How much impairment is required for ADHD? No evidence of a discrete threshold

Trine Wigh Arildskov; Edmund J.S. Sonuga-Barke; Per Hove Thomsen; Anne Virring; Søren D. Østergaard

doi:10.1111/jcpp.13440

How much impairment is required for ADHD? No evidence of a discrete threshold

Trine Wigh Arildskov^*, Edmund J.S. Sonuga-Barke, Per Hove Thomsen, Anne Virring, Søren D. Østergaard

^*Corresponding author for this work

Child & Adolescent Psychiatry

Research output: Contribution to journal › Article › peer-review

12 Citations (Scopus)

Abstract

Background: A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires the presence of impairment alongside symptoms above a specific frequency and severity threshold. However, the question of whether that symptom threshold represents anything more than an arbitrary cutoff on a continuum of impairment requires further empirical study. Therefore, we present the first study investigating if the relationship between ADHD symptom severity and functional impairment is nonlinear in a way that suggests a discrete, nonarbitrary symptom level threshold associated with a marked step increase in impairment. Methods: Parent reports on the ADHD-Rating Scale (ADHD-RS-IV), the Weiss Functional Impairment Rating Scale (WFIRS-P), and the Strengths and Difficulties Questionnaire were collected in a general population sample of 1st, 2nd, and 3rd graders (N = 1,914–2,044). Results: Piecewise linear regression analyses and nonlinear regression modeling both demonstrated that the relationship between symptom severity (ADHD-RS-IV total score) and impairment (WFIRS-P mean score) was characterized by a gradual linear increase in impairment with higher symptom severity and no apparent step increase or changing rate of increase in impairment at a certain high ADHD-RS-IV total score level. Controlling for socioeconomic status, sex, and co-occurring conduct and emotional symptoms did not alter these results, though comorbid symptoms had a significant effect on impairment. Conclusions: There was no clear evidence for a discrete, nonarbitrary symptom severity threshold with regard to impairment. The results highlight the continued need to consider both symptoms and impairment in the diagnosis of ADHD.

Original language	English
Journal	Journal of Child Psychology and Psychiatry and Allied Disciplines
Volume	63
Issue number	2
Early online date	27 May 2021
DOIs	https://doi.org/10.1111/jcpp.13440
Publication status	E-pub ahead of print - 27 May 2021

Keywords

Attention-deficit/hyperactivity disorder
continuity
diagnosis
schoolchildren
symptomatology

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1111/jcpp.13440

Cite this

@article{dfd8fa91350a4e30893ac530d837a52e,

title = "How much impairment is required for ADHD? No evidence of a discrete threshold",

abstract = "Background: A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires the presence of impairment alongside symptoms above a specific frequency and severity threshold. However, the question of whether that symptom threshold represents anything more than an arbitrary cutoff on a continuum of impairment requires further empirical study. Therefore, we present the first study investigating if the relationship between ADHD symptom severity and functional impairment is nonlinear in a way that suggests a discrete, nonarbitrary symptom level threshold associated with a marked step increase in impairment. Methods: Parent reports on the ADHD-Rating Scale (ADHD-RS-IV), the Weiss Functional Impairment Rating Scale (WFIRS-P), and the Strengths and Difficulties Questionnaire were collected in a general population sample of 1st, 2nd, and 3rd graders (N = 1,914–2,044). Results: Piecewise linear regression analyses and nonlinear regression modeling both demonstrated that the relationship between symptom severity (ADHD-RS-IV total score) and impairment (WFIRS-P mean score) was characterized by a gradual linear increase in impairment with higher symptom severity and no apparent step increase or changing rate of increase in impairment at a certain high ADHD-RS-IV total score level. Controlling for socioeconomic status, sex, and co-occurring conduct and emotional symptoms did not alter these results, though comorbid symptoms had a significant effect on impairment. Conclusions: There was no clear evidence for a discrete, nonarbitrary symptom severity threshold with regard to impairment. The results highlight the continued need to consider both symptoms and impairment in the diagnosis of ADHD.",

keywords = "Attention-deficit/hyperactivity disorder, continuity, diagnosis, schoolchildren, symptomatology",

author = "Arildskov, {Trine Wigh} and Sonuga-Barke, {Edmund J.S.} and Thomsen, {Per Hove} and Anne Virring and {\O}stergaard, {S{\o}ren D.}",

note = "Funding Information: The project was funded by the Novo Nordisk Foundation (NNF15OC0017706); the Lundbeck Foundation (R208‐2015‐3329); the A.P. M{\o}ller Foundation for the Advancement of Medical Science (15‐15); the Research Foundation for the Center for Child and Adolescent Psychiatry, Central Denmark Region (BUC16‐TWA, BUC17‐TWA); the Riisfort Foundation (no grant number); the Psychiatric Research Foundation for the Central Denmark Region (no grant number); the Graduate School of Health at Aarhus University (no grant number); and the Br{\o}drene Hartmanns Foundation (R69‐A28284‐B23205). The funders had no involvement in the design of the study; the data collection; the statistical analyses and interpretation of the results; or the writing and approval of and the decision to submit the manuscript for publication. Publisher Copyright: {\textcopyright} 2021 Association for Child and Adolescent Mental Health. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

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doi = "10.1111/jcpp.13440",

language = "English",

volume = "63",

journal = "Journal of child psychology and psychiatry",

issn = "0021-9630",

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T1 - How much impairment is required for ADHD? No evidence of a discrete threshold

AU - Arildskov, Trine Wigh

AU - Sonuga-Barke, Edmund J.S.

AU - Thomsen, Per Hove

AU - Virring, Anne

AU - Østergaard, Søren D.

N1 - Funding Information: The project was funded by the Novo Nordisk Foundation (NNF15OC0017706); the Lundbeck Foundation (R208‐2015‐3329); the A.P. Møller Foundation for the Advancement of Medical Science (15‐15); the Research Foundation for the Center for Child and Adolescent Psychiatry, Central Denmark Region (BUC16‐TWA, BUC17‐TWA); the Riisfort Foundation (no grant number); the Psychiatric Research Foundation for the Central Denmark Region (no grant number); the Graduate School of Health at Aarhus University (no grant number); and the Brødrene Hartmanns Foundation (R69‐A28284‐B23205). The funders had no involvement in the design of the study; the data collection; the statistical analyses and interpretation of the results; or the writing and approval of and the decision to submit the manuscript for publication. Publisher Copyright: © 2021 Association for Child and Adolescent Mental Health. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/5/27

Y1 - 2021/5/27

N2 - Background: A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires the presence of impairment alongside symptoms above a specific frequency and severity threshold. However, the question of whether that symptom threshold represents anything more than an arbitrary cutoff on a continuum of impairment requires further empirical study. Therefore, we present the first study investigating if the relationship between ADHD symptom severity and functional impairment is nonlinear in a way that suggests a discrete, nonarbitrary symptom level threshold associated with a marked step increase in impairment. Methods: Parent reports on the ADHD-Rating Scale (ADHD-RS-IV), the Weiss Functional Impairment Rating Scale (WFIRS-P), and the Strengths and Difficulties Questionnaire were collected in a general population sample of 1st, 2nd, and 3rd graders (N = 1,914–2,044). Results: Piecewise linear regression analyses and nonlinear regression modeling both demonstrated that the relationship between symptom severity (ADHD-RS-IV total score) and impairment (WFIRS-P mean score) was characterized by a gradual linear increase in impairment with higher symptom severity and no apparent step increase or changing rate of increase in impairment at a certain high ADHD-RS-IV total score level. Controlling for socioeconomic status, sex, and co-occurring conduct and emotional symptoms did not alter these results, though comorbid symptoms had a significant effect on impairment. Conclusions: There was no clear evidence for a discrete, nonarbitrary symptom severity threshold with regard to impairment. The results highlight the continued need to consider both symptoms and impairment in the diagnosis of ADHD.

AB - Background: A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires the presence of impairment alongside symptoms above a specific frequency and severity threshold. However, the question of whether that symptom threshold represents anything more than an arbitrary cutoff on a continuum of impairment requires further empirical study. Therefore, we present the first study investigating if the relationship between ADHD symptom severity and functional impairment is nonlinear in a way that suggests a discrete, nonarbitrary symptom level threshold associated with a marked step increase in impairment. Methods: Parent reports on the ADHD-Rating Scale (ADHD-RS-IV), the Weiss Functional Impairment Rating Scale (WFIRS-P), and the Strengths and Difficulties Questionnaire were collected in a general population sample of 1st, 2nd, and 3rd graders (N = 1,914–2,044). Results: Piecewise linear regression analyses and nonlinear regression modeling both demonstrated that the relationship between symptom severity (ADHD-RS-IV total score) and impairment (WFIRS-P mean score) was characterized by a gradual linear increase in impairment with higher symptom severity and no apparent step increase or changing rate of increase in impairment at a certain high ADHD-RS-IV total score level. Controlling for socioeconomic status, sex, and co-occurring conduct and emotional symptoms did not alter these results, though comorbid symptoms had a significant effect on impairment. Conclusions: There was no clear evidence for a discrete, nonarbitrary symptom severity threshold with regard to impairment. The results highlight the continued need to consider both symptoms and impairment in the diagnosis of ADHD.

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KW - schoolchildren

KW - symptomatology

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JO - Journal of child psychology and psychiatry

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ER -

How much impairment is required for ADHD? No evidence of a discrete threshold

Abstract

Keywords

UN SDGs

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