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Mark Wolraich, MD, CMRI/Shaun Walters Professor of Pediatrics, OUHSC, OU Child Study Center, 1100 N.E. 13th Street, Oklahoma City, OK 73117, (405) 271-6824 x45123, Mark-Wolraich@ouhsc.edu
In a study of 243 children diagnosed or at-risk for ADHD, inter-rater reliability was low between parent and teacher reports of behaviors using DSM-IV based questionnaires: inattentive (r = .34, k = .27), hyperactive/impulsive (r = .27, k = .22), and performance impairment (r = .31, k = .07). When the two-setting requirement was strictly enforced, poor agreement lowered diagnostic rates for all three types of ADHD in this clinical sample: Inattentive (15% to 5%); Hyperactive/Impulsive (11% to 3%), and Combined (23% to 7%).
Prevalence studies report ADHD rates that vary as much as 8%. Therefore, it is difficult to determine whether a lower or higher rate is more accurate. Parent-teacher discrepancies do not necessarily mean that either reporter is inaccurate. While each rater may be reasonably reliable, they observe the child in distinct situations and communicate only occasionally. Therefore, low agreement may be the rule rather than the exception.
The current DSM-IV requirement for impairment in multiple settings sets parent-teacher agreement as a de facto requirement for ADHD diagnosis, despite the fact that agreement is low. As illustrated by this analysis, if a two-setting requirement is enforced strictly inter-rater disagreement may underestimate prevalence rates. Strict use of the impairment requirement, but more lenient symptom cut scores for cases with inter-rater disagreement, may better reflect the prevalence.
Since parent-teacher information is often inconsistent, clear guidelines are needed for dealing with these inconsistencies. Further, various components of the DSM-IV diagnostic criteria require more in depth inspection and further research is necessary.
Learning Objectives:
Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.