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ABSTRACT
Objective: To examine differences in home, school, and medical functioning between preschool-age children with attentiondeficit/hyperactivity disorder (ADHD) and normal control children. Method: A sample of 94 children (58 with ADHD, 36
normal controls) between 3 and 5 years old participated. Dependent measures included parent and teacher ratings of
problem behavior and social skills, parent ratings of stress and family functioning, medical functioning data, observations
of parentchild interactions and classroom behavior, and a test of preacademic skills. Results: Young children with ADHD
exhibited more problem behavior and were less socially skilled than their normal counterparts according to behavior ratings. Parents of children with ADHD experienced greater stress and were coping less adaptively than parents of nonADHD children. Children with ADHD exhibited more noncompliant and inappropriate behavior than normal controls,
particularly during task situations. Parents of children with ADHD were more likely to display negative behavior toward
their children. Children with ADHD exhibited more negative social behavior in preschool settings and scored significantly
lower on a test of preacademic skills. No significant differences in injuries or utilization of medical services were found.
Conclusions: Preschool-age children with ADHD are at significant risk for behavioral, social, familial, and academic difficulties relative to their normal counterparts. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(5):508515. Key Words:
attention-deficit/hyperactivity disorder, preschool children, functional impairment.
Aberrant maternalchild interactions as well as disruptive, aggressive social behaviors in preschool settings are
related to ADHD (Barkley, 1998). Mothers of preschoolage children with ADHD report greater levels of parenting stress than do mothers of normal children (Byrne
et al., 1998). In preschool/day-care settings, children
with ADHD often change activities during free-play
opportunities, engage in more sensorimotor play, and
spend minimal time in social interactions during play
(Alessandri, 1992).
Young children with ADHD are more likely to use
medical services relative to their normal counterparts for
at least two reasons. First, young children with ADHD
appear to be at greater than average risk for physical
injuries and accidental poisonings, presumably due to
high rates of impulsive and overactive behavior (e.g.,
Lahey et al., 1998). Second, approximately 2% to 4% of
preschool-age children are treated with psychotropic medication (Zito et al., 2000).
Upon school entry, young children with ADHD are
likely to be behind their nondisabled peers in basic math
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METHOD
Participants
Ninety-four children between 3 and 5 years of age (mean = 4.0;
SD = 0.09) from a moderately sized urban area in the northeastern
United States participated in the investigation. Fifty-eight of these
children (50 boys, 8 girls) were identied as having one of the three
subtypes of ADHD. Thirty-six children (20 boys, 16 girls) were
assigned to a normal control group. Participants in both groups were
primarily from middle-class socioeconomic backgrounds and predominantly white (ADHD group: 79% white, 7% African American,
12% Latino, and 2% other; normal control group: 97% white, 3%
African American).
Children identied as having ADHD met the following criteria:
1. Scored at or above the 90th percentile for the childs gender and
age on the Hyperactivity or Daydreams-Attention subscale of the
Conners Teacher Rating Scale-Revised (CTRS-R) (Goyette et al.,
1978) and the Impulsivity-Hyperactivity subscale of the Conners
Parent Rating Scale-Revised (CPRS-R) (Goyette et al., 1978).
These subscales were used because they included items directly
related to ADHD symptoms.
2. Met DSM-IV (American Psychiatric Association, 1994) criteria for
one of the three subtypes of ADHD based on parent interview
using the Structured Interview for Diagnostic Assessment of Children (SIDAC) (Hynd, unpublished diagnostic interview, 1995).
Children in the normal control group met the following criteria:
1. Scored below the 84th percentile for the childs gender and age on
all subscales of the CTRS-R and CPRS-R.
2. Did not meet criteria for any psychiatric disorder based on parent
diagnostic interview.
In addition, all participants met the following criteria:
1. Not removed from the home at any time because of neglect or
abuse.
2. No evidence of mental retardation, pervasive developmental disorder, gross brain damage, or sensory impairment.
3. Enrolled in preschool or day-care classroom at least 2 days per week.
Of the 58 children with ADHD, 38 were combined type, 16 were
hyperactive-impulsive type, and 4 were inattentive type. A total of 25
(43.1%) children with ADHD also had a diagnosis of oppositional
deant disorder (based on parent SIDAC responses) and an additional
22 (39.6%) had conduct disorder. Children did not meet diagnostic
criteria for any other psychiatric diagnosis. Table 1 presents the means
and standard deviations for age and Conners Rating Scale scores for
each group. Participants with ADHD did not differ from normal controls with respect to age but, as expected, received signicantly (p <
.05) higher scores on all pertinent Conners subscales. A total of seven
children with ADHD were being treated with psychotropic medication including methylphenidate (n = 2), dextroamphetamine (n =
3), clonidine (n = 1), and an unspecied medication (n = 1). Eight
children (two of whom also received medication) had been receiving
counseling for less than 6 months prior to participating in this study.
Dependent Measures
Parents and teachers completed two rating scales about childrens
behavior at home and school, respectively. The Preschool and
Kindergarten Behavior Scales (PKBS) (Merrell, 1994) is a 42-item
questionnaire composed of three Social Skills subscales and five
Problem Behavior subscales. Raw scores for the eight subscales were
used as dependent measures in addition to standard scores for the
Social Skills and Problem Behavior subscales. The reliability and
validity of this questionnaire are adequate (Merrell, 1994).
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D U PAUL ET AL
TABLE 1
Demographics of ADHD and Normal Control Groups
Measure
Age
CTRS-R HYP
CTRS-R DA
CPRS-R IH
ADHD
(n = 58)
3.98
73.34
65.91
72.04
(0.69)
(7.78)
(10.61)
(7.56)
Control
(n = 36)
4.14
45.49
46.06
46.94
(0.73)
(3.12)
(5.34)
(6.85)
t 90
1.05
20.15***
10.27***
16.01***
Parent behaviors that were coded included alpha (i.e., direct) commands, beta (i.e., indirect and vague) commands, positive behavior,
negative behavior, questions, and reinforcement of child compliance.
Child behaviors included activity, compliance, noncompliance, inappropriate behavior, and on-task behavior. For all but the activity category, the percentage of observation intervals was used as a dependent
variable. The activity score represented the number of intervals when
activity changes occurred.
Direct observations of classroom behavior were conducted in structured (e.g., listening to teacher reading) and unstructured (e.g., freeplay) activities. Two 30-minute observations were conducted using a
combination partial-interval system for negative behaviors, wholeinterval system for positive behaviors, and momentary-interval system
to record activity changes. Each interval was 15 seconds in duration.
The social behavior observation system of the Early Screening Project
(Walker et al., 1995) was adapted to yield scores in negative social,
positive social, and activity change categories. Negative social behavior
included negative social engagement, disobeying established rules,
being off-task, and having a tantrum. Positive social behavior
included positive social engagement, parallel play, and following
established rules. Activity change was measured independently of negative and positive social behavior and was dened as a child engaging
in an activity other than the activity engaged in at the start of the previous observation interval. The observations yielded percentage of
interval scores that were used in data analyses.
The Battelle Developmental Inventory (BDI) (Newborg et al.,
1988) is a standardized individually administered test of developmental skills for children from birth to 8 years of age. The BDI Cognitive Domain consists of four subdomains (Perceptual Discrimination,
Memory, Reasoning and Academic Skills, and Conceptual Development) and a total score. The reliability and validity coefcients of the
BDI are adequate.
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Procedures
RESULTS
Between-group differences on the PKBS and ADHDIV were statistically signicant for both parent (p < .001)
and teacher (p < .001) ratings, as were all of the individual
t tests (see Tables 2 and 3; note that F values, corresponding to T 2 values, are presented in these tables). For both
parent and teacher ratings, PKBS Problem Behavior subscale scores and all three scores on the ADHD-IV were sig-
The Hotelling T 2 comparing medical outcomes between groups was not statistically signicant. The effect
size for number of injuries was large (1.20); however,
given the sample size, there was limited power to identify this difference as statistically signicant.
TABLE 2
Group Means and Standard Deviations for Parent Ratings of Child Behavior
Measure
PKBS Social Cooperation
PKBS Social Interaction
PKBS Social Independence
PKBS Social Skills standard score
PKBS Self-Centered Explosive
PKBS Attention Problems
PKBS Antisocial
PKBS Social Withdrawal
PKBS Anxiety
PKBS Problem Behavior standard score
ADHD Rating Scale Inattention score
ADHD Rating Scale Hyp-Imp score
ADHD
19.7
22.5
23.4
86.2
23.5
18.3
12.5
8.1
11.7
121.1
14.2
18.7
(5.3)
(5.2)
(4.1)
(10.9)
(5.9)
(3.7)
(5.0)
(3.3)
(4.5)
(12.5)
(5.3)
(4.6)
Normal
31.3
29.8
29.6
108.0
9.8
6.0
3.5
2.2
5.3
92.6
2.5
4.2
(3.9)
(3.5)
(4.4)
(11.7)
(4.9)
(4.0)
(3.1)
(2.7)
(3.8)
(10.4)
(2.7)
(3.7)
F1,71
Effect Size
98.5
42.9
36.6
63.5
104.4
174.0
70.6
62.3
38.4
99.4
117.3
192.1
2.97
2.09
1.41
1.86
2.80
3.08
2.90
2.18
1.68
2.74
4.33
3.92
Note: ADHD = attention-decit/hyperactivity disorder; PKBS = Preschool and Kindergarten Behavior Scales; Hyp-Imp =
Hyperactivity-Impulsivity. p < .001 for all F values.
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TABLE 3
Group Means and Standard Deviations for Teacher Ratings of Child Behavior
Measure
ADHD
19.3
16.8
20.7
78.9
23.7
17.9
12.0
10.2
7.5
117.4
14.3
16.8
Normal
(6.9)
(6.8)
(6.9)
(14.6)
(31.1)
(5.8)
(6.5)
(5.0)
(4.4)
(16.1)
(6.5)
(7.5)
32.8
25.9
29.9
107.1
5.0
4.6
2.2
3.3
3.4
87.2
2.0
2.9
(3.6)
(5.1)
(3.8)
(11.6)
(5.1)
(4.9)
(3.0)
(4.1)
(4.0)
(12.2)
(2.4)
(3.1)
F1,80
Effect Size
97.4***
39.8***
44.5***
79.6***
10.6**
108.8***
60.4***
40.7***
17.0***
77.6***
99.4***
94.4***
3.75
1.78
2.42
2.43
3.67
2.71
3.27
1.68
1.02
2.48
5.12
4.48
Note: ADHD = attention-decit/hyperactivity disorder; PKBS = Preschool and Kindergarten Behavior Scales; Hyp-Imp =
Hyperactivity-Impulsivity.
** p < .01; *** p < .001.
TABLE 4
Group Means and Standard Deviations for Parent Stress Ratings
Raw Score
Measure
PSI Difcult Child
PSI Dysfunctional Interaction
PSI Defensive Responding
PSI Parental Distress
PSI total
ADHD
40.4
24.9
18.0
29.0
94.3
(8.2)
(7.4)
(5.9)
(9.1)
(19.3)
Normal
23.3
16.3
12.7
20.6
60.3
(6.8)
(3.7)
(3.6)
(5.0)
(12.4)
F1,76
Effect Size
90.7
35.3
19.8
21.2
73.9
2.51
2.32
1.47
1.68
2.74
Note: ADHD = attention-decit/hyperactivity disorder; PSI = Parenting Stress Index. p < .001 for all F values.
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TABLE 5
Group Means and Standard Deviations for Parent Ratings of Family Functioning
Measure
FCOPES Acquiring Social Support
FCOPES Mobilizing Family
FCOPES Passive Appraisal
FCOPES Reframing
FCOPES Seeking Spiritual Support
FCOPES total raw score
ADHD
38.7
63.0
95.4
33.6
17.3
93.2
(26.6)
(28.1)
(7.0)
(29.8)
(25.0)
(13.3)
Normal
63.1
57.4
96.4
57.2
34.7
106.2
(27.7)
(31.0)
(6.2)
(30.2)
(35.3)
(13.9)
F1,75
Effect Size
15.2**
0.7
0.4
11.6**
6.4
17.2***
0.88
0.18
0.16
1.77
0.50
0.49
Note: ADHD = attention-decit/hyperactivity disorder; FCOPES = Family Crisis Oriented Personal Evaluation Scales.
** p < .01; *** p < .001.
Observations of Classroom Behavior
In contrast with the results for the parentchild interaction observations, the Hotelling T 2 for classroom
observation categories was not statistically significant.
Given our initial hypotheses, separate t tests were conducted for each observational category as an exploratory
analysis. Participants with ADHD were found to exhibit
greater levels of negative social behavior in unstructured
classroom situations (t81 = 2.6, p = .01; ES = 3.5). It
should be noted that effect sizes for some variables (e.g.,
disobeying rules in both structured and unstructured situations) were large (>1.0); however, these differences
were not statistically signicant.
Developmental Skills
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D U PAUL ET AL
interactions than did control parents. Mean ratings provided by parents of children with ADHD were associated
with a higher stress level than 83% of the PSI normative
group, and there was a difference of more than 2 SD on
these measures between ADHD and control parents.
These results are commensurate with prior research (e.g.,
Shelton et al., 1998) indicating that the stress that parents
of children with this disorder experience begins at an
early stage in the childs development.
This is the rst study to demonstrate that families of
young children with ADHD report less adaptive coping
styles in response to stressful situations. Relative to normal controls, parents of children with ADHD were less
likely to seek support from relatives and neighbors, and
less capable of redening stressful events to make them
more manageable. This difference in family coping may
be due, in part, to the fact that parents of normal control
children are not experiencing the frequency or degree of
distress that parents of children with ADHD have experienced. It is interesting that groups did not differ with
respect to seeking support from community resources.
This is not surprising because families of children with
ADHD entered this investigation as a result of seeking
community resources for their children.
As hypothesized, parentchild interactions were more
problematic for children in the ADHD group than for
control children. Children with ADHD exhibited more
than twice the level of noncompliance and greater than
ve times the level of inappropriate behavior displayed by
controls when asked to complete activities and tasks by
their parents. Furthermore, parents of children with
ADHD exhibited negative behavior toward their children
three times more frequently than did parents of controls,
particularly when asking their children to complete activities and tasks. It is interesting that minimal group differences in interactions were found during the low adult
attention situation, suggesting that for many young children with ADHD, escape from parent-directed tasks is a
prime motivation for noncompliant behavior (as opposed
to displaying negative behavior to gain parental attention).
The situational nature of disruptive behavior associated
with ADHD in young children was further demonstrated
through observations in preschool classrooms. Specically, children with ADHD were observed to exhibit a signicantly higher frequency of negative social behavior
than were controls (a difference of more than 3 SD), especially during unstructured, free-play activities. Further
research using larger samples should be conducted to spe-
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Clinical Implications
These results have several implications for practitioners working with young children. First, screening for
ADHD among young children with behavior difculties
may be important not only for the identication of this
disorder but also to promote evaluation of associated
problems such as poor social behavior, parental stress,
and family coping difficulties. Second, these results
highlight the need to assess the preacademic skills and
preschool classroom behavior of young children with
ADHD. The social behavior and academic functioning
of young children with ADHD may be important targets for treatment beyond the amelioration of symptoms. Finally, the difficulties associated with ADHD
symptoms in young children provide a strong impetus
for implementing interventions that comprehensively
address functioning across settings and over time.
Limitations
Conclusions based on the results of this study are limited by several factors. First, although the SIDAC has been
found to have adequate interdiagnostician agreement, its
psychometric properties as a diagnostic interview with
young children are unknown. In fact, the eld in general is
limited by a dearth of parent interviews designed specifically for identifying psychiatric disorders in young children. Second, although our samples were respectable in
size, power to detect statistically significant effects
appeared limited. Indeed, the combination of limited
power and the use of a relatively stringent level (i.e., p <
.01) restricted our ndings to large between-group differences. Third, the gender ratio was different between
groups, leading to the possibility that differences were due
to gender rather than diagnostic status. Secondary analyses
examining between-group differences in boys only, however, resulted in ndings that were nearly identical with
those obtained with the entire sample. Fourth, given the
high rate of comorbid disorders in our ADHD sample,
one cannot assume that group differences were only due to
the presence of ADHD in one group and not the other. Of
course, high rates of comorbidity are the rule rather than
the exception for samples of young children with ADHD
(e.g., Keenan and Wakschlag, 2000; Shelton et al., 1998).
Restricting our investigation only to pure cases of
ADHD would limit the external validity of obtained ndings. Furthermore, given that normal controls and ADHD
participants were equivalent in socioeconomic status and
were screened a priori regarding involvement of a child
protective agency for reported abuse/neglect, betweengroup differences are not likely due to adverse environmental circumstances being associated with conduct
disorder or oppositional deant disorder symptoms in the
ADHD sample. Fifth, because this was a referred rather
than an epidemiological sample, there may be other children with ADHD who are not as impaired as our sample.
In addition, because this was primarily a white, middleclass sample, generalization to more diverse populations
cannot be assumed. Finally, children were not removed
from medication prior to preschool behavior observations,
possibly accounting for lack of between-group differences
on these variables. Because only 7 of the 58 children were
medicated, it is unlikely that this variable fully accounted
for the lack of ndings in this area.
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Conclusions