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Running Head: Parental expressed emotion and ADHD 1
Attention-Deficit/Hyperactivity Disorder Developmental Trajectories related to Parental
Expressed Emotion
Musser, E.D.1, Karalunas, S.L.2, Dieckmann, N.2, Peris, T.3, & Nigg, J.T.2
1. Florida International University
2. Oregon Health & Science University
3. University of California, Los Angeles/Semel Institute
Submitted for Journal of Abnormal Psychology Special Section on ADHD Development in
Longitudinal Studies
Corresponding Author:
Erica D. Musser, Ph.D.
Florida International University
11200 SW 8th Street
AHC 4 455
Miami, FL 33199
emusser@fiu.edu
(305) 348-1034
Running Head: Parental expressed emotion and ADHD 2
Abstract
Background. In the transition from childhood to adolescence, attention-deficit/hyperactivity
disorder (ADHD) developmental trajectories diverge. Family environment, as indexed by
parental expressed emotion, may moderate these trajectories.
Methods. 388 children with ADHD and 127 control children were assessed using a multi-
informant, multi-method diagnostic procedure at up to three time points one year apart in an
accelerated longitudinal design spanning ages 7-13 years. Latent-class growth analysis (LCGA)
was used to identify developmental trajectories for both parent- and teacher-rated ADHD and
ODD symptoms within the ADHD sample. Parental expressed emotion, criticism, and emotional
over-involvement were coded from a 5-minute speech sample at two time points, one year
apart, for 208 of these children and compared to the non-ADHD sample and among the ADHD
trajectory groups.
Results. Parent-rated hyperactivity yielded a four class trajectory solution in LCGA; teacher-
rated inattention yielded a three-trajectory solution. Teacher-rated ODD also yielded three-
trajectory solution. A parent-rated high persistent hyperactive group was more likely than the
other ADHD groups to have parents with stable high criticism (34.6%, p<.001), with ODD
symptoms controlled. A teacher-identified high ODD-worsening group was more likely to
experience high criticism at either time point, particularly the initial time point; (87.5%, p<.001),
with hyperactivity controlled.
Conclusion. Parental criticism, an index of the family environment, is uniquely associated with
divergent developmental trajectories among children with ADHD in addition to those associated
with ODD symptoms.
Lay Summary. For many children, attention-deficit/hyperactivity disorder (ADHD) symptoms
decrease as they transition to adolescence. Family environmental factors, such as high levels of
parental criticism, may help explain for whom symptom remission is less likely.
Running Head: Parental expressed emotion and ADHD 3
Few would dispute that attention-deficit/hyperactivity disorder (ADHD) is heterogeneous
with respect to biology, cognition, psychosocial context, and developmental trajectory. Of
children with ADHD in childhood, 50-70% continue to have a diagnosis of ADHD during the
transition to the teen years (Langberg, Epstein, Altaye, Molina, Arnold, &Vitiello, 2008; Molina et
al., 2009; for a review see Sagvolden et al, 2005). While some individuals appear to remit,
others experience persistent problems and serious negative outcomes, including drug
abuse/addiction, school dropout, criminality, and antisocial behavior (Barkley et al, 1990;
Biederman et al., 1996, 2000; Sibley et al., 2012). However, the determinants and correlates of
this late-childhood to early-adolescent divergence are not well understood.
Clarifying determinants of developmental change in ADHD is complicated by normative
age-related changes in behavior. In particular, symptoms of hyperactivity and impulsivity
normatively decline across adolescence (Molina et al., 2009; Willoughby, 2003; Wolraich et al.,
2005). While this may be partly attributed to maturation of key neural networks (Casey, Jones, &
Somerville, 2011), it appears that trajectories of remitting hyperactive/impulsive (H/I) symptoms
are distinct from overall symptom severity (including inattentive symptoms), impairment, and
comorbid diagnoses (e.g., oppositional defiant disorder (ODD) and conduct disorder (CD);
Sibley et al., 2012), suggesting that either new genetic influences (Kuntsi et al., 2005) or
relevant familial or social experiences may be contributing. Further supporting the importance of
looking at family factors, longitudinal behavioral genetic studies suggest that as children
approach adolescence, stability of ADHD symptoms is primarily due to genetic factors, whereas
change is markedly influenced by environmental factors (Kan et al., 2013). Thus, further
consideration of environmental factors, and family factors in particular, during this
developmental period is needed to understand this clinically crucial variation in ADHD’s course.
Substantial literature has examined the association of family context with the course of
ADHD in children. These contextual factors have included parenting style and behaviors, family
conflict, parent and family stress, and more (see review by Jonhston and Mash, 2001). Both
Running Head: Parental expressed emotion and ADHD 4
ADHD and associated behavior problems, such as aggression and defiance, appear more likely
to persist in the context of negative and harsh family or parenting environments (Campbell et al.,
1996; Patterson, Reid, & Dishion, 1992).
However, two critical questions render interpretation of this association difficult. The first
is that it is not clear whether indices of negative emotional tone in the family environment are
correlated with distinct, empirically identified trajectories of ADHD symptoms, independently of
co-occuring behavior problems (Cherkasova, Sulla, Dalena, Ponde, Hechtman, 2013; Johnston
& Mash, 2001; Paidipati & Deatrick, 2015; Richards, 2013). This paper focuses on that question.
If this association is verified in relation to this fundamental test, then follow up work will need to
address the second question, which is to evaluate the causal direction of this association.
When it comes to measures of family context and emotional tone, particularly interesting
has been resurgent focus on parental expressed emotion (EE) in ADHD, which is theorized to
index emotional intensity in the home and thus to potentially influence chronicity of
maladjustment (for a review see Peris & Miklowitz, 2015). EE is classically understood as a two-
dimensional coded construct composed of criticism and emotional over-involvement (Miklowitz
et al., 1984; Vaughn & Leff, 1976). In particular, the criticism domain is designed to index
negativity or resentment directed toward the child, while the emotional over-involvement
category indexes behaviors which are overprotective or overly self-sacrificing (Leeb et al., 1991;
Magana et al., 1986). One frequently used metric is parental EE assessed and coded during a
five minute speech sample (FMSS; Baker et al., 2000; Leeb et al., 1991; Magana et al., 1986;
Miklowitz et al., 1984).
Exemplifying the core question guiding this study, parental high EE has been classically
associated with oppositional/aggressive behavior (Asarnow, Tompson, Woo, & Cantwell, 2001;
Caspi et al., 2004; McCarty & Weisz, 2002; Peris & Baker, 2000). However, ADHD symptom
severity also appears to be associated with parental high EE and high criticism (Cartwright et
al., 2011; Keown, 2010; Psychogiou et al., 2007, 2008; Peris & Hinshaw, 2003; Peris &
Running Head: Parental expressed emotion and ADHD 5
Miklowitz, 2015; Pfiffner, McBurnett, Rathouz, & Judice, 2005; Sonuga-Barke et al., 2008, 2009,
2013). While part of this association may be driven by comorbid oppositional/aggressive
behavior in ADHD (Baker et al., 2000; Hirshfeld et al., 1997; Peris & Baker, 2000; Vostanis &
Nicholls, 1992), research is mixed as to whether there is also a specific EE-ADHD association.
Some prior work has found that EE’s association with ADHD remains robust after controlling for
comorbid conditions (Peris & Hinshaw, 2003). Cartwright, Sonuga-Barke and colleagues (2011)
conducted a preliminary study of 60 sibling pairs and found that the association of components
of maternal EE with ADHD were fully explained by comorbid conduct problems, with the
exception of low maternal warmth, which was uniquely associated with ADHD. However, this
conclusion was somewhat qualified in a follow-up analysis in the same data set (Sonuga-Barke
et al., 2013), showing that family characteristics other than child misbehavior also influenced
maternal EE. That result further implicates the potential clinical importance of understanding EE
as an index of the family environment in shaping ADHD, and those authors called for
longitudinal studies to further clarify matters.
Lifford and colleagues (2009) conducted a longitudinal cross lagged twin study of
parental hostility and ADHD and concluded that the association was driven either by genetic
effects or child-on-parent effects. However, that study and did not examine divergent symptom
trajectories or EE per se. Richards et al. (2014) found no reliable association between baseline
EE and ADHD severity six years later, in a sample of 385 children with ADHD age 5-18 years at
baseline and 10-24 at follow-up. Again, differential ADHD developmental symptom trajectories
were not examined. Moreover, maternal EE was assessed using two different structured clinical
interviews at the two time points, neither initially designed to assess for EE.
In addition, it is unclear whether parental EE is related to behavioral outcome in children
in terms of mere exposure (at one time point) or to chronicity of elevated EE. It may be that
simply being exposed to high parental EE (or aspects of it, such as high criticism) is associated
with worse outcomes, in which case intervention would have to target prevention of harsh and
Running Head: Parental expressed emotion and ADHD 6
emotional family environments in ADHD cases or support of parental mental health in response
to ADHD in the child. Alternatively, it may be that children exposed to chronic and stable high
parental EE are at the greatest risk for poor outcomes, due to sustained exposure across time,
in which case interventions could target interruption of the emotional environment among
families where it is occurring. Supporting this logic, Sonuga-Barke and colleagues (2008, 2009)
investigated gene-by-environment effects and concluded that parental EE is a moderator of
genetic influences on both ADHD and associated externalizing behavior problems. While prior
work (cited above) suggests these associations may be bidirectional or else child-driven, our
focus here is simply to determine if chronicity is a correlated.
In summary, the goal of the current study was to examine parental EE domains’ unique
associations with differential ADHD and ODD symptom trajectories over the transition from
childhood to early adolescence in this context. We also tested the hypothesis that chronic
exposure to high parental EE (particularly criticism) will be associated with the worst outcomes.
Methods
Participants
A community-based recruitment strategy was employed in an effort to avoid bias
introduced by clinic ascertainment, as ADHD comorbidity and severity differ markedly in
clinically ascertained versus community or population samples (Willcutt & Pennington, 2000).
Families were recruited by public advertisements and mass mailings, seeking participants for
studies of the development of attention and impulsivity in children. ADHD cases were identified
following procedures outlined below. All DSM-IV or DSM-5 ADHD subtypes and presentations
were allowed. The local Institutional Review Board approved the studies. Parents provided
written informed consent and children provided written informed assent. The sample of 515
children included 388 with ADHD and 127 typically developing children, ages 7-11 at the
baseline assessment. Not all had parental measures at multiple time-points. Details related to
sample size for each analysis are in the Analysis Plan section below.
Running Head: Parental expressed emotion and ADHD 7
Case Identification Procedures. All families underwent a multi-gate screening process to
establish eligibility and ADHD diagnosis. After completing a brief telephone screen to determine
interest and to identify major rule outs (below), families visited the University for a research-
based diagnostic-evaluation. A KSAD-S-E (Puig-Antich & Ryan, 1996) was administered to a
parent by a trained master’s level clinician. Inter-interviewer reliability was kappa>0.70 for all
diagnoses with base rate >5% in the sample. Parents and teachers completed the following
widely used, well-normed, standardized rating forms (1) The ADHD Rating Scale for DSM-IV
(DuPaul et al., 1998), (b) the Conners 3rd Edition (Conners, 2008), (c) the Strengths and
Difficulties Questionnaire (Goodman, 2001). Each of these measures has established validity
and reliability and all yielded satisfactory intra-scale reliabilities in the current sample.
Impairment was scored using the impairment section of the parent and teacher SDQ and the
clinician impairment rating from the KSADS.
Children completed a valid (r=.88) and reliable (a=.93; Sattler, 2008) short IQ screen
comprising Information, Vocabulary, and Block Design subtests of the Wechsler (2003)
Intelligence Scales for Children-4th Ed (WISC-IV) and Wechsler (2005) Individual Achievement
Test 2nd Ed Word Reading, Numerical Operations, and Pseudoword Decoding subtests.
All of this information was presented to a clinical diagnostic team in order to establish a
best estimate diagnosis (Roy et al., 1997). The team included a board-certified child psychiatrist
and a licensed clinical psychologist, both blind to the parental expressed emotion data. They
independently reviewed all information to arrive at diagnoses using DSM-IV criteria, taking into
careful account age of onset, duration, impairment, cross-informant convergence, and likelihood
that another diagnosis would better account for the ADHD symptoms. Their agreement rate was
acceptable for ADHD (k >.80) and for ADHD as well as ODD and for all disorders with base-rate
>5% in the study. Disagreements were resolved by discussion. Youth in the current ADHD
cohort also meet ADHD criteria according to DSM-5.
Exclusion Criteria. Exclusion criteria include an estimated Full Scale IQ < 75 by our IQ
Running Head: Parental expressed emotion and ADHD 8
screen, use of long-acting psychotropic medication (e.g., anti-depressants) by parent report, as
well as presence of current major depressive episode, lifetime mania or psychosis, pervasive
developmental disorder (including autism), or major medical/neurological disorders or injuries as
identified on the KSADS, rating scales, or diagnostic team review. Other psychiatric disorders
were free to vary. Children were also excluded if they could not be diagnosed with ADHD or
designated a qualified control case at baseline (e.g., parent and teacher gave very different
ratings; or ADHD symptoms were subthreshold).
Measures
ADHD Symptom Change. ADHD symptoms were obtained at all data collection time-
points using the parent- and teacher-report ADHD Rating Scale (ADHD-RS; DuPaul, Power,
Anastopoulos & Reid, 1998). Parents and teachers rated each of the DSM ADHD symptoms on
a 4-point scale ranging from 0 (Never/Rarely) to 3 (Very Often). For children taking stimulant
medications, parents and teachers were asked to rate the child’s behavior when not taking
medication. Symptom counts were determined using standard scoring procedures in which a
symptom is considered present if rated as a “2” or “3” (DuPaul et al., 1998).
ODD Symptom Change. Parent-rated ODD symptoms for the growth models were
obtained at all data collection time-points using the symptom count from the K-SADS-E ODD
module because a symptom checklist was not available. Each symptom was coded as absent
(0), maybe (1/2) or present (1) and a total symptom score created in this way. Teacher-rated
ODD symptoms were obtained using a DSM-based symptom checklist (using the same scale as
the ADHD-RS) in which symptoms rated a “2” or a ‘3’ were counted as present and a total
symptom count was created and analyzed.
Expressed Emotion. Parental EE was measured via the Five Minute Speech Sample
(FMSS; Magana et al., 1986), which asks parents to describe their child and their relationship
for five minutes in their own words without interruption or guidance from the administrator. The
FMSS was audio-recorded and blindly coded. Tapes were transcribed to aid in interpretability
Running Head: Parental expressed emotion and ADHD 9
and accuracy. Two expert, independent raters each blind to ADHD symptom trajectories or
parent-teacher ratings, as well as to one another’s codes, independently coded the FMSS for
EE. The two raters were trained in the UCLA Family Project Lab where the measure originated
and have served as co-raters and/or reliability raters across numerous independent samples.
Parental EE was coded in two steps, following established procedures and an
established coding manual (Magana et al., 1986). First, the two subscales (Criticism and
Emotional Over-Involvement) are coded as low, borderline, or high. These subscale scores are
derived from coding specific aspects of the speech sample including the initial statement, the
description of the parent-child relationship, critical remarks, and evidence of extreme self-
sacrificing behavior or a lack of objectivity. Coding considered the respondent’s speech content
(via a transcript of the session) and tone (via listening to the session).
Then, a global EE score of “low” or “high” is assigned. A “high” final EE score is obtained
only when a parent receives a “high” score in either (or both) of the Criticism and/or Emotional
Over-Involvement domains. For the present report, the Criticism and Emotional Over-
Involvement subscale scores. 10% of tapes were coded blindly by both raters percentages of
agreement were 92% (k=.81) for the overall final score, 87% (k=.78) for criticism, and 84%
(k=.74) for emotional over-involvement.
Analysis Plan
Symptom Growth Models. Age-based growth models were estimated separately for
parent- and teacher-reported inattention, H/I, and ODD symptoms in the sample of children with
ADHD. Of the 388 ADHD children, 253 were enrolled in a prospective longitudinal study and
had multiple time points of data. The remaining children completed a single time point of
assessment. Thus for the ADHD youth, 38% (n=147) had one time-point of assessment; 19%
had two time points (n=73), and 43% had three time points (n=168). Retention was satisfactory
for those for whom a follow-up visit was planned (exceeding 95%).
Models were calculated using MPLUS v.7.2 (Muthen & Muthen, 2014). Where variability
Running Head: Parental expressed emotion and ADHD 10
in symptom trajectories was reasonably suspected (operationalized as variability around the
slope with p<.15 to avoid Type II error, which was the priority at that preliminary stage of
analysis), an unconditional linear latent class growth model (LCGA; Muthen & Muthen, 2000)
with no predictors was fit. LCGA defines three latent factors (class, intercept, and slope) from a
structural equation modeling framework. The latent class variable was regressed onto the
intercept and slope factors to examine differences between the latent trajectory classes in the
sample. Intercepts and slopes within each class were held equal. Two-, three-, and four- and
five-class LCGA models were fit to the data and the best-fitting model was selected based on
comparison of standard fit indices (BIC, CFI, RMSEA) and the parametric bootstrapped
Likelihood Ratio Test (LRT), which assesses whether the k-class model significantly improves
on the k-1 class model (Asparouhov & Muthén, 2012). Missing data modeling was handled
using Full Information Maximum Likelihood.
EE Domain Analyses. EE analyses focused on a randomly selected subset of the
longitudinal sample, for whom EE data were collected and coded at two time points one year
apart (n=208 with ADHD, n=127 controls), using logistic regression analyses. To code stability
of EE, Criticism, and Emotional Over-Involvement were dummy coded separately as
present/absent for each variable at each of the two assessments. Children rated at high in a
particular domain (i.e., EE, Criticism, Emotional Over-Involvement) at both assessments were
considered “stable high;” those with high scores at only one assessment were “ever high;” and
the others were “never high” in that particular domain of interest. To examine EE domain effects
on longitudinal symptom trajectories, the 208 ADHD participants with two time-points of EE data
were subjected to conditional growth models using EE domain (i.e., criticism, emotional over-
involvement) dummy codes as predictors of the above described symptom trajectory classes.
For ease of presentation only results for parental criticism and emotional over-involvement are
presented. Results for “overall” EE scores largely mirrored that of the criticism domain (available
from the first author).
Running Head: Parental expressed emotion and ADHD 11
Selection of covariates. The following variables were considered for use as either
invariant or time-varying covariates as appropriate: age at assessment, sex of child, ethnicity
and race of child, child stimulant medication use, two-parent family vs single-parent family
status, family income, child estimated full-scale IQ, comorbid diagnoses, and sex of respondent
for FMSS. Over 80% of FMSS respondents were women (mothers or female caregivers) at both
time points. Covariates were selected for inclusion if they were associated with either (a)
differed by EE rating or (b) differed by latent-trajectory class at using a criterion of p<.05. This
resulted in inclusion of the following covariates in all diagnostic group comparisons: age at
assessment, sex, two-parent family vs single-parent family, income, IQ, and comorbid
diagnoses (anxiety, mood disorders, ODD/CD). For trajectory class analysis, it resulted in
inclusion of IQ, comorbid diagnoses, and income. Respondent sex was also treated as a
covariate in all analyses of parental EE domain. ODD/CD was treated as a covariate in ADHD
symptom trajectory analyses, and ADHD was treated as a covariate in ODD trajectory analyses.
Results
Table S-1 provides a descriptive overview of the sample of 388 ADHD and 127 control
youth. No significant differences emerged between (a) the sample in Table 1 and the subset
used in the EE analyses; or ( b) those with any EE data (n=419) and the subset with two time-
points of EE data (N=208; all p> .31). Thus, random selection for EE coding succeeded.
ADHD diagnosis and expressed emotion. High parental EE Criticism were associated
with ADHD diagnosis at each time point Table S-1. Logistic regression (with covariates
described above), showed that this result held for at time 1 (Cox and Snell R2=0.088,
beta=0.270, p<.001) and Time 2 (Cox and Snell R2=0.053, beta=0.128, p<.001). Parental
emotional over-involvement was not associated with ADHD diagnosis at Time 1, but was at
Time 2 (Cox and Snell R2=0.013, beta=0.061, p=.021). Stability in high parental criticism was
more common in the ADHD than non-ADHD group (21.6% vs 1.6%) even after controlling for
covariates and comorbid anxiety, mood, and disruptive behavior diagnoses (i.e., ODD and CD;
Running Head: Parental expressed emotion and ADHD 12
Cox and Snell R2=0.072, beta=0.076, p=.003), suggesting a specific association with ADHD,
despite the prior literature linking EE to externalizing symptomology. ADHD and non-ADHD
children did not differ with respect to stable high emotional over-involvement (p=.51).
ADHD and ODD symptom trajectories: Preliminary results
Change in symptoms over time were modeled in six separate analyses (parent- and
teacher-rated inattention, hyperactivity, and ODD symptoms) using age-based growth models.
Quadratic models did not converge and indicated model misspecification. Linear growth models
provided good fit for parent-rated inattention (Adjusted BIC= 3229.9, RMSEA= 0.04, CFI=0.95),
H/I (Adjusted BIC= 3840.4, RMSEA= 0.04, CFI=0.97), and ODD (Adjusted BIC= 3100.1,
RMSEA= 0.05, CFI=0.92) with similar results for teacher-rated inattention (Adjusted BIC=
3579.7, RMSEA= 0.03, CFI=0.90), H/I (Adjusted BIC= 3454.6 RMSEA= .01, CFI=0.99), and
ODD (Adjusted BIC= 2898.1, RMSEA= 0.03, CFI=0.95).
Linear decreases with age were observed for parent-rated inattention (intercept= 5.68,
p<.001; slope= -0.39, p<.001) and H/I (intercept= 4.37, p<.001; slope= -0.47, p<.001), with
marginally significant decreases in ODD (intercept= 1.37, p<.001; slope= -0.08, p=.057) across
the 7-13 year age range. Similar decreases were observed for teacher-rated inattention
(intercept= 4.51, p<.001; slope= -0.43, p<.001), H/I (intercept= 3.36, p<.001; slope= -0.46,
p<.001), and ODD (intercept= 1.17, p<.001; slope= -0.13, p=.006).
Variability around the intercept was significant for all symptom domains and all reporters
(all p<.001), capturing initial heterogeneity in symptom severity. Variability in slope, however,
failed to meet our criterion for further analysis for parent-rated inattention (p=.52) or ODD
(p=.87) or for teacher-rated H/I (p=.99); but met our criterion for parent-rated H/I (p=.12) and
teacher-rated inattention (p=.02) and ODD (p=.11), warranting examination of individual
differences in trajectories for those measures.
Primary symptom trajectory findings
Parent-rated Hyperactivity-Impulsivity (H/I). For parent-rated H/I the unconditional model
Running Head: Parental expressed emotion and ADHD 13
yielded a best-fitting four trajectory solution (4-class model: Adjusted BIC= 3775.2, Parametric
Bootstrapped LRT test for 3 versus 4 classes p<.001; 5-class model: Adjusted BIC= 3831.5,
Parametric Bootstrapped LRT test for 4 versus 5 classes p> 0.05). These classes are depicted
in Figure 1. They were labeled as (1) Low H/I (hereafter, “Low), (2) Moderate H/I decreasing
(hereafter, “Moderate”), (3) Remitting (high symptoms but improving), and (4) Persistent (high
symptoms and remained high). In order to present results concisely, data is provided by
symptom trajectory class by parent-rated H/I, teacher-rated inattention, and teacher-rated ODD
in Tables 1-3, respectively, along with significant demographic and comorbid diagnostic data,
while demographic and comorbid diagnostics that did not differ significantly by trajectory group
is available in online supplemental Tables S1-S3. Thus, symptom trajectories and significant
descriptive and diagnostic group differences are in Table 1 with non-significant differences in
Table S-2.
Teacher-rated inattention. Here, the unconditional model yielded a best-fitting three
trajectory solution (3-class model: Adjusted BIC= 3535.6, Parametric Bootstrapped LRT test for
2 versus 3 classes p<.001; 4-class model: Adjusted BIC=3782.1, Parametric Bootstrapped LRT
test for 3 versus 4 classes p> 0.05). This solution is depicted in Figure 2, and the classes were
labeled as (1) Low inattention (hereafter, “Low”), (2) Remitting, and (3) Persistent. Symptom
trajectories and significant descriptive and diagnostic group differences are in Table 2 with non-
significant differences in Table S-3
Teacher-rated ODD. Again, a best-fitting three trajectory solution emerged (3-class
model: Adjusted BIC=2624.5, Parametric Bootstrapped LRT test for 2 versus 3 classes
p<0.001; 4-class model: Adjusted BIC=3782.1, Parametric Bootstrapped LRT test for 3 versus 4
classes p>.05). These are depicted in Figure 3. They were accordingly labeled as (1) Low
ODD, (2) Remitting, and (3) “Worsening” (high symptoms and worsened over time Symptom
trajectories and significant descriptive and diagnostic group differences are in Table 3 with non-
significant differences in Table S-4.
Running Head: Parental expressed emotion and ADHD 14
Comparison of solutions. Teacher-rated inattention trajectories did not significantly
overlap with either the parent-rated H/I (p=.645) or teacher-rated ODD (p=.211) trajectory
classes, suggesting that these are distinct groups of children as rated by both parents and
teachers, rather than the same groups being captured three ways. However, there was
significant overlap between parent-rated H/I and teacher-rated ODD trajectory classes
(X2(1)=19.99, p=.003). This overlap in turn was driven by a group of children (N=170, 43.8%)
who both reporters identified as relatively low in externalizing symptoms. Thus, associations of
EE may be distinct with ADHD versus ODD trajectories. We next examined that possibility.
Parental expressed emotion domain stability and change
Parent-rated H/I groups and parent EE. LCGA including covariates was used to test
associations of the H/I trajectory groups with parental criticism coded as stable or not stable
(see Methods). Class 1 (low), Class 2 (moderate), and Class 3 (remitting) were similar to each
other (all p>.55), but each differed from Class 4 (persistent); respective parameter estimate
versus class 4 were 0.561, se=0.233, p=.016, parameter estimate=0.763, se=0.280, p=.009,
and parameter estimate=0.631, se=0.220, p=.012, respectively, sample-size adjusted
BIC=2504.13. In contrast, the dummy code for “Ever high” criticism (i.e., at time point 1 OR 2
instead of 1 AND 2) failed to detect group effects (all p>.12). Thus, it was not the mere presence
of parental criticism at either time-point that accounted for differences in persistence versus
decreasing symptoms of parent-rated H/I, but rather stability in criticism across time. With
respect to emotional over-involvement, no differences were observed at any time point (all
p>.43) or with respect to stability (all p>.24) for any of the H/I trajectory groups. This suggests
that the overall EE effect is due to parental criticism rather than over-involvement.
While the preceding was interesting it could be due simply to negative halo effects by
parents who experience negative affect and see their child as highly hyperactive also. To
evaluate this we looked at teacher data two ways. First, parent H/I groups were compared on
teacher rated hyperactivity-impulsivity (recall that these were not able to be divided into
Running Head: Parental expressed emotion and ADHD 15
trajectories by teacher-rating). This analysis confirmed the parent-based results: parent-rated
H/I trajectory classes significantly differed on teacher-rated H/I symptoms with changes in the
anticipated directions based on trajectory classes (all p<.002) and ratings over time were also
similar (details are presented in Table 1). The second check was we examined the parent EE
measure in relation to teacher-rated dimensional symptoms of hyperactivity. The result was also
confirmatory. Stable high parental criticism was associated with more teacher-rated H/I
symptoms at all assessment points (all p<.05).
Teacher-rated inattention groups and parental EE. Next, we examined teacher-rated
inattention trajectory classes. These did not differ in any respect with regard to parent high EE
criticism at either time point or criticism stability, over-involvement at either time point, or over-
involvement stability (all p>.3; see details in Table 2).
Teacher-rated ODD groups and parent EE. Lastly, we examined teacher-rated ODD
trajectory classes. Teacher-rated ODD trajectory classes did not differ with respect to parent
criticism stability (all p>.12), sample-size adjusted BIC= 1785.077. However, when looking at
“Ever critical,” Class 1 (low) and Class 2 (remitting) were similar to each other (p=.52), but both
differed from Class 3 (worsening); parameter estimate=1.115, se=0.386, p=.004 and parameter
estimate=1.352, se=0.5, p=.010, respectively, sample-size adjusted BIC= 1774.97. Specifically,
teacher-rated worsening ODD was significantly associated with parental criticism at Time 1, but
not at Time 2 (see Table 3). No teacher-reported ODD trajectory based group differences were
observed with respect to emotional over-involvement at Time 1, Time 2, or stability over time (all
p>.33).’
Again, we checked results across rater. This confirmed that those in the teacher-rated
ODD low, remitting, and worsening groups significantly different parent-rated ODD symptoms
(all p<.001) with the worsening group having the highest numbers of symptoms and the low
group having the lowest number of symptoms at all time-points (Table 3). Further, high parental
criticism was associated with more parent-rated ODD symptoms at all assessment points (all
Running Head: Parental expressed emotion and ADHD 16
p<.05). Thus, it appears that the effects of parental criticism held across raters as well.
Discussion
The variable developmental course in ADHD is a central phenomenon to be better
understood. Developmental course and severity is likely involved in a bidirectional influence with
family characteristics including emotional tone of the home. It is possible both that parental
criticism influences children’s behavior problems, as well as the reverse. Parental expressed
emotion is one important index of the family emotional environment. The present report
undertook the first empirical examination of whether the parental EE domains of criticism and
emotional over-involvement are related to differential course of ADHD in a longitudinal design.
The observed normative decreases in inattention, H/I, and ODD symptoms with age observed in
our trajectory analyses were in line with prior studies (Biederman et al., 1996, 2000; Sibley et
al., 2012), although variation in this pattern has only been notable in the hyperactivity-impulsivity
domain in most studies, most of which have relied on parent report.
Also in line with prior studies, children with ADHD were more likely than their typically
developing peers to have parents with high parental criticism as well as stable high criticism
over time. Of note, this effect remained even after controlling for oppositional defiant disorder,
suggesting a unique association between ADHD and a harsh, critical family environment.
The novel finding here, however, is that children with ADHD whose families expressed
stable, high criticism violated the normative decline in symptoms and had persistent high ADHD
H/I symptoms. Again, and crucially, this effect held with ODD covaried. Further, teacher ratings
of H/I symptoms showed the same pattern of association with parental criticism as the parent
ratings, suggesting that the observed results are not likely due to parent halo effects. Taken
together, results suggest that family environment, and particularly parental criticism, is not only
associated with oppositional/aggressive behavior, but is also uniquely associated with ADHD
symptoms, particularly when patterns of parental criticism remain stable over time.
We observed four empirical trajectories of parent-rated hyperactive/impulsive symptoms
Running Head: Parental expressed emotion and ADHD 17
across the 7-13 year old period. One of these had consistent low H/I and, unsurprisingly,
overlapped with the ADHD inattentive subtype/presentation. The children with substantial H/I fell
into three additional trajectories. Of these, one was fairly mild and moving toward true
“recovery.” Another was more severe, but also showed a normative trajectory toward symptom
reduction over time. Crucially, one group failed to show the normative declining pattern
(“persistent”). These groups help validate the theory that children with ADHD diverge
developmentally into a remitting and persistent pattern with regard to their H/I symptoms. The
persistent group was associated with persistently higher parental EE criticism as just noted.
A similar developmental picture emerged for teacher-rated inattention. Again, we saw a
group with low symptoms moving toward normalization, a group with significant but improving
symptoms, and a group with persistent problems. This further supports differential and complex
developmental pathways for ADHD for which different reporters may be differentially sensitive in
lawful ways. That is, attention demands are greater at school, whereas structure is reduced at
home and multiple difficult transitions are necessary at home (morning, meals, bedtime) that
increase chances to observe hyperactivity and impulsivity. Interestingly, persistent EE criticism
was not associated with any particular inattention group, suggesting that the effects may be
specific to hyperactivity, while something different may be at play for inattention development.
A key question was specificity of effects to ADHD symptoms. To examine this, ODD
symptom trajectories were evaluated in the same way. In this case, trajectories were seen again
in teacher-rated ODD symptoms. Trajectory groups were low or no ODD, high ODD but
remitting, and high ODD with persistent or worsening symptoms. While only this last group was
associated with parental EE criticism, this association was somewhat different from that
observed in the hyperactivity trajectories. Specifically, the ODD worsening group was more
likely to have a parent with high EE criticism at Time 1, but not necessarily at Time 2. Thus,
while persistence in hyperactivity over time appears to be associated with stability in high levels
of parental criticism, persistent or worsening ODD symptoms are associated with “mere
Running Head: Parental expressed emotion and ADHD 18
exposure” such that this behavior may develop early in childhood in the face of parental criticism
and remain relatively stable despite changes in parenting behavior over time.
Although direction of effects was not evaluated here, the suggestion that oppositional
defiant symptoms are particularly sensitive to parental criticism while hyperactive/impulsive
symptoms are more dependent on chronicity of parental criticism, opens the door to a more
differentiated description of how these overlapping symptoms develop and inter-relate.
Because these data do not indicate the direction of effects, different implications can be
considered. One possibility is that intervention to reduce high parental criticism could assist
children to return to a normatively improving course of development. Alternatively, improving the
severe symptoms of this group of children could enable a “virtuous cycle” to emerge in the
home in which parental criticism improves along with child symptoms.
It was notable that parental emotional over-involvement was not uniquely associated
with any ADHD or ODD symptom trajectories. This is consistent with prior work that has shown
that the emotional over-involvement domain may is more strongly associated with internalizing
symptoms, such as anxiety, while the criticism domain tends to be more strongly associated
with the types of externalizing symptoms examined here (Hale et al., 2011).
This study addressed a key “first question,” helping to confirm that ADHD trajectories
can be empirically identified, that they are associated significantly with parental high EE
criticism, and that this association is distinct from ODD associations with parental EE. To our
knowledge, this study is the first of its kind, as it examined child ADHD and ODD symptoms, as
well as parental expressed emotion domains longitudinally, using well-validated assessment
measures for both constructs, in a well-characterized group of children with ADHD. It extends
our knowledge of ADHD developmental course and clarifies its correlation with high parent EE.
The next step now is to evaluate causal direction of these effects, which are likely to be
to some extent bidirectional. Fine tuning of causal understanding will require experimental
designs (intervention studies), the use of younger (toddler or preschool aged) samples, and we
Running Head: Parental expressed emotion and ADHD 19
also plan to undertake sibling analysis and cross-lagged designs in future studies. It may be that
high parental criticism emerges as a response to difficult temperament in children at-risk for
psychopathology, and then, in a recursive chain, maintains symptoms (Hale et al., 2011).
Despite the strengths of this study, some limitations and necessary next steps should be
noted. First, the overall variability around the slope for both parent-rated H/I and teacher-rated
ODD was only marginally significant, which presented a potential limitation to identifying
trajectories. However, well-fitting models with multiple trajectory classes could be identified,
indicating there was adequate variability for modeling distinct trajectory classes. While our
sample size with multiple EE assessments was respectable (N> 200), it was still too small for a
reliable age-based cross-lag model, which would allow for a stronger (though still not definitive)
inference about directionality. Thus, a key future direction will be to extend these analyses in a
larger sample, which we are now undertaking. Finally, while data suggest that the H/I and ODD
results are partially distinct, given that unique children composed these groups and results were
similar across raters, rater-bias and/or rater effects cannot be entirely ruled out. It may be that
the context in which these two raters observes the child influences the way in which they
perceive H/I versus ODD related behaviors.
In conclusion, longitudinal findings demonstrate that the emotional climate of the home,
as indexed by parental expressed emotion, is uniquely associated with developmental course of
ADHD and ODD symptoms. This study breaks new ground in linking variability in ADHD
developmental course with stability of high parental criticism and variability in ODD course to
early exposure to criticism. Further work to understand these associations, in regard to possible
impacts of ADHD on families and of families on ADHD, is warranted.
Running Head: Parental expressed emotion and ADHD 20
Table 1. Significant trajectory, descriptive, diagnostic, and cross-sectional parental expressed
emotion domain statistics for parent-rated H/I LCGA groups in the full sample
------------------------------------------------------------------------------------------------------------------
ADHD H/I1 ADHD H/I2 ADHD H/I3 ADHD H/I4 p ES
Low Moderate Remitting Persistent
n=96 n=101 n=123 n=68
Trajectory Information
Intercept (estimate, SE) 1.0, 0.3+3.3, 0.7+5.7, 0.2+8.0, 0.2+-- --
Slope (estimate, SE) -0.2, 0.1+-0.6, -.2+-0.5, 0.1+-0.1, 0.1 -- --
Posterior probability 0.8 0.7 0.9 0.9
Demographic Data (at Time 1)
% Prescription Stimulant 26.0% 28.7% 51.2% 72.1% <.001 0.35
ADHD Subtype/Presentation (at Time 1) <.001 0.60
Inattentive 69.8% 27.7% 4.9% 1.5%
Combined 30.2% 72.3% 95.1% 98.5%
Parent Rated ADHD and ODD Symptoms1- (mean, SD)
Time 1
Hyperactive Symptoms 0.9 (1.1) 3.4 (1.6) 5.8 (1.6) 8.0 (1.3) <.001 0.75
Inattentive Symptoms 4.7 (2.8) 5.6 (2.6) 6.1 (2.6) 7.6 (2.0) <.001 0.12
ODD Symptoms 0.6 (1.1) 1.1 (1.4) 1.8 (2.0) 2.8 (2.4) <.001 0.16
Time 2
Hyperactive Symptoms 0.7 (0.9) 2.7 (1.5) 5.2 (1.6) 7.9 (1.5) <.001 0.76
Inattentive Symptoms 3.6 (2.9) 4.8 (2.5) 5.8 (2.8) 6.9 (2.5) <.001 0.15
ODD Symptoms 0.7 (1.5) 0.8 (1.2) 1.7 (1.9) 2.2 (2.3) <.001 0.10
Time 3
Hyperactive Symptoms 0.5 (1.8) 1.9 (1.5) 4.8 (1.8) 7.5 (1.8) <.001 0.71
Inattentive Symptoms 3.1 (3.0) 4.4 (2.9) 5.9 (2.8) 7.1 (2.4) <.001 0.19
ODD Symptoms 0.5 (1.2) 0.8 (1.4) 1.6 (1.8) 2.0 (2.2) <.001 0.10
Teacher Rated Symptoms (mean, SD)
Running Head: Parental expressed emotion and ADHD 21
Time 1
Hyperactive Symptoms 2.4 (2.8) 3.2 (2.8) 3.9 (2.9) 4.1 (2.9) <.001 0.06
Inattentive Symptoms 4.9 (2.8) 5.2 (3.0) 4.2 (3.1) 4.7 (3.2) .075 0.02
ODD Symptoms 0.7 (1.7) 1.0 (1.7) 1.7 (2.5) 1.8 (2.4) .001 0.05
Time 2
Hyperactive Symptoms 1.6 (2.3) 3.1 (3.1) 3.5 (3.0) 3.8 (2.9) .002 0.07
Inattentive Symptoms 3.5 (3.1) 4.2 (3.1) 4.2 (2.9) 4.5 (2.9) .459 0.01
ODD Symptoms 0.4 (0.9) 0.9 (1.6) 1.6 (2.4) 1.2 (2.1) .009 0.06
Time 3
Hyperactive Symptoms 1.6 (2.6) 2.3 (2.5) 3.2 (2.7) 3.7 (3.3) .002 0.10
Inattentive Symptoms 3.2 (3.3) 3.6 (3.4) 4.1 (2.9) 3.6 (3.4) .501 0.02
ODD Symptoms 0.2 (0.7) 0.7 (1.3) 1.1 (1.7) 0.6 (1.2) .023 0.07
Comorbid Disorders (%; D-team) at Time 1
ODD or CD 5.2% 9.9% 26.0% 41.2% <.001 0.33
Parental Expressed Emotion for Participants with Data at Two Time-Points (n=208)
Time 1 n=49 n=53 n=72 n=34
2Crit High 36.7%a27.8% a 40.8% a,b 66.7% b .004 0.25
3EOI High 9.1% 11.1% 14.1% 20.4% .439 0.11
Time 2
Crit High 15.6% 18.8% 19.5% 25.0% .519 0.08
EOI High 5.2% 7.9% 6.5% 10.3% .635 0.07
Notes to table. ES is partial eta squared, except for % stimulant medication, ADHD presentation,
comorbid diagnosis, and EE variables are all Phi. All data from Time 1 unless otherwise indicated.
Differing + superscripts indicate significance for intercepts and slopes of the relevant groups. P-
values are for significant pairwise comparisons in ANOVA for continuous and Chi-square for
categorical variables with EE follow-up comparisons significance represented by differing
superscripts at p<.05.
1Parent-rated hyperactive and inattentive symptoms and all teacher-rated symptoms from Attention-
Deficit/Hyperactivity Disorder-Rating Scale, parent-rated ODD symptoms from KSADS;2Crit: Parental
criticism rating from expressed emotion coding of the Five Minute Speech Sample; 3EOI: Parental
emotional over-involvement from expressed emotion coding of the Five Minute Speech Sample
Running Head: Parental expressed emotion and ADHD 22
Table 2. Significant trajectory, descriptive, diagnostic, and cross-sectional parental expressed
emotion domain statistics for teacher-rated inattention LCGA groups in the full sample
Variable ADHD A1 ADHD A2 ADHD A3 pES
Low Remitting Persistent
(n=227) (n=70) (n=84)
Trajectory Information
Intercept (estimate, SE) 2.8, 0.2+ 6.7, 0.2+ 6.6, 0.3+ -- --
Slope (estimate, SE) -0.5, 0.1+ -0.6, 0.3+ 0.3, 0.2 -- --
Posterior Probability 0.9 0.6 0.6 -- --
Demographic Data (at Time 1)
Age (mos; mean, SD) 114.2 (18.5) 108.6 (17.3) 119.4 (17.5) .001 0.04
% male 62.6% 78.6% 81.0% .001 0.19
Income ($K; mean, SD) 87.5 (21.4) 83.3 (21.1) 76.8 (23.2) .028 0.02
FSIQ Estimate (mean, SD) 109.9 (13.6) 106.7 (15.2) 104.9 (14.5) .015 0.02
ADHD Subtype/Presentation (at Time 1) .017 0.12
Inattentive 29.5% 20.0% 22.6%
Combined 71.6% 80.0% 77.4%
Parent Rated ADHD and ODD Symptoms1- (mean, SD)
Time 1
Hyperactive Symptoms 4.2 (2.8) 4.5 (2.9) 4.7 (2.9) .318 0.01
Inattentive Symptoms 5.4 (2.8) 6.4 (2.4) 6.5 (2.6) .002 0.03
ODD Symptoms 1.4 (1.7) 1.5 (2.1) 1.7 (2.2) .370 0.01
Time 2
Hyperactive Symptoms 3.7 (2.9) 4.2 (2.8) 3.6 (2.9) .454 0.01
Inattentive Symptoms 4.7 (3.0) 5.6 (2.7) 5.7 (2.7) .024 0.03
ODD Symptoms 1.1 (1.7) 1.3 (1.7) 1.8 (2.1) .057 0.02
Time 3
Running Head: Parental expressed emotion and ADHD 23
Hyperactive Symptoms 3.3 (2.9) 3.6 (3.0) 3.1 (3.0) .069 0.01
Inattentive Symptoms 4.3 (3.2) 6.0 (2.7) 5.7 (3.0) .001 0.06
ODD Symptoms 1.0 (1.6) 1.2 (2.0) 1.5 (1.8) .336 0.01
Teacher Rated Symptoms (mean, SD)
Time 1
Hyperactive Symptoms 2.8 (2.7) 5.1 (3.1) 3.7 (2.8) <.001 0.09
Inattentive Symptoms 3.1 (2.5) 7.7 (1.7) 6.5 (2.1) <.001 0.45
ODD Symptoms 0.9 (1.8) 2.1 (2.8) 1.5 (2.3) <.001 0.45
Time 2
Hyperactive Symptoms 1.7 (2.3) 4.0 (3.1) 5.1 (2.9) <.001 0.23
Inattentive Symptoms 2.3 (2.2) 6.1 (2.3) 6.9 (1.8) <.001 0.49
ODD Symptoms 0.6 (1.4) 1.9 (2.3) 1.4 (2.1) <.001 0.08
Time 3
Hyperactive Symptoms 2.1 (2.5) 3.6 (3.0) 42 (2.9) <.001 0.11
Inattentive Symptoms 1.5 (1.7) 6.0 (2.4) 7.6 (1.7) <.001 0.67
ODD Symptoms 0.4 (1.1) 1.2 (1.8) 1.1 (1.4) .004 0.08
Parental Expressed Emotion for Participants with Data at Two Time-Points (n=208)
Time 1 n=122 n=38 n=48
4Crit High 39.7% 47.6% 35.9% .533 0.08
5EOI High 15.1% 11.9% 12.8% .852 0.04
Time 2
Crit High 19.8% 21.4% 17.9% .854 0.03
EOI High 6.2% 12.9% 6.0% .148 0.10
Notes to table. ES is partial eta squared, except for % male, ADHD presentation, and EE variables are
Phi. All data from Time 1 unless otherwise indicated. Differing + superscripts indicate significance for
intercepts and slopes of relevant groups. P-values are for significant pairwise comparisons in ANOVA
for continuous and Chi-square for categorical variables.
1 WISC-IV: Wechsler Intelligence Scales for Children, short form full scale IQ estimate; 2Parent-rated
hyperactive and inattentive symptoms and all teacher-rated symptoms from Attention-
Deficit/Hyperactivity Disorder-Rating Scale, parent-rated ODD symptoms from KSADS;3Crit: Parental
Running Head: Parental expressed emotion and ADHD 24
criticism rating from coding of the Five Minute Speech Sample; 4EOI: Parental emotional over-
involvement from coding of the Five Minute Speech Sample
Running Head: Parental expressed emotion and ADHD 25
Table 3. Significant trajectory, descriptive, diagnostic, and cross-sectional parental expressed emotion
domain statistics for teacher-report ODD LCGA groups in the full sample
Variable ODD1 ODD2 ODD3 p ES
Low Remitting Worsening
(n=312) (n=18) (n=51)
Trajectory Information
Intercept (estimate, SE) 0.4, 0.1+ 4.9, 0.3+ 4.0, 0.2+ -- --
Slope (estimate, SE) 0.0, 0.0 -2.0, 0.4+ 0.3, 0.1+ -- --
Posterior Probability 1.0 0.7 0.9 -- --
Demographic Data
Income ($K; mean, SD) 88.1 (23.2) 85.3 (25.1) 80.0 (28.1) .009 0.07
FSIQ estimate (mean, SD) 108.5 (13.7) 115.0 (12.2) 104.2 (16.9) .016 0.02
ADHD Subtype/Presentation .003 0.17
Inattentive 29.8% 0.0% 13.7%
Combined 70.2% 100.0% 86.3%
Parent Rated ADHD and ODD Symptoms1- (mean, SD)
Time 1
Hyperactive Symptoms 4.1 (2.9) 6.0 (2.0) 5.6 (2.7) .001 0.05
Inattentive Symptoms 5.8 (2.7) 6.1 (3.0) 6.1 (2.7) .682 0.00
ODD Symptoms 1.3 (1.8) 1.8 (1.9) 2.6 (2.3) .001 0.06
Time 2
Hyperactive Symptoms 3.5 (2.8) 4.7 (2.5) 5.1 (2.6) .003 0.04
Inattentive Symptoms 5.0 (3.0) 5.1 (3.3) 5.6 (2.7) .582 0.00
ODD Symptoms 1.1 (1.6) 1.6 (2.0) 2.3 (2.3) .001 0.06
Time 3
Hyperactive Symptoms 3.1 (2.9) 3.8 (2.3) 4.4 (3.2) .041 0.03
Inattentive Symptoms 4.8 (3.1) 4.2 (3.3) 5.8 (3.3) .163 0.02
ODD Symptoms 0.9 (1.5) 1.1 (1.6) 2.7 (2.2) .001 0.10
Teacher Rated Symptoms- (mean, SD)
Running Head: Parental expressed emotion and ADHD 26
Time 1
Hyperactive Symptoms 2.9 (2.8) 7.2 (1.9) 5.2 (2.6) .001 0.15
Inattentive Symptoms 4.4 (3.0) 5.9 (2.8) 5.7 (2.8) .006 0.03
ODD Symptoms 0.4 (0.9) 7.1 (1.2) 4.3 (2.0) .001 0.75
Time 2
Hyperactive Symptoms 2.5 (2.8) 4.9 (2.5) 4.6 (3.3) .001 0.09
Inattentive Symptoms 3.7 (2.9) 5.8 (3.0) 5.1 (3.1) .013 0.04
ODD Symptoms 0.5 (1.2) 3.5 (3.0) 3.5 (2.2) .001 0.39
Time 3
Hyperactive Symptoms 2.4 (2.7) 4.7 (2.4) 5.2 (2.8) .001 0.12
ODD Symptoms 0.4 (1.0) 1.1 (1.0) 3.0 (2.2) .001 0.27
Comorbid Disorders (%; D-team) at Time 1
DBDs (CD, ODD) 13.8% 38.9% 43.1% .001 0.27
Parental Expressed Emotion for Participants with Data at Two Time-Points (n=208)
Time 1 n=169 n=15, n=24)
4Crit High 36.7% 35.7% 70.8% .006 0.23
5EOI High 14.3% 13.0% 20.8% .587 0.07
Time 2
Crit High 19.2% 16.7% 23.5% .733 0.04
EOI High 6.1% 16.7% 11.8% .106 0.11
Notes to table. ES is partial eta squared, except for ADHD presentation, comorbid diagnosis, and EE
variables are Phi. All data from Time 1 unless otherwise indicated. Differing + superscripts indicate
significance for intercepts and slopes of relevant groups. P-values are for significant pairwise
comparisons in ANOVA for continuous and Chi-square for categorical variables.
1 WISC-IV: Wechsler Intelligence Scales for Children, short form full scale IQ estimate; 2Parent-
rated hyperactive and inattentive symptoms and all teacher-rated symptoms from Attention-
Deficit/Hyperactivity Disorder-Rating Scale, parent-rated ODD symptoms from KSADS;3Crit:
Parental criticism rating from coding of the Five Minute Speech Sample; 4EOI: Parental emotional
over-involvement from coding of the Five Minute Speech Sample
Running Head: Parental expressed emotion and ADHD 27
Figure 1. Change in parent-rated H/I symptoms numbers according to LCGA Class across 7-13
years of age.
Note: Parent-rated H/I trajectory classes with mean symptoms of H/I presented according to
age in years, including: Class 1) Low H/I (n=96, 25%; average posterior probability=0.83;
intercept estimate=1.01, se=0.31, p<.001; slope estimate=-0.22, se=0.10, p=.033), Class 2)
Moderate H/I decreasing (n=101, 26.0%; average posterior probability=0.74; intercept
estimate=3.34, se=0.67, p<.001; slope estimate= -0.63, se=0.17, p<.001), Class 3) high H/I
decreasing (n=123, 31.7%; average posterior probability=0.85; intercept estimate=5.73,
se=0.21, p<.001; slope estimate= -0.46, se=0.09, p<.001), Class 4) high H/I persistent (n=68,
17.5%; average posterior probability=0.87; intercept estimate=8.04, se=0.19, p<.001; slope
estimate=-0.09, se=0.10, p=.336).
Running Head: Parental expressed emotion and ADHD 28
Figure 2. Change in teacher-rated inattention symptoms numbers according to LCGA Class
across 7-13 years of age.
Note: Teacher-rated inattention trajectory classes with mean symptoms of inattention presented
according to age in years, including: Class 1) Low inattention decreasing (n=227, 59.6%;
average posterior probability=0.94; intercept estimate=2.76, se=0.24, p<.001; slope estimate=
-0.53, se=0.07, p<.001), Class 2) high inattention decreasing (n=70, 18.4%; average posterior
probability=0.57; intercept estimate=6.74, se=0.17, p<.001; slope estimate= -0.56, se=0.27,
p=.028), and Class 3) high inattention persistent (n=84, 23%; average posterior
probability=0.59; intercept estimate=6.58, se=0.32, p<.001; slope estimate=0.25, se=0.15,
p=.095).
Running Head: Parental expressed emotion and ADHD 29
Figure 3. Change in teacher-rated ODD symptoms numbers according to LCGA Class across
7-13 years of age.
Note: Teacher-rated ODD trajectory classes with mean symptoms of ODD presented according
to age in years, including: Class 1) Low ODD (n=312, 81.9%; average posterior
probability=0.98; intercept estimate=0.39, se=0.05, p<.001; slope estimate= 0.001, se=0.03,
p=.996), Class 2) high ODD decreasing (n=18, 4.7%; average posterior probability=0.74;
intercept estimate=4.90, se=0.28, p<.001; slope estimate= -2.04, se=0.35, p<.001), and Class
3) high ODD worsening (n=51, 13.4%; average posterior probability=0.89; intercept
estimate=4.00, se=0.24, p<.001; slope estimate=0.31, se=0.11 p=.005).
Running Head: Parental expressed emotion and ADHD 30
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Running Head: Parental expressed emotion and ADHD 36
Online Supplemental Tables
Table S-1. Descriptive, diagnostic, and cross-sectional parental expressed emotion statistics for
ADHD and control groups in the sample of children with parental expressed emotion data at one or
more time-points
Variable Control ADHD p ES
(n=127) (n=388)
Demographic Data (at Time 1)
Age at Time 1 (mos; mean, SD) 104.5 (14.2) 114.4 (18.2) < .001 0.06
% male 47.7% 69.2% < .001 0.20
Race (% White) 80.6% 78.7% .617 0.02
Income ($K; mean, SD)) 89.3 (25.7) 80.0 (26.9) .334 0.01
% 2 parent homes 87.7% 75.5% < .001 0.18
% Prescribed Stimulant 0.0% 52.6% < .001 0.43
FSIQ estimate1 (mean, SD) 115.7 (12.2) 108.2 (14.3) < .001 0.06
Parent Rated ADHD and ODD Symptoms2- (mean, SD)
Time 1
Hyperactive Symptoms 0.3 (0.8) 4.4 (2.9) < .001 0.36
Inattentive Symptoms 0.3 (0.9) 5.9 (2.7) < .001 0.55
ODD Symptoms 0.2 (0.9) 1.5 (1.9) < .001 0.10
Time 2
Hyperactive Symptoms 0.3 (0.9) 3.8 (2.9) < .001 0.32
Inattentive Symptoms 0.2 (0.9) 5.1 (2.9) < .001 0.46
ODD Symptoms 0.3 (0.8) 1.2 (1.8) < .001 0.09
Time 3
Hyperactive Symptoms 0.2 (0.8) 3.3 (2.9) < .001 0.28
Inattentive Symptoms 0.1 (0.7) 4.9 (3.1) < .001 0.45
ODD Symptoms 0.2 (0.9) 1.2 (1.7) < .001 0.10
Teacher Rated Symptoms- (mean, SD)
Time 1
Hyperactive Symptoms 0.1 (0.4) 3.4 (2.9) < .001 0.27
Inattentive Symptoms 0.1 (0.3) 4.7 (3.0) < .001 0.40
Running Head: Parental expressed emotion and ADHD 37
ODD Symptoms 0.0 (0.1) 1.3 (2.2) < .001 0.09
Time 2
Hyperactive Symptoms 0.4 (1.1) 2.9 (2.9) < .001 0.20
Inattentive Symptoms 0.6 (1.3) 4.0 (3.0) < .001 0.31
ODD Symptoms 0.0 (0.3) 1.0 (1.9) < .001 0.09
Time 3
Hyperactive Symptoms 0.4 (1.0) 2.8 (2.8) < .001 0.22
Inattentive Symptoms 0.8 (1.7) 3.6 (3.2) < .001 0.22
ODD Symptoms 0.1 (0.6) 0.7 (1.4) < .001 0.06
Comorbid Disorders3 (%; D-team)
Time 1
Mood Disorder (lifetime) 1.2% 7.80% .004 0.14
Anxiety Disorder 8.8% 17.6% .014 0.12
ODD or CD 0.6% 21.1% < .001 0.29
Learning Disorder 0.6% 1.6% .653 0.04
Time 2
Mood Disorder (new onset) 1.5% 5.7% .089 0.10
Anxiety Disorder 6.7% 22.6% < .001 0.21
ODD or CD 2.2% 20.8% < .001 0.20
Learning Disorder 2.2% 5.2% .263 0.07
Time 3
Mood Disorder (new onset) 0.0% 4.1% .060 0.15
Anxiety Disorder 5.8% 16.5% .013 0.17
ODD, CD 3.3% 13.2% .009 0.18
Learning Disorder 2.5% 7.4% .029 0.16
Parental Expressed Emotion for Participants with Data at Two Time-Points (n=335)
Time 1 n=127 n=208
4EE High 23.2% 50.5% < .001 0.27
5Crit High 13.6% 40.4% < .001 0.28
6EOI High 11.2% 13.9% .470 0.04
Running Head: Parental expressed emotion and ADHD 38
Time 2
EE High 14.4% 45.7% < .001 0.32
Crit High 10.4% 36.1% < .001 0.28
EOI High 4.0% 13.5% .005 0.15
Notes to table. ES is partial eta squared, except for Child Sex, Race, % 2 parent homes, % stimulant
medication, ADHD presentation, comorbid diagnosis, and EE variables are all Phi. All data from
Time 1 unless otherwise indicated. Differing + superscripts indicate significance for intercepts and
slopes of the relevant groups. P-values are for significant pairwise comparisons in ANOVA for
continuous and Chi-square for categorical variables with EE follow-up comparisons significance
represented by differing superscripts at p<.05.
1 Full-Scale Intelligence Quotient (estimated) from WISC-IV: Wechsler Intelligence Scales for
Children; 2Parent-rated hyperactive and inattentive symptoms and all teacher-rated symptoms from
Attention-Deficit/Hyperactivity Disorder-Rating Scale, parent-rated ODD symptoms from KSADS;
30% of the sample had autism, eating disorders, learning disorders, post-traumatic stress disorder,
psychosis, or substance use disorders; 4EE: Parental expressed emotion from coding of the Five
Minute Speech Sample; 5Crit: Parental criticism rating from expressed emotion coding of the Five
Minute Speech Sample; 6EOI: Parental emotional over-involvement rating from expressed emotion
coding of the Five Minute Speech Sample
Running Head: Parental expressed emotion and ADHD 39
Table 2S. Non-significant, descriptive and diagnostic statistics for parent-rated H/I LCGA groups in
the full sample
Variable ADHD H/I1 ADHD H/I2 ADHD H/I3 ADHD H/I4 pES
Low Moderate Remitting Persistent
(n=96) (n=101) (n=123) (n=68)
Demographics (at Time 1)
Age (mos; mean, SD) 115.1 (18.1) 115.8 (17.9) 113.2 (19.0) 113.0 (17.6) .656 0.00
% male 67.7% 64.6% 77.2% 64.7% .133 0.12
Race (% White) 80.2% 84.2% 85.4% 75.0% .293 0.10
Income ($K) 88.1 (23.2) 85.3 (25.1) 80.0 (28.1) 78.7 (24.1) .114 0.02
FSIQ estimate1110.7(13.4) 106.9 (13.5) 109.2 (15.8) 105.0 (13.6) .053 0.02
Comorbid Disorders2 (%; D-team)
Time 1
Mood Disorder (lifetime) 6.2% 7.9% 7.3% 7.4% .976 0.02
Anxiety Disorder 14.6% 24.8% 18.7% 23.5% .281 0.10
Learning Disorder 2.1% 5.0% 4.1% 7.4% .432 0.08
Time 2
Mood Disorder (T2 onset) 1.7% 3.1% 1.2% 5.6% .534 0.10
Anxiety Disorder 11.7% 26.2% 25.9% 27.8% .132 0.15
ODD, CD 42.7% 38.6% 45.5% 57.4% .108 0.13
Learning Disorder 3.3% 6.2% 7.4% 8.3% .721 0.07
Time 3
Mood Disorder (T3 onset) 0.0% 6.5% 5.4% 0.0% .230 0.16
Anxiety Disorder 11.4% 10.9% 17.9% 24.0% .395 0.13
ODD or CD 56.2% 57.4% 61.0% 69.1% .356 0.09
Learning Disorder 4.5% 6.5% 3.6% 12.0% .490 0.12
Notes to table. ES is partial eta squared, except for Child Sex, Race, and comorbid which is Phi. All
data from Time 1 unless otherwise indicated. P-values are for pairwise comparisons in ANOVA for
continuous and Chi-square for categorical variables.
1 Full-Scale Intelligence Quotient (estimated) from WISC-IV: Wechsler Intelligence Scales for
Children; 20% of the sample had autism, eating disorders, learning disorders, post-traumatic stress
Running Head: Parental expressed emotion and ADHD 40
disorder, psychosis, or substance use disorders
Running Head: Parental expressed emotion and ADHD 41
Table 3S. Non-significant descriptive and diagnostic statistics for teacher-rated inattention LCGA
groups in the full sample
Variable ADHD A1 ADHD A2 ADHD A3 pES
Low Remitting Persistent
(n=227) (n=70) (n=84)
Demographic Data (at Time 1)
Stimulant Med. (%on med.) 42.3% 34.3% 51.2% .105 0.11
Comorbid Disorders1 (%; D-team)
Time 1
Mood Disorder (lifetime) 7.0% 8.6% 7.1% .910 0.02
Anxiety Disorder 16.3% 22.9% 27.4% .075 0.12
ODD or CD 18.9% 17.1% 20.2% .887 0.03
Learning Disorder 4.0% 4.3% 6.0% .750 0.04
Time 2
Mood Disorder (onset) 2.1% 2.0% 4.0% .739 0.05
Anxiety Disorder 18.3% 34.0% 24.0% .073 0.15
ODD or CD 43.2% 37.1% 52.4% .150 0.10
Learning Disorder 4.2% 12.0% 6.0% .146 0.13
Time 3
Mood Disorder (onset) 1.9% 3.1% 8.6% .179 0.14
Anxiety Disorder 15.4% 6.2% 22.9% .167 0.15
ODD or CD 57.7% 61.4% 63.1% .650 0.05
Learning Disorder 3.8% 9.4% 8.6% .377 0.11
Notes to table. ES is Phi for all variables. All data from Time 1 unless otherwise indicated. P-values
are for pairwise comparisons in Chi-square for categorical variables.
1 0% of the sample had autism, eating disorders, learning disorders, post-traumatic stress disorder,
psychosis, or substance use disorders
Running Head: Parental expressed emotion and ADHD 42
Table 4S. Non-significant descriptive and diagnostic statistics for teacher-report ODD LCGA groups
in the full sample
Variable ODD1 ODD2 ODD3 p ES
Low Remitting Worsening
(n=312) (n=18) (n=51)
Demographic Data at Time 1
Age (mos; mean, SD) 114.6 (18.5) 104.2 (18.4) 115.7 (11.2) .053 0.02
% male 68.6% 76.0% 65.7% .189 0.09
Race (% White) 83.0% 88.9% 76.5% .398 0.07
Stimulant Med. (%on med.) 41.3% 44.4% 51.0% .431 0.07
Comorbid Disorders1 (%; D-team)
Time 1
Mood Disorder (lifetime) 1.3% 0.0% 2.0% .816 0.03
Anxiety Disorder 13.0% 24.0% 17.1% .289 0.08
Learning Disorder 0.0% 4.0% 0.0% .837 0.03
Time 2
Mood Disorder (onset) 2.0% 0.0% 6.5% .289 0.10
Anxiety Disorder 22.3% 21.4% 25.8% .906 0.03
ODD or CD 42.6% 33.3% 56.9% .106 0.12
Learning Disorder 5.1% 14.3% 9.7% .266 0.11
Time 3
Mood Disorder (onset) 2.2% 6.7% 10.0% .164 0.15
Anxiety Disorder 14.7% 20.0% 15.0% .863 0.04
Learning Disorder 5.1% 6.7% 10.0% .682 0.07
Notes to table. ES is Phi for all variables except Age which is partial eta squred. All data from Time 1
unless otherwise indicated. P-values are for pairwise comparisons in Chi-square for categorical
variables and ANOVA for continuous variables.
1 0% of the sample had autism, eating disorders, learning disorders, post-traumatic stress disorder,
psychosis, or substance use disorders
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