Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later Childhood Conduct Disorder Ji S. Hong, MD, Rebecca Tillman, MS, and Joan L. Luby, MD Objectives To investigate which disruptive behaviors in preschool were normative and transient vs markers of conduct disorder, as well as which disruptive behaviors predicted the persistence of conduct disorder into school age. Study design Data from a longitudinal study of preschool children were used to investigate disruptive behaviors. Caregivers of preschoolers ages 3.0-5.11 years (n = 273) were interviewed using the Preschool Age Psychiatric Assessment to derive the following diagnostic groups: conduct disorder, externalizing disorder without conduct disorder, internalizing disorder without externalizing disorder, and healthy. At school age, participants were again assessed via an age-appropriate diagnostic interview. Logistic and linear regression with pairwise group comparisons was used to investigate clinical markers of preschool conduct disorder and predictors of school age conduct disorder. Results Losing one’s temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing in the preschool period were found in both healthy and disordered groups. In contrast, high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems were markers of preschool conduct disorder and predictors of school age conduct disorder. Inappropriate sexual behavior was not a marker for preschool conduct disorder but was a predictor of school age conduct disorder. Conclusion These findings provide a guide for primary care clinicians to help identify preschoolers with clinical conduct disorder and those who are at risk for persistent conduct disorder in childhood. Preschoolers displaying these symptoms should be targeted for mental health assessment. (J Pediatr 2015;166:723-30).
N
umerous empirical studies have provided data suggesting that disruptive behavior disorders such as oppositional defiant disorder (ODD) and conduct disorder can be identified in early childhood.1-9 In preschool populations, disruptive behavior is one of the most common reasons for referral to a mental health clinic.1 The estimated prevalence of preschool ODD and conduct disorder ranges from 4% to 16.6%, and 3.9% to 6.6%, respectively.2-4 Despite ongoing efforts to define, describe, and validate these disorders and to differentiate clinically significant conduct problems from normative developmental extremes, ambiguity about this distinction persists.10-15 Keenan et al5-8 investigated the reliability and discriminant and predictive validity of preschool ODD and conduct disorder. They studied preschoolers from psychiatric and pediatric clinics using the Kiddie-Disruptive Behavior Disorder Schedule. Both ODD and conduct disorder symptoms were found at greater rates in the clinical sample with symptom severity correlated with functional impairment. When participants were re-evaluated 3 years later, a diagnosis of ODD and conduct disorder at baseline substantially increased the risk for later diagnosis of these disorders with ORs of 15.04 and 15.55, respectively. Notably, at the 3-year follow-up, 82% of participants with ODD at baseline and 61% with conduct disorder at baseline met the criteria for ODD and conduct disorder. The Environmental Risk Longitudinal Twin Study followed 2232 children from birth to age 10.2,9 Relative to the comparison group, 5-year-olds with conduct disorder self-reported more antisocial behaviors on a puppet interview, displayed more disruptive behaviors during an observation, as well as numerous cognitive impairments and psychosocial risks. Those with conduct disorder at age 5 had more educational difficulties and a 20-fold increased risk of diagnosis of conduct disorder at age 7 years. At the age 10 years follow-up, diagnosis of conduct disorder at age 5 years predicted increased risk for attention
CAPA DSM-IV EXTL w/o conduct disorder INTL w/o EXTL MDD ODD PAPA
Child and Adolescent Psychiatric Assessment Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Externalizing disorder without conduct disorder Internalizing disorder without externalizing disorder Major depressive disorder Oppositional defiant disorder Preschool Age Psychiatric Assessment
From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO Supported by the National Institute of Mental Health (R01 021187 [to J.L.]). The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.11.041
723
THE JOURNAL OF PEDIATRICS
www.jpeds.com
deficit-hyperactivity disorder, aggression, and delinquency as well as emotional and educational impairments. These findings suggest that the diagnosis of conduct disorder in early childhood is a robust marker of risk for persistent disruptive psychopathology and poor outcomes in later childhood. However, this study did not inform which early childhood disruptive behaviors were the most specific predictors of later childhood conduct disorder, an important issue, because disruptive behaviors during the preschool period may be common normative extremes. To address bias and confounds related to parental report, Wakschlag et al10-15 developed a behavior observation schedule and a companion parent rating scale to assess more objectively and comprehensively preschool disruptive behaviors. Using a dimensional approach to quantify disruptive behaviors, they found that preschool disruptive behaviors had 4 distinctive domains: temper loss, noncompliance, aggression, and low concern for others. Temper loss and noncompliance ranged from mild/normative to severe and clinically significant. Aggression and low concern for others were observed in a small proportion of children and represented the severe, clinically significant end of the spectrum. Despite these compelling data, ambiguity remains about how to distinguish normative developmental extremes from clinically significant phenomena, as well as which early childhood disruptive behaviors predict the persistence of conduct disorder into later childhood. The ability to distinguish children in need of early interventions from those who will simply “grow out” of their misbehaviors is a critical public health issue. Our study aimed to address this gap in the literature by investigating which preschool disruptive behaviors were normative vs markers of preschool conduct disorder and which behaviors predicted the persistence of conduct disorder into school age. Given the limited guidelines and available screening scales to identify preschool disruptive behaviors, these data may be critical to guide the identification of children in need of intervention in primary care.16
Methods Preschoolers between 3 and 5.11 years of age were recruited from multiple sites throughout the greater metropolitan St. Louis area for participation in the Preschool Depression Study. Recruitment was done through primary care practices and preschools/daycares in an effort to increase the diversity of the final sample. Participants were screened via a validated checklist to identify those with symptoms of major depressive disorder (MDD) or other psychiatric disorders, and healthy controls.17 Children with chronic illness, marked speech and language or other developmental delays, and/or neurologic disorders or autism spectrum disorder were excluded. Full details of the study recruitment process and subject flow have been described in detail by Luby et al.18 From the total baseline sample of (n = 306), 273 had complete data on the variables of interest for the current study. Participants were categorized into the following mutually exclusive diagnostic groups based on the Preschool Age 724
Vol. 166, No. 3 Psychiatric Assessment (PAPA)19: conduct disorder, externalizing disorder without conduct disorder (EXTL w/o conduct disorder), internalizing disorder without externalizing disorder (INTL w/o EXTL), and healthy. Participants with conduct disorder before age 6 were included in the preschool conduct disorder group. Participants without conduct disorder before age 6 who had attention deficit-hyperactivity disorder or ODD before age 6 were included in the EXTL w/o conduct disorder group. Participants without an externalizing disorder before age 6 who had MDD, generalized anxiety disorder, separation anxiety disorder, or posttraumatic stress disorder before the age of 6 were included in the INTL w/o EXTL group. Finally, participants without an Axis I diagnosis before age 6 were included in the healthy group. Participants who had conduct disorder between the ages of 6.0 and 9.11 years based on the PAPA or the Child and Adolescent Psychiatric Assessment (CAPA) were categorized as the school age conduct disorder group. Study participants and their primary caregivers participated in up to 7 comprehensive annual assessments that spanned from preschool into school age, conducted at the Early Emotional Development Program at the Washington University School of Medicine between 2003 and 2013. All study procedures were approved by the Washington University School of Medicine institutional research board and consent/assent were obtained from all participants. At baseline, dyads participated in a 3- to 4-hour laboratory assessment, during which primary caregivers (94% mothers) were interviewed about their children’s behaviors, emotions, and age-adjusted manifestations of psychiatric symptoms using the PAPA. The PAPA parent report was used before age 8.0 years, the CAPA parent report was used when participants were 8.0-8.11 years, and the CAPA parent and child report were used when participants were 9.0 years old or older. Raters trained to reliability and blind to the subject’s diagnostic status from previous waves administered the PAPA/CAPA at each assessment point. All interviews were audiotaped, and methods to maintain reliability and prevent drift, which included ongoing calibration of interviews by master raters for 20% of each interviewer’s cases, were performed in consultation with an experienced clinician (J.L.) at each study wave. The PAPA is an interviewer-based, caregiver-reported diagnostic assessment with established test-retest reliability designed for use with primary caregivers of children aged 2-6 years (but its use up to age 8 years has been established), which includes all relevant Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria and their age-appropriate manifestations.4,19,20 The PAPA conduct section covers all DSM-IV criteria for ODD and conduct disorder. To evaluate conduct problems, the PAPA conduct section and peer problem section were used. Most of the conduct items measure intensity, frequency, and duration. The CAPA is an interviewer-based, child/adolescent, or caregiver-reported diagnostic assessment (from which the PAPA was derived) with established test-retest reliability designed for use with children and adolescents aged 8-17.11 years, which includes all relevant DSM-IV criteria Hong, Tillman, and Luby
ORIGINAL ARTICLES
March 2015 and their age-appropriate manifestations.21,22 The PAPA and CAPA used DSM-IV–based computer algorithms to generate diagnoses, including conduct disorder diagnosis. A diagnosis was made counting all symptoms within each diagnosis category. Statistical Analyses There are 59 items in the PAPA conduct section and peer problem section, and we categorized them into 13 symptom clusters on the basis of DSM-IV definition and subtypes using data derived from the PAPA: losing temper cluster, argument/defiant behavior-low intensity cluster, argument/ defiant behavior-high intensity cluster, vindictiveness cluster, aggression to people/animals-low intensity cluster, aggression to people/animals-high intensity cluster, inappropriate sexual behavior cluster, destruction of property-low intensity cluster, destruction of property-high intensity cluster, deceitfulness/stealing-low intensity cluster, deceitfulness/ stealing-high intensity cluster, peer problem-low intensity cluster, and peer problem-high intensity cluster. Table I (available at www.jpeds.com) details the PAPA items included in each symptom cluster. The symptom
cluster score was the total number of items endorsed within the specified cluster. Preschool symptom clusters were compared between preschool diagnostic groups by the use of linear regression for continuous variables and logistic regression for dichotomous variables. Pairwise group comparisons were made via contrast statements. Logistic regression was used to determine whether preschool symptom clusters were significantly associated with schoolage conduct disorder. Demographic characteristics that differed between the conduct disorder and comparison group, psychotropic medication use during the follow-up, and preschool MDD were included as covariates in these models. All analyses were conducted with SAS v9.3 (SAS Institute, Cary, North Carolina). Bonferroni correction was used to account for multiple comparisons.
Results There were 273 participants who had at least one assessment during both the preschool (3-5.11 years) and school age periods (6-9.11 years) and were therefore included in the analyses. There were 86 children with 1 preschool assessment,
Table II. Characteristics of the sample (N = 273) School-age conduct disorder (n = 36)
Baseline age, y Income to needs ratio
Sex Male Female Race White African-American Other Family income #$20 000 $20 001-$40 000 $40 001-$60 000 >$60 000 Parental education High school diploma Some college 4-year college degree Graduate education Parental Axis I disorder Yes No History of abuse/neglect Yes No Intact family Yes No Psychotropic medication during follow-up Yes No Preschool MDD Yes No
No school-age conduct disorder (n = 237)
Mean
SD
Mean
SD
4.83 1.48
0.74 1.15
4.43 2.35
0.79 1.23
%
n
%
n
c2
P value
7.51 13.75
.0061 .0002
c2
P value
66.7 33.3
24 12
51.5 48.5
122 115
2.83
.0923
33.3 58.3 8.3
12 21 3
58.6 28.3 13.1
139 67 31
11.91
.0026
41.7 27.8 13.9 16.7
15 10 5 6
19.8 16.0 19.0 45.2
47 38 45 107
13.63
.0035
27.8 52.8 5.6 13.9
10 19 2 5
14.8 35.4 23.6 26.2
35 84 56 62
10.50
.0148
61.1 38.9
22 14
46.8 53.2
111 126
2.50
.1136
41.7 58.3
15 21
24.5 75.5
58 179
4.56
.0328
42.9 57.1
15 20
71.9 28.1
166 65
10.87
.0010
33.3 66.7
12 24
17.8 82.2
42 194
4.55
.0329
52.8 47.2
19 17
27.8 72.2
66 171
8.54
.0035
Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later Childhood Conduct Disorder
725
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 166, No. 3 conduct disorder and INTL w/o EXTL groups after Bonferroni correction (P = .0023 and P = .0012, respectively). The nonsignificant findings were likely attributable to low power, because of the relatively small size of the EXTL w/o conduct disorder and INTL w/o EXTL groups and the low rate of inappropriate sexual behavior. Only 1 subject with inappropriate sexual behavior had a history of sexual abuse in the preschool period. This subject was in the EXTL w/o conduct disorder group. Of the baseline 273 participants, 36 had a school-age conduct disorder diagnosis. The Figure illustrates the relationship between preschool symptom clusters and school-age conduct disorder diagnosis, when we adjusted for baseline age, income to needs ratio, race, history of abuse/neglect, family intactness, psychotropic medication use, and preschool MDD. High-intensity argument/ defiant behavior, both low- and high-intensity aggression to people/animals, inappropriate sexual behavior, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems were significant predictors of school-age conduct disorder.
113 children with 2 preschool assessments, and 74 children with 3 preschool assessments. There were 38 children with 1 school-age assessment, 153 children with 2 school-age assessments, and 82 children with 3 school-age assessments. The mean age of the children at the preschool assessments was 4.8 0.8 years, and the mean age of the children at the school-age assessments was 8.1 1.3 years. Table II compares characteristics of the sample in children who had a school-age conduct disorder diagnosis and those who did not. Compared with children without school-age conduct disorder, children with school-age conduct disorder were older at baseline and more likely to be nonwhite. Children with school-age conduct disorder also had lower income to needs ratios, more history of abuse/neglect, were less likely to come from an intact family, had more exposure to psychotropic medications, and were more likely to have a diagnosis of MDD during preschool period. Table III provides descriptive statistics for the preschool symptom clusters in the 4 preschool diagnostic groups and results of the group comparisons. There were no group differences in losing temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing. The following symptom clusters were significantly greater in the conduct disorder group than the other 3 groups: high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, high-intensity destruction of property, and high-intensity peer problems. Vindictiveness and high-intensity deceitfulness/stealing were greater in the conduct disorder group than in the INTL w/o EXTL group and the healthy group but were not significantly different from the EXTL w/o conduct disorder group. Of note, inappropriate sexual behavior was significantly greater in the conduct disorder group than in the healthy group (P < .0001) but was not significantly different in the conduct disorder group compared with the EXTL w/o
Discussion The first aim in our study was to investigate which misbehaviors were normative and common among preschool children. Losing one’s temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing emerged as common misbehaviors that did not serve as markers of clinical disruptive disorders. Wakschlag et al14,15 also found that temper loss was a common misbehavior in preschoolers but that it ranged from normative problems to clinically significant levels. In a previous analysis from the same study sample,23 we found that the disruptive, depressive, and healthy groups differed in temper tantrum characteristics by frequency and severity, as well as the characteristics of behavior and
Table III. Preschool symptom cluster scores by preschool diagnostic group
Losing temper* Argument/defiant behavior-low intensity Argument/defiant behavior-high intensity Vindictiveness* Aggression to people/animals-low intensity Aggression to people/animals-high intensity Inappropriate sexual behavior* Destruction of property-low intensity Destruction of property-high intensity Deceitfulness/stealing-low intensity Deceitfulness/stealing-high intensity Peer problems-low intensity Peer problems-high intensity
Conduct disorder (n = 46)
EXTL w/o conduct disorder (n = 57)
INTL w/o EXTL (n = 62)
Healthy (n = 106)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
P value
93.5% 3.59 2.85†,z,x 84.8%†,z 2.50†,z,x 1.78†,z,x 31.1%† 0.22 0.59†,z,x 0.30 2.48†,z 0.91† 0.78†,z,x
N = 43 1.57 1.78 N = 39 1.62 2.06 N = 14 0.47 0.54 0.51 0.86 0.76 0.87
96.4% 4.44† 1.63†,z 64.9% 1.40 0.37 1.8% 0.26 0.16 0.39 2.00† 0.51 0.30
N = 54 1.24 1.26 N = 37 1.50 0.70 N=1 0.44 0.37 0.56 0.93 0.76 0.60
87.1% 3.48 0.82 45.2% 1.11 0.27 4.8% 0.24 0.13 0.32 1.56 0.48 0.19
N = 54 1.75 1.06 N = 28 1.22 0.52 N=3 0.47 0.34 0.57 0.97 0.57 0.40
78.3% 2.97 0.51 35.2% 0.80 0.12 2.9% 0.12 0.06 0.27 1.34 0.35 0.08
N = 83 1.81 0.88 N = 37 1.10 0.55 N=3 0.33 0.23 0.49 0.99 0.57 0.34
.0121
N
umerous empirical studies have provided data suggesting that disruptive behavior disorders such as oppositional defiant disorder (ODD) and conduct disorder can be identified in early childhood.1-9 In preschool populations, disruptive behavior is one of the most common reasons for referral to a mental health clinic.1 The estimated prevalence of preschool ODD and conduct disorder ranges from 4% to 16.6%, and 3.9% to 6.6%, respectively.2-4 Despite ongoing efforts to define, describe, and validate these disorders and to differentiate clinically significant conduct problems from normative developmental extremes, ambiguity about this distinction persists.10-15 Keenan et al5-8 investigated the reliability and discriminant and predictive validity of preschool ODD and conduct disorder. They studied preschoolers from psychiatric and pediatric clinics using the Kiddie-Disruptive Behavior Disorder Schedule. Both ODD and conduct disorder symptoms were found at greater rates in the clinical sample with symptom severity correlated with functional impairment. When participants were re-evaluated 3 years later, a diagnosis of ODD and conduct disorder at baseline substantially increased the risk for later diagnosis of these disorders with ORs of 15.04 and 15.55, respectively. Notably, at the 3-year follow-up, 82% of participants with ODD at baseline and 61% with conduct disorder at baseline met the criteria for ODD and conduct disorder. The Environmental Risk Longitudinal Twin Study followed 2232 children from birth to age 10.2,9 Relative to the comparison group, 5-year-olds with conduct disorder self-reported more antisocial behaviors on a puppet interview, displayed more disruptive behaviors during an observation, as well as numerous cognitive impairments and psychosocial risks. Those with conduct disorder at age 5 had more educational difficulties and a 20-fold increased risk of diagnosis of conduct disorder at age 7 years. At the age 10 years follow-up, diagnosis of conduct disorder at age 5 years predicted increased risk for attention
CAPA DSM-IV EXTL w/o conduct disorder INTL w/o EXTL MDD ODD PAPA
Child and Adolescent Psychiatric Assessment Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Externalizing disorder without conduct disorder Internalizing disorder without externalizing disorder Major depressive disorder Oppositional defiant disorder Preschool Age Psychiatric Assessment
From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO Supported by the National Institute of Mental Health (R01 021187 [to J.L.]). The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.11.041
723
THE JOURNAL OF PEDIATRICS
www.jpeds.com
deficit-hyperactivity disorder, aggression, and delinquency as well as emotional and educational impairments. These findings suggest that the diagnosis of conduct disorder in early childhood is a robust marker of risk for persistent disruptive psychopathology and poor outcomes in later childhood. However, this study did not inform which early childhood disruptive behaviors were the most specific predictors of later childhood conduct disorder, an important issue, because disruptive behaviors during the preschool period may be common normative extremes. To address bias and confounds related to parental report, Wakschlag et al10-15 developed a behavior observation schedule and a companion parent rating scale to assess more objectively and comprehensively preschool disruptive behaviors. Using a dimensional approach to quantify disruptive behaviors, they found that preschool disruptive behaviors had 4 distinctive domains: temper loss, noncompliance, aggression, and low concern for others. Temper loss and noncompliance ranged from mild/normative to severe and clinically significant. Aggression and low concern for others were observed in a small proportion of children and represented the severe, clinically significant end of the spectrum. Despite these compelling data, ambiguity remains about how to distinguish normative developmental extremes from clinically significant phenomena, as well as which early childhood disruptive behaviors predict the persistence of conduct disorder into later childhood. The ability to distinguish children in need of early interventions from those who will simply “grow out” of their misbehaviors is a critical public health issue. Our study aimed to address this gap in the literature by investigating which preschool disruptive behaviors were normative vs markers of preschool conduct disorder and which behaviors predicted the persistence of conduct disorder into school age. Given the limited guidelines and available screening scales to identify preschool disruptive behaviors, these data may be critical to guide the identification of children in need of intervention in primary care.16
Methods Preschoolers between 3 and 5.11 years of age were recruited from multiple sites throughout the greater metropolitan St. Louis area for participation in the Preschool Depression Study. Recruitment was done through primary care practices and preschools/daycares in an effort to increase the diversity of the final sample. Participants were screened via a validated checklist to identify those with symptoms of major depressive disorder (MDD) or other psychiatric disorders, and healthy controls.17 Children with chronic illness, marked speech and language or other developmental delays, and/or neurologic disorders or autism spectrum disorder were excluded. Full details of the study recruitment process and subject flow have been described in detail by Luby et al.18 From the total baseline sample of (n = 306), 273 had complete data on the variables of interest for the current study. Participants were categorized into the following mutually exclusive diagnostic groups based on the Preschool Age 724
Vol. 166, No. 3 Psychiatric Assessment (PAPA)19: conduct disorder, externalizing disorder without conduct disorder (EXTL w/o conduct disorder), internalizing disorder without externalizing disorder (INTL w/o EXTL), and healthy. Participants with conduct disorder before age 6 were included in the preschool conduct disorder group. Participants without conduct disorder before age 6 who had attention deficit-hyperactivity disorder or ODD before age 6 were included in the EXTL w/o conduct disorder group. Participants without an externalizing disorder before age 6 who had MDD, generalized anxiety disorder, separation anxiety disorder, or posttraumatic stress disorder before the age of 6 were included in the INTL w/o EXTL group. Finally, participants without an Axis I diagnosis before age 6 were included in the healthy group. Participants who had conduct disorder between the ages of 6.0 and 9.11 years based on the PAPA or the Child and Adolescent Psychiatric Assessment (CAPA) were categorized as the school age conduct disorder group. Study participants and their primary caregivers participated in up to 7 comprehensive annual assessments that spanned from preschool into school age, conducted at the Early Emotional Development Program at the Washington University School of Medicine between 2003 and 2013. All study procedures were approved by the Washington University School of Medicine institutional research board and consent/assent were obtained from all participants. At baseline, dyads participated in a 3- to 4-hour laboratory assessment, during which primary caregivers (94% mothers) were interviewed about their children’s behaviors, emotions, and age-adjusted manifestations of psychiatric symptoms using the PAPA. The PAPA parent report was used before age 8.0 years, the CAPA parent report was used when participants were 8.0-8.11 years, and the CAPA parent and child report were used when participants were 9.0 years old or older. Raters trained to reliability and blind to the subject’s diagnostic status from previous waves administered the PAPA/CAPA at each assessment point. All interviews were audiotaped, and methods to maintain reliability and prevent drift, which included ongoing calibration of interviews by master raters for 20% of each interviewer’s cases, were performed in consultation with an experienced clinician (J.L.) at each study wave. The PAPA is an interviewer-based, caregiver-reported diagnostic assessment with established test-retest reliability designed for use with primary caregivers of children aged 2-6 years (but its use up to age 8 years has been established), which includes all relevant Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria and their age-appropriate manifestations.4,19,20 The PAPA conduct section covers all DSM-IV criteria for ODD and conduct disorder. To evaluate conduct problems, the PAPA conduct section and peer problem section were used. Most of the conduct items measure intensity, frequency, and duration. The CAPA is an interviewer-based, child/adolescent, or caregiver-reported diagnostic assessment (from which the PAPA was derived) with established test-retest reliability designed for use with children and adolescents aged 8-17.11 years, which includes all relevant DSM-IV criteria Hong, Tillman, and Luby
ORIGINAL ARTICLES
March 2015 and their age-appropriate manifestations.21,22 The PAPA and CAPA used DSM-IV–based computer algorithms to generate diagnoses, including conduct disorder diagnosis. A diagnosis was made counting all symptoms within each diagnosis category. Statistical Analyses There are 59 items in the PAPA conduct section and peer problem section, and we categorized them into 13 symptom clusters on the basis of DSM-IV definition and subtypes using data derived from the PAPA: losing temper cluster, argument/defiant behavior-low intensity cluster, argument/ defiant behavior-high intensity cluster, vindictiveness cluster, aggression to people/animals-low intensity cluster, aggression to people/animals-high intensity cluster, inappropriate sexual behavior cluster, destruction of property-low intensity cluster, destruction of property-high intensity cluster, deceitfulness/stealing-low intensity cluster, deceitfulness/ stealing-high intensity cluster, peer problem-low intensity cluster, and peer problem-high intensity cluster. Table I (available at www.jpeds.com) details the PAPA items included in each symptom cluster. The symptom
cluster score was the total number of items endorsed within the specified cluster. Preschool symptom clusters were compared between preschool diagnostic groups by the use of linear regression for continuous variables and logistic regression for dichotomous variables. Pairwise group comparisons were made via contrast statements. Logistic regression was used to determine whether preschool symptom clusters were significantly associated with schoolage conduct disorder. Demographic characteristics that differed between the conduct disorder and comparison group, psychotropic medication use during the follow-up, and preschool MDD were included as covariates in these models. All analyses were conducted with SAS v9.3 (SAS Institute, Cary, North Carolina). Bonferroni correction was used to account for multiple comparisons.
Results There were 273 participants who had at least one assessment during both the preschool (3-5.11 years) and school age periods (6-9.11 years) and were therefore included in the analyses. There were 86 children with 1 preschool assessment,
Table II. Characteristics of the sample (N = 273) School-age conduct disorder (n = 36)
Baseline age, y Income to needs ratio
Sex Male Female Race White African-American Other Family income #$20 000 $20 001-$40 000 $40 001-$60 000 >$60 000 Parental education High school diploma Some college 4-year college degree Graduate education Parental Axis I disorder Yes No History of abuse/neglect Yes No Intact family Yes No Psychotropic medication during follow-up Yes No Preschool MDD Yes No
No school-age conduct disorder (n = 237)
Mean
SD
Mean
SD
4.83 1.48
0.74 1.15
4.43 2.35
0.79 1.23
%
n
%
n
c2
P value
7.51 13.75
.0061 .0002
c2
P value
66.7 33.3
24 12
51.5 48.5
122 115
2.83
.0923
33.3 58.3 8.3
12 21 3
58.6 28.3 13.1
139 67 31
11.91
.0026
41.7 27.8 13.9 16.7
15 10 5 6
19.8 16.0 19.0 45.2
47 38 45 107
13.63
.0035
27.8 52.8 5.6 13.9
10 19 2 5
14.8 35.4 23.6 26.2
35 84 56 62
10.50
.0148
61.1 38.9
22 14
46.8 53.2
111 126
2.50
.1136
41.7 58.3
15 21
24.5 75.5
58 179
4.56
.0328
42.9 57.1
15 20
71.9 28.1
166 65
10.87
.0010
33.3 66.7
12 24
17.8 82.2
42 194
4.55
.0329
52.8 47.2
19 17
27.8 72.2
66 171
8.54
.0035
Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later Childhood Conduct Disorder
725
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 166, No. 3 conduct disorder and INTL w/o EXTL groups after Bonferroni correction (P = .0023 and P = .0012, respectively). The nonsignificant findings were likely attributable to low power, because of the relatively small size of the EXTL w/o conduct disorder and INTL w/o EXTL groups and the low rate of inappropriate sexual behavior. Only 1 subject with inappropriate sexual behavior had a history of sexual abuse in the preschool period. This subject was in the EXTL w/o conduct disorder group. Of the baseline 273 participants, 36 had a school-age conduct disorder diagnosis. The Figure illustrates the relationship between preschool symptom clusters and school-age conduct disorder diagnosis, when we adjusted for baseline age, income to needs ratio, race, history of abuse/neglect, family intactness, psychotropic medication use, and preschool MDD. High-intensity argument/ defiant behavior, both low- and high-intensity aggression to people/animals, inappropriate sexual behavior, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems were significant predictors of school-age conduct disorder.
113 children with 2 preschool assessments, and 74 children with 3 preschool assessments. There were 38 children with 1 school-age assessment, 153 children with 2 school-age assessments, and 82 children with 3 school-age assessments. The mean age of the children at the preschool assessments was 4.8 0.8 years, and the mean age of the children at the school-age assessments was 8.1 1.3 years. Table II compares characteristics of the sample in children who had a school-age conduct disorder diagnosis and those who did not. Compared with children without school-age conduct disorder, children with school-age conduct disorder were older at baseline and more likely to be nonwhite. Children with school-age conduct disorder also had lower income to needs ratios, more history of abuse/neglect, were less likely to come from an intact family, had more exposure to psychotropic medications, and were more likely to have a diagnosis of MDD during preschool period. Table III provides descriptive statistics for the preschool symptom clusters in the 4 preschool diagnostic groups and results of the group comparisons. There were no group differences in losing temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing. The following symptom clusters were significantly greater in the conduct disorder group than the other 3 groups: high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, high-intensity destruction of property, and high-intensity peer problems. Vindictiveness and high-intensity deceitfulness/stealing were greater in the conduct disorder group than in the INTL w/o EXTL group and the healthy group but were not significantly different from the EXTL w/o conduct disorder group. Of note, inappropriate sexual behavior was significantly greater in the conduct disorder group than in the healthy group (P < .0001) but was not significantly different in the conduct disorder group compared with the EXTL w/o
Discussion The first aim in our study was to investigate which misbehaviors were normative and common among preschool children. Losing one’s temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing emerged as common misbehaviors that did not serve as markers of clinical disruptive disorders. Wakschlag et al14,15 also found that temper loss was a common misbehavior in preschoolers but that it ranged from normative problems to clinically significant levels. In a previous analysis from the same study sample,23 we found that the disruptive, depressive, and healthy groups differed in temper tantrum characteristics by frequency and severity, as well as the characteristics of behavior and
Table III. Preschool symptom cluster scores by preschool diagnostic group
Losing temper* Argument/defiant behavior-low intensity Argument/defiant behavior-high intensity Vindictiveness* Aggression to people/animals-low intensity Aggression to people/animals-high intensity Inappropriate sexual behavior* Destruction of property-low intensity Destruction of property-high intensity Deceitfulness/stealing-low intensity Deceitfulness/stealing-high intensity Peer problems-low intensity Peer problems-high intensity
Conduct disorder (n = 46)
EXTL w/o conduct disorder (n = 57)
INTL w/o EXTL (n = 62)
Healthy (n = 106)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
P value
93.5% 3.59 2.85†,z,x 84.8%†,z 2.50†,z,x 1.78†,z,x 31.1%† 0.22 0.59†,z,x 0.30 2.48†,z 0.91† 0.78†,z,x
N = 43 1.57 1.78 N = 39 1.62 2.06 N = 14 0.47 0.54 0.51 0.86 0.76 0.87
96.4% 4.44† 1.63†,z 64.9% 1.40 0.37 1.8% 0.26 0.16 0.39 2.00† 0.51 0.30
N = 54 1.24 1.26 N = 37 1.50 0.70 N=1 0.44 0.37 0.56 0.93 0.76 0.60
87.1% 3.48 0.82 45.2% 1.11 0.27 4.8% 0.24 0.13 0.32 1.56 0.48 0.19
N = 54 1.75 1.06 N = 28 1.22 0.52 N=3 0.47 0.34 0.57 0.97 0.57 0.40
78.3% 2.97 0.51 35.2% 0.80 0.12 2.9% 0.12 0.06 0.27 1.34 0.35 0.08
N = 83 1.81 0.88 N = 37 1.10 0.55 N=3 0.33 0.23 0.49 0.99 0.57 0.34
.0121
