Journal of Abnormal Child Psychology, Vol. 25, No. 2, 1997, pp.

103-111
Behavioral Characteristics of DSM-IV ADHD Subtypes
in a School-Based Population
Miranda Gaub1 and Caryn L. Carlson1,2
Received August 8, 1995; revision received February 21, 1996;
accepted February 27, 1996
From an ethnically diverse sample of 2,744 school children, 221 attention deficit hyperactivity
disorder (ADHD) [123 (4.5%) predominantly inattentive (IA), 47 (1.7%) predominantly hy-
peractive/impulsive (HI), and 51 (1.9%) combined type (C)] were identified using teacher
ratings on a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) symptom
checklist. Subjects were compared to 221 controls on teacher ratings of behavioral, academic,
and social functioning. The results revealed relatively independent areas of impairment for
each diagnostic group. The IA children were impaired in all areas, but were rated as dis-
playing more appropriate behavior and fewer externalizing problems than HI or C children.
The HI group displayed externalizing and social problems, but was rated as no different
than controls in learning or internalizing problems. The C group demonstrated severe and
pervasive difficulties across domains. These findings support the validity of the DSM-IV
ADHD subtypes; all ADHD groups demonstrated impairment relative to controls, but show
different patterns of behavioral characteristics.
KEY WORDS: ADHD; ADHD subtypes; behavioral characteristics; impairment; teacher ratings; ethnic
minority.
Since its inception, attention deficit hyperactivity
disorder (ADHD) has been known by many names,
such as minimal brain dysfunction, hyperkinesis, hy-
peractivity, and attention deficit disorder with
(ADD/H) or without (ADD/WO) hyperactiviry. The
changing nomenclature reflects disagreement regard-
ing the diagnostic necessity of the three core charac-
teristics: impulsivity, inattention, and motor excess.
Various editions of the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM) have implemented
various subtyping systems which cluster the three core
characteristics in a number of ways. The third edition
[DSM-III; American Psychiatric Association (APA),
1The University of Texas at Austin, Austin, Texas 78712.
2Address all correspondence to Caryn L. Carlson, Department of
Psychology, Mezes 330, The University of Texas at Austin,
Austin, Texas 78712.
103
CWl-OttW/WOMWOSllSM) C 1997 Plenum Publishing Corporation
1980] subtyped ADHD children using a bidimensional
approach such that a child was diagnosed as ADD/H
or ADD/WO. The revised third edition (DSM-III-R;
APA, 1987) implemented a unidimensional approach
which included children with varying degrees of hy-
peractivity under the diagnostic category of attention
deficit hyperactivity disorder. The fourth edition (DSM-
IV; APA, 1994) has returned to a bidimensional system,
clustering hyperactivity and impulsivity symptoms into
one dimension, and separating it from the inattention
dimension. Based on this system, the DSM-IV pre-
sents an ADHD diagnosis with three subtypes: pre-
dominantly inattentive (IA), predominantly
hyperactive/impulsive (HI), and combined type (C),
Children displaying symptoms of both inatten-
tion and hyperactivity (i.e., ADD/H and ADHD) un-
der the various DSM systems have consistently
demonstrated significant difficulties in adjustment,
104
social functioning, and internalizing and externalizing
behavior (Barkley, 1990; Hinshaw, 1994; Whalen,
1989). The pervasiveness of such associated difficul-
ties has been demonstrated primarily within clinic-
referred samples. Although behavior problems
associated with ADHD have been explored in popu-
lation-based samples to a lesser extent, they have also
been documented (August, Ostrander, &
Bloomquist, 1992; Szatmari, Offord, & Boyle, 1989).
Research has demonstrated that children display-
ing both inattention and hyperactivity differ from
those who display inattention in the absence of motor
excess. This latter form of ADHD, first formally iden-
tified in DSM-III as ADD/WO, has been less widely
studied. In a recent review of the ADD/WO litera-
ture, Lahey, Carlson, and Frick (in press) concluded
that, as compared to ADD/H children, ADD/WO
children are more internalizing but less antisocial, less
rejected by peers, and less externalizing.
The DSM-IV C and IA subtypes were intended
to be congruent with past diagnoses of ADD/H and
ADD/WO, respectively. However, DSM-IV diagnos-
tic criteria deviate somewhat from those of previous
DSM versions, in terms of numbers and clusters of
symptoms. Thus, it remains to be seen whether cur-
rent DSM criteria identify children similar to those
identified in previous research.
The HI subtype, introduced to capture a group
of children who were perceived by clinicians in the
field trials to have a clinically significant disorder
(Lahey et al., 1994), has no previous diagnostic coun-
terpart. The validity of the HI subtype has been ques-
tioned by those who have suggested that these
children, who were identified primarily among pre-
schoolers in the field trials, may eventually display
inattention symptoms and qualify for a C diagnosis
(Barkley, 1997).
The DSM-IV field trials (Lahey et al., 1994)
found that, among clinic-referred children, the DSM-
IV ADHD subtypes showed different patterns of as-
sociated impairment. C and HI groups were rated as
more globally impaired than the IA group, while C
and IA children had more academic problems than
the HI group. Teachers rated C children as less liked
and more disliked than HI children, while IA chil-
dren did not differ from the other two subtypes on
like or dislike scores.
Apart from the field trials, descriptive informa-
tion about the DSM-IV diagnostic subtypes is scarce.
McBurnett, Pfiffner, Swanson, Ottolini, & Tamm
(1995) used parent and teacher ratings on a DSM-
III-R diagnostic checklist of 520 child referrals to an
ADHD clinic to retrospectively classify them into
DSM-IV subtypes. A comparison of the behavioral
characteristics of the three ADHD subtypes indicated
that, consistent with Lahey et al. (1994), HI children
were more academically successful than C or IA chil-
dren. HI children did not differ from C children on
ratings of peer dislike, but both of these groups were
more disliked than the IA group. In addition, both
the HI and C groups received higher ratings than the
IA group on measures of disruptive behavior.
Two studies examined behavioral correlates of
the DSM-IV subtypes in nonreferred samples
(Baumgaertel, Wolraich, & Dietrich, 1995; Wolraich,
Hannah, Pinnock, Baumgaertel, & Brown, in press).
Wolraich et al. obtained teacher ratings for 8,258
children in grades K-5 in a middle Tennessee county.
An overall ADHD prevalence rate of 11.4% was ob-
tained, with rates for LA, C, and HI of 5.4%, 3.6%,
and 2.4%, respectively. Baumgaertel et al. (1995)
obtained teacher ratings for 1,077 children in
Grades 1 to 4 in Regensburg, Germany. An overall
prevalence rate of 17% was obtained, with rates for
IA, C, and HI of 9%, 4.8%, and 3.9%, respectively.
Consistent with the results of Lahey et al. (1994)
and McBuraet et al. (1995), the C and HI groups
displayed behavioral problems, while the C and LA
groups were associated with academic problems.
Wolraich et al. also found the proportion of children
displaying anxiety/depression was lower for the HI
(9.2%) than for the C (29.3%) or IA (21.9%)
groups.
The goals of the present study were to enhance
the existing literature by (1) using a large-scale,
population-based sample to prevent contamination
by possible referral bias; (2) exploring behavioral cor-
relates of the three DSM-IV-diagnosed subtypes of
ADHD; and (3) attempting to evaluate the extent to
which the current DSM-IV system identifies subtypes
comparable to those identified using previous diag-
nostic systems.
METHOD
Data for the present study were obtained under
the auspices of a larger community service program
entitled the School of the Future Project. This pro-
gram, implemented by the Hogg Foundation, pro-
vides school-based mental health services to low
income communities. Since 1990, this program has
Gaub and Carlson
ADHD Subtypes
105
Table I. Demographic Characteristics of Population
Grade
Overall
Gender K 1 2 3 4 5 totals
Boys
Girls
Totals
255
263
518
19%
288
249
537
19%
261
235
496
18%
202
178
380
14%
218
184
402
15%
193
218
411
15%
1,417
52%
1,327
48%
2,744
100%
been in effect in some elementary and secondary
schools in several Texas cities. Yearly evaluations, in-
cluding teacher ratings, have been used to assess the
effectiveness of service delivery in these schools.
Data were collected for all children for whom
parental consent was obtained (approximately 96%
of eligible children). The 3% of children of unknown
or "other" ethnicity were excluded, leaving a sample
of 2744 children in nine elementary schools who had
adequate data available for the 1993-1994 school
year. Demographic characteristics for the sample are
presented in Table I. Children were predominantly
from low-socioeconomic-status (low-SES) back-
grounds. Based on paternal occupation, available for
30% of the sample, mean SES rating (using total la-
bor force comparisons) on the revised Duncan So-
cioeconomic Index (Stevens & Featherman, 1981)
was 23. The ethnic composition was 76% Hispanic,
16% African American, and 8% Caucasian.
Subjects
For the current study, 221 children, representing
8.0% of the total population, met the criteria for
ADHD (via teacher reports) and were included in
analyses. The 221 ADHD children were compared
to 221 non-ADHD subjects selected from among
nondiagnosed children and matched for gender, age,
grade, and ethnicity. Demographic characteristics of
the groups are reported in Table II.
Measures
Teacher evaluations for each subject consisted of
the Teacher's Report Form (TRF; Achenbach, 1991),
a teacher-completed DSM-IV-based diagnostic
checklist for ADHD and oppositional defiant disor-
der (ODD), and three Likert-type scale questions re-
garding social functioning [adapted from a
questionnaire developed by Dishion (1990) used in
the DSM-IV field trials].
TRF. The TRF (Achenbach, 1991) is a widely
used, standardized tool for the assessment of child-
hood functioning and impairment in behavioral and
emotional realms. All analyses used raw scores rather
than T-scores, since the latter are scaled differently
for each gender.
SNAP-IV (Swanson & Carlson, 1994). This diag-
nostic checklist for ADHD and ODD [Swanson, No-
lan, and Pelham Checklist-IV and the DSM-IIIR
Disruptive Behavior Disorder Rating Scale (Pelham,
Gnagy, Greenslade, & Milich, 1992)] consists of 26
questions that closely parallel in wording the diagnos-
tic symptoms for both ADHD and ODD as they ap-
pear in the DSM-IV The instructions ask the teacher
to indicate, for each question, which of the following
four choices best describes the child: not at all, just a
little, quite a bit, or very much.
Social Functioning. Three questions, adapted
from Dishion (1990), were included to assess the
teacher's perception of the child's level of social
functioning. Teachers estimated the proportion of the
child's peers that like/accepted, dislike/rejected, and
ignored him/her based on a 5-point Likert-type scale
ranging from 1 (very few/less than 25%) to 5 (almost
all/more than 75%).
Procedure
Data were collected during April 1994 for the
1993-1994 school year. Subjects were excluded from
the original sample if their TRF scores had more
than eight unanswered items total or more than three
unanswered items on any scab. This sample was then
screened for those children who met DSM-IV
teacher rating criteria for the three subtypes of
ADHD. For diagnostic purposes, items endorsed as
very much were tallied as "present" symptoms, and
106 Gaub and Carlson
Table II. Group Demographic Characteristics
Hyperactive/
Demographic Combined Inattentive impulsive Controls
characteristic (n = 51) (n = 123) (n = 47) (n = 221)
Age [mean (SD)]
Gender ratio (Male:Female)
Ethnicity within group:Hispanic
African American
Caucasian
7.6 years (1.6)
2.8:1
70%
24%
6%
7.6 years (1.9)
2.3:1
79%
15%
6%
7.5 years (1.6)
4.1:1
57%
30%
13%
7.6 years (1.7)
2.6:1
77%
15%
8%
students were assigned ADHD subtype diagnoses ac-
cording to DSM-IV criteria.
To form a control group, a nondiagnosed child
was matched to each ADHD child. These nondiag-
nosed controls (NC) were sought within the same
classroom to adjust for potential rater differences. If
a nondiagnosed child (of the same gender and eth-
nicity) was not in the ADHD child's classroom, a
match was chosen from the next classroom (on an
alphabetical list) of the same grade within that
school. On rare occasions, a match had to be chosen
from a same grade classroom at a different elemen-
tary school. Approximately 94% of the matches were
from the same classroom, 5% were from a different
classroom in the same school, and fewer than 1%
were from a different school.
Analyses compared the three ADHD subtypes
and the NC group on 19 variables (four TRF adjust-
ment questions, eleven TRF behavior scales, three
sociometric questions, and ODD symptom rating). To
maintain a focus on diagnostic group, data for the
current study were collapsed across ethnicity and age.
Gender was not included as an independent variable
in the current study since a separate report of gender
effects is in preparation.
RESULTS
There were no significant differences among
ADHD subgroups in age [F(2, 215) = .05, p = .96],
gender \yf(df = 2) = 2.0, p = .37], or ethnic group
composition [%2(4f = 4) = 8.8, p = .07]. The number
of children in the sample obtaining the C, LA, and
HI diagnoses were 51 (1.9%), 123 (4.5%), and 47
(1.7%), respectively.
Using a 0- to 3-point scoring system on the DSM
checklist, the following scores were obtained for the
total sample: LA symptom total (M = 6.82, SD =
7.79), HI symptom total (M = 4.22, SD = 6.29), and
ODD symptom total (M = 2.94, SD = 5.35).
Behavioral Variables
One-way analyses of variance (ANOVAs) were
executed for each of the nineteen dependent vari-
ables. Main effects were further evaluated using the
Tukey (Tukey, 1972) test to explore group differ-
ences. Cell sires, means and standard deviations, F
and p values, and post hoc comparisons for the be-
havior ratings are reported in Table III.
On the adjustment variables, the three ADHD
groups were all rated as significantly more impaired
than the NC group on measures of Hard Working,
Appropriate Behavior, and Happy. Surprisingly, on
the fourth adjustment variable, Learning, the HI
group did not differ from the NC group, while the
C and LA groups received significantly poorer ratings
than the NC and HI groups. Although more im-
paired than the NC group, the HI group received
higher ratings of Hard Working than the other two
ADHD groups, and higher ratings of Happy than the
C group. However, the LA group obtained higher Ap-
propriate Behavior ratings than the other two diag-
nosed groups.
On the three sociometric rating variables and
the TRF Social Problems scale, all three of the di-
agnosed groups were rated as having poorer social
functioning than the NC group. The C group re-
ceived higher ratings on the Peer Dislike than the
LA group and higher ratings on the TRF Social Prob-
lems variables than either the HI or LA groups, which
did not differ significantly from each other on either
variable. On the Peer Like variable, the LA group was
rated as liked by more peers than the C group, with
no significant differences between either of these two
groups and the HI group. On the Peer Ignore vari-
able, there were no differences among groups.
ADHD Subtypes 107
Table DDL Group Comparisons on Behavioral Ratingsa
Significant group differences based
ADHD ADHD ADHD on Tukey/wrt hoc tests
Variable C IA HI NC F-ratio (p < .05)
Liked by 2.44 3.11 2.70 4.14 47.09* NOC, HI, and IA;
Peers (1.26) (1.35) (1.21) (1.03) IA>C
Disliked by 2.96 2.27 2.65 1.50 35.62* C, ffl and IA > NQ OIA
Peers (1.34) (1.29) (1.23) (0.86)
Peers Neutral 112 2.22 1.98 1.44 18.5s C, HI. and IA>NC
Toward (1.21) (1.17) (1.18) (0.80)
ODD symptom 16.09 7.13 15.02 3.65 71.0* C and HI>IA>NC
ratiag (6.64) (7.53) (6.74) (5.92)
Hard working 1.67 1.68 3.26 4.32 116.9* NC>HI>C and IA
(0.97) (0.98) (1.34) (1.64)
Appropriate 1.55 2.45 1.67 4.12 67.2* NC>IA>C and HI
Behavior (0.87) (1.48) (1.15) (1.77)
Learning 1.84 1.82 3.67 4.17 86.4* NC and HI>C and IA
(1.03) (1.08) (1.49) (1.67)
Happy 2.53 3.08 3.42 4.32 30.8* NOC, HI, and IA;
(1.26) (1.35) (1.69) (1.54) HI>C
Withdrawn 4.46 5.82 2.45 2.27 29.3* C and IA>HI and NC
(3.65) (4.52) (2.19) (2.86)
Somatic 1.78 1.12 0.67 0.53 7.2* C>HI and NC; IA>NC
Complaints (Z97) (2.13) (1.60) (1.24)
Anxious/ 8.94 5.15 5.81 3.24 18.2* C>NI and IA>NC
Depressed (6.35) (4.93) (5.75) (4.62)
Social 9.79 6.12 6.36 2.32 56.2* C>HI and IA>NC
Problems (5.02) (4.62) (4.45) (3.35)
Thought 1.80 1.16 1.79 0.35 15.9* C, HI, and IA>NC
Problems (2.54) (2.01) (Z47) (1.05)
Attention 29.89 25.8 18.98 8.03 218.4* C>IA>HI>NC
Problems (4.25) (6.16) (6.85) (7.90)
Delinquency 7.43 4.83 6.59 2.04 51.2* C and HI>IA>NC
(3.87) (3.63) (4.13) (2.87)
Aggressive 31.22 14.76 31,95 8.12 88.5* C and HI>IA>NC
Behavior (11.12) (12.82) (10.31) (10.72)
Internalizing 14.35 11.57 8.36 5.85 21.2* C>HI and NC; IA>NC
Behavior (10.98) (8.84) (8.04) (7.06)
Externalizing 38.52 19.61 37.84 10.25 89.5* C and Hl>IA>NC
Behavior (13.42) (15.47) (13.13) (13.07
Total Problem 93.94 64.61 75.34 27.40 121.5* C> HI and IA>NC
Behavior (27.00) (26.93) (27.25) (26.54)
aADHD = attention deficit hyperactivity disorder; C = combined type; IA = predominantly inattentive;
HI = hyperactive/impulsive; NC = nondiagnosed controls. Mean values for ADHD C, ADHD IA,
ADHD HI, and NC groups are followed by standard deviations in parentheses.
bp < .01.
108
Gaub and Carlson
Table IV. Percentage of Children in ADHD Subtypes Classified as Impaireda
Impairment C IA HI
variable (a = 51) (n = 123) (n = 47)
Social (Peer Like or Dislike) 82 59 53
Behavioral (Appropriate Behavior) 90 58 80
Academic (Learning) 82 76 23
Not Impaired in any of the three domains 2 11 4
aADHD = attention deficit hyperactivity disorder; C = combined type; IA =
predominantly inattentive; HI = hyperactive/impulsive.
On all TRF externalizing variables (Aggressive
Behavior, Delinquency, and Externalizing Behavior)
and the ODD symptom rating, the three diagnosed
groups received higher scores than the NC group. No
differences emerged between the C and HI groups,
with both receiving significantly higher ratings than
the IA group on all variables. Thus, on externalizing
variables, the C and HI children are rated as most
deviant, while the IA children obtain lower ratings.
The pattern of group differences for the TRF in-
ternalizing variables was more complex than those in
other domains. On all four internalizing variables
(Withdrawn, Somatic Complaints, Anxious/De-
pressed, and Internalizing Behavior), the C and IA
groups were rated as significantly more impaired than
the NC group. HI children received higher ratings
than NC children only on the Anxious/Depressed
variable; on all other internalizing variables, the HI
group was rated as no different than the NC group.
The C group was rated as having significantly more
problems than the HI group on all four variables. The
IA children were not significantly different from the
other two diagnostic groups on Somatic Complaints
or Internalizing. The IA group was rated as more
Withdrawn than the HI group, but the groups did not
differ on the other three internalizing variables.
On the Thought Problems scale, the three diag-
nosed groups were rated as significantly more deviant
than the NC group, with the C group rated as signifi-
cantly more impaired than the HI and IA groups,
which did not differ from each other. On the Atten-
tion Problems scale, all three diagnosed groups re-
ceived significantly higher ratings than the NC group,
with the C group receiving significantly higher ratings
than the IA group. The HI group received signifi-
cantly lower ratings than either the C or the IA group.
On the Total Problem scale the C group was
rated by teachers as having significantly higher scores
than any other group. No differences emerged be-
tween the HI and IA groups, both of which were
rated as having significantly more problems than the
NC group.
Impairment Criteria
To approximate the impairment criteria required
by DSM-IV, NC scores were used to calculate objec-
tive criteria on various rating items. A child was con-
sidered "impaired" if he/she scored 1 SD or greater
from the NC mean (in the deviant direction) in the
following domains: academic (TRF Learning), be-
havioral (TRF Appropriate Behavior), social (Peer
Dislike or Peer Like). Table IV shows the proportion
of children in each subtype rated as unpaired in each
domain, and the proportion who did not meet im-
pairment criteria in any domain.
As indicated, the C group was most pervasively
impaired, with percentages of children rated as im-
paired socially, behaviorally, and academically of
82%, 90%, and 82%, respectively. Only one C child
(2%) did not show impairment in any domain.
Among LA children, academic impairment was most
common (76%), with moderate rates of social (59%)
and behavioral (58%) impairment. Few LA children
(11%) were rated as nonimpaired in any area. Chil-
dren in the HI group were most likely to show be-
havioral impairment (80%), with moderate rates of
social impairment (53%) and relatively low rates of
academic (23%) impairment. Very few HI children
(4%) were rated as unimpaired in any domain.
DISCUSSION
Prevalence
The present findings in this nonreferred popu-
lation indicate that prevalence ratios varied across
the three ADHD subtypes, with the following rates;
ADHD Subtypes
1.9% for C, 4.5% for LA, and 1.7% for HI. The pro-
portion of the population identified as C (1.9%) was
slightly lower than prevalence estimates of ADHD
using previous diagnostic criteria, which are generally
cited in the 2-3% range (APA, 1987). While the cur-
rent findings could merely reflect the stringent crite-
ria for symptom presence (i.e., a very much raring),
it is possible that changes in diagnostic criteria have
decreased the prevalence of the C subtype. If, as sug-
gested by the field trials (Lahey et al., 1994), most
children meeting criteria for the HI subtype would
likely have been diagnosed by clinicians as having
ADHD (according to DSM-III and DSM-C III-R cri-
teria), the current results showing a 3.6% prevalence
of these two subtypes combined (1.9% for C and
1.7% for HI) appear consistent with previous preva-
lence estimates.
The rate of IA was also higher than previous
ADD/WO prevalence rates of approximately 3%
(Szatmari et al., 1989). This was likely due to the
change in diagnostic criteria resulting in more chil-
dren qualifying for an LA diagnosis; this conclusion
is consistent with the DSM-IV field trials (Lahey et
al., 1994) finding that the majority of the new cases
identified by DSM-IV were IA children.
The higher rates of all three subtypes found in
previous population-based studies of DSM-IV crite-
ria (Baumgaertel et al., 1995; Wolraich et al., in
press) were likely due to the more lenient cutoff cri-
teria employed in those studies, both of which em-
ployed slightly differently phrasing for anchor points,
but counted symptoms as present if either of the two
most extreme ratings (i.e., often or very much) were
endorsed. Despite some differences in relative pro-
portions of the subtypes, both previous studies and
the current study found that LA was most prevalent,
and HI least prevalent, in nonreferred populations.
An interesting difference between current re-
sults and those from research using clinic-referred
samples (Lahey et al., 1994; McBurnett et al., 1995)
involves the relative ratios of the three ADHD sub-
types. In the current study, LA was identified twice
as often as C (C:IA ratio of 1:2.4); conversely, both
the field trials (Lahey et al., 1994) and McBurnett
et al. (1995) found C to be much more prevalent
than LA (C:IA ratios of 2.1:1 and 3.5:1, respectively).
In addition, while the current study found nearly
identical rates of C and HI (C: Hl ratio = 1.1:1),
both previous studies (Lahey et al., 1994; McBurnett
et al., 1995) found much higher CM ratios (3.0:1
and 4.3:1, respectively). These discrepancies in preva-
109
lence ratios likely reflected the nature of the samples
(population-based vs. clinic-referred). Relatedly,
Wolraich et al. (in press) found that C children were
two to four times more likely than LA or HI children
to be referred to a clinic.
Behavioral Characteristics
The distinctive pattern of impairment by subtype
found in the current study clearly indicates that the
DSM-IV diagnostic system distinguishes three groups
of children that are all impaired, relative to nondi-
agnosed controls, and that can be differentiated from
each other based on different patterns of difficulties.
The C subtype was associated with the most perva-
sive pattern of difficulties, with severe ratings of im-
pairment found in all major domains of functioning.
For variables including Anxious/Depressed, Social
Problems, Attention Problems, and Total Problem
Behavior, the C group was rated as more unpaired
than any of the other groups. As noted earlier, this
pattern of pervasive deficits displayed by C children
is consistent with that shown in children diagnosed
using previous ADHD criteria. In the DSM-IV field
trials sample, Lahey et al. (1994) also demonstrated
that C children experienced extensive difficulties, and
were significantly impaired in all assessed areas in-
cluding social, academic, and global functioning.
The IA children, like the C children, were rated
by teachers as significantly impaired in all major do-
mains of functioning. Nonetheless, the LA children
demonstrated areas of advantage relative to the other
two diagnosed groups. Specifically, the LA children
were perceived as displaying more appropriate behav-
ior and less externalizing behavior than C or HI chil-
dren. Previous research comparing ADD/WO and
ADD/H children found that ADD/WO children
showed more internalizing behavior, but less external-
izing and antisocial behavior, and lower rates of peer
rejection, than those with ADD/H (Lahey et al., in
press). This pattern is consistent with the present find-
ings, with IA children receiving significantly lower
TRF ratings on Aggression, Delinquency and Exter-
nalizing scales, lower ODD symptom scores, lower
Peer Dislike ratings, and higher Peer Like ratings than
C children. Surprisingly, however, LA and C children
were rated as no different from each other (although
both received significantly higher scores than NC chil-
dren) on three internalizing variables (Withdrawn, So-
matic Complaints and Internalizing Behavior).
110
Furthermore, although they did differ on the Anx-
ious/Depressed rating, this difference was in the un-
expected direction; the C children were rated as more
Anxious/Depressed than the IA children. This finding
parallels those of Wolraich et al. (in press), who also
found cooccurring anxiety/depression to be more
common among C (29.3%) than IA (21.9%) children.
While this unexpected result may be attributable
to the revised diagnostic criteria, it seems unlikely
that the changes would produce such a strong effect
A closer examination of past research, as reviewed
by Lahey, Carlson, and Frick (in press), suggests that
the epidemiological (school-based) studies available
(Lahey, Schaughency, Strauss, & Frame, 1984; Pel-
ham, Atkins, Murphy, & White, 1981) did not find
differences in anxiety/depression between the
ADD/H and ADD/WO subgroups. Rather, these dif-
ferences were evident primarily in studies using
clinic-referred samples (e.g., Lahey, Schaughency,
Hynd, Carlson, & Nieves, 1987). There may be a re-
ferral bias operating such that those IA children with
high levels of anxiety and depression are more likely
to be referred to clinics. Thus, IA (or ADD/WO)
children who are included in clinic-referred popula-
tions may be more anxious/depressed than their
counterparts in the overall population, resulting in
this discrepancy across studies.
The HI group in the current study demonstrated
a pattern of impairment that was quite different than
that of the C and IA groups. While the HI group
received significantly poorer ratings than the NC
group in the social functioning, externalizing, atten-
tion, and thought problems domains, they did not dif-
fer significantly from NC children on several
variables, including the Learning and most internal-
izing subscales (Withdrawn, Somatic Complaints, and
Internalizing). In addition, the HI group was rated
as significantly more hard working than the IA and
C groups and significantly happier than the C group.
Thus, consistent with existing research (Baumgaertel
et al., 1995; Lahey et al., 1994; McBurnett et al, 1995;
Wolraich et al., in press), HI children appear to be
characterized by externalizing and peer relationship
problems, but do not demonstrate internalizing prob-
lems or academic impairment. Overall, the results
from this and other research indicate that the new
subtype of HI is a valid and useful addition to the
DSM diagnostic system; HI children are significantly
impaired in some areas of functioning, but the pat-
tern of behavioral problems is distinctly different
from that found among IA and C children.
Gaub and Carlson
The younger age of onset for HI reported in the
field trials (5.65 years) (Lahey et al., 1994) led to
speculation that, rather than representing a separate
ADHD subtype, younger, Hi-diagnosed children
might eventually display inattentive symptoms and
qualify for C diagnoses (Barkley, 1997). In the
McBurnett et al. (1995) sample, the HI subtype was
also significantly younger than the C or IA subtypes;
however, the mean HI age (7.25 years) was not as
young as that reported in the field trials. Further-
more, in the current study, no significant age differ-
ences were found among the C (M = 7.6 years), IA
(M = 7.6 years), or HI (M = 7.5 years) groups. Since
disruptive, hyperactive behavior would likely lead to
referral at an earlier age than inattentive, less dis-
ruptive behavior, the younger ages for HI children
in studies using clinic samples (Lahey et. al, 1994;
McBurnett et al., 1995) may reflect referral patterns
rather than true differences across subtypes in age
of onset. Thus, the current findings of different as-
sociated impairment for the HI subtype, along with
evidence that this subtype was found in all age
groups, support the validity of HI as a distinct sub-
type of ADHD rather than a precursor to C.
Limitations
There are several limitations of the current study.
The exclusive use of teacher ratings on a symptom
checklist to assign diagnoses is problematic, since nei-
ther the age of onset of symptoms nor information
regarding impairment or cross-situationality was ob-
tained. In an attempt to address this limitation within
the parameters of the available data, the strictest pos-
sible cut-off scores were implemented for the SNAP-
IV The low proportion of children (2% of C, 11% of
IA, and 4% of HI) who were not rated as unpaired
in any realm suggests that the current study appro-
priately avoided identifying subthreshold cases. The
study is also limited by its reliance on teachers for
both diagnostic and dependent variable ratings, al-
though the finding of different patterns of behavior
problems across subtypes provided evidence of the as-
sociation between teacher perceptions of diagnostic
symptoms and domain-specific dysfunction .
Another limitation of the present study is the
extent to which these results are generalizable to the
overall population since the current sample consisted
primarily of lower-SES Hispanic subjects. However,
the consistency of the obtained pattern of results
ADHD Subtypes 111
(particularly regarding group differences in areas of
functioning) with findings from previous research
suggests that ADHD children from both minority
and nonminority ethnic backgrounds share common
behavioral characteristics.
This and other research supports the concurrent
validity of the DSM-IV ADHD subtypes. The com-
parability of the current results and those of the
other two population-based studies (Baumgaertel et
al., 1995; Wolraich et ah, in press), which used pri-
marily Hispanic, German, and Caucasian subjects, re-
spectively, establishes the cross-cultural congruency
of behaviors associated with ADHD. Future research
should work toward examining the etiological and
predictive validity of the current diagnostic system by
exploring potential subtype differences in causes,
outcomes, and treatment responsiveness.
ACKNOWLEDGMENTS
This study was made possible through collabora-
tion with the Hogg Foundation School of the Future
Project (SOF). The authors thank Wayne Holtzman,
Ph.D., Special Consultant to the Hogg Foundation,
as well as Scott Keir, Ph.D., SOF Director of Re-
search, and Pam Diamond, Ph.D., SOF Senior Re-
search Associate, for their enthusiastic support. Also,
thanks to Anne Anderson, Joey Martin, and Scott
Davis for their many hours of data entry.
This research was partially supported by an
NIMH FIRST grant, MH49827 awarded to the sec-
ond author.
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