To examine the Strengths and Weaknesses of ADHD–Symptoms and Normal Behavior scale (SWAN) clinical utility as a diagnostic measure of ADHD in an ADHD clinic sample.
Method:
In a sample of 357 children (6–11 years old) referred for evaluation at an academic medical center, we explored the SWAN’s diagnostic and convergent validity with the Hyperactivity–Inattention subscale of the Strengths and Difficulties Questionnaire (SDQ/HI) and concurrent validity with the Impairment Rating Scale (IRS).
Results:
The averaged (SWAN total) and the SWAN Hyperactivity/Impulsivity subscale (SWAN HI) showed significant and large correlations with the SDQ/HI (r = .69 and .65), respectively. The SWAN Attention Deficit subscale (SWAN AD) had a significant but smaller correlation (r = .49). The SWAN total had moderate correlation with the IRS average score ( = .33). In receiver operating characteristic (ROC) curve analyses (area under the curve (AUC) = 0.71) for the SWAN total, the SWAN distinguished ADHD cases from non-ADHD cases with sensitivity of 83% but specificity of 47%.
Conclusion:
In a clinical sample, the SWAN total scores displayed a near-normal distribution. ADHD cases were distinguished from non-ADHD cases by the SWAN. The SWAN showed adequate convergent and concurrent validity with other symptoms and impairment measures.
AlexanderL. M.SalumG. A.SwansonJ. M.MilhamM. P. (2020). Measuring strengths and weaknesses in dimensional psychiatry. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 61(1), 40–50. https://doi.org/10.1111/jcpp.13104
2.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders : DSM-IV. (4th ed.).
3.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/https://doi.org/10.1176/appi.books.9780890425596
4.
ArnettA. B.PenningtonB. F.FriendA.WillcuttE. G.ByrneB.SamuelssonS.OlsonR. K. (2013). The SWAN captures variance at the negative and positive ends of the ADHD symptom dimension. Journal of Attention Disorders, 17(2), 152–162. https://doi.org/10.1177/1087054711427399
5.
BritesC.Salgado-AzoniC. A.FerreiraT. L.LimaR. F.CiascaS. M. (2015). Development and applications of the SWAN rating scale for assessment of attention deficit hyperactivity disorder: A literature review. Brazilian Journal of Medical and Biological Research, 48(11), 965–972. https://doi.org/10.1590/1414-431x20154528
6.
BurtonC. L.WrightL.ShanJ.XiaoB.DupuisA.GoodaleT.ShaheenS. M.CorfieldE. C.ArnoldP. D.SchacharR. J.CrosbieJ. (2019). SWAN scale for ADHD trait-based genetic research: A validity and polygenic risk study. Journal of Child Psychology and Psychiatry, 60(9), 988–997. https://doi.org/10.1111/jcpp.13032
7.
CarlsonK. D.HerdmanA. O. (2010). Understanding the Impact of convergent validity on research results. Organizational Research Methods, 15(1), 17–32. https://doi.org/10.1177/1094428110392383
8.
ChanG. F.-C.LaiK. Y.-C.LukE. S.-L.HungS.-F.LeungP. W.-L. (2014). Clinical utility of the Chinese strengths and weaknesses of ADHD-symptoms and normal-behaviors questionnaire (SWAN) when compared with DISC-IV. Neuropsychiatric Disease and Treatment, 10, 1533–1542. https://doi.org/10.2147/NDT.S65879
9.
CoghillD.Sonuga-BarkeE. J. S. (2012). Annual research review: Categories versus dimensions in the classification and conceptualisation of child and adolescent mental disorders – implications of recent empirical study. Journal of Child Psychology and Psychiatry, 53(5), 469–489. https://doi.org/10.1111/j.1469-7610.2011.02511.x
10.
CollettB. R.OhanJ. L.MyersK. M. (2003). Ten-year review of rating scales: V. Scales assessing attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 42(9), 1015–1037. https://doi.org/10.1097/01.CHI.0000070245.24125.B6
11.
ConnersC. K. (1999). Clinical use of rating scales in diagnosis and treatment of attention-deficit/hyperactivity disorder. Pediatric Clinics of North America, 46(5), 857–870. https://doi.org/https://doi.org/10.1016/S0031-3955(05)70159-0
12.
DanielsonM. L.BitskoR. H.GhandourR. M.HolbrookJ. R.KoganM. D.BlumbergS. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47(2), 199–212. https://doi.org/10.1080/15374416.2017.1417860
13.
DeLongE. R.DeLongD. M.Clarke-PearsonD. L. (1988). Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach. Biometrics, 44(3), 837–845.
FabianoG. A.PelhamJ. W. E.WaschbuschD. A.GnagyE. M.LaheyB. B.ChronisA. M.OnyangoA. N.KippH.Lopez-WilliamsA.Burrows-MacLeanL. (2006). A practical measure of impairment: Psychometric properties of the impairment rating scale in samples of children with attention deficit hyperactivity disorder and two school-based samples. Journal of Clinical Child & Adolescent Psychology, 35(3), 369–385. https://doi.org/10.1207/s15374424jccp3503_3
16.
GarnerA. A.OʼconnorB. C.NaradM. E.TammL.SimonJ.EpsteinJ. N. (2013). The relationship between ADHD symptom dimensions, clinical correlates, and functional impairments. Journal of Developmental and Behavioral Pediatrics, 34(7), 469-477. https://doi.org/10.1097/DBP.0b013e3182a39890
17.
GathjeR. A.LewandowskiL. J.GordonM. (2008). The role of impairment in the diagnosis of ADHD. Journal of Attention Disorders, 11(5), 529–537. https://doi.org/10.1177/1087054707314028
GrevenC. U.MerwoodA.van der MeerJ. M. J.HaworthC. M. A.RommelseN.BuitelaarJ. K. (2016). The opposite end of the attention deficit hyperactivity disorder continuum: Genetic and environmental aetiologies of extremely low ADHD traits. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(4), 523–531.
20.
HayD. A.BennettK. S.LevyF.SergeantJ.SwansonJ. (2007). A twin study of attention-deficit/hyperactivity disorder dimensions rated by the strengths and weaknesses of ADHD-symptoms and normal-behavior (SWAN) scale. Biological Psychiatry, 61(5), 700–705. https://doi.org/10.1016/j.biopsych.2006.04.040
21.
HunsleyJ. (2004). Introduction to the special section on incremental validity and utility in clinical assessment. Psychological Assessment, 15, 443–445. https://doi.org/10.1037/1040-3590.15.4.443
22.
KaralunasS. L. (2022). Editorial: Can we accurately screen for Attention-Deficit/Hyperactivity Disorder? Moving to a dimensional, multistep process to support youth development. Journal of the American Academy of Child & Adolescent Psychiatry, 61(8), 965–967. https://doi.org/10.1016/j.jaac.2022.02.011
23.
KuriyanA. B.PelhamW. E.MolinaB. S. G.WaschbuschD. A.GnagyE. M.SibleyM. H.BabinskiD. E.WaltherC.CheongJ.YuJ.KentK. M. (2013). Young adult educational and vocational outcomes of children diagnosed with ADHD. Journal of Abnormal Child Psychology, 41(1), 27–41. https://doi.org/10.1007/s10802-012-9658-z
24.
LaiK. Y. C.LeungP. W. L.LukE. S. L.WongA. S. Y.LawL. S. C.HoK. K. Y. (2011). Validation of the Chinese strengths and weaknesses of ADHD-symptoms and normal-behaviors questionnaire in Hong Kong. Journal of Attention Disorders, 17(3), 194–202. https://doi.org/10.1177/1087054711430711
25.
LakatosK.BirkásE.TóthI.GervaiJ. (2010). Screening childhood behavior problems using short questionnaires II.: The Hungarian version of the SWAN-scale strength and weakness of ADHD-symptoms and normal-behavior for screening attention deficit/hyperactivity disorder. Psychiatria Hungarica, 25(6), 493–502.
26.
LakesK. D.SwansonJ. M.RiggsM. (2011). The reliability and validity of the English and Spanish strengths and weaknesses of ADHD and normal behavior rating scales in a preschool sample: Continuum measures of hyperactivity and Inattention. Journal of Attention Disorders, 16(6), 510–516. https://doi.org/10.1177/1087054711413550
27.
MulraneyM.ArrondoG.MusulluluH.Iturmendi-SabaterI.CorteseS.WestwoodS. J.DonnoF.BanaschewskiT.SimonoffE.ZuddasA.DöpfnerM.HinshawS. P.CoghillD. (2022). Systematic review and meta-analysis: Screening tools for Attention-Deficit/Hyperactivity Disorder in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 61(8), 982–996. https://doi.org/https://doi.org/10.1016/j.jaac.2021.11.031
28.
ParkerA.CorkumP. (2016). ADHD diagnosis: As simple as administering a questionnaire or a complex diagnostic process?Journal of Attention Disorders, 20(6), 478–486. https://doi.org/10.1177/1087054713495736
29.
PliszkaS. (2007). Practice parameter for the assessment and treatment of children and adolescents with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 894–921. https://doi.org/10.1097/chi.0b013e318054e724
30.
PoldermanT. J. C.DerksE. M.HudziakJ. J.VerhulstF. C.PosthumaD.BoomsmaD. I. (2007). Across the continuum of attention skills: A twin study of the SWAN ADHD rating scale. Journal of Child Psychology and Psychiatry, 48(11), 1080–1087. https://doi.org/10.1111/j.1469-7610.2007.01783.x
31.
RaikerJ. S.FreemanA. J.Perez-AlgortaG.FrazierT. W.FindlingR. L.YoungstromE. A. (2017). Accuracy of achenbach scales in the screening of attention-deficit/hyperactivity disorder in a community mental health clinic. Journal of the American Academy of Child & Adolescent Psychiatry, 56(5), 401–409.
32.
RiceM. E.HarrisG. T. (2005). Comparing effect sizes in follow-up studies: ROC area, Cohen’s d, and r. Law and Human Behavior, 29(5), 615–620. https://doi.org/10.1007/s10979-005-6832-7
33.
RobaeyP.AmreD.SchacharR.SimardL. (2007). French version of the strengths and weaknesses of ADHD symptoms and normal behaviors (SWAN-F) questionnaire. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 2, 80–89.
34.
SasserT.SchoenfelderE. N.SteinM. A. (2017). Targeting functional impairments in the treatment of children and adolescents with ADHD. CNS Drugs, 31(2), 97–107.
35.
Schulz-ZhechevaY.VoelkleM.BeauducelA.BuchN.FleischhakerC.BenderS.KaessM. (2017). ADHD traits in German school-aged children: Validation of the German Strengths and Weaknesses of ADHD Symptoms and Normal Behavior (SWAN-DE) scale. Journal of Attention Disorders, 23(6), 553–562. https://doi.org/10.1177/1087054716676365
36.
SibleyM. H.PelhamW. E.Jr.MolinaB. S. G.GnagyE. M.WaxmonskyJ. G.WaschbuschD. A.DerefinkoK. J.WymbsB. T.GarefinoA. C.BabinskiD. E.KuriyanA. B. (2012). When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment. Journal of Consulting and Clinical Psychology, 80(6), 1052–1061. https://doi.org/10.1037/a0029098
37.
SibleyM. H.SwansonJ. M.ArnoldL. E.HechtmanL. T.OwensE. B.StehliA.AbikoffH.HinshawS. P.MolinaB. S. G.MitchellJ. T.JensenP. S.HowardA. L.LakesK. D.PelhamW. E.Groupt. M. C. (2017). Defining ADHD symptom persistence in adulthood: Optimizing sensitivity and specificity. Journal of Child Psychology and Psychiatry, 58(6), 655–662. https://doi.org/https://doi.org/10.1111/jcpp.12620
38.
StoneL. L.OttenR.EngelsR. C. M. E.VermulstA. A.JanssensJ. M. A. M. (2010). Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4- to 12-year-olds: A review. Clinical Child and Family Psychology Review, 13(3), 254–274. https://doi.org/10.1007/s10567-010-0071-2
39.
SwansonJ. M.KraemerH. C.HinshawS. P.ArnoldL. E.ConnersC. K.AbikoffH. B.ClevengerW.DaviesM.ElliottG. R.GreenhillL. L.HechtmanL.HozaB.JensenP. S.MarchJ. S.NewcornJ. H.OwensE. B.PelhamW. E.SchillerE.SevereJ. B.. . . WuM. (2001). Clinical relevance of the primary findings of the MTA: Success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 40(2), 168–179. https://doi.org/10.1097/00004583-200102000-00011
40.
SwansonJ. M.WigalT.LakesK. (2009). DSM-V and the future diagnosis of attention-deficit/hyperactivity disorder. Current Psychiatry Reports, 11(5), 399–406. https://doi.org/10.1007/s11920-009-0060-7
41.
SwansonJ. M.SchuckS.PorterM. M.CarlsonC.HartmanC. A.SergeantJ. A.ClevengerW.WasdellM.McClearyR.LakesK.WigalT. (2012). Categorical and dimensional definitions and evaluations of symptoms of ADHD: History of the SNAP and the SWAN rating sales. The International Journal of Educational and Psychological Assessment, 10(1), 51–70.
42.
WolraichM. L.HaganJ. F.Jr.AllanC.ChanE.DavisonD.EarlsM.EvansS. W.FlinnS. K.FroehlichT.FrostJ.HolbrookJ. R.LehmannC. U.LessinH. R.OkechukwuK.PierceK. L.WinnerJ. D.ZurhellenW. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528
43.
WolraichM. L.LambertW.DoffingM. A.BickmanL.SimmonsT.WorleyK. (2003). Psychometric properties of the vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28(8), 559–568. https://doi.org/10.1093/jpepsy/jsg046
44.
YoungS.UysalO.KahleJ.GudjonssonG. H.HollingdaleJ.CorteseS.Sakalli-KaniA.GreerB.CocallisK.SylverN.YilmazU. E.SemerciB.KilicO. (2024). A systematic review and meta-analysis comparing the severity of core symptoms of attention-deficit hyperactivity disorder in females and males. Psychological Medicine, 54(14), 3763–3784. https://doi.org/10.1017/S0033291724001600
