46: 979-992.

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