cont 180 Some Issues and Instruments for the Assessment of Attention-Deficit Hyperacti ity Disorder in Puerto Rican Children José J. Bauermeister, Vanessa Berrios, Aida L. Jiménez, and Leticia Acevedo University of Puerto Rico Michael Gordon Health Science Center at Syracuse State University of New York Found that teachers’ ratings of a representative sample of 961 Puerto Rican 5- to 13-year-olds suggested an inordinately high number of students qualifying for a diagnosis of attention deficit disorder with hyperactivity (ADDH) or ‘attention-deficit hyperactivity disorder (ADHD). There is a need to take into consideration sociocultural issues and the use of appropriate norms in this diagnosis. We describe two instruments that have been standardized for Puerto Rican children, the Inventario de Comportamiento Escolar (the School Behavior Inventory, a teacher rating scale) and the Gordon Diagnostic System (a laboratory measure of inattention), and we present data and guidelines that could prove useful in assessing and diagnosing ADDH or ADHD in Puerto Rican children. During the past 20 years, the importance of interpreting clinical data in the context of a childs home, school, and sociocultural environment has been increasingly recognized. The need for a com- prehensive assessment that takes into consider- ation sociocultural variables has additional impor- tance when ethnic minority children, particularly Hispanics, are evaluated. Hispanic children are at high risk of biased assessments due to the absence of valid and reliable cognitive, personality, achievement, and behavioral tests (Olmedo, 1981; Padilla, 1979), Even more important isthe issue of the validity of diagnostic criteria for children whose cultural background is different from the ‘This research was supported in part by the University of Puerto Rico Institutional Research Fund to José. J Beucrmcster ‘Part of this article is based on master’s thesis research completed by Vanessa Berrios, Aida L. Jiménez, and Leticia ‘Acevedo under the direction of José J. Rauermeister in the Department of Psychology atthe University of Puerto Rio. (Copies of the IDCE and of the GDS norms ean be obtained from José J. Bauermeister. ‘We gratefully acknowledge the contributions of Dolores Miranda and Raul Sost as committee members. We are specially appreciative ofthe assistance provided by Nya E. ‘Vargas inthe analysis of the dats Requests for reprints should be sent to Jos J. Bavermeite, Department of Psychology, University of Puerto Rico, Rio Piedras, PR 00831 ‘one from which the diagnostic criteria were origi- nally formulated. Unfortunately, cultural influ- fences have not been taken into account in the formulation and application of diagnostic-clas- ification systems. This is particularly true for Hispanic children who are suspected of presenting an attention deficit disorder with hyperactivity (ADDH) or an attention-deficit hyperactivity disorder (ADHD) as defined in the Diagnostic and Statistical Manual of Mental Disorders (3rd. ed. & 3rd. ed. rev. IDSM-IT & DSM-III-R}, American Psychiatric Association, 1980, 1987, respectively). This dis- order consists of developmentally inappropriate inattention, impulsivity, and activity as reported by adults in the child’s environment. In the for- mulation of this DSM-IIT or DSM-III-R diagno- teachers’ reports of these behaviors are of considerable importance because as compared to Parents, teachers are more familiar with age- appropriate behavioral norms. The DSM-HT re- ‘quires that the following number of symptoms be present for a diagnosis of ADDU: three of five in the inattention area, three of six in the impulsivity area, and two of five in the hyperactivity area. As currently proposed in the DSM-II-R criteria, for a diagnosis of ADHD to be made, any 8 of 14 symptoms must be present. How frequently are these behaviors perceivedBAUERMEISTER, BERRIOS, JIMENEZ, ACEVEDO, & GORDON by the teachers of Hispanic children in the class- room setting? That is, what are the base rates of ADDH or ADHD symptoms? Data pertinent to this question were obtained in the process of developing a teacher rating scale for Puerto Rican children, the Inventario de Comportamiento Escolar (IDCE; the School Behavior Inventory), that included many of the ADDH and ADHD symptoms. In this study (Bauermeister, Vargas, Colberg, Gonzalez, & Carroll, 1987), 481 teachers rated 961 children, ages 5 to 13 years, who at- tended public and private schools in Puerto Rico. ‘The sample of children was randomly selected and was stratified by sex, grade, and geographical region. The items or symptoms were rated ac- cording to the following frequency scale: never, at times, frequently, most of the time, and almost always. As can be seen from Table 1, a high percentage of students were rated as presenting the “symp- toms” in the classroom setting. For example, 27% oor more of the students were rated as presenting ‘never or only at times positive behaviors such as completing schoolwork, listening, keeping busy, organizing materials, waiting turns, following in- structions, remaining seated, and remaining quiet. On the other hand, 19% or more were rated as presenting frequently, most of the time, or almost always negative behaviors such as activing impul- sively, need of supervision, acting as if “driven by ‘@ motor,” talking, and moving continuously. Possible explanations for these findings are that Puerto Rican teachers tend to overreport symp- toms and/or that the curricula, teaching methods, and school environment do not facilitate more appropriate classroom behaviors. However, an additional explanation could be found when the patterns of nonverbal communication of Hispanic children are examined. It has been stated that Hispanics, specifically Puerto Ricans, (a) manifest more body move- ments, gestures, and facial expressions, (b) have closer interpersonal space and get physically closer to others, (¢) touch more, and (d) move their eyes more and focus on the listener's face less while talking than do Anglo Americans (Nine-Curt, 1976). In addition, it has been argued that the Hispanic culture organizes activities in circular fashion, doing many things in one unit of time (polychronic), whereas the Anglo culture orga- nizes activities linearly, sequentially, doing one thing at a time (monochronic). Instances of more ‘than three children offering their homework to the teacher for inspection at the same time or an- swering at once and together are examples of the polychronic cultural style. ‘The teacher in turn could accept these students’ behaviors, and pos- sibly reinforce them at least intermittently, with- Table 1, Percentage of Students Rated as Presenting DSM-III, DSM-III-R, or Related Symptoms of ADHD in the Classroom Frequency Seale 1 2 3 4 5 Symptom Never AUTimes Frequendy Most of the Time ‘Almost Always Finishes Schoolwork 7 25 1s ry = Listens tothe Teacher 3 26 20 2 28 Distracs Easily 2 36 2 2 3 ‘Concentrates | s 28 a 9 28 Keeps Busy on Tasks 5 26 1 2 3 ‘Acts Impulsvely 2 36 2 6 6 2 2» 0 5 2 Organizes Books n 8 16 2 2 [Needs Supervision 8 8 6 10 2 Interrupts (Calls Out) *° » B 5 5 Waits Tun 8 2 4 rr) “ Follows Instructions 5 2% 0 @ 33 ‘Remains in Classroom 2 6 B 9 9 Walks Around 7 30 7 3 3 Climbs on Things a 2 4 2 1 Remains Seated 1 1 2 8 ° “Driven by a Motor" « 2 3 5 6 Talks 20 a 6 7 0 Moves Continuously a 2 " 4 1 Remains Quiet 37 9 15 B a Noie: Percentages were rounded up to the nearest whole number; therefore, the sui across frequency categories is not necessarily 10%. 0ADHID IN PUERTO RICAN CHILDREN ‘out being excessively upset by their demands (Nine- Curt, 1976). Itis conceivable that these culturally determined styles of responding in a structured environment, such as the classroom, can result in a higher frequency of behaviors of apparent inattentive- impulsivity, and overactivity in Puerto Rican children than in Anglo children. This possiblity is supported by the findings of a recent study (Achenbach et al., 1989) in which demographically. matched samples from the general population of the United States and from Puerto Rico were ‘compared with respect to teacher ratings on the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983). In this study, Puerto Rican ‘teachers reported significantly more behavior problems than their U.S. counterparts. It is also possible, according to the adult distress threshold ‘model used to describe referral problems in Thai- land and the United States (Weisz, Suwanlert, Chaiyasit, & Walter, 1987), that Anglo teachers could find the behavior pattern of Hispanic chil- dren to be distressing and in need of professional intervention, whereas a Hispanic teacher might not. If a clinician, unaware of the base rates of the symptoms and the cultural issues involved, is to give primary consideration to the teacher reports (as the DSM-III and DSM-IH-R advise), an inordinately high number of Puerto Rican chil- dren could qualify for the diagnosis of ADDH or ADHD. The need to develop diagnostic criteria that take into account sociocultural issues and relevant as- sessment instruments is further supported by the findings of a comprehensive and methodologically rigorous epidemiological study recently completed in Puerto Rico (Bird et al., 1988). The epidem- iologic survey was carried out on a probability sample of the population of Puerto Rico for ages 4 to 16 years. The survey used a Spanish adapta- tion of the CBCL as a screening instrument. Prevalence rates were estimated on the basis of DSM-III clinical diagnoses and other measures provided by child psychiatrists. The authors com- mented that inordinately high prevalence rates of childhood maladjustment are obtained if pub- lished CBCL cutpoints for U.S. children are used. as a categorical definition of disorder (Bird et a. 1988). In addition, a high proportion of children (49.4%) met the criteria for one or more disorders. when’ the applicable DSM-III categories were taken into consideration. When the degree of maladaptive functioning, as indicated by a score of 60 of less in the Children’s Global Assessment Scale (CGAS; Bird, Canino, Rubio-Stipec, & Ribera, 1987), was used as an additional criterion, the estimated prevalence rates decreased to 18.0%, ‘One of the most striking reductions brought about by the inclusion of the CGAS as a measure of impairment was found for the diagnosis of atten- tion deficit disorder. The weighted prevalence rate for this disorder based on DSM-III criteria was 16.2%; the inclusion of CGAS scores as additional, criteria reduced the prevalence rate to 9.5% (Bird et al., 1988; Bird, Gould, Yager, Staghezza, & Canino, 1989). ‘The IDCE, The comprehensive evaluation of ADDH ot ADHD children requires a multimodal assessment that includes interviews with parents, teachers, and the child; use of parent and/or teacher rating scales; behavioral measures, and other psycho- diagnostic techniques Barkley, 1981). During the last few years, we have been working on the development of assessment instruments for the identification of Puerto Rican children with a ‘behavior pattern of ADHD (Bauermeister, 1986). ‘One approach has been to examine the factorial organization of teacher ratings of classroom be- haviors and school performance difficulties with large samples of male and female children strati- fied by sex, type of school, and geographical region. Factor analyses of these samples have yielded the following factors: Inattention, Hyper- activity, Inappropriate Social Behavior, Irrita- bility-Hostility, Anxiety, Reading-Spelling, Ex- pressive Language, Memory, Directionality- Laterality, and Motor Skills (Bauermeister et al. 1987). The stability of the factorial structure ob- tained was assessed by calculating coefficients of congruence (Harman, 1967) between factors de- rived from analyses of the total sample with the male and female samples, and then between the male and female samples. The makeup of the factors remained stable across samples as shown by the size of the coefficients. The latter ranged from .84 (Anxiety) to .99 (Inappropriate Social Behavior). The factorial organization obtained provided the conceptual framework for the development of rating scales and the IDCE. The scales have adequate internal consistency (mean alpha coeffi- cients and item-total correlations = .90 and .67, respectively). Test-retest reliability ranged from .70 t0 .90 over a 4-week period (Bauermeister et al., 1987). The classroom behavior scales of the IDCE that are relevant to the diagnosis of ADDH or ADHD are briefly described. The Inattention scale in- cludes ratings of lack of motivation, persistence, and concentration; laziness; need of supervision; 1"BAUERMEISTER, BERRIOS, JIMENEZ, ACEVEDO, & GORDON, difficulties in organizing and completing works not listening and following instructions; distrac- tion; “blank stare”; and immaturity. It assesses a behavioral cluster that is similar to the symptoms of inattention listed in the DSM-I17 and DSM-II-R. The Hyperactivity scale clusters items related to calling out in class, moving around the classroom, acting as if “driven by a motor,” talking, singing, climbing, making noises, changing activities abruptly, and acting impul- sively. This scale also assesses ratings of the symptoms of hyperactivity listed in the DSM-IIT and DSM-III-R. The Inappropriate Social Be- havior scale assesses teachers’ ratings of sharing, ‘obedience, peer acceptance, waiting turns, getting along well with peers, telling the truth, remaining in the classroom or seated when so required, and happiness. This scale has the potential of pro- viding information on the child's personal and social adjustment, as perceived by the teacher. The Irritability-Hostility scale assesses ratings of anger outbursts, icitability, tantrums, being easily an- geted, abrupt mood changes, stubbornness, ing, and disrespectful behavior toward teachers. Finally, the Anxiety scale, in addition to the Inappropriate Social Behavior and_Irritability- Hostility scales, provides ratings of the teacher's perceptions of additional potential areas of be- havior difficulties for the inattentive and/or hy- peractive child (Bauermeister et al., 1987). ‘The IDCE also includes a Situational Behavior Problem scale (SBPS), which consists of 12 school situations in-which a behavior problem might be observed. The teacher is asked to indicate whether or not the child presents a behavior problem in cach situation. If the response is in the affirma- tive, the severity of the behavior problem is rated on a scale ranging from mild (1) to severe (S). This seale was developed based on Barkley’s (1981) School Situations Questionnaire to assess the per- vasiveness of the behavior problems rated by the teacher. Finally, because children with ADDH are also at risk for presenting learning disabilities and underachievement (Barkley, 1981), the IDCE includes rating scales for school performance dif- ficulties. Examples of these scales are Reading- Writing, Expressive Language, Memory, Direc- tionality-Laterality, and Motor Skill. ‘The IDCE can provide researchers and practi- tioners with data that can enhance the develop: ‘ment of a comprehensive and integrated picture of a Puerto Rican child's behavior. In addition, it permits the evaluator to compare teachers’ ratings of classroom behavior, academic difficulties, and situational behavior problems on individual chi dren with baselines for typical peers of compa- 2 rable linguistic and sociocultural environments relative to a child’s grade level, sex, and type of school. The GDS The second approach that we have followed in the assessment of Puerto Rican children who are suspected of ADDH or ADHD is the inclusion of data based on the actual behavior of the child. Relevant behavioral data can be provided by the Gordon Diagnostic System (GDS; Gordon, 1982; Gordon, McClure, & Post, 1986). The GDS is a microprocessor-based, portable unit that allows for the administration of three tasks. The delay task requires the child to inhibit responding to earn points. This task yields three primary scores: (a) total responses, (b) total correct responses, and, (© the efficiency ratio, which represents the per- centage of correct responses. This ratio is concep- tualized as an indicator of the level of impulsivity demonstrated by the child (Gordon et al.,, 1986). ‘The vigilance task, which is an adaptation of the Continuous Performance Test (CPT; Rosvold, sky, Sarason, Bransome, & Beck, 1956), re- quires the child to inhibit responding under con- ditions that make demands for sustained atten- tion. The CPT has been the measure most frequently used to identify the inattention difficul- ties of ADDH children (Klee & Garfinkel, 1983), In the GDS vigilance task, a series of digits flashes one at a time in an electronic display. The child is, told to press the button every time a “I” is, followed by a“9.” The task yields three scores: (a) total correct responses, (b) errors of omission, and (©) errors of commission. For the testing of younger children, the GDS is programmed so that the child is required to press a button every time a “1” appears. The total-correct score provides an index of the child’s ability to achieve and maintain alert, vigilant responding. The errors-of-com- mission score provides an index of impulsivity under the structure imposed by the cognitive de- mands of the task (Gordon et al., 1986). ADD. children typically obtain lower total-correct scores and higher rates of errors-of-commission relative to normal controls (Rapport, DuPaul, Stoner, & Jones, 1986). The third task is the distractibility task, which is identical to the vigilance task except that random digits flash at random intervals on the outer position of the electronic display. The child is still required to press a button when.a “9” comes right after a “I.” The only difference is that numbers flash on either side of the center digit Gordon, 1987). Research results have shown that the scores onADHD IN PUERTO RICAN CHILDREN the delay and vigilance tasks can differentiate ADDH from non-ADDH children from the United States (Gordon, 1979; McClure & Gordon, 1984), Several investigators are evaluating the effectiveness of the GDS for assessing pharmacotherapeutic effects, brain damage, and impulsivity in children | (Gordon, 1987). Validational studies with Puerto Rican children are in progress. Test-retest correlations over a 3- to 4-week period have ranged from .48 for the efficiency ratio to .86 for the errors of omission of the vigilance task (N = 144). Method ‘The GDS was standardized for Puerto Rican 6- to 16-year-old students by Berrios, Jiménez, and Acevedo (1988). In unpublished research, Bauer- ‘meister also extended the standardization to S-year- olds. The combined standardization sample in- cluded 522 children and adolescents from public and private schools or day-care centers. The sample was randomly selected and stratified by grade, sex, and geographical region. Procedures and criteria similar to the ones employed for the USS. standardization sample (Gordon & Mettel- man, 1988) were incorporated for the final selec- tion of subjects. Children who presented a known ‘story of learning disability, mental retardation, neurological dysfunction, school failure, emo- tional disturbance, or ADDH were excluded from the sample. Students with abnormally high scores on the classroom behavior scales of the IDCE or whose ratings met the DSM-II-R criteria of ADHD were also excluded. Results and Discussion To explore possible statistical differences, we conducted 4 (Age) x 2 (Sex) analyses of variance (ANOVAS) on those GDS scores that are more frequently used in clinical work: the efficiency ratio for the delay task, and total correct and errors of commission for the vigilance task. The age groups were 6 to 7, 8 10 9, 10 to 11, and 12 to 16 years. The 5-year-old group was not included because the GDS tasks are simpler and of shorter duration at that age. The ANOVAs revealed sig- nificant effects for age groups. The FG, 415) values for the efficiency ratio, total correct, and errors of commission were 4.10, $6.87, and 20.34, respectively (all ps < .01). The older the child, the higher the efficiency ratio and the total-correct scores for the vigilance task. The errors of com- mission scores for the latter task decreased with age. No significant sex effects or interactions of sex.and age group were found in these analyses. We performed two-way ANOVAs for sex ef- fects and for possible indicators of socioeconomic status (SES). Because a standardized measure of SES similar to the Hollingshead index (Hollingshead & Redlich, 1958) has not been developed for Puerto Rican families, two indica- tors of SES were employed: (a) the type of school the child attended and (b) the teacher's ratings of. the child’s SES (low, middle, or high). Children attending private schools in Puerto Rico are from families of lower-middle to high socioeconomic levels as compared to public school children, who generally come from low and lower-middle socio- economic levels. For example, it has been reported that 84.49% of Puerto Rican public school students live below the official U.S. poverty level (Hernandez, 1989). Two-way ANOVAS for sex of the student and type of school (public vs. private) revealed no significant effects of sex, school, or Sex x School interactions for any of the three scores. ‘The ANOVAS for sex and teacher-perceived level of SES did not yield statistically significant differ- cences for these measures either. The correlations between perceived SES and efficiency ratio, total- correct, and errors-of-commission scores were all nonsignificant (as were the corresponding correla- tions of the Hollingshead index and the GDS for the U.S. standardization sample according to Gordon & Mettelman, 1988). These three scores from the Puerto Rican stan- dardization sample were compared to those from the U.S. standardization sample (Ns = 963 and 830 for the delay and vigilance tasks, respectively). ‘The majority of the children were selected from the greater Syracuse, NY, area The remainder (9%) were from Charlottesville, VA (Gordon & Mettelman, 1988). A. total of 433 children were randomly selected from the U.S. sample and matched with the Puerto Rican sample on the basis of sex and age. SES was not used as a matching variable because the available measures for the two samples were not comparable. In addition, the data reported previously! suggest that GDS scores are not related to SES. The paired 1 tests for each of the four age groups of the standardization samples and for the total sample are presented in Table 2. When the total samples are analyzed, U.S. children obtained significantly higher efficiency ratios and total-correct scores and made significantly fewer errors of commis Additional evidence Is provided by the correlations ob- tained between the Holingshead SES index and the GDS scores for a group of Puecto Rican children (N= 234) who were patt ‘of the epidemiological survey previously desribed (Bird el. 1988). The correlations were —08 (efficiency rato), —.15 (otal core), and 06 (erors of commission). We thank Drs H. Bird and G. Canino for their permission to use these dat, 13BAUERMEISTER, BERRIOS, MENEZ, ACEVEDO, & GORDON Table 2, Means, Standard Deviations, and t Values for Matched Samples of Puerto Rican and U.S. Children on GDS Scores Paerto Rican ype of Seore . ™ ‘> ™ SD ‘ 610 7-Year-Olds ~ [Efficiency Ratio 100 7 18 19 “034 Total Correct 37 at 9.80 6a = 3.260 Exros of Commission a7 16.34 19.44 79 a3 3am 5 to 9-YearOide Efficiency Ratio ior 30 15 = is 150. Total Coreest aL 3891 629 39.96 495 116 Exrors of Commission aL 594 136 5.65 112 22" 10 to 1 Year-Olds Eiicency Ratio 101 a 7 8 a6 i Total Correct 81 aia 381 a2 sis 106 Errors of Commission 8 56 6a 409 60 0.98 Eto 15-Year-Olds - Eiciency Ratio at 8 36 Bn 130 ‘Total Correct BI an a2 224 208, 116 Errors of Commission BL 377 534 2.69 3.90 135 “Total Sample Efficiency Ratio 23 at is = 16 ~ 240° ‘Total Corret 380 sa ra8 40.7% 330 ~ heat Errors of Commission 380 816 ns 496 635 soe ‘Note: Efficiency ratio refers to performance on the delay task; total correct and errors of commission refer to performance on the gitance task tp < 08." < 01 sion, compared with the Puerto Rican sample. ‘Analyses by age groups indicated significant dif- ferences only for total correct and errors of com- mission by the 6- to 7-year-olds and for errors of commission by the 8 to 9-year-olds, Thus, the differences between the two samples are found in the younger age groups. These differences cannot be construed as evi- dence of different ADDH or ADHD prevalence rates for U.S, and Puerto Rican children, because the GDS does not in itself provide a clinical diagnosis. The differences do point to the need for developing norms that take into account the per- formance of Puerto Rican children. The latter GDS norms have been developed using the same procedures employed by Gordon and Mettelman (1988). To reduce the effects of extreme scores and. facilitate meaningful comparisons, GDS raw scores have been converted to percentile ranks (Gordon et al., 1986). Following the scheme de- veloped for the U.S. standardization sample, chil- dren can be classified as presenting an abnormal (Sth percentile or less), borderline (6th to 25th percentile), or normal (26th percentile or more) 4 profile scores on the GDS tasks. Borderline and abnormal scores are considered one of the diag- nostic criteria for ADDH or ADHD (Gordon et al., 1986). As would be expected, a comparison of the Puerto Rican norms with those developed for the United States reveals that applying U.S. norms to Puerto Rican children could lead to an incorrect diagnostic picture. Consider, for example, the hypothetical scores of Carmen and Pedro pre- sented in Table 3. Carmen's scores fall within the borderline range relative to U.S. norms and could be considered for a possible diagnosis of ADDH or ADHD. Relative to her peers, the GDS scores would be considered normal. Pedro, on the other hand, presents a consistent GDS profile of ADDH or ADHD relative to U.S. norms but a marginal profile relative to Puerto Rican norms. ‘As with the IDCE, the GDS can provide mea- sures of impulsivity and inattention on Puerto Rican children that can be compared with ‘baselines for typical peers of comparable sociocul- tural environments. Research is needed, however, to assess the instruments’ efficacy in discrimi- nating between ADHD and non-ADHD childrenADHD IN PUERTO RICAN CHILDREN ‘Table 3. Hypothetical GDS Scores and Classifi- ‘cations According to U.S. and Puerto Rican Norms (Classfcation Score US. Puerto Rican Profile Norms ‘Norms Carmen (Age 7 Eiceney Ratio (70) Torderine Normal Total Comet 28) Bordetline Normal Errors of Commission (2) Borderline Normal Pedro (Age 10) “Efficiency Ratio (73) Borderline Normal ‘Total Correct (39) Abnormal Borderline Errors of Commission (13) Abnormal Borderline ‘Note: Efficiency ratio refers to performance on the delay task; {otal correct and erors of commission refer o performance on the vigilance task. Furthermore, although the information provided bby the IDCE and the GDS scores is a necessary part of arriving at a diagnosis, itis not sufficient for reaching a diagnostic conclusion. ‘A conceptual definition of ADDH or ADHD that takes into account the sociocultural back- ground, values, patterns of communication, ex- pectancies, and child-rearing practices of Hispanic families is needed. In addition, it is necessary to identify whar behaviors—in which contexts, for which sex, and for what age—can be considered significantly deviant. In the case of Puerto Rican. children, the following indicators and guidelines could prove to be useful: 1. IDCE Inattention and Hyperactivity scale scores that are 2 SD above the mean for the child's age, type of school, and sex (Barkley, 1981). 2. Borderline or abnormal scores on the GDS delay and/or vigilance tasks (Gordon et al., 1986). 3. 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