Maternal Ratings of Attention Problems in ADHD: Evidence for the Existence of a Continuum

doi:10.1097/CHI.0b013e3181ba3dbb

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 48, Issue 11, November 2009, Pages 1085-1093

https://doi.org/10.1097/CHI.0b013e3181ba3dbb Get rights and content

Abstract

Objective

To investigate whether items assessing attention problems provide evidence of quantitative differences or categorically distinct subtypes of attention problems (APs) and to investigate the relation of empirically derived latent classes to DSM-IV diagnoses of subtypes of attention-deficit/hyperactivity disorder (ADHD), for example, combined subtype, predominantly inattentive type, and predominantly hyperactive/impulsive type.

Method

Data on attention problems were obtained from maternal ratings on the Child Behavior Check List (CBCL). Latent class models, which assume categorically different subtypes, and factor mixture models, which permit severity differences, are fitted to data obtained from Dutch boys at age 7 (N = 8,079), 10 (N = 5,278), and 12 years (N = 3,139). The fit of the different models to the data is compared to decide which model, and hence, which corresponding interpretation of AP, is most appropriate. Next, ADHD diagnoses are regressed on latent class membership in a subsample of children.

Results

At all the three ages, models that distinguish between three mainly quantitatively different classes (e.g., mild, moderate, and severe attention problems) provide the best fit to the data. Within each class, the CBCL items measure three correlated continuous factors that can be interpreted in terms of hyperactivity/impulsivity, inattentiveness/dreaminess, and nervous behavior. The AP severe class contains all of the subjects diagnosed with ADHD–combined subtype. Some subjects diagnosed with ADHD–predominantly inattentive type are in the moderate AP class.

Conclusions

Factor mixture analyses provide evidence that the CBCL AP syndrome varies along a severity continuum of mild to moderate to severe attention problems. Children affected with ADHD are at the extreme of the continuum. These data are important for clinicians, research scholars, and the framers of the DSM-V as they provide evidence that ADHD diagnoses exist on a continuum rather than as discrete categories. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(11):1085–1093.

Section snippets

Subjects

The subjects in this study are Dutch male twins whose parents voluntarily registered with the Netherlands Twin Registry (NTR).13, 14 The NTR families largely represent the general Dutch population. Based on available data, the average age of the mother and father at birth of the twin is 30.6 and 33.01 years, respectively. From age 7 to 12 years of the twins, the percentage of married parents decreases from 92.3% to 88.1%. Parents' educational and occupational levels are presented in Table 1.

Results

Results are compared across the age groups focusing on the best-fitting model, the relative sizes of the latent classes (i.e., class proportions), and the differences across classes with respect to the response patterns on the 11 CBCL attention items and the relation of the classes to the DSM diagnoses.

Discussion

The results of the current analysis show quantitative differences in the AP syndrome of the CBCL in children aged 7 to 12 years. The FMM analyses of the CBCL data reveal similar results as our earlier findings when we used the same approach with SWAN data obtained in the Finnish adolescents.⁴ The analysis of CBCL AP items shows that the samples consist of three latent classes that are located along correlated continua (severe-, moderate-, and low-scoring AP classes). The severe and moderate

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First, we included the other CBCL syndrome scales in our T1 and T2 analyses; this provided some evidence that the attention problems scale was a unique predictor of motor stereotypy with an effect size in the small (T1 sample) to moderate (T2 sample) range, while the other CBCL syndrome scales were not (except for somatic complaints in the T1 sample). Second, we conducted an exploratory analysis with the T2 dataset using only the items from the Attention Problems subscale shown to be associated with an inattention factor (Lubke et al., 2009). The findings were virtually unchanged.
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This article was reviewed under and accepted by Ad Hoc Editor Kenneth Towbin, M.D.

This research was supported by Spinozapremie (NWO/SPI 56-464-14192; Twin-family database for behavior genetics and genomics studies (NWO 480-04-004); the VU-CNCR (Centre Neurogenetics/Cognition Research), Developmental Study of Attention Problems in Young Twins (NIMH, RO1 MH58799-03).

This article is the subject of an editorial by Dr. Anita Thapar in this issue.

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New ResearchMaternal Ratings of Attention Problems in ADHD: Evidence for the Existence of a Continuum

Abstract

Objective

Method

Results

Conclusions

Section snippets

Subjects

Results

Discussion

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DMS-IV-TR)

A dimensional approach to developmental psychopathology

Latent class and factor analysis of DSM-IV ADHD: a twin study of female adolescents

J Am Acad Child Adolesc Psychiatry

Subtypes versus severity differences in attention-deficit hyperactivity disorder in the Northern Finnish Birth Cohort

J Am Acad Child Adolesc Psychiatry

Across the continuum of attention skills: a twin study of the SWAN ADHD rating scale

J Child Psychol Psychiatry

Estimation of prevalence of DSM-IV and latent class-defined ADHD subtypes in a population-based sample of child and adolescent twins

Twin Res Hum Genet

Familial clustering of latent class and DSM-IV defined attention-deficit/hyperactivity disorder (ADHD) subtypes

J Child Psychol Psychiatry

Replication of the latent class structure of attention-deficit/hyperactivity disorder (ADHD) subtypes in a sample of Australian twins

J Child Psychol Psychiatry

Mutation screening of the dopamine D2 receptor gene in attention-deficit hyperactivity disorder subtypes: preliminary report of a research strategy

Am J Med Genet

Discrimination of DSM-IV and latent class attention-deficit/hyperactivity disorder subtypes by educational and cognitive performance in a population-based sample of child and adolescent twins

J Am Acad Child Adolesc Psychiatry

Manual for the Child Behavior Checklist/4–18 and 1991 profile

Convergence of the Child Behavior Checklist with structured interview-based psychiatric diagnoses of ADHD children with and without comorbidity

J Child Psychol Psychiatry

Netherlands Twin Register: from twins to twin families

Twin Res Hum Genet

Young Netherlands Twin Register (Y-NTR): a longitudinal multiple informant study of problem behavior

Twin Res Hum Genet

Distinguishing between latent classes and continuous factors with categorical outcomes: class invariance of parameters of factor mixture models

Multivariate Behav Res

Statistical Analysis with Missing Data

Genetic and environmental influences on the relation between attention problems and attention deficit hyper-activity disorder

Behav Genet

Handleiding voor de CBCL/4–18 [Manual for the CBCL/4–18]

New Research
Maternal Ratings of Attention Problems in ADHD: Evidence for the Existence of a Continuum