184 Chapter 22
disorders, and emotional disorders as they grow older. Retrospectively,
this continuity is often evident when assessing the psychiatric problems of
schoolchildren, with parental accounts making it clear that the problems
go back to the preschool years. Many children with oppositional-defiant
disorder have always been irritable and prone to temper tantrums; many
children with separation anxiety disorder have always been very clingy
and fearful; and many children with ADHD have always been over-active
and inattentive.
Why, then, have clinicians often found it hard to diagnose ADHD,
conduct and emotional disorders with confidence in 3-year-olds? In part, it
is because the tools for the job were not available until recently – the sorts
of high-quality structured diagnostic assessments that have been widely
deployed in research and clinical assessments of school-age children did
not extend down to preschool children. This is now changing, at least for
the assessment of 2–4-year-olds. However, there is still a signal-to-noise
problem. For example, although many 3-year-olds are very active and
find it hard to settle to tasks, most of them develop adequate attention
and activity control by the time they start school; only a small minority
have persistent problems that eventually warrant a diagnosis of ADHD.
Detecting early ADHD (the ‘signal’) is harder when there is so much
background ‘noise’ in the form of self-limiting over-activity and inatten-
tion. As assessment techniques improve, it should be possible to predict
more accurately which preschool problems are the first signs of chronic
disorders. If so, these children could potentially be targeted for continuing
extra help before they run into serious problems. By contrast, reassurance
or a brief intervention may be all that is needed for preschool problems
that are likely to be outgrown.
Outcome in adulthood
The Preschool to School sample was followed up again, in what could
have been called the ‘Preschool to Court’ study, since the only outcome
measure obtained in young adult life was whether the individual had a
criminal record. Perhaps the single most important finding is that it is not
possible to predict accurately which 3-year-olds will turn out to be law-
breakers – a finding that will be a relief to many, though a disappointment
to some. Nevertheless, even after allowing for gender, social background
and developmental delay, some preschool problems were modestly pre-
dictive of adult criminality. Thus, 3-year-olds who were markedly over-
active or hard to manage were roughly twice as likely to commit adult
offences, while 3-year-olds with marked temper tantrums were about four
times as likely to commit violent adult offences. These findings add to
the case for providing parents of oppositional-defiant preschoolers with
effective help (see Chapter 6) and not simply assuming that they will ‘grow
out of it’.