Are all the 18 DSM-IV and DSM-5 criteria equally useful for diagnosing ADHD and predicting comorbid conduct problems?

Measurement invariance of Attention Deficit/Hyperactivity Disorder symptom criteria as rated by parents and teachers in children and adolescents: A systematic review

This systematic review aimed to establish the extent to which each Attention Deficit/Hyperactivity Disorder (ADHD) symptom criterion is being assessed without being influenced (biased) by factors such as informant, sex/gender, and age. Measurement invariance (MI) testing using confirmatory factor analysis (CFA) is the prime statistical method to ascertain how these factors may affect the measurement and colour the perception or interpretation of symptom criteria. Such effects (non-invariance) can be operationalised in the form of altered association of a symptom criterion with the measured trait (expressed via variations in CFA loadings which represent the weight of each symptom criterion) due to the factor(s) and/or artificially alter the probability of endorsement of a particular symptom criterion (expressed via variations in the CFA threshold(s) representing how mild or severe a given symptom is). Based on a pre-registered protocol (CRD42022276105), we searched PubMed, Global Health, Embase and PsycInfo up to 21-02-23 for studies that included MI assessments on specific ADHD symptom criteria in individuals aged 0-18 years old, using parental and/or teacher report. Self-reports were excluded, given the poor reliability of self-report in ADHD. All included studies met specific COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria. Results were synthesised in tabular form, grouping results by factors (e.g. informant) from 44 studies retained. Most comparisons indicated both metric (same loadings) and scalar invariance (same thresholds) with regard to informant, gender, age, temporal (repeated assessments) and co-morbidity. Therefore, the available evidence supports the current diagnostic criteria. However, findings could have been improved by systematic reporting of the direction of bias and its effect size. There appears to be a bias towards reporting MI instead of non-invariance. More studies in the literature are needed where the amalgamation of information provided by different informs and the association of specific symptoms with comorbidity are analysed.

The association between different sources of distraction and symptoms of attention deficit hyperactivity disorder

Introduction

Adults with Attention-Deficit/Hyperactivity Disorder (ADHD) are generally distractible. Yet, the precise relationship between ADHD and distractibility remains under-specified in two respects. First, different sources of distraction, such as background noise or mind wandering, may not be equally associated with ADHD. Second, ADHD itself comprises a variety of symptoms that show considerable heterogeneity and it is unclear which ADHD symptoms are associated with which type of distraction.

Methods

The current study addresses these questions using one clinically evaluated sample (N = 69) and two large non-clinically evaluated samples (N = 569, N = 651). In all samples, participants completed questionnaires about their susceptibility to external distraction, unwanted intrusive thoughts, spontaneous mind-wandering and ADHD symptomatology.

Results

Traditional regression and novel network analyses revealed an overwhelming contribution of spontaneous mind-wandering in explaining ADHD symptoms, although external distraction and unwanted intrusive thoughts were also associated with a small number of ADHD symptoms.

Discussion

Findings support a growing body of literature linking spontaneous mind-wandering and ADHD, and they highlight the heterogeneity in the association between ADHD symptoms and different sources of distraction.

Network analysis of 18 attention-deficit/hyperactivity disorder symptoms suggests the importance of "Distracted" and "Fidget" as central symptoms: Invariance across age, gender, and subtype presentations

The network theory of mental disorders conceptualizes psychiatric symptoms as networks of symptoms that causally interact with each other. Our present study aimed to explore the symptomatic structure in children with attention-deficit/hyperactivity disorder (ADHD) using network analyses. Symptom network based on 18 items of ADHD Rating Scale-IV was evaluated in 4,033 children and adolescents with ADHD. The importance of nodes was evaluated quantitatively by examining centrality indices, including Strength, Betweenness and Closeness, as well as Predictability and Expected Influence (EI). In addition, we compared the network structure across different subgroups, as characterized by ADHD subtypes, gender and age groups to evaluate its invariance. A three-factor-community structure was identified including inattentive, hyperactive and impulsive clusters. For the centrality indices, the nodes of "Distracted" and "Fidget" showed high closeness and betweenness, and represented a bridge linking the inattentive and hyperactive/impulsive domains. "Details" and "Fidget" were the most common endorsed symptoms in inattentive and hyperactive/impulsive domains respectively. On the contrary, the "Listen" item formed a peripheral node showing weak links with all other items within the inattentive cluster, and the "Loss" item as the least central node by all measures of centrality and with low predictability value. The network structure was relatively invariant across gender, age and ADHD subtypes/presentations. The 18 items of ADHD core symptoms appear not equivalent and interchangeable. "Distracted" and "Fidget" should be considered as central, or core, symptoms for further evaluation and intervention. The network-informed differentiation of these symptoms has the potentials to refine the phenotype and reduce heterogeneity.

Differential utility of teacher and parent-teacher combined information in the assessment of Attention Deficit/Hyperactivity Disorder symptoms

BACKGROUND

Consistent research findings indicate that parents and teachers observe genuinely different Attention Deficit/Hyperactivity Disorder (ADHD) behaviours in their respective settings.

OBJECTIVE

To evaluate the utility of information provided by teacher informant assessments (INFAs) of ADHD symptoms, and the implications of aggregation algorithms in combing parents' information, i.e. using 'or-rule' (endorsement by either one informant) versus 'and-rule' (endorsement by both informants).

METHOD

Teacher ratings on Conners scales and clinical data from parental accounts on 1383 probands and their siblings from the IMAGE study were analysed. The psychometric properties of teacher and combined ratings using the item response theory model (IRT) are presented. Kappa coefficients, intraclass correlations and linear regression were employed.

RESULTS

First, teacher endorsement of symptoms is located in a narrow part of the trait continuum close to the average levels. Symptoms exhibit comparable perception in the measurement of the trait(s) with similar discrimination ability and information (reliability). Second, the IRT properties of the 'or-rule' ratings are predominantly influenced by parent-INFAs; and the 'and-rule' ratings predominantly by teacher-INFAs ratings. Third, parent-teacher INFAs agreement was low, both for individual items (κ = 0.01-0.15) and for dimensional scores (r = 0.12-0.16). The 'or-rule' captured milder expressions of ADHD symptoms, whereas the 'and-rule' indexed greater severity of ADHD.

CONCLUSIONS

Parent and teacher-INFAs provide different kinds of information, while both are useful. Teacher-INFA and the 'and-rule' provide a more accurate index of severity than an additive symptom count. Parent-INFA and the 'or-rule' are more sensitive for detecting cases with milder ADHD.

Is the endorsement of the Attention Deficit Hyperactivity Disorder symptom criteria ratings influenced by informant assessment, gender, age, and co-occurring disorders? A measurement invariance study

OBJECTIVES

This study aims to ascertain whether the differences of prevalence and severity of attention deficit hyperactivity disorder (ADHD) are true or whether children are perceived and rated differently by parent and teacher informant assessments (INFAs) according to gender, age, and co-occurring disorders, even at equal levels of latent ADHD traits.

METHODS

Use of latent trait models (for binary responses) to evaluate measurement invariance in children with ADHD and their siblings from the International Multicenter ADHD Gene data.

RESULTS

Substantial measurement noninvariance between parent and teacher INFAs was detected for seven out of nine inattention (IA) and six out of nine hyperactivity/impulsivity (HI) items; the correlations between parent and teacher INFAs for six IA and four HI items were not significantly different from zero, which suggests that parent and teacher INFAs are essentially rating different kinds of behaviours expressed in different settings, instead of measurement bias. However, age and gender did not affect substantially the endorsement probability of either IA or HI symptom criteria, regardless of INFA. For co-occurring disorders, teacher INFA ratings were largely unaffected by co-morbidity; conversely, parental endorsement of HI symptoms is substantially influenced by co-occurring oppositional defiant disorder.

CONCLUSIONS

Our findings suggest general robustness of Diagnostic and Statistical Manual of Mental Disorders ADHD diagnostic items in relation to age and gender. Further research on classroom presentations is needed.

A network analysis approach to ADHD symptoms: More than the sum of its parts

In interpreting attention-deficit/hyperactivity disorder (ADHD) symptoms, categorical and dimensional approaches are commonly used. Both employ binary symptom counts which give equal weighting, with little attention to the combinations and relative contributions of individual symptoms. Alternatively, symptoms can be viewed as an interacting network, revealing the complex relationship between symptoms. Using a novel network modelling approach, this study explores the relationships between the 18 symptoms in the Diagnostic Statistical Manual (DSM-5) criteria and whether network measures are useful in predicting outcomes. Participants were from a community cohort, the Children’s Attention Project. DSM ADHD symptoms were recorded in a face-to-face structured parent interview for 146 medication naïve children with ADHD and 209 controls (aged 6–8 years). Analyses indicated that not all symptoms are equal. Frequencies of endorsement and configurations of symptoms varied, with certain symptoms playing a more important role within the ADHD symptom network. In total, 116,220 combinations of symptoms within a diagnosis of ADHD were identified, with 92% demonstrating a unique symptom configuration. Symptom association networks highlighted the relative importance of hyperactive/impulsive symptoms in the symptom network. In particular, the ‘motoric’-type symptoms as well as interrupts as a marker of impulsivity in the hyperactive domain, as well as loses things and does not follow instructions in the inattentive domain, had high measures of centrality. Centrality-measure weighted symptom counts showed significant association with clinical but not cognitive outcomes, however the relationships were not significantly stronger than symptom count alone. The finding may help to explain heterogeneity in the ADHD phenotype.

Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment

Knowledge about attention-deficit hyperactivity disorder (ADHD) is rapidly accumulating. Recent advances in diagnosis, genetics, neuroimaging, drug and non-drug treatments are considered, and the results are related to the critical attack on the ADHD diagnosis, which argues it a medicalising social construct, unhelpfully sustaining power relationships. The advances reviewed suggest that, while this attack can be conclusively dismissed as wrong and misleading, the phenomenological definition of ADHD is no longer sufficient for construct validity, though continues to be valuable as a guide for clinicians. The humanising and individualising concerns underlying the attack on the diagnosis could usefully be redirected to improving effective measurement of patient outcomes.

Evaluating the Hierarchical Structure of ADHD Symptoms and Invariance Across Age and Gender

The bifactor model of attention-deficit/hyperactivity disorder (ADHD) has been extensively explored, yet the tendency of the bifactor model to overfit data necessitates investigation of alternative, more parsimonious models, such as a modified bifactor structure. The present study used item response theory to compare unidimensional, correlated factors, bifactor, and modified bifactor models of ADHD symptoms in a clinical sample of youth ( N = 1,612) and examined differential item functioning (DIF) by age (<11 and ≥11 years) and gender. Results suggested that two restricted bifactor models showed superior fit compared with alternative models, and support strong general and inattention dimensions, with unreliable hyperactivity and impulsivity dimensions. No DIF was found across gender or age. The present study confirms that the general dimension (i.e., inhibition) and one specific dimension (i.e., sustained attention) represent distinct variability in ADHD symptoms that may improve prediction of symptom persistence, treatment response, or functional outcomes.

Predictors of relapse or maintenance of response in pediatric and adult patients with attention-deficit/hyperactivity disorder following discontinuation of long-term treatment with atomoxetine

We identified relapse/maintenance-of-response (MOR) predictors following discontinuation of long-term atomoxetine treatment in pediatric and adult patients with attention-deficit/hyperactivity disorder (ADHD) and assessed correlations between ADHD symptoms and quality of life (QoL). Post hoc analyses of data from two randomized, double-blind, placebo-controlled, phase 3 withdrawal studies in patients with ADHD meeting predefined response criteria before randomization. Study 1: patients (N = 163; 6-15 years) received atomoxetine (1.2-1.8 mg/kg/day) for 1 year, followed by randomization to atomoxetine (n = 81) or placebo (n = 82) for 6 months. Study 2: patients (N = 524; 18-50 years) received atomoxetine (80-100 mg/day) for ~6 months, followed by randomization to atomoxetine (n = 266) or placebo (n = 258) for ~6 months. Placebo patients were used for the analyses. Relapse: ≥50% worsening of prerandomization improvement in ADHD symptoms and ≥2 level severity increase on the Clinical Global Impression-Severity (CGI-S) scale at 2 consecutive visits; MOR: retaining ≥75% of prerandomization symptom improvement and CGI-S ≤ 2 at all visits (study 1); retaining ≥70% of prerandomization symptom improvement and CGI-S ≤ 3 at all visits (study 2). In adults, statistically significantly (P ≤ .05) increased likelihood of relapse was associated with prerandomization presence of Conners' Adult Attention-Deficit/Hyperactivity Disorder Rating Scale-Investigator-Rated:Screening Version (CAARS-Inv:SV) items "difficulty awaiting turn" and "careless mistakes." In pediatric patients, less MOR was associated with prerandomization presence of ADHD Rating Scale-IV-Parent Version Investigator-Rated item "does not listen"; in adults, less MOR was associated with prerandomization presence of CAARS-Inv:SV items "loses things" and "difficulty awaiting turn." Changes in patients' QoL after withdrawal from atomoxetine moderately correlated with changes in ADHD symptoms in pediatric patients and mildly in adults.

Hierarchy and Psychometric Properties of ADHD Symptoms in Spanish Children: An Application of the Graded Response Model

The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria assume that the 18 symptoms carry the same weight in an Attention Deficit with Hyperactivity Disorder (ADHD) diagnosis and bear the same discriminatory capacity. However, it is reasonable to think that symptoms may differ in terms of severity and even in the reliability with they represent the disorder. To test this hypothesis, the aim of this study was to calibrate in a sample of Spanish children (age 4–7; n = 784) a scale for assessing the symptoms of ADHD proposed by Diagnostic and Statistical Manual of Mental Disorders, IV-TR within the framework of Item Response Theory. Samejima’s Graded Response Model was used as a method for estimating the item difficulty and discrimination parameters. The results showed that ADHD subscales (Attention Deficit and Hyperactivity / Impulsivity) had good psychometric properties and had also a good fit to the model. However, relevant differences between symptoms were observed at the level of severity, informativeness and reliability for the assessment of ADHD. This finding suggests that it would be useful to identify the symptoms that are more important than the others with regard to diagnosing ADHD.