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Attention Deficit Hyperactivity Disorder symptoms reporting in Malaysian adolescents: Do adolescents, parents and teachers agree with each other?
Asian Journal of Psychiatry 6 (2013) 483–487
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Attention Deficit Hyperactivity Disorder symptoms reporting in Malaysian adolescents: Do adolescents, parents and teachers agree with each other? Wan Salwina Wan Ismaila,*, Azlin Baharudin b, Nik Ruzyanei Nik Jaafarb, Marhani Midin b, Fairuz Nazri Abdul Rahman b a
Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia b Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Malaysia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 February 2012 Received in revised form 10 May 2013 Accepted 12 May 2013
Attention Deficit Hyperactivity Disorder (ADHD) is a clinical diagnosis relying on persistence of symptoms across different settings. Information are gathered from different informants including adolescents, parents and teachers. In this cross-sectional study involving 410 twelve-year old adolescents, 37 teachers and 367 parents from seven schools in the Federal Territory of Kuala Lumpur, reliability of ADHD symptoms among the various informants were reported. ADHD symptoms (i.e. predominantly hyperactive, predominantly inattentive and combined symptoms) were assessed by adolescents, teachers and parents, using Conners-Wells’ Adolescent Self-report Scale (CASS), Conner’s Teachers Rating Scale (CTRS) and Conner’s Parents Rating Scale (CPRS) respectively. For predominantly hyperactive symptoms, there were statistically significant, weak positive correlations between parents and teachers reporting (r = 0.241, p < 0.01). Statistically significant, weak positive correlations were found between adolescents and parents for predominantly inattentive symptoms (r = 0.283, p < 0.01). Correlations between adolescents and parents reporting were statistically significant but weak (r = 0.294, p < 0.01). Weak correlations exist between the different informants reporting ADHD symptoms among Malaysian adolescents. While multiple informant ratings are required to facilitate the diagnosis of ADHD, effort should be taken to minimize the disagreement in reporting and better utilize the information. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Reliability ADHD symptoms reporting Malaysian adolescents
1. Introduction Attention Deficit Hyperactivity Disorder (ADHD) is among the most common psychiatric disorders seen worldwide as well as in Malaysia. The worldwide-pooled prevalence of ADHD was reported as 5.29% (Polanczyk et al., 2007). A study on Malaysian children reported a prevalence of inattention between 9% and 12.5% (Woo and Teoh, 2007). Another study on primary school children in Malaysia found a prevalence rate of 1.61% with the inattention subtype being the most common (0.96%), followed by hyperactive-impulsive (0.32%) and combined subtypes (0.32%) (Gomez and Hafetz, 2011). According to the Clinical Practice Guideline (Ministry of Health Malaysia, 2008), diagnosis of ADHD requires a comprehensive assessment involving parents or care-givers, teachers (Mitsis et al.,
* Corresponding author. Tel.: +60 3 91456158; fax: +60 3 91737841. E-mail address: [email protected] (W.I. Wan Salwina). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.05.001
2000) and clinical observation to determine symptoms. The Diagnostic Statistical Manual of Mental Disorders (DSM) criteria, require evidence of symptoms before the age of seven years and persistence of symptoms across different settings before diagnosis of ADHD can be established (DSM-IVTR; APA, 2000). Self-reported questionnaires reporting ADHD symptoms by different informants such as parents, teachers and adolescents themselves are commonly used to complement clinical observation. While these provide comprehensive assessment, previous studies have shown poor agreement between multiple informants (Collet et al., 2003; Coutinho et al., 2009; Frazier and Youngstrom, 2006; Gau et al., 2010; Kaner, 2011; Papageorgiou et al., 2008; Tripp et al., 2006), creating difficulties as there were no measures to blend the information together. Self-reported questionnaire is a measure of perception. Selfreported findings of ADHD symptoms among adolescents are perceptions of the symptoms from his or her own perspectives. Similarly, parents and teachers report ADHD symptoms as they perceive from their unique perspectives (Smith, 2007). Perception
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is subjective and readily influenced by various factors in the informants i.e. adolescents, parents, and teachers, as well as factors in the illness and the environment itself. Hence, the discrepancies seen in the different ratings by the different informants. ADHD symptoms change across the different stages of development (Barkley, 2005). In the young children, symptoms of hyperactivity may be more prominent compared to inattention, which are more commonly seen in the adolescents (Wolraich et al., 2005). This is further complicated by the different subtypes of ADHD, manifesting different symptoms domains such as predominantly hyperactive, predominantly inattentive and combined symptoms. Interestingly, symptoms of ADHD may also change with the different situations (Van Der Oord et al., 2006) and consequently lead to different behaviors observed and reported. For instance, in a less restrictive and demanding environment, symptoms may not be easily apparent (Barkley, 2005). As symptoms manifest at different levels of severity, the milder symptoms can go unnoticed compared with the moderate to severe symptoms that are readily observable. There were higher agreements between informants when domains of symptoms being rated are more observable (Langberg et al., 2010). Likewise, ADHD symptoms described by parents and teachers are evaluations of their perceptions of the adolescents’ behavior across different settings. These perceptions are based on their familiarity with the behavior and the specific situations where the behavior were observed (De Los Reyes and Kazdin, 2005) and their own psychological state. Parenting stress (Youngstrom et al., 2000; Van Der Oord et al., 2006) and depression (Youngstrom et al., 2000) were found to contribute to the lower agreement in reporting ADHD symptoms, particularly inattentive dimensions (Van Der Oord et al., 2006). On a different vein, parents and teachers tend to report more ADHD symptoms among adolescents with poor school achievement (Pierrehumbert et al., 2006). Likewise, adolescents with ADHD symptoms are more likely to experience academic difficulties (Birchwood and Daley, 2012). However, similar trend in reporting was not seen among children and adolescents (Pierrehumbert et al., 2006) thus contributing to the discrepancies between the informants. Interpretation of observed ADHD behavior is influenced by cultural and ethnic background (Moon, 2011). The cultural diversity and language plurality in Malaysian society further complicate the process of reporting and affect the reliability accordingly. Previous findings of poor agreement between different informants’ report were mainly from the western samples (Collet et al., 2003; Coutinho et al., 2009; Frazier and Youngstrom, 2006; Papageorgiou et al., 2008; Tripp et al., 2006), with less language and cultural diversity. It is therefore interesting to explore this issue in the local setting. To our knowledge, there has been no local study that examines the reliability of ADHD symptoms reporting by the different informants. This study aimed to examine the reliability between adolescent, parents and teachers report of the ADHD symptoms in adolescents.
study. In the final phase, a total of 410 twelve year old adolescents were recruited to participate in the study. In addition, 37 teachers and 367 parents also participated in this study. Teachers with the most contact hours with the participating students were selected to participate. Teacher: adolescent ratio was 1:11. Only one parent that knew the adolescent the best was required to participate. Active consent was obtained from the adolescents, their parents and teachers. Adolescents with poor command of language and mental retardation were excluded from this study. 2.2. Measurement instruments Conners Wells Adolescent Self-report Scale: Short (CASS:S), Conners Parent Rating Scale: Short(CPRS:S) and Conners Teacher Rating Scale: Short(CTRS:S) were used in this study. Items in the questionnaires were rated according to the behavior that occurred in the past month as observed by the adolescents (CASS: S), their parents (CPRS:S) and teachers(CTRS:S) accordingly. The CASS:S and CPRS:S consist of 27 items whereas the (CTRS:S) has 28 items (Conners, 2001). The translated version of Conners Rating Scales (CRS) in the local language i.e. Bahasa Malaysia were used in this study. The translations were done by a team of four psychiatrists including three of the authors. Two members of the team front translated the questionnaires while another two members back translated them. Two front and two back translations were carried out for each of the questionnaires. After the translations, the team met to discuss the pre-final versions and made appropriate amendments, taking into consideration the meaning of the contents within the cultural context. The pre-final versions were tested on a group of convenient samples and further changes were made based on the feedback obtained. These versions were finally sent to the Multi-Health Systems revision board, for final revision and approval before their use in this study. The CRS are diagnostic tools for assessment of ADHD in children and adolescents. In practice, diagnosis of ADHD remains a clinical diagnosis while the use of instruments was not recommended (CPG, 2008). For the purpose of this study, only three subscales of CRS i.e. combined; hyperactive and inattentive were included, while oppositional subscale was not considered in the analysis. Furthermore, the T-scores which were the cut-off scores that separate the clinical and non-clinical sample were not used. This was because the T-scores were not developed for the local population. Instead, the raw scores were used, whereby higher scores indicate higher ADHD symptoms while lower scores reflect lower ADHD symptoms. Therefore, ADHD symptoms rather than the illness were examined in this study. 2.3. Study implementation Adolescents completed the self-reported questionnaires during the given period in their respective schools. They were not allowed to discuss their responses. Teachers and parents were given two weeks to complete the questionnaires at their own leisure time.
2. Methods
2.4. Statistical analysis
2.1. Sampling
Statistical Package for Social Studies (SPSS) version 13 was used to analyze the data. Q–Q–Q plot and Kolmogorov–Smirnov test were used to test for normality of the continous data such as ADHD symptoms and parents’ age. Intraclass correlation was used to examine correlations between ADHD symptoms as reported by the different informants. Chi-square was used to examine differences between adolescent with and without parents’ report for sociodemographic profiles. Mann–whitney test was used to examine ADHD symptoms reported by adolescents and teachers, between adolescents with and without parents report.
This is part of a cross-sectional study on ADHD and bullying, Wan Ismail et al. (2010) whereby a pattern of agreement and reliability between parents, teachers and adolescents in reporting ADHD symptoms were examined. A total of 826 adolescents from seven randomly selected schools in Kuala Lumpur were approached to take part in this study. 198 adolescents failed to return the consent forms, 183 adolescents did not consent while another 35 adolescents were absent, and thus excluded from the
W.I. Wan Salwina et al. / Asian Journal of Psychiatry 6 (2013) 483–487 Table 2 Socio demographic profiles of adolescents with and without parents’ reports.
3. Results The sociodemographic profiles of the adolescents participating in this study were shown in Table 1. The study sample was overpopulated by Malays (76%), followed by Indians (13.7%), Chinese (6.8%) and other ethnic group (2.7%). There were more girls (51.2%) compared to boys (48.8%). Majority of the adolescents were girls (51.2%), had five or less siblings (81%) and had poor academic performance (65%). Most of the parents were young, aged 45 years old and below. 58.2% of the participating fathers and 82.5% of the mothers were below 46 years old at the time of study. Generally, the parents had low educational level as highlighted by the majority of fathers (86.8%) and mothers (86.8%) without tertiary educations. Most parents were married (93%) and spent ten hours or less time with their children in a day (56.5%). Of the 367 parents who participated in the study, 43 parents (10.5%) failed to complete and return the parents’ report. Adolescents with and without parents’ report were analyzed in terms of the socio-demographic variables. There were no significant different between the groups except for sex. There were significantly more boys than girls in the group without parents’ reports. (Table 2) ADHD symptoms reported by adolescents and teachers, with and without parents’ reports were shown in Table 3. There were significant difference in ADHD (combined) symptoms reported by teachers, between adolescents with and without parents’ report (Table 3). Spearman correlation coefficient was used to examine the relationship between ADHD symptoms (predominantly hyperactive, inattentive and combined) reported by the different informants (i.e. adolescents, teachers and parents) (Table 4). In general, ADHD symptoms rated by the different informants showed weak correlations. ADHD (hyperactive) symptoms rated by teachers and parents (r = 0.283, p < 0.01) and ADHD (combined)
Variables
Table 1 Socio demographic profiles of adolescents participating in the study. Adolescents profile (n = 410)
Parents profile (n = 367) Father’s age 45 years >45 years Mother’s age 45 years >45 years Father’s educational level No tertiary education With tertiary education Mother’s tertiary educational level No tertiary education With tertiary education Marital status Married Divorced/Others Amount of time spent with children 10 hours >10 hours
315(76%) 28(6.8%) 56(13.7% 11(2.7%) 200(48.8%) 210(51.2%) 326(81%) 77(19%) 246(65%) 132(35%)
192(58.2%) 138(41.8%) 282(82.5%) 60(17.5%) 290(86.8%) 44(13.2%) 303(86.8%) 46(13.2%) 330(93%) 25(7%) 181(56.6%) 139(43.4%)
Without report
Sex 30(15%) Boys Girls 13(6.2%) Ethnic groups Malay 38(12.1%) Chinese 2(7.1%) Indian 2(3.6%) 1(9.1%) Others Academic performance Poor 25(10.2%) Good 11(8.3%) Number of siblings 0–5 29(8.9%) >= 6 12(15.6%) a b *
With report
Chi-square
Significance level
170(85%) 197(93.8%)
8.468a
p < 0.01*
277(87.9%) 26(92.9%) 54(96.4%) 10(90.9%)
3.898b
p = 0.25
221(89.8%) 121(91.7%)
0.334a
p = 0.56
297(91.1%) 65(84.4%)
3.049a
p = 0.08
Pearson Chi-square. Fischer Exact Test. p < 0.05.
Table 3 ADHD symptoms as reported by adolescents and teachers in adolescents with and without parents’ reports. Without report
With report
Median score (25–75th percentiles) ADHD symptoms reported by adolescents Combined 11 (7–16) 10 (7–14) Hyperactive 6 (4.5–9) 7 (5–9) Inattentive 6 (5–5) 5 (0–4) ADHD symptoms reported by teachers Combined 4 (0.5–13) 2 (0–8) Hyperactive 1 (0–5) 0 (0–3) Inattentive 2 (0–4) 2 (0–4) *
Ethnicity Malay Chinese Indian Others Sex Boys Girls Number of siblings 0–5 6 Academic performance Poor Good
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Mann–whitney test
p value
z value
0.768 0.403 0.380
p = 0.44 p = 0.69 p = 0.70
2.331 1.874 0.097
p = 0.02* p = 0.06 p = 0.92
p < 0.05
symptoms rated by adolescents and parents (r = 0.294, p < 0.01) showed weak but significant correlations. Similarly, ADHD (inattentive) symptoms rated by adolescents and parents (r = 0.283, p < 0.01), and ADHD (inattentive) symptoms rated by teachers and parents (r = 0.294, p < 0.01) were found to have weak but significant correlations respectively. 4. Discussions In this study, 10.5% parents did not return parents report. These involved 15% adolescent boys and 6.2% adolescent girls who participated in the study. Given the fact that ADHD is more prevalent in boys (Marte´nyi et al., 2010; Rutter and Taylor, 2002), this may significantly affect the findings, leading to poor agreement in teachers and parents report. Despite that, there were no significant differences between adolescents with and without parents’ reports in terms of ADHD symptoms reporting except for combined symptoms. Teachers significantly rated adolescents without parents report to have more ADHD symptoms (combined), as evidenced by the higher median scores (z = 2.331, p = 0.02). Different informants perceive ADHD symptoms differently, which reflect their different perspectives in reporting, consequently resulting in poor agreement between them. The level of agreement between informants cannot be simply attributed to the poor inter-rater reliability (Youngstrom et al., 2000). In fact, interaction between multiple demographic and psychological factors are equally important in influencing the agreement at the different levels (Youngstrom et al., 2000). This study found significant but poor correlations between the different informants in reporting ADHD symptoms. These are in
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Table 4 Reliability of ADHD symptoms between adolescents, teachers and parents report. ADHD symptoms reported by different informants Predominantly hyperactive Adolescents & teachers Adolescents & parents Teachers & parents Predominantly inattentive Adolescents & teachers Adolescents & parents Teachers & parents Combined Adolescents & teachers Adolescents & parents Teachers & parents *
Intraclass correlations
Significance level
r = 0.301 r = 0.182 r = 0.241
p = 1.00 p = 1.00 p < 0.01*
r = 0.006 r = 0.283 r = 0.107
p = 0.45 p < 0.01* p = 0.03*
r = 0.037 r = 0.294 r = 0.093
p = 0.77 p < 0.01* p = 0.05
p < 0.05
keeping with previous findings of generally low or non-significant correlations between adolescents, teachers and parents rating of ADHD symptoms (Conners, 2001; Kaner, 2011; Mitsis et al., 2000; Tripp et al., 2006). For example, correlations between parents and teachers rating of ADHD symptoms, using Conners Rating Scales ranged from 0.34 to 0.52 for the three different subscales of ADHD (Conners, 2001). Teachers and parents had significant poor agreement in reporting predominantly hyperactive (r = 0.241, p < 0.01) and inattentive (r = 0.107, p = 0.03) symptoms. This is not surprising as the behavior can be situation specific. Teachers and parents observe different ADHD behavior in the different settings (Hartman et al., 2007). Adolescents with ADHD are more likely to have problems in formal settings where more demanding tasks are required of them (Barkley, 2005). On the other hand, hyperactivity symptoms were more readily observed compared to inattentive symptoms (Weckerly et al., 2005) thus, more readily reported. Studies measuring inter-rater reliability of assessment of symptoms had found better teacher-parent agreement for externalizing behavior such as hyperactivity symptoms compared to internalizing behavior such as inattentive symptoms (Faraone et al., 1995; Verhulst and Van Der Ende, 1991). In a standard Malaysian classroom setting, a class teacher is responsible for approximately 30–40 students. The teacher needs to be observant to be aware of ADHD symptoms among their students, particularly when they had to rate more than one student. In such circumstance, a parent is expected to be better able to detect ADHD symptoms in his or her child, having to observe only one child. Such factor can influence their reporting leading to the discrepancies between the two raters. Adolescents and parents showed similar weak, positive correlations (r = 0.283, p < 0.01) for predominantly inattentive symptoms. One limitation of self-reported questionnaire is the bias in reporting. In Malaysian culture whereby expressions of negative feelings and behavior are generally discouraged, adolescents may minimize their symptoms resulting in the poor correlations. Nevertheless, the heterogeneity of Malaysian culture allows considerable variations with regards to self expression in the different ethnic groups. Cultural differences in the perception and interpretations of the symptoms can contribute significantly to the lower informant-agreement. Language diversities in Malaysian multiracial society may similarly contribute to the lower agreement between informants. Despite Bahasa Malaysia being the official language of Malaysia, it is not the first language for the non-Malays. Hence, it may potentially limit their ability in understanding and interpreting the Bahasa Malaysia versions of the questionnaires. The ability of the adolescents as skilled reporters of their own experience have also been questioned (Weckerly et al., 2005) since
those with ADHD has tendencies to underreport their symptoms (Owens et al., 2007; Wolraich et al., 2005). In addition, parents and adolescents may have different concerns with regards to the problem they have, thus their reporting will reflect the areas of concerns resulting in disagreement in reporting (Kashani et al., 1985). Conners rating scales were also found to have low or nonsignificant correlations for teachers and adolescents report with exception to moderate correlations found for cognitive problems/ inattention subscale (Conners, 2001). Low agreement between adolescents and teachers concerning AHD symptoms using DSMIV criteria had also been observed (Wolraich et al., 2005). In contrast, this study found no significant correlations in all subtypes of ADHD symptoms for adolescents and teachers reports. Teachers and parents see similar behavior with regards to structured activities that commonly occur in the school but less frequently in the home setting. However, teachers are at a disadvantage as they lack opportunity to observe behavior that are unique to home environment which are experienced by the adolescents and observed by parents. This may explain the significant disagreement between teachers and adolescents reports in all subtypes of ADHD symptoms. In a Brazilian study, teachers reported less ADHD symptoms compared to parents for both hyperactivity and inattentive symptoms (Coutinho et al., 2009). On a different token, teachers report higher ADHD symptoms among adolescents with poor school performance (Pierrehumbert et al., 2006), who comprise the majority in this study sample. The fact that similar pattern of reporting was not seen in the adolescents (Pierrehumbert et al., 2006) may result in the poor agreement between teachers and adolescents reporting. ADHD symptoms reported are based on the informants’ reporting skills and their own interpretation of what were observed. Such interpretation is influenced by their own cultural upbringing (Moon, 2011). Poor conceptualization of the illness may lead to different interpretation of behavior and minimization of the symptoms. For instance, an adolescent who is inattentive, easily distractible and performs poorly in school may be perceived as ‘lazy’ rather than having ADHD symptoms. 86.8% of parents who participated in this study had no tertiary education. This may reflect their level of understanding of the illness and significantly affect the symptoms reporting. Caregivers’ educational level had been found to significantly affect the endorsement of inattentive symptoms but not hyperactive symptoms (Weckerly et al., 2005). Previous studies have shown that parental depression is a factor affecting the reporting of ADHD symptoms (Chi and Hinshaw, 2002; Youngstrom et al., 2000) and executive functioning in ADHD (Joyner et al., 2009) among adolescents. Depression–distortion phenomenon in a depressed mother led her to perceive the child as being more hyperactive and inattentive, thus providing a negative bias in her reporting of ADHD symptoms (Chi and Hinshaw, 2002). Another study found parental stress but not depression to significantly affect the reporting of ADHD symptoms (Van Der Oord et al., 2006). Parental disagreement on rating of ADHD symptoms potentially affect the diagnosis given. Mothers were found to evaluate higher levels of ADHD symptoms compared to fathers (Langberg et al., 2010). On the other hand, fathers tend to identify with the boys and perceive externalizing behaviors as part of childhood (Singh, 2003). In this study, the perspective of only one parent, either father or mother was taken into consideration. Multiple informants reporting are commonly used to facilitate the assessment of ADHD in Malaysia but no study had looked into the problem arising from its use. While multiple informant reports are useful in providing information observed by different informants in different settings, sources of the disagreement should be considered with caution. ADHD subtypes, manifestation
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of symptoms in the different settings, and reporting skills of the different informants as well as depression in the parents contribute accordingly. Measures need to be taken on how to blend the information together to best facilitate the assessment of ADHD in the adolescents. This study has few limitations. Firstly, only one parent was involved whereby a more accurate result may be found should both parents reporting were taken. Secondly, adolescent: teacher ratio was high which may lead to inaccuracy of reporting. Thirdly, 10.5% parent failed to return their reports, which may significantly influence the results. Finally, a bigger sample that better generalizes Malaysian adolescents may give more accurate findings. In conclusion, agreement between different informants in reporting of ADHD symptoms was poor. Factors contributing to the poor agreement between informants should be carefully understood in order to best utilize the information together and make accurate diagnosis. References American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders-IV Text Revised. Author, Washington, DC. Barkley, R., 2005. Taking charge of ADHD, revised ed. The Guilford Press, New York/ London. Birchwood, J., Daley, D., 2012. Brief report: the impact of Attention Deficit Hyperactivity Disorder (ADHD) symptoms on academic performance in an adolescent community sample. Journal of Adolescence 35, 225–231. Conners, C.K., 2001. Conners’ Rating Scales-Revised(CSR-R). Technical Manual. Multi-Health Systems Inc.. Chi, T.C., Hinshaw, S.P., 2002. Mother–child relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions. Journal of Abnormal Child Psychology 30 (4) 387–400. Collet, B.R., Ohan, J.L., Myers, K.M., 2003. Ten-year review of rating scales. V: scales assessing Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 42 (4) 1015–1037. Coutinho, G., Mattos, P., Schmitz, M., Fortes, D., Borges, M., 2009. Agreement rates between parents’ and teachers’ reports on ADHD symptomatology: findings from a Brazilian clinical sample. Revista Psiquiatria Clı´nica 36 (3) 101–104. De Los Reyes, A., Kazdin, A.E., 2005. Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study. Psychological Bulletin 131 (4) 483–509. Faraone, S.V., Biederman, J., Milberger, S., 1995. How reliable are maternal reports of their children’s psychopathology? One year recall of psychiatric diagnosis of ADHD children. Journal of American Academy of Child and Adolescent Psychiatry 34, 1001–1008. Frazier, T.W., Youngstrom, E.A., 2006. Evidence-based assessment of Attention deficit/hyperactive disorder: using multiple sources of information. Journal of American Academy Child Adolescence Psychiatry 45 (5) 614–620. Gau, S.F., Lin, Y.J., Cheng, T.A., Chiu, Y.N., Tsai, W.C., Soong, W.T., 2010. Psychopathology and symptom remission at adolescence among children with Attention-Deficit Hyperactivity Disorder. Australian and New Zealand Journal of Psychiatry 44, 323–332. Gomez, R., Hafetz, N., 2011. DSM-IV ADHD: prevalence based on parent and teacher ratings of Malaysian primary school children. Asian Journal of Psychiatry 4, 41–44. Hartman, C.A., Rhee, S.H., Willcutt, E.G., Pennington, B.F., 2007. Modelling rate disagreement for ADHD: are parents or teachers biased? Journal of Abnormal Child Psychology 35 (4) 536–542. Joyner, K.B., Silver, C.H., Stavinoha, P.L., 2009. Relationship between parenting stress and ratings of executive functioning in children with ADHD. Journal of Psychoeducational Assessment 27 (6) 452–464. Kaner, S., 2011. ADHD symptoms in national samples of Turkish adolescents: self, parent, and teacher reports. Procedia Social and Behavioural Sciences 15, 3342– 3348.
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Attention Deficit Hyperactivity Disorder symptoms reporting in Malaysian adolescents: Do adolescents, parents and teachers agree with each other? Wan Salwina Wan Ismaila,*, Azlin Baharudin b, Nik Ruzyanei Nik Jaafarb, Marhani Midin b, Fairuz Nazri Abdul Rahman b a
Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia b Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Malaysia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 February 2012 Received in revised form 10 May 2013 Accepted 12 May 2013
Attention Deficit Hyperactivity Disorder (ADHD) is a clinical diagnosis relying on persistence of symptoms across different settings. Information are gathered from different informants including adolescents, parents and teachers. In this cross-sectional study involving 410 twelve-year old adolescents, 37 teachers and 367 parents from seven schools in the Federal Territory of Kuala Lumpur, reliability of ADHD symptoms among the various informants were reported. ADHD symptoms (i.e. predominantly hyperactive, predominantly inattentive and combined symptoms) were assessed by adolescents, teachers and parents, using Conners-Wells’ Adolescent Self-report Scale (CASS), Conner’s Teachers Rating Scale (CTRS) and Conner’s Parents Rating Scale (CPRS) respectively. For predominantly hyperactive symptoms, there were statistically significant, weak positive correlations between parents and teachers reporting (r = 0.241, p < 0.01). Statistically significant, weak positive correlations were found between adolescents and parents for predominantly inattentive symptoms (r = 0.283, p < 0.01). Correlations between adolescents and parents reporting were statistically significant but weak (r = 0.294, p < 0.01). Weak correlations exist between the different informants reporting ADHD symptoms among Malaysian adolescents. While multiple informant ratings are required to facilitate the diagnosis of ADHD, effort should be taken to minimize the disagreement in reporting and better utilize the information. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Reliability ADHD symptoms reporting Malaysian adolescents
1. Introduction Attention Deficit Hyperactivity Disorder (ADHD) is among the most common psychiatric disorders seen worldwide as well as in Malaysia. The worldwide-pooled prevalence of ADHD was reported as 5.29% (Polanczyk et al., 2007). A study on Malaysian children reported a prevalence of inattention between 9% and 12.5% (Woo and Teoh, 2007). Another study on primary school children in Malaysia found a prevalence rate of 1.61% with the inattention subtype being the most common (0.96%), followed by hyperactive-impulsive (0.32%) and combined subtypes (0.32%) (Gomez and Hafetz, 2011). According to the Clinical Practice Guideline (Ministry of Health Malaysia, 2008), diagnosis of ADHD requires a comprehensive assessment involving parents or care-givers, teachers (Mitsis et al.,
* Corresponding author. Tel.: +60 3 91456158; fax: +60 3 91737841. E-mail address: [email protected] (W.I. Wan Salwina). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.05.001
2000) and clinical observation to determine symptoms. The Diagnostic Statistical Manual of Mental Disorders (DSM) criteria, require evidence of symptoms before the age of seven years and persistence of symptoms across different settings before diagnosis of ADHD can be established (DSM-IVTR; APA, 2000). Self-reported questionnaires reporting ADHD symptoms by different informants such as parents, teachers and adolescents themselves are commonly used to complement clinical observation. While these provide comprehensive assessment, previous studies have shown poor agreement between multiple informants (Collet et al., 2003; Coutinho et al., 2009; Frazier and Youngstrom, 2006; Gau et al., 2010; Kaner, 2011; Papageorgiou et al., 2008; Tripp et al., 2006), creating difficulties as there were no measures to blend the information together. Self-reported questionnaire is a measure of perception. Selfreported findings of ADHD symptoms among adolescents are perceptions of the symptoms from his or her own perspectives. Similarly, parents and teachers report ADHD symptoms as they perceive from their unique perspectives (Smith, 2007). Perception
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is subjective and readily influenced by various factors in the informants i.e. adolescents, parents, and teachers, as well as factors in the illness and the environment itself. Hence, the discrepancies seen in the different ratings by the different informants. ADHD symptoms change across the different stages of development (Barkley, 2005). In the young children, symptoms of hyperactivity may be more prominent compared to inattention, which are more commonly seen in the adolescents (Wolraich et al., 2005). This is further complicated by the different subtypes of ADHD, manifesting different symptoms domains such as predominantly hyperactive, predominantly inattentive and combined symptoms. Interestingly, symptoms of ADHD may also change with the different situations (Van Der Oord et al., 2006) and consequently lead to different behaviors observed and reported. For instance, in a less restrictive and demanding environment, symptoms may not be easily apparent (Barkley, 2005). As symptoms manifest at different levels of severity, the milder symptoms can go unnoticed compared with the moderate to severe symptoms that are readily observable. There were higher agreements between informants when domains of symptoms being rated are more observable (Langberg et al., 2010). Likewise, ADHD symptoms described by parents and teachers are evaluations of their perceptions of the adolescents’ behavior across different settings. These perceptions are based on their familiarity with the behavior and the specific situations where the behavior were observed (De Los Reyes and Kazdin, 2005) and their own psychological state. Parenting stress (Youngstrom et al., 2000; Van Der Oord et al., 2006) and depression (Youngstrom et al., 2000) were found to contribute to the lower agreement in reporting ADHD symptoms, particularly inattentive dimensions (Van Der Oord et al., 2006). On a different vein, parents and teachers tend to report more ADHD symptoms among adolescents with poor school achievement (Pierrehumbert et al., 2006). Likewise, adolescents with ADHD symptoms are more likely to experience academic difficulties (Birchwood and Daley, 2012). However, similar trend in reporting was not seen among children and adolescents (Pierrehumbert et al., 2006) thus contributing to the discrepancies between the informants. Interpretation of observed ADHD behavior is influenced by cultural and ethnic background (Moon, 2011). The cultural diversity and language plurality in Malaysian society further complicate the process of reporting and affect the reliability accordingly. Previous findings of poor agreement between different informants’ report were mainly from the western samples (Collet et al., 2003; Coutinho et al., 2009; Frazier and Youngstrom, 2006; Papageorgiou et al., 2008; Tripp et al., 2006), with less language and cultural diversity. It is therefore interesting to explore this issue in the local setting. To our knowledge, there has been no local study that examines the reliability of ADHD symptoms reporting by the different informants. This study aimed to examine the reliability between adolescent, parents and teachers report of the ADHD symptoms in adolescents.
study. In the final phase, a total of 410 twelve year old adolescents were recruited to participate in the study. In addition, 37 teachers and 367 parents also participated in this study. Teachers with the most contact hours with the participating students were selected to participate. Teacher: adolescent ratio was 1:11. Only one parent that knew the adolescent the best was required to participate. Active consent was obtained from the adolescents, their parents and teachers. Adolescents with poor command of language and mental retardation were excluded from this study. 2.2. Measurement instruments Conners Wells Adolescent Self-report Scale: Short (CASS:S), Conners Parent Rating Scale: Short(CPRS:S) and Conners Teacher Rating Scale: Short(CTRS:S) were used in this study. Items in the questionnaires were rated according to the behavior that occurred in the past month as observed by the adolescents (CASS: S), their parents (CPRS:S) and teachers(CTRS:S) accordingly. The CASS:S and CPRS:S consist of 27 items whereas the (CTRS:S) has 28 items (Conners, 2001). The translated version of Conners Rating Scales (CRS) in the local language i.e. Bahasa Malaysia were used in this study. The translations were done by a team of four psychiatrists including three of the authors. Two members of the team front translated the questionnaires while another two members back translated them. Two front and two back translations were carried out for each of the questionnaires. After the translations, the team met to discuss the pre-final versions and made appropriate amendments, taking into consideration the meaning of the contents within the cultural context. The pre-final versions were tested on a group of convenient samples and further changes were made based on the feedback obtained. These versions were finally sent to the Multi-Health Systems revision board, for final revision and approval before their use in this study. The CRS are diagnostic tools for assessment of ADHD in children and adolescents. In practice, diagnosis of ADHD remains a clinical diagnosis while the use of instruments was not recommended (CPG, 2008). For the purpose of this study, only three subscales of CRS i.e. combined; hyperactive and inattentive were included, while oppositional subscale was not considered in the analysis. Furthermore, the T-scores which were the cut-off scores that separate the clinical and non-clinical sample were not used. This was because the T-scores were not developed for the local population. Instead, the raw scores were used, whereby higher scores indicate higher ADHD symptoms while lower scores reflect lower ADHD symptoms. Therefore, ADHD symptoms rather than the illness were examined in this study. 2.3. Study implementation Adolescents completed the self-reported questionnaires during the given period in their respective schools. They were not allowed to discuss their responses. Teachers and parents were given two weeks to complete the questionnaires at their own leisure time.
2. Methods
2.4. Statistical analysis
2.1. Sampling
Statistical Package for Social Studies (SPSS) version 13 was used to analyze the data. Q–Q–Q plot and Kolmogorov–Smirnov test were used to test for normality of the continous data such as ADHD symptoms and parents’ age. Intraclass correlation was used to examine correlations between ADHD symptoms as reported by the different informants. Chi-square was used to examine differences between adolescent with and without parents’ report for sociodemographic profiles. Mann–whitney test was used to examine ADHD symptoms reported by adolescents and teachers, between adolescents with and without parents report.
This is part of a cross-sectional study on ADHD and bullying, Wan Ismail et al. (2010) whereby a pattern of agreement and reliability between parents, teachers and adolescents in reporting ADHD symptoms were examined. A total of 826 adolescents from seven randomly selected schools in Kuala Lumpur were approached to take part in this study. 198 adolescents failed to return the consent forms, 183 adolescents did not consent while another 35 adolescents were absent, and thus excluded from the
W.I. Wan Salwina et al. / Asian Journal of Psychiatry 6 (2013) 483–487 Table 2 Socio demographic profiles of adolescents with and without parents’ reports.
3. Results The sociodemographic profiles of the adolescents participating in this study were shown in Table 1. The study sample was overpopulated by Malays (76%), followed by Indians (13.7%), Chinese (6.8%) and other ethnic group (2.7%). There were more girls (51.2%) compared to boys (48.8%). Majority of the adolescents were girls (51.2%), had five or less siblings (81%) and had poor academic performance (65%). Most of the parents were young, aged 45 years old and below. 58.2% of the participating fathers and 82.5% of the mothers were below 46 years old at the time of study. Generally, the parents had low educational level as highlighted by the majority of fathers (86.8%) and mothers (86.8%) without tertiary educations. Most parents were married (93%) and spent ten hours or less time with their children in a day (56.5%). Of the 367 parents who participated in the study, 43 parents (10.5%) failed to complete and return the parents’ report. Adolescents with and without parents’ report were analyzed in terms of the socio-demographic variables. There were no significant different between the groups except for sex. There were significantly more boys than girls in the group without parents’ reports. (Table 2) ADHD symptoms reported by adolescents and teachers, with and without parents’ reports were shown in Table 3. There were significant difference in ADHD (combined) symptoms reported by teachers, between adolescents with and without parents’ report (Table 3). Spearman correlation coefficient was used to examine the relationship between ADHD symptoms (predominantly hyperactive, inattentive and combined) reported by the different informants (i.e. adolescents, teachers and parents) (Table 4). In general, ADHD symptoms rated by the different informants showed weak correlations. ADHD (hyperactive) symptoms rated by teachers and parents (r = 0.283, p < 0.01) and ADHD (combined)
Variables
Table 1 Socio demographic profiles of adolescents participating in the study. Adolescents profile (n = 410)
Parents profile (n = 367) Father’s age 45 years >45 years Mother’s age 45 years >45 years Father’s educational level No tertiary education With tertiary education Mother’s tertiary educational level No tertiary education With tertiary education Marital status Married Divorced/Others Amount of time spent with children 10 hours >10 hours
315(76%) 28(6.8%) 56(13.7% 11(2.7%) 200(48.8%) 210(51.2%) 326(81%) 77(19%) 246(65%) 132(35%)
192(58.2%) 138(41.8%) 282(82.5%) 60(17.5%) 290(86.8%) 44(13.2%) 303(86.8%) 46(13.2%) 330(93%) 25(7%) 181(56.6%) 139(43.4%)
Without report
Sex 30(15%) Boys Girls 13(6.2%) Ethnic groups Malay 38(12.1%) Chinese 2(7.1%) Indian 2(3.6%) 1(9.1%) Others Academic performance Poor 25(10.2%) Good 11(8.3%) Number of siblings 0–5 29(8.9%) >= 6 12(15.6%) a b *
With report
Chi-square
Significance level
170(85%) 197(93.8%)
8.468a
p < 0.01*
277(87.9%) 26(92.9%) 54(96.4%) 10(90.9%)
3.898b
p = 0.25
221(89.8%) 121(91.7%)
0.334a
p = 0.56
297(91.1%) 65(84.4%)
3.049a
p = 0.08
Pearson Chi-square. Fischer Exact Test. p < 0.05.
Table 3 ADHD symptoms as reported by adolescents and teachers in adolescents with and without parents’ reports. Without report
With report
Median score (25–75th percentiles) ADHD symptoms reported by adolescents Combined 11 (7–16) 10 (7–14) Hyperactive 6 (4.5–9) 7 (5–9) Inattentive 6 (5–5) 5 (0–4) ADHD symptoms reported by teachers Combined 4 (0.5–13) 2 (0–8) Hyperactive 1 (0–5) 0 (0–3) Inattentive 2 (0–4) 2 (0–4) *
Ethnicity Malay Chinese Indian Others Sex Boys Girls Number of siblings 0–5 6 Academic performance Poor Good
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Mann–whitney test
p value
z value
0.768 0.403 0.380
p = 0.44 p = 0.69 p = 0.70
2.331 1.874 0.097
p = 0.02* p = 0.06 p = 0.92
p < 0.05
symptoms rated by adolescents and parents (r = 0.294, p < 0.01) showed weak but significant correlations. Similarly, ADHD (inattentive) symptoms rated by adolescents and parents (r = 0.283, p < 0.01), and ADHD (inattentive) symptoms rated by teachers and parents (r = 0.294, p < 0.01) were found to have weak but significant correlations respectively. 4. Discussions In this study, 10.5% parents did not return parents report. These involved 15% adolescent boys and 6.2% adolescent girls who participated in the study. Given the fact that ADHD is more prevalent in boys (Marte´nyi et al., 2010; Rutter and Taylor, 2002), this may significantly affect the findings, leading to poor agreement in teachers and parents report. Despite that, there were no significant differences between adolescents with and without parents’ reports in terms of ADHD symptoms reporting except for combined symptoms. Teachers significantly rated adolescents without parents report to have more ADHD symptoms (combined), as evidenced by the higher median scores (z = 2.331, p = 0.02). Different informants perceive ADHD symptoms differently, which reflect their different perspectives in reporting, consequently resulting in poor agreement between them. The level of agreement between informants cannot be simply attributed to the poor inter-rater reliability (Youngstrom et al., 2000). In fact, interaction between multiple demographic and psychological factors are equally important in influencing the agreement at the different levels (Youngstrom et al., 2000). This study found significant but poor correlations between the different informants in reporting ADHD symptoms. These are in
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Table 4 Reliability of ADHD symptoms between adolescents, teachers and parents report. ADHD symptoms reported by different informants Predominantly hyperactive Adolescents & teachers Adolescents & parents Teachers & parents Predominantly inattentive Adolescents & teachers Adolescents & parents Teachers & parents Combined Adolescents & teachers Adolescents & parents Teachers & parents *
Intraclass correlations
Significance level
r = 0.301 r = 0.182 r = 0.241
p = 1.00 p = 1.00 p < 0.01*
r = 0.006 r = 0.283 r = 0.107
p = 0.45 p < 0.01* p = 0.03*
r = 0.037 r = 0.294 r = 0.093
p = 0.77 p < 0.01* p = 0.05
p < 0.05
keeping with previous findings of generally low or non-significant correlations between adolescents, teachers and parents rating of ADHD symptoms (Conners, 2001; Kaner, 2011; Mitsis et al., 2000; Tripp et al., 2006). For example, correlations between parents and teachers rating of ADHD symptoms, using Conners Rating Scales ranged from 0.34 to 0.52 for the three different subscales of ADHD (Conners, 2001). Teachers and parents had significant poor agreement in reporting predominantly hyperactive (r = 0.241, p < 0.01) and inattentive (r = 0.107, p = 0.03) symptoms. This is not surprising as the behavior can be situation specific. Teachers and parents observe different ADHD behavior in the different settings (Hartman et al., 2007). Adolescents with ADHD are more likely to have problems in formal settings where more demanding tasks are required of them (Barkley, 2005). On the other hand, hyperactivity symptoms were more readily observed compared to inattentive symptoms (Weckerly et al., 2005) thus, more readily reported. Studies measuring inter-rater reliability of assessment of symptoms had found better teacher-parent agreement for externalizing behavior such as hyperactivity symptoms compared to internalizing behavior such as inattentive symptoms (Faraone et al., 1995; Verhulst and Van Der Ende, 1991). In a standard Malaysian classroom setting, a class teacher is responsible for approximately 30–40 students. The teacher needs to be observant to be aware of ADHD symptoms among their students, particularly when they had to rate more than one student. In such circumstance, a parent is expected to be better able to detect ADHD symptoms in his or her child, having to observe only one child. Such factor can influence their reporting leading to the discrepancies between the two raters. Adolescents and parents showed similar weak, positive correlations (r = 0.283, p < 0.01) for predominantly inattentive symptoms. One limitation of self-reported questionnaire is the bias in reporting. In Malaysian culture whereby expressions of negative feelings and behavior are generally discouraged, adolescents may minimize their symptoms resulting in the poor correlations. Nevertheless, the heterogeneity of Malaysian culture allows considerable variations with regards to self expression in the different ethnic groups. Cultural differences in the perception and interpretations of the symptoms can contribute significantly to the lower informant-agreement. Language diversities in Malaysian multiracial society may similarly contribute to the lower agreement between informants. Despite Bahasa Malaysia being the official language of Malaysia, it is not the first language for the non-Malays. Hence, it may potentially limit their ability in understanding and interpreting the Bahasa Malaysia versions of the questionnaires. The ability of the adolescents as skilled reporters of their own experience have also been questioned (Weckerly et al., 2005) since
those with ADHD has tendencies to underreport their symptoms (Owens et al., 2007; Wolraich et al., 2005). In addition, parents and adolescents may have different concerns with regards to the problem they have, thus their reporting will reflect the areas of concerns resulting in disagreement in reporting (Kashani et al., 1985). Conners rating scales were also found to have low or nonsignificant correlations for teachers and adolescents report with exception to moderate correlations found for cognitive problems/ inattention subscale (Conners, 2001). Low agreement between adolescents and teachers concerning AHD symptoms using DSMIV criteria had also been observed (Wolraich et al., 2005). In contrast, this study found no significant correlations in all subtypes of ADHD symptoms for adolescents and teachers reports. Teachers and parents see similar behavior with regards to structured activities that commonly occur in the school but less frequently in the home setting. However, teachers are at a disadvantage as they lack opportunity to observe behavior that are unique to home environment which are experienced by the adolescents and observed by parents. This may explain the significant disagreement between teachers and adolescents reports in all subtypes of ADHD symptoms. In a Brazilian study, teachers reported less ADHD symptoms compared to parents for both hyperactivity and inattentive symptoms (Coutinho et al., 2009). On a different token, teachers report higher ADHD symptoms among adolescents with poor school performance (Pierrehumbert et al., 2006), who comprise the majority in this study sample. The fact that similar pattern of reporting was not seen in the adolescents (Pierrehumbert et al., 2006) may result in the poor agreement between teachers and adolescents reporting. ADHD symptoms reported are based on the informants’ reporting skills and their own interpretation of what were observed. Such interpretation is influenced by their own cultural upbringing (Moon, 2011). Poor conceptualization of the illness may lead to different interpretation of behavior and minimization of the symptoms. For instance, an adolescent who is inattentive, easily distractible and performs poorly in school may be perceived as ‘lazy’ rather than having ADHD symptoms. 86.8% of parents who participated in this study had no tertiary education. This may reflect their level of understanding of the illness and significantly affect the symptoms reporting. Caregivers’ educational level had been found to significantly affect the endorsement of inattentive symptoms but not hyperactive symptoms (Weckerly et al., 2005). Previous studies have shown that parental depression is a factor affecting the reporting of ADHD symptoms (Chi and Hinshaw, 2002; Youngstrom et al., 2000) and executive functioning in ADHD (Joyner et al., 2009) among adolescents. Depression–distortion phenomenon in a depressed mother led her to perceive the child as being more hyperactive and inattentive, thus providing a negative bias in her reporting of ADHD symptoms (Chi and Hinshaw, 2002). Another study found parental stress but not depression to significantly affect the reporting of ADHD symptoms (Van Der Oord et al., 2006). Parental disagreement on rating of ADHD symptoms potentially affect the diagnosis given. Mothers were found to evaluate higher levels of ADHD symptoms compared to fathers (Langberg et al., 2010). On the other hand, fathers tend to identify with the boys and perceive externalizing behaviors as part of childhood (Singh, 2003). In this study, the perspective of only one parent, either father or mother was taken into consideration. Multiple informants reporting are commonly used to facilitate the assessment of ADHD in Malaysia but no study had looked into the problem arising from its use. While multiple informant reports are useful in providing information observed by different informants in different settings, sources of the disagreement should be considered with caution. ADHD subtypes, manifestation
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of symptoms in the different settings, and reporting skills of the different informants as well as depression in the parents contribute accordingly. Measures need to be taken on how to blend the information together to best facilitate the assessment of ADHD in the adolescents. This study has few limitations. Firstly, only one parent was involved whereby a more accurate result may be found should both parents reporting were taken. Secondly, adolescent: teacher ratio was high which may lead to inaccuracy of reporting. Thirdly, 10.5% parent failed to return their reports, which may significantly influence the results. Finally, a bigger sample that better generalizes Malaysian adolescents may give more accurate findings. In conclusion, agreement between different informants in reporting of ADHD symptoms was poor. Factors contributing to the poor agreement between informants should be carefully understood in order to best utilize the information together and make accurate diagnosis. References American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders-IV Text Revised. Author, Washington, DC. Barkley, R., 2005. Taking charge of ADHD, revised ed. The Guilford Press, New York/ London. Birchwood, J., Daley, D., 2012. Brief report: the impact of Attention Deficit Hyperactivity Disorder (ADHD) symptoms on academic performance in an adolescent community sample. Journal of Adolescence 35, 225–231. Conners, C.K., 2001. Conners’ Rating Scales-Revised(CSR-R). Technical Manual. Multi-Health Systems Inc.. Chi, T.C., Hinshaw, S.P., 2002. Mother–child relationships of children with ADHD: the role of maternal depressive symptoms and depression-related distortions. Journal of Abnormal Child Psychology 30 (4) 387–400. Collet, B.R., Ohan, J.L., Myers, K.M., 2003. Ten-year review of rating scales. V: scales assessing Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 42 (4) 1015–1037. Coutinho, G., Mattos, P., Schmitz, M., Fortes, D., Borges, M., 2009. Agreement rates between parents’ and teachers’ reports on ADHD symptomatology: findings from a Brazilian clinical sample. Revista Psiquiatria Clı´nica 36 (3) 101–104. De Los Reyes, A., Kazdin, A.E., 2005. Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study. Psychological Bulletin 131 (4) 483–509. Faraone, S.V., Biederman, J., Milberger, S., 1995. How reliable are maternal reports of their children’s psychopathology? One year recall of psychiatric diagnosis of ADHD children. Journal of American Academy of Child and Adolescent Psychiatry 34, 1001–1008. Frazier, T.W., Youngstrom, E.A., 2006. Evidence-based assessment of Attention deficit/hyperactive disorder: using multiple sources of information. Journal of American Academy Child Adolescence Psychiatry 45 (5) 614–620. Gau, S.F., Lin, Y.J., Cheng, T.A., Chiu, Y.N., Tsai, W.C., Soong, W.T., 2010. Psychopathology and symptom remission at adolescence among children with Attention-Deficit Hyperactivity Disorder. Australian and New Zealand Journal of Psychiatry 44, 323–332. Gomez, R., Hafetz, N., 2011. DSM-IV ADHD: prevalence based on parent and teacher ratings of Malaysian primary school children. Asian Journal of Psychiatry 4, 41–44. Hartman, C.A., Rhee, S.H., Willcutt, E.G., Pennington, B.F., 2007. Modelling rate disagreement for ADHD: are parents or teachers biased? Journal of Abnormal Child Psychology 35 (4) 536–542. Joyner, K.B., Silver, C.H., Stavinoha, P.L., 2009. Relationship between parenting stress and ratings of executive functioning in children with ADHD. Journal of Psychoeducational Assessment 27 (6) 452–464. Kaner, S., 2011. ADHD symptoms in national samples of Turkish adolescents: self, parent, and teacher reports. Procedia Social and Behavioural Sciences 15, 3342– 3348.
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