Across the continuum of attention skills: a twin study of the SWAN ADHD rating scale

Introduction: Most behavior checklists for attention problems or attention deficit/hyperactivity disorder (ADHD) such as the Child Behavior Checklist (CBCL) have a narrow range of scores, focusing on the extent to which problems are present. It has been proposed that measuring attention on a continuum, from positive attention skills to attention problems, will add value to our understanding of ADHD and related problems. The Strengths and Weaknesses of ADHD symptoms and Normal behavior scale (SWAN) is such a scale. Items of the SWAN are scored on a seven-point scale, with in the middle 'average behavior' and on the extremes 'far below average' and 'far above average'. Method: The SWAN and the CBCL were completed by mothers of respectively 560 and 469 12-year-old twin pairs. The SWAN consists of nine DSM-IV items for Attention Deficit (AD) and nine DSM-IV items for Hyperactivity/ Impulsivity (HI). The CBCL Attention Problem (AP) scale consists of 11 items, which are rated on a three-point scale. Results: Children who had a score of zero on the CBCL AP scale can be further differentiated using the SWAN, with variation seen between the average behavior and far above average range. In addition, SWAN scores were normally distributed, rather than kurtotic or skewed as is often seen with other behavioral checklists. The CBCL AP scale and the SWAN-HI and AD scale were strongly influenced by genetic factors (73%, 90% and 82%, respectively). However, there were striking differences in genetic architecture: variation in CBCL AP scores is in large part explained by non-additive genetic influences. Variation in SWAN scores is explained by additive genetic influences only. Conclusion: Ratings on the SWAN cover the continuum from positive attention skills to attention and hyperactivity problems that define ADHD. Instruments such as the SWAN offer clinicians and researchers the opportunity to examine variation in both strengths and weaknesses in attention skills.