Routine developmental screening at 5.5 and 7 years of age is not an efficient predictor of attention-deficit / hyperactivity disorder at age 10

REGULAR ARTICLE

Routine developmental screening at 5.5 and 7 years of age is not an efficientpredictor of attention-deficit ⁄ hyperactivity disorder at age 10Kirsten Holmberg ([email protected])1, Claes Sundelin1, Anders Hjern1,2

1.Department of Women’s and Children’s Health, Section for Paediatrics, Uppsala University, Uppsala, Sweden2.Centre for Epidemiology, National Board of Health and Welfare, Stockholm, Sweden

KeywordsAttention-deficit ⁄ hyperactivity disorder, Child HealthCentres, Developmental screening, Preschoolchildren, School children

CorrespondenceKirsten Holmberg, Department of Women’s andChildren’s Health, Section for Paediatrics, CentralUnit of Child Healthcare, Uppsala University Chil-dren’s Hospital, SE-751 85 Uppsala, Sweden.Tel: +46-18-611-59-70 |Fax: +46-18-50-45-11 |Email: [email protected]

Received1 September 2008; revised 23 July 2009;accepted 13 August 2009.

DOI:10.1111/j.1651-2227.2009.01504.x

AbstractAim: The aim of this study was to assess the efficiency of developmental screening for deficits in

attention, motor control and perception or attention-deficit ⁄ hyperactivity disorder (DAMP ⁄ ADHD) at

5.5 and 7 years of age for diagnosing ADHD in grade 4.

Method: The study population consisted of 442 children from a cohort study of ADHD in 10-

year olds in one municipality in Stockholm County. Sensitivity, specificity and positive predictive value

of a developmental screening at 5.5 and at 7 years of age for being diagnosed with ADHD at 10 years

of age was calculated.

Results: The sensitivity was 44%, the specificity 85% and the positive predictive value for having

a diagnosis of pervasive ADHD in 4th grade was 15%, when at least two deviations in nine items was

used as the cut-off point in 5.5-year screening at Child Health Centres (CHCs). With a cut-off score of

at least two deviations in four items rated by parents or and teachers in 1st grade, these estimates were

58%, 81% and 15% respectively.

Conclusion: This study demonstrates that developmental screening for DAMP ⁄ ADHD at 5.5 and 7 years of age

does not identify children who are diagnosed with ADHD in grade 4 with a high degree of selectivity.

INTRODUCTIONAttention-deficit ⁄ hyperactivity disorder (ADHD) (1) is oneof the most common behavioural disturbances in schoolchildren with an onset during the preschool period (2,3).The disorder affects 3–5% of school-age children in Swedishpopulation-based studies, and 7–12% if children with lesssevere symptoms are included (3–5). A male:female ratio of6:1 has been reported in 6- to 7-year olds (4–6). ADHD maybe associated with motor and perceptual problems (devel-opmental coordination disorder, DCD) (1). The descriptiveterm deficits in attention, motor control and perception(DAMP) was created by Gillberg et al. to cover a combina-tion of ADHD and DCD in children who do not have severelearning disability or cerebral palsy (5–7). In its more severeform, it has been reported to affect 1.2–2.0% of the generalpopulation of Swedish school-age children, with 5–6% hav-ing more moderate difficulties (4,5,7,8). Comorbidity ofADHD with DCD in 6- to 7-year olds has been estimated tobe about 50% (4,5). Presence of DAMP in 6-year olds

predicts attention-deficits symptoms at age 10, while onlyhalf seems to have motor clumsiness at that age (7,9,10).Young children with ADHD tend to have high rates of lan-guage problems (5,11,12). Cognitive impairments and learn-ing problems are other developmental problems coexistingto a certain extent with ADHD and with DAMP (7,10,11).Children from households with a disadvantaged socioeco-nomic situation are more often diagnosed with ADHD andDAMP (7,11,12).

Troubled peer relationships and academic underachieve-ment have been reported to be associated with DAMP aswell as with ADHD in school children (2,3,7,13,14). Earlyrecognition of these disorders followed by effective inter-ventions has a potential to improve the prognosis of thesedisorders in terms of educational and social outcomes(2,3,15).

Screening of young children has been recommended as apart of child health surveillance for early detection of devel-opmental problems or identification of children who are atrisk of developmental deviation (16–18). Longitudinal stud-ies have demonstrated that the same child may have prob-lems in different domains at different points in time (19).Children with language delay at 2.5 years of age, e.g. maydevelop ADHD at school age (20). Motor clumsiness asso-ciated with DAMP seems to become less obvious withincreasing age (7,9).

Gillberg and Rasmussen developed a screening methodfor DAMP in 7-year-old children (4,6,21) that included

Abbreviation:

ADHD, Attention-deficit ⁄ hyperactivity disorder; CH record,child’s health record; CHS, child health service; DAMP, deficitsin attention, motor control and perception; DCD, developmentalcoordination disorder; DSM-IV, Diagnostic and Statistical Man-ual of Mental Disorders, 4th edition; PPQ, Parent PsychomotorQuestionnaire; WHO, World Health Organisation.

Acta Pædiatrica ISSN 0803–5253

112 ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 112–120

motor examination (22), information from parents (23) andpreschool teachers (6,24,25). This method was introducedas a school entry test for 5.5-year olds in many regionalChild Health Centre (CHC) surveillance programmes inSweden during the 1980s for evaluation of the child’s needfor extra support at school entry or in 1st grade. The effec-tiveness of the preschool screening at 5.5 years of age atCHCs for predicting DAMP ⁄ ADHD in school children hasbeen questioned (26). Existing screening programmesshould be followed up to ensure a scientific basis for theactivities included in the Child health surveillance pro-gramme (27).

The developmental screening at 5–6 years of age is still apart of the Child health surveillance programme (28)(http://www.growingpeople.se). Since 2004, a school entryexamination of 6- to 7-year olds including screening fordevelopmental and behavioural problems by parents andteachers interviews (open-ended questions) has been a partof the Swedish school health surveillance programme (29).Implementation of validated instruments has the potentialto improve the effectiveness of the developmental and men-tal health surveillance (30). The previous Swedish studieshave demonstrated that application of brief screeninginstruments may be feasible for screening for ADHD in theschool health settings (4,5). We decided to assess the effi-ciency of the routine developmental screening for DAM-P ⁄ ADHD at 5.5 years of age at CHC and an alternativedevelopmental screening in grade 1 to predict ADHD ingrade 4 according to the World Health Organisation(WHO) criteria (31) in a population-based sample of Swed-ish fourth graders in a suburb of Stockholm.

SUBJECTS AND METHODS10-year olds in grade 4The entire population of children born 1991 in Sigtuna, amunicipality in Stockholm County, comprised 553 childrenduring the academic year 2001–2002. All schools (main-stream as well as special) in the municipality participated ina screening programme for ADHD in this cohort. The spe-cial education classes included children with intellectualdisabilities or subnormal cognitive abilities (‘slow learners’),autistic spectrum disorders or disruptive behaviour. Com-plete screening information was obtained from teachers andparents for 506 children; 442 of these children had docu-mentation in their CHC records of having been screened forDAMP ⁄ ADHD at 5.5 years ± 3 months. Information of analternative developmental screening in grade 1 was avail-able for 422 of the 506 children in grade 4.

Ethical approval for the study was granted by the ethicscommittee at Karolinska Institutet, Stockholm.

ADHD at 10 years of ageChildren with ADHD in grade 4 were identified in a two-step procedure which has been described more extensivelyin the previous articles (13,32). In the first step, teachersand parents rated the children in a structured questionnaire.In a second step, 93% (118 ⁄ 126) of the screen-positive

children underwent further clinical diagnostic assessmentsof ADHD based on the Diagnostic and Statistical Manual ofMental Disorders, 4th edition (DSM-IV) (1), by an experi-enced child neurologist (KH).

Based on the clinical assessment, the children were classi-fied into four categories: (i) ‘pervasive ADHD’, childrenwho met the DSM-IV criteria for ADHD at home as well asat school; (ii) ‘situational ADHD’, children who fulfilled thecriteria for ADHD in one setting only, either at home (homeonly ADHD) or at school (school only ADHD) (33); (iii)‘subthreshold ADHD’ – children with four or five criteriafor ADHD in one or two settings (34) and (iv) ‘no ADHD’,all other children, including those who were not selected forclinical assessment.

Attention and hyperactivity symptoms in the eightscreen-positive children who did not participate in the clini-cal examination were assessed by information from parentand teacher questionnaires, teacher interviews, schoolnurses and telephone interviews with parents. None of theeight children who dropped out was judged to have severebehavioural or attention problems and were thereforeincluded in the study population in the ‘no ADHD’ group.

5.5-year olds at CHCResults from developmental examinations at 5.5 years ofage were collected retrospectively from the child’s health(CH) record from CHCs for the whole population in con-nection with the routine health examination in 4th grade.The CHC records had been sent to the school nurse at thetime of the child’s school start, with parental consent. Testresults from 5.5 years of age (range 63–75 months) wereavailable for 92% (N = 466) of the children; 11 were not liv-ing in Sweden at 5.5 years of age, 18 CHC records weremissing, five parents declined examination and six childrenwere never invited for assessment at the CHC. To minimizethe effect of age variance on the screening result, onlyrecords with test results from 5.5 years (66 month-s) ± 3 months of age were included. Thereby, 442 children(80% of the entire population; 213 girls, 229 boys) for whomthere were information from all three data sources wereincluded in the final study population for analysing thisscreening.

Developmental screening for DAMP ⁄ ADHD at 5.5 yearsof ageA developmental screening at 5.5 years of age comprising amotor examination and questionnaires to parent and pre-school teacher, has been a part of the Swedish surveillanceprogramme offered by the child health service (CHS) since1991 (16). This screening was based on research by Gillbergand Rasmussen (22–25), but the design varied according tolocal manuals for CHCs. The motor screening evaluated byGillberg et al. contained six items. A modified method withseven items was included in national guidelines for CHrecords from 1981 as a complementary measure (35).

In Stockholm County, the 5.5-year screening includednine items (36) rated on a scale of normal ⁄ abnormal: (i)four motor tasks: cut a paper circle, stand on one leg for

Holmberg et al. Routine developmental screening and ADHD

ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 112–120 113

12 sec, jump on one leg 10 times, associated movementswhen walking on lateral sides of feet for 10 sec (Fog’s test);(ii) five visuomotor integration ⁄ perceptual motor tasks:draw a man, draw a circle, draw a square, draw a triangleand write one’s name. The three last motor tests were exam-ined by the physician at the CHC (a general practitioner).All other screening items were carried out by the CHCnurse. At the time of the study, no structured parent inter-view was recorded in the CH record and no preschool ques-tionnaire (PSQ) was in use in Stockholm County. The fourmotor tasks are included in the 6-item method suggested byGillberg et al. and the interrater reliability was good toexcellent (9,22). All perceptual motor tasks, with the excep-tion of ‘write one’s name’, have been demonstrated to havehigh discriminating capacity for DAMP (37). The threeitems draw a circle, draw a square and draw a triangle areincluded in the Design Copying Visuomotor Test developedby Rasmussen et al. as a part of the neurological screeningfor DAMP (37).

Neither the Swedish National Board of Health andWelfare nor the national or local CHS manual recom-mended any special cut-off score as an indication ofDAMP at the time of the CHC examination of the chil-dren in the study population (16,35,36). In former Swed-ish studies using the 6-item scale in 5.5- to 7-year oldssuggested by Gillberg et al., at least two (19,22,38,39) or atleast three deviations (4,6,21,22,39,40) have been appliedas an index for DAMP ⁄ ADHD, if there was no informa-tion about developmental deviation from parent or pre-school teacher. In a modified version of this methodcomprising nine items, a cut-off score of two was found tobe appropriate (11).

According to the guidelines for the new national CHrecords from 2000, children with at least two positive testsout of seven possible positives should be referred for furtherevaluation (28). In the present manual (available at http://www.growingpeople.se), deviation on three of five motortasks is considered as screen-positive result if there are noreports on developmental problems at home or in the pre-school setting. The 2000 CHS manual for StockholmCounty recommended a cut-off score of at least three fail-ures of the nine items included in this study as a possibleindex of DAMP or mental retardation (41).

Screening for language problems was not a part of the testfor 5.5-year olds, but was assessed at 4 years of age by theCHC nurse as part of the CHC surveillance programme.Language performance was rated on a scale of normal ⁄abnormal. Results from the screening at 4 years ± 3 monthswere available for 417 children.

In addition to the 5.5-year test results, the nurse made anote in the records on children lacking the ability to under-stand the instructions for performing the test. The nurse alsoregistered all referrals to the speech pathologist or the localpaediatrician or child psychologist for further evaluationbased on the CHC physician’s general impression. Thisinformation was collected from the CHC records. Informa-tion about the child’s day care (at home or in a preschoolfacility) was collected.

Developmental screening at 7 years of ageAt school entry into 1st grade, the study population wasscreened for developmental problems by parental report ina questionnaire, Parent Psychomotor Questionnaire (PPQ)(4,23) in connection with the routine health examination.This questionnaire has been validated in 7-year olds andrecommended for school entry examination of attentionand motor-perceptual problems (23). The PPQ includedfour questions regarding the child’s speech development,general motor development and gross motor and fine motorcontrol and are rated on a 4-point scale (early, average,somewhat late and very late). The criterion for developmen-tal deviation (being screen-positive) was a score of ‘some-what late’ or ‘very late’, as suggested by Landgren et al. (4).PPQ has previously been validated in Swedish population-based studies of 5.5- to 7-year-old children as a screeninginstrument for DAMP using at least one abnormal score asan indication of DAMP ⁄ ADHD (4,23,40).

Seven months into the school year, the teacher completeda questionnaire consisting of four items pertaining to thechild’s attention and gross motor and fine motor and lan-guage capacity rated on the same 4-point scale as PPQ. Thecriterion for developmental deviation (being screen-posi-tive) was at least one abnormal score. This teacher question-naire is a shorter version of the PSQ, validated in 7-yearolds by Gillberg and Rasmussen (6,24), which comprisestwo more items on perceptual–conceptual capacity. ThePSQ has also been used in the previous Swedish studies of5.5- to 6-year olds (4,40) with reliable results.

Screening results from both information sources at7 years of age were available for 84.5% (N = 453) of all chil-dren in grade 1; 31 had moved from the municipality andwere not included in the study population in grade 4.Thereby, 422 children (76% of the entire population born1991; 204 girls, 218 boys) for whom there was informationfrom parents and teachers in grades 1 and 4 were includedin the final study population for analysing this screening.Information about having an ADHD ⁄ DAMP diagnosis froma physician at school entry was collected from the child’sschool health records.

Statistical analysisThe CHC screening items were rated as normal or deviant.Dichotomized outcome variables of each developmentitem rated by parents and teachers were created by defin-ing ‘somewhat late’ or ‘very late’ a screen-positive and‘early’ or ‘average’ as screen-negative. Chi-squared analyseswere used in bivariate analyses of individual items andsummarized indices. Relationships between parents’ andteachers’ ratings were assessed using Pearson’s productmoment correlation coefficient. Sensitivity, specificity andpositive predictive value of screen-positive variables withthe two categories ‘pervasive ADHD’, ‘situational ADHD’and a third category ADHD variable that consisted of ‘per-vasive ADHD’ and ‘situational ADHD’ collapsed into asingle category, were calculated for increasing number ofdeviations. All statistics were analysed using SPSS 15.0(SPSS Sweden, Kista, Sweden) for Windows.

Routine developmental screening and ADHD Holmberg et al.


RESULTSThe socio-demographic characteristics of the study popula-tion by developmental screening outcomes are presented inTable 1. The mean age of all the children at the CHC exami-nation was 66 months. In 1st grade, the mean age was85 months for parents’ ratings and 92 months for teachers’ratings. There were prominent differences between genderas boys had greater difficulties to draw a man (p < 0.001),write their name (p < 0.01), cut a paper circle and performFog’s test (p < 0.05) at the CHC screening at 5.5 years andmore often were reported by parents and teachers to bedelayed in fine motor skills (p < 0.01 and p < 0.001, respec-tively) and in speech development (p < 0.01 and p < 0.05,respectively). Writing and drawing tasks varied consider-ably with socio-demographic background, with childrenfrom households where the mothers had short education,children with foreign-born mothers and children notattending day care more often being screen-positive(p < 0.05–0.01). The outcome of the language test at CHCvaried little by socio-demographic variables, but childrenfrom households where the mothers were born outside Swe-den more often had language problems according to teach-ers in 1st grade (p < 0.001). Education in remedial class ingrade 4 was associated with developmental deviation atboth 5.5 and 7 years of age (p < 0.001; Table 1).

The prevalence of the complete (pervasive) ADHD syn-drome in 4th grade was 5.7% (n = 25; male:female ratio of5:1), of which 21 had the combined type according to theDSM-IV criteria (1). Situational ADHD was present inanother 7.0%. Diagnoses of pervasive and situationalADHD categories were associated with developmentaldeviations at the CHC-screening (Table 2a), and particu-larly the items ‘write one’s name’ (p < 0.001 and p < 0.05),‘draw a man’ (p < 0.01) and ‘draw a triangle’ (p < 0.01 andp < 0.05).

In 1st grade, teachers identified almost twice as manychildren with at least one developmental deviation as par-ents did (Table 2b). The interrater agreement for at leastone deviation was moderate (Pearson’s r = 0.30). Parentalreport of deviant speech and fine motor development wasassociated with a subthreshold diagnosis of ADHD in grade4 (p < 0.05). In teacher reports, on the other hand, sub-threshold and pervasive ADHD were associated with grossmotor (p < 0.05 and p < 0.01) and fine motor clumsiness(p < 0.001; Table 2b). At no age language problems werereported more prevalent in children later diagnosed withpervasive ADHD. Teacher rated attention problems in 1stgrade was 21% and seemed to be more prevalent at all levelsof ADHD compared with ‘no ADHD’ (p < 0.001).

The sensitivity, specificity and positive predictive valuesat different levels of deviation in the CHC screening forADHD-diagnoses in grade 4 are presented in Table 3. Sixty(14%) of the children were screen-positive at the languagescreening at 4 years of age and 25 (6%) were refereed to aspeech pathologist as 5.5-year olds, data not presented intables. The sensitivity for language deviation at 4 or5.5 years of age was 8% and 12%, the specificity 85% and95% and the positive predictive value 3% and 12% respec-tively.

The efficiency of the developmental screening in grade 1to predict the different ADHD categories in grade 4 isshown in Table 4. The sensitivity for teachers’ ratings of atleast one or two deviations was higher but the specificitysomewhat lower than for parental reports. Concerning tea-cher reports of attention problems, the sensitivity was 58%,the specificity 81% and the positive predictive value 16%.When combining at least one deviation according to eitherparental or teacher report, the positive predictive value forpervasive ADHD was 9%. With a cut-off score of at leastone from both raters, the positive predictive value for

Table 1 Socio-demographic variables and special education in 4th grade in 5.5 and 7-year-old children not passing developmental screening tests (screen-

positives)

Socio-demographic variables5.5-year oldsn (%)

1–9 deviationsn (%)

7-year oldsn (%)

1–4 developmental deviations

Parent’s ratingn (%)

Teacher’s ratingn (%)

Sex

Boys 229 (52) 94 (41)** 218 (52) 57 (26)* 118 (54)***

Girls 213 (48) 57 (27) 204 (48) 34 (17) 63 (31)

Maternal education

0–9 years 100 (23) 45 (45)*** 78 (19) 21 (27)* 45 (58)***

10–12 years 258 (58) 89 (34) 255 (60) 57 (22) 107 (42)

13+ years 84 (19) 17 (20) 89 (21) 13 (15) 29 (33)

Country of birth of mother

Sweden 347 (79) 112 (32) 334 (79) 71 (21) 135 (40)

Other Nordic countries 19 (4) 3 (16) 21 (5) 5 (24) 10 (48)

Other European countries 11 (2) 3 (27) 13 (3) 2 (15) 4 (31)

Rest of world 65 (15) 33 (51)** 54 (13) 13 (24) 32 (59)*

Educational setting

Special education class 19 (4) 17 (90)*** 22 (5) 16 (73)*** 19 (86)***

Normal class 423 (96) 134 (32) 400 (95) 75 (19) 162 (41)

*p < 0.05; **p < 0.01; ***p < 0.001.



pervasive ADHD increased to 11%. This estimate was nomore than 20% for any combination of data sources, evenwhen a score of 2 or more in the 5.5-year screening wasincluded in the analysis.

Among the 49 children with a score of at least three devi-ations at CHC, only 35% (n = 17) were referred from theCHC to the local paediatrician for examination. A total of30 children (10 girls, 20 boys) were referred to the

Table 2 Crude rates of not passing screening tests (screen-positives) by ADHD category in 4th grade

(a) 5.5-year olds

Developmental deviation

Total(N = 442)n (%)

No ADHD(n = 356)n (%)

SubthresholdADHD(n = 30)n (%)

SituationalADHD(n = 31)n (%)

PervasiveADHD(n = 25)n (%)

No motor-perceptual deviation 291 (66) 252 (71) 17 (57) 16 (52) 6 (24)

1–9 deviations (at least one) 151 (34) 104 (29) 13 (43) 15 (48)* 19 (76)***

2–9 deviations (at least two) 76 (17) 49 (14) 7 (23) 9 (29)* 11 (44)***

3–9 deviations (at least three) 49 (11) 27 (8) 6 (20) 8 (26)** 8 (32)***

(b) 7-year olds

Developmental deviation

Total(N = 422)n (%)

No ADHD(n = 344)n (%)

SubthresholdADHD(n = 29)n (%)

SituationalADHD(n = 25)n (%)

PervasiveADHD(n = 24)n (%)

Parent

No developmental deviation 331 (78) 276 (80) 18 (62) 20 (80) 17 (71)

1–4 deviations (at least one) 91 (22) 68 (20) 11 (38)* 5 (20) 7 (29)

2–4 deviations (at least two) 25 (6) 16 (5) 4 (14) 3 (12) 2 (8)

3–4 deviations (at least three) 8 (2) 4 (1) 2 (7) 1 (4) 1 (4)

4 deviations 3 (0.7) 0 (0) 2 (7) 1 (4) 0 (0)

Teacher

No developmental deviation 241 (57) 214 (62) 10 (34) 132 (48) 5 (21)

1–4 deviations (at least one) 181 (43) 130 (38) 19 (66)* 13 (52) 19 (79)***

2–4 deviations (at least two) 86 (20) 51 (15) 13 (45)*** 8 (32)* 14 (58)***

3–4 deviations (at least three) 42 (10) 23 (7) 6 (21)** 5 (20)* 8 (33)***

4 deviations 11 (3) 6 (2) 3 (10) 1 (4) 1 (4)

ADHD, attention-deficit ⁄ hyperactivity disorder.

*p < 0.05; **p < 0.01; ***p < 0.001.

Table 3 Crude rates of not passing screening tests (screen-positives) as 5.5-year-old, sensitivity, specificity and positive predictive value in relation to ADHD in 4th

grade

Developmental deviationNo ADHDn (%)

ADHDn (%)

Sensitivity%

Specificity%

Positive predictivevalue %

Pervasive ADHD (n = 417) (n = 25)

No motor-perceptual deviation 285 (68) 6 (24) 24 32 2

1–9 deviations (at least one) 132 (32) 19 (76)*** 76 68 13

2–9 deviations (at least two) 65 (16) 11 (44)*** 44 85 15

3–9 deviations (at least three) 4 (10) 8 (32)*** 32 90 16

Situational ADHD (n = 386) (n = 31)


1–9 deviations (at least one) 117 (30) 15 (48)* 48 69 11

2–9 deviations (at least two) 56 (15) 9 (29)* 29 86 14

3–9 deviations (at least three) 33 (9) 8 (26)** 26 92 20

Pervasive or situational ADHD (n = 386) (n = 56)






*p < 0.05; **p < 0.01; ***p < 0.001.



paediatrician, 25% of whom had pervasive ADHD and 18%situational ADHD in grade 4.

Being screen-positive was not the main reason for referralto a psychologist. Eight children with 0–2 failures wererecommended evaluation by a psychologist while three(6%) of the children with at least three deviations werereferred. Among the children referred to a psychologist,18% had pervasive ADHD and 27% had situational ADHDin grade 4.

According to the school health records, three boys hadbeen assessed by a multidisciplinary team and received thediagnosis of DAMP ⁄ ADHD at 6–7 years of age before start-ing school. One of these boys had three or more deviationsat 5.5 years of age and still fulfilled the criteria for ADHD ingrade 4. Among the 49 children with at least three devia-tions in the CHC screening, three had motor difficultiesaccording to the clinical interview in grade 4. One child ful-filled the criteria for ADHD but not DCD, and one was pre-viously diagnosed with mental retardation.

DISCUSSIONThis population-based study demonstrates a consistentsignificant, but modest, association between developmental

deviations in 5.5- and 7-year olds with a later diagnosis ofADHD at 10 years of age. The predictive value of develop-mental deviations for ADHD, however, was low: no morethan 20% for any combination of data sources, and no morethan 15–16% of children classified as screen-positive fordevelopmental deviations at the CHC at 5.5 years and 8–11% of children with at least one developmental delay in 1stgrade were diagnosed with ADHD 4 years later.

In the younger children, test items reflecting fine motorand perceptual development had the strongest associationswith ADHD. Fine motor clumsiness was the most specificdevelopmental deviation in the older children. Delayedlanguage development at 4 or 5.5 years of age according toCH record or at age 7 according to parent and teacherquestionnaire was not associated with ADHD at 10 years ofage, in contrast to the previous findings by Rasmussen andGillberg (23).

Although a greater percentage of children with ADHD ingrade 4 were screen-positive than children with no ADHD,sensitivity and positive predictive values were much too lowto allow for a routine screening procedure for ADHD withthese items at either age (Tables 3 and 4). Our motor-per-ceptual screening results of 5.5-year olds are in line with theprevious Swedish studies evaluating the developmental

Table 4 Crude rates of not passing developmental screening tests (screen-positives) as 7-year olds according to parents’ and teachers’ ratings, sensitivity, specificity

and positive predictive value in relation to pervasive or situational ADHD in 4th grade

Developmental deviationNo ADHDn (%)

ADHDn (%)

Sensitivity%

Specificity%

Positive predictivevalue %

Pervasive ADHD (n = 398) (n = 24)

Parent: 0 developmental deviation 314 (79) 17 (71) 71 21 5

1–4 deviations (at least one) 84 (21) 7 (29) 29 79 8

2–4 deviations (at least two) 23 (6) 2 (8) 8 94 8

3–4 deviations (at least three) 7 (2) 1 (4) 4 98 13

Teacher: 0 developmental deviation 236 (59) 5 (21) 21 41 2




Situational ADHD (n = 373) (n = 25)








3–4 deviations (at least three) 29 (8) 5 (20)* 20 92 15

Pervasive or situational ADHD (n = 373) (n = 49)










*p < 0.05; ***p < 0.001.



screening at CHC by teacher reports of motor, behaviourand ⁄ or learning difficulties during the first year in school(19,38,42).

The main problem with a screening procedure for ADHDwith these developmental items is the high number of falsepositive children, present at all possible cut-off points, whoneed to be evaluated in one way or another (Tables 3 and4). The high rate of false positive children does not neces-sarily have to be a serious problem if many of these childrenhave other developmental problems such as motor or lan-guage problems, which may also require professional evalu-ation and adjustment at school (17,19,26,38). Thus, furtherstudies with a wider range of outcomes are needed to deter-mine whether screening is meaningful or not in a widerchild health context.

Screen-positive results at 5.5 or 7 years of age wererelated to remedial education in special class at 10 years ofage (Table 1). Whether developmental deviation beforeschool entry predicts school achievement problems or nothas been discussed (19,38,42). Further investigations areneeded to clarify the role of delayed development in pre-school years for need of special education in school age.

Most screen-positive 5.5-year-old children were notreferred to a paediatrician or psychologist for further evalu-ation. Although this was not clearly stated in the CHrecords, this seems to indicate that either a relevant referralpolicy was lacking or that the staff did not find this screen-ing method very helpful.

Children from households where the mothers had shorteducation as well as offspring of parents born outside Eur-ope had an increased rate of screen-positive test resultson drawing and writing tasks. These findings confirm previ-ous research that demonstrates that social and culturalfactors are important determinants for the age at which chil-dren acquire drawing and writing abilities (17,43).

In this study, the prevalence of developmental devia-tions, defined as at least three failures, was found to be11% at 5.5 years (Table 2a). This is almost twice as manyas reported in other Swedish studies in study populationsof 6- to 7-year olds (21,39,42,44). One possible explanationcould be that in the previous studies, children wereassessed on six motor items, as suggested by Gillberg et al.(22), whereas nine screening items were included in thisstudy. The overall rate of motor screen abnormalities inthe general population might be in the range of 8–14%(22). Although we identified almost twice as many screen-positive children as the previously reported number andused a nine-item screening method with eight previouslyvalidated items, we still failed to identify children withADHD in a satisfactory manner. Considering that atten-tion deficits in DAMP tends to persist at age 10 (9), thesefindings are unexpected.

Gillberg and Rasmussen validated their method in a pop-ulation-based group of 7-year olds with symptoms of atten-tion deficits, motor control and perceptual problemsaccording to preschool teachers’ ratings (22,37). The major-ity of these high-risk children were diagnosed as DAMP(6,22). We have studied an unselected population of

children which may explain the low rate of being diagnosedbefore school entry.

Prevalences of delayed development among 7-year oldsin this study population were similar to those reported byRasmussen and Gillberg (23), while attention problemsrated by teachers in 1st grade were three times as prevalentas previously demonstrated in preschool children (6,42,44).The increased demands for sustained attention in the class-room may explain this difference. Despite the increased rateof teacher-reported inattentive behaviour, the positive pre-dictive value for ADHD in grade 4 was only 16%.

Gillberg and Rasmussen recommended a screeningmethod with combination of motor examination with infor-mation from parents and preschool teacher for tracingDAMP. This method has been evaluated in the previousstudies (4,11,21,38,40,42,44). Considering that attentiondeficit symptoms in DAMP at 6–7 years of age seem toremain at the age of 10 (7,9) and that most of the screeningitems have demonstrated good to excellent reliability, ourresults are unexpected. The efficiency for all three routinescreening methods evaluated in this study was low and nocombination of informant data in grade 1 resulted in esti-mated predictive value above 20%. Combination of screen-ing information from all three sources did not improve thepossibility to predict ADHD in grade 4.

Developmental screening strategy does not seem toidentify cases of ADHD at 10 years with sufficient preci-sion to be recommended for implementation in the generalpopulation. Thus, instead of screening it may be moreimportant for schools to have an effective strategy foridentifying and dealing with children who develop ADHD –or other neuropsychiatric disabilities that may interferewith learning – in the classroom when these problemsevolve, rather than before school entry. Such a strategycould be built on close collaboration between educators,who meet the children in the classroom every day, and theschool health team.

LIMITATIONSThis study was designed to assess the efficiency of develop-mental screening for ADHD in a routine child healthsetting. It is quite probable that an efficacy evaluation in anideal setting with a highly motivated and trained staff, as inthe studies validating the motor screening (9,22), wouldhave yielded a higher predictive value (45). It does not seemvery likely that the CHC nurses and physicians in thismunicipality examined children differently from otherCHCs in Sweden, as everyone had received the same educa-tion and had long experience of child health work. Sigtunais a medium-sized municipality with a population with aslightly more disadvantaged socioeconomic situation thanthe country as a whole, in terms of education, single parenthousehold and the immigrant proportion of the populationaccording to the Register of the Total Population and theSwedish Education Register. Thus, considering the higherrates of ADHD in families with low socioeconomicstatus (46), somewhat higher rates of ADHD compared



with the national average should be expected in this studypopulation.

A limitation of the study is that the developmental infor-mation in 1st grade and behavioural information in 4th gradewere collected within the school health system and used inconnection with health visits to the school nurses and physi-cians. It seems possible, for example, that parents may havewithheld information about developmental problems if theypreferred to find solutions to these problems outside ofschool. To a certain extent, this problem was minimized bycollecting information from teachers as well as parents.

IMPLICATIONSIn this article, we have demonstrated that the efficiency ofdevelopmental screening of 5.5-year olds at CHCs and 7-year olds in 1st grade for a diagnosis of ADHD in 4th gradeis low. Further developmental work is needed to find effi-cient methods that can identify school children in need ofearly interventions because of behavioural problems and ⁄ orlearning difficulties. In future, new developmental assess-ment methods in the CHC or school health surveillanceprogramme should be evaluated according to the WHO cri-teria before put into practice.

ACKNOWLEDGEMENTSFinancial support for this study has been provided by theSwedish Council for Working Life and Social Research, theSwedish Society of Medicine, the First of May FlowerAnnual Campaign and the Solstickan Foundation. Wethank the school authorities of Sigtuna, the school nursesand the teachers, without whose assistance this study couldnot have been completed.

References

1. American Psychiatric Association. Diagnostic and statisticalmanual of mental disorders, 4th ed. Washington, DC: AmericanPsychiatric Association, 1994.

2. Kadesjo C. ADHD in Swedish 3- to 7-year-old children: clinicaland child rearing aspects. Dissertation, Umea: University ofUmea, 2002.

3. Biederman J, Faraone SV. Attention-deficit hyperactivity disor-der. Lancet 2005; 366: 237–48.

4. Landgren M, Pettersson R, Kjellman B, Gillberg C. ADHD,DAMP and other neurodevelopmental ⁄ psychiatric disorders in6-year-old children: epidemiology and co-morbidity. DevMed Child Neurol 1996; 38: 891–906.

5. Kadesjo B, Gillberg C. Attention deficits and clumsiness inSwedish 7-year-old children. Dev Med Child Neurol 1998;40: 796–804.

6. Gillberg IC, Winnergard I, Gillberg C. Screening methods, epi-demiology and evaluation of intervention in DAMP in pre-school children. Eur Child Adolesc Psychiatry 1993; 3: 121–35.

7. Gillberg C. Deficits in attention, motor control, and perception:a brief review. Arch Dis Child 2003; 88: 904–10.

8. Gillberg C, Rasmussen P, Carlstrom G, Svenson B, Wald-enstrom E. Perceptual, motor and attentional deficits in six-year-old children. Epidemiological aspects. J Child PsycholPsychiatry 1982; 23: 131–44.

9. Gillberg IC. Children with minor neurodevelopmental disor-ders. III: neurological and neurodevelopmental problems at age10. Dev Med Child Neurol 1985; 27: 3–16.

10. Gillberg IC. Deficits in attention, motor control and percep-tion: follow-up from pre-school to the early teens. Dissertation,Uppsala: Uppsala University, 1987.

11. Landgren M, Kjellman B, Gillberg C. Deficits in attention,motor control and perception (DAMP): a simplified schoolentry examination. Acta Paediatr 2000; 89: 302–9.

12. Landgren M, Kjellman B, Gillberg C. Attention deficit disorderwith developmental coordination disorders. Arch Dis Child1998; 79: 207–12.

13. Holmberg K, Hjern A. Bullying and attention-deficit- hyperac-tivity disorder in 10-year-olds in a Swedish community. DevMed Child Neurol 2008; 50: 134–8.

14. Gillberg C, Hellgren L. Outcome. In: Sandberg S, editor.Hyperactivity disorders of childhood. Cambridge: CambridgeUniversity Press, 1996: 477–503.

15. Rasmussen P, Gillberg C. Natural outcome of ADHD withdevelopmental coordination disorder at age 22 years: a con-trolled, longitudinal, community-based study. J Am Acad ChildAdolesc Psychiatry 2000; 39: 1424–31.

16. Swedish National Board of Health and Welfare.Halsoundersokningar inom barnhalsovarden. [Health surveil-lance in Child Health Services]. Stockholm: Allmanna rad,1991 (in Swedish).

17. Hall D, Elliman D. Health for All Children, 4th ed. Oxford,Oxford University Press, 2003.

18. American Academy of Pediatrics. Identifying infants and youngchildren with developmental disorders in the medical home: analgorithm for developmental surveillance and screening. Pedi-atrics 2006; 118: 405–20.

19. Rydell AM, Bondestam M, Hagelin E, Westerlund M. Tea-cher rated problems and school ability tests in relation topreschool problems and parents’ health information atschool start. A study of first-graders. Scand J Psychol 1991;32: 177–90.

20. Miniscalco C, Nygren G, Hagberg B, Kadesjo B, Gillberg C.Neuropsychiatric and neurodevelopmental outcome of childrenat age 6 and 7 years who screened positive for language prob-lems at 30 months. Dev Med Child Neurol 2006; 48: 361–6.

21. Larsson JO, Aurelius G, Nordberg L, Rydelius PA, ZetterstromR. Screening for minimal brain dysfunction (MBD ⁄ DAMP) atsix years of age: results of motor test in relation to perinatalconditions, development and family situation. Acta Paediatr1995; 84: 30–6.

22. Gillberg C, Carlstrom G, Rasmussen P, Waldenstrom E.Perceptual, motor and attentional deficits in seven-year-oldchildren. Neurological screening aspects. Acta PaediatrScand 1983; 72: 119–24.

23. Rasmussen P, Gillberg C. Perceptual, motor and attentionaldeficits in seven-year-old children. Paediatric aspects. ActaPaediatr Scand 1983; 72: 125–30.

24. Gillberg C, Rasmussen P. Perceptual, motor and attentionaldeficits in six-year-old children. Screening procedure in pre-school. Acta Paediatr Scand 1982; 71: 121–9.

25. Gillberg C, Rasmussen P. A study in Gothenburg: minimalbrain dysfunction in 6–7-year-old children can be traced bysimple diagnostic aids. Lakartidningen 1982; 79: 4413–4, 9.

26. Blomquist HK. The role of the child health services in the iden-tification of children with possible attention deficit hyperactiv-ity disorder ⁄ deficits in attention, motor control and perception(ADHD ⁄ DAMP). Acta Paediatr Suppl 2000; 89: 24–32.

27. Sundelin C, Hakansson A. The importance of the child healthservices to the health of children: summary of the state-of-the-art document from the Sigtuna conference on child health



services with a view to the future. Acta Paediatr Suppl 2000;89: 76–9.

28. Swedish National Board of Health and Welfare. Barn-halsovardsjournal 2000–01. Anvisningar och kommentarer.[Manual for notification in Child Health records 2000–01].Stockholm: Kommentusgruppen AB (in Swedish). Availableat: http://www.growingpeople.se, 2000.

29. Swedish National Board of Health and Welfare. Socialstyrel-sens riktlinjer for skolhalsovarden. Rekommendationer forplanering ⁄ tillsyn ⁄ metodutveckling. [Manual for School HealthServices]. Stockholm: Socialstyrelsen, 2004 (in Swedish).

30. Sand N, Silverstein M, Glascoe FP, Gupta VB, Tonniges TP,O’Connor KG. Pediatricians’ reported practices regardingdevelopmental screening: do guidelines work? Do they help?Pediatrics 2005; 116: 174–9.

31. Wilson J, Jungner G. Principles and practice of screening fordisease. Public Health Papers No 34. Geneva: World HealthOrganization, 1968.

32. Holmberg K, Hjern A. Health complaints in children withattention-deficit ⁄ hyperactivity disorder. Acta Paediatr 2006;95: 664–70.

33. Mannuzza S, Klein RG, Moulton JL III. Young adult outcomeof children with ‘‘situational’’ hyperactivity: a prospective,controlled follow-up study. J Abnorm Child Psychol 2002; 30:191–8.

34. American Academy of Pediatrics. Diagnostic and statisticalmanual of mental disorders for primary care. Washington,DC: American Academy of Pediatrics, 1997.

35. Swedish National Board of Health and Welfare. Journal inombarnhalsovarden – Anvisningar och kommentarer. [Manual fornotification in Child Health records]: Socialstyrelsen: LIC,1981 (in Swedish).

36. Stockholms lans landsting. Metodbok for Barnhalsovarden[Manual for Child Health Services, Stockholm County]. Stock-holm: Stockholms lans landsting, 1991; 4: 7–11 (in Swedish).

37. Rasmussen P, Gillberg C, Waldenstrom E, Svenson B. Percep-tual, motor and attentional deficits in seven-year-old children:neurological and neurodevelopmental aspects. Dev MedChild Neurol 1983; 25: 315–33.

38. Bondestam M, Hagelin E, Rydell AM, Westerlund M. Healthexamination of preschool children in relation to schooladjustment in grade I. Acta Paediatr 1992; 81: 257–61.

39. Kornfalt R, Johannesson P, Svensjo G. MBD can be discoveredat the child health centers by a general examination before thestart of school. Lakartidningen 1991; 88: 2233–7.

40. Thunstrom M. Severe sleep problems in infancy associatedwith subsequent development of attention-deficit ⁄ hyperactivitydisorder at 5.5 years of age. Acta Paediatr 2002; 91: 584–92.

41. Stockholms lans landsting. Metodbok for Barnhalsovarden.[Manual for Child Health Services, Stockholm County]. Stock-holm: Stockholms lans landsting, 2000; 4: 10 (in Swedish).

42. Bergstrom E, Blomqvist HK, Ferry S, Hogstadius P, RudebeckCE. Child health services, school health services and day carecenters. Coordinated health check-ups of 6-year-old childrenmake the planning of school supportive measures easier.Lakartidningen 1988; 85: 2946–7, 2950–1.

43. McPhillips M, Jordan-Black JA. The effect of socialdisadvantage on motor development in young children:a comparative study. J Child Psychol Psychiatry 2007;48: 1214–22.

44. Bohlin G, Borres MP. Earlier school start should provide fornew routines in the check-up of 6-year olds by child healthservices. Lakartidningen 2000; 97: 4146–50.

45. Flay BR, Biglan A, Boruch RF, Castro FG, Gottfredson D,Kellam S, et al. Standards of evidence: criteria forefficacy, effectiveness and dissemination. Prev Sci 2005; 6:151–75.

46. Swedish National Board of Health and Welfare. Folkhalsor-apporten. [Health in Sweden - The National Public HealthReport 2009]. Stockholm: Socialstyrelsen (in Swedish); 2009.



Documents

Routine developmental screening at 5.5 and 7 years of age is not an efficient predictor of attention-deficit / hyperactivity disorder at age 10