Complete parent and teacher screening data Recruitment Case definition DISC-IV Wave 1 Key measures Wave 1 Key measures Wave 2 Invited into longitudinal study Cohort 1 n = 3734 n = 380 Invited into longitudinal study Cohort 2 n = 444 Consent to longitudinal study 1. DISC-IV (n = 182) 1. SCQ by interview (n = 209) 2. DISC-IV (n = 209) 3. CHQ (n = 198) 4. Kessler 6 (n = 198) 5. LSAC Couple (n = 167) 6. LSAC Parenting (n = 198) Cohort 1 Wave 1 data (baseline) Wave 1 data (baseline) 1. SCQ by phone (n = 153) 3. CHQ (n = 134) 4. Kessler 6 (n = 143) 5. LSAC Couple (n = 108) 6. LSAC Parenting (n = 134) Wave 2 data (18-month follow-up) ADHD n = 246 (n = 78) Control (n = 104) Control (n = 108) ADHD (n = 101) Consent to longitudinal study Cohort 2 n = 252 Jessica Green 1,2 Nicole Rinehart 2,3 Vicki Anderson 2,4,5 Daryl Efron 2,4,5 Jan Nicholson 2,6 Brad Jongeling 7,8 Philip Hazell 9 Emma Sciberras 2,4,5 1 School of Psychological Sciences, Monash University, VIC Australia 2 Murdoch Childrens Research Institute, Parkville, VIC Australia 3 School of Psychology, Deakin University, Burwood, VIC Australia 4 The Royal Children’s Hospital, Parkville, VIC Australia 5 The University of Melbourne, Parkville, VIC Australia 6 Judith Lumley Centre, LaTrobe University, Melbourne, VIC Australia 7 Child Development Service, Joondalup, WA Australia 8 The University of Western Australia, Perth, WA Australia 9 Discipline of Psychiatry, The University of Sydney, Sydney, NSW Australia. Conflict of Interest Statement: No authors have conflict of interests to declare. ERC 150222 June 2015 Autism spectrum disorder symptoms in children with ADHD: association with parent, couple and family functioning Background • Autism spectrum disorder (ASD) symptoms are common in children with attention deficit/hyperactivity disorder (ADHD) 1,2 • Little research has examined the association between ASD symptoms in children with ADHD and parent, couple and family functioning Objectives To examine the association between ASD symptoms in children with ADHD and: • parent mental health • family quality of life • couple conflict and couple support • parenting approaches Methods Setting and participants • 43 primary schools in Melbourne, Australia • Children aged 6 – 10 years participating in the Children’s Attention Project 3 • Sample size: 164 children with ADHD and 198 children without ADHD ADHD was assessed in two stages: • Screening using the parent and teacher Conners’ 3 4 ADHD index; and, • ADHD case confirmation using the NIMH Diagnostic Interview Schedule for Children (DISC) IV 5 Measures Measure/Construct Items Social Communication Questionnaire (SCQ) Lifetime Version 6 ASD symptoms • Total Score • Reciprocal Social Interaction subscale • Qualitative Abnormalities in Communication subscale • Restricted, Repetitive, and Stereotyped Patterns of Behaviour subscale Kessler 6 7 Parent mental health • Symptoms of depression • Symptoms of anxiety Longitudinal Study of Australian Children (LSAC) Scale 8 Couple support • Partner is a support in raising children • Partner understands and is supportive of needs as a parent Couple conflict • Disagree about basic parenting issues • Conversation is awkward or stressful • Couple argue • Anger or hostility between couple Angry parenting • Limited praise of child’s behaviour • Talk that is disapproving of child’s behaviour • Parent is angry when punishing their child • Parent has problems managing their child Child Health Questionnaire Family Impact Scale 9 Family quality of life: emotional impact • How much emotional worry or concern caused by: – Child’s emotional wellbeing or behaviour – Child’s attention or learning abilities Family quality of life: family impact • How often has your child’s health or behaviour: – Limited types of family activities – Interrupted everyday family activities – Limited spontaneous activities – Caused conflict at home – Source of arguments – Caused cancel/change work or family plans Family quality of life: time impact • How often were you limited in the amount of time you had for your own personal needs because of: – Child’s emotional wellbeing or behaviour – Child’s attention or learning abilities Results Sample characteristics Control n = 198 b ADHD n = 164 a p value Child characteristics Child age in years, mean (SD) 8.1 (1.1) 7.9 (1.1) 0.13 Male, n (%) 128 (64.7) 114 (69.5) 0.30 Existing ASD diagnosis, n (%) 3 (1.6) 35 (23.9) <0.001 ADHD subtype, n (%) ADHD – combined 83 (50.6) ADHD – inattentive 62 (37.8) ADHD – hyperactive/impulsive 19 (11.6) ADHD symptom severity c – parent report, mean (SD) 1.3 (2.4) 13.1 (4.6) <0.001 ADHD symptom severity c – teacher report, mean (SD) 0.8 (2.4) 11.5 (5.9) <0.001 Internalising comorbidity d in past year, n (%) 9 (4.5) 43 (26.2) <0.001 Externalising comorbidity d in past year, n (%) 14 (7.1) 87 (53.1) <0.001 Medication use (any), n (%) 1 (0.6) 27 (19.2) <0.001 Primary caregiver / family characteristics Parent completed high school, n (%) 156 (81.3) 97 (62.2) <0.001 SEIFA, mean (SD) 1015.3 (45.8) 1012.3 (43.4) 0.59 a n ranges between 144 –164; b n ranges between 183–198; c Conners 3 ADHD Index; d DISC-IV e Kessler 6 f LSAC Couple and parenting variables g Child Health Questionnaire Families who had a child with ADHD had poorer parental mental health, less couple support and more couple conflict, more angry and less consistent parenting, less parental self-efficacy and poorer family quality of life, compared with families of children without ADHD. ASD symptoms (IV) in children with ADHD are associated with poorer family quality of life, couple functioning and more aggressive parenting Unadjusted model Adjusted model Measure Coefficient a (95% CI) p Coefficient a (95% CI) p Parent and couple functioning Parent mental health 0.7 (-0.1, 1.4) 0.07 0.3 (-0.5, -1.2) 0.45 Couple support -0.5 (-0.9, -0.1) 0.04 0.1 (-0.5, 0.6) 0.89 Couple conflict 0.6 (0.1, 1.2) 0.04 0.3 (-0.5, 1.0) 0.51 Parenting behaviours Parental warmth - 0.1 (-0.1, 0.1) 0.89 0.1 (-0.1, 0.2) 0.47 Angry parenting 0.1 (0.0, 0.3) 0.04 0.1 (-0.1, 0.3) 0.20 Consistent parenting -0.1 (-0.2, 0.1) 0.22 -0.1 (-0.2, 0.2) 0.75 Parental self-efficacy 0.1 (-0.1, 0.2) 0.54 0.2 (0.1, 0.4) 0.13 Family quality of life Emotional impact -7.5 (-11.7, -3.2) 0.001 -6.4 (-12.6, -0.2) 0.04 Family impact -8.7 (-12.7, -4.7) <0.001 -6.8 (-12.0, -1.5) 0.01 Time impact -9.9 (-14.4, -5.3) <0.001 -10 (-16.4, -3.6) 0.002 a SCQ (IV) standardised to represent SD units; coefficient corresponds to the change in the DV for each SD increase in the IV Conclusions ASD symptoms in children with ADHD is associated with: • poorer family quality of life • greater couple relationship difficulties and less couple support ASD symptoms in children with ADHD was not associated with: • poorer parental mental health • parental consistency, warmth or self-efficacy This highlights the importance of assessing for ASD symptoms in children with ADHD to ensure appropriate intervention for these symptoms and appropriate referral to support services for parents, if required. Participant flow References 1. Van der Meer JM, Lappenschaar MG, Hartman CA, Greven CU, Buitelaar JK, Rommelse NN. Homogeneous Combinations of ASD-ADHD Traits and Their Cognitive and Behavioral Correlates in a Population-Based Sample. J Atten Disord. 2014. 2. Ronald A, Larsson H, Anckarsater H, Lichtenstein P. Symptoms of Autism and ADHD: A Swedish Twin Study Examining Their Overlap. J Abnorm Psychol. 2014;123(2):440-451. 3. Sciberras E, Efron D, Schilpzand E, et al. The Children’s Attention Project: a community-based longitudinal study of children with ADHD and non-ADHD controls. BMC Psychiatry. 2013;13(1):18. 4. Conners C. Conners. 3rd edition ed. Toronto Multi-Health Systems; 2008. 5. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry. 2000;39(1):28-38. 6. Rutter M, Bailey A, Lord C. Social Communication Questionnaire Los Angeles, CA: Western Psychological Services (WPS); 2003. 7. Furukawa TA, Kessler RC, Slade T, Andrews G. The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being. Psychol Med. 2003;33(2):357-362. 8. Zubrick S, Smith G, Nicholson J, Sanson A, Jackiewicz T. LSAC Research Consortium: Parenting and families in Australia. Canberra: ACT: Department of Families, Housing, Community Services and Indigenous Affairs; 2008. 9. Landgraf J, Abetz LW, JR. Child Health Questionnaire (CHQ): A User’s Manual. Boston, MA: The Health Institute 1996. Statistical analyses • Unadjusted and adjusted linear regressions were used to examine continuous outcomes • Adjusted analyses controlled for child (age, sex, ADHD symptom severity, internalising disorder, externalising disorder, recruitment cohort) and family factors (parent high school completion, Socio-Economic Indexes for Areas Disadvantage Index, and school clustering)