Você está na página 1de 8

Preschool Children With Attention-Decit/

Hyperactivity Disorder: Impairments in Behavioral,


Social, and School Functioning
GEORGE J. DUPAUL, PH.D., KARA E. MCGOEY, PH.D., TANYA L. ECKERT, PH.D., AND JOHN VANBRAKLE, M.D.

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.

Attention-decit/hyperactivity disorder (ADHD) typically


begins early in life, with impairing symptoms exhibited
by age 7 years (American Psychiatric Association, 1994).
Unfortunately, this disorder has not been widely studied in
children of preschool age, despite epidemiological data
indicating that approximately 2% of children from 3 to 5
years of age have ADHD (Lavigne et al. 1996). Signicant
ADHD symptoms in early childhood are associated with
chronic behavioral/academic impairment for a large percentage of affected youngsters (e.g., Pierce et al., 1999).
Accepted November 14, 2000.
Dr. DuPaul is with the School Psychology Program, Lehigh University,
Bethlehem, PA; Dr. McGoey is with the School Psychology Program, Kent State
University, Kent, OH; Dr. Eckert is with the Department of Psychology, Syracuse
University, Syracuse, NY; and Dr. VanBrakle is with the Department of
Pediatrics, Lehigh Valley Hospital, Allentown, PA.
This study was funded by a grant from the D.R. Pool Heathcare Trust, Allentown
PA. The authors thank our research assistants including Amy Boyajian, Alexander
Hirsch, Jessica Hoffman, Karen Neifer, Kristin Renouf, and Marcie Handler.
Reprint requests to Dr. DuPaul, School Psychology Program, Lehigh
University, 111 Research Drive, Bethlehem, PA 18015.
0890-8567/01/4005-05082001 by the American Academy of Child
and Adolescent Psychiatry.

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

508

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

BEHAVIORAL, SOCIAL, AND SCHOOL FUNCTIONING

concepts, prereading skills, and fine motor abilities


(Lahey et al., 1998; Mariani and Barkley, 1997; Shelton
et al., 1998); however, minimal research examining preacademic and cognitive skills among preschool children
with ADHD has been conducted.
The current literature regarding young children with
ADHD is limited for several reasons. No existing study has
comprehensively examined the functioning of preschoolage children with ADHD across home and school settings
as well as behavioral, social, preacademic, and medical arenas. Although Shelton et al. (1998) investigated behavioral outcomes across home, school, and clinic settings in
a large sample of young children with externalizing disorders, childrens functioning in preschool or day-care
classroom settings was not examined. Other studies
assessing younger children of preschool age have been
limited by (1) collecting data in only one setting (e.g.,
Alessandri, 1992), (2) examination of only one area of
functioning (e.g., Mariani and Barkley, 1997), and (3) use
of small samples and/or incomplete diagnostic criteria
(e.g., Byrne et al., 1998). In particular, the eld lacks data
as to the degree to which difculties are pervasive across
situations (e.g., structured versus unstructured), settings
(home versus school), and areas of functioning. Because
the decits associated with ADHD in older children are
pervasive across situations and deleteriously affect functioning in a variety of areas, it is important to determine
whether a similar constellation of difculties are associated with this disorder in early childhood. Finally, prior
studies are limited because of the challenge of assessing
and diagnosing ADHD in young children. Specically,
the eld lacks well-validated measures developed specically for identifying psychiatric disorders in preschool
children (Byrne et al., 1998).
The purpose of this study was to comprehensively
examine the behavioral, social, preacademic, and medical
functioning of preschool-age children with ADHD relative to a sample of normal peers. It was hypothesized that
young children with ADHD would exhibit more disruptive behavior and fewer social skills than normal peers on
parent and teacher ratings. Group differences in frequencies of directly observed behaviors in the classroom
and during motherchild interactions also were expected.
Parents of children with ADHD were predicted to report
higher levels of parenting stress and less adaptive forms of
family coping than parents of non-ADHD children.
Finally, it was hypothesized that preschool children with
ADHD would have lower preacademic skills and would
have more physical injuries than normal peers.
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

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).

509

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***

Note: ADHD = attention-decit/hyperactivity disorder; CTRS-R


HYP = Conners Teacher Rating Scale-Revised Hyperactivity score;
CTRS-R DA = Conners Teacher Rating Scale-Revised DaydreamsAttention score; CPRS-R IH = Conners Parent Rating Scale-Revised
Impulsivity-Hyperactivity score.
*** p < .001.

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.

The ADHD Rating Scale-IV (ADHD-IV) (DuPaul et al., 1998) is


an 18-item questionnaire requiring the respondent to rate the
frequency of the DSM-IV symptoms of ADHD. This measure yields
a total score and two subscale scores (Inattention and HyperactivityImpulsivity). Raw scores for all three scales were used as dependent
measures. The reliability and validity of the ADHD-IV are adequate
(DuPaul et al., 1998).
Parents also completed two questionnaires to assess perceptions of
parental stress and family functioning. The short form of the
Parenting Stress Index (PSI) (Abidin, 1995) consists of 36 items used
to measure parentchild interactions that may indicate the development of maladaptive behaviors. The domains obtained from the
instrument are Difcult Child, Dysfunctional Interaction, Parental
Distress, and Defensive Responding, as well as a total score. Raw and
percentile scores for each measure were used as dependent variables.
The psychometric properties of the PSI are adequate (Abidin, 1995).
The Family Crisis Oriented Personal Evaluation Scales (FCOPES)
(McCubbin et al., 1981, 1991) includes 30 self-report items yielding
five subscales (Acquiring Social Support, Reframing, Seeking Spiritual
Support, Mobilizing Family to Acquire and Accept Help, and Passive
Appraisal). This measure was used to assess parental perceptions of
family functioning and support systems. Raw scores on each of these
scales were used as dependent variables as well as a total percentile score.
Reliability and validity of this measure are adequate (McCubbin
et al., 1981, 1991).
Parents also were asked to report the number of injuries requiring
medical attention, number of emergency room visits, number of calls
to after-hours nurse call-in lines, and number of sick visits for their
children over the previous 3 months. These data were supplemented
by examination of each participants medical record. Complete medical data were available for 50% of the sample.
Direct observations of behavior were conducted in a clinic playroom and the preschool classroom for each participant. All observations were conducted by trained graduate students who were blind to
group membership and the hypotheses of the study. Behavioral observations of parentchild interactions in a clinic playroom setting consisted of four different controlled situations, each of which was 10
minutes in duration, in the following order. The rst situation consisted of a parent allowing his or her child to play with toys in a freeplay situation. The second situation consisted of a parent providing
minimal attention to his or her child in a low adult attention situation.
The third situation involved a parent supervising his or her childs
activity (e.g., puzzle-making and drawing) in a parent-supervised situation. The nal observation situation required each child to complete
tasks (e.g., cleaning up playroom) in a parent-directed task situation.

Local physicians, preschool teachers, and parents were requested by


project personnel (through telephone contact and newspaper advertisements) to refer 3- to 5-year-old children exhibiting high levels of inattention, impulsivity, and/or hyperactivity. Seventy-four children were
referred and after initial screening (i.e., completion of Conners Rating
Scales by parents and teachers as well as diagnostic interview with parent), 58 children were identied as having ADHD. The SIDAC was
used to establish the DSM-IV diagnostic status of all participants by
determining presence and chronicity of symptoms as well as functional
impairment associated with symptoms. Interdiagnostician agreement
rates with this interview have exceeded values of 0.80 (Morgan et al.,
1996). Potential normal control participants were referred to the project
investigators by the same physicians and teachers who referred children
with ADHD (to draw normal controls from the same geographical and
socioeconomic backgrounds as ADHD participants). All 36 children
referred as normal controls met the inclusion criteria for participation.
Informed consent was provided by all participants parents.
For all participants, parent and teacher ratings were obtained on
the PKBS and the ADHD-IV before behavioral observations were
conducted. Medical data as well as parent ratings on the PSI and
FCOPES were obtained at the same time. Observations of parentchild interactions were conducted in clinic rooms in an outpatient pediatrics clinic. Each participant and his or her parent were
observed on one occasion for approximately 40 minutes. Classroom
observations were conducted in each childs preschool or day-care
setting on two occasions for 30 minutes (i.e., 30 minutes each in
structured and unstructured conditions). The BDI was administered
on the rst day of school observations. Children who were receiving

510

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

Procedures

BEHAVIORAL, SOCIAL, AND SCHOOL FUNCTIONING

psychotropic medication for ADHD were removed from medication


24 hours prior to parentchild interaction observations.
Interobserver agreement was assessed by having a second observer
present for at least 20% of the observations. For the parentchild
interaction data, interobserver agreement percentages regarding
occurrence of behavior ranged from 60.7% to 100% (mean =
88.7%) with values ranging from 0.64 to 1.0 (mean = 0.9). For the
classroom observations, interobserver agreement percentages regarding occurrence of behavior ranged from 88.3% to 100% (mean =
93.3%) with values ranging from 0 to 1.0 (mean = 0.81).

nicantly greater for children in the ADHD group relative


to normal control children (p < .001). For both parent and
teacher ratings, PKBS Social Skills subscale scores were signicantly greater (i.e., indicating better social skills) for the
normal control children relative to children with ADHD
(all p values < .001). For all behavior rating measures, effect
sizes were large (all >1.0 using Cohens [1988] standards).

RESULTS

The Hotelling T 2 comparing PSI ratings for children


with ADHD versus normal control children was statistically signicant (p < .001). Furthermore, all individual t
tests for each PSI subscale were signicant at the .001
level. In all cases, higher ratings (indicating more stress)
were provided by parents of children in the ADHD
group relative to the parents of normal controls (Table
4). Effect sizes for all PSI scores were large (all >1.0).

Results were analyzed within each general category of


dependent measures using Hotelling T 2 tests (i.e., multivariate form of the t test) with an level of .05. Significant Hotelling T 2 tests were followed by univariate t tests
using an level of .01 to control for experiment-wise type
I error. Effect sizes (ES) were calculated for the analysis of
each variable to elucidate the magnitude of group differences in standard deviation units. Effect sizes were calculated by taking the difference between the ADHD and
normal control group means and dividing this difference
by the standard deviation of the normal control group.
Sample sizes varied across analyses because of differential
patterns of missing data for the dependent measures.
Parent and Teacher Ratings of Child Behavior

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-

Parent Stress Ratings

Parent Ratings of Family Functioning

The Hotelling T 2 comparing FCOPES scores between


groups was signicant (p < .001). Individual t tests indicated signicantly lower scores (reecting greater family
dysfunction) for the ADHD group (all p values < .01)
for Acquiring Social Support, Reframing, and total raw
score (Table 5). Effect sizes for these variables were in the
moderate-to-large range (>0.50).
Medical Functioning

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.

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

511

D U PAUL ET AL

TABLE 3
Group Means and Standard Deviations for Teacher Ratings of Child Behavior
Measure

ADHD

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

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.

Observations of ParentChild Interactions

Between-group differences in parentchild interactions


are presented separately for each of the four observation
conditions.
Free-Play Situation. The Hotelling T 2 comparing
overall differences in behavior between groups during
the free-play situation was statistically significant (p <
.05). Children with ADHD were more noncompliant
than children in the normal control group (t82 = 2.6, p =
.01; ES = 1.76). Parents of children with ADHD emitted
fewer alpha commands than did normal control parents
(t82 = 2.9, p < .01; ES = 0.6). No other group differences
were statistically signicant.
Low Adult Attention Situation. The Hotelling T 2
comparing groups in parentchild interactions during
the low adult attention situation was nonsignicant.
Parent-Supervised Situation. Overall group differences
in behavior during the parent-supervised situation were
statistically signicant (p < .01). Children with ADHD

exhibited more frequent noncompliance (t82 = 2.97, p <


.01; ES = 1.82) and inappropriate behavior (t82 = 2.7, p <
.01) than did normal controls. Parents of children with
ADHD emitted more frequent negative behavior toward
their children than did parents of the normal controls
(t82 = 2.5, p = .01; ES = 1.2). No other group differences
were statistically signicant.
Parent-Directed Task Situation. The Hotelling T 2 examining group differences in behavior during the parentdirected task situation was statistically signicant (p <
.05). Children with ADHD exhibited more frequent
inappropriate (t82 = 3.2, p < .01; ES = 7.4) and noncompliant (t82 = 3.0, p < .01; ES = 1.1) behavior than did
normal controls. Furthermore, parents of children with
ADHD emitted more frequent negative behavior toward
their children than did parents of normal controls (t82 =
2.8, p < .01; ES = 1.2). Effect sizes were large for all three
variables. No other group differences were statistically
signicant.

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.

512

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

BEHAVIORAL, SOCIAL, AND SCHOOL FUNCTIONING

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

Participants with ADHD obtained signicantly lower


scores on the Cognitive Domain subtests of the BDI (p <
.01). Participants with ADHD obtained significantly
lower scores on measures of Memory (t84 = 3.6, p < .001;
ES = 1.1), Reasoning and Academic Skills (t84 = 3.5, p =
.001; ES = 0.9), Conceptual Development,(t84 = 4.0, p <
.001; ES = 1.0), and Cognitive Total (t84 = 4.6, p < .001;
ES = 1.1). On average, children with ADHD obtained
scores 1 SD below the expected mean for their age and
relative to mean scores obtained by normal controls.
Analyses Within Gender

Because the ratio of males to females was greater in the


ADHD relative to the normal control group, all of the
above analyses were conducted again for boys only. The
results of these analyses were identical with those obtained
for the entire sample, except for the parentchild interaction and preschool observational data. Specifically,
between-group differences were absent for the parent
child free-play (effects found only for negative behavior)
and parent-supervised task (effects found only for inappro-

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

priate behavior and noncompliance) situations as well as


for negative behavior in the unstructured classroom situation. The lack of between-group differences for these variables is assumed to be due to a loss of power given reduced
sample size when conducting analyses for boys only.
DISCUSSION

Young children with ADHD exhibited more problem


behavior and were less socially skilled than their normal
counterparts according to parent and teacher ratings.
Group differences in behavior ratings were expected
because (1) children were assigned to groups based, in
part, on behavior ratings, and (2) prior research studies
have documented high levels of disruptive behavior and
social performance deficits in young children with
ADHD (Alessandri, 1992; Byrne et al., 1998; Shelton
et al., 1998). However, the magnitude (i.e., greater than 2
SD difference) and pervasive nature of between-group
differences on this variable were remarkable. Also as
expected, children with ADHD were rated as less socially
skilled than normal controls, with this difference ranging
between 1.8 (parent ratings) and 2.4 (teacher ratings) SD
on the PKBS Social Skills subscale. Somewhat surprising
were group differences in parent and teacher ratings of
internalizing behaviors such as social withdrawal and
anxiety. These differences could indicate that young children with ADHD display multiple behavior problems
across both externalizing and internalizing domains,
although the magnitude of group differences in the latter
domain was less than between-group differences in the
former domain. It also is possible that adult perceptions
of child behavior may be negatively biased because of the
stress associated with managing a child with ADHD.
Parents of children with ADHD reported higher levels
of stress associated with child behavior and dysfunctional
513

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-

cically elucidate the situations that elicit problematic


behavior in this population in preschool settings.
As has been found by other investigators (e.g., Mariani
and Barkley, 1997), children with ADHD exhibit preacademic skill deficits even prior to formal school entry.
Children with ADHD scored approximately 1 SD below
the normal controls on the BDI (who scored at the mean
for the BDI normative sample). That young children
with this disorder scored lower on this measure was not
unexpected; however, the magnitude of this difference is
sobering given that they will enter school at signicant
disadvantage relative to their classmates.
In contrast to several prior studies (e.g., Lahey et al.,
1998), signicant group differences in injuries and medical service utilization were not found. This result may be
due to two factors. First, we were unable to obtain complete data on these variables for almost 50% of the sample. This smaller sample size reduced the power to detect
group differences, particularly for number of injuries.
Second, because our sample was younger than participants in prior studies, children may have been too young
to have accumulated enough injuries and sick visits to
result in statistically signicant group differences.

514

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

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

BEHAVIORAL, SOCIAL, AND SCHOOL FUNCTIONING

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.

hensive battery of assessment measures. Certainly, the


problems faced by young children with ADHD and
their families require extensive efforts to develop empirically sound approaches to early intervention that are
based on reliable and valid assessment data.
REFERENCES

Despite methodological limitations, these results


indicate that even at a young age, children exhibiting
high rates of inattention, impulsivity, and overactivity
are likely to experience a myriad of behavior, social,
family, and academic problems. These ndings require
replication with a larger sample using a similar compre-

Abidin RR (1995), Parenting Stress Index, 3rd ed. Odessa, FL: Psychological
Assessment Resources
Alessandri SM (1992), Attention, play, and social behavior in ADHD preschoolers. J Abnorm Child Psychol 20:289302
American Psychiatric Association (1994), Diagnostic and Statistical Manual of
Mental Disorders, 4th ed (DSM-IV). Washington, DC: American Psychiatric
Association
Barkley RA (1998), Attention Decit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment, 2nd ed. New York: Guilford
Byrne JM, DeWolfe NA, Bawden HN (1998), Assessment of attention-decit
hyperactivity disorder in preschoolers. Child Neuropsychol 4:4966
Cohen J (1988), Statistical Power Analysis, 2nd ed. Hillsdale, NJ: Erlbaum
DuPaul GJ, Power TJ, Anastopoulos AD, Reid R (1998), ADHD Rating Scale
IV: Checklists, Norms, and Clinical Interpretation. New York: Guilford
Goyette CH, Conners CK, Ulrich RF (1978), Normative data on Revised
Conners Parent and Teacher Rating Scales. J Abnorm Child Psychol 6:221236
Keenan K, Wakschlag LS (2000), More than the terrible twos: the nature and
severity of behavior problems in clinic-referred preschool children. J
Abnorm Child Psychol 28:3346
Lahey BB, Pelham WE, Stein MA et al. (1998), Validity of DSM-IV attentiondeficit/hyperactivity disorder for younger children. J Am Acad Child
Adolesc Psychiatry 37:695702
Lavigne JV, Gibbons RD, Christoffel KK et al. (1996), Prevalence rates and
correlates of psychiatric disorders among preschool children. J Am Acad
Child Adolesc Psychiatry 35:204214
Mariani MA, Barkley RA (1997), Neuropsychological and academic functioning in preschool boys with attention decit hyperactivity disorder.
Dev Neuropsychol 13:111129
McCubbin HI, Larsen A, Olson DH (1981), Family Crisis Oriented Personal
Evaluation Scales. Center for Excellence in Family Studies, School of
Human Ecology, 1300 Linden Drive, University of Wisconsin, Madison,
WI 53706
McCubbin HI, Olson DH, Larsen AS (1991), Family Crisis Oriented Personal Evaluation Scales. In: Family Assessment Inventories for Research
and Practice, McCubbin HI, Thompson AI, eds. Madison: University of
Wisconsin-Madison, pp 203218
Merrell KW (1994), Preschool and Kindergarten Behavior Scales. Brandon, VT:
Clinical Psychology Publishing Company
Morgan AE, Hynd GW, Riccio CA, Hall J (1996), Validity of DSM-IV
ADHD predominantly inattentive and combined types: relationship to
previous DSM diagnoses/subtype differences. J Am Acad Child Adolesc
Psychiatry 35:325333
Newborg J, Stock JR, Wnek L (1988), Manual for the Battelle Developmental
Inventory. Boston: Houghton Mifin
Pierce E, Ewing L, Campbell SB (1999), Diagnostic status and symptomatic
behavior of hard-to-manage preschool children in middle childhood and
early adolescence. J Clin Child Psychol 28:4457
Shelton TL, Barkley RA, Crosswait C et al. (1998), Psychiatric and psychological morbidity as a function of adaptive disability in preschool children
with aggressive and hyperactive-impulsive-inattentive behavior. J Abnorm
Child Psychol 26:475494
Walker HM, Severson HH, Feil EG (1995), Early Screening Project: A Proven
Child Find Process. Longmont, CO: Sopris West
Zito JM, Safer DJ, dosReis S, Gardner JF, Boles M, Lynch F (2000), Trends in
the prescribing of psychotropic medications to preschoolers. JAMA
283:10251030

J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 5 , M AY 2 0 0 1

515

Conclusions