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Preliminary Development of the Teacher-Report ADHD Impairment Scale

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PAGE 1

1 PRELIMINARY DEVELOPMENT OF THE TE ACHER-REPORT ADHD IMPAIRMENT RATING SCALE By KATHERINE ELIZABETH KIKER A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2007

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2 2007 Katherine Elizabeth Kiker

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3 ACKNOWLEDGMENTS I would like to thank my supervisory chair for his dedicated mentoring, the participants in my study for their honest participation, and th e Center for Pediatric Psychology and Family Studies for their generous support.

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4 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................3 LIST OF TABLES................................................................................................................. ..........5 ABSTRACT....................................................................................................................... ..............6 CHAPTER 1 INTRODUCTION................................................................................................................... .7 2 METHOD......................................................................................................................... ......15 Scale Development.............................................................................................................. ...15 Procedures..................................................................................................................... ..........16 Participants................................................................................................................... ..........17 Statistical Analyses........................................................................................................... ......19 Measures....................................................................................................................... ..........20 3 RESULTS........................................................................................................................ .......23 Internal Consistency........................................................................................................... ....23 Test-Retest Reliability........................................................................................................ ....24 Discriminative Validity for the Total T eacher-Report Impairment Rating Scale..................24 Discriminative Validity for the Adaptive Functioning Subscale............................................25 Discriminative Validity for the Academic Functioning Subscale..........................................25 Discriminative Validity for the Social Functioning Subscale................................................25 Construct Validity............................................................................................................. ......25 4 DISCUSSION..................................................................................................................... ....31 LIST OF REFERENCES............................................................................................................. ..36 BIOGRAPHICAL SKETCH.........................................................................................................39

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5 LIST OF TABLES Table page 2-1 Items from the Teacher-Re port Impairment Rating Scale.................................................22 3-1 Demographic Data........................................................................................................... ..27 3-2 Intercorrelations between T-IRS Subscales.......................................................................28 3-3 Comparison of T-IRS Mean Scale Scores between the ADHD and Non-ADHD Groups......................................................................................................................... .......29 3-4 Correlations between Symptom Severity Ra tings as Indexed by the Conners Parent Rating Scale (CPRS) and T-IRS Measures of Impairment................................................30

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6 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PRELIMINARY DEVELOPMENT OF THE TE ACHER-REPORT ADHD IMPAIRMENT RATING SCALE By Katherine Elizabeth Kiker May 2007 Chair: James H. Johnson Major: Psychology The Diagnostic and Statistical Ma nual of Mental Disorders, F ourth Edition, requires that a child shows evidence of clinical ly significant impairment in so cial, academic, or occupational functioning, in addition to ADHD symptomology, in order for a di agnosis of Attention-Deficit Hyperactivity Disorder to be made. Additionally, impairment mu st be present across several settings. The paucity of appropriate impairmen t measures led to the creation of The Child Impairment Rating Scale, a parent-completed sc ale that measures ADHD-related impairment in the domains of adaptive, academic, social, and home/family functioning. The present study sought to evaluate the psychometric properties of the Teacher-Report Impairment Rating Scale (T-IRS), the teacher version of the C-IRS that measures ADHD-related impairment in the school setting in the domains of ad aptive, academic, and social functioning. Preliminary results supported the measures internal consistency and di scriminative validity. Further recruitment of subjects is necessary to examine the scales te st-retest reliability and construct validity, and bolster the generalizability of the findings.

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7 CHAPTER 1 INTRODUCTION The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV: American Psychiatric Association, 1994), esti mates the prevalence rate of Attentiondeficit/hyperactivity disorder to range from 3 to 5% in schoo l age-children. Given the high prevalence of ADHD, extensive time is dedicated to assessing and treating the disorder by health care professionals, including fam ily practitioners, pediatricians, psychiatrists, neurologists, psychologists, and school psychologists Health care professionals in the United Stat es commonly use the gui delines presented in DSM-IV in diagnosing the various subtypes of ADHD; the predom inantly inatten tive type, the predominantly hyperactive/impulsive type and the combined type. The ina ttentive type of ADHD is characterized by difficulty sustaining attention in tasks or play activities, forgetfulness, losing necessary things, making careless mistakes, diffi culty organizing tasks and activities, being easily distracted, not listening, a nd failing to finish schoolwork, chores, or work duties. The hyperactive/impulsive type of ADHD is characte rized by symptoms of h yperactivity (fidgeting, inability to remain seated, rest lessness, excessive talking, difficu lty engaging in quiet activities, and often being on the go) as we ll as symptoms of impulsivity (blurting out answers, difficulty awaiting turn, and often interrupt ing/intruding on others.) The combined type of ADHD is characterized by symptoms of both ina ttention and hyperactivity/impulsivity. In order to establish a diagnosis of ADHD, the c linician must ensure that the child displays developmentally inappropriate levels of inatte ntion and/or hyperactivit y/impulsivity that are observed across situations, that the onset of symp toms was before 7 years of age, and that the symptoms have occurred apart from other mental disorders such as Pervasive Developmental Disorder, Schizophrenia, or Psyc hotic Disorder. To diagnose the predominately inattentive type

PAGE 8

8 of ADHD, 6 or more symptoms of inattention must have been present for at least 6 months. For the predominantly hyperactive/impulsive ty pe of ADHD, 6 or more symptoms of hyperactivity/impulsivity must have been present. Finally, for a diagnosis of the combined type of ADHD, both 6 or more symptoms of in attentions and 6 or more symptoms of hyperactivity/impulsivity must have been present for at least 6 months. It is also the case that when an individuals symptoms do not meet the cr iteria for one of the subtypes of ADHD, and it is unclear whether these criteria have prev iously been met, a diagnosis of AttentionDeficit/Hyperactivity Disorder Not Otherwise Specified can be made. The criteria for a diagnosis of ADHD also require that the child shows evidence of clinically significant impairment in social, acad emic, or occupational functioning and that some impairment is seen in two or more settings. It can be noted that the re quirement that symptoms and impairment be present across multiple situati ons is new to DSM-IV and serves to minimize making inappropriate diagnoses in those situat ions where symptoms may be the result of situational factors. Although the assessment of ADHD symptoms a nd impairment is required for diagnosis, more emphasis has generally been placed on the importance of obtaining information about ADHD symptoms, rather than obtaining inform ation about impairment. There are numerous measures, such as the ADHD rating scale (DuPau l, 1991), Child Behavior Checklist (Achenbach, 1991), the Behavior Assessment System for Children (Reynolds and Kamphaus, 1992), and the Revised Conners Parent and Teacher Rating Scal es (Conners, 1997) that measure the frequency and severity of ADHD symptoms in children and adolescents. There are also computerized measures, such as the Conners Continuous Perf ormance Test (CPT; Conners, 1994) to directly assess attention problems.

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9 There are also other methods used to measure ADHD symptoms. Structured and semistructured interviews are often used for th e diagnosis of ADHD within a research context. These interviews can be used to diagnose multiple disorders and are recommended by experts for the diagnosis of ADHD (Lahey & Wilcutt, 2002). Commonly used st ructured interviews include the Diagnostic Interview for Children and Adol escents Revised (DICA-R; Reich & Welner, 1988) and the Diagnostic Interview Schedule for Children Version IV (DISC-IV; Shaffer, Fisher, & Lucas, 2000). Semistructured interviews used to diagnose ADHD include the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL: Kaufman et al., 1997) and the Child and Adolesce nt Psychiatric Assessment (CAPA; Angold & Costella, 2000). Unlike the structured interviews there is little published reliability data on semistructured interviews for children with ADH D. Although these interviews may be effective in diagnosing ADHD, they are lengt hy measures that must be admi nistered by trained clinicians or researchers; thus, they may not have much utility in a clinical setting where a thorough, efficient, and timely diagnos is of ADHD must be made. Another method of gathering information about the ADHD symptomatology that children exhibit is by using observationa l measures such as Classroom Observations of Conduct and Attention Deficit Disorders (COCADD; Atkins, Pelham, & Licht, 1985), Classroom Behavior Code (Abikoff et al., 1977), and Playroom Ob servations (Milich, Loney, & Landau, 1982). These observational measures exhibit acceptable re liability and validity in both clinical settings and natural settings. There is also evidence th at these observational measures discriminate between children with and without ADHD (Fabia no et al., 2004). Despite the usefulness of observational measures in diagnosing ADHD, it is important to note that they are extremely time-consuming and therefore not pract ical in a clinical setting.

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10 The measures reviewed thus far have focused on the diagnosis of ADHD via ADHD symptomatology. However, the DSM-IV requires that a child show evidence of clinically significant impairment in social, academic, or occupational functioning and that some impairment is seen in two or more settings in order to make a diagnosis of ADHD. Indeed, it has been argued that more focus should be placed on the assessment of ADHD related impairment, rather than ADHD symptoms, beyond the initial diagnostic phase. Children are generally referred for diagnosis because of their impaired functioning in different domains, rather than solely exhibiting ADHD symptoms (Pelham, 2004). ADHD core symptoms may improve with age, but impairment and related difficulties tend to continue into adulthood. Adults diagnosed with childhood ADHD have been found to have si gnificantly fewer years of education, lower job performance ratings from their employer, and mo re arrests than controls (Barkley, Fisher, & Smallish, 2006). They also continue to exhibit po orer social skills and exhibit more antisocial personality characteristics than controls (Manuzza & Klein, 2000). In fact, the three areas of psychosocial im pairment common in ADHD children family functioning, peer relationships, and academic fu nctioningare predictive of negative long-term outcome and are the target behaviors that must be modified in order to improve both current and long-term functioning (Pelham, 2004). Children with ADHD have been found to be impaired in multiple areas of functioning, including social, academic, and adaptive func tioning. Boys and girls with ADHD have been found to be deficient in their social functio ning (Gaub & Carlson, 1997). Relative to children without ADHD, those diagnosed with this disorder are, as a group, less so cially preferred, have fewer friends, and are more often rejected by p eers (Hoza, Mrug, & Gerdes, 2005). Peer rejection for ADHD youths also tends to continue into adolescence (Bagwell et al., 2001). Compared to

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11 other children in the classroom environment, children with ADHD are more off-task, complete less assigned work, have lower levels of academic achievement, break classroom rules, and have more problems with their teachers (Atkins et al ., 1985). In addition, problems with attention may lead to failure to progress academically over time. Also, adaptive functioning skills, which refer to a childs ability to perform independent behaviors and appropriate skills for daily activ ities, have been found to be much lower for children with ADHD than control groups (Lahey et al., 1998). Indeed, children with ADHD score lower in the areas of so cialization, communication, and da ily living in comparison with children diagnosed with Pervasive Developmental Disorder or Mental Retardation. Children with larger impairments in adaptive functioning appear to have a poorer prognosis for the disorder (Stein, Szumowski, & Blondis, 1995). Our review of research highlighting ADHD rela ted impairment in the areas of academic, adaptive, and social functioning po ints to the need for increased attention to the assessment and treatment of impairment in individuals with ADHD. In the past, clinicians relied upon the judgment of parents and teachers to determine le vels of ADHD related impairment. However, a more systematic and thorough assessment of ch ildrens every-day, functio nal abilities in the home and school environments ar e needed (Gaub & Carlson, 1997). Currently, there are several available measures that examine global/ overall impairment of children, and a couple that measure impairment in specific domains of functioning. The Child and Adolescent Functional Assessment Scal e (CAFAS; Hodges, 1990) and Childrens Global Assessment of Functioning (CGAS; Bi rd et al., 1987) are clinicianadministered measures that examine global impairment due to emotional, be havioral, and psychiatric problems. The CAFAS consists of 5 child scales: Role Performance, Thinking, Behavior Towards Self and Others,

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12 Moods/Emotions, and Substance Use. For each scal e, problems are rated on a four point Likert scale where 0 corresponds to minimal or no di sruption, and 3 correspon ds to severe. The CGAS is a scale that asks rate rs to rate the child in questi on from 0-100 on a continuous scale of impairment, where 100 corresponds to Superior functioning in all areas and 0 corresponds to Needs 24-hour care. Both of these measures ha ve been used with ADHD samples, but they also measure impairment stemming from other psychological disorders. Although global measures of impairment may be useful, measures of impairment that report functioning in key domains (such as peer family, and school) as well as globally have more treatment utility than nonsp ecific global measures of impairment (Pelham et al., 2005). In the past, researchers typically adapted impairment -related scales, which are constructed for other purposes, when studying specific impairment in children with ADHD (Gaub and Carlson, 1997). However, many impairment-related subscales tend to assess be haviors that define ADHD itself; therefore, they should not be used as independent measures of impa irment (Lahey et al., 1998). There have been several recent advancements in the development of impairment rating scales. Fabiano and Pelhams Impairment Rating Scale (IRS; 2002) asks teachers and parents to rate the impact of a childs problems on a cont inuous scale across severa l areas of functioning (relationships with peers, family and teachers; academic achievement; self-esteem) and to produce a written description of the childs problems. The ps ychometric properties of the Impairment Rating Scale were measured in 4 samples. Two included ADHD and matched comparison children and the other 2 included a sc hool sample. Preliminary evaluations of both the parent and teacher scales (Fabiano & Pelham 2002) supported the test-retest reliability of these measures, their ability to discrimi nate between ADHD and non-ADHD groups, and their correlations with other measures that assess the same construc t using different methods of

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13 measurement. Although the IRS has only 6-7 ques tions, depending on the version, the narrative portion makes it more difficult to score. In additi on, the IRS asks raters to rate children on an overall domain of functioning, rather than individu al items that make up a domain. Therefore the IRS may be less desirable in settings where a brief, easy-to-administer, quantitative index of impairment is preferred. The paucity of impairment measures has rece ntly led to the creation of an additional measure, the parent version of the Child Im pairment Rating Scale (C-IRS) by McAlister and Johnson (2004), at the University of Florida. This scale was one of the first of its kind to provide a brief and easy to complete measure of ADHD -related impairment in the home environment. The C-IRS is a 32-item scale that measures impairment in 4 different domains: adaptive functioning, social functioning, academic functi oning, and functioning in the home and family environment. In the preliminary study, the C-IRS demonstrated good psychometric properties. Cronbachs alpha for the entire scale equaled .94, and alpha levels for the Adaptive behavior, Academic, Social, and Home/Family Functioning subscales were high (range = .74 .86). With respect to reliability, item-level analyses revealed that the C-IR S items adequately discriminated between children with low total scores and childr en with high total scores on this measure. Results also demonstrated signifi cant test-retest reliability over a 2-3 week interval for the parents of children with ADHD. The test-retes t reliability coefficient was .92 for the overall total scale, .87 for the Adaptive Functioni ng subscale, .78 for the Academic Functioning subscale, .90 for the Social Functioning subs cale, and .81 for the Home/Family Functioning subscale (all p < .01).

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14 Despite the potential usefulness of this parent measure, it is also important to document evidence of impairment in the school environment. Indeed, this is a requirement of the current DSM-IV diagnostic criteria. As previously di scussed, Fabiano & Pelham (2002) demonstrated good psychometric properties for the teacher ve rsion of their Impairment Rating Scale. Additionally, the Vanderbilt Rating Scale (Wolraich et al., 2003) is a teacher scale designed to measure ADHD, Oppositional Defiant and Conduc t Disorder, and Anxiety and Depression symptoms, and has demonstrated good psychometric properties. However, the Vanderbilt Rating Scale has 35 items, of which only 8 are rela ted to ADHD impairment; 3 items related to academic impairment and 5 items related to classroom behavior. Therefore there is a need for an instrument that can quickly and efficiently measure ADHD-related impairment in the sch ool setting, as this is necessary for an accurate diagnosis of ADHD. The present study represents an attempt to fill this clinical and research void by developing a teacher-report child ADHD impairment scale (the T IRS). This study examined the scales psychometric properties, including its internal consistency, test-retest reliability, and discriminate validity. Given the assumption that severity of ADHD symptoms would relate to degree of impairment, the study also examined whether impairment scores on the T-IRS were correlated with symptom severity as measured by scales on the Conners Parent Rating Scale (The ADHD Index, DSM-IV Inatte ntive scale, DSM-IV Hyperac tive-Impulsive scale, DSM-IV Total scale). The development of a reliabl e and valid ADHD impairment measure to be completed by teachers, such as the one describe d here, should assist clinicians in accurately diagnosing ADHD, and assist in measuring treatment outcomes.

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15 CHAPTER 2 METHOD Scale Development The teacher version of the Child Impairme nt Rating Scale was generated from the previously constructed parent version on this measure (C-IRS : McAlister & Johnson, 2004). To develop the parent version, a lis t of items related to impairme nt in the domains of adaptive behavior, academic and school functioning, and social and family functioning was generated. This was done by surveying available measures that relate to these individual domains, by obtaining input from child clinical/pediatric psychologists re garding items that may reflect domain related impairment, and by obtaining clin ical data from parents of children with ADHD regarding examples of characteri stics that reflect impairment in these domains. After generating an initial item pool, items were reviewed by child clinical and pedi atric psychologists and advanced graduate students in clinical child ps ychology in an attempt to minimize item overlap, ambiguous item content, and to eliminate items that were not viewed as re levant to the specific domains being assessed. Of the remaining items, the 8 most non-redundant and most representative items for each subscale were reta ined, for a total of 32 items. Half of the items were worded in a positive direction, and half th e items were worded in a negative direction to minimize the utilization of response sets. The format of the scale asks the parent to determine how often thei r child experiences the described circumstance on a continuum from 0-3; 0 being almost never and 3 being almost always. The parent version of the Impairment Rating Scale (C-IRS) was administered to 38 parents of children with ADHD and 46 parents of children without the disorder. All of the children were within the ages of 5 and 13 y ears old. Analyses indicated that the C-IRS impairment indices reliably differentiated betw een children with and without ADHD. There was

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16 also good test-retest reliability over a 2-3 week interval and ev idence of adequate internal consistency. The teacher version used the 8 items in each subscale designed to measure levels of impairment in adaptive behavior and in sc hool/academic and social functioning. The family functioning subscale was excluded, as teachers are not expected to be able to adequately rate children on family related items as they likely se e the children only in the school environment. Table 2-1 shows the items in the T-IRS. Procedures Approval to conduct the study was first obtained from the IRB. Upon approval, parents of children with ADHD were approached through the Ps ychology Clinic to dete rmine their interest in participating in the study. These parents were at the Psychology Clinic for previously scheduled ADHD evaluations for their children ba sed on referral to the clinic by physicians or parents. Out of 24 parents of children with ADHD approached, a total of 3 parents declined to participate. Fliers to recr uit children without ADHD were pos ted at Shands Hospital and on community bulletin boards; therefore a rate of noninterest could not be determined. Parents of both groups of children (ADHD and non-ADHD) were asked to complete questionnaires with regard to one of their children. In either group, if parent had more than one child that fit the study criteria, they were asked to se lect one child on which to make responses. Parents and teachers in both groups were informed of the confidentiality of their responses as well as their ability to receive feedback about the results of the study upon its completion, if so desired. Parents in the ADHD group were given an informed consent form, a demographic information sheet, and a Child Impairment Rating S cale (the parent form). For the purposes of this study, the informed consent incorporated perm ission from the parent to use data from their childs clinical assessment, incl uding the Conners Parent Rating Scale, as well as information

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17 related to the diagnosis. It also asked the parents to grant permission to allow the childs teacher to be contacted and asked to complete the Teacher-Report Impairment Rating Scale. The demographic sheet asked parents for general information (such as name, address, phone numbers, childs date of birth and gender, fa mily income), the type of ADHD diagnosis (if known), and whether the child had been forma lly diagnosed with any other psychological condition. After the parents signed a consent form allowing the teach er to fill out the T-IRS, we mailed a copy of the T-IRS to the school along with a postage-paid envelope, which teachers completed, and then mailed back to us. After a 23 week interval, teacher s were again mailed the T-IRS for the test-retest phase of the study. We chose this time period for the test-retest phase because it is thought that adequate time would have passed so th at teachers would not remember their previous answers, and that other factors would not have resu lted in changes in the childs level of impairment. Parents in the normal comparison group were give n an informed consent that explained the nature of the study, issues of confidentiality, and which also asked permission to give the T-IRS form to the childs teacher. These parents were also given a copy of the C-IRS and a demographic information sheet to complete. Parents who expressed their willingness to participate in the study were either sent materials directly in the mail or, if the parent was located in close proximity to the hospital, a study investig ator brought materials to that location in order to have them completed. Teachers were maile d the T-IRS initially after the parents gave permission, and again after 2-3 weeks for the test-re test phase of the study. Parents in this group were also compensated 5 dolla rs for their participation. Participants A sample of 43 children was initially recru ited. However, 5 teachers of children with ADHD and 2 teachers of children without ADHD di d not return the T-IRS; therefore these

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18 subjects were excluded from all analyses. Therefor e our final sample for a ll analyses consisted of 16 children with ADHD (mean age of 8.87) a nd 20 children without ADHD (mean age of 9.95). All children were between the ages of 5 and 14. The ADHD sample consisted of 11 boys and 5 girls. Of these, 2 children were diagnosed with the Inattentive Type of ADHD, and 14 children were diagnosed with the Combined Type of ADHD. The non-ADHD sample included 10 boys and 10 girls. The mean income for the ADHD sa mple was $68,277 and the mean income for the non-ADHD sample was $78,500. Table 3-1 shows demographic data. Children with ADHD were recruited from th e psychology clinic of the Department of Clinical and Health during thei r scheduled appointments. Here children were evaluated by a licensed, board-certified Clinical Child Psychol ogist. Only those give n a diagnosis of ADHD were included in the present study. The evaluations consisted of a detailed diagnostic interview, intellectual and achievement testing, parent and teacher-report measures to assess symptoms of ADHD and possible comorbid conditi ons, computerized testing of attention problems, and other testing as needed. Children without ADHD were recruited through flie rs posted in Shands Hospital and on community bulletin boards. The children diagnosed with ADHD had one of three sub-types: predominantly inattentive type, predominantly hyperactive/impulsive type or combined type. Exclusion criteria for children in the ADHD group included the presence of Pervasive Developmental Disorder, Psychotic Disorder, or diagnosed learning disability. Children with learni ng disabilities were excluded because teachers may rate children with these di sorders as having more impairment, reflective of their learning disability, ra ther than ADHD. Exclusion cr iteria for the non-ADHD children included a diagnosis of ADHD or pa rent report of any other clinic al disorder. We attempted to match closely for family income, age, & sex, a nd were successful, as no significant differences

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19 emerged between groups on these variables. Pa rents were financially compensated $5 for completing the study. Statistical Analyses The first aim of this study was to document the internal consistency for the Teacher-Report Impairment Rating Scale (T-IRS) and its subscales in order to measure the extent to which subscales and items within subscales correlate with each other. Item-t otal correlations and Cronbachs alpha were calculated for the entire sample of partic ipants. It was hypothesized that the T-IRS would show adequate to good internal consistency, and that the item-total correlations would be moderately high and that all of the items in the T-IRS, and the subdomains, would show high homogeneity. The second aim sought to document the test-retes t reliability for the TIRS over a 2-3 week interval, which was hypothe sized to be high. A P earsons product moment correlation coefficient was calculated for T-IRS scores of children with ADHD. The third aim sought to assess whether scores on the T-IRS discriminate between children with and without ADHD. It was hypothesized that T-IRS scores would be significantly higher for children with ADHD than children without ADHD, demonstrating its utility as a diagnostic assessment instrument. For this aim, ANOVAs we re run to examine the differences between groups on scores on the entire T-IRS and each subscale. The final aim was to document the relati onship between indices of ADHD symptom severity and the degree of rated impairment in the ADHD group. It was hypothesized that there would be a significant positive correlation between indices of ADHD symptom severity and the degree of rated impairment in the ADHD gr oup. A Pearsons product moment correlation coefficient was run, and symptom severity indi ces were obtained from scores on the Conners Rating Scales completed by the parent at the ti me of the childs init ial ADHD evaluation. Scores

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20 on the Conners ADHD Index, the DSM-IV Inatte ntive subscale, the DSM-IV HyperactiveImpulsive subscale, and the DSMIV Total subscale were used. Measures The Teacher-Report Impairment Rating Scale (T-IRS): The T-IRS and its respective psychometrics are the focus of the current study. Th is 24-item teacher-report scale is divided into 3 subscales; adaptive functioning, academic functioning, and social functioning. Items included in this measure are presented in Appendix A. The format for responding to this measure asks teachers to determine how often the child ex periences the describe d circumstance on a continuum from 0-3; 0 being almost never and 3 being almost always. The Child Impairment Rating Scal e (C-IRS; McAlister & Johnson, 2004): This 32item self-report scale was the first of its kind to provide a brief and easy to complete measure of ADHD-related impairment in the home environm ent. As was suggested earlier, preliminary findings with the C-IRS demonstrated good ps ychometric properties, including adequate discriminate validity between children with a nd without ADHD, good test-r etest reliability over a 2-3 week interval, and ade quate internal consistency. The Conners Parent Rating Scale Revised (CPRS-R; Conners, 1997) : This measure contains 80 items and assesses behaviors rela ted to hyperactivity, im pulsivity, attention problems, conduct problems, cognitive problems, a nxiety problems and social problems. The directions request parents to c onsider the childs behavior duri ng the past month, and responses are given on a Likert scale, rang ing from 0, not at all true, to 3, very true. The ADHD Index is considered to be the most useful score fo r discriminating children with ADHD from a nonclinical sample, and DSM-IV Symptoms subs cales (DSM-IV Inattentive Scale; DSM-IV Hyperactive-Impulsive Scale) correspond with the DSM-IV ADHD symptoms. Research has provided considerable psychometric support for the CPRS-R, including excellent internal

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21 consistency, high test-retest re liability, and good discriminative power between clinical and nonclinical children (Conners et al., 1998).

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22 Table 2-1: Items from the Teacher-Report Impairment Rating Scale Adaptive Functioning 1. Needs close supervision 2. Shows appropriate levels of independent behavior 3. Adapts poorly to new situations 4. Shows inappropriate level of self-care 5. Is persistent in dealing with difficult tasks 6. Shows good common sense 7. Shows poor planning abilities 8. Shows appropriate concerns for safety Academic Functioning 9. Is disorganized in dealing with academic tasks 10. Meets academic time demands 11. Fails to complete or turn in assigned homework 12. Requires discipline at school 13. Shows respect for school property 14. Has unexcused absences 15. Performs well on academic tasks 16. Has good relationships with teachers Social Functioning 17. Is ignored or rejected by peers 18. Shows respect for the feelings of others 19. Displays good social skills 20. Seems socially immature 21. Shows lack of resp ect for the property of peers 22. Has good relationships with peers 23. Has problems participating in groups/games 24. Relates poorly to adults

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23 CHAPTER 3 RESULTS Internal Consistency Intercorrelations between th e three T-IRS subscales ranged from .60 to .87. Table 3-2 shows them. Corrected item-total correlations which reflect how well items discriminate between respondents with a low score and responde nts with a high score, were calculated for the total scale (containing 24 items) as well as for th e three individual subscale s (each consisting of 8 items). The mean corrected item-total correl ation for the total Teach er-Report Impairment Rating Scale was .71 (range = .50 .89). The item w ith the best discriminating ability for the full scale was Shows appropriate levels of independent behavior, wh ile the item with the smallest discriminating ability was Has unexcused absences . Cronbachs coefficient alpha for the total scale, calculated from 36 fully completed measures, was .96. The mean corrected item-total correlati on for the Adaptive Functioning subscale was .77 (range = .50 .90). The item with the highest abil ity to discriminate betw een respondents with a high and low score was Shows appr opriate levels of independent behavior, while the item with the lowest discriminating ability was adapts poo rly to new situations. Cronbachs coefficient alpha was .93 for this subscale, calcu lated from 36 completed measures. The mean corrected item-total correlation for the Academic Functioning subscale was .69 (range = .52 .86). The item Performs well on academic tasks had the best discriminating power while the item Has unexcused absences demonstrated the poorest discriminating ability. Analyses of 36 measures resulted in a coefficient alpha of .88. The mean item-total correlation for the Soci al Functioning subscale was .79 (range = .57 .88). The item with the best discriminating power was Displays good social skills and the item

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24 with the poorest discriminating power was shows re spect for the feelings of others. Analyses of 36 measures resulted in a coefficient alpha of .94. Test-Retest Reliability Due to a lower than expected return rate, only a small sample of six teachers of children with ADHD returned a second copy of the T-IRS after an interval of 2-3 weeks. This small sample size clearly does not allow a confident measurement of the te st-retest reliability for the TIRS. However, these very preliminary findings do suggest good test-retest reliability for the small sample. The test-retest reliability coeffici ent was .98 for the overall total scale, .87 for the Adaptive Functioning subscale, .78 for the Academic Functioning subscale, and .95 for the Social Functioning subscale (all p < .01). It is hypothe sized that with continued recruitment, a more accurate estimate of the scales test-retest reliability will emerge. Discriminative Validity for the Total Te acher-Report Impairment Rating Scale The second aim of the study was to assess wh ether scores on the T-IRS discriminate between children with and without ADHD. Here, t-te sts were initially run to determine if there were differences between the ADHD and non ADHD groups in terms of age, sex, or family income. No significant differences emerged be tween children with and without ADHD on any of these variables. An Analysis of Variance ( ANOVA) was subsequently conducted to evaluate whether scores from the total T-IRS differentia ted between teachers ratings of children with ADHD and ratings of children without ADHD. Ther e were significant diffe rences between these two groups, F (1,34) = 82.24, p < .001; teachers of children with ADHD ( M = 27.20, SD = 7.65) indicated higher levels of overall child impair ment than teachers of children without ADHD ( M = 4.65, SD = 6.99). The effect size, measured using Cohens d was 1.68, and statistical power was .99. Table 3-3 shows the cont rasts between the ADHD and non-ADHD group.

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25 Discriminative Validity for the Adaptive Functioning Subscale An ANOVA was conducted to determine whethe r or not teachers of children with ADHD and teachers of children without ADHD differed in terms of their scores on the Adaptive Functioning subscale of the T-IRS. The ANOVA yielded significant results, F (1,34) = 102.87, p < .001, Cohens d = 1.73, power = .99. Teachers of children with ADHD ( M = 10.60, SD = 2.95) displayed significantly higher mean scores on ad aptive impairment than teachers of children without ADHD ( M = 1.70, SD = 2.25). Discriminative Validity for the Academic Functioning Subscale An ANOVA was conducted to determine whethe r or not teachers of children with ADHD and teachers of children without ADHD differed on scores on the Academic Functioning subscale. The results were significant; F (1,34) = 54.77, p < .001, Cohens d = 1.57, power = .99. Teachers of children with ADHD ( M = 8.93, SD = 3.33) had significantly higher scores than teachers of children without ADHD ( M = 1.60, SD = 2.54). Discriminative Validity for th e Social Functioning Subscale An ANOVA was conducted to determine whethe r or not teachers of children with ADHD and teachers of children w ithout ADHD significantly differe d on scores on the Social Functioning subscale. The re sults were significant, F (1,34) = 25.66, p < .001, Cohens d = .1.31, power = .98. Teachers of children with ADHD ( M = 7.67, SD = 4.71) had significantly higher scores than teachers of children without ADHD ( M = 1.35, SD = 2.60). Construct Validity Pearson product-moment correlation coefficients were calculated in order to determine the strength and direction of the relationship betw een scores on selected scales of the Conners Parent Rating Scale (The ADHD Index, DSM-IV Inattentive scale, DSM-IV HyperactiveImpulsive scale, and DSM-IV Total scale) and th e T-IRS. Data from completed Conners Parent

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26 Rating Scales were available for 15 parents of children with ADHD. Scores on the Social Functioning subscale positively correlated with scores on the DSM-IV Hyperactive-Impulsive subscale (r=.57, p<.01); increased levels of hyperactive-impulsive symptomatology was significant correlated with higher levels of impair ment in social functioning. No significant correlations were found between scores on the C onners Parent Rating Scales and scores on the adaptive and academic functioning subscales of the T-IRS. Table 3-4 shows the bivariate correlation coefficients and their associated p -values.

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27 Table 3-1: Demographic Data n M SD Child Age Non-ADHD 20 9.95 2.56 ADHD (Total) 16 8.87 2.76 ADHD (Subtypes) Combined 14 8.75 2.86 Inattentive 2 8.00 2.83 Child Gender Non-ADHD Boys 10 Girls 10 ADHD Boys 11 Girls 5 Parent Respondent Non-ADHD Mothers 18 Fathers 2 ADHD Mothers 15 Fathers 1

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28 Table 3-2: Intercorrelations between T-IRS Subscales Subscale Adaptive Academic Social Adaptive -.81** .87** Academic -.60** Social -**p<.01

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29 Table 3-3: Comparison of T-IRS Mean S cale Scores between the ADHD and Non-ADHD Groups ADHD Non-ADHD M SD M SD F(1) d (1) Total 27.20 7.66 4.65 6.99 82.24***1.68 0.99 Adaptive 10.60 2.95 1.70 2.25 102.87***1.73 0.99 Academic 8.93 3.33 1.60 2.54 54.77***1.57 0.99 Social 7.67 4.72 1.35 2.60 25.66** 1.31 0.98 *** p < .001; ** p < .01. Cohens d = Effect size. (1) = Power estimate.

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30 Table 3-4: Correlations between Symptom Severity Ratings as Indexed by the Conners Parent Rating Scale (CPRS) and T-IRS Measures of Impairment T-IRS CPRS ADHD index CPRS DSM-IV inattentive CPRS DSM-IV hyperactiveimpulsive CPRS DSM-IV total Total -.24 -.30 .41 .04 Adaptive -.15 -.13 .44 .19 Academic -.34 -.41 -.24 -.46 Social -.05 -.13 .57* .27 N = 15. p < .05.

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31 CHAPTER 4 DISCUSSION For a child to be diagnosed with ADHD, the DS M-IV (1994) requires th at the child display developmentally inappropriate levels of inatte ntion and/or hyperactivit y/impulsivity that are observed across situations. Diagnostic criteria al so require that the child shows evidence of clinically significant impairment in social, academ ic, or occupational functioning seen in two or more settings. The addition of DSM-IV impairme nt criteria represents a significant improvement over previous editions of the Diagnostic and Statis tical Manual of Mental Disorders. Clinicians have argued that following a diagnosis of ADHD, impairment (rather than symptoms) is more predictive of negative long-term outcomes (Pelham, 2004). Clinicians have previously re lied on the verbal reports of pa rents and teachers to document ADHD-related impairment. However, as noted by Gaub and Carlson (1997), a more systematic and thorough assessment of childrens every-day, functional abilities in the home and school environments are needed. Although a few impairment measures exist, none of them fulfill the need for an instrument that can quickly a nd efficiently measure ADHD-related impairment. A previous study by McAlister & Johnson (2004) creat ed the C-IRS, a 32 item parent-report scale designed to measure the impact of inattenti on and hyperactive-impulsive symptoms on child impairment in several key areas (adaptive f unctioning, academic functioning, social functioning, and home/family functioning.) Analyses of the scales psychometric properties supported the measures internal consistency, test-retest relia bility, and discriminative and construct validity. As it is a requirement of diagnosis that ADHD-related impairment be documented across several settings, the present study attempted to develop and evaluate the psychometric properties of the Teacher-Report Impairment Rating Scale (T -IRS). This 24-item scale, derived from the CIRS (McAlister & Johnson, 2004) co ntained 3 subscales to meas ure impairment; the adaptive

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32 functioning subscale, academic functioning subscale, and social function ing subscale. The home/family functioning subscale from the C-IRS wa s eliminated from the T-IRS as teachers do not typically view childre n in the home setting. Initial data collected thus far suggest that sc ores on each of the th ree subscales of the TIRS, as well at the entire scal e, reliably differentiate between children with and without ADHD. Cronbachs alpha for the entire scale equaled .96. Cronbachs alphas for the three subscales were also high, ranging from .88 to .94. Also, item-level analyses i ndicated that individual items within each subscale, and the en tire scale, differentiated betw een children with high and low scores on the T-IRS. Items with the highest discriminative ability were items thought to broadly encompass each subdomain, such as shows appropr iate levels of independent behavior, performs well on academic tasks, and displays good social skills. In contrast, items with lower discriminative ability were items measuring specific aspect s of a domain of functioning, such as has unexcused absences, and shows resp ect for the feelings of others. However, all item-total correlations for the T-IRS exceeded .5 0. Because of our small sample size, further recruitment of children with and without ADHD is necessary in or der to increase support for our findings. Due to the difficulty of getting teachers to retu rn the T-IRS, data from only 6 subjects were included in the test-retest reliability analyses. A lthough this is not an adequate sample size to provide support for the test-retest reliability of our measure, it is important to note that the findings from this preliminary analyses suggest that with more subjects, the scale will likely demonstrate good test-retest reliability. The test -retest reliability coefficient was .98 for the overall total scale, .87 for the Adaptive Functio ning subscale, .78 for the Academic Functioning subscale, and .95 for the Soci al Functioning subscale (all p < .01).

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33 In terms of discriminative validity, scores on the T-IRS indicate that the scale distinguishes between children with and without ADHD. Mean scores for the entire scale, as well as each of the three individual subscales, were substantially higher for children with ADHD (all p<.001). Despite a small sample size, effect sizes for each analysis were very high, indicating that the magnitude of differences of scores between children with and without ADHD was very high. While is was expected that measures of ADHD symptom severity would correlate highly with indices of impairment, findings in this area were limited in the present study. Significant correlation was found between scores on the DS M-IV Hyperactive/Impulsive scale of the Conners Parent Rating Scale and scores on the social functioni ng subscale of the T-IRS. It makes sense that children w ith hyperactive/impulsive symptomatology would display impairment in the social func tioning domain. No other significan t correlations emerged between scores on the T-IRS subscales and Conners Parent Rating Scale. Th is lack of other significant correlations may be attributable to the small samp le size. Given the magnitude of several of the correlations obtained, with furthe r recruitment of subjects, we might expect to see more significant correlations between symptom seve rity and degree of rated impairment. Psychometric findings from the present study ar e in line with those found for the C-IRS, the parent version of our measure. Both meas ures provided support for the scales internal consistency and discriminative validity. However, the C-IRS also found si gnificant correlations between indices of symptom severity resul ting from inattentive and hyperactive-impulsive symptomatology with both academic and soci al impairment. In addition, inattentive symptomatology was significantly correlated with academic impairment. As previously suggested, the primary limitati on of the current study is the small sample size used in determining reliability and validity estimates. Further recruitment is necessary to

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34 strengthen and bolster the genera lizability of our findings, especia lly for our analyses of testretest reliability. However, the present study did find significant effects fo r internal consistency and discriminative validity, thus providing prelim inary support for its usefulness in measuring ADHD-related impairment in the school environment. In addition to a small sample size, our study primarily included children with Combined Type ADHD (n=14) and only a few children wi th Inattentive Type ADHD (n=2). Further recruitment of children with In attentive Type ADHD would allow us to examine differences in impairment between children with Inattentiv e and children with Combined Type ADHD. In conclusion, the present study provided good preliminary support for use of the T-IRS in discriminating between children with and w ithout ADHD in terms of measuring ADHD-related impairment in the domains of adaptive functioning, academic functioning, and social functioning. As such it highlights it s potential to assist clinicia ns in accurately diagnosing ADHD and measuring treatment outcomes. Limitations of previously constructed impairment measures are that they measure global impairment, rath er than specific ADHD-related impairment, and they are lengthy and time consuming to complete The T-IRS is a measure that has the potential to quickly and efficiently measure ADHD-rela ted impairment in the school setting. Future directions for research with the T -IRS would include recruiting a much larger sample in order to bolster the psychometric pr operties of the measure, developing preliminary norms for the measure, and determining validat ed cutoff scores for the T-IRS in order to determine mild, moderate, or severe levels of impairment. Examining the relationship between parent-reported levels of impairment on the C-IRS and teacher-reported levels of impairment on the T-IRS and conducting a factor analyses to pinpoint the specific dimensions of the T-IRS would also be important. We expect that the T -IRS will prove useful as a clinical scale for

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35 measuring ADHD-related impairment in the school setting. Therefore, w ith the use of both the T-IRS and the parent measure, the C-IRS, more accurate diagnoses of ADHD can be made in the clinical setting.

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36 LIST OF REFERENCES Abikoff, H., Gittelman-Klein, R., & Klein, D.F. (1977). Validation of a classroom observation code for hyperactive children. Journal of Consulting and Clinical Psychology 45, 772783. Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile Burlington: University of Verm ont, Department of Psychiatry. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Angold, A., & Costello, E.J. (2000). The Child a nd Adolescent Psychiatric Assessment (CAPA). Journal of the American Academy of Child & Adolescent Psychiatry 39, 39-48. Atkins, M.S., Pelham, W.E., & Licht, M.H. (1985). A comparison of objective classroom measures and teacher ratings of attention deficit disorder. Journal of Abnormal Child Psychology, 13(1), 155-167. August, G.J., Braswell, L., & Thuras, P. (1998) Diagnostic stability of ADHD in a community sample of school-age children sc reened for disruptive behavior. Journal of Abnormal Child Psychology 26, 345-356. Barkley, R.A., Fischer, M., Smallish, L., & Fletcher, K. (2002). The Persistence ofAttentionDeficit/Hyperactivity Disorder Into Young A dulthood as a Function of Reporting Source and Definition of Disorder. Journal of Abnormal Psychology 111(2), 279-289. Barkley, R.A.; Fischer, M., & Smallish, L. (2006). Young adult outcome of hyperactive children: Adaptive functioning in major life activities. Journal of the American Academy of Child & Adolescent Psychiatry 45(2), 192-202. Bagwell, C.L., Molina, B., Pelham, W.E., & Ho za, B. (2001). Attention-Deficit Hyperactivity Disorder and Problems in Peer Relations: Predictions from Ch ildhood to Adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 40(11), 1285-1292. Bird, H.R., Canino, G., Rubio-Stipec, M., & Ribe ra. J.C. (1987). Furt her measures of the psychometric properties of the Ch ildren's Global Assessment Scale. Archives of General Psychiatry, 44, 821-824 Conners, C.K. (1994). The Conners Continuous Performance Test. Toronto, Canada: Multi Health Systems. Conners, C.K. (1997). Conners Teacher and Parent Rating ScalesRevised Toronto: Multi Health Systems. Conners, C.K., Sitarenios, G., Parker, J. & Epstein, J.N. (1998). The revised Conner's Parent Rating Scale (CPRS-R): factor structure, reliability, and criterion validity. Journal of Abnormal Child Psychology 26(4), 257-269.

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37 Dupaul, G.J. (1991). Parent and teacher ratings of ADHD symptoms: Psyc hometric properties in a community-based sample. Journal of Clinical Child Psychiatry 20, 245-253. Fabiano, G.A., Pelham, W.E., Manos, M., Gna gy, E.M., Chronis, A.M., Onyango, A.N., et al., (2004). An evaluation of three time out pr ocedures for children with attention deficit/hyperactivity disorder. Behavior Therapy 35, 449-469. Fabiano, G.A. & Pelham, W.E. (2002). Measuring impairment in children with attention deficit hyperactivity disorder. The ADHD Report, 10, 6-10. Gaub, M. & Carlson, C. (1997). Behavioral char acteristics of DSM-IV ADHD subtypes in a school-based population. Journal of Abnormal Child Psychology, 25, 103-111. Hodges, K. (1990). Child and Adolescent Function al Assessment Scale. Ypsilanti, MI: Eastern Michigan University, Department of Psychology. Hoza B., Mrug, S., & Gerdes, A.C. (2005). What Asp ects of Peer Relationships Are Impaired in Children With Attention-Deficit/Hyperactivity Disorder? Journal of Consulting and Clinical Psychology 73(3), 411-423. Jensen, P.S., Watanabe, H.K., Richters, J.E., R oper, M., Hibbs, E.D., Salzberg, A.D., et al. (1996). Scales, diagnoses, and child psychopa thology: II. Comparing the CBCL and the DISC against external validators. Journal of Abnormal Child Psychology 24, 151-168. Johnston, C., & Mash, E.J. (2001). Families of children with attenti on deficit/hyperactivity disorder: Review and recomme ndations for future research. Clinical Child and Family Psychology Review 4, 183-207. Kaufman, J., Birhamer, B., Brent, D., Rao, U ., Flynn, C., Moreci, P., Williamson, D., et al. (1997). Schedule for Affective Disorders a nd Schizophrenia for School-Age Children Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry 36(7), 980-988. Lahey, B.B., Pelham, W.E., Stein, M.A., Lone y, J., Trapani, C., Nugent, K., et al. (1998).Validity of DSM-IV attention-defici t/hyperactivity disorder for younger children. Journal of the American Academy of Child & Adolescent Psychiatry 37, 695-702. Lahey, B.B., & Wilcutt, E.G. (2002). Validity of the diagnosis and dimensions of attention deficit hyperactivity disorder. In P. S. Jensen & J.R. Cooper (EDs.), Attention deficit hyperactivity disorder: State of the sciencebest practices (1-1 1-23). Kingston, NJ: Civic Research Institute. Manuzza, S., & Klein, R.G. (2000). Long-term prognosis in attention deficit/hyperactivity disorder. Child and Adolescent Psychiatri c Clinics of North America 9(3), 711-726. McAlister, L., & Johnson, J.H. (2004). Preliminary Development of the Child Impairment Rating Scale. Unpublished manuscript, University of Florida.

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38 Milich, R., Loney, J., & Landau, S. (1982). I ndependent dimensions of hyperactivity and aggression: Validation with playroom observation data. Journal of Abnormal Psychology, 91 183-198. Pelham., W.E., Fabiano, G.A., & Masetti, G. M. (2004). Evidence-Based Assessment of Attention-Deficit Hyperactivity Diso rder in Children and Adolescents. Journal of Clinical Child and Adolescent Psychology 34(3), 449-476. Reich, W., & Welner, Z. (1988). Revised version of the Diagnos tic Interview for Children and Adolescents (DICA-R) St. Louis, MO: Department of Psychiatry, Washington University School of Medicine. Reynolds, C.R. & Kamphaus, R.W. (1992). Behavior Assessment System for Children (BASC) Circle Pines, MN: American Guidance Services. Shaffer, D., Fisher, P., & Lucas, C.P. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, di fferences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry 39(1), 28-38. Stein, M.A., Szumowski, E., & Blondis, T.A. (1995). Adaptive skills dysfunction in ADD and ADHD children. Journal of Child Psychology and Psychiatry 36(4), 663-670. Wolraich, M.L., Lambert, W., Doffing, M.A., Bickma n, L., Simmons, T., & Worley, K. (2003). Psychometric Properites of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology 28, 559-568.

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39 BIOGRAPHICAL SKETCH Katherine Elizabeth Kiker was born on Sept ember 23, 1983, in Charlotte, North Carolina. An only child, she grew up mostly in Gaines ville, Florida. After graduating from the International Baccalaureate Program at East side High School in 2001, she earned both her Bachelor of Science degree in Psychology, cum laude, and her Bachelor of Arts degree in Spanish, cum laude, in December 2004. She is curre ntly a second-year graduate student in the Clinical Child and Pediatric Track of the Doctor al Program in Clinical and Health Psychology at the University of Florida.


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Title: Preliminary Development of the Teacher-Report ADHD Impairment Scale
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Copyright Date: 2008

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PRELIMINARY DEVELOPMENT OF THE TEACHER-REPORT ADHD IMPAIRMENT
RATING SCALE




















By

KATHERINE ELIZABETH KIKER


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2007
































2007 Katherine Elizabeth Kiker









ACKNOWLEDGMENTS

I would like to thank my supervisory chair for his dedicated mentoring, the participants in

my study for their honest participation, and the Center for Pediatric Psychology and Family

Studies for their generous support.










TABLE OF CONTENTS

page

A CK N O W LED G M EN TS ................................................................. ........... ............. 3

LIST OF TABLES .................. .....................................................5

ABSTRAC T .......................................................................................

CHAPTER

1 INTRODUCTION ............... ............................ ...............................7.

2 M E T H O D ..........................................................................15

S cale D ev elo p m en t ......................................................................................................15
P ro c e d u re s .............................................................................................16
P artic ip an ts .........................................................................17
Statistical Analyses ................................................................................19
M e a su re s ................... ...................2...................0..........

3 R E SU L T S .............. ... ................................................................23

In tern al C o n sisten cy ............................................................................................................... 2 3
T est-R test R eliab ility ............................................................... .................... ............... 2 4
Discriminative Validity for the Total Teacher-Report Impairment Rating Scale ...............24
Discriminative Validity for the Adaptive Functioning Subscale.............................. 25
Discriminative Validity for the Academic Functioning Subscale .......................................25
Discriminative Validity for the Social Functioning Subscale .................................... 25
C o n stru ct V alid ity ............................................................................................................. 2 5

4 D ISC U S SIO N ............................................................................... 3 1

L IST O F R EFE R EN C E S ............................................................................... 36

B IO G R A PH IC A L SK E T C H ................................................................................................... 39















4









LIST OF TABLES


Table page

2-1 Items from the Teacher-Report Impairment Rating Scale..............................................22

3-1 D em graphic D ata ..................................... .................. .......... .. ............. 27

3-2 Intercorrelations between T-IRS Subscales................................................................28

3-3 Comparison of T-IRS Mean Scale Scores between the ADHD and Non-ADHD
G groups ......... .. .............. ....... ..................... ............................. 29

3-4 Correlations between Symptom Severity Ratings as Indexed by the Conners' Parent
Rating Scale (CPRS) and T-IRS Measures of Impairment.............................................30










Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

PRELIMINARY DEVELOPMENT OF THE TEACHER-REPORT ADHD IMPAIRMENT
RATING SCALE

By

Katherine Elizabeth Kiker

May 2007

Chair: James H. Johnson
Major: Psychology

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, requires that a

child shows evidence of clinically significant impairment in social, academic, or occupational

functioning, in addition to ADHD symptomology, in order for a diagnosis of Attention-Deficit

Hyperactivity Disorder to be made. Additionally, impairment must be present across several

settings. The paucity of appropriate impairment measures led to the creation of The Child

Impairment Rating Scale, a parent-completed scale that measures ADHD-related impairment in

the domains of adaptive, academic, social, and home/family functioning. The present study

sought to evaluate the psychometric properties of the Teacher-Report Impairment Rating Scale

(T-IRS), the teacher version of the C-IRS that measures ADHD-related impairment in the school

setting in the domains of adaptive, academic, and social functioning. Preliminary results

supported the measure's internal consistency and discriminative validity. Further recruitment of

subjects is necessary to examine the scale's test-retest reliability and construct validity, and

bolster the generalizability of the findings.









CHAPTER 1
INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV:

American Psychiatric Association, 1994), estimates the prevalence rate of Attention-

deficit/hyperactivity disorder to range from 3 to 5% in school age-children. Given the high

prevalence of ADHD, extensive time is dedicated to assessing and treating the disorder by health

care professionals, including family practitioners, pediatricians, psychiatrists, neurologists,

psychologists, and school psychologists

Health care professionals in the United States commonly use the guidelines presented in

DSM-IV in diagnosing the various subtypes of ADHD; the predominantly inattentive type, the

predominantly hyperactive/impulsive type and the combined type. The inattentive type of ADHD

is characterized by difficulty sustaining attention in tasks or play activities, forgetfulness, losing

necessary things, making careless mistakes, difficulty organizing tasks and activities, being

easily distracted, not listening, and failing to finish schoolwork, chores, or work duties. The

hyperactive/impulsive type of ADHD is characterized by symptoms of hyperactivity (fidgeting,

inability to remain seated, restlessness, excessive talking, difficulty engaging in quiet activities,

and often being "on the go") as well as symptoms of impulsivity (blurting out answers, difficulty

awaiting turn, and often interrupting/intruding on others.) The combined type of ADHD is

characterized by symptoms of both inattention and hyperactivity/impulsivity.

In order to establish a diagnosis of ADHD, the clinician must ensure that the child displays

developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity that are

observed across situations, that the onset of symptoms was before 7 years of age, and that the

symptoms have occurred apart from other mental disorders such as Pervasive Developmental

Disorder, Schizophrenia, or Psychotic Disorder. To diagnose the predominately inattentive type









of ADHD, 6 or more symptoms of inattention must have been present for at least 6 months. For

the predominantly hyperactive/impulsive type of ADHD, 6 or more symptoms of

hyperactivity/impulsivity must have been present. Finally, for a diagnosis of the combined type

of ADHD, both 6 or more symptoms of inattentions and 6 or more symptoms of

hyperactivity/impulsivity must have been present for at least 6 months. It is also the case that

when an individual's symptoms do not meet the criteria for one of the subtypes of ADHD, and it

is unclear whether these criteria have previously been met, a diagnosis of Attention-

Deficit/Hyperactivity Disorder Not Otherwise Specified can be made.

The criteria for a diagnosis of ADHD also require that the child shows evidence of

clinically significant impairment in social, academic, or occupational functioning and that some

impairment is seen in two or more settings. It can be noted that the requirement that symptoms

and impairment be present across multiple situations is new to DSM-IV and serves to minimize

making inappropriate diagnoses in those situations where symptoms may be the result of

situational factors.

Although the assessment of ADHD symptoms and impairment is required for diagnosis,

more emphasis has generally been placed on the importance of obtaining information about

ADHD symptoms, rather than obtaining information about impairment. There are numerous

measures, such as the ADHD rating scale (DuPaul, 1991), Child Behavior Checklist (Achenbach,

1991), the Behavior Assessment System for Children (Reynolds and Kamphaus, 1992), and the

Revised Conners Parent and Teacher Rating Scales (Conners, 1997) that measure the frequency

and severity of ADHD symptoms in children and adolescents. There are also computerized

measures, such as the Conners Continuous Performance Test (CPT; Conners, 1994) to directly

assess attention problems.









There are also other methods used to measure ADHD symptoms. Structured and

semistructured interviews are often used for the diagnosis of ADHD within a research context.

These interviews can be used to diagnose multiple disorders and are recommended by experts for

the diagnosis of ADHD (Lahey & Wilcutt, 2002). Commonly used structured interviews include

the Diagnostic Interview for Children and Adolescents Revised (DICA-R; Reich & Welner,

1988) and the Diagnostic Interview Schedule for Children Version IV (DISC-IV; Shaffer, Fisher,

& Lucas, 2000). Semistructured interviews used to diagnose ADHD include the Kiddie Schedule

for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS-PL:

Kaufman et al., 1997) and the Child and Adolescent Psychiatric Assessment (CAPA; Angold &

Costella, 2000). Unlike the structured interviews, there is little published reliability data on

semistructured interviews for children with ADHD. Although these interviews may be effective

in diagnosing ADHD, they are lengthy measures that must be administered by trained clinicians

or researchers; thus, they may not have much utility in a clinical setting where a thorough,

efficient, and timely diagnosis of ADHD must be made.

Another method of gathering information about the ADHD symptomatology that children

exhibit is by using observational measures such as Classroom Observations of Conduct and

Attention Deficit Disorders (COCADD; Atkins, Pelham, & Licht, 1985), Classroom Behavior

Code (Abikoff et al., 1977), and Playroom Observations (Milich, Loney, & Landau, 1982).

These observational measures exhibit acceptable reliability and validity in both clinical settings

and natural settings. There is also evidence that these observational measures discriminate

between children with and without ADHD (Fabiano et al., 2004). Despite the usefulness of

observational measures in diagnosing ADHD, it is important to note that they are extremely

time-consuming and therefore not practical in a clinical setting.









The measures reviewed thus far have focused on the diagnosis of ADHD via ADHD

symptomatology. However, the DSM-IV requires that a child show evidence of clinically

significant impairment in social, academic, or occupational functioning and that some

impairment is seen in two or more settings in order to make a diagnosis of ADHD. Indeed, it has

been argued that more focus should be placed on the assessment of ADHD related impairment,

rather than ADHD symptoms, beyond the initial diagnostic phase. Children are generally

referred for diagnosis because of their impaired functioning in different domains, rather than

solely exhibiting ADHD symptoms (Pelham, 2004). ADHD core symptoms may improve with

age, but impairment and related difficulties tend to continue into adulthood. Adults diagnosed

with childhood ADHD have been found to have significantly fewer years of education, lower job

performance ratings from their employer, and more arrests than controls (Barkley, Fisher, &

Smallish, 2006). They also continue to exhibit poorer social skills and exhibit more antisocial

personality characteristics than controls (Manuzza & Klein, 2000).

In fact, the three areas of psychosocial impairment common in ADHD children family

functioning, peer relationships, and academic functioning- are predictive of negative long-term

outcome and are the target behaviors that must be modified in order to improve both current and

long-term functioning (Pelham, 2004).

Children with ADHD have been found to be impaired in multiple areas of functioning,

including social, academic, and adaptive functioning. Boys and girls with ADHD have been

found to be deficient in their social functioning (Gaub & Carlson, 1997). Relative to children

without ADHD, those diagnosed with this disorder are, as a group, less socially preferred, have

fewer friends, and are more often rejected by peers (Hoza, Mrug, & Gerdes, 2005). Peer rejection

for ADHD youths also tends to continue into adolescence (Bagwell et al., 2001). Compared to









other children in the classroom environment, children with ADHD are more off-task, complete

less assigned work, have lower levels of academic achievement, break classroom rules, and have

more problems with their teachers (Atkins et al., 1985). In addition, problems with attention may

lead to failure to progress academically over time.

Also, adaptive functioning skills, which refer to a child's ability to perform independent

behaviors and appropriate skills for daily activities, have been found to be much lower for

children with ADHD than control groups (Lahey et al., 1998). Indeed, children with ADHD

score lower in the areas of socialization, communication, and daily living in comparison with

children diagnosed with Pervasive Developmental Disorder or Mental Retardation. Children with

larger impairments in adaptive functioning appear to have a poorer prognosis for the disorder

(Stein, Szumowski, & Blondis, 1995).

Our review of research highlighting ADHD related impairment in the areas of academic,

adaptive, and social functioning points to the need for increased attention to the assessment and

treatment of impairment in individuals with ADHD. In the past, clinicians relied upon the

judgment of parents and teachers to determine levels of ADHD related impairment. However, a

more systematic and thorough assessment of children's every-day, functional abilities in the

home and school environments are needed (Gaub & Carlson, 1997).

Currently, there are several available measures that examine global/ overall impairment of

children, and a couple that measure impairment in specific domains of functioning. The Child

and Adolescent Functional Assessment Scale (CAFAS; Hodges, 1990) and Children's Global

Assessment of Functioning (CGAS; Bird et al., 1987) are clinician-administered measures that

examine global impairment due to emotional, behavioral, and psychiatric problems. The CAFAS

consists of 5 child scales: Role Performance, Thinking, Behavior Towards Self and Others,









Moods/Emotions, and Substance Use. For each scale, problems are rated on a four point Likert

scale where 0 corresponds to 'minimal or no disruption', and 3 corresponds to 'severe'. The

CGAS is a scale that asks raters to rate the child in question from 0-100 on a continuous scale of

impairment, where 100 corresponds to 'Superior functioning in all areas" and 0 corresponds to

"Needs 24-hour care." Both of these measures have been used with ADHD samples, but they

also measure impairment stemming from other psychological disorders.

Although global measures of impairment may be useful, measures of impairment that

report functioning in key domains (such as peer, family, and school) as well as globally have

more treatment utility than nonspecific global measures of impairment (Pelham et al., 2005). In

the past, researchers typically adapted impairment-related scales, which are constructed for other

purposes, when studying specific impairment in children with ADHD (Gaub and Carlson, 1997).

However, many impairment-related subscales tend to assess behaviors that define ADHD itself;

therefore, they should not be used as independent measures of impairment (Lahey et al., 1998).

There have been several recent advancements in the development of impairment rating

scales. Fabiano and Pelham's Impairment Rating Scale (IRS; 2002) asks teachers and parents to

rate the impact of a child's problems on a continuous scale across several areas of functioning

(relationships with peers, family and teachers; academic achievement; self-esteem) and to

produce a written description of the child's problems. The psychometric properties of the

Impairment Rating Scale were measured in 4 samples. Two included ADHD and matched

comparison children and the other 2 included a school sample. Preliminary evaluations of both

the parent and teacher scales (Fabiano & Pelham, 2002) supported the test-retest reliability of

these measures, their ability to discriminate between ADHD and non-ADHD groups, and their

correlations with other measures that assess the same construct using different methods of









measurement. Although the IRS has only 6-7 questions, depending on the version, the narrative

portion makes it more difficult to score. In addition, the IRS asks raters to rate children on an

overall domain of functioning, rather than individual items that make up a domain. Therefore the

IRS may be less desirable in settings where a brief, easy-to-administer, quantitative index of

impairment is preferred.

The paucity of impairment measures has recently led to the creation of an additional

measure, the parent version of the Child Impairment Rating Scale (C-IRS) by McAlister and

Johnson (2004), at the University of Florida. This scale was one of the first of its kind to provide

a brief and easy to complete measure of ADHD-related impairment in the home environment.

The C-IRS is a 32-item scale that measures impairment in 4 different domains: adaptive

functioning, social functioning, academic functioning, and functioning in the home and family

environment.

In the preliminary study, the C-IRS demonstrated good psychometric properties.

Cronbach's alpha for the entire scale equaled .94, and alpha levels for the Adaptive behavior,

Academic, Social, and Home/Family Functioning subscales were high (range = .74 .86). With

respect to reliability, item-level analyses revealed that the C-IRS items adequately discriminated

between children with low total scores and children with high total scores on this measure.

Results also demonstrated significant test-retest reliability over a 2-3 week interval for the

parents of children with ADHD. The test-retest reliability coefficient was .92 for the overall

total scale, .87 for the Adaptive Functioning subscale, .78 for the Academic Functioning

subscale, .90 for the Social Functioning subscale, and .81 for the Home/Family Functioning

subscale (allp < .01).









Despite the potential usefulness of this parent measure, it is also important to document

evidence of impairment in the school environment. Indeed, this is a requirement of the current

DSM-IV diagnostic criteria. As previously discussed, Fabiano & Pelham (2002) demonstrated

good psychometric properties for the teacher version of their Impairment Rating Scale.

Additionally, the Vanderbilt Rating Scale (Wolraich et al., 2003) is a teacher scale designed to

measure ADHD, Oppositional Defiant and Conduct Disorder, and Anxiety and Depression

symptoms, and has demonstrated good psychometric properties. However, the Vanderbilt Rating

Scale has 35 items, of which only 8 are related to ADHD impairment; 3 items related to

academic impairment and 5 items related to classroom behavior.

Therefore there is a need for an instrument that can quickly and efficiently measure

ADHD-related impairment in the school setting, as this is necessary for an accurate diagnosis of

ADHD. The present study represents an attempt to fill this clinical and research void by

developing a teacher-report child ADHD impairment scale (the T -IRS). This study examined

the scale's psychometric properties, including its internal consistency, test-retest reliability, and

discriminate validity. Given the assumption that severity of ADHD symptoms would relate to

degree of impairment, the study also examined whether impairment scores on the T-IRS were

correlated with symptom severity as measured by scales on the Conner's Parent Rating Scale

(The ADHD Index, DSM-IV Inattentive scale, DSM-IV Hyperactive-Impulsive scale, DSM-IV

Total scale). The development of a reliable and valid ADHD impairment measure to be

completed by teachers, such as the one described here, should assist clinicians in accurately

diagnosing ADHD, and assist in measuring treatment outcomes.









CHAPTER 2
METHOD

Scale Development

The teacher version of the Child Impairment Rating Scale was generated from the

previously constructed parent version on this measure (C-IRS: McAlister & Johnson, 2004). To

develop the parent version, a list of items related to impairment in the domains of adaptive

behavior, academic and school functioning, and social and family functioning was generated.

This was done by surveying available measures that relate to these individual domains, by

obtaining input from child clinical/pediatric psychologists regarding items that may reflect

domain related impairment, and by obtaining clinical data from parents of children with ADHD

regarding examples of characteristics that reflect impairment in these domains. After generating

an initial item pool, items were reviewed by child clinical and pediatric psychologists and

advanced graduate students in clinical child psychology in an attempt to minimize item overlap,

ambiguous item content, and to eliminate items that were not viewed as relevant to the specific

domains being assessed. Of the remaining items, the 8 most non-redundant and most

representative items for each subscale were retained, for a total of 32 items. Half of the items

were worded in a positive direction, and half the items were worded in a negative direction to

minimize the utilization of response sets.

The format of the scale asks the parent to determine how often their child experiences the

described circumstance on a continuum from 0-3; 0 being almost never and 3 being almost

always. The parent version of the Impairment Rating Scale (C-IRS) was administered to 38

parents of children with ADHD and 46 parents of children without the disorder. All of the

children were within the ages of 5 and 13 years old. Analyses indicated that the C-IRS

impairment indices reliably differentiated between children with and without ADHD. There was









also good test-retest reliability over a 2-3 week interval and evidence of adequate internal

consistency.

The teacher version used the 8 items in each subscale designed to measure levels of

impairment in adaptive behavior and in school/academic and social functioning. The family

functioning subscale was excluded, as teachers are not expected to be able to adequately rate

children on family related items as they likely see the children only in the school environment.

Table 2-1 shows the items in the T-IRS.

Procedures

Approval to conduct the study was first obtained from the IRB. Upon approval, parents of

children with ADHD were approached through the Psychology Clinic to determine their interest

in participating in the study. These parents were at the Psychology Clinic for previously

scheduled ADHD evaluations for their children based on referral to the clinic by physicians or

parents. Out of 24 parents of children with ADHD approached, a total of 3 parents declined to

participate. Fliers to recruit children without ADHD were posted at Shands Hospital and on

community bulletin boards; therefore a rate of non-interest could not be determined. Parents of

both groups of children (ADHD and non-ADHD) were asked to complete questionnaires with

regard to one of their children. In either group, if parent had more than one child that fit the study

criteria, they were asked to select one child on which to make responses. Parents and teachers in

both groups were informed of the confidentiality of their responses as well as their ability to

receive feedback about the results of the study upon its completion, if so desired.

Parents in the ADHD group were given an informed consent form, a demographic

information sheet, and a Child Impairment Rating Scale (the parent form). For the purposes of

this study, the informed consent incorporated permission from the parent to use data from their

child's clinical assessment, including the Conners Parent Rating Scale, as well as information









related to the diagnosis. It also asked the parents to grant permission to allow the child's teacher

to be contacted and asked to complete the Teacher-Report Impairment Rating Scale. The

demographic sheet asked parents for general information (such as name, address, phone

numbers, child's date of birth and gender, family income), the type of ADHD diagnosis (if

known), and whether the child had been formally diagnosed with any other psychological

condition. After the parents signed a consent form allowing the teacher to fill out the T-IRS, we

mailed a copy of the T-IRS to the school along with a postage-paid envelope, which teachers

completed, and then mailed back to us. After a 2-3 week interval, teachers were again mailed the

T-IRS for the test-retest phase of the study. We chose this time period for the test-retest phase

because it is thought that adequate time would have passed so that teachers would not remember

their previous answers, and that other factors would not have resulted in changes in the child's

level of impairment.

Parents in the normal comparison group were given an informed consent that explained the

nature of the study, issues of confidentiality, and which also asked permission to give the T-IRS

form to the child's teacher. These parents were also given a copy of the C-IRS and a

demographic information sheet to complete. Parents who expressed their willingness to

participate in the study were either sent materials directly in the mail or, if the parent was located

in close proximity to the hospital, a study investigator brought materials to that location in order

to have them completed. Teachers were mailed the T-IRS initially after the parents gave

permission, and again after 2-3 weeks for the test-retest phase of the study. Parents in this group

were also compensated 5 dollars for their participation.

Participants

A sample of 43 children was initially recruited. However, 5 teachers of children with

ADHD and 2 teachers of children without ADHD did not return the T-IRS; therefore these









subjects were excluded from all analyses. Therefore our final sample for all analyses consisted of

16 children with ADHD (mean age of 8.87) and 20 children without ADHD (mean age of 9.95).

All children were between the ages of 5 and 14. The ADHD sample consisted of 11 boys and 5

girls. Of these, 2 children were diagnosed with the Inattentive Type of ADHD, and 14 children

were diagnosed with the Combined Type of ADHD. The non-ADHD sample included 10 boys

and 10 girls. The mean income for the ADHD sample was $68,277 and the mean income for the

non-ADHD sample was $78,500. Table 3-1 shows demographic data.

Children with ADHD were recruited from the psychology clinic of the Department of

Clinical and Health during their scheduled appointments. Here, children were evaluated by a

licensed, board-certified Clinical Child Psychologist. Only those given a diagnosis of ADHD

were included in the present study. The evaluations consisted of a detailed diagnostic interview,

intellectual and achievement testing, parent and teacher-report measures to assess symptoms of

ADHD and possible comorbid conditions, computerized testing of attention problems, and other

testing as needed. Children without ADHD were recruited through fliers posted in Shands

Hospital and on community bulletin boards.

The children diagnosed with ADHD had one of three sub-types: predominantly inattentive

type, predominantly hyperactive/impulsive type or combined type. Exclusion criteria for children

in the ADHD group included the presence of Pervasive Developmental Disorder, Psychotic

Disorder, or diagnosed learning disability. Children with learning disabilities were excluded

because teachers may rate children with these disorders as having more impairment, reflective of

their learning disability, rather than ADHD. Exclusion criteria for the non-ADHD children

included a diagnosis of ADHD or parent report of any other clinical disorder. We attempted to

match closely for family income, age, & sex, and were successful, as no significant differences









emerged between groups on these variables. Parents were financially compensated $5 for

completing the study.

Statistical Analyses

The first aim of this study was to document the internal consistency for the Teacher-Report

Impairment Rating Scale (T-IRS) and its subscales, in order to measure the extent to which

subscales and items within subscales correlate with each other. Item-total correlations and

Cronbach's alpha were calculated for the entire sample of participants. It was hypothesized that

the T-IRS would show adequate to good internal consistency, and that the item-total correlations

would be moderately high and that all of the items in the T-IRS, and the subdomains, would

show high homogeneity. The second aim sought to document the test-retest reliability for the T-

IRS over a 2-3 week interval, which was hypothesized to be high. A Pearson's product moment

correlation coefficient was calculated for T-IRS scores of children with ADHD.

The third aim sought to assess whether scores on the T-IRS discriminate between children

with and without ADHD. It was hypothesized that T-IRS scores would be significantly higher

for children with ADHD than children without ADHD, demonstrating its utility as a diagnostic

assessment instrument. For this aim, ANOVAs were run to examine the differences between

groups on scores on the entire T-IRS and each subscale.

The final aim was to document the relationship between indices of ADHD symptom

severity and the degree of rated impairment in the ADHD group. It was hypothesized that there

would be a significant positive correlation between indices of ADHD symptom severity and the

degree of rated impairment in the ADHD group. A Pearson's product moment correlation

coefficient was run, and symptom severity indices were obtained from scores on the Conner's

Rating Scales completed by the parent at the time of the child's initial ADHD evaluation. Scores









on the Conners' ADHD Index, the DSM-IV Inattentive subscale, the DSM-IV Hyperactive-

Impulsive subscale, and the DSM-IV Total subscale were used.

Measures

The Teacher-Report Impairment Rating Scale (T-IRS): The T-IRS and its respective

psychometrics are the focus of the current study. This 24-item teacher-report scale is divided into

3 subscales; adaptive functioning, academic functioning, and social functioning. Items included

in this measure are presented in Appendix A. The format for responding to this measure asks

teachers to determine how often the child experiences the described circumstance on a

continuum from 0-3; 0 being almost never and 3 being almost always.

The Child Impairment Rating Scale (C-IRS; McAlister & Johnson, 2004): This 32-

item self-report scale was the first of its kind to provide a brief and easy to complete measure of

ADHD-related impairment in the home environment. As was suggested earlier, preliminary

findings with the C-IRS demonstrated good psychometric properties, including adequate

discriminate validity between children with and without ADHD, good test-retest reliability over

a 2-3 week interval, and adequate internal consistency.

The Conners Parent Rating Scale Revised (CPRS-R; Conners, 1997): This measure

contains 80 items and assesses behaviors related to hyperactivity, impulsivity, attention

problems, conduct problems, cognitive problems, anxiety problems and social problems. The

directions request parents to consider the child's behavior during the past month, and responses

are given on a Likert scale, ranging from 0, not at all true, to 3, very true. The ADHD Index is

considered to be the most useful score for discriminating children with ADHD from a non-

clinical sample, and DSM-IV Symptoms subscales (DSM-IV Inattentive Scale; DSM-IV

Hyperactive-Impulsive Scale) correspond with the DSM-IV ADHD symptoms. Research has

provided considerable psychometric support for the CPRS-R, including excellent internal









consistency, high test-retest reliability, and good discriminative power between clinical and non-

clinical children (Conners et al., 1998).









Table 2-1: Items from the Teacher-Report Impairment Rating Scale
Adaptive Functioning
1. Needs close supervision
2. Shows appropriate levels of independent behavior
3. Adapts poorly to new situations
4. Shows inappropriate level of self-care
5. Is persistent in dealing with difficult tasks
6. Shows good common sense
7. Shows poor planning abilities
8. Shows appropriate concerns for safety

Academic Functioning
9. Is disorganized in dealing with academic tasks
10. Meets academic time demands
11. Fails to complete or turn in assigned homework
12. Requires discipline at school
13. Shows respect for school property
14. Has unexcused absences
15. Performs well on academic tasks
16. Has good relationships with teachers

Social Functioning
17. Is ignored or rejected by peers
18. Shows respect for the feelings of others
19. Displays good social skills
20. Seems socially immature
21. Shows lack of respect for the property of peers
22. Has good relationships with peers
23. Has problems participating in groups/games
24. Relates poorly to adults









CHAPTER 3
RESULTS

Internal Consistency

Intercorrelations between the three T-IRS subscales ranged from .60 to .87. Table 3-2

shows them. Corrected item-total correlations, which reflect how well items discriminate

between respondents with a low score and respondents with a high score, were calculated for the

total scale (containing 24 items) as well as for the three individual subscales (each consisting of 8

items). The mean corrected item-total correlation for the total Teacher-Report Impairment

Rating Scale was .71 (range = .50 .89). The item with the best discriminating ability for the full

scale was "Shows appropriate levels of independent behavior," while the item with the smallest

discriminating ability was "Has unexcused absences." Cronbach's coefficient alpha for the total

scale, calculated from 36 fully completed measures, was .96.

The mean corrected item-total correlation for the Adaptive Functioning subscale was .77

(range = .50 .90). The item with the highest ability to discriminate between respondents with a

high and low score was "Shows appropriate levels of independent behavior," while the item with

the lowest discriminating ability was "adapts poorly to new situations." Cronbach's coefficient

alpha was .93 for this subscale, calculated from 36 completed measures.

The mean corrected item-total correlation for the Academic Functioning subscale was .69

(range = .52 .86). The item "Performs well on academic tasks" had the best discriminating

power while the item "Has unexcused absences" demonstrated the poorest discriminating ability.

Analyses of 36 measures resulted in a coefficient alpha of .88.

The mean item-total correlation for the Social Functioning subscale was .79 (range = .57 -

.88). The item with the best discriminating power was "Displays good social skills" and the item









with the poorest discriminating power was "shows respect for the feelings of others". Analyses

of 36 measures resulted in a coefficient alpha of .94.

Test-Retest Reliability

Due to a lower than expected return rate, only a small sample of six teachers of children

with ADHD returned a second copy of the T-IRS after an interval of 2-3 weeks. This small

sample size clearly does not allow a confident measurement of the test-retest reliability for the T-

IRS. However, these very preliminary findings do suggest good test-retest reliability for the

small sample. The test-retest reliability coefficient was .98 for the overall total scale, .87 for the

Adaptive Functioning subscale, .78 for the Academic Functioning subscale, and .95 for the

Social Functioning subscale (all p < .01). It is hypothesized that with continued recruitment, a

more accurate estimate of the scale's test-retest reliability will emerge.

Discriminative Validity for the Total Teacher-Report Impairment Rating Scale

The second aim of the study was to assess whether scores on the T-IRS discriminate

between children with and without ADHD. Here, t-tests were initially run to determine if there

were differences between the ADHD and non ADHD groups in terms of age, sex, or family

income. No significant differences emerged between children with and without ADHD on any of

these variables. An Analysis of Variance (ANOVA) was subsequently conducted to evaluate

whether scores from the total T-IRS differentiated between teachers' ratings of children with

ADHD and ratings of children without ADHD. There were significant differences between these

two groups, F(1,34) = 82.24,p < .001; teachers of children with ADHD (M= 27.20, SD = 7.65)

indicated higher levels of overall child impairment than teachers of children without ADHD (M

= 4.65, SD = 6.99). The effect size, measured using Cohen's d, was 1.68, and statistical power

was .99. Table 3-3 shows the contrasts between the ADHD and non-ADHD group.









Discriminative Validity for the Adaptive Functioning Subscale

An ANOVA was conducted to determine whether or not teachers of children with ADHD

and teachers of children without ADHD differed in terms of their scores on the Adaptive

Functioning subscale of the T-IRS. The ANOVA yielded significant results, F(1,34) = 102.87, p

< .001, Cohen's d= 1.73, power = .99. Teachers of children with ADHD (M= 10.60, SD = 2.95)

displayed significantly higher mean scores on adaptive impairment than teachers of children

without ADHD (M= 1.70, SD = 2.25).

Discriminative Validity for the Academic Functioning Subscale

An ANOVA was conducted to determine whether or not teachers of children with ADHD

and teachers of children without ADHD differed on scores on the Academic Functioning

subscale. The results were significant; F(1,34) = 54.77, p < .001, Cohen's d= 1.57, power = .99.

Teachers of children with ADHD (M = 8.93, SD = 3.33) had significantly higher scores than

teachers of children without ADHD (M= 1.60, SD = 2.54).

Discriminative Validity for the Social Functioning Subscale

An ANOVA was conducted to determine whether or not teachers of children with ADHD

and teachers of children without ADHD significantly differed on scores on the Social

Functioning subscale. The results were significant, F(1,34) = 25.66, p < .001, Cohen's d= .1.31,

power = .98. Teachers of children with ADHD (M= 7.67, SD = 4.71) had significantly higher

scores than teachers of children without ADHD (M= 1.35, SD = 2.60).

Construct Validity

Pearson product-moment correlation coefficients were calculated in order to determine the

strength and direction of the relationship between scores on selected scales of the Conners'

Parent Rating Scale (The ADHD Index, DSM-IV Inattentive scale, DSM-IV Hyperactive-

Impulsive scale, and DSM-IV Total scale) and the T-IRS. Data from completed Conners' Parent









Rating Scales were available for 15 parents of children with ADHD. Scores on the Social

Functioning subscale positively correlated with scores on the DSM-IV Hyperactive-Impulsive

subscale (r=.57, p<.01); increased levels of hyperactive-impulsive symptomatology was

significant correlated with higher levels of impairment in social functioning. No significant

correlations were found between scores on the Conners' Parent Rating Scales and scores on the

adaptive and academic functioning subscales of the T-IRS. Table 3-4 shows the bivariate

correlation coefficients and their associated p-values.









Table 3-1: Demographic Data
n M SD


Child Age
Non-ADHD
ADHD (Total)
ADHD
(Subtypes)
Combined
Inattentive
Child Gender
Non-ADHD
Boys
Girls
ADHD
Boys
Girls
Parent
Respondent
Non-ADHD
Mothers
Fathers
ADHD
Mothers
Fathers


9.95 2.56
8.87 2.76


8.75 2.86
8.00 2.83










Table 3-2: Intercorrelations between T-IRS Subscales
Subscale Adaptive Academic Social
Adaptive .81** .87**
Academic .60**
Social
**p<.01











Table 3-3: Comparison of T-IRS Mean Scale Scores between the ADHD and Non-ADHD
Groups


ADHD
M SD
Total 27.20 7.66
Adaptive 10.60 2.95
Academic 8.93 3.33
Social 7.67 4.72
***p <.001; **p < .01. Cohen's d


Non-ADHD
M SD
4.65 6.99
1.70 2.25
1.60 2.54
1.35 2.60
Effect size. (1-0)


F(1) d
82.24*** 1.68
102.87*** 1.73
54.77*** 1.57
25.66** 1.31
Power estimate.


(1-3)
0.99
0.99
0.99
0.98










Table 3-4: Correlations between Symptom Severity Ratings as Indexed by the Conners' Parent
Rating Scale (CPRS) and T-IRS Measures of Impairment
CPRS ADHD CPRS DSM-IV CPRS DSM-IV CPRS DSM-IV
T-IRS index inattentive hyperactive- total
impulsive
Total -.24 -.30 .41 .04
Adaptive -.15 -.13 .44 .19
Academic -.34 -.41 -.24 -.46
Social -.05 -.13 .57* .27
N= 15. *p<.05.









CHAPTER 4
DISCUSSION

For a child to be diagnosed with ADHD, the DSM-IV (1994) requires that the child display

developmentally inappropriate levels of inattention and/or hyperactivity/impulsivity that are

observed across situations. Diagnostic criteria also require that the child shows evidence of

clinically significant impairment in social, academic, or occupational functioning seen in two or

more settings. The addition of DSM-IV impairment criteria represents a significant improvement

over previous editions of the Diagnostic and Statistical Manual of Mental Disorders. Clinicians

have argued that following a diagnosis of ADHD, impairment (rather than symptoms) is more

predictive of negative long-term outcomes (Pelham, 2004).

Clinicians have previously relied on the verbal reports of parents and teachers to document

ADHD-related impairment. However, as noted by Gaub and Carlson (1997), a more systematic

and thorough assessment of children's every-day, functional abilities in the home and school

environments are needed. Although a few impairment measures exist, none of them fulfill the

need for an instrument that can quickly and efficiently measure ADHD-related impairment. A

previous study by McAlister & Johnson (2004) created the C-IRS, a 32 item parent-report scale

designed to measure the impact of inattention and hyperactive-impulsive symptoms on child

impairment in several key areas (adaptive functioning, academic functioning, social functioning,

and home/family functioning.) Analyses of the scale's psychometric properties supported the

measure's internal consistency, test-retest reliability, and discriminative and construct validity.

As it is a requirement of diagnosis that ADHD-related impairment be documented across

several settings, the present study attempted to develop and evaluate the psychometric properties

of the Teacher-Report Impairment Rating Scale (T-IRS). This 24-item scale, derived from the C-

IRS (McAlister & Johnson, 2004) contained 3 subscales to measure impairment; the adaptive









functioning subscale, academic functioning subscale, and social functioning subscale. The

home/family functioning subscale from the C-IRS was eliminated from the T-IRS as teachers do

not typically view children in the home setting.

Initial data collected thus far suggest that scores on each of the three subscales of the T-

IRS, as well at the entire scale, reliably differentiate between children with and without ADHD.

Cronbach's alpha for the entire scale equaled .96. Cronbach's alphas for the three subscales were

also high, ranging from .88 to .94. Also, item-level analyses indicated that individual items

within each subscale, and the entire scale, differentiated between children with high and low

scores on the T-IRS. Items with the highest discriminative ability were items thought to broadly

encompass each subdomain, such as "shows appropriate levels of independent behavior,"

"performs well on academic tasks," and "displays good social skills." In contrast, items with

lower discriminative ability were items measuring specific aspects of a domain of functioning,

such as "has unexcused absences," and "shows respect for the feelings of others." However, all

item-total correlations for the T-IRS exceeded .50. Because of our small sample size, further

recruitment of children with and without ADHD is necessary in order to increase support for our

findings.

Due to the difficulty of getting teachers to return the T-IRS, data from only 6 subjects were

included in the test-retest reliability analyses. Although this is not an adequate sample size to

provide support for the test-retest reliability of our measure, it is important to note that the

findings from this preliminary analyses suggest that with more subjects, the scale will likely

demonstrate good test-retest reliability. The test-retest reliability coefficient was .98 for the

overall total scale, .87 for the Adaptive Functioning subscale, .78 for the Academic Functioning

subscale, and .95 for the Social Functioning subscale (allp < .01).









In terms of discriminative validity, scores on the T-IRS indicate that the scale distinguishes

between children with and without ADHD. Mean scores for the entire scale, as well as each of

the three individual subscales, were substantially higher for children with ADHD (all p<.001).

Despite a small sample size, effect sizes for each analysis were very high, indicating that the

magnitude of differences of scores between children with and without ADHD was very high.

While is was expected that measures of ADHD symptom severity would correlate highly

with indices of impairment, findings in this area were limited in the present study. Significant

correlation was found between scores on the DSM-IV Hyperactive/Impulsive scale of the

Conners' Parent Rating Scale and scores on the social functioning subscale of the T-IRS. It

makes sense that children with hyperactive/impulsive symptomatology would display

impairment in the social functioning domain. No other significant correlations emerged between

scores on the T-IRS subscales and Conners' Parent Rating Scale. This lack of other significant

correlations may be attributable to the small sample size. Given the magnitude of several of the

correlations obtained, with further recruitment of subjects, we might expect to see more

significant correlations between symptom severity and degree of rated impairment.

Psychometric findings from the present study are in line with those found for the C-IRS,

the parent version of our measure. Both measures provided support for the scales' internal

consistency and discriminative validity. However, the C-IRS also found significant correlations

between indices of symptom severity resulting from inattentive and hyperactive-impulsive

symptomatology with both academic and social impairment. In addition, inattentive

symptomatology was significantly correlated with academic impairment.

As previously suggested, the primary limitation of the current study is the small sample

size used in determining reliability and validity estimates. Further recruitment is necessary to









strengthen and bolster the generalizability of our findings, especially for our analyses of test-

retest reliability. However, the present study did find significant effects for internal consistency

and discriminative validity, thus providing preliminary support for its usefulness in measuring

ADHD-related impairment in the school environment.

In addition to a small sample size, our study primarily included children with Combined

Type ADHD (n=14) and only a few children with Inattentive Type ADHD (n=2). Further

recruitment of children with Inattentive Type ADHD would allow us to examine differences in

impairment between children with Inattentive and children with Combined Type ADHD.

In conclusion, the present study provided good preliminary support for use of the T-IRS in

discriminating between children with and without ADHD in terms of measuring ADHD-related

impairment in the domains of adaptive functioning, academic functioning, and social

functioning. As such it highlights its potential to assist clinicians in accurately diagnosing ADHD

and measuring treatment outcomes. Limitations of previously constructed impairment measures

are that they measure global impairment, rather than specific ADHD-related impairment, and

they are lengthy and time consuming to complete. The T-IRS is a measure that has the potential

to quickly and efficiently measure ADHD-related impairment in the school setting.

Future directions for research with the T-IRS would include recruiting a much larger

sample in order to bolster the psychometric properties of the measure, developing preliminary

norms for the measure, and determining validated cutoff scores for the T-IRS in order to

determine mild, moderate, or severe levels of impairment. Examining the relationship between

parent-reported levels of impairment on the C-IRS and teacher-reported levels of impairment on

the T-IRS and conducting a factor analyses to pinpoint the specific dimensions of the T-IRS

would also be important. We expect that the T-IRS will prove useful as a clinical scale for









measuring ADHD-related impairment in the school setting. Therefore, with the use of both the

T-IRS and the parent measure, the C-IRS, more accurate diagnoses of ADHD can be made in the

clinical setting.









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BIOGRAPHICAL SKETCH

Katherine Elizabeth Kiker was born on September 23, 1983, in Charlotte, North Carolina.

An only child, she grew up mostly in Gainesville, Florida. After graduating from the

International Baccalaureate Program at Eastside High School in 2001, she earned both her

Bachelor of Science degree in Psychology, cum laude, and her Bachelor of Arts degree in

Spanish, cum laude, in December 2004. She is currently a second-year graduate student in the

Clinical Child and Pediatric Track of the Doctoral Program in Clinical and Health Psychology at

the University of Florida.