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

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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.

We

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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    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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