Psychiatric comorbidity in attention deficit disorder: impact on the interpretation of Child Behavior Checklist results

The child behavior checklist can aid in characterizing suspected comorbid psychopathology in clinically referred youth with ADHD

OBJECTIVE

To examine the utility of the Child Behavior Checklist (CBCL) to aid in the identification of comorbid psychopathological conditions affecting referred youth with suspected ADHD prior to the evaluation. The CBCL is an easy-to-use assessment tool that may provide invaluable information regarding the severity and characteristics of the presenting complaints.

METHODS

The sample included 332 youths consecutively referred to an ADHD program for the assessment of suspected ADHD. Parents completed the CBCL, parent-rated ADHD Self-Report Scale (ASRS), Social Responsiveness Scale (SRS), and Behavior Rating Inventory of Executive Function (BRIEF). Because of the established association between the CBCL Attention Problems scale and a structured diagnostic interview of ADHD, all youths analyzed had abnormal Attention Problems T-scores (≥60).

RESULTS

Seventy-six percent of youths with elevated Attention Problems T-scores had ≥3 additional abnormal CBCL scales, suggesting they were likely affected with multiple comorbid psychopathological conditions. Moreover, 44% had ≥1 CBCL clinical scale with a T-score more severe than their Attention Problems T-score, suggesting the putative comorbid condition was more severe than the ADHD symptoms. Additional CBCL scale elevations were associated with more severe functional impairments as assessed by the ASRS, SRS, BRIEF, and CBCL competence scales.

CONCLUSION

The CBCL obtained before the clinical assessment identified high rates of comorbid psychopathology in youths referred for the assessment of ADHD. It provided detailed information about the types and severity of suspected psychopathological conditions impacting a particular youth, which is critical to guide the assessing clinician on likely differing needs of the affected child.

Evidence-Based Assessment of ADHD in Youth Using a Receiver Operating Characteristic Approach

Guidelines exist for the assessment of attention deficit/hyperactivity disorder (ADHD), but they are often unclear as to how a clinician should consider multiple informants, methods, and co-occurring symptoms to reach an overall diagnostic probability for an individual patient. The current study used receiver operating characteristic analyses and evidence-based medicine methods to evaluate the Achenbach System of Empirically Based Assessment measures and the Conners' Continuous Performance Test for ADHD diagnosis in youth. Children (n = 379) and their parent(s) presented at an outpatient clinic for a psychoeducational assessment. Analyses examined the diagnostic efficiency and utility of study measures for predicting a best-estimate ADHD diagnosis. The Child Behavior Checklist Attention Problems construct, Teacher Report Form Attention Problems construct, and Hit Reaction Time Standard Error showed adequate diagnostic efficiency and unique contributions to the prediction of ADHD, Combined Type diagnosis. None of these measures showed good diagnostic efficiency or utility for the prediction of ADHD, Predominantly Inattentive Type. Child anxiety did not moderate the relations between predictors and ADHD diagnosis. Both the Child Behavior Checklist and Teacher Report Form Attention Problems constructs can discriminate youth with ADHD, Combined Type from other clinic-referred youth. Although Hit Reaction Time Standard Error also showed diagnostic utility, the decision to include a computerized measure should consider time and expense and be utilized in cases where diagnostic probability is unclear. Finally, anxiety may be associated with elevated attention problems, but it does not appear that anxiety affects diagnostic cutoffs for ADHD.

Differential Validity of the BASC Student Observation System and the BASC Teacher Rating Scale

This study evaluated the differerrtial validity of the BASC Teacher Rating Scale (TRS) and the BASC Student Observation System (SOS) in the differentintion of nondisabled children from children with an ADHD diagnosis, and children with only an ADHD dingrrosis from children with ADHD and comorbid dingnoses. The results indicated that the TRS and SOS exhibited good differential validity. The group differences that were found were consistent with the definition of ADHD, and a good classification rate was found for the TRS and SOS (73%). The Predictive Discriminant Analysis also indicated, however, that the SOS does not contribute a sufficient amount of information above and beyond that obtained from the TRS alone.

Besonderheiten in der multiaxialen Klassifizierung, Anamnese und Psychopathologie bei Kindern und Jugendlichen mit einer Autismus-Spektrum-Störung und einer Aufmerksamkeitsdefizit-/ Hyperaktivitätsstörung

Ziel der vorliegenden Untersuchung war es, bei Kindern und Jugendlichen mit einer Autismus Spektrum Störung (ASS) ohne oder mit einer Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) die Achsen des Multiaxialen Klassifikationsschemas (MAS), anamnestische Daten, sowie Ergebnisse psychopathologischer Fragebogenverfahren zu vergleichen. Insgesamt wurden 120 Patienten (Gruppe ASS: n=60; Gruppe ASS+ADHS: n=60) untersucht. Es wurden eigen- und familienanamnestische Daten, die sechs Achsen der MAS und testpsychologische Ergebnisse erhoben (MBAS, FSK, SRS, CBCL). Deskriptiv konnten in der Gruppe ASS+ADHS ein gehäufter Konsum schädlicher Substanzen durch die Mütter in der Schwangerschaft erhoben werden. In beiden Gruppen fand sich bei den Vätern gehäuft eine Tätigkeit in einem akademisch-technischen Beruf. Hinsichtlich der Fragebogenverfahren zeigte sich eine höhere externalisierende Psychopathologie für die Gruppe ASS+ADHS. Passend zu bisherigen Studien konnte bei den Patienten mit ASS und ADHS eine stärker ausgeprägte psychopathologische Belastung beschrieben werden, auf die bei Diagnostik und Therapie geachtet werden sollte.

Accuracy of the DSM-oriented attention problem scale of the child behavior checklist in diagnosing attention-deficit hyperactivity disorder

OBJECTIVE

The present study aimed at testing the Child Behavior Checklist (CBCL) including an adapted five-item DSM-Oriented Attention Problem Scale for predicting attention deficit hyperactivity disorders (ADHD).

METHODS

CBCL ratings were made both in a community sample (N = 390) and an outpatient child psychiatric sample (N = 392). Four different prediction models were analyzed in a community subsample (n = 195) and an outpatient subsample (n = 196) and cross-validated in two further subsamples of the same size.

RESULTS

The adapted DSM-Oriented Attention Problem Scale was superior to the original Attention Problem Scale in the identification of ADHD participants. A raw score of 5 to 6 on the reduced DSM-Oriented Attention Problem Scale was the best discriminator between cases and noncases.

CONCLUSIONS

The adapted DSM-Oriented Attention Problem Scale of the CBCL is a useful screening instrument for ADHD with adequate diagnostic accuracy in community and outpatient samples. (J. of Att. Dis. 2010; 13(5) 454-463).

Speed of language comprehension is impaired in ADHD

OBJECTIVE

Children with ADHD have an increased risk of poor academic performance. It is important to identify cognitive processes that may be related to this academic failure. In Western schooling systems, especially language processing skills may be of relevance. The present study, therefore, compares the ability to comprehend complex sentences of individuals with and without ADHD.

METHOD

Fifteen children (aged 8-11) and 15 adolescents (aged 12-16) with ADHD combined subtype are matched for age, gender, and parental level of education to 30 control subjects. Language comprehension is measured using the neuropsychological procedure proposed by Luria and an adapted version of the Token Test.

RESULTS

Compared with the control group, children and adolescents with ADHD perform significantly slower on language comprehension tasks. Differences in accuracy are limited. No interaction between age and ADHD is found.

CONCLUSIONS

Children and adolescents with ADHD are slower and less efficient than matched control subjects with regard to complex sentence comprehension.

Classifying psychiatric disorders after traumatic brain injury and orthopaedic injury in children: adequacy of K-SADS versus CBCL

PRIMARY OBJECTIVE

[corrected] To evaluate the convergence between the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) for the diagnosis of psychiatric disorders and the Child Behavior Checklist (CBCL).

RESEARCH DESIGN

Cross-sectional psychiatric study of 72 children with traumatic brain injuries or orthopaedic injuries aged 5-14.

METHODS AND PROCEDURES

Sensitivity, specificity, total predictive value and odds ratio were calculated to evaluate the association between CBCL summary scores and K-SADS diagnosis of at least one psychiatric disorder (K-SADS-1), and of CBCL subscales and K-SADS diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). Lowered cut-off scores of t > or = 60 were used.

MAIN OUTCOMES AND RESULTS

Convergence between the CBCL total problem scale and K-SADS-1 was poor. Convergence between 'at least one elevated CBCL subscale' and K-SADS-1, and between CBCL attention problems and social problems scales and K-SADS diagnosis of ADHD was excellent.

CONCLUSIONS

Caution is needed when using the total problem scale of CBCL in predicting global psychological impairment because underestimation of problems is likely. The attention and social problems scales of CBCL can be used to estimate ADHD.

Taxonomy and comorbidity of conduct problems: Evidence from empirically based approaches

Many children meet criteria for multiple Diagnostic and Statistical Manual (DSM) categories, such as oppositional defiant disorder (ODD) and conduct disorder (CD). If each disorder has been well validated as a separate entity, statistically significant co-occurrence of different disorders may be highly informative. However, ODD and CD have not been well validated as separate entities. The very high rate of overlap between diagnoses of ODD and CD may therefore arise artifactually from the lack of a valid distinction between them, rather than from potentially informative comorbidity between two different disorders. Empirical research strongly supports a distinction between two syndromes that correspond to subsets of the DSM-III-R criteria for CD. Designated as delinquent behavior and aggressive behavior, these syndromes have been found to differ in biological correlates, heritability, developmental stability, course, response to interventions, and long-term outcomes. At this stage of our knowledge, empirically based assessment and taxonomic methods can be especially useful for distinguishing between syndromes, deriving norms, doing longitudinal studies, and detecting patterns of comorbidity. These methods do not preclude categorical taxa, which can be formed by imposing cutpoints on the distributions of syndrome scores. Categorical taxa can also be formed by cluster analyzing profiles of syndrome scores. Accelerated longitudinal designs can bring multiple analyses to bear on empirically derived syndromes to test complex developmental relations more quickly and powerfully than can traditional longitudinal designs. Follow-ups of high-risk groups can identify variables that predict good versus poor outcomes if standardized baseline and outcome measures are used. Interventions for conduct problems should be designed to counteract the risk factors found to predict poor long-term outcomes.

Screening Efficiency of the Child Behavior Checklist and Strengths and Difficulties Questionnaire: A Systematic Review

OBJECTIVE

  Assess the screening efficiency of the caretaker-report CBCL and SDQ in community and clinical samples using published data.

METHODS

  PyschInfo, Medline, and EMBASE were systematically searched to identify studies with appropriate efficiency data. Estimates of sensitivity and specificity were extracted from identified studies and used to generate summary likelihood ratio estimates on which the scales were compared. Summary estimates of sensitivity and specificity were calculated with respect to a 'true' diagnosis to compare scales.

RESULTS

  A total of 29 and 3 studies met inclusion criteria for CBCL and SDQ respectively. Summary estimates of the likelihood ratios for domains assessed by CBCL ranged from 3.86 (2.23, 6.69) to 4.87 (2.90, 8.18); and for SDQ from 5.02 (1.61, 15.63) to 8.32 (2.72, 25.48). Heterogeneity was low. For total problems, the SDQ caretaker-report was found to be most specific (0.93, 95% CI 0.92, 0.94) and the CBCL caretaker-report to be most sensitive (0.66, 95%CI 0.60, 0.73).

CONCLUSIONS

  This meta-analysis supports continued use of the CBCL and SDQ via caretaker-report in clinical and community samples. Additional research is required to determine if there is a true difference in efficiency between the two scales.

Subtypes of learning disabilities: neuropsychological and behavioural functioning of 495 children referred for multidisciplinary assessment

Aim of the present study was two fold: (1) to evaluate the course of referring and diagnosing Learning Disabilities (LD) and the contribution of multidisciplinary assessment and (2) to describe characteristics of three LD subtypes: Attention with or without Motor function Disabilities (AMD), Verbal Learning Disabilities (VLD) and Non-Verbal Learning Disabilities (NVLD). Diagnostics, behavioural and neuropsychological data from 495 children aged 6-17 years were described. First, AMD and VLD was the most frequent LD. Multidisciplinary assessment could contribute to the diagnostic process of LD, especially in diagnosing uncommon LD and comorbidities. Secondly, behavioural ratings, information processing, attention regularity and visual-motor integration proved to be most sensitive in discriminating between the three LD subtypes. However, diagnosing NVLD requires additional developmental information. Multiple discriminant function analysis correctly classified 61.7% of a selection of the present sample into LD subtypes as diagnosed by the multidisciplinary team. It is believed that the three subtypes are clinically relevant and suggestions are made to test the present classification functions in an independent sample, preferably diagnosed using a structured diagnostic interview.

Attentional functions in children and adolescents with attention-deficit/hyperactivity disorder with and without comorbid tic disorder

Although the coexistence of attention-deficit/hyperactivity disorder (ADHD) and tic disorder (TD) is common, the nature of association is yet not fully understood. Thus, the aim of the present study was to explore attentional dysfunction in children with pure ADHD compared to children with comorbid ADHD + TD. Three groups of 20 children each, aged 8-15 years with either ADHD, ADHD + chronic tic disorder or Tourette syndrome (ADHD + TD) and a healthy control group were compared in their performance on three computerized attention tasks. Tasks of sustained attention, selective attention and interference control were employed. In addition, parental ratings of ADHD symptom severity and behaviour problems were obtained. Both clinical groups were rated as equally inattentive, however, externalising symptoms were more severe in the ADHD group. Objective measures of attentional performance revealed differences between the groups: whereas the ADHD group was markedly impaired in sustaining attention and selective attention/inhibitory control, the ADHD + TD group only showed marginal deficits in selective attention/inhibitory control. Possible explanations for the superior performance of the comorbid group are discussed: In particular, the results may indicate that in some patients, the tic disorder produces behavioural symptoms of ADHD, but not the broad neurocognitive deficits that usually are associated with ADHD. Alternatively, compensatory neural mechanisms of TD patients may result in a better neuropsychological performance of comorbid patients relative to patients suffering from pure ADHD.

A cross-cultural comparison between samples of Brazilian and German children with ADHD/HD using the Child Behavior Checklist

INTRODUCTION

This study aims to assess cross-cultural similarities and differences in broadband psychopathology in two naturalistic clinical samples of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) combined type according to DSM-IV criteria or with Hyperkinetic Disorder (HD) according to ICD-10 criteria.

METHODS

We compared two clinical samples of children with ADHD combined type (Brazil, N=248) and HD (Germany; N=154) to controls (Brazil N=71; Germany N=135) using the Child Behavior Checklist (CBCL). ROC-curves (Receiver Operating Characteristic) were determined to evaluate the discriminating validity of the CBCL Attention Problem scale. A two-factorial ANOVA was computed across all 8 scales of the CBCL.

RESULTS

Although Brazilian parents reported significantly higher scores on all CBCL scales than German parents (P<0.05), a similar CBCL profile was detected in both cultures.

CONCLUSION

Despite the use of different diagnostic systems (DSM-IV vs. ICD-10) and the presence of other clinical differences, the similar broadband psychopathological profile of the CBCL in the two samples provides evidence that dimensional symptoms associated with the categorical diagnosis of ADHD combined type might be comparable in two clinical settings with diverse cultural background.

Convergence between the Achenbach youth self-report and structured diagnostic interview diagnoses in ADHD and non-ADHD youth

We evaluated the convergence of Achenbach youth self-report (YSR) scales with attention-deficit hyperactivity disorder (ADHD) and psychiatric comorbidity derived from self-report structured interviews. Subjects were 251 youths older than 12 years assessed with YSR scales and directly obtained structured diagnostic interview. We evaluated the strength of association between each YSR scale and structured-interview derived diagnoses using total predictive value (TPV) and odds ratios (OR). Excellent convergence was found between the YSR attention problems with the structured interview derived diagnosis of ADHD, between the YSR delinquent behavior scale and the diagnosis of conduct disorder, and between the YSR anxiety/depression and withdrawn scales and the diagnosis of major depression, and between the YSR social problems and somatic scales and the diagnosis of anxiety. These findings indicate that the YSR could serve as a rapid and cost-effective diagnostic tool to identify major psychopathology in high-risk adolescents.

Methylphenidate improves reading performance in children with attention deficit hyperactivity disorder and comorbid dyslexia: an unblinded clinical trial

Attention Deficit Hyperactivity Disorder (ADHD) and dyslexia are frequently co-occurring disorders. Although methylphenidate (MPH) is the primary treatment for ADHD, the effect on reading in children with these comorbid problems is not yet known. This study was an unblinded clinical trial to evaluate the reading performance before and after treatment with MPH. Reading performance was compared with General Linear Model repeated measures between three groups: (1) an experimental group of children with both ADHD and dyslexia (N = 24), (2) a control group of children with ADHD (N = 9) and (3) a control group of children with dyslexia (N = 10). MPH improved reading performance significantly stronger in the experimental group than in the control groups; the number of correctly read words increased to a larger extent. In conclusion, MPH proved to be an aid in the reading process of children with ADHD and comorbid dyslexia by improving the learning conditions, but MPH cannot cure the reading disorder. Future research should study the effect of MPH on reading in a double-blind clinical trial.

Validation of population-based ADHD subtypes and identification of three clinically impaired subtypes

Statistically based classification methods have successfully refined ADHD into homogenous and heritable subtypes. External validity and impairment of these subtypes was examined using the Child Behavior Checklist (CBCL). We compared mean CBCL syndrome and competency t-scores across ADHD subtypes defined by latent class analysis in a sample of 1,346 individual twins from Missouri. The potential for comorbidity with conduct disorder (CD), oppositional defiant disorder (ODD), or major depression (MD) to increase impairment in specific ADHD subtypes was also examined. CBCL profiles confirm differences in severity, with more severe classes having increased syndrome scale and decreased competency scale CBCL scores. Clinically significant impairment was found for severe inattentive and combined subtypes and the mild combined subtype. Overall, the presence of comorbid CD, ODD, or MD did not result in increased ADHD subtype impairment. CBCL scores distinguish impairment in ADHD subtypes created through LCA. Comorbidity with CD, ODD, or MD does not significantly increase impairment among ADHD subtypes. The mild combined ADHD subtype represents a clinically significant but under-studied form of ADHD.

Screening and identification in pediatric primary care

This article reviews issues related to behavioral screening in pediatric primary care settings. Structural-organizational issues affecting the use of pediatric primary care screening are discussed. This study also reviewed selected screening instruments that have utility for use in the primary care setting. Clinical and research issues related to screening for behavior problems in pediatric primary care are presented.

The CBCL as a screen for psychiatric comorbidity in paediatric patients with ADHD

AIMS

To examine the informativeness of the Child Behavior Checklist (CBCL) as a screening tool to identify comorbid and non-comorbid cases of attention deficit hyperactivity disorder (ADHD) in a paediatrically referred population. It was hypothesised that specific scales of the CBCL would help identify specific comorbidities within ADHD cases in the primary care setting.

METHODS

The sample consisted of children and adolescents 6-17 years old of both genders with ADHD (n = 121). A receiver operating curve (ROC) approach was used to determine which CBCL scales best differentiated between ADHD cases with and without its comorbidities with conduct, anxiety, and mood disorders.

RESULTS

ROC analysis showed that the CBCL Delinquent Behavior and Aggressive Behavior scales predicted the structured interview derived diagnoses of conduct and bipolar disorder, the Anxious/Depressed and Aggressive Behavior scales predicted major depression, and the Anxious/Depressed and Attention problems scales predicted anxiety disorders.

CONCLUSIONS

These results extend to a paediatrically referred population with previously reported findings in psychiatric samples documenting good convergence between structured interview diagnoses and syndrome congruent CBCL scales. These findings support the utility of the CBCL as a screening tool for the identification of psychiatric comorbidity in ADHD youth in the primary care setting.

The child behavior checklist together with the ADHD rating scale can diagnose ADHD in Korean community-based samples

OBJECTIVE

The purpose of this study was to examine the clinical validities and efficiencies of the Child Behavior Checklist (CBCL) and the ADHD Rating Scale-IV (ARS) in identifying children with attention-deficit hyperactivity disorder (ADHD) in Korean community-based samples.

METHOD

A large sample of elementary school students (n = 1668) participated in this study. We used the CBCL and the ARS as the screening instruments. Diagnoses were determined by clinical psychiatric interviews and confirmed by DSM-IV-based structured interviews.

RESULTS

Of the 46 subjects who underwent clinical psychiatric interviews, 33 were diagnosed as having ADHD. A T score of 60 with regard to the Attention Problems profile of the CBCL resulted in a reasonable level of sensitivity or positive predictive value in the diagnosis of ADHD. In both the parent and teacher reports of the ARS, 90th percentile cut-off points resulted in a high level of predictive value. The highest levels of specificity and positive predictive value were obtained when we combined the CBCL (T > or = 60 in Attention Problems) and the ARS (parent-teacher total > or = 90th percentile) reports.

CONCLUSIONS

These findings suggest that the combined use of the CBCL and the ARS could serve as a rapid and useful clinical method of predicting or even diagnosing children with ADHD in epidemiologic case definitions.

Can teachers' behavior ratings be used to screen early adolescent boys for psychiatric diagnoses?

The present study examined if a short, 22-item teacher rating questionnaire could be used to screen young adolescent boys for psychiatric diagnoses. Subjects were 239 12-year-old boys from a community sample of low socioeconomic status families. Child and parent versions of the Diagnostic Interview Schedule for Children were used to provide DSM-III-R diagnoses. Results show a low to moderate screening value for the Short Social Behavior Questionnaire (S-SBQ) scales, with best results for externalizing disorders. The method used to establish the diagnoses had an impact on the screening efficacy of the S-SBQ, higher prevalence rates resulting in a lower proportion of false-positives for the same cutoff point. Additional research is needed to assess the screening efficacy of the S-SBQ across ages and gender, but results suggest that teacher ratings with the S-SBQ could be used to screen boys with externalizing disorders at the end of elementary school.

Screening for DSM-IV externalizing disorders with the Child Behavior Checklist: a receiver-operating characteristic analysis

BACKGROUND

This study examines the diagnostic accuracy of the CBCL syndrome AS scales for predicting DSM-IV Attention Deficit-Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder with or without Conduct Disorder (ODD/CD).

METHODS

The sample included 370 children (187 probands and 183 siblings) participating in a family genetic study of attention and aggressive behavior problems. Univariate and stepwise logistic regression analyses were used to derive models for predicting two diagnostic conditions: ADHD and ODD/CD.

RESULTS

The Attention Problems syndrome significantly predicted ADHD, and ODD/CD was significantly predicted by the Aggressive Behavior syndrome. Both scales demonstrated good diagnostic accuracy, as assessed through receiver operating characteristics analyses. Cut-point analyses confirmed the utility of low T-scores, 55 on the respective syndromes, for efficiently discriminating cases from noncases.

CONCLUSIONS

CBCL syndromes display good diagnostic efficiency for assessing common externalizing disorders in children.

Improving estimation of the prognosis of childhood psychopathology; combination of DSM-III-R/DISC diagnoses and CBCL scores

OBJECTIVE

To compare the predictive validity of the clinical-diagnostic and the empirical-quantitative approach to assessment of childhood psychopathology, and to investigate the usefulness of combining both approaches.

METHOD

A referred sample (N = 96), aged 6 to 12 years at initial assessment, was followed up across--on average--a period of 3.2 years. It was assessed to what extent DISC/DSM-III-R diagnoses--representing the clinical-diagnostic approach, and CBCL scores--representing the empirical-quantitative approach, predicted the following signs of poor outcome: outpatient/inpatient treatment, or parents' wish for professional help for the child at follow-up, disciplinary problems in school, and police/judicial contacts.

RESULTS

Both diagnostic systems added significantly to the prediction of poor outcome, and neither of the two systems was superior. Use of both systems simultaneously provided the most accurate estimation of the prognosis, reflected by the occurrence of future poor outcome. Even diagnostic concepts that are generally regarded as relatively similar, such as ADHD (DSM) and attention problems (CBCL), or conduct disorder (DSM) and delinquent behavior (CBCL), appeared to differ in their ability to predict poor outcome.

CONCLUSIONS

The present study supports the use of the empirical-quantitative approach and the clinical-diagnostic approach simultaneously, both in research and in clinical settings, to obtain a comprehensive view of the prognosis of psychopathology in children.

Heritability of attention problems in children: longitudinal results from a study of twins, age 3 to 12

BACKGROUND

Twin studies of childhood behavior problems support the conclusion that individual differences in impulsivity, hyperactivity, and inattention are largely due to genetic influences. Non-genetic variation is due to environmental influences that are unique to the individual, and possibly to rater contrast effects. In the present longitudinal twin study, we report on the size of genetic and environmental effects on individual differences in attention problems at ages 3, 7, 10 and 12 years.

METHODS

Mothers were asked to complete the CBCL for their twin offspring when the children were 3 (n = 11,938), 7 (n = 10,657), 10 (n = 6,192), and 12 years old (n = 3,124). We focus on the Overactivity (OA) scale in the Child Behavior Checklist (CBCL/2-3), and on the Attention Problem (AP) scale of the CBCL/4-18. The data were analyzed using longitudinal structural equation modeling.

RESULTS

Broad heritability of OA and AP is estimated at nearly 75%, at each age. A contrast effect was observed at age 3 only. The results revealed less stability of OA at age 3 to AP at age 7 (r = .40), compared to the stability from AP at age 7 and beyond (r = .70). Genetic effects explained between 76% and 92% of the covariance between OA and AP.

CONCLUSIONS

OA and AP are highly heritable at all ages in both genders. The same set of genes appears to be expressed in boys and girls. The size of genetic and environmental contributions remains the same across the ages studied. Stability in OA and AP is accounted for by genetic influences. Children who do not display OA or AP at a given age are unlikely to develop these problems at a subsequent age.

Heritability of attention problems in children: I. cross-sectional results from a study of twins, age 3-12 years

Multiple twin studies of attention problems (AP) from the Child Behavior Checklist or ADHD from the DSM criteria have reported on the genetic and environmental influences on these behaviors. The majority of these have studied AP and ADHD symptoms in twin samples combined across wide age spans, combined rater information and both genders. Thus, it is possible that the results are complicated by developmental, informant, and gender differences. The purpose of this study was to assess for the genetic and environmental contributions to overactive behavior (a syndrome highly related to AP in 7-, 10-, and 12-years olds) in 3-years olds (3,671 twin pairs), and attention problems in 7- (3,373 twin pairs), 10- (2,485 twin pairs), and 12-years olds (1,305 twin pairs) while controlling for developmental, gender and rater contrast contributions. Using a cross-sectional twin design, contributions from genetic additive, genetic dominance, unique environmental and rater contrast effects were estimated for CBCL maternal reports. We found that genetic influences on overactive behavior and attention problems are high across an age span that covers pre-school and elementary school age. Although girls display less problem behavior compared to boys, heritability estimates were found equal for both genders at each age. Environmental experiences that are unique to the individual accounted for the remaining influence. At the age of 3 years, a rater contrast effect was detected. We hypothesize that the contrast effect represents a maternal rater bias effect that is dependent on the age of the twins. The implications of these findings are discussed with reference to the clinical setting and in the context of future research.

Further evidence of reliability and validity of the Child Symptom Inventory-4: parent checklist in clinically referred boys

Examined reliability and validity of the parent version of the Child Symptom Inventory (CSI-4) in 247 boys between 6.0 and 10 years 11 months old referred for evaluation of behavioral and emotional problems. The CSI-4 is a behavior rating scale whose items correspond to the symptoms of disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994). Results indicated satisfactory internal consistency reliability, test-retest reliability, and temporal stability over a 4-year period for most symptom categories. CSI-4 ratings converged and diverged in a theoretically consistent pattern with respective scales of the Child Behavior Checklist (CBCL; Achenbach, 1991a) and the Diagnostic Interview for Children and Adolescents-Revised-Parent Version (DICA-P; Reich, Shayka, & Taibleson, 1991). Discriminant validity was established in that boys with specific DICA-P diagnoses received significantly higher corresponding CSI-4 parent symptom ratings than boys not so diagnosed. Clinical utility (sensitivity, specificity, positive predictive power, negative predictive power) was evaluated for screening cutoffs based on categorical (DSM-IV) and dimensional (normative distribution of Symptom Severity scores) scoring methods.

Characterization of children of bipolar parents by parent report CBCL

In past research the Child Behavior Checklist (CBCL) has differentiated among various diagnostic categories for children and adolescents. However, research has not been conducted on whether the CBCL differentiates among diagnostic categories for children at high risk for development of psychopathology. This study compares four diagnostic groups [bipolar disorder (BD), attention/deficit-hyperactivity disorder (ADHD), Depressed/Anxious and No Diagnosis] within a cohort of 58 children of bipolar parents to determine whether their CBCL scores will replicate the scores of children not at high risk for bipolar disorder. The cohort of children of bipolar parents received elevated scores on the CBCL scales in comparison with non-clinical populations. In addition, the CBCL distinguished between children of bipolar parents with and without clinical disorders. Finally the BD group differed from the ADHD group only on the Aggressive Behaviors, Withdrawn and Anxious/Depressed subscales of the CBCL. Therefore the CBCL did not discriminate between the BD and ADHD groups as it had in previous studies of children with BD and unspecified family history. It is possible that this discrepancy is due to a group of children of bipolar parents with ADHD who are currently prodromal for bipolar disorder and therefore received higher scores on the CBCL based on prodromal symptomatology. A longitudinal follow-up of this cohort is necessary to ascertain whether this is the case.

Long-term stability of the Child Behavior Checklist in a clinical sample of youth with attention deficit hyperactivity disorder

Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.

Child psychiatric diagnoses in a population of Dutch schoolchildren aged 6 to 8 years

OBJECTIVE

To determine the prevalence rates of child psychiatric diagnoses in a school-based population of children aged 6 to 8 years in the south of the province of Limburg (The Netherlands).

METHOD

In a two-stage design 1,317 children were screened with the Child Behavior Checklist. From 403 of these children, child psychiatric information was obtained with the Amsterdam Diagnostic Interview for Children and Adolescents (ADIKA, DSM-III-R/IV). Data were generalized to the responder group (n = 1,317) and to the entire cohort (N = 2,290). For the latter procedure, a prediction model was used to generalize ADIKA results to the nonresponders (n = 973).

RESULTS

Estimates of the prevalence of different ADIKA diagnoses in the responder group were quite comparable with those for the entire cohort. Twenty-four percent of the entire cohort met criteria for a single disorder, and 21.0% met criteria for two or more disorders. However, in only 5.7% of the cases parents did report a need for help.

CONCLUSIONS

Where other studies generalize psychiatric diagnoses to the responder group only, this report adds new information by generalizing the prevalence to a school-based cohort of children aged 6 to 8 years. These prevalence estimates are of importance with regard to the demand for care for child psychopathology.

Children of injection drug users: impact of parental HIV status, AIDS, and depression

We investigated the association between parental factors (including infection with human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS] diagnosis, parental medical illness, and depression) and children's behavioral and emotional problems among children of injection drug users (IDUs). IDUs were recruited through community outreach. The sample included 73 parents of 73 children, aged 4 to 12 years. Parental depression (odds ratio [OR] = 4.61) and medical illness (OR = 4.70) were found to be significantly associated with internalizing (depressive and anxiety-related symptoms), but not with externalizing (aggressive and disruptive behaviors) symptoms in the children of IDUs. The clinical implications are that children of IDUs are known to be at high risk for psychiatric symptoms and disorders; these data suggest that children of depressed and/or medically ill IDU parents may be at even higher risk of internalizing symptoms (depression and anxiety symptoms) than children of IDUs who do not suffer from these conditions.

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.

Pathways from ADHD to early drug use

OBJECTIVE

This study tests whether attention-deficit hyperactivity disorder (ADHD) increases the risk of early drug use.

METHOD

A community-based sample of 412 low birth weight and 305 normal birth weight children and their mothers initially were assessed when the children were 6 years old with a follow-up assessment at age 11.

RESULTS

The relationship of ADHD with drug use varied by level of externalizing problems. Regardless of ADHD status, children with a low level of externalizing problems had a low risk of drug use, and those with the highest level of externalizing problems had a high risk. At the middle level of externalizing problems, ADHD increased the incidence of drug use to the magnitude observed at the high level of externalizing problems, and children with ADHD were at significantly higher risk than those without ADHD (odds ratio = 2.1, p = .03). Findings were similar for low and normal birth weight children. Low parent monitoring and high peer drug use signaled increased risk of drug use for children, independent of ADHD status. Psychostimulant treatment for ADHD was unrelated to risk of drug use.

CONCLUSIONS

Risk for early drug use in children with ADHD depends on level of associated externalizing problems. Parent monitoring and peer drug use appear to be potential targets for drug prevention for children with ADHD, as well as children in general.

A review of methods and instruments for assessing externalizing disorders: theoretical and practical considerations in rendering a diagnosis

This review addresses the most current and widely used methods of assessing childhood and adolescent externalizing disorders. Interviews, rating scales, and self-report instruments are described, and their strengths and weaknesses are discussed. Direct observational techniques in naturalistic and analogue settings are also reviewed. Throughout the article, commentary is offered regarding the psychometric adequacy and clinical validity of these instruments. It is suggested that, although the instruments presently used to assist in diagnosing externalizing disorders generally possess adequate reliability and representational validity, evidence of elaborative validity is lacking. Clinicians and researchers are encouraged to adopt a broader conceptualization of the diagnostic process, to question existing standards for establishing validity, and to consider alternative means of demonstrating diagnostic utility.

A longitudinal twin study of temperament and behavior problems: common genetic or environmental influences?

OBJECTIVES

To assess the longitudinal covariance between emotionality, activity, and sociability (EAS) temperamental traits and anxious/depressed behavior, attention problems, delinquent behavior, and aggressive behavior and to assess the significance of genetic and common environmental influences on the temperament and behavior relations.

METHOD

Parental responses to the Child Behavior Checklist and the EAS Temperament Survey were collected from five national cohorts of Norwegian same-sex twins. The final sample consisted of 759 twin pairs aged 7 through 17 at 2-year follow-up.

RESULTS

High emotionality predicted anxious/depressed behavior, attention problems, delinquent behavior, and aggressive behavior. The influence on delinquent and aggressive behavior was stronger in boys. Aggressive behavior was further predicted by high activity scores, especially in younger children. Significant genetic influence was found for the covariance between emotionality and attention problems and emotionality and aggressive behavior.

CONCLUSION

Emotionality was the strongest temperamental predictor of behavior problems. The mechanisms involved in the associations between temperament and behavior problems appeared to differ with kind of behavior problems.

Associations between different diagnostic approaches for child and adolescent psychopathology

OBJECTIVE

To test the convergence between the empirical-quantitative approach of the Child Behavior Checklist (CBCL) and the clinical-diagnostic approach of the DSM.

METHOD

The parent version of the NIMH Diagnostic Interview Schedule for Children (DISC), version 2.3, was administered after completion of the CBCL for 231 children and adolescents consecutively referred to an outpatient mental health clinic.

RESULTS

Of the subjects with a DSM-III-R diagnosis, 60% scored in the clinical range of the CBCL total problem score. The Withdrawn scale predicted affective and anxiety disorders. The Somatic Complaints scale predicted anxiety and mood disorders and Attention Deficit Hyperactivity Disorder. The Anxious/Depressed scale predicted anxiety and mood disorders and, to a lesser extent, disruptive behavior disorders. The Social Problems scale predicted Oppositional Defiant Disorder. The Attention Problems scale was the only significant predictor of "pure" Attention Deficit Hyperactivity Disorder (ADHD). The Aggressive Behavior scale predicted several disruptive behavior disorders, and Major Depression. The Delinquent Behavior scale was strongly associated with Conduct Disorder.

CONCLUSIONS

Empirically based CBCL scale scores and DISC-P based DSM-III-R diagnoses converged. However, both approaches do not converge to a degree that one approach can replace the other. Instead, combining both approaches may be valuable by adding information from one approach that is not captured by the other.

Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD

OBJECTIVE

To evaluate the overlap between attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), addressing whether ODD is subsyndromal form of conduct disorder (CD) and, if so, whether it is a precursor or prodrome syndrome of CD.

METHOD

Assessments from multiple domains were used to examine 140 children with ADHD and 120 normal controls at baseline and 4 years later.

RESULTS

Of children who had ADHD at baseline, 65% had comorbid ODD and 22% had CD. Among those with ODD, 32% had comorbid CD. All but one child with CD also had ODD that preceded the onset of CD by several years. ODD+CD children had more severe symptoms of ODD, more comorbid psychiatric disorders, lower Global Assessment of Functioning Scale scores, more bipolar disorder, and more abnormal Child Behavior Checklist clinical scale scores compared with ADHD children with non-CD ODD and those without ODD or CD. In addition, ODD without CD at baseline assessment in childhood did not increase the risk for CD at the 4-year follow-up, by midadolescence.

CONCLUSIONS

Two subtypes of ODD associated with ADHD were identified: one that is prodromal to CD and another that is subsyndromal to CD but not likely to progress into CD in later years. These ODD subtypes have different correlates, course, and outcome.

Twin sibling differences in parental reports of ADHD, speech, reading and behaviour problems

Differences between twins and siblings in behaviour problems were investigated in a non-selected sample of 1938 families with children aged 4-12 years. Families were sent a questionnaire based on DSM-III-R criteria for Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD) and Separation Anxiety (SA), which was validated by formal clinical interview. The questionnaire also included measures of speech and reading problems. There were significant differences between twins and siblings for ADHD symptoms, but not for symptoms of ODD, CD or SA. Twins and siblings differed significantly for gestational age, birth weight, speech and reading problems. While there was little evidence for birth weight or gestational age contributing to the difference in ADHD symptoms, there was a strong association between ADHD symptoms and speech and reading problems.

Genetic influence on parent-reported attention-related problems in a Norwegian general population twin sample

OBJECTIVE

To assess the genetic and environmental influences on attention problems in a general population twin sample and to investigate whether there are changes in the relative genetic influence on attention problems with increasing severity.

METHOD

Parental ratings of the Child Behavior Checklist were collected from five Norwegian national cohorts of same-sex twins. The sample comprises 526 identical and 389 fraternal pairs.

RESULTS

Considerable genetic influence on attention problems was found for both sexes and across age groups (aged 5 to 9 years and 12 to 15 years). A two-parameter model with additive genetic influence and nonshared environment showed a good fit, with heritability ranging from .73 in boys aged 5 to 9 years, to .76 in girls aged 5 to 9 years. There was no change in the relative genetic influence across severity after accounting for the influence of cerebral palsy, epilepsy, and low birth weight.

CONCLUSION

The results indicate a substantial genetic influence on attention problems across sex, age, and severity.

External validation of oppositional disorder and attention deficit disorder with hyperactivity

Validity of the distinction between oppositional disorder (OD) and attention deficit disorder with hyperactivity (ADDH) was examined in a sample of 6- to 12-year-old boys with behavior problems. Problem identification, cognitive/attentional, family context, and behavioral symptom differences were examined among nine boys with OD only, 20 with ADDH, 40 with comorbid OD and ADDH, and 28 with neither disruptive behavior disorder. Systematic comparisons of groups including and excluding the OD and ADDH diagnoses were undertaken to determine the existence of pure OD and pure ADDH disorder effects. The most consistent result was the lack of evidence for either pure OD or pure ADDH effects. Most of the significant findings reflected differences between the nondisruptive (neither) and comorbid groups. The results support the importance of comorbidity, but they provide little support for disorder-specific distinctions between oppositional and attention deficit disorders.

Pilot study of behavioral and emotional disturbances in the high-risk children of parents with opioid dependence

OBJECTIVE

Despite the prevalence of nonalcohol substance abuse disorders, few data are available on the high-risk children of parents with these disorders. To this end as a preliminary study, children of opioid-dependent parents were assessed on measures of emotional and behavioral problems.

METHOD

Child Behavior Checklist data from 15 girls and 29 boys (mean age 10.4 years) from 27 families of parents receiving treatment in a methadone maintenance clinic were compared with matched data from referred children with attention-deficit hyperactivity disorder plus comorbid psychiatric disorders ("comorbid ADHD children") and medically referred children without ADHD ("controls").

RESULTS

The children of opioid-dependent parents had significantly poorer competency scores, and higher scores on both Internalizing and Externalizing subscales of the Child Behavior Checklist, compared with controls (p values < .01), but not compared with comorbid ADHD children. Twenty-four children (55%) of opioid-dependent parents had elevated subscale scores indicative of significant psychopathology.

CONCLUSIONS

These pilot data seem to indicate that the 4- to 18-year-old children of parents with opioid dependence have high rates of psychopathology and significant dysfunction and suggest the need for further controlled studies in this population.

Diagnosis, assessment, and comorbidity in psychosocial treatment research

This paper identifies problems in prevailing terminology and conceptual models that may hinder research on treatment. To avoid the multiple meanings of diagnosis, the term assessment is used in reference to identifying the distinguishing features of individual cases, while taxonomy is used to designate the grouping of cases according to their distinguishing features. Treatment research requires clear specification of the behavioral/emotional problems and competencies targeted for intervention. Artifactual comorbidity can be avoided by specifying treatment targets at several levels, including competencies, specific problems, syndromes, profiles of syndrome scores, and global problem scores. To select subjects for treatment research and to evaluate outcomes, multisource data can be coordinated by using a cross-informant computer program, taxonomic decision tree, and averaging of multisource standard scores.

Are perinatal complications relevant to the manifestation of ADD? Issues of comorbidity and familiality

OBJECTIVE

We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit disorder (ADD) addressing issues of comorbidity and familiarity by formulating and testing multiple hypotheses.

METHOD

Subjects were six to 17-year-old boys with DSM-III attention deficit disorder (ADD, N = 73), psychiatric (N = 26), and normal (N = 26) controls and their relatives. Information on PDICs was obtained from the mothers in a standardized manner blind to the proband's clinical status.

RESULTS

Using odds ratio analyses, an association was found between ADD and PDICs that was strongest for the comorbid and nonfamilial subtypes. In contrast, noncomorbid and familial ADD subgroups differed less from normal controls in the risk for PDICs.

CONCLUSIONS

The increased risk for PDICs in nonfamilial ADD children and the lack of evidence for increased risk among familial ADD patients suggests that PDICs may be part of nongenetic etiologic mechanisms in this disorder, especially for children who have comorbid disorders.