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Guest Editorial
Geriatric Psychiatry: A Subspecialty Whose Time Has Come
Nathan Herrmann
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Special Geriatric Psychiatry Section
Canadian Outcomes Study in Dementia: Study Methods and Patient Characteristics
Robert Sambrook, Nathan Herrmann, Réjean Hébert, Peter McCracken, Alain Robillard, Doanh Luong, Amanda Yu
(PDF)

Exploring the Links Between Depression, Integrity, and Hope in the Elderly
William T Chimich, Cheryl L Nekolaichuk
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Driving and Dementia in Ontario: A Quantitative Assessment of the Problem
Robert W Hopkins, Lindy Kilik, Duncan JA Day, Catherine Rows, Heidi Tseng
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GABAergic Function in Alzheimer’s Disease: Evidence for Dysfunction and Potential as a Therapeutic Target for the Treatment of Behavioural and Psychological Symptoms of Dementia
Krista L Lanctôt, Nathan Herrmann, Paolo Mazzotta, Lyla R Khan, Neil Ingber
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Surrogate Decision-Making: Special Issues in Geriatric Psychiatry
Carole A Cohen
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Defining Best Practices for Specialty Geriatric Mental Health Outreach Services: Lessons for Implementing Mental Health Reform
Mary Pat Sullivan, Linda Kessler, J Kenneth Le Clair, Paul Stolee, Whitney Berta
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Review Paper
Preventing Postpartum Depression Part I: A Review of Biological Interventions
Cindy-Lee E Dennis
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Original Research
Suicidal Ideation in Inpatients With Acute Schizophrenia
Vassilis Kontaxakis, Beata Havaki-Kontaxaki, Maria Margariti, Sophia Stamouli, Costas Kollias, George Christodoulou
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The RCPSC Oral Examination: Patient Perceptions and Impact on Participating Psychiatric Patients
Philip Tibbo, Kelly Templeman
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Brief Communication
Symptoms Defined by Parents’ and Teachers’ Ratings in Attention-Deficit Hyperactivity Disorder: Changes With Age
Bedriye Öncü, Özgür Öner, P1nar Öner, NeÕe Erol, Ayla Aysev, Saynur Canat
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Book Reviews
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The Therapist’s Notebook for Families: Solution-Oriented Exercises for Working With Parents, Children, and Adolescents
Review by
Lance Taylor, Karl Tomm

Implementing Early Intervention in Psychosis: A Guide to Establishing Early Psychosis Services
Review by
George Voineskos

Dementia: Presentations, Differential Diagnosis, and Nosology. 2nd ed.
Review by
Matthew Robillard

Letters to the Editor
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Mirtazapine-Induced Shopping Spree

Age at Onset of Bipolar II Disorder

Venlafaxine-Associated Hypomania in Unipolar Depression

Hypnopompic Hallucinations During Olanzapine Treatment

Atypical Neuroleptic Malignant Syndrome Caused by Clozapine and Venlafaxine: Early Brief Treatment With Dantrolene

A Case of de Clérambault Syndrome in a Male Stalker With Paranoid Schizophrenia

Calcitonin Treatment for Phantom Limb Pain

The Use of Atomoxetine Adjunctively in Fibromyalgia Syndrome
Re: Autism—Its Detection, Causes, and Treatment

Brief Communication

Symptoms Defined by Parents’ and Teachers’ Ratings
in Attention-Deficit Hyperactivity Disorder: Changes With Age

Bedriye Öncü, MD¹, Özgür Öner, MD2², P1nar Öner, MD³, NeÕe Erol, PhD⁴, Ayla Aysev, MD⁴, Saynur Canat, MD⁵

Attention-deficit hyperactivity disorder (ADHD) is one of the most frequent neurodevelopmental disorders of childhood. Studies that followed children with ADHD to adolescence reveal that 70% to 85% of the children may continue to have the disorder during adolescence (1–3). ADHD also continues to cause significant social and academic problems in adolescents and is usually comorbid with other psychiatric disorders (4–6). However, despite these significant findings, ADHD literature mostly relies on childhood cases (7,8).

As Biederman and colleagues indicated, treatment of children in the follow-up process makes it harder to generalize the findings in the follow-up literature to all ADHD cases (7). Therefore, cross-sectional studies of first-time diagnosed ADHD patients may be important in determining the presentations of ADHD in different age groups, which will help to control the confounding effects of treatment on the natural course of the disorder.

In this article, we report Child Behavior Checklist/4-18 (CBCL) and Teacher Report Form (TRF) scores of children and adolescents diagnosed with ADHD for the first time and compare this with scores of age- and sex-matched control subjects selected from a nationally representative epidemiologic sample. The goal of this study is to determine whether CBCL and TRF scores of first-time diagnosed ADHD patients change with age and whether there is a similar change in normal control subjects.

Materials and Method

Subjects
We included 146 patients with ADHD in the study: 124 boys (84.9%) and 22 girls (15.1%), aged 6 to 18 years (mean age 11.04 years, SD 3.56); we also included 274 age- and sex-matched control subjects. Patients with ADHD were recruited from consecutive admissions to the general child and adolescent psychiatry outpatient clinics at Ankara University’s Faculty of Medicine Child Psychiatry Department and Faculty of Medicine Adolescent Psychiatry Unit. All subjects were white. Children and adolescents from all over Turkey are referred to these 2 clinics. Diagnosis based on DSM-IV criteria was established by consensus of at least 2 psychiatrists. All subjects with ADHD had normal medical histories and were clinically screened for psychosis, eating disorders, substance use disorders, pervasive developmental disorders, and mental retardation. Most ADHD diagnoses were the combined subtype, but they also included the predominantly inattentive subtype. All patients were diagnosed for the first time and had never been previously evaluated for psychiatric disorders; none had previously received psychopharmacological treatment. CBCL and TRF scores were obtained prior to the evalution. Only 96 patients had TRF scores, owing to summer holidays.

Control subjects were recruited from a nationally representative epidemiologic sample. The sample was selected by a self-weighted, multistage, random, stratified, and clustered sampling plan. Another study details the selection of the epidemiologic sample (9). Subjects living in urban areas were selected for this study to obtain a group more resembling our clinical population. Two control subjects for each ADHD subject were selected randomly from the age- and sex- matched children and adolescents.

Materials
Child Behavior Checklist /4-18. We used the CBCL to obtain standardized parental reports of children’s problem behaviours and competencies. The CBCL includes 118 problem items (10). There are 8 syndrome scales based on the problem items: Social Withdrawal, Somatic Complaints, Anxiety–Depression, Thought Problems, Attention Problems, Social Problems, Aggressive Behavior, and Delinquency. The total scores obtained from the Social Withdrawal, Somatic Complaints, and Anxiety–Depression subscales give a broadband syndrome Internalization Problems score. The sum of the Aggressive Behavior and Delinquency subscale scores give a broadband Externalization Problems syndrome score. Back translation, bilingual retest method, and pretest field study were done for the CBCL (11). The test–retest reliability of the Turkish form was 0.84 for Total Problems. Internal consistency of the Turkish form was adequate (Cronbach’s alpha = 0. 88) (9,11).

Teacher Report Form. The TRF also includes 118 items (12). The syndrome scales and broadband syndromes are identical with those of the CBCL. The same translation methods were used for the TRF. The test–retest reliability of the Turkish form was 0.88 for Total Problems. Internal consistency of the Turkish form was adequate (Cronbach’s alpha = 0. 87) (9,11).

Data Analysis
We used analysis of variance (ANOVA) to compare the CBCL and TRF syndrome scale scores and broadband syndrome groupings (Internalizing and Externalizing) of the patients with ADHD and the control group. We used Spearman’s rank correlation test to calculate correlations of syndrome scale scores with age. Two-tailed significance tests (P < 0.05) are reported throughout. SPSS 10.0 statistical package was used for the analysis (12).

Results

Group Differences
Tables 1 and 2 summarize means and standard deviations of the syndrome scale and broadband syndrome scores obtained from the CBCL and the TRF. ADHD cases have significantly higher scores in all the CBCL scales than do control subjects. When the TRF is taken into account, subjects with ADHD have higher scores in Attention Problems, Thought Problems, Social Problems, Delinquency, Aggressive Behavior, Externalizing Problems, and Total Problems.

Correlations With Age
In the ADHD group, CBCL scores for Social Withdrawal (r = 0.242, P = 0.004), Somatic Complaints (r = 0.302, P < 0.001), Attention Problems (r = 0.202, P = 0.018), and Internalizing Problems (r = 0.200, P = 0.019) were significantly correlated with age. CBCL scores for Social Problems (r = –0.168, P = 0.049) and Externalization Problems (r = –0.191, P = 0.025) were negatively correlated with age. TRF scores for Social Withdrawal (r = 0.359, P = 0.006), Somatic Complaints (r = 0.302, P = 0.022), Anxiety–Depression (r = 0.242, P = 0.018), and Internalizing Problems (r = 0.287, P = 0.005) were also significantly correlated with age. TRF scores for Aggressive Behavior (r = –0.291, P = 0.004) and Externalizing Problems were negatively correlated with age (r = –0.263, P = 0.010).

In the control group, only CBCL scores for Somatic Complaints (r = 0.178, P = 0.003) were significantly correlated with age. Figure 1 summarizes changes in CBCL and TRF Internalizing and Externalizing Problems with age.

Discussion

Consistent with previous studies, subjects with ADHD had higher CBCL scores for Social Problems, Attention Problems, and Internalizing and Externalizing Problems, as well as higher TRF scores for Social Problems, Attention Problems, and Externalizing Problems, than did control subjects (3,13,14).

There was a significant correlation between age and scores for Social Withdrawal, Attention Problems, and Internalizing Problems in the group with ADHD. Since this was not the case for the control group, the correlation does not seem to indicate merely a more pronounced relation between age and CBCL–TRF scores. Conversely, Biederman and others’ study indicated that child and adolescent subjects had similar CBCL profiles (7). In that study, however, the sample was followed for 4 years and was probably treated. Treatment in this period may prevent the emergence of higher internalization problems in adolescence. Previous studies indicate that effective treatment may be important to prevent future internalization problems (15).

The more prominent Internalizing Problems in the adolescent group with ADHD may be a result of social problems and negative societal feedback. Again, previous studies indicate that social problems are prominent in most cases of ADHD (16,17). Indeed, interpersonal and social problems may be one of the most disabling aspects of ADHD (18) and may be related to outcome (19). Children and adolescents with ADHD are less popular than their classroom peers (20). Further, peer rejection and social-skills deficits in childhood may increase risk of later delinquency, academic failure, and psychopathology (21).

Higher somatization problems in older subjects with ADHD and in control subjects may be a correlate of other internalization disorders. However, this may also reflect a cultural difference. Earlier studies conducted with Turkish patients indicated that somatization is frequent in the Turkish population and may be a prominent part of depressive symptomatology (22,23).

These results suggest that underdiagnosis of ADHD in childhood may cause higher internalization problems in adolescence. Further, presentation of internalization problems may differ from culture to culture.

References

1. Barkley RA, Fischer M, Edelbrock S, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria. I: An 8-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1990;29:546–57.

2. Hart E, Lahey B, Loeber R, Applegate B, Frick P. Developmental change in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study. J Abnorm Child Psychol 1995;23:729–49.

3. Biederman J, Faraone S, Milberger S, Jetton JG, Chen L, Mick E, and others. A prospective 4-year follow up study attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry 1996;53:437–46.

4. Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996; 5:978–87.

5. Faraone SV, Biederman J, Mennin D, Gershon J, Tsuang MT. A prospective four-year follow-up study of children at risk for ADHD: psychiatric, neuropsychological, and psychosocial outcome. J Am Acad Child Adolesc Psychiatry 1996;35:1449–59.

6. Faraone SV, Biederman J, Mick E, Doyle AE, Wilens T, Spencer T, and others. A family study of psychiatric comorbidity in girls and boys with attention-deficit hyperactivity disorder. Biol Psychiatry 2001;50:586–92.

7. Biederman J, Faraone SV, Taylor A, Sienna M, Williamson S, Fine C. Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample. J Am Acad Child Adolesc Psychiatry 1998;37:305–13.

8. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA 1998;279:1100–7.

9. Erol N, ÔimÕek Z. Mental health of Turkish children: behavioral and emotional problems reported by parents, teachers, and adolescents. In: Singh NN, Leung JP, editors. International perspectives on child and adolescent mental health. Amsterdam (NE): Elsevier Science Ltd; 2000. p 223–47.

10. Achenbach TM. Manual for the Child Behavior Checklist/4-18 and 1991 profile. Burlington (VT): University of Vermont; 1991.

11. Erol N, Arslan BL, Akçak2n M. The adaptation and standardization of the Child Behavior Checklist among 6- to 18-year-old Turkish children. In: Sergeant J, editor. Eunethydis: European approaches to hyperkinetic disorder. Zurich: Fotoratar; 1995. p 97–113.

12. SPSS for Windows. Release 10.0.1. Standard version. Chicago (IL): SPSS, Inc; 1999.

13. Achenbach TM. Manual for the Teacher’s Report Form and 1991 profile. Burlington (VT): University of Vermont; 1991.

14. Rohde LA, Biederman J, Busnello EA, Zimmermann H, Schmitz M, Martins S, and others. ADHD in a school sample of Brazilian adolescents: study of prevalence, comorbid conditions, and impairments. J Am Acad Child Adolesc Psychiatry 1999;38:716–22.

15. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder Arch Gen Psychiatry 1999;56:1073–86.

16. Greene RW, Biederman J, Faraone SV, Monuteaux MC, Mick E, DuPre EP, and others. Social impairment in girls with ADHD: patterns, gender comparisons, and correlates. J Am Acad Child Adolesc Psychiatry 2001;40:704–10.

17. Greene RW, Biederman J, Faraone SV, Sienna M, Garcia-Jetton J. Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: results from a 4-year longitudinal follow-up study. J Consult Clin Psychol 1997;65:758–67.

18. Hinshaw SP. Externalizing behavior problems and academic underachievement in childhood and adolescence: causal relationship and underlying mechanisms. Psychol Bull 1992;111:151–9.

19. Greene RW, Biederman J, Faraone SV, Ouellette CA, Penn C, Griffin SM. Toward a new psychometric definition of social disability in children with attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1996;35:571–8.

20. Bagwell CL, Molina BS, Pelham WE Jr, Hoza B. Attention-deficit hyperactivity disorder and problems in peer relations: predictions from childhood to adolescence. J Am Acad Child Adolesc Psychiatry 2001;40:1285–92.

21. Gaub MJ, Carlson CL. Behavioral characteristics of DSM-IV subtypes in a school-based population. J Abnorm Child Psychol 1997;25:103–11.

22. Ulusahin A, Basoglu M, Paykel ES. A cross-cultural comparative study of depressive symptoms in British and Turkish clinical samples. Soc Psychiatry Psychiatr Epidemiol 1994;29:31–9.

23. Ebert D, Martus P. Somatization as a core symptom of melancholic type depression. Evidence from a cross-cultural study. J Affect Disord 1994;32:253–6.

Author(s)

Manuscript received May 2003, revised, and accepted September 2003.

1. Attending Psychiatrist, Adolescent Psychiatry Unit, Psychiatry Department, Ankara University Faculty of Medicine, Ankara, Turkey.

2. Resident and Research Fellow, Child Psychiatry Department, Ankara University Faculty of Medicine, Ankara, Turkey.

3. Child Psychiatrist, private practice, Ankara, Turkey.

4. Professor, Child Psychiatry Department, Ankara University Faculty of Medicine, Ankara, Turkey.

5. Professor, Adolescent Psychiatry Unit, Psychiatry Department, Ankara University Faculty of Medicine, Ankara, Turkey.

Address for correspondence: Dr B Öncü, Ankara Universitesi Tip Fakultesi Psikiyatri Anabilim Dali, Cebeci, Ankara, Turkey

e-mail: oncu@medicine.ankara.edu.tr or bedriyeoncu@superonline.com

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