Evidence for an independent syndrome of hyperactivity

The Preschool Behaviour Questionnaire: Stability of its Factor Structure Between Cultures, Sexes, Ages and Socioeconomic Classes

The Preschool Behaviour Questionnaire has been widely used in North-America to study social competencies and behavioural problems of preschool children. The 30 item rating scale was created by Behar and Stringfield (1974) as an adaptation of Rutter's (1967) Children's Behaviour Questionnaire intended for elementary school children. In their original study Behar and Stringfield proposed a three-component solution for their data: hostileaggressive, anxious-fearful, hyperactive-distractible. Most studies using the Behar Preschool Behaviour Questionnaire, (B-PBQ) have been using this three-component solution. Fowler and Park (1979), after a study of a "normal" population sample, concluded that a two-component solution (aggressive-hyperactive-distractible, anxious-fearful) was a better approximation to simple structure and more easily interpretable. They also concluded that the two-component solution was stable across sexes, but questioned the stability for "populations differing significantly in socioeconomic or ethnic composition". This study addresses the "simple structure" problem and the "stability of structure" problem for the B-PBQ. Four different samples ranging from N=383 to N=1161 were assessed in francophone schools in Montreal. Results of principal component analyses compared to Behar and Stringfield's data as well as Fowler and Park's data lead to the following conclusions: a two-principal-component solution has a simpler structure and is easier to interpret with reference to Rutter's Children's Behaviour Questionnaire; the two-component solution is stable across sexes, ages, socioeconomic populations and cultures. The Preschool Behaviour Questionnaire paired with the Children's Behaviour Questionnaire should be suitable for longitudinal and cross-cultural studies of social competencies from preschool to junior high school.

What is attention-deficit hyperactivity disorder (ADHD)?

Attention-deficit hyperactivity disorder (ADHD) is described as the most common neurobehavioral condition of childhood. We raise the concern that ADHD is not a disease per se but rather a group of symptoms representing a final common behavioral pathway for a gamut of emotional, psychological, and/or learning problems. Increasing numbers of children, especially boys, are diagnosed with ADHD and treated with stimulant medications according to a simplified approach. Methodical review of the literature, however, raised concerning issues. "Core" ADHD symptoms of inattentiveness, hyperactivity and impulsivity are not unique to ADHD. Rates of "comorbid" psychiatric and learning problems, including depression and anxiety, range from 12 to 60%, with significant symptom overlap with ADHD, difficulties in diagnosis, and evidence-based treatment methods that do not include stimulant medications. No neuropsychologic test result is pathognomic for ADHD, and structural and functional neuroimaging studies have not identified a unique etiology for ADHD. No genetic marker has been consistently identified, and heritability studies are confounded by familial environmental factors. The validity of the Conners' Rating Scale-Revised has been seriously questioned, and parent and teacher "ratings" of school children are frequently discrepant, suggesting that use of subjective informant data via scale or interview does not form an objective basis for diagnosis of ADHD. Empiric diagnostic trials of stimulant medication that produce a behavioral response have been shown not to distinguish between children with and without "ADHD." In summary, the working dogma that ADHD is a disease or neurobehavioral condition does not at this time hold up to scrutiny of evidence. Thorough evaluation of symptomatic children should be individualized, and include assessment of educational, psychologic, psychiatric, and family needs.

A nationwide study of developmental and gender prevalence for psychopathology in childhood and adolescence

Psychopathology was assessed through standardized observations by teachers of 1,400 youths 5 through 17 years old comprising the national norm sample of the Adjustment Scales for Children and Adolescents. The sample was stratified according to the US. population by age, sex, ethnicity, parent education, family structure, national region, community size, and handicapping condition. The maladjusted portion of the sample for each of six specific syndromes was examined for departures from expected developmental and gender prevalence. Males outnumbered females for most types of maladjustment, including attention-deficit hyperactive, both provocative and impulsive forms of solitary aggressive, oppositional defiant, and avoidant disorders. Also revealed were general patterns of reduced behavior excess and increased avoidant behavior with advancing age.

NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale

OBJECTIVE

The National Institute of Mental Health's recently initiated 5-year, multisite, multimodal treatment study of children with attention-deficit hyperactivity disorder (MTA) is the first major clinical trial in its history focused on a childhood mental disorder. This article reviews the major scientific and clinical bases for initiating the MTA.

METHOD

A selective review of the literature is presented in the service of describing the estimated prevalence of ADHD among children and adolescents, its core clinical features, evidence concerning psychopharmacological and psychosocial treatment effects, and related research issues and trends leading to the development of the MTA.

RESULTS

Despite decades of treatment research and clinical practice, there is an insufficient basis for answering the following manifold question: under what circumstances and with what child characteristics (comorbid conditions, gender, family history, home environment, age, nutritional/metabolic status, etc.) do which treatments or combinations of treatment (stimulants, behavior therapy, parent training, school-based intervention) have what impacts (improvement, stasis, deterioration) on what domains of child functioning (cognitive, academic, behavioral, neurophysiological, neuropsychological, peer relations, family relations), for how long (short versus long term), to what extent (effect sizes, normal versus pathological range), and why (processes underlying change)?

CONCLUSIONS

The important scientific, clinical, and public health issues nested within this manifold question provide both the impetus and scaffolding for the MTA.

Behaviour problems and pre-school intellectual attainment: the associations of hyperactivity and conduct problems

The relationship between behaviour problems and intelligence was examined in a sample of 106 three-year-old boys and girls selected for the presence of either conduct problems or hyperactivity. Parents' reports of hyperactivity, but not conduct problems, were negatively related to IQ scores for both boys and girls. There was a significant sex difference in the association between conduct problems and IQ. For girls IQ was positively correlated with conduct problems. The implications of the results for existing models of the relationship between behavioural deviance and cognitive functioning in childhood is discussed.

Congruence of behavioral symptomatology in children with ADD/H, ADD/WO, and learning disabilities

Although evidence generally supports the behavioral differentiation of attention deficit disorder with hyperactivity (ADD/H) and attention deficit disorder without hyperactivity (ADD/WO), a growing body of literature suggests that children with learning disabilities (LD) share behavioral symptomatology with children diagnosed as having ADD/WO. The present study examined this issue by comparing parent and teacher behavioral ratings among groups of children diagnosed as having ADD/H, ADD/WO, and LD on symptoms of impulsivity, inattention, and social withdrawal. The subjects were 77 outpatients in a diagnostic and referral-service clinic who were divided into three groups. Group 1 included children with a primary diagnosis of ADD/H (n = 35), Group 2 included children with a primary diagnosis of ADD/WO (n = 25), and Group 3 included children with a primary diagnosis of learning disabilities (n = 17). The results indicated that parents and teachers view children with ADD/H as more disruptive than children with ADD/WO or LD. Children with ADD/WO or LD were described as more underactive and shy and as daydreaming more often than children with ADD/H. Teachers rated children with ADD/WO and LD as being similar to each other on symptoms of withdrawal and impulsivity, but both parents and teachers endorsed different symptoms of inattention for children with ADD/WO or LD. Issues related to comorbidity and differentiation of behavioral symptomatology are discussed.

Behavioural and cognitive characteristics of conduct disordered-hyperactive boys from age 6 to 11: a multiple informant perspective

Three subgroups of kindergarten boys (stable conduct disordered-hyperactive (SCDH), stable conduct disordered (SCD), stable non-deviant control (SC)) were defined and followed up three, four and five years later in primary school. Using assessments from multiple informants (teachers, mothers, peers, self), the results showed that SCDH boys were more hyperactive (i.e. overactive/inattentive) and displayed a greater diversity of conduct problems in school and home at follow-up compared to the other groups. These results and the fact that during early adolescence SCDH boys tend to develop a worse prognosis than SCD boys suggest that they should be distinguished.

European perspectives on hyperkinetic disorder

Differences between, on the one hand, North American and European perspectives on Hyperkinetic Disorder, and, on the other hand, within Europe are noted and discussed in this paper. A dominant European tradition has stressed, since the beginning of this century, the organic involvement in hyperkinetic disorder, whereas the North American tradition has stressed both behavioural and social functioning in hyperactivity (Attention Deficit Hyperactivity Disorder) and its associated disorder, Conduct Disorder. Five reasons for the difference in prevalence between the two perspectives are discussed: association disorder, decision rules, expression of behaviour, weighting of symptoms, and diagnostic instruments. The review suggests that the differences within Europe in the diagnosis, management, and treatment should be utilized in well-designed collaborative studies to investigate the validity of the different diagnostic and therapeutic procedures. The coordination of such studies is seen as the main task of the newly founded European Network on Hyperkinetic Disorder (EUNETHYDIS).

Comorbidity: a critical issue in attention deficit disorder

In this report, we examine the interrelationships between attention deficit disorder (ADD), learning disabilities (LD), and conduct and oppositional disorders (COD). We indicate that it is reasonable to consider ADD as a distinct entity, frequently co-occurring with LD on the one hand, and COD on the other. The first section reviews the interrelationships between ADD and LD. Here we focus on definitional issues, trace the historical antecedents of ADD and LD, examine the prevalence of ADD and LD, and review studies designed to differentiate cognitive from attentional mechanisms in children with ADD, LD, or both. In the next section, we review the evidence linking ADD with COD, a distinction blurred in earlier investigations by problems with referral bias. More recent studies suggest that the antecedents, clinical characteristics, and prognosis may differ in children with ADD alone compared to those with ADD in association with COD.

A behavioral observation method for differentiating hyperactive and aggressive boys

This study employed a playroom observation technique to examine the behavioral differences between hyperactive and aggressive boys. Subjects were clinic-referred boys assigned to Hyperactive, Aggressive, or Hyperactive plus Aggressive groups on the basis of behavior checklists and ratings of psychiatric chart information. While significant discrimination was obtained in all three settings (free play, restricted play, and restricted academic), behavioral differences among the subject groups were most pronounced during the restricted academic period. Discriminant function analysis for the restricted academic period resulted in accurate classification of 86% of the subjects as hyperactive, aggressive, or hyperactive plus aggressive. The present findings suggest that children with externalizing disorders can be distinguished in light of their observed clinic behavior in the restricted academic setting.

Stability and natural history of DSM-III childhood diagnoses

Follow-up or natural history outcome data for various DSM-III child and adolescent psychiatric diagnoses are presented. The data are relevant not only to our understanding of the specific disorders but also to the validity of the DSM-III diagnostic categories. "Semi-blind" psychiatric evaluations of 151 children were made as they presented to a community speech/language clinic and again approximately 4 years later. The follow-up data revealed high stability for only three diagnoses: infantile autism, attention deficit disorder with hyperactivity, and oppositional disorder. The data revealed that several of the DSM-III subcategories lacked predictive validity. This was true for the distinctions between attention deficit disorder with versus without hyperactivity; and between avoidant, separation anxiety, and overanxious disorders. Surprisingly low stability was found for conduct disorder diagnoses as were surprisingly poor prognoses for parent-child problems and adjustment disorders.

Behavioral and cognitive subtypes of ADHD

Attention-deficit hyperactivity symptoms are observed by teachers in 9.2% of a nonreferred elementary school population. Two subtypes of attention-deficit hyperactivity disorder (ADHD), a cognitive form and a behavioral form, are identified. The behavioral subtype includes about 80% of those identified and is characterized by distinct clinical phenomenology of inattention, impulsivity, and hyperactivity. These children can be described on a continuum of severity, with the most severe showing behavioral features indistinguishable from conduct disorder. Children with behavioral subtypes of ADHD do not exhibit the specific skill deficits on neuropsychological tests that are characteristic of reading disabled children. There is a second, less prevalent type of cognitive attention-deficit hyperactivity disorder constituting approximately 20% of ADHD children that includes severe academic underachievement along with inattention, impulsivity, and overactivity. Children with the cognitive subtype exhibit information processing deficits that involve inadequate encoding and retrieval of linguistic information, characteristic of reading disabilities.

Conners' Teacher's Rating Scale--a validity study in Hong Kong

The validity of the Conners' teacher's rating scale (CTRS) in Hong Kong Chinese school children was examined. It was found that CTRS could significantly differentiate a behaviorally deviant group and the normal population; that CTRS has a strong positive correlation with the teacher's decision to refer a child to a mental health professional; that the CTRS by itself is not useful as a diagnostic instrument; and finally, it cannot stand alone as a screening instrument in the epidemiological study of childhood hyperactivity.

The Revised Conners Parent Rating Scale: factor structure replication with a diversified clinical sample

The Revised Conners Teacher Rating Scale was completed as part of a comprehensive evaluation of 135 consecutive new patients seen in the Pediatric Neurology Learning Disability Clinic at the Medical College of Georgia. The questionnaires were subjected to principal components analysis with varimax rotation. Item analysis was conducted on the obtained subscales, and convergent validity was determined by correlation with the Revised Behavior Problem Checklist (Quay & Peterson, 1987). Finally, comparisons of the diagnostic groups were carried out across the subscales.

Relation of attention deficit and conduct disorder to vigilance and reading lag

The relationship between DSM-III Axis I diagnoses 'attention deficit disorder with hyperactivity' (ADDH), 'conduct disorder' (CD) and 'anxiety disorder' (AD) and measures of attention and reading were studied in 158 children. Children diagnosed as having severe or moderate ADDH were found to be younger at referral and to have a lower IQ than were children with CD and AD. When age, IQ, social class and sex were controlled, children with severe ADDH were found to perform significantly worse than other diagnostic groups on some tests of vigilance and reading age. The data suggest that children with severe ADDH form a distinct group, and those with mild ADDH overlap symptomatically and on tests of vigilance with children with CD.

Screening for behaviour problems in nurseries: the reliability and validity of the Preschool Behaviour Checklist

The development of the Preschool Behaviour Checklist, for screening emotional and behavioural problems in preschool children in group settings, is described. Inter-rater reliability and internal consistency was established, and its validity was shown using a variety of methods. These include observations of the children, interviews with staff, comparison between clinic and nonclinic populations, factor and cluster analysis and comparison with another screening questionnaire. Uses of the PBCL for training and inservice work are outlined. The limitations of screening as a method of identifying children with behaviour problems are discussed.

Empirical evidence for overt and covert patterns of antisocial conduct problems: a metaanalysis

Twenty-eight factor- and cluster-analytic studies of child psychopathology were examined for patterns in antisocial behavior. A multidimensional scaling analysis yielded one dimension that was labeled overt-covert antisocial behavior. One end of this dimension consisted of overt or confrontive antisocial behaviors such as arguing, temper tantrums, and fighting. The other end consisted of covert or concealed antisocial behaviors such as stealing, truancy, and fire setting. Implications derived from the present findings are discussed as they apply to the diagnosis, prevention, and treatment of antisocial behaviors in children.

Classification of children's behavior problems: clinical and quantitative approaches

Children diagnosed Conduct Disorder, Attention Deficit Disorder, or Anxiety Disorder by DSM-III criteria were compared to contrast groups of Physically Disabled and Normal children using the Conners Teacher Rating Scale (CTRS). Discriminant function analyses of the CTRS ratings yielded accurate classification (67% correct) only when Conduct was combined with Attention Deficit and Normals were combined with Physically Disabled. The teacher raters seemed to be describing the children as behaviorally disordered with and without hyperactivity. The data also suggest that Attention Deficit Disorder is part of a broader Conduct Problems dimension.

A multitrait-multimethod analysis of the Preschool Behavior Questionnaire

The Preschool Behavior Questionnaire is a teacher rating instrument yielding a total score reflecting overall level of adjustment and three subscale scores labeled Hostile/Aggressive, Anxious/Fearful, and Hyperactive/Distractible. This study assessed the convergent and discriminant validity of this teacher rating measure against two alternative measures within a multitrait-multimethod analysis. The results supported the construct validity of the Hostile/Aggressive and Anxious/Fearful scores as well as the overall score. There was, however, no support for the validity of the Hyperactive/Distractible score.