European Child & Adolescent Psychiatry

, Volume 18, Issue 7, pp 447–457 | Cite as

Full syndrome and subthreshold attention-deficit/hyperactivity disorder in a Korean community sample: comorbidity and temperament findings

  • Soo-Churl Cho
  • Boong-Nyun Kim
  • Jae-Won Kim
  • Luis Augusto Rohde
  • Jun-Won Hwang
  • Dong-Seon Chungh
  • Min-Sup Shin
  • In Kyoon Lyoo
  • Bock-Ja Go
  • Sang-Eun Lee
  • Hyo-Won KimEmail author



The main objective of this study was to investigate the comorbid disorders and temperamental profiles of full syndrome and subthreshold attention-deficit/hyperactivity disorder (ADHD).


A sample of 2,493 students was randomly selected from six representative elementary schools in Seoul, Korea. Among 245 children with full syndrome and subthreshold ADHD diagnosed by the diagnostic interview schedule for children-4th version, parents of 185 subjects (mean age 9.0 ± 1.7 years) and of a random sample of 185 age- and gender-matched non-ADHD children have completed the parent’s version of the children behavior checklist (CBCL) and the juvenile temperament and character inventory (JTCI).


The prevalence rates of full syndrome and subthreshold ADHD were, respectively, 5.90% (95% confidence interval = 4.74–7.06) and 9.00% (95% confidence interval = 7.58–10.41). Subthreshold ADHD cases did not differ from full syndrome ADHD in any JTCI profile, showing high novelty seeking/low persistence/low self-directedness than controls. Subthreshold ADHD also showed increased risk for externalizing disorders and higher scores in eight CBCL scales (somatic complaints, anxious/depressed, social problems, attention problems, delinquent behaviors, aggressive behaviors, externalizing problems and total behavioral problems) compared to the controls.


These results support the clinical relevance of subthreshold ADHD in Asian culture. Increased clinical awareness for children with subthreshold ADHD is needed.


attention-deficit/hyperactivity disorder subthreshold comorbidity temperament DISC-IV 



This study was supported by Seoul Child and Adolescent Mental Health Center Grant 07-2005-013-02. Prof Cho receives research funding from Janssen, Eli-Lilly and Otsuka, and supported by Korea Institute of Environmental Science and Technology (091-081-059) and Korea Health Industry Development Institute (A080055). The ADHD outpatient program from Hospital de Clínicas de Porto Alegre receives research support from the following pharmaceutical companies: Bristol-Myers Squibb, Eli-Lilly, Janssen-Cilag, and Novartis. Prof. Rohde is on the speakers’ bureau or is a consultant for the same companies and is on the advisory board for Eli Lilly & Company.


  1. 1.
    Achenbach T (1991) Manual for the child behavior checklist/4–18 and 1991 profiles. University of Vermont, Department of Psychiatry, BurlingtonGoogle Scholar
  2. 2.
    American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders. American Psychiatric Press, WashingtonGoogle Scholar
  3. 3.
    Anderson JC (1996) Is childhood hyperactivity the product of western culture? Lancet 348:73–74PubMedCrossRefGoogle Scholar
  4. 4.
    Angold A, Costello EJ, Erkanli A (1999) Comorbidity. J Child Psychol Psychiatry 40:57–87PubMedCrossRefGoogle Scholar
  5. 5.
    Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rossler W (2003) Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 73:133–146PubMedCrossRefGoogle Scholar
  6. 6.
    Angst J, Merikangas KR, Preisig M (1997) Subthreshold syndromes of depression and anxiety in the community. J Clin Psychiatry 58(Suppl 8):6–10PubMedGoogle Scholar
  7. 7.
    Baldwin JS, Dadds MR (2008) Examining alternative explanations of the covariation of ADHD and anxiety symptoms in children: a community study. J Abnorm Child Psychol 36(1):67–79PubMedCrossRefGoogle Scholar
  8. 8.
    Biederman J (1998) Attention-deficit/hyperactivity disorder: a life-span perspective. J Clin Psychiatry 59(Suppl 7):4–16PubMedGoogle Scholar
  9. 9.
    Biederman J, Faraone SV (2005) Attention-deficit hyperactivity disorder. Lancet 366:237–248PubMedCrossRefGoogle Scholar
  10. 10.
    Biederman J, Faraone SV, Doyle A, Lehman BK, Kraus I, Perrin J, Tsuang MT (1993) Convergence of the child behavior checklist with structured interview-based psychiatric diagnoses of ADHD children with and without comorbidity. J Child Psychol Psychiatry 34:1241–1251PubMedCrossRefGoogle Scholar
  11. 11.
    Biederman J, Mick E, Faraone SV (2000) Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry 157:816–818PubMedCrossRefGoogle Scholar
  12. 12.
    Biederman J, Monuteaux MC, Greene RW, Braaten E, Doyle AE, Faraone SV (2001) Long-term stability of the child behavior checklist in a clinical sample of youth with attention deficit hyperactivity disorder. J Clin Child Psychol 30:492–502PubMedCrossRefGoogle Scholar
  13. 13.
    Bird HR (1996) Epidemiology of childhood disorders in a cross-cultural context. J Child Psychol Psychiatry 37:35–49PubMedCrossRefGoogle Scholar
  14. 14.
    Bird HR, Yager TJ, Staghezza B, Gould MS, Canino G, Rubio-Stipec M (1990) Impairment in the epidemiological measurement of childhood psychopathology in the community. J Am Acad Child Adolesc Psychiatry 29:796–803PubMedCrossRefGoogle Scholar
  15. 15.
    Chen WJ, Faraone SV, Biederman J, Tsuang MT (1994) Diagnostic accuracy of the child behavior checklist scales for attention-deficit hyperactivity disorder: a receiver-operating characteristic analysis. J Consult Clin Psychol 62:1017–1025PubMedCrossRefGoogle Scholar
  16. 16.
    Cho SC, Go BJ, Kim BN, Kim JW, Shin MS, Yoo HI, Lee DW, Lee JY, Lee JW, Chungh DS, Jeon SI, Jung HY, Hong JP, Hwang JW, Han SH (2006) The 2005 Seoul child and adolescent mental health survey. Seoul Child and Adolescent Mental Health Center, SeoulGoogle Scholar
  17. 17.
    Cho SC, Kim BN, Kim JW, Kim HW, Choi HJ, Jung SW, Yang YH, Chungh DS, Go BJ, Kim BS, Shin MS, Yoo HI, Yoo HJ, Lee DW, Lee SE, Lee JY, Jeon SI, Jung HY, Hong JP, Hwang JW, Han SH (2006) The reliability and validity of diagnostic interview schedule for children version IV-Korean version (DISC-IV). J Korean Acad Child Adolesc Psychiatry 18:138–144Google Scholar
  18. 18.
    Cho SC, Shin YO (1994) Prevalence of disruptive behavior disorders. J Korean Acad Child Adolesc Psychiatry 5:141–149Google Scholar
  19. 19.
    Cloninger CR, Przybeck TR, Svrakic DM (1991) The tridimensional personality questionnaire: U.S. normative data. Psychol Rep 69:1047–1057PubMedCrossRefGoogle Scholar
  20. 20.
    Cloninger CR, Svrakic DM, Przybeck TR (1993) A psychobiological model of temperament and character. Arch Gen Psychiatry 50:975–990PubMedGoogle Scholar
  21. 21.
    Crijnen AA, Achenbach TM, Verhulst FC (1997) Comparisons of problems reported by parents of children in 12 cultures: total problems, externalizing, and internalizing. J Am Acad Child Adolesc Psychiatry 36:1269–1277PubMedCrossRefGoogle Scholar
  22. 22.
    Cuijpers P, de Graaf R, van Dorsselaer S (2004) Minor depression: risk profiles, functional disability, health care use and risk of developing major depression. J Affect Disord 79:71–79PubMedCrossRefGoogle Scholar
  23. 23.
    Cuijpers P, Smit F (2004) Subthreshold depression as a risk indicator for major depressive disorder: a systematic review of prospective studies. Acta Psychiatr Scand 109:325–331PubMedCrossRefGoogle Scholar
  24. 24.
    Faraone SV, Biederman J, Doyle A, Murray K, Petty C, Adamson JJ, Seidman L (2006) Neuropsychological studies of late onset and subthreshold diagnoses of adult attention-deficit/hyperactivity disorder. Biol Psychiatry 60(10):1081–1087PubMedCrossRefGoogle Scholar
  25. 25.
    Fergusson DM, Horwood LJ, Ridder EM, Beautrais AL (2005) Subthreshold depression in adolescence and mental health outcomes in adulthood. Arch Gen Psychiatry 62:66–72PubMedCrossRefGoogle Scholar
  26. 26.
    Goodwin RD, Messineo K, Bregante A, Hoven CW, Kairam R (2005) Prevalence of probable mental disorders among pediatric asthma patients in an inner-city clinic. J Asthma 42:643–647PubMedCrossRefGoogle Scholar
  27. 27.
    Hartman CA, Hox J, Auerbach J, Erol N, Fonseca AC, Mellenbergh GJ, Novik TS, Oosterlaan J, Roussos AC, Shalev RS, Zilber N, Sergeant JA (1999) Syndrome dimensions of the child behavior checklist and the teacher report form: a critical empirical evaluation. J Child Psychol Psychiatry 40:1095–1116PubMedCrossRefGoogle Scholar
  28. 28.
    Heubeck BG (2000) Cross-cultural generalizability of CBCL syndromes across three continents: from the USA and Holland to Australia. J Abnorm Child Psychol 28:439–450PubMedCrossRefGoogle Scholar
  29. 29.
    Horwath E, Johnson J, Klerman GL, Weissman MM (1992) Depressive symptoms as relative and attributable risk factors for first-onset major depression. Arch Gen Psychiatry 49:817–823PubMedGoogle Scholar
  30. 30.
    Jensen PS, Martin D, Cantwell DP (1997) Comorbidity in ADHD: implications for research, practice, and DSM-V. J Am Acad Child Adolesc Psychiatry 36:1065–1079PubMedCrossRefGoogle Scholar
  31. 31.
    Kooij JJ, Buitelaar JK, van den Oord EJ, Furer JW, Rijnders CA, Hodiamont PP (2005) Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults. Psychol Med 35:817–827PubMedCrossRefGoogle Scholar
  32. 32.
    Lahey BB, Applegate B, McBurnett K, Biederman J, Greenhill L, Hynd GW, Barkley RA, Newcorn J, Jensen P, Richters J et al (1994) DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry 151:1673–1685PubMedGoogle Scholar
  33. 33.
    le Grange D, Binford RB, Peterson CB, Crow SJ, Crosby RD, Klein MH, Bardone-Cone AM, Joiner TE, Mitchell JE, Wonderlich SA (2006) DSM-IV threshold versus subthreshold bulimia nervosa. Int J Eat Disord 39:462–467PubMedCrossRefGoogle Scholar
  34. 34.
    Leung PW, Lucas CP, Hung SF, Kwong SL, Tang CP, Lee CC, Ho TP, Lieh-Mak F, Shaffer D (2005) The test-retest reliability and screening efficiency of DISC predictive scales-version 4.32 (DPS-4.32) with Chinese children/youths. Eur Child Adolesc Psychiatry 14:461–465PubMedCrossRefGoogle Scholar
  35. 35.
    Lewinsohn PM, Klein DN, Seeley JR (2000) Bipolar disorder during adolescence and young adulthood in a community sample. Bipolar Disord 2:281–293PubMedCrossRefGoogle Scholar
  36. 36.
    Lewinsohn PM, Shankman SA, Gau JM, Klein DN (2004) The prevalence and co-morbidity of subthreshold psychiatric conditions. Psychol Med 34:613–622PubMedCrossRefGoogle Scholar
  37. 37.
    Luby JL, Svrakic DM, McCallum K, Przybeck TR, Cloninger CR (1999) The junior temperament and character inventory: preliminary validation of a child self-report measure. Psychol Rep 84:1127–1138PubMedCrossRefGoogle Scholar
  38. 38.
    Lucas CP, Zhang H, Fisher PW, Shaffer D, Regier DA, Narrow WE, Bourdon K, Dulcan MK, Canino G, Rubio-Stipec M, Lahey BB, Friman P (2001) The DISC predictive scales (DPS): efficiently screening for diagnoses. J Am Acad Child Adolesc Psychiatry 40:443–449PubMedCrossRefGoogle Scholar
  39. 39.
    Lyoo IK, Han CH, Lee SJ, Yune SK, Ha JH, Chung SJ, Choi H, Seo CS, Hong KE (2004) The reliability and validity of the junior temperament and character inventory. Compr Psychiatry 45:121–128PubMedCrossRefGoogle Scholar
  40. 40.
    Nigg JT, Goldsmith HH, Sachek J (2004) Temperament and attention deficit hyperactivity disorder: the development of a multiple pathway model. J Clin Child Adolesc Psychol 33:42–53PubMedCrossRefGoogle Scholar
  41. 41.
    Oh KJ, Lee HR (1990) Development of Korean version of child behavior checklist (K-CBCL) Korean Research Foundation Report, SeoulGoogle Scholar
  42. 42.
    Olsen KA, Rosenbaum B (2006) Prospective investigations of the prodromal state of schizophrenia: review of studies. Acta Psychiatr Scand 113:247–272PubMedCrossRefGoogle Scholar
  43. 43.
    Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164:942–948PubMedCrossRefGoogle Scholar
  44. 44.
    Posner K, Melvin GA, Murray DW, Gugga SS, Fisher P, Skrobala A, Cunningham C, Vitiello B, Abikoff HB, Ghuman JK, Kollins S, Wigal SB, Wigal T, McCracken JT, McGough JJ, Kastelic E, Boorady R, Davies M, Chuang SZ, Swanson JM, Riddle MA, Greenhill LL (2007) Clinical presentation of attention-deficit/hyperactivity disorder in preschool children: the preschoolers with attention-deficit/hyperactivity disorder treatment study (PATS). J Child Adolesc Psychopharmacol 17:547–562PubMedCrossRefGoogle Scholar
  45. 45.
    Roberts N, Stuart H, Lam M (2008) High school mental health survey: assessment of a mental health screen. Can J Psychiatry 53:314–322PubMedGoogle Scholar
  46. 46.
    Rohde LA (2008) Is there a need to reformulate attention deficit hyperactivity disorder criteria in future nosologic classifications? Child Adolesc Psychiatr Clin N Am 17:405–420PubMedCrossRefGoogle Scholar
  47. 47.
    Sanford MN, Offord DR, Boyle MH, Peace A, Racine YA (1992) Ontario child health study: social and school impairments in children aged 6 to 16 years. J Am Acad Child Adolesc Psychiatry 31:60–67PubMedCrossRefGoogle Scholar
  48. 48.
    Scahill L, Schwab-Stone M, Merikangas KR, Leckman JF, Zhang H, Kasl S (1999) Psychosocial and clinical correlates of ADHD in a community sample of school-age children. J Am Acad Child Adolesc Psychiatry 38:976–984PubMedCrossRefGoogle Scholar
  49. 49.
    Schmitz M, Denardin D, Laufer Silva T, Pianca T, Hutz MH, Faraone S, Rohde LA (2006) Smoking during pregnancy and attention-deficit/hyperactivity disorder, predominantly inattentive type: a case-control study. J Am Acad Child Adolesc Psychiatry 45:1338–1345PubMedGoogle Scholar
  50. 50.
    Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME (2000) NIMH diagnostic interview schedule for children version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry 39:28–38PubMedCrossRefGoogle Scholar
  51. 51.
    Spencer TJ (2006) ADHD and comorbidity in childhood. J Clin Psychiatry 67(Suppl 8):27–31PubMedGoogle Scholar
  52. 52.
    Spencer TJ, Biederman J, Mick E (2007) Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Ambul Pediatr 7:73–81PubMedCrossRefGoogle Scholar
  53. 53.
    Szatmari P, Offord DR, Boyle MH (1989) Correlates, associated impairments and patterns of service utilization of children with attention deficit disorder: findings from the Ontario child health study. J Child Psychol Psychiatry 30:205–217PubMedCrossRefGoogle Scholar
  54. 54.
    Tillman R, Geller B, Craney JL, Bolhofner K, Williams M, Zimerman B, Frazier J, Beringer L (2003) Temperament and character factors in a prepubertal and early adolescent bipolar disorder phenotype compared to attention deficit hyperactive and normal controls. J Child Adolesc Psychopharmacol 13:531–543PubMedCrossRefGoogle Scholar
  55. 55.
    Vaughn ML, Riccio CA, Hynd GW, Hall J (1997) Diagnosing ADHD (predominantly inattentive and combined type subtypes): discriminant validity of the behavior assessment system for children and the Achenbach parent and teacher rating scales. J Clin Child Psychol 26:349–357PubMedCrossRefGoogle Scholar
  56. 56.
    Wagner HR, Burns BJ, Broadhead WE, Yarnall KS, Sigmon A, Gaynes BN (2000) Minor depression in family practice: functional morbidity, co-morbidity, service utilization and outcomes. Psychol Med 30:1377–1390PubMedCrossRefGoogle Scholar
  57. 57.
    Waschbusch DA, King S (2006) Should sex-specific norms be used to assess attention-deficit/hyperactivity disorder or oppositional defiant disorder? J Consult Clin Psychol 74:179–185PubMedCrossRefGoogle Scholar
  58. 58.
    Yang SJ, Cheong S, Hong SD (2006) Prevalence and correlates of attention deficit hyperactivity disorder: school-based mental health services in Seoul. J Korean Neuropsychiatr Assoc 45:69–76Google Scholar
  59. 59.
    Yoo HI, Cho SC, Kim BN, Kim SY, Shin MS, Hong KE (2005) Psychiatric morbidity of second and third grade primary school children in Korea. Child Psychiatry Hum Dev 36:215–225PubMedCrossRefGoogle Scholar
  60. 60.
    Yoo HJ, Kim M, Ha JH, Chung A, Sim ME, Kim SJ, Lyoo IK (2006) Biogenetic temperament and character and attention deficit hyperactivity disorder in Korean children. Psychopathology 39:25–31PubMedCrossRefGoogle Scholar
  61. 61.
    Zlotnick C, Franklin CL, Zimmerman M (2002) Does “subthreshold” posttraumatic stress disorder have any clinical relevance? Compr Psychiatry 43:413–419PubMedCrossRefGoogle Scholar

Copyright information

© Steinkopff Verlag Darmstadt 2009

Authors and Affiliations

  • Soo-Churl Cho
    • 1
  • Boong-Nyun Kim
    • 1
  • Jae-Won Kim
    • 1
  • Luis Augusto Rohde
    • 2
  • Jun-Won Hwang
    • 3
  • Dong-Seon Chungh
    • 4
  • Min-Sup Shin
    • 1
  • In Kyoon Lyoo
    • 5
  • Bock-Ja Go
    • 6
  • Sang-Eun Lee
    • 6
  • Hyo-Won Kim
    • 1
    Email author
  1. 1.Division of Child and Adolescent Psychiatry, Department of NeuropsychiatrySeoul National University College of MedicineSeoulKorea
  2. 2.Serviço de Psiquiatria da Infância e AdolescênciaHospital de Clínicas de Porto AlegrePorto AlegreBrazil
  3. 3.Seoul Municipal Eunpyeong HospitalSeoulKorea
  4. 4.Heasu Psychiatric ClinicSungnamKorea
  5. 5.Department of NeuropsychiatrySeoul National University College of MedicineSeoulKorea
  6. 6.Seoul School Health Promotion CenterSeoulKorea

Personalised recommendations