Impairment’s Role in the Pathway From Externalizing Psychopathology to Depressive Symptoms in Adolescents With ADHD

Abstract

Objective:

This study examined the role of academic, social, and family impairment in the pathway from externalizing psychopathology to depression among young adolescents with ADHD in a multiple mediation model.

Method:

The sample included adolescents with ADHD enrolled in an intervention trial. Parent ratings of externalizing psychopathology were measured at eligibility assessment, adolescent self-reported depressive symptoms were measured at eligibility and at the end of treatment, and parent-rated impairment was measured in the middle of treatment. A multiple mediation model was used to examine mediating effects of impairment types in the pathway from externalizing psychopathology to depression.

Results:

Parent-reported family impairment significantly mediated the association between externalizing psychopathology and depressive symptoms.

Conclusions:

Results suggest family impairment mediates the association between externalizing psychopathology and depressive symptoms beyond academic and social impairment for youth with ADHD. Findings implicate the importance of targeting family functioning during early adolescence to prevent depression.

Keywords

ADHD externalizing adolescence functional impairment depression

ADHD usually persists into adolescence (Copeland et al., 2014) and is associated with an enhanced risk of depression during childhood (Meinzer et al., 2014), adolescence (Meinzer et al., 2014), and early adulthood (Meinzer et al., 2013, 2016). Externalizing psychopathology (i.e., oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms referred to as externalizing psychopathology from this point forward) commonly co-occurs with both ADHD and depression (Angold et al., 1999) and confers unique and additional risk for the development of depression (Bagwell et al., 2006; Burke et al., 2005; Humphreys et al., 2013). Understanding how externalizing symptoms contribute to the risk for depression among adolescents with ADHD can enhance our ability to understand, predict, and prevent depression among these youth.

The enhanced risk that externalizing psychopathology confers for depression among youth with ADHD may be due to the nature of the functional impairments they experience (see McCarty et al., 2008; Patterson & Stoolmiller, 1991), including impairment in academic, social, and family domains (Barkley et al., 2006; Gathje et al., 2008). Externalizing psychopathology leads to (Biederman et al., 2008; Burke et al., 2010), and often exacerbates, functional impairment in youth with ADHD (Booker et al., 2016; Wehmeier et al., 2010), which may lead to the development of depression (e.g., Patterson & Capaldi, 1990; Patterson & Stoolmiller, 1991). Depression commonly onsets during adolescence (Merikangas et al., 2010) and portends the continuity of depressive symptoms into adulthood (Weissman et al., 1999). Thus, understanding the role of impairment may be of critical importance to understand how externalizing psychopathology enhances the risk for depression in adolescents with ADHD.

ADHD and Externalizing Psychopathology Enhance Risk for Depressive Symptoms

ADHD in childhood has been shown to predict depression across development (Biederman et al., 2008; Meinzer et al., 2013, 2014, 2016). Some studies indicate this association remains significant after accounting for externalizing psychopathology. For example, ADHD history predicted symptoms of depression throughout emerging adulthood after controlling for childhood-diagnosed ODD and CD in one sample (Meinzer et al., 2016). In addition, Meinzer et al. (2013) found that ADHD in mid-adolescence predicted major depressive disorder onset by age 30 years, after accounting for the effects of ODD and CD. Adding to this evidence, ADHD alone or in combination with ODD has been associated with increased risk of major depressive disorder among boys (Biederman et al., 2008).

Some evidence suggests an association between externalizing psychopathology and depression over and above ADHD. For example, Bagwell et al. (2006) found that children aged 5 to 12 years with ADHD were at no greater risk for developing depression by ages 13 to 18 years compared to a matched control group of children without ADHD. Instead, ODD/CD symptoms significantly predicted depression among these youth. It may be that age plays a role in the association between ADHD and externalizing psychopathology and depression (Ostrander et al., 2006). In a cross-sectional study, Ostrander et al. (2006) found that for young children (ages 6.6 years to under 9-years-old), those with ADHD alone and ADHD with ODD/CD displayed similarly high levels of depression compared to children without ADHD. However, among older children (ages 9–11.75 years), children with ADHD and ODD/CD had higher levels of depression compared to those with and without ADHD. These findings suggest externalizing psychopathology may directly enhance risk of depression above and beyond ADHD alone, at least among older children and young adolescents. Thus, research on ADHD and depression during adolescence that fails to take externalizing psychopathology into account may be limited (e.g., Eadeh et al., 2017; Powell et al., 2020).

In sum, the literature indicates that ADHD and other externalizing psychopathology enhance youth risk for depression. However, the literature is mixed regarding whether externalizing psychopathology or ADHD alone or the combination confer risk for depression. Thus, it is important that research on the risk for depression among youth with ADHD explicitly consider the role of externalizing psychopathology, particularly when examining mechanisms hypothesized to account for the risk between ADHD and depression.

Mediating Role of Impairment

Youth with externalizing psychopathology have high levels of social, academic, and family impairment alone and in association with ADHD (Booker et al., 2016; Wehmeier et al., 2010). Researchers theorize that aggression and conduct problems confer enhanced risk for depression at least partly due to functional impairments (i.e., Dual Failure model; Patterson & Capaldi, 1990; Patterson & Stoolmiller, 1991). The Dual Failure model posits that over time, functional impairments common in youth with disruptive behavior disorders, such as social rejection, academic failure, and family conflict, lead to the development of depressive symptoms. Research supports that various functional impairments predict the onset of depression in youth with ADHD or attention problems (see b path in Figure 1; Humphreys et al., 2013; Powell et al., 2020). In addition, research indicates externalizing psychopathology in childhood predicts later academic and social competence, which in turn predicts depression risk (Obradović & Hipwell, 2010). Thus, there are clear links between both ADHD and externalizing behaviors to types of impairment that predict depressive symptoms (see a path in Figure 1). However, to our knowledge, researchers have not examined how these impairments affect the relationship between behaviors associated with externalizing psychopathology and depression in youth with ADHD (i.e., mediation; see c path in Figure 1).

Figure 1.

Theoretical model in the current study.

There is some evidence to suggest a relationship between impairment associated with ADHD and depression. For example, adolescents with ADHD exhibit academic impairment, including poorer grades than their peers without ADHD (Langberg et al., 2016). They are also more likely than those without ADHD to fail classes, be late or absent from school, and drop out of school (Kent et al., 2011). Meinzer et al. (2013) found that, after controlling for academic impairment, adolescents with a history of ADHD (M_age = 16.6) remained at a significantly greater risk for depression onset into adulthood (age 30 years) compared to those without a history of ADHD. In another study, Powell et al. (2020) found that end of secondary school examination grades (at age 16 years) mediated the association between ADHD symptoms in children and depressive symptoms at age 17.5 years. Yet, Biederman et al. (1998) found no associations between school difficulties and ADHD-related impairment and persistence of major depression among 6- to 17-year-old boys with ADHD and depression over 4 years. Interestingly, when the academic impairment associated with ODD/CD (i.e., aggression and conduct problems) is considered, there is a relationship with internalizing problems in young adulthood (Obradović & Hipwell, 2010). This further highlights the potential importance of considering behaviors related to externalizing psychopathology when examining a potential mediating role for academic impairment with youth with ADHD.

Social impairment is also common in youth with ADHD and externalizing psychopathology (Hoza et al., 2005; Pardini & Fite, 2010). In one study, Powell et al. (2020) found that parent-reported peer relationships at age 16 years mediated the association between ADHD symptoms and depressive symptoms at age 17.5 years. Nevertheless, Meinzer et al. (2013) found that adolescents remained at a significantly greater risk for depression onset into adulthood even after controlling for social impairment during adolescence. One cross-sectional study by Ostrander et al. (2006) reported evidence that social functioning mediated the relationship between ADHD and depression in all children aged 6 to 12 years, but ODD/CD symptoms altered these relationships with older children (ages 9–11.75 years). Thus, there is mixed evidence indicating a mediating role for social impairment in youth with ADHD, but these studies demonstrate that taking externalizing psychopathology into account is critical to understand this relationship.

Finally, family impairment, often operationalized as parent-adolescent conflict, is common in adolescence (McCarty et al., 2008) and especially common in youth with ADHD and other externalizing psychopathology (Booker et al., 2016; McQuade et al., 2011; Wehmeier et al., 2010). Having parent-adolescent conflict predicts depression in youth, and strong family relationships may serve as a protective factor against the development of depression in youth (O’Shea et al., 2013; van Harmelen et al., 2016). Yet, Biederman et al. (1998) found no associations between family conflict and ADHD-related impairment and persistence of major depression among boys over 4 years.

Another study used data from the current study to examine how parent-adolescent conflict mediated the association between social impairment and depressive symptoms among youth with ADHD in one model (Eadeh et al., 2017). The researchers also evaluated how parent-adolescent conflict mediated the association between academic impairment and depressive symptoms in a separate model. Over one school year, the researchers found minimal to no role for academic impairment predicting depression. However, in a separate model, social impairment was found to predict depressive symptoms (Eadeh et al., 2017). Parent-adolescent conflict mediated the association between social impairment and the development of depression. Yet, Eadeh et al. (2017) did not evaluate how family impairment may account for the link between ADHD and depression nor how social, academic, and family impairment may operate together to predict depressive symptoms. Another important limitation of this study is the lack of consideration of the potential role of externalizing psychopathology in these relationships. As noted previously, when investigators include externalizing behaviors in these analyses it frequently affects the relationships, especially among youth ages 9 years and above (e.g., Ostrander et al., 2006).

Only two studies examined the mediating role of multiple impairment types simultaneously in the pathway from ADHD to depression in youth. Powell et al. (2020) examined how parent-reported peer problems and academic attainment (measured by end of secondary school examination performance) at age 16 years mediated the association between parent-rated symptoms of ADHD and adolescent self-report of depressive symptoms at age 17.5 years. The findings from this study suggest the importance of both social and academic functioning in the pathway from ADHD to depression as they found that peer problems and academic attainment mediated the association between ADHD symptoms and depressive symptoms. Yet, ADHD was not clinically diagnosed, and the contribution of externalizing psychopathology was not considered. Additionally, family impairment was not considered in the model, preventing conclusions about the contribution of this prominent impairment type in the pathway.

Research conducted by Humphreys et al. (2013) is the only other study to examine externalizing psychopathology as a predictor of later depression in youths and the mediating role of impairments. In Study 1, the researchers conducted a cross-sectional study of children ages 5 to 10 years with and without ADHD. Results indicated ODD demonstrated a significant direct effect on depressive symptoms, family impairment significantly mediated the association between ODD and depressive symptoms, and social impairment marginally significantly mediated the association between ODD and depressive symptoms. To address the limitations of their cross-sectional study, in Study 2, Humphreys et al. (2013) utilized longitudinal data from a non-clinical sample to examine the pathway from childhood attention problems and aggression (based on parent ratings at age 5 years) and depressive symptoms (measured by self-report ratings at age 20 years) and the mediating role of family impairment (measured with self- and mother-report), social impairment (measured with self-report and teacher-report), and academic impairment (self-report) measured at age 15 years. Controlling for sex and baseline internalizing symptoms, results indicated a significant mediating effect of family impairment and a marginally significant mediating effect of social impairment in the pathway from attention problems in childhood to depressive symptoms in adulthood. When aggression was added to the model, attention problems no longer predicted social or family impairment. Family impairment was a significant mediator between aggression and depressive symptoms, but social impairment exerted no significant mediating effect.

The results found by Humphreys et al (2013) demonstrate the importance of considering externalizing psychopathology when examining risk for depression and the unique role of family impairment in predicting depression. However, there are several limitations of these studies that necessitate further investigation. First, to increase our understanding of the risk for depression among youth with ADHD it is important that samples include youth who received diagnoses of ADHD based on a comprehensive evaluation. This was not the case for many of the studies described above. Second, depressive symptoms markedly increase in youth during and after puberty (Merikangas et al., 2010), yet much of the research focused on prepubertal children or older teens and adults. Third, although there is evidence in previous research about the contribution of academic, social, and family impairment contributing to the onset of depression in youth, most do not consider these domains of impairment together. This is an important omission as it is not possible to see their relative contributions to risk for depression without including all in the analyses.

The Present Study

The present study builds on the previous literature in multiple ways: (1) we examined a variety of behaviors related to externalizing psychopathology (both aggression and rule-breaking behaviors), (2) we used a sample comprised of youths with clinically diagnosed ADHD studied over time, (3) we considered the potential contributions of social, academic, and family impairment to the risk of depression, and (4) we examined young adolescents, an understudied age group at high risk for depression. Thus, in this study we can longitudinally evaluate the role of externalizing psychopathology in this pathway for youth with ADHD during a developmental period of risk for developing depression. In this way, we can specifically evaluate both the contribution of externalizing psychopathology in accounting for depression risk among young adolescents with ADHD and the contribution of multiple types of impairment that may account for this risk. We hypothesized that in a multiple mediation model (see Figure 1), parent-rated academic, social, and family impairment would mediate the positive relationship between externalizing psychopathology and depressive symptoms.

Method

Participants

Participants were 326 middle school students (71.2% male) in sixth (37.1%), seventh (36.2%), or eighth (26.7%) grade with ADHD enrolled in a randomized controlled trial (RCT) of a school-based intervention for ADHD for one school year. The portion of the sample that is female is similar to the portion estimated for worldwide prevalence of ADHD in children (~30%; Polanczyk et al., 2007). Participants were randomly assigned to an active intervention condition (68.1%) or a Community Care control condition (31.9%). Participants were between the ages of 10- and 14-years-old (M = 11.76; SD = 0.98). Most participants identified as White (77.3%), followed by Black or African American (12.0%), Asian (0.6%), Native Hawaiian/Pacific Islander (0.3%), or more than one race (8.3%). The race of three participants were unknown, not reported, or missing (0.9%). Approximately 3% of participants identified as Hispanic or Latino, and 17.5% of participants’ ethnicity was unknown, not reported, or missing. This sample included a higher proportion of White students than the population of the US (61.6%), an equivalent portion of Black students (13.4%) and a smaller portion than the population for other races and ethnicities. The average yearly income of the 324 participants’ parents who provided it was $53,811.73 (SD = $47,534.98) and ranged from $0 to $225,000.00.

Procedure

Participants in this study were recruited as part of a year-long RCT of a school-based intervention for adolescents with ADHD. Adolescents and their parents provided assent and consent to participate in the study. Adolescents were eligible to participate in this study if they met DSM-IV-TR criteria for ADHD-Predominately Inattentive Type, Predominantly Hyperactive-Impulsive Type, or Combined Type by parent-report on the Parent Children’s Interview for Psychiatric Syndromes (P-ChIPS; Weller et al., 2000) or by teacher-report on the Disruptive Behavior Disorders Rating Scale (Pelham et al., 1992), demonstrated impairment by parent- or teacher-report on the Impairment Rating Scale (Fabiano et al., 2006), had an IQ of 80 or higher as measured by the Wechsler Intelligence Scale for Children—Fourth Edition (Wechsler, 2003), and did not meet diagnostic criteria for bipolar disorder, psychosis, obsessive compulsive disorder, pervasive developmental disorder, or substance dependence other than tobacco as determined using the P-ChIPS during eligibility assessment. Participants in the current study included those in the intervention and control conditions. Parents and adolescents completed measures at several time points: prior to beginning the school year during intervention implementation (eligibility assessment; March–August; T1), in the middle of implementation (January–March; T2), and at the end of the intervention year (end of treatment; May; T3).

Measures

Externalizing Symptoms

Child Behavior Checklist (CBCL/6-18)

Parents completed the CBCL at eligibility assessment (T1) as a standardized screening measure of adolescents’ psychological symptoms (Achenbach & Rescorla, 2001). Parents rated their child’s psychological symptoms over the past 6 months on a 3-point scale from “0” meaning “not true of the child” to “2” meaning “very true or often true.” The Externalizing Problems scale was used to measure externalizing psychopathology at eligibility. The Externalizing Problems scale is composed of items assessing Rule-Breaking Behavior and Aggressive Behavior syndromes, which correlate with CD and ODD symptoms (Achenbach & Rescorla, 2001). A T-score of 64 or greater is considered clinically elevated relative to same-age, same-gender peers (Achenbach & Rescorla, 2001). Validity (α = .94) and reliability (r = .92) of the Externalizing Problems scale have been documented and are strong (Achenbach & Rescorla, 2001).

Impairment

Impairment Rating Scale (IRS)

The IRS is a parent-report measure of areas of impairment common in children with ADHD (Fabiano et al., 2006). It consists of seven items rated on a 7-point scale (0 = no problem/definitely does not need treatment, 6 = extreme problem/definitely needs treatment). In this study, scores from three domains collected at T2 were used: family impairment (average of relationship with siblings item, relationship with parents item, and family functioning item), social impairment (one item assessing relationship with peers), and academic impairment (one item assessing academic functioning). The IRS has excellent test-retest reliability and convergent and discriminant validity (Fabiano et al., 2006) and is widely used (Evans et al., 2013; Fabiano et al., 2006). Parent ratings of impairment were selected because adolescents with ADHD tend to under-report impairment (see Owens et al., 2022).

Depressive Symptoms

The Reynolds Adolescent Depression Scale, Second Edition (RADS-2)

The RADS-2 is an adolescent self-report measure of depressive symptoms consisting of 30 items measured on a 4-point scale (1 = almost never, 4 = most of the time; Reynolds, 2002). The RADS-2 assesses four dimensions of adolescent depression: dysphoric mood, anhedonia/negative affect, negative self-evaluation, and somatic complaints. Higher scores indicate more severe depressive symptoms. In this study, a total score was calculated by summing scores from all items; this total score was then converted to a T-score, where higher scores indicate higher levels of depressive symptoms. The RADS-2 has moderate to high test-retest reliability (.77–.84) for each of the subscales (Reynolds, 2002). The RADS-2 was used to measure both depression severity at eligibility assessment (T1) and depression severity at the end of treatment (T3).

Data Analytic Plan

Missing Data

Data from all eligible participants were included in analyses. Approximately 50% of participants (n = 166) were missing data on at least one study variable. No participants were missing CBCL Externalizing Problems scores, 1.2% of participants were missing RADS-2 scores at T1, 22.4% of participants were missing IRS social impairment scores, 21.5% were missing IRS family impairment scores, 21.8% were missing IRS academic impairment scores, and 18.1% were missing RADS-2 scores at T3. Participants with missing data had lower parental incomes (M = 42,057.93, SD = 39,985.56) compared to participants with no missing data (M = 65,859.38, SD = 51,600.22), t(322) = -4.65, p < .001. Participants with missing data experienced marginally greater IRS academic impairment scores (M = 3.81, SD = 1.75) compared to participants with no missing data (M = 3.36, SD = 1.94), t(253) = 1.85, p = .066. There was no significant difference between participants with and without missing data by RADS-2 score at T1 or T3, CBCL Externalizing Problems score, IRS social impairment score, IRS family impairment score, participant age at T1, study condition, participant sex, participant race, or participant ethnicity.

Given that participants from both the intervention group and control group were included in the present study, preliminary analyses were conducted to determine whether multigroup analyses may be warranted. Correlations among the primary variables were transformed to z scores and the strengths of the correlations were compared across the intervention and control groups. Results indicated that there were no significant differences in the strengths of the correlations among the primary variables between groups. As such, primary analyses were conducted with all participants treated as a single sample.

Descriptive statistics and zero-order correlations were calculated for all study variables. To understand the mediating role of parent-report of academic, social, and family impairment in the pathway from externalizing psychopathology to depressive symptoms, a multiple mediation model was tested in Mplus 8.3 (Múthen & Múthen, 1998–2017), controlling for the effects of treatment condition, sex, and depressive symptoms at eligibility. The maximum likelihood estimator was used to account for missing data. The model that was tested in the present study was just identified and therefore could not be evaluated for model fit. To test for mediation, percentile-based bootstrapping analyses (10,000 bootstrap resamples) were conducted to estimate the indirect effects. Direct effects are reported as unstandardized estimates and indirect effects are reported as unstandardized estimates with the 95% percentile-based bootstrap confidence intervals. For significant indirect effects, the ratio of indirect effects to total effects (P_m) is reported to provide information about the size of the effect (Wen & Fan, 2015).

Results

Descriptive statistics of study variables are reported in Table 1. On average, adolescents reported non-clinical levels of depression symptoms at both the beginning (M = 45.88, SD = 10.59) and end (M = 44.48, SD = 9.26) of the intervention year. Parents reported that adolescents experienced moderate levels of impairment in their family relationships (M = 2.62, SD = 1.80) and in their academic functioning (M = 3.53, SD = 1.88) and moderately low levels of social impairment (M = 2.06, SD = 1.77).

Table 1.

Descriptive Statistics.

	M (SD)	n (%)
Gender (N = 326)
Male		232 (71.2)
Female		94 (28.8)
Age (N = 326)	11.77 (0.98)
Grade (N = 326)
Sixth		121 (37.1)
Seventh		118 (36.2)
Eighth		87 (26.7)
Family income (N = 324)	$53,811.73 ($47,534.98)
Race (N = 325)
White		252 (77.5)
Black or African American		39 (12.0)
Asian		2 (0.6)
Native Hawaiian/Pacific Islander		2 (0.6)
American Indian/Alaskan native		1 (0.3)
More than one race		27 (8.3)
Unknown or not reported		2 (0.6)
Ethnicity (N = 277)
Hispanic or Latino		10 (3.6)
Not Hispanic or Latino		259 (93.5)
Unknown or not reported		8 (2.9)
Study condition (N = 326)
Treatment		222 (68.1)
Control		104 (31.9)
CBCL externalizing problems (N = 326)	60.00 (10.52)
RADS-2 (beginning of treatment) (N = 322)	45.88 (10.59)
RADS-2 (end of treatment) (N = 267)	44.48 (9.26)
Family impairment (N = 256)	2.62 (1.80)
Academic impairment (N = 255)	3.53 (1.88)
Social impairment (N = 253)	2.06 (1.77)

Note. Higher scores on Child Behavior Checklist (CBCL) Externalizing and Reynolds Adolescent Depression Scale, Second Edition (RADS-2) reflect more severe symptoms. Higher scores on impairment measures reflect greater impairment. Measures of family impairment, academic impairment, and social impairment were measured with the Impairment Rating Scale (IRS).

Results of bivariate correlations between study variables are reported in Table 2. There was no significant correlation between externalizing symptoms and depressive symptoms at the beginning of treatment. However, there was a weak positive correlation between externalizing symptoms and depressive symptoms at the end of treatment (r = .13, p = .029).

Table 2.

Bivariate Correlations Between Study Variables.

	1	2	3	4	5
1. CBCL externalizing
2. RADS-2 (beginning of treatment)	.10
3. RADS-2 (end of treatment)	.13*	.51**
4. Family impairment	.53**	.05	.20*
5. Academic impairment	.17*	−.01	.04	.39**
6. Social impairment	.37**	.07	.17*	.64**	.25**

Note. CBCL = child behavior checklist; RADS-2 = Reynolds Adolescent Depression Scale, Second Edition.

p < .05. **p < .001.

Multiple Mediation

A multiple mediation model was tested in which adolescent depressive symptoms were regressed on externalizing symptoms mediated by each rating of impairment including family, social, and academic impairment. Ratings of impairment were allowed to covary in the model, resulting in a just identified model. As such, fit indices could not be computed and evaluated. The model is shown in Figure 2. The results of the mediation analysis indicated that the total effect of externalizing symptoms on depressive symptoms was significant (B = 0.106, 95% CI [0.002, 0.205]. Parent-reported externalizing symptoms significantly predicted family impairment (B = 0.09, p < .001), social impairment (B = 0.06, p < .001), and academic impairment (B = 0.04, p = .002). Only family impairment significantly predicted later depressive symptoms (B = 1.05, p = .028). Examination of the indirect effects indicated a significant indirect effect of externalizing symptoms on depressive symptoms through family impairment (B = 0.091, 95% CI [0.011, 0.180]). Indirect effects of externalizing symptoms on depressive symptoms through the other impairment ratings were not statistically significant. P_m was 0.86, indicating the mediating effect of family impairment accounts for 86% of the effect of externalizing symptoms on later depressive symptoms.

Figure 2.

Multiple mediation model.

Discussion

This is the first study to examine the effects of three types of impairment on the relationship between externalizing psychopathology and depression in adolescents with ADHD. Previous research documented the importance of impairment and externalizing psychopathology as risk factors for depression, but previous work has not examined them together in relation to adolescents diagnosed with ADHD. We evaluated the role of parent-reported academic, social, and family impairment as mediators in the pathway from externalizing psychopathology to depression to evaluate how each impairment accounts for the mediating effect. In this way, we could account for youths’ experience of impairment as they might experience it: not in isolation but together. Partially consistent with our hypotheses, we found that the association between externalizing psychopathology and depressive symptoms was mediated by parent-report of family impairment, but not academic or social impairment. Specifically, the results revealed that parents’ report of greater family impairment was associated with adolescents’ report of more depressive symptoms.

Mediating Effects of Impairment

Partially consistent with hypotheses, parent-report of family impairment significantly mediated the association between parent-reported levels of externalizing psychopathology and self-report of depressive symptoms among young adolescents with ADHD. Even though externalizing psychopathology significantly predicted family, social, and academic impairment, the total indirect effects of family impairment alone were significant in the model.

Like the findings of Humphreys et al. (2013), we found support for the importance of family impairment in the association between externalizing psychopathology and depression. Humphreys et al. (2013) found evidence of the unique mediating role of family problems at age 15 years in the association between parent-reported ODD symptoms in childhood and depressive symptoms in early adulthood for children who experienced ADHD symptoms. Our findings uniquely highlight this pathway during early adolescence among a sample of youth with ADHD over the course of 1 year when depression commonly onsets. Thus, we were able to examine how, even during a relatively short span of time, family impairment exerts significant mediating effects in accounting for depression risk. Eadeh et al., 2017 found that parent-adolescent conflict partially mediated the association between social impairment and depression among young adolescents with ADHD, but they did not consider the role of externalizing psychopathology, which is an important factor in the development of depression among youth with and without ADHD. In fact, previous research indicated that externalizing psychopathology may diminish or eliminate the relationship between ADHD and depression (Humphreys et al., 2013). Thus, when examining how impairment may contribute to risk for depression among youth with ADHD, externalizing psychopathology must be foundational in that consideration.

The unique mediating effects of family impairment in the current study indicate that family impairment may be the most critical type of impairment for young adolescents with ADHD in determining their risk for depression. Developmentally, adolescence is a time characterized by relatively high parent-adolescent conflict (McCarty et al., 2008). Adolescents become increasingly independent from parents (Zimmer-Gembeck et al., 2003) and may experience strained relationships at this age (Hair et al., 2008). Nevertheless, for young adolescents, parents are still an important influence (Nickerson & Nagle, 2005), and the current study’s results suggest youth with ADHD who experience family impairment and externalizing psychopathology may be at increased risk of developing depression, even when considering experience of other functional impairments.

Family functioning can refer to many aspects of a family’s behaviors and relationships. For example, evidence suggests that parents’ emotional responses play a role in the ability of children with ADHD to adaptively respond to uncomfortable emotions. More specifically, parents who model adaptive responses have children with better developed emotion regulation abilities compared to children whose parents model maladaptive responses (Breaux et al., 2018). It may be that impairment in family relations is partially indicative of parents’ difficulties with emotion management resulting in less-than-ideal adult models of emotion regulation. Thus, parents and youth may both contribute to family impairment leading to subsequent problems with self-esteem and depressive symptoms for youth.

Although parents’ modeling of appropriate emotion regulation skills is a potential mechanism by which family functioning may reduce a risk for depression among adolescents with ADHD, family impairment may be a proxy for a variety of indicators of family functioning. For example, stress in the parent-child relationship, stress in the family unit, controlling parent behaviors (see Humphreys et al., 2013), parent-child conflict, ineffective parenting, sibling conflict, and inter-parental disagreements about challenging youth behaviors may all contribute to parent-report of family impairment and may differentially or additively contribute to the mediating role of family functioning in this pathway. Further, it is likely that some aspects of family, social, and academic impairment contribute to impairment in other domains. For example, impairment at school often contributes to distress at home through parent-child conflict. Regardless of the exact nature of family impairment and the relationship between impairment domains, our results indicate the unique importance of family impairment in developing depression among youth with ADHD.

Further, it is likely that externalizing psychopathology and family impairment are associated bidirectionally. In other words, externalizing psychopathology likely evokes increased family impairment and family impairment may elicit increased aggression and externalizing behavior. In general, it is not possible to determine whether one precedes the other. Yet, these findings suggest that family impairment accounts for the link between externalizing psychopathology and depressive symptoms for youth with ADHD.

Finally, although these findings are consistent with conceptual models of the acquisition of depression for youth with ADHD, it may be argued that parents have greater knowledge of family functioning for youth compared to their knowledge of academic or social functioning. As a result, their ratings of family impairment may simply be the best indicator of overall impairment when based on parent ratings. Although this is possible, parents’ ratings of impairment have been found to be sensitive to treatment effects in academic and social functioning suggesting that it is safe to have confidence in these ratings. Thus, it may be that family functioning and externalizing psychopathology are critical factors when considering risk for depression in young adolescents with ADHD.

Limitations and Future Directions

Despite the numerous strengths of this study, including the use of a diagnosed sample of adolescents with ADHD, longitudinal study design, use of multi-informant measures, and robust modeling techniques, results of this study must be interpreted considering limitations. First, this study did not include a non-ADHD control group. Thus, the specificity of these findings to young adolescents with ADHD cannot be determined. There were also low levels of representation of Asian American and Hispanic youth in this sample, so the generalizability of these findings may be limited. In addition, we utilized single items to represent academic and social impairment constructs. Although, the IRS has evidenced excellent reliability and discriminant and convergent validity and is accurate in identifying impairment in samples of youth with ADHD (Evans et al., 2013; Fabiano et al., 2006), it is possible that single item measures of these two impairment constructs may be missing important information. Finally, approximately 50% of participants were missing data on at least one study variable. This percentage of missing data is common in school-based treatment studies. Like other studies that follow youth over a year and a half, missing data tended to increase at later points in the study. Despite this missing data, our use of maximum likelihood estimation, which is a robust method for accounting for missing data, tempers concerns regarding the effects of missing data on study results.

It is important to understand the influence of adolescents’ internalization of impairment on the role of impairment in the pathway from externalizing psychopathology to depression. Theory suggests youths’ own awareness and internalization of impairment is key to depression development (Patterson & Stoolmiller, 1991). Thus, there may be a moderating effect of youth self-report of impairment such that the mediating effect of parent-reported impairment is not significant when adolescents report low levels of impairment but is significant when adolescents report high levels of impairment. Future research should examine how adolescents’ perception of their functioning might moderate parent-report of impairment.

Clinical Implications

Results of this study suggest that supporting the family functioning of adolescents with ADHD and externalizing psychopathology may be important to reduce their risk for depression. Clinicians working with adolescents with ADHD may wish to consider interventions that address family impairment. To date there is mixed evidence related to interventions focused on reducing family impairment among adolescents with ADHD. Some evaluations of family therapy for youth with ADHD indicate family therapy may not reduce impairment (Barkley et al., 2001). Skills-based interventions for adolescents with ADHD have shown some promise. Behaviorally Enhancing Adolescents’ Mood (BEAM; Meinzer et al., 2018) is a skills-based intervention designed to address mediators of the ADHD-depression pathway among adolescents with ADHD. A pilot study demonstrated promising effects on parent-reported depressive symptoms but no effects on adolescent self-ratings of depression and no effects on family support (Meinzer et al., 2018). One parent-driven skills-based intervention, Supporting Teens Academic Needs Daily (STAND; Sibley et al., 2013), in which clinicians coach parents to implement skills-based interventions to improve the academic functioning of middle school-aged adolescents with ADHD demonstrated some improvements in parent-adolescent relationships (Sibley et al., 2013). Thus, clinicians working with adolescents with ADHD and other externalizing psychopathology are encouraged to include family focused treatments in their work.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Mental Health under Grant R01MH082864 and Grant R01MH082865 awarded to Dr. Steven W. Evans and Dr. Joshua M. Langberg.

ORCID iDs

R. Elizabeth Capps

Steven W. Evans

Author Biographies

R. Elizabeth Capps, MA, is a doctoral student in clinical psychology at Ohio University. Her research interests focus on understanding the academic and social functioning of adolescents with ADHD and school-based intervention development and evaluation for adolescents with ADHD and co-occurring concerns.

Elizabeth D. Wilson is a first-year student in the clinical psychology doctoral program at the University of North Carolina at Chapel Hill, where her advisor is Eric Youngstrom, PhD. She received a bachelor’s degree in psychology and biology from the University of North Carolina at Chapel Hill in 2020. She is interested in dissemination and implementation of interventions and assessments for youth with mood disorders.

Steven W. Evans is a distinguished professor at Ohio University in the department of psychology. He is the co-director of the Center for Intervention Research in Schools. His research interests are within school mental health broadly, and specifically focused on treatment development and evaluation research for adolescents with attention-deficit/hyperactivity disorder and related problems.

Darcey M. Allan is an assistant professor at Ohio University in the department of psychology and a faculty member of the Center for Intervention Research in Schools. Her research interests focus on the development and measurement of attentional and self-regulatory processes in early childhood and how these processes relate to import aspects of academic and social functioning.

Joshua M. Langberg, PhD, is a licensed clinical psychologist, professor of psychology, and director of the Center for Youth Social Emotional Wellness (CYSEW) at Rutgers University. Prior to his position at Rutgers, he served as the associate dean for research and operations for the College of Humanities and Sciences (CHS) at Virginia Commonwealth University (VCU) from 2018 to 2021. He received his PhD in clinical-community psychology from the University of South Carolina in 2006 and completed his predoctoral internship at Duke University Medical Center. Dr. Langberg is the editor-in-chief of the journal Research on Child and Adolescent Psychopathology (formerly known as Journal of Abnormal Child Psychology) author or co-author of over 130 peer-reviewed publications, 3 books, and has served as the principal investigator on several grant awards from the National Institutes of Health (NIH) and the U.S. Department of Education, Institute of Education Sciences (IES). His clinical and research interests focus on improving the academic and behavioral functioning of adolescents and emerging adults with ADHD and the dissemination and implementation of evidence-based practices in school and community settings.

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