FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 1 Follow-Up Study of Children with ...

232 Pages·2015·2.57 MB·English

Running head: FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 1

Follow-Up Study of Children with Attention Deficit Hyperactivity Disorder Receiving
Pharmacological Treatment: Academic Outcomes, Intrinsic Motivation, and Adherence to
Treatment

Anna Polotskaia, M.Sc.
Department of Educational and Counselling Psychology
McGill University, Montreal, Quebec
Ph.D. in School and Applied Child Psychology

December 2014

A thesis submitted to McGill University in partial fulfillment of the requirements of the degree
of Doctorate of Philosophy in School and Applied Child Psychology

© Anna Polotskaia 2014
FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 2
Abstract
Attention Deficit Hyperactivity Disorder (ADHD), the most common psychopathology
diagnosed in school-age children, is associated with a risk of academic difficulties. Although
psychostimulant medication (PM) is effective in ameliorating symptoms of ADHD, long-term
outcomes remain poorly understood. This thesis is a three-part follow-up project examining
academic, motivational, and adherence characteristics in children with ADHD following 12
months of treatment with PM. The first study examined the role of neuropsychological profiles
in initial presentation and in long-term outcomes of children with ADHD. Results indicate that
the profiles in processing speed (PS) and working memory (WM) are differentially associated
with the clinical presentation, but not with the progression in academic functioning over the 12
months of treatment with PM. The second study examined the characteristics of intrinsic (IM)
and extrinsic motivation (EM) in this population with 12 months of treatment. Results indicate
an increase in IM following 12 months of treatment (p< .05); higher level of cognitive
functioning, and absence of comorbid disorders predicted increase in IM (p< .05). The third
study examined attitudes to treatment in parents and children receiving treatment with PM.
Results indicate that parental beliefs and the absence of externalizing symptoms in children
predict long-term adherence. Decrease in self-perceived stigma in children (p< .05) was observed
after 12 months of treatment. Overall, these three studies provide support for the existence of
specific subgroups within the ADHD population, defined by the neuropsychological,
motivational, and clinical profiles. Implications, such as a need for targeted interventions based
on specific profiles are discussed.
Keywords: Attention-deficit/hyperactivity disorder; intelligence; academic performance, WISC-
IV, psychostimulants, intrinsic motivation, adherence, stigma
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Résumé
Le trouble déficit d’attention/hyperactivité (TDAH), la psychopathologie la plus fréquente parmi
les enfants d’âge scolaire, est associé à un risque de difficultés académiques. Tandis que les
médicaments psychostimulants (MP) demeurent efficaces dans le soulagement de symptômes du
TDAH, les conséquences à long terme demeurent mal comprises. Ce projet de suivi, composé de
trois parties, examine les caractéristiques académiques, motivationnelles et d’adhérence chez des
enfants avec TDAH suivant 12 mois de traitement avec MP. La première étude examine le rôle
des profils neuropsychologiques dans la présentation initiale et dans les résultats à long terme
chez des enfants avec TDAH. Les résultats indiquent que les profils de la vitesse de traitement
(VT) et de la mémoire de travail (MT) sont associés de façon différentielle avec la présentation
clinique, mais pas avec la progression du fonctionnement académique durant le 12 mois de
traitement avec MP. La deuxième étude examine les caractéristiques de la motivation intrinsèque
(MI) et la motivation extrinsèque (ME) dans cette population suivant les 12 mois de traitement.
Les résultats indiquent une augmentation de MI suivant les 12 mois de traitement (p < .05). Les
plus grands niveaux du fonctionnement cognitif et l’absence de comorbidités prédit une plus
grande augmentation de MI (p < .05). La troisième étude examine les attitudes vers le traitement
chez les parents et enfants recevant le traitement avec MP. Les résultats indiquent que les
croyances parentales et l’absence de symptômes externalisants prédit l’adhérence à long terme.
La baisse de la stigmatisation perçue chez les enfants (p < .05) a été observée suivant les 12 mois
de traitement. Dans l’ensemble, ces trois études supportent l’existence de sous-groupes
spécifiques dans la population TDAH, définis par les profils neuropsychologiques,
motivationnels et cliniques. Les implications, telles que le besoin des interventions ciblées sur les
profils spécifiques, sont discutés.
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Acknowledgements
I would like to begin by thanking my doctoral thesis supervisor, Dr. Steven Shaw, for his
guidance, mentorship, and encouragement. Your great sense of humor, your support and
guidance have made a great difference! I am convinced that our future collaborations will be
valuable and productive.
I will forever be thankful for the guidance and support of my clinical and research
supervisor, Dr. Natalie Grizenko. Thank you for being my mentor all these years, and for being a
role model and a great example of dedication, loyalty, and hard work. Thank you for always
believing in me!
I am very grateful to my dissertation committee member, Dr. Armando Bertone, for his
invaluable edits and insightful suggestions throughout this process. Your support through every
step of the process has been incredibly helpful and inspiring.
I would also like to thank Dr. Kim Cornish for helping me in developing this project, and
for providing guidance in establishing collaborations with researchers in developmental and
clinical fields. This project could not have come to life without the help of the team of dedicated
professionals at the ADHD Clinic of the Douglas Research Institute: Julie (Carla) Aguilera,
Johanne Bellingham, Marie-Eve Fortier, Phuong Thao Nguyen, Jacqueline Richard, Sandra
Robinson, Shalaka Shah, Thank you for your enthusiasm and support of my project.
I would like to extend my gratitude to Dr. Ridha Joober, whose dedication to the
advancement of knowledge helped me grow as a scholar, researcher, and clinician. I have been
fortunate to work with many other clinical supervisors and professors, who have helped me in
this journey. I am grateful to Dr. Ron Stringer, Dr. Valentine Mbekou, Dr. Ada Sinacore, and Dr.
Bruce Shore and many other professors at McGill University for helping me in my development
FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 5
as a future scientist-practitioner. Infinite thanks go to Olivia Leung, Hailey Sobel, Sarah
Khayutin, and Marina Ter-Stepanian, my friends and colleagues who supported and reassured
me along the way.
I want to thank my friends and family for inexorably supporting, encouraging, and
accompanying me in this journey. Thank you Mom and Dad for your support and patience!
During my doctoral studies I married David Airapetyan, whose help and support cannot be
underestimated. His genuine curiosity and loving heart has supported me so much in this process.
As this project came to life and grew, so too, did our son Raphael. His energy, curiosity, and
passion for play have been a great source of inspiration for me.
I am grateful to all the families of children with ADHD who shared their sorrows and
joys with me during this project. Every family has been a great example of resilience and hope in
the context of mental health issues.
Finally, this research was supported by a Vanier Fellowship from the Canadian Institute
of Health Research awarded to the author. In addition, the project was completed in part with the
support of research funding awarded to Drs. Natalie Grizenko and Dr. Ridha Joober by the
Canadian Institute of Health Research.
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Contribution to Knowledge
This study investigates cognitive, academic and behavioral functioning in children
clinically diagnosed with ADHD over the 12 months of receiving continuous treatment with
psychostimulant medication. Previous follow-up studies of academic outcomes in children with
ADHD yielded inconsistent results, indicating the need for additional research. Based on the
literature review presented in this dissertation (Chapter II), several pathways for inconsistent
findings were identified, contributing to the originality of the work. In three manuscripts
presented in this dissertation these pathways were empirically examined. First manuscript
(Chapter III) provides original overview of previous research focused on the examination of
neuropsychological profiles in terms of their contribution to long-term academic outcomes
within the ADHD population, and empirically examined these profiles in relation to academic
outcomes in children receiving pharmacological treatment. Manuscript I provides additional
support to the previously documented observation that children show significant gains in
processing speed and in the domain of mathematics following 12 months of treatment
independent of their initial level of cognitive functioning. Manuscript II is an original work that
examines the contribution of motivational factors to academic outcomes following treatment.
Furthermore, it contributes to better understanding of factors contributing to changes in self-
determined forms of motivation specific to the ADHD population. This work is the first study to
apply self-determination theory to the paediatric population with ADHD, contributing to
theoretical and applied knowledge in developmental and clinical psychology. The study provided
empirical evidence for the significant role of motivational factors in academic outcome in this
high-risk population. Finally, Manuscript III (Chapter V) is focused on the examination of
correlates of adherence to medication and changes in child and parental beliefs, making a
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significant contribution to a clinically-relevant research of risk factors for non-adherence to
treatment. In addition, this original project focused on the examination of changes in parental and
child perceptions and beliefs about the ADHD over the course of long-term treatment with
psychostimulants, contributing to an emerging body of research about self-perceptions and
stigmatisation of psychiatric patients.
Contribution of Authors
I am the first author of the three manuscripts included in this thesis. As such, I
conceptualized the studies, designed the study protocols, and was responsible for the ethics
submission. I coordinated the subject recruitment, developed and coordinated tools that allowed
for appropriate monitoring and scheduling of follow-up appointments for each participant, and
coordinated the clinical aspects of the project. I have trained and supervised research assistants to
collect and enter research data. I implemented all described statistical analysis and wrote all the
manuscripts.
The specific contributions of my co-authors to the articles included in this thesis are listed
below.
This dissertation was developed in collaboration between McGill University and Douglas
Mental Health University Institute. Drs. Natalie Grizenko and Ridha Joober, the principal
investigators of the Clinical and Pharmaco-genetic Study of ADHD conducted at Douglas
Mental Health University helped with patient recruitment and psychiatric follow-ups for the
patients.
Dr. Armando Bertone provided guidance for this Ph.D. project and reviewed parts of the
manuscripts, as a member of my advisory committee.
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Dr. Ridha Joober helped with patient recruitment and provided overall guidance for this
project.
Dr. Kim Cornish, my supervisor during my first year of my Doctoral degree at McGill
University, was involved in conceptualisation of this dissertation.
Drs. Natalie Grizenko and Steven Shaw are my supervisors, and they have been involved
in data analysis and interpretation, and in revisions of this dissertation.
Dr. José Correa and Veronique Pagé were consulted for the statistical aspects of the
manuscripts.
Julie (Carla) Aguilera, Johanne Bellingham, Vanessa Chan, Shalaka Shah and Theresa
Tang provided their assistance in data collection and data entry.
Parts of the data used in the Manuscript III (Chapter V) have been analysed and
published in a co-authored manuscript (Hebert, J., Polotskaia, A., Joober, R., & Grizenko, N.,
2013). The publication was based on a preliminary data (collected at 3 months’ time point) and
was co-authored with Julien Hebert, a medical student who completed Summer Research
Bursary Program in 2012 under the supervision of Dr. Grizenko.
The following peer-reviewed conference proceedings were also produced during the
course of this project, but are not included in this thesis:
Polotskaia, A., Leung, O., Tang, T., Khayutin, S., Rogers, M., Grizenko, N. (2014, February)
Developmental progression of reading skills in children with and without ADHD
symptomatology. Poster presented at the Ontario Psychological Association, Toronto,
Canada.
FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 9
Polotskaia, A., Aguilera, J., Tang, T., Joober, R., & Grizenko N. (2013, May) Long-term
Cognitive and Academic Outcomes in Children with ADHD. Poster presented at the
Quebec Child Mental Health Research Day, Montreal, QC, Canada.
Polotskaia, A., Grizenko -Vida, M., Joober, R., & Grizenko N. (2013, February) Academic
Outcomes in Children Pharmacologically Treated for ADHD. Poster presentations at
National Association of School Psychologist Annual Convention, Seattle, WA, USA.
Polotskaia, A., Aguilera, J., Chan, V., Shah, S., Shaw, S., Joober, R., & Grizenko, N. (2013,
September). Academic Performance In Children Treated For ADHD: 6 Months Follow-
up. Poster presented at 32nd Annual Convention of Canadian Academy of Child and
Adolescent Psychiatry, Montreal, QC, Canada.
Polotskaia, A., Aguilera, J., Chan, V., Joober, R., Shah, S., Shaw, S. R., Zou, X, & Grizenko, G.
(2012, July) Association Between Improvement in Intrinsic Motivation and Academic
Performance in Children Treated For Attention Deficit/Hyperactivity Disorder. Poster
presented at the 34th International School Psychology Association (ISPA) Conference,
Montreal, QC, Canada.
Polotskaia, A. Aguilera J., Chan V., Joober, R., Shah, S., Shaw, S.R., Zou., X., Grizenko N.
(2012, October) Academic performance in children treated for ADHD: 6 months follow-
up. Poster presented at the Annual Convention of the Canadian Association of Child and
Adolescent Psychiatry, Montreal, QC, Canada
Polotskaia, A. Aguilera, J., Chan, V., Joober, R., Shah, S., Shaw, S., & Grizenko N. (2012, June)
Academic performance in children treated for ADHD. Poster presented at the annual
convention of the Canadian Psychological Association, Halifax, NS, Canada
FOLLOW-UP ADHD: ACADEMIC, MOTIVATION, ADHERENCE 10
Polotskaia, A., Grizenko N., Wang N.N., Shah, S., Joober, R. (2011, May) Academic
Performance in Mathematics at Three Months Follow-up of Optimally Treated Children
with ADHD. Poster presented at the Annual Convention of the Quebec Child Mental
Health Research Day. Montreal, QC, Canada.