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.

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.

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.

Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.

Reproduced with permission of David Rabiner, Ph.D. - HelpforADD.com