Evidence for the predictive validity of DSM-IV oppositional defiant and conduct disorders diagnosed in a clinically referred sample of preschoolers

Research on preschool psychopathology has evolved from two distinct trends: a clinical need to serve increasing numbers of young children presenting to mental health clinics (Ringel & Sturm, 1998), and emerging data indicating that the underpinnings of many disorders lie in deficits in behavioral and emotional functioning that are present early in life (Keenan & Shaw, 2003). The developmental appropriateness of DSM-IV nosology (APA, 1994), however, especially for oppositional defiant disorder (ODD) and conduct disorder (CD) for preschool children has been called into question (McClellan & Speltz, 2003; Thomas & Guskin, 2001). In response to these concerns, a research agenda was articulated calling for empirically based answers to the concerns about applying such diagnoses to preschoolers (Keenan & Wakschlag, 2002). Since then, evidence has accumulated for reliability and concurrent validity of DSM-IV ODD and CD in preschool children. Strong one-week test-retest and inter-rater reliability of ODD and CD symptoms, and concurrent validity via associations with parent- and teacher-rated impairment were reported in samples of referred an d non referred 3–5 year olds (Keenan, Wakschlag, Danis, Hill, Humphries et al., 2007). ODD diagnosed using DSM-IV criteria has demonstrated good discriminant, divergent, and convergent validity in 2–5 year old children (Birmaher, Ehmann, Axelson, Goldstein, Monk et al., 2009). Evidence for the predictive validity of preschool ODD and CD has been limited, but is critical for refuting the claim that such disorders pathologize normative behavior during this developmental period (McClellan & Speltz, 2003; Thomas & Guskin, 2001). Establishing predictive validity is also critical for identifying primary points in development for prevention and studies of etiology. ODD and CD during adolescence have been shown to predict many common forms of adult psychopathology (Kim-Cohen, Arsenault, Caspi, Tomas, Taylor et al., 2005). If ODD and CD symptoms and disorders as manifest in pre-school age children are empirically linked to those observed in older youth, then the point of deviation to focus on is early in childhood. Predictive validity of preschool diagnoses on a similar magnitude to that found for older children would be evidence of such an empirical link. There is a long history of research in non-clinical samples supporting the hypothesis that caregiver ratings of behavioral and emotional problems that emerge early in life can be stable and predictive of later impairment in community samples (Campbell, Ewing, Breaux, & Szumowski, 1986; Cummings, lanotti, & Zahn-Waxler, 1989; Earls & Jung, 1987; Stevenson, Richman & Graham, 1985). The translation of this knowledge to clinical disorders and clinical populations, however, has progressed only minimally. In a few studies, predictive validity of disruptive behavior and attention deficit disorders has been established, but data on stability for each diagnostic category is typically not provided (Harvey, Youngwirth, Thakar, Errazuriz, 2009; Lavigne, Arend, Rosenbaum, Binns, Chrisoffel & Gibbons, 1998; Pierce, Ewing & Campbell, 1999). The E-Risk Study, a representative birth cohort followed longitudinally, is the only known study in which the validity of CD from preschool to school age was tested (Kim-Cohen, Arsenault, Caspi et al., 2005). Five-year-olds who were diagnosed with CD were at significantly greater risk for a CD diagnosis when followed up at age 7 (odds ratio = 20.6). Approximately half of the preschoolers diagnosed with CD had no CD symptoms at age 7, although evidence of social and academic impairment for those diagnosed as preschoolers continued to be present through the age of 10 years (Kim-Cohen, Arsenault, Newcombe, Adams, Bolton et al., 2005). An advantage of the E-risk study is that it used a representative birth cohort to test predictive validity. A disadvantage is that such a large study precluded the use of a diagnostic interview, which may have resulted in somewhat less reliable assessments of CD symptoms. In the present study, we provide one of the first tests of the specificity of prediction of DSM-IV ODD and CD diagnosed in preschoolers (ages 3–5 years) using clinic-referred and non-referred samples that include both sexes and are largely comprised of African American children. A reliable, developmentally informed diagnostic interview was used to generate DSM-IV symptoms of ODD and CD. In addition to providing data on stability of diagnosis, we test whether stability is moderated by sex or race, examine symptom and diagnostic outcomes for children over 36 months, and test level of impairment as a function of stability of diagnosis. We focus on the utility of DSM-IV ODD and CD for children living under conditions of economic stress because they are at higher risk for developing disruptive behavior disorders, although specific mechanisms by which economic stress confers risk is not well known (Dohrenwend, Levav, Shrout, Schwarts, Naveh et al., 1992).