Skip to main content

Advertisement

SpringerLink
Log in

Subthreshold attention-deficit/hyperactivity disorder is associated with functional impairments across domains: a comprehensive analysis in a large-scale community study

  • Original Contribution
  • Published:
European Child & Adolescent Psychiatry Aims and scope Submit manuscript

Abstract

This study compared children who experience attention-deficit/hyperactivity disorder (ADHD) symptoms but do not meet criteria (i.e., subthreshold ADHD) with those with the full syndrome and healthy controls. Presence of ADHD symptoms was determined in a nationwide community sample of 921 children, aged 8–11 years. The main outcome measures comprised attentional symptoms, comorbidity profiles, academic performance, and neurocognitive ability (i.e., ADHD Rating Scale, Child Behavior Checklist, Learning Disability Evaluation Scale, and Stroop Color-Word Test, respectively). Subthreshold ADHD was equally prevalent in boys and girls, and more prevalent in low-income families. Throughout all the outcome measurements, subthreshold ADHD was both a significantly milder condition than full syndrome ADHD and a significantly more severe condition than non-ADHD status. The findings were consistent across the total as well as the subtest scores, and after correction for multiple comparisons (p < 0.0017). Children with subthreshold ADHD were found to experience significant symptoms and functional impairments. The results of this study support the clinical relevance of subthreshold ADHD in a childhood population. Subthreshold diagnostic criteria for ADHD may be more sensitive in detecting ADHD symptoms in girls than the full syndrome criteria, and subthreshold clinical, cognitive, and behavioral symptoms of ADHD may occur in a subset of children who are possibly more sensitive to their environment. Further consideration about the diagnostic threshold for ADHD may particularly benefit girls and children in low-income families.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ADHD:

Attention-deficit/hyperactivity disorder

ADHD-RS:

ADHD Rating Scale

ANOVA:

Analysis of variance

CBCL:

Child Behavior Checklist

DISC-IV:

Diagnostic Interview Schedule for Children Version IV

DSM-IV:

Diagnostic and statistical manual of mental disorders, 4th edition

IQ:

Intelligence quotient

LDES:

Learning Disability Evaluation Scale

KEDI-WISC:

Korean Educational Development Institute’s Wechsler Intelligence Scales for Children

SES:

Socioeconomic status

References

  1. Achenbach TM (1991) Manual for the Child Behavior Checklist/4-18 and 1991 profile. University of Vermont, Department of Psychiatry, Burlington, VT

  2. Aelion CM, Davis HT, McDermott S, Lawson AB (2009) Soil metal concentrations and toxicity: associations with distances to industrial facilities and implications for human health. Sci Total Environ 407:2216–2223

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Basch CE (2011) Inattention and hyperactivity and the achievement gap among urban minority youth. J Sch Health 81:641–649

    Article  PubMed  Google Scholar 

  4. Chen A, Cai B, Dietrich KN, Radcliffe J, Rogan WJ (2007) Lead exposure, IQ, and behavior in urban 5- to 7-year-olds: does lead affect behavior only by lowering IQ? Pediatrics 119:e650–e658

    Article  PubMed Central  PubMed  Google Scholar 

  5. Cho SC, Hong YC, Kim JW, Park S, Park MH, Hur J, Park EJ, Hong SB, Lee JH, Shin MS, Kim BN, Yoo HJ, Cho IH, Bhang SY, Hahn S (2013) Association between urine cotinine levels, continuous performance test variables, and attention deficit hyperactivity disorder and learning disability symptoms in school-aged children. Psychol Med 43:209–219

    Article  CAS  PubMed  Google Scholar 

  6. Cho SC, Kim BN, Kim JW, Kim HW, Choi HJ, Jung SW, Yang YH, Chungh DS, Go BJ, Kim BS, Shin MS, Yoo HI, Yoo HJ, Lee DW, Lee SE, Lee JY, Lee JW, Jeon SI, Jung HY, Hong JP, Hwang JW, Han SH (2007) The reliability and validity of Diagnostic Interview Schedule for Children Version IV-Korean version (DISC-IV). Korean J Child Adolesc Psychiatry 18:138–144

    Google Scholar 

  7. Cho SC, Kim BN, Kim JW, Rohde LA, Hwang JW, Chungh DS, Shin MS, Lyoo IK, Go BJ, Lee SE, Kim HW (2009) Full syndrome and subthreshold attention-deficit/hyperactivity disorder in a Korean community sample: comorbidity and temperament findings. Eur Child Adolesc Psychiatry 18:447–457

    Article  PubMed  Google Scholar 

  8. de Zeeuw P, Schnack HG, van Belle J, Weusten J, van Dijk S, Langen M, Brouwer RM, van Engeland H, Durston S (2012) Differential brain development with low and high IQ in attention-deficit/hyperactivity disorder. PLoS One 7:e35770

    Article  PubMed Central  PubMed  Google Scholar 

  9. DuPaul GJ, Power TJ, Anastopoulos AD, Reid R (1998) The ADHD Rating Scale-IV: checklists, norms, and clinical interpretation. Guilford Press, New York

    Google Scholar 

  10. Faraone SV (2005) The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry 14:1–10

    Article  PubMed  Google Scholar 

  11. Faraone SV, Biederman J, Doyle A, Murray K, Petty C, Adamson JJ, Seidman L (2006) Neuropsychological studies of late onset and subthreshold diagnoses of adult attention-deficit/hyperactivity disorder. Biol Psychiatry 60:1081–1087

    Article  PubMed  Google Scholar 

  12. Faraone SV, Biederman J, Spencer T, Mick E, Murray K, Petty C, Adamson JJ, Monuteaux MC (2006) Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry 163:1720–1729 quiz 1859

    Article  PubMed  Google Scholar 

  13. Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P (2005) Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry 57:1313–1323

    Article  CAS  PubMed  Google Scholar 

  14. Frazier TW, Youngstrom EA, Naugle RI (2007) The latent structure of attention-deficit/hyperactivity disorder in a clinic-referred sample. Neuropsychology 21:45–64

    Article  PubMed  Google Scholar 

  15. Galera C, Cote SM, Bouvard MP, Pingault JB, Melchior M, Michel G, Boivin M, Tremblay RE (2011) Early risk factors for hyperactivity-impulsivity and inattention trajectories from age 17 months to 8 years. Arch Gen Psychiatry 68:1267–1275

    Article  PubMed  Google Scholar 

  16. Golden CJ (1978) The Stroop color and word test. Stoelting Company, Chicago

    Google Scholar 

  17. Hackman DA, Farah MJ, Meaney MJ (2010) Socioeconomic status and the brain: mechanistic insights from human and animal research. Nat Rev Neurosci 11:651–659

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. Haslam N, Williams B, Prior M, Haslam R, Graetz B, Sawyer M (2006) The latent structure of attention-deficit/hyperactivity disorder: a taxometric analysis. Aust N Z J Psychiatry 40:639–647

    Article  PubMed  Google Scholar 

  19. Hasson R, Fine JG (2012) Gender differences among children with ADHD on continuous performance tests: a meta-analytic review. J Atten Disord 16:190–198

    Article  PubMed  Google Scholar 

  20. Hong SB, Hong YC, Kim JW, Park EJ, Shin MS, Kim BN, Yoo HJ, Cho IH, Bhang SY, Cho SC (2013) Bisphenol A in relation to behavior and learning of school-age children. J Child Psychol Psychiatry 54:890–899

    Google Scholar 

  21. Jhun HJ, Seo HG, Lee DH, Sung MW, Kang YD, Syn HC, Jun JK (2010) Self-reported smoking and urinary cotinine levels among pregnant women in Korea and factors associated with smoking during pregnancy. J Korean Med Sci 25:752–757

    Article  PubMed Central  PubMed  Google Scholar 

  22. Kaufman AS (1976) A four test short form of the WISC-R. Contemp Educ Psychol 1:180–196

    Article  Google Scholar 

  23. Kim MK, Kim ZS (1986) A study on the abbreviated form of the K-WISC. Seoul J Psychiatry 11:194–201

    Google Scholar 

  24. Kim ZS, Lee YS, Lee MS (1994) Two- and four-subtest short forms of the Korean-Wechsler Adult Intelligence Scale. Seoul J Psychiatry 19:121–126

    Google Scholar 

  25. Kret ME, De Gelder B (2012) A review on sex differences in processing emotional signals. Neuropsychologia 50:1211–1221

    Article  CAS  PubMed  Google Scholar 

  26. Larsson H, Anckarsater H, Rastam M, Chang Z, Lichtenstein P (2012) Childhood attention-deficit hyperactivity disorder as an extreme of a continuous trait: a quantitative genetic study of 8,500 twin pairs. J Child Psychol Psychiatry 53:73–80

    Article  PubMed  Google Scholar 

  27. Levy F, Hay DA, McStephen M, Wood C, Waldman I (1997) Attention-deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a large-scale twin study. J Am Acad Child Adolesc Psychiatry 36:737–744

    Article  CAS  PubMed  Google Scholar 

  28. Lubke GH, Hudziak JJ, Derks EM, van Bijsterveldt TC, Boomsma DI (2009) Maternal ratings of attention problems in ADHD: evidence for the existence of a continuum. J Am Acad Child Adolesc Psychiatry 48:1085–1093

    Article  PubMed Central  PubMed  Google Scholar 

  29. McCarney SB (1996) The Learning Disability Evaluation Scale-renormed. Hawthorne Educational Services, Columbia

    Google Scholar 

  30. Nigg JT, Knottnerus GM, Martel MM, Nikolas M, Cavanagh K, Karmaus W, Rappley MD (2008) Low blood lead levels associated with clinically diagnosed attention-deficit/hyperactivity disorder and mediated by weak cognitive control. Biol Psychiatry 63:325–331

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  31. Nigg JT, Nikolas M, Mark Knottnerus G, Cavanagh K, Friderici K (2010) Confirmation and extension of association of blood lead with attention-deficit/hyperactivity disorder (ADHD) and ADHD symptom domains at population-typical exposure levels. J Child Psychol Psychiatry 51:58–65

    Article  PubMed Central  PubMed  Google Scholar 

  32. Nomura Y, Marks DJ, Grossman B, Yoon M, Loudon H, Stone J, Halperin JM (2012) Exposure to gestational diabetes mellitus and low socioeconomic status: effects on neurocognitive development and risk of attention-deficit/hyperactivity disorder in offspring. Arch Pediatr Adolesc Med 166:337–343

    Article  PubMed  Google Scholar 

  33. Nomura Y, Marks DJ, Halperin JM (2010) Prenatal exposure to maternal and paternal smoking on attention deficit hyperactivity disorders symptoms and diagnosis in offspring. J Nerv Ment Dis 198:672–678

    Article  PubMed Central  PubMed  Google Scholar 

  34. Oh KJ, Lee HR (1990) Development of Korean version of child behavior checklist (K-CBCL). Korean Research Foundation Report, Seoul

  35. Park KS, Yoon JY, Park HJ, Park HJ, Kwon KU (1996) Development of KEDI-WISC, individual intelligence test for Korean children. Korean Educational Development Institute, Seoul

    Google Scholar 

  36. Pheula GF, Rohde LA, Schmitz M (2011) Are family variables associated with ADHD, inattentive type? A case-control study in schools. Eur Child Adolesc Psychiatry 20:137–145

    Article  PubMed  Google Scholar 

  37. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164:942–948

    Article  PubMed  Google Scholar 

  38. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME (2000) NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry 39:28–38

    Article  CAS  PubMed  Google Scholar 

  39. Shin MS, Hong KE, Kim ZS, Cho SC (1998) A standardization study of the Korean version of Learning Disability Evaluation Scale. J Korean Neuropsychiatr Assoc 37:1233–1245

    Google Scholar 

  40. Shin MS, Park MJ (2007) STROOP: Color and word test children’s version for ages 5–14. Hakjisa, Seoul

    Google Scholar 

  41. So YK, Noh JS, Kim YS, Ko SG, Koh YJ (2002) The reliability and validity of Korean parent and teacher ADHD rating scale. J Korean Neuropsychiatr Assoc 41:283–289

    Google Scholar 

  42. Stewart PW, Sargent DM, Reihman J, Gump BB, Lonky E, Darvill T, Hicks H, Pagano J (2006) Response inhibition during Differential Reinforcement of Low Rates (DRL) schedules may be sensitive to low-level polychlorinated biphenyl, methylmercury, and lead exposure in children. Environ Health Perspect 114:1923–1929

    CAS  PubMed Central  PubMed  Google Scholar 

  43. Taylor SJ, Barker LA, Heavey L, McHale S (2013) The typical developmental trajectory of social and executive functions in late adolescence and early adulthood. Dev Psychol 49:1253–1265

    Article  PubMed  Google Scholar 

  44. Thapar A, Cooper M, Eyre O, Langley K (2013) What have we learnt about the causes of ADHD? J Child Psychol Psychiatry 54:3–16

    Article  PubMed Central  PubMed  Google Scholar 

  45. Trent S, Davies W (2012) The influence of sex-linked genetic mechanisms on attention and impulsivity. Biol Psychol 89:1–13

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported by a grant (091-081-059) from the Korean Ministry of Environment (Eco-Technopia 21 Project). Prof Soon-Beom Hong was supported by a National Research Foundation of Korea (NRF) grant (Global Internship Program) funded by the Korean government (MEST). Prof Christos Pantelis was supported by a NHMRC Senior Principal Research Fellowship (ID: 628386), NARSAD Distinguished Investigator Award, and Australian NHMRC Program Grant (ID: 566529); Dominic Dwyer was also supported by the NHMRC Program Grant (ID: 566529). The funders had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Author information

Authors and Affiliations

  1. Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne and Melbourne Health, Parkville, VIC, Australia

    Soon-Beom Hong, Dominic Dwyer & Christos Pantelis

  2. Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia

    Soon-Beom Hong & Christos Pantelis

  3. Division of Child and Adolescent Psychiatry, Department of Psychiatry, Seoul National University College of Medicine, 101 Daehak-No, Chongno-Gu, Seoul, Republic of Korea

    Soon-Beom Hong, Jae-Won Kim, Min-Sup Shin, Boong-Nyun Kim, Hee-Jeong Yoo & Soo-Churl Cho

  4. Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea

    Eun-Jin Park

  5. Department of Psychiatry, Gil Medical Center, Gachon University of Medicine and Science, Incheon, Republic of Korea

    In-Hee Cho

  6. Department of Psychiatry, Gangnam Eulji Hospital, Eulji University, Seoul, Republic of Korea

    Soo-Young Bhang

  7. Department of Preventive Medicine, Institute of Environmental Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea

    Yun-Chul Hong

Authors
  1. Soon-Beom Hong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dominic Dwyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jae-Won Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eun-Jin Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Min-Sup Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Boong-Nyun Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hee-Jeong Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. In-Hee Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Soo-Young Bhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Yun-Chul Hong
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Christos Pantelis
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Soo-Churl Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Soo-Churl Cho.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 17 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hong, SB., Dwyer, D., Kim, JW. et al. Subthreshold attention-deficit/hyperactivity disorder is associated with functional impairments across domains: a comprehensive analysis in a large-scale community study. Eur Child Adolesc Psychiatry 23, 627–636 (2014). https://doi.org/10.1007/s00787-013-0501-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00787-013-0501-z

Keywords

Search

Navigation