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Greetings:
Below is an article that appeared in a prior issue of ADHD
RESEARCH UPDATE. The article summarizes an interesting study
in which the researchers examine how behavioral difficulties -
including ADHD symptoms - during the preschool years relate
to ADHD and other types of difficulties in middle childhood.
In other words, the study looks at the continuity of early
behavioral difficulties. I think this is an interesting and
important study and I hope that you enjoy the summary below.
Please feel free to forward this article to others you know
who may be interested in it.
Sincerely,
David Rabiner, Ph.D.
Duke University
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* THE CONTINUITY OF BEHAVIOR PROBLEMS
AND ADHD FROM PRESCHOOL THROUGH
EARLY ADOLESCENCE
An important issue raised by the article reviewed above
concerns the meaning of both ADHD symptoms as well
as other behavior problems that are often observed in
preschoolers. If such difficulties tend to be transient -
that is, most preschoolers who show these problems tend
to "grow out" of them as they develop and go on to make
satisfactory adjustments later on - then the need for
real caution in regards to the diagnosis and treatment of
such problems in young children would be emphasized.
If, however, these difficulties at an early age portend ongoing
adjustment problems for many children, and are clearly
associated with a diagnosis of ADHD as well as other
behavior disorders later on, then the implications would
be quite different.
Addressing these critical questions require a longitudinal
study in which children are assessed for ADHD symptoms
along with other difficulties at a young age, and then followed
into childhood and beyond. This type of longitudinal design
is really the only way to determine what the childhood and
early adolescent outcomes of ADHD symptoms and other
problems that are observed in preschoolers. As you can
imagine, these studies are time-consuming, difficult, and
expensive to do for a number of reasons. They are, however,
critically important.
A recent issue of the Journal of Clinical Child Psychology
includes an excellent study of this key question (Pierce,
E.W., Ewing, L.J., & Campbell, S.B. 1999. Diagnostic
status and symptomatic behavior of hard-to-manage
preschool children in middle childhood and early adolescence.
Journal of Clinical Child Psychology, 28, 44-57). This
paper describes the results of 2 related investigations in
which two cohorts of hard-to-manage preschoolers were
followed from age 3 or 4 into middle childhood (i.e. age 9)
or early adolescence (i.e. age 13).
Participants in these studies were initially recruited from a
variety of sources including pediatricians office, preschool
classrooms, and mother's "morning out" groups on the basis
of parent complaints that their preschooler was showing
hyperactive, impulsive, inattentive, noncompliant, and
aggressive behavior. Comparison children who were not
seen as having these same types of problems were recruited
from the same settings, and were matched as closely as
possible to the hard-to-manage group on the basis of race,
gender, and socioeconomic status. Both boys and girls
were included in the initial cohort whereas the second cohort
included boys only. Even in the first cohort, however, there
were was not a sufficient number of children to make
meaningful gender comparisons in the results that are
reported below.
In cohort 1, the original sample included 46 hard-to-manage
3-year-olds and 22 comparison children. Parents completed
standardized behavior ratings on these children at ages 3, 6,
and 9. These ratings included items covering ADHD symptoms
specifically and other types of disruptive behavior problems
more generally. When the children were 13, their mothers were
administered a semi-structured clinical interview called the Child
Assessment Schedule to assess the diagnostic status of the
child. Mothers and children also completed standardized
behavior ratings at this time. Approximately 75% of the
original sample was included in this final follow up. A
similar procedure was used with the second cohort. As
noted above, this cohort included boys only, and participants
were assessed initially at age 4 and only followed thru age
9.
RESULTS
The results from this impressive set of studies are extensive
and more than can be fully summarized here. Below are
those aspects of the results that seemed most important to
me.
---------------------------------------------------------
* Significant behavior problems during preschool persist
in many children.
---------------------------------------------------------
One important question confronting parents with a difficult
preschooler is whether their child's difficulties portend ongoing
problems, or will be likely to diminish over time. This study
provides important data on this question.
In the first cohort, about 50% of children in the "hard-to-manage"
group at age 3 were diagnosed with ADHD at the age 13
follow-up. This compared to only 8% of children in the
control group. The hard-to-manage children were also
significantly more likely to be diagnosed with ODD or CD
at follow-up. They were no more likely than comparison
children, however, to be diagnosed with an internalizing
disorder (e.g. depression or anxiety). In the second
cohort, similar results were obtained, although the differences
at follow-up (age 9 for this cohort) were not as strong
as those found with the initial group. Why this may have
been the case is unclear. (You can find a discussion of
ODD and CD at http://www.helpforadd.com/oddcd.htm).
---------------------------------------------------------
* Although continuity for early behavior problems is
often found, many "hard-to-manage" preschoolers
will make much more satisfactory adjustments
over time.
---------------------------------------------------------
This is the flip side of the data presented above. As the
figures noted above make clear, many hard-to-manage
preschoolers were not showing sufficient symptoms to
warrant any diagnosis at the follow-up evaluation. Thus,
many young children who are showing classic symptoms
of ADHD will not display sufficient symptoms later on
to warrant this diagnosis.
What seemed to make the difference? According to the
authors, preschoolers whose problems were still evident
at school entry - roughly age 6 - were those who were
much more likely to warrant a diagnosis for ADHD and/or
another behavioral disorder (i.e. ODD or CD) at the
last follow-up period. In both cohorts roughly
50% of the hard-to-manage preschoolers were still
regarded by their mothers as showing important problems
at the time of school entry. These were the children who
were likely to still be showing important difficulties -
including ADHD - at the age 13 (cohort1) or age 9 (cohort
2) follow-up.
So, overall, roughly 50% of preschool children showing
high levels of behavioral difficulty will continue to show
such problems at the time of school entry. Of this group,
the majority will continue to show sufficient problems
to warrant a clinical diagnosis of ADHD, ODD, and/or
CD in middle childhood or early adolescence.
-------------------------------------------------------
* Symptom severity during preschool is the best
predictor of which preschool children are likely to
have persistent problems.
-------------------------------------------------------
This finding was clear-cut and not surprising: among the
hard-to-manage preschool group, those whose difficulties
persisted to school-entry and beyond had significantly
more severe problems at age 3 or 4 than those hard-to-
manage children whose symptoms had diminished at school
entry. The combination of severe ADHD symptoms and
oppositional behavior at a young age was the strongest
predictor of persistent problems.
The important general conclusion to be reached from these
data are that children with high levels of early symptoms
are less likely to outgrow these problems, and once their
problems persist through school entry, they are likely to
become even more entrenched.
IMPLICATIONS
These results clearly underscore the importance of taking
parental complaints/concerns about their preschooler's
behavior seriously and of providing help in these situations.
Even though a number of hard-to-manage preschoolers
will apparently outgrow their difficulties, those displaying
the more severe problems are less likely to do so in the
absence of early intervention efforts. The longer these
difficulties persist, the more difficult it becomes to help
a child get back on a good developmental track.
Do these data support a conclusion that the increase in
medication treatment for preschoolers described in the article
above is appropriate? Not necessarily. Instead, I believe
these data argue that for many preschoolers showing
behavioral difficulties, early intervention may be extremely
important. There is no reason, however, why this intervention
necessarily needs to be the use of medication, particularly
as the initial intervention tried.
Instead, it would seem quite reasonable to consider behavioral
interventions that focus on helping parents deal with their
child's challenging behavior more effectively, and to provide
such consultation to the child's teacher where appropriate.
Environmental factors that may be contributing to the child's
difficulties also need to be carefully considered. As noted by
the American Academy of Child and Adolescent Psychiatry,
dietary interventions may also be a useful approach in some
preschool children and are another avenue to consider.
When such interventions have been carefully conceived and
carefully executed, but the child's problems show little signs
of abating, medication is another option that can be considered.
As noted in the article above, however, there is currently far
less evidence to support the use of medication for treating
emotional and behavioral problems in this age group - both in
terms of efficacy and safety. So, when attempted, this should
be done very carefully and the child's response should be
monitored regularly.
So, two common responses that parents often encounter when
seeking advice about dealing with their difficult preschooler -
"Lets try medication" or "Don't worry about it. It is just a
phase your child will grow out of" are probably not the most
helpful ways for handling such a situation. Instead, a careful
assessment of the difficulties that lead to a well-conceived
way to address them, and to evaluate the success of the
intervention(s) being used, is likely to produce better outcomes
down the road. In most circumstances, this is most likely
to be provided by an experienced child mental health professional
or developmental pediatrician, as most family physicians and
regular pediatricians will not have the same level of training
or experience with such behavior problems in young children.
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Dear Parent:
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Sincerely,
David Rabiner, Ph.D.
Licensed Psychologist
Duke University
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