Clinical Usefulness of Observational Assessment in the Diagnosis of DBD and ADHD in Preschoolers

Abstract

The aim of the present study was to investigate the clinical usefulness of an observational tool--the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS)--in the diagnosis of disruptive behavior disorders (DBD) and attention deficit/hyperactivity disorder (ADHD) in preschoolers. We hypothesized that the DB-DOS may help support the presumption of a diagnosis generated by the information from parents and teachers (or other caregivers). Participants were referred preschool children with externalizing behavioral problems (N = 193; 83% male) and typically developing children (N = 58; 71% male). In view of the clinical validity study each child was given a diagnosis of either DBD (N = 40), or ADHD (N = 54) or comorbid (DBD + ADHD; N = 66) based on best-estimate diagnosis. The DB-DOS demonstrated good interrater and test-retest reliability for DBD and ADHD symptom scores. Confirmatory factor analysis demonstrated an excellent fit of the DB-DOS multidomain model of DBD symptom scores and a satisfactory fit of ADHD symptom scores. The DB-DOS demonstrated good convergent validity, moderate divergent validity, and good clinical validity on a diagnostic group level for DBD and ADHD symptom scores. The Receiver Operating Characteristic curve analyses revealed that for DBD the sensitivity and specificity are moderate and for ADHD good to excellent. The presumption of a diagnosis based on information from parents, teachers, and cognitive assessment was supported by the DB-DOS in 60% for DBD and 75% for ADHD. The DB-DOS can be used to help support a presumption of a DBD and/or ADHD diagnosis in preschool children.

Contextual variability of ADHD symptoms: embracement not erasement of a key moderating factor

“…We completely agree with the views that ADHD symptoms may vary depending on the context that a child may still be clinically impaired when symptoms occur predominantly in one situation and less so in another [4] and also agree with the view that the absence of ADHD symptoms in the first or second clinical evaluation when a child is not challenged does not necessarily imply the absence of ADHD in this child [3,26]. However, we do believe that children that do not show any (or only minimal) symptoms in these first encounters-or that show symptoms predominantly in one setting and much less so in anotherare meaningfully different from children that show many symptoms across settings.…”

“…We disagree and believe that children able to 'mask' their ADHD symptoms are meaningfully different from children that are not able to do so. Recently, it was shown that ADHD symptoms can be systematically elicited and reliably observed and quantified in preschoolers with externalizing behavior problems using the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS) [4,5]. In this 1 h observation, the child's behavior is assessed in three interactional contexts: one parent and two examiner (engaged and non-engaged) contexts [24,25].…”

“…For example, behaviors that occur in developmentally expectable contexts (e.g., difficulty inhibiting when anticipating an exciting reward) versus developmentally unexpectable context (difficulty sitting still to participate in an age-appropriate engaging activity) are distinguished. The clinical validity for ADHD has been shown to be good to excellent [4]. Of great interest is that the severity of ADHD symptoms was moderated by context: highest in the parent-child context and lowest in the examiner engaged-child context.…”

“…According to the Practice Parameter for ADHD [21], "the primary purpose of the interview of the child or the adolescent is not to confirm or refute the diagnosis (…) but to identify signs or symptoms inconsistent with ADHD" (p. 900). Our clinical experience, however, suggests that many parents desire the clinician to observe the child in order to arrive at a diagnosis, as parents who consult a clinician would not accept that the diagnostic decision is merely based on parent and teacher reports; parents want clinicians to ''look at their child'' themselves [4]. While parents are the best informants about historical features of their child's behavior, they are less skillful at making qualitative judgments about their children's behavior [25].…”

The Child Behavior Checklist Dysregulation Profile in Preschool Children: A Broad Dysregulation Syndrome

“…22,23 Behavior regulation problems (n=15) encompassed behaviors resulting from difficulties in the ability to keep with social rules and norms. Anger modulation problems (n=6) incorporated behaviors reflecting irritable, sullen mood, and deregulated expressions of anger (e.g., often loses temper).…”