Psychiatric and psychological assessment, and course of conduct problems in preschool children

Epidemiological studies suggest that the prevalence of ADHD, ODD and CD in
preschool children is of the same size as with school age children. However, a
valid method for establishing these diagnoses lacks because the criteria are
insufficient explicit to age. Also at this young age the border is less clear
between what can be seen as normal variation and what can be seen as deviated
in the area of aggressive, attention problems, impulsivity, stubborness and
anger.

It is likely that high levels of problem behavior decline from 3 years on in a
subgroup of preschool children. At present it is not possible within a group of
young children with high levels of behavior problems to distinguish between the
preschoolers who are persistent in this behavior (and diagnosed with ADHD, ODD
or CD) and the preschoolers by whom this behavior naturally declines. It has
been shown that 50 % of the children and their families who received
intervention did not actually need it. Including many false positives leads to
a lower effect size of prevention studies, families are likely to suffer of the
negative effects of labeling, and resources are wasted as well. A better
recognition of *real children at risk* is necessary.
A method to distinguish the two groups of children is not yet present. Deficits
in executive functioning may be considered as precursor of persistent problem
behavior. These are higher-order cognitive functions such as inhibition, which
have a controlling role in thinking, problem solving and language.
Deficits in executive functions in school aged children and adolescents with
ADHD, ODD and CD have been demonstrated but few studies have been conducted in
preschool children. It is expected that deficits in executive functioning are
present in preschool children with those diagnoses as well as preschoolers who
just don*t meet the criteria but are at risk for them. These deficits, together
with unfavorable environmental factors are hypothesized to be predictors of
persistent problem behavior and in that way to the risk of the development of
ADHD, ODD and CD.

This study has three aims:
1. To investigate the differences in executive functions in 3.5- to
5.5-year-old children with (symptoms or diagnosis of) ODD/CD, ADHD or both, and
without diagnosis. And investigate if the differences between these 4 groups
increase within 18 months.
2. To find out which child (executive control disturbances, intelligence) and
parent variables (parental practices, parental distress, depression and
impulsivity with the parent and level of education) predict persistence of
symptoms of ODD/CD, ADHD or both.
3. To investigate the reliability and validity of a standardized behavior
observation which could diagnose ODD, CD and ADHD at preschool age.

In this project parents of the 3.5- to 5.5-year-old children have the
opportunity to participate in a research when their child has behavior problems.
A short prospective design (18 months) with 3 measuring moments is followed.
For the research about the predictive validity of the executive control
disturbances and the environmental factors and the course of behavior problems
with preschool children this design is necessary. To study executive control
disturbances as a correlate, a cross-sectional design is appropriate. However,
in order to assess executive control disturbances as a factor that
differentiates the development of ADHD, DBD and ADHD+DBD a longitudinal design
is needed. Finally a prospective design is needed to find out the predictive
validity in the research of the reliability and validity of the standardized
behavior observation.

There are no risks associated to this research. The child will be examined
three times, but the burdening is limited. The first time (4 hours) will take
the longest time, but parent and child only have to come to the clinic for one
morning instead of at least twice with a usual psychiatric assessment. After a
short talk between the psychiatrist and the parent and two short intelligence
tests (30 minutes) with the child there will be a break (15 min.). Further
there will be 7 playful executive functioning tasks (60 min.). Three of them
are on the computer and with three other tasks they earn a treat. All 7 tasks
are very attractive for the child. Afterwards there will be a break of one hour
where the parent and child have time to eat, drink or wander around. In the
last hour the child will be observed in interaction with the parent and
researcher. This observation consists mainly of games, like a puzzle and a
marble game. After the observation the children can take a prize home. The
second time (1 hour for the child) the same psychological tests will be
administrated, however there will be no behavior observation. The third time (2
* hour) the child will be psychological examined and observed. The research is
justified because the burdening of the child and parent is limited, while the
parents, who are in uncertainty about the problems of their child, receive well
funded information about a possible psychiatric disorder. Also the parents get
a recommendation about what they can do on the area of education, parenting and
treatment. They will be supported in the realization of this advice.