Agreement Among Categorical, Dimensional, and Impairment Criteria for ADHD and Common Comorbidities.

OBJECTIVE: To compare the results of categorically based versus dimensionally based scoring algorithms for a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV)-referenced teacher rating scale for assessing ADHD and commonly co-occurring conditions and to determine their relative agreement with ratings of symptom-induced impairment. METHOD: Teachers completed Child and Adolescent Symptom Inventory-4R (CASI-4R) ratings for 1,092 youth (ages 6-18 years) referred to a child and adolescent psychiatry outpatient service. Caseness was determined according to DSM-IV symptom count (categorical model) and T-score (dimensional model) criteria. RESULTS: Agreement between symptom count and T-score cutoffs was generally good (kappa ≥ 0.61) for ADHD-Inattentive, ADHD-Hyperactive-Impulsive, ADHD-Combined (except adolescent females), Oppositional Defiant Disorder, and Conduct Disorder, but this was not the case for anxiety and depressive disorders where only 15% of kappas were good. Agreement of impairment cutoff with T-score and symptom count cutoffs ranged from poor to good. CONCLUSION: In general, although in many cases CASI-4R categorical and dimensional scoring algorithms generated similar results, there was considerable variability across disorders, age groups, scoring method, and in some cases, gender. Moreover, symptom counts and T-scores are not a proxy for assessing impairment suggesting that each scoring strategy likely provides unique information for clinical decision-making.

Risperidone added to parent training and stimulant medication: effects on attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and peer aggression.

OBJECTIVE: In this study, we aimed to expand on our prior research into the relative efficacy of combining parent training, stimulant medication, and placebo (Basic therapy) versus parent training, stimulant, and risperidone (Augmented therapy) by examining treatment effects for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms and peer aggression, symptom-induced impairment, and informant discrepancy. METHOD: Children (6-12 years of age; N = 168) with severe physical aggression, ADHD, and co-occurring ODD/CD received an open trial of parent training and stimulant medication for 3 weeks. Participants failing to show optimal clinical response were randomly assigned to Basic or Augmented therapy for an additional 6 weeks. RESULTS: Compared with Basic therapy, children receiving Augmented therapy experienced greater reduction in parent-rated ODD severity (p = .002, Cohen's d = 0.27) and peer aggression (p = .02, Cohen's d = 0.32) but not ADHD or CD symptoms. Fewer children receiving Augmented (16%) than Basic (40%) therapy were rated by their parents as impaired by ODD symptoms at week 9/endpoint (p = .008). Teacher ratings indicated greater reduction in ADHD severity (p = .02, Cohen's d = 0.61) with Augmented therapy, but not for ODD or CD symptoms or peer aggression. Although both interventions were associated with marked symptom reduction, a relatively large percentage of children were rated as impaired for at least 1 targeted disorder at week 9/endpoint by parents (Basic 47%; Augmented 27%) and teachers (Basic 48%; Augmented 38%). CONCLUSION: Augmented therapy was superior to Basic therapy in reducing severity of ADHD and ODD symptoms, peer aggression, and symptom-induced impairment, but clinical improvement was generally context specific, and effect sizes ranged from small to moderate. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study); http://clinicaltrials.gov/; NCT00796302.

What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder?

OBJECTIVE: Although combination pharmacotherapy is common in child and adolescent psychiatry, there has been little research evaluating it. The value of adding risperidone to concurrent psychostimulant and parent training (PT) in behavior management for children with severe aggression was tested. METHOD: One hundred sixty-eight children 6 to 12 years old (mean age 8.89 ± 2.01 years) with severe physical aggression were randomized to a 9-week trial of PT, stimulant (STIM), and placebo (Basic treatment; n = 84) or PT, STIM, and risperidone (Augmented treatment; n = 84). All had diagnoses of attention-deficit/hyperactivity disorder and oppositional-defiant disorder (n = 124) or conduct disorder (n = 44). Children received psychostimulant (usually Osmotic Release Oral System methylphenidate) for 3 weeks, titrated for optimal effect, while parents received PT. If there was room for improvement at the end of week 3, placebo or risperidone was added. Assessments included parent ratings on the Nisonger Child Behavior Rating Form (Disruptive-Total subscale was the primary outcome) and Antisocial Behavior Scale; blinded clinicians rated change on the Clinical Global Impressions scale. RESULTS: Compared with Basic treatment (PT + STIM [44.8 ± 14.6 mg/day] + placebo [1.88 mg/day ± 0.72]), Augmented treatment (PT + STIM [46.1 ± 16.8 mg/day] + risperidone [1.65 mg/day ± 0.75]) showed statistically significant improvement on the Nisonger Child Behavior Rating Form Disruptive-Total subscale (treatment-by-time interaction, p = .0016), the Nisonger Child Behavior Rating Form Social Competence subscale (p = .0049), and Antisocial Behavior Scale Reactive Aggression subscale (p = .01). Clinical Global Impressions scores were substantially improved for the 2 groups but did not discriminate between treatments (Clinical Global Impressions-Improvement score ≤2, 70% for Basic treatment versus 79% for Augmented treatment). Prolactin elevations and gastrointestinal upset occurred more with Augmented treatment; other adverse events differed modestly from Basic treatment; weight gain in the Augmented treatment group was minor. CONCLUSIONS: Risperidone provided moderate but variable improvement in aggressive and other seriously disruptive child behaviors when added to PT and optimized stimulant treatment. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study), URL: http://clinicaltrials.gov, unique identifier: NCT00796302.

A brief DSM-IV-referenced teacher rating scale for monitoring behavioral improvement in ADHD and co-occurring symptoms.

OBJECTIVE: To examine the psychometric properties of the 30-item teacher's version of the Child and Adolescent Symptom Inventory Progress Monitor (CASI-PM-T), a DSM-IV-referenced rating scale for monitoring change in ADHD and co-occurring symptoms in youths receiving behavioral or pharmacological interventions. METHOD: Three separate studies were conducted to determine (a) which items from longer diagnostic instruments were most representative of ADHD and commonly occurring psychiatric syndromes in clinic-referred samples ( N = 406) aged between 3 and 18 years, (b) the reliability and validity of the CASI-PM-T in students enrolled in full-time special education programs at the elementary and middle school levels (N = 169), and (c) the clinical utility of measuring behavioral change in a sample of outpatient ADHD children beginning treatment with stimulant medication. RESULTS: Internal consistency reliabilities (.71-.94), 2-week test-retest reliabilities (r = .70-.90), and interrater agreement (r = .44-.78) for the CASI-PM-T symptom categories were comparable to the full-length CASI-4. Convergence was also found between corresponding CASI-PM-T categories and consultant diagnoses of ADHD and ODD as well as school functioning measures of grade-point average and suspensions. The CASI-PM-T also demonstrated sensitivity to stimulant medication treatment effects. CONCLUSION: Findings provide preliminary support for the reliability, validity, and clinical utility of the CASI-PM-T.

Anxiety in boys with attention-deficit/hyperactivity disorder with and without chronic multiple tic disorder.

OBJECTIVE: This study examined the psychosocial and behavioral concomitants of anxiety in clinic-referred boys with attention-deficit/hyperactivity disorder (ADHD) with and without chronic multiple tic disorder (CMTD). METHOD: ADHD boys with (n = 65) and without (n = 94) CMTD were evaluated with measures of psychiatric symptoms, mental health risk factors, and academic and social performance. RESULTS: Boys with CMTD evidenced more severe anxiety and less social competence and were more likely to be living with only one biological parent than the ADHD Only group, but the magnitude of group differences was generally small. The severity of generalized anxiety, separation anxiety, social phobia, and obsessive-compulsive symptoms were uniquely associated with a different pattern of risk factors, and there was some evidence that these patterns differed for the two groups of boys. CONCLUSION: Boys with CMTD had a relatively more severe and complex pattern of anxiety that was associated with different clinical features, all of which suggests that ADHD plus CMTD might better be conceptualized as a distinct clinical entity from ADHD Only. However, findings from the extant literature are mixed, and therefore this remains a topic for further study.

The Child and Adolescent Symptom Inventory-Progress Monitor: a brief Diagnostic and Statistical Manual of Mental Disorders, 4th edition-referenced parent-report scale for children and adolescents.

The Child and Adolescent Symptom Inventory-Progress Monitor-Parent Form (CASI-PM-P) is a 29-item rating scale designed to evaluate symptom change for commonly referred child and adolescent disorders. Its intended applications include monitoring longer-term changes in clinical status and assessing intervention responsiveness. To enhance practicality, there is one version of the CASI-PM-P for all age groups with a common set of norms for both genders. Scoring procedures allow clinicians to assess whether observed symptom changes exceeded chance fluctuations. Using a clinical sample of 2,693 children ages 3-17 years, the 29 symptom-related items were identified that had the best item-to-total minus item correlations on the three age-appropriate scales of the Symptom Inventories. Item-to-total minus item correlations of similar magnitude were also obtained for those items with the standardization sample. In clinical samples, the CASI-PM-P scores had both high levels of internal consistency and test-retest reliability and were sensitive to change in a treated sample. Collectively, the findings support the reliability and validity of the CASI-PM-P as a measure of behavioral change in clinical settings, while continued research will be necessary to improve clinical utility and provide better documentation of the scale's strengths and weaknesses.

Methylphenidate in children with oppositional defiant disorder and both comorbid chronic multiple tic disorder and ADHD.

Our primary objective was to determine if immediate-release methylphenidate is an effective treatment for oppositional defiant disorder diagnosed from mother's report in children with both chronic multiple tic disorder and attention-deficit hyperactivity disorder (ADHD). Children (n = 31) aged 6 to 12 years received placebo and 3 doses of methylphenidate twice daily for 2 weeks each under double-blind conditions and were assessed with ratings scales and laboratory measures. Results indicated significant improvement in both oppositional and ADHD behaviors with medication; however, the magnitude of treatment effect varied considerably as a function of disorder (ADHD > Oppositional behaviors), informant (teacher > mother), assessment instrument, and specific oppositional behavior (rebellious > disobeys rules). Drug response was comparable with that in children (n = 26) who did not have diagnosed oppositional defiant disorder, but comorbidity appeared to alter the perceived benefits for ADHD according to mother's report. Methylphenidate is an effective short-term treatment for oppositional behavior in children with comorbid ADHD and chronic multiple tic disorder.

Immediate-release methylphenidate for ADHD in children with comorbid chronic multiple tic disorder.

OBJECTIVE: To examine the safety and efficacy of immediate-release methylphenidate (MPH-IR) for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children (ages 6-12 years) with Tourette's syndrome (96%) or chronic motor tic disorder (4%). METHOD: Two cohorts of prepubertal children (N = 71) received placebo and three doses of MPH (0.1, 0.3, and 0.5 mg/kg) twice daily for 2 weeks each, under double-blind conditions as part of their involvement in a long-term observation study (1989-2004). Treatment effects were assessed with an extensive battery of parent-, teacher-, child-, and physician-completed rating scales and laboratory tasks. RESULTS: MPH-IR effectively suppressed ADHD, oppositional defiant disorder, and peer aggression behaviors. There was no evidence that MPH-IR altered the overall severity of tic disorder or obsessive-compulsive disorder behaviors. Teacher ratings indicated that MPH-IR therapy decreased tic frequency and severity. CONCLUSIONS: MPH-IR appears to be a safe and effective short-term treatment for ADHD in the majority of children with chronic tic disorder; nevertheless, the possibility of tic exacerbation in susceptible individuals warrants careful monitoring of all patients.

ODD, ADHD, versus ODD+ADHD in clinic and community adults.

OBJECTIVE: To seek evidence for the validity of oppositional defiant disorder (ODD) as a behavioral syndrome in adults. METHOD: Two samples of adults, mental health outpatient clinic referrals (N = 490) and community controls (N = 900), completed a Diagnostic and Statistic Manual of Mental Disorders-referenced rating scale and a brief questionnaire (social, educational, occupational, and treatment variables). Participants were separated into four groups: ODD-only, ADHD-only, ODD+ADHD, and NONE. RESULTS: In general, the three symptom groups were more severe than the NONE group; the ODD+ADHD and NONE groups were the most and least severe, respectively; and there were clear differences between the ODD-only and ADHD-only groups. The pattern of group differences was generally similar in both samples. CONCLUSION: Findings support the distinction between ADHD and ODD symptom presentations in adults, and the notion that the comorbid condition is a unique clinical entity, both of which are consistent with the child literature. Nevertheless, additional research with larger samples of patients will be necessary to establish ODD as a potential behavioral syndrome in adults.

Psychiatric comorbidity in ADHD symptom subtypes in clinic and community adults.

OBJECTIVE: To compare psychiatric comorbidity between the three symptom subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD), Inattentive (I), Hyperactive-Impulsive (H), and Combined (C), in adults. METHOD: A clinic sample (N = 487) and a nonreferred community sample (N = 900) completed a DSM-IV-referenced rating scale and a questionnaire (social, educational, occupational, and treatment variables). Participants were assigned to one of four groups: ADHD:I, ADHD:H, ADHD:C, and NONE. RESULTS: All three ADHD symptom groups reported more severe comorbid symptoms than the NONE group; the ADHD:C and NONE groups were the most and least severe, respectively; and there were clear differences between the ADHD:I and ADHD:H groups. The pattern of group differences was similar in both samples. CONCLUSION: ADHD symptom subtypes in adults are associated with distinct clinical correlates. The diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations.

Choosing an attention-deficit/hyperactivity disorder rating scale: is item randomization necessary?

OBJECTIVE: Although behavior rating scales are generally considered de riguer for best clinical practices in the diagnosis and medical management of children with attention-deficit/hyperactivity disorder (ADHD), they are often time consuming to score, especially if items are arranged in random order. This study compares two methods of ordering rating scale items; namely, diagnostic-cluster versus randomized-order formats. METHODS: Participants were the parents of 207 consecutive referrals (5-17 years) to a child psychiatry outpatient service who were diagnosed as having a variety of emotional and behavioral disorders. Children were assessed with a battery of standardized assessment instruments and clinical interviews, including the ADHD Symptom Checklist-4. Half completed a diagnostic-cluster version and half completed a randomized-order version. RESULTS: Findings indicated that the internal consistency reliability, clinical utility (for identifying children with ADHD and oppositional defiant disorder), and concurrent validity of the two-item arrangement formats were virtually identical. CONCLUSION: Item arrangement does not appear to impact the reliability or validity of a commonly used ADHD rating scale.

Co-occurrence of conduct disorder and depression in a clinic-based sample of boys with ADHD.

BACKGROUND: Children with attention-deficit/hyperactivity disorder (ADHD) are at risk for the development of comorbid conduct disorder (CD) and depression. The current study examined potential psychosocial risk factors for CD and depression in a clinic-based sample of 203 boys (aged 6-10 years) with ADHD. METHODS: The boys and their mothers participated in an evaluation that involved assessments of cognitive, behavioral, academic, and family functioning. Potential predictors of CD and depression involved four domains: parenting behaviors, family environment, academic/cognitive functioning, and peer relations. ADHD groups were defined using mother- and teacher-report of DSM-IV symptoms. Mother-ratings of DSM-IV symptoms were obtained for a subsample of 91 boys approximately 5 years after the initial assessment. RESULTS: For both mother- and teacher-defined ADHD groups, social problems were related to depression symptoms; hostile, inconsistent, and detached parenting behaviors were related to CD symptoms; and family environment characterized by low cohesion, high conflict, and low marital satisfaction was related to CD and depression symptoms. For the teacher-defined ADHD group, parenting variables also predicted depression symptoms. Academic and cognitive variables did not predict CD or depression symptoms when parenting, family, and peer relationship variables were taken into account. Depression prospectively predicted CD, but not the reverse, and parental hostile control and familial conflict prospectively predicted CD for the teacher-defined ADHD group only. CONCLUSIONS: Source-specificity is a useful consideration when describing the relation of parenting and home environment with CD and depression symptoms in boys with ADHD. Intervention efforts that address these parenting, family, and peer relationship variables may aid in preventing the development of comorbid conditions.

Comparison of ADHD symptom subtypes as source-specific syndromes.

BACKGROUND: This study examines differences between the three subtypes of attention-deficit/hyperactivity disorder (ADHD), inattentive (I), hyperactive-impulsive (H), and combined (C), in a heterogeneous sample of 248 boys (ages 6 to 10 years) with emotional and behavioral problems who were recruited for participation in a diagnostic study. METHOD: The boys and their mothers participated in an extensive evaluation that involved multiple assessments of cognitive, behavioral, academic, and family functioning. ADHD subtypes were defined on the basis of teacher alone, mother alone, and mother/teacher ratings of DSM-IV symptoms. RESULTS: Results indicated ADHD symptom groups showed a differential pattern of impairment socially (H,C>I) and cognitively (I,C>H). The C and H groups were the most and least impaired overall, respectively, and all subtypes were differentiated from the nonADHD clinical control or NONE (N) group in a manner consistent with the primary findings. External validation of group differences was limited, and there were marked inconsistencies in the pattern of findings depending on how groups were defined. For the most part, although the mother/teacher grouping strategy (compared with either alone) captured a greater diversity of differences between subtypes, it also obscured some. CONCLUSIONS: Observed findings are consistent with the notion that mothers and teachers interpret symptom statements in terms of behaviors that are most relevant for their daily concerns.

A DSM-IV-referenced teacher rating scale for use in clinical management.

OBJECTIVE: Two studies were conducted to examine the psychometric properties of a DSM-IV-referenced teacher-completed rating scale in children receiving special education. METHOD: To assess reliability, teachers rated 74 students on two separate occasions (test-retest) using the teacher version of the Child Symptom Inventory-4 (CSI-4T), and teacher aides also rated the children on the first occasion (interrater). In a second study, teacher CSI-4T and Teacher's Report Form (TRF) ratings and consultant diagnoses were obtained for 101 students. RESULTS: Internal consistency reliabilities (0.72-0.94), 2-week test-retest reliabilities (r = 0.61-0.88), and interrater agreement (r = 0.19-0.56) for the CSI-4T major symptom categories were comparable with dimensional rating scales. CSI-4T ratings showed a consistent pattern of convergent and divergent validity with TRF scores and with consultant diagnoses. CONCLUSION: Findings provide preliminary support for the reliability and validity of the CSI-4T as a measure of DSM-IV symptoms in children receiving special education.

Further evidence of reliability and validity of the Child Symptom Inventory-4: parent checklist in clinically referred boys.

Examined reliability and validity of the parent version of the Child Symptom Inventory (CSI-4) in 247 boys between 6.0 and 10 years 11 months old referred for evaluation of behavioral and emotional problems. The CSI-4 is a behavior rating scale whose items correspond to the symptoms of disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994). Results indicated satisfactory internal consistency reliability, test-retest reliability, and temporal stability over a 4-year period for most symptom categories. CSI-4 ratings converged and diverged in a theoretically consistent pattern with respective scales of the Child Behavior Checklist (CBCL; Achenbach, 1991a) and the Diagnostic Interview for Children and Adolescents-Revised-Parent Version (DICA-P; Reich, Shayka, & Taibleson, 1991). Discriminant validity was established in that boys with specific DICA-P diagnoses received significantly higher corresponding CSI-4 parent symptom ratings than boys not so diagnosed. Clinical utility (sensitivity, specificity, positive predictive power, negative predictive power) was evaluated for screening cutoffs based on categorical (DSM-IV) and dimensional (normative distribution of Symptom Severity scores) scoring methods.

A DSM-IV-referenced, adolescent self-report rating scale.

OBJECTIVE: To examine the reliability and validity of the Youth's Inventory-4 (YI-4), a DSM-IV-referenced self-report rating scale. METHOD: Youths (N = 239) aged between 11 and 18 years who were clinically evaluated between 1996 and 1999 completed the YI-4, and 79% completed at least one additional self-report. Parents and teachers completed a companion measure. A second sample (N = 47) was retested 2 weeks after an initial evaluation. RESULTS: The YI-4 demonstrated satisfactory internal consistency (alpha values = .66-.87) and test-retest reliability (r values = 0.54-0.92), convergent and to lesser extent divergent validity with other self-report measures, and discriminant validity by differentiating children with and without diagnosed attention-deficit/hyperactivity disorder, conduct disorder, substance use, generalized anxiety disorder, or major depressive disorder. Youth-parent (r values = 0.05-0.50) and youth-teacher (r values < 0.18) agreement was generally modest. CONCLUSIONS: These findings provide preliminary support for the clinical utility of the YI-4 for symptom assessment in referred youths.

Correspondence between adolescent report, parent report, and teacher report of manic symptoms.

OBJECTIVE: To examine differences between source-specific manic symptoms. METHODS: In total, 104 consecutive adolescent outpatient referrals were evaluated for their psychiatric status using a questionnaire based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders that was completed by parents, teachers, and youths. RESULTS: Approximately one third of the youths met symptom criteria for mania by at least one informant; however, only 38% of these met such criteria by at least two informants. Youths who had manic symptoms according to two informants were significantly more symptomatic both on mental status exam and in other dimensions of psychopathology than youths who did not have corroborated manic symptoms. Cross-informant agreement was generally poor when symptoms were scored dimensionally. CONCLUSIONS: Manic symptoms are relatively nonspecific in outpatient samples. Using more than one informant increases the likelihood of selecting subjects with serious and possibly manic disorders.

A DSM-IV-referenced screening instrument for preschool children: the Early Childhood Inventory-4.

OBJECTIVE: To examine the validity of the Early Childhood Inventory-4 (ECI-4), a parent and teacher rating scale designed to screen for DSM-IV emotional and behavioral disorders. METHOD: The convergent, divergent, and discriminant validity and clinical utility of the ECI-4 was studied in a sample of 224 consecutive referrals (3-6-year-old children) to a child psychiatric outpatient clinic. RESULTS: The ECI-4 demonstrated adequate criterion validity for the most common disorders (attention-deficit/hyperactivity disorder, oppositional defiant disorder, pervasive developmental disorder) when compared with data-based psychiatric diagnoses and correlated well with relevant scales of the Child Behavior Checklist, Teacher's Report Form, and Inattention/Overactivity With Aggression (IOWA) Conners. CONCLUSION: The ECI-4 appears to be a useful screening measure for certain disorders in clinically referred children, but continued research is needed to determine its value in other settings (e.g., school and community), and its validity with other measurement methodologies.

Anxiety and depression symptoms and response to methylphenidate in children with attention-deficit hyperactivity disorder and tic disorder.

This study examined response to methylphenidate in children with attention-deficit/hyperactivity disorder (ADHD) and chronic multiple tic disorder. The primary goal was to determine if children with anxiety or depression symptoms showed a less favorable response to treatment. Subjects were 38 prepubertal children who participated in an 8-week, double-blind, placebo-controlled, methylphenidate crossover evaluation. Treatment effects were assessed with direct observations of child behavior in public school and clinic settings; rating scales completed by parents, teachers, and clinicians; and laboratory analogue tasks. There was little evidence (group data) that children with anxiety or depression symptoms responded in a clinically different manner to methylphenidate than youngsters who did not exhibit these symptoms, particularly in school observations of the core features of ADHD. Seeming differences between children with and without comorbid anxiety or depression symptoms and drug response are likely explained by differences in pretreatment levels of negativistic behaviors (i.e., symptoms of oppositional defiant disorder or conduct disorder). Methylphenidate appears to be effective for the management of ADHD behaviors in children with mild to moderate anxiety or depression symptoms; nevertheless, much research remains to be performed in this area.

Tics and psychiatric comorbidity in children and adolescents.

This study examined comorbid psychiatric symptoms in a large, community-based sample of children and adolescents. The study sample comprised a total of 3006 school children: 413 preschool (3 to 5 years; 237 males, 176 females; mean age 4 years 2 months, SD 8 months), 1520 elementary school (5 to 12 years; 787 males, 733 females; mean age 8 years 2 months, SD 1 year 11 months), and 1073 secondary school children (12 to 18 years; 573 males, 500 females; mean age 14 years 4 months, SD 1 year 10 months), all of whom were attending regular education programs. Children were evaluated with a teacher-completed DSM-IV-referenced rating scale. The sample was divided into four groups: attention-deficit-hyperactivity disorder with tics (ADHD+tics), ADHD without tics (ADHD), tics without ADHD (T), and a comparison group i.e. neither ADHD nor tics (Non). The percentage of children with tic behaviors varied with age: preschool children (22.3%), elementary school children (7.8%), and adolescents (3.4%). Tic behaviors were more common in males than females, regardless of comorbid ADHD symptoms. For many psychiatric symptoms, screening prevalence rates were highest for the ADHD groups (ADHD+tics>ADHD>T>Non). However, obsessive-compulsive and simple and social phobia symptoms were more common in the groups with tic behavior. Findings for a community-based sample show many similarities with studies of clinically referred samples suggesting that teacher-completed ratings of DSM-IV symptoms may be a useful methodology for investigating the phenomenology of tic disorders.