Sex-Specific Norms for Diagnosing Attention-Deficit/Hyperactivity Disorder in Childhood: A Receiver Operating Characteristic (ROC) Analysis

This study employed Receiver Operating Characteristic (ROC) analyses to identify optimal symptom count cutoffs for girls and boys with attention-deficit/hyperactivity disorder (ADHD). A nationally representative sample of parents of 1050 children (51.5% boys; 78.8% white; 84.2% non-Hispanic) ages 5 to 12 years old (M = 8.42, SD = 2.31) completed ratings of their children’s ADHD symptoms, impairment and internalizing (i.e., depression and anxiety) and externalizing (i.e., oppositional defiant disorder and conduct disorder) problems. Results provided evidence for a sex-specific ADHD symptom cutoff for girls that was lower than the current symptom threshold required by the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). Girls with four or more symptoms of inattention and/or hyperactivity/impulsivity experienced greater co-occurring psychopathology, including internalizing (i.e., depression, and anxiety) and externalizing (i.e., oppositional defiant disorder and conduct disorder) problems, compared to girls with average levels of ADHD. Compared to girls and boys with ADHD defined using DSM-5 symptom count criteria, girls in the sex-specific ADHD group manifested lower levels of internalizing and externalizing problems, although there was also some evidence for similar levels of oppositional defiant disorder and depression among these three groups. In contrast, the symptom cutoff identified using ROC analysis among boys was consistent with existing DSM-5 guidelines. These findings add to the growing evidence supporting the use of sex-specific norms in the diagnosis of ADHD in girls. Future work should seek to extend these results using a multi-method approach to the assessment of ADHD.