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Preschool psychopathology: lessons for the lifespan

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Preschool psychopathology: lessons for the lifespan

Preschool psychopathology: lessons for the
lifespan
Adrian Angold and Helen Link Egger
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, USA
One of the clearest lessons emerging from psychiatric research over the last decade or so is that what
were once thought of as typically ‘adult’ disorders are
more often than not reported to have had their
onsets in childhood and adolescence (Insel & Fenton,
2005; Kessler et al., 2005). In the subspecialty of
child and adolescent psychiatry there has also been
a move towards identifying disorders in ever younger
groups of children. For instance, 15 years ago, when
our group began the Great Smoky Mountains Study
(Costello et al., 1996), the decision to include only
children aged nine and older was driven by the lack
of diagnostic measures of psychopathology for
younger children. Similarly, the leading birth cohort
studies of the time did not begin to diagnose psychiatric disorders until around the same age, or later
(e.g., Kashani et al., 1983). The briefest perusal of
the papers included in this special section devoted to
preschool psychopathology shows how dramatically
the situation has changed. Parent- and teacherreport questionnaires led the way (Achenbach,
Edelbrock, & Howell, 1987; Behar, 1977; Richman et
al., 1974), but now we see represented here a wide
range of reliable assessment technologies ranging
from such questionnaires to DSM-IV-based symptom checklists and more detailed assessments of
preschool behavior, full DSM-IV (American Psychiatric Association, 2000), ICD-10 (World Health
Organization, 1987) and DC:0–3-based (Zero to
Three, 2005) diagnostic interviews, child selfreports, standardized observational assessments,
and neuropsychological batteries. We can now confidently assert that we have wherewithal to assess
the psychiatric status of children down to age two. Of
course, that does not mean that we have perfected
everything we could ever want – that would not be
true of psychiatric assessment at any age – but it
does mean that there is no general methodological
reason to exclude young children from studies of
specific psychiatric disorders.
The child and adolescent psychiatric field has
become used to using the ‘or rule’ in diagnosing
disorders in older children – if either the child, the
teacher, or the parent reports a symptom as being
present, then we regard it as being present. Kerr,
Lunkenheimer, and Olsen (this issue) found that
mothers’, fathers’, teachers’, and examiners’ ratings
of child behavior at age three all predicted problems
at age 5, and confirmed that fathers were a valuable
independent source of information. Examiner information proved to be of more limited utility, but the
use of the examiners (to complete the Teacher’s
Report Form (TRF) on a child they did not know prior
to the examination) seems likely to have been
non-optimal. Wakschlag et al. (this issue) used their
examiners to implement a series of presses for
disruptive behavior incorporated in the DB-DOS,
and found that they provided significant prediction
of impairment over and above that derived from
maternal reports of the frequency of disruptive
behaviors. Coplan, Clossen, and Arbeau (this issue)
conducted a short direct interview with five-yearolds about loneliness, and their data suggest that
such interviews yield meaningful information.
Ialongo and colleagues showed some time ago that
questionnaire-based self-reports from first-graders
predicted anxiety and depressive problems and
diagnoses at ages 10 and 14 (Ialongo, Edelsohn,
Werthamer-Larsson, Crockett, & Kellam, 1995;
Ialongo, Edelsohn, & Kellam, 2001), but it remains
an open question how young we can go with selfreport assessments of this sort. Codings of responses
to story stems, doll-house scenarios or puppet-based
assessments are viable down to age four or five (see,
e.g., Stadelmann et al., this issue), but shorter
attention spans, fear of large doggy puppets, and
difficulties in inhibiting proponent play responses
suggest that more work needs to be done to develop
scorable assessments for even younger children.
Stadelmann et al.’s paper also adds to the growing
evidence that behavioral problems in preschoolers/
kindergarteners are as stable over time as they are
in older children and adolescents (Briggs-Gowan,
Carter, Bosson-Heenan, Guyer, & Horwitz, 2006).
There is also a more general problem with
incorporating child ‘self-reports’ into the diagnostic
process for younger children. By the age of nine,
most children can complete an ‘adult style’ diagnostic interview and, although it has been shown
that they have problems with time-based constructs,
such as dates of onset (Breton et al., 1995), we can
collect information that is formally equivalent to that
obtained from parents. This information feeds easily
into DSM/ICD-style diagnostic algorithms using the
‘or rule’. In younger children, such adult-style
interviews simply do not work, and we do not, as
yet, have an agreed-upon set of methods for
Conflict of interest statement: No conflicts declared. incorporating other sorts of information into our
Journal of Child Psychology and Psychiatry 48:10 (2007), pp 961–966 doi:10.1111/j.1469-7610.2007.01832.x
2007 The Authors
Journal compilation 2007 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
diagnostic algorithms (although work has been done
using a combination of drawings and symptom
descriptions with children down to age 6; Valla,
Bergeron, & Smolla, 2000). Calls for ‘developmentally-sensitive’ assessments and classification
schemes typically focus on possible age-dependent
phenotypic differences (e.g., Wakschlag et al., this
issue), but we would gain a lot just by agreeing how
to incorporate standardized phenotypic information
from self-reports or observations that does not fit
neatly into the DSM-IV history format at any age. We
know how to incorporate a standardized history into
our research, but we need to ask ‘whatever happened
to the mental status examination’. Given the long
tradition of observational studies of younger
children, and the demonstrated utility of the Autism
Diagnostic Observation Schedule (Lord, Rutter,
DiLavore, & Risi, 2003; Lord et al., 1989) in the
diagnosis of pervasive developmental disorders,
there certainly seems to be a place for the
development of standardized observational or
child- response test methods with algorithms for the
incorporation of their results into the diagnostic
process. The latter requirement actually presents
something of a problem, because the DSM-IV and
ICD-10 diagnostic criteria for most disorders are not
written in such a way as to make the inclusion of
observational data very straightforward. However, a
start has been made in this area by measures like
those reported on in this special edition. It is also
worth remembering that observational paradigms
have long been used in research on inhibited
temperamental style (which has obvious parallels
with social phobia; Perez-Edgar & Fox, 2005).
On the other hand, uncertainty about how
to incorporate such measures into the diagnostic
process should not limit the expansion of preschool
research. Adult psychiatry has learned a lot from the
use of just a history from the best available single
informant (the patient or proband), despite the fact
that we know that additional informants and mental
status exams would provide useful information.
Most would agree that the best single informant for
younger children is a parent, and useful work
was being done with parent-only reports on older
children long before child self-report diagnostic
interviews became available and accepted. We
should not impose a multiple informant straitjacket
on the preschool field at this early stage of its
development.
Sterba and colleagues (this issue), using parent
interview data and confirmatory factor analyses,
found that the symptoms of a number of the commonest disorders of preschoolers aggregated
together in a manner rather similar to that
prescribed by the DSM-IV diagnostic criteria. Where
the symptom content of the extracted factors
differed from the DSM-IV criterion sets (depression
and generalized anxiety loaded on a single factor, as
did conduct disorder and oppositional disorder
symptoms, whereas attention-deficit/hyperactivity
symptoms yielded two, albeit very highly correlated,
factors), it was notable that they did so in ways that
have previously been described in older children and
adolescents (Lahey et al., 2004). Add to this an
earlier report from the same study indicating that the
overall community prevalence of DSM-IV disorders
in preschoolers is around 10–15% (Egger et al.,
2006), and a clear impression emerges that the
overall ‘architecture’ of the common forms of
child and adolescent psychopathology is already in
place by the preschool years. In recognition of this
conclusion, it is notable that the Zero to Three
organization’s revised diagnostic classification
(DC:0–3R; Zero to Three, 2005) is much more similar
to the DSM-IV classification than was its predecessor.
Such conclusions do not, however, mean that
there is nothing developmental about psychopathology. First, there are obvious quantitative
changes in the frequencies of manifestation of
individual symptoms. For instance, acts of physical
aggression peak at ages two to three and then
become less frequent (Tremblay, 2004), and we need
to understand how such developmental changes
arise. The behavioral capacities of preschoolers also
preclude them from manifesting some symptoms
(such as car theft or running away from home), and if
we understood that ways in which new behavioral
capacities become recruited in the ‘service’ of
psychopathology, we might be better able to
interrupt the progression of some disorders. Even if
the overall annual prevalence and symptomatic
presentation of many disorders does not change very
much from the preschool years to the end of
adolescence, we also have to remember that different
individuals have onsets of disorder at different
points in time – most depressed adolescent boys
were probably not depressed as preschoolers, and
we can expect that many disordered preschoolers
will later be quite well. There are many developmental questions about the timing of onsets of disorders and their subsequent course that persist in
the face of developmental invariance of form.
At this point it is perhaps useful to distinguish
among various patterns of disorder manifestation
over developmental time:
(1) Disorders that manifest early in life and continue
in the same basic form thereafter with more or less
improvement or deterioration. The pervasive
developmental disorders are the obvious example
here, but there is growing evidence that attention-deficit/hyperactivity disorder (ADHD) also
belongs in this group (McGough & Barkley, 2004).
(2) Disorders that manifest early in life, but moreor-less disappear by adulthood. Until recently,
separation anxiety disorder would have been the
case in point, but we now know that with sensible
modifications of the criteria to take into account
the realities of adult behavior, separation anxiety
962 Adrian Angold and Helen Link Egger
2007 The Authors
Journal compilation 2007 Association for Child and Adolescent Mental Health.
disorders can be identified in adulthood (Shear,
Jin, Ruscio, Walters, & Kessler, 2006). At this
point it is quite possible that there will turn out
to be no such developmental period-specific
disorders, and we should recognize that
the search for ‘developmentally appropriate
diagnostic criteria’ does not apply only to
modifications to the criterion sets for children.
When disorders at first appear to be limited to
childhood, we should ask the question ‘what are
their adult homologues’, rather than taking such
apparent age-limitation at face value. But there is
another big problem here in that we are only likely
to find what we look for, and the studies in this
special section mirror the broader empirical
literature in focusing mostly on categories and
dimensions using item pools largely derived from
the study of older populations. For instance, the
biggest difference between the DSM-IV and DC:
0–3R is the latter’s inclusion of ‘Regulation disorders of sensory processing,’ which are defined as
‘difficulties in regulating emotions and behaviors
as well as motor abilities in response to sensory
stimulation that lead to impairment in development and functioning’ (Zero to Three, 2005, p. 28).
The evidence base relating to these disorders
is almost entirely clinical-descriptive (Miller,
Robinson, & Moulton, 2004), and it is not known
whether the ‘hypersensitive fearful/cautious’,
‘hypersensitive negative/defiant’, and ‘hyposensitive/underresponsive’ subtypes described in the
DC:0–3 can be discriminated respectively from
anxiety disorders, disruptive behavior disorders/
ADHD, and depression. Given the widespread use
of the DC:0–3 in preschool clinical settings, the
etiological assumptions implicit in the name of
this group of problems, and the use of specific
treatments aimed at modulating sensory input,
these are perhaps age-specific disorders (or at
least presentations) that deserve greater research
attention.
(3) Disorders that may begin early in life or have
onsets later in childhood, that wax and wane,
without there being very substantial changes in
prevalence or correlates over time. Oppositional
defiant disorder and social phobia appear to
belong in this group. In these cases, however, it is
possible that such disorders are really just as
continuous as, say ADHD, and perhaps belong in
group 1. We have become used to thinking of
ADHD as a ‘neurodevelopmental’ disorder, but
oppositional-defiant disorder (ODD) and social
phobia may be just as ‘neurodevelopmental’. The
problem is that there has been far less focused
study of these disorders in younger children than
there has been study of ADHD.
(4) Disorders that are not uncommon early in life,
but which show substantial changes in prevalence with age. Unipolar depression, with its
huge increase in prevalence in girls during
adolescence (Angold & Costello, 2006), is the
archetypal example here (and GAD probably follows a similar prevalence curve).
(5) Disorders that are rare or perhaps even nonexistent in early life, but become more common
in later childhood, adolescence or adulthood.
Schizophrenia is the obvious example here, but
panic disorder also follows this pattern.
It is obvious that rather different sorts of developmental mechanisms will be required to describe
the observed patterns of occurrence in these different groups, but it is not always easy to be sure
to which group a particular disorder belongs. The
current debate over the status of bipolar disorder
(particularly mania) in preschoolers and older
children illustrates this point all too clearly (Biederman et al., 2000; Brotman et al., 2006; Luby &
Belden, 2006), hinging, as it does, on the degree to
which phenomena like rapid mood cycling and
explosive irritability are equivalent to classical manic
symptoms in adolescents and adults. The studies
presented here show that we now have the
measurement tools to address questions of this sort
in preschoolers, but we have only just begun to
tackle the most basic issues concerning the nature of
psychopathology in younger children.
Once categories or dimensions of disorder have
been identified, we naturally begin to search for their
correlates and, hopefully, causes. Five papers in this
special section deal with such questions from genetic
(van Hulle), psychological (Coplan; Stadelmann;
Hughes), and neuropsychological (Brocki) perspectives. In each case, as the introductory section of
each paper makes clear, the basic strategy involved
taking measures and approaches that had been
shown to be associated with psychopathology in
older children and looking to see whether such
associations could be found in preschoolers. In every
case, the answer was that they could. If we accept
that preschool psychopathology rather closely
resembles the psychopathology of older children in
form, then it should not surprise us that the basic
‘architecture of risk’ is already in place in the preschool years. But such findings do not bode well for
primary prevention efforts in that they suggest that
expected risk–disorder associations are already well
established earlier in life than many ‘prevention’
programs begin. Of course, there is plenty of room for
secondary and tertiary prevention efforts, but if the
hope is to prevent the onset of relatively common
disorders (such as ODD or social phobia) in the first
place, then we may have already largely missed the
boat by the age of two or three. However, even if we
consider treatment services, it is still the case
that preschoolers are woefully underserved. Most
specialist psychiatric services are delivered to much
older children and teenagers in both the USA and
Europe, despite the fact that the current evidence
indicates that rates of DSM-IV disorders in
Preschool psychopathology: lessons for the lifespan 963
2007 The Authors
Journal compilation 2007 Association for Child and Adolescent Mental Health.
preschoolers are not very different from those in older
children and adolescents (Egger & Angold, 2006).
There have also been very few treatment studies of
specific disorders in younger children (with recent
studies of stimulants in ADHD being the notable
exception). Of course, a major reason for this lack of
specific treatment studies is that tools for the
standardized diagnosis of specific disorders in younger children have been lacking until very recently.
Now that they are available, it is time to catch up.
The papers in this special section indicate that we
can assess childhood psychopathology in the DSM/
ICD framework down to the age of two (using, e.g.,
the Preschool Age Psychiatric Assessment), but the
linguistic and behavioral capacities of children
younger than two substantially limit the utility of
that approach. Dimensional assessments, such as
the CBCL 1 1/2–5 (Achenbach & Rescorla, 2000) or
the Infant Toddler Social-Emotional Assessment
(ITSEA – for children ages one to four; Carter et al.,
2003) take us back another six months to a year,
but even here there is no solid empirical basis for
mapping these measures onto later DSM/ICD symptomatology. The situation becomes even more problematic when we consider the period from birth to
age one but, given the findings in the preschool
period, there can be little doubt that we need to
extend our assessments of psychopathology back to
this period. We know at a very general level that
some ‘negative’ temperamental characteristics are
associated with later elevated scores on measures of
general psychopathology but, except perhaps in the
area of inhibited temperament and its relationships
with later anxiety (Fox, Henderson, Marshall,
Nichols, & Ghera, 2005; Perez-Edgar & Fox, 2005),
we know very little about the pathways by which
these continuities are established and maintained. If
we are to fill in these gaps we will need follow-ups of
infants that use much more refined measures of the
specifics of symptomatology as it emerges. One of the
positive messages of the work presented here is that
such measures are now available. Indeed, one of the
interesting features of the ITSEA (see van Hulle, this
issue) is its inclusion of scales with content typical of
psychopathology research (e.g., ‘internalizing’ and
‘externalizing’) and a physical and emotional ‘dysregulation’ scale that clearly has its conceptual roots in
the temperament literature.
Temperament is not, however, the only infant
behavioral research construct relevant to the
development of psychopathology, as is nicely
demonstrated by Madigan’s paper on infant attachment and behavioral problems at age two (Madigan,
this issue). An important feature of this paper is its
simultaneous focus on attachment style classification, maternal representations of attachment, and
maternal behavior in a dyadic situation with the
child. The effect of disrupted maternal behavior on
later behavioral problems was found to be substantially mediated by the presence of disorganized
attachment, but the effect of unresolved maternal
representations of attachment was not. This study
involved tightly framed questions that could be
addressed with a relatively small sample (N ¼ 64),
and its authors noted their inability to examine more
extended causal models. But, in this special edition
alone, and considering only associations with
disruptive behavior problems, we see that we need to
consider genes, attachment, loneliness, theory of
mind, cognitive processing, parental behavior, and
family relationships. In such a multivariate world we
need much larger and more comprehensive studies
than have ever been done with preschoolers. There is
also every reason to begin such studies at (or preferably before) birth (or preferably conception). Even
the more recent birth cohort studies with a substantial focus on behavior and psychopathology,
such as the Avon (e.g., O’Connor, Heron, Golding,
Beveridge, & Glover, 2002), Christchurch (e.g..
Fergusson & Horwood, 2001) and Dunedin (e.g..
Gregory et al., 2005) studies were begun at a time
when measures relevant to psychopathology in
young children were very thin on the ground (Colman & Jones, 2004), and so have been much more
revealing about psychopathology in late childhood,
adolescence and young adulthood than that in early
childhood. As this special section shows, we now
have the tools to allow us to address much more
complex (and realistic) questions about the development of psychopathology in young children, and
every reason to suppose that large birth cohort
studies are needed to provide the means to develop
a comprehensive account of the development of
psychopathology. Indeed, studies of this sort have
already begun in Norway, and it is to be hoped that
as new studies (such as the National Children’s
Study (N projected to be 100,000) in the USA) come
on line, they will provide the opportunity for research
in younger children to take its rightful place as a key
component in understanding the development of
psychopathology across the life span.
Correspondence to
Adrian Angold, Box 3454 Duke University Medical
Center, Durham, NC 27710, USA; Email: adrian.
angold@duke.edu
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Diagnostic classification of mental health and developmental disorders of infancy and early childhood (rev.
edn). Washington, DC: Zero To Three Press.
Manuscript accepted 13 August 2007

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