This study examined the structure of ADHD symptoms in child adolescent samples using GSEM. This GSEM pathway analysis first supported that poor treatment outcomes in ADHD can be predicted as irritable ODD subtype of ADHD with aggressive behavior. This pathway analysis indicated higher ODD symptom levels mediated treatment outcomes for ADHD through enhancing inattentive and H/I symptoms. Treating children with ADHD is not only a matter of treating inattentive symptoms alone, but there is also a need to recognize and manage symptoms of ODD and the presented aggressive behavior, delinquent behavior, and thought problems in children with ADHD to improve ADHD treatment outcomes.
Comparison with prior work
Hinshaw et al suggested that only detailed pathway analysis can further assist clinicians in understanding the internal joint relationships among aggressive behavior, symptoms of ODD, and symptom severity of ADHD. Such pathway analysis might remind clinicians to recognize earlier risky irritable symptoms of ADHD + ODD + childhood aggression as a special subgroup and provide more effective therapeutic treatment modalities earlier.
Aggression in children and adolescents with irritable ADHD is a serious clinical and public health problem. Especially in the recent internet age, many children and adolescents present inattentive symptoms, externalizing behavior, or risk-taking behavior after excessive use of the internet[27,28]. We know that this unrecognized aggression in early childhood becomes more aggressive or violent behavior later in these irritable children[5,29]. Alternatively, the results of this study indicated that children with the irritable ODD subtype of ADHD characterized by symptoms of irritable ODD and aggressive behavior is harder to treat well. However, previous studies have focused more on conduct behavior (CD)[30,31] instead of any kind of aggression in children with ODD, which warrants more attention. Therefore, the implication of this study is that we suggest using a CBCL scale to identify aggressive children and adolescents in child and adolescent clinics or internet gaming disorder clinics in the future. The presented aggressive behavior we derived from CBCL included relational aggression (argues a lot, bragging, boasting, demands much attention), disobedience at home, disobedience at school, easily jealous, screams a lot, showing off or clowning, stubborn, sullen or irritable, sudden changes in mood or feelings, talks too much, teases a lot, temper tantrums or hot temper, direct aggression (cruelty, bullying or meanness to others, destroys his or her own things, destroys things belonging to his or her family or others), and gets in many fights (physically attacks people, threatens other people), which can all be regarded as early recognition of any kind of aggression in children with ADHD and ODD. Earlier and effective treatment inventions for children with particular heterogeneous subtypes of ADHD should be provided by ADHD experts in these days with digital technology.
In the present study, the GSEM results found that ADHD symptom severity was determined by the joint effects between ODD, aggression, and delinquent behavior symptoms. With the under recognition and undertreatment of ODD and aggression in children with ADHD, there is always a significant risk that predicts poor treatment efficacy. Here, we suggest that children and psychiatrists should record a more extensive history of oppositional symptoms because one previous study indicated that there was an underdiagnosed ODD comorbidity problem in children with ADHD. The treatment effects on ODD depend on how the underlying comorbid ADHD is treated. Usually, the core symptoms of ODD are not amenable to pharmacotherapy alone. For children with ADHD with ODD, treatments with only pharmacotherapy for inattention alone always remains noneffective for these ODD symptoms[33,34]. The use of nonstimulant drugs such as atomoxetine was recently noticed to be effective in treating ODD symptoms in children with ADHD[35,36]. However, for children with ADHD with severe ODD and behavioral symptoms, there is still a need to use pharmacotherapy with stimulants (MPH), mood stabilizers such as sodium valproate (Depakin), and antipsychotics such as risperidone with concurrent behavioral therapy.
Cognitive behavior psychotherapy in children with ADHD is also essential to regulate emotion regulation circuitry by reducing reactive aggression. Essentially, clinicians should provide effective combined pharmacotherapies with additional effective behavioral modification interventions, parenting programs, and cognitive behavioral therapy to improve treatment outcomes in this particular group of children with ADHD.
Based on the pathway analysis, both ODD and aggressive symptoms interacted as joint effects to exacerbate ADHD symptom severity, as a previous study had noticed[15,16]. We revealed the insight that aggression during childhood rarely occurs alone and is closely correlated with other symptoms of childhood psychopathology. Both ODD symptoms and aggression are important influences on the efficacy of ADHD treatment. Clinicians should consider additional assessments to detect dimensional behavioral symptoms such as childhood aggressive or destructive behaviors to further provide effective treatment modalities to achieve remission of ADHD.
Regarding the childhood H/I symptoms of ADHD, previous findings showed that hyperactive ADHD symptoms had a role in predicting children becoming more socially immature, aggressive, and peer rejected. Additionally, one recent meta-analysis indicated more severe symptoms of H/I, and children with ADHD were less likely to obtain better treatment outcomes. In this GSEM, we found that childhood H/I symptoms resulted in a greater risk of increasing the inattention symptom severity, leading to subsequent poor treatment outcomes for ADHD. ODD symptoms and the presentation of aggressive behavior mediated an increase in inattentive and H/I symptom severity of ADHD. Nevertheless, children and adolescents need more attention regarding the diagnosing and managing of H/I symptoms of ADHD. ODD, aggression, and H/I symptoms of ADHD interactively increased the symptom severity of ADHD.
A previous study indicated that the coexistence of a diagnosis of ODD/CD, learning difficulties, anxiety, younger age, family dysfunction, and socioeconomic adversity were all risk factors for predicting poor treatment efficacy for ADHD. This pathway analysis further focused on children with ADHD with ODD, and aggression led to poor treatment outcomes. ADHD is a heterogeneous disorder with complicated emotional and impulsivity deficits. From the Research Domain Criteria perspective, ADHD patients have deficits in the domains of cognition (specifically in working memory) and positive valence (in rewarding anticipation/delay/receipt). Emotional dysregulation defects may be highly associated with abnormal reward processing systems. Therefore, for children with ADHD presenting symptoms of irritable ODD and aggression, our pathway analysis suggests that the children may have deficits in both cognition and reward domains. Thus, the children with symptoms of ADHD + ODD + aggression should be a clinically distinct emotional irritability subgroup, and clinicians should provide more specific treatment guidelines for these children with ADHD. Future DSM systems need to regard ODD as an essential risk for poor treatment effects for ADHD.
This study has the following limitations. First, the construction of the subscale of the SNAP and CBCL, without a direct interview with the parents, seems to be arbitrary. Additionally, the fact that most of the scale is provided by a main caregiver, mainly mothers and teachers, may lead to sampling bias. Another limitation is the cross-sectional design of the study, which may not necessarily represent the longitudinal relationships among ADHD, ODD, aggression, and remission rate. As the main purpose of this study was to explore the association among disruptive symptoms in children and remission rates, aggression scores from the CBCL were used to represent disruptive child behaviors instead of CD measures. This was a naturalistic observational study performed in Taiwan. Most patients from the outpatient department at that time received psychopharmacologic treatment, including short-term or long-acting MPH, or long-acting drugs such as atomoxetine rather than parenting behavior therapy. However, the thrust of this study was to predict poor treatment efficacy in the children with co-occurring ADHD, ODD, and aggressive symptoms by special GSEM statistical analysis. Therefore, we did not show the detailed treatment response after different kinds of drugs or other psychosocial interventions. Finally, the definitions of direct, indirect, and total effects in SEM have not yet been established in the GSEM. Although three out of four requirements for the mediation model were satisfied in our GSEM, it might not be appropriate to call the results in Figure 4 a mediation model. Here, we only borrowed the concept and spirit of the mediation model to emphasize the relationships among remissions based on ODD, H/I, and inattention symptoms for treating children with ADHD.