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ADHD and Factor Analysis: Are There Really Three

Distinct Subtypes of ADHD?
a
Jayme Bernfeld
a
Department of Psychology, California State University, Long Beach, California

Version of record first published: 05 Jul 2012

To cite this article: Jayme Bernfeld (2012): ADHD and Factor Analysis: Are There Really Three Distinct Subtypes of ADHD?,
Applied Neuropsychology: Child, DOI:10.1080/21622965.2012.699421

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 APPLIED NEUROPSYCHOLOGY: CHILD, 0: 1–5, 2012
Copyright # Taylor & Francis Group, LLC
ISSN: 2162-2965 print=2162-2973 online
DOI: 10.1080/21622965.2012.699421

ADHD and Factor Analysis: Are There Really Three Distinct

Subtypes of ADHD?
Jayme Bernfeld
Department of Psychology, California State University, Long Beach, California
Downloaded by [b-on: Biblioteca do conhecimento online UC] at 02:36 12 July 2012

The diagnostic criteria for attention-deficit hyperactivity disorder (ADHD), a behavio-

rally defined disorder, have been changed several times since first established in the
second edition of the Diagnostic and Statistical Manual of Mental Disorders. In the cur-
rent edition, the diagnosis includes three reportedly distinct subtypes. Despite consider-
able research, there remains little evidence of the diagnostic validity of three separate
ADHD subtypes. Several posited explanations for problems delineating consistent dif-
ferences between ADHD subtypes are addressed. This article considers the underlying
factors thought to contribute to ADHD and evaluates the relevance of categorical
and dimensional diagnostic approaches.

Key words: ADHD, diagnosis, DSM

‘‘attention-deficit hyperactivity disorder’’ (ADHD) and

again emphasized hyperactivity. The two categories of
ATTENTION-DEFICIT HYPERACTIVITY symptoms present in DSM-III were consolidated into
DISORDER, A DSM HISTORY a one-dimensional group of 14 symptoms, 8 of which
had to be present for a diagnosis. The DSM-III-R cri-
The term ‘‘attention-deficit disorder’’ (ADD) was intro- teria did not allow for the possibility of an attentional
duced in the third edition of the Diagnostic and Statisti- disorder in the absence of hyperactivity, and the
cal Manual of Mental Disorders (DSM-III; American majority of the symptoms listed described hyperactive
Psychiatric Association [APA], 1980). The prior edition or impulsive behavior.
(DSM-II; APA, 1968) included a disorder called ‘‘hyper- The most recent editions of the DSM (4th edition
kinetic reaction of childhood,’’ which was defined as a [DSM-IV] and 4th edition, text revision [DSM-IV-
type of hyperactivity characterized by a short attention TR]), include three subtypes of ADHD: predominately
span, hyperactivity, and restlessness. Along with the inattentive type (ADHD-I), predominately hyperactive–
name change, the disorder in DSM-III was redefined impulsive type (ADHD-HI), and combined type
as primarily a problem with attention. The diagnostic (ADHD-C). Delineation of subtype is based on the rela-
criterion was changed to allow for the presence of atten- tive number of symptoms from each of two symptom
tion problems in the absence of impulse control prob- lists (inattention and hyperactivity=impulsivity). A
lems and hyperactivity (APA, 1980). According to the diagnosis of ADHD-I is made when six or more of
DSM-III, there were two subtypes of ADD: ADD=H the inattentive symptoms and fewer than six of the
(with hyperactivity) and ADD=WO (without hyperac- hyperactivity=impulsivity symptoms are present; a diag-
tivity). The next edition, a revised version of the nosis of ADHD-HI is made when the reverse is true (six
DSM-III (DSM-III-R; APA, 1987) named the disorder or more hyperactivity=impulsivity symptoms, fewer
than six inattentive symptoms); and a diagnosis of
Address correspondence to Jayme Bernfeld, Department of ADHD-C is made when six or more symptoms from
Psychology, California State University, 1250 Bellflower Blvd., Long both lists are evident (APA, 1994, 2000).
Beach, CA 90840. E-mail: jayme.bernfeld@csulb.edu
 2 BERNFELD

At present, the fifth edition of the DSM (DSM-V) is there are increasing questions concerning its validity and
under consideration. The proposed ADHD diagnosis utility (Lahey, Pelham, Loney, Lee, & Willcutt, 2005;
retains the two symptom lists but includes an expansion Valo & Tannock, 2010). Although some studies have
of individual symptom descriptions to include multiple found support for the validity of the three separate sub-
examples in an attempt to increase clarity and interrater types (Glutting, Youngstrom, & Watkins, 2005; Proctor
reliability. The proposed diagnosis also includes four & Prevatt, 2009), in general, the evidence for differen-
additional ‘‘hyperactivity and impulsivity’’ symptoms: tiating the three subtypes is inconsistent and equivocal
(1) ‘‘Tends to act without thinking, such as starting tasks (Baeyens, Roeyers, & Walle, 2006; Burns, Walsh, &
without adequate preparation or avoiding reading or lis- Gomez, 2003; Glutting et al.; Martel, von Eye, & Nigg,
tening to instructions, may speak out without considering 2010; Toplak et al., 2009).
consequences or make important decisions on the spur of In a recent analysis including the 4 new items,
the moment, such as impulsively buying items, suddenly Ghanizadeh (2012) examined the factor structure of
quitting a job, or breaking up with a friend’’; (2) ‘‘Is often the proposed DSM-V symptoms. Although the con-
impatient, as shown by feeling restless when waiting for firmatory factor analysis supported inattentiveness and
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others and wanting to move faster than others, wanting hyperactivity=impulsivity as two separate factors, 3 of
people to get to the point, speeding while driving, and the 4 proposed symptoms of hyperactivity=impulsivity
cutting into traffic to go faster than others’’; (3) ‘‘Is loaded on the inattentiveness factor. Additional analysis
uncomfortable doing things slowly and systematically indicated that a three-factor model was a better fit, with
and often rushes through activities or tasks’’; and (4) the 4 new proposed symptoms comprising a separate
‘‘Finds it difficult to resist temptations or opportunities, factor. An additional factor analysis was conducted on
even if it means taking risks (A child may grab toys off a the 13 proposed hyperactivity=impulsivity symptoms
store shelf or play with dangerous objects; adults may (9 from DSM-IV-TR and 4 new) to investigate whether
commit to a relationship after only a brief acquaintance they could be divided into two categories: hyperactivity
or take a job or enter into a business arrangement without and impulsivity. Results of this factor analysis sup-
doing due diligence).’’ The proposed criteria maintain the ported a two-factor structure with one factor including
three DSM-IV-TR subtypes and add a fourth, ‘‘inatten- the original 9 symptoms from DSM-IV and the second
tive presentation (restrictive),’’ which is diagnosed when factor including the 4 new proposed symptoms
six or more of the inattentive symptoms and fewer than (Ghanizadeh).
three of the hyperactivity=impulsivity symptoms are There is more evidence supporting the differentiation
present (DSM-V Development, 2012). of two subtypes (DuPaul et al., 1998; Valo & Tannock,
At each iteration of the DSM, the diagnostic criteria 2010). Interestingly, although there is some evidence
for ADHD were generated from discussions of experts supporting the validity of ADHD-I and ADHD-HI as
who, following the disease model, constructed the diag- independent subtypes (Collett, Crowley, Gimpel, &
noses based on categorical classification. The disease Greenson, 2000; DuPaul et al., 1998), there is more sup-
model includes an assumption that one disease can gen- port for the validity of ADHD-I and ADHD-C as sep-
erate a syndrome; there is therefore no need to consider arate subtypes (Baeyens et al., 2006; Bauermeister
the possibility that different or multiple etiologies can et al., 2005; Lemiere et al., 2010; Woo & Rey, 2005).
result in similar symptom presentations. In addition, Many studies have investigated whether there are
there is no consideration of the neurocognitive under- differences in performance between the ADHD subtypes
pinnings of the various symptom presentations. Diag- on a variety of cognitive and neuropsychological tasks
nosis is made solely based on assigned membership in (Adams, Derefinko, Milich, & Fillmore, 2008; Barkley
a category, which is determined by the number and & Murphy, 2010; Derefinko et al., 2008; Lemiere et al.,
types of symptoms present; in DSM-IV, six of nine inat- 2010; McBurnett, Pfiffner, & Frick, 2001; Solanto et al.,
tentive symptoms and fewer than six symptoms of 2007). Overall, the evidence for different cognitive pro-
hyperactivity=impulsivity results in a diagnosis of files is not compelling and the subtypes are more similar
ADHD-I. After the categories are established, data from than different with regard to their neuropsychogical
field trials are used to establish interrater reliability profiles (Adams et al.; Barkley & Murphy; Derefinko
(APA, 1980, 1987, 1994, 2000). The entire process is et al.; Lemiere et al.; Solanto et al., 2007). Additionally,
based upon behavioral observation. the groups show similar response to medication (Solanto
et al., 2009).
In general, the strongest support of the diagnostic
VALIDITY OF THE ADHD SUBTYPES validity of the ADHD subtypes is found when a diag-
nosis is made using structured interviews and question-
Although the DSM ADHD subtype classification naires that specifically incorporate the symptom
system is widely used by both clinicians and researchers, descriptions from the DSM (Lahey et al., 1998; Proctor
 ARE THERE REALLY THREE DISTINCT ADHD SUBTYPES? 3

& Prevatt, 2009). Conclusive evidence that the subtypes health has necessitated the use of a classification system
can be reliably differentiated using any measure other based on phenomenology. Hyman argued that although
than a semistructured interview or questionnaire there was no reasonable alternative to the use of a
designed to measure ADHD symptoms is lacking. phenomenological-based diagnostic system for mental
illness, the adoption of categorical classification was
problematic given that there is no evidence for either
EXPLANATIONS FOR LACK OF VALIDITY homogeneity within categories or discontinuity between
categories. As an alternative, Hyman proposed the use
Several explanations have been posited for problems of a dimensional classification system in which disorders
delineating consistent differences between ADHD sub- are understood to be continuous with normalcy. In the
types. One explanation addresses the heterogeneity of case of ADHD, problems with attention, impulse con-
individuals within the diagnosis (Fair, Bathula, Nikolas, trol, and hyperactivity would be defined as quantitative
& Nigg, 2012; McBurnett et al., 2001; Valo & Tannock, deviations from the mean in these areas, benchmarked
2010). From a purely mathematical perspective, hetero- for age, rather than as categories discontinuous from
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geneity is to be expected. According to the diagnostic behavior seen in typical children.

criteria, an individual is diagnosed with ADHD-I or A second explanation for the difficulty delineating
ADHD-HI when six of the nine respective symptoms consistent differences between ADHD subtypes is that
are present; given that there are 84 possible symptom the criteria for the diagnosis of ADHD lack developmen-
combinations that fulfill the six of nine criteria, hetero- tal sensitivity. Although ADHD is classified as a neurode-
geneity is largely inevitable (combinations without velopmental disorder, the DSM is not neuroanatomically
repetitions: n!=r!(n–r)! where n ¼ number of choices organized. The symptoms of ADHD do not address
and r ¼ how many you choose). Additionally, each of either the developmental changes in behavior or develop-
the 18 symptom descriptions is itself heterogeneous. mental changes neuroanatomically. Furthermore, the
For example, there can be many reasons for endorsing symptoms are not even developmentally appropriate;
‘‘fails to give close attention to details or makes careless the same list of symptoms is used for all individuals
mistakes’’ or ‘‘often does not seem to listen.’’ regardless of age (DuPaul et al., 1998). It is not surprising
As mentioned previously, the diagnostic criteria used that children diagnosed with ADHD-HI tend to be
in the DSM are based on categorical classification. younger (Chiang et al., 2010; DuPaul et al.), because
Using categorical classification for diagnoses involves hyperactive behavior tends to diminish as children reach
the assigning of symptoms to discrete categories (in this adolescence (Lahey et al., 2005).
case a subtype of ADHD) that are discontinuous from A longitudinal study investigating the diagnosis of
each other. Categorical classification is appropriate for ADHD over time found both diagnostic instability
diagnoses when (1) all members of a diagnostic class and developmental changes in symptom presentation
are homogeneous, (2) there are clear boundaries (Lahey et al., 2005). The study followed children for
between classes=subtypes, and (3) the different classes= more than 8 years and rated their symptoms seven times
subtypes are mutually exclusive (APA, 2000). Given during that time period. Results indicated that although
the heterogeneity within the subtypes, the appropriate- many children who met criteria for a diagnosis of
ness of the use of a categorical classification system for ADHD at the initial evaluation continued to do so,
ADHD has been questioned (Hyman, 2010; Toplak there was a decline over time in the number of children
et al., 2009). who met diagnostic criteria although not necessarily a
An alternative strategy to the categorical system is decline in behavioral problems. The authors noted that
one that considers the dimensional structure of inatten- children who were initially diagnosed with ADHD-C
tion, hyperactivity, and impulsivity, rather than compar- were more likely to continue to be diagnosed with this
ing categories (Hyman, 2010; Toplak et al., 2009). There disorder than were children who were initially diagnosed
is support for a bifactor model with a general unitary with ADHD-HI. The authors also found that 37% of the
component of ADHD accounting for a sizeable portion children who initially met criteria for ADHD-C and
of the variance with separate dimensional traits of 50% of the children who initially met criteria for
inattention and hyperactivity=impulsivity adding inde- ADHD-I met criteria for a different ADHD subtype
pendent variance beyond the general factor (Toplak at least twice during the subsequent six assessments.
et al.). A third explanation for the difficulty delineating con-
In a more general discussion of the diagnosis of men- sistent differences between ADHD subtypes focuses
tal disorders, Hyman (2010) points out that while the on the variability of methods used between studies.
‘‘gold standard’’ for disease classification is either etiol- Several authors have noted a relative shift in the distri-
ogy or etiology modified by pathophysiology, the lack of bution of ADHD subtypes depending on the informants
conclusive information in these areas regarding mental (Rowland et al., 2008; Valo & Tannock, 2010) and
 4 BERNFELD

methodology (Valo & Tannock). Valo and Tannock to develop a diagnostic system that is neuroanatomically
found that up to 50% of the cases they investigated were informed and based on models of attentional and
reclassified from one subtype to another based on the cognitive=neurological functioning (see Koziol &
informant and methodology, clearly indicating a lack Stevens, this issue). In the meantime, it is advisable to
of consistency across measures and reporting sources. ‘‘diagnose’’ ADHD with the observational methodology
Although neuropsychological tests are often used to dif- described above, while using neuropsychological test
ferentiate between the groups, it is not surprising when results to identify and characterize the individual’s
they fail to so do because a diagnosis of ADHD is cognitive profile with a descriptive nomenclature.
not based on underlying neurocognitive functioning;
instead, it is based on observable behavior. This then
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