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Emotional Symptoms in Inattentive Primary School Children: A Population-Based Study

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Title: Emotional Symptoms in Inattentive Primary School Children: A Population-Based Study
Language: English
Authors: Sorensen, Lin, Hugdahl, Kenneth, Lundervold, Astri Johansen
Source: Journal of Attention Disorders. 2008 11(5):580-587.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
Peer Reviewed: Y
Physical Description: PDF
Page Count: 8
Publication Date: 2008
Document Type: Journal Articles
Reports - Research
Education Level: Elementary Education
Descriptors: Emotional Problems, Parent Attitudes, Teacher Attitudes, Measures (Individuals), Program Effectiveness, Behavior Change, Symptoms (Individual Disorders), Elementary School Students, Questionnaires, Attention Deficit Disorders, Gender Differences
DOI: 10.1177/1087054707308491
ISSN: 1087-0547
Abstract: Objective: The present study investigates teacher and parent reports of inattention and emotional symptoms in 6,229 primary school children. Method: The assessment included the Emotional Symptoms subscale and the Impact scale from the Strengths and Difficulties Questionnaire and the inattention items from the Swanson, Nolan, and Pelham IV Questionnaire. Results: Children defined as inattentive showed a high risk of being defined as high scorers on the Emotional Symptoms subscale. A high score on both the Inattention and Emotional Symptoms subscales was associated with a high impact score. Teachers but not parents reported a higher risk of such co-occurrence of symptoms in girls than in boys. Conclusion: Inattentive children should be screened for emotional problems by use of the multi-informants method. (Contains 3 tables.)
Abstractor: Author
Number of References: 37
Entry Date: 2008
Accession Number: EJ793567
Database: ERIC
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  Value: <anid>AN0053241550;gs001mar.08;2010Sep08.14:39;v2.2.460</anid> <title id="AN0053241550-1">Emotional Symptoms in Inattentive Primary School Children </title> <p>580 Emotional Symptoms in Inattentive Primary School ChildrenA Population-Based Study SAGE Publications, Inc.200810.1177/1087054707308491 LinSørensen University of Bergen, Norway, lin.sorensen@psybp.uib.no KennethHugdahl University of Bergen, Norway, and Haukeland University Hospital, Bergen, Norway Astri JohansenLundervold University of Bergen, Norway, and Haukeland University Hospital, Bergen, Norway Authors' Note: This study was financially supported by the Organization of Health and Rehabilitation, the University of Bergen, the Norwegian Directorate for Health and Social Affairs, the Western Norway Regional Health Authority, and the Research Council of Norway. Thanks to the ADHD Organization in Norway for financial support. Our special thanks to C. Gillberg, E. Heiervang, M. Heimann, and K. M. Stormark and the project group of the Bergen Child Study for making this study possible and to Bruno Laeng for comments on the manuscript. And last, thanks of course to all the teachers and parents who participated in the study. Address corre- spondence to Lin Sørensen, Department of Biological and Medical Psychology, University of Bergen, Jonas Lies vei 91, 5009 Bergen, Norway; e-mail: lin.sorensen@psybp.uib.no. Objective: The present study investigates teacher and parent reports of inattention and emotional symptoms in 6,229 primary school children. Method: The assessment included the Emotional Symptoms subscale and the Impact scale from the Strengths and Difficulties Questionnaire and the inattention items from the Swanson, Nolan, and Pelham IV Questionnaire. Results: Children defined as inattentive showed a high risk of being defined as high scorers on the Emotional Symptoms subscale. A high score on both the Inattention and Emotional Symptoms subscales was associated with a high impact score. Teachers but not parents reported a higher risk of such co-occurrence of symptoms in girls than in boys. Conclusion: Inattentive children should be screened for emotional problems by use of the multi-informants method. (J. of Att. Dis. 2008; 11(<reflink idref="bib5" id="ref1">5</reflink>) 580-587 ) inattention emotional symptoms emotional problems ADHD population An “inattentive” child can be defined as one who is not able to concentrate and behave according to what is expected by teachers and parents (Cushman & Johnson, 2001). Such a behavior will very often make the child functionally impaired both at school and at home (Barkley, 1998; Öncü et al., 2004). In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) system, symp- toms of inattention are prominent markers of ADHD (Cushman & Johnson, 2001; Pennington & Ozonoff, 1996), and one of the subtypes of ADHD is described as predominantly inattentive. Typically, in population-based samples, a much higher prevalence of ADHD of the inattentive type is found than in clinical samples (Milich, Balentine, & Lynam, 2001). This may happen because inattention symptoms are more covert than hyperactive and impul- sive symptoms, leading to a “referral bias” in clinical samples (Biederman & Faraone, 2004). Furthermore, children can be defined as inattentive without fulfilling an ADHD diagnosis. Children with epilepsy, hormone disorders, learning disorders, or other psychiatric disor- ders may show symptoms of inattention as part of their dis- order (Cushman & Johnson, 2001; Wilson, 2003). Thus, in answering questions about symptoms of inat- tention, parents and teachers participating in a population- based study may characterize a child as inattentive even though the symptoms are not part of an ADHD diagno- sis. Therefore, in the present study we will use the term 581 inattention to characterize a set of symptoms, not as a term associated with a specific diagnosis. It may be rather straightforward for both teachers and parents to notice inattention symptoms in a child. However, if the child also displays emotional problems, teachers and parents tend to define the problems rather differently. According to Goodman and collaborators (Goodman, Ford, Simmons, Gatward, & Meltzer, 2000), teachers of a child showing poor concentration as well as restless and/or conflictual behavior tend to define the child as inattentive. However, when the child is a quiet student with emotional problems, a teacher may under- report both the symptoms of inattention and emotional problems. On the other hand, parents may spontaneously realize and report that their child is inattentive because of emotional problems (Cushman & Johnson, 2001). That is, whereas the parents may find that their child is exces- sively worried, unhappy, nervous, easily scared, and hav- ing more somatic symptoms than other children in the same age group, teachers are typically more influenced by the child's classroom behavior. Because attentional problems are frequent in children (Cushman & Johnson, 2001) and symptoms of emotional problems predict emotional disorders such as depression and anxiety (Goodman, Ford, et al., 2000; Goodman, Ford, Simmons, Gatward, & Meltzer 2003), it seems important to know more about the coexistence of inattention and emotional problems in primary school children and ultimately how to detect and remedy the problems as early as possible. Another factor to take into consideration in studies of children with inattention is gender. Clinical studies tend to include more boys than girls, and their results may thus be caused by referral bias because of gender differ- ences in phenotypic expression (Biederman et al., 2005; Gaub & Carlson, 1997; Gershon, 2002). Studies of non- referred children have concluded that the clinical presen- tation in inattentive girls tends to be less disruptive than in boys, but that inattentive girls show more severe emo- tional symptoms than boys (Gershon, 2002; Levy, Hay, Bennett, & McStephen, 2005). Other studies have found that gender differences are dependent on the sample source used, in that nonreferred inattentive girls tend to show less severe emotional symptoms than boys (Gaub & Carlson, 1997) or significantly lower emotional symp- tom scores than referred inattentive girls, a difference that is not seen among inattentive boys (Graetz, Sawyer, Baghurst, & Ettridge, 2006). Contradictory findings may also appear because information is collected from either teachers or parents (Gaub & Carlson, 1997; Graetz et al., 2006; Levy et al., 2005). Thus, the findings of earlier studies call for further large-scale studies of gender dif- ferences in symptoms of inattention and emotional problems in nonreferred children and how gender differ- ences are reflected in parent as well as teacher reports. The aim of the present study was to investigate the association between symptoms of inattention and emo- tional problems in a population of 7- to 9-year-old pri- mary school children. The participants were part of a longitudinal study of mental health. In the first phase, both parents and teachers filled out questionnaires (as described in the Method section) aimed at revealing symptoms of inattention as well as emotional problems. The population sample included an equal number of boys and girls. Importantly, the clinical significance of the symptoms was evaluated by specific items asking the informants to evaluate the impact of the symptoms on the child's daily life functioning. From earlier studies, we assumed that emotional problems would be reported more frequently by parents than by teachers. Finally, we expected that children defined as inattentive would show a high risk of emotional problems and that this would be associated with a high impact on everyday functioning. That is, girls were expected to show a higher prevalence of co-occurring symptoms than boys, especially in the parent reports. Method Participants The study is part of the Bergen Child Study (BCS), a large, population-based study (N = 9,430) of emotional and behavioral problems in children attending second to fourth grade (7 to 9 years old) in all schools in Bergen in October 2002. All parents and teachers were asked to complete the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997, 1999) and the DSM-IV diagnos- tic criteria for ADHD and oppositional defiant disorder (ODD; Swanson, Nolan, and Pelham IV Questionnaire [SNAP-IV]; Swanson et al., 2001). Additional ques- tionnaires included the Autism Spectrum Screening Questionnaire (ASSQ; Ehlers, Gillberg, & Wing, 1999) and items relating to learning disabilities, obsessive com- pulsive disorder (OCD), tics, eating and sleeping habits (parent questionnaire), selective mutism (teacher ques- tionnaire), hypoactivity (sluggish tempo; teacher ques- tionnaire), physical health problems, and use of health and educational services. All of the above screening questionnaires were sent to the teachers, who then forwarded the parent version to the parents of all children in their respective classes. Parents then agreed to participate in the study by return- ing an informed consent form together with the ques- tionnaire. A total of 97.4% of the teachers and 74.4% of 582 the parents returned the questionnaire. Thus, in the pre- sent study, we analyzed results from 6,229 children (66% of the total sample; 49.8% boys) where both the parents and teachers completed all items on the inattention sub- scale from the SNAP-IV Scale and the Emotional Symptoms subscales from the SDQ. For more details about the design of the study, see Posserud, Lundervold, and Gillberg (2006) and Heiervang et al. (2007). The Regional Committee of Ethics on Medical Research in Western Norway approved the study. Also, in accordance with Norwegian law, the study was reported to and approved by the ombudsman for privacy in research at Norwegian Social Science Data Services. The Inattention Subscale The Inattention subscale contains the nine items used to define the inattention part of the ADHD diagnosis in the DSM-IV system. These items are identical to the inat- tention items in the SNAP-IV (Swanson et al., 2001), except that SNAP-IV has four levels to evaluate each item, whereas in our study we used three levels: not true, somewhat true, and certainly true. This change was done to adapt the scores to the ones used in the other scales included in the questionnaire. Each answer was assigned a value of 0, 1, or 2, and a sum score ranging from 0 to 18 was computed. High scorers, that is, children labeled inattentive, were those children with a score equal to or above the 95th percentile in the sample, that is, a sum score equal to or higher than 8 points on the Inattention subscale. This cutoff point was selected because earlier studies have shown that a symptom score between the 95th and 98th percentiles is associated with the impairment criteria of an ADHD diagnosis (Root & Resnick, 2003). The Emotional Symptoms Subscale The Emotional Symptoms subscale is part of the SDQ (<ulink href="http://www.sdqinfo.com">www.sdqinfo.com</ulink>). The SDQ is composed of 25 items, divided into five subscales, with items assessing hyper- activity or inattention, emotional symptoms, conduct problems, peer relationship problems, and prosocial behavior. Each subscale consists of five questions with three possible answers: not true, somewhat true, or cer- tainly true. The answers are assigned the values 0, 1, or 2, respectively, producing sum scores ranging from 0 to 10 (McMunn, Nazroo, Marmot, Boreham, & Goodman, 2001). Earlier studies have shown that a score above the 95th percentile is associated with emotional problems (Goodman, Renfrew, & Mullick, 2000). Therefore, we used a cutoff score at or above the 95th percentile on the Emotional Symptoms subscale to define high scorers in the present study, that is, children with emotional prob- lems. This equals a sum score equal to or greater than 5 on the parent reports and 4 on the teacher reports. Impact on Everyday Functioning The SDQ impact score (Goodman, 1999) was included to evaluate the clinical significance of symptoms of inat- tention and emotional problems. If a teacher or a parent evaluated a child to have behavioral or/and emotional problems, he or she was asked to answer follow-up ques- tions about distress and social problems in different set- tings: home life, friendships, classroom learning, and leisure activities in parent reports and friendships and classroom learning in teacher reports. The answers were assigned a score of 0 (not at all and only a little), 1 (quite a lot), or 2 (a great deal) on each item, producing a sum score ranging from 0 to 10 on the parent reports and 0 to 6 on the teacher reports. In the present study, a score of 2 or higher was used to define impact, in accordance with the recommendation given by Goodman and collabora- tors (Goodman, Renfrew, et al., 2000). A total of 6,195 of the parents and 6,122 of the teachers filled in their answers on the impact part of the SDQ. Statistical Analyses All analyses were performed using SPSS (Version 13). 1. Descriptive statistics (mean, standard deviation) were used to explore the distribution of scores generated from the parent and teacher reports. A parametric independent t test was conducted to examine gender differences, and a Kappa value was calculated to assess the agreement between the two informants (i.e., parents and teachers). 2. A bivariate Pearson correlation analysis was per- formed to explore the association between the Inattention and Emotional Symptoms subscales. Chi-square tests and odds ratios were calculated to analyze differences between the frequency of girls and that of boys in the groups of high and low scorers on the two subscales. 3. To validate the clinical importance of high scores on the Inattention and Emotional Symptoms sub- scales, a cross-table was constructed for children with high and low impact scores on the SDQ, and a chi-square test was computed to evaluate the statistical significance of the results. 4. The effect sizes (d values) were calculated according to the formula d = (MeanLI – MeanNLI)/ pooled standard deviation, where pooled standard deviation2 = [nE – 1](SE)2 + [nc – 1](Sc)2/(nE + nc), 583 Table 1 Inattention and Emotional Symptoms as Reported by Parents and Teachers Note: N = 6,229; 3,103 (49.8%) boys and 3,126 (50.2%) girls. *p < .01. **p < .001. where nE and nc are the number of observations in the two groups and SE and Sc are the standard deviations for the two groups. S pooled is the square root of S2 pooled. A general guideline for interpreting the d value is that a d of .20 is small, a d of .50 is moderate, and a d of .80 is large (Cohen, 1988). Results Distribution and Informant Agreement on the Two Subscales A high percentage of children was reported with a zero-sum score on the Inattention subscale in the teacher and parent reports, 57.8% and 37.5%, respectively. On the Emotional Symptoms subscale, a zero-sum score was reported by 71.8% of the teachers and 45.8% of the parents. The agreement between the two informants was low but statistically significant for both subscales (Inattention subscale, k = .1, p < .001; Emotional Symptoms subscale, k = .09, p < .001). Table 1 presents the means and standard deviations on the two subscales. Overall, the parents reported higher symptom scores than the teachers. The mean parent score on the Inattention subscale was significantly higher for the boys than for the girls (t = 14.8, df = 6227, p < .001). The same direction of gender difference in mean scores appeared in the teacher reports (t = 20, df = 6227, p < .001). Whereas the effect size was moderate for the teachers (d = .51), it was small in the parent reports (d = .38). On the Emotional Symptoms subscale, parents reported an opposite gender difference, with the girls obtaining a significantly higher mean score than the boys (t = –2.8, df = 6227, p = .006), but with negligible effect size (d = .06). Within the two gender groups, we find that the parents reported a higher symptom score than the teachers, but the effect sizes were small on both the Inattention (d = .35) and the Emotional Symptoms subscales (d = .15). The effect size was also small on the Inattention subscale for girls (d = .32) but moderate on the Emotional Symptoms subscale (d = .41). Correlations Between the Two Subscales The correlation analysis revealed a statistically signif- icant correlation between the Inattention and Emotional Symptoms subscales in both the parent and the teacher reports (Table 1). Low and High Scorers on the Inattention and Emotional Symptoms Subscales Table 2 shows the frequency of boys and girls defined as high scorers according to the parent and teacher reports on the two subscales. On the Inattention subscale, significantly more boys than girls were defined as high scorers, according to both the parent reports (χ2 = 73.7, df = 1, p < .001) and the teacher reports (χ2 = 150.3, df = 1, p < .001). The gender differences were smaller, and nonsignificant, for the Emotional Symptoms sub- scale than for the Inattention subscale. The fourth and fifth columns in Table 2 shows the number of boys and girls who were high scorers on both the Inattention and Emotional Symptoms subscales. Both parents and teachers rated significantly more boys than girls as higher scorers on both subscales (parents, χ2 = 17.9, df = 1, p < .001; teachers, χ2 = 20.8, df = 1, p < .001). The risk of being defined as a high scorer according to the Emotional Symptoms subscale was very high in children also defined as high scorers according to the Inattention subscale, especially for girls as rated by teachers (odds ratio = 12.92). The interrater-reliability analysis revealed a moderate and statistically significant agreement between parents and teachers in their reports of high scorers on the Inattention subscale (k = .36, p < .001). The agreement 584 Table 2 Frequency of High Scorers and Risk Estimates on the Inattention and Emotional Symptoms Subscales was low, but statistically significant, when defining high scorers on the Emotional Symptoms subscale (k = .19, p < .001) as well as when defining high scorers on both the Inattention and Emotional Symptoms subscales (k = .25, p < .001). Impact on Everyday Functioning Table 3 shows the percentage of children with a high impact score among high scorers on the Inattention and Emotional Symptoms subscales. High scorers according to the Inattention subscale obtained a high impact score significantly more frequently than low scorers, as reported by both parents (χ2 = 1465.6, df = 1, p < .001) and teachers (χ2 = 1802.9, df = 1, p < .001). The same was true for high scorers on the Emotional Symptoms subscale (parents, χ2 = 715.8, df = 1, p < .001; teachers, χ2 = 524.5, df = 1, p < .001). In children defined as high scorers on both subscales, the frequency of a high impact score was even higher, as scored by both parents (χ2 = 807.3, df = 1, p < .001) and teachers (χ2 = 764, df = 1, p < .001). Compared to parents, teachers reported a high percentage of children to have a high impact score (difference compared to parent reports = 21.2%). Discussion The present study revealed a positive correlation between symptoms of inattention and emotional prob- lems in a population of Norwegian primary school children. A large proportion of children defined as inattentive also showed emotional problems. That is, children were defined as high scorers according to both the Inattention and Emotional Symptoms subscales. A corresponding high impact score indicated that a high score on both subscales is associated with a significant impact on the child's daily life functioning. In accordance with earlier studies, more parents than teachers identified emotional problems in their children (Goodman, Ford, et al., 2000). A low agreement between informants was also found on the Inattention subscale, confirming earlier studies showing that parents and teachers in general disagree on how to define children with attention difficulties (Wolraich et al., 2004). When it comes to the definition of high scorers, the agreement was found to be higher on the Inattention subscale than on the Emotional Symptoms subscale. Informant-specific reports are probably related to the fact that parents and teachers observe children in differ- ent social settings and that children may display overt emotionality more easily at home than in the school set- ting. More serious problems of inattention will often influence behavior in a more overt manner in both school and home settings and thus will be easier to identify both by parents and teachers. Earlier studies have shown that parents are more alert to emotional problems than teachers and that the latter are highly influenced by classroom behavior when eval- uating emotional problems in their students. Teachers tend to underreport emotional problems in silent girls (the so-called Halo Effect; Gaub & Carlson, 1997; Gershon, 2002; McGee & Feehan, 1991). In the present study, parents reported a somewhat higher mean score for girls than for boys on the Emotional Symptoms sub- scale, but the small effect size and the negligible gender differences in the teacher reports support that both the parents and teachers were able to observe and report emo- tional problems in girls as well as boys. On the Inattention subscale, the gender differences were found to be in accordance with earlier findings in studies of children with ADHD (Gaub & Carlson, 1997; Gershon, 2002). That is, the mean score for boys was significantly higher than for girls, and the boys were also significantly more often defined as high scorers than the girls. Although this was true for both teacher and parent reports, the identification of high scorers on both the Inattention and the Emotional Symptoms subscales was not exactly as expected. Parent reports were in line with 585 Table 3 Percentages of Children With High Impact Score on the Inattention and Emotional Symptoms Subscales some of the earlier gender findings in nonreferred sam- ples (see Gaub & Carlson, 1997), namely, that boys have a higher risk of showing both types of symptoms than girls. This is not a consistent finding in nonreferred sam- ples when parents are used as informants (Levy et al., 2005), and therefore, in the present study, an opposite gender effect was expected in the parent reports. The teachers, however, reported the highest risk of emotional problems among inattentive girls. This is in accordance with findings in an Australian study of children with ADHD (Levy et al., 2005), where the predominantly inattentive girls showed a significantly higher frequency of separation anxiety disorder than the inattentive boys. In the present study, the teachers reported the gender dif- ference we expected to find in the parent reports. This may indicate that teachers are more aware of signs of sadness and social withdrawal in girls than of those in boys when both groups are defined as inattentive. We suggest that this is influenced by the focus on the failure to detect girls with emotional problems in a classroom situation (Gaub & Carlson, 1997; Gershon, 2002; McGee & Feehan, 1991). On the other hand, if aggres- sive reactions to frustration are more frequent in boys, their problems may be defined as a behavioral problem even if it is an expression of an emotional problem. Both parents and teachers reported that the co- occurrence of inattention and emotional problems, defined as high scores on both the Inattention and Emotional Symptoms subscales, was associated with a significant influence on the child's daily life functioning. This was true in both the parent and teacher reports. There were, however, some informant-specific gender differences. That is, the teachers reported a higher per- centage of girls to have a high impact score than the parents, whereas the percentages were similar for the two informants when relating to boys. When the children were rated as high scorers on both scales, the gender difference was small in the teacher reports, indicating that gender is not as critical to the observation of impaired function in a school setting as it is at home. The main strength of the present study was the inclu- sion of a high number of 7- to 9-year-old children. Early detection of emotional problems in children with atten- tion problems is important in order to prevent more severe disorders. By including an equal number of girls and boys, we could analyze gender differences more closely than in more recent studies of nonreferred sam- ples (Biederman et al., 2005). We did confirm earlier findings of a high frequency of emotional problems among inattentive boys and girls, but we also found that the reports were informant dependent. The low agree- ment between teachers and parents, as well as the sug- gested importance of the context where the child is observed, points to the importance of including both teachers' and parents' reports in population-based studies (Arnold, 1996). Furthermore, the interindividual vari- ability among inattentive children underscores the need to take a wide range of comorbid symptoms into account. Future studies should also take into account the developmental course of the symptoms' expression. According to several studies, there are no marked gender differences in preadolescent internalizing disorders (Messer, Goodman, Rowe, Meltzer, & Maugham, 2006), but such problems will more often appear later in ado- lescence (Chesney-Lind & Sheldon, 1998; Gaub & Carlson, 1997; Wade, Cairney, & Pevalin, 2002), and they will also remain less stable in girls than in boys (Gaub & Carlson, 1997; Gershon, 2002). In the present study, we focused on symptoms of inat- tention and emotional problems but not on symptom clusters that are necessary to fulfill any diagnostic cri- terium. Difficulties in selecting cutoff points are obvious in the study. Earlier studies predicting diagnosis have shown that the use of cutoff points in population-based samples generates a higher frequency of false negatives than in a clinical sample (Goodman et al., 2003). The selection of cutoff points for defining children with inat- tention and emotional problems is thus critical. A lower cutoff score than the one used in the present study could have minimized the number of false negatives, but could have resulted in the inclusion of a higher number of children with scores that are evaluated to be within the normal range. Our cutoff points were chosen as an optimal trade-off between conflicting requirements. We did not control for the coexistence of hyperactivity, ODD, and conduct disorder (CD). A previous study has shown that the influence of depression and anxiety may be equal when predicted from hyperactivity and inatten- tion symptoms when externalizing disorders such as CD 586 and ODD are controlled for (Power, Costigan, Eiraldi, & Leff, 2004). Furthermore, a strong link between emo- tional symptoms such as depression or anxiety and behavioral disorders has been demonstrated among both boys (Loeber, Burke, Lahey, Winters, & Zera, 2000) and girls (Biederman et al., 1999). Further studies should thus include information about behavioral and emotional disorders. Conclusion The high frequency of emotional symptoms and its impact on the child's daily function has to be considered by the school and health services when dealing with an inattentive child. Symptoms of emotional problems may predict a depressive or anxiety disorder (Goodman, Ford, et al., 2000; Goodman et al., 2003), and the importance of early identification of such symptoms is emphasized by the fact that major depression is one of the main risks for suicide among children and adolescents (Wu et al., 1999). Previous studies have shown that children with emotional symptoms are less frequently identified and referred to mental health services than children with more externalizing symptoms (Angold, Costello, Farmer, Burns, & Erkanli, 1999; Wu et al., 1999), a finding that recently was confirmed in the BCS (Heiervang et al., 2007). This illustrates the importance of screening children defined as inattentive for possible emotional problems to enable optimal treatment. Early identification of inattention is probably also necessary to prevent the development of more complex emotional and behavioral problems that are difficult to treat at later stages of development (Squires, Bricker, & Twombly, 2004). This is emphasized by the Biederman et al. (1999) findings that the coexistence of ADHD, mood disorders, and/or anxiety is associated with a poor treatment out- come (Arnold, 1996). From the present results, we there- fore recommend that emotional function should be evaluated in primary school children where teachers and/or parents report symptoms of inattention. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author . Angold, A., Costello, E.J., Farmer, E.M.Z., Burns, B.J., & Erkanli, A. (1999). Impaired but undiagnosed. Journal of the American Academy of Child and Adolescent Psychiatry, 38(<reflink idref="bib2" id="ref2">2</reflink>), 129-137. Arnold, L.E. (1996). Sex differences in ADHD: Conference summary. Journal of Abnormal Child Psychology, 24(<reflink idref="bib5" id="ref3">5</reflink>), 555-569. Barkley, R.A. (1998). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford. Biederman, J., & Faraone, S.V. (2004). The Massachusetts General Hospital studies of gender influences on attention deficit/hyperactivity disorder in youth and relatives. Psychiatric Clinics of North America, 27(<reflink idref="bib2" id="ref4">2</reflink>), 225-232. Biederman, J., Faraone, S.V., Mick, E., Williamson, S., Wilens, T.E., Spencer, T.J., et al. (1999). Clinical correlates of ADHD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38(<reflink idref="bib8" id="ref5">8</reflink>), 966-975. Biederman, J., Kwon, A., Aleardi, B.A., Chouinard, V.-A., Marino, T., Cole, H., et al. (2005). Absence of gender effects on attention deficit hyperactivity disorder: Findings in nonreferred subjects. American Journal of Psychiatry, 162(<reflink idref="bib6" id="ref6">6</reflink>), 1083-1089. Chesney-Lind, M., & Sheldon, R. (1998). Girls, delinquency, and juvenile justice. Belmont, CA: Wadsworth. Cohen, J. (1988). Statistical power and analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum. Cushman, T.P., & Johnson, T.B. (2001). Understanding “inattention” in children and adolescents. Ethical Human Sciences and Services, 3(<reflink idref="bib2" id="ref7">2</reflink>), 107-125. Ehlers, S., Gillberg, C., & Wing, L. (1999). A screening questionnaire for Asperger syndrome and other high-functioning autism spectrum disorders in school age children . Journal of Autism and Developmental Disorders, 29(<reflink idref="bib2" id="ref8">2</reflink>), 129-141. Gaub, M., & Carlson, C.L. (1997). Gender differences in ADHD: A meta-analysis and critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 36(<reflink idref="bib8" id="ref9">8</reflink>), 1036-1045. Gershon, J. (2002). A meta-analytic review of gender differences in ADHD. Journal of Attention Disorders, 5(<reflink idref="bib3" id="ref10">3</reflink>), 143-154. Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry , 38(<reflink idref="bib5" id="ref11">5</reflink>), 581-586. Goodman, R. (1999). The extended version of the Strengths and Difficulties Questionnaire as a guide to child psychiatric caseness and consequent burden . Journal of Child Psychology and Psychiatry, 40(<reflink idref="bib5" id="ref12">5</reflink>), 791-799. Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2000). Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. British Journal of Psychiatry, 177, 534-539. Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2003). Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. International Review of Psychiatry, 15(1/2), 166-172. Goodman, R., Renfrew, D., & Mullick, M. (2000). Predicting type of psychiatric disorder from Strengths and Difficulties Questionnaire (SDQ) scores in child mental health clinics in London and Dhaka. European Child and Adolescent Psychiatry , 9(<reflink idref="bib2" id="ref13">2</reflink>), 129-134. Graetz, B.W., Sawyer, M.G., Baghurst, P., & Ettridge, K. (2006). Are ADHD gender patterns moderated by sample source ? Journal of Attention Disorders, 10(<reflink idref="bib1" id="ref14">1</reflink>), 36-43. Heiervang, E., Stormark, K.M., Lundervold, A.J., Heimann, M., Goodman, R., Posserud, M.B., et al. (2007). Psychiatric disorders in Norwegian 8- to 10-year-olds: An epidemiological survey of prevalence, risk factors, and service use. Journal of the American Academy of Child and Adolescent Psychiatry, 46(<reflink idref="bib4" id="ref15">4</reflink>), 438-447. Levy, F., Hay, D.A., Bennett, K.S., & McStephen, M. (2005). Gender differences in ADHD subtype comorbidity . Journal of the American Academy of Child and Adolescent Psychiatry, 44(<reflink idref="bib4" id="ref16">4</reflink>), 368-376. 587 Loeber, R., Burke, J.D., Lahey, B.B., Winters, A., & Zera, M. (2000). Oppositional defiant and conduct disorder: A review of the past 10 years, Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 39(<reflink idref="bib12" id="ref17">12</reflink>), 1468-1484. Messer, J., Goodman, R., Rowe, R., Meltzer, H., & Maugham, B. (2006). Preadolescent conduct problems in girls and boys . Journal of American Academy of Child and Adolescent Psychiatry , 45(<reflink idref="bib2" id="ref18">2</reflink>), 184-191. McGee, R., & Feehan, M. (1991). Are girls with problems of attention underrecognized? Journal of Psychopathology and Behavioral Assessment, 13(<reflink idref="bib3" id="ref19">3</reflink>), 187-198. McMunn, A.M., Nazroo, J.Y., Marmot, M.G., Boreham, R., & Goodman, R. (2001). Children's emotional and behavioural well-being and the family environment: Findings from the Health Survey for England. Social Science and Medicine, 53(<reflink idref="bib4" id="ref20">4</reflink>), 423-440. Milich, R., Balentine, A.C., & Lynam, D.R. (2001). ADHD combined type and ADHD predominantly inattentive type are distinct and unrelated disorders. Clinical Psychology Science and Practice, 8(<reflink idref="bib4" id="ref21">4</reflink>), 463-488. Öncü, B., Öner, Ö., Öner, P., Erol, N., Aysev, A., & Canat, S. (2004). Symptoms defined by parents' and teachers' ratings in attention-deficit hyperactivity disorder: Changes with age. Canadian Journal of Psychiatry, 49(<reflink idref="bib5" id="ref22">5</reflink>), 487-491. Pennington, B.F., & Ozonoff, S. (1996). Executive functions and developmental psychopathology . Journal of Child Psychology and Psychiatry, 37(<reflink idref="bib1" id="ref23">1</reflink>), 51-87. Posserud, M.-B., Lundervold, A.J., & Gillberg, C. (2006). Autistic features in a total population of 7-9-year-old children assessed by the ASSQ (Autism Spectrum Screening Questionnaire). Journal of Child Psychology and Psychiatry, 47(<reflink idref="bib2" id="ref24">2</reflink>), 167-175. Power, T.J., Costigan, T.E., Eiraldi, R.B., & Leff, S.S. (2004). Variations in anxiety and depression as a function of ADHD subtypes defined by DSM-IV: Do subtype differences exist or not? Journal of Abnormal Child Psychology, 32(<reflink idref="bib1" id="ref25">1</reflink>), 27-37. Root, R.W.I., & Resnick, R.J. (2003). An update on the diagnosis and treatment of attention-deficit/hyperactivity disorder in children. Professional Psychology: Research and Practice, 34(<reflink idref="bib1" id="ref26">1</reflink>), 34-41. Squires, J., Bricker, D., & Twombly, E. (2004). Parent-completed screening for social emotional problems in young children: The effects of risk/disability status and gender on performance. Infant Mental Health Journal, 25(<reflink idref="bib1" id="ref27">1</reflink>), 62-73. Swanson, J.M., Kraemer, H.C., Hinshaw, S.P., Arnold, L.E., Conners, C.K., Abikoff, H.B., et al. (2001). Clinical relevance of the primary findings of the MTA: Success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 40(<reflink idref="bib2" id="ref28">2</reflink>), 168-179. Wade, T., Cairney, J., & Pevalin, D. (2002). Emergence of gender differences in depression during adolescence: National panel results from three countries. Journal of American Academy of Child and Adolescent Psychiatry, 41(<reflink idref="bib2" id="ref29">2</reflink>), 190-198. Wilson, B.J. (2003). The role of attentional processes in children's prosocial behavior with peers: Attention shifting and emotion. Development and Psychopathology, 15(<reflink idref="bib2" id="ref30">2</reflink>), 313-329. Wolraich, M.L., Lambert, E.W., Bickman, L., Simmons, T., Doffing, M.A., & Worley, K.A. (2004). Assessing the impact of parent and teacher agreement on diagnosing attention-deficit hyperactivity disorder. Journal of Development and Behavioral Pediatrics, 25(<reflink idref="bib1" id="ref31">1</reflink>), 41-47. Wu, P., Hoven, C.W., Bird, H.R., Moore, R.E., Cohen, P., Alegria, M., et al. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38(<reflink idref="bib9" id="ref32">9</reflink>), 1081-1089. Lin Sørensen is a psychologist and PhD student at the University of Bergen, Norway. Her interests in research are neuropsychology and children with attention difficulties and ADHD symptoms combined with emotional symptoms. Kenneth Hugdahl is a professor of biological psychology and head of the Cognitive Neuroscience Group at the University of Bergen, Norway. His research interests are in cognitive neuro- science and functional neuroimaging, with a focus on attention and language. Astri Johansen Lundervold is a professor in neuropsychol- ogy and head of the Neuropsychological Phenotyping Group at the University of Bergen, Norway. Her research interests are in individual differences in normal functions and neuropsy- chiatric disorders.</p> <aug> <p>By Lin Sørensen; Kenneth Hugdahl and Astri Johansen Lundervold</p> </aug> <nolink nlid="nl1" bibid="bib5" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib2" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib8" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib6" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib3" firstref="ref10"></nolink> <nolink nlid="nl6" bibid="bib1" firstref="ref14"></nolink> <nolink nlid="nl7" bibid="bib4" firstref="ref15"></nolink> <nolink nlid="nl8" bibid="bib12" firstref="ref17"></nolink> <nolink nlid="nl9" bibid="bib9" firstref="ref32"></nolink>
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  Group: Ti
  Data: Emotional Symptoms in Inattentive Primary School Children: A Population-Based Study
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  Data: English
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  Data: <searchLink fieldCode="AR" term="%22Sorensen%2C+Lin%22">Sorensen, Lin</searchLink><br /><searchLink fieldCode="AR" term="%22Hugdahl%2C+Kenneth%22">Hugdahl, Kenneth</searchLink><br /><searchLink fieldCode="AR" term="%22Lundervold%2C+Astri+Johansen%22">Lundervold, Astri Johansen</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2008 11(5):580-587.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
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  Data: PDF
– Name: Pages
  Label: Page Count
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  Data: 8
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  Label: Publication Date
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  Data: 2008
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  Data: Journal Articles<br />Reports - Research
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  Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Emotional+Problems%22">Emotional Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Attitudes%22">Parent Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Teacher+Attitudes%22">Teacher Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Measures+%28Individuals%29%22">Measures (Individuals)</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Change%22">Behavior Change</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Elementary+School+Students%22">Elementary School Students</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Disorders%22">Attention Deficit Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink>
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  Label: DOI
  Group: ID
  Data: 10.1177/1087054707308491
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: The present study investigates teacher and parent reports of inattention and emotional symptoms in 6,229 primary school children. Method: The assessment included the Emotional Symptoms subscale and the Impact scale from the Strengths and Difficulties Questionnaire and the inattention items from the Swanson, Nolan, and Pelham IV Questionnaire. Results: Children defined as inattentive showed a high risk of being defined as high scorers on the Emotional Symptoms subscale. A high score on both the Inattention and Emotional Symptoms subscales was associated with a high impact score. Teachers but not parents reported a higher risk of such co-occurrence of symptoms in girls than in boys. Conclusion: Inattentive children should be screened for emotional problems by use of the multi-informants method. (Contains 3 tables.)
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  Data: 37
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  Group: Date
  Data: 2008
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  Label: Accession Number
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  Data: EJ793567
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ793567
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        Value: 10.1177/1087054707308491
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
        StartPage: 580
    Subjects:
      – SubjectFull: Emotional Problems
        Type: general
      – SubjectFull: Parent Attitudes
        Type: general
      – SubjectFull: Teacher Attitudes
        Type: general
      – SubjectFull: Measures (Individuals)
        Type: general
      – SubjectFull: Program Effectiveness
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      – SubjectFull: Behavior Change
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Elementary School Students
        Type: general
      – SubjectFull: Questionnaires
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      – SubjectFull: Attention Deficit Disorders
        Type: general
      – SubjectFull: Gender Differences
        Type: general
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      – TitleFull: Emotional Symptoms in Inattentive Primary School Children: A Population-Based Study
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            NameFull: Sorensen, Lin
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            NameFull: Lundervold, Astri Johansen
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            – TitleFull: Journal of Attention Disorders
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