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Challenging the Attention-Deficit Hyperactivity Disorder and Internalizing Disorder Subtype

Permanent Link: http://ufdc.ufl.edu/UFE0044140/00001

Material Information

Title: Challenging the Attention-Deficit Hyperactivity Disorder and Internalizing Disorder Subtype Evidence from Functional Impairment
Physical Description: 1 online resource (44 p.)
Language: english
Creator: Reid, Adam M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: adhd -- classification -- functioning
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Researchers have postulated that youth with Attention-Deficit Hyperactivity Disorder (ADHD) and an internalizing disorder represent a unique subtype of ADHD that has differential treatment and functional outcomes; however, results are inconclusive as researchers have not differentiated types of internalizing disorders. Fifty-nine youth with a diagnosis of solely ADHD (n = 34), ADHD with a mood disorder (n = 15) or ADHD with an anxiety disorder (n = 10) were included. Participants were recruited in a psychological assessment clinic. Parents filled out questionnaires examining their youth’s ADHD symptom severity, quality of life, adaptability, and executive functioning. As part of the assessment, clinicians also provided Global Assessment of Functioning scores for all youth. Multivariate analyses indicated that youth with ADHD and a mood disorder had significantly greater functional impairment across both parent and clinician rated measures compared to youth with ADHD and an anxiety disorder or youth with solely ADHD. This difference in functional impairment maybe the result of anxiety symptoms attenuating ADHD symptoms and subsequently the functional impairment caused by the addition of an Anxiety Disorder diagnosis. Results support an “ADHD-Mood Dysregulation Type” rather than an ADHD and an Internalizing Disorder subtype.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Adam M Reid.
Thesis: Thesis (M.S.)--University of Florida, 2012.
Local: Adviser: Geffken, Gary R.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044140:00001

Permanent Link: http://ufdc.ufl.edu/UFE0044140/00001

Material Information

Title: Challenging the Attention-Deficit Hyperactivity Disorder and Internalizing Disorder Subtype Evidence from Functional Impairment
Physical Description: 1 online resource (44 p.)
Language: english
Creator: Reid, Adam M
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2012

Subjects

Subjects / Keywords: adhd -- classification -- functioning
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Researchers have postulated that youth with Attention-Deficit Hyperactivity Disorder (ADHD) and an internalizing disorder represent a unique subtype of ADHD that has differential treatment and functional outcomes; however, results are inconclusive as researchers have not differentiated types of internalizing disorders. Fifty-nine youth with a diagnosis of solely ADHD (n = 34), ADHD with a mood disorder (n = 15) or ADHD with an anxiety disorder (n = 10) were included. Participants were recruited in a psychological assessment clinic. Parents filled out questionnaires examining their youth’s ADHD symptom severity, quality of life, adaptability, and executive functioning. As part of the assessment, clinicians also provided Global Assessment of Functioning scores for all youth. Multivariate analyses indicated that youth with ADHD and a mood disorder had significantly greater functional impairment across both parent and clinician rated measures compared to youth with ADHD and an anxiety disorder or youth with solely ADHD. This difference in functional impairment maybe the result of anxiety symptoms attenuating ADHD symptoms and subsequently the functional impairment caused by the addition of an Anxiety Disorder diagnosis. Results support an “ADHD-Mood Dysregulation Type” rather than an ADHD and an Internalizing Disorder subtype.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Adam M Reid.
Thesis: Thesis (M.S.)--University of Florida, 2012.
Local: Adviser: Geffken, Gary R.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2012
System ID: UFE0044140:00001


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1 CHALLENGING THE ATTENTION-DEFICIT HYPERACTIVITY DISORDER AND INTERNALIZING DISORDER SUBTYPE: EVIDENCE FROM FUNCTIONAL IMPAIRMENT By ADAM M. REID 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

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2 2012 Adam M. Reid

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3 To my mom and dad for being a compass to my life journey

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4 ACKNOWLEDGMENTS I would like to first acknowledge my family for their endless love, support and guidance. I have an eternal debt to Miguel Asse, Andrew Reid and Johanna Meyer for their love, patience, and ability to teach me that no goal is unattainable. I cannot thank Drs. Joseph McNamara and Paulo Graziano enoug h for believing in me from day one and being a role model for my career. Similarly, I would like to thank Dr. Gary Geffken for his superb graduate school mentorship and for never running out of interesting stories to tell in supervision. Finally, I owe tha nks to Amanda Roberts for keeping me in line, Alana Freedland for keeping me laughing, and all the lab members who helped in the data collection and entry for this research.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .............. 4 LIST OF TABLES ................................ ................................ ................................ ......................... 7 LIST OF FIGURES ................................ ................................ ................................ ....................... 8 ABSTRACT ................................ ................................ ................................ ................................ ... 9 CHAPTER 1. INTRODUCTION ................................ ................................ ................................ ................. 11 Excessive Comorbidity in ADHD ................................ ................................ ...................... 11 Possible ADHD Subtypes ................................ ................................ ................................ .. 12 ADHD with an Internalizing Disorder Subtype ................................ ................................ 12 ADHD with an Anxiety Disorder ................................ ................................ ................. 13 ADHD with a Mood Disorder ................................ ................................ ...................... 15 Functional Impairment in ADHD ................................ ................................ ....................... 16 Summary ................................ ................................ ................................ .............................. 17 Study Aims ................................ ................................ ................................ ........................... 17 2. METHODS ................................ ................................ ................................ ........................... 19 Procedure ................................ ................................ ................................ ............................. 19 Participants ................................ ................................ ................................ .......................... 19 Measures ................................ ................................ ................................ .............................. 20 Global Assessment of Functioning (GAF) ................................ ............................... 21 Conners, 3 rd Edition (Conners 3) ................................ ................................ .............. 21 Behavior Rating Inventory of Executive Functioning (BRIEF) .............................. 21 Behavior Assessment Sys tem for Children, 2 nd Edition (BASC 2) ...................... 22 Pediatric Quality of Life Inventory, Version 4.0 (PEDSQL) ................................ ... 23 3. RESULTS ................................ ................................ ................................ ............................. 26 Preliminary Analyses ................................ ................................ ................................ .......... 26 Homogeneity Test of Variance/Covariance ................................ ............................. 26 Linearit y of the Dependent Variable Relationships ................................ ................ 26 Absence of Singularity ................................ ................................ ................................ 26 Multivariate Normality ................................ ................................ ................................ .. 27 Results for Aim One ................................ ................................ ................................ ............ 27 ADHD versus ADHD and an Anxiety Disorder ................................ ........................ 27 ADHD versus ADHD and a Mood Disorder ................................ ............................. 28 Results for Aim Two ................................ ................................ ................................ ............ 28 GAF ................................ ................................ ................................ ................................ 29

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6 Adaptability ................................ ................................ ................................ ................... 29 Psychosocial ................................ ................................ ................................ ................. 29 Metacognition ................................ ................................ ................................ ............... 29 Results for Aim Three ................................ ................................ ................................ ......... 29 GAF ................................ ................................ ................................ ................................ 30 Adaptability ................................ ................................ ................................ ................... 30 Psychosocial ................................ ................................ ................................ ................. 30 Metacognition ................................ ................................ ................................ ............... 31 Summary ................................ ................................ ................................ .............................. 31 4. DISCUSSION ................................ ................................ ................................ ...................... 35 Implications for Subtype Classification ................................ ................................ ............ 35 Interaction of ADHD Subtype and Internalizing Disorders ................................ ........... 36 Attenuating Effect s of Anxiety on ADHD ................................ ................................ ......... 36 Limitations ................................ ................................ ................................ ............................ 37 Future Directions ................................ ................................ ................................ ................. 38 LIST OF REFERENCES ................................ ................................ ................................ ........... 39 BIOGRAPHICAL SKETCH ................................ ................................ ................................ ....... 44

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7 LIST OF TABLES Table page 3 1 Descriptive s tatistics ................................ ................................ ................................ ...... 32 3 2 Mean comparisons for youth from three diagnoses groups ................................ .... 32

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8 LIST OF FIGURES Figure page 3 1 Graph of G lobal A ssessment of F unctioning means for the three diagnostic groups ................................ ................................ ................................ .............................. 33 3 2 Graph of Adaptability me ans for the three diagnostic groups ................................ 33 3 3 Graph of Psychosocial means for the three diagnostic groups. ............................. 34 3 4 Graph of Metacognition me ans for the three diagnostic groups ............................. 34

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9 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 CHALLENGING THE A TTENTION DEFICIT HYPERACTIVIT Y DISORDER AND INTE RNALIZING DISORDER S UBTYPE: EVIDENCE FRO M FUNCTIONAL IMPAIRMENT By Adam M. Reid May 2012 Chair: Gary R. Geffken Major: Psychology Researchers have postulated that youth with Attention Deficit Hyperactivity Disorder ( ADHD ) and an internalizing disorder represent a unique subtype of ADHD that has differential treatment and functional outcomes; however, results are inconclusive as researchers have not differentiated types of internalizing disorders. Fifty nine youth with a diagnosis of solely ADHD (n = 34 ), ADHD with a mood disorder (n = 15) or ADHD with an anxiety disorder (n = 10) were included. Participants were recruited in a psychological assessment clinic. Parents filled out questionnaires examining their e, adaptability, and executive functioning. As part of the assessment, clinicians also provided Global Assessment of Functioning scores for all youth. Multivariate analyses indicated that youth with ADHD and a mood disorder had significantly greater functi onal impairment across both parent and clinician rated measures compared to youth with ADHD and an anxiety disorder or youth with solely ADHD. This difference in functional impairment maybe the result of anxiety symptoms attenuating ADHD symptoms and subse quently the functional impairment

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10

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11 CHAPTER 1 INTRODUCTION Excessive Comorbidity in ADHD Cu rrently, the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision ( DSM IV TR ) describes three subtypes of ADHD, specifically ADHD Combined Type, ADHD Predominately Inattentive Type, and ADHD Predominantly Hyperactive Impuls ive Type (American Psychiatric Association, 2000). However, youth with ADHD often have several comorbid disorders. A recent national study found that 46 percent of youth with ADHD had a Learning Disorder (7.79 higher realitive risk than national sample) 27 percent had Conduct Disorder (12.58 higher realitive risk), 18 percent had an Anxiety Disorder (7.45 higher realitive risk), 14 percent had Depression (8.04 higher realitive risk), and 12 percent had an Expressive Language Disorder (4.42 higher realitive risk) (Larson, Russ, Kahn, & Halfon, 2011). This e xcessive comorbidity in ADHD supports that ADHD is a heterogeneous clinical construct and suggests that ADHD may be comprised of numerous subtypes with unique clinical outcomes This study will investigate one of the possible subtypes: ADHD with a comorbid internalizing disorder. Several problems have been identified with the current ADHD classification system that provides additional indication that the DSM IV TR ADHD subtypes could be improved with reclas sification. The current subtypes have poor temporal stability, with children often qualifying for multiple different subtypes as they age from preschool through elementary school (Lahey, Pelham, Loney, Lee, & Willcutt, 2005). These subtypes also vary great ly in severity based off of presenting comorbid symptoms (e.g., Hurtig et al., 2007), likely a result of symptom overlap with other disorders (e.g.,

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12 inattentiveness and internalizing symptoms), further complicating the diagnostic picture. Therefore, resear ch is warranted investigating the validity of the several new subtypes of ADHD that have been suggested in the literature. Possible ADHD Subtypes Jensen and colleagues (2001) investigated possible subtypes of ADHD that have been previously suggested in t he literature to better explain the wide variety of symptom presentations in ADHD Using cross sectional and longitudinal data collected from 570 children as a part of the National Institute of Health Multisite Multimodal Treatment Study of Children With A ttention Deficit/Hyperactivity Disorder (MTA), investigators concluded that validational evidence (see Cantwell, 1995) only supported two possi ble additional subtypes of ADHD: ADHD with a co occurring D isruptive Behavior D isorder and ADHD with a co occurri ng Internalizing Disorder Numerous additional subtypes for ADHD have been posited over th e past two decades of research, such as ADHD with executive functioning deficits (Nigg, Willcut, Doyle & Sonuga Barke, 2005), ADHD with Autism (Mulligan et al., 2009) etc. However, the majority of attention has been given to the first of the two proposed subtypes by Jensen and colleagues (2001): ADHD with Disruptive Behavior Disorder ( e.g., Banaschewski et al., 2003; Hurtig et al., 2007) and little research has invest igated the proposed ADHD w ith an Internalizing D isorder subtype. ADHD with an Internalizing Disorder Subtype Roughly 33% of children with ADHD h ave a comorbid Internalizing D isorder (MTA Cooperative Group, 1999b) and thus identification of a possible ADHD with a comorbid Internalizing Disorder subtype could have diagnostic and treatment implications for up to one third of children with ADHD. The focus of the literature on this topic has been

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13 regarding a possible ADHD with a comorbid Anxiety Disorder subtyp e. Previous meta analysis reviewed the majority of research on this topic before 1997 and concluded that partial (4/8) criteria for the validation of ADHD with an Anxiety Disorder was met (Jensen, Martin & Cantwell, 1997), using the validational criteria o f Cantwell (1995) which assess multiple domains such as impairment, symptom presentation, treatment response, etc. The inconclusiveness of these findings regarding the validity of an ADHD and Anxiety Disorder subtype is echoed in the literature that is hig hlighted below. ADHD with an Anxiety Disorder Support for an ADHD with a comorbid Anxiety Disorder subtype is exemplified by research which has shown that these children have a different response to medication (e.g., Buitelaar, Van der Gaag, Swaab Barnevel d & Kuper, 1995). For example, the researchers of a double blind placebo controlled trial of Methylphenidate found that children with ADHD and lower levels of anxiety improved more on inattention and hyperactivity than peers without a comorbid Anxiety Diso rder (Buitelaar, Van der Gaag, Swaab Barneveld & Kuper, 1995). Children with ADHD and a comorbid Anxiety Disorder also differ on psychological treatment response. Work by the MTA Cooperative Group (1999a) and March and colleagues (2000) found that having a comorbid Anxiety Disorder related to improved outcome on ADHD and internalizing symptoms after behavioral therapy. These results were not moderated by having Oppositional Defiant Disorder or Conduct Disorder and were replicated by Jensen and colleagues (2 001). In terms of functioning, children with ADHD and a comorbid Anxiety Disorder show greater social ( Mikami Ransone & Calhoun, 2011) and cognitive functioning impairment (Carlson & Mann, 2002; Tannock, Schachar, & Logan, 1995) compared to their peers w ith solely ADHD.

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14 On the other hand, some research posits that ADHD and Anxiety Disorders are independently expressed and have little additional impact when presenting comorbidly (Hammerness et al., 2009). Contrary to previous findings, having co occurring anxiety did not impact response to Methylphenidate in the MTA Cooperative Group study, and the researchers posit that this is the result of a carefully titrated dose regimen (March et al., 2000). In this vein, results from the MTA Cooperative Group which s uggested that anxiety was a moderator of treatment outcome, was contradicted when Owens and colleagues (2003) reexamined the outcome data using a more sensitive statistical analysis (Receiver Operating Characteristics with multiple moderators analyzed simu ltaneously). Researchers defined a more clinically meaningful outcome measure of reported by parents or teachers to have decreased to minimal severity) and found that anxiet y did not impact treatment outcome. Highlighting a common limitation of several studies in the literature, research by Newcorn and colleagues (2004) found that after controlling for a comorbid diagnosis of Conduct Disorder, youth with ADHD and an Anxiety D isorder did not differ in social or behavioral functioning compared to peers with solely ADHD (e.g., aggression, delinquency). Regarding cognitive functioning, Oosterlaan and Sergeant (1998) conducted a meta analysis of research on children formance on the stop task (measures behavioral regulation of an already initiated task) and found that anxiety had no effect on response inhibition. Thus, the impact on treatment outcome and general functioning of having a comorbid Anxiety Disorder diagnos is remains unclear as a result of the inconsistent findings in the literature.

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15 ADHD with a Mood Disorder Despite presenting comorbidly with ADHD more often than Anxiety Disorder s (Wilens et al., 2002), substantially less research has been conducted on chil dren with ADHD and a comorbid Mood Disorder. To date, no treatment outcome trials have been conducted to identify if comorbid depression moderates response to behavioral therapy. However, pharmacological therapy is thought to be overall less effective for ADHD when comorbid depression is present (Spencer, Biederman, & Wilens, 1999). Additionally, research by Biederman and colleagues (1992) found that children with a Major Depressive Disorder diagnosis at baseline had worse psychosocial functioning, a higher rate of hospitalizations and increased interpersonal difficulties four years later than their peers with solely ADHD. Similarly, youth with ADHD and a co occuring Mood a Mood Disorder ( Greene et al., 1996 ; Blackman, Ostrander, & Herman, 2005 ). Impairment in m etacognition and other aspe cts of executive functioning is also compounded in youth with ADHD and a comorbid Mood Disorder (Shear, DelBello, Rosenberg, & Strakowski, 2002 ; Shear, DelBello, Rosenberg, Jak, & Strakowski, 2004), as is academic functioning (Blackman, Ostrander, & Herman, 2005). As with anxiety, the existing research on how comorbid Mood Disorders impact ADHD presentation and outcome is contradictory. Some researchers suggest manic symptoms or Bipolar Disorder, which are highly comorbid with pediatric ADHD, may (Youngstrom, Arnold, & Frazier, 2010). While comorbid Mood Disorde rs increase the severity and course of ADHD ( Faraone, Biederman, Me nnin, Wozniak, & Spencer, 1997), some would argue that ADHD is distinct from Mood Disorders and as such

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16 reflects a true comorbidity because both these disorders respond to their standard se parate treatments (Scheffer, Kowatch, Carmody & Rush, 2005). However, as in dicates that comorbid Mood Disorders may not hinder standard pharmacological therapy for ADHD or decrease functioning in ADHD. Functional Impairment in ADHD Improving the nosology of ADHD would facilitate more detailed clinician communication, more strate gic treatment planning, increased treatment outcome, and an overall more comprehensive understanding of ADHD. Following the validity criteria of Cantwell (1995), a new subtype would require changes in multiple facets of the disorde r (e.g., clinical phenome nology identified overlap in etiology, etc ) One of the eight criteria proposed is functional impairment (referred to as psychosocial correlates) and thus the functional impairment outcome variables chosen for this study have important implications for AD HD classification. While an ADHD with an Internalizing Disorder subtype has been suggested for over ten years, only one study has directly compared ADHD with a comorbid Anxiety Disorder versus ADHD with comorbid Mood Disorder in terms of functional impairm ent. Karustis, Power, Rescorla, Eiraldi, and Gallagher (2000) compared youth with ADHD and depression to peers with ADHD and anxiety and found that co occurring self reported anxiety was predictive of parent reported social problems above that of self repo rted depression. However, for teacher reported social problems, self reported depression was more predictive than anxiety of social functioning. Regarding academic functioning, youth with ADHD and depression had more problems with completing homework than youth with ADHD and anxiety. Taken together, these

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17 results highlight the lack of literature on how specific internalizing comorbidities in youth with ADHD impact functioning and subsequently, one key criteria for determining a new subtype related to comorb id internalizing disorders has yet to be thoroughly investigated. Summary ADHD is a heterogonous clinical construct for which multiple subtypes have been proposed in lieu of or in addition to the current DSM IV TR ADHD subtypes. Data collected from the M TA Cooperative Group, a multi site ADHD treatment outcome research study, suggested that out of all the proposed subtypes, ADHD with an Internalizing Disorder and ADHD with Oppositional Defiant Disorder/Conduct Disorder had the most empirical support in th eir study. Since these findings were reported, little research has investigated ADHD with an Internalizing Disorder as a new subtype. What research that has been conducted has found mixed findings regarding the impact of a comorbid Anxiety Disorder or Mood Disorder on treatment outcome and functional impairment. Only one study has directly compared comorbid anxiety and depression and underscores the need for more research in this area. Functional impairment is a worthy outcome to investigate due to its rele vance to subtype classification. Study Aims The first aim is to investigate if the presence of a comorbid Anxiety or Mood Disorder impacts functional impairment. It is hypothesized that youth with ADHD and a comorbid Internalizing Disorder will have worse functional impairment than youth with solely ADHD as the result of the additive effect of the internalizing symptoms. The second aim of this study is to determine if there are any differences in functional impairment between children with ADHD and a comor bid Anxiety Disorder versus

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18 children with ADHD and a comorbid Mood Disorder. It is believed that youth with a comorbid Mood Disorder will have worse impairment on psychosocial wellbeing, as a consequence of hindered social functioning, and global clinician rated functional impairment as a result of the trait like nature of depression as opposed to anxiety which is often situationally based. The third aim is to capture any interaction between internalizing symptoms and ADHD subtypes. It is thought that there will be an interaction between depression with ADHD Inattentive Type as a result of the difficulties in concentration commonly observed in depressed youth.

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19 CHAPTER 2 METHODS Procedure This study was a secondary data analysis from a larger study and only participants who were administered the included measures and met diagnostic criteria for this study were included in the sub sample. Participants parents provided consent to participate in the study at a large university hospital in the Southeastern United States Diagnostic inclusion criteria included having a diagnosis of solely ADHD (any type), or ADHD plus any Mood Disorder, or any Anxiety Disorder (not both). The only exception to this criterion was that youth were allowed to have a comorbid diagnosis of any Learning Disorder, Enuresis/Encopresis, or an Expressive Language Disorder because research has suggested that these disorders may not increase impairment beyond that of ADHD (e.g., Biederman et al., 2006). Diagnosis was determined by a clinical con sensus between two licensed psychologist who reviewed both objective and subjective data gathered from an hour interview with the patient and their family and a full battery of intellectual, emotional and behavioral assessments and questionnaires. The supe rvising clinician than assigned a Global Assessment of Functioning (GAF) score for each child based off the collected and observed data. Participants Fifty nine participants were included in this sub sample, which was 75% male and 25% female. A predominat ely male sample is common in psychological assessment clinics, due to the higher rate of behavior disturbances in male youth (Biederman et al., the sample was comprised of 69% Caucasian, 17% Hispanic, and 14% African

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20 American. The majority of the youth in this sample were referred from a psychiatrist (66%), while other major referral sources were from a pediatrician (14%), self referral (14%) or f rom another professional (6%). As stated above, this study only included youth with a diagnosis of ADHD or ADHD with a comorbid anxiety or mood disorder. Of the total sample of 59 youth, 33 had just a diagnosis of ADHD, 16 had a diagnosis of ADHD with a comorbid Mood Disorder (Ma jor Depressive Disorder or Mood Disorder NOS), and 10 had a diagnosis of ADHD with one comorbid Anxiety Disorder (Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Separation Anxiety Disorder or Panic Disorder). Youth with the following disorde rs were not excluded: any Learning Disorder, Enuresis/Encopresis, and/or an Expressive Language Disorder. There were three youth with a comorbid Reading Disorder, 10 with a comorbid Mathematics Disorder, eight with a Written Expression Disorder, one with a Learning Disorder Not Otherwise Specified, four with Enuresis, one with Encopresis, and two with Mixed Receptive Expressive Language Disorder. In terms of ADHD subtypes, over half the sample (53%) had a diagnosis of ADHD Combined Type and most of the rema ining sample had ADHD Inattentive Type (42%) with a few having a diagnosis of ADHD Not Otherwise Specified (5%). The lack of youth with an ADHD Hyperactive Impulsive Type is common in research studies due to the failure of children to meet complete criteri a for this diagnosis (Greene, Beszterczey, Katzenstein, Park, & Goring 2002 ). Measures Apart from collecting data on ADHD symptom severity, the following measures were utilized to capture functional impairment (or an aspect of functional impairment) from two different informants: the parents of the child and the supervising clinician.

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21 Global Assessment of Functioning (GAF) The GAF score is a clinician rated item where the clinician provides an estimate of how well the child is functioning, using a one to 100 point scale where every ten points represents a range of functioning generally seen in individuals with certain types of symptoms. Higher scores on this rating scale represent better levels of functioning. For example, 61 1 GAF score is reliable for analyzing group level differences in functioning (Sderberg, Tungstrm & Armelius, 2005). Conners, 3 rd Edi tion (Conners 3) The Conners 3 ( Conners, 2008) was administered to assess ADHD symptoms. The parent report version used in this study is for youth ages 6 18 years and contains 108 items. A large, representative national sample was used to s tandardize the DSM IV TR ADHD Inattentive and ADHD Hyperactive/Impulsive symptom scales used in this study to national averages using standardized T Scores. The Conners 3 has strong psychometric properties such as well established internal consistency, reliability and validity ( Conners, 2008 ). In this sample, strong internal consistency for the ADHD observed, consistent with the .83 .94 ranges observed in the national sample. For the Conners 3, higher scores refle ct increased ADHD severity. Behavior Rating Inventory of Executive Functioning (BRIEF) The BRIEF (Gioia, Isquith, Guy, & Kenworthy, 2000) was administered to assess management and problem

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22 sol ving abilities captured by the Metacognition scale of the BRIEF. Overall, the BRIEF world situations that often occur at home, school, etc. The Behavioral Regulation sc ale was not included in this analysis due to its inherent overlap with ADHD symptomology that is already captured with the Conners parent report version of the BRIEF is an 86 item survey for youth ages 5 18 years of a ge that asks parents to rate the frequency that their child displays certain behaviors established internal consistency, reliability and validity in both community and clinical sample s (Gioia et al., 2000; Gioia, Isquith, Retzlaff, & Espy, 2002). The Metacognition scale of the BRIEF collected for this study echoed the findings of these larger community and ower scores reflect more impairment in Metacognition (reversed scored for consistency with other measures). Behavior Assessment System for Children, 2 nd Edition (BASC 2) The BASC 2 (Reynolds & Kamphaus, 2004) is a widely used multidimensional assessment th parent report version used for this study is for youth ages 6 21 and contains 148 items; each is rated on a four point scale with respect to the frequency of occurrence (never, sometimes, o ften, and almost always). The Adaptability scale of the BASC 2 was used in this study to assess how youth handle unpredictable changes in their environment, such as adjusting to a new teacher at school. The BASC 2 has well established psychometric properti es, such as internal consistency, convergent validity, etc. (Reynolds & Kamphaus, 2004). Internal consistency for the Adaptability subscale in this

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23 study was .79. Similar to the BRIEF, the BASC 2 provides a nationally normed T Score for each child in this study. For the BASC 2, lower scores represent more impairment in adaptability. Pediatric Quality of Life Inventory, Version 4.0 (PEDSQL) quality of life, specifically emotional (five items), social (five items) and school functioning (five items) that is captured by the Psychosocial scale used in this study. Items are rated on a 5 point scale and lower scores on the PEDSQL indicate more impairment in psychosocial functioning. Develope d from focus groups, cognitive interviews, and pilot testing, the 23 item, parent report PEDSQL has displayed strong reliability and validity in both healthy and patient populations (Varni, Burwinkle, Seid, & Skarr, 2003; Varni, Seid, & Kurtin, 2001). For this study, strong internal consistency was observed for the Psychosocial scale (.87). Statistical Analysis All data analysis was conducted using the Statistical Package for the Social Sciences, version 19.0 and 20.0 (SPSS 19.0/ 20.0). All data entry was c onducted by the members of the research team and supervised by the first author. Procedures were conducted to check for accuracy. For the measures used, there was no missing data for the clinician rated GAF scores and no more than 2% missing for any of the parent report measures per participant. This low quantity of missing data and the nature of the data collection in which parents were waiting for their child to be tested and thus had no time constraints, extra expenses (e.g., gas) or other factors that m ay contribute to identifiable patterns of missing data, support that this data is missing completely at random and thus is justifiable to estimate. For estimation, multiple imputation with 10

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24 imputations was conducted, which is sufficient to accurately est imate the data for this small sample size (Rubin, 1987). For preparatory analyses, all variables were checked to ensure they met all normality assumptions, as well as any specific assumptions required to conduct a Multivariate Analysis of Covariates (MANCO VA). A MANCOVA was then conducted to investigate the hypotheses proposed in the first chapter. The main goal of a MANCOVA is to test whether mean differences among the groups (independent variable) on a combination of dependent variables are likely to have occurred by chance, while simultaneously controlling for extraneous variables. This is accomplished by forming a single dependent measure from a combination of all dependent measures that maximizes the between group differences. By including more than one dependent variable, the chance of discovering what more clearly defines the groups is increased. There are several reasons for conducting a MANCOVA instead of multiple Analysis of Covariance (ANCOVA). First, MANCOVA takes into account the pattern of cova riation among the dependent measures that often can greatly skew results if ignored and generally increases power if addressed (Tabachnick & Fidell, 2001). Additionally, conducting a broad MANOVA reduces family wise error by allowing the researcher to iden tify significant ANCOVAS for multiple dependent variables in one additional analyses from family wise error, several flaws in this widely cited study have been suggested (Bray & Maxw ell, 1982), and thus each post hoc analysis was conducted using a Bonferroni correction.

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25 For the MANCOVA, GAF, Metacognition, Adaptability, and Psychosocial scores were entered as dependent variables and diagnosis type (ADHD, ADHD+ Anxiety Disorder, or AD HD+ Mood Disorder) was entered as the independent variable. ADHD symptom severity for hyperactivity/impulsivity and inattentiveness, as captured by the two symptom scales of the Conners 3, were entered as covariates to control for differences in ADHD sever ity.

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26 CHAPTER 3 RESULTS Preliminary Analyses In order to conduct a MANCOVA, several sample assumptions must be met, specifically 1) the homogeneity test of variance/covariance, 2) the linearity of dependent variable relationships, 3) absence of singula rity, 4) multivariate normality, and 5) adequate sample size. Homogeneity Test of Variance/C ovariance significant (p = .170). Th us, the hypothesis that the covariances are not homogeneous was rejected and the assumption of homoscedasticity is upheld. Linearity of the Dependent Variable R elationships In order to test this assumption, all relationships between dependent variables an d/or covariates were checked by conducting line plots. Visual inspection suggests that all variables are best represented by a linear relationship as the worst fitting line between two variables had an R Squared of .06. Absence of S ingularity Singularity refers to the covariance between the dependent variables and tests if redundancies between the variables may lead to missed significant effects in the conducted MANCOVA. Singularity is tested by investigating residual correlation between the dependent vari ables, and correlations above .70 indicate that the variables share more than 50% of their variance and may be better treated as one variable. In this

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27 sample, the highest correlation observed was between adaptability and psychosocial functioning, with a co rrelation of .442. Multivariate N ormality There is no direct test for multivariate normality when conducting a MANCOVA in SPSS. However, it can be assumed that if the variables in the sample meet univariate normality, then linear combinations of these var iables may meet multivariate normality. As seen in Table 3.1, all the variables in this MANCOVA analysis meet the univariate normality tests of skewness and kurtosis. Results for Aim One Aim one examined how having ADHD or ADHD and a comorbid Anxiety or M ood Disorder impacted both global and domain specific functioning across three archetypes of functional impairment which assesses impairment in ability to adjust in new circumstances (Adaptability), impairment in social, emotional and school functioning (P sychosocial), as well as cognitive functioning (Metacognition). A global clinician assessment of functioning was also used (GAF). ADHD versus ADHD and an Anxiety Disorder Across all four measures of functional impairment, only one significant difference o ccurred between youth with solely ADHD and youth with ADHD and a comorbid Anxiety Disorder. The one exception being on the adaptability index, youth with solely ADHD functioned significantly better then youth with ADHD and a comorbid Anxiety Disorder (p <. 01). This difference between these two means was over a standard deviation difference in functioning. Additionally, youth with ADHD and a comorbid Anxiety Disorder also functioned slightly worse across Psychosocial, Metacognition and

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28 GAF measures, although none of these comparisons were significantly different. These results can be observed in Table 2. ADHD versus ADHD and a Mood Disorder Youth with solely ADHD consistently functioned better than youth with ADHD and a comorbid Mood Disorder. Youth with ADH D had significantly higher global functioning than their peers with ADHD and a comorbid Mood Disorder on GAF (p < .000). The difference observed in GAF scores was over 10 points. This implies that children with solely ADHD (mean = 63) generally were having mild difficulties in school and social functioning while children with ADHD and a comorbid Mood Disorder (53) were having moderate difficulties in school and social functioning (American Psychiatric Association, 2000). This subjective clinician observed d iscrepancy in functioning can be observed in scores on the Psychosocial scale from the PEDSQL, which asks parents to describe how their children are functioning with friends, at school, and emotionally. For this measure, youth with solely ADHD scored over one standard deviation higher (better functioning) than their peers with ADHD and a comorbid mood disorder (p < .000). This relationship was found for Adaptability (p < .000) and Metacognition scores (p < .000), where youth with ADHD and a comorbid Mood Di sorder functioned 1 2 standard deviations worse than their ADHD peers (see Table 2). Results for Aim Two Aim two investigated how having ADHD and a comorbid Anxiety or Mood Disorder impacted functioning across a subjective clinician assessment of global f unctioning and three archetypes of functional impairment (Adaptability, Psychosocial, and Metacognition). In general, youth with ADHD and a comorbid Mood Disorder functioned worse than youth with ADHD and a comorbid Anxiety Disorder.

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29 GAF On clinician rated GAF scores, youth with ADHD and a comorbid Mood Disorder were rated an average of 10 points lower than youth with ADHD and a comorbid Anxiety sychiatric Association, 2000). Adaptability Similarly, parents reported that youth with an ADHD and comorbid Anxiety Disorder diagnosis function an average of seven points higher than youth with ADHD and comorbid Mood Disorder (p < .05). While less than a standard deviation, it is notable since Adaptability was the one aspect of functioning where youth with a comorbid Anxiety Disorder scored significantly lower than youth with solely ADHD. Psychosocial As with Adaptability ratings, parents rated youth with ADHD and a comorbid Mood Disorder almost one standard deviation lower on Psychosocial functioning than youth with ADHD and a comorbid Anxiety Disorder (p < .05). Metacognition In terms of cognitive self management and daily problem solving, parents rated children with ADHD and a comorbid Mood Disorder as functioning nine points lower than children with ADHD and a comorbid Anxiety Disorder (p < .05). This is almost one standard deviation difference and thus reflects a significant deviation in functioning. Results for Aim Three Aim three inspected the interaction effect between comorbidity status and ADHD subtype. More specifically, the aim was to investigate if having a certain ADHD subtype influenced the relationship between comorbidity status and function al impairment.

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30 Because of sample size limitations, only ADHD Combined Type and ADHD Inattentive Test for the interaction between comorbidity status and ADHD subtype was non significant (p < .067). Wh ile non significant across impairment measures, an interaction between a Mood Disorder comorbidity and ADHD Inattentive Type appeared to be trending, as highlighted below. GAF In terms of GAF scores, youth with a comorbid Anxiety Disorder or solely ADHD h ad similar GAF scores regardless of ADHD subtype. However, children with a comorbid Mood Disorder had lower clinician rated functioning by 5.4 points if they had ADHD Inattentive Type compared to ADHD Combined Type, although this difference in means was no t significant (p = .136). Adaptability As with GAF scores, youth with a comorbid Mood Disorder were more impaired in Adaptability if they had a diagnosis of ADHD Inattentive Type compared to ADHD Combined Type. There was a half a standard deviation discre pancy between these subtypes but this difference was not significant (p = .105). Notably, children with a comorbid Anxiety Disorder were 8 points lower in parent ratings if they had ADHD Inattentive Type versus ADHD Comorbid Type (p =.059). Psychosocial Psychosocial scores were on average 2.2 points lower for youth with a comorbid Mood Disorder who had ADHD Inattentive Type compared to ADHD Comorbid Type (p = .787). While not significant, this difference mirrors the larger discrepancies in GAF and Adaptab ility scores.

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31 Metacognition Youth with a comorbid Mood Disorder who had a diagnosis of ADHD Inattentive Type scored 2.5 points lower in Metacognition compared to youth who had a diagnosis with ADHD Combined Type (p = .597). Summary Overall, youth who hav e ADHD and a comorbid Mood Disorder have more functional impairment than youth with ADHD and a comorbid Anxiety Disorder or youth with just solely ADHD. All three archetypes of functional impairment displayed this discrepancy (see Figure 3 1., 3 2., and 3 2.), youth with ADHD and a comorbid Anxiety Disorder had similar levels of impairment to those with just a diagnosis of ADHD Finally, no significant interaction effects between comorbidity type and ADHD subtype was observed, although a slight trend towards an interaction between a Mood Disorder and Inattentive subtype was observed.

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32 Table 3 1. Descriptive s tatistics N Minim um Maximum Mean Std. Deviation Z Statistic Skewness Kurtosis GAF a 59 40.00 80.00 59.92 8.49 .582 .080 Hyperactive/ Impulsive b 59 40.00 121.00 72.29 18.18 .961 .507 Inattentive c 59 52.00 104.00 76.44 12.91 .527 .974 Adaptability d 59 20.00 65.00 42.09 11.00 1.15 .600 Metacognition e 59 44.00 89.00 68.85 10.57 .466 1.79 Psychosocial f 59 31.67 96.67 64.85 17.56 .524 1.78 Note : Significant Skewness or Kurtosis is indicated by a Z statisitic greater than 1.96. a Global Assessment of Functiong, b Con ners 3 ADHD Hyperactive/Impulsive Type, c Conners 3 ADHD Inattentive Type, d BASC 2 Adaptability, e BRIEF Metacognition, f PEDSQL Psychosocial Table 3 2 Mean comparisons for youth from three diagnoses groups Dependent variable Group (I) Group (J) Mean d ifference (I J) GAF a ADHD ADHD MD ADHD AD ADHD MD ADHD AD 10.93*** .871 10.01** Adaptability b ADHD ADHD MD ADHD AD ADHD MD ADHD AD ADHD ADHD MD ADHD AD ADHD MD ADHD AD ADHD ADHD MD ADHD AD ADHD MD ADHD AD 17.41*** 10.40** 7.01* Psychosocial c 19.92*** 3.24 16.67*** Metacognition d 10.58*** 1.34 9.25* Note: This table displays the mean differences between youth with ADHD, ADHD and a comorbid Mood Disorder (ADHD MD), and ADHD with a comorbid Anxiety Disorder (ADHD AD). a Global Assessment of Functiong, b BASC 2 Adaptability, C PEDSQL Psychosocial, d BRIEF Metacognition. Significance is represented as follows: p < .05*, p < .0 1**, p < .001***.

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33 Figure 3 1. G raph of GAF means for the three diagnostic groups. In this graph, represents Anxiety Disorder. The X axis displays different comorbid subgroups and the Y ax is reflects score on functional impairment measure. Figure 3 2. Graph of Adaptability means for the three diagnostic groups. In this graph, Anxiety Disorder. The X axis displays different comorbid subgroups and the Y axis reflects score on functional impairment measure.

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34 Figure 3 3 Graph of Psychosocial means for the three diagnostic groups. In this graph, d Anxiety Disorder. The X axis displays different comorbid subgroups and the Y axis reflects score on functional impairment measure. Figure 3 4 Graph of Metacognition means for the three diagnostic groups. In this ood D comorbid Anxiety Disorder. The X axis displays different comorbid subgroups and the Y axis reflects score on functional impairment measure.

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35 CHAPTER 4 DISCUSSION Implications for Subtype Classification Results support th at youth with a comorbid Mood Disorder present with significantly higher impairment than their peers with a comorbid Anxiety Disorder, suggesting that if an ADHD with an Internalizing Disorder subtype were developed, it supports this possible classification; depression may stem from the same genetic vulnerability as ADHD, rather than being the emotional sequela of untreated ADHD (Wilens et al., 2002; Biederman, Faraone, Keenan & Tsuang, 1991). Biederman and colleagues (1991) found that having ADHD and a comorbid Mood Disorder did not increase the liklihood of their realitives developing a Mood Disorder, although Mood Disorders alone have a strong genetic link (see Sullivan, Neal e, & Kendler, 2000). Research has also found that Mood Disorders present comorbidly with ADHD before the age of five years old in a sample of preschool and elementary aged children with ADHD (Wilens et al., 2002), and p reliminary research suggests that tre atments typically used for ADHD may also be efficacious for treating depression in children of a similar age range (Lenze, Pautsch, & Luby, 2010). Taken together, this literature supports that these two disorders sometimes have a similar etiological patter n and may represent a unique form of ADHD. As highlighted in the introduction, there is a lack of literature on how psychological treatment for ADHD is impacted by a comorbid Mood Disorder, although it appears comorbid depression may hinder the effectiven ess of pharmacological therapy ( Spencer, Biederman, & Wilens, 1999 ) The findings of the present study echo previous

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36 literature that has found elevated functional impairment in children with ADHD and a comorbid Mood Disorder (Biederman et al., 2002; Greene et al., 1996; Shear, DelBello, Rosenberg, & Strakowski, 2002 ; Shear, DelBello, Rosenberg, Jak, & Strakowski, 2004). Taking into account the similar genetic vulnerability, negative impact on pharmacological therapy, and the clear increase in functional imp airment across multiple domains (psychosocial, cognitive, etc.) found in this study, it appears an Interaction of ADHD S ubtype and Internalizing Disorders Results of this research did not observe any significant interaction between ADHD subtypes (ADHD Combined Type and ADHD Inattentive Type) and Internalizing Disorders (Anxiety Disorders or Mood Disorders) in how they impact functional impairment. This parallels past research that has failed to fi nd a discrepancy in anxiety or depression symptoms between ADHD subtypes (Mayes, Calhoun, Chase, Mink & Stagg 2009; Power, Costigan, Eiraldi, & Leff, 2004). Attenuating Effects of Anxiety on ADHD A noteworthy finding is the nearly identical scores betwee n youth with ADHD and a comorbid Anxiety Disorder and youth with solely ADHD across the functional impairment measures utilized in this study. In three out of four impairment indices, youth in these two subsamples were not significantly different, with the one exception being Adaptability scores. While children with an Anxiety Disorder consistently had worse reported impairment, the discrepancy between the means of the two groups often differed by just a few points. One possible explanation for this discre pancy could result from the attenuating effect of anxiety on ADHD symptoms that has been documented often in the literature

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37 for over twenty years (Pliszka, 1989). Schwartz and Rostain (2006) conducted a review that concluded that comorbid anxiety in ADHD m ay inhibit impulsivity while making inattention symptoms worse. While not directly collecting data on functional impairment, it could be posited that this decrease in impulsivity and increase in inattentiveness as a result of comorbid anxiety may result in no net overall change in functioning, as observed in this study. Limitations One limitation of this study is a small sample size. Our sample had 33 youth with a diagnosis of solely ADHD, 16 with a diagnosis of ADHD with a comorbid mood disorder and 10 wi th a diagnosis of ADHD and a comorbid anxiety disorder. Researchers disagree regarding the sample size needed to obtain reliable MANCOVA results (VanVoorhis & Morgan, 2007). One consistent convention for conducting a MANOVA is that for each cell (dependent variables x independent variable) there are more participants than dependent variables. With four dependent variables for each cell, this basic requirement is easily achieved (Tabachnick & Fidell, 1996). With this criteria met, a minimal sample size sugge sted in the literature is 7 participants per cell, with a minimum of three cells and a medium effect size of .50 (Kraemer & Thiemann, 1987). Test was .484 and the lowest number of participants per ce ll for the first two aims was 10. For aim three, the lowest frequency was 5 individuals per cell and thus, these results are preliminary and may have become significant with increased power. Other limitations include reliance on mostly parent report data, a predominately male sample and cross sectional data permitting any analysis of causality between internalizing symptoms and functional impairment our sample of youth with ADHD.

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38 Future Directions These findings stand with the findings of Karustis, Power, Rescorla, Eiraldi, & Gallagher (2000) as the only research investigating differences in functional impairment between youth with ADHD and an Anxiety Disorder versus those with a comorbid Mood Disorder. Results of this study indicate that youth with ADHD an d a comorbid Mood Disorder have substantially more impairment in their functioning compared to peers with ADHD and an Anxiety Disorder. Future research should investigate what contributes to this discrepancy in impairment, beginning by exploring which aspe cts of depression contribute to the additional impairment, such as anhedonia or decreased energy. The lack of research investigating the classification criteria of Cantwell (1995) needs to be addressed before a new subtype of ADHD with a comorbid Mood Diso rder could be established. These findings addressed one component of this criteria (functional impairment), thus, research examining other aspects such as treatment outcome is warranted and would help move the field closer to better classifying ADHD. Likew ise, research, following preliminary work of Mick and colleagues (2005), regaurding how these children could be identified based on clinic presentation is also needed to help clinicians quickly recognize these youth and adjust their treatment plan accordin gly.

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39 LIST OF REFERENCES American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Banaschewski, T., Brandeis, D., Heinrich, H., Albrecht, B., Brunner, E., & Rothenberge r, A. (2003) Association of ADHD and conduct disorder brain electrical evidence for the existence of a distinct subtype. Journal of Child Psychology and Psychiatry, 44 (3), 356 376. doi: 10.1111/1469 7610.00127 Biederman, J., Faraone, S., Keenan, K., Ben Tsaung, M. T. (1992) Further evidence for family genetic risk factors in attention deficit hyperactivity disorder: patterns of comorbidity in probands and relatives in psychiatrically and pediatrically referred sample s. Archives of General Psychiatry, 49 ,728 738. Biederman J Faraone S V Keenan K & Tsuang M T (1991). Evidence of familial association between attention deficit disorder and major affective disorders Archives of General Psychiatry, 48, 633 64 2. Johnson, M. A. (2002). Influence of gender on attention deficit hyperactivity disorder in children referred to a psychiatric clinic. The American Journal of Psychiatry, 1 59 (1) 36 42. doi: 10.1176/APPI.AJP.159.1.36 Perrin, J. (2006). Clinical correlates of enuresis in ADHD and non ADHD Children. Journal of Child Psychology and Psychiat ry, 36, 865 877. doi: 10.1111/j.1469 7610.1995.tb01334.x Blackman, G. L., Ostrander, R., & Herman, K. C. (2005). Children with ADHD and Depression: A Multisource, Multimethod Assessment of Clinical, Social, and Academic Functioning Journal of Attention Disorders, 8 (4), 195 207. doi: 10.1177/1087054705278777 Bray, J. H., Maxwell, S. E. (1982). Analyzing and Interpreting Significant MANOVAs. Review of Educational Research, 52 (3), 340 367. doi: 10.3102/00346543052003340 Buitelaar J Van der Gaag R Swaa b Barneveld, H. S., Kuiper, M. (1995). Prediction of clinical response to methylphenidate in children with attention deficit hyperactivity disorder. J ournal of the Am erican Acad emy of Child and Adolesc ent Psychiatry 34, 1025 1032 doi: 10.1097/0000485 3 1995080000 00012 Cantwell D P (1995). Child psychiatry : introduction and overview. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive Textbook of Psychiatry/VI (pp. 2151 2154) Baltimore: Williams & Wilkins.

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40 Carlson, C. L., & Mann, M. (2002). Sl uggish cognitive tempo predicts a different pattern of impairment in the attention deficit hyperactivity disorder, predominantly inattentive type. Journal of Clinical Child and Adolescent Psychology, 31 ,123 129. doi: 10.1207/S15374424JCCP3101_14 Conners, K (2008). Conners 3 rd edition (3 rd ed.). Toronto, Canada: Multi Health Systems. Gioia, G., Isquith, P., Guy, S., & Kenworthy, L. (2000). BRIEF: Behavior Rating Inventory of Executive Function Odessa, FL: Psychological Assessment Resources. Gioia, G. A., Isquith, P. K., Retzlaff, P. D., & Espy, K. A. (2002c). Confirmatory factor analysis of the Behavior Rating Inventory of Executive Function (BRIEF) in a clinical sample. Child Neuropsychology, 8 249 1257. doi :10.1076/chin.8.4.249.13513 Greene, R. W., Beszterczey, S. K., Katzenstein, T., Park, K., & Goring, J. (2002). Are students with ADHD more stressful to teach? Patterns of teacher stress in an elementary school sample. Journal of Emotional and Behavioral Disorders, 10, 79 89. doi: 10.1177/106342 66020100020201 Greene, R. W., Biederman, J., Faraone, S. V., Ouellette, C., Penn, C., & Griffin, S. (1996). Toward a new psychometric definition of social disability in children with attention deficit hyperactivity disorder. Journal of the American Academ y of Child and Adolescent Psychiatry, 35 571 578. doi: 10.1097/00004583 199605000 00011 Hammerness, P., Geller, D., Petty, C., Lamb, A., Bristol, E., & Biederman, J. (2009). Does ADHD moderate the manifestation of anxiety disorders in children. European Child and Adolescent Psychiatry, 19 (2), 107 112. doi: 10.1007/s00787 009 0041 8 Hummel, T. & Sligo, J. (1971). Empirical comparison of univariate and multivariate analyses. Psychological Bulletin, 76, 49 57. doi: 10.1037/h0031323 Hurtig, T., Ebeling, H. Moilanen, I. (2007). ADHD and comorbid disorders in relation to family environment and symptom severity. European Child and Adolescent Psychiatry 16 362 369. doi: 10.1007/s00787 007 0607 2 Jense n, P. S., Hinshaw, S. P., Kraemer, H. C., Lenora, N., Newcorn, J. H., Abikoff, H. comparing comorbid subgroups. Journal of the American Academy of Child and Adolescent Psychiatry 40 147 158. doi:10.1097/00004583 200102000 00009 Jensen P Martin C Cantwell D (1997). Comorbidity in ADHD: implications for research, practice, and DSM V J ournal of the Am erican Acad emy of Child and Adolesc ent Psychiatry 36 1065 1079 Doi: 10.1 097/00004583 199708000 00014

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41 Kraemer, H. C., & Thiemann, S. (1987). How many subjects? Statistical power analysis in research. Newbury Park, CA: Sage. Karustis, J. L., Power, T. J., Rescorla, L. A., Eiraldi, R. B., & Gallagher, P. R. (2000). Anxiety an d depression in children with ADHD: Unique associations with academic and social functioning. Journal of Attention Disorders, 4 (3), 133 149. doi: 10.1177/108705470000400301 Lahey, B. B.,Pelham, W. E., Loney, J., Lee, S. S., & Willcutt, E. (2005). Insta bility of the DSM IV Subtypes of ADHD From Preschool Through Elementary School. Archives of General Psychiatry,62 (8), 896 902. doi: 10.1001/archpsyc.62.8.896 Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of c omorbidity, functionin g, and service u se for US children with ADHD 2007. Pediatrics, 127 (3), 462 470. doi: 10.1542/peds.2010 0165 Lenze, S. N., Pautsch, J., & Luby, J. (2011). Parent child interaction therapy emotion development: a novel treatment for de pression in preschoo l children. Depression and Anxiety 28 ( 2 ), 153 159. doi: 10.1002/da.20770 March, J. S., Swanson, J. M., Arnold, L. E., Hoza, B., Conners, C. K., Hinshaw, S. P., multimodal treatment study of children with ADHD (MTA1). Journal of Abnormal Child Psychology, 28 (6), 527 541 Mayes S D Calhoun S L Chase G A Mink D M & Stagg R E. (2009). ADHD subtypes and co occurring anxiety, depression, and Oppositional Defiant Disorde r: Differences in Gordon Diagnostic System and Wechsler Working Memory and Processing Speed Index scores. Journal of Attention Disorders 12 540 550. doi : 10.1177/1087054708320402 tility of the Behav ior Rating Inventory of Executive Function (BRIEF) in the d iagnosis of ADHD. Journal of Attention Disorders 10 381 389. doi: 10.1177/1087054706292115 Mikami, A. Y., Ransone, M. L., Calhoundoi, C. D. (2011). Influence of Anxiety on the Social Functionin g of Children With and Without ADHD. Journal of Attention Disorders,15 (6), 473 484. doi:10.1177/1087054710369066 Mick, E., Spencer, T., Wozniak, J., & Biederman, J. (2005). Hetrogeniety of irritability in Attention Deficit/Hyperactivity Disorder subjects with and without Mood Disorders. Biological Psychiatry, 58 (7), 576 582. doi: 10.1016/j.biopsych.2005.05.037 MTA Cooperative Group (1999b). Effects of comorbid anxiety disorder, family poverty, session attendance, and community medication on treatment ou tcome for attention deficit hyperactivity disorder. Archives of General Psychiatry, 56 ,1088 1096.

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42 (2008). Autism symptoms in attention deficit/hyperactivity diso rder: a familial trait which correlates with conduct, oppositional defiant, language and motor disorders. Journal of Autism and Developmental Disorders 39, 197 209. doi:10.1016/j.biopsych.2004.08.025 Nigg, J. T., Willcutt, E. W., Doyle, A. E., & Sonuga Ba rke, E. J. (2004). Causal heterogeneity in Attention Deficit/Hy peractivity Disorder:Do we need neuropsychologically impaired subtypes? Journal of Biological Psychiatry, 8 (25), 1 7. doi: 10.1016/j.biopsych.2004.08.025 Newcorn J H Miller S R Ivano va I Schulz K P Kalmar J Marks D J & Halperin J M (2004). Adolescent outcome of ADHD: impact of childhood conduct and anxiety disorders. CNS Spectrum, 9 (9), 668 678. Oosterlaan, J., & Sergeant, J. A. (1998). Response inhibition in AD/HD CD, co morbid AD/HD and CD, anxious, and control children: A meta analysis of studies with the stop task. Journal of Child Psychology and Psychiatry, 39 (3), 411 425. doi : 10.1111/1469 7610.00336 Owens E B Hinshaw S P & Kraemer H C (2003) W hich treatment for whom for ADHD? Moderators o f treatment response in the MTA Journal of Abnormal Child Psychology, 71 540 552 doi: 10.1037/0022 006X.71.3.540 Plizska, S. R. (1989). Effect of anxiety on cognition, behavior and stimulant response in ADH D. Journal of the American Child and Adolescent Psychiatry, 28 (6), 882 887. doi:10.1097/00004583 198911000 00012 Power, T. J., Costigan, T., Eiraldi, R., & Leff, S. (2004), Variations in anxiety and depression as a function of ADHD subtypes defined by DS M IV: do subtype differences exist or not? Journal of Abnormal Child Psychology 32 27 37. doi: 10.1023/B:JACP.0000007578.30863.93 Reynolds, C. R., & Kamphaus, R. W. (2004). Behavior Assessment System for Children (2nd ed.). Circle Pines, MN: American G uidance System Publishing. Rubin, D. B. (1987). Multiple Imputation for Nonresponse in surveys New York, New York: Wiley & Sons. Schatz, D. B., & Rostain, A. L. (2006). ADHD with comorbid anxiety: A review of the current literature. Journal of Attentio n Disorders, 10 doi: 10.1177/1087054706286698 Scheffer, R. E., Kowatch, R. A., Carmody, T., & Rush, A. J. (2005). Randomized, placebo controlled trial of mixed amphetamine salts for symptoms of comorbid ADHD in pediatric bipolar disorder after m ood stabilization with divalproex sodium. American Journal of Psychiatry, 162 (1), 58 64. doi: 10.1176/appi.ajp.162.1.58

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43 Shear, P. K., DelBello, M. P., Rosenberg, H. L., Jak, A. J., & Strakowski, S. M. (2004, February). Cognitive functioning in manic adol escents with bipolar disorder: contribution of comorbid ADHD. Paper presented at the International Neuropsychological Society, Baltimore, MD. Shear, P. K., DelBello, M. P., Rosenberg, H. L., & Strakowski, S. M. (2002). Parental reports of executive dysfun ction in manic adolescents. Child Neuropsychology, 8 (4), 285 295. doi: 10.1076/chin.8.4.285.13511 Sderberg, P., Tungstrm, S., & Armelius, B. (2005). Reliability of Global Assessment of Functioning Ratings Made by Clinical Psychiatric Staff. Psychiat ric Services, 56 (4), 434 438. 10.1176/appi.ps.56.4.434 Sullivan, P. F., Neale, M. C. & Kendler, K. S. (2000). Genetic Epidemiology of Major Depression: Review and Meta analysis. American Journal of Psychiatry, 157 1552 1562. doi: 10.1176/appi.ajp.157.10 .1552 Tabachnick, B. G., Fidell, L. S. (1996). Using Multivariate Statistics (3 rd ed.). Boston: Allyn & Bacon. Tannock, R., Schachar, R., & Logan, G. D. (1995). Methylphenidate and cognitive flexibility: Dissociated dose effects on behavior and cognitio n in hyperactive children. Journal of Abnormal Child Psychology, 23, 235 266. doi: 10.1007/BF01447091 Varni, J. W., Burwinkle, T. M., Seid, M., & Skarr, D. (2003). The PEDS QL 4.0 as a pediatric population health measure: feasibility, reliability, and va lidity. Ambulatory Pediatrics, 3 329 341. doi:10.1367/1539 4409(2003)003<0329:TPAAPP>2.0.CO;2 Varni, J. W., Seid, M., & Kurtin, P. S. (2001). The PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Medical Care, 39 800 812. doi: 10.1097/00005650 200108000 00006 Varni, J. W., Seid, M., & Rode, C. A. (1999). The PedsQL: measurement model for the pediatric quality of life inventory. Med ical Care, 37 126 13 9. doi: 10.1097/00005650 199902000 00003 Wilens, T. E., Biederman, J., Brown, S., Tanguay, S., Monuteaux, M. C., Blake, C. & Spencer, T. J. (2002). Psychiatric Comorbidity and Functioning in Clinically Referred Preschool Children and School Age Youths Wi th ADHD Journal of the American Academy of Child and Adolescent Psychiatry, 41 (3), 262. doi : 10.1097/00004583 200203000 00005 Youngstrom, E. A., Eugene L. A., & Frazier, T. W. (2011). Bipolar and ADHD Comorbidity: Both Artifact and Outgrowth of Shared Mechanisms Clinical Psychology: Science and Practice, 17 (4), 350 359. doi: 10.1111/j.1468 2850.2010.01226.x

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44 BIOGRAPHICAL SKETCH Adam Mi chael Reid was born in Titusville, Florida. The youngest of three, he spent the majority of his childhood in Gainesvil le, Florida and graduated from Buchholz High School in 2007. He then attended the University of Florida for his undergraduate education and graduat ed a year early with a Bachelor of Science in Psychology. During these three years, he maintained a 4.0 Psych ology G.P.A. while volunteering in three research labs and two community health centers. He spent a summer in Australia doing an internship at the University of Sydney Brain and Mind Research Institute and worked 10 hours a week administering psychological assessment batteries at an internship at the Behavioral Health Unit at Shands Hospital. Adam was awarded the University Scholars Award which provided funding for him to conduct two senior theses: one on the impact of sleep on Obsessive Compulsive Disorder (OCD) and a second which developed the first measure of insight for children with OCD. As a result of his academic achievement, he graduated with highest honors in 2010. Adam currently is in his second year of his doctoral training in Clinical and Health P sychology at the University of Florida, under the mentorship of Dr. Gary Geffken. His first two years have been spent treating a variety of patients, from youth with OCD to adults with Bipolar Disorder. His research interests include treatment augmentation for youth with OCD and impro ved classification of Attention Deficit Hyperactivity Disorder and pediatric Anxiety Disorders. He has submitted a National Research Service Award to the National Institute of H ealth which he hopes will fund his dissertation that aims to develop a new classification system for Anxiety Disorders. Adam is an avid Gator fan and enjoys traveling around the world.