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Vol.:(0123456789)1 3
Research on Child and Adolescent Psychopathology https://doi.org/10.1007/s10802-020-00713-9
Inhibitory Control Deficits in Children with Oppositional Defiant Disorder and Conduct Disorder Compared to Attention Deficit/ Hyperactivity Disorder: A Systematic Review and Meta‑analysis
Mikaela D. Bonham1 · Dianne C. Shanley1 · Allison M. Waters1 · Olivia M. Elvin1
Accepted: 24 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Inhibitory control decits are known to be characteristic of Oppositional Deant Disorder (ODD), Conduct Disorder (CD), and Attention-Decit/Hyperactivity Disorder (ADHD); but it is unclear whether children with ODD/CD have inhibitory control problems independent of ADHD comorbidity. Previous reviews of inhibitory control and ODD/CD have only focused on one type of measure of inhibitory control or used non-clinical samples. The current meta-analysis explored inhibitory control problems of children with ODD/CD by systematically reviewing studies where children have a diagnosis of ODD and/or CD. Comparisons were made across 25 studies between children with ODD/CD, ODD/CD + ADHD, ADHD, and healthy controls (HC) on various measures of inhibitory control and ADHD symptomatology to explore impacts of ADHD comorbidity. A small signicant eect (g = -0.58, p < .001) suggested children with ODD/CD are likely to have more diculties with inhibitory control than healthy children. However, comparisons between clinical groups suggested this eect may be due to ADHD symptomatology present in each group. As diculties with inhibitory control are similar, across clinical groups, a dimensional approach to understanding ODD/CD and ADHD may be more useful to consider in future diagnostic criteria. Similarities across clinical groups highlight that therapeutic approaches that assist children with disruptive behaviours could benet from teaching children and their families how to cope with inhibitory control decits.
Keywords Inhibitory control · Conduct disorder · Oppositional deant disorder · Executive function · Disruptive behaviour
Introduction
Children with disruptive behaviour disorders have diculty regulating emotions and inhibiting undesirable behaviours. Executive function plays an important role in the regulation of thoughts, emotions, and behaviours (Diamond 2013). Recently, empirical studies have highlighted the unique role that executive function decits can play in the aetiology of disruptive behaviours (Ezpeleta and Granero 2014; Hobson et al. 2011). Historically, these neurobiological factors have often been overlooked in favour of psychological and social factors that cause disruptive behaviour. According to the Diagnostic and Statistical Manual (DSM-5), disruptive
behaviour disorders are classied as Disruptive, Impulse- Control, and Conduct Disorders (DICCD); including conduct disorder (CD), oppositional deant disorder (ODD), kleptomania, intermittent explosive disorder, pyromania, and other or unspecied disruptive, impulse-control and conduct disorders (American Psychological Association 2013). In the past, Attention Decit/Hyperactivity Disorder (ADHD) was classied as a disruptive behaviour disorder, and as such, much of the research on the relationship between executive function deficits and disruptive behaviours has focussed on children with ADHD. However, with the introduction of the DSM-5, ADHD has been reclassified. It is now a Neurodevelopmental Disorder due to empirical evidence that neurobiological deficits (e.g., executive dysfunction) are core characteristics of ADHD (Oosterlaan et al. 1998; Thorell and Wahlstedt 2006; Senderecka et al. 2012).
Interestingly, similar deficits are present in early childhood for children with ODD/CD (Schoemaker et al. 2012), but these disorders have remained in the DICCD chapter. This systematic review uses a meta-analytic
* Mikaela D. Bonham mikaela.bonham@grithuni.edu.au
1 School of Applied Psychology, Menzies Health Institute of Queensland, Grith University, Mt Gravatt, Quensland 4122, Australia
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approach to examine the role of inhibition control, one of the three key components of executive function, in ODD/ CD. It compares the following groups on measures of inhibitory control as well as ADHD symptomatology: ODD/ CD, ODD/CD + ADHD, ADHD, and healthy controls (HC). Systematically reviewing the available empirical evidence will help us to consider whether ODD and CD are better captured within diagnostic manuals as a neurodevelopmental disorder.
Aetiology of ODD and CD
Psychopathology across the l i fespan typical ly develops from the interaction between individual and environmental factors over time (Matthys and Lochman 2017). When considering the aetiology and treatment of disruptive behaviours, learned behaviour and parenting style have received much attention. Children are exposed to disruptive models of behaviour and learn this behaviour from their environment, which in turn develops into a disruptive behavioural disorder over time (Tremblay 2010). This has been demonstrated in children who model behaviour after coercive parents or associate with delinquent peers when there is an absence of positive parenting (Matthys et al. 2012). When disruptive behaviour disorders are explained by coercive parenting or peer inf luences, interventions naturally follow a “learning-based” approach (Matthys et al., 2012, p. 235). Interventions focussed on parenting and behaviour modification for antisocial youths have demonstrated small to moderate effect sizes; with a mean effect size of 0.47 (range -0.06 to 1.68) and 0.35 (range -1.04 to 1.87), respectively (McCart et al. 2006). Similarly, parenting group interventions for externalising behaviours have also demonstrated small to moderate effect sizes; with a mean effect size of -0.38 favouring intervention (range -0.56 to -0.19; Buchanan-Pascall, Gray, Gordon & Melvin, 2018). Matthy and Lochman (2017) argue that although there is demonstrated effectiveness for behavioural parent training, the effect sizes remain small to moderate, which may be due to many studies being conducted in highly controlled environments which may not be representative of real-world practice. Further, there may also be an impact on children’s ability to learn and problem solve due to neurocognitve impairments in areas such as executive function (Matthys and Lochman, 2017; Matthys et al., 2012). Matthys and colleagues (2012) highlighted that the neurocognitive basis of skill deficits in children with ODD and CD is understudied and understanding its role in the development and maintenance of these disorders has important implications for intervention, with investigation into the role of executive function in ODD/CD as being an important next step. Understanding
children’s neurocognitive challenges would be useful to inform more individualised treatment for children and their families (Matthys and Lochman, 2017). This review will be the first to meta-analyse inhibitory control deficits across childhood, in a clinical sample of children with ODD/CD relative to healthy and clinical controls.
Inhibitory Control. Executive function deficits are a key characteristic of ADHD. Inhibitory control is one of the three established domains of executive function (Miyake et al. 2000). Broadly, inhibitory control refers to the ability to withhold an emotional or behavioural response in order to achieve a goal (Best and Miller 2010; Nigg 2000; van Goozen et al. 2004). When there is a skill deficit in this area, children have more difficulty stopping unwanted behaviour. While this is the definition used in the present review, across the literature, there are several ways of conceptualising inhibitory control; definitions tend to differ based on the function of inhibitory control. For example, some have conceptualised inhibitory control as executive, motivational, and attentional inhibitory control (Nigg 2000) or prepotent response inhibition, resistance to distractor interference, and resistance to proactive interference (Friedman and Miyake 2004).
The current review will examine cool and hot inhibitory control separately because inhibitory control may operate differently based on the emotional salience of the task at hand (Zelazo and Carlson 2012; Zelazo et al. 2010). Therefore, inhibitory control may operate as a ‘hot’ function when a person is in affective contexts, where cues for reward or punishment are present; for example, a delayed snack task employing delayed gratification (Zelazo et al. 2010). On the other hand, ‘cool’ inhibitory control is utilised when presented with abstract problems (Zelazo et al. 2010); for example, a go/ no-go behavioural task, assessing a person’s ability to not respond to a stimulus. Fundamentally, hot and cool executive function require different cognitive processes to be executed (Zelazo and Carlson 2012), which suggests that tasks assessing hot and cool inhibitory control should be analysed separately.
Measuring Inhibitory Control. Performance measures and rating scales will be examined separately throughout the review. Accurate measurement of executive function, including inhibitory control is difficult due to the overlapping nature of brain functions. It is impossible to obtain a pure measure of one cognitive process, such as inhibitory control, as all behaviours require more than one cognitive process (Anderson 2002). This issue is known as task impurity, where an outcome from a task or measurement does not solely reect a single ability, because completing the task requires more than one brain function to be executed (Miyake and Friedman 2012). For example,
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the Stroop task is a measure to assess inhibitory control however the task requires reading and comprehension to be completed. If an individual is impaired in either of these areas, it may aect their performance on the task overall. Performance measures of inhibitory control are standardised or experimental tasks that capture a child’s ability to inhibit a response when completing a task. Results of performance measures of executive function are often confounded by noise, as other executive and non-executive functions are contributing to performance (Miyake et al. 2000; Miyake and Friedman 2012). Ratng scales oer an ecological way to assess inhibitory control by documenting informant- or self- report of inhibitory control behaviours. They too continue to be aected by task impurity. Further complicating the measurement of inhibitory control, performance tasks and rating scales have been demonstrated by some researchers to not reect the same construct (Bodnar et al. 2007; Toplak et al. 2013).
Meta-analysis may allow for a way to assess overall inhibitory control performance at a group level, through a pooled eect size across all measures, providing a more global picture of inhibitory control in children with ODD/ CD. Analysing each task within inhibitory control separately makes it dicult to ascertain an overall eect of inhibitory control. However, understanding differences between performance on each task of inhibitory control is important. Prior meta-analyses of children with ADHD and ODD/CD have only reviewed the Stop Task (Lipszyc and Schachar 2010; Oosterlaan et al. 1998). As such, the analyses in the current review will pool all measures (i.e., according to cool vs. hot, and performance measures vs. rating scales) to understand inhibitory control in children with ODD/CD more globally, as well as subgroup analyses by task.
The Relationship Between ODD/CD, ADHD, and Inhibitory Control
This review will explore the similarities and dierences between children with ODD/CD, ADHD, ODD/ CD + ADHD, and healthy controls on measures of inhibitory control and ADHD symptomatology. When compared to their typically developing peers, pre-schoolers with ADHD, hard to manage behaviours, and aggressive behaviours have been found to have more diculties with inhibitory control (Schoemaker et al. 2013). However, there were too few studies to conduct ADHD and disruptive behaviour analyses separately. Oosterlaan and colleagues (1998) identied that children with CD (and no ADHD) had more diculties with inhibitory control compared to typically developing children; however, the review was limited to one measure of inhibitory control (i.e., stop signal task). Similarly, Lipszyc and Schachar (2010) meta-analysed performance on the stop signal task, revealing children with ODD/CD, ADHD,
and ADHD + ODD/CD had worse performance on the stop signal task compared to healthy controls. Greatest eects were found in children with ADHD, followed by ODD/CD and ADHD + ODD/CD respectively. Similarly, others have identied inhibitory control decits for children with ADHD compared to healthy controls (e.g., Wright, Lipszyc, Dupuis, Thayapararajah, Sathees, and Schachar 2014). There is an absence of reviews where performance on measures of hot inhibitory control has been assessed or reported for children with ODD/CD.
Often, behavioural/response inhibition (i.e., cool inhibitory control) is investigated in relation to externalising behaviours such as ODD/CD. Poor response inhibition is thought to be one factor that contributes to externalising behaviour diculties; including conduct problems (Miyake and Friedman 2012). As a result, children with diculties in response inhibition would be expected to have more diculty stopping unwanted behaviours (Hwang et al. 2016). Others have identied more diculties with hot inhibitory control, due to dysfunctional brain circuitry (cortico-striato- thalamo-corticial neurocircuitry) responsible for emotional executive function (Zhu et al. 2018). A review of imaging studies indicated abnormalities in brain regions associated with hot executive functions were more common in children with ODD/CD compared to those with ADHD (Rubia 2011). Further, diculties with emotional responding have been observed in children aged 10 to 18 years, based on fMRI data on an aective stop signal task (Hwang et al. 2016). Despite the inhibitory control decit hypothesis for children with ODD/CD, with a dearth of meta-analytic reviews, the literature lacks consensus as to whether these decits are characteristic of children with ODD/CD. Taken together, our current understanding of inhibitory control deficits in children with ODD/CD is limited; and this is further complicated by the relationship between ODD/CD and ADHD.
ADHD has often been found to be comorbid in girls with CD (OR > 40) and ODD (OR = 79), and boys with CD (OR = 3.7) and ODD (OR = 8.7; Costello et al. 2003). Other studies have also identied high comorbidity between CD and ADHD comorbidity in a community sample of children (OR = 10.7Angold et al. 1999). As ODD/CD and ADHD are often comorbid, it is dicult to ascertain whether decits in inhibitory control are due to the severity of disruptive behaviour in ODD/CD, or whether they may simply be due to sub-clinical levels of ADHD symptoms (Blair et al. 2018). For example, youths aged 10 to 18 years with conduct disorder were found to have more diculties with hot inhibitory control, however this was attributed to the presence of ADHD symptoms, rather than the severity of conduct problems (Hwang et al. 2016). Understanding whether inhibitory control decits are indeed characteristic of children with ODD/CD or if they are simply a result
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of ADHD symptomatology may help us understand if ODD/CD and ADHD are categorically dierent or similar psychopathology within the same dimension.
Aims
The aim of this review was to comprehensively assess whether children and adolescents (3–17 years) with a clinical diagnosis of ODD and/or CD demonstrate inhibitory control decits more than healthy peers, independent of ADHD comorbidity. ODD/CD and ADHD are signicantly comorbid, hence there is a need to examine whether inhibitory control is similar or dierent for these diagnostic categories. Therefore, this paper aims to determine whether children with ODD/CD have greater or lesser inhibitory control decits when compared to children with ADHD or healthy controls (HC). We sought to answer these questions by making comparisons between ODD/CD, ADHD, ODD/ CD + ADHD, and HC groups on measures of inhibitory control and ADHD symptomatology. Additionally, we explored whether there were differences between the aforementioned groups on measures of cool and hot inhibitory control, rating scales, and the implications of measuring inhibitory control. All measures of inhibitory control and ADHD symptomatology were included in the review. Determining if inhibitory control decits are characteristic of children with disruptive disorders will contribute to a more comprehensive aetiological framework, which in turn will inform more focussed intervention strategies.
Methods
Inclusion and Exclusion Criteria
Studies were included if: (1) they were written in English, (2) sample participants were 3-17 years old, (3) sample participants had a clinical diagnosis of ODD, CD, and/or comorbid ADHD based on ICD-10, DSM-IV, DSM-IV-TR, or DSM-5 criteria using either clinical interviewing or diagnostic measures, (4) outcome measures specically tested for inhibitory control using a performance or rating scale, and (5) they had a healthy control (HC) or ADHD group as a comparison. Studies were excluded if sample participants had intellectual impairment, Autism Spectrum Disorder, or other cognitive impairments as comorbid disorders.
Search Strategy and Study Selection
The meta-analysis followed the recommendations and standards set by the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA; Moher et al. 2009). A review protocol was registered with PROSPERO prior to completion of title and abstract screening. The initial protocol was amended, and all changes were reected on the published PROSPERO protocol (CRD42019121527). To obtain relevant literature, the following electronic databases were accessed in February 2020: PsycINFO, PubMed, Embase, CINAHL and Scopus. The nal title and abstract searches were conducted using the strings:
(executive function OR cognitive function OR executive dysfunction OR dysexecutive syndrome OR cognitive dysfunction OR executive control OR executive impairment OR inhibition OR inhibitory control OR attentional control OR emotional control OR cognitive control OR effortful control) AND (externalising behaviour OR externalizing behavior OR oppositional defiant disorder OR disruptive behaviour OR disruptive behavior OR problem behaviour OR problem behaviour OR conduct problems OR conduct disorder OR ADHD OR AD/HD OR attention decit hyperactivity disorder OR hyperkinetic) AND (child OR children OR adolescent OR kid OR school OR preschool OR pre-school OR pediatric OR paediatric OR teen OR teenager OR youth OR boy OR girl).
Key words and MESH terms were determined to be ineective in this search, as many records that were found explored executive function as a secondary construct of interest. Therefore, only title and abstract searches were used. Searches did not employ a restriction of year of publication. Reference list checks of review articles (Lipszyc and Schachar 2010; Oosterlaan et al. 1998; Schoemaker et al. 2013) and articles included in the current review were hand-checked to ensure all possible eligible studies were included.
Data Extraction
A total of 10,622 articles were retrieved through database and reference list searches. Following deduplication and assessment for eligibility, a total of 25 studies remained for nal review. Screening and appraisal were completed by two independent reviewers (MB and OE). Data extraction was completed by MB and with cross checks completed by another reviewer (OE). The following variables were extracted from the data: sample size, age, gender composition, country, IQ, primary diagnosis, comorbid diagnoses, medication status, details of diagnostic assessment, measures of inhibitory control, definition of inhibitory control, dependent variable as a measure of inhibitory control, measures of ADHD symptoms, eect size, and confounding variables. Where a consensus could not be reached, a third reviewer was consulted (DS). The
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PRISMA ow diagram outlines assessment of studies in Fig. 1.
Results
Studies Included
The following meta-analysis and synthesis will address differences between a healthy control (HC) group and children with a diagnosis of ODD/CD, ODD/CD + ADHD, or ADHD. In total, 25 studies were considered for meta- analysis (see Table 1), with the total included population
ranging from 3 to 14 years of age. Across the included studies, eight dierent task paradigms were employed to assess cool inhibitory, one hot inhibitory control measure was used, and one type of rating scale. When reporting ADHD symptoms, papers utilised standardised measures, symptom scales, and symptom counts from diagnostic interview schedules. Rating scales were either reported as a T-score, subscale raw score, or an average item score.
Publication Bias and Quality Appraisal
Publication bias was assessed through visual inspection of the funnel plot of standard error in Hedges G, revealing
Records idenfied through database
searching February 2020 (n = 10, 619)
Sc re en
in g
In clu
de d
El ig ib ili ty
Id en
fi ca o
n Addional records idenfied through
reference list checks (n = 3)
Records aer duplicates removed (n = 4298)
Records screened (n = 4298)
Records excluded (n = 4199)
Full-text arcles assessed for eligibility
(n = 99)
Full-text arcles excluded (n=74) Not in English (n=5) Outside 3-17yrs (n=3) No appropriate comparison (n=13) Non-clinical sample ODD/CD (n = 14) DSM-III (n= 10) ASD/II/TBI (n= 1) Did not assess inhibitory control (n=7) Conference paper/dissertaon (n=15) Duplicate sample/paper (n=2) Unable to source data from authors (n=4)
Studies included in qualitave synthesis
(n=25)
Studies included in quantave synthesis
(meta-analysis) (n = 25)
Fig. 1 PRISMA ow chart of studies included in the review
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Ta bl
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Research on Child and Adolescent Psychopathology
1 3
Ta bl
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(c on
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ou r R
ati ng
In
ve nt
or y o
f Ex
ec ut
iv e F
un cti
on
pr es
ch oo
l v er
sio n
(B RI
EF -P
); In
hi bi
t sc
ale us
ed to
as
se ss
in hi
bi to
ry
co nt
ro l
Ki dd
ie- Co
nt in
uo us
Pe
rfo rm
an ce
T as
k (K
-C PT
); m
ea su
re s
re sp
on se
in hi
bi tio
n th
ro ug
h n um
be r o
f co
m m
iss io
ns Gl
en n e
t a l.
( 2 01
7) CD
= 32
AD HD
+ C
D =
32 AD
HD =
32 Ns
re po
rte d h
er e a
re
th os
e r ep
or ted
in
an aly
sis
11 .44
(2 .05
) 11
.13 (1
.79 )
11 .03
(1 .89
)
87 .9%
M 89
.5% M
85 .9%
M
DS M
-IV ;
Di ag
no sti
c In
ter vi
ew
Sc he
du le
fo r C
hi ld
re n
(C -D
IS C)
No t r
ep or
ted Ch
ild B
eh av
io ur
Ch
ec kl
ist
– A tte
nt io
n su
bs ca
le.
Re po
rte d
as a
raw sc
or e
Co nn
er s’
Pa re
nt
Ra tin
g S ca
le Re
vi se
d: S
ho rt
Fo rm
– AD
HD
in de
x. Re
po rte
d as
ra w
sc or
e
60 .3%
of th
e sa
m pl
e w er
e tak
in g
sti m
ul an
t m
ed ica
tio n
St op
S ig
na lT
as k;
M
ea su
re of
re
sp on
se in
hi bi
tio n
an d i
m pu
lse
co nt
ro l t
hr ou
gh
SS RT
e (a n e
sti m
ate
of th
e l en
gt h o
f tim
e b etw
ee n
th e g
o an
d s to
p sti
m ul
i a t w
hi ch
th
e p ar
tic ip
an t i
s ab
le to
in hi
bi t t
he ir
re sp
on se
on 50
%
of tr
ial s)
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Gu nt
he r e
t a l.
( 2 00
6) HC
= 23
AD HD
+ D
BD =
23 11
.9( 2.2
) 11
.9( 2.1
) 18
M 5F
21 M
2F DS
M -IV
; K in
de r-
DI PS
(K -D
IP S)
Cl in
ica l:
dy
sth ym
ic di
so rd
er , m
ajo r
de pr
es sio
n, an
xi ety
di so
rd er
s HC
: N il
IO W
A Co
nn er
s ra
tin g s
ca le
– I na
tte nt
io n-
Ov er
ac tiv
ity
sc ale
. R ep
or ted
as
ra w
sc or
e
St im
ul an
ts we
re
ce as
ed 4
8h ou
rs pr
io r t
o t es
tin g
Go /N
o- Go
; M ea
su re
of
re sp
on se
se
lec tio
n/ in
hi bi
tio n
th ro
ug h t
he
nu m
be r o
f f als
e ala
rm s
Ho bs
on et
al .
(2 01
1) HC
= 34
OD D/
CD =
28 AD
HD ±
O DD
/ CD
= 31
13 .13
(1 .99
) 12
.64 (1
.98 )
13 .32
(1 .81
)
73 .53
% M
67 .86
% M
83 .87
% M
DS M
-IV ; C
hi ld
an
d A do
les ce
nt
Ps yc
hi atr
ic As
se ss
m en
t (C
AP A)
No t r
ep or
ted Co
nn er
s’ AD
HD /
DS M
-IV P
ar en
t an
d T ea
ch er
Sc
ale s.
Re po
rte d
as T
sc or
es
No t r
ep or
ted fo
r OD
D/ CD
AD HD
g ro
up
wa s w
ith ou
t m
ed ica
tio n f
or
18 ho
ur s p
rio r t
o tes
tin g
Go /N
o- Go
; M ea
su re
of
m ot
or re
sp on
se
in hi
bi tio
n t hr
ou gh
pe
rc en
tag e o
f su
cc es
sfu lly
in
hi bi
ted no
-g o
tri als
St op
T as
k; M
ot or
re
sp on
se in
hi bi
tio n
m ea
su re
d t hr
ou gh
SS
RT e (s
ub tra
cti ng
m
ea n s
to p s
ig na
l de
lay fr
om m
ea n
re ac
tio n t
im e t
o g o
tri als
)
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Hu m
m er
et al
. ( 2
01 1)
HC =
25 DB
Df = 23
DB D
+ AD
HD =
25
15 .1(
1.4 )
14 .80
(1 .3)
14 .7(
1.2 )
13 M
12 F
13 M
10 F
19 M
6F
DS M
-IV ; S
ch ed
ul e
fo r A
e cti
ve
Di so
rd er
s a nd
Sc
hi zo
ph re
ni a
fo r S
ch oo
l- Ag
ed C
hi ld
re n,
Pr es
en t a
nd
Li fet
im e V
er sio
n (K
-S AD
S)
AD HD
+ O
DD
gr ou
p: G
AD
an d s
ep ar
ati on
an
xi ety
Ad ol
es ce
nt
Sy m
pt om
In
ve nt
or y –
4:
Co m
bi ne
d AD
HD sc
or e.
Re po
rte d
as T
sc
or e
No t r
ep or
ted St
ro op
C ol
ou r W
or d
Te st;
In hi
bi tio
n of
an au
to m
ati c
re sp
on se
m ea
su re
d by
nu m
be r o
f co
m pl
ete d
ite m
s on
S tro
op C
ol ou
r W
or d (
SC W
) Co
un tin
g In
ter fer
en ce
Te
st; In
hi bi
tio n
of an
au to
m ati
c re
sp on
se m
ea su
re d
by nu
m be
r o f
co m
pl ete
d ite
m s
Co nn
er ’s
Co nt
in uo
us
Pe rfo
rm an
ce
Ta sk
(C CP
T) ; A
gr
ea ter
nu m
be r
of co
m m
iss io
ns
re e
cts po
or er
in
hi bi
to ry
co nt
ro l
Be ha
vi ou
r R ati
ng
In ve
nt or
y o f
Ex ec
ut iv
e F un
cti on
(B
RI EF
); In
hi bi
t sc
ale us
ed to
as
se ss
in hi
bi to
ry
co nt
ro l
Jia ng
et al
. ( 20
16 )
HC =
36 OD
D =
7 OD
D +
AD HD
= 17
AD HD
= 24
12 .92
(1 2.4
5– 13
.40 )
11 .76
(1 0.8
–1 2.6
8) 12
.64 (1
1.6 6–
13 .63
) 12
.17 (1
1.3 5–
13 .00
) Re
po rte
d a s M
an d
95 %
CI s
HC 27 M
9F Al
l O DD
23 M
1F
AD HD
22 M
2F
DS M
-IV ; R
efe rre
d fro
m ou
tp ati
en t
cli ni
c d ep
ar tm
en t
at a m
en tal
he alt
h ce
nt re
No co
m bo
rb id
iti es
Co nn
er s P
ar en
t Sy
m pt
om s
Qu es
tio nn
air e
(H yp
er ac
tiv ity
an
d Hy
pe ra
cti vi
ty -
Im pu
lsi vi
ty
in de
xe s).
Re
po rte
d as
ra w
sc or
es
Dr ug
na ïv
e St
ro op
C ol
ou r W
or d
Te st;
m ea
su re
of
in hi
bi to
ry
co nt
ro l/c
ap ab
ili ty.
M
ea su
re s a
s t he
co
rre ct
nu m
be r i
n th
e i nt
er fer
en ce
zte
st
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Lu m
an et
al ( 2
00 9)
HC =
50 AD
HD +
O DD
= 18
AD HD
= 20
11 4(
15 )
11 8(
18 )
10 6(
17 )
*r ep
or ted
in
m on
th s
56 %
M 69
% M
ac ro
ss
cli ni
ca l g
ro up
s
DS M
-IV ;
Di ag
no sti
c In
ter vi
ew S
ca le
(D IS
C- IV
)
No t r
ep or
ted Ch
ild B
eh av
io ur
Ch
ec kl
ist
an d T
ea ch
er
Ra tin
g F or
m –
In att
en tio
n a nd
Hy
pe ra
cti vi
ty /
Im pu
lsi vi
ty
sc ale
s. Re
po rte
d as
ra w
sc or
es DI
SC -IV
sy
m pt
om co
un t
– I na
tte nt
io n
an d
Hy pe
ra cti
vi ty
/ Im
pu lsi
vi ty
M eth
yl ph
en id
ate
ce as
ed at
le as
t 24
h pr
io r t
o tes
tin g
St op
T as
k;
slo we
r S SR
Te de
m on
str ate
s in
hi bi
tio n
pr ob
lem s.
SS
RT eq
ua l t
o th
e d i
er en
ce s
be tw
ee n m
ea n
re
ac tio
n t im
e o n
go -tr
ial s a
nd th
e m
ea n s
to p s
ig na
l de
lay
M ar
tel et
al . (
20 13
) HC
= 24
OD D
= 18
OD D
+ AD
HD =
39 AD
HD =
17
3.7 9(
0.9 3)
4.5 6(
1.2 4)
4.4 9(
1.0 7)
4.5 3(
0.9 4)
To tal
sa m
pl e
57 %M
DS M
-IV ; K
id di
e Di
sru pt
iv e
Be ha
vi ou
r Di
so rd
er s
Sc he
du le
(K -D
BD S)
No t r
ep or
ted Di
sru pt
iv e
Be ha
vi ou
r R ati
ng
Sc ale
(D BR
S)
– T ea
ch er
an d
Ca re
gi ve
r r ep
or ts
In att
en tiv
e a nd
Hy
pe ra
cti vi
ty
sc ale
s r ep
or ted
as
ra w
sc or
es
Pa re
nt s w
er e
en co
ur ag
ed
to ce
as e
ps yc
ho sti
m ul
an t
m ed
ica tio
n 24
–4 8 h
p rio
r to
te sti
ng if
ap
pr op
ria te.
No
on e o
n lo
ng -a
cti ng
ps
yc ho
tro pi
c m
ed ica
tio n
Sh ap
e S ch
oo l;
m
ea su
re of
re
sp on
se in
hi bi
tio n
th ro
ug h n
um be
r of
co rre
ct an
sw er
s di
vi de
d b y t
im e t
o co
m pl
ete th
e t ria
l
Qi an
et al
. ( 20
10 )
HC =
11 6
AD HD
+ O
DD =
53 AD
HD =
89
9.1 9(
1.6 2)
9.2 5(
1.7 9)
9.0 7(
1.9 2)
97 M
19 F
42 M
11 F
76 M
13 F
DS M
-IV ; C
lin ica
l Di
ag no
sti c
In ter
vi ew
in g
Sc ale
(C DI
S)
No co
m or
bi di
tie s
AD HD
R ati
ng
Sc ale
(A DH
D RD
-IV );
AD HD
to
tal sc
or e
an d c
om pu
ted
in att
en tio
n a nd
hy
pe ra
cti ve
/ im
pu lsi
ve sc
or es
. Re
po rte
d as
ra w
sc or
e
No t r
ep or
ted Be
ha vi
ou r R
ati ng
In
ve nt
or y o
f Ex
ec ut
iv e F
un cti
on
(B RI
EF );
In hi
bi t
sc ale
us ed
to
as se
ss in
hi bi
to ry
co
nt ro
l
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Ru bi
a e t a
l. ( 2
00 8)
g HC
= 20
CD =
13 AD
HD =
20
14 .0
(1 .9)
12 .9
(2 .2)
13 .2
(1 .4)
Al l m
ale DS
M -IV
; M
au ds
ley
Di ag
no sti
c In
ter vi
ew
No co
m or
bi di
tie s
St re
ng th
s a nd
Di
cu
lti es
Qu
es tio
nn air
e – H
yp er
ac tiv
ity
Sc or
e. Re
po rte
d as
ra w
sc or
e
Ex clu
de d i
f pr
ev io
us ly
ex
po se
d t o
sti m
ul an
t m
ed ica
tio n
St op
T as
k; M
ot or
re
sp on
se in
hi bi
tio n
m ea
su re
d t hr
ou gh
SS
RT e (s
ub tra
cti ng
m
ea n s
to p s
ig na
l de
lay fr
om m
ea n
re ac
tio n t
im e t
o g o
tri als
) Ru
bi a e
t a l.
(2 00
9) g
HC =
20 CD
= 13
AD HD
= 20
14 (2
) 13
(1 )
13 .2
(1 .5)
Al l m
ale DS
M -IV
; M
au ds
ley
Di ag
no sti
c In
ter vi
ew
No co
m or
bi di
tie s
St re
ng th
s a nd
Di
cu
lti es
Qu
es tio
nn air
e – H
yp er
ac tiv
ity
Sc or
e. Re
po rte
d as
ra w
sc or
e
Ex clu
de d i
f pr
ev io
us ly
ex
po se
d t o
sti m
ul an
t m
ed ica
tio n
Si m
on T
as k;
In
hi bi
tio n o
f a n
in co
rre ct
re sp
on se
to
in co
ng ru
en t
sti m
ul i.
M ea
su re
d by
re sp
on se
ti m
es
to in
co ng
ru en
t co
m pa
re d t
o co
ng ru
en t t
ria ls
(C on
i ct
Re ac
tio n
Ti m
e e e
ct) Sa
br y e
t a l.
(2 01
1) h
HC =
45 AD
HD
in at
ten tiv
e = 14
AD HD
hy
pe ra
cti ve
= 15
AD HD
co
m bi
ne d =
15 CD
= 24
OD D
= 13
Bi po
lar =
11
9.1 (1
.8) 8.1
7( 1.8
) 8.9
(2 .07
) 8.2
(1 .4)
9.9 (1
.8) 8.1
(1 .9)
11 .1(
0.7 )
25 M
20 F
9 M 5F
12 M
3F 12
M 3F
16 M
8F 6 M
7F 5 M
6F
DS M
-IV ;
di ag
no se
d b y
tw o i
nd ep
en de
nt
ps yc
hi atr
ist s
us in
g a s
em i-
str uc
tu re
d in
ter vi
ew
gu id
ed by
C hi
ld
M en
tal S
tat us
Ex
am in
ati on
No co
m or
bi di
tie s
No t r
ep or
ted No
t r ep
or ted
Qu an
tit yi
nh ib
iti on
tas
k; nu
m be
r o f
an sw
er s c
or re
ct Ob
jec t i
nh ib
iti on
tas
k; nu
m be
r o f
an sw
er s c
or re
ct Nu
m er
ica l s
ize
in hi
bi tio
n t as
k;
nu m
be r o
f a ns
we rs
co rre
ct Sc
ha ch
ar et
al .
(2 00
0) HC
= 33
CD =
13 AD
HD =
72 AD
HD +
C D
= 47
9.3 (1
.5) 9.5
(1 .4)
9.0 (1
.4) 9.2
(1 .5)
3: 2
6: 1
4: 1
9: 1
*m :f
ra tio
DS M
-IV ; P
ar en
t In
ter vi
ew fo
r Ch
ild S
ym pt
om s
(P IC
S) an
d Te
ac he
r Te
lep ho
ne
In ter
vi ew
(T TI
)
To tal
sa m
pl e:
Ex clu
de d i
f ps
yc ho
sis ,
or cl
in ica
lly
sig ni
c an
t m
oo d o
r a nx
iet y
di so
rd er
p re
se nt
HC : F
re e o
f co
m or
bi d
di ag
no se
s
Pa re
nt In
ter vi
ew
fo r C
hi ld
Sy
m pt
om s
an d T
ea ch
er
Te lep
ho ne
In
ter vi
ew .
Re po
rte d
as ra
w sc
or es
St im
ul an
t m
ed ica
tio n
ce as
ed 4
8h rs
pr io
r t o t
es tin
g
St op
-si gn
al; D
e cit
s of
in hi
bi to
ry
co nt
ro l m
ea su
re d
th ro
ug h
SS RT
e
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Sc ho
em ak
er et
al .
( 2 01
2) HC
= 56
DB Df =
33 AD
HD =
61 AD
HD +
D BD
= 52
55 .66
(7 .18
) 51
.88 (8
.29 )
55 .20
(7 .41
) 54
.12 (6
.80 )
*r ep
or ted
in
m on
th s
69 .6%
M 81
.8% M
80 .3%
M 82
.7% M
DS M
-IV -T
R;
Co ns
en su
s be
tw ee
n c hi
ld
ps yc
hi atr
ist an
d cli
ni ca
l c hi
ld
ps yc
ho lo
gi st
us in
g sy
m pt
om
m ea
su re
s an
d c lin
ica l
in ter
vi ew
in g
No ne
re po
rte d
Ch ild
B eh
av io
ur
Ch ec
kl ist
– Pa
re nt
an d
Te ac
he r R
ep or
t: At
ten tio
n Pr
ob lem
s S ca
le.
Re po
rte d
as T
sc
or es
No ch
ild re
n we
re
on m
ed ica
tio n
Go /N
o- Go
; M ea
su re
of
in hi
bi to
ry
sk ill
s t hr
ou gh
th e
nu m
be r o
f N o-
Go
tri als
co rre
ctl y n
ot -
pr es
se d d
iv id
ed
th e t
ot al
nu m
be r o
f No
-G o
tri als
M od
i ed
S na
ck
De lay
; M ea
su re
of
in hi
bi to
ry
sk ill
s t hr
ou gh
th
e n um
be r o
f in
ter va
ls th
at th
e ch
ild co
m pl
ied
wi th
al l t
as k r
ul es
Sh ap
e S ch
oo l –
In
hi bi
t C on
di tio
n;
M ea
su re
of
in hi
bi to
ry sk
ill s
th ro
ug h n
um be
r o f
co rre
ct re
sp on
se s
di vi
de d b
y t he
to tal
nu
m be
r o f t
ria ls
Sh ua
i e t a
l. (2
01 1)
HC =
76 AD
HD +
O DD
= 38
AD HD
= 76
AD HD
+ Le
ar ni
ng
Di so
rd er
= 38
10 .21
(2 .30
) 10
.34 (2
.53 )
10 .24
(2 .40
) 10
.38 (2
.56 )
Al l m
ale DS
M -IV
; St
ru ctu
re d
in ter
vi ew
co
nd uc
ted by
ps
yc hi
atr ist
s
Ti c a
nd m
oo d
di so
rd er
s No
t r ep
or ted
No m
ed ica
tio n
pr io
r t o t
es tin
g St
ro op
C ol
ou r a
nd
W or
d T es
t; to
m
ea su
re in
hi bi
tio n
by an
in ter
fer en
ce
sc or
e
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
Sk og
an et
al ( 2
01 4)
HC =
45 5
OD D
= 20
5 AD
HD +
O DD
= 23
5 AD
HD =
15 0
41 .7(
1.3 )
41 .8(
1.4 )
41 .7(
1.3 )
41 .5(
1.2 )
*r ep
or ted
in
m on
th s
23 9 M
21 6F
10 6 M
99 F
13 6 M
99 F
80 M
70 F
DS M
-IV -T
R;
Pr es
ch oo
l A ge
Ps
yc hi
atr ic
As se
ss m
en t
in ter
vi ew
(P AP
A)
No t r
ep or
ted PA
PA sy
m pt
om
ra tin
gs . R
ep or
ted
as a
sy m
pt om
co
un t
Ni l ps
yc ho
sti m
ul an
t m
ed ica
tio n
at th
e t im
e o f
as se
ss m
en t
NE PS
Y su
bt es
t –
St atu
e; m
ea su
re
of in
hi bi
tio n.
Sc or
in g:
tw o
po in
ts pe
r 5 -s
in ter
va l a
nd
po in
ted de
du cte
d fo
r m ov
em en
ts pe
r in
ter va
l Sp
in th
e P ot
s; as
se ss
es ab
ili ty
to
su pp
re ss
pr ep
ot en
t re
sp on
se . R
ep or
ted
as an
im pu
lsi vi
ty
sc or
e Sk
og an
et al
. ( 2
01 5)
HC =
11 7
OD D
= 39
AD HD
= 10
4 An
xi ety
= 48
To tal
sa m
pl e
41 .8(
1.3 )
*r ep
or ted
in
m on
th s
65 M
52 F
21 M
18 F
66 M
38 F
27 M
21 F
DS M
-IV ;
Pr es
ch oo
l A ge
Ps
yc hi
atr ic
As se
ss m
en t
in ter
vi ew
(P AP
A)
No t r
ep or
ted PA
PA sy
m pt
om
ra tin
gs . R
ep or
ted
as a
sy m
pt om
co
un t.
Re po
rte d
as a
m ea
n f or
th e
sa m
pl e o
ve ra
ll
Ni l ps
yc ho
sti m
ul an
t m
ed ica
tio n
at th
e t im
e o f
as se
ss m
en t
Be ha
vi ou
r R ati
ng
In ve
nt or
y o f
Ex ec
ut iv
e Fu
nc tio
n –
Pr es
ch oo
l v er
sio n
(B RI
EF -P
); In
hi bi
t sc
ale us
ed to
as
se ss
in hi
bi to
ry
co nt
ro l
Va n G
oo ze
n e t a
l. (2
00 4)
HC =
36 OD
D =
15 OD
D +
AD HD
= 26
9.2 (1
.2) 10
.1( 1.2
) 9.5
(1 .6)
14 M
22 F
36 M
5F (T
ot al
OD D)
DS M
-IV ; D
IS C-
P OD
D gr
ou p:
De
pr es
sio n,
an xi
ety , O
CD ,
To ur
ett es
/ tic
di so
rd er
, en
ur es
is/ en
co pr
es is
OD D
+ AD
HD
gr ou
p: C
D,
de pr
es sio
n, an
xi ety
, O CD
, To
ur ett
es /ti
c di
so rd
er , e
nu re
sis
an d e
nc op
re sis
HC : A
DH D
(n =
1)
Ch ild
B eh
av io
ur
Ch ec
kl ist
– Pa
re nt
an d
Te ac
he r R
ep or
t: At
ten tio
n Pr
ob lem
s S ca
le.
Re po
rte d
as T
sc
or es
No t r
ep or
ted St
ro op
co lo
ur w
or d
tes t;
Re qu
ire s
in hi
bi tio
n o f
an ov
er lea
rn ed
au
to m
ati c
re sp
on se
. M
ea su
re d v
ia SC
W T-
in tti
m e;
th e t
im e r
eq ui
re d
to co
m pl
ete th
e sti
m ul
us se
t i n
th e i
nt er
fer en
ce
co nd
iti on
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 1
(c on
tin ue
d)
Re fer
en ce
Su bj
ec ts
Ag e a
M (S
D) Se
x Di
ag no
sti c
cr ite
ria an
d as
se ssm
en t
Re po
rte d
Co
m or
bi d
di
ag no
se s
AD HD
S ym
pt om
M
ea su
re M
ed ica
tio n
sta tu
s Ta
sk
ch ar
ac ter
ist ics
W ier
se m
a e t a
l ( 2
00 6)
HC =
15 AD
HD +
O DD
= 9
AD HD
= 13
10 .2(
1.9 7)
To tal
A DH
D 10
.3( 1.5
9)
10 M
5F To
tal A
DH D
14 M
8F
DS M
-IV ;
Di ag
no sti
c In
ter vi
ew
Sc he
du le
fo r C
hi ld
re n
(D IS
C- IV
)
No t r
ep or
ted Ch
ild B
eh av
io ur
Ch
ec kl
ist an
d Te
ac he
r R ep
or t
Fo rm
Di sru
pt iv
e Be
ha vi
ou r
Di so
rd er
R ati
ng
Sc ale
Re su
lts n
ot
re po
rte d
M eth
yl ph
en id
ate
wa s c
ea se
d fo
r a t l
ea st
24 h
pr io
r t o
tes tin
g. No
ot he
r m
ed ica
tio ns
u se
d
Go /N
o- Go
ta sk
; co
rre lat
es of
in
hi bi
to ry
co
nt ro
l, as
se ss
ed
by pe
rc en
tag e
of er
ro rs
of
co m
m iss
io n
Xu et
al . (
20 17
) HC
= 52
OD D
= 14
OD D
+ AD
HD =
29 AD
HD =
39
10 .02
(2 .10
) 9.8
5( 1.9
1) 10
.11 (1
.74 )
9.1 6(
1.8 2)
Al l m
ale DS
M -IV
; S ch
ed ul
e fo
r A e
cti ve
Di
so rd
er s a
nd
Sc hi
zo ph
re ni
a fo
r S ch
oo l-
Ag ed
C hi
ld re
n, Pr
es en
t a nd
Li
fet im
e V er
sio n
(K -S
AD S-
PL )
OD D:
N o
co m
or bi
di tie
s Co
nn er
s’ Pa
re nt
Sy
m pt
om
Qu es
tio nn
air e
– h yp
er ac
tiv ity
- im
pu lsi
vi ty
in
de x.
Co nt
ro l
gr ou
p n ot
as
se ss
ed .
Re po
rte d
as ra
w sc
or es
Dr ug
na ïv
e St
ro op
co lo
ur w
or d
tes t;
In hi
bi to
ry
co nt
ro l a
bi lit
y m
ea su
re d b
y nu
m be
r o f c
or re
ct re
ad s i
n t he
in
ter fer
en ce
te st
a M ea
n a ge
an d s
tan da
rd de
vi ati
on re
po rte
d i n y
ea rs
un les
s o th
er wi
se sp
ec i
ed b A
DH D
gr ou
ps fr
om th
e B ah
civ an
S ay
da m
(2 01
5) st
ud y w
er e p
oo led
to ge
th er
re sp
ec tiv
ely w
he n c
on sid
er ed
fo r m
eta -a
na lys
is c H
yp er
ki ne
tic D
iso rd
er d H
yp er
ki ne
tic C
on du
ct Di
so rd
er e S
to p s
ig na
l r ea
cti on
ti m
e, f D
isr up
tiv e b
eh av
io ur
di so
rd er
s ( OD
D/ CD
) g R
ub ia
(2 00
8; 20
09 ) u
til ise
sa m
e s am
pl e a
nd da
ta is
po ol
ed fo
r m eta
-a na
lys is
h C D
an d
OD D
gr ou
ps an
d AD
HD g
ro up
s f ro
m th
e S ab
ry (2
01 1)
st ud
y we
re p
oo led
to ge
th er
re sp
ec tiv
ely w
he n
co ns
id er
ed fo
r m eta
-a na
lys is.
* Gr
ou ps
in b
ol d
ha ve
b ee
n us
ed in
th e
na l m
eta -
an aly
sis .
Research on Child and Adolescent Psychopathology
1 3
apparent symmetry. This was also reected by the Trim and Fill test which reected minimal change in the estimated eect between groups (Duval and Tweedie 2000). Studies included in the current review underwent a quality appraisal by two independent reviewers utilising the Joanna Briggs Institute Critical Appraisal Tools (Table 2; Moola et al. 2017). All studies in the review were deemed to be of adequate quality and as such, were included for final analysis.
Calculation of Effect Sizes
If papers reported on the same sample, the first paper published was utilised as the primary study. Provided they were dierent from the primary paper, additional measures from subsequent papers were included. Data from these papers were treated as one sample in the analyses. Two papers (Bahcivan Saydam et al. 2015; Sabry et al. 2011) reported data by subgroups. For the purpose of this meta- analysis, a single eect size was calculated according to the formula recommended by Borenstein (2009).
All extracted data were entered into and analysed by Comprehensive Meta-Analysis (CMA) software (Version 3). Meta-analyses were conducted for four outcome types: performance measures for cool inhibitory control, performance measure for hot inhibitory control, rating scales, and ADHD symptoms. Comparisons were made between HC, ODD/CD, ODD/CD + ADHD, and ADHD groups. Results are presented as a mean eect size, reected as Hedges g with associated 95% condence intervals acting as a common metric between studies. A random eects model was utilised to account for greater between study variance.
Between Study Variability and Outliers
Between-study variability was examined through a Q test of heterogeneity. A signicant Q suggests that reasons for variance between studies should be considered. For example, outliers and potential moderators should be examined through meta-regression or other appropriate methods (Borenstein 2009). Sensitivity analyses were conducted for each analysis where significant heterogeneity was indicated; outliers are only reported if they were removed from analyses.
Potential Moderators
Each study implemented a performance measure of inhibitory control, however tasks usually varied between studies. While all tasks are designed to assess the same underlying construct of inhibitory control, we know that there can be variability between tasks due to task impurity
(i.e., due to the nature of cognitive ability, performance is aected by other cognitive processes depending on the nature of the task; Anderson 2002). As such, exploratory subgroup analyses were conducted as a function of task paradigm (e.g., Stroop, Go/No-Go, Continuous Performance Tasks) to explore dierence of eect size between tasks. Additionally, rating scales were reported as mean item score, subscale total, or T-score and ADHD symptoms were reported as T-scores, raw scores, or symptom counts. These variances between studies were also considered as a potential moderator.
Age was considered as a moderator as ages of participants ranged from approximately three years to 15 years. Age was coded as a continuous variable, with weighted mean age calculated for each study if not provided. Gender was coded as a continuous variable, representing the percentage of males in the sample and was calculated when required. Medication was considered as a moderator, however most studies ceased children’s medication prior to testing and as such, was not included in moderation analyses.
Performance Measures for Cool Inhibitory Control
Following are the analyses for performance on measures of cool inhibitory control. Eect size and heterogeneity analyses are found in Table 3. Forest plots can be found in the Supplementary materials.
ODD/CD vs. HC. Across 15 studies, children with ODD/CD were found to have signicantly more diculties with cool inhibitory control compared to healthy controls (g = -0.58, p < 0.001); with signicant heterogeneity. Age was not found to be a signicant moderator (p = 0.42), nor was percentage of males in the sample (p = 0.89). However, subgroup analyses revealed signicant overall eects for the following tasks: Shape Shift (k = 2, g = -0.74, p < 0.001), Go/No-Go (k = 2, g = -0.75, p < 0.001), Stop Task (k = 4, g = 0.36, p = 0.17), and tasks employing the Stroop paradigm (k = 5, g = -0.83, p = 0.046).,
ODD/CD vs. ADHD. A meta-analysis of 13 studies did not reveal a signicant dierence between children with ODD/CD and ADHD. Moderation analyses revealed that age did not signicantly contribute to between study variance (p = 0.68) and nor did percentage of males in the sample (p = 0.51). Further exploratory subgroup analyses identied the only task with a signicant dierence in performance was the Statue Task (g = 0.38, p < 0.001), however only one study utilised this assessment.
ODD/CD vs. ODD/CD + ADHD. Across 13 studies, children with a comorbid diagnosis of ODD/CD + ADHD were found to perform more poorly on tasks of inhibitory control compared to those of a single ODD/CD diagnosis (g = 0.18, p = 0.03). The data were found to be homogenous and no follow-up moderation was required. Exploratory
Research on Child and Adolescent Psychopathology
1 3
Ta bl
e 2
Q ua
lit y a
pp ra
isa l o
f i nc
lu de
d s tu
di es
St ud
y 1.
W er
e t he
cr ite
ria
fo r i
nc lu
sio n i
n th
e s am
pl e c
lea rly
de
n ed
?
2. W
er e t
he st
ud y
su bj
ec ts
an d t
he
se tti
ng de
sc rib
ed in
de
tai l?
3. W
as th
e e xp
os ur
e (in
hi bi
to ry
co nt
ro l)
m ea
su re
d i n a
va lid
an
d r eli
ab le
wa y?
4. W
er e o
bj ec
tiv e,
sta nd
ar d
cr ite
ria us
ed fo
r m
ea su
re m
en t o
f t he
co
nd iti
on (O
DD /
CD )?
5. W
er e
co nf
ou nd
in g
fac -
to rs
id en
ti ed
?
6. W
er e s
tra teg
ies
to de
al wi
th
co nf
ou nd
in g
fac to
rs sta
ted ?
7. W
er e t
he
ou tco
m es
m
ea su
re d i
n a va
lid
an d r
eli ab
le wa
y?
8. W
as ap
pr op
ria te
sta tis
tic al
an aly
sis
us ed
?
Al br
ec ht
et al
. ( 2
00 5)
+
+
+
? +
+
+
+
An to
ni ni
et al
. (2
01 5)
+
+
+
+
+
+
+
+
Ba hc
iv an
et al
. (2
01 5)
+
+
+
? -
- +
+
Ba na
sc he
ws ki
et al
. (2
00 4)
+
+
+
? +
+
+
+
Bo rk
ow sk
a e t a
l. (2
01 6)
+
+
+
? -
- +
+
Ez pe
let a a
nd
Gr an
er o (
20 15
) +
+
+
+
+
+
+
+
Gl en
n e t a
l. (2
01 7)
+
+
+
+
+
+
+
+
Gu nt
he r e
t a l.
(2 00
6) +
+
+
+
+
+
+
+
Ho bs
on et
al .
(2 01
1) +
+
?
+
+
+
+
+
Hu m
m er
et al
. (2
01 1)
+
+
+
+
+
+
+
+
Jia ng
et al
. ( 20
16 )
+
+ +
?
- -
+
+
Lu m
an et
al . (
20 09
) +
+
+
+
+
+
+
+
M
ar tel
et al
. ( 20
13 )
+
+
+
+
+
+ +
+
Qi
an et
al . (
20 10
) +
+
+
+
+
+
+
+
Ru
bi a e
t a l.
(2 00
9) +
+
+
+
+
+
+
+
Ru
bi a e
t a l.
(2 00
8) +
+
+
+
+
+
+
+
Sa
br y e
t a l.
(2 01
1) +
+
? ?
- -
? +
Sc
ha ch
ar et
al .
(2 00
0) +
+
+
?
+
+
+
+
Sc ho
em ak
er et
al .
(2 01
2) +
+
+
+
+
+
+
+
Sh ua
i e t a
l. (2
01 0)
+
+
+
? +
+
+
+
Sk
og an
et al
. (2
01 4)
+
+
+
+
+
+
+
+
Research on Child and Adolescent Psychopathology
1 3
subgroup analyses revealed the following tasks had significant differences between groups: Continuous Performance Task (CPT; k = 3, g = 0.56, p = 0.003), and Statue task (k = 1, g = 0.51, p < 0.001).
ODD/CD + ADHD vs. ADHD. Pooling all measures of 16 studies did not reveal a signicant dierence between children with ODD/CD + ADHD and ADHD only (p = 0.88). Moderation analyses revealed that age did not signicantly account for between study variance (p = 0.65) and nor did gender (p = 0.66). Exploratory subgroup analysis revealed that the CPT was the only task where a signicant dierence in performance was observed (k = 2, g = -0.81, p = 0.002); with poorer performance in children with ODD/ CD + ADHD.
ODD/CD + ADHD vs. HC. An analysis of 19 studies revealed that children with a comorbid diagnosis of ODD/ CD and ADHD performed more poorly than healthy controls (g = -0.47, p < 0.001). Children with ODD/ CD + ADHD were found to perform more poorly on most tasks, including: CPT (k = 3, g = -0.49, p = 0.007), Spin the Pots (k = 1, g = -0.29, p < 0.001), Statue (k = 1, g = -0.34, p < 0.001), Stop Task (k = 4, g = -0.34, p 0.01), Go/No-Go (k = 4, g = -0.75, p < 0.001), and the Stroop paradigm (k = 7, g = -0.59, p < 0.001),
Performance Measures for Hot Inhibitory Control
Meta-analysis could not be conducted due to one study using a measure assessing hot inhibitory control. Schoemaker et al. (2012) administered the Modied Snack Delay as a measure of inhibitory control in a motivationally salient context. All three clinical groups (i.e., Disruptive Behaviour Disorders (DBD), ADHD, and ADHD + DBD) were found to have poorer inhibitory control than healthy controls (p < 0.01). Signicant main eects of ADHD and DBD were found, as well as a signicant interaction eect of ADHD and DBD.
Rating Scales
The analyses for group dierences on ratings of inhibitory control are presented below. Eect size and heterogeneity analyses are found in Table 4. All studies included in the following analyses reported using the BRIEF as a measure of inhibitory control. Due to so few studies included for each analysis, follow-up moderation analyses were not conducted where heterogeneity was signicant. Variability is likely due to the limited number of studies included, as well as dierent metrics utilised between studies (i.e., T-scores, raw scores, item scores). Forest plots can be found in the Supplementary materials.
ODD/CD vs. HC. Three studies revealed no signicant dierences between children with ODD/CD and healthy controls (p = 0.103). Although each study utilised the * I
tem 4
re qu
ire d u
se of
a cli
ni ca
l i nt
er vi
ew to
gu id
e d iag
no sis
; s tu
di es
re ce
iv ed
an “u
ns ur
e” if
o nl
y d iag
no sti
c c rit
er ia
we re
pr ov
id ed
(e .g.
, D SM
-IV ).
* I tem
8 wa
s a ss
es se
d a s t
o w he
th er
th e a
na lys
is wa
s a pp
ro pr
iat e f
or th
e p ap
er ’s
ow n
re se
ar ch
qu es
tio n.
Se e M
oo la
et al.
(2 01
7) fo
r f ul
l d eta
ils o
f t he
cr ite
ria fo
r e ac
h i tem
.
Ta bl
e 2
(c on
tin ue
d)
St ud
y 1.
W er
e t he
cr ite
ria
fo r i
nc lu
sio n i
n th
e s am
pl e c
lea rly
de
n ed
?
2. W
er e t
he st
ud y
su bj
ec ts
an d t
he
se tti
ng de
sc rib
ed in
de
tai l?
3. W
as th
e e xp
os ur
e (in
hi bi
to ry
co nt
ro l)
m ea
su re
d i n a
va lid
an
d r eli
ab le
wa y?
4. W
er e o
bj ec
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same measure, a non-signicant dierence may be due to dierences in reporting between each study; with Ezpeleta (2015) reporting an average total raw score, Hummer (2011) reported an average T-score, and Skogan (2015) an average item score.
ODD/CD vs. ADHD. Two studies revealed that children with ADHD had more diculties with inhibitory control than children with ODD/CD (g = 0.97, p = 0.001). While het- erogeneity was not signicant, the 95% condence intervals suggest greater variability in the presence and severity of parent-reported inhibitory control decits. As such, further empirical studies are needed.
ODD/CD vs. ODD/CD + ADHD. The meta-analysis of two studies showed that children with a comorbid diagnosis of ODD/CD + ADHD were more likely to be rated as hav- ing more diculties with inhibitory control compared to children with ODD/CD only. However, due to few studies, conclusions are tentative.
ODD/CD + ADHD vs. ADHD. Similarly, only two stud- ies used the BRIEF to assess dierences between children with ODD/CD + ADHD and ADHD (Ezpeleta, 2015; Qian,
2010). Whilst both studies employed the same metric (raw scores on the Inhibit scale), no signicant dierences were observed (p = 0.87).
ODD/CD + ADHD vs. HC. Three studies revealed that children with ODD/CD + ADHD were rated as having more diculties with inhibitory control compared to healthy con- trols (g = -1.95, p = 0.001). Signicant heterogeneity was observed; however, this is likely due to dierences in metrics employed and few studies in the analysis.
ADHD Symptomatology
The analyses for group dierences on measures of ADHD symptomatology are below. Eect size and heterogeneity statistics are reported in Table 5. Forest plots can be found in the Supplementary materials.
ODD/CD vs. HC. Across 12 studies, children with ODD/CD were found to have signicantly more symptoms of ADHD compared to healthy controls (g = -1.59, p < 0.001). However, studies were found to be signicantly heterogenous. Between measures, three types of metrics
Table 3 Eect size and heterogeneity analysis for cool inhibitory control performance measures
k = number of samples included N = number of participants g = Hedge’s g CI = condence interval I2 = proportion of variability between studies.
Eect Size Analysis Heterogeneity Analysis Comparison k N g SE 95%CI Z-value p Q df (Q) I2 p
ODD/CD vs HC 15 1931 -0.58 0.16 -0.90 – -0.26 -3.54 < 0.001 93.76 14 85.07 < 0.001 ODD/CD vs ADHD 13 993 0.06 0.07 -0.09 – 0.20 0.80 0.43 13.34 12 10.05 0.035 ODD/CD vs ODD/CD + ADHD 13 1010 0.18 0.07 0.02 – 0.35 2.13 0.03 15.96 12 24.81 0.19 ODD/CD + ADHD vs ADHD 16 1458 -0.01 0.08 -0.17 – 0.15 -0.15 0.88 27.86 15 46.17 0.02 ODD/CD + ADHD vs HC 19 2414 -0.47 0.005 -0.60 – -0.34 -7.01 < 0.001 27.61 18 34.81 0.07
Table 4 Eect size and heterogeneity analysis for inhibitory control on rating scales of inhibitory control
k = number of samples included N = number of participants g = Hedge’s g CI = condence interval I2 = proportion of variability between studies.
Eect Size Analysis Heterogeneity Analysis Comparison k N g SE 95%CI Z-value p Q df (Q) I2 p
ODD/CD vs HC 3 793 -0.81 0.50 -1.78 – 0.16 -1.63 0.10 34.44 2 94.19 < 0.001 ODD/CD vs ADHD 2 217 0.97 0.29 0.40 – 1.55 3.32 0.001 3.15 1 68.27 0.07 ODD/CD vs ODD/CD + ADHD 2 109 1.12 0.44 0.26 – 1.98 2.55 0.01 3.42 1 70.79 0.06 ODD/CD + ADHD vs ADHD 2 175 -0.10 0.61 -1.29 – 1.08 -0.17 0.87 8.54 1 88.29 0.003 ODD/CD + ADHD vs HC 3 767 -1.95 0.57 -3.07 – -0.83 -3.41 0.001 21.97 2 90.90 < 0.001
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were reported: T-scores, subscale raw scores, and symptom counts. Subgroup analyses were conducted across these metrics, with T-scores (k = 6, g = -2.02, p < 0.001), symptom counts (k = 3, g = -0.65, p = 0.02), and subscale raw scores (k = 4, g = -1.43, p = 0.003) showing signicant dierences between groups. Gender was found to signicantly moderate eect size, with a greater percentage of boys in the sample with effect size (ß = -0.05, p < 0.001). Age was not a signicant moderator (p = 0.20).
ODD/CD vs. ADHD. A meta-analysis of 11 studies did not reveal a signicant dierence in ADHD symptomatology was observed between children with ODD/CD and ADHD with all measures pooled (p = 0.29). Age was found to signicantly contribute to between study variance (ß = -0.15, p = 0.016), as was gender with eect size associated with a greater percentage of boys in the sample (ß = -0.04, p < 0.001). Exploratory subgroup analyses were conducted to examine dierences between metrics reported, however no signicant dierences were noted (all p > 0.052).
ODD/CD vs. ODD/CD + ADHD. Children with a comorbid diagnosis of ODD/CD + ADHD were reported to have signicantly more ADHD symptoms than children with ODD/CD alone across 13 studies (g = 0.74, p = 0.004). Studies were also found to be heterogenous; as such, moderation analyses were conducted. Age was not found to signicantly explain between study variance (p = 0.86), however proportion of males in the sample was signicantly associated with eect size (ß = -0.04, p < 0.001). However, this may be due to the majority of studies that reported on gender had more than 75% of males in the sample. Subgroup analyses revealed measures reported as symptom counts (k = 2, g = 1.46, p = 0.02), subscale raw scores (k = 5, g = 0.49, p = 0.005), and T scores (k = 6, g = 0.72, p = 0.03) indicated children with ODD/CD + ADHD showed greater ADHD symptomatology.
ODD/CD + ADHD vs. ADHD. Across 16 studies, children with ODD/CD + ADHD were reported to have
more ADHD symptomatology than children with ADHD alone (g = -0.49, p < 0.001). Studies showed significant heterogeneity. Age did not moderate between study variance (p = 0.72), nor did gender (p = 0.06). Through subgroup analyses, only subscale raw scores (k = 8, g = -0.71, p = 0.001) and symptom counts (k = 3, g = -0.35, p = 0.008) revealed a signicant dierence between groups.
ODD/CD + ADHD vs. HC. Meta-analysis of 19 studies revealed children with a comorbid diagnosis of ODD/ CD + ADHD had signicantly more symptoms of ADHD compared to healthy controls (g = -3.23, p < 0.001). Age was not a signicant moderator of eect size (p = 0.40) and nor was gender (p = 0.47). Subgroup analyses revealed all metrics of assessing ADHD symptomatology indicated significant differences between groups; T-scores (k = 6, g = -3.16, p < 0.001), subscale raw scores (k = 6, g = -2.77, p < 0.001), and symptom counts (k = 4, g = -4.49, p < 0.001).
Discussion
This meta-analysis explored whether children with a diagnosis of ODD and/or CD had more decits of inhibitory control compared to healthy controls, independent of a diagnosis of ADHD. To the best of our knowledge, this meta-analysis is the rst to assess inhibitory control performance in a clinical sample of children with ODD/CD, using a range of inhibitory control measurement approaches in both hot and cool contexts, and also giving consideration to ADHD symptomatology.
ADHD, ODD, and CD: Categorical Disorders or Dimensions of the Same Pathology?
Overall, results across multiple meta-analyses demonstrated that children with ODD/CD and ADHD have similar ADHD symptomatology and performance on tasks of inhibitory
Table 5 Eect size and heterogeneity analysis for ADHD symptomatology between groups
k = number of samples included N = number of participants g = Hedge’s g CI = condence interval I2 = proportion of variability between studies.
Eect Size Analysis Heterogeneity Analysis Comparison k N g SE 95%CI Z-value p Q df (Q) I2 p
ODD/CD vs HC 12 1715 -1.59 0.27 -2.11—-1.07 -6.02 < 0.001 136.77 11 91.92 < 0.001 ODD/CD vs ADHD 11 872 0.35 0.33 -0.30 – 1.00 1.05 0.29 159.88 10 93.75 < 0.001 ODD/CD vs ODD/CD + ADHD 13 1010 0.74 0.26 0.24 – 1.23 2.88 0.004 128.31 12 90.65 < 0.001 ODD/CD + ADHD vs ADHD 14 1322 -0.49 0.13 -0.73 – -0.25 -3.94 < 0.001 51.46 13 74.74 < 0.001 ODD/CD + ADHD vs HC 15 2148 -3.23 0.28 -3.79—-2.68 -11.44 < 0.001 164.63 14 91.50 < 0.001
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control. These findings further contribute to current discussions as to whether ADHD and ODD/CD are best captured under a dimensional approach to psychopathology (Frick and Nigg 2012; Wakschlag et al. 2018). Specically, results found that: (1) when children with ODD were compared to those with ADHD, there was no signicant dierence in cool inhibitory control performance; (2) this held true for the majority of tasks when subgroup analyses were conducted; (3) there was no signicant dierence between ODD/CD children and ADHD children on measures of parent reported ADHD symptomatology; (4) despite an absence of a clinical ADHD diagnosis, children with ODD still had similar ADHD symptomatology to those children with a clinical diagnosis of ADHD; (5) children with a combined diagnosis of ODD/CD + ADHD were found to have worse inhibitory control than children with ODD/ CD alone, but not signicantly dierent from children with ADHD alone; (6) children with a comorbid diagnosis were found to have signicantly greater ADHD symptomatology compared to both ODD/CD and ADHD respectively. In sum, it appears that children with ODD/CD and ADHD have diculties with inhibitory control and similar ADHD symptomatology. Future diagnostic manuals may need to consider these diagnoses within a dimensional framework of psychopathology; rather than a categorical framework.
Interestingly, previous authors have supported similar conclusions. For example, Blair et. al (2018) suggested that while children with conduct problems have inhibitory control dysfunction, this is likely manifested as ADHD symptoms. The previous meta-analysis on the Stop task by Oosterlaan et al. (1998) revealed similar results. Compared to healthy controls, children with CD were found to have more difficulties with inhibitory control as indicated by the stop signal reaction time (SSRT), however, no signicant dierences were found between ADHD and CD, or ADHD + CD and ADHD. It has also been previously established that ADHD, ODD, and CD are often co-morbid (Angold et al. 1999) and share common risk factors for development such as decits in inhibitory control (Matthys and Lochman 2017). Signicant comorbidity is challenging for categorical approaches to diagnosis. When signicant comorbidity exists, a dimensional approach can be more clinically meaningful. Even for children with non-clinical levels of disruptive behaviour, diculties with inhibitory control have been demonstrated (Schoemaker et al. 2013; Woltering et al. 2016). This would suggest that diculties with inhibitory control have been present across varying severities of disruptive behaviour. Researchers have discussed the lack of utility in classifying ADHD, ODD, and CD as separate disorders, highlighting that there is evidence to support the three disorders sharing common aetiology across a number of factors (not simply neurobiological deficits), and as such, should be considered as related
disorders (e.g., Frick and Nigg 2012; Wakschlag et al. 2018; Matthys and Lochman 2017).
Do Children with ODD/CD have Hot or Cool Inhibitory Control Decits?
Unfortunately, only one study (Schoemaker et al. 2012) utilised a measure of hot inhibitory control, and as such, further meta-analyses could not be conducted. Previous authors have suggested that disruptive behaviour (in particular CD), is associated with hot inhibitory control (Rubia 2011; Zhu et al. 2018). This makes theoretical sense as children with ODD/CD often engage in more risk-taking and rule-breaking behaviours than their healthy peers and are less sensitive to reward processing (Matthys and Lochman 2017). Tasks that involve hot executive functions usually assess this behaviour with tasks that are motivationally salient (Antonini et al. 2015). However, the dearth of research utilising or reporting on performance tasks that involve hot inhibitory control mean that no empirical conclusions can be drawn yet.
A small signicant eect was found when comparing measures of cool inhibitory control, suggesting that children with ODD and/or CD may have more difficulties with inhibitory control compared to healthy peers. Additionally, despite varying tasks assessing inhibitory control, these diculties persist for children with a clinical diagnosis of ODD/CD. This result supports those found in the review by Oosterlaan et al. (1998), which assessed inhibitory control decits in CD samples, independent of ADHD; nding that children with CD performed signicantly worse than healthy controls. However, Oosterlaan et al. (1998) reviewed performance on the Stop Signal Task only.
The Impact of How Inhibitory Control is Measured
The current review included papers that specifically identified inhibitory control as a variable of interest. However, measures such as the Continuous Performance Task (CPT) have previously defined the same outcome measure (number of commissions) as either an index of attention or inhibitory control. One could argue that inhibitory control subserves attention; however, the conceptualisation of executive function and where each cognitive process sits within the framework is an ongoing theoretical discussion in the executive function literature (Baggetta and Alexander 2016; Packwood et al. 2011). Further, the Stop Signal and Stroop tasks were most often used to assess cool inhibitory control across all comparisons between groups. Fewer studies utilised the Go/No-Go task, Continuous Performance Tasks, and the Statue and Spin the Pots tasks were used the least. It is challenging to make strong conclusions about dierences in performance
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on these tasks when so few studies are utilising the same measure. Additionally, it limits our understanding as to which tasks contribute to an overall eect of inhibitory control deficits between groups. Future research would benet from including several measures of inhibitory control to determine dierences between tasks. Unfortunately, these diculties will always be inherent in the eld of cognitive research, due to task impurity.
Strong conclusions cannot be drawn based on ratings with ecological measures (i.e., BRIEF) due to the paucity of studies. A maximum of three studies were included for most comparisons, with each generally using a dierent metric of the BRIEF. It is likely that the use of dierent metrics (T-scores, average raw subscale scores, and average item scores) contributed to greater variability between studies. This highlights two important points. First, that there is a need for further research using ecologically valid measures of inhibitory control; as these measures translate to behaviours observed in real world settings (Toplak et al. 2013). Second, that consistent use of metric is important to eectively compare and replicate research. Where available, T-scores are most meaningful as results can be compared across measures. Overall, there is much work yet to be done in the use of rating scales of executive function.
The Impact of Inhibitory Control Decits on Clinical Interventions for ODD/CD Children
Explaining disruptive behaviours from a perspective of skill decit, interacting with environmental factors (e.g., parenting style, peer inuences) highlights the importance of utilising alternative approaches to intervention. For example, children who display disruptive behaviours are more likely to elicit unhelpful parenting responses (Burke et al. 2008). Harsher parenting styles are known to be associated with increases in disruptive behaviour; and so, the cycle is perpetuated (Combs-Ronto et al. 2009). This may be an important consideration as to why learning- based interventions are not successful for some children with ODD/CD. As such, alternative interventions such as the Collaborative Problem Solving approach (Greene 2014; Pollastri et al. 2019) may be useful as such approaches consider neurodevelopmental dierences that may impact upon behaviour. We can utilise such approaches to assist children to cope with or compensate for the skill decit; which may improve clinical outcomes beyond what they would have been with only a learning-based intervention.
Limitations and Future Directions.
Limitations within the studies impact the quality of the meta- analysis overall; including, small sample sizes, dierences
in methodology and design, and demographic (Borenstein 2009). While subgroup analyses allowed for further examination between tasks, most tasks had fewer than ve studies included. Underpowered analyses contribute to greater variance between studies which cannot be adequately explored through moderation due to so few studies. Further, the meta-analyses are limited by the nature of the data they assess; mean effect sizes. A more comprehensive examination of inhibitory control between clinical groups, moderated by ADHD symptoms, could be conducted via an analysis of all individual data from each of the included studies (Stewart and Clarke 1995). The use of individual data collected from each study would allow for more comprehensive and sophisticated analyses to investigate the range of ODD/CD and ADHD symptomatology. This may facilitate further understanding of a dimensional approach to psychopathology for these disorders. Additionally, if all individual data is collected, this may allow for T-scores to be used in more analyses, providing a more standardised approach. Future research into the aetiology of disruptive behaviours may consider adapting the approach of utilising individual participant data.
Conclusion
The present review is, to our knowledge, the first to comprehensively assess inhibitory control performance in children with ODD/CD compared to healthy controls, children with ADHD, and ODD/CD + ADHD. Furthermore, this meta-analysis has taken into consideration ADHD symptomatology between groups. Importantly, in line with contemporary models of psychopathology, this review has highlighted the need to consider disruptive behaviour pathology from a dimensional perspective; which paves the way for future research and potential implications for diagnosis and treatment. While the understanding of the broader aetiological framework of disruptive behaviours is limited, the present meta-analysis found that inhibitory control decits contribute to the development of disruptive behaviours.
Electronic supplementary material The online version of this article (https:// doi. org/ 10. 1007/ s10802- 020- 00713-9) contains supplementary material, which is available to authorized users.
Acknowledgements The rst author is a recipient of a Grith Univer- sity postgraduate research scholarship. The authors would like to thank Dr David Reilly, Dr Sheri Madigan, and Mr Daniel Sullivan for their feedback on the analyses of this paper.
Author Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Mikaela Bonham and Olivia Elvin. Analyses were performed and
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the rst draft was written by Mikaela Bonham. All authors provided feedback and approved the nal manuscript.
Compliance with Ethical Standards
Conflict of Interest The authors declare they have no conicts of in- terest.
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